Original Investigation 

January 18, 2023

Association of Whole Blood With Survival Among Patients Presenting With Severe Hemorrhage in US and Canadian Adult Civilian Trauma Centers

Crisanto M. Torres, Alistair Kent, Dane Scantling, et al

JAMA Surg. 2023;158(5):532-540. doi:10.1001/jamasurg.2022.6978

Key Points

Question  Is whole blood as an adjunct to component therapy–based massive transfusion protocol (MTP) compared with MTP alone associated with improved survival among adult trauma patients presenting with severe hemorrhage?

Findings  In this cohort study of 2785 patients who presented with severe traumatic hemorrhage, whole blood as an adjunct to MTP compared with MTP alone was associated with lower mortality at 24 hours and 30 days, with a survival benefit found as early as 5 hours after emergency department arrival.

Meaning  The findings suggest that whole-blood resuscitation as an adjunct to component–based MTP is associated with improved survival among adult patients presenting to trauma centers with severe hemorrhage, with a benefit found early after administration.

Abstract

Importance  Whole-blood (WB) resuscitation has gained renewed interest among civilian trauma centers. However, there remains insufficient evidence that WB as an adjunct to component therapy–based massive transfusion protocol (WB-MTP) is associated with a survival advantage over MTP alone in adult civilian trauma patients presenting with severe hemorrhage.

Objective  To assess whether WB-MTP compared with MTP alone is associated with improved survival at 24 hours and 30 days among adult trauma patients presenting with severe hemorrhage.

Design, Setting, and Participants  This retrospective cohort study using the American College of Surgeons Trauma Quality Improvement Program databank from January 1, 2017, and December 31, 2018, included adult trauma patients with a systolic blood pressure less than 90 mm Hg and a shock index greater than 1 who received at least 4 units of red blood cells within the first hour of emergency department (ED) arrival at level I and level II US and Canadian adult civilian trauma centers. Patients with burns, death within 1 hour of ED arrival, and interfacility transfers were excluded. Data were analyzed from February 2022 to September 2022.

Exposures  Resuscitation with WB-MTP compared with MTP alone within 24 hours of ED presentation.

Main Outcomes and Measures  Primary outcomes were survival at 24 hours and 30 days. Secondary outcomes selected a priori included major complications, hospital length of stay, and intensive care unit length of stay.

Results  A total of 2785 patients met inclusion criteria: 432 (15.5%) in the WB-MTP group (335 male [78%]; median age, 38 years [IQR, 27-57 years]) and 2353 (84.5%) in the MTP-only group (1822 male [77%]; median age, 38 years [IQR, 27-56 years]). Both groups included severely injured patients (median injury severity score, 28 [IQR, 17-34]; median difference, 1.29 [95% CI, −0.05 to 2.64]). A survival curve demonstrated separation within 5 hours of ED presentation. WB-MTP was associated with improved survival at 24 hours, demonstrating a 37% lower risk of mortality (hazard ratio, 0.63; 95% CI, 0.41-0.96; P = .03). Similarly, the survival benefit associated with WB-MTP remained consistent at 30 days (HR, 0.53; 95% CI, 0.31-0.93; P = .02).

Conclusions and Relevance  In this cohort study, receipt of WB-MTP was associated with improved survival in trauma patients presenting with severe hemorrhage, with a survival benefit found early after transfusion. The findings from this study are clinically important as this is an essential first step in prioritizing the selection of WB-MTP for trauma patients presenting with severe hemorrhage.