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


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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    • "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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    • "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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    • "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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