Survey to inform trial of low‐titer group O whole‐blood compared to conventional blood components for children with severe traumatic bleeding

Abstract

Background Low‐titer group O whole‐blood (LTOWB) is being used for children with life‐threatening traumatic bleeding. A survey was conducted to determine current LTOWB utilization and interest in participation in a randomized control trial (RCT) of LTOWB versus standard blood component transfusion in this population. Study design and methods Transfusion medicine (TM) directors and pediatric trauma directors at 36 US children's hospitals were surveyed by e‐mail in June 2020. Hospitals were selected by participation in the Massive Transfusion Epidemiology and Outcomes in Children Study or being among the largest 30 children's hospitals by bed capacity per the Becker Hospital Review. Results The response rate was 83.3% (30/36) from TM directors and 88.9% (32/36) from trauma directors. The median of massive transfusion protocol activations for traumatic bleeding was reported as 12 (IQR 5.8–20) per year by TM directors. LTOWB was used by 18.8% (6/32) of trauma directors. Survey responses indicate that 86.7% (26/30) of TM directors and 90.6% (29/32) of trauma directors either moderately or strongly agree that a LTOWB RCT is important to perform. About 83.3% (25/30) of TM directors and 93.8% (30/32) of trauma directors were willing to participate in the proposed trial. About 80% (24/30) of TM directors and 71.9% (23/32) of trauma directors would transfuse RhD+ LTOWB to male children, but fewer would transfuse Rh + LTOWB to females [20% (6/30) TM directors and 37.5% (12/32) of trauma directors]. Conclusions A majority of respondents supported an RCT comparing LTOWB to component therapy in children with severe traumatic bleeding.

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

“…Interestingly, the results of this survey of females of childbearing potential are somewhat at odds with the results of a survey of the directors of the transfusion and trauma services at the 30 largest children's specialty hospitals 15 . These medical specialists were asked if they would be comfortable enrolling injured boys and girls of unknown RhD type in a study of RhD‐positive LTOWB versus components for their initial resuscitation.…”

“…Interestingly, the results of this survey of females of childbearing potential are somewhat at odds with the results of a survey of the directors of the transfusion and trauma services at the 30 largest children's specialty hospitals. 15 These medical specialists were asked if they would be comfortable enrolling injured boys and girls of unknown RhD type in a study of RhD-positive LTOWB versus components for their initial resuscitation. While 80% of the responding transfusion medicine directors and 72% of the responding trauma directors would be willing to enroll boys in this study, only 20% of the transfusion medicine directors and 38% of the trauma directors would be willing to enroll girls in this study.…”

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

“…In addition, reallocation of D‐negative RBCs away from prehospital use would facilitate the provision of these scarce RBCs to patients who are already D‐alloimmunized, and patients who require antigen‐matched RBC such as sickle cell disease patients for whom alloimmunization could pose dire long term health consequences. 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 ].…”

“…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].…”

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).…”