The North Pacific Surgical Association
A high ratio of plasma and platelets to packed red blood cells in the first 6 hours of massive transfusion improves outcomes in a large multicenter study

https://doi.org/10.1016/j.amjsurg.2008.12.014Get rights and content

Abstract

Background

In trauma, most hemorrhagic deaths occur within the first 6 hours. This study examined the effect on survival of high ratios of fresh frozen plasma (FFP) and platelets (PLTs) to packed red blood cells (PRBCs) in the first 6 hours.

Methods

Records of 466 massive transfusion trauma patients (≥10 U of PRBCs in 24 hours) at 16 level 1 trauma centers were reviewed. Transfusion ratios in the first 6 hours were correlated with outcome.

Results

All groups had similar baseline characteristics. Higher 6-hour ratios of FFP:PRBCs and PLTs:PRBCs lead to improved 6-hour mortality (from 37.3 [in the lowest ratio group] to 15.7 [in the middle ratio group] to 2.0% [in the highest ratio group] and 22.8% to 19.0% to 3.2%, respectively) and in-hospital mortality (from 54.9 to 41.1 to 25.5% and 43.7% to 46.8% to 27.4%, respectively). Initial higher ratios of FFP:PRBCs and PLTs:PRBCs decreased overall PRBC transfusion.

Conclusions

The early administration of high ratios of FFP and platelets improves survival and decreases overall PRBC need in massively transfused patients. The largest difference in mortality occurs during the first 6 hours after admission, suggesting that the early administration of FFP and platelets is critical.

Section snippets

Methods

A multicenter, retrospective analysis was performed at 16 level 1 trauma centers in the United States.10 The protocol was approved by the institutional review boards at all participating centers. Data were collected from trauma patients injured between July 2005 and June 2006 who received any PRBCs within 24 hours of admission. Patients who were transferred from other hospitals, prisoners, children less than age 16, pregnant patients, burn-injured patients, patients who had greater than or

Results

Data were obtained from 1,489 patients who received at least 1 U of PRBCs, including 466 massive transfusion patients. There were 14 patients for whom complete data was not available and they were excluded from analysis.

Demographics

The number of massively transfused patients receiving the various ratios of FFP and PLTs and their demographics are shown in Table 1, Table 2. Most patients received FFP:PRBCs in a ratio between 1:4 and 1:1 and PLTs:PRBCs in a ratio of <1:4. All groups had similar ISS, GCS, mechanism of injury, gender and age (Table 1, Table 2). The initial systolic blood pressure (SBP) and initial laboratory tests were similar among all groups, with the exception that those who received a ≥1:1 ratio of

Outcomes

The overall mortality was 41%. Mortality decreased significantly when patients received higher early ratios of FFP:PRBCs, with most of the differences occurring in the first 6 hours from admission and persisting though hospital discharge (Table 3 and Fig. 1). Similar to the FFP:PRBC ratios, mortality decreased significantly when patients received higher early ratios of PLTs:PRBCs. Again, most of the differences occurred in the first 6 hours from admission (Table 3 and Fig. 2).

With higher early

Comments

Hemorrhage remains the leading cause of preventable death in trauma patients. Most trauma deaths are not preventable, about 80% in combat operations and >90% in civilian traumas. Of the remaining potentially preventable deaths, 45% to 85% are potentially salvageable hemorrhagic deaths, most of which occur in the first 6 hours after injury.1, 2, 10, 12, 13, 14 It is this group of patients that this study is directed toward. Optimal treatment of these severely injured patients is required. Rapid

Acknowledgments

The authors thank The Trauma Outcomes Group (TOG); J.B. Holcomb, C.E. Wade, M.S. Park, and K.L. Williams from the United States Army Institute of Surgical Research and Brooke Army Medical Center, FT Sam, Houston, TX; E.A. Gonzalez and R.A. Kozar from the University of Texas Health Science Center, Houston, TX; J.E. Michalek, G.B. Chisholm, L.A. Zarzabal, R.M. Stewart, and S.M. Cohn from the University of Texas Health Science Center, San Antonio, TX; J.P. Minei and T. O'Keefe from the University

References (18)

  • J.B. MacLeod et al.

    Early coagulopathy predicts mortality in trauma

    J Trauma

    (2003)
  • P.G. Teixeira et al.

    Preventable or potentially preventable mortality at a mature trauma center

    J Trauma Inj Infect Crit Care

    (2007)
  • Advanced Trauma Life Support for Doctors

    (1997)
  • L. Ketchum et al.

    Indications for early fresh frozen plasma, cryoprecipitate, and platelet transfusion in trauma

    J Trauma

    (2006)
  • D.L. Malone et al.

    Massive transfusion practices around the globe and a suggestion for a common massive transfusion protocol

    J Trauma

    (2006)
  • M.A. Borgman et al.

    The ratio of blood products transfused affects mortality in patients receiving massive transfusions at a combat support hospital

    J Trauma

    (2007)
  • E.A. Gonzalez et al.

    Fresh frozen plasma should be given earlier to patients requiring massive transfusion

    J Trauma

    (2007)
  • J.R. Hess et al.

    Damage control resuscitation: the need for specific blood products to treat the coagulopathy of trauma

    Transfusion

    (2006)
  • J.B. Holcomb et al.

    Damage control resuscitation: directly addressing the early coagulopathy of trauma

    J Trauma

    (2007)
There are more references available in the full text version of this article.

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