A comparison of resuscitation intensity and critical administration threshold in predicting early mortality among bleeding patients: A multicenter validation in 680 major transfusion patients

David E Meyer, Bryan A Cotton, Erin E Fox, Deborah Stein, John B Holcomb, Mitchell Cohen, Kenji Inaba, Elaheh Rahbar

Research output: Contribution to journalArticle

Abstract

BACKGROUND To address deficiencies associated with the classic definition of massive transfusion (MT), critical administration threshold (CAT) and resuscitation intensity (RI) were developed to better quantify the overall severity of illness and predict the need for transfusions and early mortality. We sought to evaluate these as more appropriate replacements for MT in defining mortality risk in patients undergoing major transfusions. METHODS Patients predicted to receive MT at 12 Level I trauma centers were randomized in the Pragmatic, Randomized Optimal Platelet and Plasma Ratios (PROPPR) trial. MT of 10 U or greater red blood cell (RBC) in 24 hours; CAT+, 3 U or greater RBC in the first hour; and RI, total products in the first 30 minutes (1 U RBC, 1 U plasma, 1000 mL crystalloid, 500 mL colloid each valued at 1 U). Resuscitation intensity was evaluated as a continuous variable and dichotomized as RI4+, where RI is 4 U or greater. Each metric was evaluated for its ability to predict mortality at 3 hours, 6 hours, and 24 hours, and at 30 days. RESULTS Of the 680 patients, 301 patients met MT definition, 521 were CAT+, and 445 were RI4+. Of those that died, 23% never reached MT threshold, but all were captured by CAT+ and RI4+. The 3-hour (9% vs. 9%), 6-hour (14% vs. 14%), 24-hour (17% vs. 18%), and 30-day mortality rates (28% vs. 29%) were similar between CAT+ and RI4+ patients. When RI was evaluated as a continuous variable, each unit increase was associated with a 20% increase in hemorrhage-related mortality (odds ratio, 1.20; 95% confidence interval, 1.15-1.29; p < 0.05). CONCLUSION Both RI and CAT are valid surrogates for early mortality in patients undergoing major transfusion, capturing patients omitted by the MT definition. The CAT+ showed the best sensitivity; RI4+ demonstrated better specificity and good positive predictive values and negative predictive values. While CAT+ may be suited for patients receiving an RBC-dominant resuscitation, RI4+ is more comprehensive. RI can also be used as a continuous variable to provide quantitative as well as qualitative risk of death.

LanguageEnglish
Pages691-696
Number of pages6
JournalJournal of Trauma and Acute Care Surgery
Volume85
Issue number4
DOIs
StatePublished - Oct 1 2018

Fingerprint

Resuscitation
Hemorrhage
Mortality
Erythrocytes
Trauma Centers
Colloids
Blood Platelets
Odds Ratio
Confidence Intervals

Keywords

  • critical administration threshold
  • hemorrhage
  • massive transfusion
  • Resuscitation intensity
  • trauma

ASJC Scopus subject areas

  • Surgery
  • Critical Care and Intensive Care Medicine

Cite this

A comparison of resuscitation intensity and critical administration threshold in predicting early mortality among bleeding patients : A multicenter validation in 680 major transfusion patients. / Meyer, David E; Cotton, Bryan A; Fox, Erin E; Stein, Deborah; Holcomb, John B; Cohen, Mitchell; Inaba, Kenji; Rahbar, Elaheh.

In: Journal of Trauma and Acute Care Surgery, Vol. 85, No. 4, 01.10.2018, p. 691-696.

Research output: Contribution to journalArticle

Meyer, David E ; Cotton, Bryan A ; Fox, Erin E ; Stein, Deborah ; Holcomb, John B ; Cohen, Mitchell ; Inaba, Kenji ; Rahbar, Elaheh. / A comparison of resuscitation intensity and critical administration threshold in predicting early mortality among bleeding patients : A multicenter validation in 680 major transfusion patients. In: Journal of Trauma and Acute Care Surgery. 2018 ; Vol. 85, No. 4. pp. 691-696.
@article{5830aaca0b5e4f368a9c560f65ff39fa,
title = "A comparison of resuscitation intensity and critical administration threshold in predicting early mortality among bleeding patients: A multicenter validation in 680 major transfusion patients",
abstract = "BACKGROUND To address deficiencies associated with the classic definition of massive transfusion (MT), critical administration threshold (CAT) and resuscitation intensity (RI) were developed to better quantify the overall severity of illness and predict the need for transfusions and early mortality. We sought to evaluate these as more appropriate replacements for MT in defining mortality risk in patients undergoing major transfusions. METHODS Patients predicted to receive MT at 12 Level I trauma centers were randomized in the Pragmatic, Randomized Optimal Platelet and Plasma Ratios (PROPPR) trial. MT of 10 U or greater red blood cell (RBC) in 24 hours; CAT+, 3 U or greater RBC in the first hour; and RI, total products in the first 30 minutes (1 U RBC, 1 U plasma, 1000 mL crystalloid, 500 mL colloid each valued at 1 U). Resuscitation intensity was evaluated as a continuous variable and dichotomized as RI4+, where RI is 4 U or greater. Each metric was evaluated for its ability to predict mortality at 3 hours, 6 hours, and 24 hours, and at 30 days. RESULTS Of the 680 patients, 301 patients met MT definition, 521 were CAT+, and 445 were RI4+. Of those that died, 23{\%} never reached MT threshold, but all were captured by CAT+ and RI4+. The 3-hour (9{\%} vs. 9{\%}), 6-hour (14{\%} vs. 14{\%}), 24-hour (17{\%} vs. 18{\%}), and 30-day mortality rates (28{\%} vs. 29{\%}) were similar between CAT+ and RI4+ patients. When RI was evaluated as a continuous variable, each unit increase was associated with a 20{\%} increase in hemorrhage-related mortality (odds ratio, 1.20; 95{\%} confidence interval, 1.15-1.29; p < 0.05). CONCLUSION Both RI and CAT are valid surrogates for early mortality in patients undergoing major transfusion, capturing patients omitted by the MT definition. The CAT+ showed the best sensitivity; RI4+ demonstrated better specificity and good positive predictive values and negative predictive values. While CAT+ may be suited for patients receiving an RBC-dominant resuscitation, RI4+ is more comprehensive. RI can also be used as a continuous variable to provide quantitative as well as qualitative risk of death.",
keywords = "critical administration threshold, hemorrhage, massive transfusion, Resuscitation intensity, trauma",
author = "Meyer, {David E} and Cotton, {Bryan A} and Fox, {Erin E} and Deborah Stein and Holcomb, {John B} and Mitchell Cohen and Kenji Inaba and Elaheh Rahbar",
year = "2018",
month = "10",
day = "1",
doi = "10.1097/TA.0000000000002020",
language = "English",
volume = "85",
pages = "691--696",
journal = "Journal of Trauma and Acute Care Surgery",
issn = "2163-0755",
publisher = "Lippincott Williams and Wilkins",
number = "4",

}

TY - JOUR

T1 - A comparison of resuscitation intensity and critical administration threshold in predicting early mortality among bleeding patients

T2 - Journal of Trauma and Acute Care Surgery

AU - Meyer, David E

AU - Cotton, Bryan A

AU - Fox, Erin E

AU - Stein, Deborah

AU - Holcomb, John B

AU - Cohen, Mitchell

AU - Inaba, Kenji

AU - Rahbar, Elaheh

PY - 2018/10/1

Y1 - 2018/10/1

N2 - BACKGROUND To address deficiencies associated with the classic definition of massive transfusion (MT), critical administration threshold (CAT) and resuscitation intensity (RI) were developed to better quantify the overall severity of illness and predict the need for transfusions and early mortality. We sought to evaluate these as more appropriate replacements for MT in defining mortality risk in patients undergoing major transfusions. METHODS Patients predicted to receive MT at 12 Level I trauma centers were randomized in the Pragmatic, Randomized Optimal Platelet and Plasma Ratios (PROPPR) trial. MT of 10 U or greater red blood cell (RBC) in 24 hours; CAT+, 3 U or greater RBC in the first hour; and RI, total products in the first 30 minutes (1 U RBC, 1 U plasma, 1000 mL crystalloid, 500 mL colloid each valued at 1 U). Resuscitation intensity was evaluated as a continuous variable and dichotomized as RI4+, where RI is 4 U or greater. Each metric was evaluated for its ability to predict mortality at 3 hours, 6 hours, and 24 hours, and at 30 days. RESULTS Of the 680 patients, 301 patients met MT definition, 521 were CAT+, and 445 were RI4+. Of those that died, 23% never reached MT threshold, but all were captured by CAT+ and RI4+. The 3-hour (9% vs. 9%), 6-hour (14% vs. 14%), 24-hour (17% vs. 18%), and 30-day mortality rates (28% vs. 29%) were similar between CAT+ and RI4+ patients. When RI was evaluated as a continuous variable, each unit increase was associated with a 20% increase in hemorrhage-related mortality (odds ratio, 1.20; 95% confidence interval, 1.15-1.29; p < 0.05). CONCLUSION Both RI and CAT are valid surrogates for early mortality in patients undergoing major transfusion, capturing patients omitted by the MT definition. The CAT+ showed the best sensitivity; RI4+ demonstrated better specificity and good positive predictive values and negative predictive values. While CAT+ may be suited for patients receiving an RBC-dominant resuscitation, RI4+ is more comprehensive. RI can also be used as a continuous variable to provide quantitative as well as qualitative risk of death.

AB - BACKGROUND To address deficiencies associated with the classic definition of massive transfusion (MT), critical administration threshold (CAT) and resuscitation intensity (RI) were developed to better quantify the overall severity of illness and predict the need for transfusions and early mortality. We sought to evaluate these as more appropriate replacements for MT in defining mortality risk in patients undergoing major transfusions. METHODS Patients predicted to receive MT at 12 Level I trauma centers were randomized in the Pragmatic, Randomized Optimal Platelet and Plasma Ratios (PROPPR) trial. MT of 10 U or greater red blood cell (RBC) in 24 hours; CAT+, 3 U or greater RBC in the first hour; and RI, total products in the first 30 minutes (1 U RBC, 1 U plasma, 1000 mL crystalloid, 500 mL colloid each valued at 1 U). Resuscitation intensity was evaluated as a continuous variable and dichotomized as RI4+, where RI is 4 U or greater. Each metric was evaluated for its ability to predict mortality at 3 hours, 6 hours, and 24 hours, and at 30 days. RESULTS Of the 680 patients, 301 patients met MT definition, 521 were CAT+, and 445 were RI4+. Of those that died, 23% never reached MT threshold, but all were captured by CAT+ and RI4+. The 3-hour (9% vs. 9%), 6-hour (14% vs. 14%), 24-hour (17% vs. 18%), and 30-day mortality rates (28% vs. 29%) were similar between CAT+ and RI4+ patients. When RI was evaluated as a continuous variable, each unit increase was associated with a 20% increase in hemorrhage-related mortality (odds ratio, 1.20; 95% confidence interval, 1.15-1.29; p < 0.05). CONCLUSION Both RI and CAT are valid surrogates for early mortality in patients undergoing major transfusion, capturing patients omitted by the MT definition. The CAT+ showed the best sensitivity; RI4+ demonstrated better specificity and good positive predictive values and negative predictive values. While CAT+ may be suited for patients receiving an RBC-dominant resuscitation, RI4+ is more comprehensive. RI can also be used as a continuous variable to provide quantitative as well as qualitative risk of death.

KW - critical administration threshold

KW - hemorrhage

KW - massive transfusion

KW - Resuscitation intensity

KW - trauma

UR - http://www.scopus.com/inward/record.url?scp=85054304020&partnerID=8YFLogxK

UR - http://www.scopus.com/inward/citedby.url?scp=85054304020&partnerID=8YFLogxK

U2 - 10.1097/TA.0000000000002020

DO - 10.1097/TA.0000000000002020

M3 - Article

VL - 85

SP - 691

EP - 696

JO - Journal of Trauma and Acute Care Surgery

JF - Journal of Trauma and Acute Care Surgery

SN - 2163-0755

IS - 4

ER -