Coagulopathy and thrombocytopenia are common after traumatic brain injury (TBI), yet transfusion thresholds for mildly to moderately abnormal ranges of international normalized ratio and platelet count remain controversial. This study evaluates associations between fresh frozen plasma (FFP) and platelet transfusions with long-term functional outcome and survival in TBI patients with moderate hemostatic laboratory abnormalities.
This study is a retrospective review of prospectively collected data of patients with mild to severe TBI. Data include patient demographics, several initial injury severity metrics, daily laboratory values, Glasgow Outcome Score- Extended (GOSE) scores, Functional Status Examination (FSE) scores, and survival to 6 months. Correlations were evaluated between these variables and transfusion of FFP, platelets, packed red blood cells (RBCs), cryoprecipitate, recombinant factor VIIa, and albumin. Ordinal regression was performed to account for potential confounding variables to further define relationships between transfusion status and long-term outcome. By analyzing collected data, mild to moderate coagulopathy was defined as an international normalized ratio 1.4–2.0, moderate thrombocytopenia as platelet count 50 × 109/L to 107 × 109/L, and moderate anemia as 21%–30% hematocrit.
In patients with mild to moderate laboratory hematological abnormalities, univariate analysis shows significant correlations between poor outcome scores and FFP, platelet, or packed RBC transfusion; the volume of FFP or packed RBCs transfused also correlated with poor outcome. Several measures of initial injury and laboratory abnormalities also correlated with poor outcome. Patient age, initial Glasgow Coma Scale score, and highest recorded serum sodium were included in the ordinal regression model using backward variable selection. In the moderate coagulopathy subgroup, patients transfused with FFP were more likely to have a lower GOSE score relative to those who did not receive a transfusion (OR 5.20 [95% CI 1.72–15.73]). Patients with moderate coagulopathy who received FFP and packed RBCs were even more likely to be have a lower GOSE score (OR 7.17 [95% CI 2.12–24.12]). Moderately anemic patients who received packed RBCs alone were more likely to have a worse long-term functional outcome as determined by GOSE and FSE scores (GOSE: OR 2.41 [95% CI 1.51–3.85]; and FSE: OR 3.27 [95% CI 2.00–5.35]). No transfusion types or combinations were noted to significantly correlate with the 6-month mortality in ordinal regression.
In TBI patients with moderate coagulopathy, FFP transfusions alone or a combination of FFP and packed RBCs were associated with poorer long-term functional outcomes as measured by the GOSE. Red blood cell transfusions were associated with poor long-term functional outcome in TBI patients with moderate anemia. Platelet transfusion in patients with moderate thrombocytopenia was not significantly associated with outcome. Although transfusion is beneficial to many patients with severe hematological abnormalities, it is not without risk, and the indications for transfusion should be carefully considered in patients with moderate hematological abnormalities.
Abbreviations used in this paper:AIS = Abbreviated Injury Scale; ARDS = acute respiratory distress syndrome; DIC = disseminated intravascular coagulation; FFP = fresh frozen plasma; FSE = Functional Status Examination; GCS = Glasgow Coma Scale; GOS = Glasgow Outcome Scale; GOSE = GOS-Extended; HCT = hematocrit; INR = international normalized ratio; ISS = Injury Severity Score; PTT = partial thromboplastin time; RBC = red blood cell; TACO = transfusion-associated circulatory overload; TBI = traumatic brain injury; TCDB = Traumatic Coma Data Bank; TRALI = transfusion-related acute lung injury; TRICC = Transfusion Requirements in Critical Care.
Address correspondence to: Ramon Diaz-Arrastia, M.D., Ph.D., Uniformed Services University of the Health Sciences, 12725 Twinbrook Parkway, Rockville, Maryland 20851. email: Ramon.Diaz-Arrastia@USUHS.edu.
Please include this information when citing this paper: published online December 21, 2012; DOI: 10.3171/2012.11.JNS12622.
HébertPCWellsGBlajchmanMAMarshallJMartinCPagliarelloG: A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care. Transfusion Requirements in Critical Care Investigators, Canadian Critical Care Trials Group. N Engl J Med340:409–4171999
HudakAMCaesarRRFrolABKruegerKHarperCRTemkinNR: Functional outcome scales in traumatic brain injury: a comparison of the Glasgow Outcome Scale (Extended) and the Functional Status Examination. J Neurotrauma22:1319–13262005
McIntyreLAFergussonDAHutchisonJSPagliarelloGMarshallJCYetisirE: Effect of a liberal versus restrictive transfusion strategy on mortality in patients with moderate to severe head injury. Neurocrit Care5:4–92006
WatsonGASperryJLRosengartMRMineiJPHarbrechtBGMooreEE: Fresh frozen plasma is independently associated with a higher risk of multiple organ failure and acute respiratory distress syndrome. J Trauma67:221–2302009