Maintaining a Whole Blood-Centered Transfusion Improves Survival in Hemorrhagic Resuscitation

Abstract

Background Whole blood (WB) transfusion has been shown to improve mortality in trauma resuscitation. The optimal ratio of packed red blood cells (pRBC) to WB in emergent transfusion has not been determined. We hypothesized that a low pRBC:WB transfusion ratio is associated with improved survival in trauma patients. Methods We analyzed the 2021 Trauma Quality Improvement Program (TQIP) database to identify patients who underwent emergent surgery for hemorrhage control and were transfused within four hours of hospital arrival, excluding transfers or deaths in the emergency department. We stratified patients based on pRBC:WB ratios. The primary outcome was mortality at 24 hours. Logistic regression was performed to estimate odds of mortality among ratio groups compared to WB alone, adjusting for injury severity, time to intervention, and demographics. Results Our cohort included 17,562 patients; of those, 13,678 patients had only pRBC transfused and were excluded. FFP:pRBC ratio was balanced in all groups. Among those who received WB (n = 3,884), there was a significant increase in 24-hour mortality with higher pRBC:WB ratios (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). Using empirical cutpoint estimation we identified a 3:1 ratio or less as an optimal cutoff point. 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. Adjusted hazard ratios of 24-hour mortality were 2.83(95%CI: 1.18 – 6.77) for 3:1 ratio, 3.67(95%CI: 1.57 – 8.57) for 4:1 ratio, and 1.97(95%CI: 0.91 – 4.23) for 5:1 ratio. Conclusion Our analysis shows that higher pRBC:WB ratios at 4 hours diminished survival benefits of WB in trauma resuscitation. Further efforts should emphasize this relationship to optimize trauma resuscitation protocols.