Early massive transfusion in trauma patients: Canadian single-centre retrospective cohort study.

Mahambrey TD, Fowler RA, Pinto R, et al.
Can J Anaesth 2009;56(10):740-750.
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The authors primary objective was to describe the effects of early transfusion practices for massively bleeding trauma patients. They examined the association between RBC transfusion before 48 hours and, in those patients surviving the initial 48 hours, organ dysfunction, hospital mortality and length of stay in the ICU. They also examined the association between transfusion and 48-hour mortality in all patients. Overall, transfusion was associated with increased organ dysfunction but not mortality.

Unfortunately, the study suffers from several limitations. First, it is a retrospective review spanning a 10-year period (1992-2001), a period of time during which several changes in practice may have occurred (e.g. the introduction of universal leukodepletion). Second, the number of patients included in the final analysis was relatively small (260) but it should be kept in mind that massive hemorrhage after trauma is relatively rare. Third and foremost, in my mind, is the absence of any data on the presence or absence of coagulopathy in these severely injured patients (mean ISS 42.5) presenting massive hemorrhage. Since the work of Brohi et al., we have learned that approximately 25% of these patients present with a coagulopathy and that mortality is increased in this subgroup of patients (J Trauma 2003;54:1127-30).

In summary, while the authors were unable to detect a direct association between RBC transfusion and mortality in the 260 patients reviewed, had transfusions been managed differently in coagulopathic patients (e.g. with a RBC:FFP:platelet ratio of 1:1:1), mortality could (hopefully) have been reduced.

– Jean-Franois Hardy