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Red cell haemolysis secondary to intraosseous (IO) blood transfusion in adult patients with major trauma: a systematic review
  1. Matt Ellington1,2,
  2. I Walker3,4 and
  3. E Barnard5,6
  1. 1Anaesthetic Department, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
  2. 2Division of Anaesthesia, University of Cambridge, Cambridge, UK
  3. 3Haematology Department, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
  4. 4Department of Haematology, University of Cambridge, Cambridge, UK
  5. 5Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine (Research and Clinical Innovation), Birmingham, UK
  6. 6Emergency Department, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
  1. Correspondence to Dr Matt Ellington, Anaesthetic Department, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK; matt.ellington{at}


Introduction Intraosseous (IO) administration of medications and blood products is accepted practice in major trauma when intravenous access is not immediately available. However, there is a concern that the high infusion pressures required for IO transfusion may increase the risk of red cell haemolysis and its associated complications. The aim of this systematic review is to synthesise the existing evidence describing the risks of red cell haemolysis in IO blood transfusion.

Methods We undertook a systematic search of MEDLINE, CINAHL and EMBASE using the search terms: “intraosseous transfusion” and “haemolysis”. Two authors independently screened abstracts, and reviewed full-text articles against the inclusion criteria. Reference lists of included studies were reviewed and a grey literature search undertaken. Studies were assessed for risk of bias. Inclusion criteria were: all human and animal study types that reported novel data on IO-associated red cell haemolysis. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline was used.

Results Twenty-three abstracts were identified; n=9 full papers met the inclusion criteria. No further studies were identified from reference lists or grey literature. These papers included: seven large animal translational studies, a prospective and a retrospective human study. The overall risk of bias was high. One animal study with good translatability to adult patients with trauma demonstrated haemolysis. Other animal studies had methodological constraints that limit their human applicability. No haemolysis was observed in low-density flat bones (sternum), whereas haemolysis was reported in long bones (humerus, tibia). IO infusion using a three-way tap was associated with haemolysis. Conversely, pressure bag transfusion was not associated with haemolysis, but this method may result in insufficient flow rates for effective resuscitation.

Conclusions There is a paucity of high-quality evidence surrounding the risks of red cell haemolysis in IO blood transfusion. However, evidence from one study suggests that the likelihood is increased by use of a three-way tap to administer blood transfusion to young adult male patients with trauma. Further research is needed to address this important clinical question.

PROSPERO registration number CRD42022318902.

  • accident & emergency medicine
  • blood bank & transfusion medicine
  • trauma management

Data availability statement

No data are available.

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  • Contributors ME and IW performed the abstract review, full-text review and data extraction. ME and EB designed this article. EB provided academic supervision and guidance, as well as reviewing draft manuscripts. All authors have approved the final manuscript. ME acts as guarantor

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.