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McCullagh J, Booth C, Lancut J, Platton S, Richards P, Green L. Every minute counts: A comparison of thawing times and haemostatic quality of plasma thawed at 37°C and 45°C using four different methods. Transfus Med 2024; 34:304-310. [PMID: 38923078 DOI: 10.1111/tme.13061] [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: 10/12/2023] [Revised: 05/11/2024] [Accepted: 06/11/2024] [Indexed: 06/28/2024]
Abstract
BACKGROUND Having faster plasma thawing devices could be beneficial for transfusion services, as it may improve the rapid availability of thawed plasma for bleeding patients, and it might remove the need to have extended pre-thawed plasma: thus, reducing unnecessary plasma wastage. STUDY DESIGN AND METHODS The aims of this study were to assess (a) the thawing times and (b) in vitro haemostatic quality of thawed plasma using Barkey Plasmatherm V (PTV) at 37 and 45°C versus Barkey Plasmatherm Classic (PTC) at 37 and 45°C, Sarstedt Sahara-III Maxitherm (SS-III) at 37°C and Helmer Scientific Thermogenesis Thermoline (TT) at 37°C. Haemostatic quality was assessed using LG-Octaplas at three different time points: baseline (5 min), 24 and 120 h after thawing. RESULTS The thawing time (SD) of 2 and 4 units was significantly different between different thawers. PTV at 45°C was the fastest method for both 2 and 4 units (7.06 min [0.68], 9.6 min [0.87], respectively). SS-III at 37°C being the slowest method (24.69 min [2.09] and 27.18 min [4.4], respectively) (p = < 0.05). Baseline measurements for all assays showed no significant difference in the prothrombin time, fibrinogen, FII, FV, protein C activity or free protein S antigen between all methods tested. However, at baseline PTV (both 37°C and 45°C) had significantly higher levels of FVII, FVIII and FXI and shortened activated partial thromboplastin time. DISCUSSION PTV was the quickest method at thawing plasma at both 37 and at 45°C. The haemostatic quality of plasma thawed at 45 versus 37°C was not impaired. Thawing frozen plasma at 45°C should be considered.
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Affiliation(s)
- J McCullagh
- Clinical Haematology, Barts Health NHS Trust, London, UK
- NHS Blood and Transplant, London, UK
- Blizard Institute, Queen Mary University of London, London, UK
| | - C Booth
- Clinical Haematology, Barts Health NHS Trust, London, UK
- NHS Blood and Transplant, London, UK
| | - J Lancut
- East and Southeast London Pathology Partnership, London, UK
| | - S Platton
- Haemophilia Centre, Barts Health NHS Trust, London, UK
| | | | - L Green
- Clinical Haematology, Barts Health NHS Trust, London, UK
- NHS Blood and Transplant, London, UK
- Blizard Institute, Queen Mary University of London, London, UK
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Callaghan NI, Quinn J, Liwski R, Chisholm N, Cheng C. Process Mining Uncovers Actionable Patterns of Red Blood Cell Unit Wastage in a Health Care Network. Transfus Med Rev 2024; 38:150827. [PMID: 38642414 DOI: 10.1016/j.tmrv.2024.150827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Revised: 03/17/2024] [Accepted: 03/19/2024] [Indexed: 04/22/2024]
Abstract
Packed red blood cell transfusions are integral to the care of the critically and chronically ill patient, but require careful storage and a large, coordinated network to ensure their integrity during distribution and administration. Auditing a Transfusion Medicine service can be challenging due to the complexity of this network. Process mining is an analytical technique that allows for the identification of high-efficiency pathways through a network, as well as areas of challenge for targeted innovation. Here, we detail a case study of an efficiency audit of the Transfusion Medicine service of the Nova Scotia Health Administration Central Zone using process mining, across a period encompassing years prior to, during, and after the acute COVID-19 pandemic. Service efficiency from a product wastage perspective was consistently demonstrated at benchmarks near globally published optima. Furthermore, we detail key areas of continued challenge in product wastage, and suggest potential strategies for further targeted optimization.
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Affiliation(s)
- Neal I Callaghan
- Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Jason Quinn
- Department of Pathology and Laboratory Medicine, Division of Hematopathology, Halifax, Nova Scotia, Canada
| | - Robert Liwski
- Department of Pathology and Laboratory Medicine, Division of Hematopathology, Halifax, Nova Scotia, Canada
| | - Natalie Chisholm
- Department of Pathology and Laboratory Medicine, Division of Hematopathology, Halifax, Nova Scotia, Canada
| | - Calvino Cheng
- Department of Pathology and Laboratory Medicine, Division of Hematopathology, Halifax, Nova Scotia, Canada.
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Schoenfeld DW, Rosen CL, Harris T, Thomas SH. Assessing the one-month mortality impact of civilian-setting prehospital transfusion: A systematic review and meta-analysis. Acad Emerg Med 2024; 31:590-598. [PMID: 38517320 DOI: 10.1111/acem.14882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2023] [Revised: 01/06/2024] [Accepted: 01/10/2024] [Indexed: 03/23/2024]
Abstract
BACKGROUND Based on convincing evidence for outcomes improvement in the military setting, the past decade has seen evaluation of prehospital transfusion (PHT) in the civilian emergency medical services (EMS) setting. Evidence synthesis has been challenging, due to study design variation with respect to both exposure (type of blood product administered) and outcome (endpoint definitions and timing). The goal of the current meta-analysis was to execute an overarching assessment of all civilian-arena randomized controlled trial (RCT) evidence focusing on administration of blood products compared to control of no blood products. METHOD The review structure followed the Cochrane group's Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA). Using the Transfusion Evidence Library (transfusionevidencelibrary.com), the multidatabase (e.g. PubMed, EMBASE) Harvard On-Line Library Information System (HOLLIS), and GoogleScholar, we accessed many databases and gray literature sources. RCTs of PHT in the civilian setting with a comparison group receiving no blood products with 1-month mortality outcomes were identified. RESULTS In assessing a single patient-centered endpoint-1-month mortality-we calculated an overall risk ratio (RR) estimate. Analysis of three RCTs yielded a model with acceptable heterogeneity (I2 = 48%, Q-test p = 0.13). Pooled estimate revealed civilian PHT results in a statistically nonsignificant (p = 0.38) relative mortality reduction of 13% (RR 0.87, 95% CI 0.63-1.19). CONCLUSIONS Current evidence does not demonstrate 1-month mortality benefit of civilian-setting PHT. This should give pause to EMS systems considering adoption of civilian-setting PHT programs. Further studies should not only focus on which formulations of blood products might improve outcomes but also focus on which patients are most likely to benefit from any form of civilian-setting PHT.
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Affiliation(s)
- David W Schoenfeld
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center & Harvard Medical School, Boston, Massachusetts, USA
| | - Carlo L Rosen
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center & Harvard Medical School, Boston, Massachusetts, USA
| | - Tim Harris
- Blizard Institute for Neuroscience, Surgery, and Trauma, Barts and The London School of Medicine, London, UK
| | - Stephen H Thomas
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center & Harvard Medical School, Boston, Massachusetts, USA
- Blizard Institute for Neuroscience, Surgery, and Trauma, Barts and The London School of Medicine, London, UK
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Jama T, Lefering R, Lauronen J, Handolin L. Factors affecting physicians' decision to start prehospital blood product transfusion in blunt trauma patients: A cohort study of Helsinki Trauma Registry. Transfusion 2024; 64 Suppl 2:S167-S173. [PMID: 38511866 DOI: 10.1111/trf.17791] [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: 12/30/2023] [Revised: 02/29/2024] [Accepted: 02/29/2024] [Indexed: 03/22/2024]
Abstract
BACKGROUND Prehospital blood transfusions are increasing as a treatment for bleeding trauma patients at risk for exsanguination. Triggers for starting transfusion in the field are less studied. We analyzed the factors affecting the decision of physicians to start prehospital blood product transfusion (PHBT) in blunt adult trauma patients. STUDY DESIGN AND METHODS Data of all adult blunt trauma patients from the Helsinki Trauma Registry between March 2016 and July 2021 were retrospectively analyzed. Univariate analysis for the identification of predictive factors and multivariate regression analysis for their importance as predictive factors for the initiation of PHBT were applied. RESULTS There were 1652 patients registered in the database. A total of 556 of them were treated by a physician-level prehospital emergency care unit, of which by transfusion-capable unit in 394 patients. PHBT (red blood cells and/or plasma) was started in 19.8% of the patients. We identified three statistically highly important clinical triggers for starting PHBT: high crystalloid volume need, shock index ≥0.9, and need for prehospital pleural decompression. DISCUSSION PHBT in blunt adult trauma patients is initiated in ~20% of the patients in Southern Finland. High crystalloid volume need, shock index ≥0.9 and prehospital pleural decompression are associated with the initiation of PHBT, probably reflecting patients at high risk for bleeding.
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Affiliation(s)
- Timo Jama
- Wellbeing Services County of Päijät-Häme, Lahti, Finland
- University of Helsinki, Helsinki, Finland
| | - Rolf Lefering
- Institute for Research in Operative Medicine (IFOM), University of Witten/Herdecke, Cologne, Germany
| | - Jouni Lauronen
- University of Helsinki, Helsinki, Finland
- Finnish Red Cross Blood Service, Vantaa, Finland
| | - Lauri Handolin
- University of Helsinki, Helsinki, Finland
- Helsinki University Hospital Trauma Unit, Helsinki, Finland
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Broome JM, Nordham KD, Piehl M, Tatum D, Caputo S, Belding C, De Maio VJ, Taghavi S, Jackson-Weaver O, Harris C, McGrew P, Smith A, Nichols E, Dransfield T, Rayburn D, Marino M, Avegno J, Duchesne J. Faster refill in an urban emergency medical services system saves lives: A prospective preliminary evaluation of a prehospital advanced resuscitative care bundle. J Trauma Acute Care Surg 2024; 96:702-707. [PMID: 38189675 DOI: 10.1097/ta.0000000000004239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2024]
Abstract
INTRODUCTION Military experience has demonstrated mortality improvement when advanced resuscitative care (ARC) is provided for trauma patients with severe hemorrhage. The benefits of ARC for trauma in civilian emergency medical services (EMS) systems with short transport intervals are still unknown. We hypothesized that ARC implementation in an urban EMS system would reduce in-hospital mortality. METHODS This was a prospective analysis of ARC bundle administration between 2021 and 2023 in an urban EMS system with 70,000 annual responses. The ARC bundle consisted of calcium, tranexamic acid, and packed red blood cells via a rapid infuser. Advanced resuscitative care patients were compared with trauma registry controls from 2016 to 2019. Included were patients with a penetrating injury and systolic blood pressure ≤90 mm Hg. Excluded were isolated head trauma or prehospital cardiac arrest. In-hospital mortality was the primary outcome of interest. RESULTS A total of 210 patients (ARC, 61; controls, 149) met the criteria. The median age was 32 years, with no difference in demographics, initial systolic blood pressure or heart rate recorded by EMS, or New Injury Severity Score between groups. At hospital arrival, ARC patients had lower median heart rate and shock index than controls ( p ≤ 0.03). Fewer patients in the ARC group required prehospital advanced airway placement ( p < 0.001). Twenty-four-hour and total in-hospital mortality were lower in the ARC group ( p ≤ 0.04). Multivariable regression revealed an independent reduction in in-hospital mortality with ARC (odds ratio, 0.19; 95% confidence interval, 0.05-0.68; p = 0.01). CONCLUSION Early ARC in a fast-paced urban EMS system is achievable and may improve physiologic derangements while decreasing patient mortality. Advanced resuscitative care closer to the point of injury warrants consideration. LEVEL OF EVIDENCE Therapeutic/Care Management; Level IV.
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Affiliation(s)
- Jacob M Broome
- Department of Surgery, MedStar Georgetown Washington Hospital Center, (J.M.B.) Washington DC; Department of Surgery (K.D.N., D.T., S.C., C.B., S.T., O.J.-W., C.H., P.M., J.D.), Tulane University School of Medicine, New Orleans, Louisiana; Department of Pediatrics (M.P.), and Department of Emergency Medicine (V.J.D.M.), University of North Carolina at Chapel Hill, Chapel Hill; WakeMed Health and Hospitals (M.P.), Raleigh, North Carolina; Lousiana State University Health Science Center New Orleans (A.S.); New Orleans Emergency Medical Services (E.N., T.D., D.R., M.M.); and New Orleans Health Department, New Orleans, Louisiana (J.A.)
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Christoffel J, Maegele M. Guidelines in trauma-related bleeding and coagulopathy: an update. Curr Opin Anaesthesiol 2024; 37:110-116. [PMID: 38390904 DOI: 10.1097/aco.0000000000001346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2024]
Abstract
PURPOSE OF REVIEW The diagnosis and treatment of patients with severe traumatic bleeding and subsequent trauma-induced coagulopathy (TIC) is still inconsistent, although the implementation of standardized algorithms/treatment pathways was repeatedly linked to improved outcome. Various evidence-based guidelines for these patients now exist, three of which have recently been updated. RECENT FINDINGS A synopsis of the three recently updated guidelines for diagnosis and treatment of seriously bleeding trauma patients with TIC is presented: (i) AWMF S3 guideline 'Polytrauma/Seriously Injured Patient Treatment' under the auspices of the German Society for Trauma Surgery; (ii) guideline of the European Society of Anesthesiology and Intensive Care (ESAIC) on the management of perioperative bleeding; and (iii) European guideline on the management of major bleeding and coagulopathy after trauma in its 6th edition (EU-Trauma). SUMMARY Treatment of trauma-related bleeding begins at the scene with local compression, use of tourniquets and pelvic binders and rapid transport to a certified trauma centre. After arrival at the hospital, measures to record, monitor and support coagulation function should be initiated immediately. Surgical bleeding control is carried out according to 'damage control' principles. Modern coagulation management includes individualized treatment based on target values derived from point-of-care viscoelastic test procedures.
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Affiliation(s)
- Jannis Christoffel
- Department for Trauma and Orthopaedic Surgery, Cologne-Merheim Medical Center (CMMC)
| | - Marc Maegele
- Department for Trauma and Orthopaedic Surgery, Cologne-Merheim Medical Center (CMMC)
- Institute for Research in Operative Medicine (IFOM), Witten/Herdecke University, Campus Cologne-Merheim, Cologne, Germany
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7
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Alomar-Dominguez C, Bösch J, Fries D. Prehospital transfusion of allogeneic blood products. Curr Opin Anaesthesiol 2024; 37:144-147. [PMID: 38390984 DOI: 10.1097/aco.0000000000001353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2024]
Abstract
PURPOSE OF REVIEW The purpose of this article is to provide a structural and practical analysis of the currently available data concerning prehospital transfusion of allogeneic blood products in cases of trauma and severe bleeding. RECENT FINDINGS Prehospital transfusion of allogeneic blood products is a very early intervention, which may offer the potential to improve outcome, but that also comes with challenges including resource allocation, blood product storage, logistics, patient selection, legal and ethical considerations, adverse effects, and costs. Potential benefits including improved stability and reduction in coagulopathy and blood loss have not yet been clearly demonstrated. SUMMARY The questionable efficacy and challenges in clinical practice may outweigh the potential benefits of prehospital allogeneic transfusion.
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Affiliation(s)
- Cristina Alomar-Dominguez
- Department of Anaesthesiology and Critical Care Medicine, Medical University of Innsbruck, Innsbruck, Austria
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Facchetti G, Facchetti M, Schmal M, Lee R, Fiorelli S, Marzano TF, Lupi C, Daminelli F, Sbrana G, Massullo D, Marinangeli F. Prehospital Blood Transfusion in Helicopter Emergency Medical Services: An Italian Survey. Air Med J 2024; 43:140-145. [PMID: 38490777 DOI: 10.1016/j.amj.2023.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 10/17/2023] [Accepted: 11/12/2023] [Indexed: 03/17/2024]
Abstract
OBJECTIVE Hemorrhage remains the most common cause of preventable death after trauma. Prehospital blood product (PHBP) administration may improve outcomes. No data are available about PHBP use in Italian helicopter emergency medical services (HEMS). The primary aim of this survey was to establish the degree of PHBP used throughout Italy. The secondary aims were to evaluate the main indications for their use, the opinions about PHBPs, and users' experience. METHODS The study group performed a telephone/e-mail survey of all 56 Italian HEMS bases. The questions concerned whether PHBPs were used in their HEMS bases, the frequency of transfusions, the PHBP used, and the perceived benefits. RESULTS Four of 56 HEMS bases use PHBPs. Overall, 7% have prehospital access to packed red cells and only 1 to fresh plasma. In addition to blood product administration, 4 of 4 use tranexamic acid, and 3 of 4 also use fibrinogen. Seventy-five percent use PHBPs once a month and 25% once a week. The users' experience was that PHBPs are beneficial and lifesaving. CONCLUSION Only 4 of 56 HEMS in Italy use PHBPs. There is an absolute consensus among providers on the benefit of PHBPs despite the lack of evidence on PHBP use.
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Affiliation(s)
| | - Marilisa Facchetti
- Department Anesthesiology and Critical Care, University of L'Aquila, L'Aquila, Italy
| | - Mariette Schmal
- Jeugdgezondheidszorg Zuid-Holland West, Zoetermeer, Netherlands
| | - Ronan Lee
- European Patent Office, Team Surgery, Rijswijk, Netherlands
| | - Silvia Fiorelli
- Anesthesia and Intensive Care Medicine, Department of Clinical and Surgical Translational Medicine, Sant'Andrea Hospital, Sapienza University of Rome, Rome, Italy.
| | | | - Cristian Lupi
- HEMS Bologna, Department of Anesthesia, Intensive Care and Prehospital Emergency, Maggiore Hospital Carlo Alberto Pizzardi, Azienda Unità Sanitaria Locale Bologna, Bologna, Italy
| | - Francesco Daminelli
- HEMS Bergamo, Papa Giovanni XXIII Hospital, Agenzia Regionale Emergenza Urgenza Lombardia, Bergamo, Italy
| | - Giovanni Sbrana
- HEMS Grosseto, Emergency Department, Azienda Sanitaria Locale Toscana Sud Est, Grosseto, Italy
| | - Domenico Massullo
- Anesthesia and Intensive Care Medicine, Department of Clinical and Surgical Translational Medicine, Sant'Andrea Hospital, Sapienza University of Rome, Rome, Italy
| | - Franco Marinangeli
- Department Anesthesiology and Critical Care, University of L'Aquila, L'Aquila, Italy
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Antonacci G, Williams A, Smith J, Green L. Study of Whole blood in Frontline Trauma (SWiFT): implementation study protocol. BMJ Open 2024; 14:e078953. [PMID: 38316586 PMCID: PMC11145983 DOI: 10.1136/bmjopen-2023-078953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Accepted: 01/04/2024] [Indexed: 02/07/2024] Open
Abstract
INTRODUCTION Uncontrolled bleeding is a major cause of death for patients with major trauma. Current transfusion practices vary, and there is uncertainty about the optimal strategy. Whole blood (WB) transfusion, which contains all components in one bag, is considered potentially advantageous, particularly for resuscitating patients with major bleeding in the prehospital setting. It could potentially improve survival, reduce donor risk and simplify the processes of delivering blood transfusions outside hospitals. However, the evidence supporting the effectiveness and safety of WB compared with the standard separate blood component therapy is limited. A multicentre randomised controlled trial will be conducted, alongside an implementation study, to assess the efficacy, cost-effectiveness and implementation of prehospital WB transfusion in the prehospital environment. The implementation study will focus on evaluating the acceptability and integration of the intervention into clinical settings and on addressing broader contextual factors that may influence its success or failure. METHODS AND ANALYSIS A type 1 effectiveness-implementation hybrid design will be employed. The implementation study will use qualitative methods, encompassing comprehensive interviews and focus groups with operational staff, patients and blood donor representatives. Staff will be purposefully selected to ensure a wide range of perspectives based on their professional background and involvement in the WB pathway. The study design includes: (1) initial assessment of current practice and processes in the WB pathway; (2) qualitative interviews with up to 40 operational staff and (3) five focus groups with staff and donor representatives. Data analysis will be guided by the theoretical lenses of the Normalisation Process Theory and the Theoretical Framework of Acceptability. ETHICS AND DISSEMINATION The study was prospectively registered and approved by the South Central-Oxford C Research Ethics Committee and the Health Research Authority and Health and Care Research Wales. The results will be published in peer-reviewed journals and provided to all relevant stakeholders. TRIAL REGISTRATION NUMBER ISRCTN23657907; EudraCT: 2021-006876-18; IRAS Number: 300414; REC: 22/SC/0072.
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Affiliation(s)
- Grazia Antonacci
- Department of Primary Care and Public Health, Imperial College London, London, UK
| | - Allison Williams
- Department of Primary Care and Public Health, Imperial College London, London, UK
| | - Jason Smith
- Department of Emergency, University Hospitals Plymouth NHS Trust, Plymouth, UK
- Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine, Birmingham, UK
| | - Laura Green
- NHS Blood & Transplant and Barts Health NHS Trust, London, UK
- Queen Mary University of London Blizard Institute, London, UK
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Ghaffari-Bohlouli P, Jafari H, Okoro OV, Alimoradi H, Nie L, Jiang G, Kakkar A, Shavandi A. Gas Therapy: Generating, Delivery, and Biomedical Applications. SMALL METHODS 2024:e2301349. [PMID: 38193272 DOI: 10.1002/smtd.202301349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Revised: 12/11/2023] [Indexed: 01/10/2024]
Abstract
Oxygen (O2 ), nitric oxide (NO), carbon monoxide (CO), hydrogen sulfide (H2 S), and hydrogen (H2 ) with direct effects, and carbon dioxide (CO2 ) with complementary effects on the condition of various diseases are known as therapeutic gases. The targeted delivery and in situ generation of these therapeutic gases with controllable release at the site of disease has attracted attention to avoid the risk of gas poisoning and improve their performance in treating various diseases such as cancer therapy, cardiovascular therapy, bone tissue engineering, and wound healing. Stimuli-responsive gas-generating sources and delivery systems based on biomaterials that enable on-demand and controllable release are promising approaches for precise gas therapy. This work highlights current advances in the design and development of new approaches and systems to generate and deliver therapeutic gases at the site of disease with on-demand release behavior. The performance of the delivered gases in various biomedical applications is then discussed.
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Affiliation(s)
- Pejman Ghaffari-Bohlouli
- 3BIO-BioMatter, École polytechnique de Bruxelles, Université Libre de Bruxelles (ULB), Avenue F.D. Roosevelt, 50-CP 165/61, Brussels, 1050, Belgium
- Department of Chemistry, McGill University, 801 Sherbrooke Street West, Montréal, Québec, H3A 0B8, Canada
| | - Hafez Jafari
- 3BIO-BioMatter, École polytechnique de Bruxelles, Université Libre de Bruxelles (ULB), Avenue F.D. Roosevelt, 50-CP 165/61, Brussels, 1050, Belgium
| | - Oseweuba Valentine Okoro
- 3BIO-BioMatter, École polytechnique de Bruxelles, Université Libre de Bruxelles (ULB), Avenue F.D. Roosevelt, 50-CP 165/61, Brussels, 1050, Belgium
| | - Houman Alimoradi
- 3BIO-BioMatter, École polytechnique de Bruxelles, Université Libre de Bruxelles (ULB), Avenue F.D. Roosevelt, 50-CP 165/61, Brussels, 1050, Belgium
| | - Lei Nie
- 3BIO-BioMatter, École polytechnique de Bruxelles, Université Libre de Bruxelles (ULB), Avenue F.D. Roosevelt, 50-CP 165/61, Brussels, 1050, Belgium
- College of Life Sciences, Xinyang Normal University, Xinyang, 464000, China
| | - Guohua Jiang
- School of Materials Science and Engineering, Zhejiang Sci-Tech University, Hangzhou, 310018, China
| | - Ashok Kakkar
- Department of Chemistry, McGill University, 801 Sherbrooke Street West, Montréal, Québec, H3A 0B8, Canada
| | - Amin Shavandi
- 3BIO-BioMatter, École polytechnique de Bruxelles, Université Libre de Bruxelles (ULB), Avenue F.D. Roosevelt, 50-CP 165/61, Brussels, 1050, Belgium
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Yazer MH, Panko G, Holcomb JB, Kaplan A, Leeper C, Seheult JN, Triulzi DJ, Spinella PC. Not as "D"eadly as once thought - the risk of D-alloimmunization and hemolytic disease of the fetus and newborn following RhD-positive transfusion in trauma. HEMATOLOGY (AMSTERDAM, NETHERLANDS) 2023; 28:2161215. [PMID: 36607150 DOI: 10.1080/16078454.2022.2161215] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
The use of blood products to resuscitate injured and massively bleeding patients in the prehospital and early in-hospital phase of the resuscitation is increasing. Using group O red blood cells (RBC) and low titer group O whole blood (LTOWB) avoids an immediate hemolytic reaction from recipient's naturally occurring anti-A and - B, but choosing the RhD type for these products is more nuanced and requires the balancing of product availability and survival benefit against the risk of D-alloimmunization, especially in females of childbearing potential (FCP) due to the possible future occurrence of hemolytic disease of the fetus and newborn (HDFN). Recent models have estimated the risk of fetal/neonatal death from HDFN resulting from D-alloimmunization of an FCP during her trauma resuscitation at between 0-6.5% depending on her age at the time of the transfusion and other societal factors including trauma mortality, her age when she becomes pregnant, frequency of different RHD genotypes in the population, and the probability that the woman will have children with different fathers; this is counterbalanced by an approximately 24% risk of death from hemorrhagic shock. This review will discuss the different models of HDFN outcomes following RhD-positive transfusion as well as the results of recent surveys where the public was asked about their preferences for urgent transfusion in light of the risks of fetal/neonatal adverse events.
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Affiliation(s)
- Mark H Yazer
- Department of Pathology, University of Pittsburgh, Pittsburgh, PA, USA
| | | | - John B Holcomb
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Alesia Kaplan
- Department of Pathology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Christine Leeper
- Department of Surgery, University of Pittsburgh, Pittsburgh PA, USA
| | - Jansen N Seheult
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Darrell J Triulzi
- Department of Pathology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Philip C Spinella
- Departments of Surgery and Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA
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12
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Hough R, Cox SC, Chimelski E, Mihm FG, Tobin JM. Prehospital Critical Care Blood Product Administration: Quantifying Clinical Benefit. Dimens Crit Care Nurs 2023; 42:333-338. [PMID: 37756506 DOI: 10.1097/dcc.0000000000000608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/29/2023] Open
Abstract
BACKGROUND Prehospital blood transfusion has been widely practiced in the military and is drawing renewed scrutiny after many years of civilian use. OBJECTIVE The objective of this article is to quantify the benefit derived from prehospital transfusion of blood products. METHODS Deidentified data were extracted retrospectively from the flight records of a critical care transportation program between April 2018 and January 2020. Patients who were transported before a prehospital blood transfusion protocol were compared with patients after initiation of the blood transfusion protocol. Demographic data, vital signs, laboratory analytics, and other outcome measures were analyzed. RESULTS Nine scene transport patients who met the transfusion criteria before a blood transfusion protocol were compared with 11 patients transported after initiation of the protocol. Identical outcome measures were analyzed. Patients who received prehospital blood transfusions had a statistically significantly longer hospital length of stay (16.5 vs 3.7 days, P = .03) and were more often taken directly to the operating room (80% vs 28%, P = .04). No statistically significant difference was identified when comparing mean arterial pressure, heart rate, respiratory rate, hemoglobin, hematocrit, or survival to hospital discharge. CONCLUSIONS Trauma patients who received prehospital blood transfusion had a longer hospital length of stay and were more often taken directly to the operating room, but without improvement in survival.
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Maegele M, Lier H, Hossfeld B. Pre-Hospital Blood Products for the Care of Bleeding Trauma Patients. DEUTSCHES ARZTEBLATT INTERNATIONAL 2023; 120:670-676. [PMID: 37551452 PMCID: PMC10644958 DOI: 10.3238/arztebl.m2023.0176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 07/13/2023] [Accepted: 07/13/2023] [Indexed: 08/09/2023]
Abstract
BACKGROUND Controversy surrounds the administration of blood products to severely traumatized patients before they arrive in the hospital in order to compensate for early blood loss and/or to correct coagulation disturbances that arise shortly after the traumatic event. A number of terrestrial and air rescue services have begun to provide this kind of treatment. METHODS This review is based on articles using the PICO framework, published from January 2001 to January 2021, that were retrieved by a selective search, with structured searching strategies and searching bundles in Medline (OVIDSP), the Cochrane Central Register of Controlled Trials (CENTRAL), and Epistemonikos. A demand analysis was carried out on the basis of data from the trauma registry of the German Society of Trauma Surgery (TR-DGU) and practical experience from program development and implementation was provided by the Bundeswehr Hospital Ulm. RESULTS The currently available evidence on the pre-hospital administration of blood products in the early treatment of severely injured patients is based largely on retrospective, single-center case series. Two randomized controlled trials (RCTs) concerning the early use of fresh frozen plasma concentrates have yielded partly conflicting results. Three further RCTs on the use of lyophilized plasma (lyplas), lyplas plus erythrocyte concentrate, or whole blood likewise revealed non-uniform effects on short-term and intermediate-term mortality. Our demand analysis based on data from the TR-DGU showed that 300 to 1800 patients per year in Germany could benefit from the pre-hospital administration of blood products. This might be indicated in patients who have systolic hypotension (<100 mmHg) in combination with a suspected or confirmed hemorrhage, as well as pathological shock parameters in the point-of-care diagnostic testing performed on the scene (serum base excess ≤ -2.5 mmol/L and/or serum lactate concentration >4 mmol/L). CONCLUSION The studies that have been published to date yield no clear evidence either for or against the early pre-hospital administration of blood products. Any treatment of this kind should be accompanied by scientific evaluation.
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Affiliation(s)
- Marc Maegele
- *Joint first authors
- Department of Trauma and Orthopaedic Surgery, Cologne-Merheim Medical Centre (CMMC), University of Witten/Herdecke, Cologne
- Institute for Research in Operative Medicine (IFOM), University of Witten/Herdecke, Campus Cologne-Merheim, Cologne
| | - Heiko Lier
- *Joint first authors
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Cologne, Cologne
| | - Björn Hossfeld
- Department of Anaesthesiology and Intensive Care Medicine, Armed Forces Hospital Ulm, Ulm
- Rescue transport helicopter (RTH) „Christoph 22“ Ulm, ADAC-Air Rescue, Ulm
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Manning JE, Morrison JJ, Pepe PE. Prehospital Resuscitation: What Should It Be? Adv Surg 2023; 57:233-256. [PMID: 37536856 DOI: 10.1016/j.yasu.2023.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/05/2023]
Abstract
Prehospital resuscitation is a dynamic field now being energized by new technologies and a shift in thinking regarding intravascular resuscitation. Growing evidence discourages use of intravenous (IV) crystalloid and colloid solutions in trauma, whereas blood products, particularly whole blood, are becoming preferred. Although randomized clinical trials validating definitive resuscitative protocols are still lacking, most preclinical and clinical indicators support this approach. In addition, emerging technologies such as external and endovascular hemorrhage control devices and extracorporeal perfusion are now being used routinely, even in the prehospital setting in many countries, generating new lines of emerging investigations for trauma specialists.
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Affiliation(s)
- James E Manning
- Department of Emergency Medicine, University of North Carolina at Chapel Hill, 170 Manning Drive, CB# 7594, Chapel Hill, NC 27599-7594, USA.
| | - Jonathan J Morrison
- Division of Vascular and Endovascular Surgery, Mayo Clinic, 200 First Street, Rochester, MN 55905, USA
| | - Paul E Pepe
- University of Miami, Miller School of Medicine, Miami, FL, USA; Dallas County Public Safety, Emergency Medical Services, Dallas, TX, USA; Global Emergency Medical Services, Suite 307 Point of Americas One, 2100 South Ocean Lane, Fort Lauderdale, FL 33316-3823, USA
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Liu R, Shao M, Ke Z, Li C, Lu F, Zhong MC, Mao Y, Wei X, Zhong Z, Zhou J. Measurement of red blood cell deformability during morphological changes using rotating-glass-plate-based scanning optical tweezers. BIOMEDICAL OPTICS EXPRESS 2023; 14:4979-4989. [PMID: 37791257 PMCID: PMC10545211 DOI: 10.1364/boe.499018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 08/16/2023] [Accepted: 08/16/2023] [Indexed: 10/05/2023]
Abstract
It is important to measure the deformability of red blood cells (RBCs) before transfusion, which is a key factor in the gas transport ability of RBCs and changes during storage of RBCs in vitro. Moreover, the morphology of RBCs also changes during storage. It is proposed that the change in morphology is related to the change in deformability. However, the efficiency of typical methods that use particles as handles is low, especially in the deformability measurement of echinocyte and spherocytes. Therefore, the deformability of RBCs with different morphologies is hard to be measured and compared in the same experiment. In this study, we developed a cost-effective and efficient rotating-glass-plate-based scanning optical tweezers device for the measurement of deformability of RBCs. The performance of this device was evaluated, and the deformability of three types of RBCs was measured using this device. Our results clearly show that the change of erythrocyte morphology from discocyte to echinocyte and spherocyte during storage in vitro is accompanied by a decrease in deformability.
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Affiliation(s)
- Rui Liu
- School of Biomedical Engineering, Anhui Medical University, Hefei 230032, China
| | - Meng Shao
- School of Instrument Science and Optoelectronics Engineering, Hefei University of Technology, Hefei 230009, China
| | - Zeyu Ke
- School of Biomedical Engineering, Anhui Medical University, Hefei 230032, China
| | - Changxu Li
- School of Biomedical Engineering, Anhui Medical University, Hefei 230032, China
| | - Fengya Lu
- School of Biomedical Engineering, Anhui Medical University, Hefei 230032, China
| | - Min-Cheng Zhong
- School of Instrument Science and Optoelectronics Engineering, Hefei University of Technology, Hefei 230009, China
| | - Yuxin Mao
- School of Biomedical Engineering, Anhui Medical University, Hefei 230032, China
| | - Xunbin Wei
- School of Biomedical Engineering, Anhui Medical University, Hefei 230032, China
- Biomedical Engineering Department, Peking University, Beijing 100081, China
| | - Zhensheng Zhong
- School of Biomedical Engineering, Anhui Medical University, Hefei 230032, China
| | - Jinhua Zhou
- School of Biomedical Engineering, Anhui Medical University, Hefei 230032, China
- 3D-Printing and Tissue Engineering Center, Anhui Provincial Institute of Translational Medicine, Anhui Medical University, Hefei 230032, China
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16
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Prehospital Hemorrhage Control and Treatment by Clinicians: A Joint Position Statement. Ann Emerg Med 2023; 82:e1-e8. [PMID: 37349075 DOI: 10.1016/j.annemergmed.2023.03.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 03/10/2023] [Indexed: 06/24/2023]
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Ghossein J, Fernando SM, Rochwerg B, Inaba K, Lampron J, Tran A. A systematic review and meta-analysis of sample size methodology for traumatic hemorrhage trials. J Trauma Acute Care Surg 2023; 94:870-876. [PMID: 36879398 DOI: 10.1097/ta.0000000000003944] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/08/2023]
Abstract
BACKGROUND Trauma hemorrhage remains the most common cause of preventable mortality in trauma. To guide clinical practice, RCTs provide high-quality evidence to inform clinical decision making. The clinical relevance and inferences made by RCTs are dependent on assumptions made during sample size calculation. METHODS To describe the quality of methodology for sample size determination, we conducted a systemic review RCTs evaluating interventions that aim to improve survival in adults with trauma-related hemorrhage. Estimated and actual outcome data are compared, including components of sample size determination. RESULTS A total of 13 RCTs were included. We noted a high rate of negative trial results (11 of 13 studies). Most studies were multi-center and conducted in North America, evaluating patients with blunt and penetrating injuries. The criteria for hemorrhagic shock varied across studies. All studies did not accurately estimate the mortality rate during sample size calculation. All but one study overestimated the mortality reduction during sample size calculation; the median absolute mortality reduction was 3%, compared with a target of 10%. Only the CRASH-2 study used a minimal clinically important different for treatment effect target. No RCTs employed prognostic enrichment. Most studies were terminated (8 of 13), mainly for futility. CONCLUSION Taken together, this review highlights that current clinical trial methodology is limited by imprecise control group risk estimates, overly optimistic treatment effect estimates, and lack of transparent justification for such targets. These limitations result in studies at high risk for futility and potentially premature abandonment of promising therapies. Given the high morbidity and mortality of trauma-related hemorrhage, we recommend that future conduct of trauma RCTs incorporate (1) prognostic enrichment to inform baseline risk, (2) justify target treatment differences based on clinical importance and realistic estimates of feasibility, and (3) be transparent and provide justification for the assumptions made. LEVEL OF EVIDENCE Systematic Review/Meta-Analysis; Level III.
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Affiliation(s)
- Jamie Ghossein
- From the Faculty of Medicine (J.G.), University of Ottawa, Ottawa, Ontario, Canada; Department of Medicine (J.G.), The Ottawa Hospital, Ottawa, Ontario, Canada; Department of Critical Care (S.M.F.), Lakeridge Health Corporation, Oshawa, Canada; Division of Critical Care, Department of Medicine (B.R.), McMaster University, Hamilton, Canada; Department of Health Research Methods (B.R.), Evidence, and Impact, McMaster University, Hamilton, Canada; Division of Acute Care Surgery, Department of Surgery (K.I.), University of Southern California, Los Angeles, California; Division of General Surgery, Department of Surgery (J.L., A.T.), University of Ottawa, Ontario, Canada; and Division of Critical Care, Department of Medicine (A.T.), University of Ottawa, Ontario, Canada
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Xia J, Li Q, Tian Y, Zhao Y, Shen Z, Zhou T, Li J. An unmanned emergency blood dispatch system based on an early prediction and fast delivery strategy: Design and development study. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2023; 235:107512. [PMID: 37030176 DOI: 10.1016/j.cmpb.2023.107512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Revised: 03/10/2023] [Accepted: 03/25/2023] [Indexed: 05/08/2023]
Abstract
BACKGROUND AND OBJECTIVE For severe trauma patients, hemorrhage is the most common cause of medically preventable deaths. Early transfusion is beneficial to major hemorrhagic patients. However, the early supply of emergency blood products for major hemorrhagic patients is still a major problem in many areas. The aim of this study was to design and develop an unmanned emergency blood dispatch system for the fast delivery of blood resources and rapid emergency response to trauma events, especially those with mass hemorrhagic trauma patients and those occurred in remote areas. METHODS Based on the process of emergency medical services for trauma patients, we introduced unmanned aerial vehicle (UAV) and designed the main flowchart of the dispatch system, which combines an emergency transfusion prediction model and UAV-related dispatch algorithms to improve first aid efficiency and quality. The system identifies patients in need of emergency transfusion through a multidimensional prediction model. Then, by analyzing the blood center, hospitals and UAV stations nearby, the system recommends the patient's transfer destination for emergency transfusion and dispatch schemes of UAVs and trucks for a fast supply of blood products. Simulation experiments of urban and rural scenarios were conducted to evaluate the proposed system. RESULTS The developed emergency transfusion prediction model of the proposed system achieves a higher AUROC value of 0.8453 than a classical transfusion prediction score. In the urban experiment, by adopting the proposed system, the average wait time per patient decreased from 32 to 18 min, and the total time decreased from 42 to 29 min. Owing to the combination of the prediction and the fast delivery function, the proposed system took 4 and 11 min less wait time than the strategy with only the prediction function and the strategy with only the fast delivery function, respectively. In the rural experiment, for trauma patients requiring an emergency transfusion at 4 locations, the wait time for transfusion under the proposed system was 16.54, 17.08, 38.70 and 46.00 min less than that under the conventional strategy. The health status-related score increased by 6.9%, 0.9%, 19.1% and 36.7%, respectively. CONCLUSIONS Experimental results demonstrate that the proposed system works well with a faster blood supply speed for severe hemorrhagic patients and better health status. With the assistance of the system, emergency doctors at the scene of an injury are able to comprehensively analyze patients' status and the surrounding rescue conditions and then make decisions, especially when encountering mass casualties or casualties in remote areas.
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Affiliation(s)
- Jing Xia
- Research Center for Healthcare Data Science, Zhejiang Laboratory, Hangzhou, China
| | - Qiang Li
- Emergency Department, the Second Affiliated Hospital, Zhejiang University School of Medicine and Institute of Emergency Medicine, Zhejiang University, Hangzhou, China
| | - Yu Tian
- Engineering Research Center of EMR and Intelligent Expert System, Key Laboratory for Biomedical Engineering of Ministry of Education, Ministry of Education, College of Biomedical Engineering and Instrument Science, Zhejiang University, Hangzhou, China
| | - Yinghao Zhao
- Research Center for Healthcare Data Science, Zhejiang Laboratory, Hangzhou, China
| | - Zhuyi Shen
- Engineering Research Center of EMR and Intelligent Expert System, Key Laboratory for Biomedical Engineering of Ministry of Education, Ministry of Education, College of Biomedical Engineering and Instrument Science, Zhejiang University, Hangzhou, China
| | - Tianshu Zhou
- Research Center for Healthcare Data Science, Zhejiang Laboratory, Hangzhou, China
| | - Jingsong Li
- Research Center for Healthcare Data Science, Zhejiang Laboratory, Hangzhou, China; Engineering Research Center of EMR and Intelligent Expert System, Key Laboratory for Biomedical Engineering of Ministry of Education, Ministry of Education, College of Biomedical Engineering and Instrument Science, Zhejiang University, Hangzhou, China.
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19
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von Vopelius-Feldt J, Lockwood J, Mal S, Beckett A, Callum J, Greene A, Grushka J, Khandelwal A, Lin Y, Nahirniak S, Pavenski K, Peddle M, Prokopchuk-Gauk O, Regehr J, Schmid J, Shih AW, Smith JA, Trojanowski J, Vu E, Ziesmann M, Nolan B. Development of a national out-of-hospital transfusion protocol: a modified RAND Delphi study. CMAJ Open 2023; 11:E546-E559. [PMID: 37369521 DOI: 10.9778/cmajo.20220151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/29/2023] Open
Abstract
BACKGROUND Early resuscitation with blood components or products is emerging as best practice in selected patients with trauma and medical patients; as a result, out-of-hospital transfusion (OHT) programs are being developed based on limited and often conflicting evidence. This study aimed to provide guidance to Canadian critical care transport organizations on the development of OHT protocols. METHODS The study period was July 2021 to June 2022. We used a modified RAND Delphi process to achieve consensus on statements created by the study team guiding various aspects of OHT in the context of critical care transport. Purposive sampling ensured representative distribution of participants in regard to geography and relevant clinical specialties. We conducted 2 written survey Delphi rounds, followed by a virtual panel discussion (round 3). Consensus was defined as a median score of at least 6 on a Likert scale ranging from 1 ("Definitely should not include") to 7 ("Definitely should include"). Statements that did not achieve consensus in the first 2 rounds were discussed and voted on during the panel discussion. RESULTS Seventeen subject experts participated in the study, all of whom completed the 3 Delphi rounds. After the study process was completed, a total of 39 statements were agreed on, covering the following domains: general oversight and clinical governance, storage and transport of blood components and products, initiation of OHT, types of blood components and products, delivery and monitoring of OHT, indications for and use of hemostatic adjuncts, and resuscitation targets of OHT. INTERPRETATION This expert consensus document provides guidance on OHT best practices. The consensus statements should support efficient and safe OHT in national and international critical care transport programs.
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Affiliation(s)
- Johannes von Vopelius-Feldt
- Ornge (von Vopelius-Feldt, Lockwood, Mal, Peddle, Smith, Nolan), Mississauga, Ont.; Department of Emergency Medicine (von Vopelius-Feldt, Lockwood, Nolan), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Division of Emergency Medicine (Mal, Peddle), London Health Sciences Centre, London, Ont.; Department of Surgery, Trauma and Acute Care Surgery (Beckett), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Canadian Forces Health Services Headquarters (Beckett, Schmid), Canadian Armed Forces, Ottawa, Ont.; Department of Pathology and Molecular Medicine (Callum), Kingston Health Sciences Centre and Queen's University, Kingston, Ont.; University of Toronto Quality in Utilization, Education and Safety in Transfusion (QUEST) research program (Callum, Khandelwal, Pavenski), Toronto, Ont.; AirEvac and Critical Care Operations (Greene, Vu), British Columbia Emergency Health Services, Vancouver, BC; School of Medicine (Greene), Cardiff University, Cardiff, Wales, UK; Division of Trauma and General Surgery (Grushka), McGill University Health Centre, Montreal General Hospital Site, Montréal, Que.; Canadian Blood Services (Khandelwal); Department of Laboratory Medicine and Pathobiology (Lin), University of Toronto; Precision Diagnostics and Therapeutics Program (Lin), Sunnybrook Health Sciences Centre, Toronto, Ont.; Faculty of Medicine (Nahirniak), University of Alberta, Edmonton, Alta.; Transfusion and Transplantation Medicine (Nahirniak), Alberta Precision Laboratories, Calgary, Alta.; Departments of Medicine and Laboratory Medicine (Pavenski), St. Michael's Hospital, Unity Health Toronto and University of Toronto, Toronto, Ont.; Division of Transfusion Medicine (Prokopchuk-Gauk), Department of Pathology and Laboratory Medicine, Saskatchewan Health Authority; College of Medicine (Prokopchuk-Gauk), University of Saskatchewan, Saskatoon, Sask.; Emergency Department (Regehr), Health Sciences Centre; Shock Trauma Air Rescue Service (STARS) (Regehr), Manitoba Base, Winnipeg, Man.; Department of Pathology and Laboratory Medicine (Shih), Vancouver Coastal Health Authority; Centre for Blood Research (Shih), University of British Columbia; Department of Emergency Medicine (Trojanowski), Vancouver General Hospital and the University of British Columbia; Clinical Operations (Trojanowski), British Columbia Emergency Health Services; Departments of Emergency Medicine and Critical Care Medicine (Vu), Vancouver Coastal Health Authority and Provincial Health Services Authority, Vancouver, BC; Department of Surgery and Section of Critical Care (Ziesmann), Health Sciences Centre, Winnipeg, Man.
| | - Joel Lockwood
- Ornge (von Vopelius-Feldt, Lockwood, Mal, Peddle, Smith, Nolan), Mississauga, Ont.; Department of Emergency Medicine (von Vopelius-Feldt, Lockwood, Nolan), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Division of Emergency Medicine (Mal, Peddle), London Health Sciences Centre, London, Ont.; Department of Surgery, Trauma and Acute Care Surgery (Beckett), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Canadian Forces Health Services Headquarters (Beckett, Schmid), Canadian Armed Forces, Ottawa, Ont.; Department of Pathology and Molecular Medicine (Callum), Kingston Health Sciences Centre and Queen's University, Kingston, Ont.; University of Toronto Quality in Utilization, Education and Safety in Transfusion (QUEST) research program (Callum, Khandelwal, Pavenski), Toronto, Ont.; AirEvac and Critical Care Operations (Greene, Vu), British Columbia Emergency Health Services, Vancouver, BC; School of Medicine (Greene), Cardiff University, Cardiff, Wales, UK; Division of Trauma and General Surgery (Grushka), McGill University Health Centre, Montreal General Hospital Site, Montréal, Que.; Canadian Blood Services (Khandelwal); Department of Laboratory Medicine and Pathobiology (Lin), University of Toronto; Precision Diagnostics and Therapeutics Program (Lin), Sunnybrook Health Sciences Centre, Toronto, Ont.; Faculty of Medicine (Nahirniak), University of Alberta, Edmonton, Alta.; Transfusion and Transplantation Medicine (Nahirniak), Alberta Precision Laboratories, Calgary, Alta.; Departments of Medicine and Laboratory Medicine (Pavenski), St. Michael's Hospital, Unity Health Toronto and University of Toronto, Toronto, Ont.; Division of Transfusion Medicine (Prokopchuk-Gauk), Department of Pathology and Laboratory Medicine, Saskatchewan Health Authority; College of Medicine (Prokopchuk-Gauk), University of Saskatchewan, Saskatoon, Sask.; Emergency Department (Regehr), Health Sciences Centre; Shock Trauma Air Rescue Service (STARS) (Regehr), Manitoba Base, Winnipeg, Man.; Department of Pathology and Laboratory Medicine (Shih), Vancouver Coastal Health Authority; Centre for Blood Research (Shih), University of British Columbia; Department of Emergency Medicine (Trojanowski), Vancouver General Hospital and the University of British Columbia; Clinical Operations (Trojanowski), British Columbia Emergency Health Services; Departments of Emergency Medicine and Critical Care Medicine (Vu), Vancouver Coastal Health Authority and Provincial Health Services Authority, Vancouver, BC; Department of Surgery and Section of Critical Care (Ziesmann), Health Sciences Centre, Winnipeg, Man
| | - Sameer Mal
- Ornge (von Vopelius-Feldt, Lockwood, Mal, Peddle, Smith, Nolan), Mississauga, Ont.; Department of Emergency Medicine (von Vopelius-Feldt, Lockwood, Nolan), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Division of Emergency Medicine (Mal, Peddle), London Health Sciences Centre, London, Ont.; Department of Surgery, Trauma and Acute Care Surgery (Beckett), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Canadian Forces Health Services Headquarters (Beckett, Schmid), Canadian Armed Forces, Ottawa, Ont.; Department of Pathology and Molecular Medicine (Callum), Kingston Health Sciences Centre and Queen's University, Kingston, Ont.; University of Toronto Quality in Utilization, Education and Safety in Transfusion (QUEST) research program (Callum, Khandelwal, Pavenski), Toronto, Ont.; AirEvac and Critical Care Operations (Greene, Vu), British Columbia Emergency Health Services, Vancouver, BC; School of Medicine (Greene), Cardiff University, Cardiff, Wales, UK; Division of Trauma and General Surgery (Grushka), McGill University Health Centre, Montreal General Hospital Site, Montréal, Que.; Canadian Blood Services (Khandelwal); Department of Laboratory Medicine and Pathobiology (Lin), University of Toronto; Precision Diagnostics and Therapeutics Program (Lin), Sunnybrook Health Sciences Centre, Toronto, Ont.; Faculty of Medicine (Nahirniak), University of Alberta, Edmonton, Alta.; Transfusion and Transplantation Medicine (Nahirniak), Alberta Precision Laboratories, Calgary, Alta.; Departments of Medicine and Laboratory Medicine (Pavenski), St. Michael's Hospital, Unity Health Toronto and University of Toronto, Toronto, Ont.; Division of Transfusion Medicine (Prokopchuk-Gauk), Department of Pathology and Laboratory Medicine, Saskatchewan Health Authority; College of Medicine (Prokopchuk-Gauk), University of Saskatchewan, Saskatoon, Sask.; Emergency Department (Regehr), Health Sciences Centre; Shock Trauma Air Rescue Service (STARS) (Regehr), Manitoba Base, Winnipeg, Man.; Department of Pathology and Laboratory Medicine (Shih), Vancouver Coastal Health Authority; Centre for Blood Research (Shih), University of British Columbia; Department of Emergency Medicine (Trojanowski), Vancouver General Hospital and the University of British Columbia; Clinical Operations (Trojanowski), British Columbia Emergency Health Services; Departments of Emergency Medicine and Critical Care Medicine (Vu), Vancouver Coastal Health Authority and Provincial Health Services Authority, Vancouver, BC; Department of Surgery and Section of Critical Care (Ziesmann), Health Sciences Centre, Winnipeg, Man
| | - Andrew Beckett
- Ornge (von Vopelius-Feldt, Lockwood, Mal, Peddle, Smith, Nolan), Mississauga, Ont.; Department of Emergency Medicine (von Vopelius-Feldt, Lockwood, Nolan), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Division of Emergency Medicine (Mal, Peddle), London Health Sciences Centre, London, Ont.; Department of Surgery, Trauma and Acute Care Surgery (Beckett), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Canadian Forces Health Services Headquarters (Beckett, Schmid), Canadian Armed Forces, Ottawa, Ont.; Department of Pathology and Molecular Medicine (Callum), Kingston Health Sciences Centre and Queen's University, Kingston, Ont.; University of Toronto Quality in Utilization, Education and Safety in Transfusion (QUEST) research program (Callum, Khandelwal, Pavenski), Toronto, Ont.; AirEvac and Critical Care Operations (Greene, Vu), British Columbia Emergency Health Services, Vancouver, BC; School of Medicine (Greene), Cardiff University, Cardiff, Wales, UK; Division of Trauma and General Surgery (Grushka), McGill University Health Centre, Montreal General Hospital Site, Montréal, Que.; Canadian Blood Services (Khandelwal); Department of Laboratory Medicine and Pathobiology (Lin), University of Toronto; Precision Diagnostics and Therapeutics Program (Lin), Sunnybrook Health Sciences Centre, Toronto, Ont.; Faculty of Medicine (Nahirniak), University of Alberta, Edmonton, Alta.; Transfusion and Transplantation Medicine (Nahirniak), Alberta Precision Laboratories, Calgary, Alta.; Departments of Medicine and Laboratory Medicine (Pavenski), St. Michael's Hospital, Unity Health Toronto and University of Toronto, Toronto, Ont.; Division of Transfusion Medicine (Prokopchuk-Gauk), Department of Pathology and Laboratory Medicine, Saskatchewan Health Authority; College of Medicine (Prokopchuk-Gauk), University of Saskatchewan, Saskatoon, Sask.; Emergency Department (Regehr), Health Sciences Centre; Shock Trauma Air Rescue Service (STARS) (Regehr), Manitoba Base, Winnipeg, Man.; Department of Pathology and Laboratory Medicine (Shih), Vancouver Coastal Health Authority; Centre for Blood Research (Shih), University of British Columbia; Department of Emergency Medicine (Trojanowski), Vancouver General Hospital and the University of British Columbia; Clinical Operations (Trojanowski), British Columbia Emergency Health Services; Departments of Emergency Medicine and Critical Care Medicine (Vu), Vancouver Coastal Health Authority and Provincial Health Services Authority, Vancouver, BC; Department of Surgery and Section of Critical Care (Ziesmann), Health Sciences Centre, Winnipeg, Man
| | - Jeannie Callum
- Ornge (von Vopelius-Feldt, Lockwood, Mal, Peddle, Smith, Nolan), Mississauga, Ont.; Department of Emergency Medicine (von Vopelius-Feldt, Lockwood, Nolan), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Division of Emergency Medicine (Mal, Peddle), London Health Sciences Centre, London, Ont.; Department of Surgery, Trauma and Acute Care Surgery (Beckett), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Canadian Forces Health Services Headquarters (Beckett, Schmid), Canadian Armed Forces, Ottawa, Ont.; Department of Pathology and Molecular Medicine (Callum), Kingston Health Sciences Centre and Queen's University, Kingston, Ont.; University of Toronto Quality in Utilization, Education and Safety in Transfusion (QUEST) research program (Callum, Khandelwal, Pavenski), Toronto, Ont.; AirEvac and Critical Care Operations (Greene, Vu), British Columbia Emergency Health Services, Vancouver, BC; School of Medicine (Greene), Cardiff University, Cardiff, Wales, UK; Division of Trauma and General Surgery (Grushka), McGill University Health Centre, Montreal General Hospital Site, Montréal, Que.; Canadian Blood Services (Khandelwal); Department of Laboratory Medicine and Pathobiology (Lin), University of Toronto; Precision Diagnostics and Therapeutics Program (Lin), Sunnybrook Health Sciences Centre, Toronto, Ont.; Faculty of Medicine (Nahirniak), University of Alberta, Edmonton, Alta.; Transfusion and Transplantation Medicine (Nahirniak), Alberta Precision Laboratories, Calgary, Alta.; Departments of Medicine and Laboratory Medicine (Pavenski), St. Michael's Hospital, Unity Health Toronto and University of Toronto, Toronto, Ont.; Division of Transfusion Medicine (Prokopchuk-Gauk), Department of Pathology and Laboratory Medicine, Saskatchewan Health Authority; College of Medicine (Prokopchuk-Gauk), University of Saskatchewan, Saskatoon, Sask.; Emergency Department (Regehr), Health Sciences Centre; Shock Trauma Air Rescue Service (STARS) (Regehr), Manitoba Base, Winnipeg, Man.; Department of Pathology and Laboratory Medicine (Shih), Vancouver Coastal Health Authority; Centre for Blood Research (Shih), University of British Columbia; Department of Emergency Medicine (Trojanowski), Vancouver General Hospital and the University of British Columbia; Clinical Operations (Trojanowski), British Columbia Emergency Health Services; Departments of Emergency Medicine and Critical Care Medicine (Vu), Vancouver Coastal Health Authority and Provincial Health Services Authority, Vancouver, BC; Department of Surgery and Section of Critical Care (Ziesmann), Health Sciences Centre, Winnipeg, Man
| | - Adam Greene
- Ornge (von Vopelius-Feldt, Lockwood, Mal, Peddle, Smith, Nolan), Mississauga, Ont.; Department of Emergency Medicine (von Vopelius-Feldt, Lockwood, Nolan), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Division of Emergency Medicine (Mal, Peddle), London Health Sciences Centre, London, Ont.; Department of Surgery, Trauma and Acute Care Surgery (Beckett), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Canadian Forces Health Services Headquarters (Beckett, Schmid), Canadian Armed Forces, Ottawa, Ont.; Department of Pathology and Molecular Medicine (Callum), Kingston Health Sciences Centre and Queen's University, Kingston, Ont.; University of Toronto Quality in Utilization, Education and Safety in Transfusion (QUEST) research program (Callum, Khandelwal, Pavenski), Toronto, Ont.; AirEvac and Critical Care Operations (Greene, Vu), British Columbia Emergency Health Services, Vancouver, BC; School of Medicine (Greene), Cardiff University, Cardiff, Wales, UK; Division of Trauma and General Surgery (Grushka), McGill University Health Centre, Montreal General Hospital Site, Montréal, Que.; Canadian Blood Services (Khandelwal); Department of Laboratory Medicine and Pathobiology (Lin), University of Toronto; Precision Diagnostics and Therapeutics Program (Lin), Sunnybrook Health Sciences Centre, Toronto, Ont.; Faculty of Medicine (Nahirniak), University of Alberta, Edmonton, Alta.; Transfusion and Transplantation Medicine (Nahirniak), Alberta Precision Laboratories, Calgary, Alta.; Departments of Medicine and Laboratory Medicine (Pavenski), St. Michael's Hospital, Unity Health Toronto and University of Toronto, Toronto, Ont.; Division of Transfusion Medicine (Prokopchuk-Gauk), Department of Pathology and Laboratory Medicine, Saskatchewan Health Authority; College of Medicine (Prokopchuk-Gauk), University of Saskatchewan, Saskatoon, Sask.; Emergency Department (Regehr), Health Sciences Centre; Shock Trauma Air Rescue Service (STARS) (Regehr), Manitoba Base, Winnipeg, Man.; Department of Pathology and Laboratory Medicine (Shih), Vancouver Coastal Health Authority; Centre for Blood Research (Shih), University of British Columbia; Department of Emergency Medicine (Trojanowski), Vancouver General Hospital and the University of British Columbia; Clinical Operations (Trojanowski), British Columbia Emergency Health Services; Departments of Emergency Medicine and Critical Care Medicine (Vu), Vancouver Coastal Health Authority and Provincial Health Services Authority, Vancouver, BC; Department of Surgery and Section of Critical Care (Ziesmann), Health Sciences Centre, Winnipeg, Man
| | - Jeremy Grushka
- Ornge (von Vopelius-Feldt, Lockwood, Mal, Peddle, Smith, Nolan), Mississauga, Ont.; Department of Emergency Medicine (von Vopelius-Feldt, Lockwood, Nolan), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Division of Emergency Medicine (Mal, Peddle), London Health Sciences Centre, London, Ont.; Department of Surgery, Trauma and Acute Care Surgery (Beckett), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Canadian Forces Health Services Headquarters (Beckett, Schmid), Canadian Armed Forces, Ottawa, Ont.; Department of Pathology and Molecular Medicine (Callum), Kingston Health Sciences Centre and Queen's University, Kingston, Ont.; University of Toronto Quality in Utilization, Education and Safety in Transfusion (QUEST) research program (Callum, Khandelwal, Pavenski), Toronto, Ont.; AirEvac and Critical Care Operations (Greene, Vu), British Columbia Emergency Health Services, Vancouver, BC; School of Medicine (Greene), Cardiff University, Cardiff, Wales, UK; Division of Trauma and General Surgery (Grushka), McGill University Health Centre, Montreal General Hospital Site, Montréal, Que.; Canadian Blood Services (Khandelwal); Department of Laboratory Medicine and Pathobiology (Lin), University of Toronto; Precision Diagnostics and Therapeutics Program (Lin), Sunnybrook Health Sciences Centre, Toronto, Ont.; Faculty of Medicine (Nahirniak), University of Alberta, Edmonton, Alta.; Transfusion and Transplantation Medicine (Nahirniak), Alberta Precision Laboratories, Calgary, Alta.; Departments of Medicine and Laboratory Medicine (Pavenski), St. Michael's Hospital, Unity Health Toronto and University of Toronto, Toronto, Ont.; Division of Transfusion Medicine (Prokopchuk-Gauk), Department of Pathology and Laboratory Medicine, Saskatchewan Health Authority; College of Medicine (Prokopchuk-Gauk), University of Saskatchewan, Saskatoon, Sask.; Emergency Department (Regehr), Health Sciences Centre; Shock Trauma Air Rescue Service (STARS) (Regehr), Manitoba Base, Winnipeg, Man.; Department of Pathology and Laboratory Medicine (Shih), Vancouver Coastal Health Authority; Centre for Blood Research (Shih), University of British Columbia; Department of Emergency Medicine (Trojanowski), Vancouver General Hospital and the University of British Columbia; Clinical Operations (Trojanowski), British Columbia Emergency Health Services; Departments of Emergency Medicine and Critical Care Medicine (Vu), Vancouver Coastal Health Authority and Provincial Health Services Authority, Vancouver, BC; Department of Surgery and Section of Critical Care (Ziesmann), Health Sciences Centre, Winnipeg, Man
| | - Aditi Khandelwal
- Ornge (von Vopelius-Feldt, Lockwood, Mal, Peddle, Smith, Nolan), Mississauga, Ont.; Department of Emergency Medicine (von Vopelius-Feldt, Lockwood, Nolan), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Division of Emergency Medicine (Mal, Peddle), London Health Sciences Centre, London, Ont.; Department of Surgery, Trauma and Acute Care Surgery (Beckett), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Canadian Forces Health Services Headquarters (Beckett, Schmid), Canadian Armed Forces, Ottawa, Ont.; Department of Pathology and Molecular Medicine (Callum), Kingston Health Sciences Centre and Queen's University, Kingston, Ont.; University of Toronto Quality in Utilization, Education and Safety in Transfusion (QUEST) research program (Callum, Khandelwal, Pavenski), Toronto, Ont.; AirEvac and Critical Care Operations (Greene, Vu), British Columbia Emergency Health Services, Vancouver, BC; School of Medicine (Greene), Cardiff University, Cardiff, Wales, UK; Division of Trauma and General Surgery (Grushka), McGill University Health Centre, Montreal General Hospital Site, Montréal, Que.; Canadian Blood Services (Khandelwal); Department of Laboratory Medicine and Pathobiology (Lin), University of Toronto; Precision Diagnostics and Therapeutics Program (Lin), Sunnybrook Health Sciences Centre, Toronto, Ont.; Faculty of Medicine (Nahirniak), University of Alberta, Edmonton, Alta.; Transfusion and Transplantation Medicine (Nahirniak), Alberta Precision Laboratories, Calgary, Alta.; Departments of Medicine and Laboratory Medicine (Pavenski), St. Michael's Hospital, Unity Health Toronto and University of Toronto, Toronto, Ont.; Division of Transfusion Medicine (Prokopchuk-Gauk), Department of Pathology and Laboratory Medicine, Saskatchewan Health Authority; College of Medicine (Prokopchuk-Gauk), University of Saskatchewan, Saskatoon, Sask.; Emergency Department (Regehr), Health Sciences Centre; Shock Trauma Air Rescue Service (STARS) (Regehr), Manitoba Base, Winnipeg, Man.; Department of Pathology and Laboratory Medicine (Shih), Vancouver Coastal Health Authority; Centre for Blood Research (Shih), University of British Columbia; Department of Emergency Medicine (Trojanowski), Vancouver General Hospital and the University of British Columbia; Clinical Operations (Trojanowski), British Columbia Emergency Health Services; Departments of Emergency Medicine and Critical Care Medicine (Vu), Vancouver Coastal Health Authority and Provincial Health Services Authority, Vancouver, BC; Department of Surgery and Section of Critical Care (Ziesmann), Health Sciences Centre, Winnipeg, Man
| | - Yulia Lin
- Ornge (von Vopelius-Feldt, Lockwood, Mal, Peddle, Smith, Nolan), Mississauga, Ont.; Department of Emergency Medicine (von Vopelius-Feldt, Lockwood, Nolan), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Division of Emergency Medicine (Mal, Peddle), London Health Sciences Centre, London, Ont.; Department of Surgery, Trauma and Acute Care Surgery (Beckett), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Canadian Forces Health Services Headquarters (Beckett, Schmid), Canadian Armed Forces, Ottawa, Ont.; Department of Pathology and Molecular Medicine (Callum), Kingston Health Sciences Centre and Queen's University, Kingston, Ont.; University of Toronto Quality in Utilization, Education and Safety in Transfusion (QUEST) research program (Callum, Khandelwal, Pavenski), Toronto, Ont.; AirEvac and Critical Care Operations (Greene, Vu), British Columbia Emergency Health Services, Vancouver, BC; School of Medicine (Greene), Cardiff University, Cardiff, Wales, UK; Division of Trauma and General Surgery (Grushka), McGill University Health Centre, Montreal General Hospital Site, Montréal, Que.; Canadian Blood Services (Khandelwal); Department of Laboratory Medicine and Pathobiology (Lin), University of Toronto; Precision Diagnostics and Therapeutics Program (Lin), Sunnybrook Health Sciences Centre, Toronto, Ont.; Faculty of Medicine (Nahirniak), University of Alberta, Edmonton, Alta.; Transfusion and Transplantation Medicine (Nahirniak), Alberta Precision Laboratories, Calgary, Alta.; Departments of Medicine and Laboratory Medicine (Pavenski), St. Michael's Hospital, Unity Health Toronto and University of Toronto, Toronto, Ont.; Division of Transfusion Medicine (Prokopchuk-Gauk), Department of Pathology and Laboratory Medicine, Saskatchewan Health Authority; College of Medicine (Prokopchuk-Gauk), University of Saskatchewan, Saskatoon, Sask.; Emergency Department (Regehr), Health Sciences Centre; Shock Trauma Air Rescue Service (STARS) (Regehr), Manitoba Base, Winnipeg, Man.; Department of Pathology and Laboratory Medicine (Shih), Vancouver Coastal Health Authority; Centre for Blood Research (Shih), University of British Columbia; Department of Emergency Medicine (Trojanowski), Vancouver General Hospital and the University of British Columbia; Clinical Operations (Trojanowski), British Columbia Emergency Health Services; Departments of Emergency Medicine and Critical Care Medicine (Vu), Vancouver Coastal Health Authority and Provincial Health Services Authority, Vancouver, BC; Department of Surgery and Section of Critical Care (Ziesmann), Health Sciences Centre, Winnipeg, Man
| | - Susan Nahirniak
- Ornge (von Vopelius-Feldt, Lockwood, Mal, Peddle, Smith, Nolan), Mississauga, Ont.; Department of Emergency Medicine (von Vopelius-Feldt, Lockwood, Nolan), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Division of Emergency Medicine (Mal, Peddle), London Health Sciences Centre, London, Ont.; Department of Surgery, Trauma and Acute Care Surgery (Beckett), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Canadian Forces Health Services Headquarters (Beckett, Schmid), Canadian Armed Forces, Ottawa, Ont.; Department of Pathology and Molecular Medicine (Callum), Kingston Health Sciences Centre and Queen's University, Kingston, Ont.; University of Toronto Quality in Utilization, Education and Safety in Transfusion (QUEST) research program (Callum, Khandelwal, Pavenski), Toronto, Ont.; AirEvac and Critical Care Operations (Greene, Vu), British Columbia Emergency Health Services, Vancouver, BC; School of Medicine (Greene), Cardiff University, Cardiff, Wales, UK; Division of Trauma and General Surgery (Grushka), McGill University Health Centre, Montreal General Hospital Site, Montréal, Que.; Canadian Blood Services (Khandelwal); Department of Laboratory Medicine and Pathobiology (Lin), University of Toronto; Precision Diagnostics and Therapeutics Program (Lin), Sunnybrook Health Sciences Centre, Toronto, Ont.; Faculty of Medicine (Nahirniak), University of Alberta, Edmonton, Alta.; Transfusion and Transplantation Medicine (Nahirniak), Alberta Precision Laboratories, Calgary, Alta.; Departments of Medicine and Laboratory Medicine (Pavenski), St. Michael's Hospital, Unity Health Toronto and University of Toronto, Toronto, Ont.; Division of Transfusion Medicine (Prokopchuk-Gauk), Department of Pathology and Laboratory Medicine, Saskatchewan Health Authority; College of Medicine (Prokopchuk-Gauk), University of Saskatchewan, Saskatoon, Sask.; Emergency Department (Regehr), Health Sciences Centre; Shock Trauma Air Rescue Service (STARS) (Regehr), Manitoba Base, Winnipeg, Man.; Department of Pathology and Laboratory Medicine (Shih), Vancouver Coastal Health Authority; Centre for Blood Research (Shih), University of British Columbia; Department of Emergency Medicine (Trojanowski), Vancouver General Hospital and the University of British Columbia; Clinical Operations (Trojanowski), British Columbia Emergency Health Services; Departments of Emergency Medicine and Critical Care Medicine (Vu), Vancouver Coastal Health Authority and Provincial Health Services Authority, Vancouver, BC; Department of Surgery and Section of Critical Care (Ziesmann), Health Sciences Centre, Winnipeg, Man
| | - Katerina Pavenski
- Ornge (von Vopelius-Feldt, Lockwood, Mal, Peddle, Smith, Nolan), Mississauga, Ont.; Department of Emergency Medicine (von Vopelius-Feldt, Lockwood, Nolan), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Division of Emergency Medicine (Mal, Peddle), London Health Sciences Centre, London, Ont.; Department of Surgery, Trauma and Acute Care Surgery (Beckett), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Canadian Forces Health Services Headquarters (Beckett, Schmid), Canadian Armed Forces, Ottawa, Ont.; Department of Pathology and Molecular Medicine (Callum), Kingston Health Sciences Centre and Queen's University, Kingston, Ont.; University of Toronto Quality in Utilization, Education and Safety in Transfusion (QUEST) research program (Callum, Khandelwal, Pavenski), Toronto, Ont.; AirEvac and Critical Care Operations (Greene, Vu), British Columbia Emergency Health Services, Vancouver, BC; School of Medicine (Greene), Cardiff University, Cardiff, Wales, UK; Division of Trauma and General Surgery (Grushka), McGill University Health Centre, Montreal General Hospital Site, Montréal, Que.; Canadian Blood Services (Khandelwal); Department of Laboratory Medicine and Pathobiology (Lin), University of Toronto; Precision Diagnostics and Therapeutics Program (Lin), Sunnybrook Health Sciences Centre, Toronto, Ont.; Faculty of Medicine (Nahirniak), University of Alberta, Edmonton, Alta.; Transfusion and Transplantation Medicine (Nahirniak), Alberta Precision Laboratories, Calgary, Alta.; Departments of Medicine and Laboratory Medicine (Pavenski), St. Michael's Hospital, Unity Health Toronto and University of Toronto, Toronto, Ont.; Division of Transfusion Medicine (Prokopchuk-Gauk), Department of Pathology and Laboratory Medicine, Saskatchewan Health Authority; College of Medicine (Prokopchuk-Gauk), University of Saskatchewan, Saskatoon, Sask.; Emergency Department (Regehr), Health Sciences Centre; Shock Trauma Air Rescue Service (STARS) (Regehr), Manitoba Base, Winnipeg, Man.; Department of Pathology and Laboratory Medicine (Shih), Vancouver Coastal Health Authority; Centre for Blood Research (Shih), University of British Columbia; Department of Emergency Medicine (Trojanowski), Vancouver General Hospital and the University of British Columbia; Clinical Operations (Trojanowski), British Columbia Emergency Health Services; Departments of Emergency Medicine and Critical Care Medicine (Vu), Vancouver Coastal Health Authority and Provincial Health Services Authority, Vancouver, BC; Department of Surgery and Section of Critical Care (Ziesmann), Health Sciences Centre, Winnipeg, Man
| | - Michael Peddle
- Ornge (von Vopelius-Feldt, Lockwood, Mal, Peddle, Smith, Nolan), Mississauga, Ont.; Department of Emergency Medicine (von Vopelius-Feldt, Lockwood, Nolan), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Division of Emergency Medicine (Mal, Peddle), London Health Sciences Centre, London, Ont.; Department of Surgery, Trauma and Acute Care Surgery (Beckett), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Canadian Forces Health Services Headquarters (Beckett, Schmid), Canadian Armed Forces, Ottawa, Ont.; Department of Pathology and Molecular Medicine (Callum), Kingston Health Sciences Centre and Queen's University, Kingston, Ont.; University of Toronto Quality in Utilization, Education and Safety in Transfusion (QUEST) research program (Callum, Khandelwal, Pavenski), Toronto, Ont.; AirEvac and Critical Care Operations (Greene, Vu), British Columbia Emergency Health Services, Vancouver, BC; School of Medicine (Greene), Cardiff University, Cardiff, Wales, UK; Division of Trauma and General Surgery (Grushka), McGill University Health Centre, Montreal General Hospital Site, Montréal, Que.; Canadian Blood Services (Khandelwal); Department of Laboratory Medicine and Pathobiology (Lin), University of Toronto; Precision Diagnostics and Therapeutics Program (Lin), Sunnybrook Health Sciences Centre, Toronto, Ont.; Faculty of Medicine (Nahirniak), University of Alberta, Edmonton, Alta.; Transfusion and Transplantation Medicine (Nahirniak), Alberta Precision Laboratories, Calgary, Alta.; Departments of Medicine and Laboratory Medicine (Pavenski), St. Michael's Hospital, Unity Health Toronto and University of Toronto, Toronto, Ont.; Division of Transfusion Medicine (Prokopchuk-Gauk), Department of Pathology and Laboratory Medicine, Saskatchewan Health Authority; College of Medicine (Prokopchuk-Gauk), University of Saskatchewan, Saskatoon, Sask.; Emergency Department (Regehr), Health Sciences Centre; Shock Trauma Air Rescue Service (STARS) (Regehr), Manitoba Base, Winnipeg, Man.; Department of Pathology and Laboratory Medicine (Shih), Vancouver Coastal Health Authority; Centre for Blood Research (Shih), University of British Columbia; Department of Emergency Medicine (Trojanowski), Vancouver General Hospital and the University of British Columbia; Clinical Operations (Trojanowski), British Columbia Emergency Health Services; Departments of Emergency Medicine and Critical Care Medicine (Vu), Vancouver Coastal Health Authority and Provincial Health Services Authority, Vancouver, BC; Department of Surgery and Section of Critical Care (Ziesmann), Health Sciences Centre, Winnipeg, Man
| | - Oksana Prokopchuk-Gauk
- Ornge (von Vopelius-Feldt, Lockwood, Mal, Peddle, Smith, Nolan), Mississauga, Ont.; Department of Emergency Medicine (von Vopelius-Feldt, Lockwood, Nolan), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Division of Emergency Medicine (Mal, Peddle), London Health Sciences Centre, London, Ont.; Department of Surgery, Trauma and Acute Care Surgery (Beckett), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Canadian Forces Health Services Headquarters (Beckett, Schmid), Canadian Armed Forces, Ottawa, Ont.; Department of Pathology and Molecular Medicine (Callum), Kingston Health Sciences Centre and Queen's University, Kingston, Ont.; University of Toronto Quality in Utilization, Education and Safety in Transfusion (QUEST) research program (Callum, Khandelwal, Pavenski), Toronto, Ont.; AirEvac and Critical Care Operations (Greene, Vu), British Columbia Emergency Health Services, Vancouver, BC; School of Medicine (Greene), Cardiff University, Cardiff, Wales, UK; Division of Trauma and General Surgery (Grushka), McGill University Health Centre, Montreal General Hospital Site, Montréal, Que.; Canadian Blood Services (Khandelwal); Department of Laboratory Medicine and Pathobiology (Lin), University of Toronto; Precision Diagnostics and Therapeutics Program (Lin), Sunnybrook Health Sciences Centre, Toronto, Ont.; Faculty of Medicine (Nahirniak), University of Alberta, Edmonton, Alta.; Transfusion and Transplantation Medicine (Nahirniak), Alberta Precision Laboratories, Calgary, Alta.; Departments of Medicine and Laboratory Medicine (Pavenski), St. Michael's Hospital, Unity Health Toronto and University of Toronto, Toronto, Ont.; Division of Transfusion Medicine (Prokopchuk-Gauk), Department of Pathology and Laboratory Medicine, Saskatchewan Health Authority; College of Medicine (Prokopchuk-Gauk), University of Saskatchewan, Saskatoon, Sask.; Emergency Department (Regehr), Health Sciences Centre; Shock Trauma Air Rescue Service (STARS) (Regehr), Manitoba Base, Winnipeg, Man.; Department of Pathology and Laboratory Medicine (Shih), Vancouver Coastal Health Authority; Centre for Blood Research (Shih), University of British Columbia; Department of Emergency Medicine (Trojanowski), Vancouver General Hospital and the University of British Columbia; Clinical Operations (Trojanowski), British Columbia Emergency Health Services; Departments of Emergency Medicine and Critical Care Medicine (Vu), Vancouver Coastal Health Authority and Provincial Health Services Authority, Vancouver, BC; Department of Surgery and Section of Critical Care (Ziesmann), Health Sciences Centre, Winnipeg, Man
| | - Julian Regehr
- Ornge (von Vopelius-Feldt, Lockwood, Mal, Peddle, Smith, Nolan), Mississauga, Ont.; Department of Emergency Medicine (von Vopelius-Feldt, Lockwood, Nolan), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Division of Emergency Medicine (Mal, Peddle), London Health Sciences Centre, London, Ont.; Department of Surgery, Trauma and Acute Care Surgery (Beckett), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Canadian Forces Health Services Headquarters (Beckett, Schmid), Canadian Armed Forces, Ottawa, Ont.; Department of Pathology and Molecular Medicine (Callum), Kingston Health Sciences Centre and Queen's University, Kingston, Ont.; University of Toronto Quality in Utilization, Education and Safety in Transfusion (QUEST) research program (Callum, Khandelwal, Pavenski), Toronto, Ont.; AirEvac and Critical Care Operations (Greene, Vu), British Columbia Emergency Health Services, Vancouver, BC; School of Medicine (Greene), Cardiff University, Cardiff, Wales, UK; Division of Trauma and General Surgery (Grushka), McGill University Health Centre, Montreal General Hospital Site, Montréal, Que.; Canadian Blood Services (Khandelwal); Department of Laboratory Medicine and Pathobiology (Lin), University of Toronto; Precision Diagnostics and Therapeutics Program (Lin), Sunnybrook Health Sciences Centre, Toronto, Ont.; Faculty of Medicine (Nahirniak), University of Alberta, Edmonton, Alta.; Transfusion and Transplantation Medicine (Nahirniak), Alberta Precision Laboratories, Calgary, Alta.; Departments of Medicine and Laboratory Medicine (Pavenski), St. Michael's Hospital, Unity Health Toronto and University of Toronto, Toronto, Ont.; Division of Transfusion Medicine (Prokopchuk-Gauk), Department of Pathology and Laboratory Medicine, Saskatchewan Health Authority; College of Medicine (Prokopchuk-Gauk), University of Saskatchewan, Saskatoon, Sask.; Emergency Department (Regehr), Health Sciences Centre; Shock Trauma Air Rescue Service (STARS) (Regehr), Manitoba Base, Winnipeg, Man.; Department of Pathology and Laboratory Medicine (Shih), Vancouver Coastal Health Authority; Centre for Blood Research (Shih), University of British Columbia; Department of Emergency Medicine (Trojanowski), Vancouver General Hospital and the University of British Columbia; Clinical Operations (Trojanowski), British Columbia Emergency Health Services; Departments of Emergency Medicine and Critical Care Medicine (Vu), Vancouver Coastal Health Authority and Provincial Health Services Authority, Vancouver, BC; Department of Surgery and Section of Critical Care (Ziesmann), Health Sciences Centre, Winnipeg, Man
| | - Jo Schmid
- Ornge (von Vopelius-Feldt, Lockwood, Mal, Peddle, Smith, Nolan), Mississauga, Ont.; Department of Emergency Medicine (von Vopelius-Feldt, Lockwood, Nolan), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Division of Emergency Medicine (Mal, Peddle), London Health Sciences Centre, London, Ont.; Department of Surgery, Trauma and Acute Care Surgery (Beckett), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Canadian Forces Health Services Headquarters (Beckett, Schmid), Canadian Armed Forces, Ottawa, Ont.; Department of Pathology and Molecular Medicine (Callum), Kingston Health Sciences Centre and Queen's University, Kingston, Ont.; University of Toronto Quality in Utilization, Education and Safety in Transfusion (QUEST) research program (Callum, Khandelwal, Pavenski), Toronto, Ont.; AirEvac and Critical Care Operations (Greene, Vu), British Columbia Emergency Health Services, Vancouver, BC; School of Medicine (Greene), Cardiff University, Cardiff, Wales, UK; Division of Trauma and General Surgery (Grushka), McGill University Health Centre, Montreal General Hospital Site, Montréal, Que.; Canadian Blood Services (Khandelwal); Department of Laboratory Medicine and Pathobiology (Lin), University of Toronto; Precision Diagnostics and Therapeutics Program (Lin), Sunnybrook Health Sciences Centre, Toronto, Ont.; Faculty of Medicine (Nahirniak), University of Alberta, Edmonton, Alta.; Transfusion and Transplantation Medicine (Nahirniak), Alberta Precision Laboratories, Calgary, Alta.; Departments of Medicine and Laboratory Medicine (Pavenski), St. Michael's Hospital, Unity Health Toronto and University of Toronto, Toronto, Ont.; Division of Transfusion Medicine (Prokopchuk-Gauk), Department of Pathology and Laboratory Medicine, Saskatchewan Health Authority; College of Medicine (Prokopchuk-Gauk), University of Saskatchewan, Saskatoon, Sask.; Emergency Department (Regehr), Health Sciences Centre; Shock Trauma Air Rescue Service (STARS) (Regehr), Manitoba Base, Winnipeg, Man.; Department of Pathology and Laboratory Medicine (Shih), Vancouver Coastal Health Authority; Centre for Blood Research (Shih), University of British Columbia; Department of Emergency Medicine (Trojanowski), Vancouver General Hospital and the University of British Columbia; Clinical Operations (Trojanowski), British Columbia Emergency Health Services; Departments of Emergency Medicine and Critical Care Medicine (Vu), Vancouver Coastal Health Authority and Provincial Health Services Authority, Vancouver, BC; Department of Surgery and Section of Critical Care (Ziesmann), Health Sciences Centre, Winnipeg, Man
| | - Andrew W Shih
- Ornge (von Vopelius-Feldt, Lockwood, Mal, Peddle, Smith, Nolan), Mississauga, Ont.; Department of Emergency Medicine (von Vopelius-Feldt, Lockwood, Nolan), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Division of Emergency Medicine (Mal, Peddle), London Health Sciences Centre, London, Ont.; Department of Surgery, Trauma and Acute Care Surgery (Beckett), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Canadian Forces Health Services Headquarters (Beckett, Schmid), Canadian Armed Forces, Ottawa, Ont.; Department of Pathology and Molecular Medicine (Callum), Kingston Health Sciences Centre and Queen's University, Kingston, Ont.; University of Toronto Quality in Utilization, Education and Safety in Transfusion (QUEST) research program (Callum, Khandelwal, Pavenski), Toronto, Ont.; AirEvac and Critical Care Operations (Greene, Vu), British Columbia Emergency Health Services, Vancouver, BC; School of Medicine (Greene), Cardiff University, Cardiff, Wales, UK; Division of Trauma and General Surgery (Grushka), McGill University Health Centre, Montreal General Hospital Site, Montréal, Que.; Canadian Blood Services (Khandelwal); Department of Laboratory Medicine and Pathobiology (Lin), University of Toronto; Precision Diagnostics and Therapeutics Program (Lin), Sunnybrook Health Sciences Centre, Toronto, Ont.; Faculty of Medicine (Nahirniak), University of Alberta, Edmonton, Alta.; Transfusion and Transplantation Medicine (Nahirniak), Alberta Precision Laboratories, Calgary, Alta.; Departments of Medicine and Laboratory Medicine (Pavenski), St. Michael's Hospital, Unity Health Toronto and University of Toronto, Toronto, Ont.; Division of Transfusion Medicine (Prokopchuk-Gauk), Department of Pathology and Laboratory Medicine, Saskatchewan Health Authority; College of Medicine (Prokopchuk-Gauk), University of Saskatchewan, Saskatoon, Sask.; Emergency Department (Regehr), Health Sciences Centre; Shock Trauma Air Rescue Service (STARS) (Regehr), Manitoba Base, Winnipeg, Man.; Department of Pathology and Laboratory Medicine (Shih), Vancouver Coastal Health Authority; Centre for Blood Research (Shih), University of British Columbia; Department of Emergency Medicine (Trojanowski), Vancouver General Hospital and the University of British Columbia; Clinical Operations (Trojanowski), British Columbia Emergency Health Services; Departments of Emergency Medicine and Critical Care Medicine (Vu), Vancouver Coastal Health Authority and Provincial Health Services Authority, Vancouver, BC; Department of Surgery and Section of Critical Care (Ziesmann), Health Sciences Centre, Winnipeg, Man
| | - Justin A Smith
- Ornge (von Vopelius-Feldt, Lockwood, Mal, Peddle, Smith, Nolan), Mississauga, Ont.; Department of Emergency Medicine (von Vopelius-Feldt, Lockwood, Nolan), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Division of Emergency Medicine (Mal, Peddle), London Health Sciences Centre, London, Ont.; Department of Surgery, Trauma and Acute Care Surgery (Beckett), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Canadian Forces Health Services Headquarters (Beckett, Schmid), Canadian Armed Forces, Ottawa, Ont.; Department of Pathology and Molecular Medicine (Callum), Kingston Health Sciences Centre and Queen's University, Kingston, Ont.; University of Toronto Quality in Utilization, Education and Safety in Transfusion (QUEST) research program (Callum, Khandelwal, Pavenski), Toronto, Ont.; AirEvac and Critical Care Operations (Greene, Vu), British Columbia Emergency Health Services, Vancouver, BC; School of Medicine (Greene), Cardiff University, Cardiff, Wales, UK; Division of Trauma and General Surgery (Grushka), McGill University Health Centre, Montreal General Hospital Site, Montréal, Que.; Canadian Blood Services (Khandelwal); Department of Laboratory Medicine and Pathobiology (Lin), University of Toronto; Precision Diagnostics and Therapeutics Program (Lin), Sunnybrook Health Sciences Centre, Toronto, Ont.; Faculty of Medicine (Nahirniak), University of Alberta, Edmonton, Alta.; Transfusion and Transplantation Medicine (Nahirniak), Alberta Precision Laboratories, Calgary, Alta.; Departments of Medicine and Laboratory Medicine (Pavenski), St. Michael's Hospital, Unity Health Toronto and University of Toronto, Toronto, Ont.; Division of Transfusion Medicine (Prokopchuk-Gauk), Department of Pathology and Laboratory Medicine, Saskatchewan Health Authority; College of Medicine (Prokopchuk-Gauk), University of Saskatchewan, Saskatoon, Sask.; Emergency Department (Regehr), Health Sciences Centre; Shock Trauma Air Rescue Service (STARS) (Regehr), Manitoba Base, Winnipeg, Man.; Department of Pathology and Laboratory Medicine (Shih), Vancouver Coastal Health Authority; Centre for Blood Research (Shih), University of British Columbia; Department of Emergency Medicine (Trojanowski), Vancouver General Hospital and the University of British Columbia; Clinical Operations (Trojanowski), British Columbia Emergency Health Services; Departments of Emergency Medicine and Critical Care Medicine (Vu), Vancouver Coastal Health Authority and Provincial Health Services Authority, Vancouver, BC; Department of Surgery and Section of Critical Care (Ziesmann), Health Sciences Centre, Winnipeg, Man
| | - Jan Trojanowski
- Ornge (von Vopelius-Feldt, Lockwood, Mal, Peddle, Smith, Nolan), Mississauga, Ont.; Department of Emergency Medicine (von Vopelius-Feldt, Lockwood, Nolan), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Division of Emergency Medicine (Mal, Peddle), London Health Sciences Centre, London, Ont.; Department of Surgery, Trauma and Acute Care Surgery (Beckett), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Canadian Forces Health Services Headquarters (Beckett, Schmid), Canadian Armed Forces, Ottawa, Ont.; Department of Pathology and Molecular Medicine (Callum), Kingston Health Sciences Centre and Queen's University, Kingston, Ont.; University of Toronto Quality in Utilization, Education and Safety in Transfusion (QUEST) research program (Callum, Khandelwal, Pavenski), Toronto, Ont.; AirEvac and Critical Care Operations (Greene, Vu), British Columbia Emergency Health Services, Vancouver, BC; School of Medicine (Greene), Cardiff University, Cardiff, Wales, UK; Division of Trauma and General Surgery (Grushka), McGill University Health Centre, Montreal General Hospital Site, Montréal, Que.; Canadian Blood Services (Khandelwal); Department of Laboratory Medicine and Pathobiology (Lin), University of Toronto; Precision Diagnostics and Therapeutics Program (Lin), Sunnybrook Health Sciences Centre, Toronto, Ont.; Faculty of Medicine (Nahirniak), University of Alberta, Edmonton, Alta.; Transfusion and Transplantation Medicine (Nahirniak), Alberta Precision Laboratories, Calgary, Alta.; Departments of Medicine and Laboratory Medicine (Pavenski), St. Michael's Hospital, Unity Health Toronto and University of Toronto, Toronto, Ont.; Division of Transfusion Medicine (Prokopchuk-Gauk), Department of Pathology and Laboratory Medicine, Saskatchewan Health Authority; College of Medicine (Prokopchuk-Gauk), University of Saskatchewan, Saskatoon, Sask.; Emergency Department (Regehr), Health Sciences Centre; Shock Trauma Air Rescue Service (STARS) (Regehr), Manitoba Base, Winnipeg, Man.; Department of Pathology and Laboratory Medicine (Shih), Vancouver Coastal Health Authority; Centre for Blood Research (Shih), University of British Columbia; Department of Emergency Medicine (Trojanowski), Vancouver General Hospital and the University of British Columbia; Clinical Operations (Trojanowski), British Columbia Emergency Health Services; Departments of Emergency Medicine and Critical Care Medicine (Vu), Vancouver Coastal Health Authority and Provincial Health Services Authority, Vancouver, BC; Department of Surgery and Section of Critical Care (Ziesmann), Health Sciences Centre, Winnipeg, Man
| | - Erik Vu
- Ornge (von Vopelius-Feldt, Lockwood, Mal, Peddle, Smith, Nolan), Mississauga, Ont.; Department of Emergency Medicine (von Vopelius-Feldt, Lockwood, Nolan), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Division of Emergency Medicine (Mal, Peddle), London Health Sciences Centre, London, Ont.; Department of Surgery, Trauma and Acute Care Surgery (Beckett), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Canadian Forces Health Services Headquarters (Beckett, Schmid), Canadian Armed Forces, Ottawa, Ont.; Department of Pathology and Molecular Medicine (Callum), Kingston Health Sciences Centre and Queen's University, Kingston, Ont.; University of Toronto Quality in Utilization, Education and Safety in Transfusion (QUEST) research program (Callum, Khandelwal, Pavenski), Toronto, Ont.; AirEvac and Critical Care Operations (Greene, Vu), British Columbia Emergency Health Services, Vancouver, BC; School of Medicine (Greene), Cardiff University, Cardiff, Wales, UK; Division of Trauma and General Surgery (Grushka), McGill University Health Centre, Montreal General Hospital Site, Montréal, Que.; Canadian Blood Services (Khandelwal); Department of Laboratory Medicine and Pathobiology (Lin), University of Toronto; Precision Diagnostics and Therapeutics Program (Lin), Sunnybrook Health Sciences Centre, Toronto, Ont.; Faculty of Medicine (Nahirniak), University of Alberta, Edmonton, Alta.; Transfusion and Transplantation Medicine (Nahirniak), Alberta Precision Laboratories, Calgary, Alta.; Departments of Medicine and Laboratory Medicine (Pavenski), St. Michael's Hospital, Unity Health Toronto and University of Toronto, Toronto, Ont.; Division of Transfusion Medicine (Prokopchuk-Gauk), Department of Pathology and Laboratory Medicine, Saskatchewan Health Authority; College of Medicine (Prokopchuk-Gauk), University of Saskatchewan, Saskatoon, Sask.; Emergency Department (Regehr), Health Sciences Centre; Shock Trauma Air Rescue Service (STARS) (Regehr), Manitoba Base, Winnipeg, Man.; Department of Pathology and Laboratory Medicine (Shih), Vancouver Coastal Health Authority; Centre for Blood Research (Shih), University of British Columbia; Department of Emergency Medicine (Trojanowski), Vancouver General Hospital and the University of British Columbia; Clinical Operations (Trojanowski), British Columbia Emergency Health Services; Departments of Emergency Medicine and Critical Care Medicine (Vu), Vancouver Coastal Health Authority and Provincial Health Services Authority, Vancouver, BC; Department of Surgery and Section of Critical Care (Ziesmann), Health Sciences Centre, Winnipeg, Man
| | - Markus Ziesmann
- Ornge (von Vopelius-Feldt, Lockwood, Mal, Peddle, Smith, Nolan), Mississauga, Ont.; Department of Emergency Medicine (von Vopelius-Feldt, Lockwood, Nolan), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Division of Emergency Medicine (Mal, Peddle), London Health Sciences Centre, London, Ont.; Department of Surgery, Trauma and Acute Care Surgery (Beckett), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Canadian Forces Health Services Headquarters (Beckett, Schmid), Canadian Armed Forces, Ottawa, Ont.; Department of Pathology and Molecular Medicine (Callum), Kingston Health Sciences Centre and Queen's University, Kingston, Ont.; University of Toronto Quality in Utilization, Education and Safety in Transfusion (QUEST) research program (Callum, Khandelwal, Pavenski), Toronto, Ont.; AirEvac and Critical Care Operations (Greene, Vu), British Columbia Emergency Health Services, Vancouver, BC; School of Medicine (Greene), Cardiff University, Cardiff, Wales, UK; Division of Trauma and General Surgery (Grushka), McGill University Health Centre, Montreal General Hospital Site, Montréal, Que.; Canadian Blood Services (Khandelwal); Department of Laboratory Medicine and Pathobiology (Lin), University of Toronto; Precision Diagnostics and Therapeutics Program (Lin), Sunnybrook Health Sciences Centre, Toronto, Ont.; Faculty of Medicine (Nahirniak), University of Alberta, Edmonton, Alta.; Transfusion and Transplantation Medicine (Nahirniak), Alberta Precision Laboratories, Calgary, Alta.; Departments of Medicine and Laboratory Medicine (Pavenski), St. Michael's Hospital, Unity Health Toronto and University of Toronto, Toronto, Ont.; Division of Transfusion Medicine (Prokopchuk-Gauk), Department of Pathology and Laboratory Medicine, Saskatchewan Health Authority; College of Medicine (Prokopchuk-Gauk), University of Saskatchewan, Saskatoon, Sask.; Emergency Department (Regehr), Health Sciences Centre; Shock Trauma Air Rescue Service (STARS) (Regehr), Manitoba Base, Winnipeg, Man.; Department of Pathology and Laboratory Medicine (Shih), Vancouver Coastal Health Authority; Centre for Blood Research (Shih), University of British Columbia; Department of Emergency Medicine (Trojanowski), Vancouver General Hospital and the University of British Columbia; Clinical Operations (Trojanowski), British Columbia Emergency Health Services; Departments of Emergency Medicine and Critical Care Medicine (Vu), Vancouver Coastal Health Authority and Provincial Health Services Authority, Vancouver, BC; Department of Surgery and Section of Critical Care (Ziesmann), Health Sciences Centre, Winnipeg, Man
| | - Brodie Nolan
- Ornge (von Vopelius-Feldt, Lockwood, Mal, Peddle, Smith, Nolan), Mississauga, Ont.; Department of Emergency Medicine (von Vopelius-Feldt, Lockwood, Nolan), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Division of Emergency Medicine (Mal, Peddle), London Health Sciences Centre, London, Ont.; Department of Surgery, Trauma and Acute Care Surgery (Beckett), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Canadian Forces Health Services Headquarters (Beckett, Schmid), Canadian Armed Forces, Ottawa, Ont.; Department of Pathology and Molecular Medicine (Callum), Kingston Health Sciences Centre and Queen's University, Kingston, Ont.; University of Toronto Quality in Utilization, Education and Safety in Transfusion (QUEST) research program (Callum, Khandelwal, Pavenski), Toronto, Ont.; AirEvac and Critical Care Operations (Greene, Vu), British Columbia Emergency Health Services, Vancouver, BC; School of Medicine (Greene), Cardiff University, Cardiff, Wales, UK; Division of Trauma and General Surgery (Grushka), McGill University Health Centre, Montreal General Hospital Site, Montréal, Que.; Canadian Blood Services (Khandelwal); Department of Laboratory Medicine and Pathobiology (Lin), University of Toronto; Precision Diagnostics and Therapeutics Program (Lin), Sunnybrook Health Sciences Centre, Toronto, Ont.; Faculty of Medicine (Nahirniak), University of Alberta, Edmonton, Alta.; Transfusion and Transplantation Medicine (Nahirniak), Alberta Precision Laboratories, Calgary, Alta.; Departments of Medicine and Laboratory Medicine (Pavenski), St. Michael's Hospital, Unity Health Toronto and University of Toronto, Toronto, Ont.; Division of Transfusion Medicine (Prokopchuk-Gauk), Department of Pathology and Laboratory Medicine, Saskatchewan Health Authority; College of Medicine (Prokopchuk-Gauk), University of Saskatchewan, Saskatoon, Sask.; Emergency Department (Regehr), Health Sciences Centre; Shock Trauma Air Rescue Service (STARS) (Regehr), Manitoba Base, Winnipeg, Man.; Department of Pathology and Laboratory Medicine (Shih), Vancouver Coastal Health Authority; Centre for Blood Research (Shih), University of British Columbia; Department of Emergency Medicine (Trojanowski), Vancouver General Hospital and the University of British Columbia; Clinical Operations (Trojanowski), British Columbia Emergency Health Services; Departments of Emergency Medicine and Critical Care Medicine (Vu), Vancouver Coastal Health Authority and Provincial Health Services Authority, Vancouver, BC; Department of Surgery and Section of Critical Care (Ziesmann), Health Sciences Centre, Winnipeg, Man
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20
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Berry C, Gallagher JM, Goodloe JM, Dorlac WC, Dodd J, Fischer PE. Prehospital Hemorrhage Control and Treatment by Clinicians: A Joint Position Statement. PREHOSP EMERG CARE 2023:1-15. [PMID: 36961935 DOI: 10.1080/10903127.2023.2195487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/26/2023]
Affiliation(s)
- Cherisse Berry
- Department of Surgery, New York University Grossman School of Medicine, New York, NY
| | | | - Jeffrey M Goodloe
- Department of Emergency Medicine, University of Oklahoma Health Sciences Center, Tulsa, OK
| | - Warren C Dorlac
- Department of Surgery, University of Colorado Health Loveland, Loveland, CO
| | - Jimm Dodd
- Stop the Bleed, American College of Surgeons, Chicago, IL
| | - Peter E Fischer
- Department of Surgery, University of Tennessee Health Science Center, Memphis, TN
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21
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Rossaint R, Afshari A, Bouillon B, Cerny V, Cimpoesu D, Curry N, Duranteau J, Filipescu D, Grottke O, Grønlykke L, Harrois A, Hunt BJ, Kaserer A, Komadina R, Madsen MH, Maegele M, Mora L, Riddez L, Romero CS, Samama CM, Vincent JL, Wiberg S, Spahn DR. The European guideline on management of major bleeding and coagulopathy following trauma: sixth edition. Crit Care 2023; 27:80. [PMID: 36859355 PMCID: PMC9977110 DOI: 10.1186/s13054-023-04327-7] [Citation(s) in RCA: 115] [Impact Index Per Article: 115.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 01/20/2023] [Indexed: 03/03/2023] Open
Abstract
BACKGROUND Severe trauma represents a major global public health burden and the management of post-traumatic bleeding continues to challenge healthcare systems around the world. Post-traumatic bleeding and associated traumatic coagulopathy remain leading causes of potentially preventable multiorgan failure and death if not diagnosed and managed in an appropriate and timely manner. This sixth edition of the European guideline on the management of major bleeding and coagulopathy following traumatic injury aims to advise clinicians who care for the bleeding trauma patient during the initial diagnostic and therapeutic phases of patient management. METHODS The pan-European, multidisciplinary Task Force for Advanced Bleeding Care in Trauma included representatives from six European professional societies and convened to assess and update the previous version of this guideline using a structured, evidence-based consensus approach. Structured literature searches covered the period since the last edition of the guideline, but considered evidence cited previously. The format of this edition has been adjusted to reflect the trend towards concise guideline documents that cite only the highest-quality studies and most relevant literature rather than attempting to provide a comprehensive literature review to accompany each recommendation. RESULTS This guideline comprises 39 clinical practice recommendations that follow an approximate temporal path for management of the bleeding trauma patient, with recommendations grouped behind key decision points. While approximately one-third of patients who have experienced severe trauma arrive in hospital in a coagulopathic state, a systematic diagnostic and therapeutic approach has been shown to reduce the number of preventable deaths attributable to traumatic injury. CONCLUSION A multidisciplinary approach and adherence to evidence-based guidelines are pillars of best practice in the management of severely injured trauma patients. Further improvement in outcomes will be achieved by optimising and standardising trauma care in line with the available evidence across Europe and beyond.
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Affiliation(s)
- Rolf Rossaint
- Department of Anaesthesiology, University Hospital Aachen, RWTH, Aachen University, Pauwelsstrasse 30, D-52074, Aachen, Germany.
| | - Arash Afshari
- grid.5254.60000 0001 0674 042XDepartment of Paediatric and Obstetric Anaesthesia, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, DK-2100 Copenhagen, Denmark
| | - Bertil Bouillon
- grid.412581.b0000 0000 9024 6397Department of Trauma and Orthopaedic Surgery, Cologne-Merheim Medical Centre (CMMC), University of Witten/Herdecke, Ostmerheimer Strasse 200, D-51109 Cologne, Germany
| | - Vladimir Cerny
- grid.424917.d0000 0001 1379 0994Department of Anaesthesiology, Perioperative Medicine and Intensive Care, Masaryk Hospital, J.E. Purkinje University, Socialni pece 3316/12A, CZ-40113 Usti nad Labem, Czech Republic ,grid.4491.80000 0004 1937 116XDepartment of Anaesthesiology and Intensive Care Medicine, Charles University Faculty of Medicine, Simkova 870, CZ-50003 Hradec Králové, Czech Republic
| | - Diana Cimpoesu
- grid.411038.f0000 0001 0685 1605Department of Emergency Medicine, Emergency County Hospital “Sf. Spiridon” Iasi, University of Medicine and Pharmacy ”Grigore T. Popa” Iasi, Blvd. Independentei 1, RO-700111 Iasi, Romania
| | - Nicola Curry
- grid.410556.30000 0001 0440 1440Oxford Haemophilia and Thrombosis Centre, Nuffield Orthopaedic Centre, Oxford University Hospitals NHS Trust, Windmill Road, Oxford, OX3 7HE UK ,grid.4991.50000 0004 1936 8948Radcliffe Department of Medicine, Oxford University, Oxford, UK
| | - Jacques Duranteau
- grid.460789.40000 0004 4910 6535Department of Anesthesiology, Intensive Care and Perioperative Medicine, Assistance Publique Hôpitaux de Paris, Paris Saclay University, 78 rue du Général Leclerc, F-94275 Le Kremlin-Bicêtre Cedex, France
| | - Daniela Filipescu
- grid.8194.40000 0000 9828 7548Department of Cardiac Anaesthesia and Intensive Care, “Prof. Dr. C. C. Iliescu” Emergency Institute of Cardiovascular Diseases, Carol Davila University of Medicine and Pharmacy, Sos Fundeni 256-258, RO-022328 Bucharest, Romania
| | - Oliver Grottke
- grid.1957.a0000 0001 0728 696XDepartment of Anaesthesiology, University Hospital Aachen, RWTH, Aachen University, Pauwelsstrasse 30, D-52074 Aachen, Germany
| | - Lars Grønlykke
- grid.5254.60000 0001 0674 042XDepartment of Thoracic Anaesthesiology, The Heart Centre, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, DK-2100 Copenhagen, Denmark
| | - Anatole Harrois
- grid.460789.40000 0004 4910 6535Department of Anesthesiology, Intensive Care and Perioperative Medicine, Assistance Publique Hôpitaux de Paris, Paris Saclay University, 78 rue du Général Leclerc, F-94275 Le Kremlin-Bicêtre Cedex, France
| | - Beverley J. Hunt
- grid.420545.20000 0004 0489 3985Thrombosis and Haemophilia Centre, Guy’s and St Thomas’ NHS Foundation Trust, Westminster Bridge Road, London, SE1 7EH UK
| | - Alexander Kaserer
- grid.412004.30000 0004 0478 9977Institute of Anaesthesiology, University Hospital Zurich, Raemistrasse 100, CH-8091 Zurich, Switzerland
| | - Radko Komadina
- grid.8954.00000 0001 0721 6013Department of Traumatology, General and Teaching Hospital Celje, Medical Faculty, Ljubljana University, Oblakova ulica 5, SI-3000 Celje, Slovenia
| | - Mikkel Herold Madsen
- grid.5254.60000 0001 0674 042XDepartment of Paediatric and Obstetric Anaesthesia, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, DK-2100 Copenhagen, Denmark
| | - Marc Maegele
- grid.412581.b0000 0000 9024 6397Department of Trauma and Orthopaedic Surgery, Cologne-Merheim Medical Centre (CMMC), Institute for Research in Operative Medicine (IFOM), University of Witten/Herdecke, Ostmerheimer Strasse 200, D-51109 Cologne, Germany
| | - Lidia Mora
- grid.7080.f0000 0001 2296 0625Department of Anaesthesiology, Intensive Care and Pain Clinic, Vall d’Hebron Trauma, Rehabilitation and Burns Hospital, Autonomous University of Barcelona, Passeig de la Vall d’Hebron 119-129, ES-08035 Barcelona, Spain
| | - Louis Riddez
- grid.24381.3c0000 0000 9241 5705Department of Surgery and Trauma, Karolinska University Hospital, S-171 76 Solna, Sweden
| | - Carolina S. Romero
- grid.106023.60000 0004 1770 977XDepartment of Anaesthesia, Intensive Care and Pain Therapy, Consorcio Hospital General Universitario de Valencia, Universidad Europea of Valencia Methodology Research Department, Avenida Tres Cruces 2, ES-46014 Valencia, Spain
| | - Charles-Marc Samama
- Department of Anaesthesia, Intensive Care and Perioperative Medicine, GHU AP-HP Centre - Université Paris Cité - Cochin Hospital, 27 rue du Faubourg St. Jacques, F-75014 Paris, France
| | - Jean-Louis Vincent
- grid.4989.c0000 0001 2348 0746Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Route de Lennik 808, B-1070 Brussels, Belgium
| | - Sebastian Wiberg
- grid.5254.60000 0001 0674 042XDepartment of Thoracic Anaesthesiology, The Heart Centre, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, DK-2100 Copenhagen, Denmark
| | - Donat R. Spahn
- grid.412004.30000 0004 0478 9977Institute of Anaesthesiology, University Hospital Zurich, Raemistrasse 100, CH-8091 Zurich, Switzerland
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22
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Transfusion Management in Trauma: What is Current Best Practice? CURRENT SURGERY REPORTS 2023. [DOI: 10.1007/s40137-023-00352-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
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23
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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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24
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Krösbacher A, Fries D, Thaler M. Unkontrollierbare Blutungen prähospital – Retten Blutprodukte Leben? NOTARZT 2023. [DOI: 10.1055/a-1910-4518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/18/2023]
Affiliation(s)
- Armin Krösbacher
- Univ. Klinik für Anästhesie und Intensivmedizin, Medizinische Universität Innsbruck, Innsbruck, Österreich
| | - Dietmar Fries
- Univ. Klinik für Anästhesie und Intensivmedizin, Medizinische Universität Innsbruck, Innsbruck, Österreich
| | - Markus Thaler
- Univ. Klinik für Anästhesie und Intensivmedizin, Medizinische Universität Innsbruck, Innsbruck, Österreich
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25
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Tucker H, Brohi K, Tan J, Aylwin C, Bloomer R, Cardigan R, Davenport R, Davies ED, Godfrey P, Hawes R, Lyon R, McCullagh J, Stanworth S, Thompson J, Uprichard J, Walsh S, Weaver A, Green L. Association of red blood cells and plasma transfusion versus red blood cell transfusion only with survival for treatment of major traumatic hemorrhage in prehospital setting in England: a multicenter study. Crit Care 2023; 27:25. [PMID: 36650557 PMCID: PMC9847037 DOI: 10.1186/s13054-022-04279-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 12/14/2022] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND In-hospital acute resuscitation in trauma has evolved toward early and balanced transfusion resuscitation with red blood cells (RBC) and plasma being transfused in equal ratios. Being able to deliver this ratio in prehospital environments is a challenge. A combined component, like leukocyte-depleted red cell and plasma (RCP), could facilitate early prehospital resuscitation with RBC and plasma, while at the same time improving logistics for the team. However, there is limited evidence on the clinical benefits of RCP. OBJECTIVE To compare prehospital transfusion of combined RCP versus RBC alone or RBC and plasma separately (RBC + P) on mortality in trauma bleeding patients. METHODS Data were collected prospectively on patients who received prehospital transfusion (RBC + thawed plasma/Lyoplas or RCP) for traumatic hemorrhage from six prehospital services in England (2018-2020). Retrospective data on patients who transfused RBC from 2015 to 2018 were included for comparison. The association between transfusion arms and 24-h and 30-day mortality, adjusting for age, injury mechanism, age, prehospital heart rate and blood pressure, was evaluated using generalized estimating equations. RESULTS Out of 970 recruited patients, 909 fulfilled the study criteria (RBC + P = 391, RCP = 295, RBC = 223). RBC + P patients were older (mean age 42 vs 35 years for RCP and RBC), and 80% had a blunt injury (RCP = 52%, RBC = 56%). RCP and RBC + P were associated with lower odds of death at 24-h, compared to RBC alone (adjusted odds ratio [aOR] 0.69 [95%CI: 0.52; 0.92] and 0.60 [95%CI: 0.32; 1.13], respectively). The lower odds of death for RBC + P and RCP vs RBC were driven by penetrating injury (aOR 0.22 [95%CI: 0.10; 0.53] and 0.39 [95%CI: 0.20; 0.76], respectively). There was no association between RCP or RBC + P with 30-day survival vs RBC. CONCLUSION Prehospital plasma transfusion for penetrating injury was associated with lower odds of death at 24-h compared to RBC alone. Large trials are needed to confirm these findings.
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Affiliation(s)
- Harriet Tucker
- grid.4868.20000 0001 2171 1133Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, 4 Newark Street, London, E1 2AT UK
| | - Karim Brohi
- grid.4868.20000 0001 2171 1133Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, 4 Newark Street, London, E1 2AT UK ,grid.139534.90000 0001 0372 5777Barts Health NHS Trust, London, UK
| | - Joachim Tan
- grid.264200.20000 0000 8546 682XSt George’s University of London, London, UK
| | - Christopher Aylwin
- grid.426467.50000 0001 2108 8951St Mary’s Hospital, Imperial College NHS Foundation Trust, London, UK
| | - Roger Bloomer
- grid.429705.d0000 0004 0489 4320Kings College Hospital NHS Foundation Trust, London, UK
| | - Rebecca Cardigan
- grid.436365.10000 0000 8685 6563NHS Blood and Transplant, Cambridge, UK
| | - Ross Davenport
- grid.4868.20000 0001 2171 1133Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, 4 Newark Street, London, E1 2AT UK ,grid.139534.90000 0001 0372 5777Barts Health NHS Trust, London, UK
| | - Edward D. Davies
- grid.416204.50000 0004 0391 9602Royal Preston Hospital, Preston, UK
| | - Phillip Godfrey
- grid.411812.f0000 0004 0400 2812James Cook University Hospital, Middlesbrough, UK
| | - Rachel Hawes
- Newcastle Upon Tyne NHS Foundation Trust, Newcastle, UK ,Great North Air Ambulance, Stockton-on-Tees, UK
| | | | | | - Simon Stanworth
- grid.436365.10000 0000 8685 6563NHS Blood and Transplant, Cambridge, UK ,grid.4991.50000 0004 1936 8948Oxford University Hospital NHS Foundation Trust, Oxford, UK
| | - Julian Thompson
- grid.416201.00000 0004 0417 1173Southmead Hospital, Bristol, UK ,Great West Air Ambulance, Bristol, UK
| | - James Uprichard
- grid.264200.20000 0000 8546 682XSt George’s University Hospital NHS Foundation Trust, London, UK
| | - Simon Walsh
- grid.426467.50000 0001 2108 8951St Mary’s Hospital, Imperial College NHS Foundation Trust, London, UK ,Essex and Hertfordshire Air Ambulance Trust, Essex, UK
| | - Anne Weaver
- grid.139534.90000 0001 0372 5777Barts Health NHS Trust, London, UK
| | - Laura Green
- grid.4868.20000 0001 2171 1133Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, 4 Newark Street, London, E1 2AT UK ,grid.139534.90000 0001 0372 5777Barts Health NHS Trust, London, UK ,grid.436365.10000 0000 8685 6563NHS Blood and Transplant, Cambridge, UK
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26
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Katzenschlager S, Obermaier M, Kuhner M, Spöttl W, Dietrich M, Weigand MA, Weilbacher F, Popp E. [Focus on emergency medicine 2021/2022-Summary of selected emergency medicine studies]. DIE ANAESTHESIOLOGIE 2023; 72:130-142. [PMID: 36602555 PMCID: PMC9813891 DOI: 10.1007/s00101-022-01245-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Accepted: 12/15/2022] [Indexed: 01/06/2023]
Affiliation(s)
- S. Katzenschlager
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - M. Obermaier
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - M. Kuhner
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - W. Spöttl
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - M. Dietrich
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - M. A. Weigand
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - F. Weilbacher
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - E. Popp
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
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Sunde GA, Bjerkvig C, Bekkevold M, Kristoffersen EK, Strandenes G, Bruserud Ø, Apelseth TO, Heltne JK. Implementation of a low-titre whole blood transfusion program in a civilian helicopter emergency medical service. Scand J Trauma Resusc Emerg Med 2022; 30:65. [PMID: 36494743 PMCID: PMC9733220 DOI: 10.1186/s13049-022-01051-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 11/22/2022] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Early balanced transfusion is associated with improved outcome in haemorrhagic shock patients. This study describes the implementation and evaluates the safety of a whole blood transfusion program in a civilian helicopter emergency medical service (HEMS). METHODS This prospective observational study was performed over a 5-year period at HEMS-Bergen, Norway. Patients in haemorrhagic shock receiving out of hospital transfusion of low-titre Group O whole blood (LTOWB) or other blood components were included. Two LTOWB units were produced weekly and rotated to the HEMS for forward storage. The primary endpoints were the number of patients transfused, mechanisms of injury/illness, adverse events and survival rates. Informed consent covered patient pathway from time of emergency interventions to last endpoint and subsequent data handling/storage. RESULTS The HEMS responded to 5124 patients. Seventy-two (1.4%) patients received transfusions. Twenty patients (28%) were excluded due to lack of consent (16) or not meeting the inclusion criteria (4). Of the 52 (100%) patients, 48 (92%) received LTOWB, nine (17%) received packed red blood cells (PRBC), and nine (17%) received freeze-dried plasma. Of the forty-six (88%) patients admitted alive to hospital, 35 (76%) received additional blood transfusions during the first 24 h. Categories were blunt trauma 30 (58%), penetrating trauma 7 (13%), and nontrauma 15 (29%). The majority (79%) were male, with a median age of 49 (IQR 27-70) years. No transfusion reactions, serious complications or logistical challenges were reported. Overall, 36 (69%) patients survived 24 h, and 28 (54%) survived 30 days. CONCLUSIONS Implementing a whole blood transfusion program in civilian HEMS is feasible and safe and the logistics around out of hospital whole blood transfusions are manageable. Trial registration The study is registered in the ClinicalTrials.gov registry (NCT02784951).
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Affiliation(s)
- Geir Arne Sunde
- grid.412008.f0000 0000 9753 1393Department of Anesthesia and Intensive Care, Haukeland University Hospital, Bergen, Norway ,Helicopter Emergency Medical Services, Bergen, Norway
| | - Christopher Bjerkvig
- grid.412008.f0000 0000 9753 1393Department of Anesthesia and Intensive Care, Haukeland University Hospital, Bergen, Norway ,Helicopter Emergency Medical Services, Bergen, Norway ,grid.7914.b0000 0004 1936 7443Department of Clinical Medicine, Faculty of Medicine, University of Bergen, Bergen, Norway
| | - Marit Bekkevold
- grid.420120.50000 0004 0481 3017Department of Research, Norwegian Air Ambulance Foundation, Oslo, Norway ,grid.55325.340000 0004 0389 8485Division of Prehospital Services, Air Ambulance Department, Oslo University Hospital, Oslo, Norway
| | - Einar K. Kristoffersen
- grid.7914.b0000 0004 1936 7443Department of Clinical Science, Faculty of Medicine, University of Bergen, Bergen, Norway ,grid.412008.f0000 0000 9753 1393Department of Immunology and Transfusion Medicine, Haukeland University Hospital, Bergen, Norway
| | - Geir Strandenes
- grid.412008.f0000 0000 9753 1393Department of Immunology and Transfusion Medicine, Haukeland University Hospital, Bergen, Norway
| | - Øyvind Bruserud
- grid.412008.f0000 0000 9753 1393Department of Anesthesia and Intensive Care, Haukeland University Hospital, Bergen, Norway
| | - Torunn Oveland Apelseth
- grid.7914.b0000 0004 1936 7443Department of Clinical Science, Faculty of Medicine, University of Bergen, Bergen, Norway ,grid.412008.f0000 0000 9753 1393Department of Immunology and Transfusion Medicine, Haukeland University Hospital, Bergen, Norway ,grid.457897.00000 0004 0512 8409Norwegian Armed Forces Joint Medical Service, Sessvollmoen, Norway
| | - Jon-Kenneth Heltne
- grid.412008.f0000 0000 9753 1393Department of Anesthesia and Intensive Care, Haukeland University Hospital, Bergen, Norway ,Helicopter Emergency Medical Services, Bergen, Norway ,grid.7914.b0000 0004 1936 7443Department of Clinical Medicine, Faculty of Medicine, University of Bergen, Bergen, Norway
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ter Avest E, Carenzo L, Lendrum RA, Christian MD, Lyon RM, Coniglio C, Rehn M, Lockey DJ, Perkins ZB. Advanced interventions in the pre-hospital resuscitation of patients with non-compressible haemorrhage after penetrating injuries. Crit Care 2022; 26:184. [PMID: 35725641 PMCID: PMC9210796 DOI: 10.1186/s13054-022-04052-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 06/02/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract Early haemorrhage control and minimizing the time to definitive care have long been the cornerstones of therapy for patients exsanguinating from non-compressible haemorrhage (NCH) after penetrating injuries, as only basic treatment could be provided on scene. However, more recently, advanced on-scene treatments such as the transfusion of blood products, resuscitative thoracotomy (RT) and resuscitative endovascular balloon occlusion of the aorta (REBOA) have become available in a small number of pre-hospital critical care teams. Although these advanced techniques are included in the current traumatic cardiac arrest algorithm of the European Resuscitation Council (ERC), published in 2021, clear guidance on the practical application of these techniques in the pre-hospital setting is scarce. This paper provides a scoping review on how these advanced techniques can be incorporated into practice for the resuscitation of patients exsanguinating from NCH after penetrating injuries, based on available literature and the collective experience of several helicopter emergency medical services (HEMS) across Europe who have introduced these advanced resuscitation interventions into routine practice.
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Roberts B, Green L, Ahmed V, Latham T, O'Boyle P, Yazer MH, Cardigan R. Modelling the outcomes of different red blood cell transfusion strategies for the treatment of traumatic haemorrhage in the prehospital setting in the United Kingdom. Vox Sang 2022; 117:1287-1295. [PMID: 36102164 PMCID: PMC9825834 DOI: 10.1111/vox.13359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 07/01/2022] [Accepted: 08/22/2022] [Indexed: 01/18/2023]
Abstract
BACKGROUND AND OBJECTIVES The limited supply and increasing demand of group O RhD-negative red blood cells (RBCs) have resulted in other transfusion strategies being explored by blood services that carry potential risks but may still provide an overall benefit to patients. Our aim was to analyse the potential economic benefits of prehospital transfusion (PHT) against no PHT. MATERIALS AND METHODS The impact of three PHT strategies (RhD-negative RBC, RhD-positive RBC and no transfusion) on quality-adjusted-life-years (QALYs) of all United Kingdom trauma patients in a given year and the subset of patients considered most at risk (RhD-negative females <50 years old), was modelled. RESULTS For the entire cohort and the subset of patients, transfusing RhD-negative RBCs generated the most QALYs (141,899 and 2977, respectively), followed by the RhD-positive RBCs (141,879.8 and 2958.8 respectively), and no prehospital RBCs (119,285 and 2503 respectively). The QALY difference between RhD-negative and RhD-positive policies was smaller (19.2, both cohorts) than RhD-positive and no RBCs policies in QALYs term (22,600 all cohort, 470 for a subset), indicating that harms from transfusing RhD-positive RBCs are lower than harms associated with no RBC transfusion. A survival increase from PHT of 0.02% (entire cohort) and 0.7% (subset cohort) would still make the RhD-positive strategy better in QALYs terms than no PHT. CONCLUSION While the use of RhD-positive RBCs carries risks, the benefits measured in QALYs are higher than if no PHT are administered, even for women of childbearing potential. Group O RhD-positive RBCs could be considered when there is a national shortage of RhD-negative RBCs.
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Affiliation(s)
- Barnaby Roberts
- Department of Health and Social CareHealth Protection AnalysisLondonUK
| | - Laura Green
- Blizard InstituteQueen Mary University of LondonLondonUK,NHS Blood and TransplantLondonUK,Barts Health NHS TrustLondonUK
| | - Venus Ahmed
- Department of Health and Social CareHealth Protection AnalysisLondonUK
| | | | - Peter O'Boyle
- Department of Health and Social CareHealth Protection AnalysisLondonUK
| | - Mark H. Yazer
- Department of PathologyUniversity of PittsburghPittsburghPennsylvaniaUSA
| | - Rebecca Cardigan
- NHS Blood and TransplantLondonUK,Department of HaematologyUniversity of CambridgeCambridgeUK
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30
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Broome JM, Ali A, Simpson JT, Tran S, Tatum D, Taghavi S, DuBose J, Duchesne J. IMPACT OF TIME TO EMERGENCY DEPARTMENT RESUSCITATIVE AORTIC OCCLUSION AFTER NONCOMPRESSIBLE TORSO HEMORRHAGE. Shock 2022; 58:275-279. [PMID: 36256624 DOI: 10.1097/shk.0000000000001988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
Introduction: Time is an essential element in outcomes of trauma patients. The relationship of time to treatment in management of noncompressible torso hemorrhage (NCTH) with resuscitative endovascular balloon occlusion of the aorta (REBOA) or resuscitative thoracotomy (RT) has not been previously described. We hypothesized that shorter times to intervention would reduce mortality. Methods: A review of the Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery registry from 2013 to 2022 was performed to identify patients who underwent emergency department aortic occlusion (AO). Multivariate logistic regression was used to examine the impact of time to treatment on mortality. Results: A total of 1,853 patients (1,245 [67%] RT, 608 [33%] REBOA) were included. Most patients were male (82%) with a median age of 34 years (interquartile range, 30). Median time from injury to admission and admission to successful AO were 31 versus 11 minutes, respectively. Patients who died had shorter median times from injury to successful AO (44 vs. 72 minutes, P < 0.001) and admission to successful AO (10 vs. 22 minutes, P < 0.001). Multivariate logistic regression demonstrated that receiving RT was the strongest predictor of mortality (odds ratio [OR], 6.6; 95% confidence interval [CI], 4.4-9.9; P < 0.001). Time from injury to admission and admission to successful AO were not significant. This finding was consistent in subgroup analysis of RT-only and REBOA-only populations. Conclusions: Despite expedited interventions, time to aortic occlusion did not significantly impact mortality. This may suggest that rapid in-hospital intervention was often insufficient to compensate for severe exsanguination and hypovolemia that had already occurred before emergency department presentation. Selective prehospital advanced resuscitative care closer to the point of injury with "scoop and control" efforts including hemostatic resuscitation warrants special consideration.
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Affiliation(s)
- Jacob M Broome
- Division of Trauma and Critical Care, Department of Surgery, Tulane University School of Medicine, New Orleans, Louisiana
| | - Ayman Ali
- Division of Trauma and Critical Care, Department of Surgery, Tulane University School of Medicine, New Orleans, Louisiana
| | - John T Simpson
- Division of Trauma and Critical Care, Department of Surgery, Tulane University School of Medicine, New Orleans, Louisiana
| | - Sherman Tran
- Division of Trauma and Critical Care, Department of Surgery, Tulane University School of Medicine, New Orleans, Louisiana
| | - Danielle Tatum
- Division of Trauma and Critical Care, Department of Surgery, Tulane University School of Medicine, New Orleans, Louisiana
| | - Sharven Taghavi
- Division of Trauma and Critical Care, Department of Surgery, Tulane University School of Medicine, New Orleans, Louisiana
| | - Joseph DuBose
- R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, Maryland
| | - Juan Duchesne
- Division of Trauma and Critical Care, Department of Surgery, Tulane University School of Medicine, New Orleans, Louisiana
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Yazer MH, Cap AP, Glassberg E, Green L, Holcomb JB, Khan MA, Moore EE, Neal MD, Perkins GD, Sperry JL, Thompson P, Triulzi DJ, Spinella PC. Toward a more complete understanding of who will benefit from prehospital transfusion. Transfusion 2022; 62:1671-1679. [PMID: 35796302 DOI: 10.1111/trf.17012] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 06/14/2022] [Accepted: 06/17/2022] [Indexed: 12/11/2022]
Affiliation(s)
- Mark H Yazer
- Department of Pathology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Andrew P Cap
- U.S. Army Institute of Surgical Research, Department of Medicine, Uniformed Services University, Bethesda, Maryland, USA
| | - Elon Glassberg
- Israeli Defense Forces, Medical Corps, Israel; Azrieli Faculty of Medicine, Bar-Ilan University, Safed, Israel, The Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Laura Green
- Barts Health NHS Trust, London, UK.,Blizard Institute, Queen Mary, University of London, London, UK.,NHS Blood and Transplant, London, UK
| | - John B Holcomb
- Center for Injury Science, Department of Surgery, University of Alabama at Birmingham, Birmingham, USA
| | - Mansoor A Khan
- Department of Abdominal Surgery and Medicine, University Hospitals Sussex, Sussex, UK
| | - Ernest E Moore
- Department of Surgery, Ernest E Moore Shock Trauma Center at Denver Health, University of Colorado Denver, Denver, Colorado, USA
| | - Matthew D Neal
- Pittsburgh Trauma and Transfusion Medicine Research Center, Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Gavin D Perkins
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK; Critical Care Unit, Heartlands Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Jason L Sperry
- Division of Trauma and General Surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | | | - Darrell J Triulzi
- Department of Pathology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Philip C Spinella
- Departments of Surgery and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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Yu G, Siegler J, Hayes J, Yazer MH, Spinella PC. Attitudes of American adult women toward accepting RhD-mismatched transfusions in bleeding emergencies. Transfusion 2022; 62 Suppl 1:S211-S217. [PMID: 35753036 DOI: 10.1111/trf.16981] [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: 01/20/2022] [Revised: 02/10/2022] [Accepted: 02/10/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND There is an increasing literature demonstrating the benefits of prehospital and early in-hospital transfusions. RhD-positive products might only be available during these phases, which could pose consequences for future pregnancies if D-alloimmunization occurs. This survey measured the willingness of females to accept urgent but incompatible transfusions in light of the potential for future pregnancy complications. METHODS A survey was designed to assess the willingness of females ≥18 years of age to accept urgent incompatible transfusions when different absolute risk reductions in maternal mortality were presented along with a static rate of 0.3%-4.0% risk of harm to future pregnancies. The survey was sent electronically to women who are part of the Washington University Research Enhancement Core database. RESULTS A total of 4896 delivered survey email invitations were distributed and 325 (6.6%) responses were received; 16 responses were excluded leaving 309 responses for analysis. Most of the responding women were White, college-educated, and lived in Missouri. At least 90% of the respondents would accept an urgent incompatible transfusion when the absolute risk reduction in maternal mortality was ≥4%. Women without a college degree, who lived in Illinois, who were not able to have children appeared to be less willing than their counterparts to receive an incompatible transfusion when the absolute risk reduction in maternal mortality was low. CONCLUSION This survey demonstrated that adult women are highly likely to be open to accept urgent incompatible blood transfusions during a bleeding emergency when the absolute risk reduction in maternal mortality was ≥4%.
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Affiliation(s)
- Gabriel Yu
- Department of Emergency Medicine, Washington University in Saint Louis School of Medicine, Saint Louis, Missouri, USA
| | - Jeffrey Siegler
- Department of Emergency Medicine, Washington University in Saint Louis School of Medicine, Saint Louis, Missouri, USA
| | - Jane Hayes
- Washington University in Saint Louis School of Medicine, Saint Louis, Missouri, USA
| | - Mark H Yazer
- Department of Pathology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Philip C Spinella
- Departments of Surgery and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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33
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Hashmi ZG, Jansen JO, Kerby JD, Holcomb JB. Nationwide estimates of the need for prehospital blood products after injury. Transfusion 2022; 62 Suppl 1:S203-S210. [PMID: 35753065 DOI: 10.1111/trf.16991] [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: 02/03/2022] [Revised: 05/17/2022] [Accepted: 05/24/2022] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Prehospital blood product resuscitation after injury significantly decreases risk of mortality. However, the number of patients who may potentially benefit from this life-saving intervention is currently unknown. The primary objective of this study was to estimate the number of patients who may potentially benefit from prehospital blood product resuscitation after injury in the United States. The secondary objective was to estimate the amount of blood products needed for prehospital resuscitation of injured patients. METHODS Patients ≥16 years with blunt/penetrating injuries included in National Emergency Medical Services Information System 2019 were identified and classified into four separate cohorts of hemodynamic instability: Cohort 1 (systolic blood pressure [SBP] <90 mmHg), Cohort 2 (SBP <90 and/or heart rate [HR] >120), Cohort 3 (SBP <90 and HR >108 or SBP <70), and Cohort 4 (shock index ≥1). The need for prehospital blood was estimated by multiplying number of patients in each cohort with average number of blood products used for prehospital resuscitation. RESULTS After exclusions, 3.7 million adult trauma patients were included. The number of patients who may potentially benefit from prehospital blood products was estimated as 89,391 (Cohort 1), 901,346 (Cohort 2), 54,160 (Cohort 3), and 300,475 (Cohort 4). Assuming 1 unit of whole blood is needed per patient, a lower-bound estimate of 54,160 additional whole blood units (0.6% of current collections) will be need for prehospital resuscitation of the injured. CONCLUSIONS Annually, between 54,000 and 900,000 patients may potentially benefit from prehospital blood product resuscitation after injury in the United States. Prehospital blood utilization and collection of blood products will need to be increased to scale-up this life-saving intervention nationwide.
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Affiliation(s)
- Zain G Hashmi
- Center for Injury Science, University of Alabama at Birmingham, Birmingham, Alabama, USA.,Division of Trauma and Acute Care Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Jan O Jansen
- Center for Injury Science, University of Alabama at Birmingham, Birmingham, Alabama, USA.,Division of Trauma and Acute Care Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Jeffrey D Kerby
- Center for Injury Science, University of Alabama at Birmingham, Birmingham, Alabama, USA.,Division of Trauma and Acute Care Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - John B Holcomb
- Center for Injury Science, University of Alabama at Birmingham, Birmingham, Alabama, USA.,Division of Trauma and Acute Care Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
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Yazer MH, Beckett A, Corley J, Devine DV, Studer NM, Taylor AL, Ward KR, Cap AP. Tips, tricks, and thoughts on the future of prehospital blood transfusions. Transfusion 2022; 62 Suppl 1:S224-S230. [PMID: 35748682 DOI: 10.1111/trf.16955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Revised: 03/21/2022] [Accepted: 03/22/2022] [Indexed: 11/29/2022]
Affiliation(s)
- Mark H Yazer
- Department of Pathology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Andrew Beckett
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Jason Corley
- Army Blood Program, US Army Medical Command, JBSA-FT Sam Houston, Fort Sam Houston, Texas, USA
| | | | - Nicholas M Studer
- U.S. Army Institute of Surgical Research, JBSA-FT Sam Houston, Fort Sam Houston, Texas, USA
| | - Audra L Taylor
- Armed Services Blood Program, Defense Health Agency, Falls Church, Virginia, USA
| | - Kevin R Ward
- Departments of Emergency Medicine and Biomedical Engineering, Max Harry Weil Institute for Critical Care Research and Innovation, University of Michigan, Ann Arbor, Michigan, USA
| | - Andrew P Cap
- U.S. Army Institute of Surgical Research, JBSA-FT Sam Houston, Fort Sam Houston, Texas, USA.,Department of Medicine, Uniformed Services University, Bethesda, Maryland, USA
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Seheult JN, Callum J, Delaney M, Drake R, Dunbar NM, Harm SK, Hess JR, Jackson BP, Javanbakht A, Moore SA, Murphy MF, Raval JS, Staves J, Tuott EE, Wendel S, Ziman A, Yazer MH. Rate of D-alloimmunization in trauma does not depend on the number of RhD-positive units transfused: The BEST collaborative study. Transfusion 2022; 62 Suppl 1:S185-S192. [PMID: 35748692 DOI: 10.1111/trf.16952] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 01/12/2022] [Accepted: 01/17/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND Evidence indicates the life-saving benefits of early blood product transfusion in severe trauma resuscitation. Many of these products will be RhD-positive, so understanding the D-alloimmunization rate is important. METHODS This was a multicenter, retrospective study whereby injured RhD-negative patients between 18-50 years of age who received at least one unit of RhD-positive red blood cells (RBC) or low titer group O whole blood (LTOWB) during their resuscitation between 1 January, 2010 through 31 December, 2019 were identified. If an antibody detection test was performed ≥14 days after the index RhD-positive transfusion then basic demographic information was collected, including whether the patient became D-alloimmunized. The overall D-alloimmunization rate, and the rate stratified by the number of units transfused, were calculated. RESULTS Data were collected from nine institutions. Five institutions reported fewer than 10 eligible patients each and were excluded. From the remaining four institutions, all from the USA, there were 235 eligible patients; 77 (random effects estimate: 32.7%; 95% CI: 19.1-50.1%) became D-alloimmunized. Three of the institutions reported D-alloimmunization rates ≥38.6%, while the remaining institution's rate was 12.2%. In both random and fixed-effects models, the rate of D-alloimmunization was not significantly different between those who received one RhD-positive unit and those who received multiple RhD-positive units. CONCLUSION In this large, multicenter study of injured patients, the overall rate of D-alloimmunization fell within the range previously reported. The rate of D-alloimmunization did not increase as the number of transfused RhD-positive units increased. These data can help to inform RhD type selection decisions.
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Affiliation(s)
- Jansen N Seheult
- Department of Pathology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Jeannie Callum
- Department of Pathology and Molecular Medicine, Kingston health Sciences Centre and Queen's University, Kingston, Ontario, Canada
| | - Meghan Delaney
- Division of Pathology and Laboratory Medicine, Children's National Hospital, Washington, District of Columbia, USA.,Department of Pathology and Pediatrics, George Washington University Medical School, Washington, District of Columbia, USA
| | - Rosanna Drake
- Department of Pathology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Nancy M Dunbar
- Department of Pathology and Laboratory Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - Sarah K Harm
- Department of pathology, University of Vermont Medical Center, Burlington, Vermont, USA
| | - John R Hess
- Transfusion Service, Harborview Medical Center and the Department of Laboratory Medicine and Pathology, University of Washington School of Medicine, Seattle, Washington, USA
| | - Bryon P Jackson
- Department of Pathology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Ayda Javanbakht
- Department of Pathology and Laboratory Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - Sarah A Moore
- Department of Surgery, University of New Mexico, Albuquerque, New Mexico
| | - Michael F Murphy
- National Health Service Blood and Transplant, and Oxford Biomedical Research Centre, Oxford, UK
| | - Jay S Raval
- Department of Pathology, University of New Mexico, Albuquerque, New Mexico
| | - Julie Staves
- National Health Service Blood and Transplant, and Oxford Biomedical Research Centre, Oxford, UK
| | - Erin E Tuott
- Transfusion Service, Harborview Medical Center and the Department of Laboratory Medicine and Pathology, University of Washington School of Medicine, Seattle, Washington, USA
| | | | - Alyssa Ziman
- Wing-Kwai and Alice Lee-Tsing Chung Transfusion Service, Department of Pathology and Laboratory Medicine, UCLA Health, Los Angeles, California, USA
| | - Mark H Yazer
- Department of Pathology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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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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Scheiber CJ, Spencer CM, Neading RD, O'Connell MP, Becker CF, Scarborough TR, Horsey JD, Perez JA, Ochoa BJ, Wilkinson MA, Bentley P, Seheult JN, Boisen ML, Yazer MH. Hyperbaric effects on cold stored whole blood following a military dive mission profile. Transfusion 2022; 62 Suppl 1:S90-S97. [PMID: 35748679 DOI: 10.1111/trf.16963] [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: 02/04/2022] [Revised: 05/14/2022] [Accepted: 05/17/2022] [Indexed: 10/17/2022]
Abstract
BACKGROUND Whole blood (WB) is carried by special operations forces as part of a remote damage control resuscitation strategy. The effects of an underwater mission on the quality and coagulation profile of WB were simulated by exposure to hyperbaric pressures in a chamber. METHODS WB units collected in CPDA-1 were exposed to three different combinations of hyperbaric pressure and duration of exposure: Group A 153.52 kPa (15.24 msw; 1.52 atm) for 4 h; n = 9, Group B 506.63 kPa (50.29 msw; 5.00 atm) for 1 h; n = 9, Group C 153.52 kPa (15.24 msw; 1.52 atm) for 1 h; n = 7. The following parameters were measured on each unit: prothrombin time/international normalized ratio, activated partial thromboplastin time, thromboelastography and concentration determinations of platelets, lactate, fibrinogen, and lactate dehydrogenase. Each sample underwent baseline, prepressurization, immediate postpressurization, and 6 h postpressurization laboratory testing. RESULTS Six hours following hyperbaric exposure, the lactate concentration in group C was higher than prepressurization measurement and the platelet concentration in Group A was lower than prepressurization measurement. There were no changes in any of the other analyzed biochemical, coagulation and thromboelastogram parameters following exposure to hyperbaric stress. DISCUSSION These data suggest that pressurization of WB up to 5 atm did not impact parameters tested. Changes observed in lactate and platelet count need further study, as well as complementary testing of red blood cell integrity. Further investigation of the hyperbaric extremes is necessary to determine if there is a damage inducing pressure to which WB should not be exposed.
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Affiliation(s)
- Christopher J Scheiber
- 2d Marine Raider Battalion, Marine Forces Special Operations Command (MARSOC), Camp Lejeune, North Carolina, USA
| | - Chad M Spencer
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Richard D Neading
- 2d Marine Raider Battalion, Marine Forces Special Operations Command (MARSOC), Camp Lejeune, North Carolina, USA
| | - Michael P O'Connell
- 2d Marine Raider Battalion, Marine Forces Special Operations Command (MARSOC), Camp Lejeune, North Carolina, USA
| | - Casey F Becker
- 2d Marine Raider Battalion, Marine Forces Special Operations Command (MARSOC), Camp Lejeune, North Carolina, USA
| | - Tyler R Scarborough
- 2d Marine Raider Battalion, Marine Forces Special Operations Command (MARSOC), Camp Lejeune, North Carolina, USA
| | - Jeremy D Horsey
- 2d Marine Raider Battalion, Marine Forces Special Operations Command (MARSOC), Camp Lejeune, North Carolina, USA
| | - Joshua A Perez
- 2d Marine Raider Battalion, Marine Forces Special Operations Command (MARSOC), Camp Lejeune, North Carolina, USA
| | - Baron J Ochoa
- 2d Marine Raider Battalion, Marine Forces Special Operations Command (MARSOC), Camp Lejeune, North Carolina, USA
| | - Michael A Wilkinson
- Dive Locker, Marine Forces Special Operations Command (MARSOC), Camp Lejeune, North Carolina, USA
| | - Pasha Bentley
- Department of Pathology, Naval Medical Center Camp Lejeune, Camp Lejeune, North Carolina, USA
| | - Jansen N Seheult
- Department of Laboratory Medicine and Patholog, Mayo Clinic, Rochester, Minnesota, USA
| | - Michael L Boisen
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Mark H Yazer
- Department of Pathology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
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Tartaglione M, Carenzo L, Gamberini L, Lupi C, Giugni A, Mazzoli CA, Chiarini V, Cavagna S, Allegri D, Holcomb JB, Lockey D, Sbrana G, Gordini G, Coniglio C. Multicentre observational study on practice of prehospital management of hypotensive trauma patients: the SPITFIRE study protocol. BMJ Open 2022; 12:e062097. [PMID: 35636792 PMCID: PMC9152935 DOI: 10.1136/bmjopen-2022-062097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
INTRODUCTION Major haemorrhage after injury is the leading cause of preventable death for trauma patients. Recent advancements in trauma care suggest damage control resuscitation (DCR) should start in the prehospital phase following major trauma. In Italy, Helicopter Emergency Medical Services (HEMS) assist the most complex injuries and deliver the most advanced interventions including DCR. The effect size of DCR delivered prehospitally on survival remains however unclear. METHODS AND ANALYSIS This is an investigator-initiated, large, national, prospective, observational cohort study aiming to recruit >500 patients in haemorrhagic shock after major trauma. We aim at describing the current practice of hypotensive trauma management as well as propose the creation of a national registry of patients with haemorrhagic shock. PRIMARY OBJECTIVE the exploration of the effect size of the variation in clinical practice on the mortality of hypotensive trauma patients. The primary outcome measure will be 24 hours, 7-day and 30-day mortality. Secondary outcomes include: association of prehospital factors and survival from injury to hospital admission, hospital length of stay, prehospital and in-hospital complications, hospital outcomes; use of prehospital ultrasound; association of prehospital factors and volume of first 24-hours blood product administration and evaluation of the prevalence of use, appropriateness, haemodynamic, metabolic and effects on mortality of prehospital blood transfusions. INCLUSION CRITERIA age >18 years, traumatic injury attended by a HEMS team including a physician, a systolic blood pressure <90 mm Hg or weak/absent radial pulse and a confirmed or clinically likely diagnosis of major haemorrhage. Prehospital and in-hospital variables will be collected to include key times, clinical findings, examinations and interventions. Patients will be followed-up until day 30 from admission. The Glasgow Outcome Scale Extended will be collected at 30 days from admission. ETHICS AND DISSEMINATION The study has been approved by the Ethics committee 'Comitato Etico di Area Vasta Emilia Centro'. Data will be disseminated to the scientific community by abstracts submitted to international conferences and by original articles submitted to peer-reviewed journals. TRIAL REGISTRATION NUMBER NCT04760977.
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Affiliation(s)
- Marco Tartaglione
- Department of Anesthesia, Intensive Care and Prehospital Emergency Service, Maggiore Hospital Carlo Alberto Pizzardi, Bologna, Italy
| | - Luca Carenzo
- Department of Anesthesia and Intensive Care Medicine, IRCCS Humanitas Research Hospital, Rozzano, Milano, Italy
| | - Lorenzo Gamberini
- Department of Anesthesia, Intensive Care and Prehospital Emergency Service, Maggiore Hospital Carlo Alberto Pizzardi, Bologna, Italy
| | - Cristian Lupi
- Department of Anesthesia, Intensive Care and Prehospital Emergency Service, Maggiore Hospital Carlo Alberto Pizzardi, Bologna, Italy
| | - Aimone Giugni
- Department of Anesthesia, Intensive Care and Prehospital Emergency Service, Maggiore Hospital Carlo Alberto Pizzardi, Bologna, Italy
| | - Carlo Alberto Mazzoli
- Department of Anesthesia, Intensive Care and Prehospital Emergency Service, Maggiore Hospital Carlo Alberto Pizzardi, Bologna, Italy
| | - Valentina Chiarini
- Department of Anesthesia, Intensive Care and Prehospital Emergency Service, Maggiore Hospital Carlo Alberto Pizzardi, Bologna, Italy
| | - Silvia Cavagna
- Department of Anesthesia, Intensive Care and Prehospital Emergency Service, Maggiore Hospital Carlo Alberto Pizzardi, Bologna, Italy
| | - Davide Allegri
- Department of Clinical Governance and Quality, Azienda Unità Sanitaria Locale di Bologna, Bologna, Italy
| | - John B Holcomb
- Center for Injury Science, The University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - David Lockey
- Centre for Trauma Sciences, Queen Mary University of London, London, UK
| | - Giovanni Sbrana
- UOS 118 Gestione Territorio Area Provinciale Aretina and Grosseto HEMS, Azienda USL Toscana Sud Est, Grosseto, Italy
| | - Giovanni Gordini
- Department of Anesthesia, Intensive Care and Prehospital Emergency Service, Maggiore Hospital Carlo Alberto Pizzardi, Bologna, Italy
| | - Carlo Coniglio
- Department of Anesthesia, Intensive Care and Prehospital Emergency Service, Maggiore Hospital Carlo Alberto Pizzardi, Bologna, Italy
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Dishong D, Sperry JL, Spinella PC, Triulzi DJ, Yazer MH. Administration of blood products in the prehospital setting can decrease trauma patient mortality. Transfusion 2022; 62:725-727. [DOI: 10.1111/trf.16848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Revised: 02/17/2022] [Accepted: 02/17/2022] [Indexed: 11/30/2022]
Affiliation(s)
- Devin Dishong
- Department of Neuroscience University of Pittsburgh Pittsburgh Pennsylvania USA
| | - Jason L. Sperry
- Department of Surgery University of Pittsburgh Pittsburgh Pennsylvania USA
| | - Philip C. Spinella
- Department of Surgery, Department of Critical Care Medicine University of Pittsburgh Pittsburgh Pennsylvania USA
| | - Darrell J. Triulzi
- Department of Pathology University of Pittsburgh Pittsburgh Pennsylvania USA
| | - Mark H. Yazer
- Department of Pathology University of Pittsburgh Pittsburgh Pennsylvania USA
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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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Levin D, Zur M, Shinar E, Moshe T, Tsur AM, Nadler R, Yazer MH, Epstein D, Avital G, Gelikas S, Glassberg E, Benov A, Chen J. Low-Titer Group O Whole-Blood Resuscitation in the Prehospital Setting in Israel: Review of the First 2.5 Years' Experience. Transfus Med Hemother 2022; 48:342-349. [PMID: 35082565 DOI: 10.1159/000519623] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Accepted: 09/08/2021] [Indexed: 12/20/2022] Open
Abstract
Introduction The Israeli Defense Forces Medical Corps (IDF-MC) implemented the use of low-titer group O whole blood (LTOWB) as the first-choice resuscitation fluid in the IDF airborne Combat Search and Rescue Unit (IDF-CSAR) for aerial evacuation of both military and civilian casualties in June 2018 for injured patients with hemorrhagic shock and at least one of the following: systolic blood pressure <90 mm Hg, heart rate >130 beats/min, deterioration of consciousness without head injury or hemoglobin concentration ≤7 g/dL. Method All casualties treated with LTOWB by IDF-CSAR providers from June 2018 to January 2021 were included. Demographic and prehospital treatment data were collected in order to check compliance and adherence to the IDF-MC guidelines. This is a follow-up retrospective report. Results Overall, 1,608 LTOWB units were supplied to the IDF-CSAR during the study period. Of these, 33 were transfused to 27 casualties; 17 (69%) with blunt injury, 8 (29.6%) with penetrating injuries, and 1 (3.7%) with gastrointestinal bleeding without trauma. The leading cause of injury was motor vehicle accidents. A total of 23 casualties received 1 unit of LTOWB, 3 received 2 units and 1 patient received 4 units. Two casualties were children. The median heart rate was 120 beats/min, 8 (29.6%) casualties had heart rates >130 beats/min. Median systolic blood pressure was 95 mm Hg, 7 (26%) casualties had blood pressure <90 mm Hg. The median Glasgow Coma Score was 14. No adverse reactions were documented following the administration of LTOWB. 77.8% of patients received LTOWB in adherence to the guidelines. Conclusion Appropriate administration of LTOWB has improved over time in IDF-CSAR. Using LTOWB is feasible and simpler than administering packed red blood cells and plasma concurrently. Further efforts are needed to introduce LTOWB in other prehospital and in-hospital scenarios, with an increase in the maximum antibody titer threshold, to meet the expected increase in demand.
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Affiliation(s)
- Dan Levin
- Trauma and Combat Medicine Branch, Israel Defense Forces Medical Corps, Tel Hashomer, Ramat Gan, Israel
| | - Maoz Zur
- Military Medical Academy, Medical Corps, Israel Defense Forces, Shefayim, Israel
| | - Eilat Shinar
- Magen David National Blood Services, Ramat Gan, Israel.,Faculty of Health Sciences, Ben Gurion University of the Negev, Be'er Scheva, Israel
| | - Tzadok Moshe
- Magen David National Blood Services, Ramat Gan, Israel.,Faculty of Health Sciences, Ben Gurion University of the Negev, Be'er Scheva, Israel
| | - Avishai M Tsur
- Trauma and Combat Medicine Branch, Israel Defense Forces Medical Corps, Tel Hashomer, Ramat Gan, Israel.,Department of Medicine B, Sheba Medical Center, Tel Hashomer, affiliated with Sackler Faculty of Medicine, Tel Aviv University, Ramat Gan, Israel
| | - Roy Nadler
- Trauma and Combat Medicine Branch, Israel Defense Forces Medical Corps, Tel Hashomer, Ramat Gan, Israel.,Department of General Surgery and Transplantation - Surgery B, Chaim Sheba Medical Center, Tel Hashomer, affiliated with the Sackler School of Medicine, Ramat Gan, Israel
| | - Mark H Yazer
- Department of Pathology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Department of Pathology, Tel Aviv University, Tel Aviv, Israel
| | - Danny Epstein
- Trauma and Combat Medicine Branch, Israel Defense Forces Medical Corps, Tel Hashomer, Ramat Gan, Israel.,Critical Care Division, Rambam Health Care Campus, Haifa, Israel
| | - Guy Avital
- Trauma and Combat Medicine Branch, Israel Defense Forces Medical Corps, Tel Hashomer, Ramat Gan, Israel.,Division of Anesthesia, Intensive Care and Pain Management, Tel Aviv Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - Shaul Gelikas
- Trauma and Combat Medicine Branch, Israel Defense Forces Medical Corps, Tel Hashomer, Ramat Gan, Israel
| | - Elon Glassberg
- Trauma and Combat Medicine Branch, Israel Defense Forces Medical Corps, Tel Hashomer, Ramat Gan, Israel.,The Azrieli Faculty of Medicine, Bar-Ilan University, Safed, Israel.,The Uniformed Services, University of the Health Sciences, Bethesda, Maryland, USA
| | - Avi Benov
- Trauma and Combat Medicine Branch, Israel Defense Forces Medical Corps, Tel Hashomer, Ramat Gan, Israel.,The Azrieli Faculty of Medicine, Bar-Ilan University, Safed, Israel
| | - Jacob Chen
- Trauma and Combat Medicine Branch, Israel Defense Forces Medical Corps, Tel Hashomer, Ramat Gan, Israel.,Meir Medical Center, affiliated with Sackler School of Medicine, Tel Aviv University, Kfar Saba, Israel
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Green L, Stanworth S, McQuilten Z, Lin V, Tucker H, Jackson B, Badawi M, Hindawi S, Chaurasia R, Patidar G, Pandey HC, Fasola F, Miyata S, Matsumoto M, Matsushita T, Rahimi-Levene N, Peer V, Pavenski K, Callum J, Thompson T, Murphy M, Staves J, Maegele M, Abeyakoon C, Rushford K, Wood E, Nuñez MA, Mellado S, Saa E, Triyono T, Pratomo B, Apelseth TO, Dunbar N. International Forum on the Management of Major Haemorrhage: Summary. Vox Sang 2022; 117:746-753. [PMID: 35050497 DOI: 10.1111/vox.13244] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 12/16/2021] [Indexed: 12/24/2022]
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Cardigan R, Latham T, Weaver A, Yazer M, Green L. Estimating the risks of prehospital transfusion of D-positive whole blood to trauma patients who are bleeding in England. Vox Sang 2022; 117:701-707. [PMID: 35018634 PMCID: PMC9306525 DOI: 10.1111/vox.13249] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Revised: 12/21/2021] [Accepted: 12/22/2021] [Indexed: 01/13/2023]
Abstract
Background and Objectives D‐negative red cells are transfused to D‐negative females of childbearing potential (CBP) to prevent haemolytic disease of the foetus and newborn (HDFN). Transfusion of low‐titre group O whole blood (LTOWB) prehospital is gaining interest, to potentially improve clinical outcomes and for logistical benefits compared to standard of care. Enhanced donor selection requirements and reduced shelf‐life of LTOWB compared to red cells makes the provision of this product challenging. Materials and Methods A universal policy change to the use of D‐positive LTOWB across England was modelled in terms of risk of three specific harms occurring: risk of haemolytic transfusion reaction now or in the future, and the risk of HDFN in future pregnancies for all recipients or D‐negative females of CBP. Results The risk of any of the three harms occurring for all recipients was 1:14 × 103 transfusions (credibility interval [CI] 56 × 102–42 × 103) while for females of CBP it was 1:520 transfusions (CI 250–1700). The latter was dominated by HDFN risk, which would be expected to occur once every 5.7 years (CI 2.6–22.5). We estimated that a survival benefit of ≥1% using LTOWB would result in more life‐years gained than lost if D‐positive units were transfused exclusively. These risks would be lower, if D‐positive blood were only transfused when D‐negative units are unavailable. Conclusion These data suggest that the risk of transfusing RhD‐positive blood is low in the prehospital setting and must be balanced against its potential benefits.
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Affiliation(s)
- Rebecca Cardigan
- Clinical Services, NHS Blood and Transplant, Cambridge, UK.,Department of Haematology, University of Cambridge, Cambridge, UK
| | - Tom Latham
- Clinical Services, NHS Blood and Transplant, London, UK
| | - Anne Weaver
- Department of Emergency Medicine, Barts Health NHS Trust, London, UK
| | - Mark Yazer
- Department of Pathology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Laura Green
- Clinical Services, NHS Blood and Transplant, London, UK.,Department of Haematology, Barts Health NHS Trust, London, UK.,Blizard Institute, Queen Mary University of London, London, UK
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Tucker H, Avery P, Brohi K, Davenport R, Griggs J, Weaver A, Green L. Outcome measures used in clinical research evaluating prehospital blood component transfusion in traumatically injured bleeding patients: A systematic review. J Trauma Acute Care Surg 2021; 91:1018-1024. [PMID: 34254958 DOI: 10.1097/ta.0000000000003360] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Trial outcomes should be relevant to all stakeholders and allow assessment of interventions' efficacy and safety at appropriate timeframes. There is no consensus regarding outcome measures in the growing field of prehospital trauma transfusion research. Harmonization of future clinical outcome reporting is key to facilitate interstudy comparisons and generate cohesive, robust evidence to guide practice. The objective of this study was to evaluate outcome measures reported in prehospital trauma transfusion trials. METHODS Data Sources, Eligibility Criteria, Participants, and InterventionsWe conducted a scoping systematic review to identify the type, number, and definitions of outcomes reported in randomized controlled trials, and prospective and retrospective observational cohort studies investigating prehospital blood component transfusion in adult and pediatric patients with traumatic hemorrhage. Electronic database searching of PubMed, Embase, Web of Science, Cochrane, OVID, clinical trials.gov, and the Transfusion Evidence Library was completed in accordance with Preferred Reporting Items for Meta-analyses guidelines.Study Appraisal and Synthesis MethodsTwo review authors independently extracted outcome data. Unique lists of salutogenic (patient-reported health and wellbeing outcomes) and nonsalutogenic focused outcomes were established. RESULTS A total of 3,471 records were identified. Thirty-four studies fulfilled the inclusion criteria: 4 military (n = 1,566 patients) and 30 civilian (n = 14,398 patients), all between 2000 and 2020. Two hundred twelve individual non-patient-reported outcomes were identified, which collapsed into 20 outcome domains with varied definitions and timings. All primary outcomes measured effectiveness, rather than safety or complications. Sixty-nine percent reported mortality, with 11 different definitions. No salutogenic outcomes were reported. CONCLUSION There is heterogeneity in outcome reporting and definitions, an absence of patient-reported outcome, and an emphasis on clinical effectiveness rather than safety or adverse events in prehospital trauma transfusion trials. We recommend stakeholder consultation and a Delphi process to develop a clearly defined minimum core outcome set for prehospital trauma transfusion trials. LEVEL OF EVIDENCE Scoping systematic review, level III.
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Affiliation(s)
- Harriet Tucker
- From the Centre for Trauma Sciences, Blizard Institute (H.T., K.B., R.D., L.G.), Queen Mary University of London, London, United Kingdom; Southmead Hospital (P.A.), North Bristol NHS Trust, Bristol, United Kingdom; Learning and Development (P.A.), South Western Ambulance Service NHS Foundation Trust, Bristol, United Kingdom; Air Ambulance Kent Surrey Sussex (J.G., H.T.), Rochester, United Kingdom; Faculty of Health Sciences (J.G.), University of Surrey, Guildford, United Kingdom; London's Air Ambulance (A.W.), London, United Kingdom; Barts Health NHS Foundation Trust (K.B., R.D., A.W., L.G.), London, United Kingdom; and NHS Blood and Transplant (L.G.), London, United Kingdom
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Yazer MH. The Evolution of Blood Product Use in Trauma Resuscitation: Change Has Come. Transfus Med Hemother 2021; 48:377-380. [PMID: 35082569 PMCID: PMC8739388 DOI: 10.1159/000520011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 10/01/2021] [Indexed: 11/19/2022] Open
Affiliation(s)
- 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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Greene A, Vu EN, Archer T, Norman S, Trojanowski J, Shih AW. A Service Evaluation of Prehospital Blood Transfusion by Critical Care Paramedics in British Columbia, Canada. Air Med J 2021; 40:441-445. [PMID: 34794786 DOI: 10.1016/j.amj.2021.07.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Accepted: 07/10/2021] [Indexed: 11/19/2022]
Abstract
Early administration of blood products is emerging as best practice in selected trauma and medical patients. Blood products carried by critical care transport (CCT) teams are sometimes the first available to critically ill and injured patients. The purpose of this research was to evaluate the introduction of prehospital transfusion into a paramedic-led CCT program in Canada. A retrospective review of electronic patient care records for all patients who received a prehospital transfusion of uncrossmatched group O packed red blood cells between February 10, 2019, and September 30, 2020, was conducted. Forty-eight patients received a prehospital transfusion. The median age of the patients was 44 years, 81.3% were male, and most patients were victims of blunt trauma. Packed red blood cells were associated with a significant increase in systolic blood pressure (P < .001) and mean arterial pressure (P < .001), a decrease in shock index (P < .001), and a reduction in the time to first transfusion, with minimal waste, no patient-related adverse events, and complete traceability. The results of this service evaluation demonstrate the successful introduction of prehospital transfusion into a paramedic-led CCT program. Further prospective research is needed to assess the impact of such a protocol in this patient population.
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Affiliation(s)
- Adam Greene
- Critical Care Transport Program, British Columbia Emergency Health Services, Vancouver, British Columbia, Canada.
| | - Erik N Vu
- Critical Care Transport Program, British Columbia Emergency Health Services, Vancouver, British Columbia, Canada; Department of Emergency Medicine, University of British Columbia, Vancouver, British Columbia, Canada; Department of Critical Care Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Thomas Archer
- Emergency Medical Retrieval and Transfer Service Cymru, Wales, United Kingdom; School of Medicine, Cardiff University, Cardiff, Wales, United Kingdom
| | - Sharon Norman
- School of Medicine, Cardiff University, Cardiff, Wales, United Kingdom
| | - Jan Trojanowski
- Critical Care Transport Program, British Columbia Emergency Health Services, Vancouver, British Columbia, Canada; Department of Emergency Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Andrew W Shih
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, British Columbia, Canada; Centre for Blood Research, University of British Columbia, Vancouver, British Columbia, Canada
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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: 19] [Impact Index Per Article: 6.3] [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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Tucker H, Davenport R, Green L. The Role of Plasma Transfusion in Pre-Hospital Haemostatic Resuscitation. Transfus Med Rev 2021; 35:91-95. [PMID: 34593289 DOI: 10.1016/j.tmrv.2021.08.004] [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: 06/04/2021] [Revised: 08/22/2021] [Accepted: 08/23/2021] [Indexed: 12/15/2022]
Abstract
Traumatic haemorrhage remains a major cause of preventable death and early haemostatic resuscitation is now a mainstay of treatment internationally. Recently, 2 randomized control trials (RCTs) - PAMPer (Prehospital Air Medical Plasma) and COMBAT (Control of Major Bleeding After Trauma), evaluating the effect of pre-hospital use of plasma on mortality provided conflicting results, raising important questions on the role of plasma resuscitation in pre-hospital environment. Both PAMPer (n = 501 patients) and COMBAT (n = 144 patients) trials were pragmatic RCTs that evaluated the effect of pre-hospital plasma transfusion (two units) versus standard of care on 28/30 days mortality in trauma patients who presented with clinical signs of haemorrhagic shock (defined as hypotension or tachycardia). The PAMPer trial showed that plasma transfusion reduced 30-day mortality compared with standard of care (23% vs 33%, 95% confidence interval -18.6; -1.0%; P = 0.03), while COMBAT trial showed no difference in 28-day survival. The post-hoc analyses of the 2 trials have suggested that the benefit of pre-hospital plasma transfusion may be greater for patients who are coagulopathic, have blunt injury and have a transport time from the scene of injury to the hospital of >20 minutes. In this review we evaluate strengths and limitations of the two trials and their differences and similarities, which may explain the conflicting results, as well as provide directions for future trials to better define the target population that would most benefit from pre-hospital plasma resuscitation. Further, considering the logistical challenges of carrying any blood components on an aircraft, cost/safety of plasma, and the scarcity of universal blood group donors, there is a need for a health economic evaluation of pre-hospital plasma transfusion in trauma patients, prior to this intervention becoming universal.
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Affiliation(s)
- Harriet Tucker
- Blizard Institute, Queen Mary University of London, London, UK
| | - Ross Davenport
- Blizard Institute, Queen Mary University of London, London, UK; Departmen of Trauma, Barts Health NHS Trust, London, UK
| | - Laura Green
- Blizard Institute, Queen Mary University of London, London, UK; Departmen of Trauma, Barts Health NHS Trust, London, UK; Blood Component division, NHS Blood and Transplant, London, UK.
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Yazer MH, Dunbar NM, Delaney M. Survey of the RhD selection and issuing practices for uncrossmatched blood products at pediatric trauma hospitals in the United States: The BEST collaborative study. Transfusion 2021; 61:3328-3334. [PMID: 34595764 DOI: 10.1111/trf.16692] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 09/23/2021] [Accepted: 09/24/2021] [Indexed: 12/24/2022]
Abstract
BACKGROUND As evidence demonstrating the importance of early transfusions in trauma resuscitation accumulates, when RhD-negative products might not be available, it is important to understand the nature of the RhD-type of products provided to bleeding pediatric patients of potentially unknown RhD-type. METHODS A survey link was electronically sent to the transfusion service medical director and/or laboratory manager at American pediatric Level I and Level II hospitals inquiring about their practices for selecting RhD-type of uncrossmatched red blood cells (RBC) or low titer group O whole blood (LTOWB) for boys and girls. RESULTS There were 55/117 (47.0%) analyzable responses; 43/55 (78.2%) from Level I and 12/55 (21.8%) from Level II hospitals. For in hospital transfusions, 51/55 (92.7%) of centers use only RhD-negative blood products to resuscitate girls ≤18 years old while 30/55 (54.5%) of centers do the same for boys ≤18 years old. Most centers 41/55(74.5%) store RBCs and/or LTOWB in in-hospital remote refrigerators; 27 store only RhD-negative RBCs and 2 store only RhD-negative LTOWB units in these refrigerators. A total of 24/55 (43.6%) centers have RBCs and/or LTOWB available on road ambulances or helicopters for prehospital transfusion; 12 transport only RhD-negative RBCs and two transport only RhD-negative LTOWB. Most centers, 35/55 (63.6%), address the prophylaxis of an RhD-negative female recipient of RhD-positive transfusion on a case-by-case basis. CONCLUSION While there is some variability, most of the responding pediatric trauma centers routinely utilized RhD-negative RBCs for emergency transfusion for patients ≤18 years old of unknown RhD-type.
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Affiliation(s)
- Mark H Yazer
- Department of Pathology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Nancy M Dunbar
- Department of Pathology and Laboratory Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - Meghan Delaney
- Division of Pathology and Laboratory Medicine, Children's National Hospital, Washington, District of Columbia, USA.,Department of Pathology and Pediatrics, George Washington University Medical School, Washington, District of Columbia, USA
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Braverman MA, Smith A, Pokorny D, Axtman B, Shahan CP, Barry L, Corral H, Jonas RB, Shiels M, Schaefer R, Epley E, Winckler C, Waltman E, Eastridge BJ, Nicholson SE, Stewart RM, Jenkins DH. Prehospital whole blood reduces early mortality in patients with hemorrhagic shock. Transfusion 2021; 61 Suppl 1:S15-S21. [PMID: 34269467 DOI: 10.1111/trf.16528] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 03/02/2021] [Accepted: 03/03/2021] [Indexed: 12/01/2022]
Abstract
BACKGROUND Low titer O+ whole blood (LTOWB) is being increasingly used for resuscitation of hemorrhagic shock in military and civilian settings. The objective of this study was to identify the impact of prehospital LTOWB on survival for patients in shock receiving prehospital LTOWB transfusion. STUDY DESIGN AND METHODS A single institutional trauma registry was queried for patients undergoing prehospital transfusion between 2015 and 2019. Patients were stratified based on prehospital LTOWB transfusion (PHT) or no prehospital transfusion (NT). Outcomes measured included emergency department (ED), 6-h and hospital mortality, change in shock index (SI), and incidence of massive transfusion. Statistical analyses were performed. RESULTS A total of 538 patients met inclusion criteria. Patients undergoing PHT had worse shock physiology (median SI 1.25 vs. 0.95, p < .001) with greater reversal of shock upon arrival (-0.28 vs. -0.002, p < .001). In a propensity-matched group of 214 patients with prehospital shock, 58 patients underwent PHT and 156 did not. Demographics were similar between the groups. Mean improvement in SI between scene and ED was greatest for patients in the PHT group with a lower trauma bay mortality (0% vs. 7%, p = .04). No survival benefit for patients in prehospital cardiac arrest receiving LTOWB was found (p > .05). DISCUSSION This study demonstrated that trauma patients who received prehospital LTOWB transfusion had a greater improvement in SI and a reduction in early mortality. Patient with prehospital cardiac arrest did not have an improvement in survival. These findings support LTOWB use in the prehospital setting. Further multi-institutional prospective studies are needed.
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Affiliation(s)
| | - Alison Smith
- Department of Surgery, UT Health San Antonio, San Antonio, Texas, USA
| | - Douglas Pokorny
- Department of Surgery, UT Health San Antonio, San Antonio, Texas, USA
| | - Benjamin Axtman
- Department of Surgery, UT Health San Antonio, San Antonio, Texas, USA
| | | | - Lauran Barry
- Department of Surgery, UT Health San Antonio, San Antonio, Texas, USA
| | - Hannah Corral
- Department of Surgery, UT Health San Antonio, San Antonio, Texas, USA
| | | | - Michael Shiels
- Trauma Services, University Hospital, San Antonio, Texas, USA
| | - Randall Schaefer
- Southwest Texas Regional Advisory Council, San Antonio, Texas, USA
| | - Eric Epley
- Southwest Texas Regional Advisory Council, San Antonio, Texas, USA
| | - Christopher Winckler
- Department of Emergency Health Services, UT Health San Antonio, 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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