Jack A. Barney Resident Paper Award: Blood transfusions increase complications in moderately injured patients
Department of Surgery, The University of Kansas School of Medicine, Wichita, KS 67214, USA. American journal of surgery
(Impact Factor: 2.29).
12/2010; 200(6):746-50; discussion 750-1. DOI: 10.1016/j.amjsurg.2010.07.024
Previous assessments linked transfusions in trauma to increased respiratory and infectious complications. However, these studies included patients with severe trauma, brisk hemorrhage, and shock. Thus, the potentially harmful impact of transfusion was difficult to determine.
A retrospective review of all trauma patients with an injury severity score (ISS) of 9 to 14 admitted to a Level 1 Trauma Center over a 5-year period was performed. Patients were stratified by transfusion history and injury severity.
Records of 2,332 patients were reviewed; 208 (8.9%) received at least 1 packed red blood cell transfusion. The incidence of complications was significantly higher in patients receiving transfusions (42.3% vs 9.0%; P < .001), and transfusion was a significant independent predictor of the development of a complication (odds ratio, 5.85; P < .001). Further, the association of transfusion with complications was dose-dependent. Transfusion was associated with a significantly increased hospital length of stay (10.6 vs 3.9 days; P < .0001).
Moderately injured trauma patients receiving transfusions suffered significantly more complications. Indications for transfusion in this population should be reassessed carefully.
Available from: onlinelibrary.wiley.com
Available from: Michael J Mosier
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ABSTRACT: Historically, acute kidney injury (AKI) carried a deadly prognosis in the burn population. The aim of this study is to provide a modern description of AKI in the burn population and to develop a prediction tool for identifying patients at risk for late AKI. A large multi-institutional database, the Glue Grant's Trauma-Related Database, was used to characterize AKI in a cohort of critically ill burn patients. The authors defined AKI according to the RIFLE criteria and categorized AKI as early, late, or progressive. They then used Classification and Regression Tree (CART) analysis to create a decision tree with data obtained from the first 48 hours of admission to predict which subset of patients would develop late AKI. The accuracy of this decision tree was tested in a separate, single-institution cohort of burn patients who met the same criteria for entry into the Glue Grant study. Of the 220 total patients analyzed from the Glue Grant cohort, 49 (22.2%) developed early AKI, 39 (17.7%) developed late AKI, and 16 (7.2%) developed progressive AKI. The group with progressive AKI was statistically older, with more comorbidities and with the worst survival when compared with those with early or late AKI. Using CART analysis, a decision tree was developed with an overall accuracy of 80% for the development of late AKI for the Glue Grant dataset. The authors then tested this decision tree on a smaller dataset from our own institution to validate this tool and found it to be 73% accurate. AKI is common in severe burns with notable differences between early, late, and progressive AKI. In addition, CART analysis provided a predictive model for early identification of patients at highest risk for developing late AKI with proven clinical accuracy.
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ABSTRACT: Controversy exists about the ideal fresh frozen plasma/red blood cell (FFP/RBC) ratio for resuscitation of patients requiring massive transfusion (MT). This study correlates the FFP/RBC with clotting time (CT), prothrombin time (PT), partial thromboplastin time (PTT), and thrombin time (TT); with procoagulants (fibrinogen [FI], factor 5 [FV], and factor 8 [FVIII]); and with adult respiratory distress syndrome (pO2/FIO2).
The 32 patients studied in operating room (OR) were in shock for 47 minutes and received an average of 17.6 units RBC, 4.2 units FFP, and 14.2 L balanced electrolyte solution. The 53 patients (including 22 of the OR patients), studied an average of 9.5 hours after operation, had an average shock time of 42 minutes, and received 17.4 units RBC, 4.6 units FFP, and 12.3 L balanced electrolyte solution in OR.
The FFP/RBC in OR averaged 0.3:1 (range: 0.1:1 to 0.9:1). The OR study, done after a minimum of 10 RBC units at 3.8 hours, showed a PT of 3.5 seconds off normal (international normalized ratio < 1.3), a PTT of 34 seconds, and TT of 7.9 seconds off normal. FI, FV, and FVIII were restored to 148 mg/dL, 54%, and 81%. The pO2/FIO2 was 282. The early post-OR study showed a PT of 2.3 seconds off normal (international normalized ratio = 1.2), a PTT of 32 seconds, a TT of 7.2 seconds off normal, an FI of 207 mg/dL, an FV of 64%, an FVIII of 102%, and a pO2/FIO2 of 332. Both OR and early post-OR CTs and procoagulant levels are associated with adequate coagulation. All patients with a 0.31:1 or higher FFP/RBC had sufficient restoration of CTs and procoagulants.
These data show that an FFP/RBC ratio above 0.31:1 in injured patients requiring MT restores CTs and procoagulant to clinically effective levels while not causing adult respiratory distress syndrome. Future studies on defining the ideal FFP/RBC ratio for MT should monitor CTs, procoagulants, and organ function.
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