Asian Journal of Transfusion Science
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ORIGINAL ARTICLE  
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Review of transfusion practices and its outcome in trauma patients at an urban level 1 trauma center in India


1 Department of Transfusion Medicine, Jai Prakash Narayan Apex Trauma Center, AIIMS, New Delhi, India
2 Department of Immunohaematology and Blood Transfusion Medicine, Government Medical College and Hospital, Jammu, Jammu and Kashmir, India
3 Department of Laboratory Medicine, Jai Prakash Narayan Apex Trauma Center, AIIMS, New Delhi, India

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Date of Submission22-Feb-2021
Date of Decision06-Apr-2021
Date of Acceptance14-Apr-2021
Date of Web Publication04-Jun-2022
 

   Abstract 

CONTEXT: Implementation of appropriate transfusion strategy in a timely manner is of paramount importance during the initial resuscitation of massively bleeding trauma patients. Assessing transfusion patterns can help in planning, resource allocation, and devising proactive strategies for the management of such patients.
AIMS: To analyze transfusion requirements and its triggers in massively bleeding trauma patients.
SETTINGS AND DESIGN: Retrospective analysis of the transfusion practices for massively bleeding trauma patients requiring immediate blood transfusion.
METHODS: Clinical and transfusion details were collected from patient and the blood bank records, for massively bleeding trauma patients ≥18 years, and required at least 3 units of red blood cells (RBC's) within 1st h of presentation.
STATISTICAL ANALYSIS USED: Descriptive analysis for transfused blood components was done. Followed by regression analysis to identify predictors for transfusion.
RESULTS: A total of 215 (8.4%) patients, received at least 3 units of RBCs within the 1st h of admission. Component utilization rates were 76% for the RBC, 56% for the random donor platelets (RDP) and 68% for the fresh frozen plasma (FFP) in the first 24 h. The ratio of 1:1:1 for RBC:FFP:RDP was achieved in 81 (37.7%) patients and was associated with improved survival at 24 h. Shock index (SI) was found to be the most significant predictor for RBC, platelets, and cryoprecipitate transfusions, whereas FFP transfusions were largely associated with deranged prothrombin time.
CONCLUSIONS: Maintenance of a ratio of 1:1:1 can improve the early outcome in these patients. SI alone can be used as an important clinical tool for predicting transfusion at the time of preliminary evaluation of the bleeding trauma patients.

Keywords: Blood components, massive transfusion, transfusion–trauma


How to cite this URL:
Chaurasia R, Akhtar N, Subramanian A, Arya V, Karjee S. Review of transfusion practices and its outcome in trauma patients at an urban level 1 trauma center in India. Asian J Transfus Sci [Epub ahead of print] [cited 2022 Jul 6]. Available from: https://www.ajts.org/preprintarticle.asp?id=345994



   Introduction Top


Severe injuries have a high propensity of uncontrolled hemorrhage and subsequent hypovolemia which if untreated can lead to hypovolemic shock. Approximately, 40% early deaths in this group of patients have been attributed to uncontrolled hemorrhage.[1],[2] At the time of presentation to the emergency department, nearly one-fourth of the patients, have an underlying coagulopathy which further increases their risk of significant hemorrhage and is associated with increased incidence of multiple organ failure (MOF) and death.[3] Conventionally, resuscitation in massively bleeding trauma patients was initiated with large volumes of crystalloid, accompanied by red blood cells (RBC) transfusion and addition of plasma, platelets, and cryoprecipitate as directed by laboratory values. Over the past decade experience gained from damage control resuscitation (DCR) strategy in combat settings, has led to several modifications in the resuscitation strategy of civilian trauma. This includes minimizing the use of crystalloids, early use of blood components in balanced ratios, reversal of hypothermia and acidosis, and use of hemostatic adjuncts. In addition to the DCR, implementation of massive hemorrhage protocol has also aided in the significant improvements in overall management by institution of a multidisciplinary approach through protocolization of the transfusion therapy.[4],[5],[6]

Unfortunately, the transfusion practices in trauma care have not been well established in our country. Since knowledge and patterns of transfusion requirements in massively bleeding trauma patients are important for resource allocation, designing newer protocols for hemorrhage control and improving the survival. We performed a retrospective analysis of transfusion practices, predictor for transfusion, and its outcome in massively bleeding trauma patients.


   Methods Top


This retrospective analysis of the transfusion practices was performed at the Department of Transfusion Medicine at an urban level 1, trauma center. The study was approved by the Institutional Ethics Committee (IEC-878/03.01.2020) and conducted for 1-year duration starting from January 2018 to December 2018. All trauma patients ≥18 years of age were eligible for inclusion in the study. Patients who had received transfusion outside the hospital or were referred from other hospitals or transferred out after emergency or immediate deaths within 1 h were excluded. Patients with massive bleeding were selected and included for data analysis. Massive bleeding was defined as, transfusion of at least 3 units of RBCs with an ongoing blood loss within 1st h of presentation.[7] Patient details were collected from computerized patient record system and included the demographics (age, gender, blood group), injury details (mechanism of injury, anatomical site of injury, injury severity score as per abbreviated injury scale 2005, Glasgow coma scale [GCS] score), date and time of admission, baseline vitals (pulse rate, blood pressure, and respiratory rate) and laboratory values for hemoglobin, platelet count, prothrombin time (PT), activated partial thromboplastin time (aPTT), and base deficit were collected. Shock index (SI), which is defined as the ratio of pulse rate to systolic blood pressure was also calculated. SI has been advocated to be a better marker for stratifying patients with hypovolemic shock. Details of transfusion were collected from the blood bank records and included the timing, number, and the type of the blood components including RBC, random donor platelets (RDP), fresh frozen plasma (FFP) and cryoprecipitate that were transfused to the patients during the hospital stay.

Data collected were entered and managed using SPSS version 20.0 (SPSS Inc., Illinois, USA). Utilization of blood and blood components were assessed at 1, 4, 8, 12, and 24 h of admission (except for cryoprecipitate which was assessed at 12-and 24-h duration). Role of baseline vitals and laboratory variables were assessed for predicting transfusion utilization for all blood components using regression analysis. Factors that were found out be significant using univariate regression analysis were further analyzed using step-wise multivariate regression to balance for the role of covariates. Effect of RBC:RDP and RBC:FFP ratios on survival at 24 h was assessed using Chi-square test.


   Results Top


During the study duration of 1 year, 68,358 patients were registered at the trauma center, these included 5396, 22,167 and 40,795 patients triaged to red, yellow, and green area of the Emergency Department respectively. Transfusion was needed by a total of 2545 patients during their hospital stay. Of these, 915 patients met the inclusion and exclusion criteria. Of which 215 were classified as having massive bleeding. Majority of these patients were males 187 (87%) and the median age was 30 (interquartile range [IQR] 24–40) years. A road traffic accident was the most common mechanism (131, 60.9%) of injury in these patients, followed by homicide and attempted suicides in (34, 15.8%) patients. The median ISS was 17 (IQR: 13–25), with over 65% of the patients with ISS ≥16. Over 79% of patients had injury at multiple sites, among which injury to the lower limb (115, 53.5%) was the commonest site. Head injury was present in 110 patients, this included 28 patients with mild (GCS: 13–15), 11 patients with moderate (GCS: 9–12) and 71 patients with severe (GCS: 3–8) head injury. Median time to admission after injury was approximately 2 h (range: 00:28–4:52 h). Over two-third of the patients were admitted to the hospital within 4 h of injury. Baseline clinical and laboratory parameters of these patients are mentioned in [Table 1].
Table 1: Baseline vitals and laboratory investigations

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Transfusion data

A total of 1887 RBC, 2067 RDP, 1518 FFP, and 326 cryoprecipitate units were transfused to 215 patients included in the analysis. Majority of these blood components, 1438 (76.2%) RBC, 1030 (67.9%) FFP, 1167 (56.5%) RDP, and 249 (76.4%) cryoprecipitate units were transfused during the initial 24 h of admission. The mean time to transfusion was 21 min (range 15–43 min). All patients were transfused ABO and Rh group-specific RBC, except for 9 patients, where uncross-matched O Rh (D) positive RBCs were issued immediately, without performing blood group of the patient. Detailed utilization of the blood components during the first 24 h is shown in [Table 2]. During the 1st h, 66 (30.1%) patients were transfused with RBC, RDP, and FFP. The proportion of patients receiving all blood components increased to 192 (89.2%) collectively for all blood components. Overall, higher mean baseline PT (19.5 vs. 16.0; P − 0.025) and aPTT (40.9 vs. 32.8; P − 0.031) values were found to be clinically associated with transfusion of Platelets, FFP and Cryoprecipitate collectively, when compared with the patients transfused only with RBC. The ratio of RBC: FFP and RBC: RDP was calculated at 1, 4, 8, 12, and 24 h, and is shown in [Figure 1].
Table 2: Transfusion utilization during initial 24 h

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Figure 1: (a) Ratio of red blood cells: Fresh frozen plasma ratio at different time intervals. (b) Ratio of red blood cells: Random donor platelets ratio at different time intervals

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Transfusion predictors

Using multivariate regression SI (B = 2.678; 95% confidence interval [CI] of 1.870–3.487; P < 0.05) and base deficit (B= −0.11; 95% CI of -0.175–0.045; P < 0.05) were found to predictor for RBC transfusion. For RDP transfusion, SI was the only independent predictor with (B = 2.062; 95% CI of 1.056–3.067 and P < 0.05). Predictors for FFP transfusion included PT (B = 0.161; 95% CI of 0.071–0.252 and P = 0.001) and pulse rate (B = 0.036; 95% CI of 0.014-0.057 and P = 0.001). SI (B = 1.124; 95% CI of 0.443–1.804 and P = 0.001) and base deficit (B= −0.097; 95% CI of -0.152–0.042 and P = 0.001) were observed to be predictive of cryoprecipitate transfusion.

Blood component ratios and its effect on patient outcome

The overall mortality in this group of patients was found to be (86, 40%). Thirty-five of these deaths were reported within the first 24 h. The association of blood component ratios and patient outcome was assessed at different time intervals to determine, whether the maintenance of these ratios ≤1:1 for both RBC: RDP and RBC:FFP were associated with better survival. As shown in [Table 3] we observed that adherence to a ratio of ≤1:1 for both RBC:RDP and RBC:FFP transfusions were associated with better survival till 24 h.
Table 3: Association of blood component ratios at different time intervals with 24 h survival using Chi-square test

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   Discussion Top


Critical administration threshold-based definition for massive transfusion has increased levels of sensitivity for better identification of acutely bleeding patients.[8],[9],[10] It also aids in directing transfusion resources in prompt and timely manner for hemostatic management in significantly bleeding patients. In this study, we included 215 patients who required at least 3 units of RBC transfusion within the 1st h of arrival in the emergency department. Since transfusion of 2 units of RBC is quite common practice, decision to transfuse 3rd unit of RBC, reflected the need for the replacement of ongoing blood losses. Using of critical administration threshold-based definition in our study, allowed for the inclusion of significantly bleeding patients who required immediate transfusion and were successfully managed with transfusion of <10 units of RBC or expired within 24-h duration due to hemorrhage or other complications. Only 42 patients (19.5%) would have been categorized as cases of massive transfusion, if the traditional definition were to be used, thus undermining the overall effort directed toward the transfusion management of such patients. Patients included in our study accounted for approximately 8% of all transfused patients, with the utilization of approximately 20% of all the blood components collected annually. An average of 9 RBC, 10 RDP, 7 units of FFP, and 1.5 units of Cryoprecipitate per patient was transfused during their entire hospital stay and utilization rates were 76% for the RBC, 56% for the RDP and 68% for the FFP in the first 24 h. Utilization rates observed by us were comparable to other studies and ranged from 62% to 86% depending upon the type of trauma patients.[11],[12],[13]

Over 1/4th of the trauma patients has been shown to be coagulopathic at the time of presentation in the emergency room, plasma-based resuscitation strategy is often recommended, to avoid the harmful effect of crystalloids. Although early of the plasma components has been observed to improve the underlying coagulopathy, its effect on early and late mortality remains equivocal.[14],[15],[16] Patients who have longer transportation times for definitive care are reported to most benefit with the strategy using plasma early during resuscitation.[17] Contrary to this, earlier use of platelet components has been shown to be effective in reducing the MOF and overall mortality in significantly bleeding patients. Studies even recommend empirical use of platelets transfusion, even in the absence of laboratory test results. Since the transportation times and status of coagulopathy are not known in many patients, most of the authors recommend empirical use of plasma and platelets in addition to the RBCs.[18],[19] Ratio of the different blood components that should be used in severely bleeding trauma patients, is another area of interest. Several studies have evaluated the higher versus lower ratio of plasma and/or platelet to RBC components and show equivocal results with regards to the overall rate of mortality.[20],[21],[22],[23] Aggressive use of the plasma components, a significant amount of plasma wastage has been observed and hence needs to be addressed.[21] In our study, RBC was the predominant blood component transfused during the 1st h, with approximately 30% of the patient being transfused with all three blood components. Although the proportion of patients with the desired ratio of 1:1:1 increased with time but was still below 40% at 24 h. Maintenance of 1:1:1 ratio for blood components, as early as 4 h was associated with improved outcome. Similar results were also observed by Nunns et al. and Peralta et al.[24],[25]

Since large number of resources and efforts need to be directed toward transfusion management of these individuals, surrogate markers/predictor are often needed for timely identification of such patients. Various clinical and laboratory investigations have been evaluated to assess the transfusion requirement, based on which number of scoring systems have been devised, to predict the need for the transfusion requirement. Over 24 such scoring systems are known till date, which may range from simple scoring systems to complex scoring systems.[26] Although these scoring have been found to be useful, its universal adoption is limited. Moreover, the complexity of the clinical bleeding in such cases is often overlooked, making these scoring systems impractical in acute situations, thus used more retrospectively for research purposes.[19],[27] Therefore, clinical assessment along with monitoring of vital signs is desirable in acutely bleeding patients. However, for active monitoring individual use of vital signs such as pulse rate or systolic blood pressure is often unreliable, combined parameters such as SI, which is defined as the ratio of pulse rate to systolic blood pressure, has been advocated as a simple measure for stratifying patients with hypovolemic shock et al. have also shown that SI can be used for predicting the need for massive transfusion and emergency surgical procedures in trauma settings.[28],[29],[30]

While assessing the predictors for transfusion of individual blood components, we observed SI and base deficit as an important independent predictor for RBC transfusions. Both SI and base deficit are used for stratifying patients with hypovolemic shock and thus can be used for predicting RBC transfusions.

Thrombocytopenia in bleeding trauma patients is a late event, usually seen after loss of 1.5 blood volumes and the decision to transfuse platelets is largely based on the need for surgical intervention or presence of thrombocytopenic bleeding. In our study SI was found as a significant predictor for platelet transfusion, indicating that platelet transfusions were associated with ongoing blood loss, rather than platelet counts. For FFP transfusions, PT was observed as a significant predictor. PT and aPTT values ≥1.5 times of normal are often used as a trigger for plasma transfusion for prevention or treatment of coagulopathy in trauma patients. PT has been reported to be more sensitive than aPTT for predicting coagulopathy in trauma patients and hence necessitating platelet transfusions.[31] We also observed that an increased pulse rate was associated with FFP transfusion, possibly due to a higher grade of hemorrhagic shock in these patients. Lower levels of fibrinogen have also been reported among patients with severe hemorrhagic shock, thus explaining the correlation of cryoprecipitate transfusion with increasing SI and base excess.[32],[33]

Strengths

Using critical administration-based threshold as a criterion for identification of acutely bleeding trauma patients, allowed for the inclusion of most bleeding patients who required immediate transfusion without any survival bias.

Limitations

The determination of transfusion predictors was based only results of preliminary clinical evaluation and laboratory values. Lack of details of clinical assessment including the injury details are one of the shortcomings in this study. Second, we only assessed the effect of blood component ratios on 24-h mortality, deaths that occurred after 24 h, were excluded assuming that were not related to bleeding itself.


   Conclusions Top


Empirical use of platelets and plasma components is warranted, aiming to achieve a higher ratio of plasma and/platelets to RBCs, early during the treatment. The use of SI can be useful tool, for guiding blood component therapy trauma patients with ongoing blood loss. More prospective studies are needed to assess the role of different blood components for improving early mortality in significantly bleeding patients.

Acknowledgment

We would like to thank Mr. Ashish Dutt, for their kind help for statistical analysis of the data.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

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Moore HB, Moore EE, Chapman MP, McVaney K, Bryskiewicz G, Blechar R, et al. Plasma-first resuscitation to treat haemorrhagic shock during emergency ground transportation in an urban area: A randomised trial. Lancet 2018;392:283-91.  Back to cited text no. 14
    
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[PUBMED]  [Full text]  
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Correspondence Address:
Rahul Chaurasia,
Department of Transfusion Medicine, Jai Prakash Narayan Apex Trauma Center, AIIMS, New Delhi
India
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ajts.ajts_28_21



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