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

Joel Elterman, Karen Brasel, Siobhan Brown, Eileen Bulger, Jim Christenson, Jeffrey D Kerby, Delores Kannas, Steven Lin, Joseph P Minei, Sandro Rizoli, Samuel Tisherman, Martin A Schreiber
Journal of Trauma and Acute Care Surgery 2013, 75 (1): 8-14; discussion 14

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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