Uncrossmatched Red Blood Cells Research Articles

Transfusion of ABO-group identical red blood cells following uncrossmatched transfusion does not lead to higher mortality in civilian trauma patients.

Questions persist about the safety of switching non-group O recipients of group O uncrossmatched red blood cells (RBC) or low titer group O whole blood (LTOWB) to ABO-identical RBCs during their resuscitation. The database of an earlier nine-center study of transfusing incompatible plasma to trauma patients was reanalyzed. The patients were divided into three groups based on 24-h RBC transfusion: (1) group O patients who received group O RBC/LTOWB units (control group, n = 1203), (2) non-group O recipients who received only group O units (n = 646), (3) non-group O recipients who received at least one unit of group O and non-group O units (n = 562). Fixed marginal effect of receipt of non-O RBC units on 6- and 24-h and 30-day mortality was calculated. The non-O patients who received only group O RBCs received fewer RBC/LTOWB units and had slightly but significantly lower injury severity score compared to control group; non-group O patients who received both group O and non-O units received significantly more RBC/LTOWB units and had a slightly but significantly higher injury severity score compared to control group. In the multivariate analysis, the non-O patients who received only group O RBCs had significantly higher mortality at 6-h compared to the controls; the non-group O recipients of O and non-O RBCs did not demonstrate higher mortality. At 24-h and 30-days, there were no differences in survival between the groups. Providing non-group O RBCs to non-group O trauma patients who also received group O RBC units is not associated with higher mortality.

Incidence of Red Cell Antibody Formation Following Massive Transfusion Protocol: Experience of a Single Institution.

Injured patients in hemorrhagic shock have a survival benefit with massive transfusion protocol (MTP). While there are many published studies on the transfusion management of massively bleeding patients, the risk of alloimmunization in patients that have received products during an MTP activation is relatively unknown. Therefore, we sought to determine the frequency of new antibody formation in MTP patients that received blood products from an uncrossmatched megapack. We conducted a retrospective data review of patients who underwent an MTP activation for trauma resuscitation between May 2014 and July 2020. Data were collected from patients who met the following criteria: MTP was activated, the patients received at least one unit of packed red blood cells, one unit of fresh frozen plasma, one unit of platelets, and had a repeat type and screen within 6 weeks of transfusion. These inclusion criteria resulted in 28 patients over the 6-year timeframe. Overall, the risk of alloimmunization secondary to MTP is 3.6% in our trauma patient population. The newly developed antibodies post-MTP are considered clinically significant, meaning they can cause hemolysis if exposed to donor red blood cells containing those antigens. Blood products should be given preferentially over crystalloids to acutely bleeding patients to prevent ischemic injury during an MTP activation despite the risk of alloimmunization. In our single-institution study, the alloimmunization rate in massive transfusions where patients receive uncrossmatched red blood cells is similar to those receiving crossmatched red blood cells.

Survey of the RhD selection and issuing practices for uncrossmatched blood products at pediatric trauma hospitals in the United States: The BEST collaborative study.

As evidence demonstrating the importance of early transfusions in trauma resuscitation accumulates, when RhD-negative products might not be available, it is important to understand the nature of the RhD-type of products provided to bleeding pediatric patients of potentially unknown RhD-type. A survey link was electronically sent to the transfusion service medical director and/or laboratory manager at American pediatric Level I and Level II hospitals inquiring about their practices for selecting RhD-type of uncrossmatched red blood cells (RBC) or low titer group O whole blood (LTOWB) for boys and girls. There were 55/117 (47.0%) analyzable responses; 43/55 (78.2%) from Level I and 12/55 (21.8%) from Level II hospitals. For in hospital transfusions, 51/55 (92.7%) of centers use only RhD-negative blood products to resuscitate girls ≤18 years old while 30/55 (54.5%) of centers do the same for boys ≤18 years old. Most centers 41/55(74.5%) store RBCs and/or LTOWB in in-hospital remote refrigerators; 27 store only RhD-negative RBCs and 2 store only RhD-negative LTOWB units in these refrigerators. A total of 24/55 (43.6%) centers have RBCs and/or LTOWB available on road ambulances or helicopters for prehospital transfusion; 12 transport only RhD-negative RBCs and two transport only RhD-negative LTOWB. Most centers, 35/55 (63.6%), address the prophylaxis of an RhD-negative female recipient of RhD-positive transfusion on a case-by-case basis. While there is some variability, most of the responding pediatric trauma centers routinely utilized RhD-negative RBCs for emergency transfusion for patients ≤18 years old of unknown RhD-type.

Uncrossmatched Blood Transfusion for Resuscitation Patients at the Emergency Department

BACKGROUND: Patients with uncontrolled blood loss often require immediate blood transfusion after the bleeding is stopped. If it is an emergency situation, blood that has not been tested for compatibility (uncrossmatched red blood cell [URBC] products) can be used. However, no studies have been conducted to evaluate the effectiveness of this protocol. AIM: The aim of the study is to evaluate the effectiveness of URBC transfusion in Srinagarind Hospital’s emergency department (ED). METHODS: This was a cross-sectional study that reviewed the medical records of ninty Thai patients over 18 years of age who received at least one unit of blood through URBC transfusion in the Srinagarind Hospital ED from September 2016 to August 2018. RESULTS: The average age of the patients was 47.23 ± 18.2 years, and 73.3% were male. A total of 149 units of URBC were provided, with 54.44% of recipients being trauma patients and 27.78% being gastrointestinal bleeding patients. The 24-h and in-hospital mortality rates were 58.89 and 72.22%, respectively. There were no cases of acute blood transfusion complications or inappropriate URBC transfusion. CONCLUSIONS: The transfusion of URBC necessary in patients with uncontrolled bleeding. No complications were found due to acute blood transfusion.

Experience of Cases for Hepatic Injury Surgery Treated with Uncrossmatched Red Blood Cell of Type O Transfusion

Introduction: Patients with hemorrhagic shock need transfusion of uncrossmatched type O packed red blood cells (PRBCs) immediately on arrival at the hospital. Here, we report the outcomes of patients who received transfusion of uncrossmatched type O PRBCs for hepatic injury surgery in our hospital. This study was conducted to investigate effective management strategies for patients with severe blunt liver injuries. Patients and methods: From January 2017 to December 2019, three patients who underwent emergency laparotomy for hepatic injury underwent transfusion of uncrossmatched type O PRBCs. Data, including age, sex, AAST(American Association for the Surgery of Trauma) liver injury scale, injury severity score (ISS), revised trauma score (RTS), probability of survival (Ps), time to hemostasis, and RBC transfusion volume in 24 hours, were compared between survivors and non survivors. Results: Of the three patients, two were men and one was a woman (mean age: 73 years). The results are listed in the table1.Damage control surgery (DCS), open abdominal management, and interventional radiology (IVR) were performed in all patients. Of the three patients, one survived and two died. One case was a case with acute myocardial infarction. The Ps of the surviving patient was 0.26. The survivor underwent operation more quickly when compared with the non survivors. Conclusion: Early DCS combined with IVR may improve the outcome in patients with severe blunt hepatic injuries.Table 1Caseliver injury scale(AAST )GradeISSRTSPsTime to hemostasis(min)RBC transfusion volume in 24 hours (units)Outcome1Ⅴ217.840.9228840death2Ⅲ332.630.0617548death3Ⅴ383.190.2622100survival Open table in a new tab

Whole Blood is Superior to Component Transfusion for Injured Children

To compare a propensity-matched cohort of injured children receiving conventional blood component transfusion to injured children receiving low-titer group O negative whole blood. Transfusion of whole blood in pediatric trauma patients is feasible and safe. Effectiveness has not been evaluated. Injured children ≥1 years old can receive up to 40 mL/kg of cold-stored, uncrossmatched whole blood during initial hemostatic resuscitation. Whole blood recipients (2016-2019) were compared to a propensity-matched cohort who received at least 1 uncrossmatched red blood cell unit in the trauma bay (2013-2016). Cohorts were matched for age, hypotension, traumatic brain injury, injury mechanism, and need for emergent surgery. Outcomes included time to resolution of base deficit, product volumes transfused, and INR after resuscitation. Twenty-eight children who received whole blood were matched to 28 children who received components. The whole blood group had faster time to resolution of base deficit [median (IQR) 2 (1-2.5) hours vs 6 (2-24) hours, respectively; P < 0.001]. The post-transfusion INR was decreased in whole blood vs component cohort [median (IQR) 1.4 (1.3-1.5) vs 1.6 (1.4-2.2); P = 0.01]. Lower plasma volumes [median (IQR) = 5 (0-15) mL/kg vs 11 (5-35) mL/kg; P = 0.04] and lower platelet volumes [median (IQR) = 0 (0-2) vs 3 (0-8); P = 0.03] were administered to the whole blood group versus component group. Other clinical variables (in-hospital death, hospital length of stay, intensive care unit length of stay, and ventilator days) did not differ between groups. Compared to component transfusion, whole blood transfusion results in faster resolution of shock, lower post-transfusion INR, and decreased component product transfusion. Larger cohorts are required to support these findings.

Rational red blood cells administration - have we achieved a satisfactory level?

Introduction. The important indicators of the quality of work in blood transfusion banks and health care facilities in general is the ratio of the cross-matched red blood cell (RBC) units, and the number of transfused RBC, known as cross-match to transfusion ratio (C:T). The objective of this research was to provide an assessment of the quality of our work in a cross-sectional study, showing C:T ratios for certain areas of surgery or particular surgical indications. Methods. We analyzed the data related to the activities of the Department for Pre-Transfusion Testing and Blood Distribution at the Blood Transfusion Institute of Serbia during the September and November of 2017 period. In total, 341 patients were included in the study, for whom 1,067 RBC units were requested. Results. In pre-transfusion testing, 562 units were cross-matched and 249 units were transfused. The overall C:T ratio was 2.25. There are variations in C:T by departments. For the departments of abdominal surgery and reanimation, where uncrossmatched RBC units were requested, C:T was &lt; 2. Other departments had C:T &gt; 3 for almost all therapeutic areas. Conclusion. Our results show that the C:T ratio ranged 2.02?3.6, indicating the need to reevaluate the protocols based on which the blood is requested according to individual indications, to adequately prepare patients for surgery in order to reduce the risk of possible allogeneic transfusion, and to apply Patient Blood Management protocols, which include the use of alternatives to allogeneic blood transfusion.

Cold-stored whole blood platelet function is preserved in injured children with hemorrhagic shock.

Recent data demonstrate the safety of uncrossmatched cold-stored whole blood (WB) transfusion in pediatric trauma patients. The hemostatic capabilities of platelets within the cold-stored WB unit have been demonstrated via in vitro studies and animal models. However, platelet function has not been evaluated in pediatric recipients of cold-stored WB transfusions. Injured children, 2 years or older and 10 kg or greater with hemorrhagic shock received up to 30 mL/kg of cold-stored, low titer (<50) anti-A and -B, leukoreduced, group O- WB during their initial resuscitation. Patients were included if (1) they received WB and no conventional platelets, and (2) platelet count and thromboelastography maximum amplitude were measured both before and after transfusion. These data and relevant clinical outcomes (mortality, intensive care unit length of stay [LOS], hospital LOS and ventilator days) were compared to a historical cohort of pediatric trauma patients who received uncrossmatched red blood cells (RBC) and conventional room temperature platelets. Twenty-two children were included in the study; 14 in the component cohort versus 8 in the WB cohort. Neither posttransfusion platelet count (129 × 109/L vs. 135 × 109/L) nor function (thromboelastography maximum amplitude, 59.5 mm vs. 60.2 mm) differed significantly between children receiving cold-stored platelets within the WB unit versus children who received conventional warm platelets. Median (interquartile range) weight-adjusted platelet transfusion volume in the historical cohort was 4.6 (2.5-7.7) mL/kg vs. 2.4 (1.3-4.0) mL/kg in the WB cohort (p = 0.03). There was no difference between groups in age, race, mechanism of injury, Injury Severity Score, vital signs, and severe traumatic brain injury (TBI). Outcomes, including mortality, intensive care unit LOS, hospital LOS, and ventilator days, were not significantly different between groups. No difference was seen in posttransfusion platelet number or function in severely injured children receiving cold-stored WB platelets as compared to those receiving conventional room temperature-stored platelets. Larger cohorts are required to confirm these findings. Therapeutic, level IV.

Blood product transfusion and wastage rates in obstetric hemorrhage.

Bleeding emergencies can complicate pregnancies. Understanding the disposition of the products that are issued in this clinical setting can help inform inventory levels at hospitals where obstetric patients are seen. Patients who had an obstetric hemorrhage of any etiology between January 2013 and June 2017, and whose resuscitation began with uncrossmatched red blood cells (RBCs) or emergency-issued plasma or platelets (PLT), were included. The disposition of all blood products issued within 6hours of the first uncrossmatched or emergency-issued product was documented, as was basic patient demographic information. In total, 301 women with an obstetric hemorrhage from seven academic institutions were identified. Their mean±standard deviation age was 30.9±6.1 years, 45.2% delivered by Cesarean section, and 40.5% delivered vaginally, while 12% did not deliver. The largest single etiology of hemorrhage was related to abnormal placentation. Of the 2280 issued RBC units, 55% were transfused, 43% were returned, and 2% were wasted. The rates of transfusion of the other blood products ranged from 58% for plasma units to 82% for cryoprecipitate. Seventeen percent of the issued cryoprecipitate units were wasted, the highest of any blood product. The rate of a patient receiving a transfusion when at least one blood product had been ordered ranged from 74% for PLTs to 91% for cryoprecipitate. Although the rates of receiving a transfusion of at least one blood product when one is ordered was high, many of the issued units were returned, especially for RBCs.

How do I implement a whole blood program for massively bleeding patients?

Building on the successful military experience, interest has been rekindled in transfusing whole blood (WB) early in the resuscitation of traumatically injured civilians, often before their ABO group is known. WB efficiently provides treatment for shock and coagulopathy, as well as platelet hemostatic function, to patients losing large volumes of blood. Unlike group O uncrossmatched red blood cells (RBCs), group O WB contains a substantial amount of plasma, which is incompatible with the RBCs of all non-group O recipients. Thus, when implementing a WB program, it is important to decide how to mitigate the risk of immune-mediated hemolysis. Other questions that a hospital needs to answer before implementing a WB program include determining which patients will be eligible for this product, how many units eligible patients can receive, for how long it should be stored and under what conditions, and how to monitor for adverse events. The donor center needs to consider if the WB should be leukoreduced, how to comply with the AABB's transfusion-related acute lung injury risk mitigation standard, and into which storage solution it should be collected. This report describes the multidisciplinary approach taken to implementing a civilian WB program at a multihospital health care system in the United States.

Blood component transfusion and wastage rates in the setting of massive transfusion in three regional trauma centers.

The purpose of massive transfusion protocols (MTPs) is to provide large quantities of blood products rapidly to exsanguinating patients. The expected rates of blood product transfusion and wastage in this setting have not been defined. This study was undertaken to assess the transfusion and wastage rates for bleeding patients requiring emergency issue of blood components at three American Level I trauma centers. Three hospitals participated, all of which are Level I trauma centers that have MTPs in place where uncrossmatched red blood cells (RBCs) can be ordered with or without platelets (PLTs), plasma, and cryoprecipitate. Data on the transfusion, return to blood bank, and wastage rates were recorded on all products issued within 3 hours after MTP activation. The majority of products were issued to the emergency department and/or operating room at all three institutions (84%-95%). The percentage of RBCs, plasma, and PLTs transfused during MTPs were 39% to 65%, 43% to 66%, and 75% to 100%, respectively. Wastage rates were comparable for RBCs (0%-9%), plasma (0%-7%), and PLTs (0%-7%). Cryoprecipitate had the highest wastage rates at all three sites (7%-33%). A large portion of blood products issued during MTPs are not transfused. Some are wasted due to stringent storage requirements and/or limited shelf lives. The optimum ratio of transfused to returned products in these patients is likely to be determined more by clinical need than by transfusion service policy.

Association of Prehospital Shock Index and Trauma Bay Uncrossmatched Red Blood Cell Transfusion With Multiple Transfusion.

Early resuscitation of bleeding trauma patients with multiple blood products improves outcome, yet transfusion initiation is not standardized. Shock index (heart rate/systolic blood pressure) and trauma bay uncrossmatched red blood cell (RBC) transfusion were evaluated for association with multiple transfusions, defined as 6 or more RBCs during the first 6 hrs of hospital presentation. A prehospital shock index of 1 was significantly associated with multiple transfusions (p = .02). Subjects receiving uncrossmatched RBCs required more RBCs during the first 6 hrs (10.3 units, p < .01). Consideration of these simple variables may help trauma nurses anticipate the potentially bleeding patient.

Acute hemolytic transfusion reaction attributed to anti-Ata

Abstract Anti-Ata is a rare alloantibody that can be clinically significant. We report a case of a woman who, after emergency-released uncrossmatched red blood cell transfusion, experienced an acute hemolytic transfusion reaction attributed to anti-Ata. The case presented herein highlights the importance of recognizing that anti-Ata may indeed cause acute hemolytic reactions. Immunohematology 2016;32:140–142.

The clinical significance of platelet counts in the first 24 hours after severe injury

Admission platelet (PLT) counts are known to be associated with all-cause mortality for seriously injured patients admitted to a trauma center. The course of subsequent PLT counts, their implications, and the effects of PLT therapy are less well known. Trauma center patients who were directly admitted from the scene of injury, received 1 or more units of uncrossmatched red blood cells in the first hour of care, survived for at least 15 minutes, and had a PLT count measured in the first hour were analyzed for the association of their admission and subsequent PLT counts in the first 24 hours with injury severity and hemorrhagic and central nervous system (CNS) causes of in-hospital mortality. Over an 8.25-year period, 1292 of 45,849 direct trauma admissions met entry criteria. Admission PLT counts averaged 228×10(9) ±90×10(9) /L and decreased by 104×10(9) /L by the second hour and 1×10(9) /L each hour thereafter. The admission count was not related to time to admission. Each 1-point increase in the injury severity score was associated with a 1×10(9) /L decrease in the PLT count at all times in the first 24 hours of care. Admission PLT counts were strongly associated with hemorrhagic and CNS injury mortality and subsequent PLT counts. Effects of PLT therapy could not be ascertained. Admission PLT counts in critically injured trauma patients are usually normal, decreasing after admission. Low PLT counts at admission and during the course of trauma care are strongly associated with mortality.

Low risk of hemolysis after transfusion of uncrossmatched red blood cells

Abstract Transfusing uncrossmatched red blood cells (RBCs) can be a lifesaving bridge until crossmatched RBCs are available. The risk of using uncrossmatched RBCs is that of hemolysis from unexpected clinically significant antibodies. This study sought to quantify the risk of hemolysis after the transfusion of uncrossmatched RBCs. The records of recipients of uncrossmatched RBCs over approximately 9 months were retrieved from the regional transfusion service. Basic immunohematologic data were recorded on all recipients including the number of uncrossmatched RBCs transfused. For recipients who had either previously identified clinically significant antibodies or those identified on the day of transfusion, clinical and biochemical data were evaluated to determine whether hemolysis had occurred after uncrossmatched RBC transfusion. There were 218 recipients of 1065 units of uncrossmatched RBCs. Most of the RBCs were administered in the emergency room (48%) followed by the operating room (24%) and intensive care unit (23%). Seven (3.2%) recipients had clinically significant antibodies that were active on the day of the transfusion, whereas in four patients a clinically significant antibody had been previously identified but was not active on the day of the transfusion. One patient with active antibodies who received three units of uncrossmatched RBCs for a gastrointestinal bleed demonstrated a reactive eluate several days later as well as positive biochemical hemolysis markers. Thus the overall rate of detectable hemolysis after uncrossmatched RBC transfusion was 1 of 218 (0.5%). The use of uncrossmatched RBCs is a relatively safe intervention, although close monitoring of recipients with clinically significant antibodies for evidence of hemolysis is recommended. Immunohematology 2012;28:39–44.

Use of Emergency-Release, Uncrossmatched O Negative Red Blood Cells (RBCs) in a Tertiary Care Children's Hospital

Abstract 4341 Background:Transfusion services must offer means of issuing blood products quickly for emergent transfusions. At Lucile Packard Children's Hospital (LPCH), off-site refrigerators were installed in the Neonatal Intensive Care Unit (NICU), the LPCH operating room (OR) and the Cardiovascular Intensive Care Unit (CVICU) inventoried with uncrossmatched O negative RBCs for immediate emergency use. Uncrossmatched O negative RBCs are also provided to children undergoing cardiac catheterization at the discretion of the Pediatric Cardiologist, since these patients commonly do not have type and screen samples drawn until large vessel venous cannulation via insertion of the catheter. Uncrossmatched blood products are also provided for children per our massive transfusion protocol (MTP). The purpose of this study was to assess the utilization of these uncrossmatched blood products in children and its impact on transfusion service (TS) inventory of O negative RBCs. Methods:Orders received for emergency-release uncrossmatched RBCs for patients ages 0 days to 18 years including MTPs from January 1 2011 to March 31 2011 were evaluated retrospectively. Variables collected include: patient demographic information and diagnosis; blood products ordered, released and transfused; location of the patient and location from where blood was dispensed (off-site refrigerator versus [vs] TS). Results:Median patient age was 3.46 years (range 0 days to 15.62 years), and 82% of the patients had congenital heart disease. Sixty four RBCs were issued to 33 patients during the 3-month study period. Of those, 32 RBCs were transfused, 8 RBCs were wasted because temperature parameters were exceeded before return to the TS, and 24 RBCs (38%) were not transfused and returned to TS inventory. Nineteen of the 32 RBCs were transfused, representing 2% of the total 964 O negative RBC units transfused at our institution for that time period. Nineteen (58%) units were for children in the cardiac catheterization suite. Seven patients were in the CVICU, five children were in the NICU, and two were in the Pediatric Intensive Care Unit. Two units of O negative RBCs were dispensed from the emergency off-site refrigerator in the CVICU. Discussion:The majority of children (79%) who received emergency-release uncrossmatched O negative RBCs at LPCH were those with congenital heart disease undergoing cardiac catheterization or being cared for post-operatively in the CVICU. There were 2 instances of children requiring RBCs from off-site refrigerators for an emergent transfusion. Emergency-release, uncrossmatched O negative RBCs at LPCH either from the TS or from three off-site refrigerators caused no undue strain on our supply and inventory of donor O negative RBCs. Disclosures:No relevant conflicts of interest to declare.

How we treat: transfusion medicine support of obstetric services

Obstetric services depend on the transfusion service (TS) to provide diagnostic testing and blood component therapy for clinical care pathways. We describe three quality improvement (QI) initiatives implemented to improve TS support of obstetric services. We implemented a pathway for patients requiring an ABO/Rh order for every admission to obstetric services, along with reconciliation of the daily hospital birth manifest and TS umbilical cord log to identify every woman eligible for RhIG. After assessment over 6 months, 21 (1%) of 2041 women lacked an admission ABO/Rh; all subsequently had ABO/Rh determinations. Umbilical cords were missing for eight (0.4%) mothers; four were D- and received RhIG. We developed algorithms for diagnostic blood ordering for patients deemed at "low,""moderate," or "high" risk of blood transfusion. A 27% reduction in total diagnostic test volumes and 24% reduction in charges was documented after compared to before implementation. We analyzed the impact of our massive transfusion protocol (MTP) on blood inventory management for 31 (0.25%) women undergoing 12,945 deliveries, representing 11% of 286 MTPs for all clinical services over a 32-month interval. O- uncrossmatched red blood cells (RBCs) represented 103 (24%) of 421 RBC units issued. Wastage rates of RBCs, plasma, and platelets ordered and issued in the MTPs were 0.7, 16, and 3%, respectively. QI initiatives for RhIG prophylaxis, diagnostic blood test ordering, and MTP improve TS support of obstetric services.

Uncrossmatched blood transfusions for trauma patients in the emergency department: incidence, outcomes and recommendations

Early transfusion of blood products for severely injured patients can improve volume depletion, acidosis, dilution and coagulopathy. There is concern that some patients are unnecessarily exposed to the risks of emergent transfusion with uncrossmatched red blood cell products (URBC) in the emergency department (ED). The goal of this study was to evaluate the transfusion practices in our ED among all patients who received URBC. We analyzed all injured patients transfused at least 1 URBC in the ED at a level-1 trauma centre between Jan. 15, 2007, and Jan. 14, 2008. Demographics, injuries and outcomes were reported. We used standard statistical methodology. At least 1 URBC product was transfused into 153 patients (5% of all patients, mean 2.6 products) in the ED (median Injury Severity Score [ISS] 28; hemodynamic instability 94%). Sixty-four percent of patients proceeded to an emergent operation and 17% required massive transfusion. The overall mortality rate was 45%, which increased to 52% and 100% in patients who received 4 and 5 or more URBC products, respectively. Nonsurvivors had a higher median ISS (p=0.017), received more URBC in the ED (p=0.006) and possessed more major vascular injuries (p<0.001). Among nonsurvivors, 67% died of uncontrollable hemorrhage. Unnecessary URBC transfusions in the ED occurred in 7% of patients. Overtransfusion was minimal based on clinical acumen triggers. Early transfer of patients receiving URBC products in the ED to the operating room, intensive care unit or angiography suite for ongoing resuscitation and definitive hemorrhage control must be strongly considered.

Emergency department blood transfusion predicts early massive transfusion and early blood component requirement

The purpose of this study was to evaluate the ability of uncrossmatched transfusions in the emergency department (ED) to predict early (< 6 hr) massive transfusion (MT) of red blood cells (RBCs) and blood components. All patients admitted to a Level 1 trauma center between July 2005 and June 2007 who received any transfusions and were transported directly from the scene of injury were included. Early MT was defined as the need for 10 U or more or RBCs in the first 6 hours. Early MT plasma was defined as 6 U or more of plasma in the first 6 hours. Early MT platelets (PLTs) were defined as two or more apheresis transfusions in the first 6 hours. Univariate and multivariate analyses were performed. A total of 485 patients (34%) received ED transfusions (ED RBC+) and 956 (66%) did not receive ED transfusions (ED RBC-). ED RBC+ patients were younger, were more likely to be male, and arrived with more severe injuries. Multivariate regression identified ED transfusion of uncrossmatched RBC as an independent predictor of requiring early MT of RBCs (odds ratio [OR], 3.5; 95% confidence interval [CI], 1.36-7.59; p = 0.001), plasma (OR, 2.7; 95% CI, 1.66-4.39; p < 0.001), and PLTs (OR, 1.9; 95% CI, 1.08-3.41; p = 0.025). Patients receiving uncrossmatched RBCs in the ED are more than three times more likely to receive early MT of RBCs. Additionally, patients transfused with ED RBCs are more likely to receive 6 units or more of plasma and two or more apheresis PLT transfusions. Given these findings, ED transfusion of uncrossmatched RBCs should be considered a potential trigger for activation of an institution's MT protocol.

Hemorrhage and Subsequent Allogenic Red Blood Cell Transfusion are Associated With Characteristic Monocyte Messenger RNA Expression Patterns in Patients After Multiple Injury—A Genome Wide View

As outcome to severe trauma is frequently affected by massive blood loss and consecutive hemorrhagic shock, replacement of red blood cell (RBC) units remains indispensable. Administration of RBC units is an independent risk factor for adverse outcome in patients with trauma. The impact of massive blood transfusion or uncrossmatched blood transfusion on the patients' immune response in the early posttraumatic period remains unclear. Thirteen patients presenting with blunt multiple injuries (Injury Severity Score >16) were studied. Monocytes were obtained on admission and at 6, 12, 24, 48, and 72 hours after trauma. Biotinylated complementary RNA targets were hybridized to Affymetrix HG U 133A microarrays. The data were analyzed by a supervised analysis based on whether the patients received massive blood transfusions, and then subsequently, by hierarchical clustering, and by Ingenuity pathway analysis. Supervised analysis identified 224 probe sets to be differentially expressed (p < 0.001) in patients who received massive blood transfusion, when compared with those who did not. In addition, 331 probe sets were found differentially expressed (p < 0.001) in patients who received uncrossmatched RBC units in comparison with those who exclusively gained crossmatched ones. Functional pathway analysis of the respectively identified gene expression profiles suggests a contributory role by the AKT/PI3Kinase pathway, the mitogen-activated protein-kinase pathway, the Ubiquitin pathway, and the diverse inflammatory networks. We exhibited for the first time a serial, sequential screening analysis of monocyte messenger RNA expression patterns in patients with multiple trauma indicating a strongly significant association between the patients' genomic response in blood monocytes and massive or uncrossmatched RBC substitution.