Early Packed Red Blood Cell Transfusion and Acute Respiratory Distress Syndrome after Trauma

University of Washington Seattle, Seattle, Washington, United States
Anesthesiology (Impact Factor: 5.88). 03/2009; 110(2):351-60. DOI: 10.1097/ALN.0b013e3181948a97
Source: PubMed


Transfusion of packed red blood cells (PRBCs) is a risk factor for acute respiratory distress syndrome (ARDS) in trauma patients. Yet, there is a paucity of information regarding the risk of ARDS with incremental PRBCs exposure.
For this retrospective analysis, eligible patients from National Study on Costs and Outcomes of Trauma were included. Our main exposure was defined as units of PRBCs transfused during the first 24 h after admission. The main outcome was ARDS.
A total of 521 (4.6%) of 14070 patients developed ARDS, and 331 patients (63.5%) who developed ARDS received PRBCs transfusion. Injury severity, thoracic injury, polytrauma, and pneumonia receiving more than 5 units of fresh frozen plasma and 6-10 units of PRBCs were independent predictors of ARDS. Patients receiving more than 5 units of PRBCs had higher risk of developing ARDS (patients who received 6-10 units: adjusted odds ratio 2.5, 95% CI 1.12-5.3; patients who received more than 10 units: odds ratio 2.6, 95% CI 1.1-6.4). Each additional unit of PRBCs transfused conferred a 6% higher risk of ARDS (adjusted odds ratio 1.06; 95% CI 1.03-1.10).
Early transfusion of PRBCs is an independent predictor of ARDS in adult trauma patients. Conservative transfusion strategies that decrease PRBC exposure by even 1 unit may be warranted to reduce the risk of ARDS in injured patients.

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    • "Several authors advocate early fibrinogen substitution in the massively bleeding trauma patient [12-14]. A number of retrospective studies support a 1:1 ratio of fresh frozen plasma (FFP) to packed red blood cell (PRBC) in massive transfusion [15-17], although this strategy may have serious adverse effects in the post resuscitation phase, especially in the hypercoagulable patients [18]. Fibrinogen concentrates and cryoprecipitate have emerged as alternative sources, but their role in massive transfusion still lacks firm evidence. "
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    ABSTRACT: Impaired haemostasis following shock and tissue trauma is frequently detected in the trauma setting. These changes occur early, and are associated with increased mortality. The mechanism behind trauma-induced coagulopathy (TIC) is not clear. Several studies highlight the crucial role of fibrinogen in posttraumatic haemorrhage. This study explores the coagulation changes in a swine model of early TIC, with emphasis on fibrinogen levels and utilization of fibrinogen. A total of 18 landrace pigs were anaesthetized and divided into four groups. The Trauma-Shock group (TS) were inflicted bilateral blast femoral fractures with concomitant soft tissue injury by a high-energy rifle shot to both hind legs, followed by controlled exsanguination. The Shock group (S) was exposed to shock by exsanguination, whereas a third group was exposed to trauma only (T). A fourth group (C) served as control. Physiological data, haematological measurements, blood gas analyses and conventional coagulation assays were recorded at baseline and repeatedly over 60 minutes. Thrombelastometry were performed by means of the tissue factor activated ExTEM assay and the platelet inhibiting FibTEM assay. Data were statistically analysed by repeated measurements analyses method. A significant reduction of fibrinogen concentration was observed in both the TS and S groups. INR increased significantly in the S group and differed significantly from the TS group. Maximum clot firmness (MCF) of the ExTEM assay was significantly reduced over time in both TS and S groups. In the FibTEM assay a significant shortening of the clotting time and an increase in MCF was observed in the TS group compared to the S group. Despite a reduction in clotting capability measured by ExTEM MCF and a reduced fibrinogen concentration, extensive tissue trauma may induce an increased fibrin based clotting activity that attenuates the hypocoagulable tendency in exsanguinated animals.
    Full-text · Article · Jul 2013 · Scandinavian Journal of Trauma Resuscitation and Emergency Medicine
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    • "We were able to confirm that the transfusion of ≥10 units of PRBCs until ICU admission is an independent predictor for the development of ARDS, as previously reported by Chaiwat and co-workers [38]. They further demonstrated that one additional unit of PRBCs in patients receiving more than 10 units accounted for a 6% higher risk of ARDS [38]. However, in our analysis, liver injury (AIS ≥ 3) was not associated with pulmonary failure but revealed a significant association with transfusion of PRBCs, whereas transfusion of PRBCs was significantly associated with pulmonary failure. "
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    ABSTRACT: Background The incidence of pulmonary failure in trauma patients is considered to be influenced by several factors such as liver injury. We intended to assess the association of various potential predictors of pulmonary failure following thoracic trauma and liver injury. Methods Records of 12,585 trauma patients documented in the TraumaRegister DGU® of the German Trauma Society were analyzed regarding the potential impact of concomitant liver injury on the incidence of pulmonary failure using uni- and multivariate analyses. Pulmonary failure was defined as pulmonary failure of ≥ 3 SOFA-score points for at least two days. Patients were subdivided according to their injury pattern into four groups: group 1: AIS thorax < 3; AIS liver < 3; group 2: AIS thorax ≥ 3; AIS liver < 3; group 3: AIS thorax < 3; AIS liver ≥ 3 and group 4: AIS thorax ≥ 3; AIS liver ≥ 3. Results Overall, 2643 (21%) developed pulmonary failure, 12% (n= 642) in group 1, 26% (n= 697) in group 2, 16% (n= 30) in group 3, and 36% (n= 188) in group 4. Factors independently associated with pulmonary failure included relevant lung injury, pre-existing medical conditions (PMC), sex, transfusion of more than 10 units of packed red blood cells (PRBC), Glasgow Coma Scale (GCS) ≤ 8, and the ISS. However, liver injury was not associated with an increased risk of pulmonary failure following severe trauma in our setting. Conclusions Specific factors, but not liver injury, were associated with an increased risk of pulmonary failure following trauma. Trauma surgeons should be aware of these factors for optimized intensive care treatment.
    Full-text · Article · Apr 2013 · Scandinavian Journal of Trauma Resuscitation and Emergency Medicine
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    • "High-volume FFP transfusion is associated with considerable side effects [55,58-61]. Chaiwat et al. reported a dose-dependent relationship between FFP transfusion and acute respiratory distress syndrome (ARDS) in trauma patients [58]. In another study, FFP transfusion was independently associated with increased risk of MOF and ARDS in patients who survived beyond 48 hours [62]. "
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    ABSTRACT: Severe trauma-related bleeding is associated with high mortality. Standard coagulation tests provide limited information on the underlying coagulation disorder. Whole-blood viscoelastic tests such as rotational thromboelastometry or thrombelastography offer a more comprehensive insight into the coagulation process in trauma. The results are available within minutes and they provide information about the initiation of coagulation, the speed of clot formation, and the quality and stability of the clot. Viscoelastic tests have the potential to guide coagulation therapy according to the actual needs of each patient, reducing the risks of over- or under-transfusion. The concept of early, individualized and goal-directed therapy is explored in this review and the AUVA Trauma Hospital algorithm for managing trauma-induced coagulopathy is presented.
    Full-text · Article · Feb 2012 · Scandinavian Journal of Trauma Resuscitation and Emergency Medicine
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