Massive Transfusion Protocol Patients Research Articles

Incidence of Red Cell Antibody Formation Following Massive Transfusion Protocol: Experience of a Single Institution.

Injured patients in hemorrhagic shock have a survival benefit with massive transfusion protocol (MTP). While there are many published studies on the transfusion management of massively bleeding patients, the risk of alloimmunization in patients that have received products during an MTP activation is relatively unknown. Therefore, we sought to determine the frequency of new antibody formation in MTP patients that received blood products from an uncrossmatched megapack. We conducted a retrospective data review of patients who underwent an MTP activation for trauma resuscitation between May 2014 and July 2020. Data were collected from patients who met the following criteria: MTP was activated, the patients received at least one unit of packed red blood cells, one unit of fresh frozen plasma, one unit of platelets, and had a repeat type and screen within 6 weeks of transfusion. These inclusion criteria resulted in 28 patients over the 6-year timeframe. Overall, the risk of alloimmunization secondary to MTP is 3.6% in our trauma patient population. The newly developed antibodies post-MTP are considered clinically significant, meaning they can cause hemolysis if exposed to donor red blood cells containing those antigens. Blood products should be given preferentially over crystalloids to acutely bleeding patients to prevent ischemic injury during an MTP activation despite the risk of alloimmunization. In our single-institution study, the alloimmunization rate in massive transfusions where patients receive uncrossmatched red blood cells is similar to those receiving crossmatched red blood cells.

Whole Blood Versus Conventional Blood Component Massive Transfusion Protocol Therapy in Civilian Trauma Patients.

Military data demonstrating an improved survival rate with whole blood (WB) have led to a shift toward the use of WB in civilian trauma. The purpose of this study is to compare a low-titer group O WB (LTOWB) massive transfusion protocol (MTP) to conventional blood component therapy (BCT) MTP in civilian trauma patients. Trauma patients 15years or older who had MTP activations from February 2019 to December 2020 were included. Patients with a LTOWB MTP activation were compared to BCT MTP patients from a historic cohort. 299 patients were identified, 169 received LTOWB and 130 received BCT. There were no differences in age, gender, or injury type. The Injury Severity Score was higher in the BCT group (27 vs 25, P = .006). The LTOWB group had a longer transport time (33 min vs 26 min, P < .001) and a lower arrival temperature (35.8 vs 36.1, P < .001). Other hemodynamic parameters were similar between the groups. The LTOWB group had a lower in-hospital mortality rate compared to the BCT group (19.5% vs 30.0%, P = .035). There were no differences in total transfusion volumes at 4hours and 24hours. No differences were seen in transfusion reactions or hospital complications. Multivariable logistic regression identified ISS, age, and 24-hour transfusion volume as predictors of mortality. Resuscitating severely injured trauma patient with LTOWB is safe and may be associated with an improved survival.

After 800 Mtp Events, Mortality Due to Hemorrhagic Shock Remains High and Unchanged Despite Several In-Hospital Hemorrhage Control Advancements.

Numerous advancements in hemorrhage control and volume replacement that comprise damage control resuscitation (DCR) have been implemented in the last decade to reduce deaths from bleeding. We sought to determine the impact of DCR interventions on mortality over 12 years in a massive transfusion protocol (MTP) population. We hypothesized that mortality would be decreased in later years, which would have used more DCR interventions. This was a retrospective review of all MTP patients treated at a large regional Level I trauma center from 2008 to 2019. Interventions by year of implementation examined included MTP 1:1 ratio (2009), liquid plasma (2010), tranexamic acid (2012), prehospital tourniquets (2013), REBOA/TEG (2017), satellite blood station (2018), and whole blood transfusion (2019). Relative risk and odds of mortality for DCR interventions were examined. There were 824 MTP patients included. The cohort was primarily male (80.6%) injured by penetrating mechanism (68.1%) with median (interquartile range) age 31 years (23-44) and New Injury Severity Score 25 (16-34). Overall mortality was unchanged [(38.3%-56.6%); P = 0.26]. Tourniquets (P = 0.02) and whole blood (WB) (P = 0.03) were associated with lower unadjusted mortality; only tourniquets remained significant after adjustment (OR: 0.39; 95% CI: 0.17-0.89; P = 0.03). Despite lower mortality with use of tourniquets and WB, mortality rates due to hemorrhage have not improved at our high MTP volume institution, suggesting implementation of new in-hospital strategies is insufficient to reduce mortality. Future efforts should be directed toward moving hemorrhage control and effective resuscitation interventions to the injury scene.

Liquid plasma: A solution to optimizing early and balanced plasma resuscitation in massive transfusion

Early and balanced resuscitation for traumatic hemorrhagic shock is associated with decreased mortality, making timely plasma administration imperative. However, fresh frozen plasma (FFP) thaw time can delay administration, and the shelf life of thawed FFP limits supply and may incur wastage. Liquid plasma (LP) offers an attractive alternative given immediate transfusion potential and extended shelf life. As such, we hypothesized that the use of LP in the massive transfusion protocol (MTP) would improve optimal plasma/red blood cell (RBC) ratios, initial plasma transfusion times, and clinical outcomes in the severely injured patient. Using Trauma Quality Improvement Program data from our level 1 trauma center, we evaluated MTP activations from 2016 to 2018. Type A LP use was instated April 2017. Before this, thawed FFP was solely used. Plasma/RBC ratios and initial plasma transfusion times were compared in MTP patients before and after LP implementation. Patient and injury characteristics were accounted for using linear regression analysis. Secondary outcomes of mortality, 28-day recovery, and complications were evaluated using Cox proportional hazards regression. A total of 95 patients were included (pre-LP, 39; post-LP, 56). Time to initial plasma transfusion and plasma/RBC ratios at 4 and 24 hours were improved post-LP implementation with a coinciding reduction in RBC units transfused (p < 0.05). In a 28-day Cox proportional hazards regression LP implementation was associated with favorable recovery (hazard ratio, 3.16; 95% confidence interval, 1.60-6.24; p < 0.001) and reduction in acute kidney injury (hazard ratio, 0.092; 95% confidence interval, 0.011-0.77; p = 0.027). No post-LP patients with blood group type B or AB (n = 9) demonstrated evidence of hemolysis within 24 hours of type A LP transfusion. Initial resuscitation with LP optimizes early plasma administration and improves adherence to transfusion ratio guidelines. Furthermore, LP offers a solution to inherent delays with FFP and is associated with improved clinical outcomes, particularly 28-day recovery and odds of acute kidney injury. Liquid plasma should be considered as an alternative to FFP in MTPs. Therapeutic/care management, level IV.

LO90: The clock is ticking: using in situ simulation to improve time to blood delivery in bleeding trauma patients

Background: Massive transfusion protocols (MTP) are widely used to rapidly deliver blood products to bleeding trauma patients. Every minute delay in blood product administration in bleeding trauma patients is associated with a 5% increased odds of death. In-situ simulation (ISS) is simulation that takes place in the actual clinical work environment. We used ISS as a novel, prospective and iterative quality improvement (QI) approach to identify and improve MTP steps that impact time to blood delivery (TTBD) during actual trauma resuscitations. Aim Statement: To reduce the TTBD for bleeding trauma patients by 20% over a 12-month ISS-based QI initiative. Measures &amp;amp; Design: We conducted twelve high-fidelity, interprofessional ISS sessions at a Level-1 trauma center in Toronto, Canada. We used clinician video review as well as extensive stakeholder involvement, including with nurses, porters, blood bank and human factors experts, to develop Plan-Do-Study-Act (PDSA) cycles for MTP improvement. Our three major PDSA cycles revolved around: 1) decreasing MTP activation time; 2) reducing the unpredictable and inefficient transport times for the blood itself; and 3) improving the notification of blood product arrival in the trauma bay. Each PDSA cycle was iteratively tested with ISS prior to implementation into clinical care. Outcome measure was the mean TTBD for trauma patients requiring MTP (in minutes, standard deviation [SD]). Process measures included time to MTP activation and porter transport times. Balancing measures included stakeholder satisfaction. Evaluation/Results: Our baseline TTBD for MTP patients was 11.58min (n = 41, SD 6.8). There were 54 trauma patients that had MTP during the ISS-based QI initiative, and their mean TTBD was 10.44min (SD 6.1). The TTBD after the QI initiative was 9.12min, sustained over 1 year (n = 50, SD 5.3; 21.2% relative reduction, p &amp;lt; 0.05). A run chart did not show special cause variation chronologically related to our interventions. Patients in each group were similar in demographic data, trauma characteristics and injury severity score. Discussion/Impact: We achieved a 21.2% reduction in TTBD for trauma patients requiring MTP with an ISS-based QI initiative. ISS represents a novel approach to the identification and iterative testing of process improvements within trauma care. This methodology can and should be included in QI projects in order to safely test and improve processes of care before they impact real patients.

Shock index and pulse pressure as triggers for massive transfusion.

Hemorrhage is the most common cause of preventable death in trauma patients. These mortalities might be prevented with prehospital transfusion. We sought to characterize injured patients requiring massive transfusion to determine the potential impact of a prehospital whole blood transfusion program. The primary goal of this analysis was to determine a method to identify patients at risk of massive transfusion in the prehospital environment. Many of the existing predictive models require laboratory values and/or sonographic evaluation of the patient after arrival at the hospital. Development of an algorithm to predict massive transfusion protocol (MTP) activation could lead to an easy-to-use tool for prehospital personnel to determine when a patient needs blood transfusion. Using our Level I trauma center's registry, we retrospectively identified all adult trauma patients from January 2015 to August 2017 requiring activation of the MTP. Patients who were younger than 18 years, older than 89 years, prisoners, pregnant women, and/or with nontraumatic hemorrhage were excluded from the study. We retrospectively collected data including demographics, blood utilization, variable outcome data (survival, length of stay, intensive care unit days, ventilator days), prehospital vital signs, prehospital transport times, and Injury Severity Score. The independent-samples t test and χ test were used to compare the group who died to the group who survived. p < 0.05 was considered significant. Based on age and mechanism of injury, relative risk of death was calculated. Graphs were generated using Microsoft Excel software to plot patient variables. Our study population of 102 MTP patients had an average age of 42 years and average Injury Severity Score of 29, consisted of 80% males (82/102), and was 66% blunt trauma (67/102). The all-cause mortality was 67% (68/102). The positive predictive value of death for patients with pulse pressure of less than 45 and shock index of greater than 1 was 0.78 for all patients, but was 0.79 and 0.92 for blunt injury and elderly patients, respectively. Our data demonstrate a high mortality rate in trauma patients who require MTP despite short transport times, indicating the need for early intervention in the prehospital environment. Given our understanding that the most severely injured patients in hemorrhagic shock require blood resuscitation, this study demonstrates that this subset of trauma patients requiring massive transfusion can be identified in the prehospital setting. We recommend using Emergency Medical Services pulse pressure in combination with shock index to serve as a trigger for initiation of prehospital whole blood transfusion. Therapeutic/care management, level V.

Tolerability and effectiveness of 4-factor prothrombin complex concentrate (4F-PCC) for warfarin and non-warfarin reversals

PurposeCurrent guidelines favor 4F-PCC over plasma for warfarin reversal. Uncertainty remains on its thrombotic risk and hemostatic effectiveness when used for direct-acting oral anticoagulants (DOACs), transplants, massive transfusion protocols (MTP), and non-anticoagulated patients. This study sought to evaluate the tolerability and effectiveness of 4F-PCC in a real-world setting. Materials and methodsThis was a retrospective study of adults who received 4F-PCC from March 2014 to December 2015. The primary outcome was thromboembolic events within 14 days. The secondary outcome was hemostatic effectiveness within 24 h. ResultsThe final analysis included 212 patients. Primary reversal indication was major bleed in 165 patients (77.8%) and emergent surgery in 47 patients (22.2%). Thromboembolism occurred in 22 patients (10.4%), more in emergent surgery than major bleed reversals (17% and 8.5%, respectively). MTP and heart transplant patients had the highest thromboembolic event rates (44.4% and 28.6%, respectively). Hemostatic effectiveness was 65.8% (68% in major bleed and 58.1% in emergent surgery). DOAC patients achieved hemostasis most often (78.9%). Administration of any reversal agent, major surgery within 14 days, and MTP activation were significant predictors of thromboembolism. ConclusionsUse of 4F-PCC in this real-world setting was associated with variable thromboembolic and hemostatic effectiveness rates based on the indication for reversal.

Prehospital low-titer cold-stored whole blood: Philosophy for ubiquitous utilization of O-positive product for emergency use in hemorrhage due to injury.

The mortality from hemorrhage in trauma patients remains high. Early balanced resuscitation improves survival. These truths, balanced with the availability of local resources and our goals for positive regional impact, were the foundation for the development of our prehospital whole blood initiative-using low-titer cold-stored O RhD-positive whole blood. The main concern with use of RhD-positive blood is the potential development of isoimmunization in RhD-negative patients. We used our retrospective massive transfusion protocol (MTP) data to analyze the anticipated risk of this change in practice. In 30 months, of 124 total MTP patients, only one female of childbearing age that received an MTP was RhD-negative. With the risk of isoimmunization very low and the benefit of increased resources for the early administration of balanced resuscitation high, we determined that the utilization of low-titer cold-stored O RhD-positive whole blood would be safe and best serve our community.

Efficacy of a massive transfusion protocol for hemorrhagic trauma resuscitation

ObjectivesNew paradigm shifts in trauma resuscitation recommend that early reconstitution of whole blood ratios with massive transfusion protocols (MTP) may be associated with improved survival. We performed a preliminary study on the efficacy of MTP at an urban, Level 1 trauma center and its impact on resuscitation goals. MethodsA case-control study was performed on consecutive critically-ill trauma patients over the course of 1 year. The trauma captain designated patients as either MTP activation (cases) or routine care without MTP (controls) in matched, non-randomized fashion. Primary outcomes were: time to initial transfusion; number of total units of packed red blood cells (pRBC) and fresh frozen plasma (FFP) transfused; and ratio of pRBC to fresh frozen plasma (pRBC:FFP). Secondary outcomes were in-hospital mortality, and length of stay. ResultsOut of 226 patients screened, we analyzed 58 patients meeting study criteria (32 MTP, 26 non-MTP). Study characteristics for the MTP and non-MTP groups were similar except age (34.0 vs. 45.85 years, p=0.015). MTP patients received blood products more expeditiously (41.7 minutes vs. 62.1 minutes, p=0.10), with more pRBC (5.19 vs 3.08 units, p=0.05), more FFP (0.19 vs 0.08 units, p<0.01), and had larger pRBC:FFP ratios (1.90 vs 0.52, p<0.01). Secondary outcomes did not differ significantly but the MTP group was associated with a trend for decreased hospital length of stay (p=0.08). ConclusionsMTP resulted in clinically significant improvements in transfusion times and volumes. Further larger and randomized studies are warranted to validate these findings to optimize MTP protocols.

Liquid plasma use during “super” massive transfusion protocol

BackgroundA massive transfusion protocol (MTP) presents a logistical challenge for most blood banks and trauma centers. We compare the ratio of packed red blood cells (PRBC) and plasma transfused over serial time points in those requiring MTP (10–30 U PRBC/24 h) to those requiring “super” MTP (S-MTP; >30 U PRBC/24 h) and test the hypothesis that changes in allocation of blood products with use of readily transfusable liquid plasma (LP) improves the ratio of PRBC and plasma during S-MTP. Materials and methodsAll transfused trauma patients (n = 1305) from January 01, 2009–April, 03, 2015 were reviewed. PRBC:plasma ratio was compared for MTP (n = 277) and S-MTP (n = 61) patients, before and after the availability of LP at our institution. Data are reported as mean ± standard deviation or median (interquartile range). ResultsAge was 41 ± 19 y, 52% blunt mechanism, injury severity score 32 ± 16, and 46.3% mortality. In 24 h, requirements were 17 (14) U PRBC and 10 (11) U plasma, with a PRBC:plasma of 1.6 (0.8). Within the first hour, PRBC:plasma for S-MTP versus MTP was 2.1:1 versus 1.7:1 (P = 0.017). With LP, S-MTP patients received significantly lower PRBC:plasma at the first hour (P < 0.001). Before institutional changes, PRBC:plasma positively correlated with PRBC transfused at hour 1 (r = 0.410, R2 = 0.168, P < 0.001); after institutional changes and the advent of LP, there was no correlation (r = 0.177, R2 = 0.031, P = 0.219). ConclusionsWithin the first hour of transfusion, units of PRBC transfused positively correlated with PRBC:plasma, and patients receiving S-MTP had higher PRBC:plasma than those receiving MTP. Changes in our institution's MTP protocol to include LP improved the early PRBC:plasma transfused in patients requiring S-MTP.

Addition of tranexamic acid to a traumatic injury massive transfusion protocol.

The development of eligibility criteria and use of tranexamic acid in conjunction with a massive transfusion protocol (MTP) are described. The trauma surgery and pharmacy departments collaborated to operationalize tranexamic acid administration in trauma patients for whom an MTP was activated. The MTP at Boston Medical Center, an urban, tertiary, academic medical center, is activated by the attending physician when the patient is expected to require at least 10 units of packed red blood cells in 24 hours. Tranexamic acid was considered in MTP trauma patients who arrived at the medical center within 8 hours of traumatic injury, were 15 years of age or older, and weighed at least 40 kg. Eligible patients were to receive a loading dose of tranexamic acid 1 g i.v. over 10 minutes followed by a maintenance dose of 1 g infused over 8 hours. To ensure that tranexamic acid use was limited to trauma patients, both its location of use and physician-ordering privileges were restricted by the pharmacy department. A 16-month assessment revealed that 16 patients received tranexamic acid, 13 (81%) of whom met all criteria for use. Tranexamic acid was used in 13 (38%) of 34 eligible MTP patients. Barriers to the use of tranexamic acid include a lack of familiarity with the medication among staff, drug availability, the complexity of administration, and the critical setting of MTP activation. Multidisciplinary collaboration and standardization of tranexamic acid use in conjunction with an MTP promoted use of the drug within a trauma population.

Diluting the benefits of hemostatic resuscitation

Although minimization of crystalloids is a widely adopted practice in the resuscitation of patients with severe hemorrhage, its direct impact on high-ratio resuscitation (HRR) outcomes has not been analyzed. We hypothesize that HRR patients will have worse outcomes from crystalloid use. This was a 4-year retrospective multi-institutional analysis (MIA) of patients who received massive transfusion protocol (MTP) managed with damage-control laparotomy. Ratios of fresh frozen plasma-packed red blood cell (PRBC) were calculated and divided in two groups: HRR (1-1:2) and low-ratio resuscitation (LRR < 1:2). Major outcome of interest was to analyze the direct impact of 24-hour crystalloid volume on HRR MTP patients who received 10 or more units of PRBC. Statistical analysis included analysis of variance, Fisher's exact, Kaplan-Meier (KM) survival curves, and multiple logistic regression. Total of five Level I trauma centers participated with 451 patients who received MTP with 10 or more units of PRBC (fresh frozen plasma/PRBC ratios, n = 365 (80.9%) HRR vs. n = 86 (19.0%) LRR. Overall 24-hour KM survival for the HRR versus LRR was 85.2% versus 68.6% (p = 0.0004). The volume of crystalloids on KM survival curve in HRR MTP patients was not significant for mortality (p = 0.52). Morbidity odds ratios (95% confidence interval) for complications were not significant for HRR but were for crystalloids: bacteremia, 1.05 (1.0-1.1); adult respiratory distress syndrome, 1.13 (1.0-1.2), and acute renal failure, 1.05 (1.0-1.1). Our MIA results support previous studies with decreased mortality in HRR group when compared with LRR. This is the first MIA to demonstrate increased morbidity from crystalloid use in HRR. Within all MTPs with 10 or more units of PRBC, HRR was not a predictor of morbidity, but crystalloid volume was. Caution in overzealous use of crystalloid during HRR is warranted. Therapeutic study, level IV.

Use of a Massive Transfusion Protocol in Nontrauma Patients: Activate Away

Recently, concern has been raised that the use of massive transfusion protocols (MTPs) in nontrauma (ie, general medical/surgical [GMS]) patients might be inefficient due to protocol overactivation (activation in patients who do not ultimately receive massive transfusion). The current study was designed to investigate whether an MTP could be used effectively in GMS patients without detrimentally impacting resource allocation. A retrospective analysis was performed using institutional blood bank records from 2011. Trauma and GMS patients who had ≥10 U packed RBC issued to them in a single release were identified and categorized into MTP and no MTP (nMTP) cohorts. The protocol was overactivated in 53.8% of GMS patients. Activation of the MTP accelerated the delivery of component products for all patients. In GMS MTP patients, fresh frozen plasma units were issued a median of 7 minutes earlier than in GMS nMTP patients (MTP: median 1.0 minute; interquartile range [IQR] 0.0 to 2.0 minutes vs nMTP: median 8.0 minutes; IQR 0.0 to 37.5 minutes; p= 0.009), and platelet units were issued 17 minutes earlier (MTP: median 7.0 minutes; IQR 0.0 to 15.0 minutes vs nMTP: median 24.0 minutes; IQR 9.0 to 96.0 minutes; p= 0.010). In GMS MTP patients, there was a statistically significant increase in the percentage of platelet units wasted (MTP 12.8% vs nMTP 8.1%; p= 0.046). This increase was also seen in trauma MTP patients (MTP 12.2% vs nMTP 4.0%; p < 0.001). Despite finding that our MTP is overactivated in GMS patients, we could identify no unique disadvantages to its use with respect to resource allocation. In fact, a potential advantage to MTP activation exists, as products are issued more quickly with less variability. Our findings of increased platelet waste were not unique to GMS patients and should be used as a metric for quality improvement.

TEG-guided resuscitation is superior to standardized MTP resuscitation in massively transfused penetrating trauma patients

For nearly a decade, our center performed thromboelastograms (TEGs) to analyze coagulation profiles, allowing rapid data-driven blood component therapy. After consensus recommendations for massive transfusion protocols (MTPs), we implemented an MTP in October 2009 with 1:1:1 ratio of blood (red blood cells [RBC]), plasma (fresh-frozen plasma [FFP]), and platelets. We hypothesized that TEG-directed resuscitation is equivalent to MTP resuscitation. All patients receiving 6 units (U) or more of RBC in the first 24 hours for 21 months before and after MTP initiation in an urban Level I trauma center were examined. Demographics, mechanism of injury (MOI), Injury Severity Score (ISS), 24-hour volume of RBC, FFP, platelets, crystalloid, and 30-day mortality were compared, excluding patients with traumatic brain injuries. Variables were analyzed using Student's t-test and χ2 or Fisher's exact test. For the preMTP group, there were 165 patients. In the MTP group, there were 124 patients. There were no significant differences in ISS, age, or sex. PreMTP patients with 6U or more RBC had significantly more penetrating MOI (p = 0.017), whereas preMTP patients with 10U or more RBC had similar MOIs. All patients received less crystalloid after MTP adoption (p < 0.001). There was no difference in volume of blood products or mortality in patients receiving 6U or more RBC. Blunt trauma MTP patients who received 10U or more RBC received more FFP (p = 0.02), with no change in mortality. Penetrating trauma patients who received 10U or more RBC received a similar volume of FFP; however, mortality increased from 54.1% for MTP versus 33.3% preMTP (p = 0.04). TEG-directed resuscitation is equivalent to standardized MTP for patients receiving 6U or more RBC and for blunt MOI patients receiving 10U or more RBC. MTP therapy worsened mortality in penetrating MOI patients receiving 10U or more RBC, indicating a continued need for TEG-directed therapy. A 1:1:1 strategy may not be adequate in all patients. Therapeutic study, level IV.

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.

Implementation of a pediatric trauma massive transfusion protocol: one institution's experience

Massive transfusion protocols (MTPs) with fixed ratios of blood products may improve outcomes in coagulopathic adult trauma patients. However, there is a paucity of data on transfusion support protocols for pediatric trauma patients, whose mechanisms of injury may differ from those seen in adults. We hypothesized that an MTP would improve outcomes in children, through a balanced blood product resuscitation. A pediatric trauma MTP, with a fixed ratio of red blood cells (RBCs):fresh-frozen plasma (FFP):platelets:cryoprecipitate in quantities based on the patient's weight, was initiated at a pediatric hospital. Data on clinical status, resuscitation volumes, and hospital course were collected and compared to data from pre-MTP trauma patients requiring transfusion. Fifty-three patients were enrolled over a 15-month period and compared to 49 pre-MTP patients. Seventy-two percent of MTP patients had at least one coagulation value outside of the normal range upon emergency department (ED) arrival, and the median time to FFP transfusion decreased fourfold after MTP implementation (p<0.0001). A total of 49% of MTP patients received greater than 70 mL/kg blood products, and the 24-hour median FFP:RBC transfusion ratio was twofold higher in these patients than the pre-MTP cohort (median, 1:1.8 vs. 1:3.6; p=0.002). No improvement in mortality was observed after MTP implementation, taking into consideration injury severity, prothrombin time, and partial thromboplastin time. A pediatric trauma MTP is feasible and allows for rapid provision of balanced blood products for transfusion to coagulopathic children. Larger studies are warranted to determine whether such protocols will improve outcomes for pediatric trauma patients.

Improvements in Early Mortality and Coagulopathy are Sustained Better in Patients With Blunt Trauma After Institution of a Massive Transfusion Protocol in a Civilian Level I Trauma Center

Transfusion practices across the country are changing with aggressive use of plasma (fresh-frozen plasma [FFP]) and platelets during massive transfusion with current military recommendations to use component therapy at a 1:1:1 ratio of packed red blood cells to FFP to platelets. A massive transfusion protocol (MTP) was designed to achieve a packed red blood cell:FFP:platelet ratio of 1:1:1 We prospectively gathered demographic, transfusion, and patient outcome data during the first year of the MTP and compared this with a similar cohort of injured patients (pre-MTP) receiving > or = 10 red blood cell (RBC) in the first 24 hours of hospitalization before instituting the MTP. One hundred sixteen MTP activations occurred. Twelve non-trauma patients and 31 who did not receive 10 RBC (15 deaths, 16 early bleeding controls) were excluded. Seventy-three MTP patients were compared with 84 patients with pre-MTP who had similar demographics and injury severity score (29 vs. 29, p = 0.99). MTP patients received an average of 23.7 RBC and 15.6 FFP transfusions compared with 22.8 RBC (p = 0.67) and 7.6 FFP (p < 0.001) transfusions in pre-MTP patients. Early crystalloid usage dropped from 9.4 L (pre-MTP) to 6.9 L (MTP) (p = 0.006). Overall patient mortality was markedly improved at 24 hours, from 36% in the pre-MTP group to 17% in the MTP group (p = 0.008) and at 30 days (34% mortality MTP group vs. 55% mortality in pre-MTP group, p = 0.04). Blunt trauma survival improvements were more marked and more sustained than victims of penetrating trauma. Early deaths from coagulopathic bleeding occurred in 4 of 13 patients in the MTP group vs. 21 of 31 patients in the pre-MTP group (p = 0.023). In the civilian setting, aggressive use of FFP and platelets drastically reduces 24-hour mortality and early coagulopathy in patients with trauma. Reduction in 30 day mortality was only seen after blunt trauma in this small subset.