Increased Plasma and Platelet to Red Blood Cell Ratios Improves Outcome in 466 Massively Transfused Civilian Trauma Patients

United States Army Institute of Surgical Research, Ft Sam Houston, TX 78234, USA.
Annals of surgery (Impact Factor: 8.33). 09/2008; 248(3):447-58. DOI: 10.1097/SLA.0b013e318185a9ad
Source: PubMed


To determine the effect of blood component ratios in massive transfusion (MT), we hypothesized that increased use of plasma and platelet to red blood cell (RBC) ratios would result in decreased early hemorrhagic death and this benefit would be sustained over the ensuing hospitalization.
Civilian guidelines for massive transfusion (MT > or =10 units of RBC in 24 hours) have typically recommend a 1:3 ratio of plasma:RBC, whereas optimal platelet:RBC ratios are unknown. Conversely, military data shows that a plasma:RBC ratio approaching 1:1 improves long term outcomes in MT combat casualties. There is little consensus on optimal platelet transfusions in either civilian or military practice. At present, the optimal combinations of plasma, platelet, and RBCs for MT in civilian patients is unclear.
Records of 467 MT trauma patients transported from the scene to 16 level 1 trauma centers between July 2005 and June 2006 were reviewed. One patient who died within 30 minutes of admission was excluded. Based on high and low plasma and platelet to RBC ratios, 4 groups were analyzed.
Among 466 MT patients, survival varied by center from 41% to 74%. Mean injury severity score varied by center from 22 to 40; the average of the center means was 33. The plasma:RBC ratio ranged from 0 to 2.89 (mean +/- SD: 0.56 +/- 0.35) and the platelets:RBC ratio ranged from 0 to 2.5 (0.55 +/- 0.50). Plasma and platelet to RBC ratios and injury severity score were predictors of death at 6 hours, 24 hours, and 30 days in multivariate logistic models. Thirty-day survival was increased in patients with high plasma:RBC ratio (> or =1:2) relative to those with low plasma:RBC ratio (<1:2) (low: 40.4% vs. high: 59.6%, P < 0.01). Similarly, 30-day survival was increased in patients with high platelet:RBC ratio (> or =1:2) relative to those with low platelet:RBC ratio (<1:2) (low: 40.1% vs. high: 59.9%, P < 0.01). The combination of high plasma and high platelet to RBC ratios were associated with decreased truncal hemorrhage, increased 6-hour, 24-hour, and 30-day survival, and increased intensive care unit, ventilator, and hospital-free days (P < 0.05), with no change in multiple organ failure deaths. Statistical modeling indicated that a clinical guideline with mean plasma:RBC ratio equal to 1:1 would encompass 98% of patients within the optimal 1:2 ratio.
Current transfusion practices and survival rates of MT patients vary widely among trauma centers. Conventional MT guidelines may underestimate the optimal plasma and platelet to RBC ratios. Survival in civilian MT patients is associated with increased plasma and platelet ratios. Massive transfusion practice guidelines should aim for a 1:1:1 ratio of plasma:platelets:RBCs.

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Available from: Martin A Schreiber, Sep 29, 2015
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    • "A total of 100 patients were administered FFP:PRBC at an average ratio of 0.65, and these patients had a survival rate of 64%. Considering the 41%-74% survival rate reported by a multicenter study (23) conducted in 16 American Level I trauma centers, the results of the present study can be considered as acceptable. Eleven of the 36 deaths took place within 24 hr and were due to exsanguinating hemorrhage. "
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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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    • "Regardless, our results indicate that platelets provide adequate fV to overcome the effects of very high aPC concentrations, even in the absence of plasma fV. This finding may explain part of the apparent benefit to early platelet transfusion in trauma patients [65], [66]. However, these present results also indicate that plasma fV is significantly resistant to aPC degradation even at pharmacological levels which indicates that the cause of ATC is more complicated than simply exuberant activation of protein C. Taken together, these data illustrate that the function of aPC is to delay clotting by dampening thrombin generation in a non-linear, protein S-dependent fashion [67], which in a healthy vasculature must be sufficient to mitigate thrombotic tendencies. "
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    • "MTP’s advocate using blood transfusion earlier in resuscitation, using blood and blood products instead of crystalloid or colloid, and the infusion of red cells, plasma, and platelets in a 1:1:1 ratio. There is evidence to suggest that MTP’s and use of 1:1:1 transfusion ratios results in lower overall fluid requirements, blood utilization, and possibly improved mortality in patients with massive blood loss, severe injury and severe physiological derangements, such as are encountered in DCL patients [63,64]. In addition, fluid resuscitation should be guided by hemodynamic parameters such as stroke volume variance or pulse pressure differentials and central venous or left atrial pressures. "
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