The Effects of Storage Age of Blood in Massively Transfused Burn Patients: A Secondary Analysis of the Randomized Transfusion Requirement in Burn Care Evaluation Study

Abstract

Objective: Major trials examining storage age of blood transfused to critically-ill patients administered relatively few blood transfusions. We sought to determine if the storage age of blood affects outcomes when very large amounts of blood are transfused. Design: A secondary analysis of the multicenter randomized Transfusion Requirement in Burn Care Evaluation (TRIBE) study which compared restrictive and liberal transfusion strategies. Setting: Eighteen tertiary-care burn centers. Patients: TRIBE evaluated 345 adults with burns ≥ 20% of the body surface area. We included only the 303 patients that received blood transfusions. Interventions: The storage ages of all transfused red-cell units were collected during TRIBE. A priori measures of storage age were the the mean storage age of all transfused blood and the proportion of all transfused blood considered very old (stored ≥ 35 days). Measurements and Main Results: The primary outcome was the severity of multiple organ dysfunction (MOD). Secondary outcomes included time to wound healing, the duration of mechanical ventilation, and in-hospital mortality.There were 6786 red-cell transfusions with a mean (±SD) storage age of 25.6 ± 10.2 days. Participants received a mean of 23.4 ± 31.2 blood transfusions (range 1–219), and a mean of 5.3 ± 10.7 units of very old blood. Neither mean storage age nor proportion of very old blood had any influence on MOD severity, time to wound healing, or mortality. Duration of ventilation was significantly predicted by both mean blood storage age and the proportion of very old blood but this was of questionable clinical relevance given extreme variability in duration of ventilation (adjusted r2 ≤0.01). Conclusion: Despite massive blood transfusion, including very old blood, the duration of red-cell storage did not influence outcome in burn patients. Provision of the oldest blood first by Blood Banks is rational, even for massive transfusion. Trial Registration: Clintrials.gov NCT01079247.

Association Between Length of Storage of Transfused Packed RBC Units and Outcome of Surgical Critically Ill Adults: A Subgroup Analysis of the Age of Blood Evaluation Randomized Trial*

“…Current evidence on critically ill trauma (4), burn (5), and cardiac surgery (6) might not apply to surgical patients as they may have a different risk profile (7). Specifically, anemia in surgical critically ill patients is multifactorial: surgical blood loss, cytokines inhibition of erythropoiesis, coagulopathy, hemodilution in the context of volume administration, and iatrogenic from diagnostic phlebotomies (8).…”

Storage Wars: Is It Time to Retire the Myth of the “Storage Lesion” in Red Cell Transfusion?*

“…Additionally, it further validates the findings of the ABLE study with greater extrapolation potential. Although similar outcomes have been found in randomized trials in the burn (15), trauma (16), and cardiac surgical patients (17), the study by Lehr et al (11) provides an application to those requiring intensive care after a broader array of surgical interventions. These findings should help alleviate the concern with triaging RBC transfusions in surgical ICU patients based upon the storage age.…”

Transfusion of red blood cells ≥35 days old: A narrative review of clinical outcomes

“…9 of 11 worsened outcomes came from four single‐center studies, 14–16,18 three of which were from the same institution 14,16,18 . In contrast, the multi‐center studies collectively measured eight mortality and morbidity outcomes, yet found only a single worsened morbidity outcome 3,11–13,17 . An unrelated systematic review of 12 meta‐analyses found single‐center studies overestimate treatment effects compared with multi‐center studies.…”

“…Six found no association between RBCs ≥35 days old and increased mortality. 3,11,12,14,17,18 Eikelboom and colleagues retrospectively reviewed cardiovascular acute care patients at a single center in Canada and found a modest mortality association following transfusion with at least one unit of RBCs stored ≥35 days compared with 7-14 days. They noted a "continuous and graded" increase in mortality with increasing RBC age, not a large jump in the final week.…”

“…Eight studies evaluated all‐cause mortality, five as in‐hospital (two secondary analyses and three retrospective) and three as 90‐day (one and two, respectively; Table 2). Six found no association between RBCs ≥35 days old and increased mortality 3,11,12,14,17,18 . Eikelboom and colleagues retrospectively reviewed cardiovascular acute care patients at a single center in Canada and found a modest mortality association following transfusion with at least one unit of RBCs stored ≥35 days compared with 7–14 days.…”