Large volume transfusion with whole blood is safe compared with component therapy.
Journal
The journal of trauma and acute care surgery
ISSN: 2163-0763
Titre abrégé: J Trauma Acute Care Surg
Pays: United States
ID NLM: 101570622
Informations de publication
Date de publication:
07 2020
07 2020
Historique:
entrez:
24
6
2020
pubmed:
24
6
2020
medline:
10
9
2020
Statut:
ppublish
Résumé
Transfusion with uncrossmatched cold-stored low-titer group O-positive or -negative whole blood (WB) in civilian trauma has been investigated as an alternative to component therapy but only in limited volumes. To our knowledge, this is the first analysis of the safety and efficacy of large volume transfusion of patients with trauma with WB. This is a retrospective cohort analysis comparing trauma patients resuscitated with component therapy (COMP) versus component therapy plus WB. The COMP group was comprised of patients who presented from January 2017 through June 2018 and the WB group from patients who presented from July 2018 through January 2019 after WB became available. We included patients if they received 1 unit of WB or red blood cells (RBCs) within 24 hours of admission and had massive transfusion protocol activated. We used bivariate analysis to compare groups. For analysis, one unit of WB equaled 1 unit of RBCs, 1 unit of plasma, and 1/6 of a unit of platelets. Forty-two patients received WB and 83 patients received COMP with similar baseline characteristics. Patients had a median age of 41 years (interquartile range [IQR], 28-61 years) and 73% were male. Thirty percent had penetrating injuries with a median Injury Severity Score of 29 (IQR, 17-38). The WB group received a median of 6.5 units (IQR, 3-11). The WB group received significantly more component-equivalent units but with a plasma/RBC ratio of 0.94:1 compared with 0.8:1 (p < 0.001). There were no differences in 24-hour mortality (COMP, 27% vs. WB, 29%, p = 0.8) or 30-day mortality (COMP, 46% vs. WB, 58% p = 0.2). There were no transfusion reactions. Transfusion utilizing primarily WB in civilian trauma is feasible, even in large volumes. It appears to be a safe and effective addition to component therapy and may lead to a more balanced resuscitation but with more overall product used. Therapeutic study, Level IV.
Sections du résumé
BACKGROUND
Transfusion with uncrossmatched cold-stored low-titer group O-positive or -negative whole blood (WB) in civilian trauma has been investigated as an alternative to component therapy but only in limited volumes. To our knowledge, this is the first analysis of the safety and efficacy of large volume transfusion of patients with trauma with WB.
METHODS
This is a retrospective cohort analysis comparing trauma patients resuscitated with component therapy (COMP) versus component therapy plus WB. The COMP group was comprised of patients who presented from January 2017 through June 2018 and the WB group from patients who presented from July 2018 through January 2019 after WB became available. We included patients if they received 1 unit of WB or red blood cells (RBCs) within 24 hours of admission and had massive transfusion protocol activated. We used bivariate analysis to compare groups. For analysis, one unit of WB equaled 1 unit of RBCs, 1 unit of plasma, and 1/6 of a unit of platelets.
RESULTS
Forty-two patients received WB and 83 patients received COMP with similar baseline characteristics. Patients had a median age of 41 years (interquartile range [IQR], 28-61 years) and 73% were male. Thirty percent had penetrating injuries with a median Injury Severity Score of 29 (IQR, 17-38). The WB group received a median of 6.5 units (IQR, 3-11). The WB group received significantly more component-equivalent units but with a plasma/RBC ratio of 0.94:1 compared with 0.8:1 (p < 0.001). There were no differences in 24-hour mortality (COMP, 27% vs. WB, 29%, p = 0.8) or 30-day mortality (COMP, 46% vs. WB, 58% p = 0.2). There were no transfusion reactions.
CONCLUSION
Transfusion utilizing primarily WB in civilian trauma is feasible, even in large volumes. It appears to be a safe and effective addition to component therapy and may lead to a more balanced resuscitation but with more overall product used.
LEVEL OF EVIDENCE
Therapeutic study, Level IV.
Identifiants
pubmed: 32574485
doi: 10.1097/TA.0000000000002687
pii: 01586154-202007000-00037
doi:
Types de publication
Comparative Study
Journal Article
Research Support, Non-U.S. Gov't
Langues
eng
Sous-ensembles de citation
IM
Pagination
238-245Références
Zielinski MD, Jenkins DH, Hughes JD, Badjie KS, Stubbs JR. Back to the future: the renaissance of whole-blood transfusions for massively hemorrhaging patients. Surgery. 2014;155(5):883–886.
Hall S, Murphy MF. Limitations of component therapy for massive haemorrhage: is whole blood the whole solution? Anaesthesia. 2015;70(5):511–514.
Holcomb JB, Jenkins D, Rhee P, et al. Damage control resuscitation: directly addressing the early coagulopathy of trauma. J Trauma. 2007;62(2):307–310.
Butler FK, Holcomb JB, Schreiber MA, et al. Fluid resuscitation for hemorrhagic shock in tactical combat casualty care: TCCC guidelines change 14-01—2 June 2014. J Spec Oper Med. 2014;14(3):13–38.
Nessen SC, Eastridge BJ, Cronk D, Craig RM, Berseus O, Ellison R, Remick K, Seery J, Shah A, Spinella PC. Fresh whole blood use by forward surgical teams in Afghanistan is associated with improved survival compared to component therapy without platelets. Transfusion. 2013;53(53 Suppl 1):107S–113S.
Spinella PC, Perkins JG, Grathwohl KW, Beekley AC, Holcomb JB. Warm fresh whole blood is independently associated with improved survival for patients with combat-related traumatic injuries. J Trauma. 2009;66(Suppl 4):S69–S76.
Perkins JG, Cap AP, Spinella PC, Shorr AF, Beekley AC, Grathwohl KW, Rentas FJ, Wade CE, Holcomb JB, 31st Combat Support Hospital Research Group. Comparison of platelet transfusion as fresh whole blood versus apheresis platelets for massively transfused combat trauma patients (CME). Transfusion. 2011;51(2):242–252.
Yazer MH, Jackson B, Sperry JL, Alarcon L, Triulzi DJ, Murdock AD. Initial safety and feasibility of cold-stored uncrossmatched whole blood transfusion in civilian trauma patients. J Trauma Acute Care Surg. 2016;81(1):21–26.
Cotton BA, Podbielski J, Camp E, et al; Early Whole Blood Investigators. A randomized controlled pilot trial of modified whole blood versus component therapy in severely injured patients requiring large volume transfusions. Ann Surg. 2013;258(4):527–532; discussion 532-3.
Seheult JN, Bahr M, Anto V, Alarcon LH, Corcos A, Sperry JL, Triulzi DJ, Yazer MH. Safety profile of uncrossmatched, cold-stored, low-titer, group O+ whole blood in civilian trauma patients. Transfusion. 2018;58(10):2280–2288.
Ho KM, Leonard AD. Lack of effect of unrefrigerated young whole blood transfusion on patient outcomes after massive transfusion in a civilian setting. Transfusion. 2011;51(8):1669–1675.
Leeper CM, Yazer MH, Cladis FP, Saladino R, Triulzi DJ, Gaines BA. Use of uncrossmatched cold-stored whole blood in injured children with hemorrhagic shock. JAMA Pediatr. 2018;172(5):491–492.
Seheult JN, Anto V, Alarcon LH, Sperry JL, Triulzi DJ, Yazer MH. Clinical outcomes among low-titer group O whole blood recipients compared to recipients of conventional components in civilian trauma resuscitation. Transfusion. 2018;58(8):1838–1845.
Hazelton JP, Cannon JW, Zatorski C, Roman JS, Moore SA, Young AJ, Subramanian M, Guzman JF, Fogt F, Moran A. Cold-stored whole blood: a better method of trauma resuscitation? J Trauma Acute Care Surg. 2019;87(5):1035–1041.
Zhu CS, Pokorny DM, Eastridge BJ, Nicholson SE, Epley E, Forcum J, Long T, Miramontes D, Schaefer R, Shiels M. Give the trauma patient what they bleed, when and where they need it: establishing a comprehensive regional system of resuscitation based on patient need utilizing cold-stored, low-titer O+ whole blood. Transfusion. 2019;59(S2):1429–1438.
Zielinski MD, Stubbs JR, Berns KS, Glassberg E, Murdock AD, Shinar E, Sunde GA, Williams S, Yazer MH, Zietlow S. Prehospital blood transfusion programs: capabilities and lessons learned. J Trauma Acute Care Surg. 2017;82(6S Suppl 1):S70–S78.
Seheult JN, Triulzi DJ, Alarcon LH, Sperry JL, Murdock A, Yazer MH. Measurement of haemolysis markers following transfusion of uncrossmatched, low-titre, group O+ whole blood in civilian trauma patients: initial experience at a level 1 trauma centre. Transfus Med. 2017;27(1):30–35.
Seheult JN, Stram MN, Sperry J, Spinella PC, Triulzi DJ, Yazer MH. In silico model of the dilutional effects of conventional component therapy versus whole blood in the management of massively bleeding adult trauma patients. Transfusion. 2019;59(1):146–158.
Bjerkvig CK, Strandenes G, Eliassen HS, Spinella PC, Fosse TK, Cap AP, Ward KR. “Blood failure” time to view blood as an organ: how oxygen debt contributes to blood failure and its implications for remote damage control resuscitation. Transfusion. 2016;56(56 Suppl 2):S182–S189.
Holcomb JB, del Junco DJ, Fox EE, et al. The prospective, observational, multicenter, major trauma transfusion (PROMMTT) study: comparative effectiveness of a time-varying treatment with competing risks. JAMA Surg. 2013;148(2):127–136.
Holcomb JB, Tilley BC, Baraniuk S, et al. Transfusion of plasma, platelets, and red blood cells in a 1:1:1 vs a 1:1:2 ratio and mortality in patients with severe trauma: the PROPPR randomized clinical trial. JAMA. 2015;313(5):471–482.
Khan S, Brohi K, Chana M, Raza I, Stanworth S, Gaarder C, Davenport R, International Trauma Research Network (INTRN). Hemostatic resuscitation is neither hemostatic nor resuscitative in trauma hemorrhage. J Trauma Acute Care Surg. 2014;76(3):561–567; discussion 567-8.
Remy KE, Yazer MH, Saini A, Mehanovic-Varmaz A, Rogers SR, Cap AP, Spinella PC. Effects of platelet-sparing leukocyte reduction and agitation methods on in vitro measures of hemostatic function in cold-stored whole blood. J Trauma Acute Care Surg. 2018;84(6S Suppl 1):S104–S114.
Pidcoke HF, McFaul SJ, Ramasubramanian AK, et al. Primary hemostatic capacity of whole blood: a comprehensive analysis of pathogen reduction and refrigeration effects over time. Transfusion. 2013;(53 Suppl 1):137S–149S.
Condron M, Scanlan M, Schreiber M. Massive transfusion of low-titer cold-stored O-positive whole blood in a civilian trauma setting. Transfusion. 2019;59(3):927–930.