Trauma resuscitation requiring massive transfusion: a descriptive analysis of the role of ratio and time

Abstract

ObjectiveWe aimed to evaluate whether early administration of high plasma to red blood cells ratios influences outcomes in injured patients who received massive transfusion protocol (MTP).MethodsA retrospective analysis was conducted at the only level 1 national trauma center in Qatar for all adult patients(≥18 years old) who received MTP (≥10 units) of packed red blood cell (PRBC) during the initial 24 h post traumatic injury. Data were analyzed with respect to FFB:PRBC ratio [(high ≥ 1:1.5) (HMTP) vs. (low < 1:1.5) (LMTP)] given at the first 4 h post-injury and also between (>4 and 24 h). Mortality, multiorgan failure (MOF) and infectious complications were studied as well.ResultsDuring the study period, a total of 4864 trauma patients were admitted to the hospital, 1.6 % (n = 77) of them met the inclusion criteria. Both groups were comparable with respect to initial pH, international normalized ratio, injury severity score, revised trauma score and development of infectious complications. However, HMTP was associated with lower crude mortality (41.9 vs. 78.3 %, p = 0.001) and lower rate of MOF (48.4 vs. 87.0 %, p = 0.001). The number of deaths was 3 times higher in LMTP in comparison to HMTP within the first 30 days (36 vs. 13 cases). The majority of deaths occurred within the first 24 h (80.5 % in LMTP and 69 % in HMTP) and particularly within the first 6 h (55 vs. 46 %).ConclusionsAggressive attainment of high FFP/PRBC ratios as early as 4 h post-injury can substantially improve outcomes in trauma patients.

Early high ratio platelet transfusion in trauma resuscitation and its outcomes

“…We defined massive transfusion as the infusion of ≥10 units of PRBC over the initial 24 h postinjury. [6] Patient's data regarding demographics, mechanism of injury, initial vitals, laboratory findings, Injury Severity Score (ISS), Revise Trauma Score (RTS), Glasgow Coma Score, hospital length of stay, complications, and outcomes were collected from the trauma registry database. Based on PLT:PRBC ratio, patients who received at least a PLT:PRBC ratio of ≥1:1.5 within 4 h from the time of injury was categorized into the high ratio group (HMTP).…”

Descriptive characteristics and in‐hospital mortality of critically bleeding patients requiring massive transfusion: results from the Australian and New Zealand Massive Transfusion Registry

“…Critical bleeding requiring massive transfusion (MT) remains a major cause of death in diverse clinical settings . However, previous research describing the outcomes of MT has largely been limited to trauma or surgery, and mainly focussed on ratios of blood products in relation to survival . More recently, studies have been published describing transfusion support and patient outcomes across the range of bleeding contexts .…”

Investigation of the status quo of massive blood transfusion in China and a synopsis of the proposed guidelines for massive blood transfusion

“…Therefore, early transfusion of FFP and PLT at appropriate ratios plays an important role in preventing coagulation disorders. [ 18 , 21 , 26 – 28 ] Our findings suggest that the amount of blood components replenished should increase proportionally to blood dilution levels at different time points, and that a medium FFP:RBCs ratio of 1:1.5 or the 1:1.3:0.9 RBCs:FFP:PLT ratio (based on in vitro experiments) is optimal to prevent common coagulation disorders and reduce fatality rate related to massive transfusion. [ 19 ] Our proposed ratios are the closest approximation to reconstituted whole blood and are in line with the 1:1:1 RBCs:FFP:PLT transfusion ratio recommended in the international literature.…”

“…This practice is in accordance with the finding that balanced use of plasma early in resuscitation was associated with improved survival rates especially among trauma patients. [ 25 – 28 ] However, insufficient consideration is given to the use of platelets and cryoprecipitate. [ 15 , 16 ] According to American Association of Blood Banks recommendation, early initiation of prophylactic PLT transfusion among adult patients with a platelet count of 10 × 10 9 cells/L or less may reduce the risk for spontaneous bleeding.…”

“…Dose: early high transfusion ratio of FFP and PLT suspension can improve patient survival, [ 26 – 28 , 44 – 46 ] as well as reduce the transfusion volume of the RBC suspension. A recommended transfusion ratio of RBCs:FFP:PLT suspension is 1:1:1 (1 U manually-collected PLT suspension is prepared from 200 mL whole blood; 1 bag of machine-collected PLT suspension is equivalent to a treatment dosage of 10 U PLT, and volume is between 200 and 250 mL).…”