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Holcomb JB, Butler FK, Schreiber MA, Taylor AL, Riggs LE, Krohmer JR, Dorlac WC, Jenkins DH, Cox DB, Beckett AN, O'Connor KC, Gurney JM. Making blood immediately available in emergencies. Transfusion 2024. [PMID: 39031029 DOI: 10.1111/trf.17929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Accepted: 05/30/2024] [Indexed: 07/22/2024]
Affiliation(s)
- John B Holcomb
- Division of Trauma and Acute Care Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Frank K Butler
- Tactical Combat Casualty Care and the DoD Joint Trauma System, Ft. Sam Houston, Texas, USA
| | - Martin A Schreiber
- Department of Surgery, Oregon Health and Science University, Portland, Oregon, USA
| | | | - Leslie E Riggs
- Armed Services Blood Program, Defense Health Headquarters, Falls Church, Virginia, USA
| | - Jon R Krohmer
- Department of Emergency Medicine, Homer Stryker M.D. School of Medicine, Western Michigan University, Kalamazoo, Michigan, USA
| | - Warren C Dorlac
- Department of Surgery, University of Colorado, Denver, Colorado, USA
| | | | - Daniel B Cox
- Division of Trauma and Acute Care Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Andrew N Beckett
- Canadian Forces Health Services, University of Toronto, Toronto, Ontario, Canada
| | - Kevin C O'Connor
- Department of Medicine, George Washington University School of Medicine & Health Sciences, Washington, DC, USA
| | - Jennifer M Gurney
- Department of Defense, Joint Trauma System, US Army, Ft Sam Houston, Texas, USA
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2
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Saab MA, Jacobson E, Hanson K, Kruciak B, Miramontes D, Harper S. Prehospital Whole Blood Administration for Pediatric Gastrointestinal Hemorrhage: A Case Report. PREHOSP EMERG CARE 2024:1-4. [PMID: 38940756 DOI: 10.1080/10903127.2024.2372808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2024] [Accepted: 06/17/2024] [Indexed: 06/29/2024]
Abstract
The management of gastrointestinal (GI) hemorrhage in a prehospital setting presents significant challenges, particularly in arresting the hemorrhage and initiating resuscitation. This case report introduces a novel instance of prehospital whole blood transfusion to an 8-year-old male with severe lower GI hemorrhage, marking a shift in prehospital pediatric care. The patient, with no previous significant medical history, presented with acute rectal bleeding, severe hypotension (systolic/diastolic blood pressure [BP] 50/30 mmHg), and tachycardia (148 bpm). Early intervention by Emergency Medical Services (EMS), including the administration of 500 mL (16 mL/kg) of whole blood, led to marked improvement in vital signs (BP 97/64 mmHg and heart rate 93 bpm), physiology, and physical appearance, underscoring the potential effectiveness of prehospital whole blood transfusion in pediatric GI hemorrhage. Upon hospital admission, a Meckel's diverticulum was identified as the bleeding source, and it was successfully surgically resected. The patient's recovery was ultimately favorable, highlighting the importance of rapid, prehospital intervention and the potential role of whole blood transfusion in managing acute pediatric GI hemorrhage. This case supports the notion of advancing EMS protocols to include interventions historically reserved for the hospital setting that may significantly impact patient outcomes from the field.
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Affiliation(s)
- Mathew A Saab
- Department of Emergency Medicine, Brooke Army Medical Center, San Antonio, Texas
- Department of Emergency Health Sciences, University of Texas Health Science Center San Antonio, San Antonio, Texas
| | - Eric Jacobson
- Department of Emergency Medicine, Brooke Army Medical Center, San Antonio, Texas
- Department of Emergency Health Sciences, University of Texas Health Science Center San Antonio, San Antonio, Texas
| | - Kip Hanson
- San Antonio Fire Department, San Antonio, Texas
| | | | - David Miramontes
- Department of Emergency Health Sciences, University of Texas Health Science Center San Antonio, San Antonio, Texas
| | - Stephen Harper
- Department of Emergency Medicine, Brooke Army Medical Center, San Antonio, Texas
- Department of Emergency Health Sciences, University of Texas Health Science Center San Antonio, San Antonio, Texas
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Powell E, Keller AP, Galvagno SM. Advanced Critical Care Techniques in the Field. Crit Care Clin 2024; 40:463-480. [PMID: 38796221 DOI: 10.1016/j.ccc.2024.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2024]
Abstract
Critical care principles and techniques continue to hold promise for improving patient outcomes in time-dependent diseases encountered by emergency medical services such as cardiac arrest, acute ischemic stroke, and hemorrhagic shock. In this review, the authors discuss several current and evolving advanced critical care modalities, including extracorporeal cardiopulmonary resuscitation, resuscitative endovascular occlusion of the aorta, prehospital thrombolytics for acute ischemic stroke, and low-titer group O whole blood for trauma patients. Two important critical care monitoring technologies-capnography and ultrasound-are also briefly discussed.
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Affiliation(s)
- Elizabeth Powell
- Program in Trauma, University of Maryland School of Medicine, R Adams Cowley Shock Trauma Center, 22 S Greene Street, Baltimore, MD 21201, USA
| | - Alex P Keller
- Medical Modernization and Plans Division, 162 Dodd Boulevard, Langley Air Force Base, VA 23665, USA
| | - Samuel M Galvagno
- Department of Anesthesiology, University of Maryland School of Medicine, 22 S Greene Street, S11C16, Baltimore, MD 21201, USA.
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Shafique MA, Shaikh NA, Haseeb A, Mussarat A, Mustafa MS. Sodium bicarbonate Ringer's solution for hemorrhagic shock: A meta-analysis comparing crystalloid solutions. Am J Emerg Med 2024; 76:41-47. [PMID: 37988980 DOI: 10.1016/j.ajem.2023.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2023] [Revised: 10/21/2023] [Accepted: 11/01/2023] [Indexed: 11/23/2023] Open
Abstract
BACKGROUND The choice of fluid resuscitation in Traumatic Hemorrhagic shock (THS) remains a critical aspect of patient management. Bicarbonated Ringers solution (BRS) has shown promise due to its composition resembling human Extracellular Fluid and its potential benefits on hemodynamics. OBJECTIVE To evaluate the efficacy, mortality rates, hemodynamic effects, and adverse outcomes of Sodium Bicarbonate Ringer's Solution in the treatment of hemorrhagic shock, as compared to other relevant interventions. METHOD A comprehensive examination of the available literature was performed by conducting systematic searches in prominent databases such as Cochrane, EMBASE, MEDLINE, and PubMed. The process employed predefined criteria to extract relevant data and evaluate the quality of the studies. The outcome measures considered encompassed survival rates, mortality, mean arterial pressure (MAP), heart rate (HR), and adverse events. RESULT The meta-analysis of three studies showed that compared to the other crystalloids, the use of BRS had an odds ratio for survival of 1.86 (95% CI: 0.94, 3.71; p = 0.08; I2 = 0%), an odds ratio for total adverse events of 0.14 (95% CI: 0.06, 0.35; p < 0.0001; I2 = 22%), a mean difference in heart rate of -4.49 (95% CI: -7.55, -1.44; p = 0.004; I2 = 13%), and a mean difference in mean arterial pressure of 2.31 (95% CI: -0.85, 5.47; p = 0.15; I2 = 66%). CONCLUSION BRS demonstrated a significant reduction in complications, including adult respiratory distress syndrome (ARDS), Multiple Organ Dysfunction (MODS), and Total Adverse Effects, when compared to other solutions in the treatment of THS. Additionally, THS patients resuscitated with BRS experienced a notable decrease in heart rate. The findings suggest BRS may contribute to organ stability and potential survival improvement due to its similarity to human Extracellular Fluid and minimal impact on the liver.
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Affiliation(s)
| | | | - Abdul Haseeb
- Department of Medicine, Jinnah Sindh Medical University, Pakistan
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5
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Shea SM, Mihalko EP, Lu L, Thomas KA, Schuerer D, Brown JB, Bochicchio GV, Spinella PC. Doing more with less: low-titer group O whole blood resulted in less total transfusions and an independent association with survival in adults with severe traumatic hemorrhage. J Thromb Haemost 2024; 22:140-151. [PMID: 37797692 PMCID: PMC10841654 DOI: 10.1016/j.jtha.2023.09.025] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 09/18/2023] [Accepted: 09/22/2023] [Indexed: 10/07/2023]
Abstract
BACKGROUND Low-titer group O whole blood (LTOWB) or component therapy (CT) may be used to resuscitate hemorrhaging trauma patients. LTOWB may have clinical and logistical benefits and may improve survival. OBJECTIVES We hypothesized LTOWB would improve 24-hour survival in hemorrhaging patients and would be safe and equally efficacious in non-group O compared with group O patients. METHODS Adult trauma patients with massive transfusion protocol activations were enrolled in this observational study. The primary outcome was 24-hour mortality. Secondary outcomes included 72-hour total blood product use. A Cox regression determined the independent associations with 24-hour mortality. RESULTS In total, 348 patients were included (CT, n = 180; LTOWB, n = 168). Demographics were similar between cohorts. Unadjusted 24-hour mortality was reduced in LTOWB vs CT: 8% vs 19% (P = .003), but 6-hour and 28-day mortality were similar. In an adjusted analysis with multivariable Cox regression, LTOWB was independently associated with reduced 24-hour mortality (hazard ratio, 0.21; 95% CI, 0.07-0.67; P = .004). LTOWB patients received significantly less 72-hour total blood products (80.9 [41.6-139.3] mL/kg vs 48.9 [25.9-106.9] mL/kg; P < .001). In stratified 24-hour survival analyses, LTOWB was associated with improved survival for patients in shock or with coagulopathy. LTOWB use in non-group O patients was not associated with increased mortality, organ injury, or adverse events. CONCLUSION In this hypothesis-generating study, LTOWB use was independently associated with improved 24-hour survival, predominantly in patients with shock or coagulopathy. LTOWB also resulted in a 40% reduction in blood product use which equates to a median 2.4 L reduction in transfused products.
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Affiliation(s)
- Susan M Shea
- Trauma and Transfusion Medicine Research Center, Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA; Department of Bioengineering, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.
| | - Emily P Mihalko
- Trauma and Transfusion Medicine Research Center, Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Liling Lu
- Trauma and Transfusion Medicine Research Center, Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | | | - Douglas Schuerer
- Department of Surgery, Section of Acute and Critical Care Surgery, Washington University in St. Louis School of Medicine, St. Louis, Missouri, USA
| | - Joshua B Brown
- Trauma and Transfusion Medicine Research Center, Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Grant V Bochicchio
- Department of Surgery, Section of Acute and Critical Care Surgery, Washington University in St. Louis School of Medicine, St. Louis, Missouri, USA
| | - Philip C Spinella
- Trauma and Transfusion Medicine Research Center, Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA; Department of Critical Care, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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6
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Gaski IA, Naess PA, Baksaas-Aasen K, Skaga NO, Gaarder C. Achieving balanced transfusion early in critically bleeding trauma patients: an observational study exploring the effect of attending trauma surgical presence during resuscitation. Trauma Surg Acute Care Open 2023; 8:e001160. [PMID: 38020849 PMCID: PMC10660666 DOI: 10.1136/tsaco-2023-001160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Accepted: 10/13/2023] [Indexed: 12/01/2023] Open
Abstract
Background After 15 years of damage control resuscitation (DCR), studies still report high mortality rates for critically bleeding trauma patients. Adherence to massive hemorrhage protocols (MHPs) based on a 1:1:1 ratio of plasma, platelets, and red blood cells (RBCs) as part of DCR has been shown to improve outcomes. We wanted to assess MHP use in the early (6 hours from admission), critical phase of DCR and its impact on mortality. We hypothesized that the presence of an attending trauma surgeon during all MHP activations from 2013 would contribute to improving institutional resuscitation strategies and patient outcomes. Methods We conducted a retrospective analysis of all trauma patients receiving ≥10 RBCs within 6 hours of admission and included in the institutional trauma registry between 2009 and 2019. The cohort was divided in period 1 (P1): January 2009-August 2013, and period 2 (P2): September 2013-December 2019 for comparison of outcomes. Results A total of 141 patients were included, 81 in P1 and 60 in P2. Baseline characteristics were similar between the groups for Injury Severity Score, lactate, Glasgow Coma Scale, and base deficit. Patients in P2 received more plasma (16 units vs. 12 units; p<0.01), resulting in a more balanced plasma:RBC ratio (1.00 vs. 0.74; p<0.01), and platelets:RBC ratio (1.11 vs. 0.92; p<0.01). All-cause mortality rates decreased from P1 to P2, at 6 hours (22% to 8%; p=0.03), at 24 hours (36% vs 13%; p<0.01), and at 30 days (48% vs 30%, p=0.03), respectively. A stepwise logistic regression model predicted an OR of 0.27 (95% CI 0.08 to 0.93) for dying when admitted in P2. Conclusions Achieving balanced transfusion rates at 6 hours, facilitated by the presence of an attending trauma surgeon at all MHP activations, coincided with a reduction in all-cause mortality and hemorrhage-related deaths in massively transfused trauma patients at 6 hours, 24 hours, and 30 days. Level of evidence IV.
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Affiliation(s)
- Iver Anders Gaski
- Department of Traumatology, Oslo University Hospital Ulleval, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Paal Aksel Naess
- Department of Traumatology, Oslo University Hospital Ulleval, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | | | - Nils Oddvar Skaga
- Department of Anesthesiology, Oslo University Hospital Ullevål, Oslo, Norway
| | - Christine Gaarder
- Department of Traumatology, Oslo University Hospital Ulleval, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
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Balzi APDCC, Otsuki DA, Andrade L, Paiva W, Souza FL, Aureliano LGC, Malbouisson LMS. Can a Therapeutic Strategy for Hypotension Improve Cerebral Perfusion and Oxygenation in an Experimental Model of Hemorrhagic Shock and Severe Traumatic Brain Injury? Neurocrit Care 2023; 39:320-330. [PMID: 37535176 DOI: 10.1007/s12028-023-01802-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 07/03/2023] [Indexed: 08/04/2023]
Abstract
BACKGROUND Restoration of brain tissue perfusion is a determining factor in the neurological evolution of patients with traumatic brain injury (TBI) and hemorrhagic shock (HS). In a porcine model of HS without neurological damage, it was observed that the use of fluids or vasoactive drugs was effective in restoring brain perfusion; however, only terlipressin promoted restoration of cerebral oxygenation and lower expression of edema and apoptosis markers. It is unclear whether the use of vasopressor drugs is effective and beneficial during situations of TBI. The objective of this study is to compare the effects of resuscitation with saline solution and terlipressin on cerebral perfusion and oxygenation in a model of TBI and HS. METHODS Thirty-two pigs weighing 20-30 kg were randomly allocated into four groups: control (no treatment), saline (60 ml/kg of 0.9% NaCl), terlipressin (2 mg of terlipressin), and saline plus terlipressin (20 ml/kg of 0.9% NaCl + 2 mg of terlipressin). Brain injury was induced by lateral fluid percussion, and HS was induced through pressure-controlled bleeding, aiming at a mean arterial pressure (MAP) of 40 mmHg. After 30 min of circulatory shock, resuscitation strategies were initiated according to the group. The systemic and cerebral hemodynamic and oxygenation parameters, lactate levels, and hemoglobin levels were evaluated. The data were subjected to analysis of variance for repeated measures. The significance level established for statistical analysis was p < 0.05. RESULTS The terlipressin and saline plus terlipressin groups showed an increase in MAP that lasted until the end of the experiment (p < 0.05). There was a notable increase in intracranial pressure in all groups after starting treatment for shock. Cerebral perfusion pressure and cerebral oximetry showed no improvement after hemodynamic recovery in any group. The groups that received saline at resuscitation had the lowest hemoglobin concentrations after treatment. CONCLUSIONS The treatment of hypotension in HS with saline and/or terlipressin cannot restore cerebral perfusion or oxygenation in experimental models of HS and severe TBI. Elevated MAP raises intracranial pressure owing to brain autoregulation dysfunction caused by TBI.
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Affiliation(s)
- Ana Paula de Carvalho Canela Balzi
- Anesthesiology Department, Hospital das Clinicas SP, School of Medicine, University of São Paulo, Av. Dr. Enéas de Carvalho Aguiar, 255, Cerqueira César, São Paulo, SP, 05403-000, Brazil.
- Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil.
- Divisão de Anestesia do ICHC, UTI Cirúrgica Pediátrica, Av. Enéas Carvalho de Aguiar, 255 - 8° Andar, Cerqueira César, São Paulo, SP, 05403-900, Brazil.
| | - Denise Aya Otsuki
- Medical Research Laboratory -LIM-08, Anesthesiology Department, School of Medicine, University of São Paulo, São Paulo, Brazil
- Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Lucia Andrade
- Nephrology Department, Hospital das Clinicas SP, School of Medicine, University of São Paulo, São Paulo, Brazil
- Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Wellingson Paiva
- Neurosurgery Department, Hospital das Clinicas SP, School of Medicine, University of São Paulo, São Paulo, Brazil
- Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Felipe Lima Souza
- Medical Research Laboratory, Nephrology Department, School of Medicine, University of São Paulo, São Paulo, Brazil
- Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Luiz Guilherme Cernaglia Aureliano
- Pathology Department, Hospital das Clinicas SP, School of Medicine, University of São Paulo, São Paulo, Brazil
- Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Luiz Marcelo Sá Malbouisson
- Anesthesiology Department, Hospital das Clinicas SP, School of Medicine, University of São Paulo, Av. Dr. Enéas de Carvalho Aguiar, 255, Cerqueira César, São Paulo, SP, 05403-000, Brazil
- Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
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8
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Hosseinpour H, Magnotti LJ, Bhogadi SK, Anand T, El-Qawaqzeh K, Ditillo M, Colosimo C, Spencer A, Nelson A, Joseph B. Time to Whole Blood Transfusion in Hemorrhaging Civilian Trauma Patients: There Is Always Room for Improvement. J Am Coll Surg 2023; 237:24-34. [PMID: 37070752 DOI: 10.1097/xcs.0000000000000715] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/19/2023]
Abstract
BACKGROUND Whole blood (WB) is becoming the preferred product for the resuscitation of hemorrhaging trauma patients. However, there is a lack of data on the optimum timing of receiving WB. We aimed to assess the effect of time to WB transfusion on the outcomes of trauma patients. STUDY DESIGN The American College of Surgeons TQIP 2017 to 2019 database was analyzed. Adult trauma patients who received at least 1 unit of WB within the first 2 hours of admission were included. Patients were stratified by time to first unit of WB transfusion (first 30 minutes, second 30 minutes, and second hour). Primary outcomes were 24-hour and in-hospital mortality, adjusting for potential confounders. RESULTS A total of 1,952 patients were identified. Mean age and systolic blood pressure were 42 ± 18 years and 101 ± 35 mmHg, respectively. Median Injury Severity Score was 17 [10 to 26], and all groups had comparable injury severities (p = 0.27). Overall, 24-hour and in-hospital mortality rates were 14% and 19%, respectively. Transfusion of WB after 30 minutes was progressively associated with increased adjusted odds of 24-hour mortality (second 30 minutes: adjusted odds ratio [aOR] 2.07, p = 0.015; second hour: aOR 2.39, p = 0.010) and in-hospital mortality (second 30 minutes: aOR 1.79, p = 0.025; second hour: aOR 1.98, p = 0.018). On subanalysis of patients with an admission shock index >1, every 30-minute delay in WB transfusion was associated with higher odds of 24-hour (aOR 1.23, p = 0.019) and in-hospital (aOR 1.18, p = 0.033) mortality. CONCLUSIONS Every minute delay in WB transfusion is associated with a 2% increase in odds of 24-hour and in-hospital mortality among hemorrhaging trauma patients. WB should be readily available and easily accessible in the trauma bay for the early resuscitation of hemorrhaging patients.
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Affiliation(s)
- Hamidreza Hosseinpour
- From the Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, College of Medicine, University of Arizona, Tucson, AZ
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9
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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] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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10
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Santangini MR, Leuckel SN, King KA, Cheves TA, Sweeney JD. In vitro comparison of CPD whole blood with conventional blood components. Transfus Apher Sci 2023; 62:103526. [PMID: 36041978 DOI: 10.1016/j.transci.2022.103526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Revised: 08/04/2022] [Accepted: 08/23/2022] [Indexed: 10/15/2022]
Abstract
INTRODUCTION Resuscitation of severely injured trauma patients is commonly performed using red blood cells in additive solution supplemented with plasma and platelet concentrates. There is an increasing interest in the use of low anti-A titer Group O whole blood (LTOWB) in the early management of the resuscitation. It is unclear whether clinical outcome is improved using this approach. METHODS Expired units of CPD-LTOWB were studied on Day 22 and expired units of thawed plasma on Day 6 and Day 7. LTOWB was assessed for hemoglobin content, clotting factor levels and platelet numbers and function using thromboelastography (TEG) and impedance aggregation. Assays of fibrinogen and FV, FVIII, FVII and FX were performed on the expired plasma. The LTOWB hemoglobin was compared to red cells in additive solution (AS-RBCs) and the clotting factor levels to those of expired thawed plasma. Platelet function was compared to fresh whole blood samples from healthy subjects. RESULTS LTOWB contained slightly more hemoglobin than the AS-RBCs (Medians, 66 v 59 G), and the plasma content of fibrinogen was similar. Other clotting factors were reduced by approximately 15% except for FVIII which was 30% less. Both TEG and impedance aggregometry showed evidence of residual platelet function despite the prolonged period of refrigerator storage. CONCLUSION LTOWB contains higher hemoglobin and adequate clotting factors, and residual platelet function is demonstrated indicating that this product would be expected to be at least equivalent to a single unit of each of the conventional components commonly used in trauma resuscitation.
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Affiliation(s)
| | - Stephanie N Leuckel
- Division of Trauma and Surgical Critical Care, Providence, RI, USA; Lifespan Academic Medical Center and the Alpert Medical School of Brown University, Providence, RI, USA
| | - Karen A King
- Department of Coagulation and Transfusion Medicine, Providence, RI, USA
| | - Tracey A Cheves
- Department of Coagulation and Transfusion Medicine, Providence, RI, USA
| | - Joseph D Sweeney
- Department of Coagulation and Transfusion Medicine, Providence, RI, USA; Lifespan Academic Medical Center and the Alpert Medical School of Brown University, Providence, RI, USA.
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11
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Resuscitative practices and the use of low-titer group O whole blood in pediatric trauma. J Trauma Acute Care Surg 2023; 94:S29-S35. [PMID: 36156051 DOI: 10.1097/ta.0000000000003801] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
ABSTRACT Increasing rates of penetrating trauma in the United States makes rapid identification of hemorrhagic shock, coagulopathy, and early initiation of balanced resuscitation in injured children of critical importance. Hemorrhagic shock begins early after injury and can be challenging to identify in children, as hypotension is a late sign that a child is on the verge of circulatory collapse and should be aggressively resuscitated. Recent data support shifting away from crystalloid and toward early resuscitation with blood products because of worse coagulopathy and clinical outcomes in injured patients resuscitated with crystalloid. Multicenter studies have found improved survival in injured children who receive balanced resuscitation with higher fresh frozen plasma: red blood cell ratios. Whole blood is an efficient way to achieve balanced resuscitation in critically injured children with limited intravenous access and decreased exposure to multiple donors. Administration of cold-stored, low-titer O-negative whole blood (LTOWB) appears to be safe in adults and children and may be associated with improved survival in children with life-threatening hemorrhage. Many pediatric centers use RhD-negative LTOWB for all female children because of the risk of hemolytic disease of the fetus and newborn (0-6%); however. there is a scarcity of LTOWB compared with the demand. Low risks of hemolytic disease of the fetus and newborn affecting a future pregnancy must be weighed against high mortality rates in delayed blood product administration in children in hemorrhagic shock. Survey studies involving key stakeholder's opinions on pediatric blood transfusion practices are underway. Existing pediatric-specific literature on trauma resuscitation is often limited and underpowered; multicenter prospective studies are urgently needed to define optimal resuscitation products and practices in injured children in an era of increasing penetrating trauma.
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12
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Bonanno FG. Management of Hemorrhagic Shock: Physiology Approach, Timing and Strategies. J Clin Med 2022; 12:jcm12010260. [PMID: 36615060 PMCID: PMC9821021 DOI: 10.3390/jcm12010260] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 11/22/2022] [Accepted: 11/27/2022] [Indexed: 12/30/2022] Open
Abstract
Hemorrhagic shock (HS) management is based on a timely, rapid, definitive source control of bleeding/s and on blood loss replacement. Stopping the hemorrhage from progressing from any named and visible vessel is the main stem fundamental praxis of efficacy and effectiveness and an essential, obligatory, life-saving step. Blood loss replacement serves the purpose of preventing ischemia/reperfusion toxemia and optimizing tissue oxygenation and microcirculation dynamics. The "physiological classification of HS" dictates the timely management and suits the 'titrated hypotensive resuscitation' tactics and the 'damage control surgery' strategy. In any hypotensive but not yet critical shock, the body's response to a fluid load test determines the cut-off point between compensation and progression between the time for adopting conservative treatment and preparing for surgery or rushing to the theater for rapid bleeding source control. Up to 20% of the total blood volume is given to refill the unstressed venous return volume. In any critical level of shock where, ab initio, the patient manifests signs indicating critical physiology and impending cardiac arrest or cardiovascular accident, the balance between the life-saving reflexes stretched to the maximum and the insufficient distal perfusion (blood, oxygen, and substrates) remains in a liable and delicate equilibrium, susceptible to any minimal change or interfering variable. In a cardiac arrest by exsanguination, the core of the physiological issue remains the rapid restoration of a sufficient venous return, allowing the heart to pump it back into systemic circulation either by open massage via sternotomy or anterolateral thoracotomy or spontaneously after aorta clamping in the chest or in the abdomen at the epigastrium under extracorporeal resuscitation and induced hypothermia. This is the only way to prevent ischemic damage to the brain and the heart. This is accomplishable rapidly and efficiently only by a direct approach, which is a crush laparotomy if the bleeding is coming from an abdominal +/- lower limb site or rapid sternotomy/anterolateral thoracotomy if the bleeding is coming from a chest +/- upper limbs site. Without first stopping the bleeding and refilling the heart, any further exercise is doomed to failure. Direct source control via laparotomy/thoracotomy, with the concomitant or soon following venous refilling, are the two essential, initial life-saving steps.
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Affiliation(s)
- Fabrizio G Bonanno
- Department of Surgery, Polokwane Provincial Hospital, Cnr Hospital & Dorp Street, Polokwane 0700, South Africa
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Observation on the effectiveness and safety of sodium bicarbonate Ringer's solution in the early resuscitation of traumatic hemorrhagic shock: a clinical single-center prospective randomized controlled trial. Trials 2022; 23:825. [PMID: 36175936 PMCID: PMC9523956 DOI: 10.1186/s13063-022-06752-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Accepted: 09/14/2022] [Indexed: 11/10/2022] Open
Abstract
Background Traumatic hemorrhagic shock (THS) is the main cause of death in trauma patients with high mortality. Rapid control of the source of bleeding and early resuscitation are crucial to clinical treatment. Guidelines recommend isotonic crystal resuscitation when blood products are not immediately available. However, the selection of isotonic crystals has been controversial. Sodium bicarbonate Ringer solutions (BRS), containing sodium bicarbonate, electrolyte levels, and osmotic pressures closer to plasma, are ideal. Therefore, in this study, we will focus on the effects of BRS on the first 6 h of resuscitation, complications, and 7-day survival in patients with THS. Methods /design. This single-center, prospective, randomized controlled trial will focus on the efficacy and safety of BRS in early THS resuscitation. A total of 400 adults THS patients will be enrolled in this study. In addition to providing standard care, enrolled patients will be randomized in a 1:1 ratio to receive resuscitation with BRS (test group) or sodium lactate Ringer’s solution (control group) until successful resuscitation from THS. Lactate clearance at different time points (0.5, 1, 1.5, 3, and 6 h) and shock duration after drug administration will be compared between the two groups as primary end points. Secondary end points will compare coagulation function, temperature, acidosis, inflammatory mediator levels, recurrence of shock, complications, medication use, and 7-day mortality between the two groups. Patients will be followed up until discharge or 7 days after discharge. Discussion At present, there are still great differences in the selection of resuscitation fluids, and there is a lack of systematic and detailed studies to compare and observe the effects of various resuscitation fluids on the effectiveness and safety of early resuscitation in THS patients. This trial will provide important clinical data for resuscitation fluid selection and exploration of safe dose of BRS in THS patients. Trial registration. Chinese Clinical Trial Registry (ChiCTR), ChiCTR2100045044. Registered on 4 April 2021. Supplementary Information The online version contains supplementary material available at 10.1186/s13063-022-06752-5.
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Meizoso JP, Barrett CD, Moore EE, Moore HB. Advances in the Management of Coagulopathy in Trauma: The Role of Viscoelastic Hemostatic Assays across All Phases of Trauma Care. Semin Thromb Hemost 2022; 48:796-807. [DOI: 10.1055/s-0042-1756305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
AbstractUncontrolled bleeding is the leading cause of preventable death following injury. Trauma-induced coagulopathy can manifest as diverse phenotypes ranging from hypocoagulability to hypercoagulability, which can change quickly during the acute phase of trauma care. The major advances in understanding coagulation over the past 25 years have resulted from the cell-based concept, emphasizing the key role of platelets and their interaction with the damaged endothelium. Consequently, conventional plasma-based coagulation testing is not accurate in predicting bleeding and does not provide an assessment of which blood products are indicated. Viscoelastic hemostatic assays (VHA), conducted in whole blood, have emerged as a superior method to guide goal-directed transfusion. The major change in resuscitation has been the shift from unbridled crystalloid loading to judicious balanced blood product administration. Furthermore, the recognition of the rapid changes from hypocoagulability to hypercoagulability has underscored the importance of ongoing surveillance beyond emergent surgery. While the benefits of VHA testing are maximized when used as early as possible, current technology limits use in the pre-hospital setting and the time to results compromises its utility in the emergency department. Thus, most of the reported experience with VHA in trauma is in the operating room and intensive care unit, where there is compelling data to support its value. This overview will address the current and potential role of VHA in the seriously injured patient, throughout the continuum of trauma management.
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Affiliation(s)
- Jonathan P. Meizoso
- DeWitt Daughtry Family Department of Surgery, Ryder Trauma Center, University of Miami Miller School of Medicine, Jackson Memorial Hospital, Miami, Florida
| | - Christopher D. Barrett
- Center for Precision Cancer Medicine, Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology, Cambridge, Massachusetts
- Department of Surgery, Boston University Medical Center, Boston University School of Medicine, Boston, Massachusetts
| | - Ernest E. Moore
- Department of Surgery, University of Colorado Denver, Aurora, Colorado
- Department of Surgery, Ernest E. Moore Shock Trauma Center at Denver Health, Denver, Colorado
| | - Hunter B. Moore
- Department of Surgery, University of Colorado Denver, Aurora, Colorado
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15
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Bush K, Shea L, San Roman J, Pailloz E, Gaughan J, Porter J, Goldenberg-Sandau A. Whole Blood in Trauma Resuscitation: What is the Real Cost? J Surg Res 2022; 275:155-160. [DOI: 10.1016/j.jss.2022.01.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 12/30/2021] [Accepted: 01/29/2022] [Indexed: 10/18/2022]
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16
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Taylor AL, Corley JB, Cap AP, Swingholm MT, Nance ET, Gonzales R, Gurney JM, Shackelford S, Hebert JC, Hughes JD, Royster K, Hestilow GA, Cordrick CL, Hoiles J, Whitlock K, Whitacre R, Pederson B. The U.S. Armed Services Blood Program support to U.S. Central Command 2014-2021: Transformation of combat trauma resuscitation through blood product innovation and expansion of blood availability far forward. Transfusion 2022; 62 Suppl 1:S167-S176. [PMID: 35748678 DOI: 10.1111/trf.16951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Revised: 04/20/2022] [Accepted: 04/21/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND The United States Armed Services Blood Program (ASBP) faced complex blood supply challenges during two decades of military operations in the U.S. Central Command (CENTCOM) and through an adaptive, responsive, and agile system, gained valuable insights on blood product usage in combat casualty care. STUDY DESIGN AND METHODS A retrospective review of blood product introduction and utilization trends was compiled from ASBP data collected during CENTCOM operations from 2014 through 2021. RESULTS During the study period, several blood products were introduced to the CENTCOM area of operations including Low Titer O Whole Blood (LTOWB), Cold-Stored Platelets (CSP), Liquid Plasma (LP), and French Freeze Dried Plasma (FDP) manufactured from U.S. sourced donor plasma, all while expanding Walking Blood Bank capabilities. There was a gradual substitution of component therapy for whole blood; blood utilization peaked in 2017. Transfusion of Fresh Whole Blood (FWB) from Walking Blood Banks decreased as fully pre-tested LTOWB was supplied by the ASBP. LTOWB was initially supplied in citrate-phosphate-dextrose (CPD) anticoagulant (21-day shelf life) but was largely replaced with LTOWB in citrate-phosphate-dextrose-adenine (CPDA-1) anticoagulant (35-day shelf life) by 2019. Implementation of prehospital transfusion and expansion of surgical and resuscitation teams led to an increase in the number of sites receiving blood. DISCUSSION ASBP introduced new products to its inventory in order to meet changing blood product demands driven by changes in the Joint Trauma System Clinical Practice Guidelines and operational demands. These products were adopted into clinical practice with a resultant evolution in transfusion strategies.
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Affiliation(s)
- Audra L Taylor
- Armed Services Blood Program Division, Defense Health Agency, Falls Church, Virginia, USA
| | - Jason B Corley
- U.S. Army Medical Command, Army Blood Program, San Antonio, Texas, USA
| | - Andrew P Cap
- Army Institute of Surgical Research Army Blood Program, San Antonio, Texas, USA
| | | | - Erika T Nance
- Armed Services Blood Program Division, Defense Health Agency, Falls Church, Virginia, USA
| | | | - Jennifer M Gurney
- Army Institute of Surgical Research Army Blood Program, San Antonio, Texas, USA
| | | | - Jeffrey C Hebert
- Bureau of Medicine & Surgery, Navy Blood Program, Falls Church, Virginia, USA
| | | | - Karen Royster
- Armed Services Blood Program Division, Defense Health Agency, Falls Church, Virginia, USA
| | - George A Hestilow
- Air Force Medical Readiness Agency, Air Force Blood Program, San Antonio, Texas, USA
| | - Colleen L Cordrick
- Center for Laboratory Medicine Services, Defense Health Agency, Falls Church, Virginia, USA
| | | | | | - Robin Whitacre
- Armed Services Blood Program Division, Defense Health Agency, Falls Church, Virginia, USA
| | - Becky Pederson
- Air Force Medical Readiness Agency, Air Force Blood Program, San Antonio, Texas, USA
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17
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Braverman MA, Smith AA, Ciaraglia AV, Radowsky JS, Schauer SG, Sams VG, Greebon LJ, Shiels MD, Jonas RB, Ngamsuntikul S, Waltman E, Epley E, Rose T, Bynum JA, Cap AP, Eastridge BJ, Stewart RM, Jenkins DH, Nicholson SE. The regional whole blood program in San Antonio, TX: A 3-year update on prehospital and in-hospital transfusion practices for traumatic and non-traumatic hemorrhage. Transfusion 2022; 62 Suppl 1:S80-S89. [PMID: 35748675 DOI: 10.1111/trf.16964] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Revised: 05/16/2022] [Accepted: 05/17/2022] [Indexed: 11/30/2022]
Abstract
Low titer type O Rh-D + whole blood (LTO + WB) has become a first-line resuscitation medium for hemorrhagic shock in many centers around the World. Showing early effectiveness on the battlefield, LTO + WB is used in both the pre-hospital and in-hospital settings for traumatic and non-traumatic hemorrhage resuscitation. Starting in 2018, the San Antonio Whole Blood Collaborative has worked to provide LTO + WB across Southwest Texas, initially in the form of remote damage control resuscitation followed by in-hospital trauma resuscitation. This program has since expanded to include pediatric trauma resuscitation, obstetric hemorrhage, females of childbearing potential, and non-traumatic hemorrhage. The objective of this manuscript is to provide a three-year update on the successes and expansion of this system and outline resuscitation challenges in special populations.
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Affiliation(s)
| | - Allison A Smith
- Department of Surgery, UT Health San Antonio, San Antonio, Texas, USA
| | | | - Jason S Radowsky
- Department of Trauma and Acute Care Surgery, Brooke Army Medical Center, JBSA Fort Sam Houston, San Antonio, Texas, USA
| | - Steven G Schauer
- Department of Emergency Medicine, Brooke Army Medical Center, JBSA Fort Sam Houston, San Antonio, Texas, USA.,United States Army Institute of Surgical Research, JBSA Fort Sam Houston, San Antonio, Texas, USA
| | - Valerie G Sams
- Department of Trauma and Acute Care Surgery, Brooke Army Medical Center, JBSA Fort Sam Houston, San Antonio, Texas, USA
| | - Leslie J Greebon
- Department of Pathology, UT Health San Antonio, San Antonio, Texas, USA
| | | | | | | | | | - Eric Epley
- Southwest Texas Regional Advisory Council, San Antonio, Texas, USA
| | - Tracee Rose
- Southwest Texas Regional Advisory Council, San Antonio, Texas, USA
| | - James A Bynum
- United States Army Institute of Surgical Research, JBSA Fort Sam Houston, San Antonio, Texas, USA
| | - Andre P Cap
- United States Army Institute of Surgical Research, JBSA Fort Sam Houston, San Antonio, Texas, USA
| | - Brian J Eastridge
- Department of Surgery, UT Health San Antonio, San Antonio, Texas, USA
| | - Ronald M Stewart
- Department of Surgery, UT Health San Antonio, San Antonio, Texas, USA
| | - Donald H Jenkins
- Department of Surgery, UT Health San Antonio, San Antonio, Texas, USA
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Abstract
BACKGROUND Military involvement in Afghanistan ended in 2021 and while low intensity troop engagements continue globally, casualty numbers are dwindling. To understand the clinical and operational connections between blood utilization and clinical paradigm shifts in resuscitation strategies, a review of blood product utilization and the changes in the last decade was conducted within the US Central Command area of responsibility (AOR). The intent of this review was to assess patterns of blood use during the last decade of the US's involvement in the most recent major conflicts in order to potentially inform future blood requirements.Study DesignBlood product and types transfused between Jan 1, 2011 and Dec 31, 2020 were acquired from the Medical Situational Awareness in Theater (MSAT) blood reports. All reported blood usage data in the US Central Command area of responsibility were queried. RESULTS Packed red blood cells and fresh frozen plasma usage showed no statistically significant change over time (τb = 0.24, p = 0.3252; τb = -0.47, p = .0603). Fresh and stored whole blood use increased overtime (τb = 0.69, p = 0.0056; τb = 0.83, p = 0.0015). A strong inverse relationship was found between SWB and FFP usage (r = -0.68, p = .0309) and LP and FFP usage (r = -0.65, p = 0.0407) over time. CONCLUSION Whole blood usage increased significantly over time with a preference for stored whole blood. Component therapy is anticipated to remain a critical element of resuscitation in the event of large-scale combat operations secondary to supply chain and longer storage times. LEVEL OF EVIDENCE Level III Therapeutic/Care Management.
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19
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Schreiber K, Decouture B, Lafragette A, Chollet S, Bruneau M, Nicollet M, Wittmann C, Gadrat F, Mansour A, Forest-Villegas P, Gauthier O, Touzot-Jourde G. A novel autotransfusion device saving erythrocytes and platelets used in a 72 h survival swine model of surgically induced controlled blood loss. PLoS One 2022; 17:e0260855. [PMID: 35324911 PMCID: PMC8947136 DOI: 10.1371/journal.pone.0260855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Accepted: 11/18/2021] [Indexed: 01/28/2023] Open
Abstract
Background The purpose of this study was to develop a swine model of surgically induced blood loss to evaluate the performances of a new autotransfusion system allowing red blood cells and platelets preservation while collecting, washing and concentrating hemorrhagic blood intraoperatively. Methods Two types of surgically induced blood loss were used in 12 minipigs to assess system performance and potential animal complications following autotransfusion: a cardiac model (cardiopulmonary bypass) and a visceral model (induced splenic bleeding). Animal clinical and hematological parameters were evaluated at different time-points from before bleeding to the end of a 72-hour post-transfusion period and followed by a post-mortem examination. System performances were evaluated by qualitative and quantitative parameters. Results All animals that received the autotransfusion survived. Minimal variations were seen on the red blood cell count, hemoglobin, hematocrit at the different sampling times. Coagulation tests failed to show any hypo or hypercoagulable state. Gross and histologic examination didn’t reveal any thrombotic lesions. Performance parameters exceeded set objectives in both models: heparin clearance (≥ 90%), final heparin concentration (≤ 0.5 IU/mL), free hemoglobin washout (≥ 90%) and hematocrit (between 45% and 65%). The device treatment rate of diluted blood was over 80 mL/min. Conclusions In the present study, both animal models succeeded in reproducing clinical conditions of perioperative cardiac and non-cardiac blood loss. Sufficient blood was collected to allow evaluation of autotransfusion effects on animals and to demonstrate the system performance by evaluating its capacity to collect, wash and concentrate red blood cells and platelets. Reinfusion of the treated blood, containing not only concentrated red blood cells but also platelets, did not lead to any postoperative adverse nor thrombogenic events. Clinical and comparative studies need to be conducted to confirm the clinical benefit of platelet reinfusion.
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Affiliation(s)
- Kévin Schreiber
- CRIP, Center for research and preclinical investigation, Oniris Nantes Atlantic College of Veterinary Medicine, Food Science and Engineering, Nantes, France
| | | | - Audrey Lafragette
- CRIP, Center for research and preclinical investigation, Oniris Nantes Atlantic College of Veterinary Medicine, Food Science and Engineering, Nantes, France
| | | | | | | | | | | | - Alexandre Mansour
- CHU Rennes, Department of Anesthesiology Critical Care Medicine and Perioperative Medicine, Inserm CIC 1414 (Centre d’Investigation Clinique de Rennes), Université de Rennes, Rennes, France
| | | | - Olivier Gauthier
- CRIP, Center for research and preclinical investigation, Oniris Nantes Atlantic College of Veterinary Medicine, Food Science and Engineering, Nantes, France
- INSERM, UMRS 1229 RMeS (Regenerative Medecine and Skeleton), University of Nantes, ONIRIS, Nantes, France
| | - Gwenola Touzot-Jourde
- CRIP, Center for research and preclinical investigation, Oniris Nantes Atlantic College of Veterinary Medicine, Food Science and Engineering, Nantes, France
- INSERM, UMRS 1229 RMeS (Regenerative Medecine and Skeleton), University of Nantes, ONIRIS, Nantes, France
- * E-mail:
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20
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Muñoz C, Macia C, Hernández E, Alcalá M, Guzmán-Rodríguez M, Orlas C, Caicedo Y, García A, Parra M, Ordóñez C. Sangre total leucorreducida y filtro ahorrador de plaquetas preserva su función hemostática por 21 días: ¿La resucitación hemostática podría ser una realidad en Colombia? REVISTA COLOMBIANA DE CIRUGÍA 2022. [DOI: 10.30944/20117582.1157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Introducción. La resucitación hemostática es una estrategia para compensar la pérdida sanguínea y disminuir el impacto de la coagulación inducida por trauma. Debido a que la disponibilidad de transfundir una razón equilibrada de hemocomponentes es difícil de lograr en el entorno clínico, la sangre total ha reaparecido como una estrategia fisiológica, con ventajas logísticas, que le permiten ser accesible para iniciar tempranamente la resucitación hemostática. El objetivo de este estudio fue evaluar las propiedades celulares, coagulantes y viscoelásticas de la sangre total almacenada por 21 días.
Métodos. Las unidades de sangre total fueron obtenidas de 20 donantes voluntarios sanos. Se procesaron mediante un sistema de leucorreducción ahorrador de plaquetas y fueron almacenadas en refrigeración (1-6°C) sin agitación. Se analizaron los días 0, 6, 11 y 21. Las bolsas fueron analizadas para evaluar las líneas celulares, niveles de factores de coagulación y propiedades viscoelásticas mediante tromboelastografía.
Resultados. El conteo eritrocitario y la hemoglobina se mantuvieron estables. El conteo de plaquetas tuvo una reducción del 50 % al sexto día, pero se mantuvo estable el resto del seguimiento. Los factores de coagulación II-V-VII-X, fibrinógeno y proteína C se mantuvieron dentro del rango normal. La tromboelastografía mostró una prolongación en el tiempo del inicio de la formación del coágulo, pero sin alterar la formación final de un coágulo estable.
Conclusiones. La sangre total leucorreducida y con filtro ahorrador de plaquetas conserva sus propiedades hemostáticas por 21 días. Este es el primer paso en Colombia para la evaluación clínica de esta opción, que permita hacer una realidad universal la resucitación hemostática del paciente con trauma severo.
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Gurney JM, Staudt AM, Del Junco DJ, Shackelford SA, Mann-Salinas EA, Cap AP, Spinella PC, Martin MJ. Whole blood at the tip of the spear: A retrospective cohort analysis of warm fresh whole blood resuscitation versus component therapy in severely injured combat casualties. Surgery 2022; 171:518-525. [PMID: 34253322 DOI: 10.1016/j.surg.2021.05.051] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 05/26/2021] [Accepted: 05/31/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Death from uncontrolled hemorrhage occurs rapidly, particularly among combat casualties. The US military has used warm fresh whole blood during combat operations owing to clinical and operational exigencies, but published outcomes data are limited. We compared early mortality between casualties who received warm fresh whole blood versus no warm fresh whole blood. METHODS Casualties injured in Afghanistan from 2008 to 2014 who received ≥2 red blood cell containing units were reviewed using records from the Joint Trauma System Role 2 Database. The primary outcome was 6-hour mortality. Patients who received red blood cells solely from component therapy were categorized as the non-warm fresh whole blood group. Non- warm fresh whole blood patients were frequency-matched to warm fresh whole blood patients on identical strata by injury type, patient affiliation, tourniquet use, prehospital transfusion, and average hourly unit red blood cell transfusion rates, creating clinically unique strata. Multilevel mixed effects logistic regression adjusted for the matching, immortal time bias, and other covariates. RESULTS The 1,105 study patients (221 warm fresh whole blood, 884 non-warm fresh whole blood) were classified into 29 unique clinical strata. The adjusted odds ratio of 6-hour mortality was 0.27 (95% confidence interval 0.13-0.58) for the warm fresh whole blood versus non-warm fresh whole blood group. The reduction in mortality increased in magnitude (odds ratio = 0.15, P = .024) among the subgroup of 422 patients with complete data allowing adjustment for seven additional covariates. There was a dose-dependent effect of warm fresh whole blood, with patients receiving higher warm fresh whole blood dose (>33% of red blood cell-containing units) having significantly lower mortality versus the non-warm fresh whole blood group. CONCLUSION Warm fresh whole blood resuscitation was associated with a significant reduction in 6-hour mortality versus non-warm fresh whole blood in combat casualties, with a dose-dependent effect. These findings support warm fresh whole blood use for hemorrhage control as well as expanded study in military and civilian trauma settings.
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Affiliation(s)
- Jennifer M Gurney
- US Army Institute of Surgical Research, San Antonio, TX; Joint Trauma System, San Antonio, TX; Uniformed Services University of the Health Sciences, Bethesda, MD.
| | | | | | - Stacy A Shackelford
- Joint Trauma System, San Antonio, TX; Uniformed Services University of the Health Sciences, Bethesda, MD
| | | | - Andrew P Cap
- US Army Institute of Surgical Research, San Antonio, TX; Uniformed Services University of the Health Sciences, Bethesda, MD
| | - Philip C Spinella
- Department of Surgery, Washington University School of Medicine, St. Louis, MO
| | - Matthew J Martin
- Uniformed Services University of the Health Sciences, Bethesda, MD; Department of Surgery, Scripps Mercy Hospital, San Diego, CA. https://twitter.com/docmartin22
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22
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Thrombin Generation in Trauma Patients: How Do we Navigate Through Scylla and Charybdis? CURRENT ANESTHESIOLOGY REPORTS 2022. [DOI: 10.1007/s40140-021-00502-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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23
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Divers TJ, Radcliffe RM, Cook VL, Bookbinder LC, Hurcombe SDA. Calculating and selecting fluid therapy and blood product replacements for horses with acute hemorrhage. J Vet Emerg Crit Care (San Antonio) 2022; 32:97-107. [PMID: 35044062 DOI: 10.1111/vec.13127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2017] [Revised: 08/14/2017] [Accepted: 10/17/2017] [Indexed: 11/30/2022]
Abstract
BACKGROUND Blood products, crystalloids, and colloid fluids are used in the medical treatment of severe hemorrhage in horses with a goal of providing sufficient blood flow and oxygen delivery to vital organs. The fluid treatments for hemorrhage will vary depending upon severity and duration and whether hemorrhage is controlled or uncontrolled. DESCRIPTION With acute and severe controlled hemorrhage, treatment is focused on rapidly increasing perfusion pressure and blood flow to vital organs. This can most easily be accomplished in field cases by the administration of hypertonic saline. If isotonic crystalloids are used for resuscitation, the volume administered should be at least as great as the estimated blood loss. Following crystalloid resuscitation, clinical signs, HCT, and laboratory evidence of tissue hypoxia may help determine the need for a whole blood transfusion. In uncontrolled hemorrhage, crystalloid resuscitation is often more conservative and is referred to as "permissive hypotension." The goal of "permissive hypotension" would be to provide enough perfusion pressure to vital organs such that function is maintained while keeping blood pressure below the normal range in the hope that clot formation will not be disrupted. Whole blood and fresh frozen plasma in addition to aminocaproic acid are indicated in most horses with severe uncontrolled hemorrhage. SUMMARY Blood transfusion is a life-saving treatment for severe hemorrhage in horses. No precise HCT serves as a transfusion trigger; however, an HCT < 15%, lack of appropriate clinical response, or significant improvement in plasma lactate following crystalloid resuscitation and loss of 25% or more of blood volume is suggestive of the need for whole blood transfusion. Mathematical formulas may be used to estimate the amount of blood required for transfusion following severe but controlled hemorrhage, but these are not very accurate and, in practice, transfusion volume should be approximately 40% of estimated blood loss. KEY POINTS Modest hemorrhage, <15% of blood volume (<12 mL/kg), can be fully compensated by physiological mechanisms and generally does not require fluid or blood product therapy. More severe hemorrhage, >25% of blood volume (> 20 mL/kg), often requires crystalloid or blood product replacement, while acute loss of greater than 30% (>24 mL/kg) of blood volume may result in hemorrhagic shock requiring resuscitation treatments Uncontrolled hemorrhage is a common occurrence in equine practice, and is most commonly associated with abdominal bleeding (eg, uterine artery rupture in mares). If the hemorrhage can be controlled such as by ligation of a bleeding vessel, then initial efforts to resuscitate the horse should focus on increasing perfusion pressure and blood flow to organs as quickly as possible with crystalloids or colloids while assessing need for whole blood transfusion. While fluid therapy is being administered every effort to physically control hemorrhage should be made using ligatures, application of compression, surgical methods, and local hemostatic agents like collagen-, gelatin-, and cellulose-based products, fibrin, yunnan baiyao (YB), and synthetic glues Although some synthetic colloids have been shown to be associated with acute kidney injury in people receiving resuscitation therapy,20 this undesirable effect in horses has not been reported.
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Affiliation(s)
- Thomas J Divers
- Department of Clinical Sciences, College of Veterinary Medicine, Cornell University, Ithaca, New York, USA
| | - Rolfe M Radcliffe
- Department of Clinical Sciences, College of Veterinary Medicine, Cornell University, Ithaca, New York, USA
| | - Vanessa L Cook
- Department of Large Animal Clinical Sciences, College of Veterinary Medicine, Michigan State University, East Lansing, Michigan, USA
| | - Lauren C Bookbinder
- Department of Clinical Sciences, College of Veterinary Medicine, Cornell University, Ithaca, New York, USA
| | - Samuel D A Hurcombe
- Emergency Surgery and Medicine, Cornell Ruffian Equine Specialists, Elmont, New York, USA
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24
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Heuft HG, Yazer MH. Recent Developments in Emergency Blood Transfusion. Transfus Med Hemother 2021; 48:321-323. [PMID: 35082562 PMCID: PMC8740188 DOI: 10.1159/000520010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Accepted: 10/01/2021] [Indexed: 11/19/2022] Open
Affiliation(s)
- Hans-Gert Heuft
- Institute for Transfusion Medicine and Immunohaematology, University Hospital Magdeburg, Magdeburg, Germany
| | - Mark H. Yazer
- Department of Pathology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Department of Pathology, Tel Aviv University, Tel Aviv, Israel
- Department of Clinical Immunology, University of Southern Denmark, Odense, Denmark
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25
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Yazer MH, Spinella PC, Bank EA, Cannon JW, Dunbar NM, Holcomb JB, Jackson BP, Jenkins D, Levy M, Pepe PE, Sperry JL, Stubbs JR, Winckler CJ. THOR-AABB Working Party Recommendations for a Prehospital Blood Product Transfusion Program. PREHOSP EMERG CARE 2021; 26:863-875. [PMID: 34669564 DOI: 10.1080/10903127.2021.1995089] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
The evidence for the lifesaving benefits of prehospital transfusions is increasing. As such, emergency medical services (EMS) might increasingly become interested in providing this important intervention. While a few EMS and air medical agencies have been providing exclusively red blood cell (RBC) transfusions to their patients for many years, transfusing plasma in addition to the RBCs, or simply using low titer group O whole blood (LTOWB) in place of two separate components, will be a novel experience for many services. The recommendations presented in this document were created by the Trauma, Hemostasis and Oxygenation Research (THOR)-AABB (formerly known as the American Association of Blood Banks) Working Party, and they are intended to provide a framework for implementing prehospital blood transfusion programs in line with the best available evidence. These recommendations cover all aspects of such a program including storing, transporting, and transfusing blood products in the prehospital phase of hemorrhagic resuscitation.
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Himmler A, Galarza Armijos ME, Naranjo JR, Patiño SGP, Sarmiento Altamirano D, Lazo NF, Pino Andrade R, Aguilar HS, Fernández de Córdova L, Augurto CC, Raykar N, Puyana JC, Salamea JC. Is the whole greater than the sum of its parts? The implementation and outcomes of a whole blood program in Ecuador. Trauma Surg Acute Care Open 2021; 6:e000758. [PMID: 34869909 PMCID: PMC8603278 DOI: 10.1136/tsaco-2021-000758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Accepted: 08/21/2021] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Hemorrhagic shock is a major cause of mortality in low-income and middle-income countries (LMICs). Many institutions in LMICs lack the resources to adequately prescribe balanced resuscitation. This study aims to describe the implementation of a whole blood (WB) program in Latin America and to discuss the outcomes of the patients who received WB. METHODS We conducted a retrospective review of patients resuscitated with WB from 2013 to 2019. Five units of O+ WB were made available on a consistent basis for patients presenting in hemorrhagic shock. Variables collected included gender, age, service treating the patient, units of WB administered, units of components administered, admission vital signs, admission hemoglobin, shock index, Revised Trauma Score in trauma patients, intraoperative crystalloid (lactated Ringer's or normal saline) and colloid (5% human albumin) administration, symptoms of transfusion reaction, length of stay, and in-hospital mortality. RESULTS The sample includes a total of 101 patients, 57 of which were trauma and acute care surgery patients and 44 of which were obstetrics and gynecology patients. No patients developed symptoms consistent with a transfusion reaction. The average shock index was 1.16 (±0.55). On average, patients received 1.66 (±0.80) units of WB. Overall mortality was 13.86% (14 of 101) in the first 24 hours and 5.94% (6 of 101) after 24 hours. DISCUSSION Implementing a WB protocol is achievable in LMICs. WB allows for more efficient delivery of hemostatic resuscitation and is ideal for resource-restrained settings. To our knowledge, this is the first description of a WB program implemented in a civilian hospital in Latin America. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Amber Himmler
- Department of Surgery, MedStar Georgetown University Hospital, Washington DC, District of Columbia, USA
| | - Monica Eulalia Galarza Armijos
- Department of Surgery, Hospital Vicente Corral Moscoso Cuenca, Cuenca, Ecuador
- College of Medicine, Universidad de Cuenca, Cuenca, Ecuador
| | - Jeovanni Reinoso Naranjo
- Department of Surgery, Hospital Vicente Corral Moscoso Cuenca, Cuenca, Ecuador
- College of Medicine, Universidad de Cuenca, Cuenca, Ecuador
| | | | - Doris Sarmiento Altamirano
- College of Medicine, University of Azuay, Cuenca, Ecuador
- Department of Surgery, Hospital Jose Carrasco Arteaga, Cuenca, Ecuador
| | - Nube Flores Lazo
- Department of Surgery, Hospital Vicente Corral Moscoso Cuenca, Cuenca, Ecuador
- College of Medicine, Universidad de Cuenca, Cuenca, Ecuador
| | - Raul Pino Andrade
- Department of Surgery, Hospital Vicente Corral Moscoso Cuenca, Cuenca, Ecuador
- College of Medicine, Universidad de Cuenca, Cuenca, Ecuador
| | - Hernán Sacoto Aguilar
- Department of Surgery, Hospital Vicente Corral Moscoso Cuenca, Cuenca, Ecuador
- College of Medicine, Universidad de Azuay, Cuenca, Ecuador
| | - Lenin Fernández de Córdova
- Department of Surgery, Hospital Vicente Corral Moscoso Cuenca, Cuenca, Ecuador
- College of Medicine, Universidad Católica de Cuenca, Cuenca, Ecuador
| | - Cecibel Cevallos Augurto
- Department of Surgery, Hospital Vicente Corral Moscoso Cuenca, Cuenca, Ecuador
- College of Medicine, Universidad de Cuenca, Cuenca, Ecuador
| | - Nakul Raykar
- Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Juan Carlos Puyana
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Juan Carlos Salamea
- Department of Surgery, Hospital Vicente Corral Moscoso Cuenca, Cuenca, Ecuador
- College of Medicine, Universidad de Azuay, Cuenca, Ecuador
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Abstract
Transfusion of whole blood largely was replaced by component therapy in the 1970s and 1980s. The recent military operations in Iraq and Afghanistan returned whole blood to military trauma care. Eventually, whole blood use was incorporated into some civilian trauma care. It has been utilized in several other civilian populations as well. Trials to compare whole blood to component therapy are ongoing.
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Affiliation(s)
- Elizabeth A Godbey
- Department of Pathology, Virginia Commonwealth University Health, Richmond, VA, USA.
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Blood, balloons, and blades: State of the art trauma resuscitation. Am J Surg 2021; 224:40-44. [PMID: 34715985 DOI: 10.1016/j.amjsurg.2021.10.033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 10/08/2021] [Indexed: 11/24/2022]
Abstract
Traumatic injury remains the leading cause of death in patients 45 and younger. State of the art trauma care requires rapid interventions to provide hemodynamic support en route to definitive hemostasis. This article will review three critical elements in management of the bleeding trauma patient: blood products, resuscitative endovascular balloon occlusion of the aorta (REBOA), and the trauma hybrid operating room (THOR).
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Asif M, Hasan RA, Liu Z, Stansbury LG, Hess JR. Cold-stored whole blood and platelet counts in severe acute injury: A comparison of four retrospective cohorts. Transfusion 2021; 61:3321-3327. [PMID: 34633665 DOI: 10.1111/trf.16699] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 09/22/2021] [Accepted: 09/23/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Low-titer group O whole blood (LTOWB) is attractive for acute trauma care as it delivers concentrated and balanced hemostatic resuscitation in single large bags. Whether cold-stored LTOWB can sustain platelet counts is unclear. STUDY DESIGN AND METHODS Four cohorts of trauma patients-three historic, one retrospective-were identified by their urgency of blood use. Admission and all subsequent platelet counts over the first 24 h of care were compared with t-tests. The cohorts were as follows: 1292 patients at Maryland Shock Trauma as described by Stansbury and colleagues in 2013; 35 patients enrolled locally in the 1:1:2 arm of the pragmatic randomized optimal plasma and platelet ratios (PROPPR) trial; 34 patients enrolled locally in the 1:1:1 arm of PROPPR; and 59 patients receiving more than 3 units of LTOWB enroute to or at our Level 1 trauma center, 2019-2020. RESULTS Mean age of LTOWB units transfused was 9 ± 5 days and mean dose was 5 ± 2 units. All four cohorts were profoundly injured (mean Injury Severity Score ≥ 31), with mean first platelet counts 204-228 K/μ and subsequent counts approximately 100 k/μl lower. Through the first 24 h of care, mean platelet counts decreased least, 79 and 83 103 /μl, in the 1:1:1 PROPPR and LTOWB cohorts. Mean platelet counts in patients transfused with LTOWB remained stable after the third hour of care. DISCUSSION LTOWB transfusion was associated with lesser mean decrease in platelet counts during the first 24 h after injury, similar to those observed among patients receiving components 1:1:1 component in the PROPPR study.
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Affiliation(s)
- Maryam Asif
- Transfusion Medicine Fellowship, Bloodworks Northwest, Seattle, Washington, USA
| | - Rida A Hasan
- Transfusion Medicine Fellowship, Bloodworks Northwest, Seattle, Washington, USA
| | - Zhinan Liu
- Trauma Transfusion Research, Harborview Injury Prevention Research Center, Harborview Medical Center, Seattle, Washington, USA
| | - Lynn G Stansbury
- Trauma Transfusion Research, Harborview Injury Prevention Research Center, Harborview Medical Center, Seattle, Washington, USA.,Department of Anesthesia and Pain Medicine, University of Washington School of Medicine, Seattle, Washington, USA
| | - John R Hess
- Department of Laboratory Medicine and Pathology, University of Washington School of Medicine, Seattle, Washington, USA
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Lunde THF, Hartson L, Bailey SL, Hervig TA. In vitro characteristics and in vivo platelet quality of whole blood treated with riboflavin and UVA/UVB light and stored for 24 hours at room temperature. Transfusion 2021; 61 Suppl 1:S101-S110. [PMID: 34269459 DOI: 10.1111/trf.16500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 03/08/2021] [Accepted: 03/12/2021] [Indexed: 12/01/2022]
Abstract
BACKGROUND There is a global increase in whole blood usage and at the same time, emerging pathogens give cause for pathogen reduction technology (PRT). The Mirasol PRT has shown promising results for plasma and platelet concentrate products. Treatment of whole blood with subsequent platelet survival and recovery analysis would be of global value. STUDY DESIGN AND METHODS A two-arm, open-label laboratory study was performed with 40 whole blood collections in four groups: non-leukoreduced non-PRT-treated, non-leukoreduced PRT-treated, leukoreduced non-PRT-treated, and leukoreduced PRT-treated. Leukoreduction and/or PRT-treatment was performed on the day of collection, then all WB units were stored at room temperature for 24 h. Sampling was performed after hold-time and after 24-h storage in RT. If PRT-treatment or leukoreduction, samples were also taken subsequently after treatment. Thirteen healthy volunteer blood donors completed the in vivo study per protocol. All WB units were non-leukoreduced and PRT-treated. Radioactive labeling of platelets from RT-stored, PRT-treated whole blood, sampling of subjects, recovery, and survival calculations were performed according to the Biomedical Excellence for Safer Transfusion Collaborative protocol. RESULTS In vitro characteristics show that PRT-treatment leads to increased levels of hemolysis, potassium, and lactate, while there are decreased levels of glucose, FVIII, and fibrinogen after 24 h of storage. All values are within requirements for WB. In vivo recovery and survival of platelets were 85.4% and 81.3% of untreated fresh control, respectively. CONCLUSIONS PRT-treatment moderately reduces whole blood quality but is well within the limits of international guidelines. Recovery and survival of platelets are satisfactory after Mirasol treatment.
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Affiliation(s)
- Turid Helen Felli Lunde
- Department of Immunology and Transfusion Medicine, Haukeland University Hospital, Bergen, Norway
| | | | - Shawn Lawrence Bailey
- Platelet Transfusion Research Laboratory, Bloodworks Northwest Research Institute, Seattle, Washington, USA
| | - Tor Audun Hervig
- Department of Immunology and Transfusion Medicine, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Science, University of Bergen, Bergen, Norway
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31
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Bates M, Watts S, Doughty H, Woolley T, Miles A, Barry L, Jenner D, Sedman A, Purcell R, Kirkman E. Effect of parachute delivery on red blood cell (RBC) and plasma quality measures of blood for transfusion. Transfusion 2021; 61 Suppl 1:S223-S233. [PMID: 34269457 PMCID: PMC9290599 DOI: 10.1111/trf.16501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2021] [Revised: 02/24/2021] [Accepted: 02/24/2021] [Indexed: 11/29/2022]
Abstract
Background Parachute airdrop offers a rapid transfusion supply option for humanitarian aid and military support. However, its impact on longer‐term RBC survival is undocumented. This study aimed to determine post‐drop quality of RBCs in concentrates (RCC), and both RBCs and plasma in whole blood (WB) during subsequent storage. Study design and methods Twenty‐two units of leucodepleted RCC in saline, adenine, glucose, mannitol (SAGM) and 22 units of nonclinical issue WB were randomly allocated for air transportation, parachute drop, and subsequent storage (parachute), or simply storage under identical conventional conditions (4 ± 2°C) (control). All blood products were 6–8 days post‐donation. Parachute units were packed into Credo Cubes, (Series 4, 16 L) inside a PeliCase (Peli 0350) and rigged as parachute delivery packs. Packs underwent a 4‐h tactical flight (C130 aircraft), then parachuted from 250 to 400 ft before ground recovery. The units were sampled aseptically before and after airdrop at weekly intervals. A range of assays quantified the RBC storage lesion and coagulation parameters. Results Blood units were maintained at 2–6°C and recovered intact after recorded ground impacts of 341–1038 m s−2. All units showed a classical RBC storage lesion and increased RBC microparticles during 42 days of storage. Fibrinogen and clotting factors decreased in WB during storage. Nevertheless, no significant difference was observed between Control and Parachute groups. Air transportation and parachute delivery onto land did not adversely affect, or shorten, the shelf life of fresh RBCs or WB. Discussion Appropriately packaged aerial delivery by parachute can be successfully used for blood supply.
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Affiliation(s)
- Mark Bates
- CBR Division, Dstl Porton Down, Salisbury, UK
| | - Sarah Watts
- CBR Division, Dstl Porton Down, Salisbury, UK
| | - Heidi Doughty
- NIHR Surgical Reconstruction and Microbiology Research Centre, Institute of Translational Medicine, Birmingham, UK.,NHS Blood and Transplant, Birmingham, UK
| | - Tom Woolley
- Academic Department of Military Anaesthesia and Critical Care, Royal Centre for Defence Medicine, Birmingham, UK
| | - Andrew Miles
- Centre of Defence Pathology, Royal Centre for Defence Medicine, Birmingham, UK
| | - Liam Barry
- Centre of Defence Pathology, Royal Centre for Defence Medicine, Birmingham, UK
| | | | - Andrew Sedman
- Platform Systems Division, Dstl Porton Down, Salisbury, UK
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Kolodziej JH, Leonard JC, Josephson CD, Gaines BA, Wisniewski SR, Yazer MH, Spinella PC. Survey to inform trial of low-titer group O whole-blood compared to conventional blood components for children with severe traumatic bleeding. Transfusion 2021; 61 Suppl 1:S43-S48. [PMID: 34269453 DOI: 10.1111/trf.16460] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2021] [Accepted: 02/08/2021] [Indexed: 01/01/2023]
Abstract
BACKGROUND Low-titer group O whole-blood (LTOWB) is being used for children with life-threatening traumatic bleeding. A survey was conducted to determine current LTOWB utilization and interest in participation in a randomized control trial (RCT) of LTOWB versus standard blood component transfusion in this population. STUDY DESIGN AND METHODS Transfusion medicine (TM) directors and pediatric trauma directors at 36 US children's hospitals were surveyed by e-mail in June 2020. Hospitals were selected by participation in the Massive Transfusion Epidemiology and Outcomes in Children Study or being among the largest 30 children's hospitals by bed capacity per the Becker Hospital Review. RESULTS The response rate was 83.3% (30/36) from TM directors and 88.9% (32/36) from trauma directors. The median of massive transfusion protocol activations for traumatic bleeding was reported as 12 (IQR 5.8-20) per year by TM directors. LTOWB was used by 18.8% (6/32) of trauma directors. Survey responses indicate that 86.7% (26/30) of TM directors and 90.6% (29/32) of trauma directors either moderately or strongly agree that a LTOWB RCT is important to perform. About 83.3% (25/30) of TM directors and 93.8% (30/32) of trauma directors were willing to participate in the proposed trial. About 80% (24/30) of TM directors and 71.9% (23/32) of trauma directors would transfuse RhD+ LTOWB to male children, but fewer would transfuse Rh + LTOWB to females [20% (6/30) TM directors and 37.5% (12/32) of trauma directors]. CONCLUSIONS A majority of respondents supported an RCT comparing LTOWB to component therapy in children with severe traumatic bleeding.
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Affiliation(s)
- Julia H Kolodziej
- Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Julie C Leonard
- Division of Pediatric Emergency Medicine, Department of Pediatrics, The Ohio State University and Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Cassandra D Josephson
- Department of Pathology and Laboratory Medicine, Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Barbara A Gaines
- Division of Pediatric Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | | | - Mark H Yazer
- Division of Transfusion Medicine, Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Philip C Spinella
- Division of Critical Care Medicine, Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri, USA
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Carmichael SP, Lin N, Evangelista ME, Holcomb JB. The Story of Blood for Shock Resuscitation: How the Pendulum Swings. J Am Coll Surg 2021; 233:644-653. [PMID: 34390843 DOI: 10.1016/j.jamcollsurg.2021.08.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Revised: 08/01/2021] [Accepted: 08/02/2021] [Indexed: 11/18/2022]
Abstract
Whole blood transfusion (WBT) began in 1667 as a treatment for mental illness with predictably poor results. Its therapeutic utility and widespread use were initially limited by deficiencies in transfusion science and antisepsis. James Blundell, a British obstetrician, was recognized for the first allotransfusion in 1825. However, WBT did not become safe and therapeutic until the early 20th century with the advent of reliable equipment, sterilization and blood typing. The discovery of citrate preservation in World War I allowed a separation of donor from recipient and introduced the practice of blood banking. During World War II, Elliott and Strumia were the first to separate whole blood into blood component therapy (BCT), producing dried plasma as a resuscitative product for "traumatic shock". During the 1970s, infectious disease, blood fractionation and financial opportunities further drove the change from WBT to BCT with little supporting data. Following a period of high-volume crystalloid and BCT resuscitation well into the early 2000's, measures to avoid the resulting iatrogenic resuscitation injury were developed under the concept of damage control resuscitation. Modern transfusion strategies for hemorrhagic shock target balanced BCT to reapproximate whole blood. Contemporary research has expanded the role of WBT to therapy for the acute coagulopathy of trauma and the damaged endothelium. Many US trauma centers are now using WBT as a front-line treatment in tandem with BCT for patients suffering hemorrhagic shock. Looking ahead, it is likely that WBT will once again be the resuscitative fluid of choice for patients in hemorrhagic shock.
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Affiliation(s)
- Samuel P Carmichael
- Department of Surgery, Wake Forest University School of Medicine, Winston-Salem, NC.
| | - Nicholas Lin
- Department of Surgery, Wake Forest University School of Medicine, Winston-Salem, NC
| | - Meagan E Evangelista
- Department of Surgery, Wake Forest University School of Medicine, Winston-Salem, NC
| | - John B Holcomb
- University of Alabama at Birmingham School of Medicine, Birmingham, AL
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Richards JE, Jackson BP. Whole blood for trauma patients: Outcomes at higher doses. Transfusion 2021; 61:1661-1664. [PMID: 34142730 DOI: 10.1111/trf.16446] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Accepted: 05/07/2021] [Indexed: 12/21/2022]
Affiliation(s)
- Justin E Richards
- Department of Anesthesiology, University of Maryland School of Medicine. Baltimore, Maryland
| | - Bryon P Jackson
- Department of Pathology, University of Maryland School of Medicine. Baltimore, Maryland
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35
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Resuscitation of the Traumatically Injured Patient. Crit Care Nurs Clin North Am 2021; 33:245-261. [PMID: 34340788 DOI: 10.1016/j.cnc.2021.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Trauma is a leading cause of death. Optimal outcomes depend on a coordinated effort. Providers must be prepared to act in an organized and methodical manner. Recognizing and immediately treating causes of shock after trauma offer the best chance of survival to the patient. Incorporating evidence-based knowledge and resuscitation techniques learned from the military, the trauma victim experiencing acute hypovolemia has better outcomes because of advances in the clinical management of blood loss than ever before. Treatment focuses primarily on stopping the bleeding, providing damage control resuscitation, and monitoring and treating the patient for signs of shock. If the patient can be stabilized and avoid the lethal trauma triad, definitive surgical care can be achieved.
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36
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Khurrum M, Ditillo M, Obaid O, Anand T, Nelson A, Chehab M, Kitts DJ, Douglas M, Bible L, Joseph B. Four-factor prothrombin complex concentrate in adjunct to whole blood in trauma-related hemorrhage: Does whole blood replace the need for factors? J Trauma Acute Care Surg 2021; 91:34-39. [PMID: 33843830 DOI: 10.1097/ta.0000000000003184] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The use of whole blood (WB) for the treatment of hemorrhagic shock and coagulopathy is increasing in civilian trauma patients. Four-factor prothrombin complex concentrate (4-PCC) in adjunct to component therapy showed improved outcomes in trauma patients. Our study aims to evaluate the outcomes of trauma patients who received 4-PCC and WB (4-PCC-WB) compared with WB alone. METHODS We performed a 3-year (2015-2017) analysis of the American College of Surgeons-Trauma Quality Improvement Program database. All adult (age, ≥18 years) trauma patients who received WB were included. We excluded patients who were on preinjury anticoagulants. Patients were stratified into two groups, 4-PCC-WB versus WB alone, and matched in a 1:2 ratio using propensity score matching. Outcome measures were packed red blood cells, plasma, platelets, and cryoprecipitate transfused, in-hospital complications, hospital and intensive care unit (ICU) length of stay (LOS) among survivors, and mortality. RESULTS A total of 252 patients (4-PCC-WB, 84; WB alone, 168) were matched. The mean ± SD age was 47 ± 21 years, 63% were males, median Injury Severity Score was 30 (21-40), and 87% had blunt injuries. Patients who received 4-PCC-WB had decreased requirement for packed red blood cell (8 U vs. 10 U, p = 0.04) and fresh frozen plasma (6 U vs. 8 U, p = 0.01) transfusion, lower rates of acute kidney injury (p = 0.03), and ICU LOS (5 days vs. 8 days, p = 0.01) compared with WB alone. There was no difference in the platelet transfusion (p = 0.19), cryoprecipitate transfusion (p = 0.37), hospital LOS (p = 0.72), and in-hospital mortality (p = 0.72) between the two groups. CONCLUSION Our study demonstrates that the use of 4-PCC as an adjunct to WB is associated with a reduction in transfusion requirements and ICU LOS compared with WB alone in the resuscitation of trauma patients. Further studies are required to evaluate the role of PCC with WB in the resuscitation of trauma patients. LEVEL OF EVIDENCE Therapeutic, level III.
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Affiliation(s)
- Muhammad Khurrum
- From the Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, College of Medicine, University of Arizona, Tucson, Arizona
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Biomaterials for human space exploration: A review of their untapped potential. Acta Biomater 2021; 128:77-99. [PMID: 33962071 DOI: 10.1016/j.actbio.2021.04.033] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2020] [Revised: 04/01/2021] [Accepted: 04/15/2021] [Indexed: 02/08/2023]
Abstract
As biomaterial advances make headway into lightweight radiation protection, wound healing dressings, and microbe resistant surfaces, a relevance to human space exploration manifests itself. To address the needs of the human in space, a knowledge of the space environment becomes necessary. Both an understanding of the environment itself and an understanding of the physiological adaptations to that environment must inform design parameters. The space environment permits the fabrication of novel biomaterials that cannot be produced on Earth, but benefit Earth. Similarly, designing a biomaterial to address a space-based challenge may lead to novel biomaterials that will ultimately benefit Earth. This review describes several persistent challenges to human space exploration, a variety of biomaterials that might mitigate those challenges, and considers a special category of space biomaterial. STATEMENT OF SIGNIFICANCE: This work is a review of the major human and environmental challenges facing human spaceflight, and where biomaterials may mitigate some of those challenges. The work is significant because a broad range of biomaterials are applicable to the human space program, but the overlap is not widely known amongst biomaterials researchers who are unfamiliar with the challenges to human spaceflight. Additionaly, there are adaptations to microgravity that mimic the pathology of certain disease states ("terrestrial analogs") where treatments that help the overwhelmingly healthy astronauts can be applied to help those with the desease. Advances in space technology have furthered the technology in that field on Earth. By outlining ways that biomaterials can promote human space exploration, space-driven advances in biomaterials will further biomaterials technology.
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38
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Holcomb JB, Spinella PC, Apelseth TO, Butler FK, Cannon JW, Cap AP, Corley JB, Doughty H, Fitzpatrick M, Goldkind SF, Gurney JM, Homer MJ, Ilstrup SJ, Jansen JO, Jenkins DH, Marques MB, Moore EE, Ness PM, O'Connor KC, Schreiber MA, Shinar E, Sloan S, Strandenes G, Stubbs JR, Taylor AL, Ward KR, Waltman E, Yazer M. Civilian walking blood bank emergency preparedness plan. Transfusion 2021; 61 Suppl 1:S313-S325. [PMID: 34269450 DOI: 10.1111/trf.16458] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Revised: 01/12/2021] [Accepted: 01/14/2021] [Indexed: 12/29/2022]
Abstract
BACKGROUND The current global pandemic has created unprecedented challenges in the blood supply network. Given the recent shortages, there must be a civilian plan for massively bleeding patients when there are no blood products on the shelf. Recognizing that the time to death in bleeding patients is less than 2 h, timely resupply from unaffected locations is not possible. One solution is to transfuse emergency untested whole blood (EUWB), similar to the extensive military experience fine-tuned over the last 19 years. While this concept is anathema in current civilian transfusion practice, it seems prudent to have a vetted plan in place. METHODS AND MATERIALS During the early stages of the 2020 global pandemic, a multidisciplinary and international group of clinicians with broad experience in transfusion medicine communicated routinely. The result is a planning document that provides both background information and a high-level guide on how to emergently deliver EUWB for patients who would otherwise die of hemorrhage. RESULTS AND CONCLUSIONS Similar plans have been utilized in remote locations, both on the battlefield and in civilian practice. The proposed recommendations are designed to provide high-level guidance for experienced blood bankers, transfusion experts, clinicians, and health authorities. Like with all emergency preparedness, it is always better to have a well-thought-out and trained plan in place, rather than trying to develop a hasty plan in the midst of a disaster. We need to prevent the potential for empty shelves and bleeding patients dying for lack of blood.
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Affiliation(s)
- John B Holcomb
- Center for Injury Science, Division of Acute Care Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Philip C Spinella
- Division of Critical Care, Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Torunn Oveland Apelseth
- Department of Immunology and Transfusion Medicine, Haukeland University Hospital, Bergen, Norway
- Norwegian Armed Forces Medical Service, Sessvollmoen, Norway
| | | | - Jeremy W Cannon
- Division of Traumatology, Surgical Critical Care & Emergency Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Andrew P Cap
- Uniformed Services University, Bethesda, Maryland, USA
- US Army Institute of Surgical Research, San Antonio, Texas, USA
- Ft Sam Houston, San Antonio, Texas, USA
| | - Jason B Corley
- Army Blood Program, US Army Medical Command, JBSA - Fort Sam Houston, San Antonio, Texas, USA
| | - Heidi Doughty
- Academic Department of Military Anaesthesia and Critical Care, Royal Centre for Defence Medicine, Birmingham, UK
| | | | | | | | - Mary J Homer
- Division of Chemical, Biological, Radiological, and Nuclear Countermeasures, Biomedical Advanced Research and Development Authority (BARDA), Office of the Assistant Secretary for Preparedness and Response, Department of Health and Human Services, Washington, District of Columbia, USA
| | - Sarah J Ilstrup
- Department of Laboratory Medicine and Pathology, Intermountain Medical Center, Salt Lake City, Utah, USA
| | - Jan O Jansen
- Division of Acute Care Surgery; and Director, Center for Injury Science, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Donald H Jenkins
- Division of Trauma and Emergency Surgery, UT Health, San Antonio, Texas, USA
| | - Marisa B Marques
- Department of Pathology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Eugene E Moore
- Shock Trauma Center at Denver Health, Department of Surgery, University of Colorado Denver, Denver, Colorado, USA
| | - Paul M Ness
- Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Kevin C O'Connor
- George Washington University School of Medicine and Health Sciences, Medical Faculty Associates, Washington, District of Columbia, USA
| | | | | | - Steve Sloan
- Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Geir Strandenes
- Department of Immunology and Transfusion Medicine, Haukeland University Hospital, Bergen, Norway
- Department of War Surgery and Emergency Medicine, Norwegian Armed Forces Medical Services, Oslo, Norway
| | - James R Stubbs
- Transfusion Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Audra L Taylor
- Armed Services Blood Program, Defense Health Agency, Falls Church, Virginia, USA
| | - Kevin R Ward
- George Washington University School of Medicine and Health Sciences, Medical Faculty Associates, Washington, District of Columbia, USA
| | - Elizabeth Waltman
- BioBridge Global, Inc., San Antonio, Texas, USA
- South Texas Blood & Tissue Center, San Antonio, Texas, USA
| | - Mark Yazer
- University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Tel Aviv University, Tel Aviv, Israel
- University of Southern Denmark, Odense, Denmark
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Martinaud C, Scorer T, Lozano M, Miles A, Fitchett G, Ba A, Wikman A, Nimberger-Hansson P, Enbuske S, Bohoněk M, Devine D, Beckett AN, Mbanya D, T'Sas F, Degueldre J, Chueca M, Dedome E, Apelseth T, Strandenes G, Wendel S, Fachini R, Olszewski A, Dupont C, Glassberg E, Shinar E, Taylor AL, Corley JB, Sekaran Nadarajan V, Dunbar N. International Forum on Walking Blood Bank Programmes: Summary. Vox Sang 2021; 116:924-929. [PMID: 33939181 DOI: 10.1111/vox.13101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Accepted: 03/03/2021] [Indexed: 11/30/2022]
Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Nancy Dunbar
- Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
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Schaefer R, Long T, Wampler D, Summers R, Epley E, Waltman E, Eastridge B, Jenkins D. Operationalizing the Deployment of Low-Titer O-Positive Whole Blood Within a Regional Trauma System. Mil Med 2021; 186:391-399. [PMID: 33499434 DOI: 10.1093/milmed/usaa283] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 07/16/2020] [Accepted: 08/24/2020] [Indexed: 12/22/2022] Open
Abstract
INTRODUCTION The implementation of a low-titer O+ whole blood (LTOWB) resuscitation algorithm, particularly in the prehospital environment, has several inherent challenges, including cost, limited and inconsistent supply, and the logistics of cold-chain management. The Southwest Texas Regional Advisory Council has implemented the nation's first multidisciplinary, multi-institutional regional LTOWB program. This research effort was to illustrate the successful deployment of LTOWB within a regional trauma system. MATERIALS AND METHODS A deliberate systems approach to the deployment of LTOWB was used. Tenets of this program included the active management of blood donor sources and blood supply levels to minimize wastage as a result of expiration, maximize product utilization, the use of prehospital transfusion triggers, and efforts to decrease program costs prehospital agencies. A novel LTOWB rotation system was established using the concept of a "rotation site" and "rotation center." Standardized transfusion criteria, a regional approved equipment list, a regional Prehospital Blood Product Transfusion Record, and a robust multilevel communication plan serves as the framework for the program. The San Antonio Whole Blood Consortium was developed to create a consensus driven forum to manage and guide the program. RESULTS From January 2018 to October 2019, LTOWB has been placed at 18 helicopter emergency medical services (HEMS) bases, 12 ground emergency medical service (EMS) agencies, 1 level I trauma center, and 1 level IV trauma center. A total of 450 patients have received a prehospital LTOWB transfusion. Program wide, the wastage rate of LTOWB due to expiration is between 1% and 2%. No complications related to prehospital LTOWB administration have been identified. DISCUSSION This work demonstrates a novel model for the development of a trauma system LTOWB program. The program's implementation augments remote damage control resuscitation strategies and requires the integration and collaboration of a multidisciplinary stakeholder team to optimize efficiency, performance, and safety of the program.
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Affiliation(s)
- Randall Schaefer
- Southwest Texas Regional Advisory Council (STRAC), San Antonio, TX 78227, USA
| | - Tasia Long
- Southwest Texas Regional Advisory Council (STRAC), San Antonio, TX 78227, USA
| | | | - Rena Summers
- Southwest Texas Regional Advisory Council (STRAC), San Antonio, TX 78227, USA
| | - Eric Epley
- Southwest Texas Regional Advisory Council (STRAC), San Antonio, TX 78227, USA
| | - Elizabeth Waltman
- South Texas Blood and Tissue Center (STBTC), San Antonio, TX 7820, USA
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Kaplan A. Preparation, Storage, and Characteristics of Whole Blood, Blood Components, and Plasma Derivatives. Transfus Med 2021. [DOI: 10.1002/9781119599586.ch5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Chae MS, Lee M, Choi MH, Park JU, Park M, Kim YH, Choi H, Joo J, Moon YE. Preemptive intravenous iron therapy versus autologous whole blood therapy for early postoperative hemoglobin level in patients undergoing bimaxillary orthognathic surgery: a prospective randomized noninferiority trial. BMC Oral Health 2021; 21:16. [PMID: 33413311 PMCID: PMC7791750 DOI: 10.1186/s12903-020-01359-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Accepted: 12/09/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Previous studies have reported the efficacy and safety of intravenous (IV) iron therapy during the perioperative period as an alternative and adjunct to allogeneic blood transfusion. Preemptive IV iron therapy provides noninferior hemoglobin levels on postoperative day (POD) 1 compared to autologous whole blood therapy (AWBT) in healthy patients who had undergone bimaxillary orthognathic surgery. METHODS This was a prospective, patient-randomized, noninferiority trial. After excluding 2 patients, 64 patients were divided into two groups: the IV iron therapy group (patients received IV iron infusion 4 weeks before surgery; n = 32) and the AWBT group (2 units of autologous whole blood were collected 4 and 2 weeks before surgery; n = 32). The primary outcome was hemoglobin level on POD 1 and the prespecified noninferiority limit was - 1 g/dL. RESULTS Baseline data were comparable, including hemoglobin and iron levels, between the two groups. Immediately before surgery, the levels of hemoglobin, iron, and ferritin were higher in the IV iron group than in the AWBT group. The mean treatment difference (iron group-whole blood group) in hemoglobin level on POD 1 between the two groups was 0.09 (95% CI = - 0.83 to 1.0). As the lower limit of the 95% CI (- 0.83) was higher than the prespecified noninferiority margin (δ = - 1), noninferiority was established. On POD 2, the hemoglobin level became lower in the iron group, which eventually led to greater requirement of allogeneic blood transfusion compared to the whole blood group. However, the iron group did not require allogeneic blood transfusion during or early after surgery, and the whole blood group showed continuously higher incidence of overt iron deficiency compared to the iron group. CONCLUSION As collection of autologous whole blood caused overt iron loss and anemia before surgery and intraoperative transfusion of whole blood was not able to prevent the occurrence of persistent iron deficiency after surgery, IV iron therapy was found to have potential benefits for iron homeostasis and subsequent erythropoiesis in healthy patients early after bimaxillary orthognathic surgery. TRIAL REGISTRATION Clinical Research Information Service, Republic of Korea, approval number: KCT0003680 on March 27, 2019. https://cris.nih.go.kr/cris/search/search_result_st01_kren.jsp?seq=15769&sLeft=2<ype=my&rtype=my .
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Affiliation(s)
- Min Suk Chae
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222, Banpo-daero, Seocho-gu, Seoul, 06591, Republic of Korea
| | - Mihyun Lee
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222, Banpo-daero, Seocho-gu, Seoul, 06591, Republic of Korea
| | - Min Ho Choi
- Department of Oral and Maxillofacial Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Je Uk Park
- Department of Oral and Maxillofacial Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Misun Park
- Department of Biostatistics, Clinical Research Coordinating Center, Catholic Medical Center, The Catholic University of Korea, Seoul, Republic of Korea
| | - Young Hoon Kim
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222, Banpo-daero, Seocho-gu, Seoul, 06591, Republic of Korea
| | - Hoon Choi
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222, Banpo-daero, Seocho-gu, Seoul, 06591, Republic of Korea
| | - Jin Joo
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222, Banpo-daero, Seocho-gu, Seoul, 06591, Republic of Korea
| | - Young Eun Moon
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222, Banpo-daero, Seocho-gu, Seoul, 06591, Republic of Korea.
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Fresh frozen plasma attenuates lung injury in a novel model of prolonged hypotensive resuscitation. J Trauma Acute Care Surg 2021; 89:S118-S125. [PMID: 32282752 DOI: 10.1097/ta.0000000000002719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Hemorrhagic shock remains a leading cause of early death among severely injured in both civilian and military settings. As future military operations will require strategies allowing prolonged field care of the injured, we sought to develop an in vivo model of prolonged hypotensive resuscitation (PHR) and to evaluate the role of plasma-based resuscitation in this model. We hypothesized that resuscitation with fresh frozen plasma (FFP) would mitigate lung injury when compared with Hextend in a rodent model of PHR. METHODS Mice underwent laparotomy and hemorrhagic shock (mean arterial blood pressure, 35 ± 5 mm Hg × 90 minutes) followed by PHR with either FFP or Hextend to maintain a mean arterial blood pressure of 55 mm Hg to 60 mm Hg for 6 hours. Sham animals underwent cannulation only. At the end of 6 hours, animals were euthanized, and lung tissue harvested for measurement of histopathologic injury, inflammation and permeability using hematoxylin and eosin staining, myeloperoxidase immunofluorescence staining and Evans Blue dye. Pulmonary syndecan-1 immunostaining was assessed as an indicator of endothelial cell integrity. RESULTS All animals in the FFP, Hextend, and sham groups survived to the end of resuscitation. Resuscitation with FFP mitigated lung histopathologic injury compared with Hextend (histologic injury score of 4.38 ± 2.07 vs. 7.5 ± 0.93, scale of 0-9, p = 0.002) and was comparable to shams (histologic injury score of 4.0 ± 1.93, scale of 0-9, p = 0.99). Fresh frozen plasma also reduced lung inflammation (0.116 ± 0.044 vs. 0.308 ± 0.054 relative fluorescence of myeloperoxidase, p = 0.002) and restored pulmonary syndecan-1 (0.514 ± 0.061 vs. 0.059 ± 0.021, relative syndecan-1 fluorescence, p < 0.001) when compared with Hextend. Consistently, FFP mitigated lung hyperpermeability compared with Hextend (7.30 ± 1.34 μg vs. 14.91 ± 5.55 μg Evans blue/100 mg lung tissue, p = 0.005). CONCLUSION We have presented a novel model of PHR of military relevance to the prolonged field care environment. In this model, FFP maintains its pulmonary protective effects using a PHR strategy compared with Hextend, which supports the need for further development and implementation of plasma-based resuscitation in the forward environment. LEVEL OF EVIDENCE Basic science.
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Cruciani M, Franchini M, Mengoli C, Marano G, Pati I, Masiello F, Veropalumbo E, Pupella S, Vaglio S, Agostini V, Liumbruno GM. The use of whole blood in traumatic bleeding: a systematic review. Intern Emerg Med 2021; 16:209-220. [PMID: 32930966 DOI: 10.1007/s11739-020-02491-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Accepted: 09/01/2020] [Indexed: 12/11/2022]
Abstract
Hemostatic resuscitation is currently considered a standard of care for the management of life-threatening hemorrhage, but in some critical settings the access to high quantities of blood components is problematic. Whole blood (WB) transfusion has been proposed as an alternative modality for hemostatic resuscitation of traumatic major bleeding. To assess the efficacy and safety of WB in trauma-associated massive bleeding, we performed a systematic review of the literature. We selected studies comparing WB transfusions to transfusion of blood components (COMP) in massive trauma bleeding; both randomized clinical trial (RCT) and observational studies were considered. The outcomes were mortality (30-day/in-hospital and 24-h mortality) and adverse events/transfusion reactions. The effect sizes were crude odds ratio (OR), adjusted OR and hazard ratio (HR). The methodological quality of studies was assessed using the Cochrane Risk of Bias tool for RCTs, and the ROBIN-1 tool for observational studies. The overall quality of the available evidence was assessed with the GRADE system. One RCT (2 reports) and 6 cohort studies were included (3642 adult patients; 675 receiving WB, 2967 receiving COMP). Three studies were conducted in military setting, and 4 in civilian setting. In the overall analysis, 30-day/in-hospital and 24-h mortality did not differ significantly between groups (very low quality of the evidence due to high risk of bias, imprecision and inconsistency). After adjustment for baseline covariates in three cohort studies, the OR for mortality was significantly lower in WB recipients compared to COMP (OR 0.22; 95% CIs 0.10/0.45) (moderate grade of evidence). Adverse events and transfusion reactions were overlooked and not consistently reported. The available evidence does not allow to draw definite conclusions on the short-term and long-term efficacy and safety of WB transfusion compared to COMP transfusion. Further well designed research is needed.
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Affiliation(s)
- Mario Cruciani
- Italian National Blood Centre, Rome, Italy
- AULSS9 Scaligera, Infection Control Committee and Antibiotic Stewardship Programme, Verona, Italy
| | - Massimo Franchini
- Italian National Blood Centre, Rome, Italy.
- Department of Hematology and Transfusion Medicine, Carlo Poma Hospital, Mantua, Italy.
| | | | | | | | | | | | | | | | - Vanessa Agostini
- Italian National Blood Centre, Rome, Italy
- Immunohematology and Transfusion Service, IRCCS Policlinico San Martino, Genova, Italy
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Save it-don't waste it! Maximizing utilization of erythrocytes from previously stored whole blood. J Trauma Acute Care Surg 2020; 89:665-672. [PMID: 32590560 DOI: 10.1097/ta.0000000000002839] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND Recent military and civilian experience suggests that fresh whole blood may be the preferred for treatment of hemorrhagic shock, but its use is limited by its 21-day shelf life. The red blood cell storage lesion and coagulation status of packed red blood cells (pRBCs) salvaged from expired whole blood are unknown. We hypothesized that pRBCs can be salvaged from previously stored whole blood. METHODS Cold stored, low-titer, O-positive, nonleukoreduced, whole blood units were obtained at 21 days of storage. Erythrocytes were separated by centrifugation, resuspended in AS-3, and stored for 21 additional days as salvaged pRBCs. The red blood cell storage lesion parameters of microvesicles, Band-3, free hemoglobin, annexin V, and erythrocyte osmotic fragility were measured and compared with pRBCs prepared at the time of donation and stored in AS-3 for 42 days (standard pRBCs). In additional experiments, murine pRBCs were prepared from expired whole blood units and compared with those stored under standard conditions. Mice underwent hemorrhage and resuscitation with standard and salvaged pRBC units, and serum cytokines and free hemoglobin were determined. RESULTS There were no significant differences in microvesicle formation or cell-free hemoglobin concentration between salvaged and standard pRBCs. There was decreased Band-3 and increased phosphatidylserine in the salvaged units as well as greater osmotic fragility. Salvaged pRBCs maintained consistent clot firmness. After hemorrhage and resuscitation in a murine model, salvaged pRBCs did not demonstrate increased serum cytokine levels. CONCLUSION Salvaged pRBCs from previously stored whole blood accumulate the red blood cell storage lesion in a similar fashion to standard pRBCs and maintain consistent coagulability when reconstituted with plasma. Salvaged pRBCs are not associated with an increased inflammatory response when used for resuscitation in a murine model. Salvaged pRBCs may be a viable product for utilization in the treatment of traumatic hemorrhagic shock.
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Salamea-Molina JC, Himmler AN, Valencia-Angel LI, Ordoñez CA, Parra MW, Caicedo Y, Guzmán-Rodríguez M, Orlas C, Granados M, Macia C, García A, Serna JJ, Badiel M, Puyana JC. Whole blood for blood loss: hemostatic resuscitation in damage control. Colomb Med (Cali) 2020; 51:e4044511. [PMID: 33795899 PMCID: PMC7968429 DOI: 10.25100/cm.v51i4.4511] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Revised: 11/25/2020] [Accepted: 12/18/2020] [Indexed: 12/23/2022] Open
Abstract
Hemorrhagic shock and its complications are a major cause of death among trauma patients. The management of hemorrhagic shock using a damage control resuscitation strategy has been shown to decrease mortality and improve patient outcomes. One of the components of damage control resuscitation is hemostatic resuscitation, which involves the replacement of lost blood volume with components such as packed red blood cells, fresh frozen plasma, cryoprecipitate, and platelets in a 1:1:1:1 ratio. However, this is a strategy that is not applicable in many parts of Latin America and other low-and-middle-income countries throughout the world, where there is a lack of well-equipped blood banks and an insufficient availability of blood products. To overcome these barriers, we propose the use of cold fresh whole blood for hemostatic resuscitation in exsanguinating patients. Over 6 years of experience in Ecuador has shown that resuscitation with cold fresh whole blood has similar outcomes and a similar safety profile compared to resuscitation with hemocomponents. Whole blood confers many advantages over component therapy including, but not limited to the transfusion of blood with a physiologic ratio of components, ease of transport and transfusion, less volume of anticoagulants and additives transfused to the patient, and exposure to fewer donors. Whole blood is a tool with reemerging potential that can be implemented in civilian trauma centers with optimal results and less technical demand.
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Affiliation(s)
- Juan Carlos Salamea-Molina
- Hospital Vicente Corral Moscoso, Division of Trauma and Acute Care Surgery, Cuenca, Ecuador
- Universidad del Azuay, Escuela de Medicina. Cuenca, Ecuador
| | - Amber Nicole Himmler
- Medstar Georgetown University Hospital, Department of Surgery, Washington, D.C., USA
- Washington Hospital Center. Washington, D.C., USA
| | - Laura Isabel Valencia-Angel
- Universidad Industrial de Santander, Department of Surgery, Bucaramanga, Colombia
- Hospital Manuela Beltrán, Department of Surgery, Socorro, Colombia
| | - Carlos A Ordoñez
- Fundación Valle del Lili, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia
- Universidad Icesi, Cali, Colombia
| | - Michael W Parra
- Broward General Level I Trauma Center, Department of Trauma Critical Care, Fort Lauderdale, FL - USA
| | - Yaset Caicedo
- Fundación Valle del Lili, Centro de Investigaciones Clínicas (CIC), Cali, Colombia
| | - Mónica Guzmán-Rodríguez
- Universidad de Chile, Facultad de Medicina, Instituto de Ciencias Biomédicas, Santiago de Chile, Chile
| | - Claudia Orlas
- Brigham & Women's Hospital, Department of Surgery, Center for Surgery and Public Health, Boston, USA
- Harvard Medical School & Harvard T.H., Chan School of Public Health, Boston - USA
| | | | - Carmenza Macia
- Fundación Valle del Lili, Blood Bank and Transfusion Service, Cali, Colombia
| | - Alberto García
- Fundación Valle del Lili, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia
- Universidad Icesi, Cali, Colombia
| | - José Julián Serna
- Fundación Valle del Lili, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia
- Universidad Icesi, Cali, Colombia
- Hospital Universitario del Valle, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia
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Walker SC, Andrews J. Novel Blood Component Therapies in the Pediatric Setting. Clin Lab Med 2020; 41:153-171. [PMID: 33494883 DOI: 10.1016/j.cll.2020.10.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
There have been recent advances in safer blood component preparation and use of adjuvant blood derivatives, which have limited safety and efficacy data on use in children. This article reviews the literature on use of whole blood, solvent/detergent-treated plasma, pathogen-reduced platelets, and fibrinogen concentrate in pediatric patients. Many countries have adopted pathogen-reduced blood product technology, and hospitals in the United States are slowly adopting these products. The pediatric transfusion medicine community needs to appraise the evidence for their use and continue to advocate the inclusion of children in the most robust randomized clinical trials for novel blood components.
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Affiliation(s)
- Shannon C Walker
- Department of Pediatrics, Division of Hematology/Oncology, Vanderbilt University Medical Center, Preston Research Building #397, 2220 Pierce Avenue, Nashville, TN 37232, USA
| | - Jennifer Andrews
- Department of Pathology, Microbiology and Immunology, Division of Transfusion Medicine, Vanderbilt University Medical Center, 1301 Medical Center Drive, Suite 4605, Nashville, TN 37232, USA; Department of Pediatrics, Division of Hematology/Oncology, Vanderbilt University Medical Center, 1301 Medical Center Drive, Suite 4605, Nashville, TN 37232, USA.
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Whole Blood Administration: Comparison of In Vitro Platelet Function of Pressure Bag, Pressure Bag With Fluid Warming Device, and Rapid Infuser Methods. J Trauma Nurs 2020; 27:351-354. [PMID: 33156251 DOI: 10.1097/jtn.0000000000000542] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
BACKGROUND Use of low-titer group O whole blood for emergent transfusion of patients with unknown blood type became AABB approved in January 2018. Since that time, there is increasing use of whole blood in massive transfusion protocols. Whole blood stored at refrigerator temperature (2-4 °C) contains functional platelets that some research proposes may provide better clot dynamics than standard platelets, which are stored at room temperature (20-24 °C). Conventional teaching does not promote infusion of platelet products with pressure or warming, due to concerns of activation and subsequent inactivity of the infused platelets. Although a few reports found no significant changes in platelet function with warming or pressure during infusion of conventional room-temperature-stored platelets, there is limited data to support use of warming or pressure for infusion of whole blood products containing cold-stored platelets. METHODS This study design is to evaluate and compare three commonly used methods of administering blood products in a massive transfusion setting for their potential effects on platelets contained within whole blood units (pressure bag alone, pressure bag with fluid warming line, and rapid infuser). RESULTS Platelet function of 10 units tested pre- and post-infusion by thromboelastography (TEG) and platelet aggregation studies found no significant difference in platelet activity pre- and post-infusion with any of the three methods evaluated. CONCLUSIONS This study supports the use of rapid infuser or pressure bag devices (with or without warming) as acceptable for infusion of whole blood products. Infusion of whole blood with warming is preferable to prevent potential transfusion-associated hypothermia.
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Weeks JM, Motsinger-Reif AA, Reems MM. In vitro iatrogenic hemolysis of canine packed red blood cells during various rapid transfusion techniques. J Vet Emerg Crit Care (San Antonio) 2020; 31:25-31. [PMID: 33142048 DOI: 10.1111/vec.13020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Revised: 03/28/2019] [Accepted: 04/23/2019] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To evaluate which rapid blood administration technique causes the least iatrogenic hemolysis in canine packed red blood cells (pRBCs) as determined by plasma free hemoglobin (fHb) and percent hemolysis (% hemolysis). DESIGN Prospective in vitro randomized study. SETTING Private referral center. ANIMALS None. INTERVENTIONS Thirteen units of canine pRBCs were divided equally into 5 aliquots, resulting in 65 trials. The aliquots of each unit were subjected to the following administration techniques: gravity-driven (control), an infusion pump at maximal rate, application of a pressure bag, manual compression, and syringe bolus. Plasma fHb and % hemolysis were recorded before and after each trial. Rate of administration (mL/s) was calculated for each method. MEASUREMENTS AND MAIN RESULTS Compared to the control, there were no significant increases in % hemolysis or plasma fHb noted among any of the trial methods. The manual compression and syringe bolus methods resulted in the fastest transfusion rates, whereas the infusion pump was not faster than the gravity-driven method. Despite a storage time of ≤14 days, 15% of pRBC units had unsuitable (>0.8%) hemolysis before even being subjected to the trials. CONCLUSIONS Commonly used rapid infusion techniques in small animal transfusion medicine do not cause significant iatrogenic hemolysis of canine pRBCs in vitro, although a significant risk is present in stored blood. This suggests that if an expedited transfusion is needed, any method described in this study could be considered, although stored pRBCs should be tested for unsuitable levels of hemolysis prior to transfusion.
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Affiliation(s)
- Jessica M Weeks
- Department of Small Animal Emergency and Critical Care, BluePearl Veterinary Partners, Tampa, Florida
| | - Alison A Motsinger-Reif
- The Bioinformatics Research Center, Department of Statistics, College of Sciences, North Carolina State University, Raleigh, North Carolina
| | - Miryam M Reems
- Department of Small Animal Emergency and Critical Care, BluePearl Veterinary Partners, Tampa, Florida
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50
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Nationwide analysis of whole blood hemostatic resuscitation in civilian trauma. J Trauma Acute Care Surg 2020; 89:329-335. [PMID: 32744830 DOI: 10.1097/ta.0000000000002753] [Citation(s) in RCA: 59] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Renewed interest in whole blood (WB) resuscitation in civilians has emerged following its military use. There is a paucity of data on its role in civilians where balanced component therapy (CT) resuscitation is the standard of care. The aim of this study was to assess nationwide outcomes of using WB as an adjunct to CT versus CT alone in resuscitating civilian trauma patients. METHODS We analyzed the (2015-2016) Trauma Quality Improvement Program. We included adult (age, ≥18 years) trauma patients presenting with hemorrhagic shock and requiring at least 1 U of packed red blood cells (pRBCs) within 4 hours. Patients were stratified into WB-CT versus CT only. Primary outcomes were 24-hour and in-hospital mortality. Secondary outcomes were hospital length of stay and major complications. Hierarchical logistic regression was performed to account for clustering effect within hospitals and adjusting for patient- and hospital-level potential confounding factors. RESULTS A total of 8,494 patients were identified, of which 280 received WB-CT (WB, 1 [1-1]; pRBC, 16 [10-23]; FFP, 9 [6-16]; platelets, 3 [2-5]) and 8,214 received CT only (pRBC, 15 [10-24]; FFP, 10 [6-16]; platelets, 2 [1-4]). Mean ± SD age was 34 ± 16 years, 79% were male, Injury Severity Score was 33 (24-43), and 63% had penetrating injuries. Patients who received WB-CT had a lower 24-hour mortality (17% vs. 25%; p = 0.002), in-hospital mortality (29% vs. 40%; p < 0.001), major complications (29% vs. 41%; p < 0.001), and a shorter length of stay (9 [7-12] vs. 15 [10-21]; p = 0.011). On regression analysis, WB was independently associated with reduced 24-hour mortality (odds ratio [OR], 0.78 [0.59-0.89]; p = 0.006), in-hospital mortality (OR, 0.88 [0.81-0.90]; p = 0.011), and major complications (OR, 0.92 [0.87-0.96]; p = 0.013). CONCLUSION The use of WB as an adjunct to CT is associated with improved outcomes in resuscitation of severely injured civilian trauma patients. Further studies are required to evaluate the role of adding WB to massive transfusion protocols. LEVEL OF EVIDENCE Therapeutic, level IV.
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