An assessment of the safety, hemostatic efficacy, and clinical impact of low-titer group O whole blood in children and adolescents

A prehospital protocol for transfusion of low-titer O-positive whole blood in patients with hemorrhagic shock in Los Angeles County: Modeling the risk of hemolytic disease of the fetus and newborn

BACKGROUND

The Los Angeles Development and Rapid Operationalization of Prehospital Blood (LA-DROP) pilot will protocolize prehospital administration of low titer O-positive whole blood (LTO + WB) to patients with hemorrhagic shock in Los Angeles County (LAC). We sought to quantify the risk of death from hemolytic disease of the fetus and newborn (HDFN) associated with RhD-negative alloimmunization in females of childbearing potential (FCPs) as a result of LA-DROP.

STUDY DESIGN AND METHODS

Retrospective data from LAC EMS databases were used in combination with estimates from published literature to assign probability distributions to each event in the sequence required for a transfusion of LTO + WB to result in a death from HDFN. Markov chain Monte Carlo simulation was used to derive risk estimates.

RESULTS

We estimated that the proposed prehospital transfusion strategy would result on average in one death from HDFN for every 10,000 transfusions in the overall population (95% confidence interval [CI] 6000-25,000) and for every 1800 transfusions in FCPs (95% CI 1000-4300). Based on the projected annual volume of transfusions under LA-DROP, this would result in one death due to HDFN approximately every 26 years (95% CI 15-64).

DISCUSSION

The estimated per-transfusion risk of HDFN is similar to previously published work from other populations. The estimated frequency of deaths from HDFN associated with LA-DROP is lower than some previously published calculations, likely because of narrower eligibility criteria for transfusion.

Neonatal trauma resuscitation: Successful use of low-titer O+ whole blood in a 4-day-old infant with hemorrhagic shock

BACKGROUND

Neonatal trauma resuscitation is particularly challenging in cases of profound hemorrhagic shock. Low-titer group O+ whole blood (LTOWB+) has emerged as a potentially effective option in pediatric trauma, but its use in neonates is debated due to risks such as D-alloimmunization. In life-threatening emergencies, decisions must carefully balance immediate survival benefits against long-term risks.

STUDY DESIGN AND METHODS

We present a case report of a 4-day-old neonate transported as a Level 1 trauma following a dog attack to the head, resulting in hemorrhagic shock and cardiac arrest. Upon arrival to the trauma bay, the patient was pulseless, with unsuccessful intraosseous and intravenous vascular access attempts. Access was eventually achieved using an umbilical venous catheter, enabling administration of LTOWB+.

RESULTS

Administration of LTOWB+ resulted in the return of spontaneous circulation, improved perfusion, and hemodynamic stabilization. The patient remained alive at the 6-month follow-up. LTOWB+ facilitated rapid correction of hemorrhagic shock with no immediate complications observed.

DISCUSSION

This case underscores the challenges of neonatal trauma resuscitation, including vascular access and the use of LTOWB+. LTOWB+ proved lifesaving, enabling rapid correction of acidosis and an improved outcome. Although concerns persist regarding LTOWB+ administration, the immediate survival benefits outweigh the risks, supported by evidence demonstrating its efficacy and safety. This case highlights the need for adaptability and a systematic approach to managing complex neonatal trauma scenarios. We argue that LTOWB+ is poised to become a pillar of pediatric resuscitation, providing a lifesaving, efficient, and safe option even in the newborn.

Blood transfusion strategies for major bleeding in trauma

BACKGROUND

Trauma is a leading cause of morbidity and mortality worldwide. Research shows that haemorrhage and trauma-induced coagulopathy are reversible components of traumatic injury, if identified and treated early. Lack of consensus on definitions and transfusion strategies hinders the translation of this evidence into clinical practice.

OBJECTIVES

To assess the beneficial and harmful effects of transfusion strategies started within 24 hours of traumatic injury in adults (aged 16 years and over) with major bleeding.

SEARCH METHODS

CENTRAL, MEDLINE, Embase, five other databases, and three trial registers were searched on 20 November 2023. We also checked reference lists of included studies to identify any additional studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) of adults (aged 16 years and over) receiving blood products for the management of bleeding within 24 hours of traumatic injury.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methodology to perform the review and assessed the certainty of the evidence using GRADE.

MAIN RESULTS

We included 18 RCTs with 5041 participants. Comparison 1: Prehospital transfusion strategies Five studies compared use of plasma (fresh frozen plasma (FFP) or lyophilised plasma) versus 'standard of care'. We are uncertain of the effect of plasma on all-cause mortality at 24 hours (risk ratio (RR) 1.05, 95% confidence interval (CI), 0.48 to 2.30; 3 studies, 279 participants; very low certainty evidence). There is probably no difference between plasma and standard of care in all-cause mortality at 30 days (RR 0.95, 95% CI 0.78 to 1.17; 3 studies, 664 participants; moderate-certainty evidence). However, the results of one cluster-RCT that could not be included in our meta-analysis suggested that plasma may be associated with a lower risk of death at 30 days (RR 0.54, 95% CI 0.42 to 0.70; 1 study, 481 participants; low-certainty evidence). There may be no difference between plasma and standard of care in the total number of thromboembolic events in 30 days (RR 1.23, 95% CI 0.67 to.2.27; 4 studies, 586 participants; low-certainty evidence). Comparison 2: In-hospital transfusion strategies Ten studies evaluated this comparison, seven providing usable data. The studies evaluated cryoprecitate (three studies); fixed-ratio blood component transfusion (three studies); fresh frozen plasma (FFP) (one study); lyophilised plasma (one study); leucoreduced red blood cells (one study); and a restrictive transfusion strategy (one study). All-cause mortality at 24 hours For all-cause mortality at 24 hours, there is probably no difference between: • cryoprecipitate plus a major haemorrhage protocol (MHP) versus MHP alone (RR 0.92, 95% CI 0.70 to 1.21; 1 study, 1577 participants; moderate-certainty evidence); and • blood products (plasma:platelets:red blood cells (RBCs)) transfused in 1:1:1 ratio versus 1:1:2 ratio (RR 0.75, 95% CI 0.52 to 1.08; 1 study, 680 participants; moderate-certainty evidence). We are uncertain of the effect on all-cause mortality at 24 hours for: • blood products (RBCs:FFP) transfused in 1:1 ratio versus transfusion according to coagulation and full blood count results (Peto odds ratio (POR) 0.45, 0.17 to 1.22; 1 study, 434 participants; very low certainty evidence); and • lyophilised (FlyP) plasma versus FFP (POR 1.04, 95% CI 0.06 to 17.23; 1 study, 47 participants; very low certainty evidence); All-cause mortality at 30 days For all-cause mortality at 30 days, there is probably no difference between blood products (plasma:platelets:RBCs) transfused in a 1:1:1 ratio versus a 1:1:2 ratio (RR 0.85, 95% CI 0.65 to 1.11; 1 study, 680 participants; moderate-certainty evidence). There may be little to no difference between the following interventions in all-cause mortality at 30 days: • cryoprecipitate plus MHP versus MHP alone (RR 0.77, 95% CI 0.33 to 1.78; 2 studies, 1572 participants; low-certainty evidence); and •leucoreduced RBCs versus standard RBCs (RR 1.20, 95% CI 0.74 to 1.95; 1 study,55 participants; low certainty evidence). We are uncertain of the effect on all-cause mortality at 30 days for: •lyophilised plasma versus FFP (RR 0.75, 95% CI 0.28 to 2.02; 1 study, 47 participants; very low certainty evidence); and • blood products (plasma:platelets:RBCs) transfused in 1:1:1 ratio versus standard MHP (RR 2.25, 95% CI 0.90 to 5.62; 1 study, 69 participants; very low certainty evidence). Total number of thromboembolic events at 30 days There may be little to no difference between the following interventions for total thromboembolic events at 30 days: • cryoprecipitate plus MHP versus MHP alone (RR 0.55, 95% CI 0.08 to 3.72; 2 studies, 1645 participants; low-certainty evidence); and • blood products (plasma:platelets:RBCs) transfused in 1:1:1 ratio versus 1:1:2 ratio (RR 1.03, 95% CI 0.75 to 1.42; 1 study, 680 participants; low-certainty evidence). We are uncertain of the effect on the total number of thromboembolic events at 30 days for: •blood products (plasma:platelets:RBCs) transfused in 1:1:1 ratio versus standard MHP (POR 6.83, 95% CI 0.68 to 68.35; 1 study, 69 participants; very low certainty evidence). Comparison 3: Whole blood versus individual blood products We are uncertain of the effect of modified (leucoreduced) whole blood versus blood products (RBCs:plasma) transfused in a 1:1 ratio on all-cause mortality at 24 hours (RR 1.13, 95% CI 0.37 to 3.49) or 30 days (RR 1.62, 95% CI 0.69 to 3.80) (1 study, 107 participants; very low certainty evidence). Comparison 4: Goal-directed blood transfusion strategy of viscoelastic haemostatic assay (VHA) versus conventional laboratory coagulation tests (CCT) to guide haemostatic therapy There may be little or no difference in all-cause mortality at 24 hours between VHA and CCT (RR 0.85, 95% CI 0.54 to 1.35; 1 study, 396 participants; low-certainty evidence). We are uncertain of the effects on all-cause mortality at 30 days (RR 0.75, 95% CI 0.48 to 1.17; 2 studies, 506 participants; very low certainty evidence). There is probably no difference between VHA and CCT in total thromboembolic events at 30 days (RR 0.65, 95% CI 0.35 to 1.18; 1 study 396 participants; moderate-certainty evidence).

AUTHORS' CONCLUSIONS

Overall, there was little to no evidence of a difference between blood transfusion strategies for mortality or thromboembolic events. The studies covered a wide range of interventions, and the comparators and standard of care practice varied between trials, thereby limiting the pooling of data. Further research is needed.

Whole blood to total transfusion volume ratio in injured children: A national database analysis

BACKGROUND

Whole blood (WB) resuscitation is increasingly common in adult trauma centers and some pediatric trauma centers, as studies have noted its safety and potential superiority to component therapy (CT). Previous analyses have evaluated WB as a binary variable (any versus none), and little is known regarding the "dose response" of WB in relation to total transfusion volume (TTV) (WB/TTV ratio).

METHODS

Injured children younger than 18 years who received any blood transfusion within 4 hours of hospital arrival across 456 US trauma centers were included from the American College of Surgeons Trauma Quality Improvement Program database. The primary outcome was 24-hour mortality, and the secondary outcome was 4-hour mortality. Multivariate analysis was used to evaluate associations between WB administration and mortality and WB/TTV ratio and mortality.

RESULTS

Of 4,323 pediatric patients included in final analysis, 88% (3,786) received CT only, and 12% (537) received WB with or without CT. Compared with the CT group, WB recipients were more likely to be in shock, according to pediatric age-adjusted shock index (71% vs. 60%) and had higher median (interquartile range) Injury Severity Score (26 [17-35] vs. 25 [16-24], p = 0.007). Any WB transfusion was associated with 42% decreased odds of mortality at 4 hours (adjusted odds ratio [aOR], 0.58 [95% confidence interval, 0.35-0.97]; p = 0.038) and 54% decreased odds of mortality at 24 hours (aOR, 0.46 [0.33-0.66]; p < 0.001). Each 10% increase in WB/TTV ratio was associated with a 9% decrease in 24-hour mortality (aOR, 0.91 [0.85-0.97]; p = 0.006). Subgroup analyses for age younger than 14 years and receipt of massive transfusion (>40 mL/kg) also showed statistically significant survival benefit for 24-hour mortality.

CONCLUSION

In this retrospective American College of Surgeons Trauma Quality Improvement Program analysis, use of WB was independently associated with reduced 24-hour mortality in children; further, higher proportions of WB used over the total resuscitation (WB/TTV ratio) were associated with a stepwise increase in survival.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level III.

Whole blood: Total blood product ratio impacts survival in injured children

BACKGROUND

Some studies in both children and adults have shown a mortality benefit for the use of low titer group O whole blood (LTOWB) compared with component therapy for traumatic resuscitation. Although LTOWB is not widely available at pediatric trauma centers, its use is increasing. We hypothesized that in children who received whole blood after injury, the proportion of whole blood in relation to the total blood product resuscitation volume would impact survival.

METHODS

The trauma database from a single academic pediatric Level I trauma center was queried for pediatric (age <18 years) recipients of LTOWB after injury (years 2015-2022). Weight-based blood product (LTOWB, red blood cells, plasma, and platelet) transfusion volumes during the first 24 hours of admission were recorded. The ratio of LTOWB to total transfusion volume was calculated. The primary outcome was in-hospital mortality. Multivariable logistic regression model adjusted for the following variables: age, sex, mechanism of injury, Injury Severity Score, shock index, and Glasgow Coma Scale score. Adjusted odds ratio representing the change in the odds of mortality by a 10% increase in the LTOWB/total transfusion volume ratio was reported.

RESULTS

There were 95 pediatric LTOWB recipients included in the analysis, with median (interquartile range [IQR]) age of 10 years (5-14 years), 58% male, median (IQR) Injury Severity Score of 26 (17-35), 25% penetrating mechanism. The median (IQR) volume of LTOWB transfused was 17 mL/kg (15-35 mL/kg). Low titer group O whole blood comprised a median (IQR) of 59% (33-100%) of the total blood product resuscitation. Among patients who received LTOWB, there was a 38% decrease in in-hospital mortality for each 10% increase in the proportion of WB within total transfusion volume ( p < 0.001) after adjusting for age, sex, mechanism of injury, Injury Severity Score, shock index, and Glasgow Coma Scale score.

CONCLUSION

Increased proportions of LTOWB within the total blood product resuscitation was independently associated with survival in injured children. Based on existing data that suggests safety and improved outcomes with whole blood, consideration may be given to increasing the use of LTOWB over CT resuscitation in pediatric trauma resuscitation.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level III.

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.

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.

Survey of policies at US hospitals on the selection of RhD type of low-titer O whole blood for use in trauma resuscitation

BACKGROUND

Low-titer group O whole blood (LTOWB) use is increasing due to data suggesting improved outcomes and safety. One barrier to use is low availability of RhD-negative LTOWB. This survey examined US hospital policies regarding the selection of RhD type of blood products in bleeding emergencies.

STUDY DESIGN AND METHODS

A web-based survey of blood bank directors was conducted to determine their hospital's RhD-type selection policies for blood issued for massive bleeding.

RESULTS

There was a 61% response rate (101/157) and of those responses, 95 were complete. Respondents indicated that 40% (38/95) use only red blood cells (RBCs) and 60% (57/95) use LTOWB. For hospitals that issue LTOWB (N = 57), 67% are supplied only with RhD-positive, 2% only with RhD-negative, and 32% with both RhD-positive and RhD-negative LTOWB. At sites using LTOWB, RhD-negative LTOWB is used exclusively or preferentially more commonly in adult females of childbearing potential (FCP) (46%) and pediatric FCP (55%) than in men (4%) and boys (24%). RhD-positive LTOWB is used exclusively or preferentially more commonly in men (94%) and boys (54%) than in adult FCP (40%) or pediatric FCP (21%). At sites using LTOWB, it is not permitted for adult FCPs at 12%, pediatric FCP at 21.4%, and boys at 17.1%.

CONCLUSION

Hospitals prefer issuing RhD-negative LTOWB for females although they are often ineligible to receive RhD-negative LTOWB due to supply constraints. The risk and benefits of LTOWB compared to the rare occurrence of hemolytic disease of the fetus/newborn (HDFN) need further examination in the context of withholding a therapy for females that has the potential for improved outcomes.