Blood Transfusion in Trauma and Critical Care – Evidentiary Table
Title / Author /Class
/ NotesEffect of blood transfusions on subsequent kidney transplants. Transplant Proc 5:253-9 / 1972 Opelz G / 2 / Transplant study
Volume resuscitation in critical major trauma. J Royal Coll Surg Edinburgh 20:166-73 / 1975 Gill W / 3 / Expert Review of volume resuscitation in trauma patients. No study performed
Transfusion practices in trauma patients. West J Med 123:64-8 / 1975 Sheldon GF / 3 / Discussion panel
Fluid therapy in the critically injured patient. J Oral Surg 34:542-6 / 1976 Bergman SA / 3 / This is a review article based on their experience, which they don't present in any significant fashion. It is an old article (1976) back when the debate of crystalloid vs colloid for resuscitation was first brewing. They do site the references for transfusion of FFP and platelets and give the guidelines for that, but overall I do not see how this article would be relevant to this PMG.
The relationship between transfusion and hypoxemia in combat casualties. Ann Surg 188:513-20 / 1978 Collins JA / 3 / A retrospective review from the Vietnam war on the effects of blood transfusion on hypoxemia. When soldiers sustained peripheral injuries there was no statistical significance in hypoxemia for patients who did or did not receive blood despite the amount. For soldiers with abdominal injuries there also was not a statistically significant difference between those transfused and those not transfused, though those heavily transfused had lower means on POD #2 & #3. Those with thoracic wounds were significantly more hypoxemic than both of the other groups pre-op and those receiving blood were statistically more hypoxemic post-op than those who didnt receive blood. This may be explained by the nature of the injury itself. Overall this paper suggests that blood transfusion does not alter the lungs function to oxygenate blood but does discuss possible causes of hypoxemia due to blood transfusion. The one thing that was not mentioned in the methods was if supplemental oxygen was utilized in any of these patients if even available which will affect PaO2.
Transfusion therapy in trauma: a review of the principles and techniques used in the MIEMS program. [Review] Am Surg 45:109-25 / 1979 Sohmer PR / 3 / Good review article
Transfusion practices in emergencies. Prog in Clin & Biol Res 108:285-301 / 1982 Anonymous / 3 / Not a study. Discussion of practice. Conclusion is stop the bleeding
Primary hemostasis after massive transfusion for injury. Am Surg 48:393-6 / 1982 Harrigan C / 2 / 1) Thrombocytopenia did not correlate either # of transfusions, age of blood or duration of shock 2) Platelet counts returned to normal during the postoperative phase and then suprnormal in the convalescent phase 3) Bleeding times were elevated in all patients during operation and did not normalize untill late in the convalescent phase
Failure of RBC transfusion to increase oxygen transport or mixed venous PO2 in injured patients. J Trauma 22:741-6 / 1982 Shah DM / 2 / Prospective, non-blinded. Transfusion of stored blood resulted in 1. rise of Hg 0.9 and 1 g/dL respectively. 2) fall in cardiac index 3) fall in P50 of 4.1 Torr 4) No change in O2 delivery or consumption
Massive blood transfusion in acute trauma. Transfusion 23:404 / 1983 Courcy PA / 3 / Conclusion: Although massive transfusions are commonly associated with severe sequelae, these complications are not inevitable and the quantity of components administered may be given with minimal morbidity and survival.
This article is a Letter to the Editor and constitutes expert opinion only. The letter was written in response to another article we are reviewing: Sohmer 1979.
Resuscitation of trauma patients with type-specific uncrossmatched blood. J Trauma 24:327-31 / 1984 GervinAS / 3 / Conclusion: Type-specific uncrossmatched blood is safe and is a rapidly available alternative to crossmatched blood in the severely hypovolemic trauma patient.
This article is a retrospective study. Although the data is sparse, the hypothesis and results support the conclusion of direct and immediate safety demonstrated by lack of transfusion reactions. The indications for using type-specific uncrossmatched blood was not studied.
Serial changes in primary homeostasis after massive transfusion. Surg 98:836-44 / 1985 Harrigan C / 2 / Conclusion: The routine administration of platelets in injured patients in the OR after a minimum of 10 transfusions without "medical bleeding" is unwarranted.
Although this is a prospective study, the study group appears to be a convenience sample. While 5/22 (23%) patients died and all were in shock for an average of 47 min., no patient had clinical bleeding after 10 transfusions. The range of platelet counts was 58K - 250K. Since no patient had a platelet count < 58K, the conclusions are only valid for patients with platelet count >58K.
Whole blood in trauma resuscitations. Am J Emerg Med 3:358-9 / 1985 Iserson KV / 3 / This is an editorial that supports using whole blood, rather than PRBCs in trauma resuscitation. Points for: more volume, more clotting factors, regular crit and less lysis, longer PRBC life, less cost, antibacterial components present. Points against: decreased factors V and VIII, hypocalcemia, and most importantly logistic problems with outdating and wasting other components.
Review of problems of massive blood transfusion in surgical intensive care unit. Ann Acad Med, Singapore 14:175-84 / 1985 Lee TL / 2 / Retrospective review of massively trasnfused surgical patients. Results: n=29, rec'd from 2.3 to 12.4L (mean 5.2L) of primarily whole blood. 17 in "shock", 12 "non-shock". In non-shock patients the level of acidosis did correlate with transfusion but it did not in the shcok patients. Deficiency in V and VIII did not cause impaiment of hemostasis clinically. All patients had at least mild thrombocytopenia 24 hours after transfusion. No hyperkalemia was observed, in fact hypokalemia was observed in 53.6% pts. Overall, massive tranfsuion of whole blood appears to be less disturbing to acid base balance and coagulopathy then one would think, especially considering 20 of the 29 patients had at least their entire blood volume replaced.
Medical Vampires N Eng J Med 314:1250-1 / 1986 Burnum JF / 3 / Editorial that basically says we draw too much blood from our pts in the ICU...no kidding! A study in 1986 demonstrated that 2 units were remove on average while pt is in ICU!. Best solution, don't admit pt to ICU if you can avoid it.
Immediate trauma resuscitation with type O uncrossmatched blood: a two-year prospective experience. J Trauma 26:897-902 / 1986 Schwab CW / 3 / Use of Type O blood used as initial blood replacement until fully crossmatched blood was available. 83 patients received 880 units of blood, 330 units were uncrossmatched (3.9 units/pt). There was no incidence of transfusion reaction, and there were no reported blood unit imcompatibilities or subsequent typing difficulties. Conc: Type O blood can be universally transfused, is readily available and does not interfere with subsequent blood typing and transfusion.
Outcome of massive transfusion exceeding two blood volumes in trauma and emergency surgery. J Trauma 27:903-10 / 1987 Phillips TF / 3 / Retrospective analysis of 56 patients sustaining massive transfusion (MT) (two times the estimated blood volume). Failure to control hemorrhage at the initial operation seemed to be most closely associated with nonsurvival. There were no survivors of MT from blunt trauma and nontraumatic causes. No tests differentiated those patients who would develop coagulopathy, leaving authors to suggest prophylaxis with FFP and platelets. Blunt trauma patients were more likely than penetrating trauma patients to develop respiratory failurs. Septic complications were the most common complication in survivors.
Severity of anaemia and operative mortality and morbidity. Lancet 1:727-9 / 1988 Carson JL / 3 / Case controlled study of patients undergoing surgery who refused blood transfusion on religious grounds. Outcome measures, inhospital mortality and serious cardiac events. Mortality increased with declining Hb level, with patients 16 times more likely to die if preop Hb was <8g/dl. Mortality increased with increasing intraoperative bloodloss. Preoperative Hb and intraoperative bloodloss were independent risk factors. No patient with a preoperative Hb >8 and intraoperative bloodloss < 500 died. Concl: The practice of transfusing all patients to Hb 10g/dl preoperatively should be re-examined, as preoperative Hb alone is an inadequate index of perioperative risk, and the amount of intraoperative bloodloss should also be considered.
Perioperative RBC transfusion. JAMA 260:2700-3 / 1988 Office of Medical Applications of Research, National Institutes of Health / 3 / Panel review of a day long conference on the subject
Algorithms for evaluating the appropriateness of blood transfusion. Transfusion 29:298-303 / 1989 Coffin C / 3 / Restrospective review of evidence based transfuion guideline
Evaluation of the appropriateness of blood and blood product transfusion using preset criteria. Transfusion 29:473-76 / 1989 Mozes B / 3 / Retrospective review of the appropriateness of blood and blood product transfusion
Multiple blood transfusions reduce the recurrence rate of Crohn's disease. Dis Colon Rectum 32:749-53 / 1989 Peters WR / 3 / Lower recurrence rates of crohns dz patients possibly because of significant immunosuppression from multiple transfusions
Blood transfusion and postoperative infections. Transfusion 29:456-59 / 1989 Tartter PI / 3 / Blood transfusion is associated with increased risk of infection by an unknown mechanism. In emergency situation, blood transfusion may be necessary, but avoid blood transfusion unless absolutely necessary.
Collection and transfusion of blood and blood components in the United States. Transfusion 33:139-44 / 1989 Wallace EL / 2 / Review of data from AABB, ARC and Council of Community Blood Centers. Documented 1.2% increase blood supply form 1987 to 1989. Margin between blood supply and blood demand narrowing.
Immediate prediction of blood requirements in trauma victims. South Med J 82:186-9 / 1989 West HC / 3 / This is a class II study. However for the question being asked in the study, it probably is still helpful. The authors colclude that trauma score is the best predictor of transfusion. Patients with a TS score greater than 14 should have only type and screen. Those with a TS less than or equal to 14 should have immediate crossmatch of six units of PRBC'S. This strategy saves a significant amount of $, as well as significantly reduces blood bank inventories, in addition to reduction of lab personnel man-hours and days of wasted of blood shelf life.
Cardiovascular and metabolic response to RBC transfusion in critically ill volume-resuscitated nonsurgical patients. Crit Care Med 18:940-4 / 1990 Dietrich KA / 2 / This is a study of 32 patients with circulatory shock who received RBC transfusion for anemia after volume resuscitation. Patients were transfused if the Hgb was <10 g/dl with a volume estimated to increase the Hgb concentration by 3 g/dl. Hemodynamics were followed. Hgb and oxygen delivery increased, pulmonary artery wedge pressure and cardiac index were unchanged, and there was no significant change in Vo2 or lactate after transfusion. Oxygen-carrying capacity did not improve the degree of shock in these patients. The authors further conclude that the need for RBC transfusion after volume resuscitation cannot be based on currently available hemodynamic or cellular metabolic data. These patients were non-surgical, with cardiogenic shock and septic shock. The responses to transfusion according to type of shock were comparable to the group as a whole.
Hypothermia and acidosis worsen coagulopathy in the patient requiring massive transfusion. Am J Surg 160:515-8 / 1990 Ferrara A / 3 / This is a retrospective study of records of 45 trauma patients. The authors confirm current and commonly accepted principles of resuscitation that hypothermia and acidosis are bad and contribute to bleeding and a high mortality.
Elective surgery without transfusion: Influence of preoperative Hb level and blood loss on mortality. Am J Surg 159:320-4 / 1990 Spence RK / 3 / Retrospective study done in Jehovah’s Witnesses undergoing elective surgery. Operative blood loss has nore of an influence on mortality after elective surgery than does preoperative Hb. Mortality is 8.2% when operative blood loss is >500 cc vs 0% for blood loss <500 cc. Mortality is 3.2% when preoperative Hb > 10 g/dl vs 5% when preoperative Hb is between 6-10 g/dl.
Blood transfusion costs: A multicenter study. Transfusion 31:318-23 / 1991 Forbes JM / 2 / Multicenter study involving 19 hospitals to determine the cost of delivering a unit of blood to a hospitalized patient. Weighted average hospital charge per unit was $219. Total cost to transfuse a unit of blood was $155. 80% of this cost is due to acquisition costs and laboratory processing costs.
Massive transfusion: outcome in blunt trauma patients. J Trauma 31:1-7 / 1991 Wudel JH / 2 / To define survival rates in blunt trauma patients requiring more than 20 units of PRBC.
The factors which predicted an increased mortality in blunt trauma patients receiving more than 20 units PRBC (massive transfusion) included: age, presence of closed head injury, and presence of shock. Survival rate was 50%. 75% of those surviving led productive work lives.
Practice strategies for elective blood cell transfusion. Ann Intern Med 116:403-06 / 1992 AmericanCollege of Physicians / 3 / Guideline; Expert opinion based on published evidence. No automatic threshold value; transfuse on a unit-by-unit basis; transfuse to relieve symptoms in acute blood loss only after volume repletion with crystalloid; consider erythropoietin for anemia associated with chronic disease.
Reevaluation of current transfusion practices in patients in surgical intensive care units. Am J Surg 164:22-5 / 1992 Babineau TJ / 2 / Prospective cohort study; Evaluated the impact of PRBCs transfusion (administered for a Hb concentration less than 10 g/dL) on oxygen consumption in 30 surgical ICU pts who were euvolemic and hemodynamically stable. For the group as a whole, transfusion had a negligible effect on oxygen consumption. Fifty-eight percent of all such transfusions failed to change oxygen consumption by greater than 10% and could therefore be considered of questionable benefit.
Association between blood transfusion and infection in injured patients. J Trauma 33:659-61 / 1992 Edna TH / 2 / Prospective; eval relation of infections to PRBC Tx; logistic regression; relationship between blood Tx and infection was independent of other factors; PRBC (saline-adenine-glucose-mannitol preservative); 484 pts; 46 infections (26 UTI), wound,pneumonia, sepsis (pneumonia definition included only clinical signs and an infiltrate); no association between PRBC and mortality
Postoperative infections following autologous and homologous blood transfusions. Transfusion 32:27-30 / 1992 Mezrow CK / 2 / Retrospective case controlled study;100 pts undergoing same surgery, 50 autologous blood, 50 homologous; all infections documented with Cx; logistic regression; homologous pts had longer procedures with higher EBL, and received more units PRBC; 16% homologous + infections, 4% autologous p<0.05; less risk of infection in autologous group may be due to uncontrolled differences in the groups and not the source of PRBC
Infection after injury: association with blood transfusion. Am Surg 58:104-7 / 1992 RosemurgyAS / 3 / Retrospective study. Pts with 7 or more units rbc transfused had higher iss, higer rates of single and multiple infections, and more serious infections. The infectious risk apprears to increases with increased blood transfusions
Gastric tonometry in patients with sepsis: effects of dobutamine infusion and packed RBC transfusions. Chest 102:184-8 / 1992 Silverman HJ / 3 / Retrospective study. In septic pts, Dobutamine infusion increases pHi, while PRBC does not.
Prudent strategies for elective RBC transfusion. Ann Intern Med 116:393-402 / 1992 Welch HG / 3 / Older review article. Although studies show human tolerance of anemia, transfusion practices vary widely. They concluded that transfusion practices should be guided by clinical situation.
Blood transfusion increases the risk of infection after trauma. Arch Surg 128:171-7 / 1993 Agarwal N / 3 / This is a multicenter retrospective analysis of 5434 patients over a 2 year period. Data were analyzed for independent risk factors for infection following trauma. Statistical analysis of the data is plentiful and complicated. The results suggest that ISS and amount of blood received were the only two variables that were significant predictors of infection across groups. The major limitations of the study is that it is retrospective, infections are defined based upon medical record coding, and data regarding other blood component therapy was not available. This study supports other, better conducted studies, regarding transfusion and the risk of infection in trauma.
Blood conservation in critical care--the evidence accumulates. Crit Care Med 21:481-82 / 1993 Chernow B / 3 / This editorial discusses the potential importance of four articles published in the same issue as the editorial in Critical Care Medicine. The articles revolve around the concept of blood conservation. Two discuss in-line blood gas determinations and two discuss the use of in-line reservoirs to avoid the practice of discarding blood. These are the authors opinions.
Descriptive analysis of critical care units in the United States: patient characteristics and intensive care unit utilization. Crit Care Med 21:279-91 / 1993 Groeger JS / 3 / This is a survey from 2876 separate ICUs in 1706 hospitals in the United States. The study is essentially a snapshot of a day in all the ICUs in the United States. The census tool was developed by the SCCM with implementation and database development performed by an outside agency. The overall census response was 40%. Occupancy data, admission source, age, treatments, length of stay/transfers were reported by respondents. Differences between pediatric and adult units are discussed.
Effects of blood transfusion on oxygen transport variables in severe sepsis. Crit Care Med 21:1312-8 / 1993 Lorente JA / 1 / 16 patients with severe sepsis and hgb <10 were enrolled. in patients with an abnormal DO2-dependent VO2 as shown by increases in VO2 brought about by an infusion of dobutamine blood transfusion does not significantly increase VO2 despite significant changes in DO2
Effect of stored-blood transfusion on oxygen delivery in patients with sepsis. JAMA 269:3024-9 / 1993 Marik PE / 2 / Prospective study to determine the affect of RBC transfusion on GI and whole body O2 uptake. 23 pts. with sepsis on mechanical ventilation. Failed to demonstrate a beneficial effect of RBC transfusion on measured systemic O2 uptake. Patients receiving old blood (> 15 days)developed evidence of splanchnic ischemia
Relationship between postoperative anemia and cardiac morbidity in high-risk vascular patients in the intensive care unit. Crit Care Med 21:860-6 / 1993 Nelson AH / 2 / 27 patients undergoing infra-inguinal arterial bypass. 13/27 pts with HCT< 28. 10/13 hand psotop ischemia and 6 had morbid cardiac event. Patients with > HCT 28% (14) only 2 had myocardial;ischemia and ) deaths P=0.001
Perioperative blood transfusion and colorectal cancer recurrence: a qualitative statistical overview and meta-analysis. Transfusion 22:754-65 / 1993 Vamvakas E / never received this ariticle and could not find it on Pub Med or MD consult
The effects of massive transfusion and haptoglobin therapy on hemolysis in trauma patients. Surg Today 24:785-90 / 1994 Gando S / 3 / A retrospective review out of Japan from 1989-1991 that analyzed if patients who received massive transfusions had a lower likelihood of acute renal failure if they were given haptoglobin. This is a poorly done study. There was no randomization and those who received haptoglobin had received nearly 3x the amount of blood transfusion compared with those who didnt. They do not mention anything about when they reached endpoints of resuscitation or how they decided that the patient had been resuscitated. Patients are more likely to have ARF from inadequate renal perfusion after massive transfusion than from hemolysis or at least the two combined put the patient at great risk. There results suggested that there was no improvement in reducing the likelihood of ARF if haptoglobin was given.