This very rigorous and interesting study investigates the common finding that severely bleeding trauma patients requiring massive transfusion (MT) often experience poor outcomes. The authors’ purpose was to determine the potential role of near infrared spectrometry derived tissue hemoglobin oxygen saturation (StO2) monitoring in early prediction of MT, and in the identification of those MT patients who will have poor outcomes.

Large epidemiological and physiological multivariable datasets on 383 patients were collected in 7 level one trauma centres in North America. The group used a definition of MT as transfusion volume >=10 units packed red blood cells in 24 hours of hospitalization. Multivariate logistic regression was used to develop prediction models.

114 (30%) required MT. MT progressed rapidly (40% exceeded MT threshold 2 hours after TC arrival, 80% after 6 hours). One third of MT patients died. Two thirds of deaths were due to early exsanguination and two thirds of early exsanguination patients died within 6 hours. One third of the early MT survivors developed multiple organ dysfunction syndrome.

MT could be predicted with standard, readily available clinical data within 30 minutes and 60 minutes of TC arrival (area under the receiver operating characteristic curve = 0.78 and 0.80). In patients who required MT, StO2 was the only consistent predictor of poor outcome (multiple organ dysfunction syndrome or death).

The authors concluded that MT progresses rapidly to significant morbidity and mortality despite level I TC care. They claim that patients who require MT can be predicted early, and persistent low StO2 identifies those MT patients destined to have poor outcome. This potentially allows the clinician to identify these patients at an early stage and initiate aggressive treatment.