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

Abstract

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.

Massive transfusion in trauma

“…Morbidity and mortality rates increase as transfusion requirements increase [2 ▪▪ ]; yet, there is a debate whether the absolute transfusion volume or the transfusion rate (i.e., >7 units/h at 24 h) provides better discriminatory power for mortality [3 ▪ ]. Based on high transfusion volumes alone, futility of resuscitation should not be declared in MT [63]; constantly reevaluating the need for ongoing transfusion is recommended [3 ▪ ]. However, during a time of urgent blood bank shortage, a combination of the recently proposed evidence-based STOP-criteria [64] and certain VHA results [65] might be helpful in this evaluation.…”

“…Trauma accounts for 15% of perioperative massive transfusion (MT) [1 ▪▪ ,2 ▪▪ ] and, following traumatic brain injury (TBI), hemorrhage remains the leading cause of death, especially in individuals aged ≤46 years [3 ▪ ]. Hemorrhagic shock (HS) is present in up to 40%; nevertheless, in 12–34% of trauma and hemorrhage, deaths are preventable [4 ▪ ].…”

Saving Blood for the Bleeding

“…To the Editor, K im et al 1 present a review of mortality associated with ultramassive transfusion (UMT) in trauma patients, asking if there is a threshold dose of red blood cells beyond which transfusion is no longer beneficial. This question arises from a recurring observation in massive bleeding: mortality rises monotonically with the amount of red cells transfused, and at least a quarter of patients who receive more than 20 units of red blood cells in a resuscitation are dead within 30 days.…”

“…In Response W e thank Dr Hess for providing astute comments pertaining to our narrative review, and we appreciate the time dedicated and valuable insights provided. 1 Hess raises numerous important and valid points, and we would like to respond to and expand on several key statements. 1.…”