Resuscitate early with plasma and platelets or balance blood products gradually: findings from the PROMMTT study. J Trauma Acute Care Surg. 2013;75:S24-S30. [PMID: 23778507 DOI: 10.1097/ta.0b013e31828fa3b9]

Using microfluidic shear to assess transfusion requirements in trauma patients

Background

Viscoelastic assays have widely been used for evaluating coagulopathies but lack the addition of shear stress important to in vivo clot formation. Stasys technology subjects whole blood to shear forces over factor-coated surfaces. Microclot formation is analyzed to determine clot area (CA) and platelet contractile forces (PCFs). We hypothesize the CA and PCF from this novel assay will provide information that correlates with trauma-induced coagulopathy and transfusion requirements.

Methods

Blood samples were collected on adult trauma patients from a single-institution prospective cohort study of high-level activations. Patient and injury characteristics, transfusion data, and outcomes were collected. Thromboelastography, coagulation studies, and Stasys assays were run on paired samples collected at admission. Stasys CA and PCFs were quantified as area under the curve calculations and maximum values. Normal ranges for Stasys assays were determined using healthy donors. Data were compared using Kruskal-Wallis tests and simple linear regression.

Results

From March 2021 to January 2023, 108 samples were obtained. Median age was 37.5 (IQR 27.5-52) years; patients were 77% male. 71% suffered blunt trauma, 26% had an Injury Severity Score of ≥25. An elevated international normalized ratio significantly correlated with decreased cumulative PCF (p=0.05), maximum PCF (p=0.05) and CA (p=0.02). Lower cumulative PCF significantly correlated with transfusion of any products at 6 and 24 hours (p=0.04 and p=0.05) as well as packed red blood cells (pRBCs) at 6 and 24 hours (p=0.04 and p=0.03). A decreased maximum PCF showed significant correlation with receiving any transfusion at 6 (p=0.04) and 24 hours (p=0.02) as well as transfusion of pRBCs, fresh frozen plasma, and platelets in the first 6 hours (p=0.03, p=0.03, p=0.03, respectively).

Conclusions

Assessing coagulopathy in real time remains challenging in trauma patients. In this pilot study, we demonstrated that microfluidic approaches incorporating shear stress could predict transfusion requirements at time of admission as well as requirements in the first 24 hours.

Level of evidence

Level II.

Influence of blood hemodynamics on the treatment outcomes of limited fluid resuscitation in emergency patients with traumatic hemorrhagic shock

OBJECTIVES

Traumatic hemorrhagic shock is a major death-related factor contributing to mortality in emergencies and can be effectively handled by the Limited Fluid Resuscitation (LFR) method. In the current investigation, the authors analyzed the influence of different administrating blood pressure on the treatment outcomes of LFR.

METHODS

276 participants were enrolled in the current study retrospectively from January 2016 to December 2021 and were divided into three groups based on the administrating blood pressure of LFR. The difference among the three groups regarding serum levels of cytokines as well as blood hemodynamics parameters was analyzed.

RESULTS

The results showed after the T2 stage treatment, cytokine levels in the three groups were all significantly influenced by different LFR strategies with medium MAP showing the strongest effects on the expression of all cytokine genes. Moreover, the MAP value was in positive correlation with IL-6, IL-10, and TNF-α levels, but showed no clear relation with IL-4 level in all three groups. Regarding the effects on hemodynamics parameters, the levels of CVP, CO, and CI were slightly increased by the different LFR administrating strategies, and the effect of medium and high MAP was statistically stronger than that of low MAP.

CONCLUSION

The present results showed that LFR would influence serum inflammatory levels by improving blood hemodynamics parameters. Medium MAP showed the strongest improving effects with the least side effects, which can be employed as the optimal administrating strategy for LFR in the future.

Review of Current Insights and Therapeutic Approaches for the Treatment of Refractory Postpartum Hemorrhage

Refractory postpartum hemorrhage (PPH) affects 10-20% of patients with PPH when they do not respond adequately to first-line treatments. These patients require second-line interventions, including three or more uterotonics, additional medications, transfusions, non-surgical treatments, and/or surgical intervention. Multiple studies have suggested that patients with refractory PPH have different clinical characteristics and causes of PPH when compared to patients who respond to first-line agents. This review highlights current insights into therapeutic approaches for the management of refractory PPH. Early management of refractory PPH relies on both hypovolemic resuscitation and achievement of hemostasis, with an emphasis on early blood product replacement and massive transfusion protocols. Transfusion needs can be more rapidly and accurately identified through point-of-care tests such as thromboelastography. Medical therapies for the treatment of refractory PPH involve treatment of both uterine atony as well as the underlying coagulopathy, with the use of tranexamic acid and adjunct therapies such as factor replacement. The principles guiding the management of refractory PPH include restoring normal uterine and pelvic anatomy, through the evaluation and management of retained products of conception, uterine inversion, and obstetric lacerations. Intrauterine vacuum-induced hemorrhage control devices are novel methods for the treatment of refractory PPH secondary to uterine atony, in addition to other uterine-sparing surgical procedures that are under investigation. Resuscitative endovascular balloon occlusion of the aorta can be considered for cases of critical refractory PPH, to prevent or decrease ongoing blood loss while definitive surgical interventions are performed. Finally, for patients with critical hemorrhage resulting in hemorrhagic shock, damage control resuscitation (a staged surgical approach focused on restoring normal physiologic recovery and maximizing tissue oxygenation prior to proceeding with definitive surgical management) has been shown to successfully control refractory PPH, with an overall mortality decrease for obstetric patients.

Severe Trauma-Induced Coagulopathy: Molecular Mechanisms Underlying Critical Illness

Trauma remains one of the leading causes of death in adults despite the implementation of preventive measures and innovations in trauma systems. The etiology of coagulopathy in trauma patients is multifactorial and related to the kind of injury and nature of resuscitation. Trauma-induced coagulopathy (TIC) is a biochemical response involving dysregulated coagulation, altered fibrinolysis, systemic endothelial dysfunction, platelet dysfunction, and inflammatory responses due to trauma. The aim of this review is to report the pathophysiology, early diagnosis and treatment of TIC. A literature search was performed using different databases to identify relevant studies in indexed scientific journals. We reviewed the main pathophysiological mechanisms involved in the early development of TIC. Diagnostic methods have also been reported which allow early targeted therapy with pharmaceutical hemostatic agents such as TEG-based goal-directed resuscitation and fibrinolysis management. TIC is a result of a complex interaction between different pathophysiological processes. New evidence in the field of trauma immunology can, in part, help explain the intricacy of the processes that occur after trauma. However, although our knowledge of TIC has grown, improving outcomes for trauma patients, many questions still need to be answered by ongoing studies.

Comprehensive analysis of coagulation factor delivery strategies in a cohort of trauma patients

PURPOSE

The 5^th edition of The European recommendations for the management of major bleeding and coagulopathy following trauma leaves room for various coagulation factor administration strategies. The present study examines these strategies reporting prevalence and timing of administration, quantity dispensed, and transfusion ratios in French trauma centers and their compliance with recommendations alongside associated mortality data.

METHODS

All adult patients, admitted directly to participating centers between 2011 and 2019, were extracted from a trauma registry. Two subpopulations were studied: severe hemorrhage (SH) and massive transfusion (MT) groups.

RESULTS

A total of 19,396 patients were included, among whom 8.4% (1630) experienced SH and 3% (579) received MT. Within the first 24 hours, 10% received fresh frozen plasma (FFP), rising to 93% and 99% in the subgroups of patients experiencing SH and MT respectively. Only, 8% received fibrinogen concentrate (FC), increasing to 75% and 92% in subgroups SH and MT respectively. Co-administration of FFP and FC became the dominant strategy with 68% of patients at 6 h and 72% at 24 h in SH subgroup. In unadjusted data, mortality was systematically lower in groups that complied with recommendations, a lower mortality than expected was mostly observed in contrast to non-compliant subgroups. The per-patient compliance to studied recommendations was 21% and 22% in SH and MT subgroups.

CONCLUSION

The main hemostatic strategy for major bleeding combined the administration of both FFP and FC, favoring an early additional supply of fibrinogen. Compliance with the recommendations was low in SH and MT subgroups.

Whole Blood Trauma Resuscitation in Community Trauma Centers Confers Survival Benefit Over Component Therapy

Whole blood (WB) for trauma resuscitation in civilian populations has become more common. The utilization of WB in community trauma centers has not been reported. Previous studies have centered around large academic medical centers. We hypothesized that WB-based resuscitation compared to component-only resuscitation (CORe) would demonstrate a survival benefit and that WB resuscitation is safe, feasible, and benefits trauma patients regardless of setting. Our results indicate that receiving whole blood during resuscitation conferred a clear survival benefit to discharge, and this benefit was independent of ISS, age, gender, and initial SBP. We conclude WB should be incorporated into all resuscitation protocols for exsanguinating trauma patients and preferred over component therapy in all centers treating trauma patients.

Prediction of pre-hospital blood transfusion in trauma patients based on scoring systems

BACKGROUND

Pre-hospital blood transfusion (PHBT) is a safe and gradually expanding procedure applied to trauma patients. A proper decision to activate PHBT with the presently limited diagnostic options at the site of an incident poses a challenge for pre-hospital crews. The purpose of this study was to compare the selected scoring systems and to determine whether they can be used as valid tools in identifying patients with PHBT requirements.

METHODS

A retrospective single-center study was conducted between June 2018 and December 2020. Overall, 385 patients (aged [median; IQR]: 44; 24-60; 73% males) were included in this study. The values of five selected scoring systems were calculated in all patients. To determine the accuracy of each score for the prediction of PHBT, the Receiver Operating Characteristic (ROC) analysis was used and to measure the association, the odds ratio with 95% confidence intervals was counted (Fig. 1).

RESULTS

Regarding the proper indication of PHBT, shock index (SI) and pulse pressure (PP) revealed the highest value of AUC and sensitivity/specificity ratio (SI: AUC 0.88; 95% CI 0.82-0.93; PP: AUC 0.85 with 95% CI 0.79-0.91).

CONCLUSION

Shock index and pulse pressure are suitable tools for predicting PHBT in trauma patients.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Platelet Transfusion for Trauma Resuscitation

Purpose of Review

To review the role of platelet transfusion in resuscitation for trauma, including normal platelet function and alterations in behavior following trauma, blood product transfusion ratios and the impact of platelet transfusion on platelet function, platelet function assays, risks of platelet transfusion and considerations for platelet storage, and potential adjunct therapies and synthetic platelets.

Recent Findings

Platelets are a critical component of clot formation and breakdown following injury, and in addition to these hemostatic properties, have a complex role in vascular homeostasis, inflammation, and immune function. Evidence supports that platelets are activated following trauma with several upregulated functions, but under conditions of severe injury and shock are found to be impaired in their hemostatic behaviors. Platelets should be transfused in balanced ratios with red blood cells and plasma during initial trauma resuscitation as this portends improved outcomes including survival. Multiple coagulation assays can be used for goal-directed resuscitation for traumatic hemorrhage; however, these assays each have drawbacks in terms of their ability to measure platelet function. While resuscitation with balanced transfusion ratios is supported by the literature, platelet transfusion carries its own risks such as bacterial infection and lung injury. Platelet supply is also limited, with resource-intensive storage requirements, making exploration of longer-term storage options and novel platelet-based therapeutics attractive. Future focus on a deeper understanding of the biology of platelets following trauma, and on optimization of novel platelet-based therapeutics to maintain hemostatic effects while improving availability should be pursued.

Summary

While platelet function is altered following trauma, platelets should be transfused in balanced ratios during initial resuscitation. Severe injury and shock can impair platelet function, which can persist for several days following the initial trauma. Assays to guide resuscitation following the initial period as well as storage techniques to extend platelet shelf life are important areas of investigation.

A comparison between liquid group A plasma and thawed group A plasma for massive transfusion activation in trauma patients

BACKGROUND AND OBJECTIVES

The use of group A thawed 24-h plasma when resuscitating haemorrhagic shock patients has become more common; however, limited data exist on the clinical use of liquid plasma (LP). Our aim is to determine whether LP is of clinical benefit to patients requiring massive transfusion.

MATERIALS AND METHODS

The objective of this retrospective study was to detect any difference in 24-h survival between patients receiving liquid or thawed plasma (TP) during their massive transfusion activation. Other objectives were to report any difference in hospital length of stay (LOS), intensive care unit (ICU) LOS and in-hospital survival. Data collected included gender, age, mechanism of injury, Injury Severity Score, Revised Trauma Score and Trauma Injury Severity Score.

RESULTS

A total of 178 patients received 1283 units of LP, median 4 and range (1-56), whereas 270 patients received 2031 units of TP, median 5 and range (1-87). The two study groups were comparable in terms of gender, age, mechanism of injury, whole blood, red blood cells, platelets and cryoprecipitate transfused. The use of LP during the massive transfusion activation in traumatically injured patients was not associated with increased 24-h survival compared to when using TP, p = 0.553.

CONCLUSION

Our study did not show a difference in 24-h or 30-day survival between the use of LP compared to TP in trauma patients. LP should be considered an alternative to TP in trauma patients requiring immediate plasma resuscitation.

Whole blood versus component therapy for haemostatic resuscitation of major bleeding: a protocol for a systematic review and meta-analysis

INTRODUCTION

There is a renewed interest in the use of whole blood (WB) to manage patients with life-threatening bleeding. We aimed to estimate mortality and complications risk between WB and blood component therapy for haemostatic resuscitation of major bleeding.

METHODS

We will conduct a systematic review and meta-analysis of studies published between 1 January 1980 and 1 January 2020, identified from PubMed and Scopus databases. Population will be patients who require blood transfusion (traumatic operative, obstetric and gastrointestinal bleeding). Intervention is WB transfusion such as fresh WB (WB unit stored for less than 48 hours), leukoreduced modified WB (with platelets removed during filtration), warm fresh WB (stored warm at 22°C for up to 8 hours and then for a maximum of an additional 24 hours at 4°C). The primary outcomes will be the 24-hour and 30-day survival rates (in-hospital mortality). Comparator is blood component therapy (red blood cells, fresh-frozen plasma and platelets given together in a 1:1:1 unit ratio). The Cochrane risk of bias tool for randomised controlled trials and Risk Of Bias In Non-randomised Studies - of Interventions (ROBINS-I) for observation studies will be used to assess the risk of bias of included studies. We will use random-effects models for the pooling of studies. Interstudy heterogeneity will be assessed by the Cochran Q statistic, where p<0.10 will be considered statistically significant and quantified by I² statistic, where I² ≥50% will indicate substantial heterogeneity. We will perform subgroup and meta-regression analyses to assess geographical differences and other study-level factors explaining variations in the reported mortality risk. Results will be reported as risk ratios and their 95% CIs.

ETHICS AND DISSEMINATION

No ethics clearance is required as no primary data will be collected. The results will be presented at scientific conferences and published in a peer-reviewed journal.

Risk of ABO-Incompatible Plasma From Non-ABO-Identical Components

The last several decades have seen significant changes in the approach to resuscitation of bleeding patients. These include the adoption of ABO-incompatible plasma transfusion in the form of group A plasma and/or low titer group O whole blood for trauma patients of unknown ABO group. Studies to date have examined the impact of these practices on patient outcomes and clinical markers of hemolysis in recipients of ABO-incompatible plasma compared to those for whom the plasma is ABO-compatible. Risk for increased mortality and/or overt hemolysis appear to be low among recipients of ABO-incompatible plasma; however, nearly all of studies are retrospective and most have focused only on adult trauma patients so results may not be generalizable to other bleeding patients. Work continues to evaluate the role of various titer thresholds in decreasing hemolytic risk and opportunities remain to improve our understanding of anti-A and anti-B antibody interactions with complement/endothelium and identify strategies to minimize risk.

The FASILA Score: A Novel Bio-Clinical Score to Predict Massive Blood Transfusion in Patients with Abdominal Trauma

Background

Early identification of patients who may need massive blood transfusion remains a major challenge in trauma care. This study proposed a novel and easy-to-calculate prediction score using clinical and point of care laboratory findings in patients with abdominal trauma (AT).

Methods

Patients with AT admitted to a trauma center in Qatar between 2014 and 2017 were retrospectively analyzed. The FASILA score was proposed and calculated using focused assessment with sonography in trauma (0 = negative, 1 = positive), Shock Index (SI) (0 = 0.50–0.69, 1 = 0.70–0.79, 2 = 0.80–0.89, and 3 ≥ 0.90), and initial serum lactate (0 ≤ 2.0, 1 = 2.0–4.0, and 2 ≥ 4.0 mmol/l). Outcome variables included mortality, laparotomy, and massive blood transfusion (MT). FASILA was compared to other prediction scores using receiver operating characteristics and areas under the curves. Bootstrap procedure was employed for internal validation.

Results

In 1199 patients with a mean age of 31 ± 13.5 years, MT, MT protocol (MTP) activation, exploratory laparotomy (ExLap), and hospital mortality were related linearly with the FASILA score, Injury Severity Score, and total length of hospital stay. Initial hemoglobin, Revised Trauma Score (RTS), and Trauma Injury Severity Score (TRISS) were inversely proportional. FASILA scores correlated significantly with the Assessment of Blood Consumption (ABC) (r = 0.65), Revised Assessment of Bleeding and Transfusion (RABT) (r = 0.63), SI (r = 0.72), RTS (r = − 0.34), and Glasgow Coma Scale (r = − 0.32) and outperformed other predictive systems (RABT, ABC, and SI) in predicting MT, MTP, ExLap, and mortality.

Conclusions

The novel FASILA score performs well in patients with abdominal trauma and offers advantages over other scores.

Electronic supplementary material

The online version of this article (10.1007/s00268-019-05289-0) contains supplementary material, which is available to authorized users.

A Pilot Study Assessing the Impact of rs174537 on Circulating Polyunsaturated Fatty Acids and the Inflammatory Response in Patients with Traumatic Brain Injury

Traumatic brain injury (TBI) is a leading cause of death and disability in persons under age 45. The hallmark secondary injury profile after TBI involves dynamic interactions between inflammatory and metabolic pathways including fatty acids. Omega-3 polyunsaturated fatty acids (PUFAs) such as docosahexaenoic acid (DHA) have been shown to provide neuroprotective benefits by minimizing neuroinflammation in rodents. These effects have been less conclusive in humans, however. We postulate genetic variants influencing PUFA metabolism in humans could contribute to these disparate findings. Therefore, we sought to (1) characterize the circulating PUFA response and (2) evaluate the impact of rs174537 on inflammation after TBI. A prospective, single-center, observational pilot study was conducted to collect blood samples from Level-1 trauma patients (N = 130) on admission and 24 h post-admission. Plasma was used to quantify PUFA levels and inflammatory cytokines. Deoxyribonucleic acid was extracted and genotyped at rs174537. Associations between PUFAs and inflammatory cytokines were analyzed for all trauma cases and stratified by race (Caucasians only), TBI (TBI: N = 47; non-TBI = 83) and rs174537 genotype (GG: N = 33, GT/TT: N = 44). Patients with TBI had higher plasma DHA levels compared with non-TBI at 24 h post-injury (p = 0.013). The SNP rs174537 was associated with both PUFA levels and inflammatory cytokines (p < 0.05). Specifically, TBI patients with GG genotype exhibited the highest plasma levels of DHA (1.33%) and interleukin-8 (121.5 ± 43.3 pg/mL), which were in turn associated with poorer outcomes. These data illustrate the impact of rs174537 on the post-TBI response. Further work is needed to ascertain how this genetic variant directly influences inflammation after trauma.

Review of Existing Scoring Systems for Massive Blood Transfusion in Trauma Patients: Where Do We Stand?

BACKGROUND

Uncontrolled bleeding is the main cause of the potential preventable death in trauma patients. Accordingly, we reviewed all the existing scores for massive transfusion posttraumatic hemorrhage and summarized their characteristics, thus making it easier for the reader to have a global view of these scores-how they were created, their accuracy and to which population they apply.

METHODS

A narrative review with a systematic search method to retrieve the journal articles on the predictive scores or models for massive transfusion was carried out. A literature search using PubMed, SCOPUS, and Google scholar was performed using relevant keywords in different combinations. The keywords used were "massive transfusion," "score," "model," "trauma," and "hemorrhage" in different combinations. The search was limited for full-text articles published in English language, human species and for the duration from January 1, 1998 to November 30, 2018.

RESULTS

The database search yielded 295 articles. The search was then restricted to the inclusion criteria which retrieved 241 articles. Duplicates were removed and full-texts were assessed for the eligibility to include in the review which resulted in inclusion of 24 articles. These articles identified 24 scoring systems including modified or revised scores. Different models and scores for identifying patients requiring massive transfusion in military and civilian settings have been described. Many of these scorings were complex with difficult calculation, while some were simple and easy to remember.

CONCLUSIONS

The current prevailing practice that is best described as institutional or provider centered should be supplemented with score-based protocol with auditing and monitoring tools to refine it. This review summarizes the current scoring models in predicting the need for MT in civilian and military trauma. Several questions remain open; i.e., do we need to develop new score, merge scores, modify scores, or adopt existing score for certain trauma setting?

Sex Differences in the Massively Transfused Trauma Patient

INTRODUCTION

Recent studies have suggested the female hypercoaguable state may have a protective effect in trauma. However, whether this hypercoagulable profile confers a survival benefit in massively transfused trauma patients has yet to be determined. We hypothesized that females would have better outcomes than males after traumatic injury that required massive transfusion protocol (MTP).

PATIENTS AND METHODS

All trauma patients who underwent MTP at an urban, level 1, academic trauma center were reviewed from November 2007 to October 2018. Female MTP patients were compared to their male counterparts.

RESULTS

There were a total of 643 trauma patients undergoing MTP. Of these, 90 (13.8%) were female and 563 (86.2%) were male. Presenting blood pressure, heart rate, shock index, and injury severity score (ISS) were not significantly different. Overall mortality and incidence of venous thromboembolism were similar. Complication profile and hospital stay were similar. On logistic regression, female sex was not associated with survival (HR: 1.04, 95% CI: 0.56-1.92, P = 0.91). Variables associated with mortality included age (HR: 1.02, 95% CI: 1.05-1.09, P = 0.03) and ISS (HR: 1.07, 95% CI: 1.05-1.09, P < 0.001). Increasing Glascow Coma Scale was associated with survival (HR: 0.85, 95% CI: 0.82-0.89, P < 0.001). On subset analysis, premenopausal women (age < 50) did not have a survival advantage in comparison with similar aged males (HR: 0.68, 95% CI: 0.36-1.28, P = 0.24).

DISCUSSION

Sex differences in coagulation profile do not result in a survival advantage for females when MTP is required.

The ABC-D score improves the sensitivity in predicting need for massive transfusion in pediatric trauma patients

PURPOSE

Early and accurate identification of pediatric trauma patients who will require massive transfusion (MT) remains difficult, and MT activation criteria are not well established. In children, the addition of shock index-pediatric age-adjusted (SIPA) to the ABC score (ABC-S) only modestly improves the sensitivity of the ABC score. We hypothesized that the discriminate ability of the ABC-S score would improve with the addition of elevated serum lactate and base deficit (ABCD score).

METHODS

We identified children between 1 and 18 years old who received a pRBC transfusion between 2008 and 2018 from our trauma registry. We calculated sensitivity, specificity, and accuracy of the ABC, ABC-S, and ABCD scores to determine the need for MT.

RESULTS

We included 211 children, of which 66 required MT. The best predictor of MT was achieved by adding BD and lactate to the ABC-S score, with an AUC of 0.805. An ABCD score of 3 or greater was 77.4% sensitive and 78.8% specific at predicting the need for MT. Pediatric trauma patients that required MT had higher injury severity score (p = 0.005), lactate (p = 0.002), base deficit (p = <0.0001). Mortality was higher in the MT group (45.5% vs 15.3%, p = 0.0004).

CONCLUSIONS

The ABCD score improves the sensitivity of activating MT in pediatric trauma patients.

STUDY TYPE

Treatment Study.

LEVEL OF EVIDENCE

Level III.

Incidence, morbidity, and mortality of traumatic superior mesenteric artery injuries compared to other visceral arteries

Objectives

Celiac artery, superior mesenteric artery, and inferior mesenteric artery injuries are often grouped together as major visceral artery injuries with an incidence of <1%. The mortality rates range from 38–75% for celiac artery injuries and 25–68% for superior mesenteric artery injuries. No large series have investigated the mortality rate of inferior mesenteric artery injuries. We hypothesize that from all the major visceral artery injuries, superior mesenteric artery injury leads to the highest risk of mortality in adult trauma patients.

Methods

The Trauma Quality Improvement Program (2010–2016) was queried for patients with injury to the celiac artery, superior mesenteric artery, or inferior mesenteric artery. A multivariable logistic regression model was used for analysis. Separate subset analyses using blunt trauma patients and penetrating trauma patients were performed.

Results

From 1,403,466 patients, 1730 had single visceral artery injuries with 699 (40.4%) involving the celiac artery, 889 (51.4%) involving the superior mesenteric artery, and 142 (8.2%) involving the inferior mesenteric artery. The majority of patients were male (79.2%) with a median age of 39 years old, and median injury severity score of 22. Compared to celiac artery and inferior mesenteric artery injuries, superior mesenteric artery injuries had a higher rate of severe (grade >3) abbreviated injury scale for the abdomen (57.5% vs. 42.5%, p < 0.001). The overall mortality for patients with a single visceral artery injury was 20%. Patients with superior mesenteric artery injury had higher mortality compared to those with celiac artery and inferior mesenteric artery injuries (23.7% vs. 16.3%, p < 0.001). After controlling for covariates, traumatic superior mesenteric artery injury increased risk of mortality (OR = 1.72, CI = 1.24–2.37, p < 0.01) in adult trauma patients, while celiac artery ( p = 0.59) and inferior mesenteric artery ( p = 0.31) injury did not. After stratifying by mechanism, superior mesenteric artery injury increased risk of mortality (OR = 3.65, CI = 2.01–6.45, p < 0.001) in adult trauma patients with penetrating mechanism of injury but not in those with blunt force mechanism (OR = 1.22, CI = 0.81–1.85, p = 0.34).

Conclusions

Compared to injuries of the celiac artery and inferior mesenteric artery, traumatic superior mesenteric artery injury is associated with a higher mortality. Moreover, while superior mesenteric artery injury does not act as an independent risk factor for mortality in adult patients with blunt force trauma, it nearly quadruples the risk of mortality in adult trauma patients with penetrating mechanism of injury. Future prospective research is needed to confirm these findings and evaluate factors to improve survival following major visceral artery injury.

Blood Products in the Management of Abnormal Placentation

A critical tool in the successful management of patients with abnormal placentation is an established massive transfusion protocol designed to rapidly deliver blood products in obstetrical and surgical hemorrhage. Spurred by trauma research and an understanding of consumptive coagulopathy, the past 2 decades have seen a shift in volume resuscitation from an empiric, crystalloid-based method to balanced, targeted transfusion therapy. The present article reviews patient blood management in abnormal placentation, beginning with optimizing the patient's status in the antenatal period to the laboratory assessment and transfusion strategy for blood products at the time of hemorrhage.

Transfusion strategies for major haemorrhage in trauma

Trauma is a leading cause of death worldwide in persons under 44 years of age, and uncontrolled haemorrhage is the most common preventable cause of death in this patient group. The transfusion management of trauma haemorrhage is unrecognisable from 20 years ago. Changes in clinical practice have been driven primarily by an increased understanding of the pathophysiology of trauma-induced coagulopathy (TIC), which is associated with poor clinical outcomes, including a 3- to 4-fold increased risk of death. Targeting this coagulopathy alongside changes to surgical and anaesthetic practices (an overarching strategy known as damage control surgery/damage control resuscitation) has led to a significant reduction in mortality rates over the last two decades. This narrative review will discuss the transfusion practices that are currently used for trauma haemorrhage and the evidence that supports these practices.

Variability of fluid administration during exploratory laparotomy for abdominal trauma

Background

Approximately 8% of traumatically injured patients require transfusion with packed red blood cells (pRBC) and only 1% to 2% require massive transfusion. Intraoperative massive transfusion was defined as requiring greater than 5 units (u) of pRBC in 4 hours. Despite the majority of patients not requiring transfusion, the appropriate amount and type of crystalloid administered during the era of damage control resuscitation have not been analyzed. We sought to determine the types of crystalloid used during trauma laparotomies and the potential effects on resuscitation.

Methods

Patients who underwent laparotomy after abdominal trauma from January 2014 to December 2016 at the University of Cincinnati Medical Center were identified. Patients were grouped based on requiring 0u, 1u to 4u, and ≥5u pRBC during intraoperative resuscitation. Demographic, physiologic, pharmacologic, operative, and postoperative data were collected. Statistical analysis was performed with Kruskal-Wallis test and Pearson’s correlation coefficient.

Results

Lactated Ringer’s (LR) solution was the most used crystalloid type received in the 0u and 1u to 4u pRBC cohorts, whereas normal saline (NS) was the most common in the ≥5u pRBC cohort. Most patients received two types of crystalloid intraoperatively. NS and LR were most frequently the first crystalloids administered, with Normosol infusion occurring later. The amount of crystalloid received correlated with operative length, but did not correlate with the estimated blood loss. Neither the type of crystalloid administered nor the anesthesia provider type was associated with changes in postoperative resuscitation parameters or electrolyte concentrations.

Discussion

There is a wide variation in the amount and types of crystalloids administered during exploratory laparotomy for trauma. Interestingly, the amount or type of crystalloid given did not affect resuscitation parameters regardless of blood product requirement.

Level of evidence

Level IV.

Effect of Pre-Hospital Use of the Assessment of Blood Consumption Score and Pre-Thawed Fresh Frozen Plasma on Resuscitation and Trauma Mortality

BACKGROUND

Early blood product resuscitation reduces trauma patient mortality from hemorrhage. This mortality benefit depends on a system that can rapidly identify actively bleeding patients, initiate massive transfusion protocol (MTP), and mobilize resources to the bedside. We hypothesized that process improvement efforts that identify patients early and mobilize appropriate blood products to the bedside for immediate use would improve mortality.

STUDY DESIGN

Pre-implementation, MTP activation was at the discretion of the trauma surgeon, and only PRBCs were immediately available. In June 2016, the Assessment of Blood Consumption (ABC) score was incorporated in our pre-hospital triage process, and a process for thawed plasma to be available was developed. We performed a retrospective review of patients who were hypotensive on arrival or had MTP activated. We compared mortality and MTP component ratios 15 months pre- vs 15 months post-implementation.

RESULTS

Activations of MTP increased 6-fold, while the specificity of the process remained the same. In patients receiving MTP, appropriate blood product transfusion ratios increased 44%. Overall and penetrating trauma mortality improved by 23% and 41%, respectively. When divided by the Injury Severity Score (ISS), penetrating trauma mortality decreased by 65% for the ISS subgroup 15 to 24 and by 38% for ISS subgroup ≥ 25. Length of stay, ICU length of stay, and readmission rates were not significantly different.

CONCLUSIONS

Delivery of balanced blood product resuscitation is essential to confer mortality benefits. Process improvement directed at early recognition of the hemorrhagic patient, immediate product availability, and product delivery to the bedside for transfusion allows for mortality reduction without increased resource use.

Blood transfusion management in the severely bleeding military patient

PURPOSE OF REVIEW

Hemorrhage remains the primary cause of preventable death on the battlefield and in civilian trauma. Hemorrhage control is multifactorial and starts with point-of-injury care. Surgical hemorrhage control and time from injury to surgery is paramount; however, interventions in the prehospital environment and perioperative period affect outcomes. The purpose of this review is to understand concepts and strategies for successful management of the bleeding military patient. Understanding the life-threatening nature of coagulopathy of trauma and implementing strategies aimed at full spectrum hemorrhage management from point of injury to postoperative care will result in improved outcomes in patients with life-threatening bleeding.

RECENT FINDINGS

Timely and appropriate therapies impact survival. Blood product resuscitation for life-threatening hemorrhage should either be with whole blood or a component therapy strategy that recapitulates the functionality of whole blood. The US military has transfused over 10 000 units of whole blood since the beginning of the wars in Iraq and Afghanistan. The well recognized therapeutic benefits of whole blood have pushed this therapy far forward into prehospital care in both US and international military forces. Multiple hemostatic adjuncts are available that are likely beneficial to the bleeding military patient; and other products and techniques are under active investigation.

SUMMARY

Lessons learned in the treatment of combat casualties will likely continue to have positive impact and influence and the management of hemorrhage in the civilian trauma setting.

Recommendations on RBC Transfusion in Critically Ill Children With Nonlife-Threatening Bleeding or Hemorrhagic Shock From the Pediatric Critical Care Transfusion and Anemia Expertise Initiative

OBJECTIVES

To present the recommendations and supporting literature for RBC transfusions in critically ill children with bleeding developed by the Pediatric Critical Care Transfusion and Anemia Expertise Initiative.

DESIGN

Consensus conference series of international, multidisciplinary experts in RBC transfusion management of critically ill children.

METHODS

The panel of 38 experts developed evidence-based and, when evidence was lacking, expert-based clinical recommendations as well as research priorities for RBC transfusions in critically ill children. The bleeding subgroup included five experts. Electronic searches were conducted using PubMed, EMBASE, and Cochrane Library databases from 1980 to May 2017. Agreement was obtained using the Research and Development/UCLA Appropriateness Method. Results were summarized using the Grading of Recommendations Assessment, Development, and Evaluation method.

RESULTS

Transfusion and Anemia Expertise Initiative Consensus Conference experts developed a total of six recommendations focused on transfusion in the critically ill child with acute bleeding. In critically ill children with nonlife-threatening bleeding, we recommend giving a RBC transfusion for a hemoglobin concentration less than 5 g/dL, and be considered for a hemoglobin concentration between 5 and 7 g/dL. In critically ill children with hemorrhagic shock, we suggest that RBCs, plasma and platelets transfusion ratio between 2:1:1 to 1:1:1 until the bleeding is no longer life-threatening. We recommend future studies to develop physiologic and laboratory measures to indicate the need for RBC transfusions, and to determine if goal directed hemostatic resuscitation improves survival. Finally, we recommend future studies to determine if low titer group O whole blood is more efficacious and safe compared with reconstituted whole blood in children with hemorrhagic shock.

CONCLUSIONS

The Transfusion and Anemia Expertise Initiative Consensus Conference developed pediatric specific recommendations regarding RBC transfusion management in the critically ill child with acute bleeding, as well as recommendations to help guide future research priorities.

New Advances in the Care of the Hemorrhaging Patient

Thirty-three percent of early traumatic deaths are secondary to hemorrhage. In addition to timing to source control, the literature has seen a surge of research on adjuncts in hemorrhage control. This review focuses on three of the latest interventions in the management of the bleeding patient; an endovascular aortic occlusive balloon, tranexamic acid (TXA), and updates to the massive transfusion protocol.

Diagnostic performance of prothrombin time point-of-care to detect acute traumatic coagulopathy on admission: experience of 522 cases in trauma center

BACKGROUND

Early identification of acute traumatic coagulopathy is a key challenge during initial management to determine whether to initiate early hemostatic support. We assessed the performance of prothrombin time (PT) at point-of-care in trauma patients to detect moderate and severe coagulopathy on admission.

STUDY DESIGN AND METHODS

All admitted consecutive trauma patients were analyzed retrospectively between April 2014 and July 2015. PT was measured on admission with both a PT point-of-care device (PTr-CGK) and a standard coagulation test (PTr-STD). The results for PTr-CGK and PTr-STD were compared using analysis of agreement, precision, and accuracy. The diagnostic performance of PTr-CGK to predict coagulopathy was established by analysis of receiver operating characteristic curves. The predictive performance of different thresholds and risk factors for misclassification were also studied.

RESULTS

Over a 16-month period, 522 patients were included. PTr-CGK estimated PTr-STD with a bias of 0.00 (95% confidence interval [CI], -0.48 to 0.50) and a precision of 0.25. The optimal threshold was 1.4 to predict severe coagulopathy (sensitivity 81% [95% CI, 68%-94%], negative predictive value 98% [95% CI, 97%-99%]), and 1.2 for moderate coagulopathy (sensitivity 80% [95% CI, 72%-88%], negative predictive value 94% [95% CI, 91%-96%]). A low PTr-CGK in the presence of severity criteria (Injury Severity Score ≥ 16, Trauma Associated Severe Hemorrhage score ≥ 12, hemoglobin level < 7 g/dL, fibrinogen level < 2 g/L, base deficit ≥ 6 mmol/L) was strongly associated with a false-negative risk.

CONCLUSIONS

The PT point-of-care device is reliable and accurate for the early identification of coagulopathic trauma patients.

Early transfusion on battlefield before admission to role 2: A preliminary observational study during "Barkhane" operation in Sahel

INTRODUCTION

Haemorrage is the leading cause of death after combat related injuries and bleeding management is the cornerstone of management of these casualties. French armed forces are deployed in Barkhane operation in the Sahel-Saharan Strip who represents an immense area. Since this constraint implies evacuation times beyond doctrinal timelines, an institutional decision has been made to deploy blood products on the battlefield and transfuse casualties before role 2 admission if indicated. The purpose of this study was to evaluate the transfusion practices on battlefield during the first year following the implementation of this policy.

MATERIALS AND METHODS

Prospective collection of data about combat related casualties categorized alpha evacuated to a role 2. Battlefield transfusion was defined as any transfusion of blood product (red blood cells, plasma, whole blood) performed by role 1 or Medevac team before admission at a role 2. Patients' characteristics, battlefield transfusions' characteristics and complications were analysed.

RESULTS

During the one year study, a total of 29 alpha casualties were included during the period study. Twenty-eight could be analysed, 7/28 (25%) being transfused on battlefield, representing a total of 22 transfusion episodes. The most frequently blood product transfused was French lyophilized plasma (FLYP). Most of transfusion episodes occurred during medevac. Compared to non-battlefield transfused casualties, battlefield transfused casualties suffered more wounded anatomical regions (median number of 3 versus 2, p = 0.04), had a higher injury severity score (median ISS of 45 versus 25, p = 0,01) and were more often transfused at role 2, received more plasma units and whole blood units. There was no difference in evacuation time to role 2 between patients transfused on battlefield and non-transfused patients. There was no complication related to battlefield transfusions. Blood products transfusion onset on battlefield ranged from 75 min to 192 min after injury.

CONCLUSION

Battlefield transfusion for combat-related casualties is a logistical challenge. Our study showed that such a program is feasible even in an extended area as Sahel-Saharan Strip operation theatre and reduces time to first blood product transfusion for alpha casualties. FLYP is the first line blood product on the battlefield.

The Role of Plasma Transfusion in Massive Bleeding: Protecting the Endothelial Glycocalyx?

Massive hemorrhage is a leading cause of death worldwide. During the last decade several retrospective and some prospective clinical studies have suggested a beneficial effect of early plasma-based resuscitation on survival in trauma patients. The underlying mechanisms are unknown but appear to involve the ability of plasma to preserve the endothelial glycocalyx. In this mini-review, we summarize current knowledge on glycocalyx structure and function, and present data describing the impact of hemorrhagic shock and resuscitation fluids on glycocalyx. Animal studies show that hemorrhagic shock leads to glycocalyx shedding, endothelial inflammatory changes, and vascular hyper-permeability. In these animal models, plasma administration preserves glycocalyx integrity and functions better than resuscitation with crystalloids or colloids. In addition, we briefly present data on the possible plasma components responsible for these effects. The endothelial glycocalyx is increasingly recognized as a critical component for the physiological vasculo-endothelial function, which is destroyed in hemorrhagic shock. Interventions for preserving an intact glycocalyx shall improve survival of trauma patients.

Is Coagulopathy an Appropriate Therapeutic Target During Critical Illness Such as Trauma or Sepsis?

Coagulopathy is a common and vexing clinical problem in critically ill patients. Recently, major advances focused on the treatment of coagulopathy in trauma and sepsis have emerged. However, the targeting of coagulopathy with blood product transfusion and drugs directed at attenuating the physiologic response to these conditions has major potential risk to the patient. Therefore, the identification of coagulopathy as a clinical target is an area of uncertainty and controversy. To analyze the state of the science regarding coagulopathy in critical illness, a symposium addressing the problem was organized at the 39th annual meeting of the Shock Society in the summer of 2016. This manuscript synthesizes the viewpoints of the four expert panelists at the debate and presents an overview of the potential positive and negative consequences of targeting coagulopathy in trauma and sepsis.

Plasma First Resuscitation Reduces Lactate Acidosis, Enhances Redox Homeostasis, Amino Acid and Purine Catabolism in a Rat Model of Profound Hemorrhagic Shock

The use of aggressive crystalloid resuscitation to treat hypoxemia, hypovolemia, and nutrient deprivation promoted by massive blood loss may lead to the development of the blood vicious cycle of acidosis, hypothermia, and coagulopathy and, utterly, death. Metabolic acidosis is one of the many metabolic derangements triggered by severe trauma/hemorrhagic shock, also including enhanced proteolysis, lipid mobilization, as well as traumatic diabetes. Appreciation of the metabolic benefit of plasma first resuscitation is an important concept. Plasma resuscitation has been shown to correct hyperfibrinolysis secondary to severe hemorrhage better than normal saline. Here, we hypothesize that plasma first resuscitation corrects metabolic derangements promoted by severe hemorrhage better than resuscitation with normal saline. Ultra-high-performance liquid chromatography-mass spectrometry-based metabolomics analyses were performed to screen plasma metabolic profiles upon shock and resuscitation with either platelet-free plasma or normal saline in a rat model of severe hemorrhage. Of the 251 metabolites that were monitored, 101 were significantly different in plasma versus normal saline resuscitated rats. Plasma resuscitation corrected lactate acidosis by promoting glutamine/amino acid catabolism and purine salvage reactions. Plasma first resuscitation may benefit critically injured trauma patients by relieving the lactate burden and promoting other non-clinically measured metabolic changes. In the light of our results, we propose that plasma resuscitation may promote fueling of mitochondrial metabolism, through the enhancement of glutaminolysis/amino acid catabolism and purine salvage reactions. The treatment of trauma patients in hemorrhagic shock with plasma first resuscitation is likely not only to improve coagulation, but also to promote substrate-specific metabolic corrections.

Prehospital Blood Product Resuscitation for Trauma: A Systematic Review

Introduction:

Administration of high ratios of plasma to packed red blood cells is a routine practice for in-hospital trauma resuscitation. Military and civilian emergency teams are increasingly carrying prehospital blood products (PHBP) for trauma resuscitation. This study systematically reviewed the clinical literature to determine the extent to which the available evidence supports this practice.

Methods:

Bibliographic databases and other sources were searched to July 2015 using keywords and index terms related to the intervention, setting, and condition. Standard systematic review methodology aimed at minimizing bias was used for study selection, data extraction, and quality assessment (protocol registration PROSPERO: CRD42014013794). Synthesis was mainly narrative with random effects model meta-analysis limited to mortality outcomes.

Results:

No prospective comparative or randomized studies were identified. Sixteen case series and 11 comparative studies were included in the review. Seven studies included mixed populations of trauma and non-trauma patients. Twenty-five of 27 studies provided only very low quality evidence. No association between PHBP and survival was found (OR for mortality: 1.29, 95% CI: 0.84–1.96, P = 0.24). A single study showed improved survival in the first 24 h. No consistent physiological or biochemical benefit was identified, nor was there evidence of reduced in-hospital transfusion requirements. Transfusion reactions were rare, suggesting the short-term safety of PHBP administration.

Conclusions:

While PHBP resuscitation appears logical, the clinical literature is limited, provides only poor quality evidence, and does not demonstrate improved outcomes. No conclusions as to efficacy can be drawn. The results of randomized controlled trials are awaited.

Plasma Transfusion: History, Current Realities, and Novel Improvements

Traumatic hemorrhage is the leading cause of preventable death after trauma. Early transfusion of plasma and balanced transfusion have been shown to optimize survival, mitigate the acute coagulopathy of trauma, and restore the endothelial glycocalyx. There are a myriad of plasma formulations available worldwide, including fresh frozen plasma, thawed plasma, liquid plasma, plasma frozen within 24 h, and lyophilized plasma (LP). Significant equipoise exists in the literature regarding the optimal plasma formulation. LP is a freeze-dried formulation that was originally developed in the 1930s and used by the American and British military in World War II. It was subsequently discontinued due to risk of disease transmission from pooled donors. Recently, there has been a significant amount of research focusing on optimizing reconstitution of LP. Findings show that sterile water buffered with ascorbic acid results in decreased blood loss with suppression of systemic inflammation. We are now beginning to realize the creation of a plasma-derived formulation that rapidly produces the associated benefits without logistical or safety constraints. This review will highlight the history of plasma, detail the various types of plasma formulations currently available, their pathophysiological effects, impacts of storage on coagulation factors in vitro and in vivo, novel concepts, and future directions.

Treatment of combined traumatic brain injury and hemorrhagic shock with fractionated blood products versus fresh whole blood in a rat model

INTRODUCTION

Treatment of combined traumatic brain injury and hemorrhagic shock, poses a particular challenge due to the possible conflicting consequences. While restoring diminished volume is the treatment goal for hypovolemia, maintaining adequate cerebral perfusion pressure and avoidance of secondary damage remains a treatment goal for the injured brain. Various treatment modalities have been proposed, but the optimal resuscitation fluid and goals have not yet been clearly defined. A growing body of evidence suggests that in hypovolemic shock, resuscitation with fresh whole blood (FWB) may be superior to component therapy without platelets (which are likely to be unavailable in the pre-hospital setting). Nevertheless, the effects of this approach have not been studied in the combined injury. Previously, in a rat model of combined injury we have found that mild resuscitation to MABP of 80 mmHg with FWB is superior to fluid resuscitation or aggressive resuscitation with FWB. In this study, we investigate the physiological and neurological outcomes in a rat model of combined traumatic brain injury (TBI) and hypovolemic shock, submitted to treatment with varying amounts of FWB, compared to similar resuscitation goals with fractionated blood products-red blood cells (RBCs) and plasma in a 1:1 ratio regimen.

MATERIALS AND METHODS

40 male Lewis rats were divided into control and treatment groups. TBI was inflicted by a free-falling rod on the exposed cranium. Hypovolemia was induced by controlled hemorrhage of 30% blood volume. Treatment groups were treated either with fresh whole blood or with RBC + plasma in a 1:1 ratio, achieving a resuscitation goal of a mean arterial blood pressure (MAP) of 80 mmHg at 15 min. MAP was assessed at 60 min, and neurological outcomes and mortality in the subsequent 24 h.

RESULTS

At 60 min, hemodynamic parameters were improved compared to controls, but not significantly different between treatment groups. Survival rates at 48 h were 100% for both of the mildly resuscitated groups (MABP 80 mmHg) with FWB and RBC + plasma. The best neurological outcomes were found in the group mildly resuscitated with FWB and were better when compared to resuscitation with RBC + plasma to the same MABP goal (FWB: Neurological Severity Score (NSS) 6 ± 2, RBC + plasma: NSS 10 ± 2, p = 0.02).

CONCLUSIONS

In this study, we find that mild resuscitation with goals of restoring MAP to 80 mmHg (which is lower than baseline) with FWB, provided better hemodynamic stability and survival. However, the best neurological outcomes were found in the group resuscitated with FWB. Thus, we suggest that resuscitation with FWB is a feasible modality in the combined TBI + hypovolemic shock scenario, and may result in improved outcomes compared to platelet-free component blood products.

RePHILL: protocol for a randomised controlled trial of pre-hospital blood product resuscitation for trauma

OBJECTIVES

To describe the 'Resuscitation with Pre-HospItaL bLood products' trial (RePHILL) - a multi-centre randomised controlled trial of pre-hospital blood product (PHBP) administration vs standard care for traumatic haemorrhage.

BACKGROUND

PHBP are increasingly used for pre-hospital trauma resuscitation despite a lack of robust evidence demonstrating superiority over crystalloids. Provision of PHBP carries additional logistical and regulatory implications, and requires a sustainable supply of universal blood components.

METHODS

RePHILL is a multi-centre, two-arm, parallel group, open-label, phase III randomised controlled trial currently underway in the UK. Patients attended by a pre-hospital emergency medical team, with traumatic injury and hypotension (systolic blood pressure <90 mmHg or absent radial pulse) believed to be due to traumatic haemorrhage are eligible. Exclusion criteria include age <16 years, blood product receipt on scene prior to randomisation, Advanced Medical Directive forbidding blood product administration, pregnancy, isolated head injury and prisoners. A total of 490 patients will be recruited in a 1 : 1 ratio to receive either the intervention (up to two units of red blood cells and two units of lyophilised plasma) or the control (up to four boluses of 250 mL 0.9% saline). The primary outcome measure is a composite of failure to achieve lactate clearance of ≥20%/h over the first 2 hours after randomisation and all-cause mortality between recruitment and discharge from the primary receiving facility to non-acute care. Secondary outcomes include pre-hospital time, coagulation indices, in-hospital transfusion requirements and morbidity.

RESULTS

Pilot study recruitment began in December 2016. Approval to proceed to the main trial was received in June 2017. Recruitment is expected to continue until 2020.

CONCLUSIONS

RePHILL will provide high-quality evidence regarding the efficacy and safety of PHBP resuscitation for trauma.

Prehospital Blood Transfusions in Non-Trauma Patients

INTRODUCTION

Despite advances in trauma care, hemorrhage continues to be the leading cause of preventable mortality in trauma. The evidence to support its use in non-trauma patients is limited. We aim to report our experience with prehospital blood product transfusion. We hypothesize that it is safe, appropriately utilized, and that our protocol, which was designed for trauma patients, is adaptable to fit the needs of non-trauma patients.

METHODS

Patients transfused with blood products, packed red blood cells (pRBCs) or plasma, in the prehospital environment between 2002 and 2014 were included. Trauma patients were compared to non-trauma patients using descriptive statistics.

RESULTS

A total of 857 patients (n = 549 trauma and n = 308 non-trauma) were transfused with pRBCs (76 %, n = 654, mean 1.6 ± 1.1 units en route), plasma (53 %, n = 455, mean 1.7 ± 0.7 unit), or both (29 %, n = 252) during ground (12 %) or air (84 %) critical care transport. Mean age was 60.8 ± 21.6 years with 60.1 % (n = 515) males. Subsequently, in-hospital blood transfusions were performed in 80 % of patients, operations in 44 %, and endoscopy in 31 %. Five percent (n = 41) of patients did not require any of these interventions. Thirty-day mortality rate was 18 %, and one patient (<0.01 %) had a transfusion reaction. The majority of patients were non-trauma (n = 549, 64 %). Of the non-trauma patients, 219 (40 %) were surgical, 193 (35 %) gastrointestinal bleeds, and 137 (25 %) medical.

CONCLUSION

Both non-trauma and trauma patients require blood products for life threatening hemorrhage and the majority required further interventions. Further research on the benefits of transfusion among non-trauma patients is warranted.

Prehospital plasma resuscitation associated with improved neurologic outcomes after traumatic brain injury

BACKGROUND

Trauma-related hypotension and coagulopathy worsen secondary brain injury in patients with traumatic brain injuries (TBIs). Early damage control resuscitation with blood products may mitigate hypotension and coagulopathy. Preliminary data suggest resuscitation with plasma in large animals improves neurologic function after TBI; however, data in humans are lacking.

METHODS

We retrospectively identified all patients with multiple injuries age >15 years with head injuries undergoing prehospital resuscitation with blood products at a single Level I trauma center from January 2002 to December 2013. Inclusion criteria were prehospital resuscitation with either packed red blood cells (pRBCs) or thawed plasma as sole colloid resuscitation. Patients who died in hospital and those using anticoagulants were excluded. Primary outcomes were Glasgow Outcomes Score Extended (GOSE) and Disability Rating Score (DRS) at dismissal and during follow-up.

RESULTS

Of 76 patients meeting inclusion criteria, 53% (n = 40) received prehospital pRBCs and 47% (n = 36) received thawed plasma. Age, gender, injury severity or TBI severity, arrival laboratory values, and number of prehospital units were similar (all p > 0.05). Patients who received thawed plasma had an improved neurologic outcome compared to those receiving pRBCs (median GOSE 7 [7-8] vs. 5.5 [3-7], p < 0.001). Additionally, patients who received thawed plasma had improved functionality compared to pRBCs (median DRS 2 [1-3.5] vs. 9 [3-13], p < 0.001). Calculated GOSE and DRS scores during follow-up, median 6 [5-7] months, demonstrated increased function in those resuscitated with thawed plasma compared to pRBCs by both median GOSE (8 [7-8] vs. 6 [6-7], p < 0.001) and DRS (0 [0-1] vs. 4 [2-8], p < 0.001).

CONCLUSION

In critically injured trauma patients with TBI, early resuscitation with thawed plasma is associated with improved neurologic and functional outcomes at discharge and during follow-up compared to pRBCs alone. These preliminary data support the further investigation and use of plasma in the resuscitation of critically injured TBI patients.

LEVEL OF EVIDENCE

Therapeutic, level V.

Every minute counts: Time to delivery of initial massive transfusion cooler and its impact on mortality

BACKGROUND

American College of Surgeons Trauma Quality Improvement Best Practices recommends initial massive transfusion (MT) cooler delivery within 15 minutes of protocol activation, with a goal of 10 minutes. The current study sought to examine the impact of timing of first cooler delivery on patient outcomes.

METHODS

Patients predicted to receive MT at 12 Level I trauma centers were randomized to two separate transfusion ratios as described in the PROPPR trial. Assessment of Blood Consumption score or clinician gestalt prediction of MT was used to randomize patients and call for initial study cooler. In this planned subanalysis, the time to MT protocol activation and time to delivery of the initial cooler were evaluated. The impact of these times on mortality and time to hemostasis were examined using both Wilcoxon rank sum and linear and logistic regression.

RESULTS

Among 680 patients, the median time from patient arrival to MT protocol activation was 9 minutes with a median time from MT activation call to delivery of first cooler of 8 minutes. An increase in both time to MT activation and time to arrival of first cooler were associated with prolonged time to achieving hemostasis (coefficient, 1.09; p = 0.001 and coefficient, 1.16; p < 0.001, respectively). Increased time to MT activation and time to arrival of first cooler were associated with increased mortality (odds ratio [OR], 1.02; p = 0.009 and OR, 1.02; p = 0.012, respectively). Controlling for injury severity, physiology, resuscitation intensity, and treatment arm (1:1:1 vs. 1:1:2), increased time to arrival of first cooler was associated with an increased mortality at 24 hours (OR, 1.05; p = 0.035) and 30 days (OR, 1.05, p = 0.016).

CONCLUSION

Delays in MT protocol activation and delays in initial cooler arrival were associated with prolonged time to achieve hemostasis and an increase in mortality. Independent of products ratios, every minute from time of MT protocol activation to time of initial cooler arrival increases odds of mortality by 5%.

LEVEL OF EVIDENCE

Prognostic, level II; Therapeutic, level III.

Incompatible type A plasma transfusion in patients requiring massive transfusion protocol: Outcomes of an Eastern Association for the Surgery of Trauma multicenter study

With a relative shortage of type AB plasma, many centers have converted to type A plasma for resuscitation of patients whose blood type is unknown. The goal of this study is to determine outcomes for trauma patients who received incompatible plasma transfusions as part of a massive transfusion protocol (MTP).

METHODS

As part of an Eastern Association for the Surgery of Trauma multi-institutional trial, registry and blood bank data were collected from eight trauma centers for trauma patients (age, ≥ 15 years) receiving emergency release plasma transfusions as part of MTPs from January 2012 to August 2016. Incompatible type A plasma was defined as transfusion to patient blood type B or type AB.

RESULTS

Of the 1,536 patients identified, 92% received compatible plasma transfusions and 8% received incompatible type A plasma. Patient characteristics were similar except for greater penetrating injuries (48% vs 36%; p = 0.01) in the incompatible group. In the incompatible group, patients were transfused more plasma units at 4 hours (median, 9 vs. 5; p < 0.001) and overall for stay (11 vs. 9; p = 0.03). No hemolytic transfusion reactions were reported. Two transfusion-related acute lung injury events were reported in the compatible group. Between incompatible and compatible groups, there was no difference in the rates of acute respiratory distress syndrome (6% vs. 8%; p = 0.589), thromboembolic events (9% vs. 7%; p = 0.464), sepsis (6% vs. 8%; p = 0.589), or acute renal failure (8% vs. 8%, p = 0.860). Mortality at 6 (17% vs. 15%, p = 0.775) and 24 hours (25% vs. 23%, p = 0.544) and at 28 days or discharge (38% vs. 35%, p = 0.486) were similar between groups. Multivariate regression demonstrated that Injury Severity Score, older age and more red blood cell transfusion at 4 hours were independently associated with death at 28 days or discharge; Injury Severity Score and more red blood cell transfusion at 4 hours were predictors for morbidity. Incompatible transfusion was not an independent determinant of mortality or morbidity.

CONCLUSION

Transfusion of type A plasma to patients with blood groups B and AB as part of a MTP does not appear to be associated with significant increases in morbidity or mortality.

LEVEL OF EVIDENCE

Therapeutic study, level IV.

Prehospital Transfusion for Gastrointestinal Bleeding

OBJECTIVE

Gastrointestinal (GI) bleeding is a common medical emergency with significant morbidity and mortality. Many patients are coagulopathic, which may perpetuate bleeding. Remote damage control resuscitation, including early correction of coagulopathy and anemia, may benefit exsanguinating patients with GI bleeding.

METHODS

We conducted a retrospective review of patients with acute GI bleeding who received packed red blood cells (pRBC) and/or plasma during transportation to our institution between 2010 and 2014. A comparison group of patients who were not transfused en route was selected, and demographics, outcomes, and response to resuscitation were compared.

RESULTS

A total of 112 patients with GI bleeding received pRBC (82%, n = 92 pRBC, mean 1.7 ± 0.9 units), plasma (62%, n = 69, mean 1.7 ± 0.8 units) or both (44%, n = 49) en-route. The comparison group comprised 49 patients transported by helicopter who were not transfused en-route. Demographics, crystalloid resuscitation, transfusion prior to transfer, rate of intervention, ICU days, length of stay, and mortality were similar between groups. Patients transfused en route had a significant increase in hemoglobin from 8.3 ± 2.2 to 8.9 ± 2.1 (P = .03) and decrease in INR from 2.0 ± 1.0 to 1.6 ± 1.4 (P = .01), whereas those not transfused en route experienced stable hemoglobin (8.7 ± 2.8 to 9.4 ± 2.5; P = .21) and INR values (1.9 ± 1.0 to 1.6 ± 1.4; P = .32). Both groups had a significant improvement in hemodynamic parameters with resuscitation.

CONCLUSION

Prehospital damage control resuscitation with pRBC and/or plasma resulted in the improvement of hemodynamic instability, coagulopathy and anemia in patients with acute GI bleeding. Almost all patients required additional inpatient interventions and/or transfusions, suggesting that pre-hospital transfusion is being utilized for appropriately selected patients.

Damage control resuscitation in patients with severe traumatic hemorrhage: A practice management guideline from the Eastern Association for the Surgery of Trauma

BACKGROUND

The resuscitation of severely injured bleeding patients has evolved into a multi-modal strategy termed damage control resuscitation (DCR). This guideline evaluates several aspects of DCR including the role of massive transfusion (MT) protocols, the optimal target ratio of plasma (PLAS) and platelets (PLT) to red blood cells (RBC) during DCR, and the role of recombinant activated factor VII (rVIIa) and tranexamic acid (TXA).

METHODS

Using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology, a subcommittee of the Practice Management Guidelines (PMG) Section of EAST conducted a systematic review using MEDLINE and EMBASE. Articles in English from1985 through 2015 were considered in evaluating four PICO questions relevant to DCR.

RESULT

A total of 37 studies were identified for analysis, of which 31 met criteria for quantitative meta-analysis. In these studies, mortality decreased with use of an MT/DCR protocol vs. no protocol (OR 0.61, 95% CI 0.43-0.87, p = 0.006) and with a high ratio of PLAS:RBC and PLT:RBC (relatively more PLAS and PLT) vs. a low ratio (OR 0.60, 95% CI 0.46-0.77, p < 0.0001; OR 0.44, 95% CI 0.28-0.71, p = 0.0003). Mortality and blood product use were no different with either rVIIa vs. no rVIIa or with TXA vs. no TXA.

CONCLUSION

DCR can significantly improve outcomes in severely injured bleeding patients. After a review of the best available evidence, we recommend the use of a MT/DCR protocol in hospitals that manage such patients and recommend that the protocol target a high ratio of PLAS and PLT to RBC. This is best achieved by transfusing equal amounts of RBC, PLAS, and PLT during the early, empiric phase of resuscitation. We cannot recommend for or against the use of rVIIa based on the available evidence. Finally, we conditionally recommend the in-hospital use of TXA early in the management of severely injured bleeding patients.

Early resuscitation with lyophilized plasma provides equal neuroprotection compared with fresh frozen plasma in a large animal survival model of traumatic brain injury and hemorrhagic shock

BACKGROUND

Combined traumatic brain injury (TBI) and hemorrhagic shock (HS) is highly lethal. In previous models of combined TBI + HS, we showed that early resuscitation with fresh frozen plasma (FFP) improves neurologic outcomes. Delivering FFP, however, in austere environments is difficult. Lyophilized plasma (LP) is a logistically superior alternative to FFP, but data are limited regarding its efficacy for treatment of TBI. We conducted this study to determine the safety and long-term outcomes of early treatment with LP in a large animal model of TBI + HS.

METHODS

Adult anesthetized swine underwent TBI and volume-controlled hemorrhage (40% blood volume) concurrently. After 2 hours of shock, animals were randomized (n = 5 per /group) to FFP or LP (1× shed blood) treatment. Serial blood gases were drawn, and thromboelastography was performed on citrated, kaolin-activated whole-blood samples. Five hours after treatment, packed red blood cells were administered, and animals recovered. A 32-point Neurologic Severity Score was assessed daily for 30 days (0 = normal, 32 = most severe injury). Cognitive functions were tested by training animals to retrieve food from color-coded boxes. Brain lesion size was measured on serial magnetic resonance imaging, and an autopsy was performed at 30 days.

RESULTS

The severity of shock and the degree of resuscitation were similar in both groups. Administration of FFP and LP was well tolerated with no differences in reversal of shock or thromboelastography parameters. Animals in both groups displayed the worst Neurologic Severity Score on postoperative Day 1 with rapid recovery and return to baseline within 7 days of injury. Lesion size on Day 3 in FFP-treated animals was 645 ± 85 versus 219 ± 20 mm in LP-treated animals (p < 0.05). There were no differences in cognitive functions or delayed treatment-related complications.

CONCLUSIONS

Early treatment with LP in TBI + HS is safe and provides neuroprotection that is comparable to FFP.

Coagulation factor concentrate-based therapy for remote damage control resuscitation (RDCR): a reasonable alternative?

The concept of remote damage control resuscitation (RDCR) is still in its infancy and there is significant work to be done to improve outcomes for patients with life-threatening bleeding secondary to injury. The prehospital phase of resuscitation is critical and if shock and coagulopathy can be rapidly minimized before hospital admission this will very likely reduce morbidity and mortality. The optimum transfusion strategy for these patients is still highly debated and the potential implications of the recently published pragmatic, randomize, optimal platelet, and plasma ratios trial (PROPPR) for RDCR have been reviewed. Identifying the appropriate transfusion strategy is mandatory before adopting prehospital hemostatic resuscitation strategies. An alternative approach is based on the early administration of coagulation factor concentrates combined with the antifibrinolytic tranexamic acid (TXA). The three major components to this approach in the context of RDCR target the following steps to achieve hemostasis: 1) stop (hyper)fibrinolysis; 2) support clot formation; and 3) increase thrombin generation. Strong evidence exists for the use of TXA. The data from the prospective fibrinogen in trauma induced coagulopathy (FIinTIC) study will inform on the prehospital use of fibrinogen in bleeding trauma patients. Deficits in thrombin generation may be addressed by the administration of prothrombin complex concentrates. Handheld point-of-care devices may be able to support and guide the prehospital and remote use of intravenous hemostatic agents including coagulation factor concentrates along with clinical presentation, assessment, and the extent of bleeding. Combinations may even be more effective for bleeding control. More studies are urgently needed.

Whole blood transfusion closest to the point-of-injury during French remote military operations

To improve the survival of combat casualties, interest in the earliest resort to whole blood (WB) transfusion on the battlefield has been emphasized. Providing volume, coagulation factors, plasma, and oxygenation capacity, WB appears actually as an ideal product severe trauma management. Whole blood can be collected in advance and stored for subsequent use, or can be drawn directly on the battlefield, once a soldier is wounded, from an uninjured companion and immediately transfused.Such concepts require a great control of risks at each step, especially regarding ABO mismatches, and transfusion-transmitted diseases. We present here the "warm and fresh" WB field transfusion program implemented among the French armed forces. We focus on the followed strategies to make it applicable on the battlefield, even during special operations and remote settings, and safe for recipients as well as for donors.