Hello,

We are a small rural hospital looking to update our massive transfusion protocol. Our current protocol utilizes a 1:1:1 ratio but there is some confusion about the platelet portion of that ratio. We use all apheresis platelets so have been issuing one apheresis pack for every 8-10 RBC/FFP units. Most of the literature that I have read refers to the 1:1:1 ratio, but not much is said about the use of apheresis platelets and how that affects the ratio. After how many RBC/FFP units do you give one platelet pack? 

We give one apheresis per 4 units of blood and FFP (or one pooled). One bag of apheresis platelets is supposed to be the equivalent of of one pooled.

The local university hospital has a massive transfusion protocol for adults in the OR which starts with 8 RBC units, 8 units of OctaplasLG, and 12 units of platelets (3 bags of 4 units each). A bag of platelets here contains pooled buffy coat platelets from 4 whole blood donors, or apheresis platelets with pretty much the equivalent platelet count, depending on what's available. So that's more like a 1:1:1,5 ratio in one sense, but in terms of "how many bags do I send up" it's 8:8:3. It used to be 1:1:1 (or 8:8:2).

 

The general idea of the 1:1:1 ratio as I understand it is to be roughly in the same ratio as whole blood: and ideally, to be simple to remember and apply. Once you move from single units (of single donor platelets from whole blood) to pooled platelets or apheresis platelets, I don't think it's going to be perfectly clear for everyone all the time what is meant by 1:1:1. You might need to look at the platelet count of your apheresis platelets if you want to estimate what would be a 1:1:1 ratio for them.

We have a 6 RC, 6 Plasma and 1 Platelet Pheresis prescribed in our MTP policy.

I guess you would have to ask your blood center what they would say about how many platelets are in your units.  Here, we assume that a unit, whether a pooled 5-pack or apherised, is equivalent to 5 "units" (or close enough anyway).  So our massive transfusion protocol ratio is 5:5:1.

 

Scott

We do a 1:1:1 ratio with 6 packed cells, 6 ffp, and 1 pheresis platelet - the 1 pheresis platelet being the equivelant of a 6 pack pooled.

We also assume a pheresis plt is equal to 6 whole-blood derived platelets, although our MTP actually ends up about 8:8:1 (apheresis) partly because we are far from our supplier and don't hand out a platelet until the 2nd round of 4 RBCs.

We also assume a pheresis plt is equal to 6 whole-blood derived platelets, although our MTP actually ends up about 8:8:1 (apheresis) partly because we are far from our supplier and don't hand out a platelet until the 2nd round of 4 RBCs.

Ditto! 

Ditto!

Ditto

Ditto

 

Ditto

In the journal article John Holcomb, MD et al, Transfusion of Plasma, Platelets, and Red Blood Cells in a 1:1:1 vs a 1:1:2 Ratio and Mortality in Patients with Severe Trauma.  The PROPPR Randomized Clinical Trial. JAMA 2015;313(5):471-482, the 1:1:1 refers to the dose of plasma, platelets, and red blood cells used.  For the study, a dose of platelets for  was defined as 6 platelet concentrates (derived from whole blood).   This definition was necessary so as to accommodate platelet products from single donors collected by apheresis and pooled platelets products since in some areas apheresis derived platelets are in short supply.

 

Just in case you might be wondering about the conclusins drawn in the article, in the abstract the authors state: " Among patieints with severe trauma and major bleeding, early administration of plasma, platelets, and RBCs in a 1:1:1 ratio compared with a 1:1:2 ratio did not result in significant differences in mortality and 24 nours or at 30 days. However, more patieints  in the 1:1:1 group achieved hemostasis and fewer experienced death from exsanguination by 24 hours. Even though there was an increase in plasma and platelets transfused in the 1:1:1 group no other safety differences were identified between the 2 groups."

Edited June 24, 201510 yr by Kip Kuttner

We also assume a pheresis plt is equal to 6 whole-blood derived platelets, although our MTP actually ends up about 8:8:1 (apheresis) partly because we are far from our supplier and don't hand out a platelet until the 2nd round of 4 RBCs.

Ditto. Our only exception is if they come in bleeding and they are on an anti-platelet agent (Plavix, etc), we move the platelet unit up "in the lineup".

Our massive protocol is following:

 

First pack: 4 RBC units, 4 FFP and 4 units of platelets (equal to one bag).

Second bag: same as the first

...And continuing as long as the physician in charge tells us that the situation is okay and they don't need any more. Usually one pack is enough to have the patient to stable situation.