Elsevier

Surgery

Volume 160, Issue 6, December 2016, Pages 1560-1567
Surgery

Trauma/Critical Care
Ideal hemoglobin transfusion target for resuscitation of massive-transfusion patients

https://doi.org/10.1016/j.surg.2016.05.022Get rights and content

Background

Overtransfusion of packed red blood cells is known to increase the risk of death in stable patients. With the delineation of minimum transfusion ratios in hemorrhaging patients complete, attention must be turned to the other end of the massive transfusion spectrum—that of defining the maximum transfusion of packed red blood cells. We aimed to define the ideal hemoglobin range 24 hours after anatomic hemostasis associated with the lowest mortality.

Methods

Massive-transfusion patients (≥10 units packed red blood cells within 24 hours) were reviewed from 2010–2013. The hemoglobin 24 ± 6 hours after anatomic hemostasis was used to stratify patients into undertransfusion (<8.0 g/dL), hemoglobin transfusion target (8.0–11.9 g/dL), and overtransfusion (>12.0 g/dL) groups; patients not surviving to 24 hours were excluded.

Results

We identified 418 patients (351 [84%] in the hemoglobin transfusion target group, 38 [9%] in the undertransfusion group, and 29 [7%] in the overtransfusion group) with an overall mortality of 18%. Undertransfusion patients had the greatest risk of death (odds ratio 3.3; 95% confidence interval 1.6–6.7) followed by overtransfusion patients (odds ratio 2.5; 95% confidence interval 1.1–5.6). Though pretransfusion hemoglobin was similar (9.5 ± 2.2 g/dL vs 9.5 ± 2.3 g/dL), overtransfusion patients had greater hemoglobin values during massive transfusion (8.3 ± 3.0 g/dL vs 6.9 ± 1.4 g/dL), persisting until hospital dismissal/death (11.4 ± 2.3 g/dL vs 9.6 ± 1.1 g/dL). In total, 657.4 excess packed red blood cell units were transfused (1.9 ± 1.5 per patient).

Conclusion

Overtransfusion patients had increased mortality, comparable to undertransfusion patients, despite younger age and fewer comorbidities. Shorter massive transfusion durations foster a scenario in which patients are at greater risk of overtransfusion.

Section snippets

Methods

Institutional review board approval was obtained to review the medical records of operative and trauma patients who underwent MT between 2010 and 2013 at a single institution. Patients who underwent a cardiac operation or required cardiopulmonary bypass were excluded. The HgB value obtained 24 ± 6 hours after anatomic hemostasis, defined as the time point of the last (tenth or higher) consecutive pRBC transfusion followed by no pRBC transfusions for at least 6 hours, was used to stratify

Results

In total, 547 MT patients survived to the 24-hour time point; of these patients, 129 were excluded due to undergoing a cardiac operation or cardiopulmonary bypass. Therefore, 418 patients were included in the analysis. The cohort was heterogeneous and made up of 39% general surgery, 13% trauma, 12% spine, 9% vascular, 8% liver transplant, 6% orthopedics, 5% urology, 3% noncardiac thoracic, 3% oral-maxillofacial, 2% neurosurgery, and 0.3% kidney/pancreas transplant patients (Table I).

Overall,

Discussion

The results of this study represent an initial attempt at defining optimal blood product transfusion practice for hemorrhage resuscitation. HgB values between 8.0 and 11.9 g/dL 24 hours after anatomic hemostasis provided the lowest odds of death in massively hemorrhaging patients when controlled for potential confounders. Not surprisingly, UT patients had the greatest mortality odds but, more significantly, the data demonstrated that OT patients had substantially increased odds of death, which

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Supported by CTSA grant number UL1 TR000135 from the National Center for Advancing Translational Sciences, a component of the National Institutes of Health (NIH). Its contents are solely the responsibility of the authors and do not necessarily represent the official view of NIH.

The authors declare no conflicts of interest relevant to this research.

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