Trauma Blood Management: Avoiding the Collateral Damage of Trauma Resuscitation Protocols

Abstract

The use of high ratios of red blood cells to platelets and plasma in trauma resuscitation protocols is quickly gaining favor in civilian trauma centers. The use of higher ratios of coagulation factors to red blood cells has been shown to improve outcomes in both military and civilian centers, but does the evidence support the use of a 1:1:1 ratio, as has been suggested? There is growing evidence that the use of such high ratios may be excessive and potentially harmful, and there has not been enough emphasis on the other components of evidence-based "damage control" resuscitation.Transfusion therapy has come full cycle in Iraq and Afghanistan as fresh whole blood use has again found a place in the resuscitation of military casualties. The use of equal ratios of packed red blood cells, plasma, and platelets (so called 1:1:1 therapy) to effectively reconstitute whole blood is gaining ground in civilian trauma centers to attempt to replicate the approach of military trauma teams. Although this is an exciting and potential livesaving therapy, have we considered the "collateral damage" of these trauma resuscitation protocols and does the current evidence support this approach? A cautionary note to begin the discussion was best phrased by Dr. Stephen Cohen: "As mortality rates range from one-third to one-half of these massively transfused individuals, heroic new measures are aggressively sought after and easily embraced." 1

Reasons for moving toward a patient‐centric paradigm of clinical transfusion medicine practice

“…Should old RBCs be found to be associated with common adverse patient outcomes (i.e., increased mortality, infection, and/or multiple organ failure), 7‐10,90 or should the resuscitation of trauma victims with a plasma‐to‐RBCs ratio close to 1:1 be found to improve survival, 91‐95 there will be additional reasons for us to progress toward a patient‐centric transfusion medicine paradigm (to, respectively, avoid transfusion of old RBCs [by avoiding RBC transfusion through use of various PBM modalities and also by planning multicomponent collections proximally to planned procedures and around the needs of specific patients] or expose trauma victims to one [rather than two] allogeneic donors for each dose of both plasma and RBCs received). Because the term “patient blood management” was introduced by adherents to the belief that PBM can achieve better patient outcomes by reducing mortality and morbidity (through avoidance of allogeneic blood transfusion 24,29‐31,89 and the ensuing prevention of the purported immumomodulatory effects of transfusion 96 and the ill‐defined adverse effects of old RBCs 90 ), the premise that PBM can reduce the risk of common adverse effects of transfusion (i.e., increased mortality, infection, and/or multiple organ failure) is still embedded—even if inexplicitly—in the definition of PBM.…”

Documento multidisciplinar de consenso sobre el manejo de la hemorragia masiva (documento HEMOMAS)

“…En 2010 una revisión más detallada del ejército estadounidense en 777 pacientes traumáticos transfundidos con la relación 1:1 no pudo demostrar una disminución de la mortalidad 108 . Por el contrario, distintos estudios indicaban la posibilidad de que los protocolos 1:1 podrían inducir efectos indeseables que superaban a los beneficios [109][110][111][112] . Se pudo identificar que:…”

Cirurgia para controle de danos: estado atual

“…É importante também salientar que o uso de derivados de sangue pode ter consequências desastrosas, devido as suas propriedades inflamatórias e imunomodulatórias. A lesão pulmonar aguda (TRALI-transfusion related acute lung injury) é a principal e mais temida consequência 33,34 . Além disso, todos os estudos recentes são retrospectivos e possuem vieses sobre a mortalidade.…”