Hemostatic strategies for minimizing mortality in surgery with major blood loss

Abstract

Continued hemorrhage remains a major contributor of mortality in massively transfused patients and controversy regarding their optimal management exists. This article reviews recent advances that impact the use and effectiveness of massive transfusion. In the past 18 months, nine retrospective studies and three before and after studies have evaluated the implementation of massive transfusion protocols in massively transfused patients receiving more than 10 units of red blood cells (RBCs) within 24 h from arrival. All studies demonstrate that patients receiving a high fresh frozen plasma (FFP):RBC or platelet:RBC ratio have improved survival, with patients receiving both high FFP:RBC and platelet:RBC ratios exhibiting the highest survival rate. When whole blood thrombelastography is used to guide transfusion therapy in massively bleeding patients, an increase in FFP and platelet to RBC ratio is also seen, and this is associated with improved survival. This indicates that thrombelastography is better than conventional coagulation assays to monitor coagulopathy and predict transfusion requirements in massive bleeders. Implementation of more aggressive hemostatic resuscitation strategies in massively bleeding patients seems reasonable, and optimally, thrombelastography should be used to monitor coagulopathy and guide FFP and platelet transfusions.