The dose-dependent relationship between blood transfusions and infections after trauma: A population-based study

Balanced resuscitation with whole blood versus component therapy in critically injured preadolescent children: Getting there faster with fewer exposures

PURPOSE

Balanced blood product resuscitation with red blood cells, plasma, and platelets can be achieved using whole blood (WB) or component therapy (CT). However, balanced resuscitation of younger children with severe traumatic hemorrhage may be complicated by delays in delivering all blood components and concerns regarding multiple product exposures. We hypothesized that WB achieves balanced resuscitation faster than CT, with fewer product exposures and improved clinical outcomes.

METHODS

Children younger than 12 years receiving balanced resuscitation within 4 hours of arrival were identified from the 2017 to 2019 Trauma Quality Improvement Program database. Time to balanced resuscitation was defined as the time of initiation of WB or all three components. Patient characteristics, resuscitation details, and outcomes were compared between WB and CT groups. Time to balanced resuscitation was compared using Kaplan-Meier analysis and Cox regression modeling to adjust for covariates. Additional multivariable regression models compared number of transfusion exposures, intensive care unit (ICU) length of stay, and mortality.

RESULTS

There were 390 patients (109 WB, 281 CT) with median age 7 years, 12% penetrating mechanism, 42% severe traumatic brain injury, and 49% in-hospital mortality. Time to balanced resuscitation was shorter for WB versus CT (median, 28 vs. 87 minutes; hazard ratio [HR], 2.93; 95% confidence interval [CI], 2.31-3.72; p < 0.0001). Whole blood patients received fewer transfusion exposures (mean, 3.2 vs. 3.9; adjusted incidence rate ratio, 0.82; 95% CI, 0.72-0.92; p = 0.001) and lower total product volumes (50 vs. 85 mL/kg; p = 0.01). Intensive care unit stays trended shorter for WB versus CT (median, 10 vs. 12 days; adjusted HR, 1.32; 95% CI, 0.93-1.86), while in-hospital mortality was similar (50% vs. 45%; adjusted odds ratio, 1.11; 95% CI, 0.65-1.88).

CONCLUSION

In critically injured preadolescent children receiving emergent transfusion, WB was associated with faster time to balanced resuscitation, fewer transfusion exposures, lower blood product volumes, and a trend toward shorter ICU stays than CT.

LEVEL OF EVIDENCE

Prognostic and Epidemiological; Level III.

Potential benefits of restrictive transfusion in upper gastrointestinal bleeding: a systematic review and meta-analysis of randomised controlled trials

The optimal red blood cell (RBC) transfusion strategy in acute gastrointestinal bleeding (GIB) is debated. We aimed to assess the efficacy and safety of restrictive compared to liberal transfusion strategies in the GIB population. We searched PubMed, CENTRAL, Embase, and Web of Science for randomised controlled trials on 15.01.2022 without restrictions. Studies comparing lower to higher RBC transfusion thresholds after GIB were eligible. We used the random effect model and calculated pooled mean differences (MD), risk ratios (RR) and proportions with 95% confidence intervals (CI) to calculate the overall effect size. The search yielded 3955 hits. All seven eligible studies reported on the upper GIB population. Restrictive transfusion did not increase the in-hospital- (RR: 0.94; CI 0.46, 1.94) and 30-day mortality (RR: 0.71; CI 0.35, 1.45). In-hospital- and 28 to 45-day rebleeding rate was also not higher with the restrictive modality (RR: 0.67; CI 0.30, 1.50; RR:0.75; CI 0.49, 1.16, respectively). Results of individual studies showed a lower rate of transfusion reactions and post-transfusion intervention if the transfusion was started at a lower threshold. A haemoglobin threshold > 80 g/L may result in a higher untoward outcome rate. In summary, restrictive transfusion does not appear to lead to a higher rate of significant clinical endpoints. The optimal restrictive transfusion threshold should be further investigated.

Outcomes in Pediatric Trauma Patients Who Receive Blood Transfusion

INTRODUCTION

Increased blood volumes, due to massive transfusion (MT), are known to be associated with both infectious and noninfectious adverse outcomes. The aim of this study was to assess the association between MT and outcomes in pediatric trauma patients, and, secondarily, determine if these outcomes are differential by age once MT is reached.

METHODS

Pediatric patients (ages 1-18 y old) in the ACS pediatric Trauma Quality Improvement Program (TQIP) database (2015-2018) who received blood were included. Patients were stratified by MT status, which was defined as blood product volume of 40 mL/kg within 24 h of admission (MT+) and compared to children who received blood products but did not meet the MT threshold (MT-). Defined MT + patients were matched 1:1 to MT-patients via propensity score matching of characteristics before comparisons. Adjusted logistic regression was performed on univariably significant outcomes of interest.

RESULTS

There were 2318 patients in the analytic cohort. Patients who received MT had higher rates of deep venous thrombosis (DVT) (2.5% versus 1.0%, P < 0.001), acute kidney injury (AKI) (1.5% versus 0.0%, P = 0.022), CLABSI (4.0% versus 2.0% P = 0.008), and severe sepsis (2.3% versus. 1.1%, P = 0.02). On logistic regression MT was an independent risk factor for these outcomes. There was no differential effect of MT on these outcomes based on age.

CONCLUSIONS

Outcomes associated with blood transfusion in pediatric trauma patients are low overall, but rates of DVT, AKI, CLABSI, and sepsis are higher in those who receive MT+ with no differences based on age.

Transfusion management in the trauma patient

PURPOSE OF REVIEW

Transfusion of blood products is lifesaving in the trauma ICU. Intensivists must be familiar with contemporary literature to develop the optimal transfusion strategy for each patient.

RECENT FINDINGS

A balanced ratio of red-blood cells to plasma and platelets is associated with improved mortality and has therefore become the standard of care for resuscitation. There is a dose-dependent relationship between units of product transfused and infections. Liquid and freeze-dried plasma are alternatives to fresh frozen plasma that can be administered immediately and may improve coagulation parameters more rapidly, though higher quality research is needed. Trauma induced coagulopathy can occur despite a balanced transfusion, and administration of prothrombin complex concentrate and cryoprecipitate may have a role in preventing this. In addition to balanced ratios, viscoelastic guidance is being increasingly utilized to individualize component transfusion. Alternatively, whole blood can be used, which has become the standard in military practice and is gaining popularity at civilian centers.

SUMMARY

Hemorrhagic shock is the leading cause of death in trauma. Improved resuscitation strategy has been one of the most important contemporary advancements in trauma care and continues to be a key area of clinical research.

Clinical characteristics and risk factors associated with ICU-acquired infections in sepsis: A retrospective cohort study

Intensive care unit (ICU)-acquired infection is a common cause of poor prognosis of sepsis in the ICU. However, sepsis-associated ICU-acquired infections have not been fully characterized. The study aims to assess the risk factors and develop a model that predicts the risk of ICU-acquired infections in patients with sepsis.

Overtransfusion of packed red blood cells during massive transfusion activation: a potential quality metric for trauma resuscitation

Objectives

The goal of this study was to explore the incidence of overtransfusion in trauma patients requiring massive transfusion protocol (MTP) activation and identify modifiable risk factors. We hypothesized that overtransfusion is common after MTP activation.

Methods

Patients admitted to a level I trauma center from July 2016 to December 2019 and who required MTP activation were selected. The primary outcome was overtransfusion, defined as a hemoglobin (Hg) ≥11 g/dL at 24 hours (±2 hours). A Cox regression model was used to identify independent risk factors for overtransfusion.

Results

140 patients met inclusion criteria. The median age was 39.0 years, with the majority (74.3%) being male. The median (IQR) Injury Severity Score (ISS) was 24.0 (58.0) and 38.4% had a penetrating mechanism. The median (IQR) admission Hg was 12.6 (11.7) g/dL. Overall, 71.4% of patients were overtransfused by the conclusion of MTP, 43.6% 24 hours later, and 29.5% at discharge. Overtransfusion did not correlate with the number of units of blood transfused nor with the duration of MTP. Overtransfused patients at 24 hours after the conclusion of MTP were significantly more likely to present with a penetrating injury (52.5% vs. 27.3%, p=0.003) and have a significantly lower ISS (median (IQR) 18.5 (44.0) vs. 26.0 (58.0), p=0.035.) In a Cox regression model, penetrating mechanism (adjusted HR (AHR): 2.93; adjusted p=0.004) and admission base excess (BE) (AHR: 1.15; adjusted p=0.001) were the only variables independently associated with overtransfusion.

Conclusions

Overtransfusion of trauma patients requiring MTP activation is highly common, leading to overutilization of a limited resource. Penetrating trauma and BE may be modifiable risk factors that can help limit overtransfusion. Overtransfusion should be tracked as a data point by blood banks and trauma centers and be further studied as a potential quality metric for the resuscitation of massively transfused trauma patients.

Level of evidence

III.

Haemoglobin value and red blood cell transfusions in prolonged weaning from mechanical ventilation: a retrospective observational study

INTRODUCTION

The role of haemoglobin (Hb) value and red blood cell (RBC) transfusions in prolonged weaning from mechanical ventilation (MV) is still controversial. Pathophysiological considerations recommend a not too restrictive transfusion strategy, whereas adverse effects of transfusions are reported. We aimed to investigate the association between Hb value, RBC transfusion and clinical outcome of patients undergoing prolonged weaning from MV.

METHODS

We performed a retrospective, single-centred, observational study including patients being transferred to a specialised weaning unit. Data on demographic characteristics, comorbidities, current and past medical history and the current course of treatment were collected. Weaning failure and mortality were chosen as primary and secondary endpoint, respectively. Differences between transfused and non-transfused patients were analysed. To evaluate the impact of different risk factors including Hb value and RBC transfusion on clinical outcome, a multivariate logistic regression analysis was used.

RESULTS

184 patients from a specialised weaning unit were analysed, of whom 36 (19.6%) failed to be weaned successfully. In-hospital mortality was 18.5%. 90 patients (48.9%) required RBC transfusion during the weaning process, showing a significantly lower Hb value (g/L) (86.3±5.3) than the non-transfusion group (95.8±10.5). In the multivariate regression analysis (OR 3.24; p=0.045), RBC transfusion was associated with weaning failure. However, the transfusion group had characteristics indicating that these patients were still in a more critical state of disease.

CONCLUSIONS

In our analysis, the need for RBC transfusion was independently associated with weaning failure. However, it is unclear whether the transfusion itself should be considered an independent risk factor or an additional symptom of a persistent critical patient condition.

Improving packed red blood cell storage with a high-viscosity buffered storage solution

BACKGROUND

Massive transfusion with older packed red blood cells is associated with increased morbidity and mortality. As packed red blood cells age, they undergo biochemical and structural changes known as the storage lesion. We developed a novel solution to increase viscosity in stored packed red blood cells. We hypothesized that packed red blood cell storage in this solution would blunt storage lesion formation and mitigate the inflammatory response after resuscitation.

METHODS

Blood was obtained from 8- to 10-week-old C57BL/6 male donor mice or human volunteers and stored as packed red blood cell units for 14 days for mice or 42 days for humans in either standard AS-3 storage solution or EAS-1587, the novel packed red blood cell storage solution. Packed red blood cells were analyzed for microvesicles, cell-free hemoglobin, phosphatidylserine, band-3 protein, glucose utilization, and osmotic fragility. Additional mice underwent hemorrhage and resuscitation with packed red blood cells stored in either AS-3 or EAS-1587. Serum was analyzed for inflammatory markers.

RESULTS

Murine packed red blood cells stored in EAS-1587 demonstrated reductions in microvesicle and cell-free hemoglobin accumulation as well as preserved band-3 expression, increase glucose utilization, reductions in phosphatidylserine expression, and susceptibility to osmotic stress. Serum from mice resuscitated with packed red blood cells stored in EAS-1587 demonstrated reduced proinflammatory cytokines. Human packed red blood cells demonstrated a reduction in microvesicle and cell-free hemoglobin as well as an increase in glucose utilization.

CONCLUSION

Storage of packed red blood cells in a novel storage solution mitigated many aspects of the red blood cell storage lesion as well as the inflammatory response to resuscitation after hemorrhage. This modified storage solution may lead to improvement of packed red blood cell storage and reduce harm after massive transfusion.

Does autotransfusion from a contaminated trauma laparotomy field increase the risk of complications?

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.

Postinjury Sepsis-Associations With Risk Factors, Impact on Clinical Course, and Mortality: A Retrospective Observational Study

OBJECTIVES

Overall outcomes for trauma patients have improved over time. However, mortality for postinjury sepsis has been reported to be unchanged. Estimate incidence of and risk factors for sepsis in ICU patients after major trauma and the association between sepsis, mortality, and clinical course.

DESIGN SETTING AND PATIENTS

ICU in a large urban trauma center in Sweden with a well-developed trauma system. Retrospective cohort study of trauma patients admitted to the ICU for more than 24 hours were included.

MEASUREMENTS AND MAIN RESULTS

Primary outcome measure was 30-day mortality. Secondary outcomes were 1-year mortality and impact on clinical course. In total, 722 patients with a median Injury Severity Score of 26 (interquartile range, 18-38) were included. Incidence of sepsis was 22%. Septic patients had a four-fold increase in length of stay and need for organ supportive therapy. The overall 30-day mortality rate was 9.3%. After exclusion of early trauma-related deaths in the first 48 hours, the 30-day mortality rate was 6.7%. There was an association between sepsis and this adjusted 30-day mortality (day 3 odds ratio, 2.1 [95% CI, 1.1-3.9]; day 4 odds ratio, 3.1 [95% CI, 1.5-6.1]; day 5 odds ratio, 3.0 [95% CI, 1.4-6.2]). Septic patients had a 1-year mortality of 17.7% (nonseptic 11.0%). Development of sepsis was independently associated with age, spine and chest injury, shock, red cell transfusion, and positive blood alcohol concentration at admission. The risk of sepsis increased, in a dose-dependent manner, with the number of transfusions.

CONCLUSIONS

Postinjury sepsis was associated with a complicated clinical course and with mortality after exclusion of early, trauma-related deaths.

Dose-dependent association between blood transfusion and nosocomial infections in trauma patients: A secondary analysis of patients from the PAMPer trial

BACKGROUND

The Prehospital Air Medical Plasma (PAMPer) trial demonstrated a survival benefit to trauma patients who received thawed plasma as part of early resuscitation. The objective of our study was to examine the association between blood transfusion and nosocomial infections among trauma patients who participated in the PAMPer trial. We hypothesized that transfusion of blood products will be associated with the development of nosocomial infections in a dose-dependent fashion.

METHODS

We performed a secondary analysis of prospectively collected data of patients in the PAMPer trial with hospital length of stay of at least 3 days. Demographics, injury characteristics, and number of blood products transfused were obtained to evaluate outcomes. Bivariate analysis was performed to identify differences between patients with and without nosocomial infections. Two logistic regression models were created to evaluate the association between nosocomial infections and (1) any transfusion of blood products, and (2) quantity of blood products. Both models were adjusted for age, sex, and Injury Severity Score.

RESULTS

A total of 399 patients were included: age, 46 years (interquartile range, 29-59 years); Injury Severity Score, 22 (interquartile range, 12-29); 73% male; 80% blunt mechanism; and 40 (10%) deaths. Ninety-three (27%) developed nosocomial infections, including pneumonia (n = 67), bloodstream infections (n = 14), catheter-associated urinary tract infection (n = 10), skin and soft tissue infection (n = 8), Clostridium difficile colitis (n = 7), empyema (n = 6), and complicated intra-abdominal infections (n = 3). Nearly 80% (n = 307) of patients received packed red blood cells (PRBCs); 12% received cryoprecipitate, 69% received plasma, and 27% received platelets. Patients who received any PRBCs had more than a twofold increase in nosocomial infections (odds ratio, 2.15; 95% confidence interval, 1.01-4.58; p = 0.047). The number of PRBCs given was also associated with the development of nosocomial infection (odds ratio, 1.10; 95% confidence interval, 1.05-1.16; p < 0.001).

CONCLUSION

Trauma patients in the PAMPer trial who received a transfusion of at least 1 U of PRBCs incurred a twofold increased risk of nosocomial infection, and the risk of infection was dose dependent.

LEVEL OF EVIDENCE

Therapeutic/care management, level IV.

Procalcitonin Assay Has No Role in the Routine Assessment of Severe Trauma Patients at Admission to the Emergency Department

Introduction A key challenge in emergency departments (ED) is the early recognition of sepsis or the potential for sepsis in patients. Appropriate and accurate ED triage will ensure improved case management. This study analysed the association between ED findings at admission and outcomes in patients presenting with severe trauma. Methods This was a prospective study conducted at a tertiary level ED and included severely injured adult patients who presented to the ED within 24 hours of injury. Data collected included clinical findings and imaging reports at initial assessment, serum procalcitonin (PCT), length of ICU and hospital stay, the incidence of bloodstream and other infections, and patient outcome as discharge from care or death. Multiple logistic regression was used to assess the association between outcome variables and independent variables. Results A total of 155 patients were included in the study. Head and neck (61.9%), extremity (58%), and chest (45%) were more commonly injured. Injury Severity Score (ISS) >25, Glasgow Coma Scale (GCS) score <8, head and neck injuries, and extremity injuries were found to be significantly associated with mortality. Bloodstream infections were more common in the presence of lung contusions, abdominal injury, operative management, and blood transfusions. PCT levels at admission did not have a significant predictive value for mortality, bloodstream infections, other infectious complications, or length of ICU stay. Conclusions Head injuries were the most common cause of mortality in our study. In addition to the anatomical region involved, ISS and GCS have a significant association with mortality. PCT levels at ED admission do not have any prognostic value and need not be routinely analysed.

Risk Factors for Deep Surgical Site Infection in Patients With Operatively Treated Tibial Plateau Fractures: A Retrospective Multicenter Study

OBJECTIVES

To identify the potential controllable risk factors for surgical site infection (SSI).

DESIGN

A retrospective cohort study.

SETTING

Seven Level-I trauma centers.

PATIENTS/PARTICIPANTS

Patients with OTA/AO 41 B or C tibial plateau fractures (n = 2106).

INTERVENTION

Various surgical treatments for tibial plateau fractures.

MAIN OUTCOME MEASUREMENTS

The primary outcome was SSI after the index operation. The secondary outcomes were the risk factors for SSI, identified using backward stepwise generalized multiple regression analysis.

RESULTS

Of the 2106 enrolled patients, 94 had deep SSIs. The average SSI rate was 4.5%. Fracture morphology revealed type B injuries in 57.5% and type C in 42.5% of the patients. Univariate regression analysis revealed that several factors, namely, number of comorbidities [>6 vs. none; odds ratio (OR) 8.01, 95% confidence interval (CI) 2.8-22.8, P < 0.001], diabetes mellitus (OR 3.5, 95% CI 2.0-6.3, P < 0.001), high body mass index (OR 1.3, 95% CI 1.1-1.6, P = 0.001), OTA/AO fracture type C (OR 5.6, 95% CI 3.3-9.5, P < 0.001), compartment syndrome (OR 9.1, 95% CI 5.7-14.8, P < 0.001), and open fracture (OR 6.6, 95% CI 3.7-11.7, P < 0.001), were associated with a significantly higher SSI risk. Analysis of microbial sensitivity tests revealed that 55.1% of the pathogens were resistant to perioperative antibiotic prophylaxis.

CONCLUSIONS

Most of the identified risk factors cannot be controlled or are subject to other factors that are difficult to control. However, our data suggest that the choice of perioperative antibiotic prophylaxis may influence the rate of SSI. This possibility should be investigated in a prospective randomized controlled trial.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Prolonged Prehospital Time is a Risk Factor for Pneumonia in Trauma (the PRE-TRIP study): A Retrospective Analysis of the United States National Trauma Data Bank

BACKGROUND

Although multiple risk factors for development of pneumonia in patients with trauma sustained in a motor vehicle accident have been studied, the effect of prehospital time on pneumonia incidence post-trauma is unknown.

RESEARCH QUESTION

Is prolonged prehospital time an independent risk factor for pneumonia?

STUDY DESIGN AND METHODS

We retrospectively analyzed prospectively collected clinical data from 806,012 motor vehicle accident trauma incidents from the roughly 750 trauma hospitals contributing data to the National Trauma Data Bank between 2010 and 2016.

RESULTS

Prehospital time was independently associated with development of pneumonia post-motor vehicle trauma (p < 0.001). This association was primarily driven by patients with low Glasgow Coma Scale scores. Post-trauma pneumonia was uncommon (1.5% incidence) but was associated with a significant increase in mortality (p < 0.001, 4.3% mortality without pneumonia vs. 12.1% mortality with pneumonia). Other pneumonia risk factors included age, sex, race, primary payor, trauma center teaching status, bed size, geographic region, intoxication, comorbid lung disease, steroid use, lower Glasgow Coma Scale score, higher Injury Severity Scale score, blood product transfusion, chest trauma, and respiratory burns.

INTERPRETATION

Increased prehospital time is an independent risk factor for development of pneumonia and increased mortality in patients with trauma caused by a motor vehicle accident. Although prehospital time is often not modifiable, its recognition as a pneumonia risk factor is important as prolonged prehospital time may need to be considered in subsequent decision making.

CLINICAL TRIAL REGISTRATION

Not applicable.

Effect of fracturoscopy on the incidence of surgical site infections post tibial plateau fracture surgery

PURPOSE

Surgical treatment of tibial plateau fracture (TPF) is common. Surgical site infections (SSI) are among the most serious complications of TPF. This multicentre study aimed to evaluate the effect of fracturoscopy on the incidence of surgical site infections in patients with TPF.

METHODS

We performed a retrospective multicentre study. All patients with an AO/OTA 41 B and C TPF from January 2005 to December 2014 were included. Patients were divided into three groups: those who underwent arthroscopic reduction and internal fixation (ARIF), and those who underwent open reduction and internal fixation (ORIF) with fracturoscopy, and those treated with ORIF without fracturoscopy. The groups were compared to assess the effect of fracturoscopy. We characterised our cohort and the subgroups using descriptive statistics. Furthermore, we fitted a logistic regression model which was reduced and simplified by a selection procedure (both directions) using the Akaike information criterion (AIC). From the final model, odds ratios and inclusive 95% confidence intervals were calculated.

RESULTS

Overall, 52 patients who underwent fracturoscopy, 48 patients who underwent ARIF, and 2000 patients treated with ORIF were identified. The rate of SSI was 0% (0/48) in the ARIF group and 1.9% (1/52) in the fracturoscopy group compared to 4.7% (93/2000) in the ORIF group (OR = 0.40, p = 0.37). Regression analyses indicated a potential positive effect of fracturoscopy (OR, 0.65; 95% CI, 0.07-5.68; p = 0.69).

CONCLUSION

Our study shows that fracturoscopy is associated with reduced rates of SSI. Further studies with larger cohorts are needed to investigate this.

LEVEL OF EVIDENCE

Level III.