Outcomes of patients receiving a massive transfusion for major trauma

Endo, Akira; Shiraishi, Atsushi; Fushimi, Kiyohide; Murata, Kiyoshi; Otomo, Yasuhiro

doi:10.1002/bjs.10905

Cited by 19 publications

(28 citation statements)

References 37 publications

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“… 11 Transfusion strategies of high plasma to RBC and platelet/RBC ratios did not have survival benefits but were associated with an increase in adverse events. 12 REBOA is also an important approach in trauma and emergency medicine, 3 13 14 but the use of plasma and REBOA for trauma remains controversial. Some large studies have shown a higher mortality rate in severely injured trauma patients who underwent REBOA than in those who did not.…”

Section: Discussionmentioning

confidence: 99%

Impact of a streamlined trauma management approach and determinants of mortality among hemodynamically unstable patients with severe multiple injuries: a before-and-after retrospective cohort study

Otsuka

Uehata

Sakoda

et al. 2020

Trauma Surg Acute Care Open

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BackgroundTrauma management requires a multidisciplinary approach, but coordination of staff and procedures is challenging in patients with severe trauma. In October 2014, we implemented a streamlined trauma management system involving emergency physicians trained in severe trauma management, surgical techniques, and interventional radiology. We evaluated the impact of streamlined trauma management on patient management and outcomes (study 1) and evaluated determinants of mortality in patients with severe trauma (study 2).MethodsWe conducted a retrospective cohort study of 125 patients admitted between January 2011 and 2019 with severe trauma (Injury Severity Score ≥16) and persistent hypotension (≥2 systolic blood pressure measurements <90 mm Hg). Patients were divided into a Before cohort (January 2011 to September 2014) and an After cohort (October 2014 to January 2019) according to whether they were admitted before or after the new approach was implemented. The primary outcome was in-hospital mortality.ResultsCompared with the Before cohort (n=59), the After cohort (n=66) had a significantly lower in-hospital mortality (36.4% vs. 64.4%); required less time from hospital arrival to initiation of surgery/interventional radiology (median, 41.0 vs. 71.5 minutes); and was more likely to undergo resuscitative endovascular balloon occlusion of the aorta (24.2% vs. 6.8%). Plasma administration before initiating hemostasis (adjusted OR 1.49 (95% CI 1.04 to 2.14)), resuscitative endovascular balloon occlusion of the aorta (9.48 (95% CI 1.25 to 71.96)), and shorter time to initiation of surgery/interventional radiology (0.97 (95% CI 0.96 to 0.99)) were associated with significantly lower mortality.DiscussionImplementing a streamlined trauma management protocol improved outcomes among hemodynamically unstable patients with severe multiple trauma.Level of evidenceLevel III.

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Section: Discussionmentioning

confidence: 99%

Impact of a streamlined trauma management approach and determinants of mortality among hemodynamically unstable patients with severe multiple injuries: a before-and-after retrospective cohort study

Otsuka

Uehata

Sakoda

et al. 2020

Trauma Surg Acute Care Open

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“…First, early plasma treatment might improve mortality and increase the risk of complications. 5,6,11,12 Therefore, we used in-hospital mortality as an objective variable to analyze the independent risk factors. Second, we did not include age, mechanism of injury, or Revised Trauma Score in the multivariable logistic regression analysis because variables did not differ significantly between the two groups.…”

Section: Discussionmentioning

confidence: 99%

“…It is difficult to determine the optimal volume of plasma before or after the initiation of hemostasis. Additionally, giving high volumes of plasma in relation to PRBC can have harmful effects, such as acute lung injury‐induced acute respiratory distress syndrome 11,12 . We used laboratory evaluations, such as hemoglobin, fibrinogen, and PT‐INR, to decide whether to continue transfusion of PRBC and plasma when the patients became hemodynamically stable.…”

Section: Discussionmentioning

confidence: 99%

Indications for early plasma transfusion and its optimal use following trauma

Otsuka

Sakoda

Uehata

et al. 2020

Acute Medicine & Surgery

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This study aimed to evaluate the effect of plasma transfusion before urgent hemostasis initiation on in-hospital mortality in hemodynamically unstable patients with severe trauma. Methods: This retrospective observational study of patients admitted to hospital between January 2011 and January 2019 grouped patients according to whether plasma transfusion was initiated before (Before group) or after (After group) hemostasis initiation. Patients with severe trauma who were unable to wait for plasma transfusion and had started hemostasis before the plasma infusion were excluded. We used multivariable logistic regression analysis to determine the effect of plasma transfusion before the initiation of urgent hemostasis on in-hospital mortality. Results: We included 47 and 73 patients in the Before and After groups, respectively. Blunt trauma was more common, and the Ddimer levels and Injury Severity Score were significantly higher in the Before group than in the After group (median D-dimer, 57.5 versus 38.1 lg/mL; P = 0.040; median Injury Severity Score, 50 versus 34; P < 0.001). Plasma given before hemostasis initiation was associated with significantly lower in-hospital mortality (adjusted odds ratio, 0.27; 95% confidence interval, 0.078-0.900; P = 0.033) in contrast with the total plasma volume given in the first 6 or 24 h. Conclusion: Plasma transfusion before hemostasis initiation could be an important factor for improving outcomes in hemodynamically unstable patients with blunt trauma, high D-dimer levels, or a high Injury Severity Score.

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“…In this study, the lungs tended to be more severely damaged in high PLT dose group, although not reaching statistical significance. Although an optimal PLT-to-RBC ratio of 1.6 has been suggested [16], however, it remains to be determined whether higher doses of PLTs in massively transfused patients increases the risk of lung injury. Other organ failures were not different between groups, suggesting that a high PLT dose does not augment the risk of organ injury.…”

Section: Discussionmentioning

confidence: 99%

“…Although current resuscitation strategies aim to reach a 1:1 PLT-to-RBC ratio, it is unknown whether increasing the dose to even higher ratios (> 1:1) may further improve clot formation, resulting in earlier hemostasis with subsequent improved outcome. On the other hand, high PLT doses may also predispose patients to the development of adverse events, mediated by platelet aggregation, thereby promoting (micro) thrombi formation, which may lead to thromboembolic events and/or MODS [16]. A possible mechanism of harm leading to these adverse events might be the release of trauma alarmin high-mobility group box 1 (HMGB-1), passively released by endothelial cell damage and actively secreted by platelets [17, 18].…”

Section: Introductionmentioning

confidence: 99%

Use of a high platelet-to-RBC ratio of 2:1 is more effective in correcting trauma-induced coagulopathy than a ratio of 1:1 in a rat multiple trauma transfusion model

Kleinveld

Wirtz

Brink

et al. 2019

ICMx

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Background Platelet dysfunction importantly contributes to trauma-induced coagulopathy (TIC). Our aim was to examine the impact of transfusing platelets (PLTs) in a 2:1 PLT-to-red blood cell (RBC) ratio versus the standard 1:1 ratio on transfusion requirements, correction of TIC, and organ damage in a rat multiple trauma transfusion model. Methods Mechanically ventilated male Sprague Dawley rats were traumatized by crush injury to the small intestine and liver and a fracture of the femur, followed by exsanguination until a mean arterial pressure (MAP) of 40 mmHg. Animals were randomly assigned to receive resuscitation in a high PLT dose (PLT to plasma to RBC in a ratio of 2:1:1) or a standard PLT dose (ratio of 1:1:1) until a MAP of 60 mmHg was reached ( n = 8 per group). Blood samples were taken for biochemical and thromboelastometry (ROTEM) assessment. Organs were harvested for histopathology.Outcome measures were transfusion requirements needed to reach a pretargeted MAP, as well as ROTEM correction and organ failure. Results Trauma resulted in coagulopathy as assessed by deranged ROTEM results. Mortality rate was 19%, with all deaths occurring in the standard dose group. The severity of hypovolemic shock as assessed by lactate and base excess was not different in both groups. The volume of transfusion needed to reach the MAP target was lower in the high PLT dose group compared to the standard dose, albeit not statistically significant ( p = 0.054). Transfusion with a high PLT dose resulted in significant stronger clot firmness compared to the standard dose at all time points following trauma, while platelet counts were similar. Organ failure as assessed by biochemical analysis and histopathology was not different between groups, nor were there any thromboembolic events recorded. Conclusions Resuscitation with a high (2:1) PLT-to-RBC ratio was more effective compared to standard (1:1) PLT-to-RBC ratio in treating TIC, with a trend towards reduced transfusion volumes. Also, high PLT dose did not aggravate organ damage. Transfusion strategies using higher PLT dose regiments might be a feasible treatment option in hemorrhaging trauma patients for the correction of TIC.

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Outcomes of patients receiving a massive transfusion for major trauma

Abstract: In this study, transfusion strategies with high plasma to red blood cell and platelet to red blood cell ratios did not have survival benefits, but were associated with an increase in adverse events.

Cited by 19 publications

References 37 publications

Impact of a streamlined trauma management approach and determinants of mortality among hemodynamically unstable patients with severe multiple injuries: a before-and-after retrospective cohort study

Impact of a streamlined trauma management approach and determinants of mortality among hemodynamically unstable patients with severe multiple injuries: a before-and-after retrospective cohort study

Indications for early plasma transfusion and its optimal use following trauma

Use of a high platelet-to-RBC ratio of 2:1 is more effective in correcting trauma-induced coagulopathy than a ratio of 1:1 in a rat multiple trauma transfusion model

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