Massive blood transfusions post trauma in the elderly compared to younger patients

Introduction

Older age and blood transfusion have both been independently associated with higher mortality post trauma and the combination is expected to be associated with catastrophic outcomes. Among patients who received a massive transfusion post trauma, we aimed to investigate mortality at hospital discharge of patients ≥65 years old and explore variables associated with poor outcomes.

Methods

A retrospective review of registry data on all major trauma patients presenting to a level I trauma centre between 2006 and 2011 was conducted. Mortality at hospital discharge among patients ≥65 years old was compared to the younger cohort. A multivariable logistic regression model was constructed to determine independent risk-factors for mortality among older patients.

Results

There were 51 (16.4%) patients of age ≥65 years who received a massive transfusion. There were 20 (39.2%) deaths, a proportion significantly higher than 55 (21.1%) deaths among younger patients (p < 0.01). Pre-hospital GCS, the presence of acute traumatic coagulopathy and higher systolic blood pressure on presentation were independently associated with higher mortality. Age and volume of red cells transfused were not significantly associated with higher mortality.

Conclusions

Survival to hospital discharge was demonstrated in elderly patients receiving massive transfusions post trauma, even in the presence of multiple risk factors for mortality. Restrictive resuscitation or transfusion on the basis of age alone cannot be supported. Early aggressive resuscitation of elderly trauma patients along specific guidelines directed at the geriatric population is justified and may further improve outcomes.     

The utility of a shock index ≥ 1 as an indication for pre-hospital oxygen carrier administration in major trauma

Introduction and aims

The use of intravenous oxygen carriers (packed red blood cells (PRBC), whole blood and synthetic haemoglobins (HBOCs) for selected pre-hospital trauma resuscitation cases has been reported, despite a lack of validated clinical indications. The aim of this study was to retrospectively identify a sub-group of adult major trauma patients most likely to benefit from pre-hospital oxygen carrier administration and determine the predictive relationship between pre-hospital shock index (SI) [pulse rate/systolic blood pressure] and haemorrhagic shock, blood transfusion and mortality.

Methods

A retrospective review of adult major trauma patients recorded in The Alfred Trauma Registry was conducted. Patients were included if they received at least 1 L of pre-hospital crystalloid and spent over 30 min in transit. The association of shock index and transfusion was determined. Patients were further sub-grouped by mode of transport to determine the population of trauma patients who could be included into prospective studies of intravenous oxygen carriers.

Results

There were 1149 patients included of whom 311 (21.9%) received an acute blood transfusion. The SI correlated well with transfusion practice. A SI ≥ 1.0, calculated after at least 1 L of crystalloid transfusion, identified patients with a high specificity (93.5%; 95% CI: 91.8–94.8) for receiving a blood transfusion within 4 h of hospital arrival. While patients transported by helicopter had higher injury severity and blood transfusion requirement, there were no difference in physiological variables and outcomes when compared to patients transported by road car.

Conclusions

A shock index ≥ 1.0 is an easily calculated variable that may identify patients for inclusion into trials for pre-hospital oxygen carriers. Shocked patients have high mortality rates whether transported by road car or by helicopter. The efficacy of pre-hospital intravenous oxygen carriers should be trialled using a shock index ≥ 1.0 despite fluid resuscitation as the clinical trigger for administration.     

Risks associated with red blood cell transfusion in the trauma population,a meta-analysis

Introduction

A previous meta-analysis has found an association between red blood cell (RBC) transfusions and mortality in critically ill patients, but no review has focused on the trauma population only.

Objectives

To determine the association between RBC transfusion and mortality in the trauma population, with secondary outcomes of multiorgan failure (MOF) and acute respiratory distress syndrome (ARDS) or acute lung injury (ALI).

Data sources

EMBASE (1947–2012) and MEDLINE (1946–2012).

Study eligibility criteria

Randomized controlled trials and observational studies were to be included if they assessed the association between RBC transfusion and either the primary (mortality) or secondary outcomes (MOF, ARDS/ALI).

Participants

Trauma patients.

Exposure

Red blood cell transfusion.

Methods

A literature search was completed and reviewed in duplicate to identify eligible studies. Studies were included in the pooled analyses if an attempt was made to determine the association between RBC and the outcomes, after adjusting for important confounders. A random effects model was used for and heterogeneity was quantified using the I² statistic. Study quality was assessed using the Newcastle-Ottawa Scale.

Results

40 observational studies were included in the qualitative review. Including studies which adjusted for important confounders found the odds of mortality increased with each additional unit of RBC transfused (9 Studies, OR 1.07, 95%CI 1.04–1.10, I² 82.9%). The odds of MOF (3 studies, OR 1.08, 95%CI 1.02–1.14, I² 95.9%) and ARDS/ALI (2 studies, OR 1.06, 95%CI 1.03–1.10, I² 0%) also increased with each additional RBC unit transfused.

Conclusions

We have found an association between RBC transfusion and the primary and secondary outcomes, based on observational studies only. This represents the extent of the published literature. Further interventional studies are needed to clarify how limiting transfusion can affect mortality and other outcomes.     

The impact of blood product ratios in massively transfused pediatric trauma patients

Background

Few studies have examined the impact of balanced resuscitation in pediatric trauma patients requiring massive transfusions. Adult data may not be generalizable to children.

Methods

Retrospective analysis assessed patients seen at a level I trauma center between 2003 and 2010 aged ≤18 years requiring massive packed red blood cell (PRBC) transfusion, defined as transfusion of ≥50% total blood volume. After excluding mortalities in the first 24 hours, the impact of plasma and platelet ratios on mortality was evaluated.

Results

Of 6,675 pediatric trauma patients, 105 were massively transfused (mean age, 12.4 ± 6.3 years; mean Injury Severity Score, 25.8 ± 11.4; mortality rate, 18.1%). All deceased patients sustained severe head injuries. Plasma/PRBC and platelet/PRBC ratios were not significantly associated with mortality.

Conclusions

In this study, higher plasma/PRBC and platelet/PRBC ratios were not associated with increased survival in children. The value of aggressive blood product transfusion for injured pediatric patients requires further prospective validation.     

Initial assessment on the impact of crystalloids versus colloids during damage control resuscitation

Background

High ratios of fresh frozen plasma:packed red blood cells in damage control resuscitation (DCR) are associated with increased survival. The impact of volume and type of resuscitative fluid used during high ratio transfusion has not been analyzed. We hypothesize a difference in outcomes based on the type and quantity of resuscitative fluid used in patients that received high ratio DCR.

Methods

A matched case control study of patients who received transfusions of ≥ four units of PRBC during damage control surgery over 4 1/2 y, was conducted at a Level I Trauma Center. All patients received a high ratio DCR, >1:2 of fresh frozen plasma:packed red blood cells. Demographics and outcomes of the type and quantity of resuscitative fluids used in combination with high ratio DCR were compared and analyzed. A Kaplan-Meier survival analysis was computed among four groups: colloid (median quantity = 1.0 L), <3 L crystalloid, 3–6 L crystalloid, and >6 L crystalloid.

Results

There were 56 patients included in the analysis (28 in the crystalloid group and 28 in the colloid group). Demographics were statistically similar. Intraoperative median units of PRBC: crystalloid versus colloid groups was 13 (IQR 8-21) versus 16 (IQR 12–19), P = 0.135; median units of FFP: 12 (IQR 7–18) versus 12 (IQR 10–18), P = 0.440. OR for 10-d mortality in the crystalloid group was 8.41 [95% CI 1.65–42.76 (P = 0.01)]. Kaplan-Meier survival analysis demonstrated lowest mortality in the colloid group and higher mortality with increasing amounts of crystalloid (P = 0.029).

Conclusions

During high ratio DCR, resuscitation with higher volumes of crystalloids was associated with an overall decreased survival, whereas low volumes of colloid use were associated with increased survival. In order to improve outcomes without diluting the survival benefit of hemostatic resuscitation, guidelines should focus on effective low volume resuscitation when high ratio DCR is used. A multi-institutional analysis is needed in order to validate these results.     

Meta-analysis of plasma to red blood cell ratios and mortality in massive blood transfusions for trauma

Background

The current military paradigm for blood transfusion in major trauma favours high plasma:RBC ratios. This study aimed determine whether high plasma:red blood cell (RBC) ratios during massive transfusion for trauma decrease mortality, using meta-analysis of contemporaneous groups matched for injury severity score.

Methods

A systemic review of the published literature for massive blood transfusions in trauma was performed. Patients were categorised into groups based on plasma:RBC transfusion ratios. Meta-analysis was only performed when there were no significant differences in Injury Severity Score (ISS) between ratio groups within studies. The main endpoint was 30-day mortality.

Results

Six observational studies reporting outcomes for 1885 patients were included in this meta-analysis. Five studies were from civilian environments and one from a military setting. Ratio cut-offs at 1:2 were the most commonly reported, demonstrating a survival advantage with higher ratios (OR 0.49, 95% CI 0.31–0.80, p = 0.004). Ratios ≥ 1:2 showed a significant reduction in mortality compared to lower ratios (OR 0.56, 95% CI 0.40–0.78, p < 0.001). Reducing the cut-off level was still protective (ratios between 1:2.5 and 1:4, OR 0.41), although the confidence interval was wide (0.16–1.00, p = 0.05) and data heterogenous (I² = 78%). Ratios of 1:1 were not proven to confer additional benefit beyond ratios of 1:2 (OR 0.50, 95% CI 0.37–0.68, p < 0.001).

Conclusions

In groups matched for ISS, there was a survival benefit with high plasma:RBC resuscitation ratios. No additional benefits of 1:1 over 1:2 ratios were identified.     

Mortality after trauma laparotomy in geriatric patients

Background

Geriatric patients are at higher risk for adverse outcomes after injury because of their altered physiological reserve. Mortality after trauma laparotomy remains high; however, outcomes in geriatric patients after trauma laparotomy have not been well established. The aim of our study was to identify factors predicting mortality in geriatric trauma patients undergoing laparotomy.

Methods

A retrospective study was performed of all trauma patients undergoing a laparotomy at our level 1 trauma center over a 6-y period (2006–2012). Patients with age ≥55 y who underwent a trauma laparotomy were included. Patients with head abbreviated injury scale (AIS) score ≥ 3 or thorax AIS ≥ 3 were excluded. Our primary outcome measure was mortality. Significant factors in univariate regression model were used in multivariate regression analysis to evaluate the factors predicting mortality.

Results

A total of 1150 patients underwent a trauma laparotomy. Of which 90 patients met inclusion criteria. The mean age was 67 ± 10 y, 63% were male, and median abdominal AIS was 3 (2–4). Overall mortality rate was 23.3% (21/90) and progressively increased with age (P = 0.013). Age (P = 0.02) and lactate (P = 0.02) were the independent predictors of mortality in geriatric patients undergoing laparotomy.

Conclusions

Mortality rate after trauma laparotomy increases with increasing age. Age and admission lactate were the predictors of mortality in geriatric population undergoing trauma laparotomies.     

The impact of leukoreduced red blood cell transfusion on mortality of neonates undergoing extracorporeal membrane oxygenation

Background

Blood products containing leukocytes have been associated with negative immunomodulatory and infectious effects. Transfusion-related acute lung injury is partially explained by leucocyte agglutination. The Food and Drug Administration has therefore recommended leukoreduction strategies for blood product transfusion. Our institution has been using leukocyte-reduced blood via filtration for neonates on Extracorporeal Membrane Oxygenation (ECMO). We hypothesized that the use of leukocyte-reduced blood would decrease mortality and morbidity of neonatal ECMO patients.

Methods

Retrospective review of noncardiac ECMO in neonates from 1984–2011, stratified into year groups I and II (≤1996 and ≥1997). Demographics, duration and type of ECMO, complications, and outcome data were collected. Blood product use data was collected. Univariate, bivariate, and multivariate analyses determined predictors of risk-adjusted mortality by year group.

Results

Patients (827) underwent ECMO with 65.3% (540) in group I. Overall median blood product use in mL/kg/d was 36.2 packed red blood cells (pRBC), 8.1 platelets, and 0 cyroprecipitate and/or fresh-frozen plasma. Overall mortality was 16.4%. Median pRBC used or transfused was 42.1 mL/kg/d in group I versus 19.1 mL/kg/d group II (P <0.001). On bivariate analysis, there was no difference in crude mortality between the 2 year groups (17.2% versus 16.0%, P = 0.66). However, on multivariate analysis adjusting for demographics, diagnosis, complications, and blood product use other than pRBCs, each additional transfusion of 10 mL/kg/d of pRBC was associated with a 33% increase in mortality in group I (P <0.05). Group II also showed an increase in mortality with each additional transfusion (21%) but this was not statistically significant (P = 0.07). Days on ECMO were not associated with pRBC transfusion in group I but increased in group II (additional 3 d for each 10 mL/kg/d transfused). There was no difference in infectious complications between groups I and II.

Conclusions

Blood transfusion requirement has diminished in newborns undergoing ECMO at our institution. Transfusion of non leukocyte-reduced blood is associated with an increase in mortality whereas transfusion of leukocyte-reduced blood provided no benefit with a trend toward increased mortality. Further research is recommended to understand these trends.     

Impact of Model for End-Stage Liver Disease Score on Transfusion Rates in Liver Transplantation

Background

Liver transplantation (OLT) can entail a high risk of blood loss requiring transfusions, which increase morbidity and mortality. In recent years many efforts have been spent to improve the surgical and anesthetic management to decrease transfusion rates during OLT. Preoperative predictors for transfusion in OLT, remain uncertain.

Methods

We retrospectively reviewed the 219 OLT performed from 2005 to 2011 focusing on blood product (BP) transfusions. Statistical analysis sought the impact of transfusions on OLT outcomes to identify possible independent predictors of higher BP requirements.

Results

The 1- and 3-year survival rates were 86.6% and 76.45% for patients and 81.0% and 71.8% for grafts respectively. The mean intra- and perioperative red blood cell (RBC) transfusion rates were 12.3 ± 11.7 U and 15.5 ± 13.0 U respectively. A statistical analysis demonstrated a significant influence of BP transfusion on post-OLT complications and survivals. Multivariate logistic regression analysis showed the Model for End-Stage Liver Disease (MELD) score to be the only independent predictor of perioperative RBC transfusions.

Conclusions

Our results confirmed the link between intra- and perioperative transfusions and outcome of OLT patients. MELD score resulted the only independent variable associated with increased perioperative RBC transfusions.     

Implantable cardioverter defibrillators and permanent pacemakers: prevalence and patient outcomes after trauma

Background

The prevalence and outcomes of older trauma patients with implantable cardioverter defibrillators (ICDs) or permanent pacemakers (PPMs) is unknown.

Methods

The trauma registry at a regional trauma center was reviewed for blunt trauma patients, aged ≥ 60 years, admitted between 2007 and 2014. Medical records of cardiac devices patients were reviewed.

Results

Of 4,193 admissions, there were 146 ICD, 233 PPM, and 3,814 no device patients; median Injury Severity Score was 9. Most cardiac device patients had substantial underlying heart disease. Patients with ICDs (13.0%) and PPMs (8.6%) had higher mortality rates than no device patients (5.6%, P = .0002). Among cardiac device patients who died, the device was functioning properly in all that were interrogated; the most common cause of death was intracranial hemorrhage. On propensity score analysis, cardiac devices were not independent predictors of mortality but rather surrogate variables associated with other predictors of mortality.

Conclusions

Approximately 9.0% of admitted older patients had cardiac devices. Their presence identified patients who had higher mortality rates, likely because of their underlying comorbidities, including cardiac dysfunction.     

Potential disparities in trauma: the undocumented Latino immigrant

Background

Little is known about the quality of trauma care undocumented immigrants receive. Documentation status may serve as a risk factor for health disparities. We hypothesized that undocumented Latino immigrants have an increased risk of mortality after trauma compared with Latinos with legal residence.

Materials and methods

The medical records for Latino trauma patients at our university-based trauma center between 2007 and 2012 were retrospectively reviewed. Undocumented status was defined using two criteria: (1) lack of social security number and (2) insurance status as either “county,” the local program that covers undocumented immigrants, or “self pay”. Regression models were used to estimate the comparable risks of in-hospital mortality.

Results

Out of 2441 Latino trauma patients treated at our institution during the study period, 465 were undocumented. Latinos with legal residence and undocumented Latinos did not differ with regard to in-hospital mortality (3.4% versus 3.9%, respectively; P = 0.61). We found no association between documentation status and in-hospital mortality after trauma (odds ratio = 1.12 [0.43, 2.9]; P = 0.81). The independent predictors of in-hospital mortality included age, injury severity score, penetrating mechanism, and lack of private insurance but not documentation status.

Conclusions

Undocumented Latino immigrants did not have an increased risk of in-hospital mortality after trauma; however, being uninsured was associated with a higher risk of death after trauma. For Latinos, we found no disparities based on immigration status for mortality after trauma, though disparities based on insurance status continue to persist.     

Supratherapeutic vancomycin levels after trauma predict acute kidney injury and mortality

Introduction

High-dose vancomycin is increasingly prescribed for critically ill trauma patients at risk for methicillin-resistant Staphylococcus aureus pneumonia. Although trauma patients have multiple known risk factors for acute kidney injury (AKI), a link between vancomycin and AKI or mortality has not been established. We hypothesize that high vancomycin trough concentration (VT) after trauma is associated with AKI and increased mortality.

Methods

This was a retrospective analysis from a single institution Level I trauma center. Data were reviewed for all adult trauma patients who were admitted between 2006 and 2010. Patients were included if they received intravenous vancomycin, had serum creatinine levels before and after vancomycin administration, and had at least one recorded VT. Patients were stratified by VT into four groups: VT1 = 0–10 mg/L, VT2 = 10.1–15 mg/L, VT3 = 15.1–20 mg/L, VT4 >20 mg/L. Multivariable logistic regression was performed to determine the association between VT, AKI, and mortality.

Results

Of the 6781 trauma patients reviewed, 263 (3.9%) fit inclusion criteria. Ninety-seven (36.9%) patients developed AKI and 25 (9.5%) died. AKI and mortality increased progressively with VT. Ninety-one patients (34.6%) had troughs >20 mg/L and VT4 was independently associated with AKI (AOR 4.7, P < 0.01) and mortality (AOR 4.8, P = 0.05).

Conclusion

AKI is common in trauma patients who receive intravenous vancomycin. A supratherapeutic trough level of >20 mg/L is an independent predictor of AKI and mortality in trauma patients.     

Emergency department referral for organ donation: more organ donors and more organs per donor

Background

This study sought to determine whether early referral from the emergency department (ED) would increase the number of organ donors and the number of organs transplanted per donor (OTPD).

Methods

This is a retrospective cohort analysis of all patients referred to a single organ procurement organization for a period of 60 months.

Results

Patients referred for organ donation evaluation from the ED were more likely to become organ donors than patients referred from the intensive care unit (19.3% vs 5.2%, P < .001). ED referrals had a greater number of OTPD than those referred from the intensive care unit (mean 3.79 vs 3.16, P = .024), even after adjusting for the higher proportion of ED referrals who were trauma patients (P = .001).

Conclusions

Referral for organ donation from the ED is associated with an increased likelihood of organ recovery and with an increased number of OTPD.     

The epidemiology of burn injuries in an Australian setting, 2000–2006

Objectives

To describe presentation characteristics of burn leading to death or hospital treatment (i.e. inpatient admissions and emergency department [ED] presentations) across the state of Victoria, Australia, for the years 2000–2006 inclusive.

Methods

Data were provided by the Victorian Injury Surveillance Unit (VISU) from three different datasets pertaining to burn deaths, hospital inpatient admissions and non-admitted ED presentations. Population estimates were derived from census data provided by Australian Bureau of Statistics.

Results

During the 7-year period, 178 people died and 36,430 were treated for non-fatal burn injury, comprising 7543 hospital admissions and 28,887 non-admitted ED presentations. Males, children aged less than 5 years of age, and the elderly (≥65 years of age) were at the highest risk of injury. Contact with heat and hot substances represented the major aetiological factor contributing to thermal injuries accounting for 64% of all hospital admissions and 90% of ED presentations. Temporal trends indicate no change in the population rate of burn deaths or hospital admissions during the study period.

Conclusions

ED presentations and hospital admissions and deaths have remained the same over this study period, but rates of burn remain high in males, children and the elderly. This could be due to variations in the implementation of government prevention and control programs and the divergence in efficient treatments and clinical practices amongst hospital care providers. Therefore, educational efforts for prevention should be the keystone to minimise the incidence of burns.     

Falls from ladders: age matters more than height

Background

Falls from ladders account for a significant number of hospital visits. However, the epidemiology, injury pattern, and how age affects such falls are poorly described in the literature.

Materials and methods

Patients ≥18 y who suffered falls from ladders over a 5½-y period were identified in our trauma registry. Dividing patients into three age groups (18–45, 46–65, and >66 y), we compared demographic characteristics, clinical data, and outcomes including injury pattern and mortality. The odds ratios (ORs) were calculated with the group 18–45 y as reference; group means were compared with one-way analysis of variance.

Results

Of 27,155 trauma patients, 340 (1.3%) had suffered falls from ladders. The average age was 55 y, with a male predominance of 89.3%. Average fall height was 9.8 ft, and mean Injury Severity Score was 10.6. Increasing age was associated with a decrease in the mean fall height (P < 0.001), an increase in the mean Injury Severity Score (P < 0.05), and higher likelihood of admission (>66 y: OR, 5.3; confidence interval [CI], 2.5–11.5). In univariate analysis, patients in the >66-y age group were more likely to sustain traumatic brain injuries (OR, 3.4; CI, 1.5–7.8) and truncal injuries (OR, 3.6; CI, 1.9–7.0) and less likely to sustain hand and/or forearm fractures (OR, 0.3; CI, 0.1–0.9).

Conclusions

Older people are particularly vulnerable after falling from ladders. Although they fell from lower heights, the elderly sustained different and more severe injury patterns. Ladder safety education should be particularly tailored at the elderly.     

A trauma quality improvement programme associated with improved patient outcomes: 21 years of experience at an Australian Major Trauma Centre

Introduction

Quality improvement programmes are an important part of care delivery in trauma centres. The objective was to describe the effect of a comprehensive quality improvement programme on long term patient outcome trends at a low volume major trauma centre in Australia.

Methods

All patients aged 15 years and over with major trauma (Injury Severity Score > 15) admitted to a single inner city major trauma centre between 1992 and 2012 were studied. The outcomes of interest were in-hospital mortality and transfer to rehabilitation. Time series analysis using integer valued autoregressive Poisson models was used to determine the reduction in adjusted monthly count data associated with the intervention period (2007–2012). Risk adjusted odds ratios for mortality over three yearly intervals was also obtained using multivariable logistic regression. Crude and risk adjusted mortality was compared before and after the implementation period.

Results

3856 patients were analysed. Crude in-hospital mortality fell from 16% to 10% after implementation (p < 0.001). The intervention period was associated with a 25% decrease in monthly mortality counts. Risk adjusted mortality remained stable from 1992 to 2006 and did not fall until the intervention period. Crude and risk adjusted transfer to in-patient rehabilitation after major trauma also declined during the intervention period.

Conclusion

In this low volume major trauma centre, the implementation of a comprehensive quality improvement programme was associated with a reduction in crude and risk adjusted mortality and risk adjusted discharge to rehabilitation in severely injured patients.     

Massive transfusion in paediatric and adolescent trauma patients: Incidence,patient profile,and outcomes prior to a massive transfusion protocol

Objectives

The purpose of this study was to quantify the incidence, patient profile, and outcomes associated with massive transfusion in paediatric trauma patients prior to establishing a massive transfusion protocol.

Methods

We performed a retrospective review of paediatric trauma patients treated at London Heath Sciences Centre between January 1, 2006, and December 31, 2011. Inclusion criteria were Injury Severity Score (ISS) greater than 12 and age less than 18 years.

Results

435 patients met the inclusion criteria. Three hundred and fifty-six (82%) did not receive packed red blood cells in the first 24 h, 66 (15%) received a non-massive transfusion (<40 mL/kg), and 13 (3%) received a massive transfusion (>40 mL/kg). Coagulopathy of any kind was more common in massive transfusion (11/13; 85%) than non-massive (32/66; 49%) (p = 0.037). Hyperkalemia (18% versus 23%; p = 0.98) and hypocalcemia (41% versus 46%; p = 1.00) were similar in both groups. Of the 13 massively transfused patients, 9 had multisystem injuries due to a motor vehicle collision, 3 had non-accidental head injuries requiring surgical evacuation, and 1 had multiple stab wounds. In the absence of a massive transfusion protocol, only 8 of the 13 patients received both fresh frozen plasma and platelets in the first 24 h. Massive transfusion occurred in patients from across the age spectrum and was associated with severe injuries (mean ISS = 33), a higher incidence of severe head injuries (92%), longer hospital stay (mean = 36 days), and increased mortality (38%).

Conclusions

This study is the first to describe the incidence, complications, and outcomes associated with massive transfusion in paediatric trauma patients prior to a massive transfusion protocol. Massive transfusion occurred in 3% of patients and was associated with coagulopathy and poor outcomes. Protocols are needed to ensure that resuscitation occurs in a coordinated fashion and that patients are given appropriate amounts of fresh frozen plasma, platelets, and cryoprecipitate.     

The use of tranexamic acid to reduce blood loss and transfusion in major orthopedic surgery: a meta-analysis

Background

Conflicting reports have been published regarding the effect of tranexamic acid (TXA) on reducing blood loss and transfusion in patients undergoing orthopedic surgery. We performed a meta-analysis to evaluate the effectiveness and safety of TXA treatment in reducing blood loss and transfusion in major orthopedic surgery.

Materials and methods

MEDLINE, PubMed, EMBASE, and Cochrane databases were searched for relevant studies. Only randomized controlled trials were eligible for this study. The weighted mean difference in blood loss, number of transfusions per patient, and the summary risk ratio of transfusion and deep vein thrombosis (DVT) were calculated in the TXA-treated group and the control group.

Results

A total of 46 randomized controlled trials involving 2925 patients were included. The use of TXA reduced total blood loss by a mean of 408.33 mL (95% confidence interval [CI], −505.69 to −310.77), intraoperative blood loss by a mean of 125.65 mL (95% CI, −182.58 to −68.72), postoperative blood loss by a mean of 214.58 mL (95% CI, −274.63 to −154.52), the number of blood transfusions per patient by 0.78 U (95% CI, −0.19 to −0.37), and the volumes of blood transfusions per patient by 205.33 mL (95% CI, −301.37 to −109.28). TXA led to a significant reduction in transfusion requirements (relative risk, 0.51; 95% CI, 0.46–0.56), and no increase in the risk of DVT (relative risk, 1.11; 95% CI, 0.69–1.79).

Conclusions

TXA significantly reduced blood loss and blood transfusion requirements in patients undergoing orthopedic surgery, and did not appear to increase the risk of DVT.     

Is a surgical approach justified for octogenarians with pancreatic carcinoma? Projecting surgical decision making for octogenarian patients

Background

In recent years, more elderly patients have undergone surgery for pancreatic cancer, although the safety and efficacy of performing complex pancreatic resections in patients older than 80 years remain controversial.

Methods

Patients with pancreatic cancer who underwent curative surgical treatment were divided into 2 subgroups: the younger group (<80 years) and the octogenarian group (≥80 years).

Results

From March 2005 to December 2013, 194 consecutive surgically curable patients with diagnosed pancreatic cancer were studied, among which 34 (17.5%) were of 80 years or older. There were no significant differences in postoperative severe complication rates for younger and octogenarian groups (16% vs 20%, respectively) or perioperative mortality rates (1.3% vs .0%). The incidence of postoperative delirium in the octogenarian group was greater than that in the younger group (23.5% vs 3.8%).

Conclusions

Octogenarian pancreatic cancer patients should not be denied a priori the opportunity for surgery, particularly if the patient represents an ideal candidate and if the co-operation of the family can be obtained.     

Prognostic Value of Model for End-Stage Liver Disease Scores in Patients with Fulminant Hepatic Failure

Background

This study was undertaken to investigate risk factors of mortality in patients with fulminant hepatic failure (FHF).

Methods

Fifty-three patients with FHF treated from January 2006 to April 2011 were allocated to a spontaneous survival group (group 1), a death without liver transplantation (LT) group (group 2), and an LT group (group 3). To analyze risk factors associated with mortality in FHF, we excluded group 3 patients. Clinical features, Model for End-Stage Liver Disease (MELD) scores, and King's College Hospital criteria at the time of hepatic encephalopathy in group 2 were compared with those of group 1.

Results

The causes of FHF were acute viral infection (n = 29, hepatitis A:B, 28:1), drugs (n = 18; including 4 acetaminophen and 14 herbal medication), autoimmune (n = 4), and miscellaneous (n = 2). Of the 53 patients, 19 were allocated to group 1, 18 to group 2, and 16 to group 3. According to univariate analysis, risk factors for mortality in group 2 were acute renal failure requiring renal replacement therapy and a MELD score ≥30 at the time of hepatic encephalopathy. However, by multivariate analysis, a MELD score ≥30 was the only independent risk factor for mortality in group 2 (P = .042; hazard ratio, 4.500).

Conclusions

A MELD score ≥30 was found to be the only independent risk factor of mortality in FHF patients without LT. Therefore, the findings of this study suggest that these patients may need emergent LT for survival.