Introduction: Massive transfusion (MT) is defined as the administration of ≥10 U of packed red blood cells (PRBCs) in 24 hours. Alternative definitions have been proposed which have not been compared regarding mortality or multiorgan failure (MOF). The objective is to compare the discriminative ability of proposed definitions of MT concerning mortality and MOF. Materials and methods: Patients with trauma team activation in a level I trauma hospital of Cali, Colombia, between 2015 and 2017 were included. Demographics and trauma characteristics were evaluated. The following MT definitions were measured: ≥50 U of total blood products in 24 hours (MT50-24), ≥6 U of PRBCs in 6 hours (MT6-6), ≥10 U of PRBCs in 6 hours (MT10-6), a combination of MT10-24 plus MT6-6 (MTcombi), ≥5 U of PRBC in 4 hours (MT5-4), ≥4 U of PRBC in 1 hour (MT4-1), and the critical administration threshold (CAT) which is 3 U of PRBCs in 1 hour. The operative characteristics were calculated for each definition. Multiorgan failure was defined as a sequential organ failure assessment (SOFA) score of ≥6 points. Results: We included 394 subjects. A total of 266 (67%) received at least 1 unit of PRBCs in the first 24 hours, from which trauma mechanism was penetrating in 84.6%; 86.8% were male, with a median [interquartile range (IQR)] age of 29 (22–38) years and injury severity score (ISS) of 25 (25–29). A positive ABC score for massive transfusion score was positive in 87.2%. Sensitivity and specificity were as follows: multiorgan failure: MT10-24 18.6% and 98.2%, MT6-6 34.3% and 91.3%, MTcombi 38.2% and 91.3%, MT5-4 38.2% and 92.2%, and MT4-1 48% and 78.4%. Mortality: MT10-24 40.6% and 92.2%, MT6-6 62.7% and 82.6%, MTcombi 64.4% and 80.6%, MT5-4 61% and 81.1% and MT4-1 71.1% and 68.6%. Conclusion: All definitions showed an association with a higher risk of mortality and MOF, generally with low sensitivity but high specificity. The MT definition of ≥10 PRBCs in 24 hours should be revised.
Cdc.gov. (2018). [online] Available at: https://www.cdc.gov/injury/images/lc-charts/leading_causes_of_death_by_age_group_2017_1100w850h.jpg [Accessed 21 Aug. 2019].
Rodríguez-García J, Peñaloza-Quintero R, Amaya-Lara J. Estimación de la carga global de enfermedad en Colombia 2012: nuevos aspectos metodológicos. Revista de Salud Pública 2017;19(2):235–240. DOI: 10.15446/rsap.v19n2.66179.
Acosta JA, Yang JC, Winchell RJ, et al. Lethal injuries and time to death in a level I trauma center. J Am Coll Surg 1998;186(528-533):528–533. DOI: 10.1016/s1072-7515(98)00082-9.
Cotton BA, Gunter OL, Isbell J, et al. Damage control hematology: the impact of a trauma exsanguination protocol on survival and blood product utilization. J Trauma 2008;64(5):1177–1183. DOI: 10.1097/TA.0b013e31816c5c80.
Kauvar D, Lefering R, Wade C. Impact of hemorrhage on trauma outcome: an overview of epidemiology, clinical presentations, and therapeutic considerations. J Trauma 2006;60(Suppl):S3–S11. DOI: 10.1097/01.ta.0000199961.02677.19.
Brohi K, Singh J, Heron M, et al. Acute traumatic coagulopathy. J Trauma 2003;54(6):1127–1130. DOI: 10.1097/01.TA.0000069184. 82147.06.
Maegele M, Spinella P, Schöchl H. The acute coagulopathy of trauma. Shock 2012;38(5):450–458. DOI: 10.1097/SHK.0b013e31826dbd23.
McDaniel L, Etchill E, Raval J, et al. State of the art: massive transfusion. Transfus Med 2014;24(3):138–144. DOI: 10.1111/tme.12125.
Vogt K, Van Koughnett J, Dubois L, et al. The use of trauma transfusion pathways for blood component transfusion in the civilian population: a systematic review and meta-analysis*. Transfus Med 2012;22(3):156–166. DOI: 10.1111/j.1365-3148.2012.01150.x.
Holcomb JB, del Junco DJ, Fox EE, et al. The prospective, observational, multicenter, major trauma transfusion (PROMMTT) study. JAMA Surg 2013;148(2):127. DOI: 10.1001/2013.jamasurg.387.
Shaz B, Dente C, Harris R, et al. Transfusion management of trauma patients. Anesth Analg 2009;108(6):1760–1768. DOI: 10.1213/ane.0b013e3181a0b6c6.
Mitra B, Cameron P, Gruen R, et al. The definition of massive transfusion in trauma. Europ J Emerg Med 2011;18(3):137–142. DOI: 10.1097/MEJ.0b013e328342310e.
Cosgriff N, Moore E, Sauaia A, et al. Predicting life-threatening coagulopathy in the massively transfused trauma patient. J Trauma 1997;42(5):857–862. DOI: 10.1097/00005373-199705000- 00016.
Wilson R, Mammen E, Walt A. Eight years of experience with massive blood transfusions. J Trauma 1971;11(4):275–285. DOI: 10.1097/00005373-197104000-00001.
Lim R, Olcott IVC, Robinson A, et al. Platelet response and coagulation changes following massive blood replacement. J Trauma 1973;13(7):577–582. DOI: 10.1097/00005373-197307000- 00001.
Beal R. The rational use of blood. Aust NZ Surg 1976;46(4):309–313. DOI: 10.1111/j.1445-2197.1976.tb03239.x.
Stanworth SJ, Morris TP, Gaarder C, et al. Reappraising the concept of massive transfusion in trauma. Crit Care 2010;14(6):R239. DOI: 10.1186/cc9394.
Vaslef S, Knudsen N, Neligan P, et al. Massive transfusion exceeding 50 units of blood products in trauma patients. J Trauma 2002;53(2): 291–296. DOI: 10.1097/00005373-200208000-00017.
Hodgman EI, Cripps MW, Mina MJ, et al. External validation of a smartphone app model to predict the need for massive transfusion using five different definitions. J Traum Acut Care Surg 2018;84(2):397–402. DOI: 10.1097/TA.0000000000001756.
Kashuk JL, Moore EE, Johnson JL, et al. Postinjury life threatening coagulopathy: is 1:1 fresh frozen plasma: packed red blood cells the answer? J Trauma 2008;65(2):261–271. DOI: 10.1097/TA.0b013e31817de3e1.
Moore FA, Nelson T, McKinley BA, et al. Massive transfusion in trauma patients: tissue hemoglobin oxygen saturation predicts poor outcome. J Trauma 2008;64(4):1010–1023. DOI: 10.1097/TA.0b013e31816a2417.
Moren AM, Hamptom D, Diggs B, et al. Recursive partitioning identifies greater than 4 U of packed red blood cells per hour as an improved massive transfusion definition. J Traum Acut Care Surg 2015;79(6):920–924. DOI: 10.1097/TA.0000000000000830.
Savage S, Zarzaur B, Croce M, et al. Redefining massive transfusion when every second counts. J Traum Acut Care Surg 2013;74(2): 396–402. DOI: 10.1097/TA.0b013e31827a3639.
Savage S, Sumislawski J, Zarzaur B, et al. The new metric to define large-volume hemorrhage. J Trauma Acute Care Surg 2015;78(2): 224–230. DOI: 10.1097/TA.0000000000000502.
Teixeira PGR, Inaba K, Shulman I, et al. Impact of plasma transfusion in massively transfused trauma patients. J Trauma 2009;66(3):693–697. DOI: 10.1097/TA.0b013e31817e5c77.
Sperry JL, Ochoa JB, Gunn SR, et al. An FFP:PRBC transfusion ratio ≥1:1.5 is associated with A lower risk of mortality after massive transfusion. J Trauma 2008;65(5):986–993. DOI: 10.1097/TA.0b013e3181878028.
Holcomb JB, Tilley BC, Baraniuk S, et al. Transfusion of plasma, platelets, and red blood cells in a 1:1:1 vs a 1:1:2 ratio and mortality in patients with severe trauma. JAMA 2015;313(5):471. DOI: 10.1001/jama.2015.12.
Cap AP, Pidcoke HF, Spinella P, et al. Damage control resuscitation. Mil Med 2018;183(Suppl. 2):36–43. DOI: 10.1093/milmed/usy112.
Spahn DR, Bouillon B, Cerny V, et al. The european guideline on management of major bleeding and coagulopathy following trauma: fifth edition. Crit Care 2019;23(1):98. DOI: 10.1186/s13054-019-2347-3.
Garcia A. Critical care issues in the early management of severe trauma. Surg Clin Nor Am 2006;86(6):1359–1387. DOI: 10.1016/j.suc.2006.07.004.
Kautza BC, Cohen MJ, Cuschieri J, et al. Changes in massive transfusion over time. J Traum Acut Care Surg 2012;72(1):106–111. DOI: 10.1097/TA.0b013e3182410a3c.
Amin M, Fergusson D, Wilson K, et al. The societal unit cost of allogenic red blood cells and red blood cell transfusion in Canada. Transfusion 2004;44(10):1479–1486. DOI: 10.1111/j.1537-2995.2004.04065.x.
