Predictors of Massive Transfusion in Patients With Hollow Organ Injury After Blunt Multiple Trauma: A Cohort of Blunt Bowel Mesenteric Injury.

Background Massive transfusion (MT) is life-saving for patients with exsanguination, especially after blunt abdominopelvic trauma, due to subtle manifestations. Blunt bowel mesenteric injuries (BBMI), besides their potential risk of peritonitis, are still one of the few indications for emergency laparotomy for hemorrhagic shock in the era of non-operative management. Early prediction of the necessity for MT is a critical point in resuscitation. Methods This retrospective study reviewed the data of hospitalized patients with trauma between 2009 and 2022, and included 163 adult patients with surgically proven BBMI. The patients were divided based on the presence or absence of MT before emergency laparotomy. Associated injury parameters and bowel mesenteric injury characteristics were used in multivariate regression analysis to identify independent predictors of MT. Results The MT (+) group included 30.6% of patients (n = 50). Compared to the MT (-) group, BBMI patients receiving MT had worse clinical injury severity, vital signs, and prognosis; received more units of blood products and more invasive treatments; had more isolated mesenteric injury or combined injury; and had both higher morbidity and mortality rates (94% vs. 55.8%, p < 0.001 and 32% vs. 4.4%, p < 0.001). In multivariate analysis, the presence of traumatic brain injury (TBI) (odds ratio [OR] = 6.7, 95% confidence intervals [CIs]: 1.66–27.02) and pelvic fracture (OR = 6.01, 95% CIs = 1.45–24.89) was identified as an independent predictor of MT after adjusting for confounding factors. Conclusions Almost half the patients with BBMI present with shock episodes, and one-third of them require MT before laparotomy, reflecting the critical status for their exsanguination. Patients with associated TBI and pelvic fracture injuries are at increased risk of MT and need to be prioritized for resuscitation.

Fibrinogen level on admission is a predictive marker of the need for massive blood transfusion after pelvic fracture

The definition of massive transfusion (MT) in civilian pediatric trauma patients is not established. In combat-injured pediatric patients, the definition of MT is based on the volume of total blood products transfused. The aim of this study is to define MT in civilian pediatric trauma patients based on a packed red blood cell (PRBC) volume threshold and compare its predictive power to a total blood products volume threshold. An analysis of the pediatric American College of Surgeons Trauma Quality Improvement Program database was performed (2014-2016) including pediatric trauma patients (4-18 years) who received blood products within 24 hours. Receiver operator characteristic curves for predicting mortality determined the optimal PRBC MT threshold. Area under receiver operating characteristic curve (AUROC) curve analysis was performed to compare the predictive power of a PRBC threshold to a total blood product threshold. A total of 1,495 patients were included. Sensitivity and specificity for 24-hour and in-hospital mortality were optimal at a PRBC threshold of 20 mL/kg. As compared with total blood products threshold, 20 mL/kg PRBCs volume achieved higher discriminatory power for predicting 24-hour (AUROC, 0.803 vs. 0.672; p < 0.001) and in-hospital mortality (AUROC, 0.815 vs. 0.686, p < 0.001). Patients who received an MT had higher Injury Severity Score (p < 0.001) and were more likely to receive mechanical ventilation (p < 0.001) and intensive care unit admission (p < 0.001). Overall 24-hour mortality (23.1% vs. 7.6%, p < 0.001) and in-hospital mortality (44.9% vs. 15.8%, p < 0.001) were higher in the MT group. On regression analysis, MT significantly predicted in-hospital mortality (odds ratio, 3.8 [2.9-4.9, 95% CI]) and 24-hour mortality (odds ratio, 3.3 [2.4-4.7, 95% CI]). The use of a PRBCs MT definition in civilian pediatric patients is a better predictor of mortality compared with total blood products threshold. These results provide a framework for MT protocol development. Prognostic study, level III.

Fibrinogen level on admission is a predictor for massive transfusion in patients with severe blunt trauma: Analyses of a retrospective multicentre observational study

Background: Liver transplantation (LT) is associated with a significant risk of intraoperative hemorrhage and massive blood transfusion. However, there are few relevant reports addressing the long-term impacts of massive transfusion (MT) on liver transplantation recipients.Aim: To assess the effects of MT on the short and long-term outcomes of adult liver transplantation recipients.Methods: We included adult patients who underwent liver transplantation at West China Hospital from January 2011 to February 2015. MT was defined as red blood cell (RBC) transfusion of ≥10 units within 48 hours since the application of LT. Preoperative, intraoperative and postoperative information were collected for data analyzing. We used one-to-one propensity-matching to create pairs. Kaplan-Meier survival analysis was used to compare long-term outcomes of LT recipients between the MT and non-MT groups. Univariate and multivariate logistic regression analyses were performed to evaluate the risk factors associated with MT in LT.Results: Finally, a total of 227 patients were included in our study. After propensity score matching, 59 patients were categorized into the MT and 59 patients in non-MT groups. Compared with the non-MT group, the MT group had a higher 30-day mortality (15.3% vs 0, p=0.006), and a higher incidence of postoperative complications, including postoperative pulmonary infection, abdominal hemorrhage, pleural effusion and severe acute kidney injury. Furthermore, MT group had prolonged postoperative ventilation support (42 vs 25 h, p=0.007) and prolonged durations of ICU (12.9 vs 9.5 d, p<0.001) stay. Multivariate COX regression indicated that massive transfusion (OR: 2.393, 95% CI: 1.164-4.923, p=0.018) and acute rejection (OR: 7.295, 95% CI: 2.108-25.246, p=0.02) were significant risk factors affecting long-term survivals of LT patients. The 1-year and 3-year survival rates patients in MT group were 82.5% and 67.3%, respectively, while those of non-MT group were 93.9% and 90.5%, respectively. The MT group exhibited a lower long-term survival rate than the non-MT group (HR: 2.393, 95% CI: 1.164-4.923, p<0.001). Finally, the multivariate logistic regression revealed that preoperative hemoglobin <118 g/L (OR: 5.062, 95% CI: 2.292-11.181, p<0.001) and intraoperative blood loss ≥1100 ml (OR: 3.212, 95% CI: 1.586-6.506, p = 0.001) were the independent risk factor of MT in patients undergoing LT.Conclusion: Patients receiving MT in perioperative periods of LT had worse short-term and long-term outcomes than the non-MT patients. Massive transfusion and acute rejection were significant risk factors affecting long-term survivals of LT patients, and intraoperative blood loss of over 1100 ml was the independent risk factor of MT in patients undergoing LT. The results may offer valuable information on perioperative management in LT recipients who experience high risk of MT.

ObjectiveSeveral scoring systems have been developed to identify patients who require massive transfusion (MT) after major trauma to improve survival. The primary goal of this study was to investigate the usefulness of enhanced computed tomography attenuation values (CTAVs) of major vessels to determine the need for MT in patients with major blunt trauma.MethodsThis single-center retrospective cohort study evaluated patients aged 16 years or older who underwent contrast-enhanced computed tomography scan of the torso after major blunt trauma. The CTAVs of six major vessel points in both the arterial and portal venous phases at initial computed tomography examination were assessed and compared between the MT and the no MT group. The capability of enhanced CTAVs to predict the necessity for MT was estimated based on the area under the receiver operating characteristic curve.ResultsOf the 254 eligible patients, 36 (14%) were in the MT group. Patients in the MT group had significantly higher CTAVs at all sites except the inferior vena cava in both the arterial and portal venous phases than that in the no MT group. The descending aorta in the arterial phase had the highest accuracy for predicting MT, with an AUROC of 0.901 (95% confidence interval, 0.855 to 0.947; P<0.001).ConclusionInitial elevation of enhanced CTAV of the aorta is a predictor for the need for MT. A higher CTAV of the aorta should alert the trauma surgeon or emergency physician to activate their MT protocol.

Combination of blood lactate level with assessment of blood consumption (ABC) scoring system: A more accurate predictor of massive transfusion requirement

Analysis of risk classification for massive transfusion in severe trauma using the gray zone approach

Massive transfusion (MT) protocols have emphasized the importance of ratio-based transfusion of plasma and platelets relative to packed red blood cells (PRBCs); however, the risks attributable to crystalloid resuscitation in patients requiring MT remain largely unexplored. We hypothesized that an increased crystalloid:PRBC (C:PRBC) ratio would be associated with increased morbidity and poor outcome after MT. Data were obtained from a multicenter prospective cohort study evaluating outcomes in blunt injured adults with hemorrhagic shock. Patients requiring MT (≥ 10 units PRBCs in first 24 hours) were analyzed. The C:PRBC ratio was computed by the ratio of crystalloid infused in liters (L) to the units of PRBCs transfused in the first 24 hours postinjury. Logistic regression modeling was used to characterize the independent risks associated with the 24-hour C:PRBC ratio, after controlling for important confounders and other blood component transfusion requirements. Logistic regression revealed that the 24-hour C:PRBC ratio was significantly associated with a greater independent risk of multiple organ failure (MOF), acute respiratory distress syndrome (ARDS), and abdominal compartment syndrome (ACS). No association with mortality or nosocomial infection was found. A dose-response analysis revealed that patients with a C:PRBC ratio >1.5:1 had over a 70% higher independent risk of MOF and over a twofold higher risk of ARDS and ACS. In patients requiring MT, crystalloid resuscitation in a ratio greater than 1.5:1 per unit of PRBCs transfused was independently associated with a higher risk of MOF, ARDS, and ACS. These results suggest overly aggressive crystalloid resuscitation should be minimized in these severely injured patients. Further research is required to determine whether incorporation of the C:PRBC ratio into MT protocols improves outcome.

The aim of this study was to determine whether initial shock index (SI) was independently associated with the requirement for massive transfusion (MT) in emergency department (ED) patients with primary postpartum hemorrhage (PPH). A retrospective cohort study of ED patients with primary PPH was performed at a university-affiliated, tertiary referral center between January 2004 and May 2012. Patients were classified to two groups: MT group (patients who received ≥10 U of packed red blood cells within 24 h of ED admission) and non-MT group (patients who received <10 U). Variables of the two groups were compared using univariate and multivariate analyses. A total of 126 patients were included in this study. Of these patients, 26 (20.6%) were included in MT group and 100 (79.4%) in non-MT group. Patients in MT group had significantly lower blood pressure and higher heart rate compared with patients in non-MT group (P < 0.01). Initial SI was significantly higher in MT group than in non-MT group (1.3 vs 0.8, P < 0.01). In multivariate logistic regression analysis, initial SI and heart rate were the only variables associated with the requirement for MT, with an odds ratio of 9.47 (95% confidence interval, 1.75-51.28; P < 0.01) and 1.06 (95% confidence interval, 1.02-1.09; P < 0.01), respectively. In conclusion, initial SI was independently associated with the requirement for MT in ED patients with primary PPH. Routine calculation of initial SI can help clinicians to identify patients who may benefit from timely and appropriate use of MT to improve clinical outcomes.

ABSTRACTBACKGROUND:Exsanguination can be fatal in patients with traumatic brain injury (TBI). We aimed to analyze and compare the prognostic performances of injury severity score (ISS), revised trauma score (RTS), shock index (SI), and modified early warning score (MEWS) for predicting massive transfusion (MT) in severe trauma patients with TBI.METHODS:In this retrospective observational study, severe trauma patients with TBI who visited our emergency department between January 2018 and December 2020 were included in the study. TBI was considered when abbreviated injury scale was 3 or higher. The primary outcome was MT.RESULTS:A total of 1108 patients were included, and MT was performed in 92 (8.3%) patients. Receiver operating characteristic analyses were performed to evaluate the accuracy of ISS, RTS, SI, and MEWS for predicting MT. The area under curves (AUCs) of ISS, SI, RTS, and MEWS for predicting MT were 0.725 (95% confidence interval [CI], 0.698–0.751), 0.676 (95% CI, 0.648–0.704), 0.769 (95% CI, 0.743–0.793), and 0.808 (95% CI, 0.784–0.831), respectively. The AUC of MEWS was significantly different from the AUCs of ISS and SI but not the AUC of RTS for predicting MT. In a multivariate analysis, Glasgow Coma Scale (odds ratio [OR], 0.856; 95% CI, 0.803–0.911), body temperature (OR, 0.596; 95% CI, 0.386–0.920), and fresh frozen plasma (OR, 2.031; 95% CI, 1.794–2.299) were independently associated with MT. MEWS (OR, 1.425; 95% CI, 1.256–1.618) was independently associated with MT after adjustment for confounders.CONCLUSION:MEWS may be a useful tool for predicting MT in severe trauma patients with TBI.

INTRODUCTION:Massive hemorrhage calls for massive transfusions (MTs) to maintain adequate hemostasis. Massive transfusion protocols (MTPs) are the appropriate treatment strategy for such patients replacing conventional use of crystalloids. These help in standardizing and optimizing the delivery of blood components in a well-balanced ratio.AIM AND OBJECTIVES:The aim of the study is to propose an ideal ratio of blood components for MTP after assessing relationship between ratios of blood components transfused and mortality.METHODOLOGY:MT was defined as receiving >4 packed red blood cell (PRBC) units within 1 h with the anticipation of continued need for blood products. All MT patients above 13 years of age regardless of cause of bleed were included in the study from December 2015 to October 2017 accounting for a total of 61 patients. Subgroup categorization of study population was done, and physician-driven ratios of the blood components were calculated for each case. The ratios were grouped as high (>1), equal (=1), and low (<1) ratios of fresh frozen plasma (FFP):PRBC and platelet: PRBC, and the relationship of these ratios to the clinical outcome in terms of mortality was examined.RESULTS AND DISCUSSION:Sixty-one patients underwent MT of which the overall hospital mortality rate was 8.1% with 100% mortality among patients with penetrating trauma followed by 25% with gastrointestinal bleed. Emergency admission was an independent risk factor for mortality. Hypotension before the initiation of MT was detrimental for survival. Efficient communication existed between the treating physicians and transfusion. Majority of survivors received equal ratios of FFP: PRBC and platelet: PRBC, and all nonsurvivors received low ratios of FFP: PRBC. Analysis was statistically indicating better survival with 1:1:1 ratio of PRBC: FFP: platelet.CONCLUSION:The need of the hour is to establish an institutional MTP and ensure compliance with the same. A prospective randomized controlled trial needs to be done to overcome the limitations and confounders of the present study and establish a universal protocol.

Prehospital shock index, modified shock index, and pulse pressure heart rate ratio as predictors of massive blood transfusions in modern warfare injuries: A retrospective analysis

It is important to predict massive postpartum hemorrhage in patients with placenta previa totalis (PPT) and a method that accurately predicts this event is needed. The present study developed a scoring system that predicts massive transfusion in patients with PPT. This single-center retrospective cohort study comprised 238 patients with PPT who underwent caesarean section between January 2004 and December 2010. Massive transfusion was defined as the transfusion of ≥8units of packed red blood cells within 24h after delivery. Multivariate regression analysis was used to estimate the risks of massive transfusion. A probability score model was then constructed and tested for performance. Subsequently, the model was validated in other patients with PPT (n=117). Thirty-one patients (13.0%) underwent massive transfusion. Ultrasound suspicion of placental adhesion, previous caesarean section, gestational age <37weeks, sponge-like appearance of the cervix, and anterior placenta were all independent predictors of massive transfusion. The performance for the score model revealed good calibration (Hosmer-Lemeshow chi-squared 1.64; P=0.44), and its discrimination (the area under the receiver operating characteristic for this model was 0.84) was better than when suspicion of placental adhesion was used alone (0.67; P<0.001). In the validation set, the performance was 0.88. The scoring system developed using the five independent risk factors had better performance to predict massive transfusion in patients with PPT than when suspicion of placental adhesion was used alone. However, further large-scale studies are warranted to clarify the usefulness and accuracy of this model.

Massive blood transfusion and trauma resuscitation