Effect of Plasma and Red Blood Cell Transfusions on Survival in Patients With Combat Related Traumatic Injuries

Bleeding management for pediatric craniotomies and craniofacial surgery

Pediatric patients when undergoing craniotomies and craniofacial surgery may potentially have significant blood loss. The amount and extent will be dictated by the nature of the surgical procedure, the proximity to major blood vessels, and the age, and weight of the patient. The goals should be to maintain hemodynamic stability and oxygen carrying capacity and to prevent and treat hyperfibrinolysis and dilutional coagulopathy. Over transfusion and transfusion-related side effects should be minimized. This article will highlight the pertinent considerations for managing massive blood loss in pediatric patients undergoing craniotomies and craniofacial surgery. North American and European guidelines for intraoperative administration of fluid and blood products will be discussed.

Blood component transfusion increases the risk of death in children with traumatic brain injury

BACKGROUND

Blood transfusion has been associated with worse outcomes in adult trauma patients with traumatic brain injury (TBI). However, the effects in injured children have not been evaluated. We hypothesize that blood transfusion is also associated with worse outcomes in children with TBI.

METHODS

A retrospective review of the trauma database at two Level I pediatric trauma centers was performed. We reviewed all patients 18 years and younger with TBI, who survived at least 24 hours, from 2002 to 2011. Exclusion criteria include those who underwent craniotomy, thoracotomy, exploratory laparotomy, and any orthopedic procedure.

RESULTS

A total of 1,607 children with TBI were included in the study population (mean age, 6.4 [5.7] years; 65% male), 178 of whom received a blood transfusion. Mean Injury Severity Score (ISS) was 16.5 (9.1). Patients who received a transfusion had a higher ISS than those who did not (26.7 vs. 15.3). After controlling for age, sex, ISS, Glasgow Coma Scale (GCS) score on presentation, and mechanism of injury, patients who received a blood transfusion were more likely to be admitted to the intensive care unit (p < 0.0001), less likely to survive to hospital discharge (p = 0.02), more likely to be discharged to a rehabilitation facility (p = 0.01) and be dependent on caretakers at follow-up (p < 0.0001), as well as more likely to develop urinary tract infection (p = 0.02) and bacteremia (p = 0.02) during their hospital stay. These differences in outcomes among those who did and did not receive a blood transfusion began to disappear in patients with a nadir hemoglobin of less than 8.0 g/dL.

CONCLUSION

Pediatric patients sustaining TBI who receive blood transfusion and do not require operative intervention have worse outcomes compared with patients who do not receive transfusion. This includes an increased risk of death. These data suggest that a transfusion trigger of hemoglobin level at 8.0 g/dL in injured children with TBI may be beneficial.

LEVEL OF EVIDENCE

Epidemiologic study, level III. Therapeutic study, level IV.

Trauma-induced coagulopathy: from biology to therapy

Trauma is a leading cause of death and disability. Hemorrhage is the major mechanism responsible for death during the first 24 hours following trauma. One quarter of severely injured patients present in the emergency room with acute coagulopathy of trauma and shock (ACOT). The drivers of ACOT are tissue hypoperfusion, inflammation, and activation of the neurohumoral system. ACOT is a result of protein C activation with cleavage of activated factor VIII and V and inhibition of plasminogen activator inhibitor-1 (PAI-1). The resuscitation-associated coagulopathy (RAC) is secondary to a combination of acidosis, hypothermia and dilution from intravenous blood and fluid therapy. RAC may further aggravate acidosis and hypoxia resulting in a vicious cycle. This review focuses on the biology of the trauma-associated coagulopathy, and reviews current therapeutic strategies.

Hyperosmolar reconstituted lyophilized plasma is an effective low-volume hemostatic resuscitation fluid for trauma

BACKGROUND

We performed this study to optimize reconstituted lyophilized plasma (LP) into a minimal volume fluid that provides effective hemostatic resuscitation for trauma while minimizing logistical limitations.

METHODS

We performed a prospective, blinded animal study. Plasma was lyophilized following whole blood collection from anesthetized swine. The minimal volume needed for reconstitution was determined, and this solution was evaluated for safe infusion into the swine. Reconstituted LP was analyzed for electrolyte content, osmolarity, and coagulation factor activity. Twenty swine were anesthetized and subjected to a validated model of polytrauma and hemorrhagic shock (including a Grade V liver injury), then randomized to resuscitation with LP reconstituted to either 100% of the original plasma volume (100%LP) or the minimal volume LP fluid. Physiologic data were monitored, and blood loss and hematocrit were measured. Coagulation status was evaluated using thrombelastography.

RESULTS

The minimal volume of reconstituted LP safe for infusion in swine was 50% of the original plasma volume (50%LP). The 50%LP had higher electrolyte concentrations, osmolarity, and increased coagulation factor activity levels by volume compared with 100%LP (p < 0.05). Blood loss, hematocrit, mean arterial pressure, and heart rate did not differ between animals receiving 100%LP (n = 10) or 50%LP (n = 10) at any time point (p > 0.05). International normalized ratio and thrombelastography parameters were not different between groups (R time, α angle, or maximal amplitude, p > 0.05).

CONCLUSION

Resuscitation with 50%LP fluid was well tolerated and equally effective compared with 100%LP, with respect to physiologic and hemostatic properties. The smaller volume of fluid necessary to reconstitute hypertonic LP makes it logistically superior to 100%LP for first responders and may reduce adverse effects of large-volume resuscitation.

The impact of a massive transfusion protocol (1:1:1) on major hepatic injuries: does it increase abdominal wall closure rates?

BACKGROUND

Massive transfusion protocols (MTPs) using high plasma and platelet ratios for exsanguinating trauma patients are increasingly popular. Major liver injuries often require massive resuscitations and immediate hemorrhage control. Current published literature describes outcomes among patients with mixed patterns of injury. We sought to identify the effects of an MTP on patients with major liver trauma.

METHODS

Patients with grade 3, 4 or 5 liver injuries who required a massive blood component transfusion were analyzed. We compared patients with high plasma:red blood cell:platelet ratio (1:1:1) transfusions (2007-2009) with patients injured before the creation of an institutional MTP (2005-2007).

RESULTS

Among 60 patients with major hepatic injuries, 35 (58%) underwent resuscitation after the implementation of an MTP. Patient and injury characteristics were similar between cohorts. Implementation of the MTP significantly improved plasma: red blood cell:platelet ratios and decreased crystalloid fluid resuscitation (p = 0.026). Rapid improvement in early acidosis and coagulopathy was superior with an MTP (p = 0.009). More patients in the MTP group also underwent primary abdominal fascial closure during their hospital stay (p = 0.021). This was most evident with grade 4 injuries (89% vs. 14%). The mean time to fascial closure was 4.2 days. The overall survival rate for all major liver injuries was not affected by an MTP (p = 0.61).

CONCLUSION

The implementation of a formal MTP using high plasma and platelet ratios resulted in a substantial increase in abdominal wall approximation. This occurred concurrently to a decrease in the delivered volume of crystalloid fluid.

How we manage the haematological aspects of major obstetric haemorrhage

Major obstetric haemorrhage (MOH) remains an important medical challenge worldwide, contributing to significant maternal morbidity and mortality. Prompt and appropriate management is essential if we are to improve outcomes and reduce substandard care that may result in adverse consequences. This review describes the current understanding of the pathophysiological aspects of MOH together with the principles of transfusion and haemostatic therapy, with emphasis on a coordinated multidisciplinary approach. We also highlight the current lack of evidence available from randomized controlled trials to inform best practice and the need to prioritize research in this key clinical area.

Cause and timing of death in massively transfused trauma patients

BACKGROUND

The purpose of this study was to characterize the cause of death in severely injured trauma patients to define potential responses to resuscitation.

METHODS

Prospective analysis of 190 critically injured patients who underwent massive transfusion protocol (MTP) activation or received massive transfusion (>10 U of packed red blood cells [RBC] per 24 hours). Cause of death was adjudicated into one of four categories as follows: (1) exsanguination, (2) early physiologic collapse, (3) late physiologic collapse, and (4) nonsurvivable injury.

RESULTS

A total 190 patients underwent massive transfusion or MTP with 76 deaths (40% mortality), of whom 72 deaths were adjudicated to one of four categories: 33.3% died of exsanguination, 16.6% died of early physiologic collapse, 11.1% died of late physiologic collapse, while 38.8% died of nonsurvivable injuries. Patients who died of exsanguination were younger and had the highest RBC/fresh frozen plasma ratio (2.97 [2.24]), although the early physiologic collapse group survived long enough to use the most blood products (p < 0.001). The late physiologic collapse group had significantly fewer penetrating injuries, was older, and had significantly more crystalloid use but received a lower RBC/fresh frozen plasma ratio (1.50 [0.42]). Those who were determined to have a nonsurvivable injury had a lower presenting Glasgow Coma Scale (GCS) score, fewer penetrating injuries, and higher initial blood pressure reflecting a preponderance of nonsurvivable traumatic brain injury. The average survival time for patients with potentially survivable injuries was 2.4 hours versus 18.4 hours for nonsurvivable injuries (p < 0.001).

CONCLUSION

Severely injured patients requiring MTP have a high mortality rate. However, no studies to date have addressed the cause of death after MTP. Characterization of cause of death will allow targeting of surgical and resuscitative conduct to allow extension of the physiologic reserve time, therefore rendering previously nonsurvivable injury potentially survivable.

Fresh frozen plasma lessens pulmonary endothelial inflammation and hyperpermeability after hemorrhagic shock and is associated with loss of syndecan 1

We have recently demonstrated that injured patients in hemorrhagic shock shed syndecan 1 and that the early use of fresh frozen plasma (FFP) in these patients is correlated with improved clinical outcomes. As the lungs are frequently injured after trauma, we hypothesized that hemorrhagic shock-induced shedding of syndecan 1 exposes the underlying pulmonary vascular endothelium to injury resulting in inflammation and hyperpermeability and that these effects would be mitigated by FFP. In vitro, pulmonary endothelial permeability, endothelial monolayer flux, transendothelial electrical resistance, and leukocyte-endothelial binding were measured in pulmonary endothelial cells after incubation with equal volumes of FFP or lactated Ringer's (LR). In vivo, using a coagulopathic mouse model of trauma and hemorrhagic shock, pulmonary hyperpermeability, neutrophil infiltration, and syndecan 1 expression and systemic shedding were assessed after 3 h of resuscitation with either 1× FFP or 3× LR and compared with shock alone and shams. In vitro, endothelial permeability and flux were decreased, transendothelial electrical resistance was increased, and leukocyte-endothelial binding was inhibited by FFP compared with LR-treated endothelial cells. In vivo, hemorrhagic shock was associated with systemic shedding of syndecan 1, which correlated with decreased pulmonary syndecan 1 and increased pulmonary vascular hyperpermeability and inflammation. Fresh frozen plasma resuscitation, compared with LR resuscitation, abrogated these injurious effects. After hemorrhagic shock, FFP resuscitation inhibits endothelial cell hyperpermeability and inflammation and restores pulmonary syndecan 1 expression. Modulation of pulmonary syndecan 1 expression may mechanistically contribute to the beneficial effects FFP.

A brief review of 50 years of perioperative thrombosis and hemostasis management

Perioperative thrombosis and hemostasis management has changed dramatically over the past 50 years. From two anticoagulants and one anti-aggregant, the number of currently available drugs has recently increased several-fold, leaving clinicians with the problem of choosing the optimal agent. Individualized preoperative assessment of bleeding risk based on bleeding history and testing limited to high-risk patients is an emerging concept. Based on the identification of risk factors for venous thromboembolism (VTE), pharmacologic and non-pharmacologic strategies for perioperative VTE prophylaxis have had a major impact on patient outcome. For patients undergoing surgery who are treated with anticoagulants and anti-aggregants, "bridging" strategies have been proposed. Bleeding management strategies have shifted focus from replacing lost blood volume to new approaches aimed at preventing blood loss, reducing the potential complications of blood loss, and preventing the transfusion of blood products. For some areas of perioperative thrombosis and hemostasis management, randomized controlled trial (RCT) data are emerging, but the database remains insufficient to date. Clearly, more RCTs need to be published for perioperative thrombosis and hemostasis management to become an evidence-based approach.

The use of lyophilized plasma in a severe multi-injury pig model

BACKGROUND

Shock and severe tissue injury lead to an endogenous coagulopathy mediated by activation of Protein C and hyperfibrinolysis known as acute traumatic coagulopathy. Together, hemodilution, acidosis, inflammation, and hypothermia result in a global trauma-induced coagulopathy. Coagulopathy in trauma is associated with mortality. Early and effective hemostatic resuscitation is critical in restoring perfusion, correcting coagulopathy, and saving lives in exsanguinating trauma. Lyophilized plasma (LP) provides a logistically superior alternative to fresh frozen plasma (FFP).

STUDY DESIGN AND METHODS

Plasma was lyophilized following whole blood collection from anesthetized swine. A series of studies were performed using anesthetized swine subjected to a validated model of polytrauma and hemorrhagic shock including a Grade V liver injury. Animals were randomized to resuscitation using reconstituted LP fluids. Physiologic data and blood loss were measured. Coagulation status and inflammatory mediators were evaluated.

RESULTS

Full volume reconstituted LP (100%LP) retains on average 86% coagulation factor activity compared to fresh plasma and when used in 1:1 ratios with red blood cells demonstrated superior hemostatic efficacy compared to FFP. Hypertonic LP reconstituted using 50% of the original plasma volume (50%LP) had higher coagulation factor concentrations, was well tolerated in swine, and equally effective compared to 100%LP with respect to physiologic and hemostatic properties. Buffering with ascorbic acid resulted in significant reductions in serum levels of tumor necrosis factor alpha and interleukin-6.

CONCLUSION

By minimizing the volume of reconstituted LP and optimizing its anti-inflammatory properties, an LP resuscitation fluid may be created to provide effective hemostatic resuscitation with superior logistical properties.

Efficacy of a high FFP:PRBC transfusion ratio on the survival of severely injured patients: a retrospective study in a single tertiary emergency center in Japan

PURPOSE

Recent studies have shown increased survival benefits when a high fresh frozen plasma (FFP) to packed red blood cell (PRBC) ratio is used during trauma resuscitation. However, some reports have raised questions about the effect of higher FFP:PRBC transfusion ratios. The aim of this study was to examine the efficacy of high FFP:PRBC ratios in injured patients with regard to survival and morbidity in a single tertiary emergency center in Japan.

METHODS

This study examined severe trauma patients who received 10 or more PRBC units during the first 24 h of admission. We examined the relationship between the FFP:PRBC ratios during the first 6 h and the patient outcome.

RESULTS

The severity was similar among all groups. The mortality rate was 44.4% in the high (>1:1.5), 16.7% in the middle (1:1.5-1:2) and 33.3% in the low (<1:2) F:P ratio groups. Only one patient in the high group developed sepsis, and none of the patients developed ARDS.

CONCLUSIONS

The current results indicate that the FFP:PRBC ratios during the first 6 h after admission might not affect the mortality or morbidity. However, differences between trauma care systems in Japan and other countries, along with other study limitations, necessitate that a subsequent prospective multicenter study be undertaken before any definitive conclusions can be made.

Assessment and management of massive bleeding: coagulation assessment, pharmacologic strategies, and transfusion management

This review details the current knowledge in massive hemorrhage with regard to the pathophysiology and laboratory assessment of the coagulation disturbance, the role of plasma and platelet transfusion, the role of pharmaceutical strategies, and the clinical value of having a massive transfusion protocol. The bulk of the recent medical literature on this topic stems from the study of military and civilian trauma; however, where applicable, reference to postcardiac and post-noncardiac surgery and postpartum hemorrhage will also be discussed.

Criteria for empiric treatment of hyperfibrinolysis after trauma

BACKGROUND

Recent studies identify a survival benefit from the administration of antifibrinolytic agents in patients with severe injury and trauma. However, identification of hyperfibrinolysis requires thromboelastography, which is not widely available. We hypothesized that analysis of patients with thromboelastography-diagnosed hyperfibrinolysis would identify clinical criteria for empiric antifibrinolytic treatment in the absence of thromboelastography.

METHODS

From November 2010 to March 2012, serial blood samples were collected from 115 patients with critical injury on arrival to the emergency department of an urban Level I trauma center. Rotational thromboelastography was performed to assess viscoelastic properties of clot formation in the presence and absence of aprotinin to identify treatable hyperfibrinolysis. For 20 patients identified with treatable hyperfibrinolysis, clinical predictors were investigated using receiver operating characteristic analysis.

RESULTS

Of the 115 patients evaluated, 20% had hyperfibrinolysis, defined as an admission maximal clot lysis of 10% or higher, reversible by aprotinin treatment. Patients with hyperfibrinolysis had significantly lower temperature, pH, and platelet counts and higher international normalized ratio, activated partial thromboplastin time, and D-dimer. Hyperfibrinolysis was associated with multiorgan failure (63.2% vs. 24.6%, p = 0.004) and mortality (52.2% vs. 12.9%, p < 0.001). We then evaluated all non-rotational thromboelastography clinical and laboratory parameters predictive of hyperfibrinolysis using receiver operating characteristic analysis to evaluate potential empiric treatment guidelines. The presence of hypothermia (temperature ≤36.0°C), acidosis (pH ≤7.2), relative coagulopathy (international normalized ratio ≥1.3 or activated partial thromboplastin time ≥30), or relative thrombocytopenia (platelet count ≤200) identified hyperfibrinolysis with 100% sensitivity and 55.4% specificity (area under the curve, 0.777).

CONCLUSION

Consideration of empiric antifibrinolytic therapy is warranted for patients with critical injury and trauma who present with acidosis, hypothermia, coagulopathy, or relative thrombocytopenia. These clinical predictors identified hyperfibrinolysis with 100% sensitivity while simultaneously eliminating 46.6% of inappropriate therapy compared with the empiric treatment of all injured patients. These criteria will facilitate empiric treatment of hyperfibrinolysis for clinicians without access to thromboelastography.

LEVEL OF EVIDENCE

Prognostic study, level III.

The US military experience with fresh whole blood during the conflicts in Iraq and Afghanistan

Since its introduction in the early part of the last century, fresh whole blood (FWB) has been used by the US military as a battlefield expedient resuscitation method, even after the development of component therapy in the 1960s. In the recent conflicts in Iraq and Afghanistan, FWB was used once more, often collected in the setting of a walking blood bank (WBB). Considerable research and opinion from military circles has cited these experiences and sparked renewed interest in FWB as an effective resuscitation tool in the setting of trauma. Despite efforts by the US military to improve the effectiveness and safety of FWB through a series of widely published guidelines, transfusion transmitted infections (TTI) remain a vexing challenge. These experiences in Iraq and Afghanistan will help inform a larger discussion regarding the reintroduction of FWB in civilian trauma resuscitation.

Adverse effects of plasma transfusion

Plasma utilization has increased over the past two decades, and there is a growing concern that many plasma transfusions are inappropriate. Plasma transfusion is not without risk, and certain complications are more likely with plasma than other blood components. Clinical and laboratory investigations of the patients suffering reactions after infusion of fresh-frozen plasma (FFP) define the etiology and pathogenesis of the panoply of adverse effects. We review here the pathogenesis, diagnosis, and management of the risks associated with plasma transfusion. Risks commonly associated with FFP include: 1) transfusion-related acute lung injury, 2) transfusion-associated circulatory overload, and 3) allergic and/or anaphylactic reactions. Other less common risks include 1) transmission of infections, 2) febrile nonhemolytic transfusion reactions, 3) red blood cell alloimmunization, and 4) hemolytic transfusion reactions. The effects of pathogen inactivation or reduction methods on these risks are also discussed. Fortunately, a majority of the adverse effects are not lethal and are adequately treated in clinical practice.

Plasma transfusion for patients with severe hemorrhage: what is the evidence?

The following review will detail the current knowledge in massive hemorrhage with regard to the pathophysiology of the coagulation disturbance, the role of plasma, the role of alternatives to plasma, and the clinical value of having a massive transfusion protocol. The coagulation disturbance in trauma patients is more than just the result of consumption of clotting factors at sites of injury and dilution from the infusion of intravenous fluids and red blood cells (RBCs). Even before substantial amounts of fluid resuscitation and RBC transfusion, one-quarter of trauma patients already have abnormal coagulation variables. There is an apparent role for the activation of protein C, hypofibrinogenemia, and fibrin(gen)olysis in the coagulation disturbance after trauma and massive hemorrhage. None of these three disturbances would be completely mitigated by the use of plasma alone, suggesting that there may be an opportunity to improve care of these patients with alternative strategies, such as fibrinogen concentrates and antifibrinolytics. Despite numerous retrospective cohort studies evaluating 1:1 plasma to RBC formula-driven resuscitation, the overall clinical value of this approach is unclear. Studies have even raised concerns regarding a potential increase in morbidity associated with this approach, particularly for patients overtriaged to 1:1 where a massive transfusion is unlikely. We also do not have sufficient evidence to recommend either goal-directed therapy with thromboelastography or early use of fibrinogen replacement, with either cryoprecipitate or fibrinogen concentrates. We have high-quality data that argue against the role for recombinant Factor VIIa that should prompt removal of this strategy from existing protocols. In contrast, we have high-level evidence that all bleeding trauma patients should receive tranexamic acid as soon as possible after injury. This therapy must be included in hemorrhage protocols. If we are to improve the care of massively bleeding patients on a firm scientific ground, we will need large-scale randomized trials to delineate the role of coagulation replacement and the utility of laboratory monitoring. But even until these trials are completed, it is clear that a massive transfusion protocol is needed in all hospitals that manage bleeding patients, to ensure a prompt and coordinated response to hemorrhage.

Predictors of postoperative mortality of ruptured abdominal aortic aneurysm: a retrospective clinical study

PURPOSE

Despite significant improvements in surgery, anesthesia, and postoperative critical care, the postoperative mortality rate of ruptured abdominal aortic aneurysm (RAAA) has remained at 40% to 50% for several decades. Therefore, we evaluated factors associated with the postoperative mortality of RAAA.

MATERIALS AND METHODS

From January 1999 to December 2008, a retrospective study was performed with 34 patients who underwent open repair of RAAA. The preoperative factors included age, sex, smoking, comorbidities, serum creatinine, hemoglobin, shock, pulse rate, and time from emergency room to operation room. The intraoperative factors included blood loss, transfusion, aortic clamping site and time, aneurysmal characteristics, rupture type, graft type, hourly urine output (HUO), and operative time. The postoperative factors included inotropic support, renal replacement therapy (RRT), reoperation, bowel ischemia, multiple organ failure (MOF), and intensive care unit stay. The 2-day and the 30-day mortality rates were analyzed separately.

RESULTS

The 2-day and the 30-day mortality rates were 14.7% and 41.2%, respectively. On univariate analysis, shock, transfusion, HUO, inotropic support and MOF for the 2-day mortality and serum creatinine, transfusion, aortic clamping site, HUO, inotropic support, RRT and MOF for the 30-day mortality were statistically significant. On multivariate analysis, shock, inotropic support and MOF for the 2-day mortality and aortic clamping site, RRT and MOF for the 30-day mortality were statistically significant.

CONCLUSION

To decrease the postoperative mortality rate of RAAA, prevention of massive hemorrhage and acute renal failure with infrarenal aortic clamping, as well as prompt operative control of bleeding and maintenance of systemic perfusion are important.

Temporal trends in the treatment of severe traumatic hemorrhage

BACKGROUND

This study examined the evolution of damage control resuscitation (DCR) and outcomes in severe traumatic hemorrhage (STH) at a large Canadian trauma center.

METHODS

This was a retrospective cohort study of trauma patients admitted to a level 1 trauma center between 2005 and 2010, who received 10 or more units of packed red blood cells within 24 hours of admission. Demographic and clinical findings were compared between survivors and nonsurvivors.

RESULTS

Forty-five patients were included. Twenty-five percent of patients were coagulopathic at admission. Early crystalloid use declined over the study period. The mean 24-hour fresh-frozen plasma:platelets:packed red blood cells ratio was 1:1:2. Hemorrhage-related mortality was 69%. No pedestrians survived STH. A total of 1,032 blood product units were used in the first day for nonsurvivors.

CONCLUSIONS

Principles of DCR crept into clinical practice even before the implementation of a formal STH protocol. DCR appeared to reduce the intensive care unit length of stay but not mortality. STH is associated with heavy use of blood bank resources and high mortality rates. Futility of resuscitative efforts may be predictable by mechanism and early physiological markers.

[Treatment of massive bleeding: summary of the updated European guidelines]

Despite improved strategies in the treatment of polytraumatized patients the mortality rate of severely injured patients remains high. Thus, worldwide 5 million patients die due to trauma or trauma-related complications each year. As the majority of early trauma-related deaths are attributed to or caused by exsanguination the prevention and treatment of coagulopathy is of paramount significance. With the aim of developing guidelines and improve strategies to treat polytraumatized patients the multidisciplinary Task Force for Advanced Bleeding Care in Trauma was founded in 2005. Under consideration of new clinical studies, an updated version of the original publication from 2007 has recently been published. Based on a systematic review of published literature the recommendations were formed according to "Grading of Recommendations Assessment, Development and Evaluation" (GRADE). This publication summarizes the main recommendations with a special emphasis on revisions and new aspects.

Clinical effectiveness of fresh frozen plasma compared with fibrinogen concentrate: a systematic review

Introduction

Haemostatic therapy in surgical and/or massive trauma patients typically involves transfusion of fresh frozen plasma (FFP). Purified human fibrinogen concentrate may offer an alternative to FFP in some instances. In this systematic review, we investigated the current evidence for the use of FFP and fibrinogen concentrate in the perioperative or massive trauma setting.

Methods

Studies reporting the outcome (blood loss, transfusion requirement, length of stay, survival and plasma fibrinogen level) of FFP or fibrinogen concentrate administration to patients in a perioperative or massive trauma setting were identified in electronic databases (1995 to 2010). Studies were included regardless of type, patient age, sample size or duration of patient follow-up. Studies of patients with congenital clotting factor deficiencies or other haematological disorders were excluded. Studies were assessed for eligibility, and data were extracted and tabulated.

Results

Ninety-one eligible studies (70 FFP and 21 fibrinogen concentrate) reported outcomes of interest. Few were high-quality prospective studies. Evidence for the efficacy of FFP was inconsistent across all assessed outcomes. Overall, FFP showed a positive effect for 28% of outcomes and a negative effect for 22% of outcomes. There was limited evidence that FFP reduced mortality: 50% of outcomes associated FFP with reduced mortality (typically trauma and/or massive bleeding), and 20% were associated with increased mortality (typically surgical and/or nonmassive bleeding). Five studies reported the outcome of fibrinogen concentrate versus a comparator. The evidence was consistently positive (70% of all outcomes), with no negative effects reported (0% of all outcomes). Fibrinogen concentrate was compared directly with FFP in three high-quality studies and was found to be superior for > 50% of outcomes in terms of reducing blood loss, allogeneic transfusion requirements, length of intensive care unit and hospital stay and increasing plasma fibrinogen levels. We found no fibrinogen concentrate comparator studies in patients with haemorrhage due to massive trauma, although efficacy across all assessed outcomes was reported in a number of noncomparator trauma studies.

Conclusions

The weight of evidence does not appear to support the clinical effectiveness of FFP for surgical and/or massive trauma patients and suggests it can be detrimental. Perioperatively, fibrinogen concentrate was generally associated with improved outcome measures, although more high-quality, prospective studies are required before any definitive conclusions can be drawn.

Early blood product and crystalloid volume resuscitation: risk association with multiple organ dysfunction after severe blunt traumatic injury

BACKGROUND

Elements of volume resuscitation from hemorrhagic shock, such as amount of blood product and crystalloid administration, have been shown to be associated with multiple organ dysfunction (MOD). However, it is unknown whether these are causative factors or merely markers of an underlying requirement for large-volume resuscitation. We sought to further delineate the relevance of the major individual components of early volume resuscitation to onset of MOD after severe blunt traumatic injury.

METHODS

We performed a secondary analysis of a large, multicenter prospective observational cohort of severely injured blunt trauma patients, the NIGMS Trauma Glue Grant, to assess the relevance of individual components of resuscitation administered in the first 12 hours of resuscitation including packed red blood cells (PRBC), fresh frozen plasma (FFP), and isotonic crystalloid, to the onset of MOD within the first 28 days after injury. Deaths within 48 hours of injury were excluded. We used a two tiered, exhaustive logistic regression model search technique to adjust for potential confounders from clinically relevant MOD covariates, including indicators of shock severity, injury severity, comorbidities, age, and gender.

RESULTS

The study cohort consisted of 1,366 severely injured blunt trauma patients (median new Injury Severity Score = 34). Incidence of 28-day Marshall MOD was 19.6%. Transfusion of ≥10 Units of PRBC in the first 12 hours (odds ratio, 2.06; 95% confidence interval 1.44-2.94), but not FFP (≥8 U) or large volume crystalloid administration (≥12 L), was independently associated with onset of 28-day Marshall MOD. PRBC:FFP ratio in the first 12 hours was not significantly associated with MOD.

CONCLUSIONS

When controlling for all major components of acute volume resuscitation, massive-transfusion volumes of PRBC's within the first 12 hours of resuscitation are modestly associated with MOD, whereas FFP and large volume crystalloid administration are not independently associated with MOD. Previous reported associations of blood products and large-volume crystalloid with MOD may be reflecting overall resuscitation requirements and burden of injury rather than independent causation.

Modulation of syndecan-1 shedding after hemorrhagic shock and resuscitation

The early use of fresh frozen plasma as a resuscitative agent after hemorrhagic shock has been associated with improved survival, but the mechanism of protection is unknown. Hemorrhagic shock causes endothelial cell dysfunction and we hypothesized that fresh frozen plasma would restore endothelial integrity and reduce syndecan-1 shedding after hemorrhagic shock. A prospective, observational study in severely injured patients in hemorrhagic shock demonstrated significantly elevated levels of syndecan-1 (554±93 ng/ml) after injury, which decreased with resuscitation (187±36 ng/ml) but was elevated compared to normal donors (27±1 ng/ml). Three pro-inflammatory cytokines, interferon-γ, fractalkine, and interleukin-1β, negatively correlated while one anti-inflammatory cytokine, IL-10, positively correlated with shed syndecan-1. These cytokines all play an important role in maintaining endothelial integrity. An in vitro model of endothelial injury then specifically examined endothelial permeability after treatment with fresh frozen plasma orlactated Ringers. Shock or endothelial injury disrupted junctional integrity and increased permeability, which was improved with fresh frozen plasma, but not lactated Ringers. Changes in endothelial cell permeability correlated with syndecan-1 shedding. These data suggest that plasma based resuscitation preserved endothelial syndecan-1 and maintained endothelial integrity, and may help to explain the protective effects of fresh frozen plasma after hemorrhagic shock.

Increased transforming growth factor β contributes to deterioration of refrigerated fresh frozen plasma's effects in vitro on endothelial cells

Resuscitation with fresh frozen plasma (FFP) is associated with improved outcomes after hemorrhagic shock. Many trauma centers are using thawed plasma that has been stored for up to 5 days at 4°C (refrigeration), yet the effect of refrigeration on FFP is relatively unknown. Previously, our group showed that refrigeration of FFP changed its coagulation factors and diminished its beneficial effects on endothelial cell (EC) function and resuscitation in an animal model of hemorrhagic shock. We hypothesize that growth factor composition of FFP is altered during refrigeration, leading to a diminished beneficial effect on EC. Transforming growth factor (TGF-β) is a potent inhibitor of EC migration and is released during refrigeration of platelets. We found increased TGF-β1 protein levels and greater activation of downstream mediators Smad2/3 during refrigeration of FFP. Both day 0 FFP (used on the same day after being thawed) and day 5 FFP (used after being thawed and refrigerated for 5 days) stimulated EC migration in vitro; however, the EC migration in day 5 FFP was significantly reduced. Inhibition of TGF-β type I receptor blocked FFP-induced Smad3 signaling in EC cells and restored the effectiveness of day 5 FFP on EC migration to a comparable level seen in day 0 FFP. These data suggest that the increased TGF-β levels during FFP refrigeration contribute to the deterioration of refrigerated FFP's effects on EC migration. This study identifies a novel molecular mechanism contributing to the reduced efficacy of refrigerated FFP.

Early risk stratification of patients with major trauma requiring massive blood transfusion

BACKGROUND

There is limited evidence to guide the recognition of patients with massive, uncontrolled hemorrhage who require initiation of a massive transfusion (MT) protocol.

OBJECTIVE

To risk stratify patients with major trauma and to predict need for MT.

DESIGNS

Retrospective analysis of an administrative trauma database of major trauma patients. A REGIONAL TRAUMA CENTRE: A regional trauma centres in Hong Kong.

PATIENTS

Patients with Injury Severity Score ≥ 9 and age ≥ 12 years were included. Burn patients, patients with known severe anemia and renal failure, or died within 24h were excluded.

MAIN OUTCOME MEASURES

Delivery of ≥ 10 units of packed red blood cells (RBC) within 24h.

RESULTS

Between 01/01/2001 and 30/06/2009, 1891 patients met the inclusion criteria. 92 patients required ≥ 10 units RBC within 24h. Seven variables which were easy to be measured in the ED and significantly predicted the need for MT are heart rate ≥ 120/min; systolic blood pressure ≤ 90 mm Hg; Glasgow coma scale ≤ 8; displaced pelvic fracture; CT scan or FAST positive for fluid; base deficit >5 mmol/L; hemoglobin ≤ 7 g/dL; and hemoglobin 7.1-10 g/dL. At a cut off of ≥ 6, the overall correct classification for predicting need for MT was 96.9%, with a sensitivity of 31.5% and specificity of 99.7%, and an incidence of MT of 82.9%. The area under the curve was 0.889.

CONCLUSION

A prediction rule for determining an increased likelihood for the need for massive transfusion has been derived. This needs validation in an independent data set.

Resuscitation and coagulation in the severely injured trauma patient

Developments in the resuscitation of the severely injured trauma patient in the last decade have been through the increased understanding of the early pathophysiological consequences of injury together with some observations and experiences of recent casualties of conflict. In particular, the recognition of early derangements of haemostasis with hypocoagulopathy being associated with increased mortality and morbidity and the prime importance of tissue hypoperfusion as a central driver to this process in this population of patients has led to new resuscitation strategies. These strategies have focused on haemostatic resuscitation and the development of the ideas of damage control resuscitation and damage control surgery continuum. This in turn has led to a requirement to be able to more closely monitor the physiological status, of major trauma patients, including their coagulation status, and react in an anticipatory fashion.

Plasma restoration of endothelial glycocalyx in a rodent model of hemorrhagic shock

BACKGROUND

The use of plasma-based resuscitation for trauma patients in hemorrhagic shock has been associated with a decrease in mortality. Although some have proposed a beneficial effect through replacement of coagulation proteins, the putative mechanisms of protection afforded by plasma are unknown. We have previously shown in a cell culture model that plasma decreases endothelial cell permeability in comparison with crystalloid. The endothelial glycocalyx consists of proteoglycans and glycoproteins attached to a syndecan backbone, which together protect the underlying endothelium. We hypothesize that endothelial cell protection by plasma is due, in part, to its restoration of the endothelial glycocalyx and preservation of syndecan-1 after hemorrhagic shock.

METHODS

Rats were subjected to hemorrhagic shock to a mean arterial blood pressure of 30 mm Hg for 90 minutes followed by resuscitation with either lactated Ringer's (LR) solution or fresh plasma to a mean arterial blood pressure of 80 mm Hg and compared with shams or shock alone. After 2 hours, lungs were harvested for syndecan mRNA, immunostained with antisyndecan-1, or stained with hematoxylin and eosin. To specifically examine the effect of plasma on the endothelium, we infused small bowel mesentery with a lanthanum-based solution, identified venules, and visualized the glycocalyx by electron microscopy. All data are presented as mean ± SEM. Results were analyzed by 1-way analysis of variance with Tukey post hoc tests.

RESULTS

Electron microscopy revealed degradation of the glycocalyx after hemorrhagic shock, which was partially restored by plasma but not LR. Pulmonary syndecan-1 mRNA expression was higher in animals resuscitated with plasma (2.76 ± 0.03) in comparison with shock alone (1.39 ± 0.22) or LR (0.82 ± 0.03) and correlated with cell surface syndecan-1 immunostaining. Shock also resulted in significant lung injury by histopathology scoring (1.63 ± 0.26), which was mitigated by resuscitation with plasma (0.67 ± 0.17) but not LR (2.0 ± 0.25).

CONCLUSION

The protective effects of plasma may be due in part to its ability to restore the endothelial glycocalyx and preserve syndecan-1 after hemorrhagic shock.

Goal-directed Coagulation Management in Major Trauma

Severe tissue trauma is frequently associated with hemorrhagic shock and subsequent pronounced coagulopathy [1]. Uncontrolled bleeding is the second most common cause of death, and hemorrhage is directly responsible for 40 % of all trauma-related deaths [2]. Coagulopathy can be detected with standard coagulation tests immediately after arrival in the emergency room (ER) in approximately 25–35 % of all trauma patients [1], [2]. Moreover, early trauma-induced coagulopathy is associated with a 4-fold increase in mortality [1]. Blood coagulation monitoring is essential in order to assess the underlying coagulation disorder and to tailor hemostatic treatment. Thromboelastometry (TEM) and thrombelastography (TEG) are promising point-of-care technologies providing rapid information on the initiation process of clot formation, clot quality, and stability of the clot [3].

Emergency department blood transfusion predicts early massive transfusion and early blood component requirement

BACKGROUND

The purpose of this study was to evaluate the ability of uncrossmatched transfusions in the emergency department (ED) to predict early (< 6 hr) massive transfusion (MT) of red blood cells (RBCs) and blood components.

STUDY DESIGN AND METHODS

All patients admitted to a Level 1 trauma center between July 2005 and June 2007 who received any transfusions and were transported directly from the scene of injury were included. Early MT was defined as the need for 10 U or more or RBCs in the first 6 hours. Early MT plasma was defined as 6 U or more of plasma in the first 6 hours. Early MT platelets (PLTs) were defined as two or more apheresis transfusions in the first 6 hours. Univariate and multivariate analyses were performed.

RESULTS

A total of 485 patients (34%) received ED transfusions (ED RBC+) and 956 (66%) did not receive ED transfusions (ED RBC-). ED RBC+ patients were younger, were more likely to be male, and arrived with more severe injuries. Multivariate regression identified ED transfusion of uncrossmatched RBC as an independent predictor of requiring early MT of RBCs (odds ratio [OR], 3.5; 95% confidence interval [CI], 1.36-7.59; p = 0.001), plasma (OR, 2.7; 95% CI, 1.66-4.39; p < 0.001), and PLTs (OR, 1.9; 95% CI, 1.08-3.41; p = 0.025).

CONCLUSION

Patients receiving uncrossmatched RBCs in the ED are more than three times more likely to receive early MT of RBCs. Additionally, patients transfused with ED RBCs are more likely to receive 6 units or more of plasma and two or more apheresis PLT transfusions. Given these findings, ED transfusion of uncrossmatched RBCs should be considered a potential trigger for activation of an institution's MT protocol.

Evaluation and management of shock States: hypovolemic, distributive, and cardiogenic shock

Shock states have multiple etiologies, but all result in hypoperfusion to vital organs, which can lead to organ failure and death if not quickly and appropriately managed. Pharmacists should be familiar with cardiogenic, distributive, and hypovolemic shock and should be involved in providing safe and effective medical therapies. An accurate diagnosis is necessary to initiate appropriate lifesaving interventions and target therapeutic goals specific to the type of shock. Clinical signs and symptoms, as well as hemodynamic data, help with initial assessment and continued monitoring to provide adequate support for the patient. It is necessary to understand these hemodynamic parameters, medication mechanisms of action, and available mechanical support when developing a patient-specific treatment plan. Rapid therapeutic intervention has been proven to decrease morbidity and mortality and is crucial to providing the best patient outcomes. Pharmacists can provide their expertise in medication selection, titration, monitoring, and dose adjustment in these critically ill patients. This review will focus on parameters used to assess hemodynamic status, the major causes of shock, pathophysiologic factors that cause shock, and therapeutic interventions that should be employed to improve patient outcomes.

Initial resuscitation with plasma and other blood components reduced bleeding compared to hetastarch in anesthetized swine with uncontrolled splenic hemorrhage

BACKGROUND

Damage control resuscitation recommends use of more plasma and less crystalloid as initial resuscitation in treating hemorrhage. The purpose of this study was to evaluate resuscitation with either blood components or conventional fluids on coagulation and blood loss.

STUDY DESIGN AND METHODS

Isofluorane-anesthetized, instrumented pigs (eight per group) underwent controlled hemorrhage of 24 mL/kg, 20-minute shock period, splenic injury with 15-minute initial bleeding, and hypotensive fluid resuscitation. Lactated Ringer's (LR) was infused at 45 mL/kg while hetastarch (high-molecular-weight hydroxyethyl starch 6%, Hextend, Hospira, Inc., Lake Forest, IL) and blood component (fresh-frozen plasma [FFP], 1:1 FFP:[red blood cells] RBCs, 1:4 FFP : RBCs, and fresh whole blood [FWB]) were infused at 15 mL/kg. Postresuscitation blood loss (PRBL), hemodynamics, coagulation, hematocrit, and oxygen metabolism were measured postinjury for 5 hours.

RESULTS

Resuscitation with any blood component reduced PRBL of 52% to 70% compared to Hextend, with FFP resulting in the lowest PRBL. PRBL with LR (11.5 ± 3.0 mL/kg) was not significantly different from Hextend (17.9 ± 2.5 mL/kg) or blood components (range, 5.5 ± 1.5 to 8.6 ± 2.6 mL/kg). The volume expansion effect of LR was transient. All fluids produced similar changes in hemodynamics, oxygen delivery, and demand despite the oxygen-carrying capacity of RBC-containing fluids. Compared with other fluids, Hextend produced greater hemodilution and reduced coagulation measures, which could be caused by an indirect dilutional effect or a direct hypocoagulable effect.

CONCLUSIONS

These data suggest that blood products as initial resuscitation fluids reduced PRBL from a noncompressible injury compared to Hextend, preserved coagulation, and provided sustained volume expansion. There were no differences on PRBL among RBCs-to-FFP, FWB, or FFP in this nonmassive transfusion model.

Post injury multiple organ failure

The understanding of post injury multiple organ failure (MOF) has evolved considerably since it was first described more than 30 years ago. Improved trauma care has decreased the mortality of single organ injury, although these patients may go on to MOF. There has been significant investigation in both the basic science and clinical understanding of MOF. This research has altered management strategies thereby decreasing the incidence and mortality related to MOF. Despite this MOF remains the greatest contributor to late trauma death and morbidity. This review defines essential terminology, examines the historical perspective of MOF, describes common scoring systems, describes the changes in epidemiology, discusses the aetiology and pathophysiology, reviews current prevention, resuscitation and treatment strategies and provides future direction for research.

Protective effects of fresh frozen plasma on vascular endothelial permeability, coagulation, and resuscitation after hemorrhagic shock are time dependent and diminish between days 0 and 5 after thaw

BACKGROUND

Clinical studies have shown that resuscitation with fresh frozen plasma (FFP) is associated with improved outcome after severe hemorrhagic shock (HS). We hypothesized that in addition to its effects on hemostasis, FFP has protective and stabilizing effects on the endothelium that translate into diminished endothelial cell (EC) permeability and improved resuscitation in vivo after HS. We further hypothesized that the beneficial effects of FFP would diminish over 5 days of routine storage at 4 degrees C.

METHODS

EC permeability was induced by hypoxia and assessed by the passage of 70-kDa Dextran between monolayers. Thrombin generation time and coagulation factor levels or activity were assessed in FFP. An in vivo rat model of HS and resuscitation was used to determine the effects of FFP on hemodynamic stability.

RESULTS

Thawed FFP inhibits EC permeability in vitro by 10.2-fold. Protective effects diminish (to 2.5-fold) by day 5. Thrombin generation time is increased in plasma that has been stored between days 0 and 5. In vivo data show that day 0 FFP is superior to day 5 FFP in maintaining mean arterial pressure in rats undergoing HS with resuscitation.

CONCLUSION

Both in vitro and in vivo studies show that FFP has beneficial effects on endothelial permeability, vascular stability, and resuscitation in rats after HS. The benefits are independent of hemostasis and diminish between days 0 and 5 of storage.

Creation, implementation, and maturation of a massive transfusion protocol for the exsanguinating trauma patient

The majority of trauma patients (>90%) do not require any blood product transfusion and their mortality is <1%. However, 3% to 5% of civilian trauma patients will receive a massive transfusion (MT), defined as >10 units of packed red blood cells (PRBC) in 24 hours. In addition, more than 25% of these patients will arrive to emergency departments with evidence of trauma-associated coagulopathy. With this combination of massive blood loss and coagulopathy, it has become increasingly more common to transfuse early the trauma patients and with a combination of PRBC, plasma, and platelets. Given the inherent uncertainties common early in the care of patients with severe injuries, the efficient administration of massive amounts of PRBC and clotting factors tends to work best in a predefined, protocol driven system. Our purpose here is to (1) define the problem of massive hemorrhage and coagulopathy in the trauma patient, (2) identify which group of patients this type of protocol should be applied, (3) describe the extensive coordination required to implement this multispecialty MT protocol, (4) explain in detail how the MT was developed and implemented, and (5) emphasize the need for a robust performance improvement or quality improvement process to monitor the implementation of such a protocol and to help identify problems and deliver feedback in a "real-time" fashion. The successful implementation of such a complex process can only be accomplished in a multispecialty setting. Input and representation from departments of Trauma, Critical Care, Anesthesiology, Transfusion Medicine, and Emergency Medicine are necessary to successfully formulate (and implement) such a protocol. Once a protocol has been agreed upon, education of the entire nursing and physician staff is equally essential to the success of this effort. Once implemented, this process may lead to improved clinical outcomes and decreased overall blood utilization with extremely small wastage of vital blood products.

Fresh frozen plasma increases adhesion molecule expression on human pulmonary endothelial cells

BACKGROUND

Current blood banking practices allow fresh frozen plasma (FFP) to be thawed and then stored for 5 d between 1 and 6 °C. We hypothesized that aged plasma (d 5 FFP) would be pro-inflammatory to the endothelium compared with fresh plasma (d 0 FFP).

MATERIALS AND METHODS

Human pulmonary endothelial cells (PECs) were treated with (1) media, (2) media + lipopolysaccharide (LPS), (3) lactated Ringer's (LR), (4) LR + LPS, (5) d 0 FFP, (6) d 0 FFP + LPS, (7) d 5 FFP, and (8) d 5 FFP + LPS. After a 24 h incubation, the PECs were stained with antibodies for I-CAM, V-CAM, P-selectin, and E-selectin. The cells were subsequently analyzed by flow cytometry.

RESULTS

In both PEC groups treated with FFP and stimulated with LPS, I-CAM, V-CAM, P-selectin, and E-selectin were significantly up-regulated compared with LR when stimulated by LPS.

CONCLUSION

FFP at both ages significantly increased expression of four different adhesion molecules compared with LR in PECs. This may represent a possible mechanism for increased leukocyte binding on the endothelium as a result of FFP transfusion.

Perioperative coagulation management--fresh frozen plasma

Clinical studies support the use of perioperative fresh frozen plasma (FFP) in patients who are actively bleeding with multiple coagulation factor deficiencies and for the prevention of dilutional coagulopathy in patients with major trauma and/or massive haemorrhage. In these settings, current FFP dosing recommendations may be inadequate. However, a substantial proportion of FFP is transfused in non-bleeding patients with mild elevations in coagulation screening tests. This practice is not supported by the literature, is unlikely to be of benefit and unnecessarily exposes patients to the risks of FFP. The role of FFP in reversing the effects of warfarin anticoagulation is dependent on the clinical context and availability of alternative agents. Although FFP is commonly transfused in patients with liver disease, this practice needs broad reconsideration. Adverse effects of FFP include febrile and allergic reactions, transfusion-associated circulatory overload and transfusion-related acute lung injury. The latter is the most serious complication, being less common with the preferential use of non-alloimmunised, male-donor predominant plasma. FP24 and thawed plasma are alternatives to FFP with similar indications for administration. Both provide an opportunity for increasing the safe plasma donor pool. Although prothrombin complex concentrates and factor VIIa may be used as alternatives to FFP in a variety of specific clinical contexts, additional study is needed.

Impact of plasma transfusion in trauma patients who do not require massive transfusion

BACKGROUND

For trauma patients requiring massive blood transfusion, aggressive plasma usage has been demonstrated to confer a survival advantage. The aim of this study was to evaluate the impact of plasma administration in nonmassively transfused patients.

STUDY DESIGN

Trauma patients admitted to a Level I trauma center (2000-2005) requiring a nonmassive transfusion (<10 U packed RBC [PRBC] within 12 hours of admission) were identified retrospectively. Propensity scores were calculated to match and compare patients receiving plasma in the first 12 hours with those who did not.

RESULTS

The 1,716 patients (86.1% of 1,933 who received PRBC transfusion) received a nonmassive transfusion. After exclusion of 31 (1.8%) early deaths, 284 patients receiving plasma were matched to patients who did not. There was no improvement in survival with plasma transfusion (17.3% versus 14.1%; p = 0.30) irrespective of the plasma-to-PRBC ratio achieved. However, the overall complication rate was significantly higher for patients receiving plasma (26.8% versus 18.3%, odds ratio [OR] = 1.7; 95% CI, 1.1-2.4; p = 0.016). As the volume of plasma increased, an increase in complications was seen, reaching 37.5% for patients receiving >6 U. The ARDS rate specifically was also significantly higher in patients receiving plasma (9.9% versus 3.5%, OR = 3.0; 95% CI, 1.4-6.2; p = 0.004]. Patients receiving >6 U plasma had a 12-fold increase in ARDS, a 6-fold increase in multiple organ dysfunction syndrome, and a 4-fold increase in pneumonia and sepsis.

CONCLUSIONS

For nonmassively transfused trauma patients, plasma administration was associated with a substantial increase in complications, in particular ARDS, with no improvement in survival. An increase in multiple organ dysfunction, pneumonia, and sepsis was likewise seen as increasing volumes of plasma were transfused. The optimal trigger for initiation of a protocol for aggressive plasma infusion warrants prospective evaluation.

Association between length of storage of red blood cell units and outcome of critically ill children: a prospective observational study

INTRODUCTION

Transfusion is a common treatment in pediatric intensive care units (PICUs). Studies in adults suggest that prolonged storage of red blood cell units is associated with worse clinical outcome. No prospective study has been conducted in children. Our objectives were to assess the clinical impact of the length of storage of red blood cell units on clinical outcome of critically ill children.

METHODS

Prospective, observational study conducted in 30 North American centers, in consecutive patients aged <18 years with a stay >or= 48 hours in a PICU. The primary outcome measure was the incidence of multiple organ dysfunction syndrome after transfusion. The secondary outcomes were 28-day mortality and PICU length of stay. Odds ratios were adjusted for gender, age, number of organ dysfunctions at admission, total number of transfusions, and total dose of transfusion, using a multiple logistic regression model.

RESULTS

The median length of storage was 14 days in 296 patients with documented length of storage. For patients receiving blood stored >or= 14 days, the adjusted odds ratio for an increased incidence of multiple organ dysfunction syndrome was 1.87 (95% CI 1.04;3.27, P = 0.03). There was also a significant difference in the total PICU length of stay (adjusted median difference +3.7 days, P < 0.001) and no significant change in mortality.

CONCLUSIONS

In critically ill children, transfusion of red blood cell units stored for >or= 14 days is independently associated with an increased occurrence of multiple organ dysfunction syndrome and prolonged PICU stay.

Association between length of storage of red blood cell units and outcome of critically ill children: a prospective observational study

INTRODUCTION

Transfusion is a common treatment in pediatric intensive care units (PICUs). Studies in adults suggest that prolonged storage of red blood cell units is associated with worse clinical outcome. No prospective study has been conducted in children. Our objectives were to assess the clinical impact of the length of storage of red blood cell units on clinical outcome of critically ill children.

METHODS

Prospective, observational study conducted in 30 North American centers, in consecutive patients aged <18 years with a stay >or= 48 hours in a PICU. The primary outcome measure was the incidence of multiple organ dysfunction syndrome after transfusion. The secondary outcomes were 28-day mortality and PICU length of stay. Odds ratios were adjusted for gender, age, number of organ dysfunctions at admission, total number of transfusions, and total dose of transfusion, using a multiple logistic regression model.

RESULTS

The median length of storage was 14 days in 296 patients with documented length of storage. For patients receiving blood stored >or= 14 days, the adjusted odds ratio for an increased incidence of multiple organ dysfunction syndrome was 1.87 (95% CI 1.04;3.27, P = 0.03). There was also a significant difference in the total PICU length of stay (adjusted median difference +3.7 days, P < 0.001) and no significant change in mortality.

CONCLUSIONS

In critically ill children, transfusion of red blood cell units stored for >or= 14 days is independently associated with an increased occurrence of multiple organ dysfunction syndrome and prolonged PICU stay.

Goal-directed coagulation management of major trauma patients using thromboelastometry (ROTEM)-guided administration of fibrinogen concentrate and prothrombin complex concentrate

Introduction

The appropriate strategy for trauma-induced coagulopathy management is under debate. We report the treatment of major trauma using mainly coagulation factor concentrates.

Methods

This retrospective analysis included trauma patients who received ≥ 5 units of red blood cell concentrate within 24 hours. Coagulation management was guided by thromboelastometry (ROTEM^®). Fibrinogen concentrate was given as first-line haemostatic therapy when maximum clot firmness (MCF) measured by FibTEM (fibrin-based test) was <10 mm. Prothrombin complex concentrate (PCC) was given in case of recent coumarin intake or clotting time measured by extrinsic activation test (EXTEM) >1.5 times normal. Lack of improvement in EXTEM MCF after fibrinogen concentrate administration was an indication for platelet concentrate. The observed mortality was compared with the mortality predicted by the trauma injury severity score (TRISS) and by the revised injury severity classification (RISC) score.

Results

Of 131 patients included, 128 received fibrinogen concentrate as first-line therapy, 98 additionally received PCC, while 3 patients with recent coumarin intake received only PCC. Twelve patients received FFP and 29 received platelet concentrate. The observed mortality was 24.4%, lower than the TRISS mortality of 33.7% (P = 0.032) and the RISC mortality of 28.7% (P > 0.05). After excluding 17 patients with traumatic brain injury, the difference in mortality was 14% observed versus 27.8% predicted by TRISS (P = 0.0018) and 24.3% predicted by RISC (P = 0.014).

Conclusions

ROTEM^®-guided haemostatic therapy, with fibrinogen concentrate as first-line haemostatic therapy and additional PCC, was goal-directed and fast. A favourable survival rate was observed. Prospective, randomized trials to investigate this therapeutic alternative further appear warranted.

Effect of early plasma transfusion on mortality in patients with ruptured abdominal aortic aneurysm

BACKGROUND

The ratio of red blood cell (PRBC) transfusion to plasma (FFP) transfusion (PRBC:FFP ratio) has been shown to impact survival in trauma patients with massive hemorrhage. The purpose of this study was to determine the effect of the PRBC:FFP ratio on mortality for patients with massive hemorrhage after ruptured abdominal aortic aneurysm (RAAA).

METHODS

A retrospective review was performed of patients undergoing emergent open RAAA repair from January 1987 to December 2007. Patients with massive hemorrhage (≥10 units of blood products transfused prior to conclusion of the operation) were included. The effects of patient demographics, admission vital signs, laboratory values, peri-operative variables, amount of blood products transfused, and the PRBC:FFP ratio on 30-day mortality were analyzed by multivariate analysis.

RESULTS

One hundred and twenty-eight of the 168 (76%) patients undergoing repair for RAAA received at least 10 units of blood products within the peri-operative period. Mean age was 73.1 ± 9.1 years, and 109 (85%) were men. Thirty-day mortality was 22.6% (29/128), including 11 intra-operative deaths. By multivariate analysis, 30-day mortality was markedly lower (15% vs 39%; P < .03) for patients transfused at a PRBC:FFP ratio ≤2:1 (HIGH FFP group) compared with those transfused at a ratio of >2:1 (LOW FFP), and the likelihood of death was more than 4-fold greater in the LOW FFP group (odds ratio 4.23; 95% confidence interval, 1.2-14.49). Patients in the HIGH FFP group had a significantly lower incidence of colon ischemia than those in the LOW FFP group (22.4% vs 41.1%; P = .004).

CONCLUSION

For RAAA patients requiring massive transfusion, more equivalent transfusion of PRBC to FFP (HIGH FFP) was independently associated with lower 30-day mortality. The lower incidence of colonic ischemia in the HIGH FFP group may suggest an additional benefit of early plasma transfusion that could translate into further mortality reduction. Analysis from this study suggests the potential feasibility for a more standardized protocol of initial resuscitation for these patients, and prospective studies are warranted to determine the optimum PRBC:FFP ratio in RAAA patients.