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Meizoso JP, Cotton BA, Lawless RA, Kodadek LM, Lynde JM, Russell N, Gaspich J, Maung A, Anderson C, Reynolds JM, Haines KL, Kasotakis G, Freeman JJ. Whole blood resuscitation for injured patients requiring transfusion: A systematic review, meta-analysis, and practice management guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg 2024; 97:460-470. [PMID: 38531812 DOI: 10.1097/ta.0000000000004327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/28/2024]
Abstract
INTRODUCTION Whole blood (WB) resuscitation has reemerged as a resuscitation strategy for injured patients. However, the effect of WB-based resuscitation on outcomes has not been established. The primary objective of this guideline was to develop evidence-based recommendations on whether WB should be considered in civilian trauma patients receiving blood transfusions. METHODS An Eastern Association for the Surgery of Trauma working group performed a systematic review and meta-analysis using the Grading of Recommendations Assessment, Development and Evaluation methodology. One Population, Intervention, Comparison, and Outcomes question was developed to analyze the effect of WB resuscitation in the acute phase on mortality, transfusion requirements, infectious complications, and intensive care unit length of stay. English language studies including adult civilian trauma patients comparing in-hospital WB to component therapy were included. Medline, Embase, Cochrane CENTRAL, CINAHL Plus, and Web of Science were queried. GRADEpro (McMaster University; Evidence Prime, Inc.; Ontario) was used to assess quality of evidence and risk of bias. The study was registered on International Prospective Register of Systematic Reviews (CRD42023451143). RESULTS A total of 21 studies were included. Most patients were severely injured and required blood transfusion, massive transfusion protocol activation, and/or a hemorrhage control procedure in the early phase of resuscitation. Mortality was assessed separately at the following intervals: early (i.e., emergency department, 3 hours, or 6 hours), 24 hours, late (i.e., 28 days or 30 days), and in-hospital. On meta-analysis, WB was not associated with decreased mortality. Whole blood was associated with decreased 4-hour red blood cell (mean difference, -1.82; 95% confidence interval [CI], -3.12 to -0.52), 4-hour plasma (mean difference, -1.47; 95% CI, -2.94 to 0), and 24-hour red blood cell transfusions (mean difference, -1.22; 95% CI, -2.24 to -0.19) compared with component therapy. There were no differences in infectious complications or intensive care unit length of stay between groups. CONCLUSION We conditionally recommend WB resuscitation in adult civilian trauma patients receiving blood transfusions, recognizing that data are limited for certain populations, including women of childbearing age, and therefore this guideline may not apply to these populations. LEVEL OF EVIDENCE Systematic Review/Meta-Analysis; Level III.
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Affiliation(s)
- Jonathan P Meizoso
- From the Divisions of Trauma, Surgical Critical Care, and Burns, DeWitt Daughtry Family Department of Surgery (J.P.M.), University of Miami Miller School of Medicine; Ryder Trauma Center (J.P.M.), Jackson Memorial Hospital, Miami, Florida; Department of Surgery (B.A.C.), McGovern Medical School, University of Texas Health Science Center at Houston; Red Duke Trauma Institute (B.A.C.), Memorial Hermann Hospital, Houston, Texas; Orlando Health Medical Group (R.A.L.), Orlando, Florida; Department of Surgery (L.M.K., A.M., C.A.), Yale School of Medicine, New Haven, Connecticut; Department of Surgery (J.M.L.), University of California, Davis, Sacramento; United States Air Force (J.M.L.), Travis Air Force Base, California; Burnett School of Medicine (N.R., J.J.F.), Texas Christian University, Fort Worth, Texas; Brigham and Women's Hospital (J.G.); Department of Surgery (J.G.), Harvard Medical School, Boston, Massachusetts; Louis Calder Memorial Library (J.M.R.), University of Miami Miller School of Medicine, Miami, Florida; Department of Surgery (K.L.H.), Duke University School of Medicine, Durham, North Carolina; and Inova Fairfax (G.K.), Falls Church, Virginia
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Morgan KM, Abou Khalil E, Feeney EV, Spinella PC, Lucisano AC, Gaines BA, Leeper CM. The Efficacy of Low-Titer Group O Whole Blood Compared With Component Therapy in Civilian Trauma Patients: A Meta-Analysis. Crit Care Med 2024; 52:e390-e404. [PMID: 38483205 DOI: 10.1097/ccm.0000000000006244] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2024]
Abstract
OBJECTIVES To assess if transfusion with low-titer group O whole blood (LTOWB) is associated with improved early and/or late survival compared with component blood product therapy (CT) in bleeding trauma patients. DATA SOURCES A systematic search of PubMed, CINAHL, and Web of Science was performed from their inception through December 1, 2023. Key terms included injury, hemorrhage, bleeding, blood transfusion, and whole blood. STUDY SELECTION All studies comparing outcomes in injured civilian adults and children who received LTOWB versus CT were included. DATA EXTRACTION Data including author, publication year, sample size, total blood volumes, and clinical outcomes were extracted from each article and reported following the Meta-analysis Of Observational Studies in Epidemiology guidelines. Main outcomes were 24-hour (early) and combined 28-day, 30-day, and in-hospital (late) mortality rates between recipients of LTOWB versus CT, which were pooled using random-effects models. DATA SYNTHESIS Of 1297 studies reviewed, 24 were appropriate for analysis. Total subjects numbered 58,717 of whom 5,164 received LTOWB. Eleven studies included adults-only, seven included both adults and adolescents, and six only included children. The median (interquartile range) age for patients who received LTOWB and CT was 35 years (24-39) and 35.5 years (23-39), respectively. Overall, 14 studies reported early mortality and 22 studies reported late mortality. LTOWB was associated with improved 24-hour survival (risk ratios [RRs] [95% CI] = 1.07 [1.03-1.12]) and late (RR [95% CI] = 1.05 [1.01-1.09]) survival compared with component therapy. There was no evidence of small study bias and all studies were graded as a moderate level of bias. CONCLUSIONS These data suggest hemostatic resuscitation with LTOWB compared with CT improves early and late survival outcomes in bleeding civilian trauma patients. The majority of subjects were injured adults; multicenter randomized controlled studies in injured adults and children are underway to confirm these findings.
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Affiliation(s)
- Katrina M Morgan
- Department of Surgery and Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA
| | | | - Erin V Feeney
- Department of Surgery and Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Philip C Spinella
- Department of Surgery and Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Amelia C Lucisano
- Department of Surgery and Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Barbara A Gaines
- Department of Surgery, Division of Pediatric Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Christine M Leeper
- Department of Surgery and Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA
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van der Horst RA, Rijnhout TWH, Noorman F, Borger van der Burg BLS, van Waes OJF, Verhofstad MHJ, Hoencamp R. Whole blood transfusion in the treatment of acute hemorrhage, a systematic review and meta-analysis. J Trauma Acute Care Surg 2023; 95:256-266. [PMID: 37125904 DOI: 10.1097/ta.0000000000004000] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2023]
Abstract
BACKGROUND Whole blood (WB) transfusion received renewed interest after recent armed conflicts. The effectiveness as compared with blood component transfusion (BCT) is, however, still topic of debate. Therefore, this study investigated the effect of WB ± BCT as compared with BCT transfusion on survival in trauma patients with acute hemorrhage. METHODS Studies published up to January 16, 2023, including patients with traumatic hemorrhage comparing WB ± BCT and BCT were included in meta-analysis. Subanalyses were performed on the effectiveness of WB in the treatment of civilian or military trauma patients, patients with massive hemorrhage and on platelet (PLT)/red blood cell (RBC), plasma/RBC and WB/RBC ratios. Methodological quality of studies was interpreted using the Cochrane risk of bias tool. The study protocol was registered in PROSPERO under number CRD42022296900. RESULTS Random effect pooled odds ratio (OR) for 24 hours mortality in civilian and military patients treated with WB as compared with BCT was 0.72 (95% confidence interval [CI], 0.53-0.97). In subanalysis of studies conducted in civilian setting (n = 20), early (4 hours, 6 hours, and emergency department) and 24 hours mortality was lower in WB groups compared with BCT groups (OR, 0.65; 95% CI, 0.44-0.96 and OR, 0.71; 95% CI, 0.52-0.98). No difference in late mortality (28 days, 30 days, in-hospital) was found. In military settings (n = 7), there was no difference in early, 24 hours, or late mortality between groups. The WB groups received significant higher PLT/RBC ( p = 0.030) during early treatment and significant higher PLT/RBC and plasma/RBC ratios during 24 hours of treatment ( p = 0.031 and p = 0.007). The overall risk of bias in the majority of studies was judged as serious due to serious risk on confounding and selection bias, and unclear information regarding cointerventions. CONCLUSION Civilian trauma patients with acute traumatic hemorrhage treated with WB ± BCT as compared to BCT had lower odds on early and 24-hour mortality. In addition, WB transfusion resulted in higher PLT/RBC and plasma/RBC ratios. LEVEL OF EVIDENCE Systematic Review and Meta-Analysis; Level III.
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Affiliation(s)
- Robert A van der Horst
- From the Department of Surgery (R.A.V.D.H., T.W.H.R., B.L.S.B.V.D.B.), Alrijne Medical Center, Leiderdorp; Trauma Research Unit Department of Surgery (R.A.V.D.H., T.W.H.R., O.J.F.V.W., M.H.J.V., R.H.), Erasmus MC, University Medical Center Rotterdam, Rotterdam; Military Blood Bank (F.N.), Defense Healthcare Organization (R.H.), Ministry of Defense, Utrecht; and Department of Surgery (R.H.), Leiden University Medical Center, Leiden, The Netherlands
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Ngatuvai M, Zagales I, Sauder M, Andrade R, Santos RG, Bilski T, Kornblith L, Elkbuli A. Outcomes of Transfusion With Whole Blood, Component Therapy, or Both in Adult Civilian Trauma Patients: A Systematic Review and Meta-Analysis. J Surg Res 2023; 287:193-201. [PMID: 36947979 DOI: 10.1016/j.jss.2023.02.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Revised: 12/18/2022] [Accepted: 02/17/2023] [Indexed: 03/22/2023]
Abstract
INTRODUCTION This systematic review and meta-analysis was conducted to compare outcomes, including transfusion volume, complications, intensive care unit length of stay, and mortality for adult civilian trauma patients transfused with whole blood (WB), components (COMP), or both (WB + COMP). METHODS A systematic review and meta-analysis were conducted using studies that evaluated outcomes of transfusion of WB, COMP, or WB + COMP for adult civilian trauma patients. A search of PubMed, Embase, and Cochrane from database inception to March 3, 2022 was conducted. The search resulted in 18,400 initial articles with 16 studies remaining after the removal of duplicates and screening for inclusion and exclusion criteria. RESULTS This study identified an increased risk of 24-h mortality with COMP versus WB + COMP (relative risk: 1.40 [1.10, 1.78]) and increased transfusion volumes of red blood cells with COMP versus WB at 6 and 24 h, respectively (-2.26 [-3.82, -0.70]; -1.94 [-3.22, -0.65] units). There were no differences in the calculated rates of infections or intensive care unit length of stay between WB and COMP, respectively (relative risks: 1.35 [0.53, 3.46]; -0.91 [-2.64, 0.83]). CONCLUSIONS Transfusion with WB + COMP is associated with lower 24-h mortality versus COMP and transfusion with WB is associated with a lower volume of red blood cells transfused at both 6 and 24 h. Based on these findings, greater utilization of whole blood in civilian adult trauma resuscitation may lead to improved mortality and reduced transfusion requirements.
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Affiliation(s)
- Micah Ngatuvai
- Dr Kiran.C. Patel College of Allopathic Medicine, NSU NOVA Southeastern University, Fort Lauderdale, Florida
| | - Israel Zagales
- Universidad Iberoamericana (UNIBE) Escuela de Medicina, Santo Domingo, Dominican Republic
| | - Matthew Sauder
- Dr Kiran.C. Patel College of Allopathic Medicine, NSU NOVA Southeastern University, Fort Lauderdale, Florida
| | - Ryan Andrade
- A.T. Still University School of Osteopathic Medicine, Mesa, Arizona
| | - Radleigh G Santos
- Department of Mathematics, NSU NOVA Southeastern University, Fort Lauderdale, Florida
| | - Tracy Bilski
- Division of Trauma and Surgical Critical Care, Department of Surgery, Orlando Regional Medical Center, Orlando, Florida; Department of Surgical Education, Orlando Regional Medical Center, Orlando, Florida
| | - Lucy Kornblith
- Division of Trauma and Surgical Critical Care, Department of Surgery, Zuckerberg San Francisco General Hospital & Trauma Center, San Francisco, California; Department of Surgery, University of San Francisco, San Francisco, California
| | - Adel Elkbuli
- Division of Trauma and Surgical Critical Care, Department of Surgery, Orlando Regional Medical Center, Orlando, Florida; Department of Surgical Education, Orlando Regional Medical Center, Orlando, Florida.
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Mitra B, Wood EM, Reade MC. Whole blood for trauma resuscitation? Injury 2022; 53:1573-1575. [PMID: 35526869 DOI: 10.1016/j.injury.2022.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Affiliation(s)
- Biswadev Mitra
- Emergency & Trauma Centre, The Alfred Hospital; National Trauma Research Institute, The Alfred Hospital; School of Public Health & Preventive Medicine, Monash University.
| | - Erica M Wood
- School of Public Health & Preventive Medicine, Monash University; Department of Clinical Haematology, Monash Health
| | - Michael C Reade
- Faculty of Medicine, University of Queensland; Joint Health Command, Australian Defence Force; Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital
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