Publications

BACKGROUND: Low Titer Group O Whole Blood (LTOWB) use has expanded to include patients with non-traumatic bleeding etiologies. While a large body of evidence supports a potential survival benefit of LTOWB in trauma patients, data demonstrating the safety and efficacy of LTOWB in non-trauma patients are lacking.

STUDY DESIGN AND METHODS: Non-trauma adult patients at two hospitals who received at least one unit of LTOWB were included in the study. Patient demographics, transfusion and laboratory data, diagnoses, mortality, and hospital length of stay were collected between January 1, 2018, and June 30, 2024. LTOWB recipients were further stratified by O versus non-group O blood group, and laboratory markers of renal failure and hemolysis were compared between these two groups.

RESULTS: A total of 319 unique patients with 320 LTOWB transfusion episodes were included. The most common indications for transfusion were gastrointestinal and cardiovascular bleeding (266/320, 83%). In-hospital survival at 24 h and 30 days posttransfusion was 75% and 53%, respectively. There was no statistically significant difference in markers of hemolysis between group O and non-group O LTOWB recipients. There were no reported transfusion reactions.

DISCUSSION: In non-trauma settings, LTOWB was most commonly utilized in patients with gastrointestinal and cardiovascular bleeding. LTOWB is a safe alternative to component therapy in non-trauma adult populations. However, additional studies are needed to focus on efficacy and clinical outcomes in non-trauma patients that receive LTOWB for severe hemorrhage.

BACKGROUND: Early transfusion improves survival of traumatic hemorrhage. We hypothesized that increased ratios of prehospital to total blood (red blood cell or whole blood) transfusion within 24 hours would be associated with improved outcomes.

METHODS: A retrospective cohort study using a harmonized database of six hemorrhagic shock trials was conducted. Decedents within 4 hours and those not transfused within 24 hours were excluded. The primary outcome was 24-hour mortality; secondary outcomes included 28-day mortality, intensive care unit (ICU)-free and ventilator-free days, and incidence of acute lung injury (ALI). Prehospital blood ratio was calculated as volume prehospital transfusion:volume 24-hour total transfusion (prehospital plus 24-h total at the admitting facility). Multivariable analyses adjusted for age, sex, mechanism, Injury Severity Score (ISS), inter-facility transfer, transport mode, arrival systolic blood pressure and Glasgow Coma Scale, treatment group, trial, and transfusion volume were conducted. Sensitivity analyses (prehospital-only recipients, excluding traumatic brain injury) were conducted.

RESULTS: Overall, 2,340 subjects were eligible, and 1,024 (43.8%) received prehospital blood. Prehospital recipients were older (median age 41 vs. 38 y, P=0.013), more likely blunt mechanism (81.6% vs. 66.0%; P<0.001), more likely transferred (13.3% vs. 4.3%; P<0.001), more likely transported by air (77.4% vs. 47.1%; P<0.001), and had higher ISS (median 29 vs. 25, P<0.001) compared with in-hospital only recipients. For every 10% increase in prehospital (PH):total blood ratio, there was an 8.8% decrease in odds of ALI (95% CI: 1.8-15.4%; P=0.015) and no significant association with mortality, ICU-free or ventilator-free days. Among prehospital recipients, for every 10% increase in PH:total blood ratio, there was a 16.7% decrease in odds of ALI (95% CI: 5.3-26.6%; P=0.005; n=375) and 0.21 (95% CI: 0.01-0.41; P=0.036; n=909) more ICU-free days.

CONCLUSIONS: An increased proportion of resuscitation in the prehospital phase of care was associated with improved secondary clinical outcomes for select subjects. These data support initiating transfusion for hemorrhage as early as feasible. (J Trauma Acute Care Surg. 2026;00: 000-000. Copyright© 2026 Wolters Kluwer Health, Inc. All rights reserved.).

LEVEL OF EVIDENCE: Therapeutic/Care Management; Level III.

BACKGROUND: Hemorrhage is the leading cause of preventable death in severe trauma, with primary hemostasis relying on platelet-rich clot formation under high shear flow. This study quantifies the incidence, severity, and heterogeneity of platelet dysfunction in Level I trauma patients.

STUDY DESIGN AND METHODS: A whole blood assay mimicking arterial hemorrhage fluidic conditions was used to measure platelet-rich clot formation in Level I trauma patients. Blood samples from patients were collected at arrival and tested for defects in platelet clotting immediately and after 12, 24, and 48 h. Additional clinical parameters such as injury severity, complete blood counts, and blood product use were collected.

RESULTS: The high shear assays were completed in under 5 min using 3 mL of blood. All trauma patients exhibited severe defects in platelet clotting at various time points compared to control blood from healthy donors (p < .01). Platelet function varied over time, with some patients exhibiting initial hyper-clotting followed by dysfunction at 24 h, while others showed persistent impairment for the entire 48 h.

DISCUSSION: The rapid assay was able to distinguish heterogeneous platelet dysfunction in Level I trauma patients. The assay enabled real-time tracking of a patient's platelet clotting function and response to interventions. By identifying patients with impaired hemostatic function, this assay could potentially inform targeted resuscitation strategies to improve trauma care outcomes.

BACKGROUND: The optimal thromboprophylaxis among critically ill adults with COVID-19 is uncertain.

OBJECTIVES: To determine the effectiveness and safety of intermediate-dose heparin compared to standard low-dose thromboprophylaxis.

PATIENTS/METHODS: In an ongoing adaptive platform trial (REMAP-CAP), critically ill patients with COVID-19 were randomized to intermediate-dose heparin or standard low-dose thromboprophylaxis. Interventions were continued in hospital for up to 14 days. The primary endpoint was organ support-free days (OSFDs), an ordinal outcome combining in-hospital survival and the number of days free of ICU-based respiratory or cardiovascular organ support through 21 days. The primary analysis was an adjusted Bayesian hierarchical cumulative logistic model. An odds ratio (OR)> 1.0 represents an improved outcome with intermediate-dose heparin.

RESULTS: Between 27 April 2021 and 25 November 2023, 1255 critically ill adults with COVID-19 were enrolled from 78 sites in 15 countries, of whom 1254 completed follow-up (n=572 intermediate-dose, n=682 low-dose). Enrolment was terminated prior to reaching a pre-specified statistical trigger due to declining case numbers and slow recruitment. Median age was 59 years and 36.7% were female (n=461/1255). The probability that intermediate-dose heparin improved OSFDs was 73.5% (OR: 1.06, 95% credible interval (CrI): 0.87, 1.30) which did not meet the pre-specified superiority threshold of 99%. Hospital survival was 77.1% (441/572) and 76.7% (523/682) in the intermediate and low-dose heparin groups respectively (median adjusted OR:1.14 (95% CrI:0.86, 1.52). Major bleeding occurred in 10/572 (1.7%) and 14/682 (2.1%) of patients receiving intermediate and standard low-dose respectively.

CONCLUSION: Intermediate-dose heparin did not improve organ support-free days or survival compared with standard thromboprophylaxis in critically ill patients with COVID-19. (ClinicalTrials.gov number:CT02735707).

BACKGROUND: Blood transfusion and hemorrhage control procedures can be unreliable surrogates for bleeding requiring intervention in children. Some receive unnecessary blood transfusions or lack intraoperative findings for hemorrhage, while others die before an intervention occurs. Standardized criteria for adjudicating the presence of actionable hemorrhage are needed. We aimed to define expert consensus criteria for retrospectively identifying actionable hemorrhage within 6 hours of emergency department (ED) arrival.

METHODS: Experts from six specialties involved in pediatric trauma care participated in a modified Delphi study. Panelists were prompted to consider "actionable hemorrhage" as "severe bleeding or injuries at risk of progression to class III or IV shock without prompt intervention." In Round 1, panelists answered five free-response questions identifying criteria for actionable hemorrhage, including indicators for transfusion and hemorrhage control procedures, postmortem findings, and other relevant factors. Responses were consolidated and rated on a five-point strength-of-indication scale in subsequent rounds. Consensus was defined a priori as ≥70% agreement among panelists. Stability of consensus (p>0.05) between rounds was assessed using the Wilcoxon Signed-Rank Test.

RESULTS: Three Delphi rounds were required to achieve a stable consensus. Twenty-nine of 32 participating panelists participated in all three rounds. Thirteen statements achieved stable consensus as strong indicators of actionable hemorrhage. Criteria with the highest agreement included partial/total resection of intrathoracic/abdominal bleeding solid organs (96.4%), hemoglobin<6 g/dL (93.1%), and resuscitative thoracotomy/sternotomy with hilar or thoracic/abdominal aortic cross-clamp, cardiac massage, or cardiorrhaphy (92.9%). No statements reached a stable consensus as weak indicators of actionable hemorrhage.

CONCLUSIONS: We established expert consensus criteria for adjudication of actionable hemorrhage in injured children within 6 hours of ED arrival. These criteria reflect strong indicators that an intervention or death was due to an actionable hemorrhage. Prospective validation of these criteria is needed. (J Trauma Acute Care Surg. 2026;00:00-00. Copyright © 2026 Wolters Kluwer Health, Inc. All rights reserved.).

LEVEL OF EVIDENCE: Diagnostic Test/Criteria; Level III.

BACKGROUND: Prehospital blood transfusion is increasingly recognized as an important early resuscitation intervention for patients with hemorrhagic shock. However, comprehensive evaluations of such programs have been limited by heterogeneity in data collection, outcome definitions, and reporting methodologies. This impedes effective benchmarking, quality improvement initiatives, research efforts, and the creation of protocols and policies. The Standardized Emergency Medical Service (EMS) Metrics for Survival in Transfusion and Advanced Resuscitation (SEMSTAR) project sought to develop consensus-driven data elements and standardized outcome definitions to facilitate consistent reporting of prehospital blood transfusion programs.

METHODS: Initial data metrics were identified through a literature review and surveyed across US EMS systems that perform prehospital transfusions. A modified Delphi methodology was then used by a multidisciplinary panel of 28 subject-matter experts in EMS, trauma surgery, transfusion medicine, and resuscitation science. Predefined thresholds analyzed metric inclusion, classification as either core or expanded elements, and endorsement of standardized outcome definitions.

RESULTS: 89 EMS systems completed the initial survey of 208 potential data elements. Of these, 193 (93%) advanced to expert review. Experts reached consensus on 168 data elements: 86 core metrics for universal reporting and 82 expanded metrics for comprehensive analysis. Consensus was also achieved on standardized definitions for hemorrhagic circulatory collapse, including stratification by pretransfusion circulatory collapse status and survival after prehospital transfusion. Wherever possible, the resulting framework draws from existing data infrastructure, including the National Emergency Medical Services Information System and trauma registry variables.

CONCLUSION: SEMSTAR establishes the first national, consensus-driven framework for standardized data collection and outcome reporting among prehospital blood transfusion programs. By defining core and expanded metrics with standardized survival definitions, this framework enables benchmarking, quality improvement, and multicenter research across diverse EMS systems. SEMSTAR adoption will enable rigorous program evaluation and support the development of a national registry to advance evidence-based care for patients with hemorrhagic shock.

LEVEL OF EVIDENCE: IV.