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Parts or the Whole Blood for Trauma Patients?

February 14, 2024

Written by Rebecca White

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In trauma patients, 24-hour mortality rate increased with increasing ratio of packed red blood cells (pRBC) to whole blood (WB) transfusion, even when pRBC transfusion was balanced with platelets and fresh frozen plasma (FFP). Mortality rate was lowest in patients transfused with whole blood alone.

Looks like Aristotle knew what he was talking about…
Yesterday, we covered an article in JTH that showed improved short-term mortality and reduced transfusion volume for trauma patients receiving whole blood. However, the ideal ratio of pRBC to WB is unclear. In this study, the 2021 Trauma Quality Improvement Program (TQIP) database was analyzed to include patients transfused within four hours of hospital arrival who underwent hemorrhage-control surgery, excluding transfers or deaths in the ED. Patients were stratified by pRBC:WB transfusion ratio, and the primary outcome was 24-hour mortality.

Of 17,562 patients, 13,768 received pRBC alone and were excluded. Of the 3,884 who received WB, 24-hour mortality increased significantly with higher pRBC:WB ratios at 4 hours (WB alone 5.2%, 1:1 10.9%, 2:1 11.8%, 3:1 14.9%, 4:1 20.9%, 5:1 34.1%, p=0.0001). A ratio of 3:1 or less was an optimal cutoff point using empirical cutpoint estimation. Adjusted odds ratios of 24-hour mortality for 4:1 and 5:1 groups were 2.85 (95%CI 1.19-6.81) and 2.89 (95%CI 1.29-6.49), respectively.

All transfusion ratio groups received balanced resuscitation with an average pRBC:FFP ratio of 1:1. Platelet administration was variable, though it appeared to increase with higher pRBC:WB ratio.

How will this change my practice?
The results of this study indicate that WB is greater than the sum of its parts. However, WB supply is limited in many settings due to the resources required for its preservation compared to individual blood components. Practically speaking, it may not be feasible to meet the optimal 3:1 ratio, especially in large-volume transfusion. When it is available, I will prioritize WB transfusion in trauma patients over component therapy.

Maintaining a Whole Blood-Centered Transfusion Improves Survival in Hemorrhagic ResuscitationJ Trauma Acute Care Surg. Published online December 21, 2023. doi:10.1097/TA.0000000000004222