British Journal of Anaesthesia 113 (S2): ii3–ii8 (2014)
doi:10.1093/bja/aeu379
CRITICAL CARE
Role of the massive transfusion protocol in the management
of haemorrhagic shock
J. H. Waters
Department of Anesthesiology, Magee Womens Hospital, University of Pittsburgh Medical Center, Pittsburgh, USA
E-mail: watejh@upmc.edu
Editor’s key points
† Retrospective data from victims of severe military
trauma have led to fixed blood component ratio
therapy in trauma.
† Close inspection of these studies reveals important
limitations in their interpretation including a
prominent effect of survivor bias.
† Point-of-care viscoelastic testing of whole blood
coagulation provides an individualized approach to
therapy to reduce unnecessary plasma transfusion.
From the experience gained during the Iraq and Afghanistan
conflicts, a concept of damage control resuscitation has
arisen. Within the context of damage control resuscitation is
the incorporation of the massive transfusion protocol, which
dictates that blood is delivered expeditiously to the bleeding
patient, generally in a fixed ratio. The protocol is intended
to provide blood to the patient bedside in a rapid fashion.
At the author’s institution for example, 10 units of O+ uncross-
matched packed red blood cell (RBC) units, 6 units of AB
plasma, and 2 bags of platelets are provided.
The importance of the ratio of these products is where
controversy arises. Some evidence, which will be discussed,
implies that these products should be administered in a
fixed ratio of 1 unit of packed erythrocytes to 1 unit of
plasma to 1 unit of platelets (generally termed the 1:1:1
transfusion ratio). Most of these studies focus primarily on
the erythrocyte to plasma ratio so in reality, this discussion
primarily entails a 1:1 erythrocyte:plasma transfusion ratio.
In 1982, the phrase ‘viscious circle of trauma’ was coined,
which refers to the acidosis, hypothermia, and coagulopathy
of trauma.1 The intent of aggressive plasma use is to address
the coagulopathy of trauma at an early stage. The following dis-
cussion is an unsystematic review of literature related to the
fixed ratio plasma to red cell transfusion strategy.
Fixed ratio transfusion
The evidence for a 1:1 transfusion ratio derives from a number
of studies. The landmark study that started this practice was by
Borgman and colleagues in 2007.2 This was a retrospective
chart review of massive transfusion at a US Army combat
& The Author 2014. Published by Oxford University Press on behalf of the British Journal of Anaesthesia. All rights reserved.
For Permissions, please email: journals.permissions@oup.com
The concept of rapid delivery of multiple blood products to the bedside of
a massively haemorrhaging patient seems to be a logical approach to the
management of the massively bleeding patient. However, controversy
exists in the use of fixed blood component ratios. Assessing the extent
of the coagulopathy through point-of-care testing might provide
Downloaded from http://bja.oxfordjournals.org/ by guest on January 2, 2016
patients with product administration as needed, and avoid excessive
transfusion and its associated complications.
Keywords: blood component transfusion; consumption coagulopathy;
erythrocytes; trauma
Accepted for publication: 29 September 2014
support hospital. Massive transfusion was defined as .10
RBC units in 24 h. They separated 246 patients into three
groups, depending on the ratio of RBCs to plasma. High
plasma patients who received high ratios of plasma units to
RBCs had higher survival rates compared with those who
received a low ratio of plasma units to RBCs. From this non-
randomized, retrospective analysis, the authors concluded
that a higher ratio of plasma to erythrocytes contributed to a
better outcome. What seems to have been neglected in the
analysis was that the patients who received the high ratio
had lower rates of thoracic and head injuries; had haemoglobin
concentrations on presentation to the combat hospital that
were 1.5 gm dl21 higher than the low ratio group; had
reduced base deficit (8 compared with the low ratio group
with a base deficit of 13); and had a lower International nor-
malized ratio (INR) of 1.54 compared with the low ratio group
whose INR was 1.78. So, the low ratio group was more acidotic,
more coagulopathic, and more anaemic than the high ratio
group. In addition, for the patients who died in the low ratio
group, they did so at an average of 2 h from arrival into the
combat facility; whereas, the patients in the high ratio group
died on average at 37 h and died more commonly from
sepsis, multi-organ failure, and central nervous system injury.
A number of studies similar in study design followed the
Borgman study (see Table 1). In 2008, a retrospective civilian
study involving 16 level I trauma centres and 467 patients
was published,5 which also found improved survival with
higher ratios of plasma and platelets. This study appeared to
be the catalyst for many trauma surgeons to adopt the 1:1
transfusion strategy. Like the Borgman study, there were
BJA
stark differences in time-to-death between the patients that
received high ratios of plasma and platelets. If the time of
death and the average number of blood products administered
to the patients who died in each group are used to estimate
rates of blood product administration between ratio groups,
stark differences in patient populations appear to exist in this
study also. Patients who were categorized in a low plasma,
low platelet group, received erythrocytes at a rate of 5.25
units per hour before death whereas for the high plasma,
high platelet group erythrocytes were given at a rate of 0.63
units per hour (Table 2). Additionally, the mechanism of
injury was truncal and head injury in 58% of the low ratio
patients and 23% in the high ratio patients. While this study
has been highly influential, caution would be suggested in
translating these findings to civilian trauma.
Each of the studies outlined in Table 1 has flaws associated
with their retrospective study design. Most prominently, sur-
vivor bias has been a repetitive source of error in these 1:1
ratio studies. Survivor bias is associated with having survived
long enough to receive a particular therapy. A nice example
to illustrate this bias is shown in Figure 1. In Figure 1A, four
erythrocyte units are administered to a patient followed by a
plasma unit, at which point the patient dies. In Figure 1B, the
same pattern of blood administration occurred; however, the
patient did not die and was given further plasma units before
the end of resuscitation. So, the short survival patient in
Figure 1A received an erythrocyte:plasma ratio of 4:1 (low
ratio); whereas the surviving patient in Figure 1B received a
1:1 ratio of erythrocyte to plasma (high ratio). This illustrates
survivor bias in that the only real difference is that the
patient in Figure 1A simply died earlier whereas the therapy
was identical up until that point.
To assess the effect of survivor bias, Snyder and colleagues12
looked at the impact of a high ratio of plasma to RBCs com-
pared with a low ratio (Table 3). In this study, 40% of the high
ratio patients died while 58% of the low ratio patients died.
However, if one looks at the time of death, there is clearly a
difference between groups. Like the aforementioned studies,
the low ratio group patients died much earlier in their care.
When Snyder and colleagues looked at the relative risk of
death with a time-varying covariate, the survival advantage
of the added plasma disappeared, thus confirming the exist-
ence of this bias.
Effect of plasma on coagulation function
Many of the studies outlined in Table 1 report average INR
values that are mildly or slightly elevated, generally around
an INR of 1.8. While there is no debate that trauma is asso-
ciated with coagulopathy, there is substantial evidence that
transfusing plasma in circumstances where the INR is mini-
mally elevated has a minimal effect on the INR.15 – 17 While
minimal effect on INR occurs, it does expose the patient to
risks associated with plasma transfusion.18 These risks pri-
marily relate to acute allergic reactions,19 transfusion related
acute lung injury,20 21 and transfusion associated circulatory
overload.22
ii4
Waters
Part of this minimal effect relates to the variable pro-
coagulant potency of transfused plasma. The INR of trans-
fused plasma ranges from ,1 to .1 based on the donor
and the effect of storage. Some plasma can have an INR as
high as 1.3.23 So, if an INR level is ,1.3, there is a good
chance that plasma transfusion will raise the INR. In addition,
correction of an INR is not linear and at low INR values,
plasma has little effect.24 25 If plasma is given to raise
coagulation factor concentrations by 10%, the effect will be
very different depending upon the starting INR. For instance,
if the INR is 1.5 and enough plasma is given to raise factor
concentrations by 10%, then the result will be to correct it
to 1.4. A similar change in 10% when the INR is 3.0 will
result in a new INR of 2.3, so the effect is much greater at
higher INRs. Recent evidence suggests that conventional la-
boratory tests of coagulation are insensitive in detection
acquired coagulopathy as in trauma, or in guiding procoagu-
lant therapy.26 27
With the understanding that varying effects of plasma
Downloaded from http://bja.oxfordjournals.org/ by guest on January 2, 2016
transfusion are seen at varying INR values, what is necessary
to raise the INR level by 10%? First, each plasma unit varies in
volume depending on how it is collected and the haematocrit
of the donor. In general, each unit contains 250 ml with each
millilitre of plasma containing one unit of procoagulant activ-
ity. Since the procoagulant content of a unit of plasma is
diluted by anticoagulant and since some activity is lost in pro-
cessing, a 250 ml unit of plasma might be expected to provide
200 units of procoagulant activity on average. Recovery of
procoagulant factors in plasma is not 100%, however, and
may be as low as 20 –40%. Thus, in a 70 kg patient with a
3000 ml plasma volume, transfusion of one 250 ml unit of
plasma might be expected to increase most factors by
2.5% (or 0.025 U ml21). Transfusion of four units would
raise levels by 10%. The 1:1 RBC: plasma ratio is predicated
on correction of one arm of the lethal triad of trauma (acidosis,
hypothermia, and coagulopathy). Administration of 1 unit of
plasma to treat mildly abnormal INR elevations would be
anticipated to have little to no effect on coagulation function
while exposing the patient to the adverse effects of plasma.
Adverse effects of aggressive plasma use
Logically, it would seem that more plasma would facilitate re-
suscitation early in the hospital course of a trauma patient, but
the question must be asked as to whether such aggressive
plasma use simply facilitates resuscitation that could be
achieved with a different colloid solution such as albumin. If
this better resuscitation is facilitated, is there harm that
could potentially arise from aggressive plasma use compared
with an alternate therapy.
Several investigators have attempted to answer this ques-
tion. Perel and colleagues,28 in a secondary analysis of the
CRASH-2 (clinical randomization of an antifibrinolytic in sig-
nificant haemorrhage 2) trial data (a study to assess the
impact of tranexamic acid in trauma patients), found that
transfusion increased the survival in a patient population
where 50% of the patients were predicted to die; whereas
 MTP in haemorrhagic shock
Table 1 Studies advocating 1:1 transfusion ratios. PRBC, packed red blood cells. NR, not reported; FFP, plasma; PRBC, erythrocytes; TEP, transfusion exsanguination protocol; MT, massive transfusion;
MTP, massive transfusion protocol; LOS, length of stay; MOF, multiple organ failure; ARDS, acute respiratory distress syndrome.

Author, year Study design Follow-up Interventions Control Outcomes

Borgman, 20071 Retrospective, cohort NR FFP:PRBC ratios from 1:8 to FFP:PRBC ratio 1:1.4 High FFP, lower death
1:2.5
Cotton, 20083 Non-randomized pre- post- 30 days TEP (PRBC:FFP:Plts 10:4:2) No TEP less FFP, also needed TEP reduced death
.10 units PRBC in first 24 h
Cotton, AAST, 20083 Non-randomized pre- post- NR TEP (PRBC:FFP 3:2) No TEP, less FFP TEP reduced MOF
Gunter, 20084 Non-randomized pre- post- 30 days PRBC:FFP 3:2 or greater PRBC:FFP 3:2 or less High FFP, lower death
Holcomb, 20085 Retrospective cohort 30 days High plasma to PRBC≥1:2 Low plasma to PRBC.1:2 High FFP, lower death
Duchesne, 20086 Retrospective cohort Death High plasma to PRBC.1:2 Low plasma to PRBC.1:2 High FFP, lower death
Kashuk, 20087 Retrospective cohort Death, or LOS FFP:PRBC ratios from 1:1 to 1:4 FFP:PRBC ratio 1:5 No benefit
Moore, 20088 Prospective cohort, Death, or LOS MT protocol, subgroups of early, No MT MT provides better outcomes
retrospective control late death, survivors
Scalea, 20089 Prospective, cohort Death, or LOS Transfusion, stratification by No transfusion No benefit
ratio
Sperry, 200810 Prospective, cohort Death, or LOS PRBC:FFP ,1:1.5 PRBC:FFP.1:1.5 High FFP, lower death, higher
ARDS
Dente, 200911 Prospective, cohort 30 days MTP 1:1:1 No MTP Reduces short-term
mortality but no difference at
30 days
Snyder, 200912 Retrospective , cohort Death, or LOS Survivors Non-survivors PRBC:FFP ratio predictive of
death but survival bias
negated effect
Zink, 200913 Retrospective, cohort 30 days PRBC:FFP 1:1 PRBC:FFP.1:1 Survival better in 1:1
Teixeira, 200914 Retrospective, cohort Death, or LOS PRBC:FFP 1:1 PRBC:FFP in lower ratios Survival better in 1:1

BJA
ii5

Downloaded from http://bja.oxfordjournals.org/ by guest on January 2, 2016

BJA Waters

Table 2: Blood component transfusions by plasma and platelet ratios. Reproduced with permission from Holcomb and colleagues.2
RBC = erythrocytes; FFP = Plasma; rFVIIa = recombinant factor VIIa

High plasma, High High plasma, low Low plasma, high Low plasma, low P
Platelets platelets platelets platelets
Plasma (units) 17 (12) 16 (10) 7 (5) 6 (6) ,0.001
Platelets (units) 20 (16) 5 (6) 18 (10) 4 (6) ,0.001
RBC (units) 22 (17) 21 (12) 21 (11) 21 (12)
Crystalloid (L) 14 (10) 13 (7) 17 (12) 11(10) ,0.001
FFP:RBC ratio 0.8 (0.3) 0.8 (0.3) 0.3 (0.1) 0.2 (0.1) ,0.001
Platelet:RBC ratio 0.9 (0.4) 0.2 (0.2) 0.9 (0.4) 0.1 (0.2) ,0.001
Crystalloid:RBC 0.8 (0.5) 0.8 (0.6) 0.9 (0.6) 0.6 (0.5) ,0.001
ratio
Received rFVIIa (%) 34 (22) 11 (11) 21 (25) 15 (12) 0.006

Downloaded from http://bja.oxfordjournals.org/ by guest on January 2, 2016

A Death B
Survivor

Time Time

Fig 1 Survivor bias. (A) a theoretical patient receives 4 erythrocyte units followed by a plasma unit and subsequently dies, so a 4:1 ratio results. (B), a
theoretical patient receives 4 erythrocyte units followed by 4 plasma units but doesn’t die resulting in a 1:1 ratio. The therapy is identical with the
exception being the death of the patient.

Table 3: Group sizes* and numbers of deaths in low (,1:2) and high (.1:2) FFP:PRBC ratio groups by time interval of hospitalization. Reproduced
with permission from Snyder and colleagues.12

≤30 >30 –60 >60 – 90 >90 – >2 –3 >3 –4 >4–5 >5–6 >6–12 >12 – 18 >18– 24 >24 Total
min. min. min. 120 min. hrs. hrs. hrs. hrs. hrs. hrs. hrs. hrs.
,1:2 (low ratio)
No. pts in group 86 102 103 102 95 91 85 87 74 73 74 74 74
No. deaths 0 0 8 10 9 3 2 1 2 2 0 6 43
during interval
.1:2 (high ratio)
No. pts in group 1 6 13 20 34 39 46 46 60 61 60 60 60
No. deaths 0 0 0 0 0 2 1 0 7 1 0 13 24
during interval

plasma transfusion increased the risk of death in a cohort of
patients that had a predicted risk of death ,20%. Similarly,
Inaba and colleagues29 found an association between
plasma use and overall complications in non-massively trans-
fused patients (defined as patients receiving ,10 units of
PRBCs during the first 24 h of their hospitalization). In a retro-
spective review of 1440 trauma patients, Johnson and
colleagues30 found an increased risk of multiple organ
failure when patients were transfused aggressively with
plasma. These authors suggested that caution is warranted
when empirically transfusing plasma. These three studies
suggest that in the bleeding patient, more plasma might
have unpredictable results when given using a fixed ratio
strategy.

ii6
MTP in haemorrhagic shock
Laboratory-guided plasma use
In order to avoid excessive or overzealous administration of
blood products, several investigators now suggest that transfu-
sion be guided by laboratory testing. In a randomized study,
Nascimento and colleagues31 compared a fixed transfusion
ratio with transfusion guided by laboratory data every 2 h.
This study enrolled 78 patients with the primary aim being to
assess the feasibility of doing a larger study of this topic. They
found a trend towards worse outcomes with the fixed ratio
strategy of care compared with laboratory-guided plasma
and platelet use, but concluded that a larger study size was
needed in order to show statistical significance. Regardless,
the authors make a significant leap in sophistication from the
recipe of giving blood products in a fixed ratio to one that is
guided by laboratory data.
Traditional laboratory testing provides slow information
by which to make a care decision but the concept of point-
of-care testing allows for rapid testing and resulting of coagu-
lation data at the point of the patient bedside. This appears
to be the direction that the literature is evolving as it relates
to the massively bleeding patient. Point-of-care devices
that have been used for this purpose include the thromboelas-
tograph (Haemonetics, Inc., Braintree, MA, USA), the Rotem
(TEM, Munich, Germany), and the Sonoclot (Sienco, Inc.,
Boulder, CO, USA). Each of these devices measures viscoelastic
changes in whole blood as it clots. Changes in fibrinogen, pla-
telets, and coagulation factors influence the result from
these devices so that goal-directed therapy can be achieved.
Multiple investigators have now shown improved outcomes
when using a goal-directed strategy of transfusion compared
with fixed ratio strategies.32 – 35
Similar conclusions have been demonstrated in cardiac
surgery where it has been demonstrated that when plasma
and platelet transfusions are guided by thromboelastography,
better patient outcomes with fewer blood products result.27 36 37
The evidence appears compelling in cardiac surgery to the point
that national guidelines have been developed suggesting that
point-of-care testing be used for guidance of transfusion.38 It
would seem reasonable that the cardiac patient is similar
enough to the massively bleeding patient that these guidelines
could be extrapolated to the trauma patient. Recently, a multi-
disciplinary task force foradvanced bleeding care in trauma con-
curred with the recommendation that viscoelastometry be used
for guiding transfusion.39
Conclusions
The concept of rapid delivery of multiple blood products—
irrespective of their specific ratio—to the bedside of a massive-
ly haemorrhaging patient seems to be a logical approach to
management only if a pathophysiology-oriented point-of-
care-guided management cannot be applied. Hyperfibrinolysis
can be treated with anti-fibrinolytic drugs or hypofibrinoinae-
mia with cryoprecipitate or fibrinogen concentrate rather
than plasma transfusion. Studies of plasma use suggest that
the immediate benefits of plasma transfusion only outweigh
the risks when a coagulopathy is severe. However, overall
BJA
risks increase with escalating plasma exposure, thus affecting
patient safety. Assessing the extent of coagulopathy through
conventional laboratory testing cannot help guide bleeding
management, but minor derangements in routine coagulation
tests can be used to avoid excessive allogeneic blood transfu-
sions including plasma and its associated complications.
Future prospective research is warranted to assess the poten-
tial benefits of rapid delivery of plasma in a fixed ratio to
RBC concentrates compared with laboratory testing guided
plasma without a fixed ratio to other blood products compared
with individualized coagulation management based on point-
of-care coagulation monitoring.
Declaration of interest
None declared.
References
1 Kashuk JL, Moore EE, Millikan JS, Moore JB. Major abdominal vascu-
Downloaded from http://bja.oxfordjournals.org/ by guest on January 2, 2016
lar trauma—a unified approach. J Trauma Inj Infect Crit Care 1982;
22: 672–9
2 Borgman MA, Spinella PC, Perkins JG, et al. The ratio of blood products
transfused affects mortality in patients receiving massive transfu-
sions at a combat support hospital. J Trauma 2007; 63: 805–13
3 Cotton BA, Gunter OL, Isbell J, et al. Damage control hematology:
the impact of a trauma exsanguination protocol on survival and
blood product utilization. J Trauma 2008; 64: 1177– 82
4 Gunter OL Jr, Au BK, Isbell JM, Mowery NT, Young PP, Cotton BA. Op-
timizing outcomes in damage control resuscitation: identifying
blood product ratios associated with improved survival. J Trauma
2008; 65: 527– 34
5 Holcomb JB, Wade CE, Michalek JE, et al. Increased plasma and
platelet to red blood cell ratios improves outcome in 466 massively
transfused civilian trauma patients. Ann Surg 2008; 248: 447–58
6 Duchesne JC, Hunt JP, Wahl G, et al. Review of current blood transfu-
sions strategies in a mature level I trauma center: were we wrong
for the last 60 years? Trauma 2008; 65: 272– 6
7 Kashuk JL, Moore EE, Johnson JL, et al. Postinjury life threatening
coagulopathy: is 1:1 fresh frozen plasma:packed red blood cells
the answer? J Trauma Inj Infect Crit Care 2008; 65: 261– 70
8 Moore FA, Nelson T, McKinley BA, et al. Is there a role for aggressive
use of fresh frozen plasma in massive transfusion of civilian trauma
patients? Am J Surg 2008; 196: 948–58
9 Scalea TM, Bochicchio KM, Lumpkins K, et al. Early aggressive use of
fresh frozen plasma does not improve outcome in critically injured
trauma patients. Ann Surg 2008; 248: 578– 84
10 Sperry JL, Ochoa JB, Gunn SR, et al; Inflammation the Host Re-
sponse to Injury Investigators. An FFP:PRBC transfusion ratio
≥1:1.5 is associated with a lower risk of mortality after massive
transfusion. J Trauma Inj Infect Crit Care 2008; 65: 986–93
11 Dente CJ, Shaz BH, Nicholas JM, et al. Improvements in early mortal-
ity and coagulopathy are sustained better in patients with blunt
trauma after institution of a massive transfusion protocol in a civilian
level I trauma center. J Trauma Inj Infect Crit Care 2009; 66: 1616–24
12 Snyder CW, Weinberg JA, McGwin G Jr, et al. The relationship of
blood product ratio to mortality: survival benefit or survival bias?
J Trauma 2009; 66: 358– 62
13 Zink KA, Sambasivan CN, Holcomb JB, Chisholm G, Schreiber MA. A
high ratio of plasma and platelets to packed red blood cells in the
first 6 hours of massive transfusion improves outcomes in a large
multicenter study. Am J Surg 2009; 197: 565– 70
ii7
BJA
14 Teixeira PG, Inaba K, Shulman I, et al. Impact of plasma transfu-
sion in massively transfused trauma patients. J Trauma 2009;
66: 693 – 7
15 McVay PA, Toy PT. Lack of increased bleeding after liver biopsy in
patients with mild hemostatic abnormalities. Am J Clin Pathol
1990; 94: 747–53
16 Ewe K. Bleeding after liver biopsy does not correlate with indices of
peripheral coagulation. Dig Dis Sci 1981; 26: 388– 93
17 Counts RB, Haisch C, Simon TL, et al. Hemostasis in massively trans-
fused trauma patients. Ann Surg 1979; 190: 91– 9
18 Yazer MH. The how’s and why’s of evidence based plasma therapy.
Korean J Hematol 2010; 45: 152–7
19 Domen RE, Hoeltge GA. Allergic transfusion reactions: an evalu-
ation of 273 consecutive reactions. Arch Pathol Lab Med 2003;
127: 316– 20
20 Kleinman S, Caulfield T, Chan P, et al. Toward an understanding of
transfusion-related acute lung injury: statement of a consensus
panel. Transfusion 2004; 44: 1774– 89
21 Bux J. Transfusion-related acute lung injury (TRALI): a serious
adverse event of blood transfusion. Vox Sang 2005; 89: 1 –10
22 Popovsky MA. Transfusion and the lung: circulatory overload and
acute lung injury. Vox Sang 2004; 87: 62– 5
23 Holland LL, Foster TM, Marlar RA, Brooks JP. Fresh frozen plasma is
ineffective for correcting minimally elevated international normal-
ized ratios. Transfusion 2005; 45: 1234– 5
24 Holland LL, Brooks JP. Toward rational fresh frozen plasma transfu-
sion: the effect of plasma transfusion on coagulation test results.
Am J Clin Pathol 2006; 126: 133–9
25 Dzik WH. Component Therapy Before Bedside Procedures, 2nd Edn.
Baltimore, MD: AABB Press, 2005
26 Haas T, Fries D, Tanaka KA, et al. Usefulness of standard plasma co-
agulation tests in the management of perioperative coagulopathic
bleeding: is there any evidence? Br J Anaesth Advance Access pub-
lished on September 8, 2014, doi:10.1093/bja/aeu303
27 Kozek-Langenecker SA, Afshari A, Albaladejo P, et al. Management
of severe perioperative bleeding: Guidelines from the European
Society of Anaesthesiology. Eur J Anaesthesiol 2013; 30: 270–382
28 Perel P, Clayton T, Altman DG, et al. Red blood cell transfusion
and mortality in trauma patients: risk-stratified analysis of an
observational study. PLoS Med 2014; 11: e1001664. doi:10.1371/
journal.pmed.1001664
ii8
Waters
29 Inaba K, Branco BC, Rhee P, et al. Impact of plasma transfusion in
trauma patients who do not require massive transfusion. J Am
Coll Surg 2010; 210: 957– 65
30 Johnson JL, Moore EE, Kashuk JL, et al. Effect of blood products
transfusion on the development of postinjury multiple organ
failure. Arch Surg 2010; 145: 973–7
31 Nascimento B, Callum J, Tien H, et al. Effect of a fixed-ratio (1:1:1)
transfusion protocol versus laboratory-results-guided transfusion
in patients with severe trauma: a randomized feasibility trial.
Can Med Anaesth J 2013; 185: E583–9
32 Carroll RC, Craft RM, Langdon RJ, et al. Early evaluation of acute trau-
matic coagulopathy by thrombelastography. Transl Res 2009; 154:
34–9
33 Kashuk JL, Moore EE, Wohlauer M, et al. Initial experiences
with point-of-care rapid thrombelastography for management of
life-threatening postinjury coagulopathy. Transfusion 2012; 52:
23–33
34 Johansson PI, Sorensen AM, Larsen CF, et al. Low hemorrhage-
related mortality in trauma patients in a Level I trauma center
employing transfusion packages and early thromboelastography-
directed hemostatic resuscitation with plasma and platelets.
Downloaded from http://bja.oxfordjournals.org/ by guest on January 2, 2016
Transfusion 2013; 53: 3088– 99
35 Yin J, Zhao Z, Li Y, et al. Goal-directed transfusion protocol via
thrombelastography in patients with abdominal trauma: a retro-
spective study. World J Emerg Surg 2014; 9: 28
36 Nuttall GA, Oliver WC, Santrach PJ, et al. Efficacy of a simple intra-
operative transfusion algorithm for non erythrocyte component
utilization after cardiopulmonary bypass. Anesthesiology 2001;
94: 773– 81
37 Shore-Lesserson L, Manspeizer HE, DePerio M, Francis S, Vela-
Cantos F, Ergin MA. Thromboelastography-guided transfusion algo-
rithm reduces transfusions in complex cardiac surgery. Anesth
Analg 1999; 88: 312– 9
38 Ferraris VA, Brown JR, Despotis GJ, et al. 2011 update to the Society
of Thoracic Surgeons and the Society of Cardiovascular Anesthe-
siologists blood conservation clinical practice guidelines. Ann
Thorac Surg 2011; 91: 944–82
39 Rossaint R, Bouillon B, Cerny V, et al. Management of bleeding fol-
lowing major trauma: an updated European guideline. Crit Care
2010; 14: R52
Handling editor: H. C. Hemmings