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Holcomb JB, Butler FK, Schreiber MA, Taylor AL, Riggs LE, Krohmer JR, Dorlac WC, Jenkins DH, Cox DB, Beckett AN, O'Connor KC, Gurney JM. Making blood immediately available in emergencies. Transfusion 2024; 64:1543-1550. [PMID: 39031029 DOI: 10.1111/trf.17929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Accepted: 05/30/2024] [Indexed: 07/22/2024]
Affiliation(s)
- John B Holcomb
- Division of Trauma and Acute Care Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Frank K Butler
- Tactical Combat Casualty Care and the DoD Joint Trauma System, Ft. Sam Houston, Texas, USA
| | - Martin A Schreiber
- Department of Surgery, Oregon Health and Science University, Portland, Oregon, USA
| | | | - Leslie E Riggs
- Armed Services Blood Program, Defense Health Headquarters, Falls Church, Virginia, USA
| | - Jon R Krohmer
- Department of Emergency Medicine, Homer Stryker M.D. School of Medicine, Western Michigan University, Kalamazoo, Michigan, USA
| | - Warren C Dorlac
- Department of Surgery, University of Colorado, Denver, Colorado, USA
| | | | - Daniel B Cox
- Division of Trauma and Acute Care Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Andrew N Beckett
- Canadian Forces Health Services, University of Toronto, Toronto, Ontario, Canada
| | - Kevin C O'Connor
- Department of Medicine, George Washington University School of Medicine & Health Sciences, Washington, DC, USA
| | - Jennifer M Gurney
- Department of Defense, Joint Trauma System, US Army, Ft Sam Houston, Texas, USA
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2
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McCullagh J, Basham P, Davies J, Hicks V, Hunter A, Lancut J, Green L. The feasibility of introducing a whole blood component for traumatic haemorrhage in the UK. Transfus Med 2024; 34:175-181. [PMID: 38576265 DOI: 10.1111/tme.13039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Revised: 02/24/2024] [Accepted: 03/19/2024] [Indexed: 04/06/2024]
Abstract
BACKGROUND The interest in re-introducing whole blood (WB) transfusion for the management of traumatic major haemorrhage is increasing. However, due to the current leucodepletion filters used in the UK a WB component was not readily available. Instead, an alternative but similar component, leucocyte depleted red cell and plasma (LD-RCP), which provided a unique experience in assessing the feasibility of a WB component was used whilst a WB component was being manufactured. STUDY DESIGN AND METHODS Between November 2018 and October 2020, LD-RCP replaced RBC as standard of care for all trauma patients with major haemorrhage in London. The aims of the study were to assess (a) deliverability, (b) component wastage and (c) safety. RESULTS Over the study period a total of 1208 LD-RCP units were delivered, of which 96.5% were delivered 'On Time In Full' (OTIF). Of the 1208 units, 733 (60.68%) were transfused and 475 (39.3%) units were wasted. Component wastage reduced significantly throughout the study (p = 0.001). A total of 177 patients had a blood group recorded, 86 were group O and 91 were non-group O. There was no statistically significantly difference between haemoglobin (p = 0.422), or bilirubin levels (p = 0.084) between group O and non-group O patients. DISCUSSION It was feasible for NHS Blood and Transplant to deliver LD-RCP on time in full, however component wastage was high due to short shelf life and limited use of the component. Low titre group O LD-RCP units were not associated with clinical evidence of haemolysis.
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Affiliation(s)
- Josephine McCullagh
- Clinical Haematology, Barts Health NHS Trust, London, UK
- Red Cell Immunoheamatology, NHS Blood and Transplant (NHSBT), London, UK
| | - Peter Basham
- Manufacturing, NHS Blood and Transplant, London, UK
| | - Jane Davies
- Manufacturing, NHS Blood and Transplant, London, UK
| | - Vicky Hicks
- Manufacturing, NHS Blood and Transplant, London, UK
| | | | - Julia Lancut
- Blood Transfusion, East and Southeast London Pathology Partnership, London, UK
| | - Laura Green
- Clinical Haematology, Barts Health NHS Trust, London, UK
- Blizard Institute, Queen Mary University of London, London, UK
- Blood Transfusion and Components, NHS Blood and Transplant, London, UK
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Gammon RR, Meena-Leist C, Al Mozain N, Cruz J, Hartwell E, Lu W, Karp JK, Noone S, Orabi M, Tayal A, Bocquet C, Tanhehco Y. Whole blood in civilian transfusion practice: A review of the literature. Transfusion 2023; 63:1758-1766. [PMID: 37465986 DOI: 10.1111/trf.17480] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Accepted: 06/12/2023] [Indexed: 07/20/2023]
Affiliation(s)
- Richard R Gammon
- OneBlood, Scientific, Medical, Technical Direction, Florida, USA
| | - Claire Meena-Leist
- Department of Pathology and Laboratory Medicine, University of Louisville School of Medicinee, Louisville, Kentucky, USA
| | - Nour Al Mozain
- Department of Pathology and Laboratory Medicine, King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia
| | | | | | - Wen Lu
- Department of Pathology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Julie Katz Karp
- Department of Pathology and Genomic Medicine, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Susan Noone
- Administration, Vitalant, Ventura, California, USA
| | - Mustafa Orabi
- Department of Pathology and Laboratory Medicine, University of Louisville School of Medicinee, Louisville, Kentucky, USA
| | | | | | - Yvette Tanhehco
- Department of Pathology and Cell Biology, Columbia University Irving Medical Center, NewYork-Presbyterian Hospital, New York, New York, USA
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Coyle C, Zitek T, Pepe PE, Stotsenburg M, Scheppke KA, Antevy P, Giroux R, Farcy DA. The Implementation of a Prehospital Whole Blood Transfusion Program and Early Results. Prehosp Disaster Med 2023; 38:513-517. [PMID: 37357937 DOI: 10.1017/s1049023x23005952] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/27/2023]
Abstract
INTRODUCTION In far-forward combat situations, the military challenged dogma by using whole blood transfusions (WBTs) rather than component-based therapy. More recently, some trauma centers have initiated WBT programs with reported success. There are a few Emergency Medical Service (EMS) systems that are using WBTs, but the vast majority are not. Given the increasing data supporting the use of WBTs in the prehospital setting, more EMS systems are likely to consider or begin WBT programs in the future. OBJECTIVE A prehospital WBT program was recently implemented in Palm Beach County, Florida (USA). This report will discuss how the program was implemented, the obstacles faced, and the initial results. METHODS This report describes the process by which a prehospital WBT program was implemented by Palm Beach County Fire Rescue and the outcomes of the initial case series of patients who received WBTs in this system. Efforts to initiate the prehospital WBT program for this system began in 2018. The program had several obstacles to overcome, with one of the major obstacles being the legal team's perception of potential liability that might occur with a new prehospital blood transfusion program. This obstacle was overcome through education of local elected officials regarding the latest scientific evidence in favor of prehospital WBTs with potential life-saving benefits to the community. After moving past this hurdle, the program went live on July 6, 2022. The initial indications for transfusion of cold-stored, low titer, leukoreduced O+ whole blood in the prehospital setting included traumatic injuries with systolic blood pressure (SBP) < 70mmHg or SBP < 90mmHg plus heart rate (HR) > 110 beats per minute. FINDINGS From the date of onset through December 31, 2022, Palm Beach County Fire Rescue transported a total of 881 trauma activation patients, with 20 (2.3%) receiving WBT. Overall, nine (45%) of the patients who had received WBTs so far remain alive. No adverse events related to transfusion were identified following WBT administration. A total of 18 units of whole blood reached expiration of the unit's shelf life prior to transfusion. CONCLUSION Despite a number of logistical and legal obstacles, Palm Beach County Fire Rescue successfully implemented a prehospital WBT program. Other EMS systems that are considering a prehospital WBT program should review the included protocol and the barriers to implementation that were faced.
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Affiliation(s)
- Charles Coyle
- Palm Beach County Fire Rescue, West Palm Beach, FloridaUSA
| | - Tony Zitek
- Department of Emergency Medicine, Mt. Sinai Medical Center, Miami Beach, FloridaUSA
| | - Paul E Pepe
- Palm Beach County Fire Rescue, West Palm Beach, FloridaUSA
| | - Madonna Stotsenburg
- Department of Trauma Services and Emergency Management, St. Mary's Medical Center, West Palm Beach, FloridaUSA
| | | | - Peter Antevy
- Palm Beach County Fire Rescue, West Palm Beach, FloridaUSA
| | - Richard Giroux
- Palm Beach County Fire Rescue, West Palm Beach, FloridaUSA
| | - David A Farcy
- Palm Beach County Fire Rescue, West Palm Beach, FloridaUSA
- Department of Emergency Medicine, Mt. Sinai Medical Center, Miami Beach, FloridaUSA
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5
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Morgan KM, Gaines BA, Leeper CM. Pediatric Trauma Resuscitation Practices. CURRENT TRAUMA REPORTS 2022. [DOI: 10.1007/s40719-022-00238-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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6
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Assessing the risks of haemolysis as an adverse reaction following the transfusion of ABO incompatible plasma-containing components - A scoping review. Blood Rev 2022; 56:100989. [PMID: 35871104 DOI: 10.1016/j.blre.2022.100989] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 05/30/2022] [Accepted: 07/05/2022] [Indexed: 11/20/2022]
Abstract
Background The limited supply of universal plasma has resulted in transfusion of ABO incompatible plasma to patients. As the need to implement whole blood transfusion in pre-hospitals setting rises, the lowest cut-off for anti-A/anti-B that does not cause haemolysis remains unknown. In this first scoping review, we aimed to determine the lowest ABO titre and volume reported in the literature to cause haemolysis from ABO incompatible plasma transfusions (plasma, platelets, cryoprecipitate, and whole blood). Methods We searched several databases from inception to April 2022, including all study types. Three independent reviewers extracted and reviewed the data. Primary outcome was the anti-A and anti-B titre (measured by IgM or IgG) that resulted in measurable haemolysis following ABO incompatible plasma transfusion. Results We identified 5681 citations, of which 49 studies were eligible, reporting a total of 62 cases (34 adults, 14 children and 14 did not specify age). The methods for antibody measurement and antibody type (IgG or IgM) varied significantly between studies. Component volumes were poorly reported. The most common component responsible for the haemolysis was apheresis platelets followed by pooled platelets and whole blood. Most haemolytic cases reported were due to anti-A. The lowest anti-A titre reported to cause haemolysis (children and adults) was 32 (IgG), while for anti-B it was 512 (IgG and IgM) for adults, 16,384 for paediatrics (IgG and IgM) and 128 (IgM) in cases where the age was not specified. The lowest reported volume associated with haemolysis were 100 ml (adults) and 15 ml (children). Of the 62 15 (24%) died. Conclusion The lowest titre reported to cause haemolysis was an anti-A of 32. ABO mismatch plasma transfusion may be associated with significant mortality. There is a need to agree/standardise methods for ABO titration measurement internationally for plasma components and agree the lowest anti-A/anti-B titre for transfusing ABO mismatched plasma.
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Barmparas G, Huang R, Hayes C, Pepkowitz SH, Abumuhor IA, Thomasian SE, Margulies DR, Klapper EB. Implementation of a low-titer stored whole blood transfusion program for civilian trauma patients: Early experience and logistical challenges. Injury 2022; 53:1576-1580. [PMID: 35123798 DOI: 10.1016/j.injury.2022.01.043] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 01/05/2022] [Accepted: 01/26/2022] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Cold-stored low titer group O whole blood (LTOWB) is increasingly utilized in the initial resuscitation of exsanguinating trauma patients. We report on our early experience with LTOWB, focusing on logistics, implementation challenges, and outcomes. METHODS In February, 2019, LTOWB was incorporated into the massive transfusion protocol (MTP) activated for trauma patients in the emergency department (ED.) Up to 4 units of LTOWB were included in the MTP cooler, depending on availability, and were transfused prior to transfusion of any other blood products from the MTP cooler. Demographics, injury characteristics, and outcomes were obtained, and the logistics of LTOWB availability were reviewed. RESULTS Over a 12-month period, MTP was activated for 74 trauma patients. Of those, 38 (51%) MTP included at least one unit of LTOWB, with 19/38 (50%) including 4 LTOWB units. A total of 177 units of LTOWB were purchased during the study period, and of those, 74 (42%) expired before use. Patients who received LTOWB had a similar mortality compared to those who received component therapy (39% vs. 47%; Odds Ratio [95% CI]: 0.7 [0.3, 2.0]; p = 0.72,) however, they were able to achieve a significantly higher plasma:pRBC ratio during the duration of MTP activation (mean [SD] 0.8 [0.2] vs. 0.4 [0.4]; mean difference [95% CI]: 0.4 [0.2, 0.5]; p < 0.01.) CONCLUSIONS: Our early experience with LTOWB transfusion demonstrates feasibility, but also highlights challenges with inventory management. These findings triggered changes to our protocol aiming at minimizing wastage. The use of LTOWB may yield a higher plasma:pRBC ratio early during the resuscitation period. Further investigation is required to explore whether this may yield a survival advantage. LEVEL OF EVIDENCE III (Therapeutic/Care Management).
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Affiliation(s)
- Galinos Barmparas
- Department of Surgery, Division of Acute Care Surgery and Surgical Critical Care, Cedars-Sinai Medical Center, Los Angeles, CA USA.
| | - Raymond Huang
- Department of Surgery, Division of Acute Care Surgery and Surgical Critical Care, Cedars-Sinai Medical Center, Los Angeles, CA USA.
| | - Chelsea Hayes
- Department of Pathology, Division of Transfusion Medicine, Cedars-Sinai Medical Center, Los Angeles, CA USA.
| | - Samuel H Pepkowitz
- Department of Pathology, Division of Transfusion Medicine, Cedars-Sinai Medical Center, Los Angeles, CA USA.
| | - Ihab A Abumuhor
- Department of Pathology, Division of Transfusion Medicine, Cedars-Sinai Medical Center, Los Angeles, CA USA.
| | - Sandra E Thomasian
- Department Emergency Medicine, Cedars-Sinai Medical Center, Los Angeles, CA USA.
| | - Daniel R Margulies
- Department of Surgery, Division of Acute Care Surgery and Surgical Critical Care, Cedars-Sinai Medical Center, Los Angeles, CA USA.
| | - Ellen B Klapper
- Department of Pathology, Division of Transfusion Medicine, Cedars-Sinai Medical Center, Los Angeles, CA USA.
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8
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Jackson BP, Sperry JL, Yazer MH. Prehospital Plasma Transfusion: What Does the Literature Show? Transfus Med Hemother 2022; 48:358-365. [PMID: 35082567 DOI: 10.1159/000519627] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 09/08/2021] [Indexed: 11/19/2022] Open
Abstract
Background Early initiation of blood products transfusion after injury has been associated with improved patient outcomes following traumatic injury. The ability to transfuse patients' plasma in the prehospital setting provides a prime opportunity to begin resuscitation with blood products earlier and with a more balanced plasma: RBC ratio than what has traditionally been done. Published studies on the use of prehospital plasma show a complex relationship between its use and improved survival. Summary Examination of the literature shows that there may be a mortality benefit from the use of prehospital plasma, but that it may be limited to certain subgroups of trauma patients. The likelihood of realizing these survival benefits appears to be predicted by several factors including the type of injury, length of transport time, presence of traumatic brain injury, and total number of blood products transfused, whether the patient required only a few products or a massive transfusion. When taken as a whole the evidence appears to show that prehospital plasma may have a mortality benefit that is most clearly demonstrated in patients with blunt injuries, moderate transfusion requirements, traumatic brain injury, and/or transport time greater than 20 min, as well as those who demonstrate a certain cytokine expression profile. Key Messages The evidence suggests that a targeted use of prehospital plasma will most likely maximize the benefits from the use of this limited resource. It is also possible that prehospital plasma may best be provided through whole blood as survival benefits were greatest in patients who received both prehospital plasma and RBCs.
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Affiliation(s)
- Bryon P Jackson
- Department of Pathology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Jason L Sperry
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Mark H Yazer
- Department of Pathology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
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9
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Cardigan R, Latham T, Weaver A, Yazer M, Green L. Estimating the risks of prehospital transfusion of D-positive whole blood to trauma patients who are bleeding in England. Vox Sang 2022; 117:701-707. [PMID: 35018634 PMCID: PMC9306525 DOI: 10.1111/vox.13249] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Revised: 12/21/2021] [Accepted: 12/22/2021] [Indexed: 01/13/2023]
Abstract
Background and Objectives D‐negative red cells are transfused to D‐negative females of childbearing potential (CBP) to prevent haemolytic disease of the foetus and newborn (HDFN). Transfusion of low‐titre group O whole blood (LTOWB) prehospital is gaining interest, to potentially improve clinical outcomes and for logistical benefits compared to standard of care. Enhanced donor selection requirements and reduced shelf‐life of LTOWB compared to red cells makes the provision of this product challenging. Materials and Methods A universal policy change to the use of D‐positive LTOWB across England was modelled in terms of risk of three specific harms occurring: risk of haemolytic transfusion reaction now or in the future, and the risk of HDFN in future pregnancies for all recipients or D‐negative females of CBP. Results The risk of any of the three harms occurring for all recipients was 1:14 × 103 transfusions (credibility interval [CI] 56 × 102–42 × 103) while for females of CBP it was 1:520 transfusions (CI 250–1700). The latter was dominated by HDFN risk, which would be expected to occur once every 5.7 years (CI 2.6–22.5). We estimated that a survival benefit of ≥1% using LTOWB would result in more life‐years gained than lost if D‐positive units were transfused exclusively. These risks would be lower, if D‐positive blood were only transfused when D‐negative units are unavailable. Conclusion These data suggest that the risk of transfusing RhD‐positive blood is low in the prehospital setting and must be balanced against its potential benefits.
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Affiliation(s)
- Rebecca Cardigan
- Clinical Services, NHS Blood and Transplant, Cambridge, UK.,Department of Haematology, University of Cambridge, Cambridge, UK
| | - Tom Latham
- Clinical Services, NHS Blood and Transplant, London, UK
| | - Anne Weaver
- Department of Emergency Medicine, Barts Health NHS Trust, London, UK
| | - Mark Yazer
- Department of Pathology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Laura Green
- Clinical Services, NHS Blood and Transplant, London, UK.,Department of Haematology, Barts Health NHS Trust, London, UK.,Blizard Institute, Queen Mary University of London, London, UK
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10
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Yazer MH. The Evolution of Blood Product Use in Trauma Resuscitation: Change Has Come. Transfus Med Hemother 2021; 48:377-380. [PMID: 35082569 PMCID: PMC8739388 DOI: 10.1159/000520011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 10/01/2021] [Indexed: 11/19/2022] Open
Affiliation(s)
- Mark H. Yazer
- Department of Pathology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Department of Pathology, Tel Aviv University, Tel Aviv, Israel
- Department of Clinical Immunology, University of Southern Denmark, Odense, Denmark
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11
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Yazer MH, Spinella PC, Bank EA, Cannon JW, Dunbar NM, Holcomb JB, Jackson BP, Jenkins D, Levy M, Pepe PE, Sperry JL, Stubbs JR, Winckler CJ. THOR-AABB Working Party Recommendations for a Prehospital Blood Product Transfusion Program. PREHOSP EMERG CARE 2021; 26:863-875. [PMID: 34669564 DOI: 10.1080/10903127.2021.1995089] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
The evidence for the lifesaving benefits of prehospital transfusions is increasing. As such, emergency medical services (EMS) might increasingly become interested in providing this important intervention. While a few EMS and air medical agencies have been providing exclusively red blood cell (RBC) transfusions to their patients for many years, transfusing plasma in addition to the RBCs, or simply using low titer group O whole blood (LTOWB) in place of two separate components, will be a novel experience for many services. The recommendations presented in this document were created by the Trauma, Hemostasis and Oxygenation Research (THOR)-AABB (formerly known as the American Association of Blood Banks) Working Party, and they are intended to provide a framework for implementing prehospital blood transfusion programs in line with the best available evidence. These recommendations cover all aspects of such a program including storing, transporting, and transfusing blood products in the prehospital phase of hemorrhagic resuscitation.
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12
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Raykar NP, Makin J, Khajanchi M, Olayo B, Munoz Valencia A, Roy N, Ottolino P, Zinco A, MacLeod J, Yazer M, Rajgopal J, Zeng B, Lee HK, Bidanda B, Kumar P, Puyana JC, Rudd K. Assessing the global burden of hemorrhage: The global blood supply, deficits, and potential solutions. SAGE Open Med 2021; 9:20503121211054995. [PMID: 34790356 PMCID: PMC8591638 DOI: 10.1177/20503121211054995] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Accepted: 10/04/2021] [Indexed: 01/28/2023] Open
Abstract
There is a critical shortage of blood available for transfusion in many low- and middle-income countries. The consequences of this scarcity are dire, resulting in uncounted morbidity and mortality from trauma, obstetric hemorrhage, and pediatric anemias, among numerous other conditions. The process of collecting blood from a donor to administering it to a patient involves many facets from donor availability to blood processing to blood delivery. Each step faces particular challenges in low- and middle-income countries. Optimizing existing strategies and introducing new approaches will be imperative to ensure a safe and sufficient blood supply worldwide.
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Affiliation(s)
- Nakul P Raykar
- Trauma & Emergency General Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA.,Departments of Surgery and Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Jennifer Makin
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | | | - Bernard Olayo
- Center for Public Health and Development, Nairobi, Kenya
| | | | - Nobhojit Roy
- Health Systems Strengthening Unit, CARE-India, Bihar, India.,Department of Surgery, KEM Hospital, Mumbai, India
| | - Pablo Ottolino
- Department of Surgery, Hospital Sotero Del Rio, Universidad Católica, Santiago, Chile
| | - Analia Zinco
- Department of Surgery, Hospital Sotero Del Rio, Universidad Católica, Santiago, Chile
| | - Jana MacLeod
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.,Business School, Strathmore University, Nairobi, Kenya
| | - Mark Yazer
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Jayant Rajgopal
- Department of Industrial Engineering, School of Engineering, University of Pittsburgh, Pittsburgh, PA, USA
| | - Bo Zeng
- Department of Industrial Engineering, School of Engineering, University of Pittsburgh, Pittsburgh, PA, USA
| | - Hyo Kyung Lee
- Department of Industrial Engineering, School of Engineering, University of Pittsburgh, Pittsburgh, PA, USA
| | - Bopaya Bidanda
- Department of Industrial Engineering, School of Engineering, University of Pittsburgh, Pittsburgh, PA, USA
| | - Pratap Kumar
- Business School, Strathmore University, Nairobi, Kenya
| | - Juan Carlos Puyana
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Kristina Rudd
- Department of Critical Care Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
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13
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Ramos-Jimenez RG, Leeper C. Hemostatic Resuscitation in Children. Transfus Med Rev 2021; 35:113-117. [PMID: 34716083 DOI: 10.1016/j.tmrv.2021.06.008] [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: 05/14/2021] [Revised: 06/29/2021] [Accepted: 06/30/2021] [Indexed: 02/02/2023]
Abstract
Trauma is a major source of morbidity and mortality for children worldwide; life-threatening hemorrhage is a primary cause of preventable death. Essential interventions in children with life-threatening hemorrhage include hemostatic resuscitation and mechanical control of bleeding. Herein we review pediatric hemostatic resuscitation, a strategy that addresses both hemorrhagic shock and the coagulopathic complications described in patients with major hemorrhage. Some components of hemostatic resuscitation may include: early and aggressive resuscitation with blood products, minimizing crystalloid and hemodilution, antifibrinolytic adjuncts such as tranexamic acid, and the novel use of low-titer group O whole-blood (LTOWB) transfusion in injured children. The following selection of important publications address the current state of hemostatic resuscitation strategies in pediatric trauma patients as well as the remaining knowledge gaps and areas for further research.
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Affiliation(s)
| | - Christine Leeper
- Department of Surgery, UPMC Presbyterian Shadyside, Pittsburgh, PA, USA; University of Pittsburgh School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
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14
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Abstract
Transfusion of whole blood largely was replaced by component therapy in the 1970s and 1980s. The recent military operations in Iraq and Afghanistan returned whole blood to military trauma care. Eventually, whole blood use was incorporated into some civilian trauma care. It has been utilized in several other civilian populations as well. Trials to compare whole blood to component therapy are ongoing.
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Affiliation(s)
- Elizabeth A Godbey
- Department of Pathology, Virginia Commonwealth University Health, Richmond, VA, USA.
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15
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Yazer MH, Dunbar NM, Delaney M. Survey of the RhD selection and issuing practices for uncrossmatched blood products at pediatric trauma hospitals in the United States: The BEST collaborative study. Transfusion 2021; 61:3328-3334. [PMID: 34595764 DOI: 10.1111/trf.16692] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 09/23/2021] [Accepted: 09/24/2021] [Indexed: 12/24/2022]
Abstract
BACKGROUND As evidence demonstrating the importance of early transfusions in trauma resuscitation accumulates, when RhD-negative products might not be available, it is important to understand the nature of the RhD-type of products provided to bleeding pediatric patients of potentially unknown RhD-type. METHODS A survey link was electronically sent to the transfusion service medical director and/or laboratory manager at American pediatric Level I and Level II hospitals inquiring about their practices for selecting RhD-type of uncrossmatched red blood cells (RBC) or low titer group O whole blood (LTOWB) for boys and girls. RESULTS There were 55/117 (47.0%) analyzable responses; 43/55 (78.2%) from Level I and 12/55 (21.8%) from Level II hospitals. For in hospital transfusions, 51/55 (92.7%) of centers use only RhD-negative blood products to resuscitate girls ≤18 years old while 30/55 (54.5%) of centers do the same for boys ≤18 years old. Most centers 41/55(74.5%) store RBCs and/or LTOWB in in-hospital remote refrigerators; 27 store only RhD-negative RBCs and 2 store only RhD-negative LTOWB units in these refrigerators. A total of 24/55 (43.6%) centers have RBCs and/or LTOWB available on road ambulances or helicopters for prehospital transfusion; 12 transport only RhD-negative RBCs and two transport only RhD-negative LTOWB. Most centers, 35/55 (63.6%), address the prophylaxis of an RhD-negative female recipient of RhD-positive transfusion on a case-by-case basis. CONCLUSION While there is some variability, most of the responding pediatric trauma centers routinely utilized RhD-negative RBCs for emergency transfusion for patients ≤18 years old of unknown RhD-type.
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Affiliation(s)
- Mark H Yazer
- Department of Pathology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Nancy M Dunbar
- Department of Pathology and Laboratory Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - Meghan Delaney
- Division of Pathology and Laboratory Medicine, Children's National Hospital, Washington, District of Columbia, USA.,Department of Pathology and Pediatrics, George Washington University Medical School, Washington, District of Columbia, USA
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Dishong D, Cap AP, Holcomb JB, Triulzi DJ, Yazer MH. The rebirth of the cool: a narrative review of the clinical outcomes of cold stored low titer group O whole blood recipients compared to conventional component recipients in trauma. ACTA ACUST UNITED AC 2021; 26:601-611. [PMID: 34411495 DOI: 10.1080/16078454.2021.1967257] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
There has been renewed interest in the use of low titer group O whole blood (LTOWB) for the resuscitation of civilian casualties. LTOWB offers several advantages over conventional components such as providing balanced resuscitation in one bag that contains less additive/preservative solution than an equivalent volume of conventional components, is easier and faster to transfuse than multiple components, avoids blood product ratio confusion, contains cold stored platelets, and reduces donor exposures. The resurgence in its use in the resuscitation of civilian trauma patients has led to the publication of an increasing number of studies on its use, primarily amongst adult recipients but also in pediatric patients. These studies have indicated that hemolysis does not occur amongst adult and pediatric non-group O recipients of a modest quantity of LTOWB. The published studies to date on mortality have shown conflicting results with some demonstrating a reduction following LTOWB transfusion while most others have not shown a reduction; there have not been any studies to date that have found significantly increased overall mortality amongst LTOWB recipients. Similarly, when other clinical outcomes, such as venous thromboembolism, sepsis, hospital or intensive care unit lengths of stay are evaluated, LTOWB recipients have not demonstrated worse outcomes compared to conventional component recipients. While definitive proof of the trends in these morbidity and mortality outcomes awaits confirmation in randomized controlled trials, the evidence to date indicates the safety of transfusing LTOWB to injured civilians.
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Affiliation(s)
| | - Andrew P Cap
- U.S. Army Institute of Surgical Research, JBSA-FT Sam Houston, TX, USA.,Department of Medicine, Uniformed Services University, Bethesda, MD, USA
| | - John B Holcomb
- Department of Surgery, University of Alabama, Birmingham, AL, USA
| | - Darrell J Triulzi
- Vitalant, Pittsburgh, PA, USA.,Department of Pathology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Mark H Yazer
- Vitalant, Pittsburgh, PA, USA.,Department of Pathology, University of Pittsburgh, Pittsburgh, PA, USA
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17
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Hagen KG, Strandenes G, Kristoffersen EK, Braathen H, Sivertsen J, Bjerkvig CK, Sommerfelt-Pettersen N, Aasheim IB, Lunde THF, Hervig T, Apelseth TO. A whole blood based resuscitation strategy in civilian medical services: Experience from a Norwegian hospital in the period 2017-2020. Transfusion 2021; 61 Suppl 1:S22-S31. [PMID: 34269432 DOI: 10.1111/trf.16490] [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: 01/05/2021] [Revised: 03/11/2021] [Accepted: 03/11/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND Civilian and military guidelines recommend early balanced transfusion to patients with life-threatening bleeding. Low titer group O whole blood was introduced as the primary blood product for resuscitation of massive hemorrhage at Haukeland University Hospital, Bergen, Norway, in December 2017. In this report, we describe the whole blood program and present results from the first years of routine use. STUDY DESIGN AND METHODS Patients who received whole blood from December 2017 to April 2020 were included in our quality registry for massive transfusions. Post-transfusion blood samples were collected to analyze isohemagglutinin (anti-A/-B) and hemolysis markers. Administration of other blood products, transfusion reactions, and patient survival (days 1 and 30) were recorded. User experiences were surveyed for both clinical and laboratory staff. RESULTS Two hundred and five patients (64% male and 36% female) received 836 units in 226 transfusion episodes. Patients received a mean of 3.7 units (range 1-35) in each transfusion episode. The main indications for transfusion were trauma (26%), gastrointestinal (22%), cardiothoracic/vascular (18%), surgical (18%), obstetric (11%), and medical (5%) bleeding. There was no difference in survival between patients with blood type O when compared with non-group O. Haptoglobin level was lower in the transfusion episodes for non-O group patients, however no clinical hemolysis was reported. No patients had conclusive transfusion-associated adverse events. Both clinical and laboratory staff preferred whole blood to component therapy for massive transfusion. DISCUSSION The experience from Haukeland University Hospital indicates that whole blood is feasible, safe, and effective for in-hospital treatment of bleeding.
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Affiliation(s)
- Kristin Gjerde Hagen
- Department of Immunology and Transfusion Medicine, Haukeland University Hospital, Bergen, Norway
| | - Geir Strandenes
- Department of Immunology and Transfusion Medicine, Haukeland University Hospital, Bergen, Norway.,Department of War Surgery and Emergency Medicine, Norwegian Armed Forces Medical Services, Sessvollmoen, Norway
| | - Einar Klaeboe Kristoffersen
- Department of Immunology and Transfusion Medicine, Haukeland University Hospital, Bergen, Norway.,Institute of Clinical Science, University of Bergen, Bergen, Norway
| | - Hanne Braathen
- Department of Immunology and Transfusion Medicine, Haukeland University Hospital, Bergen, Norway.,Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Joar Sivertsen
- Department of Immunology and Transfusion Medicine, Haukeland University Hospital, Bergen, Norway.,Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Christopher Kalhagen Bjerkvig
- Institute of Clinical Science, University of Bergen, Bergen, Norway.,Department of Anesthesia and Intensive Care, Haukeland University Hospital, Bergen, Norway
| | | | - Irmelin Beathe Aasheim
- Department of Immunology and Transfusion Medicine, Haukeland University Hospital, Bergen, Norway
| | - Turid Helen Felli Lunde
- Department of Immunology and Transfusion Medicine, Haukeland University Hospital, Bergen, Norway
| | - Tor Hervig
- Department of Immunology and Transfusion Medicine, Haukeland University Hospital, Bergen, Norway.,Institute of Clinical Science, University of Bergen, Bergen, Norway.,Laboratory of Immunology and Transfusion Medicine, Haugesund Hospital, Haugesund, Norway
| | - Torunn Oveland Apelseth
- Department of Immunology and Transfusion Medicine, Haukeland University Hospital, Bergen, Norway.,Department of War Surgery and Emergency Medicine, Norwegian Armed Forces Medical Services, Sessvollmoen, Norway
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18
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Meledeo MA, Peltier GC, McIntosh CS, Bynum JA, Corley JB, Cap AP. Coagulation function of never frozen liquid plasma stored for 40 days. Transfusion 2021; 61 Suppl 1:S111-S118. [PMID: 34269464 DOI: 10.1111/trf.16526] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2020] [Revised: 02/23/2021] [Accepted: 02/23/2021] [Indexed: 12/22/2022]
Abstract
BACKGROUND Never frozen liquid plasma (LP) has limited shelf life versus fresh frozen plasma (FFP) or plasma frozen within 24 h (PF24). Previous studies showed decreasing factor activities after Day (D)14 in thawed FFP but no differences between LP and FFP until D10. This study examined LP function through D40. STUDY DESIGN AND METHODS FFP and PF24 were stored at -20°C until assaying. LP was assayed on D5 then stored (4°C) for testing through D40. A clinical coagulation analyzer measured Factor (F)V, FVIII, fibrinogen, prothrombin time (PT), and activated partial thromboplastin time (aPTT). Thromboelastography (TEG) and thrombogram measured functional coagulation. Ristocetin cofactor assay quantified von Willebrand factor (vWF) activity. Residual platelets were counted. RESULTS FV/FVIII showed diminished activity over time in LP, while PT and aPTT both increased over time. LP vWF declined significantly by D7. Fibrinogen remained high through D40. Thrombin lagtime was delayed in LP but consistent to D40, while peak thrombin was significantly lower in LP but did not significantly decline over time. TEG R-time and angle remained constant. LP and PF24 (with residual platelets) had initially higher TEG maximum amplitudes (MA), but by D14 LP was similar to FFP. CONCLUSION Despite significant declines in some factors in D40 LP, fibrinogen concentration and TEG MA were stable suggesting stored LP provides fibrinogen similarly to frozen plasmas even at D40. LP is easier to store and prepare for prehospital transfusion, important benefits when the alternative is crystalloid.
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Affiliation(s)
| | - Grantham C Peltier
- U.S. Army Institute of Surgical Research, JBSA-Fort Sam Houston, Texas, USA
| | - Colby S McIntosh
- U.S. Army Institute of Surgical Research, JBSA-Fort Sam Houston, Texas, USA
| | - James A Bynum
- U.S. Army Institute of Surgical Research, JBSA-Fort Sam Houston, Texas, USA
| | - Jason B Corley
- Armed Services Blood Program, JBSA-Fort Sam Houston, Texas, USA
| | - Andrew P Cap
- U.S. Army Institute of Surgical Research, JBSA-Fort Sam Houston, Texas, USA
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19
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Schaefer R, Long T, Wampler D, Summers R, Epley E, Waltman E, Eastridge B, Jenkins D. Operationalizing the Deployment of Low-Titer O-Positive Whole Blood Within a Regional Trauma System. Mil Med 2021; 186:391-399. [PMID: 33499434 DOI: 10.1093/milmed/usaa283] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 07/16/2020] [Accepted: 08/24/2020] [Indexed: 12/22/2022] Open
Abstract
INTRODUCTION The implementation of a low-titer O+ whole blood (LTOWB) resuscitation algorithm, particularly in the prehospital environment, has several inherent challenges, including cost, limited and inconsistent supply, and the logistics of cold-chain management. The Southwest Texas Regional Advisory Council has implemented the nation's first multidisciplinary, multi-institutional regional LTOWB program. This research effort was to illustrate the successful deployment of LTOWB within a regional trauma system. MATERIALS AND METHODS A deliberate systems approach to the deployment of LTOWB was used. Tenets of this program included the active management of blood donor sources and blood supply levels to minimize wastage as a result of expiration, maximize product utilization, the use of prehospital transfusion triggers, and efforts to decrease program costs prehospital agencies. A novel LTOWB rotation system was established using the concept of a "rotation site" and "rotation center." Standardized transfusion criteria, a regional approved equipment list, a regional Prehospital Blood Product Transfusion Record, and a robust multilevel communication plan serves as the framework for the program. The San Antonio Whole Blood Consortium was developed to create a consensus driven forum to manage and guide the program. RESULTS From January 2018 to October 2019, LTOWB has been placed at 18 helicopter emergency medical services (HEMS) bases, 12 ground emergency medical service (EMS) agencies, 1 level I trauma center, and 1 level IV trauma center. A total of 450 patients have received a prehospital LTOWB transfusion. Program wide, the wastage rate of LTOWB due to expiration is between 1% and 2%. No complications related to prehospital LTOWB administration have been identified. DISCUSSION This work demonstrates a novel model for the development of a trauma system LTOWB program. The program's implementation augments remote damage control resuscitation strategies and requires the integration and collaboration of a multidisciplinary stakeholder team to optimize efficiency, performance, and safety of the program.
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Affiliation(s)
- Randall Schaefer
- Southwest Texas Regional Advisory Council (STRAC), San Antonio, TX 78227, USA
| | - Tasia Long
- Southwest Texas Regional Advisory Council (STRAC), San Antonio, TX 78227, USA
| | | | - Rena Summers
- Southwest Texas Regional Advisory Council (STRAC), San Antonio, TX 78227, USA
| | - Eric Epley
- Southwest Texas Regional Advisory Council (STRAC), San Antonio, TX 78227, USA
| | - Elizabeth Waltman
- South Texas Blood and Tissue Center (STBTC), San Antonio, TX 7820, USA
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20
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Bahr M, Cap AP, Dishong D, Yazer MH. Practical Considerations for a Military Whole Blood Program. Mil Med 2021; 185:e1032-e1038. [PMID: 32350539 DOI: 10.1093/milmed/usz466] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Revised: 12/10/2019] [Accepted: 12/12/2019] [Indexed: 02/06/2023] Open
Abstract
INTRODUCTION Prehospital care in the combat environment has always been of great importance to the U.S. military, and trauma resuscitation has remained a cornerstone. More evidence continues to demonstrate the advantages of intervention with early transfusion of blood products at the point of injury. The military has recognized these benefits; as such, the Department of Defense Joint Trauma System and the Committee on Tactical Combat Casualty Care have developed new advanced resuscitation guidelines, which now encourage the use of whole blood (WB) in the prehospital setting. MATERIALS AND METHODS This general review of peer-reviewed journal articles was performed through an extensive electronic search from the databases of PubMed Central (MEDLINE) and the Cochrane Library. RESULTS Based on this literature search, the current evidence suggests that transfusion with WB is safe and efficacious. Additionally, soldier function is preserved after donating fresh WB in the field. Currently, the collection and implementation of WB is accomplished through several different protocol-driven techniques. CONCLUSION WB has become the favored transfusion product as it provides all of the components of blood in a convenient package that is easy to store and transport. Specifically, group O WB containing low titers of anti-A and -B antibodies has become the transfusion product of choice, offering the ability to universally fluid resuscitate patients despite not knowing their blood group. This new ability to obtain low titer group O WB has transformed the approach to the management of hemorrhagic shock in the prehospital combat environment.
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Affiliation(s)
- Marshall Bahr
- Department of Internal Medicine, Allegheny Health Network, 320 E. North Ave, Pittsburgh, PA 15212
| | - Andrew P Cap
- US Army Institute of Surgical Research, 3650 Chambers Pass, JBSA-FT Sam Houston, San Antonio, TX 78234
| | - Devin Dishong
- Vitalant, 3636 Blvd of the Allies, Pittsburgh, PA 15213
| | - Mark H Yazer
- Vitalant, 3636 Blvd of the Allies, Pittsburgh, PA 15213.,Department of Pathology, University of Pittsburgh, 200 Lothrop St., Pittsburgh, PA 15213
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21
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Yazer MH, Freeman A, Harrold IM, Anto V, Neal MD, Triulzi DJ, Sperry JL, Seheult JN. Injured recipients of low-titer group O whole blood have similar clinical outcomes compared to recipients of conventional component therapy: A single-center, retrospective study. Transfusion 2021; 61:1710-1720. [PMID: 33811640 DOI: 10.1111/trf.16390] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Revised: 03/15/2021] [Accepted: 03/19/2021] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Low-titer group O whole blood (LTOWB) is being increasingly transfused to injured patients. This study evaluated a range of clinical outcomes to determine if receipt of LTOWB predisposed recipients to worse outcomes compared to recipients of conventional component therapy (CCT). METHODS A retrospective analysis of trauma patients who received at least 3 units of LTOWB (LTOWB group) versus those that received at least 3 units of RBCs, 1 unit of plasma and 1 unit of platelets but no LTOWB (CCT group) during the first 24 h of their admission was performed. Causal treatment effects were explored using propensity score matching (PSM) and coarsened exact matching (CEM). Important clinical outcomes were evaluated. RESULTS There were 165 CCT and 155 LTOWB recipients eligible for matching. PSM and CEM reduced covariate imbalances between the CCT and LTOWB groups, with the exception that males remained over-represented in the LTOWB group due to the hospital's former resuscitation policy of not administering RhD-positive LTOWB to females <50. In both of the matched analyses, the LTOWB group received a median of 4 LTOWB units. There were no significant differences in 6-, 24-h mortality or 30-day mortality between groups, nor were there differences in the frequency of other clinical outcomes such as acute kidney injury, sepsis, venous/arterial thromboembolism; delta MODS was lower for the LTOWB recipients in the exact match group. CONCLUSION In both matched analyses, administration of a median of four LTOWB units did not result in a different frequency of major clinical outcomes including mortality.
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Affiliation(s)
- Mark H Yazer
- Department of Pathology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Vitalant, Pittsburgh, Pennsylvania, USA
| | - Andrew Freeman
- Department of Pathology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Ian M Harrold
- Department of Pathology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Vincent Anto
- Department of Surgery, Pittsburgh Trauma Research Center, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Matthew D Neal
- Department of Surgery, Pittsburgh Trauma Research Center, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Darrell J Triulzi
- Department of Pathology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Vitalant, Pittsburgh, Pennsylvania, USA
| | - Jason L Sperry
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Jansen N Seheult
- Department of Pathology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Vitalant, Pittsburgh, Pennsylvania, USA
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22
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Yazer MH, Spinella PC, Anto V, Dunbar NM. Survey of group A plasma and low-titer group O whole blood use in trauma resuscitation at adult civilian level 1 trauma centers in the US. Transfusion 2021; 61:1757-1763. [PMID: 33797100 DOI: 10.1111/trf.16394] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 03/09/2021] [Accepted: 03/22/2021] [Indexed: 12/22/2022]
Abstract
BACKGROUND Recently revisited products like low-titer group O whole blood (LTOWB) and novel applications of group A as a universal donor of plasma are being used for trauma resuscitation. A survey of American Level 1 trauma centers was performed to elucidate the extent to which these products are currently employed. METHODS A survey was written that probed into the current use of blood products in trauma resuscitation with specific emphasis on LTOWB and group A plasma. A list of adult civilian Level 1 trauma centers in the continental USA was obtained from two public surgery and trauma focused websites. An email was then sent to each center's transfusion service medical director or laboratory manager providing them with a link to the online survey. RESULTS Responses were received from 103/187 (55%) adult civilian Level 1 trauma centers. For the resuscitation of trauma patients, group A plasma was used at 94/103 (91%) centers, while LTOWB was used at 43/103 (42%) centers. There were 39/103 (38%) centers that used both products. At 62/94 (66%) of the centers that used group A plasma, there was no limit on the number of units that could be administered, while an unlimited number of LTOWB units could be used at 5/43 (12%) of the centers that used LTOWB. RhD-positive LTOWB could be transfused to RhD-negative or RhD-type unknown females of childbearing potential at 22/43 (51%) of centers. CONCLUSION The use of group A plasma and LTOWB in trauma is increasing at American Level 1 trauma centers.
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Affiliation(s)
- Mark H Yazer
- Department of Pathology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Philip C Spinella
- Department of Pediatrics, Division of Critical Care Medicine, Washington University in St Louis, St Louis, Missouri, USA
| | - Vincent Anto
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Nancy M Dunbar
- Department of Pathology and Laboratory Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
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23
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Pulliam KE, Joseph B, Veile RA, Friend LA, Makley AT, Caldwell CC, Lentsch AB, Goodman MD, Pritts TA. Expired But Not Yet Dead: Examining the Red Blood Cell Storage Lesion in Extended-Storage Whole Blood. Shock 2021; 55:526-535. [PMID: 32826814 PMCID: PMC7937408 DOI: 10.1097/shk.0000000000001646] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
ABSTRACT Whole blood is a powerful resuscitation strategy for trauma patients but has a shorter shelf life than other blood products. The red blood cell storage lesion in whole blood has not previously been investigated beyond the standard storage period. In the present study, we hypothesized that erythrocytes in stored whole blood exhibit similar aspects of the red blood cell storage lesion and that transfusion of extended storage whole blood would not result in a more severe inflammatory response after hemorrhage in a murine model. To test this hypothesis, we stored low-titer, O-positive, whole blood units, and packed red blood cells (pRBCs) for up to 42 days, then determined aspects of the red blood cell storage lesion. Compared with standard storage pRBCs, whole blood demonstrated decreased microvesicle and free hemoglobin at 21 days of storage and no differences in osmotic fragility. At 42 days of storage, rotational thromboelastometry demonstrated that clotting time was decreased, alpha angle was increased, and clot formation time and maximum clot firmness similar in whole blood as compared with pRBCs with the addition of fresh frozen plasma. In a murine model, extended storage whole blood demonstrated decreased microvesicle formation, phosphatidylserine, and cell-free hemoglobin. After hemorrhage and resuscitation, TNF-a, IL-6, and IL-10 were decreased in mice resuscitated with whole blood. Red blood cell survival was similar at 24 h after transfusion. Taken together, these data suggest that red blood cells within whole blood stored for an extended period of time demonstrate similar or reduced accumulation of the red blood cell storage lesion as compared with pRBCs. Further examination of extended-storage whole blood is warranted.
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Affiliation(s)
- Kasiemobi E Pulliam
- Section of General Surgery, Department of Surgery, University of Cincinnati, Cincinnati, Ohio
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24
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Whole Blood Resuscitation for Pediatric Trauma: Why We Must Move Forward. CURRENT SURGERY REPORTS 2021. [DOI: 10.1007/s40137-021-00287-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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25
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Buren N. Laboratory Testing of Donated Blood. Transfus Med 2021. [DOI: 10.1002/9781119599586.ch7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Walsh M, Moore EE, Moore HB, Thomas S, Kwaan HC, Speybroeck J, Marsee M, Bunch CM, Stillson J, Thomas AV, Grisoli A, Aversa J, Fulkerson D, Vande Lune S, Sjeklocha L, Tran QK. Whole Blood, Fixed Ratio, or Goal-Directed Blood Component Therapy for the Initial Resuscitation of Severely Hemorrhaging Trauma Patients: A Narrative Review. J Clin Med 2021; 10:320. [PMID: 33477257 PMCID: PMC7830337 DOI: 10.3390/jcm10020320] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 01/15/2021] [Accepted: 01/15/2021] [Indexed: 12/21/2022] Open
Abstract
This narrative review explores the pathophysiology, geographic variation, and historical developments underlying the selection of fixed ratio versus whole blood resuscitation for hemorrhaging trauma patients. We also detail a physiologically driven and goal-directed alternative to fixed ratio and whole blood, whereby viscoelastic testing guides the administration of blood components and factor concentrates to the severely bleeding trauma patient. The major studies of each resuscitation method are highlighted, and upcoming comparative trials are detailed.
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Affiliation(s)
- Mark Walsh
- Notre Dame Campus, Indiana University School of Medicine, South Bend, IN 46617, USA; (M.W.); (J.S.); (M.M.); (C.M.B.); (J.S.); (A.V.T.); (A.G.)
- Departments of Emergency & Internal Medicine, Saint Joseph Regional Medical Center, Mishawaka, IN 46545, USA
| | - Ernest E. Moore
- Ernest E. Moore Shock Trauma Center, Denver Health, Denver, CO 80204, USA;
- Department of Surgery, University of Colorado Health Science Center, Denver, CO 80204, USA;
| | - Hunter B. Moore
- Department of Surgery, University of Colorado Health Science Center, Denver, CO 80204, USA;
| | - Scott Thomas
- Department of Trauma Surgery, Memorial Leighton Trauma Center, Beacon Health System, South Bend, IN 46601, USA;
| | - Hau C. Kwaan
- Division of Hematology and Oncology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA;
| | - Jacob Speybroeck
- Notre Dame Campus, Indiana University School of Medicine, South Bend, IN 46617, USA; (M.W.); (J.S.); (M.M.); (C.M.B.); (J.S.); (A.V.T.); (A.G.)
| | - Mathew Marsee
- Notre Dame Campus, Indiana University School of Medicine, South Bend, IN 46617, USA; (M.W.); (J.S.); (M.M.); (C.M.B.); (J.S.); (A.V.T.); (A.G.)
| | - Connor M. Bunch
- Notre Dame Campus, Indiana University School of Medicine, South Bend, IN 46617, USA; (M.W.); (J.S.); (M.M.); (C.M.B.); (J.S.); (A.V.T.); (A.G.)
| | - John Stillson
- Notre Dame Campus, Indiana University School of Medicine, South Bend, IN 46617, USA; (M.W.); (J.S.); (M.M.); (C.M.B.); (J.S.); (A.V.T.); (A.G.)
| | - Anthony V. Thomas
- Notre Dame Campus, Indiana University School of Medicine, South Bend, IN 46617, USA; (M.W.); (J.S.); (M.M.); (C.M.B.); (J.S.); (A.V.T.); (A.G.)
| | - Annie Grisoli
- Notre Dame Campus, Indiana University School of Medicine, South Bend, IN 46617, USA; (M.W.); (J.S.); (M.M.); (C.M.B.); (J.S.); (A.V.T.); (A.G.)
| | - John Aversa
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN 46202, USA;
| | - Daniel Fulkerson
- Department of Neurosurgery, Beacon Medical Group, South Bend, IN 46601, USA;
| | - Stefani Vande Lune
- Emergency Medicine Department, Navy Medicine Readiness and Training Command, Portsmouth, VA 23708, USA;
| | - Lucas Sjeklocha
- The R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD 21201, USA;
| | - Quincy K. Tran
- The R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD 21201, USA;
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Cruciani M, Franchini M, Mengoli C, Marano G, Pati I, Masiello F, Veropalumbo E, Pupella S, Vaglio S, Agostini V, Liumbruno GM. The use of whole blood in traumatic bleeding: a systematic review. Intern Emerg Med 2021; 16:209-220. [PMID: 32930966 DOI: 10.1007/s11739-020-02491-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Accepted: 09/01/2020] [Indexed: 12/11/2022]
Abstract
Hemostatic resuscitation is currently considered a standard of care for the management of life-threatening hemorrhage, but in some critical settings the access to high quantities of blood components is problematic. Whole blood (WB) transfusion has been proposed as an alternative modality for hemostatic resuscitation of traumatic major bleeding. To assess the efficacy and safety of WB in trauma-associated massive bleeding, we performed a systematic review of the literature. We selected studies comparing WB transfusions to transfusion of blood components (COMP) in massive trauma bleeding; both randomized clinical trial (RCT) and observational studies were considered. The outcomes were mortality (30-day/in-hospital and 24-h mortality) and adverse events/transfusion reactions. The effect sizes were crude odds ratio (OR), adjusted OR and hazard ratio (HR). The methodological quality of studies was assessed using the Cochrane Risk of Bias tool for RCTs, and the ROBIN-1 tool for observational studies. The overall quality of the available evidence was assessed with the GRADE system. One RCT (2 reports) and 6 cohort studies were included (3642 adult patients; 675 receiving WB, 2967 receiving COMP). Three studies were conducted in military setting, and 4 in civilian setting. In the overall analysis, 30-day/in-hospital and 24-h mortality did not differ significantly between groups (very low quality of the evidence due to high risk of bias, imprecision and inconsistency). After adjustment for baseline covariates in three cohort studies, the OR for mortality was significantly lower in WB recipients compared to COMP (OR 0.22; 95% CIs 0.10/0.45) (moderate grade of evidence). Adverse events and transfusion reactions were overlooked and not consistently reported. The available evidence does not allow to draw definite conclusions on the short-term and long-term efficacy and safety of WB transfusion compared to COMP transfusion. Further well designed research is needed.
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Affiliation(s)
- Mario Cruciani
- Italian National Blood Centre, Rome, Italy
- AULSS9 Scaligera, Infection Control Committee and Antibiotic Stewardship Programme, Verona, Italy
| | - Massimo Franchini
- Italian National Blood Centre, Rome, Italy.
- Department of Hematology and Transfusion Medicine, Carlo Poma Hospital, Mantua, Italy.
| | | | | | | | | | | | | | | | - Vanessa Agostini
- Italian National Blood Centre, Rome, Italy
- Immunohematology and Transfusion Service, IRCCS Policlinico San Martino, Genova, Italy
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Nationwide analysis of whole blood hemostatic resuscitation in civilian trauma. J Trauma Acute Care Surg 2020; 89:329-335. [PMID: 32744830 DOI: 10.1097/ta.0000000000002753] [Citation(s) in RCA: 62] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Renewed interest in whole blood (WB) resuscitation in civilians has emerged following its military use. There is a paucity of data on its role in civilians where balanced component therapy (CT) resuscitation is the standard of care. The aim of this study was to assess nationwide outcomes of using WB as an adjunct to CT versus CT alone in resuscitating civilian trauma patients. METHODS We analyzed the (2015-2016) Trauma Quality Improvement Program. We included adult (age, ≥18 years) trauma patients presenting with hemorrhagic shock and requiring at least 1 U of packed red blood cells (pRBCs) within 4 hours. Patients were stratified into WB-CT versus CT only. Primary outcomes were 24-hour and in-hospital mortality. Secondary outcomes were hospital length of stay and major complications. Hierarchical logistic regression was performed to account for clustering effect within hospitals and adjusting for patient- and hospital-level potential confounding factors. RESULTS A total of 8,494 patients were identified, of which 280 received WB-CT (WB, 1 [1-1]; pRBC, 16 [10-23]; FFP, 9 [6-16]; platelets, 3 [2-5]) and 8,214 received CT only (pRBC, 15 [10-24]; FFP, 10 [6-16]; platelets, 2 [1-4]). Mean ± SD age was 34 ± 16 years, 79% were male, Injury Severity Score was 33 (24-43), and 63% had penetrating injuries. Patients who received WB-CT had a lower 24-hour mortality (17% vs. 25%; p = 0.002), in-hospital mortality (29% vs. 40%; p < 0.001), major complications (29% vs. 41%; p < 0.001), and a shorter length of stay (9 [7-12] vs. 15 [10-21]; p = 0.011). On regression analysis, WB was independently associated with reduced 24-hour mortality (odds ratio [OR], 0.78 [0.59-0.89]; p = 0.006), in-hospital mortality (OR, 0.88 [0.81-0.90]; p = 0.011), and major complications (OR, 0.92 [0.87-0.96]; p = 0.013). CONCLUSION The use of WB as an adjunct to CT is associated with improved outcomes in resuscitation of severely injured civilian trauma patients. Further studies are required to evaluate the role of adding WB to massive transfusion protocols. LEVEL OF EVIDENCE Therapeutic, level IV.
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Jacob RP, Wang D, Hodghead K, Pham TD. Identifying correlations between donor demographics and isohemagglutinin titers as a potential method to screen for low-titer group O whole blood. Transfus Apher Sci 2020; 60:102970. [PMID: 33223473 DOI: 10.1016/j.transci.2020.102970] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 09/17/2020] [Accepted: 10/14/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND With more hospitals using low-titer group O whole blood in trauma resuscitation, having an efficient screening method for low-titer donors is critical. Our blood center uses an automated screen for high-titer isohemagglutinins in our platelet donations while collecting detailed donor demographic information. Using this data, we can identify key demographics often associated with titer status, thereby helping develop a donor-triaging method for titering. STUDY DESIGN AND METHODS Titer results were read with an automated microplate system as either high or low, based on agglutination, with a cutoff equivalent to 1:256 (both anti-A and anti-B). Donor demographic data analyzed included date of donation, blood group, age, gender, and ethnicity. RESULTS 57,508 donations were collected from 2073 unique donors between 2014 and 2018. We found the following demographics to be correlated with titer status: gender, ABO blood group, age, and ethnicity. Variability in titer status was identified in 215 individuals. This represented around 10 % of the total unique donors and was split equally amongst gender. We also found that donors between the ages of 41-60 ha d the highest likelihood of having variability in titer status, peaking at 13 %, and this proportion declined past age 60. CONCLUSION Titer status is associated with the following donor demographics: gender, ABO type, age, and ethnicity. We also discovered that variability in titer status is correlated with age. In blood centers that do not have automated and routine titer screening procedure, these findings could be used as a method to efficiently identify low-titer donors a-priori.
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Affiliation(s)
- Reuben P Jacob
- Department of Pathology, Stanford University School of Medicine, Stanford, CA, 94305, United States
| | - Duan Wang
- Stanford Blood Center, Stanford Medicine, Stanford, CA 94305, United States
| | - Kathryn Hodghead
- Stanford Blood Center, Stanford Medicine, Stanford, CA 94305, United States
| | - Tho D Pham
- Department of Pathology, Stanford University School of Medicine, Stanford, CA, 94305, United States; Stanford Blood Center, Stanford Medicine, Stanford, CA 94305, United States.
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Stanworth SJ, New HV, Apelseth TO, Brunskill S, Cardigan R, Doree C, Germain M, Goldman M, Massey E, Prati D, Shehata N, So-Osman C, Thachil J. Effects of the COVID-19 pandemic on supply and use of blood for transfusion. Lancet Haematol 2020; 7:e756-e764. [PMID: 32628911 PMCID: PMC7333996 DOI: 10.1016/s2352-3026(20)30186-1] [Citation(s) in RCA: 187] [Impact Index Per Article: 46.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 06/05/2020] [Accepted: 06/08/2020] [Indexed: 01/28/2023]
Abstract
The COVID-19 pandemic has major implications for blood transfusion. There are uncertain patterns of demand, and transfusion institutions need to plan for reductions in donations and loss of crucial staff because of sickness and public health restrictions. We systematically searched for relevant studies addressing the transfusion chain-from donor, through collection and processing, to patients-to provide a synthesis of the published literature and guidance during times of potential or actual shortage. A reduction in donor numbers has largely been matched by reductions in demand for transfusion. Contingency planning includes prioritisation policies for patients in the event of predicted shortage. A range of strategies maintain ongoing equitable access to blood for transfusion during the pandemic, in addition to providing new therapies such as convalescent plasma. Sharing experience and developing expert consensus on the basis of evolving publications will help transfusion services and hospitals in countries at different stages in the pandemic.
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Affiliation(s)
- Simon J Stanworth
- Transfusion Medicine, NHS Blood and Transplant, Oxford, UK; Department of Haematology, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford, UK; Radcliffe Department of Medicine and NIHR Oxford Biomedical Research Centre-Haematology Theme, University of Oxford, Oxford, UK.
| | - Helen V New
- NHS Blood and Transplant, London, UK; Department of Haematology, Imperial College London, London, UK
| | - Torunn O Apelseth
- Department of Immunology and Transfusion Medicine, Haukeland University Hospital, Bergen, Norway; Norwegian Armed Forces Medical Services, Oslo, Norway
| | - Susan Brunskill
- Systematic Review Initiative, NHS Blood and Transplant, Oxford, UK
| | - Rebecca Cardigan
- NHS Blood and Transplant, Cambridge, UK; Department of Haematology, University of Cambridge, Cambridge, UK
| | - Carolyn Doree
- Systematic Review Initiative, NHS Blood and Transplant, Oxford, UK
| | - Marc Germain
- Medical Affairs and Innovation, Héma-Québec, Québec, QC, Canada
| | - Mindy Goldman
- Medical Affairs and Innovation, Canadian Blood Services, Ottawa, ON, Canada
| | | | - Daniele Prati
- Department of Transfusion Medicine and Hematology, IRCCS Ca 'Granda Hospital Maggiore Policlinico Foundation, Milan, Italy
| | - Nadine Shehata
- Department of Medicine, Division of Haematology, Mount Sinai Hospital, ON, Canada; Department of Medicine, and Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada; University Health Network, Department of Medicine, Division of Medical Oncology and Haematology, Toronto, ON, Canada
| | - Cynthia So-Osman
- Department of Transfusion Medicine, Sanquin Blood Supply Foundation, Amsterdam, Netherlands; Department of Haematology, Erasmus Medical Center, Rotterdam, Netherlands
| | - Jecko Thachil
- Manchester University NHS Foundation Trust, Manchester, UK
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Hervig TA, Doughty HA, Cardigan RA, Apelseth TO, Hess JR, Noorman F, Bohoněk M, Yazer MH, Lu J, Wendel S, Sparrow RL. Re-introducing whole blood for transfusion: considerations for blood providers. Vox Sang 2020; 116:167-174. [PMID: 32996604 DOI: 10.1111/vox.12998] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 08/11/2020] [Indexed: 12/31/2022]
Abstract
Whole blood is the original blood preparation but disappeared from the blood bank inventories in the 1980s following the advent of component therapy. In the early 2000s, both military and civilian practice called for changes in the transfusion support for massive haemorrhage. The 'clear fluid' policy was abandoned and replaced by early balanced transfusion of platelets, plasma and red cells. Whole blood is an attractive alternative to multi-component therapy, which offers reduced hemodilution, lower donor exposure and simplified logistics. However, the potential for wider re-introduction of whole blood requires re-evaluation of haemolysins, storage conditions and shelf-life, the need for leucocyte depletion/ pathogen reduction and inventory management for blood providers. This review addresses these questions and calls for research to define the optimal whole blood product and the indications for its use.
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Affiliation(s)
- Tor A Hervig
- Blood Bank, Haugesund hospital, Haugesund, Norway
| | | | | | - Torunn O Apelseth
- Department of Immunology and Transfusion Medicine, Haukeland University Hospital, Bergen, Norway
| | - John R Hess
- Laboratory Medicine, University of Washington, Seattle, WA, USA
| | - Femke Noorman
- Quality, Research and Development, Military Blood Bank, Leiden, Netherlands
| | - Miloš Bohoněk
- Hematology, Biochemistry and Blood Transfusion, Central Military Hospital Prague, Prague, Czech Republic
| | - Mark H Yazer
- Department of Pathology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jia Lu
- Defence Medical & Environmental Research Institute, DSO National Laboratories (Kent Ridge), Singapore City, Singapore
| | | | - Rosemary L Sparrow
- Epidemiology and Preventive Medicine, Monash University, Melbourne, Vic, Australia
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Herzig MC, Fedyk CG, Montgomery RK, Schaffer BS, Bynum JA, Pidcoke HF, Cap AP. Blood component separation of pathogen-reduced whole blood by the PRP method produces acceptable red cells but platelet yields and function are diminished. Transfusion 2020; 60 Suppl 3:S124-S133. [PMID: 32478864 DOI: 10.1111/trf.15766] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Revised: 03/03/2020] [Accepted: 03/03/2020] [Indexed: 12/23/2022]
Abstract
BACKGROUND This study evaluated blood components processed by the platelet rich plasma (PRP) method from fresh whole blood (FWB) treated with a pathogen reduction technology (PRT). The effects of storage temperature on PRT treated platelet concentrates (PCs) were also examined. STUDY DESIGN AND METHODS PRT was performed using riboflavin and ultraviolet light on FWB in citrate phosphate dextrose anticoagulant. Following PRT, red blood cells (RBCs), PCs, and plasma for fresh frozen plasma (FFP), were isolated by sequential centrifugation. RBCs were stored at 4°C, FFP at -80°C, and PC at 22°C or at 4°C. Components were assayed throughout their storage times for blood gases, chemistry and CBC, hemostatic function as well as platelet (PLT) and RBC integrity. RESULTS Component processing following PRT resulted in a significant drop in platelet recovery. Most PRT-PC bags fell below AABB guidelines for platelet count. PRT-PC also showed a decrease in clot strength and decreased aggregometry response. Platelet caspases were activated by PRT. Storage at 4°C improved platelet function. In PRT-FFP, prothrombin time and partial thromboplastin time (PT and aPTT) were prolonged; factors V, VII, VIII, and XI, protein C, and fibrinogen were significantly decreased. Free hemoglobin was elevated two-fold in PRT-RBC. CONCLUSION Blood components isolated by the PRP method from PRT-treated WB result in a high percentage of PC that fail to meet AABB guidelines. FFP also shows diminished coagulation capacity. However, PRT-RBC are comparable to control-RBC. PRT-WB retains acceptable hemostatic function but alternatives to the PRP method of component separation may be more suitable.
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Affiliation(s)
- Maryanne C Herzig
- Coagulation & Blood Research, US Army Institute of Surgical Research, JBSA Fort Sam Houston, Texas, USA
| | - Chriselda G Fedyk
- Coagulation & Blood Research, US Army Institute of Surgical Research, JBSA Fort Sam Houston, Texas, USA
| | - Robbie K Montgomery
- Coagulation & Blood Research, US Army Institute of Surgical Research, JBSA Fort Sam Houston, Texas, USA
| | - Beverly S Schaffer
- Coagulation & Blood Research, US Army Institute of Surgical Research, JBSA Fort Sam Houston, Texas, USA
| | - James A Bynum
- Coagulation & Blood Research, US Army Institute of Surgical Research, JBSA Fort Sam Houston, Texas, USA.,Institute of Biomedical Studies, Baylor University, Waco, Texas, USA.,Joint Interdisciplinary Biomedical Engineering Program, UT San Antonio & UT Health San Antonio, San Antonio, Texas, USA
| | - Heather F Pidcoke
- Coagulation & Blood Research, US Army Institute of Surgical Research, JBSA Fort Sam Houston, Texas, USA
| | - Andrew P Cap
- Coagulation & Blood Research, US Army Institute of Surgical Research, JBSA Fort Sam Houston, Texas, USA.,Department of Surgery, UT Health San Antonio, San Antonio, Texas, USA
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33
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Jackson B, Murphy C, Fontaine MJ. Current state of whole blood transfusion for civilian trauma resuscitation. Transfusion 2020; 60 Suppl 3:S45-S52. [DOI: 10.1111/trf.15703] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Revised: 01/24/2020] [Accepted: 01/24/2020] [Indexed: 12/14/2022]
Affiliation(s)
- Bryon Jackson
- Department of Pathology, University of Maryland School of Medicine Baltimore Maryland
| | - Colin Murphy
- Department of Pathology, University of Maryland School of Medicine Baltimore Maryland
| | - Magali J. Fontaine
- Department of Pathology, University of Maryland School of Medicine Baltimore Maryland
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Abstract
OBJECTIVES To critically assess available high-level clinical studies regarding RBC transfusion strategies, with a focus on hemoglobin transfusion thresholds in the ICU. DATA SOURCES Source data were obtained from a PubMed literature review. STUDY SELECTION English language studies addressing RBC transfusions in the ICU with a focus on the most recent relevant studies. DATA EXTRACTION Relevant studies were reviewed and the following aspects of each study were identified, abstracted, and analyzed: study design, methods, results, and implications for critical care practice. DATA SYNTHESIS Approximately 30-50% of ICU patients receive a transfusion during their hospitalization with anemia being the indication for 75% of transfusions. A significant body of clinical research evidence supports using a restrictive transfusion strategy (e.g., hemoglobin threshold < 7 g/dL) compared with a more liberal approach (e.g., hemoglobin threshold < 10 g/dL). A restrictive strategy (hemoglobin < 7 g/dL) is recommended in patients with sepsis and gastrointestinal bleeds. A slightly higher restrictive threshold is recommended in cardiac surgery (hemoglobin < 7.5 g/dL) and stable cardiovascular disease (hemoglobin < 8 g/dL). Although restrictive strategies are generally supported in hematologic malignancies, acute neurologic injury, and burns, more definitive studies are needed, including acute coronary syndrome. Massive transfusion protocols are the mainstay of treatment for hemorrhagic shock; however, the exact RBC to fresh frozen plasma ratio is still unclear. There are also emerging complimentary practices including nontransfusion strategies to avoid and treat anemia and the reemergence of whole blood transfusion. CONCLUSIONS The current literature supports the use of restrictive transfusion strategies in the majority of critically ill populations. Continued studies of optimal transfusion strategies in various patient populations, coupled with the integration of novel complementary ICU practices, will continue to enhance our ability to treat critically ill patients.
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Acker JP, Seghatchian J. Opportunities for standardization of cold stored, low-titre group O WB products. Transfus Apher Sci 2020; 59:102787. [PMID: 32354678 DOI: 10.1016/j.transci.2020.102787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Interest in the use of cold-stored low-titre, group O whole blood (LTO-WB) in civilian trauma medicine has motivated regional and national blood services to explore the operational implications of providing this product to their hospital customers. While simpler to produce, store and administer than conventional blood components, LTO-WB is only distributed by a limited number of civilian blood services to date. To improve the availability of LTO-WB, there are still a number of clinical and basic research challenges that need to be addressed including 1. Standardization of the methods and definitions for what constitutes "low-titre" whole blood; 2. Updating regulatory standards for the in vitro quality of cold stored whole blood; 3. Development of standards for the post-storage component separation of red blood cells from cold stored whole blood; and 4. Optimization of the logistics for collection and distribution of cold stored whole blood in regional and national blood systems. The main objective of this concise overview is to highlight the opportunities for future research and product development efforts that will improve the availability of standardised LTO-WB products in emergency cases to the benefit of all concerned.
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Affiliation(s)
- Jason P Acker
- Centre for Innovation, Canadian Blood Services, Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, Alberta, Canada.
| | - Jerard Seghatchian
- International Consultancy in Strategic Safety/Quality Improvements of Blood- Derived Bioproducts and Suppliers Quality Audit / Inspection, London, England, UK
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Abstract
Over the past decade, the shift toward damage control surgery for bleeding trauma patients has come with an increased emphasis on optimal resuscitation. Two lifesaving priorities predominate: to quickly stop the bleed and effectively resuscitate the hemorrhagic shock. Blood is separated into components for efficient storage and distribution; however, bleeding patients require all components in a balanced ratio. A variety of blood products are available to surgeons, and these products have evolved over time. This review article describes the current standards for resuscitation of bleeding patients, including characteristics of all available products. The relevant details of blood donation and collection, blood banking, blood components, and future therapies are discussed, with the goal of guiding surgeons in their emergency transfusion practice.
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37
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Jassim H, Al-Mamoori H. Evaluation of anti-A and anti-B IgM and anti-AB IgG antibody titers in Group O blood Iraqi donors. IRAQI JOURNAL OF HEMATOLOGY 2020. [DOI: 10.4103/ijh.ijh_43_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Gallaher JR, Schreiber MA. A Review of Whole Blood: Current Trauma Reports. CURRENT TRAUMA REPORTS 2019. [DOI: 10.1007/s40719-019-00178-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Yazer MH, Delaney M, Doughty H, Dunbar NM, Al‐Riyami AZ, Triulzi DJ, Watchko JF, Wood EM, Yahalom V, Emery SP. It is time to reconsider the risks of transfusing RhD negative females of childbearing potential with RhD positive red blood cells in bleeding emergencies. Transfusion 2019; 59:3794-3799. [DOI: 10.1111/trf.15569] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Revised: 09/21/2019] [Accepted: 09/26/2019] [Indexed: 12/17/2022]
Affiliation(s)
- Mark H. Yazer
- Department of PathologyUniversity of Pittsburgh Pittsburgh Pennsylvania
- Vitalant Pittsburgh Pennsylvania
| | - Meghan Delaney
- Division of Pathology and Laboratory MedicineChildren's National Medical Center Washington District of Columbia
- Department of Pathology and PediatricsGeorge Washington University Medical School Washington District of Columbia
| | | | - Nancy M. Dunbar
- Department of Pathology and Laboratory MedicineDartmouth‐Hitchcock Medical Center Lebanon New Hampshire
| | - Arwa Z. Al‐Riyami
- Department of HematologySultan Qaboos University Hospital Muscat Oman
| | - Darrell J. Triulzi
- Department of PathologyUniversity of Pittsburgh Pittsburgh Pennsylvania
- Vitalant Pittsburgh Pennsylvania
| | - Jon F. Watchko
- Department of PediatricsUniversity of Pittsburgh School of Medicine Pittsburgh Pennsylvania
| | - Erica M. Wood
- Transfusion Research UnitSchool of Public Health and Preventive Medicine, Monash University Melbourne Australia
- Department of Clinical HaematologyMonash Health Melbourne Australia
| | - Vered Yahalom
- Rabin Medical CenterBlood Services and Apheresis Institute Petah Tiqva Israel
| | - Stephen P. Emery
- Department of Obstetrics, Gynecology and Reproductive SciencesUniversity of Pittsburgh School of Medicine Pittsburgh Pennsylvania
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40
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Doughty H, Strandenes G. Whole blood in disaster and major incident planning. ACTA ACUST UNITED AC 2019. [DOI: 10.1111/voxs.12503] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Heidi Doughty
- NHS Blood and Transplant Birmingham UK
- College of Medical and Dental Sciences University of Birmingham Birmingham UK
| | - Geir Strandenes
- Department of Immunology and Transfusion Medicine Haukeland University Hospital Bergen Norway
- Department of War Surgery and Emergency Medicine Norwegian Armed Forces Medical Services Oslo Norway
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Wang S, Zhao G, Li N, Hou T, Shao X, Tang W, Wang F, Luan J, Zhu P. An
in vitro
study of coagulation properties in refrigerated whole blood and reconstituted whole blood. Vox Sang 2019; 114:694-700. [PMID: 31286533 DOI: 10.1111/vox.12825] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Revised: 06/09/2019] [Accepted: 06/10/2019] [Indexed: 11/27/2022]
Affiliation(s)
- Shujun Wang
- Department of Blood Transfusion Jinling Hospital Nanjing University School of Medicine Nanjing China
- Department of Hematology Zhongda Hospital Southeast University School of Medicine Nanjing China
| | - Guangchao Zhao
- Department of Blood Transfusion Jinling Hospital Nanjing University School of Medicine Nanjing China
| | - Na Li
- Department of Blood Transfusion Jinling Hospital Nanjing University School of Medicine Nanjing China
| | - Tao Hou
- TaiKang Xian Lin Drum Tower Hospital Nanjing China
| | - Xiaobao Shao
- Department of Transfusion Medicine Third Affiliated Hospital of Nanjing University of Chinese Medicine Nanjing China
| | - Wen Tang
- Department of Blood Transfusion Jinling Hospital Nanjing University School of Medicine Nanjing China
| | - Fei Wang
- Department of Hematology Zhongda Hospital Southeast University School of Medicine Nanjing China
| | - Jianfeng Luan
- Department of Blood Transfusion Jinling Hospital Nanjing University School of Medicine Nanjing China
| | - Peiyuan Zhu
- Department of Transfusion Medicine Third Affiliated Hospital of Nanjing University of Chinese Medicine Nanjing China
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42
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Seheult JN, Bahr MP, Spinella PC, Triulzi DJ, Yazer MH. The Dead Sea needs salt water… massively bleeding patients need whole blood: The evolution of blood product resuscitation. Transfus Clin Biol 2019; 26:174-179. [PMID: 31262629 DOI: 10.1016/j.tracli.2019.06.003] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Accepted: 06/09/2019] [Indexed: 01/30/2023]
Abstract
Whole blood, that is blood that is not manufactured into its component red blood cells (RBC) plasma, and platelets (PLT) units, was the mainstay of transfusion for many years until it was discovered that the component parts of a blood donation could be stored under different conditions thereby optimizing the storage length of each product. The use of low anti-A and -B titer group O whole blood (LTOWB) has recently been rediscovered for use in massively bleeding trauma patients. Whole blood has several advantages over conventional component therapy for these patients, including simplifying the logistics of the resuscitation, being more concentrated than whole blood that is reconstituted from conventional components, and providing cold-stored PLTs, amongst other benefits. While randomized controlled trials to determine the efficacy of using LTOWB in the resuscitation of massively bleeding trauma patients are currently underway, retrospective data has shown that massively bleeding recipients of LTOWB with traumatic injury do not have worse outcomes compared to patients who received conventional components and, in some cases, recipients of LTOWB have more favourable outcomes. This paper will describe some of the advantages of using LTOWB and will discuss the emerging evidence for its use in massively bleeding patients.
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Affiliation(s)
- J N Seheult
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN 55905, USA.
| | - M P Bahr
- Vitalant, 3636 Boulevard of the Allies, Pittsburgh, PA 15213, USA.
| | - P C Spinella
- Department of Pediatrics, Division of Critical Care Medicine, Washington University in St Louis, 660 S Euclid Avenue # 8124, Saint Louis, MO 63110, USA.
| | - D J Triulzi
- Vitalant, 3636 Boulevard of the Allies, Pittsburgh, PA 15213, USA; Department of Pathology, University of Pittsburgh, Pittsburgh, PA 15269, USA.
| | - M H Yazer
- Vitalant, 3636 Boulevard of the Allies, Pittsburgh, PA 15213, USA; Department of Pathology, University of Pittsburgh, Pittsburgh, PA 15269, USA.
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Wang Z, Zhang Y, Zhou Q, Ma P, Wang X, Zhan L. Noninvasive imaging of hepatocyte IL-6/STAT3 signaling pathway for evaluating inflammation responses induced by end-stage stored whole blood transfusion. Biotechnol Lett 2019; 41:733-742. [DOI: 10.1007/s10529-019-02688-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2018] [Accepted: 05/05/2019] [Indexed: 12/13/2022]
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Harm SK, Dunbar NM. Immunologic risks of whole blood: ABO compatibility, D alloimmunization, and transfusion-related acute lung injury. Transfusion 2019; 59:1507-1511. [PMID: 30980758 DOI: 10.1111/trf.15168] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Revised: 10/02/2018] [Accepted: 10/03/2018] [Indexed: 11/30/2022]
Affiliation(s)
- Sarah K Harm
- University of Vermont Medical Center, Burlington, Vermont
| | - Nancy M Dunbar
- Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
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45
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Bailey JD, Fisher AD, Yazer MH, Howard JT, Corley JB, Miles EA, Cap AP. Changes in donor antibody titer levels over time in a military group O low‐titer whole blood program. Transfusion 2019; 59:1499-1506. [DOI: 10.1111/trf.15162] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Revised: 10/26/2018] [Accepted: 10/28/2018] [Indexed: 11/30/2022]
Affiliation(s)
| | - Andrew D. Fisher
- 75th Ranger Regiment FT Benning Georgia
- Texas A&M College of Medicine Temple Bryan Texas
- Texas Army National Guard San Antonio Texas
| | - Mark H. Yazer
- The Institute for Transfusion Medicine and Department of PathologyUniversity of Pittsburgh Pittsburgh Pennsylvania
| | | | | | | | - Andrew P. Cap
- U.S. Army Institute of Surgical Research JBSA‐FT Sam Houston Texas
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46
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Implementation of a protocol for prehospital transfusion of low-titer, leukocyte-depleted whole blood for civilian bleeding patients. Transfus Apher Sci 2019; 58:212-215. [DOI: 10.1016/j.transci.2019.03.012] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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47
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Beddard R, Ngamsuntikul S, Wafford T, Aranda L. Immunoglobulin M anti-A and anti-B titers in South Texas group O D+ male donors. Transfusion 2019; 59:2207-2210. [PMID: 30897224 DOI: 10.1111/trf.15273] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Revised: 02/21/2019] [Accepted: 02/28/2019] [Indexed: 01/22/2023]
Abstract
BACKGROUND The success of whole blood (WB) in damage control resuscitation on the battlefield has generated interest in its use for civilian trauma. Blood centers must maintain a committed donor pool with low isoagglutinin titers to provide this product. Information regarding isoagglutinin titers in different donor populations will help with targeted recruitment of these donors. STUDY DESIGN AND METHODS Sequential O D+ male donors with a history of two or more donations at a fixed site were tested for immunoglobulin (Ig)M anti-A and anti-B using a single titer cutoff of 256. Donors testing negative at this cutoff were considered "low titer" while positive donors were considered "high titer." Age and self-identified race/ethnicity were retrospectively obtained from the blood establishment computer system. Fisher's exact analysis was used for statistical analysis with a p value of less than 0.05 considered significant. RESULTS Of 3274 donors, 426 tested as high titer, while 2848 tested as low titer. The data show an association of donor age and prevalence of high titers with older age groups showing a lower prevalence of high titers. In addition, different races/ethnicities have different prevalences of high titers with the Caucasian/white group showing a lower prevalence of high-titer donors versus the Hispanic and undeclared race groups. CONCLUSION The prevalence of high-titer IgM anti-A or -B donors varies by age group and race/ethnicity in our data set. This information will provide information on what donor groups to target for collection of low-titer O WB.
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Affiliation(s)
| | | | - Tiffany Wafford
- Immunohematology Reference Laboratory, QualTex Laboratories, San Antonio, Texas
| | - Lorena Aranda
- Immunohematology Reference Laboratory, QualTex Laboratories, San Antonio, Texas
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48
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Vanderspurt CK, Spinella PC, Cap AP, Hill R, Matthews SA, Corley JB, Gurney JM. The use of whole blood in US military operations in Iraq, Syria, and Afghanistan since the introduction of low-titer Type O whole blood: feasibility, acceptability, challenges. Transfusion 2018; 59:965-970. [PMID: 30548277 DOI: 10.1111/trf.15086] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2018] [Revised: 09/14/2018] [Accepted: 09/18/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND Hemorrhage is the leading cause of preventable death in military and civilian traumatic injury. Blood product resuscitation improves survival. Low-titer Type O Whole Blood (LTOWB) was recently re-introduced to the combat theater as a universal resuscitation product for hemorrhagic shock. This study assessed the utilization patterns of LTOWB compared to warm fresh whole blood (WFWB) and blood component therapy (CT) in US Military Operations in Iraq/Syria and Afghanistan known as Operation Inherent Resolve (OIR) and Operation Freedom's Sentinel (OFS) respectively. We hypothesized LTOWB utilization would increase over time given its advantages. STUDY DESIGN AND METHODS Using the Theater Medical Data Store, patients receiving blood products between January 2016 and December 2017 were identified. Product utilization ratios (PUR) for LTOWB, WFWB, and CT were compared across Area of Operations (AORs), medical treatment facilities (Role 2 vs. Role 3), and time. PUR was defined as number of blood products transfused/(number of blood products transfused + number of blood products wasted). RESULTS The overall PUR for all blood products was 17.4%; the LTOWB PUR was 14.3%. Over the study period, the total number of blood products transfused increased 133%. Although the total whole blood (WB) increased from 2.1% to 6.6% of all products transfused, WFWB use remained at 2% while LTOWB transfusions increased from 0.5% to 4%. Transfusion of LTOWB occurred more in austere Role 2 facilities compared to Role 3 hospitals. CONCLUSIONS LTOWB transfusion is feasible in austere, far-forward environments. Further investigation is needed regarding the safety, clinical outcomes, and drivers of LTOWB transfusions.
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Affiliation(s)
- Cecily K Vanderspurt
- Division of Emergency Medicine, Martin Army Community Hospital, Fort Benning, Georgia
| | - Philip C Spinella
- Division of Critical Care, Department of Pediatrics, Washington University in St Louis School of Medicine, St. Louis, Missouri
| | - Andrew P Cap
- Joint Trauma System, U.S. Army Institute of Surgical Research, JBSA-Fort Sam Houston, Texas
| | - Ronnie Hill
- Department of Pathology, Carl R. Darnall Army Medical Center, Fort Hood, Texas
| | - Sarah A Matthews
- Department of Pathology, Madigan Army Medical Center, Joint Base Lewis-McChord, Washington
| | - Jason B Corley
- Armed Service Blood Program, Brooke Army Medical Center, JBSA-Fort Sam Houston, Texas
| | - Jennifer M Gurney
- Armed Service Blood Program, Brooke Army Medical Center, JBSA-Fort Sam Houston, Texas.,Department of Surgery, Uniformed Services University of Health Sciences, Bethesda, Maryland
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49
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Shi W, Al-Sabti R, Burke PA, Gonzalez M, Mantilla-Rey N, Quillen K. Quality Management of massive transfusion protocol incorporating tranexamic acid adherence. Transfus Apher Sci 2018; 57:785-789. [PMID: 30455154 DOI: 10.1016/j.transci.2018.10.003] [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: 07/27/2018] [Revised: 09/22/2018] [Accepted: 10/16/2018] [Indexed: 11/16/2022]
Abstract
Massive transfusion protocols (MTP) vary at different institutions. We implemented an algorithm in the transfusion service to support our Level I trauma center in 2007 and periodically monitor MTP utilization as part of ongoing quality management. At the last review in 2013, median plasma: RBC ratio was 1:1.8. We undertook a retrospective 3-year review of MTP activations stratifying by trauma versus non-trauma indications, and blood component utilization of the massive transfusion (MT) cases, adding a review of tranexamic acid (TXA) administration to the audit. The median transfused plasma: RBC ratio was 1:1.9 in trauma MT, and 1:1.6 in the non-trauma MT cases. Non-trauma MT patients at our institution were significantly older and more coagulopathic at MTP initiation compared to trauma MT patients, received fewer RBC units (15.5 versus 20.2), and had higher mortality. TXA adherence increased over the 3-year period to 60% of all trauma MTP activations in 2017.
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Affiliation(s)
- Weiwei Shi
- Department of Pathology and Laboratory Medicine, Boston University Medical Center, Boston, MA, 02118, United States.
| | - Ram Al-Sabti
- Department of Pathology and Laboratory Medicine, Boston University Medical Center, Boston, MA, 02118, United States
| | - Peter A Burke
- Department of Surgery, Boston University Medical Center, United States
| | - Mauricio Gonzalez
- Department of Anesthesiology, Boston University Medical Center, United States
| | - Nelson Mantilla-Rey
- Department of Pathology and Laboratory Medicine, Boston University Medical Center, Boston, MA, 02118, United States
| | - Karen Quillen
- Department of Pathology and Laboratory Medicine, Boston University Medical Center, Boston, MA, 02118, United States
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DeMario VM, Sikorski RA, Efron DT, Serbanescu MA, Buchanan RM, Wang EJ, Visagie M, Gehrie EA, Manukyan MC, Noll K, Ken Lee KH, Ness PM, Frank SM. Blood utilization and mortality in victims of gun violence. Transfusion 2018; 58:2326-2334. [PMID: 30209804 DOI: 10.1111/trf.14925] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2018] [Revised: 08/08/2018] [Accepted: 08/08/2018] [Indexed: 12/23/2022]
Abstract
BACKGROUND Blood transfusion can be lifesaving for patients with hemorrhage; however, transfusion requirements for victims of gun violence are poorly understood. STUDY DESIGN AND METHODS In an urban, Level 1 trauma center, 23,422 trauma patients were analyzed in a retrospective cohort study. Patients with gunshot wounds (GSWs) (n = 2,672; 11.4% of trauma patients) were compared to those with non-GSW traumatic injuries from 2005 to 2017, to assess blood utilization. RESULTS The GSW cohort was approximately five times more likely to require transfusion (538 of 2672 [20.1%] vs. 798 of 20,750 [3.9%]; p < 0.0001), and the number of blood component units transfused per patient was approximately 10 times greater (3.3 ± 13.5 vs. 0.31 ± 3.8 units/patient; p < 0.0001), compared to the non-GSW cohort. The risk-adjusted likelihood of requiring high-dose transfusion was greater in the GSW cohort (odds ratio, 2.38; 95% confidence interval, 1.14-5.80), and requirements were increased for all four blood components (red blood cells, platelets, plasma, and cryoprecipitate). Patients with GSWs had approximately 14 times greater overall mortality (653 of 2672 [24.4%] vs. 352 of 20,750 [1.7%]; p < 0.0001]. Compared to non-GSW penetrating injuries (e.g., stab wounds), those with GSWs had approximately four times higher transfusion requirements (3.3 ± 13.5 vs. 0.80 ± 3.8 units/patient; p < 0.0001), and approximately eight times greater overall mortality (653 of 2672 [24.4%] vs. 28 of 956 [2.9%]; p < 0.0001). CONCLUSIONS Compared to other traumatic injuries, GSW injuries are associated with substantially greater blood utilization and mortality. Trauma centers treating GSW injuries should have ready access to all blood components and ability to implement massive transfusions.
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Affiliation(s)
- Vincent M DeMario
- Department of Anesthesiology/Critical Care Medicine, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Robert A Sikorski
- Department of Anesthesiology/Critical Care Medicine, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - David T Efron
- Department of Surgery, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Mara A Serbanescu
- Department of Anesthesiology/Critical Care Medicine, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Rica M Buchanan
- Department of Anesthesiology/Critical Care Medicine, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Eric J Wang
- Department of Anesthesiology/Critical Care Medicine, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Mereze Visagie
- Department of Anesthesiology/Critical Care Medicine, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Eric A Gehrie
- Department of Surgery, Johns Hopkins Medical Institutions, Baltimore, Maryland.,Department of Pathology (Transfusion Medicine), Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Mariuxi C Manukyan
- Department of Surgery, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Kathy Noll
- Department of Surgery, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - K H Ken Lee
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Paul M Ness
- Department of Pathology (Transfusion Medicine), Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Steven M Frank
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medical Institutions, Baltimore, Maryland.,Department of Anesthesiology/Critical Care Medicine, Johns Hopkins Medical Institutions, Baltimore, Maryland
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