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Ten-year analysis of transfusion in Operation Iraqi Freedom and Operation Enduring Freedom: Increased plasma and platelet use correlates with improved survival

Pidcoke, Heather F. MD; Aden, James K. PhD; Mora, Alejandra G.; Borgman, Matthew A. MD; Spinella, Philip C. MD; Dubick, Michael A. PhD; Blackbourne, Lorne H. MD; Cap, Andrew P. MD, PhD

Journal of Trauma and Acute Care Surgery: December 2012 - Volume 73 - Issue 6 - p S445–S452
doi: 10.1097/TA.0b013e3182754796
Original Articles

BACKGROUND: The Joint Theater Trauma Registry database, begun early in Operation Iraqi Freedom and Operation Enduring Freedom, created a comprehensive repository of information that facilitated research efforts and produced rapid changes in clinical care. New clinical practice guidelines were adopted throughout the last decade. The damage-control resuscitation clinical practice guideline sought to provide high-quality blood products in support of tissue perfusion and hemostasis. The goal was to reduce death from hemorrhagic shock in patients with severe traumatic bleeding. This 10-year review of the Joint Theater Trauma Registry database reports the military’s experience with resuscitation and coagulopathy, evaluates the effect of increased plasma and platelet (PLT)–to–red blood cell ratios, and analyzes other recent changes in practice.

METHODS: Records of US active duty service members at least 18 years of age who were admitted to a military hospital from March 2003 to February 2012 were entered into a database. Those who received at least one blood product (n = 3,632) were included in the analysis. Data were analyzed with respect to interactions within and between categories (demographics, admission characteristics, hospital course, and outcome). Transfusions were analyzed with respect to time, survival, and effect of increasing transfusion ratios.

RESULTS: Coagulopathy was prevalent upon presentation (33% with international normalized ratio ≥ 1.5), correlated with increased mortality (fivefold higher), and was associated with the need for massive transfusion. High transfusion ratios of fresh frozen plasma and PLT to red blood cells were correlated with higher survival but not decreased blood requirement. Survival was most correlated with PLT ratio, but high fresh frozen plasma ratio had an additive effect (PLT odds ratio, 0.22).

CONCLUSION: This 10-year evaluation supports earlier studies reporting the benefits of damage-control resuscitation strategies in military casualties requiring massive transfusion. The current analysis suggests that defects in PLT function may contribute to coagulopathy of trauma.

LEVEL OF EVIDENCE: Epidemiologic study, level IV.

Supplemental digital content is available in the article.

From the US Army Institute of Surgical Research (H.F.P., J.K.A., A.G.M., M.A.B., P.C.S., M.A.D., L.H.B., A.P.C.), Brooke Army Medical Center, San Antonio, Texas; Department of Pediatrics (P.C.S.), Washington University in St. Louis, St Louis, Missouri.

This study was conducted under a protocol reviewed and approved by the US Army Medical Research and Materiel Command Institutional Review Board and in accordance with the approved protocol.

The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the Department of the Army or the Department of Defense.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text, and links to the digital files are provided in the HTML text of this article on the journal’s Web site (www.jtrauma.com).

Address for reprints: Andrew P. Cap, MD, PhD, US Army Institute of Surgical Research3400 Rawley E. Chambers Ave, Fort Sam Houston, TX 78234-6315; email: ANDRE.P.CAP@US.ARMY.MIL.

© 2012 Lippincott Williams & Wilkins, Inc.