Safety and efficacy of low-titer O whole blood resuscitation in a civilian level I trauma center

DOES WHOLE BLOOD RESUSCITATION INCREASE RISK FOR VENOUS THROMBOEMBOLISM IN TRAUMA PATIENTS? A COMPARISON OF WHOLE BLOOD VERSUS COMPONENT THERAPY IN 3,468 PATIENTS

ABSTRACT

Background: Whole blood (WB) resuscitation has been shown to provide mortality benefit. However, the impact of whole blood transfusions on the risk of venous thromboembolism (VTE) remains unclear. We sought to compare the VTE risk in patients resuscitated with WB versus component therapy (COMP). Methods: Trauma patients aged 18 and older, admitted to two Level 1 trauma centers between 2016 and 2021, who received at least one unit of emergency-release blood products were identified. Clinical and transfusion data were collected. Patients that received any WB during resuscitation were compared to those who received only COMP therapy. The primary outcome was VTE incidence, defined as deep vein thrombosis and/or pulmonary embolism. Results: 3,468 patients met inclusion criteria (WB: 1,775, COMP: 1,693). WB patients were more likely to be male (82 vs. 68%), receive tranexamic acid (21 vs. 16%), and had higher Injury Severity Score (26 vs. 19; all P < 0.001). WB patients exhibited less hospital-free days (11 vs. 15), intensive care unit-free days (23 vs. 25), and 30-day survival (74 vs. 84; all P < 0.001). The WB group had lower VTE incidence (6 vs. 10%, P < 0.001). Logistic regression revealed WB was protective against VTE (OR 0.70, 95% CI 0.54-091, P = 0.009), while red blood cell transfusions and tranexamic acid (TXA) exposure increased VTE risk. Discussion: Using WB as part of resuscitation was associated with a 30% reduction in VTE, while TXA and red blood cell transfusion increased VTE risk. Further research is needed to evaluate VTE risk with empiric use of TXA in the setting of early WB transfusion capability.

Prehospital Whole Blood Administration Not Associated with Increased Transfusion Reactions: The Experience of a Metropolitan EMS Agency

OBJECTIVES

Low titer O+ whole blood (LTO+WB) has been shown to improve outcomes in trauma patients and use is increasingly common. Studies on prehospital use and efficacy have been published throughout the literature, but few of these fully address the risks of transfusion reactions and other side effects. The focus of this study is to look at prehospital LTO+WB transfusions in trauma patients and review for transfusion reactions.

METHODS

This was a retrospective review of consecutive trauma patients who received prehospital LTO+WB over a 4.5-year period. We used EMS agency transfusion records and institutional blood bank data from two urban level I trauma centers for records on blood transfusion reactions. Excluded from the study were patients declared dead on arrival to the hospital, patients transfused for non-traumatic complaints, patients for whom hospital records were unavailable, and any transfusion reaction that occurred more than 10 days after the prehospital transfusion. Descriptive statistics were used for data analysis.

RESULTS

Of 1126 prehospital transfusions 572 met inclusion criteria. There were 2 (0.35%) suspected transfusion reactions, none of which were determined to be hemolytic reactions. There was 1 febrile non-hemolytic reaction on hospital day 1 and there was 1 allergic reaction with hives and shortness of breath that occurred on hospital day 1.

CONCLUSIONS

Prehospital LTO+WB is safe to use and has a similar rate of transfusion reaction as when given in-hospital. Concerns about transfusion reactions caused by LTO+WB should not preclude its use prehospital. Regardless of the low incidence of transfusion reactions, prehospital personnel should be trained in their recognition and management. Limitations include retrospective study design and the inability to distinguish transfusion reactions from prehospital LTO+WB versus reaction to blood products transfused at the trauma center.

Evolution of whole blood trauma resuscitation in childbearing age females: practice patterns and trends

Background

The use of low titer group O whole blood (LTOWB) for resuscitation of patients with traumatic hemorrhage is becoming increasingly common. Practices regarding the administration of RhD-positive LTOWB to childbearing age females (CBAFs) vary between institutions due to concerns about RhD alloimmunization. This study examined practices related to LTOWB transfusion as they pertain to age and sex.

Methods

This was a secondary analysis of the Shock, Whole blood, and Assessment of TBI (traumatic brain injury) trial, a prospective, multicenter observational cohort study where outcomes following LTOWB transfusion were analyzed at seven level 1 trauma centers between 2018 and 2021, as well as a survey on transfusion practices at these centers conducted in 2023. The proportion of patients who received LTOWB or components was examined over the course of the study and grouped by age and sex, and the RhD group of injured CBAFs was documented.

Results

A total of 1046 patients were evaluated: 130 females aged <50 years (CBAFs), 77 females aged ≥50 years; 661 males aged <50 years, and 178 males aged ≥50 years. Among them, 26.2% of CBAFs received RhD-positive LTOWB, whereas 57.1%-66.3% of other sex/age groups received LTOWB. The proportion of CBAFs who received LTOWB increased significantly throughout the 4 years of this study. Except for older women in years 2 and 4, CBAFs were significantly less likely to receive LTOWB than all other groups for the study period and individual years. Among the 33 CBAFs who received LTOWB and for whom an RhD type was available, 4/33 (12.1%) were RhD-negative, while 9/95 (9.5%) CBAFs who received component therapy were RhD-negative. RhD blood product selection practices varied considerably between institutions.

Conclusions

Many institutions transfused LTOWB to CBAFs. Policies regarding RhD product selection varied. Of the total cohort, the proportion of RhD-negative CBAFs who received LTOWB increased over time but remained lower than all other groups.

Level of evidence

3.

Whole blood versus balanced resuscitation in massive hemorrhage: Six of one or half dozen of the other?

BACKGROUND

Whole blood (WB) resuscitation is increasingly used at trauma centers. Prior studies investigating outcomes in WB versus component-only (CO) resuscitation have been limited by small cohorts, low volumes of WB resuscitation, and unbalanced CO resuscitation. This study aimed to address these limitations using data from a high-volume Level I trauma center, which adopted a WB-first resuscitation paradigm in 2018. We hypothesized that the resuscitation method, WB or balanced CO, would have no impact on patient mortality.

METHODS

A single-center, retrospective cohort study of adults presenting as a trauma activation from July 2016 through July 2021 was performed. Receipt of three or more units of WB or packed red blood cells (RBC) within the first hour of resuscitation was required for inclusion. Patients were grouped into WB versus CO resuscitation and important clinical outcomes were compared. Mortality was evaluated with Kaplan-Meier analysis, log-rank testing, and multivariable Cox proportional hazards modeling.

RESULTS

There were 180 patients in the WB group and 170 patients in the CO group. Of the 180 WB patients, 110 (61%) received only WB during the first 24 hours. The WB group received a median of 5.0 units (interquartile range, 4.0-8.0) of WB and CO group received a median of 6.0 units (interquartile range, 4.0-11.8) of RBCs during the first 24 hours of resuscitation. In the CO group, median RBC/plasma and RBC/platelet ratios approximated 1:1:1. Groups were similar in clinicopathologic characteristics including age, Injury Severity Score, mechanism of injury, and requirement for hemorrhage control interventions (WB 55% vs. CO 59%, p = 0.60). Unadjusted survival was equivalent at 24 hours ( p = 0.52) and 30 days ( p = 0.70) between both groups on Kaplan-Meier analysis with log-rank testing. On multivariable Cox regression, WB resuscitation was not independently associated with improved survival after accounting for age, Injury Severity Score, mechanism of injury, and receipt of hemorrhage control procedure (hazard ratio, 0.85; 95% confidence interval, 0.61-1.19, p = 0.34).

CONCLUSION

Balanced CO resuscitation is associated with similar mortality outcomes to that of WB based resuscitation.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level IV.

The Efficacy of Low-Titer Group O Whole Blood Compared With Component Therapy in Civilian Trauma Patients: A Meta-Analysis

OBJECTIVES

To assess if transfusion with low-titer group O whole blood (LTOWB) is associated with improved early and/or late survival compared with component blood product therapy (CT) in bleeding trauma patients.

DATA SOURCES

A systematic search of PubMed, CINAHL, and Web of Science was performed from their inception through December 1, 2023. Key terms included injury, hemorrhage, bleeding, blood transfusion, and whole blood.

STUDY SELECTION

All studies comparing outcomes in injured civilian adults and children who received LTOWB versus CT were included.

DATA EXTRACTION

Data including author, publication year, sample size, total blood volumes, and clinical outcomes were extracted from each article and reported following the Meta-analysis Of Observational Studies in Epidemiology guidelines. Main outcomes were 24-hour (early) and combined 28-day, 30-day, and in-hospital (late) mortality rates between recipients of LTOWB versus CT, which were pooled using random-effects models.

DATA SYNTHESIS

Of 1297 studies reviewed, 24 were appropriate for analysis. Total subjects numbered 58,717 of whom 5,164 received LTOWB. Eleven studies included adults-only, seven included both adults and adolescents, and six only included children. The median (interquartile range) age for patients who received LTOWB and CT was 35 years (24-39) and 35.5 years (23-39), respectively. Overall, 14 studies reported early mortality and 22 studies reported late mortality. LTOWB was associated with improved 24-hour survival (risk ratios [RRs] [95% CI] = 1.07 [1.03-1.12]) and late (RR [95% CI] = 1.05 [1.01-1.09]) survival compared with component therapy. There was no evidence of small study bias and all studies were graded as a moderate level of bias.

CONCLUSIONS

These data suggest hemostatic resuscitation with LTOWB compared with CT improves early and late survival outcomes in bleeding civilian trauma patients. The majority of subjects were injured adults; multicenter randomized controlled studies in injured adults and children are underway to confirm these findings.

Damage Control Resuscitation in Traumatic Hemorrhage: It Is More Than Fixing the Holes and Filling the Tank

Damage control resuscitation is the foundation of hemorrhagic shock management and includes early administration of plasma, tranexamic acid, and limited crystalloid-containing products.

War at Sea: Burn Care Challenges-Past, Present and Future

Throughout history, seafarers have been exposed to potential thermal injuries during naval warfare; however, injury prevention, including advances in personal protective equipment, has saved lives. Thankfully, burn injuries have decreased over time, which has resulted in a significant clinical skills gap. Ships with only Role 1 (no surgical capability) assets have worse outcomes after burn injury compared to those with Role 2 (surgical capability) assets. To prepare for future burn care challenges during a war at sea, Military Medicine must re-learn the lessons of World War I and World War II. Burn injuries do not occur in isolation during war and are associated with concomitant traumatic injuries. To care for burn casualties at sea, there is an urgent need to increase the availability of whole blood and dried plasma, resuscitation fluids that were ubiquitous throughout the naval force during World War II for both hemorrhagic and burn shock resuscitation. Furthermore, those providing trauma care at sea require formal burn care training and skills sustainment experiences in the clinical management of Burn, Trauma, and Critical Care patients. While burn education, training, and experience must be improved, modern high-energy weapons systems and anti-ship ballistic missiles necessitate concurrent investments in prevention, countermeasures, and personal protective equipment to decrease the likelihood of burn injury and damage resulting from these attacks.

Time to Whole Blood Transfusion in Hemorrhaging Civilian Trauma Patients: There Is Always Room for Improvement

BACKGROUND

Whole blood (WB) is becoming the preferred product for the resuscitation of hemorrhaging trauma patients. However, there is a lack of data on the optimum timing of receiving WB. We aimed to assess the effect of time to WB transfusion on the outcomes of trauma patients.

STUDY DESIGN

The American College of Surgeons TQIP 2017 to 2019 database was analyzed. Adult trauma patients who received at least 1 unit of WB within the first 2 hours of admission were included. Patients were stratified by time to first unit of WB transfusion (first 30 minutes, second 30 minutes, and second hour). Primary outcomes were 24-hour and in-hospital mortality, adjusting for potential confounders.

RESULTS

A total of 1,952 patients were identified. Mean age and systolic blood pressure were 42 ± 18 years and 101 ± 35 mmHg, respectively. Median Injury Severity Score was 17 [10 to 26], and all groups had comparable injury severities (p = 0.27). Overall, 24-hour and in-hospital mortality rates were 14% and 19%, respectively. Transfusion of WB after 30 minutes was progressively associated with increased adjusted odds of 24-hour mortality (second 30 minutes: adjusted odds ratio [aOR] 2.07, p = 0.015; second hour: aOR 2.39, p = 0.010) and in-hospital mortality (second 30 minutes: aOR 1.79, p = 0.025; second hour: aOR 1.98, p = 0.018). On subanalysis of patients with an admission shock index >1, every 30-minute delay in WB transfusion was associated with higher odds of 24-hour (aOR 1.23, p = 0.019) and in-hospital (aOR 1.18, p = 0.033) mortality.

CONCLUSIONS

Every minute delay in WB transfusion is associated with a 2% increase in odds of 24-hour and in-hospital mortality among hemorrhaging trauma patients. WB should be readily available and easily accessible in the trauma bay for the early resuscitation of hemorrhaging patients.

Therapeutic Interventions and Outcomes in Civilian and Military Isolated Gunshot Wounds to the Head: A Department of Defense Trauma Registry and ACS TQIP-matched Study

OBJECTIVE

The purpose of this study was to compare therapeutic strategies and outcomes, following isolated gunshot wounds of the head, between military and civilian populations.

BACKGROUND

Recent military conflicts introduced new concepts in trauma care, including aggressive surgical intervention in severe head trauma.

METHODS

This was a cohort-matched study, using the civilian Trauma Quality Improvement Program (TQIP) database of the American College of Surgeons (ACS) and the Department of Defense Trauma Registry (DoDTR), during the period 2013 to 2016. Included in the study were patients with isolated gunshots to the head. Exclusion criteria were dead on arrival, civilians transferred from other hospitals, and patients with major extracranial associated injuries (body area Abbreviated Injury Scale >3). Patients in the military database were propensity score-matched 1:3 with patients in the civilian database.

RESULTS

A total of 136 patients in the DoDTR database were matched for age, sex, year of injury, and head Abbreviated Injury Scale with 408 patients from TQIP. Utilization of blood products was significantly higher in the military population ( P <0.001). In the military group, patients were significantly more likely to have intracranial pressure monitoring (17% vs 6%, P <0.001) and more likely to undergo craniotomy or craniectomy (34% vs 13%, P <0.001) than in the civilian group. Mortality in the military population was significantly lower (27% vs 38%, P =0.013).

CONCLUSIONS

Military patients are more likely to receive blood products, have intracranial pressure monitoring and undergo craniectomy or craniotomy than their civilian counterparts after isolated head gunshot wounds. Mortality is significantly lower in the military population.

LEVEL OF EVIDENCE

Level III-therapeutic.

Transfusion management in the trauma patient

PURPOSE OF REVIEW

Transfusion of blood products is lifesaving in the trauma ICU. Intensivists must be familiar with contemporary literature to develop the optimal transfusion strategy for each patient.

RECENT FINDINGS

A balanced ratio of red-blood cells to plasma and platelets is associated with improved mortality and has therefore become the standard of care for resuscitation. There is a dose-dependent relationship between units of product transfused and infections. Liquid and freeze-dried plasma are alternatives to fresh frozen plasma that can be administered immediately and may improve coagulation parameters more rapidly, though higher quality research is needed. Trauma induced coagulopathy can occur despite a balanced transfusion, and administration of prothrombin complex concentrate and cryoprecipitate may have a role in preventing this. In addition to balanced ratios, viscoelastic guidance is being increasingly utilized to individualize component transfusion. Alternatively, whole blood can be used, which has become the standard in military practice and is gaining popularity at civilian centers.

SUMMARY

Hemorrhagic shock is the leading cause of death in trauma. Improved resuscitation strategy has been one of the most important contemporary advancements in trauma care and continues to be a key area of clinical research.

The Role of Whole Blood Transfusions in Civilian Trauma: A Review of Literature in Military and Civilian Trauma

Resuscitation techniques for the management of adult trauma patients have evolved over the 20th century. Whole blood transfusions were previously used as the standard of care, whereas blood component therapy is the current method employed across most trauma centers across the United States. Prior to the transition, no studies were conducted to show improved efficacy of hemostatic potential in trauma patients. Recent conflicts in Iraq and Afghanistan have challenged the dogma that whole blood transfusions are not the standard of care and have shown potential as the superior transfusion product for adult trauma patients. The purpose of this review is to provide a comprehensive review and elucidate if whole blood transfusions have a role in civilian trauma patients based upon recent military medical literature and civilian pilot studies using whole blood transfusions.

The Pathophysiology and Management of Hemorrhagic Shock in the Polytrauma Patient

The recognition and management of life-threatening hemorrhage in the polytrauma patient poses several challenges to prehospital rescue personnel and hospital providers. First, identification of acute blood loss and the magnitude of lost volume after torso injury may not be readily apparent in the field. Because of the expression of highly effective physiological mechanisms that compensate for a sudden decrease in circulatory volume, a polytrauma patient with a significant blood loss may appear normal during examination by first responders. Consequently, for every polytrauma victim with a significant mechanism of injury we assume substantial blood loss has occurred and life-threatening hemorrhage is progressing until we can prove the contrary. Second, a decision to begin damage control resuscitation (DCR), a costly, highly complex, and potentially dangerous intervention must often be reached with little time and without sufficient clinical information about the intended recipient. Whether to begin DCR in the prehospital phase remains controversial. Furthermore, DCR executed imperfectly has the potential to worsen serious derangements including acidosis, coagulopathy, and profound homeostatic imbalances that DCR is designed to correct. Additionally, transfusion of large amounts of homologous blood during DCR potentially disrupts immune and inflammatory systems, which may induce severe systemic autoinflammatory disease in the aftermath of DCR. Third, controversy remains over the composition of components that are transfused during DCR. For practical reasons, unmatched liquid plasma or freeze-dried plasma is transfused now more commonly than ABO-matched fresh frozen plasma. Low-titer type O whole blood may prove safer than red cell components, although maintaining an inventory of whole blood for possible massive transfusion during DCR creates significant challenges for blood banks. Lastly, as the primary principle of management of life-threatening hemorrhage is surgical or angiographic control of bleeding, DCR must not eclipse these definitive interventions.