CME Articles

Transfusion of red blood cells in patients with a prehospital Glasgow Coma Scale score of 8 or less and no evidence of shock is associated with worse outcomes

Elterman, Joel MD; Brasel, Karen MD; Brown, Siobhan PhD; Bulger, Eileen MD; Christenson, Jim MD; Kerby, Jeffrey D. MD, PhD; Kannas, Delores RN, MS; Lin, Steven MD; Minei, Joseph P. MD; Rizoli, Sandro MD, PhD; Tisherman, Samuel MD; Schreiber, Martin A. MD the Resuscitation Outcomes Consortium Investigators

Author Information

From the Oregon Health & Science University (J.E., M.A.S.), Portland, Oregon; Medical College of Wisconsin (K.B.), Milwaukie, Wisconsin; University of Washington (S.B., E.B., D.K.), Seattle, Washington; University of Alabama (J.D.K.), Birmingham, Alabama; University of Texas Southwestern Medical Center (J.P.M.), Dallas, Texas; University of Pittsburgh (S.T.), Pittsburgh, Pennsylvania; and University of British Columbia (J.C.), Vancouver, British Columbia; and St Michaels Hospital (S.L.); and Sunnybrook Health Sciences Centre (S.R.), Toronto, Ontario, Canada.

Submitted: November 30, 2012, Revised: February 5, 2013, Accepted: March 11, 2013.

This study was presented at the 26th Annual Scientific Assembly of the Eastern Association for the Surgery of Trauma, January 15–19, 2013, in Scottsdale, Arizona.

The content of this article is solely the responsibility of the authors and does not necessarily represent the official views of the National Heart, Lung and Blood Institute or the National Institutes of Health.

Address for reprints: Joel Elterman, MD, Oregon Health & Science University, 3181 S.W. Sam Jackson Park Road, Mail Code L611, Portland, OR 97239; email: [email protected].

Journal of Trauma and Acute Care Surgery 75(1):p 8-14, July 2013. | DOI: 10.1097/TA.0b013e318298492e

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Abstract

BACKGROUND

Red blood cell transfusion practices vary, and the optimal hemoglobin for patients with traumatic brain injury has not been established.

METHODS

A retrospective review of data collected prospectively as part of a randomized, controlled trial involving emergency medical service agencies within the Resuscitation Outcomes Consortium was conducted. In patients with a Glasgow Coma Scale (GCS) score of 8 or less without evidence of shock (defined by a systolic blood pressure [SBP] < 70 or SBP of 70 to 90 with a heart rate ≥108), the association of red blood cell transfusion with 28-day survival, adult respiratory distress syndrome–free survival, Multiple Organ Dysfunction Score (MODs), and 6-month Extended Glasgow Outcome Scale (GOSE) score was modeled using multivariable logistic regression with robust SEs adjusting for age, sex, injury severity (Injury Severity Score [ISS]), initial GCS score, initial SBP, highest field heart rate, penetrating injury, fluid use, study site, and hemoglobin (Hgb) level.

RESULTS

A total of 1,158 patients had a mean age of 40, 76% were male, and 98% experienced blunt trauma. The initial mean GCS score was 5, and the initial mean SBP was 134. The mean head Abbreviated Injury Scale (AIS) score was 3.5. A categorical interaction of red blood cell transfusion stratified by initial Hgb showed that when the first Hgb was greater than 10 g/dL, volume of packed red blood cell was associated with a decreased 28-day survival (odds ratio, 0.83; 95% confidence interval [CI], 0.74–0.93; p < 0.01) and decreased adult respiratory distress syndrome–free survival (odds ratio, 0.82; 95% CI, 0.74–0.92; p < 0.01). When the initial Hgb was greater than 10, each unit of blood transfused increased the MODs by 0.45 (coefficient 95% CI, 0.19–0.70; p < 0.01).

CONCLUSION

In patients with a suspected traumatic brain injury and no evidence of shock, transfusion of red blood cells was associated with worse outcomes when the initial Hgb was greater than 10.

LEVEL OF EVIDENCE

Therapeutic study, level III.

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Transfusion of red blood cells in patients with a prehospital Glasgow Coma Scale score of 8 or less and no evidence of shock is associated with worse outcomes