Outcomes after ultramassive transfusion in the modern era: An Eastern Association for the Surgery of Trauma multicenter study

Abstract

BACKGROUND:Despite the widespread institution of modern massive transfusion protocols with balanced blood product ratios, survival for patients with traumatic hemorrhage receiving ultramassive transfusion (UMT) (defined as ≥20 U of packed red blood cells [RBCs]) in 24 hours) remains low and resource consumption remains high. Therefore, we aimed to identify factors associated with mortality in trauma patients receiving UMT in the modern resuscitation era. METHODS:An Eastern Association for the Surgery of Trauma multicenter retrospective study of 461 trauma patients from 17 trauma centers who received ≥20 U of RBCs in 24 hours was performed (2014)(2015)(2016)(2017)(2018)(2019). Multivariable logistic regression and Classification and Regression Tree analysis were used to identify clinical characteristics associated with mortality. RESULTS:The 461 patients were young (median age, 35 years), male (82%), severely injured (median Injury Severity Score, 33), in shock (median shock index, 1.2; base excess, −9), and transfused a median of 29 U of RBCs, 22 U of fresh frozen plasma (FFP), and 24 U of platelets (PLT). Mortality was 46% at 24 hours and 65% at discharge. Transfusion of RBC/FFP ≥1.5:1 or RBC/PLT ≥1.5:1 was significantly associated with mortality, most pronounced for the 18% of patients who received both RBC/PLT and RBC/FFP ≥1.5:1 (odds ratios, 3.11 and 2.81 for mortality at 24 hours and discharge; both p < 0.01). Classification and Regression Tree identified that age older than 50 years, low initial Glasgow Coma Scale, thrombocytopenia, and resuscitative thoracotomy were associated with low likelihood of survival (14-26%), while absence of these factors was associated with the highest survival (71%). CONCLUSION:Despite modern massive transfusion protocols, one half of trauma patients receiving UMT are transfused with either RBC/FFP or RBC/PLT in unbalanced ratios ≥1.5:1, with increased associated mortality. Maintaining focus on balanced ratios during UMT is critical, and consideration of advanced age, poor initial mental status, thrombocytopenia, and resuscitative thoracotomy can aid in prognostication.

Cresting mortality: Defining a plateau in ongoing massive transfusion

“…However, a transfusion volume at which benefit ceased was not elucidated. In the recent Eastern Association for the Surgery of Trauma multicenter trial, Matthay et al 21 In-hospital mortality rates at increasing TTVs. The TTV is defined as the total volume of PRBCs, FFP, and platelets transfused within 4 hours.…”

Better than ‘normal’: Describing the distribution of and outliers in RBC usage

“…This is in part due to low probability, high‐impact events of blood usage at the patient level. As an example, one hospital's typical daily RBC usage can average between 70 and 100 units, 9 yet individual patients can use over several hundred blood products in a single day 10,11 . In contrast, the majority of transfusion episodes tend to be 1–2 units per patient 12 .…”

“…As an example, one hospital's typical daily RBC usage can average between 70 and 100 units, 9 yet individual patients can use over several hundred blood products in a single day. 10,11 In contrast, the majority of transfusion episodes tend to be 1-2 units per patient. 12 By assuming that blood utilization is normal, we fail to appropriately represent a rightward skew in product utilization that could impact our ability to stock blood products.…”

Place of tranexamic acid in modern medicine

“…According to the data provided by the WHO on their website, injuries are responsible for up to 10% of global deaths annually. In 2003, they caused the death of 5 million people worldwide, mainly as a result of traffic accidents, and required hundreds of millions of medical services provided in emergency departments [5,6]. In 2019, road accidents accounted for the 7th cause of death in countries with low financial status and 10th in countries with a slightly higher status; in highly developed countries, deaths resulting from traffic accidents were outside the top ten causes of mortality [7,8].…”