Empirical transfusion strategies for major hemorrhage in trauma patients: A systematic review

Authors: Ritchie, DT, Philbrook, FGA, Leadbitter, S, Kokwe, KN, Meehan, E, McGeady, M, Beaton, M.

Publication: J Trauma Acute Care Surg.; 88,6:855-865. June 2020

Affiliations: School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, United Kingdom.

Abstract: BACKGROUND: Major hemorrhage is a significant cause of mortality and morbidity around the world. There is currently no consensus on the best empirical transfusion strategy. The current National Institute for Clinical Excellence (NICE) guidelines suggest a ratio of 1:1 of red blood cells and plasma. The aim of this study is to compare this to alternative strategies identified through review of the available literature with the objective of identifying the best protocol for mortality outcomes and complication rates. METHODS: A systematic review of the literature was conducted using four databases. Inclusion and exclusion criteria were applied to produce a suitable list of randomized control trials for review. Critical appraisal of each article was then performed, using a Scottish Intercollegiate Guidelines Network- approved checklist, in duplicate and was subject to further independent scrutiny when required. RESULTS: Evidence suggests that early administration of cryoprecipitate within the standard practiced major hemorrhage protocol is associated with a lower risk of mortality. Other strategies suggested a negative impact. Complications including incidence of thromboembolic events, multiple organ failure and sepsis as well as length of stay in hospital following activation of the different protocols and overall transfusion requirements were assessed. No clear optimal protocol was identified from our analysis. CONCLUSION: This project demonstrates that there is no significant clarity regarding morbidity and mortality. As a preliminary recommendation, cryoprecipitate supplementation suggests more favorable mortality over the current protocol. Due to the limited sample populations, we recommend the inclusion of retrospective/prospective cohort studies to bolster the statistical power of any future reviews until randomized control trials of sufficient power are available. LEVEL OF EVIDENCE: Systematic review, Level III.