There has been a renewed interest in the use of whole blood (WB) in trauma resuscitation, with studies showing improved mortality rate with WB. However, there is a paucity of studies assessing the impact of WB on infectious complications. The aim of this study was to assess the impact of WB during trauma resuscitation on infectious complications.
Methods:
A retrospective cohort study utilizing the National Trauma Databank of patients who underwent hemorrhage control laparotomy within one hour was performed. The primary outcome was the impact of receiving WB during trauma resuscitation on surgical infections. Secondary outcome included analysis of a dose–response relation between units of WB and infection. Subgroup analysis was performed on patients undergoing massive transfusion. Multi-variable logistic regression was performed to evaluate outcomes.
Results:
A total of 2,151 patients received WB compared with 10,641 patients who did not. Receiving WB was not associated with increased odds of infection (odds ratio [OR] = 1.12, 95% confidence interval [95% CI]: 0.94–1.32, p = 0.22). However, each unit of WB received was associated with a 4% increase in odds of infection (OR = 1.04, 95% CI: 1.00–1.08, p = 0.04). In the massive transfusion subgroup, receiving WB was not associated with increased risk of infection.
Conclusions:
Receiving WB during trauma resuscitation was associated with increased odds of infection in a dose-dependent manner, but not in patients undergoing massive transfusion. Further studies evaluating effects beyond mortality are needed to better evaluate the impact of WB use on trauma patients.
HolcombJB, del JuncoDJ, FoxEE, et al.; PROMMTT Study Group. The prospective, observational, multicenter, major trauma transfusion (PROMMTT) study: Comparative effectiveness of a time-varying treatment with competing risks. JAMA Surg, 2013; 148(2):127–136; doi: 10.1001/2013.jamasurg.387
2.
BorgmanMA, SpinellaPC, PerkinsJG, et al.The ratio of blood products transfused affects mortality in patients receiving massive transfusions at a combat support hospital. J Trauma, 2007; 63(4):805–813; doi: 10.1097/TA.0b013e3181271ba3
3.
CottonBA, ReddyN, HatchQM, et al.Damage control resuscitation is associated with a reduction in resuscitation volumes and improvement in survival in 390 damage control laparotomy patients. Ann Surg, 2011; 254(4):598–605; doi: 10.1097/SLA.0b013e318230089e
4.
MenesesE, BonevaD, McKenneyM, et al.Massive transfusion protocol in adult trauma population. Am J Emerg Med, 2020; 38(12):2661–2666; doi: 10.1016/j.ajem.2020.07.041
5.
HolcombJB, JenkinsD, RheeP, et al.Damage control resuscitation: Directly addressing the early coagulopathy of trauma. J Trauma, 2007; 62(2):307–310; doi: 10.1097/TA.0b013e3180324124
6.
CantlePM, CottonBA. Balanced resuscitation in trauma management. Surg Clin North Am, 2017; 97(5):999–1014; doi: 10.1016/j.suc.2017.06.002
7.
WalshM, FriesD, MooreE, et al.Whole blood for civilian urban trauma resuscitation: Historical, present, and future considerations. Semin Thromb Hemost, 2020; 46(2):221–234; doi: 10.1055/s-0040-1702174
8.
RepineTB, PerkinsJG, KauvarDS, et al.The use of fresh whole blood in massive transfusion. J Trauma, 2006; 60(6 Suppl):S59–S69; doi: 10.1097/01.ta.0000219013.64168.b2
9.
SpinellaPC, PerkinsJG, GrathwohlKW, et al.Warm fresh whole blood is independently associated with improved survival for patients with combat-related traumatic injuries. J Trauma, 2009; 66(4 Suppl):S69–S76; doi: 10.1097/TA.0b013e31819d85fb
10.
TorresCM, KentA, ScantlingD, et al.Association of whole blood with survival among patients presenting with severe hemorrhage in US and Canadian Adult Civilian Trauma Centers. JAMA Surg, 2023; 158(5):532–540; doi: 10.1001/jamasurg.2022.6978
11.
TorresCM, KenzikKM, SaillantNN, et al.Timing to first whole blood transfusion and survival following severe hemorrhage in trauma patients. JAMA Surg, 2024; 159(4):374–381; doi: 10.1001/jamasurg.2023.7178
12.
SperryJL, CottonBA, LutherJF, et al.; Shock, Whole Blood, and Assessment of Traumatic Brain Injury (SWAT) Study Group. Whole blood resuscitation and association with survival in injured patients with an elevated probability of mortality. J Am Coll Surg, 2023; 237(2):206–219; doi: 10.1097/XCS.0000000000000708
13.
HeckbertSR, VedderNB, HoffmanW, et al.Outcome after hemorrhagic shock in trauma patients. J Trauma, 1998; 45(3):545–549; doi: 10.1097/00005373-199809000-00022
LivingstonDH, AppelSH, WellhausenSR, et al.Depressed interferon gamma production and monocyte HLA-DR expression after severe injury. Arch Surg, 1988; 123(11):1309–1312; doi: 10.1001/archsurg.1988.01400350023002
16.
O’MahonyJB, PalderSB, WoodJJ, et al.Depression of cellular immunity after multiple trauma in the absence of sepsis. J Trauma, 1984; 24(10):869–875; doi: 10.1097/00005373-198410000-00001
17.
DitschkowskiM, KreuzfelderE, RebmannV, et al.HLA-DR expression and soluble HLA-DR levels in septic patients after trauma. Ann Surg, 1999; 229(2):246–254; doi: 10.1097/00000658-199902000-00013
18.
ShahS, SpinellaPC, MuszynskiJA. Immunologic effects of trauma and transfusion. J Trauma Acute Care Surg, 2017; 82(6S Suppl 1):S50–S56; doi: 10.1097/TA.0000000000001434
19.
BochicchioGV, NapolitanoL, JoshiM, et al.Blood product transfusion and ventilator-associated pneumonia in trauma patients. Surg Infect (Larchmt), 2008; 9(4):415–422; doi: 10.1089/sur.2006.069
20.
HorvathKA, AckerMA, ChangH, et al.Blood transfusion and infection after cardiac surgery. Ann Thorac Surg, 2013; 95(6):2194–2201; doi: 10.1016/j.athoracsur.2012.11.078
21.
LadhaniHA, HoVP, CharbonnetCC, et al.; PAMPer Study Group. Dose-dependent association between blood transfusion and nosocomial infections in trauma patients: A secondary analysis of patients from the PAMPer trial. J Trauma Acute Care Surg, 2021; 91(2):272–278; doi: 10.1097/TA.0000000000003251
22.
ClaridgeJA, SawyerRG, SchulmanAM, et al.Blood transfusions correlate with infections in trauma patients in a dose-dependent manner. Am Surg, 2002; 68(7):566–572; doi: 10.1177/000313480206800702
23.
McQuiltenZK, FlintAW, GreenL, et al.Epidemiology of massive transfusion—A common intervention in need of a definition. Transfus Med Rev, 2021; 35(4):73–79; doi: 10.1016/j.tmrv.2021.08.006
24.
ZattaAJ, McQuiltenZK, MitraB, et al.; Massive Transfusion Registry Steering Committee. Elucidating the clinical characteristics of patients captured using different definitions of massive transfusion. Vox Sang, 2014; 107(1):60–70; doi: 10.1111/vox.12121
25.
Dorken-GallastegiA, RenneAM, BokenkampM, et al.Balanced blood component resuscitation in trauma: Does it matter equally at different transfusion volumes? Surgery, 2023; 173(5):1281–1288; doi: 10.1016/j.surg.2022.11.010
26.
Dorken-GallastegiA, SpinellaPC, NealMD, et al.Whole blood and blood component resuscitation in trauma: Interaction and association with mortality. Ann Surg, 2024; 280(6):1014–1020; doi: 10.1097/SLA.0000000000006316
27.
MatthayZA, HellmannZJ, CallcutRA, et al.Outcomes after ultramassive transfusion in the modern era: An Eastern Association for the Surgery of Trauma multicenter study. J Trauma Acute Care Surg, 2021; 91(1):24–33; doi: 10.1097/TA.0000000000003121
28.
ChesnayeNC, StelVS, TripepiG, et al.An introduction to inverse probability of treatment weighting in observational research. Clin Kidney J, 2022; 15(1):14–20; doi: 10.1093/ckj/sfab158
29.
SheppardFR, SchaubLJ, CapAP, et al.Whole blood mitigates the acute coagulopathy of trauma and avoids the coagulopathy of crystalloid resuscitation. J Trauma Acute Care Surg, 2018; 85(6):1055–1062; doi: 10.1097/TA.0000000000002046
30.
HannaM, KnittelJ, GillihanJ. The use of whole blood transfusion in trauma. Curr Anesthesiol Rep, 2022; 12(2):234–239; doi: 10.1007/s40140-021-00514-w
31.
PerkinsJG, CapAP, SpinellaPC, et al.; 31st Combat Support Hospital Research Group. Comparison of platelet transfusion as fresh whole blood versus apheresis platelets for massively transfused combat trauma patients (CME). Transfusion, 2011; 51(2):242–252; doi: 10.1111/j.1537-2995.2010.02818.x
32.
CottonBA, PodbielskiJ, CampE, et al.; Early Whole Blood Investigators. A randomized controlled pilot trial of modified whole blood versus component therapy in severely injured patients requiring large volume transfusions. Ann Surg, 2013; 258(4):527–532; discussion 532-523; doi: 10.1097/SLA.0b013e3182a4ffa0
33.
HannaK, BibleL, ChehabM, et al.Nationwide analysis of whole blood hemostatic resuscitation in civilian trauma. J Trauma Acute Care Surg, 2020; 89(2):329–335; doi: 10.1097/TA.0000000000002753
34.
RosemurgyAS, HartMB, MurphyCG, et al.Infection after injury: Association with blood transfusion. Am Surg, 1992; 58(2):104–107.
35.
AgarwalN, MurphyJG, CaytenCG, et al.Blood transfusion increases the risk of infection after trauma. Arch Surg, 1993; 128(2):171–176; discussion 176-177; doi: 10.1001/archsurg.1993.01420140048008
36.
HenslerT, HeinemannB, SauerlandS, et al.Immunologic alterations associated with high blood transfusion volume after multiple injury: Effects on plasmatic cytokine and cytokine receptor concentrations. Shock, 2003; 20(6):497–502; doi: 10.1097/01.shk.0000095058.62263.1f
37.
HillGE, FrawleyWH, GriffithKE, et al.Allogeneic blood transfusion increases the risk of postoperative bacterial infection: A meta-analysis. J Trauma, 2003; 54(5):908–914; doi: 10.1097/01.TA.0000022460.21283.53
ZallenG, OffnerPJ, MooreEE, et al.Age of transfused blood is an independent risk factor for postinjury multiple organ failure. Am J Surg, 1999; 178(6):570–572; doi: 10.1016/s0002-9610(99)00239-1
FrieseRS, SperryJL, PhelanHA, et al.The use of leukoreduced red blood cell products is associated with fewer infectious complications in trauma patients. Am J Surg, 2008; 196(1):56–61; doi: 10.1016/j.amjsurg.2007.08.063
44.
EnglehartMS, ChoSD, MorrisMS, et al.Use of leukoreduced blood does not reduce infection, organ failure, or mortality following trauma. World J Surg, 2009; 33(8):1626–1632; doi: 10.1007/s00268-009-0076-5
45.
RohdeJM, DimcheffDE, BlumbergN, et al.Health care-associated infection after red blood cell transfusion: A systematic review and meta-analysis. JAMA, 2014; 311(13):1317–1326; doi: 10.1001/jama.2014.2726
46.
DonnellCA, DanielSJ, FerraraJJ. Fibrinogen degradation products in fresh frozen plasma. Possible contribution to immunosuppression. Am Surg, 1989; 55(8):505–507.
47.
BlumbergN, HealJM. Evidence for plasma-mediated immunomodulation–transfusions of plasma-rich blood components are associated with a greater risk of acquired immunodeficiency syndrome than transfusions of red blood cells alone. Transplant Proc, 1988; 20(6):1138–1142.
48.
SaraniB, DunkmanWJ, DeanL, et al.Transfusion of fresh frozen plasma in critically ill surgical patients is associated with an increased risk of infection. Crit Care Med, 2008; 36(4):1114–1118; doi: 10.1097/CCM.0b013e318168f89d
49.
InabaK, BrancoBC, RheeP, et al.Impact of plasma transfusion in trauma patients who do not require massive transfusion. J Am Coll Surg, 2010; 210(6):957–965; doi: 10.1016/j.jamcollsurg.2010.01.031
50.
O’DellJC, McCoyCC, WinfieldRD, et al.Infection is not associated with plasma or cryoprecipitate transfusion volumes in trauma: a retrospective study using the national trauma data bank. Surg Infect (Larchmt), 2024; 25(4):291–299; doi: 10.1089/sur.2023.273
Supplementary Material
Please find the following supplemental material available below.
For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.
For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.
