title: Profoundly abnormal initial physiologic and biochemical data cannot be used to determine futility in massively transfused trauma patients.
abstract: BACKGROUND
  Improvements in prehospital care and resuscitation have led to increases in the number of severely injured patients who are salvageable. Massive transfusion has been increasingly used. Patients often present with markedly abnormal physiologic and biochemical data. The purpose of this study was to identify objective data that can be used to identify clinical futility in massively transfused trauma patients to allow for early termination of resuscitative efforts.
  
  
  METHODS
  A multicenter database was used. Initial physiologic and biochemical data were obtained, and mortality was determined for patients in the 5th and 10th percentiles for each variable. Raw data from the extreme outliers for each variable were also examined to determine whether a point of excessive mortality could be identified. Injury scoring data were also analyzed. A classification tree model was used to look for variable combinations that predict clinical futility.
  
  
  RESULTS
  The cohort included 704 patients. Overall mortality was 40.2%. The highest mortality rates were seen in patients in the 10th percentile for lactate (77%) and pH (72%). Survivors at the extreme ends of the distribution curves for each variable were not uncommon. The classification tree analysis failed to identify any biochemical and physiologic variable combination predictive of >90% mortality. Patients older than 65 years with severe head injuries had 100% mortality.
  
  
  CONCLUSIONS
  Consideration should be given to withholding massive transfusion for patients older than 65 years with severe head injuries. Otherwise we did not identify any objective variables that reliably predict clinical futility in individual cases. Significant survival rates can be expected even in patients with profoundly abnormal physiologic and biochemical data.
authors.affiliation: Trauma Services, Legacy Emanuel Hospital and Health Center, Portland, Oregon 97227, USA. rbarbosa@lhs.org
authors.forename: Ronald R
authors.initials: RR
authors.lastname: Barbosa
authors.forename: Susan E
authors.initials: SE
authors.lastname: Rowell
authors.forename: Brian S
authors.initials: BS
authors.lastname: Diggs
authors.forename: Martin A
authors.initials: MA
authors.lastname: Schreiber
authors.forename: J B
authors.initials: JB
authors.lastname: Holcomb
authors.forename: C E
authors.initials: CE
authors.lastname: Wade
authors.forename: K J
authors.initials: KJ
authors.lastname: Brasel
authors.forename: G
authors.initials: G
authors.lastname: Vercruysse
authors.forename: J
authors.initials: J
authors.lastname: MacLeod
authors.forename: R P
authors.initials: RP
authors.lastname: Dutton
authors.forename: J R
authors.initials: JR
authors.lastname: Hess
authors.forename: J C
authors.initials: JC
authors.lastname: Duchesne
authors.forename: N E
authors.initials: NE
authors.lastname: McSwain
authors.forename: P
authors.initials: P
authors.lastname: Muskat
authors.forename: J
authors.initials: J
authors.lastname: Johannigamn
authors.forename: H M
authors.initials: HM
authors.lastname: Cryer
authors.forename: A
authors.initials: A
authors.lastname: Tillou
authors.forename: M J
authors.initials: MJ
authors.lastname: Cohen
authors.forename: J F
authors.initials: JF
authors.lastname: Pittet
authors.forename: P
authors.initials: P
authors.lastname: Knudson
authors.forename: M A
authors.initials: MA
authors.lastname: De Moya
authors.forename: M A
authors.initials: MA
authors.lastname: Schreiber
authors.forename: B
authors.initials: B
authors.lastname: Tieu
authors.forename: S
authors.initials: S
authors.lastname: Brundage
authors.forename: L M
authors.initials: LM
authors.lastname: Napolitano
authors.forename: M
authors.initials: M
authors.lastname: Brunsvold
authors.forename: K C
authors.initials: KC
authors.lastname: Sihler
authors.forename: G
authors.initials: G
authors.lastname: Beilman
authors.forename: A B
authors.initials: AB
authors.lastname: Peitzman
authors.forename: M S
authors.initials: MS
authors.lastname: Zenait
authors.forename: J
authors.initials: J
authors.lastname: Sperry
authors.forename: L
authors.initials: L
authors.lastname: Alarcon
authors.forename: M A
authors.initials: MA
authors.lastname: Croce
authors.forename: J P
authors.initials: JP
authors.lastname: Minei
authors.forename: R
authors.initials: R
authors.lastname: Kozar
authors.forename: E A
authors.initials: EA
authors.lastname: Gonzalez
authors.forename: R M
authors.initials: RM
authors.lastname: Stewart
authors.forename: S M
authors.initials: SM
authors.lastname: Cohn
authors.forename: J E
authors.initials: JE
authors.lastname: Mickalek
authors.forename: E M
authors.initials: EM
authors.lastname: Bulger
authors.forename: B A
authors.initials: BA
authors.lastname: Cotton
authors.forename: T C
authors.initials: TC
authors.lastname: Nunez
authors.forename: R
authors.initials: R
authors.lastname: Ivatury
authors.forename: J W
authors.initials: JW
authors.lastname: Meredith
authors.forename: P
authors.initials: P
authors.lastname: Miller
authors.forename: G J
authors.initials: GJ
authors.lastname: Pomper
authors.forename: B
authors.initials: B
authors.lastname: Marin
mesh_terms: D000328:Adult; D000368:Aged; D001803:Blood Transfusion; D005260:Female; D006470:Hemorrhage / Q000378:metabolism* / Q000503:physiopathology* / Q000628:therapy; D006801:Humans; D008297:Male; D018447:Medical Futility; D008875:Middle Aged; D011237:Predictive Value of Tests; D012151:Resuscitation; D012189:Retrospective Studies; D012307:Risk Factors; D015996:Survival Rate; D014947:Wounds and Injuries / Q000378:metabolism* / Q000401:mortality / Q000503:physiopathology*; D055815:Young Adult