The effect of FFP:RBC ratio on morbidity and mortality in trauma patients based on transfusion prediction score

Children's Hospital, Boston, MA, USA.
Vox Sanguinis (Impact Factor: 2.8). 03/2011; 101(1):44-54. DOI: 10.1111/j.1423-0410.2011.01466.x
Source: PubMed


The empiric use of a high plasma to packed red-blood-cell [fresh frozen plasma:red-blood-cells (FFP:RBC)] ratio in trauma resuscitation for patients with massive bleeding has become well accepted without clear or objective indications. Increased plasma transfusion is associated with worse outcome in some patient populations. While previous studies analyse only patients who received a massive transfusion, this study analyses those that are at risk to receive a massive transfusion, based on the trauma-associated severe haemorrhage (TASH) score, to objectively determine which patients after severe trauma would benefit or have increased complications by the use of a high FFP:RBC ratio.
Multicentre retrospective study from the Trauma Registry of the German Trauma Society. Multivariate logistic regression and statistical risk adjustments utilized in analyses.
A high ratio of FFP:RBC in the ≥15 TASH group was independently associated with survival, with an odds ratio of 2·5 (1·6-4·0), while the <15 TASH group was associated with increased multi-organ failure, 47% vs. 38%, (P<0·005).
A predictive model of massive transfusion upon admission might be able to rapidly identify which severe trauma patients would benefit or have increased complications from the immediate application of a high ratio of FFP:RBCs. This study helps to identify the appropriate population for a prospective, interventional trial.

Download full-text


Available from: Charles Wade
  • Source
    • "In contrast, FFP concentrates were administered to a lesser extent and platelet concentrates were only transfused in 18% and 36% of patients, respectively, and if administered at all only at very low quantities. This is in contrast to recent evidence from the literature indicating a survival benefit if coagulation abnormalities after trauma are addressed aggressively from the very moment on as the bleeding trauma patient hits the ER door [3-5,21-23]. Previous work from our group together with work from others has shown that mortality from trauma hemorrhage can be reduced by more balanced transfusion strategies involving pRBC and FFP transfusion in more equal ratios. "
    [Show abstract] [Hide abstract]
    ABSTRACT: Trauma is the leading cause of death in young people with an injury related mortality rate of 47.6/100,000 in European high income countries. Early deaths often result from rapidly evolving and deteriorating secondary complications e.g. shock, hypoxia or uncontrolled hemorrhage. The present study assessed how well ABC priorities (A: Airway, B: Breathing/Ventilation and C: Circulation with hemorrhage control) with focus on the C-priority including coagulation management are addressed during early trauma care and to what extent these priorities have been controlled for prior to ICU admission among patients arriving to the ER in states of moderate or severe hemorrhagic shock. A retrospective analysis of data documented in the TraumaRegister of the ‘Deutsche Gesellschaft für Unfallchirurgie’ (TR-DGU®) was conducted. Relevant clinical and laboratory parameters reflecting status and basic physiology of severely injured patients (ISS ≥ 25) in either moderate or severe shock according to base excess levels (BE -2 to -6 or BE < -6) as surrogate for shock and hemorrhage combined with coagulopathy (Quick’s value <70%) were analyzed upon ER arrival and ICU admission. A total of 517 datasets was eligible for analysis. Upon ICU admission shock was reversed to BE > -2 in 36.4% and in 26.4% according to the subgroups. Two of three patients with initially moderate shock and three out of four patients with severe shock upon ER arrival were still in shock upon ICU admission. All patients suffered from coagulation dysfunction upon ER arrival (Quick’s value ≤ 70%). Upon ICU admission 3 out of 4 patients in both groups still had a disturbed coagulation function. The number of patients with significant thrombocytopenia had increased 5-6 fold between ER and ICU admission. The C-priority including coagulation management was not adequately addressed during primary survey and initial resuscitation between ER and ICU admission, in this cohort of severely injured patients.
    Full-text · Article · Dec 2012 · Scandinavian Journal of Trauma Resuscitation and Emergency Medicine
  • Source
    • "This can result from reliance on assays with low sensitivity and predictive value for the hemostatic derangements among trauma patients, or from delays in test turnaround time. A potential short-coming of ratio-driven blood support, as the only strategy of transfusion care, is overtransfusion with plasma and platelets resulting either in no benefit [75,76] or in added toxicity (especially pulmonary) [13,76-78]. The evidence supporting a 1:1:1 transfusion strategy in civilian trauma was not sufficiently strong to overcome concerns about its toxicity to patients, nor to recommend it as a standard of care in Canada. "
    [Show abstract] [Hide abstract]
    ABSTRACT: In June 2011 the Canadian National Advisory Committee on Blood and Blood Products sponsored an international consensus conference on transfusion and trauma. A panel of 10 experts and two external advisors reviewed the current medical literature and information presented at the conference by invited international speakers and attendees. The Consensus Panel addressed six specific questions on the topic of blood transfusion in trauma. The questions focused on: ratio-based blood resuscitation in trauma patients; the impact of survivorship bias in current research conclusions; the value of nonplasma coagulation products; the role of protocols for delivery of urgent transfusion; the merits of traditional laboratory monitoring compared with measures of clot viscoelasticity; and opportunities for future research. Key findings include a lack of evidence to support the use of 1:1:1 blood component ratios as the standard of care, the importance of early use of tranexamic acid, the expected value of an organized response plan, and the recommendation for an integrated approach that includes antifibrinolytics, rapid release of red blood cells, and a foundation ratio of blood components adjusted by results from either traditional coagulation tests or clot viscoelasticity or both. The present report is intended to provide guidance to practitioners, hospitals, and policy-makers.
    Preview · Article · Dec 2011 · Critical care (London, England)
  • Source
    • "To date, TRALI is the most important cause of transfusion-associated morbidity and mortality [29]. In previous retrospective studies, a trend was observed in that the survival benefit associated with the high FFP:pRBC ratio approach was bought on the account of increasing frequencies of complications, such as nosocomial infections, sepsis and organ failure, resulting in prolonged days on ventilators and increased ICU and overall in-hospital stays [16,30]. When considering all patients included in the present study, survivors' and nonsurvivors' duration of ventilation, ICU length of stay and HLOS were significantly longer for patients who had received a high FFP:pRBC transfusion ratio. "
    [Show abstract] [Hide abstract]
    ABSTRACT: Retrospective studies have demonstrated a potential survival benefit from transfusion strategies using an early and more balanced ratio between fresh frozen plasma (FFP) concentration and packed red blood cell (pRBC) transfusions in patients with acute traumatic coagulopathy requiring massive transfusions. These results have mostly been derived from non-head-injured patients. The aim of the present study was to analyze whether a regime using a high FFP:pRBC transfusion ratio (FFP:pRBC ratio >1:2) would be associated with a similar survival benefit in severely injured patients with traumatic brain injury (TBI) (Abbreviated Injury Scale (AIS) score, head ≥ 3) as demonstrated for patients without TBI requiring massive transfusion (≥ 10 U of pRBCs). A retrospective analysis of severely injured patients from the Trauma Registry of the Deutsche Gesellschaft für Unfallchirurgie (TR-DGU) was conducted. Inclusion criteria were primary admission, age ≥ 16 years, severe injury (Injury Severity Score (ISS) ≥ 16) and massive transfusion (≥ 10 U of pRBCs) from emergency room to intensive care unit (ICU). Patients were subdivided into patients with TBI (AIS score, head ≥ 3) and patients without TBI (AIS score, head <3), as well as according to the transfusion ratio they had received: high FFP:pRBC ratio (FFP:pRBC ratio >1:2) and low FFP:pRBC ratio (FFP:pRBC ratio ≤1:2). In addition, morbidity and mortality between the two groups were compared. A total of 1,250 data sets of severely injured patients from the TR-DGU between 2002 and 2008 were analyzed. The mean patient age was 42 years, the majority of patients were male (72.3%), the mean ISS was 41.7 points (±15.4 SD) and the principal mechanism of injury was blunt force trauma (90%). Mortality was statistically lower in the high FFP:pRBC ratio groups versus the low FFP:pRBC ratio groups, regardless of the presence or absence of TBI and across all time points studied (P < 0.001). The frequency of sepsis and multiple organ failure did not differ among groups, except for sepsis in patients with TBI who received a high FFP:pRBC ratio transfusion. Other secondary end points such as ventilator-free days, length of stay in the ICU and overall in-hospital length of stay differed significantly between the two study groups, but not when only data for survivors were analyzed. These results add more detailed knowledge to the concept of a high FFP:pRBC ratio during early aggressive resuscitation, including massive transfusion, to decrease mortality in severely injured patients both with and without accompanying TBI. Future research should be conducted with a larger number of patients to prove these results in a prospective study.
    Full-text · Article · Feb 2011 · Critical care (London, England)
Show more