Impact of Whole Blood Resuscitation on Infection Risk in Trauma Patients Undergoing Surgery for Hemorrhage Control

Authors:
Amy McDonald, Chris Guidry, Jonathan Wisler, Joseph Cuschieri, Justin Dvorak, Laura Kreiner, Nimitt Patel, Rondi Gelbard, Todd Costantini

Body of Abstract:
Background: Blood transfusion is a cornerstone of trauma resuscitation. While early transfusion is associated with improved survival, blood transfusion is also associated with increased risk of infection, likely due to immunomodulatory mediators in blood products. Whole blood use is becoming increasingly common in trauma resuscitation, with a growing body of literature showing improved survival in patients that receive whole blood. However, less is known about the impact of whole blood on other outcomes, including infection. The aim of this study is to evaluate the association between whole blood and infection in trauma patients undergoing hemorrhage control laparotomy.

Methods: The American College of Surgeons Trauma Quality Improvement (TQIP) registry was queried for adult trauma patients between the years 2020 – 2022. Patients were included if they underwent early laparotomy for hemorrhage control, were undergoing resuscitation with PRBCs, and survived at least 30 days, or were discharged alive. Patient demographics, arrival vital signs, Injury Severity Score (ISS), units of packed red blood cells (PRBC), Fresh Frozen Plasma (FFP), Platelets (Plt), and Whole Blood (WB) transfused, length of stay, and surgical site infection (SSI) were collected. Primary outcome was the association between receipt of WB with SSI (defined in TQIP as a Deep SSI, Organ/Space SSI, or superficial SSI). For the primary outcome, receipt of WB was a binary variable (received or did not receive). Secondary outcome was the association between the total number of units of WB received and SSI. Subgroup analysis of patients who underwent a Massive Transfusion (MT) was also performed. Logistic regression was used to evaluate the association between WB and infection, with multivariate regression used to control for potential confounders, including age, race, ISS, shock index, and transfusion requirement.

Results: 19,144 patients were included in the study. Patients who received WB in the first 4 hours of arrival had higher odds for SSI on multivariate analysis compared to patients who did not (OR 1.27, 95% CI 1.11 – 1.46, p < 0.01). Increase risk of infection with WB was also seen in a dose dependent manner, with each additional unit of WB conferring a 6% increase in odds of infection (OR 1.06, 95% CI 1.03 – 1.09, p < 0.01). On subgroup analysis of patients who underwent MT, the association between receiving WB with and infection persisted on multivariate analysis (OR 1.31, 95% CI 1.11 – 1.55, p < 0.01) (Table). This was also seen in a dose-dependent manner for patients undergoing MT (OR 1.07, 95% CI 1.02 – 1.12, p < 0.01). Conclusions: Trauma patients undergoing hemorrhage control laparotomy who receive WB had increased odds of SSI compared to patients who did not. This was also seen in a dose-dependent manner, with increased SSI odds with each unit of WB. As WB use becomes more common, further research is needed to evaluate outcomes beyond survival.