FFP Ratio Research Articles

Effects of Tariff on the Management of Blood Products in Fars Province Hospitals

Background In Iran, blood products were being delivered to healthcare centers without charge. For optimum usage and reducing wastage, the tariff was set on October 23, 2015. Thus, hospitals must pay for blood products to blood transfusion services and then the expenses are paid to healthcare centers by the insurance. Objectives This study aimed to explore the effects of the tariff policy on utilization pattern of blood products in healthcare centers of Fars province, Iran. Design This is a retrospective study which analyzes the recorded data. Methods Throughout this retrospective study, the number of units requested, delivered, returned, and return/delivery ratio of RBC, FFP, cryoprecipitate, and platelet were examined before and after the tariff in different cities of Fars province of Iran. Results After the tariff, return/delivery ratios of FFP, cryoprecipitate, and platelet increased in comparison with before tariff but were not statistically significant which means the return of unused units was increased after imposing tariff. Conclusion The results of this investigation showed that tariff may lead to more return of FFP, cryoprecipitate, and platelet units to the transfusion services of Fars province. More research must be performed to further approve it.

Outcome of Major Hemorrhage at a Major Cardiothoracic Center in Patients with Activated Major Hemorrhage Protocol versus Nonactivated Protocol.

This study aimed to determine the impact of major hemorrhage (MH) protocol (MHP) activation on blood administration and patient outcome at a UK major cardiothoracic center. MH was defined in patients (> 16 years) as those who received > 5 units of red blood cells (RBCs) in < 4 hours, or > 10 units in 24 hours. Data were collected retrospectively from patient electronic records and hospital transfusion databases recording issue of blood products from January 2016 to December 2018. Of 134 patients with MH, 24 had activated MHP and 110 did not have activated MHP. Groups were similar for age, sex, baseline hemoglobin, platelet count, coagulation screen, and renal function with no difference in the baseline clinical characteristics. The total number of red cell units (median and [IQR]) transfused was no different in the patients with activated (7.5 [5-11.75]) versus nonactivated (9 [6-12]) MHP (p = 0.35). Patients in the nonactivated MHP group received significantly higher number of platelet units (median: 3 vs. 2, p = 0.014), plasma (median: 4.5 vs. 1.5, p = 0.0007), and cryoprecipitate (median: 2 vs. 1, p = 0.008). However, activation of MHP was associated with higher mortality at 24 hours compared with patients with nonactivation of MHP (33.3 vs. 10.9%, p = 0.005) and 30 days (58.3 vs. 30.9%, p = 0.01). The total RBC and platelet (but not fresh frozen plasma [FFP]) units received were higher in deceased patients than in survivors. Increased mortality was associated with a higher RBC:FFP ratio. Only 26% of patients received tranexamic acid and these patients had higher mortality at 30 days but not at 24 hours. Deceased patients at 30 days had higher levels of fibrinogen than those who survived (median: 2.4 vs. 1.8, p = 0.01). Patients with activated MHP had significantly higher mortality at both 24 hours and 30 days despite lack of difference in the baseline characteristics of the patients with activated MHP versus nonactivated MHP groups. The increased mortality associated with a higher RBC:FFP ratio suggests dilutional coagulopathy may contribute to mortality, but higher fibrinogen at baseline was not protective.

Does the evidence support the importance of high transfusion ratios of plasma and platelets to red blood cells in improving outcomes in severely injured patients: a systematic review and meta-analyses.

BACKGROUNDDeaths by exsanguination in trauma are preventable with hemorrhage control and resuscitation with allogeneic blood products (ABPs). The ideal transfusion ratio is unknown. We compared efficacy and safety of high transfusion ratios of FFP:RBC and PLT:RBC with low ratios in trauma.STUDY DESIGN AND METHODSMedline, Embase, Cochrane, and Controlled Clinical Trials Register were searched. Observational and randomized data were included. Risk of bias was assessed using validated tools. Primary outcome was 24‐h and 30‐day mortality. Secondary outcomes were exposure to ABPs and improvement of coagulopathy. Meta‐analysis was conducted using a random‐effects model. Strength and evidence quality were graded using GRADE profileRESULTS55 studies were included (2 randomized and 53 observational), with low and moderate risk of bias, respectively, and overall low evidence quality. The two RCTs showed no mortality difference (odds ratio [OR], 1.35; 95% confidence interval [CI], 0.40‐4.59). Observational studies reported lower mortality in high FFP:RBCs ratio (OR, 0.38 [95% CI, 0.22‐0.68] for 1:1 vs. <1:1; OR, 0.42 [95% CI, 0.22‐0.81] for 1:1.5 vs. <1:1.5; and OR, 0.47 [95% CI, 0.31‐0.71] for 1:2 vs. <1:2, respectively). Meta‐analyses in observational studies showed no difference in exposure to ABPs. No data on coagulopathy for meta‐analysis was identified.CONCLUSIONSMeta‐analyses in observational studies suggest survival benefit and no difference in exposure to ABPs. No survival benefit in RCTs was identified. These conflicting results should be interpreted with caution. Studies are mostly observational, with relatively small sample sizes, nonrandom treatment allocation, and high potential for confounding. Further research is warranted.

Massive transfusion in pediatric trauma: An ATOMAC perspective

Background/PurposeMassive transfusion protocols (MTPs) are considered valuable in pediatric trauma. Important questions regarding the survival benefit and optimal blood component ratio remain unknown. MethodsThe study time frame was January 2007 through December 2013 five Level I Pediatric Trauma Centers reviewed all trauma activations involving children ≤18 years of age. Included were patients who either had the institutional MTP or received >20 mL/kg or > 2 units packed red blood cells (PRBCs). Results110/202 qualified for inclusion. Median age was 5.9 years (3.0–11.4). 73% survived to discharge; median hospitalization was 10 (3.1–22.8) days. Survival did not vary by arrival hemoglobin (Hgb), gender or age. Partial prothrombin time (PTT), INR, GCS and injury severity score (ISS) significantly differed for nonsurvivors (all p < 0.05). Logistic regression found increased mortality (OR 3.08 (1.10–8.57), 95% CI; p = 0.031) per unit increase over a 1:1 ratio of pRBC:FFP. ConclusionIn pediatric trauma pRBC:FFP ratio of 1:1 was associated with the highest survival of severely injured children receiving massive transfusion. Ratios 2:1 or ≥3:1 were associated with significantly increased risk of death. These data support a higher proportion of plasma products for pediatric trauma patients requiring massive transfusion. Level of evidenceLevel IV.

Optimal Dose, Timing and Ratio of Blood Products in Massive Transfusion: Results from a Systematic Review

Optimal dose, timing and ratio to red blood cells (RBC) of blood component therapy (fresh frozen plasma [FFP], platelets, cryoprecipitate or fibrinogen concentrate) to reduce morbidity and mortality in critically bleeding patients requiring massive transfusion is unknown. We performed a systematic review for randomized controlled trials (RCT) in MEDLINE, The Cochrane Library, Embase, CINAHL, PubMed the Transfusion Evidence Library and using multiple clinical trials registries to 21 February 2017. Sixteen RCTs were identified: six completed (five in adult trauma patients, one pediatric burn patients) and ten ongoing trials. Of the completed trials: three were feasibility trials, comparing a FFP, platelets and RBC ratio of 1:1:1 to laboratory-guided transfusion practice [n=69], early cryoprecipitate compared to standard practice [n=41], and early fibrinogen concentrate compared to placebo [n=45]; one trial compared the effect of FFP, platelets and RBC ratio of 1:1:1 with 1:1:2 on 24-hour and 30-day mortality [n=680]; one compared whole blood to blood component therapy on 24-hour blood use [n=107]; one compared a FFP to RBC ratio of 1:1 with 1:4 [n=16]. Data from two trials were pooled in a meta-analysis for 28-day mortality because the transfusion ratios achieved were similar. Results from these two trials suggest higher transfusion ratios were associated with transfusion of more FFP and platelets without evidence of significant difference with respect to mortality or morbidity. On the limited evidence available, there is insufficient basis to recommend a 1:1:1 over a 1:1:2 ratio or standard care for adult patients with critical bleeding requiring massive transfusion.

Any changes in recent massive transfusion practices in a tertiary level institution?

Background & objectivesA previous review of transfusion practices in our institution between 1998 and 2008 showed a trend of high ratios of red cells (RC) to plasma (FFP) and platelets to RC towards the later years of review period. The aim of the study was to further evaluate transfusion practices in the form of blood product usage and outcomes following massive transfusion (MT) MethodsAll adult patients with critical bleeding who received a MT (defined as ≥10 units of RC in 24h) in 2008 and between January 2010 and December 2014 were identified. Blood and blood products transfused, in-hospital mortality, 24h and 90-day mortality were analysed for the period 2010–2014. Blood and blood product usage, massive transfusion protocol (MTP) activation and use of ROTEM between 2008 and 2014 were compared. ResultsA total of 190 MT including surgical (52.1%), gastro-intestinal bleeding (25.3%), trauma (11.6%) and obstetric haemorrhage (5.8%) episodes were identified between 2010 and 2014. The overall in-hospital mortality was 26.7% with a significant difference in 24h (p=0.04) and 90-day mortality (p=0.02) between diagnostic groups. Comparing 2008 (n=33) and 2014 (n=23), there was no significant difference in median RC, FFP and platelet units, cryoprecipitate doses and RC:FFP ratio; however there was an increase in number of patients who used cryoprecipitate (54.5% vs 87%, p=0.01). ConclusionAligned with haemostatic resuscitation, the trend continues in the form of increased use of plasma and higher RC:FFP transfusion ratios including an increase in number of patients receiving cryoprecipitate.

Implementation of a management protocol for massive bleeding reduces mortality in non-trauma patients: Results from a single centre audit

ObjectiveTo audit the impact upon mortality of a massive bleeding management protocol (MBP) implemented in our center since 2007. DesignA retrospective, single-center study was carried out. Patients transfused after MBP implementation (2007–2012, Group 2) were compared with a historical cohort (2005–2006, Group 1). BackgroundMassive bleeding is associated to high mortality rates. Available MBPs are designed for trauma patients, whereas specific recommendations in the medical/surgical settings are scarce. PatientsAfter excluding patients who died shortly (<6h) after MBP activation (n=20), a total of 304 were included in the data analysis (68% males, 87% surgical). InterventionsOur MBP featured goal-directed transfusion with early use of adjuvant hemostatic medications. Variables of interestPrimary endpoints were 24-h and 30-day mortality. Fresh frozen plasma-to-red blood cells (FFP:RBC) and platelet-to-RBC (PLT:RBC) transfusion ratios, time to first FFP unit and the proactive MBP triggering rate were secondary endpoints. ResultsAfter MBP implementation (Group 2; n=222), RBC use remained stable, whereas FFP and hemostatic agents increased, when compared with Group 1 (n=82). Increased FFP:RBC ratio (p=0.053) and earlier administration of FFP (p=0.001) were also observed, especially with proactive MBP triggering. Group 2 patients presented lower rates of 24-h (0.5% vs. 7.3%; p=0.002) and 30-day mortality (15.9% vs. 30.2%; p=0.018) – the greatest reduction corresponding to non-surgical patients. Logistic regression showed an independent protective effect of MBP implementation upon 30-day mortality (OR=0.3; 95% CI 0.15–0.61). ConclusionsThese data suggest that the implementation of a goal-directed MBP for prompt and aggressive management of non-trauma, massive bleeding patients is associated to reduced 24-h and 30-day mortality rates.

Autotransfusion of Hemothorax Blood Is Prothrombotic but Inhibits Platelet Aggregation: A Potentiator of Disseminated Intravascular Coagulation

IntroductionHemostatic resuscitation in combat casualty care presents unique challenges not typically encountered in metropolitan areas. Fresh whole blood and blood components are considered preferable to crystalloid or colloid solutions, but availability may be limited in austere wartime environments. Autologous shed blood from a traumatic hemothorax or hemoperitoneum, in theory, is an attractive alternative. This position is supported by the American Academy of Blood Banking, Eastern Association for the Surgery of Trauma, and Society of Critical Care Medicine, despite the fact that the safety and efficacy of shed blood has never been evaluated in randomized trials. Recent reports suggest that shed blood has poor hemostatic properties. This study was performed to evaluate the effects of shed hemothorax plasma and microparticles on platelet function and global tests of coagulation.MethodsShed traumatic hemothorax blood was obtained from 17 adult trauma patients requiring tube thoracostomy, every hour up to 4 hours after placement, according to IRB approved protocol. The hemothorax plasma was then isolated and frozen for later analysis. The effects of shed frozen plasma at 1 and 4 hours (HFP1; HFP4) was examined by performing mixing studies with fresh platelet rich plasma from normal donors at pre-specified serial dilutions of 1:8, 1:4, and 1:2 to mimic intravascular resuscitation . This was then analyzed by several assays. Thromboelastometry (ROTEM) of HFP was done to evaluate clotting time (CT), clot formation time (CFT), alpha angle, and lysis index at 45 minutes. Platelet aggregometry was done to assess the effect of shed HFP on platelet function in response to adenosine diphosphate (ADP), arachidonic acid (ASPI) and collagen. Fibrin degradation products (FDP), von Willebrand factor (vWF) and tissue factor (TF) levels in HFP were determined by enzyme-linked immunosorbent assays (ELISA ). vWF multimers in HFP were further separated by size using gel electrophoresis and detected by immunostaining. Microparticle analysis was performed using isolated microparticles from ultra-centrifuged HFP1 and HFP4 (HMP1 and HMP4) and compared to control isolated microparticles from fresh frozen plasma (FMP). HMP and FMP were then diluted with platelet rich plasma to a predetermined platelet count after which, ROTEM and platelet aggregometry were performed as described above. Non-diluted HFP and resuspended HMP1, HMP4 and FMP were then analyzed by flow cytometry for a variety of microparticle (MP) derived antigens including APC-H7-CD41a (GPIIb/IIIa derived MP), and APC-CD235a (Glycophorin A from red cell derived MP), and FITC-Lactadherin phosphatidylserine (platelet derived MP).ResultsROTEM of HFP demonstrated a CT of 55.8% and 60.6% at the 1:8 dilution and 69.3% and 71.4% at the 1:2 dilution, for HFP1 and HFP4 respectively, compared to platelet rich plasma (PRP) and FFP (p<0.05) controls. Similar findings were seen in the CFT at the 1:8 dilution. HMP1 and HMP4 demonstrated decreased CT when compared to PRP and FMP (p<0.05).HMP1 and HMP4 inhibited platelet aggregation in response to ADP, TXA2, and collagen with data expressed as area under the curve (U), when compared to FMP and PRP, all statistically significant (p<0.05). For example, PRP and FMP response to ADP was greater than 100U and HMP less than 50U (p<0.05). ELISA of HFP demonstrated significantly higher levels of FDP (>700ng/mL vs 0ng/mL p<0.05) and TF (>500 pg/mL vs <200 pg/mL p<0.05) when compared to FFP controls.Flow cytometry showed increased microparticle concentrations in HFP1, HFP4, HMP1, and HMP4 samples with greater than 10 fold increase (MP/uL) in several markers (p<0.05) when compared to FFP and FMP. vWF multimer ratio demonstrated a loss in high molecular weight multimers and a gain in low molecular weight multimers in HFP1 and HFP4 (ratio high molecular weight:low molecular weight <1) when compared to FFP (ratio 2.5) with p value <0.05.ConclusionThese results demonstrate that autologous shed hemothorax blood promotes a prothrombotic state due to increased tissue factor and microparticle content. Furthermore, clot localization may be impaired through inhibition of platelet aggregation by microparticles and degradation of vWF. These data suggest that randomized trials are indicated to establish the safety and efficacy of autologous shed traumatic hemothorax blood for trauma resuscitation. DisclosuresNo relevant conflicts of interest to declare.

The impact of increased plasma ratios in massively transfused trauma patients: a prospective analysis.

Transfusion ratios approaching 1:1 FFP:PRBC for trauma resuscitation have become the de facto standard of care. The aim of this study was to prospectively evaluate the effect of increasing ratios of FFP:PRBC transfusion on survival for massively transfused civilian trauma patients as well as determine if time to reach the target ratio had any effect on outcomes. This is a prospective, observational study of all trauma patients requiring a massive transfusion (≥10 PRBC in ≤24h) at a level 1 trauma center over a 2.5-year period. The ratio of FFP:PRBC was tracked hourly up to 24h post-initiation of massive transfusion. A logistic regression model was utilized to identify the ideal ratio associated with mortality prediction. A stepwise logistic regression was performed to identify independent predictors of mortality. The study population was predominantly male (89%) with a mean age of 34.8±16. On admission, 22% had a systolic blood pressure ≤90mmHg, 47% had a heart rate ≥120, and 25% had a GCS ≤8. The overall mortality was 33%. The ratio of FFP:PRBC≥1:1.5 was the second most important independent predictor of mortality for this population (R (2)=0.59). Survivors had a higher FFP:PRBC ratio at all times during the first 24h of resuscitation. Achieving a ratio of FFP:PRBC≥1:1.5 after the initial 24h of resuscitation significantly improves survival in massively transfused trauma patients compared to patients that achieved a ratio <1:1.5.

Risk factors for trauma-induced coagulopathy- and transfusion-associated multiple organ failure in severely injured trauma patients.

Both trauma-induced coagulopathy (TIC) and transfusion strategies influence early outcome in hemorrhagic trauma patients. Their impact on late outcome is less well characterized. This study systematically reviews risk factors for TIC- and transfusion-associated multiple organ failure (MOF) in severely injured trauma patients. A systematic search was conducted in PubMed and Embase. Studies published from 1986 to 2013 on adult trauma patients with an injury severity score ≥16, investigating TIC or transfusion strategies with MOF as primary or secondary outcome, were eligible for inclusion. Results of the included studies were evaluated with meta-analyses of pooled data. In total, 50 studies were included with a total sample size of 63,586 patients. Due to heterogeneity of the study populations and outcome measures, results from 7 studies allowed for pooling of data. Risk factors for TIC-associated MOF were hypocoagulopathy, hemorrhagic shock, activated protein C, increased histone levels, and increased levels of markers of fibrinolysis on admission. After at least 24 h after admission, the occurrence of thromboembolic events was associated with MOF. Risk factors for transfusion-associated MOF were the administration of fluids and red blood cell units within 24 h post-injury, the age of red blood cells (>14 days) and a ratio of FFP:RBC ≥ 1:1 (OR 1.11, 95% CI 1.04-1.19). Risk factors for TIC-associated MOF in severely injured trauma patients are early hypocoagulopathy and hemorrhagic shock, while a hypercoagulable state with the occurrence of thromboembolic events later in the course of trauma predisposes to MOF. Risk factors for transfusion-associated MOF include administration of crystalloids and red blood cells and a prolonged storage time of red blood cells. Future prospective studies investigating TIC- and transfusion-associated risk factors on late outcome are required.

MP18-03 PENILE FRACTURE: NATIONAL TRENDS IN URETHRAL EVALUATION AND RISK FACTORS FOR URETHRAL INJURY

angiographic findings requiring embolization. The average EBL was 6.5 liters (range 2.5-18) for those 5 patients who bled massively during their index renal surgery. The average number of total units utilized was 12.8 for pRBC (median 8, range 4e28) and 8.3 for FFP (median 6.5, range 1e20). The average total pRBC to FFP ratio was 1.78:1 (median 1.4:1, range 4:1 e 1:1). One patient expired 3 days postoperatively due to multi-system organ failure. Results demonstrated a linear trend between the pRBC:FFP ratio and the percent decrease in serum bicarbonate. As the pRBC:FFP ratio increases from 1:1, the percent bicarbonate decreases proportionately. CONCLUSIONS: Recognizing massive hemorrhage in urologic surgeries and instituting a MTP as soon as an injury is identified yielded clinical benefits, as such MTP mobilizes blood products rapidly and in a pRBC:FFP ratio that approximates 1:1, which improved overall survival after excessive surgical bleeding.

Outcomes of patients receiving massive transfusions after trauma

Introduction: Transfusion of red blood cells is a key component in the resuscitation of massively hemorrhaging patients post-injury. Little is known about the functional status of patients at discharge or the outcome of patients after discharge from acute hospitalization. We assessed the changes among major trauma patients who had received massive transfusions. Material and method: This article is an overview of internal and external resources available. Results: Massive transfusions, independent of injury severity, have been previously associated with adverse outcomes. We showed that this association was no longer demonstrable at 12 months after injury. Long-term outcomes and variables associated with unfavorable outcomes. Such as a significant reduction in the average volume of red cells transfused and with volumes of FFP transfusion remaining constant; a significantly higher proportion of patients received high ratios of FFP: RBC. In addition, prehospital plasma and RBC transfusions were associated with improved early outcomes and negligible blood products wastage; but not an overall survival advantage. In patients with a closed head injury, neither the administration of erythropoietin nor the maintenance hemoglobin concentration of greater than 10 g/dL resulted in improved neurological outcome at 6-months. The transfusion threshold of 10 g/dL was associated with a higher incidence of adverse events. Conclusion: Massive transfusion rates after trauma had unfavorable outcomes at 6and 12-months with little change over time. Long-term outcomes with functional status should be measured and more commonly reported to reflect the actual sequelae of major trauma and massive blood transfusions.

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Introduction: There is a growing debate surrounding the optimal ratio of FFP:RBC in massive transfusion protocols [MTP] for patients with massive traumatic hemorrhage. The discussion has evolved to include the time at which the appropriate ratio is achieved and its effect on mortality, both within and beyond 4 hours. This report aimed to describe the effect of attaining a high FFP:RBC ratio [FFP:RBC ≥ 1–1.5] [HMTP] within 4 hours on a trauma population receiving MTP. Methods: Data were obtained from the trauma registry of the Hamad Trauma Center in Doha, Qatar. All adult [≥ 18 years] patients with traumatic injury who received a massive blood transfusion [≥10 U of PRBC over the initial 24 hours post injury] from 1st January 2010 to 31st December 2012 were included. A low ratio MTP [LMTP] was FFP:RBC ≤ 1–1.5 at 4 hours post-injury. One MTP shipment was defined as infusion of ≥ 6 units of PRBC. Patients were followed up to 30 days, hospital discharge or death. Outcomes measured were mortality, post-shipment International Normalized Ratio [INR], multi-organ failure [MOF] and infectious complications. Data was analyzed using a Chi-square and Student’s T-test, p< 0.05 was considered significant. Results: There were 4864 trauma admissions during the study period, 77 [1.6%] patients met inclusion criteria. Admission hemoglobin level, arterial pH, INR, Injury Severity Score [ISS] and Revised Trauma Score [RTS] were similar between both groups. HMTP was associated with lower crude [41.9% v. 78.3%, p=0.001] and 24-hour mortality [3.2% v. 6.5%, p=0.468] when compared to LMTP. A similar association was noted for MOF [48.4% v 87.0%, p=0.001]. HMTP patients had significantly better mean INR values after the 2nd MTP shipment [1.1 v 1.5, p=0.032]. No significant differences were noted for the incidence of infectious complications between the 2 groups. Conclusions: These results suggest that the survival advantage of HMTP for trauma patients is realized early, within 4 hours post-injury. Our findings demonstrate that aggressive attainment of HMTP within 4 hours post injury can substantially improve coagulopathy, reduce mortality, and multi-organ failure rates.

Goal-directed therapy in trauma induced coagulopathy and focus on traumatic brain injury

In recent years there have been major advances in the management of trauma-induced coagulopathy (TIC) and many experiences have demonstrated how we can achieve significant improvements with multidisciplinary approach and implementation of standardized protocols and algorithms. Central nervous system injuries and exanguination remain the primary causes of early trauma-related mortality. Traumatic brain injuries (TBI) make hemostasis in TIC even more complex and it is known that the onset of coagulopathy in a patient with severe brain injury has a negative impact on the patient’s outcome in terms of mortality. Standard coagulation tests provide limited information on coagulation disorder. The advantages of whole-blood viscoelastic tests, such as rotational thromboelastometry or thrombelastography, are shorter turn-around time and better diagnostic performance compared to routine plasmatic coagulation tests. In contrast to a fixed ratio of FFP:PC:RBC, the aim of the goal-directed coagulation therapy is to set treatment to the actual needs of the individual patient, based on viscoelastic test results. This article describes the improvements achieved through the implementation of ROTEM-guided treatment algorithms for visceral surgery and liver trasplantation, severe trauma and post-partum hemorrhage and cardiovascular surgery.

Impact of High Ratios of Plasma–to–Red Cell Concentrate on the Incidence of Acute Respiratory Distress Syndrome in UK Transfused Combat Casualties

Trauma transfusion strategies, which incorporate balanced red-cell concentrate (RCC)-to-fresh frozen plasma (FFP) ratios, may be associated with improved survival in massively transfused patients. However, the use of this approach in nonmassively transfused patients has led to concern regarding an increase in acute respiratory distress syndrome (ARDS). The aim of this study was to assess the incidence of ARDS in transfused UK military casualties. All UK military casualties receiving an RCC transfusion within a 16-month period were identified from the UK Trauma Registry, and chest radiographs retrieved. If bilateral infiltrates were present, case notes were retrieved to calculate the PaO2/FIO2 ratio in accordance with the American-European Consensus Conference criteria. Patients were divided into massively transfused (≥ 10 U/24 h) and nonmassively transfused (<10 U/24 h) receiving a high ratio (≥ 0.75) or low (<0.75) RCC:FFP ratio. The primary outcome was the development of ARDS within 7 days of transfusion. Primary blast lung injury was excluded. Of 145 patients identified, 144 had records available for analysis with a median injury severity score of 21. The majority were injured by explosion (76%), and the remainder by gunshot (24%). There were 60 nonmassively transfused patients with 18 in the low and 42 in the high RCC:FFP ratio groups. Of the remaining 80 massively transfused patients, 11 were in the low and 73 were in the high-ratio groups. There was no difference in the incidence of ARDS between low- and high-ratio groups in either nonmassively transfused (22.2% vs. 9.5%; P = 0.232) or massively transfused (18.2% vs. 23.3%; P = 1.000) casualties. There was no statistically significant increase in the incidence of ARDS in UK casualties treated with high, compared with low, ratios of plasma to RCC.

The Initial Trauma Center Fluid Management of Penetrating Injury: A Systematic Review

Damage-control resuscitation is the prevailing trauma resuscitation technique that emphasizes early and aggressive transfusion with balanced ratios of red blood cells (RBCs), plasma (FFP), and platelets (Plt) while minimizing crystalloid resuscitation, which is a departure from Advanced Trauma Life Support (ATLS) guidelines. It is unclear whether the newer approach is superior to the approach recommended by ATLS. With these recent changes pervading resuscitation protocols, we performed a systematic review to determine if the shift in trauma resuscitation from ATLS guidelines to damage control resuscitation has improved mortality in patients with penetrating injuries. A systematic search of PubMed, the Cochrane Library, and the Current Controlled Trials Register was performed for studies comparing mortality in massively transfused penetrating trauma patients receiving either balanced ratios of blood transfusion per damage control resuscitation tenets or undergoing an alternate blood volume resuscitation strategy. Studies were deemed appropriate for inclusion if they had a Newcastle-Ottawa Scale score of 6 or greater as well as at least 30% penetrating trauma. Twenty studies that reported on a total of 12,154 patients were included. Transfusion ratios varied widely, with 1:1 and 1:2 ratios of FFP:RBC most often defined as high ratios for purposes of comparison with other low ratio groups. Fourteen of 20 studies found significantly lower 30-day mortality when higher transfusion ratios of FFP, RBC, and/or Plt were used; six of 20 studies found mortality to be similar between higher and lower transfusion ratios. Patients with penetrating injuries who require massive transfusion should be transfused early using balanced ratios of RBC, FFP, and Plt. Randomized, controlled trials are needed to determine optimal ratios for transfusion.

Impact of Crystalloid to PRBC Ratio in Patients with Exsanguinating Penetrating Abdominal Injuries: The Conundrum of Resuscitation

ABSTRACTBackgroundWhen intraoperative hemostatic resuscitation (IHR) implements high transfusion ratios of FFP:PRBC (&gt;1:2), there is an associated increased survival in patients with exsanguinating penetrating abdominal injuries (EPAI). The impact of crystalloids: PRBC during IHR has not been analyzed. We hypothesize that minimizing the amount of intraoperative crystalloids:PRBC in combination with high ratio FFP: PRBC will correlate with a survival benefit in patients with EPAI.MethodsThis was a 9-year retrospective analysis of patients with EPAI at a Level 1 Trauma Center. EPAI was defined as any patient who received &gt;20 units of PRBC during IHR. Intraoperative ratio for FFP:PRBC was recorded, and patients were placed in three separate categories accordingly: high (&gt;1:2), mid (1:4 - 1:2), and low ratio (&lt;1:4) groups. Quantity of crystalloids used during each category was recorded and a ratio of crystalloids:PRBC calculated. Logistic regression model was applied to analyze impact of crystalloid:PRBC on mortality, comparing the high FFP:PRBC ratio group to the low FFP: PRBC ratio group.ResultsIntraoperative high ratio FFP:PRBC conveyed a 32% overall survival benefit when compared with low ratio groups. Patients that received a high ratio FFP:PRBC when compared to low ratio group, received less intraoperative crystalloids (calculated crystalloids:PRBC ratios 1:3.4vs1:1.1; p = 0.001). Our logistic regression demonstrated a survival benefit with a high FFP:PRBC [OR 95%;0.19 , CI (0.05-0.33), p = 0.003] and the calculated low crystalloid:PRBC [OR 95%; 0.11 CI (0.01- 0.59), p = 0.001].ConclusionWe were able to demonstrate a survival advantage in patients with EPAI that received IHR of a high ratio of FFP:PRBC and a low ratio of crystalloids:PRBC. These findings suggest that in patients with EAPI requiring massive volumes of PRBC, the ratio of intraoperative FFP:PRBC should be high and crystalloids:PRBC should be low.How to cite this articleGuidry C, Unruh M, Duke M, Meade P, McSwain NE Jr, Duchesne JC. Impact of Crystalloid to PRBC Ratio in Patients with Exsanguinating Penetrating Abdominal Injuries: The Conundrum of Resuscitation. Panam J Trauma Critical Care Emerg Surg 2013;2(1):52-57.

Effect of Early Plasma Transfusion on Mortality in Patients with Ruptured Abdominal Aortic Aneurysm

Research in the area of trauma resuscitation has shown a decrease in mortality with a lower packed-red-blood-cell (RPBC) to fresh-frozen-plasma (FFP) transfusion ratio. The authors of the current study sought to determine the effect of the PRBC:FFP ratio on mortality of patients with massive hemorrhage after ruptured abdominal aortic aneurysm (RAAA). The authors conducted a retrospective review of RAAA patients at the University of Wisconsin who suffered massive hemorrhage, requiring 10 or more units of blood products before the conclusion of their operative repair. They examined a host of clinical variables, including patient demographics, pre- and post-operative vital signs and laboratory tests, and PRBC:FFP ratio, and their effect on 30-day mortality. Over the 20-year study period, 128 RAAA patients had massive hemorrhage. The authors found the 30-day mortality rate was significantly lower in patients who received blood products at a PRBC:FFP ratio≤2:1, dubbed the high FFP group, compared to those with a PRBC:FFP ratio>2:1, the low FFP group (14.9% vs. 39%, p<0.03). Moreover, the likelihood of death was more than fourfold greater in the low FFP group (odds ratio 4.23, 95% confidence interval 1.23–14.49). Finally, the high FFP group had a lower incidence of colonic ischemia than the low FFP group (22.4% vs. 41.1%, p=0.004).

The effect of FFP:RBC ratio on morbidity and mortality in trauma patients based on transfusion prediction score

The empiric use of a high plasma to packed red-blood-cell [fresh frozen plasma:red-blood-cells (FFP:RBC)] ratio in trauma resuscitation for patients with massive bleeding has become well accepted without clear or objective indications. Increased plasma transfusion is associated with worse outcome in some patient populations. While previous studies analyse only patients who received a massive transfusion, this study analyses those that are at risk to receive a massive transfusion, based on the trauma-associated severe haemorrhage (TASH) score, to objectively determine which patients after severe trauma would benefit or have increased complications by the use of a high FFP:RBC ratio. Multicentre retrospective study from the Trauma Registry of the German Trauma Society. Multivariate logistic regression and statistical risk adjustments utilized in analyses. A high ratio of FFP:RBC in the ≥15 TASH group was independently associated with survival, with an odds ratio of 2·5 (1·6-4·0), while the <15 TASH group was associated with increased multi-organ failure, 47% vs. 38%, (P<0·005). A predictive model of massive transfusion upon admission might be able to rapidly identify which severe trauma patients would benefit or have increased complications from the immediate application of a high ratio of FFP:RBCs. This study helps to identify the appropriate population for a prospective, interventional trial.

Effect of early plasma transfusion on mortality in patients with ruptured abdominal aortic aneurysm

Background. The ratio of red blood cell (PRBC) transfusion to plasma (FFP) transfusion (PRBC:FFP ratio) has been shown to impact survival in trauma patients with massive hemorrhage. The purpose of this study was to determine the effect of the PRBC:FFP ratio on mortality for patients with massive hemorrhage after ruptured abdominal aortic aneurysm (RAAA). Methods. A retrospective review was performed of patients undergoing emergent open RAAA repair from January 1987 to December 2007. Patients with massive hemorrhage ($10 units of blood products transfused prior to conclusion of the operation) were included. The effects of patient demographics, admission vital signs, laboratory values, peri-operative variables, amount of blood products transfused, and the PRBC:FFP ratio on 30-day mortality were analyzed by multivariate analysis. Results. One hundred and twenty-eight of the 168 (76%) patients undergoing repair for RAAA received at least 10 units of blood products within the peri-operative period. Mean age was 73.1 ± 9.1 years, and 109 (85%) were men. Thirty-day mortality was 22.6% (29/128), including 11 intra-operative deaths. By multivariate analysis, 30-day mortality was markedly lower (15% vs 39%; P 2:1 (LOW FFP), and the likelihood of death was more than 4-fold greater in the LOW FFP group (odds ratio 4.23; 95% confidence interval, 1.2--14.49). Patients in the HIGH FFP group had a significantly lower incidence of colon ischemia than those in the LOW FFP group (22.4% vs 41.1%; P = .004). Conclusion. For RAAA patients requiring massive transfusion, more equivalent transfusion of PRBC to FFP (HIGH FFP) was independently associated with lower 30-day mortality. The lower incidence of colonic ischemia in the HIGH FFP group may suggest an additional benefit of early plasma transfusion that could translate into further mortality reduction. Analysis from this study suggests the potential feasibility for a more standardized protocol of initial resuscitation for these patients, and prospective studies are warranted to determine the optimum PRBC:FFP ratio in RAAA patients. (Surgery 2010;148:955-62.)