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Thu Feb 14 12:01:37 GMT 2008

Karim

An old addage says that if you aim at nothing - you're sure to hit it.

With the 1:1:1 philosophy if we aim to get the FFP & PLT in to the bleeding patient as soon as possible we may just prevent the complications of the coagulopathy than if we tried to play catch-up later after the massive red-cell only transfusion.

My thought therefore is that by getting the blood bank "on the go" to get the products will end up with something of the comprimise you advocate: somewhere between 1:1 and 1:3 or 4. Some is still better than none.

Also there is more evidence out there for this than just the trials you mention!

My 2c of personal bias
tim
Dr T C Hardcastle
M.B.,Ch.B.(Stell); M.Med(Chir); FCS(SA)
Senior Surgeon / Senior Lecturer: Surgery (Trauma and ICU)
ATLS  instructor and DSTC Cape Town Course Director
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-----Original Message-----
From: trauma-list-bounces at trauma.org
[mailto:trauma-list-bounces at trauma.org]On Behalf Of Karim Brohi
Sent: Wednesday, February 13, 2008 1:42 AM
To: 'Trauma &amp; Critical Care mailing list'
Subject: RE: Who's doing 1:1 blood transfusions for shock?

<<  It has NOT been universally accepted, however, and I am not sure why. >>
Ron

Because one swallow doesn't make a spring, and one retrospective military
study shouldn't change global practice.

Most of the evidence of effect lies in those patients that are significantly
under-treated - those that receive no plasma or ratios below 1:4.  There is
less effect in lowering the ratio below 1:4.  Some studies show benefit,
some no effect, some worse outcome (see paper from Denver at last year's
AAST).

There are huge potential for bias and confounding factors in these
retrospective studies.  Gonzalez has shown that patients who are really
bleeding are more likely to fall below the desired transfusion algorithm
(whichever is being used).  Those patients who are sickest are more likely
to get lower ratios, as teams struggle to keep up with the haemorrhage and
plasma is delivered slower than red cells.

Those of you who anecdotally believe that less transfusions are used are not
supported by the data, which suggest that an equal amount of products are
used in each group within the first 24 hours.  Whatever the mechanism, it's
not clear that the actual number of blood products administered is different
between groups.

The evidence for platelets is even shakier (read non-existent).  Especially
if you believe in plasma, because the volume of plasma that the platelets
are stored in could potentially completely explain the platelet effect.

There are significant implications for providing 1:1 plasma instead of 1:3 -
more use of AB plasma, increased risks, increased work for transfusion
staff, increased likelihood of error, and inability to keep up (Par
Johansson, a world-class transfusionist in Copenhagen has been running 1:1
for years and has modelled resource provision.  He is clear that provision
of 1:1 ratios during multiple casualty events is almost impossible).

Now I'm not saying that 1:1 is not the right thing to do.   It may be, but
we have a suggestion of effect and that is all at present.  Read the
Cochrane review on plasma therapy - for any indication.  There's so little
evidence out there it behoves us to investigate this more thoroughly before
we expose our patients to 3-4 times the dose of a product we have little
knowledge of.

Sadly I'm speaking 'For' 1:1 in Vegas - which is much easier and more boring
:-)

Karim

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Who's doing 1:1 blood transfusions for shock?