Category Archives: Critical care

EAST 2017 #4: A More Restrictive Transfusion Trigger?

For many years, patients were automatically given not one, but two units of blood anytime they got “anemic” while in the hospital. And anemia was defined as a hemoglobin (Hgb) value < 10. Wow! Then we recognized that blood was a dangerous drug, with many potential complications.

We’ve come a long way, with our transfusion trigger slowly dropping and giving just one unit of blood at a time when needed. Many trauma centers use a transfusion trigger Hgb of 7 in younger, healthier patients. The question is, how low can you (safely) go?

The trauma program at Wake Forest University analyzed their data, and found that there was no “physiologic advantage” to transfusions in patients with Hgb of 6.5 to 7. Therefore, they lowered their transfusion trigger from 7 to 6.5 and retrospectively studied the results for the six months before and six months after the switch. Patients with hemorrhage, anticipated surgical procedures, or unreconstructed coronary artery disease were excluded.

Here are the factoids:

  • Of 852 patients admitted to the ICU, 131 met criteria and had a Hgb < 7
  • 72 patients were transfused with a trigger of 7, and 59 with a trigger of 6.5
  • There was no difference in ventilator, ICU, or hospital days, or mortality
  • The transfusion rate dropped by 27%, saving 72 units of blood

Bottom line: We continue to determine how low we can go with this. In healthy patients, the magic number is probably even lower. But we are increasingly seeing older, less healthy trauma patients. The next step is to start looking at subsets to determine what is safe for each group.

Questions and comments for the authors/presenter

  • Tell us the nature of the “preliminary work” that led to this paper. Was it animal data, or some kind of analysis of your patient data?
  • Since coronary artery disease was an exclusion criterion, how did you know a patient had it? By history alone?
  • Please show an age histogram of all units given at each threshold. This will let us see if there is any age bias present.
  • How low did the Hgb actually get in both groups? A histogram would be nice on this one, too.
  • Do you have any recommendations regarding selection based on age, frailty, or other parameters? What is your practice now?
  • Your outcome measures are somewhat crude, meaning that one would not really expect much of a change in those variables due to an extra unit or two of blood. What about adverse reactions that necessitated a fever workup or other intervention? Any differences between the groups there?

Click here to go the the EAST 2017 page to see comments on other abstracts.

Related posts:

Reference:   Effects of a more restrictive transfusion trigger in trauma patients. Poster #38, EAST 2017.

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Which ICU For Neurotrauma Patients: Neuro-, Trauma-, or Med/Surg?

Different hospitals have different arrangements for taking care of critically injured patients. All Level I or II trauma centers have at least a mixed med/surg ICU, with most level I centers having a dedicated surgical unit. A few have specific trauma or neuro-critical care ICUs.

In general, severely injured trauma patients do better when taken care of by trauma teams who have sufficient experience (volume). What about patients with severe traumatic brain injury (TBI)? Does the experience and volume of patients receiving care in the ICU make a difference?

A group of 12 trauma centers with varying ICU arrangements pooled their outcome data to see if the type of ICU makes a difference. All patients admitted with GCS<14 with CT evidence of TBI were evaluated if they were admitted to an ICU.

Here are the factoids:

  • 2951 patients from the 12 centers met inclusion criteria
  • Type of ICU, age, and ISS were independent predictors of death
  • Patients admitted to a trauma ICU had the best probability of survival, and stayed high across all ISS scores
  • Those admitted to med/surg ICUs had higher probabilities of death, especially with higher ISS (> 38 or so)
  • Survival for isolated TBI patients in a neuro ICU was similar to a trauma ICU in patients with lower ISS (< 32)


Bottom line: This is a fascinating study, but it is giving us just a glimpse of the complete picture. What’s the difference between a med/surg ICU vs a trauma ICU. How much head trauma does a neuro ICU have to see? What kind of nurses work in them? What types of critical care physicians? 

These questions are not answered in the abstract. And they may not be answered during the presentation at the meeting. But they are extremely important, and must be resolved in the next iteration of this study. Hopefully, there will be one!

Reference: Neuro-, trauma-, or med/surg-ICU: does it matter where polytrauma patients with TBI are admitted? Secondary analysis of the AAST-MITC decompressive craniectomy study. AAST 2016, paper #21.

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