Looking for the best benchmark to avoid unnecessary massive transfusion protocol activation: A pilot cluster analysis from a Level-1 trauma center

Abstract text (incl. references and figure legends)

Introduction: Massive transfusion protocols (MTP) are used in bleeding trauma patients (TP) undergoing damage control strategies to control critical hemorrhages (CH). CH is defined as the need for at least four red blood cells (RBC) within an hour. Current tools (shock index[SI], TASH, and ABC score) to predict the risk of MTP activation have good accuracy but are not helpful to identify early TP in which the MTP should be effectively continued. The focus of the study is to identify specific features of TP in which MTP was activated but not continued.

Material and Methods: We included TP with MTP activation from May 2020 to October 2021 treated at Niguarda Trauma Center. We performed a pilot cluster analysis of TP considering MTP risk prediction tools with the Kamila method. We then made a group comparison between clusters to look for differences in terms of clinical features, Arterial Blood Gas analysis parameters and blood products transfused.

Results: Fifty-six TP were included in the analysis. Three clusters (C1, C2, C3) were identified. C1 and C2 included patients with the lowest and highest use of RBC in the first six hours (C1 3,8 vs C2 16 vs C3 8,8) and Injury Severity Score (C1 29,1 vs C2 43,7 vs C3 37,5). C2 patients had the worst arterial blood gas parameters and underwent more damage control procedures, especially compared to C1. The mortality rate was not different at any time of trauma management.

Conclusion: In this pilot study, we identified a cluster in which MTP was not continued, therefore probably not needed for resuscitation, with specific features. Further multi-institutional studies on larger samples should focus on tools to early identify TP who really need MTP to avoid inappropriate activation and optimize resource allocation.

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