PRBC Ratio Research Articles

High Plasma to Red Blood Cell Ratios Are Associated With Lower Mortality Rates in Patients Receiving Multiple Transfusion (4 ≤ Red Blood Cell Units < 10) During Acute Trauma Resuscitation

Benefits of high ratios of fresh frozen plasma (FFP) to packed red blood cells (pRBC) in massively transfused trauma patients have been reported previously. This study aimed to assess the effect of higher FFP:pRBC ratios on outcome in patients receiving less than massive transfusion during acute trauma care. The multicenter trauma registry of the German Trauma Society (2005-2008) was retrospectively analyzed for patients aged≥16 years with an Injury Severity Score≥16 who had received multiple but not massive transfusion between emergency room arrival and intensive care unit (ICU) admission, i.e., at least 4 but less than 10 pRBC units (4≤pRBC units<10). Patients who died within 1 hour after hospital admission were excluded. Three groups were analyzed according to FFP:pRBC ratio: low (<1:1, LR), balanced (1:1, BR), and high ratio (>1:1, HR). BR was defined as pRBC units=FFP units±1 FFP unit. A total of 1,362 patients met study criteria (LR=760, BR=392, and HR=210). Patient characteristics were similar among groups. For the three groups (LR, BR, and HR) sepsis was reported in 17.1%, 18.2%, and 17.6% (p=0.9), incidence of multiple organ failure was 49.1%, 47.9%, and 52.4% (p=0.6), whereas mortality was 26.8%, 21.7%, and 15.2% (p=0.001), respectively. Ongoing pRBC-transfusion after ICU admission occurred in 68.1%, 66.7%, and 53.9% (p<0.001), respectively. ICU/hospital lengths of stay were comparable between groups. Multivariate logistic regression identified a high FFP:pRBC ratio as independent predictor for survival (odds ratio, 0.52, p=0.013). Trauma patients receiving less than massive transfusion might also benefit from higher FFP:pRBC ratios, as these were associated with significantly lower mortality rates and decreased blood product utilization during subsequent ICU treatment, whereas morbidity was comparable among groups. Additional prospective trials are necessary.

Determinants of mortality in trauma patients following massive blood transfusion

Aim:This study was designed to find out the factors influencing mortality in trauma patients receiving massive blood transfusion (MBT).Materials and Methods:Records of all patients admitted during December 2007 to November 2008 at a Level I Trauma Center emergency and who underwent massive transfusion (≥10 units of packed red cells in 24 h) were retrospectively analyzed. Death during the hospital stay was considered as the study outcome and various demographic, laboratory, and clinical parameters were included as its potential determinants.Statistical Analysis:Bivariate and multivariate logistic regression analyses were done to identify the risk factors associated with mortality.Results:Of the 4054 transfused patients who were admitted to the trauma center during the study period, 71 (1.8%) patients underwent massive transfusion. Of this, there were 37 survivors and 34 nonsurvivors (48%). The median overall ISS was 27 (22–34). The patients who died had shorter mean length of hospital stay, shorter mean duration of intensive care unit (ICU) stay, and low admission Glasgow Coma Scale (GCS) compared to the survivors (P < 0.01). The mean prothrombin time (PT) and the mean activated partial thromboplastin time was significantly high (P < 0.01) among nonsurvivors. Total leukocyte count (TLC ≥ 10,000 cells/cubic mm), GCS ≤ 8, the presence of coagulopathy and major vascular surgery were the four independent determinants of mortality in multivariate logistic regression analysis. The FFP:PRBC (fresh frozen plasma:packed red cells) ratio and PC:PRBC (platelet concentrate:packed red cells) ratio calculated in our study was not statistically significant in correlation to the in hospital mortality.Conclusions:Overall mortality among the MBT patients was comparable with the studies in the literature. Mortality is not affected by the amount of packed red cells given in the first 12 h and the total number of packed red cells transfused. Prospective studies are required to further validate the determinants of mortality and establish guidelines for MBT.

Clinical Observation Study of Massive Blood Transfusion in a Tertiary Care Hospital in Korea

PurposeMassive blood transfusios are uncommon. The goal of this study was to propose an ideal ratio for the blood component of massive hemorrhage treatment after review of five years of massive transfusion practice, in order to have the best possible clinical outcomes.Materials and MethodsWe defined a 'massive transfusion' as receiving 10 or more units of red blood cells in one day. A list of patients receiving a massive transfusion from 2004 to 2008 was generated using the electronic medical records. For each case, we calculated the ratio of blood components and examined its relationship to their survival.ResultsThree hundred thirty four patients underwent massive transfusion during the five years of the study. The overall seven-day hospital mortality for massive transfusion patients was 26.1%. Factors independently predictive of survival were a fresh-frozen plasma (FFP)/packed red blood cell (pRBC) ratio≥1.1 with an odds ratio (OR) of 1.96 (1.03-3.70), and elective admission with an OR of 2.6 (1.52-4.40). The receiver operation characteristic (ROC) curve suggest that a 1 : 1 : 1 ratio of pRBCs to FFP to platelets is the best ratio for survival.ConclusionFixing blood-component ratios during active hemorrhage shows improved outcomes. Thus, the hospital blood bank and physician hypothesized that a fixed blood component ratio would help to reduce mortality and decrease utilization of the overall blood component.

The Impact of Platelet Transfusion in Massively Transfused Trauma Patients

The impact of platelet transfusion in trauma patients undergoing a massive transfusion (MT) was evaluated. The Institutional Trauma Registry and Blood Bank Database at a Level I trauma center was used to identify all patients requiring an MT (≥10 packed red blood cells [PRBC] within 24 hours of admission). Mortality was evaluated according to 4 apheresis platelet (aPLT):PRBC ratios: Low ratio (<1:18), medium ratio (≥1:18 and <1:12), high ratio (≥1:12 and <1:6), and highest ratio (≥1:6). Of 32,289 trauma patients, a total of 657 (2.0%) required an MT. At 24 hours, 171 patients (26.0%) received a low ratio, 77 (11.7%) a medium ratio, 249 (37.9%) a high ratio, and 160 (24.4%) the highest ratio of aPLT:PRBC. After correcting for differences between groups, the mortality at 24 hours increased in a stepwise fashion with decreasing aPLT:PRBC ratio. Using the highest ratio group as a reference, the adjusted relative risk of death was 1.67 (adjusted p = 0.054) for the high ratio group, 2.28 (adjusted p = 0.013) for the medium ratio group, and 5.51 (adjusted p < 0.001) for the low ratio group. A similar stepwise increase in mortality with decreasing platelet ratio was observed at 12 hours after admission and for overall survival to discharge. After stepwise logistic regression, a high aPLT:PRBC ratio (adjusted p < 0.001) was independently associated with improved survival at 24 hours. For injured patients requiring a massive transfusion, as the apheresis platelet-to-red cell ratio increased, a stepwise improvement in survival was seen. Prospective evaluation of the role of platelet transfusion in massively transfused patients is warranted.

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.

Optimizing Outcomes in Damage Control Resuscitation: Identifying Blood Product Ratios Associated With Improved Survival

Despite recent attention and impressive results with damage control resuscitation, the appropriate ratio of blood products to be transfused has yet to be defined. The purpose of this study was to evaluate whether suggested blood product ratios yield superior survival rates. After IRB approval, a retrospective evaluation was performed on all trauma exsanguination protocol (TEP, n = 118) activations from February 1, 2006 to July 31, 2007. A comparison cohort (pre-TEP, n = 140) was selected from all trauma admissions between August 1, 2004 and January 31, 2006 that (1) underwent immediate surgery by the trauma team and (2) received greater than 10 units of PRBC in the first 24 hours. We then compared those who received FFP:RBC (2:3) and platelet:RBC (1:5) ratios with those who did not reach these ratios. Multivariate analysis was performed for independent predictors of mortality. A total of 259 patients were available for study. Patients receiving FFP:RBC at a ratio of 2:3 or greater (n = 64) had a significant reduction in 30-day mortality compared with those who received less than a 2:3 ratio (n = 195); 41% versus 62%, p = 0.008. Patients receiving platelets:RBC at a ratio of 1:5 or greater (n = 63) had a lower 30-day mortality when compared with those with who received less than this ratio (n = 196); (38% vs. 61%, p = 0.001). Regression model demonstrated that a ratio of FFP to PRBC is an independent predictor of 30-day mortality, controlling for age and TRISS (OR 1.78, 95% CI 1.01-3.14). Increased FFP:PRBC and PLT:PRBC ratios during a period of massive transfusion improved survival after major trauma. Massive transfusion protocols should be designed to achieve these ratios to provide maximal benefit.

Fresh Frozen Plasma Should be Given Earlier to Patients Requiring Massive Transfusion

Acidosis, hypothermia, and coagulopathy were identified more than 20 years ago as a deadly triad for patients presenting with exsanguinating hemorrhage. This led to fundamental changes in initial management of severely injured patients. Despite major advances, hemorrhage remains a leading cause of early death in trauma patients. Recent studies report most severely injured patients to be coagulopathic at admission, before resuscitation interventions, and that traditional massive transfusion practice grossly underestimates needs. The hypothesis for this study is that our pre-intensive care unit (ICU) massive transfusion (MT) protocol does not adequately correct coagulopathy, and that early uncorrected coagulopathy is predictive of mortality. Data maintained in our Trauma Research Database were reviewed. Univariate logistic regression analysis was used to analyze the association of early ICU international normalized ratio (INR) and outcomes, including survival. Ninety-seven of 200 patients admitted during 51 months (ending January 2003) and resuscitated using our standardized ICU shock resuscitation protocol received MT (> or =10 units packed red blood cells [PRBC]) during hospital day 1 (age, 39 +/- 2; ISS, 29 +/- 1; survival, 70%.) All patients required emergency operating room and/or interventional radiology procedures and arrived in the ICU 6.8 +/- 0.3 hours after admission. Coagulopathy, present at hospital admission (pre-ICU INR, 1.8 +/- 0.2), persisted at ICU admission (initial ICU INR, 1.6 +/- 0.1). Pre-ICU resuscitation, 9 +/- 1 L crystalloid fluid, 12 +/- 1 units PRBC, 5 +/- 0.4 units fresh frozen plasma (FFP), was consistent with our MT protocol by which FFP was not given until after 6 units PRBC. ICU resuscitation involved 11 +/- 1 L lactated Ringer's solution (LR) and 10 +/- 1 units PRBC. Mean pH was normal within 8 hours. Mean temperature increased from approximately 35 degrees C to >37 degrees C within 4 hours. In the ICU during resuscitation, patients received 10 +/- 1 units FFP for coagulopathy; the ratio of FFP:PRBC was 1:1. Mean INR decreased to 1.4 +/- 0.03 within 8 hours and remained nearly constant for the remaining 16 hours of ICU resuscitation, indicating moderate coagulopathy. Statistical analysis found severity of coagulopathy (INR) at ICU admission associated with survival outcome (p = 0.02; area under receiver operator curve [ROC] = 0.71.) These data indicate acidosis and hypothermia to be well managed. Coagulopathy was not corrected in the ICU despite adherence to pre-ICU MT and ICU protocols, likely because of inadequate pre-ICU intervention. More aggressive pre-ICU intervention to correct coagulopathy may be effective in decreasing PRBC requirement during ICU resuscitation, and, because of the association with increased mortality, could improve outcome. We have revised our pre-ICU MT protocol to emphasize early FFP in a FFP:PRBC ratio of 1:1. We think that treatment of coagulopathy can be improved with the development of standardized protocols, both empiric and data driven.