Massive  transfusions for  critical  bleeding: is  everything old new again?

Flint, Andrew W. J.; McQuilten, Zoe; Wood, Erica M.

doi:10.1111/tme.12524

Cited by 18 publications

(24 citation statements)

References 73 publications

(118 reference statements)

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“…Treatment of severely bleeding and coagulopathic trauma patients has evolved considerably over the past two decades. MTPs have been adopted for the treatment of this population . Additionally, in limited military observational data, the concept of component therapy with higher fixed transfusion ratios of FFP and/or PLTs to RBCs has shown a survival benefit leading to an extension of its use to civilian trauma population and other settings .…”

Section: Discussionmentioning

confidence: 99%

“…MTPs have been adopted for the treatment of this population. 79 Additionally, in limited military observational data, the concept of component therapy with higher fixed transfusion ratios of FFP and/or PLTs to RBCs has shown a survival benefit leading to an extension of its use to civilian trauma population and other settings. 80 Currently, most trauma centers use MTPs designed to achieve administration of high amounts of FFP and PLTs early in the resuscitation process.…”

Section: Discussion Main Findingsmentioning

confidence: 99%

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Does the evidence support the importance of high transfusion ratios of plasma and platelets to red blood cells in improving outcomes in severely injured patients: a systematic review and meta‐analyses

et al. 2019

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BACKGROUNDDeaths by exsanguination in trauma are preventable with hemorrhage control and resuscitation with allogeneic blood products (ABPs). The ideal transfusion ratio is unknown. We compared efficacy and safety of high transfusion ratios of FFP:RBC and PLT:RBC with low ratios in trauma.STUDY DESIGN AND METHODSMedline, Embase, Cochrane, and Controlled Clinical Trials Register were searched. Observational and randomized data were included. Risk of bias was assessed using validated tools. Primary outcome was 24‐h and 30‐day mortality. Secondary outcomes were exposure to ABPs and improvement of coagulopathy. Meta‐analysis was conducted using a random‐effects model. Strength and evidence quality were graded using GRADE profileRESULTS55 studies were included (2 randomized and 53 observational), with low and moderate risk of bias, respectively, and overall low evidence quality. The two RCTs showed no mortality difference (odds ratio [OR], 1.35; 95% confidence interval [CI], 0.40‐4.59). Observational studies reported lower mortality in high FFP:RBCs ratio (OR, 0.38 [95% CI, 0.22‐0.68] for 1:1 vs. <1:1; OR, 0.42 [95% CI, 0.22‐0.81] for 1:1.5 vs. <1:1.5; and OR, 0.47 [95% CI, 0.31‐0.71] for 1:2 vs. <1:2, respectively). Meta‐analyses in observational studies showed no difference in exposure to ABPs. No data on coagulopathy for meta‐analysis was identified.CONCLUSIONSMeta‐analyses in observational studies suggest survival benefit and no difference in exposure to ABPs. No survival benefit in RCTs was identified. These conflicting results should be interpreted with caution. Studies are mostly observational, with relatively small sample sizes, nonrandom treatment allocation, and high potential for confounding. Further research is warranted.

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Section: Discussionmentioning

confidence: 99%

Section: Discussion Main Findingsmentioning

confidence: 99%

Does the evidence support the importance of high transfusion ratios of plasma and platelets to red blood cells in improving outcomes in severely injured patients: a systematic review and meta‐analyses

et al. 2019

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“…To date, no consensus has been reached regarding what, when, how much fluid, and what blood component should be given during massive transfusion [ 10 ]. Appropriate blood component therapy during hemostatic resuscitation might be different between intraoperative bleeding and traumatic bleeding.…”

Section: Introductionmentioning

confidence: 99%

Comparing hemostatic resuscitation management of intraoperative massive bleeding with traumatic massive bleeding: a computer simulation

et al. 2020

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Background: Appropriate blood component transfusion might differ between intraoperative massive bleeding and traumatic massive bleeding in the emergency department because trauma patients initially bleed undiluted blood and replacement typically lags behind blood loss. We compared these two blood loss scenarios, intraoperative and traumatic, using a computer simulation.Methods: We modified the multi-compartment dynamic model developed by Hirshberg and implemented it using STELLA 9.0. In this model, blood pressure changes as blood volume fluctuates as bleeding rate and transcapillary refill rate are controlled by blood pressure. Using this simulation, we compared the intraoperative bleeding scenario with the traumatic bleeding scenario. In both scenarios, patients started to bleed at a rate of 50 ml/min. In the intraoperative bleeding scenario, fluid was administered to maintain isovolemic status; however, in the traumatic bleeding scenario, no fluid was supplied for up to 30 min and no blood was supplied for up to 50 min. Each unit of packed red blood cells (PRBC) was given when the hematocrit decreased to 27%, fresh frozen plasma (FFP) was transfused when plasma was diluted to 30%, and platelet concentrate (PC) was transfused when platelet count became 50,000/ml.Results: In both scenarios, the appropriate ratio of PRBC:FFP was 1:0.47 before PC transfusion, and the ratio of PRBC:FFP:platelets was 1:0.35:0.39 after initiation of PC transfusion.Conclusion: The ratio of transfused blood component did not differ between the intraoperative bleeding and traumatic bleeding scenarios.

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“…() provide practical advice on transfusion management in stable gastrointestinal haemorrhage, whereas Flint et al . () discuss the most recent approach to transfusion in major haemorrhage.…”

mentioning

confidence: 99%

“…Crighton et al (2018) highlight that the evidence base for transfusion in neonates lags behind that in adults and propose specific PBM criteria for neonates. Gastrointestinal bleeding is a common medical and surgical emergency, and Oakland et al (2018) provide practical advice on transfusion management in stable gastrointestinal haemorrhage, whereas Flint et al (2018) discuss the most recent approach to transfusion in major haemorrhage.…”

mentioning

confidence: 99%