title: Risk factors for trauma-induced coagulopathy- and transfusion-associated multiple organ failure in severely injured trauma patients.
abstract: BACKGROUND
  Both trauma-induced coagulopathy (TIC) and transfusion strategies influence early outcome in hemorrhagic trauma patients. Their impact on late outcome is less well characterized. This study systematically reviews risk factors for TIC- and transfusion-associated multiple organ failure (MOF) in severely injured trauma patients.
  
  
  METHODS
  A systematic search was conducted in PubMed and Embase. Studies published from 1986 to 2013 on adult trauma patients with an injury severity score ≥16, investigating TIC or transfusion strategies with MOF as primary or secondary outcome, were eligible for inclusion. Results of the included studies were evaluated with meta-analyses of pooled data.
  
  
  RESULTS
  In total, 50 studies were included with a total sample size of 63,586 patients. Due to heterogeneity of the study populations and outcome measures, results from 7 studies allowed for pooling of data. Risk factors for TIC-associated MOF were hypocoagulopathy, hemorrhagic shock, activated protein C, increased histone levels, and increased levels of markers of fibrinolysis on admission. After at least 24 h after admission, the occurrence of thromboembolic events was associated with MOF. Risk factors for transfusion-associated MOF were the administration of fluids and red blood cell units within 24 h post-injury, the age of red blood cells (>14 days) and a ratio of FFP:RBC ≥ 1:1 (OR 1.11, 95% CI 1.04-1.19).
  
  
  CONCLUSIONS
  Risk factors for TIC-associated MOF in severely injured trauma patients are early hypocoagulopathy and hemorrhagic shock, while a hypercoagulable state with the occurrence of thromboembolic events later in the course of trauma predisposes to MOF. Risk factors for transfusion-associated MOF include administration of crystalloids and red blood cells and a prolonged storage time of red blood cells. Future prospective studies investigating TIC- and transfusion-associated risk factors on late outcome are required.
authors.affiliation: Trauma Unit, Department of Surgery, Academic Medical Center , Amsterdam , Netherlands ; Department of Intensive Care, Academic Medical Center , Amsterdam , Netherlands.
authors.forename: Kirsten
authors.initials: K
authors.lastname: Balvers
authors.affiliation: Trauma Unit, Department of Surgery, Academic Medical Center , Amsterdam , Netherlands ; Department of Intensive Care, Academic Medical Center , Amsterdam , Netherlands.
authors.forename: Mathijs R
authors.initials: MR
authors.lastname: Wirtz
authors.affiliation: Clinical Research Unit, Academic Medical Center , Amsterdam , Netherlands.
authors.forename: Susan
authors.initials: S
authors.lastname: van Dieren
authors.affiliation: Trauma Unit, Department of Surgery, Academic Medical Center , Amsterdam , Netherlands.
authors.forename: J Carel
authors.initials: JC
authors.lastname: Goslings
authors.affiliation: Department of Intensive Care, Academic Medical Center , Amsterdam , Netherlands.
authors.forename: Nicole P
authors.initials: NP
authors.lastname: Juffermans
keywords: coagulopathy; multiple organ failure; resuscitation; transfusion; trauma