Massive Transfusion Protocols: The Role of Aggressive Resuscitation Versus Product Ratio in Mortality Reduction

Department of Surgery, Stanford School of Medicine, Stanford, CA, USA.
Journal of the American College of Surgeons (Impact Factor: 5.12). 09/2009; 209(2):198-205. DOI: 10.1016/j.jamcollsurg.2009.04.016
Source: PubMed


Exsanguinating hemorrhage necessitating massive blood product transfusion is associated with high mortality rates. Recent data suggest that altering the fresh frozen plasma to packed red blood cell ratio (FFP:PRBC) results in significant mortality reductions. Our purpose was to evaluate mortality and blood product use in the context of a newly initiated massive transfusion protocol (MTP).
In July 2005, our American College of Surgeons-verified Level I trauma center implemented an MTP supporting a 1:1.5 FFP:PRBC ratio, improved communications, and enhanced systems flow to optimize rapid blood product availability. During the 4 years surrounding protocol implementation, we reviewed data on trauma patients directly admitted through the emergency department and requiring 10 or more units PRBCs during the first 24 hours.
For the 2 years before and subsequent to MTP initiation, there were 4,223 and 4,414 trauma activations, of which 40 and 37 patients, respectively, met study criteria. The FFP:PRBC ratios were identical, at 1:1.8 and 1:1.8 (p = 0.97). Despite no change in FFP:PRBC ratio, mortality decreased from 45% to 19% (p = 0.02). Other significant findings included decreased mean time to first product: cross-matched RBCs (115 to 71 minutes; p = 0.02), FFP (254 to 169 minutes; p = 0.04), and platelets (418 to 241 minutes; p = 0.01).
MTP implementation is associated with mortality reductions that have been ascribed principally to increased plasma use and decreased FFP:PRBC ratios. Our study found a significant reduction in mortality despite unchanged FFP:PRBC ratios and equivalent overall mean numbers of transfusions. Our data underscore the importance of expeditious product availability and emphasize that massive transfusion is a complex process in which product ratio and time to transfusion represent only the beginning of understanding.

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    • "In contrast, stored thawed plasma, which retains acceptable levels of all coagulation factors for up to 5 days [97] [98] [99] [100] can be transfused immediately. Immediate transfusion of plasma is associated with an overall reduction in the amount of plasma and other blood components transfused during DCR and with reduced plasma wastage [4] [13] [83]. Also, plasma separated from whole blood and stored at 4 °C for 21 days, and referred to as liquid plasma, retains close to 90% coagulation factor activity, and is the primary source of plasma in many European DCR strategies [101]. "
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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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    • "To better understand the value of HRV for decision making, we decided to focus on the identification of trauma patients with major hemorrhage who receive PRBC transfusion because exsanguination is a leading cause of death in both civilian [16] and military [17] trauma populations, whereas many hemorrhagic deaths can be prevented with time-sensitive interventions such as surgery and optimal resuscitation [18] [19]. In theory, a reliable and simple diagnostic indicator of which patients require such interventions could enhance the quality and efficiency of clinical decision making, leading to optimal patient outcomes. "
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    ABSTRACT: During initial assessment of trauma patients, metrics of heart rate variability (HRV) have been associated with high-risk clinical conditions. Yet, despite numerous studies, the potential of HRV to improve clinical outcomes remains unclear. Our objective was to evaluate whether HRV metrics provide additional diagnostic information, beyond routine vital signs, for making a specific clinical assessment: identification of hemorrhaging patients who receive packed red blood cell (PRBC) transfusion. Adult prehospital trauma patients were analyzed retrospectively, excluding those who lacked a complete set of reliable vital signs and a clean electrocardiogram for computation of HRV metrics. We also excluded patients who did not survive to admission. The primary outcome was hemorrhagic injury plus different PRBC transfusion volumes. We performed multivariate regression analysis using HRV metrics and routine vital signs to test the hypothesis that HRV metrics could improve the diagnosis of hemorrhagic injury plus PRBC transfusion vs routine vital signs alone. As univariate predictors, HRV metrics in a data set of 402 subjects had comparable areas under receiver operating characteristic curves compared with routine vital signs. In multivariate regression models containing routine vital signs, HRV parameters were significant (P < .05) but yielded areas under receiver operating characteristic curves with minimal, nonsignificant improvements (+0.00 to +0.05). A novel diagnostic test should improve diagnostic thinking and allow for better decision making in a significant fraction of cases. Our findings do not support that HRV metrics add value over routine vital signs in terms of prehospital identification of hemorrhaging patients who receive PRBC transfusion. Published by Elsevier Inc.
    American Journal of Emergency Medicine 12/2014; 33(2). DOI:10.1016/j.ajem.2014.11.046 · 1.27 Impact Factor
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    • "Nowadays, it is well recognised that early detection of bleeding patients is a major determinant of initial management for severe trauma patients [1] [2] [3]. This triage may be challenging for physicians upon hospital admission, however early and aggressive transfusion strategy was well validated to improve outcome of exsanguinating patients [4] [5] [6]. Therefore, composite scores have been developed to early identify patients at high-risk of massive blood loss; these scoring systems, such as Trauma Associated Severe Haemorrhage (TASH), Prince of Walls Hospital (PWH) or ABC, include classically clinical haemodynamic parameters (i.e., systolic arterial pressure, tachycardia), obvious severe injuries (i.e., pelvic or femoral fractures, haemoperitoneum), and biological data (anaemia, base excess) available soon after patients admission [7] [8] [9]. "
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    Injury 09/2014; 46(1). DOI:10.1016/j.injury.2014.08.040 · 2.14 Impact Factor
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