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Management of bleeding following major trauma: is a target haemoglobin of 7 to 9 g/dl high enough?

In the latest recommendations for the management of bleeding following major trauma, Spahn and colleagues recommend a target haemoglobin of 7 to 9 g/dl to initiate blood transfusion [1]. In their rationale the authors use a subgroup of trauma patients from the Transfusion Requirements in Critical Care study; however, patients with active blood loss were excluded from this trial.

Expressing a current opinion about transfusion and trauma patients, in 2006 McIntyre and Hebert wrote: 'It is important to put RBC [red blood cell] transfusions into the context of three main time frames, i.e. prehospital care, initial 24-48 h after admission to hospital and thereafter, because each frame has its own set of circumstances which may dictate the need for different timing, volume and rapidity of transfusions' [2]. To our knowledge, the only trial to evaluate a target haemoglobin in shock involved early goal-directed therapy in septic shock [3]. The early goal-directed therapy protocol included maintaining a haematocrit of 30% (haemoglobin at 10 g/dl). In the results, the early goal-directed therapy group had a significantly higher haematocrit than the control group and also received more transfusions.

Raising the target haemoglobin to 10 g/dl has two interesting effects: haemodilution is reduced, harmful in the present case; and the transfusion delay is decreased. Riskin and colleagues showed that reducing the transfusion delay may decrease the mortality rate [4]. For the first time, three studies suggest that transfusion may be associated with a reduced mortality rate [5].

The real beneficial effect of blood transfusion is probably that it gives time to stop the bleeding.

References

  1. 1.

    Spahn DR, Bouillon B, Cerny V, Coats TJ, Duranteau J, Fernandez-Mondejar E, Filipescu D, Hunt BJ, Komadina R, Nardi G, Neugebauer E, Ozier Y, Riddez L, Schultz A, Vincent JL, Rossaint R: Management of bleeding and coagulopathy following major trauma: an updated European guideline. Crit Care 2013, 17: R76.

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    McIntyre LA, Hebert PC: Can we safely restrict transfusion in trauma patients? Curr Opin Crit Care 2006, 12: 575-583.

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    Rivers E, Nguyen B, Havstad S, Ressler J, Muzzin A, Knoblich B, Peterson E, Tomlanovich M: Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med 2001, 345: 1368-1377.

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    Riskin DJ, Tsai TC, Riskin L, Hernandez-Boussard T, Purtill M, Maggio PM, Spain DA, Brundage SI: Massive transfusion protocols: the role of aggressive resuscitation versus product ratio in mortality reduction. J Am Coll Surg 2009, 209: 198-205.

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    Vincent JL: Transfusion triggers: getting it right! Crit Care Med 2012, 40: 3308-3309.

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Correspondence to Nicolas Morel.

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The authors declare that they have no competing interests.

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Morel, N., Delaunay, F. & Dubuisson, V. Management of bleeding following major trauma: is a target haemoglobin of 7 to 9 g/dl high enough?. Crit Care 17, 442 (2013). https://doi.org/10.1186/cc12767

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Keywords

  • Septic Shock
  • Blood Transfusion
  • Trauma Patient
  • Transfusion Requirement
  • Major Trauma