An emergency department thawed plasma protocol for severely injured patients

Zayde A Radwan, Yu Bai, Nena Matijevic, Deborah J del Junco, James J McCarthy, Charles E Wade, John B Holcomb, Bryan A Cotton
JAMA Surgery 2013, 148 (2): 170-5

IMPORTANCE: In an effort to expedite delivery of plasma for patients requiring massive transfusions, US medical centers began keeping thawed plasma (TP) in their blood banks (BBs), markedly reducing time to release of plasma; however, the time to transfusion was still excessively long.

OBJECTIVE: To expedite delivery and transfusion of TP through implementation of an emergency department (ED) protocol.

DESIGN AND SETTING: Retrospective cohort study in an American College of Surgeons-verified level I trauma center.

PARTICIPANTS: Using the Trauma Registry of the American College of Surgeons database, we evaluated all adult trauma patients admitted from June 1, 2009, through August 31, 2010, who arrived directly from the scene, were the institution's highest level trauma activation, and received at least 1 U of red blood cells and 1 U of plasma in the first 6 hours after admission. The protocol was initiated in February 2010 by giving 4 U of AB plasma to patients in the ED. Patients were then divided into 2 groups: those admitted 8 months before (TP-BB) and 8 months after implementing TP location change (TP-ED).

MAIN OUTCOME MEASURES: Primary outcome was time to first unit of plasma. Secondary outcomes included 24-hour blood use and 24-hour and 30-day mortality.

RESULTS: A total of 294 patients met the study criteria (130 in the TP-BB group and 164 in the TP-ED). Although the patient demographics were similar, TP-ED patients had greater anatomical injury (median Injury Severity Score, 18 vs 25; P = .02) and more physiologic disturbances (median weighted Revised Trauma Score, 6.81 vs 3.83; P = .008). The TP-ED patients had a shorter time to first plasma transfusion (89 vs 43 minutes, P < .001). The TP-ED protocol was associated with a reduction in 24-hour transfusion of RBCs (P = .04), plasma (P = .04), and platelets (P < .001). Logistic regression identified TP-ED as an independent predictor of decreased 30-day mortality (odds ratio, 0.43; 95% CI, 0.194-0.956; P = .04).

CONCLUSIONS: We demonstrated that implementation of an ED-TP protocol expedites transfusion of plasma to severely injured patients. This approach is associated with a reduction in overall blood product use and a 60% decreased odds in 30-day mortality.

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