Implementation Of Massive Transfusion Protocol Research Articles

Risk Factors Associated with Receiving Nonbalanced Massive Transfusion Protocol

INTRODUCTION: Implementation of massive transfusion protocol (MTP) with balanced blood product ratios results in improved mortality rates in trauma patients. However, compliance with MTP is still not universal. Our study investigated the risk factors for receiving nonbalanced MTP (NBMTP). METHODS: We retrospectively reviewed trauma patients who received massive transfusion, defined as at least 10 units of packed red blood cells within 24 hours of admission, using the American College of Surgeons TQIP database between 2016 and 2019. Demographics, comorbidities, prehospitalization data, hospital characteristics, injury-related variables, transfusions, and clinical outcomes were abstracted. Patients who received balanced MTP (BMTP), defined as blood products transfused in a 1:1 to 1:2 ratio of fresh frozen plasma to packed red blood cells, were compared with patients who received NBMTP. Risk factors for receiving NBMTP were analyzed by Student’s t-test and chi-square test. Multivariate logistic regression was used as required. RESULTS: A total of 15,435 patients who received massive transfusions were included. Of these, 71% patients received BMTP, and 29% patients received NBMTP. Patients who received BMTP had significantly longer emergency medical services transit times to hospital (87.5 vs 99.2, p = 0.03), had a higher Injury Severity Score (32.4 vs 31.5, p = 0.001), and received more units of packed red blood cells (22.0 vs 19.6, p < 0.001). Logistic regression identified admission to Level II trauma centers (odds ratio 1.20, 95% CI 1.07 to 1.34) and lower Injury Severity Score (odds ratio 0.995, 95% CI 0.992 to 0.998) as independent risk factors for receiving NBMTP. CONCLUSION: Trauma patients at Level II trauma centers or who had lower Injury Severity Scores were less likely to receive BMTP. Clinicians should be mindful of this predisposition for decreased compliance with BMTP in these patients and institutions.

The impact of a multilevel approach to reduce emergency hysterectomy for postpartum haemorrhage: Insights from a tertiary referral centre in Northern Italy

ObjectiveTo assess the effectiveness of the implementation of a multilevel institutional program to reduce the rate of emergency peripartum hysterectomy (EPH) secondary to postpartum haemorrhage (PPH) in a Western world referral centre for obstetrics. Study designWomen who delivered at a tertiary care regional obstetric hub in Milan between 2012 and 2020 were retrospectively reviewed to identify cases of EPH. During the study period, several measures aimed at preventing EPH were progressively implemented: reduction of primary and repeated caesarean, update of PPH treatment protocol, implementation of massive transfusion protocol, dedicated clinical pathway for high-risk patients, regular educational sessions, daily review of critical cases with senior consultant, and periodical review of near miss cases by quality improvement committee. To investigate the possible benefits, we divided the detected cases into two groups based on the historical period (Period I, 2012–2016 vs. Period II, 2017–2020) with the main aim of comparing the rate of EPH calculated as EPH ratio per 1000 deliveries. ResultsDuring Period I and II there were 30,241 and 21,270 births; a total of 60 and 25 EPH were performed, respectively. EPH incidence decreased from 2.0 to 1.2‰ across the study periods (p = 0.027). Between Period I and II, we observed a reduction of institutional caesarean section rate (44.4% vs. 40.4%, p < 0.0001); among cases undergoing EPH, we reported a significant reduction of massive blood transfusion (83.3% vs. 52.2%, p = 0.002), increased use (56.7% vs. 96.0%, p = 0.0004) and appropriate administration (25.0% vs. 88.0%, p < 0.0001) of tranexamic acid, increased use of non-invasive Bakri Balloon tamponade (3.3% vs. 32.0%, p = 0.0002) instead of surgical techniques (38.3% vs. 16.0%, p = 0.043). ConclusionA reduction of EPH incidence as a severe outcome of obstetric haemorrhage is achievable through a multilevel institutional effort. Our study may inspire a larger-scale program to improve the safety of patients experiencing PPH.

The effect of massive transfusion protocol implementation on the survival of trauma patients: a systematic review and meta-analysis.

Massive transfusion protocol (MTP) has been widely adopted for the care of bleeding trauma patients but its actual effectiveness is unclear. An earlier meta-analysis on the implementation of MTP for injured patients from 1990 to 2013 reported that only 2 out of 8 studies showed statistical improvement in survival. This study aimed to conduct an updated systematic review and meta-analysis to evaluate the effect of implementing an MTP on the mortality of trauma patients. MEDLINE, PubMed, Cochrane Library and Google scholar databases were systematically searched for relevant studies published from 1st January 2008 to 30th September 2019 using a combination of keywords and additional manual searching of reference lists. Inclusion criteria were: original study in English, study population including trauma patients, and comparison of mortality outcomes before and after institutional implementation of an MTP. Primary outcomes were 24-hour, 30-day, and overall mortality. Fourteen studies met inclusion criteria, analysing outcomes from 3,201 trauma patients. There was a wide range of outcomes, patient populations, and process indicators utilised by the different authors. MTP significantly reduced the overall mortality for trauma patients (OR 0.71 [0.56-0.90]). No significant reduction was seen in either the 24-hour mortality (OR 0.81 [0.57-1.14]) or the 30-day mortality (OR 0.73 [0.46-1.16]). However, when mortality timing was unspecified, mortality was statistically reduced (OR 0.69 [0.55-0.86]). The present study found a significant reduction in mortality following MTP implementation and thus it should be recommended to all institutions managing acutely injured patients. To better identify which elements of an MTP contribute to this effect, we encourage the use of standard nomenclature, indicators, protocols and patient populations in all future MTP studies.

Effects of Massive Transfusion Protocol Implementation in Trauma Patients at a Level I Trauma Center

Purpose: This study was conducted to investigate whether rapid and efficient administration of blood products was achieved and whether clinical outcomes were improved by applying a massive transfusion protocol (MTP). Methods: From January 2016 to September 2019, the medical records of trauma patients who received at least 10 units of packed red blood cells (PRBC) at Pusan National University Hospital (level I trauma center) were retrospectively reviewed. The patients treated from January 2016 to January 2018 were designated as the non-MTP group, and those treated from February 2018 to September 2019 were designated as the MTP group. Results: During the study period, 370 patients received massive transfusions. The non-MTP and MTP groups comprised 84 and 55 patients, respectively. No significant between-group differences were found in the units of PRBC (23.2 vs. 25.3, respectively; p=0.46), fresh frozen plasma (FFP) (21.1 vs. 24.4, respectively; p=0.40), and platelets (PLT) (15.4 vs. 17.0, respectively; p=0.54) administered in the first 24 hours. No statistically significant differences between the non-MTP and MTP groups were found in the FFP-to-PRBC ratio (0.9 vs. 0.94, respectively; p=0.44) and or the PLT-to-PRBC ratio (0.72 vs. 0.72, respectively; p=0.21). However, the total number of cryoprecipitate units was significantly higher in the MTP group than in the non-MTP group (7.4 vs. 15.3 units, respectively; p=0.003) and the ratio of cryoprecipitate to PRBC in the MTP group was significantly higher than in the non-MTP group (0.31 vs. 0.62, respectively; p=0.021). The time to transfusion was significantly reduced after MTP implementation (41.0 vs. 14.9 minutes, respectively; p=0.003). Conclusions: Although no significant differences were found in the clinical outcomes of patients who had undergone severe trauma, rapid and balanced transfusion was achieved after implementing the MTP.

Massive transfusion protocols in nontrauma patients: A systematic review and meta-analysis.

Massive bleeding is a major cause of death both in trauma and nontrauma patients. In trauma patients, the implementation of massive transfusion protocols (MTP) led to improved outcomes. However, the majority of patients with massive bleeding are nontrauma patients. To assess if the implementation of MTP in nontrauma patients with massive bleeding leads to improved survival. National Library of Medicine's Medline database (PubMed). Original research articles in English language investigating MTP in nontrauma patients. Nontrauma patients with massive bleeding 18 years or older. Transfusion according to MTP versus off-protocol. Systematic literature review using PubMed. Outcomes assessed were mortality and transfused blood products. Studies that compared mortality of MTP and non-MTP groups were included in meta-analysis using Mantel-Haenszel random effect models. A total of 252 abstracts were screened. Of these, 12 studies published 2007 to 2017 were found to be relevant to the topic, including 2,475 patients. All studies were retrospective and comprised different patient populations. Most frequent indications for massive transfusion were perioperative, obstetrical and gastrointestinal bleeding, as well as vascular emergencies. Four of the five studies that compared the number of transfused blood products in MTP and non-MTP groups revealed no significant difference. Meta-analysis revealed no significant effect of MTP on the 24-hour mortality (odds ratio 0.42; 95% confidence interval 0.01-16.62; p = 0.65) and a trend toward lower 1-month mortality (odds ratio 0.56; 95% confidence interval 0.30-1.07; p = 0.08). Heterogeneous patient populations and MTP in the studies included. There is limited evidence that the implementation of MTP may be associated with decreased mortality in nontrauma patients. However, patient characteristics, as well as the indication and definition of MTP were highly heterogeneous in the available studies. Further prospective investigation into this topic is warranted. Systematic review and meta-analysis, level III.

Use of Plasma-Based Trauma Transfusion Protocols at Level IV Trauma Centers.

Early initiation of a high ratio massive transfusion can lower trauma patient mortality by 80%. Long transport times from rural Level IV trauma centers therefore require that damage control resuscitation begin before patient transfer. This study evaluates the current use of fresh frozen plasma (FFP) at Level IV trauma centers and the feasibility of implementing trauma transfusion protocols at these centers. Demographic and clinical data were collected for trauma patients at all state Level IV trauma centers who would have met criteria for massive transfusion protocol (MTP) activation based on the Assessment of Blood Consumption (ABC) score. All state Level IV trauma centers were also surveyed to determine availability of blood bank plasma resources. A total of 760 adult trauma patients presented to a Level IV trauma center during the study period. Three hundred sixty-eight patients (48.4%) were transferred to a higher level of care. Because FAST (Focused Assessment with Sonography for Trauma) results were not available in the state registry data, we included all blunt trauma patients with an ABC score of 1 as "potential ABC-positive patients." Forty-two (5.5%) patients were potentially ABC positive. Fifteen of 22 Level IV centers responded to our survey. Seventy-three percent of respondents have FFP available. Mean time to FFP availability was 63.1 min. Median total length of stay from registration to emergency department discharge for potentially ABC-positive patients was 2 hr. Because most Level IV trauma centers have FFP and thaw times are such that administration would not delay transport to a higher level of care, we recommend implementation of MTPs at Level IV trauma centers to reduce hemorrhage-associated mortality.

Implementation of Massive Transfusion Protocols in the United States

(Abstracted from Anesth Analg, 124:9–11, 2017) This editorial reviews and augments the article “Massive Transfusion Protocols: A Survey of Academic Medical Centers in the United States” by Treml et al.1 The authors conducted a Web-based survey of massive transfusion protocol (MTP) implementation at US blood banks.

Improvement of Treatment Outcomes after Implementation of a Massive Transfusion Protocol: A Level I Trauma Center Experience

We assessed the effectiveness of the implementation of an institutional massive transfusion protocol (MTP) for resuscitation with a 1:1:1 transfusion ratio of packed red blood cell (PRBC), fresh frozen plasma, and platelet units. In a Level I trauma center database, all trauma admissions (2004-2012) that received massive transfusions (≥10 units PRBCs in the first 24 hours) were reviewed retrospectively. Demographic data, transfusion ratios, and outcomes were compared before (PRE) and after (POST) MTP implementation in May 2008. Age, sex, and mechanism of injury were similar between 239 PRE and 208 POST trauma patients requiring massive transfusion. Transfusion ratios of fresh frozen plasma:PRBC and platelet:PRBC increased after MTP implementation. Among survivors, MTP implementation shortened hospital length of stay from 31 to 26 days (P = 0.04) and intensive care unit length of stay from 31 to 26 days (P = 0.02). Linear regression identified treatment after (versus before) implementation of MTP as an independent predictor of decreased ventilator days after adjusting for age, Glasgow Coma Scale, and chest Abbreviated Injury Score (P < 0.0001). Modest improvement in ratios likely does not account for all significant improvements in outcomes. Implementing a standardized protocol likely impacts automation, efficiency, and/or timeliness of product delivery.

Implementation of massive transfusion protocol (MTP) for trauma

Introduction Massive transfusion, the administration of 10 or more units of packed red blood cells (RBC) in less than 24 hours, can be a lifesaving therapy in the treatment of severe bleeding following injury. The rapid delivery and administration of large numbers of Packed Red Blood cells (PRBC), along with sufficient plasma and platelets is frequently a disorderly process. Establishment of MTP addresses this issue and has shown to reduce mortality and reduce the effects of coagulopathy associated with trauma. Methods Following a preliminary discussion with all the stake holders including the administrators, we implemented a protocol which supports the ratio of 1:1:1, of PRBC: FFP(Fresh Frozen Plasma) : Platelet. Each step of the process, from activation of protocol to termination was defined. The contents of boxes 1, 2 and 3 were Predetermined. Conclusion We hope to encourage the use of MTP in other centres in the country to achieve better results with post-trauma bleeding patients. The effectivenes of implementing such a protocol depends on the understanding and collaboration of each member responsible. The Sri Lanka Journal of Surgery 2015; 33(2): 3-7

The Effect of Evolving Fluid Resuscitation on the Outcome of Severely Injured Patients: An 8-year Experience at a Tertiary Trauma Center.

Fluid resuscitation of severely injured patients has shifted over the last decade toward less crystalloids and more blood products. Helsinki University trauma center implemented the massive transfusion protocol in the end of 2009. The aim of the study was to review the changes in fluid resuscitation and its influence on outcome of severely injured patients with hemodynamic compromise treated at the single tertiary trauma center. Data on severely injured patients (New Injury Severity Score > 15) from Helsinki University Hospital trauma center's trauma registry was reviewed over 2006-2013. The isolated head-injury patients, patients without hemodynamic compromise on admission (systolic blood pressure > 90 or base excess > -5.0), and those transferred in from another hospital were excluded. The primary outcome measure was 30-day in-hospital mortality. The study period was divided into three phases: 2006-2008 (pre-protocol, 146 patients), 2009-2010 (the implementation of massive transfusion protocol, 85 patients), and 2011-2013 (post massive transfusion protocol, 121 patients). Expected mortality was calculated using the Revised Injury Severity Classification score II. The Standardized Mortality Ratio, as well as the amounts of crystalloids, colloids, and blood products (red blood cells, fresh frozen plasma, platelets) administered prehospital and in the emergency room were compared. Of the 354 patients that were included, Standardized Mortality Ratio values decreased (indicating better survival) during the study period from 0.97 (pre-protocol), 0.87 (the implementation of massive transfusion protocol), to 0.79 (post massive transfusion protocol). The amount of crystalloids used in the emergency room decreased from 3870 mL (pre-protocol), 2390 mL (the implementation of massive transfusion protocol), to 2340 mL (post massive transfusion protocol). In these patients, the blood products' (red blood cells, fresh frozen plasma, and platelets together) relation to crystalloids increased from 0.36, 0.70, to 0.74, respectively, in three phases. During the study period, no other major changes in the protocols on treatment of severely injured patients were implemented. The overall awareness of damage control fluid resuscitation and introduction of massive transfusion protocol in a trauma center has a significant positive effect on the outcome of severely injured patients.

The Impact of a Massive Transfusion Protocol on Outcomes Among Patients with Abdominal Aortic Injuries

Injuries of the abdominal aorta are uncommon and associated with a high mortality. The purpose of this study was to examine the impact of an institutional massive transfusion protocol (MTP) on outcomes in patients with injuries of the abdominal aorta. A 12.5-year retrospective analysis of a Level 1 trauma center database to identify patients with abdominal aortic injuries was conducted. Demographics, associated injuries and severity, operative procedures, resuscitation requirements, and outcomes were compared among patients before and after implementation of an MTP. Of the 46 patients with abdominal aortic injuries, 29 (63%) were in the pre-MTP group and 17 (37%) were in the post-MTP group. The mean age of the entire cohort was 32±17years and the two most common mechanisms of injury were gunshot wounds (63%) followed by motor vehicle collisions (24%). Thirteen patients (28%) underwent an emergency department thoracotomy and 11 patients (24%) sustained concomitant inferior vena cava injuries. There was a significant reduction in the volume of pre- and intraoperative crystalloids administered between the pre- and post-MTP groups. Intraoperatively, the use of tranexamic acid was increased in the post-MTP group (P<0.001). A statistically significant difference in achievement of a low packed red blood cells to fresh frozen plasma ratio was observed for the post- versus the pre-MTP group (88% vs. 30%, P=0.015). Overall survival was improved among post- versus pre-MTP patients (47% vs. 14%, P=0.03). Abdominal aortic injuries continue to represent a challenge and remain associated with a high mortality. Modern improvements in damage control resuscitation techniques including implementation of an institutional MTP may improve outcomes in patients with these injuries.

Evaluation of the implementation of a massive transfusion protocol

A massive transfusion protocol (MTP) aims to provide standardized and early delivery of blood products and prohemostatic agents by keeping pre-thawed fresh frozen plasma (FFP) available. Implementation of MTP is assumed to result in transfusion with higher ratios of FFPs and platelets to red blood cells (RBCs). Pre-thawing may also result in waste of FFPs. These MTP benefits or disadvantages have not yet been demonstrated. The aim of this study was to evaluate efficacy of a MTP 1 year after implementation in our level I trauma center in an academic hospital.

Not only in trauma patients: hospital‐wide implementation of a massive transfusion protocol

To review outcomes of massive transfusion protocol (MTP) activation and determine the impact of MTP implementation on blood bank use. MTP has been established to rapidly provide plasma and packed red blood cells in ratios approaching 1 : 1. Due to availability, MTP has been utilised in non-traumatic haemorrhage despite evidence of benefit in this population. Our hospital-wide implementation of MTP was reviewed for propriety, outcomes and effect on blood bank resources. Retrospective cohort study of patients receiving transfusion after MTP activation from October 2009 to 2011. Underlying medical conditions and baseline medication use were determined. In-hospital and 24-h mortality were compared with evaluation for confounding by Acute Physiology And Chronic Health Evaluation (APACHE) score and duration of MTP activation. Blood product use before and after MTP implementation was reviewed. MTP activation occurred in 62 trauma and 63 non-trauma patients. Non-trauma patients were older, had more underlying medical conditions and higher APACHE scores compared with trauma patients; 24-h mortality was higher in trauma compared with non-trauma patients (27·4 vs 11·1%, P = 0·02). There was no significant difference of in-hospital mortality. Transfusion ratio did not differ between trauma and non-trauma patients and was not associated with mortality even when MTP activation duration and APACHE score were considered. Hospital-wide blood product use did not change with MTP implementation. MTP may be successfully used in trauma and non-trauma settings without significantly impacting overall blood product utilisation. Inclusion of non-trauma patients into prospective studies of resuscitation with blood products is warranted to ensure benefit in these patients.

The impact of a massive transfusion protocol (1:1:1) on major hepatic injuries: Does it increase abdominal wall closure rates?

Massive transfusion protocols (MTPs) using high plasma and platelet ratios for exsanguinating trauma patients are increasingly popular. Major liver injuries often require massive resuscitations and immediate hemorrhage control. Current published literature describes outcomes among patients with mixed patterns of injury. We sought to identify the effects of an MTP on patients with major liver trauma. Patients with grade 3, 4 or 5 liver injuries who required a massive blood component transfusion were analyzed. We compared patients with high plasma:red blood cell:platelet ratio (1:1:1) transfusions (2007-2009) with patients injured before the creation of an institutional MTP (2005-2007). Among 60 patients with major hepatic injuries, 35 (58%) underwent resuscitation after the implementation of an MTP. Patient and injury characteristics were similar between cohorts. Implementation of the MTP significantly improved plasma: red blood cell:platelet ratios and decreased crystalloid fluid resuscitation (p = 0.026). Rapid improvement in early acidosis and coagulopathy was superior with an MTP (p = 0.009). More patients in the MTP group also underwent primary abdominal fascial closure during their hospital stay (p = 0.021). This was most evident with grade 4 injuries (89% vs. 14%). The mean time to fascial closure was 4.2 days. The overall survival rate for all major liver injuries was not affected by an MTP (p = 0.61). The implementation of a formal MTP using high plasma and platelet ratios resulted in a substantial increase in abdominal wall approximation. This occurred concurrently to a decrease in the delivered volume of crystalloid fluid.

Case Scenario: Management of Trauma-induced Coagulopathy in a Severe Blunt Trauma Patient

Case Scenario: Management of Trauma-induced Coagulopathy in a Severe Blunt Trauma Patient

Massive Transfusion

The design and implementation of massive transfusion protocols with ratio-based transfusion of blood and blood products are important and active areas of investigation. A significant yet controversial body of literature exists to support the use of hemostatic resuscitation in massive transfusion and new data to support the use of adjuncts, such as recombinant factor VIIa and tranexamic acid. We review the developments in massive transfusion research during the past 5 years, including protocol implementation, hemostatic resuscitation, the use of tranexamic acid, and goal-directed therapy for coagulopathy. Furthermore, we provide a level of evidence analysis of the data surrounding the use of component therapy and recombinant factor VIIa in massive transfusion, summary recommendations for the various agents of resuscitation, and new methods of goal-directed therapy.

Massive transfusion in trauma: blood product ratios should be measured at 6 hours

Most potentially preventable haemorrhagic deaths occur within 6 h of injury. Conventionally, blood component therapy delivery is measured by 24-h cumulative totals and ratios. The study aim was to examine the effect of a massive transfusion protocol (MTP) on early (6 h) balanced component therapy. An 88-month retrospective clinical study at a level 1 trauma centre was undertaken, examining consecutive trauma patients receiving ≥10 units of packed red blood cells (PRBCs) within 24 h, before (pre-MTP) and after implementation of MTP. Demographic data, injury severity score (ISS), abbreviated injury scale (AIS), shock parameters, coagulation profile, the need for surgical intervention (<24 h), mortality and intensive care unit length of stay were collected. The ratios of blood products given by 6 h, by 24 h and the time between administrations of components was collected and analysed. Pre-MTP and MTP patients had similar demographics, shock severity and initial laboratory findings. Despite MTP patients having had a higher ISS (42 ± 12 versus 36 ± 12, P < 0.05) and AIS head score (2.6 ± 1.8 versus 1.6 ± 2.0, P < 0.05), there was no difference in mortality. Area under the curve (AUC) of the MTP period showed earlier delivery of higher median ratios of fresh frozen plasma (FFP)/PRBC (P= 0.004). Similar findings were found for cryoprecipitate/PRBC and platelet/PRBC ratios. By 24 h, the AUC for FFP/PRBC ratios were no different. Implementation of MTP resulted in earlier balanced transfusion. The difference between the FFP/PRBC ratios of the two types of resuscitations levelled by 24 h. The efficacy of component therapy delivery should be measured earlier than 24 h.

REVIEWS: Hemostatic resuscitation for massive bleeding: the paradigm of plasma and platelets—a review of the current literature

Continued hemorrhage remains a major contributor of mortality in massively transfused patients and controversy regarding the optimal management exists. Recent studies indicate a possible survival benefit in patients receiving a higher ratio of plasma and platelets (PLTs) to red blood cells (RBCs) than what is recommended in current transfusion guidelines. English databases were searched for reports of patients receiving massive transfusion that tested the effects of administration of plasma and/or PLTs in relation to RBCs on survival from January 1990 to March 2009. Fourteen retrospective studies involving 4594 patients were identified. Six tested the effect on survival in relation to fresh-frozen plasma (FFP)-to-RBC ratio, and five investigated FFP- and PLT-to-RBC ratios. Two studies evaluated implementation of massive transfusion protocols with preemptive FFP and PLT administration; one study based transfusion therapy on the result of the thrombelastograph (TEG) analysis versus historic controls. All studies reviewed demonstrate a survival benefit for patients who receive more FFP and PLT as part of the hemostatic resuscitation. When TEG was used to guide transfusion therapy an increase in FFP and PLT was also seen when compared to historic controls and this was associated with improved survival. High FFP- and PLT-to-RBC ratios seem to improve survival in patients with massive bleeding. Randomized studies evaluating TEG-guided transfusion therapy versus fixed ratios of plasma and PLTs to RBCs in massively bleeding patients is highly warranted.

Hemostatic strategies for minimizing mortality in surgery with major blood loss

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.

Massive Transfusion Protocols: The Role of Aggressive Resuscitation Versus Product Ratio in Mortality Reduction

Exsanguinating hemorrhage necessitating massive blood product transfusion is associated with high mortality rates. Recent data suggest that altering the fresh frozen plasma to packed red blood cell ratio (FFP:PRBC) results in significant mortality reductions. Our purpose was to evaluate mortality and blood product use in the context of a newly initiated massive transfusion protocol (MTP). In July 2005, our American College of Surgeons-verified Level I trauma center implemented an MTP supporting a 1:1.5 FFP:PRBC ratio, improved communications, and enhanced systems flow to optimize rapid blood product availability. During the 4 years surrounding protocol implementation, we reviewed data on trauma patients directly admitted through the emergency department and requiring 10 or more units PRBCs during the first 24 hours. For the 2 years before and subsequent to MTP initiation, there were 4,223 and 4,414 trauma activations, of which 40 and 37 patients, respectively, met study criteria. The FFP:PRBC ratios were identical, at 1:1.8 and 1:1.8 (p = 0.97). Despite no change in FFP:PRBC ratio, mortality decreased from 45% to 19% (p = 0.02). Other significant findings included decreased mean time to first product: cross-matched RBCs (115 to 71 minutes; p = 0.02), FFP (254 to 169 minutes; p = 0.04), and platelets (418 to 241 minutes; p = 0.01). MTP implementation is associated with mortality reductions that have been ascribed principally to increased plasma use and decreased FFP:PRBC ratios. Our study found a significant reduction in mortality despite unchanged FFP:PRBC ratios and equivalent overall mean numbers of transfusions. Our data underscore the importance of expeditious product availability and emphasize that massive transfusion is a complex process in which product ratio and time to transfusion represent only the beginning of understanding.