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Davies RL, Thompson J, McGuire R, Smith JE, Webster S, Woolley T. Haemostatic resuscitation in practice: a descriptive analysis of blood products administered during Operation HERRICK, Afghanistan. BMJ Mil Health 2023:e002408. [PMID: 37400127 DOI: 10.1136/military-2023-002408] [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: 03/18/2023] [Accepted: 06/10/2023] [Indexed: 07/05/2023]
Abstract
INTRODUCTION Life-threatening haemorrhage is the leading cause of potentially survivable injury in battlefield casualties. During Operation HERRICK (Afghanistan), mortality rates improved year on year due to a number of advances in trauma care, including haemostatic resuscitation. Blood transfusion practice has not previously been reported in detail during this period. METHODS A retrospective analysis of blood transfusion at the UK role 3 medical treatment facility (MTF) at Camp Bastion between March 2006 and September 2014 was performed. Data were extracted from two sources: the UK Joint Theatre Trauma Registry (JTTR) and the newly established Deployed Blood Transfusion Database (DBTD). RESULTS 3840 casualties were transfused 72 138 units of blood and blood products. 2709 adult casualties (71%) were fully linked with JTTR data and were transfused a total of 59 842 units. Casualties received between 1 unit and 264 units of blood product with a median of 13 units per patient. Casualties wounded by explosion required almost twice the volume of blood product transfusion as those wounded by small arms fire or in a motor vehicle collision (18 units, 9 units, and 10 units, respectively). More than half of blood products were transfused within the first 2 hours following arrival at the MTF. There was a trend towards balanced resuscitation with more equal ratios of blood and blood products being used over time. CONCLUSION This study has defined the epidemiology of blood transfusion practice during Operation HERRICK. The DBTD is the largest combined trauma database of its kind. It will ensure that lessons learnt during this period are defined and not forgotten; it should also allow further research questions to be answered in this important area of resuscitation practice.
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Affiliation(s)
- Rhys L Davies
- Anaesthetic Department, University Hospital Southampton NHS Foundation Trust, Southampton, UK
- Academic Department of Military Anaesthesia and Critical Care, Royal Centre for Defence Medicine, Birmingham, UK
| | - J Thompson
- Academic Department of Military Anaesthesia and Critical Care, Royal Centre for Defence Medicine, Birmingham, UK
| | | | - J E Smith
- Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine, Birmingham, UK
- Emergency Department, University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - S Webster
- Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine, Birmingham, UK
| | - T Woolley
- Academic Department of Military Anaesthesia and Critical Care, Royal Centre for Defence Medicine, Birmingham, UK
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2
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Taylor AL, Corley JB, Cap AP, Swingholm MT, Nance ET, Gonzales R, Gurney JM, Shackelford S, Hebert JC, Hughes JD, Royster K, Hestilow GA, Cordrick CL, Hoiles J, Whitlock K, Whitacre R, Pederson B. The U.S. Armed Services Blood Program support to U.S. Central Command 2014-2021: Transformation of combat trauma resuscitation through blood product innovation and expansion of blood availability far forward. Transfusion 2022; 62 Suppl 1:S167-S176. [PMID: 35748678 DOI: 10.1111/trf.16951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Revised: 04/20/2022] [Accepted: 04/21/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND The United States Armed Services Blood Program (ASBP) faced complex blood supply challenges during two decades of military operations in the U.S. Central Command (CENTCOM) and through an adaptive, responsive, and agile system, gained valuable insights on blood product usage in combat casualty care. STUDY DESIGN AND METHODS A retrospective review of blood product introduction and utilization trends was compiled from ASBP data collected during CENTCOM operations from 2014 through 2021. RESULTS During the study period, several blood products were introduced to the CENTCOM area of operations including Low Titer O Whole Blood (LTOWB), Cold-Stored Platelets (CSP), Liquid Plasma (LP), and French Freeze Dried Plasma (FDP) manufactured from U.S. sourced donor plasma, all while expanding Walking Blood Bank capabilities. There was a gradual substitution of component therapy for whole blood; blood utilization peaked in 2017. Transfusion of Fresh Whole Blood (FWB) from Walking Blood Banks decreased as fully pre-tested LTOWB was supplied by the ASBP. LTOWB was initially supplied in citrate-phosphate-dextrose (CPD) anticoagulant (21-day shelf life) but was largely replaced with LTOWB in citrate-phosphate-dextrose-adenine (CPDA-1) anticoagulant (35-day shelf life) by 2019. Implementation of prehospital transfusion and expansion of surgical and resuscitation teams led to an increase in the number of sites receiving blood. DISCUSSION ASBP introduced new products to its inventory in order to meet changing blood product demands driven by changes in the Joint Trauma System Clinical Practice Guidelines and operational demands. These products were adopted into clinical practice with a resultant evolution in transfusion strategies.
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Affiliation(s)
- Audra L Taylor
- Armed Services Blood Program Division, Defense Health Agency, Falls Church, Virginia, USA
| | - Jason B Corley
- U.S. Army Medical Command, Army Blood Program, San Antonio, Texas, USA
| | - Andrew P Cap
- Army Institute of Surgical Research Army Blood Program, San Antonio, Texas, USA
| | | | - Erika T Nance
- Armed Services Blood Program Division, Defense Health Agency, Falls Church, Virginia, USA
| | | | - Jennifer M Gurney
- Army Institute of Surgical Research Army Blood Program, San Antonio, Texas, USA
| | | | - Jeffrey C Hebert
- Bureau of Medicine & Surgery, Navy Blood Program, Falls Church, Virginia, USA
| | | | - Karen Royster
- Armed Services Blood Program Division, Defense Health Agency, Falls Church, Virginia, USA
| | - George A Hestilow
- Air Force Medical Readiness Agency, Air Force Blood Program, San Antonio, Texas, USA
| | - Colleen L Cordrick
- Center for Laboratory Medicine Services, Defense Health Agency, Falls Church, Virginia, USA
| | | | | | - Robin Whitacre
- Armed Services Blood Program Division, Defense Health Agency, Falls Church, Virginia, USA
| | - Becky Pederson
- Air Force Medical Readiness Agency, Air Force Blood Program, San Antonio, Texas, USA
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Quinn JM, Bencko V, Bongartz AV, Stoeva P, Atanasoska Arsov A, De Porzi S, Bohonek M, Ti R, Taylor J, Mitchell J, Reinhard V, Majovsky P, Kuca J, Kral P, Fazekas L, Bubenik Z. NATO and evidence-based military and disaster medicine: case for Vigorous Warrior Live Exercise Series. Cent Eur J Public Health 2020; 28:325-330. [PMID: 33338371 DOI: 10.21101/cejph.a6045] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Accepted: 09/15/2020] [Indexed: 11/15/2022]
Abstract
The North Atlantic Treaty Organization (NATO) is the premier and only security alliance uniting 30 countries and growing with many partner states in the provision of collective security and against threats posed by conflict and natural disasters. Security of countries and communities is increasingly threatened by a broad spectrum of unconventional types of war and disease threats - from hybrid and asymmetric to multi-domain and peer-to-peer/near-peer conflict. The NATO Centre of Excellence for Military Medicine (MILMED COE) is the centre of gravity for medical best practices and promotion of medical doctrine across the NATO alliance. Disaster medicine is multidisciplinary and in NATO, multinational, requiring best practices that are driven by data and evidence to prevent death on the battlefield and prepare for future conflicts. "Vigorous Warrior" is a live military and disaster medicine exercise series using both civilian and military actors across all sectors of health focused on health security and identifying lessons learned to ready the alliance for future threats. In this brief report, we make the case that the Vigorous Warrior exercise exposes gaps, highlights challenges and generates an evidence base to make NATO military medicine systems more robust, more efficient and in provision of best medical practices. We specifically argue that clinical data capture must be duplicated and continuous across the alliance to ensure evidence-based medicine stays current in NATO military medical doctrine.
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Affiliation(s)
- John M Quinn
- Prague Centre for Global Health, Institute of Hygiene and Epidemiology, First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Vladimír Bencko
- Prague Centre for Global Health, Institute of Hygiene and Epidemiology, First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Alexander V Bongartz
- Emergency Medical Faculty, Prague Institute of Postgraduate Medical Education, Prague, Czech Republic
| | - Preslava Stoeva
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Adrijana Atanasoska Arsov
- Medical Military Centre Skopje, Army of the Republic of North Macedonia, Skopje, Republic of North Macedonia
| | - Stefano De Porzi
- Interoperability Branch, NATO Centre of Excellence for Military Medicine, Budapest, Hungary
| | - Milos Bohonek
- Department of Haematology and Blood Transfusion, Military University Hospital, Prague, Czech Republic.,Faculty of Biomedical Engineering, Czech Technical University in Prague, Prague, Czech Republic
| | - Ronald Ti
- Specialist Technical Advisor, Poland Office, Department of Defence, Canberra, Australia
| | - Jack Taylor
- Interoperability Branch, NATO Centre of Excellence for Military Medicine, Budapest, Hungary
| | - John Mitchell
- Secretary of Defence, Operational Medicine Readiness Policy and Oversight, Pentagon, Washington, D.C., USA
| | - Veronika Reinhard
- Estonian Military Academy, Tartu University Hospital, Tartu, Estonia
| | - Petr Majovsky
- Ministry of Defence of the Czech Republic, Prague, Czech Republic
| | - Jozef Kuca
- Interoperability Branch, NATO Centre of Excellence for Military Medicine, Budapest, Hungary
| | - Petr Kral
- Interoperability Branch, NATO Centre of Excellence for Military Medicine, Budapest, Hungary
| | - Laszlo Fazekas
- Interoperability Branch, NATO Centre of Excellence for Military Medicine, Budapest, Hungary
| | - Zoltan Bubenik
- Ministry of Defence of the Czech Republic, Prague, Czech Republic.,Committee of Chiefs of Military Medical Services in NATO, Brussels, Belgium
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4
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Knapp J, Pietsch U, Kreuzer O, Hossfeld B, Bernhard M, Lier H. Prehospital Blood Product Transfusion in Mountain Rescue Operations. Air Med J 2018; 37:392-399. [PMID: 30424860 DOI: 10.1016/j.amj.2018.08.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Revised: 07/08/2018] [Accepted: 08/24/2018] [Indexed: 12/13/2022]
Abstract
Severely injured patients with hemorrhage present major challenges for emergency medical services, especially during mountain rescue missions in which harsh environmental conditions and long out-of-hospital times are frequent. Because uncontrolled hemorrhage is the leading cause of death within the first 48 hours after severe trauma, initiating damage control resuscitation (DCR) as early as possible after severe trauma and exporting the concept of DCR to the out-of-hospital arena is pivotal for patient survival. Appropriate bleeding control, management of coagulopathy, and transfusion of blood products are core aspects of DCR. This review summarizes the available evidence on out-of-hospital blood product transfusion and the management of coagulopathy with a special focus on mountain rescue missions. An overview of upcoming trials and possible future trends in the management of coagulopathy during rescue operations is provided.
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Affiliation(s)
- Jürgen Knapp
- Department of Anaesthesiology and Pain Therapy, University Hospital of Bern, Bern, Switzerland; Air Zermatt, Emergency Medical Service, Zermatt, Switzerland.
| | - Urs Pietsch
- Air Zermatt, Emergency Medical Service, Zermatt, Switzerland; Department of Anaesthesiology and Intensive Care Medicine, Cantonal Hospital St Gallen, St Gallen, Switzerland
| | - Oliver Kreuzer
- Air Zermatt, Emergency Medical Service, Zermatt, Switzerland
| | - Björn Hossfeld
- Department of Anaesthesiology and Intensive Care Medicine, Armed Forces Hospital Ulm, Ulm, Germany; Task Force "Tactical Medicine" of the Scientific Working Group Emergency Medicine of the German Society of Anaesthesiology and Intensive Care Medicine, Nürnberg, Germany
| | - Michael Bernhard
- Emergency Department, University Hospital of Düsseldorf, Düsseldorf, Germany; Task Force "Trauma and Resuscitation Room Management" of the Scientific Working Group Emergency Medicine of the German Society of Anaesthesiology and Intensive Care Medicine, Nürnberg, Germany
| | - Heiko Lier
- Task Force "Tactical Medicine" of the Scientific Working Group Emergency Medicine of the German Society of Anaesthesiology and Intensive Care Medicine, Nürnberg, Germany; Department of Anaesthesiology and Postoperative Intensive Care Medicine, University of Cologne, Köln, Germany
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5
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Lier H, Bernhard M, Knapp J, Buschmann C, Bretschneider I, Hossfeld B. [Approaches to pre-hospital bleeding management : Current overview on civilian emergency medicine]. Anaesthesist 2018; 66:867-878. [PMID: 28785773 DOI: 10.1007/s00101-017-0350-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Severe bleeding is a typical result of traumatic injuries. Hemorrhage is responsible for almost 50% of deaths within the first 6 h after trauma. Appropriate bleeding control and coagulation therapy depends on an integrated concept of local hemostasis by primary pressure with the hands, compression, and tourniquets accompanied by prevention of hypothermia, acidosis and hypocalcemia. Additionally, permissive hypotension is accepted for suitable patients and tranexamic acid should be administered early. Multiple publications prove that prehospital transfusion of blood products (e. g. red blood cells and plasma) and coagulation factors (e. g. fibrinogen) is feasible and safe, but only required for <5% of polytrauma patients in the civilian setting.
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Affiliation(s)
- H Lier
- Klinik für Anästhesiologie und Operative Intensivmedizin, Universitätsklinikum Köln (AöR), Kerpener Straße 62, 50937, Köln, Deutschland. .,Arbeitsgruppe "Taktische Medizin" des Arbeitskreises Notfallmedizin, Deutsche Gesellschaft für Anästhesiologie und Intensivmedizin, Nürnberg, Deutschland.
| | - M Bernhard
- Zentrale Notaufnahme, Universitätsklinikum Leipzig, Leipzig, Deutschland.,Arbeitsgruppe "Trauma- und Schockraummanagement" des Arbeitskreis Notfallmedizin, Deutschen Gesellschaft für Anästhesiologie und Intensivmedizin, Nürnberg, Deutschland
| | - J Knapp
- Klinik für Anästhesiologie und Schmerztherapie, Universitätsspital Bern, Bern, Schweiz.,Air Zermatt, Zermatt, Schweiz
| | - C Buschmann
- Institut für Rechtsmedizin, Charité - Universitätsmedizin Berlin, Berlin, Deutschland
| | - I Bretschneider
- Klinik für Anästhesiologie & Intensivmedizin, Bundeswehrkrankenhaus, Ulm, Deutschland
| | - B Hossfeld
- Klinik für Anästhesiologie & Intensivmedizin, Bundeswehrkrankenhaus, Ulm, Deutschland.,Arbeitsgruppe "Taktische Medizin" des Arbeitskreises Notfallmedizin, Deutsche Gesellschaft für Anästhesiologie und Intensivmedizin, Nürnberg, Deutschland
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6
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Sahloul M, Bowley D, Kirkman E, Doughty H. Blood salvage technology after combat injury. J ROY ARMY MED CORPS 2018; 164:316-317. [DOI: 10.1136/jramc-2018-000947] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/14/2018] [Indexed: 11/04/2022]
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7
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Woolley T, Round J, Ingram M. Global lessons: developing military trauma care and lessons for civilian practice. Br J Anaesth 2017; 119:i135-i142. [DOI: 10.1093/bja/aex382] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
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8
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Doughty H, Maguire A, Fitchett G, Parker P. Group O low titre only emergency donor panels for small combat teams. J ROY ARMY MED CORPS 2017; 163:401-404. [PMID: 28883026 DOI: 10.1136/jramc-2017-000830] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2017] [Revised: 06/22/2017] [Accepted: 06/26/2017] [Indexed: 11/03/2022]
Abstract
INTRODUCTION Military elements increasingly operate in small teams in remote areas with no immediate blood product support. Planners and operators may endorse collection of fresh whole blood from pretested donors in emergency situations. The biggest risk of transfusion is the accidental use of ABO incompatible blood which can be fatal. The risk may be mitigated by using only group O LOw (OLO) titre donors with plasma containing low levels of the naturally occurring antibody to group A and B red cells. This paper reviews the ABO blood group distribution in potential blood donors from a high readiness UK medical regiment and explores the feasibility of using only group OLO donors in small teams. METHODS A retrospective review of routine volunteer blood donor samples was undertaken at 6 monthly intervals during a 2-year period. Personnel were tested in groups when available during training to create multiple donor panels to simulate small teams. RESULTS 206 donation samples were collected from 157 potential donors. All donors were acceptable based on the lifestyle questionnaire, serology and microbiology screen. Of the 206 samples reviewed, 85 (41%) were group O (D pos and D neg). 14 group O (16.5%) were shown to have high titre of anti-A or B. Therefore, 71, that is, 34% overall were suitable as OLO donors. The donor panel size varied from 15 to 44. The absolute number of OLO donors in each panel ranged from 4 to 17 and the number of O neg donors was 0-3. CONCLUSION A third of samples were suitable as OLO donors; however, there were insufficient 'universal' donors within smaller subgroups (<10). In this situation, we recommend the careful use of both group O and group A donors or the use of a buddy-buddy blood group matrix.
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Affiliation(s)
- Heidi Doughty
- NHS Blood and Transplant, Birmingham, UK.,Academic Department of Military Anaesthesia and Critical Care, Birmingham, UK
| | - A Maguire
- The Royal Centre for Defence Medicine, Queen Elizabeth Hospital, Birmingham, UK
| | - G Fitchett
- The Royal Centre for Defence Medicine, Queen Elizabeth Hospital, Birmingham, UK
| | - P Parker
- The Royal Centre for Defence Medicine, Queen Elizabeth Hospital, Birmingham, UK.,Senior Lecturer in SOF Medicine, University College Cork, Cork, Republic of Ireland
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