Patients with a trauma-induced coagulopathy account for more than half of hemorrhagic deaths in the United States. About 25% of severely injured patients are already coagulopathic and thrombocytopenic upon arrival to trauma centers. Mortality rates have been shown to decrease in these patients when they receive higher ratios of plasma and platelets. “Early transfusion of red blood cells (RBCs) has been established as a core element of trauma resuscitation,” says Bryan A. Cotton, MD, MPH. “Most trauma centers store RBCs in their EDs, but few store plasma in their EDs. This makes it challenging to achieve high plasma-RBC ratios early during care, which in turn can worsen coagulopathy and increase patient mortality.”
Expediting Plasma Delivery
Over the past several years, more and more trauma centers have implemented massive transfusion (MT) protocols to ensure that severely injured patients receive higher plasma-RBC ratios early. “This was shown to markedly reduce the time to release of plasma, but the time to transfusion was still excessively long,” Dr. Cotton says. In an effort to expedite the delivery of plasma for patients requiring MT, some medical centers began keeping thawed plasma (TP) in their blood banks (BBs).
MT protocols vary throughout trauma centers in the U.S., but those reporting the most marked changes in survival are the ones that have implemented concurrent TP programs. Furthermore, trauma centers that develop TP programs concurrent with MT protocols have shown that they can reduce the time to first plasma transfusion and the overall number of blood components transfused.
Testing a New Thawed Plasma Protocol
In 2006, Dr. Cotton and colleagues began a TP program in their BB to make plasma readily available for delivery in their MT protocol. This process involved keeping at least 10 units of group AB TP and some group A plasma available at all times. A marked decrease in blood product use was observed; mortality rates also decreased from 66% to 51%. However, despite having a mature MT protocol and a focus on earlier transfusion of plasma, the time to first unit of plasma was still delayed by 60 to 75 minutes from arrival in an internal audit.
“Most trauma centers store RBCs in their EDs, but few store plasma in their EDs.”
More recently, Dr. Cotton and colleagues had a retrospective study published in JAMA Surgery that assessed a new strategy to delivery and transfusion of plasma. The research team implemented a TP-ED program that involved placing 4 units of thawed AB plasma in the ED emergency release blood refrigerator. “The thought was that having TP readily available in the ED would reduce the time to first plasma transfusion,” says Dr. Cotton. “We were also hoping to reduce 24-hour blood product use and mortality rates.”
Thawed Plasma in the ED Yields Significant Results
In the study, adult trauma patients with severe injuries were divided into two groups. The pre-intervention group consisted of those who were admitted 8 months before implementing a protocol using TP in blood banks (TP-BB), whereas the post-intervention group consisted of similar patients who were admitted 8 months after implementing TP location change (TP-ED).
Although median times to the first unit of RBCs were similar between pre- and post-intervention study groups, the time from arrival to first unit of plasma was just 43 minutes for patients in the TP-ED group, compared with 89 minutes for the TP-BB group. Time to first plasma transfusion among those receiving an MT was reduced from 59 to 14 minutes. The earliest plasma was infused 3 minutes after arrival. Furthermore, the TP-ED protocol was associated with a reduction in 24-hour transfusion of RBCs, plasma, and platelets (Table 1). After controlling for the anatomical severity of injury, physiologic instability, shock, and the mechanism of injury, the TP-ED protocol was an independent predictor of decreased 30-day mortality, decreasing the risk of death by about 60% (Table 2).
More Work to Be Done
While the TP-ED protocol evaluated in the study by Dr. Cotton and colleagues was successful in reducing time to first plasma transfusion, blood product use, and mortality, more studies are needed to validate the findings. “Our protocol reduced 30-day mortality, but this may have been the result of our institution being able to provide a more hemostatic resuscitation immediately after patients arrive to the ED,” says Dr. Cotton. “However, the protocol was successful enough to have our institution begin keeping plasma and RBC products readily available in the ED. In turn, this has replaced initial resuscitation that used crystalloid-based strategies.”
Readings & Resources (click to view)
Radwan ZA, Matijevic N, del Junco DJ, et al. An emergency department thawed plasma protocol for severely injured patients. JAMA Surg. 2013;148:170-175. Available at: http://archsurg.jamanetwork.com/article.aspx?articleid=1654848.
Cotton BA, Dossett LA, Au BK, Nunez TC, Robertson AM, Young PP. Room for (performance) improvement: provider-related factors associated with poor outcomes in massive transfusion. J Trauma. 2009;67:1004-1012.
Young PP, Cotton BA, Goodnough LT. Massive transfusion protocols for patients with substantial hemorrhage. Transfus Med Rev. 2011;25:293-303.
Holcomb JB, Wade CE, Michalek JE, et al. Increased plasma and platelet to red blood cell ratios improves outcome in 466 massively transfused civilian trauma patients. Ann Surg. 2008;248:447-458.