Loading summary
Transcript11 lines
- [00:00]
A
Foreign. Prior to the 1970s, when component therapy became the preferred method of resuscitation, it was all about whole blood. Whole blood was a resuscitative medium of choice for hemorrhagic shock. Well, sometimes in modern medicine, it turns out that doing things the old way is. Is actually better than the new way. This issue of this was our Intro back on August 2024. A year ago, guys. The exact date was August 9, 2024. Now, the title of that episode whose intro you just heard was, quote, the Return to Low Tighter O Whole Blood for OB Transfusion. End quote. Now, we're not going to go through all the specifics. You can go back and listen to that one from August 9, 2024. We'll put the link in our show. We bring that up for two main reasons. Number one, things tend to gain momentum in print. So something comes out, somebody else put something out. Because good ideas breeds good ideas, and that's good. We should do that as we build momentum for a certain genre of evidence and or theme. And that leads us to our second thing. Our commitment on the show, of course, is to highlight things that are brand new in print. And we're going to do that. There's a brand new publication out of O and G, that is Obstetrics of Gynecology. That's the open version, the free version of the Green Journal O N G that actually comes out of my alma mater. This comes out of UT Southwestern and Parkland. Exactly. Covering and proving what we talked about one year ago on August 9, 2024. Now, Texas really has been leading some of this charge here because back in 2017, an advisory committee, both together with Emergency Medical services and the trauma divisions of our major universities got together and said, you know what? We really need to do this differently. We need to return to whole blood for trauma resuscitation. And then that spilled over then to OB resuscitation for postpartum hemorrhage. Now, the original protocol was low titer, O type, RHD positive. Now, I know what you're thinking, and we covered this in that episode. I'm not going to rehash all that, but you got to go back and listen to that. We're giving people rhd. What if they're RH negative? I get that. Totally true. You can give them rhogam. Because the important thing is, what is more important? That we not sensitize them. Yeah, that's important. Or how about that they not die. Okay, I choose not dying. So that's the purpose here. Even if Somebody is RHD negative. The original protocol was give them low titer O type RHD positive blood because the vast majority of the population, guys is RHD positive. The vast majority of the population is RHD positive. Although there is some ethnic racial differences in blood type. As a whole, more people are gonna be RHD positive than negative. And should your patient be RHD negative then great. If you have the time, do a proper cross match, do type specific RHD negative blood in those. But if you don't have time for that and somebody's hemorrhaging to death, give them low titer, type O, RHD positive and then we'll worry about the rest later and. Or give them rhogam. That is a proposal that we covered one year ago and we talked about all that data of how that had spilled over into ob, postpartum hemorrhage control, the return to whole blood. Now when I trained at Southwestern, that was the thing. I mean nobody got compartment therapy in. It was whole blood because what patients bleed at time of postpartum hemorrhage isn't red blood cells, isn't just platelets, it's entire blood. So give them back what they have lost. Well, there's new data building on this that just came out a few days ago from when we were recording this. And we're at the end of October 2025 and we're going to highlight this from David Nelson and the group. Nelson, great guy, very, very hard worker, great research, author, pillar in mfm. So good for David for putting this together. We're going to cover this. I just came out a couple of days ago out of UT Southwestern, my alma mater, very proud of that and Parkland Hospital. But just goes to show guys that there's, there's momentum here that builds and this is not new. We've covered this a year ago and we advocated. Talk to your unit next time that you do policy and procedures about the possibility of returning to whole blood for postpartum hemorrhage management and especially in labor and delivery, the use of type O negative whole blood because the value seems to be there. Again, we're going to quickly, we're going to go over the small number of N in this study. Small N, it wasn't an rct, it was observational but a prospective study. So very good. Which builds on the data that we covered August 9, 2024. So this is now part two, I guess a year later of what this was covered, of what we discussed one year ago. So fascinating. I really think this is a Big deal. Definitely talk to your units about the possibility of doing whole blood for PPH resuscitation. Listen, component therapy is never gonna go away. It's never gonna go away. Some people just need platelets, in other words, like for ITP or TTP or whatever. Sometimes you just need platelets, sometimes you just need fibrinogen and you need cryo for that. But in a massive hemorrhage state where the patient is otherwise euvolemic and then goes into hypovolemic shock, whole blood is the trick. We're briefly going to touch on ACOG's practice bulletin, which is 183. ACOG's practice bulletin 183. And cover some key specifics here. To act fast, you've got to act fast and get on top of postpartum hemorrhage and do not wait for vital signs to be unstable. And I hear this a lot, especially every to August when we get new team members on board. Those are called interns. They're like, well, she bled, she bled a lot, but her vitals are fine. Don't wait for the vitals. You have to lose like 15 to 20% of blood volume before your vitals kick in. And now thankfully, and that's a good thing. Could you imagine if we lost 10 MLS and we got reflex tachycardia? I mean we would never. That'd be not functionable. So the body has a normal set mechanism to go. I'm gonna give you time, I'm gonna let you do what you do. You can bleed a little bit, you can bleed a little bit. Once you hit 15 to 20, I'm gon start kicking up the gears to get blood flow going to where it needs to go, mainly heart, kidneys, brain, heart, kidney, brain. Not necessarily in that order because we need to increase pulse so that, that, that reflex tachycardia happens around 15 to 20% so it's a relatively later finding. Do not wait for vital signs to tell you that you need blood. I think we covered this last year. Same thing with thirst. If you wait to get thirsty, you are already behind because thirst is a in the dehydration schema cascade. All right, so briefly, briefly, just mention we'll get into practice bulletin 183 just to highlight a few things there and then we'll get into this new publication out of O and G open that just came out a few days ago. I think I've set it up enough. Now let's get into the ins and outs, if you will, of whole Blood. We'll be right back. Can I take your order? Can I get a tall Chai, a large black coffee. A what? Large black coffee. Do you mean a Venti? No, I mean a large. He means a Venti. Yeah, the biggest one you got. Venti is large. No, Venti is 20. Danny. Yeah, large is large. In fact, tall is large and grande is Spanish for large. Venti's the only one that doesn't mean large. He's also the only one that's Italian. So now you can skip all of the coffee shop etiquette or pseudo etiquette and make your great tasting coffee at home. We're thankful for our partnership with the Strong Coffee company that is striving to reach our natural greatness, which is not your ordinary cup of coffee. It has adaptogens, collagen and nootropics to help you reach your maximum potential without the caffeine crash. So thank you to the strong coffee company for your partnership. 20% discount with the link only in our show notes. That is 20% off whatever you buy online so that you can make your own grande Venti large at home. Thank you for the Strong Coffee company, for your partnership. This is Dr. Chapa's OBGYN N no Spin podcast. Right before we left the intro, I said, let's get into the ins and outs of blood transfusion or blood therapy for pph. And it reminded me of an old school movie. Y' all don't know what I'm talking about. Come on now. It was based on Latino kind of, you know, gang life, but not gang life or wannabe gang life, I guess I should say out of kind of like east la. Man, you all don't know about Blood In Blood out, do you? Super melodramatic. It's actually a really good movie. A lot. Launched a lot of careers. Blood In, Blood Out.
- [10:24]
B
Blood In, Blood Out.
- [10:29]
A
Man, if you don't know what I'm talking about, go watch you some. Blood In Blood out also helped launch, like a Danny Trejo machete because, man, he was crazy in that Blood In.
- [10:43]
B
Blood Out.
- [10:44]
A
Chale. See, if you don't know what I'm talking about, you gotta go back and listen. And for all my Latino Hispanic friends, friends, especially LA or, you know, on the border of Texas, man, I grew up those. I grew up with. People talking that way is so, so, I mean, so nostalgic for me. I mean, we'd say, hey, you want to go to the mall, Chale? I mean, Charlie was like, yeah, man, right on. I mean, it was Anyway, blood in, blood out, not a sponsor. All right, now that we've said all that nonsense, let's get into what we're talking about here. Now back to the vital sign issue very quickly. Remember that in the old trauma ways of talking about blood loss, and it's a little different for postpartum hemorrhage because you got different hemodynamics and blood volume. But in general, Class 2 blood loss, which is around 15 to 30% of blood loss, that's where you start getting mild tachycardia, y'. All. That's mild tachycardia, like the low one hundreds. That's already class two blood loss. That's like 15 up to 30. Based on who you read. I've always said 15 to 20. And then class three, which is anything above 20 or 25, that's where you get more significant blood loss. That's a lot of blood loss. All to say that if you're having a patient who's bleeding and they're tachycardic and it's related to the blood loss, not something else going on, man, you're behind. You are behind. Now, I'm not saying they need massive blood transfusion, but they need some blood and volume resuscitation. If you're doing component therapy. Remember that ACOG's Practice Bulletin 183 says, in the presence of ongoing blood loss, if they're at 1.5 liters of blood loss 1500 MLS, you gotta start, you gotta give them some blood. At least give them one unit to see what they do. But they need blood component therapy. Now, blood component therapy is what is mentioned in Practice Bulletin 183. In a typical ratio that we all know of, 1 to 1 to 1. 1 to 1 to 1 was originally a trauma principle, and before that it was like 4, 3, 1, but now it's 1, 1, 1, which is, of course, one unit of packed red blood cells, one of FFP, and then one of platelets. Well, what are you trying to do in patients who have high volume bleeding that you're giving one to one therapy? Now, if you've got controlled postpartum hemorrhage and you're at like 1,500, you can probably just give them one unit of packed red blood cells and. Or one unit of whole blood. Okay? Because the whole blood already has the FFP and the platelets, See how much easier it is? My point is, if you're gonna do component therapy, the 1 to 1 to 1 isn't for otherwise mild and controlled PPH. This is for massive blood transfusion where you're trying to give back and reconstitute whole blood. Okay, so let's just say that again. If you've got 1,500 mls of blood loss, but the bleeding is now controlled, you can consider giving just one unit of whole blood or one of FFP alone without the one unit of FFP and one unit of platelets. Usually you add the component therapy after giving two or three packs of component therapy. Do you all get this? So the one to one to one is done after giving two or three individual packs of red blood cells. Because now you can get into some dilutional iatrogenic coagulopathy or avoid all that nonsense and give a unit of whole blood. Whole blood also gives volume. You already have the inherent addition of FFP and platelets. And so it's much more beneficial. And we covered that last year. Okay, so again, just to recoup, just to kind of rephrase and rehash that, massive blood transfusions as component therapy is one to one to one, that is one of packed red blood cells, one of FFP and one of platelets. To reconstitute whole blood, whole blood was divided up into components. Really in the 70s when there was a shortage of components. We're like, man, we gotta spread this thing out. We have a limited resource here that's golden. So let's just compartmentalize things out to give patients what they need. However, for postpartum hemorrhage, turns out they need everything. That brings us to our new publication. Remember, guys, we're trying to just tell you what you need to know and keep moving. But this new publication that just came out of ONG Open, which is the Green Journal's Open Access, the title is appropriately, quote, whole Blood in the Management of Postpartum Hemorrhage. End quote. Great. Lead author, of course, is David Nelson and the entire group who did a fantastic, fantastic job out of my alma mater, UT Southwestern and Parkland Hospital. We're not going to rehash it very quickly. This wasn't an rct. This was an observational study. It was prospective. And to tell you this takes a while to do. This was between January of 2019 and November of 2023. And the publication is just now. See, guys, this is why it takes a lot. You gotta have a lot of patience doing research because it just takes a while and you gotta write it up. It goes through several cycles of editing, then comes out. But this was from 2019 to 2023. For all patients who had PPH due to acne and required transfusion within the first two hours after delivery. All right, now these were vaginal deliveries, so PPH two hours after delivery. And while the protocol pretty much was preferentially to order whole blood, there were some where whole blood wasn't available or the patient had a specific, you know, antibody type where component therapy was given. And then they compared those outcomes between component therapy and those who had whole blood just to see how they did. Right. So it's very quick, very simple, but elegant. Still, as a study design, and the study numbers weren't big. We're talking about an N of 52. That's five two. Okay, it's good. It's all you need. I mean, because this already builds on the data of what we already knew. So let's just get very quickly into this quote. Those who initially received whole blood were transfused significantly fewer total blood products overall and required operative procedures less frequently. They go on to say, quote, there were no significant differences in time from blood product order to transfusion between the groups. Patients who received whole blood received less crystalloid. That makes sense because you're giving volume, extra volume with the whole blood. They received less crystalloid than those who received component therapy. So very appropriately, as we covered last year, the conclusion was, hey, this kind of works. Consider whole blood when possible for postpartum hemorrhage because patients are going to do overall well to slightly better than component therapy. This study suggests improved clinical outcomes with the use of whole blood. However, and here's a disclosure, due to limited study numbers, additional research is needed before widespread implementation. End quote. So I get that now, again, just to be fair balance, we have to give the limitation in there. But this isn't the only one. There's plenty of data, especially out of UT Health in San Antonio, who've already implemented this and show that whole blood does have an advantage. Whether you're doing low titer, type O, RHD positive, where the majority of the patients are RHD positive and they come in literally as we've had in our team, guys, they literally come up from the er cause they had a delivery at home and they're massively hemorrhaging. We don't have any labs, we're gonna give them whole blood. This is something that can be considered even if it's RHD positive, because if they're RH, you can give them RhoGam later, but they're going to be alive. Or ideally, if you have time to cross match, you can give type specific Component or type specific RHD negative whole blood. So I just found this interesting. Consider this for your journal club. Consider this up to discussion when your department has a PMP up for review. Again, component therapy is never going away, nor should it. Some patients need component therapy for other things, but for postpartum hemorrhage, they're not hemorrhaging components. They are hemorrhaging whole blood. So as blood leaves the body, blood should enter the body as a basic principle to keep patients healthy.
- [19:11]
B
Blood in, blood out.
- [19:15]
A
Chale. So if they're bleeding whole blood, give whole blood back. Podcast family, this is very quick. I just want to let you know what was up in print. And oddly, guys, isn't that odd. We covered this a year ago, and things gained momentum. So now that we've covered that, I think we've done what we're going to do. Let's do one more time, baby. One more time.
- [19:34]
B
Blood in, blood out.
- [19:39]
A
If I haven't taught you anything else this episode about the value of whole blood, at least you've learned, Chale. Okay, so tell your resin that when you're. When they're checking out to you, you got a fellow and they're telling you something and you agree with it, you're like, right on. You know what, Charlie? And they're gonna go, oh, man. All right, you got it. Podcast family, as always, we're thankful for you. Please don't unsubscribe from us. We just have a good time with it. If you can't have a good time with it, then you're listening to the wrong show. There's plenty of boring podcasts out there you can listen to. Plenty. Oh, my gosh. I can't even get through it. We have a good time here.
- [20:13]
B
Blood in, blood out.
- [20:17]
A
That's right. Essay. All right, let's bring it home. Michael. Let's stop this before I get in trouble. Podcast family, we'll see you on another episode of the no Spin podcast. Let's take it home. Foreign. This has been Dr. Chapa's OB GYN no Spin podcast. Podcast family. Thank you for your support. Thank you for listening. And as always, we'll see you on another episode of the no Spin podcast. Sam.