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Adkins BD, Libby TA, Mayberry MM, Brady TW, Halls JB, Corbett SM, Schoeny J, Shields EP, Chowdhury J, Kinsinger-Stickel AN, Wehrli G, Jaeger NR, Robertson MP, Butler KM, Lowson SM, Calland JF, Gorham JD. How did we reform our out of control massive transfusion protocol program? Transfusion 2021; 61:3066-3074. [PMID: 34661301 DOI: 10.1111/trf.16706] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 09/14/2021] [Accepted: 09/21/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND The massive transfusion protocol (MTP) is designed to quickly provide blood products at a fixed ratio for the exsanguinating patient. At our academic medical center, the frequency of MTP activation increased over 10-fold between 2008 and 2015, putting inordinate stress on our transfusion service. STUDY DESIGN AND METHODS Gathering a large number of relevant stakeholders, we performed a multidisciplinary root cause analysis (RCA) in response to the acute clinical need to reform our MTP. RESULTS Through the RCA, we identified four principal opportunities for improvement (OFI) associated with our MTP: education, stewardship, process improvement, and communication. Through the deployment of new approaches to each of these OFI, we reduced MTP activations, blood product waste, and transfusion service technologist stress. CONCLUSION The MTP is amenable to improvement, and, although time intensive, the RCA process yields significant favorable effects: improving communication with colleagues, reducing stress within the transfusion service, and improving resource utilization. Activation of the MTP at our institution is now more aligned with its primary purpose: rapidly providing large quantities of blood products to exsanguinating patients.
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Affiliation(s)
- Brian D Adkins
- Department of Pathology, University of Virginia School of Medicine, Charlottesville, Virginia, USA
| | - Theresa A Libby
- Department of Medical Laboratories, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Marlene M Mayberry
- Department of Medical Laboratories, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Thomas W Brady
- Department of Medical Laboratories, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Justin B Halls
- Department of Pathology, University of Virginia School of Medicine, Charlottesville, Virginia, USA
| | - Stephanie Mallow Corbett
- Department of Performance Improvement, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Joseph Schoeny
- Department of Performance Improvement, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Eric P Shields
- Department of Performance Improvement, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Jahan Chowdhury
- Department of Medical Laboratories, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Amanda N Kinsinger-Stickel
- Department of Medical Laboratories, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Gay Wehrli
- Department of Pathology, University of Virginia School of Medicine, Charlottesville, Virginia, USA
| | - Nicholas R Jaeger
- Department of Pathology, University of Virginia School of Medicine, Charlottesville, Virginia, USA
| | - Matthew P Robertson
- Department of Surgery, University of Virginia School of Medicine, Charlottesville, Virginia, USA
| | - Kathy M Butler
- Department of Surgery, University of Virginia School of Medicine, Charlottesville, Virginia, USA
| | - Stuart M Lowson
- Department of Surgery, University of Virginia School of Medicine, Charlottesville, Virginia, USA.,Department of Anesthesiology, University of Virginia School of Medicine, Charlottesville, Virginia, USA
| | - James Forrest Calland
- Department of Surgery, University of Virginia School of Medicine, Charlottesville, Virginia, USA
| | - James D Gorham
- Department of Pathology, University of Virginia School of Medicine, Charlottesville, Virginia, USA
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102
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Fecher A, Stimpson A, Ferrigno L, Pohlman TH. The Pathophysiology and Management of Hemorrhagic Shock in the Polytrauma Patient. J Clin Med 2021; 10:jcm10204793. [PMID: 34682916 PMCID: PMC8541346 DOI: 10.3390/jcm10204793] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Revised: 10/14/2021] [Accepted: 10/15/2021] [Indexed: 11/16/2022] Open
Abstract
The recognition and management of life-threatening hemorrhage in the polytrauma patient poses several challenges to prehospital rescue personnel and hospital providers. First, identification of acute blood loss and the magnitude of lost volume after torso injury may not be readily apparent in the field. Because of the expression of highly effective physiological mechanisms that compensate for a sudden decrease in circulatory volume, a polytrauma patient with a significant blood loss may appear normal during examination by first responders. Consequently, for every polytrauma victim with a significant mechanism of injury we assume substantial blood loss has occurred and life-threatening hemorrhage is progressing until we can prove the contrary. Second, a decision to begin damage control resuscitation (DCR), a costly, highly complex, and potentially dangerous intervention must often be reached with little time and without sufficient clinical information about the intended recipient. Whether to begin DCR in the prehospital phase remains controversial. Furthermore, DCR executed imperfectly has the potential to worsen serious derangements including acidosis, coagulopathy, and profound homeostatic imbalances that DCR is designed to correct. Additionally, transfusion of large amounts of homologous blood during DCR potentially disrupts immune and inflammatory systems, which may induce severe systemic autoinflammatory disease in the aftermath of DCR. Third, controversy remains over the composition of components that are transfused during DCR. For practical reasons, unmatched liquid plasma or freeze-dried plasma is transfused now more commonly than ABO-matched fresh frozen plasma. Low-titer type O whole blood may prove safer than red cell components, although maintaining an inventory of whole blood for possible massive transfusion during DCR creates significant challenges for blood banks. Lastly, as the primary principle of management of life-threatening hemorrhage is surgical or angiographic control of bleeding, DCR must not eclipse these definitive interventions.
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Affiliation(s)
- Alison Fecher
- Division of Acute Care Surgery, Lutheran Hospital of Indiana, Fort Wayne, IN 46804, USA; (A.F.); (A.S.)
| | - Anthony Stimpson
- Division of Acute Care Surgery, Lutheran Hospital of Indiana, Fort Wayne, IN 46804, USA; (A.F.); (A.S.)
| | - Lisa Ferrigno
- Department of Surgery, UCHealth, University of Colorado-Denver, Aurora, CO 80045, USA;
| | - Timothy H. Pohlman
- Surgery Section, Woodlawn Hospital, Rochester, IN 46975, USA
- Correspondence:
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103
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Liu Z, Ayyagari RC, Martinez Monegro EY, Stansbury LG, Arbabi S, Bulger EM, Vavilala MS, Hess JR. Blood component use and injury characteristics of acute trauma patients arriving from the scene of injury or as transfers to a large, mature US Level 1 trauma center serving a large, geographically diverse region. Transfusion 2021; 61:3139-3149. [PMID: 34632587 DOI: 10.1111/trf.16679] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Revised: 08/09/2021] [Accepted: 08/30/2021] [Indexed: 12/23/2022]
Abstract
BACKGROUND Advanced trauma care demands the timely availability of hemostatic blood products, posing special challenges for regional systems in geographically diverse areas. We describe acute trauma blood use by transfer status and injury characteristics at a large regional Level 1 trauma center. STUDY DESIGN AND METHODS We reviewed Harborview Medical Center (HMC) Trauma Registry, Transfusion Service, and electronic medical records on acute trauma patients for demographics, injury patterns, blood use, and in-hospital mortality, 2011-2019. RESULTS Among 47,471 patients (mean age 45.2 ± 23.0 years; 68.3% male; Injury Severity Score 12.6 ± 11.1), 4.7% died and 8547 (18%) received at least one blood component through HMC. Firearms injuries were the most often transfused (690/2596, 26.6%) and the most urgently (39.9% ≥3 units in <1 h; 40.6% ≥5 units in <4 h), and had the highest mortality (case-fatality, 12.2%) (all p < .001). From-scene patients were younger than transfers (42.9 ± 21.0 vs. 47.2 ± 24.4), predominated among firearms injuries (68.2% from-scene vs. 31.8% transfers), were more likely to receive blood (18.5% vs. 17.6%) more urgently (≥3 units first hour, 24.4% vs. 7.7%; ≥5 units first 4 h: 25.6% vs. 8.2%), were more likely to die of hemorrhage (15.5% vs. 4.3%) and from firearms injuries (310/1360, 22.8%) (all p < .001). DISCUSSION Early blood use, firearms injuries, and mortality were all greater among from-scene patients, and firearms injuries had worse outcomes despite greater and more urgent blood use, but the role of survivor bias for transfer patients must be clarified. Future research must identify strategies for providing local hemostatic transfusion support, particularly for firearms injuries.
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Affiliation(s)
- Zhinan Liu
- Harborview Injury Prevention and Research Center (HIPRC), Seattle, Washington, USA
| | - Rajiv C Ayyagari
- Harborview Injury Prevention and Research Center (HIPRC), Seattle, Washington, USA
| | - Edison Y Martinez Monegro
- Harborview Injury Prevention and Research Center (HIPRC), Seattle, Washington, USA.,San Juan Bautista School of Medicine, Cauguas, Puerto Rico
| | - Lynn G Stansbury
- Harborview Injury Prevention and Research Center (HIPRC), Seattle, Washington, USA.,Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington, USA
| | - Saman Arbabi
- Harborview Injury Prevention and Research Center (HIPRC), Seattle, Washington, USA.,Department of Surgery, University of Washington School of Medicine, Seattle, Washington, USA
| | - Eileen M Bulger
- Harborview Injury Prevention and Research Center (HIPRC), Seattle, Washington, USA.,Department of Surgery, University of Washington School of Medicine, Seattle, Washington, USA
| | - Monica S Vavilala
- Harborview Injury Prevention and Research Center (HIPRC), Seattle, Washington, USA.,Department of Surgery, University of Washington School of Medicine, Seattle, Washington, USA.,Department of Pediatrics, University of Washington, Seattle, Washington, USA
| | - John R Hess
- Harborview Injury Prevention and Research Center (HIPRC), Seattle, Washington, USA.,Department of Laboratory Medicine and Pathology, University of Washington, Seattle, Washington, USA.,Harborview Medical Center Transfusion Medicine Service, Harborview Transfusion Medicine Service, Seattle, Washington, USA
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104
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Tucker H, Davenport R, Green L. The Role of Plasma Transfusion in Pre-Hospital Haemostatic Resuscitation. Transfus Med Rev 2021; 35:91-95. [PMID: 34593289 DOI: 10.1016/j.tmrv.2021.08.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Revised: 08/22/2021] [Accepted: 08/23/2021] [Indexed: 12/15/2022]
Abstract
Traumatic haemorrhage remains a major cause of preventable death and early haemostatic resuscitation is now a mainstay of treatment internationally. Recently, 2 randomized control trials (RCTs) - PAMPer (Prehospital Air Medical Plasma) and COMBAT (Control of Major Bleeding After Trauma), evaluating the effect of pre-hospital use of plasma on mortality provided conflicting results, raising important questions on the role of plasma resuscitation in pre-hospital environment. Both PAMPer (n = 501 patients) and COMBAT (n = 144 patients) trials were pragmatic RCTs that evaluated the effect of pre-hospital plasma transfusion (two units) versus standard of care on 28/30 days mortality in trauma patients who presented with clinical signs of haemorrhagic shock (defined as hypotension or tachycardia). The PAMPer trial showed that plasma transfusion reduced 30-day mortality compared with standard of care (23% vs 33%, 95% confidence interval -18.6; -1.0%; P = 0.03), while COMBAT trial showed no difference in 28-day survival. The post-hoc analyses of the 2 trials have suggested that the benefit of pre-hospital plasma transfusion may be greater for patients who are coagulopathic, have blunt injury and have a transport time from the scene of injury to the hospital of >20 minutes. In this review we evaluate strengths and limitations of the two trials and their differences and similarities, which may explain the conflicting results, as well as provide directions for future trials to better define the target population that would most benefit from pre-hospital plasma resuscitation. Further, considering the logistical challenges of carrying any blood components on an aircraft, cost/safety of plasma, and the scarcity of universal blood group donors, there is a need for a health economic evaluation of pre-hospital plasma transfusion in trauma patients, prior to this intervention becoming universal.
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Affiliation(s)
- Harriet Tucker
- Blizard Institute, Queen Mary University of London, London, UK
| | - Ross Davenport
- Blizard Institute, Queen Mary University of London, London, UK; Departmen of Trauma, Barts Health NHS Trust, London, UK
| | - Laura Green
- Blizard Institute, Queen Mary University of London, London, UK; Departmen of Trauma, Barts Health NHS Trust, London, UK; Blood Component division, NHS Blood and Transplant, London, UK.
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105
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Hrebinko KA, Sperry JL, Guyette FX, Brown JB, Daley BJ, Miller RS, Harbrecht BG, Claridge JA, Phelan HA, Neal MD, Zuckerbraun BS, Yazer MH, Nicholson KJ. Evaluating the Cost-effectiveness of Prehospital Plasma Transfusion in Unstable Trauma Patients: A Secondary Analysis of the PAMPer Trial. JAMA Surg 2021; 156:1131-1139. [PMID: 34550318 DOI: 10.1001/jamasurg.2021.4529] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Importance Prehospital plasma transfusion is lifesaving for trauma patients in hemorrhagic shock but is not commonly used owing to cost and feasibility concerns. Objective To evaluate the cost-effectiveness of prehospital thawed plasma transfusion in trauma patients with hemorrhagic shock during air medical transport. Design, Setting, and Participants A decision tree and Markov model were created to compare standard care and prehospital thawed plasma transfusion using published and unpublished patient-level data from the Prehospital Plasma in Air Medical Transport in Trauma Patients at Risk for Hemorrhagic Shock (PAMPer) trial conducted from May 2014 to October 2017, health care and trauma-specific databases, and the published literature. Prehospital transfusion, short-term inpatient care, and lifetime health care costs and quality of life outcomes were included. One-way, 2-way, and Monte Carlo probabilistic sensitivity analyses were performed across clinically plausible ranges. Data were analyzed in December 2019. Main Outcomes and Measures Relative costs and health-related quality of life were evaluated by an incremental cost-effectiveness ratio at a standard willingness-to-pay threshold of $100 000 per quality-adjusted life-year (QALY). Results The trial included 501 patients in the modified intention-to-treat cohort. Median (interquartile range) age for patients in the thawed plasma and standard care cohorts were 44 (31-59) and 46 (28-60) years, respectively. Overall, 364 patients (72.7%) were male. Thawed plasma transfusion was cost-effective with an incremental cost-effectiveness ratio of $50 467.44 per QALY compared with standard care. The preference for thawed plasma was robust across all 1- and 2-way sensitivity analyses. When considering only patients injured by a blunt mechanism, the incremental cost-effectiveness ratio decreased to $37 735.19 per QALY. Thawed plasma was preferred in 8140 of 10 000 iterations (81.4%) on probabilistic sensitivity analysis. A detailed analysis of incremental costs between strategies revealed most were attributable to the in-hospital and postdischarge lifetime care of critically ill patients surviving severe trauma. Conclusions and Relevance In this study, prehospital thawed plasma transfusion during air medical transport for trauma patients in hemorrhagic shock was lifesaving and cost-effective compared with standard care and should become commonplace.
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Affiliation(s)
| | - Jason L Sperry
- Division of Trauma & Acute Care Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Francis X Guyette
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Joshua B Brown
- Division of Trauma & Acute Care Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Brian J Daley
- Division of Trauma & Critical Care Surgery, Department of Surgery, University of Tennessee Graduate School of Medicine, Knoxville
| | | | - Brian G Harbrecht
- Division of Trauma Surgery, Department of Surgery, University of Louisville, Louisville, Kentucky
| | - Jeffrey A Claridge
- Division of Trauma & Critical Care, Metrohealth Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - Herb A Phelan
- Division of Burn Surgery, Department of Surgery, Louisiana State University Health Sciences Center, New Orleans
| | - Matthew D Neal
- Division of Trauma & Acute Care Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Brian S Zuckerbraun
- Division of Trauma & Acute Care Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Mark H Yazer
- Department of Pathology, University of Pittsburgh, Pittsburgh, Pennsylvania
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106
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Lima LPDST, Santos PRS, Martins HJ, Rodrigues DADS, Silva LM, Libardi MBO, Azevedo NAM. Use of Tranexamic Acid in Traumatic Resuscitation in a Prehospital Setting: A Case Report. Air Med J 2021; 40:359-362. [PMID: 34535245 DOI: 10.1016/j.amj.2021.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Revised: 03/28/2021] [Accepted: 05/27/2021] [Indexed: 10/21/2022]
Abstract
This study describes the use of tranexamic acid associated with other measures in the initial approach to contain bleeding in a situation of hemorrhagic shock in a trauma patient. The case describes the care of a young man with multiple thorax punctures by a melee weapon, quickly progressing to a condition of severe shock, in addition to the action of a helicopter emergency medical team supporting the patient's transportation from a low-complexity emergency care unit to a specialized unit.
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Affiliation(s)
- Lilyan Paula de Sousa Teixeira Lima
- Mobile Emergency Care Service, Serviço de Atendimento Móvel de Urgência, Brasília, Brazil; Helicopter Emergency Medical Services, Military Firefighters Corps of the Federal District, Brasília, Brazil.
| | - Paulo Regis Souza Santos
- Mobile Emergency Care Service, Serviço de Atendimento Móvel de Urgência, Brasília, Brazil; Helicopter Emergency Medical Services, Military Firefighters Corps of the Federal District, Brasília, Brazil.
| | - Herberth Jessie Martins
- Mobile Emergency Care Service, Serviço de Atendimento Móvel de Urgência, Brasília, Brazil; Helicopter Emergency Medical Services, Military Firefighters Corps of the Federal District, Brasília, Brazil.
| | - Daniel Augusto de Souza Rodrigues
- Mobile Emergency Care Service, Serviço de Atendimento Móvel de Urgência, Brasília, Brazil; Helicopter Emergency Medical Services, Military Firefighters Corps of the Federal District, Brasília, Brazil.
| | - Larissa Michetti Silva
- Mobile Emergency Care Service, Serviço de Atendimento Móvel de Urgência, Brasília, Brazil; Trauma Center of the Federal District, Brasília, Brazil.
| | - Mônica Beatriz Ortolan Libardi
- Mobile Emergency Care Service, Serviço de Atendimento Móvel de Urgência, Brasília, Brazil; Helicopter Emergency Medical Services, Military Firefighters Corps of the Federal District, Brasília, Brazil.
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107
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Yamamoto R, Suzuki M, Sasaki J. Reply to Swinging the pendulum in prehospital trauma mortality needs a more holistic approach. J Trauma Acute Care Surg 2021; 91:e81-e82. [PMID: 34039919 DOI: 10.1097/ta.0000000000003292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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108
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Peng HT, Rhind SG, Devine D, Jenkins C, Beckett A. Ex vivo hemostatic and immuno-inflammatory profiles of freeze-dried plasma. Transfusion 2021; 61 Suppl 1:S119-S130. [PMID: 34269465 DOI: 10.1111/trf.16502] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 04/01/2021] [Accepted: 04/01/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND Hemorrhage is a leading cause of preventable death in civilian and military trauma. Freeze-dried plasma is promising for hemostatic resuscitation in remote prehospital settings, given its potential benefits in reducing blood loss and mortality, long storage at ambient temperatures, high portability, and rapid reconstitution for transfusion in austere environments. Here we assess the ex vivo characteristics of a novel Terumo's freeze-dried plasma product (TFDP). STUDY DESIGN AND METHODS Rotational thromboelastometry (ROTEM) tests (INTEM, EXTEM, and FIBTEM) were conducted on plasma samples at 37°C with a ROTEM delta-machine using standard reagents and procedures. The following samples were analyzed: pooled plasma to produce TFDP, TFDP reconstituted, and stored immediately at -80°C, reconstituted TFDP stored at 4°C for 24 h and room temperature (RT) for 4 h before freezing at -80°C. Analysis of plasma concentrations of selected cytokines, chemokines, and vascular molecules was performed using a multiplex immunoassay system. One-way ANOVA with post hoc tests assessed differences in hemostatic and inflammatory properties. RESULTS No significant differences in ROTEM variables (coagulation time [CT], clot formation time, α-angle, maximum clot firmness, and lysis index 30) between the TFDP-producing plasma and reconstituted TFDP samples were observed. Compared to control plasma, reconstituted TFDP stored at 4°C for 24 h or RT for 4 h showed a longer INTEM CT. Levels of immuno-inflammatory mediators were similar between frozen plasma and TFDP. CONCLUSIONS TFDP is equivalent to frozen plasma with respect to global hemostatic and immuno-inflammatory mediator profiles. Further investigations of TFDP in trauma-induced coagulopathy models and bleeding patients are warranted.
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Affiliation(s)
- Henry T Peng
- Defence Research and Development Canada, Toronto Research Centre, Toronto, Ontario, Canada
| | - Shawn G Rhind
- Defence Research and Development Canada, Toronto Research Centre, Toronto, Ontario, Canada
| | - Dana Devine
- Canadian Blood Services, Ottawa, Ontario, Canada
| | | | - Andrew Beckett
- St. Michael's Hospital, Toronto, Ontario, Canada.,Royal Canadian Medical Services, Ottawa, Ontario, Canada
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109
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Edwards TH, Rizzo JA, Pusateri AE. Hemorrhagic shock and hemostatic resuscitation in canine trauma. Transfusion 2021; 61 Suppl 1:S264-S274. [PMID: 34269447 DOI: 10.1111/trf.16516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 02/18/2021] [Accepted: 02/19/2021] [Indexed: 11/27/2022]
Abstract
Hemorrhage is a significant cause of death among military working dogs and in civilian canine trauma. While research specifically aimed at canine trauma is limited, many principles from human trauma resuscitation apply. Trauma with significant hemorrhage results in shock and inadequate oxygen delivery to tissues. This leads to aberrations in cellular metabolism, including anaerobic metabolism, decreased energy production, acidosis, cell swelling, and eventual cell death. Considering blood and endothelium as a single organ system, blood failure is a syndrome of endotheliopathy, coagulopathy, and platelet dysfunction. In severe cases following injury, blood failure develops and is induced by inadequate oxygen delivery in the presence of hemorrhage, tissue injury, and acute stress from trauma. Severe hemorrhagic shock is best treated with hemostatic resuscitation, wherein blood products are used to restore effective circulating volume and increase oxygen delivery to tissues without exacerbating blood failure. The principles of hemostatic resuscitation have been demonstrated in severely injured people and the authors propose an algorithm for applying this to canine patients. The use of plasma and whole blood to resuscitate severely injured canines while minimizing the use of crystalloids and colloids could prove instrumental in improving both mortality and morbidity. More work is needed to understand the canine patient that would benefit from hemostatic resuscitation, as well as to determine the optimal resuscitation strategy for these patients.
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Affiliation(s)
- Thomas H Edwards
- U.S. Army Institute of Surgical Research, Joint Base San Antonio - Fort Sam Houston, Texas, USA
| | - Julie A Rizzo
- U.S. Army Institute of Surgical Research, Joint Base San Antonio - Fort Sam Houston, Texas, USA.,Uniformed Services University of Health Sciences, Bethesda, Maryland, USA
| | - Anthony E Pusateri
- Naval Medical Research Unit San Antonio, Joint Base San Antonio - Fort Sam Houston, Texas, USA
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110
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Avital G, Gelikas S, Radomislensky I, Tsur AM, Sorkin A, Shinar E, Bodas M, Yazer MH, Cap AP, Chen J, Glassberg E, Benov A. A prehospital scoring system for predicting the need for emergent blood product transfusion. Transfusion 2021; 61 Suppl 1:S195-S205. [PMID: 34269466 DOI: 10.1111/trf.16529] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Revised: 03/11/2021] [Accepted: 03/12/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Several tools have been proven to predict the need for massive transfusion in trauma casualties, yet tools that are easily applicable in the prehospital setting for predicting the need for any blood product transfusion in the emergency department (ED) are lacking. METHODS A retrospective analysis of the cross-referenced Israeli Defense Forces Trauma Registry and the Israeli National Trauma Registry databases was performed to identify predictors for any blood product transfusion in the ED. A scoring system was developed after internally validating the prediction model. Division to risk groups was performed. RESULTS Seven variables (systolic blood pressure, heart rate, arterial oxygen saturation, trunk involvement, mechanism of injury, chest decompression, and tourniquet application) were included in the scoring system, ranging from 0 to 11.5. Risk groups for ED transfusion included very low (0.8%), low (3.2%), intermediate (8.5%), and high (31.2%) risk. CONCLUSION A scoring system for predicting the need for any blood product transfusion in the ED was developed, based on information readily available in the early stages of prehospital resuscitation, allowing the receiving medical facility to prepare for that need.
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Affiliation(s)
- Guy Avital
- The Trauma and Combat Medicine Branch, Surgeon General's Headquarters, Israel Defense Forces, Ramat Gan, Israel.,Division of Anesthesia, Intensive Care, and Pain Management, Tel-Aviv Medical Center, Tel-Aviv University, Tel-Aviv, Israel
| | - Shaul Gelikas
- The Trauma and Combat Medicine Branch, Surgeon General's Headquarters, Israel Defense Forces, Ramat Gan, Israel
| | - Irina Radomislensky
- The National Center for Trauma and Emergency Medicine Research, The Gertner Institute for Epidemiology and Health Policy Research, Sheba Medical Center, Tel-HaShomer, Israel
| | - Avishai M Tsur
- The Trauma and Combat Medicine Branch, Surgeon General's Headquarters, Israel Defense Forces, Ramat Gan, Israel.,Department of Medicine 'B'. Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel-Hashomer; affiliated with Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Alex Sorkin
- The Trauma and Combat Medicine Branch, Surgeon General's Headquarters, Israel Defense Forces, Ramat Gan, Israel.,Department of Plastic and Reconstructive Surgery, Shamir Medical Centre, Zrifin, Israel
| | - Eilat Shinar
- National Blood Services, Magen David Adom, Ramat Gan, Israel
| | - Moran Bodas
- The National Center for Trauma and Emergency Medicine Research, The Gertner Institute for Epidemiology and Health Policy Research, Sheba Medical Center, Tel-HaShomer, Israel.,Department of Emergency Management and Disaster Medicine, Schoole of Public Health, Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv-Yafo, Israel
| | - Mark H Yazer
- Department of Pathology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Department of Pathology, Tel Aviv University, Tel Aviv, Israel
| | - Andrew P Cap
- Division of Transfusion Medicine, Department of Laboratory Medicine and Pathology, US Army Institute of Surgical Research and Uniformed Services University, JBSA-FT Sam Houston, San Antonio, Texas, USA
| | - Jacob Chen
- Meir Medical Center, Kfar Saba, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Elon Glassberg
- The Azrieli Faculty of Medicine, Bar-Ilan University, Safed, Israel.,Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA.,Surgeon General's Headquarters, Israel Defense Forces, Ramat Gan, Israel
| | - Avi Benov
- The Trauma and Combat Medicine Branch, Surgeon General's Headquarters, Israel Defense Forces, Ramat Gan, Israel.,The Azrieli Faculty of Medicine, Bar-Ilan University, Safed, Israel
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111
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Hagen KG, Strandenes G, Kristoffersen EK, Braathen H, Sivertsen J, Bjerkvig CK, Sommerfelt-Pettersen N, Aasheim IB, Lunde THF, Hervig T, Apelseth TO. A whole blood based resuscitation strategy in civilian medical services: Experience from a Norwegian hospital in the period 2017-2020. Transfusion 2021; 61 Suppl 1:S22-S31. [PMID: 34269432 DOI: 10.1111/trf.16490] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 03/11/2021] [Accepted: 03/11/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND Civilian and military guidelines recommend early balanced transfusion to patients with life-threatening bleeding. Low titer group O whole blood was introduced as the primary blood product for resuscitation of massive hemorrhage at Haukeland University Hospital, Bergen, Norway, in December 2017. In this report, we describe the whole blood program and present results from the first years of routine use. STUDY DESIGN AND METHODS Patients who received whole blood from December 2017 to April 2020 were included in our quality registry for massive transfusions. Post-transfusion blood samples were collected to analyze isohemagglutinin (anti-A/-B) and hemolysis markers. Administration of other blood products, transfusion reactions, and patient survival (days 1 and 30) were recorded. User experiences were surveyed for both clinical and laboratory staff. RESULTS Two hundred and five patients (64% male and 36% female) received 836 units in 226 transfusion episodes. Patients received a mean of 3.7 units (range 1-35) in each transfusion episode. The main indications for transfusion were trauma (26%), gastrointestinal (22%), cardiothoracic/vascular (18%), surgical (18%), obstetric (11%), and medical (5%) bleeding. There was no difference in survival between patients with blood type O when compared with non-group O. Haptoglobin level was lower in the transfusion episodes for non-O group patients, however no clinical hemolysis was reported. No patients had conclusive transfusion-associated adverse events. Both clinical and laboratory staff preferred whole blood to component therapy for massive transfusion. DISCUSSION The experience from Haukeland University Hospital indicates that whole blood is feasible, safe, and effective for in-hospital treatment of bleeding.
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Affiliation(s)
- Kristin Gjerde Hagen
- Department of Immunology and Transfusion Medicine, Haukeland University Hospital, Bergen, Norway
| | - Geir Strandenes
- Department of Immunology and Transfusion Medicine, Haukeland University Hospital, Bergen, Norway.,Department of War Surgery and Emergency Medicine, Norwegian Armed Forces Medical Services, Sessvollmoen, Norway
| | - Einar Klaeboe Kristoffersen
- Department of Immunology and Transfusion Medicine, Haukeland University Hospital, Bergen, Norway.,Institute of Clinical Science, University of Bergen, Bergen, Norway
| | - Hanne Braathen
- Department of Immunology and Transfusion Medicine, Haukeland University Hospital, Bergen, Norway.,Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Joar Sivertsen
- Department of Immunology and Transfusion Medicine, Haukeland University Hospital, Bergen, Norway.,Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Christopher Kalhagen Bjerkvig
- Institute of Clinical Science, University of Bergen, Bergen, Norway.,Department of Anesthesia and Intensive Care, Haukeland University Hospital, Bergen, Norway
| | | | - Irmelin Beathe Aasheim
- Department of Immunology and Transfusion Medicine, Haukeland University Hospital, Bergen, Norway
| | - Turid Helen Felli Lunde
- Department of Immunology and Transfusion Medicine, Haukeland University Hospital, Bergen, Norway
| | - Tor Hervig
- Department of Immunology and Transfusion Medicine, Haukeland University Hospital, Bergen, Norway.,Institute of Clinical Science, University of Bergen, Bergen, Norway.,Laboratory of Immunology and Transfusion Medicine, Haugesund Hospital, Haugesund, Norway
| | - Torunn Oveland Apelseth
- Department of Immunology and Transfusion Medicine, Haukeland University Hospital, Bergen, Norway.,Department of War Surgery and Emergency Medicine, Norwegian Armed Forces Medical Services, Sessvollmoen, Norway
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Meledeo MA, Peltier GC, McIntosh CS, Bynum JA, Corley JB, Cap AP. Coagulation function of never frozen liquid plasma stored for 40 days. Transfusion 2021; 61 Suppl 1:S111-S118. [PMID: 34269464 DOI: 10.1111/trf.16526] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2020] [Revised: 02/23/2021] [Accepted: 02/23/2021] [Indexed: 12/22/2022]
Abstract
BACKGROUND Never frozen liquid plasma (LP) has limited shelf life versus fresh frozen plasma (FFP) or plasma frozen within 24 h (PF24). Previous studies showed decreasing factor activities after Day (D)14 in thawed FFP but no differences between LP and FFP until D10. This study examined LP function through D40. STUDY DESIGN AND METHODS FFP and PF24 were stored at -20°C until assaying. LP was assayed on D5 then stored (4°C) for testing through D40. A clinical coagulation analyzer measured Factor (F)V, FVIII, fibrinogen, prothrombin time (PT), and activated partial thromboplastin time (aPTT). Thromboelastography (TEG) and thrombogram measured functional coagulation. Ristocetin cofactor assay quantified von Willebrand factor (vWF) activity. Residual platelets were counted. RESULTS FV/FVIII showed diminished activity over time in LP, while PT and aPTT both increased over time. LP vWF declined significantly by D7. Fibrinogen remained high through D40. Thrombin lagtime was delayed in LP but consistent to D40, while peak thrombin was significantly lower in LP but did not significantly decline over time. TEG R-time and angle remained constant. LP and PF24 (with residual platelets) had initially higher TEG maximum amplitudes (MA), but by D14 LP was similar to FFP. CONCLUSION Despite significant declines in some factors in D40 LP, fibrinogen concentration and TEG MA were stable suggesting stored LP provides fibrinogen similarly to frozen plasmas even at D40. LP is easier to store and prepare for prehospital transfusion, important benefits when the alternative is crystalloid.
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Affiliation(s)
| | - Grantham C Peltier
- U.S. Army Institute of Surgical Research, JBSA-Fort Sam Houston, Texas, USA
| | - Colby S McIntosh
- U.S. Army Institute of Surgical Research, JBSA-Fort Sam Houston, Texas, USA
| | - James A Bynum
- U.S. Army Institute of Surgical Research, JBSA-Fort Sam Houston, Texas, USA
| | - Jason B Corley
- Armed Services Blood Program, JBSA-Fort Sam Houston, Texas, USA
| | - Andrew P Cap
- U.S. Army Institute of Surgical Research, JBSA-Fort Sam Houston, Texas, USA
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113
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Sayce AC, Neal MD, Leeper CM. Viscoelastic monitoring in trauma resuscitation. Transfusion 2021; 60 Suppl 6:S33-S51. [PMID: 33089933 DOI: 10.1111/trf.16074] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 06/13/2020] [Accepted: 06/14/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND Traumatic injury results in both physical and physiologic insult. Successful care of the trauma patient depends upon timely correction of both physical and biochemical injury. Trauma-induced coagulopathy is a derangement of hemostasis and thrombosis that develops rapidly and can be fatal if not corrected. Viscoelastic monitoring (VEM) assays have been developed to provide rapid, accurate, and relatively comprehensive depictions of an individual's coagulation profile. VEM are increasingly being integrated into trauma resuscitation guidelines to provide dynamic and individualized guidance to correct coagulopathy. STUDY DESIGN AND METHODS We performed a narrative review of the search terms viscoelastic, thromboelastography, thromboelastometry, TEG, ROTEM, trauma, injury, resuscitation, and coagulopathy using PubMed. Particular focus was directed to articles describing algorithms for management of traumatic coagulopathy based on VEM assay parameters. RESULTS Our search identified 16 papers with VEM-guided resuscitation strategies in adult patients based on TEG, 12 such protocols in adults based on ROTEM, 1 protocol for children based on TEG, and 2 protocols for children based on ROTEM. CONCLUSIONS This review presents evidence to support VEM use to detect traumatic coagulopathy, discusses the role of VEM in trauma resuscitation, provides a summary of proposed treatment algorithms, and discusses pending questions in the field.
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Affiliation(s)
- Andrew C Sayce
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Matthew D Neal
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Christine M Leeper
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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Ramirez-Arcos S, Howell A, Bearne J, Bhakta V, Bower L, Cardigan R, Girard M, Kou Y, McDonald C, Nolin MÈ, Sawicka D, Sheffield W. Challenging the 30-min rule for thawed plasma. Vox Sang 2021; 117:328-336. [PMID: 34346087 DOI: 10.1111/vox.13189] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Revised: 07/09/2021] [Accepted: 07/20/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND OBJECTIVES Frozen plasma (FP) is thawed prior to transfusion and stored for ≤5 days at 1-6°C. The effect of temperature excursions on the quality and safety of thawed plasma during 5-day storage was determined. MATERIALS AND METHODS Four plasma units were pooled, split and stored at ≤-18°C for ≤90 days. Test units T30 and T60 were exposed to 20-24°C (room temperature [RT]) for 30 or 60 min, respectively, on days 0 and 2 of storage. Negative and positive control units remained refrigerated or at RT for 5 days, respectively. On Day 5, test units were exposed once to RT for 5 h. Quality assays included stability of coagulation factors FV, FVII, FVIII, fibrinogen and prothrombin time. Bacterial growth was performed in units inoculated with ~1 CFU/ml or ~100 CFU/ml of Serratia liquefaciens, Pseudomonas putida, Pseudomonas aeruginosa or Staphylococcus epidermidis on Day 0. RESULTS Testing results of all quality parameters were comparable between T30 and T60 units (p < 0.05). Serratia liquefaciens proliferated in cold-stored plasma, while P. putida showed variable viability. Serratia epidermidis and P. aeruginosa survived but did not grow in cold-stored plasma. Positive and negative controls showed expected results. Overall, no statistical differences in bacterial concentration between T30 and T60 units were observed (p < 0.05). CONCLUSION Multiple RT exposures for 30 or 60 min do not affect the stability of coagulation factors or promote bacterial growth in thawed plasma stored for 5 days. It is therefore safe to expose thawed plasma to uncontrolled temperatures for limited periods of 60 min.
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Affiliation(s)
- Sandra Ramirez-Arcos
- Centre for Innovation, Canadian Blood Services, Ottawa, Ontario, Canada.,Department of Biochemistry, Microbiology and Immunology, University of Ottawa, Ottawa, Ontario, Canada
| | - Anita Howell
- Centre for Innovation, Canadian Blood Services, Ottawa, Ontario, Canada
| | - Jennifer Bearne
- National Bacteriology Laboratory, National Health Service Blood and Transplant, London, UK
| | - Varsha Bhakta
- Centre for Innovation, Canadian Blood Services, Ottawa, Ontario, Canada
| | - Lucy Bower
- Component Development, National Health Service Blood and Transplant, Cambridge, UK
| | - Rebecca Cardigan
- Component Development, National Health Service Blood and Transplant, Cambridge, UK
| | - Mélissa Girard
- Medicals Affairs and Innovation, Héma-Québec, Québec, Quebec, Canada
| | - Yuntong Kou
- Centre for Innovation, Canadian Blood Services, Ottawa, Ontario, Canada
| | - Carl McDonald
- National Bacteriology Laboratory, National Health Service Blood and Transplant, London, UK
| | - Marie-Ève Nolin
- Medicals Affairs and Innovation, Héma-Québec, Québec, Quebec, Canada
| | - Danuta Sawicka
- National Bacteriology Laboratory, National Health Service Blood and Transplant, London, UK
| | - William Sheffield
- Centre for Innovation, Canadian Blood Services, Ottawa, Ontario, Canada
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Yamamoto R, Suzuki M, Yoshizawa J, Nishida Y, Junichi S. Physician-staffed ambulance and increased in-hospital mortality of hypotensive trauma patients following prolonged prehospital stay: A nationwide study. J Trauma Acute Care Surg 2021; 91:336-343. [PMID: 33852563 DOI: 10.1097/ta.0000000000003239] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The benefits of physician-staffed emergency medical services (EMS) for trauma patients remain unclear because of the conflicting results on survival. Some studies suggested potential delays in definitive hemostasis due to prolonged prehospital stay when physicians are dispatched to the scene. We examined hypotensive trauma patients who were transported by ambulance, with the hypothesis that physician-staffed ambulances would be associated with increased in-hospital mortality, compared with EMS personnel-staffed ambulances. METHODS A retrospective cohort study that included hypotensive trauma patients (systolic blood pressure ≤ 90 mm Hg at the scene) transported by ambulance was conducted using the Japan Trauma Data Bank (2004-2019). Physician-staffed ambulances are capable of resuscitative procedures, such as thoracotomy and surgical airway management, while EMS personnel-staffed ambulances could only provide advanced life support. In-hospital mortality and prehospital time until the hospital arrival were compared between patients who were classified based on the type of ambulance. Inverse probability weighting was conducted to adjust baseline characteristics including age, sex, comorbidities, mechanism of injury, vital signs at the scene, injury severity, and ambulance dispatch time. RESULTS Among 14,652 patients eligible for the study, 738 were transported by a physician-staffed ambulance. In-hospital mortality was higher in the physician-staffed ambulance than in the EMS personnel-staffed ambulance (201/699 [28.8%] vs. 2287/13,090 [17.5%]; odds ratio, 1.90 [1.61-2.26]; adjusted odds ratio, 1.22 [1.14-1.30]; p < 0.01), and the physician-staffed ambulance showed longer prehospital time (50 [36-66] vs. 37 [29-48] min, difference = 12 [11-12] min, p < 0.01). Such potential harm of the physician-staffed ambulance was only observed among patients who arrived at the hospital with persistent hypotension (systolic blood pressure < 90 mm Hg on hospital arrival) in subgroup analyses. CONCLUSION Physician-staffed ambulances were associated with prolonged prehospital stay and increased in-hospital mortality among hypotensive trauma patients compared with EMS personnel-staffed ambulance. LEVEL OF EVIDENCE Therapeutic, level IV.
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Affiliation(s)
- Ryo Yamamoto
- From the Department of Emergency and Critical Care Medicine (R.Y., J.Y., Y.N., J.S.), Keio University School of Medicine, Tokyo; and Department of Emergency Medicine (M.S.), Tokyo Dental College, Ichikawa General Hospital, Chiba, Japan
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116
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Ladhani HA, Ho VP, Charbonnet CC, Sperry JL, Guyette FX, Brown JB, Daley BJ, Miller RS, Harbrecht BG, Phelan HA, Claridge JA. Dose-dependent association between blood transfusion and nosocomial infections in trauma patients: A secondary analysis of patients from the PAMPer trial. J Trauma Acute Care Surg 2021; 91:272-278. [PMID: 34397951 PMCID: PMC8664092 DOI: 10.1097/ta.0000000000003251] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The Prehospital Air Medical Plasma (PAMPer) trial demonstrated a survival benefit to trauma patients who received thawed plasma as part of early resuscitation. The objective of our study was to examine the association between blood transfusion and nosocomial infections among trauma patients who participated in the PAMPer trial. We hypothesized that transfusion of blood products will be associated with the development of nosocomial infections in a dose-dependent fashion. METHODS We performed a secondary analysis of prospectively collected data of patients in the PAMPer trial with hospital length of stay of at least 3 days. Demographics, injury characteristics, and number of blood products transfused were obtained to evaluate outcomes. Bivariate analysis was performed to identify differences between patients with and without nosocomial infections. Two logistic regression models were created to evaluate the association between nosocomial infections and (1) any transfusion of blood products, and (2) quantity of blood products. Both models were adjusted for age, sex, and Injury Severity Score. RESULTS A total of 399 patients were included: age, 46 years (interquartile range, 29-59 years); Injury Severity Score, 22 (interquartile range, 12-29); 73% male; 80% blunt mechanism; and 40 (10%) deaths. Ninety-three (27%) developed nosocomial infections, including pneumonia (n = 67), bloodstream infections (n = 14), catheter-associated urinary tract infection (n = 10), skin and soft tissue infection (n = 8), Clostridium difficile colitis (n = 7), empyema (n = 6), and complicated intra-abdominal infections (n = 3). Nearly 80% (n = 307) of patients received packed red blood cells (PRBCs); 12% received cryoprecipitate, 69% received plasma, and 27% received platelets. Patients who received any PRBCs had more than a twofold increase in nosocomial infections (odds ratio, 2.15; 95% confidence interval, 1.01-4.58; p = 0.047). The number of PRBCs given was also associated with the development of nosocomial infection (odds ratio, 1.10; 95% confidence interval, 1.05-1.16; p < 0.001). CONCLUSION Trauma patients in the PAMPer trial who received a transfusion of at least 1 U of PRBCs incurred a twofold increased risk of nosocomial infection, and the risk of infection was dose dependent. LEVEL OF EVIDENCE Therapeutic/care management, level IV.
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Affiliation(s)
- Husayn A Ladhani
- From the Division of Trauma, Critical Care, Burns, and Acute Care Surgery, Department of Surgery (H.A.L., V.P.H., C.C.C., J.A.C.), MetroHealth Medical Center, Case Western Reserve University, Cleveland, Ohio; Department of Surgery and Critical Care Medicine (J.L.S., J.B.B.), Department of Emergency Medicine (F.X.G.), University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; Department of Surgery (B.J.D.), University of Tennessee Health Science Center, Knoxville; Department of Surgery, John Peter Smith Hospital (R.S.M.), Fort Worth, Texas; Department of Surgery (B.G.H.), University of Louisville, Louisville, Kentucky; and Department of Surgery (H.A.P.), Louisiana State University Health Sciences Center, New Orleans, Louisiana
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Hall K, Drobatz K. Volume Resuscitation in the Acutely Hemorrhaging Patient: Historic Use to Current Applications. Front Vet Sci 2021; 8:638104. [PMID: 34395568 PMCID: PMC8357988 DOI: 10.3389/fvets.2021.638104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2020] [Accepted: 05/21/2021] [Indexed: 11/13/2022] Open
Abstract
Acute hemorrhage in small animals results from traumatic and non-traumatic causes. This review seeks to describe current understanding of the resuscitation of the acutely hemorrhaging small animal (dog and cat) veterinary patient through evaluation of pre-clinical canine models of hemorrhage and resuscitation, clinical research in dogs and cats, and selected extrapolation from human medicine. The physiologic dose and response to whole blood loss in the canine patient is repeatable both in anesthetized and awake animals and is primarily characterized clinically by increased heart rate, decreased systolic blood pressure, and increased shock index and biochemically by increased lactate and lower base excess. Previously, initial resuscitation in these patients included immediate volume support with crystalloid and/or colloid, regardless of total volume, with a target to replace lost vascular volume and bring blood pressure back to normal. Newer research now supports prioritizing hemorrhage control in conjunction with judicious crystalloid administration followed by early consideration for administration of platelets, plasma and red blood during the resuscitation phase. This approach minimizes blood loss, ameliorates coagulopathy, restores oxygen delivery and correct changes in the glycocalyx. There are many hurdles in the application of this approach in clinical veterinary medicine including the speed with which the bleeding source is controlled and the rapid availability of blood component therapy. Recommendations regarding the clinical approach to volume resuscitation in the acutely hemorrhaging veterinary patient are made based on the canine pre-clinical, veterinary clinical and human literature reviewed.
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Affiliation(s)
- Kelly Hall
- Department of Clinical Sciences, Critical Care Services, Colorado State University, Fort Collins, CO, United States
| | - Kenneth Drobatz
- Section of Critical Care, Department of Clinical Studies, University of Pennsylvania, Philadelphia, PA, United States
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Chanthima P, Yuwapattanawong K, Thamjamrassri T, Nathwani R, Stansbury LG, Vavilala MS, Arbabi S, Hess JR. Association Between Ionized Calcium Concentrations During Hemostatic Transfusion and Calcium Treatment With Mortality in Major Trauma. Anesth Analg 2021; 132:1684-1691. [PMID: 33646983 DOI: 10.1213/ane.0000000000005431] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND Transfusion of citrated blood products may worsen resuscitation-induced hypocalcemia and trauma outcomes, suggesting the need for protocolized early calcium replacement in major trauma. However, the dynamics of ionized calcium during hemostatic resuscitation of severe injury are not well studied. We determined the frequency of hypocalcemia and quantified the association between the first measured ionized calcium concentration [iCa] and calcium administration early during hemostatic resuscitation and in-hospital mortality. METHODS We performed a retrospective cohort study of all admissions to our regional level 1 trauma center who (1) were ≥15 years old; (2) presented from scene of injury; (3) were admitted between October 2016 and September 2018; and (4) had a Massive Transfusion Protocol activation. They also (1) received blood products during transport or during the first 3 hours of in-hospital care (1st3h) of trauma center care and (2) had at least one [iCa] recorded in that time. Demographic, injury severity, admission shock and laboratory data, blood product use and timing, and in-hospital mortality were extracted from Trauma Registry and Transfusion Service databases and electronic medical records. Citrate load was calculated on a unit-by-unit basis and used to calculate an administered calcium/citrate molar ratio. Univariate and multivariable logistic regression analyses for the binary outcome of in-hospital death were performed. RESULTS A total of 11,474 trauma patients were admitted to the emergency department over the study period, of whom 346 (3%; average age: 44 ± 18 years; 75% men) met all study criteria. In total, 288 (83.2%) had hypocalcemia at first [iCa] determination; 296 (85.6%) had hypocalcemia in the last determination in the 1st3h; and 177 (51.2%) received at least 1 calcium replacement dose during that time. Crude risk factors for in-hospital death included age, injury severity score (ISS), new ISS (NISS), Abbreviated Injury Scale (AIS) head, admission systolic blood pressure (SBP), pH, and lactate; all P < .001. Higher in-hospital mortality was significantly associated with older age, higher NISS, AIS head, and admission lactate, and lower admission SBP and pH. There was no relationship between mortality and first [iCa] or calcium dose corrected for citrate load. CONCLUSIONS In our study, though most patients had hypocalcemia during the 1st3h of trauma center care, neither first [iCa] nor administered calcium dose corrected for citrate load were significantly associated with in-patient mortality. Clinically, hypocalcemia during early hemostatic resuscitation after severe injury is important, but specific treatment protocols must await better understanding of calcium physiology in acute injury.
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Affiliation(s)
| | | | | | - Rajen Nathwani
- Department of Anesthesiology and Pain Medicine University of Washington, School of Medicine, Seattle, Washington
| | - Lynn G Stansbury
- From the Harborview Injury Prevention and Research Center, Seattle, Washington.,Department of Anesthesiology and Pain Medicine University of Washington, School of Medicine, Seattle, Washington
| | - Monica S Vavilala
- From the Harborview Injury Prevention and Research Center, Seattle, Washington.,Department of Anesthesiology and Pain Medicine University of Washington, School of Medicine, Seattle, Washington
| | - Saman Arbabi
- From the Harborview Injury Prevention and Research Center, Seattle, Washington.,Department of Surgery, University of Washington, School of Medicine, Seattle, Washington
| | - John R Hess
- From the Harborview Injury Prevention and Research Center, Seattle, Washington.,Department of Laboratory Medicine and Pathology, University of Washington, Seattle, Washington
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119
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Nagasawa H, Shibahashi K, Omori K, Yanagawa Y. The effect of prehospital intravenous access in traumatic shock: a Japanese nationwide cohort study. Acute Med Surg 2021; 8:e681. [PMID: 34295503 PMCID: PMC8286450 DOI: 10.1002/ams2.681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Accepted: 06/14/2021] [Indexed: 11/17/2022] Open
Abstract
Aim We aimed to evaluate effect of prehospital intravenous (IV) access on mortality in traumatic shock using a large nationwide dataset. Methods We used the Japan Trauma Data Bank to identify adults (≥18 years) with a systolic blood pressure <90 mm Hg at the trauma scene and were directly transported to the hospital between 2010 and 2019. We compared patients who had prehospital IV access (IV (+)) or not (IV (−)), using propensity score‐matched analysis, and 1:1 nearest‐neighbor matching without replacement. Standardized mean difference was used to evaluate the match balance between the two matched groups; a standardized mean difference >0.1 was considered a significant imbalance. Primary outcome was 72‐h mortality. Results Propensity scores matching generated 479 pairs from 5,857 patients. No significant between group differences occurred in 72‐h mortality (7.8 versus 8.8%; difference, −1.0%; 95% confidence interval [CI]: −2.5–4.5%), 28‐day mortality (11.8 versus 11.3%; 95% CI: −4.6–3.6%), blood transfusion administration within 24 h (55.3 versus 49.1%; 95% CI: −0.1–12.6%), prehospital time (56.3 versus 53.0 min; 95% CI: −1.8–8.4 min), and cardiopulmonary arrest on hospital arrival (1.3 versus 1.3%; 95% CI: −1.4–1.4%). However, significantly higher systolic blood pressure on hospital arrival was found in the IV (+) than in the IV (−) group (104.6 versus 100.1 mm Hg; 95% CI: 0.3‐8.7 mm Hg). Conclusion We found no significant effect of establishing IV access in the prehospital setting on survival outcomes of patients with traumatic shock.
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Affiliation(s)
- Hiroki Nagasawa
- Department of Acute Critical Care Medicine Shizuoka Hospital Juntendo University Shizuoka Japan
| | - Keita Shibahashi
- Tertiary Emergency Medical Center Tokyo Metropolitan Bokutoh Hospital Tokyo Japan
| | - Kazuhiko Omori
- Department of Acute Critical Care Medicine Shizuoka Hospital Juntendo University Shizuoka Japan
| | - Youichi Yanagawa
- Department of Acute Critical Care Medicine Shizuoka Hospital Juntendo University Shizuoka Japan
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van den Brink DP, Kleinveld DJB, Sloos PH, Thomas KA, Stensballe J, Johansson PI, Pati S, Sperry J, Spinella PC, Juffermans NP. Plasma as a resuscitation fluid for volume-depleted shock: Potential benefits and risks. Transfusion 2021; 61 Suppl 1:S301-S312. [PMID: 34057210 PMCID: PMC8361764 DOI: 10.1111/trf.16462] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 03/04/2021] [Accepted: 03/04/2021] [Indexed: 12/13/2022]
Affiliation(s)
- Daan P. van den Brink
- Department of Intensive Care MedicineAmsterdam UMCAmsterdamThe Netherlands
- Laboratory of Experimental Intensive Care and AnesthesiologyAmsterdam UMCAmsterdamThe Netherlands
| | - Derek J. B. Kleinveld
- Department of Intensive Care MedicineAmsterdam UMCAmsterdamThe Netherlands
- Laboratory of Experimental Intensive Care and AnesthesiologyAmsterdam UMCAmsterdamThe Netherlands
- Department of Trauma SurgeryAmsterdam UMCAmsterdamThe Netherlands
| | - Pieter H. Sloos
- Laboratory of Experimental Intensive Care and AnesthesiologyAmsterdam UMCAmsterdamThe Netherlands
- Department of Trauma SurgeryAmsterdam UMCAmsterdamThe Netherlands
| | | | - Jakob Stensballe
- Department of Anesthesia and Trauma Center, Centre of Head and OrthopedicsRigshospitalet, Copenhagen University HospitalCopenhagenDenmark
- Department of Clinical immunologyRigshospitalet, Copenhagen University HospitalCopenhagenDenmark
| | - Pär I. Johansson
- Department of Clinical immunologyRigshospitalet, Copenhagen University HospitalCopenhagenDenmark
| | - Shibani Pati
- Department of Laboratory MedicineUniversity of California San FranciscoSan FranciscoCaliforniaUSA
| | - Jason Sperry
- Department of Surgery and Critical Care MedicineUniversity of Pittsburgh Medical CenterPittsburghPennsylvaniaUSA
| | | | - Nicole P. Juffermans
- Laboratory of Experimental Intensive Care and AnesthesiologyAmsterdam UMCAmsterdamThe Netherlands
- Department of Intensive CareOLVG HospitalAmsterdamThe Netherlands
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Abstract
PURPOSE OF REVIEW Posttraumatic bleeding following major trauma is life threatening for the patient and remains a major global health issue. Bleeding after major trauma is worsened by trauma-induced coagulopathy (TIC). TIC consists of acute trauma coagulopathy and resuscitation coagulopathy. The early diagnosis and management of prehospital TIC management are challenging. RECENT FINDINGS Concepts for early diagnosis and management of civilian prehospital TIC management are evolving. The feasibility of prehospital blood component as well as coagulation factor transfusion has been proven. SUMMARY Due to different national guidelines and regulations of blood component therapies there is a wide heterogeneity in concepts of prehospital damage control resuscitation. Tranexamic acid administration is widely accepted, whereas the transfusion of whole blood, blood components, or coagulations factors needs further examination in the civilian setting.
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Hashmi ZG, Chehab M, Nathens AB, Joseph B, Bank EA, Jansen JO, Holcomb JB. Whole truths but half the blood: Addressing the gap between the evidence and practice of pre-hospital and in-hospital blood product use for trauma resuscitation. Transfusion 2021; 61 Suppl 1:S348-S353. [PMID: 34086349 DOI: 10.1111/trf.16515] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 03/12/2021] [Accepted: 03/13/2021] [Indexed: 12/24/2022]
Abstract
BACKGROUND In recent years, several studies have demonstrated the efficacy of using pre-hospital blood product and in-hospital whole blood for trauma resuscitation. While some observations suggest an encouraging uptake of this evidence by emergency medical service (EMS) agencies and trauma centers, a nationwide characterization of blood product utilization for bleeding trauma patients remains unknown. The objective of this study is to determine nationwide estimates of pre-hospital blood product and in-hospital whole blood utilization for trauma resuscitation. STUDY DESIGN AND METHODS All adult trauma patients reported to the National Emergency Medical Services Information System (NEMSIS) dataset 2019 were included. Proportions of patients who received any pre-hospital blood product were calculated. The American College of Surgeons (ACS) Trauma Quality Programs (TQP) databases 2015-2017 and first quarter of 2020 were used to calculate the proportion of ACS-verified trauma centers that transfused whole blood. RESULTS Among a total of 3,058,804 pre-hospital trauma patients, only 313 (0.01%) received any blood transfusion; 208 (0.21%) patients with systolic blood pressure (SBP) ≤90 mmHg and 121 (0.67%) patients with SBP ≤90 mmHg and heart rate ≥120 beats per minute received any blood product. The proportion of ACS-verified trauma centers transfusing whole blood increased from 16.7% (45/269) in 2015 to 24.5% (123/502) in first quarter of 2020. DISCUSSION Despite strong evidence and recommendations, pre-hospital utilization of blood products for trauma resuscitation remains low. Additionally, while the overall in-hospital whole blood use also remains low, its use has increased at ACS-verified trauma centers over the past 5 years.
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Affiliation(s)
- Zain G Hashmi
- Center for Injury Science, University of Alabama at Birmingham, Birmingham, Alabama, USA.,Division of Trauma and Acute Care Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Mohamad Chehab
- Division of Trauma, Critical Care, Burn, and Emergency Surgery, Department of Surgery, College of Medicine, University of Arizona, Tucson, Alabama, USA
| | - Avery B Nathens
- Department of Surgery, Sunnybrook Health Sciences Center, University of Toronto, Toronto, Ontario, Canada
| | - Bellal Joseph
- Division of Trauma, Critical Care, Burn, and Emergency Surgery, Department of Surgery, College of Medicine, University of Arizona, Tucson, Alabama, USA
| | - Eric A Bank
- Harris County Emergency Services District No. 48, Katy, Texas, USA
| | - Jan O Jansen
- Center for Injury Science, University of Alabama at Birmingham, Birmingham, Alabama, USA.,Division of Trauma and Acute Care Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - John B Holcomb
- Center for Injury Science, University of Alabama at Birmingham, Birmingham, Alabama, USA.,Division of Trauma and Acute Care Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
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Edwards TH, Pusateri AE, Mays EL, Bynum JA, Cap AP. Lessons Learned From the Battlefield and Applicability to Veterinary Medicine - Part 2: Transfusion Advances. Front Vet Sci 2021; 8:571370. [PMID: 34026881 PMCID: PMC8138582 DOI: 10.3389/fvets.2021.571370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 03/29/2021] [Indexed: 11/13/2022] Open
Abstract
Since the inception of recent conflicts in Afghanistan and Iraq, transfusion practices in human military medicine have advanced considerably. Today, US military physicians recognize the need to replace the functionality of lost blood in traumatic hemorrhagic shock and whole blood is now the trauma resuscitation product of choice on the battlefield. Building on wartime experiences, military medicine is now one of the country's strongest advocates for the principle of hemostatic resuscitation using whole blood or balanced blood components as the primary means of resuscitation as early as possibly following severe trauma. Based on strong evidence to support this practice in human combat casualties and in civilian trauma care, military veterinarians strive to practice similar hemostatic resuscitation for injured Military Working Dogs. To this end, canine whole blood has become increasingly available in forward environments, and non-traditional storage options for canine blood and blood components are being explored for use in canine trauma. Blood products with improved shelf-life and ease of use are not only useful for military applications, but may also enable civilian general and specialty practices to more easily incorporate hemostatic resuscitation approaches to canine trauma care.
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Affiliation(s)
- Thomas H Edwards
- U.S. Army Institute of Surgical Research, Joint Base San Antonio, San Antonio, TX, United States
| | - Anthony E Pusateri
- U.S. Army Institute of Surgical Research, Joint Base San Antonio, San Antonio, TX, United States
| | - Erin Long Mays
- Veterinary Specialty Services, Manchester, MO, United States
| | - James A Bynum
- U.S. Army Institute of Surgical Research, Joint Base San Antonio, San Antonio, TX, United States
| | - Andrew P Cap
- U.S. Army Institute of Surgical Research, Joint Base San Antonio, San Antonio, TX, United States
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Nace GW, Nance ML. Early Cryoprecipitate Use-Time to Change Our Pediatric Massive Transfusion Protocol? JAMA Surg 2021; 156:460-461. [PMID: 33595623 DOI: 10.1001/jamasurg.2020.7266] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Affiliation(s)
- Gary W Nace
- Division of Pediatric Surgery, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Michael L Nance
- Division of Pediatric Surgery, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
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Manzano-Nuñez R, Chica-Yanten J, Naranjo MP, Caicedo-Holguin I, Ordoñez JM, McGreevy D, Puyana JC, Hörer TM, Moore EE, García AF. Use of REBOA in the universe of magical realism: a real-world review. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2021. [DOI: 10.5554/22562087.e973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
While reading the novella “Chronicle of a Death Foretold” by the Colombian Nobel Laureate Gabriel García-Marquez, we were surprised to realize that the injuries sustained by the main character could have been successfully treated had he received modern trauma care in which REBOA may have been considered. This is a discussion of Mr. Nasar's murder to explore whether he could have been saved by deploying REBOA as a surgical adjunct to bleeding control and resuscitation. In reading García-Marquez's novel we noted the events that unfolded at the time of Santiago Nasar's murder. To contextualize the claim that Mr. Nasar could have survived, had his injuries been treated with REBOA, we explored and illustrated what could have done differently and why. On the day of his death, Mr. Nasar sustained multiple penetrating stab wounds. Although he received multiple stab wounds to his torso, the book describes seven potentially fatal injuries, resulting in hollow viscus, solid viscus, and major vascular injuries. We provided a practical description of the clinical and surgical management algorithm we would have followed in Mr. Nasar's case. This algorithm included the REBOA deployment for hemorrhage control and resuscitation. The use of REBOA as part of the surgical procedures performed could have saved Mr. Nasar's life. Based on our current knowledge about REBOA in trauma surgery, we claim that its use, coupled with appropriate surgical care for hemorrhage control, could have saved Santiago Nasar's life, and thus prevent a death foretold.
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Harris D, Martin D, Bednarz J, Ellis DY. Acute traumatic coagulopathy and the relationship to prehospital care and on-scene red blood cell transfusion. Emerg Med Australas 2021; 33:834-840. [PMID: 33556992 DOI: 10.1111/1742-6723.13734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Revised: 01/14/2021] [Accepted: 01/15/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To identify the incidence of acute traumatic coagulopathy (ATC) in trauma patients presenting to the Royal Adelaide Hospital, analyse prehospital contributors, including red blood cell transfusion and assess the clinical significance of ATC. METHODS A retrospective database review was undertaken using conventional coagulation assays and viscoelastic testing (ROTEM) for diagnosis of ATC. RESULTS Baseline ATC incidence is 10% in trauma patients, increasing to over 80% among those where the prehospital team has attended and given a transfusion of red cells. ATC was significantly associated with higher severity of trauma (odds ratio [OR] 1.11, P < 0.0001), prehospital (OR 11.8, P < 0.0001) and in-hospital blood transfusions (OR 17.9, P < 0.0001), and massive transfusions (P < 0.001). CONCLUSIONS Prehospital blood transfusions are given to the most severely injured trauma patients and the incidence of ATC in this group is more than 80%. There is an association with prehospital blood transfusion and increased ATC in part related to patient selection and severity of trauma, with the contribution of red cell transfusions to ATC unclear. This association should allow earlier identification of patients at increased risk of ATC to ensure rapid correction of coagulopathy to decrease the morbidity and mortality of trauma.
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Affiliation(s)
- Daniel Harris
- Trauma Service, Royal Adelaide Hospital, Adelaide, South Australia, Australia.,Emergency Department, Royal Adelaide Hospital, Adelaide, South Australia, Australia.,Emergency Department, The Queen Elizabeth Hospital, Adelaide, South Australia, Australia.,Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, South Australia, Australia.,MedSTAR Emergency Medical Retrieval, SA Ambulance Service, Adelaide, South Australia, Australia
| | - Daniel Martin
- MedSTAR Emergency Medical Retrieval, SA Ambulance Service, Adelaide, South Australia, Australia.,School of Public Health and Tropical Medicine, James Cook University, Townsville, Queensland, Australia
| | - Jana Bednarz
- Adelaide Health Technology Assessment, The University of Adelaide, Adelaide, South Australia, Australia
| | - Daniel Y Ellis
- Trauma Service, Royal Adelaide Hospital, Adelaide, South Australia, Australia.,Emergency Department, Royal Adelaide Hospital, Adelaide, South Australia, Australia.,MedSTAR Emergency Medical Retrieval, SA Ambulance Service, Adelaide, South Australia, Australia.,School of Public Health and Tropical Medicine, James Cook University, Townsville, Queensland, Australia
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Yang S, Mackenzie CF, Rock P, Lin C, Floccare D, Scalea T, Stumpf F, Winans C, Galvagno S, Miller C, Stein D, Hu PF. Comparison of massive and emergency transfusion prediction scoring systems after trauma with a new Bleeding Risk Index score applied in-flight. J Trauma Acute Care Surg 2021; 90:268-273. [PMID: 33502145 DOI: 10.1097/ta.0000000000003031] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Assessment of blood consumption (ABC), shock index (SI), and Revised Trauma Score (RTS) are used to estimate the need for blood transfusion and triage. We compared Bleeding Risk Index (BRI) score calculated with trauma patient noninvasive vital signs and hypothesized that prehospital BRI has better performance compared with ABC, RTS, and SI for predicting the need for emergent and massive transfusion (MT). METHODS We analyzed 2-year in-flight data from adult trauma patients transported directly to a Level I trauma center via helicopter. The BRI scores 0 to 1 were derived from continuous features of photoplethymographic and electrocardiographic waveforms, oximetry values, blood pressure trends. The ABC, RTS, and SI were calculated using admission data. The area under the receiver operating characteristic curve (AUROC) with 95% confidence interval (CI) was calculated for predictions of critical administration threshold (CAT, ≥3 units of blood in the first hour) or MT (≥10 units of blood in the first 24 hours). DeLong's method was used to compare AUROCs for different scoring systems. p < 0.05 was considered statistically significant. RESULTS Among 1,396 patients, age was 46.5 ± 20.1 years (SD), 67.1% were male. The MT rate was 3.2% and CAT was 7.6%, most (92.8%) were blunt injury. Mortality was 6.6%. Scene arrival to hospital time was 35.3 ± (10.5) minutes. The BRI prediction of MT with AUROC 0.92 (95% CI, 0.89-0.95) was significantly better than ABC, SI, or RTS (AUROCs = 0.80, 0.83, 0.78, respectively; 95% CIs 0.73-0.87, 0.76-0.90, 0.71-0.85, respectively). The BRI prediction of CAT had an AUROC of 0.91 (95% CI, 0.86-0.94), which was significantly better than ABC (AUROC, 077; 95% CI, 0.73-0.82) or RTS (AUROC, 0.79; 95% CI, 0.74-0.83) and better than SI (AUROC, 0.85; 95% CI, 0.80-0.89). The BRI score threshold for optimal prediction of CAT was 0.25 and for MT was 0.28. CONCLUSION The autonomous continuous noninvasive patient vital signs-based BRI score performs better than ABC, RTS, and SI predictions of MT and CAT. Bleeding Risk Index does not require additional data entry or expert interpretation. LEVEL OF EVIDENCE Prognostic test, level III.
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Affiliation(s)
- Shiming Yang
- From the Departments of Anesthesiology (S.Y., C.F.M., P.R., C.L., F.S., S.G., P.F.H.); Department of Surgery and Program in Trauma (T.S., S.G., D.S., P.F.H.), University of Maryland School of Medicine; Maryland Institute for Emergency Medical Services Systems (MIEMSS) (D.F., C.W.); and US Air Force C-STARS, (C.M.) Baltimore, Maryland
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128
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Seheult JN, Stram MN, Pearce T, Bub CB, Emery SP, Kutner J, Watanabe-Okochi N, Sperry JL, Takanashi M, Triulzi DJ, Yazer MH. The risk to future pregnancies of transfusing Rh(D)-negative females of childbearing potential with Rh(D)-positive red blood cells during trauma resuscitation is dependent on their age at transfusion. Vox Sang 2021; 116:831-840. [PMID: 33491789 DOI: 10.1111/vox.13065] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Revised: 12/16/2020] [Accepted: 12/30/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND A risk assessment model for predicting the risk of haemolytic disease of the fetus and newborn (HDFN) in future pregnancies following the transfusion of Rh(D)-positive red blood cell (RBC)-containing products to females of childbearing potential (FCP) was developed, accounting for the age that the FCP is transfused in various countries. METHODS The HDFN risk prediction model included the following inputs: risk of FCP death in trauma, Rh(D) alloimmunization rate following Rh(D)-positive RBC transfusion, expected number of live births following resuscitation, probability of carrying an Rh(D)-positive fetus, the probability of HDFN in an Rh(D)-positive fetus carried by an alloimmunized mother. The model was implemented in Microsoft R Open, and one million FCPs of each age between 18 and 49 years old were simulated. Published data from eight countries, including the United States, were utilized to generate country-specific HDFN risk estimates. RESULTS The risk predictions showed similar characteristics for each country in that the overall risk of having a pregnancy affected by HDFN was higher if the FCP was younger when she received her Rh(D)-positive transfusion than if she was older. In the United States, the overall risk of HDFN if the FCP was transfused at age 18 was 3·4% (mild: 1·20%, moderate: 0·45%; severe: 1·15%; IUFD: 0·57%); the risk was approximately 0% if the FCP was 43 years or older at the time of transfusion. CONCLUSION This model can be used to predict HDFN outcomes when establishing transfusion policies as it relates to the administration of Rh(D)-positive products for massively bleeding FCPs.
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Affiliation(s)
- Jansen N Seheult
- Department of Pathology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.,Vitalant, Pittsburgh, PA, USA
| | | | - Thomas Pearce
- Department of Pathology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | | | - Stephen P Emery
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Jose Kutner
- Hospital Israelita Albert Einstein, Sao Paulo, Brazil
| | | | - Jason L Sperry
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Minoko Takanashi
- Japanese Red Cross Society Blood Service Headquarters, Tokyo, Japan
| | - Darrell J Triulzi
- Department of Pathology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.,Vitalant, Pittsburgh, PA, USA
| | - Mark H Yazer
- Department of Pathology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.,Vitalant, Pittsburgh, PA, USA
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129
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Napolitano LM. Hemostatic defects in massive transfusion: an update and treatment recommendations. Expert Rev Hematol 2021; 14:219-239. [PMID: 33267678 DOI: 10.1080/17474086.2021.1858788] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Acute hemorrhage is a global healthcare issue, and remains the leading preventable cause of death in trauma. Acute severe hemorrhage can be related to traumatic, peripartum, gastrointestinal, and procedural causes. Hemostatic defects occur early in patients requiring massive transfusion. Early recognition and treatment of hemorrhage and hemostatic defects are required to save lives and to achieve optimal patient outcomes. AREAS COVERED This review discusses current evidence and trials aimed at identifying the optimal treatment for hemostatic defects in hemorrhage and massive transfusion. Literature search included PubMed and Embase. EXPERT OPINION Patients with acute hemorrhage requiring massive transfusion commonly develop coagulopathy due to specific hemostatic defects, and accurate diagnosis and prompt correction are required for definitive hemorrhage control. Damage control resuscitation and massive transfusion protocols are optimal initial treatment strategies, followed by goal-directed individualized resuscitation using real-time coagulation monitoring. Distinct phenotypes exist in trauma-induced coagulopathy, including 'Bleeding' or 'Thrombotic' phenotypes, and hyperfibrinolysis vs. fibrinolysis shutdown. The trauma 'lethal triad' (hypothermia, coagulopathy, acidosis) has been updated to the 'lethal diamond' (including hypocalcemia). A number of controversies in optimal management exist, including whole blood vs. component therapy, use of factor concentrates vs. blood products, optimal use of tranexamic acid, and prehospital plasma and tranexamic acid administration.
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Affiliation(s)
- Lena M Napolitano
- Department of Surgery, University of Michigan Health System, University Hospital, Ann Arbor, Michigan, USA
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Bedard AF, Mata LV, Dymond C, Moreira F, Dixon J, Schauer SG, Ginde AA, Bebarta V, Moore EE, Mould-Millman NK. A scoping review of worldwide studies evaluating the effects of prehospital time on trauma outcomes. Int J Emerg Med 2020; 13:64. [PMID: 33297951 PMCID: PMC7724615 DOI: 10.1186/s12245-020-00324-7] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 11/21/2020] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Annually, over 1 billion people sustain traumatic injuries, resulting in over 900,000 deaths in Africa and 6 million deaths globally. Timely response, intervention, and transportation in the prehospital setting reduce morbidity and mortality of trauma victims. Our objective was to describe the existing literature evaluating trauma morbidity and mortality outcomes as a function of prehospital care time to identify gaps in literature and inform future investigation. MAIN BODY We performed a scoping review of published literature in MEDLINE. Results were limited to English language publications from 2009 to 2020. Included articles reported trauma outcomes and prehospital time. We excluded case reports, reviews, systematic reviews, meta-analyses, comments, editorials, letters, and conference proceedings. In total, 808 articles were identified for title and abstract review. Of those, 96 articles met all inclusion criteria and were fully reviewed. Higher quality studies used data derived from trauma registries. There was a paucity of literature from studies in low- and middle-income countries (LMIC), with only 3 (3%) of articles explicitly including African populations. Mortality was an outcome measure in 93% of articles, predominantly defined as "in-hospital mortality" as opposed to mortality within a specified time frame. Prehospital time was most commonly assessed as crude time from EMS dispatch to arrival at a tertiary trauma center. Few studies evaluated physiologic morbidity outcomes such as multi-organ failure. CONCLUSION The existing literature disproportionately represents high-income settings and most commonly assessed in-hospital mortality as a function of crude prehospital time. Future studies should focus on how specific prehospital intervals impact morbidity outcomes (e.g., organ failure) and mortality at earlier time points (e.g., 3 or 7 days) to better reflect the effect of early prehospital resuscitation and transport. Trauma registries may be a tool to facilitate such research and may promote higher quality investigations in Africa and LMICs.
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Affiliation(s)
- Alexander F Bedard
- University of Colorado, Anschutz Medical Campus, 13001 E 17th Place, Aurora, CO, 80045, USA.
- United States Air Force Medical Corps, 7700 Arlington Boulevard, Falls Church, VA, 22042, USA.
| | - Lina V Mata
- University of Colorado, Anschutz Medical Campus, 13001 E 17th Place, Aurora, CO, 80045, USA
| | - Chelsea Dymond
- University of Colorado, Anschutz Medical Campus, 13001 E 17th Place, Aurora, CO, 80045, USA
- Denver Health and Hospital Authority, 777 Bannock St, Denver, CO, 80204, USA
| | - Fabio Moreira
- Western Cape Government, Emergency Medical Services, 9 Wale Street, Cape Town, 8001, South Africa
| | - Julia Dixon
- University of Colorado, Anschutz Medical Campus, 13001 E 17th Place, Aurora, CO, 80045, USA
| | - Steven G Schauer
- US Army Institute of Surgical Research, 3698 Chambers Rd., San Antonio, TX, 78234, USA
| | - Adit A Ginde
- University of Colorado, Anschutz Medical Campus, 13001 E 17th Place, Aurora, CO, 80045, USA
| | - Vikhyat Bebarta
- University of Colorado, Anschutz Medical Campus, 13001 E 17th Place, Aurora, CO, 80045, USA
| | - Ernest E Moore
- University of Colorado, Anschutz Medical Campus, 13001 E 17th Place, Aurora, CO, 80045, USA
- Ernest E. Moore Shock Trauma Center at Denver Health, 777 Bannock St, Denver, CO, 80204, USA
| | - Nee-Kofi Mould-Millman
- University of Colorado, Anschutz Medical Campus, 13001 E 17th Place, Aurora, CO, 80045, USA
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Shand S, Curtis K, Dinh M, Burns B. Retrieval transfusion protocol in New South Wales, Australia: A retrospective review of the first 5 years. Transfusion 2020; 61:730-737. [PMID: 33615494 DOI: 10.1111/trf.16217] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2020] [Revised: 10/28/2020] [Accepted: 10/29/2020] [Indexed: 12/01/2022]
Abstract
BACKGROUND Ambulance service blood transfusion is an area of rapid development. In New South Wales, Australia, the blood products carried by ambulance medical teams are often the first available to patients with critical bleeding. In addition to the blood products routinely carried by these teams, the Service created and implemented a method of initiating large-volume, mixed-product transfusions using existing blood banks: the Retrieval Transfusion Procedure (RTP). This article describes the trends and characteristics of New South Wales Ambulance RTP activations. MATERIALS AND METHODS This retrospective database review examines the patient records for all RTP activations. Key areas of investigation include logistics, product requests, population demographics, etiologies, physiology, mission timings, and transfusions. RESULTS Ambulance medical teams attended 27 531 missions in the reviewed period, 1573 patients received transfusion, and there were 138 RTP activations. Blood products were sourced from 40 banks and transported by police (46.7%), ambulance (27.1%), and helicopter (13.0%) to refueling stops (39.2%), prehospital scenes (24.2%) and hospitals (15.8%). The median time engaged on each mission was 189 minutes for metropolitan and 222 minutes for rural locations. Seventy-eight patients were transfused with RTP blood products; 83.3% were traumas, of which 63.1% were motor vehicle collisions. Up to 18 units of blood products were administered before hospital arrival. There was significant (P < .001) improvement in the mean shock index of transfused patients between the first and final observations recorded. CONCLUSIONS Ambulance service extended blood product transfusion is logistically achievable and facilitates emergency transfusions throughout the state with minimal additional infrastructure.
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Affiliation(s)
- Sophie Shand
- Susan Wakil School of Nursing, Faculty of Medicine and Health, University of Sydney, Camperdown, New South Wales, Australia.,Sydney Ambulance Centre, NSW Ambulance, Eveleigh, New South Wales, Australia
| | - Kate Curtis
- Susan Wakil School of Nursing, Faculty of Medicine and Health, University of Sydney, Camperdown, New South Wales, Australia.,Illawara Shoalhaven Local Health District, Warrawong, New South Wales, Australia
| | - Michael Dinh
- Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia.,Institute of Trauma and Injury Management, Chatswood, New South Wales, Australia.,Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Camperdown, New South Wales, Australia
| | - Brian Burns
- Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Camperdown, New South Wales, Australia.,Greater Sydney Area HEMS, NSW Ambulance, Rozelle, New South Wales, Australia
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Edwards TH, Meledeo MA, Peltier GC, Ruiz DD, Henderson AF, Travieso S, Pusateri AE. Effects of refrigerated storage on hemostatic stability of four canine plasma products. Am J Vet Res 2020; 81:964-972. [PMID: 33251844 DOI: 10.2460/ajvr.81.12.964] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To assess clotting times, coagulation factor activities, sterility, and thromboelastographic parameters of liquid plasma (LP), thawed fresh frozen plasma (FFP-T), and 2 novel formulations of freeze-dried plasma (FDP) stored refrigerated over 35 days. SAMPLE 6 units of canine LP and FFP-T from a commercial animal blood bank and 5 units each of 2 formulations of canine FDP. PROCEDURES Prothrombin time; activated partial thromboplastin time; activities of coagulation factors II, V, VII, VIII, IX, X, XI, and XII; and thromboelastographic parameters were determined for each product on days 0 (baseline), 3, 7, 14, 21, 28, and 35. For each day, a sample of each product was also submitted for aerobic bacterial culture. RESULTS Small changes in coagulation factor activities and mild increased time to initial clot formation in LP and FFP-T were noted over the 35-day storage period. Activities of factor VIII in FDP1 and factor XII in FDP2 were < 50% at baseline but varied throughout. Compared with FFP-T, time to initial clot formation was increased and clot strength was preserved or increased for the FDPs throughout the study. One FDP had decreased pH, compared with other products. No plasma product yielded bacterial growth. CONCLUSIONS AND CLINICAL RELEVANCE Liquid plasma and FFP-T would be reasonable to use when stored refrigerated for up to 35 days. Both FDP products showed variability in coagulation factor activities. Studies investigating the usefulness of these plasma products (FDPs) in dogs and the variable days of refrigerated storage (all products) are warranted. (Am J Vet Res 2020;81:964-972).
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Whole Blood is Superior to Component Transfusion for Injured Children: A Propensity Matched Analysis. Ann Surg 2020; 272:590-594. [PMID: 32932312 DOI: 10.1097/sla.0000000000004378] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVE To compare a propensity-matched cohort of injured children receiving conventional blood component transfusion to injured children receiving low-titer group O negative whole blood. SUMMARY OF BACKGROUND DATA Transfusion of whole blood in pediatric trauma patients is feasible and safe. Effectiveness has not been evaluated. METHODS Injured children ≥1 years old can receive up to 40 mL/kg of cold-stored, uncrossmatched whole blood during initial hemostatic resuscitation. Whole blood recipients (2016-2019) were compared to a propensity-matched cohort who received at least 1 uncrossmatched red blood cell unit in the trauma bay (2013-2016). Cohorts were matched for age, hypotension, traumatic brain injury, injury mechanism, and need for emergent surgery. Outcomes included time to resolution of base deficit, product volumes transfused, and INR after resuscitation. RESULTS Twenty-eight children who received whole blood were matched to 28 children who received components. The whole blood group had faster time to resolution of base deficit [median (IQR) 2 (1-2.5) hours vs 6 (2-24) hours, respectively; P < 0.001]. The post-transfusion INR was decreased in whole blood vs component cohort [median (IQR) 1.4 (1.3-1.5) vs 1.6 (1.4-2.2); P = 0.01]. Lower plasma volumes [median (IQR) = 5 (0-15) mL/kg vs 11 (5-35) mL/kg; P = 0.04] and lower platelet volumes [median (IQR) = 0 (0-2) vs 3 (0-8); P = 0.03] were administered to the whole blood group versus component group. Other clinical variables (in-hospital death, hospital length of stay, intensive care unit length of stay, and ventilator days) did not differ between groups. CONCLUSIONS Compared to component transfusion, whole blood transfusion results in faster resolution of shock, lower post-transfusion INR, and decreased component product transfusion. Larger cohorts are required to support these findings.
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Schneider AM, Ewing JA, Cull JD. Helicopter Transport of Trauma Patients Improves Survival Irrespective of Transport Time. Am Surg 2020; 87:538-542. [PMID: 33111567 DOI: 10.1177/0003134820943564] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES Helicopter transport of trauma patients remains controversial. We examined the survival rates of patients undergoing helicopter versus ground transport to a Level 1 trauma center. METHODS Retrospective analysis was performed on trauma patients treated between 2014 and 2017. Student's t-test was used to compare air versus ground transport times. A logistic regression was then used to examine the association of transportation type on survival controlling for demographics, mechanism of injury, transport time, field intubation, and injury severity. RESULTS Of 3967 patients identified, 69.6% (2762) were male, and the average age was 40 years. Most patients suffered blunt injuries (86.8%, 3445), while the remaining had penetrating injuries (11.6%, 459) or burns (1.6%, 63). The majority of patients were transferred by ground (3449) with only 13% (518) transferred by air. Patients transported by air had increased Injury Severity Score (ISS) with a median of 17 (IQR 9-24) versus 9 (IQR 5-14), increased length of stay (LOS) at 6 days versus 3 (P < .001), and increased mortality at 12.6% vs 6.5% (P < .001). Patients transported by air arrived 16.6 ± 6.7 minutes faster compared with ground for the zip codes examined. When adjusting for the mechanism of injury, ISS, age, gender, intubation status, and transport time, air transport was associated with an increased likelihood of survival (odds ratio [OR] = 1.57, 95% CI = 1.06-2.40). CONCLUSION In our analysis of 3967 patients, those transported by air had a significant improvement in the likelihood of survival compared with those transported by ground even when adjusting for both ISS and time.
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Affiliation(s)
- Andrew M Schneider
- Department of Surgery, Prisma Health Greenville Memorial Hospital, Greenville, SC, USA
| | - Joseph A Ewing
- Department of Surgery, Prisma Health Greenville Memorial Hospital, Greenville, SC, USA
| | - John D Cull
- Department of Surgery, Prisma Health Greenville Memorial Hospital, Greenville, SC, USA
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Hanley C, Callum J, Jerath A. Tranexamic acid and trauma coagulopathy: where are we now? Br J Anaesth 2020; 126:12-17. [PMID: 33069339 DOI: 10.1016/j.bja.2020.09.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 09/14/2020] [Accepted: 09/16/2020] [Indexed: 01/16/2023] Open
Affiliation(s)
- Ciara Hanley
- Department of Anesthesia, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada.
| | - Jeannie Callum
- Department of Laboratory Medicine and Molecular Diagnostics, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Angela Jerath
- Department of Anesthesia, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada; Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
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136
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Gruen DS, Guyette FX, Brown JB, Okonkwo DO, Puccio AM, Campwala IK, Tessmer MT, Daley BJ, Miller RS, Harbrecht BG, Claridge JA, Phelan HA, Neal MD, Zuckerbraun BS, Yazer MH, Billiar TR, Sperry JL. Association of Prehospital Plasma With Survival in Patients With Traumatic Brain Injury: A Secondary Analysis of the PAMPer Cluster Randomized Clinical Trial. JAMA Netw Open 2020; 3:e2016869. [PMID: 33057642 PMCID: PMC7563075 DOI: 10.1001/jamanetworkopen.2020.16869] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
IMPORTANCE Prehospital plasma administration improves survival in injured patients at risk for hemorrhagic shock and transported by air ambulance. Traumatic brain injury (TBI) is a leading cause of death following trauma, but few early interventions improve outcomes. OBJECTIVE To assess the association between prehospital plasma and survival in patients with TBI. DESIGN, SETTING, AND PARTICIPANTS The Prehospital Air Medical Plasma (PAMPer) trial was a pragmatic, multicenter, phase 3, cluster randomized clinical trial involving injured patients who were at risk for hemorrhagic shock during air medical transport to a trauma center. The trial was conducted at 6 US sites with 9 level-I trauma centers (comprising 27 helicopter emergency services bases). The original trial analyzed 501 patients, including 230 patients who were randomized to receive plasma and 271 randomized to standard care resuscitation. This secondary analysis of a predefined subgroup included patients with TBI. Data analysis was performed from October 2019 to February 2020. INTERVENTIONS Patients were randomized to receive standard care fluid resuscitation or 2 units of thawed plasma. MAIN OUTCOMES AND MEASURES The primary outcome was mortality at 30 days. Patients with TBI were prespecified as a subgroup for secondary analysis and for measurement of markers of brain injury. The 30-day survival benefit of prehospital plasma in subgroups with and without TBI as diagnosed by computed tomography was characterized using Kaplan-Meier survival analysis and Cox proportional hazard regression. RESULTS In total, 166 patients had TBI (median [interquartile range] age, 43.00 [25.00-59.75] years; 125 men [75.3%]). When compared with the 92 patients who received standard care, the 74 patients with TBI who received prehospital plasma had improved 30-day survival even after adjustment for multiple confounders and assessment of the degree of brain injury with clinical variables and biomarkers (hazard ratio [HR], 0.55; 95% CI, 0.33-0.94; P = .03). Receipt of prehospital plasma was associated with improved survival among patients with TBI with a prehospital Glasgow Coma Scale score of less than 8 (HR, 0.56; 95% CI, 0.35-0.91) and those with polytrauma (HR, 0.50; 95% CI, 0.28-0.89). Patients with TBI transported from the scene of injury had improved survival following prehospital plasma administration (HR, 0.45; 95% CI, 0.26-0.80; P = .005), whereas patients who were transferred from an outside hospital showed no difference in survival for the plasma intervention (HR, 1.00; 95% CI, 0.33-3.00; P = .99). CONCLUSIONS AND RELEVANCE These findings are exploratory, but they suggest that receipt of prehospital plasma is associated with improved survival in patients with computed tomography-positive TBI. The prehospital setting may be a critical period to intervene in the care of patients with TBI. Future studies are needed to confirm the clinical benefits of early plasma resuscitation following TBI and concomitant polytrauma. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT01818427.
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Affiliation(s)
- Danielle S. Gruen
- Department of Surgery and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
- Pittsburgh Trauma Research Center, Pittsburgh, Pennsylvania
| | - Francis X. Guyette
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Joshua B. Brown
- Department of Surgery and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
- Pittsburgh Trauma Research Center, Pittsburgh, Pennsylvania
| | - David O. Okonkwo
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Ava M. Puccio
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Insiyah K. Campwala
- Department of Surgery and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
- Pittsburgh Trauma Research Center, Pittsburgh, Pennsylvania
| | - Matthew T. Tessmer
- Department of Surgery and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
- Pittsburgh Trauma Research Center, Pittsburgh, Pennsylvania
| | - Brian J. Daley
- Department of Surgery, University of Tennessee Health Science Center, Knoxville
| | - Richard S. Miller
- Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | | | - Jeffrey A. Claridge
- MetroHealth Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - Herb A. Phelan
- Department of Surgery, University of Texas Southwestern, Dallas
| | - Matthew D. Neal
- Department of Surgery and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
- Pittsburgh Trauma Research Center, Pittsburgh, Pennsylvania
| | - Brian S. Zuckerbraun
- Department of Surgery and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
- Pittsburgh Trauma Research Center, Pittsburgh, Pennsylvania
| | - Mark H. Yazer
- Department of Pathology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Timothy R. Billiar
- Department of Surgery and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
- Pittsburgh Trauma Research Center, Pittsburgh, Pennsylvania
| | - Jason L. Sperry
- Department of Surgery and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
- Pittsburgh Trauma Research Center, Pittsburgh, Pennsylvania
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137
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Stanworth SJ, New HV, Apelseth TO, Brunskill S, Cardigan R, Doree C, Germain M, Goldman M, Massey E, Prati D, Shehata N, So-Osman C, Thachil J. Effects of the COVID-19 pandemic on supply and use of blood for transfusion. Lancet Haematol 2020; 7:e756-e764. [PMID: 32628911 PMCID: PMC7333996 DOI: 10.1016/s2352-3026(20)30186-1] [Citation(s) in RCA: 180] [Impact Index Per Article: 45.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 06/05/2020] [Accepted: 06/08/2020] [Indexed: 01/28/2023]
Abstract
The COVID-19 pandemic has major implications for blood transfusion. There are uncertain patterns of demand, and transfusion institutions need to plan for reductions in donations and loss of crucial staff because of sickness and public health restrictions. We systematically searched for relevant studies addressing the transfusion chain-from donor, through collection and processing, to patients-to provide a synthesis of the published literature and guidance during times of potential or actual shortage. A reduction in donor numbers has largely been matched by reductions in demand for transfusion. Contingency planning includes prioritisation policies for patients in the event of predicted shortage. A range of strategies maintain ongoing equitable access to blood for transfusion during the pandemic, in addition to providing new therapies such as convalescent plasma. Sharing experience and developing expert consensus on the basis of evolving publications will help transfusion services and hospitals in countries at different stages in the pandemic.
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Affiliation(s)
- Simon J Stanworth
- Transfusion Medicine, NHS Blood and Transplant, Oxford, UK; Department of Haematology, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford, UK; Radcliffe Department of Medicine and NIHR Oxford Biomedical Research Centre-Haematology Theme, University of Oxford, Oxford, UK.
| | - Helen V New
- NHS Blood and Transplant, London, UK; Department of Haematology, Imperial College London, London, UK
| | - Torunn O Apelseth
- Department of Immunology and Transfusion Medicine, Haukeland University Hospital, Bergen, Norway; Norwegian Armed Forces Medical Services, Oslo, Norway
| | - Susan Brunskill
- Systematic Review Initiative, NHS Blood and Transplant, Oxford, UK
| | - Rebecca Cardigan
- NHS Blood and Transplant, Cambridge, UK; Department of Haematology, University of Cambridge, Cambridge, UK
| | - Carolyn Doree
- Systematic Review Initiative, NHS Blood and Transplant, Oxford, UK
| | - Marc Germain
- Medical Affairs and Innovation, Héma-Québec, Québec, QC, Canada
| | - Mindy Goldman
- Medical Affairs and Innovation, Canadian Blood Services, Ottawa, ON, Canada
| | | | - Daniele Prati
- Department of Transfusion Medicine and Hematology, IRCCS Ca 'Granda Hospital Maggiore Policlinico Foundation, Milan, Italy
| | - Nadine Shehata
- Department of Medicine, Division of Haematology, Mount Sinai Hospital, ON, Canada; Department of Medicine, and Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada; University Health Network, Department of Medicine, Division of Medical Oncology and Haematology, Toronto, ON, Canada
| | - Cynthia So-Osman
- Department of Transfusion Medicine, Sanquin Blood Supply Foundation, Amsterdam, Netherlands; Department of Haematology, Erasmus Medical Center, Rotterdam, Netherlands
| | - Jecko Thachil
- Manchester University NHS Foundation Trust, Manchester, UK
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138
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Apelseth TO, Strandenes G, Kristoffersen EK, Hagen KG, Braathen H, Hervig T. How do I implement a whole blood–based blood preparedness program in a small rural hospital? Transfusion 2020; 60:2793-2800. [DOI: 10.1111/trf.16057] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 06/27/2020] [Accepted: 06/27/2020] [Indexed: 12/17/2022]
Affiliation(s)
- Torunn O. Apelseth
- Department of Immunology and Transfusion Medicine Haukeland University Hospital Bergen Norway
- Department of War Surgery and Emergency Medicine Norwegian Armed Forces Medical Services Oslo Norway
| | - Geir Strandenes
- Department of Immunology and Transfusion Medicine Haukeland University Hospital Bergen Norway
- Department of War Surgery and Emergency Medicine Norwegian Armed Forces Medical Services Oslo Norway
| | - Einar K. Kristoffersen
- Department of Immunology and Transfusion Medicine Haukeland University Hospital Bergen Norway
- Institute of Clinical Science University of Bergen Bergen Norway
| | - Kristin G. Hagen
- Department of Immunology and Transfusion Medicine Haukeland University Hospital Bergen Norway
| | - Hanne Braathen
- Department of Immunology and Transfusion Medicine Haukeland University Hospital Bergen Norway
- Institute of Clinical Science University of Bergen Bergen Norway
| | - Tor Hervig
- Department of Immunology and Transfusion Medicine Haukeland University Hospital Bergen Norway
- Institute of Clinical Science University of Bergen Bergen Norway
- Haugesund Hospital Haugesund Norway
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139
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Thies KC, Truhlář A, Keene D, Hinkelbein J, Rützler K, Brazzi L, Vivien B. Pre-hospital blood transfusion - an ESA survey of European practice. Scand J Trauma Resusc Emerg Med 2020; 28:79. [PMID: 32795320 PMCID: PMC7427720 DOI: 10.1186/s13049-020-00774-1] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 07/29/2020] [Indexed: 01/17/2023] Open
Abstract
Background Blood products are a lifesaving commodity in the treatment of major trauma. Although there is little evidence for use of pre-hospital blood products (PHBP) in seriously injured patients, an increasing number of emergency medical services have started using PHBP for treatment of major haemorrhage. The primary aim of this survey was to establish the degree of prehospital blood product use throughout Europe and discover main indications. The secondary aim was to evaluate opinions about PHBP and also the experience and the personal views of its users. Methods The subcommittee for Critical Emergency Medicine of the European Society of Anaesthesiology (ESA) held an online survey of European Helicopter Emergency Services (HEMS) and all French Services d’Aide Médicale Urgente (SAMU) regions. It contained 13 questions both open and multiple-choice about the frequency transfusions are carried out, the PHBP used and the perceived benefit. The survey was distributed to the corresponding HEMS leads in 14 European countries. Results In total there were 172 valid responses; overall 48% of all respondents have prehospital access to packed red cells, 22% to fresh plasma and 14% use lyophilised plasma. Besides blood product administration, 94% of all services use tranexamic acid. Sixty five percent of all replies came from French and from German services (37 and 28% respectively). PHBP were mainly used for trauma related emergencies. France has the highest uptake of use of blood products at 89%, whereas the rate in Germany was far lower at 6%. Fifty five percent of the service leads felt that PHBP are beneficial, and even lifesaving in individual cases despite being needed infrequently. Conclusions We found remarkable dissimilarities in practice between the different European countries. Even if there is not an absolute consensus amongst providers on the benefit of PHBP, the majority feel they are beneficial. The difference in practice is possibly related to the perceived lack of evidence on prehospital blood transfusion. We suggest to include the use of PHBP in trauma registries in order to consolidate the existing evidence.
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Affiliation(s)
- Karl-Christian Thies
- Dept of Anaesthesiology, Critical Care and Pain Medicine, Greifswald University Medical Centre, Greifswald, Germany.
| | - Anatolij Truhlář
- Emergency Medical Services of the Hradec Kralove Region, Hradec Kralove, Czech Republic.,Department of Anaesthesiology and Intensive Care, Charles University in Prague, Faculty of Medicine, Hradec Kralove, Czech Republic.,University Hospital Hradec Kralove, Hradec Kralove, Czech Republic
| | - Damian Keene
- Department of Military Anaesthetics and Critical Care, Royal Centre for Defence Medicine, Birmingham, United Kingdom
| | - Jochen Hinkelbein
- Department of Anaesthesiology and Intensive Care Medicine, Medical Faculty and University Hospital of Cologne, Cologne, Germany
| | - Kurt Rützler
- Departments of General Anaesthesiology and Outcomes Research, Cleveland Clinic, Anaesthesiology Institute, Cleveland, USA
| | - Luca Brazzi
- Department of Surgical Sciences, University of Turin, Turin, Italy.,Italy Department of Anesthesia, Intensive Care and Emergency, Città della Salute e della Scienza' hospital, Turin, Italy.,University of Torino, Turin, Italy
| | - Benoît Vivien
- SAMU de Paris, Anaesthesiology and Critical Care Department, Universitary Hospital Necker - Enfants Malades, APHP Centre - University of Paris, Paris, France
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140
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Moore HB, Tessmer MT, Moore EE, Sperry JL, Cohen MJ, Chapman MP, Pusateri AE, Guyette FX, Brown JB, Neal MD, Zuckerbraun B, Sauaia A. Forgot calcium? Admission ionized-calcium in two civilian randomized controlled trials of prehospital plasma for traumatic hemorrhagic shock. J Trauma Acute Care Surg 2020; 88:588-596. [PMID: 32317575 PMCID: PMC7802822 DOI: 10.1097/ta.0000000000002614] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Randomized clinical trials (RCTs) support the use of prehospital plasma in traumatic hemorrhagic shock, especially in long transports. The citrate added to plasma binds with calcium, yet most prehospital trauma protocols have no guidelines for calcium replacement. We reviewed the experience of two recent prehospital plasma RCTs regarding admission ionized-calcium (i-Ca) blood levels and its impact on survival. We hypothesized that prehospital plasma is associated with hypocalcemia, which in turn is associated with lower survival. METHODS We studied patients enrolled in two institutions participating in prehospital plasma RCTs (control, standard of care; experimental, plasma), with i-Ca collected before calcium supplementation. Adults with traumatic hemorrhagic shock (systolic blood pressure ≤70 mm Hg or 71-90 mm Hg + heart rate ≥108 bpm) were eligible. We use generalized linear mixed models with random intercepts and Cox proportional hazards models with robust standard errors to account for clustered data by institution. Hypocalcemia was defined as i-Ca of 1.0 mmol/L or less. RESULTS Of 160 subjects (76% men), 48% received prehospital plasma (median age, 40 years [interquartile range, 28-53 years]) and 71% suffered blunt trauma (median Injury Severity Score [ISS], 22 [interquartile range, 17-34]). Prehospital plasma and control patients were similar regarding age, sex, ISS, blunt mechanism, and brain injury. Prehospital plasma recipients had significantly higher rates of hypocalcemia compared with controls (53% vs. 36%; adjusted relative risk, 1.48; 95% confidence interval [CI], 1.03-2.12; p = 0.03). Severe hypocalcemia was significantly associated with decreased survival (adjusted hazard ratio, 1.07; 95% CI, 1.02-1.13; p = 0.01) and massive transfusion (adjusted relative risk, 2.70; 95% CI, 1.13-6.46; p = 0.03), after adjustment for confounders (randomization group, age, ISS, and shock index). CONCLUSION Prehospital plasma in civilian trauma is associated with hypocalcemia, which in turn predicts lower survival and massive transfusion. These data underscore the need for explicit calcium supplementation guidelines in prehospital hemotherapy. LEVEL OF EVIDENCE Therapeutic, level II.
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Affiliation(s)
| | | | - Ernest E. Moore
- University of Colorado
- Ernest E. Moore Shock Trauma Center at Denver Health
| | | | - Mitchell J. Cohen
- University of Colorado
- Ernest E. Moore Shock Trauma Center at Denver Health
| | | | - Anthony E. Pusateri
- Combat Casualty Care Research Program, US Army Medical Research Materiel Command, Fort Detrick, Maryland
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