Whole Blood Transfusion

Effect of the delayed wash (deglycerolisation) on the red blood cell morphology: Comparison of AFM and optical profilometry

The morphological characterisation is crucial for analysing cell states, especially for red blood cells (RBCs), which are used in transfusions. This study compared the applicability of atomic force microscopy (AFM) and confocal optical profilometry in the accurate characterisation of the RBC morphological parameters. The imaging of RBCs thawed after cryopreservation with immediate and delayed washing steps (deglycerolisation) was performed, and the morphological data obtained with AFM and optical profilometry were compared with the clinical laboratory studies. Both techniques provided close data on the morphological parameters, but optical profilometry allowed a faster and more convenient data acquisition. However, the membrane roughness analysis on discocytes and the submembrane cytoskeleton analysis on RBC ghosts was only possible with AFM due to its higher spatial resolution. Both techniques confirmed that delayed washing did not have negative effects on cells compared to immediate washing. Additional 3-day storage of both types of RBCs resulted in increased haemolysis. A decrease in the fraction of area occupied by pores in the submembrane cytoskeleton with the storage time was observed, possibly associated with the cytoskeleton deterioration. The studied conditions model the transportation of thawed RBCs in a cryoprotectant solution to medical facilities that have technical conditions to wash thawed RBCs and confirm its feasibility.

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

ABSTRACT

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

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

BACKGROUND

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

STUDY DESIGN AND METHODS

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

RESULTS

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

CONCLUSION

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

An Analysis of the Association of Whole Blood Transfusion With the Development of Acute Respiratory Distress Syndrome

OBJECTIVES

To determine the association of whole blood and other blood products (components, prothrombin complex concentrate, and fibrinogen concentrate) with the development of acute respiratory distress syndrome (ARDS) among blood recipients.

DESIGN

Retrospective cohort study.

SETTING

American College of Surgeons Trauma Quality Improvement Program (TQIP) database between 2020 and 2021.

PATIENTS

Patients 15 years old or older in the TQIP database between 2020 and 2022 who received at least one blood product.

INTERVENTIONS

We compared characteristics and blood product administration between patients who developed ARDS versus those who did not.

MEASUREMENTS AND MAIN RESULTS

There were 134,863 that met inclusion for this analysis. Within the included population, 1% (1927) was diagnosed with ARDS. The no ARDS group had a lower portion of serious injuries to the head/neck (31% vs. 46%), thorax (51% vs. 78%), abdomen (34% vs. 48%), and extremities (37% vs. 47%). The median composite Injury Severity Score was 21 (11-30) in the no ARDS group vs. 30 (22-41) in the ARDS group. Unadjusted survival of discharge was 74% in the no ARDS group vs. 61% in the ARDS group. In our multivariable model, we found that whole blood (unit odds ratio [uOR], 1.05; 95% CI, 1.02-1.07), male sex (odds ratio, 1.44; 95% CI, 1.28-1.63), arrival shock index (uOR, 1.03; 95% CI, 1.01-1.06), and composite Injury Severity Score (uOR, 1.03; 95% CI, 1.03-1.04) were associated with the development of ARDS. These persisted on sensitivity testing.

CONCLUSIONS

We found an association between whole blood and the development of ARDS among trauma patients who received blood transfusions. Contrary to previous studies, we found no association between ARDS and fresh frozen plasma administration. The literature would benefit from further investigation via prospective study designs.

Fresh whole blood: A feasible alternative in disasters and mass casualty incidents? a systematic review and meta-analysis

INTRODUCTION

While balanced blood component therapy (BCT) is pivotal in trauma patient damage control resuscitation in well-resourced settings, disasters, and mass casualty incidents (MCIs) pose significant challenges, especially in securing sufficient access to blood products. This systematic review and meta-analysis aim to explore the utilization of fresh whole blood (FWB) transfusion as a potential alternative to BCT, informing future research and clinical strategies.

METHODS

We searched Pubmed, MEDLINE, Embase, CINAHL, the Cochrane Library and grey literature for articles identifying FWB transfusions, limited to those published in English or French. We evaluated the outcomes of post-FWB transfusion and conducted a meta-analysis comparing overall mortality in patients receiving FWB in addition to BCT during damage control resuscitation with those receiving BCT or single blood components alone.

RESULTS

Of the 4830 studies identified, only 74 articles met all the eligibility criteria; the majority of them were conducted in military contexts. Mortality was lower among the FWB group compared to the BCT alone group, with a pooled OR of 0.61 (95% CI: 0.38-0.98) overall, and a pooled OR of 0.47 (95% CI: 0.25-0.87) among studies adjusting for confounders. FWB transfusion related complications rarely occurred.

CONCLUSIONS

While FWB shows potential as an alternative to BCT for managing severe haemorrhagic shock in disasters and MCIs, additional research is essential to validate FWB's efficacy before considering it as a standard approach in civilian scenarios. Further studies focusing on the feasibility of implementing FWB in civilian contexts are also warranted.

TXA combined with whole blood transfusion in trauma patients does not increase the risk of VTE but shock index does

INTRODUCTION

Previous studies have demonstrated the benefits of tranexamic acid (TXA) administration in combination with packed red blood cell (PRBC) transfusion in trauma patients without increasing the risk of venous thromboembolism (VTE). However, the effect of TXA in combination with whole blood (WB) has not been studied. Injury, abbreviated injury severity scores (ISS and AIS) and the need for blood transfusions are historically associated with VTE. The objective of this study was to determine the relationship between VTE and the combination of TXA administration and transfusion of PRBCs vs. WB.

METHODS

Our institutional trauma registry was queried for trauma patients between 2015 and 2022 who received either WB ​+ ​TXA or PRBC ​+ ​TXA either prehospital or within 4 ​h of arrival. Multivariate analysis was utilized to determine independent risk factors for VTE, which were defined as either a deep vein thrombosis (DVT) or a pulmonary embolism (PE). Model covariates included age, mechanism of injury (MOI), ISS, lower extremity AIS, comorbid conditions, and shock index (SI). Additional outcomes analyzed were hospital length of stay (LOS), ICU LOS, and ventilator days.

RESULTS

Three hundred and five patients had complete data and were included in the analysis. Of those, 251 received WB ​+ ​TXA and 54 received PRBC ​+ ​TXA. A total of 34 patients were found to have VTE event (11.1 ​%); 28 (11.2 ​%) and 6 (11.1 ​%) from the WB ​+ ​TXA and PRBC ​+ ​TXA groups, respectively. An elevated pre-hospital SI was independently associated with increased VTE rate (OR 1.85, 95 ​% CI 1.07-3.20). WB transfusion, TXA administration, ISS, and MOI did not influence the rate of VTE.

CONCLUSION

These data demonstrate that the combination of WB ​+ ​TXA administered to trauma patients has no higher risk of VTE than patients who receive PRBC ​+ ​TXA, a comparison that has not been studied clinically to date. Despite the pro thrombotic state enhanced by TXA and the decreased dilutional coagulopathy seen in WB resuscitation, there was no increased risk of VTE compared to TXA ​+ ​PRBC. There is no evidence that TXA combined with whole blood transfusion is associated with an increased risk of VTE. However, higher pre-hospital SI was associated with an elevated rate of VTE. These clinical features provide insight into patients who may be at an increased risk of developing VTE and may benefit from targeted prevention strategies.

In vivo evaluation of an adaptive resuscitation controller using whole blood and crystalloid infusates for hemorrhagic shock

Introduction

Hemorrhage remains the leading cause of preventable death on the battlefield. The most effective means to increase survivability is early hemorrhage control and fluid resuscitation. Unfortunately, fluid resuscitation requires constant adjustments to ensure casualty is properly managed, which is often not feasible in the pre-hospital setting. In this study, we showed how an adaptive closed-loop controller for hemorrhage resuscitation can be used to automate hemodynamic management using a swine hemorrhagic shock injury model.

Methods

The adaptive resuscitation controller (ARC) was previously developed to track pressure-volume responsiveness in real time and adjust its infusion rate to reach the target mean arterial pressure (MAP). Swine while maintained under a surgical plane of anesthesia and analgesia underwent a splenectomy, followed by two hemorrhage and resuscitation events. For the first resuscitation event, hemorrhage was induced to reduce the MAP to 35 mmHg until arterial lactate reached 4 mmol/L. The ARC system then infused whole blood (WB) to reach the target MAP and maintained the subject using crystalloids for 120 min. For the second resuscitation event, the subjects were hemorrhaged again but resuscitated using only crystalloid infusion to reach the target MAP and 120-min maintenance.

Results

The ARC was effective at WB resuscitation, reaching the target MAP in 2.0 ± 1.0 min. The median performance error was 1.1% ± 4.6%, and target overshoot was 14.4% ± 7.0% of the target MAP. The ARC maintained all animals throughout the 120 min maintenance period. For the second crystalloid-based resuscitation, ARC required a longer time to reach the target MAP, at an average rise time of 4.3 ± 4.0 min. However, target overshoot was reduced to 8.4% ± 7.3% of the target MAP. Much higher flow rates were required to maintain the target MAP during the second resuscitation event than during the first resuscitation event.

Discussion

The ARC was able to rapidly reach and maintain the target MAP effectively. However, this sometimes required large volumes of fluid as the ARC's only goal was to reach the target MAP. Further clinical insight is needed regarding the preferred aggression level to achieve the target MAP. In conclusion, the ARC was successful in its programmed objective of reaching and maintaining the target MAP for extended periods of time in vivo, a critical next step toward improving hemorrhage treatment in the pre-hospital environment.

Comparison of manual titrations to automated microplate and gel titration assays used in the screening of blood donors for production of Low-Titer O Whole Blood

BACKGROUND

The popularity of Low-Titer O Whole Blood (LTOWB) for treating trauma patients requires that donor centers and transfusion services make decisions on what titer testing capabilities to institute and an appropriate titer level threshold. This study compared the titer results determined by four methods to find a rate of agreement.

STUDY DESIGN AND METHODS

Isohemagglutinin titers were tested on 300 plasma samples utilizing various methods, each determining IgM antibody levels by direct hemagglutination with A1 and B reference cells. The methods used were the Beckman Coulter's PK7300, Immucor's NEO Iris microplate technology, Ortho Clinical Diagnostics (OCD) Vision, and manual titrations.

RESULTS

Only 42.7% of the samples tested showed agreement across all methods on ABO isohemaglutinin titer levels and only 32.5% demonstrated "High titer" agreement. Sample agreement was close to 90% if the Immucor method was excluded. At a <1:256 titer level threshold, the pass rate was 94.3% for Immucor, 89.7% for the PK7300, 87.3% for manual testing, and 75.7% for OCD's gel method. Sensitivity and specificity rates at a ± 1 titer level were respectively 100% and 95.4% for OCD's gel, 73.7% and 100% for Immucor, and 100% and 99.6% for the PK7300. Overall method accuracy was 91.7% for Immucor, 90.3% for the PK7300, and 86.7% for OCD's gel method as compared to manual titration.

CONCLUSION

All three automated methods perform comparably to the manual method at a ± 1 titer tolerance level. Based on these comparisons, a titer level of <1:256 would maximize LTOWB production regardless of the method used.

Cost Savings of Whole Blood Versus Component Therapy at a Community Level 1 Trauma Center

BACKGROUND

Blood product component-only resuscitation (CORe) has been the standard of practice in both military and civilian trauma care with a 1:1:1 ratio used in attempt to recreate whole blood (WB) until recent data demonstrated WB to confer a survival advantage, leading to the emergence of WB as the contemporary resuscitation strategy of choice. Little is known about the cost and waste reduction associated with WB vs CORe.

METHODS

This study is a retrospective single-center review of adult trauma patients admitted to a community trauma center who received WB or CORe as part of their massive transfusion protocol (MTP) resuscitation from 2017 to 2021. The WB group received a minimum of one unit WB while CORe received no WB. Univariate and multivariate analyses were completed. Statistical analysis was conducted using a 95% confidence level. Non-normally distributed, continuous data were analyzed using the Wilcoxon rank sum test.

RESULTS

576 patients were included (201 in WB and 375 in CORe). Whole blood conveyed a survival benefit vs CORe (OR 1.49 P < .05, 1.02-2.17). Whole blood use resulted in an overall reduction in products prepared (25.8%), volumes transfused (16.5%), product waste (38.7%), and MTP activation (56.3%). Cost savings were $849 923 annually and $3 399 693 over the study period.

DISCUSSION

Despite increased patient volumes over the study period (43.7%), the utilization of WB as compared to CORe resulted in an overall $3.39 million cost savings while improving mortality. As such, we propose WB should be utilized in all resuscitation strategies for the exsanguinating trauma patient.

Type-specific whole blood still has a role in the era of low-titer O universal donor transfusion for severe trauma hemorrhage

ABSTRACT

Whole blood can be ABO-type specific (type-specific whole blood (TSWB)) or low-titer O universal donor (low-titer O whole blood (LTOWB)). Having previously used LTOWB, the US Armed Forces Blood Program began using TSWB in 1965 as a method of increasing the donor pool. In contrast to military practice, the Association for the Advancement of Blood and Biotherapies formerly the American association of blood banks (AABB), from its first guidelines in 1958 until 2018, permitted only TSWB. Attempting to reduce time to transfusion, the US military reintroduced LTOWB in the deployed environment in 2015; this practice was endorsed by the AABB in 2018 and is progressively being implemented by military and civilian providers worldwide. Low-titer O whole blood is the only practical solution prehospital. However, there are several reasons to retain the option of TSWB in hospitals with a laboratory. These include (1) as-yet ill-defined risks of immunological complications from ABO-incompatible plasma (even when this has low titers of anti-A and -B), (2) risks of high volumes of LTOWB including published historical advice (based on clinical experience) not to transfuse type-specific blood for 2 to 3 weeks following a substantial LTOWB transfusion, (3) uncertainty as to the optimal definition of "low titer," and (4) expanding the potential donor pool by allowing type-specific transfusion. Several large randomized controlled trials currently underway are comparing LTOWB with component therapy, but none address the question of LTOWB versus TSWB. There are sufficient data to suggest that the additional risks of transfusing LTOWB to non-group O recipients should be avoided by using TSWB as soon as possible. Combined with the advantage of maintaining an adequate supply of blood products in times of high demand, this suggests that retaining TSWB within the civilian and military blood supply system is desirable. TSWB should be preferred when patient blood group is confirmed in facilities with a hematology laboratory, with LTOWB reserved for patients whose blood group is unknown.

Optimizing RBC Transfusion Strategies in Traumatic Brain Injury: Insights on Early Resuscitation and Cerebral Oxygenation

Effective early resuscitation and maintenance of brain oxygenation are critical for improving the outcomes of patients with severe traumatic brain injury (TBI). Red blood cell (RBC) transfusion plays a vital role in this process. Although RBC transfusion can enhance cerebral oxygenation and stabilize hemodynamics, it also poses significant risks including transfusion-related lung injury and transfusion-associated circulatory overload, highlighting the importance of meticulous transfusion management. This review explores transfusion strategies during the early resuscitation phase and the management of anemia in patients with severe TBI, focusing on appropriate treatment targets, utilizing monitoring-based personalized approaches, and summarizing recent research and current insights.

Whole Blood Program: Implementation in a Rural Trauma Center

BACKGROUND

The balanced transfusion of blood components plays a leading role in traumatic hemostatic resuscitation. Yet, previous whole blood studies have only focused on urban trauma center settings.

OBJECTIVE

To compare component vs whole blood therapy on wastage rates and mortality in the rural setting.

METHODS

This study was a nonrandomized, retrospective, observational, single-center study on a cold-stored whole blood program implementation for adult massive transfusions from 2020 to 2022 at a Level II trauma center. Trauma registry data determined the facility's whole blood needs and facilitated sustainable blood supplies. Whole blood use protocols were established, and utilization and laboratory compliance for incompatible ABO antibody hemolysis was monitored and reviewed monthly at stakeholder and trauma services meetings.

RESULTS

From 2018 to 2019, the facility initiated component therapy massive transfusions every 9 days (n = 41). Therefore, four units of low-titer, O-positive whole blood delivered fortnightly was determined to provide patient coverage and minimize wastage. Across the study time frame (2020-2022), there were n = 68 hemodynamically unstable patients, consisting of those receiving whole blood, n = 37, and patients receiving component therapy, n = 31. Mortality rates were significantly lower (p = .030) in the whole blood population (n = 3, 8%) compared to those solely receiving component therapy (n = 9, 29%). Wastage rates were constantly evaluated; in 2021, 43.4% was not utilized, and in 2022, this was reduced to 38.7%. Anecdotally, nurses appreciated the ease of administration and documentation of transfusing whole blood, as it negated ratio compliance.

CONCLUSION

This evidence-based whole blood program provides vital care to severely injured trauma patients in a vast, rural region.

Military Blood Supply and Distribution in USCENTCOM

In expeditionary environments, the consistent availability of blood for casualty care is imperative yet challenging. Responding to evidence and the specific needs of its expeditionary context, the US Central Command (USCENTCOM) prioritized supplying stored low titer O whole blood (LTOWB) to its units from March, 2023 onward. A strategy was devised to set minimal LTOWB on-hand supply benchmarks, determined by the number of operating beds and point of injury teams. This transition led to a 54% reduction in orders for packed red blood cells. As a countermove, the Armed Services Blood Program (ASBP) enhanced LTOWB production at a conversion rate 2:1 from packed red blood cell to LTOWB. Consequently, there was a decline in expired blood products, and fulfillment rates for blood requests are projected to reach 100% consistently. This paper delves into the intricacies of the expeditionary blood supply, the rationale behind the LTOWB transition, the devised allocation strategy, and the subsequent impacts of this change.

Hemostatic Evaluation of Refrigerated Whole Blood Stored 7 Days Post-Expiration

INTRODUCTION

The United States Army has shifted doctrine to focus on large-scale combat operations against peer to near-peer adversaries. Future conflicts could result in a limited supply chain, leaving medical providers with only expired blood products for treatment of hemorrhagic shock. This study evaluated quality, function, and safety metrics of whole blood stored for 1 week past regulated expiration (i.e., 35 days, in CPDA-1).

MATERIALS AND METHODS

Whole blood units (n = 6) were collected in citrate phosphate dextrose adenine-1 (CPDA-1) anticoagulant and stored refrigerated for up to 42 days. Units were sampled on days 35, 37, 39, and 42 of storage and evaluated for the following: complete blood count, blood metabolism and chemistries, clotting dynamics, and presence of bacteria.

RESULTS

The majority of evaluated parameters fell outside of normal clinical ranges beginning at day 35 of storage. At 42 days, blood pH was 6.58 ± 0.038, hemolysis was significantly increased (P = .037 vs day 35), and bacterial contamination was not evident. Glucose levels continuously dropped during extended storage. K+ was significantly increased at day 42 compared to day 35 (P = .010). A significant reduction in clot strength, factor V activity, and factor VIII activity was evident beginning at day 39 of storage.

CONCLUSIONS

Storage of whole blood out to 42 days results in a continuous decline in function, but further in vivo safety studies should be performed to determine if the benefits of expired blood outweigh the risks. Other methods to safely extend storage of whole blood that maintain hemostatic function and preserve safety should be investigated, with emphasis placed on methods that reduce potassium leak and/or hemolysis.

Barriers and Challenges to Implementing Whole Blood Transfusion Protocols in Civilian Hospitals: A Systematic Review and Meta-Analysis

Background: Whole blood is a product that contains all three blood components (plasma, red blood cells, and platelets). This systemic review and meta-analysis was conducted to identify barriers and obstacles to establishing whole blood transfusion protocols in civilian hospitals. Methods: The study was conducted using PRISMA guidelines with PROSPERO registration No. CRD42024519898. Traumatic patients who needed or received whole blood transfusion were included. A systematic literature review employed a comprehensive search strategy through the PubMed, Google Scholar, Web of Science, ScienceDirect, and ProQuest databases. Meta-analysis was utilized to analyze the outcomes. The risk of bias was assessed using the Newcastle-Ottawa Scale. Results: In total, 310 studies were identified, and 11 studies met the inclusion criteria. The following intervals were used to assess the prevalence of mortality: 6 h 12.15% (0.081, 95% CI [0.023, 0.139]), 24 h 14.08% (0.141, 95% CI [0.111, 0.171]), delayed mortality (28-30 days) 22.89% (0.284, 95% CI [0.207, 0.360]), and in-hospital 18.72%, with relative risk (0.176, 95% CI [0.114,0.238]). Conclusions: Traumatic patients can be effectively resuscitated and stabilized with whole blood transfusion (WBT), but it is essential to provide ongoing critical care, address logistical challenges, and prevent blood product wastage. We recommend utilizing WBT in the early stages of resuscitation for adult civilian trauma patients.

The impact of simulation-based training on medical students' whole blood transfusion abilities

BACKGROUND

Whole blood transfusion has been found to increase the likelihood of patient survival within both military and civilian medicine contexts. However, no whole blood transfusion training curriculum currently exists within undergraduate or graduate medical education in the United States. The purpose of our study was to: (1) determine the impact of simulation-based training on medical students' abilities to conduct whole blood transfusions; and (2) determine the impact of simulation-based training on medical students' confidence in conducting whole blood transfusions.

STUDY DESIGN AND METHODS

We assessed 157 third-year military medical students' ability to conduct whole blood transfusion before and after Operation Gunpowder, a 2-day high-fidelity prolonged casualty care simulation. We conducted a paired samples t-test to compare the students' pre- and post-simulation performance scores as well as self-reported confidence and stress ratings.

RESULTS

There was a significant difference in students' scores at the beginning of the course (M = 20.469, SD 6.40675) compared to their scores at the end of the course (M = 30.361, SD = 2.10053); t(155) = -18.833, p < .001. The effect size for this analysis (d = 6.56) was large. There was a significant difference (p < .001) between the pre- and post-ratings for all self-reported confidence and stress survey items.

DISCUSSION

Our results suggest that simulation-based training is an effective means of training medical students to conduct whole blood transfusiontraining in a limited resource simulated environment where blood inventories may be limited.

Comparison of shelf-stable and conventional resuscitation products in a canine model of hemorrhagic shock

BACKGROUND

Treatment of severe hemorrhagic shock typically involves hemostatic resuscitation with blood products. However, logistical constraints often hamper the wide distribution of commonly used blood products like whole blood. Shelf-stable blood products and blood substitutes are poised to be able to effectively resuscitate individuals in hemorrhagic shock when more conventional blood products are not readily available.

METHODS

Purpose-bred adult dogs (n = 6) were anesthetized, instrumented, and subjected to hemorrhagic shock (mean arterial pressure <50 mm Hg or 40% blood volume loss). Then each dog was resuscitated with one of five resuscitation products: (1) lactated ringers solution and hetastarch (LRS/Heta), (2) canine chilled whole blood (CWB), (3) fresh frozen plasma (FFP) and packed red blood cells (pRBC), (4) canine freeze-dried plasma (FDP) and hemoglobin-based oxygen carrier (HBOC), or (5) HBOC/FDP and canine lyophilized platelets (LyoPLT). Each dog was allowed to recover after the hemorrhage resuscitation event and was then subjected to another hemorrhage event and resuscitated with a different product until each dog was resuscitated with each product.

RESULTS

At the time when animals were determined to be out of shock as defined by a shock index <1, mean arterial pressure (mmHg) values (mean ± standard error) were higher for FFP/pRBC (n = 5, 83.7 ± 4.5) and FDP/HBOC+LyoPLT (n = 4, 87.8 ± 2.1) as compared with WB (n = 4, 66.0 ± 13.1). A transient increase in creatinine was seen in dogs resuscitated with HBOC and FDP. Albumin and base excess increased in dogs resuscitated with HBOC and FDP products compared with LRS/heta and CWB ( p < 0.01).

CONCLUSION

Combinations of shelf-stable blood products compared favorably to canine CWB for resolution of shock. Further research is needed to ascertain the reliability and efficacy of these shelf-stable combinations of products in other models of hemorrhage that include a component of tissue damage as well as naturally occurring trauma.

A Descriptive Analysis of Blood Products Utilized by a Forward Deployed Surgical Team in Syria

INTRODUCTION

Traumatically injured combat casualties urgently need both blood and surgery. Forward Surgical Teams (FSTs) or Role 2 (R2) surgical teams were created to minimize the time-space distance from point of injury to damage control surgery. Our goal is to describe the use of blood products from a Split FST deployed to Green Village from July 2018 to April 2019.

MATERIALS AND METHODS

A retrospective review of a collection of patients treated by a single R2 was conducted following institutional regulatory approval. De-identified data were input into the study database and were then retrospectively reviewed for patients who presented to and received treatment at the R2 facility.

RESULTS

Of the 470 total patients treated in 10 months: 226 (48%) received blood products and 132 (28%) underwent operative procedures. The patients were 98% male; 74% Host Nationals (HN), 24% North American Treaty Organization members. Mechanism of injury was 75% explosive and 98% penetrating. Documented Injury Severity Scores (n = 214) were: <9 (n = 57/27%), 9 to 15 (n = 34/16%), 16 to 25 (n = 64/30%), and >25 (n = 59/28%). In total 1,052 units of blood products were administered: whole blood (n = 495), red blood cells (n = 200), fresh frozen plasma (n = 109), and liquid plasma (n = 248). HN whole blood used was 337/495 (68%) units for 78 patients; walking blood bank was mobilized six times for HN patients. Of the patients seen, >99% who arrived with a pulse survived to be discharged to a higher level of care.

CONCLUSIONS

This analysis describes blood usage associated with one high volume forward deployed operative team and demonstrates the vital importance of the R2 split FST to provide coalition forces with surgical care in proximity to the point of injury. Over time, the supply chain has improved with more component therapy available at R2s; however, the need for walking blood bank and innovative solutions to care for all casualties must be part of small team capabilities. Liquid plasma use should be expanded as soon as it is feasible.

Advanced Critical Care Techniques in the Field

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.

Maximum surgical blood ordering schedule for elective surgical procedures in Omdurman teaching hospital, Sudan

BACKGROUND

The need for blood during a surgical procedure is greater than what blood banks are able to provide. There is an excessive amount of blood being ordered for elective surgeries, surpassing the actual requirements. Only 30% of the cross matched blood is actually used in these surgeries. The accuracy of estimating the transfusion needs before a surgical procedure can be determined by looking at the cross match to transfusion ratio and the transfusion index. "These indicators play a crucial role in developing the maximum surgical blood ordering schedule; in this study, these indicators were tested."

AIM OF STUDY

Is to determine the efficiency of blood ordering and transfusion practices for patients undergoing elective surgeries.

METHODS

This study is a prospective cross-sectional hospital-based study done at Omdurman Teaching Hospital-Sudan. Conducted for the duration of 6 months period from July to December 2019.The study participants were patients who underwent elective surgical procedures in general surgery and Urology departments as total coverage sample over a period of study duration. Ethical clearance obtained from ethical committee of Sudan Medical Specialization Board.

RESULTS

Two hundreds seven patients included in this study, the amount of blood units requested were 443-unit, cross matching for 98.6% (n 437) of units were done. Only 100 unit were Transfused (22,8%). The calculated CT ratio was 4.4, transfusion index was 1.6 and transfusion probability was 29.9%.

CONCLUSION

Transfusion probability and transfusion index of the present study were optimal but comparatively higher than the standard guidelines as most of the cross matched blood was not utilized.

Effective approaches to address noncompressible torso hemorrhage

PURPOSE OF REVIEW

Noncompressible torso hemorrhage (NCTH) is now considered as the major cause of preventable death after both severe military and civilian trauma. Around 20% of all trauma patients still die from uncontrolled exsanguination along with rapidly evolving hemostatic failure. This review highlights the most recent advances in the field and provides an outline for future research directions.

RECENT FINDINGS

The updated definition of NCTH includes a combination of high-grade anatomical torso injury, hemodynamic instability, urgent need for hemorrhage control and aggressive hemostatic resuscitation. Therapeutic concepts consider the following three aspects: control the bleeding source (close the tap), resuscitate to maintain organ perfusion and restore hemostasis (fill the tank), and increase the body's resistance against ischemia (upgrade the armor).

SUMMARY

The concepts for the early management of NCTH have substantially evolved over the last decade. The development of new devices and techniques combined with early intervention of hemostatic failure have contributed to more successful resuscitations. Future research needs to refine and validate their potential clinical application.

The 2023 WSES guidelines on the management of trauma in elderly and frail patients

BACKGROUND

The trauma mortality rate is higher in the elderly compared with younger patients. Ageing is associated with physiological changes in multiple systems and correlated with frailty. Frailty is a risk factor for mortality in elderly trauma patients. We aim to provide evidence-based guidelines for the management of geriatric trauma patients to improve it and reduce futile procedures.

METHODS

Six working groups of expert acute care and trauma surgeons reviewed extensively the literature according to the topic and the PICO question assigned. Statements and recommendations were assessed according to the GRADE methodology and approved by a consensus of experts in the field at the 10th international congress of the WSES in 2023.

RESULTS

The management of elderly trauma patients requires knowledge of ageing physiology, a focused triage, including drug history, frailty assessment, nutritional status, and early activation of trauma protocol to improve outcomes. Acute trauma pain in the elderly has to be managed in a multimodal analgesic approach, to avoid side effects of opioid use. Antibiotic prophylaxis is recommended in penetrating (abdominal, thoracic) trauma, in severely burned and in open fractures elderly patients to decrease septic complications. Antibiotics are not recommended in blunt trauma in the absence of signs of sepsis and septic shock. Venous thromboembolism prophylaxis with LMWH or UFH should be administrated as soon as possible in high and moderate-risk elderly trauma patients according to the renal function, weight of the patient and bleeding risk. A palliative care team should be involved as soon as possible to discuss the end of life in a multidisciplinary approach considering the patient's directives, family feelings and representatives' desires, and all decisions should be shared.

CONCLUSIONS

The management of elderly trauma patients requires knowledge of ageing physiology, a focused triage based on assessing frailty and early activation of trauma protocol to improve outcomes. Geriatric Intensive Care Units are needed to care for elderly and frail trauma patients in a multidisciplinary approach to decrease mortality and improve outcomes.

Frequency of deployed emergency donor panel use prior to implementation of the low titre group O whole blood program

INTRODUCTION

The US military has frequently used a 'walking blood bank', formally known as an 'emergency donor panel' (EDP) to obtain warm fresh whole blood (WFWB) which is then immediately transfused into the casualty. We describe the frequency of EDP activation by the US military.

METHODS

We analysed data from 2007 to 2015 within the Department of Defense Trauma Registry for US, Coalition and US contractor casualties that received at least 1 unit of blood product within the first 24 hours and described the frequency of WFWB use.

RESULTS

There were 3474 casualties that met inclusion, of which, 290 casualties (8%) required activation of the EDP. The highest proportion of EDP events was in 2014, whereas the highest number of EDP events was in 2011. Median injury severity scores were higher in the recipients, compared with non-EDP recipients (29 vs 20), as were proportions with serious injuries to the abdomen (43% vs 19%) and extremities (77% vs 65%). The median number of units of all blood products, except for packed red blood cells, was higher for WFWB recipients. Of the WFWB recipients, the median was 5 units (IQR 2-10) with a maximum documented 144 units. There were four documented cases of EDP recipients receiving >100 units of WFWB with only one surviving to hospital discharge. During the study period, there were a total of 3102 (3%) units of WFWB transfused among a total of 104 288 total units.

CONCLUSIONS

We found nearly 1 in 11 casualties who received blood required activation of the EDP. Blood from the EDP accounted for 3% of all units transfused. These findings will enable future mission planning and medical training, especially for units with smaller, limited blood supplies. The lessons learned here can also enable mass casualty planning in civilian settings.

Empiric Cryoprecipitate Transfusion in Patients with Severe Hemorrhage: Results from the US Experience in the International CRYOSTAT-2 Trial

BACKGROUND

Hypofibrinogenemia has been shown to predict massive transfusion and is associated with higher mortality in severely injured patients. However, the role of empiric fibrinogen replacement in bleeding trauma patients remains controversial. We sought to determine the effect of empiric cryoprecipitate as an adjunct to a balanced transfusion strategy (1:1:1).

STUDY DESIGN

This study is a subanalysis of patients treated at the single US trauma center in a multicenter randomized controlled trial. Trauma patients (more than 15 years) were eligible if they had evidence of active hemorrhage requiring emergent surgery or interventional radiology, massive transfusion protocol (MTP) activation, and received at least 1 unit of blood. Transfer patients, those with injuries incompatible with life, or those injured more than 3 hours earlier were excluded. Patients were randomized to standard MTP (STANDARD) or MTP plus 3 pools of cryoprecipitate (CRYO). Primary outcomes included all-cause mortality at 28 days. Secondary outcomes were transfusion requirements, intraoperative and postoperative coagulation laboratory values, and quality-of-life measures (Glasgow outcome score-extended).

RESULTS

Forty-nine patients (23 in the CRYO group and 26 in the STANDARD group) were enrolled between May 2021 and October 2021. Time to randomization was similar between groups (14 vs 24 minutes, p = 0.676). Median time to cryoprecipitate was 41 minutes (interquartile range 37 to 48). There were no differences in demographics, arrival physiology, laboratory values, or injury severity. Intraoperative and ICU thrombelastography values, including functional fibrinogen, were similar between groups. There was no benefit to CRYO with respect to post-emergency department transfusions (intraoperative and ICU through 24 hours), complications, Glasgow outcome score, or mortality.

CONCLUSIONS

In this study of severely injured, bleeding trauma patients, empiric cryoprecipitate did not improve survival or reduce transfusion requirements. Cryoprecipitate should continue as an "on-demand" addition to a balanced transfusion strategy, guided by laboratory values and should not be given empirically.

Resuscitation and Care in the Trauma Bay

Start balanced resuscitation early (pre-hospital if possible), either in the form of whole blood or 1:1:1 ratio. Minimize resuscitation with crystalloid to minimize patient morbidity and mortality. Trauma-induced coagulopathy can be largely avoided with the use of balanced resuscitation, permissive hypotension, and minimized time to hemostasis. Using protocolized "triggers" for massive and ultramassive transfusion will assist in minimizing delays in transfusion of products, achieving balanced ratios, and avoiding trauma induced coagulopathy. Once "audible" bleeding has been addressed, further blood product resuscitation and adjunct replacement should be guided by viscoelastic testing. Early transfusion of whole blood can reduce patient morbidity, mortality, decreases donor exposure, and reduces nursing logistics during transfusions. Adjuncts to resuscitation should be guided by laboratory testing and carefully developed, institution-specific guidelines. These include empiric calcium replacement, tranexamic acid (or other anti-fibrinolytics), and fibrinogen supplementation.

Progress in injectable hydrogels for the treatment of incompressible bleeding: an update

Uncontrollable haemorrhage from deep, noncompressible wounds remains a persistent and intractable challenge, accounting for a very high proportion of deaths in both war and disaster situations. Recently, injectable hydrogels have been increasingly studied as potential haemostatic materials, highlighting their enormous potential for the management of noncompressible haemorrhages. In this review, we summarize haemostatic mechanisms, commonly used clinical haemostatic methods, and the research progress on injectable haemostatic hydrogels. We emphasize the current status of injectable hydrogels as haemostatic materials, including their physical and chemical properties, design strategy, haemostatic mechanisms, and application in various types of wounds. We discuss the advantages and disadvantages of injectable hydrogels as haemostatic materials, as well as the opportunities and challenges involved. Finally, we propose cutting-edge research avenues to address these challenges and opportunities, including the combination of injectable hydrogels with advanced materials and innovative strategies to increase their biocompatibility and tune their degradation profile. Surface modifications for promoting cell adhesion and proliferation, as well as the delivery of growth factors or other biologics for optimal wound healing, are also suggested. We believe that this paper will inform researchers about the current status of the use of injectable haemostatic hydrogels for noncompressible haemorrhage and spark new ideas for those striving to propel this field forward.

Walking blood bank: a plan to ensure self-sufficiency in an era of blood shortage

Mass casualty incidents and massive transfusion requirements continue to plague the USA with hemorrhage remaining the number one cause of death in trauma. The unfortunate reality of numerous mass shootings in Southwest Texas has led to the need for a way in which to provide blood during these events as rapidly as it is required. Multiple agencies within the Southwest Texas system have united to help provide this life-saving blood to people when they need it most. This effort began with the development of a system for safe, efficient, and now widespread use of whole blood in the region. After demonstrating the success of delivering large quantities of blood during the Uvalde shooting, we have begun to develop a walking blood bank that is similar to what the miliary uses on the battlefield. The concept behind this initiative is to have a cohort of whole blood donors who are preselected to join the program which is now dubbed 'Heroes in Arms'. These donors will be called upon to donate whole blood during a massive transfusion event. Their blood will be rapidly screened prior to transfusion to the patient. This blood will still undergo the normal rigorous testing and, should any potentially transmissible diseases by discovered post-transfusion, the individual who received that product will be treated accordingly. Given the low rate of transmissible disease among this preselected population, combined with rapid screening prior to transfusion, the risk of a person receiving a transmissible disease is insignificant in comparison to the benefit of having blood to transfuse during hemorrhage. This model is a promising collaborative effort to provide in a timely and sufficient blood product in cases of major need which will consequently minimize the number of traumatically injured civilian patients who die from hemorrhage.

The Use of Whole Blood in Rural Trauma Leads to Decreased Resource Utilization

BACKGROUND

Nearly 40% of trauma deaths result from uncontrolled hemorrhage. Most of these deaths occur within 24 hours, highlighting the importance of early resuscitation. Balanced component resuscitation has been shown to improve outcomes in hemorrhagic shock. However, hemostatic properties may then be decreased, leading to inadequate coagulopathy treatment or higher transfusion requirements. Data comparing the efficacy of component vs. whole blood (WB) resuscitation in early trauma is poor, particularly in the rural population. This study investigates WB use and resource utilization at a rural Level 1 trauma center.

METHODS

A prospective cohort study with historical controls (HC) was performed using patients over age 17 presenting as the highest priority trauma. Two units of WB were available to patients with signs of hemorrhagic shock, with subsequent transfusions via massive transfusion protocol or thromboelastography guidance. Component utilization, time to hemorrhage control, complications, and transfer times were examined.

RESULTS

Forty patients received WB vs. 153 HC. WB patients had lower complication rates (35% vs. 55.6%; P = .02), and a significant reduction in pRBC utilization in the emergency department (0 vs. 2; P < .0001) and throughout admission (2.0 vs. 4.0; P = .0003). All patients had prolonged transport times given the rural setting (1.42 hours HC vs. 2.03 hours WB; P = .002).

DISCUSSION

Unlike most urban WB studies, this study occurred in a rural area with extended transportation times, when WB is inaccessible for patients. Despite this delay, WB patients demonstrated lower component utilization and complication rates. Further research is needed to characterize the impact of early WB access.

Low-titer group O whole blood in military ground ambulances: Lessons from the Israel Defense Forces initial experience

BACKGROUND

Cold-stored low-titer group O whole blood (LTOWB) has become increasingly utilised in both prehospital and in-hospital settings for resuscitation of traumatic haemorrhage. However, implementing the use of LTOWB to ground medical teams has been limited due to logistic challenges.

METHODS

In 2022, the Israel Defense Forces (IDF) started using LTOWB in ambulances for the first time in Israel. This report details the initial experience of this rollout and presents a case-series of the first patients treated with LTOWB.

RESULTS

Between January-December 2022, seven trauma patients received LTOWB administered by ground IDF intensive care ambulances after presenting with profound shock. Median time from injury to administration of LTOWB was 35 min. All patients had evidence of severe bleeding upon hospital arrival with six undergoing damage control laparotomy and all but one surviving to discharge.

CONCLUSIONS

The implementation of LTOWB in ground medical units is in its early stages, but continued experience may demonstrate its feasibility, safety, and effectiveness in the prehospital setting. Further research is necessary to fully understand the indications, methodology, and benefits of LTOWB in resuscitating severely injured trauma patients in this setting.

Whole Blood Administration for Obstetric-Related Hemorrhage During Prehospital Transport

BACKGROUND

Whole blood transfusion has been used for resuscitation in trauma patients; however, case reports of whole blood transfusion for obstetric-related hemorrhage are limited. Whole blood transfusion typically is accomplished with low titer O-positive whole blood, and, despite success in trauma, use in persons with childbearing potential is of concern due to risk of alloimmunization.

CASE

We present a case series of patients who received low titer O-positive whole blood for obstetric hemorrhage. One patient was Rh-negative and received immune globulin treatment after whole blood transfusion. All patients survived to hospital discharge. None experienced transfusion-related complications.

CONCLUSION

Whole blood can be successfully administered both in and out of the hospital setting, even for obstetric hemorrhage. The benefits of easily administered balanced resuscitation, limited donor exposure, and improved patient outcomes likely outweigh potential alloimmunization, especially in resource-limited settings. Addressing concerns of alloimmunization cannot be accomplished without more research, and we encourage others to investigate using whole blood in this population.

Cold-stored platelets for acute bleeding in cardiac surgical patients: a narrative review

PURPOSE

Cold-stored platelets (CSP) are an increasingly active topic of international research. They are maintained at 1-6 °C, in contrast to standard room-temperature platelets (RTP) kept at 20-24 °C. Recent evidence suggests that CSP have superior hemostatic properties compared with RTP. This narrative review explores the application of CSP in adult cardiac surgery, summarizes the preclinical and clinical evidence for their use, and highlights recent research.

SOURCE

A targeted search of MEDLINE and other databases up to 24 February 2022 was conducted. Search terms combined concepts such as cardiac surgery, blood, platelet, and cold-stored. Searches of trial registries ClinicalTrials.gov and WHO International Clinical Trials Registry Platform were included. Articles were included if they described adult surgical patients as their population of interest and an association between CSP and clinical outcomes. References of included articles were hand searched.

PRINCIPAL FINDINGS

When platelets are stored at 1-6 °C, their metabolic rate is slowed, preserving hemostatic function for increased storage duration. Cold-stored platelets have superior adhesion characteristics under physiologic shear conditions, and similar or superior aggregation responses to physiologic agonists. Cold-stored platelets undergo structural, metabolic, and molecular changes which appear to "prime" them for hemostatic activity. While preliminary, clinical evidence supports the conduct of trials comparing CSP with RTP for patients with platelet-related bleeding, such as those undergoing cardiac surgery.

CONCLUSION

Cold-stored platelets may have several advantages over RTP, including increased hemostatic capacity, extended shelf-life, and reduced risk of bacterial contamination. Large clinical trials are needed to establish their potential role in the treatment of acutely bleeding patients.

What is the Role of Whole Blood Transfusions on Trauma Patients?

Whole blood use in trauma has historically been limited to military use, but in recent years, there has been increasing data for use in civilian trauma. Emerging clinical data demonstrate an associated survival benefit, while some authors have also identified decreased use of an overall number of blood products and decreased complications. Use of whole blood is gradually moving toward becoming the standard of care in the hemorrhaging trauma patient.

Blood Utilization Trends in Obstetrics and Gynecology: A Seven-Year Retrospective Study in a Teaching Hospital in Sikkim, India

INTRODUCTION

Unutilized cross-matched blood due to excess cross-match requisitions results in unnecessary wastage of inventory, time, labor, and financial resources. This retrospective cross-sectional study aims to assess the blood utilization practices in obstetrics/gynecology (OB/GYN) over a period of seven years with respect to "blood utilization indices" and standard recommendations.

MATERIAL AND METHODS

Cross-match requisitions from the OB/GYN Department over a period of seven years (2012-2018) were selected and included in the study using a suitable sampling technique. Patient details were retrieved from the Hospital Information System (HIS) database. The preoperative crossmatch requisitions and blood utilization data were recorded. "Blood utilization indices" and whole blood/component utilization patterns were analyzed.

RESULTS

A total of 894 units of blood were cross-matched for 523 patients included in the study. A total of 305 of these patients were transfused with 445 units. During the initial phase of the study (2012-2014), the average cross-match-to-transfusion ratio (CTR, 6.6), transfusion probability (12.3), transfusion index (0.23), and component utilization (4%) were in marked deviation from recommended "blood utilization indices." This was in contrast with the later phase of the study (2015-2018) wherein the average CTR (1.5), transfusion probability (69.3), transfusion index (1.3), and component utilization (91.8%) were compliant with recommended "blood utilization indices."

CONCLUSION

A progressive improvement in blood utilization practices was observed in the OB/GYN Department during the study period. Awareness campaigns have contributed to the implementation of rational and judicious blood transfusion practices in our center.

Lessons learned from patient outcomes when lowering hemoglobin transfusion thresholds during COVID-19 blood shortages

OBJECTIVES

This study examines whether patient outcomes were affected when the hemoglobin (Hb) transfusion threshold was lowered by 1 g/dL during COVID-19-related blood shortages.

METHODS

Outcomes of lowered Hb thresholds (from <7 to <6 g/dL) were defined by 14-month intervals in 2 patient groups (prepandemic [January 2019-February 2020] and pandemic [April 2020-May 2021]). We evaluated patient admissions, pretransfusion (if transfused) or nadir admission (if not transfused) Hb levels between 5.0 and 8.0 g/dL, and total red blood cell (RBC) transfusions during admission (if transfused). Baseline variables and outcomes were selected from electronic health records. Primary COVID-19-related admissions were excluded. Regression analysis was conducted to determine outcomes.

RESULTS

Those in the prepandemic group (1976) and pandemic group (1547) were transfused. Fewer RBCs (2186, vs 3337) were used in the prepandemic group than in the pandemic group, respectively. Those in the prepandemic group had significantly higher rates of hypertension and diabetes as well as more smokers. Significant differences were observed when comparing the number of procedures and incidence of sepsis between the patient groups. Similar patterns were observed for the not transfused and transfused subgroups.

CONCLUSIONS

Patient outcomes were not affected after implementing lower Hb pretransfusion thresholds. Although confounding factors were mitigated, some may have been associated with procedures or sepsis. Proactive patient blood management strategies during COVID-19-related blood shortages may include adopting lower Hb thresholds.

Impact of Transfused Citrate on Pathophysiology in Massive Transfusion

This narrative review article seeks to highlight the effects of citrate on physiology during massive transfusion of the bleeding patient.

DATA SOURCES

A limited library of curated articles was created using search terms including "citrate intoxication," "citrate massive transfusion," "citrate pharmacokinetics," "hypocalcemia of trauma," "citrate phosphate dextrose," and "hypocalcemia in massive transfusion." Review articles, as well as prospective and retrospective studies were selected based on their relevance for inclusion in this review.

STUDY SELECTION

Given the limited number of relevant studies, studies were reviewed and included if they were written in English. This is not a systematic review nor a meta-analysis.

DATA EXTRACTION AND SYNTHESIS

As this is not a meta-analysis, new statistical analyses were not performed. Relevant data were summarized in the body of the text.

CONCLUSIONS

The physiologic effects of citrate independent of hypocalcemia are poorly understood. While a healthy individual can rapidly clear the citrate in a unit of blood (either through the citric acid cycle or direct excretion in urine), the physiology of hemorrhagic shock can lead to decreased clearance and prolonged circulation of citrate. The so-called "Diamond of Death" of bleeding-coagulopathy, acidemia, hypothermia, and hypocalcemia-has a dynamic interaction with citrate that can lead to a death spiral. Hypothermia and acidemia both decrease citrate clearance while circulating citrate decreases thrombin generation and platelet function, leading to ionized hypocalcemia, coagulopathy, and need for further transfusion resulting in a new citrate load. Whole blood transfusion typically requires lower volumes of transfused product than component therapy alone, resulting in a lower citrate burden. Efforts should be made to limit the amount of citrate infused into a patient in hemorrhagic shock while simultaneously addressing the induced hypocalcemia.

Training of medical students in the use of emergency whole blood collection and transfusion in the framework of a civilian walking blood

INTRODUCTION

In this report, we describe a training program in emergency whole blood collection and transfusion for medical students at the University of Bergen. The overall aim of the program is to improve the availability of early balanced blood transfusion for the treatment of patients with life-threatening bleeding in rural health care services.

STUDY DESIGN AND METHODS

The voluntary training program provides the knowledge needed to practice emergency whole blood transfusions and understand the system for emergency whole blood collection in the framework of a civilian walking blood bank (WBB). It includes theoretical and practical sessions. In-person teaching and web-based learning resources are provided. An anonymous survey of the students attending the training course in the autumn of 2022 and spring 2023 was performed.

RESULTS

128 of 178 students participated in the practical training. 88 of 128 (69%) responded to the survey. 82 (93%) performed blood typing, 71 (81%) performed donor interviews, 61 (69%) partially performed whole blood collection (up to blood in bag) and 27 (30%) participated in complete whole blood collection and performed autologous reinfusion. No complications occurred during training. The students reported that the training course increased their understanding of how to ensure access to emergency blood transfusion by the use of a WBB.

DISCUSSION

Structured theoretical and practical training in emergency whole blood collection and emergency transfusion is feasible and of interest to medical students. A multidisciplinary approach to student training in emergency whole blood collection and transfusion should be considered.

Blood types and antibody profiles of Straight Egyptian Arabian horses in Qatar: Preliminary results

The characterization of the blood groups, antibody profiles, and its distribution pattern among different horse breeds and geographic locations, can be very useful in life-threatening situations where a blood transfusion is needed, and compatibility tests are not readily available. This study estimated the distribution of blood types and antibody profiles in Straight Egyptian Arabian horses from Qatar. A total of 20 Straight Egyptian Arabian horses, from multiple origins and genetic background were included. Venous blood from each horse was typed and screened for anti-red blood cell (RBC) hemolytic and agglutinating antibodies. Descriptive statistical analysis and Fisher Exact test were applied, considering 95% confidence interval (95% CI). All included horses (100%) had Aa and Ca blood types (95% CI: 83.2%-100.0%). Other blood types found less frequently included Ua (50%), Qc (45%), Pa (40%), Qb (25%) and Qa (5%). Only horses with travel history developed anti-RBC antibodies (6 out of 9), however, no horse carried more than one type of anti-RBC antibodies, supporting the premise that environmental factors may influence the development of alloantibodies. Although pre-transfusion testing regardless the circumstances should be prioritized, even considering a small population of horses, our findings suggest that Straight Egyptian Arabian horses in Qatar could be safely used as blood donors, due to the apparent omnivalence of Aa and Ca blood types and lower incidence of alloantibodies, important in emergency situations where pre-transfusion testing is unavailable.

Whole Blood Resuscitation is Safe in Pediatric Trauma Patients: A Multicenter Study

INTRODUCTION

Whole blood (WB) resuscitation has been associated with a mortality benefit in trauma patients. Several small series report the safe use of WB in the pediatric trauma population. We performed a subgroup analysis of the pediatric patients from a large prospective multicenter trial comparing patients receiving WB or blood component therapy (BCT) during trauma resuscitation. We hypothesized that WB resuscitation would be safe compared to BCT resuscitation in pediatric trauma patients.

METHODS

This study included pediatric trauma patients (0-17 y), from ten level-I trauma centers, who received any blood transfusion during initial resuscitation. Patients were included in the WB group if they received at least one unit of WB during their resuscitation, and the BCT group was composed of patients receiving traditional blood product resuscitation. The primary outcome was in-hospital mortality with secondary outcomes being complications. Multivariate logistic regression was performed to assess for mortality and complications in those treated with WB vs BCT.

RESULTS

Ninety patients, with both penetrating and blunt mechanisms of injury (MOI), were enrolled in the study (WB: 62 (69%), BCT: 28 (21%)). Whole blood patients were more likely to be male. There were no differences in age, MOI, shock index, or injury severity score between groups. On logistic regression, there was no difference in complications. Mortality was not different between the groups (P = .983).

CONCLUSION

Our data suggest WB resuscitation is safe when compared to BCT resuscitation in the care of critically injured pediatric trauma patients.

Whole blood administration within USCENTCOM

Introduction

Blood product use by the U.S. military has evolved during the conflicts in the U.S. Central Command's area of responsibility to become the preferred resuscitative fluid for damage control procedures. This study evaluates the transition to a whole blood-based trauma system over the past 5 years.

Methods

Patients who received blood product transfusion within USCENTCOM between January 1, 2017, and December 31, 2021, were identified from the Medical Situational Awareness in Theater (MSAT) blood reports. Transfusion recipients were categorized as recipients of whole blood only, component therapy only, or mixed therapy. The type of transfusions, number of recipients, number of available blood products were compared over the 5-year period.

Results

A total of 1762 unique patients were included. Of this population, 220 (12.5%) received whole blood only, 1196 (68.9%) received component therapy, and 346 (19.6%) received mixed therapy. The monthly proportion of individuals receiving whole blood (only or mixed) significantly increased over the 5-year period ( p < .0001). The number of individuals requiring transfusions over this same period decreased significantly ( p < .0001). Individuals receiving component therapy (only or mixed) were transfused component platelets 15.7% of the time. The mean and median number of units required per patient receiving whole blood was 2.39 and 1 unit of blood respectively (IQR 1.0–2.5).

Conclusion

Whole blood use increased significantly within USCENTCOM's AOR secondary to increased supply and low clinical requirement. Without a long-lasting platelet component, component therapy cannot be expected to provide a balanced therapy to casualties in remote locations.

Effects of hemodilution on coagulation function during prolonged hypotensive resuscitation in a porcine model of severe hemorrhagic shock

Background

Although hemorrhage remains the leading cause of survivable death in casualties, modern conflicts are becoming more austere limiting available resources to include resuscitation products. With limited resources also comes prolonged evacuation time, leaving suboptimal prehospital field care conditions. When blood products are limited or unavailable, crystalloid becomes the resuscitation fluid of choice. However, there is concern of continuous crystalloid infusion during a prolonged period to achieve hemodynamic stability for a patient. This study evaluates the effect of hemodilution from a 6-hour prehospital hypotensive phase on coagulation in a porcine model of severe hemorrhagic shock.

Methods

Adult male swine (n=5/group) were randomized into three experimental groups. Non-shock (NS)/normotensive did not undergo injury and were controls. NS/permissive hypotensive (PH) was bled to the PH target of systolic blood pressure (SBP) 85±5 mm Hg for 6 hours of prolonged field care (PFC) with SBP maintained via crystalloid, then recovered. Experimental group underwent controlled hemorrhage to mean arterial pressure 30 mm Hg until decompensation (Decomp/PH), followed by PH resuscitation with crystalloid for 6 hours. Hemorrhaged animals were then resuscitated with whole blood and recovered. Blood samples were collected at certain time points for analysis of complete blood counts, coagulation function, and inflammation.

Results

Throughout the 6-hour PFC, hematocrit, hemoglobin, and platelets showed significant decreases over time in the Decomp/PH group, indicating hemodilution, compared with the other groups. However, this was corrected with whole blood resuscitation. Despite the appearance of hemodilution, coagulation and perfusion parameters were not severely compromised.

Conclusions

Although significant hemodilution occurred, there was minimal impact on coagulation and endothelial function. This suggests that it is possible to maintain the SBP target to preserve perfusion of vital organs at a hemodilution threshold in resource-constrained environments. Future studies should address therapeutics that can mitigate potential hemodilutional effects such as lack of fibrinogen or platelets.

Level of evidence

Not applicable-Basic Animal Research.

Blood banking considerations in pediatric trauma

ABSTRACT

Transfusion of blood products to a hemorrhaging pediatric trauma patient requires seamless partnership and communication between trauma, emergency department, critical care, and transfusion team members. To avoid confusion and delays, understanding of blood banking principles and mutually agreed upon procedures and policies must be regularly updated as knowledge evolves. Because pediatric patients require specialized considerations distinct from those in adults, this brief review covers transfusion principles, policies, and procedures specific to the resuscitation of pediatric trauma patients.

A call for disciplined patience instead of crystalloid infusion for the trauma patient

LAY SUMMARY

Bleeding trauma patients require resuscitation with blood rather than an infusion of salt solution. However, a short delay often occurs from the time a resuscitation provider calls for blood and its availability. When facing a bleeding trauma patient with life-threatening low blood pressure, providers feel pressure to give immediately available salt-containing fluids. These fluids may help increase a patient’s blood pressure but will also decrease the body’s ability to deliver oxygen to organs and may increase bleeding and shock. It is proposed that providers maintain disciplined patience and wait for blood to be available rather than transfusing saltwater solutions.

Bleeding, Hemorrhagic Shock, and the Global Blood Supply

Hemorrhage is responsible for at least 40% of deaths after trauma and 27% of maternal deaths worldwide. Patients with hemorrhagic shock require attentive critical care and transfusion of blood products. Access to a safe and affordable blood supply is critical to providing safe surgical care. Traumatic injury, obstetric hemorrhage, and upper gastrointestinal bleed are the main causes of severe bleeding requiring transfusion. This article discusses the presentation and management of these causes across the world and provides a brief overview of the current challenges in maintaining a global blood supply.

Achieving optimal massive transfusion ratios: The trauma white board, whole blood, and liquid plasma. Real world low-tech solutions for a high stakes issue

BACKGROUND

It is well established that achieving optimal ratios of packed red blood cells (PRBC) to fresh frozen plasma (FFP) to platelet ratios during massive transfusion leads to improved outcomes but is difficult to accomplish.

METHODS

Between September 2018 and May 2019 our level 2 trauma center implemented 3 new processes to optimize transfusion ratios during massive transfusion protocol (MTP). Two units of low titer group O whole blood (LTOWB) were added as the first step to our MTP. Second, a dry erase board whiteboard was attached to each fluid warmer for real time recording of transfusions. Last, liquid plasma was incorporated into our MTP. We performed a retrospective review evaluating PRBC:FFP ratios for patients who had the massive transfusion protocol initiated and received 4 or more units of blood.

RESULTS

A total of 50 patients had the massive transfusion protocol initiated and received 4 or more units of PRBCs and/or LTOWB within 4 h of arrival. There were 21 patients evaluated prior to protocol changes and 29 patients after the changes. In the study group mean age, sex, pulse, systolic blood pressure (SBP), and injury severity scale (ISS) on admission were not different. In the pre-protocol (preP) group 90% of patients were blunt trauma and in the post-protocol group (postP) 72% were blunt trauma, p = 0. 22. For the preP group the mean units of PRBCs was 7.6 units and FFP 4.7 units. PostP the mean units of PRBCs was 11.4 units and FFP 10.0 units. PRBC/FFP ratios were 1.7 preP and 1.2 postP, p = 0.0072.

CONCLUSION

The institution of whole blood, use of the trauma white board, and the addition of liquid plasma to our transfusion services have allowed us to approach a 1:1 transfusion ratio during the course of our massive transfusions.

Blood Transfusion in Equids—A Practical Approach and Review

Simple Summary

Transfusion medicine is an accessible, technically simple, and often lifesaving tool that can be used in both field and hospital settings, in cases of significant bleeding or anemia. A thorough understanding of the indications, methodology and complications of blood transfusion allows the practitioner to identify cases where administration of whole blood is necessary, and how to safely perform the transfusion. This review collects the current literature surrounding blood transfusion into one readily accessible document to allow clinicians a comprehensive understanding of all aspects of equine blood transfusion, while serving as a reference for performing these procedures.

Abstract

Transfusion medicine is a crucial part of equine intensive and critical care. Blood transfusions can save lives in both acute and chronic cases of anemia, hemorrhage, and hemolysis. It is vital to have a comprehensive theoretical and practical understanding of the techniques, implications, risks, and complications. This review covers the physiology and pathophysiology of conditions requiring transfusion, as well as step by step guidance for practitioners of all experience levels. This review is designed to serve as a practical reference for those who are treating horses in either the field or hospital setting. It aims to provide both theoretical background and easy to locate formulae with guidance that is easy to refer to in a critical situation. When risks and benefits are well understood, these techniques can be confidently employed in critical situations to improve outcomes and save lives.