A Derivation and Validation Study of an Early Blood Transfusion Needs Score for Severe Trauma Patients

Trauma-induced disturbances in ionized calcium levels correlate parabolically with coagulopathy, transfusion, and mortality: a multicentre cohort analysis from the TraumaRegister DGU®

BACKGROUND

To which extent trauma- induced disturbances in ionized calcium (iCa2+) levels have a linear relationship with adverse outcomes remains controversial. The goal of this study was to determine the association between the distribution and accompanying characteristics of transfusion-independent iCa2+ levels versus outcome in a large cohort of major trauma patients upon arrival at the emergency department.

METHODS

A retrospective observational analysis of the TraumaRegister DGU® (2015-2019) was performed. Adult major trauma patients with direct admission to a European trauma centre were selected as the study cohort. Mortality at 6 h and 24 h, in-hospital mortality, coagulopathy, and need for transfusion were considered as relevant outcome parameters. The distribution of iCa2+ levels upon arrival at the emergency department was calculated in relation to these outcome parameters. Multivariable logistic regression analysis was performed to determine independent associations.

RESULTS

In the TraumaRegister DGU® 30 183 adult major trauma patients were found eligible for inclusion. iCa2+ disturbances affected 16.4% of patients, with hypocalcemia (< 1.10 mmol/l) being more frequent (13.2%) compared to hypercalcemia (≥ 1.30 mmol/l, 3.2%). Patients with hypo- and hypercalcemia were both more likely (P < .001) to have severe injury, shock, acidosis, coagulopathy, transfusion requirement, and haemorrhage as cause of death. Moreover, both groups had significant lower survival rates. All these findings were most distinct in hypercalcemic patients. When adjusting for potential confounders, mortality at 6 h was independently associated with iCa2+ < 0.90 mmol/L (OR 2.69, 95% CI 1.67-4.34; P < .001), iCa2+ 1.30-1.39 mmol/L (OR 1.56, 95% CI 1.04-2.32, P = 0.030), and iCa2+  ≥ 1.40 mmol/L (OR 2.87, 95% CI 1.57-5.26; P < .001). Moreover, an independent relationship was determined for iCa2+ 1.00-1.09 mmol/L with mortality at 24 h (OR 1.25, 95% CI 1.05-1.48; P = .0011), and with in-hospital mortality (OR 1.29, 95% CI 1.13-1.47; P < .001). Both hypocalcemia < 1.10 mmol/L and hypercalcemia ≥ 1.30 mmol/L had an independent association with coagulopathy and transfusion.

CONCLUSIONS

Transfusion-independent iCa2+ levels in major trauma patients upon arrival at the emergency department have a parabolic relationship with coagulopathy, need for transfusion, and mortality. Further research is needed to confirm whether iCa2+ levels change dynamically and are more a reflection of severity of injury and accompanying physiological derangements, rather than an individual parameter that needs to be corrected as such.

BUPNN: Manifold Learning Regularizer-Based Blood Usage Prediction Neural Network for Blood Centers

Blood centers are an essential component of the healthcare system, as timely blood collection, processing, and efficient blood dispatch are critical to the treatment of patients and the performance of the entire healthcare system. At the same time, an efficient blood dispatching system through the high-precision predictive capability of artificial intelligence is crucial for the efficiency improvement of the blood centers. However, the current artificial intelligence (AI) models for predicting blood usage do not meet the needs of blood centers. The challenges of AI models mainly include lower generalization ability in different hospitals, limited stability under missing values, and low interpretability. An artificial neural network-based model named the blood usage prediction neural network (BUPNN) has been developed to address these challenges. BUPNN includes a novel similarity-based manifold regularizer that aims to enhance network mapping consistency and, thus, overcome the domain bise of different hospitals. Moreover, BUPNN diminishes the performance degradation caused by missing values through data enhancement. Experimental results on a large amount of accurate data demonstrate that BUPNN outperforms the baseline method in classification and regression tasks and excels in generalization and consistency. Moreover, BUPNN has solid potential to be interpreted. Therefore, the decision-making process of BUPNN is explored to the extent that it acts as an aid to the experts in the blood center.

Massive transfusion prediction in patients with multiple trauma by decision tree: a retrospective analysis

Early initial massive transfusion protocol and blood transfusion can reduce patient mortality, however accurately identifying the risk of massive transfusion (MT) remains a major challenge in severe trauma patient therapy. We retrospectively analyzed clinical data of severe trauma patients with and without MT. Based on analysis results, we established a MT prediction model of clinical and laboratory data by using the decision tree algorithm in patients with multiple trauma. Our results demonstrate that shock index, injury severity score, international normalized ratio, and pelvis fracture were the most significant risk factors of MT. These four indexes were incorporated into the prediction model, and the model was validated by using the testing dataset. Moreover, the sensitivity, specificity, accuracy and area under curve values of prediction model for MT risk prediction were 60%, 92%, 90% and 0.85. Our study provides an easy and understandable classification rules for identifying risk factors associated with MT that may be useful for promoting trauma management.

Pre-hospital blood transfusion - an ESA survey of European practice

Background

Blood products are a lifesaving commodity in the treatment of major trauma.

Although there is little evidence for use of pre-hospital blood products (PHBP) in seriously injured patients, an increasing number of emergency medical services have started using PHBP for treatment of major haemorrhage.

The primary aim of this survey was to establish the degree of prehospital blood product use throughout Europe and discover main indications. The secondary aim was to evaluate opinions about PHBP and also the experience and the personal views of its users.

Methods

The subcommittee for Critical Emergency Medicine of the European Society of Anaesthesiology (ESA) held an online survey of European Helicopter Emergency Services (HEMS) and all French Services d’Aide Médicale Urgente (SAMU) regions. It contained 13 questions both open and multiple-choice about the frequency transfusions are carried out, the PHBP used and the perceived benefit. The survey was distributed to the corresponding HEMS leads in 14 European countries.

Results

In total there were 172 valid responses; overall 48% of all respondents have prehospital access to packed red cells, 22% to fresh plasma and 14% use lyophilised plasma. Besides blood product administration, 94% of all services use tranexamic acid. Sixty five percent of all replies came from French and from German services (37 and 28% respectively). PHBP were mainly used for trauma related emergencies. France has the highest uptake of use of blood products at 89%, whereas the rate in Germany was far lower at 6%.

Fifty five percent of the service leads felt that PHBP are beneficial, and even lifesaving in individual cases despite being needed infrequently.

Conclusions

We found remarkable dissimilarities in practice between the different European countries. Even if there is not an absolute consensus amongst providers on the benefit of PHBP, the majority feel they are beneficial. The difference in practice is possibly related to the perceived lack of evidence on prehospital blood transfusion. We suggest to include the use of PHBP in trauma registries in order to consolidate the existing evidence.

G, Guillaume M, Husson E, Donneau AF, Poplavsky JL, Minon JM, Ghuysen A. Impact of a prehospital discrimination between trauma patients with or without early acute coagulopathy of trauma and the need for damage control resuscitation: rationale and design of a multicenter randomized phase II trial

BACKGROUND

The evidence of the Trauma Induced Coagulopathy Clinical Score (TICCS) accuracy has been evaluated in several studies but the potential effect of its use on patient outcomes needs to be evaluated. The primary objective of this study is to evaluate the impact on mortality of a prehospital discrimination between trauma patients with or without a potential need for damage control resuscitation.

METHODS

The trial will be designed as randomized phase II clinical trial with comparison of the experimental protocol against the standard of care. The TICCS will be calculated on the site of injury for the patients of the intervention group and treatment will be guided by the TICCS value. Seven days mortality, 30 days mortality, global use of blood products and global hospital length-of-stay will be compared.

DISCUSSION

Many data suggest that a very early flagging of trauma patients in need for DCR would be beneficial but this need to be proved. Do we improve our quality of care by an earlier diagnosis? Does a prehospital discrimination between trauma patients with or without a potential need for DCR has a positive impact?

Prehospital Blood Product Transfusion in Mountain Rescue Operations

Severely injured patients with hemorrhage present major challenges for emergency medical services, especially during mountain rescue missions in which harsh environmental conditions and long out-of-hospital times are frequent. Because uncontrolled hemorrhage is the leading cause of death within the first 48 hours after severe trauma, initiating damage control resuscitation (DCR) as early as possible after severe trauma and exporting the concept of DCR to the out-of-hospital arena is pivotal for patient survival. Appropriate bleeding control, management of coagulopathy, and transfusion of blood products are core aspects of DCR. This review summarizes the available evidence on out-of-hospital blood product transfusion and the management of coagulopathy with a special focus on mountain rescue missions. An overview of upcoming trials and possible future trends in the management of coagulopathy during rescue operations is provided.

[Approaches to pre-hospital bleeding management : Current overview on civilian emergency medicine]

Severe bleeding is a typical result of traumatic injuries. Hemorrhage is responsible for almost 50% of deaths within the first 6 h after trauma. Appropriate bleeding control and coagulation therapy depends on an integrated concept of local hemostasis by primary pressure with the hands, compression, and tourniquets accompanied by prevention of hypothermia, acidosis and hypocalcemia. Additionally, permissive hypotension is accepted for suitable patients and tranexamic acid should be administered early. Multiple publications prove that prehospital transfusion of blood products (e. g. red blood cells and plasma) and coagulation factors (e. g. fibrinogen) is feasible and safe, but only required for <5% of polytrauma patients in the civilian setting.