Transfusion management of trauma patients

Abstract

The management of massively transfused trauma patients has improved with a better understanding of trauma-induced coagulopathy, the limitations of crystalloid infusion, and the implementation of massive transfusion protocols (MTPs), which encompass transfusion management and other patient care needs to mitigate the "lethal triad" of acidosis, hypothermia, and coagulopathy. MTPs are currently changing in the United States and worldwide because of recent data showing that earlier and more aggressive transfusion intervention and resuscitation with blood components that approximate whole blood significantly decrease mortality. In this context, MTPs are a key element of "damage control resuscitation," which is defined as the systematic approach to major trauma that addresses the lethal triad mentioned above. MTPs using adequate volumes of plasma, and thus coagulation factors, improve patient outcome. The ideal amounts of plasma, platelet, cryoprecipitate and other coagulation factors given in MTPs in relationship to the red blood cell transfusion volume are not known precisely, but until prospective, randomized, clinical trials are performed and more clinical data are obtained, current data support a target ratio of plasma:red blood cell:platelet transfusions of 1:1:1. Future prospective clinical trials will allow continued improvement in MTPs and thus in the overall management of patients with trauma.

Figure 1

Laboratory-based blood product administration. Fluid and blood component treatment in major bleeding. Values of various parameters represent trigger points at which relevant blood components should be transfused. RBC = red blood cells; FFP = fresh frozen plasma; PCC = prothrombin complex concentrate; Fg = fibrinogen; Plt = platelets; Hct = hematocrit; PT = prothrombin time; aPTT = activated partial thromboplastin time. (Reprinted with permission from Spahn and Rossaint.)

Figure 2

Predetermined blood product administration. The Grady Memorial Hospital/Emory University Massive Transfusion Protocol (modified from Dente et al.).

Figure 3

Ratio of blood products transfused affects mortality in patients receiving massive transfusions. Percentage mortality associated with low, medium, and high plasma to RBC ratios transfused at admission in a combat hospital. Ratios are median ratios per group and include units of fresh whole blood counted both as plasma and RBCs. (Reprinted with permission from Borgman et al.)