Elsevier

Surgery

Volume 148, Issue 5, November 2010, Pages 955-962
Surgery

Original Communication
Effect of early plasma transfusion on mortality in patients with ruptured abdominal aortic aneurysm

https://doi.org/10.1016/j.surg.2010.02.002Get rights and content

Background

The ratio of red blood cell (PRBC) transfusion to plasma (FFP) transfusion (PRBC:FFP ratio) has been shown to impact survival in trauma patients with massive hemorrhage. The purpose of this study was to determine the effect of the PRBC:FFP ratio on mortality for patients with massive hemorrhage after ruptured abdominal aortic aneurysm (RAAA).

Methods

A retrospective review was performed of patients undergoing emergent open RAAA repair from January 1987 to December 2007. Patients with massive hemorrhage (≥10 units of blood products transfused prior to conclusion of the operation) were included. The effects of patient demographics, admission vital signs, laboratory values, peri-operative variables, amount of blood products transfused, and the PRBC:FFP ratio on 30-day mortality were analyzed by multivariate analysis.

Results

One hundred and twenty-eight of the 168 (76%) patients undergoing repair for RAAA received at least 10 units of blood products within the peri-operative period. Mean age was 73.1 ± 9.1 years, and 109 (85%) were men. Thirty-day mortality was 22.6% (29/128), including 11 intra-operative deaths. By multivariate analysis, 30-day mortality was markedly lower (15% vs 39%; P < .03) for patients transfused at a PRBC:FFP ratio ≤2:1 (HIGH FFP group) compared with those transfused at a ratio of >2:1 (LOW FFP), and the likelihood of death was more than 4-fold greater in the LOW FFP group (odds ratio 4.23; 95% confidence interval, 1.2–14.49). Patients in the HIGH FFP group had a significantly lower incidence of colon ischemia than those in the LOW FFP group (22.4% vs 41.1%; P = .004).

Conclusion

For RAAA patients requiring massive transfusion, more equivalent transfusion of PRBC to FFP (HIGH FFP) was independently associated with lower 30-day mortality. The lower incidence of colonic ischemia in the HIGH FFP group may suggest an additional benefit of early plasma transfusion that could translate into further mortality reduction. Analysis from this study suggests the potential feasibility for a more standardized protocol of initial resuscitation for these patients, and prospective studies are warranted to determine the optimum PRBC:FFP ratio in RAAA patients.

Section snippets

Methods

All patients treated for RAAA at the University of Wisconsin between January 1, 1987 and December 31, 2007 were identified from either our institutional vascular database or through medical records review using ICD-9-CM codes. Only patients suffering massive hemorrhage were included, defined as those receiving 10 or more units of blood products from admission to the conclusion of the operation. This definition of massive hemorrhage was adapted from criteria described by Duchesne et al18

Results

Overall, 168 patients were treated for RAAA during the study period. Of this cohort, 128 (76%) patients met the criteria of massive hemorrhage. Mean age among the cohort was 73 ± 9 years, and 109 (85%) were men. Pre-existing comorbidities are shown in Table I. Although 18 (14%) patients were direct admissions, most (110, 86%) were transferred from other facilities. AAA had been diagnosed previously in 45 (35%) patients.

Historically at our institution, permissive hypotension was used for initial

Discussion

Our study exemplifies that repair of RAAA still incurs a substantial mortality. Most publications of large series report an operative mortality from 38% to 50%,1, 2, 3 with an overall mortality of up to 85% when including those who die prior to reaching an operating room.19 Factors affecting mortality have been documented broadly, and various reports have identified advanced age,7 female sex,7 preexisting renal insufficiency,20, 21 chronic obstructive lung disease,21 postoperative intestinal

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