Accounting for differences in transfusion volume: Are all massive transfusions created equal?

BACKGROUND Among patients subjected to massive transfusion (MT), some will require considerably more blood than others, depending on the rate and quantity of hemorrhage. In analyses concerning plasma to red blood cell (RBC) ratios and platelet to RBC ratios, this has yet to be examined. We sought to evaluate the effect of the number of RBC units transfused on both plasma:RBC and platelet:RBC and their association with mortality in MT patients. METHODS Prospective data were collected on trauma patients taken directly to surgery from the resuscitation room who received ≥10 RBC units by completion of operation. MT protocol was in place for all patients. To account for survival bias, intra-operative deaths were excluded. Patients were stratified by plasma:RBC and platelet:RBC (HIGH > 0.5, MID 0.33-0.5, LOW < 0.33). Crude and adjusted risk ratios (RRs) for hospital mortality were determined, using the HIGH ratio as the reference group. RESULTS One hundred thirty-five patients met inclusion criteria. There were no significant differences with respect to demographics, injury characteristics, or shock severity. However, the mean number of intra-operative RBC units transfused was significantly different between plasma:RBC groups (HIGH: 16.2, MID: 19.7, LOW: 25.1; p < 0.001). The crude risk for mortality was significantly higher for the LOW group relative to the HIGH group (RR 1.99, 95% confidence interval [CI] 1.02–3.89). However, after adjustment for the number of RBCs transfused, the risk was not significantly different (RR 1.54, 95% CI 0.75–3.15). The adjusted mortality risk for the LOW versus HIGH platelet:RBC groups was also not statistically different (RR 1.92, 95% CI 0.99–3.71). CONCLUSIONS Among patients subjected to MT, those who receive relatively higher quantities of RBCs are both more likely to receive a lower plasma:RBC and are more likely to die. Any analysis concerning transfusion ratios should take the potential confounding of this heterogeneity among MT patients into account. Level of Evidence Prognostic study, level III.

[1]  A. Sauaia,et al.  Initial experiences with point‐of‐care rapid thrombelastography for management of life‐threatening postinjury coagulopathy , 2012, Transfusion.

[2]  B. Seifert,et al.  Hyperfibrinolysis Diagnosed by Rotational Thromboelastometry (ROTEM®) Is Associated with Higher Mortality in Patients with Severe Trauma , 2011, Anesthesia and analgesia.

[3]  A. Peitzman,et al.  Effect of high product ratio massive transfusion on mortality in blunt and penetrating trauma patients. , 2011, The Journal of trauma.

[4]  C. Wade,et al.  Rapid thrombelastography delivers real-time results that predict transfusion within 1 hour of admission. , 2011, The Journal of trauma.

[5]  A. Peitzman,et al.  Increased platelet:RBC ratios are associated with improved survival after massive transfusion. , 2011, The Journal of trauma.

[6]  A. Peitzman,et al.  Gender-based differences in mortality in response to high product ratio massive transfusion. , 2011, The Journal of trauma.

[7]  L. Blackbourne,et al.  The effect of FFP:RBC ratio on morbidity and mortality in trauma patients based on transfusion prediction score , 2011, Vox sanguinis.

[8]  P. Rhee,et al.  Impact of plasma transfusion in trauma patients who do not require massive transfusion. , 2010, Journal of the American College of Surgeons.

[9]  C. Hillyer,et al.  Increased number of coagulation products in relationship to red blood cell products transfused improves mortality in trauma patients , 2010, Transfusion.

[10]  B. Cotton,et al.  Transfusion therapy in hemorrhagic shock , 2009, Current opinion in critical care.

[11]  Lesly A. Dossett,et al.  Room for (performance) improvement: provider-related factors associated with poor outcomes in massive transfusion. , 2009, The Journal of trauma.

[12]  John B Holcomb,et al.  Resuscitation and transfusion principles for traumatic hemorrhagic shock. , 2009, Blood reviews.

[13]  Richard L. George,et al.  The relationship of blood product ratio to mortality: survival benefit or survival bias? , 2009, The Journal of trauma.

[14]  B. Cotton,et al.  Optimizing outcomes in damage control resuscitation: identifying blood product ratios associated with improved survival. , 2008, The Journal of trauma.

[15]  J. Michalek,et al.  Increased Plasma and Platelet to Red Blood Cell Ratios Improves Outcome in 466 Massively Transfused Civilian Trauma Patients , 2008, Annals of surgery.

[16]  J. Duchesne,et al.  Review of current blood transfusions strategies in a mature level I trauma center: were we wrong for the last 60 years? , 2008, The Journal of trauma.

[17]  A. Sauaia,et al.  Postinjury life threatening coagulopathy: is 1:1 fresh frozen plasma:packed red blood cells the answer? , 2008, The Journal of trauma.

[18]  C. Wade,et al.  The ratio of blood products transfused affects mortality in patients receiving massive transfusions at a combat support hospital. , 2007, The Journal of trauma.

[19]  Michal Abrahamowicz,et al.  Survival bias associated with time-to-treatment initiation in drug effectiveness evaluation: a comparison of methods. , 2005, American journal of epidemiology.

[20]  A. Sauaia,et al.  Viscoelastic clot strength predicts coagulation-related mortality within 15 minutes. , 2012, Surgery.

[21]  T. Fabian,et al.  Improved survival after hemostatic resuscitation: does the emperor have no clothes? , 2011, The Journal of trauma.

[22]  D. Mozingo.  An FFP:PRBC Transfusion Ratio ≥1:1.5 Is Associated With a Lower Risk of Mortality After Massive Transfusion , 2009 .