Evaluation of blood product transfusion therapies in acute injury care in low- and middle-income countries: a systematic review

Crystalloid resuscitation is associated with decreased treatment delays and improved systolic blood pressures in a blood-constrained setting

Objectives

We analyzed resuscitation practices in Cameroonian patients with trauma as a first step toward developing a context-appropriate resuscitation protocol. We hypothesized that more patients would receive crystalloid-based (CB) resuscitation with a faster time to administration than blood product (BL) resuscitation.

Methods

We included patients enrolled between 2017 and 2019 in the Cameroon Trauma Registry (CTR). Patients presenting with hemorrhagic shock (systolic blood pressure (SBP) <100 mm Hg and active bleeding) were categorized as receiving CB, BL, or no resuscitation (NR). We evaluated differences between cohorts with the Kruskal-Wallis test for continuous variables and Fisher's exact test for categorical variables. We compared time to treatment with the Wilcoxon rank sum test.

Results

Of 9635 patients, 403 (4%) presented with hemorrhagic shock. Of these, 278 (69%) patients received CB, 39 (10%) received BL, and 86 (21%) received NR. BL patients presented with greater injury severity (Highest Estimated Abbreviated Injury Scale (HEAIS) 4 BL vs 3 CB vs 1 NR, p<0.001), and lower median hemoglobin (8.0 g/dL BL, 11.4 g/dL CB, 10.6 g/dL NR, p<0.001). CB showed greater initial improvement in SBP (12 mm Hg CB vs 9 mm Hg BL vs 0 NR mm Hg, p=0.04) compared with BL or no resuscitation, respectively. Median time to treatment was lower for CB than BL (12 vs 131 min, p<0.01). Multivariate logistic regression adjusted for injury severity found no association between resuscitation type and mortality (CB adjusted OR (aOR) 1.28, p=0.82; BL aOR 1.05, p=0.97).

Conclusions

CB was associated with faster treatment, greater SBP elevation, and similar survival compared with BL in Cameroonian patients with trauma with hemorrhagic shock. In blood-constrained settings, treatment delays associated with blood product transfusion may offset the physiologic benefits of an early BL strategy. CB prior to definitive hemorrhage control in this resource-limited setting may be a necessary strategy to optimize perfusion pressure.

Level of evidence and study type

III, retrospective study.

A Cross-sectional Study of Self-Perceived Educational Needs of Emergency Nurses in Two Tertiary Hospitals in Nairobi, Kenya

BACKGROUND

Many low- and middle-income countries lack resources for well-functioning emergency care systems. Emergency nurses interact with injured and critically ill patients as the first contact in many health care settings. However, insufficient training limits nurses from providing ideal emergency care. The purpose of this research was to highlight educational needs specific to nurses working in 2 emergency departments in Nairobi, Kenya.

METHODS

A descriptive cross-sectional study involving emergency units of 2 of the largest referral and teaching hospitals (Aga Khan University Hospital, Nairobi, and Kenyatta National Hospital) in Nairobi, Kenya, was conducted. Data were collected by using an adapted structured, self-administered questionnaire. The data were analyzed using descriptive statistics. The skills and competencies of the participants were assessed. In addition, the educational gaps and needs of the participants around emergency care such as trauma, cardiovascular diseases, and respiratory and neurological illnesses were described. Results were presented in frequencies and percentages.

RESULTS

The questionnaire response rate was 63.6% (n = 84). Most of the respondents held associate degrees in nursing (72.6%), whereas 19% had a bachelor's degree in nursing. Most respondents (84.5%) perceived themselves as being highly competent in basic skills such as performing cardiopulmonary resuscitation and assessment of body systems. Less than half of the respondents (48.8%) perceived themselves as being highly competent in intermediate skills such as assisting with endotracheal intubation. In advanced competencies, such as analyzing electrocardiograms and administering thrombolytic medications, only 16.7% perceived themselves as highly competent.

CONCLUSION

The results of this study suggest there is a knowledge gap and educational needs among emergency nurses in Nairobi, Kenya. It identified injuries/trauma; cardiovascular, respiratory, and neurological disease; and other emergencies as topics of focus areas with a high need. To address these knowledge and skills needs, a future specialty training in emergency nursing is recommended and this could be achieved through continuing professional development and short courses or postgraduate-level training.

Autotransfusion in low-resource settings: a scoping review

INTRODUCTION

Globally, haemorrhage is the leading cause of both maternal mortality and preventable trauma death. For patients suffering from haemorrhage, prompt blood transfusion can be life-saving; however, safe and sufficient blood is often lacking in low-resource settings (LRS). Autotransfusion (AT), in which the patient's own blood is collected and transfused back, is an established alternative to donor blood transfusions, although one that is primarily performed with advanced AT systems. Research on basic AT in LRS is scarce. Therefore, we aimed to consolidate all available information on the current use of basic AT in LRS and to identify AT techniques and devices described for use in such settings.

DESIGN

Scoping review.

METHODS

We systematically searched four key databases: PubMed, Web of Science, Global Health and Cochrane Library as well as several grey literature databases and databases of relevant organisations. The final search was conducted on 22 April 2019. We included all types of studies referring to any information on basic AT used or sought to be used in LRS, published in English and dated after 31 December 2008. We synthesised the data from the included studies, results were charted or summarised narratively.

RESULTS

Some 370 records were reviewed, yielding 38 included documents. We found a paucity of scientific evidence as well as contradictory information on the extent of AT use and that AT use is largely undocumented. The most commonly described indications were haemoperitoneum (primarily among obstetric patients) and haemothorax. We identified three AT techniques used in LRS. Additionally, two new devices and one filter are described for potential use in LRS.

CONCLUSIONS

Basic AT is practiced for certain obstetric and trauma indications. However, context-specific studies are needed to determine the technique's safety and effectiveness. Extent of use is difficult to assess, but our results indicate that basic AT is not a widely established practice in LRS. Future research should address the bottlenecks hampering basic AT availability. New AT devices for use in LRS are described, but their utility and cost-effectiveness remain to be assessed.

Supply, Demand, and Quality: A Three-Pronged Approach to Blood Product Management in Developing Countries

While transfusion of blood and blood products is instinctively linked to the provision of emergent care, blood and blood products are also routinely used for the treatment of subacute and chronic conditions. Despite the efforts of the World Health Organization and others, developing countries are faced with a three-part problem when it comes to access to and delivery of transfusions: insufficient supply, excessive demand, and inadequate quality of available supply. Developing countries rely heavily on replacement and remunerated donors rather than voluntary nonremunerated donors due to concerns regarding donation- and transfusion-transmitted infection as well as local and cultural beliefs. While increased awareness of HIV and improved testing techniques have jointly reduced infection-related apprehensions and improved the quality of available blood and blood products, continued efforts are warranted to bolster testing for other bloodborne pathogens. Similarly, although prevalence rates of anemia are high in some areas of the world, success in adequate widespread management of these conditions has been limited. One of the keys to expanding access to high-quality blood and blood products is thus to improve medical management of conditions that would otherwise require transfusion. Through a three-pronged approach to address quantity, quality, and demand, developing countries can enable themselves to build toward self-sufficient blood management services and increased independence from the support of international organizations.