In this study, multiple co-interventions make it impossible to establish the contribution of any of them.Two other studies analysed survival before and after implementation sellekchem of massive transfusion protocols [13,17]. Both studies demonstrated better survival with the protocol despite no difference in 24-hour FFP transfusion before and after protocol implementation and despite FFP:RBC ratios other than 1:1. The results could be interpreted as the protocol, and not the high FFP:RBC ratios, leading to better survival.Potential harmIn a study demonstrating the survival advantage of aggressive FFP transfusion in the intensive care unit, Gonzalez and colleagues reported an unusual high incidence of early and lethal acute respiratory distress syndrome [10].

The aggressive FFP transfusion was aimed at correcting the International Normalized Ratio to ��1.3, probably an unattainable goal given that the International Normalized Ratio of FFP is near 1.3 [61-63]. Considering that the deaths might represent transfusion-associated circulatory overload or TRALI, the study raises concerns on the aggressive FFP transfusion strategy. In a separate study of 415 trauma patients [64], early acute respiratory distress syndrome (before day 4) occurred significantly more among those patients transfused more FFP. Some studies, however, suggest that the adoption of early and aggressive FFP transfusion in fact reduces the overall exposure to blood and blood products [19]. Here also, the evidence is conflicting and precludes definitive conclusions.

Ethical and logistical considerationsIn many countries, blood transfusion requires written informed consent, which is deferred only in life-threatening situations, including massive bleeding. The proposal to transfuse FFP early and aggressively raises important ethical considerations. First, traumatic massive bleeding carries upm to 40% mortality even when current resuscitation guidelines are strictly followed, and early coagulopathy increases mortality threefold. The marked reduction Cilengitide in mortality recently reported with early and high FFP:RBC resuscitation has prompted many trauma centres to adopt this strategy. The evidence behind early formula-driven haemostatic resuscitation is concordant with recent advances in the understanding of early trauma coagulopathy, but they also have methodological flaws and bias that seriously question the survival benefit.Many trauma centres keep thawed AB plasma (uni-versal donor) available at all times for resuscitation. In countries that have implemented policies favouring male-only plasma to minimize the risks of TRALI, supplying AB plasma becomes an even greater challenge.