Blood product utilisation during massive transfusions : audit and review of the literature

Abstract

Acute exsanguination is the leading cause of mortality in trauma patients.1-3 Massive blood loss potentially results in the development of the ‘lethal triad’, comprising hypothermia, acidosis and coagulopathy.4 Without prompt intervention, including the appropriate administration of blood and blood products, the majority of these patients will demise within 6 hours.2,4,5 Utilisation of blood and blood products in this setting is considered a lifesaving intervention. A massive transfusion can be defined as the 1) the infusion of five units or more of packed red cell concentrate (RCC) within 4 hours;6 2) infusion of more than ten units RCC within the first 24 hours;7-15 or 3) infusion of six or more units RCC within 12 hours.16-18 Irrespective of the formal definition, it has become evident that patients requiring six to nine units of RCC within a 24-hour period have a 2.5 times higher mortality. This mortality risk was significantly higher in patients requiring massive transfusion, than compared to patient groups requiring transfusion of less than six units of RCC.19 Despite controversy with regard to the definition, the aim of these definitions remains the same: early identification of patients with life-threatening bleeds, to ensure proper resuscitation and prevention of complications associated with resuscitation.6 The use of fixed ratios of infused blood products in massive transfusion remains controversial as authors fail to reach consensus on appropriate ratios. These ratios vary from a 1:1:1 ratio for RCC:fresh frozen plasma (FFP):platelets7,12,20-24 to a 6:4:1 ratio.25,26 Despite this lack in consensus, it is evident that the practice of fixed ratio transfusions27,28 in the form of a consistent protocol25,29 has led to a significant reduction in mortality10,30 from in excess of 90%31 to between 30 and 70%,32 although some authors refute these findings.13,17 The aim of this study was to determine local practices with regard to transfusion of blood and blood products in patients undergoing massive transfusion.