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Callaghan NI, Quinn J, Liwski R, Chisholm N, Cheng C. Process Mining Uncovers Actionable Patterns of Red Blood Cell Unit Wastage in a Health Care Network. Transfus Med Rev 2024; 38:150827. [PMID: 38642414 DOI: 10.1016/j.tmrv.2024.150827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Revised: 03/17/2024] [Accepted: 03/19/2024] [Indexed: 04/22/2024]
Abstract
Packed red blood cell transfusions are integral to the care of the critically and chronically ill patient, but require careful storage and a large, coordinated network to ensure their integrity during distribution and administration. Auditing a Transfusion Medicine service can be challenging due to the complexity of this network. Process mining is an analytical technique that allows for the identification of high-efficiency pathways through a network, as well as areas of challenge for targeted innovation. Here, we detail a case study of an efficiency audit of the Transfusion Medicine service of the Nova Scotia Health Administration Central Zone using process mining, across a period encompassing years prior to, during, and after the acute COVID-19 pandemic. Service efficiency from a product wastage perspective was consistently demonstrated at benchmarks near globally published optima. Furthermore, we detail key areas of continued challenge in product wastage, and suggest potential strategies for further targeted optimization.
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Affiliation(s)
- Neal I Callaghan
- Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Jason Quinn
- Department of Pathology and Laboratory Medicine, Division of Hematopathology, Halifax, Nova Scotia, Canada
| | - Robert Liwski
- Department of Pathology and Laboratory Medicine, Division of Hematopathology, Halifax, Nova Scotia, Canada
| | - Natalie Chisholm
- Department of Pathology and Laboratory Medicine, Division of Hematopathology, Halifax, Nova Scotia, Canada
| | - Calvino Cheng
- Department of Pathology and Laboratory Medicine, Division of Hematopathology, Halifax, Nova Scotia, Canada.
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2
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Berry CL, Golden D, Tubby B, Berry S, Hall D, Christiansen G. Prehospital Massive Transfusion for Resuscitation of an Entrapped Patient in a Rural Setting: A Case Report. PREHOSP EMERG CARE 2024:1-5. [PMID: 38809662 DOI: 10.1080/10903127.2024.2362307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2024] [Accepted: 05/15/2024] [Indexed: 05/31/2024]
Abstract
Resuscitation of injured patients suffering from hemorrhagic shock with blood products in the prehospital environment is becoming more commonplace. However, blood product utilization is typically restricted and can be exhausted in the event of a prolonged entrapment. Delivery of large amounts of blood products to a scene is rare, particularly in rural settings. We present the case of a 26-year-old male who was entrapped in a motor vehicle for 144 min. First responders assessed the entrapped patient to be in hemorrhagic shock from lower extremities injuries. The Helicopter Emergency Medical Services team exhausted their supply of blood products shortly after arrival on scene. The local trauma center's Surgical Emergency Response Team (SERT) was requested to the scene. The preplanned response included seven units of blood components to provide massive transfusion at the point of injury and released directly to field responders by the blood bank. During extrication, the patient was given two units of packed red blood cells by initial responders with three more units of blood components from the SERT supply. During transfer to the hospital, the patient received an additional three units, and four units were transfused on initial trauma resuscitation in the hospital. He was found to have severe lower extremities injuries as the cause of his hemorrhage. The patient survived to hospital discharge. Delivery of large volumes of blood products to an entrapped patient with prolonged extrication time may be a lifesaving intervention. We advocate for integration of blood bank services and on scene physician guided resuscitation for prolonged extrications.
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Affiliation(s)
- Christopher L Berry
- Department of Emergency Medicine, Guthrie Robert Packer Hospital, Sayre, Pennsylvania
| | - Daniel Golden
- Department of Trauma Surgery, Guthrie Robert Packer Hospital, Sayre, Pennsylvania
| | - Barbara Tubby
- Blood Bank, Guthrie Medical Group Laboratories, Sayre, Pennsylvania
| | - Sarah Berry
- Department of Emergency Medicine, Guthrie Robert Packer Hospital, Sayre, Pennsylvania
| | - Derrick Hall
- Greater Valley Emergency Medical Services, Sayre, Pennsylvania
| | - Gregory Christiansen
- Department of Emergency Medicine, Guthrie Robert Packer Hospital, Sayre, Pennsylvania
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Jama T, Lefering R, Lauronen J, Handolin L. Factors affecting physicians' decision to start prehospital blood product transfusion in blunt trauma patients: A cohort study of Helsinki Trauma Registry. Transfusion 2024; 64 Suppl 2:S167-S173. [PMID: 38511866 DOI: 10.1111/trf.17791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2023] [Revised: 02/29/2024] [Accepted: 02/29/2024] [Indexed: 03/22/2024]
Abstract
BACKGROUND Prehospital blood transfusions are increasing as a treatment for bleeding trauma patients at risk for exsanguination. Triggers for starting transfusion in the field are less studied. We analyzed the factors affecting the decision of physicians to start prehospital blood product transfusion (PHBT) in blunt adult trauma patients. STUDY DESIGN AND METHODS Data of all adult blunt trauma patients from the Helsinki Trauma Registry between March 2016 and July 2021 were retrospectively analyzed. Univariate analysis for the identification of predictive factors and multivariate regression analysis for their importance as predictive factors for the initiation of PHBT were applied. RESULTS There were 1652 patients registered in the database. A total of 556 of them were treated by a physician-level prehospital emergency care unit, of which by transfusion-capable unit in 394 patients. PHBT (red blood cells and/or plasma) was started in 19.8% of the patients. We identified three statistically highly important clinical triggers for starting PHBT: high crystalloid volume need, shock index ≥0.9, and need for prehospital pleural decompression. DISCUSSION PHBT in blunt adult trauma patients is initiated in ~20% of the patients in Southern Finland. High crystalloid volume need, shock index ≥0.9 and prehospital pleural decompression are associated with the initiation of PHBT, probably reflecting patients at high risk for bleeding.
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Affiliation(s)
- Timo Jama
- Wellbeing Services County of Päijät-Häme, Lahti, Finland
- University of Helsinki, Helsinki, Finland
| | - Rolf Lefering
- Institute for Research in Operative Medicine (IFOM), University of Witten/Herdecke, Cologne, Germany
| | - Jouni Lauronen
- University of Helsinki, Helsinki, Finland
- Finnish Red Cross Blood Service, Vantaa, Finland
| | - Lauri Handolin
- University of Helsinki, Helsinki, Finland
- Helsinki University Hospital Trauma Unit, Helsinki, Finland
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Christoffel J, Maegele M. Guidelines in trauma-related bleeding and coagulopathy: an update. Curr Opin Anaesthesiol 2024; 37:110-116. [PMID: 38390904 DOI: 10.1097/aco.0000000000001346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2024]
Abstract
PURPOSE OF REVIEW The diagnosis and treatment of patients with severe traumatic bleeding and subsequent trauma-induced coagulopathy (TIC) is still inconsistent, although the implementation of standardized algorithms/treatment pathways was repeatedly linked to improved outcome. Various evidence-based guidelines for these patients now exist, three of which have recently been updated. RECENT FINDINGS A synopsis of the three recently updated guidelines for diagnosis and treatment of seriously bleeding trauma patients with TIC is presented: (i) AWMF S3 guideline 'Polytrauma/Seriously Injured Patient Treatment' under the auspices of the German Society for Trauma Surgery; (ii) guideline of the European Society of Anesthesiology and Intensive Care (ESAIC) on the management of perioperative bleeding; and (iii) European guideline on the management of major bleeding and coagulopathy after trauma in its 6th edition (EU-Trauma). SUMMARY Treatment of trauma-related bleeding begins at the scene with local compression, use of tourniquets and pelvic binders and rapid transport to a certified trauma centre. After arrival at the hospital, measures to record, monitor and support coagulation function should be initiated immediately. Surgical bleeding control is carried out according to 'damage control' principles. Modern coagulation management includes individualized treatment based on target values derived from point-of-care viscoelastic test procedures.
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Affiliation(s)
- Jannis Christoffel
- Department for Trauma and Orthopaedic Surgery, Cologne-Merheim Medical Center (CMMC)
| | - Marc Maegele
- Department for Trauma and Orthopaedic Surgery, Cologne-Merheim Medical Center (CMMC)
- Institute for Research in Operative Medicine (IFOM), Witten/Herdecke University, Campus Cologne-Merheim, Cologne, Germany
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5
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Dion PM, Greene A, Beckett A, von Vopelius-Feldt J, Nolan B. A comparative analysis of current out-of-hospital transfusion protocols to expert recommendations. Resusc Plus 2023; 16:100498. [PMID: 38026143 PMCID: PMC10663952 DOI: 10.1016/j.resplu.2023.100498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 10/26/2023] [Accepted: 10/27/2023] [Indexed: 12/01/2023] Open
Abstract
Aim This study aimed to compare current out-of-hospital transfusion (OHT) protocols in Canadian civilian critical care transport organizations (CCTO) to expert recommendations and explore the variability and potential benefits of standardizing OHT practices across Canada. Methods A comprehensive cross-sectional study was conducted, encompassing all seven Canadian CCTOs that provide OHT. The study assessed adherence to expert recommendations and examined specific aspects of the transfusion process, such as indications for transfusion and cessation criteria. Results The study found an 89% adherence to expert recommendations for OHT among Canadian CCTOs. It highlighted a strong alignment between current practices and recommendations, possibly attributed to collaborative frameworks like the CAN-PATT network. However, notable variability and ambiguity were observed in transfusion indications and cessation criteria. The study also emphasized the potential benefits of standardizing OHT practices, such as improved policy formulation, better interpretation of emerging literature, and evaluation of OHT efficacy. Conclusion This cross-sectional study assessed how Canadian CCTOs implement OHT practices compared to expert-recommended practices. The findings underscore the importance of structured protocols in trauma management. Given the consistency in OHT protocol adoption and the comprehensive approach across CCTOs, there's a solid foundation for managing trauma patients in prehospital and transport settings across Canada. As OHT practices continue to evolve, sustained efforts are vital to refine, adapt, and elevate patient care standards in trauma management.
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Affiliation(s)
- Pierre-Marc Dion
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Canadian Forces Health Services, Canadian Armed Forces, Ottawa, Ontario, Canada
| | - Adam Greene
- Air Operations, British Columbia Emergency Health Services, British Columbia, Canada
- School of Medicine, Cardiff University, Cardiff, Wales, United Kingdom
| | - Andrew Beckett
- Canadian Forces Health Services, Canadian Armed Forces, Ottawa, Ontario, Canada
- Department of Surgery, St. Michael’s Hospital, Unity Health Toronto, Toronto, Ontario, Canada
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, Unity Health Toronto, Toronto, Ontario, Canada
| | - Johannes von Vopelius-Feldt
- Li Ka Shing Knowledge Institute, Unity Health Toronto, Toronto, Ontario, Canada
- Department of Emergency Medicine, St. Michael’s Hospital, Unity Health Toronto, Toronto, Ontario, Canada
- Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Ornge, Mississauga, Ontario, Canada
| | - Brodie Nolan
- Li Ka Shing Knowledge Institute, Unity Health Toronto, Toronto, Ontario, Canada
- Department of Emergency Medicine, St. Michael’s Hospital, Unity Health Toronto, Toronto, Ontario, Canada
- Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Ornge, Mississauga, Ontario, Canada
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Maegele M, Lier H, Hossfeld B. Pre-Hospital Blood Products for the Care of Bleeding Trauma Patients. DEUTSCHES ARZTEBLATT INTERNATIONAL 2023; 120:670-676. [PMID: 37551452 PMCID: PMC10644958 DOI: 10.3238/arztebl.m2023.0176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 07/13/2023] [Accepted: 07/13/2023] [Indexed: 08/09/2023]
Abstract
BACKGROUND Controversy surrounds the administration of blood products to severely traumatized patients before they arrive in the hospital in order to compensate for early blood loss and/or to correct coagulation disturbances that arise shortly after the traumatic event. A number of terrestrial and air rescue services have begun to provide this kind of treatment. METHODS This review is based on articles using the PICO framework, published from January 2001 to January 2021, that were retrieved by a selective search, with structured searching strategies and searching bundles in Medline (OVIDSP), the Cochrane Central Register of Controlled Trials (CENTRAL), and Epistemonikos. A demand analysis was carried out on the basis of data from the trauma registry of the German Society of Trauma Surgery (TR-DGU) and practical experience from program development and implementation was provided by the Bundeswehr Hospital Ulm. RESULTS The currently available evidence on the pre-hospital administration of blood products in the early treatment of severely injured patients is based largely on retrospective, single-center case series. Two randomized controlled trials (RCTs) concerning the early use of fresh frozen plasma concentrates have yielded partly conflicting results. Three further RCTs on the use of lyophilized plasma (lyplas), lyplas plus erythrocyte concentrate, or whole blood likewise revealed non-uniform effects on short-term and intermediate-term mortality. Our demand analysis based on data from the TR-DGU showed that 300 to 1800 patients per year in Germany could benefit from the pre-hospital administration of blood products. This might be indicated in patients who have systolic hypotension (<100 mmHg) in combination with a suspected or confirmed hemorrhage, as well as pathological shock parameters in the point-of-care diagnostic testing performed on the scene (serum base excess ≤ -2.5 mmol/L and/or serum lactate concentration >4 mmol/L). CONCLUSION The studies that have been published to date yield no clear evidence either for or against the early pre-hospital administration of blood products. Any treatment of this kind should be accompanied by scientific evaluation.
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Affiliation(s)
- Marc Maegele
- *Joint first authors
- Department of Trauma and Orthopaedic Surgery, Cologne-Merheim Medical Centre (CMMC), University of Witten/Herdecke, Cologne
- Institute for Research in Operative Medicine (IFOM), University of Witten/Herdecke, Campus Cologne-Merheim, Cologne
| | - Heiko Lier
- *Joint first authors
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Cologne, Cologne
| | - Björn Hossfeld
- Department of Anaesthesiology and Intensive Care Medicine, Armed Forces Hospital Ulm, Ulm
- Rescue transport helicopter (RTH) „Christoph 22“ Ulm, ADAC-Air Rescue, Ulm
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7
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Prehospital Hemorrhage Control and Treatment by Clinicians: A Joint Position Statement. Ann Emerg Med 2023; 82:e1-e8. [PMID: 37349075 DOI: 10.1016/j.annemergmed.2023.03.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 03/10/2023] [Indexed: 06/24/2023]
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8
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Berry C, Gallagher JM, Goodloe JM, Dorlac WC, Dodd J, Fischer PE. Prehospital Hemorrhage Control and Treatment by Clinicians: A Joint Position Statement. PREHOSP EMERG CARE 2023:1-15. [PMID: 36961935 DOI: 10.1080/10903127.2023.2195487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/26/2023]
Affiliation(s)
- Cherisse Berry
- Department of Surgery, New York University Grossman School of Medicine, New York, NY
| | | | - Jeffrey M Goodloe
- Department of Emergency Medicine, University of Oklahoma Health Sciences Center, Tulsa, OK
| | - Warren C Dorlac
- Department of Surgery, University of Colorado Health Loveland, Loveland, CO
| | - Jimm Dodd
- Stop the Bleed, American College of Surgeons, Chicago, IL
| | - Peter E Fischer
- Department of Surgery, University of Tennessee Health Science Center, Memphis, TN
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9
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Transfusion Management in Trauma: What is Current Best Practice? CURRENT SURGERY REPORTS 2023. [DOI: 10.1007/s40137-023-00352-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
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10
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Greene A, Trojanowski J, Shih AW, Evans R, Chang E, Nahirniak S, Pearson D, Prokopchuk-Gauk O, Martin D, Musuka C, Seidl C, Peddle M, Lin Y, Smith JA, MacDonald S, Richards L, Farrell M, Nolan B. A descriptive analysis of the Canadian prehospital and transport transfusion (CAN-PATT) network. Resusc Plus 2023; 13:100357. [PMID: 36691447 PMCID: PMC9860513 DOI: 10.1016/j.resplu.2022.100357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Revised: 12/19/2022] [Accepted: 12/29/2022] [Indexed: 01/13/2023] Open
Abstract
Objective Out-of-hospital blood transfusion (OHBT) is becoming increasingly common across the prehospital environment, yet there is significant variability in OHBT practices. The Canadian Prehospital and Transport Transfusion (CAN-PATT) network was established to collaborate, standardize, and evaluate the effectiveness of out-of-hospital blood transfusion (OHBT) across Canada. The objectives of this study are to describe the setting and organizational characteristics of CAN-PATT member organizations and to provide a cross-sectional examination of the current OHBT practices of CAN-PATT organizations. Methods This was a cross-sectional examination of all six critical care transport organizations that are involved in CAN-PATT network. Surveys were sent to identified leads from each organization. The survey focused on three main areas of interest: 1) critical care transport organizational service and coverage, 2) provider, and crew configurations, and 3) OHBT transfusion practices. Results All six surveys were completed and returned. There are a total of 30 critical care transport bases (19 rotor-wing, 20 fixed-wing and 6 land) across Canada and 11 bases have a blood-on-board program. Crew configurations very between organizations as either dual paramedic or paramedic/nurse teams. Median transport times range from 30 to 46 minutes for rotor-wing assets and 64 to 90 minutes for fixed-wing assets. Half of the CAN-PATT organizations started their out-of-hospital blood transfusion programs within the last three years. Most organizations carry at least two units of O-negative, K-negative red blood cells and some organizations also carry group A thawed plasma, fibrinogen concentrate and/or prothrombin complex concentrate. All organizations advocate for early administration of tranexamic acid for injured patients suspected of bleeding. All organizations return un-transfused blood components to their local transfusion medicine laboratory within a predefined timeframe to reduce wastage. Conclusions Variations in OHBT practices were identified and we have suggested considerations for standardization of transfusion practices and patient care as it relates to OHBT. This standardization will also enable a robust means of data collection to study and optimize outcomes of patients receiving OHBT. A fulsome description of the participating organizations within CAN-PATT should enhance interpretation of future OHBT studies that will be conducted by this network.
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Affiliation(s)
- Adam Greene
- AirEvac and Critical Care Operations, British Columbia Emergency Health Services, Vancouver, BC, Canada
- School of Medicine, Cardiff University, Cardiff, Wales, United Kingdom
| | - Jan Trojanowski
- AirEvac and Critical Care Operations, British Columbia Emergency Health Services, Vancouver, BC, Canada
| | - Andrew W. Shih
- Department of Pathology and Laboratory Medicine, Vancouver Coastal Health Authority, Vancouver, BC, Canada
- Centre for Blood Research, University of British Columbia, Vancouver, BC, Canada
| | - Rob Evans
- AirEvac and Critical Care Operations, British Columbia Emergency Health Services, Vancouver, BC, Canada
| | | | - Susan Nahirniak
- Faculty of Medicine, University of Alberta, Edmonton, AB, Canada
- Alberta Precision Laboratories, Transfusion and Transplantation Medicine, AB, Canada
| | | | - Oksana Prokopchuk-Gauk
- Division of Transfusion Medicine, Department of Pathology and Laboratory Medicine, Saskatchewan Health Authority, Saskatoon, SK, Canada
- College of Medicine, University of Saskatchewan, Saskatoon, SK, Canada
| | | | - Charles Musuka
- Department of Transfusion Medicine, Shared Health Manitoba, MB, Canada
| | - Cindy Seidl
- Shock Trauma Air Rescue Service, AB, Canada
- Shock Trauma Air Rescue Service, SK, Canada
- Shock Trauma Air Rescue Service, MB, Canada
| | - Michael Peddle
- Ornge, Mississauga, ON, Canada
- Division of Emergency Medicine, Schulich School of Medicine, Western University, London, ON, Canada
| | - Yulia Lin
- Precision Diagnostics and Therapeutics Program, Sunnybrook Health Sciences Centre, Toronto, Ontario and Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada
| | | | - Scott MacDonald
- Emergency Health Services LifeFlight, Halifax, Nova Scotia, ON, Canada
| | - Lindsay Richards
- Emergency Health Services LifeFlight, Halifax, Nova Scotia, ON, Canada
| | - Michael Farrell
- Nova Scotia Health Authority Provincial Blood Coordinating Team, Nova Scotia, Canada
| | - Brodie Nolan
- Ornge, Mississauga, ON, Canada
- Department of Emergency Medicine, St. Michael’s Hospital, Unity Health Toronto, Toronto, ON, Canada
- Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, ON, Canada
- Corresponding author at: Department of Emergency Medicine, St. Michael’s Hospital, Unity Health Toronto, 80 Bond Street, Toronto, ON M5B 1W8, Canada. @@brodie_nolan
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ter Avest E, Carenzo L, Lendrum RA, Christian MD, Lyon RM, Coniglio C, Rehn M, Lockey DJ, Perkins ZB. Advanced interventions in the pre-hospital resuscitation of patients with non-compressible haemorrhage after penetrating injuries. Crit Care 2022; 26:184. [PMID: 35725641 PMCID: PMC9210796 DOI: 10.1186/s13054-022-04052-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 06/02/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract Early haemorrhage control and minimizing the time to definitive care have long been the cornerstones of therapy for patients exsanguinating from non-compressible haemorrhage (NCH) after penetrating injuries, as only basic treatment could be provided on scene. However, more recently, advanced on-scene treatments such as the transfusion of blood products, resuscitative thoracotomy (RT) and resuscitative endovascular balloon occlusion of the aorta (REBOA) have become available in a small number of pre-hospital critical care teams. Although these advanced techniques are included in the current traumatic cardiac arrest algorithm of the European Resuscitation Council (ERC), published in 2021, clear guidance on the practical application of these techniques in the pre-hospital setting is scarce. This paper provides a scoping review on how these advanced techniques can be incorporated into practice for the resuscitation of patients exsanguinating from NCH after penetrating injuries, based on available literature and the collective experience of several helicopter emergency medical services (HEMS) across Europe who have introduced these advanced resuscitation interventions into routine practice.
Graphical Abstract ![]()
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Stanworth SJ, Dowling K, Curry N, Doughty H, Hunt BJ, Fraser L, Narayan S, Smith J, Sullivan I, Green L. A guideline for the haematological management of major haemorrhage: a British Society for Haematology Guideline. Br J Haematol 2022; 198:654-667. [PMID: 35687716 DOI: 10.1111/bjh.18275] [Citation(s) in RCA: 30] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 05/07/2022] [Accepted: 05/09/2022] [Indexed: 12/17/2022]
Affiliation(s)
- Simon J Stanworth
- Transfusion Medicine, NHS Blood and Transplant, Oxford, UK.,Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.,Radcliffe Department of Medicine, University of Oxford, and NIHR Oxford Biomedical Research Centre, Oxford, UK
| | - Kerry Dowling
- Transfusion Laboratory Manager, Southampton University Hospitals NHS Foundation Trust, Southampton, UK
| | - Nikki Curry
- Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.,Radcliffe Department of Medicine, University of Oxford, and NIHR Oxford Biomedical Research Centre, Oxford, UK
| | - Heidi Doughty
- Institute of Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK.,NIHR Surgical Reconstruction and Microbiology Research Centre, Birmingham, UK
| | - Beverley J Hunt
- Department of Haematology, Guy's and St Thomas's Hospital, London, UK
| | - Laura Fraser
- Transfusion Practitioner, NHS Lanarkshire, University Hospital Wishaw, Wishaw, UK.,National Services Scotland/Scottish National Blood Transfusion, Edinburgh, UK
| | - Shruthi Narayan
- Medical director, Serious Hazards of Transfusion, Manchester, UK
| | - Juliet Smith
- Lead Transfusion Practitioner, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Ian Sullivan
- Transfusion Laboratory Manager, Royal Cornwall Hospitals NHS Trust, Truro, UK
| | - Laura Green
- Transfusion Medicine, NHS Blood and Transplant, London, UK.,Barts Health NHS Trust, London, UK.,Blizzard Institute, Queen Mary University of London, London, UK
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13
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Initial experiences of prehospital blood product transfusions between 2016 and 2020 in Päijät-Häme hospital district, Finland. Scand J Trauma Resusc Emerg Med 2022; 30:39. [PMID: 35668435 PMCID: PMC9169387 DOI: 10.1186/s13049-022-01027-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 05/25/2022] [Indexed: 11/25/2022] Open
Abstract
Background Treating hemorrhaging patients with prehospital blood product transfusions (PHBT) narrows transfusion delays and potentially benefits the patient. We describe our initial experiences of PHBT in a ground-based emergency medical service (EMS), where the transfusion protocol covers both traumatic and nontraumatic hemorrhaging patients. Methods A descriptive retrospective analysis was performed on the records of all the patients receiving red blood cells, freeze-dried plasma, or both during prehospital care from September 2016 to December 2020. The delays of PHBT and the effects on patients’ vital signs were analyzed and reported as the median and interquartile range (IQR) and analyzed using a Wilcoxon Signed rank test. Results 65 patients received prehospital blood product transfusions (PHBT), 29 (45%) were non-traumatic, and 36 (55%) traumatic. The main two reasons for PHBT were blunt trauma (n = 30, 46%) and gastrointestinal hemorrhage (n = 20, 31%). The median time from the emergency call to the start of PHBT was 54 min (IQR 38), and the transfusion began on a median of 61 min (IQR 42) before arrival at the hospital. The median systolic blood pressure improved from a median 76.5 mmHg (IQR 36.5) before transfusion to a median of 116.60 mmHg (IQR 26.5) (p < 0.001) on arrival to the hospital. No transfusion-related severe adverse events were noted. Conclusions Starting PHBT in ground-based EMS is a feasible and viable option. The PHBT began significantly earlier than it would have started on arrival to the hospital, and it seems to be safe and improve patients’ physiology. Study approval D/2603/07.01.04.05/2019.
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14
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Csete M. Prehospital Blood Transfusion for Severe Trauma: Translating Experience From the Military to the Civilian Setting Is Not Always Straightforward. Anesth Analg 2022; 134:675-677. [PMID: 35299207 DOI: 10.1213/ane.0000000000005780] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Affiliation(s)
- Marie Csete
- From the ConeSight Therapeutics, c/o Pasadena Bio Collaborative Incubator, Pasadena, California.,Department of Anesthesiology, University of Southern California Keck School of Medicine, Los Angeles, California
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15
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Dudaryk R, Heim C, Ruetzler K, Pivalizza EG. Pro-Con Debate: Prehospital Blood Transfusion-Should It Be Adopted for Civilian Trauma? Anesth Analg 2022; 134:678-682. [PMID: 35299208 DOI: 10.1213/ane.0000000000005747] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Exsanguination is the leading cause of death in severely injured patients; nevertheless, prehospital blood transfusion (PHT) remains a controversial topic. Here, we review the pros and cons of PHT, which is now routine in treatment of military trauma patients in the civilian setting. While PHT may improve survival in those who suffer blunt injury or require prolonged transport from the site of injury, PHT for civilian trauma generally is not supported by high-quality evidence. This article was originally presented as a pro-con debate at the 2020 meeting of the European Society of Anesthesiology and Intensive Care.
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Affiliation(s)
- Roman Dudaryk
- From the Department of Anesthesiology, Perioperative Medicine, and Pain Management, University of Miami Health System, Miami, Florida
| | - Catherine Heim
- Department of Anesthesiology, University Hospital, CHUV Lausanne, Lausanne, Switzerland
| | - Kurt Ruetzler
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio
| | - Evan G Pivalizza
- Department of Anesthesiology, University of Texas, McGovern Medical School, Houston, Texas
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16
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Smith H, Doughty H, Bishop J, Herbert M, Nash M. Temperature mapping in an air ambulance helicopter: Implications for the delivery of pre-hospital transfusion. Transfusion 2021; 61 Suppl 1:S206-S213. [PMID: 34269452 DOI: 10.1111/trf.16517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 01/25/2021] [Accepted: 01/25/2021] [Indexed: 12/01/2022]
Abstract
BACKGROUND Pre-hospital blood products, including freeze-dried plasma, are increasingly carried on air ambulance helicopters. The purpose of this study was to map the temperatures within a civilian air ambulance and consider the implications for pre-hospital transfusion. MATERIALS AND METHODS We conducted a single-site prospective observational study in the United Kingdom. Tinytag temperature data-loggers (Gemini, UK) were secured on to three locations throughout an air ambulance, and one was placed inside an insulated drug-pouch. Temperatures were monitored at 5-min intervals. Data were downloaded monthly and processed using R and MKT software to collate maximum, minimum, and day/night mean kinetic temperatures (MKTs). Blood was transported in Crēdo ProMed 4 containers (Peli Products, S.L.U) and monitored with QTA data-loggers (Tridentify, Sweden). RESULTS A total of 344,844 temperature recordings were made on 302 days during a 12-month period from January 2019. The external ambient temperatures varied seasonally from -7.1°C to 31.2°C, whereas internal temperatures ranged from -0.3°C to 60.6°C. The warmest area was alongside the left front-crew position (range 1.9-60.6°C, MKT 24.8°C). The lowest daytime MKT (16.9°C) and range (1.7°C-36.4°C) were recorded next to the patient stretcher. Temperatures ranged from 4.2°C to 40.1°C inside the insulated drugs-pouch, exceeding 25°C on 47 days (15%) and falling below 15°C on 192 days (63%) In contrast, thermally packed blood maintained a range of 2-6°C. CONCLUSION The temperatures within an air ambulance varied throughout the cabin and often exceeded the external ambient temperature. Appropriately selected thermal protection and monitoring is required for the successful delivery of pre-hospital transfusion, even in a temperate climate.
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Affiliation(s)
- Hazel Smith
- NIHR Surgical Reconstruction and Microbiology Research Centre, Institute of Translational Medicine, Birmingham, UK
| | - Heidi Doughty
- NIHR Surgical Reconstruction and Microbiology Research Centre, Institute of Translational Medicine, Birmingham, UK.,NHS Blood and Transplant, Birmingham, UK
| | - Jonathan Bishop
- NIHR Surgical Reconstruction and Microbiology Research Centre, Institute of Translational Medicine, Birmingham, UK
| | - Mike Herbert
- The Royal Wolverhampton NHS Trust, New Cross Hospital, Wolverhampton, UK
| | - Mark Nash
- Midlands Air Ambulance, RAF Cosford, Wolverhampton, UK
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17
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Harris D, Martin D, Bednarz J, Ellis DY. Acute traumatic coagulopathy and the relationship to prehospital care and on-scene red blood cell transfusion. Emerg Med Australas 2021; 33:834-840. [PMID: 33556992 DOI: 10.1111/1742-6723.13734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Revised: 01/14/2021] [Accepted: 01/15/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To identify the incidence of acute traumatic coagulopathy (ATC) in trauma patients presenting to the Royal Adelaide Hospital, analyse prehospital contributors, including red blood cell transfusion and assess the clinical significance of ATC. METHODS A retrospective database review was undertaken using conventional coagulation assays and viscoelastic testing (ROTEM) for diagnosis of ATC. RESULTS Baseline ATC incidence is 10% in trauma patients, increasing to over 80% among those where the prehospital team has attended and given a transfusion of red cells. ATC was significantly associated with higher severity of trauma (odds ratio [OR] 1.11, P < 0.0001), prehospital (OR 11.8, P < 0.0001) and in-hospital blood transfusions (OR 17.9, P < 0.0001), and massive transfusions (P < 0.001). CONCLUSIONS Prehospital blood transfusions are given to the most severely injured trauma patients and the incidence of ATC in this group is more than 80%. There is an association with prehospital blood transfusion and increased ATC in part related to patient selection and severity of trauma, with the contribution of red cell transfusions to ATC unclear. This association should allow earlier identification of patients at increased risk of ATC to ensure rapid correction of coagulopathy to decrease the morbidity and mortality of trauma.
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Affiliation(s)
- Daniel Harris
- Trauma Service, Royal Adelaide Hospital, Adelaide, South Australia, Australia.,Emergency Department, Royal Adelaide Hospital, Adelaide, South Australia, Australia.,Emergency Department, The Queen Elizabeth Hospital, Adelaide, South Australia, Australia.,Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, South Australia, Australia.,MedSTAR Emergency Medical Retrieval, SA Ambulance Service, Adelaide, South Australia, Australia
| | - Daniel Martin
- MedSTAR Emergency Medical Retrieval, SA Ambulance Service, Adelaide, South Australia, Australia.,School of Public Health and Tropical Medicine, James Cook University, Townsville, Queensland, Australia
| | - Jana Bednarz
- Adelaide Health Technology Assessment, The University of Adelaide, Adelaide, South Australia, Australia
| | - Daniel Y Ellis
- Trauma Service, Royal Adelaide Hospital, Adelaide, South Australia, Australia.,Emergency Department, Royal Adelaide Hospital, Adelaide, South Australia, Australia.,MedSTAR Emergency Medical Retrieval, SA Ambulance Service, Adelaide, South Australia, Australia.,School of Public Health and Tropical Medicine, James Cook University, Townsville, Queensland, Australia
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18
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Shand S, Curtis K, Dinh M, Burns B. Prehospital Blood Transfusion in New South Wales, Australia: A Retrospective Cohort Study. PREHOSP EMERG CARE 2020; 25:404-411. [DOI: 10.1080/10903127.2020.1769781] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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19
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Doughty H, Naumann D. Pre-hospital transfusion: Trials and tribulations. Transfus Med 2020; 30:81-83. [PMID: 32378250 DOI: 10.1111/tme.12679] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Accepted: 03/09/2020] [Indexed: 12/18/2022]
Affiliation(s)
| | - David Naumann
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Queen Elizabeth Hospital Birmingham, Birmingham, UK
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20
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van Turenhout EC, Bossers SM, Loer SA, Giannakopoulos GF, Schwarte LA, Schober P. Pre-hospital transfusion of red blood cells. Part 1: A scoping review of current practice and transfusion triggers. Transfus Med 2020; 30:86-105. [PMID: 32080942 PMCID: PMC7317877 DOI: 10.1111/tme.12667] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Revised: 12/18/2019] [Accepted: 01/16/2020] [Indexed: 12/21/2022]
Abstract
OBJECTIVES The primary aim of this scoping review is to describe the current use of pre-hospital transfusion of red blood cells (PHTRBC) and to evaluate criteria used to initiate PHTRBC. The effects on patients' outcomes will be reviewed in Part 2. BACKGROUND Haemorrhage is a preventable cause of death in trauma patients, and transfusion of red blood cells is increasingly used by Emergency Medical Services (EMS) for damage control resuscitation. However, there are no guidelines and little consensus on when to initiate PHTRBC. METHODS PubMed and Web of Science were searched through January 2019; 71 articles were included. RESULTS Transfusion triggers vary widely and involve vital signs, clinical signs of poor tissue perfusion, point of care measurements and pre-hospital ultrasound imaging. In particular, hypotension (most often defined as systolic blood pressure ≤ 90 mmHg), tachycardia (most often defined as heart rate ≥ 120/min), clinical signs of poor perfusion (eg, prolonged capillary refill time or changes in mental status) and injury type (ie, penetrating wounds) are common pre-hospital transfusion triggers. CONCLUSIONS PHTRBC is increasingly used by Emergency Medical Services, but guidelines on when to initiate transfusion are lacking. We identified the most commonly used transfusion criteria, and these findings may provide the basis for consensus-based pre-hospital transfusion protocols.
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Affiliation(s)
| | - Sebastiaan M. Bossers
- Department of AnaesthesiologyAmsterdam UMC, Vrije Universiteit AmsterdamAmsterdamThe Netherlands
| | - Stephan A. Loer
- Department of AnaesthesiologyAmsterdam UMC, Vrije Universiteit AmsterdamAmsterdamThe Netherlands
| | - Georgios F. Giannakopoulos
- Department of Trauma SurgeryAmsterdam UMC, Vrije Universiteit AmsterdamAmsterdamThe Netherlands
- Helicopter Emergency Medical Service “Lifeliner 1”Amsterdam UMC, Vrije Universiteit AmsterdamAmsterdamThe Netherlands
| | - Lothar A. Schwarte
- Department of AnaesthesiologyAmsterdam UMC, Vrije Universiteit AmsterdamAmsterdamThe Netherlands
- Helicopter Emergency Medical Service “Lifeliner 1”Amsterdam UMC, Vrije Universiteit AmsterdamAmsterdamThe Netherlands
| | - Patrick Schober
- Department of AnaesthesiologyAmsterdam UMC, Vrije Universiteit AmsterdamAmsterdamThe Netherlands
- Helicopter Emergency Medical Service “Lifeliner 1”Amsterdam UMC, Vrije Universiteit AmsterdamAmsterdamThe Netherlands
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21
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van Turenhout EC, Bossers SM, Loer SA, Giannakopoulos GF, Schwarte LA, Schober P. Pre-hospital transfusion of red blood cells. Part 2: A systematic review of treatment effects on outcomes. Transfus Med 2020; 30:106-133. [PMID: 31903684 PMCID: PMC7317762 DOI: 10.1111/tme.12659] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Accepted: 12/06/2019] [Indexed: 12/11/2022]
Abstract
The primary aim of this systematic review is to describe the effects of prehospital transfusion of red blood cells (PHTRBC) on patient outcomes. Damage control resuscitation attempts to prevent death through haemorrhage in trauma patients. In this context, transfusion of red blood cells is increasingly used by emergency medical services (EMS). However, evidence on the effects on outcomes is scarce. PubMed and Web of Science were searched through January 2019; 55 articles were included. No randomised controlled studies were identified. While several observational studies suggest an increased survival after PHTRBC, consistent evidence for beneficial effects of PHTRBC on survival was not found. PHTRBC appears to improve haemodynamic parameters, but there is no evidence that shock on arrival to hospital is averted, nor of an association with trauma induced coagulopathy or with length of stay in hospitals or intensive care units. In conclusion, PHTRBC is increasingly used by EMS, but there is no strong evidence for effects of PHTRBC on mortality. Further research with study designs that allow causal inferences is required for more conclusive evidence. The combination of PHTRBC with plasma, as well as the use of individualised transfusion criteria, may potentially show more benefits and should be thoroughly investigated in the future. The review was registered at Prospero (CRD42018084658).
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Affiliation(s)
| | - Sebastiaan M. Bossers
- Department of Anaesthesiology, Amsterdam UMCVrije Universiteit AmsterdamAmsterdamThe Netherlands
| | - Stephan A. Loer
- Department of Anaesthesiology, Amsterdam UMCVrije Universiteit AmsterdamAmsterdamThe Netherlands
| | - Georgios F. Giannakopoulos
- Department of Trauma Surgery, Amsterdam UMCVrije Universiteit AmsterdamAmsterdamThe Netherlands
- Helicopter Emergency Medical Service “Lifeliner 1”, Amsterdam UMCVrije Universiteit AmsterdamAmsterdamThe Netherlands
| | - Lothar A. Schwarte
- Department of Anaesthesiology, Amsterdam UMCVrije Universiteit AmsterdamAmsterdamThe Netherlands
- Helicopter Emergency Medical Service “Lifeliner 1”, Amsterdam UMCVrije Universiteit AmsterdamAmsterdamThe Netherlands
| | - Patrick Schober
- Department of Anaesthesiology, Amsterdam UMCVrije Universiteit AmsterdamAmsterdamThe Netherlands
- Helicopter Emergency Medical Service “Lifeliner 1”, Amsterdam UMCVrije Universiteit AmsterdamAmsterdamThe Netherlands
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