Review of Current Blood Transfusions Strategies in a Mature Level I Trauma Center: Were We Wrong for the Last 60 Years?

Duchesne, Juan; Hunt, John P.; Wahl, Georgia; Marr, Alan B.; Wang, Yi Zarn; Weintraub, Sharon; Wright, Mary Johanna; McSwain, Norman E.

doi:10.1097/ta.0b013e31817e5166

Cited by 241 publications

(187 citation statements)

References 30 publications

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“…Several retrospective cohort studies have found substantial survival gains with this approach in both military 45 and civilian [46][47][48] trauma settings. More recently, however, other investigators 49 have not confirmed this finding when applying statistical techniques to correct for immortal time bias.…”

Section: Discussionmentioning

confidence: 99%

Early massive transfusion in trauma patients: Canadian single-centre retrospective cohort study

Mahambrey

Fowler

Pinto

et al. 2009

Can J Anesth/J Can Anesth

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Purpose To determine associations between red blood cell (RBC) transfusion and early and late clinical outcomes in massively transfused adult trauma patients. Methods A retrospective cohort study (1992)(1993)(1994)(1995)(1996)(1997)(1998)(1999)(2000)(2001) including 260 patients receiving C10 RBC units B24 hr after admission to a university-affiliated trauma centre. We extracted demographic and clinical data and used multivariable regression to determine independent effects of RBC transfusion on clinical outcomes. ]).Conclusions Hospital mortality is high among massively transfused trauma patients. Among early survivors, 48-hr RBC transfusion volume is associated with increased organ dysfunction, but not hospital mortality. Also, it is not associated with 48-hr mortality. Future research should continue to explore methods to improve hemostasis and minimize the need for RBC transfusion. RésuméObjectif De´terminer les associations qui existent entre la transfusion d'e´rythrocytes et les devenirs cliniques R. A. Fowler and N. K. J. Adhikari contributed equally to this study.

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Section: Discussionmentioning

confidence: 99%

Early massive transfusion in trauma patients: Canadian single-centre retrospective cohort study

Mahambrey

Fowler

Pinto

et al. 2009

Can J Anesth/J Can Anesth

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“…A high plasma to RBC ratio (1:1.4) was independently associated with improved survival, primarily by decreasing death from hemorrhage. Following this article, several studies investigating the survival benefit of a high ratio of fresh frozen plasma (FFP) to RBC were reported [35][36][37][38][39][40]. Although the ratio of FFP to RBC differed between the studies, a significant decrease in the mortality of the massively transfused patients in the high-ratio population as compared to the low-ratio population was achieved in both the civilian setting and the combat situation.…”

Section: Hemostatic Resuscitationmentioning

confidence: 99%

Damage control resuscitation: a practical approach for severely hemorrhagic patients and its effects on trauma surgery

Mizobata

2017

j intensive care

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Coagulopathy observed in trauma patients was thought to be a resuscitation-associated phenomenon. The replacement of lost and consumed coagulation factors was the mainstay in the resuscitation of hemorrhagic shock for many decades. Twenty years ago, damage control surgery (DCS) was implemented to challenge the coagulopathy of trauma. It consists of three steps: abbreviated surgery to control the hemorrhage and contamination, resuscitation in the intensive care unit (ICU), and planned re-operation with definitive surgery. The resuscitation strategy of DCS focused on the rapid reversal of acidosis and prevention of hypothermia through the first two steps. However, direct treatment of coagulopathy was not emphasized in DCS. Recently, better understanding of the pathophysiology of coagulopathy in trauma patients has led to the logical opinion that we should directly address this coagulopathy during major trauma resuscitation. Damage control resuscitation (DCR), the strategic approach to the trauma patient who presents in extremis, consists of balanced resuscitation, hemostatic resuscitation, and prevention of acidosis, hypothermia, and hypocalcemia. In balanced resuscitation, fluid administration is restricted and hypotension is allowed until definitive hemostatic measures begin. The administration of blood products consisting of fresh frozen plasma, packed red blood cells, and platelets, the ratio of which resembles whole blood, is recommended early in the resuscitation. DCR strategy is now the most beneficial measure available to address trauma-induced coagulopathy, and it can change the treatment strategy of trauma patients. DCS is now incorporated as a component of DCR. DCR as a structured intervention begins immediately after rapid initial assessment in the emergency room and progresses through the operating theater into the ICU in combination with DCS. By starting from ground zero with the performance of DCS, DCR allows the trauma surgeon to correct the coagulopathy of trauma. The effect of the reversal of coagulopathy in massively hemorrhagic patients may change the operative strategy with DCS.

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“…However, until few years ago plasma transfusion was not recommended in absence of a prolongation of PT or INR or fibrinogen decrease to less than 1.5 gr/L. More recently, retrospective evidence from both military [5] and civilian [6] practice suggested improved outcomes in patients with massive bleeding after the adoption of a massive-transfusion protocol (MTP), including the early administration of highdose plasma therapy. Although the first reports based on the military experience suggested a 1:1 plasma/packed red blood cells (PRBCs) ratio, more recent data, supported by thromboelastometry, have shown that a lower rate (i.e., 1:2) may be preferable [7].…”

Section: Introductionmentioning

confidence: 99%

Prevention and treatment of trauma induced coagulopathy (TIC). An intended protocol from the Italian trauma update research group

Agostini¹,

Rondinelli²,

Bocci³

et al. 2013

J Anesthesiol Clin Sci

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In recent years, a strong focus has been put on the need to assure early coagulation support in order to prevent and treat coagulopathy in patients with severe trauma, and to improve survival. Aggressive plasma administration with high plasma/ red blood cells ratio is increasingly used worldwide. However, plasma transfusion is associated with increased risks of multiple organ dysfunction syndrome (MODS), adult respiratory distress syndrome (ARDS) and infection, which may prolong hospital stay and the need for artificial ventilation. Moreover, in the majority of European hospitals plasma cannot be immediately available and therefore it has been reported a significant delay in coagulation support. This has lead to the proposal of using clotting factors as an alternative to plasma. However, strong evidence to define the best strategy is still missing, and the only published protocols are Institution-specific, thus depending on the local organization and the available resources. The Italian Trauma Centers Network (TUN) recently developed a treatment protocol aiming at shortening the interval before the onset of coagulation support and at reducing the use of plasma. We present this protocol-Early Coagulation Support (ECS) Protocol -and discuss its rationale. Its implications for the trauma-team workflow and hospital organization are also addressed. The ECS protocol must be considered as an integrated part of a comprehensive Damage Control Strategy. The impact of the ECS Protocol on blood products consumption, trauma mortality and morbidity as well as its financial aspects, will be strictly monitored by the TUN hospitals.

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Review of Current Blood Transfusions Strategies in a Mature Level I Trauma Center: Were We Wrong for the Last 60 Years?

Abstract: An FFP to PRBC ratio close to 1:1 confers a survival advantage in patients requiring massive transfusion.

Cited by 241 publications

References 30 publications

Early massive transfusion in trauma patients: Canadian single-centre retrospective cohort study

Early massive transfusion in trauma patients: Canadian single-centre retrospective cohort study

Damage control resuscitation: a practical approach for severely hemorrhagic patients and its effects on trauma surgery

Prevention and treatment of trauma induced coagulopathy (TIC). An intended protocol from the Italian trauma update research group

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