Postinjury Life Threatening Coagulopathy: Is 1:1 Fresh Frozen Plasma: Packed Red Blood Cells the Answer?

University of Colorado, Denver, Colorado, United States
The Journal of trauma (Impact Factor: 2.96). 08/2008; 65(2):261-70; discussion 270-1. DOI: 10.1097/TA.0b013e31817de3e1
Source: PubMed

ABSTRACT Recent military experience suggests that immediate 1:1 fresh frozen plasma (FFP); red blood cells (RBC) for casualties requiring >10 units packed red blood cells (RBC) per 24 hours reduces mortality, but no clinical trials exist to address this issue. Consequently, we reviewed our massive transfusion practices during a 5-year period to test the hypothesis that 1:1 FFP:RBC within the first 6 hours reduces life threatening coagulopathy.
We queried our level I trauma center's prospective registry from 2001 to 2006 for patients undergoing massive transfusion. Logistic regression was used to evaluate the independent effect of FFP:RBC in 133 patients who received >10 units RBC in 6 hours on (1) Coagulopathy (international normalized ratio [INR] >1.5 at 6 hours), controlling for our previously described risk factors predictive of coagulopathy, as well as RBC, FFP, and platelet administration (2) Death (controlling for all variables plus age, crystalloids per 24 hours, INR >1.5 at 6 hours).
Overall mortality was 56%; 50% died from acute blood loss in the operating room. Over 80% of the RBC transfusions were completed in the first 6 hours: (Median RBC: 18 units) Median FFP:RBC survivors, 1:2, nonsurvivors: 1:4. (p < 0.001) INR >1.5 at 6 hours occurred in 30 (23%); 81% died. Regarding mortality, logistic regression showed significant variables (p < 0.05) included: RBC per 6 hours (OR = 1.248, 95%CI: 1.957-53.255), INR at 6 hours >1.5 (OR = 10.208, 95% CI: 1.957-53.255), ED temperature <34 degrees C (OR = 15.491, 95% CI 1.376-174.396), and age >55 years (OR = 40.531, CI 5.315-309.077). The adjusted OR for FFP:RBC ratio including the quadratic term was found to follow a U-shaped association (quadratic term estimate 0.6737 +/- 0.0345, p = 0.0189).
Although our data suggest that 1:1 FFP:RBC reduced coagulopathy, this did not translate into a survival benefit. Our findings indicate that the relationship between coagulopathy and mortality is more complex, and further clinical investigation is necessary before recommending routine 1:1 in the exsanguinating trauma patient.

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Available from: Jeffry L Kashuk, Sep 26, 2015
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    • "By one typically used definition (≥ 10 units of packed red blood cells within a 24-hour period), a patient may be considered massively transfused after receiving blood at a deliberate rate of one unit every 2 h over the course of 20 h. This is, of course, a distinctly different clinical scenario than a patient receiving the same amount of blood within 2 h or even less [14]. Moreover, resuscitations for massive blood loss are rare events. "
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    ABSTRACT: The early recognition and management of hemorrhage shock are among the most difficult tasks challenging the clinician during primary assessment of the acutely bleeding patient. Often with little time, within a chaotic setting, and without sufficient clinical data, a decision must be reached to begin transfusion of blood components in massive amounts. The practice of massive transfusion has advanced considerably and is now a more complete and, arguably, more effective process. This new therapeutic paradigm, referred to as damage control resuscitation (DCR), differs considerably in many important respects from previous management strategies for catastrophic blood loss. We review several important elements of DCR including immediate correction of specific coagulopathies induced by hemorrhage and management of several extreme homeostatic imbalances that may appear in the aftermath of resuscitation. We also emphasize that the foremost objective in managing exsanguinating hemorrhage is always expedient and definitive control of the source of bleeding. Copyright © 2015. Published by Elsevier Ltd.
    Blood Reviews 01/2015; 46(4). DOI:10.1016/j.blre.2014.12.006 · 5.57 Impact Factor
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    • "Further, the correct ratio of fresh frozen plasma (FFP) to packed red blood cells (PRBC) that should be used remains unclear. Recent studies have suggested that it is more beneficial to use more amount of FFP, to the extent that its ratio to PRBC is close to 1:1 (11, 12). However, the excessive use of FFP may cause infection, transfusion-related acute lung injury (TRALI), and acute respiratory distress syndrome (ARDS) (13, 14, 15). "
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    ABSTRACT: When treating trauma patients with severe hemorrhage, massive transfusions are often needed. Damage control resuscitation strategies can be used for such patients, but an adequate fresh frozen plasma: packed red blood cell (FFP:PRBC) administration ratio must be established. We retrospectively reviewed the medical records of 100 trauma patients treated with massive transfusions from March 2010 to October 2012. We divided the patients into 2 groups according to the FFP:PRBC ratio: a high-ratio (≥0.5) and a low-ratio group (<0.5). The patient demographics, fluid and transfusion quantities, laboratory values, complications, and outcomes were analyzed and compared. There were 68 patients in the high-ratio and 32 in the low-ratio group. There were statistically significant differences between groups in the quantities of FFP, FFP:PRBC, platelets, and crystalloids administered, as well as the initial diastolic blood pressure. Bloodstream infections were noted only in the high-ratio group, and the difference was statistically significant (P=0.028). Kaplan-Meier plots revealed that the 24-hr survival rate was significantly higher in the high-ratio group (71.9% vs. 97.1%, P<0.001). In severe hemorrhagic trauma, raising the FFP:PRBC ratio to 0.5 or higher may increase the chances of survival. Efforts to minimize bloodstream infections during the resuscitation must be increased. Graphical Abstract
    Journal of Korean Medical Science 07/2014; 29(7):1007-11. DOI:10.3346/jkms.2014.29.7.1007 · 1.27 Impact Factor
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    • "The current United States (US) Department of Defense (DoD) guideline specifies the use of 1:1:1 [12]. In civilian observational studies, investigators have reported good outcomes across a range of different blood product ratios [13] [14] [15] [16] [17] [18] [19]; the largest observational transfusion study of bleeding trauma patients, the PRospective Observational Multicenter Major Trauma Transfusion (PROMMTT) study, was conducted in 10 Level I trauma centres in the US. In PROMMTT, clinicians generally delivered transfusion ratios that cumulated in the range of 1:1 or 1:2 [20], showing clinical equipoise for these two ratios. "
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    ABSTRACT: Background: Forty percent of in-hospital deaths among injured patients involve massive truncal haemorrhage. These deaths may be prevented with rapid haemorrhage control and improved resuscitation techniques. The Pragmatic Randomized Optimal Platelet and Plasma Ratios (PROPPR) Trial was designed to determine if there is a difference in mortality between subjects who received different ratios of FDA approved blood products. This report describes the design and implementation of PROPPR. Study design: PROPPR was designed as a randomized, two-group, Phase III trial conducted in subjects with the highest level of trauma activation and predicted to have a massive transfusion. Subjects at 12 North American level 1 trauma centres were randomized into one of two standard transfusion ratio interventions: 1:1:1 or 1:1:2, (plasma, platelets, and red blood cells). Clinical data and serial blood samples were collected under Exception from Informed Consent (EFIC) regulations. Co-primary mortality endpoints of 24h and 30 days were evaluated. Results: Between August 2012 and December 2013, 680 patients were randomized. The overall median time from admission to randomization was 26min. PROPPR enrolled at higher than expected rates with fewer than expected protocol deviations. Conclusion: PROPPR is the largest randomized study to enrol severely bleeding patients. This study showed that rapidly enrolling and successfully providing randomized blood products to severely injured patients in an EFIC study is feasible. PROPPR was able to achieve these goals by utilizing a collaborative structure and developing successful procedures and design elements that can be part of future trauma studies.
    Injury 06/2014; 45(9). DOI:10.1016/j.injury.2014.06.001 · 2.14 Impact Factor
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