Anything But Crystalloid

The balanced transfusion ratio has been in vogue for many years in military settings (read: whole blood), but, until recently, less popular with civilians. There are probably still kinks to be worked out with respect to improving the value of resource consumption in massive transfusion, but, at the least, it appears roughly equivalent ratios of plasma to blood cells are beneficial.

So, given the opportunity, why not initiate this sort of balanced resuscitation in the prehospital setting?

This somewhat messy and heterogenous trial does precisely that – randomizing 523 unstable trauma patients to either standard resuscitation or transfusion of 2 units of FFP, followed by standard resuscitation. The randomization took place in clusters at the aeromedical transport base level, and included bases whose initial protocol included PRBC transfusions for eligible patients. In these instances, the FFP was transfused first, and then the PRBCs. Additionally, 111 of the enrolled aeromedical transports were transfers from an outlying hospital. This meant the pre-enrollment resuscitation could be virtually any permutation of potential volume replacement. While the two groups were roughly balanced as far as etiologies of trauma, injury severity, and other baseline features, the initiation of FFP prior to standard resuscitation did skew the numbers with respect towards prehospital PRBCs, as they had to wait until the intervention transfusion was complete.

Overall, 24-hour mortality was 22% in the “standard care” group and 14% in the plasma group. Only a handful of potentially transfusion-related adverse events occurred, and this early survival advantage proved durable through the length of follow-up. There is enough in the pre-specified subgroup analysis to fuel any number of editorials, other retrospective analyses, and homegrown inclusion or exclusion criteria for prehospital FFP – but, overall, this grossly consistent with our priors for a survival advantage associated with balanced transfusions.

Now, what we really need, is a plasma product with a better shelf-life ….

“Prehospital Plasma during Air Medical Transport in Trauma Patients at Risk for Hemorrhagic Shock”