Transfusion of plasma, platelets, and red blood cells in a 1:1:1 vs a 1:1:2 ratio and mortality in patients with severe trauma: the PROPPR randomized clinical trial

Acute obstetric coagulopathy is associated with excess plasmin generation and proteolysis of fibrinogen and factor V

ABSTRACT

Hemostatic impairment may exacerbate postpartum hemorrhage (PPH). Previously, we described a distinct coagulopathy, associated with multiple causes of PPH including placental abruption and amniotic fluid embolus, termed acute obstetric coagulopathy (AOC). AOC is characterized by very high plasmin/antiplasmin complexes and rapid depletion of functional fibrinogen and factor V (FV). To determine mechanisms underlying AOC, we investigated the plasma from 12 women with AOC (defined by raised plasmin/antiplasmin) and 21 with severe PPH (blood loss >2000 mL or placental abruption) without AOC. Plasma from patients with AOC had a fourfold increased ability to generate plasmin compared with those with severe PPH without AOC (P < .0002). AOC was associated with fibrinogen cleavage in the circulation, demonstrated by fragment D and other breakdown products (P < .0001). D-dimer was increased 36-fold in AOC compared with severe PPH without AOC, thrombin/antithrombin complexes were not raised. FV was reduced on western blot in AOC but not severe PPH without AOC (P < .001) suggesting FV cleavage. Confocal microscopy revealed similar clot structure between AOC and non-AOC samples, but both groups differed from nonbleeding pregnant controls. These data suggest that in AOC an excess of plasmin cleaves fibrinogen and FV in the circulation causing a specific, pathognomonic depletion of coagulation factors. Fibrin(ogen) breakdown products have cofactor function for tissue plasminogen activator, and these data are consistent with these breakdown products, enhancing plasmin generation and potentially driving aberrant plasmin generation in AOC. These results have implications for the clinical management of coagulopathy during PPH.

Trauma-Induced Coagulopathy: A Review of Specific Molecular Mechanisms

Trauma remains a leading cause of death and disability in adults, and about 20% of deaths occur due to intractable bleeding. Trauma-induced coagulopathy (TIC) is a complex hemostatic disorder characterized by an abnormal coagulation response, which can manifest as either a hypo-coagulable state, leading to excessive bleeding, or a hypercoagulable state, resulting in thromboembolic events and multiple organ failure. Early diagnosis and correction of hypocoagulability may be lifesaving. Replacement of coagulation factors using blood components as well as counteracting enhanced fibrinolysis with tranexamic acid in association with a strategy of damage control are the current practices in the management of TIC. Nevertheless, the improved comprehension of the several mechanisms involved in the development of TIC might offer space for a tailored treatment with improvement of clinical outcome. This review aims to outline the pathophysiology of TIC and evaluate both established and emerging management strategies. A thorough literature review was made with a specific emphasis on articles discussing the molecular mechanisms of trauma-induced coagulopathy. We utilized PubMed, Scopus, and Web of Science with the main search terms "trauma-induced coagulopathy", "molecular mechanisms", and "coagulation pathways".

Injury induced endotheliopathy: overview, diagnosis, and management

PURPOSE OF REVIEW

This review aims to examine recent advances in the understanding of injury-induced endotheliopathy and therapeutics to mitigate its development in critically injured patients.

RECENT FINDINGS

Clinical studies have clearly demonstrated that syndecan-1 ectodomains can be found in circulation after various types of trauma and injury and correlates with worse outcomes. As the mechanisms of endotheliopathy are better understood, pathologic hyperadhesive forms of von Willebrand factor, along with a relative deficiency of its cleaving enzyme, a disintegrin and metalloprotease with thrombospondin type I motifs, member 13 (ADAMTS13), have emerged as additional biomarkers. Therapeutics to date have focused primarily on the protective effects of fresh frozen plasma and its constituents to restore the glycocalyx. Human recombinant ADAMTS13 holds promise, as do synthetic variants of heparan sulfate and activated protein C, although all data to date are preclinical.

SUMMARY

Injury-induced endotheliopathy represents an important pathologic response to trauma. Key biomarkers, such as syndecan-1, can aid in the diagnosis, but testing is not yet available clinically. As the mechanisms of endotheliopathy are better understood, therapeutics are being identified and show promise. To date, plasma has been the most widely studied; however, like all therapeutics for injury-induced endotheliopathy, it has primarily been studied in the preclinical setting.

Anesthetic Considerations and Blood Utilization for Placenta Accreta Spectrum

The anesthetic management of the patient with placenta accreta spectrum begins before surgery by assessing the patient and their comorbidities and providing psychological preparation for the perioperative period. Choosing neuraxial or general anesthesia for surgery balances the procedure's clinical needs with the patient's desires. Intraoperatively, management of homeostasis during acute blood loss requires assessments of central volume to avoid over-transfusion. Viscoelastic testing may be useful to assess coagulation to target the replacement of coagulation factors. Postoperative care is an essential continuum of the procedure, and the availability of bedside ultrasound can aid rapid decision-making.

Evidence-Based Perioperative Management of Placenta Accreta Spectrum Disorder

Placenta accreta spectrum (PAS) disorder, characterized by failure of the abnormally adherent placenta to detach from the uterus after delivery, is a leading cause of severe maternal morbidity. Despite its relatively low incidence, disproportional contributions to perinatal hemorrhage, massive transfusion, and emergency hysterectomy underscore the critical need for development of evidence-based surgical management strategies for PAS. There is clear benefit to preoperative management of anemia, as well as preparation for intraoperative resuscitation with blood products and cell salvage. Several tenets of normal cesarean delivery should be maintained in PAS delivery such as the use of neuraxial anesthesia until delivery, prophylactic antibiotics, mechanical thromboprophylaxis intraoperatively, and administration of tranexamic acid if excessive bleeding occurs. Elements of surgical management distinctive to PAS and accepted as best practice include the following: planning delivery at centers with experienced teams when PAS is suspected antenatally, global intraoperative uterine and pelvic survey on entry into the abdominal cavity to assess for anatomic distortion or abnormal vascularity, selection of hysterotomy site for delivery well away from the placental margin, and direct visual assessment of the placental relationship with the myometrium after neonatal delivery and during the start of uterine involution. Other morbidity-reducing strategies such as routine cystoscopy with or without ureteral stent placement, unconventional transverse abdominal entry, hysterotomy extension with surgical staplers, and endovascular hemorrhage reduction tactics involving aortic or iliac balloon occlusion and multivessel arterial embolization remain experimental and require further research.

Is there an association between inflammatory biomarkers and organ space surgical site infection after emergency laparotomy in massively transfused trauma patients?

BACKGROUND

The relationship between inflammatory biomarkers (IB) and organ space surgical site infections (OS-SSIs) after emergency laparotomy (EL) is poorly understood.

METHODS

Retrospective, single-center analysis of patients in the Pragmatic, Randomized Optimal Platelet and Plasma Ratios (PROPPR) trial who underwent EL and survived 48 ​h after admission was performed. IB levels of IL-6, IL-8, G-CSF, MCP-1, neutrophil to lymphocyte ratio, and platelet to lymphocyte ratio were analyzed. IB and OS-SSIs association was evaluated using the Wilcoxon rank sum test.

RESULTS

Of 74 eligible patients, 80 ​% were male, 69 ​% sustained blunt trauma, the injury severity score was 31 (24-41), and 22 ​% developed OS-SSIs. Levels of IL-6 (12, 24 ​h), IL-8 (2, 12, 24, 72 ​h), and MCP-1 (24 ​h) were higher in OS-SSI patients (P ​< ​0.05).

CONCLUSIONS

IL-6, IL-8, and MCP-1 levels were associated with OS-SSIs in PROPPR patients who underwent EL. The IB may help to predict high-risk patients for OS-SSIs.

Perioperative Blood Management

Perioperative blood management strategies include evidence-based guidelines to efficiently manage blood products and transfusions while minimizing blood loss and improving patient outcomes. Perioperative Medicine has made evident that anemia is often under-recognized and not appropriately addressed prior to surgery. Early recognition and correction of anemia is imperative for better surgical optimization, fewer transfusions perioperatively, and improved outcomes. Patient blood management utilize evidence-based guidelines for the establishment of a framework to promote treatment of the causes of anemia, reduce blood loss and coagulopathy as well as to improve patient safety and outcomes by efficiently managing blood products, decrease complications associated with blood transfusions and reduce overall costs. Both liberal and restrictive strategies for blood transfusions established thresholds for hemoglobin: restrictive transfusion threshold of hemoglobin 7-8 g/dL in stable patients, and a higher transfusion threshold of hemoglobin > 8 g/dL may be considered in patients with cardiac disease. Intraoperatively, tests such as viscoelastic testing, including rotational thromboelastometry and thrombelastography, offer real-time analysis of a patient's clotting ability, allowing for targeted transfusions of fresh frozen plasma, platelets, cryoprecipitate or antifibrinolytic drugs. Complications associated with blood transfusions include allergic reactions, delayed hemolytic reactions, transfusion related acute lung injury, transfusion-associated circulatory overload, and the transmission of infectious diseases such as Hepatitis B, Hepatitis C, and Human-immunodeficiency virus. This review will discuss the management of blood products for surgical patients in the entire perioperative setting, with specific considerations for the peri-, intra- and post-operative stages.

Comment on Jeon et al. Predictive Limitations of the Geriatric Trauma Outcome Score: A Retrospective Analysis of Mortality in Elderly Patients with Multiple Traumas and Severe Traumatic Brain Injury. Diagnostics 2025, 15, 586

The authors, Jeon et al [...].

Blood product administration in the prehospital setting: a multisociety consensus statement

The Italian Society of Anesthesia, Analgesia, Resuscitation and Intensive Care (SIAARTI) has led the development of a Good Clinical Practice (GCP) document, engaging multiple scientific societies-including the Italian Society of Transfusion Medicine and Immunohematology (SIMTI), the Italian Society of Infectious and Tropical Diseases (SIMIT), the Italian Society of Emergency Medicine (SIMEU), the National Association of Critical Care Nurses (ANIARTI), and the Italian National Blood Centre (Centro Nazionale Sangue-CNS). This collaborative effort aims to establish a multidisciplinary consensus on the administration of blood products in the prehospital management of patients with life-threatening hemorrhage. The increasing adoption of prehospital transfusion programs worldwide, particularly in trauma care, highlighted the need for structured recommendations that ensure safety, effectiveness, and compliance with current regulations. In prehospital settings, the early administration of packed red blood cells, fibrinogen concentrate, and fresh frozen plasma is not only considered feasible but has also shown to be potentially effective in improving hemodynamic stability and reducing mortality in patients with hemorrhagic shock. However, these benefits are strongly influenced by factors such as patient selection, timing of intervention, and the integration of transfusion protocols into advanced prehospital care systems. Implementing strict clinical governance, ensuring appropriate storage conditions, and developing standardized documentation processes are key to the success of these programs. Furthermore, close collaboration between emergency medical services and blood banks is essential to ensure compliance with national guidelines and to optimize patient outcomes. This consensus document was developed through a systematic literature review and a modified Delphi method, involving blind voting and consensus evaluation using a Likert scale. The process was conducted over two rounds of online voting. The document addresses four critical topics: the selection of blood product derivatives for prehospital use, safety requirements for their transport, documentation and traceability standards, and procedures for the return of unused components.

Bridging the gap: whole blood and plasma in prehospital hemorrhagic shock resuscitation

Life-threatening hemorrhage remains a leading cause of preventable trauma-related mortality. Prehospital blood product administration has shown promise in improving outcomes; however, widespread implementation of whole blood programs faces significant logistical and operational challenges. Plasma represents a practical alternative that warrants thorough examination. Contemporary evidence, specifically the landmark PAMPer trial and secondary analysis of the COMBAT trial, demonstrates that prehospital plasma administration reduces 30-day mortality by 9.8% in trauma patients at risk of hemorrhagic shock, particularly when transport times exceed 20 minute. Plasma's efficacy stems from a reduction in trauma-induced coagulopathy and endothelial glycocalyx damage. While liquid plasma has a limited shelf life, dried plasma offers extended storage capability at room temperature for up to 2 years, presenting a logistically favorable option for emergency medical service (EMS) systems. Costs vary significantly between formulations, ranging from US$40 to US$100 for liquid plasma to US$700 to US$1500 for dried plasma. However, consideration must be given to the short shelf-life of liquid plasma. Prehospital plasma, particularly dried plasma, represents an important advancement in trauma management and represents a viable alternative to crystalloid-only resuscitation where whole blood may not be available or feasible. Implementation success depends on regional deployment strategies, blood bank partnerships, funding, training, and community engagement. Future research should focus on optimizing plasma utilization and improving patient outcomes through clinical and implementation-science approaches for EMS systems for which whole blood may not be an option.

Rethinking Platelet and Plasma Transfusion Strategies for Neonates: Evidence, Guidelines, and Unanswered Questions

The transfusion of platelets and fresh frozen plasma (FFP) to critically ill neonates in neonatal intensive care units (NICUs) is a common intervention, yet it is still widely performed without adhering to international guidelines. The guidance itself on the therapeutic management of neonatal coagulation disorders is generally limited due to the absence of strong indications for treatment and is mainly aimed at the prevention of major hemorrhagic events such as intraventricular hemorrhage (IVH) in premature neonates. Historically, the underrepresentation of neonates in clinical studies related to transfusion medicine had led to significant gaps in our knowledge regarding the best transfusion practices in this vulnerable group and to a wide variability in policies among different neonatal units, often based on local experience or guidance designed for older children or adults, and possibly increasing the risk of inappropriate or ineffective interventions. Platelet transfusion and, particularly, FFP administration have been linked to potentially fatal complications in neonates and thus any decision needs to be carefully balanced and requires a thorough consideration of multiple factors in the neonatal population. Despite recent advances toward more restrictive practices, platelet and FFP transfusions are still subject to wide variability in practices.This review examines the existing literature on platelet and FFP transfusions and on the management of massive hemorrhage in neonates, provides a summary of evidence-based guidelines on these topics, and highlights current developments and areas for ongoing and future research with the aim of improving clinical practices.

Association between whole blood versus balanced component therapy and survival in isolated severe traumatic brain injury

Background

Whole blood transfusion (WBT) is associated with improved hemostasis and possibly mortality in patients with hemorrhagic shock after injury but there are no studies in patients with isolated severe traumatic brain injury (TBI). The objective of this investigation was to compare outcomes of balanced component therapy (BCT) versus WBT in patients with an isolated severe TBI.

Methods

Adult patients (≥18 years) registered in the Trauma Quality Improvement Program (2016-2019) who suffered a blunt isolated severe TBI (head Abbreviated Injury Score ≥3 in the head and ≤1 in the remaining body regions) and who received a BCT (1-2:1 packed red blood cell (PRBC):fresh frozen plasma and 1-2:1 PRBC:platelets) or WBT were eligible for inclusion. Patients were matched, based on the transfusion received, using propensity score matching. The primary outcome of interest was in-hospital mortality.

Results

A total of 217 patients received either WBT (n=82) or BCT (n=135). After propensity score matching, 50 matched pairs were analyzed. The rate of in-hospital mortality was significantly lower in the WBT compared with BCT group (43.1% vs 66.7%, p=0.025) corresponding to a relative risk (RR) reduction of 35% in in-hospital mortality (RR (CI 95%): 0.65 (0.43 to 0.97)). However, in subgroup analyses comparing those who were managed surgically and conservatively, this association only remained significant among patients who underwent neurosurgical intervention.

Conclusions

WBT in patients with severe isolated TBI is associated with better survival compared with BCT in patients who require neurosurgical intervention. Further investigation into this finding using an appropriately powered, prospective study design is warranted.

Level of evidence

Level III, therapeutic.

How I manage major hemorrhage

ABSTRACT

Acute hemorrhage can be a life-threatening emergency that is complex in its management and affects many patient populations. The past 15 years has seen the introduction of comprehensive massive hemorrhage protocols, wider use of viscoelastic testing, new coagulation factor products, and the publication of robust randomized controlled trials in diverse bleeding patient populations. Although gaps continue to exist in the evidence base for several aspects of patient care, there is now sufficient evidence to allow for an individualized hemostatic response based on the type of bleeding and specific hemostatic defects. We present 3 clinical cases that highlight some of the challenges in acute hemorrhage management, focusing on the importance of interprofessional communication, rapid provision of hemostatic resuscitation, repeated measures of coagulation, immediate administration of tranexamic acid, and prioritization of surgical or radiologic control of hemorrhage. This article provides a framework for the clear and collaborative conversation between the bedside clinical team and the consulting hematologist to achieve prompt and targeted hemostatic resuscitation. In addition to providing consultations on the hemostatic management of individual patients, the hematology service must be involved in setting hospital policies for the prevention and management of patients with major hemorrhage.

From shortages to solutions: Liquid plasma as a practical alternative to whole blood for prehospital trauma resuscitation

Trauma-induced hemorrhagic shock remains a leading cause of preventable mortality, necessitating timely and effective resuscitation strategies. While low-titer O whole blood (LTOWB) is the preferred choice for prehospital resuscitation due to its balanced composition and ease of use, overall widespread implementation is hindered by persistent supply chain issues and daily logistical challenges of access and deployment. Platelets, containing plasma as a component, are considered the next best alternative to LTOWB but are constrained by their short shelf life and ongoing scarcity, and ongoing storage compliance, rendering their use impractical. This review evaluates plasma-based alternatives, particularly liquid plasma (LP), as a viable and cost-effective substitute therapeutic modality. LP offers a 26-day refrigerated shelf life compared to the 5-day limit of thawed fresh frozen plasma (FFP) and eliminates the challenges associated with freezing and thawing while maintaining clinical efficacy. Preliminary economic analyses further underscore the advantages of LP, demonstrating reduced wastage and lower costs compared to LTOWB, especially when partnering with a hospital system. Acknowledging the barriers in implementing prehospital blood transfusion programs due to blood supply and costs, we advocate for emergency medical service (EMS) adoption of LP, highlighting its availability, comparable efficacy to LTOWB, and cost-effectiveness. Until LTOWB becomes more accessible, LP should be prioritized in prehospital care to optimize outcomes for trauma patients in hemorrhagic shock.

Analysis of time to death for children with life-threatening hemorrhage from traumatic, surgical, and medical etiologies

INTRODUCTION

Life-threatening hemorrhage (LTH) is a significant cause of mortality in pediatrics. Timing of mortality in children with LTH is important for future trials.

METHODS

In a secondary analysis of the prospective observational massive transfusion in children (MATIC) study, time-to-event analysis was performed to determine timing of death based on etiology of LTH and cause of death.

RESULTS

There were 449 children with LTH; the etiologies of LTHs included trauma (46%), operative (34%), and medical (20%). The cause of death at 24 h in the trauma group was 56% from hemorrhage and 42% from central nervous system (CNS) failure; in operative group it was 94% from hemorrhage and 6% CNS failure; in medical group it was 84% hemorrhage and 3% CNS failure. The median (interquartile range [IQR]) time to death (hours) varied by cause of death (hemorrhagic: 3.3 [1.0-10.3], CNS failure: 30.4 [9.0-63.6]). For traumatic LTH, 90% of hemorrhage-related deaths occurred within 19 h and 90% of CNS failure deaths occurred within 92 h. For operative LTH, 90% of hemorrhage-related deaths occurred within 5 days and 90% of CNS failure deaths occurred within 28 days. For medical LTH, 90% of hemorrhage-related deaths occurred within 44 h and 90% of CNS failure deaths occurred within 24 days.

CONCLUSION

In children, timing of death differs according to etiology of LTH and by cause of death. The choice of primary outcome for trials in children with LTH should consider these differences based on the etiology of LTH being studied.

Comparative analysis of cold-stored platelets using Golden Hour transport boxes: Function and quality

BACKGROUND

The Emergency Medical Retrieval and Transfer Service in Wales provides prehospital critical care, including the transfusion of red blood cells and plasma. However, the logistical challenges of storing platelet concentrates (PCs) at 22°C with constant agitation limit their prehospital use. Cold-stored platelets (CSP) at 4°C without agitation offer a potential solution, demonstrating superior hemostatic capabilities in vitro and longer storage potential. This study investigated the viability of storing CSP in Golden Hour boxes for up to 96 h, followed by refrigeration, to enhance prehospital damage control resuscitation.

METHODS

Two buffy-coat-derived PCs were combined and split into two: one PC was refrigerated at 4°C ± 2°C without agitation (CSP) for 15 days, and the other was stored in a Golden Hour cold box from days 2 to 6 (GH-CSP) before being rotated back into refrigeration. In vitro assessments included aggregometry, thrombin generation, thromboelastography, and platelet activation via P-selectin and annexin V binding.

RESULTS

Temperature data demonstrated that a Golden Hour box can maintain a temperature of 2-6°C for up to 84 h with a CSP and two red cell concentrates. Platelet function was not significantly different between the two storage conditions. GH-CSP displayed increased annexin V binding on day 8 compared with CSP (32.31 ± 3.27% vs 26.36 ± 2.17%, p = .0026) and day 15 (41.76 ± 6.13% vs 38.41 ± 3.99%, p = .0199).

CONCLUSION

CSP stored in a Golden Hour box was comparable with conventional CSP, suggesting this method may be viable for prehospital use.

Clinical practice guidelines for management of disseminated intravascular coagulation in Japan 2024: part 4-trauma, burn, obstetrics, acute pancreatitis/liver failure, and others

Disseminated intravascular coagulation (DIC) is a complex condition with diverse etiologies. While its association with sepsis has been widely studied, less focus has been given to DIC arising from other critical conditions, such as trauma, burns, acute pancreatitis, and obstetric complications. The 2024 Clinical Practice Guidelines, developed by the Japanese Society on Thrombosis and Hemostasis (JSTH), aim to fill this gap and offer comprehensive recommendations for managing DIC across various conditions. This study, Part 4 of the guideline series, addresses DIC management in trauma, burns, obstetric complications, acute pancreatitis/liver failure, viral infections, and autoimmune diseases. For trauma-associated DIC, early administration of fresh-frozen plasma (FFP), coagulation factor concentrates such as fibrinogen and prothrombin complex concentrates, and tranexamic acid is recommended. The guidelines also highlight DIC in obstetrics, which is associated with massive bleeding, and recommend the administration of fibrinogen concentrate, antithrombin concentrate, and tranexamic acid. Through a systematic review of the current evidence, the guidelines provide stratified recommendations aimed at improving clinical outcomes in DIC management beyond sepsis, thereby serving as a valuable resource for healthcare providers globally.

Transfusion of modified whole blood versus blood components therapy in patients with severe trauma: Randomized controlled trial protocol (WEBSTER trial)

Hemostatic resuscitation is a mainstay in the management of trauma patients. Factors such as blood loss and tissue injury contribute to coagulation and hemodynamic status imbalances. Hemorrhage remains a leading cause of death in trauma patients, despite advances in strategies such as damage control surgery, massive transfusion protocol, and intensive care. Conventional hemostatic resuscitation often involves a 1:1:1 ratio of red blood cells, plasma, and platelets. However, this ratio has disadvantages, especially in low-resource settings. Whole blood transfusion maintains a physiological rate of cells, clotting factors, and hemostatic properties. Advances in the whole blood elucidated a new opportunity for its implementation in civilian trauma centers. However, the effect of initial resuscitation with whole blood in trauma patients is unclear. This study aims to determine the effect of hemostatic resuscitation using whole blood on mortality and evolution of organ dysfunction in severe trauma patients compared to blood components therapy. This clinical trial attempts to resolve the debate and uncertainty of using whole blood vs. blood components. An open-label, randomized, prospective, single-center and controlled trial will be performed. Participants will be randomly assigned to receive either 3 units of whole blood or 3 units each of red blood cells and fresh frozen plasma, plus half an apheresis unit of platelets (equivalent to 3 platelet units). A second intervention of the same ratio will be administered if further transfusion is required. The primary outcome is a hierarchical composite outcome based on mortality at 28 days and the evolution of organ dysfunction. Organ dysfunction will be measured as the difference in the score between the fifth and first days of the SOFA (Sequential Organ Failure Assessment). Secondary outcomes are mortality, coagulopathy profile, intensive care unit free days, length of hospital stay, and volumes of transfusion requirements. Safety outcomes are complications related to transfusion and complications related to trauma (acute distress respiratory syndrome, pulmonary embolism, deep vein thrombosis, acute kidney injury with or without dialysis, stroke, myocardial infarction, cardiac arrest, sepsis, abdominal complications, abdominal compartment syndrome). TRIAL REGISTRATION: ClinicalTrials.gov: NCT05634109 - Whole Blood in Trauma Patients with Hemorrhagic Shock (WEBSTER).

Freeze-dried plasma: Hemostasis and biophysical analyses for damage control resuscitation

BACKGROUND

Effective hemorrhage protocols prioritize immediate hemostatic resuscitation to manage hemorrhagic shock. Prehospital resuscitation using blood products, such as whole blood or alternatively dried plasma in its absence, has the potential to improve outcomes in hemorrhagic shock patients. However, integrating blood products into prehospital care poses substantial logistical challenges due to issues with storage, transport, and administration in field environments.

STUDY DESIGN AND METHODS

We utilized hemostatic assays and advanced biophysical techniques, such as calorimetry, infrared spectoscopy, dynamic light scattering, and biolayer interferometry, to compare the functional and structural properties of freeze-dried plasma (FDP; OctaplasLG Powder, Octapharma AB) with those of fresh plasma controls.

RESULTS

Hemostatic characterization of FDP revealed that clot formation properties and coagulation parameters were largely comparable to fresh plasma controls, with some variations observed in Von Willebrand factor-ADAMTS13 axis and fibrinolysis. No change to moisture content of FDP (~1% water content) was observed after 6-month storage at ambient conditions. Biophysical analyses of FDP during transfusion demonstrated spontaneous exothermic mixing of FDP in plasma, a dilution effect from saline, as well as comparable stability to plasma controls. Quantification of ligand-binding affinities of platelet receptors activated GPIIbIIIa and GPIbα showed comparable binding properties to plasma controls.

CONCLUSION

Our results show that FDP exhibits hemostatic functionality and protein stability on par with fresh plasma, as assessed by novel, highly sensitive techniques. FDP therefore represents a viable alternative to conventional plasma in damage control resuscitation, offering significant logistical and storage advantages for prehospital and remote applications, especially in scenarios where whole blood is unavailable.

A narrative review: Resuscitation of older adults with hemorrhagic shock

BACKGROUND

The increasing population of older adults presents unique challenges in trauma care due to their reduced physiologic reserve compared to younger patients. Trauma-induced hemorrhage remains a leading cause of mortality, yet there is a significant gap in the optimal management of hemodynamically unstable older adults. This review aims to synthesize current literature on resuscitation strategies, coagulopathy, triage, and the impact of timely interventions in older adult trauma patients experiencing hemorrhagic shock.

STUDY DESIGN AND METHODS

A comprehensive narrative review was conducted following PRISMA-Scr guidelines. A systematic literature search was performed using PubMed, Scopus, and Web of Science databases, yielding 380 titles. After removing duplicates, 287 unique articles were screened, of which 120 full-text articles were reviewed. A total of 45 studies met the inclusion criteria and were analyzed. Studies were categorized based on resuscitation protocols (14 studies), coagulopathy management (7 studies), frailty and aging physiology (10 studies), and timing/triage in trauma care (14 studies).

RESULTS

Studies highlight the effectiveness of the shock index (SI) over traditional vital signs for identifying hemodynamic instability in older adults. Balanced transfusion ratios and whole blood resuscitation show potential benefits, though data specific to older adults remain limited. Goal-directed resuscitation protocols improve outcomes by addressing the unique physiological needs of this population. While trauma-induced coagulopathy rates are similar across age groups, older adults frequently present with pre-existing anticoagulation, complicating management. Standardized care pathways, early activation of massive transfusion protocols (MTP), and tailored resuscitation approaches are critical for optimizing care.

DISCUSSION

The growing geriatric trauma population necessitates improved resuscitation strategies tailored to their unique physiological responses. While balanced transfusions and goal-directed protocols have demonstrated efficacy, further research is required to refine these interventions specifically for older adults. Establishing standardized resuscitation guidelines and defining futility criteria will enhance decision-making and improve outcomes for this vulnerable population.

Nationwide trends in prehospital blood product use after injury 2020-2023

INTRODUCTION

Prehospital blood transfusion improves survival after injury. Understanding potential demand for and usage of prehospital blood transfusion is important to help improve supply and utilization of this prehospital intervention. The primary objective of this study is to describe potential current demand for prehospital blood product in adults after blunt and penetrating injury from 2020 to 2023. We also estimate the extent to which this potential demand is being met.

METHODS

Patients ≥16 years with blunt/penetrating injuries included in the National Emergency Medical Services Information System (NEMSIS) from 2020 to 2023 were identified. Patients were classified into Cohort 1 (systolic blood pressure (SBP) <90 and heart rate (HR) >108 or SBP <70) and Cohort 2 (shock index ≥1), and total numbers in each cohort were reported. Additionally, the number and percentage of patients who were potentially eligible for and who received prehospital blood transfusion were calculated and trended over time.

RESULTS

After exclusions, 20.4 million trauma patients were included. A total of 262,761 Cohort 1 patients and 1,227,556 Cohort 2 patients were potentially eligible for transfusion. Estimated demand for blood transfusion increased from 2020 to 2023 (p < 0.001) in both cohorts. Cohort 1 had the highest estimated proportion of patients (0.9%, n = 2,289) who received transfusion, demonstrating that few potentially eligible adult trauma patients received blood product.

CONCLUSIONS

Altogether, 1.2 million hemodynamically unstable trauma patients were potentially eligible for prehospital blood transfusion after injury during 2020-2023, yet less than 1% received this intervention. These data underscore the need to evaluate and resolve barriers to wider use of prehospital blood transfusions.

Potential military applications for a new freeze-dried plasma

Hemorrhage is a leading cause of potentially preventable death in both military and civilian trauma. Current resuscitation approaches minimize crystalloids and emphasize plasma and other blood components to achieve a balanced transfusion as early as possible after injury. Owing to the nature of military operations, military medical systems must contend with great distances, degraded infrastructure, and harsh environments, as well as combat and humanitarian assistance and disaster relief (HADR) scenarios. These factors limit both patient movement and the ability to deliver blood products to the point of need. Current projections are that future military scenarios will have longer times to reach a medical treatment facility than experienced in recent conflicts, increasing the need for logistically efficient blood products. Freeze-dried plasma (FDP) is rapidly available, easy to use, and shelf-stable at room temperature, making it easier to deliver at the point of need in challenging military environments. For the past 30 years, FDP has been available in only a few countries. Where it has been available, it has become the preferred plasma for austere or military expeditionary settings. Recently, a new FDP, OctaplasLG Powder, was approved in 17 countries worldwide and for emergency use by the Canadian and United States militaries. It is expected that FDP will soon become available to many more militaries. This review discusses the importance of plasma, reassesses the potential military uses of FDP across the range of military operations, and provides a brief discussion of OctaplasLG Powder.

Nationwide estimates of potential lives saved with prehospital blood transfusions

INTRODUCTION

Prehospital blood transfusions result in a significant reduction in mortality risk for injured patients in hemorrhagic shock; however, prehospital blood transfusions have not been widely implemented across the United States. Thus, a paucity of data surrounding the impact of achieving near-complete population-level access to this resource exists. We aimed to determine the number of lives that could potentially have been saved among injured patients in hemorrhagic shock between 2020 and 2023 had prehospital blood products (blood components or whole blood, pBP) been fully implemented.

METHODS

We performed a retrospective review of the National Emergency Medical Services Information System (NEMSIS) from 2020 to 2023 for all trauma patients ≥16 years. Patients with prehospital systolic blood pressure <90 mmHg and heart rate >108 beats per minute, or a systolic blood pressure <70 mmHg, and who did not receive pBP products were included in the analysis. Potential lives saved were calculated using mortality and risk ratio estimates (RR) from previously published studies, assuming 100% nationwide access to pBP. A series of models were developed incorporating varying RR, mortality rate assumptions, and nationwide access to pBP to encompass a wide range of scenarios.

RESULTS

A total of 260,472 patients met our inclusion criteria. Using a 22.1% 24-h mortality rate and an RR of 0.629, 21,356 deaths over the four-year study period could have potentially been saved with the nationwide implementation of pBP.

CONCLUSION

Transfusion of pBP offers the potential to save thousands of injured patients lives. Efforts toward making policy-level interventions aimed at increasing the adoption and availability of pBP should be sought.

Massive transfusion policy in the Netherlands, a nationwide survey

BACKGROUND

Massive transfusion protocols (MTPs) guide the physician in optimizing transfusion strategies. Although international guidelines on massive transfusion exist, it is unknown whether all Dutch hospitals adhere to these guidelines. The main objective of this study was to create an overview of the massive transfusion strategies of Dutch hospitals and to evaluate if logistical factors, for example, the unavailability of thawed plasma, influence transfusion practices. Furthermore, this study was initiated to evaluate the interest in a ready-to-use plasma product.

STUDY DESIGN AND METHODS

A questionnaire on transfusion strategy, available resources, and yearly usage/wastage of transfusion products was distributed to all hospitals in the Netherlands.

RESULTS

Sixty-nine hospitals were approached, of which 58 responded (response rate 84%). The majority of hospitals (67%) strived for a 1:1 erythrocyte/plasma ratio. Five percent of the hospitals used an erythrocyte/plasma ratio >2:1, which did not meet (inter)national guidelines. No relation was found between the clinical strategy described in the MTP and available resources; moreover, direct plasma availability did not increase plasma wastage. Hospitals for which it takes longer to have plasma available for transfusion generally are more interested in a ready-to-use plasma product (n = 55, 75.0% vs. 57%).

CONCLUSION

This was the first nationwide survey on massive transfusion practices in the Netherlands. There is clear uniformity when it comes to using an MTP. Logistics surrounding plasma availability or plasma thawing capacity did not influence MTPs. Nevertheless, there seems to be substantial interest in a ready-to-use plasma product, especially in hospitals with limited plasma use.

Can heroic roadside care save lives?

Prehospital emergency care is an important part of trauma systems across the USA and the world. From a once 'load and go' service, the provider's skillsets and scope of practice have evolved to include multiple procedures that can be performed in the field. It is still debated if performing some prehospital procedures contributes to improved patient outcomes after traumatic injury and saves lives. The topic was debated at the 40th Annual Point/Counterpoint Acute Care Surgery Conference. Level of evidence: III.

Fibrinogen Replacement: A Questionable Dogma

Management of hemostasis in the perioperative setting, in trauma or in acute care, has considerably changed over the last two decades. Viscoelastic testing and single-factor replacement therapies have become cornerstones of the respective clinical approaches. Here, we illuminate the basic theories for these approaches as well as the important evidence available. Both viscoelastic assays and single-factor replacements are important improvements; their use must be based on the strongest scientific evidence available.

Blood transfusion strategies for major bleeding in trauma

BACKGROUND

Trauma is a leading cause of morbidity and mortality worldwide. Research shows that haemorrhage and trauma-induced coagulopathy are reversible components of traumatic injury, if identified and treated early. Lack of consensus on definitions and transfusion strategies hinders the translation of this evidence into clinical practice.

OBJECTIVES

To assess the beneficial and harmful effects of transfusion strategies started within 24 hours of traumatic injury in adults (aged 16 years and over) with major bleeding.

SEARCH METHODS

CENTRAL, MEDLINE, Embase, five other databases, and three trial registers were searched on 20 November 2023. We also checked reference lists of included studies to identify any additional studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) of adults (aged 16 years and over) receiving blood products for the management of bleeding within 24 hours of traumatic injury.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methodology to perform the review and assessed the certainty of the evidence using GRADE.

MAIN RESULTS

We included 18 RCTs with 5041 participants. Comparison 1: Prehospital transfusion strategies Five studies compared use of plasma (fresh frozen plasma (FFP) or lyophilised plasma) versus 'standard of care'. We are uncertain of the effect of plasma on all-cause mortality at 24 hours (risk ratio (RR) 1.05, 95% confidence interval (CI), 0.48 to 2.30; 3 studies, 279 participants; very low certainty evidence). There is probably no difference between plasma and standard of care in all-cause mortality at 30 days (RR 0.95, 95% CI 0.78 to 1.17; 3 studies, 664 participants; moderate-certainty evidence). However, the results of one cluster-RCT that could not be included in our meta-analysis suggested that plasma may be associated with a lower risk of death at 30 days (RR 0.54, 95% CI 0.42 to 0.70; 1 study, 481 participants; low-certainty evidence). There may be no difference between plasma and standard of care in the total number of thromboembolic events in 30 days (RR 1.23, 95% CI 0.67 to.2.27; 4 studies, 586 participants; low-certainty evidence). Comparison 2: In-hospital transfusion strategies Ten studies evaluated this comparison, seven providing usable data. The studies evaluated cryoprecitate (three studies); fixed-ratio blood component transfusion (three studies); fresh frozen plasma (FFP) (one study); lyophilised plasma (one study); leucoreduced red blood cells (one study); and a restrictive transfusion strategy (one study). All-cause mortality at 24 hours For all-cause mortality at 24 hours, there is probably no difference between: • cryoprecipitate plus a major haemorrhage protocol (MHP) versus MHP alone (RR 0.92, 95% CI 0.70 to 1.21; 1 study, 1577 participants; moderate-certainty evidence); and • blood products (plasma:platelets:red blood cells (RBCs)) transfused in 1:1:1 ratio versus 1:1:2 ratio (RR 0.75, 95% CI 0.52 to 1.08; 1 study, 680 participants; moderate-certainty evidence). We are uncertain of the effect on all-cause mortality at 24 hours for: • blood products (RBCs:FFP) transfused in 1:1 ratio versus transfusion according to coagulation and full blood count results (Peto odds ratio (POR) 0.45, 0.17 to 1.22; 1 study, 434 participants; very low certainty evidence); and • lyophilised (FlyP) plasma versus FFP (POR 1.04, 95% CI 0.06 to 17.23; 1 study, 47 participants; very low certainty evidence); All-cause mortality at 30 days For all-cause mortality at 30 days, there is probably no difference between blood products (plasma:platelets:RBCs) transfused in a 1:1:1 ratio versus a 1:1:2 ratio (RR 0.85, 95% CI 0.65 to 1.11; 1 study, 680 participants; moderate-certainty evidence). There may be little to no difference between the following interventions in all-cause mortality at 30 days: • cryoprecipitate plus MHP versus MHP alone (RR 0.77, 95% CI 0.33 to 1.78; 2 studies, 1572 participants; low-certainty evidence); and •leucoreduced RBCs versus standard RBCs (RR 1.20, 95% CI 0.74 to 1.95; 1 study,55 participants; low certainty evidence). We are uncertain of the effect on all-cause mortality at 30 days for: •lyophilised plasma versus FFP (RR 0.75, 95% CI 0.28 to 2.02; 1 study, 47 participants; very low certainty evidence); and • blood products (plasma:platelets:RBCs) transfused in 1:1:1 ratio versus standard MHP (RR 2.25, 95% CI 0.90 to 5.62; 1 study, 69 participants; very low certainty evidence). Total number of thromboembolic events at 30 days There may be little to no difference between the following interventions for total thromboembolic events at 30 days: • cryoprecipitate plus MHP versus MHP alone (RR 0.55, 95% CI 0.08 to 3.72; 2 studies, 1645 participants; low-certainty evidence); and • blood products (plasma:platelets:RBCs) transfused in 1:1:1 ratio versus 1:1:2 ratio (RR 1.03, 95% CI 0.75 to 1.42; 1 study, 680 participants; low-certainty evidence). We are uncertain of the effect on the total number of thromboembolic events at 30 days for: •blood products (plasma:platelets:RBCs) transfused in 1:1:1 ratio versus standard MHP (POR 6.83, 95% CI 0.68 to 68.35; 1 study, 69 participants; very low certainty evidence). Comparison 3: Whole blood versus individual blood products We are uncertain of the effect of modified (leucoreduced) whole blood versus blood products (RBCs:plasma) transfused in a 1:1 ratio on all-cause mortality at 24 hours (RR 1.13, 95% CI 0.37 to 3.49) or 30 days (RR 1.62, 95% CI 0.69 to 3.80) (1 study, 107 participants; very low certainty evidence). Comparison 4: Goal-directed blood transfusion strategy of viscoelastic haemostatic assay (VHA) versus conventional laboratory coagulation tests (CCT) to guide haemostatic therapy There may be little or no difference in all-cause mortality at 24 hours between VHA and CCT (RR 0.85, 95% CI 0.54 to 1.35; 1 study, 396 participants; low-certainty evidence). We are uncertain of the effects on all-cause mortality at 30 days (RR 0.75, 95% CI 0.48 to 1.17; 2 studies, 506 participants; very low certainty evidence). There is probably no difference between VHA and CCT in total thromboembolic events at 30 days (RR 0.65, 95% CI 0.35 to 1.18; 1 study 396 participants; moderate-certainty evidence).

AUTHORS' CONCLUSIONS

Overall, there was little to no evidence of a difference between blood transfusion strategies for mortality or thromboembolic events. The studies covered a wide range of interventions, and the comparators and standard of care practice varied between trials, thereby limiting the pooling of data. Further research is needed.

Trauma Pneumonectomy: Has Survival Improved Over Two Decades?

IntroductionThe hypothesis of this study is that recent advances in mechanical cardiopulmonary support and operative management have improved survival in patients requiring a trauma pneumonectomy.MethodsRetrospective, single center study from January 2003 to December 2023 of all patients who underwent a pneumonectomy for trauma. Data collected included demographics, admission physiology, use of venovenous extracorporeal membrane oxygenation (VV-ECMO), and mortality, defined as early (within 24 hours of surgery) and late (>24 hours after surgery). Outcomes were compared between decades, the first decade (2003-2010) and second decade (2011-2023).ResultsTwenty patients met inclusion criteria, 9 in the first decade and 11 in the second decade. There were no differences in Injury Severity Score (ISS) (26.4 vs 34.3, P = 0.23). However, those in the second decade had significantly lower mean admission pH (6.89 vs 7.14, P = 0.01) and higher admission base deficit (19.3 vs 9.8, P = 0.003). The use of thoracic damage control surgery increased from 33% in the first decade to 100% in the second decade (P = 0.002). VV-ECMO with lung rest ventilation increased from 22% to 64% (P = 0.06). Overall and early mortality did not change (55.6% vs 45.5%, p-0.65 and 11% vs 36.3%, P = 0.09, respectively). However, late mortality was dramatically lower in the second decade compared to the first (9% vs 50%, P = 0.06).ConclusionEarly mortality remains high; however, the combination of thoracic damage control and early initiation of VV-ECMO may contribute to the dramatic decrease in late mortality in the second decade.

Understanding metabolic remodeling in shock through metabolomics lenses

The management of shock in critical care must transition from a predominantly hemodynamic approach to one that comprehensively addresses the biological intricacies of this complex multisystemic syndrome. A thorough understanding of the metabolic mechanisms involved in shock is pivotal for precise patient phenotyping and accurate risk stratification. Metabolomics, an emerging "-omics" approach, offers a powerful tool for unraveling the molecular underpinnings of shock. By analyzing the metabolic pathways within the cardiovascular system, metabolomics can elucidate the diverse mechanisms leading to circulatory insufficiency. This approach holds significant promise for identifying clinically actionable diagnostic and prognostic biomarkers, which can enhance individualized patient management and potentially prevent the progression to multi-organ failure. Improved insight into the metabolic alterations in shock may pave the way for novel therapeutic strategies and more targeted treatments, ultimately improving patient outcomes in critical care settings. This work provides a comprehensive overview of metabolomic investigations in shock, focusing on septic shock and the main metabolic pathways involved in cardiac and vascular dysfunction.

[Explanation and interpretation of blood transfusion provisions for critically ill and severely bleeding pediatric patients in the national health standard "Guideline for pediatric transfusion"]

To guide clinical blood transfusion practices for pediatric patients, the National Health Commission has issued the health standard "Guideline for pediatric transfusion" (WS/T 795-2022). Critically ill children often present with anemia and have a higher demand for transfusions compared to other pediatric patients. This guideline provides guidance and recommendations for blood transfusions in cases of general critical illness, septic shock, acute brain injury, extracorporeal membrane oxygenation, non-life-threatening bleeding, and hemorrhagic shock. This article interprets the background and evidence of the blood transfusion provisions for critically ill and severely bleeding children in the "Guideline for pediatric transfusion", aiming to enhance understanding and implementation of this aspect of the guidelines. Citation:Chinese Journal of Contemporary Pediatrics, 2025, 27(4): 395-403.

Prehospital whole blood use in civilian trauma care: A review of current evidence and practices

ABSTRACT

The use of whole blood (WB) as an adjunct to component therapy has gained popularity for the resuscitation of civilian trauma patients in the last decade. Additionally, it has been shown that earlier transfusion of WB is associated with improved early and late mortality. Despite the proven association of improved outcomes with the emergency transfusion of WB, the role of prehospital whole blood in the resuscitation of hemorrhaging trauma patients remains uncertain because of conflicting results in previous studies. This article will review the existing literature on the use of WB in prehospital settings and the rationale behind its potential advantages among hemorrhaging trauma patients.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level V.

Hemofiltration system for the post traumatic treatment of hyperkalemia in austere conditions

BACKGROUND

Hyperkalemia, the buildup of serum potassium to levels >6 mEq L-1, has been a recognized complication of combat injuries such as acute kidney injury since World War II. Currently, renal replacement therapy (RRT) serves as the standard of care for hyperkalemic patients who fail to respond to medical management. However, RRT is difficult to administer in combat settings, and the time between evacuation and RRT is critical in preventing post-traumatic hyperkalemia. Therefore, the need for portable, easily operable hemofiltration technology is pressing to improve the survival of hyperkalemic patients in austere settings.

METHODS

In this manuscript, we present extra-corporeal direct contact and hemodialysis filtration systems for treating severe hyperkalemia and tested the efficacy, biocompatibility, and performance of a zeolite-based renal RRT. We tested the uptake capacity of an adsorbent zeolite optimized for the selective binding and removal of potassium in various mediums, including dialysate, bovine serum, and whole bovine sodium heparinized blood.

RESULTS AND CONCLUSIONS

Our results show that we can restore physiological normokalemic levels within just 2 h of testing and maintain these levels for 6 h. Furthermore, calcium and sodium levels were maintained within normal physiological ranges, confirming the selectivity of our sorbent material for potassium binding.

Don't break the bank: Description of survivors in high-volume transfusion and utility of transfusion in trauma

INTRODUCTION

In response to blood shortages, providers face pressure to conserve blood. No metrics exist to calculate transfusion utility. We describe characteristics of survivors after high-volume resuscitation and evaluate transfusion utility in low-volume and high-volume resuscitation.

METHODS

A retrospective analysis of 2019 American College of Surgeons Trauma Quality Improvement Program was performed on trauma patients ≥16 years old receiving transfusion within 4 hours of arrival. Patients excluded if they died in the emergency department, were dead on arrival, received <2 units of packed red blood cells, did not receive fresh-frozen plasma, or were missing data. High-volume survivors received more blood than 95% of the surviving population (≥17 U of packed red blood cells). High-volume mortality patients received ≥17 U of packed red blood cells and did not survive to discharge. Characteristics of high-volume survivors were identified by multivariable logistic regression. Utility of transfusion was compared between low-volume (<17 U of packed red blood cells) and high-volume (≥17 U of packed red blood cells) groups by totaling U transfused to yield 1 survivor.

RESULTS

In total, 17,407 patients met study criteria, 12,585 (72%) survived. A total of 5.3% (663/12,585) of survivors were high-volume survivors. In total, 23% (1,112/4,823) of mortalities received ≥17 U of packed red blood cells. Low-volume survivors received a greater proportion of product than high-volume survivors (71% vs 34%, P < .001). Low-volume transfusions better used the blood supply (12.6 vs 130.8 U per survivor, P < .001).

CONCLUSION

High-volume resuscitation yields few survivors and strains the blood supply. Standardized assessment protocols should identify patients with a favorable survival profile to guide allocation. Units transfused per survivor can be used to monitor the effect that blood-conservation protocols have on transfusion utility.

Emulating Target Trials to Study Perioperative and Critical Care Interventions with Observational Data: Promise and Limitations

Estimating effects of interventions is a central task in perioperative and critical care outcomes research. While randomized trials remain the accepted standard for causal inference, trial data are not always available to inform clinical decisions, and some questions cannot be answered feasibly or efficiently with trials. In these settings, studies using observational healthcare data may be used to inform practice. Causal inference from observational data has been reconsidered in recent years, challenging the prevailing notion among clinical researchers that causal conclusions cannot be drawn from observational studies. The "target trial framework" is one contribution within a growing methodologic field that helps investigators avoid common pitfalls in observational study design and analysis. Importantly, researchers must understand which biases this framework can-and cannot-help avoid. The authors present an overview of target trial emulation and describe the promise and limitations of this framework for improving observational perioperative and critical care outcomes research.

Anesthetic Considerations for Pediatric Patients with Craniofacial Anomalies: An Overview of Key Elements

This article reviews the key elements of anesthesia care for patients presenting for craniofacial surgeries, including preoperative evaluation and preparation, intraoperative management, and pain management strategies.

Prehospital Trauma Compendium: Transfusion of Blood Products in Trauma - A Position Statement and Resource Document of NAEMSP

Hemorrhagic shock remains the leading cause of potentially preventable death among injured patients with life-threatening bleeding. Prehospital resuscitation has been evolving with increasing use of blood product resuscitation. The impact of blood administration on patient outcomes remains poorly defined with significant heterogeneity in the quality of literature supporting prehospital blood product resuscitation after trauma. We completed a structured search of the literature using a rapid review framework based on three distinct PICO questions to develop systematic and consensus recommendations.

The National Association of Emergency Medical Services Physicians (NAEMSP) recommends, in EMS agencies/systems that can support a high-quality prehospital blood transfusion program:Use of blood components over crystalloids for the first-line treatment of patients with traumatic life-threatening bleeding in the prehospital phase of resuscitationUse of low titer group O whole blood (LTOWB) as the first-choice blood product for treatment of patients with traumatic life-threatening bleeding in the prehospital phase of resuscitationUse of a combination or composite of prehospital transfusion indications, focused on physiologic abnormalities and/or injury patterns with obvious significant blood loss.Use of active monitoring for transfusion-related adverse events.Developing a mechanism to recycle unused blood product units nearing their expiration date to a high-use hospital facility to minimize wastage.Engaging in a comprehensive longitudinal active collaboration between EMS agencies, trauma centers, and blood suppliers to ensure the success of a prehospital transfusion program.

Blood Product Utilization in Thromboelastography-Aided Transfusion in Gastrointestinal Bleeding: A Single-Center Experience

Background

Gastrointestinal bleeding (GIB) is a common cause for intensive care unit (ICU) admissions and is associated with high mortality rates. Effective resuscitation is essential prior to definitive procedural intervention. Thromboelastography (TEG) assesses patients' dynamic coagulation profiles and has been shown to reduce blood product usage and mortality in specific patient populations; however, its role in the management of GIB remains controversial.

Methods

We performed a retrospective study of patients who had TEG performed during resuscitation of GIB in the ICU between January 1, 2017 and December 31, 2020 at a single center. Patients were identified through ICD-10 codes and blood bank's database.

Results

A cohort of 244 patients was identified, of which 18 were excluded. The cohort was mainly represented by White (72%, n = 162) males (65%, n = 147) with a mean age of 61 (standard deviation (SD) 14) years. Alcoholic liver disease (31%, n = 69) and esophageal varices (30%, n = 65) were the most common comorbidities. Mean nadir systolic blood pressure was 75 (SD 18) mm Hg. Mean nadir hemoglobin concentration was 6.5 (SD 1.7) g/dL. Patients received a median of 5 packed red blood cells (pRBC) (interquartile range (IQR) 5.8), 1 fresh frozen plasma (FFP) (IQR 2), and 0 platelets and cryoprecipitate units (IQR 1 and 0, respectively). The median ICU length of stay was 3 (IQR 3) days. The observed mortality rate was 39% (n = 88).

Conclusion

Although TEG may help reduce unnecessary blood product transfusions, its overall clinical benefit remains uncertain given the high mortality observed among patients with hemorrhagic shock secondary to GIB. Further studies are warranted to better evaluate the efficacy and clinical utility of TEG-guided transfusion strategies in this patient population.

Impact of Massive Transfusion Activation on Time to Delivery of the First Cooler and Patient Survival: A Study of 4,313 Consecutive Activations

BACKGROUND

In 2012, TQIP guidelines for massive transfusion protocols (MTPs) recommended delivery of blood product coolers within 15 minutes. Subsequent work found that every minute delay in cooler arrival was associated with a 5% increased risk of mortality. We sought to assess the impact and sustainability of quality improvement (QI) interventions on time to MTP cooler delivery and their association with trauma patient survival.

STUDY DESIGN

In 2009, a QI process was initiated to improve MTP activation and delivery of blood (QI 1). In 2012, TQIP Best Practice Guidelines were implemented at our facility (QI 2). In 2016, we implemented measures to activate our MTP based off prehospital Assessment of Blood Consumption score higher than 1 or any prehospital blood transfusion (QI 3). All patients receiving MTP from January 2009 and December 2022 were included. Patients were compared by year and their respective QI interventions. Primary outcome was time from MTP activation to delivery of the first cooler. A regression model was then constructed to evaluate time to the first cooler on outcomes.

RESULTS

During the study period, 52,328 trauma patients were admitted, with 4,313 MTP trauma activations. With each subsequent QI intervention, time to first MTP cooler and mortality both decreased, whereas injury severity increased. Multivariate regression noted that when the time to first cooler could be kept to 8 minutes or less, mortality was reduced by 35% (odds ratio 0.64, 95% CI 0.44 to 0.92; p = 0.019).

CONCLUSIONS

With increased MTP activations, delivery of the first cooler was faster and mortality improved. Keeping cooler times under 8 minutes was associated with increased survival. The measurement and monitoring of "door-to-cooler" time should be considered as a metric to assess performance and delivery of institutional MTP.

Individualized and targeted coagulation management in bleeding trauma patients

PURPOSE OF REVIEW

This review aims to summarize current evidence on hemostatic management of bleeding trauma patients, with a focus on resuscitation strategies using either coagulation factor concentrates or fixed-ratio transfusion concepts. It discusses the potential benefits and limitations of both approaches.

RECENT FINDINGS

Recent studies have shown that coagulopathy caused by massive traumatic hemorrhage often cannot be reversed by empiric treatment. During initial resuscitation, a fixed-ratio transfusion approach uses the allogeneic blood products red blood cells, plasma, and platelets to mimic 'reconstituted whole blood'. However, this one-size-fits-all strategy risks both overtransfusion and undertransfusion in trauma patients.Many European trauma centers have shifted toward individualized hemostatic therapy based on point-of-care diagnostics, particularly using viscoelastic tests. These tests provide rapid insight into the patient's hemostatic deficiencies, enabling a more targeted and personalized treatment approach.

SUMMARY

Individualized, goal-directed hemostatic management offers several advantages over fixed-ratio transfusion therapy for trauma patients. However, there is a paucity of data regarding the direct comparison of these two approaches.

Assessing the need for blood transfusion in patients with haemorrhage transported by air ambulance in Northern Ontario

INTRODUCTION

Haemorrhage is the leading preventable cause of death following traumatic injury, additionally affecting morbidity and mortality in a variety of other conditions. Timely intervention with blood products and definitive management is essential. In Northern Ontario, limited access to care poses challenges in managing these conditions. The objective of our study was to describe the prevalence with which patients suffering from known or suspected haemorrhage, transported by air ambulance in Northern Ontario, received a blood transfusion.

METHODS

This was a retrospective cohort study of patients in Northern Ontario with known or suspected haemorrhage, transported by air ambulance to hospital. Patients included had a primary problem of trauma, gastrointestinal (GI) bleeding, obstetrical haemorrhage or vascular and other bleeding, and met pre-defined physiologic indications for transfusion. Data were abstracted from electronic patient care records.

RESULTS

A total of 1165 patients were included, with a mean age of 48.5 years and 54.8% being male. The most common reasons for transfusion included traumatic injury (46.1%), GI bleeding (29.5%) and vascular/other etiologies (13.8%). Only 233 (20%) patients received a transfusion. Patients with GI haemorrhage most frequently received transfusion, accounting for 46.8% of patients, while those suffering from traumatic injury accounted for 28.7% of the total transfusions.

CONCLUSIONS

Eighty percent of patients who may have required a transfusion did not receive one, illustrating the importance of expanded access to blood products in rural and remote communities across Ontario. Further investigation into mechanisms that support residents of these communities who may suffer from haemorrhage is required.

INTRODUCTION

L'hémorragie est la principale cause évitable de décès à la suite d'une blessure traumatique. Elle affecte également la morbidité et la mortalité dans une variété d'autres conditions. Une intervention rapide avec des produits sanguins et une prise en charge définitive sont essentielles. Dans le nord de l'Ontario, l'accès limité aux soins pose des problèmes pour la prise en charge de ces pathologies. L'objectif de notre étude était de décrire la fréquence avec laquelle les patients souffrant d'une hémorragie connue ou présumée, transportés par ambulance aérienne dans le nord de l'Ontario, ont reçu une transfusion sanguine.

MTHODES

Il s'agit d'une étude de cohorte rétrospective de patients du nord de l'Ontario présentant une hémorragie connue ou présumée, transportés par ambulance aérienne à l'hôpital. Les patients inclus avaient un problème primaire de traumatisme, d'hémorragie gastro-intestinale, d'hémorragie obstétricale, d'hémorragie vasculaire ou d'autres formes d'hémorragies et répondaient à des indications physiologiques prédéfinies pour la transfusion. Les données ont été extraites des dossiers électroniques des patients.

RSULTATS

Au total, 1165 patients ont été inclus, avec un âge moyen de 48.5 ans et 54,8% d'hommes. Les raisons les plus fréquentes de la transfusion étaient des lésions traumatiques (46,1%), des hémorragies gastro-intestinales (29,5%) et des étiologies vasculaires/autres (13,8%). Seuls 233 patients (20%) ont reçu une transfusion. Les patients souffrant d'hémorragie gastro-intestinale ont le plus souvent reçu une transfusion, soit 46,8% des patients, tandis que ceux souffrant de lésions traumatiques représentaient 28,7% du total des transfusions.

CONCLUSIONS

80% des patients susceptibles d'avoir besoin d'une transfusion sanguine n'en ont pas reçu, ce qui illustre l'importance d'un accès élargi aux produits sanguins pour les patients des communautés rurales et éloignées de l'Ontario. Il est nécessaire de poursuivre les recherches sur les mécanismes qui soutiennent les résidents de ces communautés susceptibles de souffrir d'une hémorragie.

Prehospital Blood Administration in Traumatic Hemorrhagic Shock

Following the military's advancement of prehospital blood into the field, civilian prehospital blood programs are becoming more prevalent. However, there are significant differences between civilian and military prehospital operations that should be considered. Civilian prehospital systems also vary widely in terms of resources, transport times, and patient types. Given these variations and the logistical challenges associated with establishing a prehospital blood program, careful consideration of the state of the science is warranted. Although blood is the preferred fluid for patients in hemorrhagic shock, there have only been a few high-quality studies that have examined the efficacy of administering blood in the prehospital setting. Given the conflicting results of these studies, individual medical directors must determine whether the risk-benefit analysis for their system warrants establishing such a resource-intensive operation. Efforts to establish a prehospital blood program should not supersede attempts to optimize the fundamental components of trauma operations and management.

A full response chain surge capacity test of a small rural hospital, prehospital resources and collaborating organisations

BACKGROUND

Increased surge capacity is key in mass casualty incidents. Rural hospitals face other challenges in terms of transport capacity and available resources. The aim was to examine if a simulation system previously used to test surge capacity at large hospitals, could be used to test surge capacity at a small rural hospital.

METHOD

A qualitative study was conducted to assess surge capacity at a small rural hospital using a previously validated simulation system. The simulation system was adopted to the Norwegian trauma system and local context. New simulated patient cards were developed, inspired by traffic victims. A tunnel accident scenario involving a bus, a heavy goods vehicle and a motorcyclist was used. Test staff ensured that real consumption of time and resources were followed. 98 persons representing 16 organisations, participated. A post-test survey was collected.

RESULTS

Access to the scene and transport resources were bottlenecks in the initial phase. The emergency department and lack of surgeons and anaesthetic doctors in the trauma team became the first and most prominent in-hospital surge capacity limiting factors. Operating theatre reached surge capacity, but never exceeded. The intensive care unit avoided depletion of beds/staff/ventilators due to transfer of patients to the trauma centre. Surge capacity was enhanced by obtaining staff, blood and equipment from the trauma centre. Water lock systems and replenishment routines for chest tube trays was inadequate. Blood supply was insufficient in the initial phase and a lack of overview of blood products was identified. Some communication gaps and deficiencies in victim identification were detected. The hospital participants evaluated the method as useful in assessing hospital surge capacity. Half of the participants requested increased time to learn the system pre-test. The inclusion of several organisations in the mass casualty incident exercise was appreciated and ranked high as a simulation training.

CONCLUSION

The simulation system provided detailed data to determine surge capacity and capacity-limiting factors in the mass casualty incidents response at a rural hospital and performed as a training tool for staff. Methods to improve pre-test simulation system knowledge should be examined. Broad inclusion of cooperating organisations was found beneficial.

Rethinking Balanced Resuscitation in Trauma

Hemorrhagic shock from traumatic injury results in a massive systemic response with activation of the hypothalamic-pituitary-adrenal (HPA) axis, pro-thrombotic and clot-lysis pathways as well as development of an endotheliopathy. With ongoing hemorrhage, these responses become dysregulated and are associated with worsening coagulopathy, microvascular dysfunction, and increased transfusion requirements. Our transfusion practices as well as our understanding of the molecular response to hemorrhage have undergone significant advancement during war. Currently, resuscitation practices address the benefit of the early recognition and management of acute coagulopathy and advocates for balanced resuscitation with either whole blood or a 1:1 ratio of packed red blood cells to fresh frozen plasma (respectively). However, a significant volume of evidence in the last two decades has recognized the importance of the early modulation of traumatic endotheliopathy and the HPA axis via the early administration of plasma, whole blood, and adjunctive treatments such as tranexamic acid (TXA) and calcium. This evidence compels us to rethink our understanding of 'balanced resuscitation' and begin creating a more structured practice to address additional competing priorities beyond coagulopathy. The following manuscript reviews the benefits of addressing the additional interrelated physiologic responses to hemorrhage and seeks to expand beyond our understanding of 'balanced resuscitation'.

Initial management of patients with burns and combined injuries for acute care surgeons: What you need to know

ABSTRACT

There are nearly 700,000 adults and children with burn injuries who seek care in America each year. While most patients with major burn injuries are cared for at American Burn Association-verified burn centers, many of them present to nonburn centers initially or present with combined burns and other injuries. Despite this, burn surgery is no longer mandated by the Accreditation Council for Graduate Medical Education for general surgery residency and is rarely a meaningful component of surgical critical care fellowships. However, general surgeons are called to participate in and, occasionally, lead the care of adults and children with burn injuries when burn expertise is not available, for patients with combined burns and other injuries, when procedures are required, in intensive care units, and/or during multiple casualty incidents and disasters. Fundamental burn care knowledge and skills deployed during these moments can radically impact patients' chances of survival and future quality of life. This clinical review covers burn-specific aspects of the primary survey and follows the ABCDE approach. Additional details about core burn care principles (e.g., inhalation injury, resuscitation, wound care) and special considerations in combined burns and other injuries are also presented (e.g., burns with concomitant abdominal, thoracic, skeletal, and/or intracranial injury(ies)).

LEVEL OF EVIDENCE

Expert Opinion; Level V.

A comprehensive review of massive transfusion and major hemorrhage protocols: origins, core principles and practical implementation

Until the beginning of the century, bleeding management was similar in elective surgeries or exsanguination scenarios: clotting tests were used to guide blood product orders and, while awaiting these results, an aggressive resuscitation with crystalloids was recommended. The high mortality rate in severe hemorrhages managed with this strategy endorsed the need for a special resuscitation plan. As a result, modifications were recommended to develop a new clinical approach to these patients, called "Damage Control Resuscitation". This strategy includes four principles: damage control surgery, minimization of crystalloids, permissive hypotension and hemostatic resuscitation. The latter involves the use of antifibrinolytics, correction of preconditions of hemostasis (calcium, pH and temperature) and the early and rapid restoration of intravascular volume with blood products. To enable timely availability and transfusion of blood products, specific actions in different hospital areas need to be synchronized, which are usually organized through Massive Transfusion Protocols or, as they have recently been rebranded, Major Hemorrhage Protocols (MHPs). Although these bundles of actions represent a paradigm change, essential aspects such as their historical evolution, theoretical foundations, terminology and operational elements have yet to be well explored. Considering the wide application range of these tools (emergency departments, interventional radiology, operating rooms and military fields), it is essential to integrate all professionals involved with severe hemorrhage scenarios in the implementation of the aforementioned protocols, from conception to execution and management. This review paper addresses MHP aspects relevant to anesthesiologists, transfusion services and other areas involved with the care of patients with severe bleeding.

Whole Blood Requirements in Civilian Trauma Resuscitation: Implications for Blood Inventory Program

INTRODUCTION

It is unclear what volume of whole blood (WB) a center may need to maintain an adequate inventory. This study aimed to determine the current WB requirements, using the military concept of WB equivalent (WBE), across different levels of trauma centers.

METHODS

This is a retrospective analysis of the American College of Surgeons Trauma Quality Improvement Program database (2017-2018), including adult (≥16 ys) trauma patients who received massive transfusions. The primary outcome was WBE, which was calculated for each patient as units of WB plus equivalent component product units (1 red blood cell + 1 fresh frozen plasma + 0.2 platelet).

RESULTS

A total of 9976 patients were identified. The mean (standard deviation) age was 41 (18), and 77.8% were male. The mean initial shock index was 1.2 (1.1), with the mean (standard deviation) systolic blood pressure of 104 (40) during resuscitation in the emergency department. The median (interquartile range) 24-h packed red blood cell, fresh frozen plasma, platelet, and WB were 12 (8-17), 8 (5-13), 2 (1-3), and 2 (1-3), respectively. The median 24-h WBE transfusion was 10 units, 75% of patients required 14 units or less, and 90% required 17 units or less. There was no difference in terms of median WBE transfusions across different levels of trauma centers (Level I: 10U, Level II: 10U, Level III and lower: 10U, P = 0.126).

CONCLUSIONS

On a nationwide scale, 75% of patients with massive transfusions received a maximum of 14 WBE units. These findings provide important insights to trauma centers on the volume of WB required to maintain adequate WB inventory to effectively support the successful implementation of future WB programs.

Early achievement of hemostasis defined by transfusion velocity: A possible mechanism for whole blood survival benefit

INTRODUCTION

Whole blood resuscitation is associated with survival benefits in observational cohort studies. The mechanisms responsible for outcome benefits have not been adequately determined. We sought to characterize the achievement of hemostasis across patients receiving early whole blood versus component resuscitation. We hypothesized that achieving hemostasis would be associated with outcome benefits and patients receiving whole blood would be more likely to achieve hemostasis.

METHODS

We performed a post hoc retrospective secondary analysis of data from a recent prospective observational cohort study comparing early whole blood and component resuscitation in patients at risk of hemorrhagic shock. Achievement of hemostasis was defined by receiving a single unit of blood or less, including whole blood or red cells, in any 60-minute period, over the first 4 hours from the time of arrival. Time-to-event analysis with log-rank comparison and regression modeling were used to determine the independent benefits of achieving hemostasis and whether achieving hemostasis was associated with whole blood resuscitation.

RESULTS

For the current analysis, 1,047 patients met the inclusion criteria for the study. When we compared patients who achieved hemostasis versus those who did not, achievement of hemostasis had significantly more hemostatic coagulation parameters, had lower transfusion requirements, and was independently associated with 4-hour, 24-hour and 28-day survival. Whole blood patients were significantly more likely to achieve hemostasis (88.9% vs. 81.1%, p < 0.001). Whole blood patients achieved hemostasis earlier (log-rank χ 2 = 8.2, p < 0.01) and were independently associated with over twofold greater odds of achieving hemostasis (odds ratio, 2.4; 95% confidence interval, 1.6-3.7; p < 0.001).

CONCLUSION

Achievement of hemostasis is associated with significant outcome benefits. Early whole blood resuscitation is associated with a greater independent odds of achieving hemostasis and at an earlier time point. Reaching a nadir transfusion rate early following injury represents a possible mechanism of whole blood resuscitation and its attributable outcome benefits.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level III.

Effective utilisation of rapid infusion catheters in perioperative care: a narrative review

The Rapid Infusion Catheter (RIC) has transformed intravenous (i.v.) access, allowing for rapid fluid delivery peripherally. It may negate the need for a central vein sheath to be placed. This review explores the clinical utility of RICs while addressing technical considerations and potential risks. The RIC is a large-bore i. v. sheath available in two sizes. Its maximal flow rate is 1200 ml min-1, making it advantageous in significant blood loss scenarios such as trauma and major surgeries. Insertion involves the Seldinger technique. Monitoring and maintaining the RIC is crucial to detect and address immediate complications such as occlusions, infiltration, phlebitis, and extravasation of infusate. Although the related complications share similarities with those of other peripheral i. v. cannulae, they have a lower risk of occlusion and accidental displacement. Catheter removal should be considered once the patient is stable or alternative access is available to avoid infectious complications. Removal of the RIC needs to be performed by those educated in RIC management. Maximal flow rate is an essential factor in assessing the performance of i. v. cannulae, and studies have shown that RICs outperform other peripheral and central catheters in this regard. In conclusion, RIC offers advantages over large-bore central venous access for large-volume rapid infusions, including ease of insertion and reduced severe complications. The RIC demonstrates lower thrombosis rates and a different complication profile than peripherally inserted central catheters. Understanding the characteristics and applications of RICs can help healthcare professionals make informed decisions about their use in various medical scenarios.

DOES WHOLE BLOOD RESUSCITATION INCREASE RISK FOR VENOUS THROMBOEMBOLISM IN TRAUMA PATIENTS? A COMPARISON OF WHOLE BLOOD VERSUS COMPONENT THERAPY IN 3,468 PATIENTS

ABSTRACT

Background: Whole blood (WB) resuscitation has been shown to provide mortality benefit. However, the impact of whole blood transfusions on the risk of venous thromboembolism (VTE) remains unclear. We sought to compare the VTE risk in patients resuscitated with WB versus component therapy (COMP). Methods: Trauma patients aged 18 and older, admitted to two Level 1 trauma centers between 2016 and 2021, who received at least one unit of emergency-release blood products were identified. Clinical and transfusion data were collected. Patients that received any WB during resuscitation were compared to those who received only COMP therapy. The primary outcome was VTE incidence, defined as deep vein thrombosis and/or pulmonary embolism. Results: 3,468 patients met inclusion criteria (WB: 1,775, COMP: 1,693). WB patients were more likely to be male (82 vs. 68%), receive tranexamic acid (21 vs. 16%), and had higher Injury Severity Score (26 vs. 19; all P < 0.001). WB patients exhibited less hospital-free days (11 vs. 15), intensive care unit-free days (23 vs. 25), and 30-day survival (74 vs. 84; all P < 0.001). The WB group had lower VTE incidence (6 vs. 10%, P < 0.001). Logistic regression revealed WB was protective against VTE (OR 0.70, 95% CI 0.54-091, P = 0.009), while red blood cell transfusions and tranexamic acid (TXA) exposure increased VTE risk. Discussion: Using WB as part of resuscitation was associated with a 30% reduction in VTE, while TXA and red blood cell transfusion increased VTE risk. Further research is needed to evaluate VTE risk with empiric use of TXA in the setting of early WB transfusion capability.