Trends in transfusion of trauma victims--evaluation of changes in clinical practice.

Abstract

The present study was performed to compare blood product consumption and clinical results in consecutive, unselected trauma patients during the first 6 months of year 2002, 2004 and 2007.
Clinical data, blood product consumption, lowest haemoglobin values on day 1-10 after admission, and 30-day mortality were extracted from in-hospital trauma registry and the blood bank data base. The subpopulation of massively transfused patients was identified and analysed separately.
The total number of admitted trauma patients increased by 48% from 2002 to 2007, but the clinical data remained essentially unchanged. The mean number of erythrocyte units given day 1-10 decreased insignificantly from 9.4 in 2002 to 6.8 in 2007. New Injury Severity Score (NISS) increased in transfused and massively transfused patients, but not significantly. The number of patients transfused with plasma increased and the mean ratio of erythrocyte to plasma units transfused decreased by about 50%. The mean haemoglobin value in transfused patients on day 2 after admittance was significantly lower in 2007 than in 2002, while that on day 10 was significantly higher in 2007 than in 2002 and 2004. There was no change of 30-day survival from 2002 to 2007.
Significant changes of transfusion practice occurred during the past decade, probably as a result of increased focus on haemostasis and more precise criteria for transfusion. Despite a lower consumption of erythrocytes in 2007 than in 2002 and 2004, the mean haemoglobin level of transfused patients was higher on day 10 in 2007. The low number of transfused patients in this material makes evaluation of effect on survival difficult. Larger studies with strict control of all influencing factors are needed.

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ORIGINAL RESEARCHOpen Access
Trends in transfusion of trauma victims -
evaluation of changes in clinical practice
Anders R Nakstad1,2*, Nils O Skaga1, Johan Pillgram-Larsen3, Berit Gran4and Hans E Heier4,5
Abstract
Background: The present study was performed to compare blood product consumption and clinical results in
consecutive, unselected trauma patients during the first 6 months of year 2002, 2004 and 2007.
Methods: Clinical data, blood product consumption, lowest haemoglobin values on day 1-10 after admission, and
30-day mortality were extracted from in-hospital trauma registry and the blood bank data base. The subpopulation
of massively transfused patients was identified and analysed separately.
Results: The total number of admitted trauma patients increased by 48% from 2002 to 2007, but the clinical data
remained essentially unchanged. The mean number of erythrocyte units given day 1-10 decreased insignificantly
from 9.4 in 2002 to 6.8 in 2007. New Injury Severity Score (NISS) increased in transfused and massively transfused
patients, but not significantly. The number of patients transfused with plasma increased and the mean ratio of
erythrocyte to plasma units transfused decreased by about 50%. The mean haemoglobin value in transfused
patients on day 2 after admittance was significantly lower in 2007 than in 2002, while that on day 10 was
significantly higher in 2007 than in 2002 and 2004. There was no change of 30-day survival from 2002 to 2007.
Conclusions: Significant changes of transfusion practice occurred during the past decade, probably as a result of
increased focus on haemostasis and more precise criteria for transfusion. Despite a lower consumption of
erythrocytes in 2007 than in 2002 and 2004, the mean haemoglobin level of transfused patients was higher on day
10 in 2007. The low number of transfused patients in this material makes evaluation of effect on survival difficult.
Larger studies with strict control of all influencing factors are needed.
Background
Intravenous volume replacement and transfusion poli-
cies in bleeding trauma patients have traditionally been
based largely on local tradition and current opinions [1].
The main focus was on restoring intravascular volume
and heamatocrit, thereby securing oxygen transport
capacity. During recent years several studies have sug-
gested that early and aggressive use of prohaemostatic
blood components (thrombocyte concentrates, fresh fro-
zen plasma) may improve the survival rate significantly
[2-6]. However, studies also have been published which
fail to support this view [7-9]. The significance of
aggressive prohaemostatic transfusion regimens remains
unsettled, and there is a need for further studies to
extend current knowledge [10]. Parallel to the evolving
knowledge in transfusion therapy surgical and angio-
embolization techniques improve and patient groups
may change. In this study we wanted to describe the
change in trauma transfusion practice at Oslo University
Hospital - Ullevål (OUHU) during a 5-year period and
to evaluate if there is any visible clinical effect of antici-
pated changes in transfusion practice. Because blood
products are a limited resource, we also wanted to eval-
uate how the total consumption of blood products in
trauma care has changed.
Methods
Population and study database
The OUHU is the trauma referral centre in a mixed
urban and rural area with 2.5 million inhabitants and
the major trauma hospital for 550 000 citizens in the
Norwegian capital Oslo. Approximately 40% of admitted
trauma patients have Injury Severity Score (ISS) >15
[11]. The volume-criterion for a Level-1 trauma hospital
of 500 patients in this group per year is met [12]. The
* Correspondence: andersrn@akuttmedisin.info
1Department of Anaesthesia, Oslo University Hospital, Oslo, Norway
Full list of author information is available at the end of the article
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© 2011 Nakstad et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons
Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in
any medium, provided the original work is properly cited.

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OUHU blood bank facility serves all hospitals in the
community of Oslo and provides about 25% of the total
consumption of blood products in Norway. To gain a
representative five-year period all trauma patients
admitted during the first six months of the years 2002,
2004 and 2007 were included. These periods were cho-
sen because they represent stable periods between possi-
ble local changes in transfusion practice. Clinical data
from the first 10 days of treatment and 30-day mortality
data were sampled. Length of stay in the hospital (LOS)
and LOS in the intensive care unit (LOS ICU) was not
used due to lack of complete data and several confound-
ing factors. No data were available to calculate the exact
time from accident to transfusion. To indirectly control
for substantial changes of this parameter we calculated
the time from accident to arrival in OUHU for all
trauma patients in each of the whole years of 2002,
2004 and 2007. We also calculated the frequency of
patients arriving directly from the accident scene.
Study design and data collection
The study including extraction and analysis of data was
approved as a quality-assessing project. The following
data were extracted from the hospital based trauma reg-
istry; Anatomic injury according to Injury Severity Score
(ISS) and New Injury Severity Score (NISS) [13], both
based on coding of anatomic injury according to The
Abbreviated Injury Scale 1998, AIS 98 [14]. Physiological
derangement on admission by Revised Trauma Score
(RTS; the variables Glasgow Coma Scale score, respira-
tory rate and systolic blood pressure) [15]. Moreover,
we extracted age, gender, type of injury, and outcome
(30-day mortality) [16] for all trauma patients during
the first 6 months of the years 2002, 2004, and 2007.
Number of transfused units of erythrocytes, plasma, pla-
telets, and haemoglobin values were registered for the
first 10 days of hospital stay. When more than one hae-
moglobin value was recorded per day, the lowest one
was used for this study. Transfusion algorithms for the
respective periods were studied. The subpopulation of
massively transfused patients (10 or more units of ery-
throcytes in 24 hours) was identified and analysed sepa-
rately using Trauma Injury Severity Score (TRISS)
methodology [17].
Change in clinical practise in the study period
Transfusion practise in the year 2002 followed widely
accepted principles [18]; blood loss up to one blood
volume (equals 10 units of erythrocytes) was corrected
with crystalloids, colloids and erythrocytes. In the inter-
val 10 to 20 units of erythrocytes transfused, 1 unit of
plasma was administered per 4 units of erythrocytes.
This ratio was continued as long as massive transfusion
protocol went on. Following transfusion of 15 units of
erythrocytes, 1 unit of platelets was administered per 5
units of erythrocytes. The consultant anaesthesiologist
in the trauma team used a variety of clinical criteria
when initiating massive transfusion, but no formal pro-
tocol existed. In 2004, more focus was set on the need
for immediate administration of erythrocytes in the
emergency department in patients arriving in haemor-
rhagic shock, and to prevent hypothermia high capacity
blood warmers (Level One®, Smiths Medical Inc.) were
introduced. From 2006, damage control resuscitation
(DCR) gained more awareness among surgeons and
anaesthesiologists in the trauma team following publica-
tions from the United States [19-21]. Scandinavian
guidelines in massive transfusion and achievements in
massive transfusion presented from Denmark influenced
our decisions [22,23]. Our totally revised massive trans-
fusion protocol - following DCR principles - was imple-
mented and practised from late 2006, including the
delivery of “trauma packages” from the blood bank on
request. Each package contains 5 units of erythrocytes, 5
units of plasma and 2 units of platelets.
Statistical Analysis
Data were analyzed using a spreadsheet (Excel) and the
statistical package EPI-INFO (CDC, WHO). The chi
square test and Fisher’s exact test were used for com-
paring frequencies. Mann-Whitney/Wilcoxon Two-Sam-
ple test was employed for other nonparametric data.
Probability of Survival (Ps) was calculated using TRISS
methodology - a logistic regression model based on the
Major Trauma Outcome Study (MTOS), where the pre-
diction variables are Revised Trauma Score (RTS), Injury
Severity Score (ISS), age-index, and mechanism of injury
(blunt/penetrating) [13-15]. W-statistic (expressing
excess survivors per 100 patients treated at OUHU com-
pared to TRISS model predictions) was calculated
according to convention [17]. Updated coefficients from
the US National Trauma Data Bank (NTDB) in 2005
were used [24].
Results
Population characteristics
The number of admitted trauma patients increased by
48% (149 patients) from 2002 to 2007 (Table 1). There
was no significant change in ISS, NISS, RTS, age, gen-
der, or mortality rate when comparing the whole trauma
populations as well as the populations of transfused
patients from the three periods. Damage control surgery,
including emergency thoracotomy and/or laparatomy,
was performed in 16 patients in the 2002 period, 15
patients in the 2004 period and 11 patients in the 2007
period. OUHU participated in a randomized study eval-
uating recombinant Coagulation Factor VIIa in uncon-
trolled through 2007, but very few patients were
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included. The product was not used therapeutically in
the three periods studied.
Timing of transfusions
The logistics and procedures for preparation of blood
products have been unchanged during the study period.
Thus time from order to delivery of erythrocytes and
platelets in the trauma room is likely to have been
unchanged during the study period and is approximately
10 minutes including transport. The time from order to
delivery of plasma is, following the same reasoning,
unchanged at approximately 30 minutes. The longer
time for this product is because prethawed plasma is
not available. When a critically unstable patient is
reported by the emergency medical service (EMS) ery-
throcytes stored in the trauma bay can be prepared
ready for transfusion upon arrival of the patient.
Trauma packages (including plasma) can also be
requested before arrival of the patient to reduce delay in
balanced transfusion. The latter is dependent on early
report from the EMS.
Time from accident to transfusion
The percentage of trauma patients arriving directly from
the scene decreased from 88.9% in whole year of 2002,
85.3% in 2004 to 80.7% in 2007. Mean time from accident
to arrival in the trauma room (for patients transported
directly) was 1 hour 21 minutes in year 2002, 1 hour 42
minutes in 2004 and 1 hour 12 minutes in 2007.
In the groups of transfused patients the mean number
of erythrocyte units given day 1-10 decreased from 9.4
in 2002 to 6.8 in 2007 (Table 2). This change was not
statistically significant (p = 0.056). The changes in mean
units of plasma and thrombocytes given day 1-10 were
small. However, the ratio of total consumption of ery-
throcytes to total consumption of plasma decreased
from 5.2 in 2002 to 3.5 in 2004 (p < 0.001) and further
to 2.5 in 2007 (p = 0.02). The ratio of total consumption
of erythrocytes to total consumption of thrombocytes
decreased from 16.3 in 2002 to 9.4 in 2007 (p = 0.004),
but not significantly from 10.8 in 2004 to 9.4 in 2007 (p
= 0.44). A similar trend was seen in the subpopulation
of massively transfused patients.
Massive transfusion patients contributed greatly to the
consumption of blood products, especially in 2004,
when more than 40% of the consumption of erythro-
cytes was due to treatment of the 20 patients transfused
with 10 or more units during the first 24 hours. Signifi-
cantly fewer patients were massively transfused during
the first six months of 2007 compared to 2004 (p =
0.008). When comparing 2007 to 2002 there was a non-
significant decrease (p = 0.11). Massively transfused
patients are characterised by a high ISS, low RTS and a
high mortality rate (Table 3).
Median and mean New Injury Severity Score (NISS)
for both transfused patients and massively transfused
did not increase significantly (Table 4).
Haemoglobin values recorded during the first 10 days
after admittance
Mean haemoglobin values for each day in the whole
population of trauma patients were not significantly
Table 1 The trauma population at Oslo University Hospital Ullevål in the first six months of 2002, 2004 and 2007
First six months of 2002
AllTransfused day 1-10
First six months of 2004
AllTransfused day 1-10
First six months of 2007
AllTransfused day 1-10
Number of trauma patients
Total (% transfused)31588 (28%) 34196 (28%) 459107 (23%)
Age
Mean (SD) 33.8 (18.2)37.8 (21.0)33.7 (18.0)39.9 (21.3) 34.5 (18.2)39.9 (19.4)
Gender (male)
N (%)240 (76%) 68 (79%)302 (70%)76 (65%)336 (74%)76 (71%)
Non-survival
N (%)25 (8%) 15 (17%)40 (9%)27 (23%) 33 (7%) 21 (20%)
ISS
Mean (SD) 14.9 (15.6)29.9 (15.6)15.2 (13.9)31.5 (14.3)14.7 (14.3)30.7 (13.1)
RTS
Mean (SD)7.0 (1.5)6.4 (1.8)7.1 (1.4) 6.4 (1.8)7.2 (1.3) 6.3 (1.8)
ISS = Injury Severity Score. Calculations based on coding according to AIS 98 (see reference [14] for details of ISS calculation). RTS = Revised Trauma Score (see
reference [15] for details of calculation).
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Table 2 Consumption of blood products day 1-10 after the trauma incident for patients admitted in the first six
months of 2002, 2004 and 2007
First six months
of 2002
First six months
of 2004
First six months
of 2007
Relevant p-
values
Number of patients transfused with erythrocytes day 1-10
N (% of whole trauma population)88 (28%) 96 (28%) 107 (23%)
Consumption of erythrocytes
Total (median, mean units per. patient)842 (5, 9.4) 834 (7.5, 8.7)729 (5, 6.8)2002 vs 2007: p =
0.056
Number of patients given plasma
Total (percentage of transfused patients)26 (30%)37 (39%)44 (41%) 2002 vs 2004: p =
0.38
2004 vs 2007: p =
0.26
Consumption of plasma
Total (median, mean units per. patient)162 (4.5, 6.2)270 (4, 7.3) 296 (4, 6.7)
Number of patients given trombocytes
Total (percentage of transfused patients) 15 (17%) 19 (22%)22 (21%) 2002 vs 2004: p =
0.71
Consumption of trombocytes
Total (median, mean units per. patient) 51.5 (3, 3.4) 77 (2, 3.6)77.5 (2, 3.5)
Total units of erythrocytes consumed by massively
transfused patients day 1-2
Total (% of total consumption)283 (33.6%)356 (42.7%)171 (23,5%)
No of erythrocyte unites per massively transfused patient
21.8 18.719.0
The table lists total consumption and relevant data for the subgroup of patients receiving the different types of blood products. For comparing consumption of
erythrocytes, plasma and trombocytes Mann-Whitney test was employed. Both median and mean values are reported.
Table 3 Characteristics and survival rates for the population of patients that were massively transfused day 1-2 after
admittance
First six months of 2002First six months of 2004First six months of 2007
Number of patients
Proportion of all transfused patients (%)
13 199
13/62 (21%) **19/74 (26%)**/*9/94 (10%)*
Age
Mean (SD)33.5 (21.7) 34.8 (16.5) 45.2 (14.0)
Gender (male)
N (%)10 (76.9%) 15 (75.0%) 14 (73.7%)
Non-survival
N (%) 4 (30.8%)8 (40.0%)3 (33.3%)
ISS
Mean (SD) 38.5 (18.2)42.0 (16.6) 41.1 (11.2)
RTS
Mean (SD)5.5 (2.0)5.2 (2.2) 5.9 (1.8)
* p = 0.002 ** p = 0.10
Massive transfusion is defined as transfusion of more than 10 units of erythrocytes in 24 hours. ISS = Injury Severity Score. RTS = Revised Trauma Score. Fisher’s
exact test was used for comparing frequencies.
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different at any day during the 10-day period after
admittance when comparing the patient groups from
2002, 2004 and 2007. The mean value seemed to stabi-
lize around 9-9.5 g/dL (Figure 1).
In the group of transfused patients the mean haemo-
globin value day 1-2 after the accident in 2002 (9.52 g/
dL) was significantly higher than in 2004 (8.04 g/dL, p <
0,001) and in 2007 (8.55 g/dL, p = 0,005) (Figure 1).
The next day, however, a marked reduction in mean
haemoglobin in 2002 was noticed while mean haemo-
globin in 2007 increased. Thus, on day 3 mean haemo-
globin in 2007 (9.45 g/dL) was significantly higher than
in 2002 (8.9 g/dL, p = 0,0013) and in 2004 (8.7 g/dL, p
< 0.001). Mean haemoglobin value in 2007 remained
significantly higher than in 2002 and 2004 until day 6
after trauma incident. No significant difference was
found when comparing the values on day 7-9, but on
day 10 mean haemoglobin in 2007 (9.53 g/dL) was sig-
nificantly higher than in 2004 (9.06 g/dL, p = 0.022) and
in 2002 (9.12 g/dL, p = 0.023).
The proportion of patients transfused with one or two
units of erythrocytes showed little change during the 5-
year period (26.1%, 29.2% and 29.0%).
30-day mortality
Overall 30-day mortality was slightly better in 2007 than
in 2002 and 2004, but the change did not reach statisti-
cal significance. No significant changes were found
when comparing groups of patients minimally, moder-
ately or massively transfused. Using TRISS-methodology
no significant change in W-statistic (excess survivors
per 100 patients) was found in any group (Table 4).
Discussion
We have shown that significant changes of transfusion
practice has occurred during the past decade, probably
as a result of increased focus on the need for early hae-
mostasis and more precise criteria for initiation of mas-
sive transfusion. However, despite a lower consumption
of erythrocytes in 2007 than in 2002 and 2004, the
mean haemoglobin level of transfused patients was
higher on day 10 in 2007.
Trauma activity
The number of trauma patient admissions increased by
48% from 2002 to 2007. Despite this increase, no signifi-
cant change in core variables like ISS, RTS, age and survi-
val rate was found. The proportion of patients with severe
injury was also unchanged (40% in the whole period). For
transfused and massively transfused patients, the apparent
increase of NISS failed to reach statistical significance.
Thus the patients receiving erythrocytes were not more
seriously injured in 2004 and 2007 (Table 4).
During the five-year period major changes in the orga-
nisation of the hospitals in central parts of Norway
occurred. Key data from the national statistical service
does not indicate a marked increase of number of acci-
dents from 2002 to 2007 - in fact the number of
severely injured patients in road traffic accidents
decreased from 1329 to 828 in the 10-year period from
Table 4 W-statistic based on TRISS comparing all trauma patients, transfused patients and massively transfused
patients day 1-2
All trauma patientsTransfused trauma patients
First six months of2002 20042007 2002
Massively transfused trauma patients
2002 2004 20042007 2007
Number
315 341 459 62749413199
Non-survivalN (%)24(7,6) 34(10,0) 34(7,4)12(19,4)22(29,7) 19(20,2)4(30,8) 8(42,1)3(33,3)
W-statistic
(NTDB 05)
1,980,340,663,99 3,9 5,1815,38,899,76
95% C.I
(-0,15 -4,12) (-1,66 -2,34) (-1,03 -2,35) (-3,21 -11,19) (-3,08 -10,88) (-0,92 -11,28) (-2,40 -33,0) (-6,47 -24,26) (-13,87 -33,4)
ISSmedian 1010 1027 29,529 3843 38
ISSmean14,915,214,729,9 31,5 30,7 38,542 41,1
NISSmedian11 13 1234 384143 5057
NISSmean19,320 1939,640,5 41,542,8 */** 48,7 *52,6 **
* p = 0.36** p = 0.24
ISS = Injury Severity Score. RTS = Revised Trauma Score.
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1998 to 2008. The number of patients with moderate
injury also decreased from 10800 to 7300 according to
the national statistical service. An extra physician-
manned (anaesthesiologist) emergency medical helicop-
ter was assigned to the region from the summer of
2002. This significant increase in helicopter transport
capacity may have facilitated transport of more trauma
victims to OUHU. The increased proportion of patients
arriving from other hospital may be a natural finding
given the increase of the total number of trauma
patients. We think this reflects that more patients that
otherwise would have been treated in smaller hospitals
are transferred to the trauma hospital. We believe that
OUHU has become more of a regional and national
trauma centre during the study.
In Scandinavia efforts have been made to unite on
guidelines for massive transfusion [22]. Norway gener-
ally has the lowest consumption of blood products per
capita of the Nordic countries [25] - a fact that is inter-
esting enough to merit further investigation, also on the
use of transfusion in trauma care.
Time from accident to transfusion
Because of lack of precise data our calculation based on
the whole trauma population in the years of 2002, 2004
and 2007 must be interpreted with care. Mean time
seems to increase in 2004 and decrease in 2007
Procurement and consumption of blood products
The blood products used at OUHU are units of erythro-
cytes (mean volume of 1 unit of erythrocytes is 245 ml,
and hct is on average = 55), plasma (all hospitals in
Norway use the product Octaplas®instead of single unit
fresh frozen plasma. Mean volume of 1 unit is 200 ml).
Our platelet units (volume ca. 350 ml) contain platelets
from 4 donors of similar blood ABO and Rh(D) blood
groups mixed together. All units of erythrocytes and
platelets were leukocyte filtrated before storage. To our
knowledge, Octaplas®has never been reported to induce
transfusion related acute lung injury (TRALI). This
probably results from dilution and neutralisation of
TRALI-inducing antibodies in the production process.
Octalpas®is produced by pooling of 3000 units of FFP
for preparation of each Octaplas batch.
Consumption of blood products
The decrease in the ratios of erythrocytes to plasma as
well as to thrombocytes is in accordance with modern
guidelines for transfusion in trauma patients [22]. No
formal change in local guidelines occurred from 2002 to
2004, and our results may therefore reflect that clini-
cians change their practice according to evidence before
formal guidelines are revised.
Massively transfused patients contributed largely to
the consumption of erythrocytes and plasma in all three
6,8 6,8
7,8 7,8
8,8 8,8
9,8 9,8
10,8 10,8
11,811,8
112233445566778899
All?patients?2002 All?patients?2002
All?patients?2004All?patients?2004
All?patients?2007All?patients?2007
All?transfused?patients?2002 All?transfused?patients?2002
All?transfused?patients?2004All?transfused?patients?2004
All?transfused?patients?2007 All?transfused?patients?2007
Massively?transfused?2002Massively?transfused?2002
Massively?transfused?2004Massively?transfused?2004
Massively?transfused?2007 Massively?transfused?2007
Total?units?of?erythrocytes?consumed
Day?1?2?(1)
517
534
464
Day?3?(2)
111
96
86
Day?4?(3)
42
56
56
Day?5?(4)
29
30
41
Day?6?(5)
34
43
13
Day?7?(6)
35
15
22
Day?8?(7)
32
30
14
Day?9?(8)
21
18
14
Day?10?(9)
21
12
19
2002?(Q1?Q2)
2004?(Q1?Q2)
2007?(Q1?Q2)
Figure 1 Mean haemoglobin values for the groups of all trauma patients, transfused trauma patients and massively transfused
trauma patients day 1-10 after admittance. Total units of erythrocytes administered each day to the transfused patients are listed in the
separate table below the figure.
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periods studied, but the number of massively transfused
patients decreased significantly from 2004 to 2007. This
may explain the small change in consumption of throm-
bocytes. The reduced use of massive transfusion may
reflect improvements in trauma care like earlier use of
DCR principles (permissive hypotension prior to defini-
tive surgery, damage control surgery including angio-
graphicembolization techniques,
hypothermia), and increased focus on acute traumatic
coagulopathy and haemostatic resuscitation [26-28].
Almost 8% of patients (2007) received one or two
units of erythrocytes. Transfusion of such small volumes
is controversial because the increase in haemoglobin
value is small, while the hazards of transfusion persist
[29-32]. Some of these transfusion episodes may have
occurred because the clinical diagnosis of hypovolaemic
shock in the trauma room is uncertain and that some
transfusions are aborted when the first blood samples
are analyzed and early stabilisation of the patient is
obtained.
avoidance of
Haemoglobin trends
The mean lowest haemoglobin value was significantly
higher on day two in 2002 compared to day two in
2007. This may reflect differences in the way the first
blood sample was provided or differences in the amount
of fluids given, but also that the practice of erythrocyte
transfusion has become more restrictive. The change in
mean number of units of erythrocytes given to the
transfused patients in 2002 and 2007 is marked and sup-
ports the latter assumption, although not statistically
significant (p = 0,056). The somewhat reduced percen-
tage of patients who were transfused, may further sup-
port this interpretation. Unfortunately, we were not able
to obtain sufficient data about the infusion of fluids in
the pre-hospital phase and in the trauma room. The
haemoglobin values will be influenced by changes in
amounts of fluids given.
In accordance with the observations of Vincent et al.
our results illustrate that the mean haemoglobin values
tend to stabilize 3-4 days after admittance at values
around 9-9.5 g/dL [33]. It is tempting to propose that
this reflects an adaptation of the production of ery-
throcytes to the situation of the intensive care unit
patient, reducing blood viscosity to facilitate microcir-
culation [34].
Why does the clinical practice change?
There are probably several reasons for the reduced use
of erythrocytes. A more restrictive use of infusions in
the pre-hospital phase during recent years may present
the team with trauma patients that have a slightly higher
primary haemoglobin values. It is also possible that the
increased use of plasma and platelets in the early phase
of treatment improves coagulation and thus reduces the
total blood loss. A more restrictive use of fluids in the
hospital may reduce the total blood loss and thus
decrease the need for erythrocytes. Unfortunately, we do
not have precise data about the amount of fluids given
in any phase of treatment. In addition, increased use of
arterial blood samples (blood gas analyzers have been
installed in the ED and operation unit during the study
period) could give the clinicians the possibility to reduce
the number of transfused units when adequate haemo-
globin level is noted.
Mortality
Several retrospective reports exist which indicate that
aggressive use of prohaemostatic blood products reduce
mortality in bleeding trauma patients [35,36]. Others
have failed to find such a correlation [7,9]. In our study
mortality was low at the outset, and only relatively small
changes might be expected to occur. Also, and especially
for massively transfused patients, the number of patients
included may be too low to show any change. Prospec-
tive studies, preferably randomized clinical trials with
large enough patient groups and strict control with
influencing factors, are needed to reach a conclusion on
the effect of pro-haemostatic blood products in trauma
patients [8].
The increased use of DCS and radiological interven-
tions could be thought to increase survival rates in our
material, but the number of patients receiving this treat-
ment is low and a possible effect on mortality would
probably not be reflected because we compared short
periods of six months. In another study from our hospi-
tal a significant increase in survival rates for the whole
trauma population in has been reported [37].
Our results support what Dutton and co-workers
point out in a large study of trauma mortality patterns
in a ten year material [38]. Improved survival in pro-
spective randomized trials is difficult to find because of
the low mortality in modern trauma centres and the
small number of patients in whom outcome can be
influenced. New knowledge on post-injury haemostasis
and implementation of goal-directed approach to post-
injury coagulopathy may provide more answers in the
future [39].
Limitations of the study
This study has limitations due to patient number and
lack of some key data that would be valuable to our
analysis. Even if there were major positive changes in
transfusion therapy and total quality of trauma care, the
likelihood of this being reflected as changed mortality
outcome in a survey of this size is small. One important
reason for this is that only a small fraction of the trans-
fused patients are massively transfused and in need of a
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modern balanced ratio of blood components to increase
survival. We do, however, believe it is methodically cor-
rect to analyze for such changes despite these
assumptions.
Exact time from accident to arrival in the trauma room
would be of importance, because the timing of transfu-
sion is of importance. Unfortunately the time can only be
estimated due to lack of complete data in our trauma
registry. Exact data regarding pre-hospital and in-hospital
volumes of infused fluids would also be of great interest
and valuable when interpreting the changes in haemoglo-
bin and transfusion found in our data.
Do improvements in other parts of trauma care affect our
results?
In 2004 highly efficient blood and fluid warmers were
introduced at OUHU, thus reducing the hypothermic
effect of massive transfusions and infusions, and improv-
ing the conditions for efficient haemostasis. In the same
period a 24/7/365 service of haemostatic angiographic
embolization became available. This service may have
reduced the number of massively bleeding patients. The
increased focus on early external fixation of pelvic frac-
tures and the use of a high-quality and faster CT-facility
may also be influential. In addition the constant training
and increased use of video-feedback in the trauma team
may improve quality of care.
Resource considerations
Consumption of blood products is increasing in many
countries, Norway included [24,40]. It is interesting,
therefore, to note that a reduced consumption of erythro-
cytes in the treatment of trauma had no negative effect
on 30-day mortality. This should encourage attempts at
reducing erythrocyte consumption also for other patient
groups in order to avoid shortage of blood supply.
Conclusions
Significant changes of transfusion practice occurred dur-
ing the five year period studied, possibly as result of
increased multimodal focus on haemostasis and as a
result of new transfusion algorithms reflecting such a
focus. Despite a lower consumption of erythrocytes in
2007 than in 2002 and 2004, which was probably
reflected in a lower mean haemoglobin value on day
two, the mean haemoglobin level of transfused patients
was higher on day 10 in 2007. This may reflect a more
restrictive practice of fluid resuscitation or improve-
ments in other parts of trauma care. The reduced con-
sumption of erythrocytes is valuable per se, since
shortage of erythrocyte supply is threatening due to an
ageing population in general and difficulties of recruiting
and retaining blood donors [36].
High plasma - and platelets to erythrocyte ratios have
been reported to improve survival in patients with mas-
sive bleeding [41]. Like some other studies our results
fail to support this, but the effect of this therapeutic
approach must be subject to future studies of larger
patient groups with strict control of all influencing fac-
tors before final conclusions are drawn.
Author details
1Department of Anaesthesia, Oslo University Hospital, Oslo, Norway.2Air
Ambulance Department, Oslo University Hospital, Oslo, Norway.3Department
of Cardiothoracic Surgery, Oslo University Hospital, Oslo, Norway.4Blood
Bank of Oslo, Department of Immunology and Transfusion Medicine, Oslo
University Hospital, Oslo, Norway.5University of Oslo, Faculty of Medicine,
Oslo, Norway.
Authors’ contributions
HEH, JPL and NOS made the first analysis on data from 2002. HEH designed
the study. NOS generated the data from the trauma registry. BG generated
the data from the Blood Bank. ARN merged the data for all three periods
and performed statistical analysis. NOS performed the TRISS-analysis. ARN
was responsible for making figures and tables. All authors participated in the
writing process. All read and approved the final manuscript.
Competing interests
None of the authors have any conflict of interest with regard to the material
discussed in this manuscript.
Received: 13 December 2010 Accepted: 11 April 2011
Published: 11 April 2011
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doi:10.1186/1757-7241-19-23
Cite this article as: Nakstad et al.: Trends in transfusion of trauma
victims - evaluation of changes in clinical practice. Scandinavian Journal
of Trauma, Resuscitation and Emergency Medicine 2011 19:23.
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