Implementation of a management protocol for massive bleeding reduces mortality in non-trauma patients: Results from a single centre audit.

OBJECTIVE:
To audit the impact upon mortality of a massive bleeding management protocol (MBP) implemented in our center since 2007.

DESIGN:
A retrospective, single-center study was carried out. Patients transfused after MBP implementation (2007-2012, Group 2) were compared with a historical cohort (2005-2006, Group 1).

BACKGROUND:
Massive bleeding is associated to high mortality rates. Available MBPs are designed for trauma patients, whereas specific recommendations in the medical/surgical settings are scarce.

PATIENTS:
After excluding patients who died shortly (<6h) after MBP activation (n=20), a total of 304 were included in the data analysis (68% males, 87% surgical).

INTERVENTIONS:
Our MBP featured goal-directed transfusion with early use of adjuvant hemostatic medications.

VARIABLES OF INTEREST:
Primary endpoints were 24-h and 30-day mortality. Fresh frozen plasma-to-red blood cells (FFP:RBC) and platelet-to-RBC (PLT:RBC) transfusion ratios, time to first FFP unit and the proactive MBP triggering rate were secondary endpoints.

RESULTS:
After MBP implementation (Group 2; n=222), RBC use remained stable, whereas FFP and hemostatic agents increased, when compared with Group 1 (n=82). Increased FFP:RBC ratio (p=0.053) and earlier administration of FFP (p=0.001) were also observed, especially with proactive MBP triggering.

Group 2 patients presented lower rates of 24-h (0.5% vs. 7.3%; p=0.002) and 30-day mortality (15.9% vs. 30.2%; p=0.018) - the greatest reduction corresponding to non-surgical patients. Logistic regression showed an independent protective effect of MBP implementation upon 30-day mortality (OR=0.3; 95% CI 0.15-0.61).

CONCLUSIONS:
These data suggest that the implementation of a goal-directed MBP for prompt and aggressive management of non-trauma, massive bleeding patients is associated to reduced 24-h and 30-day mortality rates.

CITA DEL ARTÍCULO Med Intensiva. 2016 Jul 14. pii: S0210-5691(16)30097-3. doi: 10.1016/j.medin.2016.05.003