Massive Transfusion Requirements Research Articles

Tranexamic Acid for Trauma Care: An Updated Meta-Analysis of Mortality and Thromboembolic Events in Severely Injured Patients

Introduction : Tranexamic Acid (TXA) is an anti-fibrinolytic agent that inhibits fibrinolysis and prevents blood clot breakdown. Widely used to manage hemorrhage in various clinical scenarios, including trauma, menorrhagia, bleeding in hemophilia, cardiac surgery, and orthopedic surgery, its impact on morbidity and mortality in severely injured patients necessitates an updated systematic review and meta-analysis. Our study aimed to evaluate the association of TXA with mortality and thromboembolic events in trauma patients. Methods: We conducted a comprehensive literature search on PubMed, EMBASE, CENTRAL, and Google Scholar up to July 2023, focusing on randomized controlled trials (RCTs) involving adult trauma patients receiving Tranexamic Acid (TXA) compared to standard care or placebo. Primary outcomes included mortality rates and thromboembolic event incidence. Statistical analyses used Review Manager Software (RevMan, version 5.3) with the Mantel-Haenszel random-effect model. Results : A total of 8 randomized controlled trials (RCTs) with 36,416 patients were included in this meta-analysis, comparing Tranexamic Acid (TXA) to control (placebo or standard care). The mean age of the included patients was 39 years. The analysis focused on various patient categories, including multiple trauma versus predominantly traumatic brain injury (TBI) patients, severely injured ( Injury Severity Score ,ISS ≥ 16, massive transfusion requirement, signs of shock) versus non-severely injured patients, blunt versus penetrating versus burn trauma, in-hospital versus prehospital TXA administration, and TXA administration within 3 hours versus beyond 3 hours of injury. The meta-analysis showed that TXA administration was not significantly associated with mortality (odds ratio: 0.98, 95% CI: 0.76 to 1.27, p = 0.89), with moderate heterogeneity observed (I 2 = 56%). However, TXA use demonstrated a significant reduction in the incidence of thromboembolic events (odds ratio: 0.90, 95% CI: 0.84 to 0.95, p = 0.0002), with no significant heterogeneity (I 2 = 0%). (Figure 1 & 2) Conclusion TXA administration was not significantly associated with mortality in patients with significant trauma; however, it significantly reduced thromboembolic events, suggesting its potential benefit in preventing such complications. Further research is needed to explore its efficacy and safety in specific patient categories and administration settings to optimize its use in trauma care.

Association of Contrast Extravasation Grade With Massive Transfusion in Pediatric Blunt Liver and Spleen Injuries: A Multicenter Retrospective Cohort Study

BackgroundThis study aimed to assess whether the grade of contrast extravasation (CE) on CT scans was associated with massive transfusion (MT) requirements in pediatric blunt liver and/or spleen injuries (BLSI). MethodsThis multicenter retrospective cohort study included pediatric patients (≤16 years old) who sustained BLSI between 2008 and 2019. MT was defined as transfusion of all blood products ≥40 mL/kg within the first 24 h of admission. Associations between CE and MT requirements were assessed using multivariate logistic regression analysis with cluster-adjusted robust standard errors to calculate the adjusted odds ratio (AOR). ResultsA total of 1407 children (median age: 9 years) from 83 institutions were included in the analysis. Overall, 199 patients (14 %) received MT. CT on admission revealed that 54 patients (3.8 %) had CE within the subcapsular hematoma, 100 patients (7.1 %) had intraparenchymal CE, and 86 patients (6.1 %) had CE into the peritoneal cavity among the overall cohort. Multivariate analysis, adjusted for age, sex, age-adjusted shock index, injury severity, and laboratory and imaging factors, showed that intraparenchymal CE and CE into the peritoneal cavity were significantly associated with the need for MT (AOR: 2.50; 95 % CI, 1.50–4.16 and AOR: 4.98; 95 % CI, 2.75–9.02, respectively both p < 0.001). The latter significant association persisted in the subgroup of patients with spleen and liver injuries. ConclusionActive CE into the free peritoneal cavity on admission CT was independently associated with a greater probability of receiving MT in pediatric BLSI. The CE grade may help clinicians plan blood transfusion strategies. Level of EvidenceLevel 4; Therapeutic/Care management.

A proposed clinical coagulation score for research in trauma-induced coagulopathy.

Trauma-induced coagulopathy (TIC) has been the subject of intense study for greater than a century, and it is associated with high morbidity and mortality. The Trans-Agency Consortium for Trauma-Induced Coagulopathy, funded by the National Health Heart, Lung and Blood Institute, was tasked with developing a clinical TIC score, distinguishing between injury-induced bleeding from persistent bleeding due to TIC. We hypothesized that the Trans-Agency Consortium for Trauma-Induced Coagulopathy clinical TIC score would correlate with laboratory measures of coagulation, transfusion requirements, and mortality. Trauma activation patients requiring a surgical procedure for hemostasis were scored in the operating room (OR) and in the first ICU day by the attending trauma surgeon. Conventional and viscoelastic (thrombelastography) coagulation assays, transfusion requirements, and mortality were correlated to the coagulation scores using the Cochran-Armitage trend test or linear regression for numerical variables. Increased OR TIC scores were significantly associated with abnormal conventional and viscoelastic measurements, including hyperfibrinolysis incidence, as well as with higher mortality and more frequent requirement for massive transfusion ( p < 0.0001 for all trends). Patients with OR TIC score greater than 3 were more than 31 times more likely to have an ICU TIC score greater than 3 (relative risk, 31.6; 95% confidence interval, 12.7-78.3; p < 0.0001). A clinically defined TIC score obtained in the OR reflected the requirement for massive transfusion and mortality in severely injured trauma patients and also correlated with abnormal coagulation assays. The OR TIC score should be validated in multicenter studies. Prognostic and Epidemiological; Level IV.

Early Hypocalcemia in Severe Trauma: An Independent Risk Factor for Coagulopathy and Massive Transfusion.

The rapid identification of patients at risk for massive blood transfusion is of paramount importance as uncontrolled exsanguination may lead to death within 2 to 6 h. The aim of this study was to analyze a cohort of severe trauma patients to identify risk factors associated with massive transfusion requirements and hypocalcemia. All major trauma (ISS &gt; 16) presented directly from the scene to the Niguarda hospital between 1 January 2015 and 31 December 2021 were analyzed. A total of 798 patients were eligible out of 1586 screened. Demographic data showed no significant difference between hypocalcemic (HC) and normocalcemic (NC) patients except for the presence of crush trauma, alcohol intake (27% vs. 15%, p &lt; 0.01), and injury severity score (odds ratio 1.03, p = 0.03). ISS was higher in the HC group and was an independent, even if weak, predictor of hypocalcemia (odds ratio 1.03, p = 0.03). Prehospital data showed a lower mean systolic arterial pressure (SAP) and a higher heart rate (HR) in the HC group (105 vs. 127, p &lt; 0.01; 100 vs. 92, p &lt; 0.001, respectively), resulting in a higher shock index (SI) (1.1 vs. 0.8, p &lt; 0.001). Only retrospective studies such as ours are available, and while hypocalcemia seems to be an independent predictor of mortality and massive transfusion, there is not enough evidence to support causation. Therefore, randomized prospective studies are suggested.

Factors associated with postoperative respiratory conditions and critical outcomes on pediatric liver transplantation: A single-center experience.

Orthotopic liver transplantation (OLT) is an established therapeutic option for pediatric end-stage liver disease (PELD). The postoperative respiratory conditions of OLT recipients may be associated with subsequent clinical outcomes including length of stay (LOS) in the pediatric intensive care unit (PICU). This study aimed to characterize the postoperative respiratory conditions, associated factors, and outcomes after pediatric OLT. Clinical data of children receiving OLT from July 2014 to July 2020 were retrospectively collected. Postoperative respiratory conditions were defined as time to extubation, significant pleural effusion, and initial postoperative PaO2/FiO2 ratio. Logistic and multiple regressions were applied to analyze the associations among clinical factors, postoperative respiratory conditions, and clinical outcomes. Twenty-two patients with median age of 1.4-year-old (range: 25 days to 12 years old) were analyzed. Mortality within 28 days was 4.5% and median LOS in the PICU was 18 days. Of 22 patients, 11 patients (50.0%) were extubated over 24 hours after surgery, and 8 patients (36.4%) required drainage for pleural effusions. Longer LOS in the PICU were noted in patients extubated over 24 hours (p = 0.008), complicated with significant pleural effusions (p = 0.02) after surgery, and having low initial postoperative PaO2/FiO2 (<300 mmHg) (p = 0.001). Among clinical factors, massive intraoperative blood transfusion (>40 mL/kg) was significantly associated with prolonged intubations, significant pleural effusions, low initial postoperative PaO2/FiO2, and prolonged LOS in the PICU (>14 days). The initial postoperative PaO2/FiO2 significantly depended on age, disease severity (PELD score), and whether the patient received massive intraoperative blood transfusion. Pediatric patients of OLT with poor postoperative respiratory conditions including low initial PaO2/FiO2 ratio, extubation over 24 hours or significant pleural effusions have longer LOS in the PICU, and the requirement of massive intraoperative transfusion was a risk factor for both poor postoperative respiratory conditions and prolonged LOS in the PICU.

Delta neutrophil index and shock index can stratify risk for the requirement for massive transfusion in patients with primary postpartum hemorrhage in the emergency department.

Postpartum hemorrhage (PPH) constitutes a major risk for maternal mortality and morbidity. Unfortunately, the severity of PPH can be underestimated because it is difficult to accurately measure blood loss by visual estimation. The delta neutrophil index (DNI), which reflects circulating immature granulocytes, is automatically calculated in hematological analyzers. We evaluated the significance of the DNI in predicting hemorrhage severity based on the requirement for massive transfusion (MT) in patients with PPH. We retrospectively analyzed data from a prospective registry to evaluate the association between the DNI and MT. Moreover, we assessed the predictive ability of the combination of DNI and shock index (SI) for the requirement for MT. MT was defined as a transfusion of ≥10 units of red blood cells within 24 h of PPH. In total, 278 patients were enrolled in this study and 60 required MT. Multivariable logistic regression revealed that the DNI and SI were independent predictors of MT. The optimal cut-off values of ≥3.3% and ≥1.0 for the DNI and SI, respectively, were significantly associated with an increased risk of MT (DNI: positive likelihood ratio [PLR] 3.54, 95% confidence interval [CI] 2.5-5.1 and negative likelihood ratio [NLR] 0.48, 95% CI 0.4-0.7; SI: PLR 3.21, 95% CI 2.4-4.2 and NLR 0.31, 95% CI 0.19-0.49). The optimal cut-off point for predicted probability was calculated for combining the DNI value and SI value with the equation derived from logistic regression analysis. Compared with DNI or SI alone, the combination of DNI and SI significantly improved the specificity, accuracy, and positive likelihood ratio of the MT risk. The DNI and SI can be routinely and easily measured in the ED without additional costs or time and can therefore, be considered suitable parameters for the early risk stratification of patients with primary PPH.

An examination by year of cases applied with caesarean hysterectomy because of placenta percreta in a tertiary centre: a retrospective cohort study.

To examine cases applied with caesarean hysterectomy because of placenta percreta by comparing changes in treatment strategies and complications according to year. A retrospective examination was made of 93 patients applied with caesarean hysterectomy with a diagnosis of placenta percreta in 5-year periods of 2005-2009, 2010-2014, and 2015-2019. Demographic characteristics were recorded, and previous caesareans, history of myomectomy and curettage, gestational weeks, and infant birthweight. Intraoperative and postoperative findings were recorded as operating time, length of stay in hospital and Intensive Care Unit (ICU), transfusion requirement, the amount of erythrocyte suspension (ES) and fresh frozen plasma (FFP) transfused, and requirement for massive transfusion. Anaesthesia type, complications, and the preferred skin-uterus incision were also recorded. The 93 patients comprised 8 cases in the period 2005-2009, 23 in 2010-2014, and 62 in 2015-2019. The number of previous caesarean procedures was observed to increase in parallel with these case numbers. A significant increase was observed in the gestational week of birth, and infant birthweight, and a decrease in operating times. In later years there was seen to be a lower amount of ES and FFP transfused and fewer patients with massive transfusion. Preoperative diagnosis of placenta percreta, the highest preference for general anaesthesia, selection of midline vertical skin incision and uterine fundal incision were greatest in the period 2015-2019. In cases with placenta percreta, of which there is an increasing incidence, maternal and infant outcomes can be optimised with prenatal diagnosis and planned caesarean hysterectomy by a multidisciplinary team with optimal prenatal preparation.

Quantifying the need for pediatric REBOA: A gap analysis

BackgroundTrauma is the leading cause of death in children. Resuscitative endovascular balloon occlusion of the aorta (REBOA) provides temporary hemorrhage control, but its potential benefit has not been assessed in children. We hypothesized that there are pediatric patients who may benefit from REBOA. MethodsTrauma patients <18 years old at a level 1 pediatric trauma center between 2009 and 2019 were queried for deaths, pre-hospital cardiac arrest, massive transfusion protocol activation, transfusion requirement, or hemorrhage control surgery. These patients defined the cohort of severely injured patients. From this cohort, patients with intraabdominal injuries for which REBOA may provide temporary hemorrhage control were identified, including solid organ injury necessitating intervention, vascular injury, or pelvic hemorrhage. ResultsThere were 239 severely injured patients out of 6538 pediatric traumas. Of these, 38 had REBOA-amenable injuries (15.9%) with 34.2% mortality, accounting for 10.2% of all pediatric trauma deaths at one center. Eleven patients with REBOA-amenable injuries had TBI (28.9%). Patients with REBOA-amenable injuries represented 0.6% of all pediatric traumas. ConclusionNearly 20% of severely injured pediatric patients could potentially benefit from REBOA. The overall proportion of pediatric patients with REBOA-amenable injuries is similar to adult studies. Type of StudyRetrospective comparative study. Level of EvidenceLevel III.

449. Epidemiology of Combat-Related Deep Soft-Tissue Wound Infections

BackgroundDeep soft-tissue infections (DSTIs) are a common complication of combat-related extremity trauma. We present an epidemiologic assessment of combat-related DSTIs among wounded military personnel.MethodsWounded personnel were included in the analysis if they sustained an open combat-related extremity wound (2009–2014), were admitted to a participating US military hospital, had a DSTI as the first confirmed extremity wound infection (within 30 days post-injury), started antibiotics ±3 days of DSTI diagnosis, and received ≥5 days of directed antibiotic treatment.ResultsAmong 1961 combat casualties with open extremity wounds, 259 had a DSTI diagnosis with 173 (67%) having only 1 index DSTI and 86 (33%) having >1 index DSTI diagnosed on the same day. Nearly all patients (95%) were injured via a blast mechanism. Patients with >1 index DSTI were more severely injured (median injury severity score: 35 vs. 33; P = 0.009) and required large volume blood transfusions within 24 hours of injury (median units: 23 vs. 17; P < 0.001). Initial empiric antibiotic treatment largely involved carbapenem and vancomycin (77% and 72% of patients, respectively). For diagnosis timing, 130 (50%) patients had an early DSTI diagnosis (≤7 days post-injury), while the remaining 129 (50%) patients had a delayed diagnosis (>7 days post-injury). Patients with early DSTI diagnoses more often had >1 index DSTI (47% vs. 19% with delayed DSTI; P < 0.001). Polymicrobial DSTIs were common (73% of early DSTIs; 58% of delayed DSTIs) with Enterococcus spp. most frequently identified (56% of early DSTIs; 31% of delayed DSTIs) as well as Enterobacter spp., Escherichia coli, Pseudomonas aeruginosa, and Acinetobacter spp. Moreover, 26% and 39% of early and delayed DSTIs had multidrug-resistant Gram-negative bacteria. Receipt of >20 units of blood within 24 hours of injury and having >1 index DSTI were independently associated with an early DSTI diagnosis (odds ratio [OR]: 3.21; 95% CI: 1.47–7.02 and OR: 2.98; 95% CI: 1.63–5.42, respectively).ConclusionMultiple index DSTIs and massive blood transfusion requirement are associated with early infection onset post-injury. Awareness of wound microbiology findings relative to DSTI onset provides guidance on empiric antimicrobial therapy.Disclosures All authors: No reported disclosures.

Lactate and fibrinogen as good predictors of massive transfusion in postpartum hemorrhage.

AimThis study aims to identify the clinical factors that can predict the requirement of massive transfusion among patients with postpartum hemorrhage (PPH).MethodsConsecutive anonymized patients with PPH who were treated at the emergency department of our perinatal medical center were examined. Patients who had received transfusions before admission, those who had cardiac arrest on arrival, and those without history of blood gas analysis were excluded. Our primary outcome was the requirement of massive transfusion defined as packed red blood cells of ≥10 units/24 h. Univariable logistic analysis was carried out to identify the odds ratio and 95% confidence interval (CI) of the explanatory variables for the outcome.ResultsA total of 31 patients (massive transfusion, n = 19) were included in the main analysis. The crude odds ratio for fibrinogen per mg/dL and lactate per mmol/L were calculated as 0.98 (95% CI, 0.97–0.99) and 1.62 (95% CI, 1.08–3.02), respectively. The area under the curves for fibrinogen and lactate were 0.814 and 0.734, respectively, and optimal cut‐off values for fibrinogen and lactate were 211 mg/dL and 4 mmol/L, respectively.ConclusionThese findings suggest that lactate and fibrinogen can be predictors for the requirement of massive transfusion in patients with PPH.

乳酸値とフィブリノゲンは産科危機的出血に対する大量輸血の予測因子となりえる(Lactate and fibrinogen as good predictors of massive transfusion in postpartum hemorrhage)

要旨【目的】産後出血に対する大量輸血の予測因子の同定を目的とした。【方法】対象は産後出血で母体搬送された連続60症例。来院後24時間以内にRBC10単位以上輸血された症例を大量輸血群（MT群），10単位未満を非MT群に分け，年齢，BMI，バイタルサイン，採血結果について2群間で比較し，単変量解析を行った。【結果】31名が参加基準を満たした（MT群19名）。2群間比較でフィブリノゲン（Fib）と乳酸値のみが有意差を認めた。SIは有意差を認めなかった。Fib，乳酸値を説明変数とし，大量輸血の有無を目的変数とした単変量解析の結果，Fibの単位オッズ比は0.98 [95% CI: 0.97–0.99]，乳酸値の単位オッズ比は1.62 [95% CI: 1.08–3.02]であった。【結論】Fibと乳酸値が産後出血における大量輸血の予測因子として有用な可能性がある。

Massive transfusion in upper gastrointestinal bleeding: a new scoring system

Background: Massive transfusion in patients with upper gastrointestinal bleeding (UGIB) was not investigated. We developed a new scoring system to predict massive transfusion and to enhance care and early resource mobilization.Methods: Massive transfusion was defined as transfusion with ≥10 units of red blood cells within the first 24 h. Data were extracted from a 10-year, six-hospital database. Logistic regression was applied to derive a risk score for massive transfusion using data from 2006 to 2010, in 24,736 patients (developmental cohort). The score was then validated using data from 2011 to 2015 in 27,449 patients (validation cohort). Area under the receiver operating characteristic (AUROC) curve was performed to assess prediction accuracy.Results: Five characteristics were independently associated (p < .001) with massive transfusion: presence of band-form cells among white blood cells (band form >0), international normalized ratio (INR) >1.5, pulse >100 beats per minute or systolic blood pressure <100 mmHg (shock), haemoglobin <8.0 g/dL and endoscopic therapy. The new scoring system successfully discriminated well between UGIB patients requiring massive transfusion and those who did not in both cohorts (AUROC: 0.831, 95%CI: 0.827–0.836; AUROC: 0.822, 95% CI: 0.817–0.826, respectively).Conclusions: The new scoring system predicts massive transfusion requirement in patients with UGIB well.Key messagesMassive transfusion is a life-saving management in massive upper gastrointestinal bleeding. How to identify patients requiring massive transfusion in upper gastrointestinal bleeding is poorly documented.Approximately 3.9% of upper gastrointestinal bleeding patients require massive transfusion.A new scoring system is developed to identify patients requiring massive transfusion with high accuracy.

Incidence of Massive Transfusion and Overall Transfusion Requirements During Lung Transplantation Over a 25-Year Period

To establish the incidence of massive transfusion and overall transfusion requirements during lung transplantation, changes over time, and association with outcome in relation to patient complexity. Retrospective cohort study. University hospital. All 514 adult patients who underwent transplantation from 1990 until 2015. None. Patient records and transfusion data, divided into 5-year intervals, were analyzed. The incidence of massive transfusion (>10 units of red blood cells [RBCs] in 24 h) was 27% and did not change over time, whereas the median (interquartile range) transfusion requirement in the whole cohort decreased from 8 (5-12) to 3 (0-10) RBCs (p < 0.001). In patients transplanted from the intensive care unit, the incidence of massive transfusion increased over time from 25% to 54% (p = 0.04) and median transfusion requirements from 4.5 (3-8.5) units to 14.5 (5-26) units of RBCs (p = 0.03). Multivariable analysis showed that circulatory support, pulmonary hypertension, re-transplantation, cystic fibrosis, Eisenmenger syndrome, bilateral transplantation, and low body mass index were associated with massive transfusion. Patients with massive transfusion had more primary graft dysfunction grade III at 0, 24, 48, and 72 hours (p < 0.001), higher 30-day mortality (13% v 4%; p < 0.001), and lower 5-year survival (hazard ratio 3.67 [95% confidence interval 1.72-7.85]; p < 0.001). The incidence of massive transfusion did not change over time, whereas transfusion requirements in the whole cohort decreased. In patients transplanted from the intensive care unit, massive transfusion and transfusion requirements increased. Massive transfusion was associated with poor outcome.

Impact of initial temporary abdominal closure in damage control surgery: a retrospective analysis

BackgroundDamage control surgery has revolutionized trauma surgery. Use of damage control surgery allows for resuscitation and reversal of coagulopathy at the risk of loss of abdominal domain and intra-abdominal complications. Temporary abdominal closure is possible with multiple techniques, the choice of which may affect ability to achieve primary fascial closure and further complication.MethodsA retrospective analysis of all trauma patients requiring damage control laparotomy upon admission to an ACS-verified level one trauma center from 2011 to 2016 was performed. Demographic and clinical data including ability and time to attain primary fascial closure, as well as complication rates, were recorded. The primary outcome measure was ability to achieve primary fascial closure during initial hospitalization.ResultsTwo hundred and thirty-nine patients met criteria for inclusion. Primary skin closure (57.7%), ABThera™ VAC system (ABT) (15.1%), Bogota bag (BB) (25.1%), or a modified Barker’s vacuum-packing (BVP) (2.1%) were used in the initial laparotomy. Patients receiving skin-only closure had significantly higher rates of primary fascial closure and lower hospital mortality, but also significantly lower mean lactate, base deficit, and requirement for massive transfusion. Between ABT or BB, use of ABT was associated with increased rates of fascial closure. Multivariate regression revealed primary skin closure to be significantly associated with primary fascial closure while BB was associated with failure to achieve fascial closure.ConclusionsPrimary skin closure is a viable option in the initial management of the open abdomen, although these patients demonstrated less injury burden in our study. Use of vacuum-assisted dressings continues to be the preferred method for temporary abdominal closure in damage control surgery for trauma.

Blood lactate concentration and shock index associated with massive transfusion in emergency department patients with primary postpartum haemorrhage

We hypothesised that lactate concentrations are independently associated with massive transfusion in patients with primary postpartum haemorrhage. Moreover, combining lactate concentrations with the shock index, defined as the ratio of heart rate to systolic arterial blood pressure, can improve the predictive performance for massive transfusion. We retrospectively analysed patients with primary postpartum haemorrhage in the emergency department of a tertiary referral centre in Korea between January 1, 2004 and December 31, 2015. Of the 302 patients, 101 (33.4%) patients required massive transfusion. Lactate concentration was independently associated with the requirement for massive transfusion [odds ratio, 1.56; 95% confidence interval (CI), 1.31-1.87; P<0.01]. The area under the receiver operating characteristic curve of lactate concentration and shock index for massive transfusion was 0.788 (95% CI: 0.736-0.840; P<0.01) and 0.776 (95% CI: 0.717-0.836; P<0.01), respectively. Lactate elevation (>4.0mML-1) was associated with 86.1% specificity and 67.8% positive predictive value for massive transfusion. When combining elevated lactate concentrations (>4.0mML-1) with a shock index >1.0, the specificity and positive predictive value increased to 95.5% and 82.4%, respectively. Point-of-care testing of lactate concentrations in the emergency department may be useful to predict massive transfusion requirements in primary postpartum haemorrhage. Combining initial lactate concentrations with the shock index improves the predictive performance for massive transfusion requirements and may contribute to rapid risk stratification of patients with primary postpartum haemorrhage in need of transfusion and further focus on early interventions to control bleeding.

Using rotational thromboelastometry clot firmness at 5 minutes (ROTEM® EXTEM A5) to predict massive transfusion and in-hospital mortality in trauma: a retrospective analysis of 1146 patients.

SummaryViscoelastic assays such as TEG ® and ROTEM ® are increasingly used to guide transfusion of blood products. The EXTEM assay maximum clot firmness (MCF) is a ROTEM measure available after 25–29 min used to guide early decisions. EXTEM A10, the clot firmness at 10 min, is an accepted early surrogate, but investigators differ on whether A5, the clot firmness at 5 min, is acceptable. We re‐examined this in a retrospective observational analysis of 1146 trauma patients in one centre who had ROTEM data recorded. A5 and A10 both correlated well with maximum clot firmness, with Pearson coefficients of r = 0.92 and r = 0.96, respectively. The correlations of A5, A10 and maximum clot firmness with requirement for massive transfusion were all similarly high, with c‐stats of 0.87, 0.89 and 0.90, respectively. The correlations with mortality were also similar but weaker, with c‐stats of 0.67, 0.69 and 0.69, respectively. Using a previously validated cut‐off of A5 < 35 mm to predict massive transfusion gave a sensitivity of 95%, specificity 83%, positive predictive value 9.3% and negative predictive value 100%. Using a value of A5 < 29 mm, for a pragmatic positive predictive value of 20%, gave a sensitivity of 67%, specificity 95% and negative predictive value 99%. Whether aiming for a high sensitivity or a strong predictive value, A5 was non‐inferior to A10 and actually missed fewer cases needing massive transfusion. A5 has similar utility to both A10 and maximum clot firmness as an early measure of clot firmness, and a low A5 value is strongly predictive of the need for massive transfusion.

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

PurposeExsanguination is the most common leading cause of death in trauma patients. The massive transfusion (MT) protocol may influence therapeutic strategies and help provide blood components in timely manner. The assessment of blood consumption (ABC) score is a popular MT protocol but has low predictability. The lactate level is a good parameter to reflect poor tissue perfusion or shock states that can guide the management. This study aimed to modify the ABC scoring system by adding the lactate level for better prediction of MT. MethodsThe data were retrospectively collected from 165 trauma patients following the trauma activated criteria at Songklanagarind Hospital from January 2014 to December 2014. The ABC scoring system was applied in all patients. The patients who had an ABC score ≥2 as the cut point for MT were defined as the ABC group. All patients who had a score ≥2 with a lactate level >4 mmol/dL were defined as the ABC plus lactate level (ABC + L) group. The prediction for the requirement of massive blood transfusion was compared between the ABC and ABC + L groups. The ability of ABC and ABC + L groups to predict MT was estimated by the area under the receiver operating characteristic curve (AUROC). ResultsAmong 165 patients, 15 patients (9%) required massive blood transfusion. There were no significant differences in age, gender, mechanism of injury or initial vital signs between the MT group and the non-MT group. The group that required MT had a higher Injury Severity Score and mortality. The sensitivity and specificity of the ABC scoring system in our institution were low (81%, 34%, AUC 0.573). The sensitivity and specificity were significantly better in the ABC + L group (92%, 42%, AUC = 0.745). ConclusionThe ABC scoring system plus lactate increased the sensitivity and specificity compared with the ABC scoring system alone.

Thrombelastography early amplitudes in bleeding and coagulopathic trauma patients: Results from a multicenter study.

Early amplitudes in the viscoelastic hemostatic assays, thrombelastography (TEG) and rotation thromboelastometry (ROTEM), provide fast results, which is critical in the resuscitation of bleeding patients. This study investigated associations between TEG early amplitudes and standard TEG variables in a large multicenter cohort of moderately to severely injured trauma patients admitted at three North European Level I Trauma Centers. Prospective observational study of 404 trauma patients with clinical suspicion of severe injury from London, UK, Copenhagen, Denmark and Oslo, Norway. Biochemistry and clinical data including outcome and TEG parameters were recorded upon arrival. Kaolin TEG, Rapid TEG, and TEG functional fibrinogen curves were extracted, and early amplitudes A5 and A10 (amplitude at 5 and 10 minutes) were registered. Patients were stratified according to international normalized ratio of 1.2 or less or greater than 1.2, as well as transfusion requirements (nontransfused, 1-9 red blood cell units and ≥10 red blood cell units in 12 hours). In total, 404 patients were included, median Injury Severity Score was 13. There were strong positive correlations between A5/A10 and maximum amplitude in all investigated assays. All TEG values except rTEG maximum amplitude and kTEG maximum amplitude correlated significantly with mortality in transfused patients. Time from initiation of assay to A5 and A10 were lowest for rapid TEG and TEG functional fibrinogen compared with kaolin TEG. Rapid TEG A5 reduced time to result with greater than 50% compared with rapid TEG maximum amplitude. We found strong associations between TEG early amplitudes A5/A10 and maximum amplitude in rapid TEG, kaolin TEG, and TEG functional fibrinogen across trauma patients with coagulopathy and massive transfusion requirements. Introducing the use of early amplitudes can reduce time to diagnosis of coagulopathy and may be used in TEG monitoring of trauma patient. Further randomized controlled trials evaluating the role of TEG in guiding hemostatic resuscitation are warranted. Prognostic study, level III.

Combat-related acetabular fractures: Outcomes of open versus closed injuries

IntroductionSince the onset of the Global War on Terror close to 50,000 United States service members have been injured in combat, many of these injuries would have previously been fatal. Among these injuries, open acetabular fractures are at an increased number due to the high percentage of penetrating injuries such as high velocity gunshot wounds and blast injuries. These injuries lead to a greater degree of contamination, and more severe associated injuries. There is a significantly smaller proportion of the classic blunt trauma mechanism typically seen in civilian trauma. MethodsWe performed a retrospective review of the Department of Defense Trauma Registry into which all US combat-injured patients are enrolled, as well as reviewed local patient medical records, and radiologic studies from March 2003 to April 2012. Eighty seven (87) acetabular fractures were identified with 32 classified as open fractures. Information regarding mechanism of injury, fracture pattern, transfusion requirements, Injury Severity Score (ISS), and presence of lower extremity amputations was analyzed. ResultsThe mechanism of injury was an explosive device in 59% (n=19) of patients with an open acetabular fracture; the remaining 40% (n=13) were secondary to ballistic injury. In contrast, in the closed acetabular fracture cohort 38% (21/55) of fractures were due to explosive devices, and all remaining (n=34) were secondary to blunt trauma such as falls, motor vehicle collisions, or aircraft crashes. Patients with open acetabular fractures required a median of 17units of PRBC within the first 24h after injury. The mean ISS was 32 in the open group compared with 22 in the closed group (p=0.003). In the open fracture group nine patients (28%) sustained bilateral lower extremity amputations, and 10 patients (31%) ultimately underwent a hip disarticulation or hemi-pelvectomy as their final amputation level. DiscussionOpen acetabular fractures represent a significant challenge in the management of combat-related injuries. High ISS and massive transfusion requirements are common in these injuries. This is one of the largest series reported of open acetabular fractures. Open acetabular fractures require immediate damage control surgery and resuscitation as well as prolonged rehabilitation due to their severity. The dramatic number of open acetabular fractures (37%) in this review highlights the challenge in treatment of combat related acetabular fractures.

The trauma center is too late: Major limb trauma without a pre-hospital tourniquet has increased death from hemorrhagic shock.

To date, no civilian studies have demonstrated that pre-hospital (PH) tourniquets improve survival. We hypothesized that late, trauma center (TC) tourniquet use would increase death from hemorrhagic shock compared to early (PH) placement. All patients arriving to a Level 1, urban TC between October 2008 and January 2016 with a tourniquet placed before (T-PH) or after arrival to the TC (T-TC) were evaluated. Cases were assigned the following designations: indicated (absolute indication [vascular injury requiring repair/ligation, operation within 2 hours for extremity injury, or traumatic amputation] or relative indication [major musculoskeletal/soft tissue injury requiring operation 2-8 hours after arrival, documented large blood loss]) or non-indicated. Outcomes were death from hemorrhagic shock, physiology upon arrival to the TC, and massive transfusion requirements. After univariate analysis, logistic regression was carried out to assess independent predictors of death from hemorrhagic shock. A total of 306 patients received 326 tourniquets for injuries to 157 upper and 147 lower extremities. Two hundred eighty-one (92%) had an indication for placement. Seventy percent of patients had a blunt mechanism of injury. T-TC patients arrived with a lower systolic blood pressure (SBP, 101 [86, 123] vs. 125 [100, 145] mm Hg, p < 0.001), received more transfusions in the first hour of arrival (55% vs. 34%, p = 0.02), and had a greater mortality from hemorrhagic shock (14% vs. 3.0%, p = 0.01). When controlling for year of admission, mechanism of injury and shock upon arrival (SBP ≤90 mm Hg or HR ≥120 bpm or base deficit ≤ 4) indicated T-TC had a 4.5-fold increased odds of death compared to T-PH (OR 4.5, 95% CI 1.23-16.4, p = 0.02). Waiting until TC arrival to control hemorrhage with a tourniquet was associated with worsened blood pressure and increased transfusion within the first hour of arrival. In routine civilian trauma patients, delaying to T-TC was associated with 4.5-fold increased odds of mortality from hemorrhagic shock. Level IV.