Optimizing Transfusion Ratios in Massive Transfusion Protocols: An Argument Against the 1:1:1 Dogma and Approach to Trauma Resuscitation

Gregory, Jason A.; Huitron, Sonny S.; George, Alan A.; Simon, Clayton D.

doi:10.1309/lmjqnoqcfg4gkqrj

Cited by 12 publications

(7 citation statements)

References 30 publications

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“…Concordant with the related literature, whole blood reconstituted at a 1:1:1 ratio had only limited oxygen‐carrying capacity (median hematocrit, 30% in both FFP200 and LP200) and reduced coagulation proteins (compared with the pure FFP or LP units) because of the mutual dilution of RBCs, plasma, and platelets. The use of low‐volume LPs allowed us to reduce the extent of dilution on the cellular count (higher hematocrit and platelet count) and coagulation factors (increased fibrinogen and both procoagulant and anticoagulant levels) compared with the other two groups.…”

Section: Discussionsupporting

confidence: 85%

Concentrated lyophilized plasma used for reconstitution of whole blood leads to higher coagulation factor activity but unchanged thrombin potential compared with fresh‐frozen plasma

et al. 2017

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BACKGROUND During massive hemorrhage, it is recommended to transfuse red blood cells, platelet concentrate, and fresh‐frozen plasma in a ratio close to 1:1:1. To avoid the thawing process of fresh frozen plasma, lyophilized plasma (LP) is increasingly used. Evidence is limited on the activity of coagulation factors in reconstituted blood using LP and concentrated LP versions. STUDY DESIGN AND METHODS Whole blood from ten healthy volunteers was separated into red blood cell, fresh frozen plasma, and platelet concentrate units. Aliquots of red blood cells and plasma concentrate were mixed with either fresh frozen plasma (200 mL) or LP at reconstitution ratios of 2:1:1, 1:1:1, and 1:1:2. LP was used either at the recommended standard volume of 200 mL (LP200) or was more concentrated at volumes of 100 and 50 mL (LP100 and LP50, respectively). The hemostatic capacity of each reconstituted whole blood sample was tested with blood cell counts, standard coagulation tests, factor activity, thrombin generation, and viscoelastic assays. RESULTS Hematocrit, platelet counts, and fibrinogen levels of the three ratios were similar between FFP200 and LP200 units but were lower compared with the corresponding ratios in LP100 and LP50 units. The activity of procoagulant and anticoagulant factors increased linearly with the increasing plasmatic fraction and, at 1:1:2 ratio, was significantly higher in LP50 units compared with FFP200 and LP200 units. Thrombin generation was similar throughout the four plasma groups at any ratio. CONCLUSIONS Decreasing the dilution volume of LP facilitates reaching higher hematocrit and coagulation protein levels without a relevant increase in thrombin generation. This is due to preserved balance between procoagulant and anticoagulant factors in the concentrated LP preparations.

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Section: Discussionsupporting

confidence: 85%

Concentrated lyophilized plasma used for reconstitution of whole blood leads to higher coagulation factor activity but unchanged thrombin potential compared with fresh‐frozen plasma

et al. 2017

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“… 3 , 5 , 35 – 38 When taking this into account, the ratio 1:1:1:1, which includes fibrinogen, seems to be very smart and advantageous. 3 , 5 , 14 , 21 , 25 , 36 – 38 …”

Section: Component Therapymentioning

confidence: 99%

“… 5 , 3 , 35 – 38 Therefore a single injection of fibrinogen concentrate at a dose of 2–4 g intravenously seems to be a smart and useful intervention. 3 , 5 , 14 , 21 , 25 , 36 – 38 There is no evidence that cryoprecipitate would improve the outcome of patients with low fibrinogen levels caused by massive bleeding. 43 Hypothermic coagulopathy is very challenging to treat in bleeding patients, but it was shown that coagulopathy caused by hypothermia can be reversed and successfully corrected by fibrinogen concentrate.…”

Section: Fibrinogenmentioning

confidence: 99%

Massive hemorrhage management – a best evidence topic report

Vymazal¹

2015

TCRM

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IntroductionMassive hemorrhage remains a major cause of potentially preventable deaths. Better control of bleeding could improve survival rates by 10%–20%. Transfusion intervention concepts have been formulated in order to minimize acute traumatic coagulopathy. These interventions still have not been standardized and vary among medical centers.Materials and MethodsBased on a literature search using free term keywords and Medical Subject Heading (MeSH) index, we analyzed published articles addressing massive hemorrhage, component therapy, fresh whole blood, and fibrinogen from the year 2000 onward, in journals with impact factor >1.000, in Medline, PubMed, and Google Scholar. The evidence was grouped into topics including laboratory testing and transfusion interventions/viscoelastic assays vs standard laboratory tests, the effect of component therapy on patient outcome, the effect of warm fresh whole blood on patient outcome, and the effects of fibrinogen in severe bleeding. The obtained information was compared, evaluated, confronted, and was focused on to present an adequate and individual-based massive hemorrhage management approach.ResultsViscoelastic whole-blood assays are superior to standard coagulation blood tests for the identification of coagulopathy and for guiding decisions on appropriate therapy in patients with severe bleeding. Replacement of plasma, red blood cells, platelets, and fibrinogen in a ratio of 1:1:1:1 has appeared to be the best substitution for lost whole blood. There is no evidence that cryoprecipitate improves the outcome of patients with severe hemorrhage. Current literature promotes the transfusion of warm fresh whole blood, which seems to be superior to the component therapy in certain clinical situations. Some authors recommend that fibrinogen and other coagulation factors be administered according to the viscoelastic attributes of the blood clot.ConclusionThis best-evidence topic report brings comprehensive information about massive hemorrhage management.

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“…From a theoretical standpoint, a 2:1 ratio of PRBC to FFP by volume has been proposed in order to maintain adequate coagulation factor activity as well as oxygen carrying capacity. 21 The theoretical risk of improperly proportioned ratios (by volume) in children is magnified as the total circulating blood volume decreases. Moreover, an analysis of the Department of Defense Trauma Registry demonstrated that a low ratio of PRBC to FFP (approaching 1:1 by volume) increased the odds of mortality of pediatric patients receiving any blood product within the first 24 hours of trauma admission.…”

Section: Discussionmentioning

confidence: 99%

Development of transfusion guidelines for injured children using a Modified Delphi Consensus Process

Trappey

Thompson

Kuppermann

et al. 2019

J Trauma Acute Care Surg

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BACKGROUND: There is wide variability of transfusion practices for children with hemorrhagic injuries across trauma centers. We are planning a multicenter, randomized clinical trial evaluating tranexamic acid in children with hemorrhage. Standardization of transfusion practices across sites is important to minimize confounding. Therefore, we sought to generate consensus-based transfusion guidelines for the trial. METHODS:We used a modified Delphi process utilizing a multi-site, multi-disciplinary panel of experts to develop our transfusion guidelines. A survey of 23 clinical categories on various aspects of transfusion practices was developed and distributed via SurveyMonkey®. Statements were graded on a 5-point Likert scale ("Strongly agree" to "This intervention may be harmful"). Statements were accepted if ≥ 80% of the panelists rated the statement as "Strongly agree" or "Agree". After each round, the responses were calculated and the results included on subsequent rounds. RESULTS:35 panelists from four pediatric trauma centers participated in the study, including 11 (31%) pediatric EM physicians, 8 (23%) pediatric trauma surgeons, 5 (14%) transfusionists, 5 (14%) pediatric anesthesiologists, and 6 (17%) pediatric critical care physicians (range of 8 to 10 from each clinical site). Four survey iterations were performed. In total 176 statements were rated and 39 were accepted by criteria across all 23 categories. An rational algorithm for transfusion in trauma was then developed. CONCLUSIONS: We successfully developed transfusion guidelines for various aspects of the management of children with hemorrhagic injuries using a modified Delphi process with broad interdisciplinary participation. We anticipate implementation of these guidelines will help minimize heterogeneity of transfusion practices across clinical sites for the upcoming clinical trial evaluating tranexamic acid in children with hemorrhage.

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Optimizing Transfusion Ratios in Massive Transfusion Protocols: An Argument Against the 1:1:1 Dogma and Approach to Trauma Resuscitation

Cited by 12 publications

References 30 publications

Concentrated lyophilized plasma used for reconstitution of whole blood leads to higher coagulation factor activity but unchanged thrombin potential compared with fresh‐frozen plasma

Concentrated lyophilized plasma used for reconstitution of whole blood leads to higher coagulation factor activity but unchanged thrombin potential compared with fresh‐frozen plasma

Massive hemorrhage management – a best evidence topic report

Development of transfusion guidelines for injured children using a Modified Delphi Consensus Process

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Optimizing Transfusion Ratios in Massive Transfusion Protocols: An Argument Against the 1:1:1 Dogma and Approach to Trauma Resuscitation

Cited by 12 publications

References 30 publications

Concentrated lyophilized plasma used for reconstitution of whole blood leads to higher coagulation factor activity but unchanged thrombin potential compared with fresh‐frozen plasma

Concentrated lyophilized plasma used for reconstitution of whole blood leads to higher coagulation factor activity but unchanged thrombin potential compared with fresh‐frozen plasma

Massive hemorrhage management &ndash; a best evidence topic report

Development of transfusion guidelines for injured children using a Modified Delphi Consensus Process

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Massive hemorrhage management – a best evidence topic report