Massive Transfusion In Trauma Research Articles

Machine learning in the prediction of massive transfusion in trauma: a retrospective analysis as a proof-of-concept.

Early administration and protocolization of massive hemorrhage protocols (MHP) has been associated with decreases in mortality, multiorgan system failure, and number of blood products used. Various prediction tools have been developed for the initiation of MHP, but no single tool has demonstrated strong prediction with early clinical data. We sought to develop a massive transfusion prediction model using machine learning and early clinical data. Using the National Trauma Data Bank from 2013 to 2018, we included severely injured trauma patients and extracted clinical features available from the pre-hospital and emergency department. We subsequently balanced our dataset and used the Boruta algorithm to determine feature selection. Massive transfusion was defined as five units at 4h and ten units at 24h. Six machine learning models were trained on the balanced dataset and tested on the original. A total of 326,758 patients met our inclusion with 18,871 (5.8%) requiring massive transfusion. Emergency department models demonstrated strong performance characteristics with mean areas under the receiver-operating characteristic curve of 0.83. Extreme gradient boost modeling slightly outperformed and demonstrated adequate predictive performance with pre-hospital data only, as well as 4-h transfusion thresholds. We demonstrate the use of machine learning in developing an accurate prediction model for massive transfusion in trauma patients using early clinical data. This research demonstrates the potential utility of artificial intelligence as a clinical decision support tool.

Massive Transfusion in Trauma: A Retrospective analysis of MTP utilization and Futility Across Sociodemographic Groups

Massive Transfusion in Trauma: A Retrospective analysis of MTP utilization and Futility Across Sociodemographic Groups

373 Massive Transfusion in Trauma: Does Payer Status Decrease Futile Transfusion?

373 Massive Transfusion in Trauma: Does Payer Status Decrease Futile Transfusion?

The Use of Whole Blood Transfusion in Trauma.

Purpose of ReviewThis review illustrates the current benefits, limitations, ongoing research, and future paths for Low Titer O Whole Blood compared to Component Therapy in massive transfusion for trauma patients.Recent FindingsMany studies show that compared to Component Therapy, Low Titer O Whole Blood transfusion is associated with better patient outcomes and simplified transfusion logistics among others. There are, however, issues with cost, supply/demand and handling of Whole Blood that limit its use, but experience in the military setting has shown that these limitations can be easily overcome.SummaryThe use of Whole Blood has increased in the civilian trauma population and there is a growing body of evidence to support its current use. More research looking at Whole Blood in females of child-bearing age, pediatric populations, and cold-stored platelets is underway.

Massive transfusion in trauma: an evolving paradigm.

A considerable amount of literature has nurtured the idea that massive transfusion is an independent trauma disease and therapeutic tool. In this opinion paper, the authors expose the evolution and challenge the classic paradigm and historic definition of massive transfusion. Based on current evidence the elements of an evolving strategy in transfusion management and bleeding control are exposed to use of tranexamic acid, combination and ratios of blood products, use of fluids and viscoelastic testing, etc. The synergy of these elements provides the basis to develop updated strategies and perspectives for transfusion management after trauma and to consider a classic definition of massive transfusion as outdated or the need for massive transfusion as failure. An alternative concept, time critical transfusion may be better placed to take into account modern transfusion management after trauma.

1336: Blunt Trauma Massive Transfusion (B-MaT) Score: A Novel Scoring Tool

1336: Blunt Trauma Massive Transfusion (B-MaT) Score: A Novel Scoring Tool

Reverse shock index multiplied by Glasgow coma scale as a predictor of massive transfusion in trauma.

Previous studies have identified that the reverse shock index multiplied by the Glasgow Coma Scale score (rSIG) is a good predictor of mortality in trauma patients. However, it is unknown if rSIG has utility as a predictor for massive transfusion (MT) in trauma patients. The present study evaluated the ability of rSIG to predict MT in trauma patients. This was a retrospective, observational study performed at a level 1 trauma center. Consecutive patients who presented to the trauma center emergency department between January 2016 and December 2018 were included. The predictive ability of rSIG for MT was assessed as our primary outcome measure. Our secondary outcome measures were the predictive ability of rSIG for coagulopathy, in-hospital mortality, and 24-h mortality. We compared the prognostic performance of rSIG with the shock index, age shock index, and quick Sequential Organ Failure Assessment. In total, 1627 patients were included and 117 (7.2%) patients received MT. rSIG showed the highest area under the receiver operating characteristic (AUROC) curve (0.842; 95% confidence interval [CI], 0.806--0.878) for predicting MT. rSIG also showed the highest AUROC for predicting coagulopathy (0.769; 95% CI, 0.728-0.809), in-hospital mortality (AUROC 0.812; 95% CI, 0.772-0.852), and 24-h mortality (AUROC 0.826; 95% CI, 0.789-0.864). The sensitivity of rSIG for MT was 0.79, and the specificity of rSIG for MT was 0.77. All tools had a high negative predictive value and low positive predictive value. rSIG is a useful, rapid, and accurate predictor for MT, coagulopathy, in-hospital mortality, and 24- h mortality in trauma patients.

Predictive Factors for Massive Transfusion in Trauma: A Novel Clinical Score from an Italian Trauma Center and German Trauma Registry.

Early management of critical bleeding and coagulopathy can improve patient survival. The aim of our study was to identify independent predictors of critical bleeding and to build a clinical score for early risk stratification. A prospective analysis was performed on a cohort of trauma patients with at least one hypotensive episode during pre-hospital (PH) care or in the Emergency Department (ED). Patients who received massive transfusion (MT+) (≥4 blood units during the first hour) were compared to those who did not (MT−). Hemodynamics, Glagow Coma Score (GCS), diagnostics and blood tests were evaluated. Using multivariate analysis, we created and validated a predictive score for MT+ patients. The predictive score was validated on a matched cohort of patients of the German Trauma Registry TR-DGU. One hundred thirty-nine patients were included. Independent predictors of MT+ included a prehospital (PH) GCS of 3, PH administration of tranexamic acid, hypotension and tachycardia upon admission, coagulopathy and injuries with significant bleeding such as limb amputation, hemoperitoneum, pelvic fracture, massive hemothorax. The derived predictive score revealed an area under the curve (AUC) of 0.854. Massive transfusion is essential to damage control resuscitation. Altered GCS, unstable hemodynamics, coagulopathy and bleeding injuries can allow early identification of patients at risk for critical hemorrhage.

Quality Management of massive transfusion protocol incorporating tranexamic acid adherence

Massive transfusion protocols (MTP) vary at different institutions. We implemented an algorithm in the transfusion service to support our Level I trauma center in 2007 and periodically monitor MTP utilization as part of ongoing quality management. At the last review in 2013, median plasma: RBC ratio was 1:1.8. We undertook a retrospective 3-year review of MTP activations stratifying by trauma versus non-trauma indications, and blood component utilization of the massive transfusion (MT) cases, adding a review of tranexamic acid (TXA) administration to the audit. The median transfused plasma: RBC ratio was 1:1.9 in trauma MT, and 1:1.6 in the non-trauma MT cases. Non-trauma MT patients at our institution were significantly older and more coagulopathic at MTP initiation compared to trauma MT patients, received fewer RBC units (15.5 versus 20.2), and had higher mortality. TXA adherence increased over the 3-year period to 60% of all trauma MTP activations in 2017.

Citrated kaolin thrombelastography (TEG) thresholds for goal-directed therapy in injured patients receiving massive transfusion.

Goal-directed hemostatic resuscitation based on thrombelastography (TEG) has a survival benefit compared with conventional coagulation assays such as international normalized ratio, activated partial thromboplastin time, fibrinogen level, and platelet count. While TEG-based transfusion thresholds for patients at risk for massive transfusion (MT) have been defined using rapid TEG, cutoffs have not been defined for TEG using other activators such as kaolin. The purpose of this study was to develop thresholds for blood product transfusion using citrated kaolin TEG (CK-TEG) in patients at risk for MT. CK-TEG was assessed in trauma activation patients at two Level 1 trauma centers admitted between 2010 and 2017. Receiver operating characteristic (ROC) curve analyses were performed to test the predictive performance of CK-TEG measurements in patients requiring MT, defined as >10 units of red blood cells or death within the first 6 hours. The Youden Index defined optimal thresholds for CK-TEG-based resuscitation. Of the 825 trauma activations, 671 (81.3%) were men, 419 (50.8%) suffered a blunt injury, and 62 (7.5%) received a MT. Patients who had a MT were more severely injured, had signs of more pronounced shock, and more abnormal coagulation assays. CK-TEG R-time was longer (4.9 vs. 4.4 min, p = 0.0084), angle was lower (66.2 vs. 70.3 degrees, p < 0.0001), maximum amplitude was lower in MT (57 vs. 65.5 mm, p < 0.0001), and LY30 was greater (1.8% vs. 1.2%, p = 0.0012) in patients with MT compared with non-MT. To predict MT, R-time yielded an area under the ROC curve (AUROC) = 0.6002 and a cut point of >4.45 min. Angle had an AUROC = 0.6931 and a cut point of <67 degrees. CMA had an AUROC = 0.7425, and a cut point of <60 mm. LY30 had an AUROC = 0.623 with a cut point of >4.55%. We have identified CK-TEG thresholds that can guide MT in trauma. We propose plasma transfusion for R-time >4.45 min, fibrinogen products for an angle <67 degrees, platelet transfusion for MA <60 mm, and antifibrinolytics for LY30 >4.55%. Therapeutic study, level V.

Relative effects of plasma, fibrinogen concentrate, and factor XIII on ROTEM coagulation profiles in an in vitro model of massive transfusion in trauma

Massive traumatic haemorrhage is aggravated through the development of trauma-induced coagulopathy, which is managed by plasma transfusion and/or fibrinogen concentrate administration. It is yet unclear whether these treatments are equally potent in ensuring adequate haemostasis, and whether additional factor XIII (FXIII) administration provides further benefits. In this study, we compared ROTEM whole blood coagulation profiles after experimental massive transfusion with different transfusion regimens in an in vitro model of dilution- and transfusion-related coagulopathy. Healthy donor blood was mixed 1 + 1 with six different transfusion regimens. Each regimen contained RBC, platelet concentrate, and either fresh frozen plasma (FFP) or Ringer’s acetate (RA). The regimens were further augmented through addition of a low- or medium-dose fibrinogen concentrate and FXIII. Transfusion with FFP alone was insufficient to maintain tissue-factor activated clot strength, coincidental with a deficiency in fibrin-based clot strength. Fibrinogen concentrate conserved, but did not improve coagulation kinetics and overall clot strength. Only combination therapy with FFP and low-dose fibrinogen concentrate improved both coagulation kinetics and fibrin-based clot strength. Administration of FXIII did not result in an improvement of clot strength. In conclusion, combination therapy with both FFP and low-dose fibrinogen concentrate improved clotting time and produced firm clots, representing a possible preferred first-line regimen to manage trauma-induced coagulopathy when RBC and platelets are also transfused. Further research is required to identify optimal first-line transfusion fluids for massive traumatic haemorrhage.

Viscoelastic Tissue Plasminogen Activator Challenge Predicts Massive Transfusion in 15 Minutes

Coagulopathy is associated with massive transfusion in trauma, yet most clinical scores to predict this end point do not incorporate coagulation assays. Previous work has identified that shock increases circulating tissue plasminogen activator (tPA). When tPA levels saturate endogenous inhibitors, systemic hyperfibrinolysis can occur. Therefore, the addition of tPA to a patient's blood sample could stratify a patients underlying degree of shock and early coagulation changes to predict progression to massive transfusion. We hypothesized that a modified thrombelastography (TEG) assay with exogenous tPA would unmask patients' impending risk for massive transfusion. Trauma activations were analyzed using rapid TEG and a modified TEG assay with a low and high dose of tPA. Clinical scores (shock index, assessment of blood consumption, and trauma-associated severe hemorrhage) were compared with TEG measurements to predict the need for massive transfusion using areas under the receiver operating characteristic curves. Three hundred and twenty-four patients were analyzed, 17% required massive transfusion. Massive transfusion patients had a median shock index of 1.2, assessment of blood consumption score of 1, and trauma-associated severe hemorrhage score of 12. Rapid TEG and tPA TEG parameters were significantly different in all massive transfusion patients compared with non-massive transfusion patients (all p < 0.02). The low-dose tPA lysis at 30 minutes had the largest the area under the receiver operating characteristic curve (0.86; 95% CI 0.79 to 0.93) for prediction of massive transfusion, similar to international normalized ratio of prothrombin time of 0.86 (95% CI 0.81 to 0.91), followed by trauma-associated severe hemorrhage score (0.83; 95% CI 0.77 to 0.89). Combing trauma-associated severe hemorrhage and tPA-TEG variables results in a positive prediction of massive transfusion in 49% of patients with a 98% negative predictive value. The tPA-TEG identifies trauma patients who require massive transfusion efficiently in a single assay that can be completed in a shorter time than other scoring systems, which has improved performance when combined with international normalized ratio. This new method is consistent with our understanding of the molecular events responsible for trauma-induced coagulopathy.

Modelling the effects of blood component storage lesions on the quality of haemostatic resuscitation in massive transfusion for trauma.

All blood components undergo loss of potency during storage. These loss-of-potency storage lesions are important in trauma resuscitation because they reduce the haemostatic capacity of mixtures of components that attempt to reconstitute whole blood. Even red cell storage-related loss of potency, which averages 17% with modern additive solutions, is important because 6 units of red cells must be given to achieve the effect of 5 fully potent units. Loss of potency of stored units of red blood cells, plasma, platelets, and cryoprecipitate were summed for dilutional, storage-related, pathogen reduction-related, and splenic sequestration-related causes and expressed as fractional plasma coagulation factor concentrations and platelet counts. Production of reconstituted whole blood from 1:1:1 unit ratios of red cells:plasma:platelets is associated with a 38% loss of plasma coagulation factor concentration and 56% loss of platelets. Storage losses of 17% for red cells, 10% for coagulation factors, and 30% for platelets are additive to pathogen reduction-related losses of 18% for coagulation factors and 30% for platelets. Component preparation and storage-related losses of potency for all blood components are serious problems for trauma resuscitation. Even red cell storage contributes to this problem and this can be made better in ways that can save many lives each year.

Proactive Use of Plasma and Platelets in Massive Transfusion in Trauma: The Long Road to Acceptance and a Lesson in Evidence-Based Medicine.

Proactive Use of Plasma and Platelets in Massive Transfusion in Trauma: The Long Road to Acceptance and a Lesson in Evidence-Based Medicine.

Massive Transfusion for Trauma in a Lower Middle Income Country

Massive Transfusion for Trauma in a Lower Middle Income Country

The traditional vs “1:1:1” approach debate on massive transfusion in trauma should not be treated as a dichotomy

Traditional transfusion guidelines suggest that fresh frozen plasma (FFP) should be given based on laboratory or clinical evidence of coagulopathy or acute loss of 1 blood volume. This approach tends to result in a significant lag time between the first units of erythrocytes and FFP in trauma requiring massive transfusion. In severe trauma, observational studies have found an association between increased survival and aggressive use of FFP and platelets such that FFP:platelet:erythrocyte ratio approaches 1:1:1 to 2 from the first units of erythrocytes given. There are considerable concerns over either approach, and no randomized controlled trials have been published comparing the 2 approaches. Nowadays, trauma clinicans are incorporating the strenghts of both approaches and are no longer treating them as a dichotomy. Specifically, “1:1:1” proponents have devised 1:1:1 activation criteria to minimize unnecessary FFP and platelet transfusion and are prepared to deactivate the protocol as soon as patient is stabilized. Similarly, 1:1:1 skeptics are more mindful of the need to be proactive about trauma coagulopathy and the inherent delays in FFP administration in trauma patients.

Predicting massive transfusion in trauma and non-trauma patients

Predicting massive transfusion in trauma and non-trauma patients

New simplified criteria for predicting massive transfusion in trauma

Several predicting models have been described to identify the necessity for massive transfusion (MT) for trauma patients [1]. The purpose of this study is to validate the simplified scoring systems reported previously and establish new criteria at emergency and in the ICU in Japan.

A major haemorrhage protocol improves the delivery of blood component therapy and reduces waste in trauma massive transfusion

BackgroundMajor haemorrhage protocols (MHP) are required as part of damage control resuscitation regimens in modern trauma care. The primary objectives of this study were to ascertain whether a MHP improved blood product administration and reduced waste compared to traditional massive transfusion protocols (MTP). MethodsDatasets on adult trauma admissions 1 year prior and 1 year post implementation of a MHP at a Level 1 trauma centre were obtained from the trauma registry. Demographic and clinical data were collected prospectively including mechanism of injury, physiological observations, ICU admission and length of stay. The volume of blood components (packed red blood cells, platelets, cryoprecipitate and fresh frozen plasma) issued, transfused, returned to stock and wasted within the first 24h was gathered retrospectively. ResultsOver the 2-year study period 2986 patient records were available for analysis. 40 patients required a 10+ Units of packed red blood ells transfusion in the MTP group vs. 56 patients post MHP implementation. The administration of blood component therapy improved significantly post MHP implementation. FFP:PRBC transfusion improved from 1:3 to 1:2 (p<0.01) and CRYO:PRBC improved from 1:10 to 1:7 (p<0.05). We reported a significant reduction in the waste of platelets from 14% to 2% (p<0.01). Outcomes had improved: Median hospital length of stay was reduced from 54 days to 26 days (p<0.05). ConclusionImplementation of a MHP results in improved delivery of blood components and a reduction in the waste of blood products compared to the older model of MTP. In combination with educational programmes MHP can significantly improve blood product administration and patient outcomes in trauma haemorrhage. Level of evidenceLevel III diagnostic test study.

Massive transfusion in trauma: blood product ratios should be measured at 6 hours

Most potentially preventable haemorrhagic deaths occur within 6 h of injury. Conventionally, blood component therapy delivery is measured by 24-h cumulative totals and ratios. The study aim was to examine the effect of a massive transfusion protocol (MTP) on early (6 h) balanced component therapy. An 88-month retrospective clinical study at a level 1 trauma centre was undertaken, examining consecutive trauma patients receiving ≥10 units of packed red blood cells (PRBCs) within 24 h, before (pre-MTP) and after implementation of MTP. Demographic data, injury severity score (ISS), abbreviated injury scale (AIS), shock parameters, coagulation profile, the need for surgical intervention (<24 h), mortality and intensive care unit length of stay were collected. The ratios of blood products given by 6 h, by 24 h and the time between administrations of components was collected and analysed. Pre-MTP and MTP patients had similar demographics, shock severity and initial laboratory findings. Despite MTP patients having had a higher ISS (42 ± 12 versus 36 ± 12, P < 0.05) and AIS head score (2.6 ± 1.8 versus 1.6 ± 2.0, P < 0.05), there was no difference in mortality. Area under the curve (AUC) of the MTP period showed earlier delivery of higher median ratios of fresh frozen plasma (FFP)/PRBC (P= 0.004). Similar findings were found for cryoprecipitate/PRBC and platelet/PRBC ratios. By 24 h, the AUC for FFP/PRBC ratios were no different. Implementation of MTP resulted in earlier balanced transfusion. The difference between the FFP/PRBC ratios of the two types of resuscitations levelled by 24 h. The efficacy of component therapy delivery should be measured earlier than 24 h.