Association between whole blood transfusion and mortality,Critical Care

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Association between whole blood transfusion and mortality
Critical Care ( IF 8.8 ) Pub Date : 2024-11-29 , DOI: 10.1186/s13054-024-05184-8
Shangzhong Chen

In a recent study [1], Dr. Aoki and his colleagues investigated the association between whole blood ratio (WBR: whole blood volume/total blood volume) and the risk of mortality in trauma patients requiring massive blood transfusion. To adjust for potential confounders, multivariable logistic regression analysis with generalized estimating equations was adopted. The results showed that a higher proportion of whole blood transfusions was associated with an increased probability of survival in trauma patients undergoing massive transfusions. These findings suggest that a liberal use of whole blood transfusion could be beneficial for resuscitating trauma patients in need of extensive transfusion support. However, certain details merit careful consideration when interpreting and applying these findings.

In the current study, the whole cohort was divided into four quantiles according to the WBR. The whole blood transfusion volume showed a slight increase across WBR1 to WBR4 (1.4 (1.0 – 2.0) vs. 2.0 (1.4 – 3.0) vs. 2.8 (2.0 – 4.0) vs. 5.0 (4.0 – 6.0) unit), while the total blood transfusion volume decreased significantly from WBR1 (40.1 (24.5 – 65.1) unit) to WBR4 (9.7 (7.0 – 14.5) unit). Clinically, the need for massive transfusion in trauma patients generally signals a critical condition with a high mortality risk. Due to this selection bias (severe trauma often requires more transfusions and has higher mortality), a strong non-causal association between transfusion volume and mortality is often observed. For instance, in an observational study of 9,257 patients with severe traumatic brain injury, Dr. Baucom et al. [2] reported that mortality increased by approximately 4% per RBC unit transfused, reaching a peak mortality rate of 74% for those receiving 11 or more units. Similarly, a retrospective study [3] at a single trauma center found that mortality rose with each additional unit in balanced transfusion protocols. Also in the current study, the authors also reported that the total transfusion volume was significantly linked to high mortality.

However, when calculating the WBR, the total blood transfusion volume is used as the denominator. Consequently, groups with a higher total blood transfusion volume may have a lower WBR. Since total transfusion volume is closely related to mortality, this can create an apparent correlation where a low WBR is associated with higher mortality. However, this correlation is more likely a reflection of the association between total transfusion volume and mortality, rather than a true causal relationship between WBR and mortality. In such cases, mediation analysis, treating total transfusion volume as a mediator, could help clarify the interactions among these factors. Therefore, we suggest that these potential biases should be taken into consideration when interpreting these finding.

We thank Dr. Aoki and his team for their significant contributions and hope that our insights will assist in further clarifying and interpreting their findings.

No datasets were generated or analysed during the current study.

Aoki M, Abe T, Komori A, Katsura M, Matsushima K. Association between whole blood ratio and risk of mortality in massively transfused trauma patients: retrospective cohort study. Crit Care. 2024;28(1):253.
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Baucom MR, Price AD, Whitrock JN, Hanseman D, Smith MP, Pritts TA, Goodman MD. Need for blood transfusion volume is associated with increased mortality in severe traumatic brain injury. J Surg Res. 2024;301:163–71.
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Health Commission of Zhejiang Province Applied Project (ID 2022KY464).

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Intensive Care Unit, Zhejiang Hospital, Hangzhou, 310000, Zhejiang, China
Shangzhong Chen

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Shangzhong Chen wrote the letter. He has reviewed and approved the letter.

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Correspondence to Shangzhong Chen.

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