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Timing and location of blood product transfusion and outcomes in massively transfused combat casualties

Cap, Andrew P. MD, PhD; Spinella, Philip C. MD; Borgman, Matthew A. MD; Blackbourne, Lorne H. MD; Perkins, Jeremy G. MD

Journal of Trauma and Acute Care Surgery: August 2012 - Volume 73 - Issue 2 - p S89–S94
doi: 10.1097/TA.0b013e318260625a

BACKGROUND Hemostatic resuscitation using blood components in a 1:1:1 ratio of platelets:fresh frozen plasma:red blood cells (RBCs) is based on analyses of massive transfusion (MT, ≥10 RBC units in 24 hours). These 24-hour analyses are weakened by survival bias and do not describe the timing and location of transfusions. Mortality outcomes associated with early (first 6 hours) resuscitation incorporating platelets, for combat casualties requiring MT, have not been reported.

METHODS We analyzed records for 8,618 casualties treated at the United States military hospital in Baghdad, Iraq, between January 2004 and December 2006. Patients (n = 414) requiring MT, not receiving fresh whole blood, and surviving at least 1 hour (reducing survival bias) were divided into 6-hour apheresis platelet (aPLT) transfusion ratio groups: LOW (aPLT:RBC, ≤0.1, n = 344) and HIGH (aPLT:RBC, >0.1, n = 70). Baseline characteristics of groups were compared. Factors influencing survival on univariate analysis were included in Cox proportional hazards models of 24-hour and 30-day survival.

RESULTS Patients received aPLT in the emergency department (4%), operating room (45%), intensive care unit (51%). The HIGH group presented with higher (p < 0.05) admission International Normalized Ratio (1.6 vs. 1.4), base deficit (8 vs. 7), and temperature (36.7 vs. 36.4). Overall mortality was 27%. At 24 hours, the HIGH group showed lower mortality (10.0% vs. 22.1%, p = 0.02). Absolute differences in 30-day mortality were not significant (HIGH, 18.6%; LOW, 28.8%, p = 0.08). On adjusted analysis, the HIGH group was independently associated with increased survival: LOW group mortality hazard ratios were 4.1 at 24 hours and 2.3 at 30 days compared with HIGH group (p = 0.03 for both). Increasing 6-hour FFP:RBC ratio was also independently associated with increased survival.

CONCLUSION Early (first 6 hours) hemostatic resuscitation incorporating platelets and plasma is associated with improved 24-hour and 30-day survival in combat casualties requiring MT.

LEVEL OF EVIDENCE Therapeutic study, level III.

From the United States Army Institute of Surgical Research (A.P.C., P.C.S., L.H.B.), Fort Sam Houston, Texas; Washington University in St. Louis (P.C.S.), St. Louis, Missouri; San Antonio Military Medical Center (M.A.B.), Fort Sam Houston, Texas; and Walter Reed Army Medical Center (J.G.P.), Washington, District of Columbia.

The views and opinions expressed in the article are those of the authors and do not reflect the official policy or position of the Army Medical Department, Department of the Army, the Department of Defense, or the United States Government.

Address for reprints: Andrew P. Cap, MD, PhD, US Army Institute of Surgical Research, 3698 Chambers Pass, Bldg 3610, Fort Sam Houston, TX 78234-6315; email:

© 2012 Lippincott Williams & Wilkins, Inc.