From the Guidelines
After 6 units of blood, platelets and FFP should be given to maintain hemostatic balance and prevent coagulopathy. During massive transfusion protocols, the administration of platelets and fresh frozen plasma (FFP) is crucial to prevent dilutional coagulopathy. According to the guidelines, a minimum target platelet count of 75 · 10^9.l^-1 is appropriate in this clinical situation 1.
Key Considerations
- The major haemorrhage protocol must be mobilised immediately when a massive haemorrhage situation is declared 1.
- Early infusion of fresh frozen plasma (FFP; 15 ml.kg^-1) should be used to prevent haemostatic failure if a senior clinician anticipates a massive haemorrhage 1.
- Established coagulopathy will require more than 15 ml.kg^-1 of FFP to correct, and the most effective way to achieve fibrinogen replacement rapidly is by giving fibrinogen concentrate or cryoprecipitate if fibrinogen is unavailable 1.
- A 1:1:1 red cell:FFP:platelet regimen, as used by the military, is reserved for the most severely traumatised patients 1.
Administration Guidelines
- Platelets should be administered at a ratio of 1 unit per 6 units of packed red blood cells (PRBCs) to maintain a count above 75 · 10^9.l^-1.
- FFP should be given at a ratio of 1 unit per 1-2 units of PRBCs to maintain fibrinogen levels above 1 g.l^-1 and correct coagulation parameters.
- Administration should begin early in the resuscitation process, ideally with the first units of PRBCs rather than waiting for laboratory evidence of coagulopathy.
From the Research
Guidelines for Administering Platelets and Fresh Frozen Plasma (FFP)
- The optimal dose, timing, and ratio of blood products, including FFP and platelets, to packed red blood cells (PRBCs) in massive transfusion is still unknown 2.
- Studies suggest that higher ratios of FFP and platelets to PRBCs in the first 6 hours of massive transfusion may improve outcomes, with a ratio of 1:1:1 or 1:1:2 being commonly recommended 3, 4.
- A systematic review of randomized controlled trials found that higher transfusion ratios were associated with the transfusion of more FFP and platelets, but did not significantly impact mortality or morbidity 2.
- Current massive transfusion protocols should utilize between 1:1:1 and 1:1:2 ratios of plasma, platelets, and red blood cells 4.
Transfusion Ratios
- A study comparing a 1:1 vs 4:1 PRBC/FFP transfusion ratio during acute massive burn excision found that the 1:1 group received significantly more FFP per patient, with decreased postoperative markers of coagulopathy and acidosis 5.
- Another study found that reconstitution of blood with FFP at different ratios resulted in haematocrit or fibrinogen levels that were borderline with regard to recommended substitution triggers 6.
Administration of Platelets and FFP
- The administration of high ratios of FFP and platelets in the first 6 hours of massive transfusion has been shown to improve survival and decrease overall PRBC need in massively transfused patients 3.
- The use of coagulation factor concentrates for the reconstitution of blood may allow for delivery of a higher haematocrit and a higher fibrinogen content compared with FFP 6.