AHRQ Systematic Review Finds Insufficient Evidence to Determine Optimal Prehospital Transfusion and Fluid Strategies

The Agency for Healthcare Research and Quality (AHRQ) recently published a systematic review, which found that published studies provide insufficient evidence to determine which blood transfusion or fluid interventions offer the greatest benefit to inform clinical guidance or policy recommendations. The review also highlights the need for additional research to identify effective strategies for implementing, sustaining and evaluating prehospital blood transfusion and fluid resuscitation programs.

For the review, AHRQ developed a protocol with input from 14 experts to synthesize evidence on prehospital transfusion and infusion interventions for traumatic and nontraumatic hemorrhagic shock across all age groups. Interventions evaluated included whole blood, packed red blood cells (pRBCs), plasma, crystalloid fluids and bundled resuscitation strategies. The review included 119 studies, most of which were rated as having moderate to high risk of bias.

The review found insufficient strength of evidence to support mortality benefits for most prehospital transfusion and fluid resuscitation strategies. No differences in mortality were observed for pRBCs or plasma compared with usual care in most analyses, and evidence was insufficient to determine mortality effects for whole blood or for low- versus high-volume crystalloid fluids. However, an advanced resuscitative care bundle that included calcium, tranexamic acid and pRBCs was associated with a moderate reduction in mortality at discharge compared with usual care.

The systematic review also identified several research gaps. AHRQ emphasized the need for more rigorous, generalizable studies that directly compare patient-centered outcomes across blood products and transfusion strategies. Future research should also address implementation factors, including trauma center and blood bank partnerships, organizational support, personnel training and systematic data collection, to strengthen the evidence base guiding prehospital transfusion programs.