A review of a trauma database for inappropriateness of transfused blood products

Objectives

A trauma database was reviewed to characterize the appropriateness of transfused blood products (packed red blood cells [RBC], platelets [PLT], fresh frozen plasma [FFP], cryoprecipitate [CRY]) in actively, massively bleeding trauma patients in the first 48 hours of their admission.

Setting

The trauma database at Sunnybrook and Women's College Health Sciences Centre, University of Toronto, Toronto, Canada, a regional, level one, trauma centre.

Methods

Two hundred and seventy-five consecutive patients receiving 10 or more units of packed red blood cells in the first 24 hours of admission to the hospital, from January 1992 to December 2001, were reviewed from the trauma database.

The criteria used to determine the appropriateness of transfused blood products in the first 48 hours of their admission were according to the American Society of Anesthesiologists [1]: hemoglobin > 80 g/l, platelet count > 50 × 10⁹/l, International Normalised Ratio (INR) < 1.5, fibrinogen > 1.0 g/l. Inappropriately transfused units of blood products were counted as those blood units administered despite the last laboratory reading meeting the aforementioned criteria. Each assessment period time frame and clinical action extended from 15 min after the last laboratory data until 15 min after the next laboratory data.

Data collection

Laboratory data (hemoglobin value, platelet count, INR, fibrinogen level) and transfusion data (packed RBC, PLT, and FFP, CRY) in the first 48 hours of admission were collected.

Results

See Table 1.

Table 1 Table

Conclusions

There may exist substantial inappropriate blood product transfusion in the treatment and resuscitation of trauma patients. However, it is also possible that routine laboratory measurements are not sensitive enough indicators of appropriateness for this patient population; that is, patients frequently may have active bleeding without the opportunity for laboratory samples to be obtained. The potential causes for the former include lack of knowledge of the existing guidelines, decision of not to follow the guidelines, or overcorrection of coagulopathy. Possible solutions include: the redistribution of guidelines to various departments of a hospital (operating room, emergency room, critical care); cell saver techniques; accepting lower blood pressures in select patients; use of antifibrinolytics; use of factor VIIa.