title: Acute transfusion practice during trauma resuscitation: who, when, where and why?
abstract: BACKGROUND
  Early transfusion (ET=within 24h) has been shown to be required in approximately 5% of trauma patients. Critical care transfusion guidelines control transfusion triggers by evidence based cut-offs. Empirical guidelines influence decision making for ET in trauma.
  
  
  OBJECTIVE
  to describe the patterns, indications and timing of ET at level 1 trauma centre.
  
  
  METHODS
  A 12-month prospective study was performed on all trauma admissions requiring ET. Demographics, mechanism, injury severity (ISS) were collected. Timing, location, volume, the clinician initiating first unit of transfusion, reason for transfusion was recorded, with corresponding blood gas results and physiological parameters. Mortality, ICU admission, length of stay, need for emergent surgery were outcomes.
  
  
  RESULTS
  From 965 trauma admissions 91 (9%) required ET (76% male, median age: 38 (10-88, IQR: 22-59), blunt mechanism: 87%, ISS: 25 (4-66, IQR: 16-34). 43% (39/91) had massive transfusion protocol (MTP) activation. ET was initiated in ED (52%), OR (38%) or ICU (10%). MTP transfusions were started at a median of 0.5h (0.5-4, IQR: 0.5-1.5), whilst non-MTP transfusions were initiated at a median 3h (0.5-23, IQR: 2-9). The first unit of ET was initiated by trauma surgeon (35%), anaesthetist (30%), ED (19%), ICU (13%) and general surgeon (3%). Transfusions triggers at the first unit of transfusion were 'expected or ongoing bleeding' 29%, dropping haemoglobin 26%, haemorrhagic shock 24%, hypotension 10%, tachycardia 8%. Median systolic blood pressure was 90 (45-125, IQR: 80-100), heart rate was 100 (53-163, IQR: 80-120), haemoglobin was 96 (50-166, IQR: 85-114)g/l and base excess was -4.2(-22.1 to 2.7, IQR: -7.2 to 2.4)mmol/l at the time of transfusion. Emergency surgery was required in 86% (78/91). ICU admission rate was 69% (63/91). Mortality was 14%. Low volume transfusion (1-2 units) was more likely to lead to overtransfusion (Hb>110 g/l).
  
  
  CONCLUSIONS
  The prospective evaluation of acutely transfused trauma patients showed a distinct pattern of transfusion triggers as the patient passes from ED to the OT and arrives to the ICU. The conventional transfusion trigger (haemoglobin level) is not appropriate in ET as early transfusion triggers are based on vital signs, blood gas results, injury patterns and anticipated major bleeding.
authors.affiliation: Department of Traumatology, Division of Surgery, John Hunter Hospital and University of Newcastle, Newcastle, NSW, Australia. sisakkrisztian@hotmail.com
authors.forename: Krisztian
authors.initials: K
authors.lastname: Sisak
authors.forename: Michael
authors.initials: M
authors.lastname: Manolis
authors.forename: Benjamin M
authors.initials: BM
authors.lastname: Hardy
authors.forename: Natalie
authors.initials: N
authors.lastname: Enninghorst
authors.forename: Cino
authors.initials: C
authors.lastname: Bendinelli
authors.forename: Zsolt J
authors.initials: ZJ
authors.lastname: Balogh
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001315:Australia / Q000453:epidemiology; D001803:Blood Transfusion / Q000379:methods; D002648:Child; D003422:Critical Care; D003657:Decision Making; D019317:Evidence-Based Medicine; D005260:Female; D006801:Humans; D007022:Hypotension / Q000175:diagnosis / Q000453:epidemiology / Q000628:therapy*; D015601:Injury Severity Score; D008297:Male; D008875:Middle Aged; D017410:Practice Guidelines as Topic; D011446:Prospective Studies; D012151:Resuscitation / Q000379:methods* / Q000401:mortality; D012307:Risk Factors; D012771:Shock, Hemorrhagic / Q000175:diagnosis / Q000453:epidemiology / Q000628:therapy*; D013610:Tachycardia / Q000175:diagnosis / Q000453:epidemiology / Q000628:therapy*; D014193:Trauma Centers / Q000706:statistics & numerical data*