Stratifying Early Risk of Death From Hemorrhage in the Era of Whole Blood

Background Definitions of massive transfusion following injury help identify patients at the greatest risk of death. However, these definitions primarily use blood component therapy. The use of whole blood (WB) transfusion protocols has seen a resurgence, with evidence of improved outcomes compared to component therapy. Therefore, our aim was to define and stratify patients into low, intermediate, and high risk for death based on volume of blood products transfused utilizing a WB-first resuscitation strategy. Methods Patients that received at least 1 unit of whole blood following injury between January 2016 and November 2021 were identified. Receiver operating characteristic (ROC) curves to predict death based on volume of blood products transfused were constructed. Patients were stratified to low, intermediate, and high risk of death based on positive likelihood ratios. Results There were 785 patients identified to have received at least 1 unit of WB following injury during the study period. Based on ROC curve analysis, the best predictor of death was volume of whole blood plus packed red blood cells (PRBC) in the first hour (AUC 0.66, P < 0.001). Low risk of mortality was defined as WB + PRBC volume 5100 mL in the first hour (66.7% mortality). Discussion The combination of WB + PRBC volume within the first hour following injury is the best predictor of death. Further, volumes of WB + PRBC transfused within the first hour can be used to stratify patients’ risk of death. Level of Evidence Level IV. Study Type Prognostic and Epidemiological.