Increasing hematocrit above 28% during early resuscitative phase is not associated with decreased mortality following severe traumatic brain injury

• Published in: Acta neurochirurgica Vol. 152; no. 4; pp. 627 - 636
• Main Authors: Flückiger, Carole, Béchir, Markus, Brenni, Mirko, Ludwig, Silke, Sommerfeld, Jutta, Cottini, Silvia R., Keel, Marius, Stocker, Reto, Stover, John F.
• Format: Journal Article
• Language: English
• Published: Vienna Springer Vienna 01-04-2010; Springer Nature B.V
• Subjects: Adult; Blood Pressure - physiology; Brain - blood supply; Brain Injuries - blood; Brain Injuries - mortality; Brain Injuries - surgery; Clinical Article; Craniotomy; Critical Care; Erythrocyte Transfusion; Female; Glasgow Coma Scale; Glasgow Outcome Scale; Hematocrit; Humans; Interventional Radiology; Intracranial Pressure - physiology; Length of Stay - statistics & numerical data; Male; Medicine; Medicine & Public Health; Minimally Invasive Surgery; Multiple Trauma - blood; Multiple Trauma - mortality; Multiple Trauma - surgery; Neurology; Neuroradiology; Neurosurgery; Plasma; Postoperative Complications - blood; Postoperative Complications - etiology; Postoperative Complications - mortality; Resuscitation; Retrospective Studies; Surgical Orthopedics; Survival Rate; Tomography, X-Ray Computed; Critical care; Emergency room; Secondary brain injury; Transfusion; Intracranial pressure
• ISSN: 0001-6268; 0942-0940
• DOI: 10.1007/s00701-009-0579-8

Background
To prevent iatrogenic damage, transfusions of red blood cells should be avoided. For this, specific and reliable transfusion triggers must be defined. To date, the optimal hematocrit during the initial operating room (OR) phase is still unclear in patients with severe traumatic brain injury (TBI). We hypothesized that hematocrit values exceeding 28%, the local hematocrit target reached by the end of the initial OR phase, resulted in more complications, increased mortality, and impaired recovery compared to patients in whom hematocrit levels did not exceed 28%.
Methods
Impact of hematocrit (independent variable) reached by the end of the OR phase on mortality and morbidity determined by the extended Glasgow outcome scale (eGOS; dependent variables) was investigated retrospectively in 139 TBI patients. In addition, multiple logistic regression analysis was performed to identify additional important variables.
Findings
Following severe TBI, mortality and morbidity were neither aggravated by hematocrit above 28% reached by the end of the OR phase nor worsened by the required transfusions. Upon multiple logistic regression analysis, eGOS was significantly influenced by the highest intracranial pressure and the lowest cerebral perfusion pressure values during the initial OR phase.
Conclusions
Based on this retrospective observational analysis, increasing hematocrit above 28% during the initial OR phase following severe TBI was not associated with improved or worsened outcome. This questions the need for aggressive transfusion management. Prospective analysis is required to determine the lowest acceptable hematocrit value during the OR phase which neither increases mortality nor impairs recovery. For this, a larger caseload and early monitoring of cerebral metabolism and oxygenation are indispensable.