Transfusion of blood products in trauma: an update

Predictors for anaemia, blood transfusion and outcome in plastic surgery patients

OBJECTIVE

In patients undergoing plastic surgery, to identify specific risk factors for anaemia and use of blood products, and assess their impact on patient outcome.

METHOD

For this retrospective study, data were analysed from patients who attended the Plastic Surgery Department at our hospital over a three-year period (2018 to 2020). Adult patients who presented with traumatic injuries, oncologic patients who underwent reconstructive procedures, and patients with soft tissue infections (STIs) who required plastic surgery for tissue coverage were included. Demographic and injury data, hospital admission characteristics, surgical procedures, laboratory test results, transfusion events, and in-hospital complications were extracted from patient records.

RESULTS

Of the 350 patients included in the study, 228 (65%) presented with trauma, 76 (22%) underwent reconstructive surgery for cancers and 46 (13%) had STIs. In total, 175 (50%) patients developed anaemia, and 37 (11%) received blood transfusions; these were 20 (54%), 5 (14%), and 12 (32%) patients in the trauma, cancer and STI groups, respectively. Associated comorbidities and upper and lower limb surgery were the most significant risk factors for anaemia, while the number of surgeries and NSTIs were identified as risk factors for blood transfusions. Direct wound closure was consistently a protective factor for both anaemia and blood transfusions. Blood transfusions were independently associated with a high risk of sepsis, wound complications, and prolonged hospital stay.

CONCLUSION

While transfusions are necessary and even lifesaving in surgical patients, blood is a finite resource and its use may negatively impact patient outcome. Therefore, ongoing research must focus on providing safe and restrictive clinical practices while developing sustainable and accessible alternatives.

Blood Product Replacement for Postpartum Hemorrhage

Consideration for blood products replacement in postpartum hemorrhage should be given when blood loss exceeds 1.5 L or when an estimated 25% of blood has been lost. In cases of massive hemorrhage, standardized transfusion protocols have been shown to improve maternal morbidity and mortality. Most protocols recommend a balanced transfusion involving a 1:1:1 ratio of packed red blood cells, platelets, and fresh frozen plasma. Alternatives such as cryoprecipitate, fibrinogen concentrate, and prothrombin complex concentrates can be used in select clinical situations. Although transfusion of blood products can be lifesaving, it does have associated risks.

Massive Trauma and Resuscitation Strategies

Massive trauma remains the leading cause of mortality among people aged younger than 45 years. In this review, we discuss the initial care and diagnosis of trauma patients followed by a comparison of resuscitation strategies. We discuss various strategies including use of whole blood and component therapy, examine viscoelastic techniques for management of coagulopathy, and consider the benefits and limitations of the resuscitation strategies and consider a series of questions that will be important for researchers to answer to provide the best and most cost-effective therapy for severely injured patients.

Temporal trends, predictors of blood transfusion and in-hospital outcomes among patients with severe burn injury in the United States-A national database-based analysis

BACKGROUND

Severe burn can be accompanied by life-threatening bleeding on some occasions, thus, blood transfusion is often required in these patients during their hospitalization. Therefore, we aimed to examine temporal trends, predictors, and in-hospital outcomes of blood transfusion in these patients in the United States.

METHODS

The National Inpatient Sample was used to identify severe burn patients between January 2010 and September 2017 in the United States. Trends in the utilization of blood transfusion were analyzed using the Cochran-Armitage trend test. Moreover, propensity score matching (PSM) was employed, and then in-hospital outcomes were compared between these two groups in the matched cohort. Multivariable logistic regressions were further used to validate the results of PSM.

RESULTS

Among 27,260 severe burn patients identified during the study period, 2120 patients (7.18%) received blood transfusion. Blood transfusion rates decreased significantly from 9.52% in 2010 to 5.02% in 2017 (p for trend <.001). In the propensity-matched cohort (2120 pairs with and without transfusion), patients transfused were at increased risk of in-hospital mortality (13.3% vs 8.77%, p < .001), overall postoperative complications (88.3% vs 72.59%, p < .001), longer hospital stays (defined as > median hospital stays = 5 d) (73.8% vs 50.6%, p < .001) and increased overall cost (defined as > median overall costs = 30,746) (81.6% vs 57.3%, p < .001). This was also the case for the multivariable analysis.

CONCLUSIONS

Blood transfusion following severe burn injury may be associated with worse clinical outcomes. The utility for blood transfusion in burn patients warrants further prospective exploration.

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.

Increased risk of blood transfusion in patients with diabetes mellitus sustaining non-major burn injury

BACKGROUND

Due to the increased mortality and morbidity associated with blood transfusion, identifying modifiable predictors of transfusion are vital to prevent or minimise blood use. We hypothesised that burn patients with diabetes mellitus were more likely to be prescribed a transfusion. These patients tend to have increased age, number of comorbidities, infection risk and need for surgery which are all factors reported previously to be associated with blood use.

OBJECTIVE

To determine whether patients with diabetes mellitus who have sustained a burn ≤20% total body surface area (TBSA) are at higher risk of receiving red blood cell transfusion compared to those without diabetes mellitus.

METHOD

This was a retrospective cohort study including patients admitted to the major Burns Unit in Western Australia for management of a burn injury. Only the first hospital admission between May 2008 to February 2017 were included.

RESULTS

Among 2101 patients with burn injuries ≤20% TBSA, 48 (2.3%) received packed red blood cells and 169 (8.0%) had diabetes. There were 13 (7.7%) diabetic patients that were transfused versus 35 (1.8%) non-diabetic patients. Patients with diabetes were 5.2 (p = 0.034) times more likely to receive packed red blood cells after adjusting for percentage TBSA, haemoglobin at admission or prior to transfusion, number of surgeries, total comorbid burden and incidence of infection. As percentage TBSA increases, the probability of packed red blood cell transfusion increases at a higher rate in DM patients.

CONCLUSIONS

This study showed that diabetic patients with burn injuries ≤20% TBSA have a higher probability of receiving packed red blood cell transfusion compared to patients without diabetes. This effect was compounded in burns with higher percentage TBSA.

Massive transfusion in pediatric trauma: An ATOMAC perspective

BACKGROUND/PURPOSE

Massive transfusion protocols (MTPs) are considered valuable in pediatric trauma. Important questions regarding the survival benefit and optimal blood component ratio remain unknown.

METHODS

The study time frame was January 2007 through December 2013 five Level I Pediatric Trauma Centers reviewed all trauma activations involving children ≤18 years of age. Included were patients who either had the institutional MTP or received >20 mL/kg or > 2 units packed red blood cells (PRBCs).

RESULTS

110/202 qualified for inclusion. Median age was 5.9 years (3.0-11.4). 73% survived to discharge; median hospitalization was 10 (3.1-22.8) days. Survival did not vary by arrival hemoglobin (Hgb), gender or age. Partial prothrombin time (PTT), INR, GCS and injury severity score (ISS) significantly differed for nonsurvivors (all p < 0.05). Logistic regression found increased mortality (OR 3.08 (1.10-8.57), 95% CI; p = 0.031) per unit increase over a 1:1 ratio of pRBC:FFP.

CONCLUSION

In pediatric trauma pRBC:FFP ratio of 1:1 was associated with the highest survival of severely injured children receiving massive transfusion. Ratios 2:1 or ≥3:1 were associated with significantly increased risk of death. These data support a higher proportion of plasma products for pediatric trauma patients requiring massive transfusion.

LEVEL OF EVIDENCE

Level IV.

Comparison the efficacy of hemorrhage control of Surgiflo Haemostatic Matrix and absorbable gelatin sponge in posterior lumbar surgery: A randomized controlled study

OBJECTIVE

To compare the hemostatic effect of hematostatic agent Surgiflo and absorbable gelatin sponge (AGS) in posterior lumbar surgery.

METHODS

A total of 60 cases were recruited during August 2016 and June 2017 according to the inclusion and exclusion criteria. Patients were randomly allocated to the Surgiflo Haemostatic Matrix (SHM) group or the AGS group (AGS) by computer-generated randomization codes. The success rates of hemostasis for 3 minutes and 5 minutes, the time of operation, the amount of intraoperative bleeding, the volume of autogenously blood transfusion, the amount of blood during hemostasis, the amount of blood transfusion, and BP, RBC, HCT, HB of preoperative, 2 to 3 days, and 5 to 7 days following operation were recorded to compare. Daily drainage and all adverse events after operation were also compared.

RESULTS

All the patients were followed up for at least 1 month. The RBC and HCT of the AGS group before operation were lower than those in the control group (P = .039, P = .029), but there was no difference after operation (P >.05). In the control group, 19 cases were successfully hemostatic in 3 minutes, 4 cases were successful in 5 minutes, and 7 cases were combined with hemostasis. In the SHM group, it was 22, 3, and 5 cases respectively. There was significant difference in blood loss during hemostatic process between the 2 groups (P <.001). There was no difference in the amount of blood loss and autologous blood transfusion between the 2 groups, and there was no difference in the operation time between the 2 groups. In the AGS group, allogeneic blood was infused in 1 case during operation, and no allogeneic blood was infused in the other patients. The drainage volume on the 1st day and the 2nd to 4th day after operation in the AGS group was less than that in the control group (P = .015, P = .010).

CONCLUSION

Compared with AGS, SHM could decrease the blood loss during hemostatic process and the postoperative drainage volume in posterior operation of lumbar degenerative disease. SHM is a safe and effective hemostatic agent in lumbar posterior surgery.

Secondary hemochromatosis as a result of acute transfusion-induced iron overload in a burn patient

Background

Red blood cell transfusions are critical in burn management. The subsequent iron overload that can occur from this treatment can lead to secondary hemochromatosis with multi-organ damage.

Case Presentation

While well recognized in patients receiving chronic transfusions, we present a case outlining the acute development of hemochromatosis secondary to multiple transfusions in a burn patient.

Conclusions

Simple screening laboratory measures and treatment options exist which may significantly reduce morbidity; thus, we believe awareness of secondary hemochromatosis in those treating burn patients is critical.

Retrospective Study of 122 Dogs That Were Treated with the Antifibrinolytic Drug Aminocaproic Acid: 2010-2012

Antifibrinolytic drugs are used to promote hemostasis and decrease the need for red blood cell transfusion. Medical records of 122 dogs that were prescribed either oral or intravenous aminocaproic acid between 2010 and 2012 were evaluated retrospectively. Of the 122 dogs, three experienced possible drug-related adverse effects. No significant differences were identified between dogs that experienced adverse effects and those that did not and the possible adverse effects noted were all minor. All dogs that received packed red blood cell transfusions were evaluated for correlations between baseline packed cell volume or dose of red blood cells and aminocaproic acid dose and no correlation was identified. Dogs that received aminocaproic acid as a treatment for active bleeding were divided by cause of hemorrhage into the following groups: neoplastic, non-neoplastic, and unknown. No significant differences in aminocaproic acid dose or the percentage of patients requiring a blood transfusion were identified between groups.

Relative hypotension increases the probability of the need for angioembolisation in pelvic fracture patients without contrast extravasation on computed tomography scan

INTRODUCTION

In the evaluation of haemorrhage in trauma patients with pelvic fractures, contrast extravasation (CE) on computed tomography (CT) scan often implies active arterial bleeding. However, the absence of CE on CT scan does not always exclude the need for transcatheter arterial embolisation (TAE) to achieve haemostasis. In the current study, we evaluated the factors associated with the need for TAE in patients without CE on CT scan. These factors may be evaluated as adjuncts to CT scanning in the management of patients with pelvic fractures.

METHODS

We retrospectively reviewed our trauma registry and medical records of patients with pelvic fractures. When CE was observed, indicating active haemorrhage, the patients underwent TAE to achieve haemostasis. In contrast, patients without CE were held for observation and treatment of their injuries, and if their condition deteriorated after a delayed interval, they were then also referred for TAE if no other focus of haemorrhage was found. Patients without CE on CT scan but with retroperitoneal haemorrhage requiring TAE were investigated. Their demographic characteristics, associated injuries, fracture patterns, and changes in systolic blood pressure were described and analysed.

RESULTS

In total, 201 patients with pelvic fracture underwent CT scan examination; 47 (23.4%) had CE by CT scan, whereas the other 154 (76.6%) did not. Of the 154 patients who did not show CE by CT scan, 124 (80.5%) patients never underwent TAE; however, 30 (19.5%) of these patients did eventually undergo TAE. In comparing the patients who underwent TAE to those who did not undergo TAE among patients without CE on CT scan, the systolic blood pressure (SBP) on arrival (median: 100.0 mmHg vs 136.0 mmHg, p<0.01) and the lowest SBP recorded in the ED (median: 68.0 mmHg vs 129.0 mmHg, p<0.01) were significantly lower in the patients who underwent TAE. The ROC curve analysis revealed that the most appropriate cutoff value of decrement of SBP (SBP on arrival minus the lowest SBP in the ED) was 30 mmHg (AUC=0.89).

CONCLUSION

In the management of pelvic fracture patients, greater attention should be directed toward patients with relative hypotension. The higher likelihood of haemodynamic deterioration and the need for TAE for haemorrhage control should remain under consideration in such cases, despite the absence of CE by CT scan.

Impact of the age of stored blood on trauma patient mortality: a systematic review

BACKGROUND

The impact of the age of stored red blood cells on mortality in patients sustaining traumatic injuries requiring transfusion of blood products is unknown. The objective of this systematic review was to identify and describe the available literature on the use of older versus newer blood in trauma patient populations.

METHODS

We searched PubMed, Embase, Lilac and the Cochrane Database for published studies comparing the transfusion of newer versus older red blood cells in adult patients sustaining traumatic injuries. Studies included for review reported on trauma patients receiving transfusions of packed red blood cells, identified the age of stored blood that was transfused and reported patient mortality as an end point. We extracted data using a standardized form and assessed study quality using the Newcastle-Ottawa Scale.

RESULTS

Seven studies were identified (6780 patients) from 3936 initial search results. Four studies reported that transfusion of older blood was independently associated with increased mortality in trauma patients, while 3 studies did not observe any increase in patient mortality with the use of older versus newer blood. Three studies associated the transfusion of older blood with adverse patient outcomes, including longer stay in the intensive care unit, complicated sepsis, pneumonia and renal dysfunction. Studies varied considerably in design, volumes of blood transfused and definitions applied for old and new blood..

CONCLUSION

The impact of the age of stored packed red blood cells on mortality in trauma patients is inconclusive. Future investigations are warranted.

Low-dose 3-factor prothrombin complex concentrate for warfarin reversal prior to heart transplant

BACKGROUND

Anticoagulation with warfarin is common in patients presenting for heart transplant. Prior to surgery, anticoagulation reversal is necessary to avoid significant intraoperative and perioperative bleeding complications. Commonly, warfarin reversal is achieved with vitamin K and fresh frozen plasma (FFP); however, these therapies have significant limitations. An alternative to FFP for reversal exists with prothrombin complex concentrate (PCC). A warfarin reversal protocol prior to heart transplant was implemented using low-dose PCC at our institution.

OBJECTIVE

To assess blood product use, effectiveness, and safety post-low-dose PCC administration in patients needing warfarin reversal prior to heart transplant compared with historical controls.

METHODS

This was a single-center, retrospective cohort study. The PCC cohort included patients undergoing heart transplant presenting with an international normalized ratio ≥1.5 on warfarin therapy and who received at least 1 dose of PCC. Blood product use was measured from postoperative day 0 to 2.

RESULTS

The PCC and historical control cohorts included 16 and 50 patients, respectively. There was a significant reduction in the use of FFP (4 vs 8 units, P = 0.0239) in the PCC cohort compared with the historical control cohort. No differences were identified in the use of other blood products as well as other secondary efficacy or safety end points.

CONCLUSIONS

Use of PCC, per the reversal protocol, prior to heart transplant reduced FFP use and showed a non-statistically significant trend toward reductions in the use of other blood products in the intraoperative and perioperative setting, with no difference identified in thrombotic or embolic complications compared with historical controls.

Strategies for the management of haemorrhage following pelvic fractures and associated trauma-induced coagulopathy

Exsanguination is the second most common cause of death in patients who suffer severe trauma. The management of haemodynamically unstable high-energy pelvic injuries remains controversial, as there are no universally accepted guidelines to direct surgeons on the ideal use of pelvic packing or early angio-embolisation. Additionally, the optimal resuscitation strategy, which prevents or halts the progression of the trauma-induced coagulopathy, remains unknown. Although early and aggressive use of blood products in these patients appears to improve survival, over-enthusiastic resuscitative measures may not be the safest strategy. This paper provides an overview of the classification of pelvic injuries and the current evidence on best-practice management of high-energy pelvic fractures, including resuscitation, transfusion of blood components, monitoring of coagulopathy, and procedural interventions including pre-peritoneal pelvic packing, external fixation and angiographic embolisation.

Immediate screening method for predicting the necessity of massive transfusions in trauma patients: a retrospective single-center study

Background

Hemostatic resuscitation might improve the survival of severely injured trauma patients. Our objective was to establish a simplified screening system for determining the necessity of massive transfusions (MT) at an early stage in trauma cases.

Methods

We retrospectively analyzed the cases of trauma patients who had been transported to our institution between November 2011 and October 2013. Patients who were younger than 18 years of age or who were confirmed to have suffered a cardiac arrest at the scene or on arrival were excluded. MT were defined as transfusions involving the delivery of ≥10 units of red blood cell concentrate within the first 24 h after arrival.

Results

A total of 259 trauma patients were included in this study (males: 178, 69%). Their mean age was 49 ± 20, and their median injury severity score was 14.4. Thirty-three (13%) of the patients required MT. The presence of a shock index of ≥1, a base excess of ≤ −3 mmol/L, or a positive focused assessment of sonography for trauma (FAST) result was found to exhibit sensitivity and specificity values of 0.97 and 0.81, respectively, for predicting the necessity of MT. Furthermore, this method displayed an area under the receiver operating characteristic curve of 0.934 (95% confidence interval, 0.891–0.978), which indicated that it was highly accurate.

Conclusions

Our screening method based on the shock index, base excess, and FAST result is a simple and useful way of predicting the necessity of MT early after trauma.

Volume therapy in trauma and neurotrauma

Volume therapy in trauma should be directed at the restitution of disordered physiology including volume replacement to re-establishment of tissue perfusion, correction of coagulation deficits and avoidance of fluid overload. Recent literature has emphasised the importance of damage control resuscitation, focussing on the restoration of normal coagulation through increased use of blood products including fresh frozen plasma, platelets and cryoprecipitate. However, once these targets have been met, and in patients not in need of damage control resuscitation, clear fluid volume replacement remains essential. Such volume therapy should include a balance of crystalloids and colloids. Pre-hospital resuscitation should be limited to that required to sustain a palpable radial artery and adequate mentation. Neurotrauma patients require special consideration in both pre-hospital and in-hospital management.

Tranexamic acid corrects fibrinolysis in the presence of acidemia in a swine model of severe ischemic reperfusion

BACKGROUND

Tranexamic acid (TXA) is an antifibrinolytic with anti-inflammatory properties associated with improved outcomes when administered to trauma patients at risk for bleeding; however, its efficacy is unknown in acidemia. We evaluated the efficacy of TXA on hyperfibrinolysis using an established porcine traumatic hemorrhage ischemic shock model.

METHODS

Ten Yorkshire swine underwent a controlled hemorrhage followed by supraceliac aortic cross-clamping. During standard resuscitation, control animals received recombinant tissue plasminogen activator (rtPA) after cross-clamp removal, and experimental animals received rtPA followed by TXA. Rotational thromboelastometry analysis was performed at baseline, 5 minutes and 15 minutes after rtPA dosing, and 4 hours after cross-clamp removal.

RESULTS

Control and experimental animals had similar hemodynamics and routine laboratory values at baseline and throughout resuscitation. At the time of TXA administration, average pH was 7.2. Clot formation time was prolonged from baseline and all resuscitation time points in both groups, with no difference at any time point. Maximum clot firmness decreased from baseline at all resuscitation time points in both groups. Maximum lysis increased from baseline (9% control vs. 9% TXA) after tissue plasminogen activator administration in both groups (100% control vs. 99% TXA). In experimental animals, maximum lysis returned to baseline 10 minutes after TXA administration (92% vs. 9%, p < 0.001).

CONCLUSION

TXA rapidly and fully reverses hyperfibrinolysis despite severe acidemia in a porcine trauma model. TXA is a promising adjunct to trauma resuscitation that is easily administered in austere or prehospital settings.

A pediatric massive transfusion protocol

BACKGROUND

Pediatric massive blood transfusions occur widely at hospitals across the nation; however, there are limited data on pediatric massive transfusion protocols (MTPs) and their impact. We present a pediatric MTP and examine its impact on morbidity and mortality as well as identify factors that may prompt protocol initiation.

METHODS

Using a prospective cohort, we collected data on all pediatric patients who required un-cross-matched blood from January 1, 2009, through January 1, 2011. This captured patients who received blood products according to the protocol as well as patients who were massively transfused at physician discretion. Outcomes between groups were compared.

RESULTS

A total of 55 patients received un-cross-matched blood, with 22 patients in the MTP group and 33 patients receiving blood at physician discretion (non-MTP group). Mortality was not significantly different between groups. Injury Severity Score for the MTP group was 42 versus 25 for the non-MTP group (p ≤ 0.01). Thromboembolic complications occurred more exclusively in the non-MTP group (p ≤ 0.04). Coagulopathy, evidenced by partial thromboplastin time (PTT) greater than 36, was associated with initiation of the MTP.

CONCLUSION

MTPs have been widely adopted by hospitals to minimize the coagulopathy associated with hemorrhage. Blood transfusion via MTP was associated with fewer thromboembolic events. Coagulopathy was associated with initiation of the MTP. These results support the institution of pediatric MTPs and suggest a need for further research on the protective relationship between MTP and thromboembolic events and on identifying objective factors associated with MTP initiation.

LEVEL OF EVIDENCE

Therapeutic study, level IV.

Hypovolemic shock resuscitation

Several changes in the way patients with hemorrhagic shock are resuscitated have occurred over the past decades, including permissive hypotension, minimal crystalloid resuscitation, earlier blood transfusion, and higher plasma and platelet-to-red cell ratios. Hemostatic adjuncts, such as tranexamic acid and prothrombin complex, and the use of new methods of assessing coagulopathy are also being incorporated into resuscitation of the bleeding patient. These ideas have been incorporated by many trauma centers into institutional massive transfusion protocols, and adoption of these protocols has resulted in improvements in mortality and morbidity. This article discusses each of these new resuscitation strategies and the evidence supporting their use.

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.

Blood transfusion utilization and recipient survival at Hospital das Clinicas in São Paulo, Brazil

BACKGROUND

The characteristics of blood recipients including diagnoses associated with transfusion and posttransfusion survival are unreported in Brazil. The goals of this analysis were: 1) to describe blood utilization according to clinical diagnoses and patient characteristics and 2) to determine the factors associated with survival of blood recipients.

STUDY DESIGN AND METHODS

A retrospective cross-sectional analysis was conducted on all inpatients in 2004. Data came from three sources: The first two files consist of data about patient characteristics, clinical diagnosis, and transfusion. Analyses comparing transfused and nontransfused patients were conducted. The third file was used to determine survival recipients up to 3 years after transfusion. Logistic regression was conducted among transfused patients to examine characteristics associated with survival.

RESULTS

In 2004, a total of 30,779 patients were admitted, with 3835 (12.4%) transfused. These patients had 10,479 transfusions episodes, consisting of 39,561 transfused components: 16,748 (42%) red blood cells, 15,828 (40%) platelets (PLTs), and 6190 (16%) plasma. The median number of components transfused was three (range, 1-656) per patient admission. Mortality during hospitalization was different for patients whose admissions included transfusion or not (24% vs. 4%). After 1 year, 56% of transfusion recipients were alive. The multivariable model of factors associated with mortality after transfusion showed that the most significant factors in descending order were hospital ward, increasing age, increasing number of components transfused, and type of components received.

CONCLUSION

Ward and transfusion are markers of underlying medical conditions and are associated with the probability of survival. PLT transfusions are common and likely reflect the types of patients treated. This comprehensive blood utilization study, the first of its kind in Brazil, can help in developing transfusion policy analyses in South America.

[Treatment alternatives in massive hemorrhage]

Massive hemorrhage is the main cause of mortality and morbidity in trauma patients, and is one of the most important causes in any patient following major surgery. Conventional treatment consists of volume replacement, including the transfusion of blood products, so that tissue perfusion and oxygenation may be maintained. Associated hypothermia, acidosis and coagulopathy is a lethal triad. This review focuses on the latest therapeutic management of massive hemorrhage. The authors advocate the use of crystalloids as per protocol (controlled volumes) in order to achieve a systolic blood pressure of 85mmHg. The administration of the three blood products (red cells, plasma, and platelets) should be on a 1:1:1 basis. Where possible, this in turn should be guided by thromboelastography performed at point of care near the patient. Coagulopathy can occur early and late. With the exception of tranexamic acid, the cost-benefit relationships of the hemostatic agents, such as fibrinogen, prothrombin complex, and recombinant F VII, are subject to discussion.