Elsevier

Injury

Volume 41, Issue 1, January 2010, Pages 35-39
Injury

Fresh frozen plasma (FFP) use during massive blood transfusion in trauma resuscitation

https://doi.org/10.1016/j.injury.2009.09.029Get rights and content

Abstract

Introduction

Recent retrospective studies have found high fresh frozen plasma (FFP) to packed red blood cell (PRBC) ratios during trauma resuscitation to be associated with improved mortality. Whilst this association may be related to a mortality bias present in these studies, there has been an overall tendency towards a 1:1 FFP:PRBC ratio in massive transfusion guidelines worldwide. The aim of this study was to retrospectively review the administration of FFP in patients undergoing massive transfusion during trauma resuscitation, to add to the evidence base for massive transfusion guidelines.

Materials and methods

Multi-trauma patients who were administered blood transfusions of 5 units or more of packed red blood cells (PRBCs) in the first 4 h were included in this study. Mortality was the primary endpoint with length of hospital stay, ICU hours and mechanically ventilated hours secondary endpoints.

Results

There were 331 patients included in this study with a median Injury Severity Score (ISS) of 36 (25–50) and a mortality of 29.9%. There was little change in the ratio of FFP:PRBC transfused per patient from 2005 to 2008. A low FFP:PRBC ratio in the first 4 h of resuscitation, older age, low initial GCS and coagulopathy on presentation were significant independent factors associated with mortality. When deaths in the first 24 h were excluded, the FFP:PRBC ratio had no association with mortality.

Discussion

This study has shown increased initial survival in association with higher FFP:PRBC ratios during massive transfusion in a population with a high proportion of blunt injuries. The association is difficult to interpret because of an inherent survival bias. The optimal ratio of FFP:PRBC during massive transfusion may be different to 1:1 and further prospective research is required. There is now an increasing need for well designed randomised controlled trials to determine the best FFP:PRBC ratio for the resuscitation of blunt multi-trauma patients.

Introduction

Uncontrolled haemorrhage is a leading cause of early mortality and remains a major challenge in trauma resuscitation.15, 17 Inadequate evidence has hampered attempts to establish transfusion guidelines in major trauma. The sub-group of patients requiring massive transfusions during trauma resuscitation depletes even well resourced centres of blood products. Because of the high mortality rate there has been considerable interest worldwide in establishing massive transfusion guidelines for trauma resuscitation.12, 13 An important component of massive transfusion guidelines is the amount of fresh frozen plasma (FFP) transfused.

Since military studies were published suggesting improved outcomes,2, 6 there have been multiple recent retrospective reviews on the benefits of high volumes of FFP transfusion.3, 4, 5, 7, 8, 11, 18, 19, 20, 22 A change of practice from the traditional administration of 1 unit of FFP for 4 units of packed red blood cells (PRBCs) to a 1:1 ratio has been advocated, but the optimal ratio during resuscitation has also been questioned.9, 18Most of these studies did not focus on trauma reception and resuscitation. Furthermore, our civilian trauma epidemiology differs from the military experience and most international studies, with a relatively low percentage of patients with penetrating and blast injuries.16

The aims of this study were to retrospectively review the administration of FFP in patients undergoing massive transfusion during trauma resuscitation in a Level 1 civilian trauma centre. Current transfusion practice was examined to study any change in transfusion practice in light of the abovementioned literature. This was performed to add to the evidence base for the development of massive transfusion guidelines and identify areas requiring further research and practice change.

Section snippets

Setting

The state of Victoria, Australia has one paediatric and two adult Major Trauma Services (MTS) located within metropolitan Melbourne. Major trauma triage guidelines are in place and intended to increase the proportion of major trauma patients treated at a MTS. Ambulance services triage adult major trauma patients and suspected adult major trauma patients directly to an adult MTS when the travel time is less than 30 min. There are no current provisions for the administration of blood products

Results

There were 331 patients included in this study from January 2005 to August 2008. The transfusion practice of PRBC and FFP in the first 4 h over this time is presented in Fig. 1. Demographics, ED vital signs, initial investigations and management are presented in Table 1 together with univariate associations with mortality. Head injuries were present in 226 (68.3%) of patients and were significantly associated with mortality (OR 3.9, CI: 2.9–7.3; p < 0.001). There were no other body regions injured

Discussion

Despite published literature recommending a 1:1 transfusion ratio, this study of patients undergoing massive blood transfusion demonstrated little change in the ratio of FFP:PRBC used at our institution over time. A low FFP:PRBC ratio was associated with higher mortality, but not in patients who survived greater than 24 h. This is similar to a previous report, and highlights early death as a confounder in this association.18

Early mortality secondary to the traumatic insult rather than

Conclusions

There has been little change in transfusion practice at our centre, despite worldwide reports of associations with improvement in survival to a 1:1 FFP:PRBC ratio. A higher FFP:PRBC transfusion ratio was associated with significantly improved mortality but the associated mortality benefit did not remain when early deaths were excluded. The optimal ratio of FFP:PRBC during massive transfusion may be different to 1:1 and further prospective research is required.

Conflict of interest

Prof. Peter Cameron is a chief investigator on the Australian Haemostasis Registry, supported by an educational grant from NovoNordisk; rFVIIa has not been discussed in this manuscript.

Acknowledgements

We would like to acknowledge Mr. Steve White for data extraction. Dr. Mitra and Prof. Cameron are supported by grants from the National Health & Medical Research Council, Commonwealth of Australia.

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