medigraphic.com
Colegio de Medicina Interna de México.

2023, Number 3

<< Back Next >>

Med Int Mex 2023; 39 (3)

Massive transfusion: An approach from the damage control protocol

Roldán-Tabares MD, Arboleda-Rojas M, Martínez-Sánchez LM, Hernández-Restrepo F

Language: Spanish
References: 93
Page: 523-535
PDF size: 255.65 Kb.


ABSTRACT

Massive hemorrhage is one of the main causes of death in the critically ill patient, especially in the emergency department, being the transfusion of hemocomponents a very important strategy to save the life of these patients. Massive transfusion protocols were created to ensure that these patients receive blood components efficiently. Damage control resuscitation aims to rapidly control hemorrhage and prevent or treat if applicable the lethal triad of hypothermia, acidosis and coagulopathy; for this, three strategies were established: hemodynamic resuscitation by restrictive fluid therapy, permissive hypotension and massive transfusion, metabolic resuscitation and hemostatic resuscitation protocol. The damage control protocol has demonstrated benefits and a reduction in the risk of mortality in patients with massive hemorrhage; however, it requires multidisciplinary work and adequate coordination among the services involved in the process.


REFERENCES

  1. Yang JC, Wang QS, Dang QL, Sun Y, Xu CX, Jin ZK, et al. Investigationof the status quo of massive blood transfusionin China and a synopsis of the proposed guidelines formassive blood transfusion. Medicine (Baltimore) 2017;96 (31): e7690. DOI: 10.1097/MD.0000000000007690.

  2. Bell C, Prokopchuk-Gauk O, Cload B, Stirling A, Davis PJ.Optimum accuracy of massive transfusion protocol activation:The clinician's view. Cureus 2018; 10 (12): e3688.DOI: 10.7759/cureus.3688.

  3. Malone DL, Hess JR, Fingerhut A. Massive transfusionpractices around the globe and a suggestion for a commonmassive transfusion protocol. J Trauma 2006; 60 (6 Suppl):S91-6. DOI: 10.1097/01.ta.0000199549.80731.e6.

  4. McDaniel LM, Etchill EW, Raval JS, Neal MD. State of the art:massive transfusion. Transfus Med 2014; 24 (3): 138-44.DOI: 10.1111/tme.12125.

  5. Dente CJ, Shaz BH, Nicholas JM, Harris RS, WyrzykowskiAD, Patel S, et al. Improvements in early mortality andcoagulopathy are sustained better in patients with blunttrauma after institution of a massive transfusion protocolin a civilian level I trauma center. J Trauma 2009; 66 (6):1616-24. DOI: 10.1097/TA.0b013e3181a59ad5.

  6. Meyer DE, Vincent LE, Fox EE, OʼKeeffe T, Inaba K, BulgerE, et al. Every minute counts: Time to delivery of initialmassive transfusion cooler and its impact on mortality. JTrauma Acute Care Surg 2017; 83 (1): 19-24. DOI: 10.1097/TA.0000000000001531.

  7. Foster JC, Sappenfield JW, Smith RS, Kiley SP. Initiationand termination of massive transfusion protocols: Currentstrategies and future prospects. Anesth Analg 2017; 125(6): 2045-2055. DOI: 10.1213/ANE.0000000000002436.

  8. Chin V, Cope S, Yeh CH, Thompson T, Nascimento B, PavenskiK, et al; QUEST Research Group. Massive hemorrhageprotocol survey: Marked variability and absent in one-thirdof hospitals in Ontario, Canada. Injury 2019; 50 (1): 46-53.DOI: 10.1016/j.injury.2018.11.026.

  9. Camazine MN, Hemmila MR, Leonard JC, Jacobs RA, HorstJA, Kozar RA, et al. Massive transfusion policies at traumacenters participating in the American College of SurgeonsTrauma Quality Improvement Program. J Trauma AcuteCare Surg 2015; 78 (6 Suppl 1): S48-53. DOI: 10.1097/TA.0000000000000641.

  10. Horst J, Leonard JC, Vogel A, Jacobs R, Spinella PC. A surveyof US and Canadian hospitals’ paediatric massive transfusionprotocol policies. Transfus Med 2016; 26 (1): 49-56.DOI: 10.1111/tme.12277.

  11. Treml AB, Gorlin JB, Dutton RP, Scavone BM. Massive transfusionprotocols: A survey of academic medical centers inthe United States. Anesth Analg 2017; 124 (1): 277-281.DOI: 10.1213/ANE.0000000000001610.

  12. Boutefnouchet T, Gregg R, Tidman J, Isaac J, Doughty H.Emergency red cells first: Rapid response or speed bump?The evolution of a massive transfusion protocol for traumain a single UK centre. Injury 2015; 46 (9): 1772-8. DOI:10.1016/j.injury.2015.05.046.

  13. Sauaia A, Moore FA, Moore EE, Moser KS, Brennan R, ReadRA, et al. Epidemiology of trauma deaths: a reassessment.J Trauma 1995; 38 (2): 185-93. DOI: 10.1097/00005373-199502000-00006.

  14. Riskin DJ, Tsai TC, Riskin L, Hernandez-Boussard T, PurtillM, Maggio PM, et al. Massive transfusion protocols: therole of aggressive resuscitation versus product ratio inmortality reduction. J Am Coll Surg 2009; 209 (2): 198-205.DOI: 10.1016/j.jamcollsurg.2009.04.016.

  15. Callum JL, Yeh CH, Petrosoniak A, McVey MJ, Cope S,Thompson T, et al. A regional massive hemorrhage protocoldeveloped through a modified Delphi technique.CMAJ Open 2019; 7 (3): E546-E561. DOI: 10.9778/cmajo.20190042.

  16. Young P, Cotton B, Goodnough L. Massive transfusion protocolsfor patients with substantial hemorrhage. Transfus MedRev 2011; 25: 293-303. doi: 10.1016/j.tmrv.2011.04.002.

  17. Spinella PC. Zero preventable deaths after traumatic injury:an achievable goal. J Trauma Acute Care Surg 2017; 82:S2-8. doi: 10.1097/TA.0000000000001425.

  18. Tien HC, Spencer F, Tremblay LN, Rizoli S, et al. Preventabledeaths from hemorrhage at a level I Canadiantrauma center. J Trauma 2007; 62: 142-6. doi: 10.1097/01.ta.0000251558.38388.47.

  19. Hoyt DB, Dutton RP, Hauser CJ, Hess JR, Holcomb JB, KlugerY, et al. Management of coagulopathy in the patients withmultiple injuries: results from an international survey ofclinical practice. J Trauma 2008; 65 (4): 755-64; discussion764-5. DOI: 10.1097/TA.0b013e318185fa9f.

  20. Davenport R, Khan S. Management of major traumahaemorrhage: treatment priorities and controversies. BrJ Haematol 2011; 155 (5): 537-48. DOI: 10.1111/j.1365-

  21. 2141.2011.08885.x.21. CRASH-2 trial collaborators, Shakur H, Roberts I, BautistaR, Caballero J, Coats T, Dewan Y, et al. Effects of tranexamicacid on death, vascular occlusive events, and bloodtransfusion in trauma patients with significant haemorrhage(CRASH-2): a randomised, placebo-controlled trial.Lancet 2010; 376 (9734): 23-32. DOI: 10.1016/S0140-6736(10)60835-5.

  22. Brohi K, Singh J, Heron M, Coats T. Acute traumatic coagulopathy.J Trauma 2003; 54 (6): 1127-30. DOI: 10.1097/01.TA.0000069184.82147.06.

  23. Maegele M, Lefering R, Yucel N, Tjardes T, Rixen D, PaffrathT, et al; AG Polytrauma of the German Trauma Society(DGU). Early coagulopathy in multiple injury: an analysisfrom the German Trauma Registry on 8724 patients. Injury2007; 38 (3): 298-304. DOI: 10.1016/j.injury.2006.10.003.

  24. Campos A, Muñoz M, García-Erce J, Ramírez G. Incidenciay mortalidad de la transfusión masiva en un hospital universitario:estudio del período 2001-2005. Medicina Clinica2007; 129 (10): 366-371.

  25. Suarez N, Nanwani K, Saravia A, Quintana M. Estudiopiloto sobre escalas predictivas de transfusión masiva:¿iguales en el paciente traumático que en el médico?. ActaColomb Cuid Intensivo 2020; 20 (1): 1-10. DOI: https://doi.org.10.1016/j.acci.2019.12.006.

  26. Gil-García E. Indicaciones de transfusión de hemocomponentes.Rev Hematol Mex 2018; 19 (2): 83-90.

  27. Quiltenet Mc, Crighton G, Brunskill S, Morison JK, RichterTH, Waters N, et al. Optimal dose,timing and ratio ofblood products in massive transfusion: results from asystematic review. Transfus Med Rev 2018; 32 (1): 6-15.DOI: 10.1016/j.tmrv.2017.06.003.

  28. Llaua J, Acosta F, Escolar G , Fernández-Mondéjar E,Guasche E, Marco P, et al. Documento multidisciplinarde consenso sobre el manejo de la hemorragia masiva(documento HEMOMAS). Med Intensiva 2015; 39 (8): 483-504. DOI: http://dx.doi.org/10.1016/j.medin.2015.05.002.

  29. Abuzeid A, O'Keeffe T. Review of massive transfusionprotocols in the injured, bleeding patient. CurrOpin Crit Care 2019; 25 (6): 661-67. DOI: 10.1097/MCC.0000000000000668.

  30. Cotton A, Dossett L, Au B, Nunez T, Robertson A, Young P.Room for (performance) improvement: Provider-relatedfactors associated with poor outcomes in massive transfusion.J Trauma 2009; 67 (5): 1001-1012. DOI: 10.1097 /TA.0b013e3181bcb2a8

  31. O’Keeffe T, Refaai M, Tchorz K, Forestner JE, Sarode R. Amassive transfusion protocol to decrease blood componentuse and costs. Arch Surg 2008; 143 (7): 686-691. DOI:10.1001 / archsurg.143.7.686.

  32. De Jong A, Deras P, Martinez O, Latry P, Jaber S, CapdevilaX, et al. Relationship between obesity and massive transfusionneeds in trauma patients, and validation of TASHscore in obese population: A retrospective study on 910trauma patients. PLoS One 2016; 11 (3): e0152109. DOI:10.1371/journal.pone.0152109.

  33. Guerrero M, Jankelevich A. Actualización en transfusiónde productos sanguíneos en el perioperatorio. Rev MedClin Condes 2017; 28 (5): 770-75.

  34. Flint A, McQuilten Z, Wood E. Massive transfusions forcritical bleeding: is everything old new again? Transfus Med2018; 28 (2): 140-49. DOI: 10.1111/tme.12524.

  35. Contreras M, Carmona A, Montelongo F. Índice de choquecomo marcador inicial de choque hipovolémico en hemorragiaobstétrica de primer trimestre. Col Mex Med Crit2019; 33 (2): 73-8.

  36. El-Menyar A, Goyal P, Tilley E, Latifi R. The clinical utilityof shock index to predict the need for blood transfusionand outcomes in trauma. J Surg Res 2018; 227: 52-9. DOI:10.1016/j.jss.2018.02.013.

  37. Curry N, Hopewell S, Dorée C, Hyde C, Brohi K, StanworthS. The acute management of trauma hemorrhage: a systematicreview of randomized controlled trials. Critical Care2011; 15: R92. DOI:10.1186/cc10096.

  38. Farrell MS, Cho Kim W, Stein MD. Emergency Transfusions.Emerg Med Clin N Am 2020; 38 (4): 795-805. DOI: https://doi.org/10.1016/j.emc.2020.06.005.

  39. Wise R., Faurie M., Malbrain M, Hodgson. Strategies for intravenousfluid resuscitation in trauma patients. World J Surg2017; 41: 1170-1183. DOI: 10.1007/s00268-016-3865-7.

  40. Bickell W, Wall M, Pepe P, Allen M, Ginger V, Mattox K, et. al.Immediate versus delayed fluid resuscitation for hypotensivepatients with penetrating torso injuries. N Engl J Med 1994;331: 1105-09. DOI:10.1056/NEJM199410273311701.

  41. Kornblith L, Moore H, Cohen M. Trauma-induced coagulopathy:The past, present, and future. J Thromb Haemost2019; 17: 852-862. DOI: https://doi.org/10.1111/jth.14450.

  42. Campos-Serra A, Montmany-Vioque S, Rebasa-Cladera P,Llaquet-Bayo H, Gràcia-Roman R, Colom-Gordillo A, et al.The use of the Shock Index as a predictor of active bleedingin trauma patients. Cir Esp (Engl Ed) 2018; 96 (8): 494-500.DOI: 10.1016/j.ciresp.2018.04.004.

  43. Cantle P, Cotton B. Balanced resuscitation in trauma management.Surg Clin N Am 2017; 97 (5): 999-1014. DOI:http://dx.doi.org/10.1016/j.suc.2017.06.002.

  44. Chang R, Kerby J, Kalkwarf K, Van B, Erin E, Cohen M, et.al. Earlier time to hemostasis is associated with decreasedmortality and rate of complications: Results from the PragmaticRandomized Optimal Platelet and Plasma Ratio trial. JTrauma Acute Care Surg 2019; 87 (2): 342-49. DOI:10.1097/TA.0000000000002263.

  45. Llau J. Medicina transfusional perioperatoria (editorial).Rev Esp Anestesiol Reanim 2001; 48: 103-5.

  46. Llau J, Duca A, Ferrandis R, Rosas M. Criterios actuales enla medicina transfusional perioperatoria. Salud(i)Ciencia2016; 22: 140-46.

  47. Hébert PC, Tinmouth A, Corwin HL. Controversies in RBCtransfusion in the critically ill. Chest 2007; 131 (5): 1583-90.DOI: 10.1378/chest.06-1055.

  48. American Society of Anesthesiologists Task Force onPerioperative Blood Management. Practice guidelines forperioperative blood management: an updated report bythe American Society of Anesthesiologists Task Force onPerioperative Blood Management*. Anesthesiology 2015;122 (2): 241-75. DOI: 10.1097/ALN.0000000000000463.

  49. Llau J, Acosta F, Escolar G, Fernández-Mondéjar E, GuaschE, Marco P, et al. Documento multidisciplinar de consensosobre el manejo de la hemorragia masiva (documentoHEMOMAS). Med Intensiva 2015; 39 (8): 483-504.DOI:http://dx.doi.org/10.1016/j.medin.2015.05.002.

  50. Say L, Chou D, Gemmill A, Tuncalp O, Moller A, DanielsJ, et al. Global causes of maternal death: a WHO systematicanalysis. Lancet Glob Health 2014; 2 (6): 323-33.DOI:10.1016/s2214-109x(14)70227-x.

  51. Kwee A, Bots ML, Visser GH, Bruinse HW. Emergencyperipartum hysterectomy: A prospective study in TheNetherlands. Eur J Obstet Gynecol Reprod Biol 2006; 124(2): 187-92. DOI:10.1016/j.ejogrb.2005.06.012.

  52. Cannon JW. Hemorrhagic shock. N Engl J Med 2018; 378(4): 370-9. DOI:10.1056/NEJMra1705649.

  53. Shields L, Wiesner S, Fulton J, Pelletreau B. Comprehensivematernal hemorrhage protocols reduce the use of bloodproducts and improve patient safety. Am J Obstet Gynecol2015; 212 (3): 272-80. DOI10.1016/j.ajog.2014.07.012.

  54. Guasch E, Gilsanz F. Hemorragia masiva obstétrica: enfoqueterapéutico actual. Med Intensiva 2016; 40 (5): 298-310.DOI: http://dx.doi.org/10.1016/j.medin.2016.02.010.

  55. Pham HP, Shaz BH. Update on massive transfusion. Br JAnaesth 2013; 111 Suppl 1: i71-82. DOI: 10.1093/bja/aet376.

  56. Dumbar NM, Seheult JN, Yazer M. Massive transfusion. En:Shaz BH, Hillyer CD, Reyes Gil M editors. Transfusion medicineand hemostasis. New York: Elsevier; 2019: 365-369.

  57. Mizobata Y. Damage control resuscitation: a practical approachfor severely hemorrhagic patients and its effectson trauma surgery. J Intensive Care 2017; 5 (4): 1-9. DOI:https://doi.org/10.1186/s40560-016-0197-5.

  58. Giannoudi M, Harwood P. Damage control resuscitation:lessons learned. Eur J Trauma Emerg Surg 2016; 42 (3):273-282. DOI:10.1007/s00068-015-0628-3.

  59. Mora JA. Resucitación en control de daños: Un nuevoconcepto. Cirujano general 2010; 32 (1): S46-S48.

  60. González MA, Biarnés A, Naya JM, Salvadores C I, ColominaSoler MJ. Damage Control Resuscitation en el pacientetraumático. Rev Esp Anestesiol Reanim 2019; 66 (7): 394-404. DOI: 10.1016/j.redar.2019.03.009.

  61. Kasotakis G, Sideris A, Yang Y. Aggressive early crystalloidresuscitation adversely affects outcomes in adult blunttrauma patients: An analysis of the Glue Grant database.J Trauma Acute Care Surg 2013; 74 (5): 1215-1221.

  62. Cotton BA, Guy JS, Morris JA. The cellular, metabolic, andsystemic consequences of aggressive fluid resuscitationstrategies. Shock 2006; 26 (2): 115-121. doi: 10.1097/01.shk.0000209564.84822.f2.

  63. Kaafarani HM, Velmahos GC. Damage control resuscitationin trauma. Scandinavian J Surg 2014; 103 (2):81-88. DOI:https://doi.org/10.1177/1457496914524388.

  64. Cap AP, Pidcoke HF, Spinella P, Strandenes G, Borgman MA,Schreiber M, et al. Damage Control Resuscitation. Mil Med2018; 183 (suppl 2): 36-43. DOI: 10.1093/milmed/.

  65. Holcomb JB, Tilley BC, Baraniuk S, Fox EE, Wade CE, PodbielskiJM, et al. Transfusion of plasma, platelets, andred blood cells in a 1:1:1 vs a 1:1:2 ratio and mortalityin patients with severe trauma: the PROPPR randomizedclinical trial. JAMA 2015; 313 (5): 471-82. DOI: 10.1001/jama.2015.12.

  66. Cap AP, Beckett A, Benov A, Borgman M, Chen J, CorleyJB, et al. Whole blood transfusion. Mil Med 2018; 183(suppl_2): 44-51. DOI: 10.1093/milmed/usy12.

  67. Spinella PC, Pidcoke HF, Strandenes G, Hervig T, Fisher A,Jenkins D, et al. Whole blood for hemostatic resuscitation ofmajor bleeding. Transfusion 2016; 56 (Suppl 2): S190-202.DOI: 10.1111/trf.13491.

  68. Ordoñez CA, Parra MW, Serna JJ, Rodriguez F, Garcia A,Salcedo A, et al. Resucitación en control de daños: REBOA,el cuarto pilar. Colombia Medica 2020; 51 (4): e-4014353.DOI: https://doi.org/10.25100/cm.v51i4.4353.

  69. Borgman MA, Spinella PC, Perkins JG, Grathwohl KW,Repine T, Beekley AC, et al. The ratio of blood productstransfused affects mortality in patients receiving massivetransfusions at a combat support hospital. J Trauma 2007;63: 805-13. DOI: 10.1097/TA.0b013e3181271ba3.

  70. Yazer MH, Cap AP, Spinella PC. Raising the standards onwhole blood. J Trauma Acute Care Surg 2018; 84 (6S Suppl1): S14-S7. DOI: 10.1097/TA.0000000000001778.

  71. Himmler A, Galarza M, Reinoso J, Peña S, Sarmiento D,Flores N, et al. Is the whole greater than the sum of itsparts? The implementation and outcomes of a wholeblood program in Ecuador. Res Sq 2020. DOI: 10.21203/rs.3.rs-66244/v1.

  72. Leibner E, Andreae M, Galvagno SM, Scalea T. Damagecontrol resuscitation. Clin Exp Emerg Med 2020; 7 (1): 5-13.DOI: 10.15441/ceem.19.089.

  73. Spahn DR, Bouillon B, Cerny V, Duranteau J, Filipescu D,Hunt BJ, et al. The European guideline on management ofmajor bleeding and coagulopathy following trauma: CritCare 2019; 23: 98.

  74. Leal S, Jiménez M. La transfusión de hematíes incrementala oxigenación tisular y mejora el resultado clínico. MedicinaIntensiva 2010; 34 (7): 471-475. DOI: https://doi.org/10.1016/j.medin.2010.06.001.

  75. Bolliger D, Görlinger K, Tanaka K, Warner D. Pathophysiologyand treatment of coagulopathy in massive hemorrhageand hemodilution. Anesthesiology 2010; 113: 1205-1219.DOI: https://doi.org/10.1097/ALN.0b013e3181f22b5a.

  76. Fernández E, Murillo F, Puppo A, Leal SR. Alternativas terapéuticasde la hemorragia masiva. Med Intensiva 2012; 36(7): 496-503. DOI:10.1016/j.medin.2011.11.010,

  77. Fraga G, Bansal V, Coimbra R. Transfusion of blood productsin trauma: An update. J Emerg Med 2010; 39 (2): 253-260DOI: https://doi.org/10.1016/j.jemermed.2009.02.034.

  78. Gil-Betacur A, Mantilla-Gutierrez C, Cardona-Arias J.Efecto de la plaquetoféresis sobre el recuento de leucocitos:metaanálisis 1980-2018. Rev Esp Salud Publica2019; 93: 1-12.

  79. Rajasekhar A, Gowing R, Zarychanski R, Arnold,Donald M, Lim W, et al. Survival of trauma patientsafter massive red blood cell transfusion using a highor low red blood cell to plasma transfusion ratio. CritCare Med 2011; 39 (6): 1507-1513. DOI: 10.1097/CCM.0b013e31820eb517.

  80. Jennings LK, Watson S. Massive transfusion. 2021. In:StatPearls Treasure Island (FL): StatPearls.

  81. Kramer L, Bauer E, Joukhadar C, Strobl W, Gendo A,Madl C, et al. Citrate pharmacokinetics and metabolismin cirrhotic and noncirrhotic critically ill patients. CritCare Med 2003; 31 (10): 2450-2455. DOI: 10.1097/01.CCM.0000084871.76568.E6.

  82. Pohlman TH, Fecher AM, Arreola-Garcia C. Optimizingtransfusion strategies in damage control resuscitation: currentinsights. J Blood Med 2018; 9: 117-133. DOI: https://doi.org/10.2147/JBM.S165394.

  83. Pohlman TH, Walsh M, Aversa J, Hutchison EM, Olsen KP,Lawrence Reed R. Damage control resuscitation. Blood Rev2015; 29 (4): 251-262. doi: 10.1016/j.blre.2014.12.006.

  84. Toy P, Gajic O, Bacchetti P, Looney M, Gropper M, HubmayrR, Lowell C, Norris P, et al. Transfusion-relatedacute lung injury: incidence and risk factors. Blood2012; 119 (7): 1757-1767. DOI: https://doi.org/10.1182/blood-2011-08-370932.

  85. Lim F, Chen LL, Borski D. Controlar la hipocalcemia en latransfusión masiva de hemoderivados. Nursing 2018; 35(1): 22-9. Doi: 10.1016/j.nursi.2018.02.009.

  86. Kraft. Phosphorus and calcium: a review for the adultnutrition support clinician. Nutr Clin Pract 2015; 30 (1): 21-33. Doi: http://dx.doi.org/10.1177/0884533614565251.

  87. Rojas-Chávez C. TRALI. Lesión pulmonar aguda relacionadacon transfusión sanguínea. Rev Mex Anestesiol 2016; 39(1): 48-52.

  88. Añón JM, García de Lorenzo A, Quintana M, González E,Bruscas MJ. Lesión pulmonar aguda producida por transfusión.Med Intensiva 2010; 34 (2): 139-149.

  89. Rafaelano-Miranda A, Morales-Flores I, Tolentino-Sosa M,Barbabosa-Vilchis J. Lesión pulmonar aguda relacionadacon la transfusión (TRALI) durante el embarazo. Reportede un caso y revisión bibliográfica. Ginecol Obstet Méx2019; 87 (11): 747-55. Doi: https://doi.org/10.24245/gom.v87i11.3287.

  90. Seghatchian J, Samama MM. Massive transfusion: Anoverview of the main characteristics and potential risksassociated with substances used for correction of a coagulopathy.A Transfus Apher Sci 2012; 47 (2): 235-43.

  91. Maldonado-Rojas M, Piña-Farías L, Vásquez-Rojas M,Toro-Opazo C. Complicaciones asociadas a la transfusiónmasiva. Revista Cubana de Hematología, Inmunología yHemoterapia 2013; 29 (3): 1-15.

  92. Murphy EL, Kwaan N, Looney MR, Gajic O, Hubmayr RD,Gropper MA, et al. Risk factors and outcomes in transfusionassociated circulatory overload. Am J Med 2013; 126: e29-e38. doi: 10.1016/j.amjmed.2012.08.019.

  93. Aubron C, Aries P, Le Niger C, Sparrow RL, Ozier Y. ¿Cómopueden los médicos minimizar los eventos adversos relacionadoscon las transfusiones? Transfus Clin Biol 2018;25 (4): 257-261.




2020     |     www.medigraphic.com