Transfusion in surgery and trauma

Is It Beneficial to Optimize Vital Signs Before Embolization for Pelvic Fractures? A Dilemma Between Resuscitation and Hemostasis

Purpose

Adequate resuscitation and definitive hemostasis are both important in the management of hemorrhage related to pelvic fracture. The goal of this study was to analyze the relationship between the amount of blood transfused before transcatheter arterial embolization (TAE) and the clinical outcome later in the disease course.

Methods

Patients with pelvic fractures who underwent TAE for hemostasis from January 2018 to December 2019 were studied. The characteristics of patients who received blood transfusions of >2 U (1000 mL) and ≤2 U before TAE were compared. The mortality rate, blood transfusion-related complications, and length of stay were compared between these two groups.

Results

Among the 75 studied patients, 39 (52.0%) received blood transfusions of ≤2 U before TAE, and the other 36 (48.0%) patients received blood transfusions of >2 U before TAE. The incidence rates of systemic inflammatory response syndrome, sepsis, and coagulopathy were significantly higher in the >2 U group (97.2% vs 81.1%, P = .027; 50.0% vs 27.0%, P = .045; and 44.4% vs 5.4%, P < .01, respectively). After nonsurvivors were excluded, the >2 U group had a significantly higher proportion (43.8% vs 14.7%, P < .001) of prolonged intensive care unit (ICU) length of stay (7 days or more) and a longer hospital length of stay (33.8 ± 15.1 vs 21.9 ± 94.0, P < .01) than the ≤2 U group. Pre-TAE blood transfusion >2 U serves as an independent risk factor for prolonged ICU length of stay and increased hospital length of stay.

Conclusion

Early hemostasis for pelvic fracture-related hemorrhage is suggested to prevent pre-TAE blood transfusion-associated adverse effects of blood transfusion.

Packed red blood cell transfusions in critically ill patients

Anemia, which is prevalent in critically ill patients, often requires frequent blood transfusions. These blood transfusions are not without risks. A critical review of 6 studies shows an association between red blood cell transfusion and increased mortality. However, when disease state was adjusted for in 2 studies, researchers found that red blood cell transfusion correlated with decreased mortality. Thus further research, particularly on leukoreduction and age of stored blood, must be done before a change in practice can be implemented. It is vital that nurses stay current on this research in order to improve patients' outcomes.

Transfusion of blood products in trauma: an update

BACKGROUND

Blood transfusion in the management of severely injured patients can be lifesaving. These patients are susceptible to developing early coagulopathy, thus perpetuating bleeding.

OBJECTIVES

This article presents recent advances in both the civilian and military clinical arena to improve the treatment of trauma patients with severe hemorrhage, the use of agents to support coagulation, perspectives on restrictive transfusion strategies, and transfusion-related risks.

DISCUSSION

Massive blood transfusion is an adjunct to surgical care. The volume of blood products transfused and the ratio of blood components have been associated with increased morbidity and mortality rates. The adverse clinical effects of transfusion and the limited supply of blood products have resulted in modern resuscitation protocols to limit the volume of blood transfused.

CONCLUSION

A restrictive blood transfusion strategy and the use of hemostatic agents may decrease morbidity and mortality in trauma patients, but insufficient data are available for their use in trauma patients. Massive transfusion should reflect an equal ratio of packed red cells and plasma to limit coagulopathy. Prospective randomized trials are needed to standardize an effective protocol.

Haemorrhagic shock therapy

BACKGROUND

Severe injury is often associated with haemorrhagic shock and this is the most common cause of preventable mortality after injury. Care of the injured patient in shock involves an overlapping continuum of care beginning during the prehospital phase of care and extending through the interventional and critical care phases.

OBJECTIVE

This study aimed to review emerging therapies in the treatment of haemorrhagic shock.

METHODS

A review of recent clinical articles (1996 - 2007) examining therapeutic measures for haemorrhagic shock treatment was undertaken.

CONCLUSIONS

Although the mainstay of therapy continues to be obtaining haemostasis and restoring tissue perfusion, a multitude of novel strategies are emerging, including advanced haemostatic agents, hypertonic resuscitation and massive transfusion protocols, as well as blood substitutes and an improved understanding of damage control principles, thereby allowing increased survival and improved outcomes in the severely injured patient with major haemorrhage.

Blood transfusion is an independent predictor of mortality after blunt trauma

Allogeneic blood transfusion is associated with increased morbidity and mortality. The authors evaluated the affect of blood transfusion, independent of injury severity on mortality. The authors conducted a retrospective review of all patients, age > or =18 years with blunt injury admitted to their Level 2 trauma center from 1994 to 2004 by query of the NTRACS trauma registry. Initial systolic blood pressure and heart rate determined the shock index. Logistic regression was used to model the affect of blood transfusion on mortality. Transfusion requirements were categorized as follows: A, 0 U; B, 1 to 2 U; C, 3 to 5 U; D, > or =6 U blood. In this sample of 8215 blunt trauma patients, 324 patients received blood transfusion. Mortality rates between the transfused and nontransfused groups were 15.12 per cent and 1.84 per cent (P < 0.000) respectively. In the logistic regression model, transfusion category B did not have a significant affect on the odds of death (P = 0.176); the affect of transfusing 3 to 5 U and > or =6 U had a mortality odds ratio of 3.22 (P = 0.002). and 4.87 (P = 0.000) respectively. Transfusing > or =2U blood was strongly associated with mortality in this blunt trauma population. There must be a continuous attempt to limit blood transfusion when feasible and physiologically appropriate.

Coagulopathy and blood component transfusion in trauma

Trauma is a serious global health problem, accounting for approximately one in 10 deaths worldwide. Uncontrollable bleeding accounts for 39% of trauma-related deaths and is the leading cause of potentially preventable death in patients with major trauma. While bleeding from vascular injury can usually be repaired surgically, coagulopathy-related bleeding is often more difficult to manage and may also mask the site of vascular injury. The causes of coagulopathy in patients with severe trauma are multifactorial, including consumption and dilution of platelets and coagulation factors, as well as dysfunction of platelets and the coagulation system. The interplay between hypothermia, acidosis and progressive coagulopathy, referred to as the 'lethal triad', often results in exsanguination. Current management of coagulopathy-related bleeding is based on blood component replacement therapy. However, there is a limit on the level of haemostasis that can be restored by replacement therapy. In addition, there is evidence that transfusion of red blood cells immediately after injury increases the incidence of post-injury infection and multiple organ failure. Strategies to prevent significant coagulopathy and to control critical bleeding effectively in the presence of coagulopathy may decrease the requirement for blood transfusion, thereby improving clinical outcome of patients with major trauma.

Allogeneic red blood cell transfusions: efficacy, risks, alternatives and indications

Careful assessment of risks and benefits has to precede each decision on allogeneic red blood cell (RBC) transfusion. Currently, a number of key issues in transfusion medicine are highly controversial, most importantly the influence of different transfusion thresholds on clinical outcome. The aim of this article is to review current evidence on blood transfusions, to highlight 'hot topics' with respect to efficacy, outcome and risks, and to provide the reader with transfusion guidelines. In addition, a brief synopsis of transfusion alternatives will be given. Based on up-to-date information of current evidence, together with clinical knowledge and experience, the physician will be able to make transfusion decisions that bear the lowest risk for the patient.