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Low hemorrhage-related mortality in trauma patients in a Level I trauma center employing transfusion packages and early thromboelastography-directed hemostatic resuscitation with plasma and platelets

Authors

  • Pär I. Johansson,

    Corresponding author
    1. Section for Transfusion Medicine, Capital Region Blood Bank, the Department of Anesthesia and TraumaCenter 3193, Centre for Head and Orthopedic, and the Department of Intensive Care, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
    2. Department of Surgery, Division of Acute Care Surgery, Centre for Translational Injury Research, CeTIR, University of Texas Medical School at Houston, Houston, Texas
    • Address reprint requests to: Pär I. Johansson, MD, MPA, Section for Transfusion Medicine, Capital Region Blood Bank, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, DK-2100 Copenhagen, Denmark; e-mail: per.johansson@rh.regionh.dk.

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  • Anne Marie Sørensen,

    1. Section for Transfusion Medicine, Capital Region Blood Bank, the Department of Anesthesia and TraumaCenter 3193, Centre for Head and Orthopedic, and the Department of Intensive Care, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
    2. Department of Surgery, Division of Acute Care Surgery, Centre for Translational Injury Research, CeTIR, University of Texas Medical School at Houston, Houston, Texas
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  • Claus F. Larsen,

    1. Section for Transfusion Medicine, Capital Region Blood Bank, the Department of Anesthesia and TraumaCenter 3193, Centre for Head and Orthopedic, and the Department of Intensive Care, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
    2. Department of Surgery, Division of Acute Care Surgery, Centre for Translational Injury Research, CeTIR, University of Texas Medical School at Houston, Houston, Texas
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  • Nis A. Windeløv,

    1. Section for Transfusion Medicine, Capital Region Blood Bank, the Department of Anesthesia and TraumaCenter 3193, Centre for Head and Orthopedic, and the Department of Intensive Care, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
    2. Department of Surgery, Division of Acute Care Surgery, Centre for Translational Injury Research, CeTIR, University of Texas Medical School at Houston, Houston, Texas
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  • Jakob Stensballe,

    1. Section for Transfusion Medicine, Capital Region Blood Bank, the Department of Anesthesia and TraumaCenter 3193, Centre for Head and Orthopedic, and the Department of Intensive Care, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
    2. Department of Surgery, Division of Acute Care Surgery, Centre for Translational Injury Research, CeTIR, University of Texas Medical School at Houston, Houston, Texas
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  • Anders Perner,

    1. Section for Transfusion Medicine, Capital Region Blood Bank, the Department of Anesthesia and TraumaCenter 3193, Centre for Head and Orthopedic, and the Department of Intensive Care, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
    2. Department of Surgery, Division of Acute Care Surgery, Centre for Translational Injury Research, CeTIR, University of Texas Medical School at Houston, Houston, Texas
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  • Lars S. Rasmussen,

    1. Section for Transfusion Medicine, Capital Region Blood Bank, the Department of Anesthesia and TraumaCenter 3193, Centre for Head and Orthopedic, and the Department of Intensive Care, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
    2. Department of Surgery, Division of Acute Care Surgery, Centre for Translational Injury Research, CeTIR, University of Texas Medical School at Houston, Houston, Texas
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  • Sisse R. Ostrowski

    1. Section for Transfusion Medicine, Capital Region Blood Bank, the Department of Anesthesia and TraumaCenter 3193, Centre for Head and Orthopedic, and the Department of Intensive Care, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
    2. Department of Surgery, Division of Acute Care Surgery, Centre for Translational Injury Research, CeTIR, University of Texas Medical School at Houston, Houston, Texas
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  • The study was supported by an unrestricted research grant from Haemonetics Corp. (Braintree, MA). NAW received a fellowship grant from the University of Copenhagen and LSR received funding from the Tryg Foundation. AP received grant support from B. Braun Medical and Fresenius Kabi.

Abstract

Background

Hemorrhage accounts for most preventable trauma deaths, but still the optimal strategy for hemostatic resuscitation remains debated.

Study Design and Methods

This was a prospective study of adult trauma patients admitted to a Level I trauma center. Demography, Injury Severity Score (ISS), transfusion therapy, and mortality were registered. Hemostatic resuscitation was based on a massive transfusion protocol encompassing transfusion packages and thromboelastography (TEG)-guided therapy.

Results

A total of 182 patients were included (75% males, median age 43 years, ISS of 17, 92% with blunt trauma). Overall 28-day mortality was 12% with causes of death being exsanguinations (14%), traumatic brain injury (72%, two-thirds expiring within 24 hr), and other (14%). One-fourth, 16 and 15% of the patients, received red blood cells (RBCs), plasma, or platelets (PLTs) within 2 hours from admission and 68, 71, and 75%, respectively, of patients transfused within 24 hours received the respective blood products within the first 2 hours. In patients transfused within 24 hours, the median number of blood products at 2 hours was 5 units of RBCs, 5 units of plasma, and 2 units of PLT concentrates. Nonsurvivors had lower clot strength by kaolin-activated TEG and TEG functional fibrinogen and lower kaolin–tissue factor-activated TEG α-angle and lysis after 30 minutes compared to survivors. None of the TEG variables were independent predictors of massive transfusion or mortality.

Conclusion

Three-fourths of the patients transfused with plasma or PLTs within 24 hours received these in the first 2 hours. Hemorrhage caused 14% of the deaths. We introduced transfusion packages and early TEG-directed hemostatic resuscitation at our hospital 10 years ago and this may have contributed to reducing hemorrhagic trauma deaths.

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