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Consider Using FFP Earlier in Cases of Massive Transfusion


 

WAIKOLOA, HAWAII — Early administration of fresh-frozen plasma to address coagulopathy can potentially reduce mortality, according to a study of 97 patients who received massive transfusions.

Although hemorrhage is still a major cause of early mortality in trauma patients, it is commonly believed that patients are not coagulopathic when they arrive in the emergency department, and that coagulopathy develops over time, said Dr. Swaminatha Mahadevan, who is associate chief of emergency medicine at Stanford (Calif.) University.

However, recent studies suggest that patients are coagulopathic when they “hit the ED door,” Dr. Mahadevan said at a symposium on emergency medicine sponsored by Stanford University.

“Most massive-transfusion protocols don't address this,” he added.

In Stanford's massive-transfusion protocol, and in many such guidelines throughout the United States, fresh-frozen plasma (FFP) is not given until the patient has received 4–6 U of blood, Dr. Mahadevan said.

In his presentation, Dr. Mahadevan referred to findings from a published study done at the University of Texas, Houston, which pointed to the need for earlier administration of FFP (J. Trauma 2007;62:112–9).

The University of Texas investigators reviewed data on 97 severely injured patients who required a massive transfusion of at least 10 U of packed red blood cells during their first 24 hours in the university hospital. “These patients were sick enough that they eventually had to go to the operating room, or to interventional radiology, to stop the bleeding,” Dr. Mahadevan said.

All of the patients studied were found to have had severe coagulopathy on arrival at the ED, with international normalized ratios (INRs) of 1.8, plus or minus 0.2.

Nevertheless, Dr. Mahadevan noted, because of the way the massive-transfusion guidelines have been set up, none of the patients received FFP until after they received 6 U of packed red cells.

Upon arrival in the ICU following initial resuscitation in the ED, the patients' INRs were still high (1.6, plus or minus 0.1).

Finally, they would start receiving packed red cells and FFP in a 1:1 ratio, Dr. Mahadevan said.

The patients were still moderately coagulopathic 8 hours later, he noted, with a mean INR of 1.4, plus or minus 0.03.

The University of Texas study found that the severity of coagulopathy on ICU admission correlated with an increase in mortality, Dr. Mahadevan observed.

“If your INR was greater than 2, you had a 50% mortality, which, obviously, is significant,” he commented.

Learning from this study, Dr. Mahadevan stressed that “we should be assuming that these patients are coagulopathic, and [we should be] giving FFP right out of the gates,” with an initial transfusion in a 1:1 ratio with packed red blood cells.

Based on the study's findings, the University of Texas investigators influenced the hospital to revise its massive-transfusion protocol for severe bleeding, Dr. Mahadevan noted.

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