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

[Karim Brohi]

<<  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