Transfusion of red blood cells in patients with a prehospital Glasgow Coma Scale score of 8 or less and no evidence of shock is associated with worse outcomes

Abstract

Background Red blood cell transfusion practices vary and the optimal hemoglobin for patients with traumatic brain injury (TBI) has not been established. We sought to identify the interaction between initial hemoglobin (Hgb) and red cell transfusion on 28-day survival, Acute Respiratory Distress Syndrome (ARDS) free survival, Multi-organ dysfunction (MODs) score, and 6-month Glascow Outcome Score extended (GOSE) score in a cohort of patients with a pre-hospital Glascow Coma Score (GCS) less than or equal to 8 and no evidence of shock. Methods A retrospective review of data collected prospectively as part of a randomized, controlled trial involving emergency medical services (EMS) agencies within the Resuscitation Outcomes Consortium was conducted. In patients with a GCS ≤ 8 without evidence of shock {defined by a systolic blood pressure (SBP) <70 or SBP of 70–90 with a heart rate (HR) ≥ 108}, the association of red cell transfusion with 28-day survival, ARDS free survival, MODs score and 6 month GOSE was modeled using multivariable logistic regression with robust standard errors adjusting for age, sex, injury severity (ISS), initial GCS, initial SBP, highest field HR, penetrating injury, fluid use, study site and Hgb. Results 1158 patients had a mean (m) age of 40, 76% were male and 98% suffered blunt trauma. The initial GCS (m) was 5 and initial SBP (m) was 134. The head abbreviated injury score (AIS) (m) was 3.5. A categorical interaction of red cell transfusion stratified by initial Hgb showed when the first hemoglobin was >10 grams/deciliter (g/dL), volume of pRBC was associated with a decreased 28 day survival (odd ratio [OR] 0.83 per unit with a 95% confidence interval [CI] of [0.74, 0.93] p<0.01) and decreased ARDS free survival (OR 0.82 per unit (95% CI [0.74, 0.92] p<0.01). When the initial Hgb was > 10, each unit of blood transfused increased the MODs score by 0.45 (Co-efficient 95% CI [0.19, 0.70] p-value<0.01). Conclusion In patients with a suspected TBI and no evidence of shock, transfusion of red blood cells was associated with worse outcomes when the initial hemoglobin was > 10. There was no relationship between blood transfusion and outcomes in the patients with initial hemoglobin ≤ 10. Level of Evidence II

Effects of Red Blood Cell Transfusion on Long-Term Disability of Patients with Traumatic Brain Injury

“…After adjusting for Neurocrit Care Our results confirm the previously observed relationship between RBCT and poor clinical outcomes in patients with TBI [4][5][6][7][8][9][10][11][12][13]. However, this study adds to the current knowledge by revealing that RBCT is associated with higher rates of major cognitive dysfunction and disabilities at the 12-month follow-up, regardless of the statistical approach used (Table 3; Fig.…”

“…The median [interquartile range] pretransfusion Hb concentration was 82 [60-110] g/L. Transfused patients received a median of 5 [3][4][5][6][7][8] units of packed RBC with a median length of storage of 15 [11][12][13][14][15][16][17][18][19][20] days. Concomitantly with RBCT, 29 (17.6 %) patients received fresh frozen plasma and 27 (16.4 %) received pooled platelets.…”

“…In the United States, more than 1.7 million persons sustain a TBI annually [1], and the annual burden of TBI has been estimated at more than $76 billion [2]. Mortality rates of approximately 40 % were reported in a review of unselected observational studies [3], but permanent disability is also prevalent, affecting 80,000-90,000 patients annually in the United States alone [4].…”

“…Because reduced hemoglobin (Hb) concentrations can decrease cerebral oxygen delivery and contribute to brain hypoxia, nearly 50 % of anemic patients with TBI receive at least one red blood cell transfusion (RBCT) during their stay at the neurological intensive care unit (NICU) [4][5][6][7][8].…”

Do not drown the patient: appropriate fluid management in critical illness

“…A recent meta-analysis of randomized controlled trials and cohort studies and cohort studies found that conservative fluid strategies were associated with lower mortality in trauma patients [14]. In addition, it is not only unrestrained crystalloid infusion that is being called into question; a recent study reported that transfusion of red blood cells was associated with significantly worse outcomes in patients with traumatic brain injury and no evidence of shock if the initial hemoglobin was greater than 10 g/dL [15]. Twenty years ago, Bickell et al [16] challenged the practice of early fluid resuscitation in patients with penetrating injuries, suggesting that this practice might be linked to increased bleeding and adverse outcomes.…”