The reports of my death are greatly exaggerated: An evaluation of futility cut points in massive transfusion

Transfusion quantities associated with 24-h mortality in trauma patients

INTRODUCTION

Data on the correlation between transfusion volumes and trauma mortality are limited. The association between the total number of red blood cell (RBC) and low titer group O whole blood (LTOWB) units, as well as the total volume of all transfused products that were administered up to 4-h after admission and 24-h mortality was determined.

METHODS

The Trauma Quality Improvement Program (TQIP) datasets from 2020 to 2022 were reviewed to identify patients aged ≥15 who received any volume of blood products. Receiver operating characteristic (ROC) were constructed along with the calculated area under the ROC curve (AUROC) to determine the association between the quantity of transfusion and 24-h mortality.

RESULTS

There were 144,379 encounters that met inclusion, with 22,467 patients who died within the first 24 h. There was a 90% probability of 24-h mortality following the transfusion of 56 RBC/LTOWB units (AUROC 0.673), with the 90% specificity, Youden's index, and 90% sensitivity surrounding this probability occurring after the transfusion of 8, 4, and 2 units, respectively. In terms of the volume of transfusion, there was a 90% probability of 24-h mortality following the transfusion of 36,000 mL of all blood products combined (AUROC 0.662), with the 90% specificity, Youden's index, and 90% sensitivity surrounding this probability occurring after the transfusion of 4400, 2000, and 500 mL, respectively.

CONCLUSIONS

Both the total number of RBC and LTOWB units transfused and the total volume of all blood products transfused demonstrated poor predictive association with the risk of 24-h mortality in the civilian trauma population.

Where does cryoprecipitate fit into balanced resuscitation? An evaluation of 2,117 hemorrhaging patients using viscoelastic-based resuscitation

BACKGROUND

Empiric cryoprecipitate administration has recently failed to show survival benefit in hemorrhaging trauma patients. However, a recent Trauma Quality Improvement Program query suggested a survival benefit in massive transfusions when administering 1 U of cryoprecipitate to every 7 to 8 U of red blood cells (RBCs). We describe transfusion ratios when cryoprecipitate was indicated by viscoelastic testing (VET) and evaluated whole blood (WB)'s impact on this ratio.

METHODS

Adult trauma patients admitted from July 2017 to December 2021 who received emergency-release blood products prehospital or in the emergency department were included. Patients who died within 60 minutes were excluded. Massive transfusion patients received arrival VET, which was repeated serially while on massive transfusion protocol. Cryoprecipitate transfusion was based on VET results. Blood product ratios were calculated for RBC, plasma, platelets, and cryoprecipitate in the first four and 24 hours of resuscitation. Each WB unit was counted as 1 RBC, 1 plasma, and 0.17 U of platelets. Outcomes were evaluated based on blood component ratios. Patients receiving WB were compared with patients who only received blood components.

RESULTS

A total of 2,117 patients were included. Overall, the median age was 37 (25, 55) years, 74% were male, 37% were white, and 67% sustained blunt trauma. Overall survival was 77%. The median 4-hour RBC/plasma/platelet/cryoprecipitate ratio was 9:9.5:1.3:1. Patients who received WB did not require cryoprecipitate until later in their resuscitation when compared with blood components (10:9.5:1.7:1 vs. 7:6:1:1, p = 0.008).

CONCLUSION

When using routine VET to guide resuscitation for hemorrhage, cryoprecipitate transfusion occurred later in patients receiving WB incorporated resuscitations compared with the component only strategy. For centers that do not use VET and use algorithmic resuscitation protocols, cryoprecipitate transfusion should be considered after 7 U of RBCs/plasma and after 10 U of a WB incorporated resuscitation.

LEVEL OF EVIDENCE

Retrospective Comparative Study Without Negative Criteria; Level III.

Impact of Massive Transfusion Activation on Time to Delivery of the First Cooler and Patient Survival: A Study of 4,313 Consecutive Activations

BACKGROUND

In 2012, TQIP guidelines for massive transfusion protocols (MTPs) recommended delivery of blood product coolers within 15 minutes. Subsequent work found that every minute delay in cooler arrival was associated with a 5% increased risk of mortality. We sought to assess the impact and sustainability of quality improvement (QI) interventions on time to MTP cooler delivery and their association with trauma patient survival.

STUDY DESIGN

In 2009, a QI process was initiated to improve MTP activation and delivery of blood (QI 1). In 2012, TQIP Best Practice Guidelines were implemented at our facility (QI 2). In 2016, we implemented measures to activate our MTP based off prehospital Assessment of Blood Consumption score higher than 1 or any prehospital blood transfusion (QI 3). All patients receiving MTP from January 2009 and December 2022 were included. Patients were compared by year and their respective QI interventions. Primary outcome was time from MTP activation to delivery of the first cooler. A regression model was then constructed to evaluate time to the first cooler on outcomes.

RESULTS

During the study period, 52,328 trauma patients were admitted, with 4,313 MTP trauma activations. With each subsequent QI intervention, time to first MTP cooler and mortality both decreased, whereas injury severity increased. Multivariate regression noted that when the time to first cooler could be kept to 8 minutes or less, mortality was reduced by 35% (odds ratio 0.64, 95% CI 0.44 to 0.92; p = 0.019).

CONCLUSIONS

With increased MTP activations, delivery of the first cooler was faster and mortality improved. Keeping cooler times under 8 minutes was associated with increased survival. The measurement and monitoring of "door-to-cooler" time should be considered as a metric to assess performance and delivery of institutional MTP.

Predictive Limitations of the Geriatric Trauma Outcome Score: A Retrospective Analysis of Mortality in Elderly Patients with Multiple Traumas and Severe Traumatic Brain Injury

Background/Objectives: The Geriatric Trauma Outcome Score (GTOS) is used to predict in-hospital mortality in geriatric patients with trauma. However, its applicability to elderly patients with multiple traumas and severe traumatic brain injury (TBI) remains poorly understood. This study aimed to evaluate the predictive accuracy of the GTOS in elderly patients with multiple traumas and TBI and assess its performance in patients with mild and severe TBI. Methods: We retrospectively analyzed 1283 geriatric multiple trauma patients (aged ≥ 65 years) treated at a regional trauma center from 2019 to 2023. Patients were stratified into mild (head Abbreviated Injury Scale [AIS] ≤ 3) and severe (head AIS ≥ 4) TBI groups. GTOS values were calculated for each patient, and predicted mortality was compared with in-hospital mortality. GTOS predictive accuracy was assessed by analyzing the receiver operating characteristic curve. Results: Patients had a median Injury Severity Score of 18 (interquartile range: 10-25); 33.3% of patients received red blood cell transfusions within 24 h. The overall in-hospital mortality rate was 17.9%; GTOS predicted a mortality rate of 17.6% ± 0.17. The GTOS accurately predicted the in-hospital mortality in the entire cohort, achieving an Area Under the Curve (AUC) of 0.798. Predictive accuracy diminished for patients with severe TBI (AUC = 0.657), underestimating actual mortality (39.5% vs. 28.8% predicted). Conclusions: While the GTOS remains a useful tool for predicting in-hospital mortality in elderly patients with multiple traumas, it consistently underestimates mortality risk in those with severe TBI. Therefore, applying the GTOS in this patient subgroup warrants careful consideration.

The inability to predict futility in hemorrhaging trauma patients using 4-hour transfusion volumes and rates

BACKGROUND

Blood shortages and utilization stewardship have motivated the trauma community to evaluate futility cutoffs during massive transfusions (MTs). Recent single-center studies have confirmed meaningful survival in ultra-MT (≥20 U) and super-MT (≥50 U), while others advocate for earlier futility cut points. We sought to evaluate whether transfusion volume and intensity cut points could predict 100% mortality in a multicenter analysis.

METHODS

A prospective, multicenter, observational cohort study was performed at seven trauma centers. Injured patients at risk for MT who required both blood transfusion and hemorrhage control procedures were enrolled. Four-hour volumes and intensities (average units per hour) were evaluated. Primary outcome of interest was 28-day mortality.

RESULTS

A total of 1,047 patients met the study inclusion with an overall mortality rate of 17% (n = 176). The median age was 35 years, 80% were male, and 62% had a penetrating mechanism, with an Injury Severity Score of 22. At 4 hours, transfusion volumes below 110 U and transfusion intensity averaging up to 21 U/h did not demonstrate futility. Total transfusion volume above 110 U was associated with 100% mortality (n = 9). Multivariable analysis noted only nonmodifiable risk factors as predictors of increased mortality (blunt mechanism, shock index).

CONCLUSION

In this study from seven Level 1 trauma centers, survival was observed at transfusion volumes up to 110 U and at transfusion velocities up to 21 U/h during the first 4 hours of resuscitation. Data are limited on transfusion volumes above 110 U in the first 4 hours. Survival can be observed in both the ultra and super-MT settings.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level II.

Fluid resuscitation in trauma: What you need to know

ABSTRACT

There have been numerous changes in resuscitation strategies for severely injured patients over the last several decades. Certain strategies, such as aggressive crystalloid resuscitation, have largely been abandoned because of the high incidence of complications and worsening of trauma-induced coagulopathy. Significant emphasis has been placed on restoring a normal coagulation profile with plasma or whole blood transfusion. In addition, the importance of the lethal consequences of trauma-induced coagulopathy, such as hyperfibrinolysis, has been easily recognized by the use of viscoelastic testing, and its treatment with tranexamic acid has been extensively studied. Furthermore, the critical role of early intravenous calcium administration, even before blood transfusion administration, has been emphasized. Other adjuncts, such as fibrinogen supplementation with fibrinogen concentrate or cryoprecipitate and prothrombin complex concentrate, are being studied and incorporated in some of the institutional massive transfusion protocols. Finally, balanced blood component transfusion (1:1:1 or 1:1:2) and whole blood have become commonplace in trauma centers in North America. This review provides a description of recent developments in resuscitation and a discussion of recent innovations and areas for future investigation.

Are trauma centers penalized for improved prehospital resuscitation?: The effect of prehospital transfusion on arrival vitals and predicted mortality

BACKGROUND

Prediction models for survival in trauma rely on arrival vital signs to generate survival probabilities. Hospitals are benchmarked on expected and observed outcomes. Prehospital blood (PB) transfusion has been shown to improve mortality, which may affect survival prediction modeling. We hypothesize that the use of PB increases the predicted survival derived from probability models compared with non-blood-based resuscitation.

METHODS

All adult trauma patients presenting to a level 1 trauma center requiring emergency release blood transfusion from January 2017 to December 2021 were reviewed. Patients were grouped into those receiving PB or those who did not (no PB). Prehospital Trauma and Injury Severity Score (TRISS) and shock index were compared with those at presentation to hospital. Univariate and multivariate regressions were performed to identify factors associated with changes in survival probability at presentation.

RESULTS

In total, 2117 patients were reviewed (PB, 1,011; no PB, 1,106). Patients receiving PB were younger (35 vs. 40 years, p < 0.001), more likely to have blunt mechanism (71% vs. 65%, p = 0.002), and more severely injured (Injury Severity Score, 27 vs. 25; p < 0.001) and had higher rates of prehospital hypotension (44% vs. 19%, p < 0.001) and shock index (1.10 vs. 0.87, p < 0.001). Upon arrival, PB patients had lower rates of ED hypotension (34% vs. 39%, p = 0.01), and significant improvements in arrival TRISS scores (+0.09 vs. -0.02, p < 0.001) and shock index (+0.10 vs. -0.07, p < 0.001) compared with prehospital. On multivariate analysis, PB was associated with a threefold increase in unexpected survivors (odds ratio, 3.28; 95% confidence interval, 2.23-4.60).

CONCLUSION

The use of PB was associated with improved probability of survival and an increase in unexpected survivors. Applying TRISS and shock index at hospital arrival does not account for en route hemostatic resuscitation, causing patients to arrive with improved vitals despite severity of injury. Caution should be used when implementing survival probability calculations using arrival vitals in centers with prehospital transfusion capability.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level IV.

Need for Blood Transfusion Volume Is Associated With Increased Mortality in Severe Traumatic Brain Injury

INTRODUCTION

Many patients suffering from isolated severe traumatic brain injury (sTBI) receive blood transfusion on hospital arrival due to hypotension. We hypothesized that increasing blood transfusions in isolated sTBI patients would be associated with an increase in mortality.

METHODS

We performed a trauma quality improvement program (TQIP) (2017-2019) and single-center (2013-2021) database review filtering for patients with isolated sTBI (Abbreviated Injury Scale head ≥3 and all other areas ≤2). Age, initial Glasgow Coma Score (GCS), Injury Severity Score (ISS), initial systolic blood pressure (SBP), mechanism (blunt/penetrating), packed red blood cells (pRBCs) and fresh frozen plasma (FFP) transfusion volume (units) within the first 4 h, FFP/pRBC ratio (4h), and in-hospital mortality were obtained from the TQIP Public User Files.

RESULTS

In the TQIP database, 9257 patients had isolated sTBI and received pRBC transfusion within the first 4 h. The mortality rate within this group was 47.3%. The increase in mortality associated with the first unit of pRBCs was 20%, then increasing approximately 4% per unit transfused to a maximum mortality of 74% for 11 or more units. When adjusted for age, initial GCS, ISS, initial SBP, and mechanism, pRBC volume (1.09 [1.08-1.10], FFP volume (1.08 [1.07-1.09]), and FFP/pRBC ratio (1.18 [1.08-1.28]) were associated with in-hospital mortality. Our single-center study yielded 138 patients with isolated sTBI who received pRBC transfusion. These patients experienced a 60.1% in-hospital mortality rate. Logistic regression corrected for age, initial GCS, ISS, initial SBP, and mechanism demonstrated no significant association between pRBC transfusion volume (1.14 [0.81-1.61]), FFP transfusion volume (1.29 [0.91-1.82]), or FFP/pRBC ratio (6.42 [0.25-164.89]) and in-hospital mortality.

CONCLUSIONS

Patients suffering from isolated sTBI have a higher rate of mortality with increasing amount of pRBC or FFP transfusion within the first 4 h of arrival.

Markers of Futile Resuscitation in Traumatic Hemorrhage: A Review of the Evidence and a Proposal for Futility Time-Outs during Massive Transfusion

The reduction in the blood supply following the 2019 coronavirus pandemic has been exacerbated by the increased use of balanced resuscitation with blood components including whole blood in urban trauma centers. This reduction of the blood supply has diminished the ability of blood banks to maintain a constant supply to meet the demands associated with periodic surges of urban trauma resuscitation. This scarcity has highlighted the need for increased vigilance through blood product stewardship, particularly among severely bleeding trauma patients (SBTPs). This stewardship can be enhanced by the identification of reliable clinical and laboratory parameters which accurately indicate when massive transfusion is futile. Consequently, there has been a recent attempt to develop scoring systems in the prehospital and emergency department settings which include clinical, laboratory, and physiologic parameters and blood products per hour transfused as predictors of futile resuscitation. Defining futility in SBTPs, however, remains unclear, and there is only nascent literature which defines those criteria which reliably predict futility in SBTPs. The purpose of this review is to provide a focused examination of the literature in order to define reliable parameters of futility in SBTPs. The knowledge of these reliable parameters of futility may help define a foundation for drawing conclusions which will provide a clear roadmap for traumatologists when confronted with SBTPs who are candidates for the declaration of futility. Therefore, we systematically reviewed the literature regarding the definition of futile resuscitation for patients with trauma-induced hemorrhagic shock, and we propose a concise roadmap for clinicians to help them use well-defined clinical, laboratory, and viscoelastic parameters which can define futility.

Traumatic Brain Injury as an Independent Predictor of Futility in the Early Resuscitation of Patients in Hemorrhagic Shock

This review explores the concept of futility timeouts and the use of traumatic brain injury (TBI) as an independent predictor of the futility of resuscitation efforts in severely bleeding trauma patients. The national blood supply shortage has been exacerbated by the lingering influence of the COVID-19 pandemic on the number of blood donors available, as well as by the adoption of balanced hemostatic resuscitation protocols (such as the increasing use of 1:1:1 packed red blood cells, plasma, and platelets) with and without early whole blood resuscitation. This has underscored the urgent need for reliable predictors of futile resuscitation (FR). As a result, clinical, radiologic, and laboratory bedside markers have emerged which can accurately predict FR in patients with severe trauma-induced hemorrhage, such as the Suspension of Transfusion and Other Procedures (STOP) criteria. However, the STOP criteria do not include markers for TBI severity or transfusion cut points despite these patients requiring large quantities of blood components in the STOP criteria validation cohort. Yet, guidelines for neuroprognosticating patients with TBI can require up to 72 h, which makes them less useful in the minutes and hours following initial presentation. We examine the impact of TBI on bleeding trauma patients, with a focus on those with coagulopathies associated with TBI. This review categorizes TBI into isolated TBI (iTBI), hemorrhagic isolated TBI (hiTBI), and polytraumatic TBI (ptTBI). Through an analysis of bedside parameters (such as the proposed STOP criteria), coagulation assays, markers for TBI severity, and transfusion cut points as markers of futilty, we suggest amendments to current guidelines and the development of more precise algorithms that incorporate prognostic indicators of severe TBI as an independent parameter for the early prediction of FR so as to optimize blood product allocation.

What's new in whole blood resuscitation? In the trauma bay and beyond

PURPOSE OF REVIEW

Transfusion therapy commonly supports patient care during life-threatening injury and critical illness. Herein we examine the recent resurgence of whole blood (WB) resuscitation for patients in hemorrhagic shock following trauma and other causes of severe bleeding.

RECENT FINDINGS

A growing body of literature supports the use of various forms of WB for hemostatic resuscitation in military and civilian trauma practice. Different types of WB include warm fresh whole blood (FWB) principally used in the military and low titer O cold stored whole blood (LTOWB) used in a variety of military and civilian settings. Incorporating WB initial resuscitation alongside subsequent component therapy reduces aggregate blood product utilization and improves early mortality without adversely impacting intensive care unit length of stay or infection rate. Applications outside the trauma bay include prehospital WB and use in patients with nontraumatic hemorrhagic shock.

SUMMARY

Whole blood may be transfused as FWB or LTOWB to support a hemostatic approach to hemorrhagic shock management. Although the bulk of WB resuscitation literature has appropriately focused on hemorrhagic shock following injury, extension to other etiologies of severe hemorrhage will benefit from focused inquiry to address cost, efficacy, approach, and patient-centered outcomes.

Massive transfusion in trauma

PURPOSE OF REVIEW

The purpose of this review is to provide an overview of currently recommended treatment approaches for traumatic hemorrhage shock, with a special focus on massive transfusion.

RECENT FINDINGS

Severe trauma patients require massive transfusion, but consensual international definitions for traumatic hemorrhage shock and massive transfusion are missing. Current literature defines a massive transfusion as transfusion of a minimum of 3-4 packed red blood cells within 1 h. Using standard laboratory and/or viscoelastic tests, earliest diagnosis and treatment should focus on trauma-induced coagulopathy and substitution of substantiated deficiencies.

SUMMARY

To initiate therapy immediately massive transfusion protocols are helpful focusing on early hemorrhage control using hemostatic dressing and tourniquets, correction of metabolic derangements to decrease coagulopathy and substitution according to viscoelastic assays and blood gases analysis with tranexamic acid, fibrinogen concentrate, red blood cells, plasma and platelets are recommended. Alternatively, the use of whole blood is possible. If needed, further support using prothrombin complex, factor XIII or desmopressin is suggested.

Microvesicles from stored red blood cells induce P-selectin and von Willebrand factor release from endothelial cells via a protein kinase C-dependent mechanism

INTRODUCTION

The use of packed red blood cells (pRBCs) for resuscitation is limited by the red blood cell storage lesion, a series of biochemical and physiological changes that occur during the storage and aging of blood. Microvesicles (MVs) shed from pRBCs during this process are one component of the red blood cell storage lesion and lead to acute lung injury and pulmonary vascular microthrombi. We hypothesized that MVs from stored pRBCs lead to the release of P-selectin and von Willebrand factor (vWF) from endothelial cells and that this mechanism is mediated via activation of protein kinase C (PKC) or protein kinase A (PKA).

METHODS

Leukoreduced, platelet-poor murine pRBCs were isolated from C57BL/6 8-12 week-old male mice via cardiac puncture, prepared via centrifugation using a Ficoll gradient, and stored for up to 14 days, the equivalent of 42 days of storage in humans. MVs were isolated from the stored pRBC units via sequential high-speed centrifugation. Murine lung endothelial cells (MLECs) were cultured and grown to confluence, then treated with MVs and either calphostin C, a PKC inhibitor (10 μg/mL), or PKI 14-22 amide, a PKA inhibitor (10 μM). The supernatant was collected after 1 h. P-selectin and vWF A2 concentrations were quantified via ELISA. Immunofluorescent staining for vWF was performed on MLECs. Statistical analysis was performed via unpaired t-test or ANOVA as indicated and reported as mean ± SD. Concentration is reported as pg/mL.

RESULTS

MLECs treated with MVs isolated from stored pRBCs demonstrated increased release of P-selectin and vWF A2 in a dose-dependent fashion. MLECs treated with MVs prepared from stored as compared to fresh pRBCs demonstrated increased release of P-selectin (3751 ± 726 vs 359 ± 64 pg/mL, p < 0.0001) and vWF A2 (3141 ± 355 vs 977 ± 75 pg/mL, p < 0.0001) with increasing duration of storage. The treatment of MVs with calphostin C decreased the amount of P-selectin (1471 ± 444 vs 3751 ± 726 pg/mL, p < 0.0001) and VWF A2 (2401 ± 289 vs 3141 ± 355 pg/mL, p = 0.0017) released into the supernatant by MLECs compared to MVs alone. The treatment of MVs with PKI 14-22 increased the amount of P-selectin released compared to MVs alone (1999 ± 67 vs 1601 ± 135 pg/mL, p = 0.0018).

CONCLUSIONS

MVs from stored pRBCs stimulate the release of P-selectin and VWF A2 from endothelial cells. The effect of MVs increases with both dose of MVs and age of stored pRBCs from which they are formed. This mechanism is dependent on activation of PKC and inhibition of this enzyme represents a potentially significant strategy to modulate the inflammatory response to resuscitation with stored pRBCs.

Resuscitation and Care in the Trauma Bay

Start balanced resuscitation early (pre-hospital if possible), either in the form of whole blood or 1:1:1 ratio. Minimize resuscitation with crystalloid to minimize patient morbidity and mortality. Trauma-induced coagulopathy can be largely avoided with the use of balanced resuscitation, permissive hypotension, and minimized time to hemostasis. Using protocolized "triggers" for massive and ultramassive transfusion will assist in minimizing delays in transfusion of products, achieving balanced ratios, and avoiding trauma induced coagulopathy. Once "audible" bleeding has been addressed, further blood product resuscitation and adjunct replacement should be guided by viscoelastic testing. Early transfusion of whole blood can reduce patient morbidity, mortality, decreases donor exposure, and reduces nursing logistics during transfusions. Adjuncts to resuscitation should be guided by laboratory testing and carefully developed, institution-specific guidelines. These include empiric calcium replacement, tranexamic acid (or other anti-fibrinolytics), and fibrinogen supplementation.

Use of Low-Titer O-Positive Whole Blood in Female Trauma Patients: A Literature Review, Qualitative Multidisciplinary Analysis of Risk/Benefit, and Guidelines for Its Use as a Universal Product in Hemorrhagic Shock

BACKGROUND

Whole blood transfusion is associated with benefits including improved survival, coagulopathy, and decreased transfusion requirements. The majority of whole blood transfusion is in the form of low-titer O-positive whole blood (LTOWB). Practice at many trauma centers withholds the use of LTOWB in women of childbearing potential due to concerns of alloimmunization. The purpose of this article is to review the evidence for LTOWB transfusion in female trauma patients and generate guidelines for its application.

STUDY DESIGN

Literature and evidence for LTOWB transfusion in hemorrhagic shock are reviewed. The rates of alloimmunization and subsequent obstetrical outcomes are compared to the reported outcomes of LTOWB vs other resuscitation media. Literature regarding patient experiences and preferences in regards to the risk of alloimmunization is compared to current trauma practices.

RESULTS

LTOWB has shown improved outcomes in both military and civilian settings. The overall risk of alloimmunization for Rhesus factor (Rh) - female patients in hemorrhagic shock exposed to Rh + blood is low (3% to 20%). Fetal outcomes in Rh-sensitized patients are excellent compared to historical standards, and treatment options continue to expand. The majority of female patients surveyed on the risk of alloimmunization favor receiving Rh + blood products to improve trauma outcomes. Obstetrical transfusion practices have incorporated LTOWB with excellent results.

CONCLUSIONS

The use of whole blood resuscitation in trauma is associated with benefits in the resuscitation of severely injured patients. The rate at which severely injured, Rh-negative patients develop anti-D antibodies is low. Treatments for alloimmunized pregnancies have advanced, with excellent results. Fears of alloimmunization in female patients are likely overstated and may not warrant the withholding of whole blood resuscitation. The benefits of whole blood resuscitation likely outweigh the risks of alloimmunization.

Transfusion futility thresholds and mortality in geriatric trauma: Does frailty matter?

BACKGROUND

Data on massive transfusion (MT) in geriatric trauma patients is lacking. This study aims to determine geriatric transfusion futility thresholds (TT) and TT variations based on frailty.

METHODS

Patients from 2013 to 2018 TQIP database receiving MT were stratified by age and frailty. TTs and outcomes were compared between geriatric and younger adults and among geriatric adults based on frailty status.

RESULTS

The TT was lower for geriatric than younger adults (34 vs 39 units; p ​= ​0.03). There was no difference in TT between the non-frail, frail, and severely frail geriatric adults (37, 30 and 25 units, respectively, p ​> ​0.05). Geriatric adults had higher mortality than younger adults (63.1% vs 45.8%, p < 0.01). Non-frail geriatric adults had the highest mortality (69.4% vs 56.5% vs 56.2%, p < 0.01).

CONCLUSIONS

Geriatric patients have a lower TT than younger adults, irrespective of frailty. This may help improve outcomes and optimize MT utilization.