This may also delay administration of the appropriate strategy. Third, cutaneous lacerations and wounds may lead to larger blood loss from abundant and hyper-vascularized adipose tissue. Fourth, obese patients might be more likely to have severe or complex fractures, as found in our series Table 1. Fifth, many surgical procedures are challenging due to more difficult and prolonged intervention, poor visibility, requiring longer instruments and additional assistants [ 16 ]. Physiological disturbances can aggravate shock and increase the occurrence of multiple organ failure or trauma-induced coagulopathy.
It is thus interesting to note in our series that rate of hypotensive patients in obese group was higher than non-obese one Table 1. The TASH scoring system was built to predict MT using admission parameters such as mean occult shock, blood spoliation or specific bleeding injuries. This score was found to have the highest overall accuracy in comparison with other composite scoring systems established for predicting MT, with AUCs included between 0.
In the present study, the AUC found was slightly higher in our overall population 0. One explanation could be that, over the last 10 years, clinicians in our center have become accustomed to use the TASH score at admission to trigger aggressive transfusion [ 3 , 4 , 31 ]. The present series is the first study to assess and validate the performance of the TASH score in a specific population of obese patients.
Despite the difference in terms of transfusion requirements, the AUC for the obese patients in our analysis was comparable with the AUC for the non-obese patients 0. Similarly, observed probabilities of different values of the TASH score were comparable between the two groups Fig 3.
Our findings underscore that criteria of the TASH score remain strongly predictive of massive blood loss even in an obese population more at risk of MT and that the statistical performance of the TASH score is excellent in an obese trauma population. Previous series on the TASH score have already provided several statistical thresholds; the optimal threshold for Yucel et al.
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Statistical debate remains about the best criterion for classification accuracy [ 44 ]. Youden's index reflects mathematically the intention of maximizing the overall correct classification rates and thus minimizing misclassification rates, while the point on the ROC curve closest to 0,1 involves a quadratic term for which the clinical meaning is unknown.
A unique cutoff value does not allow the test results to simultaneously confirm and exclude diagnostic hypotheses, whereas the grey zone approach offers values that will either confirm or exclude it [ 46 ]. This approach is increasingly used in the medical literature [ 46 ]. In our analysis, the lower and upper thresholds delimiting the grey zone were 9 and 12, respectively.
When analyzing this grey zone according to obesity status, it can be seen that the boundary thresholds were nearly the same in obese and non-obese populations; 10—13 and 9—12, respectively Fig 4. The alternative method of bootstrapping Youden's index to determine the grey zone did not change these values Fig 5.
As a result of the grey zone determination, simple thresholds of the TASH score allow physicians to exclude or predict the MT risk with near certainty for most patients, whether obese or not. Below the high sensitive threshold i. Furthermore, the stratification of the TASH score into three categories using the grey zone in our analysis was significantly associated with increased hospital length of stay in both populations Fig 6. Therefore, bleeding risk must be considered really carefully in obese trauma patients.
For this purpose, TASH score has been proved to be a robust tool to early identify likelihood of massive blood loss and MT risk during initial assessment and to trigger as soon as possible administration of transfusion packs and coagulation factor concentrates.
Present study provides thus reliable and specific thresholds for clinical practice, which were comparable in obese and non-obese populations. In addition, our findings might suggest also that some risky strategies should be considered differently in the specific obese population; nonoperative management of high-risk abdominal injuries or early definitive stabilization of complex fractures could for example be associated with a higher bleeding in obese patients.
A specific adjustment of therapeutic strategy in these patients would be desirable. Studies assessing appropriate specific strategies for obese population could definitively answer to these questions. The following limitations should be considered when assessing the clinical relevance of our results. First, this was a retrospective study. Second, the criteria for initiating a transfusion in trauma patients were not standardized and left to the physician appreciation.
Getting a massive transfusion is different from needing a massive transfusion, and we cannot exclude an over transfusion in obese patients. However, TASH score was strongly predictive of MT in the specific obese population, with comparable thresholds with the non-obese population, which is an argument against over transfusion in these patients. However, the cohort of obese patients in the current study is very large in comparison with the existing literature and the CI of the AUC was narrow, showing a high predictive ability of MT with the TASH score.
Fourth, the prediction of the TASH score in the overall population was slightly higher than in previous studies. However, the difference was minimal and the potential bias induced appears low. In conclusion, obesity was associated with an increased risk of MT. For the first time, the TASH score was validated in obese patients and a grey zone was established for this predictive score, allowing the MT risk to be affirmed or rejected with accuracy.
Performed the experiments: PD OM. Browse Subject Areas? Click through the PLOS taxonomy to find articles in your field. Abstract Background Prediction of massive transfusion MT is challenging in management of trauma patients. Conclusions Obesity was associated with a higher rate of MT in trauma patients. Data Availability: All relevant data are within the paper. Funding: The authors have no support or funding to report. Introduction The early detection of patients at risk of massive transfusion MT is nowadays the main challenge of initial management of bleeding trauma patients.
Determination of TASH score The following variables needed to calculate the TASH score were collected [ 3 , 24 ]: systolic arterial blood pressure and heart rate on admission to the emergency department, hemoglobin and base deficit on admission samples, complex pelvic fracture defined as Tile B and C fractures , open or complex femur fracture.
Download: PPT. Outcome measurements The primary end point was the rate of MT, defined as the administration of 10 units of packed red blood cells within the 24 first hours or death due to hemorrhagic shock [ 19 ]. Table 2. Baseline population characteristics in obese and non-obese patients. Fig 2.
Rates of massive transfusion according to the level of obesity. Fig 4. Table 3. TASH score stratification and outcome According to the respective grey zones obtained by the standard approach, obese and non-obese populations were separated into three subgroups using the TASH score: low, intermediate and high risk. Fig 6. Discussion In this 5-year study performed on trauma patients, we found that obesity was significantly associated with MT needs, when considering trauma severity.
Conclusions In conclusion, obesity was associated with an increased risk of MT. References 1. Management of bleeding and coagulopathy following major trauma: an updated European guideline.
Crit Care. Damage control hematology: the impact of a trauma exsanguination protocol on survival and blood product utilization. J Trauma.
Critical care London, England. View Article Google Scholar 5. Global and regional mortality from causes of death for 20 age groups in and a systematic analysis for the Global Burden of Disease Study Obese trauma patients are at increased risk of early hypovolemic shock: a retrospective cohort analysis of 1, severely injured patients.
Impaired blood pressure recovery to hemorrhage in obese Zucker rats with orthopedic trauma. Modification of the beta-adrenoceptor stimulation pathway in Zucker obese and obese diabetic rat myocardium. Novembre ISBN : Y. Article Article Outline. Access to the text HTML. Access to the PDF text. Recommend this article. Subscribe Register Login. Your Name: optional. Your Email:.
Colleague's Email:. Separate multiple e-mails with a ;. Thought you might appreciate this item s I saw at Current Opinion in Anesthesiology. Send a copy to your email. Some error has occurred while processing your request. Please try after some time. Scherpereel, Philippe A. Continuous professional development for anaesthetists. Current Opinion in Anesthesiology12 6 , December