Survival and Early Ultra-massive Transfusion: High Red Blood Cell Volumes Are Not Uniformly Futile

Massive transfusion protocols for hemorrhagic shock in trauma are instrumental in improving patient outcomes. However, blood products are limited resources. We hypothesized that adult trauma patients receiving early ultra-massive transfusion (UMT) would have higher mortality compared to those receiving non-UMT, but there would be no strict transfusion volume threshold indicating uniform futility.

Using the Trauma Quality Improvement Program database from 2017 to 2021, we compared mortality and outcomes between adult (≥ 18 y) trauma patients who underwent early UMT (≥ 20 units of packed red blood cells (pRBCs) within 4h of emergency department arrival) to non-UMT transfused 1-9 units and 10-19 units of pRBC. Patients who died prior to arrival to the emergency department were excluded. We also analyzed mortality for patients who received > 100 units of pRBCs.

Of 179,003 patients who underwent transfusion, 5323 (3.0%) received UMT. Mortality was greater for early UMT patients (71.0% versus 1-9 units: 24.3% and 10-19 units: 51.5%, P < 0.001) versus non-UMT patients. Of the 22 patients receiving > 100 units of pRBC, 8 (36.4%) survived to discharge.

This national analysis, spanning 5 y of data, demonstrated that 3% of adult trauma patients received early UMT. Although mortality was higher for those receiving UMT, 29% survived hospitalization. Notable survival was also observed in patients receiving > 100 units of pRBCs. Thus, the decision to continue or terminate massive transfusion protocol should involve multidisciplinary discussions among trauma providers and be tailored to individual patients, factoring in history, injuries, and resource availability.