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Abstract

Introduction: There is a growing debate surrounding the optimal ratio of FFP:RBC in massive transfusion protocols [MTP] for patients with massive traumatic hemorrhage. The discussion has evolved to include the time at which the appropriate ratio is achieved and its effect on mortality, both within and beyond 4 hours. This report aimed to describe the effect of attaining a high FFP:RBC ratio [FFP:RBC ≥ 1–1.5] [HMTP] within 4 hours on a trauma population receiving MTP. Methods: Data were obtained from the trauma registry of the Hamad Trauma Center in Doha, Qatar. All adult [≥ 18 years] patients with traumatic injury who received a massive blood transfusion [≥10 U of PRBC over the initial 24 hours post injury] from 1st January 2010 to 31st December 2012 were included. A low ratio MTP [LMTP] was FFP:RBC ≤ 1–1.5 at 4 hours post-injury. One MTP shipment was defined as infusion of ≥ 6 units of PRBC. Patients were followed up to 30 days, hospital discharge or death. Outcomes measured were mortality, post-shipment International Normalized Ratio [INR], multi-organ failure [MOF] and infectious complications. Data was analyzed using a Chi-square and Student’s T-test, p< 0.05 was considered significant. Results: There were 4864 trauma admissions during the study period, 77 [1.6%] patients met inclusion criteria. Admission hemoglobin level, arterial pH, INR, Injury Severity Score [ISS] and Revised Trauma Score [RTS] were similar between both groups. HMTP was associated with lower crude [41.9% v. 78.3%, p=0.001] and 24-hour mortality [3.2% v. 6.5%, p=0.468] when compared to LMTP. A similar association was noted for MOF [48.4% v 87.0%, p=0.001]. HMTP patients had significantly better mean INR values after the 2nd MTP shipment [1.1 v 1.5, p=0.032]. No significant differences were noted for the incidence of infectious complications between the 2 groups. Conclusions: These results suggest that the survival advantage of HMTP for trauma patients is realized early, within 4 hours post-injury. Our findings demonstrate that aggressive attainment of HMTP within 4 hours post injury can substantially improve coagulopathy, reduce mortality, and multi-organ failure rates.