Blood product use in trauma resuscitation: Plasma deficit versus plasma ratio as predictors of mortality in trauma (CME)

Department of Surgery, University of Maryland, Baltimore, Baltimore, Maryland, United States
Transfusion (Impact Factor: 3.23). 02/2011; 51(9):1925-32. DOI: 10.1111/j.1537-2995.2010.03050.x
Source: PubMed


Resuscitation of rapidly bleeding trauma patients with units of red blood cells (RBCs) and plasma given in a 1:1 ratio has been associated with improved outcome. However, demonstration of a benefit is confounded by survivor bias, and past work from our group has been unable to demonstrate a benefit.
We identified 438 adult direct primary trauma admissions at risk for massive transfusion who received 5 or more RBC units in the first 24 hours and had a probability of survival of 0.010 to 0.975. We correlated survival with RBC and plasma use by hour, both as a ratio (units of plasma/units of RBC) and as a plasma deficit (units of RBC - units of plasma) in the group as a whole and among those using 5 to 9 and more than 9 units of RBCs.
Resuscitation was essentially complete in 58.3% by the end of the third hour and 77.9% by the end of the sixth hour. Mortality by hour was significantly associated with worse plasma deficit status in the first 2 hours of resuscitation (p < 0.001 and p < 0.01) but not with plasma ratio. In a subgroup with a Trauma Revised Injury Severity Score of 0.200 to 0.800, early plasma repletion was associated with less blood product use independently of injury severity (p < 0.001).
1) The efficacy of plasma repletion plays out in the first few hours of resuscitation, 2) plasma deficit may be a more sensitive marker of efficacy in some populations, and 3) early plasma repletion appears to prevent some patients from going on to require massive transfusion.

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    • "An alternative strategy is " 1:1, " which calls for early FFP transfusion in patients predicted to require MT, such that the FFP:packed red blood cell (PRBC) ratio approaches approximately 1:1 to 2 from the start [5]. Many observational studies comparing low (b 1:2) vs high (≥ 1:2) FFP:PRBC ratio [6] or deficit [7] have shown that the use of equivalent units of FFP and PRBC was associated with improved survival. How to transfuse with platelets is almost as controversial. "
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    ABSTRACT: Traditional transfusion guidelines suggest that fresh frozen plasma (FFP) should be given based on laboratory or clinical evidence of coagulopathy or acute loss of 1 blood volume. This approach tends to result in a significant lag time between the first units of erythrocytes and FFP in trauma requiring massive transfusion. In severe trauma, observational studies have found an association between increased survival and aggressive use of FFP and platelets such that FFP:platelet:erythrocyte ratio approaches 1:1:1 to 2 from the first units of erythrocytes given. There are considerable concerns over either approach, and no randomized controlled trials have been published comparing the 2 approaches. Nowadays, trauma clinicans are incorporating the strenghts of both approaches and are no longer treating them as a dichotomy. Specifically, "1:1:1" proponents have devised 1:1:1 activation criteria to minimize unnecessary FFP and platelet transfusion and are prepared to deactivate the protocol as soon as patient is stabilized. Similarly, 1:1:1 skeptics are more mindful of the need to be proactive about trauma coagulopathy and the inherent delays in FFP administration in trauma patients. Copyright © 2015. Published by Elsevier Inc.
    The American journal of emergency medicine 10/2015; 33:1501-1504. DOI:10.1016/j.ajem.2015.06.065 · 1.27 Impact Factor
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    • "A similar recommendation has been recently established by the French Health Products Safety Agency (Agence nationale de sécurité du médicament et des produits de santé-AFSSAPS). The RBC:FFP ratio is an important element of the aggressive RBC and plasma resuscitation, but the time course for transfusion is a major element, and, more important than the crude RBC:FFP ratio, the early use of RBCs and FFP could improve the outcome of patients with traumatic hemorrhagic shock [35]. Therefore, it is critical to begin the plasma transfusion as quickly as possible (ideally at the same time as the RBC transfusion) (Figure 2). "
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    ABSTRACT: Managing trauma patients with hemorrhagic shock is complex and difficult. Despite our knowledge of the pathophysiology of hemorrhagic shock in trauma patients that we have accumulated during recent decades, the mortality rate of these patients remains high. In the acute phase of hemorrhage, the therapeutic priority is to stop the bleeding as quickly as possible. As long as this bleeding is uncontrolled, the physician must maintain oxygen delivery to limit tissue hypoxia, inflammation, and organ dysfunction. This process involves fluid resuscitation, the use of vasopressors, and blood transfusion to prevent or correct acute coagulopathy of trauma. The optimal resuscitative strategy is controversial. To move forward, we need to establish optimal therapeutic approaches with clear objectives for fluid resuscitation, blood pressure, and hemoglobin levels to guide resuscitation and limit the risk of fluid overload and transfusion.
    Annals of Intensive Care 01/2013; 3(1):1. DOI:10.1186/2110-5820-3-1 · 3.31 Impact Factor
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    • "The most likely reason for the improvement was a significant reduction in mean time to administration of FFP, from 254 to 169 minutes [56]. Early haemostatic therapy appears to prevent the development of coagulopathy in some patients, eliminating the need for MT; plasma transfusion seems to be most effective during the first 2-3 hours of care for massively bleeding patients [57]. "
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    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
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