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Improving Outcomes of Babies and Mothers Who Require Emergency-Release Transfusions

by Robert D. Christensen, MD

Dr. Robert Christensen first spoke for Symposia Medicus seven years ago this month at our inaugural Neonatal Care conference. With September being Neonatal Intensive Care Unit (NICU) Awareness Month, Symposia Spotlight reached out to Dr. Christensen, who provided some important updates on neonatal transfusions.
Timothy M. Bahr, MS, MD, Fellow in Neonatology and Neonatal Hematology; Whitley Hulse, MD, Fellow in Neonatology; and Robert D. Christensen, MD, Professor of Pediatrics, Divisions of Neonatology and Hematology/Oncology, University of Utah Health and Intermountain Healthcare, Salt Lake City, Utah.

Emergency-release blood transfusions can be life-saving, but they also carry risks. Emergency transfusions are those needed urgently from the blood bank without time for a type and cross-match, because of life-threatening unanticipated massive bleeding. We recently reviewed all such transfusions given to neonates and (in a separate report) to mothers in our multihospital healthcare system, Intermountain Healthcare, in Utah. Over the past eight years, emergency-release transfusions were given to 6 neonates in every 10,000 live births1 (typically because of fetal bleeding just before or during delivery), and to 4 women in every 10,000 births2 (for unanticipated massive postpartum hemorrhage). The mortality rate among our neonates requiring an emergency-release transfusion was 35% (similar to that in a recent report from Ireland). For new mothers needing emergency-release blood, two-thirds had the morbidities of hysterectomy, uterine artery embolization, or ICU admission, with one death. Recognizing these poor outcomes compelled us to propose and test novel advances to treat massive perinatal hemorrhage.

Transfusion medicine began, in the last century, using whole blood as the only available product. This changed with the capability to separate donor blood into components (packed erythrocytes, platelets, plasma): a procedure that was found to be more cost-efficient, producing less product wastage and better resource utilization. However, in recent years, a new product, “cold-stored, low titer, type O, whole blood” has been shown to be superior to component therapy for patients with acute massive blood loss. The benefits include providing, at once, all of the components being lost by the hemorrhage with less anticoagulant and better hemostatic function. We recently reported the first use of this product to treat a woman who had massive postpartum hemorrhage3, and it is now our standard blood product at Intermountain Medical Center for Emergency-Release and Massive Transfusion Protocol use for trauma, surgical, and postpartum hemorrhage.            

Emergency whole blood, as well as blood components, come to the NICU or postpartum wards cold (2 to 6oC), because they come directly from the blood bank refrigerator. A second transfusion advance involves warming blood products to 37oC using a point-of-care blood warmer. Physiological warming of blood permits better function of the individual constituents, all of which are made to function properly at 37oC, while it also lowers the risk of transfusion-associated hypothermia. Our encouraging in vitro studies of employing a blood warmer in the NICU4 have now advanced to multicentered, cross-over, prospective trials of standard-practice (transfusing cold blood) vs. experimental-practice (transfusing blood warmed to 37oC) for NICU transfusions of whole blood, as well as for transfusing platelets, fresh frozen plasma, or packed red blood cells. We hope other blood centers, trauma centers, maternal-fetal centers, and NICUs will also test these techniques and will devise and test other innovative ways to improve outcomes of babies—and mothers—who require emergency blood transfusions to treat massive hemorrhage.

REFERENCES
  1. Bahr TM, et al. Evaluating emergency-release blood transfusion of newborn infants at the Intermountain Healthcare hospitals. Transfusion. 2019;59(10):3113-3119.
  2. Hulse W, Bahr TM, et al. Emergency-release blood transfusions after postpartum hemorrhage at the Intermountain Healthcare hospitals. Transfusion. 2020;60(7):1418-1423.
  3. Bahr TM, et al. First report of using low-titer cold-stored type O whole blood in massive postpartum hemorrhage. Transfusion. 2019;59(10):3089-3092.
  4. Hulse W, Bahr TM, et al. Warming blood products for transfusion to neonates: In vitro assessments [published online ahead of print, 2020 Aug 10]. Transfusion. 2020;10.1111/trf.16007.

Dr. Christensen is the Director of Neonatology Research at Intermountain Healthcare and a Professor of Pediatrics at University of Utah Health. He lives in Layton, Utah.