EAST PLENARY PAPER

Every minute counts: Time to delivery of initial massive transfusion

cooler and its impact on mortality

David E. Meyer, MD, Laura E. Vincent, RN, Erin E. Fox, PhD, Terence O'Keeffe, MBChB, Kenji Inaba, MD,
Eileen Bulger, MD, John B. Holcomb, MD, and Bryan A. Cotton, MD, Houston, Texas

BACKGROUND: American College of Surgeons Trauma Quality Improvement Best Practices recommends initial massive transfusion (MT) cooler
delivery within 15 minutes of protocol activation, with a goal of 10 minutes. The current study sought to examine the impact of
timing of first cooler delivery on patient outcomes.
METHODS: Patients predicted to receive MTat 12 Level I trauma centers were randomized to two separate transfusion ratios as described in the PROPPR
trial. Assessment of Blood Consumption score or clinician gestalt prediction of MTwas used to randomize patients and call for initial study
cooler. In this planned subanalysis, the time to MT protocol activation and time to delivery of the initial cooler were evaluated. The impact
of these times on mortality and time to hemostasis were examined using both Wilcoxon rank sum and linear and logistic regression.
RESULTS: Among 680 patients, the median time from patient arrival to MT protocol activation was 9 minutes with a median time from MT activation
call to delivery of first cooler of 8 minutes. An increase in both time to MT activation and time to arrival of first cooler were associated with
prolonged time to achieving hemostasis (coefficient, 1.09; p = 0.001 and coefficient, 1.16; p < 0.001, respectively). Increased time to MT
activation and time to arrival of first cooler were associated with increased mortality (odds ratio [OR], 1.02; p = 0.009 and OR, 1.02;
p = 0.012, respectively). Controlling for injury severity, physiology, resuscitation intensity, and treatment arm (1:1:1 vs. 1:1:2), increased time
to arrival of first cooler was associated with an increased mortality at 24 hours (OR, 1.05; p = 0.035) and 30 days (OR, 1.05, p = 0.016).
CONCLUSION: Delays in MT protocol activation and delays in initial cooler arrival were associated with prolonged time to achieve hemostasis and
an increase in mortality. Independent of products ratios, every minute from time of MT protocol activation to time of initial cooler
arrival increases odds of mortality by 5%. (J Trauma Acute Care Surg. 2017;83: 19–24. Copyright © 2017 Wolters Kluwer Health,
Inc. All rights reserved.)
LEVEL OF EVIDENCE: Prognostic, level II; Therapeutic, level III.
KEY WORDS: Massive transfusion; protocol; activation; blood product delivery.

D amage control resuscitation (DCR) has dramatically changed

the care of the bleeding patient. Much of the focus of re-
cent research has been on optimizing the ratio of blood product
(MT) was developed with DCR and has been associated with
decreased mortality, decreased multiorgan failure, and an overall
decrease in the amount of product transfused.2 In part, this is
administration and minimizing the use of crystalloid.1 How- because MT protocols (MTPs) are associated with a decrease
ever, it is the early and timely delivery of higher balanced ratios in time to the availability of the first blood products.3
of plasma and platelets that allows for the achievement of the The specific timing of the delivery of these blood prod-
ultimate goal of DCR: the rapid restoration of circulating red ucts, however, has not been examined thoroughly. A 2013
cells, plasma proteins and platelets while definitive control of single-center retrospective study evaluated this variable indi-
bleeding is achieved. The protocolization of massive transfusion rectly by comparing 30-day mortality in MT patients before
and after instituting an initiative to maintain a small but fre-
quently resupplied stock of thawed plasma to the emergency de-
Submitted: December 1, 2016, Revised: March 17, 2017, Accepted: April 10, 2017, partment (thereby decreasing the time necessary to procure and
Published online: April 27, 2017.
From the Department of Surgery, Division of Acute Care Surgery, McGovern School deliver it).4 That study found that moving thawed plasma to the
of Medicine (D.E.M.), University of Texas Health Sciences Center; The Center emergency department (ED) resulted in cutting the time to
for Translational Injury Research (L.E.V., E.E.F.), Houston, Texas; Department plasma administration in half and decreased the odds of mortal-
of Surgery, Division of Trauma, Critical Care, Burn, and Emergency Surgery,
College of Medicine (T.O.K.), University of Arizona, Tucson, Arizona; Depart-
ity at 30 days by approximately 60%. Of note, the time to first
ment of Surgery, Division of Acute Care Surgery and Surgical Critical Care, red blood cell transfusion remained the same. This suggests that
The Keck School of Medicine (K.I.) Los Angeles County Hospital, Los Angeles, timing of the administration of other blood products (plasma,
California; Department of Surgery, Division of Trauma, Burn, and Critical Care platelets) may play as crucial a role as the eventual ratio of prod-
Surgery, Harborview Medical Center (E.B.), The University of Washington
Medical School, Seattle, Washington; and Department of Surgery, Division of ucts or limiting of crystalloid volumes.
Acute Care Surgery McGovern School of Medicine, The Center for Transla- The recent multicenter, prospective, randomized con-
tional Injury Research (J.B.H., B.A.C.), University of Texas Health Sciences trolled trial from the Pragmatic, Randomized Optimal Platelets
Center, Houston, Texas.
To be presented in the Raymond H. Alexander, MD Resident Paper Competition
and Plasma Ratios (PROPPR) study group sought to evaluate
of the 2017 EAST Annual Scientific Assembly. mortality with respect to the ratio of blood products given in
Address for reprints: David E. Meyer, MD, University of Texas Health Sciences MT.5 The study found that there was a significant decrease in
Center at Houston, 6431 Fannin St, MSB 4.284 Houston, TX 77030; email: deaths due to bleeding in the 1:1:1 group, but the significance
david.e.meyer@uth.tmc.edu.
of the effect was not observed in overall mortality at 30 days.
DOI: 10.1097/TA.0000000000001531 One possible explanation is that the PROPPR 1:1:2 group
J Trauma Acute Care Surg
Volume 83, Number 1 19

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 J Trauma Acute Care Surg
Meyer et al. Volume 83, Number 1

outperformed all previously reported data, with previous studies activation and were present before patient arrival. Given the
noting mortality rates in excess of 30% when a blood product ra- aim of rapidly enrolling those patients with severe hemorrhage,
tio of 1:1:2 was used.6–8 In PROPPR, however, the mortality rate inclusion criteria were as follows: (1) highest-level trauma team
in the 1:1:2 group was roughly 20%. It has been suggested that activation, (2) estimated age of 15 years or older or weight of
this dramatic improvement in mortality in PROPPR compared 50 kg or greater if age unknown, (3) patient received directly
with other published research was the result of the rapid and bal- from the injury scene, (4) having received at least one unit of
anced delivery of blood products (i.e., alternating red blood any blood component transfused before hospital arrival or
cells, plasma, and platelets as opposed to previous descriptions within 1 hour of admission, and (5) predicted by an Assessment
of transfusing six units of red blood cells followed by six units of Blood Consumption (ABC) score of 2 or greater or by physi-
of plasma, then platelets).9 In this planned subanalysis of the cian judgment of the need for a MT (defined as ≥10 U of RBCs
PROPPR data set, we hypothesized that the timely delivery of within 24 hours).13 Patients were excluded if they (1) did not re-
blood products to the exsanguinating patient, regardless of ratio, ceive at least one unit of a blood component within 1 hour of ar-
would result in decreased mortality. rival to the hospital or during prehospital transport, (2) were
expected to die within 1 hour of ED arrival from a devastating
injury, or (3) improved during initial stabilization and did not re-
MATERIALS AND METHODS quire further transfusion. A total of 680 patients were enrolled in
Study Design the original PROPPR study of blood product ratios, and all of
The PROPPR study was a pragmatic phase III, multicenter, those patients were included in this planned subanalysis.
randomized trial that compared the effectiveness of two resuscita-
tion strategies for bleeding patients. The study began August 3, Outcomes and Definitions
2012, and concluded enrollment on December 2, 2013. Patients The primary outcomes of interest in this subanalysis were
were randomized to receive a ratio of 1:1:1 or 1:1:2 of platelets: 24-hour and 30-day mortality. Secondary outcomes included
plasma: red blood cells during the acute phase of resuscitation.10 time to death, time to hemostasis, and 24-hour blood product
The study was approved by the US Food and Drug Adminis- use. A clinician blinded to group assignment and external to
tration (Investigational New Drug No. 14929), Health Canada, the trial site adjudicated each death. Time to death was measured
National Heart, Lung, and Blood Institute, and the Department in both minutes and hours. Anatomic hemostasis in the operat-
of Defense, as well as each individual site's institutional review ing room was defined as an objective assessment by the surgeon
boards. The PROPPR study used exception from informed con- indicating that bleeding within the surgical field was controlled,
sent (21 CFR 50.24), including community consultation with and no further hemostatic interventions were anticipated. This
delayed patient or legally authorized representative content. was also captured and recorded in minutes and hours. Blood
This represents a subanalysis of the original PROPPR product use was noted in units.
study, investigating the impact of time to activation of local To best describe the aggressiveness of transfusion and re-
MTPs and then time from activation to delivery of the first suscitation administered by the trauma team, independent of
MTP cooler. These timepoints were specifically included in specific product availability and site, we used resuscitation in-
the PROPPR protocol for collection and later analysis and were tensity (RI) as a surrogate measurement.14 RI is defined as the
audited throughout the study to evaluate compliance with study total amount of product given in the first 30 minutes after patient
requirements. Before starting the study, and as part of site train- arrival. Each 1 L of crystalloid, one 500 mL bag/bottle of colloid,
ing and verification, each site was evaluated for the ability of its one unit of red blood cells, one unit of plasma, and one 6-pack
blood bank to randomize, prepare, and deliver the first MTP cooler (or one apheresis) platelet (=1 unit) were defined as one RI unit.
to the bedside within 10 minutes, as well as to prepare and deliver Resuscitation with four or more units of any fluid in the first
subsequent coolers on-demand.11 As such, time of arrival, time to 30 minutes is significantly associated with mortality as early
MTP activation, and time to arrival of initial and each subsequent as six hours.
cooler were collected as timepoints of interest. The content of each The time to MTP activation was defined as the time from
MTP cooler was identical between centers, varying only by ran- patient arrival until the initial phone call made to a site’s Blood
domization group (i.e., 1:1:1 vs. 1:1:2). Additionally, the sequence Bank for activation, captured and recorded in minutes. Time to
of transfusion was also identical between centers, so as to ensure a initial MTP cooler arrival was defined as time from MTP activa-
rapid and balanced transfusion strategy. Finally, as part of an ongo- tion by phone call until cooler arrival at the patient’s bedside,
ing quality improvement initiative, the study protocol was evalu- also captured and recorded in minutes.
ated and reevaluated at each site and then refined as necessary to
function seamlessly within a center’s specific milieu and to ensure Statistical Analysis
rigorous protocol fidelity.12 Continuous data are presented with the 25th and 75th
percentile interquartile range (IQR) with comparisons between
Study Population groups performed by use of the Wilcoxon rank sum (Mann-
The PROPPR study was conducted at 12 North American Whitney U test). Categorical data are reported as proportions
Level I trauma centers, screening those patients who were se- and, where appropriate, tested for significance using χ2 or
verely injured and who met local criteria for highest-level trauma Fisher's exact tests. All statistical tests were two-tailed. To
activation. To meet the study’s intended focus on those injured evaluate the above outcomes, we carefully examined the time
patients who were bleeding at the time of arrival, research team to MTP activation and time to delivery of the initial cooler.
personnel were notified simultaneously with trauma team These were specifically chosen to investigate whether (1) early

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J Trauma Acute Care Surg
Volume 83, Number 1 Meyer et al.

recognition of the need for MT and (2) time to the delivery of

TABLE 2. Multivariate Regression Predicting 24-h Mortality
MTP products impacted outcomes, regardless of transfused ra-
tios. Initial analysis of the impact of these times on mortality OR 95% CI p
and time to hemostasis were performed using Wilcoxon rank Time to receipt of first cooler, min 1.05 1.01–1.10 0.035
sum. This was followed by simple (univariate) linear and logistic Anatomic injury severity (ISS) 1.03 1.02–1.05 <0.001
regression, then a multivariate regression analysis. The logistic Disturbed arrival physiology (w-RTS) 0.69 0.60–0.81 <0.001
multivariate model was created through first selecting variables Randomization group (1:1:2) 1.69 1.01–2.86 0.047
a priori based on clinical judgment that the potential con- RI, units 1.12 0.60–2.05 0.719
founders may be associated with recognition of bleeding and
95% CI, 95% confidence interval.
outcomes related to bleeding and mortality. These were then en-
tered into stepwise regression to identify statistically significant
variables (p < 0.05). Although this initial model included the in- MTP activation in minutes was associated with prolonged time
dividual site as a variable to evaluate for differences between to achieving hemostasis (coefficient, 1.09; p = 0.001). Similarly,
centers, this was not statistically significant and was not in- increased time in minutes to receipt of first cooler was associated
cluded in the subsequent model. This model did, however, iden- with longer time to achieving hemostasis (coefficient, 1.16;
tify anatomic severity of injury (Injury Severity Score [ISS]), p < 0.001). More importantly, both an increased time to MTP ac-
physiology on arrival (weighted revised trauma score, weighted tivation and time to receipt of first MTP cooler were also associ-
Revised Trauma Score [w-RTS]), RI, and randomization group ated with increased unadjusted mortality (odds ratio [OR], 1.02;
as significant. These four variables were then entered into a mul- p = 0.009 and OR, 1.02; p = 0.012, respectively). Neither time to
tiple logistic regression model, along with time to MTP activa- MTP activation nor time to receipt of initial cooler was associ-
tion and time to arrival of initial cooler (entered separately). ated with 24-hour blood product transfusion volumes.
All analyses were performed using STATA Statistical software Controlling for injury severity, admission physiology, RI,
(version 12.1; StataCorp, College Station, TX). and treatment arm (1:1:1 vs. 1:1:2), the time to arrival of first
cooler was associated with an increased mortality at 24 hours
RESULTS (OR, 1.05; p = 0.035) and 30 days (OR, 1.05; p = 0.016)
(Table 2 and Table 3). Controlling for these same variables in a
During the study period, 14,313 highest-level trauma acti- multivariate linear model demonstrated that decreased time to
vations occurred at the 12 sites, with 11,185 patients undergoing receiving the initial cooler was associated with a marked
screening. Among these, 680 patients were enrolled and ran- reduction in time to death (coefficient, −271.029; p = 0.023).
domized (338 to the 1:1:1 group and 342 to the 1:1:2 group). The above model controlling for injury severity, admis-
Overall, 80% of patients were male and 64% were white, with sion physiology, RI, and treatment arm (1:1:1 vs. 1:1:2) was re-
a median age of 34 (24–51). Mechanism of injury was blunt in peated to evaluate the impact of time to MTP activation.
53%, with an overall median ISS of 26 (17–41) and w-RTS of Increased time to MTP activation showed a trend, but was not
6.81 (4.09–7.84). For the study population, 24-hour and significantly associated with an increase in 24-hour mortality
30-day mortality were 14.7% and 24.1%, respectively. (OR, 1.03; p = 0.154) and 30-day mortality (OR, 1.04;
Dichotomizing groups by outcome of 24-hour mortality, p = 0.160). As well, a linear model using these same variables
Table 1 demonstrates the differences between baseline and ad- demonstrated that decreased time to MTP activation was associ-
mission variables. Patients who died within the first 24 hours ated with a trend toward reduction in time to death, but this was
had greater anatomic injury, more disturbed arrival physiology, not statistically significant (coefficient, −51.098; p = 0.130).
and had more intense resuscitation in the first 30 minutes of
their arrival.
Among the 680 patients enrolled, the median time from DISCUSSION
patient arrival to MTP activation was 9 minutes (IQR, 3–20). The concept of improved outcomes with decreased time
The median time from MTP activation to delivery of the first to the delivery of an intervention is well described throughout
cooler was 8 minutes (IQR, 5–11). An increase in time to medicine. Acute myocardial infarction patients have decreased
mortality with decreased time to reperfusion.15 As a result, hos-
TABLE 1. Baseline and Arrival Data by Those Who Live and Die pitals are now graded and ranked based on response times and
Within 24 h “STEMI” teams have been developed to dramatically reduce
Death Within 24 h Alive at 24 h “door-to-balloon times” for such patients. Similarly, hospital
(n = 100) (n = 580) p stroke teams have been developed based on data demonstrating
Male sex 77% 81% 0.352
TABLE 3. Multivariate Regression Predicting 30-d Mortality
Median age, y 39 (24–56) 34 (25–49) 0.223
White race 68% 63% 0.336 OR 95% CI p
Blunt mechanism 62% 51% 0.042 Time to receipt of first cooler, min 1.05 1.01–1.09 0.016
Median ISS 36 (25–48) 25 (17–37) <0.001 Anatomic injury severity (ISS) 1.05 1.03–1.06 <0.001
Median w-RTS 4.09 (3.80–6.37) 6.90 (4.09–7.84) <0.001 Disturbed arrival physiology (w-RTS) 0.61 0.53–0.69 <0.001
Median RI 6 (4–9) 4 (3–6) <0.001 Randomization group (1:1:2) 1.46 0.92–2.29 0.102
Medians are expressed with 25th and 75th IQR. RI, units 1.03 0.60–1.44 0.184

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 J Trauma Acute Care Surg
Meyer et al. Volume 83, Number 1

improved neurologic outcomes in ischemic stroke patients with cannot be explicitly stated. Finally, this study may not be easily
decreased time to reperfusion; “door-to-tPA” times.”16 Intensive generalizable. Before beginning the PROPPR study, each of the
care unit patients with severe sepsis and septic shock have de- 12 North American Level I trauma centers was vetted for its abil-
creased mortality with decreased time to first antibiotic ad- ity to provide blood products within the strict, predetermined
ministration.17 A recent study has also demonstrated decreased time criteria. Further, periodic assessments of each center’s abil-
mortality in traumatic brain injury patients with multifocal hem- ity to continue to meet these goals were continued throughout
orrhage that receive early administration of plasma.18 the data acquisition phase. Smaller hospitals with fewer re-
The American College of Surgeons Trauma Quality Im- sources may find it more difficult to consistently meet stringent
provement guidelines for MT have recently recommended deliv- time criteria. It is difficult to calculate the cost of such an effort,
ery of the first blood product cooler within 15 minutes of especially when measuring against the value of a life saved.
activation, and the delivery of each subsequent cooler within However, research suggests that the protocolization of MT actu-
10 minutes of the request.19 Yet these recommendations were ally decreases both product wastage and costs.20 Further, provi-
based on expert opinion and not prospectively collected data. sion of timely blood products is a benchmark of quality that
The current study, however, found a 5% increase in the odds should be continuously reevaluated at every trauma center.
of mortality with every minute of delay in the administration “Door-to-balloon” times are measured for cardiac referral cen-
of blood products from time of MTP activation. This suggests ters; no less should be expected for trauma centers.
that even the availability of blood within 10 to 15 minutes may
be too long for many critically injured patients. Furthermore,
CONCLUSION
decreasing the time to delivery of blood products may be
one of the modifiable risk factors that impacts mortality in the Delays in the activation of MTP and delays in the delivery
trauma patient. of the first blood product cooler were both associated with in-
To improve the timeliness of blood product delivery, sev- creased time to hemostasis and increased mortality. In the
eral challenges must be overcome. One challenge is to decrease PROPPR dataset, every minute of delay between the activa-
the time to activation of MTP by decreasing the time to physi- tion of MTP and the arrival of the first blood cooler regardless
cian recognition of the need for blood product administration. of ratio, resulted in a 5% increase in the odds of mortality. In
There are several clear opportunities for improving this variable. fact, it appears that decreasing the time to blood product admin-
One is simply physician awareness that timing of blood admin- istration is one of the modifiable risk factors that affect mortality
istration is of critical importance. Additionally, clinical adjuncts in the exsanguinating trauma patient. Every effort should be
can be used to predict the need for MT. The ABC score, for ex- made to decrease the time to recognition of the need for MTP
ample, is a rapid bedside clinical scoring system that is 75% sen- and the time to administration of the first blood product.
sitive and 86% specific for predicting the need for MT.10
Another challenge is to decrease the physical distance between
AUTHORSHIP
the blood and the patient. To this end, many trauma centers have
transitioned to having a small reserve of thawed/liquid blood J.B.H., T.O.K., K.I., E.B., and B.A.C. contributed to study conception and
design. J.B.H., T.O.K., K.I., E.B., L.A.V., and B.A.C. contributed to acquisi-
products immediately available within the emergency depart- tion of data. D.E.M., L.A.V., E.E.F., and B.A.C. contributed to analysis
ment: The Mayo Clinic (Rochester, MN) has a full MTP cooler and interpretation of data. DEM and BAC contributed to drafting the
at all times within their ED; the R Adams Cowley Shock Trauma manuscript. D.E.M., J.B.H., T.O.K., K.I., E.B., E.E.F., and B.A.C. contributed
Center (Baltimore, MD) maintains an entire MTP refrigerator to critical revision.
within their ED; Memorial Hermann- Texas Medical Center also
maintains a blood product refrigerator within the ED, with RBCs ACKNOWLEDGMENTS
and liquid plasma. Another way to significantly decrease the dis-
Pragmatic, Randomized Optimal Platelet and Plasma Ratios (PROPPR)
tance (and therefore time to administration) of blood products Study Group:
is to make them available in the prehospital setting. Memorial Clinical Coordinating Center, University of Texas Health Science Center at
Hermann Hospital and the Mayo Clinic, as examples, have Houston: John B. Holcomb, MD; Charles E. Wade, PhD; Deborah J. del
maintained red blood cells and plasma on-board every air ambu- Junco, PhD; Erin E. Fox, PhD; Nena Matijevic, PhD (Laboratory Committee
co-Chair); Jeanette M. Podbielski, RN; Angela M. Beeler, BS.
lance since 2011. Blood product administration prehospital is Data Coordinating Center, University of Texas Health Science Center at
protocolized, and the administration of any prehospital blood Houston: Barbara C. Tilley, PhD; Sarah Baraniuk, PhD; Stacia M. DeSantis,
products automatically activates the hospital’s MTP. A full PhD; Hongjian Zhu, PhD; Joshua Nixon, MS; Roann Seay, MS; Savitri N.
MTP cooler is then present at the bedside in the ED before the Appana, MS; Hui Yang, MS; Michael O. Gonzalez, MS.
Core Laboratory, University of Texas Health Science Center at Houston:
arrival of the patient. Lisa Baer, MS; Yao-Wei Willa Wang, MD; Brittany S. Hula, MS; Elena
Several limitations are apparent in this study. First, al- Espino, BS; An Nguyen, BS; Nicholas Pawelczyk, BS; Kisha D. Arora-Nutall,
though the data regarding time to blood cooler delivery was BS; Rishika Sharma, MD; Jessica C. Cardenas, PhD; Elaheh Rahbar, PhD;
collected prospectively, and intended for subanalysis, patients Tyrone Burnett, Jr., BS; David Clark, BS.
Resuscitation Outcomes Consortium, University of Washington: Gerald
were not randomized by time nor were evaluation of time to ac- van Belle, PhD; Susanne May, PhD; Brian Leroux, PhD; David Hoyt, MD;
tivation and time to initial cooler designated primary outcomes. Judy Powell, BSN, RN; Kellie Sheehan, BSN.
Second, the actual time of administration of the first blood prod- Systems Biology Committee, University of California, Berkeley: Alan
uct was not used but rather time to arrival of first cooler. Al- Hubbard, PhD (co-Chair); Adam P. Arkin, PhD.
Transfusion Committee: John R. Hess, MD, MPH (co-Chair, University of
though it seems unlikely that MTP would be activated for any Washington); Jeannie L. Callum, MD (co-Chair, Sunnybrook Health Sci-
trauma patient and blood products not given immediately, this ences Centre)

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J Trauma Acute Care Surg
Volume 83, Number 1 Meyer et al.

Anesthesiology Committee: Jean-Francois Pittet, MD (Chair, University of 2. Cotton BA, Au BK, Nunez TC, Gunter OL, Robertson AM, Young PP.
Alabama at Birmingham) Predefined massive transfusion protocols are associated with a reduction in
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versity of Cincinnati); discussion 48–49.
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The authors disclose no conflicts of interest. Study Group. Early resuscitation intensity as a surrogate for bleeding severity
This work was supported with grant U01HL077863 from the US National and early mortality in the PROMMTT study. J Trauma Acute Care Surg.
Heart, Lung, and Blood Institute and funding from the US Department of 2013;75:S16–S23.
Defense, the Defence Research and Development Canada in partnership 15. McNamara RL, Wang Y, Herrin J, Curtis JP, Bradley EH, Magid DJ, Peterson
with the Canadian Institutes of Health Research-Institute of Circulatory ED, Blaney M, Frederick PD, Krumholz HM, et al. Effect of door-to-balloon
and Respiratory Health (grant CRR-120612). time on mortality in patients with ST-segment elevation myocardial infarc-
tion. J Am Coll Cardiol. 2006;47:2180–2186.
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 J Trauma Acute Care Surg
Meyer et al. Volume 83, Number 1

sepsis: a prospective, multicenter, observational study. Am J Respir Crit Care whether time to the first massive transfusion cooler, regardless
Med. 2009;180:861–866. of blood transfusion ratio, had any effect on mortality. Indeed,
18. Chang R, Folkerson LE, Sloan D, Tomasek JS, Kitagawa RS, Choi HA,
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they were able to determine that timely delivery of the first
survival after isolated traumatic brain injury in patients with multifocal intra- massive transfusion cooler did lead to a decrease in mortality.
cranial hemorrhage. Surgery. 2016;161:538–545. Importantly, the authors nicely call attention to the signif-
19. American College of Surgeons. ACS TQIP Massive Transfusion in Trauma icance of time and clinical judgment in caring for a hemorrhag-
Guidelines. Chicago, IL. Available at: https://www.facs.org/~/media/files/ ing patient. As the authors note, every minute of delay led to a
quality%20programs/trauma/tqip/massive%20transfusion%20in%20trauma
%20guildelines.ashx. Accessed November 20, 2016.
5% increase in odds of mortality, and they made recommenda-
20. Wehrli G, Taylor NE, Haines AL, Brady TW, Mintz PD. Instituting a thawed tions for bringing blood products closer to the patient to mini-
plasma procedure: it just makes sense and saves cents. Transfusion. 2009;49: mize the time delay. Unfortunately, nothing can replace sound
2625–2630. clinical judgment, but the development of clinical decision sup-
port tools can assist the surgeon in optimizing patient care.
One limitation in this study that needs consideration is the
EDITORIAL CRITIQUE amount of non-randomized, pre-MT blood products patients may
As the authors point out, this study was intended to be a have received. The amount and timing of these transfusions could
planned sub-analysis of the PROPPR study. The original PROPPR be significant confounding variables.
trial was designed to compare the effects of two blood product
transfusion ratios (1:1:1 versus 1:1:2) on mortality. The results
Matthew J. Bradley, MD, MS
demonstrated no difference in 24-hour or 30-day mortality be-
tween the groups. However, the authors were able to determine Trauma/Critical Care Surgeon
that there were fewer patients that died from exsanguination Uniformed Services University
and more patients that achieved hemostasis in the 1:1:1 group. and the Walter Reed National
Using this same dataset, the current authors then investigated Military Medical Center

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Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.