Early massive transfusion in trauma patients: Canadian single-centre retrospective cohort study

Prediction of massive transfusion in trauma patients in the surgical intensive care units (THAI-SICU study)

PURPOSE

After damage control surgery, trauma patients are transferred to intensive care units to restore the physiology. During this period, massive transfusion might be required for ongoing bleeding and coagulopathy. This research aimed to identify predictors of massive blood transfusion in the surgical intensive care units (SICUs).

METHODS

This is an analysis of the THAI-SICU study which was a prospective cohort that was done in the 9-university-based SICUs in Thailand. The study included only patients admitted due to trauma mechanisms. Massive transfusion was defined as received ≥10 units of packed red blood cells on the first day of admission. Patient characteristics and physiologic data were analyzed to identify the potential factors. A multivariable regression was then performed to identify the significant model.

RESULTS

Three hundred and seventy patients were enrolled. Sixteen patients (5%) received massive transfusion in the SICUs. The factors that significantly predicted massive transfusion were an initial sequential organ failure assessment (SOFA) ≥9 (risk difference (RD) 0.13, 95% confidence interval (CI): 0.03-0.22, p = 0.01); intra-operative blood loss ≥ 4900 mL (RD 0.33, 95% CI: 0.04-0.62, p = 0.02) and intra-operative blood transfusion ≥ 10 units (RD 0.45, 95% CI: 0.06 to 0.84, p = 0.02). The probability to have massive transfusion was 0.976 in patients who had these 3 factors.

CONCLUSION

Massive blood transfusion in the SICUs occurred in 5%. An initial SOFA ≥9, intra-operative blood loss ≥4900 mL, and intra-operative blood transfusion ≥10 units were the significant factors to predict massive transfusion in the SICUs.

Improving decision making for massive transfusions in a resource poor setting: a preliminary study in Kenya

Background

The reality of finite resources has a real-world impact on a patient’s ability to receive life-saving care in resource-poor settings. Blood for transfusion is an example of a scarce resource. Very few studies have looked at predictors of survival in patients requiring massive transfusion. We used data from a rural hospital in Kenya to develop a prediction model of survival among patients receiving massive transfusion.

Methods

Patients who received five or more units of whole blood within 48 hours between 2004 and 2010 were identified from a blood registry in a rural hospital in Kenya. Presenting characteristics and in-hospital survival were collected from charts. Using stepwise selection, a logistic model was developed to predict who would survive with massive transfusion versus those who would die despite transfusion. An ROC curve was created from this model to quantify its predictive power.

Results

Ninety-five patients with data available met inclusion criteria, and 74% survived to discharge. The number of units transfused was not a predictor of mortality, and no threshold for futility could be identified. Preliminary results suggest that initial blood pressure, lack of comorbidities, and indication for transfusion are the most important predictors of survival. The ROC curve derived from our model demonstrates an area under the curve (AUC) equal to 0.757, with optimism of 0.023 based on a bootstrap validation.

Conclusions

This study provides a framework for making prioritization decisions for the use of whole blood in the setting of massive bleeding. Our analysis demonstrated an overall survival rate for patients receiving massive transfusion that was higher than clinical perception. Our analysis also produced a preliminary model to predict survival in patients with massive bleeding. Prediction analyses can contribute to more efficient prioritization decisions; these decisions must also include other considerations such as equity, acceptability, affordability and sustainability.

Risk factors for trauma-induced coagulopathy- and transfusion-associated multiple organ failure in severely injured trauma patients

Background

Both trauma-induced coagulopathy (TIC) and transfusion strategies influence early outcome in hemorrhagic trauma patients. Their impact on late outcome is less well characterized. This study systematically reviews risk factors for TIC- and transfusion-associated multiple organ failure (MOF) in severely injured trauma patients.

Materials and methods

A systematic search was conducted in PubMed and Embase. Studies published from 1986 to 2013 on adult trauma patients with an injury severity score ≥16, investigating TIC or transfusion strategies with MOF as primary or secondary outcome, were eligible for inclusion. Results of the included studies were evaluated with meta-analyses of pooled data.

Results

In total, 50 studies were included with a total sample size of 63,586 patients. Due to heterogeneity of the study populations and outcome measures, results from 7 studies allowed for pooling of data. Risk factors for TIC-associated MOF were hypocoagulopathy, hemorrhagic shock, activated protein C, increased histone levels, and increased levels of markers of fibrinolysis on admission. After at least 24 h after admission, the occurrence of thromboembolic events was associated with MOF. Risk factors for transfusion-associated MOF were the administration of fluids and red blood cell units within 24 h post-injury, the age of red blood cells (>14 days) and a ratio of FFP:RBC ≥ 1:1 (OR 1.11, 95% CI 1.04–1.19).

Conclusion

Risk factors for TIC-associated MOF in severely injured trauma patients are early hypocoagulopathy and hemorrhagic shock, while a hypercoagulable state with the occurrence of thromboembolic events later in the course of trauma predisposes to MOF. Risk factors for transfusion-associated MOF include administration of crystalloids and red blood cells and a prolonged storage time of red blood cells. Future prospective studies investigating TIC- and transfusion-associated risk factors on late outcome are required.

Risks associated with red blood cell transfusion in the trauma population, a meta-analysis

INTRODUCTION

A previous meta-analysis has found an association between red blood cell (RBC) transfusions and mortality in critically ill patients, but no review has focused on the trauma population only.

OBJECTIVES

To determine the association between RBC transfusion and mortality in the trauma population, with secondary outcomes of multiorgan failure (MOF) and acute respiratory distress syndrome (ARDS) or acute lung injury (ALI).

DATA SOURCES

EMBASE (1947-2012) and MEDLINE (1946-2012).

STUDY ELIGIBILITY CRITERIA

Randomized controlled trials and observational studies were to be included if they assessed the association between RBC transfusion and either the primary (mortality) or secondary outcomes (MOF, ARDS/ALI).

PARTICIPANTS

Trauma patients.

EXPOSURE

Red blood cell transfusion.

METHODS

A literature search was completed and reviewed in duplicate to identify eligible studies. Studies were included in the pooled analyses if an attempt was made to determine the association between RBC and the outcomes, after adjusting for important confounders. A random effects model was used for and heterogeneity was quantified using the I(2) statistic. Study quality was assessed using the Newcastle-Ottawa Scale.

RESULTS

40 observational studies were included in the qualitative review. Including studies which adjusted for important confounders found the odds of mortality increased with each additional unit of RBC transfused (9 Studies, OR 1.07, 95%CI 1.04-1.10, I(2) 82.9%). The odds of MOF (3 studies, OR 1.08, 95%CI 1.02-1.14, I(2) 95.9%) and ARDS/ALI (2 studies, OR 1.06, 95%CI 1.03-1.10, I(2) 0%) also increased with each additional RBC unit transfused.

CONCLUSIONS

We have found an association between RBC transfusion and the primary and secondary outcomes, based on observational studies only. This represents the extent of the published literature. Further interventional studies are needed to clarify how limiting transfusion can affect mortality and other outcomes.

Persistence of elevated plasma CXCL8 concentrations following red blood cell transfusion in a trauma cohort

Red blood cell (RBC) transfusion is associated with alterations in systemic concentrations of IL-8/CXCL8 functional homologs in a murine model. Whether RBC transfusion alters systemic neutrophil chemokine concentrations in individuals sustaining traumatic injury is not known. We conducted a retrospective, single-center study of severely injured trauma patients presenting within 12 h of injury with a base deficit greater than 6 and hypotension in the field. Plasma concentrations of 25 chemokines, cytokines, and growth factors were obtained from both transfused (n = 22) and nontransfused (n = 33) groups in the first 48 h following admission. The transfused group (mean RBC units, 2.7 [SD, 1.7]) tended to be older (49.9 [SD, 21.1] vs. 40.4 [SD, 19.9] years, P = 0.10), with a higher percentage of females (40.9% vs. 18.2%, P = 0.06) and a higher Injury Severity Score (27.1 [SD, 12.7] vs. 21.4 [SD, 10.2], P = 0.07). In univariate and multivariate analyses, transfusion was associated with increased hospital and intensive care unit length of stay but not ventilator-free days. Plasma CXCL8 concentrations were higher in the transfused (84 [SD, 88] pg/mL) than the nontransfused group (31 [SD, 21] pg/mL, P = 0.003). Using a linear prediction model to calculate bioanalyte concentrations standardized for age, sex, Injury Severity Score, and admission SBP, we observed that CXCL8 concentrations diverged within 12 h following injury, with the transfused group showing persistently elevated CXCL8 concentrations by contrast to the decay observed in the nontransfused group. Other bioanalytes showed no differences across time. Red blood cell transfusion is associated with persistently elevated neutrophil chemokine CXCL8 concentrations following traumatic injury.

The use of trauma transfusion pathways for blood component transfusion in the civilian population: a systematic review and meta-analysis

This study was undertaken to determine if, amongst civilian trauma patients requiring massive transfusion (MT), the use of a formal trauma transfusion pathway (TTP), in comparison with transfusion without a TTP, is associated with a reduction in mortality, or changes in indices of coagulation, blood product utilisation and complications. A systematic review of three bibliographic databases, reference lists and conference proceedings was conducted. Studies were included if comparisons were made between patients receiving transfusion with and without a TTP. Data were extracted by two independent reviewers on population characteristics, transfusion strategies, blood product utilisation, indices of coagulation, clinical outcomes and complications. Data were pooled using a random effects model and heterogeneity explored. Seven observational studies met all eligibility criteria. Amongst 1801 patients requiring MT, TTPs were associated with a significant reduction in mortality (RR 0·69, 95% CI 0·55, 0·87). No significant increase in the mean number of PRBC transfused between TTP and control patients was seen (MD -1·17 95% CI -2·70, 0·36). When studies assessing only trauma patients were considered, TTPs were associated with a reduction in the mean number of units of plasma transfused (MD -2·63, 95% CI -4·24, -1·01). In summary, the use of TTPs appears to be associated with a reduction in mortality amongst trauma patients requiring MT without a clinically significant increase in the number of PRBC transfused and a potential reduction in plasma transfusion. Effects of TTPs on platelet transfusion, indices of coagulation and complications remain unclear. A randomised controlled trial is warranted.