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The use of whole blood in traumatic bleeding: a systematic review

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Abstract

Hemostatic resuscitation is currently considered a standard of care for the management of life-threatening hemorrhage, but in some critical settings the access to high quantities of blood components is problematic. Whole blood (WB) transfusion has been proposed as an alternative modality for hemostatic resuscitation of traumatic major bleeding. To assess the efficacy and safety of WB in trauma-associated massive bleeding, we performed a systematic review of the literature. We selected studies comparing WB transfusions to transfusion of blood components (COMP) in massive trauma bleeding; both randomized clinical trial (RCT) and observational studies were considered. The outcomes were mortality (30-day/in-hospital and 24-h mortality) and adverse events/transfusion reactions. The effect sizes were crude odds ratio (OR), adjusted OR and hazard ratio (HR). The methodological quality of studies was assessed using the Cochrane Risk of Bias tool for RCTs, and the ROBIN-1 tool for observational studies. The overall quality of the available evidence was assessed with the GRADE system. One RCT (2 reports) and 6 cohort studies were included (3642 adult patients; 675 receiving WB, 2967 receiving COMP). Three studies were conducted in military setting, and 4 in civilian setting. In the overall analysis, 30-day/in-hospital and 24-h mortality did not differ significantly between groups (very low quality of the evidence due to high risk of bias, imprecision and inconsistency). After adjustment for baseline covariates in three cohort studies, the OR for mortality was significantly lower in WB recipients compared to COMP (OR 0.22; 95% CIs 0.10/0.45) (moderate grade of evidence). Adverse events and transfusion reactions were overlooked and not consistently reported. The available evidence does not allow to draw definite conclusions on the short-term and long-term efficacy and safety of WB transfusion compared to COMP transfusion. Further well designed research is needed.

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Authors and Affiliations

  1. Italian National Blood Centre, Rome, Italy

    Mario Cruciani, Massimo Franchini, Carlo Mengoli, Giuseppe Marano, Ilaria Pati, Francesca Masiello, Eva Veropalumbo, Simonetta Pupella, Stefania Vaglio, Vanessa Agostini & Giancarlo Maria Liumbruno

  2. AULSS9 Scaligera, Infection Control Committee and Antibiotic Stewardship Programme, Verona, Italy

    Mario Cruciani

  3. Department of Hematology and Transfusion Medicine, Carlo Poma Hospital, Mantua, Italy

    Massimo Franchini

  4. Immunohematology and Transfusion Service, IRCCS Policlinico San Martino, Genova, Italy

    Vanessa Agostini

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  1. Mario Cruciani
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Contributions

MF, GML and MC had the idea for the article. GM, SV, IP, FM and EV performed the literature search and data analysis, MC performed quality assessment, CM performed statistical analysis, MF, GML, SP and VA drafted and/or critically revised the manuscript. All authors read and approved the final manuscript.

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Correspondence to Massimo Franchini.

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Electronic supplementary material

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Supplementary file1 (DOCX 151 kb) Online Supplementary Table S1. Risk of bias assessment.

11739_2020_2491_MOESM2_ESM.docx

Supplementary file2 (DOCX 20 kb) Online Supplementary Table S2. Use of whole blood in traumatic bleeding: summary of findings.

11739_2020_2491_MOESM3_ESM.docx

Supplementary file3 (DOCX 17 kb) Online Supplementary Figure S1. Risk of bias summary: review authors' judgements about each risk of bias item for RCT included in the analysis.

11739_2020_2491_MOESM4_ESM.docx

Supplementary file4 (DOCX 45 kb) Online Supplementary Figure S2. Forest plot of whole blood effect on 30 days/ in-hospital mortality (adjusted hazard ratio). Legend. Inverse-variance, fixed effect pooling of adjusted HR from survival-time, multiple Cox regression. TE is treatment effect as log HR at study level; SE is the standard error. The summary measure is expressed as HR.

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Cruciani, M., Franchini, M., Mengoli, C. et al. The use of whole blood in traumatic bleeding: a systematic review. Intern Emerg Med 16, 209–220 (2021). https://doi.org/10.1007/s11739-020-02491-0

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