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Does autotransfusion from a contaminated trauma laparotomy field increase the risk of complications? Am J Surg 2021; 223:988-992. [PMID: 34657721 DOI: 10.1016/j.amjsurg.2021.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Revised: 09/30/2021] [Accepted: 10/05/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND Autotransfusion (AT) in trauma laparotomy is limited by concern that enteric contamination (EC) increases complications, including infections. Our goal was to determine if AT use increases complications in trauma patients undergoing laparotomy with EC. METHODS Trauma patients undergoing laparotomy from October 2011-November 2020 were reviewed. Patients were excluded if they did not receive blood in the operating room, did not have a full thickness hollow viscus injury, or died <24 h from admission. AT and non-AT patients were matched. Outcomes were compared. RESULTS 185 patients were included, 60 received AT, and 46 pairs were matched. After matching, demographics were similar. No differences were noted in septic complications (33 vs 41%, p = 0.39), overall complications (59% vs 54%, p = 0.67), or mortality (13 vs 6%, p = 0.29). CONCLUSIONS AT use in contaminated trauma laparotomy fields was not associated with a higher rate of complications.
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Nederpelt CJ, El Hechi M, Parks J, Fawley J, Mendoza AE, Saillant N, King DR, Fagenholz PJ, Velmahos GC, Kaafarani HMA. The dose-dependent relationship between blood transfusions and infections after trauma: A population-based study. J Trauma Acute Care Surg 2020; 89:51-57. [PMID: 32102046 DOI: 10.1097/ta.0000000000002637] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVE The relationship between total transfusion volume and infection in the trauma patient remains unclear, especially at lower volumes of transfusion. We sought to quantify the cumulative, independent impact of transfusion within 24 hours of admission on the risk of infection in trauma patients. METHODS Using the Trauma Quality Improvement Program 2013 to 2016 database, we included all patients who received blood transfusions in the first 4 hours. Patients who were transferred or had incomplete/wrongly coded information on transfusion volume were excluded. Patients were divided into 20 cohorts based on the total blood product volume transfused in the first 24 hours. A composite infection variable (INF) was created, including surgical site infection, ventilator-associated pneumonia, urinary tract infection, central line associated blood stream infection, and sepsis. Univariate and stepwise multivariable logistic regression analyses were performed to study the relationship between blood transfusion and INF, controlling for demographics (e.g., age, sex), comorbidities (e.g., cirrhosis, diabetes, steroid use), severity of injury (e.g., vital signs on arrival, mechanism, Injury Severity Score), and operative and angiographic interventions. RESULTS Of 1,002,595 patients, 37,568 were included. The mean age was 42 ± 18.6 years, 74.6% were males, 68% had blunt trauma, and median Injury Severity Score was 25 [17-34]. Adjusting for all available confounders, odds of INF increased incrementally from 1.00 (reference, 0-2 units) to 1.23 (95% confidence interval, 1.11-1.37) for 4 units transfused to 4.89 (95% confidence interval, 2.72-8.80) for 40 units transfused. Each additional unit increased the odds of INF by 7.6%. CONCLUSION Transfusion of the bleeding trauma patient was associated with a dose-dependent increased risk of infectious complications. Trauma surgeons and anesthesiologists should resuscitate the trauma patient until prompt hemorrhage control while avoiding overtransfusion. LEVEL OF EVIDENCE Retrospective cohort study, Therapeutic IV.
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Affiliation(s)
- Charlie J Nederpelt
- From the Division of Trauma, Emergency Surgery and Surgical Critical Care (C.J.N., M.E.H., J.P., J.F., A.E.M., N.S., D.R.K., P.J.F., G.C.V., H.M.A.K.), Massachusetts General Hospital, Boston, Massachusetts; Department of Trauma Surgery (C.J.N.), Leiden University Medical Center, Leiden, The Netherlands; Harvard Medical School (J.P., J.F., A.E.M., N.S., D.R.K., P.J.F., G.C.V., H.M.A.K.), Cambridge; and Center for Outcomes and Patient Safety in Surgery (COMPASS) (H.M.A.K.), Massachusetts General Hospital, Boston, Massachusetts
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Abstract
Massive transfusion protocol (MTP) with fresh-frozen plasma and packed red blood cells (PRBCs) in a 1:1 ratio is one of the most common resuscitative strategies used in patients with severe hemorrhage. There are no studies to date that examine the best postoperative hematocrit range as a marker for survival after MTP. We hypothesize a postoperative hematocrit dose-dependent survival benefit in patients receiving MTP. This was a 53-month retrospective analysis of patients with intra-abdominal injuries requiring surgery and transfusion of 10 units PRBCs or more at a single Level I trauma center. Groups were defined by postoperative hematocrit (less than 21, 21 to 29, 29.1 to 39, and 39 or more). Kaplan-Meier (KM) survival probability was calculated. One hundred fifty patients requiring operative abdominal explorations and 10 units PRBCs or more were identified. There were no significant differences in demographics between groups. When comparing postoperative hematocrit groups, relative to a hematocrit of less than 21 per cent in KM survival analysis, an overall survival advantage was only evident in patients transfused to hematocrits 29.1 to 39 per cent ( P < 0.03; odds ratio [OR], 0.284; 95% confidence interval [CI], 0.089 to 0.914). This survival advantage was not seen in the other groups (21 to 29: OR, 0.352; 95% CI, 0.103 to 1.195 or 39% or greater: OR, 0.107; 95% CI, 0.010 to 1.121). This is the first study to examine the impact of postoperative hematocrit as an indicator of survival after MTP in the trauma patient. Transfusion to hematocrits between 29.1 and 39 per cent conveyed a survival benefit, whereas resuscitation to supraphysiologic hematocrits 39 per cent or greater conveyed no additional survival benefit. This study highlights the need for judicious PRBC administration during MTP and its potential impact on survival in patients with postoperative supraphysiologic hematocrits.
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Abstract
BACKGROUND Hypothermia is associated with poor outcomes after injury. The relationship between hypothermia during contemporary large volume resuscitation and blood product consumption is unknown. We evaluated this association, and the predictive value of hypothermia on mortality. METHODS Patients predicted to receive massive transfusion at 12 level 1 trauma centers were randomized in the Pragmatic Randomized Optimal Platelet and Plasma Ratios (PROPPR) trial and were grouped into those who were hypothermic (<36°C) or normothermic (36-38.5°C) within the first 6 hours of emergency department arrival. The impact of hypothermia or normothermia on the volume of blood product required during the first 24 hours was determined via negative binomial regression, adjusting for treatment arm, injury severity score, mechanism, demographics, pre-emergency department fluid volume, blood administered before becoming hypothermic, pulse and systolic blood pressure on arrival, and the time exposed to hypothermic or normothermic temperatures. RESULTS Of 680 patients, 590 had a temperature measured during the first 6 hours in hospital, and 399 experienced hypothermia. The mean number of red blood cell (RBC) units given to all patients in the first 24 hours of admission was 8.8 (95% confidence interval [CI], 7.9-9.6). In multivariable analysis, every 1°C decrease in temperature below 36.0°C was associated with a 10% increase (incidence rate ratio, 0.90; 95% CI, 0.89-0.92; p < 0.00) in consumption of RBCs during the first 24 hours of admission. There was no association between RBC administration and a temperature above 36°C. Hypothermia on arrival was an independent predictor of mortality, with an adjusted odds ratio of 2.7 (95% CI, 1.7-4.5; p < 0.00) for 24-hour mortality and 1.8 (95% CI, 1.3-2.4; p < 0.00) for 30-day mortality. CONCLUSION Hypothermia is associated with increase in blood product consumption and mortality. These findings support the maintenance of normothermia in trauma patients and suggest that further investigation on the impact of cooling or rewarming during massive transfusion is warranted. LEVEL OF EVIDENCE Prognostic, level III.
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An Integrated Clinico-transcriptomic Approach Identifies a Central Role of the Heme Degradation Pathway for Septic Complications after Trauma. Ann Surg 2016; 264:1125-1134. [DOI: 10.1097/sla.0000000000001553] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Mica L, Simmen H, Werner CML, Plecko M, Keller C, Wirth SH, Sprengel K. Fresh frozen plasma is permissive for systemic inflammatory response syndrome, infection, and sepsis in multiple-injured patients. Am J Emerg Med 2016; 34:1480-5. [PMID: 27260556 DOI: 10.1016/j.ajem.2016.04.041] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2016] [Revised: 04/27/2016] [Accepted: 04/28/2016] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND The correction of coagulopathy with fresh frozen plasma (FFP) is one of the main issues in the treatment of multiple-injured patients. Infectious and septic complications contribute to an adverse outcome in multiple-injured patients. Here, we investigated the role of FFP in the development of inflammatory complications given within the first 48 hours. METHODS A total of 2033 patients with multiple injuries and an Injury Severity Score greater than 16 points and aged 16 years or older were included. The population was subdivided into 2 groups: those who received FFP and those who did not. The data were analyzed using SPSS version 22.0. Associations between the data were tested using Pearson correlation. Independent predictivity was analyzed by binary logistic regression and multivariate regression. Data were considered as significant if P<.05. RESULTS The prothrombin time at admission was significantly lower (68.5%±23.3% vs 81.8%±21.0% normal; P<.001) in the group receiving FFP. The application of FFP led to a more severe systemic inflammatory response syndrome (SIRS) grade (3.0±1.2 vs 2.2±1.4; P<.001), to a higher infection rate (48% vs 28%; P<.001), and to a higher sepsis rate (29% vs 13%; P<.001) in the patients receiving FFP. The correlations between SIRS and the incidence of infections and sepsis increased with the amount of FFP applied (P<.001). CONCLUSIONS Treatment with FFP of bleeding patients with multiple injuries enhances the risk of SIRS, infection, and sepsis; however, a multifactorial genesis has to be postulated.
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Affiliation(s)
- Ladislav Mica
- Division of Trauma Surgery, University Hospital of Zürich, 8091 Zürich, Switzerland.
| | - Hanspeter Simmen
- Division of Trauma Surgery, University Hospital of Zürich, 8091 Zürich, Switzerland
| | - Clément M L Werner
- Division of Trauma Surgery, University Hospital of Zürich, 8091 Zürich, Switzerland
| | - Michael Plecko
- Division of Trauma Surgery, University Hospital of Zürich, 8091 Zürich, Switzerland
| | | | | | - Kai Sprengel
- Division of Trauma Surgery, University Hospital of Zürich, 8091 Zürich, Switzerland
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Cata JP, Gutierrez C, Mehran RJ, Rice D, Nates J, Feng L, Rodriguez-Restrepo A, Martinez F, Mena G, Gottumukkala V. Preoperative anemia, blood transfusion, and neutrophil-to-lymphocyte ratio in patients with stage i non-small cell lung cancer. ACTA ACUST UNITED AC 2016; 3:e1116. [PMID: 26949721 DOI: 10.14800/ccm.1116] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Perioperative and postoperative blood transfusions (BT), anemia and inflammation are associated with poor survivals in patients with non-small cell lung cancer (NSCLC). This study investigated the impact of perioperative BT on the survival of patients with NSCLC taking into account their preoperative inflammatory status and the presence of anemia. Demographic, perioperative, and survival data for 861 patients with stage I NSCLC was collected retrospectively. The primary endpoints of interest were recurrence-free (RFS) and overall survival (OS). Before and after propensity score matching, univariate and multivariable Cox proportional hazards models were used to evaluate the association between covariates and survival. A neutrophil-to-lymphocyte ratio (NLR) < 5 (hazard ratio [HR]: 0.58, 95% CI: 0.38-0.87; p = 0.009) and normal Hb concentration (HR: 0.72, 95% CI: 0.72; p = 0.022) were independently associated with longer RFS. The administration of blood perioperatively was associated with a trend towards worse RFS (HR: 0.69, 95% CI: 0.47-1.02; p = 0.066). The multivariate analysis also revealed that an NLR < 5 (HR: 0.48, 95% CI: 0.3-0.76; p = 0.001) and the absence of BT (HR: 0.63, 95% CI: 0.4-0.98; p = 0.04) were significantly associated with lower mortality risk. The propensity score matching analysis did not confirm the association between BT and poor RFS (HR: 0.63, 95% CI: 0.35-1.1; p = 0.108) and OS (HR: 0.52, 95% CI: 0.26-1.04; p = 0.06). Inflammation and anemia are common finding in patients with stage 1 NSCLC. After adjusting for these two important confounders, this study confirms that previous reports demonstrating an association between BT and poor survival after NSCLC surgery.
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Affiliation(s)
- Juan P Cata
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA; Anesthesia and Surgical Oncology Research Group, Houston, Texas, USA
| | - Cristina Gutierrez
- Department of Critical Care Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Reza J Mehran
- Department of Thoracic and Cardiovascular Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA; Department of Laboratory Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - David Rice
- Department of Thoracic and Cardiovascular Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA; Department of Laboratory Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Joseph Nates
- Department of Critical Care Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Lei Feng
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Andrea Rodriguez-Restrepo
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Fernando Martinez
- Department of Thoracic and Cardiovascular Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Gabriel Mena
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA; Anesthesia and Surgical Oncology Research Group, Houston, Texas, USA
| | - Vijaya Gottumukkala
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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Guerado E, Medina A, Mata MI, Galvan JM, Bertrand ML. Protocols for massive blood transfusion: when and why, and potential complications. Eur J Trauma Emerg Surg 2015; 42:283-95. [PMID: 26650716 DOI: 10.1007/s00068-015-0612-y] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2015] [Accepted: 11/23/2015] [Indexed: 12/31/2022]
Abstract
PURPOSE An update paper on massive bleeding after major trauma. A review of protocols to address massive bleeding, and its possible complications, including coagulation abnormalities, complications related to blood storage, immunosuppression and infection, lung injury associated with transfusion, and hypothermia is carried out. METHODS Literature review and discussion with authors' experience. RESULTS Massive bleeding is an acute life-threatening complication of major trauma, and consequently its prompt diagnosis and treatment is of overwhelming importance. Treatment requires rapid surgical management together with the massive infusion of colloid and blood. CONCLUSIONS Since massive transfusion provokes further problems in patients who are already severely traumatized and anaemic, once this course of action has been decided upon, a profound knowledge of its potential complications, careful monitoring and proper follow-up are all essential. To diagnose this bleeding, most authors favour, as the main first choice tool, a full-body CT scan (head to pelvis), in non-critical severe trauma cases. In addition, focused abdominal sonography for trauma (FAST, an acronym that highlights the necessity of rapid performance) is a very important diagnostic test for abdominal and thoracic bleeding. Furthermore, urgent surgical intervention should be undertaken for patients with significant free intraabdominal fluid and haemodynamic instability. Although the clinical situation and the blood haemoglobin concentration are the key factors considered in this rapid decision-making context, laboratory markers should not be based on a single haematocrit value, as its sensitivity to significant bleeding may be very low. Serum lactate and base deficit are very sensitive markers for detecting and monitoring the extent of bleeding and shock, in conjunction with repeated combined measurements of prothrombin time, activated partial thromboplastin time, fibrinogen and platelets.
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Affiliation(s)
- E Guerado
- Department of Orthopaedic Surgery and Traumatology, Hospital Costa del Sol, University of Malaga, Autovía A-7, Km 187, 29603, Marbella, Malaga, Spain.
| | - A Medina
- Department of Haematology, Hospital Costa del Sol, 29603, Marbella, Spain
| | - M I Mata
- Department of Haematology, Hospital Costa del Sol, 29603, Marbella, Spain
| | - J M Galvan
- Intensive Care Unit, Hospital Costa del Sol, 29603, Marbella, Spain
| | - M L Bertrand
- Department of Orthopaedic Surgery and Traumatology, Hospital Costa del Sol, University of Malaga, Autovía A-7, Km 187, 29603, Marbella, Malaga, Spain
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Ferraris VA, Hochstetler M, Martin JT, Mahan A, Saha SP. Blood transfusion and adverse surgical outcomes: The good and the bad. Surgery 2015; 158:608-17. [DOI: 10.1016/j.surg.2015.02.027] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2015] [Revised: 02/15/2015] [Accepted: 02/27/2015] [Indexed: 01/09/2023]
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Abstract
PURPOSE Sepsis in severely injured patients is one of the leading causes of death in hospitals. The incidence of and risk factors for sepsis after trauma have been studied outside, but not within Korea. Therefore, this study investigated the incidence of sepsis and the independent risk factors for sepsis in moderately to severely injured patients in Korea. METHODS The electronic medical records of patients who visited the emergency department from January 2010 to December 2012 were reviewed retrospectively. Patients older than 18 years of age with an Injury Severity Score (ISS) greater than or equal to nine points were included. RESULTS A total of 183 patients met the study inclusion criteria. The median ISS was 14 (range 9-17) points and 15 (8 %) patients developed sepsis. The patients' age [adjusted OR, 1.053; 95 % confidence intervals (CI), 1.015-1.094], ISS (adjusted OR, 1.114; 95 % CI, 1.046-1.187), and emergency surgery (adjusted OR, 3.727; 95 % CI, 1.051-13.221) were independent risk factors for post-traumatic sepsis. CONCLUSIONS Among the risk factors identified in the literature, our research confirmed only the patients' age and ISS as risk factors for sepsis after trauma, and, additionally, identified emergency surgery as a risk factor in Korean patients. Therefore, trauma patients who have any of the risk factors mentioned above have a high risk of post-traumatic sepsis, which requires certain precautionary clinical measures.
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Ashbrook MJ, McDonough KL, Pituch JJ, Christopherson PL, Cornell TT, Selewski DT, Shanley TP, Blatt NB. Citrate modulates lipopolysaccharide-induced monocyte inflammatory responses. Clin Exp Immunol 2015; 180:520-30. [PMID: 25619261 DOI: 10.1111/cei.12591] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/14/2015] [Indexed: 12/25/2022] Open
Abstract
Citrate, a central component of cellular metabolism, is a widely used anti-coagulant due to its ability to chelate calcium. Adenosine triphosphate (ATP)-citrate lyase, which metabolizes citrate, has been shown to be essential for inflammation, but the ability of exogenous citrate to impact inflammatory signalling cascades remains largely unknown. We hypothesized that citrate would modulate inflammatory responses as both a cellular metabolite and calcium chelator, and tested this hypothesis by determining how clinically relevant levels of citrate modulate monocyte proinflammatory responses to lipopolysaccharide (LPS) in a human acute monocytic leukaemia cell line (THP-1). In normal medium (0.4 mM calcium), citrate inhibited LPS-induced tumour necrosis factor (TNF)-α and interleukin (IL)-8 transcripts, whereas in medium supplemented with calcium (1.4 mM), TNF-α and IL-8 levels increased and appeared independent of calcium chelation. Using an IL-8-luciferase plasmid construct, the same increased response was observed in the activation of the IL-8 promoter region, suggesting transcriptional regulation. Tricarballylic acid, an inhibitor of ATP-citrate lyase, blocked the ability of citrate to augment TNF-α, linking citrate's augmentation effect with its metabolism by ATP-citrate lyase. In the presence of citrate, increased histone acetylation was observed in the TNF-α and IL-8 promoter regions of THP-1 cells. We observed that citrate can both augment and inhibit proinflammatory cytokine production via modulation of inflammatory gene transactivation. These findings suggest that citrate anti-coagulation may alter immune function through complex interactions with the inflammatory response.
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Affiliation(s)
- M J Ashbrook
- Divisions of Pediatric Nephrology, University of Michigan, Ann Arbor, MI, USA
| | - K L McDonough
- Pediatric Critical Care, Department of Pediatrics and Communicable Diseases, University of Michigan, Ann Arbor, MI, USA
| | - J J Pituch
- Divisions of Pediatric Nephrology, University of Michigan, Ann Arbor, MI, USA
| | - P L Christopherson
- Divisions of Pediatric Nephrology, University of Michigan, Ann Arbor, MI, USA
| | - T T Cornell
- Pediatric Critical Care, Department of Pediatrics and Communicable Diseases, University of Michigan, Ann Arbor, MI, USA
| | - D T Selewski
- Divisions of Pediatric Nephrology, University of Michigan, Ann Arbor, MI, USA
| | - T P Shanley
- Pediatric Critical Care, Department of Pediatrics and Communicable Diseases, University of Michigan, Ann Arbor, MI, USA
| | - N B Blatt
- Divisions of Pediatric Nephrology, University of Michigan, Ann Arbor, MI, USA
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Zalpuri S, Middelburg RA, Schonewille H, de Vooght KMK, le Cessie S, van der Bom JG, Zwaginga JJ. Intensive red blood cell transfusions and risk of alloimmunization. Transfusion 2013; 54:278-84. [PMID: 23782244 DOI: 10.1111/trf.12312] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2012] [Revised: 04/03/2013] [Accepted: 04/30/2013] [Indexed: 12/24/2022]
Abstract
BACKGROUND Exposure to allogenic red blood cells (RBCs) may lead to formation of antibodies against nonself-antigens in transfused patients. While alloimmunization rates are known to increase with the number of transfusions, the transfusion course in patients can vary from receiving multiple units during a single transfusion event or getting them dispersed over a long(er) period. In this study we compared the immunization risk between different transfusion intensities. STUDY DESIGN AND METHODS An incident new-user cohort study was conducted among consecutive transfused patients at two university medical centers. All patients who received their first RBC transfusion within the study period from January 2005 to December 2011 were eligible. Intensive transfusions were defined as at least 5, at least 10, and at least 20 RBC units within 48 hours. Alloimmunization hazard ratios (HRs), comparing patients receiving intensive transfusions to patients never receiving intensive transfusions, were estimated. RESULTS The study cohort was composed of 5812 patients who had received a median of 7 (interquartile range, 4-12) units. RBC alloantibodies were formed by 156 patients. The adjusted Cox regression HRs for alloimmunization, with number of units as the time covariate and adjusted for patient age, sex, and follow-up time after first transfusion, ranged from 0.8 to 1.2 (95% confidence interval, 0.4-2.6). CONCLUSION The occurrence of RBC alloimmunization in patients receiving intensive transfusions did not differ significantly from patients receiving nonintensive transfusions.
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Affiliation(s)
- Saurabh Zalpuri
- Center for Clinical Transfusion Research, Sanquin Research, Leiden, Netherlands; Department of Clinical Epidemiology, Jon J. van Rood Center for Clinical Transfusion Research, Leiden, Netherlands; Department of Immunohematology and Blood Transfusion, Leiden University Medical Center, Leiden, Netherlands; Department of Medical Statistics, Leiden University Medical Center, Leiden, Netherlands; Department of Clinical Chemistry and Haematology, University Medical Center Utrecht, Utrecht, Netherlands
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13
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Emergency department blood transfusion: the first two units are free. J Surg Res 2013; 184:546-50. [PMID: 23578753 DOI: 10.1016/j.jss.2013.03.043] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2013] [Revised: 03/08/2013] [Accepted: 03/13/2013] [Indexed: 11/20/2022]
Abstract
INTRODUCTION Studies on blood product transfusions after trauma recommend targeting specific ratios to reduce mortality. Although crystalloid volumes as little as 1.5 L predict increased mortality after trauma, little data is available regarding the threshold of red blood cell (RBC) transfusion volume that predicts increased mortality. MATERIALS AND METHODS Data from a level I trauma center between January 2000 and December 2008 were reviewed. Trauma patients who received at least 100 mL RBC in the emergency department (ED) were included. Each unit of RBC was defined as 300 mL. Demographics, RBC transfusion volume, and mortality were analyzed in the nonelderly (<70 y) and elderly (≥70 y). Multivariate logistic regression was performed at various volume cutoffs to determine whether there was a threshold transfusion volume that independently predicted mortality. RESULTS A total of 560 patients received ≥100 mL RBC in the ED. Overall mortality was 24.3%, with 22.5% (104 deaths) in the nonelderly and 32.7% (32 deaths) in the elderly. Multivariate logistic regression demonstrated that RBC transfusion of ≥900 mL was associated with increased mortality in both the nonelderly (adjusted odds ratio 2.06, P = 0.008) and elderly (adjusted odds ratio 5.08, P = 0.006). CONCLUSIONS Although transfusion of greater than 2 units in the ED was an independent predictor of mortality, transfusion of 2 units or less was not. Interestingly, unlike crystalloid volume, stepwise increases in blood volume were not associated with stepwise increases in mortality. The underlying etiology for mortality discrepancies, such as transfusion ratios, hypothermia, or immunosuppression, needs to be better delineated.
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14
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The relationship between intraoperative blood transfusion and postoperative systemic inflammatory response syndrome. Am J Surg 2013; 205:457-65. [DOI: 10.1016/j.amjsurg.2012.07.042] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2012] [Revised: 07/06/2012] [Accepted: 07/17/2012] [Indexed: 12/17/2022]
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15
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Hirst C, Adamantos S. Autologous blood transfusion following red blood cell salvage for the management of blood loss in 3 dogs with hemoperitoneum. J Vet Emerg Crit Care (San Antonio) 2012; 22:355-60. [DOI: 10.1111/j.1476-4431.2012.00747.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Mitra B, Cameron PA, Mori A, Fitzgerald M. Acute coagulopathy and early deaths post major trauma. Injury 2012; 43:22-5. [PMID: 21145056 DOI: 10.1016/j.injury.2010.10.015] [Citation(s) in RCA: 81] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2010] [Revised: 10/14/2010] [Accepted: 10/25/2010] [Indexed: 02/02/2023]
Abstract
INTRODUCTION AND AIMS Acute traumatic coagulopathy is observed in 10-25% of patients post major trauma and its management forms an integral part of haemostatic resuscitation. The identification and treatment of this coagulopathy is difficult and there is uncertainty regarding optimal therapeutic guidelines during the early phases of trauma resuscitation. This study aimed to examine the association between acute coagulopathy and early deaths post major trauma. METHODS A retrospective review of data over a 5 year period was performed to determine the associations between variables considered to contribute to mortality for adult major trauma patients (Injury Severity Score (ISS)>15) receiving blood transfusions as part of their initial resuscitation. Early death, defined as death in ED, or death in the operating theatre (OT), Intensive Care Unit (ICU) or wards within 24 h of admission was the primary end-point. Patients with non-survivable head injury on initial imaging were excluded. Univariate associations were calculated and multivariable logistic regression analysis was used to determine independent associations with mortality. RESULTS There were 772 patients included in this study with a median ISS of 29 (19-41), with 91.7% blunt trauma. All-cause in-hospital mortality was 17.5%, while 77 (9.7%) patients died early. Increasing age (OR 1.04), a GCS of 3-8 (OR 5.05), and the presence of acute coagulopathy (OR 8.77) were significant independent variables associated with early death. CONCLUSIONS Acute traumatic coagulopathy, independent of injury severity, transfusion practice or other physiological markers for haemorrhage, was associated with early death in major trauma patients requiring a blood transfusion. Early recognition and management of coagulopathy, independent of massive transfusion guidelines, may improve outcome from trauma resuscitation. Further studies are required for the early recognition of acute traumatic coagulopathy to enable the development of an evidence base for management.
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Affiliation(s)
- Biswadev Mitra
- Emergency & Trauma Centre, The Alfred Hospital, Melbourne, VIC, Australia.
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Epidemiology and risk factors of sepsis after multiple trauma: an analysis of 29,829 patients from the Trauma Registry of the German Society for Trauma Surgery. Crit Care Med 2011; 39:621-8. [PMID: 21242798 DOI: 10.1097/ccm.0b013e318206d3df] [Citation(s) in RCA: 118] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
OBJECTIVES The objectives of this study were 1) to assess potential changes in the incidence and outcome of sepsis after multiple trauma in Germany between 1993 and 2008 and 2) to evaluate independent risk factors for posttraumatic sepsis. DESIGN Retrospective analysis of a nationwide, population-based prospective database, the Trauma Registry of the German Society for Trauma Surgery. SETTING A total of 166 voluntarily participating trauma centers (levels I-III). PATIENTS Patients registered in the Trauma Registry of the German Society for Trauma Surgery between 1993 and 2008 with complete data sets who presented with a relevant trauma load (Injury Severity Score of ≥ 9) and were admitted to an intensive care unit (n = 29,829). INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Over the 16-yr study period, 10.2% (3,042 of 29,829) of multiply injured patients developed sepsis during their hospital course. Annual data were summarized into four subperiods: 1993-1996, 1997-2000, 2001-2004, and 2005-2008. The incidences of sepsis for the four subperiods were 14.8%, 12.5%, 9.4%, and 9.7% (p < .0001), respectively. In-hospital mortality for all trauma patients decreased for the respective subperiods (16.9%, 16.0%, 13.7%, and 11.9%; p < .0001). For the subgroup of patients with sepsis, the mortality rates were 16.2%, 21.5%, 22.0%, and 18.2% (p = .054), respectively. The following independent risk factors for posttraumatic sepsis were calculated from a multivariate logistic regression analysis: male gender, age, preexisting medical condition, Glasgow Coma Scale score of ≤ 8 at scene, Injury Severity Score, Abbreviated Injury ScaleTHORAX score of ≥ 3, number of injuries, number of red blood cell units transfused, number of operative procedures, and laparotomy. CONCLUSIONS The incidence of sepsis decreased significantly over the study period; however, in this decade the incidence remained unchanged. Although overall mortality from multiple trauma has declined significantly since 1993, there has been no significant decrease of mortality in the subgroup of septic trauma patients. Thus, sepsis has remained a challenging complication after trauma during the past 2 decades. Recognition of the identified risk factors may guide early diagnostic workup and help to reduce septic complications after multiple trauma.
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Hassan N, Halanski M, Wincek J, Reischman D, Sanfilippo D, Rajasekaran S, Wells C, Tabert D, Kurt B, Mitchell D, Huntington J, Cassidy J. Blood management in pediatric spinal deformity surgery: review of a 2-year experience. Transfusion 2011; 51:2133-41. [DOI: 10.1111/j.1537-2995.2011.03175.x] [Citation(s) in RCA: 69] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Risk of cardiac arrhythmias and conduction abnormalities in patients with acute myocardial infarction receiving packed red blood cell transfusions. J Crit Care 2010; 26:335-41. [PMID: 20869199 DOI: 10.1016/j.jcrc.2010.08.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2010] [Revised: 08/12/2010] [Accepted: 08/12/2010] [Indexed: 11/23/2022]
Abstract
PURPOSE Although transfusion has been linked to the development of atrial fibrillation (AF) in cardiac surgical patients, this association has not been investigated in patients with acute myocardial infarction (AMI). Evidence supports an inflammatory mechanism in the development of AF, and red cell transfusions also elicit an inflammatory response. We therefore sought to evaluate whether packed red blood cell transfusion increases the risk of AF, ventricular tachycardia (VT), and other arrhythmias and conduction abnormalities in patients with AMI. MATERIALS AND METHODS This is a retrospective study on patients with AMI and no prior history of AF, admitted to a critical care area and entered in Project Impact database from 08/2003-12/2007. Primary outcome measures were new-onset cardiac arrhythmias or conduction disturbances. RESULTS Transfused patients had significantly higher incidences of AF (4.7% vs 1.3%, P = .008), cardiac arrest (9.5% vs 1.7%, P < .001) and heart block (3.4% vs 0.1%, P < .001), and a trend toward a higher incidence of VT (3.4% vs 1.3%, P = .058). Multivariate regression analysis confirmed transfusion as an independent risk factor for "non-lethal" cardiac events (AF/heart block; odds ratio [OR], 4.7 [1.9-11.9]; P = .001), "lethal" events (VT/cardiac arrest; OR, 2.4 [1.1-5]; P = .016), and all cardiac events (OR, 2.8 [1.5-65.1]; P = .001). Transfused patients had significantly longer length of stay (P < .0001) and significantly higher mortality rates than nontransfused patients (OR, 3 [1.7-5.5]; P < .001). CONCLUSIONS Packed red blood cell transfusion is independently associated with an increased risk of new-onset cardiac arrhythmias and conduction abnormalities in the setting of AMI, even after controlling for traditional risk factors.
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Abstract
Massive transfusion (MT) is a lifesaving treatment of hemorrhagic shock, but can be associated with significant complications. The lethal triad of acidosis, hypothermia, and coagulopathy associated with MT is associated with a high mortality rate. Other complications include hypothermia, acid/base derangements, electrolyte abnormalities (hypocalcemia, hypomagnesemia, hypokalemia, hyperkalemia), citrate toxicity, and transfusion-associated acute lung injury. Blood transfusion in trauma, surgery, and critical care has been identified as an independent predictor of multiple organ failure, systemic inflammatory response syndrome, increased infection, and increased mortality in multiple studies. Once definitive control of hemorrhage has been established, a restrictive approach to blood transfusion should be implemented to minimize further complications.
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Affiliation(s)
- Kristen C Sihler
- University of Michigan School of Medicine, Ann Arbor, MI 48109-0033, USA
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21
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Perna V, Morera R. [Prognostic factors in chest traumas: a prospective study of 500 patients]. Cir Esp 2010; 87:165-70. [PMID: 20074711 DOI: 10.1016/j.ciresp.2009.11.020] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2009] [Revised: 06/28/2009] [Accepted: 11/17/2009] [Indexed: 01/25/2023]
Abstract
OBJECTIVE Identify the factors of greatest impact in patients with chest trauma. PATIENTS AND METHODS prospective study of 500 patients (425 men and 75 women) with chest trauma treated between January 2006 and December 2008. The parameters assessed include the degree of trauma, the abbreviated injury scale (AIS), the injury severity score (ISS), pre-hospital intubation, duration of mechanical ventilation, stay in the intensive care unit (ICU), number of rib fractures, presence of pulmonary contusion, haemothorax and cardio-pulmonary effects. RESULTS The presence of polytrauma, the number of rib fractures, the presence of flail chest, pulmonary contusion, the delay in mechanical ventilation and age were shown to be effective markers of severity. CONCLUSIONS Thoracic injuries have a number of indicators of severity. The mortality risk is associated with an ISS >25, the presence of 3 or more rib fractures with flail chest, pulmonary contusion, the development of ARDS, and with an age >55 years.
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Affiliation(s)
- Valerio Perna
- Servicio Cirugía Torácica, Hospital de Navarra, Pamplona, España.
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22
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Clinical practice guideline: Red blood cell transfusion in adult trauma and critical care*. Crit Care Med 2009; 37:3124-57. [DOI: 10.1097/ccm.0b013e3181b39f1b] [Citation(s) in RCA: 364] [Impact Index Per Article: 24.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
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23
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Maegele M, Lefering R, Paffrath T, Simanski C, Wutzler S, Bouillon B. Changes in transfusion practice in multiple injury between 1993 and 2006: a retrospective analysis on 5389 patients from the German Trauma Registry. Transfus Med 2009; 19:117-24. [PMID: 19566668 DOI: 10.1111/j.1365-3148.2009.00920.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
To evaluate transfusion practices in multiple injured patients and to demonstrate changes in the pattern of packed red blood cell (pRBC) transfusions over the last one-and-half decade (1993-2006). A retrospective analysis using the German Trauma Registry database (DGU-Traumaregister) including 29 353 multiple injured patients was conducted. The study population included primary admissions presenting to the emergency room (ER) with clinical and laboratory signs of active haemorrhage [haemoglobin < 9 g x dL(-1), platelets < 90000 xmicroL(-1) and prothrombin time (Quick-value) < 60%]. The pattern of pRBC transfusions was followed from ER to intensive care unit (ICU) admission. A total of 5389 patients with complete data sets were divided into the following three groups according to the year of treatment and analysed: (a) group 1: 1993-1998 (n = 870), (b) group 2: 1999-2002 (n = 2044) and (c) group 3: 2003-2006 (n = 2475). Patients had a mean age of 40.5 (+/-20) years and were predominantly male (67.2%). All patients were substantially injured (mean injury severity score = 32 +/- 15.5) and in 93% the mechanism of injury was blunt. The percentage of patients who received pRBC transfusions between ER and ICU dropped from 72% in 1993-1998 to 54% in 2003-2006 (P < 0.005). Similarly, the percentage of patients receiving mass transfusions (> 10 pRBC units) dropped from 51.3 to 17.1%. This decline was accompanied by lower incidence rates for septic complications, ventilator days, ICU length-of-stay and mortality. pRBC transfusion practices in acute trauma care have changed substantially over the last one-and-half decade and were associated with better outcome.
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Affiliation(s)
- Marc Maegele
- Department of Trauma and Orthopedic Surgery, University of Witten/Herdecke, Cologne-Merheim Medical Center (CMMC), Cologne, Germany.
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Lustenberger T, Turina M, Seifert B, Mica L, Keel M. The Severity of Injury and the Extent of Hemorrhagic Shock Predict the Incidence of Infectious Complications in Trauma Patients. Eur J Trauma Emerg Surg 2009; 35:538-46. [PMID: 26815377 DOI: 10.1007/s00068-009-8128-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2008] [Accepted: 01/17/2009] [Indexed: 12/19/2022]
Abstract
BACKGROUND Trauma patients are at high risk of developing systemic inflammatory response syndrome (SIRS) and infections. The aim of this study was to evaluate the influence of the severity of injury and the extent of hemorrhagic shock at admission on the incidence of SIRS, infection and septic complications. METHODS A total of 972 patients who had an injury severity score (ISS) of ≥ 17, survived more than 72 h, and were admitted to a level I trauma center within 24 h after trauma were included in this retrospective analysis. SIRS, sepsis and infection rates were measured in patientswith different severities of injury as assessed by ISS, or with various degrees of hemorrhagic shock according to ATLS(®) guidelines, andwere compared using both uni- and multivariate analysis. RESULTS Infection rates and septic complications increase significantly (p < 0.001) with higher ISS. Severe hemorrhagic shock on admission is associated with a higher rate of infection (72.8%) and septic complications (43.2%) compared to mild hemorrhagic shock (43.4%, p < 0.001 and 21.7%, p < 0.001, respectively). CONCLUSION The severity of injury and the severity of hemorrhagic shock are risk factors for infectious and septic complications. Early diagnostic and adequate therapeutic work up with planned early "second look" interventions in such high-risk patients may help to reduce these common posttraumatic complications.
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Affiliation(s)
- Thomas Lustenberger
- Department of Trauma Surgery, University Hospital of Zurich, Zurich, Switzerland
| | - Matthias Turina
- Department of Trauma Surgery, University Hospital of Zurich, Zurich, Switzerland. .,Department of Trauma Surgery, University Hospital of Zurich, Rämistrasse 100, 8091, Zurich, Switzerland.
| | - Burkhardt Seifert
- Biostatistics Unit, Institute for Social and Preventive Medicine, University of Zurich, Zurich, Switzerland
| | - Ladislav Mica
- Department of Trauma Surgery, University Hospital of Zurich, Zurich, Switzerland
| | - Marius Keel
- Department of Trauma Surgery, University Hospital of Zurich, Zurich, Switzerland
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Kanakaris NK, Petsatodis G, Chalidis B, Manidakis N, Kontakis G, Giannoudis PV. The role of erythropoietin in the acute phase of trauma management: evidence today. Injury 2009; 40:21-7. [PMID: 19117559 DOI: 10.1016/j.injury.2008.09.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2008] [Revised: 09/05/2008] [Accepted: 09/05/2008] [Indexed: 02/02/2023]
Abstract
Trauma patients often present in a state of haemorrhagic shock. Blood products remain the gold standard of resuscitation, but allogeneic blood transfusions (ABTs) are associated with several risks. The stimulating effect of recombinant-erythropoietin (EPO-A) on erythropoiesis has raised interest in its administration as an alternative. The existing evidence on the early use of EPO-A in the acute phase of trauma patients management consists of only 14 publications. The level of evidence of these studies and the number of treated patients was not found to be adequate to support its generalised use, despite their favourable results. Its safety profile, the preliminary proofs of its efficacy, and the additional cyto-protective properties of EPO-A strongly encourage further controlled studies assessing its use in the acute setting of initial trauma management.
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Affiliation(s)
- N K Kanakaris
- Academic Department of Trauma & Orthopaedics, Leeds Teaching Hospitals, Leeds, UK
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Teixeira PG, Oncel D, Demetriades D, Inaba K, Shulman I, Green D, Plurad D, Rhee P. Blood Transfusions in Trauma: Six-Year Analysis of the Transfusion Practices at a Level I Trauma Center. Am Surg 2008. [DOI: 10.1177/000313480807401015] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The objective of this study was to analyze the transfusion practices in trauma patients in one institution. A retrospective analysis of the Trauma Registry linked with the Blood Bank Database of a Level 1 trauma center was conducted. Over 6 years, 17 per cent of the 25,599 trauma patients received blood transfusions. The overall mortality in transfused patients was 20 per cent and remained the same during the study period. There was no change in the proportion of patients receiving transfusions throughout the years, however there was a significant 23.5 per cent reduction in the mean number of packed red blood cells (PRBC) units transfused (P < 0.001 for trend). This reduction in PRBC used remained true and even more evident in the group of more severely injured patients (Injury Severity Score ≥ 16), with a 27.9 per cent decrease in mean units of PRBC (P < 0.001 for trend). The highest reduction in PRBC transfusion was seen in blunt trauma patients (34.6%, P < 0.001). During the study period there was a concurrent increase in mean units of fresh frozen plasma used (60.7%, P < 0.001) and no change in the use of platelets and cryoprecipitate. In conclusion, transfusions of PRBC were significantly reduced over time in trauma patients without any evident negative impact on mortality.
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Affiliation(s)
| | - Didem Oncel
- Division of Trauma Surgery and Surgical Critical Care
| | | | - Kenji Inaba
- Division of Trauma Surgery and Surgical Critical Care
| | | | - Donald Green
- Division of Trauma Surgery and Surgical Critical Care
- Department of Pathology
| | - David Plurad
- Division of Trauma Surgery and Surgical Critical Care
- Department of Pathology
| | - Peter Rhee
- Division of Trauma, Critical Care and Emergency Surgery, University of Arizona, Tucson, Arizona
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Maegele M, Lefering R, Paffrath T, Tjardes T, Simanski C, Bouillon B. Red blood cell to plasma ratios transfused during massive transfusion are associated with mortality in severe multiply injury: a retrospective analysis from the Trauma Registry of the Deutsche Gesellschaft fr Unfallchirurgie. Vox Sang 2008; 95:112-9. [DOI: 10.1111/j.1423-0410.2008.01074.x] [Citation(s) in RCA: 213] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Abstract
Clinical pharmacists often participate on critical care teams that manage patients with bleeding emergencies. Although blood products are usually dispensed from the blood bank and not the pharmacy, pharmacists should be conversant in the language and trends of transfusion medicine, much like they are with other therapeutic agents. Toward that goal, this review provides a concise transfusion medicine tutorial, covering all commonly used blood products, including red blood cells, platelets, fresh frozen plasma, and plasma derivatives such as cryoprecipitate, prothrombin complex concentrates, and albumin. Usage patterns, the rationale for administering the various blood products, and studies that have attempted to determine appropriate criteria for ordering transfusions (transfusion triggers) are discussed. The benefits, risks, and several ongoing controversies that relate to the appropriateness and safety of blood product use are also summarized.
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Affiliation(s)
- Aryeh Shander
- Department of Anesthesiology and Critical Care and Hyperbaric Medicine and the New Jersey Institute for the Advancement of Bloodless Medicine and Surgery, Englewood Hospital and Medical Center, Englewood, New Jersey 07631, USA.
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29
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Mitra B, Mori A, Cameron PA, Fitzgerald M, Street A, Bailey M. Massive blood transfusion and trauma resuscitation. Injury 2007; 38:1023-9. [PMID: 17572415 DOI: 10.1016/j.injury.2007.03.021] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2006] [Revised: 01/09/2007] [Accepted: 03/18/2007] [Indexed: 02/02/2023]
Abstract
AIMS To review the massive transfusion practice at a Level I adult Trauma Centre during initial trauma reception and resuscitation. METHODS All trauma patients presenting to The Alfred Emergency & Trauma Centre and receiving a transfusion of five units or more of packed red blood cells within 4h of presentation over a 26-month period were included in this study. Patient demographics, clinical characteristics, injuries, surgical management and volume of blood transfused were analysed with mortality as the primary endpoint. Initial clinical features and injuries predictive of massive transfusion were also analysed. RESULTS There were 119 patients who received a transfusion of five units or more of packed red blood cells (PRBCs) within 4h of presentation. The median Injury Severity Score of this group of patients was 34.0 (IQR 26-48) and mortality was 27.7%. The median number of packed red blood cell transfused was 8.0 (IQR 6-14) in the 1st 4h. Initial clinical features and injuries independently associated with a larger volume of blood transfused were initial hypotension, fractures of the pelvis, kidney injuries, initial acidaemia, and thrombocytopaenia. The Injury Severity Score, initial coagulopathy measured by APTT and the presence of head injuries were the independent predictors of mortality. CONCLUSIONS The volume of blood transfused during trauma resuscitation was not found to be an independent predictor of mortality. Prospective studies into transfusion practice and clinical features of patients during the trauma resuscitation phase requiring massive transfusion are needed to establish evidence-based guidelines for massive transfusion.
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Affiliation(s)
- Biswadev Mitra
- Emergency & Trauma Centre, The Alfred Hospital, Melbourne, Australia.
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