The impact of hypothermia on outcomes in massively transfused patients

Erica Louise Walsh Lester, Erin E. Fox, John B. Holcomb, Karen Brasel, Eileen M. Bulger, Mitchell J. Cohen, Bryan A. Cotton, Timothy C. Fabian, Jeffery D. Kerby, Terrence O'Keefe, Sandro B. Rizoli, Thomas M. Scalea, Martin Schreiber, Kenji Inaba

Research output: Contribution to journalArticle

2 Citations (Scopus)

Abstract

BACKGROUND Hypothermia is associated with poor outcomes after injury. The relationship between hypothermia during contemporary large volume resuscitation and blood product consumption is unknown. We evaluated this association, and the predictive value of hypothermia on mortality. METHODS Patients predicted to receive massive transfusion at 12 level 1 trauma centers were randomized in the Pragmatic Randomized Optimal Platelet and Plasma Ratios (PROPPR) trial and were grouped into those who were hypothermic (<36°C) or normothermic (36-38.5°C) within the first 6 hours of emergency department arrival. The impact of hypothermia or normothermia on the volume of blood product required during the first 24 hours was determined via negative binomial regression, adjusting for treatment arm, injury severity score, mechanism, demographics, pre-emergency department fluid volume, blood administered before becoming hypothermic, pulse and systolic blood pressure on arrival, and the time exposed to hypothermic or normothermic temperatures. RESULTS Of 680 patients, 590 had a temperature measured during the first 6 hours in hospital, and 399 experienced hypothermia. The mean number of red blood cell (RBC) units given to all patients in the first 24 hours of admission was 8.8 (95% confidence interval [CI], 7.9-9.6). In multivariable analysis, every 1°C decrease in temperature below 36.0°C was associated with a 10% increase (incidence rate ratio, 0.90; 95% CI, 0.89-0.92; p < 0.00) in consumption of RBCs during the first 24 hours of admission. There was no association between RBC administration and a temperature above 36°C. Hypothermia on arrival was an independent predictor of mortality, with an adjusted odds ratio of 2.7 (95% CI, 1.7-4.5; p < 0.00) for 24-hour mortality and 1.8 (95% CI, 1.3-2.4; p < 0.00) for 30-day mortality. CONCLUSION Hypothermia is associated with increase in blood product consumption and mortality. These findings support the maintenance of normothermia in trauma patients and suggest that further investigation on the impact of cooling or rewarming during massive transfusion is warranted. LEVEL OF EVIDENCE Prognostic, level III.

Original languageEnglish (US)
Pages (from-to)458-463
Number of pages6
JournalJournal of Trauma and Acute Care Surgery
Volume86
Issue number3
DOIs
StatePublished - Mar 1 2019

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Hypothermia
Blood Volume
Mortality
Confidence Intervals
Temperature
Hospital Emergency Service
Arm Injuries
Erythrocytes
Blood Pressure
Rewarming
Injury Severity Score
Trauma Centers
Wounds and Injuries
Resuscitation
Blood Platelets
Odds Ratio
Maintenance
Demography
Incidence

Keywords

  • hemorrhage
  • Hypothermia
  • massive transfusion
  • normothermia
  • resuscitation

ASJC Scopus subject areas

  • Surgery
  • Critical Care and Intensive Care Medicine

Cite this

Lester, E. L. W., Fox, E. E., Holcomb, J. B., Brasel, K., Bulger, E. M., Cohen, M. J., ... Inaba, K. (2019). The impact of hypothermia on outcomes in massively transfused patients. Journal of Trauma and Acute Care Surgery, 86(3), 458-463. https://doi.org/10.1097/TA.0000000000002144

The impact of hypothermia on outcomes in massively transfused patients. / Lester, Erica Louise Walsh; Fox, Erin E.; Holcomb, John B.; Brasel, Karen; Bulger, Eileen M.; Cohen, Mitchell J.; Cotton, Bryan A.; Fabian, Timothy C.; Kerby, Jeffery D.; O'Keefe, Terrence; Rizoli, Sandro B.; Scalea, Thomas M.; Schreiber, Martin; Inaba, Kenji.

In: Journal of Trauma and Acute Care Surgery, Vol. 86, No. 3, 01.03.2019, p. 458-463.

Research output: Contribution to journalArticle

Lester, ELW, Fox, EE, Holcomb, JB, Brasel, K, Bulger, EM, Cohen, MJ, Cotton, BA, Fabian, TC, Kerby, JD, O'Keefe, T, Rizoli, SB, Scalea, TM, Schreiber, M & Inaba, K 2019, 'The impact of hypothermia on outcomes in massively transfused patients', Journal of Trauma and Acute Care Surgery, vol. 86, no. 3, pp. 458-463. https://doi.org/10.1097/TA.0000000000002144
Lester, Erica Louise Walsh ; Fox, Erin E. ; Holcomb, John B. ; Brasel, Karen ; Bulger, Eileen M. ; Cohen, Mitchell J. ; Cotton, Bryan A. ; Fabian, Timothy C. ; Kerby, Jeffery D. ; O'Keefe, Terrence ; Rizoli, Sandro B. ; Scalea, Thomas M. ; Schreiber, Martin ; Inaba, Kenji. / The impact of hypothermia on outcomes in massively transfused patients. In: Journal of Trauma and Acute Care Surgery. 2019 ; Vol. 86, No. 3. pp. 458-463.
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abstract = "BACKGROUND Hypothermia is associated with poor outcomes after injury. The relationship between hypothermia during contemporary large volume resuscitation and blood product consumption is unknown. We evaluated this association, and the predictive value of hypothermia on mortality. METHODS Patients predicted to receive massive transfusion at 12 level 1 trauma centers were randomized in the Pragmatic Randomized Optimal Platelet and Plasma Ratios (PROPPR) trial and were grouped into those who were hypothermic (<36°C) or normothermic (36-38.5°C) within the first 6 hours of emergency department arrival. The impact of hypothermia or normothermia on the volume of blood product required during the first 24 hours was determined via negative binomial regression, adjusting for treatment arm, injury severity score, mechanism, demographics, pre-emergency department fluid volume, blood administered before becoming hypothermic, pulse and systolic blood pressure on arrival, and the time exposed to hypothermic or normothermic temperatures. RESULTS Of 680 patients, 590 had a temperature measured during the first 6 hours in hospital, and 399 experienced hypothermia. The mean number of red blood cell (RBC) units given to all patients in the first 24 hours of admission was 8.8 (95{\%} confidence interval [CI], 7.9-9.6). In multivariable analysis, every 1°C decrease in temperature below 36.0°C was associated with a 10{\%} increase (incidence rate ratio, 0.90; 95{\%} CI, 0.89-0.92; p < 0.00) in consumption of RBCs during the first 24 hours of admission. There was no association between RBC administration and a temperature above 36°C. Hypothermia on arrival was an independent predictor of mortality, with an adjusted odds ratio of 2.7 (95{\%} CI, 1.7-4.5; p < 0.00) for 24-hour mortality and 1.8 (95{\%} CI, 1.3-2.4; p < 0.00) for 30-day mortality. CONCLUSION Hypothermia is associated with increase in blood product consumption and mortality. These findings support the maintenance of normothermia in trauma patients and suggest that further investigation on the impact of cooling or rewarming during massive transfusion is warranted. LEVEL OF EVIDENCE Prognostic, level III.",
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AU - Lester, Erica Louise Walsh

AU - Fox, Erin E.

AU - Holcomb, John B.

AU - Brasel, Karen

AU - Bulger, Eileen M.

AU - Cohen, Mitchell J.

AU - Cotton, Bryan A.

AU - Fabian, Timothy C.

AU - Kerby, Jeffery D.

AU - O'Keefe, Terrence

AU - Rizoli, Sandro B.

AU - Scalea, Thomas M.

AU - Schreiber, Martin

AU - Inaba, Kenji

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N2 - BACKGROUND Hypothermia is associated with poor outcomes after injury. The relationship between hypothermia during contemporary large volume resuscitation and blood product consumption is unknown. We evaluated this association, and the predictive value of hypothermia on mortality. METHODS Patients predicted to receive massive transfusion at 12 level 1 trauma centers were randomized in the Pragmatic Randomized Optimal Platelet and Plasma Ratios (PROPPR) trial and were grouped into those who were hypothermic (<36°C) or normothermic (36-38.5°C) within the first 6 hours of emergency department arrival. The impact of hypothermia or normothermia on the volume of blood product required during the first 24 hours was determined via negative binomial regression, adjusting for treatment arm, injury severity score, mechanism, demographics, pre-emergency department fluid volume, blood administered before becoming hypothermic, pulse and systolic blood pressure on arrival, and the time exposed to hypothermic or normothermic temperatures. RESULTS Of 680 patients, 590 had a temperature measured during the first 6 hours in hospital, and 399 experienced hypothermia. The mean number of red blood cell (RBC) units given to all patients in the first 24 hours of admission was 8.8 (95% confidence interval [CI], 7.9-9.6). In multivariable analysis, every 1°C decrease in temperature below 36.0°C was associated with a 10% increase (incidence rate ratio, 0.90; 95% CI, 0.89-0.92; p < 0.00) in consumption of RBCs during the first 24 hours of admission. There was no association between RBC administration and a temperature above 36°C. Hypothermia on arrival was an independent predictor of mortality, with an adjusted odds ratio of 2.7 (95% CI, 1.7-4.5; p < 0.00) for 24-hour mortality and 1.8 (95% CI, 1.3-2.4; p < 0.00) for 30-day mortality. CONCLUSION Hypothermia is associated with increase in blood product consumption and mortality. These findings support the maintenance of normothermia in trauma patients and suggest that further investigation on the impact of cooling or rewarming during massive transfusion is warranted. LEVEL OF EVIDENCE Prognostic, level III.

AB - BACKGROUND Hypothermia is associated with poor outcomes after injury. The relationship between hypothermia during contemporary large volume resuscitation and blood product consumption is unknown. We evaluated this association, and the predictive value of hypothermia on mortality. METHODS Patients predicted to receive massive transfusion at 12 level 1 trauma centers were randomized in the Pragmatic Randomized Optimal Platelet and Plasma Ratios (PROPPR) trial and were grouped into those who were hypothermic (<36°C) or normothermic (36-38.5°C) within the first 6 hours of emergency department arrival. The impact of hypothermia or normothermia on the volume of blood product required during the first 24 hours was determined via negative binomial regression, adjusting for treatment arm, injury severity score, mechanism, demographics, pre-emergency department fluid volume, blood administered before becoming hypothermic, pulse and systolic blood pressure on arrival, and the time exposed to hypothermic or normothermic temperatures. RESULTS Of 680 patients, 590 had a temperature measured during the first 6 hours in hospital, and 399 experienced hypothermia. The mean number of red blood cell (RBC) units given to all patients in the first 24 hours of admission was 8.8 (95% confidence interval [CI], 7.9-9.6). In multivariable analysis, every 1°C decrease in temperature below 36.0°C was associated with a 10% increase (incidence rate ratio, 0.90; 95% CI, 0.89-0.92; p < 0.00) in consumption of RBCs during the first 24 hours of admission. There was no association between RBC administration and a temperature above 36°C. Hypothermia on arrival was an independent predictor of mortality, with an adjusted odds ratio of 2.7 (95% CI, 1.7-4.5; p < 0.00) for 24-hour mortality and 1.8 (95% CI, 1.3-2.4; p < 0.00) for 30-day mortality. CONCLUSION Hypothermia is associated with increase in blood product consumption and mortality. These findings support the maintenance of normothermia in trauma patients and suggest that further investigation on the impact of cooling or rewarming during massive transfusion is warranted. LEVEL OF EVIDENCE Prognostic, level III.

KW - hemorrhage

KW - Hypothermia

KW - massive transfusion

KW - normothermia

KW - resuscitation

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