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Hemostatic Effects of Fresh Frozen Plasma May be Maximal at Red Cell Ratios of 1:2

Davenport, Ross BSc, MD, MRCS; Curry, Nicola MD, MRCP; Manson, Joanna MD, MRCS; De'Ath, Henry MD, MRCS; Coates, Amy BSc; Rourke, Claire BSc; Pearse, Rupert MD, FRCA; Stanworth, Simon MD, MRCP; Brohi, Karim MD, FRCA, FRCS

The Journal of Trauma: Injury, Infection, and Critical Care: January 2011 - Volume 70 - Issue 1 - p 90-96
doi: 10.1097/TA.0b013e318202e486
Original Article

Background: Damage control resuscitation targets acute traumatic coagulopathy with the early administration of high-dose fresh frozen plasma (FFP). FFP is administered empirically and as a ratio with the number of packed red blood cells (PRBC). There is controversy over the optimal FFP:PRBC ratio with respect to outcomes, and their hemostatic effects have not been studied. We report preliminary findings on the effects of different FFP:PRBC ratios on coagulation.

Methods: This is a prospective observational cohort study of trauma patients requiring >4 U of PRBCs. Blood was drawn before and after each 4-U PRBC interval for prothrombin time and analysis by rotational thromboelastometry. Interval change in coagulation parameters were compared with the FFP:PRBC ratio received during each interval.

Results: Sixty 4-U PRBC intervals from 50 patients were available for analysis. All measures of coagulation deteriorated with low FFP:PRBC ratios (<1:2). Maximal hemostatic effect was observed in the 1:2 to 3:4 group: 12% decrease in prothrombin time (p = 0.006), 56% decrease in clotting time (p = 0.047), and 38% increase in maximum clot firmness (p = 0.024). Transfusion with ≥1:1 ratio did not confer any additional improvement. There was a marked variability in response to FFP, and hemostatic function deteriorated in some patients exposed to 1:1 ratios. The beneficial effects of plasma were confined to patients with coagulopathy.

Conclusions: Interim results from this prospective study suggest that FFP:PRBC ratios of ≥1:1 do not confer any additional advantage over ratios of 1:2 to 3:4. Hemostatic benefits of plasma therapy are limited to patients with coagulopathy.

From the Trauma Clinical Academic Unit, Blizard Institute of Cell and Molecular Science (R.D., J.M., H.D., A.C., C.R., K.B.) and William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom; and NHS Blood and Transplant (N.C., R.P., S.S.), John Radcliffe Hospital, Oxford, United Kingdom.

Submitted for publication January 9, 2010.

Accepted for publication October 21, 2010.

Supported by the National Institute for Health Research Programme Grant for Applied Research (RP-PG-0407-10036).

Rupert Pearse is a National Institute for Health Research (UK) Clinician Scientist. Pentapharm GmbH (Munich, Germany) provided ROTEM reagent and equipment on an unrestricted basis.

Presented at the 23rd Annual Meeting of the Eastern Association for the Surgery of Trauma, January 19–23, 2010, Phoenix, Arizona.

Address for reprints: Karim Brohi, Trauma Clinical Academic Unit, Royal London Hospital, Whitechapel, London E1 1BB, United Kingdom; email:

© 2011 Lippincott Williams & Wilkins, Inc.