Plasma Transfusion for Gastrointestinal Hemorrhage in the Pre-hospital Setting in Appropriately Chosen Patients Can Be Beneficial

Abstract

Purpose: Hemostatic resuscitation in patients with coagulopathies relies on early and aggressive plasma infusion. Patient selection is crucial, as plasma is limited and expensive. Our group previously evaluated outcomes of patients receiving plasma in the rural setting during air ambulance transport per defined selection criteria. To confirm the validity of our selection of patients, we sought to compare the original data to a group of patients who were not empirically infused with plasma. Methods: Comparison between 17 patients transported to our institution who met criteria through our plasma transfusion protocol from February 2010 and April 2012 to a second group of 27 patients who were transfused only with packed red blood cells. The two groups were then analyzed using chi-square, Fisher's exact, two-sample Student's t-test, and Wilcoxon rank-sum tests as appropriate. Examined variables included gender, age, mortality, length of stay, change in international normalized ratio and admission to the intensive care unit. Results: 76.4% of the plasma-transfused patients required endoscopy in comparison to 85.1% of the non-plasma transfused patients. The average time from admission to endoscopy was 410 minutes for the plasma-infused patients compared to 578 minutes in the non-transfused group (p=0.4). Endoscopic findings included duodenal ulcers, esophageal varices, esophageal ulcerations, Mallory-Weiss tear, antral ulcer, friable colonic vessel and no findings to explain bleeding. Hemostasis after endoscopy, length of hospital stay, time to endoscopy, re-bleeding rates and need for surgery were also similar between the two groups. Mortality was not different between the two groups (11.8% vs. 3.7%; p=0.3). As expected, the only examined variables found to be significant were the pre-transfused INR (4.1 vs. 1.4; p=0.0005) and change in INR after plasma transfusion (2.1 vs. 0.04; p=0.0001). Conclusion: Pre-hospital plasma transfusion during air transport in appropriately chosen patients seems to have similar outcomes to patients not requiring plasma despite statistically significant differences in pre-transfusion INR after plasma. Although it is unclear if empiric plasma transfusion is beneficial, this study suggests early recognition and transfusion of plasma in appropriate patients may improve outcomes of GI bleeding. Larger studies are needed to effectively examine looking at critical primary endpoints.