Death by Decade: Establishing a Transfusion Ceiling for Futility in Massive Transfusion

Morris, Mackenzie C.; Niziolek, Grace M.; Baker, Jennifer E.; Huebner, Benjamin R.; Hanseman, Dennis J.; Makley, Amy T.; Pritts, Timothy A.; Goodman, Michael D.

doi:10.1016/j.jss.2020.03.004

Cited by 18 publications

(21 citation statements)

References 34 publications

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“…Finally, in this study we found that age ≥65 years and RBC transfusion volumes ≥50 units were associated with significantly higher rates of in‐hospital mortality. This is in line with clinical practice, as older patients likely had more comorbidities and less physiologic reserve to withstand the stress of surgery, while those who were transfused more RBC units represented a higher severity of injury or illness 38,39 . Interestingly, however, there was no association between nadir pH and in‐hospital mortality among patients ≥65 years old.…”

Section: Discussionsupporting

confidence: 65%

“…This is in line with clinical practice, as older patients likely had more comorbidities and less physiologic reserve to withstand the stress of surgery, while those who were transfused more RBC units represented a higher severity of injury or illness. 38,39 Interestingly, however, there was no association between nadir pH and in-hospital mortality among patients ≥65 years old. Potential explanations include that our study was underpowered to detect differences among this relatively small subgroup, or that mortality was so high in these older patients that laboratory values showed little or no relation to mortality.…”

Section: Discussionmentioning

confidence: 96%

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Assessing predictors of futility in patients receiving massive transfusions

Merkel

Dougherty

et al. 2021

Transfusion

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Background: Massive transfusions are associated with a high mortality rate, but there is little evidence indicating when such efforts are futile. The purpose of this study was to identify clinical variables that could be used as futility indicators in massively transfused patients. Methods: We retrospectively analyzed 138 adult surgical patients at our institution receiving a massive transfusion (2016)(2017)(2018)(2019). Peak lactate and nadir pH within 24 h of massive transfusion initiation, along with other clinical variables, were assessed as predictors of the primary outcome, in-hospital mortality. Results:The overall rate of in-hospital mortality among our patient population was 52.9% (n = 73). Increasing lactate and decreasing pH were associated with greater mortality among massively transfused patients. Mortality rates were~2-fold higher for patients in the highest lactate category (≥10.0 mmol/L: 25 of 37; 67.6%) compared to the lowest category (0.0-4.9 mmol/L: 17 of 48; 35.4%) (p = .005), and~2.5-fold higher for patients in the lowest pH category (<7.00: 8 of 9; 88.9%) compared to the highest category (≥7.40: 8 of 23; 34.7%) (p = .016). Increasing age was also associated with higher mortality (≥65 years: 24 of 33; 72.7%) when compared to younger patients (18-64 years: 49 of 105; 46.7%) (p = .010).Conclusions: Peak lactate ≥10.0 mmol/L, nadir pH <7.00, and age ≥65 years were significantly associated with higher rates of in-hospital mortality among massively transfused patients. Incorporating these clinical parameters into a futility index for massive transfusions will be useful in situations where blood products are scarce and/or mortality may be unavoidable.

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Section: Discussionsupporting

confidence: 65%

Section: Discussionmentioning

confidence: 96%

Assessing predictors of futility in patients receiving massive transfusions

Merkel

Dougherty

et al. 2021

Transfusion

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“…Studies that predate current balanced transfusion strategies are no longer relevant given the known benefits of a balanced transfusion. Recent work by Morris et al 20 revealed that although mortality increases with age, improved mortality is observed in all age groups that receive large-volume massive transfusion. However, a transfusion volume at which benefit ceased was not elucidated.…”

Section: Discussionmentioning

confidence: 99%

Cresting mortality: Defining a plateau in ongoing massive transfusion

Quintana¹,

Zebley²,

Vincent³

et al. 2022

J Trauma Acute Care Surg

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BACKGROUND:Blood-based balanced resuscitation is a standard of care in massively bleeding trauma patients. No data exist as to when this therapy no longer significantly affects mortality. We sought to determine if there is a threshold beyond which further massive transfusion will not affect in-hospital mortality. METHODS:The Trauma Quality Improvement database was queried for all adult patients registered between 2013 and 2017 who received at least one unit of blood (packed red blood cell) within 4 hours of arrival. In-hospital mortality was evaluated based on the total transfusion volume (TTV) at 4 hours and 24 hours in the overall cohort (OC) and in a balanced transfusion cohort, composed of patients who received transfusion at a ratio of 1:1 to 2:1 packed red blood cell to plasma. A bootstrapping method in combination with multivariable Poisson regression was used to find a cutoff after which additional transfusion no longer affected in-hospital mortality. Multivariable Poisson regression was used to control for age, sex, race, highest Abbreviated Injury Scale score in each body region, comorbidities, advanced directives limiting care, and the primary surgery performed for hemorrhage control. RESULTS:The OC consisted of 99,042 patients, of which 28,891 and 30,768 received a balanced transfusion during the first 4 hours and 24 hours, respectively. The mortality rate plateaued after a TTVof 40.5 units (95% confidence interval [CI], 40-41) in the OC at 4 hours and after a TTV of 52.8 units (95% CI, 52-53) at 24 hours following admission. In the balanced transfusion cohort, mortality plateaued at a TTV of 39 units (95% CI, 39-39) and 53 units (95% CI, 53-53) at 4 hours and 24 hours following admission, respectively. CONCLUSION:Transfusion thresholds exist beyond which ongoing transfusion is not associated with any clinically significant change in mortality. These TTVs can be used as markers for resuscitation timeouts to assess the plan of care moving forward.

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“…There are few studies examining blood transfusion volume as an indicator for futility in trauma patients receiving MT and UMT. 7,26,28,32,38,39 Dzik et al's 26 multicenter retrospective study of 1360 trauma, surgical, and medical patients who received UMT demonstrated that although transfusion volume was associated with an increase in mortality, it was the underlying diagnosis category that was more strongly associated with mortality. The trauma patient subgroup had the lowest survival rates of all the patients.…”

Section: Discussionmentioning

confidence: 99%

Narrative Review: Is There a Transfusion Cutoff Value After Which Nonsurvivability Is Inevitable in Trauma Patients Receiving Ultramassive Transfusion?

Kim

Casem

Baral

et al. 2023

Anesthesia &Amp; Analgesia

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The institution of massive transfusion protocols (MTPs) has improved the timely delivery of large quantities of blood products and improves patient outcomes. In recent years, the cost of blood products has increased, compounded by significant blood product shortages. There is practical need for identification of a transfusion volume in trauma patients that is associated with increased mortality, or a threshold after which additional transfusion is futile and associated with nonsurvivability. This transfusion threshold is often described in the setting of an ultramassive transfusion (UMT). There are few studies defining what constitutes amount or outcomes associated with such large volume transfusion. The purpose of this narrative review is to provide an analysis of existing literature examining the effects of UMT on outcomes including survival in adult trauma patients and to determine whether there is a threshold transfusion limit after which mortality is inevitable. Fourteen studies were included in this review. The data examining the utility of UMT in trauma are of poor quality, and with the variability inherent in trauma patients, and the surgeons caring for them, no universally accepted cutoff for transfusion exists. Not surprisingly, there is a trend toward increasing mortality with increasing transfusions. The decision to continue transfusing is multifactorial and must be individualized, taking into consideration patient characteristics, institution factors, blood bank supply, and most importantly, constant reevaluation of the need for ongoing transfusion rather than blind continuous transfusion until the heart stops.

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Death by Decade: Establishing a Transfusion Ceiling for Futility in Massive Transfusion

Cited by 18 publications

References 34 publications

Assessing predictors of futility in patients receiving massive transfusions

Assessing predictors of futility in patients receiving massive transfusions

Cresting mortality: Defining a plateau in ongoing massive transfusion

Narrative Review: Is There a Transfusion Cutoff Value After Which Nonsurvivability Is Inevitable in Trauma Patients Receiving Ultramassive Transfusion?

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