Massive transfusion and severe blood shortages: establishing and implementing predictors of futility

Mladinov, Domagoj; Frank, Steven M.

doi:10.1016/j.bja.2021.10.013

Cited by 13 publications

(10 citation statements)

References 24 publications

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“…The model best able to predict 30-day mortality included the 24-hour model variables plus age and ISS. Mladinov and Frank 20 discussed the framework for creating a futility index score by utilizing large data to develop prediction models. The authors suggested the following variables to be used in a futility score, many of which have been shown to be independent predictors of mortality in UMT: cardiac arrest, loss of consciousness, ISS, ECG signs of ischemia, HR, SBP, nadir pH and base excess, hemoglobin, INR, PLT count, vasopressor use, and duration of aortic cross-clamp.…”

Section: Discussionmentioning

confidence: 99%

“…The study emphasized that a mortality prediction tool should be used to aid the clinical decision-making process, and rather than utilizing the futility score at one point in time, its trend may be more relevant in recognizing clinical futility. 20 Loudon et al 32 discussed performing a “time-out” when patients received 16 units RBC to reevaluate the chance of survival and need for continued transfusion. Similarly, the National Health Service guidelines suggested performing serial assessments after every 8 units RBC using these parameters: total blood products administered, necessity of additional transfusion, Sequential Organ Failure Assessment score, and hemorrhage control attainability.…”

Section: Discussionmentioning

confidence: 99%

“…7 A serious ongoing issue is a national blood shortage due to decreased blood donations and cancelation of blood drives resulting in 86,000 fewer blood donations in 2020. 19,20 Furthermore, there is a significant cost associated with blood products. US hospitals, on average, spend approximately $204 per unit of nonleukocytereduced RBC, $211 per unit of leukocyte-reduced RBC, and $52 per unit of fresh frozen plasma (FFP).…”

Section: Glossarymentioning

confidence: 99%

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Narrative Review: Is There a Transfusion Cutoff Value After Which Nonsurvivability Is Inevitable in Trauma Patients Receiving Ultramassive Transfusion?

Kim

Casem

Baral

et al. 2023

Anesthesia &Amp; Analgesia

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The institution of massive transfusion protocols (MTPs) has improved the timely delivery of large quantities of blood products and improves patient outcomes. In recent years, the cost of blood products has increased, compounded by significant blood product shortages. There is practical need for identification of a transfusion volume in trauma patients that is associated with increased mortality, or a threshold after which additional transfusion is futile and associated with nonsurvivability. This transfusion threshold is often described in the setting of an ultramassive transfusion (UMT). There are few studies defining what constitutes amount or outcomes associated with such large volume transfusion. The purpose of this narrative review is to provide an analysis of existing literature examining the effects of UMT on outcomes including survival in adult trauma patients and to determine whether there is a threshold transfusion limit after which mortality is inevitable. Fourteen studies were included in this review. The data examining the utility of UMT in trauma are of poor quality, and with the variability inherent in trauma patients, and the surgeons caring for them, no universally accepted cutoff for transfusion exists. Not surprisingly, there is a trend toward increasing mortality with increasing transfusions. The decision to continue transfusing is multifactorial and must be individualized, taking into consideration patient characteristics, institution factors, blood bank supply, and most importantly, constant reevaluation of the need for ongoing transfusion rather than blind continuous transfusion until the heart stops.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Glossarymentioning

confidence: 99%

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Narrative Review: Is There a Transfusion Cutoff Value After Which Nonsurvivability Is Inevitable in Trauma Patients Receiving Ultramassive Transfusion?

Kim

Casem

Baral

et al. 2023

Anesthesia &Amp; Analgesia

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“…9–11 However, as episodic blood shortages and blood bank worker shortages—exacerbated in the early years of the coronavirus disease 2019 (COVID-19) pandemic 12 —put this response-capacity at risk, questions have reemerged about UMT as a metric of futility. 13…”

mentioning

confidence: 99%

“…[9][10][11] However, as episodic blood shortages and blood bank worker shortages-exacerbated in the early years of the coronavirus disease 2019 (COVID-19) pandemic 12 put this response-capacity at risk, questions have reemerged about UMT as a metric of futility. 13 Harborview Medical Center (Harborview), in Seattle, Washington, is the level-1 adult and pediatric trauma center for roughly 25% of the US land mass, cares for approximately 6000 acute trauma patients per year, and was a participant in the Pragmatic Randomized Optimal Platelet and Plasma Ratios (PROPPR) trial. 14 Since April 2011, the 1:1:1 arm of PROPPR has formed the basis of our massive transfusion protocol.…”

mentioning

confidence: 99%

Ultramassive Transfusion for Trauma in the Age of Hemostatic Resuscitation: A Retrospective Single-Center Cohort From a Large US Level-1 Trauma Center, 2011–2021

Muldowney

Liu

Stansbury

et al. 2023

Anesthesia &Amp; Analgesia

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BACKGROUND: Uncontrolled bleeding is a leading cause of death in trauma. In the last 40 years, ultramassive transfusion (UMT; ≥20 units of red blood cells [RBCs]/24 hours) for trauma has been associated with 50% to 80% mortality; the question remains as to whether the increasing number of units transfused in urgent resuscitation is a marker of futility. We asked whether the frequency and outcomes of UMT have changed in the era of hemostatic resuscitation. METHODS: We performed a retrospective cohort study of all UMTs in the first 24 hours of care over an 11-year period at a major US level-1 adult and pediatric trauma center. UMT patients were identified, and a dataset was built by linking blood bank and trauma registry data, then reviewing individual electronic health records. Success in achieving hemostatic proportions of blood products was estimated as (units of plasma + apheresis-platelets-in-plasma + cryoprecipitatepools + whole blood]/[all units given] ≥0.5. Demographics, injury type (blunt or penetrating), severity (Injury Severity Score [ISS]), severity pattern (Abbreviated Injury Scale score for head [AIS-Head] ≥4), admitting laboratory, transfusion, selected emergency department interventions, and discharge status were assessed using χ 2 tests of categorical association, the Student t-test of means, and multivariable logistic regression. P <.05 was considered significant. RESULTS: Among 66,734 trauma admissions from April 6, 2011 to December 31, 2021, we identified 6288 (9.4%) who received any blood products in the first 24 hours, 159 of whom received UMT (0.23%; 154 aged 18-90 + 5 aged 9-17), 81% in hemostatic proportions. Overall mortality was 65% (n = 103); mean ISS = 40; median time to death, 6.1 hours. In univariate analyses, death was not associated with age, sex, or more RBC units transfused beyond 20 but was associated with blunt injury, increasing injury severity, severe head injury, and failure to receive hemostatic blood product ratios. Mortality was also associated with decreased pH and evidence of coagulopathy at admission, especially hypofibrinogenemia. Multivariable logistic regression showed severe head injury, admission hypofibrinogenemia and not receiving a hemostatic resuscitation proportion of blood products as independently associated with death. CONCLUSIONS: One in 420 acute trauma patients at our center received UMT, a historically low rate. A third of these patients lived, and UMT was not itself a marker of futility. Early identification of coagulopathy was possible, and failure to give blood components in hemostatic ratios was associated with excess mortality. (Anesth Analg 2023;136:927-33) KEY POINTS• Question: Is there a point beyond the conventional metric of "ultramassive transfusion (UMT)" (≥20 units of red blood cell [RBC] in 24 hours) at which increasing numbers of units transfused are associated with futility? • Findings: In a retrospective review of >66,000 acute trauma patients over an 11-year period, among 159 patients (0.2%) (mean injury severity score 40 ± 16) wh...

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Consensus of the Brazilian association of hematology, hemotherapy and cellular therapy on patient blood management

Oliveira,

Montano-Pedroso,

Perini

et al. 2024

Hematology, Transfusion and Cell Therapy

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Massive transfusion and severe blood shortages: establishing and implementing predictors of futility

Cited by 13 publications

References 24 publications

Narrative Review: Is There a Transfusion Cutoff Value After Which Nonsurvivability Is Inevitable in Trauma Patients Receiving Ultramassive Transfusion?

Narrative Review: Is There a Transfusion Cutoff Value After Which Nonsurvivability Is Inevitable in Trauma Patients Receiving Ultramassive Transfusion?

Ultramassive Transfusion for Trauma in the Age of Hemostatic Resuscitation: A Retrospective Single-Center Cohort From a Large US Level-1 Trauma Center, 2011–2021

Consensus of the Brazilian association of hematology, hemotherapy and cellular therapy on patient blood management

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