Do not forget the platelets: The independent impact of red blood cell to platelet ratio on mortality in massively transfused trauma patients

Gallastegi, Ander Dorken; Naar, Leon; Gaitanidis, Apostolos; Gebran, Anthony; Nederpelt, Charlie; Parks, Jonathan; Hwabejire, John O.; Fawley, Jason; Mendoza, April E.; Saillant, Noelle; Fagenholz, Peter J.; Velmahos, George C.; Kaafarani, Haytham M.A.

doi:10.1097/ta.0000000000003598

Cited by 15 publications

(13 citation statements)

References 49 publications

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“…The effect of higher platelet doses as well as empiric platelet transfusion in trauma patients without thrombocytopenia as part of a balanced transfusion strategy with other blood products is controversial. Data from French [ 262 ] and US [ 312 ] trauma registries support platelet transfusion despite a normal platelet count [ 262 ] and maintenance of a platelet/pRBC ratio closer to1:1, respectively. Recent systematic reviews also found that higher platelet/pRBC ratios result in a significant decrease in short-term (24 h) and long-term (28–30 day) mortalities [ 313 , 314 ], lower ICU length of stay (LOS) and higher ICU-free days [ 314 ], without influencing the occurrence of thromboembolic events or organ failure [ 313 ] when compared with lower platelet/pRBC ratios.…”

Section: Resultsmentioning

confidence: 99%

The European guideline on management of major bleeding and coagulopathy following trauma: sixth edition

et al. 2023

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Background Severe trauma represents a major global public health burden and the management of post-traumatic bleeding continues to challenge healthcare systems around the world. Post-traumatic bleeding and associated traumatic coagulopathy remain leading causes of potentially preventable multiorgan failure and death if not diagnosed and managed in an appropriate and timely manner. This sixth edition of the European guideline on the management of major bleeding and coagulopathy following traumatic injury aims to advise clinicians who care for the bleeding trauma patient during the initial diagnostic and therapeutic phases of patient management. Methods The pan-European, multidisciplinary Task Force for Advanced Bleeding Care in Trauma included representatives from six European professional societies and convened to assess and update the previous version of this guideline using a structured, evidence-based consensus approach. Structured literature searches covered the period since the last edition of the guideline, but considered evidence cited previously. The format of this edition has been adjusted to reflect the trend towards concise guideline documents that cite only the highest-quality studies and most relevant literature rather than attempting to provide a comprehensive literature review to accompany each recommendation. Results This guideline comprises 39 clinical practice recommendations that follow an approximate temporal path for management of the bleeding trauma patient, with recommendations grouped behind key decision points. While approximately one-third of patients who have experienced severe trauma arrive in hospital in a coagulopathic state, a systematic diagnostic and therapeutic approach has been shown to reduce the number of preventable deaths attributable to traumatic injury. Conclusion A multidisciplinary approach and adherence to evidence-based guidelines are pillars of best practice in the management of severely injured trauma patients. Further improvement in outcomes will be achieved by optimising and standardising trauma care in line with the available evidence across Europe and beyond.

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Section: Resultsmentioning

confidence: 99%

The European guideline on management of major bleeding and coagulopathy following trauma: sixth edition

et al. 2023

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“…Platelets are important in the treatment of bleeding but are often not available or of insufficient supply in many rural hospitals in our country as well as other countries and thus bleeding patients may not be optimally treated (2,21). Initially, we included patients in two remote hospitals.…”

Section: Discussionmentioning

confidence: 99%

“…As a result, many smaller hospitals have no platelets stored locally, leading to several hours of delay before treatment. In treatment guidelines for bleeding, the early use of blood products is recommended and has improved survival (2,3). Platelets are crucial for hemostasis in bleeding patients (4) resulting in reduced use of red blood cells and plasma products, which is important in hospitals with limited blood inventory (5).…”

Section: Introductionmentioning

confidence: 99%

Cryopreserved platelets in bleeding management in remote hospitals: A clinical feasibility study in Sweden

Wikman

Diedrich

Björling

et al. 2023

Front. Public Health

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BackgroundBalanced transfusions, including platelets, are critical for bleeding patients to maintain hemostasis. Many rural hospitals have no or limited platelet inventory, with several hours of transport time from larger hospitals. This study aimed to evaluate the feasibility of using cryopreserved platelets that can be stored for years, in remote hospitals with no or limited platelet inventory.Material and methodsThree remote hospitals participated in a prospective study including adult bleeding patients where platelet transfusions were indicated. Cryopreserved platelets were prepared in a university hospital, concentrated in 10 ml, transported on dry ice, and stored at −80°C at the receiving hospital. At request, the concentrated platelet units were thawed and diluted in fresh frozen plasma. The indications, blood transfusion needs, and laboratory parameters pre- and post-transfusion, as well as logistics, such as time from request to transfusion and work efforts in preparing cryopreserved platelets, were evaluated.ResultsTwenty-three bleeding patients were included. Nine patients (39%) were treated for gastrointestinal bleeding, five (22%) for perioperative bleeding, and four (17%) for trauma bleeding. The transfusion needs were 4.9 ± 3.3 red blood cell units, 3.2 ± 2.3 plasma units, and 1.9 ± 2.2 platelet units, whereof cryopreserved were 1.5 ± 1.1 (mean ± SD). One patient had a mild allergic reaction. We could not show the difference in laboratory results between pre- and post-transfusion of the cryopreserved units in the bleeding patients. The mean time from the order of cryopreserved platelets to transfusion was 64 min, with a range from 25 to 180 min.ConclusionCryopreserved platelets in remote hospitals are logistically feasible in the treatment of bleeding. The ability to have platelets in stock reduces the time to platelet transfusion in bleeding patients where the alternative often is many hours delay. Clinical effectiveness and safety previously shown in other studies are supported in this small feasibility study.

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“…The three exposure groups will be defined as receipt of (1) only WFWB, (2) only LTOWB, and (3) both WFWB and LTOWB compared with the receipt of a 1:1:1 balanced ratio of plasma/platelets/RBCs (nonexposure). Balanced component transfusion will be defined as RBC/plasma ≤2 and RBC/platelet ≤2 22,23 …”

Section: Methodsmentioning

confidence: 99%

Determining resuscitation outcomes in combat casualties: Design of the Deployed Hemostatic Emergency Resuscitation of Traumatic Exsanguinating Shock (Deployed HEROES) study

Gurney

Staudt

Junco

et al. 2022

J Trauma Acute Care Surg

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BACKGROUND:During the course of the recent conflicts, the recommendations for resuscitation practices have evolved, but there has been no comprehensive comparative effectiveness study of these resuscitation strategies. The objective of this study was to describe the development and study design of the Deployed Hemostatic Emergency Resuscitation of Traumatic Exsanguinating Shock (Deployed HEROES) study-the first comprehensive analysis of military resuscitation practices in the deployed environment from October 2001 to October 2019. METHODS:This retrospective cohort study uses the Department of Defense Trauma Registry, Armed Services Blood Program database, and Military Trauma Mortality Review, while abstractors will use Theater Medical Data Store and Web Interface Patient Records to collect transfusion timing data. This study includes patients, who received blood products or died before receiving blood, treated at US military medical treatment facilities. The primary endpoints are survival at 6 hours, 24 hours, and 30 days postinjury. Secondary outcomes include infection, renal dysfunction, pulmonary dysfunction, and thromboembolic event. Exposure will be defined by blood product transfusion. Study groups will be frequency matched. Cox proportional hazards will compare patients who received warm fresh whole blood, low titer type-O whole blood, or only component therapy, while using adjustment for type of blood product transfused as a time-dependent covariate. Multilevel mixed-effects logistic regression will determine the effect of incompatible plasma in low titer type-O whole blood. RESULTS:An analysis plan for the Deployed HEROES study was developed with the aim of minimizing bias. CONCLUSION:This study will inform the optimal resuscitation strategies, which will potentially have a substantial impact on combat mortality. If whole blood is found to be the optimal transfusion strategy, this finding will be crucial in future operating environments involving dispersed medical assets. These results will provide critical information necessary for combat casualty care guidelines.

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Do not forget the platelets: The independent impact of red blood cell to platelet ratio on mortality in massively transfused trauma patients

Abstract: In this nationwide analysis of massively transfused trauma patients, unbalanced PLT transfusion was more prevalent than unbalanced FFP. The impact of unbalanced PLT transfusion on 24-hour mortality was independent from and potentially more pronounced than unbalanced FFP.

Cited by 15 publications

References 49 publications

The European guideline on management of major bleeding and coagulopathy following trauma: sixth edition

The European guideline on management of major bleeding and coagulopathy following trauma: sixth edition

Cryopreserved platelets in bleeding management in remote hospitals: A clinical feasibility study in Sweden

Determining resuscitation outcomes in combat casualties: Design of the Deployed Hemostatic Emergency Resuscitation of Traumatic Exsanguinating Shock (Deployed HEROES) study

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