The Reports of my Death are Greatly Exaggerated: An Evaluation of Futility Cut-Points in Massive Transfusion : Journal of Trauma and Acute Care Surgery

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Original Article

The Reports of my Death are Greatly Exaggerated: An Evaluation of Futility Cut-Points in Massive Transfusion

Clements, Thomas W. MD, FRCSC; Van Gent, Jan-Michael DO, FACS; Lubkin, David E. MD; Wandling, Michael W. MD, FACS; Meyer, David E. MD, FACS; Moore, Laura J. MD, FACS; Cotton, Bryan A. MD, FACS

Author Information

University of Texas Health Science Center at Houston, Red Duke Trauma Institute, and The Mcgovern School of Medicine

This work was presented at the 52nd Annual Meeting of the Western Trauma Association, March 5-10, 2023, in Lake Louise, Alberta.

Conflict of Interest: None declared

Funding: There are no sources of funding to declare

Author contribution: TWC and MVG were responsible for data collection, literature search, study design, data interpretation, manuscript writing, and revisions. KM and DEL were involved in data collection, study design, data interpretation, and revisions. MWW, DEM, and LJM were involved in study design, data analysis, manuscript writing and revisions. BAC was involved in all aspects of the manuscripts production.

Corresponding Author and Address for Reprints: Dr. Thomas W. Clements, MD, FRCSC, MSB 4.331 - 6431 Fannin St Houston, Tx, 77030, Phone: (713) 500-7216, Fax: (713) 486-0971. Email: [email protected], ORCID: 0000-0001-9723-5196

Journal of Trauma and Acute Care Surgery ():10.1097/TA.0000000000003980, May 1, 2023. | DOI: 10.1097/TA.0000000000003980

Abstract

Background 

Following COVID and the subsequent blood shortage, several investigators evaluated futility cut-points in massive transfusion. We hypothesized that early, aggressive use of damage control resuscitation, including whole blood (WB), would demonstrate that these cut-points of futility were significantly underestimating potential survival among patients receiving >50 units of blood in the first four hours.

Methods 

Adult trauma patients admitted from 11/2017-10/2021 who received emergency-release blood products in prehospital or ED setting were included. Deaths within 30 min of arrival were excluded. Total blood products were defined as total RBC, plasma, WB in the field and in the first 4 hours after arrival. Patients were first divided into those receiving ≤50 or > 50 units of blood in the first 4 hours. We then evaluated patients by whether they received any WB or received only component therapy (COMP). 30-day survival was evaluated for all included patients.

Results 

2,299 patients met inclusion (2,043 in ≤50 U, 256 in >50 U groups). While there were no differences in age or gender, the >50 U group was more likley to sustain penetrating injury (47 vs 30%, p < 0.05). Patients receiving >50 U of blood had lower field and arrival blood pressure and larger prehospital and ED resuscitation volumes (p < 0.05). Patients in the >50 U group had lower survival than those in the ≤50 cohort (31 vs 79%; p < 0.05). Patients who received WB (n = 1,291) had 43% increased odds of survival compared to those who received COMP (n = 1,008)(1.09-1.87, p = 0.009) as well as higher 30-day survival at transfusion volumes >50 U.

Conclusion 

Patient survival rates in patients receiving >50 units of blood in the first 4 hours of care are as high as 50-60%, with survival still at 15-25% after 100 units. While responsible blood stewardship is critical, futility should not be declared based on high transfusion volumes alone.

Level of Evidence 

Level III, Retrospective comparative study without negative criteria

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