Recursive partitioning identifies greater than 4 U of packed red blood cells per hour as an improved massive transfusion definition

BACKGROUND Massive transfusion (MT) is classically defined as greater than 10 U of packed red blood cells (PRBCs) in 24 hours. This fails to capture the most severely injured patients. Extending the previous work of Savage and Rahbar, a rolling hourly rate-based definition of MT may more accurately define critically injured patients requiring early, aggressive resuscitation. METHODS The Prospective Observational Multicenter Major Trauma Transfusion (PROMMTT) trial collected data from 10 Level 1 trauma centers. Patients were placed into rate-based transfusion groups by maximal number of PRBCs transfused in any hour within the first 6 hours. A nonparametric analysis using classification trees partitioned data according to mortality at 24 hours using a predictor variable of maximum number PRBC units transfused in an hour. Dichotomous variables significant in previous scores and models as predictors of MT were used to identify critically ill patients: a positive finding on Focused Assessment with Sonography in Trauma (FAST) examination, Glasgow Coma Scale (GCS) score less than 8, heart rate greater than 120 beats/min, systolic blood pressure less than 90 mm Hg, penetrating mechanism of injury, international normalized ratio greater than 1.5, hemoglobin less than 11, and base deficit greater than 5. These critical indicators were then compared among the nodes of the classification tree. Patients omitted included those who did not receive PRBCs (n = 24) and those who did not have all eight critical indicators reported (n = 449). RESULTS In a population of 1,245 patients, the classification tree included 772 patients. Analysis by recursive partitioning showed increased mortality among patients receiving greater than 13 U/h (73.9%, p < 0.01). In those patients receiving less than or equal to 13 U/h, mortality was greater in patients who received more than 4 U/h (16.7% vs. 6.0%, p < 0.01) (Fig. 1). Nodal analysis showed that the median number of critical indicators for each node was 3 (2–4) (⩽4 U/h), 4 (3–5) (>4 U/h and ⩽13 U/h), and 5 (4–5.5) (>13 U/h). CONCLUSION A rate-based transfusion definition identifies a difference in mortality in patients who receive greater than 4 U/h of PRBCs. Redefining MT to greater than 4 U/h allows early identification of patients with a significant mortality risk who may be missed by the current definition. LEVEL OF EVIDENCE Prognostic/epidemiologic study, level III.

[1]  E. Bulger,et al.  Early resuscitation intensity as a surrogate for bleeding severity and early mortality in the PROMMTT study , 2013, The journal of trauma and acute care surgery.

[2]  T. Fabian,et al.  Redefining massive transfusion when every second counts , 2013, The journal of trauma and acute care surgery.

[3]  C. Probst,et al.  Predictive Models and Algorithms for the Need of Transfusion Including Massive Transfusion in Severely Injured Patients , 2012, Transfusion Medicine and Hemotherapy.

[4]  P. Cameron,et al.  The definition of massive transfusion in trauma: a critical variable in examining evidence for resuscitation , 2011, European journal of emergency medicine : official journal of the European Society for Emergency Medicine.

[5]  A. Ho,et al.  Early risk stratification of patients with major trauma requiring massive blood transfusion. , 2011, Resuscitation.

[6]  B. Robinson,et al.  All massive transfusion criteria are not created equal: defining the predictive value of individual transfusion triggers to better determine who benefits from blood. , 2011, The Journal of trauma.

[7]  G. Mcgwin,et al.  Prospective Identification of Patients at Risk for Massive Transfusion: An Imprecise Endeavor , 2011, The American surgeon.

[8]  M. Cohen,et al.  Reappraising the concept of massive transfusion in trauma , 2010, Critical care.

[9]  J. Holcomb,et al.  Emergency department blood transfusion predicts early massive transfusion and early blood component requirement , 2010, Transfusion.

[10]  Lesly A. Dossett,et al.  Multicenter validation of a simplified score to predict massive transfusion in trauma. , 2010, The Journal of trauma.

[11]  D. Dries.  A high ratio of plasma and platelets to packed red blood cells in the first 6 hours of massive transfusion improves outcomes in a large multicenter study , 2010 .

[12]  G. Rozycki,et al.  Improvements in early mortality and coagulopathy are sustained better in patients with blunt trauma after institution of a massive transfusion protocol in a civilian level I trauma center. , 2009, The Journal of trauma.

[13]  Lesly A. Dossett,et al.  Early prediction of massive transfusion in trauma: simple as ABC (assessment of blood consumption)? , 2009, The Journal of trauma.

[14]  Kevin Mackway-Jones,et al.  The coagulopathy of trauma: a review of mechanisms. , 2008, The Journal of trauma.

[15]  Jose Salinas,et al.  A predictive model for massive transfusion in combat casualty patients. , 2008, The Journal of trauma.

[16]  C. Wade,et al.  Early predictors of massive transfusion in combat casualties. , 2007, Journal of the American College of Surgeons.

[17]  C. Wade,et al.  The ratio of blood products transfused affects mortality in patients receiving massive transfusions at a combat support hospital. , 2007, The Journal of trauma.

[18]  Michael A Dubick,et al.  Damage control resuscitation: directly addressing the early coagulopathy of trauma. , 2007, The Journal of trauma.

[19]  J. Holcomb,et al.  Coagulopathy: Its Pathophysiology and Treatment in the Injured Patient , 2007, World Journal of Surgery.

[20]  R. Lefering,et al.  Trauma Associated Severe Hemorrhage (TASH)-Score: probability of mass transfusion as surrogate for life threatening hemorrhage after multiple trauma. , 2006, The Journal of trauma.

[21]  J. Hess,et al.  Massive transfusion practices around the globe and a suggestion for a common massive transfusion protocol. , 2006, The Journal of trauma.

[22]  J. Como,et al.  Blood transfusion rates in the care of acute trauma , 2004, Transfusion.

[23]  Mauricio Lynn,et al.  Early coagulopathy predicts mortality in trauma. , 2003, The Journal of trauma.