The effect of massive transfusion protocol implementation on the survival of trauma patients: a systematic review and meta-analysis

Retooling the Massive Transfusion Protocol at a Veterans Affairs Medical Center

INTRODUCTION

Massive transfusion protocols (MTPs) ensure the timely and life-saving delivery of blood products to patients who are rapidly exsanguinating. Although essential, MTPs are also highly resource-intensive. Effective MTP implementation must balance the resources of the hospital with the needs of the patient population that they serve, as well as avoid instances of unjustified activations. Toward this goal, we implemented a set of policy improvements to our institution's MTP aimed at ensuring appropriate clinical activation.

MATERIALS AND METHODS

Following interdisciplinary discussions with clinical teams, we revamped our institution's MTP in the spring of 2019, focusing on the improved training of junior clinicians by requiring final approval of all MTP activations by attendings and fellows, and providing opportunities to review MTP execution during quarterly meetings. Other changes included implementing blood warmers and streamlining the MTP ordering process. We then performed a retrospective study to evaluate the effects of our refurbished MTP on the frequency, characteristics, and outcomes of massive transfusions activated at the Washington DC Veterans Affairs Medical Center between March 2018 to February 2019 and March 2019 to February 2020 (before and after the policy change, respectively). Descriptive statistics were used to summarize the data. Fisher exact test, Wilcoxon test, and Poisson test were used to compare differences in categorical variables, continuous variables, and the rate of MTP activation, before and after policy changes were implemented, respectively. This study is exempt from the Institutional Review Board's review.

RESULTS

We did not detect statistically significant changes in patient and MTP-related parameters, nor survival outcomes following policy improvement. However, we observed a decreasing trend in MTP activations, and concomitantly, a significant increase in the number of days between MTP activations, from 12.5 days (median) in the first year to 41 days (median) in the second year (P = 0.0274).

CONCLUSIONS

In summary, we developed an MTP tailored to the needs of our Veterans Affairs Medical Center, providing a reliable system for blood product administration to patients with real massive transfusion requirements while reducing unjustified MTP activations. We credit the reduction in MTP activations mainly to improved education and training of clinicians, which, in turn, changed their ordering behaviors. Fewer unjustified MTP activations decrease the potential for wastage of resources such as blood and blood components and preserves work hours of staff for patients with true transfusion needs. We believe our strategy may have a widespread and compounding effect on improving blood stewardship nationwide, given our trainees' propensity to work at medical centers across the country and educate future trainees of their own.

A Case of Atraumatic Splenic Rupture Due to T-Cell/Histiocyte-Rich Large B-Cell Lymphoma and a Potential Role for Massive Transfusion Protocol

Splenic rupture leads to massive hemorrhage and requires immediate surgical intervention. Splenic rupture results from trauma or from underlying disease processes. Lymphoma is a rare cause of atraumatic splenic rupture (ASR) with high mortality rates. We present a case of ASR due to T-cell/histiocyte-rich large B-cell lymphoma (THRLBCL) requiring splenectomy and large-volume transfusion. This case report highlights the necessity of prompt surgical intervention and massive transfusion for hemodynamically unstable ASR. This report also discusses massive transfusion protocol (MTP) and its limited use in nontraumatic surgical patients.

Transfusion in trauma: empiric or guided therapy?

A state of the art lecture titled "Transfusion therapy in trauma-what to give? Empiric vs guided" was presented at the International Society on Thrombosis and Haemostasis Congress in 2024. Uncontrolled bleeding is the commonest preventable cause of death after traumatic injury. Hemostatic resuscitation is the foundation of contemporary transfusion practice for traumatic bleeding and has 2 main aims: to immediately support the circulating blood volume and to treat/prevent the associated trauma-induced coagulopathy. There are 2 broad types of hemostatic resuscitation strategy: empiric ratio-based therapy, often using red blood cells and fresh frozen plasma in a 1:1 ratio, and targeted therapy where the use of platelets, plasma, or fibrinogen is guided by laboratory or viscoelastic hemostatic tests. There are benefits, and limitations, to each strategy and neither approach has yet been shown to improve outcomes across all patient groups. Questions remain, and future directions for improving transfusion therapy are likely to require novel approaches that have greater flexibility to evaluate and treat heterogeneous trauma cohorts. Such approaches may include the integration of machine learning technologies in clinical systems, with real-time linkage of clinical and laboratory data, to aid early recognition of patients at the greatest risk of bleeding and to direct and individualize transfusion therapies. Greater mechanistic understanding of the underlying pathobiology of trauma-induced coagulopathy and the direct effects of common treatments on this process will be of equal importance to the development of new treatments. Finally, we summarize relevant new data on this topic presented at the 2024 ISTH Congress.

Identification of Predictive Factors for Massive Transfusion Activation in Trauma Patients: A Systematic Review and Meta-analysis

Introduction

Acute blood loss and uncontrolled hemorrhage in trauma require quick identification and action to restore circulating volume and save the patient. These patients have the opportunity to receive massive transfusion (MT) to reduce mortality rates and avoid overtransfusion using a suitable ratio of blood components. This study aims to systematically review and analyze the predictive factors for the activation of MT protocol (MTP) in trauma patients, which is critical for improving clinical decision-making and patient outcomes.

Methods

PubMed, ScienceDirect, Cochrane, and other sources were searched for articles from 2007 to 2020. Conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement, this systematic review included original studies published in English, involving trauma patients aged 15 years or older who received MTP. The risk of bias (RoB) was assessed using the RoB in Nonrandomized Studies of Interventions-I and RoB 2 tools, and statistical analysis was performed, focusing on the homogeneity of effect sizes across trials.

Results

The articles search identified a total of 424 studies. Nine studies met all inclusion criteria. The most common predictors were age, sex, systolic blood pressure (SBP), heart rate (HR), hemoglobin (Hb) levels, international normalized ratio (INR), base excess (BE), and lactate levels. The analysis showed that parameters such as SBP, HR, Hb, INR, BE, and lactate were significantly associated with the activation of MTP. However, age and sex were not significant predictors. The survival rate was notably lower in the MTP group compared to the non-MTP group. There was no evidence of publication bias.

Conclusion

Several physiological parameters: low SBP, elevated HR, reduced Hb, increased INR, diminished BE, and elevated lactate are significantly correlated with an increased likelihood of necessitating MTP in trauma patients. Among those who received MTP, the survival rate was lower compared to the non-MTP group.

Platelet-Lymphocyte and Neutrophil-Lymphocyte Ratio for Prediction of Hospital Outcomes in Patients with Abdominal Trauma

Background

The platelet-to-lymphocyte ratio (PLR) and neutrophil-to-lymphocyte ratio (NLR) reflect the patient inflammatory and immunity status. We investigated the role of on-admission PLR and NLR in predicting massive transfusion protocol (MTP) activation and mortality following abdominal trauma.

Methods

A 4-year retrospective analysis of all adult abdominal trauma patients was conducted. Patients were classified into survivors and nonsurvivors and low vs. high PLR. The discriminatory power for PLR and NLR to predict MTP and mortality was determined. Multivariate logistic regression analysis was performed for predictors of mortality.

Results

A total of 1199 abdominal trauma patients were included (18.7% of all the trauma admissions). Low PLR was associated with more severe injuries and greater rates of hospital complications including mortality in comparison to high PLR. On-admission PLR and NLR were higher in the survivors than in nonsurvivors (149.3 vs. 76.3 (p = 0.001) and 19.1 vs. 13.7 (p = 0.009), respectively). Only PLR significantly correlated with injury severity score, revised trauma score, TRISS, serum lactate, shock index, and FASILA score. Optimal cutoffs of PLR and NLR for predicting mortality were 98.5 and 18.5, respectively. The sensitivity and specificity of PLR were 81.3% and 61.1%, respectively, and 61.3% and 51.3%, respectively, for NLR. The AUROC for predicting MTP was 0.69 (95% CI: 0.655–0.743) for PLR and 0.55 (95% CI: 0.510–0.598) for NLR. To predict hospital mortality, the area under the curve (AUROC) for PLR was 0.77 (95% CI: 0.712–0.825) and 0.59 (95% CI: 0.529–0.650) for the NLR. On multivariate logistic regression analysis, the age, Glasgow Coma Scale, sepsis, injury severity score, and PLR were independent predictors of mortality.

Conclusion

On-admission PLR but not NLR helps early risk stratification and timely management and predicts mortality in abdominal trauma patients. Further prospective studies are required.

Transfusion strategies in bleeding critically ill adults: a clinical practice guideline from the European Society of Intensive Care Medicine

PURPOSE

To develop evidence-based clinical practice recommendations regarding transfusion practices and transfusion in bleeding critically ill adults.

METHODS

A taskforce involving 15 international experts and 2 methodologists used the GRADE approach to guideline development. The taskforce addressed three main topics: transfusion support in massively and non-massively bleeding critically ill patients (transfusion ratios, blood products, and point of care testing) and the use of tranexamic acid. The panel developed and answered structured guideline questions using population, intervention, comparison, and outcomes (PICO) format.

RESULTS

The taskforce generated 26 clinical practice recommendations (2 strong recommendations, 13 conditional recommendations, 11 no recommendation), and identified 10 PICOs with insufficient evidence to make a recommendation.

CONCLUSIONS

This clinical practice guideline provides evidence-based recommendations for the management of massively and non-massively bleeding critically ill adult patients and identifies areas where further research is needed.

A Selection of Trauma Scores Might Not Correlate with Coagulation Factor Activity following Multiple Injuries: A Retrospective Observational Study from a Level 1 Trauma Center

Loss and dilution of coagulation factors have been observed following multiple trauma. Timely recognition of reduced clotting factor activity might facilitate therapeutic action to restore normal coagulation function. This study investigates the potential role of some well-known trauma scores in predicting coagulation factor activity after multiple injuries. A dataset comprising the coagulation factor activities of 68 multiply injured adult patients was analyzed. The following trauma scores were evaluated: AIS, ISS, NISS, GCS, RTS, TRISS, RISC, and TASH score. To investigate the effect of trauma severity with respect to a single anatomic injury location, two groups according to the AIS (<3 vs. ≥3 points) were formed. Differences between these two groups were analyzed for five different body regions (head, thorax, abdomen, pelvis, extremities) using the Mann–Whitney U-test. Spearman's rank correlation coefficient rho was calculated to reveal possible relationships between trauma scores and clotting factor activities. The analysis showed clearly reduced clotting factor activities with a significant reduction of FII (83 vs. 50%; P = .021) and FV (83 vs. 46%; P = .008) for relevant (AIS ≥ 3 points) pelvic injuries. In contrast, traumatic brain injury according to the AIS head or the GCS does not appear to lead to a significant decrease in coagulation factor activities. Furthermore, the other scores studied show at best a fair correlation with coagulation factor activity. In this context, the RTS score seems to be the most suitable. Additionally, the predictive value of the TASH score, which was specifically developed to predict the need for mass transfusion, was also limited in this study. We would like to explicitly point out that this is not a criticism of the trauma scores, since they were developed in a completely different context.