Jean-François Hardy, MD
CHUM Hôpital Notre-Dame
Montréal, Québec, Canada
The management of massive hemorrhage/transfusion in trauma has evolved considerably in the past few years, mainly because of the experience of the US military in the Iraq war. Based on a consensus established in 2005, several civilian trauma centers have adopted a restrictive approach to the administration of crystalloids in view of minimizing hemodilution, along with the transfusion of red blood cells (RBC), fresh frozen plasma (FFP) and platelet concentrates (PC) in a 1:1:1 ratio . However, it must be remembered that this practice is based on retrospective analyses, subject to a number of limitations and biases, and that the civilian context is, most often, quite different from that of the battlefield [2-4].
Aside the obvious age and health differences between the civilian and military populations, all published studies are affected by the “ascertainment bias”, i.e. the difficulty of collecting data in the extreme and hostile environment of trauma . The “survivorship bias” may also limit interpretation of the results: more severely injured patients surviving less than two hours are less likely to receive FFP if the product is not pre-thawed (as in most centers) . Finally, as mentioned elsewhere, retrospective studies, contrary to randomized controlled trials, cannot establish causality between an intervention and the observed outcome .
Proponents of the 1:1:1 ratio invoke the need to treat diligently the acute coagulopathy of trauma (ACT) which is present in approximately 25% of patients at the time they present in the emergency room. When present, the ACT considerably increases the risk of mortality (46% vs. 10.9% when it is absent) . Nevertheless, we still do not know if the ACT is simply a marker of the severity of trauma or a determinant of survival, i.e. no one has established that treating the ACT improves patient prognosis. Others have postulated that fulminant hyperfibrinolysis, as observed in severe trauma and associated with a mortality of 100%, could be the marker of an unsurvivable injury .
On the other hand, initiation of the 1:1:1 massive transfusion protocol (MTP) when transfusion of RBC would have sufficed exposes patients to the adverse events associated to the transfusion of FFP and PC. It should be kept in mind that approximately 17% of civilian trauma patients require a transfusion and that, in total, 2 to 5% of patients will require 10 or more RBC units. Thus, the 1:1:1 MTP applies to only a small proportion of trauma victims. Finally, it is clear that the MTP does not apply to elective surgery or in the medical context where bleeding is controlled/slower, transfusion is progressive, normothermia and normovolemia can be maintained and hemostasis can be monitored in an ongoing fashion [8, 9].
In summary, there has been no clear demonstration to this day that the 1:1:1 MTP decreases morbidity or improves survival in civilian trauma patients. Despite the major difficulties of conducting research in the context of severe trauma, randomized controlled trials will be necessary to establish the true benefits of this transfusion strategy . In the meantime, clinicians should keep in mind that (1) a MTP is required in less than 5% of civilian major trauma patients and that (2) a traditional approach based on the monitoring of hemostasis and the transfusion of the appropriate blood products should be adopted in the vast majority of bleeding patients. Point-of-care diagnostic tools, such as thromboelastography (TEG) or thromboelastometry (ROTEM), may prove useful, eventually, in the context of trauma and surgery [7, 11, 12] but, at present, the benefits of TEG/ROTEM remain uncertain .
1. Holcomb JB, Jenkins D, Rhee P, et al. Damage control resuscitation: directly addressing the early coagulopathy of trauma. J Trauma 2007;62(2):307-310.
2. Callum JL, Nascimento B, Tien H, Rizoli S. Editorial: "formula-driven" versus "lab-driven" massive transfusion protocols: at a state of clinical equipoise. Transfus Med Rev 2009;23(4):247-254.
3. Nascimento B, Callum J, Rubenfeld G, Neto JB, Lin Y, Rizoli S. Clinical review: Fresh frozen plasma in massive bleedings - more questions than answers. Crit Care 2010;14(1):202.
4. Stansbury LG, Dutton RP, Stein DM, Bochicchio GV, Scalea TM, Hess JR. Controversy in trauma resuscitation: do ratios of plasma to red blood cells matter? Transfus Med Rev 2009;23(4):255-265.
5. Hardy JF, Bélisle S, Van der Linden P. Efficacy and safety of recombinant activated factor VII to control bleeding in nonhemophiliac patients: a review of 17 randomized controlled trials. Ann Thorac Surg 2008;86(3):1038-1048.
6. Brohi K, Singh J, Heron M, Coats T. Acute traumatic coagulopathy. J Trauma 2003;54(6):1127-1130.
7. Schöchl H, Frietsch T, Pavelka M, Jambor C. Hyperfibrinolysis after major trauma: differential diagnosis of lysis patterns and prognostic value of thrombelastometry. J Trauma 2009;67(1):125-131.
8. Erber WN. Massive blood transfusion in the elective surgical setting. Transfus Apheresis Sci 2002;27(1):83-92.
9. Hardy JF, de Moerloose P, Samama CM. The coagulopathy of massive transfusion. Vox Sang 2005;89(3):123-127.
10. Hardy JF, Van der Linden P, Fergusson D. If we have bandwagons, magic bullets, and theoretical constructs, why do we need randomized clinical trials in transfusion medicine and perioperative hemostasis? Can J Anaesth 2011;58:240-245.
11. Johansson PI, Stissing T, Bochsen L, Ostrowski SR. Thrombelastography and tromboelastometry in assessing coagulopathy in trauma. Scand J Trauma Resusc Emerg Med 2009;17:45.
12. Kashuk JL, Moore EE, Sawyer M, et al. Postinjury coagulopathy management: goal directed resuscitation via POC thrombelastography. Ann Surg 2010;251(4):604-614.
13. Afshari A, Wikkelso A, Brok J, Moller AM, Wetterslev J. Thrombelastography (TEG) or thromboelastometry (ROTEM) to monitor haemotherapy versus usual care in patients with massive transfusion. Cochrane Database Syst Rev 2011;3:CD007871.