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Ye J, Shi C, Lan J, Chen Q, Si Q, Xu P, Zhang X, Zheng C. Tannic acid coating gauze immobilized with thrombin with ultra-high coagulation activity and antimicrobial property for uncontrollable hemorrhage. Sci Rep 2024; 14:16139. [PMID: 38997417 PMCID: PMC11245493 DOI: 10.1038/s41598-024-67049-y] [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: 04/04/2024] [Accepted: 07/08/2024] [Indexed: 07/14/2024] Open
Abstract
Rapid and safe hemostasis is crucial for the survival of bleeding patients in prehospital care. It is urgent to develop high performance hemostatic material to control the massive hemorrhage in the military field and accidental trauma. In this work, an efficient protein hemostat of thrombin was immobilized onto commercial gauze, which was mediated by self-polymerization and anchoring of tannic acid (TA). Through TA treatment, the efficient immobilization of thrombin was achieved, preserving both the biological activity of thrombin and the physical properties of the dressing, including absorbency, breathability, and mechanical performance. Moreover, in the presence of TA coating and thrombin, Gau@TA/Thr could obviously shortened clotting time and enriched blood components such as plasma proteins, platelets, and red blood cells, thereby exhibiting an enhanced in vitro coagulation effect. In SD rat liver volume defect and artery transection hemorrhage models, Gau@TA/Thr still had outstanding hemostatic performance. Besides, the Gau@TA/Thr gauze had inherent antibacterial property and demonstrated excellent biocompatibility. All results suggested that Gau@TA/Thr would be a potential candidate for treating uncontrollable hemorrhage in prehospital care.
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Affiliation(s)
- Jian Ye
- Department of Critical Care Medicine, Municipal Hospital Affiliated to Taizhou University, Zhejiang, 318000, China
| | - Chenyang Shi
- Department of Critical Care Medicine, Municipal Hospital Affiliated to Taizhou University, Zhejiang, 318000, China
| | - Jian Lan
- Department of Critical Care Medicine, Municipal Hospital Affiliated to Taizhou University, Zhejiang, 318000, China
| | - Qingqing Chen
- Department of Critical Care Medicine, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Zhejiang, 318000, China
| | - Qin Si
- Department of Critical Care Medicine, Municipal Hospital Affiliated to Taizhou University, Zhejiang, 318000, China
| | - Panpan Xu
- Department of Critical Care Medicine, Municipal Hospital Affiliated to Taizhou University, Zhejiang, 318000, China
| | - Xijiang Zhang
- Department of Critical Care Medicine, Municipal Hospital Affiliated to Taizhou University, Zhejiang, 318000, China.
| | - Cheng Zheng
- Department of Critical Care Medicine, Municipal Hospital Affiliated to Taizhou University, Zhejiang, 318000, China.
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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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Peng HT, Singh K, Rhind SG, da Luz L, Beckett A. Dried Plasma for Major Trauma: Past, Present, and Future. Life (Basel) 2024; 14:619. [PMID: 38792640 PMCID: PMC11122082 DOI: 10.3390/life14050619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Revised: 04/26/2024] [Accepted: 05/08/2024] [Indexed: 05/26/2024] Open
Abstract
Uncontrollable bleeding is recognized as the leading cause of preventable death among trauma patients. Early transfusion of blood products, especially plasma replacing crystalloid and colloid solutions, has been shown to increase survival of severely injured patients. However, the requirements for cold storage and thawing processes prior to transfusion present significant logistical challenges in prehospital and remote areas, resulting in a considerable delay in receiving thawed or liquid plasma, even in hospitals. In contrast, freeze- or spray-dried plasma, which can be massively produced, stockpiled, and stored at room temperature, is easily carried and can be reconstituted for transfusion in minutes, provides a promising alternative. Drawn from history, this paper provides a review of different forms of dried plasma with a focus on in vitro characterization of hemostatic properties, to assess the effects of the drying process, storage conditions in dry form and after reconstitution, their distinct safety and/or efficacy profiles currently in different phases of development, and to discuss the current expectations of these products in the context of recent preclinical and clinical trials. Future research directions are presented as well.
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Affiliation(s)
- Henry T. Peng
- Defence Research and Development Canada, Toronto Research Centre, Toronto, ON M3K 2C9, Canada; (K.S.); (S.G.R.)
| | - Kanwal Singh
- Defence Research and Development Canada, Toronto Research Centre, Toronto, ON M3K 2C9, Canada; (K.S.); (S.G.R.)
| | - Shawn G. Rhind
- Defence Research and Development Canada, Toronto Research Centre, Toronto, ON M3K 2C9, Canada; (K.S.); (S.G.R.)
| | - Luis da Luz
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON M4N 3M5, Canada;
| | - Andrew Beckett
- St. Michael’s Hospital, University of Toronto, Toronto, ON M5B 1W8, Canada;
- Royal Canadian Medical Services, Ottawa, ON K1A 0K2, Canada
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Bradley O, Mitra B, Meadley B, Clair TS, Anderson D. Prehospital Blood Transfusion in Helicopter Emergency Medical Services: An Italian Survey. Air Med J 2024; 43:190. [PMID: 38821691 DOI: 10.1016/j.amj.2024.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2024] [Accepted: 02/14/2024] [Indexed: 06/02/2024]
Affiliation(s)
| | - Biswadev Mitra
- Alfred Health Emergency Services, Melbourne, Victoria, Australia; School of Public Health & Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Ben Meadley
- Ambulance Victoria, Doncaster, Victoria, Australia; Department of Paramedicine, Monash University, Frankston, Victoria, Australia
| | - Toby St Clair
- Ambulance Victoria, Doncaster, Victoria, Australia; Department of Paramedicine, Monash University, Frankston, Victoria, Australia
| | - David Anderson
- Ambulance Victoria, Doncaster, Victoria, Australia; Department of Intensive Care, Alfred Health, Melbourne, Victoria, Australia
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Singh K, Peng HT, Moes K, Kretz CA, Beckett A. Past meets present: Reviving 80-year-old Canadian dried serum from World War II and its significance in advancing modern freeze-dried plasma for prehospital management of haemorrhage. Br J Haematol 2024; 204:1515-1522. [PMID: 38272068 DOI: 10.1111/bjh.19298] [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: 10/10/2023] [Revised: 12/03/2023] [Accepted: 01/01/2024] [Indexed: 01/27/2024]
Abstract
During World War II, Charles H. Best utilized Charles R. Drew's plasma isolation and drying technique to lead Canada's initiative to provide dried serum as a means of primary resuscitation for British casualties on the frontlines. Serum was likely utilized over plasma for its volume expansion properties without the risk of clotting during prolonged storage. We reconstituted dried serum from 1943 and discovered intact albumin, as well as anti-thrombin, plasminogen, protein C and protein S activity. Proteomic analysis identified 71 proteins, most prominent being albumin, and positive for hepatitis B by serological testing. Transmission of blood-borne diseases ended the programme, until modern advances in testing and pathogen reduction revived this technology. We tested the latest iteration of Canadian freeze-dried plasma (FDP), which was stored for 4 years, and demonstrated that its clotting capacity remained equivalent to fresh frozen plasma. We recommend that FDP is a strong alternative to contemporary prehospital resuscitation fluids (e.g. normal saline/lactated Ringer's) in managing prehospital haemorrhage where whole blood is unavailable.
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Affiliation(s)
- Kanwal Singh
- Trauma and Acute Care Surgery, Faculty of Medicine, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
- Canadian Forces Health Services, Ottawa, Ontario, Canada
| | - Henry T Peng
- Defence Research and Development Canada, Toronto Research Centre, Toronto, Ontario, Canada
| | - Katy Moes
- Defence Research and Development Canada, Toronto Research Centre, Toronto, Ontario, Canada
| | - Colin A Kretz
- Department of Medicine, Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Andrew Beckett
- Trauma and Acute Care Surgery, Faculty of Medicine, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
- Canadian Forces Health Services, Ottawa, Ontario, Canada
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Peng HT, Moes K, Singh K, Rhind SG, Pambrun C, Jenkins C, da Luz L, Beckett A. Post-Reconstitution Hemostatic Stability Profiles of Canadian and German Freeze-Dried Plasma. Life (Basel) 2024; 14:172. [PMID: 38398681 PMCID: PMC10890410 DOI: 10.3390/life14020172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Revised: 12/31/2023] [Accepted: 01/03/2024] [Indexed: 02/25/2024] Open
Abstract
Despite the importance of the hemostatic properties of reconstituted freeze-dried plasma (FDP) for trauma resuscitation, few studies have been conducted to determine its post-reconstitution hemostatic stability. This study aimed to assess the short- (≤24 h) and long-term (≥168 h) hemostatic stabilities of Canadian and German freeze-dried plasma (CFDP and LyoPlas) after reconstitution and storage under different conditions. Post-reconstitution hemostatic profiles were determined using rotational thromboelastometry (ROTEM) and a Stago analyzer, as both are widely used as standard methods for assessing the quality of plasma. When compared to the initial reconstituted CFDP, there were no changes in ROTEM measurements for INTEM maximum clot firmness (MCF), EXTEM clotting time (CT) and MCF, and Stago measurements for prothrombin time (PT), partial thromboplastin time (PTT), D-dimer concentration, plasminogen, and protein C activities after storage at 4 °C for 24 h and room temperature (RT) (22-25 °C) for 4 h. However, an increase in INTEM CT and decreases in fibrinogen concentration, factors V and VIII, and protein S activities were observed after storage at 4 °C for 24 h, while an increase in factor V and decreases in antithrombin and protein S activities were seen after storage at RT for 4 h. Evaluation of the long-term stability of reconstituted LyoPlas showed decreased stability in both global and specific hemostatic profiles with increasing storage temperatures, particularly at 35 °C, where progressive changes in CT and MCF, PT, PTT, fibrinogen concentration, factor V, antithrombin, protein C, and protein S activities were seen even after storage for 4 h. We confirmed the short-term stability of CFDP in global hemostatic properties after reconstitution and storage at RT, consistent with the shelf life of reconstituted LyoPlas. The long-term stability analyses suggest that the post-reconstitution hemostatic stability of FDP products would decrease over time with increasing storage temperature, with a significant loss of hemostatic functions at 35 °C compared to 22 °C or below. Therefore, the shelf life of reconstituted FDP should be recommended according to the storage temperature.
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Affiliation(s)
- Henry T. Peng
- Defence Research and Development Canada, Toronto Research Centre, Toronto, ON M3K 2C9, Canada
| | - Katherine Moes
- Defence Research and Development Canada, Toronto Research Centre, Toronto, ON M3K 2C9, Canada
| | - Kanwal Singh
- St. Michael’s Hospital, University of Toronto, Toronto, ON M5B 1W8, Canada; (K.S.); (A.B.)
| | - Shawn G. Rhind
- Defence Research and Development Canada, Toronto Research Centre, Toronto, ON M3K 2C9, Canada
| | - Chantale Pambrun
- Centre for Innovation, Canadian Blood Services, Ottawa, ON K1G 4J5, Canada; (C.P.); (C.J.)
| | - Craig Jenkins
- Centre for Innovation, Canadian Blood Services, Ottawa, ON K1G 4J5, Canada; (C.P.); (C.J.)
| | - Luis da Luz
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON M4N 3M5, Canada;
| | - Andrew Beckett
- St. Michael’s Hospital, University of Toronto, Toronto, ON M5B 1W8, Canada; (K.S.); (A.B.)
- Royal Canadian Medical Services, Ottawa, ON K1A 0K2, Canada
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Wigginton O, Johnson S, Jervis B, Joshi A, Steere M, Ferguson I. Prehospital Blood Transfusion: A Cross-Sectional Study of Prehospital and Retrieval Medicine Services across Australia & Aotearoa-New Zealand. PREHOSP EMERG CARE 2024:1-5. [PMID: 38241180 DOI: 10.1080/10903127.2024.2306249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Accepted: 01/05/2024] [Indexed: 01/21/2024]
Abstract
BACKGROUND The frequency and type of prehospital blood product delivery across Australia and Aotearoa-New Zealand is unknown. This study aims to describe transfusion practice across different services in the two nations, as well as identifying potential barriers to the carriage of blood products. METHODOLOGY Prehospital and retrieval medicine services operating teams of doctors, specialist paramedics, and/or flight nurses out of specialty bases across Australia and Aotearoa-New Zealand were sent a standardized questionnaire regarding their base characteristics and their current blood transfusion practice. Bases that only performed inter-hospital transfers or search & rescue operations were excluded. Bases were queried on personnel, equipment, transport times, type and volume of blood products carried, frequency of use, and barriers to implementation for those without prehospital blood transfusion programs. RESULTS 64 bases were identified and contacted, of which 5 were excluded and 45 of the remaining 59 (76.3%) responded. 62% (28/45) of respondents routinely carry prehospital blood products. 78.6% (22/28) carried packed red blood cells (PRBC) only, 14.3% (4/28) carried both PRBC and plasma, and 1 service (3.6%) carried whole blood. The mean number of units of blood product carried was 3.3 (SD 0.82). 2 bases (7.1%) carried fibrinogen concentrate. All services carried tranexamic acid and calcium. 734 patients received a blood transfusion in 2021, with trauma being the most common indication (552, 75.2%). Base characteristics varied significantly in staffing, vehicle platform and transfer times. The median transfer time from scene to hospital was 65 min (IQR of 40-92). Services without access to prehospital blood products identified multiple barriers to implementation, including training and supply chain. CONCLUSION Approximately two-thirds of prehospital services operating advanced teams across Australia and Aotearoa-New Zealand carried blood products and there was wide variation both in the type and number of blood products carried by each base. Multiple barriers to the carriage of blood by all bases were reported, which have implications for service equity. Transfer times are generally long in Australia and Aotearoa-New Zealand, which may impact the generalizability of overseas research performed in prehospital systems with significantly shorter transfer times to services operating in Australia and Aotearoa-New Zealand.
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Affiliation(s)
- Oscar Wigginton
- Aeromedical Retrieval Service, New South Wales Ambulance, Bankstown, New South Wales, Australia
- South West Clinical School, University of New South Wales, Sydney, New South Wales, Australia
- Liverpool Hospital, Liverpool, New South Wales, Australia
| | - Sue Johnson
- Aeromedical Retrieval Service, New South Wales Ambulance, Bankstown, New South Wales, Australia
- Auckland Rescue Helicopter Trust (ARHT), Auckland, Aotearoa-New Zealand
| | - Bethan Jervis
- CareFlight Australia, Northmead, New South Wales, Australia
| | - Anil Joshi
- Aeromedical Retrieval Service, New South Wales Ambulance, Bankstown, New South Wales, Australia
- Auckland Rescue Helicopter Trust (ARHT), Auckland, Aotearoa-New Zealand
| | - Mardi Steere
- Royal Flying Doctor Service, RFDS Central Operations, Adelaide, South Australia, Australia
| | - Ian Ferguson
- Aeromedical Retrieval Service, New South Wales Ambulance, Bankstown, New South Wales, Australia
- South West Clinical School, University of New South Wales, Sydney, New South Wales, Australia
- Liverpool Hospital, Liverpool, New South Wales, Australia
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Sheffield WP, Singh K, Beckett A, Devine DV. Prehospital Freeze-Dried Plasma in Trauma: A Critical Review. Transfus Med Rev 2024; 38:150807. [PMID: 38114340 DOI: 10.1016/j.tmrv.2023.150807] [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: 09/20/2023] [Revised: 11/13/2023] [Accepted: 11/16/2023] [Indexed: 12/21/2023]
Abstract
Major traumatic hemorrhage is now frequently treated by early hemostatic resuscitation on hospital arrival. Prehospital hemostatic resuscitation could therefore improve outcomes for bleeding trauma patients, but there are logistical challenges. Freeze-dried plasma (FDP) offers indisputable logistical advantages over conventional blood products, such as long shelf life, stability at ambient temperature, and rapid reconstitution without specialized equipment. We sought high level, randomized, controlled evidence of FDP clinical efficacy in trauma. A structured systematic search of MEDLINE/PubMed was carried out and identified 52 relevant English language publications. Three studies involving 607 patients met our criteria: Resuscitation with Blood Products in Patients with Trauma-related Hemorrhagic Shock receiving Prehospital Care (RePHILL, n = 501); Prehospital Lyophilized Plasma Transfusion for Trauma-Induced Coagulopathy in Patients at Risk for Hemorrhagic Shock (PREHO-PLYO, n = 150); and a pilot Australian trial (n = 25). RePHILL found no effect of FDP plus packed red blood cells (PRBC) concentrate transfusion versus saline on mortality. PREHO-PLYO found no effect of FDP versus saline on International Normalized Ratio (INR) at hospital arrival. The pilot trial found that study of PRBC versus PRBC plus FDP was feasible during long air transport times to an Australian trauma centre. Further research is required to determine under what conditions FDP might provide prehospital benefit to trauma patients.
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Affiliation(s)
- William P Sheffield
- Medical Affairs and Innovation, Canadian Blood Services, Hamilton, Ontario, Canada; Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Ontario, Canada.
| | - Kanwal Singh
- Trauma Surgery, Critical Care Medicine and Acute Care Surgery, St. Michael's Hospital, Toronto, Ontario, Canada; Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Andrew Beckett
- Trauma Surgery, Critical Care Medicine and Acute Care Surgery, St. Michael's Hospital, Toronto, Ontario, Canada; Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; Canadian Forces Health Services, Ottawa, Ontario, Canada
| | - Dana V Devine
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, Canada
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