Massive transfusion in trauma: blood product ratios should be measured at 6 hours Krisztian Sisak, Kathleen Soeyland, Monique McLeod, Melanie Jansen, Natalie Enninghorst, Andrew Martin and Zsolt J. Balogh Department of Traumatology, Division of Surgery, John Hunter Hospital and University of Newcastle, Newcastle, New South Wales, Australia Key words blood product ratio, component therapy, massive transfusion protocol, shock, trauma. Correspondence Professor Zsolt J. Balogh, Department of Traumatology, Division of Surgery, John Hunter Hospital and University of Newcastle, Locked Bag 1, Newcastle, NSW 2310, Australia. Email: zsolt.balogh@hnehealth.nsw.gov.au K. Sisak MD; K. Soeyland MBBS; M. McLeod MBBS; M. Jansen MBBS; N. Enninghorst MD; A. Martin FRACS; Z. J. Balogh MD, FRACS. Accepted for publication 8 June 2011. doi: 10.1111/j.1445-2197.2011.05967.x Abstract Background: Most potentially preventable haemorrhagic deaths occur within 6 h of injury. Conventionally, blood component therapy delivery is measured by 24-h cumu- lative totals and ratios. The study aim was to examine the effect of a massive trans- fusion protocol (MTP) on early (6 h) balanced component therapy. Methods: An 88-month retrospective clinical study at a level 1 trauma centre was undertaken, examining consecutive trauma patients receiving 10 units of packed red blood cells (PRBCs) within 24 h, before (pre-MTP) and after implementation of MTP. Demographic data, injury severity score (ISS), abbreviated injury scale (AIS), shock parameters, coagulation profile, the need for surgical intervention (<24 h), mortality and intensive care unit length of stay were collected. The ratios of blood products given by 6 h, by 24 h and the time between administrations of components was collected and analysed. Results: Pre-MTP and MTP patients had similar demographics, shock severity and initial laboratory findings. Despite MTP patients having had a higher ISS (42  12 versus 36  12, P < 0.05) and AIS head score (2.6  1.8 versus 1.6  2.0, P < 0.05), there was no difference in mortality. Area under the curve (AUC) of the MTP period showed earlier delivery of higher median ratios of fresh frozen plasma (FFP)/PRBC (P = 0.004). Similar findings were found for cryoprecipitate/PRBC and platelet/PRBC ratios. By 24 h, the AUC for FFP/PRBC ratios were no different. Discussion: Implementation of MTP resulted in earlier balanced transfusion. The difference between the FFP/PRBC ratios of the two types of resuscitations levelled by 24 h. The efficacy of component therapy delivery should be measured earlier than 24 h. Introduction Haemorrhagic shock accounts for 30–40% of all trauma deaths, 1,2 and more importantly, is the leading cause of preventable death. 3 Timely haemorrhage control and judicious resuscitation are the key principles of haemorrhagic shock management. Recently, numerous studies attempted to show the superiority of liberal component therapy with ratios that approximate whole blood. 4–7 The development of massive transfusion protocols (MTPs) has been central in achieving improved component ratios and fre- quently improved outcomes compared to historic cohorts. Most of the published evidence on MTPs compares outcomes based on the cumulative ratios of blood products administered during the first 24 h following injury. This is due to the retrospective nature of the studies, which define massive transfusion as >10 U packed red blood cell (PRBC)/24 h. By 24 h, especially among survivors, balanced cumulative values are achieved in most cases. However, these results are affected by survival bias, given that the majority of trauma deaths because of haemorrhage occur early fol- lowing injury and most potentially preventable haemorrhagic deaths happen within the first 6 h. 8 The aim of this study was to examine the effect of implementing a MTP on the timeliness of the delivery of balanced blood compo- nent therapy. We hypothesized that implementation of an MTP will significantly accelerate the process of providing an improved volume of fresh frozen plasma (FFP), cryoprecipitate (CRYO) and platelets (PLT) to complement PRBC transfusion, especially within the first 6 h of resuscitation. ORIGINAL ARTICLE ANZJSurg.com © 2012 The Authors ANZ Journal of Surgery © 2012 Royal Australasian College of Surgeons ANZ J Surg 82 (2012) 161–167