Massive transfusion in critical haemorrhage following trauma: Aren't we missing something?

Abstract

We read with interest the recent review by Olaussen et al., presenting 36 models for prediction of critical haemorrhage following trauma. The authors present the different models, their respective variables and their performance. They also discuss the utility of the individual variables. As mentioned in the publication, early diagnosis of haemorrhagic shock is a key step in improving outcomes after severe trauma. Critical bleedings indeed require aggressive treatments and need them to be applied as early as possible. Moreover, any unilateral approach would cause harm as critical bleedings require integrative care associating a mechanical (surgical or endovascular) strategy to stop the bleeding with adequate haemostatic resuscitation. Damage control resuscitation (DCR) associates damage control surgery (DCS), massive transfusion (MT) with the optimal 1/1/1 ratio of blood products, permissive hypotension and careful attention for identification and correction of the early acute coagulopathy of trauma (EACT). Adequate and early selection of trauma patients in need for DCR is pivotal to prevent wasting time as well as unnecessary activation of the technical and human resources needed for DCR. The presented models all have been developed by retrospective identification of individual parameters independently associated with MT. Massive transfusion is commonly defined as the transfusion of more than 10 units of red blood cells (RBC) within the first 24 hours of care. This definition is problematic since it excludes trauma patients presenting to hospital with active bleeding and a need for an emergent surgical control of the bleeding. Thanks to a highly effective DCR, some of those patients do not need a large number of RBC transfusions. Moreover, severe blunt trauma patients can suffer from an EACT and are in need of a specific haemostatic resuscitation (associating treatments such as tranexamic acid, plasma, platelets or fibrinogen concentrate) and not necessarily in need of massive RBC transfusion. Defining critical haemorrhage with MT therefore does not properly consider the other crucial components of DCR (DCS and correction of EACT) which are as important as RBC transfusion. Shouldn’t we both in the clinical setting and in clinical research change our perspective, going from a massive transfusion approach to a critical haemorrhage approach? Other scoring systems have been developed with a different endpoint. The coagulopathy of severe trauma (COAST) score, developed by the same team of the present review, aims to identify trauma patients suffering from EACT. The trauma induced coagulopathy clinical score (TICCS) aims to identify trauma patients associating EACT, the need for blood products transfusion and the need for emergent surgery. There is no doubt that the presented models are all very useful in clinical practice as they bring an objective tool for prediction of critical haemorrhage. We would like to know the authors’ opinion about choosingMT as the focused outcome variable and if it is the answer to critical haemorrhage after trauma.