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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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2
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Facchetti G, Facchetti M, Schmal M, Lee R, Fiorelli S, Marzano TF, Lupi C, Daminelli F, Sbrana G, Massullo D, Marinangeli F. Prehospital Blood Transfusion in Helicopter Emergency Medical Services: An Italian Survey. Air Med J 2024; 43:140-145. [PMID: 38490777 DOI: 10.1016/j.amj.2023.11.007] [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: 05/24/2023] [Revised: 10/17/2023] [Accepted: 11/12/2023] [Indexed: 03/17/2024]
Abstract
OBJECTIVE Hemorrhage remains the most common cause of preventable death after trauma. Prehospital blood product (PHBP) administration may improve outcomes. No data are available about PHBP use in Italian helicopter emergency medical services (HEMS). The primary aim of this survey was to establish the degree of PHBP used throughout Italy. The secondary aims were to evaluate the main indications for their use, the opinions about PHBPs, and users' experience. METHODS The study group performed a telephone/e-mail survey of all 56 Italian HEMS bases. The questions concerned whether PHBPs were used in their HEMS bases, the frequency of transfusions, the PHBP used, and the perceived benefits. RESULTS Four of 56 HEMS bases use PHBPs. Overall, 7% have prehospital access to packed red cells and only 1 to fresh plasma. In addition to blood product administration, 4 of 4 use tranexamic acid, and 3 of 4 also use fibrinogen. Seventy-five percent use PHBPs once a month and 25% once a week. The users' experience was that PHBPs are beneficial and lifesaving. CONCLUSION Only 4 of 56 HEMS in Italy use PHBPs. There is an absolute consensus among providers on the benefit of PHBPs despite the lack of evidence on PHBP use.
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Affiliation(s)
| | - Marilisa Facchetti
- Department Anesthesiology and Critical Care, University of L'Aquila, L'Aquila, Italy
| | - Mariette Schmal
- Jeugdgezondheidszorg Zuid-Holland West, Zoetermeer, Netherlands
| | - Ronan Lee
- European Patent Office, Team Surgery, Rijswijk, Netherlands
| | - Silvia Fiorelli
- Anesthesia and Intensive Care Medicine, Department of Clinical and Surgical Translational Medicine, Sant'Andrea Hospital, Sapienza University of Rome, Rome, Italy.
| | | | - Cristian Lupi
- HEMS Bologna, Department of Anesthesia, Intensive Care and Prehospital Emergency, Maggiore Hospital Carlo Alberto Pizzardi, Azienda Unità Sanitaria Locale Bologna, Bologna, Italy
| | - Francesco Daminelli
- HEMS Bergamo, Papa Giovanni XXIII Hospital, Agenzia Regionale Emergenza Urgenza Lombardia, Bergamo, Italy
| | - Giovanni Sbrana
- HEMS Grosseto, Emergency Department, Azienda Sanitaria Locale Toscana Sud Est, Grosseto, Italy
| | - Domenico Massullo
- Anesthesia and Intensive Care Medicine, Department of Clinical and Surgical Translational Medicine, Sant'Andrea Hospital, Sapienza University of Rome, Rome, Italy
| | - Franco Marinangeli
- Department Anesthesiology and Critical Care, University of L'Aquila, L'Aquila, Italy
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Hough R, Cox SC, Chimelski E, Mihm FG, Tobin JM. Prehospital Critical Care Blood Product Administration: Quantifying Clinical Benefit. Dimens Crit Care Nurs 2023; 42:333-338. [PMID: 37756506 DOI: 10.1097/dcc.0000000000000608] [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: 09/29/2023] Open
Abstract
BACKGROUND Prehospital blood transfusion has been widely practiced in the military and is drawing renewed scrutiny after many years of civilian use. OBJECTIVE The objective of this article is to quantify the benefit derived from prehospital transfusion of blood products. METHODS Deidentified data were extracted retrospectively from the flight records of a critical care transportation program between April 2018 and January 2020. Patients who were transported before a prehospital blood transfusion protocol were compared with patients after initiation of the blood transfusion protocol. Demographic data, vital signs, laboratory analytics, and other outcome measures were analyzed. RESULTS Nine scene transport patients who met the transfusion criteria before a blood transfusion protocol were compared with 11 patients transported after initiation of the protocol. Identical outcome measures were analyzed. Patients who received prehospital blood transfusions had a statistically significantly longer hospital length of stay (16.5 vs 3.7 days, P = .03) and were more often taken directly to the operating room (80% vs 28%, P = .04). No statistically significant difference was identified when comparing mean arterial pressure, heart rate, respiratory rate, hemoglobin, hematocrit, or survival to hospital discharge. CONCLUSIONS Trauma patients who received prehospital blood transfusion had a longer hospital length of stay and were more often taken directly to the operating room, but without improvement in survival.
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Yazer MH, Jenkins DH, Sperry JL, Spinella PC. How do we forecast tomorrow's transfusion? Prehospital transfusion. Transfus Clin Biol 2023; 30:39-42. [PMID: 35914700 PMCID: PMC9371791 DOI: 10.1016/j.tracli.2022.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Mark H Yazer
- Department of Pathology, University of Pittsburgh, Pittsburgh, PA, United States.
| | - Donald H Jenkins
- Department of Surgery, University of Texas Health Sciences Center, San Antonio, TX, United States
| | - Jason L Sperry
- Division of Trauma and General Surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, PA, United States
| | - Philip C Spinella
- Trauma and Transfusion Medicine Research Center, Department of Surgery, University of Pittsburgh, Pittsburgh, PA, United States; Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, United States
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Krösbacher A, Fries D, Thaler M. Unkontrollierbare Blutungen prähospital – Retten Blutprodukte Leben? NOTARZT 2023. [DOI: 10.1055/a-1910-4518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/18/2023]
Affiliation(s)
- Armin Krösbacher
- Univ. Klinik für Anästhesie und Intensivmedizin, Medizinische Universität Innsbruck, Innsbruck, Österreich
| | - Dietmar Fries
- Univ. Klinik für Anästhesie und Intensivmedizin, Medizinische Universität Innsbruck, Innsbruck, Österreich
| | - Markus Thaler
- Univ. Klinik für Anästhesie und Intensivmedizin, Medizinische Universität Innsbruck, Innsbruck, Österreich
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Initial experiences of prehospital blood product transfusions between 2016 and 2020 in Päijät-Häme hospital district, Finland. Scand J Trauma Resusc Emerg Med 2022; 30:39. [PMID: 35668435 PMCID: PMC9169387 DOI: 10.1186/s13049-022-01027-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 05/25/2022] [Indexed: 11/25/2022] Open
Abstract
Background Treating hemorrhaging patients with prehospital blood product transfusions (PHBT) narrows transfusion delays and potentially benefits the patient. We describe our initial experiences of PHBT in a ground-based emergency medical service (EMS), where the transfusion protocol covers both traumatic and nontraumatic hemorrhaging patients. Methods A descriptive retrospective analysis was performed on the records of all the patients receiving red blood cells, freeze-dried plasma, or both during prehospital care from September 2016 to December 2020. The delays of PHBT and the effects on patients’ vital signs were analyzed and reported as the median and interquartile range (IQR) and analyzed using a Wilcoxon Signed rank test. Results 65 patients received prehospital blood product transfusions (PHBT), 29 (45%) were non-traumatic, and 36 (55%) traumatic. The main two reasons for PHBT were blunt trauma (n = 30, 46%) and gastrointestinal hemorrhage (n = 20, 31%). The median time from the emergency call to the start of PHBT was 54 min (IQR 38), and the transfusion began on a median of 61 min (IQR 42) before arrival at the hospital. The median systolic blood pressure improved from a median 76.5 mmHg (IQR 36.5) before transfusion to a median of 116.60 mmHg (IQR 26.5) (p < 0.001) on arrival to the hospital. No transfusion-related severe adverse events were noted. Conclusions Starting PHBT in ground-based EMS is a feasible and viable option. The PHBT began significantly earlier than it would have started on arrival to the hospital, and it seems to be safe and improve patients’ physiology. Study approval D/2603/07.01.04.05/2019.
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Selleng K, Baschin M, Henkel B, Jenichen G, Thies KC, Rudolph M, Reifferscheid F, Braun J, Hannich M, Winter T, Hahnenkamp K, Greinacher A. Blood Product Supply for a Helicopter Emergency Medical Service. Transfus Med Hemother 2022; 48:332-341. [PMID: 35082564 DOI: 10.1159/000519825] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Accepted: 09/15/2021] [Indexed: 11/19/2022] Open
Abstract
Background Long patient transport times to trauma centers are a well-known problem in sparsely populated regions with a low hospital density. Transfusion of red blood cell concentrates (RBC) and plasma improves outcome of trauma patients with severe bleeding. Helicopter emergency services (HEMS) are frequently employed to provide early advanced medical care and to reduce time to hospital admission. Supplying HEMS with blood products allows prehospital transfusion and may help to prevent exsanguination or prolonged hemorrhagic shock. We have investigated the maintenance of blood product quality under air transport conditions and the logistical steps to introduce a HEMS blood depot into routine practice. Methods A risk analysis was performed and a validation plan developed. A special, commercially available transport container for blood products was identified. Maintenance of temperature conditions between 2 and 6°C in the box were monitored at ambient temperatures up to 35°C over 48 h. Quality of blood products before and after helicopter air transport were evaluated including (1) for RBCs: hemoglobin, hematocrit, hemolysis rate; (2) for thawed plasma: aPTT, INR, single clotting factor activities. The logistics for blood supply of the regional HEMS were developed by the transfusion service of the Greifswald University Hospital in collaboration with the in-hospital transport team, the HEMS team, and the HEMS operator. Results The transport container maintained a temperature below 6°C up to 36 h at 35°C ambient temperature. Vibration during helicopter operation did not impair quality of RBC and thawed plasma. To provide blood products for HEMS at least two transport containers and an additional set of cooling tiles is needed as the cooling tiles need a special temperature priming over 20 h. The two boxes were used at alternate days. To reduce wastage, RBCs and thawed plasmas were exchanged every fourth day and reintegrated into the blood bank inventory for further in-hospital use. Conclusions Supplying HEMS with RBCs and plasma is feasible. Helicopter transport has no negative impact on blood product quality. The logistic challenges require close collaboration between the HEMS team and the blood transfusion service.
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Affiliation(s)
- Kathleen Selleng
- Institut für Immunologie und Transfusionsmedizin, Abteilung Transfusionsmedizin, Universitätsmedizin Greifswald, Greifswald, Germany
| | - Marcel Baschin
- Institut für Immunologie und Transfusionsmedizin, Abteilung Transfusionsmedizin, Universitätsmedizin Greifswald, Greifswald, Germany
| | - Berthold Henkel
- Klinik für Anästhesiologie, Universitätsmedizin Greifswald, Greifswald, Germany
| | - Gregor Jenichen
- Klinik für Anästhesiologie, Universitätsmedizin Greifswald, Greifswald, Germany
| | - Karl-Christian Thies
- DRF Stiftung Luftrettung gemeinnützige AG, Wissenschaftlicher Arbeitskreis, Filderstadt, Germany.,Universitätsklinik für Anästhesiologie, Intensiv-, Notfallmedizin, Transfusionsmedizin und Schmerztherapie, EvKB, Universitätsklinikum OWL der Universität Bielefeld, Campus Bielefeld-Bethel, Bielefeld, Germany
| | - Marcus Rudolph
- DRF Stiftung Luftrettung gemeinnützige AG, Wissenschaftlicher Arbeitskreis, Filderstadt, Germany.,Universitätsmedizin Mannheim, Klinik für Anästhesiologie und operative Intensivmedizin, Mannheim, Germany
| | - Florian Reifferscheid
- DRF Stiftung Luftrettung gemeinnützige AG, Wissenschaftlicher Arbeitskreis, Filderstadt, Germany.,Universitätsklinikum Schleswig-Holstein, Campus Kiel, Klinik für Anästhesiologie und Operative Intensivmedizin, Kiel, Germany
| | - Jörg Braun
- DRF Stiftung Luftrettung gemeinnützige AG, Wissenschaftlicher Arbeitskreis, Filderstadt, Germany
| | - Malte Hannich
- Institut für Klinische Chemie und Laboratoriumsmedizin, Universitätsmedizin Greifswald, Greifswald, Germany
| | - Theresa Winter
- Institut für Klinische Chemie und Laboratoriumsmedizin, Universitätsmedizin Greifswald, Greifswald, Germany
| | - Klaus Hahnenkamp
- Klinik für Anästhesiologie, Universitätsmedizin Greifswald, Greifswald, Germany
| | - Andreas Greinacher
- Institut für Immunologie und Transfusionsmedizin, Abteilung Transfusionsmedizin, Universitätsmedizin Greifswald, Greifswald, Germany
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Tucker H, Avery P, Brohi K, Davenport R, Griggs J, Weaver A, Green L. Outcome measures used in clinical research evaluating prehospital blood component transfusion in traumatically injured bleeding patients: A systematic review. J Trauma Acute Care Surg 2021; 91:1018-1024. [PMID: 34254958 DOI: 10.1097/ta.0000000000003360] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Trial outcomes should be relevant to all stakeholders and allow assessment of interventions' efficacy and safety at appropriate timeframes. There is no consensus regarding outcome measures in the growing field of prehospital trauma transfusion research. Harmonization of future clinical outcome reporting is key to facilitate interstudy comparisons and generate cohesive, robust evidence to guide practice. The objective of this study was to evaluate outcome measures reported in prehospital trauma transfusion trials. METHODS Data Sources, Eligibility Criteria, Participants, and InterventionsWe conducted a scoping systematic review to identify the type, number, and definitions of outcomes reported in randomized controlled trials, and prospective and retrospective observational cohort studies investigating prehospital blood component transfusion in adult and pediatric patients with traumatic hemorrhage. Electronic database searching of PubMed, Embase, Web of Science, Cochrane, OVID, clinical trials.gov, and the Transfusion Evidence Library was completed in accordance with Preferred Reporting Items for Meta-analyses guidelines.Study Appraisal and Synthesis MethodsTwo review authors independently extracted outcome data. Unique lists of salutogenic (patient-reported health and wellbeing outcomes) and nonsalutogenic focused outcomes were established. RESULTS A total of 3,471 records were identified. Thirty-four studies fulfilled the inclusion criteria: 4 military (n = 1,566 patients) and 30 civilian (n = 14,398 patients), all between 2000 and 2020. Two hundred twelve individual non-patient-reported outcomes were identified, which collapsed into 20 outcome domains with varied definitions and timings. All primary outcomes measured effectiveness, rather than safety or complications. Sixty-nine percent reported mortality, with 11 different definitions. No salutogenic outcomes were reported. CONCLUSION There is heterogeneity in outcome reporting and definitions, an absence of patient-reported outcome, and an emphasis on clinical effectiveness rather than safety or adverse events in prehospital trauma transfusion trials. We recommend stakeholder consultation and a Delphi process to develop a clearly defined minimum core outcome set for prehospital trauma transfusion trials. LEVEL OF EVIDENCE Scoping systematic review, level III.
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Affiliation(s)
- Harriet Tucker
- From the Centre for Trauma Sciences, Blizard Institute (H.T., K.B., R.D., L.G.), Queen Mary University of London, London, United Kingdom; Southmead Hospital (P.A.), North Bristol NHS Trust, Bristol, United Kingdom; Learning and Development (P.A.), South Western Ambulance Service NHS Foundation Trust, Bristol, United Kingdom; Air Ambulance Kent Surrey Sussex (J.G., H.T.), Rochester, United Kingdom; Faculty of Health Sciences (J.G.), University of Surrey, Guildford, United Kingdom; London's Air Ambulance (A.W.), London, United Kingdom; Barts Health NHS Foundation Trust (K.B., R.D., A.W., L.G.), London, United Kingdom; and NHS Blood and Transplant (L.G.), London, United Kingdom
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Abstract
PURPOSE OF REVIEW Posttraumatic bleeding following major trauma is life threatening for the patient and remains a major global health issue. Bleeding after major trauma is worsened by trauma-induced coagulopathy (TIC). TIC consists of acute trauma coagulopathy and resuscitation coagulopathy. The early diagnosis and management of prehospital TIC management are challenging. RECENT FINDINGS Concepts for early diagnosis and management of civilian prehospital TIC management are evolving. The feasibility of prehospital blood component as well as coagulation factor transfusion has been proven. SUMMARY Due to different national guidelines and regulations of blood component therapies there is a wide heterogeneity in concepts of prehospital damage control resuscitation. Tranexamic acid administration is widely accepted, whereas the transfusion of whole blood, blood components, or coagulations factors needs further examination in the civilian setting.
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Suppan L, Chan M, Gartner B, Regard S, Campana M, Chatellard G, Cottet P, Larribau R, Sarasin FP, Niquille M. Evaluation of a Prehospital Rotation by Senior Residents: A Web-Based Survey. Healthcare (Basel) 2020; 9:healthcare9010024. [PMID: 33383633 PMCID: PMC7824315 DOI: 10.3390/healthcare9010024] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Revised: 12/14/2020] [Accepted: 12/24/2020] [Indexed: 11/16/2022] Open
Abstract
The added value of prehospital emergency medicine is usually assessed by measuring patient-centered outcomes. Prehospital rotations might however also help senior residents acquire specific skills and knowledge. To assess the perceived added value of the prehospital rotation in comparison with other rotations, we analyzed web-based questionnaires sent between September 2011 and August 2020 to senior residents who had just completed a prehospital rotation. The primary outcome was the perceived benefit of the prehospital rotation in comparison with other rotations regarding technical and non-technical skills. Secondary outcomes included resident satisfaction regarding the prehospital rotation and regarding supervision. A pre-specified subgroup analysis was performed to search for differences according to the participants’ service of origin (anesthesiology, emergency medicine, or internal medicine). The completion rate was of 71.5% (113/158), and 91 surveys were analyzed. Most senior residents found the prehospital rotation either more beneficial or much more beneficial than other rotations regarding the acquisition of technical and non-technical skills. Anesthesiology residents reported less benefits than other residents regarding pharmacological knowledge acquisition and confidence as to their ability to manage emergency situations. Simulation studies should now be carried out to confirm these findings.
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Affiliation(s)
- Laurent Suppan
- Division of Emergency Medicine, Department of Anaesthesiology, Clinical Pharmacology, Intensive Care and Emergency Medicine, Faculty of Medicine University of Geneva, Geneva University Hospitals, CH-1211 Geneva, Switzerland; (M.C.); (B.G.); (S.R.); (M.C.); (G.C.); (P.C.); (R.L.); (F.P.S.); (M.N.)
- Correspondence:
| | - Michèle Chan
- Division of Emergency Medicine, Department of Anaesthesiology, Clinical Pharmacology, Intensive Care and Emergency Medicine, Faculty of Medicine University of Geneva, Geneva University Hospitals, CH-1211 Geneva, Switzerland; (M.C.); (B.G.); (S.R.); (M.C.); (G.C.); (P.C.); (R.L.); (F.P.S.); (M.N.)
| | - Birgit Gartner
- Division of Emergency Medicine, Department of Anaesthesiology, Clinical Pharmacology, Intensive Care and Emergency Medicine, Faculty of Medicine University of Geneva, Geneva University Hospitals, CH-1211 Geneva, Switzerland; (M.C.); (B.G.); (S.R.); (M.C.); (G.C.); (P.C.); (R.L.); (F.P.S.); (M.N.)
| | - Simon Regard
- Division of Emergency Medicine, Department of Anaesthesiology, Clinical Pharmacology, Intensive Care and Emergency Medicine, Faculty of Medicine University of Geneva, Geneva University Hospitals, CH-1211 Geneva, Switzerland; (M.C.); (B.G.); (S.R.); (M.C.); (G.C.); (P.C.); (R.L.); (F.P.S.); (M.N.)
| | - Mathieu Campana
- Division of Emergency Medicine, Department of Anaesthesiology, Clinical Pharmacology, Intensive Care and Emergency Medicine, Faculty of Medicine University of Geneva, Geneva University Hospitals, CH-1211 Geneva, Switzerland; (M.C.); (B.G.); (S.R.); (M.C.); (G.C.); (P.C.); (R.L.); (F.P.S.); (M.N.)
- Division of Anaesthesiology, Department of Anaesthesiology, Clinical Pharmacology, Intensive Care and Emergency Medicine, Faculty of Medicine University of Geneva, Geneva University Hospitals, CH-1211 Geneva, Switzerland
| | - Ghislaine Chatellard
- Division of Emergency Medicine, Department of Anaesthesiology, Clinical Pharmacology, Intensive Care and Emergency Medicine, Faculty of Medicine University of Geneva, Geneva University Hospitals, CH-1211 Geneva, Switzerland; (M.C.); (B.G.); (S.R.); (M.C.); (G.C.); (P.C.); (R.L.); (F.P.S.); (M.N.)
- Division of Anaesthesiology, Department of Anaesthesiology, Clinical Pharmacology, Intensive Care and Emergency Medicine, Faculty of Medicine University of Geneva, Geneva University Hospitals, CH-1211 Geneva, Switzerland
| | - Philippe Cottet
- Division of Emergency Medicine, Department of Anaesthesiology, Clinical Pharmacology, Intensive Care and Emergency Medicine, Faculty of Medicine University of Geneva, Geneva University Hospitals, CH-1211 Geneva, Switzerland; (M.C.); (B.G.); (S.R.); (M.C.); (G.C.); (P.C.); (R.L.); (F.P.S.); (M.N.)
| | - Robert Larribau
- Division of Emergency Medicine, Department of Anaesthesiology, Clinical Pharmacology, Intensive Care and Emergency Medicine, Faculty of Medicine University of Geneva, Geneva University Hospitals, CH-1211 Geneva, Switzerland; (M.C.); (B.G.); (S.R.); (M.C.); (G.C.); (P.C.); (R.L.); (F.P.S.); (M.N.)
| | - François Pierre Sarasin
- Division of Emergency Medicine, Department of Anaesthesiology, Clinical Pharmacology, Intensive Care and Emergency Medicine, Faculty of Medicine University of Geneva, Geneva University Hospitals, CH-1211 Geneva, Switzerland; (M.C.); (B.G.); (S.R.); (M.C.); (G.C.); (P.C.); (R.L.); (F.P.S.); (M.N.)
| | - Marc Niquille
- Division of Emergency Medicine, Department of Anaesthesiology, Clinical Pharmacology, Intensive Care and Emergency Medicine, Faculty of Medicine University of Geneva, Geneva University Hospitals, CH-1211 Geneva, Switzerland; (M.C.); (B.G.); (S.R.); (M.C.); (G.C.); (P.C.); (R.L.); (F.P.S.); (M.N.)
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Sumann G, Moens D, Brink B, Brodmann Maeder M, Greene M, Jacob M, Koirala P, Zafren K, Ayala M, Musi M, Oshiro K, Sheets A, Strapazzon G, Macias D, Paal P. Multiple trauma management in mountain environments - a scoping review : Evidence based guidelines of the International Commission for Mountain Emergency Medicine (ICAR MedCom). Intended for physicians and other advanced life support personnel. Scand J Trauma Resusc Emerg Med 2020; 28:117. [PMID: 33317595 PMCID: PMC7737289 DOI: 10.1186/s13049-020-00790-1] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 09/10/2020] [Indexed: 12/11/2022] Open
Abstract
Background Multiple trauma in mountain environments may be associated with increased morbidity and mortality compared to urban environments. Objective To provide evidence based guidance to assist rescuers in multiple trauma management in mountain environments. Eligibility criteria All articles published on or before September 30th 2019, in all languages, were included. Articles were searched with predefined search terms. Sources of evidence PubMed, Cochrane Database of Systematic Reviews and hand searching of relevant studies from the reference list of included articles. Charting methods Evidence was searched according to clinically relevant topics and PICO questions. Results Two-hundred forty-seven articles met the inclusion criteria. Recommendations were developed and graded according to the evidence-grading system of the American College of Chest Physicians. The manuscript was initially written and discussed by the coauthors. Then it was presented to ICAR MedCom in draft and again in final form for discussion and internal peer review. Finally, in a face-to-face discussion within ICAR MedCom consensus was reached on October 11th 2019, at the ICAR fall meeting in Zakopane, Poland. Conclusions Multiple trauma management in mountain environments can be demanding. Safety of the rescuers and the victim has priority. A crABCDE approach, with haemorrhage control first, is central, followed by basic first aid, splinting, immobilisation, analgesia, and insulation. Time for on-site medical treatment must be balanced against the need for rapid transfer to a trauma centre and should be as short as possible. Reduced on-scene times may be achieved with helicopter rescue. Advanced diagnostics (e.g. ultrasound) may be used and treatment continued during transport.
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Affiliation(s)
- G Sumann
- Austrian Society of Mountain and High Altitude Medicine, Emergency physician, Austrian Mountain and Helicopter Rescue, Altach, Austria
| | - D Moens
- Emergency Department Liège University Hospital, CMH HEMS Lead physician and medical director, Senior Lecturer at the University of Liège, Liège, Belgium
| | - B Brink
- Mountain Emergency Paramedic, AHEMS, Canadian Society of Mountain Medicine, Whistler Blackcomb Ski Patrol, Whistler, Canada
| | - M Brodmann Maeder
- Department of Emergency Medicine, University Hospital and University of Bern, Switzerland and Institute of Mountain Emergency Medicine, Eurac Research, Bolzano, Italy
| | - M Greene
- Medical Officer Mountain Rescue England and Wales, Wales, UK
| | - M Jacob
- Department of Anaesthesiology, Intensive Care and Pain Medicine, Hospitallers Brothers Saint-Elisabeth-Hospital Straubing, Bavarian Mountain Rescue Service, Straubing, Germany
| | - P Koirala
- Adjunct Assistant Professor, Emergency Medicine, University of Maryland School of Medicine, Mountain Medicine Society of Nepal, Kathmandu, Nepal
| | - K Zafren
- ICAR MedCom, Department of Emergency Medicine, Stanford University Medical Center, Stanford, CA, USA.,Alaska Native Medical Center, Anchorage, AK, USA
| | - M Ayala
- University Hospital Germans Trias i Pujol, Badalona, Spain
| | - M Musi
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - K Oshiro
- Department of Cardiovascular Medicine and Director of Mountain Medicine, Research, and Survey Division, Hokkaido Ohno Memorial Hospital, Sapporo, Japan
| | - A Sheets
- Emergency Department, Boulder Community Health, Boulder, CO, USA
| | - G Strapazzon
- Institute of Mountain Emergency Medicine, Eurac Research, Bolzano, Italy.,The Corpo Nazionale Soccorso Alpino e Speleologico, National Medical School (CNSAS SNaMed), Milan, Italy
| | - D Macias
- Department of Emergency Medicine, International Mountain Medicine Center, University of New Mexico, Albuquerque, NM, USA
| | - P Paal
- Department of Anaesthesiology and Intensive Care Medicine, St. John of God Hospital, Paracelsus Medical University, Salzburg, Austria.
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13
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Cassignol A, Marmin J, Mattei P, Goffinet L, Pons S, Renard A, Demory D, Bordes J. Civilian prehospital transfusion - experiences from a French region. Vox Sang 2020; 115:745-755. [PMID: 32895933 DOI: 10.1111/vox.12984] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Revised: 05/23/2020] [Accepted: 07/07/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND AND OBJECTIVES Haemorrhagic shock is a leading cause of avoidable mortality in prehospital care. For several years, our centre has followed a procedure of transfusing two units of packed red blood cells outside the hospital. Our study's aim was twofold: describe the patient characteristics of those receiving prehospital blood transfusions and analyse risk factors for the 7-day mortality rate. MATERIALS AND METHODS We performed a monocentric retrospective observational study. Demographic and physiological data were recovered from medical records. The primary outcome was mortality at seven days for all causes. All patients receiving prehospital blood transfusions between 2013 and 2018 were included. RESULTS Out of 116 eligible patients, 56 patients received transfusions. Trauma patients (n = 18) were younger than medical patients (n = 38) (P = 0·012), had lower systolic blood pressure (P = 0·001) and had higher haemoglobin levels (P = 0·016). Mortality was higher in the trauma group than the medical group (P = 0·015). In-hospital trauma patients received more fresh-frozen plasma and platelet concentrate than medical patients (P < 0·05). Predictive factors of 7-day mortality included transfusion for trauma-related reasons, low Glasgow Coma Scale, low peripheral oxygen saturation, prehospital intensive resuscitation, existing coagulation disorders, acidosis and hyperlactataemia (P < 0·05). CONCLUSION Current guidelines recommend early transfusion in patients with haemorrhagic shock. Prehospital blood transfusions are safe. Coagulation disorders and acidosis remain a cause of premature death in patients with prehospital transfusions.
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Affiliation(s)
- Arnaud Cassignol
- SMUR Department, Timone Hospital, Aix-Marseille University, Marseille, France
| | - Julien Marmin
- SMUR Department, Timone Hospital, Aix-Marseille University, Marseille, France
| | - Pascal Mattei
- SMUR Department, Sainte-Musse Public Hospital, Toulon, France
| | - Léa Goffinet
- French Blood Establishment, Sainte-Musse Public Hospital, Toulon, France
| | - Sandrine Pons
- French Blood Establishment, Sainte-Anne Military Hospital, Toulon, France
| | - Aurélien Renard
- Emergency Department, Sainte-Anne Military Hospital, Toulon, France
| | - Didier Demory
- Clinical Research Unit, Sainte-Musse Public Hospital, Toulon, France
| | - Julien Bordes
- Anesthesia and Intensive Care Department, Sainte-Anne Military Hospital, Toulon, France
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14
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Vuorinen P, Kiili JE, Setälä P, Kämäräinen A, Hoppu S. Prehospital administration of blood products: experiences from a Finnish physician-staffed helicopter emergency medical service. BMC Emerg Med 2020; 20:55. [PMID: 32635889 PMCID: PMC7341661 DOI: 10.1186/s12873-020-00350-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 06/25/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Massive infusions of crystalloids into bleeding hypotensive patients can worsen the outcome. Military experience suggests avoiding crystalloids using early damage control resuscitation with blood components in out of hospital setting. Civilian emergency medical services have since followed this idea. We describe our red blood cell protocol in helicopter emergency medical services (HEMS) and initial experience with prehospital blood products from the first 3 years after implementation. METHODS We performed an observational study of patients attended by the HEMS unit between 2015 and 2018 to whom packed red blood cells, freeze-dried plasma, or both were transfused. The Student's two-sided T-test was used to compare vitals in prehospital phase with those at the hospital's emergency department. A p-value < 0.05 was considered significant. RESULTS Altogether, 62 patients received prehospital transfusions. Of those, 48 (77%) were trauma patients and most (n = 39, 81%) suffered blunt trauma. The transfusion began at a median of 33 (IQR 21-47) minutes before hospital arrival. Median systolic blood pressure showed an increase from 90 mmHg (IQR 75-111 mmHg) to 107 mmHg (IQR 80-124 mmHg; P < 0.026) during the prehospital phase. Four units of red blood cells were handled incorrectly when unused red blood cells were returned and required disposal during a three-year period. There were no reported adverse effects from prehospital transfusions. CONCLUSION We treated two patients per month with prehospital blood products. A prehospital physician-staffed HEMS unit carrying blood products is a feasible and safe method to start transfusion roughly 30 min before arrival to the hospital. TRIAL REGISTRATION The study was retrospectively registered by the Tampere University Hospital's Medical Director (R19603) 5.11.2019.
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Affiliation(s)
- Pauli Vuorinen
- Emergency Medical Services, Tampere University Hospital, PO Box 2000, FI-33521, Tampere, Finland.
| | - Joonas-Eemeli Kiili
- Emergency Medical Services, Tampere University Hospital, PO Box 2000, FI-33521, Tampere, Finland.,Faculty of Medicine and Health Technology, Tampere University, PO Box 2000, FI-33520, Tampere, Finland
| | - Piritta Setälä
- Emergency Medical Services, Tampere University Hospital, PO Box 2000, FI-33521, Tampere, Finland
| | - Antti Kämäräinen
- Emergency Medical Services, Tampere University Hospital, PO Box 2000, FI-33521, Tampere, Finland.,Department of Emergency Medicine, Hyvinkää District Hospital, Hyvinkää, Finland
| | - Sanna Hoppu
- Emergency Medical Services, Tampere University Hospital, PO Box 2000, FI-33521, Tampere, Finland
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15
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Leemeyer AMR, Van Lieshout EMM, Bouwens M, Breeman W, Verhofstad MHJ, Van Vledder MG. Decision making in prehospital traumatic cardiac arrest; A qualitative study. Injury 2020; 51:1196-1202. [PMID: 31926614 DOI: 10.1016/j.injury.2020.01.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Accepted: 01/03/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND Despite improving survival of patients in prehospital traumatic cardiac arrest (TCA), initiation and/or discontinuation of resuscitation of TCA patients remains a subject of debate among prehospital emergency medical service providers. The aim of this study was to identify factors that influence decision making by prehospital emergency medical service providers during resuscitation of patients with TCA. METHODS Twenty-five semi-structured interviews were conducted with experienced ambulance nurses, HEMS nurses and HEMS physicians individually, followed by a focus group discussion. Participants had to be currently active in prehospital medicine in the Netherlands. Interviews were encoded for analysis using ATLAS.ti. Using qualitative analysis, different themes around decision making in TCA were identified. RESULTS Eight themes were identified as being important factors for decision making during prehospital TCA. These themes were: (1) factual information (e.g., electrocardiography rhythm or trauma mechanism); (2) fear of providing futile care or major impairment if return of spontaneous circulation was obtained; (3) potential organ donation; (4) patient age; (5) suspicion of attempted suicide; (6) presence of bystanders or family; (7) opinions of other team members; and (8) training and education. Several ambulance nurses reported they do not feel adequately supported by the current official national ambulance guidelines on TCA, nor did they feel sufficiently trained to perform pre-hospital interventions such as endotracheal intubation or needle thoracocentesis on these patients. CONCLUSION Eight themes were identified as being important for decision making during prehospital TCA. While guidelines based on prognostic factors are important, it should be recognized that decision making in TCA is impacted by more than factual information alone. This should be reflected in educational programs and future guidelines.
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Affiliation(s)
- Anna-Marie R Leemeyer
- Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Esther M M Van Lieshout
- Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Maneka Bouwens
- Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Wim Breeman
- AmbulanceZorg Rotterdam-Rijnmond, Barendrecht, the Netherlands
| | - Michael H J Verhofstad
- Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Mark G Van Vledder
- Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands.
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16
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van Turenhout EC, Bossers SM, Loer SA, Giannakopoulos GF, Schwarte LA, Schober P. Pre-hospital transfusion of red blood cells. Part 1: A scoping review of current practice and transfusion triggers. Transfus Med 2020; 30:86-105. [PMID: 32080942 PMCID: PMC7317877 DOI: 10.1111/tme.12667] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Revised: 12/18/2019] [Accepted: 01/16/2020] [Indexed: 12/21/2022]
Abstract
OBJECTIVES The primary aim of this scoping review is to describe the current use of pre-hospital transfusion of red blood cells (PHTRBC) and to evaluate criteria used to initiate PHTRBC. The effects on patients' outcomes will be reviewed in Part 2. BACKGROUND Haemorrhage is a preventable cause of death in trauma patients, and transfusion of red blood cells is increasingly used by Emergency Medical Services (EMS) for damage control resuscitation. However, there are no guidelines and little consensus on when to initiate PHTRBC. METHODS PubMed and Web of Science were searched through January 2019; 71 articles were included. RESULTS Transfusion triggers vary widely and involve vital signs, clinical signs of poor tissue perfusion, point of care measurements and pre-hospital ultrasound imaging. In particular, hypotension (most often defined as systolic blood pressure ≤ 90 mmHg), tachycardia (most often defined as heart rate ≥ 120/min), clinical signs of poor perfusion (eg, prolonged capillary refill time or changes in mental status) and injury type (ie, penetrating wounds) are common pre-hospital transfusion triggers. CONCLUSIONS PHTRBC is increasingly used by Emergency Medical Services, but guidelines on when to initiate transfusion are lacking. We identified the most commonly used transfusion criteria, and these findings may provide the basis for consensus-based pre-hospital transfusion protocols.
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Affiliation(s)
| | - Sebastiaan M. Bossers
- Department of AnaesthesiologyAmsterdam UMC, Vrije Universiteit AmsterdamAmsterdamThe Netherlands
| | - Stephan A. Loer
- Department of AnaesthesiologyAmsterdam UMC, Vrije Universiteit AmsterdamAmsterdamThe Netherlands
| | - Georgios F. Giannakopoulos
- Department of Trauma SurgeryAmsterdam UMC, Vrije Universiteit AmsterdamAmsterdamThe Netherlands
- Helicopter Emergency Medical Service “Lifeliner 1”Amsterdam UMC, Vrije Universiteit AmsterdamAmsterdamThe Netherlands
| | - Lothar A. Schwarte
- Department of AnaesthesiologyAmsterdam UMC, Vrije Universiteit AmsterdamAmsterdamThe Netherlands
- Helicopter Emergency Medical Service “Lifeliner 1”Amsterdam UMC, Vrije Universiteit AmsterdamAmsterdamThe Netherlands
| | - Patrick Schober
- Department of AnaesthesiologyAmsterdam UMC, Vrije Universiteit AmsterdamAmsterdamThe Netherlands
- Helicopter Emergency Medical Service “Lifeliner 1”Amsterdam UMC, Vrije Universiteit AmsterdamAmsterdamThe Netherlands
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17
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van Turenhout EC, Bossers SM, Loer SA, Giannakopoulos GF, Schwarte LA, Schober P. Pre-hospital transfusion of red blood cells. Part 2: A systematic review of treatment effects on outcomes. Transfus Med 2020; 30:106-133. [PMID: 31903684 PMCID: PMC7317762 DOI: 10.1111/tme.12659] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Accepted: 12/06/2019] [Indexed: 12/11/2022]
Abstract
The primary aim of this systematic review is to describe the effects of prehospital transfusion of red blood cells (PHTRBC) on patient outcomes. Damage control resuscitation attempts to prevent death through haemorrhage in trauma patients. In this context, transfusion of red blood cells is increasingly used by emergency medical services (EMS). However, evidence on the effects on outcomes is scarce. PubMed and Web of Science were searched through January 2019; 55 articles were included. No randomised controlled studies were identified. While several observational studies suggest an increased survival after PHTRBC, consistent evidence for beneficial effects of PHTRBC on survival was not found. PHTRBC appears to improve haemodynamic parameters, but there is no evidence that shock on arrival to hospital is averted, nor of an association with trauma induced coagulopathy or with length of stay in hospitals or intensive care units. In conclusion, PHTRBC is increasingly used by EMS, but there is no strong evidence for effects of PHTRBC on mortality. Further research with study designs that allow causal inferences is required for more conclusive evidence. The combination of PHTRBC with plasma, as well as the use of individualised transfusion criteria, may potentially show more benefits and should be thoroughly investigated in the future. The review was registered at Prospero (CRD42018084658).
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Affiliation(s)
| | - Sebastiaan M. Bossers
- Department of Anaesthesiology, Amsterdam UMCVrije Universiteit AmsterdamAmsterdamThe Netherlands
| | - Stephan A. Loer
- Department of Anaesthesiology, Amsterdam UMCVrije Universiteit AmsterdamAmsterdamThe Netherlands
| | - Georgios F. Giannakopoulos
- Department of Trauma Surgery, Amsterdam UMCVrije Universiteit AmsterdamAmsterdamThe Netherlands
- Helicopter Emergency Medical Service “Lifeliner 1”, Amsterdam UMCVrije Universiteit AmsterdamAmsterdamThe Netherlands
| | - Lothar A. Schwarte
- Department of Anaesthesiology, Amsterdam UMCVrije Universiteit AmsterdamAmsterdamThe Netherlands
- Helicopter Emergency Medical Service “Lifeliner 1”, Amsterdam UMCVrije Universiteit AmsterdamAmsterdamThe Netherlands
| | - Patrick Schober
- Department of Anaesthesiology, Amsterdam UMCVrije Universiteit AmsterdamAmsterdamThe Netherlands
- Helicopter Emergency Medical Service “Lifeliner 1”, Amsterdam UMCVrije Universiteit AmsterdamAmsterdamThe Netherlands
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18
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Shander A, Zacharowski K, Spahn DR. Red cell use in trauma. Curr Opin Anaesthesiol 2020; 33:220-226. [PMID: 32004168 DOI: 10.1097/aco.0000000000000837] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Red cell transfusions are commonly used in management of hemorrhage in trauma patients. The appropriate indications and criteria for transfusion are still debated. Here, we summarize the recent findings on the use of red cell transfusion in trauma setting. RECENT FINDINGS Recent evidence continues to support the long-established link between allogeneic transfusion and worse clinical outcomes, reinstating the importance of more judicious use of allogeneic blood and careful consideration of benefits versus risks when making transfusion decisions. Studies support restrictive transfusion strategies (often based on hemoglobin thresholds of 7-8 g/dl) in most patient populations, although some argue more caution in specific populations (e.g. patients with traumatic brain injury) and more studies are needed to determine if these patients benefit from less restrictive transfusion strategies. It should be remembered that anemia remains an independent risk factor for worse outcomes and red cell transfusion does not constitute a lasting treatment. Anemia should be properly assessed and managed based on the cause and using hematinic medications as indicated. SUMMARY Although the debate on hemoglobin thresholds for transfusion continues, clinicians should not overlook proper management of the underlying issue (anemia).
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Affiliation(s)
- Aryeh Shander
- Department of Anesthesiology and Critical Care Medicine; Englewood Hospital and Medical Center.,TeamHealth Research Institute; Englewood.,Icahn School Of Medicine at Mount Sinai, New York, NY, USA
| | - Kai Zacharowski
- Department of Anesthesiology, Intensive Care Medicine & Pain Therapy, University Hospital Frankfurt, Goethe University, Frankfurt, Main, Germany
| | - Donat R Spahn
- Institute of Anesthesiology, University and University Hospital Zürich, Zürich, Switzerland
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19
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Pusateri AE, Moore EE, Moore HB, Le TD, Guyette FX, Chapman MP, Sauaia A, Ghasabyan A, Chandler J, McVaney K, Brown JB, Daley BJ, Miller RS, Harbrecht BG, Claridge JA, Phelan HA, Witham WR, Putnam AT, Sperry JL. Association of Prehospital Plasma Transfusion With Survival in Trauma Patients With Hemorrhagic Shock When Transport Times Are Longer Than 20 Minutes: A Post Hoc Analysis of the PAMPer and COMBAT Clinical Trials. JAMA Surg 2020; 155:e195085. [PMID: 31851290 DOI: 10.1001/jamasurg.2019.5085] [Citation(s) in RCA: 144] [Impact Index Per Article: 36.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Importance Both military and civilian clinical practice guidelines include early plasma transfusion to achieve a plasma to red cell ratio approaching 1:1 to 1:2. However, it was not known how early plasma should be given for optimal benefit. Two recent randomized clinical trials were published, with apparently contradictory results. The Prehospital Air Medical Plasma (PAMPer) clinical trial showed a nearly 30% reduction in mortality with plasma transfusion in the prehospital environment, while the Control of Major Bleeding After Trauma (COMBAT) clinical trial showed no survival improvement. Objective To facilitate a post hoc combined analysis of the COMBAT and PAMPer trials to examine questions that could not be answered by either clinical trial alone. We hypothesized that prehospital transport time influenced the effects of prehospital plasma on 28-day mortality. Design, Setting, and Participants A total of 626 patients in the 2 clinical trials were included. Patients with trauma and hemorrhagic shock were randomly assigned to receive either standard care or 2 U of thawed plasma followed by standard care in the prehospital environment. Data analysis was performed between September 2018 and January 2019. Interventions Prehospital transfusion of 2 U of plasma compared with crystalloid-based resuscitation. Main Outcomes and Measures The main outcome was 28-day mortality. Results In this post hoc analysis of 626 patients (467 men [74.6%] and 159 women [25.4%]; median [interquartile range] age, 42 [27-57] years) who had trauma with hemorrhagic shock, a Cox regression analysis showed a significant overall survival benefit for plasma (hazard ratio [HR], 0.65; 95% CI, 0.47-0.90; P = .01) after adjustment for injury severity, age, and clinical trial cohort (COMBAT or PAMPer). A significant association with prehospital transport time was detected (from arrival on scene to arrival at the trauma center). Increased mortality was observed in patients in the standard care group when prehospital transport was longer than 20 minutes (HR, 2.12; 95% CI, 1.05-4.30; P = .04), while increased mortality was not observed in patients in the prehospital plasma group (HR, 0.78; 95% CI, 0.40-1.51; P = .46). No serious adverse events were associated with prehospital plasma transfusion. Conclusions and Relevance These data suggest that prehospital plasma is associated with a survival benefit when transport times are longer than 20 minutes and that the benefit-risk ratio is favorable for use of prehospital plasma. Trial Registration ClinicalTrials.gov identifiers: NCT01838863 (COMBAT) and NCT01818427 (PAMPer).
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Affiliation(s)
- Anthony E Pusateri
- US Army Institute of Surgical Research, JBSA-Fort Sam Houston, San Antonio, Texas
| | - Ernest E Moore
- Department of Surgery, School of Medicine, University of Colorado Denver, Aurora
| | - Hunter B Moore
- Department of Surgery, School of Medicine, University of Colorado Denver, Aurora
| | - Tuan D Le
- US Army Institute of Surgical Research, JBSA-Fort Sam Houston, San Antonio, Texas
| | - Francis X Guyette
- Division of Emergency Medicine, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Michael P Chapman
- Department of Radiology, School of Medicine, University of Colorado Denver, Aurora
| | - Angela Sauaia
- Department of Health Systems, Management, and Policy, School of Public Health, University of Colorado Denver, Aurora
| | - Arsen Ghasabyan
- Department of Surgery, School of Medicine, University of Colorado Denver, Aurora
| | - James Chandler
- Department of Surgery, School of Medicine, University of Colorado Denver, Aurora
| | - Kevin McVaney
- Department of Emergency Medicine, School of Medicine, University of Colorado Denver, Aurora
| | - Joshua B Brown
- Division of Trauma and General Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Brian J Daley
- Department of Surgery, University of Tennessee Health Science Center, Knoxville
| | - Richard S Miller
- Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Brian G Harbrecht
- Department of Surgery, University of Louisville, Louisville, Kentucky
| | - Jeffrey A Claridge
- MetroHealth Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - Herb A Phelan
- Department of Surgery, Parkland Memorial Hospital, University of Texas Southwestern, Dallas
| | | | - A Tyler Putnam
- Altoona Hospital, University of Pittsburgh Medical Center, Altoona, Pennsylvania
| | - Jason L Sperry
- Division of Trauma and General Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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20
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Reassessment of the Need for an Oxygen Carrier for the Treatment of Traumatic Hemorrhage When Blood is not an Option. Shock 2019; 52:55-59. [DOI: 10.1097/shk.0000000000001417] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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21
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Knapp J, Pietsch U, Kreuzer O, Hossfeld B, Bernhard M, Lier H. Prehospital Blood Product Transfusion in Mountain Rescue Operations. Air Med J 2018; 37:392-399. [PMID: 30424860 DOI: 10.1016/j.amj.2018.08.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Revised: 07/08/2018] [Accepted: 08/24/2018] [Indexed: 12/13/2022]
Abstract
Severely injured patients with hemorrhage present major challenges for emergency medical services, especially during mountain rescue missions in which harsh environmental conditions and long out-of-hospital times are frequent. Because uncontrolled hemorrhage is the leading cause of death within the first 48 hours after severe trauma, initiating damage control resuscitation (DCR) as early as possible after severe trauma and exporting the concept of DCR to the out-of-hospital arena is pivotal for patient survival. Appropriate bleeding control, management of coagulopathy, and transfusion of blood products are core aspects of DCR. This review summarizes the available evidence on out-of-hospital blood product transfusion and the management of coagulopathy with a special focus on mountain rescue missions. An overview of upcoming trials and possible future trends in the management of coagulopathy during rescue operations is provided.
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Affiliation(s)
- Jürgen Knapp
- Department of Anaesthesiology and Pain Therapy, University Hospital of Bern, Bern, Switzerland; Air Zermatt, Emergency Medical Service, Zermatt, Switzerland.
| | - Urs Pietsch
- Air Zermatt, Emergency Medical Service, Zermatt, Switzerland; Department of Anaesthesiology and Intensive Care Medicine, Cantonal Hospital St Gallen, St Gallen, Switzerland
| | - Oliver Kreuzer
- Air Zermatt, Emergency Medical Service, Zermatt, Switzerland
| | - Björn Hossfeld
- Department of Anaesthesiology and Intensive Care Medicine, Armed Forces Hospital Ulm, Ulm, Germany; Task Force "Tactical Medicine" of the Scientific Working Group Emergency Medicine of the German Society of Anaesthesiology and Intensive Care Medicine, Nürnberg, Germany
| | - Michael Bernhard
- Emergency Department, University Hospital of Düsseldorf, Düsseldorf, Germany; Task Force "Trauma and Resuscitation Room Management" of the Scientific Working Group Emergency Medicine of the German Society of Anaesthesiology and Intensive Care Medicine, Nürnberg, Germany
| | - Heiko Lier
- Task Force "Tactical Medicine" of the Scientific Working Group Emergency Medicine of the German Society of Anaesthesiology and Intensive Care Medicine, Nürnberg, Germany; Department of Anaesthesiology and Postoperative Intensive Care Medicine, University of Cologne, Köln, Germany
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