Transfusion of Packed Red Blood Cells and Fresh Frozen Plasma are Synergistic Risk Factors for Venous Thromboembolism in Trauma Patients

Vol. 223, No. 4S2, October 2016

Scientific Poster Presentations: 2016 Clinical Congress

accounted for nor adequately studied. We therefore sought to determine the effect of comorbidities, using the Charlson comorbidity index (CCI), on burn mortality. METHODS: The purpose of this study was to determine the effect of comorbidities on burn mortality as determined by the LA50 (lethal TBSA burn at which 50% of the cohort will succumb from the burn injury) in a retrospective analysis of patients admitted to a regional burn center from 2002-2012. Bivariate analysis was performed and logistic regression modeling using significant variables was utilized to estimate odds of death. RESULTS: A total of 7,640 patients were included in this study. Overall survival rate was 96%. 40% of our burn cohort had at least one comorbidity. The logistic regression model for mortality outcomes identified four statistically significant variables: age, TBSA, inhalation injury, and the presence of comorbidities (OR ¼ 1.59 for each 1 point increase in CCI; 95% CI 1.44-1.77). There was a linear increase in the likelihood of death with an increase in CCI. Table. Effect of Prognostic Factors on LA50a in a Prediction Model Variable

Overall Age  18 years 19-64 years  65 years

Partially Adjusted for inhalation injury Unadjusted and mechanism Fully Adjustedb

53%

45%

35%

81% 55% 30%

76% 48% 20%

61% 43% 19%

a Lethal TBSA burn at which 50% of the cohort will succumb from the burn injury. b Adjusted for inhalation injury, burn mechanism, and preexisting comorbidities.

CONCLUSIONS: Preexisting comorbidities have a significant effect on burn injury mortality in all age groups, particularly the younger burn population. The measured effect of comorbidities in the >65yr age cohort was mitigated by the co-linearity between age and comorbidities. The inclusion of CCI is imperative to better prognosticate burn outcome, help guide expectations, and resources. Presence of Traumatic Brain Injury Does Not Lead to an Increased Rate of Splenectomy in Blunt Splenic Injury Abid D Khan, MD, Ashley D Meagher, MD, MPH, Eileen B O’Halloran, MD, Michael J Anstadt, MD, Richard P Gonzalez, MD, FACS Loyola University Medical Center, Maywood, IL INTRODUCTION: Traumatic brain injury (TBI) is reported to be associated with an increased rate of splenectomy in blunt splenic injury (BSI). Our objective was to determine if the presence of TBI was a risk factor for splenectomy in BSI.

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METHODS: All National Trauma Database (NTDB) entries from 2008-2012 with BSI treated at American College of Surgeons (ACS) verified trauma centers (levels I, II and III) were included in our analysis (n¼37,432). A univariate analysis using chi-squared test was performed. Additionally, a multivariate analysis using logistic regression was performed to control for potentially confounding variables. RESULTS: 4,742 of 25,454 (18.63%) patients with BSI and no TBI had splenectomy; 2,410 of 11,978 (20.12%) patients with both TBI and BSI underwent splenectomy [p<0.01]. Multivariate regression was performed controlling for age, sex, race, AAST grade of spleen injury, overall ISS, SBP<90 on admission, presence of TBI, and payor status. The odds ratio that patients with both BSI and TBI had splenectomy compared to patients with BSI and no TBI was 0.78 [(95% CI 0.73-0.83) (p<0.001)]. CONCLUSIONS: Overall, patients with both BSI and TBI treated at ACS verified trauma centers were more likely to undergo splenectomy than patients with BSI but no TBI. However, when controlling for age, severity of injury and systolic blood pressure on admission, patients with both TBI and BSI are actually less likely to undergo splenectomy than patients with BSI alone. Transfusion of Packed Red Blood Cells and Fresh Frozen Plasma are Synergistic Risk Factors for Venous Thromboembolism in Trauma Patients Charles A Karcutskie, MD, Jonathan P Meizoso, MD, Juliet J Ray, MD, Davis B Horkan, MD, Xiomara Ruiz, MD, Alan S Livingstone, MD, FACS, Carl I Schulman, MD, FACS, Enrique Ginzburg, MD, FACS, Nicholas Namias, Kenneth G Proctor, PhD University of Miami Leonard M Miller School of Medicine, Miami, FL INTRODUCTION: Transfusion is a known risk factor for venous thromboembolism (VTE) in trauma patients, but its magnitude is not well-defined. We hypothesize that transfusion of packed red blood cells (PRBC) and fresh frozen plasma (FFP) are synergistic risk factors. METHODS: Retrospective review of 1,177 patients admitted to the intensive care unit at a level I trauma center from 8/2011-1/2015 was performed. Those who died without a VTE were excluded. Univariate analysis and multivariate logistic regressions established independent predictors of VTE, with significance at p0.05. RESULTS: Overall VTE rate was 8.9%. For +VTE (n¼105) & eVTE (n¼1072), age, sex, and mechanism were similar, but injury severity score (2714 vs 2012) was worse in the +VTE group (p<0.001). The +VTE group had more transfusions of any type (86% vs 49%, p<0.001), PRBC (38% vs 29%, p¼0.047), PRBC+FFP (47% vs 18%, p<0.001), and delayed (>48h) prophylaxis initiation (23.7% vs 12.9%, p¼0.004). Additionally, this group had more abnormal coagulation tests, femoral lines, vascular injuries, leg or pelvic fractures, longer operations, and higher AIS abdomen scores (all p<0.005). Controlling for these factors, the

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J Am Coll Surg

Scientific Poster Presentations: 2016 Clinical Congress

relationship between VTE & PRBC units was dose-dependent (OR: 1.1, 95% CI: 1.030-1.111). Receiving transfusion of any type, femoral line, operation >2h, and pelvic fracture independently predicted VTE, with VTE 3.7X as likely with only PRBC transfusion but 7.5X as likely with PRBC+FFP (Table). Table. Analysis

Analysis 1 Any Transfusion Abnormal Coagulation Tests Femoral Line Operation > 2h Pelvic Fracture Any Transfusion Analysis 2 PRBC, FFP, or PRBC+FFP Abnormal Coagulation Tests Pelvic Fracture Only PRBC Transfusion PRBC and FFP Transfusion

OR

CI

p Value

0.037 0.029 0.022 <0.001 <0.001

1.612 2.167 1.73 2.555 3.548

1.03 1.081 1.083 1.578 1.913

-

2.524 4.345 2.761 4.139 6.583

1.69 2.246 3.749 7.523

1.079 1.391 1.928 3.922

-

2.647 0.022 3.624 0.001 7.292 <0.001 14.432 <0.001

blood product administration within 24 hours of admission [24-hour pRBC (8.5 vs 0.9, p<0.0001), 24-hour FFP (5.7 vs 0.6, p<0.0001), 24-hour platelet (1 vs 0.1, p<0.0001)]. Multivariate analysis revealed independent predictors of hypocalcemia were penetrating mechanism (AOR 1.565), depressed GCS (AOR 0.961), decreased SBP (AOR 0.995), increased ISS (AOR 1.014), higher 24-hour pRBC (AOR 1.337), and intubation (AOR 1.612). There was a stepwise increase in AOR of hypocalcemia as pRBC administration increased (see Table). Table. 24 hour pRBC administered*

Adjusted p Value

Adjusted Odds Ratio (AOR)

95% Confidence Interval

1
<0.0001 <0.0001 <0.0001 <0.0001 <0.0001 <0.0001

3.298 6.762 11.596 33.354 38.903 159.365

2.691-4.043 5.610-8.151 9.492-14.168 25.080-44.358 24.133-62.714 49.792-510.071

Covariates : penetrating mechanism, GCS, ED SBP, ISS, intubation *Compared to reference of pRBC1, each category placed one at a time in forward conditional regression with covariates.

CONCLUSIONS: Transfusion of each PRBC unit increases VTE risk in trauma patients, and this is potentiated by FFP. Increased surveillance may be indicated in transfused patients after trauma.

CONCLUSIONS: Transfusion of pRBC is an independent predictor of hypocalcemia with increased predicted probability of hypocalcemia as more pRBC are administered.

Transfusion-Related Hypocalcemia after Trauma Saskya Byerly, MD, Kenji Inaba, MD, FACS, FRCSC, Subarna Biswas, MD, Eugene Wang, MD, Monica D Wong, Elizabeth R Benjamin, MD, PhD, FACS, Lydia Lam, MD, FACS, Demetrios Demetriades, MD, PhD, FACS University of Southern California, Los Angeles, CA

Trauma Surgeons Consensus vs Trauma Registry-Derived Injury Severity Score and Probability of Survival: Is There a Difference? Gary G Lombardo, MD, FACS, Patrizio Petrone, MD, MPH, MHA, FACS, Alejandro Betancourt, MD, Kartik Prabhakaran, MD, Anthony Policastro, MD, FACS, Kathy Aronow, Corrado P Marini, MD, FACS Westchester Medical Center University Hospital, Valhalla, NY

INTRODUCTION: Hypocalcemia has been cited as a complication of massive transfusion due to the complex of citrate with serum calcium. However, this has not been well-studied as a primary outcome in trauma patients. METHODS: Retrospective single-center study (01/2004-12/2014) including trauma patients 18 yo presenting to the emergency department (ED) that had an ionized calcium level drawn. Our primary outcome was to determine if transfusion of packed red blood cells (pRBC) was an independent predictor of hypocalcemia (ionized calcium 4mg/dL). RESULTS: 8,379 patients met inclusion criteria, 2,068 (24.6%) developed hypocalcemia within 48 hours of admission. Mean age 39.3 yo (SD 21.1), systolic blood pressure (SBP) 130 (SD 32), median Glascow Coma Scale (GCS) 15 (IQR:10-15), injury severity score (ISS) 14 (IQR:9-24). Hypocalcemia patients had depressed GCS (14 vs 15, p<0.0001), more hypotension (15.6% vs 3.9%) and more tachycardia (55.6% vs 42.6%, p<0.0001) compared to non-hypocalcemia patients. They also had a higher emergency operative intervention rate (60.2% vs 23.2%, p<0.0001), more

INTRODUCTION: The Injury Severity Score (ISS) remains the standard of anatomic trauma scoring used with age and physiologic variables to predict mortality. It can be derived by clinical consensus or from the trauma registry (TR). In this study we compare trauma surgeons (TS) assigned ISS and predicted mortality (PM) with those derived from the TR at discharge. METHODS: The ISS and PM assigned to 305 patients admitted between 4/1/2013 and 11/30/2013 on morning report by five TS, first independently, and then by consensus, were compared to those derived from the TR in an analysis stratified by three ISS groups: 1-14, 15-25 and 26-75. Statistical analysis included inter-rater agreement assessed by intraclass correlation coefficient between TR and TS assigned ISS and PM. Data are reported as means  SD and median with IQR. Statistical significance was accepted to correspond to a p < 0.05. RESULTS: Inter-rate agreement among the 5 surgeons was 98% for the all ISS and PM. Shown in the Table are the results stratified