An Emergency Department Thawed Plasma Protocol for Severely Injured Patients

Abstract

Objectives To expedite delivery and transfusion of plasma through implementation of an emergency department (TP-ED) protocol. Design Retrospective cohort study Setting ACS-verified level 1 trauma center Patients Protocol was initiated February 2010, placing four units of AB plasma in the ED. All trauma patients admitted eight months before (TP-BB) and after implementing the TP-ED protocol. Patients were included if they received at least one unit of RBC and one unit of plasma in the first six hours after ED admission. Main Outcome Measures Primary outcome was time to first unit of plasma. Secondary outcomes included 24-hour blood use and 24-hour and 30-day mortality. Results 294 patients met study criteria (130 TP-BB, 164 TP-ED). While demographics were similar, TP-ED patients had greater anatomic injury (median ISS 18 vs. 25, p=0.018) and more physiological disturbances (median w-RTS 6.81 vs. 3.83, p=0.008). TP-ED had shorter time to first plasma transfusion (83 min vs. 42 min, p<0.001). TP-ED was associated with a reduction in 24-hour transfusion of RBC (p=0.036), plasma (p=0.044), and platelets (p<0.001). Logistic regression identified TP-ED as an independent predictor of decreased 30-day mortality (OR 0.43, 95% C.I. 0.194–0.956, p=0.038). Conclusions We demonstrated that implementation of a ED-TP protocol expedites transfusion of plasma to severely injured patients. This approach is associated with a reduction in overall blood product use and a 60% decreased odds in 30-day mortality.

How I treat patients with massive hemorrhage

“…59,60 This notion was further corroborated by Rawdan and colleagues, who reported that moving thawed plasma from the blood bank to the emergency department, enabling early balanced blood product transfusion, was associated with a reduction in overall blood product use and a 60% decrease in odds of 30-day mortality. 61 These studies all suggest that rapid infusion of balanced blood products into bleeding patients is critical to improved survival.…”

Optimal trauma resuscitation with plasma as the primary resuscitative fluid: the surgeon's perspective

“…In 2010, we moved thawed plasma from the blood bank to the emergency department because it was taking up to 40 minutes to infuse plasma into patients. 11 We now have 4 units of RBCs and 4 units of liquid AB plasma in our emergency department, which are available for rapid infusion as the primary resuscitative fluid. Infusion times of plasma are now within 3 minutes of patient arrival.…”

The traditional vs “1:1:1” approach debate on massive transfusion in trauma should not be treated as a dichotomy

“…In one study, having a "1:1:1" protocol resulted in earlier use of FFP, but the FFP:PRBC ratio at 24 hours was identical to that before "1:1:1" implementation; and mortality and blood products use decreased [18]. Other centers have documented increased survival and/or reduced blood product use after implementation of "1:1:1" [19][20][21][22][23][24][25][26][27][28]. There is conflicting data on FFP wastage.…”