Massive Transfusion Activations in Non-Trauma Patients.

INTRODUCTION: Massive transfusion activations (MTAs) are commonly used in the care of the trauma patient. However, MTA for trauma patients constitutes only a small fraction of MTA at our institution. The aim of this study was to characterize MTA in non-trauma patients to better understand how this strategy is employed at a larger tertiary hospital. METHODS: All MTA involving non-trauma patients from January 2017 to April 2019 were reviewed. Patients with unclear indications for MTA were excluded. Data collected included patient demographics, reason for MTA, transfusion ratios, use of adjunctive antifibrinolytics, use of viscoelastic testing, and vasopressor administration at the time of MTA. RESULTS: There were 328 patients and 353 MTA identified over the study period. The mean age was 52.0 years and 40.9% were male. Patients were most commonly under the care of a medical service (55.2%), while 25.3% were obstetric patients and 19.5% were surgical patients. Compliance with 1:1:1 transfusion ratios was low. Concomitant vasopressor use was high (70.8%), while antifibrinolytic agents (13.0%) and viscoelastic testing (19.0%) were used less commonly. The overall mortality of the study population was 56.1%. CONCLUSIONS: Massive transfusion activations are frequently used in non-trauma patients. There was a low rate of adherence to 1:1:1 transfusion ratios as well as utilization of adjuncts and tools that could allow for targeted resuscitation. Understanding practice patterns relating to MTA may allow for an opportunity for improvement.

Implementation of a low-titer stored whole blood transfusion program for civilian trauma patients: Early experience and logistical challenges.

INTRODUCTION: Cold-stored low titer group O whole blood (LTOWB) is increasingly utilized in the initial resuscitation of exsanguinating trauma patients. We report on our early experience with LTOWB, focusing on logistics, implementation challenges, and outcomes. METHODS: In February, 2019, LTOWB was incorporated into the massive transfusion protocol (MTP) activated for trauma patients in the emergency department (ED.) Up to 4 units of LTOWB were included in the MTP cooler, depending on availability, and were transfused prior to transfusion of any other blood products from the MTP cooler. Demographics, injury characteristics, and outcomes were obtained, and the logistics of LTOWB availability were reviewed. RESULTS: Over a 12-month period, MTP was activated for 74 trauma patients. Of those, 38 (51%) MTP included at least one unit of LTOWB, with 19/38 (50%) including 4 LTOWB units. A total of 177 units of LTOWB were purchased during the study period, and of those, 74 (42%) expired before use. Patients who received LTOWB had a similar mortality compared to those who received component therapy (39% vs. 47%; Odds Ratio [95% CI]: 0.7 [0.3, 2.0]; p = 0.72,) however, they were able to achieve a significantly higher plasma:pRBC ratio during the duration of MTP activation (mean [SD] 0.8 [0.2] vs. 0.4 [0.4]; mean difference [95% CI]: 0.4 [0.2, 0.5]; p < 0.01.) CONCLUSIONS: Our early experience with LTOWB transfusion demonstrates feasibility, but also highlights challenges with inventory management. These findings triggered changes to our protocol aiming at minimizing wastage. The use of LTOWB may yield a higher plasma:pRBC ratio early during the resuscitation period. Further investigation is required to explore whether this may yield a survival advantage. LEVEL OF EVIDENCE: III (Therapeutic/Care Management).

Toward extended phenotype matching: a new operational paradigm for the transfusion service.

BACKGROUND: Conventional pretransfusion testing uses hemagglutination to ensure donor-recipient compatibility for ABO/D status and recipient alloantibodies. While screening large numbers of donor units for multiple antigens by hemagglutination is impractical, novel methods of DNA analysis permit the rapid determination of an extended human erythrocyte antigen (xHEA) phenotype. A prospective observational study was conducted at four hospital transfusion services to test an alternative paradigm of identifying xHEA-typed units for patients in three cohorts by utilizing DNA analysis and a novel inventory management model. STUDY DESIGN AND METHODS: xHEA typing of recipient samples and donor units of known ABO/D status was performed by HEA analysis (BeadChip, BioArray Solutions). xHEA-typed units were assigned to pending transfusion requests using an inventory management system designed to simulate blood order processing. The fraction of requests fulfilled, or "fill fraction" (FF) was determined at four levels of matching stringency. RESULTS: For alloimmunized patients, all but one participating site observed an FF of more than 95% when matching for ABO, D, and known alloantibodies and an FF of more than 90% when additionally matching for C, c, E, e, and K; the site handling the most challenging requests still observed FFs of 62 and 51%, respectively. FF was found to correlate positively with the ratio of available donor units to units requested and negatively with the degree of recipient alloimmunization. CONCLUSION: This study demonstrates that substantial fill fractions can be achieved by selecting existing donor units for xHEA analysis and operating an inventory management system for efficient allocation of units to recipients.