title: Progressive hemorrhagic injury after severe traumatic brain injury: effect of hemoglobin transfusion thresholds.
abstract: OBJECT There is limited literature available to guide transfusion practices for patients with severe traumatic brain injury (TBI). Recent studies have shown that maintaining a higher hemoglobin threshold after severe TBI offers no clinical benefit. The present study aimed to determine if a higher transfusion threshold was independently associated with an increased risk of progressive hemorrhagic injury (PHI), thereby contributing to higher rates of morbidity and mortality. METHODS The authors performed a secondary analysis of data obtained from a recently performed randomized clinical trial studying the effects of erythropoietin and blood transfusions on neurological recovery after severe TBI. Assigned hemoglobin thresholds (10 g/dl vs 7 g/dl) were maintained with packed red blood cell transfusions during the acute phase after injury. PHI was defined as the presence of new or enlarging intracranial hematomas on CT as long as 10 days after injury. A severe PHI was defined as an event that required an escalation of medical management or surgical intervention. Clinical and imaging parameters and transfusion thresholds were used in a multivariate Cox regression analysis to identify independent risk factors for PHI. RESULTS Among 200 patients enrolled in the trial, PHI was detected in 61 patients (30.5%). The majority of patients with PHI had a new, delayed contusion (n = 29) or an increase in contusion size (n = 15). The mean time interval between injury and identification of PHI was 17.2 ± 15.8 hours. The adjusted risk of severe PHI was 2.3 times higher for patients with a transfusion threshold of 10 g/dl (95% confidence interval 1.1-4.7; p = 0.02). Diffuse brain injury was associated with a lower risk of PHI events, whereas higher initial intracranial pressure increased the risk of PHI (p < 0.001). PHI was associated with a longer median length of stay in the intensive care unit (18.3 vs 14.4 days, respectively; p = 0.04) and poorer Glasgow Outcome Scale scores (42.9% vs 25.5%, respectively; p = 0.02) at 6 months. CONCLUSIONS A higher transfusion threshold of 10 g/dl after severe TBI increased the risk of severe PHI events. These results indicate the potential adverse effect of using a higher hemoglobin transfusion threshold after severe TBI.
authors.affiliation: Department of Neurosurgery, Baylor College of Medicine; and.
authors.forename: Aditya
authors.initials: A
authors.lastname: Vedantam
authors.affiliation: Department of Biostatistics, University of Texas School of Public Health, Houston, Texas.
authors.forename: Jose-Miguel
authors.initials: JM
authors.lastname: Yamal
authors.affiliation: Department of Biostatistics, University of Texas School of Public Health, Houston, Texas.
authors.forename: Maria Laura
authors.initials: ML
authors.lastname: Rubin
authors.affiliation: Department of Neurosurgery, Baylor College of Medicine; and.
authors.forename: Claudia S
authors.initials: CS
authors.lastname: Robertson
authors.affiliation: Department of Neurosurgery, Baylor College of Medicine; and.
authors.forename: Shankar P
authors.initials: SP
authors.lastname: Gopinath
mesh_terms: D000328:Adult; D001803:Blood Transfusion / Q000592:standards; D000070642:Brain Injuries, Traumatic / Q000150:complications*; D018450:Disease Progression; D005260:Female; D006454:Hemoglobins / Q000008:administration & dosage*; D006801:Humans; D015601:Injury Severity Score; D020198:Intracranial Hemorrhage, Traumatic / Q000628:therapy*; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D018570:Risk Assessment; D055815:Young Adult
chemical_list: D006454:Hemoglobins
keywords: EPO = erythropoietin; ER = emergency room; GCS = Glasgow Coma Scale; GOS = Glasgow Outcome Scale; ICP = intracranial pressure; PHI = progressive hemorrhagic injury; PT = prothrombin time; PTT = partial thromboplastin time; RCT = randomized controlled trial; TBI = traumatic brain injury; hemoglobin transfusion threshold; progressive hemorrhagic injury; secondary brain injury; severe traumatic brain injury