Mortality in civilian trauma patients and massive blood transfusion treated with high vs low plasma: red blood cell ratio. Systematic review and meta-analysis

  • Henry Oliveros Rodríguez School of Medicine, Universidad de La Sabana, Chía, Colombia
  • Fernando Ríos a. School of Medicine, Universidad de La Sabana, Chía, Colombia. b. Clínica Universidad de La Sabana, Chía, Colombia
  • Cristhian Rubio Epidemiology Postgraduate Program, Facultad de Medicina, Universidad de la Sabana Chía, Colombia
  • Daniel Martin Arsanios School of Medicine, Universidad de La Sabana, Chía, Colombia
  • Andrés Felipe Herazo School of Medicine, Universidad de La Sabana, Chía, Colombia
  • Luis Mateo Beltrán School of Medicine, Universidad de La Sabana, Chía, Colombia
  • Paloma García School of Medicine, Universidad de La Sabana, Chía, Colombia
  • Annie Cifuentes School of Medicine, Universidad de La Sabana, Chía, Colombia
  • Juliana Muñoz School of Medicine, Universidad de La Sabana, Chía, Colombia
  • Javier Polanía School of Medicine, Universidad de La Sabana, Chía, Colombia
Keywords: Meta-analysis, Massive transfusion, Civilian trauma, Mortality, Plasma, Red blood cells

Abstract

Introduction: Massive bleeding in civilian trauma patients leads to dilutional coagulopathy. Transfusion with high plasma: red blood cell (RBC) ratio has been effective in reducing mortality in war trauma patients. However, in civilian trauma the evidence is controversial.

Objective: To assess the impact on mortality of high vs low plasma: RBC ratio transfusion, in civilian trauma patients with massive bleeding.

Methods: A systematic review and meta-analysis, including observational studies and clinical trials, was conducted. Databases were systemically searched for relevant studies between January 2007 and June 2019. The main outcome was early (24-hours) and late (30-day) mortality. Fixed and random effects models were used.

Results: Out of 1295 studies identified, 33 were selected: 2 clinical trials and 31 observational studies. The analysis of observational trials showed both decreased early mortality (odds ratio [OR] 0.67; 95% confidence interval [CI], 0.60–0.75) and late mortality (OR 0.79; 95% CI, 0.71–0.87) with the use of high plasma:RBC ratio transfusion, but there were no differences when clinical trials were evaluated (OR 0.89; 95% CI, 0.64–1.26). The exclusion of patients who died within the first 24hours was a source of heterogeneity. The Injury Severity Score (ISS) altered the association between high plasma: RBC ratio and mortality, with a reduced protective effect when the ISS was high.

Conclusion: The use of high vs low plasma: RBC ratio transfusion, in patients with massive bleeding due to civil trauma, has a protective effect on early and late mortality in observational studies. The exclusion of patients who died within the first 24 hours was a source of heterogeneity.

References

Kauvar DS, Lefering R, Wade CE. Impact of hemorrhage on trauma outcome: an overview of epidemiology, clinical presentations, and therapeutic considerations. J Trauma 2006;60 (6 suppl):S3–S11.

Hess JR, Brohi K, Dutton RP, et al. The coagulopathy of trauma: a review of mechanisms. J Trauma 2008;65:748–754.

MacLeod JB, Lynn M, McKenney MG, et al. Early coagulopathy predicts mortality in trauma. J Trauma 2003;55:39–44.

Brohi K, Singh J, Heron M, et al. Acute traumatic coagulopathy. J Trauma 2003;54:1127–1130.

Ball CG. Damage control resuscitation: history, theory and technique. Can J Surg 2014;57:55–60.

Cotton BA, Reddy N, Hatch QM, et al. Damage control resuscitation is associated with a reduction in resuscitation volumes and improvement in survival in 390 damage control laparotomy patients. Ann Surg 2011;254:598–605.

Duchesne JC, McSwain NE Jr, Cotton BA, et al. Damage control resuscitation: the new face of damage control. J Trauma 2010;69: 976–990.

Spinella PC, Perkins JG, Grathwohl KW, et al. Fresh whole blood transfusions in coalition military, foreign national, and enemy combatant patients during Operation Iraqi Freedom at a U.S. combat support hospital. World J Surg 2008;32:2–6.

Holcomb JB, Fox EE, Wade CE, et al. The PRospective Observational Multicenter Major Trauma Transfusion (PROMMTT) study. J Trauma Acute Care Surg 2013;75 (1 suppl 1):S1–S2.

Baraniuk S, Tilley BC, del Junco DJ, et al. Pragmatic Randomized Optimal Platelet and Plasma Ratios (PROPPR) Trial: design, rationale and implementation. Injury 2014;45:1287–1295.

Holcomb JB, Tilley BC, Baraniuk S, et al. 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.

Gajic O, Dzik WH, Toy P. Fresh frozen plasma and platelet transfusion for nonbleeding patients in the intensive care unit: benefit or harm? Crit Care Med 2006;34 (5 suppl):S170–S173.

Dunbar N, Cooke M, Diab M, et al. Transfusion-related acute lung injury after transfusion of maternal blood: a case–control study. Spine 2010;35:E1322–E1327.

Cohen MJ, West M. Acute traumatic coagulopathy: from endogenous acute coagulopathy to systemic acquired coagulopathy and back. J Trauma 2011;70 (5 suppl):S47–S49.

Rahouma M, Kamel M, Jodeh D, et al. Does a balanced transfusion ratio of plasma to packed red blood cells improve outcomes in both trauma and surgical patients? A meta-analysis of randomized controlled trials and observational studies. Am J Surg 2018;216:342–350.

Zehtabchi S, Nishijima DK. Impact of transfusion of fresh-frozen plasma and packed red blood cells in a 1:1 ratio on survival of emergency department patients with severe trauma. Acad Emerg Med 2009;16:371–378.

Moher D, Liberati A, Tetzlaff J, et al. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. BMJ 2009;339:b2535.

Stang A. Critical evaluation of the Newcastle-Ottawa scale for the assessment of the quality of nonrandomized studies in metaanalyses. Eur J Epidemiol 2010;25:603–605.

Cumpston M, Li T, Page MJ, et al. Updated guidance for trusted systematic reviews: a new edition of the Cochrane Handbook for Systematic Reviews of Interventions. Cochrane Database Syst Rev 2019;10:ED000142.

Chico-Fernández M, García-Fuentes C, Alonso-Fernández MA, et al. Massive transfusion predictive scores in trauma. Experience of a transfusion registry. Med Intensiva 2011;35:546–551.

Peralta R, Vijay A, El-Menyar A, et al. Trauma resuscitation requiring massive transfusion: a descriptive analysis of the role of ratio and time. World J Emerg Surg 2015;10:36.

Holcomb JB, Wade CE, Michalek JE, et al. Increased plasma and platelet to red blood cell ratios improves outcome in 466 massively transfused civilian trauma patients. Ann Surg 2008; 248:447–458.

Sperry JL, Ochoa JB, Gunn SR, et al. An FFP:PRBC transfusion ratio ≥1:1.5 is associated with a lower risk of mortality after massive transfusion. J Trauma 2008;65:986–993.

Duchesne JC, Hunt JP, Wahl G, et al. Review of current blood transfusions strategies in a mature level I trauma center: were we wrong for the last 60 years? J Trauma 2008;65:272–276.

Maegele M, Lefering R, Paffrath T, et al. Red-blood-cell to plasma ratios transfused during massive transfusion are associated with mortality in severe multiple injury: a retrospective analysis from the Trauma Registry of the Deutsche Gesellschaft fur Unfallchirurgie. Vox Sanguinis 2008;95:112–119.

Gunter OL Jr, Au BK, Isbell JM, et al. Optimizing outcomes in damage control resuscitation: identifying blood product ratios associated with improved survival. J Trauma 2008;65:527–534.

Kashuk JL, Moore EE, Johnson JL, et al. Postinjury life threatening coagulopathy: is 1:1 fresh frozen plasma:packed red blood cells the answer? J Trauma 2008;65:261–270.

Teixeira PG, Inaba K, Shulman I, et al. Impact of plasma transfusion in massively transfused trauma patients. J Trauma 2009;66:693–697.

Snyder CW, Weinberg JA, McGwin G Jr, et al. The relationship of blood product ratio to mortality: survival benefit or survival bias? J Trauma 2009;66:358–362.

Dente CJ, Shaz BH, Nicholas JM, et al. 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 Trauma 2009;66:1616–1624.

Zink KA, Sambasivan CN, Holcomb JB, et al. A high ratio of plasma and platelets to packed red blood cells in the first 6hours of massive transfusion improves outcomes in a large multicenter study. Am J Surg 2009;197:565–570.

Mitra B, Mori A, Cameron PA, et al. Fresh frozen plasma (FFP) use during massive blood transfusion in trauma resuscitation. Injury 2010;41:35–39.

Shaz BH, Dente CJ, Nicholas J, et al. Increased number of coagulation products in relationship to red blood cell products transfused improves mortality in trauma patients. Transfusion 2010;50:493–500.

Lustenberger T, Frischknecht A, Bruesch M, et al. Blood component ratios in massively transfused, blunt trauma patients—a time-dependent covariate analysis. J Trauma 2011;71:1144–1150.

Spoerke N, Michalek J, Schreiber M, et al. Crystalloid resuscitation improves survival in trauma patients receiving low ratios of fresh frozen plasma to packed red blood cells. J Trauma 2011;71 (2 suppl 3):S380–S383.

Rowell SE, Barbosa RR, Allison CE, et al. Gender-based differences in mortality in response to high product ratio massive transfusion. J Trauma 2011;71 (2 suppl 3):S375–S379.

Peiniger S, Nienaber U, Lefering R, et al. Balanced massive transfusion ratios in multiple injury patients with traumatic brain injury. Crit Care 2011;15:R68.

Magnotti LJ, Zarzaur BL, Fischer PE, et al. Improved survival after hemostatic resuscitation: does the emperor have no clothes? J Trauma 2011;70:97–102.

Borgman MA, Spinella PC, Holcomb JB, et al. The effect of FFP:RBC ratio on morbidity and mortality in trauma patients based on transfusion prediction score. Vox Sanguinis 2011;101:44–54.

De Biasi AR, Stansbury LG, Dutton RP, et al. Blood product use in trauma resuscitation: plasma deficit versus plasma ratio as predictors of mortality in trauma (CME). Transfusion 2011 51:1925–1932.

Brasel KJ, Vercruysse G, Spinella PC, et al. The association of blood component use ratios with the survival of massively transfused trauma patients with and without severe brain injury. J Trauma 2011;71 (2 suppl 3):S343–S352.

Wafaisade A, MaegeleM, Lefering R, et al. High plasma to red blood cell ratios are associated with lower mortality rates in patients receiving multiple transfusion (4=red blood cell units<10) during acute trauma resuscitation. J Trauma 2011;70:81–88.

Brown JB, Cohen MJ, Minei JP, et al. Debunking the survival bias myth: characterization of mortality during the initial 24hours for patients requiring massive transfusion. J Trauma Acute Care Surg 2012;73:358–364.

Sharpe JP, Weinberg JA, Magnotti LJ, et al. Accounting for differences in transfusion volume: are all massive transfusions created equal? J Trauma Acute Care Surg 2012;72:1536–1540.

Duchesne JC, Heaney J, Guidry C, et al. Diluting the benefits of hemostatic resuscitation: a multi-institutional analysis. J Trauma Acute Care Surg 2013;75:76–82.

Simms ER, Hennings DL, Hauch A, et al. Impact of infusion rates of fresh frozen plasma and platelets during the first 180 minutes of resuscitation. J Am College Surg 2014;219:181–188.

Guidry C, DellaVope J, Simms E, et al. Impact of inverse ratios on patients with exsanguinating vascular injuries: should more be the new paradigm? J Trauma Acute Care Surg 2013;74:403–409.

Nascimento B, Callum J, Tien H, et al. Effect of a fixed-ratio (1:1:1) transfusion protocol versus laboratory-results-guided transfusion in patients with severe trauma: a randomized feasibility trial. CMAJ 2013;185:E583–E589.

Kudo D, Sasaki J, Akaishi S, et al. 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. Surg Today 2014;44:653–661.

Kim Y, Lee K, Kim J, et al. Application of damage control resuscitation strategies to patients with severe traumatic hemorrhage: review of plasma to packed red blood cell ratios at a single

institution. J Korean Med Sci 2014;29:1007–1011.

Stanworth SJ, Davenport R, Curry N, et al. Mortality from trauma haemorrhage and opportunities for improvement in transfusion practice. Br J Surg 2016;103:357–365.

Endo A, Shiraishi A, Fushimi K, et al. Outcomes of patients receiving a massive transfusion for major trauma. Br J Surg 2018; 105:1426–1434.

Stensballe J, Henriksen HH, Johansson PI. Early haemorrhage control and management of trauma-induced coagulopathy: the importance of goal-directed therapy. Curr Opin Crit Care 2017;23:503–510.

Cannon JW, Khan MA, Raja AS, et al. Damage control resuscitation in patients with severe traumatic hemorrhage: A practice management guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg 2017;82:605–617.

Riskin DJ, Tsai TC, Riskin L, et al. Massive transfusion protocols: the role of aggressive resuscitation versus product ratio in mortality reduction. J Am College Surg 2009;209:198–205.

González EA, Moore FA, Holcomb JB, et al. Fresh frozen plasma should be given earlier to patients requiring massive transfusion. J Trauma 2007;62:112–119.

Neal MD, Hoffman MK, Cuschieri J, et al. Crystalloid to packed red blood cell transfusion ratio in the massively transfused patient: when a little goes a long way. J Trauma Acute Care Surg 2012;72:892–898.

Tapia NM, Suliburk J, Mattox KL. The initial trauma center fluid management of penetrating injury: a systematic review. Clin Orthopaedics Related Res 2013;471:3961–3973.

Savage SA, Zarzaur BL, Croce MA, et al. Redefining massive transfusion when every second counts. J Trauma Acute Care Surg 2013;74:396–400.

Cantle PM, Cotton BA. Prediction of massive transfusion in trauma. Crit Care Clin 2017;33:71–84.

Terceros-Almanza LJ, García-Fuentes C, Bermejo-Aznarez S, et al. Prediction of massive bleeding. Shock index and modified shock index. Med Intensiva 2017;41:532–538.

Nunez TC, Voskresensky IV, Dossett LA, et al. Early prediction of massive transfusion in trauma: simple as ABC (assessment of blood consumption)? J Trauma 2009;66:346–352.

Yucel N, Lefering R, Maegele M, et al. Trauma Associated Severe Hemorrhage (TASH)-Score: probability of mass transfusion as surrogate for life threatening hemorrhage after multiple trauma. J Trauma 2006;60:1228–1236.

Schreiber MA, Perkins J, Kiraly L, et al. Early predictors of massive transfusion in combat casualties. J Am College Surg 2007;205: 541–545.

Kuhne CA, Zettl RP, Fischbacher M, et al. Emergency Transfusion Score (ETS): a useful instrument for prediction of blood transfusion requirement in severely injured patients. World J Surg 2008;32:1183–1188.

Rainer TH, Ho AM, Yeung JH, et al. Early risk stratification of patients with major trauma requiring massive blood transfusion. Resuscitation 2011;82:724–729.

Schochl H, Nienaber U, Hofer G, et al. Goal-directed coagulation management of major trauma patients using thromboelastometry (ROTEM)-guided administration of fibrinogen concentrate and prothrombin complex concentrate. Crit Care 2010;14:R55.

Johansson PI, Stensballe J. Effect of haemostatic control resuscitation on mortality in massively bleeding patients: a before and after study. Vox Sanguinis 2009;96:111–118.

How to Cite
Oliveros Rodríguez, H., Ríos, F., Rubio, C., Arsanios, D. M., Herazo, A. F., Beltrán, L. M., García, P., Cifuentes, A., Muñoz, J., & Polanía, J. (2020). Mortality in civilian trauma patients and massive blood transfusion treated with high vs low plasma: red blood cell ratio. Systematic review and meta-analysis. Colombian Journal of Anesthesiology, 48(3), 126-137. Retrieved from https://www.revcolanest.com.co/index.php/rca/article/view/904

Downloads

Download data is not yet available.
Published
2020-07-01
How to Cite
Oliveros Rodríguez, H., Ríos, F., Rubio, C., Arsanios, D. M., Herazo, A. F., Beltrán, L. M., García, P., Cifuentes, A., Muñoz, J., & Polanía, J. (2020). Mortality in civilian trauma patients and massive blood transfusion treated with high vs low plasma: red blood cell ratio. Systematic review and meta-analysis. Colombian Journal of Anesthesiology, 48(3), 126-137. Retrieved from https://www.revcolanest.com.co/index.php/rca/article/view/904
Section
Systematic review

Most read articles by the same author(s)