title: Postinjury life threatening coagulopathy: is 1:1 fresh frozen plasma:packed red blood cells the answer?
abstract: BACKGROUND
  Recent military experience suggests that immediate 1:1 fresh frozen plasma (FFP); red blood cells (RBC) for casualties requiring >10 units packed red blood cells (RBC) per 24 hours reduces mortality, but no clinical trials exist to address this issue. Consequently, we reviewed our massive transfusion practices during a 5-year period to test the hypothesis that 1:1 FFP:RBC within the first 6 hours reduces life threatening coagulopathy.
  
  
  METHODS
  We queried our level I trauma center's prospective registry from 2001 to 2006 for patients undergoing massive transfusion. Logistic regression was used to evaluate the independent effect of FFP:RBC in 133 patients who received >10 units RBC in 6 hours on (1) Coagulopathy (international normalized ratio [INR] >1.5 at 6 hours), controlling for our previously described risk factors predictive of coagulopathy, as well as RBC, FFP, and platelet administration (2) Death (controlling for all variables plus age, crystalloids per 24 hours, INR >1.5 at 6 hours).
  
  
  RESULTS
  Overall mortality was 56%; 50% died from acute blood loss in the operating room. Over 80% of the RBC transfusions were completed in the first 6 hours: (Median RBC: 18 units) Median FFP:RBC survivors, 1:2, nonsurvivors: 1:4. (p < 0.001) INR >1.5 at 6 hours occurred in 30 (23%); 81% died. Regarding mortality, logistic regression showed significant variables (p < 0.05) included: RBC per 6 hours (OR = 1.248, 95%CI: 1.957-53.255), INR at 6 hours >1.5 (OR = 10.208, 95% CI: 1.957-53.255), ED temperature <34 degrees C (OR = 15.491, 95% CI 1.376-174.396), and age >55 years (OR = 40.531, CI 5.315-309.077). The adjusted OR for FFP:RBC ratio including the quadratic term was found to follow a U-shaped association (quadratic term estimate 0.6737 +/- 0.0345, p = 0.0189).
  
  
  CONCLUSIONS
  Although our data suggest that 1:1 FFP:RBC reduced coagulopathy, this did not translate into a survival benefit. Our findings indicate that the relationship between coagulopathy and mortality is more complex, and further clinical investigation is necessary before recommending routine 1:1 in the exsanguinating trauma patient.
authors.affiliation: Department of Surgery and Surgical Research, Denver Health Medical Center, Denver, Colorado 80204-4507, USA. Jeffry.Kashuk@dhha.org
authors.forename: Jeffry L
authors.initials: JL
authors.lastname: Kashuk
authors.forename: Ernest E
authors.initials: EE
authors.lastname: Moore
authors.forename: Jeffrey L
authors.initials: JL
authors.lastname: Johnson
authors.forename: James
authors.initials: J
authors.lastname: Haenel
authors.forename: Michael
authors.initials: M
authors.lastname: Wilson
authors.forename: John B
authors.initials: JB
authors.lastname: Moore
authors.forename: C Clay
authors.initials: CC
authors.lastname: Cothren
authors.forename: Walter L
authors.initials: WL
authors.lastname: Biffl
authors.forename: Anirban
authors.initials: A
authors.lastname: Banerjee
authors.forename: Angela
authors.initials: A
authors.lastname: Sauaia
mesh_terms: D000328:Adult; D001778:Blood Coagulation Disorders / Q000209:etiology / Q000517:prevention & control*; D016913:Blood Component Transfusion / Q000379:methods* / Q000401:mortality; D016063:Blood Loss, Surgical / Q000401:mortality; D017707:Erythrocyte Transfusion; D005260:Female; D006801:Humans; D016015:Logistic Models; D008297:Male; D016017:Odds Ratio; D010949:Plasma; D012189:Retrospective Studies; D016019:Survival Analysis; D014947:Wounds and Injuries / Q000150:complications* / Q000401:mortality / Q000601:surgery