Large volume transfusion with whole blood is safe compared with component therapy

Abstract

BACKGROUND Transfusion with uncrossmatched cold-stored low-titer group O-positive or -negative whole blood (WB) in civilian trauma has been investigated as an alternative to component therapy but only in limited volumes. To our knowledge, this is the first analysis of the safety and efficacy of large volume transfusion of patients with trauma with WB. METHODS This is a retrospective cohort analysis comparing trauma patients resuscitated with component therapy (COMP) versus component therapy plus WB. The COMP group was comprised of patients who presented from January 2017 through June 2018 and the WB group from patients who presented from July 2018 through January 2019 after WB became available. We included patients if they received 1 unit of WB or red blood cells (RBCs) within 24 hours of admission and had massive transfusion protocol activated. We used bivariate analysis to compare groups. For analysis, one unit of WB equaled 1 unit of RBCs, 1 unit of plasma, and 1/6 of a unit of platelets. RESULTS Forty-two patients received WB and 83 patients received COMP with similar baseline characteristics. Patients had a median age of 41 years (interquartile range [IQR], 28–61 years) and 73% were male. Thirty percent had penetrating injuries with a median Injury Severity Score of 29 (IQR, 17–38). The WB group received a median of 6.5 units (IQR, 3–11). The WB group received significantly more component-equivalent units but with a plasma/RBC ratio of 0.94:1 compared with 0.8:1 (p < 0.001). There were no differences in 24-hour mortality (COMP, 27% vs. WB, 29%, p = 0.8) or 30-day mortality (COMP, 46% vs. WB, 58% p = 0.2). There were no transfusion reactions. CONCLUSION Transfusion utilizing primarily WB in civilian trauma is feasible, even in large volumes. It appears to be a safe and effective addition to component therapy and may lead to a more balanced resuscitation but with more overall product used. LEVEL OF EVIDENCE Therapeutic study, Level IV.

Injured recipients of low‐titer group O whole blood have similar clinical outcomes compared to recipients of conventional component therapy: A single‐center, retrospective study

“…Initially, the data that were generated on the use of LTOWB surrounded implementation strategies in the pre‐hospital and in‐hospital phases of the resuscitation, 1–3 as well as data on the serological safety of transfusing LTOWB to non‐group‐O recipients 4–6 . As the use of LTOWB began to increase in the US and in other countries, 7–9 several studies have attempted to determine whether the use of LTOWB in trauma resuscitation resulted in a survival benefit compared with the transfusion of conventional components (CCT) using different study methodologies and have found conflicting results 10–15 . For example, in a single‐center analysis of 198 injured LTOWB patients who received a median of one unit either pre‐hospital or early in their in‐hospital course, 30‐day mortality was reduced in a multivariate logistic regression model compared to 152 conventional component recipients 11 .…”

“…A multivariate analysis performed on the American College of Surgeons Trauma Quality Improvement Program (TQIP) database during the calendar years of 2015 and 2016 also revealed that 24‐h and in‐hospital mortality was significantly reduced among the 280 patients who had received a median (IQR) of 1 (1–1) unit LTOWB compared to 8214 patients who received only component therapy 12 . Conversely, three other observational single‐center studies in which the LTOWB patients received a median (IQR) of 2 (1–3), 6.5 (3–11), and 2 (1–2) units of LTOWB, respectively, 13–15 did not demonstrate a mortality benefit compared to the patients who received CCT. A recent meta‐analysis of studies reporting 24‐h and 30‐day/in‐hospital survival among LTOWB recipients compared to those resuscitated with conventional components also did not find a survival advantage to the receipt of LTOWB 16 .…”

Whole blood for trauma patients: Outcomes at higher doses

“…In a third study, an analysis of a large national database found that trauma patients receiving a combination of WB plus component therapy had significantly reduced 24‐h and in‐hospital mortality compared with patients receiving component therapy alone 12 . In contrast, three other observational, single‐center studies with median WB doses of 2, 6.5, and 2 units did not show a decrease in mortality 13‐15 . Finally, a meta‐analysis of studies that measured 24‐h and 30‐day in‐hospital survival failed to demonstrate a survival advantage to patients treated with WB compared with CT 17 …”

“…There have been multiple studies comparing LTOWB to component therapy that have sought to demonstrate the potential benefits of LTOWB with varying results. These studies have used different methodologies and varying doses of WB 10‐15 . A 2020 review of WB studies concluded that there is substantial evidence that WB is safe and feasible, but it has not been shown to be superior to component therapy in any large or randomized studies 16 .…”

“…Initial reports of LTOWB in the civilian trauma setting allowed 2 units of LTOWB in the emergency department. Recent literature describes more robust volumes, with a median dose of 6.5 WB units per patient in one study 14 . However, it is important to consider that the Critical Administration Threshold (CAT) considers 3 or more units of PRBCs within an hour to identify patients at risk for massive transfusion and subsequent increased mortality 19 .…”