Reappraising the concept of massive transfusion in trauma

Abstract

IntroductionThe massive-transfusion concept was introduced to recognize the dilutional complications resulting from large volumes of packed red blood cells (PRBCs). Definitions of massive transfusion vary and lack supporting clinical evidence. Damage-control resuscitation regimens of modern trauma care are targeted to the early correction of acute traumatic coagulopathy. The aim of this study was to identify a clinically relevant definition of trauma massive transfusion based on clinical outcomes. We also examined whether the concept was useful in that early prediction of massive transfusion requirements could allow early activation of blood bank protocols.MethodsDatasets on trauma admissions over a 1 or 2-year period were obtained from the trauma registries of five large trauma research networks. A fractional polynomial was used to model the transfusion-associated probability of death. A logistic regression model for the prediction of massive transfusion, defined as 10 or more units of red cell transfusions, was developed.ResultsIn total, 5,693 patient records were available for analysis. Mortality increased as transfusion requirements increased, but the model indicated no threshold effect. Mortality was 9% in patients who received none to five PRBC units, 22% in patients receiving six to nine PRBC units, and 42% in patients receiving 10 or more units. A logistic model for prediction of massive transfusion was developed and validated at multiple sites but achieved only moderate performance. The area under the receiver operating characteristic curve was 0.81, with specificity of only 50% at a sensitivity of 90% for the prediction of 10 or more PRBC units. Performance varied widely at different trauma centers, with specificity varying from 48% to 91%.ConclusionsNo threshold for definition exists at which a massive transfusion specifically results in worse outcomes. Even with a large sample size across multiple trauma datasets, it was not possible to develop a transportable and clinically useful prediction model based on available admission parameters. Massive transfusion as a concept in trauma has limited utility, and emphasis should be placed on identifying patients with massive hemorrhage and acute traumatic coagulopathy.

Infrastructure and clinical practice for the detection and management of trauma-associated haemorrhage and coagulopathy

“…There is still lack of consensus about the definition and treatment of trauma-associated coagulopathy and a variety of tools exist to detect, assess and monitor haemostatic [17][18][19][20]. The 2013 updated European guideline for the management of bleeding and coagulopathy following major trauma [14] currently suggests to clinically assess haemorrhage via physiology, injury pattern/mechanism and fluid response according to the Advanced Trauma Life Support concept (ATLS) as a 1C recommendation extended by the early use of imaging (1B recommendation).…”

Emergency red cells first: Rapid response or speed bump? The evolution of a massive transfusion protocol for trauma in a single UK centre

“…Importantly they all serve as a 'gatekeeper' at the point of activation. This is a very limiting concept because, for many clinicians, unless the sensitivity approaches 100% they represent an unacceptably high risk to use in clinical practice [29]. Equally, the parameters required for the accurate measurement of such predictors are often unavailable at the point of activation.…”

Massive Transfusion Protocols

“…Multiple prediction models for MT have been proposed; however, many of these are retrospective. Current [ 45 ]. The minute-to-minute prediction of MT from standard admission parameters remains diffi cult.…”

“…The minute-to-minute prediction of MT from standard admission parameters remains diffi cult. New approaches and prospective studies are required for the early diagnosis of patients with acute traumatic coagulopathy who will require transfusions [ 45 ]. Redefi ning MT in a manner that accounts for both the intensity of the ongoing resuscitation and survivor bias will lead to a more accurate method with which to identify potentially salvageable patients at highest risk of death from hemorrhagic shock.…”