Role of Transfusion Volume and Transfusion Rate as Markers of Futility During Ultramassive Blood Transfusion in Trauma

Abstract

BACKGROUND: Using a large national database, we evaluated the relationship between RBC transfusion volume, RBC transfusion rate, and in-hospital mortality to explore the presence of a futility threshold in trauma patients receiving ultramassive blood transfusion. STUDY DESIGN: The ACS-TQIP 2013 to 2018 database was analyzed. Adult patients who received ultramassive blood transfusion (≥20 units of RBC/24 hours) were included. RBC transfusion volume and rate were captured at the only 2 time points available in TQIP (4 hours and 24 hours), or time of death, whichever came first. RESULTS: Among 5,135 patients analyzed, in-hospital mortality rate was 62.1% (n = 3,190), and 4-hour and 24-hour mortality rates were 17.53% (n = 900) and 42.41% (n = 2,178), respectively. RBC transfusion volumes at 4 hours (area under the receiver operating characteristic curve [AUROC] 0.59 [95% CI 0.57 to 0.60]) and 24 hours (AUROC 0.59 [95% CI 0.57 to 0.60]) had low discriminatory ability for mortality and were inconclusive for futility. Mean RBC transfusion rates calculated within 4 hours (AUROC 0.65 [95% CI 0.63 to 0.66]) and 24 hours (AUROC 0.85 [95% CI 0.84 to 0.86]) had higher discriminatory ability than RBC transfusion volume. A futility threshold was not found for the mean RBC transfusion rate calculated within 4 hours. All patients with a final mean RBC transfusion rate of ≥7 U/h calculated within 24 hours of arrival experienced in-hospital death (n = 1,326); the observed maximum length of survival for these patients during the first 24 hours ranged from 24 hours for a rate of 7 U/h to 4.5 hours for rates ≥21 U/h. CONCLUSION: RBC transfusion volume within 4 or 24 hours and mean RBC transfusion rate within 4 hours were not markers of futility. The observed maximum length of survival per mean RBC transfusion rate could inform resuscitation efforts in trauma patients receiving ongoing transfusion between 4 and 24 hours.

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

“…Loudon et al also reported that mortality increased with the number of units transfused in trauma patients. Their multivariate analysis showed that patients who received MT (>10 units RBC/4 hours) were 3 times 32 Gallastegi et al 13 reported slightly different findings, that it was not the absolute transfusion volume that was associated with increased mortality, but rather the transfusion rate, which had better discriminatory power for increasing mortality risk. The mean RBC transfusion rate calculated at 24 hours had a better ability to predict mortality (area under the receiver operating curve, 0.85 [95% CI, 0.84-0.86]), and the results showed that all patients with a final mean RBC transfusion rate of >7 units/h at 24 hours experienced in-hospital death.…”

“…[2][3][4][5][6][7] Hospital implementation of MTPs is associated with reduced blood consumption, decreased incidence of multiorgan failure, and complications such as abdominal compartment syndrome, decreased hospital length of stay, overall cost, and mortality. [8][9][10][11][12] Ultra-MT (UMT), which may be defined as ≥20 units of RBC within 24 hours, 13,14 is increasingly being studied in trauma and surgical patients.…”

“…Combination of both RBC/PLT and RBC/FFP transfused in ratios ≥1.5:1 was associated with 3.1-and 2.8-fold increased odds of death at 24 h and discharge, respectively (P < .01). No stat sig difference in mortality when evaluating cryo or TXA administration Yu et al, 2018 6 Lower GCS Higher ISS Exploratory thoracotomy Female sex associated with lower mortality Dzik et al, 2016 26 Survival after UMT associated more strongly with the underlying diagnostic category than the quantity of RBC required Highest odds ratio (OR) for nonsurvival was the diagnostic category of trauma In trauma patients, significant decrease in survival for those patients receiving >60 units RBC/ laboratory values such as lactate, 7 pH, 7,29 base deficit, 30,31 and PLT count 14 to clinical factors such as age, 7,13 Glasgow Coma Scale (GCS), 6,13,14 Injury Severity Score (ISS), 6,29 medical history, 33,34 surgical diagnosis, 26 presence or absence of hemorrhagic shock, 28,29,33 transfusion ratio, 13,14,29 and need for operative intervention such as thoracotomy. 6,14,28 Gallastegi et al 13 analyzed a national trauma database over a 5-year period to evaluate the association between RBC transfusion volumes and rates, and in-hospital mortality of UMT recipients.…”

“…No stat sig difference in mortality when evaluating cryo or TXA administration Yu et al, 2018 6 Lower GCS Higher ISS Exploratory thoracotomy Female sex associated with lower mortality Dzik et al, 2016 26 Survival after UMT associated more strongly with the underlying diagnostic category than the quantity of RBC required Highest odds ratio (OR) for nonsurvival was the diagnostic category of trauma In trauma patients, significant decrease in survival for those patients receiving >60 units RBC/ laboratory values such as lactate, 7 pH, 7,29 base deficit, 30,31 and PLT count 14 to clinical factors such as age, 7,13 Glasgow Coma Scale (GCS), 6,13,14 Injury Severity Score (ISS), 6,29 medical history, 33,34 surgical diagnosis, 26 presence or absence of hemorrhagic shock, 28,29,33 transfusion ratio, 13,14,29 and need for operative intervention such as thoracotomy. 6,14,28 Gallastegi et al 13 analyzed a national trauma database over a 5-year period to evaluate the association between RBC transfusion volumes and rates, and in-hospital mortality of UMT recipients. The independent predictors of in-hospital mortality identified were as follows: increased age (≥40 years), higher systolic blood pressure (SBP) (≥100 mm Hg), lower heart rate (HR) (≤120 beats per minute), lower oxygen saturation (≤98%), lower GCS score (≤13) at time of presentation, blunt mechanism of injury, and higher Abbreviated Injury Scale (AIS) scores for head and abdomen.…”

Biochemical disturbance in damage control resuscitation: mechanisms, management and prognostic utility

“…The timely cessation of futile resuscitation is essential for patient dignity and resource preservation. A recent article established a high discriminatory value for predicting early mortality in mean pRBC infusion rate at 24 h but not at 4 h among trauma patients who receive ultramassive transfusions [67 ▪ ]. Although this is applicable to intensivists, it is less so to trauma anaesthesiologists managing DCR.…”