Low Titer Group O Whole Blood In Injured Children Requiring Massive Transfusion

Abstract

Objective: The aim of this study was to assess the survival impact of low-titer group O whole blood (LTOWB) in injured pediatric patients who require massive transfusion. Summary Background Data: Limited data are available regarding the effectiveness of LTOWB in pediatric trauma. Methods: A prospective observational study of children requiring massive transfusion after injury at UPMC Children’s Hospital of Pittsburgh, an urban academic pediatric Level 1 trauma center. Injured children ages 1 to 17 years who received a total of >40 mL/kg of LTOWB and/or conventional components over the 24 hours after admission were included. Patient characteristics, blood product utilization and clinical outcomes were analyzed using Kaplan-Meier survival curves, log rank tests and Cox proportional hazards regression analyses. The primary outcome was 28-day survival. Results: Of patients analyzed, 27 of 80 (33%) received LTOWB as part of their hemostatic resuscitation. The LTOWB group was comparable to the component therapy group on baseline demographic and physiologic parameters except older age, higher body weight, and lower red blood cell and plasma transfusion volumes. After adjusting for age, total blood product volume transfused in 24 hours, admission base deficit, international normalized ratio (INR), and injury severity score (ISS), children who received LTOWB as part of their resuscitation had significantly improved survival at both 72 hours and 28 days post-trauma [adjusted odds ratio (AOR) 0.23, P = 0.009 and AOR 0.41, P = 0.02, respectively]; 6-hour survival was not statistically significant (AOR = 0.51, P = 0.30). Survivors at 28 days in the LTOWB group had reduced hospital LOS, ICU LOS, and ventilator days compared to the CT group. Conclusion: Administration of LTOWB during the hemostatic resuscitation of injured children requiring massive transfusion was independently associated with improved 72-hour and 28-day survival.

Low titer Group O whole blood utilization in pediatric trauma resuscitation: A National Survey

“…27,33,47 There is a small, yet increasing number of studies that suggest there may be some benefits for pediatric LTOWB recipients, including faster resolution of shock, improved coagulation profile, and decreased transfusion volumes 32,33 In a single-center, retrospective study of 80 children requiring massive transfusion, receipt of LTOWB was associated with improved 72-hour and 28-day survival after adjusting for age, Injury Severity Score, total blood product volume transfused, admission base deficit, and admission INR in a Cox proportional hazard regression model (Adjusted Odds Ratio [AOR] 0.23, p = .009 and AOR 0.41, p = .02, respectively). 48 Larger cohorts, and ideally prospective, multi-center studies are necessary to confirm these findings and to Note: Note that responses from the 3 programs that are imminently implementing an LTOWB program are included along with the responses from established programs.…”

Pediatric traumatic hemorrhagic shock consensus conference recommendations

“…Using LTOWB instead of individual blood components in children more rapidly provides RBCs, plasma, and platelets to children with severe traumatic bleeding; more effectively resolves shock and coagulopathy 23 ; is associated with less total amount of blood products administered and mechanical ventilation days 24 ; and is independently associated with increased 72-hour (OR, 0.23; 95% CI, 0.08-0.70) and 28-day mortality (OR, 0.41; 95% CI, 0.23-0.98) in a single-center retrospective study. 8 Adult data indicate that the use of LTOWB compared with individual blood components is independently associated with improved 24-hour and 28-day survival and is also associated with less (40-60%) total blood products administered. [25][26][27] Data from studies performed on children and adults suggest no increased risk of hemolysis in non-group O recipients and no increase in any other adverse outcomes to include organ failure.…”

“…An stimated 1,000 to 2,000 preventable traumatic deaths in children per year after injury occur in the United States because of inadequate or delayed care 5 . Recent retrospective and prospective observational studies indicate that transfusion strategies (limiting crystalloid, appropriate transfusion ratios, and use of whole blood [WB]) and intravenous hemostatic adjunct therapies can reduce morbidity and mortality in children with traumatic hemorrhagic shock 6–9 . For this reason, hemostatic strategies represent a key target for standardization and subsequent investigation.…”

“…5 Recent retrospective and prospective observational studies indicate that transfusion strategies (limiting crystalloid, appropriate transfusion ratios, and use of whole blood [WB]) and intravenous hemostatic adjunct therapies can reduce morbidity and mortality in children with traumatic hemorrhagic shock. [6][7][8][9] For this reason, hemostatic strategies represent a key target for standardization and subsequent investigation. However, because of the lack of high-quality clinical trials to guide practice, hemostatic resuscitation strategies and the utilization of global assays of hemostasis for goal-directed therapy are highly variable across sites.…”

Preface: Pediatric traumatic hemorrhagic shock consensus conference

“…Mortality in children with traumatic hemorrhagic shock is between 36% and 50% based on recent studies 3,4 . Recent retrospective and prospective observational studies indicate that resuscitation practices (limiting crystalloid, appropriate blood product ratios, use of whole blood, and tranexamic acid use) can dramatically reduce morbidity and mortality in children with traumatic hemorrhagic shock 5–9 . Because of these alarming statistics, resuscitation and hemostatic strategies are a key target for standardization and subsequent investigation.…”