Trauma Transfusion Research Articles

Pathogen inactivation treatment of plasma and platelet concentrates and their predicted functionality in massive transfusion protocols.

Trauma transfusion packages for hemorrhage control consist of red blood cells, plasma, and platelets at a set ratio. Although pathogen reduction improves the transfusion safety of platelet and plasma units, there is an associated reduction in quality. This study aimed to investigate the impact of riboflavin/ultraviolet light-treated plasma or platelets in transfusion trauma packages composed of red blood cell, plasma, and platelet units in a ratio of 1:1:1 in vitro by modeling transfusion scenarios for trauma patients and assessing function by rotational thromboelastometry. Pathogen-reduced or untreated plasma and buffy coat platelet concentrate units produced in plasma were used in different combinations with red blood cells in trauma transfusion packages. After reconstitution of these packages with hemodiluted blood, the hemostatic functionality was analyzed by rotational thromboelastometry. Hemostatic profiles of pathogen-inactivated buffy coat platelet concentrate and plasma indicated decreased activity compared with their respective controls. Reconstitution of hemodiluted blood (hematocrit = 20%) with packages that contained treated or nontreated components resulted in increased alpha and maximum clot firmness and enhanced clot-formation time. Simulating transfusion scenarios based on 30% blood replacement with a transfusion trauma package resulted in a nonsignificant difference in rotational thromboelastometry parameters between packages containing treated and nontreated blood components (p ≥ 0.05). Effects of pathogen inactivation treatment were evident when the trauma package percentage was 50% or greater and contained both pathogen inactivation-treated plasma and buffy coat platelet concentrate. Rotational thromboelastometry investigations suggest that there is relatively little impact of pathogen inactivation treatment on whole blood clot formation unless large amounts of treated components are used.

Injury severity, sex, and transfusion volume, but not transfusion ratio, predict inflammatory complications after traumatic injury

BackgroundBlood component (packed red blood cells [PRBC], fresh frozen plasma [FFP], platelets [PLT]) ratios transfused in a 1:1:1 fashion are associated with survival after trauma; the relationship among blood component ratios and inflammatory complications after trauma is not fully understood. ObjectivesTo evaluate the relationship among blood component ratios (1:1 vs other for PRBC:FFP and PRBC:PLT) and inflammatory complications (primary outcome) in patients with major trauma. MethodsSecondary analysis of a multi-institution database (N = 1538). Survival methods were used to determine the relationship among blood component ratios and inflammatory complications. ResultsPatients were primarily male (68%), Caucasians (89%), aged 39 ± 14 years, involved in a motor vehicle collision (53%). Eighty-six percent of patients developed an inflammatory complication; 76% developed organ failure, 27% ventilator-associated pneumonia, and 24% acute respiratory distress syndrome. Injury severity, sex, and total PRBC transfusion volume, not blood component ratio, predicted inflammatory complications. ConclusionsIncreased understanding of factors associated with inflammation after trauma and PRBC transfusion is needed.

Viscoelastic hemostatic assays in the management of the pediatric trauma patient

Viscoelastic hemostatic assays (VHA), such as TEG and ROTEM, are whole blood tests that depict functional coagulation both numerically and graphically. The development of rapid VHA technology, which allows for the first data points to result within minutes of test initiation, has increased the utility of these tests in the treatment of trauma patients. Both adult and pediatric centers have integrated VHAs into trauma resuscitation and transfusion protocols. Literature regarding the use of VHAs for injured children is limited. Here, we discuss the mechanics and interpretation of VHAs as well as the use of VHAs in data-driven resuscitation of pediatric trauma patients. Novel research on fibrinolysis states after injury as well as hypercoagulable state diagnosed with VHAs are presented.

Massive transfusion in pediatric trauma: We need to focus more on "how".

Massive transfusion in pediatric trauma: We need to focus more on "how".

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.

Evaluation of a Pediatric Assessment of Blood Consumption Score to Predict Blood Transfusion in Pediatric Trauma

Evaluation of a Pediatric Assessment of Blood Consumption Score to Predict Blood Transfusion in Pediatric Trauma

Impact of Massive Transfusion and Aging Blood in Acute Trauma

Blood transfusions cause altered immunity and the duration of storage is contributory. In the era of massive transfusion protocols (MTPs) this impact is unclear, particularly as it relates to balanced transfusions. Trauma patients requiring our MTP after admission to our Level II trauma center were studied. The average age of blood transfused was calculated; old blood was a storage time of ≥14 days versus new blood <14 days. Blood to plasma ratios of 1:1 were compared with ratios >1:1. Infections, organ dysfunction multiorgan injury (MOI), and death were compared based on ratios and blood storage times. Of 2200 trauma admissions, 89 patients required MTP. Penetrating injuries were the majority, n = 53; and Injury Severity Score was 33 ± 14. Overall mortality was 31 per cent and sepsis was 28 per cent. Outcomes (storage time): Patients receiving old versus new blood had comparable age and Injury Severity Score. Sepsis rates, multiorgan injury and mortality were similar. Outcomes (packed red blood cells:fresh frozen plasma): Balanced transfusions (ratios of 1:1) demonstrated significant survival benefit and less infections compared with ratios >1:1. These data underscore the complexity of transfusion-related morbidity. In the modern era of MTP and balanced transfusions, the age of stored blood may not impact outcomes as demonstrated historically.

Massive transfusion in pediatric trauma: analysis of the National Trauma Databank

BackgroundMassive transfusion (MT) in pediatric trauma has been described in combat populations and other single institutions studies. We aim to define the incidence of MT in a large US civilian pediatric trauma population, identify predictive parameters of MT, and the mortality associated with MT. MethodsData from the National Trauma Databank (2010-2012), a trauma registry maintained by the American College of Surgeons, were analyzed. We included pediatric trauma patients ≤14 y that underwent MT, as defined by 40 mL/kg of blood products within the first 24 h after admission. We compared the MT group with children receiving any transfusion within the same time frame. Univariate and multivariate analysis were performed. ResultsOf 356,583 pediatric trauma patients, 13,523 (4%) received any transfusion in the first 24 h and 173 (0.04%) had a MT. On multivariate analysis, factors predicting MT were: older patients (5-12: OR 2.71, P = 0.006, and ≥12: OR 5.14, P < 0.001), hypothermic patients (temperature <35: OR 2.48, P < 0.025), low Glasgow Coma Scale (Glasgow Coma Scale <8: OR 2.82, P = 0.009), and Injury Severity Scores ≥25 (OR 2.01, P = 0.03). Overall mortality for the entire group, any transfusion group, and MT group were 2.5%, 13.6%, and 50.6%, respectively (P < 0.001). ConclusionsMT in pediatric trauma is an uncommon event associated with a significant mortality. Patients undergoing MT are older, more likely to be hypothermic and have sustained more severe injuries as measured by traditional trauma scoring systems than transfused trauma patients.

Prospective validation of the shock index pediatric-adjusted (SIPA) in blunt liver and spleen trauma: An ATOMAC + study

BackgroundAge-adjusted pediatric shock index (SIPA) does not require knowledge of age-adjusted blood pressure norms, yet correlates with mortality, serious injury, and need for transfusion in trauma. No prospective studies support its validity. MethodsA multicenter prospective observational study of patients 4–16years presenting April 2013–January 2016 with blunt liver and/or spleen injury (BLSI). SIPA (maximum heart rate/minimum systolic blood pressure) thresholds of >1.22, >1.0, and >0.9 in the emergency department were used for 4–6, 7–12 and 13–16year-olds, respectively. Patients with ISS ≤15 were excluded to conform to the original paper. Discrimination outcomes were compared between SIPA and shock index (SI). ResultsOf 1008 patients, 386 met inclusion. SI was elevated in 321, and SIPA elevated in 282. The percentage of patients with elevated index (SI or SIPA) and blood transfusion within 24 hours (30% vs 34%), BLSI grade ≥3 requiring transfusion (28% vs 32%), operative intervention (14% vs 16%) and ICU admission (64% vs 67%) was higher in the SIPA group. ConclusionSIPA was validated in this multi-institutional prospective study and identified a higher percentage of children requiring additional resources than SI in BLSI patients. SIPA may be useful for determining necessary resources for injured patients with BLSI. Level of evidenceLevel II prognosis.

Potential effects of high plasma to red blood cell ratio transfusion in pediatric trauma

ObjectiveHigh ratio of plasma to red blood cells during massive transfusion is associated with improved survival of traumatic injuries in adults, but this has not been demonstrated in children. Our objective was to compare the outcome of children who received high (≥1:2) versus low (&lt;1:2) plasma: red blood cells (P:R) ratios at 24 h from injury.MethodsWe conducted a retrospective chart review of children &lt;18 years of age who presented to the emergency department over a 7-year period and received massive transfusion (≥40 ml/kg red blood cells or ≥80 ml/kg total blood products in 24 h). Our primary outcome of interest was in-hospital mortality.ResultsWe identified 38 children who received massive transfusion. There was no significant difference in in-hospital mortality (45.8% vs. 64.3%) between the high (n = 24, median ratio 1:1.1) and low P:R ratio (n = 14, median 1:3.2) groups. In subset analyses, there was reduced mortality for high P:R patients with BIG score ≥24 (69.2% vs. 100%) and those taken to the operating room within 6 h of arrival (21.4% vs. 60.0%), respectively ( p &lt; 0.05). There was a trend for improved survival in high P:R patients without severe traumatic brain injury (TBI) (0% vs. 40.0%).ConclusionsThis study suggests that high P:R transfusion may improve in-hospital survival of injured children at high risk of mortality and in children without severe TBI, supporting the need for large, multi-center studies.

Guidelines for Imaging and Transfusion in Trauma

Sponsoring Organization: U.K.'s National Institute for Health and Care Excellence (NICE) Target Population: Emergency physicians, surgeons, and other clinicians who care for patients with trauma Background and Objective An expert panel commissioned by the U.K.'s National Health Service reported recommendations for assessment and resuscitation of major trauma in the context of a system of care organized by regional trauma networks. Key Recommendations

Shiraz Trauma Transfusion Score: A Scoring System for Blood Transfusion in Trauma Patients.

Uncontrolled hemorrhage is a major preventable cause of death after trauma [1]. Hemorrhagic shock can result in a critical reduction in tissues perfusion and oxygenation, which may produce profound tissue lactic acidosis and cellular dysfunction. In such a condition, rapid restoration of oxygen delivery is essential to prevent end-organ damage [1, 2]. Parallel to advances in the field of trauma treatment, resuscitation guidelines have evolved and developed. However, there are still ongoing discussions about various aspects of the application of these guidelines in clinical practice; particularly, about blood products transfusion [3].In the field of transfusion, two basic, important issues are the start and end point of the process and how long each patient will benefit from a transfusion. It would be very simplistic to consider only one factor, like hemoglobin level, when starting or ending the procedure. In fact, making the decision to transfuse is multifactorial, comprising the following factors: (1) the type of acute event that resulted in the patient’s hospitalization; (2) the patient’s underlying medical conditions; (3) the blood pressure needed for preserving vital organs function (particularly that of the central nervous system) in different situations; (4) the patient’s heart rate as an early indicator of the inability of compensatory mechanisms to maintain oxygen flow to tissues (cardiovascular system); (5) hemoglobin level as a general index for the blood's ability to carry oxygen (the suitable level differs in various conditions); and (6) base deficit (BD) level of blood as an available indicator of shock severity (the appropriate level of BD varies in different situations) [4-7]. It seems that by considering these factors and carrying out individualized risk stratification for each patient, more precise decisions can be made regarding patients who are more likely to benefit from blood transfusion. These targeted transfusions will be more beneficial in reducing the currently occurring significant percentage of inappropriate transfusions [8].All the above-mentioned factors should be assessed not only for beginning a blood transfusion, but also for continuing and ending it. For example, in the field of trauma, the most important principle is to preserve the body’s circulatory function in an acceptable manner to avoid (or minimize) any possible damage to brain (and heart) tissue. The second aim is to prevent the patient’s coagulopathy. Finally, preventing irreversible damage to other body organs is a priority. Therefore, higher blood pressure levels are needed to preserve the brain in situations where its autoregulatory mechanisms are disturbed, concomitant brain damage exists, or brain tissue is susceptible to injury following a relative decrease in blood flow and the consequential deoxygenation. The best witness for this claim is the significant increase in mortality rates among major trauma patients with traumatic brain injury when their systolic blood pressure (SBP) decreases to less than 100 mmHg; whereas, penetrating trauma patients that have not experienced traumatic brain injury will well tolerate SBP levels of 80 mmHg.Obviously, underlying conditions affecting the cardiovascular system limit its function and lead to a patient’s decreased physiologic reserves, thus requiring the implementation of early interventions, including blood transfusion [9]. Moreover, it is evident that critical and goal levels of blood pressure vary in different situations. This is also true for BD levels. For instance, it has been shown that mortality rates increase in patients with trauma when the BD value is more than 6 mMol/L [6, 9]. In the busy trauma center of Shahid Rajaee Trauma Hospital, not all patients are resuscitated in the same way. Considering the aforementioned facts and based on our previous clinical and research experiences, we developed a transfusion guide scoring system for trauma patients, named Shiraz Trauma Transfusion Score (Table 1). This score considers patients’ pre-existing medical conditions, blood pressure levels, pulse rate, hemoglobin level, and the amount of base excess. In this scoring system, patients are being categorized into 3 groups based on the mechanism of injury, including cases of multiple traumas with and without concomitant brain injury, and those with penetrating injuries. Shiraz Trauma Transfusion Score is applicable after early hydration with 2 liters of crystalloids. This scoring system was assessed based on experts’ opinions in systematic method. The experts’ opinion regarding current transfusion guidelines was assessed and was compared to the results obtained from Shiraz Trauma Transfusion Score. The agreement between these two approaches validated clinical application of this scoring system.

Capillary lactate concentration on admission of normotensive trauma patients: a prospective study.

BackgroundElevated serum blood lactate is an indicator of on-going bleeding in severe trauma patients. Point-of-care (POC) capillary lactate measurement devices may be useful to rapidly assess lactate concentration at the bedside. The aim of this study was to test the diagnostic performance of capillary lactate to predict significant transfusion in normotensive trauma patients.MethodsWe conducted a prospective observational study in one level-I trauma centre. From August 2011 to February 2013, 120 consecutive adult patients with systolic blood pressure (SBP) higher than 90 mmHg were included. Capillary lactate was measured on admission in the trauma bay. The primary outcome was defined as a significant transfusion within the first 48 h. Diagnostic performance was determined using receiver operating characteristic (ROC) curve analysis. We also tested the agreement between capillary lactate and blood lactate concentrations using Bland and Altman analysis.ResultsOf the 120 normotensive trauma patients, 30 (25 %) required at least one unit of packed red blood cells (RBC) and 12 (10 %) patients received at least four RBC within the first 48 h. All patients with significant RBC transfusion had capillary lactate higher than 3.5 mmol/l. The area under the ROC curve of capillary lactate on admission to predict transfusion of at least 4 RBC units was 0.68 [95 % CI 0.58 – 0.78]. The average bias between capillary and blood lactate measurements was 2.4 mmol/l with a standard deviation of 3.0 mmol/l (n = 60 patients).ConclusionsAlthough a significant association was found between POC lactate concentration and transfusion requirements, the diagnostic performance of capillary lactate measurements was poor. Due to large disagreement between capillary lactate and blood lactate, capillary lactate cannot be considered in the clinical setting.Trial registrationClinicalTrials.gov, No. NCT01793428.Electronic supplementary materialThe online version of this article (doi:10.1186/s13049-016-0272-x) contains supplementary material, which is available to authorized users.

Influence of surgical bleeding on the relationship between admission coagulopathy and risk of massive transfusion: lesson from 704 severe trauma patients.

This study hypothesized that the relationship between early coagulopathy and massive transfusion (MT) in trauma was highly dependent on the presence of surgical bleeding. Consecutive severe trauma patients admitted to our institution over a 4-year period were included in this retrospective study. Surgical bleeding was defined as an injury requiring an invasive endovascular or surgical haemostatic procedure. The ability of prothrombin time ratio (PTr) and activated partial thromboplastin time ratio (aPTTr) to predict MT (≥10 units of packed red blood cells during the first 24h) was determined by ROC curves. The strength of association and interaction between PTr, surgical bleeding and MT was assessed using a logistic regression analysis. Among the 704 patients included (ISS 21·0±16·2), MT rate was higher in patients with surgical bleeding than in those with no surgical bleeding (47% vs. 5%; P<0·001). The global performance of PTr and aPTTr to predict MT was only fair in our study population (AUCs 0·83 and 0·81). MT rate was widely higher in the surgical bleeding group whatever the severity of coagulopathy (P<0·001). PTr was found to be significantly associated with TM [PTr≥1·5, OR 23·6 (95% CI 13·4-41·7); PTr 1·2-1·5, OR 3·0 (95% CI 1·7-5·3)]. Corresponding ORs were reduced after adjusting for the surgical bleeding: 12·1 (95% CI 6·5-22·5) and 2·1 (95% CI 1·2-4·0), respectively. However, no significant interaction was found regression models. The strength of association between MT and coagulation status on admission was found strongly influenced by surgical bleeding. The admission coagulopathy monitoring in trauma patients without considering the surgical bleeding does not allow a reliable determination of MT probability.

Recurrent event frailty models reduced time-varying and other biases in evaluating transfusion protocols for traumatic hemorrhage

ObjectiveTransfusion research seeks to improve survival for severely injured and hemorrhaging patients using optimal plasma and platelet ratios over red blood cells (RBCs). However, most published studies comparing different ratios are plagued with serious bias and ignore time-varying effects. We applied joint recurrent event frailty models to increase validity and clinical utility. Study Design and SettingUsing the PRospective Observational Multicenter Major Trauma Transfusion study data, our joint random-effects models estimated the association of (1) clinical covariates with transfusion rate intensities and (2) varying plasma:RBC and platelet:RBC ratios with survival over the 24 hours after hospital admission. Along with survival time, baseline patient vital signs, laboratory values, and longitudinal data on types and volumes of transfusions were included. ResultsBaseline systolic blood pressure, heart rate, pH, and hemoglobin were significantly associated with RBC transfusion rates. Increased transfusion rates (per hour) of plasma (P = 0.05), platelets (P < 0.001), or RBCs were associated with increased 24-hour mortality. Higher ratios of plasma:RBC (P = 0.107) and platelet:RBC (P < 0.001) were associated with reduced mortality in a time-varying pattern (P < 0.001). ConclusionsThe proposed joint analysis of transfusion rates and ratios offers a more valid statistical approach to evaluate survival effects in the presence of informative censoring by early death.

Association of Blood Component Ratio With Clinical Outcomes in Patients After Trauma and Massive Transfusion: A Systematic Review.

Component ratios that mimic whole blood may produce survival benefit in patients massively transfused after trauma; other outcomes have not been reviewed. The purpose of this review was to systematically analyze studies where clinical outcomes were compared on the basis of the component ratios administered during massive transfusion in adult patients after trauma. PubMed, CINAHL, and MEDLINE (Ovid) were searched for studies published in English between 2007 and 2015, performed at Level I or major trauma centers. Twenty-one studies were included in the analysis. We used an adapted 9-item instrument to assess bias risk. The average bias score for the studies was 2.86 ± 1.39 out of 16, indicating a low bias risk. The most common bias sources were lack of data about primary outcomes and adverse events. Those who received high ratios experienced not only greater survival benefit but also higher rates of multiple-organ failure; all other clinical outcomes findings were equivocal.

Recursive partitioning identifies greater than 4 U of packed red blood cells per hour as an improved massive transfusion definition.

Massive transfusion (MT) is classically defined as greater than 10 U of packed red blood cells (PRBCs) in 24 hours. This fails to capture the most severely injured patients. Extending the previous work of Savage and Rahbar, a rolling hourly rate-based definition of MT may more accurately define critically injured patients requiring early, aggressive resuscitation. The Prospective Observational Multicenter Major Trauma Transfusion (PROMMTT) trial collected data from 10 Level 1 trauma centers. Patients were placed into rate-based transfusion groups by maximal number of PRBCs transfused in any hour within the first 6 hours. A nonparametric analysis using classification trees partitioned data according to mortality at 24 hours using a predictor variable of maximum number PRBC units transfused in an hour. Dichotomous variables significant in previous scores and models as predictors of MT were used to identify critically ill patients: a positive finding on Focused Assessment with Sonography in Trauma (FAST) examination, Glasgow Coma Scale (GCS) score less than 8, heart rate greater than 120 beats/min, systolic blood pressure less than 90 mm Hg, penetrating mechanism of injury, international normalized ratio greater than 1.5, hemoglobin less than 11, and base deficit greater than 5. These critical indicators were then compared among the nodes of the classification tree. Patients omitted included those who did not receive PRBCs (n = 24) and those who did not have all eight critical indicators reported (n = 449). In a population of 1,245 patients, the classification tree included 772 patients. Analysis by recursive partitioning showed increased mortality among patients receiving greater than 13 U/h (73.9%, p < 0.01). In those patients receiving less than or equal to 13 U/h, mortality was greater in patients who received more than 4 U/h (16.7% vs. 6.0%, p < 0.01) (Fig. 1). Nodal analysis showed that the median number of critical indicators for each node was 3 (2-4) (≤4 U/h), 4 (3-5) (>4 U/h and ≤13 U/h), and 5 (4-5.5) (>13 U/h). A rate-based transfusion definition identifies a difference in mortality in patients who receive greater than 4 U/h of PRBCs. Redefining MT to greater than 4 U/h allows early identification of patients with a significant mortality risk who may be missed by the current definition. Prognostic/epidemiologic study, level III.

Massive Transfusion for Trauma in a Lower Middle Income Country

Massive Transfusion for Trauma in a Lower Middle Income Country

A joint latent class model for classifying severely hemorrhaging trauma patients.

BackgroundIn trauma research, “massive transfusion” (MT), historically defined as receiving ≥10 units of red blood cells (RBCs) within 24 h of admission, has been routinely used as a “gold standard” for quantifying bleeding severity. Due to early in-hospital mortality, however, MT is subject to survivor bias and thus a poorly defined criterion to classify bleeding trauma patients.MethodsUsing the data from a retrospective trauma transfusion study, we applied a latent-class (LC) mixture model to identify severely hemorrhaging (SH) patients. Based on the joint distribution of cumulative units of RBCs and binary survival outcome at 24 h of admission, we applied an expectation-maximization (EM) algorithm to obtain model parameters. Estimated posterior probabilities were used for patients’ classification and compared with the MT rule. To evaluate predictive performance of the LC-based classification, we examined the role of six clinical variables as predictors using two separate logistic regression models.ResultsOut of 471 trauma patients, 211 (45 %) were MT, while our latent SH classifier identified only 127 (27 %) of patients as SH. The agreement between the two classification methods was 73 %. A non-ignorable portion of patients (17 out of 68, 25 %) who died within 24 h were not classified as MT but the SH group included 62 patients (91 %) who died during the same period. Our comparison of the predictive models based on MT and SH revealed significant differences between the coefficients of potential predictors of patients who may be in need of activation of the massive transfusion protocol.ConclusionsThe traditional MT classification does not adequately reflect transfusion practices and outcomes during the trauma reception and initial resuscitation phase. Although we have demonstrated that joint latent class modeling could be used to correct for potential bias caused by misclassification of severely bleeding patients, improvement in this approach could be made in the presence of time to event data from prospective studies.

Transfusion in acute trauma: a conundrum for the African emergency care system

Transfusion in acute trauma: a conundrum for the African emergency care system