Managing Major Bleeding

October 19, 2021

One of several “new frontiers” in transfusion medicine relates to how best to treat patients who are bleeding profusely. The 2021 AABB Annual Meeting session titled “New Developments in Optimizing Transfusion Management for Major Bleeding: “One Size Does Not Fit All Causes” addressed key issues in optimizing treatment for these patients by using an individualized approach. The session objectives included the following:
• Consider the evidence for different interventions in massive bleeding from diverse causes.
• Evaluate the use of viscoelastic testing vs. conventional coagulation testing.
• Review the effectiveness of whole blood instead of component therapy in treating major bleeding.

Monica Pagano, MD, from the University of Washington in Seattle, Wash., provided an overview of settings in which major bleeding can occur, including liver disease, gastrointestinal disease, postpartum hemorrhage, cardiac surgery and trauma. She also emphasized the importance of determining the pathophysiology of any bleeding and using testing results to tailor transfusion algorithms for each patient’s clinical course.

Do We Need More than One Protocol?
Simon Stanworth, MA, FRCP(Paeds, UK), PhD, FRCPath from the National Health Service Blood and Transplant in Oxford, United Kingdom, continued the discussion by presenting data from several studies, including the following:
• Halt-It trial (tranexamic acid in patients with gastrointestinal bleeding).
• FIDEL trial (fibrinogen concentrate in patients with postpartum hemorrhage).
• ITACTIC trial (viscoelastic testing used with transfusion algorithms).

For these studies, he shared trial profiles, results, complications and implications for practice.

Stanworth’s review demonstrated that effective treatment of major bleeding can vary with the underlying cause for the blood loss. In other words, a treatment that works in one situation (eg, trauma) will not always work in another setting. His closing remarks to the audience were that we need to consider how such protocols can be individualized, although this is logistically challenging and can require considerable efforts in education.

Mirroring Mother Nature
In his presentation, Mark Yazer, MD, from the University of Pittsburgh, Pittsburgh, Pa., focused on the timing of treatment in major bleeding, demonstrating that pre-hospital (eg, in ambulance, helicopter) blood transfusion can save lives. He shared study results showing impressive decreases in mortality rates with pre-hospital treatment, especially when balanced resuscitation was achieved with both red cell and plasma transfusion.

He further emphasized the benefits of whole blood transfusion—specifically, low-titer group O whole blood (LTOWB)—in both adult and pediatric patients with major bleeding.

He presented data from multiple observational studies showing that whole blood is associated with better survival rates than component therapy. He characterized the benefits of LTOWB from recent studies and a national trauma database, as follows:
• Lower mortality rates.
• Shorter length of stay in the hospital.
• Fewer complications (eg, kidney injury, deep venous thrombosis, pulmonary embolism).
• More rapid availability of the units.

He also shared a study just published in the October issue of Annals of Surgery showing reduced time to base deficit correction in injured children when whole blood was transfused instead of blood components. In closing, he noted that data on LTOWB have come from mostly observational studies and that definitive answers will await the completion of randomized trials that are either under way or will begin shortly.