Perioperative Blood Transfusion in Combat Casualties: A Pilot Study

Abstract

In recent studies, blood transfusion has been shown to increase the rate of wound healing disturbances in orthopedic patients. Furthermore, our group has determined a correlation between delayed wound healing and elevations in inflammatory mediators in combat casualties. Therefore, we sought to determine the effect of blood transfusion on wound healing and inflammatory mediator release in combat casualties. Prospective data were collected on 20 severely injured combat casualties sustaining extremity wounds. Patients were admitted to the National Naval Medical Center during a 13-month period from January 2007 to January 2008. Data variables included age, gender, Glasgow coma score (GCS), mechanism of injury, and transfusion history. Injury severity was assessed using the Injury Severity Score (ISS). Serum was collected initially and before each surgical wound debridement and analyzed using a panel of 21 cytokines and chemokines. The association between blood transfusion and wound healing, incidence of perioperative infection, intensive care unit (ICU) admission rate, and ICU and hospital length of stay was assessed. Differences were considered significant when p < 0.05. The study cohort had a mean age of 22 +/- 1, a mean ISS of 15.8 +/- 2.6, and a mean GCS 13.9 +/- 0.6; all were men and suffered penetrating injuries (90% improvised explosive device [IED] and 10% gunshot wound [GSW]). The cohort was divided into two groups. Patients receiving <or=4 units of blood initially (group 1, n = 11) were compared with patients who received >4 units of blood initially (group 2, n = 9). There was no significant difference in age, ISS, GCS, or mortality between the two groups. However, group 2 patients had significant impairment in wound healing rate (54% vs. 9%, p < 0.05), higher ICU admission rate (78% vs. 9%, p < 0.01), perioperative infection rate (89% vs. 27%, p < 0.01), and a longer hospital length of stay (49.9 +/- 12.8 vs. 23.8 +/- 2.9, p < 0.05) compared with group 1 patients. In addition, there was a significant correlation between the initial mean serum cytokine/chemokine level of interleukin (IL)-10, IL-8, interferon inducible protein (IP)-10, IL-6, and IL-12p40 and the number of units of blood transfused (p < 0.05). Allogeneic blood transfusions in combat casualties were associated with impaired wound healing, increased perioperative infection rate, and resource utilization. In addition, the extent of blood transfusion was associated with significant differences in inflammatory chemokine and cytokine release.