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Red blood cell transfusion and mortality in trauma patients: risk-stratified analysis of an observational study

Perel, Pablo; Clayton, Tim; Altman, Doug G.; Croft, Peter; Douglas, Ian; Hemingway, Harry; Hingorani, Aroon; Morley, Katherine I.; Riley, Richard; Timmis, Adam; Van der Windt, Danielle; Roberts, Ian

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Authors

Pablo Perel

Tim Clayton

Doug G. Altman

Peter Croft

Ian Douglas

Harry Hemingway

Aroon Hingorani

Katherine I. Morley

Richard Riley

Adam Timmis

Ian Roberts



Abstract

BACKGROUND: Haemorrhage is a common cause of death in trauma patients. Although transfusions are extensively used in the care of bleeding trauma patients, there is uncertainty about the balance of risks and benefits and how this balance depends on the baseline risk of death. Our objective was to evaluate the association of red blood cell (RBC) transfusion with mortality according to the predicted risk of death. METHODS AND FINDINGS: A secondary analysis of the CRASH-2 trial (which originally evaluated the effect of tranexamic acid on mortality in trauma patients) was conducted. The trial included 20,127 trauma patients with significant bleeding from 274 hospitals in 40 countries. We evaluated the association of RBC transfusion with mortality in four strata of predicted risk of death: <6%, 6%-20%, 21%-50%, and >50%. For this analysis the exposure considered was RBC transfusion, and the main outcome was death from all causes at 28 days. A total of 10,227 patients (50.8%) received at least one transfusion. We found strong evidence that the association of transfusion with all-cause mortality varied according to the predicted risk of death (p-value for interaction <0.0001). Transfusion was associated with an increase in all-cause mortality among patients with <6% and 6%-20% predicted risk of death (odds ratio [OR] 5.40, 95% CI 4.08-7.13, p<0.0001, and OR 2.31, 95% CI 1.96-2.73, p<0.0001, respectively), but with a decrease in all-cause mortality in patients with >50% predicted risk of death (OR 0.59, 95% CI 0.47-0.74, p<0.0001). Transfusion was associated with an increase in fatal and non-fatal vascular events (OR 2.58, 95% CI 2.05-3.24, p<0.0001). The risk associated with RBC transfusion was significantly increased for all the predicted risk of death categories, but the relative increase was higher for those with the lowest (<6%) predicted risk of death (p-value for interaction <0.0001). As this was an observational study, the results could have been affected by different types of confounding. In addition, we could not consider haemoglobin in our analysis. In sensitivity analyses, excluding patients who died early; conducting propensity score analysis adjusting by use of platelets, fresh frozen plasma, and cryoprecipitate; and adjusting for country produced results that were similar. CONCLUSIONS: The association of transfusion with all-cause mortality appears to vary according to the predicted risk of death. Transfusion may reduce mortality in patients at high risk of death but increase mortality in those at low risk. The effect of transfusion in low-risk patients should be further tested in a randomised trial. TRIAL REGISTRATION: www.ClinicalTrials.gov NCT01746953.

Journal Article Type Article
Acceptance Date May 8, 2014
Online Publication Date Jun 17, 2014
Publication Date Jun 17, 2014
Journal PLoS Medicine
Print ISSN 1549-1277
Publisher Public Library of Science
Peer Reviewed Peer Reviewed
Volume 11
Issue 6
Article Number e1001664
DOI https://doi.org/10.1371/journal.pmed.1001664
Keywords adult, cause of death, erythrocyte transfusion, hemorrhage, humans, odds ratio, risk, risk assessment, tranexamic acid, wounds and injuries, young adult
Publisher URL http://dx.doi.org/10.1371/journal.pmed.1001664

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