1
|
Yao R, Yan D, Fu X, Deng Y, Xie X, Li N. The effects of plasma to red blood cells transfusion ratio on in-hospital mortality in patients with acute type A aortic dissection. Front Cardiovasc Med 2023; 10:1091468. [PMID: 37252125 PMCID: PMC10213885 DOI: 10.3389/fcvm.2023.1091468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 04/26/2023] [Indexed: 05/31/2023] Open
Abstract
Background Blood transfusion is a frequent and necessary practice in acute type A aortic dissection (AAAD) patients, but the effect of plasma/red blood cells (RBCs) ratio on mortality remains unclear. The aim of this study is to investigate the association between plasma/RBCs transfusion ratio and in-hospital mortality in patients with AAAD. Methods Patients were admitted to Xiangya Hospital of Central South University from January 1, 2016 to December 31, 2021. Clinical parameters were recorded. Multivariate Cox regression model was used to analyze the association between transfusion and in-hospital mortality. We used the smooth curve fitting and segmented regression model to assess the threshold effect between plasma/RBCs transfusion ratio and in-hospital mortality in patients with AAAD. Results The volumes of RBCs [14.00 (10.12-20.50) unit] and plasma [19.25 (14.72-28.15) unit] transfused in non-survivors were significantly higher than in survivors [RBCs: 8.00 (5.50-12.00) unit]; plasma: [10.35 (6.50-15.22) unit]. Multivariate Cox regression analysis showed plasma transfusion was an independent risk factor of in-hospital mortality. Adjusted HR was 1.03 (95% CI: 0.96-1.11) for RBCs transfusion and 1.08 (95% CI: 1.03-1.13) for plasma transfusion. In the spline smoothing plot, mortality risk increased with plasma/RBCs transfusion ratio leveling up to the turning point 1. Optimal plasma/RBCs transfusion ratio with least mortality risk was 1. When the plasma/RBCs ratio was <1 (adjusted HR per 0.1 ratio: 0.28, 95% CI per 0.1 ratio: 0.17-0.45), mortality risk decreased with the increase of ratio. When the plasma/RBCs ratio was 1-1.5 (adjusted HR per 0.1 ratio: 2.73, 95% CI per 0.1 ratio:1.13-6.62), mortality risk increased rapidly with the increase of ratio. When the plasma/RBCs ratio was >1.5 (adjusted HR per 0.1 ratio: 1.09, 95% CI per 0.1 ratio:0.97-1.23), mortality risk tended to reach saturation, and increased non-significantly with the increase of ratio. Conclusion A 1:1 plasma/RBCs ratio was associated with the lowest mortality in the patients with AAAD. And non-linear relationship existed between plasma/RBCs ratio and mortality.
Collapse
Affiliation(s)
- Run Yao
- Department of Blood Transfusion, National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Clinical Transfusion Research Center, Central South University, Changsha, China
| | - Danyang Yan
- Department of Blood Transfusion, National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Clinical Transfusion Research Center, Central South University, Changsha, China
| | - Xiangjie Fu
- Department of Blood Transfusion, National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Clinical Transfusion Research Center, Central South University, Changsha, China
| | - Ying Deng
- Office, Ningxiang People's Hospital Affiliated to Hunan University of Traditional Chinese Medicine, Ningxiang, China
| | - Xi Xie
- Department of Blood Transfusion, National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Clinical Transfusion Research Center, Central South University, Changsha, China
| | - Ning Li
- Department of Blood Transfusion, National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Clinical Transfusion Research Center, Central South University, Changsha, China
| |
Collapse
|
2
|
Lier H, Gooßen K, Trentzsch H. [The chapters "Stop the bleed-prehospital" and "Coagulation management and volume therapy (emergency departement)" in the new S3 guideline "Polytrauma/severe injury treatment"]. Notf Rett Med 2023; 26:259-268. [PMID: 37261335 PMCID: PMC10117256 DOI: 10.1007/s10049-023-01147-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/15/2023] [Indexed: 06/02/2023]
Abstract
The S3 guideline on the treatment of patients with severe/multiple injuries by the German Association of the Scientific Medical Societies was updated between 2020 and 2022. This article describes the essence of the new chapter "Stop the bleed-prehospital" and the revised chapter "Coagulation management and volume therapy".
Collapse
Affiliation(s)
- H. Lier
- Medizinische Fakultät und Uniklinik Köln, Klinik für Anästhesiologie und Operative Intensivmedizin, Universität zu Köln, Kerpener Straße 62, 50937 Köln, Deutschland
- Sektion „Klinische Hämotherapie und Hämostasemanagement“ der Deutschen Gesellschaft für Intensiv- und Notfallmedizin (DIVI), Schumannstr. 2, 10117, Berlin, Deutschland
| | - K. Gooßen
- Institut für Forschung in der Operativen Medizin (IFOM), Universität Witten/Herdecke, Ostmerheimer Straße 200, 51109 Köln, Deutschland
| | - H. Trentzsch
- Institut für Notfallmedizin und Medizinmanagement (INM), Klinikum der Universität München, LMU München, Schillerstr. 53, 80336 München, Deutschland
| |
Collapse
|
3
|
Xu X, Zhang Y, Tang B, Yu X, Huang Y. Association between perioperative plasma transfusion and in-hospital mortality in patients undergoing surgeries without massive transfusion: A nationwide retrospective cohort study. Front Med (Lausanne) 2023; 10:1130359. [PMID: 36873874 PMCID: PMC9975265 DOI: 10.3389/fmed.2023.1130359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Accepted: 01/30/2023] [Indexed: 02/17/2023] Open
Abstract
Background An aggressive plasma transfusion is associated with a decreased mortality in traumatic patients requiring massive transfusion (MT). However, it is controversial whether non-traumatic or non-massively transfused patients can benefit from high doses of plasma. Methods We performed a nationwide retrospective cohort study using data from Hospital Quality Monitoring System, which collected anonymized inpatient medical records from 31 provinces in mainland China. We included the patients who had at least one record of surgical procedure and received red blood cell transfusion on the day of surgery from 2016 to 2018. We excluded those receiving MT or diagnosed with coagulopathy at admission. The exposure variable was the total volume of fresh frozen plasma (FFP) transfused, and the primary outcome was in-hospital mortality. The relationship between them was assessed using multivariable logistic regression model adjusting 15 potential confounders. Results A total of 69319 patients were included, and 808 died among them. A 100-ml increase in FFP transfusion volume was associated with a higher in-hospital mortality (odds ratio 1.05, 95% confidence interval 1.04-1.06, p < 0.001) after controlling for the confounders. FFP transfusion volume was also associated with superficial surgical site infection, nosocomial infection, prolonged length of hospital stay, ventilation time, and acute respiratory distress syndrome. The significant association between FFP transfusion volume and in-hospital mortality was extended to the subgroups of cardiac surgery, vascular surgery, and thoracic or abdominal surgery. Conclusions A higher volume of perioperative FFP transfusion was associated with an increased in-hospital mortality and inferior postoperative outcomes in surgical patients without MT.
Collapse
Affiliation(s)
- Xiaohan Xu
- Department of Anesthesiology, Chinese Academy of Medical Sciences & Peking Union Medical College Hospital, Beijing, China
| | - Yuelun Zhang
- Medical Research Center, Chinese Academy of Medical Sciences & Peking Union Medical College Hospital, Beijing, China
| | - Bo Tang
- Department of Anesthesiology, Chinese Academy of Medical Sciences & Peking Union Medical College Hospital, Beijing, China
| | - Xuerong Yu
- Department of Anesthesiology, Chinese Academy of Medical Sciences & Peking Union Medical College Hospital, Beijing, China
| | - Yuguang Huang
- Department of Anesthesiology, Chinese Academy of Medical Sciences & Peking Union Medical College Hospital, Beijing, China
| |
Collapse
|
4
|
Achieving optimal massive transfusion ratios: The trauma white board, whole blood, and liquid plasma. Real world low-tech solutions for a high stakes issue. Injury 2022; 53:2974-2978. [PMID: 35791968 DOI: 10.1016/j.injury.2022.06.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2021] [Revised: 05/27/2022] [Accepted: 06/08/2022] [Indexed: 02/02/2023]
Abstract
BACKGROUND It is well established that achieving optimal ratios of packed red blood cells (PRBC) to fresh frozen plasma (FFP) to platelet ratios during massive transfusion leads to improved outcomes but is difficult to accomplish. METHODS Between September 2018 and May 2019 our level 2 trauma center implemented 3 new processes to optimize transfusion ratios during massive transfusion protocol (MTP). Two units of low titer group O whole blood (LTOWB) were added as the first step to our MTP. Second, a dry erase board whiteboard was attached to each fluid warmer for real time recording of transfusions. Last, liquid plasma was incorporated into our MTP. We performed a retrospective review evaluating PRBC:FFP ratios for patients who had the massive transfusion protocol initiated and received 4 or more units of blood. RESULTS A total of 50 patients had the massive transfusion protocol initiated and received 4 or more units of PRBCs and/or LTOWB within 4 h of arrival. There were 21 patients evaluated prior to protocol changes and 29 patients after the changes. In the study group mean age, sex, pulse, systolic blood pressure (SBP), and injury severity scale (ISS) on admission were not different. In the pre-protocol (preP) group 90% of patients were blunt trauma and in the post-protocol group (postP) 72% were blunt trauma, p = 0. 22. For the preP group the mean units of PRBCs was 7.6 units and FFP 4.7 units. PostP the mean units of PRBCs was 11.4 units and FFP 10.0 units. PRBC/FFP ratios were 1.7 preP and 1.2 postP, p = 0.0072. CONCLUSION The institution of whole blood, use of the trauma white board, and the addition of liquid plasma to our transfusion services have allowed us to approach a 1:1 transfusion ratio during the course of our massive transfusions.
Collapse
|
5
|
Boye M, Py N, Libert N, Chrisment A, Pissot M, Dedome E, Martinaud C, Ausset S, Boutonnet M, De Rudnicki S, Pasquier P, Martinez T. Step by step transfusion timeline and its challenges in trauma: A retrospective study in a level one trauma center. Transfusion 2022; 62 Suppl 1:S30-S42. [PMID: 35781713 DOI: 10.1111/trf.16953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2021] [Revised: 03/30/2022] [Accepted: 04/01/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Hemorrhagic shock is the leading cause of preventable early death in trauma patients. Transfusion management is guided by international guidelines promoting early and aggressive transfusion strategies. This study aimed to describe transfusion timelines in a trauma center and to identify key points to performing early and efficient transfusions. METHODS This is a monocentric retrospective study of 108 severe trauma patients, transfused within the first 48 h and hospitalized in an intensive care unit between January 2017 and May 2019. RESULTS One hundred and eight patients were transfused with 1250 labile blood products. Half of these labile blood products were transfused within 3 h of admission and consumed by 26 patients requiring massive transfusion (≥4 red blood cells [RBC] within 1 h). Among these, the median delay from patient's admission to labile blood products prescription was -11 min (-34 to -1); from admission to delivery of labile blood products was 1 min (-20 to 16); and from admission to first transfusion was 20 min (7-37) for RBC, 26 min (13-38) for plasma, and 72 min (51-103) for platelet concentrates. The anticipated prescription of labile blood products and the use of massive transfusion packs and lyophilized plasma units were associated with earlier achievement of high transfusion ratios. CONCLUSION This study provides detailed data on the transfusion timelines and composition, from prescription to initial transfusion. Transfusion anticipation, use of preconditioned transfusion packs including platelets, and lyophilized plasma allow rapid and high-ratio transfusion practices in severe trauma patients.
Collapse
Affiliation(s)
- Matthieu Boye
- Federation of anesthesiology, intensive care unit, burns and operating theater, Percy Military Training Hospital, Clamart, France.,École du Val-de-Grâce, French Military Medical Service Academy, Paris, France
| | - Nicolas Py
- Federation of anesthesiology, intensive care unit, burns and operating theater, Percy Military Training Hospital, Clamart, France.,École du Val-de-Grâce, French Military Medical Service Academy, Paris, France
| | - Nicolas Libert
- Federation of anesthesiology, intensive care unit, burns and operating theater, Percy Military Training Hospital, Clamart, France
| | - Anne Chrisment
- Federation of anesthesiology, intensive care unit, burns and operating theater, Percy Military Training Hospital, Clamart, France
| | - Mathieu Pissot
- Federation of anesthesiology, intensive care unit, burns and operating theater, Percy Military Training Hospital, Clamart, France
| | | | - Christophe Martinaud
- École du Val-de-Grâce, French Military Medical Service Academy, Paris, France.,FMBI, French Military Blood Institute, Clamart, France
| | - Sylvain Ausset
- École du Val-de-Grâce, French Military Medical Service Academy, Paris, France.,FMHSS, French Military Health Service Schools, Lyon, France
| | - Mathieu Boutonnet
- Federation of anesthesiology, intensive care unit, burns and operating theater, Percy Military Training Hospital, Clamart, France.,École du Val-de-Grâce, French Military Medical Service Academy, Paris, France
| | - Stéphane De Rudnicki
- Federation of anesthesiology, intensive care unit, burns and operating theater, Percy Military Training Hospital, Clamart, France
| | - Pierre Pasquier
- Federation of anesthesiology, intensive care unit, burns and operating theater, Percy Military Training Hospital, Clamart, France.,École du Val-de-Grâce, French Military Medical Service Academy, Paris, France.,1ère Chefferie du Service de Santé, French Military Medical Service, Villacoublay, France
| | - Thibault Martinez
- Federation of anesthesiology, intensive care unit, burns and operating theater, Percy Military Training Hospital, Clamart, France
| |
Collapse
|
6
|
Dynamic impact of transfusion ratios on outcomes in severely injured patients: Targeted machine learning analysis of the Pragmatic, Randomized Optimal Platelet and Plasma Ratios randomized clinical trial. J Trauma Acute Care Surg 2021; 89:505-513. [PMID: 32520897 DOI: 10.1097/ta.0000000000002819] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Massive transfusion protocols to treat postinjury hemorrhage are based on predefined blood product transfusion ratios followed by goal-directed transfusion based on patient's clinical evolution. However, it remains unclear how these transfusion ratios impact patient outcomes over time from injury. METHODS The Pragmatic, Randomized Optimal Platelet and Plasma Ratios (PROPPR) is a phase 3, randomized controlled trial, across 12 Level I trauma centers in North America. From 2012 to 2013, 680 severely injured patients required massive transfusion. We used semiparametric machine learning techniques and causal inference methods to augment the intent-to-treat analysis of PROPPR, estimating the dynamic relationship between transfusion ratios and outcomes: mortality and hemostasis at different timepoints during the first 24 hours after admission. RESULTS In the intention-to-treat analysis, the 1:1:1 group tended to have decreased mortality, but with no statistical significance. For patients in whom hemostasis took longer than 2 hours, the 1:1:1 ratio was associated with a higher probability of hemostasis, statistically significant from the 4 hour on. In the per-protocol, actual-transfusion-ratios-received analysis, during four successive time intervals, no significant association was found between the actual ratios and mortality. When comparing patient groups who received both high plasma/PRBC and high platelet/PRBC ratios to the group of low ratios in both, the relative risk of achieving hemostasis was 2.49 (95% confidence interval, 1.19-5.22) during the third hour after admission, suggesting a significant beneficial impact of higher transfusion ratios of plasma and platelets on hemostasis. CONCLUSION Our results suggest that the impact of transfusion ratios on hemostasis is dynamic. Overall, the transfusion ratios had no significant impact on mortality over time. However, receiving higher ratios of platelets and plasma relative to red blood cells hastens hemostasis in subjects who have yet to achieve hemostasis within 3 hours after hospital admission. LEVEL OF EVIDENCE Therapeutic IV.
Collapse
|
7
|
May LA, Harrell KN, Bell CM, Basham-Saif A, Barker DE, Maxwell RA. Intraoperative Resuscitation by Specialized Trauma Nurse Clinicians Improves Adherence to Massive Transfusion Protocol. Am Surg 2020. [DOI: 10.1177/000313482008600120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
A massive transfusion protocol (MTP) was implemented at a Level I trauma center in 2007 for patients with massive blood loss. A goal ratio of plasma to pheresed platelets to packed red blood cells (PRBCs) of 1:1:1 was established. From 2007 to 2014, trauma nurse clinicians (TNCs) administered the MTP during initial resuscitation and anesthesia personnel administered the MTP intraoperatively. In 2015, TNCs began administering the MTP intraoperatively. This study evaluates intraoperative blood product ratios and crystalloid volume administered by anesthesia personnel or TNCs. A retrospective review of trauma registry patients requiring MTP from 2007 to 2017 was performed. Patient data were stratified according to MTP administration by either anesthesia personnel (2007–2015) or TNCs (2015–2017). Ninety-seven patients were included with 54 anesthesia patients and 44 TNC patients. Patients undergoing resuscitation by MTP administered by TNCs received less median crystalloid (3000 mL vs 1500 mL, P < 0.001). The ratio of plasma:PRBC (0.75 vs 0.93, P = 0.027) and platelets:PRBC (0.75 vs 1.04, P = 0.003) was found to be significantly closer to 1:1 for TNC patients. MTP intraoperative blood product administration by TNCs reduced the amount of infused crystalloid and improved adherence to MTP in achieving a 1:1:1 ratio of blood products.
Collapse
Affiliation(s)
- L. Andrew May
- University of Tennessee College of Medicine Chattanooga, Chattanooga, Tennessee
| | - Kevin N. Harrell
- University of Tennessee College of Medicine Chattanooga, Chattanooga, Tennessee
| | | | | | - Donald E. Barker
- University of Tennessee College of Medicine Chattanooga, Chattanooga, Tennessee
| | - Robert A. Maxwell
- University of Tennessee College of Medicine Chattanooga, Chattanooga, Tennessee
| |
Collapse
|
8
|
Fresh Frozen Plasma-to-Packed Red Blood Cell Ratio and Mortality in Traumatic Hemorrhage: Nationwide Analysis of 4,427 Patients. J Am Coll Surg 2019; 230:893-901. [PMID: 31759164 DOI: 10.1016/j.jamcollsurg.2019.10.012] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Revised: 10/21/2019] [Accepted: 10/21/2019] [Indexed: 11/23/2022]
Abstract
BACKGROUND Despite the presence of highly reliable data, studies on packed red blood cells (pRBC):fresh frozen plasma (FFP) ratio suffer from limited sample size and the presence of survivor bias. We sought to study the association between FFP:pRBC and early mortality in the hemorrhaging trauma patient. STUDY DESIGN This was a retrospective nationwide cohort that included all TQIP participating hospitals (2013 to 2016). We included all trauma patients who were transfused ≥10 pRBCs and ≥1 FFP within 24 hours. We excluded transferred patients and those who died in the emergency department or had missing/inaccurate transfusion data. Patients were assigned to 7 FFP:pRBC cohorts (range 1:1 to 1:6, and 1:6+) only if the ratio was similar at 4 and 24 hours and, to avoid survival bias, were excluded otherwise. Multivariable analyses correcting for all available confounders (age, demographics, comorbidities, vital signs, Injury Severity Score [ISS] and mechanism, procedures performed) were derived to study the independent relationship between FFP:pRBC and 24-hour mortality. RESULTS Of 1,002,595 patients, 4,427 patients were included. Mean age was 41 years, 79% were males, 61% had blunt trauma, and median ISS was 29. Most patients were transfused in a 1:1, 1:2, or 1:3 ratio (31%, 41%, and 11%, respectively); mortality ranged between 28% for 1:1 and 62% for 1:4. In multivariable analyses, the odds of mortality independently and incrementally increased to 1.23 (95% CI 1.02 to 1.48) for a 1:2 ratio, 2.11 (95% CI 1.42 to 3.13) for 1:4, and as high as 4.11 (95% CI 2.31 to 7.31) for 1:5 (all p < 0.05). CONCLUSIONS A 1:1 FFP:pRBC ratio is associated with the lowest mortality in the hemorrhaging trauma patient, and mortality increases with decreasing ratios.
Collapse
|
9
|
da Luz LT, Shah PS, Strauss R, Mohammed AA, D'Empaire PP, Tien H, Nathens AB, Nascimento B. Does the evidence support the importance of high transfusion ratios of plasma and platelets to red blood cells in improving outcomes in severely injured patients: a systematic review and meta-analyses. Transfusion 2019; 59:3337-3349. [PMID: 31614006 PMCID: PMC6900194 DOI: 10.1111/trf.15540] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Revised: 08/13/2019] [Accepted: 08/21/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND Deaths by exsanguination in trauma are preventable with hemorrhage control and resuscitation with allogeneic blood products (ABPs). The ideal transfusion ratio is unknown. We compared efficacy and safety of high transfusion ratios of FFP:RBC and PLT:RBC with low ratios in trauma. STUDY DESIGN AND METHODS Medline, Embase, Cochrane, and Controlled Clinical Trials Register were searched. Observational and randomized data were included. Risk of bias was assessed using validated tools. Primary outcome was 24-h and 30-day mortality. Secondary outcomes were exposure to ABPs and improvement of coagulopathy. Meta-analysis was conducted using a random-effects model. Strength and evidence quality were graded using GRADE profile RESULTS: 55 studies were included (2 randomized and 53 observational), with low and moderate risk of bias, respectively, and overall low evidence quality. The two RCTs showed no mortality difference (odds ratio [OR], 1.35; 95% confidence interval [CI], 0.40-4.59). Observational studies reported lower mortality in high FFP:RBCs ratio (OR, 0.38 [95% CI, 0.22-0.68] for 1:1 vs. <1:1; OR, 0.42 [95% CI, 0.22-0.81] for 1:1.5 vs. <1:1.5; and OR, 0.47 [95% CI, 0.31-0.71] for 1:2 vs. <1:2, respectively). Meta-analyses in observational studies showed no difference in exposure to ABPs. No data on coagulopathy for meta-analysis was identified. CONCLUSIONS Meta-analyses in observational studies suggest survival benefit and no difference in exposure to ABPs. No survival benefit in RCTs was identified. These conflicting results should be interpreted with caution. Studies are mostly observational, with relatively small sample sizes, nonrandom treatment allocation, and high potential for confounding. Further research is warranted.
Collapse
Affiliation(s)
| | - Prakesh S. Shah
- Department of PediatricsMount Sinai HospitalTorontoOntarioCanada
| | - Rachel Strauss
- Department SurgerySunnybrook Health Sciences CentreTorontoOntarioCanada
| | | | - Pablo Perez D'Empaire
- Department Anesthesia, Sunnybrook Health Sciences CentreUniversity of TorontoTorontoOntarioCanada
| | - Homer Tien
- Department SurgerySunnybrook Health Sciences CentreTorontoOntarioCanada
| | - Avery B. Nathens
- Department SurgerySunnybrook Health Sciences CentreTorontoOntarioCanada
| | - Barto Nascimento
- Department SurgerySunnybrook Health Sciences CentreTorontoOntarioCanada
| |
Collapse
|
10
|
Roquet F, Neuschwander A, Hamada S, Favé G, Follin A, Marrache D, Cholley B, Pirracchio R. Association of Early, High Plasma-to-Red Blood Cell Transfusion Ratio With Mortality in Adults With Severe Bleeding After Trauma. JAMA Netw Open 2019; 2:e1912076. [PMID: 31553473 PMCID: PMC6763975 DOI: 10.1001/jamanetworkopen.2019.12076] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
IMPORTANCE Optimal transfusion management is crucial when treating patients with trauma. However, the association of an early, high transfusion ratio of fresh frozen plasma (FFP) to packed red blood cells (PRBC) with survival remains uncertain. OBJECTIVE To study the association of an early, high FFP-to-PRBC ratio with all-cause 30-day mortality in patients with severe bleeding after trauma. DESIGN, SETTING, AND PARTICIPANTS This cohort study analyzes the data included in a multicenter national French trauma registry, Traumabase, from January 2012 to July 2017. Traumabase is a prospective, active, multicenter adult trauma registry that includes all consecutive patients with trauma treated at 15 trauma centers in France. Overall, 897 patients with severe bleeding after trauma were identified using the following criteria: (1) received 4 or more units of PRBC during the first 6 hours or (2) died from hemorrhagic shock before receiving 4 units of PRBC. EXPOSURES Eligible patients were divided into a high-ratio group, defined as an FFP-to-PRBC ratio more than 1:1.5, and a low-ratio group, defined as an FFP-to-PRBC ratio of 1:1.5 or less. The ratio was calculated using the cumulative units of FFP and PRBC received during the first 6 hours of management. MAIN OUTCOMES AND MEASURES A Cox regression model was used to analyze 30-day survival with the transfusion ratio as a time-dependent variable to account for survivorship bias. RESULTS Of the 12 217 patients included in the registry, 897 (7.3%) were analyzed (median [interquartile range] age, 38 (29-54) years; 639 [71.2%] men). The median (interquartile range) injury severity score was 34 (22-48), and the overall 30-day mortality rate was 33.6% (301 patients). A total of 506 patients (56.4%) underwent transfusion with a high ratio and 391 (43.6%) with a low ratio. A high transfusion ratio was associated with a significant reduction in 30-day mortality (hazard ratio, 0.74; 95% CI, 0.58-0.94; P = .01). When only analyzing patients who had complete data, a high transfusion ratio continued to be associated with a reduction in 30-day mortality (hazard ratio, 0.57; 95% CI, 0.33-0.97; P = .04). CONCLUSIONS AND RELEVANCE In this analysis of the Traumabase registry, an early FFP-to-PRBC ratio of more than 1:1.5 was associated with increased 30-day survival among patients with severe bleeding after trauma. This result supports the use of early, high FFP-to-PRBC transfusion ratios in patients with severe trauma.
Collapse
Affiliation(s)
- Florian Roquet
- Service d’Anesthésie-réanimation, Hôpital Européen Georges-Pompidou, Assistance Publique–Hôpitaux de Paris, Paris, France
- Service de Biostatistique et Informatique Médicale, Unité INSERM UMR 1153, Université Paris Diderot, Paris, France
| | - Arthur Neuschwander
- Service d’Anesthésie-réanimation, Hôpital Européen Georges-Pompidou, Assistance Publique–Hôpitaux de Paris, Paris, France
| | - Sophie Hamada
- Service d’Anesthésie-réanimation, Centre Hospitalier Universitaire Bicêtre, Université Paris Sud, Assistance Publique–Hôpitaux de Paris, Le Kremlin Bicêtre, France
| | - Gersende Favé
- Service d’Anesthésie-réanimation, Hôpital Européen Georges-Pompidou, Assistance Publique–Hôpitaux de Paris, Paris, France
| | - Arnaud Follin
- Service d’Anesthésie-réanimation, Hôpital Européen Georges-Pompidou, Assistance Publique–Hôpitaux de Paris, Paris, France
| | - David Marrache
- Service d’Anesthésie-réanimation, Hôpital Européen Georges-Pompidou, Assistance Publique–Hôpitaux de Paris, Paris, France
| | - Bernard Cholley
- Service d’Anesthésie-réanimation, Hôpital Européen Georges-Pompidou, Assistance Publique–Hôpitaux de Paris, Paris, France
| | - Romain Pirracchio
- Service d’Anesthésie-réanimation, Hôpital Européen Georges-Pompidou, Assistance Publique–Hôpitaux de Paris, Paris, France
- Service de Biostatistique et Informatique Médicale, Unité INSERM UMR 1153, Université Paris Diderot, Paris, France
| |
Collapse
|
11
|
虞 芳, 钟 涛, 武 钢. [Efficacy of high versus low plasma: red blood cell ratio resuscitation in patients with severe trauma requiring massive blood transfusion: a meta-analysis]. NAN FANG YI KE DA XUE XUE BAO = JOURNAL OF SOUTHERN MEDICAL UNIVERSITY 2017; 37:119-123. [PMID: 28109111 PMCID: PMC6765755 DOI: 10.3969/j.issn.1673-4254.2017.01.22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 10/13/2016] [Indexed: 06/06/2023]
Abstract
OBJECTIVE To evaluate the efficacy of high (≥1:2) and low (<1:2) plasma: red blood cell (RBC) ratio resuscitation in patients with severe trauma requiring massive blood transfusion. METHODS The databases including the Cochrane Library, Pubmed, Web of Science, and EMBASE were systemically searched for relevant studies published between January, 2009 and April, 2016. The selection of studies, assessment of methodological quality and data extraction were performed by two researchers independently according to the inclusion and exclusion criteria. The main endpoint was 24-h mortality, 30-day mortality and 24-h survival rate. RESULTS Five observational studies reporting outcomes of 1024 patients were included in this meta-analysis. Four studies documented civilian cases and one study had a military setting. No significant differences were found in the Injury Severity Score (ISS) between patient groups receiving high and low plasma: RBC ratio resuscitation. Compared with the low-ratio group, the patients with high-ratio resuscitation showed a significant reduction in the 24-h mortality rate (OR=0.35, 95%CI [0.25, 0.48], P<0.000 01) and the 30-day mortality rate (OR=0.55, 95%CI [0.41, 0.75], P=0.0001). An increased survival rate was observed in patients receiving high plasma: RBC ratio resuscitation within the initial 24 h following the trauma (HR=2.34, 95%CI [1.46, 3.73], P=0.00001). CONCLUSION Raising the plasma: RBC ratio to 0.5 or higher may decrease the mortality rate of the patients with severe trauma who need massive blood transfusion.
Collapse
Affiliation(s)
- 芳 虞
- />南方医科大学南方医院急诊科,广东 广州 510515Department of Emergency Medicine, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - 涛 钟
- />南方医科大学南方医院急诊科,广东 广州 510515Department of Emergency Medicine, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - 钢 武
- />南方医科大学南方医院急诊科,广东 广州 510515Department of Emergency Medicine, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| |
Collapse
|