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What Is the Best Ratio of Plasma, Platelets, and Red Blood Cells for Massive Transfusions?

By Ken Milne, MD | on April 14, 2015 | 1 Comment
CME CME Now Skeptics' Guide to EM
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Case

A 23-year-old male presents to the ED with multiple gunshot wounds to the chest and is hemodynamically unstable. Your clinical gestalt tells you he is going to need a massive transfusion.

Question

What is the effectiveness and safety of transfusing adult patients with severe trauma and major bleeding using plasma, platelets, and red blood cells (RBCs) in a 1:1:1 ratio versus a 1:1:2 ratio?

Background

Trauma is the leading cause of death in the United States among patients between the ages of 1 and 44. The U.S. Department of Defense developed damage-control resuscitation to try to prevent some of these deaths. It involves taking a balanced approach of providing blood products in a 1:1:1 ratio of plasma, platelets, and RBCs.

There have been no large, multicenter, randomized clinical trials with survival as a primary end point. The Prospective, Observational, Multicenter, Major Trauma Transfusion (PROMMTT) was a large observational trial that demonstrated that many clinicians were transfusing patients with a ratio of 1:1:1 or 1:1:2 and that early transfusion of plasma and platelets was associated with improved six-hour survival after admission.

Relevant Article

Holcomb JB, Tilley BC, Baraniuk S, et al. Transfusion of plasma, platelets, and red blood cells in a 1:1:1 vs a 1:1:2 ratio and mortality in patients with severe trauma: the PROPPR randomized clinical trial. JAMA. 2015;313(5):471-482.

  • Population: Patients ≥15 years of age requiring at least 1 U of any blood component within the first hour of arrival or during prehospital transport and/or predicted by the Assessment of Blood Consumption (ABC) Score ≥2 or clinical gestalt to need massive transfusion.
  • Intervention: 1:1:1 ratio
  • Comparison: 1:1:2 ratio
  • Outcome: All cause mortality at 24 hours and 30 days. Secondary outcomes: time to hemostasis, blood product volumes transfused, and complications.

Authors’ Conclusions

“Among patients with severe trauma and major bleeding, early administration of plasma, platelets, and red blood cells in a 1:1:1 ratio compared with a 1:1:2 ratio did not result in significant differences in mortality at 24 hours or at 30 days. However, more patients in the 1:1:1 group achieved hemostasis, and fewer experienced death due to exsanguination by 24 hours. Even though there was an increased use of plasma and platelets transfused in the 1:1:1 group, no other safety differences were identified between the two groups.”

Key Results

No statistically significant difference in mortality at 24 hours (12.7 percent versus 17.0 percent) or at 30 days (22.4 percent versus 26.1 percent) for 1:1:1 compared to 1:1:2 ratio.

Pages: 1 2 3 Single Page

Topics: Continuing Medical EducationCritical CareEmergency DepartmentEmergency PhysicianPatient SafetyPlasmaPlateletsProcedures and SkillsTransfusionTrauma and Injury

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About the Author

Ken Milne, MD

Ken Milne, MD, is chief of emergency medicine and chief of staff at South Huron Hospital, Ontario, Canada. He is on the Best Evidence in Emergency Medicine faculty and is creator of the knowledge translation project the Skeptics Guide to Emergency Medicine.

View this author's posts »

One Response to “What Is the Best Ratio of Plasma, Platelets, and Red Blood Cells for Massive Transfusions?”

  1. March 22, 2018

    Allan Reply

    This article was decently helpful, and i found it interesting. Thanks! 🙂

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Polls

With regard to state legislative activity regulating the opioid prescribing practices of emergency physicians, which of the following wouId you support? Check all that apply.

  • Restrictions on duration (36%, 229 Votes)
  • Restrictions of quantity (34%, 219 Votes)
  • Mandatory checking of prescription drug monitoring systems for all opioid prescriptions from the ED (30%, 194 Votes)

Total Voters: 367

Polls results not statistically significant.
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