Original Investigation
January 31, 2024
Timing to First Whole Blood Transfusion and Survival Following Severe Hemorrhage in Trauma Patients
Crisanto M. Torres, Kelly M. Kenzik, Noelle N. Saillant, et al
JAMA Surg. Published online January 31, 2024. doi:10.1001/jamasurg.2023.7178
Question Is the timing of first whole blood transfusion associated with improved early and late survival among adult trauma patients presenting with severe hemorrhage?
Findings In this cohort study of 1394 patients who presented with severe traumatic hemorrhage requiring massive transfusion, less time to first whole blood transfusion was associated with a reduced time to death at 24 hours and 30 days, with a survival benefit seen as early as 1 hour after emergency department arrival.
Meaning These findings suggest the importance of timing to first whole blood transfusion when given as an adjunct to a massive transfusion protocol.
Abstract
Importance Civilian trauma centers have revived interest in whole-blood (WB) resuscitation for patients with life-threatening bleeding. However, there remains insufficient evidence that the timing of WB transfusion when given as an adjunct to a massive transfusion protocol (MTP) is associated with a difference in patient survival outcome.
Objective To evaluate whether earlier timing of first WB transfusion is associated with improved survival at 24 hours and 30 days for adult trauma patients presenting with severe hemorrhage.
Design, Setting, and Participants This retrospective cohort study used the American College of Surgeons Trauma Quality Improvement Program databank from January 1, 2019, to December 31, 2020, for adult patients presenting to US and Canadian adult civilian level 1 and 2 trauma centers with systolic blood pressure less than 90 mm Hg, with shock index greater than 1, and requiring MTP who received a WB transfusion within the first 24 hours of emergency department (ED) arrival. Patients with burns, prehospital cardiac arrest, deaths within 1 hour of ED arrival, and interfacility transfers were excluded. Data were analyzed from January 3 to October 2, 2023.
Exposure Patients who received WB as an adjunct to MTP (earlier) compared with patients who had yet to receive WB as part of MTP (later) at any given time point within 24 hours of ED arrival.
Main Outcomes and Measures Primary outcomes were survival at 24 hours and 30 days.
Results A total of 1394 patients met the inclusion criteria (1155 male [83%]; median age, 39 years [IQR, 25-51 years]). The study cohort included profoundly injured patients (median Injury Severity Score, 27 [IQR, 17-35]). A survival curve demonstrated a difference in survival within 1 hour of ED presentation and WB transfusion. Whole blood transfusion as an adjunct to MTP given earlier compared with later at each time point was associated with improved survival at 24 hours (adjusted hazard ratio, 0.40; 95% CI, 0.22-0.73; P = .003). Similarly, the survival benefit of earlier WB transfusion remained present at 30 days (adjusted hazard ratio, 0.32; 95% CI, 0.22-0.45; P < .001).
Conclusions and Relevance In this cohort study, receipt of a WB transfusion earlier at any time point within the first 24 hours of ED arrival was associated with improved survival in patients presenting with severe hemorrhage. The survival benefit was noted shortly after transfusion. The findings of this study are clinically important as the earlier timing of WB administration may offer a survival advantage in actively hemorrhaging patients requiring MTP.
