Earlier Transfusion of Whole Blood Linked to Improved Survival in Patients with Severe Traumatic Hemorrhage

Patients with severe traumatic hemorrhage who received whole blood earlier after arrival at the emergency department had a lower risk of mortality by both 24 hours and 30 days, according to the results of a new study published in JAMA Surgery.

“Patients who benefitted most were those who received whole blood toward the beginning of those first 24 hours,” lead author Crisanto M. Torres, MD, MPH, told AABB. “We actually started to see a separation in survival between those who got whole blood earlier versus those who got it later within the first hour.”

In addition, survival was better for patients who received whole blood earlier throughout 30 days.

The retrospective study included 1,394 individuals (83% male with a median age of 39 years) with severe traumatic hemorrhage, which required activation of a massive transfusion protocol (MTP), at 173 level-1 and -2 trauma centers. MTP was defined as receiving a balanced ratio of packed red blood cells, plasma and platelets of at least 4 units transfused within the first hour after a patient’s arrival at the emergency department.

The cohort data came from the American College of Surgeons Trauma Quality Improvement Program (ACS TQIP) data set from 2019 to 2020. The researchers noted patients included in the study “were profoundly injured, with a median Injury Severity Score of 27 [range 1-75].”

Overall, the median time to whole blood transfusion was 30 minutes and the median time to receipt of the first MTP product was 36 minutes. Median 30-day survival was 16%.

The researchers conducted a survival analysis, which uses time as a continuous variable, allowing them to calculate the probability of survival on a minute-by-minute basis and to determine when the risk of death was greatest based on early or later receipt of whole blood.

“We saw an inflection point at 14 minutes. So, if you got whole blood up to 14 minutes [after arrival], your chance of survival was 96%. But if you got whole blood at 15 minutes, your chance of survival was 91%,” Torres said.

They also found that for survival in the first 4 hours, the secondary outcome, every 1-minute increase in time to whole blood transfusion was associated with an increased risk of mortality. There was no difference in overall length of stay or ICU stay between earlier and later whole blood transfusion patients.

The authors noted that the lack of clear evidence regarding outcomes and timing of whole blood transfusion in the ED are part of the reason that there no clear ACS TQIP management guidelines for massive transfusion in trauma that include the adoption of whole blood as part of MTP.

In an accompanying commentary, Jason L. Sperry, MD, and Matthew D. Neal, MD, wrote that “This study, along with other recent reports that whole-blood resuscitation reduces transfusion requirements in addition to improving mortality, adds to the mounting observational evidence in support of whole blood transfusion in trauma.”

Sperry and Neal, both of the Pittsburgh Trauma and Transfusion Medicine Research Center, University of Pittsburgh, noted the limitations of observational trials, but added that studies such as this one, add to the rigor observational studies through the “appropriate characterization of timing and dose-response relationships.” They added that definitive randomized clinical trials are enrolling currently and are likely “provide definitive evidence for early whole-blood resuscitation to become the standard of care in the management of severely injured patients.”