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

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.

Antithrombin Activity Is Associated with Persistent Thromboinflammation and Mortality in Patients with Severe COVID-19 Illness.

INTRODUCTION: Severe COVID-19 illness can lead to thrombotic complications, organ failure, and death. Antithrombin (AT) regulates thromboinflammation and is a key component of chemical thromboprophylaxis. Our goal was to examine the link between AT activity and responsiveness to thromboprophylaxis, markers of hypercoagulability, and inflammation among severe COVID-19 patients. METHODS: This was a single-center, prospective observational study enrolling SARS-CoV-2-positive patients admitted to the intensive care unit on prophylactic enoxaparin. Blood was collected daily for 7 days to assess AT activity and anti-factor Xa levels. Patient demographics, outcomes, and hospital laboratory results were collected. Continuous variables were compared using Mann-Whitney tests, and categorical variables were compared using χ2 tests. Multivariable logistic regression was used to determine the association between AT activity and mortality. RESULTS: In 36 patients, 3 thromboembolic events occurred, and 18 (50%) patients died. Patients who died had higher fibrinogen, D-dimer, and C-reactive protein (CRP) levels and lower AT activity. Reduced AT activity was independently associated with mortality and correlated with both markers of hypercoagulability (D-dimer) and inflammation (CRP). CONCLUSION: Low AT activity is associated with mortality and persistent hypercoagulable and proinflammatory states in severe COVID-19 patients. The anti-thromboinflammatory properties of AT make it an appealing therapeutic target for future studies.

Green Plasma Has a Superior Hemostatic Profile Compared With Standard Color Plasma.

BACKGROUND: Limitations in available donors have dramatically reduced plasma availability over the past several decades, concurrent with increasing demand for some types of plasma. Plasma from female donors who are pregnant or taking oral contraceptives often has a green appearance, which frequently results in these units being discarded. This pilot study aimed to evaluate the hemostatic potential of green compared to standard-color plasma. MATERIALS AND METHODS: Plasma from twelve blood group-matched female and twelve male donors was obtained from the local blood center. Six of the female and all of the male units of plasma had a normal appearance (STANDARD), while six of the female units were grossly green (GREEN). The hemostatic potential was evaluated by thrombelastography (TEG), calibrated automated thrombogram (CAT), and coagulation factor level measurements. Univariate analysis was performed using Wilcoxon Rank-Sum. RESULTS: GREEN plasma was more procoagulant for all TEG values (r-value, k-time, angle, mA) when compared to STANDARD plasma. Differences were also observed in coagulation factor levels, with GREEN plasma having higher than STANDARD (factors II; VII, IX; X, XI, Protein S, and plasminogen); conversely, GREEN plasma had a longer lag time in CAT. DISCUSSION: This pilot study demonstrates that female donors with green plasma have a superior hemostatic profile than standard plasma. GREEN plasma should be further investigated for its safety profile and hemostatic potential, so if it is found to be a safe and functionally non-inferior product, it should be actively re-introduced for transfusion in bleeding patients.