Perception of risk in massive transfusion as it relates to fetal outcomes: A survey of surgeons and nurses at one American trauma center

Abstract

Background The use of blood products early in the resuscitation of bleeding trauma patients is widely accepted, but made difficult by limited supplies of D− red blood cell (RBC)‐containing products. Use of D+ RBC‐containing products would alleviate this issue, but could lead to alloimmunization. Risk associated with transfusing D+ RBC in emergency bleeding situations is being reconsidered. The level of concern surrounding emergency transfusion as it relates to future fetal harm was surveyed among surgeons and nurses. Methods Faculty and staff in the Departments of Surgery and Nursing were surveyed on the risks of receiving an emergency RBC transfusion and the subsequent potential for fetal harm. Answers were grouped as likely to accept (likely/very likely) or refuse transfusion (unlikely/very unlikely). Participants were compared by sex, and women by child‐bearing age, ([15–50 years] vs. [>50 years]). Results Ninety surveys were initiated with 76 fully completed. Male (n = 39) and female (n = 37) respondents were comparable. Most female respondents (30/37, 81%) were of childbearing age. Overall, both males (38/39, 95%) and females (33/37, 89%; p = .19) were likely to accept a transfusion in an emergency. There was no difference in transfusion acceptance if the risk of fetal harm was presented as 1% (p = .73) or 0.1% (p = .51). Most females (34/37, 92%) were not opposed to transfusion even if there was an unspecified risk of future fetal harm. Conclusion Most of the surgeons and nurses who responded would accept a transfusion in an emergency situation even if it might lead to harming a future fetus.

Attitudes of American adult women toward accepting RhD‐mismatched transfusions in bleeding emergencies

“…In a survey of the faculty and staff of the department of surgery and the school of nursing at the University of Alabama at Birmingham, 89% of the 37 female respondents of childbearing age and 87% of the 39 males responding on behalf of a theoretical female partner indicated that they would accept a life-saving transfusion even with the knowledge that it could harm future pregnancies even when the actual risk was not directly specified. 14 When the risks of fetal harm were defined as affecting 1/100 or 1/1000 future pregnancies, the response rates for both males and females were similar to the responses when the risk to future babies was not specified. The findings of the University of Alabama at Birmingham survey are not directly comparable to the results of the current survey because the phrasing of the risks and benefits of receiving urgent transfusions in light of potential fetal harm was somewhat different.…”

“…Several surveys of transfusion preferences in trauma vis‐à‐vis adverse pregnancy outcomes have been previously conducted. In a survey of the faculty and staff of the department of surgery and the school of nursing at the University of Alabama at Birmingham, 89% of the 37 female respondents of childbearing age and 87% of the 39 males responding on behalf of a theoretical female partner indicated that they would accept a life‐saving transfusion even with the knowledge that it could harm future pregnancies even when the actual risk was not directly specified 14 . When the risks of fetal harm were defined as affecting 1/100 or 1/1000 future pregnancies, the response rates for both males and females were similar to the responses when the risk to future babies was not specified.…”

Estimating the risks of prehospital transfusion of D‐positive whole blood to trauma patients who are bleeding in England

“…A survey of transfusion and trauma services directors at the 30 largest children's specialty hospitals in the United States revealed some reluctance to enroll injured girls of unknown D‐type in a study of D‐positive LTOWB transfusion versus component therapy, consistent with the traditional practice of providing D‐negative blood components in this clinical setting [ 29 ]. However, in a survey of staff at a large American university, 90% of the respondents who were females of CBP indicated that they would accept a lifesaving transfusion even with the knowledge that it could harm future pregnancies [ 30 ]. Further work is needed to understand the views of patients and the general public as to whether these risk are acceptable, so that their views can be taken into account when determining policy.…”

“…Based on these risk estimates, a survival benefit of 1% or greater components in this clinical setting [29]. However, in a survey of staff at a large American university, 90% of the respondents who were females of CBP indicated that they would accept a lifesaving transfusion even with the knowledge that it could harm future pregnancies [30]. Further work is needed to understand the views of patients and the general public as to whether these risk are acceptable, so that their views can be taken into account when determining policy.…”

Primum, non nocere: Whole blood, prehospital transfusion and anti‐D hemolytic disease of the fetus and newborn

“…5 There have been several recent articles presenting the case that this practice should be reconsidered to ensure optimal trauma care as, due to supply issues, it is difficult to provide group O RhD-negative (ONEG) RBCs in the pre-hospital setting or when using whole blood (WB). [6][7][8][9][10][11][12] The recommendation is that group O RhD-positive (OPOS) RBCs or WB be used in these circumstances since the benefit of transfusion outweighs the harm to a patient of childbearing potential developing anti-D and having a pregnancy affected by HDFN. As in all areas of medicine, it is healthy to thoughtfully debate possible changes in practice with an eye towards evidence and a risk to benefit assessment. In this commentary, we will review our understanding and interpretation of current data supporting the use of pre-hospital transfusion and WB in trauma care (i.e., the benefits) and the current morbidity and mortality related to anti-D HDFN (i.e., the harms).…”