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Dowd S, Sharo C, Abdulmalik O, Elmer J. Optimizing the lyophilization of Lumbricus terrestris erythrocruorin. ARTIFICIAL CELLS, NANOMEDICINE, AND BIOTECHNOLOGY 2024; 52:291-299. [PMID: 38733371 PMCID: PMC11218865 DOI: 10.1080/21691401.2024.2352003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Accepted: 04/29/2024] [Indexed: 05/13/2024]
Abstract
Haemorrhagic shock is a leading cause of death worldwide. Blood transfusions can be used to treat patients suffering severe blood loss but donated red blood cells (RBCs) have several limitations that limit their availability and use. To solve the problems associated with donated RBCs, several acellular haemoglobin-based oxygen carriers (HBOCs) have been developed to restore the most important function of blood: oxygen transport. One promising HBOC is the naturally extracellular haemoglobin (i.e. erythrocruorin) of Lumbricus terrestris (LtEc). The goal of this study was to maximise the portability of LtEc by lyophilising it and then testing its stability at elevated temperatures. To prevent oxidation, several cryoprotectants were screened to determine the optimum formulation for lyophilisation that could minimise oxidation of the haem iron and maximise recovery. Furthermore, samples were also deoxygenated prior to storage to decrease auto-oxidation, while resuspension in a solution containing ascorbic acid was shown to partially reduce LtEc that had oxidised during storage (e.g. from 42% Fe3+ to 11% Fe3+). Analysis of the oxygen equilibria and size of the resuspended LtEc showed that the lyophilisation, storage, and resuspension processes did not affect the oxygen transport properties or the structure of the LtEc, even after 6 months of storage at 40 °C. Altogether, these efforts have yielded a shelf-stable LtEc powder that can be stored for long periods at high temperatures, but future animal studies will be necessary to prove that the resuspended product is a safe and effective oxygen transporter in vivo.
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Affiliation(s)
- Sean Dowd
- Department of Chemical & Biological Engineering, Villanova University, Villanova, Pennsylvania, USA
| | - Catherine Sharo
- Department of Chemical & Biological Engineering, Villanova University, Villanova, Pennsylvania, USA
| | - Osheiza Abdulmalik
- Division of Hematology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Jacob Elmer
- Department of Chemical & Biological Engineering, Villanova University, Villanova, Pennsylvania, USA
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2
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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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3
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Riff JC, Duranteau O, Ausset S, Pasquier P, Fleuriot E, Corominas V, Boutonnet M. The first two years of the use of low titer group O whole blood during French Military overseas operations: A retrospective study. Transfusion 2024; 64 Suppl 2:S34-S41. [PMID: 38441209 DOI: 10.1111/trf.17776] [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: 12/30/2023] [Revised: 02/16/2024] [Accepted: 02/18/2024] [Indexed: 05/12/2024]
Abstract
BACKGROUND On the battlefield, hemorrhage is the main cause of potentially preventable death. To reduce mortality due to hemorrhagic injuries, the French Military Medical Service (FMMS) has deployed low titer group O whole blood (LTOWB) since June 2021 during operation BARKHANE in the Sahel-Saharan strip. Questions persist regarding the circumstances under which the FMMS employs LTOWB during overseas operations. STUDY DESIGN We performed a retrospective analysis of all LTOWB transfused by the FMMS during overseas operations in the Sahel-Saharan strip between June 1, 2021, and June 1, 2023. Information was collected from battlefield forward transfusion sheets. RESULTS Over the 2-year study period, 40 units of LTOWB were transfused into 25 patients. Of the 25 patients, 18 were combat casualties and seven were transfused for non-trauma surgery. Of the 40 units of LTOWB transfused, 22 were provided during Role 2 care, 11 during tactical medical evacuation (MEDEVAC), and seven in light and mobile surgical units. Among combat casualties, LTOWB was the first blood product transfused in 13 patients. In combat casualties, 6 h post-trauma, the median ratio of plasma: red blood cells (RBCs) was 1.5, and the median equivalent platelet concentrate (PC) transfused was 0.17. No immediate adverse events related to LTOWB transfusion were reported. CONCLUSION LTOWB is transfused by the FMMS during overseas operations from the tactical MEDEVAC until Role 2 care. Deployment of LTOWB by the FMMS enables an early high-ratio plasma/RBC transfusion and an early platelet transfusion for combat casualties.
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Affiliation(s)
- Jean-Clément Riff
- Intensive Care Unit, Percy Military Training Hospital, Clamart, France
| | - Olivier Duranteau
- Intensive Care Unit, Percy Military Training Hospital, Clamart, France
| | - Sylvain Ausset
- French Military Medical Schools, Lyon, France
- Ecole du Val-de-Grâce, French Military Medical Service Academy, Paris, France
| | - Pierre Pasquier
- Intensive Care Unit, Percy Military Training Hospital, Clamart, France
- Ecole du Val-de-Grâce, French Military Medical Service Academy, Paris, France
- Special Operation Forces Medical Command, Villacoublay, France
| | | | | | - Mathieu Boutonnet
- Intensive Care Unit, Percy Military Training Hospital, Clamart, France
- Ecole du Val-de-Grâce, French Military Medical Service Academy, Paris, France
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4
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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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Hornez E, Cotte J, Thomas G, Prat N, Vauchaussade de Chaumont A, Daban JL, Boddaert G, Pasquier P, Castel F, Mahe P, Balandraud P. Ultra-forward surgical support for special operations forces. Conception, development and certification of the French Special Operations Surgical Team (SOST) airborne capability. Injury 2024; 55:111002. [PMID: 37633765 DOI: 10.1016/j.injury.2023.111002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 07/11/2023] [Accepted: 08/09/2023] [Indexed: 08/28/2023]
Abstract
When special operations forces (SOF) are in action, a surgical team (SOST) is usually ground deployed as close as possible to the combat area, to try and provide surgical support within the golden hour. The French SOST is composed of 6 people: 2 surgeons, 1 scrub nurse, 1 anaesthetist, 1 anesthetic nurse and 1 SOF paramedic. It can be deployed in 45 min under a tent or in a building. However, some tactical situations prevent the ground deployment. A solution is to deploy the SOST in a tactical unprepared aircraft hold, to make it possible to offer DCS, to treat non-compressible exsanguinating trauma, without any ground logistical footprint. This article describes the stages of the design, development and certification process of the airborne SOST capability. The authors report the modifications and adaptations of the equipment and the surgical paradigms which make it possible to solve the constraints linked to the aeronautical and combat environment. Study type/level of evidence Care management Level of Evidence IV.
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Affiliation(s)
- Emmanuel Hornez
- Digestive surgery, Percy Military teaching hospital, 1 rue Raoul Batany, 92140, Clamart, France; École du Val-de-Grâce, French Military Medical Service Academy, Paris, France.
| | - Jean Cotte
- Intensive care unit, Sainte Anne Military teaching hospital, Toulon, France
| | - Gil Thomas
- 1 CSS/FS, French Military Medical Service, Villacoublay, France
| | - Nicolas Prat
- French Military Biomedical Research Institute, bretigny, France; École du Val-de-Grâce, French Military Medical Service Academy, Paris, France
| | | | - Jean Louis Daban
- Intensive care unit, Percy Military teaching hospital, 1 rue Raoul Batany, 92140, Clamart, France
| | - Guillaume Boddaert
- Thoracic surgery, Percy Military teaching hospital, 1 rue Raoul Batany, 92140, Clamart, France; École du Val-de-Grâce, French Military Medical Service Academy, Paris, France
| | - Pierre Pasquier
- 1 CSS/FS, French Military Medical Service, Villacoublay, France; École du Val-de-Grâce, French Military Medical Service Academy, Paris, France
| | - Fabrice Castel
- 1 CSS/FS, French Military Medical Service, Villacoublay, France
| | - Pierre Mahe
- 1 CSS/FS, French Military Medical Service, Villacoublay, France
| | - Paul Balandraud
- Digestive surgery, Sainte Anne Military teaching hospital, Toulon, France; École du Val-de-Grâce, French Military Medical Service Academy, Paris, France
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6
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Py N, Pons S, Boye M, Martinez T, Ausset S, Martinaud C, Pasquier P. An observational study of the blood use in combat casualties of the French Armed Forces, 2013-2021. Transfusion 2023; 63:69-82. [PMID: 36433844 DOI: 10.1111/trf.17193] [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: 07/05/2022] [Revised: 08/30/2022] [Accepted: 09/07/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND The French Armed Forces conduct asymmetric warfare in the Sahara-Sahel Strip. Casualties are treated with damage control resuscitation to the extent possible. Questions remain about the feasibility and sustainability of using blood for wider use in austere environments. METHODS We performed a retrospective analysis of all French military trauma patients transfused after injury in overseas military operations in Sahel-Saharan Strip, from the point of injury, until day 7, between January 11, 2013 to December 31, 2021. RESULTS Forty-five patients were transfused. Twenty-three (51%) of them required four red blood cells units (RBC) or more in the first 24H defining a severe hemorrhage. The median blood product consumption within the first 48 h, was 8 (IQR [3; 18]) units of blood products (BP) for all study population but up to 17 units (IQR [10; 27.5]) for the trauma patients with severe hemorrhage. Transfusion started at prehospital stage for 20 patients (45%) and included several blood products: French lyophilized plasma, RBCs, and whole blood. Patients with severe hemorrhage required a median of 2 [IQR 0; 34] further units of BP from day 3 to day 7 after injury. Eight patients died in theater, 4 with severe hemorrhage and these 4 used an average of 12 products at Role 1 and 2. CONCLUSION The transfusion needs were predominant in the first 48 h after the injury but also continued throughout the first week for the most severe trauma patients. Importantly, our study involved a low-intensity conflict, with a small number of injured combatants.
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Affiliation(s)
- Nicolas Py
- Federation of Anesthesiology, Intensive Care Unit, Burns and Operating Theater, Percy Military Training Hospital, Clamart, France
| | - Sandrine Pons
- French Military Blood Institute, Saint Anne Military Training Hospital, Toulon, France
| | - Matthieu Boye
- Federation of Anesthesiology, Intensive Care Unit, Burns and Operating Theater, Percy Military Training Hospital, Clamart, France
| | - Thibault Martinez
- Federation of Anesthesiology, Intensive Care Unit, Burns and Operating Theater, Percy Military Training Hospital, Clamart, France
| | - Sylvain Ausset
- French Military Medical Schools, Lyon, France.,École du Val-de-Grâce, French Military Medical Service Academy, Paris, France
| | - Christophe Martinaud
- École du Val-de-Grâce, French Military Medical Service Academy, Paris, France.,French Military Blood Institute, Clamart, France
| | - Pierre Pasquier
- Federation of Anesthesiology, Intensive Care Unit, Burns and Operating Theater, Percy Military Training Hospital, Clamart, France.,École du Val-de-Grâce, French Military Medical Service Academy, Paris, France.,Special Operation Forces Medical Headquarter, Villacoublay, France
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7
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Transfusion management in the trauma patient. Curr Opin Crit Care 2022; 28:725-731. [PMID: 36226706 DOI: 10.1097/mcc.0000000000000992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
PURPOSE OF REVIEW Transfusion of blood products is lifesaving in the trauma ICU. Intensivists must be familiar with contemporary literature to develop the optimal transfusion strategy for each patient. RECENT FINDINGS A balanced ratio of red-blood cells to plasma and platelets is associated with improved mortality and has therefore become the standard of care for resuscitation. There is a dose-dependent relationship between units of product transfused and infections. Liquid and freeze-dried plasma are alternatives to fresh frozen plasma that can be administered immediately and may improve coagulation parameters more rapidly, though higher quality research is needed. Trauma induced coagulopathy can occur despite a balanced transfusion, and administration of prothrombin complex concentrate and cryoprecipitate may have a role in preventing this. In addition to balanced ratios, viscoelastic guidance is being increasingly utilized to individualize component transfusion. Alternatively, whole blood can be used, which has become the standard in military practice and is gaining popularity at civilian centers. SUMMARY Hemorrhagic shock is the leading cause of death in trauma. Improved resuscitation strategy has been one of the most important contemporary advancements in trauma care and continues to be a key area of clinical research.
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8
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Peng HT, Rhind SG, Moes K, Devine D, Jenkins C, Beckett A. Freeze‐dried plasma: From damage control resuscitation to coronavirus disease 2019 therapy. Transfusion 2022; 62:1408-1416. [DOI: 10.1111/trf.16947] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Accepted: 05/15/2022] [Indexed: 11/28/2022]
Affiliation(s)
- Henry T. Peng
- Defence Research and Development Canada, Toronto Research Centre Toronto Ontario Canada
| | - Shawn G. Rhind
- Defence Research and Development Canada, Toronto Research Centre Toronto Ontario Canada
| | - Katy Moes
- Defence Research and Development Canada, Toronto Research Centre Toronto Ontario Canada
| | - Dana Devine
- Centre for Innovation, Canadian Blood Services, Edmonton, Hamilton, Ottawa, and Vancouver Canada
| | - Craig Jenkins
- Centre for Innovation, Canadian Blood Services, Edmonton, Hamilton, Ottawa, and Vancouver Canada
| | - Andrew Beckett
- St. Michael's Hospital, Toronto, Ontario and Royal Canadian Medical Services Ottawa Canada
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9
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Cartotto R, Burmeister DM, Kubasiak JC. Burn Shock and Resuscitation: Review and State of the Science. J Burn Care Res 2022; 43:irac025. [PMID: 35218662 DOI: 10.1093/jbcr/irac025] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Indexed: 12/31/2022]
Abstract
Burn shock and acute fluid resuscitation continue to spark intense interest and debate among burn clinicians. Following a major burn injury, fluid resuscitation of burn shock is life-saving, but paradoxically can also be a source of increased morbidity and mortality because of the unintended consequence of systemic edema formation. Considerable research over the past two decades has been devoted to understanding the mechanisms of edema formation, and to develop strategies to curb resuscitation fluids and limit edema development. Recognition of burn endotheliopathy - injury to the endothelium's glycocalyx layer- is one of the most important recent developments in our understanding of burn shock pathophysiology. Newer monitoring approaches and resuscitation endpoints, along with alternative resuscitation strategies to crystalloids alone, such as administration of albumin, or plasma, or high dose ascorbic acid, have had mixed results in limiting fluid creep. Clear demonstration of improvements in outcomes with all of these approaches remains elusive. This comprehensive review article on burn shock and acute resuscitation accompanies the American Burn Association's State of the Science meeting held in New Orleans, LA on November 2-3, 2021 and the Proceedings of that conference published in this journal.
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Affiliation(s)
- Robert Cartotto
- Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre, and University of Toronto, Canada
| | - David M Burmeister
- Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland and United States Army Institute of Surgical Research, JBSA Fort Sam Houston, Texas USA
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10
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Abstract
More than 1,000,000 units of lyophilized plasma have been used in France, Germany, and South Africa. Recently, numerous other countries have adopted lyophilized plasma for patients with severe bleeding in prehospital and austere settings.
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11
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Fecher A, Stimpson A, Ferrigno L, Pohlman TH. The Pathophysiology and Management of Hemorrhagic Shock in the Polytrauma Patient. J Clin Med 2021; 10:4793. [PMID: 34682916 PMCID: PMC8541346 DOI: 10.3390/jcm10204793] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Revised: 10/14/2021] [Accepted: 10/15/2021] [Indexed: 11/16/2022] Open
Abstract
The recognition and management of life-threatening hemorrhage in the polytrauma patient poses several challenges to prehospital rescue personnel and hospital providers. First, identification of acute blood loss and the magnitude of lost volume after torso injury may not be readily apparent in the field. Because of the expression of highly effective physiological mechanisms that compensate for a sudden decrease in circulatory volume, a polytrauma patient with a significant blood loss may appear normal during examination by first responders. Consequently, for every polytrauma victim with a significant mechanism of injury we assume substantial blood loss has occurred and life-threatening hemorrhage is progressing until we can prove the contrary. Second, a decision to begin damage control resuscitation (DCR), a costly, highly complex, and potentially dangerous intervention must often be reached with little time and without sufficient clinical information about the intended recipient. Whether to begin DCR in the prehospital phase remains controversial. Furthermore, DCR executed imperfectly has the potential to worsen serious derangements including acidosis, coagulopathy, and profound homeostatic imbalances that DCR is designed to correct. Additionally, transfusion of large amounts of homologous blood during DCR potentially disrupts immune and inflammatory systems, which may induce severe systemic autoinflammatory disease in the aftermath of DCR. Third, controversy remains over the composition of components that are transfused during DCR. For practical reasons, unmatched liquid plasma or freeze-dried plasma is transfused now more commonly than ABO-matched fresh frozen plasma. Low-titer type O whole blood may prove safer than red cell components, although maintaining an inventory of whole blood for possible massive transfusion during DCR creates significant challenges for blood banks. Lastly, as the primary principle of management of life-threatening hemorrhage is surgical or angiographic control of bleeding, DCR must not eclipse these definitive interventions.
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Affiliation(s)
- Alison Fecher
- Division of Acute Care Surgery, Lutheran Hospital of Indiana, Fort Wayne, IN 46804, USA; (A.F.); (A.S.)
| | - Anthony Stimpson
- Division of Acute Care Surgery, Lutheran Hospital of Indiana, Fort Wayne, IN 46804, USA; (A.F.); (A.S.)
| | - Lisa Ferrigno
- Department of Surgery, UCHealth, University of Colorado-Denver, Aurora, CO 80045, USA;
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12
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Peng HT, Rhind SG, Devine D, Jenkins C, Beckett A. Ex vivo hemostatic and immuno-inflammatory profiles of freeze-dried plasma. Transfusion 2021; 61 Suppl 1:S119-S130. [PMID: 34269465 DOI: 10.1111/trf.16502] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 04/01/2021] [Accepted: 04/01/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND Hemorrhage is a leading cause of preventable death in civilian and military trauma. Freeze-dried plasma is promising for hemostatic resuscitation in remote prehospital settings, given its potential benefits in reducing blood loss and mortality, long storage at ambient temperatures, high portability, and rapid reconstitution for transfusion in austere environments. Here we assess the ex vivo characteristics of a novel Terumo's freeze-dried plasma product (TFDP). STUDY DESIGN AND METHODS Rotational thromboelastometry (ROTEM) tests (INTEM, EXTEM, and FIBTEM) were conducted on plasma samples at 37°C with a ROTEM delta-machine using standard reagents and procedures. The following samples were analyzed: pooled plasma to produce TFDP, TFDP reconstituted, and stored immediately at -80°C, reconstituted TFDP stored at 4°C for 24 h and room temperature (RT) for 4 h before freezing at -80°C. Analysis of plasma concentrations of selected cytokines, chemokines, and vascular molecules was performed using a multiplex immunoassay system. One-way ANOVA with post hoc tests assessed differences in hemostatic and inflammatory properties. RESULTS No significant differences in ROTEM variables (coagulation time [CT], clot formation time, α-angle, maximum clot firmness, and lysis index 30) between the TFDP-producing plasma and reconstituted TFDP samples were observed. Compared to control plasma, reconstituted TFDP stored at 4°C for 24 h or RT for 4 h showed a longer INTEM CT. Levels of immuno-inflammatory mediators were similar between frozen plasma and TFDP. CONCLUSIONS TFDP is equivalent to frozen plasma with respect to global hemostatic and immuno-inflammatory mediator profiles. Further investigations of TFDP in trauma-induced coagulopathy models and bleeding patients are warranted.
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Affiliation(s)
- Henry T Peng
- Defence Research and Development Canada, Toronto Research Centre, Toronto, Ontario, Canada
| | - Shawn G Rhind
- Defence Research and Development Canada, Toronto Research Centre, Toronto, Ontario, Canada
| | - Dana Devine
- Canadian Blood Services, Ottawa, Ontario, Canada
| | | | - Andrew Beckett
- St. Michael's Hospital, Toronto, Ontario, Canada.,Royal Canadian Medical Services, Ottawa, Ontario, Canada
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13
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Cartotto R, Callum J. A Review on the Use of Plasma During Acute Burn Resuscitation. J Burn Care Res 2021; 41:433-440. [PMID: 31734693 DOI: 10.1093/jbcr/irz184] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
The problem of fluid creep has generated renewed interest in the use of colloids during acute burn resuscitation. Currently, human albumin solution is usually chosen as the resuscitation colloid. However, human plasma was a fundamental component of numerous burn resuscitation formulas historically, but it largely fell out of favor due to concerns surrounding transmission of infectious viruses. Nevertheless, plasma is an effective volume expander which has been demonstrated to reduce overall volume requirements during burn resuscitation. Furthermore, plasma may have beneficial effects on the endothelium by diminishing the microvascular leak that follows a major burn injury. Fresh frozen plasma (FFP) is now much safer from a disease transmission standpoint, and newer forms of solvent-detergent-treated plasma and lyophilized plasma offer potentially even greater safety and efficacy. The use of FFP and newer forms of plasma, which have not been extensively studied, should be investigated as potential adjuncts to acute burn resuscitation.
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Affiliation(s)
| | - Jeannie Callum
- Department of Laboratory Medicine and Molecular Diagnostics, Sunnybrook Health Sciences Centre, University of Toronto, Canada
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14
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Guénot P, Coudreuse M, Lely L, Granger-Veyron N. Helicopter Rescue Missions for Emergency Medical Aid at Sea: A New Assignment for the French Military Medical Service? Air Med J 2021; 40:225-231. [PMID: 34172229 DOI: 10.1016/j.amj.2021.03.016] [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: 01/17/2021] [Revised: 03/10/2021] [Accepted: 03/30/2021] [Indexed: 06/13/2023]
Abstract
Historically in charge of the search and rescue of aircraft in distress alongside military aeronautical crews, the doctors and nurses of the French Military Medical Service (FMMS) also participate in helicopter rescue missions for emergency medical aid at sea off the French metropolitan coast. This public service mission is placed at the heart of force medicine because it can be transposed to external theaters of operations (OPEX). Recent changes in the regulation of medical aid at sea, in particular the creation in 2013 of maritime emergency mobile resuscitation services, initially weakened the role of the teams of the FMMS. However, their 2018 and 2019 activity report reflects the persistence of strong involvement. The "FMMS 2020" model, especially through its "openness" aspect, allows the FMMS the optimal conditions to maintain its position as a key player in this field, particularly through the development of institutional partnerships with the public health service. Associated with their mastery of the air-maritime environment, strengthening the skills in emergency medicine of the military medical teams in charge of this mission appears to be 1 of the main measures ensuring the achievement of this objective and a high quality of care for patients.
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Affiliation(s)
- Pierre Guénot
- French Military Medical Service, Air Force Medical Center, Reunion Island, France.
| | - Matthieu Coudreuse
- Basque Coast Hospital, Maritime Medical Emergency Co-ordination Service, Bayonne, France
| | - Laurent Lely
- French Military Medical Service, 7th Special forces Medical Service, Lanester, France
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15
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Edwards TH, Pusateri AE, Mays EL, Bynum JA, Cap AP. Lessons Learned From the Battlefield and Applicability to Veterinary Medicine - Part 2: Transfusion Advances. Front Vet Sci 2021; 8:571370. [PMID: 34026881 PMCID: PMC8138582 DOI: 10.3389/fvets.2021.571370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 03/29/2021] [Indexed: 11/13/2022] Open
Abstract
Since the inception of recent conflicts in Afghanistan and Iraq, transfusion practices in human military medicine have advanced considerably. Today, US military physicians recognize the need to replace the functionality of lost blood in traumatic hemorrhagic shock and whole blood is now the trauma resuscitation product of choice on the battlefield. Building on wartime experiences, military medicine is now one of the country's strongest advocates for the principle of hemostatic resuscitation using whole blood or balanced blood components as the primary means of resuscitation as early as possibly following severe trauma. Based on strong evidence to support this practice in human combat casualties and in civilian trauma care, military veterinarians strive to practice similar hemostatic resuscitation for injured Military Working Dogs. To this end, canine whole blood has become increasingly available in forward environments, and non-traditional storage options for canine blood and blood components are being explored for use in canine trauma. Blood products with improved shelf-life and ease of use are not only useful for military applications, but may also enable civilian general and specialty practices to more easily incorporate hemostatic resuscitation approaches to canine trauma care.
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Affiliation(s)
- Thomas H Edwards
- U.S. Army Institute of Surgical Research, Joint Base San Antonio, San Antonio, TX, United States
| | - Anthony E Pusateri
- U.S. Army Institute of Surgical Research, Joint Base San Antonio, San Antonio, TX, United States
| | - Erin Long Mays
- Veterinary Specialty Services, Manchester, MO, United States
| | - James A Bynum
- U.S. Army Institute of Surgical Research, Joint Base San Antonio, San Antonio, TX, United States
| | - Andrew P Cap
- U.S. Army Institute of Surgical Research, Joint Base San Antonio, San Antonio, TX, United States
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16
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Flaumenhaft EJ, Khat T, Marschner S. Retention of Coagulation Factors and Storage of Freeze-Dried Plasma. Mil Med 2021; 186:400-407. [PMID: 33499449 DOI: 10.1093/milmed/usaa347] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 08/19/2020] [Accepted: 12/15/2020] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Terumo BCT is developing a system to produce a freeze-dried plasma product, Terumo's freeze-dried plasma (TFDP), that is stored in a rugged, light-weight plastic package suitable for field use, which retains a stable level of specific coagulation factors and proteins within clinical range, when stored for up to 2 years at room temperature and 4°C. MATERIALS AND METHODS Plasma frozen within 24 hours of phlebotomy (PF24) were thawed, sampled, and individually lyophilized to produce a corresponding TFDP unit. Fresh frozen plasma (FFP) units were thawed, sampled, pooled in groups of 10 units (also sampled) and lyophilized to produce 2 lots of TFDP. Each TFDP unit was reconstituted with water for injection (WFI) and tested for pH, prothrombin time, activated partial thromboplastin time, factors V and VIII, fibrinogen, protein C, and protein S. Results were compared with PF24/FFP. Additional FFP units were thawed, sampled, pooled, divided to generate 2 TFDP units for each time point (1, 2, 3, 6, 12, 18, and 24 months, one each stored at 4°C and 25°C) and lyophilized. Postlyophilization, TFDP units were stored at 4°C or 25°C, reconstituted with WFI, and tested for the factors listed above. Residual moisture content of the lyophilized plasma was also tested. RESULTS Coagulation factor activity of TFDP was ±20% of PF24/FFP. Pooling standardized variation in TFDP coagulation factor activities, which were within clinical ranges postlyophilization. The pH of TFDP and PF24/FFP were within required range. Residual moisture content of TFDP was <2%. CONCLUSIONS The TFDP process had no negative impact on coagulation factor activity. Input plasma and anticoagulant type did not affect TFDP quality. Pooling FFP normalized factor variability in TFDP and did not negatively impact product quality. The TFDP is stable for up to 24 months at room and refrigerated temperatures. Terumo's freeze-dried plasma is comparable to PF24/FFP. It does not require complex logistics or time-consuming thawing. Terumo's freeze-dried plasma may be suitable for rapid treatment of coagulopathies with logistical advantages over PF24/FFP.
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Affiliation(s)
| | - Terry Khat
- Innovation and Development, Terumo BCT, Lakewood, CO 80215, USA
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17
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Abstract
Fluids are a vital tool in the armament of acute care clinicians in both civilian and military resuscitation. We now better understand complications from inappropriate resuscitation with currently available fluids; however, fluid resuscitation undeniably remains a life-saving intervention. Military research has driven the most significant advances in the field of fluid resuscitation and is currently leading the search for the fluids of the future. The veterinary community, much like our civilian human counterparts, should expect the fluid of the future to be the fruit of military research. The fluids of the future not only are expected to improve patient outcomes but also be field expedient. Those fluids should be compatible with military environments or natural disaster environments. For decades, military personnel and disaster responders have faced the peculiar demands of austere environments, prolonged field care, and delayed evacuation. Large scale natural disasters present field limitations often similar to those encountered in the battlefield. The fluids of the future should, therefore, have a long shelf-life, a small footprint, and be resistant to large temperature swings, for instance. Traumatic brain injury and hemorrhagic shock are the leading causes of preventable death for military casualties and a significant burden in civilian populations. The military and civilian health systems are focusing efforts on field-expedient fluids that will be specifically relevant for the management of those conditions. Fluids are expected to be compatible with blood products, increase oxygen-carrying capabilities, promote hemostasis, and be easy to administer in the prehospital setting, to match the broad spectrum of current acute care challenges, such as sepsis and severe systemic inflammation. This article will review historical military and civilian contributions to current resuscitation strategies, describe the expectations for the fluids of the future, and describe select ongoing research efforts with a review of current animal data.
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Affiliation(s)
- Thomas H. Edwards
- US Army Institute of Surgical Research, San Antonio, TX, United States
| | - Guillaume L. Hoareau
- Emergency Medicine, School of Medicine, University of Utah, Salt Lake City, UT, United States
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18
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Bercovitz RS, Drew CS, Bushee CL, Popovsky MA, Friedman KD, Anani WQ. A microfluidic analysis of thrombus formation in reconstituted whole blood samples comparing spray-dried plasma versus fresh frozen plasma. Vox Sang 2020; 116:540-546. [PMID: 33277925 DOI: 10.1111/vox.13027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 10/20/2020] [Accepted: 10/21/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND Prompt resuscitation with plasma and other blood products reduces trauma-related morbidity and mortality. Standard storage and preparation techniques for frozen plasma limit its utility in the pre-hospital setting. Plasma can be dehydrated using hot air (spray-dried plasma), stored at room temperature and rehydrated quickly for use. The spray-dry process decreases high-molecular-weight multimers of von Willebrand factor compared with conventional plasma. The objective of this study was to compare platelet adhesion and thrombus formation in a microfluidic perfusion assay facilitated by spray-dried compared with frozen plasma using a non-inferiority design. STUDY DESIGN AND METHODS Whole blood was centrifuged to obtain red cell concentrate, and a platelet pellet that was suspended in either spray-dried or frozen plasma to create recombined whole blood. Platelets were fluorescently labelled, and samples were flowed through a collagen-coated microchannel. Surface area coverage by platelets and thrombi was analysed and compared between each spray-dried and frozen plasma pair. RESULTS Compared with whole blood samples containing frozen plasma, samples with spray-dried plasma had similar surface area coverage of platelets and thrombi after 180 s of flow. Even when diluted with von Willebrand factor-free plasma, there was no reduction thrombus formation. CONCLUSION Spray-dried plasma is not inferior in supporting haemostasis compared with fresh frozen plasma in a paired analysis. It offers advantages with respect to portability and ease of preparation over frozen plasma in the pre-hospital setting. This study supports development of clinical studies to evaluate the efficacy and safety of spray-dried plasma in trauma patients.
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Affiliation(s)
- Rachel S Bercovitz
- Blood Center of Wisconsin, Medical Sciences Institute, Medical College of Wisconsin, Milwaukee, WI, USA.,Department of Pathology, Medical College of Wisconsin, Milwaukee, WI, USA.,Department of Pediatrics, Children's Hospital of Wisconsin, Milwaukee, WI, USA.,Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Caleb S Drew
- Blood Center of Wisconsin, Medical Sciences Institute, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Chana L Bushee
- Blood Center of Wisconsin, Medical Sciences Institute, Medical College of Wisconsin, Milwaukee, WI, USA
| | | | - Kenneth D Friedman
- Blood Center of Wisconsin, Medical Sciences Institute, Medical College of Wisconsin, Milwaukee, WI, USA.,Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Waseem Q Anani
- Blood Center of Wisconsin, Medical Sciences Institute, Medical College of Wisconsin, Milwaukee, WI, USA.,Department of Pathology, Medical College of Wisconsin, Milwaukee, WI, USA
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19
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Edwards TH, Meledeo MA, Peltier GC, Ruiz DD, Henderson AF, Travieso S, Pusateri AE. Effects of refrigerated storage on hemostatic stability of four canine plasma products. Am J Vet Res 2020; 81:964-972. [PMID: 33251844 DOI: 10.2460/ajvr.81.12.964] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To assess clotting times, coagulation factor activities, sterility, and thromboelastographic parameters of liquid plasma (LP), thawed fresh frozen plasma (FFP-T), and 2 novel formulations of freeze-dried plasma (FDP) stored refrigerated over 35 days. SAMPLE 6 units of canine LP and FFP-T from a commercial animal blood bank and 5 units each of 2 formulations of canine FDP. PROCEDURES Prothrombin time; activated partial thromboplastin time; activities of coagulation factors II, V, VII, VIII, IX, X, XI, and XII; and thromboelastographic parameters were determined for each product on days 0 (baseline), 3, 7, 14, 21, 28, and 35. For each day, a sample of each product was also submitted for aerobic bacterial culture. RESULTS Small changes in coagulation factor activities and mild increased time to initial clot formation in LP and FFP-T were noted over the 35-day storage period. Activities of factor VIII in FDP1 and factor XII in FDP2 were < 50% at baseline but varied throughout. Compared with FFP-T, time to initial clot formation was increased and clot strength was preserved or increased for the FDPs throughout the study. One FDP had decreased pH, compared with other products. No plasma product yielded bacterial growth. CONCLUSIONS AND CLINICAL RELEVANCE Liquid plasma and FFP-T would be reasonable to use when stored refrigerated for up to 35 days. Both FDP products showed variability in coagulation factor activities. Studies investigating the usefulness of these plasma products (FDPs) in dogs and the variable days of refrigerated storage (all products) are warranted. (Am J Vet Res 2020;81:964-972).
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20
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Scallan NJ, Keene DD, Breeze J, Hodgetts TJ, Mahoney PF. Extending existing recommended military casualty evacuation timelines will likely increase morbidity and mortality: a UK consensus statement. BMJ Mil Health 2020; 166:287-293. [PMID: 32665423 DOI: 10.1136/bmjmilitary-2020-001517] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 05/12/2020] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Future conflicts may have limited use of aviation-based prehospital emergency care for evacuation. This will increase the likelihood of extended evacuation timelines and an extended hold at a forward hospital care facility following the completion of damage control surgery or acute medical interventions. METHODS A three-round Delphi Study was undertaken using a panel comprising 44 experts from the UK armed forces including clinicians, logisticians, medical planners and commanders. The panel was asked to consider the effect of an extended hold at Deployed Hospital Care (Forward) from the current 2-hour timeline to +4, +8, +12 and +24 hours on a broad range of clinical and logistical issues. Where 75% of respondents had the same opinion, consensus was accepted. Areas where consensus could not be achieved were used to identify future research priorities. RESULTS Consensus was reached that increasing timelines would increase the personnel, logistics and equipment support required to provide clinical care. There is a tipping point with a prolonged hold over 8 hours, after which the greatest number of clinical concerns emerge. Additional specialties of surgeons other than general and orthopaedic surgeons will likely be required with holds over 24 hours, and robust telemedicine would not negate this requirement. CONCLUSIONS Retaining acute medical emergencies at 4 hours, and head injuries was considered a particular risk. This could potentially be mitigated by an increased forward capacity of some elements of medical care and availability of a CT scanner and intracranial pressure monitoring at over 12 hours. Any efforts to mitigate the effects of prolonged timelines will come at the expense of an increased logistical burden and a reduction in mobility. Ultimately the true effect of prolonged timelines can only be answered by close audit and analysis of clinical outcomes during future operations with an extended hold.
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Affiliation(s)
- Nicholas James Scallan
- Academic Department of Military Anaesthesia and Critical Care, Royal Centre for Defence Medicine, Birmingham, UK.,Currently Serving: 3 Medical Regiment, Army Medical Services, Preston, UK
| | - D D Keene
- Academic Department of Military Anaesthesia and Critical Care, Royal Centre for Defence Medicine, Birmingham, UK
| | - J Breeze
- Department of Maxillofacial Surgery, Royal Centre for Defence Medicine, Birmingham, UK
| | - T J Hodgetts
- Senior health Advisor & Head of Army Medical Services, Army Headquarters, Andover, UK
| | - P F Mahoney
- Academic Department of Military Anaesthesia and Critical Care, Royal Centre for Defence Medicine, Birmingham, UK
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21
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Abstract
Hemorrhage is the leading cause of preventable death in combat trauma and the secondary cause of death in civilian trauma. A significant number of deaths due to hemorrhage occur before and in the first hour after hospital arrival. A literature search was performed through PubMed, Scopus, and Institute of Scientific Information databases for English language articles using terms relating to hemostatic agents, prehospital, battlefield or combat dressings, and prehospital hemostatic resuscitation, followed by cross-reference searching. Abstracts were screened to determine relevance and whether appropriate further review of the original articles was warranted. Based on these findings, this paper provides a review of a variety of hemostatic agents ranging from clinically approved products for human use to newly developed concepts with great potential for use in prehospital settings. These hemostatic agents can be administered either systemically or locally to stop bleeding through different mechanisms of action. Comparisons of current hemostatic products and further directions for prehospital hemorrhage control are also discussed.
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Affiliation(s)
- Henry T Peng
- Defence Research and Development Canada, Toronto Research Centre, 1133 Sheppard Avenue West, Toronto, ON, M3K 2C9, Canada.
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22
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Jost D, Lemoine S, Lemoine F, Lanoe V, Maurin O, Derkenne C, Franchin Frattini M, Delacote M, Seguineau E, Godefroy A, Hervault N, Delhaye L, Pouliquen N, Louis-Delauriere E, Trichereau J, Roquet F, Salomé M, Verret C, Bihannic R, Jouffroy R, Frattini B, Hong Tuan Ha V, Dang-Minh P, Travers S, Bignand M, Martinaud C, Garrabe E, Ausset S, Prunet B, Sailliol A, Tourtier JP. French lyophilized plasma versus normal saline for post-traumatic coagulopathy prevention and correction: PREHO-PLYO protocol for a multicenter randomized controlled clinical trial. Trials 2020; 21:106. [PMID: 31969168 PMCID: PMC6977230 DOI: 10.1186/s13063-020-4049-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Accepted: 01/06/2020] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Post-trauma bleeding induces an acute deficiency in clotting factors, which promotes bleeding and hemorrhagic shock. However, early plasma administration may reduce the severity of trauma-induced coagulopathy (TIC). Unlike fresh frozen plasma, which requires specific hospital logistics, French lyophilized plasma (FLYP) is storable at room temperature and compatible with all blood types, supporting its use in prehospital emergency care. We aim to test the hypothesis that by attenuating TIC, FLYP administered by prehospital emergency physicians would benefit the severely injured civilian patient at risk for hemorrhagic shock. METHODS/DESIGN This multicenter randomized clinical trial will include adults severely injured and at risk for hemorrhagic shock, with a systolic blood pressure < 70 mmHg or a Shock Index > 1.1. Two parallel groups of 70 patients will receive either FLYP or normal saline in addition to usual treatment. The primary endpoint is the International Normalized Ratio (INR) at hospital admission. Secondary endpoints are transfusion requirement, length of stay in the intensive care unit, survival rate at day 30, usability and safety related to FLYP use, and other biological coagulation parameters. CONCLUSION With this trial, we aim to confirm the efficacy of FLYP in TIC and its safety in civilian prehospital care. The study results will contribute to optimizing guidelines for treating hemorrhagic shock in civilian settings. TRIAL REGISTRATION ClinicalTrials.gov, NCT02736812. Registered on 13 April 2016. The trial protocol has been approved by the French ethics committee (CPP 3342) and the French Agency for the Safety of Medicines and Health Products (IDRCB 2015-A00866-43).
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Affiliation(s)
- Daniel Jost
- Paris Fire Brigade Medical Emergency Department, 1 place Jules Renard, 75017, Paris, France.
| | - Sabine Lemoine
- Paris Fire Brigade Medical Emergency Department, 1 place Jules Renard, 75017, Paris, France
| | - Frederic Lemoine
- Paris Fire Brigade Medical Emergency Department, 1 place Jules Renard, 75017, Paris, France
| | - Vincent Lanoe
- Paris Fire Brigade Medical Emergency Department, 1 place Jules Renard, 75017, Paris, France
| | - Olga Maurin
- Paris Fire Brigade Medical Emergency Department, 1 place Jules Renard, 75017, Paris, France
| | - Clément Derkenne
- Paris Fire Brigade Medical Emergency Department, 1 place Jules Renard, 75017, Paris, France
| | | | - Maëlle Delacote
- Paris Fire Brigade Medical Emergency Department, 1 place Jules Renard, 75017, Paris, France
| | - Edouard Seguineau
- Paris Fire Brigade Medical Emergency Department, 1 place Jules Renard, 75017, Paris, France
| | - Anne Godefroy
- Paris Fire Brigade Medical Emergency Department, 1 place Jules Renard, 75017, Paris, France
| | - Nicolas Hervault
- Paris Fire Brigade Medical Emergency Department, 1 place Jules Renard, 75017, Paris, France
| | - Ludovic Delhaye
- Paris Fire Brigade Medical Emergency Department, 1 place Jules Renard, 75017, Paris, France
| | - Nicolas Pouliquen
- Paris Fire Brigade Medical Emergency Department, 1 place Jules Renard, 75017, Paris, France
| | - Emilie Louis-Delauriere
- Department of Education, Research and Innovation, Service de Santé des Armées, 1 Place Alphonse Laveran, 75230, Paris, France
| | - Julie Trichereau
- Paris Fire Brigade Medical Emergency Department, 1 place Jules Renard, 75017, Paris, France
| | - Florian Roquet
- Paris Fire Brigade Medical Emergency Department, 1 place Jules Renard, 75017, Paris, France
| | - Marina Salomé
- Paris Fire Brigade Medical Emergency Department, 1 place Jules Renard, 75017, Paris, France
| | - Catherine Verret
- Department of Education, Research and Innovation, Service de Santé des Armées, 1 Place Alphonse Laveran, 75230, Paris, France
| | - René Bihannic
- Paris Fire Brigade Medical Emergency Department, 1 place Jules Renard, 75017, Paris, France
| | - Romain Jouffroy
- Paris Fire Brigade Medical Emergency Department, 1 place Jules Renard, 75017, Paris, France
| | - Benoit Frattini
- Paris Fire Brigade Medical Emergency Department, 1 place Jules Renard, 75017, Paris, France
| | - Vivien Hong Tuan Ha
- Paris Fire Brigade Medical Emergency Department, 1 place Jules Renard, 75017, Paris, France
| | - Pascal Dang-Minh
- Paris Fire Brigade Medical Emergency Department, 1 place Jules Renard, 75017, Paris, France
| | - Stéphane Travers
- Paris Fire Brigade Medical Emergency Department, 1 place Jules Renard, 75017, Paris, France
- French Military Health Service, Val de Grâce military hospital, 1, Place Alphonse Laveran, 75230, Paris, France
| | - Michel Bignand
- Paris Fire Brigade Medical Emergency Department, 1 place Jules Renard, 75017, Paris, France
| | - Christophe Martinaud
- French Military Health Service, Val de Grâce military hospital, 1, Place Alphonse Laveran, 75230, Paris, France
- French army blood transfusion center, 1 Rue du Lieutenant Raoul Batany, 92140, Clamart, France
| | - Eliane Garrabe
- French Military Health Service, Val de Grâce military hospital, 1, Place Alphonse Laveran, 75230, Paris, France
- French army blood transfusion center, 1 Rue du Lieutenant Raoul Batany, 92140, Clamart, France
| | - Sylvain Ausset
- French Military Health Service, Val de Grâce military hospital, 1, Place Alphonse Laveran, 75230, Paris, France
- Department of Anesthesiology and Intensive Care, Percy military teaching hospital, 101 avenue Henri Barbusse, BP 406, 92141, Clamart, Cedex, France
| | - Bertrand Prunet
- Paris Fire Brigade Medical Emergency Department, 1 place Jules Renard, 75017, Paris, France
- French Military Health Service, Val de Grâce military hospital, 1, Place Alphonse Laveran, 75230, Paris, France
| | - Anne Sailliol
- French Military Health Service, Val de Grâce military hospital, 1, Place Alphonse Laveran, 75230, Paris, France
- French army blood transfusion center, 1 Rue du Lieutenant Raoul Batany, 92140, Clamart, France
- French Military Research Institute, 1 place Valérie Andre, BP 73, 91223, Brétigny sur Orge, France
| | - Jean Pierre Tourtier
- Paris Fire Brigade Medical Emergency Department, 1 place Jules Renard, 75017, Paris, France
- French Military Health Service, Val de Grâce military hospital, 1, Place Alphonse Laveran, 75230, Paris, France
- Department of Anaesthesiology and Intensive Care, Begin military teaching hospital, 94160, Saint-Mande, France
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23
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Guénot P, Beauchamps V, Madec S, Carfantan C, Boutonnet M, Bareau L, Romain H, Travers S. Fixed Wing Tactical Aircraft for Air Medical Evacuation in Sahel. Air Med J 2019; 38:350-355. [PMID: 31578973 DOI: 10.1016/j.amj.2019.05.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Revised: 04/06/2019] [Accepted: 05/10/2019] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The medical support of military operations over a 5 million km2 area in the Sahel-Saharan strip has justified the use of a medical fixed wing aircraft. Two CASA CN 235 aircraft currently perform medical evacuation (medevac) from the point of injury to forward surgical structures and then to the international airport before strategic medevac to France. METHODS A retrospective observational study including all flights performed from January 2013 to December 2017 by the medical CASA located in Mali. RESULTS Three thousand three flight hours were achieved. Four hundred twenty-four medevacs were performed for 898 patients. Seventy-five percent were evacuated from forward surgical structures. Their initial categorization included 10% Alpha, 23% Bravo, and 67% Charlie. Mechanical ventilation was performed for 5%; 34.5% had common medical or surgical pathologies, 34.2% were combat casualties mostly by explosion, and 18.7% were nonbattle injuries. No difficulties related to the aeronautical environment were reported by the teams. CONCLUSION Tactical medevac with fixed wing aircraft has become a crucial link in the French medical evacuation chain in remote areas. Military emergency medical teams were able to provide in-flight intensive care before and after damage control surgery. Discussions are underway to consider possible doctrinal and logistical evolutions.
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Affiliation(s)
- Pierre Guénot
- French Military Medical Service, 186th Medical Service, Cazaux Air Base, France.
| | - Vincent Beauchamps
- French Military Medical Service, 3rd Special Medical Service, Pau Special Forces Helicopter Squadron, France
| | - Samuel Madec
- French Military Medical Service, 2nd Medical Center, Versailles, France
| | - Cyril Carfantan
- French Military Medical Service, Operational Headquarters, Paris, France
| | - Mathieu Boutonnet
- French Military Medical Service, Department of Anesthesiology and Intensive Care, Percy Military Teaching Hospital, Clamart, France
| | - Laura Bareau
- French Military Medical Service, 186th Medical Service, Cazaux Air Base, France
| | - Hélène Romain
- French Military Medical Service, 105th Medical Service, Mérignac Air Base, France
| | - Stéphane Travers
- French Military Medical Service, 12th Medical Service, Villacoublay Air Base, France
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24
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Clough RAJ, Khan M. Initial CABC: Advances that have led to increased survival in military casualties. TRAUMA-ENGLAND 2019. [DOI: 10.1177/1460408619838438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Reece AJ Clough
- Barts and The London School of Medicine and Dentistry, London, UK
| | - Mansoor Khan
- Department of Surgery and Cancer, St Mary’s Hospital, London, UK
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25
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Pusateri AE, Butler FK, Shackelford SA, Sperry JL, Moore EE, Cap AP, Taylor AL, Homer MJ, Hoots WK, Weiskopf RB, Davis MR. The need for dried plasma - a national issue. Transfusion 2019; 59:1587-1592. [PMID: 30980738 DOI: 10.1111/trf.15261] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Accepted: 11/06/2018] [Indexed: 01/10/2023]
Abstract
Recent studies have demonstrated that early transfusion of plasma or RBCs improves survival in patients with severe trauma and hemorrhagic shock. Time to initiate transfusion is the critical factor. It is essential that transfusion begin in the prehospital environment when transport times are longer than approximately 15 to 20 minutes. Unfortunately, logistic constraints severely limit the use of blood products in the prehospital setting, especially in military, remote civilian, and mass disaster circumstances, where the need can be most acute. US military requirements for logistically supportable blood products are projected to increase dramatically in future conflicts. Although dried plasma products have been available and safely used in a number of countries for over 20 years, there is no dried plasma product commercially available in the United States. A US Food and Drug Administration-approved dried plasma is urgently needed. Considering the US military, disaster preparedness, and remote civilian trauma perspectives, this is an urgent national health care issue.
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Affiliation(s)
- Anthony E Pusateri
- US Army Institute of Surgical Research, JBSA Fort Sam Houston, San Antonio, Texas
| | - Frank K Butler
- Committee on Tactical Combat Casualty Care, Joint Trauma System, Defense Center of Excellence for Trauma, JBSA, Fort Sam Houston
| | - Stacy A Shackelford
- Joint Trauma System, Defense Center of Excellence for Trauma, JBSA Fort Sam Houston, San Antonio, Texas
| | - Jason L Sperry
- Department of Surgery and Critical Care, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Ernest E Moore
- Department of Surgery, Denver Health Medical Center, Denver, Colorado
| | - Andrew P Cap
- US Army Institute of Surgical Research, JBSA Fort Sam Houston, San Antonio, Texas
| | | | - Mary J Homer
- US Department of Health and Human Services (BARDA), Washington, DC
| | - W Keith Hoots
- National Institutes of Health (NHLBI), Bethesda, Maryland
| | | | - Michael R Davis
- US Army Medical Research and Materiel Command, Fort Detrick, Maryland
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Travers S, Carfantan C, Luft A, Aigle L, Pasquier P, Martinaud C, Renard A, Dubourg O, Derkenne C, Kedzierewicz R, Franchin M, Bay C, Cap AP, Ausset S. Five years of prolonged field care: prehospital challenges during recent French military operations. Transfusion 2019; 59:1459-1466. [PMID: 30980759 DOI: 10.1111/trf.15262] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Revised: 01/18/2019] [Accepted: 01/18/2019] [Indexed: 12/21/2022]
Abstract
BACKGROUND French military operations in the Sahel conducted since 2013 over more than 5 million square kilometers have challenged the French Military Health Service with specific problems in prolonged field care. STUDY DESIGN AND METHODS To describe these challenges, we retrospectively analyzed the prehospital data from the first 5 years of these operations within a delimited area. RESULTS One hundred eighty-three servicemen of different nationalities were evacuated, mainly as a result of explosions (73.2%) or gunshots (21.9%). Their mean number evacuation was 2.2 (minimum, 1; maximum, 8) per medical evacuation with a direct evacuation from the field to a Role 2 medical treatment facility (MTF) for 62% of them. For the highest-priority casualties (N = 46), the median time [interquartile range] from injury to a Role 2 MTF was 130 minutes [70 minutes to 252 minutes], exceeding 120 minutes in 57% of cases and 240 minutes in 26%. The most frequent out-of-hospital medical interventions were external hemostasis, airway and hemopneumothorax management, hypotensive resuscitation, analgesia, immobilization, and antibiotic administration. Prehospital transfusion (RBCs and/or lyophilized plasma) was started three times in the field, two times during helicopter medical evacuation, and five times in tactical fixed wing medical aircraft. Lyophilized plasma was confirmed to be particularly suitable in these settings. One of the specific issues involved in lengthy prehospital time was the importance to reassess and convert tourniquets prior to Role 2 MTF admission. CONCLUSION Main challenges identified include reducing evacuation times as much as possible, preserving ground deployment of sufficiently trained medics and medical teams, optimization of transfusion strategies, and strengthening specific prolonged field care equipment and training.
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Affiliation(s)
- Stéphane Travers
- 2ème Centre Médical des Armées, 12ème Antenne Médicale, French Military Health Service, Villacoublay, France.,French Military Health Service, Val de Grâce Military Academy, Paris, Paris, France
| | - Cyril Carfantan
- French Military Health Service - Operational Headquarters, Paris, France
| | - Antoine Luft
- French Military Health Service - Operational Headquarters, Paris, France
| | - Luc Aigle
- French Military Health Service, Val de Grâce Military Academy, Paris, Paris, France.,10ème Centre Médical des Armées, 154ème Antenne Médicale, French Military Health Service, Aubagne, France
| | - Pierre Pasquier
- French Military Health Service, Val de Grâce Military Academy, Paris, Paris, France.,French Military Health Service, Percy Military Hospital, Clamart, France
| | - Christophe Martinaud
- French Military Health Service, Val de Grâce Military Academy, Paris, Paris, France.,Centre de Transfusion Sanguine des Armées, French Military Health Service, Clamart, France
| | - Aurelien Renard
- Emergency Department, Saint Anne Military Hospital, French Military Health Service, Toulon, France
| | - Olivier Dubourg
- CMIA Saint-Denis, Antenne Médicale de St Pierre, French Military Health Service, La Réunion, France
| | - Clement Derkenne
- Paris Fire Brigade Medical Emergency Department, French Military Health Service, Paris, France
| | - Romain Kedzierewicz
- Paris Fire Brigade Medical Emergency Department, French Military Health Service, Paris, France
| | - Marilyn Franchin
- 2ème Centre Médical des Armées, 12ème Antenne Médicale, French Military Health Service, Villacoublay, France
| | - Christian Bay
- French Military Health Service - Ground Forces Headquarters, Tours, France
| | - Andrew P Cap
- Medical Corps, US Army, US Army Institute of Surgical Research, Fort Sam Houston, Texas
| | - Sylvain Ausset
- French Military Health Service, Val de Grâce Military Academy, Paris, Paris, France
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Abstract
Contrary to economically comparable countries, France has had a versatile policy to process and manufacture therapeutic plasma, and to apply safety measures. This has principally affected the origin of plasma (whole blood supernatant versus apheresis), and the application or not of a chemical process. At the time being, the civilian and Army Forces blood establishments produce more than 99% of the plasma issued for patients in need; safety means consist in a large part of quarantine and, to a lesser extent, to a pathogen reduction technology process (Amotosalen-HCl-UVA). The blood establishments ship plasma to the national manufacturer of blood derivatives. Plasma in France is strictly within the Voluntary Non-Remunerated pathway with no breach to this principle to be expected for both labile components and source plasma. The constant hemovigilance allows reflection to make policies evolving, with respect to safety measures particularly to reduce cases of allergy.
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Affiliation(s)
- O Garraud
- EA3064, faculty of medicine of Saint-Etienne, University of Lyon, 42023, Saint-Etienne, France; Palliative Care, the Ruffec Hospital, 16700, Ruffec, France; The National Institute for Blood Transfusion INTS, 75015, Paris, France.
| | - C Martinaud
- CTSA, département des activités cliniques, 92140, Clamart, France; INSERM UMRS-MD 1197, CTSA, 92140, Clamart, France
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28
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Garraud O, Coppo P. Types of fresh plasma with focus on therapeutic plasma exchange. Transfus Apher Sci 2019; 58:258-261. [DOI: 10.1016/j.transci.2019.04.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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29
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Abstract
Dried plasma provides an alternative for early plasma transfusion in the resuscitation of hemorrhagic shock in environments where fresh frozen plasma is not immediately available. It is produced by freeze-drying or spray-drying liquid or thawed plasma. It is shelf-stable for prolonged periods, can be stored at room temperature, and is easy to transport, reconstitute, and administer. It was widely used in WWII but fell out of favor due to the risk of infectious disease transmission. The German and French experiences with lyophilized plasma are the most extensive and show a good track record of efficacy and safety. Recent studies show many beneficial effects of dried plasma in the treatment of shock in large animal models. Currently, no FDA-licensed product is available in the USA, but several are under development.
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Affiliation(s)
- Philip C. Spinella
- School of Medicine, Washington University in St. Louis, St. Louis, MO USA
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30
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Use of French lyophilized plasma transfusion in severe trauma patients is associated with an early plasma transfusion and early transfusion ratio improvement. J Trauma Acute Care Surg 2019; 84:780-785. [PMID: 29334571 DOI: 10.1097/ta.0000000000001801] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Early transfusion of high ratio of fresh frozen plasma (FFP) and red blood cells (RBC) is associated with mortality reduction. However, time to reach high ratio is limited by the need to thaw the FFP. French lyophilized plasma (FLYP) used by French army and available in military teaching hospital does not need to be thawed and is immediately available. We hypothesize that the use of FLYP may reduce time to reach a plasma/RBC ratio of 1:1. METHODS A retrospective study performed in a Level 1 trauma center between January 2012 and December 2015. Severe trauma patients who received 2 U of RBC in the emergency room were included and assigned to two groups according to first plasma transfused: FLYP group and FFP group. RESULTS Forty-three severe trauma patients in the FLYP group and 29 in the FFP group were included. The time until first plasma transfusion was shorter in the FLYP group than in the FFP group, respectively 15 min (10-25) versus 95 min (70-145) (p < 0.0001). Time until a 1:1 ratio was shorter in the FLYP group than in the FFP group. There were significantly fewer cases of massive transfusion in the FLYP group than in the FFP group with respectively 7% vs. 45% (p < 0.0001). CONCLUSION The use of FLYP provided significantly faster plasma transfusions than the use of FFP as well as a plasma and RBC ratio superior to 1:2 that was reached more rapidly in severe trauma patients. These results may explain the less frequent need for massive transfusion in the patients who received FLYP. These positive results should be confirmed by a prospective and randomized evaluation. LEVEL OF EVIDENCE Therapeutic, level IV.
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31
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Challenges to producing novel therapies - dried plasma for use in trauma and critical care. Transfusion 2019; 59:837-845. [DOI: 10.1111/trf.14985] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Accepted: 09/19/2018] [Indexed: 12/31/2022]
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32
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Efficacy of the perfluorocarbon dodecafluoropentane as an adjunct to pre-hospital resuscitation. PLoS One 2018; 13:e0207197. [PMID: 30496190 PMCID: PMC6264877 DOI: 10.1371/journal.pone.0207197] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Accepted: 10/27/2018] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Hemorrhage is the most common cause of preventable death in the pre-hospital phase in trauma, with a critical capability gap optimizing pre-hospital resuscitation in austere environments. One promising avenue is the concept of a multi-functional resuscitation fluid (MRF) that contains a blood product backbone with agents that promote clotting and enhance oxygen delivery. Oxygen therapeutics, such as hemoglobin based oxygen carriers(HBOCs) and perfluorocarbons(PFCs), may be a critical MRF component. Our purpose was to assess the efficacy of resuscitation with a PFC, dodecafluoropentane(DDFPe), compared to fresh whole blood(FWB). METHODS AND FINDINGS Forty-five swine(78±5kg) underwent splenectomy and controlled hemorrhage via femoral arterial catheter until shock physiology(lactate = 7.0) was achieved prior to randomization into the following groups: 1) Control-no intervention, 2)Hextend-500mL, 3)FFP-500mL, 4)FFP+DDFPe-500mL, 5)FWB-500mL. Animals were observed for an additional 180 minutes following randomization. RESULTS Baseline physiologic values did not statistically differ. At T = 60min, FWB had significantly decreased lactate(p = 0.001) and DDFPe was not statistically different from control. There was no statistical significance in tissue oxygenation(StO2) between groups at T = 60min. Survival was highest in the FWB and Hextend groups(30% at 180min). Kaplan-Meier analysis showed decreased survival of DDFPe+FFP in comparison to FWB(p<0.05) and was not significantly different from control or FFP. Four animals who received DDFPe died within 10 minutes of administration. This study was limited by a group receiving DDFPe alone, however this would not be feasible in this lethal swine model as DDFPe given its small volume. CONCLUSION DDFPe administration with FFP does not improve survival or enhance tissue oxygenation. However, given similar survival rates of Hextend and FWB, there is evidence that an ideal MRF should contain an element of volume expansion to enhance oxygen delivery.
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Liu QP, Carney R, Sohn J, Sundaram S, Fell M. Single‐donor spray‐dried plasma. Transfusion 2018; 59:707-713. [DOI: 10.1111/trf.15035] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Revised: 09/21/2018] [Accepted: 09/23/2018] [Indexed: 01/27/2023]
Affiliation(s)
| | | | - Jihae Sohn
- Velico Medical, Inc. Beverly Massachusetts
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Martin PV, Fogelman J, Dubecq C, Galant J, Travers S, Fritsch N. Intérêt de l’échographie dans la prise en charge du blessé de guerre dyspnéique. ANNALES FRANCAISES DE MEDECINE D URGENCE 2018. [DOI: 10.3166/afmu-2018-0077] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
La médecine militaire s’adapte aux dernières évolutions médicales, et l’échographie s’inscrit désormais dans les algorithmes de prise en charge des blessés de guerre. Grâce à la plus-value apportée à la clinique dans l’évaluation des blessés associée à l’amélioration des performances et à la miniaturisation des appareils, le positionnement de l’échographie en médecine de guerre a évolué pour trouver sa place « à l’avant », parfois dans des conditions sanitaires très dégradées. Après avoir rappelé les principes du secourisme au combat pour le blessé de guerre dyspnéique, cet article replace l’intérêt diagnostique et thérapeutique de l’échographie dans la « médecine de l’avant » en détaillant la sémiologie échographique des principales pathologies du blessé de guerre dans la phase de réanimation préhospitalière. L’article souligne aussi l’importance opérationnelle qu’occupe l’échographie, que ce soit sur le terrain lors des évacuations sanitaires ou lors d’afflux massif de victimes. Certains aspects de la doctrine militaire d’emploi pourraient s’adapter à la pratique en préhospitalier ou lors des situations d’exception en métropole.
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Abstract
PURPOSE OF REVIEW Traumatic injuries are a major cause of mortality worldwide. Damage control resuscitation or balanced transfusion of plasma, platelets, and red blood cells for the management of exsanguinating hemorrhage after trauma has become the standard of care. We review the literature regarding the use of alternatives to achieve the desired 1 : 1:1 ratio as availability of plasma and platelets can be problematic in some environments. RECENT FINDINGS Liquid and freeze dried plasma (FDP) are logistically easier to use and may be superior to fresh frozen plasma. Cold storage platelets (CSPs) have improved hemostatic properties and resistance to bacterial contamination. Low titer type O whole blood can be transfused safely in civilian patients. SUMMARY In the face of hemorrhagic shock from traumatic injury, resuscitation should be initiated with 1 : 1 : 1 transfusion of plasma, platelets, and red blood cells with limited to no use of crystalloids. Availability of plasma and platelets is limited in some environments. In these situations, the use of low titer type O whole blood, thawed or liquid plasma, cold stored platelets or reconstituted FDP can be used as substitutes to achieve optimal transfusion ratios. The hemostatic properties of CSPs may be superior to room temperature platelets.
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36
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Fernandez-Moure J, Maisha N, Lavik EB, Cannon JW. The Chemistry of Lyophilized Blood Products. Bioconjug Chem 2018; 29:2150-2160. [PMID: 29791137 DOI: 10.1021/acs.bioconjchem.8b00271] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
With the development of new biologics and bioconjugates, storage and preservation have become more critical than ever before. Lyophilization is a method of cell and protein preservation by removing a solvent such as water from a substance followed by freezing. This technique has been used in the past and still holds promise for overcoming logistic challenges in safety net hospitals with limited blood banking resources, austere environments such as combat, and mass casualty situations where existing resources may be outstripped. This method allows for long-term storage and transport but requires the bioconjugation of preservatives to prevent cell destabilization. Trehalose is utilized as a bioconjugate in platelet and red blood cell preservation to maintain protein thermodynamics and stabilizing protein formulations in liquid and freeze-dried states. Biomimetic approaches have been explored as alternatives to cryo- and lyopreservation of blood components. Intravascular hemostats such as PLGA nanoparticles functionalized with PEG motifs, topical hemostats utilizing fibrinogen or chitosan, and liposomal encapsulated hemoglobin with surface modifications are effectively stored long-term through bioconjugation. In thinking about the best methods for storage and transport, we are focusing this topical review on blood products that have the longest track record of preservation and looking at how these methods can be applied to synthetic systems.
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Affiliation(s)
- Joseph Fernandez-Moure
- Division of Trauma, Surgical Critical Care & Emergency Surgery , Perelman School of Medicine at the University of Pennsylvania , Philadelphia , Pennsylvania 19104 , United States
| | - Nuzhat Maisha
- Department of Chemical, Biochemical & Environmental Engineering , University of Maryland, Baltimore County , Baltimore , Maryland 21250 , United States
| | - Erin B Lavik
- Department of Chemical, Biochemical & Environmental Engineering , University of Maryland, Baltimore County , Baltimore , Maryland 21250 , United States
| | - Jeremy W Cannon
- Division of Trauma, Surgical Critical Care & Emergency Surgery , Perelman School of Medicine at the University of Pennsylvania , Philadelphia , Pennsylvania 19104 , United States.,Department of Surgery , Uniformed Services University of the Health Sciences , Bethesda , Maryland 20814 , United States
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37
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Care of the Injured Patients at Nursing Stations and during Air Medical Transport. Air Med J 2018; 37:161-164. [PMID: 29735227 DOI: 10.1016/j.amj.2017.11.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2017] [Revised: 10/16/2017] [Accepted: 11/29/2017] [Indexed: 11/21/2022]
Abstract
INTRODUCTION Nursing stations are the only access point into the health care system for some communities and have limited capabilities and resources. We describe characteristics of patients injured in Northern Ontario who present to nursing stations and require transport by air ambulance. Secondary objectives are to compare interventions performed at nursing stations with those performed by flight paramedics and to identify systemic gaps in trauma care. METHODS A retrospective cohort study was performed of all injured patients transported by air ambulance from April 1, 2014, to March 31, 2015. RESULTS A total of 125 injured patients were transported from nursing stations. Blunt trauma accounted for 82.5% of injuries, and alcohol intoxication was suspected in 41.6% of patients. The most frequently performed interventions were intravenous fluids and analgesia. Paramedics administered oxygen 62.4% of the time, whereas nursing stations only applied in 8.8% of cases. Flight paramedics were the only providers to intubate and administer tranexamic acid, mannitol, or vasopressors. CONCLUSION Care for patients at nursing stations may be improved by updating the drug formulary based on gap analyses. Further research should examine the role of telemedicine support for nursing station staff and the use of point-of-care devices to screen for traumatic intracranial hemorrhage.
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Garrigue D, Godier A, Glacet A, Labreuche J, Kipnis E, Paris C, Duhamel A, Resch E, Bauters A, Machuron F, Renom P, Goldstein P, Tavernier B, Sailliol A, Susen S. French lyophilized plasma versus fresh frozen plasma for the initial management of trauma-induced coagulopathy: a randomized open-label trial. J Thromb Haemost 2018; 16:481-489. [PMID: 29274254 DOI: 10.1111/jth.13929] [Citation(s) in RCA: 55] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2017] [Indexed: 01/08/2023]
Abstract
Essentials An immediate supply of plasma in case of trauma-induced coagulopathy is required. The Traucc trial compared French Lyophilised Plasma (FLyP) and Fresh Frozen Plasma (FFP). FLyP achieved higher fibrinogen concentrations compared with FFP. FLyP led to a more rapid coagulopathy improvement than FFP. SUMMARY Background Guidelines recommend beginning hemostatic resuscitation immediately in trauma patients. We aimed to investigate if French lyophilized plasma (FLyP) was more effective than fresh frozen plasma (FFP) for the initial management of trauma-induced coagulopathy. Methods In an open-label, phase 3, randomized trial (NCT02750150), we enrolled adult trauma patients requiring an emergency pack of 4 plasma units within 6 h of injury. We randomly assigned patients to receive 4-FLyP units or 4-FFP units. The primary endpoint was fibrinogen concentration at 45 min after randomization. Secondary outcomes included time to transfusion, changes in hemostatic parameters at different time-points, blood product requirements and 30-day in-hospital mortality. Results Forty-eight patients were randomized (FLyP, n = 24; FFP, n = 24). FLyP reduced the time from randomization to transfusion of first plasma unit compared with FFP (median[IQR],14[5-30] vs. 77[64-90] min). FLyP achieved a higher fibrinogen concentration 45 min after randomization compared with FFP (baseline-adjusted mean difference, 0.29 g L-1 ; 95% confidence interval [CI], 0.08-0.49) and a greater improvement in prothrombin time ratio, factor V and factor II. The between-group differences in coagulation parameters remained significant at 6 h. FLyP reduced fibrinogen concentrate requirements. Thirty-day in-hospital mortality rate was 22% with FLyP and 29% with FFP. Conclusion FLyP led to a more rapid, pronounced and extended increase in fibrinogen concentrations and coagulopathy improvement compared with FFP in the initial management of trauma patients. FLyP represents an attractive option for trauma management, especially when facing logistical issues such as combat casualties or mass casualties related to terror attacks or disasters.
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Affiliation(s)
- D Garrigue
- CHU de Lille, Pôle d'Anesthésie-Réanimation, Lille, France
- CHU Lille, Pôle de l'Urgence, Lille, France
| | - A Godier
- Service d'Anesthésie-Réanimation, Fondation Ophtalmologique Adolphe de Rothschild, Paris, France
- NSERM, UMR-S1140, Université Paris Descartes, Sorbonne Paris Cité, Paris, France
| | - A Glacet
- CHU de Lille, Pôle d'Anesthésie-Réanimation, Lille, France
- CHU Lille, Pôle de l'Urgence, Lille, France
| | - J Labreuche
- Université Lille, CHU Lille, EA 2694 - Santé Publique: Épidémiologie et Qualité des Soins, Lille, France
| | - E Kipnis
- CHU de Lille, Pôle d'Anesthésie-Réanimation, Lille, France
- Université Lille, EA 7366, Lille, France
| | - C Paris
- CHU de Lille, Institut d'Hématologie-Transfusion, Lille, France
| | - A Duhamel
- Université Lille, CHU Lille, EA 2694 - Santé Publique: Épidémiologie et Qualité des Soins, Lille, France
| | - E Resch
- EFS Hauts de France, Lille, France
| | - A Bauters
- CHU de Lille, Institut d'Hématologie-Transfusion, Lille, France
| | - F Machuron
- Université Lille, CHU Lille, EA 2694 - Santé Publique: Épidémiologie et Qualité des Soins, Lille, France
| | - P Renom
- CHU de Lille, Institut d'Hématologie-Transfusion, Lille, France
| | - P Goldstein
- CHU de Lille, Pôle d'Anesthésie-Réanimation, Lille, France
- CHU Lille, Pôle de l'Urgence, Lille, France
| | - B Tavernier
- CHU de Lille, Pôle d'Anesthésie-Réanimation, Lille, France
| | - A Sailliol
- Centre de Transfusion Sanguine des Armées, Clamart, France
| | - S Susen
- CHU de Lille, Institut d'Hématologie-Transfusion, Lille, France
- Université Lille, Inserm, CHU Lille, U1011 - EGID, Lille, France
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Abstract
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.
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Improvement of Blood-Brain Barrier Integrity in Traumatic Brain Injury and Hemorrhagic Shock Following Treatment With Valproic Acid and Fresh Frozen Plasma. Crit Care Med 2017; 46:e59-e66. [PMID: 29095204 DOI: 10.1097/ccm.0000000000002800] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVE Combined traumatic brain injury and hemorrhagic shock are highly lethal. Following injuries, the integrity of the blood-brain barrier can be impaired, contributing to secondary brain insults. The status of the blood-brain barrier represents a potential factor impacting long-term neurologic outcomes in combined injuries. Treatment strategies involving plasma-based resuscitation and valproic acid therapy have shown efficacy in this setting. We hypothesize that a component of this beneficial effect is related to blood-brain barrier preservation. DESIGN Following controlled traumatic brain injury, hemorrhagic shock, various resuscitation and treatment strategies were evaluated for their association with blood-brain barrier integrity. Analysis of gene expression profiles was performed using Porcine Gene ST 1.1 microarray. Pathway analysis was completed using network analysis tools (Gene Ontology, Ingenuity Pathway Analysis, and Parametric Gene Set Enrichment Analysis). SUBJECTS Female Yorkshire swine were subjected to controlled traumatic brain injury and 2 hours of hemorrhagic shock (40% blood volume, mean arterial pressure 30-35 mmHg). INTERVENTIONS Subjects were resuscitated with 1) normal saline, 2) fresh frozen plasma, 3) hetastarch, 4) fresh frozen plasma + valproic acid, or 5) hetastarch + valproic acid (n = 5 per group). After 6 hours of observation, brains were harvested for evaluation. MEASUREMENTS AND MAIN RESULTS Immunofluoroscopic evaluation of the traumatic brain injury site revealed significantly increased expression of tight-junction associated proteins (zona occludin-1, claudin-5) following combination therapy (fresh frozen plasma + valproic acid and hetastarch + valproic acid). The extracellular matrix protein laminin was found to have significantly improved expression with combination therapies. Pathway analysis indicated that valproic acid significantly modulated pathways involved in endothelial barrier function and cell signaling. CONCLUSIONS Resuscitation with fresh frozen plasma results in improved expression of proteins essential for blood-brain barrier integrity. The addition of valproic acid provides significant improvement to these protein expression profiles. This is likely secondary to activation of key pathways related to endothelial functions.
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Smith IM, Crombie N, Bishop JR, McLaughlin A, Naumann DN, Herbert M, Hancox JM, Slinn G, Ives N, Grant M, Perkins GD, Doughty H, Midwinter MJ. RePHILL: protocol for a randomised controlled trial of pre-hospital blood product resuscitation for trauma. Transfus Med 2017; 28:346-356. [PMID: 29193548 DOI: 10.1111/tme.12486] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2017] [Revised: 10/16/2017] [Accepted: 10/17/2017] [Indexed: 12/20/2022]
Abstract
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.
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Affiliation(s)
- I M Smith
- NIHR Surgical Reconstruction and Microbiology Research Centre, University of Birmingham, Birmingham, UK
| | - N Crombie
- NIHR Surgical Reconstruction and Microbiology Research Centre, University of Birmingham, Birmingham, UK.,Department of Anaesthesia, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.,West Midlands Ambulance Service Medical Emergency Response Incident Team, Brierley Hill, UK.,Midlands Air Ambulance, Stourbridge, UK
| | - J R Bishop
- NIHR Surgical Reconstruction and Microbiology Research Centre, University of Birmingham, Birmingham, UK.,Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - A McLaughlin
- NIHR Surgical Reconstruction and Microbiology Research Centre, University of Birmingham, Birmingham, UK
| | - D N Naumann
- NIHR Surgical Reconstruction and Microbiology Research Centre, University of Birmingham, Birmingham, UK
| | - M Herbert
- Department of Haematology, Royal Wolverhampton Hospitals NHS Trust, Wolverhampton, UK
| | - J M Hancox
- NIHR Surgical Reconstruction and Microbiology Research Centre, University of Birmingham, Birmingham, UK.,Midlands Air Ambulance, Stourbridge, UK
| | - G Slinn
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - N Ives
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - M Grant
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - G D Perkins
- West Midlands Ambulance Service Medical Emergency Response Incident Team, Brierley Hill, UK.,Warwick Clinical Trials Unit, University of Warwick, Coventry, UK.,Critical Care Unit, Heart of England NHS Foundation Trust, Birmingham, UK
| | - H Doughty
- NHS Blood and Transplant, Birmingham, UK
| | - M J Midwinter
- NIHR Surgical Reconstruction and Microbiology Research Centre, University of Birmingham, Birmingham, UK.,School of Biomedical Sciences, University of Queensland, Brisbane, Queensland, Australia
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Ausset S. Quelles sont les leçons récentes et quel est l’avenir de la médecine opérationnelle ? ANESTHESIE & REANIMATION 2017. [DOI: 10.1016/j.anrea.2017.06.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Daniel Y, Sailliol A, Pouget T, Peyrefitte S, Ausset S, Martinaud C. Whole blood transfusion closest to the point-of-injury during French remote military operations. J Trauma Acute Care Surg 2017; 82:1138-1146. [PMID: 28328685 DOI: 10.1097/ta.0000000000001456] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
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.
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Affiliation(s)
- Yann Daniel
- French Medical Unit, Naval Special Operations Commandos Command, Lanester, France (Y.D., S.P.); French Military Blood Institute, Clamart, France (A.S., T. P., C.M.); Anaesthesia and Intensive Care Unit, Percy Military Teaching Hospital, Clamart, France (S. A.); and Department of Biology, Laveran Military Teaching Hospital, Marseille, France (C.M.)
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Huebner BR, Moore EE, Moore HB, Sauaia A, Stettler G, Dzieciatkowska M, Hansen K, Banerjee A, Silliman CC. Freeze-dried plasma enhances clot formation and inhibits fibrinolysis in the presence of tissue plasminogen activator similar to pooled liquid plasma. Transfusion 2017; 57:2007-2015. [PMID: 28500652 DOI: 10.1111/trf.14149] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Revised: 03/24/2017] [Accepted: 03/28/2017] [Indexed: 12/31/2022]
Abstract
BACKGROUND Systemic hyperfibrinolysis is an integral part of trauma-induced coagulopathy associated with uncontrolled bleeding. Recent data suggest that plasma-first resuscitation attenuates hyperfibrinolysis; however, the availability, transport, storage, and administration of plasma in austere environments remain challenging and have limited its use. Freeze-dried plasma (FDP) is a potential alternative due to ease of storage, longer shelf life, and efficient reconstitution. FDP potentially enhances clot formation and resists breakdown better than normal saline (NS) and albumin and similar to liquid plasma. STUDY DESIGN AND METHODS Healthy volunteers underwent citrated blood draw followed by 50% dilution with NS, albumin, pooled plasma (PP), or pooled freeze-dried plasma (pFDP). Citrated native and tissue plasminogen activator (t-PA)-challenge (75 ng/mL) thrombelastography were done. Proteins in PP, pFDP, and albumin were analyzed by mass spectroscopy. RESULTS pFDP and PP had superior clot-formation rates (angle) and clot strength (maximum amplitude) compared with NS and albumin in t-PA-challenge thrombelastographies (angle: pFDP, 67.9 degrees; PP, 67.8 degrees; NS, 40.6 degrees; albumin, 35.8 degrees; maximum amplitude: pFDP, 62.4 mm; PP, 63.5 mm; NS, 44.8 mm; albumin, 41.1 mm). NS and albumin dilution increased susceptibility to t-PA-induced hyperfibrinolysis compared with pFDP and PP (NS, 62.4%; albumin, 62.6%; PP, 8.5%; pFDP, 6.7%). pFDP was similar to PP in the attenuation of t-PA-induced fibrinolysis. Most proteins (97%) were conserved during the freeze-dry process, with higher levels in 12% of pFDP proteins compared with PP. CONCLUSION pFDP enhances clot formation and attenuates hyperfibrinolysis better than NS and albumin and is a potential alternative to plasma resuscitation in the treatment of hemorrhagic shock.
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Affiliation(s)
| | - Ernest E Moore
- Department of Surgery, University of Colorado, Aurora, Colorado.,Department of Surgery, Denver Health Medical Center, Aurora, Colorado
| | - Hunter B Moore
- Department of Surgery, University of Colorado, Aurora, Colorado
| | - Angela Sauaia
- Department of Surgery, University of Colorado, Aurora, Colorado.,Department of Surgery, Denver Health Medical Center, Aurora, Colorado
| | | | - Monika Dzieciatkowska
- Department of Biochemistry and Molecular Genetics, University of Colorado, Aurora, Colorado
| | - Kirk Hansen
- Department of Biochemistry and Molecular Genetics, University of Colorado, Aurora, Colorado
| | | | - Christopher C Silliman
- Department of Pediatrics, University of Colorado, Aurora, Colorado.,Bonfils Blood Center, Denver, Colorado
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Bordes J, Joubert C, Esnault P, Montcriol A, Nguyen C, Meaudre E, Dulou R, Dagain A. Coagulopathy and transfusion requirements in war related penetrating traumatic brain injury. A single centre study in a French role 3 medical treatment facility in Afghanistan. Injury 2017; 48:1047-1053. [PMID: 27938877 DOI: 10.1016/j.injury.2016.11.023] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2016] [Revised: 10/30/2016] [Accepted: 11/19/2016] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Traumatic brain injury associated coagulopathy is frequent, either in isolated traumatic brain injury in civilian practice and in combat traumatic brain injury. In war zone, it is a matter of concern because head and neck are the second most frequent site of wartime casualty burden. Data focusing on transfusion requirements in patients with war related TBI coagulopathy are limited. MATERIALS AND METHODS A descriptive analysis was conducted of 77 penetrating traumatic brain injuries referred to a French role 3 medical treatment facility in Kabul, Afghanistan, deployed on the Kabul International Airport (KaIA), over a 30 months period. RESULTS On 77 patients, 23 died during the prehospital phase and were not included in the study. Severe traumatic brain injury represented 50% of patients. Explosions were the most common injury mechanism. Extracranial injuries were present in 72% of patients. Traumatic brain injury coagulopathy was diagnosed in 67% of patients at role 3 admission. Red blood cell units (RBCu) were transfused in 39 (72%) patients, French lyophilized plasma (FLYP) in 41 (76%), and fresh whole blood (FWB) in 17 (31%). CONCLUSION The results of this study support previous observations of coagulopathy as a frequent complication of traumatic brain injury. The majority of patients with war related penetrating traumatic brain injury presented with extracranial lesions. Most of them required a high level of transfusion capacity.
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Affiliation(s)
- J Bordes
- Sainte Anne Military Teaching Hospital, Intensive Care Unit, Toulon, France.
| | - C Joubert
- Sainte Anne Military Teaching Hospital, Neurosurgery Unit, Toulon, France
| | - P Esnault
- Sainte Anne Military Teaching Hospital, Intensive Care Unit, Toulon, France
| | - A Montcriol
- Sainte Anne Military Teaching Hospital, Intensive Care Unit, Toulon, France
| | - C Nguyen
- Sainte Anne Military Teaching Hospital, Intensive Care Unit, Toulon, France
| | - E Meaudre
- Sainte Anne Military Teaching Hospital, Intensive Care Unit, Toulon, France; French Military Health Service Academy, Ecole du Val-de-Grâce, Paris, France
| | - R Dulou
- French Military Health Service Academy, Ecole du Val-de-Grâce, Paris, France; Val-de-Grâce Military Teaching Hospital, Neurosurgery Unit, Paris, France
| | - A Dagain
- Sainte Anne Military Teaching Hospital, Neurosurgery Unit, Toulon, France; French Military Health Service Academy, Ecole du Val-de-Grâce, Paris, France
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Georgoff PE, Nikolian VC, Halaweish I, Chtraklin K, Bruhn PJ, Eidy H, Rasmussen M, Li Y, Srinivasan A, Alam HB. Resuscitation with Lyophilized Plasma Is Safe and Improves Neurological Recovery in a Long-Term Survival Model of Swine Subjected to Traumatic Brain Injury, Hemorrhagic Shock, and Polytrauma. J Neurotrauma 2017; 34:2167-2175. [PMID: 28228060 DOI: 10.1089/neu.2016.4859] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
We have shown previously that fresh frozen plasma (FFP) and lyophilized plasma (LP) decrease brain lesion size and improve neurological recovery in a swine model of traumatic brain injury (TBI) and hemorrhagic shock (HS). In this study, we examine whether these findings can be validated in a clinically relevant model of severe TBI, HS, and polytrauma. Female Yorkshire swine were subjected to TBI (controlled cortical impact), hemorrhage (40% volume), grade III liver and splenic injuries, rib fracture, and rectus abdominis crush. The animals were maintained in a state of shock (mean arterial pressure 30-35 mm Hg) for 2 h, and then randomized to resuscitation with normal saline (NS), FFP, or LP (n = 5 swine/group). Animals were recovered and monitored for 30 d, during which time neurological recovery was assessed. Brain lesion sizes were measured via magnetic resonance imaging (MRI) on post-injury days (PID) three and 10. Animals were euthanized on PID 30. The severity of shock and response to resuscitation was similar in all groups. When compared with NS-treated animals, plasma-treated animals (FFP and LP) had significantly lower neurologic severity scores (PID 1-7) and a faster return to baseline neurological function. There was no significant difference in brain lesion sizes between groups. LP treatment was well tolerated and similar to FFP. In this clinically relevant large animal model of severe TBI, HS, and polytrauma, we have shown that plasma-based resuscitation strategies are safe and result in neurocognitive recovery that is faster than recovery after NS-based resuscitation.
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Affiliation(s)
- Patrick E Georgoff
- 1 Department of Surgery, Section of Neuroradiology, University of Michigan , Ann Arbor, Michigan
| | - Vahagn C Nikolian
- 1 Department of Surgery, Section of Neuroradiology, University of Michigan , Ann Arbor, Michigan
| | - Ihab Halaweish
- 1 Department of Surgery, Section of Neuroradiology, University of Michigan , Ann Arbor, Michigan
| | - Kiril Chtraklin
- 1 Department of Surgery, Section of Neuroradiology, University of Michigan , Ann Arbor, Michigan
| | - Peter J Bruhn
- 1 Department of Surgery, Section of Neuroradiology, University of Michigan , Ann Arbor, Michigan
| | - Hassan Eidy
- 1 Department of Surgery, Section of Neuroradiology, University of Michigan , Ann Arbor, Michigan
| | - Monica Rasmussen
- 1 Department of Surgery, Section of Neuroradiology, University of Michigan , Ann Arbor, Michigan
| | - Yongqing Li
- 1 Department of Surgery, Section of Neuroradiology, University of Michigan , Ann Arbor, Michigan
| | - Ashok Srinivasan
- 2 Department of Radiology, Section of Neuroradiology, University of Michigan , Ann Arbor, Michigan
| | - Hasan B Alam
- 1 Department of Surgery, Section of Neuroradiology, University of Michigan , Ann Arbor, Michigan
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Cardenas JC, Holcomb JB. Time to plasma transfusion: a patient centered approach and modifiable risk factor. Transfusion 2017; 57:869-873. [PMID: 28394421 DOI: 10.1111/trf.14019] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Accepted: 12/19/2016] [Indexed: 12/16/2022]
Affiliation(s)
- Jessica C Cardenas
- The Center for Advanced Heart Failure, University of Texas Health Science Center, Houston, Texas
| | - John B Holcomb
- Center for Translational Injury Research, University of Texas Health Science Center, Houston, Texas
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48
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Figueiredo S, Benhamou D. Use of fresh frozen plasma: from the 2012 French guidelines to recent advances. Transfus Apher Sci 2017; 56:20-25. [DOI: 10.1016/j.transci.2016.12.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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49
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Falzone E, Pasquier P, Hoffmann C, Barbier O, Boutonnet M, Salvadori A, Jarrassier A, Renner J, Malgras B, Mérat S. Triage in military settings. Anaesth Crit Care Pain Med 2017; 36:43-51. [DOI: 10.1016/j.accpm.2016.05.004] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2015] [Revised: 04/05/2016] [Accepted: 05/16/2016] [Indexed: 11/30/2022]
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Carfantan C, Goudard Y, Butin C, Duron-Martinaud S, Even JP, Anselme A, Dulaurent E, Géhant M, Vitalis V, Bay C, Bancarel J, Bordes J. Forward medevac during Serval and Barkhane operations in Sahel: A registry study. Injury 2017; 48:58-63. [PMID: 27829492 DOI: 10.1016/j.injury.2016.10.043] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2016] [Revised: 10/19/2016] [Accepted: 10/28/2016] [Indexed: 02/02/2023]
Abstract
INTRODUCTION The French army has been deployed in Mali since January 2013 with the Serval Operation and since July 2014 in the Sahel-Saharan Strip (SSS) with the Barkhane Operation where the distances (up to 1100km) can be very long. French Military Medical Service deploys an inclusive chain from the point of injury (POI) to hospital in France. A patient evacuation coordination cell (PECC) has been deployed since February 2013 to organise forward medical evacuation (MEDEVAC) in the area between the POI and three forward surgical units. The purpose of this work was to study the medical evacuation length and duration between the call for Medevac location accidents and forward surgical units (role 2) throughout the five million square kilometers French joint operation area. MATERIALS AND METHODS Our retrospective study concerns the French patients evacuated by MEDEVAC from February 2013 to July 2016. The PECC register was analysed for patients' characteristics, NATO categorisation of gravity (Alpha, Bravo or Charlie who must be respectively at hospital facility within 90min, 4h or 24h), medical motive for MEDEVAC and the time line of each MEDEVAC (from operational commander request to entrance in role 2). RESULTS A total of 1273 French military were evacuated from February to 2013 to July 2016; 533 forward MEDEVAC were analysed. 12,4% were Alpha, 28,1% Bravo, 59,5% Charlie. War-related injury represented 18,2% of MEDEVAC. The median time for Alpha category MEDEVAC patients was 145min [100-251], for Bravo category patients 205min [125-273] and 310min [156-669] for Charlie. The median distance from the point of injury to role 2 was 126km [90-285] for Alpha patients, 290km [120-455] km for Bravo and 290km [105-455] for Charlie. CONCLUSIONS Patient evacuation in such a large area is a logistic and human challenge. Despite this, Bravo and Charlie patients were evacuated in NATO recommended time frame. However, due to distance, Alpha patients time frame was longer than this recommended by NATO organisation. That's where French doctrine with forward medical teams embedded in the platoons is relevant to mitigate this distance and time frame challenge.
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Affiliation(s)
- Cyril Carfantan
- French Military Medical Service, Medical Center of Solenzara air base, BA 126 RN 198 Cs 10001 Ventiseri 20223 Ghisonaccia Cedex, France.
| | - Yvain Goudard
- French Military Medical Service, 7th paratrooper forward surgical unit, Laveran Military teaching hospital, general surgery unit, Marseille France
| | - Christophe Butin
- French Military Medical Service, 7th paratrooper forward surgical unit, Sainte-Anne Military teaching hospital, orthopedic surgery unit, Toulon France
| | - Sandrine Duron-Martinaud
- French Military Medical Service, French Military Center for Epidemiology and Public Health, France
| | - Jean-Philippe Even
- French Military Medical Service, Medical Center of Luxeuil air base, France
| | - Anthony Anselme
- French Military Medical Service, Medical Center of Angers, France
| | - Erwan Dulaurent
- French Military Medical Service, Medical Center of Mont-de-Marsan air base, France
| | - Mélanie Géhant
- French Military Medical Service, Medical Center of Solenzara air base, BA 126 RN 198 Cs 10001 Ventiseri 20223 Ghisonaccia Cedex, France
| | - Vicky Vitalis
- French Military Medical Service, Medical Center of Lyon, France
| | - Christian Bay
- French Military Medical Service, French Military Medical Service Academy - École du Val-de-Grâce, France
| | - Jérôme Bancarel
- French Military Medical Service, Operational headquarters, M3 Current operations officer, France
| | - Julien Bordes
- French Military Medical Service, 7th paratrooper forward surgical unit, Sainte-Anne Military teaching hospital, intensive care and anaesthesiology unit, Toulon, France
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