Association between ratio of fresh frozen plasma to red blood cells during massive transfusion and survival among patients without traumatic injury.

Following reports from US military and civilian trauma centres, the practice of transfusing massively bleeding patients with a high FFP:RBC ratio has been widely adopted for the resuscitation of trauma patients. The authors wanted to determine whether such a transfusion strategy was being used in non-trauma patients and, if this was the case, whether such a transfusion strategy was beneficial.

Mesar et al. reviewed all massive transfusions provided at the Massachusetts General Hospital from January 1, 2009, through December 31, 2012. Massive transfusion was defined as the transfusion of at least 10 units of RBCs in the first 24  hours after a patient’s admission to the operating room, emergency department, or intensive care unit. There were 865 massive transfusion events that occurred within 4 years. Most massive transfusion episodes occurred in patients without trauma (767 [88.7%]), in men (582 [67.3%]), and relative to intraoperative bleeding (544 [62.9%]). The FFP:RBC ratios of survivors and nonsurvivors were nearly identical (1:1.5 vs. 1:1.4, respectively; P = 0.43). Overall, no benefit was observed for a high or low FFP:RBC ratio, including in trauma and cardiac surgery. However, in vascular surgery, a high FFP:RBC ratio was associated with a survival benefit while in medicine and general surgery, a high FFP:RBC ratio was associated with increased mortality.

This study is of particular interest because it highlights two major points. First, the authors show that, contrary to the general perception, nearly 90% of massive transfusions were received by non-trauma patients. Second, there is no evidence that use of a high FFP:RBC transfusion ratio provides any benefit to the non-trauma patient population, except maybe in vascular surgery. Thus, more studies are required to determine the optimal FFP:RBC ratio in different patient populations before clinicians decide to adopt a specific line of conduct when faced with a massively bleeding non-trauma patient. Extending a practice from one indication where it is beneficial to another may not always prove beneficial to the latter…

– Jean-François Hardy