Changes in transfusion practice in multiple injury between 1993 and 2006: a retrospective analysis on 5389 patients from the German Trauma Registry

Changes in transfusion and fluid therapy practices in severely injured children: an analysis of 5118 children from the TraumaRegister DGU®

Purpose

Trauma is the leading cause of death in children. In adults, blood transfusion and fluid resuscitation protocols changed resulting in a decrease of morbidity and mortality over the past 2 decades. Here, transfusion and fluid resuscitation practices were analysed in severe injured children in Germany.

Methods

Severely injured children (maximum Abbreviated Injury Scale (AIS) ≥ 3) admitted to a certified trauma-centre (TraumaZentrum DGU®) between 2002 and 2017 and registered at the TraumaRegister DGU® were included and assessed regarding blood transfusion rates and fluid therapy.

Results

5,118 children (aged 1–15 years) with a mean ISS 22 were analysed. Blood transfusion rates administered until ICU admission decreased from 18% (2002–2005) to 7% (2014–2017). Children who are transfused are increasingly seriously injured. ISS has increased for transfused children aged 1–15 years (2002–2005: mean 27.7–34.4 in 2014–2017). ISS in non-transfused children has decreased in children aged 1–15 years (2002–2005: mean 19.6 to mean 17.6 in 2014–2017). Mean prehospital fluid administration decreased from 980 to 549 ml without affecting hemodynamic instability.

Conclusion

Blood transfusion rates and amount of fluid resuscitation decreased in severe injured children over a 16-year period in Germany. Restrictive blood transfusion and fluid management has become common practice in severe injured children. A prehospital restrictive fluid management strategy in severely injured children is not associated with a worsened hemodynamic state, abnormal coagulation or base excess but leads to higher hemoglobin levels.

Pre-hospital transfusion of red blood cells. Part 1: A scoping review of current practice and transfusion triggers

OBJECTIVES

The primary aim of this scoping review is to describe the current use of pre-hospital transfusion of red blood cells (PHTRBC) and to evaluate criteria used to initiate PHTRBC. The effects on patients' outcomes will be reviewed in Part 2.

BACKGROUND

Haemorrhage is a preventable cause of death in trauma patients, and transfusion of red blood cells is increasingly used by Emergency Medical Services (EMS) for damage control resuscitation. However, there are no guidelines and little consensus on when to initiate PHTRBC.

METHODS

PubMed and Web of Science were searched through January 2019; 71 articles were included.

RESULTS

Transfusion triggers vary widely and involve vital signs, clinical signs of poor tissue perfusion, point of care measurements and pre-hospital ultrasound imaging. In particular, hypotension (most often defined as systolic blood pressure ≤ 90 mmHg), tachycardia (most often defined as heart rate ≥ 120/min), clinical signs of poor perfusion (eg, prolonged capillary refill time or changes in mental status) and injury type (ie, penetrating wounds) are common pre-hospital transfusion triggers.

CONCLUSIONS

PHTRBC is increasingly used by Emergency Medical Services, but guidelines on when to initiate transfusion are lacking. We identified the most commonly used transfusion criteria, and these findings may provide the basis for consensus-based pre-hospital transfusion protocols.

Clinical predictors of early acute respiratory distress syndrome in trauma patients

BACKGROUND

The objectives of this study were to examine the incidence and severity of early acute respiratory distress syndrome (ARDS) according to the Berlin Definition and to identify risk factors associated with the development of early post-traumatic ARDS.

METHODS

A 2.5-year retrospective database of adult trauma patients who required mechanical ventilation for greater than 48 hours at a level 1 trauma center was analyzed for variables predictive of early (<48 hours after injury), mild, moderate, and severe ARDS and in-hospital mortality.

RESULTS

Of 305 patients, 59 (19.3%) developed early ARDS: mild, 27 (45.8%); moderate, 26 (44.1%); and severe, 6 (10.1%). Performance of an emergent thoracotomy, blunt mechanism, and fresh frozen plasma administration were independently associated with the development of early ARDS. ARDS was not predictive of mortality.

CONCLUSIONS

Trauma patients with blunt mechanism, who receive fresh frozen plasma, or undergo thoracotomy, are at risk of developing early ARDS.

Management of postpartum haemorrhage

Postpartum Haemorrhage (PPH) is a major cause of maternal morbidity and mortality. Treatment of acquired coagulopathy observed in severe PPH is an important part of PPH management, but is mainly based on literature in trauma patients, and data thus should be interpreted with caution. This review describes recent advances in transfusion strategy and in the use of tranexamic acid and fibrinogen concentrates in women with PPH.

Validation of the revised injury severity classification score in patients with moderate-to-severe traumatic brain injury

INTRODUCTION

By analysing risk-adjusted mortality ratios, weaknesses in the process of care might be identified. Traumatic brain injury (TBI) is the main cause of death in trauma, and thus it is crucial that trauma prediction models are valid for TBI patients. Accordingly, we assessed the validity of the RISC score in TBI patients by internal and external validation analyses.

METHODS

Patients with moderate-to-severe TBI admitted to the TraumaRegister DGU® (TR-DGU) and the trauma registry of Helsinki University Hospital (TR-THEL) in 2006-2011 were included in this retrospective open cohort study. Definition of moderate-to-severe TBI was head abbreviated injury scale of 3 or higher. Subgroup analysis for patients with isolated and polytrauma TBI was performed. The performance of the RISC score was evaluated by assessing its discrimination (area under the curve, AUC) and calibration (Hosmer-Lemeshow [H-L] test).

RESULTS

Among the 9106 and 809 patients with moderate-to-severe TBI admitted to TR-DGU and TR-THEL, unadjusted mortality was 26% and 23%, respectively. Internal and external validation of the RISC score showed good discrimination (TR-DGU AUC 0.89, 95% confidence interval [CI] 0.88-0.90 and TR-THEL AUC 0.84, 95% CI 0.81-0.87), but poor calibration (p<0.001) in patients with moderate-to-severe TBI. Subgroup analysis found the discrimination only to be modest in isolated TBI (AUC 0.76) and calibration to be particularly poor in polytrauma TBI (TR-DGU H-L=4356, p<0.001; TR-THEL H-L 112, p<0.001).

CONCLUSION

The RISC score was found to be of limited predictive value in patients with moderate-to-severe TBI. A new general trauma scoring system that includes TBI specific prognostic factors is warranted.

Risks associated with red blood cell transfusion in the trauma population, a meta-analysis

INTRODUCTION

A previous meta-analysis has found an association between red blood cell (RBC) transfusions and mortality in critically ill patients, but no review has focused on the trauma population only.

OBJECTIVES

To determine the association between RBC transfusion and mortality in the trauma population, with secondary outcomes of multiorgan failure (MOF) and acute respiratory distress syndrome (ARDS) or acute lung injury (ALI).

DATA SOURCES

EMBASE (1947-2012) and MEDLINE (1946-2012).

STUDY ELIGIBILITY CRITERIA

Randomized controlled trials and observational studies were to be included if they assessed the association between RBC transfusion and either the primary (mortality) or secondary outcomes (MOF, ARDS/ALI).

PARTICIPANTS

Trauma patients.

EXPOSURE

Red blood cell transfusion.

METHODS

A literature search was completed and reviewed in duplicate to identify eligible studies. Studies were included in the pooled analyses if an attempt was made to determine the association between RBC and the outcomes, after adjusting for important confounders. A random effects model was used for and heterogeneity was quantified using the I(2) statistic. Study quality was assessed using the Newcastle-Ottawa Scale.

RESULTS

40 observational studies were included in the qualitative review. Including studies which adjusted for important confounders found the odds of mortality increased with each additional unit of RBC transfused (9 Studies, OR 1.07, 95%CI 1.04-1.10, I(2) 82.9%). The odds of MOF (3 studies, OR 1.08, 95%CI 1.02-1.14, I(2) 95.9%) and ARDS/ALI (2 studies, OR 1.06, 95%CI 1.03-1.10, I(2) 0%) also increased with each additional RBC unit transfused.

CONCLUSIONS

We have found an association between RBC transfusion and the primary and secondary outcomes, based on observational studies only. This represents the extent of the published literature. Further interventional studies are needed to clarify how limiting transfusion can affect mortality and other outcomes.

Risk stratification in trauma and haemorrhagic shock: scoring systems derived from the TraumaRegister DGU(®)

Scoring systems commonly attempt to reduce complex clinical situations into one-dimensional values by objectively valuing and combining a variety of clinical aspects. The aim is to allow for a comparison of selected patients or cohorts. To appreciate the true value of scoring systems in patients with multiple injuries it is necessary to understand the different purposes of quantifying the severity of specific injuries and overall trauma load, being: (1) clinical decision making; (2) triage; (3) planning of trauma systems and resources; (4) epidemiological and clinical research; (5) evaluation of outcome and trauma systems, including quality assessment; and (6) estimation of costs and allocation of resources. For the first two, easy-to estimate scores with immediate availability are necessary, mainly based on initial physiology. More sophisticated scores considering age, gender, injury pattern/severity and more are usually used for research and outcome evaluation, once the diagnostic and therapeutic process has been completed. For score development large numbers of data are necessary and thus, it appears as a logical consequence that large registries as the TraumaRegister DGU(®) of the German Trauma Society (TR-DGU) are used to derive and validate clinical scoring systems. A variety of scoring systems have been derived from this registry, the majority of them with focus on hospital mortality. The most important among these systems is probably the RISC score, which is currently used for quality assessment and outcome adjustment in the annual audit reports. This report summarizes the various scoring systems derived from the TraumaRegister DGU(®) over the recent years.

Glasgow Coma Scale as a predictor for hemocoagulative disorders after blunt pediatric traumatic brain injury

OBJECTIVE

Coagulopathy is a complication of traumatic brain injury and its presence after injury has been identified as a risk factor for prognosis. It was our aim to determine whether neurologic findings reflected by Glasgow Coma Scale at initial resuscitation can predict hemocoagulative disorders resulting from traumatic brain injury that may aggravate clinical sequelae and outcome in children.

DESIGN

A retrospective analysis of 200 datasets from children with blunt, isolated traumatic brain injury documented in the Trauma Registry of the Deutsche Gesellschaft für Unfallchirurgie was conducted. Inclusion criteria were primary admission, age <14 yrs, and sustained isolated blunt traumatic brain injury.

SETTING

Trauma Registry of the Deutsche Gesellschaft für Unfallchirurgie-affiliated trauma centers in Germany.

PATIENTS

: Two hundred datasets of children (age <14 yrs) with blunt isolated traumatic brain injury were analyzed: children were subdivided into two groups according to Glasgow Coma Scale at the scene (Glasgow Coma Scale ≤ 8 vs. Glasgow Coma Scale >8) and reviewed for coagulation abnormalities upon emergency room admission and outcome.

MEASUREMENT AND MAIN RESULTS

Fifty-one percent (n = 102 of 200) of children had Glasgow Coma Scale >8 and 49% (n = 98 of 200) had Glasgow Coma Scale ≤ 8 at the scene. The incidence of coagulopathy at admission was higher in children with Glasgow Coma Scale ≤ 8 compared to children with Glasgow Coma Scale >8: 44% (n = 31 of 71) vs. 14% (n = 11 of 79) (p < .001). Multivariate logistic regression revealed that Glasgow Coma Scale ≤ 8 at scene was associated with coagulopathy at admission (odds ratio 3.378, p = .009) and stepwise regression identified Glasgow Coma Scale ≤ 8 as an independent risk factor for coagulopathy. Mortality in children with Glasgow Coma Scale ≤ 8 at scene was substantially higher with the presence of coagulation abnormalities at admission compared to children in which coagulopathy was absent (51.6%, n = 16 of 31 vs. 5% n = 2 of 40).

CONCLUSIONS

Glasgow Coma Scale ≤ 8 at scene in children with isolated traumatic brain injury is associated with increased risk for coagulopathy and mortality. These results may guide laboratory testing, management, and blood bank resources in acute pediatric trauma care.

Epidemiology and risk factors of sepsis after multiple trauma: an analysis of 29,829 patients from the Trauma Registry of the German Society for Trauma Surgery

OBJECTIVES

The objectives of this study were 1) to assess potential changes in the incidence and outcome of sepsis after multiple trauma in Germany between 1993 and 2008 and 2) to evaluate independent risk factors for posttraumatic sepsis.

DESIGN

Retrospective analysis of a nationwide, population-based prospective database, the Trauma Registry of the German Society for Trauma Surgery.

SETTING

A total of 166 voluntarily participating trauma centers (levels I-III).

PATIENTS

Patients registered in the Trauma Registry of the German Society for Trauma Surgery between 1993 and 2008 with complete data sets who presented with a relevant trauma load (Injury Severity Score of ≥ 9) and were admitted to an intensive care unit (n = 29,829).

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Over the 16-yr study period, 10.2% (3,042 of 29,829) of multiply injured patients developed sepsis during their hospital course. Annual data were summarized into four subperiods: 1993-1996, 1997-2000, 2001-2004, and 2005-2008. The incidences of sepsis for the four subperiods were 14.8%, 12.5%, 9.4%, and 9.7% (p < .0001), respectively. In-hospital mortality for all trauma patients decreased for the respective subperiods (16.9%, 16.0%, 13.7%, and 11.9%; p < .0001). For the subgroup of patients with sepsis, the mortality rates were 16.2%, 21.5%, 22.0%, and 18.2% (p = .054), respectively. The following independent risk factors for posttraumatic sepsis were calculated from a multivariate logistic regression analysis: male gender, age, preexisting medical condition, Glasgow Coma Scale score of ≤ 8 at scene, Injury Severity Score, Abbreviated Injury ScaleTHORAX score of ≥ 3, number of injuries, number of red blood cell units transfused, number of operative procedures, and laparotomy.

CONCLUSIONS

The incidence of sepsis decreased significantly over the study period; however, in this decade the incidence remained unchanged. Although overall mortality from multiple trauma has declined significantly since 1993, there has been no significant decrease of mortality in the subgroup of septic trauma patients. Thus, sepsis has remained a challenging complication after trauma during the past 2 decades. Recognition of the identified risk factors may guide early diagnostic workup and help to reduce septic complications after multiple trauma.

Reappraising the concept of massive transfusion in trauma

INTRODUCTION

The massive-transfusion concept was introduced to recognize the dilutional complications resulting from large volumes of packed red blood cells (PRBCs). Definitions of massive transfusion vary and lack supporting clinical evidence. Damage-control resuscitation regimens of modern trauma care are targeted to the early correction of acute traumatic coagulopathy. The aim of this study was to identify a clinically relevant definition of trauma massive transfusion based on clinical outcomes. We also examined whether the concept was useful in that early prediction of massive transfusion requirements could allow early activation of blood bank protocols.

METHODS

Datasets on trauma admissions over a 1 or 2-year period were obtained from the trauma registries of five large trauma research networks. A fractional polynomial was used to model the transfusion-associated probability of death. A logistic regression model for the prediction of massive transfusion, defined as 10 or more units of red cell transfusions, was developed.

RESULTS

In total, 5,693 patient records were available for analysis. Mortality increased as transfusion requirements increased, but the model indicated no threshold effect. Mortality was 9% in patients who received none to five PRBC units, 22% in patients receiving six to nine PRBC units, and 42% in patients receiving 10 or more units. A logistic model for prediction of massive transfusion was developed and validated at multiple sites but achieved only moderate performance. The area under the receiver operating characteristic curve was 0.81, with specificity of only 50% at a sensitivity of 90% for the prediction of 10 or more PRBC units. Performance varied widely at different trauma centers, with specificity varying from 48% to 91%.

CONCLUSIONS

No threshold for definition exists at which a massive transfusion specifically results in worse outcomes. Even with a large sample size across multiple trauma datasets, it was not possible to develop a transportable and clinically useful prediction model based on available admission parameters. Massive transfusion as a concept in trauma has limited utility, and emphasis should be placed on identifying patients with massive hemorrhage and acute traumatic coagulopathy.