Whole Blood Administration: Comparison of In Vitro Platelet Function of Pressure Bag, Pressure Bag With Fluid Warming Device, and Rapid Infuser Methods

Prehospital Massive Transfusion for Resuscitation of an Entrapped Patient in a Rural Setting: A Case Report

Resuscitation of injured patients suffering from hemorrhagic shock with blood products in the prehospital environment is becoming more commonplace. However, blood product utilization is typically restricted and can be exhausted in the event of a prolonged entrapment. Delivery of large amounts of blood products to a scene is rare, particularly in rural settings. We present the case of a 26-year-old male who was entrapped in a motor vehicle for 144 min. First responders assessed the entrapped patient to be in hemorrhagic shock from lower extremities injuries. The Helicopter Emergency Medical Services team exhausted their supply of blood products shortly after arrival on scene. The local trauma center's Surgical Emergency Response Team (SERT) was requested to the scene. The preplanned response included seven units of blood components to provide massive transfusion at the point of injury and released directly to field responders by the blood bank. During extrication, the patient was given two units of packed red blood cells by initial responders with three more units of blood components from the SERT supply. During transfer to the hospital, the patient received an additional three units, and four units were transfused on initial trauma resuscitation in the hospital. He was found to have severe lower extremities injuries as the cause of his hemorrhage. The patient survived to hospital discharge. Delivery of large volumes of blood products to an entrapped patient with prolonged extrication time may be a lifesaving intervention. We advocate for integration of blood bank services and on scene physician guided resuscitation for prolonged extrications.

The effect of the Belmont rapid infuser on cold stored whole blood coagulability

INTRODUCTION

With the large-scale use of whole blood in massive transfusion using rapid infusers/fluid warmers such as the Belmont, questions remain as to whether coagulation potency, platelet number and function are preserved.  We aimed to study functional coagulation capacity and cell counts in whole blood before and after infusion through the Belmont rapid infuser utilizing TEG analysis and complete blood counts.

METHODS

We evaluated 10 whole blood units before and after infusion through a Belmont Fluid Management System at a set rate of 200 mL/min and a temperature of 37.4 °C.  Cell counts and thromboelastography function of the specimens were measured. Parameters were compared utilizing paired Student's t-tests and paired Wilcoxon Rank Sign tests.

RESULTS

Platelet count, R time, and Maximum amplitude showed significant decreases (defined as p<0.05) after being infused through the Belmont. Hemoglobin, hematocrit, MCV, and alpha angle were not statistically different before and after infusion.

CONCLUSION

Infusion of cold stored whole blood in a Belmont infuser, appeared to decrease platelet counts and function as well as activate clotting factors as demonstrated by a shorter R time while not affecting red cell counts or fibrin cross-linking as measured by TEG parameters and cell counts. This suggests that while it is possible to transfuse whole blood through a rapid infuser, platelet quantity and function may be negatively impacted.

Effects of a Single Rapid Infusion System on Platelet Function in Stored Whole Blood: An Ex Vivo Study

Introduction

Rapid infusion systems (RIS) are used to warm and rapidly infuse crystalloids and blood products. Current guidelines do not approve of platelet transfusion through a RIS, but data supporting these guidelines are scarce. Our hypothesis was that an infusion of whole blood through a RIS would degrade platelet quantity, impede viscoelastic clot strength, and inhibit platelet aggregation response to adenosine diphosphate pathway (ADP) activation.

Methods

Ten iterations of a simulated scenario of transfusing whole blood via a single brand and make of RIS (Belmont Fluid Management System 2000, Belmont Medical Technologies, Billerica, MA) were performed. Units of whole blood, which were two to nine days old, were leukoreduced prestorage. Blood was used to prime the RIS and then warmed and infused at 100 mL/min into a reservoir. Blood samples were collected before and immediately after infusion. Samples were tested for platelet count, size, and viscoelastic clot strength using thromboelastographic and aggregation assays.

Results

The study sample (n = 10) included platelets with an average age of 5.3 days. The infusion through the RIS had a detrimental effect on all the maximal amplitudes (MA) of viscoelastic testing: MA ADP (mean difference = −18.7 mm; 95% CI: −24.1 to −13.3, P = 0.004), MA rapid thromboelastography (MA rTEG) (mean difference = −6.0; 95% CI: −10.0 to −2.0, P = 0.008), MA TEG (mean difference = −7.1; 95% CI: −10.9 to −3.4, P = 0.004), mean platelet volume (MPV) (mean difference = −0.3; 95% CI: −0.6 to −0.1, P = 0.02), and platelet count (mean difference = −68.3 × 10³/µL; 95% CI: −86.9 to −49.7, P = 0.004).

Conclusions

Platelet quantity, viscoelastic clot strength, and platelet aggregation response to ADP each decline after infusion through a RIS. Further studies regarding microaggregates and platelet activation are required.