The contemporary role of blood products and components used in trauma resuscitation

Abstract

Introduction: There is renewed interest in blood product use for resuscitation stimulated by recent military experience and growing recognition of the limitations of large-volume crystalloid resuscitation.

Methods: An editorial review of recent reports published by investigators from the United States and Europe is presented. There is little prospective data in this area.

Results: Despite increasing sophistication of trauma care systems, hemorrhage remains the major cause of early death after injury. In patients receiving massive transfusion, defined as 10 or more units of packed red blood cells in the first 24 hours after injury, administration of plasma and platelets in a ratio equivalent to packed red blood cells is becoming more common. There is a clear possibility of time dependent enrollment bias. The early use of multiple types of blood products is stimulated by the recognition of coagulopathy after reinjury which may occur as many as 25% of patients. These patients typically have large-volume tissue injury and are acidotic. Despite early enthusiasm, the value of administration of recombinant factor VIIa is now in question. Another dilemma is monitoring of appropriate component administration to control coagulopathy.

Conclusion: In patients requiring large volumes of blood products or displaying coagulopathy after injury, it appears that early and aggressive administration of blood component therapy may actually reduce the aggregate amount of blood required. If recombinant factor VIIa is given, it should be utilized in the fully resuscitated patient. Thrombelastography is seeing increased application for real-time assessment of coagulation changes after injury and directed replacement of components of the clotting mechanism.

Figure 1

Behavior of the computer model for massive bleeding without replacement of clotting factors or platelets. Bleeding fraction is the volume of blood lost divided by the estimated blood volume (4,900 mL). Early loss of clotting factors is seen. (Dotted line is threshold for critical component deficit.)

Figure 2

Diagram showing some of mechanisms leading to coagulopathy in the injured. ACoTS = Acute Coagulopathy of Trauma-Shock.

Figure 3

Mortality Decrease with Higher FFP:PRBC Ratios.

Figure 4

30-day survival using Kaplan-Meier curves comparing patients receiving high ratios of fresh frozen plasma (FFP) and platelets to PRBCs versus patients receiving low ratios of either FFP or platelets. Patients with best outcomes had high ratios of both FFP and platelets to PRBCs while worst outcomes came with low ratios of both FFP and platelets to PRBCs. Where one component, either FFP or platelets was low, intermediate outcomes were obtained.

Figure 5

Rate of Massive Transfusion by ABC Score.

Figure 6

Individual contribution of each component of ABC Score to the likelihood of massive transfusion.

Figure 7

Denver rTEG Protocol - G is a computer-generated value reflecting the complete strength of the clot from initial fibrin burst through fibrinolysis and is calculated from amplitude which begins at the bifurcation of the tracing. This is based on a curvilinear relationship: G = (5,000 × amplitude)/(100 minus amplitude). Conceptually, G is the best measure of clot strength as it reflects the contributions of the enzymatic and platelet components of hemostasis. Normal coagulation is defined as G between 5.3 and 12.4 dynes/cm².