Transfusion in Traumatic Brain Injury

There are three primary blood products that are often transfused in traumatic brain injury: packed red blood cells (pRBCs), platelets, and plasma. For pRBCs, hemoglobin thresholds for transfusion in anemia should be set at 7 g/dl. Higher threshold is warranted only when the patient is clinically symptomatic. For platelets, transfusion thresholds should be at least 50,000/mm3 for patients without and 100,000/mm3 for patients with evidence of hemorrhage. Reversal of antiplatelet therapy with platelet transfusion is advisable only in patients with active bleeding. Tests for platelet function are helpful in determining an adequate platelet transfusion in these situations. Fresh frozen plasma transfusion for correction of warfarin-induced coagulopathy is also advisable in patients with active bleeding. If available, activated factor VII can be used in refractory cases. Prothrombin concentrate complexes are also another alternative in refractory situations. Transfusion goals for patients with evidence of hemorrhage should be an international normalization ratio of 1.3 or less. Prophylactic transfusion of plasma in severe traumatic brain injury without intracranial hemorrhage has not been demonstrated to improve outcome. In all situations of product transfusion, patients should be closely observed for signs of volume overload and the development of transfusion-related acute lung injury. The benefit of product transfusion should always be weighed against the risk of a transfusion-related complication.