E. W. Etchill1, L. M. McDaniel1, S. P. Myers1, J. S. Raval2, A. B. Peitzman1, J. L. Sperry1, M. D. Neal1 1University Of Pittsburgh School Of Medicine,Department Of Surgery,Pittsburgh, PENNSYLVANIA, USA 2University Of North Carolina School Of Medicine,Division Of Transfusion Medicine,Chapel Hill, NORTH CAROLINA, USA
Introduction: Current resuscitation strategies in trauma focus on the delivery of fixed ratios of fresh frozen plasma (FFP) and platelets (PLT) along with packed red blood cells (PRBC) as part of massive transfusion protocols. Unfortunately, there is a paucity of evidence regarding the outcomes of massive transfusion protocols in the non-trauma setting where patients may exhibit a different coagulopathic profile. We hypothesized that the use of increased plasma and platelet to red blood cell ratios ( > 1:2) results in no significant difference in morbidity or mortality compared to lower plasma and platelet to red blood cell ratios ( ≤ 1:2).
Methods: This was a 2-year retrospective single institutional analysis of massively transfused non-trauma patients. Pediatric and obstetric patients, patients on anticoagulants, and patients who died within 24 hours of transfusion were excluded. Ratios of fresh frozen plasma-packed red blood cell (PRBC) were calculated and divided in to a high ratio (FFP:PRBC >1:2) and a low-ratio (FFP:PRBC ≤1:2) group. Platelet ratios were calculated in the same manner. The primary outcomes of interest were 48-hour and 30-day mortality among patients receiving greater than 10 units of PRBC in a 24 hour period. Secondary outcomes included length of stay, ICU days, and ventilator free days. Logistical regression was utilized and a Cox regression survival analysis was performed after controlling for major co-morbidities, ASA and APACHE II scores.
Results: Among 292 massively transfused non-trauma patients, cardiovascular surgery, GI bleeds, and intraoperative complications were the most common indications for massive transfusion. 48-hour mortality, post-transfusion hospital length of stay, ICU length of stay, and ventilator-free days were not significantly different between the high and low ratio FFP:PRBC groups. Interestingly, giving higher ratios of FFP (>1:2 FFP:PRBC) was significantly associated with decreased 30-day survival (66.6% vs. 82.2 %, p =0.0056).
30-day mortality, post-transfusion hospital length of stay, ICU length of stay, and ventilator-free days did not significantly differ between the high and low ratio PLT:PRBC groups. Using multivariate logistic regression analysis, neither FFP:PRBC nor PLT:PRBC ratios were predictors of 48-hour or 30-day mortality.
Conclusion: Our study suggests that higher ratios of FFP and PLT to PRBC, which have been shown to provide a survival benefit in trauma populations, may be of limited benefit in the non-trauma, massively transfused population. Furthermore, a higher ratio of FFP may actually be associated with an increased mortality. Further prospective investigation into the appropriateness of balanced resuscitation in non-trauma populations is warranted.