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Purpose: Transfusion ratios approaching 1:1 FFP:PRBC for trauma resuscitation have become the de facto standard of care. The aim of this study was to prospectively evaluate the effect of increasing ratios of FFP:PRBC transfusion on survival for massively transfused civilian trauma patients as well as determine if time to reach the target ratio had any effect on outcomes., Methods: This is a prospective, observational study of all trauma patients requiring a massive transfusion (≥10 PRBC in ≤24 h) at a level 1 trauma center over a 2.5-year period. The ratio of FFP:PRBC was tracked hourly up to 24 h post-initiation of massive transfusion. A logistic regression model was utilized to identify the ideal ratio associated with mortality prediction. A stepwise logistic regression was performed to identify independent predictors of mortality., Results: The study population was predominantly male (89 %) with a mean age of 34.8 ± 16. On admission, 22 % had a systolic blood pressure ≤90 mmHg, 47 % had a heart rate ≥120, and 25 % had a GCS ≤8. The overall mortality was 33 %. The ratio of FFP:PRBC ≥ 1:1.5 was the second most important independent predictor of mortality for this population (R (2) = 0.59). Survivors had a higher FFP:PRBC ratio at all times during the first 24 h of resuscitation., Conclusions: Achieving a ratio of FFP:PRBC ≥ 1:1.5 after the initial 24 h of resuscitation significantly improves survival in massively transfused trauma patients compared to patients that achieved a ratio <1:1.5.

Background: The objective of this study was to analyze the outcomes associated with uncross-matched blood transfusion during trauma resuscitation. Our hypothesis was that uncross-matched blood transfusion is a predictor of the need for massive transfusion and mortality., Methods: All injured patients receiving packed red blood cell (PRBC) transfusion during a 6-year period ending December 2005 were identified from the blood bank database at a level I trauma center. Uncross-matched red blood cell (URBC) and cross-matched red blood cells, plasma and platelet utilization, and injury demographics were abstracted for each patient., Results: Of 25,599 trauma patients, 4,241 (16.6%) patients received 29,375 units of PRBC and 1,236 (29.1%) of the transfused patients received 5,166 units of URBC during their resuscitation. Patients requiring URBC had a higher mortality (39.6% vs. 11.9%, p < 0.001) and were more likely to require massive (> or = 10 PRBC during 12 hours) transfusion (29.3% vs. 1.8%, p < 0.001). There was a stepwise increase in mortality with increasing URBC transfusion. After adjusting for age, gender, mechanism, hypotension at admission, emergency department intubation, initial hemoglobin, Glasgow Coma Scale, Abbreviated Injury Scale, Injury Severity Score, and amount of blood products received; URBC remained an independent predictor of mortality (adjusted odds ratio 2.15; 95% confidence interval 1.58-2.94; p < 0.001) and massive transfusion (adjusted odds ratio, 11.87; 95% confidence interval, 8.43-16.7; p < 0.001). Patients receiving URBC also utilized more blood components (11.9 +/- 12.7 vs. 4.9 +/- 5.8 units of PRBC, p < 0.001; 5.1 +/- 8.9 vs. 2.0 +/- 4.8 units of plasma, p < 0.001; and 1.1 +/- 2.5 vs. 0.4 +/- 1.6 units of platelets, p < 0.001)., Conclusion: The requirement for uncross-matched blood during the acute resuscitation of trauma patients is an independent predictor of mortality and the need for massive transfusion. A URBC request during resuscitation should be considered by the blood bank as a potential trigger to prepare for massive transfusion.

Background: Despite evolving evidence that transfusion risks outweigh benefits in some patients, the critically injured continue to receive large quantities of blood. The present study evaluated patterns of red blood cell transfusions and risk factors for transfusions at various stages of admission in trauma patients., Study Design: Prospective, observational study of transfusion practices in patients (n = 120) admitted to a single Level 1 academic trauma centre. Patients were expected to remain in the surgical intensive care unit for greater than 48 h., Results: Patients had a mean age of 34.1+/- 16.0 years, a mean injury severity score (ISS) of 21.5 +/- 9.5, and were equally distributed by major injury type (48% blunt, 52% penetrating). One hundred and four patients (87%) received a total of 324 transfusions, 20 (6%) of which were given in the emergency room, 186 (57%) in the SICU, 22 (7%) post-SICU and 96 (30%) in the operating room. The mean volume of blood per patient transfused was 3144 +/- 2622 mL. One hundred and one patients received an allogeneic transfusion (mean volume 3126 +/- 2639 mL) and 10 patients received an autotransfusion (844 +/- 382 mL). The mean pre-transfusion Hb level was 9.1 +/- 1.4 g/dL. Transfusion volumes correlated with injury severity score (p = 0.011). Patients with an admission Hb < or =12 g/dL or age >55 years were at significant risk to receive increased transfusions (P < .001 and P = .035, respectively). An admission Hb < or =12 g/dL and any mention of long bone orthopedic operations or laparotomy or thoracotomy were associated with increased risk of blood transfusion during the first week of admission. Logistic regression analysis identified transfusion of >4 units of blood as a significant risk factor for SIRS. After 1 week of ICU stay, ISS > 20 and blunt injury were associated with increased risk of transfusion., Conclusions: Trauma patients are heavily transfused with allogeneic blood throughout the course of their hospital stay and transfusions are administered at relatively high pre-transfusion haemoglobin levels (mean of 9 g/dL). Transfusion of >4 units of blood is an independent risk factor for SIRS. Strategies to limit blood transfusions should be investigated in this population.

The purpose of pretransfusion compatibility testing is to prevent incompatible red blood cell transfusions that could lead to immune mediated hemolytic transfusion reactions. Some hemolytic transfusion reactions may have serious sequelae including hemoglobinemia, disseminated intravascular coagulation, renal failure, and death. This article reviews the most comprehensive recent analyses of the laboratory methods used during pretransfusion compatibility testing in the United States. Most of the laboratory practice data have been published in the College of American Pathologists Transfusion Medicine Survey Sets and in a national survey called the Pre-Transfusion Testing Survey. This article couples and trends the data of these comprehensive surveys with an assessment of the literature to present the current practice of pretransfusion compatibility testing.

Background: Monitoring blood transfusion for overutilization is standard practice at most institutions., Study Design and Methods: This study monitored for underutilization of blood transfusion over a 14-month period, by evaluating patients who had Hb levels that were reported to be <5 g per dL or platelet counts <10 x 10(9) per L and who did not receive an RBC or platelet transfusion within 24 hours of the reported results., Results: During the study period, 24,004 units of RBCs and 3,967 units of apheresis platelets were transfused. There were 148 patients who had a Hb level that was reported to be <5 g per dL or a platelet count reported to be <10 x 10(9) per L and who did not receive a transfusion during the 24 hours after the reporting of these results. In 5 cases, the patients died before the reporting of the low Hb or platelet counts, which precluded the low Hb or low platelet count reports from triggering transfusion therapy. In 8 cases, an underutilization review investigation could not be done, because of the unavailability of patient charts. Of the remaining 135 cases, investigation revealed justifiable reasons for withholding transfusion in 133. In 2 cases, the withholding of transfusion was deemed by peer review to be inappropriate, as the patients should have received a transfusion. Overall, there was one documented underutilization of RBC transfusion therapy during a period when 24,004 units were transfused and one underutilization of platelet transfusion therapy during a period when 3,967 units of apheresis platelets were transfused., Conclusion: Monitoring for underutilization of transfusion therapy fulfills the requirements of the Joint Commission on the Accreditation of Healthcare Organizations: While the underutilization of transfusion therapy did not appear to be a significant problem at this medical center, determining the reasons for withholding transfusions shed light on important patient care-related issues, including preexisting causes of falsely low platelet counts and Hb levels, delays in investigating critical laboratory values, and the need for policies for the treatment of patients who refuse transfusion for personal or religious reasons.

A practice parameter has been developed to assist physicians in the therapeutic use of red blood cell transfusions. The developers of this parameter used the best available information from the medical literature, as well as clinical experience and the extensive reality testing required by the College of American Pathologists for approval. In acute anemia, a fall in hemoglobin values below 6 g/dL or a rapid blood volume loss of more than 30% to 40% requires red blood cell transfusions in most patients. However, tissue oxygenation provides a better indication of physiologic need in situations where invasive monitoring provides this information. When these data are not available, heart rate and blood pressure measurements and the nature of bleeding (active, controlled, uncontrolled) supplement the hemoglobin value in guiding the transfusion decision. In sickle cell disease and thalassemias, red blood cells are transfused to prevent acute or chronic complications. Red blood cell transfusions are used in chronic anemias unresponsive to pharmacologic agents based on the patient's symptoms. Guidelines must be altered for neonates who require an increase in hematocrit to above 0.30 to 0.35 when respiratory distress is present. Indications for red blood cell transfusion for the pregnant or postpartum patient are similar to those for the nonpregnant patient. Risks of transfusion, particularly transmissible disease and incompatibility, remain but have been reduced. Thus, red blood cell transfusion continues to be a powerful therapeutic tool when used judiciously and carries less risk than in the recent past.

Objective: This research used a study-control group design and examined data collected from five hospitals to evaluate the effectiveness of retrospective peer-review systems on reducing utilization of red blood cells (RBCs)., Design: The effects of retrospective peer-review systems were studied in three parts: (1) trends of RBC utilization were compared by the slopes of linear regression lines that assessed the effect of time on RBC utilization among four study hospitals and one control hospital, (2) diagnosis-specific RBC utilization was compared between the control hospital and one matched study hospital, and (3) the effect of the retrospective review system of one study hospital was assessed by linear regression using data accumulated 1 year before and 2 years after implementation of the program., Results: Three study hospitals showed no significant changes in RBC utilization during the 10-month study period. One study hospital and the control hospital demonstrated trends of reduced RBC use with negative slopes of regression lines; however, there was no difference in the degree of the two slopes, and the diagnosis-specific RBC utilization was not lower at the study hospital than at the control hospital. Furthermore, implementation of the retrospective peer-review system at one study hospital demonstrated no effect on RBC utilization., Conclusions: We conclude that the retrospective peer-review systems implemented at these four hospitals had no effect on reducing red blood cell utilization.

The routine pretransfusion red blood cell antibody detection test (PADT), performed at the authors' institution, consists of a three-phase, saline-antiglobulin technique (immediate spin, 30-minute incubation at 37 degrees C, IgG indirect antihuman globulin test [IAT]), and each phase is examined for hemolysis and agglutination. To determine if it would be safe to omit reading the 37 degrees C phase of the PADT, a 6-year retrospective review of records (February 1986 to February 1992) was undertaken. Of approximately 280,000 sera tested for unexpected red cell alloantibodies, 1480 (.53%) were reactive at only 37 degrees C. Of 1480 sera, 1313 contained alloantibodies of no or questionable significance (eg, anti-Le(a), anti-Leb, and anti-P1), 71 sera contained antibodies of undetermined specificity, and 10 sera were reactive because of rouleaux. Eighty-six serum samples from 53 different patients contained alloantibodies of potential significance (anti-K, anti-E, etc). These 86 sera represented approximately 2.2% of all reactive sera that contained potentially significant alloantibodies. Although most antibodies (approximately 94%) detected only at 37 degrees C were of no or questionable significance, the other 6% could have increased the risk of missing a potentially significant antibody from approximately 1 in every 4700 sera tested to 1 in every 1875 sera tested, had they not been detected. The authors suggest that the increased risk of an acute or delayed hemolytic transfusion reaction would be too high to justify a procedural change. Based on these data, the authors continue to read the 37 degrees C phase of the PADT for hemolysis and agglutination.