Massive Transfusion in Trauma Patients: Tissue Hemoglobin Oxygen Saturation Predicts Poor Outcome

Department of Surgery, The Methodist Hospital, Houston Texas, USA.
The Journal of trauma (Impact Factor: 2.96). 05/2008; 64(4):1010-23. DOI: 10.1097/TA.0b013e31816a2417
Source: PubMed


Severely bleeding trauma patients requiring massive transfusion (MT) often experience poor outcomes. Our purpose was to determine the potential role of near infrared spectrometry derived tissue hemoglobin oxygen saturation (StO2) monitoring in early prediction of MT, and in the identification of those MT patients who will have poor outcomes.
Data from a prospective multi-institution StO2 monitoring study were analyzed to determine the current epidemiology of MT (defined as transfusion volume >/=10 units packed red blood cells in 24 hours of hospitalization). Multivariate logistic regression was used to develop prediction models.
Seven US level I trauma centers (TC) enrolled 383 patients. 114 (30%) required MT. MT progressed rapidly (40% exceeded MT threshold 2 hours after TC arrival, 80% after 6 hours). One third of MT patients died. Two thirds of deaths were due to early exsanguination and two thirds of early exsanguination patients died within 6 hours. One third of the early MT survivors developed multiple organ dysfunction syndrome. MT could be predicted with standard, readily available clinical data within 30 minutes and 60 minutes of TC arrival (area under the receiver operating characteristic curve = 0.78 and 0.80). In patients who required MT, StO2 was the only consistent predictor of poor outcome (multiple organ dysfunction syndrome or death).
MT progresses rapidly to significant morbidity and mortality despite level I TC care. Patients who require MT can be predicted early, and persistent low StO2 identifies those MT patients destined to have poor outcome. The ultimate goal is to identify these high risk patients as early as possible to test new strategies to improve outcome. Further validation studies are needed to analyze appropriate allocation and study appropriate use of damage control interventions.

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Available from: Peter Rhee, May 13, 2014
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    • "Furthermore, the absolute value of StO2 has repeatedly demonstrated its prognostic value in this patient population. Low StO2 values during the initial approach to these patients have been associated with larger transfusion requirements [39–41], increased risk of infection [42], multiorgan failure [42, 43], and even higher mortality rates [43, 44]. Importantly, this predictive value was maintained in apparently stable hemodynamic conditions (defined as systolic blood pressure > 90 mmHg) [40, 41]. "
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    ABSTRACT: According to current critical care management guidelines, the overall hemodynamic optimization process seeks to restore macrocirculatory oxygenation, pressure, and flow variables. However, there is increasing evidence demonstrating that, despite normalization of these global parameters, microcirculatory and regional perfusion alterations might occur, and persistence of these alterations has been associated with worse prognosis. Such observations have led to great interest in testing new technologies capable of evaluating the microcirculation. Near-infrared spectroscopy (NIRS) measures tissue oxygen saturation (StO2) and has been proposed as a noninvasive system for monitoring regional circulation. The present review aims to summarize the existing evidence on NIRS and its potential clinical utility in different scenarios of critically ill patients.
    Full-text · Article · Aug 2013
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    • "The lowest StO2 in the trauma bay has been shown to be as good as the lowest systolic blood pressure at identifying severe shock as defined by experienced clinicians [58]. Furthermore, StO2 within 1 hour of admission is lower in trauma patients who develop multiorgan dysfunction (MODS) or die, and a strongest predictor of MODS or death than other diagnostic modalities [60,61]. Low StO2 within 1 hour of admission was as sensitive as a high base deficit in identifying patients who developed MODS or died, although specificity for both was low [62]. "
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    ABSTRACT: Near infrared spectroscopy of the thenar eminence (NIRSth) is a noninvasive bedside method for assessing tissue oxygenation. The NIRS probe emits light with several wavelengths in the 700- to 850-nm interval and measures the reflected light mainly from a predefined depth. Complex physical models then allow the measurement of the relative concentrations of oxy and deoxyhemoglobin, and thus tissue saturation (StO2), as well as an approximation of the tissue hemoglobin, given as tissue hemoglobin index. Here we review of current knowledge of the application of NIRSth in anesthesia and intensive care. We performed an analytical and descriptive review of the literature using the terms “near-infrared spectroscopy” combined with “anesthesia,” “anesthesiology,” “intensive care,” “critical care,” “sepsis,” “bleeding,” “hemorrhage,” “surgery,” and “trauma” with particular focus on all NIRS studies involving measurement at the thenar eminence. We found that NIRSth has been applied as clinical research tool to perform both static and dynamic assessment of StO2. Specifically, a vascular occlusion test (VOT) with a pressure cuff can be used to provide a dynamic assessment of the tissue oxygenation response to ischemia. StO2 changes during such induced ischemia-reperfusion yield information on oxygen consumption and microvasculatory reactivity. Some evidence suggests that StO2 during VOT can detect fluid responsiveness during surgery. In hypovolemic shock, StO2 can help to predict outcome, but not in septic shock. In contrast, NIRS parameters during VOT increase the diagnostic and prognostic accuracy in both hypovolemic and septic shock. Minimal data are available on static or dynamic StO2 used to guide therapy. Although the available data are promising, further studies are necessary before NIRSth can become part of routine clinical practice.
    Full-text · Article · May 2012 · Annals of Intensive Care
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    • "Additionally, in the setting of MT we observed that a drop in StO2 portends early death from exsanguination [25,26] and may be helpful in making critical decisions. "
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    ABSTRACT: The purpose of the present review is to review our experience with near-infrared spectroscopy (NIRS) monitoring in shock resuscitation and predicting clinical outcomes. The management of critically ill patients with goal-oriented intensive care unit (ICU) resuscitation continues to evolve as our understanding of the appropriate physiologic targets improves. It is now recognized that resuscitation to achieve supranormal indices is not beneficial in all patients and may precipitate abdominal compartment syndrome. Over the years, ICU technology has provided physicians with specific physiologic parameters to guide shock resuscitation. Throughout this time, the tissue hemoglobin oxygen saturation (StO2) monitor has emerged as a non-invasive means to obtain reliable physiologic parameters to guide clinicians' resuscitative efforts. StO2 monitors have been shown to aid in early identification of nonresponders and to predict outcomes in hemorrhagic shock and ICU resuscitation. These data have also been used to better understand and refine existing resuscitation protocols. More recently, use of NIRS technology to guide resuscitation in septic shock has been shown to predict outcomes in high-risk patients. StO2 is an important tool in identifying high-risk patients in septic and hemorrhagic shock. It is a non-invasive means of obtaining vital information regarding outcome and adequacy of resuscitation.
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