1
|
Bhogadi SK, Ditillo M, Khurshid MH, Stewart C, Hejazi O, Spencer AL, Anand T, Nelson A, Magnotti LJ, Joseph B. Development and Validation of Futility of Resuscitation Measure in Older Adult Trauma Patients. J Surg Res 2024; 301:591-598. [PMID: 39094517 DOI: 10.1016/j.jss.2024.07.019] [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: 03/06/2024] [Revised: 06/08/2024] [Accepted: 07/04/2024] [Indexed: 08/04/2024]
Abstract
INTRODUCTION This study aimed to develop and validate Futility of Resuscitation Measure (FoRM) for predicting the futility of resuscitation among older adult trauma patients. METHODS This is a retrospective analysis of the American College of Surgeons-Trauma Quality Improvement Program database (2017-2018) (derivation cohort) and American College of Surgeons level I trauma center database (2017-2022) (validation cohort). We included all severely injured (injury severity score >15) older adult (aged ≥60 y) trauma patients. Patients were stratified into decades of age. Injury characteristics (severe traumatic brain injury [Glasgow Coma Scale ≤ 8], traumatic brain injury midline shift), physiologic parameters (lowest in-hospital systolic blood pressure [≤1 h], prehospital cardiac arrest), and interventions employed (4-h packed red blood cell transfusions, emergency department resuscitative thoracotomy, resuscitative endovascular balloon occlusion of the aorta, emergency laparotomy [≤2 h], early vasopressor requirement [≤6 h], and craniectomy) were identified. Regression coefficient-based weighted scoring system was developed using the Schneeweiss method and subsequently validated using institutional database. RESULTS A total of 5562 patients in derivation cohort and 873 in validation cohort were identified. Mortality was 31% in the derivation cohort and FoRM had excellent discriminative power to predict mortality (area under the receiver operator characteristic = 0.860; 95% confidence interval [0.847-0.872], P < 0.001). Patients with a FoRM score of >16 had a less than 10% chance of survival, while those with a FoRM score of >20 had a less than 5% chance of survival. In validation cohort, mortality rate was 17% and FoRM had good discriminative power (area under the receiver operator characteristic = 0.76; 95% confidence interval [0.71-0.80], P < 0.001). CONCLUSIONS FoRM can reliably identify the risk of futile resuscitation among older adult patients admitted to our level I trauma center.
Collapse
Affiliation(s)
- Sai Krishna Bhogadi
- Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, College of Medicine, University of Arizona, Tucson, Arizona
| | - Michael Ditillo
- Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, College of Medicine, University of Arizona, Tucson, Arizona
| | - Muhammad Haris Khurshid
- Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, College of Medicine, University of Arizona, Tucson, Arizona
| | - Collin Stewart
- Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, College of Medicine, University of Arizona, Tucson, Arizona
| | - Omar Hejazi
- Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, College of Medicine, University of Arizona, Tucson, Arizona
| | - Audrey L Spencer
- Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, College of Medicine, University of Arizona, Tucson, Arizona
| | - Tanya Anand
- Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, College of Medicine, University of Arizona, Tucson, Arizona
| | - Adam Nelson
- Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, College of Medicine, University of Arizona, Tucson, Arizona
| | - Louis J Magnotti
- Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, College of Medicine, University of Arizona, Tucson, Arizona
| | - Bellal Joseph
- Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, College of Medicine, University of Arizona, Tucson, Arizona.
| |
Collapse
|
2
|
Schmulevich D, Geng Z, Joergensen SM, McLauchlan NR, Winter E, Zone A, Bishop KE, Hinkle A, Holland S, Cacchione PZ, Fox EE, Abella BS, Meador CL, Wade CE, Hynes AM, Cannon JW. Real-time performance improvement optimizes damage control resuscitation best practice adherence: Results of a pilot prospective observational study. Transfusion 2024. [PMID: 39072759 DOI: 10.1111/trf.17970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Revised: 07/03/2024] [Accepted: 07/07/2024] [Indexed: 07/30/2024]
Abstract
BACKGROUND Maintaining balanced blood product ratios during damage control resuscitation (DCR) is independently associated with improved survival. We hypothesized that real-time performance improvement (RT-PI) would increase adherence to DCR best practice. STUDY DESIGN AND METHODS From December 2020-August 2021, we prospectively used a bedside RT-PI tool to guide DCR in severely injured patients surviving at least 30 min. RT-PI study patients were compared to contemporary control patients at our institution and historic PROMMTT study patients. A subset of patients transfused ≥6 U red blood cells (RBC) in 6 h (MT+) was also identified. The primary endpoint was percentage time in a high ratio range (≥3:4) of plasma (PLAS):RBC and platelet (PLT):RBC over 6 h. Secondary endpoints included time to massive transfusion protocol activation, time to calcium and tranexamic acid (TXA) dosing, and cumulative 6-h ratios. RESULTS Included patients (n = 772) were 35 (24-51) years old with an Injury Severity Score of 27 (17-38) and 42% had penetrating injuries. RT-PI (n = 10) patients spent 96% of the 6-h resuscitation in a high PLAS:RBC range, no different versus CONTROL (n = 87) (96%) but more than PROMMTT (n = 675) (25%, p < .001). In the MT+ subgroup, optimal PLAS:RBC and PLT:RBC were maintained for the entire 6 h in RT-PI (n = 4) versus PROMMTT (n = 391) patients for both PLAS (p < .001) and PLT ratios (p < .001). Time to TXA also improved significantly in RT-PI versus CONTROL patients (27 min [22-31] vs. 51 min [29-98], p = .035). CONCLUSION In this prospective study, RT-PI was associated with optimized DCR. Multicenter validation of this novel approach to optimizing DCR implementation is warranted.
Collapse
Affiliation(s)
- Daniela Schmulevich
- Division of Traumatology, Surgical Critical Care, and Emergency Surgery, Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio, USA
| | - Zhi Geng
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Sarah M Joergensen
- Penn Acute Research Collaboration (PARC), Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Nathaniel R McLauchlan
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Eric Winter
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Alea Zone
- Penn Acute Research Collaboration (PARC), Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Kathleen E Bishop
- Penn Acute Research Collaboration (PARC), Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Alyson Hinkle
- Department of Nursing, Penn Presbyterian Medical Center, Penn Medicine, Philadelphia, Pennsylvania, USA
| | - Sara Holland
- Department of Nursing, Penn Presbyterian Medical Center, Penn Medicine, Philadelphia, Pennsylvania, USA
| | - Pamela Z Cacchione
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Nursing, Penn Presbyterian Medical Center, Penn Medicine, Philadelphia, Pennsylvania, USA
- Department of Family and Community Health, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, USA
| | - Erin E Fox
- Center for Translational Injury Research, Department of Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Benjamin S Abella
- Penn Acute Research Collaboration (PARC), Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Emergency Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | | | - Charles E Wade
- Center for Translational Injury Research, Department of Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Allyson M Hynes
- Division of Traumatology, Surgical Critical Care, and Emergency Surgery, Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jeremy W Cannon
- Division of Traumatology, Surgical Critical Care, and Emergency Surgery, Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Penn Acute Research Collaboration (PARC), Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| |
Collapse
|
3
|
Shibahashi K, Aoki M, Hikone M, Sugiyama K. Association between transfusion volume and survival outcome following trauma: Insight into the limit of transfusion from an analysis of nationwide trauma registry in Japan. J Trauma Acute Care Surg 2024; 96:742-748. [PMID: 37962149 DOI: 10.1097/ta.0000000000004206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2023]
Abstract
BACKGROUND Whether and how the transfusion volume should be limited in resuscitation after trauma remains unclear. We investigated the association between transfusion volume and survival outcome following trauma. METHODS Using the Japan Trauma Data Bank (2019-2021), we identified patients 18 years or older who received balanced blood transfusion within the first 24 hours of injury. We evaluated the association between the total number of red blood cell (RBC) units transfused and survival at discharge using logistic regression analysis and generalized additive model. Subgroup analyses based on patient characteristics were performed. RESULTS Overall, 5,123 patients from 165 hospitals were eligible for analysis. The transfusion volume was significantly associated with survival rate. Compared with that of patients receiving 4 to 9 RBC units, the within-hospital odds ratios (95% confidence interval) for survival at discharge were 0.62 (0.55-0.75), 0.32 (0.25-0.40), and 0.15 (0.12-0.20) for those receiving 10 to 19, 20 to 29, and ≥30 U, respectively. The probability of survival decreased consistently without any discernible threshold; however, the survival rates remained >40% and >20% even in patients receiving 50 and 80 RBC units, respectively. Significant interactions were observed between the number of RBC units transfused and each subgroup for survival at discharge. CONCLUSION The probability of survival consistently diminished as the transfusion volume increased. The absence of a threshold and lack of exceedingly low probability of survival support massive transfusion when clinicians perceive ongoing transfusion as beneficial. The unique context of each clinical situation must be considered in decision making. LEVEL OF EVIDENCE Therapeutic/Care Management; Level III.
Collapse
Affiliation(s)
- Keita Shibahashi
- From the Tertiary Emergency Medical Center (K. Shibahashi, M.H., K. Sugiyama), Tokyo Metropolitan Bokutoh Hospital, Tokyo; Advanced Medical Emergency Department and Critical Care Center (M.A.), Japan Red Cross Maebashi Hospital, Maebashi, Japan
| | | | | | | |
Collapse
|
4
|
LaGrone LN, Stein D, Cribari C, Kaups K, Harris C, Miller AN, Smith B, Dutton R, Bulger E, Napolitano LM. American Association for the Surgery of Trauma/American College of Surgeons Committee on Trauma: Clinical protocol for damage-control resuscitation for the adult trauma patient. J Trauma Acute Care Surg 2024; 96:510-520. [PMID: 37697470 DOI: 10.1097/ta.0000000000004088] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/13/2023]
Abstract
ABSTRACT Damage-control resuscitation in the care of critically injured trauma patients aims to limit blood loss and prevent and treat coagulopathy by combining early definitive hemorrhage control, hypotensive resuscitation, and early and balanced use of blood products (hemostatic resuscitation) and the use of other hemostatic agents. This clinical protocol has been developed to provide evidence-based recommendations for optimal damage-control resuscitation in the care of trauma patients with hemorrhage.
Collapse
Affiliation(s)
- Lacey N LaGrone
- From the Department of Surgery (D.S.), University of Maryland, Baltimore, Maryland; Department of Surgery (L.N.L., C.C.), UCHealth, Loveland, Colorado; Department of Surgery (K.K), University of California San Francisco Fresno, San Francisco, California; Department of Surgery (C.H.), Tulane University, New Orleans, Louisiana; Orthopedic Surgery (A.N.M.), Washington University in St. Louis, St. Louis, Missouri; Department of Surgery (B.S.), University of Pennsylvania, Philadelphia, Pennsylvania; American Society of Anesthesiologists (R.D.), Anesthesia, Waco, Texas; Department of Surgery (E.B.), University of Washington, Seattle, Washington; and Department of Surgery (L.M.N.), University of Michigan, Ann Arbor, Michigan
| | | | | | | | | | | | | | | | | | | |
Collapse
|
5
|
Meyer CH, Nguyen J, ElHabr A, Venkatayogi N, Steed T, Gichoya J, Sciarretta JD, Sikora J, Dente C, Lyons J, Coopersmith CM, Nguyen C, Smith RN. TiME OUT: Time-specific machine-learning evaluation to optimize ultramassive transfusion. J Trauma Acute Care Surg 2024; 96:443-454. [PMID: 37962139 PMCID: PMC10922246 DOI: 10.1097/ta.0000000000004187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2023]
Abstract
BACKGROUND Ultramassive transfusion (UMT) is a resource-demanding intervention for trauma patients in hemorrhagic shock, and associated mortality rates remains high. Current research has been unable to identify a transfusion ceiling or point where UMT transitions from lifesaving to futility. Furthermore, little consideration has been given to how time-specific patient data points impact decisions with ongoing high-volume resuscitation. Therefore, this study sought to use time-specific machine learning modeling to predict mortality and identify parameters associated with survivability in trauma patients undergoing UMT. METHODS A retrospective review was conducted at a Level I trauma (2018-2021) and included trauma patients meeting criteria for UMT, defined as ≥20 red blood cell products within 24 hours of admission. Cross-sectional data were obtained from the blood bank and trauma registries, and time-specific data were obtained from the electronic medical record. Time-specific decision-tree models predicating mortality were generated and evaluated using area under the curve. RESULTS In the 180 patients included, mortality rate was 40.5% at 48 hours and 52.2% overall. The deceased received significantly more blood products with a median of 71.5 total units compared with 55.5 in the survivors ( p < 0.001) and significantly greater rates of packed red blood cells and fresh frozen plasma at each time interval. Time-specific decision-tree models predicted mortality with an accuracy as high as 81%. In the early time intervals, hemodynamic stability, undergoing an emergency department thoracotomy, and injury severity were most predictive of survival, while, in the later intervals, markers of adequate resuscitation such as arterial pH and lactate level became more prominent. CONCLUSION This study supports that the decision of "when to stop" in UMT resuscitation is not based exclusively on the number of units transfused but rather the complex integration of patient and time-specific data. Machine learning is an effective tool to investigate this concept, and further research is needed to refine and validate these time-specific decision-tree models. LEVEL OF EVIDENCE Prognostic and Epidemiological; Level IV.
Collapse
Affiliation(s)
- Courtney H Meyer
- Department of Trauma & Surgical Critical Care, Grady Health System, Atlanta, GA
- Department of Surgery, Emory University School of Medicine, Atlanta, GA
- Department of Behavioral, Social and Health Sciences, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Jonathan Nguyen
- Department of Trauma & Surgical Critical Care, Grady Health System, Atlanta, GA
- Department of Surgery, Morehouse School of Medicine, Atlanta, GA
| | - Andrew ElHabr
- Department of Operations Research, Georgia Institute of Technology, Atlanta, GA
| | - Nethra Venkatayogi
- Department of Biomedical Engineering, University of Texas at Austin, Austin, TX
| | - Tyler Steed
- Department of Trauma & Surgical Critical Care, Grady Health System, Atlanta, GA
- Department of Surgery, Emory University School of Medicine, Atlanta, GA
| | - Judy Gichoya
- Department of Trauma & Surgical Critical Care, Grady Health System, Atlanta, GA
- Department of Surgery, Emory University School of Medicine, Atlanta, GA
| | - Jason D Sciarretta
- Department of Trauma & Surgical Critical Care, Grady Health System, Atlanta, GA
- Department of Surgery, Emory University School of Medicine, Atlanta, GA
| | - James Sikora
- Department of Trauma & Surgical Critical Care, Grady Health System, Atlanta, GA
- Department of Surgery, Emory University School of Medicine, Atlanta, GA
| | - Christopher Dente
- Department of Trauma & Surgical Critical Care, Grady Health System, Atlanta, GA
- Department of Surgery, Emory University School of Medicine, Atlanta, GA
| | - John Lyons
- Department of Surgery, Emory University School of Medicine, Atlanta, GA
- Department of Surgery and Emory Critical Care Center, Emory University School of Medicine, Atlanta, GA
| | - Craig M Coopersmith
- Department of Surgery, Emory University School of Medicine, Atlanta, GA
- Department of Surgery and Emory Critical Care Center, Emory University School of Medicine, Atlanta, GA
| | - Crystal Nguyen
- Department of Trauma & Surgical Critical Care, Grady Health System, Atlanta, GA
| | - Randi N Smith
- Department of Trauma & Surgical Critical Care, Grady Health System, Atlanta, GA
- Department of Surgery, Emory University School of Medicine, Atlanta, GA
- Department of Behavioral, Social and Health Sciences, Rollins School of Public Health, Emory University, Atlanta, GA
| |
Collapse
|
6
|
Loudon AM, Rushing AP, Badrinathan A, Moorman ML. Benefit of balance? Odds of survival by unit transfused: Retrospective analysis of the ACS-TQIP database. Surgery 2024; 175:885-892. [PMID: 37852833 DOI: 10.1016/j.surg.2023.08.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Revised: 07/21/2023] [Accepted: 08/08/2023] [Indexed: 10/20/2023]
Abstract
BACKGROUND The critical blood shortage in January 2022 threatened the availability of blood. Utility of transfusion per unit was reported in a previous study, revealing patients receiving balanced transfusion are more likely to die after 16 units of packed red blood cells. We aimed to validate this study using a larger database. METHODS Retrospective analysis utilizing the American College of Surgeons Trauma Quality Improvement Program was performed. Trauma patients aged ≥16 receiving transfusion within 4 hours of arrival were included and excluded if they died in the emergency department, received <2 units of packed red blood cells, did not receive fresh frozen plasma, or were missing data. Primary outcome was mortality. Subgroups were balanced transfusion if receiving ≤2:1 ratio of packed red blood cells:fresh frozen plasma, and unbalanced transfusion if >2:1 ratio. RESULTS A total of 17,047 patients were evaluated with 28% mortality (4,822/17,408). Multivariable logistic regression identified advancing age (odds ratio 1.03 95% confidence interval 1.03-1.04), higher ISS (odds ratio 1.04, 95% confidence interval 1.03-1.04), and lower GCS (odds ratio 0.82, 95% confidence interval 0.82-0.83) as risk factors for mortality. Protective factors were balanced transfusion (odds ratio 0.81 95% confidence interval 0.71-0.93), male sex (odds ratio 0.90, 95% confidence interval 0.81-0.99), and blunt mechanism (odds ratio 0.74, 95% confidence interval 0.67-0.81). At 11 units of packed red blood cells, balanced transfusion patients were more likely to die (odds ratio 0.88, 95% confidence interval 0.80-0.98). Balanced transfusion patients survived at a higher rate for each unit of packed red blood cells, between 6 and 23 units of packed red blood cells. CONCLUSION Mortality increases with each unit of packed red blood cell transfused. At 11 units of packed red blood cells, mortality is the more likely outcome. Balanced transfusion improves the chance of survival through 23 units of packed red blood cells.
Collapse
Affiliation(s)
- Andrew M Loudon
- Department of Surgery, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH.
| | - Amy P Rushing
- Department of Surgery, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH
| | - Avanti Badrinathan
- Department of Surgery, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH
| | - Matthew L Moorman
- Department of Surgery, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH
| |
Collapse
|
7
|
Meyer CH, Bailey NM, Leslie SL, Thrasher K, Grady Z, Sanders M, Moore E, Nicely KW, Smith RN. Defining Ultra-Massive Transfusion through a Systematic Review. Am J Surg 2024; 228:192-198. [PMID: 38616968 PMCID: PMC11008908 DOI: 10.1016/j.amjsurg.2023.09.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/16/2024]
Abstract
Background Despite the widespread use of ultra-massive transfusion (UMT) as an intervention for trauma patients in hemorrhagic shock, no standard definition exists. We performed a systematic review to determine a consensus definition for UMT. Methods A search was performed from 1979-2022. The authors screened studies defining UMT and associated outcomes as defined by our prespecified PICO questions. The PRISMA guidelines were used. Results 1662 articles met criteria for eligibility assessment, 17 for full-text review and eight for data extraction. Only two studies demonstrated a consensus definition of UMT, which used ≥20 units of red blood cell product within 24hrs. Parameters associated with increased mortality included lower blood pressure, lower pulse and lower Glasgow Coma Score at the time of presentation and a higher injury severity score and undergoing a resuscitative thoracotomy. Conclusions The absence of a consensus definition for UMT raises challenges from clinical, research and ethical perspectives. Based on our findings, the authors advocate for the feasibility of standardizing the definition of UMT as ≥20 units of red blood cell product within 24hrs.
Collapse
Affiliation(s)
- Courtney H Meyer
- Grady Health System, Atlanta, GA
- Emory University School of Medicine, Atlanta, GA
- Emory University Rollins School of Public Health, Atlanta, GA
| | | | - Sharon L Leslie
- Emory University Woodruff Health Sciences Center Library, Atlanta, GA
| | - Kenya Thrasher
- Grady Health System, Atlanta, GA
- Morehouse School of Medicine, Atlanta, GA
| | - Zach Grady
- Grady Health System, Atlanta, GA
- Emory University School of Medicine, Atlanta, GA
| | - M Sanders
- Emory University Nell Hodgson Woodruff School of Nursing, Atlanta, GA
| | - Erica Moore
- Emory University Nell Hodgson Woodruff School of Nursing, Atlanta, GA
| | - K W Nicely
- Emory University Nell Hodgson Woodruff School of Nursing, Atlanta, GA
| | - Randi N Smith
- Grady Health System, Atlanta, GA
- Emory University School of Medicine, Atlanta, GA
- Emory University Rollins School of Public Health, Atlanta, GA
| |
Collapse
|
8
|
L'Huillier JC, Hua S, Logghe HJ, Yu J, Myneni AA, Noyes K, Guo WA. Transfusion futility thresholds and mortality in geriatric trauma: Does frailty matter? Am J Surg 2024; 228:113-121. [PMID: 37684168 DOI: 10.1016/j.amjsurg.2023.08.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Revised: 08/14/2023] [Accepted: 08/22/2023] [Indexed: 09/10/2023]
Abstract
BACKGROUND Data on massive transfusion (MT) in geriatric trauma patients is lacking. This study aims to determine geriatric transfusion futility thresholds (TT) and TT variations based on frailty. METHODS Patients from 2013 to 2018 TQIP database receiving MT were stratified by age and frailty. TTs and outcomes were compared between geriatric and younger adults and among geriatric adults based on frailty status. RESULTS The TT was lower for geriatric than younger adults (34 vs 39 units; p = 0.03). There was no difference in TT between the non-frail, frail, and severely frail geriatric adults (37, 30 and 25 units, respectively, p > 0.05). Geriatric adults had higher mortality than younger adults (63.1% vs 45.8%, p < 0.01). Non-frail geriatric adults had the highest mortality (69.4% vs 56.5% vs 56.2%, p < 0.01). CONCLUSIONS Geriatric patients have a lower TT than younger adults, irrespective of frailty. This may help improve outcomes and optimize MT utilization.
Collapse
Affiliation(s)
- Joseph C L'Huillier
- Department of Surgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, 14203, USA; Division of Health Services Policy and Practice, Department of Epidemiology and Environmental Health, School of Public Health and Health Professions, University at Buffalo, Buffalo, NY, 14203, USA
| | - Shuangcheng Hua
- Department of Biostatistics, School of Public Health and Health Professions, University at Buffalo, Buffalo, NY, 14203, USA
| | - Heather J Logghe
- Department of Surgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, 14203, USA
| | - Jihnhee Yu
- Department of Biostatistics, School of Public Health and Health Professions, University at Buffalo, Buffalo, NY, 14203, USA
| | - Ajay A Myneni
- Department of Surgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, 14203, USA
| | - Katia Noyes
- Department of Surgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, 14203, USA; Division of Health Services Policy and Practice, Department of Epidemiology and Environmental Health, School of Public Health and Health Professions, University at Buffalo, Buffalo, NY, 14203, USA
| | - Weidun A Guo
- Department of Surgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, 14203, USA.
| |
Collapse
|
9
|
Jackson M, Berman S, Rueda M, Borrego R, Lottenberg L, Azar F. Ultramassive transfusion and adjunctive therapies in a case of blood bank depletion. Trauma Case Rep 2023; 48:100955. [PMID: 37955000 PMCID: PMC10632100 DOI: 10.1016/j.tcr.2023.100955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/17/2023] [Indexed: 11/14/2023] Open
Abstract
Background We present the case of a patient who presents with a high velocity thoracoabdominal gunshot wound requiring ultramassive transfusion who exhausted the county blood bank requiring adjunctive therapies to balanced blood product transfusion while additional blood products could be obtained. Summary Thoracoabdominal gunshot wounds carry a high mortality of 14-37 % because of the risk to produce cardiopulmonary, solid organ as well as major vascular injuries (Mandal and Oparah (1989) [1]). Ultramassive transfusion (>20 units of blood product transfusion) also carries high morbidity and mortality and management has generally centered on balanced transfusion (Matthay et al. (2021) [2]). Conclusion Balanced blood product transfusion reduces mortality for patients requiring ultramassive transfusion but when this is not possible utilization of adjuncts to blood products may temporize resuscitation until additional blood products can be obtained.
Collapse
Affiliation(s)
- Max Jackson
- Corresponding author at: Department of Surgery, Charles E. Schmidt College of Medicine, Florida Atlantic University, 800 Meadows Road, Boca Raton, FL 33486, United States of America.
| | - Spencer Berman
- Department of Surgery, Charles E. Schmidt College of Medicine, Florida Atlantic University, 800 Meadows Road, Boca Raton, FL 33486, United States of America
- Division of Trauma, St. Mary's Medical Center, 901 45th Street, West Palm Beach, FL 33407, United States of America
| | - Mario Rueda
- Department of Surgery, Charles E. Schmidt College of Medicine, Florida Atlantic University, 800 Meadows Road, Boca Raton, FL 33486, United States of America
- Division of Trauma, St. Mary's Medical Center, 901 45th Street, West Palm Beach, FL 33407, United States of America
| | - Robert Borrego
- Department of Surgery, Charles E. Schmidt College of Medicine, Florida Atlantic University, 800 Meadows Road, Boca Raton, FL 33486, United States of America
- Division of Trauma, St. Mary's Medical Center, 901 45th Street, West Palm Beach, FL 33407, United States of America
| | - Lawrence Lottenberg
- Department of Surgery, Charles E. Schmidt College of Medicine, Florida Atlantic University, 800 Meadows Road, Boca Raton, FL 33486, United States of America
- Division of Trauma, St. Mary's Medical Center, 901 45th Street, West Palm Beach, FL 33407, United States of America
| | - Faris Azar
- Department of Surgery, Charles E. Schmidt College of Medicine, Florida Atlantic University, 800 Meadows Road, Boca Raton, FL 33486, United States of America
- Division of Trauma, St. Mary's Medical Center, 901 45th Street, West Palm Beach, FL 33407, United States of America
| |
Collapse
|
10
|
Gaski IA, Naess PA, Baksaas-Aasen K, Skaga NO, Gaarder C. Achieving balanced transfusion early in critically bleeding trauma patients: an observational study exploring the effect of attending trauma surgical presence during resuscitation. Trauma Surg Acute Care Open 2023; 8:e001160. [PMID: 38020849 PMCID: PMC10660666 DOI: 10.1136/tsaco-2023-001160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Accepted: 10/13/2023] [Indexed: 12/01/2023] Open
Abstract
Background After 15 years of damage control resuscitation (DCR), studies still report high mortality rates for critically bleeding trauma patients. Adherence to massive hemorrhage protocols (MHPs) based on a 1:1:1 ratio of plasma, platelets, and red blood cells (RBCs) as part of DCR has been shown to improve outcomes. We wanted to assess MHP use in the early (6 hours from admission), critical phase of DCR and its impact on mortality. We hypothesized that the presence of an attending trauma surgeon during all MHP activations from 2013 would contribute to improving institutional resuscitation strategies and patient outcomes. Methods We conducted a retrospective analysis of all trauma patients receiving ≥10 RBCs within 6 hours of admission and included in the institutional trauma registry between 2009 and 2019. The cohort was divided in period 1 (P1): January 2009-August 2013, and period 2 (P2): September 2013-December 2019 for comparison of outcomes. Results A total of 141 patients were included, 81 in P1 and 60 in P2. Baseline characteristics were similar between the groups for Injury Severity Score, lactate, Glasgow Coma Scale, and base deficit. Patients in P2 received more plasma (16 units vs. 12 units; p<0.01), resulting in a more balanced plasma:RBC ratio (1.00 vs. 0.74; p<0.01), and platelets:RBC ratio (1.11 vs. 0.92; p<0.01). All-cause mortality rates decreased from P1 to P2, at 6 hours (22% to 8%; p=0.03), at 24 hours (36% vs 13%; p<0.01), and at 30 days (48% vs 30%, p=0.03), respectively. A stepwise logistic regression model predicted an OR of 0.27 (95% CI 0.08 to 0.93) for dying when admitted in P2. Conclusions Achieving balanced transfusion rates at 6 hours, facilitated by the presence of an attending trauma surgeon at all MHP activations, coincided with a reduction in all-cause mortality and hemorrhage-related deaths in massively transfused trauma patients at 6 hours, 24 hours, and 30 days. Level of evidence IV.
Collapse
Affiliation(s)
- Iver Anders Gaski
- Department of Traumatology, Oslo University Hospital Ulleval, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Paal Aksel Naess
- Department of Traumatology, Oslo University Hospital Ulleval, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | | | - Nils Oddvar Skaga
- Department of Anesthesiology, Oslo University Hospital Ullevål, Oslo, Norway
| | - Christine Gaarder
- Department of Traumatology, Oslo University Hospital Ulleval, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| |
Collapse
|
11
|
Clements TW, Van Gent JM, Lubkin DE, Wandling MW, Meyer DE, Moore LJ, Cotton BA. The reports of my death are greatly exaggerated: An evaluation of futility cut points in massive transfusion. J Trauma Acute Care Surg 2023; 95:685-690. [PMID: 37125814 DOI: 10.1097/ta.0000000000003980] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2023]
Abstract
BACKGROUND Following COVID and the subsequent blood shortage, several investigators evaluated futility cut points in massive transfusion. We hypothesized that early aggressive use of damage-control resuscitation, including whole blood (WB), would demonstrate that these cut points of futility were significantly underestimating potential survival among patients receiving >50 U of blood in the first 4 hours. METHODS Adult trauma patients admitted from November 2017 to October 2021 who received emergency-release blood products in prehospital or emergency department setting were included. Deaths within 30 minutes of arrival were excluded. Total blood products were defined as total red blood cell, plasma, and WB in the field and in the first 4 hours after arrival. Patients were first divided into those receiving ≤50 or >50 U of blood in the first 4 hours. We then evaluated patients by whether they received any WB or received only component therapy. Thirty-day survival was evaluated for all included patients. RESULTS A total of 2,299 patients met the inclusion criteria (2,043 in ≤50 U, 256 in >50 U groups). While there were no differences in age or sex, the >50 U group was more likely to sustain penetrating injury (47% vs. 30%, p < 0.05). Patients receiving >50 U of blood had lower field and arrival blood pressure and larger prehospital and emergency department resuscitation volumes ( p < 0.05). Patients in the >50 U group had lower survival than those in the ≤50 cohort (31% vs. 79%; p < 0.05). Patients who received WB (n = 1,291) had 43% increased odds of survival compared with those who received only component therapy (n = 1,008) (1.09-1.87, p = 0.009) and higher 30-day survival at transfusion volumes >50 U. CONCLUSION Patient survival rates in patients receiving >50 U of blood in the first 4 hours of care are as high as 50% to 60%, with survival still at 15% to 25% after 100 U. While responsible blood stewardship is critical, futility should not be declared based on high transfusion volumes alone. LEVEL OF EVIDENCE Therapeutic/Care Management; Level III.
Collapse
Affiliation(s)
- Thomas W Clements
- From the University of Texas Health Science Center at Houston, Red Duke Trauma Institute, and McGovern Medical School, Division of Acute Care Surgery, Department of Surgery, Houston, Texas
| | | | | | | | | | | | | |
Collapse
|
12
|
Lapisatepun W, Ma C, Lapisatepun W, Agopian V, Wray C, Xia VW. Super-massive transfusion during liver transplantation. Transfusion 2023; 63:1677-1684. [PMID: 37493440 DOI: 10.1111/trf.17496] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Revised: 05/17/2023] [Accepted: 06/09/2023] [Indexed: 07/27/2023]
Abstract
BACKGROUND Massive hemorrhage and transfusion during liver transplantation (LT) present great challenges. We aimed to investigate the incidence and risk factors for super-massive transfusion (SMT) and survival outcome and factors that negatively affect survival in patients who received SMT during LT. STUDY DESIGN AND METHODS We included adult patients undergoing LT from 2004 to 2019. SMT was defined as transfusion of ≥50 units of red blood cells (RBC) during LT. Independent risk factors were identified by multivariable logistic regression. Ninety-day survival was recorded and factors that negatively affected survival were analyzed by the Cox survival test. RESULTS Of 2772 patients, 158 (5.6%) received SMT during LT. Mean RBC transfusion was 72.6 (±23.4) units with a maximum of 168 units. Four variables (MELD-Na score, previous upper abdominal surgery, portal vein thrombosis, and remote retransplant) were independent risk factors for SMT (odds ratio 1.800-8.274, 95% CI 1.008-16.685, all p < .005). The 90-day survival rate in SMT patients was 81.6%. Preoperative pulmonary hypertension and massive postreperfusion transfusion negatively affected 90-day survival (hazard ratio 2.658-4.633, 95% CI 1.144-10.130, and all p < .05). CONCLUSIONS In this large retrospective study, we found that SMT occurred in a small percentage of patients and was associated with relatively satisfactory short-term survival. Identification of preoperative risk factors for SMT and factors that negatively affect survival improve our understanding of this unique LT patient population.
Collapse
Affiliation(s)
- Warangkana Lapisatepun
- Departments of Anesthesiology, Ronald Reagan UCLA Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
- Department of Anesthesiology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Christina Ma
- Departments of Anesthesiology, Ronald Reagan UCLA Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Worakitti Lapisatepun
- Department of Surgery, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Vatche Agopian
- Departments of Surgery, Ronald Reagan UCLA Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Christopher Wray
- Departments of Anesthesiology, Ronald Reagan UCLA Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Victor W Xia
- Departments of Anesthesiology, Ronald Reagan UCLA Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| |
Collapse
|
13
|
Kim JS, Casem CF, Baral E, Inaba K, Kuza CM. Narrative Review: Is There a Transfusion Cutoff Value After Which Nonsurvivability Is Inevitable in Trauma Patients Receiving Ultramassive Transfusion? Anesth Analg 2023; 137:354-364. [PMID: 37115716 DOI: 10.1213/ane.0000000000006504] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/29/2023]
Abstract
The institution of massive transfusion protocols (MTPs) has improved the timely delivery of large quantities of blood products and improves patient outcomes. In recent years, the cost of blood products has increased, compounded by significant blood product shortages. There is practical need for identification of a transfusion volume in trauma patients that is associated with increased mortality, or a threshold after which additional transfusion is futile and associated with nonsurvivability. This transfusion threshold is often described in the setting of an ultramassive transfusion (UMT). There are few studies defining what constitutes amount or outcomes associated with such large volume transfusion. The purpose of this narrative review is to provide an analysis of existing literature examining the effects of UMT on outcomes including survival in adult trauma patients and to determine whether there is a threshold transfusion limit after which mortality is inevitable. Fourteen studies were included in this review. The data examining the utility of UMT in trauma are of poor quality, and with the variability inherent in trauma patients, and the surgeons caring for them, no universally accepted cutoff for transfusion exists. Not surprisingly, there is a trend toward increasing mortality with increasing transfusions. The decision to continue transfusing is multifactorial and must be individualized, taking into consideration patient characteristics, institution factors, blood bank supply, and most importantly, constant reevaluation of the need for ongoing transfusion rather than blind continuous transfusion until the heart stops.
Collapse
Affiliation(s)
- Jennie S Kim
- From the Department of Surgery, University of Southern California Trauma and Acute Care Surgery, Los Angeles, California
| | - Christleen F Casem
- Department of Surgery, University of California San Francisco East Bay Surgery, Oakland, Californiaand
| | - Erika Baral
- Department of Anesthesiology, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Kenji Inaba
- From the Department of Surgery, University of Southern California Trauma and Acute Care Surgery, Los Angeles, California
| | - Catherine M Kuza
- Department of Anesthesiology, Keck School of Medicine of the University of Southern California, Los Angeles, California
| |
Collapse
|
14
|
Muldowney M, Liu Z, Stansbury LG, Vavilala MS, Hess JR. Ultramassive Transfusion for Trauma in the Age of Hemostatic Resuscitation: A Retrospective Single-Center Cohort From a Large US Level-1 Trauma Center, 2011-2021. Anesth Analg 2023; 136:927-933. [PMID: 37058729 DOI: 10.1213/ane.0000000000006388] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/16/2023]
Abstract
BACKGROUND Uncontrolled bleeding is a leading cause of death in trauma. In the last 40 years, ultramassive transfusion (UMT; ≥20 units of red blood cells [RBCs]/24 hours) for trauma has been associated with 50% to 80% mortality; the question remains as to whether the increasing number of units transfused in urgent resuscitation is a marker of futility. We asked whether the frequency and outcomes of UMT have changed in the era of hemostatic resuscitation. METHODS We performed a retrospective cohort study of all UMTs in the first 24 hours of care over an 11-year period at a major US level-1 adult and pediatric trauma center. UMT patients were identified, and a dataset was built by linking blood bank and trauma registry data, then reviewing individual electronic health records. Success in achieving hemostatic proportions of blood products was estimated as (units of plasma + apheresis-platelets-in-plasma + cryoprecipitate-pools + whole blood]/[all units given] ≥0.5. Demographics, injury type (blunt or penetrating), severity (Injury Severity Score [ISS]), severity pattern (Abbreviated Injury Scale score for head [AIS-Head] ≥4), admitting laboratory, transfusion, selected emergency department interventions, and discharge status were assessed using χ2 tests of categorical association, the Student t-test of means, and multivariable logistic regression. P <.05 was considered significant. RESULTS Among 66,734 trauma admissions from April 6, 2011 to December 31, 2021, we identified 6288 (9.4%) who received any blood products in the first 24 hours, 159 of whom received UMT (0.23%; 154 aged 18-90 + 5 aged 9-17), 81% in hemostatic proportions. Overall mortality was 65% (n = 103); mean ISS = 40; median time to death, 6.1 hours. In univariate analyses, death was not associated with age, sex, or more RBC units transfused beyond 20 but was associated with blunt injury, increasing injury severity, severe head injury, and failure to receive hemostatic blood product ratios. Mortality was also associated with decreased pH and evidence of coagulopathy at admission, especially hypofibrinogenemia. Multivariable logistic regression showed severe head injury, admission hypofibrinogenemia and not receiving a hemostatic resuscitation proportion of blood products as independently associated with death. CONCLUSIONS One in 420 acute trauma patients at our center received UMT, a historically low rate. A third of these patients lived, and UMT was not itself a marker of futility. Early identification of coagulopathy was possible, and failure to give blood components in hemostatic ratios was associated with excess mortality.
Collapse
Affiliation(s)
- Maeve Muldowney
- From the Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington
| | - Zhinan Liu
- Harborview Injury Prevention Research Center, Harborview Medical Center, Seattle, Washington
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, Washington
| | - Lynn G Stansbury
- From the Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington
- Harborview Injury Prevention Research Center, Harborview Medical Center, Seattle, Washington
| | - Monica S Vavilala
- From the Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington
- Harborview Injury Prevention Research Center, Harborview Medical Center, Seattle, Washington
| | - John R Hess
- Harborview Injury Prevention Research Center, Harborview Medical Center, Seattle, Washington
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, Washington
| |
Collapse
|
15
|
Abstract
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.
Collapse
Affiliation(s)
- Carter M Galbraith
- Division of Critical Care Medicine, Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, 619 19th Street South, JT 845, Birmingham, AL 35249, USA
| | - Brant M Wagener
- Division of Critical Care Medicine, University of Alabama at Birmingham, 901 19th Street South, PBMR 302, Birmingham, AL 35294, USA; Division of Molecular and Translational Biomedicine, Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, 901 19th Street South, PBMR 302, Birmingham, AL 35294, USA
| | - Athanasios Chalkias
- Department of Anesthesiology, University of Thessaly, Biopolis, Larisa 41500, Greece; Outcomes Research Consortium, Cleveland, OH 44195, USA
| | - Shahla Siddiqui
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, Boston, MA 02215, USA.
| | - David J Douin
- Department of Anesthesiology, University of Colorado School of Medicine, 12401 East 17th Avenue, 7th Floor, Aurora, CO 80045, USA.
| |
Collapse
|
16
|
Loudon AM, Rushing AP, Hue JJ, Ziemak A, Sarode AL, Moorman ML. When is enough enough? Odds of survival by unit transfused. J Trauma Acute Care Surg 2023; 94:205-211. [PMID: 36694331 DOI: 10.1097/ta.0000000000003835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND Balanced transfusion is lifesaving for hemorrhagic shock. The American Red Cross critical blood shortage in 2022 threatened the immediate availability of blood. To eliminate waste, we reviewed the utility of transfusions per unit to define expected mortality at various levels of balanced transfusion. METHODS A retrospective study of 296 patients receiving massive transfusion on presentation at a level 1 trauma center was performed from January 2018 to December 2021. Units of packed red blood cells (PRBCs), fresh frozen plasma (FFP), and platelets received in the first 4 hours were recorded. Patients were excluded if they died in the emergency department, died on arrival, received <2 U PRBCs or FFP, or received PRBC/FFP >2:1. Primary outcomes were mortality and odds of survival to discharge. Subgroups were defined as transfused if receiving 2 to 9 U PRBCs, massive transfusion for 10 to 19 U PRBCs, and ultramassive transfusion for ≥20 U PRBCs. RESULTS A total of 207 patients were included (median age, 32 years; median Injury Severity Score, 25; 67% with penetrating mechanism). Mortality was 29% (61 of 207 patients). Odds of survival is equal to odds of mortality at 11 U PRBCs (odds ratio [OR], 0.95; 95% confidence interval [CI], 0.50-1.79). Beyond 16 U PRBCs, odds of mortality exceed survival (OR, 0.36; 95% CI, 0.16-0.82). Survival approaches zero >36 U PRBCs (OR, 0.09; 95% CI, 0.00-0.56). Subgroup mortality rates increased with unit transfused (16% transfused vs. 36% massive transfusion, p = 0.003; 36% massive transfusion vs. 67% ultramassive transfusion, p = 0.006). CONCLUSION Mortality increases with each unit balanced transfusion. Surgeons should view efforts heroic beyond 16 U PRBCs/4 hours and near futile beyond 36 U PRBCs/4 hours. While extreme outliers can survive, consider cessation of resuscitation beyond 36 U PRBCs. This is especially true if hemostasis has not been achieved or blood supplies are limited. LEVEL OF EVIDENCE Prognostic and Epidemiologic; Level IV.
Collapse
Affiliation(s)
- Andrew M Loudon
- From the Department of Surgery, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | | | | | | | | | | |
Collapse
|
17
|
Mills H, Acquah R, Tang N, Cheung L, Klenk S, Glassen R, Pirson M, Albert A, Hoang DT, Van TN. Emergency Medicine with Advanced Surgery Protocols: A Review. JOURNAL OF ENVIRONMENTAL AND PUBLIC HEALTH 2022; 2022:3513250. [PMID: 36200087 PMCID: PMC9529385 DOI: 10.1155/2022/3513250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Revised: 09/05/2022] [Accepted: 09/07/2022] [Indexed: 11/17/2022]
Abstract
One of the most burning issues in health system is the concern of handling patients that requires emergency surgery. Emergency general surgery is done on both traumatic and nontraumatic acute disorders. Severe traumatic injury and bleeding is one of the causing agents for high mortality rate globally. Another group of patients that are in need of emergency surgery are those with heart failure, and in this particular paper, we analyzed emergency medicine with advanced surgery protocols focusing on gastric cancer, cardiac surgery, and bleeding as well as coagulopathy following traumatic injury.
Collapse
Affiliation(s)
- Hilla Mills
- Clinical Center of Vojvodina, Novi Sad, Serbia
- Clinical Analysis Lab, Center of Bio-Medicine, Hanoi, Vietnam
| | - Ronald Acquah
- Clinical Center of Vojvodina, Novi Sad, Serbia
- Clinical Analysis Lab, Center of Bio-Medicine, Hanoi, Vietnam
| | - Nova Tang
- RD Lab, The Hospital Institute for Herbal Research, 50200 Toluca, MEX, Mexico
| | - Luke Cheung
- RD Lab, The Hospital Institute for Herbal Research, 50200 Toluca, MEX, Mexico
| | - Susanne Klenk
- Research Institution of Clinical Biomedicine, Hospital University Medical Centre, 89000 Ulm, Germany
| | - Ronald Glassen
- Research Institution of Clinical Biomedicine, Hospital University Medical Centre, 89000 Ulm, Germany
| | - Magali Pirson
- Industrial Research Group, International College of Science and Technology, Route de Lennik 800, CP 590, 1070 Brussels, Belgium
| | - Alain Albert
- Industrial Research Group, International College of Science and Technology, Route de Lennik 800, CP 590, 1070 Brussels, Belgium
| | | | | |
Collapse
|
18
|
Dorken Gallastegi A, Secor JD, Maurer LR, Dzik WS, Saillant NN, Hwabejire JO, Fawley J, Parks J, Kaafarani HM, Velmahos GC. Role of Transfusion Volume and Transfusion Rate as Markers of Futility During Ultramassive Blood Transfusion in Trauma. J Am Coll Surg 2022; 235:468-480. [PMID: 35972167 DOI: 10.1097/xcs.0000000000000268] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Using a large national database, we evaluated the relationship between RBC transfusion volume, RBC transfusion rate, and in-hospital mortality to explore the presence of a futility threshold in trauma patients receiving ultramassive blood transfusion. STUDY DESIGN The ACS-TQIP 2013 to 2018 database was analyzed. Adult patients who received ultramassive blood transfusion (≥20 units of RBC/24 hours) were included. RBC transfusion volume and rate were captured at the only 2 time points available in TQIP (4 hours and 24 hours), or time of death, whichever came first. RESULTS Among 5,135 patients analyzed, in-hospital mortality rate was 62.1% (n = 3,190), and 4-hour and 24-hour mortality rates were 17.53% (n = 900) and 42.41% (n = 2,178), respectively. RBC transfusion volumes at 4 hours (area under the receiver operating characteristic curve [AUROC] 0.59 [95% CI 0.57 to 0.60]) and 24 hours (AUROC 0.59 [95% CI 0.57 to 0.60]) had low discriminatory ability for mortality and were inconclusive for futility. Mean RBC transfusion rates calculated within 4 hours (AUROC 0.65 [95% CI 0.63 to 0.66]) and 24 hours (AUROC 0.85 [95% CI 0.84 to 0.86]) had higher discriminatory ability than RBC transfusion volume. A futility threshold was not found for the mean RBC transfusion rate calculated within 4 hours. All patients with a final mean RBC transfusion rate of ≥7 U/h calculated within 24 hours of arrival experienced in-hospital death (n = 1,326); the observed maximum length of survival for these patients during the first 24 hours ranged from 24 hours for a rate of 7 U/h to 4.5 hours for rates ≥21 U/h. CONCLUSION RBC transfusion volume within 4 or 24 hours and mean RBC transfusion rate within 4 hours were not markers of futility. The observed maximum length of survival per mean RBC transfusion rate could inform resuscitation efforts in trauma patients receiving ongoing transfusion between 4 and 24 hours.
Collapse
Affiliation(s)
- Ander Dorken Gallastegi
- From the Division of Trauma, Emergency Surgery, and Surgical Critical Care (Dorken Gallastegi, Saillant, Hwabejire, Fawley, Parks, Kaafarani, Velmahos)
| | | | | | - Walter S Dzik
- Department of Pathology (Dzik), Massachusetts General Hospital & Harvard Medical School, Boston
- Blood Transfusion Service, Massachusetts General Hospital, Boston (Dzik)
| | - Noelle N Saillant
- From the Division of Trauma, Emergency Surgery, and Surgical Critical Care (Dorken Gallastegi, Saillant, Hwabejire, Fawley, Parks, Kaafarani, Velmahos)
| | - John O Hwabejire
- From the Division of Trauma, Emergency Surgery, and Surgical Critical Care (Dorken Gallastegi, Saillant, Hwabejire, Fawley, Parks, Kaafarani, Velmahos)
| | - Jason Fawley
- From the Division of Trauma, Emergency Surgery, and Surgical Critical Care (Dorken Gallastegi, Saillant, Hwabejire, Fawley, Parks, Kaafarani, Velmahos)
| | - Jonathan Parks
- From the Division of Trauma, Emergency Surgery, and Surgical Critical Care (Dorken Gallastegi, Saillant, Hwabejire, Fawley, Parks, Kaafarani, Velmahos)
| | - Haytham Ma Kaafarani
- From the Division of Trauma, Emergency Surgery, and Surgical Critical Care (Dorken Gallastegi, Saillant, Hwabejire, Fawley, Parks, Kaafarani, Velmahos)
| | - George C Velmahos
- From the Division of Trauma, Emergency Surgery, and Surgical Critical Care (Dorken Gallastegi, Saillant, Hwabejire, Fawley, Parks, Kaafarani, Velmahos)
| |
Collapse
|
19
|
Platelet Transfusion for Trauma Resuscitation. CURRENT TRAUMA REPORTS 2022. [DOI: 10.1007/s40719-022-00236-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Abstract
Purpose of Review
To review the role of platelet transfusion in resuscitation for trauma, including normal platelet function and alterations in behavior following trauma, blood product transfusion ratios and the impact of platelet transfusion on platelet function, platelet function assays, risks of platelet transfusion and considerations for platelet storage, and potential adjunct therapies and synthetic platelets.
Recent Findings
Platelets are a critical component of clot formation and breakdown following injury, and in addition to these hemostatic properties, have a complex role in vascular homeostasis, inflammation, and immune function. Evidence supports that platelets are activated following trauma with several upregulated functions, but under conditions of severe injury and shock are found to be impaired in their hemostatic behaviors. Platelets should be transfused in balanced ratios with red blood cells and plasma during initial trauma resuscitation as this portends improved outcomes including survival. Multiple coagulation assays can be used for goal-directed resuscitation for traumatic hemorrhage; however, these assays each have drawbacks in terms of their ability to measure platelet function. While resuscitation with balanced transfusion ratios is supported by the literature, platelet transfusion carries its own risks such as bacterial infection and lung injury. Platelet supply is also limited, with resource-intensive storage requirements, making exploration of longer-term storage options and novel platelet-based therapeutics attractive. Future focus on a deeper understanding of the biology of platelets following trauma, and on optimization of novel platelet-based therapeutics to maintain hemostatic effects while improving availability should be pursued.
Summary
While platelet function is altered following trauma, platelets should be transfused in balanced ratios during initial resuscitation. Severe injury and shock can impair platelet function, which can persist for several days following the initial trauma. Assays to guide resuscitation following the initial period as well as storage techniques to extend platelet shelf life are important areas of investigation.
Collapse
|
20
|
Meshkin D, Yazer MH, Dunbar NM, Spinella PC, Leeper CM. Low titer Group O whole blood utilization in pediatric trauma resuscitation: A National Survey. Transfusion 2022; 62 Suppl 1:S63-S71. [PMID: 35748128 DOI: 10.1111/trf.16979] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 01/12/2022] [Accepted: 01/21/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Renewed interest in low titer group O whole blood (LTOWB) transfusion has led to increased utilization in adult trauma centers; little is known regarding LTOWB use in pediatric centers. STUDY DESIGN AND METHODS A survey of LTOWB utilization at American pediatric level 1 trauma centers. RESULTS Responses were received from 43/72 (60%) centers. These institutions were primarily urban (84%) and pediatric-specific (58%). There were 16% (7/43) centers using LTOWB, 7% (3/43) imminently initiating an LTOWB program, 47% (20/43) with interest but no current plan to develop a LTOWB program, and 30% (13/43) with no immediate interest in an LTOWB program. For the hospitals actively or imminently using LTOWB, 70% (3/10) have a minimum recipient weight criterion, 60% (6/10) have a minimum age criterion, and 70% (7/10) restrict the maximum volume transfused. Before the patient's RhD type becomes known, 30% (3/10) use RhD negative LTOWB for males and females, 40% (4/10) use RhD positive LTOWB for males and RhD negative LTOWB for females, 20% (2/10) use RhD positive LTOWB for males and RhD negative RBCs for females, and 10% (1/10) use RhD positive LTOWB for both males and females. Maximum LTOWB storage duration was 14-35 days and units nearing expiration were used for non-trauma patients (40%), processed to RBC (40%), and/or discarded (40%). The most common barriers to implementation were concerns about inventory management (37%), wastage (35%), infrequent use (33%), cost (21%) and unclear efficacy (14%). CONCLUSION LTOWB utilization is increasing in pediatric level 1 trauma centers in the United States.
Collapse
Affiliation(s)
- Dana Meshkin
- School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Mark H Yazer
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Nancy M Dunbar
- Department of Pathology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - Philip C Spinella
- Department of Surgery and Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Christine M Leeper
- Department of Surgery and Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| |
Collapse
|
21
|
Reppucci ML, Stevens J, Pickett K, Moulton SL. Reply to Letter to the Editor: Pediatric massive transfusion protocols applied to intraoperative complications of common pediatric surgeries. J Pediatr Surg 2022; 57:1173. [PMID: 35221033 DOI: 10.1016/j.jpedsurg.2022.01.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Accepted: 01/28/2022] [Indexed: 12/01/2022]
Affiliation(s)
- Marina L Reppucci
- Division of Pediatric Surgery, Children's Hospital Colorado, Aurora, CO, USA; Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA.
| | - Jenny Stevens
- Division of Pediatric Surgery, Children's Hospital Colorado, Aurora, CO, USA; Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Kaci Pickett
- The Center for Research in Outcomes for Children's Surgery, Center for Children's Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Steven L Moulton
- Division of Pediatric Surgery, Children's Hospital Colorado, Aurora, CO, USA; Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| |
Collapse
|
22
|
Cresting Mortality: Defining a Plateau in Ongoing Massive Transfusion. J Trauma Acute Care Surg 2022; 93:43-51. [PMID: 35393379 DOI: 10.1097/ta.0000000000003641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Blood-based balanced resuscitation is a standard of care in massively bleeding trauma patients. No data exists as to when this therapy no longer significantly affects mortality. We sought to determine if there is a threshold beyond which further massive transfusion will not affect in-hospital mortality. METHODS The Trauma Quality Improvement database was queried for all adult patients registered between 2013 and 2017 who received at least one unit of blood (PRBC) within 4 hours of arrival. In-hospital mortality was evaluated based on the total transfusion volume (TTV) at 4 and 24 hours in the overall cohort (OC) and in a balanced transfusion cohort (BC), composed of patients who received transfusion at a ratio of 1:1-2:1 PRBC-to-plasma. A bootstrapping method in combination with multivariable Poisson regression (MVR) was used to find a cutoff after which additional transfusion no longer affected in-hospital mortality. MVR was used to control for age, sex, race, highest abbreviated injury score in each body region, comorbidities, advanced directives limiting care, and the primary surgery performed for hemorrhage control. RESULTS The OC consisted of 99,042 patients of which 28,891 and 30,768 received a balanced transfusion during the first 4 and 24 hours, respectively. The mortality rate plateaued after a TTV of 40.5 units (95% CI, 40-41) in the OC at 4 hours and after a TTV of 52.8 units (95% CI, 52-53) at 24 hours following admission. In the BC, mortality plateaued at a TTV of 39 units (95% CI, 39-39) and 53 units (95% CI, 53-53) at 4- and 24-hours following admission, respectively. CONCLUSION Transfusion thresholds exist beyond which ongoing transfusion is not associated with any clinically significant change in mortality. These TTVs can be used as markers for resuscitation timeouts in order to assess the plan of care moving forward. LEVEL OF EVIDENCE Level V, prognostic and epidemiological.
Collapse
|
23
|
Saillant NN, Kornblith LZ, Moore H, Barrett C, Schreiber MA, Cotton BA, Neal MD, Makar R, Cap AP. The National Blood Shortage-An Impetus for Change. Ann Surg 2022; 275:641-643. [PMID: 35081570 PMCID: PMC9055632 DOI: 10.1097/sla.0000000000005393] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Affiliation(s)
| | - Lucy Z. Kornblith
- Zuckerberg San Francisco General Hospital, University of California San Francisco, San Francisco, CA
| | - Hunter Moore
- University of Colorado Hospital, University of Colorado School of Medicine, Aurora, CO
| | | | - Martin A. Schreiber
- Oregon Health and Science University Hospital, OHSU School of Medicine, Portland, OR
| | - Bryan A. Cotton
- University of Texas Health and Science Center at Houston, McGovern Medical School, Houston, TX
| | - Matthew D. Neal
- Trauma and Transfusion Medicine Research Center, Department of Surgery, University of Pittsburgh, Pittsburgh, PA
| | - Robert Makar
- Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Andrew P. Cap
- U.S. Army Institute of Surgical Research, Uniformed Services University, University of Texas Health Science Centers – San Antonio & Houston, TX
| |
Collapse
|
24
|
Muldowney M, Aichholz P, Nathwani R, Stansbury LG, Hess JR, Vavilala MS. Advances in hemorrhage control resuscitation. Curr Opin Anaesthesiol 2022; 35:176-181. [PMID: 35081057 DOI: 10.1097/aco.0000000000001093] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Despite significant advances in trauma management over the last twenty years, uncontrolled hemorrhage remains the leading cause of preventable death in trauma. We review recent changes affecting hemorrhage control resuscitation. RECENT FINDINGS Early blood product usage has become well established as a standard of care in trauma hemorrhage control. To enable this, low titer group A liquid plasma and group O whole blood are increasingly utilized. Single donor apheresis platelets have now replaced pooled donor platelets in the USA and are often pathogen reduced, which has implications for trauma resuscitation. Further work is examining timing and dosing of tranexamic acid and the debate in factor concentrate usage in trauma induced coagulopathy continues to evolve. The 'Stop the bleed' campaign has highlighted how important the use of hemostatic dressings are in hemorrhage control, as too is the expanded use of endovascular aortic occlusion. We highlight the ongoing research into desmopressin use and the undetermined significance of ionized calcium levels in trauma. Finally, we discuss our own hospital experience with coagulation testing and the paucity of evidence of improved outcomes with viscoelastic testing. SUMMARY Improving trauma coagulopathy diagnostics and hemorrhage control are vital if we are to decrease the mortality associated with trauma.
Collapse
Affiliation(s)
- Maeve Muldowney
- Department of Anesthesiology and Pain Medicine, Harborview Medical Center
| | - Pudkrong Aichholz
- Department of Anesthesiology and Pain Medicine, Harborview Medical Center
| | - Rajen Nathwani
- Department of Anesthesiology and Pain Medicine, Harborview Medical Center
| | | | - John R Hess
- Department of Laboratory Medicine and Pathology, Harborview Medical Center, Seattle, Washington, USA
| | - Monica S Vavilala
- Department of Anesthesiology and Pain Medicine, Harborview Medical Center
- Harborview Injury Prevention and Research Center
| |
Collapse
|
25
|
Murphy C, Silva de Leonardi N. Better than 'normal': Describing the distribution of and outliers in RBC usage. Transfusion 2022; 62:817-825. [PMID: 35170040 DOI: 10.1111/trf.16831] [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: 09/17/2021] [Revised: 01/26/2022] [Accepted: 01/28/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND/CASE STUDIES Optimizing a hospital blood inventory requires understanding the distribution of blood usage at the institution. Standard methods for describing red blood cell (RBC) usage like mean and standard deviation assume a normal distribution. Other distributions may fit the distribution of daily RBC usage better and provide more accurate insights into blood usage and in6ventory management. STUDY DESIGN/METHODS RBC usage data from 2014 through 2020 were queried from the laboratory information system. Theoretical distributions were fit against this empirical distribution of daily RBC usage. Goodness-of-fit was assessed visually using Pearson/Cullen and Frey plots as well as quantitatively using Kolomogorov-Smirnov (K-S) distance and the Akaike Information Criterion (AIC). RESULTS/FINDINGS 241,957 units of RBCs were transfused over 2557 days in the study period. The log-normal and gamma distributions had superior K-S distances and AICs for daily RBC usage. The top percentile of days for RBC usage was significantly more likely to have at least one ultramassively transfused patient (p < .001, Fisher's Exact Test). CONCLUSIONS The log-normal and gamma distributions better describe the right-skewed and entirely positive empirical distribution of daily RBC usage as compared to the normal distribution. This should broadly inform inventory management efforts and future descriptions of RBC usage at the institutional level.
Collapse
Affiliation(s)
- Colin Murphy
- Department of Pathology, University of Maryland School of Medicine, Baltimore, United States
| | | |
Collapse
|
26
|
Reppucci ML, Pickett K, Stevens J, Phillips R, Recicar J, Annen K, Moulton SL. Massive transfusion in pediatric trauma-does more blood predict mortality? J Pediatr Surg 2022; 57:308-313. [PMID: 34736771 DOI: 10.1016/j.jpedsurg.2021.09.051] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Accepted: 09/27/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Treatment of severe hemorrhage focuses on the control of bleeding and intravascular volume expansion through massive transfusion (MT). This study aimed to determine if transfusion volumes in pediatric trauma patients who receive MT is associated with increased risk of death, and to establish if there is a threshold above which further resuscitation with blood products is futile. METHODS Pediatric patients (2-18 years old) in the 2014-2017 Trauma Quality Improvement Program (TQIP) database with complete age and blood transfusion data who met the MT definition of 40 mL/kg/24 h were included in analysis. Data elements were cleaned to eliminate discrepancies in reporting blood volumes and erroneous values were excluded. Early mortality was defined as death within 24 h. Late mortality was defined as death more than 24 h after hospital admission. Area under the curve (AUC) was calculated from receiver operating characteristic (ROC) curve analyses to determine upper volume thresholds to predict early versus late mortality. RESULTS There were 633 patients who met the MT definition of 40 mL/kg/24 h. The overall mortality rate was 21.6%. Volume of blood had poor predicting early and late mortality with an AUC of 0.50 [95% CI (0.42, 0.59)] and 0.50 [95% CI (0.43,0.57)], respectively. Regardless of mechanism, no transfusion volume was associated with a predictably high rate of mortality. CONCLUSIONS There is no upper transfusion volume threshold to predict mortality in pediatric trauma patients who are massively transfused, regardless of mechanism. Severely injured children can tolerate massive amounts of blood products and still survive. LEVEL OF EVIDENCE III.
Collapse
Affiliation(s)
- Marina L Reppucci
- Division of Pediatric Surgery, Children's Hospital Colorado, 13123 E 16th Ave, Box 323, Anschutz Medical Campus, Aurora, CO 80045, USA; Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA.
| | - Kaci Pickett
- The Center for Research in Outcomes for Children's Surgery, Center for Children's Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Jenny Stevens
- Division of Pediatric Surgery, Children's Hospital Colorado, 13123 E 16th Ave, Box 323, Anschutz Medical Campus, Aurora, CO 80045, USA; Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Ryan Phillips
- Division of Pediatric Surgery, Children's Hospital Colorado, 13123 E 16th Ave, Box 323, Anschutz Medical Campus, Aurora, CO 80045, USA
| | - John Recicar
- Division of Pediatric Surgery, Children's Hospital Colorado, 13123 E 16th Ave, Box 323, Anschutz Medical Campus, Aurora, CO 80045, USA; Division of Nursing, Children's Hospital Colorado, Aurora, CO, USA
| | - Kyle Annen
- Department of Pathology, Children's Hospital of Colorado, Aurora, CO, USA
| | - Steven L Moulton
- Division of Pediatric Surgery, Children's Hospital Colorado, 13123 E 16th Ave, Box 323, Anschutz Medical Campus, Aurora, CO 80045, USA; Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| |
Collapse
|