Working Group on Polytrauma of the German Society of Trauma Surgery (DGU). Red-blood-cell to plasma ratios transfused during massive transfusion are associated with mortality in severe multiple injury: a retrospective analysis from the Trauma Registry of the Deutsche Gesellschaft für Unfallchirurgie

Vox Sanguinis (Impact Factor: 2.8). 07/2008; 95(2):112 - 119. DOI: 10.1111/j.1423-0410.2008.01074.x


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.

Download full-text


Available from: Rolf Lefering, Oct 02, 2014
1 Follower
128 Reads
  • Source
    • "While the immediate deaths after trauma are usually due to apnoea, severe brain or spinal cord injury or large vessel rupture, early deaths often result from rapidly evolving and deteriorating secondary complications such as shock, hypoxia, respiratory failure or uncontrolled hemorrhage. It has frequently been shown that early detection and aggressive management of complications secondary to trauma may improve survival and outcome for example via early damage control resuscitation [3-5]. To date, the Advanced Trauma Life Support (ATLS) has been implemented widely as a standard of care for initial assessment and treatment in trauma centres on the premise to “treat first what kills first”. "
    [Show abstract] [Hide abstract]
    ABSTRACT: Trauma is the leading cause of death in young people with an injury related mortality rate of 47.6/100,000 in European high income countries. Early deaths often result from rapidly evolving and deteriorating secondary complications e.g. shock, hypoxia or uncontrolled hemorrhage. The present study assessed how well ABC priorities (A: Airway, B: Breathing/Ventilation and C: Circulation with hemorrhage control) with focus on the C-priority including coagulation management are addressed during early trauma care and to what extent these priorities have been controlled for prior to ICU admission among patients arriving to the ER in states of moderate or severe hemorrhagic shock. A retrospective analysis of data documented in the TraumaRegister of the ‘Deutsche Gesellschaft für Unfallchirurgie’ (TR-DGU®) was conducted. Relevant clinical and laboratory parameters reflecting status and basic physiology of severely injured patients (ISS ≥ 25) in either moderate or severe shock according to base excess levels (BE -2 to -6 or BE < -6) as surrogate for shock and hemorrhage combined with coagulopathy (Quick’s value <70%) were analyzed upon ER arrival and ICU admission. A total of 517 datasets was eligible for analysis. Upon ICU admission shock was reversed to BE > -2 in 36.4% and in 26.4% according to the subgroups. Two of three patients with initially moderate shock and three out of four patients with severe shock upon ER arrival were still in shock upon ICU admission. All patients suffered from coagulation dysfunction upon ER arrival (Quick’s value ≤ 70%). Upon ICU admission 3 out of 4 patients in both groups still had a disturbed coagulation function. The number of patients with significant thrombocytopenia had increased 5-6 fold between ER and ICU admission. The C-priority including coagulation management was not adequately addressed during primary survey and initial resuscitation between ER and ICU admission, in this cohort of severely injured patients.
    Scandinavian Journal of Trauma Resuscitation and Emergency Medicine 12/2012; 20(1):78. DOI:10.1186/1757-7241-20-78 · 2.03 Impact Factor
    • "Furthermore, equally important, the timing of the FFP transfusions in relation to when administration of RBC was commenced were not reported in most of the studies evaluated and without this information, mere ratios provide insufficient information. This is illustrated by that the literature demonstrates conflicting results: Maegele et al. showed that an FFP : RBC ratio >1 : 1 was associated with the highest survival in German trauma patients,[10] whereas Kashuk et al. reported that patients receiving an FFP : RBC ratio of 1 : 2-1 : 3 had the highest survival and that a higher ratio was not associated with better outcome, but instead might be harmful.[28] This is in alignment with Davenport et al. who recently reported that FFP : PRBC ratios of ≥1 : 1 do not confer any additional advantage over ratios of 1 : 2 to 3 : 4, although it should be noted that in this study, the most severely bleeding patients were excluded due to blood sampling failure.[29] "
    [Show abstract] [Hide abstract]
    ABSTRACT: Continued hemorrhage remains a major contributor of mortality in massively transfused patients and controversy regarding the optimal management exists although recently, the concept of hemostatic resuscitation, i.e., providing large amount of blood products to critically injured patients in an immediate and sustained manner as part of an early massive transfusion protocol has been introduced. The aim of the present review was to investigate the potential effect on survival of proactive administration of plasma and/or platelets (PLT) in trauma patients with massive bleeding. English databases were searched for reports of trauma patients receiving massive transfusion (10 or more red blood cell (RBC) within 24 hours or less from admission) that tested the effects of administration of plasma and/or PLT in relation to RBC concentrates on survival from January 2005 to November 2010. Comparison between highest vs lowest blood product ratios and 30-day mortality was performed. Sixteen studies encompassing 3,663 patients receiving high vs low ratios were included. This meta-analysis of the pooled results revealed a substantial statistical heterogeneity (I(2) = 58%) and that the highest ratio of plasma and/or PLT or to RBC was associated with a significantly decreased mortality (OR: 0.49; 95% confidence interval: 0.43-0.57; P<0.0001) when compared with lowest ratio. Meta-analysis of 16 retrospective studies concerning massively transfused trauma patients confirms a significantly lower mortality in patients treated with the highest fresh frozen plasma (FFP) and/or PLT ratio when compared with the lowest FFP and/or PLT ratio. However, optimal ranges of FFP: RBC and PLT : RBC should be established in randomized controlled trials.
    Journal of Emergencies Trauma and Shock 04/2012; 5(2):120-5. DOI:10.4103/0974-2700.96479
  • Source
    • "Inadequate replacement of coagulation factors during the initial care was identified as the main cause of prolonged INR upon admission to the intensive care unit (ICU) [36]. Recent data indicate that early and aggressive transfusion of FFP and PC is associated with improved survival rates among major trauma patients [37-42]. To increase the effectiveness of coagulation therapy, massive transfusion protocols (MTPs) have been implemented. "
    [Show abstract] [Hide abstract]
    ABSTRACT: Severe trauma-related bleeding is associated with high mortality. Standard coagulation tests provide limited information on the underlying coagulation disorder. Whole-blood viscoelastic tests such as rotational thromboelastometry or thrombelastography offer a more comprehensive insight into the coagulation process in trauma. The results are available within minutes and they provide information about the initiation of coagulation, the speed of clot formation, and the quality and stability of the clot. Viscoelastic tests have the potential to guide coagulation therapy according to the actual needs of each patient, reducing the risks of over- or under-transfusion. The concept of early, individualized and goal-directed therapy is explored in this review and the AUVA Trauma Hospital algorithm for managing trauma-induced coagulopathy is presented.
    Scandinavian Journal of Trauma Resuscitation and Emergency Medicine 02/2012; 20(1):15. DOI:10.1186/1757-7241-20-15 · 2.03 Impact Factor
Show more