Red blood cell to plasma ratios transfused during massive transfusion are associated with mortality in severe multiply injury: a retrospective analysis from the Trauma Registry of the Deutsche Gesellschaft fr Unfallchirurgie

Vox Sanguinis (Impact Factor: 3.3). 07/2008; 95(2):112 - 119. DOI: 10.1111/j.1423-0410.2008.01074.x

ABSTRACT Background To test whether an acute transfusion practice of packed red blood cells (pRBC) : fresh-frozen plasma (FFP) 1 : 1 would be associated with reduced mortality in acute bleeding multiply injury.Methods Retrospective analysis using the TR-DGU database (Trauma Registry of the Deutsche Gesellschaft für Unfallchirurgie 2002–2006) on primary admissions with substantial injury (Injury Severity Score > 16) and massive transfusion (> 10 pRBCs). Seven hundred thirteen patients were divided into three groups according to the pRBC : FFP ratio transfused, that is, (i) pRBC : FFP > 1·1; (ii) pRBC : FFP 0·9–1·1 (1 : 1); and (iii) pRBC : FFP < 0·9, and mortality rates were compared.Results Four hundred ninety-seven (69·7%) of patients were male, the mean age was 40·1 (± 18·3) years. Injury characteristics and pathophysiological state upon emergency room arrival were comparable between groups. Out of 713, 484 patients had undergone massive transfusion with pRBC : FFP > 1·1, 114 with pRBC : FFP 0·9–1·1 (1 : 1), and 115 with pRBC : FFP < 0·9 ratios. Acute mortality (< 6 h) rates for pRBC : FFP > 1·1, pRBC : FFP 0·9–1·1 (1 : 1), and pRBC : FFP < 0·9 ratios were 24·6, 9·6 and 3·5% (P < 0·0001), 24-h mortality rates were 32·6, 16·7 and 11·3% (P < 0·0001), and 30-day mortality rates were 45·5, 35·1 and 24·3% (P < 0·001). The frequency for septic complications and organ failure was higher in the pRBC : FFP 0·9–1·1 (1 : 1) group, ventilator days and length of stays for intensive care unit and overall in-hospital were highest in the pRBC : FFP < 0·9 ratio group (P < 0·0005).Conclusions An association between pRBC : FFP transfusion ratios and mortality to favour early aggressive FFP administration was observed. Further investigation is necessary prior to recommending routine 1 : 1 or more aggressive FFP use in exsanguinating patients.


Available from: Rolf Lefering, Oct 02, 2014
1 Follower
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Although terrorist bombings have tormented the world for a long time, currently they have reached unprecedented levels and become a continuous threat without borders, race or age. Almost all of them are caused by improvised explosive devices. The unpredictability of the terrorist bombings, leading to simultaneous generation of a large number of casualties and severe "multidimensional" blast trauma require a constant vigilance and preparedness of every hospital worldwide. Approximately 1-2.6% of all trauma patients and 7% of the combat casualties require a massive blood transfusion. Coagulopathy is presented in 65% of them with mortality exceeding 50%. Damage control resuscitation is a novel approach, developed in the military practice for treatment of this subgroup of trauma patients. The comparison with the conventional approach revealed mortality reduction with 40-74%, lower frequency of abdominal compartment syndrome (8% vs. 16%), sepsis (9% vs. 20%), multiorgan failure (16% vs. 37%) and a significant reduction of resuscitation volumes, both crystalloids and blood products. DCS and DCR are promising new approaches, contributing for the mortality reduction among the most severely wounded patients. Despite the lack of consensus about the optimal ratio of the blood products and the possible influence of the survival bias, we think that DCR carries survival benefit and recommend it in trauma patients with exsanguinating bleeding.
    06/2014; 1:13. DOI:10.1186/2054-9369-1-13
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: IntroductionDifferent transfusion ratio concepts of packed red blood cells (pRBCs), fresh frozen plasma (FFP) and platelets (PLTs) have been implemented in trauma care, but the optimal ratios are still discussed. In this study the hemostatic potential of two predefined ratios was assessed by using an in vitro thrombelastometric approach. Furthermore, age effects of reconstituted blood were analyzed.Methods Whole blood (WB) of voluntary donors was separated into pRBCs, FFP and PLTs and reconstituted into the ratios 1:1:1 and 3:1:1 at day 1, 4, 14, and 24. Standard blood count, electrolytes and coagulation proteins were quantified. The functional coagulation in ratio- and age-specific groups was evaluated using rotational thromboelastometry (ROTEM).ResultsSeveral coagulation factors reduced significantly in the 3:1:1 ratio and were consistent with increased INR, decelerated clot formation times and A10 (amplitude 10 minutes after clotting time (CT)), flattened ¿-angle during the EXTEM and diminished MCF for distinct time points during the INTEM, FIBTEM and APTEM assays. With rising age of pRBCs the pH, sodium and potassium reached non-physiological levels.Conclusion Under standardized in vitro conditions the higher amount of pRBCs in the 3:1:1 ratio diluted coagulation factors significantly on the expense of its functional coagulation capacity as revealed by ROTEM results. Thus, the coagulation functionality of the 1:1:1 ratio predominated.
    Scandinavian Journal of Trauma Resuscitation and Emergency Medicine 01/2015; 23(1):2. DOI:10.1186/s13049-014-0080-0 · 1.93 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Haemorrhage is the principal cause of death in the first few hours following severe injury. Coagulopathy is a frequent complication of critical bleeding. A network of Italian Trauma Centres, recently developed a protocol to prevent and treat trauma-induced coagulopathy. A pre/post-cohort multicenter study was conducted to assess the impact of the Early Coagulation Support (ECS) protocol on blood products consumption, mortality and treatment costs. We prospectively collected data from all severely injured patients (ISS > 15) admitted to two Trauma Centers in 2013 and compared these findings with the same time period in 2011. Patients transfused with at least three units of Packed Red Blood Cells (PRBC) within 24 hours of an accident were included in the study. In 2011, patients with significant hemorrhaging were treated with "early" administration of plasma aiming at a high (≥1:2) Plasma/to PRBC ratio. In 2013 the ECS protocol was the treatment strategy. Outcome data, blood products consumption and treatment costs were compared. The two groups were well matched for demographics, injury severity (ISS 32.9 vs. 33.6), clinical and laboratory data on admission. In 2013 a 40% overall reduction in PRBCs was observed , together with a 65% reduction for plasma and 52% for platelets (PTL). Patients in the ECS group received fewer blood products: 6.51 units of PRBC vs. 8.14. Plasma transfusions decreased from 8.98 units to 4.21 (p < 0.05) and platelets from 4.14 units to 2.53 (p < 0.05). Mortality in 2013 was 13.4% vs. 20% in 2011 (13 vs. 26) (n.s.). When costs for blood components, factors and point-of-care tests were compared, a 76,340 saving in 2013 vs. 2011 (23%) was recorded. The introduction of the ECS protocol in two Italian Trauma Centers was associated with a marked reduction in blood products consumption, reaching statistical significance for plasma and platelets, and with a non-significant trend toward a reduction in early and 28-days mortality. The overall costs for transfusion and coagulation support (including point-of-care tests) decreased by 23%.
    Critical care (London, England) 12/2015; 19(1):817. DOI:10.1186/s13054-015-0817-9