Intern 謝旻翰

Introduction (I) Benefit –Volume restoration, improved O2 carrying capacity Risk –Transfusion reaction, blood-bore pathogen, limited supply, deleterious immunologic impact Blood transfusion?? –Class III or IV hemorrhage ongoing, life-threaten Trauma Hemorrhage Blood transfusion

Outline Prediction of blood transfusion –Scoring system –Physiologic parameter Oxygen debt, coagulopathy, hypothermia Prediction of mortality –Scoring system –Physiologic parameter Base deficit, hypothermia

Purpose Early predictors for Transfusion & Mortality ???

Method Medline Cochrane National Guideline Clearinghouse Agency for Healthcare Research and Quality

Predict Transfusion

Predict Transfusion - Scoring Prehospital index –>3, 77% 需 transfusion –≤3, 14 需 transfusion Trauma score Trauma –<14, 90% 不需 transfusion –≥14, 70% 需 transfusion Revised trauma score – 和 traumatic injury, pelvic fracture 正相關 - BP - RR - GCS

Predict Transfusion - Scoring Injury Severity scoring (ISS) –Mean ISS of 17, 1-10u pRBC –Mean ISS of 28, 11-20u pRBC –Mean ISS of 33, >20u pRBC

Predict Transfusion - Scoring Physiologic scoring data & injury severity –BP < 90 mmHg –HR > 120/min –GCS < 9 –High risk injury 4/4  100%, 3/4  68%, 2/4  42%, 1/4  12%, 0/4  2% Hypotension: highest relative risk for transfusion Chest injury, abdominal injury, survival of vehicular crash, penetrating torso injury

Predict Transfusion - oxygen debt Marker –Base deficit –Serum lactate Base deficit: 2-5, 6-14, >15 Oxygen debt data & trauma score, revised trauma score

Predict Transfusion - Coagulopathy & hypothermia Not mutually exclusive Acute traumatic hemorrhage, resuscitation, transfusion  abnormalities of clotting factors, acid-base homeostasis, thermo- regulation Coagulopathy in injured p ’ t –Consumption and dilution of coagulation factor, hypothermia, acidosis, excessive fibrinolytic activity, tissue thromboplastin release

Predict Transfusion - Coagulopathy & hypothermia Progressively worsening hypothermia  decreased survival Blood transfusion requirement – 正比 injury severity – 反比 core temperature

Predict Mortality

Predict Mortality – Scoring Most significant predictive –PTT –CT of head –Low initial hemoglobin –Base dficit –Hypotension Moderate predictive –Trauma scoring system SIRS score, GCS, age

Predict Mortality – Base deficit Elevated base deficit  increase mortality Failure to resuscitate from oxygen debt in 24hr  worst prognosis –Can ’ t improve >4 in 24hr  50% mortality –Normalized within 24hr  9% mortality Occult hypo-perfusion demonstrate by lactic acidosis within 24 hr in ICU ??

Predict Mortality – hypothermia Increased hypothermia  increase mortality (core temperature) –< 34°C associated with increased mortality Hypothermia prone to coagulopathy

Transfusion & Mortality Increasing volume of blood transfusion  increased mortality Blood transfusion was a strong predictor of mortality Age & blood transfusion

Conclusion Review base on class II, III data Need for transfusion –Prehosipital and presentation physiology –Oxygen debt –Injury severity –Coagulopathy –Hypothermia Shock index & oxygen debt  transfusion volume requirement  mortality Quantify?? Predict transfusion volume need??

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