RBC Ratio Research Articles

Predictors of Clinical Outcomes and the Need for Massive Transfusion Protocols in Geriatric Trauma Patients With Hemorrhagic Shock: A Systematic Review.

The current literature lacks a clear consensus on the predictors of mortality and outcomes of geriatric trauma patients in hemorrhagic shock. This systematic review aims to investigate predictors of clinical outcomes and the need for massive transfusion protocol in the geriatric trauma population with hemorrhagic shock. PubMed, EMBASE, Cochrane, ProQuest, and Google Scholar were searched for studies evaluating geriatric trauma patients in hemorrhagic shock or receiving MTP. Outcomes of interest included the effect of advanced age on clinical outcomes, the accuracy of SI and other variables in predicting mortality and need for MTP, and associations between blood product ratio and clinical outcomes. Fifteen studies were included in this systematic review. In most studies, advanced age was an accurate predictor of mortality and complication rates in geriatric patients undergoing management of shock with MTP. SI along with other variables such as systolic blood pressure (SBP) were sensitive predictors of mortality and the need for MTP. Studies evaluating blood product ratio found an increased incidence of complications with higher plasma: red blood cell ratios. Advanced age among geriatric patients is associated with increased mortality and complications when undergoing MTP. Shock Index and age x Shock Index are accurate and reliable predictors of mortality and need for MTP in the geriatric trauma population with hemorrhagic shock suffering blunt and/or penetrating injuries. An increased plasma: RBC ratio was associated with more complications in geriatric patients.

FINDING THE SWEET SPOT: THE ASSOCIATION BETWEEN WHOLE BLOOD TO RED BLOOD CELLS RATIO AND OUTCOMES OF HEMORRHAGING CIVILIAN TRAUMA PATIENTS.

Purpose: To evaluate the dose-dependent effect of whole blood (WB) on the outcomes of civilian trauma patients with hemorrhagic shock. Methods: We performed a 2-year (2020-2021) retrospective analysis of the ACS-TQIP dataset. Adult (≥18) trauma patients with a shock index (SI) >1 who received at least 5 units of PRBC and one unit of WB within the first 4 h of admission were included. Primary outcomes were 6-h, 24-h, and in-hospital mortality. Secondary outcomes were major complications and hospital and intensive care unit length of stay. Results: A total of 830 trauma patients with a mean (SD) age of 38 (16) were identified. The median [IQR] 4-h WB and PRBC requirements were 2 [2-4] U and 10 [7-15] U, respectively, with a median WB:RBC ratio of 0.2 [0.1-0.3]. Every 0.1 increase in WB:RBC ratio was associated with decreased odds of 24-h mortality (aOR: 0.916, P = 0.035) and in-hospital mortality (aOR: 0.878, P < 0.001). Youden's index identified 0.25 (1 U of WB for every 4 U of PRBC) as the optimal WB:PRBC ratio to reduce 24-h mortality. High ratio (≥0.25) group had lower adjusted odds of 24-h mortality (aOR: 0.678, P = 0.021) and in-hospital mortality (aOR: 0.618, P < 0.001) compared to the low ratio group. Conclusions: A higher WB:PRBC ratio was associated with improved early and late mortality in trauma patients with hemorrhagic shock. Given the availability of WB in trauma centers across the United States, at least one unit of WB for every 4 units of packed red blood cells may be administered to improve the survival of hemorrhaging civilian trauma patients.

Evaluation of the Potential for Improvement of Clinical Outcomes in Trauma Patients with Massive Hemorrhage by Maintaining a High Plasma-to-Red Blood Cell Ratio during the First Hour of Hospitalization.

Several reports indicate that early plasma transfusion may promote survival and reduce the incidence of traumatic coagulopathy in situations of massive bleeding. Consequently, it is recommended to maintain a plasma and RBC transfusion ratio between 1 : 1 and 1 : 2 at the start of admission. This retrospective study examined the effect of an early high plasma : RBC ratio on mortality rates by adopting a massive transfusion protocol (MTP) that forced an early and rapid issue of plasma products. Patients who received massive transfusions at a single trauma center between January 2014 and May 2020 were included in the study. A new protocol was established in January 2020, wherein a fixed amount of plasma was issued following MTP activation. Patients who underwent massive transfusions before and after the adoption of the new protocol were compared. In total, 1059 patients met the inclusion criteria. Fifty-one patients who underwent MTP were propensity score-matched with the patients who received a nonprotocolized massive transfusion. The MTP group had a higher plasma : RBC ratio at 1 h (0.8 vs. 0.2) and 4 h of hospitalization (1.1 vs. 0.6), with no significant between-group difference in the plasma : RBC ratio at 24 h of hospitalization. The MTP group had a lower 24 h mortality rate than the control group. There was no significant difference in the 30-day mortality. Using MTP to achieve a high plasma : RBC ratio in the early period of hospitalization appeared to affect 24-hour mortality; however, 30-day mortality did not change.

The Effect of Growth of Net Premium, Claim Ratio, RBC, and Retention Ratio on the Financial Performance of Insurance Companies in the ASEAN Region

This research aims to find out the constraints that can affect the financial performance of insurance service companies in the ASEAN region that are currently running. Insurance companies operating in the ASEAN Region can use the research results. This research can be used as a basis for making a policy related to information on net premium growth, claims ratio, risk-based capital, and retention ratio. This study uses the research object of insurance companies in the ASEAN region. Insurance companies are overgrowing. This issue happened because Southeast Asia is one of the regions with the fastest development globally over the last 10 years. The use of insurance services in the Southeast Asia Region reached 3.77%. This percentage reflects that half of the use of services in the Southeast Asia Region represents half the use of insurance globally. The population in this study is Insurance Service Companies in the ASEAN Region. In contrast, the sample in this study is Insurance Service Companies in the ASEAN Region that are listed on the Stock Exchange in each country in the 2017-2019 period. Partially, net premium growth has a positive effect on financial performance, and claim ratios, risk-based capital, and retention ratios do not affect financial performance.

The Effect of Growth of Net Premium, Claim Ratio, RBC, and Retention Ratio on the Financial Performance of Insurance Companies in the ASEAN Region

The Effect of Growth of Net Premium, Claim Ratio, RBC, and Retention Ratio on the Financial Performance of Insurance Companies in the ASEAN Region

Transfusion Ratios and Deficits in Injured Children With Life-Threatening Bleeding.

To assess the impact of plasma and platelet ratios and deficits in injured children with life-threatening bleeding. Secondary analysis of the MAssive Transfusion epidemiology and outcomes In Children study dataset, a prospective observational study of children with life-threatening bleeding events. Twenty-four childrens hospitals in the United States, Canada, and Italy. Injured children 0-17 years old who received greater than 40 mL/kg total blood products over 6 hours or were transfused under activation of massive transfusion protocol. Weight-adjusted blood product volumes received during the bleeding event were recorded. Plasma:RBC ratio (plasma/RBC weight-adjusted volume in mL/kg) and platelet:RBC ratio (platelet/RBC weight-adjusted volume in mL/kg) were analyzed. Plasma deficit was calculated as RBC mL/kg - plasma mL/kg; platelet deficit was calculated as RBC mL/kg - platelet mL/kg. Of 191 patients analyzed, median (interquartile range) age was 10 years (5-15 yr), 61% were male, 61% blunt mechanism, and median (interquartile range) Injury Severity Score was 29 (24-38). After adjusting for Pediatric Risk of Mortality score, cardiac arrest, use of vasoactive medications, and blunt mechanism, a high plasma:RBC ratio (> 1:2) was associated with improved 6-hour survival compared with a low plasma:RBC ratio (odds ratio [95% CI] = 0.12 [0.03-0.52]; p = 0.004). Platelet:RBC ratio was not associated with survival. After adjusting for age, Pediatric Risk of Mortality score, cardiac arrest, and mechanism of injury, 6-hour and 24-hour mortality were increased in children with greater plasma deficits (10% and 20% increased odds of mortality for every 10 mL/kg plasma deficit at 6 hr [p = 0.04] and 24 hr [p = 0.01], respectively); 24-hour mortality was increased in children with greater platelet deficits (10% increased odds of 24-hr mortality for every 10 mL/kg platelet deficit [p = 0.02)]). In injured children, balanced resuscitation may improve early survival according to this hypothesis generating study. Multicenter clinical trials are needed to assess whether clinicians should target ratios and deficits as optimal pediatric hemostatic resuscitation practice.

Platelet-to-red blood cell ratio and mortality in bleeding trauma patients: A systematic review and meta-analysis.

BackgroundIn traumatic bleeding, transfusion practice has shifted toward higher doses of platelets and plasma transfusion. The aim of this systematic review was to investigate whether a higher platelet‐to‐red blood cell (RBC) transfusion ratio improves mortality without worsening organ failure when compared with a lower ratio of platelet‐to‐RBC.MethodsPubmed, Medline, and Embase were screened for randomized controlled trials (RCTs) in bleeding trauma patients (age ≥16 years) receiving platelet transfusion between 1946 until October 2020. High platelet:RBC ratio was defined as being the highest ratio within an included study. Primary outcome was 24 hour mortality. Secondary outcomes were 30‐day mortality, thromboembolic events, organ failure, and correction of coagulopathy.ResultsIn total five RCTs (n = 1757 patients) were included. A high platelet:RBC compared with a low platelet:RBC ratio significantly improved 24 hour mortality (odds ratio [OR] 0.69 [0.53–0.89]) and 30‐ day mortality (OR 0.78 [0.63–0.98]). There was no difference between platelet:RBC ratio groups in thromboembolic events and organ failure. Correction of coagulopathy was reported in five studies, in which platelet dose had no impact on trauma‐induced coagulopathy.ConclusionsIn traumatic bleeding, a high platelet:RBC improves mortality as compared to low platelet:RBC ratio. The high platelet:RBC ratio does not influence thromboembolic or organ failure event rates.

The Association of Increased FFP:RBC Transfusion Ratio to Primary Graft Dysfunction in Bleeding Lung Transplantation Patients

Lung transplantation is associated with a significant risk of needed transfusion. Although algorithm-based transfusion strategies that promote a high fresh frozen plasma:red blood cells (FFP:RBC) ratio have reduced overall blood product requirements in other populations, large-volume transfusions have been linked to primary graft dysfunction (PGD) in lung transplantation, particularly use of platelets and plasma. The authors hypothesized that in lung transplant recipients requiring large-volume transfusions, a higher FFP:RBC ratio would be associated with increased PGD severity at 72 hours. Observational retrospective review. Single tertiary academic center. Adult patients undergoing bilateral or single orthotopic lung transplantation and receiving >4 U PRBC in the first 72 hours from February 2014 to March 2019. None. Patient demographics, operative characteristics, blood transfusions, and outcomes including PGD scores and length of stay were collected. Eighty-nine patients received >4U PRBC, had available 72-hour PGD data, and were included in the study. These patients were grouped into a high-ratio (>1:2 units of FFP:RBC, N = 38) or low-ratio group (<1:2 units of FFP:RBC, N = 51). Patients in the high-ratio group received more transfusions and factor concentrates and had significantly longer case length. The high-ratio group had a higher rate of severe PGD at 72 hours (60.5% v 23.5%, p = 0.0013) and longer hospital length of stay (40 v 32 days, p = 0.0273). In bleeding lung transplantation patients at high risk for PGD, a high FFP:RBC transfusion ratio was associated with worsened 72-hour PGD scores when compared with the low-ratio cohort.

Association of Blood Component Ratios With 24-Hour Mortality in Injured Children Receiving Massive Transfusion.

To determine if higher fresh frozen plasma and platelet to packed RBC ratios are associated with lower 24-hour mortality in bleeding pediatric trauma patients. Retrospective cohort study using the Pediatric Trauma Quality Improvement Program Database from 2014 to 2016. Level I and II pediatric trauma centers participating in the Trauma Quality Improvement Program PATIENTS:: Injured children (≤ 14 yr old) who received massive transfusion (≥ 40 mL/kg total blood products in 24 hr). Of 123,836 patients, 590 underwent massive transfusion, of which 583 met inclusion criteria. None. Ratios of fresh frozen plasma:packed RBC and platelet:packed RBC. Of the 583 patients, 60% were male and the median age was 5 years (interquartile range, 2-10 yr). Overall mortality was 19.7% (95% CI, 16.6-23.2%) at 24 hours. There was 51% (adjusted relative risk, 0.49; 95% CI, 0.27-0.87; p = 0.02) and 40% (adjusted relative risk, 0.60; 95% CI, 0.39-0.92; p = 0.02) lower risk of death at 24 hours for the high (≥ 1:1) and medium (≥ 1:2 and < 1:1) fresh frozen plasma:packed RBC ratio groups, respectively, compared with the low ratio group (< 1:2). Platelet:packed RBC ratio was not associated with mortality (adjusted relative risk, 0.94; 95% CI, 0.51-1.71; p = 0.83). Higher fresh frozen plasma ratios were associated with lower 24-hour mortality in massively transfused pediatric trauma patients. The platelet ratio was not associated with mortality. Although these findings represent the largest study evaluating blood product ratios in pediatric trauma patients, prospective studies are necessary to determine the optimum blood product ratios to minimize mortality in this population.

Effects of Dietary β-glucan Supplementation on Growth, Innate Immune, and Capacity Against Pathogen Streptococcus iniae of Juvenile Pompano (Trachinotus ovatus)

This study investigated the effect of dietary β-glucan on growth, immunity, and resistance against Streptococci in pompano T. ovatus. Pompano were fed a control diet, and diets which included 0.10% or 0.20% of β-glucan. After being fed the diets for 3-weeks, growth rate, survival, blood parameters, and immunity were examined, and the fish were challenged with Steptococcus aniae for 10 days. At the end of the feeding trial, RBC, WBC, WBC:RBC ratio, and lymphocytes significantly increased (P ≤ 0.032), while monocytes significantly decreased (P ≤ 0.007) in fish fed 0.10-0.20% of β-glucan. Moreover, lysozyme was significantly higher (P ≤ 0.003) in fish fed β-glucan, while the phagocytic ratio was only significantly higher (P = 0.037) in fish fed 0.10% β-glucan. Furthermore, fish fed 0.10-0.20% β-glucan showed higher protection against S. iniae (P ≤ 0.002). Thus, a diet of β-glucan is recommended to improve non-specific immunity, growth in T. ovatus, and also to limit the adverse effects of S. aniae disease in this species.

Quality Management of massive transfusion protocol incorporating tranexamic acid adherence

Massive transfusion protocols (MTP) vary at different institutions. We implemented an algorithm in the transfusion service to support our Level I trauma center in 2007 and periodically monitor MTP utilization as part of ongoing quality management. At the last review in 2013, median plasma: RBC ratio was 1:1.8. We undertook a retrospective 3-year review of MTP activations stratifying by trauma versus non-trauma indications, and blood component utilization of the massive transfusion (MT) cases, adding a review of tranexamic acid (TXA) administration to the audit. The median transfused plasma: RBC ratio was 1:1.9 in trauma MT, and 1:1.6 in the non-trauma MT cases. Non-trauma MT patients at our institution were significantly older and more coagulopathic at MTP initiation compared to trauma MT patients, received fewer RBC units (15.5 versus 20.2), and had higher mortality. TXA adherence increased over the 3-year period to 60% of all trauma MTP activations in 2017.

Abstract 638: Microbubble enrichment of CTCs

Abstract Despite numerous new cell analysis technologies, contaminating red- and white blood cells remain a central barrier to the efficient characterization of circulating tumor cells. Microbubbles, which capture and separate cells by flotation, recently have been described as an alternative or adjunct to magnetic beads or microfluidic methods for CTC sample preparation. This technology may find particular value in applications where mechanical force needs to be minimized or magnetization of cells needs to be avoided. Here, we evaluate novel RBC-targeting microbubbles for buoyancy-based enrichment of CTCs. Cultured human pancreatic cancer cells (line CFPAC-1, ATCC CRL 1918) were spiked into standardized samples representative of common CTC workflows (106 RBC : 5x104 WBC : 1.5x102 tumor cells). Microbubbles bearing antibodies to human erythrocytes were added at various Bubble:RBC ratios and mixed via trituration for 1 minute. Samples were then centrifuged, the microbubble-captured RBCs removed, and the remaining pelleted cells analyzed for the fraction of RBCs removed and the extent of off-target depletion of tumor cells. Cells were quantified with an automated cell counter, and all experimental conditions were performed in at least triplicate. RBC removal rose with increasing Bubble:RBC ratio ( p &amp;lt; 0.001 ). At a ratio of 1:1, 92 +/- 1% of RBCs were removed with one minute of mixing; at a ratio of 1.5:1, 97 +/- 1% of RBCs were removed. Off-target binding of CFPAC-1 cells was minimal at a Bubble:RBC ratio of 1:1, with 0 +/- 6% of tumor cells captured. Off-target capture increased at a Bubble:RBC ratio of 2:1, with 12 +/- 9% tumor cell loss from the experimental samples. Using a standardized blood sample with a clinically relevant low concentration of cultured tumor cells, microbubbles targeting RBCs and dosed at a ratio of one bubble per target erythrocyte were able to achieve &amp;gt; 90% removal without statistically detectable loss of a cultured cancer line. Higher bubble concentrations resulted in more exhaustive RBC removal, but with some loss of cultured cells. Microbubble-based cell separation may have a useful role in CTC purification protocols. Citation Format: Thomas Jones, Leo J. Ostruszka, Shamileh Fouladdel, Ebrahim Azizi, Jaroslav Slamecka, Brandon H. McNaughton, John Younger, Max Wicha, Steven McClellan. Microbubble enrichment of CTCs [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr 638.

A high plasma: red blood cell transfusion ratio during liver transplantation is associated with decreased blood utilization.

During massive transfusion, the volume ratio of administered plasma (PL Vol) to red blood cell (RBC Vol) appears to be associated with reduced blood utilization and improved survival. The aim of this study was to evaluate the optimal component ratio in the setting of liver transplantation. This is a retrospective chart review of patients who underwent liver transplantation and received at least 500 ml of red blood cells from January 2013 through December 2015. Kernel smoothing analysis determined the proper component ratios to evaluate were a ≥0·85:1 ratio (high) to a ≤0·85:1 ratio (low). Two groups, plasma volume to RBC volume (PL Vol/RBC Vol) and plasma contained in the platelet units added to the plasma calculation [PL + PLT (platelet)] Vol/RBC Vol, were used to evaluate the component ratios. A total of 188 patients were included in the analysis. In the PL Vol/RBC Vol evaluation, a low ratio revealed that 1238 ml (977-1653 ml) (P < 0·0001) and 1178 ml (747-1178) (P < 0·0001) of RBC were used in excess compared to the high ratio, in the univariable and multivariable analysis, respectively. In the PL +PLT Vol/RBC Vol evaluation, a low ratio used 734 ml (193-1275) (P = 0·008) and 886 ml (431-1340) (P < 0·0001) of RBC in excess when compared to high ratio in the univariable and multivariable analysis, respectively. In patients undergoing liver transplantation, the transfusion of plasma to RBC ratio ≥0·85 was associated with decreased need of RBC transfusions.

Forestalling capital regulation or masking financial weakness? Evidence from loss reserve management in the property–liability insurance industry

This study examines the extent to which capital thresholds induce insurers to strategically exert accounting discretion to forestall regulatory actions. Using a sample of US property–liability insurers during 1994–2009, we find that when managing their claim loss reserves, the average insurers are insensitive to the pressure of capital regulation as measured by the distance of their RBC ratio to the action threshold. Yet, when the insurers are virtually partitioned by their reserving tendency, the effect of regulatory pressure is significantly related to the downward reserve bias in the under-reserving insurer cohorts. This finding continues to hold even after we utilize the number of ratio violations in the insurance regulatory information systems to purge the financial weakness effect embedded in the distance to RBC bound ratio. Hence, our empirical evidence suggests that insurers that are about to trigger the regulatory threshold will have the incentives to understate their loss reserves to preclude the impending authorized preventive actions. Finally, our analyses also shed light on the heterogeneity of incentives to managing loss reserves among over- and under-reserving insurers.

Descriptive characteristics and in-hospital mortality of critically bleeding patients requiring massive transfusion: results from the Australian and New Zealand Massive Transfusion Registry.

Critically bleeding patients requiring massive transfusion (MT) are clinically challenging, and limited data exist to support management decisions. This study describes patient characteristics, transfusion support and clinical outcomes from the Australian and New Zealand (NZ) Massive Transfusion Registry (ANZ-MTR). Retrospective, cohort study of all adult patients receiving MT (≥5 units red blood cells [RBC] in 4 h) at participating ANZ-MTR hospitals, 2011-2015. Mortality information was collected from the Australian National Death Index and NZ Ministry of Health. Associations between patient characteristics and outcomes were modelled using logistic regression. A total of 3560 MT cases were identified. For in-hospital deaths, cardiothoracic surgery was the most frequent bleeding context (24·5%) followed by trauma (18·3%). Age (OR = 1·03; 95% CI: 1·02-1·04), more comorbidities (OR = 1·14; 95% CI: 1·09-1·21), larger volume of RBC in first 24 h from MT onset (OR = 1·04; 95% CI: 1·02-1·06), higher platelet to RBC ratio at 4 h (OR = 2·76; 95% CI: 1·14-6·65) and higher activated partial thromboplastin time (OR = 1·02; 95% CI: 1·01-1·03) were associated with in-hospital mortality. Patients with more comorbidities, older age, traumatic or surgical bleeding or requiring more blood components had higher in-hospital mortality. These findings provide a basis to evaluate and monitor practice relating to optimal use of blood products, variation in transfusion practices and patient outcomes, and also enable benchmarking of hospital performance for management of MT in specific patient groups.

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.

Reconstruction-based contribution approaches for improved fault diagnosis using principal component analysis

This paper provides two new proposed data-based fault diagnosis approaches using the principal component analysis (PCA). Since faults are really complex and may be in multidimensional directions, the first proposal is a generalized RBC method. The theoretical diagnosability analysis using this one guarantees correct fault diagnosis in the case of complex faults that have large magnitudes. Nevertheless, the common assumption resulting from the use of the contribution methods in general is that variables with largest contributions to the fault detection indices are more likely to be the root causes of the fault occurrence. To handle the more complex faults and remedy the defective of the RBC method, the second proposal presents an alternative approach called RBC ratio (RBCR). A theoretical diagnosability analysis testifies to its strong performance in identifying the detectable faults. Indeed, the isolation of fault is guaranteed once its magnitude has satisfied a sufficient condition for isolability. These proposed approaches have been successfully applied to a numerical example as well as the CSTR process.

Use of Blood Components in Major Obstetric Hemorrhage: Preliminary Findings from the Australian and New Zealand Massive Transfusion Registry (ANZ-MTR)

▪Introduction:Major obstetric hemorrhage (MOH) can develop rapidly and, due to the unique characteristics of maternity patients, early recognition and management can be challenging. Use of blood components in MOH can be life-saving however there is uncertainty about optimal use of these products and the role of adjunctive therapies.The ANZ-MTR generates observational data on current transfusion management and outcomes in critically bleeding patients receiving massive transfusion (MT) across all clinical settings. This study aimed to describe the transfusion strategies used in the MOH population and report their outcomes.Methods:Patients who had a MOH and received a MT (≥5 units of red blood cells [RBC] in 4h) between April 2011 and December 2013 at 15 Australian & NZ hospitals were identified. Data on the type and volume of blood products transfused as well as selected laboratory results and clinical outcomes were reviewed.Results:A total of 154 cases were identified and reviewed, representing 6% of the total ANZ-MTR cohort. Median age was 34 [IQR29-37] years and 99% of women had a Charlson Comorbidity Index score ≤ 1. Table 1 presents the blood products transfused. The median [IQR] fresh frozen plasma (FFP) to RBC ratio and platelets to RBC ratio was 0.6 [0.3-0.8] and 0.1 [0-0.2], respectively. FFP, platelets and cryoprecipitate were transfused in 87%, 66% and 49% of patients. Prothrombinex-HT was administered to 1 patient and 3 patients received rFVIIa. Table 2 presents the laboratory results taken prior to MT onset as well as the lowest and highest result reported within 24hours after the MT onset. Fibrinogen levels following MT onset was available for 121 (79%) patients. Of these, 46% women had a fibrinogen level <2 g/L of which 34% did not receive cryoprecipitate. Mean [SD] hemoglobin level 24h post-MT onset was 108g/L [19]. Regarding patient outcomes, median [IQR] hospital length of stay was 8 [4-43] days, 59 (38%) women were admitted to ICU, 40 (26%) underwent a subtotal or total hysterectomy and 3 (1.9%) died in-hospital.Table 1Number of patients and median number of units transfused 24h post-MT onset (n = 154).Blood productn (%)Median units (IQR)Red blood cells154 (100)7 [6-10]Fresh frozen plasma134 (87)4 [2-6]Platelets102 (66.2)1 [0-1]Cryoprecipitate76 (49.4)0 [0-5]Table 2Laboratory values* reportedValue prior to MT onsetLowest value0-24h post-MT onsetHighest value0-24h post-MT onsetHemoglobin (g/L)102 [81-120], 8477 [67-90]; 92108 [95-119]; 92INR1.1 [0.9-1.2]; 331.1 [.9-1.2]; 721.3 [1.1-1.4]; 72aPPT(s)31 [28-35]; 3931 [29-34]; 8837 [33-46]; 88Fibrinogen level (g/L)3.2 [1.6-3.9]; 251.9 [1.4-2.6]; 792.9 [2.5-3.5]; 79Platelet Count (109/L)210 [158-249];84102 [74-135]; 92146 [110-190]; 92pH7.3 [7.3-7.4]; 227.3 [7.2-7.3]; 707.4 [7.4-7.5]; 70*Data are Median [IQR]; % patients with laboratory test availableConclusion:Women with MOH requiring massive transfusion were generally healthier and younger than patients of other clinical contexts in the ANZ-MTR. Although there were few in-hospital deaths reported (1.9%), a large proportion of the cohort required a hysterectomy during their hospital admission. Further information on transfusion practice, including understanding optimal blood component ratios, is required to inform clinical practice and minimize risk in the obstetric setting. DisclosuresMcLintock:Novo Nordisk Australasia: Honoraria.

Compliance with a massive transfusion protocol (MTP) impacts patient outcome

BackgroundAbout 5% of civilian trauma requires massive transfusion. Protocolized resuscitation with blood products to achieve high plasma:RBC ratio has been advocated to improve survival. Our objectives were to measure compliance to our institutional MTP, to identify quality assurance activities that could improve protocol compliance and to determine if protocol compliance was related to patient outcome. MethodsThe investigators determined 13 compliance criteria based upon our institutional protocol. We measured compliance in 72 consecutive MTP activations between January 2010 and September 2011 at a Level I trauma centre. Data elements were retrospectively retrieved from blood bank, trauma registry and clinical records. Patients were stratified into three groups based on compliance level, and mortality differences were compared. ResultsAverage compliance for the cohort (n=72) was 66%. The most common cause of non-compliance was failure to send a complete haemorrhage panel from the trauma bay (96%). Failure to monitoring blood work every 30min occurred in 89% of cases. Delay in activation and deactivation occurred in 50% and 50% respectively. Non-compliance to protocol-based administration of blood products happened in 47%.The cohort was stratified into three groups based on compliance, A: <60%, B: 60–80% and C: >80% (low, moderate and high compliance groups). There was no statistical significance with regard to median age, median ISS, ED SBP, ED GCS and AIS of the head/spine, chest and abdomen. The mortality rates in each group were 62%, 50% and 10% in the low, moderate and high compliance groups respectively. Mortality differences were compared using adjusted logistic regression. The OR for mortality between Groups A and B=1.1 [95% CI 0.258–4.687 (P=0.899)] while the OR for mortality between Groups C and B=0.02 [95% CI <0.001–0.855 (P=0.041)]. ConclusionsMeasures should be directed towards provider and system factors to improve compliance. In this study, there was an association between survival and higher level of compliance.

The Use of Higher Platelet

With the recognition of early coagulopathy, trauma resuscitation has shifted toward liberal platelet transfusions. The overall benefit of this strategy remains controversial. Our objective was to compare the effects of a liberal use of platelet (higher platelet:RBC ratios) with a conservative approach (lower ratios) in trauma resuscitation. We systematically searched Medline, Embase, Web of Science, Biosis, Cochrane Central, and Scopus. Two independent reviewers selected randomized controlled trials and observational studies comparing two or more platelet:RBC ratios in trauma resuscitation. We excluded studies investigating the use of whole blood or hemostatic products. Two independent reviewers extracted data and assessed the risk of bias. Primary outcomes were early (in ICU or within 30 d) and late (in hospital or after 30 d) mortality. Secondary outcomes were multiple organ failure, lung injury, and sepsis. From 6,123 citations, no randomized controlled trials were identified. We included seven observational studies (4,230 patients) addressing confounders through multivariable regression or propensity scores. Heterogeneity of studies precluded meta-analysis. Among the five studies including exclusively patients requiring massive transfusions, four observed a lower mortality with higher ratios. Two studies considering nonmassively bleeding patients observed no benefit of using higher ratios. Two studies evaluated the implementation of a massive transfusion protocol; only one study observed a decrease in mortality with higher ratios. Of the two studies at low risk of survival bias, one study observed a survival benefit. Three studies assessed secondary outcomes. One study observed an increase in multiple organ failure with higher ratios, whereas no study demonstrated an increased risk in lung injury or sepsis. There is insufficient evidence to strongly support the use of a precise platelet:RBC ratio for trauma resuscitation, especially in nonmassively bleeding patients. Randomized controlled trials evaluating both the safety and efficacy of liberal platelet transfusions are warranted.