Dose-dependent association between blood transfusion and nosocomial infections in trauma patients: A secondary analysis of patients from the PAMPer trial

Abstract

BACKGROUND:The Prehospital Air Medical Plasma (PAMPer) trial demonstrated a survival benefit to trauma patients who received thawed plasma as part of early resuscitation. The objective of our study was to examine the association between blood transfusion and nosocomial infections among trauma patients who participated in the PAMPer trial. We hypothesized that transfusion of blood products will be associated with the development of nosocomial infections in a dose-dependent fashion. METHODS:We performed a secondary analysis of prospectively collected data of patients in the PAMPer trial with hospital length of stay of at least 3 days. Demographics, injury characteristics, and number of blood products transfused were obtained to evaluate outcomes. Bivariate analysis was performed to identify differences between patients with and without nosocomial infections. Two logistic regression models were created to evaluate the association between nosocomial infections and (1) any transfusion of blood products, and (2) quantity of blood products. Both models were adjusted for age, sex, and Injury Severity Score. RESULTS:A total of 399 patients were included: age, 46 years (interquartile range, 29-59 years); Injury Severity Score, 22 (interquartile range, 12-29); 73% male; 80% blunt mechanism; and 40 (10%) deaths. Ninety-three (27%) developed nosocomial infections, including pneumonia (n = 67), bloodstream infections (n = 14), catheter-associated urinary tract infection (n = 10), skin and soft tissue infection (n = 8), Clostridium difficile colitis (n = 7), empyema (n = 6), and complicated intra-abdominal infections (n = 3). Nearly 80% (n = 307) of patients received packed red blood cells (PRBCs); 12% received cryoprecipitate, 69% received plasma, and 27% received platelets. Patients who received any PRBCs had more than a twofold increase in nosocomial infections (odds ratio, 2.15; 95% confidence interval, 1.01-4.58; p = 0.047). The number of PRBCs given was also associated with the development of nosocomial infection (odds ratio, 1.10; 95% confidence interval, 1.05-1.16; p < 0.001). CONCLUSION:Trauma patients in the PAMPer trial who received a transfusion of at least 1 U of PRBCs incurred a twofold increased risk of nosocomial infection, and the risk of infection was dose dependent.

Establishing a core outcomes set for massive transfusion: An Eastern Association for the Surgery of Trauma modified Delphi method consensus study

“…33 In addition to mortality, morbidity occurs quite frequently in the MT population with estimates ranging from 14% to 42%. 34,35 Even after hemorrhage is controlled, the cellular response of individual organ systems and the balance of inflammatory mediators over hours or days can lead to multiple organ failure weeks after the initial insult. 34 As such, it is not surprising that morbidity was selected as a noncore but important outcome.…”

Pediatric traumatic hemorrhagic shock consensus conference research priorities

“…To understand the inflammatory response of trauma and the immune consequences of related therapies, future studies should focus on the immunological effects of trauma and transfusion after pediatric injury. Blood product transfusion is a potentially lifesaving therapy for hemorrhagic shock but can be associated with nosocomial infections and mortality in critically ill children and adults 32–35 . The future direction of this research may involve consideration of developing immunomodulating blood products or better characterization of the immunologic patient phenotype.…”

“…Blood product transfusion is a potentially lifesaving therapy for hemorrhagic shock but can be associated with nosocomial infections and mortality in critically ill children and adults. [32][33][34][35] The future direction of this research may involve consideration of developing immunomodulating blood products or better characterization of the immunologic patient phenotype. This may include determining which therapies are more advantageous than others based on their immunogenic properties.…”

Transfusion management in the trauma patient

“…The PAMPer trial identified a significant reduction in mortality when prehospital FFP was given to trauma patients during air transport [12]. A recent secondary analysis of the trial data evaluated the risk of nosocomial infections with blood transfusions and found that both PRBC and cryoprecipitate transfusion were significantly associated with increased odds of infection [13 ▪ ]. A dose-dependent relationship between the number of PRBC's transfused and nosocomial infection was identified [13 ▪ ].…”

“…A recent secondary analysis of the trial data evaluated the risk of nosocomial infections with blood transfusions and found that both PRBC and cryoprecipitate transfusion were significantly associated with increased odds of infection [13 ▪ ]. A dose-dependent relationship between the number of PRBC's transfused and nosocomial infection was identified [13 ▪ ]. Though causality was not established, the relationship suggests benefit to minimizing transfused products, which is aided by a balanced transfusion strategy.…”