Hemostatic resuscitation for massive bleeding: the paradigm of plasma and platelets-a review of the current literature

BACKGROUND: Continued hemorrhage remains a major contributor of mortality in massively transfused patients and controversy regarding the optimal management exists. Recent studies indicate a possible survival benefit in patients receiving a higher ratio of plasma and platelets (PLTs) to red blood cells (RBCs) than what is recommended in current transfusion guidelines. STUDY DESIGN AND METHODS: English databases were searched for reports of patients receiving massive transfusion that tested the effects of administration of plasma and/or PLTs in relation to RBCs on survival from January 1990 to March 2009. RESULTS: Fourteen retrospective studies involving 4594 patients were identified. Six tested the effect on survival in relation to fresh-frozen plasma (FFP)-to-RBC ratio, and five investigated FFP-and PLT-to-RBC ratios. Two studies evaluated implementation of massive transfusion protocols with preemptive FFP and PLT administration; one study based transfusion therapy on the result of the thrombelastograph (TEG) analysis versus historic controls. All studies reviewed demonstrate a survival benefit for patients who receive more FFP and PLT as part of the hemostatic resuscitation. When TEG was used to guide transfusion therapy an increase in FFP and PLT was also seen when compared to historic controls and this was associated with improved survival. CONCLUSIONS: High FFP-and PLT-to-RBC ratios seem to improve survival in patients with massive bleeding. Randomized studies evaluating TEG-guided transfusion therapy versus fixed ratios of plasma and PLTs to RBCs in massively bleeding patients is highly warranted.