Abstract
Background
It remains unclear whether the association between balanced blood component transfusion
and lower mortality is generalizable to trauma patients receiving varying transfusion
volumes. We sought to study the role red blood cell transfusion volume plays in the
relationships between red blood cell:platelet and red blood cell:fresh frozen plasma
ratios and 4-hour mortality.
Methods
Adult patients in the 2013 to 2018 American College of Surgeons Trauma Quality Improvement
Program database receiving ≥6 red blood cell, ≥1 platelet, and ≥1 fresh frozen plasma
within 4 hours were included. The following 4 cohorts were defined based on 4-hour
red blood cell transfusion volume: (1) 6 to 10 units, (2) 11 to 15 units, (3) 16 to
20 units, and (4) >20 units. The association between red blood cell:fresh frozen plasma,
red blood cell:platelet, and 4-hour mortality was evaluated discretely for each red
blood cell transfusion volume category, statistically adjusting for confounders.
Results
A total of 14,549 patients were included. In patients receiving 6 to 10 units of red
blood cells, red blood cell:platelet ratios were not associated with 4-hour mortality,
and only red blood cell:fresh frozen plasma ≥4:1 were associated with significantly
higher odds of 4-hour mortality compared to 1:1. For patients receiving >10 red blood
cell units, increasing red blood cell:platelet and red blood cell:fresh frozen plasma
ratios were consistently associated with increased odds of 4-hour mortality. For example,
in red blood cell volumes of 11 to 15, 16 to 20, and >20 units, risk-adjusted 4-hour
mortality odds ratios for red blood cell:platelet ≥4:1 were 2.27 (1.47–3.51), 3.32
(2.26–4.90), and 3.01 (2.33–3.88), respectively.
Conclusion
The association between balanced blood component transfusion and 4-hour mortality
is not homogenous in trauma patients requiring different transfusion volumes and is
specifically less evident in patients receiving lower volumes. Such findings should
be considered in the current and future blood shortage crises across the nation.
Graphical abstract
Graphical Abstract
To read this article in full you will need to make a payment
Purchase one-time access:
Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online accessOne-time access price info
- For academic or personal research use, select 'Academic and Personal'
- For corporate R&D use, select 'Corporate R&D Professionals'
Subscribe:
Subscribe to SurgeryAlready a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
References
- Detailed description of all deaths in both the shock and traumatic brain injury hypertonic saline trials of the resuscitation outcomes consortium.Ann Surg. 2015; 261: 586-590
- Died of wounds on the battlefield: causation and implications for improving combat casualty care.J Trauma. 2011; 71: S4-S8
- Death on the battlefield (2001-2011): implications for the future of combat casualty care.J Trauma Acute Care Surg. 2012; 735: S431-S437
- Outcomes of traumatic hemorrhagic shock and the epidemiology of preventable death from injury.Transfusion. 2019; 59: 1423-1428
- An analysis of prehospital deaths: who can we save?.J Trauma Acute Care Surg. 2014; 77: 213-218
- The epidemiology of noncompressible torso hemorrhage in the wars in Iraq and Afghanistan.J Trauma Acute Care Surg. 2013; 74: 830-834
- Injury severity and causes of death from Operation Iraqi Freedom and Operation Enduring Freedom: 2003-2004 versus 2006.J Trauma. 2008; 64: S21-S27
- Staged laparotomy for the hypothermia, acidosis, and coagulopathy syndrome.Am J Surg. 1996; 172: 405-410
- “Damage control”: an approach for improved survival in exsanguinating penetrating abdominal injury.J Trauma. 1993; 35: 375-383
- Management of the major coagulopathy with onset during laparotomy.Ann Surg. 1983; 197: 532-535
- Damage control resuscitation: directly addressing the early coagulopathy of trauma.J Trauma. 2007; 62: 307-310
- Complications of hemorrhagic shock and massive transfusion-a comparison before and after the damage control resuscitation era.Shock. 2021; 56: 42-51
- Improvements in early mortality and coagulopathy are sustained better in patients with blunt trauma after institution of a massive transfusion protocol in a civilian level I trauma center.J Trama. 2009; 66: 1616-1624
- Trends in 1029 trauma deaths at a level 1 trauma center: impact of a bleeding control bundle of care.Injury. 2017; 48: 5-12
- Trauma-induced coagulopathy.Nat Rev Dis Primers. 2021; 7: 30
- The ratio of blood products transfused affects mortality in patients receiving massive transfusions at a combat support hospital.J Trauma. 2007; 63: 805-813
- Ten-year analysis of transfusion in Operation Iraqi Freedom and Operation Enduring Freedom: increased plasma and platelet use correlates with improved survival.J Trauma Acute Care Surg. 2012; 73: S445-S452
- Increased plasma and platelet to red blood cell ratios improves outcome in 466 massively transfused civilian trauma patients.Ann Surg. 2008; 248: 447-458
- Increased platelet: RBC ratios are associated with improved survival after massive transfusion.J Trauma. 2011; 71: S318-S328
- The Impact of Platelet Transfusion in Massively Transfused Trauma Patients.J Vasc Surg. 2011; 53: 1159-1160
- Impact of plasma transfusion in massively transfused trauma patients.J Trauma. 2009; 66: 693-697
- The prospective, observational, multicenter, major trauma transfusion (PROMMTT) Study: comparative effectiveness of a time-varying treatment with competing risks.JAMA Surg. 2013; 148: 127-136
- Transfusion of plasma, platelets, and red blood cells in a 1:1:1 vs a 1:1:2 ratio and mortality in patients with severe trauma: the PROPPR randomized clinical trial.JAMA. 2015; 313: 471-482
- ACS TQIP massive transfusion in trauma guidelines.https://www.facs.org/-/media/files/quality-programs/trauma/tqip/transfusion_guildelines.ashxDate accessed: June 9, 2021
- Joint Trauma System clinical practice guideline (JTS CPG). Damage control resuscitation (CPG ID:18).https://jts.amedd.army.mil/assets/docs/cpgs/Damage_Control_Resuscitation_12_Jul_2019_ID18.pdfDate: 2018Date accessed: March 16, 2022
- Fresh frozen plasma-to-packed red blood cell ratio and mortality in traumatic hemorrhage: nationwide analysis of 4,427 patients.J Am Coll Surg. 2020; 230: 893-901
- Do not forget the platelets: the independent impact of red blood cell to platelet ratio on mortality in massively transfused trauma patients.J Trauma Acute Care Surg. 2022; 93: 21-29
- Multiple imputation of missing values.Stata J. 2004; 4: 227-241
- Multiple Imputation for Nonresponse in Surveys.Wiley, Hoboken, NJ1987
- The strengthening the reporting of observational studies in epidemiology (STROBE) statement: Guidelines for reporting observational studies.Int J Surg. 2014; 12: 1495-1499
- The REporting of studies Conducted using Observational Routinely-collected health Data (RECORD) Statement.PLoS Med. 2015; 12e1001885
- Group on behalf of the PS, Zhang X, et al. Platelet transfusions improve hemostasis and survival in a substudy of the prospective, randomized PROPPR trial.Blood Adv. 2018; 2: 1696-1704
- Red blood cell to plasma ratios transfused during massive transfusion are associated with mortality in severe multiply injury: a retrospective analysis from the Trauma Registry of the Deutsche Gesellschaft für Unfallchirurgie the Working Group on Polytrauma of the German Society of Trauma Surgery (DGU).Vox Sang. 2008; 95: 112-119
- Aggressive fresh frozen plasma (FFP) with massive blood transfusion in the absence of acute traumatic coagulopathy.Injury. 2011; 43: 33-37
- A high ratio of plasma and platelets to packed red blood cells in the first 6 hours of massive transfusion improves outcomes in a large multicenter study.Am J Surg. 2009; 197: 565-570
- Seven deadly sins in trauma outcomes research: an epidemiologic post mortem for major causes of bias.J Trauma Acute Care Surg. 2013; 75: S97-S103
- Development of a field artificial intelligence triage tool: confidence in the prediction of shock, transfusion, and definitive surgical therapy in patients with truncal gunshot wounds.J Trauma Acute Care Surg. 2021; 90: 1054-1060
The American National Red Cross. Red Cross National Blood Supply Shortage Crisis. https://www.redcross.org/about-us/news-and-events/press-release/2022/blood-donors-needed-now-as-omicron-intensifies.html. Accessed April 29, 2022.
- Shortage of plasma-derived products: a looming crisis?.Blood. 2022; 139: 3222-3225
- Expansion of hospital-based blood collections in the face of COVID-19 associated national blood shortage.Transfusion. 2020; 60: 1470-1475
- Triage tool for the rationing of blood for massively bleeding patients during a severe national blood shortage: guidance from the National Blood Transfusion Committee.Br J Haematol. 2020; 191: 340-346
- Survival after ultramassive transfusion: a review of 1360 cases.Transfusion. 2016; 56: 558-563
- Is there a limit to massive blood transfusion after severe trauma?.Arch Surg. 1998; 133: 947-952
- Implementation of massive transfusion protocols in the United States: the relationship between evidence and practice.Anesth Analg. 2017; 124: 9-11
- Massive transfusion protocols: a survey of academic medical centers in the United States.Anesth Analg. 2016; 124: 277-281
- The status of massive transfusion protocols in United States trauma centers: massive transfusion or massive confusion?.Transfusion. 2010; 50: 1545-1551
- TEG-guided resuscitation is superior to standardized MTP resuscitation in massively transfused penetrating trauma patients.J Trauma Acute Care Surg. 2013; 74: 378-386
- Goal-directed hemostatic resuscitation of trauma-induced coagulopathy: a pragmatic randomized clinical trial comparing a viscoelastic assay to conventional coagulation assays.Ann Surg. 2016; 263: 1051-1059
- Rapid thrombelastography thresholds for goal-directed resuscitation of patients at risk for massive transfusion.J Trauma Acute Care Surg. 2017; 82: 114-119
- Older blood is associated with increased mortality and adverse events in massively transfused trauma patients: secondary analysis of the PROPPR trial.Ann Emerg Med. 2019; 73: 650-661
Article info
Publication history
Published online: December 16, 2022
Accepted:
November 13,
2022
Publication stage
In Press Corrected ProofIdentification
Copyright
© 2022 Elsevier Inc. All rights reserved.
