Massive blood loss in trauma patients

Challenges to improving patient outcome following massive transfusion in severe trauma

Introduction: Uncontrolled hemorrhage with trauma-induced coagulopathy (TIC) still represents the most common cause of preventable death after trauma. Timely diagnosis and treatment including bleeding control and hemostatic resuscitation to correct TIC are important, as death from exsanguination occurs rapidly. Recognizing who requires an early massive transfusion together with the initiation of corresponding massive transfusion protocols (MTPs) is key to outcome.Areas covered: This expert review summarizes the current state of MT including the activation and termination of MTPs, complications of MT, and strategies for refinement in the administration of blood products in order to avoid harmful over-transfusion.Expert opinion: MTPs should be initiated and continued until normal physiologic parameters are reached and definitive control of bleeding is achieved. Hospitals should develop their own MTPs, guided by evidence, and according to local infrastructure, logistics, needs and patient populations. Massive transfusion, defined as > 10 units of packed red blood cell concentrates (pRBCs) within the first 24 hours of hospital admission, can be life-saving, but is not without complications. MTPs are currently being refined through targeted and early goal-directed approaches which include functional coagulation testing assays to better guide the administration of blood products and hemostatic agents once the patient is stabilized.

Statistical Machines for Trauma Hospital Outcomes Research: Application to the PRospective, Observational, Multi-Center Major Trauma Transfusion (PROMMTT) Study

Improving the treatment of trauma, a leading cause of death worldwide, is of great clinical and public health interest. This analysis introduces flexible statistical methods for estimating center-level effects on individual outcomes in the context of highly variable patient populations, such as those of the PRospective, Observational, Multi-center Major Trauma Transfusion study. Ten US level I trauma centers enrolled a total of 1,245 trauma patients who survived at least 30 minutes after admission and received at least one unit of red blood cells. Outcomes included death, multiple organ failure, substantial bleeding, and transfusion of blood products. The centers involved were classified as either large or small-volume based on the number of massive transfusion patients enrolled during the study period. We focused on estimation of parameters inspired by causal inference, specifically estimated impacts on patient outcomes related to the volume of the trauma hospital that treated them. We defined this association as the change in mean outcomes of interest that would be observed if, contrary to fact, subjects from large-volume sites were treated at small-volume sites (the effect of treatment among the treated). We estimated this parameter using three different methods, some of which use data-adaptive machine learning tools to derive the outcome models, minimizing residual confounding by reducing model misspecification. Differences between unadjusted and adjusted estimators sometimes differed dramatically, demonstrating the need to account for differences in patient characteristics in clinic comparisons. In addition, the estimators based on robust adjustment methods showed potential impacts of hospital volume. For instance, we estimated a survival benefit for patients who were treated at large-volume sites, which was not apparent in simpler, unadjusted comparisons. By removing arbitrary modeling decisions from the estimation process and concentrating on parameters that have more direct policy implications, these potentially automated approaches allow methodological standardization across similar comparativeness effectiveness studies.

Asking for the 22-modifier in isolated ankle fractures: does the operative note make the case?

We evaluated the operative notes for justification on the use of the 22-modifier in ankle fracture cases and compared the differences in physician billing and reimbursement. A total of 265 patients who had undergone operative management of isolated ankle fractures across a 10-year period were identified at a level I trauma center through a retrospective chart review. Of the 265 patients, 61 (23.0%) had been billed with the 22-modifier. The radiographs were reviewed by 3 surgeons to determine the complexity of the case. The amount of the professional fees and payments was obtained from the financial services department. Operative reports were reviewed for inclusion of eight 22-modifier criteria and word count. Mann-Whitney U tests of means were used to compare cases with and without the 22-modifier. From our analysis of preoperative radiographs, 37 (60%) showed evidence of a significantly complex fracture that justified the use of the 22-modifier. A review of the operative reports showed that 42 (68%) did not identify 2 or more reasons for requesting the 22-modifier in the report. Overall, the 22-modifier cases were not always reimbursed significantly greater amounts than the nonmodifier cases. No significant difference in the average word count of the operative notes was found. We have concluded that orthopedic trauma surgeons do not appropriately justify the use of the 22-modifier within their operative report. Further education on modifiers and the use of the operative report as billing documentation is required to ensure surgeons are adequately reimbursed for difficult trauma cases.

Damage control hematology: the impact of a trauma exsanguination protocol on survival and blood product utilization

BACKGROUND

The importance of early and aggressive management of trauma- related coagulopathy remains poorly understood. We hypothesized that a trauma exsanguination protocol (TEP) that systematically provides specified numbers and types of blood components immediately upon initiation of resuscitation would improve survival and reduce overall blood product consumption among the most severely injured patients.

METHODS

We recently implemented a TEP, which involves the immediate and continued release of blood products from the blood bank in a predefined ratio of 10 units of packed red blood cells (PRBC) to 4 units of fresh frozen plasma to 2 units of platelets. All TEP activations from February 1, 2006 to July 31, 2007 were retrospectively evaluated. A comparison cohort (pre-TEP) was selected from all trauma admissions between August 1, 2004 and January 31, 2006 that (1) underwent immediate surgery by the trauma team and (2) received greater than 10 units of PRBC in the first 24 hours. Multivariable analysis was performed to compare mortality and overall blood product consumption between the two groups.

RESULTS

Two hundred eleven patients met inclusion criteria (117 pre-TEP, 94 TEP). Age, sex, and Injury Severity Score were similar between the groups, whereas physiologic severity (by weighted Revised Trauma Score) and predicted survival (by trauma-related Injury Severity Score, TRISS) were worse in the TEP group (p values of 0.037 and 0.028, respectively). After controlling for age, sex, mechanism of injury, TRISS and 24-hour blood product usage, there was a 74% reduction in the odds of mortality among patients in the TEP group (p = 0.001). Overall blood product consumption adjusted for age, sex, mechanism of injury, and TRISS was also significantly reduced in the TEP group (p = 0.015).

CONCLUSIONS

We have demonstrated that an exsanguination protocol, delivered in an aggressive and predefined manner, significantly reduces the odds of mortality as well as overall blood product consumption.

Massive blood transfusion and outcome in 1062 polytrauma patients: a prospective study based on the Trauma Registry of the German Trauma Society

BACKGROUND AND OBJECTIVES

About 15% of polytrauma patients receive massive blood transfusion (MBT) defined as > or = 10 units of packed red blood cells (PRBC). In general, the prognosis of trauma patients receiving MBT is considered to be poor. The purpose of this study was to investigate the impact of MBT on the outcome of polytrauma patients.

MATERIALS AND METHODS

Records of 10 997 patients in the Trauma Registry of the German Trauma Society were analysed. Transfusion data were available from 8182 severe trauma patients with a mean injury severity score of 24.5 and, of these 8182 patients, 1062 received > or = 10 units of PRBC. First, a logistic regression model for the predictors of mortality was performed. Second, incidences of organ failure and sepsis as well as survival rates were analysed.

RESULTS

The highest risk for mortality was age over 55 years (odds ratios [OR] 4.7; confidence intervals [CI 95%], 3.5-6.5) followed by Glasgow Coma Scale < or = 8 (OR 4.6; 3.4-6.1), MBT > or = 20 units of PRBC (OR 3.3; 2.1-5.4), thromboplastin time < 50% (OR 3.2; 2.2-4.4) and injury severity score > or = 24 (OR 2.9; 2.1-4.1). Transfusion of 10-19 PRBC was identified as the variable with the lowest risk for mortality (OR 1.5; 1.0-2.3). Risk of organ failure, sepsis and death correlated with increasing transfusion amount. For the MBT patients, the survival rate was 56.9% (CI 95%, 53.9-59.9%) compared to 85.2% (84.4-86.0%) of non-MBT patients (P < 0.001). In the MBT group with > 30 PRBC (mean 40.6 PRBC) 39.6% survived (31.7-47.5%).

CONCLUSION

Massive blood transfusion is one main prognostic factor for mortality in trauma. Although MBT is generally considered to be critical, every second trauma patient with MBT survived. A cut-off value for the number of PRBC could not be determined. Extended transfusion management even with high amounts of PRBC seems to be justified.

Can we safely restrict transfusion in trauma patients?

PURPOSE OF REVIEW

Transfusion of red blood cells in the trauma patient can be lifesaving. The question is how much and when? It is important to weigh the risks and benefits of red blood cell transfusions, as well alternatives to transfusion as these products are not benign.

RECENT FINDINGS

We explore the evidence, and provide the rationale for current and future red blood cell transfusion strategies within a framework of prehospital and hospital care of the trauma patient. We also describe how red blood cell transfusion trends are changing in trauma, discuss alternatives to red blood cell transfusion and present evidence from randomized controlled trials that support a lower transfusion trigger.

SUMMARY

Optimal transfusion practice and use of alternatives in trauma is a rapidly expanding and important area of research. Strong clinical evidence derived by future randomized controlled trials in the area of transfusion triggers as well as transfusion alternatives is required to determine their roles in clinical practice.

Intraoperative pediatric blood transfusion therapy: a review of common issues. Part I: hematologic and physiologic differences from adults; metabolic and infectious risks

Pediatric intraoperative transfusion therapy, particularly the approach to massive blood transfusion (blood loss > or =one blood volume) can be quite complex because of the unique relationship between the patient's blood volume and the volume of the individual blood product transfused. This paper is divided into two parts: part 1 presents an overview of the physiologic and hematologic differences between children and adults as well as an overview of the metabolic consequences of blood transfusions, risks of disease transmission, and blood compatibility issues.

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.

Assessment of red blood cell and coagulation laboratory data

Critically ill patients present with a myriad of hematologic problems of various etiologies. The astute advanced practice nurse carefully reviews laboratory data incorporating principles of diagnostic reasoning and critical thinking while developing the plan of care. An in-depth understanding of hematology including red blood cells, red blood cell indices, and coagulation laboratory data is essential in the quest to understand the patient's pathophysiology. With every decade, nurses and physicians learn more about diseases that have plagued mankind for centuries--learning in greater detail about the deleterious effects and subsequent outcomes that often begin as subtle changes in traditional laboratory data. Greater focus on interpreting hematologic data and seeking support for diagnoses in clinical correlates will serve nurses well. This article intends to move advanced practice nurses beyond their current understanding of hematologic values--enabling them to understand that how and why we measure is as important as what we measure. No longer is it enough to simply measure physiologic data to develop a care plan driven by the patient's diagnoses. The contemporary nurse understands the importance of assigning meaning to data. Meaningful data are manageable data.

To transfuse or not in trauma patients: a presentation of the evidence and rationale

The administration of allogeneic red blood cell transfusions to the trauma patient is an essential and potentially life-saving component of trauma care. The big question is when to transfuse, and how much? In this review, we explore the evidence and provide rationales for current and future red blood cell transfusion strategies in the trauma patient. We also discuss the changing trends and competing risks associated with transfusions as well as current evidence for different blood conservation strategies in the context of trauma.

Changes in red cell transfusion practice among adult trauma victims

BACKGROUND

Recent attention concerning the adverse outcomes of blood transfusion has resulted in decreased blood product usage for nonemergency care. We hypothesized that there has also been a decrease in blood product use in the management of seriously injured adults.

METHODS

A retrospective review of institutional database records was conducted at a regional trauma center for adults admitted during 1991, 1993, and 1995. Data was analyzed for trends in amount, type, and timing of blood product use.

RESULTS

A total of 1,738 patients were assessed, with 1,605 meeting inclusion. The three patient groups were similar, including injury severity (overall mean Injury Severity Score of 23.6), mechanism (88% blunt), and survival (87%). In 1991, 54% of the patients were transfused a total of 2,341 units of packed red blood cells (mean 4.67 units/pt treated) versus 42% of patients in 1995 (p < 0.0001) who received 2,018 packed red blood cells (mean 3.57 units/patient treated, p = 0.05). A significantly higher proportion of units was transfused in the first 24 hours of care in 1995 (64%) compared with 1991 (21%, p < 0.0001). A reduction in the use of universal donor type-O blood use was also found (1.21 vs. 0.65 units/patient transfused, p < 0.0001). Despite similar admission hemoglobin concentrations (124.1 vs. 125.3, not significant), significant reductions were found in the average 24-hour (109.2 vs. 103.8, p < 0.001), lowest (96.5 vs 92.1, p < 0.01) and discharge (115.8 vs. 110.5, p < 0.001) concentrations.

CONCLUSIONS

Between 1991 and 1995 there have been significant reductions in both the number of trauma patients receiving blood products and the total number of units transfused. These findings may reflect lower or abandoned hemoglobin transfusion triggers and increased awareness of complications related to transfusion.

Blood and blood product use in perioperative patient care

A variety of health care personnel are involved in the collection, storage, and administration of the 20 million units of blood products that are transfused into millions of patients each year. This article reviews blood transfusion practices, nursing care guidelines, and new developments to help perioperative nurses prevent or ameliorate adverse transfusion outcomes in surgical patients.

Blood substitutes: fluids, drugs, or miracle solutions?

Oxygen-carrying volume-expanding solutions that can sustain life in the absence of red blood cells have been developed. Concerns about side effects, sources of hemoglobin, and the ultimate demonstration of efficacy will have to be satisfactorily addressed before anesthesiologists routinely administer such solutions in place of red cells during surgery.