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Ma K, Bebawy JF. Anemia and Optimal Transfusion Thresholds in Brain-Injured Patients: A Narrative Review of the Literature. Anesth Analg 2024; 138:992-1002. [PMID: 38109853 DOI: 10.1213/ane.0000000000006772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2023]
Abstract
Anemia is a highly prevalent condition that may compromise oxygen delivery to vital organs, especially among the critically ill. Although current evidence supports the adoption of a restrictive transfusion strategy and threshold among the nonbleeding critically ill patient, it remains unclear whether this practice should apply to the brain-injured patient, given the predisposition to cerebral ischemia in this patient population, in which even nonprofound anemia may exert a detrimental effect on clinical outcomes. The purpose of this review is to provide an overview of the pathophysiological changes related to impaired cerebral oxygenation in the brain-injured patient and to present the available evidence on the effect of anemia and varying transfusion thresholds on the clinical outcomes of patients with acute brain injury.
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Affiliation(s)
- Kan Ma
- From the Department of Anesthesiology and Pain Medicine, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - John F Bebawy
- Department of Anesthesiology and Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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2
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Filipovic MG, Luedi MM. Transfusion strategies in traumatic brain injury - A clinical debate. J Clin Anesth 2023; 90:111233. [PMID: 37633045 DOI: 10.1016/j.jclinane.2023.111233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 08/13/2023] [Accepted: 08/16/2023] [Indexed: 08/28/2023]
Affiliation(s)
- Mark G Filipovic
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
| | - Markus M Luedi
- Department of Anaesthesiology and Pain Medicine, Cantonal Hospital of St. Gallen, St. Gallen, Switzerland
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Montgomery EY, Barrie U, Kenfack YJ, Edukugho D, Caruso JP, Rail B, Hicks WH, Oduguwa E, Pernik MN, Tao J, Mofor P, Adeyemo E, Ahmadieh TYE, Tamimi MA, Bagley CA, Bedros N, Aoun SG. Transfusion Guidelines in Traumatic Brain Injury: A Systematic Review and Meta-Analysis of the Currently Available Evidence. Neurotrauma Rep 2022; 3:554-568. [PMID: 36636743 PMCID: PMC9811955 DOI: 10.1089/neur.2022.0056] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Our study aims to provide a synthesis of the best available evidence on the hemoglobin (hgb) red blood cell (RBC) transfusion thresholds in adult traumatic brain injury (TBI) patients, as well as describing the risk factors and outcomes associated with RBC transfusion in this population. A systematic review and meta-analysis was conducted using PubMed, Google Scholar, and Web of Science electronic databases according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to assess articles discussing RBC transfusion thresholds and describe complications secondary to transfusion in adult TBI patients in the perioperative period. Fifteen articles met search criteria and were reviewed for analysis. Compared to non-transfused, TBI patients who received transfusion tended to be primarily male patients with worse Injury Severity Score (ISS) and Glasgow Coma Scale. Further, the meta-analysis corroborated that transfused TBI patients are older (p = 0.04), have worse ISS scores (p = 0.001), receive more units of RBCs (p = 0.02), and have both higher mortality (p < 0.001) and complication rates (p < 0.0001). There were no differences identified in rates of hypertension, diabetes mellitus, and Abbreviated Injury Scale scores. Additionally, whereas many studies support restrictive (hgb <7 g/dL) transfusion thresholds over liberal (hgb <10 g/dL), our meta-analysis revealed no significant difference in mortality between those thresholds (p = 0.79). Current Class B/C level III evidence predominantly recommends against a liberal transfusion threshold of 10 g/dL for TBI patients (Class B/C level III), but our meta-analysis found no difference in survival between groups. There is evidence suggesting that an intermediate threshold between 7 and 9 g/dL, reflecting the physiological oxygen needs of cerebral tissue, may be worth exploring.
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Affiliation(s)
- Eric Y. Montgomery
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
- Address correspondence to: Eric Y. Montgomery, BA, Department of Neurosurgery, The University of Texas Southwestern, 5151 Harry Hines Boulevard, Dallas, TX 75235, USA.
| | - Umaru Barrie
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Yves J. Kenfack
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Derrek Edukugho
- Department of Neurological Surgery, Boonshoft School of Medicine, Wright State University, Dayton, Ohio, USA
| | - James P. Caruso
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Benjamin Rail
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - William H. Hicks
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Emmanuella Oduguwa
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Mark N. Pernik
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Jonathan Tao
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Paula Mofor
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Emmanuel Adeyemo
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Tarek Y. El Ahmadieh
- Department of Neurological Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Mazin Al Tamimi
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Carlos A. Bagley
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Nicole Bedros
- Department of Surgery, Baylor University Medical Center, Dallas, Texas, USA
| | - Salah G. Aoun
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
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Navarro JC, Kofke WA. Perioperative Management of Acute Central Nervous System Injury. Perioper Med (Lond) 2022. [DOI: 10.1016/b978-0-323-56724-4.00024-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
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Egea-Guerrero JJ, García-Sáez I, Quintana-Díaz M. Trigger transfusion in severe traumatic brain injury. Med Intensiva 2021; 46:157-160. [PMID: 34952791 DOI: 10.1016/j.medine.2021.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 03/08/2021] [Accepted: 03/21/2021] [Indexed: 11/28/2022]
Affiliation(s)
- J J Egea-Guerrero
- Unidad de Gestión Clínica de Medicina Intensiva, Hospital Universitario Virgen del Rocío, Sevilla, IBIS/CSIC/Universidad de Sevilla, Sevilla, Spain.
| | - I García-Sáez
- Servicio de Medicina Intensiva, Hospital Universitario de Donostia, San Sebastián, Guipúzcoa, Spain
| | - M Quintana-Díaz
- Servicio de Medicina Intensiva, Hospital Universitario de La Paz, Idipaz, Madrid, Spain
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Zusman BE, Dixon CE, Jha RM, Vagni VA, Henchir JJ, Carlson SW, Janesko-Feldman KL, Bailey ZS, Shear DA, Gilsdorf JS, Kochanek PM. Choice of Whole Blood versus Lactated Ringer's Resuscitation Modifies the Relationship between Blood Pressure Target and Functional Outcome after Traumatic Brain Injury plus Hemorrhagic Shock in Mice. J Neurotrauma 2021; 38:2907-2917. [PMID: 34269621 PMCID: PMC8672104 DOI: 10.1089/neu.2021.0157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Civilian traumatic brain injury (TBI) guidelines recommend resuscitation of patients with hypotensive TBI with crystalloids. Increasing evidence, however, suggests that whole blood (WB) resuscitation may improve physiological and survival outcomes at lower resuscitation volumes, and potentially at a lower mean arterial blood pressure (MAP), than crystalloid after TBI and hemorrhagic shock (HS). The objective of this study was to assess whether WB resuscitation with two different MAP targets improved behavioral and histological outcomes compared with lactated Ringer's (LR) in a mouse model of TBI+HS. Anesthetized mice (n = 40) underwent controlled cortical impact (CCI) followed by HS (MAP = 25-27 mm Hg; 25 min) and were randomized to five groups for a 90 min resuscitation: LR with MAP target of 70 mm Hg (LR70), LR60, WB70, WB60, and monitored sham. Mice received a 20 mL/kg bolus of LR or autologous WB followed by LR boluses (10 mL/kg) every 5 min for MAP below target. Shed blood was reinfused after 90 min. Morris Water Maze testing was performed on days 14-20 post-injury. Mice were euthanized (21 d) to assess contusion and total brain volumes. Latency to find the hidden platform was greater versus sham for LR60 (p < 0.002) and WB70 (p < 0.007) but not LR70 or WB60. The WB resuscitation did not reduce contusion volume or brain tissue loss. The WB targeting a MAP of 60 mm Hg did not compromise function versus a 70 mm Hg target after CCI+HS, but further reduced fluid requirements (p < 0.03). Using LR, higher achieved MAP was associated with better behavioral performance (rho = -0.67, p = 0.028). Use of WB may allow lower MAP targets without compromising functional outcome, which could facilitate pre-hospital TBI resuscitation.
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Affiliation(s)
- Benjamin E. Zusman
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - C. Edward Dixon
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
- Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Ruchira M. Jha
- Department of Neurology, Barrow Neurological Institute, Phoenix, Arizona, USA
- Department of Neurobiology, and Barrow Neurological Institute, Phoenix, Arizona, USA
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Vincent A. Vagni
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
- Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Jeremy J. Henchir
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
- Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Shaun W. Carlson
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
- Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Keri L. Janesko-Feldman
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
- Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Zachary S. Bailey
- Brain Trauma Neuroprotection Branch, Center for Military Psychiatry and Neuroscience, Walter Reed Army Institute of Research, Silver Spring, Maryland, USA
| | - Deborah A. Shear
- Brain Trauma Neuroprotection Branch, Center for Military Psychiatry and Neuroscience, Walter Reed Army Institute of Research, Silver Spring, Maryland, USA
| | - Janice S. Gilsdorf
- Brain Trauma Neuroprotection Branch, Center for Military Psychiatry and Neuroscience, Walter Reed Army Institute of Research, Silver Spring, Maryland, USA
| | - Patrick M. Kochanek
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
- Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
- Clinical and Translational Science Institute, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
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Egea-Guerrero JJ, García-Sáez I, Quintana-Díaz M. Trigger transfusion in severe traumatic brain injury. Med Intensiva 2021; 46:S0210-5691(21)00071-1. [PMID: 33962806 DOI: 10.1016/j.medin.2021.03.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 03/08/2021] [Accepted: 03/21/2021] [Indexed: 11/17/2022]
Affiliation(s)
- J J Egea-Guerrero
- Unidad de Gestión Clínica de Medicina Intensiva, Hospital Universitario Virgen del Rocío, Sevilla. IBIS/CSIC/Universidad de Sevilla, Sevilla, España.
| | - I García-Sáez
- Servicio de Medicina Intensiva, Hospital Universitario de Donostia, San Sebastián, Guipúzcoa, España
| | - M Quintana-Díaz
- Servicio deMedicina Intensiva, Hospital Universitario de La Paz. Idipaz, Madrid, España
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Mader MMD, Lefering R, Westphal M, Maegele M, Czorlich P. Traumatic brain injury with concomitant injury to the spleen: characteristics and mortality of a high-risk trauma cohort from the TraumaRegister DGU®. Eur J Trauma Emerg Surg 2020; 48:4451-4459. [PMID: 33206232 DOI: 10.1007/s00068-020-01544-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 10/31/2020] [Indexed: 11/28/2022]
Abstract
PURPOSE Based on the hypothesis that systemic inflammation contributes to secondary injury after initial traumatic brain injury (TBI), this study aims to describe the effect of splenectomy on mortality in trauma patients with TBI and splenic injury. METHODS A retrospective cohort analysis of patients prospectively registered into the TraumaRegister DGU® (TR-DGU) with TBI (AISHead ≥ 3) combined with injury to the spleen (AISSpleen ≥ 1) was conducted. Multivariable logistic regression modeling was performed to adjust for confounding factors and to assess the independent effect of splenectomy on in-hospital mortality. RESULTS The cohort consisted of 1114 patients out of which 328 (29.4%) had undergone early splenectomy. Patients with splenectomy demonstrated a higher Injury Severity Score (median: 34 vs. 44, p < 0.001) and lower Glasgow Coma Scale (median: 9 vs. 7, p = 0.014) upon admission. Splenectomized patients were more frequently hypotensive upon admission (19.8% vs. 38.0%, p < 0.001) and in need for blood transfusion (30.3% vs. 61.0%, p < 0.001). The mortality was 20.7% in the splenectomy group and 10.3% in the remaining cohort. After adjustment for confounding factors, early splenectomy was not found to exert a significant effect on in-hospital mortality (OR 1.29 (0.67-2.50), p = 0.45). CONCLUSION Trauma patients with TBI and spleen injury undergoing splenectomy demonstrate a more severe injury pattern, more compromised hemodynamic status and higher in-hospital mortality than patients without splenectomy. Adjustment for confounding factors reveals that the splenectomy procedure itself is not independently associated with survival.
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Affiliation(s)
- Marius Marc-Daniel Mader
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany. .,Institute for Stem Cell Biology and Regenerative Medicine, Stanford University School of Medicine, 265 Campus Drive, Stanford, CA, 94305, USA.
| | - Rolf Lefering
- Institute for Research in Operative Medicine (IFOM), University of Witten/Herdecke, Ostmerheimer Strasse 200, 51109, Cologne, Germany
| | - Manfred Westphal
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Marc Maegele
- Institute for Research in Operative Medicine (IFOM), University of Witten/Herdecke, Ostmerheimer Strasse 200, 51109, Cologne, Germany.,Department of Trauma and Orthopaedic Surgery, University of Witten/Herdecke, Cologne-Merheim Medical Center, Ostmerheimer Strasse 200, 51109, Cologne, Germany
| | - Patrick Czorlich
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
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Xiao K, Zhao F, Liu Q, Jiang J, Chen Z, Gong W, Zheng Z, Le A. Effect of Red Blood Cell Storage Duration on Outcomes of Isolated Traumatic Brain Injury. Med Sci Monit 2020; 26:e923448. [PMID: 33159032 PMCID: PMC7657062 DOI: 10.12659/msm.923448] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Background The aim of this study was to investigate the effects of red blood cell (RBC) storage duration on the outcomes of adult isolated traumatic brain injury (iTBI) patients after transfusion. Material/Methods A total of 1252 adult iTBI patients who received the fresh RBCs (stored for ≤14 days) or old RBCs (stored for >14 days) were finally enrolled in this study. The primary outcome was 90-day mortality. The secondary outcomes were in-hospital mortality, nosocomial infection, and complications. Results By 90 days after RBC transfusion, 89 patients (17.0%) had died in the fresh RBC group, and 107 had died (14.7%) in the old RBC group, with no significant difference in 90-day mortality between the 2 groups (OR=1.192, 95% CI: 0.877–1.620, P=0.261). According to ISS score, no differences were discovered in mild injury (OR=1.079, 95% CI: 0.682–1.707, P=0.746), severe injury (OR=1.055, 95% CI: 0.634–1.755, P=0.838), and more severe injury (OR=1.940, 95% CI: 0.955–3.943, P=0.064). For GCS score, there were no differences in mild injury (OR=1.546, 95% CI: 0.893–2.676, P=0.118), moderate injury (OR=0.965, 95% CI: 0.616–1.513, P=0.877), and severe injury (OR=1.332, 95% CI: 0.677–2.620, P=0.406). We also observed no significant differences in secondary outcomes. Conclusions Use of old RBCs did not increase the 90-day mortality in adult iTBI patients.
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Affiliation(s)
- Kun Xiao
- Department of Blood Transfusion, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China (mainland)
| | - Fei Zhao
- Department of Neurology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China (mainland)
| | - Qiang Liu
- Department of Information, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China (mainland)
| | - Jinliang Jiang
- Department of Science and Technology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China (mainland)
| | - Zhiyong Chen
- Department of Personnel, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China (mainland)
| | - Wei Gong
- President's Office, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China (mainland)
| | - Zengwang Zheng
- Department of Medical Administration, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China (mainland)
| | - Aiping Le
- Department of Blood Transfusion, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China (mainland)
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Multifaceted Benefit of Whole Blood Versus Lactated Ringer's Resuscitation After Traumatic Brain Injury and Hemorrhagic Shock in Mice. Neurocrit Care 2020; 34:781-794. [PMID: 32886294 DOI: 10.1007/s12028-020-01084-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Accepted: 08/19/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Despite increasing use in hemorrhagic shock (HS), whole blood (WB) resuscitation for polytrauma with traumatic brain injury (TBI) is largely unexplored. Current TBI guidelines recommend crystalloid for prehospital resuscitation. Although WB outperforms lactated Ringer's (LR) in increasing mean arterial pressure (MAP) in TBI + HS models, effects on brain tissue oxygenation (PbtO2), and optimal MAP remain undefined. METHODS C57BL/6 mice (n = 72) underwent controlled cortical impact followed by HS (MAP = 25-27 mmHg). Ipsilateral hippocampal PbtO2 (n = 40) was measured by microelectrode. Mice were assigned to four groups (n = 18/group) for "prehospital" resuscitation (90 min) with LR or autologous WB, and target MAPs of 60 or 70 mmHg (LR60, WB60, LR70, WB70). Additional LR (10 ml/kg) was bolused every 5 min for MAP below target. RESULTS LR requirements in WB60 (7.2 ± 5.0 mL/kg) and WB70 (28.3 ± 9.6 mL/kg) were markedly lower than in LR60 (132.8 ± 5.8 mL/kg) or LR70 (152.2 ± 4.8 mL/kg; all p < 0.001). WB70 MAP (72.5 ± 2.9 mmHg) was higher than LR70 (59.8 ± 4.0 mmHg, p < 0.001). WB60 MAP (68.7 ± 4.6 mmHg) was higher than LR60 (53.5 ± 3.2 mmHg, p < 0.001). PbtO2 was higher in WB60 (43.8 ± 11.6 mmHg) vs either LR60 (25.9 ± 13.0 mmHg, p = 0.04) or LR70 (24.1 ± 8.1 mmHg, p = 0.001). PbtO2 in WB70 (40.7 ± 8.8 mmHg) was higher than in LR70 (p = 0.007). Despite higher MAP in WB70 vs WB60 (p = .002), PbtO2 was similar. CONCLUSION WB resuscitation after TBI + HS results in robust improvements in brain oxygenation while minimizing fluid volume when compared to standard LR resuscitation. WB resuscitation may allow for a lower prehospital MAP without compromising brain oxygenation when compared to LR resuscitation. Further studies evaluating the effects of these physiologic benefits on outcome after TBI with HS are warranted, to eventually inform clinical trials.
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Blood product transfusion during air medical transport: A needs assessment. CAN J EMERG MED 2020; 22:S67-S73. [DOI: 10.1017/cem.2020.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
ABSTRACTObjectivesEarly administration of blood products to patients with hemorrhagic shock has a positive impact on morbidity and mortality. Smaller hospitals may have limited supply of blood, and air medical systems may not carry blood. The primary outcome is to quantify the number of patients meeting established physiologic criteria for blood product administration and to identify which patients receive and which ones do not receive it due to lack of availability locally.MethodsElectronic patient care records were used to identify a retrospective cohort of patients undergoing emergent air medical transport in Ontario, Canada, who are likely to require blood. Presenting problems for blood product administration were identified. Physiologic data were extracted with criteria for transfusion used to identify patients where blood product administration is indicated.ResultsThere were 11,520 emergent patient transports during the study period, with 842 (7.3%) where blood product administration was considered. Of these, 290 met established physiologic criteria for blood products, with 167 receiving blood, of which 57 received it at a hospital with a limited supply. The mean number of units administered per patient was 3.5. The remaining 123 patients meeting criteria did not receive product because none was unavailable.ConclusionIndications for blood product administration are present in 2.5% of patients undergoing time-sensitive air medical transport. Air medical services can enhance access to potentially lifesaving therapy in patients with hemorrhagic shock by carrying blood products, as blood may be unavailable or in limited supply locally in the majority of patients where it is indicated.
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Wise RD, de Vasconcellos K, Gopalan D, Ahmed N, Alli A, Joubert I, Kabambi KF, Mathiva LR, Mdladla N, Mer M, Miller M, Mrara B, Omar S, Paruk F, Richards GA, Skinner D, von Rahden R. Critical Care Society of Southern Africa adult patient blood management guidelines: 2019 Round-table meeting, CCSSA Congress, Durban, 2018. SOUTHERN AFRICAN JOURNAL OF CRITICAL CARE 2020; 36:10.7196/SAJCC.2020.v36i1b.440. [PMID: 37415775 PMCID: PMC10321416 DOI: 10.7196/sajcc.2020.v36i1b.440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/28/2020] [Indexed: 07/08/2023] Open
Abstract
The CCSSA PBM Guidelines have been developed to improve patient blood management in critically ill patients in southern Africa. These consensus recommendations are based on a rigorous process by experts in the field of critical care who are also practicing in South Africa (SA). The process comprised a Delphi process, a round-table meeting (at the CCSSA National Congress, Durban, 2018), and a review of the best available evidence and international guidelines. The guidelines focus on the broader principles of patient blood management and incorporate transfusion medicine (transfusion guidelines), management of anaemia, optimisation of coagulopathy, and administrative and ethical considerations. There are a mix of low-middle and high-income healthcare structures within southern Africa. Blood products are, however, provided by the same not-for-profit non-governmental organisations to both private and public sectors. There are several challenges related to patient blood management in SA due most notably to a high incidence of anaemia, a frequent shortage of blood products, a small donor population, and a healthcare system under financial strain. The rational and equitable use of blood products is important to ensure best care for as many critically ill patients as possible. The summary of the recommendations provides key practice points for the day-to-day management of critically ill patients. A more detailed description of the evidence used to make these recommendations follows in the full clinical guidelines section.
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Affiliation(s)
- R D Wise
- Discipline of Anaesthesiology and Critical Care, School of Clinical Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - K de Vasconcellos
- Department of Critical Care, King Edward VIII Hospital, Durban; Discipline of Anaesthesiology and Critical Care, School of Clinical Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - D Gopalan
- Discipline of Anaesthesiology and Critical Care, School of Clinical Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - N Ahmed
- Surgical ICU, Tygerberg Academic Hospital; Department of Surgical Sciences and Department of Anaesthesiology and Critical Care, Stellenbosch University, Cape Town, South Africa
| | - A Alli
- Department of Anaesthesia, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - I Joubert
- Division of Critical Care, Department of Anaesthesia and Perioperative Medicine, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa
| | - K F Kabambi
- Department of Anaesthesia and Critical Care, Nelson Mandela Academic Hospital, Mthatha; Department of Surgery, Faculty of Health Sciences, Walter Sisulu University, Mthatha, South Africa
| | - L R Mathiva
- Intensive Care Unit, Chris Hani Baragwanath Academic Hospital and University of the Witwatersrand, Johannesburg, South Africa
| | - N Mdladla
- Dr George Mukhari Academic Hospital; Sefako Makgatho Health Sciences University, Pretoria, South Africa
| | - M Mer
- Department of Medicine, Divisions of Critical Care and Pulmonology, Charlotte Maxeke Johannesburg Academic Hospital and Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - M Miller
- Department of Anaesthesia and Peri-operative Medicine, Division of Critical Care, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa
| | - B Mrara
- Anaesthesia Department, Walter Sisulu University, Mthatha, South Africa
| | - S Omar
- Department of Critical Care, Chris Hani Baragwanath Academic Hospital and School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | - F Paruk
- Department of Critical Care, Steve Biko Academic Hospital and Critical Care, School of Medicine, University of Pretoria, South Africa
| | - G A Richards
- Department of Critical Care, Charlotte Maxeke Johannesburg Academic Hospital and University of the Witwatersrand, Johannesburg, South Africa
| | - D Skinner
- Department of Critical Care, King Edward VIII Hospital, Durban; Discipline of Anaesthesiology and Critical Care, School of Clinical Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - R von Rahden
- Private practice (Critical Care), Rodseth and Partners, Pietermaritzburg, South Africa
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Lee EP, Hsia SH, Chan OW, Lin CY, Lin JJ, Wu HP. Clinical role of low hemoglobin ratio in poor neurologic outcomes in infants with traumatic intracranial hemorrhage. Sci Rep 2020; 10:400. [PMID: 31942018 PMCID: PMC6962163 DOI: 10.1038/s41598-019-57334-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Accepted: 12/18/2019] [Indexed: 11/04/2022] Open
Abstract
Traumatic brain injury (TBI) is the leading cause of pediatric morbidity and mortality worldwide, and half of all fatalities occur in infants aged less than 1 year. We analyzed 129 infants diagnosed with TBI complicated with intracranial hemorrhage confirmed by brain computed tomography. We defined delta hemoglobin (ΔHB) as nadir HB - age specific mean HB, and the ratio of HB (%) as ΔHB/age specific mean HB x 100. Infants with poor neurologic outcomes had a lower admission HB and ΔHB (p < 0.05). The in-hospital mortality rate was 10.1% (13 infants), and the infants who died had a significantly lower ΔHB ratio compared to the survivors. The area under the receiving operating characteristic curve (AUC) of initial Glasgow Coma Score (GCS) in predicting neurologic outcomes was higher than that of ratio of ΔHB (0.881 v.s 0.859). In multivariate logistic regression analysis with the optimal cutoff ratio of ΔHB, it remained an independent predictor for in-hospital mortality and poor neurologic outcomes at discharge and at 6 months. AUC analysis for the ratio of ΔHB for poor neurologic outcomes in infants aged from 0–6 months was 0.85 and the optimal cutoff was −30.7% (sensitivity, 69%; specificity, 92%; positive likelihood ratio (LR+), 8.24; negative likelihood ratio (LR−), 0.34); the AUC was 0.88 in infants aged from 6–12 months and the optimal cutoff was −20.6% (sensitivity, 89%; specificity, 79%; LR+, 4.13; LR−, 0.15).
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Affiliation(s)
- En-Pei Lee
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Chang Gung Memorial Hospital at Linko, Kweishan, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Shao-Hsuan Hsia
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Chang Gung Memorial Hospital at Linko, Kweishan, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Oi-Wa Chan
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Chang Gung Memorial Hospital at Linko, Kweishan, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chia-Ying Lin
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Chang Gung Memorial Hospital at Linko, Kweishan, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Jainn-Jim Lin
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Chang Gung Memorial Hospital at Linko, Kweishan, Taoyuan, Taiwan. .,College of Medicine, Chang Gung University, Taoyuan, Taiwan.
| | - Han-Ping Wu
- Department of Pediatric Emergency Medicine, Children's Hospital, China Medical University, Taichung, Taiwan. .,Department of Medical Research, Children's Hospital, China Medical University, Taichung, Taiwan. .,Department of Medicine, School of Medicine, China Medical University, Taichung, Taiwan.
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16
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Lee EP, Zhao LL, Hsia SH, Lee J, Chan OW, Lin CY, Su YT, Lin JJ, Wu HP. Clinical Significance of Nadir Hemoglobin in Predicting Neurologic Outcome in Infants With Abused Head Trauma. Front Pediatr 2020; 8:140. [PMID: 32318527 PMCID: PMC7147474 DOI: 10.3389/fped.2020.00140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Accepted: 03/11/2020] [Indexed: 12/02/2022] Open
Abstract
Traumatic brain injury (TBI) is a leading cause of pediatric morbidity and mortality and is categorized as abusive head trauma (AHT) and accidental head injury. A retrospective chart review of 124 children aged <1 year diagnosed with TBI were analyzed. Outcomes were evaluated at discharge and 6 months later by using the Pediatric Cerebral Performance Category (PCPC) Scale. The receiver operating characteristic (ROC) curve was applied to determine the cutoff values for hemoglobin (HB) levels. In the study, 50 infants (40.3%) achieved a favorable neurologic outcome (PCPC ≦ 2) and 74 (59.7%) had poor neurologic outcomes (PCPC ≧ 3). Infants with poor neurologic outcomes had lower HB on admission and nadir HB (p < 0.05). Based on multivariate logistic regression analysis, the nadir HB was a predictor of poor neurologic outcomes at discharge and 6 months later in both AHT and accidental head injury. Nadir HB had the largest area under the ROC curve for predicting poor neurologic outcomes. We determined the appropriate cutoff value of nadir HB as 9.35 g/dl for predicting neurologic outcomes in infants with TBI. Furthermore, the cutoff value of nadir HB in predicting poor neurologic outcomes in infants caused by AHT and accidental head injury were taken as 9.36 and 8.75 g/dl, respectively.
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Affiliation(s)
- En-Pei Lee
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Chang Gung Memorial Hospital at Linko, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Lu-Lu Zhao
- Department of Pediatrics, Taipei Tzu Chi Hospital, New Taipei, Taiwan.,Department of Medicine, School of Medicine, Tzu Chi University, Hualien, Taiwan
| | - Shao-Hsuan Hsia
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Chang Gung Memorial Hospital at Linko, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Jung Lee
- College of Medicine, Chang Gung University, Taoyuan, Taiwan.,Division of Pediatric General Medicine, Department of Pediatrics, Chang Gung Memorial Hospital at Linko, Taoyuan, Taiwan
| | - Oi-Wa Chan
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Chang Gung Memorial Hospital at Linko, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chia-Ying Lin
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Chang Gung Memorial Hospital at Linko, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Ya-Ting Su
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Chang Gung Memorial Hospital at Linko, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Jainn-Jim Lin
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Chang Gung Memorial Hospital at Linko, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Han-Ping Wu
- Division of Pediatric General Medicine, Department of Pediatrics, Chang Gung Memorial Hospital at Linko, Taoyuan, Taiwan.,Department of Pediatric Emergency Medicine, Children's Hospital, China Medical University, Taichung, Taiwan.,Department of Medical Research, Children's Hospital, China Medical University, Taichung, Taiwan.,Department of Medicine, School of Medicine, China Medical University, Taichung, Taiwan
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17
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Stolla M, Zhang F, Meyer MR, Zhang J, Dong JF. Current state of transfusion in traumatic brain injury and associated coagulopathy. Transfusion 2019; 59:1522-1528. [PMID: 30980753 DOI: 10.1111/trf.15169] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Revised: 11/10/2018] [Accepted: 11/17/2018] [Indexed: 12/15/2022]
Abstract
Traumatic brain injury (TBI)-induced coagulopathy has long been recognized as a significant risk for poor outcomes in patients with TBI, but its pathogenesis remains poorly understood. As a result, current treatment options for the condition are limited and ineffective. The lack of information is most significant for the impact of blood transfusions on patients with isolated TBI and in the absence of confounding influences from trauma to the body and limbs and the resultant hemorrhagic shock. Here we discuss recent progress in understanding the pathogenesis of TBI-induced coagulopathy and the current state of blood transfusions for patients with TBI and associated coagulopathy.
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Affiliation(s)
- Moritz Stolla
- Bloodworks Research Institute, Seattle, Washington.,Division of Hematology, Department of Medicine, University of Washington, School of Medicine, Seattle, Washington
| | - Fangyi Zhang
- Department of Neurological Surgery, University of Washington School of Medicine, Seattle, Washington
| | - Michael R Meyer
- Department of Neurological Surgery, University of Washington School of Medicine, Seattle, Washington
| | - Jianning Zhang
- Tianjin Institute of Neurology, Tianjin, China.,Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Jing-Fei Dong
- Bloodworks Research Institute, Seattle, Washington.,Division of Hematology, Department of Medicine, University of Washington, School of Medicine, Seattle, Washington
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18
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Lessard Bonaventure P, Lauzier F, Zarychanski R, Boutin A, Shemilt M, Saxena M, Zolfagari P, Griesdale D, Menon DK, Stanworth S, English S, Chassé M, Fergusson DA, Moore L, Kramer A, Robitaille A, Myburgh J, Cooper J, Hutchinson P, Turgeon AF. Red blood cell transfusion in critically ill patients with traumatic brain injury: an international survey of physicians' attitudes. Can J Anaesth 2019; 66:1038-1048. [PMID: 31012052 DOI: 10.1007/s12630-019-01369-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Revised: 02/17/2019] [Accepted: 02/18/2019] [Indexed: 01/28/2023] Open
Abstract
INTRODUCTION Restrictive transfusion strategies have been advocated in critically ill patients. Nevertheless, considerable uncertainty exists regarding optimal transfusion thresholds in traumatic brain injury (TBI) patients because the injured brain is susceptible to hypoxemic damage. We aimed to identify the determinants of red blood cell (RBC) transfusion and the perceived optimal transfusion thresholds in adult patients with moderate-to-severe TBI. METHODS We conducted an electronic, self-administered survey targeting critical care specialists and neurosurgeons from Canada, Australia, and the United Kingdom caring for TBI patients. The questionnaire was initially developed by a panel of experts using a structured process (domains/items generation and reduction). The questionnaire was validated for clinical sensibility, reliability, and content. RESULTS The response rate was 28.7% (218/760). When presented with the hypothetical scenario of a young adult TBI patient, a wide range of transfusion practices was observed, with 47 (95% confidence interval [CI], 41 to 54)% favouring RBC transfusion at a hemoglobin level of ≤ 70 g·L-1 in the acute phase of care, while 73 (95% CI, 67 to 79)% would use this trigger in the plateau phase of care. Multiple trauma, neuro-monitoring data, hemorrhagic shock, and planned surgery were the main factors that influenced the need for transfusion. The lack of clinical evidence and guidelines was responsible for uncertainty regarding RBC transfusion strategies in this patient population. CONCLUSION In our survey about critically ill TBI patients, transfusion practice was found to be mainly influenced by the acuity of care, patient characteristics, and neuro-monitoring. Clinical equipoise regarding optimal transfusion strategy is believed to be mainly attributed to the lack of clear clinical evidence and guidelines. Appropriate randomized-controlled trials are required to determine the optimal transfusion strategies in TBI patients.
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Affiliation(s)
- Paule Lessard Bonaventure
- CHU de Québec - Université Laval Research Center, Population Health and Optimal Health Practices Research Unit, Traumatology - Emergency - Critical Care Medicine, CHU de Québec-Université Laval (Hôpital de l'Enfant-Jésus), 1401, 18e rue, Québec City, QC, G1J 1Z4, Canada.,Department of Surgery, Division of Neurosurgery, Université Laval, Québec City, QC, Canada
| | - Francois Lauzier
- CHU de Québec - Université Laval Research Center, Population Health and Optimal Health Practices Research Unit, Traumatology - Emergency - Critical Care Medicine, CHU de Québec-Université Laval (Hôpital de l'Enfant-Jésus), 1401, 18e rue, Québec City, QC, G1J 1Z4, Canada.,Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Université Laval, Québec City, QC, Canada.,Department of Medicine, Université Laval, Québec City, QC, Canada
| | - Ryan Zarychanski
- Department of Internal Medicine, Sections of Critical Care Medicine, of Haematology and of Medical Oncology, Faculty of Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Amélie Boutin
- CHU de Québec - Université Laval Research Center, Population Health and Optimal Health Practices Research Unit, Traumatology - Emergency - Critical Care Medicine, CHU de Québec-Université Laval (Hôpital de l'Enfant-Jésus), 1401, 18e rue, Québec City, QC, G1J 1Z4, Canada
| | - Michèle Shemilt
- CHU de Québec - Université Laval Research Center, Population Health and Optimal Health Practices Research Unit, Traumatology - Emergency - Critical Care Medicine, CHU de Québec-Université Laval (Hôpital de l'Enfant-Jésus), 1401, 18e rue, Québec City, QC, G1J 1Z4, Canada
| | - Manoj Saxena
- The George Institute for Global Health, Sydney, Australia
| | - Parjam Zolfagari
- Neurocritical Care Unit, Addenbrooke's Hospital, Cambridge University Hospitals Trust, Cambridge University, Cambridge, UK
| | - Donald Griesdale
- Division of Critical Care Medicine, Department of Medicine, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada
| | - David K Menon
- Neurocritical Care Unit, Addenbrooke's Hospital, Cambridge University Hospitals Trust, Cambridge University, Cambridge, UK
| | - Simon Stanworth
- National Institute for Health Research (NIHR), Oxford Biomedical Research Centre, Oxford University Hospitals and the University of Oxford, Oxford, UK
| | - Shane English
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada.,Department of Medicine (Critical Care), University of Ottawa, Ottawa, ON, Canada
| | - Michaël Chassé
- CHUM Research Center, Université de Montréal, Montréal, QC, Canada
| | - Dean A Fergusson
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Lynne Moore
- CHU de Québec - Université Laval Research Center, Population Health and Optimal Health Practices Research Unit, Traumatology - Emergency - Critical Care Medicine, CHU de Québec-Université Laval (Hôpital de l'Enfant-Jésus), 1401, 18e rue, Québec City, QC, G1J 1Z4, Canada.,Department of Preventive and Social Medicine, Université Laval, Québec City, QC, Canada
| | - Andreas Kramer
- Department of Critical Care Medicine, Foothills Medical Center, Calgary, AB, Canada
| | - Amélie Robitaille
- CHU de Québec - Université Laval Research Center, Population Health and Optimal Health Practices Research Unit, Traumatology - Emergency - Critical Care Medicine, CHU de Québec-Université Laval (Hôpital de l'Enfant-Jésus), 1401, 18e rue, Québec City, QC, G1J 1Z4, Canada
| | - John Myburgh
- The George Institute for Global Health, Sydney, Australia
| | - Jamie Cooper
- The George Institute for Global Health, Sydney, Australia.,The Alfred Hospital, Melbourne, Australia
| | - Peter Hutchinson
- Neurocritical Care Unit, Addenbrooke's Hospital, Cambridge University Hospitals Trust, Cambridge University, Cambridge, UK
| | - Alexis F Turgeon
- CHU de Québec - Université Laval Research Center, Population Health and Optimal Health Practices Research Unit, Traumatology - Emergency - Critical Care Medicine, CHU de Québec-Université Laval (Hôpital de l'Enfant-Jésus), 1401, 18e rue, Québec City, QC, G1J 1Z4, Canada. .,Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Université Laval, Québec City, QC, Canada.
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19
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Spahn DR, Bouillon B, Cerny V, Duranteau J, Filipescu D, Hunt BJ, Komadina R, Maegele M, Nardi G, Riddez L, Samama CM, Vincent JL, Rossaint R. The European guideline on management of major bleeding and coagulopathy following trauma: fifth edition. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2019; 23:98. [PMID: 30917843 PMCID: PMC6436241 DOI: 10.1186/s13054-019-2347-3] [Citation(s) in RCA: 663] [Impact Index Per Article: 132.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Accepted: 02/06/2019] [Indexed: 12/24/2022]
Abstract
Background Severe traumatic injury continues to present challenges to healthcare systems around the world, and post-traumatic bleeding remains a leading cause of potentially preventable death among injured patients. Now in its fifth edition, this document aims to provide guidance on the management of major bleeding and coagulopathy following traumatic injury and encourages adaptation of the guiding principles described here to individual institutional circumstances and resources. Methods The pan-European, multidisciplinary Task Force for Advanced Bleeding Care in Trauma was founded in 2004, and the current author group included representatives of six relevant European professional societies. The group applied a structured, evidence-based consensus approach to address scientific queries that served as the basis for each recommendation and supporting rationale. Expert opinion and current clinical practice were also considered, particularly in areas in which randomised clinical trials have not or cannot be performed. Existing recommendations were re-examined and revised based on scientific evidence that has emerged since the previous edition and observed shifts in clinical practice. New recommendations were formulated to reflect current clinical concerns and areas in which new research data have been generated. Results Advances in our understanding of the pathophysiology of post-traumatic coagulopathy have supported improved management strategies, including evidence that early, individualised goal-directed treatment improves the outcome of severely injured patients. The overall organisation of the current guideline has been designed to reflect the clinical decision-making process along the patient pathway in an approximate temporal sequence. Recommendations are grouped behind the rationale for key decision points, which are patient- or problem-oriented rather than related to specific treatment modalities. While these recommendations provide guidance for the diagnosis and treatment of major bleeding and coagulopathy, emerging evidence supports the author group’s belief that the greatest outcome improvement can be achieved through education and the establishment of and adherence to local clinical management algorithms. Conclusions A multidisciplinary approach and adherence to evidence-based guidance are key to improving patient outcomes. If incorporated into local practice, these clinical practice guidelines have the potential to ensure a uniform standard of care across Europe and beyond and better outcomes for the severely bleeding trauma patient. Electronic supplementary material The online version of this article (10.1186/s13054-019-2347-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Donat R Spahn
- Institute of Anaesthesiology, University of Zurich and University Hospital Zurich, Raemistrasse 100, CH-8091, Zurich, Switzerland
| | - Bertil Bouillon
- Department of Trauma and Orthopaedic Surgery, Cologne-Merheim Medical Centre (CMMC), University of Witten/Herdecke, Ostmerheimer Strasse 200, D-51109, Cologne, Germany
| | - Vladimir Cerny
- Department of Anaesthesiology, Perioperative Medicine and Intensive Care, J.E. Purkinje University, Masaryk Hospital, Usti nad Labem, Socialni pece 3316/12A, CZ-40113, Usti nad Labem, Czech Republic.,Centre for Research and Development, University Hospital Hradec Kralove, Hradec Kralove, Czech Republic, Sokolska 581, CZ-50005, Hradec Kralove, Czech Republic.,Department of Anaesthesiology and Intensive Care Medicine, Faculty of Medicine in Hradec Kralove, Charles University, Simkova 870, CZ-50003, Hradec Kralove, Czech Republic.,Department of Anaesthesia, Pain Management and Perioperative Medicine, QE II Health Sciences Centre, Dalhousie University, Halifax, 10 West Victoria, 1276 South Park St, Halifax, NS, B3H 2Y9, Canada
| | - Jacques Duranteau
- Department of Anaesthesia and Intensive Care, Hôpitaux Universitaires Paris Sud, University of Paris XI, Faculté de Médecine Paris-Sud, 78 rue du Général Leclerc, F-94275, Le Kremlin-Bicêtre Cedex, France
| | - Daniela Filipescu
- Department of Cardiac Anaesthesia and Intensive Care, C. C. Iliescu Emergency Institute of Cardiovascular Diseases, Sos Fundeni 256-258, RO-022328, Bucharest, Romania
| | - Beverley J Hunt
- King's College and Departments of Haematology and Pathology, Guy's and St Thomas' NHS Foundation Trust, Westminster Bridge Road, London, SE1 7EH, UK
| | - Radko Komadina
- Department of Traumatology, General and Teaching Hospital Celje, Medical Faculty Ljubljana University, SI-3000, Celje, Slovenia
| | - Marc Maegele
- Department of Trauma and Orthopaedic Surgery, Cologne-Merheim Medical Centre (CMMC), Institute for Research in Operative Medicine (IFOM), University of Witten/Herdecke, Ostmerheimer Strasse 200, D-51109, Cologne, Germany
| | - Giuseppe Nardi
- Department of Anaesthesia and ICU, AUSL della Romagna, Infermi Hospital Rimini, Viale Settembrini, 2, I-47924, Rimini, Italy
| | - Louis Riddez
- Department of Surgery and Trauma, Karolinska University Hospital, S-171 76, Solna, Sweden
| | - Charles-Marc Samama
- Hotel-Dieu University Hospital, 1, place du Parvis de Notre-Dame, F-75181, Paris Cedex 04, France
| | - Jean-Louis Vincent
- Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Route de Lennik 808, B-1070, Brussels, Belgium
| | - Rolf Rossaint
- Department of Anaesthesiology, University Hospital Aachen, RWTH Aachen University, Pauwelsstrasse 30, D-52074, Aachen, Germany.
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Abstract
Purpose of review The aim of this review is to summarize the recent studies looking at the effects of anemia and red blood cell transfusion in critically-ill patients with traumatic brain injury (TBI), describe the transfusion practice variations observed worldwide, and outline the ongoing trials evaluating restrictive versus liberal transfusion strategies for TBI. Recent findings Anemia is common among critically-ill patients with TBI, it is also thought to exacerbate secondary brain injury, and is associated with an increased risk of poor outcome. Conversely, allogenic red blood cell transfusion carries its own risks and complications, and has been associated with worse outcomes. Globally, there are large reported differences in the hemoglobin threshold used for transfusion after TBI. Observational studies have shown differential results for improvements in cerebral oxygenation and metabolism after red blood cell transfusion in TBI. Summary Currently, there is insufficient evidence to make strong recommendations regarding which hemoglobin threshold to use as a transfusion trigger in critically-ill patients with TBI. There is also uncertainty whether the restrictive transfusion strategy used in general critical care can be extrapolated to acutely brain injured patients. Ultimately, the consequences of anemia-induced cerebral injury need to be weighed up against the risks and complications associated with red blood cell transfusion.
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21
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Boutin A, Moore L, Green RS, Zarychanski R, Erdogan M, Lauzier F, English S, Fergusson DA, Butler M, McIntyre L, Chassé M, Lessard Bonaventure P, Léger C, Desjardins P, Griesdale D, Lacroix J, Turgeon AF. Hemoglobin thresholds and red blood cell transfusion in adult patients with moderate or severe traumatic brain injuries: A retrospective cohort study. J Crit Care 2018; 45:133-139. [PMID: 29459342 DOI: 10.1016/j.jcrc.2018.01.023] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Revised: 01/18/2018] [Accepted: 01/19/2018] [Indexed: 10/18/2022]
Abstract
PURPOSE We aimed to evaluate the association between transfusion practices and clinical outcomes in patients with traumatic brain injury. MATERIAL AND METHODS We conducted a retrospective cohort study of adult patients with moderate or severe traumatic brain injury admitted to the intensive care unit (ICU) of a level I trauma center between 2009 and 2013. The associations between hemoglobin (Hb) level, red blood cell (RBC) transfusion and clinical outcomes were estimated using robust Poisson models and proportional hazard models with time-dependent variables, adjusted for confounders. RESULTS We included 215 patients. Sixty-six patients (30.7%) were transfused during ICU stay. The median pre-transfusion Hb among transfused patients was 81g/L (IQR 67-100), while median nadir Hb among non-transfused patients was 110g/L (IQR 93-123). Poor outcomes were significantly more frequent in patients who were transfused (mortality risk ratio [RR]: 2.15 [95% CI 1.37-3.38] and hazard ratio: 3.06 [95% CI 1.57-5.97]; neurological complications RR: 3.40 [95% CI 1.35-8.56]; trauma complications RR: 1.65 [95% CI 1.31-2.08]; ICU length of stay geometric mean ratio: 1.42 [95% CI 1.06-1.92]). CONCLUSIONS During ICU stay, transfused patients tended to have lower Hb levels and worse outcomes than patients who did not receive RBCs, after adjustment for confounders.
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Affiliation(s)
- Amélie Boutin
- CHU de Québec - Université Laval Research Center, Population Health and Optimal Health Practices Research Unit (Trauma - Emergency - Critical Care Medicine), Université Laval, Z-207, 1401, 18e rue, Québec, QC G1J 1Z4, Canada; Department of Social and Preventive Medicine, Université Laval, 1050, avenue de la Médecine, Québec, QC G1V 0A6, Canada.
| | - Lynne Moore
- CHU de Québec - Université Laval Research Center, Population Health and Optimal Health Practices Research Unit (Trauma - Emergency - Critical Care Medicine), Université Laval, Z-207, 1401, 18e rue, Québec, QC G1J 1Z4, Canada; Department of Social and Preventive Medicine, Université Laval, 1050, avenue de la Médecine, Québec, QC G1V 0A6, Canada.
| | - Robert S Green
- Department of Critical Care, Dalhousie University, Suite 377, Bethune Building, 1276 South Park Street, Halifax, NS B3H 2Y9, Canada.
| | - Ryan Zarychanski
- Department of Internal Medicine, Sections of Critical Care Medicine of Haematology and of Medical Oncology, University of Manitoba, Room GC430, 820 Sherbrook Street, Winnipeg, MB R3A 1R9, Canada.
| | - Mete Erdogan
- Department of Critical Care, Dalhousie University, Suite 377, Bethune Building, 1276 South Park Street, Halifax, NS B3H 2Y9, Canada.
| | - François Lauzier
- CHU de Québec - Université Laval Research Center, Population Health and Optimal Health Practices Research Unit (Trauma - Emergency - Critical Care Medicine), Université Laval, Z-207, 1401, 18e rue, Québec, QC G1J 1Z4, Canada; Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Université Laval, 1050, avenue de la Médecine, Québec, QC G1V 0A6, Canada; Department of Medicine, Université Laval, 1050, avenue de la Médecine, Québec, QC G1V 0A6, Canada.
| | - Shane English
- Department of Critical Care Medicine, The Ottawa Hospital, 206-501 Smyth Road, Ottawa, ON K1H 8L6, Canada; Clinical Epidemiology Unit, Ottawa Hospital Research Institute, 511-501 Smyth Road, Ottawa, ON K1H 8L6, Canada.
| | - Dean A Fergusson
- Clinical Epidemiology Unit, Ottawa Hospital Research Institute, 511-501 Smyth Road, Ottawa, ON K1H 8L6, Canada.
| | - Michael Butler
- Department of Critical Care, Dalhousie University, Suite 377, Bethune Building, 1276 South Park Street, Halifax, NS B3H 2Y9, Canada.
| | - Lauralyn McIntyre
- Department of Critical Care Medicine, The Ottawa Hospital, 206-501 Smyth Road, Ottawa, ON K1H 8L6, Canada; Clinical Epidemiology Unit, Ottawa Hospital Research Institute, 511-501 Smyth Road, Ottawa, ON K1H 8L6, Canada.
| | - Michaël Chassé
- Department of Medicine, Centre Hospitalier Universitaire de Montréal, 3840 Rue Saint-Urbain, Montréal, QC H2W 1T8, Canada
| | - Paule Lessard Bonaventure
- CHU de Québec - Université Laval Research Center, Population Health and Optimal Health Practices Research Unit (Trauma - Emergency - Critical Care Medicine), Université Laval, Z-207, 1401, 18e rue, Québec, QC G1J 1Z4, Canada; Department of Surgery, Division of Neurosurgery, Université Laval, 1050, avenue de la Médecine, Québec, QC G1V 0A6, Canada.
| | - Caroline Léger
- CHU de Québec - Université Laval Research Center, Population Health and Optimal Health Practices Research Unit (Trauma - Emergency - Critical Care Medicine), Université Laval, Z-207, 1401, 18e rue, Québec, QC G1J 1Z4, Canada.
| | - Philippe Desjardins
- CHU de Québec - Université Laval Research Center, Population Health and Optimal Health Practices Research Unit (Trauma - Emergency - Critical Care Medicine), Université Laval, Z-207, 1401, 18e rue, Québec, QC G1J 1Z4, Canada; Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Université Laval, 1050, avenue de la Médecine, Québec, QC G1V 0A6, Canada.
| | - Donald Griesdale
- Department of Anesthesia, Vancouver, University of British Columbia, 217-2176 Health Sciences Mall, Vancouver, BC V6T 1Z3, Canada.
| | - Jacques Lacroix
- Department of Pediatrics, Critical Care Medicine, Université de Montréal, 1001 Boulevard Décarie, Montréal, QC H4A 3J1, Canada.
| | - Alexis F Turgeon
- CHU de Québec - Université Laval Research Center, Population Health and Optimal Health Practices Research Unit (Trauma - Emergency - Critical Care Medicine), Université Laval, Z-207, 1401, 18e rue, Québec, QC G1J 1Z4, Canada; Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Université Laval, 1050, avenue de la Médecine, Québec, QC G1V 0A6, Canada.
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Kumar MA, Levine J, Faerber J, Elliott JP, Winn HR, Doerfler S, Le Roux P. The Effects of Red Blood Cell Transfusion on Functional Outcome after Aneurysmal Subarachnoid Hemorrhage. World Neurosurg 2017; 108:807-816. [PMID: 29038077 DOI: 10.1016/j.wneu.2017.09.038] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2016] [Revised: 09/06/2017] [Accepted: 09/07/2017] [Indexed: 11/25/2022]
Abstract
BACKGROUND The optimal red blood cell transfusion (RBCT) trigger for patients with aneurysmal subarachnoid hemorrhage (SAH) is unknown. In patients with cerebral vasospasm, anemia may increase susceptibility to ischemic injury; conversely, RBCT may worsen outcome given known deleterious effects. OBJECTIVE To examine the association between RBCT, delayed cerebral ischemia (DCI), vasospasm, and outcome after SAH. METHODS A total of 421 consecutive patients with SAH, admitted to a neurocritical care unit at a university-affiliated hospital and who underwent surgical occlusion of their ruptured aneurysm were retrospectively identified from a prospective observational database. Propensity score methods were used to reduce the bias associated with treatment selection. RESULTS Two hundred and sixty-one patients (62.0%) received an RBCT. Angiographic vasospasm (odds ratio [OR] 1.6; 95% confidence interval [CI], 1.1-2.3; P = 0.025) but not severe angiographic spasm, DCI, or delayed infarction was associated with RBCT. A total of 283 patients (67.2%) experienced a favorable outcome, defined as good or moderately disabled on the Glasgow Outcome Scale; 47 (11.2%) were severely disabled or vegetative and 91 patients (21.6%) were dead at 6-month follow-up. Among patients who survived ≥2 days, RBCT was associated with unfavorable outcome (OR, 2.6; 95% CI, 1.6-4.1). Transfusion of ≥3 units of blood was associated with an increased incidence of unfavorable outcome. Propensity analysis to control for the probability of exposure to RBCT conditional on observed covariates measured before RBCT indicates that RBCT is associated with unfavorable outcome in the absence of DCI (OR, 2.17; 95% CI, 1.56-3.01; P < 0.0001) but not when DCI is present (OR, 0.82; 95% CI, 0.35-1.92; P = 0.65). CONCLUSIONS Blood transfusions are associated with unfavorable outcome after SAH particularly when DCI is absent. Propensity analysis suggests that RBCT may be associated with poor outcome rather than being a marker of disease severity. However, when DCI is present, RBCT may help improve outcome.
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Affiliation(s)
- Monisha A Kumar
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA; Department of Neurology, University of Pennsylvania, Philadelphia, Pennsylvania, USA; Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Joshua Levine
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA; Department of Neurology, University of Pennsylvania, Philadelphia, Pennsylvania, USA; Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jennifer Faerber
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - J Paul Elliott
- Colorado Neurological Institute, Englewood, Colorado, USA
| | - H Richard Winn
- Department of Neurosurgery, Mount Sinai Hospital, New York, New York, USA
| | - Sean Doerfler
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Peter Le Roux
- Brain and Spine Center and Lankenau Institute of Medical Research Lankenau Medical Center, Wynnewood, Pennsylvania, USA.
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Effects of Red Blood Cell Transfusion on Long-Term Disability of Patients with Traumatic Brain Injury. Neurocrit Care 2017; 24:371-80. [PMID: 26627227 DOI: 10.1007/s12028-015-0220-z] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND This 3-year prospective study examined the association between red blood cell transfusion (RBCT) and 1-year neurocognitive and disability levels in 309 patients with traumatic brain injury (TBI) admitted to the neurological intensive care unit (NICU). METHODS Using a telephone interview-based survey, functional outcomes were assessed by the Glasgow Outcome Scale (GOS), Rancho Los Amigos Levels of Cognitive Functioning Scale (RLCFS), and Disability Rating Scale (DRS) and dichotomized as favorable and unfavorable (dependent variable). The adjusted influence of RBCT on unfavorable results was assessed by conventional logistic regression, controlling for illness severity and propensity score (introduced as a continuous variable and by propensity score-matched patients). RESULTS Overall, 164 (53 %) patients received ≥1 unit of RBCT during their NICU stay. One year postinjury, transfused patients exhibited significantly higher unfavorable GOS (46.0 vs. 22.0 %), RLCFS (37.4 vs. 15.4 %), and DRS (39.6 vs. 18.7 %) scores than nontransfused patients. Although transfused patients were more severely ill upon admission, their adjusted odds ratios (95 % confidence intervals) for unfavorable GOS, RLCFS, and DRS scores were 2.5 (1.2-5.1), 3.0 (1.4-6.3), and 2.3 (1.1-4.8), respectively. These odds ratios remained largely unmodified when the calculated propensity score was incorporated as an independent continuous variable into the multivariate analysis. Furthermore, in 76 pairs of propensity score-matched patients, the rate of an unfavorable RLCFS score at the 1-year (but not 6-month) follow-up was significantly higher in transfused than nontransfused patients [3.0 (1.1-8.2)]. CONCLUSION Our results strongly suggest an independent association between RBCT and unfavorable long-term functional outcomes of patients with TBI.
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Clancy J, Karish C, Roddy M, Sicilia JJ, Bigham MT. Temperature-sensitive Medications in Interfacility Transport: The Ice Pack Myth. Air Med J 2017; 36:302-306. [PMID: 29122111 DOI: 10.1016/j.amj.2017.05.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Revised: 04/16/2017] [Accepted: 05/15/2017] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Critical Care Transport teams use various strategies to maintain temperature sensitive drugs and equipment at optimal temperature. The purpose of this study was to examine the effectiveness of current passive refrigeration of temperature sensitive transport medications/equipment. METHODS Initially, we performed a retrospective review of transport durations. Subsequently, an experimental paradigm was created using a temperature probe inside of the transport cooler packs utilizing various configurations and initial starting temperatures with high and low "in range" temperature margins of 8°C (max) and 2°C (min). RESULTS The mean round-trip transport time was 2.5 hours and over 15% of transports last longer than 4 hours. At a starting temperature of -3.9°C, the cooler and ice pack maintained "in range" temperatures for 3 hours. When the ice pack starting temperature was -12.9°C, high temperatures excursions weren't experienced until 6 hours 55 minutes, but initially low excursions fell below for up to 3 hours. iSTAT® cartridges remained within range between 1-4 hours at cooler and ice pack starting temperature of -3.9°C. CONCLUSION The current system of passive refrigeration does not appear to be sufficient for safely storing medications or point-of-care testing equipment for our transport services. This might reveal a flaw in the existing practices around medication refrigeration in transport.
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Affiliation(s)
- Jason Clancy
- Division of Emergency Medicine, Akron Children's Hospital, Akron, OH
| | | | - Meghan Roddy
- Department of Pharmacy, Akron Children's Hospital, Akron, OH
| | | | - Michael T Bigham
- Department of Pediatric Critical Care, Akron Children's Hospital, Akron, OH; Department of Pediatrics, Northeast Ohio Medical University, Rootstown, OH.
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Abstract
BACKGROUND The use of prehospital blood transfusion (PBT) in air medical transport has become more widespread. However, the effect of PBT remains unknown. The aim of this study was to examine the impact of PBT on 24-hour and overall in-hospital mortality. METHODS This is a retrospective cohort study of all trauma patients carried by air medical transport from the scene to a Level I trauma center from 2007 to 2013. We excluded patients who died on the helipad or in the emergency department. Primary outcomes measured were 24-hour and overall in-hospital mortality. Multivariable logistic regressions using all available patient data or the propensity score (for receiving PBT)-matched patient data were performed to study the effect of PBT on these outcomes. RESULTS Of the 5,581 patients included in the study, 231 (4%) received PBT. Multivariable regression analyses did not show evidence of PBT effect on 24-hour in-hospital mortality (odds ratio [OR], 1.22; 95% confidence interval [CI], 0.61-2.44) and on overall in-hospital mortality (OR, 1.20; 95% CI, 0.55-1.79). In addition, using 1:1 propensity score-matched data, the analysis did not show evidence of PBT effect on 24-hour in-hospital mortality (OR, 1.04; 95% CI, 0.54-1.98) and on overall in-hospital mortality (OR, 1.05; 95% CI, 0.56-1.96). Factors associated with increased 24-hour mortality were advanced age, penetrating injury, increased blood transfusion requirement in the first 24 hours, and decreased Glasgow Coma Scale (GCS) score (p < 0.05). These factors were also associated with overall mortality, in addition to increased Injury Severity Score (ISS) (p < 0.05). CONCLUSION This is the largest study to date of trauma patients who received PBT and were transported from the scene by air medical transport. Our results show no effect of PBT on 24-hour and overall in-hospital mortality. Previous studies also suggest no benefit of PBT, which is counterintuitive to damage-control resuscitation. Prospective data on PBT are needed to assess risk, cost, and benefit. LEVEL OF EVIDENCE Therapeutic study, level III.
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Brockman EC, Jackson TC, Dixon CE, Bayɪr H, Clark RSB, Vagni V, Feldman K, Byrd C, Ma L, Hsia C, Kochanek PM. Polynitroxylated Pegylated Hemoglobin-A Novel, Small Volume Therapeutic for Traumatic Brain Injury Resuscitation: Comparison to Whole Blood and Dose Response Evaluation. J Neurotrauma 2017; 34:1337-1350. [PMID: 27869558 PMCID: PMC5385578 DOI: 10.1089/neu.2016.4656] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
Resuscitation with polynitroxylated pegylated hemoglobin (PNPH), a pegylated bovine hemoglobin decorated with nitroxides, eliminated the need for fluid administration, reduced intracranial pressure (ICP) and brain edema, and produced neuroprotection in vitro and in vivo versus Lactated Ringer's solution (LR) in experimental traumatic brain injury (TBI) plus hemorrhagic shock (HS). We hypothesized that resuscitation with PNPH would improve acute physiology versus whole blood after TBI+HS and would be safe and effective across a wide dosage range. Anesthetized mice underwent controlled cortical impact and severe HS to mean arterial pressure (MAP) of 25-27 mm Hg for 35 min, then were resuscitated with PNPH, autologous whole blood, or LR. Markers of acute physiology, including mean arterial blood pressure (MAP), heart rate (HR), blood gases/chemistries, and brain oxygenation (PbtO2), were monitored for 90 min on room air followed by 15 min on 100% oxygen. In a second experiment, the protocol was repeated, except mice were resuscitated with PNPH with doses between 2 and 100 mL/kg. ICP and 24 h %-brain water were evaluated. PNPH-resuscitated mice had higher MAP and lower HR post-resuscitation versus blood or LR (p < 0.01). PNPH-resuscitated mice, versus those resuscitated with blood or LR, also had higher pH and lower serum potassium (p < 0.05). Blood-resuscitated mice, however, had higher PbtO2 versus those resuscitated with LR and PNPH, although PNPH had higher PbtO2 versus LR (p < 0.05). PNPH was well tolerated across the dosing range and dramatically reduced fluid requirements in all doses-even 2 or 5 mL/kg (p < 0.001). ICP was significantly lower in PNPH-treated mice for most doses tested versus in LR-treated mice, although %-brain water did not differ between groups. Resuscitation with PNPH, versus resuscitation with LR or blood, improved MAP, HR, and ICP, reduced acidosis and hyperkalemia, and was well tolerated and effective across a wide dosing range, supporting ongoing pre-clinical development of PNPH for TBI resuscitation.
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Affiliation(s)
- Erik C. Brockman
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pennsylvania
- Children's Hospital of Pittsburgh of UPMC, Pittsburgh, Pennsylvania
| | - Travis C. Jackson
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pennsylvania
| | - C. Edward Dixon
- Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pennsylvania
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Hülya Bayɪr
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pennsylvania
- Children's Hospital of Pittsburgh of UPMC, Pittsburgh, Pennsylvania
- Pittsburgh Center for Free Radical and Antioxidant Health, Pittsburgh, Pennsylvania
| | - Robert S. B. Clark
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pennsylvania
- Children's Hospital of Pittsburgh of UPMC, Pittsburgh, Pennsylvania
| | - Vincent Vagni
- Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pennsylvania
| | - Keri Feldman
- Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pennsylvania
| | - Catherine Byrd
- Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pennsylvania
| | - Li Ma
- Department of Physics, Georgia Southern University, Statesboro, Georgia
| | | | - Patrick M. Kochanek
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pennsylvania
- Children's Hospital of Pittsburgh of UPMC, Pittsburgh, Pennsylvania
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Boutin A, Moore L, Lauzier F, Chassé M, English S, Zarychanski R, McIntyre L, Griesdale D, Fergusson DA, Turgeon AF. Transfusion of red blood cells in patients with traumatic brain injuries admitted to Canadian trauma health centres: a multicentre cohort study. BMJ Open 2017; 7:e014472. [PMID: 28360248 PMCID: PMC5372060 DOI: 10.1136/bmjopen-2016-014472] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Optimisation of healthcare practices in patients sustaining a traumatic brain injury is of major concern given the high incidence of death and long-term disabilities. Considering the brain's susceptibility to ischaemia, strategies to optimise oxygenation to brain are needed. While red blood cell (RBC) transfusion is one such strategy, specific RBC strategies are debated. We aimed to evaluate RBC transfusion frequency, determinants of transfusions and associated clinical outcomes. METHODS We conducted a retrospective multicentre cohort study using data from the National Trauma Registry of Canada. Patients admitted with moderate or severe traumatic brain injury to participating hospitals between April 2005 and March 2013 were eligible. Patient information on blood products, comorbidities, interventions and complications from the Discharge Abstract Database were linked to the National Trauma Registry data. Relative weights analyses evaluated the contribution of each determinant. We conducted multivariate robust Poisson regression to evaluate the association between potential determinants, mortality, complications, hospital-to-home discharge and RBC transfusion. We also used proportional hazard models to evaluate length of stay for time to discharge from ICU and hospital. RESULTS Among the 7062 patients with traumatic brain injury, 1991 patients received at least one RBC transfusion during their hospital stay. Female sex, anaemia, coagulopathy, sepsis, bleeding, hypovolemic shock, other comorbid illnesses, serious extracerebral trauma injuries were all significantly associated with RBC transfusion. Serious extracerebral injuries altogether explained 61% of the observed variation in RBC transfusion. Mortality (risk ratio (RR) 1.23 (95% CI 1.13 to 1.33)), trauma complications (RR 1.38 (95% CI 1.32 to 1.44)) and discharge elsewhere than home (RR 1.88 (95% CI 1.75 to 2.04)) were increased in patients who received RBC transfusion. Discharge from ICU and hospital were also delayed in transfused patients. CONCLUSIONS RBC transfusion is common in patients with traumatic brain injury and associated with unfavourable outcomes. Trauma severity is an important determinant of RBC transfusion. Prospective studies are needed to further evaluate optimal transfusion strategies in traumatic brain injury.
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Affiliation(s)
- Amélie Boutin
- Population Health and Optimal Health Practices Research Unit (Trauma—Emergency—Critical Care Medicine), CHU de Québec—Université Laval Research Centre, Université Laval, Québec, Québec, Canada
- Department of Social and Preventive Medicine, Université Laval, Québec, Québec, Canada
| | - Lynne Moore
- Population Health and Optimal Health Practices Research Unit (Trauma—Emergency—Critical Care Medicine), CHU de Québec—Université Laval Research Centre, Université Laval, Québec, Québec, Canada
- Department of Social and Preventive Medicine, Université Laval, Québec, Québec, Canada
| | - François Lauzier
- Population Health and Optimal Health Practices Research Unit (Trauma—Emergency—Critical Care Medicine), CHU de Québec—Université Laval Research Centre, Université Laval, Québec, Québec, Canada
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Université Laval, Québec, Québec, Canada
| | - Michaël Chassé
- Population Health and Optimal Health Practices Research Unit (Trauma—Emergency—Critical Care Medicine), CHU de Québec—Université Laval Research Centre, Université Laval, Québec, Québec, Canada
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Université Laval, Québec, Québec, Canada
| | - Shane English
- Clinical Epidemiology Unit, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Ryan Zarychanski
- Department of Internal Medicine, Sections of Critical Care Medicine, of Haematology and of Medical Oncology, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Lauralyn McIntyre
- Clinical Epidemiology Unit, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Donald Griesdale
- Department of Anesthesia, University of British Columbia, Vancouver, British Columbia, Canada
| | - Dean A Fergusson
- Clinical Epidemiology Unit, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Alexis F Turgeon
- Population Health and Optimal Health Practices Research Unit (Trauma—Emergency—Critical Care Medicine), CHU de Québec—Université Laval Research Centre, Université Laval, Québec, Québec, Canada
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Université Laval, Québec, Québec, Canada
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Shroyer MC, Griffin RL, Mortellaro VE, Russell RT. Massive transfusion in pediatric trauma: analysis of the National Trauma Databank. J Surg Res 2017; 208:166-172. [DOI: 10.1016/j.jss.2016.09.039] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2016] [Revised: 08/21/2016] [Accepted: 09/21/2016] [Indexed: 10/20/2022]
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Abstract
OBJECTIVES Controversy exists over association of blood transfusions with complications. The purpose was to assess effects of limited transfusions on complication rates and hospital course. SETTING Level 1 trauma center. PATIENTS AND METHODS Three hundred seventy-one consecutive patients with Injury Severity Score ≥16 underwent fixation of fractures of spine (n = 111), pelvis (n = 72), acetabulum (n = 57), and/or femur (n = 179). Those receiving >3 units of packed red blood cell were excluded. MAIN OUTCOME MEASUREMENTS Fracture type, associated injuries, treatment details, ventilation time, complications, and hospital stay were prospectively recorded. RESULTS Ninety-eight patients with 107 fractures received limited transfusion, and 119 patients with 123 fractures were not transfused. The groups did not differ in age, fracture types, time to fixation, or associated injuries. Lowest hematocrit was lower in the transfused group (22.8 vs. 30.0, P < 0.0001). Surgical duration (3:23 vs. 2:28) and estimated blood loss (462 vs. 211 mL) were higher in transfused patients (all P < 0.003). Pulmonary complications occurred in 12% of transfused and 4% of nontransfused, (P = 0.10). Mean days of mechanical ventilation (2.51 vs. 0.45), intensive care unit days (4.5 vs. 1.5) and total hospital stay (8.8 vs. 5.7) were higher in transfused patients (all P ≤ 0.006). After multivariate analysis, limited transfusion was associated with increased hospital and intensive care unit stays and mechanical ventilation time, but not with complications. CONCLUSIONS Patients receiving ≤3 units of packed red blood cell had lower hematocrit and greater surgical burden, but no difference in complications versus the nontransfused group. Limited blood transfusions are likely safe, excepting a possible association with longer mechanical ventilation times and hospital stays. LEVEL OF EVIDENCE Therapeutic level III. See Instructions for Authors for a complete description of levels of evidence.
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Travers S, Martin S, Litofsky NS. The effects of anaemia and transfusion on patients with traumatic brain injury: A review. Brain Inj 2016; 30:1525-1532. [PMID: 27680103 DOI: 10.1080/02699052.2016.1199907] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Anaemia in traumatic brain injury (TBI) is frequently encountered. Neurosurgical texts continue to recommend transfusion for hematocrit below 30%, despite clear evidence to do so. Transfusion should increase oxygen delivery to the brain, but it may also increase morbidity and mortality. METHODS This study reviewed the relevant literature to better understand the risks of anaemia and benefits of correction of anaemia by transfusion. RESULTS Of the 21 studies reviewed, eight found that anaemia was harmful to patients with TBI; five found no significant outcome; seven found transfusion was associated with higher rates of morbidity and mortality; two found that transfusion lowered mortality and increased brain tissue oxygen levels; and ten found no correlation between transfusion and outcome. However, the levels of anaemia severity and the outcome measurements varied widely and the majority of outcomes focused on crude measurements rather than detailed functional assessments. CONCLUSIONS No division of response based on gender difference or impact of anaemia in the post-hospital treatment setting was observed. A randomized control trial is recommended to determine the impact of anaemia and transfusion on detailed outcome assessment in comparison of transfusion thresholds ranging from ≤ 7 g dL-1 to ≤ 9 g dL-1 in patients with moderate-to-severe TBI.
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Affiliation(s)
- Sarah Travers
- a Division of Neurological Surgery , University of Missouri School of Medicine , Columbia , MO , USA
| | - Simon Martin
- a Division of Neurological Surgery , University of Missouri School of Medicine , Columbia , MO , USA
| | - N Scott Litofsky
- a Division of Neurological Surgery , University of Missouri School of Medicine , Columbia , MO , USA
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Mena-Munoz J, Srivastava U, Martin-Gill C, Suffoletto B, Callaway CW, Guyette FX. Characteristics and Outcomes of Blood Product Transfusion During Critical Care Transport. PREHOSP EMERG CARE 2016; 20:586-93. [PMID: 27484298 DOI: 10.3109/10903127.2016.1163447] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Civilian out-of-hospital transfusions have not been adequately studied. This study seeks to characterize patients receiving out-of-hospital blood product transfusion during critical care transport. STUDY DESIGN AND METHODS We studied patients transported by a regional critical care air-medical service who received blood products during transport. This service carries two units of uncrossmatched packed Red Blood Cells (pRBCs) on every transport in addition to blood obtained from referring facilities. The pRBC are administered according to a protocol for the treatment of hemorrhagic shock or based on medical command physician order. Transfusion amount was categorized into three groups based on the volume transfused (<350 mL, 350-700 mL, >700 mL). The association between prehospital transfusion and in-hospital outcomes (mortality, subsequent blood transfusion and emergent surgery) was estimated using logistic regression models, controlling for age, first systolic blood pressure, first heart rate, Glasgow Coma Score, time of transfer, and length of hospital admission. RESULTS Among the 1,440 critical care transports with transfusions examined, 81% were for medical patients, being gastrointestinal hemorrhage the most common indication (26%, CI 24-28%). pRBC transfusions were associated with emergent surgery (OR = 1.81, 95% CI = 1.31-2.52) and in-hospital transfusions (OR = 2.00, 95% CI = 1.46-2.76). Those with transfusions >700 mL were associated with emergent surgery (OR = 1.79, 95% CI = 1.10-2.92) and mortality (OR = 2.11; 95% CI = 1.21-3.69). CONCLUSIONS In this sample, the majority of patients receiving blood products during air-medical transport were transfused for medic conditions; gastrointestinal hemorrhage was the most common chief complaint. The pRBC transfusions were associated with emergent surgery and in-hospital transfusion. Transfusions of >700 mL were associated with mortality.
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Wang H, Umejiego J, Robinson RD, Schrader CD, Leuck J, Barra M, Buca S, Shedd A, Bui A, Zenarosa NR. A Derivation and Validation Study of an Early Blood Transfusion Needs Score for Severe Trauma Patients. J Clin Med Res 2016; 8:591-7. [PMID: 27429680 PMCID: PMC4931805 DOI: 10.14740/jocmr2598w] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/26/2016] [Indexed: 01/11/2023] Open
Abstract
Background There is no existing adequate blood transfusion needs determination tool that Emergency Medical Services (EMS) personnel can use for prehospital blood transfusion initiation. In this study, a simple and pragmatic prehospital blood transfusion needs scoring system was derived and validated. Methods Local trauma registry data were reviewed retrospectively from 2004 through 2013. Patients were randomly assigned to derivation and validation cohorts. Multivariate logistic regression was used to identify the independent approachable risks associated with early blood transfusion needs in the derivation cohort in which a scoring system was derived. Sensitivity, specificity, and area under the receiver operational characteristic (AUC) were calculated and compared using both the derivation and validation data. Results A total of 24,303 patients were included with 12,151 patients in the derivation and 12,152 patients in the validation cohorts. Age, penetrating injury, heart rate, systolic blood pressure, and Glasgow coma scale (GCS) were risks predictive of early blood transfusion needs. An early blood transfusion needs score was derived. A score > 5 indicated risk of early blood transfusion need with a sensitivity of 83% and a specificity of 80%. A sensitivity of 82% and a specificity of 80% were also found in the validation study and their AUC showed no statistically significant difference (AUC of the derivation = 0.87 versus AUC of the validation = 0.86, P > 0.05). Conclusions An early blood transfusion scoring system was derived and internally validated to predict severe trauma patients requiring blood transfusion during prehospital or initial emergency department resuscitation.
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Affiliation(s)
- Hao Wang
- Department of Emergency Medicine, Integrative Emergency Services, John Peter Smith Health Network, 1500 S. Main St., Fort Worth, TX 76104, USA
| | - Johnbosco Umejiego
- Department of Emergency Medicine, Integrative Emergency Services, John Peter Smith Health Network, 1500 S. Main St., Fort Worth, TX 76104, USA
| | - Richard D Robinson
- Department of Emergency Medicine, Integrative Emergency Services, John Peter Smith Health Network, 1500 S. Main St., Fort Worth, TX 76104, USA
| | - Chet D Schrader
- Department of Emergency Medicine, Integrative Emergency Services, John Peter Smith Health Network, 1500 S. Main St., Fort Worth, TX 76104, USA
| | - JoAnna Leuck
- Department of Emergency Medicine, Integrative Emergency Services, John Peter Smith Health Network, 1500 S. Main St., Fort Worth, TX 76104, USA
| | - Michael Barra
- Department of Emergency Medicine, Integrative Emergency Services, John Peter Smith Health Network, 1500 S. Main St., Fort Worth, TX 76104, USA
| | - Stefan Buca
- Department of Emergency Medicine, Integrative Emergency Services, John Peter Smith Health Network, 1500 S. Main St., Fort Worth, TX 76104, USA
| | - Andrew Shedd
- Department of Emergency Medicine, Integrative Emergency Services, John Peter Smith Health Network, 1500 S. Main St., Fort Worth, TX 76104, USA
| | - Andrew Bui
- Department of Emergency Medicine, Integrative Emergency Services, John Peter Smith Health Network, 1500 S. Main St., Fort Worth, TX 76104, USA
| | - Nestor R Zenarosa
- Department of Emergency Medicine, Integrative Emergency Services, John Peter Smith Health Network, 1500 S. Main St., Fort Worth, TX 76104, USA
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Litofsky NS, Martin S, Diaz J, Ge B, Petroski G, Miller DC, Barnes SL. The Negative Impact of Anemia in Outcome from Traumatic Brain Injury. World Neurosurg 2016; 90:82-90. [DOI: 10.1016/j.wneu.2016.02.076] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Revised: 02/12/2016] [Accepted: 02/13/2016] [Indexed: 11/28/2022]
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Rossaint R, Bouillon B, Cerny V, Coats TJ, Duranteau J, Fernández-Mondéjar E, Filipescu D, Hunt BJ, Komadina R, Nardi G, Neugebauer EAM, Ozier Y, Riddez L, Schultz A, Vincent JL, Spahn DR. The European guideline on management of major bleeding and coagulopathy following trauma: fourth edition. Crit Care 2016; 20:100. [PMID: 27072503 PMCID: PMC4828865 DOI: 10.1186/s13054-016-1265-x] [Citation(s) in RCA: 594] [Impact Index Per Article: 74.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Accepted: 03/11/2016] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Severe trauma continues to represent a global public health issue and mortality and morbidity in trauma patients remains substantial. A number of initiatives have aimed to provide guidance on the management of trauma patients. This document focuses on the management of major bleeding and coagulopathy following trauma and encourages adaptation of the guiding principles to each local situation and implementation within each institution. METHODS The pan-European, multidisciplinary Task Force for Advanced Bleeding Care in Trauma was founded in 2004 and included representatives of six relevant European professional societies. The group used a structured, evidence-based consensus approach to address scientific queries that served as the basis for each recommendation and supporting rationale. Expert opinion and current clinical practice were also considered, particularly in areas in which randomised clinical trials have not or cannot be performed. Existing recommendations were reconsidered and revised based on new scientific evidence and observed shifts in clinical practice; new recommendations were formulated to reflect current clinical concerns and areas in which new research data have been generated. This guideline represents the fourth edition of a document first published in 2007 and updated in 2010 and 2013. RESULTS The guideline now recommends that patients be transferred directly to an appropriate trauma treatment centre and encourages use of a restricted volume replacement strategy during initial resuscitation. Best-practice use of blood products during further resuscitation continues to evolve and should be guided by a goal-directed strategy. The identification and management of patients pre-treated with anticoagulant agents continues to pose a real challenge, despite accumulating experience and awareness. The present guideline should be viewed as an educational aid to improve and standardise the care of the bleeding trauma patients across Europe and beyond. This document may also serve as a basis for local implementation. Furthermore, local quality and safety management systems need to be established to specifically assess key measures of bleeding control and outcome. CONCLUSIONS A multidisciplinary approach and adherence to evidence-based guidance are key to improving patient outcomes. The implementation of locally adapted treatment algorithms should strive to achieve measureable improvements in patient outcome.
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Affiliation(s)
- Rolf Rossaint
- />Department of Anaesthesiology, University Hospital Aachen, RWTH Aachen University, Pauwelsstrasse 30, 52074 Aachen, Germany
| | - Bertil Bouillon
- />Department of Trauma and Orthopaedic Surgery, Witten/Herdecke University, Cologne-Merheim Medical Centre, Ostmerheimer Strasse 200, 51109 Cologne, Germany
| | - Vladimir Cerny
- />Department of Anaesthesiology, Perioperative Medicine and Intensive Care, J.E. Purkinje University, Masaryk Hospital, Usti nad Labem, Socialni pece 3316/12A, 40113 Usti nad Labem, Czech Republic
- />Department of Research and Development, Charles University in Prague, Faculty of Medicine in Hradec Kralove, Sokolska 581, 50005 Hradec Kralove, Czech Republic
- />Department of Anaesthesiology and Intensive Care, Charles University in Prague, Faculty of Medicine in Hradec Kralove, Sokolska 581, 50005 Hradec Kralove, Czech Republic
- />Department of Anaesthesia, Pain Management and Perioperative Medicine, Dalhousie University, Halifax, QE II Health Sciences Centre, 10 West Victoria, 1276 South Park St., Halifax, NS B3H 2Y9 Canada
| | - Timothy J. Coats
- />Emergency Medicine Academic Group, University of Leicester, University Road, Leicester, LE1 7RH UK
| | - Jacques Duranteau
- />Department of Anaesthesia and Intensive Care, Hôpitaux Universitaires Paris Sud, University of Paris XI, Faculté de Médecine Paris-Sud, 78 rue du Général Leclerc, 94275 Le Kremlin-Bicêtre, Cedex France
| | - Enrique Fernández-Mondéjar
- />Servicio de Medicina Intensiva, Complejo Hospitalario Universitario de Granada, ctra de Jaén s/n, 18013 Granada, Spain
| | - Daniela Filipescu
- />Department of Cardiac Anaesthesia and Intensive Care, C. C. Iliescu Emergency Institute of Cardiovascular Diseases, Sos Fundeni 256-258, 022328 Bucharest, Romania
| | - Beverley J. Hunt
- />King’s College, Departments of Haematology, Pathology and Lupus, Guy’s and St Thomas’ NHS Foundation Trust, Westminster Bridge Road, London, SE1 7EH UK
| | - Radko Komadina
- />Department of Traumatology, General and Teaching Hospital Celje, Oblakova 5, 3000 Celje, Slovenia
| | - Giuseppe Nardi
- />Shock and Trauma Centre, S. Camillo Hospital, Viale Gianicolense 87, 00152 Rome, Italy
| | - Edmund A. M. Neugebauer
- />Faculty of Health - School of Medicine, Witten/Herdecke University, Ostmerheimer Strasse 200, Building 38, 51109 Cologne, Germany
| | - Yves Ozier
- />Division of Anaesthesia, Intensive Care and Emergency Medicine, Brest University Hospital, Boulevard Tanguy Prigent, 29200 Brest, France
| | - Louis Riddez
- />Department of Surgery and Trauma, Karolinska University Hospital, 171 76 Solna, Sweden
| | - Arthur Schultz
- />Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, Lorenz Boehler Trauma Centre, Donaueschingenstrasse 13, 1200 Vienna, Austria
| | - Jean-Louis Vincent
- />Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Route de Lennik 808, 1070 Brussels, Belgium
| | - Donat R. Spahn
- />Institute of Anaesthesiology, University of Zurich and University Hospital Zurich, Raemistrasse 100, 8091 Zurich, Switzerland
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Boutin A, Chassé M, Shemilt M, Lauzier F, Moore L, Zarychanski R, Griesdale D, Desjardins P, Lacroix J, Fergusson D, Turgeon AF. Red Blood Cell Transfusion in Patients With Traumatic Brain Injury: A Systematic Review and Meta-Analysis. Transfus Med Rev 2015; 30:15-24. [PMID: 26409622 DOI: 10.1016/j.tmrv.2015.08.004] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2015] [Revised: 06/14/2015] [Accepted: 08/15/2015] [Indexed: 01/23/2023]
Abstract
Our objectives were to evaluate the frequency of red blood cell (RBC) transfusion in patients with traumatic brain injury (TBI) as well as potential determinants and outcomes associated with RBC transfusion in this population. We conducted a systematic review of cohort studies and randomized trials of patients with TBI. We searched Medline, Embase, the Cochrane Library, and BIOSIS databases from their inception up to April 2015. We selected studies of adult patients with acute TBI reporting data on RBC transfusions. Cumulative incidences of transfusion were pooled using random-effect models with a DerSimonian approach. To evaluate the association between RBC transfusion and potential determinants or clinical outcomes, we pooled risk ratios or mean differences with random-effect models and the Mantel-Haenszel method. We identified 24 eligible studies (17414 patients). After pooling data from 23 studies (7524 patients), approximately 36% (95% confidence interval [CI], 28-44; I(2) = 98%) of patients received RBC transfusion at some point during their hospital stay. Hemoglobin thresholds for transfusion were rarely available (reported in 9 studies) and varied from 6 to 10 g/dL. Glasgow Coma Scale scores at admission were lower in patients who were transfused than those who were not (3 cohort studies; 1371 patients; mean difference of 1.38 points [95% CI, 0.86-1.89]; I(2) = 12%). Mortality was not significantly different among transfused and nontransfused patients in univariate and multivariate meta-analyses. Hospital length of stay was longer among patients receiving RBC transfusion compared to those who did not (3 studies; n = 455; mean difference, 9.58 days [95% CI, 3.94-15.22]; I(2) = 74%). Results should be considered cautiously due to the high heterogeneity and high risk of confounding from the observational nature of included studies. Red blood cell transfusion is frequent in patients with TBI, and transfusion practices varied widely between studies. Current published data highlight the lack of clinical evidence guiding transfusion strategies in TBI.
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Affiliation(s)
- Amélie Boutin
- CHU de Québec-Université Laval Research Center (Hôpital de l'Enfant-Jésus), Population Health and Optimal Health Practices Research Unit, Université Laval, Quebec City, QC, Canada; Department of Social and Preventive Medicine, Université Laval, Quebec City, QC, Canada
| | - Michaël Chassé
- CHU de Québec-Université Laval Research Center (Hôpital de l'Enfant-Jésus), Population Health and Optimal Health Practices Research Unit, Université Laval, Quebec City, QC, Canada; Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Université Laval, Quebec City, QC, Canada
| | - Michèle Shemilt
- CHU de Québec-Université Laval Research Center (Hôpital de l'Enfant-Jésus), Population Health and Optimal Health Practices Research Unit, Université Laval, Quebec City, QC, Canada
| | - François Lauzier
- CHU de Québec-Université Laval Research Center (Hôpital de l'Enfant-Jésus), Population Health and Optimal Health Practices Research Unit, Université Laval, Quebec City, QC, Canada; Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Université Laval, Quebec City, QC, Canada; Department of Medicine, Université Laval, Quebec City, QC, Canada
| | - Lynne Moore
- CHU de Québec-Université Laval Research Center (Hôpital de l'Enfant-Jésus), Population Health and Optimal Health Practices Research Unit, Université Laval, Quebec City, QC, Canada; Department of Social and Preventive Medicine, Université Laval, Quebec City, QC, Canada
| | - Ryan Zarychanski
- Department of Internal Medicine, Sections of Critical Care Medicine and of Haematology & Medical Oncology, University of Manitoba, Winnipeg, MB, Canada
| | - Donald Griesdale
- Department of Anesthesia, University of British Columbia, Vancouver, BC, Canada
| | - Philippe Desjardins
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Université Laval, Quebec City, QC, Canada
| | - Jacques Lacroix
- Department of Pediatrics, Critical Care Medicine, Université de Montréal, Montreal, QC, Canada
| | - Dean Fergusson
- Clinical Epidemiology Unit, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Alexis F Turgeon
- CHU de Québec-Université Laval Research Center (Hôpital de l'Enfant-Jésus), Population Health and Optimal Health Practices Research Unit, Université Laval, Quebec City, QC, Canada; Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Université Laval, Quebec City, QC, Canada.
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Abstract
PURPOSE OF REVIEW Anemia is common in neurosurgical patients, and is associated with secondary brain injury. Although recent studies in critically ill patients have shifted practice toward more restrictive red blood cell (RBC) transfusion strategies, the evidence for restrictive versus liberal transfusion strategies in neurosurgical patients has been controversial. In this article, we review recent studies that highlight issues in RBC transfusion in neurosurgical patients. RECENT FINDINGS Recent observational, retrospective studies in patients with traumatic brain injury, subarachnoid hemorrhage, and intracranial hemorrhage have demonstrated that prolonged anemia and RBC transfusions were associated with worsened outcomes. Anemia in patients with ischemic stroke was associated with increased ICU length of stay and longer mechanical ventilation requirements, but mortality and functional outcomes did not improve with RBC transfusion. In elective craniotomy, perioperative anemia was associated with increased hospital length of stay but no difference in 30-day morbidity or mortality. SUMMARY There is a lack of definitive evidence to guide RBC transfusion practices in neurosurgical patients. Large randomized control trials are needed to better assess when and how aggressively to transfuse RBCs in neurosurgical patients.
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Holst LB, Petersen MW, Haase N, Perner A, Wetterslev J. Restrictive versus liberal transfusion strategy for red blood cell transfusion: systematic review of randomised trials with meta-analysis and trial sequential analysis. BMJ 2015; 350:h1354. [PMID: 25805204 PMCID: PMC4372223 DOI: 10.1136/bmj.h1354] [Citation(s) in RCA: 293] [Impact Index Per Article: 32.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/10/2015] [Indexed: 01/28/2023]
Abstract
OBJECTIVE To compare the benefit and harm of restrictive versus liberal transfusion strategies to guide red blood cell transfusions. DESIGN Systematic review with meta-analyses and trial sequential analyses of randomised clinical trials. DATA SOURCES Cochrane central register of controlled trials, SilverPlatter Medline (1950 to date), SilverPlatter Embase (1980 to date), and Science Citation Index Expanded (1900 to present). Reference lists of identified trials and other systematic reviews were assessed, and authors and experts in transfusion were contacted to identify additional trials. TRIAL SELECTION Published and unpublished randomised clinical trials that evaluated a restrictive compared with a liberal transfusion strategy in adults or children, irrespective of language, blinding procedure, publication status, or sample size. DATA EXTRACTION Two authors independently screened titles and abstracts of trials identified, and relevant trials were evaluated in full text for eligibility. Two reviewers then independently extracted data on methods, interventions, outcomes, and risk of bias from included trials. random effects models were used to estimate risk ratios and mean differences with 95% confidence intervals. RESULTS 31 trials totalling 9813 randomised patients were included. The proportion of patients receiving red blood cells (relative risk 0.54, 95% confidence interval 0.47 to 0.63, 8923 patients, 24 trials) and the number of red blood cell units transfused (mean difference -1.43, 95% confidence interval -2.01 to -0.86) were lower with the restrictive compared with liberal transfusion strategies. Restrictive compared with liberal transfusion strategies were not associated with risk of death (0.86, 0.74 to 1.01, 5707 patients, nine lower risk of bias trials), overall morbidity (0.98, 0.85 to 1.12, 4517 patients, six lower risk of bias trials), or fatal or non-fatal myocardial infarction (1.28, 0.66 to 2.49, 4730 patients, seven lower risk of bias trials). Results were not affected by the inclusion of trials with unclear or high risk of bias. Using trial sequential analyses on mortality and myocardial infarction, the required information size was not reached, but a 15% relative risk reduction or increase in overall morbidity with restrictive transfusion strategies could be excluded. CONCLUSIONS Compared with liberal strategies, restrictive transfusion strategies were associated with a reduction in the number of red blood cell units transfused and number of patients being transfused, but mortality, overall morbidity, and myocardial infarction seemed to be unaltered. Restrictive transfusion strategies are safe in most clinical settings. Liberal transfusion strategies have not been shown to convey any benefit to patients. TRIAL REGISTRATION PROSPERO CRD42013004272.
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Affiliation(s)
- Lars B Holst
- Department of Intensive Care 4131, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 9, DK-2100 Copenhagen, Denmark
| | - Marie W Petersen
- Department of Intensive Care 4131, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 9, DK-2100 Copenhagen, Denmark
| | - Nicolai Haase
- Department of Intensive Care 4131, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 9, DK-2100 Copenhagen, Denmark
| | - Anders Perner
- Department of Intensive Care 4131, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 9, DK-2100 Copenhagen, Denmark
| | - Jørn Wetterslev
- Copenhagen Trial Unit, Centre for Clinical Intervention Research 7812, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
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Do not drown the patient: appropriate fluid management in critical illness. Am J Emerg Med 2015; 33:448-50. [PMID: 25698681 DOI: 10.1016/j.ajem.2015.01.051] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2014] [Revised: 01/28/2015] [Accepted: 01/29/2015] [Indexed: 12/18/2022] Open
Abstract
Administering intravenous fluids to support the circulation in critically ill patients has been a mainstay of emergency medicine and critical care for decades, especially (but not exclusively) in patients with distributive or hypovolemic shock. However, in recent years, this automatic use of large fluid volumes is beginning to be questioned. Analysis from several large trials in severe sepsis and/or acute respiratory distress syndrome have shown independent links between volumes of fluid administered and outcome; conservative fluid strategies have also been associated with lower mortality in trauma patients. In addition, it is becoming ever more clear that central venous pressure, which is often used to guide fluid administration, is a completely unreliable parameter of volume status or fluid responsiveness. Furthermore, 2 recently published large multicenter trials (ARISE and ProCESS) have discredited the "early goal-directed therapy" approach, which used prespecified targets of central venous pressure and venous saturation to guide fluid and vasopressor administration. This article discusses the risks of "iatrogenic submersion" and strategies to avoid this risk while still giving our patients the fluids they need. The key lies in combining good clinical judgement, awareness of the potential harm from excessive fluid use, restraint in reflexive administration of fluids, and use of data from sophisticated monitoring tools such as echocardiography and transpulmonary thermodilution. Use of smaller volumes to perform fluid challenges, monitoring of extravascular lung water, earlier use of norepinephrine, and other strategies can help further reduce morbidity and mortality from severe sepsis.
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Robertson CS, Hannay HJ, Yamal JM, Gopinath S, Goodman JC, Tilley BC, Baldwin A, Rivera Lara L, Saucedo-Crespo H, Ahmed O, Sadasivan S, Ponce L, Cruz-Navarro J, Shahin H, Aisiku IP, Doshi P, Valadka A, Neipert L, Waguspack JM, Rubin ML, Benoit JS, Swank P. Effect of erythropoietin and transfusion threshold on neurological recovery after traumatic brain injury: a randomized clinical trial. JAMA 2014; 312:36-47. [PMID: 25058216 PMCID: PMC4113910 DOI: 10.1001/jama.2014.6490] [Citation(s) in RCA: 333] [Impact Index Per Article: 33.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE There is limited information about the effect of erythropoietin or a high hemoglobin transfusion threshold after a traumatic brain injury. OBJECTIVE To compare the effects of erythropoietin and 2 hemoglobin transfusion thresholds (7 and 10 g/dL) on neurological recovery after traumatic brain injury. DESIGN, SETTING, AND PARTICIPANTS Randomized clinical trial of 200 patients (erythropoietin, n = 102; placebo, n = 98) with closed head injury who were unable to follow commands and were enrolled within 6 hours of injury at neurosurgical intensive care units in 2 US level I trauma centers between May 2006 and August 2012. The study used a factorial design to test whether erythropoietin would fail to improve favorable outcomes by 20% and whether a hemoglobin transfusion threshold of greater than 10 g/dL would increase favorable outcomes without increasing complications. Erythropoietin or placebo was initially dosed daily for 3 days and then weekly for 2 more weeks (n = 74) and then the 24- and 48-hour doses were stopped for the remainder of the patients (n = 126). There were 99 patients assigned to a hemoglobin transfusion threshold of 7 g/dL and 101 patients assigned to 10 g/dL. INTERVENTIONS Intravenous erythropoietin (500 IU/kg per dose) or saline. Transfusion threshold maintained with packed red blood cells. MAIN OUTCOMES AND MEASURES Glasgow Outcome Scale score dichotomized as favorable (good recovery and moderate disability) or unfavorable (severe disability, vegetative, or dead) at 6 months postinjury. RESULTS There was no interaction between erythropoietin and hemoglobin transfusion threshold. Compared with placebo (favorable outcome rate: 34/89 [38.2%; 95% CI, 28.1% to 49.1%]), both erythropoietin groups were futile (first dosing regimen: 17/35 [48.6%; 95% CI, 31.4% to 66.0%], P = .13; second dosing regimen: 17/57 [29.8%; 95% CI, 18.4% to 43.4%], P < .001). Favorable outcome rates were 37/87 (42.5%) for the hemoglobin transfusion threshold of 7 g/dL and 31/94 (33.0%) for 10 g/dL (95% CI for the difference, -0.06 to 0.25, P = .28). There was a higher incidence of thromboembolic events for the transfusion threshold of 10 g/dL (22/101 [21.8%] vs 8/99 [8.1%] for the threshold of 7 g/dL, odds ratio, 0.32 [95% CI, 0.12 to 0.79], P = .009). CONCLUSIONS AND RELEVANCE In patients with closed head injury, neither the administration of erythropoietin nor maintaining hemoglobin concentration of greater than 10 g/dL resulted in improved neurological outcome at 6 months. The transfusion threshold of 10 g/dL was associated with a higher incidence of adverse events. These findings do not support either approach in this setting. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00313716.
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Affiliation(s)
| | - H Julia Hannay
- Department of Psychology, University of Houston, Houston, Texas
| | - José-Miguel Yamal
- Division of Biostatistics, University of Texas Health Science Center at Houston School of Public Health, Houston
| | - Shankar Gopinath
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - J Clay Goodman
- Department of Pathology and Immunology, Baylor College of Medicine, Houston, Texas
| | - Barbara C Tilley
- Division of Biostatistics, University of Texas Health Science Center at Houston School of Public Health, Houston
| | | | - Athena Baldwin
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Lucia Rivera Lara
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | | | - Osama Ahmed
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | | | - Luciano Ponce
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | | | - Hazem Shahin
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | | | - Pratik Doshi
- University of Texas Health Sciences Center, Houston
| | - Alex Valadka
- University of Texas Health Sciences Center, Houston
| | - Leslie Neipert
- Department of Psychology, University of Houston, Houston, Texas
| | | | - M Laura Rubin
- Division of Biostatistics, University of Texas Health Science Center at Houston School of Public Health, Houston
| | - Julia S Benoit
- Division of Biostatistics, University of Texas Health Science Center at Houston School of Public Health, Houston
| | - Paul Swank
- Division of Biostatistics, University of Texas Health Science Center at Houston School of Public Health, Houston
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Blood component transfusion increases the risk of death in children with traumatic brain injury. J Trauma Acute Care Surg 2014; 76:1082-7; discussion 1087-8. [PMID: 24662875 DOI: 10.1097/ta.0000000000000095] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Blood transfusion has been associated with worse outcomes in adult trauma patients with traumatic brain injury (TBI). However, the effects in injured children have not been evaluated. We hypothesize that blood transfusion is also associated with worse outcomes in children with TBI. METHODS A retrospective review of the trauma database at two Level I pediatric trauma centers was performed. We reviewed all patients 18 years and younger with TBI, who survived at least 24 hours, from 2002 to 2011. Exclusion criteria include those who underwent craniotomy, thoracotomy, exploratory laparotomy, and any orthopedic procedure. RESULTS A total of 1,607 children with TBI were included in the study population (mean age, 6.4 [5.7] years; 65% male), 178 of whom received a blood transfusion. Mean Injury Severity Score (ISS) was 16.5 (9.1). Patients who received a transfusion had a higher ISS than those who did not (26.7 vs. 15.3). After controlling for age, sex, ISS, Glasgow Coma Scale (GCS) score on presentation, and mechanism of injury, patients who received a blood transfusion were more likely to be admitted to the intensive care unit (p < 0.0001), less likely to survive to hospital discharge (p = 0.02), more likely to be discharged to a rehabilitation facility (p = 0.01) and be dependent on caretakers at follow-up (p < 0.0001), as well as more likely to develop urinary tract infection (p = 0.02) and bacteremia (p = 0.02) during their hospital stay. These differences in outcomes among those who did and did not receive a blood transfusion began to disappear in patients with a nadir hemoglobin of less than 8.0 g/dL. CONCLUSION Pediatric patients sustaining TBI who receive blood transfusion and do not require operative intervention have worse outcomes compared with patients who do not receive transfusion. This includes an increased risk of death. These data suggest that a transfusion trigger of hemoglobin level at 8.0 g/dL in injured children with TBI may be beneficial. LEVEL OF EVIDENCE Epidemiologic study, level III. Therapeutic study, level IV.
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