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Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine

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Open Access 01-12-2015 | Original research

Functional capacity of reconstituted blood in 1:1:1 versus 3:1:1 ratios: A thrombelastometry study

Authors: Arne Driessen, Nadine Schäfer, Ursula Bauerfeind, Sigune Kaske, Carolin Fromm-Dornieden, Ewa K Stuermer, Marc Maegele

Published in: Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine | Issue 1/2015

Abstract

Introduction

Different transfusion ratio concepts of packed red blood cells (pRBCs), fresh frozen plasma (FFP) and platelets (PLTs) have been implemented in trauma care, but the optimal ratios are still discussed. In this study the hemostatic potential of two predefined ratios was assessed by using an in vitro thrombelastometric approach. Furthermore, age effects of reconstituted blood were analyzed.

Methods

Whole blood (WB) of voluntary donors was separated into pRBCs, FFP and PLTs and reconstituted into the ratios 1:1:1 and 3:1:1 at day 1, 4, 14, and 24. Standard blood count, electrolytes and coagulation proteins were quantified. The functional coagulation in ratio- and age-specific groups was evaluated using rotational thromboelastometry (ROTEM).

Results

Several coagulation factors reduced significantly in the 3:1:1 ratio and were consistent with increased INR, decelerated clot formation times and A10 (amplitude 10 minutes after clotting time (CT)), flattened α-angle during the EXTEM and diminished MCF for distinct time points during the INTEM, FIBTEM and APTEM assays. With rising age of pRBCs the pH, sodium and potassium reached non-physiological levels.

Conclusion

Under standardized in vitro conditions the higher amount of pRBCs in the 3:1:1 ratio diluted coagulation factors significantly on the expense of its functional coagulation capacity as revealed by ROTEM results. Thus, the coagulation functionality of the 1:1:1 ratio predominated.

Curry N, Stanworth S, Hopewell S, Dorée C, Brohi K, Hyde C. Trauma-induced coagulopathy--a review of the systematic reviews: is there sufficient evidence to guide clinical transfusion practice? Transfus Med Rev. 2011;25:217–31. e2.PubMedCrossRef

Borgman MA, Spinella PC, Perkins JG, Grathwohl KW, Repine T, Beekley AC, et al. The ratio of blood products transfused affects mortality in patients receiving massive transfusions at a combat support hospital. J Trauma. 2007;63:805–13.PubMedCrossRef

Gunter OL, Au BK, Isbell JM, Mowery NT, Young PP, Cotton BA. Optimizing outcomes in damage control resuscitation: identifying blood product ratios associated with improved survival. J Trauma. 2008;65:527–34.PubMedCrossRef

Hoyt DB, Dutton RP, Hauser CJ, Hess JR, Holcomb JB, Kluger Y, et al. Management of coagulopathy in the patients with multiple injuries: results from an international survey of clinical practice. J Trauma. 2008;65:755–64. discussion 764–5.PubMedCrossRef

Young PP, Cotton BA, Goodnough LT. Massive transfusion protocols for patients with substantial hemorrhage. Transfus Med Rev. 2011;25:293–303.PubMedCentralPubMedCrossRef

Levi M, Fries D, Gombotz H, van der Linden P, Nascimento B, Callum JL, et al. Prevention and treatment of coagulopathy in patients receiving massive transfusions. Vox Sang. 2011;101:154–74.PubMedCrossRef

Lier H, Krep H, Schroeder S, Stuber F. Preconditions of hemostasis in trauma: a review. The influence of acidosis, hypocalcemia, anemia, and hypothermia on functional hemostasis in trauma. J Trauma. 2008;65:951–60.PubMedCrossRef

Cushing M, Shaz BH. Blood transfusion in trauma patients: unresolved questions. Minerva Anestesiol. 2011;77:349–59.PubMed

Stahel PF, Moore EE, Schreier SL, Flierl MA, Kashuk JL. Transfusion strategies in postinjury coagulopathy. Curr Opin Anaesthesiol. 2009;22:289–98.PubMedCrossRef

10.

Johansson PI, Stensballe J. Hemostatic resuscitation for massive bleeding: the paradigm of plasma and platelets–a review of the current literature. Transfusion. 2010;50:701–10.PubMedCrossRef

11.

Phan HH, Wisner DH. Should we increase the ratio of plasma/platelets to red blood cells in massive transfusion: what is the evidence? Vox Sang. 2010;98(3 Pt 2):395–402.PubMedCrossRef

12.

Maegele M, Lefering R, Paffrath T, Tjardes T, Simanski C, Bouillon B. Red-blood-cell to plasma ratios transfused during massive transfusion are associated with mortality in severe multiple injury: a retrospective analysis from the Trauma Registry of the Deutsche Gesellschaft für Unfallchirurgie. Vox Sang. 2008;95:112–9.PubMedCrossRef

13.

Kozek-Langenecker S, Sørensen B, Hess JR, Spahn DR. Clinical effectiveness of fresh frozen plasma compared with fibrinogen concentrate: a systematic review. Crit Care. 2011;15:R239.PubMedCentralPubMedCrossRef

14.

Lier H, Böttiger BW, Hinkelbein J, Krep H, Bernhard M. Coagulation management in multiple trauma: a systematic review. Intensive Care Med. 2011;37:572–82.PubMedCrossRef

15.

Rajasekhar A, Gowing R, Zarychanski R, Arnold DM, Lim W, Crowther MA, et al. Survival of trauma patients after massive red blood cell transfusion using a high or low red blood cell to plasma transfusion ratio. Crit Care Med. 2011;39:1507–13.PubMedCrossRef

16.

Murad MH, Stubbs JR, Gandhi MJ, Wang AT, Paul A, Erwin PJ, et al. The effect of plasma transfusion on morbidity and mortality: a systematic review and meta-analysis. Transfusion. 2010;50:1370–83.PubMedCrossRef

17.

Koch CG, Li L, Sessler DI, Figueroa P, Hoeltge GA, Mihaljevic T, et al. Duration of red-cell storage and complications after cardiac surgery. N Engl J Med. 2008;358:1229–39.PubMedCrossRef

18.

Tung J-P, Fraser JF, Nataatmadja M, Colebourne KI, Barnett AG, Glenister KM, et al. Age of blood and recipient factors determine the severity of transfusion-related acute lung injury (TRALI). Crit Care. 2012;16:R19.PubMedCentralPubMedCrossRef

19.

Solomon SB, Wang D, Sun J, Kanias T, Feng J, Helms CC, et al. Mortality increases after massive exchange transfusion with older stored blood in canines with experimental pneumonia. Blood. 2013;121:1663–72.PubMedCentralPubMedCrossRef

20.

Inaba K, Branco BC, Rhee P, Blackbourne LH, Holcomb JB, Spinella PC, et al. Impact of the duration of platelet storage in critically ill trauma patients. J Trauma. 2011;71:1766–73. discussion 1773–4.PubMedCrossRef

21.

Spinella PC, Carroll CL, Staff I, Gross R, Mc Quay J, Keibel L, et al. Duration of red blood cell storage is associated with increased incidence of deep vein thrombosis and in hospital mortality in patients with traumatic injuries. Crit Care. 2009;13:R151.PubMedCentralPubMedCrossRef

22.

Weinberg JA, McGwin G, Griffin RL, Huynh VQ, Cherry SA, Marques MB, et al. Age of transfused blood: an independent predictor of mortality despite universal leukoreduction. J Trauma. 2008;65:279–82. discussion 282–4.PubMedCrossRef

23.

Wang D, Sun J, Solomon SB, Klein HG, Natanson C. Transfusion of older stored blood and risk of death: a meta-analysis. Transfusion. 2012;52:1184–95.PubMedCrossRef

24.

Leal-Noval SR, Muñoz-Gómez M, Arellano-Orden V, Marín-Caballos A, Amaya-Villar R, Marín A, et al. Impact of age of transfused blood on cerebral oxygenation in male patients with severe traumatic brain injury. Crit Care Med. 2008;36:1290–6.PubMedCrossRef

25.

Frank SM, Abazyan B, Ono M, Hogue CW, Cohen DB, Berkowitz DE, et al. Decreased erythrocyte deformability after transfusion and the effects of erythrocyte storage duration. Anesth Analg. 2013;116:975–81.PubMedCentralPubMedCrossRef

26.

Tinmouth A, Chin-Yee I. The clinical consequences of the red cell storage lesion. Transfus Med Rev. 2001;15:91–107.PubMedCrossRef

27.

Simak J, Gelderman MP. Cell membrane microparticles in blood and blood products: potentially pathogenic agents and diagnostic markers. Transfus Med Rev. 2006;20:1–26.PubMedCrossRef

28.

Holovati JL, Wong KA, Webster JM, Acker JP. The effects of cryopreservation on red blood cell microvesiculation, phosphatidylserine externalization, and CD47 expression. Transfusion. 2008;48:1658–68.PubMedCrossRef

29.

Almizraq R, Tchir JDR, Holovati JL, Acker JP. Storage of red blood cells affects membrane composition, microvesiculation, and in vitro quality. Transfusion. 2013;53:2258–67.PubMed

30.

Gonzalez EA, Moore FA, Holcomb JB, Miller CC, Kozar RA, Todd SR, et al. Fresh frozen plasma should be given earlier to patients requiring massive transfusion. J Trauma. 2007;62:112–9.PubMedCrossRef

31.

Baraniuk S, Tilley BC, del Junco DJ, Fox EE, van Belle G, Wade CE, et al. Pragmatic Randomized Optimal Platelet and Plasma Ratios (PROPPR) Trial: Design, rationale and implementation. Injury. 2014;45:1287–95.PubMedCrossRef

32.

Tholpady A, Monson J, Radovancevic R, Klein K, Bracey A. Analysis of prolonged storage on coagulation Factor (F)V, FVII, and FVIII in thawed plasma: is it time to extend the expiration date beyond 5 days? Transfusion. 2013;53:645–50.PubMedCrossRef

33.

Armand R, Hess JR. Treating coagulopathy in trauma patients. Transfus Med Rev. 2003;17:223–31.PubMedCrossRef

34.

Spahn DR, Bouillon B, Cerny V, Coats TJ, Duranteau J, Fernández-Mondéjar E, et al. Management of bleeding and coagulopathy following major trauma: an updated European guideline. Crit Care. 2013;17:R76.PubMedCentralPubMedCrossRef

35.

Farber MK, Sadana N, Kaufman RM, Liu X, Kodali BS. Transfusion ratios for postpartum hemodilutional coagulopathy: an in vitro thromboelastographic model. Am J Obstet Gynecol. 2014;210:323. e1–7.PubMed

36.

Agren A, Edgren G, Kardell M, Ostlund A, Wikman AT. In vitro combinations of red blood cell, plasma and platelet components evaluated by thromboelastography. Blood Transfus. 2014;12:491–6.PubMedCentralPubMed

37.

Wafaisade A, Wutzler S, Lefering R, Tjardes T, Banerjee M, Paffrath T, et al. MMTR of D: Drivers of acute coagulopathy after severe trauma: a multivariate analysis of 1987 patients. Emerg Med J. 2010;27:934–9.PubMedCrossRef

38.

Meng ZH, Wolberg AS, Monroe DM, Hoffman M. The effect of temperature and pH on the activity of factor VIIa: implications for the efficacy of high-dose factor VIIa in hypothermic and acidotic patients. J Trauma. 2003;55:886–91.PubMedCrossRef

39.

Engström M, Schött U, Romner B, Reinstrup P. Acidosis impairs the coagulation: A thromboelastographic study. J Trauma. 2006;61:624–8.PubMedCrossRef

40.

Ostrowski SR, Johansson PI. Endothelial glycocalyx degradation induces endogenous heparinization in patients with severe injury and early traumatic coagulopathy. J Trauma Acute Care Surg. 2012;73:60–6.PubMedCrossRef

41.

Brohi K, Cohen MJ, Ganter MT, Matthay MA, Mackersie RC, Pittet J-F. Acute traumatic coagulopathy: initiated by hypoperfusion: modulated through the protein C pathway? Ann Surg. 2007;245:812–8.PubMedCentralPubMedCrossRef

42.

Brohi K, Cohen MJ, Davenport RA. Acute coagulopathy of trauma: mechanism, identification and effect. Curr Opin Crit Care. 2007;13:680–5.PubMedCrossRef

43.

Hess JR. Resuscitation of trauma-induced coagulopathy. Hematology Am Soc Hematol Educ Program. 2013;2013:664–7.PubMedCrossRef

44.

Cohen MJ. Acute traumatic coagulopathy: Clinical characterization and mechanistic investigation. Thromb Res. 2014;133(Suppl):S25–7.PubMedCrossRef

45.

Maegele M, Schöchl H, Cohen MJ. An update on the coagulopathy of trauma. Shock. 2014;41 Suppl 1:21–5.PubMedCrossRef

46.

Ozment CP, Mamo LB, Campbell ML, Lokhnygina Y, Ghio AJ, Turi JL. Transfusion-related biologic effects and free hemoglobin, heme, and iron. Transfusion. 2013;53:732–40.PubMedCrossRef

47.

Sambasivan CN, Kunio NR, Nair PV, Zink KA, Michalek JE, Holcomb JB, et al. High ratios of plasma and platelets to packed red blood cells do not affect mortality in nonmassively transfused patients. J Trauma. 2011;71(2 Suppl 3):S329–36.PubMedCrossRef

48.

Tinmouth A, Fergusson D, Yee IC, Hébert PC. Clinical consequences of red cell storage in the critically ill. Transfusion. 2006;46:2014–27.PubMedCrossRef

Title: Functional capacity of reconstituted blood in 1:1:1 versus 3:1:1 ratios: A thrombelastometry study
Authors: Arne Driessen
Nadine Schäfer
Ursula Bauerfeind
Sigune Kaske
Carolin Fromm-Dornieden
Ewa K Stuermer
Marc Maegele
Publication date: 01-12-2015
Publisher: BioMed Central
Published in: Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine / Issue 1/2015
Electronic ISSN: 1757-7241
DOI: https://doi.org/10.1186/s13049-014-0080-0

2024 ASCO Annual Meeting

Springer Medicine

Functional capacity of reconstituted blood in 1:1:1 versus 3:1:1 ratios: A thrombelastometry study

Abstract

Introduction

Methods

Results

Conclusion

2024 ASCO Annual Meeting

Springer Medicine

Abstract

Introduction

Methods

Results

Conclusion

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