A high fresh frozen plasma: packed red blood cell transfusion ratio decreases mortality in all massively transfused trauma patients regardless of admission international normalized ratio

Abstract

Background: Coagulopathy is present in 25% to 38% of trauma patients on arrival to the hospital, and these patients are four times more likely to die than trauma patients without coagulopathy. Recently, a high ratio of fresh frozen plasma (FFP) to packed red blood cells (PRBCs) has been shown to decrease mortality in massively transfused trauma patients. Therefore, we hypothesized that patients with elevated International Normalized Ratio (INR) on arrival to the hospital may benefit more from transfusion with a high ratio of FFP:PRBC than those with a lower INR.

Methods: Retrospective multicenter cohort study of 437 massively transfused trauma patients was conducted to determine whether the effect of the ratio of FFP:PRBC on death at 24 hours is modified by a patient's admission INR on arrival to the hospital. Contingency tables and logistic regression were used.

Results: Trauma patients who arrived to the hospital with an elevated INR had a greater risk of death than those with a lower INR. However, as the ratio of FFP:PRBC transfused increased, mortality decreased similarly between the INR quartiles.

Conclusions: The mortality benefit from a high FFP:PRBC ratio is similar for all massively transfused trauma patients. This is contrary to the current belief that only coagulopathic trauma patients benefit from a high FFP:PRBC ratio. Furthermore, it is unnecessary to determine whether INR is elevated before transfusing a high FFP:PRBC ratio. Future studies are needed to determine the mechanism by which a high FFP:PRBC ratio decreases mortality in all massively transfused trauma patients.

Figure 1

Proportion of survivors and non-survivors at 24 hours by International Normalized Ratio (INR) Quartile on arrival to the hospital.

Figure 2. Relationship between the ratio of FFP:PRBC transfused and the probability of death at 24 hours by Admission INR Quartile

This logistic regression model also controls for ISS, GCS, and admission base deficit. Area under the ROC curve=0.79. FFP, fresh frozen plasma; PRBCs, packed red blood cells

Figure 3. Survival analysis demonstrating the probability of survival over the first 24 hours according to admission INR and the ratio of FFP:PRBCs transfused

High Ratio is FFP:PRBC ≥1:2 and Low Ratio is FFP:PRBC <1.2 (log-rank test p=0.009). FFP, fresh frozen plasma; PRBCs, packed red blood cells