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Blood Transfusion Predicts Mortality in Patients with Blunt Spleen and Liver Injuries Managed Nonop


Blood Transfusion Predicts Mortality in Patients with Blunt Spleen and Liver Injuries Managed Nonop

Tuesday, March 15th, 2005
Author: SABM Staff

Blood Transfusion Predicts Mortality
in Patients With Blunt Spleen and Liver Injuries Managed Nonoperatively

Recently, blood transfusion was identified as an independent predictor of mortality and poor outcome in a large series of unselected patients with blunt and penetrating trauma, even after controlling for significant indices of shock and injury severity (Malone DL et al., J Trauma 2003;54:898-907). In the March issue of The Journal of Trauma: Injury, Infection, and Critical Care, Dr. William P. Robinson and colleagues from the University of North Carolina report a retrospective study evaluating the impact of red blood cell (RBC) transfusion on mortality and intensive care unit (ICU) and hospital length of stay.

“Nonoperative management of blunt traumatic liver and spleen injuries in hemodynamically stable patients is now the standard of care in many institutions� and “blood transfusion is an important element of nonoperative management,� the authors explain. A large single-institution study of nonoperatively managed blunt hepatic injuries reported that patients managed without operation received an average of 4.4 units of packed RBCs during the first 24 hours of observation (Malhotra AK et al., Ann Surg 2000;231:804-13).

The authors retrospectively reviewed a total of 316 patients with blunt injury to the liver, spleen, or both organs, who were admitted to a Level I trauma center between August 1, 1998, and October 30, 2002. Patients who underwent celiotomy for hemodynamic instability or another indication within the first 24 hours composed the operative group, whereas patients managed without operation composed the nonoperative group. Nonoperative management was left to the discretion of the attending trauma surgeon. The decision to transfuse was made on the basis of clinical criteria, and there was no formal hospital transfusion policy or transfusion trigger during the study period.

Of the 316 patients included in the study, 143 (45%) were administered RBC transfusions within the first 24 hours after admission. Logistic regression modeling showed that patients receiving blood in the first 24 hours were 4.75 times as likely to die as those not transfused. The association was still statistically significant after controlling for indices of shock and injury severity (odds ratio [OR], 4.75; 95% confidence interval [CI], 1.37-16.4; p = 0.0137). The nonoperative group comprised 230 patients (72.8%), of whom 75 (33%) required transfusion in the first 24 hours. “Blood transfusion,� the authors report, “also independently predicted mortality in the subset of nonoperatively managed patients, even after controlling for indices of shock and injury severity (OR, 8.45; 95% CI, 1.95-36.53; p = 0.0043).�

When blood transfusion was entered into logistic regression as a continuous variable, it was found that the risk of death significantly increased with each unit of packed red blood cells transfused (OR per unit transfused, 1.16; 95% CI, 1.01-1.24; p < 0.001). Anemia, on the other hand, was not found to be a predictor of mortality nor accounted for the independent predictive association of blood transfusion on mortality. Mean hospital length of stay (but not ICU length of stay) was significantly greater in transfused patients (transfused, 19 ± 20 days; not transfused, 11 ± 13 days; p < 0.0001). By logistic regression, blood transfusion emerged as the only significant independent predictor of hospital length of stay (coefficient, 5.45; 95% CI, 1.64-9.25; p = 0.0052).

Although this study documents a strong association between transfusion and mortality in trauma patients with solid organ injury, it cannot demonstrate a cause-and-effect relationship due to its retrospective design. The authors note, however, that “blood transfusion may adversely impact outcome by means of its well-documented effects on immunologic and inflammatory responses and the increased infectious complications previously reported in other studies.�

“At our institution, the authors conclude, “we are currently designing a prospective trial to compare blood-restrictive transfusion policies, which may include a higher incidence of celiotomy, against a more liberal transfusion algorithm that potentially would reduce the need for operative intervention. In addition, we plan to prospectively investigate the use of therapies such as hemoglobin-based oxygen carriers and activated factor VII as adjuncts to treatment plans in blood-restrictive algorithms.�

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Mr. Jan B. Wade
Blood Management Consultant
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