Changes in Transfusion Protocols Linked to Improved Outcomes

Joe Barber Jr, PhD

July 18, 2013

Changes in transfusion practices for patients with traumatic injury are associated with reductions in mortality, according to the findings of a prospective cohort study.

Matthew E. Kutcher, MD, from the Department of Surgery, San Francisco General Hospital, University of California, and colleagues present their findings in an article published online July 17 in JAMA Surgery.

The researchers evaluated the outcomes of 174 trauma patients who received a massive transfusion (10 units or more of red blood cells [RBCs] in 24 h) or required activation of the institutional massive transfusion protocol between February 2005 and June 2011. Univariate analysis identified increasing transfusion requirements (hazard ratio [HR], 1.01; 95% confidence interval [CI], 1.01 - 1.02) and a higher RBC-to-fresh frozen plasma (FFP) ratio (HR, 1.91; 95% CI, 1.47 - 2.48) as predictors of mortality.

The authors excluded patients if they were younger than 18 years, had more than 5% surface area burns, received more than 2 L intravenous fluid before admission, were transferred from another institution, or had nontraumatic mechanisms of hemorrhage.

The included patients had a mean Injury Severity Score of 28.4 ± 16.2, a mean base deficit at admission of −9.8 ± 6.3, and a median international normalized ratio of 1.3 (interquartile range, 1.2 - 1.6). Clinicians activated the institutional massive transfusion protocol for 76.4% of the patients. The overall in-hospital mortality rate was 40.8% for the patient cohort.

During the study period, the median number of blood products administered in the first 24 h declined from 57 units in 2006 to 22 units in 2011 (P = .03), and the mean RBC:FFP ratio declined nonsignificantly from 1.84:1 in 2007 to 1.55:1 in 2011. In Cox regression analysis adjusted for age, Injury Severity Score, Glasgow Coma Scale at admission, and base deficit at admission, the investigators found that increasing transfusion requirements (HR, 1.02; 95% CI, 1.01 - 1.03) and a higher RBC:FFP ratio (HR, 1.71; 95% CI, 1.16 - 2.52) remained significantly predictive of mortality.

The limitations of the study included residual confounding and the single-institution nature of the study.

"Overall, the data presented herein provide both an informative exposition of trauma resuscitation trends, reflecting a sea change in the conduct of trauma resuscitation, and a clear statement that clinical equipoise exists and, in fact, demands well-designed multicenter clinical trials on the resuscitation of the critically injured," the authors write. "In the meantime, despite the unavailability of high-quality evidence, it appears that clinicians who care for injured patients are forging ahead, regardless of the controversies in clinical evidence, by migrating toward crystalloid- restricted, more plasma-based MT practices."

The study was supported by the National Institutes of Health. The authors have disclosed no relevant financial relationships.

JAMA Surg. Published July 17, 2013. Abstract

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