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Powell E, Keller AP, Galvagno SM. Advanced Critical Care Techniques in the Field. Crit Care Clin 2024; 40:463-480. [PMID: 38796221 DOI: 10.1016/j.ccc.2024.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2024]
Abstract
Critical care principles and techniques continue to hold promise for improving patient outcomes in time-dependent diseases encountered by emergency medical services such as cardiac arrest, acute ischemic stroke, and hemorrhagic shock. In this review, the authors discuss several current and evolving advanced critical care modalities, including extracorporeal cardiopulmonary resuscitation, resuscitative endovascular occlusion of the aorta, prehospital thrombolytics for acute ischemic stroke, and low-titer group O whole blood for trauma patients. Two important critical care monitoring technologies-capnography and ultrasound-are also briefly discussed.
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Affiliation(s)
- Elizabeth Powell
- Program in Trauma, University of Maryland School of Medicine, R Adams Cowley Shock Trauma Center, 22 S Greene Street, Baltimore, MD 21201, USA
| | - Alex P Keller
- Medical Modernization and Plans Division, 162 Dodd Boulevard, Langley Air Force Base, VA 23665, USA
| | - Samuel M Galvagno
- Department of Anesthesiology, University of Maryland School of Medicine, 22 S Greene Street, S11C16, Baltimore, MD 21201, USA.
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2
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McCartin MP, Wool GD, Thomas SA, Panfil M, Schoenfeld D, Blumen IJ, Tataris KL, Thomas SH. Management Considerations for Air Medical Transport Programs Transfusing RhD-Positive Red Blood Cell-Containing Products to Females of Childbearing Potential. Air Med J 2024; 43:348-356. [PMID: 38897700 DOI: 10.1016/j.amj.2024.03.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2023] [Revised: 03/11/2024] [Accepted: 03/21/2024] [Indexed: 06/21/2024]
Abstract
Recent years have seen increased discussion surrounding the benefits of damage control resuscitation, prehospital transfusion (PHT) of blood products, and the use of whole blood over component therapy. Concurrent shortages of blood products with the desire to provide PHT during air medical transport have prompted reconsideration of the traditional approach of administering RhD-negative red cell-containing blood products first-line to females of childbearing potential (FCPs). Given that only 7% of the US population has blood type O negative and 38% has O positive, some programs may be limited to offering RhD-positive blood products to FCPs. Adopting the practice of giving RhD-positive blood products first-line to FCPs extends the benefits of PHT to such patients, but this practice does incur the risk of future hemolytic disease of the fetus and newborn (HDFN). Although the risk of future fetal mortality after an RhD-incompatible transfusion is estimated to be low in the setting of acute hemorrhage, the number of FCPs who are affected by this disease will increase as more air medical transport programs adopt this practice. The process of monitoring and managing HDFN can also be time intensive and costly regardless of the rates of fetal mortality. Air medical transport programs planning on performing PHT of RhD-positive red cell-containing products to FCPs should have a basic understanding of the pathophysiology, prevention, and management of hemolytic disease of the newborn before introducing this practice. Programs should additionally ensure there is a reliable process to notify receiving centers of potentially RhD-incompatible PHT because alloimmunization prophylaxis is time sensitive. Facilities receiving patients who have had PHT must be prepared to identify, counsel, and offer alloimmunization prophylaxis to these patients. This review aims to provide air medical transport professionals with an understanding of the pathophysiology and management of HDFN and provide a template for the early management of FCPs who have received an RhD-positive red cell-containing PHT. This review also covers the initial workup and long-term anticipatory guidance that receiving trauma centers must provide to FCPs who have received RhD-positive red cell-containing PHT.
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Affiliation(s)
| | | | - Sarah A Thomas
- Department of Molecular Microbiology and Immunology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD
| | | | - David Schoenfeld
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA
| | - Ira J Blumen
- Section of Emergency Medicine, University of Chicago, Chicago, IL
| | - Katie L Tataris
- Section of Emergency Medicine, University of Chicago, Chicago, IL
| | - Stephen H Thomas
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA; Blizard Institute for Neuroscience, Surgery, and Trauma, Barts and The London School of Medicine, London, UK
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3
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Nwankiti K. Prehospital transfusion in paediatric trauma can improve patient outcomes: further research and collaboration is needed to increase availability and appropriate application. Evid Based Nurs 2024; 27:96. [PMID: 37940364 DOI: 10.1136/ebnurs-2023-103818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/20/2023] [Indexed: 11/10/2023]
Affiliation(s)
- Kelly Nwankiti
- Tranfusion and Patient Blood Managment, King's College Hospital, London, UK
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Plodr M, Chalusova E. Current trends in the management of out of hospital cardiac arrest (OHCA). Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2024; 168:105-116. [PMID: 38441422 DOI: 10.5507/bp.2024.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Accepted: 02/27/2024] [Indexed: 06/16/2024] Open
Abstract
Sudden cardiac arrest remains a relevant problem with a significant number of deaths worldwide. Although survival rates have more than tripled over the last 20 years (4% in 2001 vs. 14% in 2020), survival rates with good neurological outcomes remain persistently low, representing a major socioeconomic problem. Every minute of delay from patient collapse to start cardiopulmonary resuscitation (CPR) and early defibrillation reduces the chance of survival by approximately 10-12%. Therefore, the time to treatment is a crucial factor in the prognosis of patients with out-of-hospital cardiac arrest (OHCA). Research teams working in the pre-hospital setting are therefore looking for ways to improve the transmission of information from the site of an emergency event and to make it easier for emergency medical dispatch centres (EMDC) to recognise life-threatening conditions with minimal deviation. For emergency unit procedures already at the scene of the event, methods are being sought to efficiently and temporarily replace a non-functioning cardiopulmonary system. In the case of traumatic cardiac arrest (TCA), the focus is mainly on effective affecting non-compressible haemorrhage.
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Affiliation(s)
- Michal Plodr
- Department of Emergency Medicine and Military General Medicine, Military Faculty of Medicine, University of Defence, Hradec Kralove, Czech Republic
- Emergency Medical Services of the Hradec Kralove Region, Hradec Kralove, Czech Republic
| | - Eva Chalusova
- Department of Emergency Medicine and Military General Medicine, Military Faculty of Medicine, University of Defence, Hradec Kralove, Czech Republic
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Apelseth TO, Raza S, Callum J, Ipe T, Blackwood B, Akhtar A, Hess JR, Marks DC, Brown B, Delaney M, Wendel S, Stanworth SJ. A review and analysis of outcomes in randomized clinical trials of plasma transfusion in patients with bleeding or for the prevention of bleeding: The BEST collaborative study. Transfusion 2024; 64:1116-1131. [PMID: 38623793 DOI: 10.1111/trf.17835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 03/26/2024] [Accepted: 03/28/2024] [Indexed: 04/17/2024]
Abstract
BACKGROUND Previous systematic reviews have revealed an inconsistency of outcome definitions as a major barrier in providing evidence-based guidance for the use of plasma transfusion to prevent or treat bleeding. We reviewed and analyzed outcomes in randomized controlled trials (RCTs) to provide a methodology for describing and classifying outcomes. STUDY DESIGN AND METHODS RCTs involving transfusion of plasma published after 2000 were identified from a prior review (Yang 2012) and combined with an updated systematic literature search of multiple databases (July 1, 2011 to January 17, 2023). Inclusion of publications, data extraction, and risk of bias assessments were performed in duplicate. (PROSPERO registration number is: CRD42020158581). RESULTS In total, 5579 citations were identified in the new systematic search and 22 were included. Six additional trials were identified from the previous review, resulting in a total of 28 trials: 23 therapeutic and five prophylactic studies. An increasing number of studies in the setting of major bleeding such as in cardiovascular surgery and trauma were identified. Eighty-seven outcomes were reported with a mean of 11 (min-max. 4-32) per study. There was substantial variation in outcomes used with a preponderance of surrogate measures for clinical effect such as laboratory parameters and blood usage. CONCLUSION There is an expanding literature on plasma transfusion to inform guidelines. However, considerable heterogeneity of reported outcomes constrains comparisons. A core outcome set should be developed for plasma transfusion studies. Standardization of outcomes will motivate better study design, facilitate comparison, and improve clinical relevance for future trials of plasma transfusion.
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Affiliation(s)
- Torunn O Apelseth
- Department of Immunology and Transfusion Medicine, Haukeland University Hospital, Bergen, Norway
- Faculty of Medicine, University of Bergen, Bergen, Norway
- Norwegian Armed Forces Joint Medical Services, Oslo, Norway
| | - Sheharyar Raza
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Canada
| | - Jeannie Callum
- Department of Pathology and Molecular Medicine, Kingston Health Sciences Centre and Queen's University, Kingston, Canada
| | - Tina Ipe
- Our Blood Institute, Oklahoma City, Oklahoma, USA
- Department of Pathology, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Bronagh Blackwood
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University, Belfast, UK
| | | | - John R Hess
- Department of Laboratory Medicine and Pathology, University of Washington School of Medicine, Seattle, Washington, USA
| | - Denese C Marks
- Research and Development, Australian Red Cross Lifeblood, Sydney, Australia
| | - Bethany Brown
- American Red Cross, Medical and Scientific Office, Washington, DC, USA
| | | | | | - Simon J Stanworth
- NHSBT, Oxford University Hospitals NHS Trust; Blood Transfusion Research Unit (BTRU), University of Oxford, Oxford, UK
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Schoenfeld DW, Rosen CL, Harris T, Thomas SH. Assessing the one-month mortality impact of civilian-setting prehospital transfusion: A systematic review and meta-analysis. Acad Emerg Med 2024; 31:590-598. [PMID: 38517320 DOI: 10.1111/acem.14882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2023] [Revised: 01/06/2024] [Accepted: 01/10/2024] [Indexed: 03/23/2024]
Abstract
BACKGROUND Based on convincing evidence for outcomes improvement in the military setting, the past decade has seen evaluation of prehospital transfusion (PHT) in the civilian emergency medical services (EMS) setting. Evidence synthesis has been challenging, due to study design variation with respect to both exposure (type of blood product administered) and outcome (endpoint definitions and timing). The goal of the current meta-analysis was to execute an overarching assessment of all civilian-arena randomized controlled trial (RCT) evidence focusing on administration of blood products compared to control of no blood products. METHOD The review structure followed the Cochrane group's Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA). Using the Transfusion Evidence Library (transfusionevidencelibrary.com), the multidatabase (e.g. PubMed, EMBASE) Harvard On-Line Library Information System (HOLLIS), and GoogleScholar, we accessed many databases and gray literature sources. RCTs of PHT in the civilian setting with a comparison group receiving no blood products with 1-month mortality outcomes were identified. RESULTS In assessing a single patient-centered endpoint-1-month mortality-we calculated an overall risk ratio (RR) estimate. Analysis of three RCTs yielded a model with acceptable heterogeneity (I2 = 48%, Q-test p = 0.13). Pooled estimate revealed civilian PHT results in a statistically nonsignificant (p = 0.38) relative mortality reduction of 13% (RR 0.87, 95% CI 0.63-1.19). CONCLUSIONS Current evidence does not demonstrate 1-month mortality benefit of civilian-setting PHT. This should give pause to EMS systems considering adoption of civilian-setting PHT programs. Further studies should not only focus on which formulations of blood products might improve outcomes but also focus on which patients are most likely to benefit from any form of civilian-setting PHT.
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Affiliation(s)
- David W Schoenfeld
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center & Harvard Medical School, Boston, Massachusetts, USA
| | - Carlo L Rosen
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center & Harvard Medical School, Boston, Massachusetts, USA
| | - Tim Harris
- Blizard Institute for Neuroscience, Surgery, and Trauma, Barts and The London School of Medicine, London, UK
| | - Stephen H Thomas
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center & Harvard Medical School, Boston, Massachusetts, USA
- Blizard Institute for Neuroscience, Surgery, and Trauma, Barts and The London School of Medicine, London, UK
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Peng HT, Singh K, Rhind SG, da Luz L, Beckett A. Dried Plasma for Major Trauma: Past, Present, and Future. Life (Basel) 2024; 14:619. [PMID: 38792640 PMCID: PMC11122082 DOI: 10.3390/life14050619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Revised: 04/26/2024] [Accepted: 05/08/2024] [Indexed: 05/26/2024] Open
Abstract
Uncontrollable bleeding is recognized as the leading cause of preventable death among trauma patients. Early transfusion of blood products, especially plasma replacing crystalloid and colloid solutions, has been shown to increase survival of severely injured patients. However, the requirements for cold storage and thawing processes prior to transfusion present significant logistical challenges in prehospital and remote areas, resulting in a considerable delay in receiving thawed or liquid plasma, even in hospitals. In contrast, freeze- or spray-dried plasma, which can be massively produced, stockpiled, and stored at room temperature, is easily carried and can be reconstituted for transfusion in minutes, provides a promising alternative. Drawn from history, this paper provides a review of different forms of dried plasma with a focus on in vitro characterization of hemostatic properties, to assess the effects of the drying process, storage conditions in dry form and after reconstitution, their distinct safety and/or efficacy profiles currently in different phases of development, and to discuss the current expectations of these products in the context of recent preclinical and clinical trials. Future research directions are presented as well.
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Affiliation(s)
- Henry T. Peng
- Defence Research and Development Canada, Toronto Research Centre, Toronto, ON M3K 2C9, Canada; (K.S.); (S.G.R.)
| | - Kanwal Singh
- Defence Research and Development Canada, Toronto Research Centre, Toronto, ON M3K 2C9, Canada; (K.S.); (S.G.R.)
| | - Shawn G. Rhind
- Defence Research and Development Canada, Toronto Research Centre, Toronto, ON M3K 2C9, Canada; (K.S.); (S.G.R.)
| | - Luis da Luz
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON M4N 3M5, Canada;
| | - Andrew Beckett
- St. Michael’s Hospital, University of Toronto, Toronto, ON M5B 1W8, Canada;
- Royal Canadian Medical Services, Ottawa, ON K1A 0K2, Canada
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8
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Malone JR. Ethical considerations in the use of RhD-positive blood products in trauma. Transfusion 2024; 64 Suppl 2:S4-S10. [PMID: 38491917 DOI: 10.1111/trf.17787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Revised: 03/05/2024] [Accepted: 03/06/2024] [Indexed: 03/18/2024]
Abstract
BACKGROUND Prehospital and early in-hospital use of low titer group O whole blood (LTOWB) for life-threatening bleeding has been independently associated with improved survival compared to component therapy. However, when RhD-positive blood products are administered to RhD-negative females of childbearing potential (FCP), there is a small future risk of hemolytic disease of the fetus and newborn (HDFN). This raises important ethical questions that must be explored in order to justify the use of RhD-positive blood products, including LTOWB, both in clinical practice and research. METHODS This essay explores the ethical challenges related to RhD-positive blood product administration to RhD-negative or RhD-unknown FCPs as a first-line resuscitation fluid in the trauma setting. These ethical issues include: issues related to decision-making, ethical analysis based on the doctrine of double effect (DDE), and attendant obligations incurred by hospitals that administer RhD-positive blood to FCPs. RESULTS Ethical analysis through the use of the DDE demonstrates that utilization of RhD-positive blood products, including LTOWB, in the early resuscitation of FCPs is an ethically appropriate approach. By accepting the risk of HDFN, hospitals generate obligations to promote blood donation, evaluate for alloimmunization and counsel patients on the future risk of HDFN, and maintain an understanding of the ethical rationale for RhD-positive blood transfusion.
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Affiliation(s)
- Jay R Malone
- Department of Pediatrics, Washington University in St. Louis School of Medicine, St. Louis, Missouri, USA
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9
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Broome JM, Nordham KD, Piehl M, Tatum D, Caputo S, Belding C, De Maio VJ, Taghavi S, Jackson-Weaver O, Harris C, McGrew P, Smith A, Nichols E, Dransfield T, Rayburn D, Marino M, Avegno J, Duchesne J. Faster refill in an urban emergency medical services system saves lives: A prospective preliminary evaluation of a prehospital advanced resuscitative care bundle. J Trauma Acute Care Surg 2024; 96:702-707. [PMID: 38189675 DOI: 10.1097/ta.0000000000004239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2024]
Abstract
INTRODUCTION Military experience has demonstrated mortality improvement when advanced resuscitative care (ARC) is provided for trauma patients with severe hemorrhage. The benefits of ARC for trauma in civilian emergency medical services (EMS) systems with short transport intervals are still unknown. We hypothesized that ARC implementation in an urban EMS system would reduce in-hospital mortality. METHODS This was a prospective analysis of ARC bundle administration between 2021 and 2023 in an urban EMS system with 70,000 annual responses. The ARC bundle consisted of calcium, tranexamic acid, and packed red blood cells via a rapid infuser. Advanced resuscitative care patients were compared with trauma registry controls from 2016 to 2019. Included were patients with a penetrating injury and systolic blood pressure ≤90 mm Hg. Excluded were isolated head trauma or prehospital cardiac arrest. In-hospital mortality was the primary outcome of interest. RESULTS A total of 210 patients (ARC, 61; controls, 149) met the criteria. The median age was 32 years, with no difference in demographics, initial systolic blood pressure or heart rate recorded by EMS, or New Injury Severity Score between groups. At hospital arrival, ARC patients had lower median heart rate and shock index than controls ( p ≤ 0.03). Fewer patients in the ARC group required prehospital advanced airway placement ( p < 0.001). Twenty-four-hour and total in-hospital mortality were lower in the ARC group ( p ≤ 0.04). Multivariable regression revealed an independent reduction in in-hospital mortality with ARC (odds ratio, 0.19; 95% confidence interval, 0.05-0.68; p = 0.01). CONCLUSION Early ARC in a fast-paced urban EMS system is achievable and may improve physiologic derangements while decreasing patient mortality. Advanced resuscitative care closer to the point of injury warrants consideration. LEVEL OF EVIDENCE Therapeutic/Care Management; Level IV.
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Affiliation(s)
- Jacob M Broome
- Department of Surgery, MedStar Georgetown Washington Hospital Center, (J.M.B.) Washington DC; Department of Surgery (K.D.N., D.T., S.C., C.B., S.T., O.J.-W., C.H., P.M., J.D.), Tulane University School of Medicine, New Orleans, Louisiana; Department of Pediatrics (M.P.), and Department of Emergency Medicine (V.J.D.M.), University of North Carolina at Chapel Hill, Chapel Hill; WakeMed Health and Hospitals (M.P.), Raleigh, North Carolina; Lousiana State University Health Science Center New Orleans (A.S.); New Orleans Emergency Medical Services (E.N., T.D., D.R., M.M.); and New Orleans Health Department, New Orleans, Louisiana (J.A.)
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10
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Lewin A, McGowan E, Ou-Yang J, Boateng LA, Dinardo CL, Mandal S, Almozain N, Ribeiro J, Sasongko SL. The future of blood services amid a tight balance between the supply and demand of blood products: Perspectives from the ISBT Young Professional Council. Vox Sang 2024; 119:505-513. [PMID: 38272856 DOI: 10.1111/vox.13590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Revised: 12/07/2023] [Accepted: 12/29/2023] [Indexed: 01/27/2024]
Abstract
BACKGROUND AND OBJECTIVES Blood services manage the increasingly tight balance between the supply and demand of blood products, and their role in health research is expanding. This review explores the themes that may define the future of blood banking. MATERIALS AND METHODS We reviewed the PubMed database for articles on emerging/new blood-derived products and the utilization of blood donors in health research. RESULTS In high-income countries (HICs), blood services may consider offering these products: whole blood, cold-stored platelets, synthetic blood components, convalescent plasma, lyophilized plasma and cryopreserved/lyophilized platelets. Many low- and middle-income countries (LMICs) aim to establish a pool of volunteer, non-remunerated blood donors and wean themselves off family replacement donors; and many HICs are relaxing the deferral criteria targeting racial and sexual minorities. Blood services in HICs could achieve plasma self-sufficiency by building plasma-dedicated centres, in collaboration with the private sector. Lastly, blood services should expand their involvement in health research by establishing donor cohorts, conducting serosurveys, studying non-infectious diseases and participating in clinical trials. CONCLUSION This article provides a vision of the future for blood services. The introduction of some of these changes will be slower in LMICs, where addressing key operational challenges will likely be prioritized.
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Affiliation(s)
- Antoine Lewin
- Medical Affairs and Innovation, Héma-Québec, Montreal, Quebec, Canada
- Medicine faculty and health science, Sherbrooke University, Sherbrooke, Quebec, Canada
| | - Eunike McGowan
- Research and Development, Australian Red Cross Lifeblood, Brisbane, Australia
- Division of Hematology and Transfusion Medicine, Department of Laboratory Medicine, Lund University, Lund, Sweden
| | | | - Lilian Antwi Boateng
- Department of Medical Diagnostics, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
- Immunohaematology laboratory, University Health Services, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | | | - Saikat Mandal
- Medical Oncology, Hull York Medical School, University of Hull, Hull, UK
| | - Nour Almozain
- Department of Pathology and Laboratory Medicine, King Faisal Specialist Hospital and Research Centre, Riyadh, Kingdom of Saudi Arabia
- Department of Pathology, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Jannison Ribeiro
- Centro de Hematologia e Hemoterapia do Ceará - Hemoce, Fortaleza, Brazil
- Instituto Pró-Hemo Saúde - IPH, Fortaleza, Brazil
| | - Syeldy Langi Sasongko
- Department of Public and Occupational Health, Amsterdam UMC, Location VUmc, Amsterdam, The Netherlands
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Mergoum AM, Rhone AR, Larson NJ, Dries DJ, Blondeau B, Rogers FB. A Guide to the Use of Vasopressors and Inotropes for Patients in Shock. J Intensive Care Med 2024:8850666241246230. [PMID: 38613381 DOI: 10.1177/08850666241246230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/14/2024]
Abstract
Shock is a life-threatening circulatory failure that results in inadequate tissue perfusion and oxygenation. Vasopressors and inotropes are vasoactive medications that are vital in increasing systemic vascular resistance and cardiac contractility, respectively, in patients presenting with shock. To be well versed in using these agents is an important skill to have in the critical care setting where patients can frequently exhibit symptoms of shock. In this review, we will discuss the pathophysiological mechanisms of shock and evaluate the current evidence behind the management of shock with an emphasis on vasopressors and inotropes.
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Affiliation(s)
| | | | | | - David J Dries
- Department of Surgery, Regions Hospital, Saint Paul, MN, USA
| | - Benoit Blondeau
- Department of Surgery, Regions Hospital, Saint Paul, MN, USA
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Nellenbach K, Mihalko E, Nandi S, Koch DW, Shetty J, Moretti L, Sollinger J, Moiseiwitsch N, Sheridan A, Pandit S, Hoffman M, Schnabel LV, Lyon LA, Barker TH, Brown AC. Ultrasoft platelet-like particles stop bleeding in rodent and porcine models of trauma. Sci Transl Med 2024; 16:eadi4490. [PMID: 38598613 DOI: 10.1126/scitranslmed.adi4490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 03/18/2024] [Indexed: 04/12/2024]
Abstract
Uncontrolled bleeding after trauma represents a substantial clinical problem. The current standard of care to treat bleeding after trauma is transfusion of blood products including platelets; however, donated platelets have a short shelf life, are in limited supply, and carry immunogenicity and contamination risks. Consequently, there is a critical need to develop hemostatic platelet alternatives. To this end, we developed synthetic platelet-like particles (PLPs), formulated by functionalizing highly deformable microgel particles composed of ultralow cross-linked poly (N-isopropylacrylamide) with fibrin-binding ligands. The fibrin-binding ligand was designed to target to wound sites, and the cross-linking of fibrin polymers was designed to enhance clot formation. The ultralow cross-linking of the microgels allows the particles to undergo large shape changes that mimic platelet shape change after activation; when coupled to fibrin-binding ligands, this shape change facilitates clot retraction, which in turn can enhance clot stability and contribute to healing. Given these features, we hypothesized that synthetic PLPs could enhance clotting in trauma models and promote healing after clotting. We first assessed PLP activity in vitro and found that PLPs selectively bound fibrin and enhanced clot formation. In murine and porcine models of traumatic injury, PLPs reduced bleeding and facilitated healing of injured tissue in both prophylactic and immediate treatment settings. We determined through biodistribution experiments that PLPs were renally cleared, possibly enabled by ultrasoft particle properties. The performance of synthetic PLPs in the preclinical studies shown here supports future translational investigation of these hemostatic therapeutics in a trauma setting.
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Affiliation(s)
- Kimberly Nellenbach
- Joint Department of Biomedical Engineering, North Carolina State University and University of North Carolina at Chapel Hill, Raleigh, NC 27606, USA
- Comparative Medicine Institute, North Carolina State University, Raleigh, NC 27606, USA
| | - Emily Mihalko
- Joint Department of Biomedical Engineering, North Carolina State University and University of North Carolina at Chapel Hill, Raleigh, NC 27606, USA
- Comparative Medicine Institute, North Carolina State University, Raleigh, NC 27606, USA
| | - Seema Nandi
- Joint Department of Biomedical Engineering, North Carolina State University and University of North Carolina at Chapel Hill, Raleigh, NC 27606, USA
- Comparative Medicine Institute, North Carolina State University, Raleigh, NC 27606, USA
| | - Drew W Koch
- Comparative Medicine Institute, North Carolina State University, Raleigh, NC 27606, USA
- Department of Clinical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, NC 27606, USA
| | - Jagathpala Shetty
- Department of Biomedical Engineering, University of Virginia, Charlottesville, VA 22904, USA
| | - Leandro Moretti
- Department of Biomedical Engineering, University of Virginia, Charlottesville, VA 22904, USA
| | - Jennifer Sollinger
- Joint Department of Biomedical Engineering, North Carolina State University and University of North Carolina at Chapel Hill, Raleigh, NC 27606, USA
- Comparative Medicine Institute, North Carolina State University, Raleigh, NC 27606, USA
| | - Nina Moiseiwitsch
- Joint Department of Biomedical Engineering, North Carolina State University and University of North Carolina at Chapel Hill, Raleigh, NC 27606, USA
- Comparative Medicine Institute, North Carolina State University, Raleigh, NC 27606, USA
- School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Ana Sheridan
- Joint Department of Biomedical Engineering, North Carolina State University and University of North Carolina at Chapel Hill, Raleigh, NC 27606, USA
- Comparative Medicine Institute, North Carolina State University, Raleigh, NC 27606, USA
| | - Sanika Pandit
- Joint Department of Biomedical Engineering, North Carolina State University and University of North Carolina at Chapel Hill, Raleigh, NC 27606, USA
- Comparative Medicine Institute, North Carolina State University, Raleigh, NC 27606, USA
| | | | - Lauren V Schnabel
- Comparative Medicine Institute, North Carolina State University, Raleigh, NC 27606, USA
- Department of Clinical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, NC 27606, USA
| | - L Andrew Lyon
- Fowler School of Engineering and Schmid College of Science and Technology, Chapman University, Orange, CA 92866, USA
| | - Thomas H Barker
- Department of Biomedical Engineering, University of Virginia, Charlottesville, VA 22904, USA
| | - Ashley C Brown
- Joint Department of Biomedical Engineering, North Carolina State University and University of North Carolina at Chapel Hill, Raleigh, NC 27606, USA
- Comparative Medicine Institute, North Carolina State University, Raleigh, NC 27606, USA
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Andrews T, Meadley B, Gabbe B, Beck B, Dicker B, Cameron P. Review article: Pre-hospital trauma guidelines and access to lifesaving interventions in Australia and Aotearoa/New Zealand. Emerg Med Australas 2024; 36:197-205. [PMID: 38253461 DOI: 10.1111/1742-6723.14373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 11/12/2023] [Accepted: 01/02/2024] [Indexed: 01/24/2024]
Abstract
The centralisation of trauma services in western countries has led to an improvement in patient outcomes. Effective trauma systems include a pre-hospital trauma system. Delivery of high-level pre-hospital trauma care must include identification of potential major trauma patients, access and correct application of lifesaving interventions (LSIs) and timely transport to definitive care. Globally, many nations endorse nationwide pre-hospital major trauma triage guidelines, to ensure a universal approach to patient care. This paper examined clinical guidelines from all 10 EMS in Australia and Aotearoa/New Zealand. All relevant trauma guidelines were included, and key information was extracted. Authors compared major trauma triage criteria, all LSI included in guidelines, and guidelines for transport to definitive care. The identification of major trauma patients varied between all 10 EMS, with no universal criteria. The most common approach to trauma triage included a three-step assessment process: physiological criteria, identified injuries and mechanism of injury. Disparity between physiological criteria, injuries and mechanism was found when comparing guidelines. All 10 EMS had fundamental LSI included in their trauma guidelines. Fundamental LSI included haemorrhage control (arterial tourniquets, pelvic binders), non-invasive airway management (face mask ventilation, supraglottic airway devices) and pleural wall needle decompression. Variation in more advanced LSI was evident between EMS. Optimising trauma triage guidelines is an important aspect of a robust and evidence driven trauma system. The lack of consensus in trauma triage identified in the present study makes benchmarking and comparison of trauma systems difficult.
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Affiliation(s)
- Tim Andrews
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Clinical Operations, Ambulance Victoria, Melbourne, Victoria, Australia
- Department of Paramedicine, Monash University, Melbourne, Victoria, Australia
| | - Ben Meadley
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Clinical Operations, Ambulance Victoria, Melbourne, Victoria, Australia
- Department of Paramedicine, Monash University, Melbourne, Victoria, Australia
| | - Belinda Gabbe
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Ben Beck
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Bridget Dicker
- Clinical Audit and Research, Hato Hone St John New Zealand, Auckland, New Zealand
- Paramedicine Department, Auckland University of Technology, Auckland, New Zealand
| | - Peter Cameron
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Emergency and Trauma Centre, The Alfred Hospital, Melbourne, Victoria, Australia
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Wend CM, Fransman RB, Haut ER. Prehospital Trauma Care. Surg Clin North Am 2024; 104:267-277. [PMID: 38453301 DOI: 10.1016/j.suc.2023.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/09/2024]
Abstract
Prehospital trauma evaluation begins with the primary assessment of airway, breathing, circulation, disability, and exposure. This is closely followed by vital signs and a secondary assessment. Key prehospital interventions include management and resuscitation according to the aforementioned principles with a focus on major hemorrhage control, airway compromise, and invasive management of tension pneumothorax. Determining the appropriate time and method for transportation (eg, ground ambulance, helicopter, police, private vehicle) to the hospital or when to terminate resuscitation are also important decisions to be made by emergency medical services clinicians.
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Affiliation(s)
- Christopher M Wend
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, 1830 East Monument Street Suite 6-100, Baltimore, MD 21287, USA
| | - Ryan B Fransman
- Department of Trauma, Acute Care Surgery, and Surgical Critical Care, Emory University School of Medicine, Grady Memorial Hospital, 80 Jesse Hill Jr. Drive, SE, Atlanta, GA 30303, USA
| | - Elliott R Haut
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, 1830 East Monument Street Suite 6-100, Baltimore, MD 21287, USA; Department of Surgery, Division of Acute Care Surgery, Johns Hopkins University School of Medicine, Sheikh Zayed 6107C, 1800 Orleans Street, Baltimore, MD 21287, USA; Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Department of Health Policy and Management, The Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
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Yilmaz S, Tatliparmak AC, Karakayali O, Turk M, Uras N, Ipek M, Polat D, Yazici MM, Yilmaz S. February 6 th, Kahramanmaraş earthquakes and the disaster management algorithm of adult emergency medicine in Turkey: An experience review. Turk J Emerg Med 2024; 24:80-89. [PMID: 38766417 PMCID: PMC11100575 DOI: 10.4103/tjem.tjem_32_24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Revised: 03/07/2024] [Accepted: 03/11/2024] [Indexed: 05/22/2024] Open
Abstract
This compilation covers emergency medical management lessons from the February 6th Kahramanmaraş earthquakes. The objective is to review relevant literature on emergency services patient management, focusing on Koenig's 1996 Simple Triage and Rapid Treatment (START) and Secondary Assessment of Victim Endpoint (SAVE) frameworks. Establishing a comprehensive seismic and mass casualty incident (MCI) protocol chain is the goal. The prehospital phase of seismic MCIs treats hypovolemia and gets patients to the nearest hospital. START-A plans to expedite emergency patient triage and pain management. The SAVE algorithm is crucial for the emergency patient secondary assessment. It advises using Glasgow Coma Scale, Mangled Extremity Severity Score, Burn Triage Score, and Safe Quake Score for admission, surgery, transfer, discharge, and outcomes. This compilation emphasizes the importance of using diagnostic tools like bedside blood gas analyzers and ultrasound devices during the assessment process, drawing from 6 February earthquake research. The findings create a solid framework for improving emergency medical response strategies, making them applicable in similar situations.
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Affiliation(s)
- Sarper Yilmaz
- Department of Emergency Medicine, University of Health Sciences, Kartal Dr. Lutfi Kirdar City Hospital, Istanbul, Turkey
| | - Ali Cankut Tatliparmak
- Department of Emergency Medicine, Uskudar University Faculty of Medicine, Istanbul, Turkey
| | - Onur Karakayali
- Department of Emergency Medicine, Sakarya University Faculty of Medicine, Sakarya, Turkey
| | - Mehmet Turk
- Department of Emergency Medicine, Silvan Dr. Yusuf Azizoğlu State Hospital, Diyarbakır, Turkey
| | - Nimet Uras
- Department of Emergency Medicine, Battalgazi State Hospital, Malatya, Turkey
| | - Mustafa Ipek
- Department of Emergency Medicine, Selahaddin Eyyubi State Hospital, Diyarbakır, Turkey
| | - Dicle Polat
- Department of Emergency Medicine, Mälarsjukhuset, Eskilstuna, Sweden
| | - Mümin Murat Yazici
- Department of Emergency Medicine, Recep Tayyip Erdoğan University Training and Research Hospital, Rize, Turkey
| | - Serkan Yilmaz
- Department of Emergency Medicine, Kocaeli University Faculty of Medicine, Kocaeli, Turkey
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16
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Christoffel J, Maegele M. Guidelines in trauma-related bleeding and coagulopathy: an update. Curr Opin Anaesthesiol 2024; 37:110-116. [PMID: 38390904 DOI: 10.1097/aco.0000000000001346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2024]
Abstract
PURPOSE OF REVIEW The diagnosis and treatment of patients with severe traumatic bleeding and subsequent trauma-induced coagulopathy (TIC) is still inconsistent, although the implementation of standardized algorithms/treatment pathways was repeatedly linked to improved outcome. Various evidence-based guidelines for these patients now exist, three of which have recently been updated. RECENT FINDINGS A synopsis of the three recently updated guidelines for diagnosis and treatment of seriously bleeding trauma patients with TIC is presented: (i) AWMF S3 guideline 'Polytrauma/Seriously Injured Patient Treatment' under the auspices of the German Society for Trauma Surgery; (ii) guideline of the European Society of Anesthesiology and Intensive Care (ESAIC) on the management of perioperative bleeding; and (iii) European guideline on the management of major bleeding and coagulopathy after trauma in its 6th edition (EU-Trauma). SUMMARY Treatment of trauma-related bleeding begins at the scene with local compression, use of tourniquets and pelvic binders and rapid transport to a certified trauma centre. After arrival at the hospital, measures to record, monitor and support coagulation function should be initiated immediately. Surgical bleeding control is carried out according to 'damage control' principles. Modern coagulation management includes individualized treatment based on target values derived from point-of-care viscoelastic test procedures.
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Affiliation(s)
- Jannis Christoffel
- Department for Trauma and Orthopaedic Surgery, Cologne-Merheim Medical Center (CMMC)
| | - Marc Maegele
- Department for Trauma and Orthopaedic Surgery, Cologne-Merheim Medical Center (CMMC)
- Institute for Research in Operative Medicine (IFOM), Witten/Herdecke University, Campus Cologne-Merheim, Cologne, Germany
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17
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Alomar-Dominguez C, Bösch J, Fries D. Prehospital transfusion of allogeneic blood products. Curr Opin Anaesthesiol 2024; 37:144-147. [PMID: 38390984 DOI: 10.1097/aco.0000000000001353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2024]
Abstract
PURPOSE OF REVIEW The purpose of this article is to provide a structural and practical analysis of the currently available data concerning prehospital transfusion of allogeneic blood products in cases of trauma and severe bleeding. RECENT FINDINGS Prehospital transfusion of allogeneic blood products is a very early intervention, which may offer the potential to improve outcome, but that also comes with challenges including resource allocation, blood product storage, logistics, patient selection, legal and ethical considerations, adverse effects, and costs. Potential benefits including improved stability and reduction in coagulopathy and blood loss have not yet been clearly demonstrated. SUMMARY The questionable efficacy and challenges in clinical practice may outweigh the potential benefits of prehospital allogeneic transfusion.
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Affiliation(s)
- Cristina Alomar-Dominguez
- Department of Anaesthesiology and Critical Care Medicine, Medical University of Innsbruck, Innsbruck, Austria
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18
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Torres CM, Kenzik KM, Saillant NN, Scantling DR, Sanchez SE, Brahmbhatt TS, Dechert TA, Sakran JV. Timing to First Whole Blood Transfusion and Survival Following Severe Hemorrhage in Trauma Patients. JAMA Surg 2024; 159:374-381. [PMID: 38294820 PMCID: PMC10831629 DOI: 10.1001/jamasurg.2023.7178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Accepted: 10/01/2023] [Indexed: 02/01/2024]
Abstract
Importance Civilian trauma centers have revived interest in whole-blood (WB) resuscitation for patients with life-threatening bleeding. However, there remains insufficient evidence that the timing of WB transfusion when given as an adjunct to a massive transfusion protocol (MTP) is associated with a difference in patient survival outcome. Objective To evaluate whether earlier timing of first WB transfusion is associated with improved survival at 24 hours and 30 days for adult trauma patients presenting with severe hemorrhage. Design, Setting, and Participants This retrospective cohort study used the American College of Surgeons Trauma Quality Improvement Program databank from January 1, 2019, to December 31, 2020, for adult patients presenting to US and Canadian adult civilian level 1 and 2 trauma centers with systolic blood pressure less than 90 mm Hg, with shock index greater than 1, and requiring MTP who received a WB transfusion within the first 24 hours of emergency department (ED) arrival. Patients with burns, prehospital cardiac arrest, deaths within 1 hour of ED arrival, and interfacility transfers were excluded. Data were analyzed from January 3 to October 2, 2023. Exposure Patients who received WB as an adjunct to MTP (earlier) compared with patients who had yet to receive WB as part of MTP (later) at any given time point within 24 hours of ED arrival. Main Outcomes and Measures Primary outcomes were survival at 24 hours and 30 days. Results A total of 1394 patients met the inclusion criteria (1155 male [83%]; median age, 39 years [IQR, 25-51 years]). The study cohort included profoundly injured patients (median Injury Severity Score, 27 [IQR, 17-35]). A survival curve demonstrated a difference in survival within 1 hour of ED presentation and WB transfusion. Whole blood transfusion as an adjunct to MTP given earlier compared with later at each time point was associated with improved survival at 24 hours (adjusted hazard ratio, 0.40; 95% CI, 0.22-0.73; P = .003). Similarly, the survival benefit of earlier WB transfusion remained present at 30 days (adjusted hazard ratio, 0.32; 95% CI, 0.22-0.45; P < .001). Conclusions and Relevance In this cohort study, receipt of a WB transfusion earlier at any time point within the first 24 hours of ED arrival was associated with improved survival in patients presenting with severe hemorrhage. The survival benefit was noted shortly after transfusion. The findings of this study are clinically important as the earlier timing of WB administration may offer a survival advantage in actively hemorrhaging patients requiring MTP.
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Affiliation(s)
- Crisanto M. Torres
- Division of Trauma and Acute Care Surgery, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts
| | - Kelly M. Kenzik
- Division of Trauma and Acute Care Surgery, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts
| | - Noelle N. Saillant
- Division of Trauma and Acute Care Surgery, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts
| | - Dane R. Scantling
- Division of Trauma and Acute Care Surgery, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts
| | - Sabrina E. Sanchez
- Division of Trauma and Acute Care Surgery, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts
| | - Tejal S. Brahmbhatt
- Division of Trauma and Acute Care Surgery, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts
| | - Tracey A. Dechert
- Division of Trauma and Acute Care Surgery, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts
| | - Joseph V. Sakran
- Johns Hopkins School of Medicine, Baltimore, Maryland
- Division of Acute Care Surgery, Johns Hopkins Hospital, Baltimore, Maryland
- Johns Hopkins School of Nursing, Baltimore, Maryland
- Satcher Health Leadership Institute, Morehouse School of Medicine, Atlanta, Georgia
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19
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Callaghan NI, Quinn J, Liwski R, Chisholm N, Cheng C. Process Mining Uncovers Actionable Patterns of Red Blood Cell Unit Wastage in a Health Care Network. Transfus Med Rev 2024; 38:150827. [PMID: 38642414 DOI: 10.1016/j.tmrv.2024.150827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Revised: 03/17/2024] [Accepted: 03/19/2024] [Indexed: 04/22/2024]
Abstract
Packed red blood cell transfusions are integral to the care of the critically and chronically ill patient, but require careful storage and a large, coordinated network to ensure their integrity during distribution and administration. Auditing a Transfusion Medicine service can be challenging due to the complexity of this network. Process mining is an analytical technique that allows for the identification of high-efficiency pathways through a network, as well as areas of challenge for targeted innovation. Here, we detail a case study of an efficiency audit of the Transfusion Medicine service of the Nova Scotia Health Administration Central Zone using process mining, across a period encompassing years prior to, during, and after the acute COVID-19 pandemic. Service efficiency from a product wastage perspective was consistently demonstrated at benchmarks near globally published optima. Furthermore, we detail key areas of continued challenge in product wastage, and suggest potential strategies for further targeted optimization.
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Affiliation(s)
- Neal I Callaghan
- Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Jason Quinn
- Department of Pathology and Laboratory Medicine, Division of Hematopathology, Halifax, Nova Scotia, Canada
| | - Robert Liwski
- Department of Pathology and Laboratory Medicine, Division of Hematopathology, Halifax, Nova Scotia, Canada
| | - Natalie Chisholm
- Department of Pathology and Laboratory Medicine, Division of Hematopathology, Halifax, Nova Scotia, Canada
| | - Calvino Cheng
- Department of Pathology and Laboratory Medicine, Division of Hematopathology, Halifax, Nova Scotia, Canada.
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20
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van Wyk P, Wannberg M, Gustafsson A, Yan J, Wikman A, Riddez L, Wahlgren CM. Characteristics of traumatic major haemorrhage in a tertiary trauma center. Scand J Trauma Resusc Emerg Med 2024; 32:24. [PMID: 38528572 DOI: 10.1186/s13049-024-01196-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Accepted: 03/15/2024] [Indexed: 03/27/2024] Open
Abstract
BACKGROUND Major traumatic haemorrhage is potentially preventable with rapid haemorrhage control and improved resuscitation techniques. Although advances in prehospital trauma management, haemorrhage is still associated with high mortality. The aim of this study was to use a recent pragmatic transfusion-based definition of major bleeding to characterize patients at risk of major bleeding and associated outcomes in this cohort after trauma. METHODS This was a retrospective cohort study including all trauma patients (n = 7020) admitted to a tertiary trauma center from January 2015 to June 2020. The major bleeding cohort (n = 145) was defined as transfusion of 4 units of any blood components (red blood cells, plasma, or platelets) within 2 h of injury. Univariate and multivariable logistic regression analyses were performed to identify risk factors for 24-hour and 30-day mortality post trauma admission. RESULTS In the major bleeding cohort (n = 145; 145/7020, 2.1% of the trauma population), there were 77% men (n = 112) and 23% women (n = 33), median age 39 years [IQR 26-53] and median Injury Severity Score (ISS) was 22 [IQR 13-34]. Blunt trauma dominated over penetrating trauma (58% vs. 42%) where high-energy fall was the most common blunt mechanism and knife injury was the most common penetrating mechanism. The major bleeding cohort was younger (OR 0.99; 95% CI 0.98 to 0.998, P = 0.012), less female gender (OR 0.66; 95% CI 0.45 to 0.98, P = 0.04), and had more penetrating trauma (OR 4.54; 95% CI 3.24 to 6.36, P = 0.001) than the rest of the trauma cohort. A prehospital (OR 2.39; 95% CI 1.34 to 4.28; P = 0.003) and emergency department (ED) (OR 6.91; 95% CI 4.49 to 10.66, P = 0.001) systolic blood pressure < 90 mmHg was associated with the major bleeding cohort as well as ED blood gas base excess < -3 (OR 7.72; 95% CI 5.37 to 11.11; P < 0.001) and INR > 1.2 (OR 3.09; 95% CI 2.16 to 4.43; P = 0.001). Emergency damage control laparotomy was performed more frequently in the major bleeding cohort (21.4% [n = 31] vs. 1.5% [n = 106]; OR 3.90; 95% CI 2.50 to 6.08; P < 0.001). There was no difference in transportation time from alarm to hospital arrival between the major bleeding cohort and the rest of the trauma cohort (47 [IQR 38;59] vs. 49 [IQR 40;62] minutes; P = 0.17). However, the major bleeding cohort had a shorter time from ED to first emergency procedure (71.5 [IQR 10.0;129.0] vs. 109.00 [IQR 54.0; 259.0] minutes, P < 0.001). In the major bleeding cohort, patients with penetrating trauma, compared to blunt trauma, had a shorter alarm to hospital arrival time (44.0 [IQR 35.5;54.0] vs. 50.0 [IQR 41.5;61.0], P = 0.013). The 24-hour mortality in the major bleeding cohort was 6.9% (10/145). All fatalities were due to blunt trauma; 40% (4/10) high energy fall, 20% (2/10) motor vehicle accident, 10% (1/10) motorcycle accident, 10% (1/10) traffic pedestrian, 10% (1/10) traffic other, and 10% (1/10) struck/hit by blunt object. In the logistic regression model, prehospital cardiac arrest (OR 83.4; 95% CI 3.37 to 2063; P = 0.007) and transportation time (OR 0.95, 95% CI 0.91 to 0.99, P = 0.02) were associated with 24-hour mortality. RESULTS Early identification of patients at high risk of major bleeding is challenging but essential for rapid definitive haemorrhage control. The major bleeding trauma cohort is a small part of the entire trauma population, and is characterized of being younger, male gender, higher ISS, and exposed to more penetrating trauma. Early identification of patients at high risk of major bleeding is challenging but essential for rapid definitive haemorrhage control.
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Affiliation(s)
- Pieter van Wyk
- Section of Acute and Trauma Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Marcus Wannberg
- Department of Molecular Medicine and Surgery, Department of Vascular Surgery, Karolinska Institute, Karolinska University Hospital, SE-171 76, Stockholm, Sweden
| | - Anna Gustafsson
- Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institute, Department of Clinical Immunology and Transfusion Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Jane Yan
- Division of Biostatistics, Institute of Environmental Medicine, Karolinska Institute, Stockholm, Sweden
| | - Agneta Wikman
- Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institute, Department of Clinical Immunology and Transfusion Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Louis Riddez
- Section of Acute and Trauma Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Carl-Magnus Wahlgren
- Department of Molecular Medicine and Surgery, Department of Vascular Surgery, Karolinska Institute, Karolinska University Hospital, SE-171 76, Stockholm, Sweden.
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Bath MF, Schloer J, Strobel J, Rea W, Lefering R, Maegele M, De'Ath H, Perkins ZB. Trends in pre-hospital volume resuscitation of blunt trauma patients: a 15-year analysis of the British (TARN) and German (TraumaRegister DGU®) National Registries. Crit Care 2024; 28:81. [PMID: 38491444 PMCID: PMC10941386 DOI: 10.1186/s13054-024-04854-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2023] [Accepted: 02/28/2024] [Indexed: 03/18/2024] Open
Abstract
INTRODUCTION Fluid resuscitation has long been a cornerstone of pre-hospital trauma care, yet its optimal approach remains undetermined. Although a liberal approach to fluid resuscitation has been linked with increased complications, the potential survival benefits of a restrictive approach in blunt trauma patients have not been definitively established. Consequently, equipoise persists regarding the optimal fluid resuscitation strategy in this population. METHODS We analysed data from the two largest European trauma registries, the UK Trauma Audit and Research Network (TARN) and the German TraumaRegister DGU® (TR-DGU), between 2004 and 2018. All adult blunt trauma patients with an Injury Severity Score > 15 were included. We examined annual trends in pre-hospital fluid resuscitation, admission coagulation function, and mortality rates. RESULTS Over the 15-year study period, data from 68,510 patients in the TARN cohort and 82,551 patients in the TR-DGU cohort were analysed. In the TARN cohort, 3.4% patients received pre-hospital crystalloid fluids, with a median volume of 25 ml (20-36 ml) administered. Conversely, in the TR-DGU cohort, 91.1% patients received pre-hospital crystalloid fluids, with a median volume of 756 ml (750-912 ml) administered. Notably, both cohorts demonstrated a consistent year-on-year decrease in the volume of pre-hospital fluid administered, accompanied by improvements in admission coagulation function and reduced mortality rates. CONCLUSION Considerable variability exists in pre-hospital fluid resuscitation strategies for blunt trauma patients. Our data suggest a trend towards reduced pre-hospital fluid administration over time. This trend appears to be associated with improved coagulation function and decreased mortality rates. However, we acknowledge that these outcomes are influenced by multiple factors, including other improvements in pre-hospital care over time. Future research should aim to identify which trauma populations may benefit, be harmed, or remain unaffected by different pre-hospital fluid resuscitation strategies.
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Affiliation(s)
- M F Bath
- Centre for Trauma Sciences, Queen Mary, University of London, London, UK
- Health Systems Design Group, Department of Engineering, University of Cambridge, Cambridge, UK
| | - J Schloer
- Centre for Trauma Sciences, Queen Mary, University of London, London, UK
- Department of Emergency Medicine, Klinikum St. Marien Amberg, Amberg, Germany
| | - J Strobel
- London's Air Ambulance, London, UK
- Berufsfeuerwehr Hamburg, Emergency Medical Services, Hamburg, Germany
| | - W Rea
- Centre for Trauma Sciences, Queen Mary, University of London, London, UK
| | - R Lefering
- Institute for Research in Operative Medicine, Cologne Merheim Medical Center, University of Witten/Herdecke, Cologne, Germany
| | - M Maegele
- Institute for Research in Operative Medicine, Cologne Merheim Medical Center, University of Witten/Herdecke, Cologne, Germany
| | - H De'Ath
- Centre for Trauma Sciences, Queen Mary, University of London, London, UK
| | - Z B Perkins
- Centre for Trauma Sciences, Queen Mary, University of London, London, UK.
- London's Air Ambulance, London, UK.
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22
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Butterfield ED, Price J, Bonsano M, Lachowycz K, Starr Z, Edmunds C, Barratt J, Major R, Rees P, Barnard EBG. Prehospital invasive arterial blood pressure monitoring in critically ill patients attended by a UK helicopter emergency medical service- a retrospective observational review of practice. Scand J Trauma Resusc Emerg Med 2024; 32:20. [PMID: 38475832 DOI: 10.1186/s13049-024-01193-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2023] [Accepted: 03/04/2024] [Indexed: 03/14/2024] Open
Abstract
BACKGROUND Accurate haemodynamic monitoring in the prehospital setting is essential. Non-invasive blood pressure measurement is susceptible to vibration and motion artefact, especially at extremes of hypotension and hypertension: invasive arterial blood pressure (IABP) monitoring is a potential solution. This study describes the largest series to date of cases of IABP monitoring being initiated prehospital. METHODS This retrospective observational study was conducted at East Anglian Air Ambulance (EAAA), a UK helicopter emergency medical service (HEMS). It included all patients attended by EAAA who underwent arterial catheterisation and initiation of IABP monitoring between 1st February 2015 and 20th April 2023. The following data were retrieved for all patients: sex; age; aetiology (medical cardiac arrest, other medical emergency, trauma); site of arterial cannulation; operator role (doctor/paramedic); time of insertion and, where applicable, times of pre-hospital emergency anaesthesia, and return of spontaneous circulation following cardiac arrest. Descriptive analyses were performed to characterise the sample. RESULTS 13,556 patients were attended: IABP monitoring was initiated in 1083 (8.0%) cases, with a median age 59 years, of which 70.8% were male. 546 cases were of medical cardiac arrest: in 22.4% of these IABP monitoring was initiated during cardiopulmonary resuscitation. 322 were trauma cases, and the remaining 215 were medical emergencies. The patients were critically unwell: 981 required intubation, of which 789 underwent prehospital emergency anaesthesia; 609 received vasoactive medication. In 424 cases IABP monitoring was instituted en route to hospital. CONCLUSION This study describes over 1000 cases of prehospital arterial catheterisation and IABP monitoring in a UK HEMS system and has demonstrated feasibility at scale. The high-fidelity of invasive arterial blood pressure monitoring with the additional benefit of arterial blood gas analysis presents an attractive translation of in-hospital critical care to the prehospital setting.
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Affiliation(s)
- Emma D Butterfield
- Department of Research, Audit, Innovation, and Development (RAID), East Anglian Air Ambulance, Norwich, UK.
| | - James Price
- Department of Research, Audit, Innovation, and Development (RAID), East Anglian Air Ambulance, Norwich, UK
- Emergency Department, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Marco Bonsano
- Department of Research, Audit, Innovation, and Development (RAID), East Anglian Air Ambulance, Norwich, UK
| | - Kate Lachowycz
- Department of Research, Audit, Innovation, and Development (RAID), East Anglian Air Ambulance, Norwich, UK
| | - Zachary Starr
- Department of Research, Audit, Innovation, and Development (RAID), East Anglian Air Ambulance, Norwich, UK
| | - Christopher Edmunds
- Department of Research, Audit, Innovation, and Development (RAID), East Anglian Air Ambulance, Norwich, UK
- Emergency and Critical Care Departments, Peterborough City Hospital, North West Anglia Foundation Trust, Peterborough, UK
- University of East Anglia, Norwich, UK
| | - Jon Barratt
- Department of Research, Audit, Innovation, and Development (RAID), East Anglian Air Ambulance, Norwich, UK
- Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine (Research & Clinical Innovation), Birmingham, UK
- Emergency Department, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, UK
| | - Rob Major
- Department of Research, Audit, Innovation, and Development (RAID), East Anglian Air Ambulance, Norwich, UK
| | - Paul Rees
- Department of Research, Audit, Innovation, and Development (RAID), East Anglian Air Ambulance, Norwich, UK
- Barts Heart Centre, London, UK
- The Blizard Institute, Queen Mary University of London, London, UK
- Academic Department of Military Medicine, Royal Centre for Defence Medicine (Research & Clinical Innovation), Birmingham, UK
| | - Ed B G Barnard
- Department of Research, Audit, Innovation, and Development (RAID), East Anglian Air Ambulance, Norwich, UK
- Emergency Department, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
- EuReCa, PACE Section, Department of Medicine, Cambridge University, Cambridge, UK
- Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine (Research & Clinical Innovation), Birmingham, UK
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23
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Benson MA, Tolich D, Callum JL, Auron M. Plasma: indications, controversies, and opportunities. Postgrad Med 2024; 136:120-130. [PMID: 38362605 DOI: 10.1080/00325481.2024.2320080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Accepted: 02/13/2024] [Indexed: 02/17/2024]
Abstract
Plasma is overused as a blood product worldwide; however, data supporting appropriate use of plasma is scant. Its most common utilization is for treatment of coagulopathy in actively bleeding patients; it is also used for coagulation optimization prior to procedures with specific coagulation profile targets. A baseline literature review in PUBMED and Google Scholar was done (1 January 2000 to 1 June 2023), utilizing the following search terms: plasma, fresh frozen plasma, lyophilized plasma, indications, massive transfusion protocol, liver disease, warfarin reversal, cardiothoracic surgery, INR < 2. An initial review of the titles and abstracts excluded all articles that were not focused on transfusional medicine. Additional references were obtained from citations within the retrieved articles. This narrative review discusses the main indications for appropriate plasma use, mainly coagulation factor replacement, major hemorrhage protocol, coagulopathy in liver disease, bleeding in the setting of vitamin K antagonists, among others. The correlation between concentration of coagulation factors and INR, as well as the proper plasma dosing with its volume being weight-based, is also discussed. A high value approach to plasma utilization is supported with a review of the clinical situations where plasma is overutilized or unnecessary. Finally, a discussion of novel plasma products is presented for enhanced awareness.
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Affiliation(s)
- Michael A Benson
- Department of General Anesthesiology, Cleveland Clinic, Cleveland, OH, USA
| | - Deborah Tolich
- Blood Management, Pathology and Laboratory Medicine Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Jeannie L Callum
- Department of Laboratory Medicine and Pathobiology, Queens University, Kingston, ON, Canada
| | - Moises Auron
- Department of Hospital Medicine and Department of Pediatric Hospital Medicine, Cleveland Clinic, Outcomes Research Consortium, Cleveland, OH, USA
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24
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Rushton TJ, Tian DH, Baron A, Hess JR, Burns B. Hypocalcaemia upon arrival (HUA) in trauma patients who did and did not receive prehospital blood products: a systematic review and meta-analysis. Eur J Trauma Emerg Surg 2024:10.1007/s00068-024-02454-6. [PMID: 38319350 DOI: 10.1007/s00068-024-02454-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2023] [Accepted: 01/14/2024] [Indexed: 02/07/2024]
Abstract
PURPOSE Hypocalcaemia upon arrival (HUA) to hospital is associated with morbidity and mortality in the trauma patient. It has been hypothesised that there is an increased incidence of HUA in patients receiving prehospital transfusion as a result of citrated blood products. This research aimed to determine if there was a difference in arrival ionised calcium (iCa) levels in trauma patients who did and did not receive prehospital transfusion. METHODS We conducted a systematic review and meta-analysis of patients with an Injury Severity Score (ISS) > / = 15 and an iCa measured on hospital arrival. We then derived mean iCa levels and attempted to compare between-group variables across multiple study cohorts. RESULTS Nine studies reported iCa on arrival to ED, with a mean of 1.08 mmol/L (95% CI 1.02-1.13; I2 = 99%; 2087 patients). Subgroup analysis of patients who did not receive prehospital transfusion had a mean iCa of 1.07 mmol/L (95% CI 1.01-1.14; I2 = 99%, 1661 patients). Transfused patients in the 3 comparative studies had a slightly lower iCa on arrival compared to those who did not receive transfusion (mean difference - 0.03 mmol/L, 95% CI - 0.04 to - 0.03, I2 = 0%, p = 0.001, 561 patients). CONCLUSION HUA is common amongst trauma patients irrespective of transfusion. Transfused patients had a slightly lower initial iCa than those without transfusion, though the clinical impact of this remains to be clarified. These findings question the paradigm of citrate-induced hypocalcaemia alone in trauma. There is a need for consensus for the definition of hypocalcaemia to provide a basis for future research into the role of calcium supplementation in trauma.
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Affiliation(s)
- Timothy J Rushton
- School of Medicine Sydney, University of Notre Dame Australia, Sydney, NSW, Australia.
| | - David H Tian
- Department of Anaesthesia and Perioperative Medicine, Westmead Hospital, Sydney, NSW, Australia
- Department of Surgery, University of Melbourne, Melbourne, VIC, Australia
| | - Aidan Baron
- School of Medicine Sydney, University of Notre Dame Australia, Sydney, NSW, Australia
- Faculty of Health, Science, Social Care and Education, Kingston University, London, UK
| | - John R Hess
- Transfusion Service, Harborview Medical Center, Seattle, WA, USA
- Department of Laboratory Medicine and Pathology, University of Washington School of Medicine, Seattle, WA, USA
| | - Brian Burns
- Trauma Service, Royal North Shore Hospital, Reserve Rd, St Leonards, Sydney, NSW, 2065, Australia.
- Aeromedical Operations, NSW Ambulance, Sydney, NSW, Australia.
- Sydney Medical School, Sydney University, Sydney, NSW, Australia.
- Faculty of Medicine, Macquarie University, Sydney, NSW, Australia.
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25
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Antonacci G, Williams A, Smith J, Green L. Study of Whole blood in Frontline Trauma (SWiFT): implementation study protocol. BMJ Open 2024; 14:e078953. [PMID: 38316586 PMCID: PMC11145983 DOI: 10.1136/bmjopen-2023-078953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Accepted: 01/04/2024] [Indexed: 02/07/2024] Open
Abstract
INTRODUCTION Uncontrolled bleeding is a major cause of death for patients with major trauma. Current transfusion practices vary, and there is uncertainty about the optimal strategy. Whole blood (WB) transfusion, which contains all components in one bag, is considered potentially advantageous, particularly for resuscitating patients with major bleeding in the prehospital setting. It could potentially improve survival, reduce donor risk and simplify the processes of delivering blood transfusions outside hospitals. However, the evidence supporting the effectiveness and safety of WB compared with the standard separate blood component therapy is limited. A multicentre randomised controlled trial will be conducted, alongside an implementation study, to assess the efficacy, cost-effectiveness and implementation of prehospital WB transfusion in the prehospital environment. The implementation study will focus on evaluating the acceptability and integration of the intervention into clinical settings and on addressing broader contextual factors that may influence its success or failure. METHODS AND ANALYSIS A type 1 effectiveness-implementation hybrid design will be employed. The implementation study will use qualitative methods, encompassing comprehensive interviews and focus groups with operational staff, patients and blood donor representatives. Staff will be purposefully selected to ensure a wide range of perspectives based on their professional background and involvement in the WB pathway. The study design includes: (1) initial assessment of current practice and processes in the WB pathway; (2) qualitative interviews with up to 40 operational staff and (3) five focus groups with staff and donor representatives. Data analysis will be guided by the theoretical lenses of the Normalisation Process Theory and the Theoretical Framework of Acceptability. ETHICS AND DISSEMINATION The study was prospectively registered and approved by the South Central-Oxford C Research Ethics Committee and the Health Research Authority and Health and Care Research Wales. The results will be published in peer-reviewed journals and provided to all relevant stakeholders. TRIAL REGISTRATION NUMBER ISRCTN23657907; EudraCT: 2021-006876-18; IRAS Number: 300414; REC: 22/SC/0072.
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Affiliation(s)
- Grazia Antonacci
- Department of Primary Care and Public Health, Imperial College London, London, UK
| | - Allison Williams
- Department of Primary Care and Public Health, Imperial College London, London, UK
| | - Jason Smith
- Department of Emergency, University Hospitals Plymouth NHS Trust, Plymouth, UK
- Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine, Birmingham, UK
| | - Laura Green
- NHS Blood & Transplant and Barts Health NHS Trust, London, UK
- Queen Mary University of London Blizard Institute, London, UK
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26
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Shafique MA, Shaikh NA, Haseeb A, Mussarat A, Mustafa MS. Sodium bicarbonate Ringer's solution for hemorrhagic shock: A meta-analysis comparing crystalloid solutions. Am J Emerg Med 2024; 76:41-47. [PMID: 37988980 DOI: 10.1016/j.ajem.2023.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2023] [Revised: 10/21/2023] [Accepted: 11/01/2023] [Indexed: 11/23/2023] Open
Abstract
BACKGROUND The choice of fluid resuscitation in Traumatic Hemorrhagic shock (THS) remains a critical aspect of patient management. Bicarbonated Ringers solution (BRS) has shown promise due to its composition resembling human Extracellular Fluid and its potential benefits on hemodynamics. OBJECTIVE To evaluate the efficacy, mortality rates, hemodynamic effects, and adverse outcomes of Sodium Bicarbonate Ringer's Solution in the treatment of hemorrhagic shock, as compared to other relevant interventions. METHOD A comprehensive examination of the available literature was performed by conducting systematic searches in prominent databases such as Cochrane, EMBASE, MEDLINE, and PubMed. The process employed predefined criteria to extract relevant data and evaluate the quality of the studies. The outcome measures considered encompassed survival rates, mortality, mean arterial pressure (MAP), heart rate (HR), and adverse events. RESULT The meta-analysis of three studies showed that compared to the other crystalloids, the use of BRS had an odds ratio for survival of 1.86 (95% CI: 0.94, 3.71; p = 0.08; I2 = 0%), an odds ratio for total adverse events of 0.14 (95% CI: 0.06, 0.35; p < 0.0001; I2 = 22%), a mean difference in heart rate of -4.49 (95% CI: -7.55, -1.44; p = 0.004; I2 = 13%), and a mean difference in mean arterial pressure of 2.31 (95% CI: -0.85, 5.47; p = 0.15; I2 = 66%). CONCLUSION BRS demonstrated a significant reduction in complications, including adult respiratory distress syndrome (ARDS), Multiple Organ Dysfunction (MODS), and Total Adverse Effects, when compared to other solutions in the treatment of THS. Additionally, THS patients resuscitated with BRS experienced a notable decrease in heart rate. The findings suggest BRS may contribute to organ stability and potential survival improvement due to its similarity to human Extracellular Fluid and minimal impact on the liver.
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Affiliation(s)
| | | | - Abdul Haseeb
- Department of Medicine, Jinnah Sindh Medical University, Pakistan
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27
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Peng HT, Moes K, Singh K, Rhind SG, Pambrun C, Jenkins C, da Luz L, Beckett A. Post-Reconstitution Hemostatic Stability Profiles of Canadian and German Freeze-Dried Plasma. Life (Basel) 2024; 14:172. [PMID: 38398681 PMCID: PMC10890410 DOI: 10.3390/life14020172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Revised: 12/31/2023] [Accepted: 01/03/2024] [Indexed: 02/25/2024] Open
Abstract
Despite the importance of the hemostatic properties of reconstituted freeze-dried plasma (FDP) for trauma resuscitation, few studies have been conducted to determine its post-reconstitution hemostatic stability. This study aimed to assess the short- (≤24 h) and long-term (≥168 h) hemostatic stabilities of Canadian and German freeze-dried plasma (CFDP and LyoPlas) after reconstitution and storage under different conditions. Post-reconstitution hemostatic profiles were determined using rotational thromboelastometry (ROTEM) and a Stago analyzer, as both are widely used as standard methods for assessing the quality of plasma. When compared to the initial reconstituted CFDP, there were no changes in ROTEM measurements for INTEM maximum clot firmness (MCF), EXTEM clotting time (CT) and MCF, and Stago measurements for prothrombin time (PT), partial thromboplastin time (PTT), D-dimer concentration, plasminogen, and protein C activities after storage at 4 °C for 24 h and room temperature (RT) (22-25 °C) for 4 h. However, an increase in INTEM CT and decreases in fibrinogen concentration, factors V and VIII, and protein S activities were observed after storage at 4 °C for 24 h, while an increase in factor V and decreases in antithrombin and protein S activities were seen after storage at RT for 4 h. Evaluation of the long-term stability of reconstituted LyoPlas showed decreased stability in both global and specific hemostatic profiles with increasing storage temperatures, particularly at 35 °C, where progressive changes in CT and MCF, PT, PTT, fibrinogen concentration, factor V, antithrombin, protein C, and protein S activities were seen even after storage for 4 h. We confirmed the short-term stability of CFDP in global hemostatic properties after reconstitution and storage at RT, consistent with the shelf life of reconstituted LyoPlas. The long-term stability analyses suggest that the post-reconstitution hemostatic stability of FDP products would decrease over time with increasing storage temperature, with a significant loss of hemostatic functions at 35 °C compared to 22 °C or below. Therefore, the shelf life of reconstituted FDP should be recommended according to the storage temperature.
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Affiliation(s)
- Henry T. Peng
- Defence Research and Development Canada, Toronto Research Centre, Toronto, ON M3K 2C9, Canada
| | - Katherine Moes
- Defence Research and Development Canada, Toronto Research Centre, Toronto, ON M3K 2C9, Canada
| | - Kanwal Singh
- St. Michael’s Hospital, University of Toronto, Toronto, ON M5B 1W8, Canada; (K.S.); (A.B.)
| | - Shawn G. Rhind
- Defence Research and Development Canada, Toronto Research Centre, Toronto, ON M3K 2C9, Canada
| | - Chantale Pambrun
- Centre for Innovation, Canadian Blood Services, Ottawa, ON K1G 4J5, Canada; (C.P.); (C.J.)
| | - Craig Jenkins
- Centre for Innovation, Canadian Blood Services, Ottawa, ON K1G 4J5, Canada; (C.P.); (C.J.)
| | - Luis da Luz
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON M4N 3M5, Canada;
| | - Andrew Beckett
- St. Michael’s Hospital, University of Toronto, Toronto, ON M5B 1W8, Canada; (K.S.); (A.B.)
- Royal Canadian Medical Services, Ottawa, ON K1A 0K2, Canada
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Wigginton O, Johnson S, Jervis B, Joshi A, Steere M, Ferguson I. Prehospital Blood Transfusion: A Cross-Sectional Study of Prehospital and Retrieval Medicine Services across Australia & Aotearoa-New Zealand. PREHOSP EMERG CARE 2024:1-5. [PMID: 38241180 DOI: 10.1080/10903127.2024.2306249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Accepted: 01/05/2024] [Indexed: 01/21/2024]
Abstract
BACKGROUND The frequency and type of prehospital blood product delivery across Australia and Aotearoa-New Zealand is unknown. This study aims to describe transfusion practice across different services in the two nations, as well as identifying potential barriers to the carriage of blood products. METHODOLOGY Prehospital and retrieval medicine services operating teams of doctors, specialist paramedics, and/or flight nurses out of specialty bases across Australia and Aotearoa-New Zealand were sent a standardized questionnaire regarding their base characteristics and their current blood transfusion practice. Bases that only performed inter-hospital transfers or search & rescue operations were excluded. Bases were queried on personnel, equipment, transport times, type and volume of blood products carried, frequency of use, and barriers to implementation for those without prehospital blood transfusion programs. RESULTS 64 bases were identified and contacted, of which 5 were excluded and 45 of the remaining 59 (76.3%) responded. 62% (28/45) of respondents routinely carry prehospital blood products. 78.6% (22/28) carried packed red blood cells (PRBC) only, 14.3% (4/28) carried both PRBC and plasma, and 1 service (3.6%) carried whole blood. The mean number of units of blood product carried was 3.3 (SD 0.82). 2 bases (7.1%) carried fibrinogen concentrate. All services carried tranexamic acid and calcium. 734 patients received a blood transfusion in 2021, with trauma being the most common indication (552, 75.2%). Base characteristics varied significantly in staffing, vehicle platform and transfer times. The median transfer time from scene to hospital was 65 min (IQR of 40-92). Services without access to prehospital blood products identified multiple barriers to implementation, including training and supply chain. CONCLUSION Approximately two-thirds of prehospital services operating advanced teams across Australia and Aotearoa-New Zealand carried blood products and there was wide variation both in the type and number of blood products carried by each base. Multiple barriers to the carriage of blood by all bases were reported, which have implications for service equity. Transfer times are generally long in Australia and Aotearoa-New Zealand, which may impact the generalizability of overseas research performed in prehospital systems with significantly shorter transfer times to services operating in Australia and Aotearoa-New Zealand.
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Affiliation(s)
- Oscar Wigginton
- Aeromedical Retrieval Service, New South Wales Ambulance, Bankstown, New South Wales, Australia
- South West Clinical School, University of New South Wales, Sydney, New South Wales, Australia
- Liverpool Hospital, Liverpool, New South Wales, Australia
| | - Sue Johnson
- Aeromedical Retrieval Service, New South Wales Ambulance, Bankstown, New South Wales, Australia
- Auckland Rescue Helicopter Trust (ARHT), Auckland, Aotearoa-New Zealand
| | - Bethan Jervis
- CareFlight Australia, Northmead, New South Wales, Australia
| | - Anil Joshi
- Aeromedical Retrieval Service, New South Wales Ambulance, Bankstown, New South Wales, Australia
- Auckland Rescue Helicopter Trust (ARHT), Auckland, Aotearoa-New Zealand
| | - Mardi Steere
- Royal Flying Doctor Service, RFDS Central Operations, Adelaide, South Australia, Australia
| | - Ian Ferguson
- Aeromedical Retrieval Service, New South Wales Ambulance, Bankstown, New South Wales, Australia
- South West Clinical School, University of New South Wales, Sydney, New South Wales, Australia
- Liverpool Hospital, Liverpool, New South Wales, Australia
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29
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Sheffield WP, Singh K, Beckett A, Devine DV. Prehospital Freeze-Dried Plasma in Trauma: A Critical Review. Transfus Med Rev 2024; 38:150807. [PMID: 38114340 DOI: 10.1016/j.tmrv.2023.150807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Revised: 11/13/2023] [Accepted: 11/16/2023] [Indexed: 12/21/2023]
Abstract
Major traumatic hemorrhage is now frequently treated by early hemostatic resuscitation on hospital arrival. Prehospital hemostatic resuscitation could therefore improve outcomes for bleeding trauma patients, but there are logistical challenges. Freeze-dried plasma (FDP) offers indisputable logistical advantages over conventional blood products, such as long shelf life, stability at ambient temperature, and rapid reconstitution without specialized equipment. We sought high level, randomized, controlled evidence of FDP clinical efficacy in trauma. A structured systematic search of MEDLINE/PubMed was carried out and identified 52 relevant English language publications. Three studies involving 607 patients met our criteria: Resuscitation with Blood Products in Patients with Trauma-related Hemorrhagic Shock receiving Prehospital Care (RePHILL, n = 501); Prehospital Lyophilized Plasma Transfusion for Trauma-Induced Coagulopathy in Patients at Risk for Hemorrhagic Shock (PREHO-PLYO, n = 150); and a pilot Australian trial (n = 25). RePHILL found no effect of FDP plus packed red blood cells (PRBC) concentrate transfusion versus saline on mortality. PREHO-PLYO found no effect of FDP versus saline on International Normalized Ratio (INR) at hospital arrival. The pilot trial found that study of PRBC versus PRBC plus FDP was feasible during long air transport times to an Australian trauma centre. Further research is required to determine under what conditions FDP might provide prehospital benefit to trauma patients.
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Affiliation(s)
- William P Sheffield
- Medical Affairs and Innovation, Canadian Blood Services, Hamilton, Ontario, Canada; Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Ontario, Canada.
| | - Kanwal Singh
- Trauma Surgery, Critical Care Medicine and Acute Care Surgery, St. Michael's Hospital, Toronto, Ontario, Canada; Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Andrew Beckett
- Trauma Surgery, Critical Care Medicine and Acute Care Surgery, St. Michael's Hospital, Toronto, Ontario, Canada; Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; Canadian Forces Health Services, Ottawa, Ontario, Canada
| | - Dana V Devine
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, Canada
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30
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Blais-Normandin I, Rymer T, Feenstra S, Burry A, Colavecchia C, Duncan J, Farrell M, Greene A, Gupta A, Huynh Q, Lawrence R, Lehto P, Lett R, Lin Y, Lyon B, McCarthy J, Nahirniak S, Nolan B, Peddle M, Prokopchuk-Gauk O, Sham L, Trojanowski J, Shih AW. Current state of technical transfusion medicine practice for out-of-hospital blood transfusion in Canada. Vox Sang 2023; 118:1086-1094. [PMID: 37794849 DOI: 10.1111/vox.13542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 09/11/2023] [Accepted: 09/18/2023] [Indexed: 10/06/2023]
Abstract
BACKGROUND AND OBJECTIVES Canadian out-of-hospital blood transfusion programmes (OHBTPs) are emerging, to improve outcomes of trauma patients by providing pre-hospital transfusion from the scene of injury, given prolonged transport times. Literature is lacking to guide its implementation. Thus, we sought to gather technical transfusion medicine (TM)-specific practices across Canadian OHBTPs. MATERIALS AND METHODS A survey was sent to TM representatives of Canadian OHBTPs from November 2021 to March 2022. Data regarding transport, packaging, blood components and inventory management were included and reported descriptively. Only practices involving Blood on Board programme components for emergency use were included. RESULTS OHBTPs focus on helicopter emergency medical service programmes, with some supplying fixed-wing aircraft and ground ambulances. All provide 1-3 coolers with 2 units of O RhD/Kell-negative red blood cells (RBCs) per cooler, with British Columbia trialling coolers with 2 units of pre-thawed group A plasma. Inventory exchanges are scheduled and blood components are returned to TM inventory using visual inspection and internal temperature data logger readings. Coolers are validated to storage durations ranging from 72 to 124 h. All programmes audit to manage wastage, though there is no consensus on appropriate benchmarks. All programmes have a process for documenting units issued, reconciliation after transfusion and for transfusion reaction reporting; however, training programmes vary. Common considerations included storage during extreme temperature environments, O-negative RBC stewardship, recipient notification, traceability, clinical practice guidelines co-reviewed by TM and a common audit framework. CONCLUSION OHBTPs have many similarities throughout Canada, where harmonization may assist in further developing standards, leveraging best practice and national coordination.
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Affiliation(s)
- Isabelle Blais-Normandin
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Tihiro Rymer
- Alberta Precision Labs, Transfusion and Transplantation Medicine, Edmonton, Alberta, Canada
| | - Shelley Feenstra
- Vancouver Coastal Health Authority, Vancouver, British Columbia, Canada
| | - Anne Burry
- Alberta Precision Labs, Transfusion and Transplantation Medicine, Edmonton, Alberta, Canada
| | | | - Jennifer Duncan
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- Vancouver Island Health Authority, Courtenay, British Columbia, Canada
| | - Michael Farrell
- Provincial Blood Coordinating Team, Nova Scotia Health Authority, Halifax, Nova Scotia, Canada
| | - Adam Greene
- British Columbia Emergency Health Services, Parksville, British Columbia, Canada
| | - Akash Gupta
- Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
| | - Queenie Huynh
- Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Robin Lawrence
- Saskatchewan Health Authority, Regina, Saskatchewan, Canada
| | - Paula Lehto
- Saskatchewan Health Authority, Saskatoon, Saskatchewan, Canada
| | - Ryan Lett
- Saskatchewan Health Authority, Regina, Saskatchewan, Canada
- Department of Anesthesiology, Regina, Saskatchewan, Canada
| | - Yulia Lin
- Vancouver Island Health Authority, Courtenay, British Columbia, Canada
- Saskatchewan Health Authority, Regina, Saskatchewan, Canada
| | - Bruce Lyon
- Alberta Precision Labs, Transfusion and Transplantation Medicine, Edmonton, Alberta, Canada
| | - Joanna McCarthy
- Alberta Precision Labs, Transfusion and Transplantation Medicine, Edmonton, Alberta, Canada
| | - Susan Nahirniak
- Alberta Precision Labs, Transfusion and Transplantation Medicine, Edmonton, Alberta, Canada
- Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, Alberta, Canada
| | - Brodie Nolan
- Provincial Blood Coordinating Team, Nova Scotia Health Authority, Halifax, Nova Scotia, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Emergency Medicine, Unity Health Toronto, Toronto, Ontario, Canada
| | - Michael Peddle
- Ornge, Mississauga, Ontario, Canada
- Division of Emergency Medicine, Western University, London, Ontario, Canada
| | - Oksana Prokopchuk-Gauk
- Saskatchewan Health Authority, Saskatoon, Saskatchewan, Canada
- Department of Pathology and Laboratory Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Lawrence Sham
- Vancouver Coastal Health Authority, Vancouver, British Columbia, Canada
| | - Jan Trojanowski
- Vancouver Coastal Health Authority, Vancouver, British Columbia, Canada
- Department of Emergency Medicine, Vancouver, British Columbia, Canada
- British Columbia Emergency Health Services, Vancouver, British Columbia, Canada
| | - Andrew W Shih
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- Vancouver Coastal Health Authority, Vancouver, British Columbia, Canada
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31
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Yazer MH, Panko G, Holcomb JB, Kaplan A, Leeper C, Seheult JN, Triulzi DJ, Spinella PC. Not as "D"eadly as once thought - the risk of D-alloimmunization and hemolytic disease of the fetus and newborn following RhD-positive transfusion in trauma. HEMATOLOGY (AMSTERDAM, NETHERLANDS) 2023; 28:2161215. [PMID: 36607150 DOI: 10.1080/16078454.2022.2161215] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
The use of blood products to resuscitate injured and massively bleeding patients in the prehospital and early in-hospital phase of the resuscitation is increasing. Using group O red blood cells (RBC) and low titer group O whole blood (LTOWB) avoids an immediate hemolytic reaction from recipient's naturally occurring anti-A and - B, but choosing the RhD type for these products is more nuanced and requires the balancing of product availability and survival benefit against the risk of D-alloimmunization, especially in females of childbearing potential (FCP) due to the possible future occurrence of hemolytic disease of the fetus and newborn (HDFN). Recent models have estimated the risk of fetal/neonatal death from HDFN resulting from D-alloimmunization of an FCP during her trauma resuscitation at between 0-6.5% depending on her age at the time of the transfusion and other societal factors including trauma mortality, her age when she becomes pregnant, frequency of different RHD genotypes in the population, and the probability that the woman will have children with different fathers; this is counterbalanced by an approximately 24% risk of death from hemorrhagic shock. This review will discuss the different models of HDFN outcomes following RhD-positive transfusion as well as the results of recent surveys where the public was asked about their preferences for urgent transfusion in light of the risks of fetal/neonatal adverse events.
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Affiliation(s)
- Mark H Yazer
- Department of Pathology, University of Pittsburgh, Pittsburgh, PA, USA
| | | | - John B Holcomb
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Alesia Kaplan
- Department of Pathology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Christine Leeper
- Department of Surgery, University of Pittsburgh, Pittsburgh PA, USA
| | - Jansen N Seheult
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Darrell J Triulzi
- Department of Pathology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Philip C Spinella
- Departments of Surgery and Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA
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32
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Gianola S, Castellini G, Biffi A, Porcu G, Napoletano A, Coclite D, D'Angelo D, Di Nitto M, Fauci AJ, Punzo O, Iannone P, Chiara O. Volume replacement in the resuscitation of trauma patients with acute hemorrhage: an umbrella review. Int J Emerg Med 2023; 16:87. [PMID: 38036955 PMCID: PMC10687916 DOI: 10.1186/s12245-023-00563-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Accepted: 10/26/2023] [Indexed: 12/02/2023] Open
Abstract
BACKGROUND The use of intravenous fluid therapy in patients with major trauma in prehospital settings is still controversial. We conducted an umbrella review to evaluate which is the best volume expansion in the resuscitation of a hemorrhagic shock to support the development of major trauma guideline recommendations. METHODS We searched PubMed, Embase, and CENTRAL up to September 2022 for systematic reviews (SRs) investigating the use of volume expansion fluid on mortality and/or survival. Quality assessment was performed using AMSTAR 2 and the Certainty of the evidence was assessed with the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. RESULTS We included 14 SRs investigating the effects on mortality with the comparisons: use of crystalloids, blood components, and whole blood. Most SRs were judged as critically low with slight overlapping of primary studies and high consistency of results. For crystalloids, inconsistent evidence of effectiveness in 28- to 30-day survival (primary endpoint) was found for the hypertonic saline/dextran group compared with isotonic fluid solutions with moderate certainty of evidence. Pre-hospital blood component infusion seems to reduce mortality, however, as the certainty of evidence ranges from very low to moderate, we are unable to provide evidence to support or reject its use. The blood component ratio was in favor of higher ratios among all comparisons considered with moderate to very low certainty of evidence. Results about the effects of whole blood are very uncertain due to limited and heterogeneous interventions in studies included in SRs. CONCLUSION Hypertonic crystalloid use did not result in superior 28- to 30-day survival. Increasing evidence supports the scientific rationale for early use of high-ratio blood components, but their use requires careful consideration. Preliminary evidence is very uncertain about the effects of whole blood and further high-quality studies are required.
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Affiliation(s)
- Silvia Gianola
- Unit of Clinical Epidemiology, IRCCS Istituto Ortopedico Galeazzi, Milan, Italy
| | - Greta Castellini
- Unit of Clinical Epidemiology, IRCCS Istituto Ortopedico Galeazzi, Milan, Italy
| | - Annalisa Biffi
- Department of Statistics and Quantitative Methods, National Centre for Healthcare Research and Pharmacoepidemiology, University of Milano-Bicocca, Milan, Italy
- Department of Statistics and Quantitative Methods, Unit of Biostatistics, Epidemiology and Public Health, University of Milano-Bicocca, Milan, Italy
| | - Gloria Porcu
- Department of Statistics and Quantitative Methods, National Centre for Healthcare Research and Pharmacoepidemiology, University of Milano-Bicocca, Milan, Italy
- Department of Statistics and Quantitative Methods, Unit of Biostatistics, Epidemiology and Public Health, University of Milano-Bicocca, Milan, Italy
| | - Antonello Napoletano
- Centro Nazionale Per L'Eccellenza Clinica, La Qualità E La Sicurezza Delle Cure, Istituto Superiore Di Sanità, Rome, Italy
| | - Daniela Coclite
- Centro Nazionale Per L'Eccellenza Clinica, La Qualità E La Sicurezza Delle Cure, Istituto Superiore Di Sanità, Rome, Italy
| | - Daniela D'Angelo
- Azienda Sanitaria Locale Roma/6, Via Borgo Garibaldi, 12 00041 Albano Laziale, Rome, Italy.
- CECRI Evidence-Based Practice Group for Nursing Scholarship: A JBI Affiliated Group, Rome, Italy.
| | - Marco Di Nitto
- Centro Nazionale Per L'Eccellenza Clinica, La Qualità E La Sicurezza Delle Cure, Istituto Superiore Di Sanità, Rome, Italy
| | - Alice Josephine Fauci
- Centro Nazionale Per L'Eccellenza Clinica, La Qualità E La Sicurezza Delle Cure, Istituto Superiore Di Sanità, Rome, Italy
| | - Ornella Punzo
- Centro Nazionale Per L'Eccellenza Clinica, La Qualità E La Sicurezza Delle Cure, Istituto Superiore Di Sanità, Rome, Italy
| | - Primiano Iannone
- Dipartimento Di Medicina Interna, Azienda USL, Ospedale Maggiore, Largo Nigrisoli 2, 40133, Bologna, Italy
| | - Osvaldo Chiara
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
- General Surgery and Trauma Team, ASST Grande Ospedale Metropolitano Niguarda, University of Milan, Milano, Piazza Ospedale Maggiore, Milan, Italy
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Smith JE, Barnard EBG, Brown-O'Sullivan C, Cardigan R, Davies J, Hawton A, Laing E, Lucas J, Lyon R, Perkins GD, Smith L, Stanworth SJ, Weaver A, Woolley T, Green L. The SWiFT trial (Study of Whole Blood in Frontline Trauma)-the clinical and cost effectiveness of pre-hospital whole blood versus standard care in patients with life-threatening traumatic haemorrhage: study protocol for a multi-centre randomised controlled trial. Trials 2023; 24:725. [PMID: 37964393 PMCID: PMC10644622 DOI: 10.1186/s13063-023-07711-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 10/06/2023] [Indexed: 11/16/2023] Open
Abstract
BACKGROUND Early blood transfusion improves survival in patients with life-threatening bleeding, but the optimal transfusion strategy in the pre-hospital setting has yet to be established. Although there is some evidence of benefit with the use of whole blood, there have been no randomised controlled trials exploring the clinical and cost effectiveness of pre-hospital administration of whole blood versus component therapy for trauma patients with life-threatening bleeding. The aim of this trial is to determine whether pre-hospital leukocyte-depleted whole blood transfusion is better than standard care (blood component transfusion) in reducing the proportion of participants who experience death or massive transfusion at 24 h. METHODS This is a multi-centre, superiority, open-label, randomised controlled trial with internal pilot and within-trial cost-effectiveness analysis. Patients of any age will be eligible if they have suffered major traumatic haemorrhage and are attended by a participating air ambulance service. The primary outcome is the proportion of participants with traumatic haemorrhage who have died (all-cause mortality) or received massive transfusion in the first 24 h from randomisation. A number of secondary clinical, process, and safety endpoints will be collected and analysed. Cost (provision of whole blood, hospital, health, and wider care resource use) and outcome data will be synthesised to present incremental cost-effectiveness ratios for the trial primary outcome and cost per quality-adjusted life year at 90 days after injury. We plan to recruit 848 participants (a two-sided test with 85% power, 5% type I error, 1-1 allocation, and one interim analysis would require 602 participants-after allowing for 25% of participants in traumatic cardiac arrest and an additional 5% drop out, the sample size is 848). DISCUSSION The SWiFT trial will recruit 848 participants across at least ten air ambulances services in the UK. It will investigate the clinical and cost-effectiveness of whole blood transfusion versus component therapy in the management of patients with life-threatening bleeding in the pre-hospital setting. TRIAL REGISTRATION ISRCTN: 23657907; EudraCT: 2021-006876-18; IRAS Number: 300414; REC: 22/SC/0072, 21 Dec 2021.
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Affiliation(s)
- Jason E Smith
- Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine, Birmingham, UK.
- University Hospitals Plymouth NHS Trust, Plymouth, UK.
| | - Ed B G Barnard
- Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine, Birmingham, UK
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | | | - Rebecca Cardigan
- NHS Blood & Transplant, Bristol, UK
- Department of Haematology, University of Cambridge, Cambridge, UK
| | | | - Annie Hawton
- Health Economics Group, University of Exeter, Exeter, UK
| | - Emma Laing
- Intensive Care National Audit and Research Centre (ICNARC), London, UK
| | - Joanne Lucas
- NHS Blood and Transplant Clinical Trials Unit, Cambridge, UK
| | - Richard Lyon
- Air Ambulance Kent Surrey Sussex, Rochester, UK
- Department of Health Sciences, University of Surrey, Guildford, UK
| | - Gavin D Perkins
- Warwick Medical School, University of Warwick, Coventry, CV4 7AL, UK
| | - Laura Smith
- NHS Blood and Transplant Clinical Trials Unit, Cambridge, UK
| | - Simon J Stanworth
- NHS Blood & Transplant, Bristol, UK
- Oxford University Hospitals, Oxford, UK
- University of Oxford, Oxford, UK
| | - Anne Weaver
- London's Air Ambulance and Royal London Hospital, London, UK
| | - Tom Woolley
- Academic Department of Military Anaesthesia and Critical Care, Royal Centre for Defence Medicine, Birmingham, UK
| | - Laura Green
- NHS Blood & Transplant, Bristol, UK
- Barts Health NHS Trust, London, UK
- Queen Mary University of London, London, UK
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Hannadjas I, James A, Davenport R, Lindsay C, Brohi K, Cole E. Prothrombin complex concentrate (PCC) for treatment of trauma-induced coagulopathy: systematic review and meta-analyses. Crit Care 2023; 27:422. [PMID: 37919775 PMCID: PMC10621181 DOI: 10.1186/s13054-023-04688-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 10/14/2023] [Indexed: 11/04/2023] Open
Abstract
BACKGROUND Trauma-induced coagulopathy (TIC) is common in trauma patients with major hemorrhage. Prothrombin complex concentrate (PCC) is used as a potential treatment for the correction of TIC, but the efficacy, timing, and evidence to support its use in injured patients with hemorrhage are unclear. METHODS A systematic search of published studies was performed on MEDLINE and EMBASE databases using standardized search equations. Ongoing studies were identified using clinicaltrials.gov. Studies investigating the use of PCC to treat TIC (on its own or in combination with other treatments) in adult major trauma patients were included. Studies involving pediatric patients, studies of only traumatic brain injury (TBI), and studies involving only anticoagulated patients were excluded. Primary outcomes were in-hospital mortality and venous thromboembolism (VTE). Pooled effects of PCC use were reported using random-effects model meta-analyses. Risk of bias was assessed for each study, and we used the Grading of Recommendations Assessment, Development, and Evaluation to assess the quality of evidence. RESULTS After removing duplicates, 1745 reports were screened and nine observational studies and one randomized controlled trial (RCT) were included, with a total of 1150 patients receiving PCC. Most studies used 4-factor-PCC with a dose of 20-30U/Kg. Among observational studies, co-interventions included whole blood (n = 1), fibrinogen concentrate (n = 2), or fresh frozen plasma (n = 4). Outcomes were inconsistently reported across studies with wide variation in both measurements and time points. The eight observational studies included reported mortality with a pooled odds ratio of 0.97 [95% CI 0.56-1.69], and five reported deep venous thrombosis (DVT) with a pooled OR of 0.83 [95% CI 0.44-1.57]. When pooling the observational studies and the RCT, the OR for mortality and DVT was 0.94 [95% CI 0.60-1.45] and 1.00 [95% CI 0.64-1.55] respectively. CONCLUSIONS Among published studies of TIC, PCCs did not significantly reduce mortality, nor did they increase the risk of VTE. However, the potential thrombotic risk remains a concern that should be addressed in future studies. Several RCTs are currently ongoing to further explore the efficacy and safety of PCC.
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Affiliation(s)
- Ioannis Hannadjas
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, England
| | - Arthur James
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, England.
- GRC 29, AP-HP, DMU DREAM, Department of Anaesthesiology and Critical Care, Pitié-Salpêtrière Hospital, Sorbonne University, 47-83 Boulevard de l'Hôpital, 75013, Paris, France.
| | - Ross Davenport
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, England
| | - Charlotte Lindsay
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, England
| | - Karim Brohi
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, England
| | - Elaine Cole
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, England
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Alruwaili A, Khorram-Manesh A, Ratnayake A, Robinson Y, Goniewicz K. The Use of Prehospital Intensive Care Units in Emergencies-A Scoping Review. Healthcare (Basel) 2023; 11:2892. [PMID: 37958036 PMCID: PMC10647734 DOI: 10.3390/healthcare11212892] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Revised: 10/20/2023] [Accepted: 10/30/2023] [Indexed: 11/15/2023] Open
Abstract
BACKGROUND Amidst a rising tide of trauma-related emergencies, emergency departments worldwide grapple with the challenges of overcrowding and prolonged patient wait times. Addressing these challenges, the integration of prehospital intensive care units has appeared as a promising solution, streamlining trauma care and enhancing patient safety. Nevertheless, the feasibility of such an initiative becomes murky when considered globally. This review delves into the intricacies of prehospital intensive care units' deployment for trauma care, scrutinizing their configurations, operational practices, and the inherent challenges and research priorities. METHODS A scoping review was performed for eligible studies. The result was uploaded to the RAYYAN research platform, facilitating simultaneous evaluation of the studies by all researchers. RESULTS A total of 42 studies were initially selected. Four studies were duplicates, and 25 studies were unanimously removed as irrelevant. The remaining studies (n = 13) were included in the review, and the outcomes were categorized into diverse subgroups. CONCLUSIONS A country's emergency medical services must achieve specific milestones in education, competency, resource availability, and performance to effectively harness the potential of a prehospital intensive care unit. While certain nations are equipped, others lag, highlighting a global disparity in readiness for such advanced care modalities.
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Affiliation(s)
- Abdullah Alruwaili
- Emergency Medical Services Department, College of Applied Medical Sciences, King Saud Bin Abdulaziz University for Health Sciences, Al Ahsa 36428, Saudi Arabia
- King Abdullah International Medical Research Center, Al Ahsa 36428, Saudi Arabia
- Ministry of National Guard—Health Affairs, Al Ahsa 36428, Saudi Arabia
- School of Health, University of New England, Armidale, NSW 2350, Australia
| | - Amir Khorram-Manesh
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, 41345 Goteborg, Sweden;
- Center for Disaster Medicine, University of Gothenburg, 40530 Gothenburg, Sweden;
- Gothenburg Emergency Medicine Research Group (GEMREG), Sahlgrenska University Hospital, 41305 Goteborg, Sweden
| | - Amila Ratnayake
- Army Hospital Colombo, Department of Surgery, Colombo 08, Sri Lanka;
| | - Yohan Robinson
- Center for Disaster Medicine, University of Gothenburg, 40530 Gothenburg, Sweden;
- Swedish Armed Forces Centre for Defence Medicine, 42605 Västra Frölunda, Sweden
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Katzenschlager S, Obermaier M, Kuhner M, Spöttl W, Dietrich M, Weigand MA, Weilbacher F, Popp E. [Focus emergency medicine 2022/2023-Summary of selected studies in emergency medicine]. DIE ANAESTHESIOLOGIE 2023; 72:809-820. [PMID: 37725144 DOI: 10.1007/s00101-023-01330-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 08/02/2023] [Indexed: 09/21/2023]
Affiliation(s)
- S Katzenschlager
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland.
| | - M Obermaier
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - M Kuhner
- Klinik für Intensivmedizin, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland
| | - W Spöttl
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - M Dietrich
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - M A Weigand
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - F Weilbacher
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - E Popp
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
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Douin DJ, Fernandez-Bustamante A. Early Fibrinogen Replacement to Treat the Endotheliopathy of Trauma: Novel Resuscitation Strategies in Severe Trauma. Anesthesiology 2023; 139:675-683. [PMID: 37815472 PMCID: PMC10575674 DOI: 10.1097/aln.0000000000004711] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/11/2023]
Abstract
The authors provide a comprehensive review of the endothelial glycocalyx, the components that may be targeted to improve clinical outcomes, and the next steps for evaluation in human subjects.
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Affiliation(s)
- David J Douin
- Department of Anesthesiology, University of Colorado School of Medicine, Aurora, Colorado
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Maegele M, Lier H, Hossfeld B. Pre-Hospital Blood Products for the Care of Bleeding Trauma Patients. DEUTSCHES ARZTEBLATT INTERNATIONAL 2023; 120:670-676. [PMID: 37551452 PMCID: PMC10644958 DOI: 10.3238/arztebl.m2023.0176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 07/13/2023] [Accepted: 07/13/2023] [Indexed: 08/09/2023]
Abstract
BACKGROUND Controversy surrounds the administration of blood products to severely traumatized patients before they arrive in the hospital in order to compensate for early blood loss and/or to correct coagulation disturbances that arise shortly after the traumatic event. A number of terrestrial and air rescue services have begun to provide this kind of treatment. METHODS This review is based on articles using the PICO framework, published from January 2001 to January 2021, that were retrieved by a selective search, with structured searching strategies and searching bundles in Medline (OVIDSP), the Cochrane Central Register of Controlled Trials (CENTRAL), and Epistemonikos. A demand analysis was carried out on the basis of data from the trauma registry of the German Society of Trauma Surgery (TR-DGU) and practical experience from program development and implementation was provided by the Bundeswehr Hospital Ulm. RESULTS The currently available evidence on the pre-hospital administration of blood products in the early treatment of severely injured patients is based largely on retrospective, single-center case series. Two randomized controlled trials (RCTs) concerning the early use of fresh frozen plasma concentrates have yielded partly conflicting results. Three further RCTs on the use of lyophilized plasma (lyplas), lyplas plus erythrocyte concentrate, or whole blood likewise revealed non-uniform effects on short-term and intermediate-term mortality. Our demand analysis based on data from the TR-DGU showed that 300 to 1800 patients per year in Germany could benefit from the pre-hospital administration of blood products. This might be indicated in patients who have systolic hypotension (<100 mmHg) in combination with a suspected or confirmed hemorrhage, as well as pathological shock parameters in the point-of-care diagnostic testing performed on the scene (serum base excess ≤ -2.5 mmol/L and/or serum lactate concentration >4 mmol/L). CONCLUSION The studies that have been published to date yield no clear evidence either for or against the early pre-hospital administration of blood products. Any treatment of this kind should be accompanied by scientific evaluation.
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Affiliation(s)
- Marc Maegele
- *Joint first authors
- Department of Trauma and Orthopaedic Surgery, Cologne-Merheim Medical Centre (CMMC), University of Witten/Herdecke, Cologne
- Institute for Research in Operative Medicine (IFOM), University of Witten/Herdecke, Campus Cologne-Merheim, Cologne
| | - Heiko Lier
- *Joint first authors
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Cologne, Cologne
| | - Björn Hossfeld
- Department of Anaesthesiology and Intensive Care Medicine, Armed Forces Hospital Ulm, Ulm
- Rescue transport helicopter (RTH) „Christoph 22“ Ulm, ADAC-Air Rescue, Ulm
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Mitra B, Meadley B, Bernard S, Maegele M, Gruen RL, Bradley O, Wood EM, McQuilten ZK, Fitzgerald M, St. Clair T, Webb A, Anderson D, Reade MC. Pre-hospital freeze-dried plasma for critical bleeding after trauma: A pilot randomized controlled trial. Acad Emerg Med 2023; 30:1013-1019. [PMID: 37103482 PMCID: PMC10946458 DOI: 10.1111/acem.14745] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 04/06/2023] [Accepted: 04/13/2023] [Indexed: 04/28/2023]
Abstract
OBJECTIVES Transfusion of a high ratio of plasma to packed red blood cells (PRBCs), to treat or prevent acute traumatic coagulopathy, has been associated with survival after major trauma. However, the effect of prehospital plasma on patient outcomes has been inconsistent. The aim of this pilot trial was to assess the feasibility of transfusing freeze-dried plasma with red blood cells (RBCs) using a randomized controlled design in an Australian aeromedical prehospital setting. METHODS Patients attended by helicopter emergency medical service (HEMS) paramedics with suspected critical bleeding after trauma managed with prehospital RBCs were randomized to receive 2 units of freeze-dried plasma (Lyoplas N-w) or standard care (no plasma). The primary outcome was the proportion of eligible patients enrolled and provided the intervention. Secondary outcomes included preliminary data on effectiveness, including mortality censored at 24 h and at hospital discharge, and adverse events. RESULTS During the study period of June 1 to October 31, 2022, there were 25 eligible patients, of whom 20 (80%) were enrolled in the trial and 19 (76%) received the allocated intervention. Median time from randomization to hospital arrival was 92.5 min (IQR 68-101.5 min). Mortality may have been lower in the freeze-dried plasma group at 24 h (RR 0.24, 95% CI 0.03-1.73) and at hospital discharge (RR 0.73, 95% CI 0.24-2.27). No serious adverse events related to the trial interventions were reported. CONCLUSIONS This first reported experience of freeze-dried plasma use in Australia suggests prehospital administration is feasible. Given longer prehospital times typically associated with HEMS attendance, there is potential clinical benefit from this intervention and rationale for a definitive trial.
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Affiliation(s)
- Biswadev Mitra
- Alfred Health Emergency ServicesMelbourneVictoriaAustralia
- School of Public Health & Preventive MedicineMonash UniversityMelbourneVictoriaAustralia
| | - Ben Meadley
- Department of ParamedicineMonash UniversityFrankstonVictoriaAustralia
- Ambulance VictoriaDoncasterVictoriaAustralia
| | - Stephen Bernard
- School of Public Health & Preventive MedicineMonash UniversityMelbourneVictoriaAustralia
- Ambulance VictoriaDoncasterVictoriaAustralia
- Department of Intensive CareThe Alfred HospitalMelbourneVictoriaAustralia
| | - Marc Maegele
- Department of Traumatology and Orthopaedic SurgeryCologne‐Merheim Medical CentreCologneGermany
- Institute for Research in Operative Medicine, Experimental/Clinical Research UnitUniversity Witten‐HerdeckeCologneGermany
| | - Russell L. Gruen
- College of Health and MedicineAustralian National UniversityCanberraAustralian Capital TerritoryAustralia
| | | | - Erica M. Wood
- School of Public Health & Preventive MedicineMonash UniversityMelbourneVictoriaAustralia
- Department of HaematologyMonash HealthMelbourneVictoriaAustralia
| | - Zoe K. McQuilten
- School of Public Health & Preventive MedicineMonash UniversityMelbourneVictoriaAustralia
- Department of HaematologyMonash HealthMelbourneVictoriaAustralia
| | - Mark Fitzgerald
- Trauma ServiceThe Alfred HospitalMelbourneVictoriaAustralia
- Central Clinical SchoolMonash UniversityMelbourneVictoriaAustralia
- National Trauma Research InstituteMelbourneVictoriaAustralia
| | - Toby St. Clair
- Department of ParamedicineMonash UniversityFrankstonVictoriaAustralia
- Ambulance VictoriaDoncasterVictoriaAustralia
| | - Andrew Webb
- Department of HaematologyThe Alfred HospitalPrahran, MelbourneVictoriaAustralia
| | - David Anderson
- Department of ParamedicineMonash UniversityFrankstonVictoriaAustralia
- Ambulance VictoriaDoncasterVictoriaAustralia
- Department of Intensive CareThe Alfred HospitalMelbourneVictoriaAustralia
| | - Michael C. Reade
- School of Public Health & Preventive MedicineMonash UniversityMelbourneVictoriaAustralia
- Faculty of MedicineRoyal Brisbane and Women's Hospital, The University of QueenslandHerstonQueenslandAustralia
- Joint Health Command, Australian Defence ForceCanberraAustralian Capital TerritoryAustralia
- Department of Intensive Care MedicineRoyal Brisbane and Women's HospitalBrisbaneQueenslandAustralia
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Jeanmougin T, Cole E, Duceau B, Raux M, James A. Heterogeneity in defining multiple trauma: a systematic review of randomized controlled trials. Crit Care 2023; 27:363. [PMID: 37736733 PMCID: PMC10515068 DOI: 10.1186/s13054-023-04637-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 09/05/2023] [Indexed: 09/23/2023] Open
Abstract
INTRODUCTION While numerous randomized controlled trials (RCTs) have been conducted in the field of trauma, a substantial portion of them are yielding negative results. One potential contributing factor to this trend could be the lack of agreement regarding the chosen definitions across different trials. The primary objective was to identify the terminology and definitions utilized for the characterization of multiple trauma patients within randomized controlled trials (RCTs). METHODS A systematic review of the literature was performed in MEDLINE, EMBASE and clinicaltrials.gov between January 1, 2002, and July 31, 2022. RCTs or RTCs protocols were eligible if they included multiple trauma patients. The terms employed to characterize patient populations were identified, and the corresponding definitions for these terms were extracted. The subsequent impact on the population recruited was then documented to expose clinical heterogeneity. RESULTS Fifty RCTs were included, and 12 different terms identified. Among these terms, the most frequently used were "multiple trauma" (n = 21, 42%), "severe trauma" (n = 8, 16%), "major trauma" (n = 4, 8%), and trauma with hemorrhagic shock" (n = 4, 8%). Only 62% of RCTs (n = 31) provided a definition for the terms used, resulting a total of 21 different definitions. These definitions primarily relied on the injury severity score (ISS) (n = 15, 30%), displaying an important underlying heterogeneity. The choice of the terms had an impact on the study population, affecting both the ISS and in-hospital mortality. Eleven protocols were included, featuring five different terms, with "severe trauma" being the most frequent, occurring six times (55%). CONCLUSION This systematic review uncovers an important heterogeneity both in the terms and in the definitions employed to recruit trauma patients within RCTs. These findings underscore the imperative of promoting the use of a unique and consistent definition.
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Affiliation(s)
- Thomas Jeanmougin
- Sorbonne University, GRC 29, AP-HP, DMU DREAM, Department of Anesthesiology and critical care, Pitié-Salpêtrière Hospital, Paris, France
| | - Elaine Cole
- Centre of Trauma Sciences, Blizard Institute, Queen Mary University of London, London, UK
| | - Baptiste Duceau
- Sorbonne University, GRC 29, AP-HP, DMU DREAM, Department of Anesthesiology and critical care, Pitié-Salpêtrière Hospital, Paris, France
| | - Mathieu Raux
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique; AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, site Pitié-Salpêtrière, Département d'Anesthésie Réanimation, F-75013, Paris, France
| | - Arthur James
- Sorbonne University, GRC 29, AP-HP, DMU DREAM, Department of Anesthesiology and critical care, Pitié-Salpêtrière Hospital, Paris, France.
- Centre of Trauma Sciences, Blizard Institute, Queen Mary University of London, London, UK.
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Manning JE, Morrison JJ, Pepe PE. Prehospital Resuscitation: What Should It Be? Adv Surg 2023; 57:233-256. [PMID: 37536856 DOI: 10.1016/j.yasu.2023.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/05/2023]
Abstract
Prehospital resuscitation is a dynamic field now being energized by new technologies and a shift in thinking regarding intravascular resuscitation. Growing evidence discourages use of intravenous (IV) crystalloid and colloid solutions in trauma, whereas blood products, particularly whole blood, are becoming preferred. Although randomized clinical trials validating definitive resuscitative protocols are still lacking, most preclinical and clinical indicators support this approach. In addition, emerging technologies such as external and endovascular hemorrhage control devices and extracorporeal perfusion are now being used routinely, even in the prehospital setting in many countries, generating new lines of emerging investigations for trauma specialists.
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Affiliation(s)
- James E Manning
- Department of Emergency Medicine, University of North Carolina at Chapel Hill, 170 Manning Drive, CB# 7594, Chapel Hill, NC 27599-7594, USA.
| | - Jonathan J Morrison
- Division of Vascular and Endovascular Surgery, Mayo Clinic, 200 First Street, Rochester, MN 55905, USA
| | - Paul E Pepe
- University of Miami, Miller School of Medicine, Miami, FL, USA; Dallas County Public Safety, Emergency Medical Services, Dallas, TX, USA; Global Emergency Medical Services, Suite 307 Point of Americas One, 2100 South Ocean Lane, Fort Lauderdale, FL 33316-3823, USA
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Callum J, Evans CCD, Barkun A, Karkouti K. Prise en charge non chirurgicale de l’hémorragie majeure. CMAJ 2023; 195:E1126-E1135. [PMID: 37640404 PMCID: PMC10462413 DOI: 10.1503/cmaj.221731-f] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/31/2023] Open
Affiliation(s)
- Jeannie Callum
- Département de pathologie et de médecine moléculaire (Callum), Centre des sciences de la santé Kingston et Université Queen's; Département de médecine d'urgence et Division de traumatologie (Evans), Centre des sciences de la santé de Kingston, Kingston, Ont.; Département de médecine, Université McGill et Centre universitaire de santé McGill (Barkun), Montréal, Qc; Département d'anesthésiologie et de traitement de la douleur (Karkouti), Hôpital général de Toronto et Université de Toronto, Toronto, Ont.
| | - Christopher C D Evans
- Département de pathologie et de médecine moléculaire (Callum), Centre des sciences de la santé Kingston et Université Queen's; Département de médecine d'urgence et Division de traumatologie (Evans), Centre des sciences de la santé de Kingston, Kingston, Ont.; Département de médecine, Université McGill et Centre universitaire de santé McGill (Barkun), Montréal, Qc; Département d'anesthésiologie et de traitement de la douleur (Karkouti), Hôpital général de Toronto et Université de Toronto, Toronto, Ont
| | - Alan Barkun
- Département de pathologie et de médecine moléculaire (Callum), Centre des sciences de la santé Kingston et Université Queen's; Département de médecine d'urgence et Division de traumatologie (Evans), Centre des sciences de la santé de Kingston, Kingston, Ont.; Département de médecine, Université McGill et Centre universitaire de santé McGill (Barkun), Montréal, Qc; Département d'anesthésiologie et de traitement de la douleur (Karkouti), Hôpital général de Toronto et Université de Toronto, Toronto, Ont
| | - Keyvan Karkouti
- Département de pathologie et de médecine moléculaire (Callum), Centre des sciences de la santé Kingston et Université Queen's; Département de médecine d'urgence et Division de traumatologie (Evans), Centre des sciences de la santé de Kingston, Kingston, Ont.; Département de médecine, Université McGill et Centre universitaire de santé McGill (Barkun), Montréal, Qc; Département d'anesthésiologie et de traitement de la douleur (Karkouti), Hôpital général de Toronto et Université de Toronto, Toronto, Ont
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Ye H, Du Y, Jin Y, Liu F, He S, Guo Y. Articles on hemorrhagic shock published between 2000 and 2021: A CiteSpace-Based bibliometric analysis. Heliyon 2023; 9:e18840. [PMID: 37636355 PMCID: PMC10450864 DOI: 10.1016/j.heliyon.2023.e18840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2022] [Revised: 07/28/2023] [Accepted: 07/31/2023] [Indexed: 08/29/2023] Open
Abstract
Objective To conduct a bibliometric analysis of literature on hemorrhagic shock published between 2000 and 2021 with the help of Citespace to explore the current status, hotspots and research trends in this regard, with the results presented in a visualized manner. Methods The data over the past 22 years were retrieved from the Web of Science (WOS) Core Collection database and downloaded as the "Full Record and Cited References". Cooperative analysis, cluster analysis, co-citation analysis, and burst analysis were performed based on the data on countries/regions, institutions, journals, authors, and keywords through Citespace. Results A total of 2027 articles were retrieved. The number of annual publications fluctuated but was generally on an upward trend. The United States stands out as the most productive country (989 articles), the University of Pittsburgh the most productive publishing institution (109 articles), SHOCK the most cited journal (1486 articles), TAO LI the most productive author (40 articles), DEITCH EA the most cited author (261 times of citation), hemorrhagic shock the most frequent keyword (725 times of occurrence), and "traumatic brain injury" the most covered article in keyword clustering (29 articles). The burst analysis revealed Harvard University as the institution with the highest strength value and the Journal of Trauma and Acute Care Surgery the most important journal. It was also concluded that HASAN B ALAM, AARON M WILLIAMS, and LIMIN ZHANG may continue to publish high-quality articles in the future. In the meanwhile, both "protect" and "transfusion" were considered the hotspots and trends in current research. Conclusions The United States has been a major contributor to the publication of the articles over the past 22 years, with the most productive publishing institution, the most cited journal, and the most cited author all coming from the US. Hemorrhagic shock, injury, resuscitation, trauma, models, activation, expression, fluid resuscitation, rats, and nitric oxide are hot topics in relevant research. According to the keyword burst analysis, the areas related to "protect" and "transfusion" may rise as the research directions in the future. However, since the hotspots in the research of hemorrhagic shock are short-lived and fast-changing, the researchers should pay more attention to the development trend in this field.
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Affiliation(s)
- Haoran Ye
- Beijing Hospital of Traditional Chinese Medicine, Capital Medical University, Beijing, China
- Beijing Institute of Traditional Chinese Medicine, Beijing, China
- Beijing Key Laboratory of Basic Research with Traditional Chinese Medicine on Infectious Diseases, Beijing, China
| | - Yuan Du
- Beijing Hospital of Traditional Chinese Medicine, Capital Medical University, Beijing, China
- Beijing University of Chinese Medicine, Beijing, China
| | - Yueting Jin
- Beijing Hospital of Traditional Chinese Medicine, Capital Medical University, Beijing, China
- Beijing Institute of Traditional Chinese Medicine, Beijing, China
- Beijing Key Laboratory of Basic Research with Traditional Chinese Medicine on Infectious Diseases, Beijing, China
| | - Fangyu Liu
- Beijing Hospital of Traditional Chinese Medicine, Capital Medical University, Beijing, China
- Beijing University of Chinese Medicine, Beijing, China
| | - Shasha He
- Beijing Hospital of Traditional Chinese Medicine, Capital Medical University, Beijing, China
- Beijing Institute of Traditional Chinese Medicine, Beijing, China
- Beijing Key Laboratory of Basic Research with Traditional Chinese Medicine on Infectious Diseases, Beijing, China
| | - Yuhong Guo
- Beijing Hospital of Traditional Chinese Medicine, Capital Medical University, Beijing, China
- Beijing Institute of Traditional Chinese Medicine, Beijing, China
- Beijing Key Laboratory of Basic Research with Traditional Chinese Medicine on Infectious Diseases, Beijing, China
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Metcalf RA, Cohn CS, Bakhtary S, Gniadek T, Gupta G, Harm S, Haspel RL, Hess AS, Jacobson J, Lokhandwala PM, Murphy C, Poston JN, Prochaska MT, Raval JS, Saifee NH, Salazar E, Shan H, Zantek ND, Pagano MB. Current advances in 2022: A critical review of selected topics by the Association for the Advancement of Blood and Biotherapies (AABB) Clinical Transfusion Medicine Committee. Transfusion 2023; 63:1590-1600. [PMID: 37403547 DOI: 10.1111/trf.17475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 05/16/2023] [Indexed: 07/06/2023]
Abstract
BACKGROUND The Association for the Advancement of Blood and Biotherapies Clinical Transfusion Medicine Committee (CTMC) composes a summary of new and important advances in transfusion medicine (TM) on an annual basis. Since 2018, this has been assembled into a manuscript and published in Transfusion. STUDY DESIGN AND METHODS CTMC members selected original manuscripts relevant to TM that were published electronically and/or in print during calendar year 2022. Papers were selected based on perceived importance and/or originality. References for selected papers were made available to CTMC members to provide feedback. Members were also encouraged to identify papers that may have been omitted initially. They then worked in groups of two to three to write a summary for each new publication within their broader topic. Each topic summary was then reviewed and edited by two separate committee members. The final manuscript was assembled by the first and senior authors. While this review is extensive, it is not a systematic review and some publications considered important by readers may have been excluded. RESULTS For calendar year 2022, summaries of key publications were assembled for the following broader topics within TM: blood component therapy; infectious diseases, blood donor testing, and collections; patient blood management; immunohematology and genomics; hemostasis; hemoglobinopathies; apheresis and cell therapy; pediatrics; and health care disparities, diversity, equity, and inclusion. DISCUSSION This Committee Report reviews and summarizes important publications and advances in TM published during calendar year 2022, and maybe a useful educational tool.
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Affiliation(s)
- Ryan A Metcalf
- Department of Pathology, University of Utah, Salt Lake City, Utah, USA
| | - Claudia S Cohn
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Sara Bakhtary
- Department of Laboratory Medicine, University of California San Francisco, San Francisco, California, USA
| | | | - Gaurav Gupta
- Department of Pathology and Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Sarah Harm
- Department of Pathology and Laboratory Medicine, University of Vermont, Burlington, Vermont, USA
| | - Richard L Haspel
- Department of Pathology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, USA
| | - Aaron S Hess
- Departments of Anesthesiology and Pathology & Laboratory Medicine, University of Wisconsin, Madison, Wisconsin, USA
| | - Jessica Jacobson
- Department of Pathology, NYU Grossman School of Medicine, New York, New York, USA
| | - Parvez M Lokhandwala
- Department of Pathology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Colin Murphy
- TriCore Reference Laboratories, Albuquerque, New Mexico, USA
| | - Jacqueline N Poston
- Department of Pathology and Laboratory Medicine, University of Vermont, Burlington, Vermont, USA
- Department of Medicine, University of Vermont, Burlington, Vermont, USA
| | - Micah T Prochaska
- Department of Medicine, University of Chicago, Chicago, Illinois, USA
| | - Jay S Raval
- Department of Pathology, University of New Mexico, Albuquerque, New Mexico, USA
| | | | - Eric Salazar
- Department of Pathology, UT Health San Antonio, San Antonio, Texas, USA
| | - Hua Shan
- Department of Pathology, Stanford University, Palo Alto, California, USA
| | - Nicole D Zantek
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Monica B Pagano
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, Washington, USA
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Coyle C, Zitek T, Pepe PE, Stotsenburg M, Scheppke KA, Antevy P, Giroux R, Farcy DA. The Implementation of a Prehospital Whole Blood Transfusion Program and Early Results. Prehosp Disaster Med 2023; 38:513-517. [PMID: 37357937 DOI: 10.1017/s1049023x23005952] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/27/2023]
Abstract
INTRODUCTION In far-forward combat situations, the military challenged dogma by using whole blood transfusions (WBTs) rather than component-based therapy. More recently, some trauma centers have initiated WBT programs with reported success. There are a few Emergency Medical Service (EMS) systems that are using WBTs, but the vast majority are not. Given the increasing data supporting the use of WBTs in the prehospital setting, more EMS systems are likely to consider or begin WBT programs in the future. OBJECTIVE A prehospital WBT program was recently implemented in Palm Beach County, Florida (USA). This report will discuss how the program was implemented, the obstacles faced, and the initial results. METHODS This report describes the process by which a prehospital WBT program was implemented by Palm Beach County Fire Rescue and the outcomes of the initial case series of patients who received WBTs in this system. Efforts to initiate the prehospital WBT program for this system began in 2018. The program had several obstacles to overcome, with one of the major obstacles being the legal team's perception of potential liability that might occur with a new prehospital blood transfusion program. This obstacle was overcome through education of local elected officials regarding the latest scientific evidence in favor of prehospital WBTs with potential life-saving benefits to the community. After moving past this hurdle, the program went live on July 6, 2022. The initial indications for transfusion of cold-stored, low titer, leukoreduced O+ whole blood in the prehospital setting included traumatic injuries with systolic blood pressure (SBP) < 70mmHg or SBP < 90mmHg plus heart rate (HR) > 110 beats per minute. FINDINGS From the date of onset through December 31, 2022, Palm Beach County Fire Rescue transported a total of 881 trauma activation patients, with 20 (2.3%) receiving WBT. Overall, nine (45%) of the patients who had received WBTs so far remain alive. No adverse events related to transfusion were identified following WBT administration. A total of 18 units of whole blood reached expiration of the unit's shelf life prior to transfusion. CONCLUSION Despite a number of logistical and legal obstacles, Palm Beach County Fire Rescue successfully implemented a prehospital WBT program. Other EMS systems that are considering a prehospital WBT program should review the included protocol and the barriers to implementation that were faced.
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Affiliation(s)
- Charles Coyle
- Palm Beach County Fire Rescue, West Palm Beach, FloridaUSA
| | - Tony Zitek
- Department of Emergency Medicine, Mt. Sinai Medical Center, Miami Beach, FloridaUSA
| | - Paul E Pepe
- Palm Beach County Fire Rescue, West Palm Beach, FloridaUSA
| | - Madonna Stotsenburg
- Department of Trauma Services and Emergency Management, St. Mary's Medical Center, West Palm Beach, FloridaUSA
| | | | - Peter Antevy
- Palm Beach County Fire Rescue, West Palm Beach, FloridaUSA
| | - Richard Giroux
- Palm Beach County Fire Rescue, West Palm Beach, FloridaUSA
| | - David A Farcy
- Palm Beach County Fire Rescue, West Palm Beach, FloridaUSA
- Department of Emergency Medicine, Mt. Sinai Medical Center, Miami Beach, FloridaUSA
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Lin VS, Sun E, Yau S, Abeyakoon C, Seamer G, Bhopal S, Tucker H, Doree C, Brunskill SJ, McQuilten ZK, Stanworth SJ, Wood EM, Green L. Definitions of massive transfusion in adults with critical bleeding: a systematic review. Crit Care 2023; 27:265. [PMID: 37407998 DOI: 10.1186/s13054-023-04537-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 06/19/2023] [Indexed: 07/07/2023] Open
Abstract
BACKGROUND Definitions for massive transfusion (MT) vary widely between studies, contributing to challenges in interpretation of research findings and practice evaluation. In this first systematic review, we aimed to identify all MT definitions used in randomised controlled trials (RCTs) to date to inform the development of consensus definitions for MT. METHODS We systematically searched the following databases for RCTs from inception until 11 August 2022: MEDLINE, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), PubMed, Cumulative Index to Nursing and Allied Health Literature, and Transfusion Evidence Library. Ongoing trials were sought from CENTRAL, ClinicalTrials.gov, and World Health Organisation International Clinical Trials Registry Platform. To be eligible for inclusion, studies had to fulfil all the following three criteria: (1) be an RCT; (2) include an adult patient population with major bleeding who had received, or were anticipated to receive, an MT in any clinical setting; and (3) specify a definition for MT as an inclusion criterion or outcome measure. RESULTS Of the 8,458 distinct references identified, 30 trials were included for analysis (19 published, 11 ongoing). Trauma was the most common clinical setting in published trials, while for ongoing trials, it was obstetrics. A total of 15 different definitions of MT were identified across published and ongoing trials, varying greatly in cut-offs for volume transfused and time period. Almost all definitions specified the number of red blood cells (RBCs) within a set time period, with none including plasma, platelets or other haemostatic agents that are part of contemporary transfusion resuscitation. For completed trials, the most commonly used definition was transfusion of ≥ 10 RBC units in 24 h (9/19, all in trauma), while for ongoing trials it was 3-5 RBC units (n = 7), with the timing for transfusion being poorly defined, or in some trials not provided at all (n = 5). CONCLUSIONS Transfusion of ≥ 10 RBC units within 24 h was the most commonly used definition in published RCTs, while lower RBC volumes are being used in ongoing RCTs. Any consensus definitions should reflect the need to incorporate different blood components/products for MT and agree on whether a 'one-size-fits-all' approach should be used across different clinical settings.
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Affiliation(s)
- Victor S Lin
- Transfusion Research Unit, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Emily Sun
- Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Parkville, Australia
| | - Serine Yau
- Faculty of Medicine, Nursing, and Health Sciences, Monash University, Clayton, Australia
| | | | - Georgia Seamer
- Faculty of Medicine, Nursing, and Health Sciences, Monash University, Clayton, Australia
| | - Simran Bhopal
- Faculty of Medicine, Nursing, and Health Sciences, Monash University, Clayton, Australia
| | - Harriet Tucker
- Blizard Institute, Queen Mary University of London, London, UK
| | - Carolyn Doree
- Systematic Review Initiative, NHS Blood and Transplant, Oxford, UK
| | | | - Zoe K McQuilten
- Transfusion Research Unit, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Department of Clinical Haematology, Monash Health, Clayton, Australia
| | - Simon J Stanworth
- Systematic Review Initiative, NHS Blood and Transplant, Oxford, UK
- Radcliffe Department of Medicine, University of Oxford, Oxford, UK
- National Institute for Health Research Biomedical Research Centre Haematology Theme, Oxford, UK
- Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Erica M Wood
- Transfusion Research Unit, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Department of Clinical Haematology, Monash Health, Clayton, Australia
| | - Laura Green
- Blizard Institute, Queen Mary University of London, London, UK.
- NHS Blood and Transplant, London, UK.
- Barts Health NHS Trust, London, UK.
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Latif RK, Clifford SP, Baker JA, Lenhardt R, Haq MZ, Huang J, Farah I, Businger JR. Traumatic hemorrhage and chain of survival. Scand J Trauma Resusc Emerg Med 2023; 31:25. [PMID: 37226264 DOI: 10.1186/s13049-023-01088-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Accepted: 05/05/2023] [Indexed: 05/26/2023] Open
Abstract
Trauma is the number one cause of death among Americans between the ages of 1 and 46 years, costing more than $670 billion a year. Following death related to central nervous system injury, hemorrhage accounts for the majority of remaining traumatic fatalities. Among those with severe trauma that reach the hospital alive, many may survive if the hemorrhage and traumatic injuries are diagnosed and adequately treated in a timely fashion. This article aims to review the recent advances in pathophysiology management following a traumatic hemorrhage as well as the role of diagnostic imaging in identifying the source of hemorrhage. The principles of damage control resuscitation and damage control surgery are also discussed. The chain of survival for severe hemorrhage begins with primary prevention; however, once trauma has occurred, prehospital interventions and hospital care with early injury recognition, resuscitation, definitive hemostasis, and achieving endpoints of resuscitation become paramount. An algorithm is proposed for achieving these goals in a timely fashion as the median time from onset of hemorrhagic shock and death is 2 h.
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Affiliation(s)
- Rana K Latif
- Department of Anesthesiology and Perioperative Medicine, University of Louisville School of Medicine, University of Louisville Hospital, 530 S. Jackson St., Louisville, KY, 40202, USA.
- Paris Simulation Center, Office of Medical Education, University of Louisville School of Medicine, Louisville, KY, USA.
- Outcomes Research Consortium, Cleveland, OH, USA.
| | - Sean P Clifford
- Department of Anesthesiology and Perioperative Medicine, University of Louisville School of Medicine, University of Louisville Hospital, 530 S. Jackson St., Louisville, KY, 40202, USA
| | - Jeffery A Baker
- Department of Emergency Medicine, University of Louisville School of Medicine, Louisville, KY, USA
| | - Rainer Lenhardt
- Department of Anesthesiology and Perioperative Medicine, University of Louisville School of Medicine, University of Louisville Hospital, 530 S. Jackson St., Louisville, KY, 40202, USA
| | - Mohammad Z Haq
- Department of Anesthesiology and Perioperative Medicine, University of Louisville School of Medicine, University of Louisville Hospital, 530 S. Jackson St., Louisville, KY, 40202, USA
| | - Jiapeng Huang
- Department of Anesthesiology and Perioperative Medicine, University of Louisville School of Medicine, University of Louisville Hospital, 530 S. Jackson St., Louisville, KY, 40202, USA
- Department of Cardiovascular & Thoracic Surgery, Cardiovascular Innovation Institute, University of Louisville, Louisville, KY, USA
- The Center for Integrative Environmental Health Sciences, University of Louisville, Louisville, KY, USA
- Department of Pharmacology and Toxicology, University of Louisville School of Medicine, Louisville, KY, USA
- Division of Infectious Diseases, Department of Medicine, Center of Excellence for Research in Infectious Diseases (CERID), University of Louisville, Louisville, KY, USA
| | - Ian Farah
- Department of Anesthesiology and Perioperative Medicine, University of Louisville School of Medicine, University of Louisville Hospital, 530 S. Jackson St., Louisville, KY, 40202, USA
| | - Jerrad R Businger
- Department of Anesthesiology and Perioperative Medicine, University of Louisville School of Medicine, University of Louisville Hospital, 530 S. Jackson St., Louisville, KY, 40202, USA
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von Vopelius-Feldt J, Lockwood J, Mal S, Beckett A, Callum J, Greene A, Grushka J, Khandelwal A, Lin Y, Nahirniak S, Pavenski K, Peddle M, Prokopchuk-Gauk O, Regehr J, Schmid J, Shih AW, Smith JA, Trojanowski J, Vu E, Ziesmann M, Nolan B. Development of a national out-of-hospital transfusion protocol: a modified RAND Delphi study. CMAJ Open 2023; 11:E546-E559. [PMID: 37369521 DOI: 10.9778/cmajo.20220151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/29/2023] Open
Abstract
BACKGROUND Early resuscitation with blood components or products is emerging as best practice in selected patients with trauma and medical patients; as a result, out-of-hospital transfusion (OHT) programs are being developed based on limited and often conflicting evidence. This study aimed to provide guidance to Canadian critical care transport organizations on the development of OHT protocols. METHODS The study period was July 2021 to June 2022. We used a modified RAND Delphi process to achieve consensus on statements created by the study team guiding various aspects of OHT in the context of critical care transport. Purposive sampling ensured representative distribution of participants in regard to geography and relevant clinical specialties. We conducted 2 written survey Delphi rounds, followed by a virtual panel discussion (round 3). Consensus was defined as a median score of at least 6 on a Likert scale ranging from 1 ("Definitely should not include") to 7 ("Definitely should include"). Statements that did not achieve consensus in the first 2 rounds were discussed and voted on during the panel discussion. RESULTS Seventeen subject experts participated in the study, all of whom completed the 3 Delphi rounds. After the study process was completed, a total of 39 statements were agreed on, covering the following domains: general oversight and clinical governance, storage and transport of blood components and products, initiation of OHT, types of blood components and products, delivery and monitoring of OHT, indications for and use of hemostatic adjuncts, and resuscitation targets of OHT. INTERPRETATION This expert consensus document provides guidance on OHT best practices. The consensus statements should support efficient and safe OHT in national and international critical care transport programs.
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Affiliation(s)
- Johannes von Vopelius-Feldt
- Ornge (von Vopelius-Feldt, Lockwood, Mal, Peddle, Smith, Nolan), Mississauga, Ont.; Department of Emergency Medicine (von Vopelius-Feldt, Lockwood, Nolan), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Division of Emergency Medicine (Mal, Peddle), London Health Sciences Centre, London, Ont.; Department of Surgery, Trauma and Acute Care Surgery (Beckett), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Canadian Forces Health Services Headquarters (Beckett, Schmid), Canadian Armed Forces, Ottawa, Ont.; Department of Pathology and Molecular Medicine (Callum), Kingston Health Sciences Centre and Queen's University, Kingston, Ont.; University of Toronto Quality in Utilization, Education and Safety in Transfusion (QUEST) research program (Callum, Khandelwal, Pavenski), Toronto, Ont.; AirEvac and Critical Care Operations (Greene, Vu), British Columbia Emergency Health Services, Vancouver, BC; School of Medicine (Greene), Cardiff University, Cardiff, Wales, UK; Division of Trauma and General Surgery (Grushka), McGill University Health Centre, Montreal General Hospital Site, Montréal, Que.; Canadian Blood Services (Khandelwal); Department of Laboratory Medicine and Pathobiology (Lin), University of Toronto; Precision Diagnostics and Therapeutics Program (Lin), Sunnybrook Health Sciences Centre, Toronto, Ont.; Faculty of Medicine (Nahirniak), University of Alberta, Edmonton, Alta.; Transfusion and Transplantation Medicine (Nahirniak), Alberta Precision Laboratories, Calgary, Alta.; Departments of Medicine and Laboratory Medicine (Pavenski), St. Michael's Hospital, Unity Health Toronto and University of Toronto, Toronto, Ont.; Division of Transfusion Medicine (Prokopchuk-Gauk), Department of Pathology and Laboratory Medicine, Saskatchewan Health Authority; College of Medicine (Prokopchuk-Gauk), University of Saskatchewan, Saskatoon, Sask.; Emergency Department (Regehr), Health Sciences Centre; Shock Trauma Air Rescue Service (STARS) (Regehr), Manitoba Base, Winnipeg, Man.; Department of Pathology and Laboratory Medicine (Shih), Vancouver Coastal Health Authority; Centre for Blood Research (Shih), University of British Columbia; Department of Emergency Medicine (Trojanowski), Vancouver General Hospital and the University of British Columbia; Clinical Operations (Trojanowski), British Columbia Emergency Health Services; Departments of Emergency Medicine and Critical Care Medicine (Vu), Vancouver Coastal Health Authority and Provincial Health Services Authority, Vancouver, BC; Department of Surgery and Section of Critical Care (Ziesmann), Health Sciences Centre, Winnipeg, Man.
| | - Joel Lockwood
- Ornge (von Vopelius-Feldt, Lockwood, Mal, Peddle, Smith, Nolan), Mississauga, Ont.; Department of Emergency Medicine (von Vopelius-Feldt, Lockwood, Nolan), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Division of Emergency Medicine (Mal, Peddle), London Health Sciences Centre, London, Ont.; Department of Surgery, Trauma and Acute Care Surgery (Beckett), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Canadian Forces Health Services Headquarters (Beckett, Schmid), Canadian Armed Forces, Ottawa, Ont.; Department of Pathology and Molecular Medicine (Callum), Kingston Health Sciences Centre and Queen's University, Kingston, Ont.; University of Toronto Quality in Utilization, Education and Safety in Transfusion (QUEST) research program (Callum, Khandelwal, Pavenski), Toronto, Ont.; AirEvac and Critical Care Operations (Greene, Vu), British Columbia Emergency Health Services, Vancouver, BC; School of Medicine (Greene), Cardiff University, Cardiff, Wales, UK; Division of Trauma and General Surgery (Grushka), McGill University Health Centre, Montreal General Hospital Site, Montréal, Que.; Canadian Blood Services (Khandelwal); Department of Laboratory Medicine and Pathobiology (Lin), University of Toronto; Precision Diagnostics and Therapeutics Program (Lin), Sunnybrook Health Sciences Centre, Toronto, Ont.; Faculty of Medicine (Nahirniak), University of Alberta, Edmonton, Alta.; Transfusion and Transplantation Medicine (Nahirniak), Alberta Precision Laboratories, Calgary, Alta.; Departments of Medicine and Laboratory Medicine (Pavenski), St. Michael's Hospital, Unity Health Toronto and University of Toronto, Toronto, Ont.; Division of Transfusion Medicine (Prokopchuk-Gauk), Department of Pathology and Laboratory Medicine, Saskatchewan Health Authority; College of Medicine (Prokopchuk-Gauk), University of Saskatchewan, Saskatoon, Sask.; Emergency Department (Regehr), Health Sciences Centre; Shock Trauma Air Rescue Service (STARS) (Regehr), Manitoba Base, Winnipeg, Man.; Department of Pathology and Laboratory Medicine (Shih), Vancouver Coastal Health Authority; Centre for Blood Research (Shih), University of British Columbia; Department of Emergency Medicine (Trojanowski), Vancouver General Hospital and the University of British Columbia; Clinical Operations (Trojanowski), British Columbia Emergency Health Services; Departments of Emergency Medicine and Critical Care Medicine (Vu), Vancouver Coastal Health Authority and Provincial Health Services Authority, Vancouver, BC; Department of Surgery and Section of Critical Care (Ziesmann), Health Sciences Centre, Winnipeg, Man
| | - Sameer Mal
- Ornge (von Vopelius-Feldt, Lockwood, Mal, Peddle, Smith, Nolan), Mississauga, Ont.; Department of Emergency Medicine (von Vopelius-Feldt, Lockwood, Nolan), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Division of Emergency Medicine (Mal, Peddle), London Health Sciences Centre, London, Ont.; Department of Surgery, Trauma and Acute Care Surgery (Beckett), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Canadian Forces Health Services Headquarters (Beckett, Schmid), Canadian Armed Forces, Ottawa, Ont.; Department of Pathology and Molecular Medicine (Callum), Kingston Health Sciences Centre and Queen's University, Kingston, Ont.; University of Toronto Quality in Utilization, Education and Safety in Transfusion (QUEST) research program (Callum, Khandelwal, Pavenski), Toronto, Ont.; AirEvac and Critical Care Operations (Greene, Vu), British Columbia Emergency Health Services, Vancouver, BC; School of Medicine (Greene), Cardiff University, Cardiff, Wales, UK; Division of Trauma and General Surgery (Grushka), McGill University Health Centre, Montreal General Hospital Site, Montréal, Que.; Canadian Blood Services (Khandelwal); Department of Laboratory Medicine and Pathobiology (Lin), University of Toronto; Precision Diagnostics and Therapeutics Program (Lin), Sunnybrook Health Sciences Centre, Toronto, Ont.; Faculty of Medicine (Nahirniak), University of Alberta, Edmonton, Alta.; Transfusion and Transplantation Medicine (Nahirniak), Alberta Precision Laboratories, Calgary, Alta.; Departments of Medicine and Laboratory Medicine (Pavenski), St. Michael's Hospital, Unity Health Toronto and University of Toronto, Toronto, Ont.; Division of Transfusion Medicine (Prokopchuk-Gauk), Department of Pathology and Laboratory Medicine, Saskatchewan Health Authority; College of Medicine (Prokopchuk-Gauk), University of Saskatchewan, Saskatoon, Sask.; Emergency Department (Regehr), Health Sciences Centre; Shock Trauma Air Rescue Service (STARS) (Regehr), Manitoba Base, Winnipeg, Man.; Department of Pathology and Laboratory Medicine (Shih), Vancouver Coastal Health Authority; Centre for Blood Research (Shih), University of British Columbia; Department of Emergency Medicine (Trojanowski), Vancouver General Hospital and the University of British Columbia; Clinical Operations (Trojanowski), British Columbia Emergency Health Services; Departments of Emergency Medicine and Critical Care Medicine (Vu), Vancouver Coastal Health Authority and Provincial Health Services Authority, Vancouver, BC; Department of Surgery and Section of Critical Care (Ziesmann), Health Sciences Centre, Winnipeg, Man
| | - Andrew Beckett
- Ornge (von Vopelius-Feldt, Lockwood, Mal, Peddle, Smith, Nolan), Mississauga, Ont.; Department of Emergency Medicine (von Vopelius-Feldt, Lockwood, Nolan), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Division of Emergency Medicine (Mal, Peddle), London Health Sciences Centre, London, Ont.; Department of Surgery, Trauma and Acute Care Surgery (Beckett), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Canadian Forces Health Services Headquarters (Beckett, Schmid), Canadian Armed Forces, Ottawa, Ont.; Department of Pathology and Molecular Medicine (Callum), Kingston Health Sciences Centre and Queen's University, Kingston, Ont.; University of Toronto Quality in Utilization, Education and Safety in Transfusion (QUEST) research program (Callum, Khandelwal, Pavenski), Toronto, Ont.; AirEvac and Critical Care Operations (Greene, Vu), British Columbia Emergency Health Services, Vancouver, BC; School of Medicine (Greene), Cardiff University, Cardiff, Wales, UK; Division of Trauma and General Surgery (Grushka), McGill University Health Centre, Montreal General Hospital Site, Montréal, Que.; Canadian Blood Services (Khandelwal); Department of Laboratory Medicine and Pathobiology (Lin), University of Toronto; Precision Diagnostics and Therapeutics Program (Lin), Sunnybrook Health Sciences Centre, Toronto, Ont.; Faculty of Medicine (Nahirniak), University of Alberta, Edmonton, Alta.; Transfusion and Transplantation Medicine (Nahirniak), Alberta Precision Laboratories, Calgary, Alta.; Departments of Medicine and Laboratory Medicine (Pavenski), St. Michael's Hospital, Unity Health Toronto and University of Toronto, Toronto, Ont.; Division of Transfusion Medicine (Prokopchuk-Gauk), Department of Pathology and Laboratory Medicine, Saskatchewan Health Authority; College of Medicine (Prokopchuk-Gauk), University of Saskatchewan, Saskatoon, Sask.; Emergency Department (Regehr), Health Sciences Centre; Shock Trauma Air Rescue Service (STARS) (Regehr), Manitoba Base, Winnipeg, Man.; Department of Pathology and Laboratory Medicine (Shih), Vancouver Coastal Health Authority; Centre for Blood Research (Shih), University of British Columbia; Department of Emergency Medicine (Trojanowski), Vancouver General Hospital and the University of British Columbia; Clinical Operations (Trojanowski), British Columbia Emergency Health Services; Departments of Emergency Medicine and Critical Care Medicine (Vu), Vancouver Coastal Health Authority and Provincial Health Services Authority, Vancouver, BC; Department of Surgery and Section of Critical Care (Ziesmann), Health Sciences Centre, Winnipeg, Man
| | - Jeannie Callum
- Ornge (von Vopelius-Feldt, Lockwood, Mal, Peddle, Smith, Nolan), Mississauga, Ont.; Department of Emergency Medicine (von Vopelius-Feldt, Lockwood, Nolan), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Division of Emergency Medicine (Mal, Peddle), London Health Sciences Centre, London, Ont.; Department of Surgery, Trauma and Acute Care Surgery (Beckett), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Canadian Forces Health Services Headquarters (Beckett, Schmid), Canadian Armed Forces, Ottawa, Ont.; Department of Pathology and Molecular Medicine (Callum), Kingston Health Sciences Centre and Queen's University, Kingston, Ont.; University of Toronto Quality in Utilization, Education and Safety in Transfusion (QUEST) research program (Callum, Khandelwal, Pavenski), Toronto, Ont.; AirEvac and Critical Care Operations (Greene, Vu), British Columbia Emergency Health Services, Vancouver, BC; School of Medicine (Greene), Cardiff University, Cardiff, Wales, UK; Division of Trauma and General Surgery (Grushka), McGill University Health Centre, Montreal General Hospital Site, Montréal, Que.; Canadian Blood Services (Khandelwal); Department of Laboratory Medicine and Pathobiology (Lin), University of Toronto; Precision Diagnostics and Therapeutics Program (Lin), Sunnybrook Health Sciences Centre, Toronto, Ont.; Faculty of Medicine (Nahirniak), University of Alberta, Edmonton, Alta.; Transfusion and Transplantation Medicine (Nahirniak), Alberta Precision Laboratories, Calgary, Alta.; Departments of Medicine and Laboratory Medicine (Pavenski), St. Michael's Hospital, Unity Health Toronto and University of Toronto, Toronto, Ont.; Division of Transfusion Medicine (Prokopchuk-Gauk), Department of Pathology and Laboratory Medicine, Saskatchewan Health Authority; College of Medicine (Prokopchuk-Gauk), University of Saskatchewan, Saskatoon, Sask.; Emergency Department (Regehr), Health Sciences Centre; Shock Trauma Air Rescue Service (STARS) (Regehr), Manitoba Base, Winnipeg, Man.; Department of Pathology and Laboratory Medicine (Shih), Vancouver Coastal Health Authority; Centre for Blood Research (Shih), University of British Columbia; Department of Emergency Medicine (Trojanowski), Vancouver General Hospital and the University of British Columbia; Clinical Operations (Trojanowski), British Columbia Emergency Health Services; Departments of Emergency Medicine and Critical Care Medicine (Vu), Vancouver Coastal Health Authority and Provincial Health Services Authority, Vancouver, BC; Department of Surgery and Section of Critical Care (Ziesmann), Health Sciences Centre, Winnipeg, Man
| | - Adam Greene
- Ornge (von Vopelius-Feldt, Lockwood, Mal, Peddle, Smith, Nolan), Mississauga, Ont.; Department of Emergency Medicine (von Vopelius-Feldt, Lockwood, Nolan), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Division of Emergency Medicine (Mal, Peddle), London Health Sciences Centre, London, Ont.; Department of Surgery, Trauma and Acute Care Surgery (Beckett), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Canadian Forces Health Services Headquarters (Beckett, Schmid), Canadian Armed Forces, Ottawa, Ont.; Department of Pathology and Molecular Medicine (Callum), Kingston Health Sciences Centre and Queen's University, Kingston, Ont.; University of Toronto Quality in Utilization, Education and Safety in Transfusion (QUEST) research program (Callum, Khandelwal, Pavenski), Toronto, Ont.; AirEvac and Critical Care Operations (Greene, Vu), British Columbia Emergency Health Services, Vancouver, BC; School of Medicine (Greene), Cardiff University, Cardiff, Wales, UK; Division of Trauma and General Surgery (Grushka), McGill University Health Centre, Montreal General Hospital Site, Montréal, Que.; Canadian Blood Services (Khandelwal); Department of Laboratory Medicine and Pathobiology (Lin), University of Toronto; Precision Diagnostics and Therapeutics Program (Lin), Sunnybrook Health Sciences Centre, Toronto, Ont.; Faculty of Medicine (Nahirniak), University of Alberta, Edmonton, Alta.; Transfusion and Transplantation Medicine (Nahirniak), Alberta Precision Laboratories, Calgary, Alta.; Departments of Medicine and Laboratory Medicine (Pavenski), St. Michael's Hospital, Unity Health Toronto and University of Toronto, Toronto, Ont.; Division of Transfusion Medicine (Prokopchuk-Gauk), Department of Pathology and Laboratory Medicine, Saskatchewan Health Authority; College of Medicine (Prokopchuk-Gauk), University of Saskatchewan, Saskatoon, Sask.; Emergency Department (Regehr), Health Sciences Centre; Shock Trauma Air Rescue Service (STARS) (Regehr), Manitoba Base, Winnipeg, Man.; Department of Pathology and Laboratory Medicine (Shih), Vancouver Coastal Health Authority; Centre for Blood Research (Shih), University of British Columbia; Department of Emergency Medicine (Trojanowski), Vancouver General Hospital and the University of British Columbia; Clinical Operations (Trojanowski), British Columbia Emergency Health Services; Departments of Emergency Medicine and Critical Care Medicine (Vu), Vancouver Coastal Health Authority and Provincial Health Services Authority, Vancouver, BC; Department of Surgery and Section of Critical Care (Ziesmann), Health Sciences Centre, Winnipeg, Man
| | - Jeremy Grushka
- Ornge (von Vopelius-Feldt, Lockwood, Mal, Peddle, Smith, Nolan), Mississauga, Ont.; Department of Emergency Medicine (von Vopelius-Feldt, Lockwood, Nolan), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Division of Emergency Medicine (Mal, Peddle), London Health Sciences Centre, London, Ont.; Department of Surgery, Trauma and Acute Care Surgery (Beckett), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Canadian Forces Health Services Headquarters (Beckett, Schmid), Canadian Armed Forces, Ottawa, Ont.; Department of Pathology and Molecular Medicine (Callum), Kingston Health Sciences Centre and Queen's University, Kingston, Ont.; University of Toronto Quality in Utilization, Education and Safety in Transfusion (QUEST) research program (Callum, Khandelwal, Pavenski), Toronto, Ont.; AirEvac and Critical Care Operations (Greene, Vu), British Columbia Emergency Health Services, Vancouver, BC; School of Medicine (Greene), Cardiff University, Cardiff, Wales, UK; Division of Trauma and General Surgery (Grushka), McGill University Health Centre, Montreal General Hospital Site, Montréal, Que.; Canadian Blood Services (Khandelwal); Department of Laboratory Medicine and Pathobiology (Lin), University of Toronto; Precision Diagnostics and Therapeutics Program (Lin), Sunnybrook Health Sciences Centre, Toronto, Ont.; Faculty of Medicine (Nahirniak), University of Alberta, Edmonton, Alta.; Transfusion and Transplantation Medicine (Nahirniak), Alberta Precision Laboratories, Calgary, Alta.; Departments of Medicine and Laboratory Medicine (Pavenski), St. Michael's Hospital, Unity Health Toronto and University of Toronto, Toronto, Ont.; Division of Transfusion Medicine (Prokopchuk-Gauk), Department of Pathology and Laboratory Medicine, Saskatchewan Health Authority; College of Medicine (Prokopchuk-Gauk), University of Saskatchewan, Saskatoon, Sask.; Emergency Department (Regehr), Health Sciences Centre; Shock Trauma Air Rescue Service (STARS) (Regehr), Manitoba Base, Winnipeg, Man.; Department of Pathology and Laboratory Medicine (Shih), Vancouver Coastal Health Authority; Centre for Blood Research (Shih), University of British Columbia; Department of Emergency Medicine (Trojanowski), Vancouver General Hospital and the University of British Columbia; Clinical Operations (Trojanowski), British Columbia Emergency Health Services; Departments of Emergency Medicine and Critical Care Medicine (Vu), Vancouver Coastal Health Authority and Provincial Health Services Authority, Vancouver, BC; Department of Surgery and Section of Critical Care (Ziesmann), Health Sciences Centre, Winnipeg, Man
| | - Aditi Khandelwal
- Ornge (von Vopelius-Feldt, Lockwood, Mal, Peddle, Smith, Nolan), Mississauga, Ont.; Department of Emergency Medicine (von Vopelius-Feldt, Lockwood, Nolan), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Division of Emergency Medicine (Mal, Peddle), London Health Sciences Centre, London, Ont.; Department of Surgery, Trauma and Acute Care Surgery (Beckett), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Canadian Forces Health Services Headquarters (Beckett, Schmid), Canadian Armed Forces, Ottawa, Ont.; Department of Pathology and Molecular Medicine (Callum), Kingston Health Sciences Centre and Queen's University, Kingston, Ont.; University of Toronto Quality in Utilization, Education and Safety in Transfusion (QUEST) research program (Callum, Khandelwal, Pavenski), Toronto, Ont.; AirEvac and Critical Care Operations (Greene, Vu), British Columbia Emergency Health Services, Vancouver, BC; School of Medicine (Greene), Cardiff University, Cardiff, Wales, UK; Division of Trauma and General Surgery (Grushka), McGill University Health Centre, Montreal General Hospital Site, Montréal, Que.; Canadian Blood Services (Khandelwal); Department of Laboratory Medicine and Pathobiology (Lin), University of Toronto; Precision Diagnostics and Therapeutics Program (Lin), Sunnybrook Health Sciences Centre, Toronto, Ont.; Faculty of Medicine (Nahirniak), University of Alberta, Edmonton, Alta.; Transfusion and Transplantation Medicine (Nahirniak), Alberta Precision Laboratories, Calgary, Alta.; Departments of Medicine and Laboratory Medicine (Pavenski), St. Michael's Hospital, Unity Health Toronto and University of Toronto, Toronto, Ont.; Division of Transfusion Medicine (Prokopchuk-Gauk), Department of Pathology and Laboratory Medicine, Saskatchewan Health Authority; College of Medicine (Prokopchuk-Gauk), University of Saskatchewan, Saskatoon, Sask.; Emergency Department (Regehr), Health Sciences Centre; Shock Trauma Air Rescue Service (STARS) (Regehr), Manitoba Base, Winnipeg, Man.; Department of Pathology and Laboratory Medicine (Shih), Vancouver Coastal Health Authority; Centre for Blood Research (Shih), University of British Columbia; Department of Emergency Medicine (Trojanowski), Vancouver General Hospital and the University of British Columbia; Clinical Operations (Trojanowski), British Columbia Emergency Health Services; Departments of Emergency Medicine and Critical Care Medicine (Vu), Vancouver Coastal Health Authority and Provincial Health Services Authority, Vancouver, BC; Department of Surgery and Section of Critical Care (Ziesmann), Health Sciences Centre, Winnipeg, Man
| | - Yulia Lin
- Ornge (von Vopelius-Feldt, Lockwood, Mal, Peddle, Smith, Nolan), Mississauga, Ont.; Department of Emergency Medicine (von Vopelius-Feldt, Lockwood, Nolan), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Division of Emergency Medicine (Mal, Peddle), London Health Sciences Centre, London, Ont.; Department of Surgery, Trauma and Acute Care Surgery (Beckett), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Canadian Forces Health Services Headquarters (Beckett, Schmid), Canadian Armed Forces, Ottawa, Ont.; Department of Pathology and Molecular Medicine (Callum), Kingston Health Sciences Centre and Queen's University, Kingston, Ont.; University of Toronto Quality in Utilization, Education and Safety in Transfusion (QUEST) research program (Callum, Khandelwal, Pavenski), Toronto, Ont.; AirEvac and Critical Care Operations (Greene, Vu), British Columbia Emergency Health Services, Vancouver, BC; School of Medicine (Greene), Cardiff University, Cardiff, Wales, UK; Division of Trauma and General Surgery (Grushka), McGill University Health Centre, Montreal General Hospital Site, Montréal, Que.; Canadian Blood Services (Khandelwal); Department of Laboratory Medicine and Pathobiology (Lin), University of Toronto; Precision Diagnostics and Therapeutics Program (Lin), Sunnybrook Health Sciences Centre, Toronto, Ont.; Faculty of Medicine (Nahirniak), University of Alberta, Edmonton, Alta.; Transfusion and Transplantation Medicine (Nahirniak), Alberta Precision Laboratories, Calgary, Alta.; Departments of Medicine and Laboratory Medicine (Pavenski), St. Michael's Hospital, Unity Health Toronto and University of Toronto, Toronto, Ont.; Division of Transfusion Medicine (Prokopchuk-Gauk), Department of Pathology and Laboratory Medicine, Saskatchewan Health Authority; College of Medicine (Prokopchuk-Gauk), University of Saskatchewan, Saskatoon, Sask.; Emergency Department (Regehr), Health Sciences Centre; Shock Trauma Air Rescue Service (STARS) (Regehr), Manitoba Base, Winnipeg, Man.; Department of Pathology and Laboratory Medicine (Shih), Vancouver Coastal Health Authority; Centre for Blood Research (Shih), University of British Columbia; Department of Emergency Medicine (Trojanowski), Vancouver General Hospital and the University of British Columbia; Clinical Operations (Trojanowski), British Columbia Emergency Health Services; Departments of Emergency Medicine and Critical Care Medicine (Vu), Vancouver Coastal Health Authority and Provincial Health Services Authority, Vancouver, BC; Department of Surgery and Section of Critical Care (Ziesmann), Health Sciences Centre, Winnipeg, Man
| | - Susan Nahirniak
- Ornge (von Vopelius-Feldt, Lockwood, Mal, Peddle, Smith, Nolan), Mississauga, Ont.; Department of Emergency Medicine (von Vopelius-Feldt, Lockwood, Nolan), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Division of Emergency Medicine (Mal, Peddle), London Health Sciences Centre, London, Ont.; Department of Surgery, Trauma and Acute Care Surgery (Beckett), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Canadian Forces Health Services Headquarters (Beckett, Schmid), Canadian Armed Forces, Ottawa, Ont.; Department of Pathology and Molecular Medicine (Callum), Kingston Health Sciences Centre and Queen's University, Kingston, Ont.; University of Toronto Quality in Utilization, Education and Safety in Transfusion (QUEST) research program (Callum, Khandelwal, Pavenski), Toronto, Ont.; AirEvac and Critical Care Operations (Greene, Vu), British Columbia Emergency Health Services, Vancouver, BC; School of Medicine (Greene), Cardiff University, Cardiff, Wales, UK; Division of Trauma and General Surgery (Grushka), McGill University Health Centre, Montreal General Hospital Site, Montréal, Que.; Canadian Blood Services (Khandelwal); Department of Laboratory Medicine and Pathobiology (Lin), University of Toronto; Precision Diagnostics and Therapeutics Program (Lin), Sunnybrook Health Sciences Centre, Toronto, Ont.; Faculty of Medicine (Nahirniak), University of Alberta, Edmonton, Alta.; Transfusion and Transplantation Medicine (Nahirniak), Alberta Precision Laboratories, Calgary, Alta.; Departments of Medicine and Laboratory Medicine (Pavenski), St. Michael's Hospital, Unity Health Toronto and University of Toronto, Toronto, Ont.; Division of Transfusion Medicine (Prokopchuk-Gauk), Department of Pathology and Laboratory Medicine, Saskatchewan Health Authority; College of Medicine (Prokopchuk-Gauk), University of Saskatchewan, Saskatoon, Sask.; Emergency Department (Regehr), Health Sciences Centre; Shock Trauma Air Rescue Service (STARS) (Regehr), Manitoba Base, Winnipeg, Man.; Department of Pathology and Laboratory Medicine (Shih), Vancouver Coastal Health Authority; Centre for Blood Research (Shih), University of British Columbia; Department of Emergency Medicine (Trojanowski), Vancouver General Hospital and the University of British Columbia; Clinical Operations (Trojanowski), British Columbia Emergency Health Services; Departments of Emergency Medicine and Critical Care Medicine (Vu), Vancouver Coastal Health Authority and Provincial Health Services Authority, Vancouver, BC; Department of Surgery and Section of Critical Care (Ziesmann), Health Sciences Centre, Winnipeg, Man
| | - Katerina Pavenski
- Ornge (von Vopelius-Feldt, Lockwood, Mal, Peddle, Smith, Nolan), Mississauga, Ont.; Department of Emergency Medicine (von Vopelius-Feldt, Lockwood, Nolan), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Division of Emergency Medicine (Mal, Peddle), London Health Sciences Centre, London, Ont.; Department of Surgery, Trauma and Acute Care Surgery (Beckett), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Canadian Forces Health Services Headquarters (Beckett, Schmid), Canadian Armed Forces, Ottawa, Ont.; Department of Pathology and Molecular Medicine (Callum), Kingston Health Sciences Centre and Queen's University, Kingston, Ont.; University of Toronto Quality in Utilization, Education and Safety in Transfusion (QUEST) research program (Callum, Khandelwal, Pavenski), Toronto, Ont.; AirEvac and Critical Care Operations (Greene, Vu), British Columbia Emergency Health Services, Vancouver, BC; School of Medicine (Greene), Cardiff University, Cardiff, Wales, UK; Division of Trauma and General Surgery (Grushka), McGill University Health Centre, Montreal General Hospital Site, Montréal, Que.; Canadian Blood Services (Khandelwal); Department of Laboratory Medicine and Pathobiology (Lin), University of Toronto; Precision Diagnostics and Therapeutics Program (Lin), Sunnybrook Health Sciences Centre, Toronto, Ont.; Faculty of Medicine (Nahirniak), University of Alberta, Edmonton, Alta.; Transfusion and Transplantation Medicine (Nahirniak), Alberta Precision Laboratories, Calgary, Alta.; Departments of Medicine and Laboratory Medicine (Pavenski), St. Michael's Hospital, Unity Health Toronto and University of Toronto, Toronto, Ont.; Division of Transfusion Medicine (Prokopchuk-Gauk), Department of Pathology and Laboratory Medicine, Saskatchewan Health Authority; College of Medicine (Prokopchuk-Gauk), University of Saskatchewan, Saskatoon, Sask.; Emergency Department (Regehr), Health Sciences Centre; Shock Trauma Air Rescue Service (STARS) (Regehr), Manitoba Base, Winnipeg, Man.; Department of Pathology and Laboratory Medicine (Shih), Vancouver Coastal Health Authority; Centre for Blood Research (Shih), University of British Columbia; Department of Emergency Medicine (Trojanowski), Vancouver General Hospital and the University of British Columbia; Clinical Operations (Trojanowski), British Columbia Emergency Health Services; Departments of Emergency Medicine and Critical Care Medicine (Vu), Vancouver Coastal Health Authority and Provincial Health Services Authority, Vancouver, BC; Department of Surgery and Section of Critical Care (Ziesmann), Health Sciences Centre, Winnipeg, Man
| | - Michael Peddle
- Ornge (von Vopelius-Feldt, Lockwood, Mal, Peddle, Smith, Nolan), Mississauga, Ont.; Department of Emergency Medicine (von Vopelius-Feldt, Lockwood, Nolan), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Division of Emergency Medicine (Mal, Peddle), London Health Sciences Centre, London, Ont.; Department of Surgery, Trauma and Acute Care Surgery (Beckett), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Canadian Forces Health Services Headquarters (Beckett, Schmid), Canadian Armed Forces, Ottawa, Ont.; Department of Pathology and Molecular Medicine (Callum), Kingston Health Sciences Centre and Queen's University, Kingston, Ont.; University of Toronto Quality in Utilization, Education and Safety in Transfusion (QUEST) research program (Callum, Khandelwal, Pavenski), Toronto, Ont.; AirEvac and Critical Care Operations (Greene, Vu), British Columbia Emergency Health Services, Vancouver, BC; School of Medicine (Greene), Cardiff University, Cardiff, Wales, UK; Division of Trauma and General Surgery (Grushka), McGill University Health Centre, Montreal General Hospital Site, Montréal, Que.; Canadian Blood Services (Khandelwal); Department of Laboratory Medicine and Pathobiology (Lin), University of Toronto; Precision Diagnostics and Therapeutics Program (Lin), Sunnybrook Health Sciences Centre, Toronto, Ont.; Faculty of Medicine (Nahirniak), University of Alberta, Edmonton, Alta.; Transfusion and Transplantation Medicine (Nahirniak), Alberta Precision Laboratories, Calgary, Alta.; Departments of Medicine and Laboratory Medicine (Pavenski), St. Michael's Hospital, Unity Health Toronto and University of Toronto, Toronto, Ont.; Division of Transfusion Medicine (Prokopchuk-Gauk), Department of Pathology and Laboratory Medicine, Saskatchewan Health Authority; College of Medicine (Prokopchuk-Gauk), University of Saskatchewan, Saskatoon, Sask.; Emergency Department (Regehr), Health Sciences Centre; Shock Trauma Air Rescue Service (STARS) (Regehr), Manitoba Base, Winnipeg, Man.; Department of Pathology and Laboratory Medicine (Shih), Vancouver Coastal Health Authority; Centre for Blood Research (Shih), University of British Columbia; Department of Emergency Medicine (Trojanowski), Vancouver General Hospital and the University of British Columbia; Clinical Operations (Trojanowski), British Columbia Emergency Health Services; Departments of Emergency Medicine and Critical Care Medicine (Vu), Vancouver Coastal Health Authority and Provincial Health Services Authority, Vancouver, BC; Department of Surgery and Section of Critical Care (Ziesmann), Health Sciences Centre, Winnipeg, Man
| | - Oksana Prokopchuk-Gauk
- Ornge (von Vopelius-Feldt, Lockwood, Mal, Peddle, Smith, Nolan), Mississauga, Ont.; Department of Emergency Medicine (von Vopelius-Feldt, Lockwood, Nolan), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Division of Emergency Medicine (Mal, Peddle), London Health Sciences Centre, London, Ont.; Department of Surgery, Trauma and Acute Care Surgery (Beckett), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Canadian Forces Health Services Headquarters (Beckett, Schmid), Canadian Armed Forces, Ottawa, Ont.; Department of Pathology and Molecular Medicine (Callum), Kingston Health Sciences Centre and Queen's University, Kingston, Ont.; University of Toronto Quality in Utilization, Education and Safety in Transfusion (QUEST) research program (Callum, Khandelwal, Pavenski), Toronto, Ont.; AirEvac and Critical Care Operations (Greene, Vu), British Columbia Emergency Health Services, Vancouver, BC; School of Medicine (Greene), Cardiff University, Cardiff, Wales, UK; Division of Trauma and General Surgery (Grushka), McGill University Health Centre, Montreal General Hospital Site, Montréal, Que.; Canadian Blood Services (Khandelwal); Department of Laboratory Medicine and Pathobiology (Lin), University of Toronto; Precision Diagnostics and Therapeutics Program (Lin), Sunnybrook Health Sciences Centre, Toronto, Ont.; Faculty of Medicine (Nahirniak), University of Alberta, Edmonton, Alta.; Transfusion and Transplantation Medicine (Nahirniak), Alberta Precision Laboratories, Calgary, Alta.; Departments of Medicine and Laboratory Medicine (Pavenski), St. Michael's Hospital, Unity Health Toronto and University of Toronto, Toronto, Ont.; Division of Transfusion Medicine (Prokopchuk-Gauk), Department of Pathology and Laboratory Medicine, Saskatchewan Health Authority; College of Medicine (Prokopchuk-Gauk), University of Saskatchewan, Saskatoon, Sask.; Emergency Department (Regehr), Health Sciences Centre; Shock Trauma Air Rescue Service (STARS) (Regehr), Manitoba Base, Winnipeg, Man.; Department of Pathology and Laboratory Medicine (Shih), Vancouver Coastal Health Authority; Centre for Blood Research (Shih), University of British Columbia; Department of Emergency Medicine (Trojanowski), Vancouver General Hospital and the University of British Columbia; Clinical Operations (Trojanowski), British Columbia Emergency Health Services; Departments of Emergency Medicine and Critical Care Medicine (Vu), Vancouver Coastal Health Authority and Provincial Health Services Authority, Vancouver, BC; Department of Surgery and Section of Critical Care (Ziesmann), Health Sciences Centre, Winnipeg, Man
| | - Julian Regehr
- Ornge (von Vopelius-Feldt, Lockwood, Mal, Peddle, Smith, Nolan), Mississauga, Ont.; Department of Emergency Medicine (von Vopelius-Feldt, Lockwood, Nolan), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Division of Emergency Medicine (Mal, Peddle), London Health Sciences Centre, London, Ont.; Department of Surgery, Trauma and Acute Care Surgery (Beckett), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Canadian Forces Health Services Headquarters (Beckett, Schmid), Canadian Armed Forces, Ottawa, Ont.; Department of Pathology and Molecular Medicine (Callum), Kingston Health Sciences Centre and Queen's University, Kingston, Ont.; University of Toronto Quality in Utilization, Education and Safety in Transfusion (QUEST) research program (Callum, Khandelwal, Pavenski), Toronto, Ont.; AirEvac and Critical Care Operations (Greene, Vu), British Columbia Emergency Health Services, Vancouver, BC; School of Medicine (Greene), Cardiff University, Cardiff, Wales, UK; Division of Trauma and General Surgery (Grushka), McGill University Health Centre, Montreal General Hospital Site, Montréal, Que.; Canadian Blood Services (Khandelwal); Department of Laboratory Medicine and Pathobiology (Lin), University of Toronto; Precision Diagnostics and Therapeutics Program (Lin), Sunnybrook Health Sciences Centre, Toronto, Ont.; Faculty of Medicine (Nahirniak), University of Alberta, Edmonton, Alta.; Transfusion and Transplantation Medicine (Nahirniak), Alberta Precision Laboratories, Calgary, Alta.; Departments of Medicine and Laboratory Medicine (Pavenski), St. Michael's Hospital, Unity Health Toronto and University of Toronto, Toronto, Ont.; Division of Transfusion Medicine (Prokopchuk-Gauk), Department of Pathology and Laboratory Medicine, Saskatchewan Health Authority; College of Medicine (Prokopchuk-Gauk), University of Saskatchewan, Saskatoon, Sask.; Emergency Department (Regehr), Health Sciences Centre; Shock Trauma Air Rescue Service (STARS) (Regehr), Manitoba Base, Winnipeg, Man.; Department of Pathology and Laboratory Medicine (Shih), Vancouver Coastal Health Authority; Centre for Blood Research (Shih), University of British Columbia; Department of Emergency Medicine (Trojanowski), Vancouver General Hospital and the University of British Columbia; Clinical Operations (Trojanowski), British Columbia Emergency Health Services; Departments of Emergency Medicine and Critical Care Medicine (Vu), Vancouver Coastal Health Authority and Provincial Health Services Authority, Vancouver, BC; Department of Surgery and Section of Critical Care (Ziesmann), Health Sciences Centre, Winnipeg, Man
| | - Jo Schmid
- Ornge (von Vopelius-Feldt, Lockwood, Mal, Peddle, Smith, Nolan), Mississauga, Ont.; Department of Emergency Medicine (von Vopelius-Feldt, Lockwood, Nolan), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Division of Emergency Medicine (Mal, Peddle), London Health Sciences Centre, London, Ont.; Department of Surgery, Trauma and Acute Care Surgery (Beckett), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Canadian Forces Health Services Headquarters (Beckett, Schmid), Canadian Armed Forces, Ottawa, Ont.; Department of Pathology and Molecular Medicine (Callum), Kingston Health Sciences Centre and Queen's University, Kingston, Ont.; University of Toronto Quality in Utilization, Education and Safety in Transfusion (QUEST) research program (Callum, Khandelwal, Pavenski), Toronto, Ont.; AirEvac and Critical Care Operations (Greene, Vu), British Columbia Emergency Health Services, Vancouver, BC; School of Medicine (Greene), Cardiff University, Cardiff, Wales, UK; Division of Trauma and General Surgery (Grushka), McGill University Health Centre, Montreal General Hospital Site, Montréal, Que.; Canadian Blood Services (Khandelwal); Department of Laboratory Medicine and Pathobiology (Lin), University of Toronto; Precision Diagnostics and Therapeutics Program (Lin), Sunnybrook Health Sciences Centre, Toronto, Ont.; Faculty of Medicine (Nahirniak), University of Alberta, Edmonton, Alta.; Transfusion and Transplantation Medicine (Nahirniak), Alberta Precision Laboratories, Calgary, Alta.; Departments of Medicine and Laboratory Medicine (Pavenski), St. Michael's Hospital, Unity Health Toronto and University of Toronto, Toronto, Ont.; Division of Transfusion Medicine (Prokopchuk-Gauk), Department of Pathology and Laboratory Medicine, Saskatchewan Health Authority; College of Medicine (Prokopchuk-Gauk), University of Saskatchewan, Saskatoon, Sask.; Emergency Department (Regehr), Health Sciences Centre; Shock Trauma Air Rescue Service (STARS) (Regehr), Manitoba Base, Winnipeg, Man.; Department of Pathology and Laboratory Medicine (Shih), Vancouver Coastal Health Authority; Centre for Blood Research (Shih), University of British Columbia; Department of Emergency Medicine (Trojanowski), Vancouver General Hospital and the University of British Columbia; Clinical Operations (Trojanowski), British Columbia Emergency Health Services; Departments of Emergency Medicine and Critical Care Medicine (Vu), Vancouver Coastal Health Authority and Provincial Health Services Authority, Vancouver, BC; Department of Surgery and Section of Critical Care (Ziesmann), Health Sciences Centre, Winnipeg, Man
| | - Andrew W Shih
- Ornge (von Vopelius-Feldt, Lockwood, Mal, Peddle, Smith, Nolan), Mississauga, Ont.; Department of Emergency Medicine (von Vopelius-Feldt, Lockwood, Nolan), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Division of Emergency Medicine (Mal, Peddle), London Health Sciences Centre, London, Ont.; Department of Surgery, Trauma and Acute Care Surgery (Beckett), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Canadian Forces Health Services Headquarters (Beckett, Schmid), Canadian Armed Forces, Ottawa, Ont.; Department of Pathology and Molecular Medicine (Callum), Kingston Health Sciences Centre and Queen's University, Kingston, Ont.; University of Toronto Quality in Utilization, Education and Safety in Transfusion (QUEST) research program (Callum, Khandelwal, Pavenski), Toronto, Ont.; AirEvac and Critical Care Operations (Greene, Vu), British Columbia Emergency Health Services, Vancouver, BC; School of Medicine (Greene), Cardiff University, Cardiff, Wales, UK; Division of Trauma and General Surgery (Grushka), McGill University Health Centre, Montreal General Hospital Site, Montréal, Que.; Canadian Blood Services (Khandelwal); Department of Laboratory Medicine and Pathobiology (Lin), University of Toronto; Precision Diagnostics and Therapeutics Program (Lin), Sunnybrook Health Sciences Centre, Toronto, Ont.; Faculty of Medicine (Nahirniak), University of Alberta, Edmonton, Alta.; Transfusion and Transplantation Medicine (Nahirniak), Alberta Precision Laboratories, Calgary, Alta.; Departments of Medicine and Laboratory Medicine (Pavenski), St. Michael's Hospital, Unity Health Toronto and University of Toronto, Toronto, Ont.; Division of Transfusion Medicine (Prokopchuk-Gauk), Department of Pathology and Laboratory Medicine, Saskatchewan Health Authority; College of Medicine (Prokopchuk-Gauk), University of Saskatchewan, Saskatoon, Sask.; Emergency Department (Regehr), Health Sciences Centre; Shock Trauma Air Rescue Service (STARS) (Regehr), Manitoba Base, Winnipeg, Man.; Department of Pathology and Laboratory Medicine (Shih), Vancouver Coastal Health Authority; Centre for Blood Research (Shih), University of British Columbia; Department of Emergency Medicine (Trojanowski), Vancouver General Hospital and the University of British Columbia; Clinical Operations (Trojanowski), British Columbia Emergency Health Services; Departments of Emergency Medicine and Critical Care Medicine (Vu), Vancouver Coastal Health Authority and Provincial Health Services Authority, Vancouver, BC; Department of Surgery and Section of Critical Care (Ziesmann), Health Sciences Centre, Winnipeg, Man
| | - Justin A Smith
- Ornge (von Vopelius-Feldt, Lockwood, Mal, Peddle, Smith, Nolan), Mississauga, Ont.; Department of Emergency Medicine (von Vopelius-Feldt, Lockwood, Nolan), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Division of Emergency Medicine (Mal, Peddle), London Health Sciences Centre, London, Ont.; Department of Surgery, Trauma and Acute Care Surgery (Beckett), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Canadian Forces Health Services Headquarters (Beckett, Schmid), Canadian Armed Forces, Ottawa, Ont.; Department of Pathology and Molecular Medicine (Callum), Kingston Health Sciences Centre and Queen's University, Kingston, Ont.; University of Toronto Quality in Utilization, Education and Safety in Transfusion (QUEST) research program (Callum, Khandelwal, Pavenski), Toronto, Ont.; AirEvac and Critical Care Operations (Greene, Vu), British Columbia Emergency Health Services, Vancouver, BC; School of Medicine (Greene), Cardiff University, Cardiff, Wales, UK; Division of Trauma and General Surgery (Grushka), McGill University Health Centre, Montreal General Hospital Site, Montréal, Que.; Canadian Blood Services (Khandelwal); Department of Laboratory Medicine and Pathobiology (Lin), University of Toronto; Precision Diagnostics and Therapeutics Program (Lin), Sunnybrook Health Sciences Centre, Toronto, Ont.; Faculty of Medicine (Nahirniak), University of Alberta, Edmonton, Alta.; Transfusion and Transplantation Medicine (Nahirniak), Alberta Precision Laboratories, Calgary, Alta.; Departments of Medicine and Laboratory Medicine (Pavenski), St. Michael's Hospital, Unity Health Toronto and University of Toronto, Toronto, Ont.; Division of Transfusion Medicine (Prokopchuk-Gauk), Department of Pathology and Laboratory Medicine, Saskatchewan Health Authority; College of Medicine (Prokopchuk-Gauk), University of Saskatchewan, Saskatoon, Sask.; Emergency Department (Regehr), Health Sciences Centre; Shock Trauma Air Rescue Service (STARS) (Regehr), Manitoba Base, Winnipeg, Man.; Department of Pathology and Laboratory Medicine (Shih), Vancouver Coastal Health Authority; Centre for Blood Research (Shih), University of British Columbia; Department of Emergency Medicine (Trojanowski), Vancouver General Hospital and the University of British Columbia; Clinical Operations (Trojanowski), British Columbia Emergency Health Services; Departments of Emergency Medicine and Critical Care Medicine (Vu), Vancouver Coastal Health Authority and Provincial Health Services Authority, Vancouver, BC; Department of Surgery and Section of Critical Care (Ziesmann), Health Sciences Centre, Winnipeg, Man
| | - Jan Trojanowski
- Ornge (von Vopelius-Feldt, Lockwood, Mal, Peddle, Smith, Nolan), Mississauga, Ont.; Department of Emergency Medicine (von Vopelius-Feldt, Lockwood, Nolan), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Division of Emergency Medicine (Mal, Peddle), London Health Sciences Centre, London, Ont.; Department of Surgery, Trauma and Acute Care Surgery (Beckett), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Canadian Forces Health Services Headquarters (Beckett, Schmid), Canadian Armed Forces, Ottawa, Ont.; Department of Pathology and Molecular Medicine (Callum), Kingston Health Sciences Centre and Queen's University, Kingston, Ont.; University of Toronto Quality in Utilization, Education and Safety in Transfusion (QUEST) research program (Callum, Khandelwal, Pavenski), Toronto, Ont.; AirEvac and Critical Care Operations (Greene, Vu), British Columbia Emergency Health Services, Vancouver, BC; School of Medicine (Greene), Cardiff University, Cardiff, Wales, UK; Division of Trauma and General Surgery (Grushka), McGill University Health Centre, Montreal General Hospital Site, Montréal, Que.; Canadian Blood Services (Khandelwal); Department of Laboratory Medicine and Pathobiology (Lin), University of Toronto; Precision Diagnostics and Therapeutics Program (Lin), Sunnybrook Health Sciences Centre, Toronto, Ont.; Faculty of Medicine (Nahirniak), University of Alberta, Edmonton, Alta.; Transfusion and Transplantation Medicine (Nahirniak), Alberta Precision Laboratories, Calgary, Alta.; Departments of Medicine and Laboratory Medicine (Pavenski), St. Michael's Hospital, Unity Health Toronto and University of Toronto, Toronto, Ont.; Division of Transfusion Medicine (Prokopchuk-Gauk), Department of Pathology and Laboratory Medicine, Saskatchewan Health Authority; College of Medicine (Prokopchuk-Gauk), University of Saskatchewan, Saskatoon, Sask.; Emergency Department (Regehr), Health Sciences Centre; Shock Trauma Air Rescue Service (STARS) (Regehr), Manitoba Base, Winnipeg, Man.; Department of Pathology and Laboratory Medicine (Shih), Vancouver Coastal Health Authority; Centre for Blood Research (Shih), University of British Columbia; Department of Emergency Medicine (Trojanowski), Vancouver General Hospital and the University of British Columbia; Clinical Operations (Trojanowski), British Columbia Emergency Health Services; Departments of Emergency Medicine and Critical Care Medicine (Vu), Vancouver Coastal Health Authority and Provincial Health Services Authority, Vancouver, BC; Department of Surgery and Section of Critical Care (Ziesmann), Health Sciences Centre, Winnipeg, Man
| | - Erik Vu
- Ornge (von Vopelius-Feldt, Lockwood, Mal, Peddle, Smith, Nolan), Mississauga, Ont.; Department of Emergency Medicine (von Vopelius-Feldt, Lockwood, Nolan), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Division of Emergency Medicine (Mal, Peddle), London Health Sciences Centre, London, Ont.; Department of Surgery, Trauma and Acute Care Surgery (Beckett), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Canadian Forces Health Services Headquarters (Beckett, Schmid), Canadian Armed Forces, Ottawa, Ont.; Department of Pathology and Molecular Medicine (Callum), Kingston Health Sciences Centre and Queen's University, Kingston, Ont.; University of Toronto Quality in Utilization, Education and Safety in Transfusion (QUEST) research program (Callum, Khandelwal, Pavenski), Toronto, Ont.; AirEvac and Critical Care Operations (Greene, Vu), British Columbia Emergency Health Services, Vancouver, BC; School of Medicine (Greene), Cardiff University, Cardiff, Wales, UK; Division of Trauma and General Surgery (Grushka), McGill University Health Centre, Montreal General Hospital Site, Montréal, Que.; Canadian Blood Services (Khandelwal); Department of Laboratory Medicine and Pathobiology (Lin), University of Toronto; Precision Diagnostics and Therapeutics Program (Lin), Sunnybrook Health Sciences Centre, Toronto, Ont.; Faculty of Medicine (Nahirniak), University of Alberta, Edmonton, Alta.; Transfusion and Transplantation Medicine (Nahirniak), Alberta Precision Laboratories, Calgary, Alta.; Departments of Medicine and Laboratory Medicine (Pavenski), St. Michael's Hospital, Unity Health Toronto and University of Toronto, Toronto, Ont.; Division of Transfusion Medicine (Prokopchuk-Gauk), Department of Pathology and Laboratory Medicine, Saskatchewan Health Authority; College of Medicine (Prokopchuk-Gauk), University of Saskatchewan, Saskatoon, Sask.; Emergency Department (Regehr), Health Sciences Centre; Shock Trauma Air Rescue Service (STARS) (Regehr), Manitoba Base, Winnipeg, Man.; Department of Pathology and Laboratory Medicine (Shih), Vancouver Coastal Health Authority; Centre for Blood Research (Shih), University of British Columbia; Department of Emergency Medicine (Trojanowski), Vancouver General Hospital and the University of British Columbia; Clinical Operations (Trojanowski), British Columbia Emergency Health Services; Departments of Emergency Medicine and Critical Care Medicine (Vu), Vancouver Coastal Health Authority and Provincial Health Services Authority, Vancouver, BC; Department of Surgery and Section of Critical Care (Ziesmann), Health Sciences Centre, Winnipeg, Man
| | - Markus Ziesmann
- Ornge (von Vopelius-Feldt, Lockwood, Mal, Peddle, Smith, Nolan), Mississauga, Ont.; Department of Emergency Medicine (von Vopelius-Feldt, Lockwood, Nolan), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Division of Emergency Medicine (Mal, Peddle), London Health Sciences Centre, London, Ont.; Department of Surgery, Trauma and Acute Care Surgery (Beckett), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Canadian Forces Health Services Headquarters (Beckett, Schmid), Canadian Armed Forces, Ottawa, Ont.; Department of Pathology and Molecular Medicine (Callum), Kingston Health Sciences Centre and Queen's University, Kingston, Ont.; University of Toronto Quality in Utilization, Education and Safety in Transfusion (QUEST) research program (Callum, Khandelwal, Pavenski), Toronto, Ont.; AirEvac and Critical Care Operations (Greene, Vu), British Columbia Emergency Health Services, Vancouver, BC; School of Medicine (Greene), Cardiff University, Cardiff, Wales, UK; Division of Trauma and General Surgery (Grushka), McGill University Health Centre, Montreal General Hospital Site, Montréal, Que.; Canadian Blood Services (Khandelwal); Department of Laboratory Medicine and Pathobiology (Lin), University of Toronto; Precision Diagnostics and Therapeutics Program (Lin), Sunnybrook Health Sciences Centre, Toronto, Ont.; Faculty of Medicine (Nahirniak), University of Alberta, Edmonton, Alta.; Transfusion and Transplantation Medicine (Nahirniak), Alberta Precision Laboratories, Calgary, Alta.; Departments of Medicine and Laboratory Medicine (Pavenski), St. Michael's Hospital, Unity Health Toronto and University of Toronto, Toronto, Ont.; Division of Transfusion Medicine (Prokopchuk-Gauk), Department of Pathology and Laboratory Medicine, Saskatchewan Health Authority; College of Medicine (Prokopchuk-Gauk), University of Saskatchewan, Saskatoon, Sask.; Emergency Department (Regehr), Health Sciences Centre; Shock Trauma Air Rescue Service (STARS) (Regehr), Manitoba Base, Winnipeg, Man.; Department of Pathology and Laboratory Medicine (Shih), Vancouver Coastal Health Authority; Centre for Blood Research (Shih), University of British Columbia; Department of Emergency Medicine (Trojanowski), Vancouver General Hospital and the University of British Columbia; Clinical Operations (Trojanowski), British Columbia Emergency Health Services; Departments of Emergency Medicine and Critical Care Medicine (Vu), Vancouver Coastal Health Authority and Provincial Health Services Authority, Vancouver, BC; Department of Surgery and Section of Critical Care (Ziesmann), Health Sciences Centre, Winnipeg, Man
| | - Brodie Nolan
- Ornge (von Vopelius-Feldt, Lockwood, Mal, Peddle, Smith, Nolan), Mississauga, Ont.; Department of Emergency Medicine (von Vopelius-Feldt, Lockwood, Nolan), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Division of Emergency Medicine (Mal, Peddle), London Health Sciences Centre, London, Ont.; Department of Surgery, Trauma and Acute Care Surgery (Beckett), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Canadian Forces Health Services Headquarters (Beckett, Schmid), Canadian Armed Forces, Ottawa, Ont.; Department of Pathology and Molecular Medicine (Callum), Kingston Health Sciences Centre and Queen's University, Kingston, Ont.; University of Toronto Quality in Utilization, Education and Safety in Transfusion (QUEST) research program (Callum, Khandelwal, Pavenski), Toronto, Ont.; AirEvac and Critical Care Operations (Greene, Vu), British Columbia Emergency Health Services, Vancouver, BC; School of Medicine (Greene), Cardiff University, Cardiff, Wales, UK; Division of Trauma and General Surgery (Grushka), McGill University Health Centre, Montreal General Hospital Site, Montréal, Que.; Canadian Blood Services (Khandelwal); Department of Laboratory Medicine and Pathobiology (Lin), University of Toronto; Precision Diagnostics and Therapeutics Program (Lin), Sunnybrook Health Sciences Centre, Toronto, Ont.; Faculty of Medicine (Nahirniak), University of Alberta, Edmonton, Alta.; Transfusion and Transplantation Medicine (Nahirniak), Alberta Precision Laboratories, Calgary, Alta.; Departments of Medicine and Laboratory Medicine (Pavenski), St. Michael's Hospital, Unity Health Toronto and University of Toronto, Toronto, Ont.; Division of Transfusion Medicine (Prokopchuk-Gauk), Department of Pathology and Laboratory Medicine, Saskatchewan Health Authority; College of Medicine (Prokopchuk-Gauk), University of Saskatchewan, Saskatoon, Sask.; Emergency Department (Regehr), Health Sciences Centre; Shock Trauma Air Rescue Service (STARS) (Regehr), Manitoba Base, Winnipeg, Man.; Department of Pathology and Laboratory Medicine (Shih), Vancouver Coastal Health Authority; Centre for Blood Research (Shih), University of British Columbia; Department of Emergency Medicine (Trojanowski), Vancouver General Hospital and the University of British Columbia; Clinical Operations (Trojanowski), British Columbia Emergency Health Services; Departments of Emergency Medicine and Critical Care Medicine (Vu), Vancouver Coastal Health Authority and Provincial Health Services Authority, Vancouver, BC; Department of Surgery and Section of Critical Care (Ziesmann), Health Sciences Centre, Winnipeg, Man
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49
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Gupta B, Singh Y, Bagaria D, Nagarajappa A. Comprehensive Management of the Patient With Traumatic Cardiac Injury. Anesth Analg 2023; 136:877-893. [PMID: 37058724 DOI: 10.1213/ane.0000000000006380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/16/2023]
Abstract
Cardiac injuries are rare but potentially life-threatening, with a significant proportion of victims dying before arrival at the hospital. The in-hospital mortality among patients who arrive in-hospital alive also remains significantly high, despite major advancements in trauma care including the continuous updating of the Advanced Trauma Life Support (ATLS) program. Stab and gunshot wounds due to assault or self-inflicted injuries are the common causes of penetrating cardiac injuries, while motor vehicular accidents and fall from height are attributable causes of blunt cardiac injury. Rapid transport of victim to trauma care facility, prompt recognition of cardiac trauma by clinical evaluation and focused assessment with sonography for trauma (FAST) examination, quick decision-making to perform emergency department thoracotomy, and/or shifting the patient expeditiously to the operating room for operative intervention with ongoing resuscitation are the key components for a successful outcome in cardiac injury victims with cardiac tamponade or exsanguinating hemorrhage. Blunt cardiac injury with arrhythmias, myocardial dysfunction, or cardiac failure may need continuous cardiac monitoring or anesthetic care for operative procedure of other associated injuries. This mandates a multidisciplinary approach working in concert with agreed local protocols and shared goals. An anesthesiologist has a pivotal role to play as a team leader or member in the trauma pathway of severely injured patients. They are not only involved in in-hospital care as a perioperative physician but also participate in the organizational aspects of prehospital trauma systems and training of prehospital care providers/paramedics. There is sparse literature available on the anesthetic management of cardiac injury (penetrating as well as blunt) patients. This narrative review discusses the comprehensive management of cardiac injury patients, focusing on the anesthetic concerns and is guided by our experience in managing cardiac injury cases at Jai Prakash Narayan Apex Trauma Center (JPNATC), All India Institute of Medical Sciences, New Delhi. JPNATC is the only level 1 trauma center in north India, providing services to a population of approximately 30 million with around 9000 operations being performed annually.
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Affiliation(s)
- Babita Gupta
- From the Department of Anaesthesiology, Pain Medicine and Critical Care, Jai Prakash Narayan Apex Trauma Center, All India Institute of Medical Sciences, New Delhi, India
| | - Yudhyavir Singh
- From the Department of Anaesthesiology, Pain Medicine and Critical Care, Jai Prakash Narayan Apex Trauma Center, All India Institute of Medical Sciences, New Delhi, India
| | - Dinesh Bagaria
- Division of Trauma Surgery and Critical Care, Jai Prakash Narayan Apex Trauma Center, All India Institute of Medical Sciences, New Delhi, India
| | - Abhishek Nagarajappa
- Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India
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50
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Bouzat P, Charbit J, Abback PS, Huet-Garrigue D, Delhaye N, Leone M, Marcotte G, David JS, Levrat A, Asehnoune K, Pottecher J, Duranteau J, Courvalin E, Adolle A, Sourd D, Bosson JL, Riou B, Gauss T, Payen JF. Efficacy and Safety of Early Administration of 4-Factor Prothrombin Complex Concentrate in Patients With Trauma at Risk of Massive Transfusion: The PROCOAG Randomized Clinical Trial. JAMA 2023; 329:1367-1375. [PMID: 36942533 PMCID: PMC10031505 DOI: 10.1001/jama.2023.4080] [Citation(s) in RCA: 26] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Accepted: 03/05/2023] [Indexed: 03/22/2023]
Abstract
Importance Optimal transfusion strategies in traumatic hemorrhage are unknown. Reports suggest a beneficial effect of 4-factor prothrombin complex concentrate (4F-PCC) on blood product consumption. Objective To investigate the efficacy and safety of 4F-PCC administration in patients at risk of massive transfusion. Design, Setting, and Participants Double-blind, randomized, placebo-controlled superiority trial in 12 French designated level I trauma centers from December 29, 2017, to August 31, 2021, involving consecutive patients with trauma at risk of massive transfusion. Follow-up was completed on August 31, 2021. Interventions Intravenous administration of 1 mL/kg of 4F-PCC (25 IU of factor IX/kg) vs 1 mL/kg of saline solution (placebo). Patients, investigators, and data analysts were blinded to treatment assignment. All patients received early ratio-based transfusion (packed red blood cells:fresh frozen plasma ratio of 1:1 to 2:1) and were treated according to European traumatic hemorrhage guidelines. Main Outcomes and Measures The primary outcome was 24-hour all blood product consumption (efficacy); arterial or venous thromboembolic events were a secondary outcome (safety). Results Of 4313 patients with the highest trauma level activation, 350 were eligible for emergency inclusion, 327 were randomized, and 324 were analyzed (164 in the 4F-PCC group and 160 in the placebo group). The median (IQR) age of participants was 39 (27-56) years, Injury Severity Score was 36 (26-50 [major trauma]), and admission blood lactate level was 4.6 (2.8-7.4) mmol/L; prehospital arterial systolic blood pressure was less than 90 mm Hg in 179 of 324 patients (59%), 233 patients (73%) were men, and 226 (69%) required expedient hemorrhage control. There was no statistically or clinically significant between-group difference in median (IQR) total 24-hour blood product consumption (12 [5-19] U in the 4F-PCC group vs 11 [6-19] U in the placebo group; absolute difference, 0.2 U [95% CI, -2.99 to 3.33]; P = .72). In the 4F-PCC group, 56 patients (35%) presented with at least 1 thromboembolic event vs 37 patients (24%) in the placebo group (absolute difference, 11% [95% CI, 1%-21%]; relative risk, 1.48 [95% CI, 1.04-2.10]; P = .03). Conclusions and Relevance Among patients with trauma at risk of massive transfusion, there was no significant reduction of 24-hour blood product consumption after administration of 4F-PCC, but thromboembolic events were more common. These findings do not support systematic use of 4F-PCC in patients at risk of massive transfusion. Trial Registration ClinicalTrials.gov Identifier: NCT03218722.
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Affiliation(s)
- Pierre Bouzat
- Université Grenoble Alpes, Inserm, U1216, CHU Grenoble Alpes, Grenoble Institute Neurosciences, Grenoble, France
| | - Jonathan Charbit
- Trauma Critical Care Unit, Montpellier University Hospital, F-34295 Montpellier Cedex 5, France
| | - Paer-Selim Abback
- Department of Anesthesiology and Critical Care, Beaujon Hospital, DMU Parabol, AP-HP. Nord, Clichy, France
| | - Delphine Huet-Garrigue
- Department of Anesthesiology and Critical Care, Centre Hospitalier Universitaire Lille, Surgical Critical Care, Lille, France
| | - Nathalie Delhaye
- AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, site Pitié-Salpêtrière, Département d’Anesthésie Réanimation, Paris, France
| | - Marc Leone
- Aix Marseille University, Assistance Publique Hôpitaux Universitaires de Marseille, Department of Anesthesiology and Intensive Care Unit, North Hospital, and Centre for CardioVascular and Nutrition Research (C2VN), Inserm 1263, Inrae 1260, Marseille, France
| | - Guillaume Marcotte
- Hospices Civils de Lyon, Hopital Edouard Herriot, Department of Anesthesia and Intensive Care, Lyon, France
| | - Jean-Stéphane David
- University Claude Bernard Lyon 1, INSERM U1290, Research on Healthcare Performance (RESHAPE), and Hospices Civils de Lyon, Groupement Hospitalier Sud, Department of Anesthesia and Intensive Care, Pierre Benite, France
| | | | - Karim Asehnoune
- Université de Nantes, CHU Nantes, Pôle anesthésie réanimations, Service d'Anesthésie Réanimation chirurgicale, Hôtel Dieu, Nantes, France
| | - Julien Pottecher
- Hôpitaux Universitaires de Strasbourg, Hôpital de Hautepierre, Service d’Anesthésie-Réanimation & Médecine Péri-Opératoire - Université de Strasbourg, Faculté de Médecine, FMTS, ER3072, Strasbourg, France
| | - Jacques Duranteau
- Département d’Anesthésie-Réanimation, Hôpitaux Universitaires Paris Sud, Université Paris XI, Faculté de Médecine Paris-Sud, Le Kremlin-Bicêtre, France
| | - Elie Courvalin
- Trauma Critical Care Unit, Montpellier University Hospital, F-34295 Montpellier Cedex 5, France
| | - Anais Adolle
- Pôle d’Anesthésie-Réanimation, CHU Grenoble Alpes, Grenoble, France
| | - Dimitri Sourd
- Univ. Grenoble Alpes, CNRS, Public Health department CHU Grenoble Alpes, TIMC-IMAG, Grenoble, France
| | - Jean-Luc Bosson
- Univ. Grenoble Alpes, CNRS, Public Health department CHU Grenoble Alpes, TIMC-IMAG, Grenoble, France
| | - Bruno Riou
- Sorbonne Université, UMR-S INSERM 1166, IHU ICAN, and Assistance Publique-Hôpitaux de Paris, Hôpital Pitié-Salpêtrière, Department of Emergency medicine and Surgery, Paris, France
| | - Tobias Gauss
- Department of Anesthesiology and Critical Care, Beaujon Hospital, DMU Parabol, AP-HP. Nord, Clichy, France
| | - Jean-François Payen
- Université Grenoble Alpes, Inserm, U1216, CHU Grenoble Alpes, Grenoble Institute Neurosciences, Grenoble, France
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