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Massive Transfusion in Trauma Patients: Tissue Hemoglobin Oxygen Saturation Predicts Poor Outcome

Moore, Frederick A. MD; Nelson, Teresa MS; McKinley, Bruce A. PhD; Moore, Ernest E. MD; Nathens, Avery B. MD, PhD, MPH; Rhee, Peter MD, MPH; Puyana, Juan Carlos MD; Beilman, Gregory J. MD; Cohn, Stephen M. MD

The Journal of Trauma: Injury, Infection, and Critical Care: April 2008 - Volume 64 - Issue 4 - p 1010-1023
doi: 10.1097/TA.0b013e31816a2417
Original Articles

Background: Severely bleeding trauma patients requiring massive transfusion (MT) often experience poor outcomes. Our purpose was to determine the potential role of near infrared spectrometry derived tissue hemoglobin oxygen saturation (StO2) monitoring in early prediction of MT, and in the identification of those MT patients who will have poor outcomes.

Methods: Data from a prospective multi-institution StO2 monitoring study were analyzed to determine the current epidemiology of MT (defined as transfusion volume ≥10 units packed red blood cells in 24 hours of hospitalization). Multivariate logistic regression was used to develop prediction models.

Results: Seven US level I trauma centers (TC) enrolled 383 patients. 114 (30%) required MT. MT progressed rapidly (40% exceeded MT threshold 2 hours after TC arrival, 80% after 6 hours). One third of MT patients died. Two thirds of deaths were due to early exsanguination and two thirds of early exsanguination patients died within 6 hours. One third of the early MT survivors developed multiple organ dysfunction syndrome. MT could be predicted with standard, readily available clinical data within 30 minutes and 60 minutes of TC arrival (area under the receiver operating characteristic curve = 0.78 and 0.80). In patients who required MT, StO2 was the only consistent predictor of poor outcome (multiple organ dysfunction syndrome or death).

Conclusion: MT progresses rapidly to significant morbidity and mortality despite level I TC care. Patients who require MT can be predicted early, and persistent low StO2 identifies those MT patients destined to have poor outcome. The ultimate goal is to identify these high risk patients as early as possible to test new strategies to improve outcome. Further validation studies are needed to analyze appropriate allocation and study appropriate use of damage control interventions.

From the Department of Surgery (F.A.M., B.A.M.), The Methodist Hospital, Houston Texas; Department of Surgery (E.E.M.), University of Colorado Denver, Colorado; Department of Surgery (A.B.N.), University of Toronto, Toronto, Ontario, Canada; Department of Surgery (P.R.), University of Southern California, Los Angeles, California; Department of Surgery (J.C.P.), University of Pittsburgh, Pittsburgh, Pennsylvania; Department of Surgery (G.J.B.), University of Minnesota, Minneapolis, Minnesota; Department of Surgery (S.M.C.), University of Texas Health Science Center San Antonio, San Antonio, Texas; and Technomics Research (T.N.), LLC, Minneapolis, Minnesota.

Submitted for publication March 8, 2007.

Accepted for publication January 22, 2008.

This study was funded by Hutchinson Technology, Inc., Hutchinson, Minnesota.

Presented at the 37th Annual Meeting of the Western Trauma Association, February 25–March 2, 2007, Steamboat Springs, Colorado.

Address for reprints: Frederick A. Moore, MD, Department of Surgery, The Methodist Hospital, 6550 Fannin Street, Smith Tower 1661, Houston, TX 77030; email: famoore@tmhs.org.

© 2008 Lippincott Williams & Wilkins, Inc.