Whole blood transfusion and angioembolization are seeing increasing use in both adult and pediatric trauma populations as methods to control bleeding—but their growth is forcing surgeons to critically examine whether these methods are safe and effective.
Expert panelists held a collegial debate on these treatment modalities in yesterday’s Panel Session, “The Great Debate: Whole Blood Transfusion and Angioembolization in Pediatric and Adult Trauma: Life-Saving Adjuncts, or Not Worth the Trouble.”
Whole Blood in Pediatric Patients
Lucas P. Neff, MD, FACS, a pediatric surgeon from the Wake Forest University School of Medicine in Winston-Salem, North Carolina, provided the “pro” argument for whole blood in pediatric trauma populations, suggesting that it is feasible, safe, and efficacious.
He argued that whole blood is a complete resuscitation resource in situations where a child requires a massive transfusion protocol for stabilization.
While component blood transfusion requires precise calculations to find the right balance of products, “whole blood is perfectly balanced from the start, and research is showing that it gets patients hemodynamically balanced much faster,” Dr. Neff said.
In addition to better efficacy, he noted that component transfusion entails logistical concerns such as requiring more resources and total product by volume and introduces more than three times the preservatives into the patient due to different storage needs.
Obtaining whole blood is part of the challenge, but any amount of whole blood can act as a “transfusion kick-starter” and lead to better outcomes, Dr. Neff said.
Taking the “con” side, Barbara A. Gaines, MD, FACS, a pediatric surgeon at The University of Texas Southwestern Medical Center in Dallas, discussed logistical issues and the rare, but impactful, possibility of alloimmunization in female patients.
Because all components of blood are a valuable resource that come entirely from voluntary donations, it must be recognized that a blood donation from one individual can treat up to three patients with blood components, she noted, adding that improvements can be made to place blood closer to “point-of-care locations” to reduce the logistical burden of storage.
With whole blood, female pediatric trauma patients and parents also are faced with the additional potential burden of alloimmunization occurring if O negative blood isn’t used, which can lead to a future complicated pregnancy and neonatal period.
“The risk of a fetus and mother facing alloimmunization is low for whole blood recipients, and they can be treated, but treatment is resource intensive—and not every treatment is successful,” Dr. Gaines said, adding that while whole blood has been shown to be effective, its risks should be considered.
Role of Angioembolization in Trauma and Hemorrhagic Emergencies
Pedro G. Teixeira, MD, FACS, a vascular surgeon at The UT Health Austin Institute for Cardiovascular Health in Texas, took on the “pro” side for the angioembolization debate, arguing that the nonoperative management option can be a viable option to achieve hemostasis.
He suggested that surgeons should care about angioembolization “because it offers a minimally invasive approach to controlling bleeding when traditional surgical methods are too risky or challenging.”
Dr. Teixeira shared details about several scenarios where angioembolization has proven to be effective, especially in pelvic fracture—which can have a high mortality when combined with shock. The tool also has seen effective use in hepatic, splenic, and kidney injuries.
It is important to look for the indicators for appropriate use because “angioembolization is a tool that doesn’t work for every situation, but it’s nice to have a tool that works for specific circumstances,” Dr. Teixeira said.
Taking the “con” side, session moderator Christopher W. Snyder, MD, MSPH, FACS, a trauma and pediatric surgeon at Johns Hopkins All Children’s Hospital in Tampa, Florida, presented evidence the technique may be overutilized and have an unclear medical benefit.
In solid organ injuries, angioembolization has seen significant increases in use—a more than three times increase in splenic injuries in recent years, for example—but at the same time, there has been no change in nonoperative management success or failure, with one study showing there was no difference in outcomes between angioembolization and observation alone for spleens.
For solid organs and the pelvis alike, angioembolization has not made enough of a difference to justify the significant resource expenditure, Dr. Snyder said, also noting the risk of some significant complications such as proximal organ damage when treating spleens or major hepatic necrosis in livers.
If you missed in in-person session, it is now available on the virtual platform.
