An evaluation of the impact of apheresis platelets used in the setting of massively transfused trauma patients.

INTRODUCTION: Trauma is a major cause of morbidity and mortality worldwide. Of patients arriving to trauma centers, patients requiring massive transfusion (MT, >or=10 units in 24 hours) are a small patient subset but are at the highest risk of mortality. Transfusion of appropriate ratios of blood products to such patients has recently been an area of interest to both the civilian and military medical community. Plasma is increasingly recognized as a critical component, though less is known about appropriate ratios of platelets. Combat casualties managed at the busiest combat hospital in Iraq provided an opportunity to examine this question. METHODS: In-patient records for 8,618 trauma casualties treated at the military hospital in Baghdad more than a 3-year interval between January 2004 and December 2006 were retrospectively reviewed and patients requiring MT (n = 694) were identified. Patients who required MT in the first 24 hours and did not receive fresh whole blood were divided into study groups defined by source of platelets: (1) patient receiving a low ratio of platelets (<1:16 apheresis platelets per stored red cell unit, aPLT:RBC) (n = 214), (2) patients receiving a medium ratio of platelets (1:16 to <1:8 aPLT:RBC) (n = 154), and (3) patients receiving a high ratio of platelets (>or=1:8 aPLT:RBC) (n = 96). The primary endpoint was survival at 24 hours and at 30 days. RESULTS: At 24 hours, patients receiving a high ratio of platelets had higher survival (95%) as compared with patients receiving a medium ratio (87%) and patients receiving the lowest ratio of platelets (64%) (log-rank p = 0.04 and p < 0.001, respectively). The survival benefit for the high and medium ratio groups remained at 30 days as compared with those receiving the lowest ratio of platelets (75% and 60% vs. 43%, p < 0.001 for both comparisons). On multivariate regression, plasma:RBC ratios and aPLT:RBC were both independently associated with improved survival at 24 hours and at 30 days. CONCLUSION: Transfusion of a ratio of >or=1:8 aPLT:RBC is associated with improved survival at 24 hours and at 30 days in combat casualties requiring a MT within 24 hours of injury. Although prospective study is needed to confirm this finding, MT protocols outside of investigational research should consider incorporation of appropriate ratios of both plasma and platelets.

The use of fresh whole blood in massive transfusion.

BACKGROUND: Most indications for whole blood transfusion are now well managed exclusively with blood component therapy, yet the use of fresh whole blood for resuscitating combat casualties has persisted in the U.S. military. METHODS: Published descriptions of whole blood use in military and civilian settings were compared with use of whole blood at the 31st Combat Support Hospital (31st CSH) stationed in Baghdad in 2004-2005. FINDINGS: Concerns about logistics, safety, and relative efficacy of whole blood versus component therapy have argued against the use of whole blood in most settings. However, military physicians have observed some distinct advantages in fresh warm whole blood over component therapy during the massive resuscitation of acidotic, hypothermic, and coagulopathic trauma patients. In this critical role, fresh whole blood was eventually incorporated as an adjunct into a novel whole-blood-based massive transfusion protocol. CONCLUSIONS: Under extreme and austere circumstances, the risk:benefit ratio of whole blood transfusion favors its use. Fresh whole blood may, at times, be advantageous even when conventional component therapy is available.

The dynamics and ethics of triage: rationing care in hard times.

Triage of medical care, whether necessary because of routine daily limitations or forced by exceptional circumstances, such as for soldiers injured in combat or civilians in mass casualty situations, is increasingly coming under scrutiny. The decisions that limit access to fundamental and even life-or-death treatments are fraught with controversy. These decisions are difficult for the medical provider to make and are even more difficult for the patient to understand. Medical providers are poorly trained to address the numerous factors involved in triage decisions under the pressure of limited time. Patients are understandably selfish and short-sighted regarding their own care. Both provider and patient can feel that triage is immoral. In contrast, when triage is taught proactively and reviewed relative to the situation, the ethical principles that guide triage are evident and intact. Both provider and patient must learn the considerations and consequences of triage.