Whole blood versus component therapy for haemostatic resuscitation of major bleeding: a protocol for a systematic review and meta-analysis

IntroductionThere is a renewed interest in the use of whole blood (WB) to manage patients with life-threatening bleeding. We aimed to estimate mortality and complications risk between WB and blood component therapy for haemostatic resuscitation of major bleeding.MethodsWe will conduct a systematic review and meta-analysis of studies published between 1 January 1980 and 1 January 2020, identified from PubMed and Scopus databases. Population will be patients who require blood transfusion (traumatic operative, obstetric and gastrointestinal bleeding). Intervention is WB transfusion such as fresh WB (WB unit stored for less than 48 hours), leukoreduced modified WB (with platelets removed during filtration), warm fresh WB (stored warm at 22°C for up to 8 hours and then for a maximum of an additional 24 hours at 4°C). The primary outcomes will be the 24-hour and 30-day survival rates (in-hospital mortality). Comparator is blood component therapy (red blood cells, fresh-frozen plasma and platelets given together in a 1:1:1 unit ratio). The Cochrane risk of bias tool for randomised controlled trials and Risk Of Bias In Non-randomised Studies - of Interventions (ROBINS-I) for observation studies will be used to assess the risk of bias of included studies. We will use random-effects models for the pooling of studies. Interstudy heterogeneity will be assessed by the Cochran Q statistic, where p<0.10 will be considered statistically significant and quantified by I2 statistic, where I2 ≥50% will indicate substantial heterogeneity. We will perform subgroup and meta-regression analyses to assess geographical differences and other study-level factors explaining variations in the reported mortality risk. Results will be reported as risk ratios and their 95% CIs.Ethics and disseminationNo ethics clearance is required as no primary data will be collected. The results will be presented at scientific conferences and published in a peer-reviewed journal.

Practical limitations of emergency donor panels as a risk mitigation in small-scale short-term training team operations

Haemostatic resuscitation with blood products has become the expected standard of care for trauma casualties. As UK Defence increases its deployment of small-scale, short-term training teams (STTTs) in Defence Engagement and influence operations, ever greater reliance is being placed on emergency donor panels (EDP) as a source of whole blood. This paper outlines the practical limitations of using EDPs as a risk mitigation in conventional STTTs which must be considered prior to every deployment.

Dynamics of Platelet Counts in Major Trauma: The Impact of Haemostatic Resuscitation and Effects of Platelet Transfusion—A Sub-Study of the Randomized Controlled RETIC Trial

Although platelets play a central role in haemostasis, the dynamics of platelet counts during haemostatic resuscitation, the response to platelet transfusion, and effects on clinical outcome are poorly described for trauma patients. As a sub-study of the already published randomized controlled RETIC Study “Reversal of Trauma-induced Coagulopathy using First-line Coagulation Factor Concentrates or Fresh-Frozen Plasma” trial, we here analysed whether the type of first-line haemostatic resuscitation influences the frequency of platelet transfusion and determined the effects of platelet transfusion in coagulopathic patients with major trauma. Patients randomly received first-line plasma (FFP) or coagulation factor concentrates (CFC), mainly fibrinogen concentrate. In both groups, platelets were transfused to maintain platelet counts between 50 and 100 × 109/L. Transfusion rates were significantly higher in the FFP (n = 44) vs. CFC (n = 50) group (FFP 47.7% vs. CFC 26%); p = 0.0335. Logistic regression analysis adjusted for the stratification variables injury severity score (ISS) and brain injury confirmed that first-line FFP therapy increases the odds for platelet transfusion (odds ratio (OR) 5.79 (1.89 to 20.62), p = 0.0036) and this effect was larger than a 16-point increase in ISS (OR 4.33 (2.17 to 9.74), p = 0.0001). In conclusion, early fibrinogen supplementation exerted a platelet-saving effect while platelet transfusions did not substantially improve platelet count and might contribute to poor clinical outcome.