Clinical gestalt and the prediction of massive transfusion after trauma

Abstract

Introduction Early recognition and treatment of trauma patients requiring massive transfusion (MT) has been shown to reduce mortality. While many risk factors predicting MT have been demonstrated, there is no universally accepted method or algorithm to identify these patients. We hypothesized that even among experienced trauma surgeons, the clinical gestalt of identifying patients who will require MT is unreliable. Methods Transfusion and mortality outcomes after trauma were observed at 10 U.S. Level-1 trauma centers in patients who survived ≥30 minutes after admission and received ≥1 unit of RBC within 6 hours of arrival. Subjects who received ≥ 10 units within 24 hours of admission were classified as MT patients. Trauma surgeons were asked the clinical gestalt question “Is the patient likely to be massively transfused?” ten minutes after the patients arrival. The performance of clinical gestalt to predict MT was assessed using chi-square tests and ROC analysis to compare gestalt to previously described scoring systems. Results Of the 1,245 patients enrolled, 966 met inclusion criteria and 221 (23%) patients received MT. 415 (43%) were predicted to have a MT and 551(57%) were predicted to not have MT. Patients predicted to have MT were younger, more often sustained penetrating trauma, had higher ISS scores, higher heart rates, and lower systolic blood pressures (all p < 0.05). Gestalt sensitivity was 65.6% and specificity was 63.8%. PPV and NPV were 34.9% and 86.2% respectively. Conclusion Data from this large multicenter trial demonstrates that predicting the need for MT continues to be a challenge. Because of the increased mortality associated with delayed therapy, a more reliable algorithm is needed to identify and treat these severely injured patients earlier. Level of Evidence II; Diagnostic study - Development of diagnostic criteria on basis of consecutive patients (with universally applied reference standard)

Association of Prehospital Shock Index and Trauma Bay Uncrossmatched Red Blood Cell Transfusion With Multiple Transfusion

“…Transfusion for bleeding must be initiated early after injury to optimize outcome Nunez et al, 2009 ;Pommerening et al, 2015 ). MULT initiation can be resource intensive even for high-volume centers, requiring coordination between nursing, laboratory, blood bank, and frequently involving multiple location changes to services such as imaging, interventional radiology, and the operating room.…”

“…This may suggest the potential for overtriage if using an SI of 1 or more as the trigger value. Although overtriage is not the intention, one author suggested overtriage resulting in early preparation is more desirable than lack of preparation ( Pommerening et al, 2015 ).…”

“…While limiting the overall sample size, the inclusion requirement of RBC transfusion targets potentially bleeding subjects more likely to receive MULT or traditional massive transfusion. This criterion is commonly used in previous studies of massive transfusion ( Ball et al, 2011 ;Callcut et al, 2013 ;Inaba et al, 2008 ;Larson et al, 2010 ;Nunez et al, 2009Nunez et al, , 2010Pommerening et al, 2015 ;Zink et al, 2009 ), including two recent, prospective, multicenter investigations .…”

“…Criteria for massive transfusion initiation are poorly defined, and activation may be inconsistent among providers ( Callcut, Johanningman, Kadon, Hanseman, & Robinson, 2011 ;Nunez et al, 2010 ;Pommerening et al, 2015 ;Riskin et al, 2009 ). Timely massive transfusion initiation is a challenge because need may not be identified, especially with ongoing occult bleeding ( Gruen et al, 2006 ;Larson et al, 2010 ;Nunez et al, 2009 ;Pommerening et al, 2015 ;Riha & Schreiber, 2013 ;Teixeira et al, 2007 ).…”

“…Timely massive transfusion initiation is a challenge because need may not be identified, especially with ongoing occult bleeding ( Gruen et al, 2006 ;Larson et al, 2010 ;Nunez et al, 2009 ;Pommerening et al, 2015 ;Riha & Schreiber, 2013 ;Teixeira et al, 2007 ). Clinician prediction of estimated blood loss may be inaccurate, especially in the ED ( Ashburn, Harrison, Ham, & Strote, 2012 ;Gruen et al, 2006 ;Teixeira et al, 2007 ).…”