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HOUSTON – Giving severe trauma patients a transfusion with a balanced ratio of plasma, platelets, and red blood cells (RBCs) is more likely to stop severe bleeding and reduce the risk of death from blood loss over 24 hours than transfusing a higher ratio of RBCs, according to a new study.
Background in the article, published recently in the Journal of the American Medical Association, notes that about 20% to 40% percent of trauma deaths occurring after hospital admission involve extensive hemorrhage from an injury to the trunk of the body and are potentially preventable with rapid hemorrhage control and improved resuscitation techniques, including massive transfusion.
The authors, led by researchers from the University of Texas Health Science Center at Houston, add that earlier transfusion with balanced blood product ratios (1:1:1 ratios for plasma, platelets, and red blood cells) – dubbed "damage control resuscitation” – has been associated with improved outcomes. No large multicenter clinical trials had previously tested that supposition, however.
To determine the value of using a balanced transfusion, researchers focused on the cases of 680 severely injured patients who arrived at one of 12 level 1 trauma centers and were predicted to require massive transfusion. The patients were randomly assigned to receive blood product ratios of 1:1:1 for units of plasma to platelets to red blood cells – a ratio that is the closest approximation to reconstituted whole blood – or 1:1:2 during active resuscitation. The patients also received all local standard-of-care interventions.
Patients were assigned to one the component ratios within eight minutes of calling the blood bank to allow the rapid delivery and infusion of the predetermined ratios, according to the study.
No statistically significant differences for the primary outcomes of the study were found; mortality at 24 hours was 12.7% in the 1:1:1group vs. 17% in the 1:1:2 , while mortality at 30 days was 22.4% vs. 26.1%, respectively.
Exsanguination, the predominant cause of death within the first 24 hours, was significantly decreased in the 1:1:1 group, 9.2% vs. 14.6% in the 1:1:2 group, however. In addition, more patients in the 1:1:1 group achieved hemostasis than in the 1:1:2 group – 86% vs. 78%.
The authors emphasize that, despite concerns that the 1:1:1 group would experience higher rates of multiple inflammatory-mediated complications such as acute respiratory distress syndrome, multiple organ failure, infection, blood clots, and sepsis, no such differences were detected between the two treatment groups.
"Given the lower percentage of deaths from exsanguination and our failure to find differences in safety, clinicians should consider using a 1:1:1 transfusion protocol, starting with the initial units transfused while patients are actively bleeding, and then transitioning to laboratory-guided treatment once hemorrhage control is achieved,” the researchers write. “Future studies of hemorrhage control products, devices, and interventions should concentrate on the physiologically relevant period of active bleeding after injury and use acute complications and later deaths (24 hours and 30 days) as safety end points.”