{"id":472,"date":"2022-10-20T19:48:17","date_gmt":"2022-10-20T16:48:17","guid":{"rendered":"https:\/\/tatd.org.tr\/travma\/?p=472"},"modified":"2022-10-20T19:48:17","modified_gmt":"2022-10-20T16:48:17","slug":"travma-hastasinda-masif-transfuzyon","status":"publish","type":"post","link":"https:\/\/tatd.org.tr\/travma\/slider\/travma-hastasinda-masif-transfuzyon\/","title":{"rendered":"Travma Hastas\u0131nda Masif Transf\u00fczyon"},"content":{"rendered":"<p>Merhaba. Travma y\u00f6netiminin temel konular\u0131ndan olan masif transf\u00fczyondan bahsedece\u011fiz.<\/p>\n<p>Masif transf\u00fczyondan bahsedece\u011fiz ancak, \u00f6ncelikle, herhangi bir transf\u00fczyon i\u00e7in hastan\u0131n kanama durumunu anlamal\u0131y\u0131z.<\/p>\n<h4>Hastan\u0131n kanama miktar\u0131n\u0131 anlamak<\/h4>\n<p>Burada (Tablo 1), ATLS bir \u00f6nceki bask\u0131s\u0131 olan 9. Bask\u0131daki klasik kanama s\u0131n\u0131fland\u0131rma tablosunu g\u00f6r\u00fcyoruz. ATLS, hipovolemik \u015fokun erkenden tan\u0131nmas\u0131 ve y\u00f6netimi i\u00e7in tahmini kan kayb\u0131 y\u00fczdesine e\u015flik eden vital bulgular\u0131n 4 s\u0131n\u0131fa ayr\u0131ld\u0131\u011f\u0131 bir hipovolemik \u015fok s\u0131n\u0131fland\u0131rmas\u0131n\u0131 \u00f6neriyor.<\/p>\n<div class=\"pcrstb-wrap\"><table style=\"height: 656px;width: 799px\" width=\"799\" cellspacing=\"0\" cellpadding=\"0\">\n<caption><span class=\"s1\"><b>Tablo 1. ATLS 9. Bask\u0131 Hemorajik \u015eok S\u0131n\u0131flamas\u0131<\/b><\/span><\/caption>\n<tbody>\n<tr style=\"height: 68px\">\n<td style=\"width: 767px;height: 68px\" colspan=\"5\" valign=\"top\">\n<p align=\"center\"><span class=\"s1\"><b>ATLS 9. Bask\u0131 Hemorajik \u015eok S\u0131n\u0131flamas\u0131<\/b><\/span><\/p>\n<\/td>\n<\/tr>\n<tr style=\"height: 36px\">\n<td style=\"width: 210px;height: 36px\" valign=\"top\"><span style=\"color: #000000;font-family: Calibri;font-size: x-large\"><b>Parametre<\/b><\/span><\/td>\n<td style=\"width: 123px;height: 36px\" valign=\"top\"><span style=\"color: #000000;font-family: Calibri;font-size: x-large\"><b>Evre 1<span class=\"Apple-converted-space\">\u00a0<\/span><\/b><\/span><\/td>\n<td style=\"width: 103px;height: 36px\" valign=\"top\"><span style=\"color: #000000;font-family: Calibri;font-size: x-large\"><b>Evre 2<span class=\"Apple-converted-space\">\u00a0<\/span><\/b><\/span><\/td>\n<td style=\"width: 169px;height: 36px\" valign=\"top\"><span style=\"color: #000000;font-family: Calibri;font-size: x-large\"><b>Evre 3<span class=\"Apple-converted-space\">\u00a0<\/span><\/b><\/span><\/td>\n<td style=\"width: 162px;height: 36px\" valign=\"top\"><span style=\"color: #000000;font-family: Calibri;font-size: x-large\"><b>Evre 4<\/b><\/span><\/td>\n<\/tr>\n<tr style=\"height: 72px\">\n<td style=\"width: 210px;height: 39px\" valign=\"top\"><span style=\"color: #000000;font-family: Calibri;font-size: x-large\">Kan kayb\u0131 (ml)<\/span><\/td>\n<td style=\"width: 123px;height: 39px\" valign=\"top\"><span style=\"color: #000000;font-family: Calibri;font-size: x-large\">&lt; 750 ml<\/span><\/td>\n<td style=\"width: 103px;height: 39px\" valign=\"top\"><span style=\"color: #000000;font-family: Calibri;font-size: x-large\">750-1500<\/span><\/td>\n<td style=\"width: 169px;height: 39px\" valign=\"top\"><span style=\"color: #000000;font-family: Calibri;font-size: x-large\">1500-2000<\/span><\/td>\n<td style=\"width: 162px;height: 39px\" valign=\"top\"><span style=\"color: #000000;font-family: Calibri;font-size: x-large\">&gt;2000<\/span><\/td>\n<\/tr>\n<tr style=\"height: 36px\">\n<td style=\"width: 210px;height: 36px\" valign=\"top\"><span style=\"color: #000000;font-family: Calibri;font-size: x-large\">Kan kayb\u0131 (%)<\/span><\/td>\n<td style=\"width: 123px;height: 36px\" valign=\"top\"><span style=\"color: #000000;font-family: Calibri;font-size: x-large\">%15\u2019e kadar<\/span><\/td>\n<td style=\"width: 103px;height: 36px\" valign=\"top\"><span style=\"color: #000000;font-family: Calibri;font-size: x-large\">%15-30<\/span><\/td>\n<td style=\"width: 169px;height: 36px\" valign=\"top\"><span style=\"color: #000000;font-family: Calibri;font-size: x-large\">%30-40<\/span><\/td>\n<td style=\"width: 162px;height: 36px\" valign=\"top\"><span style=\"color: #000000;font-family: Calibri;font-size: x-large\">&gt;%40<\/span><\/td>\n<\/tr>\n<tr style=\"height: 36px\">\n<td style=\"width: 210px;height: 36px\" valign=\"top\"><span style=\"color: #000000;font-family: Calibri;font-size: x-large\">Nab\u0131z (vuru\/dk)<\/span><\/td>\n<td style=\"width: 123px;height: 36px\" valign=\"top\"><span style=\"color: #000000;font-family: Calibri;font-size: x-large\">&lt;100<\/span><\/td>\n<td style=\"width: 103px;height: 36px\" valign=\"top\"><span style=\"color: #000000;font-family: Calibri;font-size: x-large\">100-120<\/span><\/td>\n<td style=\"width: 169px;height: 36px\" valign=\"top\"><span style=\"color: #000000;font-family: Calibri;font-size: x-large\">120-140<\/span><\/td>\n<td style=\"width: 162px;height: 36px\" valign=\"top\"><span style=\"color: #000000;font-family: Calibri;font-size: x-large\">&gt;140<\/span><\/td>\n<\/tr>\n<tr style=\"height: 72px\">\n<td style=\"width: 210px;height: 39px\" valign=\"top\"><span style=\"color: #000000;font-family: Calibri;font-size: x-large\">Sistolik kan bas\u0131nc\u0131<\/span><\/td>\n<td style=\"width: 123px;height: 39px\" valign=\"top\"><span style=\"color: #000000;font-family: Calibri;font-size: x-large\">Normal<\/span><\/td>\n<td style=\"width: 103px;height: 39px\" valign=\"top\"><span style=\"color: #000000;font-family: Calibri;font-size: x-large\">Normal<\/span><\/td>\n<td style=\"width: 169px;height: 39px\" valign=\"top\"><span style=\"color: #000000;font-family: Calibri;font-size: x-large\">Azalm\u0131\u015f<\/span><\/td>\n<td style=\"width: 162px;height: 39px\" valign=\"top\"><span style=\"color: #000000;font-family: Calibri;font-size: x-large\">Azalm\u0131\u015f<\/span><\/td>\n<\/tr>\n<tr style=\"height: 72px\">\n<td style=\"width: 210px;height: 72px\" valign=\"top\"><span style=\"color: #000000;font-family: Calibri;font-size: x-large\">Nab\u0131z bas\u0131nc\u0131 (mmHg)<\/span><\/td>\n<td style=\"width: 123px;height: 72px\" valign=\"top\"><span style=\"color: #000000;font-family: Calibri;font-size: x-large\">Normal veya artm\u0131\u015f<\/span><\/td>\n<td style=\"width: 103px;height: 72px\" valign=\"top\"><span style=\"color: #000000;font-family: Calibri;font-size: x-large\">Azalm\u0131\u015f<\/span><\/td>\n<td style=\"width: 169px;height: 72px\" valign=\"top\"><span style=\"color: #000000;font-family: Calibri;font-size: x-large\">Azalm\u0131\u015f<\/span><\/td>\n<td style=\"width: 162px;height: 72px\" valign=\"top\"><span style=\"color: #000000;font-family: Calibri;font-size: x-large\">Azalm\u0131\u015f<\/span><\/td>\n<\/tr>\n<tr style=\"height: 72px\">\n<td style=\"width: 210px;height: 52px\" valign=\"top\"><span style=\"color: #000000;font-family: Calibri;font-size: x-large\">Solunum say\u0131s\u0131 (\/dk)<\/span><\/td>\n<td style=\"width: 123px;height: 52px\" valign=\"top\"><span style=\"color: #000000;font-family: Calibri;font-size: x-large\">14-20<\/span><\/td>\n<td style=\"width: 103px;height: 52px\" valign=\"top\"><span style=\"color: #000000;font-family: Calibri;font-size: x-large\">20-30<\/span><\/td>\n<td style=\"width: 169px;height: 52px\" valign=\"top\"><span style=\"color: #000000;font-family: Calibri;font-size: x-large\">30-40<\/span><\/td>\n<td style=\"width: 162px;height: 52px\" valign=\"top\"><span style=\"color: #000000;font-family: Calibri;font-size: x-large\">&gt;35<\/span><\/td>\n<\/tr>\n<tr style=\"height: 72px\">\n<td style=\"width: 210px;height: 72px\" valign=\"top\"><span style=\"color: #000000;font-family: Calibri;font-size: x-large\">\u0130drar \u00e7\u0131k\u0131\u015f\u0131 (ml\/s)<\/span><\/td>\n<td style=\"width: 123px;height: 72px\" valign=\"top\"><span style=\"color: #000000;font-family: Calibri;font-size: x-large\">&gt;30<\/span><\/td>\n<td style=\"width: 103px;height: 72px\" valign=\"top\"><span style=\"color: #000000;font-family: Calibri;font-size: x-large\">20-30<\/span><\/td>\n<td style=\"width: 169px;height: 72px\" valign=\"top\"><span style=\"color: #000000;font-family: Calibri;font-size: x-large\">5-15<\/span><\/td>\n<td style=\"width: 162px;height: 72px\" valign=\"top\"><span style=\"color: #000000;font-family: Calibri;font-size: x-large\">\u00d6nemsiz miktar<\/span><\/td>\n<\/tr>\n<tr style=\"height: 72px\">\n<td style=\"width: 210px;height: 51px\" valign=\"top\"><span style=\"color: #000000;font-family: Calibri;font-size: x-large\">SSS\/bilin\u00e7 durumu<\/span><\/td>\n<td style=\"width: 123px;height: 51px\" valign=\"top\"><span style=\"color: #000000;font-family: Calibri;font-size: x-large\">Hafif anksiy\u00f6z<\/span><\/td>\n<td style=\"width: 103px;height: 51px\" valign=\"top\"><span style=\"color: #000000;font-family: Calibri;font-size: x-large\">Orta derece anksiy\u00f6z<\/span><\/td>\n<td style=\"width: 169px;height: 51px\" valign=\"top\"><span style=\"color: #000000;font-family: Calibri;font-size: x-large\">Anksiy\u00f6z, konf\u00fc<\/span><\/td>\n<td style=\"width: 162px;height: 51px\" valign=\"top\"><span style=\"color: #000000;font-family: Calibri;font-size: x-large\">Konf\u00fc, letarjik<\/span><\/td>\n<\/tr>\n<tr style=\"height: 72px\">\n<td style=\"width: 210px;height: 46px\" valign=\"top\"><span style=\"color: #000000;font-family: Calibri;font-size: x-large\">Ba\u015flang\u0131\u00e7 s\u0131v\u0131s\u0131<\/span><\/td>\n<td style=\"width: 123px;height: 46px\" valign=\"top\"><span style=\"color: #000000;font-family: Calibri;font-size: x-large\">Kristalloid<\/span><\/td>\n<td style=\"width: 103px;height: 46px\" valign=\"top\"><span style=\"color: #000000;font-family: Calibri;font-size: x-large\">Kristalloid<\/span><\/td>\n<td style=\"width: 169px;height: 46px\" valign=\"top\"><span style=\"color: #000000;font-family: Calibri;font-size: x-large\">Kristalloid ve kan<\/span><\/td>\n<td style=\"width: 162px;height: 46px\" valign=\"top\"><span style=\"color: #000000;font-family: Calibri;font-size: x-large\">Kristalloid ve kan<\/span><\/td>\n<\/tr>\n<\/tbody>\n<\/table><\/div>\n<p>Bu evrelemede, ATLS\u2019nin tahmini kan kayb\u0131na g\u00f6re olu\u015fturdu\u011fu \u015fok s\u0131n\u0131flar\u0131na g\u00f6re tedavi \u00f6nerileri var. Bu t\u00fcm d\u00fcnyada kabul g\u00f6rm\u00fc\u015f bir s\u0131n\u0131fland\u0131rma ve kanama y\u00fczdesi i\u00e7in kabaca bir tahmin olu\u015fturmay\u0131 sa\u011fl\u0131yor ancak bu s\u0131n\u0131fland\u0131rman\u0131n validasyonu da k\u0131s\u0131tl\u0131.<\/p>\n<p>ATLS\u2019nin hipovolemik \u015fok s\u0131n\u0131flamas\u0131n\u0131 validate etmek i\u00e7in bir\u00e7ok \u00e7al\u0131\u015fma y\u00fcr\u00fct\u00fcl\u00fcyor.<\/p>\n<h5>Mutschler et al. 2013<sup>1<\/sup><\/h5>\n<ul>\n<li>Mutscher ve ark., ATLS hipovolemik \u015fok s\u0131n\u0131fland\u0131rmas\u0131ndaki parametreleri, Almanya Travma Register DGU veri taban\u0131ndan hastalar\u0131n datasetleri \u00fczerine uygulanarak uygunlu\u011funa e\u015fle\u015fmesine bak\u0131l\u0131yor.<\/li>\n<li>2002-2010 y\u0131llar\u0131 aras\u0131nda TraumaRegister DGU\u2019 ya kay\u0131tl\u0131 36.504 hasta \u00f6ncelikle nab\u0131z,GKS ve SKB\u2019lerine g\u00f6re ATLS s\u0131n\u0131fland\u0131rmas\u0131na uygun olarak e\u015fle\u015ftiriliyor.<\/li>\n<li>Hastalar\u0131n sadece %9.3\u2019\u00fc bu \u015fekilde e\u015fle\u015ftirilebiliyor. Bu grubun da \u00e7o\u011funlu\u011fu evre 1 hasta grubu. Geri kalan 33.093 hasta(%90.7), nab\u0131z, GKS ve SKB\u2019lerine g\u00f6re ATLS s\u0131n\u0131fland\u0131rmalar\u0131 ile uyu\u015fmuyor.<\/li>\n<li>Ikincil olarak, hastalar\u0131n SKB, GKS, nab\u0131z parametreleri tek tek ele al\u0131narak di\u011fer parametrelerinin ATLS s\u0131n\u0131fland\u0131rmas\u0131ndaki parametrelerle e\u015fle\u015fip e\u015fle\u015fmedi\u011fine bak\u0131l\u0131yor. Burada da uygunsuzluk g\u00f6r\u00fcl\u00fcyor.<\/li>\n<\/ul>\n<h5>Mutschler et al.\u00a0 2013<sup>2<\/sup><\/h5>\n<ul>\n<li>Ayn\u0131 \u00e7al\u0131\u015fma grubu, yine Trauma Register DGU veri bankas\u0131 ile bir \u00e7al\u0131\u015fma daha y\u00fcr\u00fct\u00fcyor ve 2002-2010 y\u0131llar\u0131 aras\u0131nda 16305 hastadan \u00e7ekilen verilerle yap\u0131lan analizler sonucu baz defisitinin 4 gruba ayr\u0131lmas\u0131 ile, risk derecelendirmesi konusunda ATLS\u2019nin s\u0131n\u0131flamas\u0131ndan daha \u00fcst\u00fcn oldu\u011fu g\u00f6steriliyor.<\/li>\n<li>Baz defisiti\u00a0 artt\u0131k\u00e7a, SKBnin ve GKS\u2019nin d\u00fc\u015ft\u00fc\u011f\u00fc g\u00f6r\u00fcl\u00fcyor.<\/li>\n<li>Mortalite ve masif transf\u00fczyon ihtiyac\u0131n\u0131 BD\u2019nin daha ba\u015far\u0131l\u0131 bir \u015fekilde g\u00f6sterdi\u011fi g\u00f6r\u00fcl\u00fcyor. Bunun yan\u0131s\u0131ra, \u015fok indeksinin de bu gruplarda 1\u2019den 4\u2019e do\u011fru belirgin \u015fekilde artt\u0131\u011f\u0131 g\u00f6r\u00fcl\u00fcyor.<\/li>\n<\/ul>\n<p>Bu tabloda (Tablo 2) ise ATLS 10. bask\u0131s\u0131nda verilen hemoraji s\u0131n\u0131fland\u0131rmas\u0131n\u0131 g\u00f6r\u00fcyoruz. Yukar\u0131daki \u00e7al\u0131\u015fmalar gibi kan\u0131tlar\u0131n sonucunda,<\/p>\n<ul>\n<li>S\u0131n\u0131fland\u0131rmaya baz defisiti de ekleniyor,<\/li>\n<li>Bilin\u00e7 durumunu netle\u015ftirmek ad\u0131na bilin\u00e7 GKS skorunda y\u00fckselme\/d\u00fc\u015fme \u015feklinde belirtiliyor.<\/li>\n<li>Bu evrelemeye g\u00f6re evre 3 i\u00e7in muhtemel massif transf\u00fczyon ihtiyac\u0131 olacak, ve evre 4 i\u00e7in kesin masif transf\u00fczyon ihtiyac\u0131 olacak diyebiliz.<\/li>\n<\/ul>\n<div class=\"pcrstb-wrap\"><table style=\"height: 488px\" cellspacing=\"0\" cellpadding=\"0\">\n<caption><strong>Tablo 2.<\/strong> <span class=\"s1\"><b>ATLS 10. Bask\u0131 Hemorajik \u015eok S\u0131n\u0131flamas\u0131<\/b><\/span><\/caption>\n<tbody>\n<tr style=\"height: 56px\">\n<td style=\"height: 56px\" colspan=\"5\" valign=\"top\">\n<p align=\"center\"><span class=\"s1\"><b>ATLS 10. Bask\u0131 Hemorajik \u015eok S\u0131n\u0131flamas\u0131<\/b><\/span><\/p>\n<\/td>\n<\/tr>\n<tr style=\"height: 36px\">\n<td style=\"height: 36px\" valign=\"top\"><span style=\"color: #000000;font-family: Calibri;font-size: x-large\"><b>Parametre<\/b><\/span><\/td>\n<td style=\"height: 36px\" valign=\"top\"><span style=\"color: #000000;font-family: Calibri;font-size: x-large\"><b>Evre 1<span class=\"Apple-converted-space\">\u00a0<\/span><\/b><\/span><\/td>\n<td style=\"height: 36px\" valign=\"top\"><span style=\"color: #000000;font-family: Calibri;font-size: x-large\"><b>Evre 2<span class=\"Apple-converted-space\">\u00a0<\/span><\/b><\/span><\/td>\n<td style=\"height: 36px\" valign=\"top\"><span style=\"color: #000000;font-family: Calibri;font-size: x-large\"><b>Evre 3<span class=\"Apple-converted-space\">\u00a0<\/span><\/b><\/span><\/td>\n<td style=\"height: 36px\" valign=\"top\"><span style=\"color: #000000;font-family: Calibri;font-size: x-large\"><b>Evre 4<\/b><\/span><\/td>\n<\/tr>\n<tr style=\"height: 36px\">\n<td style=\"height: 36px\" valign=\"top\"><span style=\"color: #000000;font-family: Calibri;font-size: x-large\">Kan kayb\u0131 (%)<\/span><\/td>\n<td style=\"height: 36px\" valign=\"top\"><span style=\"color: #000000;font-family: Calibri;font-size: x-large\">&lt; %15<\/span><\/td>\n<td style=\"height: 36px\" valign=\"top\"><span style=\"color: #000000;font-family: Calibri;font-size: x-large\">%15-30<\/span><\/td>\n<td style=\"height: 36px\" valign=\"top\"><span style=\"color: #000000;font-family: Calibri;font-size: x-large\">%31-40<\/span><\/td>\n<td style=\"height: 36px\" valign=\"top\"><span style=\"color: #000000;font-family: Calibri;font-size: x-large\">&gt;%40<\/span><\/td>\n<\/tr>\n<tr style=\"height: 36px\">\n<td style=\"height: 36px\" valign=\"top\"><span style=\"color: #000000;font-family: Calibri;font-size: x-large\">Nab\u0131z<span class=\"Apple-converted-space\">\u00a0<\/span><\/span><\/td>\n<td style=\"height: 36px\" valign=\"top\"><span style=\"color: #000000;font-family: Calibri;font-size: x-large\">De\u011fi\u015fmez<\/span><\/td>\n<td style=\"height: 36px\" valign=\"top\"><span style=\"color: #000000;font-family: Calibri;font-size: x-large\">De\u011fi\u015fmez\/artm\u0131\u015f<\/span><\/td>\n<td style=\"height: 36px\" valign=\"top\"><span style=\"color: #000000;font-family: Calibri;font-size: x-large\">Atm\u0131\u015f<\/span><\/td>\n<td style=\"height: 36px\" valign=\"top\"><span style=\"color: #000000;font-family: Calibri;font-size: x-large\">Artm\u0131\u015f\/\u00e7ok artm\u0131\u015f<\/span><\/td>\n<\/tr>\n<tr style=\"height: 72px\">\n<td style=\"height: 72px\" valign=\"top\"><span style=\"color: #000000;font-family: Calibri;font-size: x-large\">Sistolik kan bas\u0131nc\u0131<\/span><\/td>\n<td style=\"height: 72px\" valign=\"top\"><span style=\"color: #000000;font-family: Calibri;font-size: x-large\">De\u011fi\u015fmez<\/span><\/td>\n<td style=\"height: 72px\" valign=\"top\"><span style=\"color: #000000;font-family: Calibri;font-size: x-large\">De\u011fi\u015fmez<\/span><\/td>\n<td style=\"height: 72px\" valign=\"top\"><span style=\"color: #000000;font-family: Calibri;font-size: x-large\">De\u011fi\u015fmez\/azalm\u0131\u015f<\/span><\/td>\n<td style=\"height: 72px\" valign=\"top\"><span style=\"color: #000000;font-family: Calibri;font-size: x-large\">Azalm\u0131\u015f<\/span><\/td>\n<\/tr>\n<tr style=\"height: 36px\">\n<td style=\"height: 36px\" valign=\"top\"><span style=\"color: #000000;font-family: Calibri;font-size: x-large\">Nab\u0131z bas\u0131nc\u0131<\/span><\/td>\n<td style=\"height: 36px\" valign=\"top\"><span style=\"color: #000000;font-family: Calibri;font-size: x-large\">De\u011fi\u015fmez<\/span><\/td>\n<td style=\"height: 36px\" valign=\"top\"><span style=\"color: #000000;font-family: Calibri;font-size: x-large\">Azalm\u0131\u015f<\/span><\/td>\n<td style=\"height: 36px\" valign=\"top\"><span style=\"color: #000000;font-family: Calibri;font-size: x-large\">Azalm\u0131\u015f<\/span><\/td>\n<td style=\"height: 36px\" valign=\"top\"><span style=\"color: #000000;font-family: Calibri;font-size: x-large\">Azalm\u0131\u015f<\/span><\/td>\n<\/tr>\n<tr style=\"height: 36px\">\n<td style=\"height: 36px\" valign=\"top\"><span style=\"color: #000000;font-family: Calibri;font-size: x-large\">Solunum say\u0131s\u0131<\/span><\/td>\n<td style=\"height: 36px\" valign=\"top\"><span style=\"color: #000000;font-family: Calibri;font-size: x-large\">De\u011fi\u015fmez<\/span><\/td>\n<td style=\"height: 36px\" valign=\"top\"><span style=\"color: #000000;font-family: Calibri;font-size: x-large\">De\u011fi\u015fmez<\/span><\/td>\n<td style=\"height: 36px\" valign=\"top\"><span style=\"color: #000000;font-family: Calibri;font-size: x-large\">De\u011fi\u015fmez\/artm\u0131\u015f<\/span><\/td>\n<td style=\"height: 36px\" valign=\"top\"><span style=\"color: #000000;font-family: Calibri;font-size: x-large\">Artm\u0131\u015f<\/span><\/td>\n<\/tr>\n<tr style=\"height: 36px\">\n<td style=\"height: 36px\" valign=\"top\"><span style=\"color: #000000;font-family: Calibri;font-size: x-large\">\u0130drar \u00e7\u0131k\u0131\u015f\u0131<\/span><\/td>\n<td style=\"height: 36px\" valign=\"top\"><span style=\"color: #000000;font-family: Calibri;font-size: x-large\">De\u011fi\u015fmez<\/span><\/td>\n<td style=\"height: 36px\" valign=\"top\"><span style=\"color: #000000;font-family: Calibri;font-size: x-large\">De\u011fi\u015fmez<\/span><\/td>\n<td style=\"height: 36px\" valign=\"top\"><span style=\"color: #000000;font-family: Calibri;font-size: x-large\">Azalm\u0131\u015f<\/span><\/td>\n<td style=\"height: 36px\" valign=\"top\"><span style=\"color: #000000;font-family: Calibri;font-size: x-large\">\u00c7ok azalm\u0131\u015f<\/span><\/td>\n<\/tr>\n<tr style=\"height: 36px\">\n<td style=\"height: 36px\" valign=\"top\"><span style=\"color: #000000;font-family: Calibri;font-size: x-large\">GKS<\/span><\/td>\n<td style=\"height: 36px\" valign=\"top\"><span style=\"color: #000000;font-family: Calibri;font-size: x-large\">De\u011fi\u015fmez<\/span><\/td>\n<td style=\"height: 36px\" valign=\"top\"><span style=\"color: #000000;font-family: Calibri;font-size: x-large\">De\u011fi\u015fmez<\/span><\/td>\n<td style=\"height: 36px\" valign=\"top\"><span style=\"color: #000000;font-family: Calibri;font-size: x-large\">Azalm\u0131\u015f<\/span><\/td>\n<td style=\"height: 36px\" valign=\"top\"><span style=\"color: #000000;font-family: Calibri;font-size: x-large\">Azalm\u0131\u015f<\/span><\/td>\n<\/tr>\n<tr style=\"height: 36px\">\n<td style=\"height: 36px\" valign=\"top\"><span style=\"color: #000000;font-family: Calibri;font-size: x-large\">Baz a\u00e7\u0131\u011f\u0131<\/span><\/td>\n<td style=\"height: 36px\" valign=\"top\"><span style=\"color: #000000;font-family: Calibri;font-size: x-large\">0 &#8211; (-2)<\/span><\/td>\n<td style=\"height: 36px\" valign=\"top\"><span style=\"color: #000000;font-family: Calibri;font-size: x-large\">(-2) &#8211; (-6)<\/span><\/td>\n<td style=\"height: 36px\" valign=\"top\"><span style=\"color: #000000;font-family: Calibri;font-size: x-large\">(-6) &#8211; (-10)<\/span><\/td>\n<td style=\"height: 36px\" valign=\"top\"><span style=\"color: #000000;font-family: Calibri;font-size: x-large\"><span class=\"Apple-converted-space\">\u00a0<\/span>\u2264 -10<\/span><\/td>\n<\/tr>\n<tr style=\"height: 72px\">\n<td style=\"height: 72px\" valign=\"top\"><span style=\"color: #000000;font-family: Calibri;font-size: x-large\">Kan \u00fcr\u00fcn\u00fc ihtiyac\u0131<\/span><\/td>\n<td style=\"height: 72px\" valign=\"top\"><span style=\"color: #000000;font-family: Calibri;font-size: x-large\">\u0130zle<\/span><\/td>\n<td style=\"height: 72px\" valign=\"top\"><span style=\"color: #000000;font-family: Calibri;font-size: x-large\">Olas\u0131<\/span><\/td>\n<td style=\"height: 72px\" valign=\"top\"><span style=\"color: #000000;font-family: Calibri;font-size: x-large\">Evet<\/span><\/td>\n<td style=\"height: 72px\" valign=\"top\"><span style=\"color: #000000;font-family: Calibri;font-size: x-large\">Masif Transf\u00fczyon Protokol\u00fc<\/span><\/td>\n<\/tr>\n<\/tbody>\n<\/table><\/div>\n<p>&nbsp;<\/p>\n<p>Mutschler ve di\u011fer \u00e7al\u0131\u015fma gruplar\u0131n\u0131n sonu\u00e7lar\u0131 Avrupa k\u0131lavuzlar\u0131n\u0131 da etkiliyor. Avrupa Travma sonras\u0131 kanama y\u00f6netimi k\u0131lavuzunun son bask\u0131s\u0131nda da, hastada hipovolemik \u015fokun derecesinin de\u011ferlendirilmesinde \u015fok indeksi kullan\u0131lmas\u0131 \u00f6nerisi k\u0131lavuza giriyor <sup>3<\/sup>.<\/p>\n<p>Buna g\u00f6re, ilk de\u011ferlendirmede;<\/p>\n<ul class=\"ul1\">\n<li class=\"li1\"><span class=\"s2\">Hekimin travmatik kanaman\u0131n yayg\u0131nl\u0131\u011f\u0131n\u0131 klinik olarak de\u011ferlendirirken, hasta fizyolojisi, anatomik yaralanma paterni, yaralanma mekanizmas\u0131 ve ba\u015flang\u0131\u00e7 res\u00fcsitasyonuna hastan\u0131n cevab\u0131 birlikteli\u011fini kullanmas\u0131 tavsiye edilmektedir (Grade 1C).<\/span><\/li>\n<li class=\"li2\"><span class=\"s2\">Hipovolemik \u015fokun derecesinin de\u011ferlendirilmesinde \u015fok indeksinin (\u015e\u0130) kullan\u0131m\u0131 \u00f6nerilmektedir (Grade 2C).<\/span><\/li>\n<\/ul>\n<h4>Travma hastas\u0131 neden kanamaya devam eder?<\/h4>\n<p>Peki bu hastalar neden kan\u0131yor? Daha do\u011frusu, bir odaktan kaynaklanan kanama baz\u0131 travmalarda neden devam ediyor, kendini s\u0131n\u0131rlam\u0131yor?<\/p>\n<p>Bu \u015fekilde (\u015fekil 1) yaralanmada koag\u00fclopatiye yol a\u00e7an mekanizmalardan baz\u0131lar\u0131n\u0131 g\u00f6r\u00fcyoruz.<\/p>\n<div id=\"attachment_473\" style=\"width: 1034px\" class=\"wp-caption aligncenter\"><img fetchpriority=\"high\" decoding=\"async\" aria-describedby=\"caption-attachment-473\" class=\"wp-image-473 size-large\" src=\"https:\/\/tatd.org.tr\/travma\/wp-content\/uploads\/sites\/32\/2021\/12\/Screen-Shot-2021-12-22-at-09.35.10-1024x488.png\" alt=\"\" width=\"1024\" height=\"488\" srcset=\"https:\/\/tatd.org.tr\/travma\/wp-content\/uploads\/sites\/32\/2021\/12\/Screen-Shot-2021-12-22-at-09.35.10-1024x488.png 1024w, https:\/\/tatd.org.tr\/travma\/wp-content\/uploads\/sites\/32\/2021\/12\/Screen-Shot-2021-12-22-at-09.35.10-300x143.png 300w, https:\/\/tatd.org.tr\/travma\/wp-content\/uploads\/sites\/32\/2021\/12\/Screen-Shot-2021-12-22-at-09.35.10-768x366.png 768w, https:\/\/tatd.org.tr\/travma\/wp-content\/uploads\/sites\/32\/2021\/12\/Screen-Shot-2021-12-22-at-09.35.10.png 1195w\" sizes=\"(max-width: 1024px) 100vw, 1024px\" \/><p id=\"caption-attachment-473\" class=\"wp-caption-text\">\u015eekil 1. Travmada koag\u00fclopatiye yol a\u00e7an mekanizmalar.<\/p><\/div>\n<ol>\n<li>Travma sonras\u0131 kanama varl\u0131\u011f\u0131nda yap\u0131lan res\u00fcsitasyonun bir sonucu olarak hastan\u0131n kan\u0131nda dil\u00fcsyon ve verilen s\u0131v\u0131lar\u0131n veya ortam\u0131n etkisiyle hipotermi meydana geliyor. Hipotermi durumunda koag\u00fclasyon kaskad\u0131nda bulunan enzim aktiviteleri bozuldu\u011fu i\u00e7in bu durum koag\u00fclopatiye katk\u0131 sa\u011fl\u0131yor.<\/li>\n<li>\u015eoktaki hipoperf\u00fczyona ba\u011fl\u0131 asidemi-hipotermi-koag\u00fclopati \u00f6l\u00fcmc\u00fcl triad\u0131 da bu s\u00fcrecin i\u00e7erisinde.<\/li>\n<li>Bunlara ek olarak fakt\u00f6r t\u00fcketimi ve fibrinoliz ile ili\u015fkili olan travmatik \u015foka ba\u011fl\u0131 akut koag\u00fclopati de hastadaki koag\u00fclopatiye katk\u0131 sa\u011flayacakt\u0131r.<\/li>\n<li>Travman\u0131n yol a\u00e7t\u0131\u011f\u0131 inflamatuvar s\u00fcrece mevcut hastal\u0131klar, kullan\u0131lan ila\u00e7lar ve genetik fakt\u00f6rler de etki edip koag\u00fclopatiye katk\u0131 sa\u011flayacakt\u0131r.<\/li>\n<li>Ve t\u00fcm bunlar\u0131n sonucunda geli\u015fen koag\u00fclopati de daha \u00e7ok kanamaya yol a\u00e7acakt\u0131r.<\/li>\n<\/ol>\n<h4>Hasar kontrol res\u00fcsitasyon<\/h4>\n<p>\u0130\u015fte asl\u0131nda hasar kontrol res\u00fcsitasyon da burada devreye girerek, koag\u00fclopatinin engellenmesini hedefliyor.<\/p>\n<p>Hasar kontrol res\u00fcsitasyonda ama\u00e7 :<\/p>\n<ul>\n<li>Dola\u015fan hacmin sa\u011flanmas\u0131,<\/li>\n<li>Kanama kontrol\u00fc,<\/li>\n<li>Koag\u00fclopati\/hipotermi\/asidoz \u00f6l\u00fcmc\u00fcl triad\u0131n\u0131n engellenmesi.<\/li>\n<\/ul>\n<h5>Hasar kontrol res\u00fcsitasyon bile\u015fenleri<\/h5>\n<ol>\n<li>Permisif hipotansiyon<\/li>\n<li>Erken hemostatik res\u00fcsitasyon<\/li>\n<li>Hasar kontrol cerrahi<\/li>\n<\/ol>\n<ul>\n<li>Permisif hipotansiyon hedefinde ama\u00e7, s\u0131v\u0131 y\u00fcklenmesi, hemodil\u00fcsyon ve koag\u00fclopati riskinden \u00f6t\u00fcr\u00fc a\u015f\u0131r\u0131 s\u0131v\u0131 verilmesinden ka\u00e7\u0131n\u0131lmas\u0131, kan bas\u0131nc\u0131n\u0131n perf\u00fczyonu s\u00fcrd\u00fcrebilecek s\u0131n\u0131rda tutulmas\u0131.<\/li>\n<li>Erken hemostatik res\u00fcsitasyon ise asl\u0131nda masif transf\u00fczyon protokol\u00fcn\u00fcn temelini olu\u015fturuyor. Dola\u015fan hacmi sa\u011flarken agresif kristalloid transf\u00fczyonundan kaynaklanabilecek komplikasyonlar\u0131 ve travmaya ba\u011fl\u0131 koag\u00fclopatiyi \u00f6nleyerek perf\u00fczyonu iyile\u015ftirmeyi hedefler. Bu ama\u00e7la, tam kan ile i\u00e7erik oranlar\u0131 benzer kan \u00fcr\u00fcnleri vermeyi hedefler.<\/li>\n<li>Hasar kontrol cerrahi kolu ise, hastan\u0131n fizyolojik rezervi d\u00fczelip esas definitif m\u00fcdahaleye haz\u0131r olana kadar, kanama ve kontaminasyon kontrol\u00fc i\u00e7in s\u0131n\u0131rl\u0131 cerrahi m\u00fcdahale yap\u0131lmas\u0131d\u0131r. Ama\u00e7 \u00f6l\u00fcmc\u00fcl triyad\u0131 kontrol alt\u0131na al\u0131p hastay\u0131 ileri giri\u015fimleri tolere edebilecek duruma getirmek.<\/li>\n<\/ul>\n<h4>Masif transf\u00fczyon<\/h4>\n<p><strong><span class=\"s2\">Geleneksel tan\u0131m : 24 saatlik s\u00fcre i\u00e7erisinde en az 10 \u00fcnite k\u0131rm\u0131z\u0131 kan transf\u00fcze edilmesi.<\/span><\/strong><\/p>\n<ul>\n<li>Masif transf\u00fczyonu geleneksel olarak 24 saatlik s\u00fcre i\u00e7erisinde en az 10 \u00fcnite k\u0131rm\u0131z\u0131 kan kullan\u0131m\u0131 olarak tan\u0131ml\u0131yoruz ancak bu tan\u0131mda baz\u0131 s\u0131k\u0131nt\u0131lar var.<\/li>\n<li>24 saat i\u00e7erisinde 10 \u00fcnite ES ihtiyac\u0131 oldu\u011funun belirlenip bu tan\u0131m\u0131n yap\u0131lmas\u0131 bu s\u00fcre\u00e7 i\u00e7in biraz uygunsuz \u00e7\u00fcnk\u00fc \u00e7ok daha h\u0131zl\u0131 bir s\u00fcre\u00e7 s\u00f6z konusu.<\/li>\n<li>Hastan\u0131n daha \u00f6nceden tan\u0131nmas\u0131 gerekiyor \u00e7\u00fcnk\u00fc bu hastalar erken hemostatik res\u00fcsitasyondan fayda g\u00f6r\u00fcyor.<\/li>\n<li>Yani bu hastalara 24. Saatin sonunda \u201cmasif transf\u00fczyon\u201d hastas\u0131 demek, erken hemostatik res\u00fcsitasyon \u015fans\u0131n\u0131 kaybetmemize neden olacak.<\/li>\n<li>24 saatten k\u0131sa s\u00fcrede, masif kanamaya ba\u011fl\u0131, 10 \u00fcnite ES almaya vakit bulamadan kaybedilen bir hasta, bu tan\u0131ma giremeyecek.<\/li>\n<li>Masif transf\u00fczyonun daha k\u0131sa s\u00fcrede tayin edilmesi, ve duruma g\u00f6re masif transf\u00fczyon protokol\u00fcn\u00fcn aktive edilmesi gerekiyor.<\/li>\n<\/ul>\n<p>Bunun i\u00e7in ba\u015fka tan\u0131mlar da ortaya at\u0131lm\u0131\u015f.<\/p>\n<ul>\n<li>\u0130lk 1 saatte- veya \u201cilk saatlerde\u201d, 4 \u00fcniteden fazla ES ihtiyac\u0131<\/li>\n<li>4 saatte kan hacminin %50\u2019si kadar ES almas\u0131<\/li>\n<li>Kritik Uygulama E\u015fi\u011fi (CAT)<sup>4<\/sup>, daha k\u0131sa s\u00fcre aral\u0131klar\u0131nda kullan\u0131lan kan \u00fcr\u00fcn\u00fc miktar\u0131 ile<\/li>\n<\/ul>\n<h5>Masif transf\u00fczyon protokol\u00fc<\/h5>\n<ul>\n<li>Masif transf\u00fczyon, hastan\u0131n ihtiyac\u0131na binaen olduk\u00e7a fazla miktarda k\u0131rm\u0131z\u0131 kan verilmesiyken, masif transf\u00fczyon protokol\u00fc, dil\u00fcsyonel koag\u00fclopatiyi \u00f6nlemek amac\u0131yla, kan \u00fcr\u00fcnlerinin v\u00fccudun kan bile\u015fenleriyle uyumlu \u015fekilde, dengeli halde verilmesi anlam\u0131na geliyor. Ve bunun sa\u011fl\u0131k merkezinin kendi imkanlar\u0131 do\u011frultusunda sabit bir protokole ba\u011fl\u0131 olarak yap\u0131lmas\u0131 demek.<\/li>\n<li>Ba\u011fl\u0131 bulundu\u011fumuz merkezde uygulanan masif transf\u00fczyon protokol\u00fc elbette hasar kontrol prensiplerine uygun olmal\u0131. Ampirik olarak, \u00f6nceden belirlenmi\u015f settler halinde kan \u00fcr\u00fcnlerine eri\u015fim olmal\u0131.<\/li>\n<li>Protokoller ayr\u0131ca koag\u00fclopatinin de\u011ferlendirilmesine, asidoz, hipotermi ve hipokalsemiye y\u00f6nelik de\u011ferlendirme ve tedaviye olanak vermeli.<\/li>\n<\/ul>\n<h5>Kime masif transf\u00fczyon protokol\u00fc?<\/h5>\n<ul>\n<li>Erken ba\u015flanan masif transf\u00fczyon mortaliteyi iyile\u015ftirdi\u011fi gibi, kan \u00fcr\u00fcnlerine gereksiz yere maruz kalman\u0131n da komplikasyonlar\u0131 var.<\/li>\n<li>Hem askeri hem de sivil, k\u00fcnt ve penetran travmalar da dahil edilerek \u00e7e\u015fitli \u00f6ng\u00f6r\u00fc ara\u00e7lar\u0131 (skorlamalar)\u00a0 geli\u015ftirilmi\u015f. Bir\u00e7ok skorlama sistemi var ancak pek \u00e7o\u011funun validasyonu yok.<\/li>\n<\/ul>\n<p>Skorlamalardan beklenen :<\/p>\n<ul>\n<li>Y\u00fcksek miktarda kan \u00fcr\u00fcn\u00fc ihtiyac\u0131 olmayan hastalar\u0131 d\u0131\u015flayabilmek i\u00e7in uygun duyarl\u0131l\u0131k ve \u00f6zg\u00fcll\u00fc\u011fe sahip olmalar\u0131<\/li>\n<li>Gereksiz kan \u00fcr\u00fcn\u00fc transf\u00fczyonundan ve bundan dolay\u0131 do\u011facak olumsuz sonu\u00e7lardan korumalar\u0131.<\/li>\n<li>Kaynaklar\u0131n ak\u0131lc\u0131 kullan\u0131m\u0131.<\/li>\n<\/ul>\n<h5>ABC Skoru<\/h5>\n<p>Bu skorlardan en yayg\u0131n kullan\u0131lanlardan birisi ABC skoru. ABC skoru 4 de\u011fi\u015fkenden olu\u015fuyor (Tablo 3).<\/p>\n<p>&nbsp;<\/p>\n<div class=\"pcrstb-wrap\"><table style=\"height: 300px;width: 300px;border-style: solid\" width=\"300\" cellspacing=\"0\" cellpadding=\"0\">\n<caption><strong>Tablo 3. ABC skorlama sistemi<\/strong><\/caption>\n<tbody>\n<tr style=\"height: 104px\">\n<td style=\"width: 446px;height: 75px\" colspan=\"2\" valign=\"top\"><span style=\"color: #000000;font-family: Calibri;font-size: x-large\"><b>Assesment of Blood Consumption (ABC) Score<\/b><\/span><\/td>\n<\/tr>\n<tr style=\"height: 68px\">\n<td style=\"width: 332px;height: 32px\" valign=\"top\"><span style=\"color: #000000;font-family: Calibri;font-size: x-large\"><b>Parametre<\/b><\/span><\/td>\n<td style=\"width: 114px;height: 32px\" valign=\"top\"><span style=\"color: #000000;font-family: Calibri;font-size: x-large\"><b>Puan<\/b><\/span><\/td>\n<\/tr>\n<tr style=\"height: 68px\">\n<td style=\"width: 332px;height: 68px\" valign=\"top\"><span style=\"color: #000000;font-family: Calibri;font-size: x-large\">Acil servis SKB \u2264 90 mmHg<span class=\"Apple-converted-space\">\u00a0<\/span><\/span><\/td>\n<td style=\"width: 114px;height: 68px\" valign=\"top\"><span style=\"color: #000000;font-family: Calibri;font-size: x-large\">1<\/span><\/td>\n<\/tr>\n<tr style=\"height: 68px\">\n<td style=\"width: 332px;height: 68px\" valign=\"top\"><span style=\"color: #000000;font-family: Calibri;font-size: x-large\">Acil servis kalp h\u0131z\u0131 \u2265<\/span><span style=\"color: #000000;font-family: Calibri;font-size: medium\"><span class=\"Apple-converted-space\">\u00a0<\/span><\/span><span style=\"color: #000000;font-family: Calibri;font-size: x-large\"> 120 vuru\/dk<\/span><\/td>\n<td style=\"width: 114px;height: 68px\" valign=\"top\"><span style=\"color: #000000;font-family: Calibri;font-size: x-large\">1<\/span><\/td>\n<\/tr>\n<tr style=\"height: 68px\">\n<td style=\"width: 332px;height: 38px\" valign=\"top\"><span style=\"color: #000000;font-family: Calibri;font-size: x-large\">Penetran mekanizma<\/span><\/td>\n<td style=\"width: 114px;height: 38px\" valign=\"top\"><span style=\"color: #000000;font-family: Calibri;font-size: x-large\">1<\/span><\/td>\n<\/tr>\n<tr style=\"height: 68px\">\n<td style=\"width: 332px;height: 40px\" valign=\"top\"><span style=\"color: #000000;font-family: Calibri;font-size: x-large\">FAST\u2019de s\u0131v\u0131 +<\/span><\/td>\n<td style=\"width: 114px;height: 40px\" valign=\"top\"><span style=\"color: #000000;font-family: Calibri;font-size: x-large\">1<\/span><\/td>\n<\/tr>\n<tr style=\"height: 10px\">\n<td style=\"width: 446px;height: 10px\" colspan=\"2\" valign=\"top\"><span style=\"color: #000000;font-family: Calibri;font-size: x-large\">\u22652 puan = Masif Transf\u00fczyon Protokol\u00fc<span class=\"Apple-converted-space\">\u00a0 <\/span><\/span><\/td>\n<\/tr>\n<\/tbody>\n<\/table><\/div>\n<p>2 veya \u00fczeri skor masif transf\u00fczyon protokol\u00fc aktivasyonunu gerektiriyor.<\/p>\n<ul class=\"ul1\">\n<li class=\"li1\"><span class=\"s2\">\u22652 puan i\u00e7in duyarl\u0131l\u0131k %75, \u00f6zg\u00fcll\u00fck %86; AUROC 0.859<sup>5<\/sup><\/span><\/li>\n<li class=\"li1\"><span class=\"s2\">Validasyon<sup>6<\/sup> : \u22652 puan i\u00e7in<\/span>\n<ul class=\"ul1\">\n<li class=\"li1\"><span class=\"s2\">\u0130lk 24 saatte duyarl\u0131l\u0131k %76-90 \u00f6zg\u00fcll\u00fck %67-87; <b>PPV %55,<\/b> <b>NPV %97<\/b>; AUROC 0.833-0.903.<\/span><\/li>\n<li class=\"li1\"><span class=\"s2\">\u0130lk 6 saatte duyarl\u0131l\u0131k %87, \u00f6zg\u00fcll\u00fck %82;<span class=\"Apple-converted-space\">\u00a0 <\/span>PPV %38, NPV %98; AUROC 0.898-0.905<\/span><\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<ul>\n<li>ABC skoru ile transf\u00fczyon ihtiyac\u0131 varolandan daha y\u00fcksek olabiliyor.<\/li>\n<li>Validasyon \u00e7al\u0131\u015fmas\u0131ndaki pozitif prediktif de\u011ferinin %55 civar\u0131 olmas\u0131 demek, masif transf\u00fczyon protokol\u00fcn\u00fcn aktive edildi\u011fi hastalar\u0131n %45\u2019inin asl\u0131nda masif transf\u00fczyon ihtiyac\u0131 olmad\u0131\u011f\u0131n\u0131 g\u00f6steriyor.<\/li>\n<li>Bu skor, kimin masif transf\u00fczyon ihtiyac\u0131 olmayaca\u011f\u0131n\u0131 daha iyi \u00f6n g\u00f6r\u00fcyor. Negatif prediktif de\u011feri %5in alt\u0131nda. Yani bu skor, masif transf\u00fczyon ihtiyac\u0131 olan hastalar\u0131n en az %95ini yakal\u0131yor.<\/li>\n<li>\u00c7ok basit\u00e7e ve h\u0131zl\u0131ca hesaplanabilmesi, laboratuvar de\u011ferlerine, hesaplama ara\u00e7lar\u0131na ihtiya\u00e7 duymamas\u0131 avantaj.<\/li>\n<\/ul>\n<h5>TASH Skoru<\/h5>\n<ul>\n<li>Bir di\u011fer yayg\u0131n kullan\u0131lan skor ise TASH skoru.<\/li>\n<li>Bu de\u011fi\u015fkenler ABC skoru kadar h\u0131zl\u0131 hesaplanamayabiliyor \u00e7\u00fcnk\u00fc i\u00e7erisinde hemoglobin ve baz fazlas\u0131 de\u011feri var.<\/li>\n<li>Ayr\u0131ca k\u0131r\u0131klar\u0131 tespit etmek sekonder bak\u0131ya kalabilir veya g\u00f6r\u00fcnt\u00fcleme gerekebilir.<\/li>\n<\/ul>\n<p>&nbsp;<\/p>\n<div class=\"pcrstb-wrap\"><table style=\"height: 481px;width: 423px;border-style: solid;border-color: #000000\" width=\"423\" cellspacing=\"0\" cellpadding=\"0\">\n<caption><strong>Tablo 4. TASH Skorlama sistemi<\/strong><\/caption>\n<tbody>\n<tr style=\"height: 86px\">\n<td style=\"width: 419px;height: 53px\" colspan=\"3\" valign=\"top\"><strong>TASH Skoru (Trauma Associated Severe Hemorrhage)<\/strong><\/td>\n<\/tr>\n<tr style=\"height: 59px\">\n<td style=\"width: 256.625px;height: 31px\" valign=\"top\"><strong><span style=\"color: #000000;font-family: Calibri;font-size: large\">De\u011fi\u015fken<span class=\"Apple-converted-space\">\u00a0<\/span><\/span><\/strong><\/td>\n<td style=\"width: 76.8594px;height: 31px\" valign=\"top\"><strong><span style=\"color: #000000;font-family: Calibri;font-size: large\">De\u011fer<span class=\"Apple-converted-space\">\u00a0<\/span><\/span><\/strong><\/td>\n<td style=\"width: 81.5156px;height: 31px\" valign=\"top\"><span style=\"color: #000000;font-family: Calibri;font-size: large\"><strong>Puan<\/strong><span class=\"Apple-converted-space\">\u00a0<\/span><\/span><\/td>\n<\/tr>\n<tr style=\"height: 59px\">\n<td style=\"width: 256.625px;height: 139px\" rowspan=\"5\" valign=\"top\"><span style=\"color: #000000;font-family: Calibri;font-size: large\">Hemoglobin (mg\/dl)<\/span><\/td>\n<td style=\"width: 76.8594px;height: 31px\" valign=\"top\"><span style=\"color: #000000;font-family: Calibri;font-size: large\">&lt;7<\/span><\/td>\n<td style=\"width: 81.5156px;height: 31px\" valign=\"top\"><span style=\"color: #000000;font-family: Calibri;font-size: large\">8<\/span><\/td>\n<\/tr>\n<tr style=\"height: 59px\">\n<td style=\"width: 76.8594px;height: 28px\" valign=\"top\"><span style=\"color: #000000;font-family: Calibri;font-size: large\">&lt;9<\/span><\/td>\n<td style=\"width: 81.5156px;height: 28px\" valign=\"top\"><span style=\"color: #000000;font-family: Calibri;font-size: large\">6<\/span><\/td>\n<\/tr>\n<tr style=\"height: 59px\">\n<td style=\"width: 76.8594px;height: 27px\" valign=\"top\"><span style=\"color: #000000;font-family: Calibri;font-size: large\">&lt;10<\/span><\/td>\n<td style=\"width: 81.5156px;height: 27px\" valign=\"top\"><span style=\"color: #000000;font-family: Calibri;font-size: large\">4<\/span><\/td>\n<\/tr>\n<tr style=\"height: 59px\">\n<td style=\"width: 76.8594px;height: 27px\" valign=\"top\"><span style=\"color: #000000;font-family: Calibri;font-size: large\">&lt;11<\/span><\/td>\n<td style=\"width: 81.5156px;height: 27px\" valign=\"top\"><span style=\"color: #000000;font-family: Calibri;font-size: large\">3<\/span><\/td>\n<\/tr>\n<tr style=\"height: 59px\">\n<td style=\"width: 76.8594px;height: 26px\" valign=\"top\"><span style=\"color: #000000;font-family: Calibri;font-size: large\">&lt;12<\/span><\/td>\n<td style=\"width: 81.5156px;height: 26px\" valign=\"top\"><span style=\"color: #000000;font-family: Calibri;font-size: large\">2<\/span><\/td>\n<\/tr>\n<tr style=\"height: 59px\">\n<td style=\"width: 256.625px;height: 82px\" rowspan=\"3\" valign=\"top\"><span style=\"color: #000000;font-family: Calibri;font-size: large\">Baz fazlas\u0131 (mmol\/l)<\/span><\/td>\n<td style=\"width: 76.8594px;height: 27px\" valign=\"top\"><span style=\"color: #000000;font-family: Calibri;font-size: large\">&lt;-10<\/span><\/td>\n<td style=\"width: 81.5156px;height: 27px\" valign=\"top\"><span style=\"color: #000000;font-family: Calibri;font-size: large\">4<\/span><\/td>\n<\/tr>\n<tr style=\"height: 59px\">\n<td style=\"width: 76.8594px;height: 29px\" valign=\"top\"><span style=\"color: #000000;font-family: Calibri;font-size: large\">&lt;-6<\/span><\/td>\n<td style=\"width: 81.5156px;height: 29px\" valign=\"top\"><span style=\"color: #000000;font-family: Calibri;font-size: large\">3<\/span><\/td>\n<\/tr>\n<tr style=\"height: 59px\">\n<td style=\"width: 76.8594px;height: 26px\" valign=\"top\"><span style=\"color: #000000;font-family: Calibri;font-size: large\">&lt;-2<\/span><\/td>\n<td style=\"width: 81.5156px;height: 26px\" valign=\"top\"><span style=\"color: #000000;font-family: Calibri;font-size: large\">1<\/span><\/td>\n<\/tr>\n<tr style=\"height: 59px\">\n<td style=\"width: 256.625px;height: 54px\" rowspan=\"2\" valign=\"top\"><span style=\"color: #000000;font-family: Calibri;font-size: large\">Sistolik kan bas\u0131nc\u0131 (mmHg)<\/span><\/td>\n<td style=\"width: 76.8594px;height: 27px\" valign=\"top\"><span style=\"color: #000000;font-family: Calibri;font-size: large\">&lt;100<\/span><\/td>\n<td style=\"width: 81.5156px;height: 27px\" valign=\"top\"><span style=\"color: #000000;font-family: Calibri;font-size: large\">4<\/span><\/td>\n<\/tr>\n<tr style=\"height: 59px\">\n<td style=\"width: 76.8594px;height: 27px\" valign=\"top\"><span style=\"color: #000000;font-family: Calibri;font-size: large\">&lt;120<\/span><\/td>\n<td style=\"width: 81.5156px;height: 27px\" valign=\"top\"><span style=\"color: #000000;font-family: Calibri;font-size: large\">1<\/span><\/td>\n<\/tr>\n<tr style=\"height: 59px\">\n<td style=\"width: 256.625px;height: 29px\" valign=\"top\"><span style=\"color: #000000;font-family: Calibri;font-size: large\">Serbest bat\u0131n i\u00e7i s\u0131v\u0131<\/span><\/td>\n<td style=\"width: 76.8594px;height: 29px\" valign=\"top\"><span style=\"color: #000000;font-family: Calibri;font-size: large\">+<\/span><\/td>\n<td style=\"width: 81.5156px;height: 29px\" valign=\"top\"><span style=\"color: #000000;font-family: Calibri;font-size: large\">3<\/span><\/td>\n<\/tr>\n<tr style=\"height: 59px\">\n<td style=\"width: 256.625px;height: 29px\" valign=\"top\"><span style=\"color: #000000;font-family: Calibri;font-size: large\">Anstabil pelvis k\u0131r\u0131\u011f\u0131<\/span><\/td>\n<td style=\"width: 76.8594px;height: 29px\" valign=\"top\"><span style=\"color: #000000;font-family: Calibri;font-size: large\">+<\/span><\/td>\n<td style=\"width: 81.5156px;height: 29px\" valign=\"top\"><span style=\"color: #000000;font-family: Calibri;font-size: large\">6<\/span><\/td>\n<\/tr>\n<tr style=\"height: 59px\">\n<td style=\"width: 256.625px;height: 32px\" valign=\"top\"><span style=\"color: #000000;font-family: Calibri;font-size: large\">A\u00e7\u0131k\/disloke femur k\u0131r\u0131\u011f\u0131<\/span><\/td>\n<td style=\"width: 76.8594px;height: 32px\" valign=\"top\"><span style=\"color: #000000;font-family: Calibri;font-size: large\">+<\/span><\/td>\n<td style=\"width: 81.5156px;height: 32px\" valign=\"top\"><span style=\"color: #000000;font-family: Calibri;font-size: large\">3<\/span><\/td>\n<\/tr>\n<tr style=\"height: 59px\">\n<td style=\"width: 256.625px;height: 32px\" valign=\"top\"><span style=\"color: #000000;font-family: Calibri;font-size: large\">Erkek cinsiyet<\/span><\/td>\n<td style=\"width: 76.8594px;height: 32px\" valign=\"top\"><span style=\"color: #000000;font-family: Calibri;font-size: large\">+<\/span><\/td>\n<td style=\"width: 81.5156px;height: 32px\" valign=\"top\"><span style=\"color: #000000;font-family: Calibri;font-size: large\">1<\/span><\/td>\n<\/tr>\n<\/tbody>\n<\/table><\/div>\n<p>&nbsp;<\/p>\n<div id=\"attachment_496\" style=\"width: 123px\" class=\"wp-caption alignright\"><img decoding=\"async\" aria-describedby=\"caption-attachment-496\" class=\"wp-image-496 size-medium\" src=\"https:\/\/tatd.org.tr\/travma\/wp-content\/uploads\/sites\/32\/2022\/01\/f9f296d3fb02a975658dcb3856b6fd35-113x300.png\" alt=\"\" width=\"113\" height=\"300\" srcset=\"https:\/\/tatd.org.tr\/travma\/wp-content\/uploads\/sites\/32\/2022\/01\/f9f296d3fb02a975658dcb3856b6fd35-113x300.png 113w, https:\/\/tatd.org.tr\/travma\/wp-content\/uploads\/sites\/32\/2022\/01\/f9f296d3fb02a975658dcb3856b6fd35.png 126w\" sizes=\"(max-width: 113px) 100vw, 113px\" \/><p id=\"caption-attachment-496\" class=\"wp-caption-text\">\u015eekil 2. TASH skoruna g\u00f6re masif transf\u00fczyon olas\u0131l\u0131\u011f\u0131<\/p><\/div>\n<p>TASH skoruna g\u00f6re masif transf\u00fczyon olas\u0131l\u0131\u011f\u0131 :<\/p>\n<ul class=\"ul1\">\n<li class=\"li1\"><span class=\"s2\">Orjinal \u00e7al\u0131\u015fma<sup>7<\/sup> : p = 1\/[1 + exp(4.9 &#8211; 0.3 x TASH)]<\/span><\/li>\n<li class=\"li2\"><span class=\"s2\">Revalidasyon<sup>8<\/sup> : p = 1\/[1 1 exp(5.3\u20130.3 x TASH)]<span class=\"Apple-converted-space\">\u00a0<\/span><\/span>\n<ul class=\"ul1\">\n<li class=\"li3\"><span class=\"s2\">Buna g\u00f6re TASH skorunun 18 olmas\u0131 durumunda= %50 olas\u0131l\u0131k<br \/>\n<\/span><\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<h5><\/h5>\n<h5>\u015eok indeksi<\/h5>\n<p>\u015eok indeksinin travma hastalar\u0131 i\u00e7in \u00e7\u0131k\u0131\u015f noktas\u0131, hastane \u00f6ncesi triyajda, hen\u00fcz erken d\u00f6nemde, kanamal\u0131 hastalarda periferik vazokonstr\u00fcksiyon, anjiotensin sal\u0131n\u0131m\u0131 gibi kompansatuvar mekanizmalar sonucu kan bas\u0131n\u0131c\u0131n\u0131n 90 mmHg \u00fczerinde tutulabilmesi, ilerleyen evrelerde hipotansiyon geli\u015fiyor olmas\u0131.<\/p>\n<p>\u015eok indeksinde bu kompansatuvar evredeki hastalar\u0131 yakalamak hedeflenmi\u015f.<\/p>\n<p>Normal de\u011ferleri 0.5-0.7 aras\u0131 olan bu indeksin artmas\u0131 masif transf\u00fczyon riskini artt\u0131r\u0131yor.<\/p>\n<p>Hipovolemik \u015fokun derecesinin de\u011ferlendirilmesinde art\u0131k \u015fok indeksi de kullan\u0131lan parametreler aras\u0131nda.<\/p>\n<ul class=\"ul1\">\n<li class=\"li1\"><span class=\"s2\">Hastane \u00f6ncesinde<sup>9<\/sup><\/span>\n<ul class=\"ul1\">\n<li class=\"li1\"><span class=\"s2\">0.9 \u2013 1.1 =&gt; 1.5 kat artm\u0131\u015f risk<\/span><\/li>\n<li class=\"li1\"><span class=\"s2\">1.1 \u2013 1.3 =&gt; 5 kat artm\u0131\u015f risk<\/span><\/li>\n<li class=\"li2\"><span class=\"s2\">&lt;1.3 =&gt; 8 kat artm\u0131\u015f risk<\/span><\/li>\n<\/ul>\n<\/li>\n<li class=\"li2\"><span class=\"s2\">Acil serviste<sup>9<\/sup><\/span>\n<ul class=\"ul1\">\n<li class=\"li2\"><span class=\"s2\">0.7 \u2013 0.9 =&gt; 2 kat artm\u0131\u015f risk<\/span><\/li>\n<li class=\"li2\"><span class=\"s2\">0.9 \u2013 1.1 =&gt; 3.5 kat artm\u0131\u015f risk<span class=\"Apple-converted-space\">\u00a0<\/span><\/span><\/li>\n<li class=\"li2\"><span class=\"s2\">1.1 \u2013 1.3 =&gt;<span class=\"Apple-converted-space\">\u00a0 <\/span>10 kat artm\u0131\u015f risk<\/span><\/li>\n<li class=\"li2\"><span class=\"s2\">&gt; 1.3 =&gt; 19 kat artm\u0131\u015f risk<\/span><\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<p>Pratikte, American College of Surgeons <a href=\"https:\/\/www.facs.org\/-\/media\/files\/quality-programs\/trauma\/tqip\/transfusion_guildelines.ashx\">masif transf\u00fczyon \u00f6nerisi<\/a>:<\/p>\n<ul class=\"ul1\">\n<li class=\"li1\"><span class=\"s2\">\u2265 2 ABC Skoru<\/span><\/li>\n<li class=\"li1\"><span class=\"s2\">\u0130nat\u00e7\u0131 hemodinamik instabilite<\/span><\/li>\n<li class=\"li1\"><span class=\"s2\">Ameliyat veya anjioembolizasyon gerektiren aktif kanama<span class=\"Apple-converted-space\">\u00a0<\/span><\/span><\/li>\n<li class=\"li1\"><span class=\"s2\">Travma bak\u0131s\u0131nda kan \u00fcr\u00fcn\u00fc verilmi\u015f olmas\u0131 \u015feklinde.<\/span><\/li>\n<\/ul>\n<h4>Masif transf\u00fczyon i\u00e7in ne \u00f6neriliyor?<\/h4>\n<ul>\n<li>Masif transf\u00fczyon protokol\u00fcnde optimum TDP:ES ve TS:ES oran\u0131 hala tam net de\u011fil.<\/li>\n<li>Ama bildi\u011fimiz \u015fey, ES, TS ve TDP ile dengeli transf\u00fczyon yapmam\u0131z gerekti\u011fi.<\/li>\n<li>En yayg\u0131n kabul g\u00f6ren oran 1:1:1 oran\u0131nda ES:TDP:TS kullan\u0131m\u0131<\/li>\n<li>Hastanelerde kan setlerini h\u0131zl\u0131ca temin edecek ve ula\u015ft\u0131racak bir protokol olmal\u0131.<\/li>\n<li>Masif transf\u00fczyon protokol\u00fc i\u00e7in kan setleri, ayr\u0131 so\u011futucularda saklanmal\u0131<\/li>\n<li>Bu esnada Kristalloid sadece damar yolunu a\u00e7\u0131k tutacak kadar verilmeli ki dil\u00fcsyona ve s\u0131v\u0131 y\u00fcklenmesine yol a\u00e7mas\u0131n.<\/li>\n<li>Masif transf\u00fczyon protokol\u00fcnde kan \u00fcr\u00fcnleri oranlar\u0131nda hen\u00fcz bir g\u00f6r\u00fc\u015f birli\u011fi sa\u011flanamam\u0131\u015f olsa da, PROPPR<sup>10<\/sup>\u00a0bu konuda s\u0131k\u00e7a refere edilen bir \u00e7al\u0131\u015fma.\n<ul>\n<li>Bu 12 merkezli RK\u00c7&#8217;de, ciddi travmal\u0131 kanamal\u0131 hastalarda 1:1:1 ve 1:1:2 plazma:platelet:ES oran\u0131n\u0131n mortalite \u00fczerine etkileri incelenmi\u015f.<\/li>\n<li>680 hastan\u0131n dahil edildi\u011fi bu \u00e7al\u0131\u015fman\u0131n sonunda, bu iki grup aras\u0131nda 24 saat sonunda (1:1:1 grubunda %12.7\u2019ye 1:1:2 grubunda %17; p=0.12 ) veya 30 g\u00fcn sonunda (%22.4\u2019e %26.1; p=0.26) mortalite a\u00e7\u0131s\u0131ndan fark g\u00f6r\u00fclmemi\u015f.<\/li>\n<li>Bununla birlikte, 1: 1: 1 grubunda daha fazla hastada hemostaz sa\u011flanm\u0131\u015f (%86\u2019ya %78; p=0.006) ve 24 saat i\u00e7inde kanamaya ba\u011fl\u0131 daha az \u00f6l\u00fcm ya\u015fanm\u0131\u015f (%9.2\u2019ye %14.6; p=0.03).<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<h4>Ekipman<\/h4>\n<ul>\n<li>\u00d6ncelikle, kan \u00fcr\u00fcnlerini uygun \u015fekilde verebilmek i\u00e7in eri\u015fime ihtiyac\u0131m\u0131z var.<\/li>\n<li>Kan \u00fcr\u00fcnleri periferal IV kateterler ile, santral IV kateterler ile veya intraosseoz yoldan verilebilir.\n<ul>\n<li style=\"list-style-type: none\">\n<ul class=\"ul1\">\n<li class=\"li1\">7 F 3 l\u00fcmenli kateter 16-18 G<\/li>\n<li class=\"li1\">12 F HD kateteri 12-16 G<\/li>\n<li>Periferik IV kateter 16 G<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<\/li>\n<li>Santral ven\u00f6z kataterler uzun oldu\u011fundan, baz\u0131 geni\u015f l\u00fcmenli periferik damar yollar\u0131n\u0131n baz\u0131 santral kateterlerden daha y\u00fcksek h\u0131zda kan \u00fcr\u00fcn\u00fc transf\u00fczyonuna olanak verebildi\u011fi unutulmamal\u0131 (Poiseuille Yasas\u0131).<\/li>\n<li>Santral ven\u00f6z kateterler res\u00fcsitasyon esnas\u0131nda sterilite kurallar\u0131na uygun olarak tak\u0131lamayabilece\u011fi i\u00e7in bu kateterler en fazla 24 saat durmal\u0131.<\/li>\n<li>Bunun yan\u0131 s\u0131ra, inf\u00fczyon pompalar\u0131, \u0131s\u0131t\u0131c\u0131lar, s\u0131k ve h\u0131zl\u0131 tetkik imkanlar\u0131, imkan varsa yatak ba\u015f\u0131 testler gerekli.<\/li>\n<li>Elbette, hastan\u0131n v\u00fccut \u0131s\u0131s\u0131, saturasyon, nab\u0131z, kan bas\u0131nc\u0131 de\u011ferlerinin s\u00fcrekli olarak takibine olanak sa\u011flayan monitorizasyon gerekli.<\/li>\n<\/ul>\n<h4>Di\u011fer tedaviler<\/h4>\n<h5>Fibrinojen<\/h5>\n<ul>\n<li>Fibrinojen, trombositlerle birlikte, p\u0131ht\u0131 olu\u015fumundaki en \u00f6ncelikli, en gerekli elementlerden.<\/li>\n<li>Masif kanamada fibrinojen d\u00fczeyleri di\u011fer kan bile\u015fenlerinden daha h\u0131zl\u0131 \u015fekilde kritik d\u00fczeylere inebilir. Fibrinojen masif transf\u00fczyonda dil\u00fcsyona ba\u011fl\u0131 olarak azalabilir.<\/li>\n<li>Y\u0131k\u0131m\u0131 ve sentezi hipotermi ve asidozdan etkilenerek anormal p\u0131ht\u0131 olu\u015fumu ve kanamayla seyreden bir k\u0131s\u0131r d\u00f6ng\u00fcye girer.<strong>\u00a0<\/strong><\/li>\n<li>Fibrinojen konsantreleri veya kriyopresipitat ile fibrinojen takviye edilebilir. Ancak kriyopresispitat daha yayg\u0131n. TDP\u2019de bir miktar fibrinojen var ancak yetersiz.<\/li>\n<li>Fibrinojen d\u00fczeyleri \u00f6l\u00e7\u00fclmeli ve 100 mg\/dl nin alt\u0131ndaki d\u00fczeylere kriyopresipitat verilmelidir.<\/li>\n<li>Ba\u015flang\u0131\u00e7 dozu olarak 10 \u00fcnite (8-12) \u00f6nerilir. 10 \u00fcnite kriyopresipitat fibrinojeni yakla\u015f\u0131k 75 mg\/dl artt\u0131r\u0131r.<\/li>\n<\/ul>\n<h5>Traneksamik asit<\/h5>\n<p>Plazminojenin yar\u0131\u015fmal\u0131 inhibit\u00f6r\u00fc olan sentetik bir lizin analo\u011fudur.<\/p>\n<p>\u00d6nerilen uygulama : \u0130lk 3 saatte getirilen, kanama riski olan hastalarda 1 gr iv bolus, ve 1 gr \u0131v 8 saat i\u00e7erisinde<sup>11<\/sup>.<\/p>\n<p>Traneksamik asitin m\u00fcmk\u00fcn mertebe erken verilmesi gerekti\u011fi vurguland\u0131\u011f\u0131ndan, prehospital d\u00f6nemde uygulanmas\u0131 da g\u00f6z \u00f6n\u00fcnde bulundurulabilir ve viskoelastik test sonucunu beklememesi \u00f6nerilir.<\/p>\n<h5 class=\"p1\">Protrombin kompleks konsantresi (PCC)<\/h5>\n<ul>\n<li>Her ne kadar masif transf\u00fczyon protokol\u00fcnde dil\u00fcsyonel koag\u00fclopatiden ka\u00e7\u0131nsak da, daha \u00f6nceden var olan koag\u00fclopatinin de d\u00fczeltilmesi gerekli.<\/li>\n<li>Hasta warfarin kullan\u0131yorsa 4 fakt\u00f6rl\u00fc PCC ve 5 mg K vitamini ile warfarin etkisinin geri \u00e7evrilmesi \u00f6nerilir.<\/li>\n<li>Ciddi travmatik beyin hasar\u0131 olan hastalar koag\u00fclopatiye yatk\u0131n. bu hastalar antikoag\u00fclan veya antiplatelet kullan\u0131yorsa plazma veya p\u0131ht\u0131la\u015fma fakt\u00f6rleri veya TS verilmesi sa\u011fkal\u0131ma katk\u0131 sa\u011flar.<\/li>\n<\/ul>\n<h5>Kalsiyum<\/h5>\n<ul>\n<li>Kan \u00fcr\u00fcnlerindeki sitrat kalsiyumu ba\u011flar. Normal \u015fartlar alt\u0131nda sitrat karaci\u011ferde metabolize edilir ancak kan \u00fcr\u00fcnlerinin h\u0131zl\u0131 verildi\u011fi masif transf\u00fczyon durumunda sitrat birikerek hipokalsemiye yol a\u00e7abilir.<\/li>\n<li>Kalsiyum, koag\u00fclasyon kaskad\u0131nda g\u00f6rev ald\u0131\u011f\u0131ndan, hipokalsemi durumunda koag\u00fclopati geli\u015fir.<\/li>\n<li>Her bir masif transf\u00fczyon seti ba\u015f\u0131na 1 gr IV kalsiyum klorid veya 3 gram IV kalsiyum glukonat \u00f6nerilir.<\/li>\n<li>Kalsiyum glukonat damar d\u0131\u015f\u0131na \u00e7\u0131karsa daha az doku hasar\u0131na sebep olaca\u011f\u0131ndan periferik damar yolunda \u00f6ncelikle tercih edilir.<\/li>\n<\/ul>\n<h4>Komplikasyonlar<\/h4>\n<h5>Metabolik alkaloz<\/h5>\n<p>Kan \u00fcr\u00fcnlerindeki Na sitrat ve sitrik asit metabolizmas\u0131yla a\u00e7\u0131\u011fa \u00e7\u0131kan bikarbonat sonucu geli\u015fir.<\/p>\n<h5>Hipokalsemi<\/h5>\n<p>Sitrat\u0131n iyonize kalsiyumu ba\u011flamas\u0131 sonucu geli\u015fir.<\/p>\n<h5>Hipotermi<\/h5>\n<p>Y\u00fcksek miktarda \u0131s\u0131t\u0131lmam\u0131\u015f kan \u00fcr\u00fcn\u00fc verilmesiyle ve maruziyet sonucu geli\u015fir.<\/p>\n<h5>Hiperkalemi<\/h5>\n<p>Beklemi\u015f kan \u00fcr\u00fcnleri kullan\u0131m\u0131n\u0131n sonucu geli\u015febilir.<\/p>\n<h5>Abdominal kompartman sendromu<\/h5>\n<p>Masif transf\u00fczyon yap\u0131lan hastalarda organ perf\u00fczyonunun azalmas\u0131 sonucu iskemi ve organ yetmezli\u011fi geli\u015fmesidir.<\/p>\n<p>20 mmHg veya &lt; 60 mmHg abdominal perf\u00fczyon bas\u0131nc\u0131 + yeni ba\u015flayan tek ya da multiorgan disfonksiyonu varl\u0131\u011f\u0131 ile tan\u0131n\u0131r.<\/p>\n<h5>\u0130mmunojenik reaksiyonlar<\/h5>\n<ul>\n<li>Akut\/gecikmi\u015f hemolitik reaksiyonlar<\/li>\n<li class=\"p1\">Febril non hemolitik reaksiyonlar<\/li>\n<li class=\"p1\">Alerjik reaksiyonlar<\/li>\n<\/ul>\n<h5>TACO (Transfusion Associated Circulatory Overload)<\/h5>\n<p class=\"p1\">Vol\u00fcm y\u00fcklenmesi. TDP ile s\u0131k.<\/p>\n<h5>TRALI (transfusion Related Acute Lung Injury)<\/h5>\n<p class=\"p1\">Kan \u00fcr\u00fcnlerinde bulunan alloreaktif plazma antikorlar\u0131 ile l\u00f6kositlerin aggl\u00fctinasyonu ve aktivasyonu sonucu geli\u015fen akut akci\u011fer hasar\u0131<span class=\"Apple-converted-space\">\u00a0<\/span><\/p>\n<p class=\"p1\">Hafif nefes darl\u0131\u011f\u0131ndan ARDS\u2019ye kadar de\u011fi\u015fken klinik.<\/p>\n<h4>Monitorizasyon<\/h4>\n<ul>\n<li>Monitorizasyonda ama\u00e7 res\u00fcsitasyonun etkinli\u011fini g\u00f6rmek ve ona g\u00f6re tedaviyi titre etmek.<\/li>\n<li>Kan bas\u0131nc\u0131, nab\u0131z, solunum say\u0131s\u0131 ve GKS, daha \u00f6nceden bahsetti\u011fimiz gibi ATLS evrelemesiyle tam e\u015fle\u015fmedi\u011finden yan\u0131lt\u0131c\u0131 olabilir.<\/li>\n<li>Res\u00fcsitasyonda hangi noktada oldu\u011fumuzu anlamak i\u00e7in, doku d\u00fczeyinde metabolik bozukluklar\u0131 g\u00f6steren testler daha g\u00fcvenilir.<\/li>\n<li>Serum baz defisiti ve laktat d\u00fczeyleri \u015fok ile yak\u0131ndan ili\u015fkili.<\/li>\n<li>Baz defisitinin -6 dan fazla olmas\u0131 \u015fok ile yak\u0131ndan ili\u015fkili ve vital parametreleri normal seyreden hastalarda bize okk\u00fclt \u015foku g\u00f6sterebilir.<\/li>\n<li>Ancak baz defisitini etkileyen travmadan ba\u015fka nedenler de mevcut. Diyabet gibi, b\u00f6brek yetmezli\u011fi gibi.<\/li>\n<li>Laktat da baz defisiti ile benzer bilgileri verir. Laktat klerensini takip ederek res\u00fcsitasyonun etkinli\u011fini de\u011ferlendirebiliriz.<\/li>\n<li>Res\u00fcsitasyonun ilk 2 saatinde %20 d\u00fc\u015f\u00fc\u015f kabul edilebilir.<\/li>\n<li>End organ perf\u00fczyonu hedefinin bir g\u00f6stergesi olarak 0.5 ml\/kg\/saat idrar \u00e7\u0131k\u0131\u015f\u0131 g\u00f6r\u00fclmesi de renal perf\u00fczyon i\u00e7in yeterli.<\/li>\n<li>Hasta ba\u015f\u0131nda de\u011ferlendirebilece\u011fimiz geleneksel parametreler ise parmak-v\u00fccut \u0131s\u0131 fark\u0131, kapiller refill gibi g\u00f6stergeler.<\/li>\n<\/ul>\n<h4>Ne zaman sonland\u0131ral\u0131m? &#8211; Hedefler<\/h4>\n<ul>\n<li>Masif transf\u00fczyonu sonland\u0131rmam\u0131z i\u00e7in kanaman\u0131n kontrol alt\u0131na al\u0131nd\u0131\u011f\u0131ndan emin olmam\u0131z gerekiyor<\/li>\n<li>Bunun yan\u0131 s\u0131ra, hastan\u0131n klini\u011finin stabille\u015fmesi, vazopress\u00f6r ihtiyac\u0131n\u0131n ortadan kalkmas\u0131, koag\u00fclasyon parametrelerinin ve kan bile\u015fenlerinin uygun d\u00fczeyde seyretti\u011fini g\u00f6r\u00fcyorsak, baz defisiti ve laktat da perf\u00fczyonun iyile\u015fti\u011fini g\u00f6steriyorsa \u00a0masif transf\u00fczyon protokol\u00fcn\u00fc sonland\u0131rabiliriz.<\/li>\n<\/ul>\n<p><strong>Hedefler<\/strong><\/p>\n<ul>\n<li class=\"p1\">MAP : 60-65 mmHg (vazopress\u00f6r ihtiyac\u0131nda azalma)<\/li>\n<li class=\"p1\">V\u00fccut \u0131s\u0131s\u0131 &gt; 35 C<\/li>\n<li class=\"p1\">Hg : 7-9 g\/dl<\/li>\n<li class=\"p1\">INR &lt; 1.5<\/li>\n<li class=\"p1\">Fibrinojen &gt; 150-200 mg\/dl<\/li>\n<li class=\"p1\">Platelet &gt; 50.000\/dll (TBH\u2019da 100.000)<\/li>\n<li class=\"p1\">pH&gt;7.35-7.45<\/li>\n<li class=\"p1\">Baz defisiti &lt; -6<\/li>\n<li class=\"p1\">Laktat &lt; 4 mmol\/l<\/li>\n<li class=\"p1\">Iyonize kalsiyum &gt; 1.1 mmol\/l<\/li>\n<\/ul>\n<h5>Son olarak<\/h5>\n<ul>\n<li>Masif transf\u00fczyon protokol\u00fcn\u00fcn ba\u015flanmas\u0131yla ilgili, veya optimum ES:TS:TDP oranlar\u0131yla ilgili net bir g\u00f6r\u00fc\u015f birli\u011fi, bir standart yok. Merkezden merkeze de\u011fi\u015fen uygulamalar var.<\/li>\n<li>Ama masif transf\u00fczyon protokol\u00fcnde temel ama\u00e7 kaybedilen kan \u00fcr\u00fcnlerini ve koag\u00fclasyon fakt\u00f6rlerini yerine koymak ve hastaya verilen kan \u00fcr\u00fcn\u00fc i\u00e7eri\u011finin hastan\u0131n kan i\u00e7eri\u011fi ile benzer olmas\u0131n\u0131 sa\u011flamak, kristalloidler ile geli\u015fecek dil\u00fcsyonel koag\u00fclopatiye engel olmak.<\/li>\n<li>Bu hastalar\u0131n esas tedavisinin kanama oda\u011f\u0131n\u0131n kontrol\u00fcd\u00fcr. Masif transf\u00fczyon protokol\u00fcne yo\u011funla\u015f\u0131p kanama kontrol\u00fc giri\u015fimlerinden uzakla\u015fmamam\u0131z gerekiyor.<\/li>\n<\/ul>\n<p>* \u00d6ne \u00e7\u0131kar\u0131lm\u0131\u015f g\u00f6rsel i\u00e7in istockphoto&#8217;ya telif \u00f6denmi\u015ftir.<\/p>\n<hr \/>\n<p><strong>Referanslar\u00a0<\/strong><\/p>\n<ol>\n<li>Mutschler M, Nienaber U, Brockamp T, Wafaisade A, Wyen H, Peiniger S, Paffrath T, Bouillon B, Maegele M; TraumaRegister DGU. A critical reappraisal of the ATLS classification of hypovolaemic shock: does it really reflect clinical reality? Resuscitation. 2013 Mar;84(3):309-13. doi: 10.1016\/j.resuscitation.2012.07.012. Epub 2012 Jul 24. PMID: 22835498.<\/li>\n<li>Mutschler M, Nienaber U, Brockamp T, et al. Renaissance of base deficit for the initial assessment of trauma patients: a base deficit-based classification for hypovolemic shock developed on data from 16,305 patients derived from the TraumaRegister DGU\u00ae.\u00a0<i>Crit Care<\/i>. 2013;17(2):R42. Published 2013 Mar 6. doi:10.1186\/cc12555<\/li>\n<li>Spahn, D.R., Bouillon, B., Cerny, V.\u00a0<i>et al.<\/i>\u00a0The European guideline on management of major bleeding and coagulopathy following trauma: fifth edition.\u00a0<i>Crit Care<\/i>\u00a0<b>23,\u00a0<\/b>98 (2019). https:\/\/doi.org\/10.1186\/s13054-019-2347-3<\/li>\n<li>Savage SA, Zarzaur BL, Croce MA, Fabian TC. Redefining massive transfusion when every second counts. J Trauma Acute Care Surg. 2013 Feb;74(2):396-400; discussion 400-2. doi: 10.1097\/TA.0b013e31827a3639. PMID: 23354230.<\/li>\n<li>Nunez TC, Voskresensky IV, Dossett LA, Shinall R, Dutton WD, Cotton BA. Early prediction of massive transfusion in trauma: simple as ABC (assessment of blood consumption)? J Trauma. 2009 Feb;66(2):346-52. doi: 10.1097\/TA.0b013e3181961c35. PMID: 19204506.<\/li>\n<li>Cotton BA, Dossett LA, Haut ER, Shafi S, Nunez TC, Au BK, Zaydfudim V, Johnston M, Arbogast P, Young PP. Multicenter validation of a simplified score to predict massive transfusion in trauma. J Trauma. 2010 Jul;69 Suppl 1:S33-9. doi: 10.1097\/TA.0b013e3181e42411. PMID: 20622617.<\/li>\n<li>Y\u00fccel N, Lefering R, Maegele M, Vorweg M, Tjardes T, Ruchholtz S, Neugebauer EA, Wappler F, Bouillon B, Rixen D; Polytrauma Study Group of the German Trauma Society. Trauma Associated Severe Hemorrhage (TASH)-Score: probability of mass transfusion as surrogate for life threatening hemorrhage after multiple trauma. J Trauma. 2006 Jun;60(6):1228-36; discussion 1236-7. doi: 10.1097\/01.ta.0000220386.84012.bf. PMID: 16766965.<\/li>\n<li>Maegele M, Lefering R, Wafaisade A, Theodorou P, Wutzler S, Fischer P, Bouillon B, Paffrath T; Trauma Registry of Deutsche Gesellschaft f\u00fcr Unfallchirurgie (TR-DGU). Revalidation and update of the TASH-Score: a scoring system to predict the probability for massive transfusion as a surrogate for life-threatening haemorrhage after severe injury. Vox Sang. 2011 Feb;100(2):231-8. doi: 10.1111\/j.1423-0410.2010.01387.x. Epub 2010 Aug 24. PMID: 20735809.<\/li>\n<li>Vandromme MJ, Griffin RL, Kerby JD, McGwin G Jr, Rue LW 3rd, Weinberg JA. Identifying risk for massive transfusion in the relatively normotensive patient: utility of the prehospital shock index. J Trauma. 2011 Feb;70(2):384-8; discussion 388-90. doi: 10.1097\/TA.0b013e3182095a0a. PMID: 21307738.<\/li>\n<li>Holcomb JB, Tilley BC, Baraniuk S, Fox EE, Wade CE, Podbielski JM, del Junco DJ, Brasel KJ, Bulger EM, Callcut RA, Cohen MJ, Cotton BA, Fabian TC, Inaba K, Kerby JD, Muskat P, O&#8217;Keeffe T, Rizoli S, Robinson BR, Scalea TM, Schreiber MA, Stein DM, Weinberg JA, Callum JL, Hess JR, Matijevic N, Miller CN, Pittet JF, Hoyt DB, Pearson GD, Leroux B, van Belle G; PROPPR Study Group. Transfusion of plasma, platelets, and red blood cells in a 1:1:1 vs a 1:1:2 ratio and mortality in patients with severe trauma: the PROPPR randomized clinical trial. JAMA. 2015 Feb 3;313(5):471-82. doi: 10.1001\/jama.2015.12. PMID: 25647203; PMCID: PMC4374744.<\/li>\n<li>CRASH-2 trial collaborators, Shakur H, Roberts I, Bautista R, Caballero J, Coats T, Dewan Y, El-Sayed H, Gogichaishvili T, Gupta S, Herrera J, Hunt B, Iribhogbe P, Izurieta M, Khamis H, Komolafe E, Marrero MA, Mej\u00eda-Mantilla J, Miranda J, Morales C, Olaomi O, Olldashi F, Perel P, Peto R, Ramana PV, Ravi RR, Yutthakasemsunt S. Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage (CRASH-2): a randomised, placebo-controlled trial. Lancet. 2010 Jul 3;376(9734):23-32. doi: 10.1016\/S0140-6736(10)60835-5. Epub 2010 Jun 14. PMID: 20554319.<\/li>\n<\/ol>\n<p>&nbsp;<\/p>\n","protected":false},"excerpt":{"rendered":"<p>Merhaba. Travma y\u00f6netiminin temel konular\u0131ndan olan masif transf\u00fczyondan bahsedece\u011fiz. Masif transf\u00fczyondan bahsedece\u011fiz ancak, \u00f6ncelikle, herhangi bir transf\u00fczyon i\u00e7in hastan\u0131n kanama durumunu anlamal\u0131y\u0131z.&hellip;<\/p>\n","protected":false},"author":883,"featured_media":476,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_acf_changed":false,"inline_featured_image":false,"_lmt_disableupdate":"","_lmt_disable":"","footnotes":""},"categories":[10010,10014],"tags":[10048,10052,10047,10051,10049,10050,10046],"class_list":["post-472","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-slider","category-akademik-blog-yazisi","tag-hemoraji","tag-hemostatik-resusitasyon","tag-kanama","tag-masif-transfuzyon","tag-resusitasyon","tag-transfuzyon","tag-travma"],"acf":[],"_links":{"self":[{"href":"https:\/\/tatd.org.tr\/travma\/wp-json\/wp\/v2\/posts\/472","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/tatd.org.tr\/travma\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/tatd.org.tr\/travma\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/tatd.org.tr\/travma\/wp-json\/wp\/v2\/users\/883"}],"replies":[{"embeddable":true,"href":"https:\/\/tatd.org.tr\/travma\/wp-json\/wp\/v2\/comments?post=472"}],"version-history":[{"count":0,"href":"https:\/\/tatd.org.tr\/travma\/wp-json\/wp\/v2\/posts\/472\/revisions"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/tatd.org.tr\/travma\/wp-json\/wp\/v2\/media\/476"}],"wp:attachment":[{"href":"https:\/\/tatd.org.tr\/travma\/wp-json\/wp\/v2\/media?parent=472"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/tatd.org.tr\/travma\/wp-json\/wp\/v2\/categories?post=472"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/tatd.org.tr\/travma\/wp-json\/wp\/v2\/tags?post=472"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}