- Journal club critique
- Open Access
Black Hawk Down: The evolution of resuscitation strategies in massive traumatic hemorrhage
© BioMed Central Ltd 2008
- Published: 23 July 2008
Borgman MA, Spinella PC, Perkins JG, Grathwohl KW, Repine T, Beekley AC, Sebesta J, Jenkins D, Wade CE, Holcomb JB: The ratio of blood products transfused affects mortality in patients receiving massive transfusions at a combat support hospital. J Trauma 2007, 63: 805–813 .
Patients with severe traumatic injuries often present with coagulopathy and require massive transfusion. The risk of death from hemorrhagic shock increases in this population. To treat the coagulopathy of trauma, some have suggested early, aggressive correction using a 1:1 ratio of plasma to red blood cell (RBC) units.
To determine whether the ratio of plasma to RBCs transfused would affect survival by decreasing death from hemorrhage.
Retrospective chart review.
United States Army combat support hospital in Iraq.
246 patients who received a massive transfusion (≥10 units of RBCs in 24 hours) from November 2003 to September 2005. Three groups of patients were constructed according to the plasma to RBC ratio transfused during massive transfusion.
Hospital mortality rates and the cause of death were compared among groups. Multivariable logistic regression was used to determine the independent association between plasma to RBC ratio and hospital mortality.
For the low ratio group the plasma to RBC median ratio was 1:8 (interquartile range (IQR), 0:12–1:5), for the medium ratio group, 1:2.5 (IQR, 1:3.0–1:2.3), and for the high ratio group, 1:1.4 (IQR, 1:1.7–1:1.2) (p < 0.001). Median Injury Severity Score (ISS) was 18 for all groups (IQR, 14–25). For low, medium, and high plasma to RBC ratios, overall mortality rates were 65%, 34%, and 19%, (p < 0.001); and hemorrhage mortality rates were 92.5%, 78%, and 37%, respectively (p < 0.001). Upon logistic regression, plasma to RBC ratio was independently associated with survival (odds ratio 8.6, 95% confidence interval 2.1–35.2).
In patients with combat-related trauma requiring massive transfusion, a high 1:1.4 plasma to RBC ratio is independently associated with improved survival to hospital discharge, primarily by decreasing death from hemorrhage. For practical purposes, massive transfusion protocols should utilize a 1:1 ratio of plasma to RBCs for all patients who are hypocoagulable with traumatic injuries.
In massively injured patients, the prevention and/or treatment of coagulopathy with plasma administered in a 1:1 ratio with RBCs has a certain degree of face validity and growing support in observational studies. The increased use of plasma, however, is not without risk and may have important implications for blood supply management. Whether similar associations might also be seen in patients bleeding from non-traumatic injuries is unknown, with the exception of those bleeding from ruptured abdominal aortic aneurysms. Prospective trials investigating the optimal plasma to RBC ratio in patients requiring massive transfusion are warranted.
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