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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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2
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Smith JE, Barnard EBG, Brown-O'Sullivan C, Cardigan R, Davies J, Hawton A, Laing E, Lucas J, Lyon R, Perkins GD, Smith L, Stanworth SJ, Weaver A, Woolley T, Green L. The SWiFT trial (Study of Whole Blood in Frontline Trauma)-the clinical and cost effectiveness of pre-hospital whole blood versus standard care in patients with life-threatening traumatic haemorrhage: study protocol for a multi-centre randomised controlled trial. Trials 2023; 24:725. [PMID: 37964393 PMCID: PMC10644622 DOI: 10.1186/s13063-023-07711-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 10/06/2023] [Indexed: 11/16/2023] Open
Abstract
BACKGROUND Early blood transfusion improves survival in patients with life-threatening bleeding, but the optimal transfusion strategy in the pre-hospital setting has yet to be established. Although there is some evidence of benefit with the use of whole blood, there have been no randomised controlled trials exploring the clinical and cost effectiveness of pre-hospital administration of whole blood versus component therapy for trauma patients with life-threatening bleeding. The aim of this trial is to determine whether pre-hospital leukocyte-depleted whole blood transfusion is better than standard care (blood component transfusion) in reducing the proportion of participants who experience death or massive transfusion at 24 h. METHODS This is a multi-centre, superiority, open-label, randomised controlled trial with internal pilot and within-trial cost-effectiveness analysis. Patients of any age will be eligible if they have suffered major traumatic haemorrhage and are attended by a participating air ambulance service. The primary outcome is the proportion of participants with traumatic haemorrhage who have died (all-cause mortality) or received massive transfusion in the first 24 h from randomisation. A number of secondary clinical, process, and safety endpoints will be collected and analysed. Cost (provision of whole blood, hospital, health, and wider care resource use) and outcome data will be synthesised to present incremental cost-effectiveness ratios for the trial primary outcome and cost per quality-adjusted life year at 90 days after injury. We plan to recruit 848 participants (a two-sided test with 85% power, 5% type I error, 1-1 allocation, and one interim analysis would require 602 participants-after allowing for 25% of participants in traumatic cardiac arrest and an additional 5% drop out, the sample size is 848). DISCUSSION The SWiFT trial will recruit 848 participants across at least ten air ambulances services in the UK. It will investigate the clinical and cost-effectiveness of whole blood transfusion versus component therapy in the management of patients with life-threatening bleeding in the pre-hospital setting. TRIAL REGISTRATION ISRCTN: 23657907; EudraCT: 2021-006876-18; IRAS Number: 300414; REC: 22/SC/0072, 21 Dec 2021.
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Affiliation(s)
- Jason E Smith
- Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine, Birmingham, UK.
- University Hospitals Plymouth NHS Trust, Plymouth, UK.
| | - Ed B G Barnard
- Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine, Birmingham, UK
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | | | - Rebecca Cardigan
- NHS Blood & Transplant, Bristol, UK
- Department of Haematology, University of Cambridge, Cambridge, UK
| | | | - Annie Hawton
- Health Economics Group, University of Exeter, Exeter, UK
| | - Emma Laing
- Intensive Care National Audit and Research Centre (ICNARC), London, UK
| | - Joanne Lucas
- NHS Blood and Transplant Clinical Trials Unit, Cambridge, UK
| | - Richard Lyon
- Air Ambulance Kent Surrey Sussex, Rochester, UK
- Department of Health Sciences, University of Surrey, Guildford, UK
| | - Gavin D Perkins
- Warwick Medical School, University of Warwick, Coventry, CV4 7AL, UK
| | - Laura Smith
- NHS Blood and Transplant Clinical Trials Unit, Cambridge, UK
| | - Simon J Stanworth
- NHS Blood & Transplant, Bristol, UK
- Oxford University Hospitals, Oxford, UK
- University of Oxford, Oxford, UK
| | - Anne Weaver
- London's Air Ambulance and Royal London Hospital, London, UK
| | - Tom Woolley
- Academic Department of Military Anaesthesia and Critical Care, Royal Centre for Defence Medicine, Birmingham, UK
| | - Laura Green
- NHS Blood & Transplant, Bristol, UK
- Barts Health NHS Trust, London, UK
- Queen Mary University of London, London, UK
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3
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Mihalko EP, Srinivasan AJ, Rahn KC, Seheult JN, Spinella PC, Cap AP, Triulzi DJ, Yazer MH, Neal MD, Shea SM. Hemostatic In Vitro Properties of Novel Plasma Supernatants Produced from Late-storage Low-titer Type O Whole Blood. Anesthesiology 2023; 139:77-90. [PMID: 37027803 PMCID: PMC10247395 DOI: 10.1097/aln.0000000000004574] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/09/2023]
Abstract
BACKGROUND The use of low-titer group O whole blood is increasing. To reduce wastage, unused units can be converted to packed red blood cells. Supernatant is currently discarded post-conversion; however, it could be a valuable transfusable product. The aim of this study was to evaluate supernatant prepared from late-storage low-titer group O whole blood being converted to red blood cells, hypothesizing it will have higher hemostatic activity compared to fresh never-frozen liquid plasma. METHODS Low-titer group O whole blood supernatant (n = 12) prepared on storage day 15 was tested on days 15, 21, and 26 and liquid plasma (n = 12) on 3, 15, 21, and 26. Same-day assays included cell counts, rotational thromboelastometry, and thrombin generation. Centrifuged plasma from units was banked for microparticle characterization, conventional coagulation, clot structure, hemoglobin, and additional thrombin generation assays. RESULTS Low-titer group O whole blood supernatant contained more residual platelets and microparticles compared to liquid plasma. At day 15, low-titer group O whole blood supernatant elicited a faster intrinsic clotting time compared to liquid plasma (257 ± 41 vs. 299 ± 36 s, P = 0.044), and increased clot firmness (49 ± 9 vs. 28 ± 5 mm, P < 0.0001). Low-titer group O whole blood supernatant showed more significant thrombin generation compared to liquid plasma (day 15 endogenous thrombin potential 1,071 ± 315 vs. 285 ± 221 nM·min, P < 0.0001). Flow cytometry demonstrated low-titer group O whole blood supernatant contained significantly more phosphatidylserine and CD41+ microparticles. However, thrombin generation in isolated plasma suggested residual platelets in low-titer group O whole blood supernatant were a greater contributor than microparticles. Additionally, low-titer group O whole blood supernatant and liquid plasma showed no difference in clot structure, despite higher CD61+ microparticle presence. CONCLUSIONS Plasma supernatant produced from late-storage low-titer group O whole blood shows comparable, if not enhanced, in vitro hemostatic efficacy to liquid plasma. EDITOR’S PERSPECTIVE
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Affiliation(s)
- Emily P. Mihalko
- Trauma and Transfusion Medicine Research Center, Department of Surgery, University of Pittsburgh, Pittsburgh, PA
| | - Amudan J. Srinivasan
- Trauma and Transfusion Medicine Research Center, Department of Surgery, University of Pittsburgh, Pittsburgh, PA
| | - Katelin C. Rahn
- Trauma and Transfusion Medicine Research Center, Department of Surgery, University of Pittsburgh, Pittsburgh, PA
| | - Jansen N. Seheult
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - Philip C. Spinella
- Trauma and Transfusion Medicine Research Center, Department of Surgery, University of Pittsburgh, Pittsburgh, PA
- Department of Critical Care, University of Pittsburgh, Pittsburgh, PA
| | - Andrew P. Cap
- United States Army Institute of Surgical Research, JBSA-Fort Sam Houston, Texas
| | - Darrell J. Triulzi
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Mark H. Yazer
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Matthew D. Neal
- Trauma and Transfusion Medicine Research Center, Department of Surgery, University of Pittsburgh, Pittsburgh, PA
- Department of Critical Care, University of Pittsburgh, Pittsburgh, PA
| | - Susan M. Shea
- Trauma and Transfusion Medicine Research Center, Department of Surgery, University of Pittsburgh, Pittsburgh, PA
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4
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Tucker H, Brohi K, Tan J, Aylwin C, Bloomer R, Cardigan R, Davenport R, Davies ED, Godfrey P, Hawes R, Lyon R, McCullagh J, Stanworth S, Thompson J, Uprichard J, Walsh S, Weaver A, Green L. Association of red blood cells and plasma transfusion versus red blood cell transfusion only with survival for treatment of major traumatic hemorrhage in prehospital setting in England: a multicenter study. Crit Care 2023; 27:25. [PMID: 36650557 PMCID: PMC9847037 DOI: 10.1186/s13054-022-04279-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 12/14/2022] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND In-hospital acute resuscitation in trauma has evolved toward early and balanced transfusion resuscitation with red blood cells (RBC) and plasma being transfused in equal ratios. Being able to deliver this ratio in prehospital environments is a challenge. A combined component, like leukocyte-depleted red cell and plasma (RCP), could facilitate early prehospital resuscitation with RBC and plasma, while at the same time improving logistics for the team. However, there is limited evidence on the clinical benefits of RCP. OBJECTIVE To compare prehospital transfusion of combined RCP versus RBC alone or RBC and plasma separately (RBC + P) on mortality in trauma bleeding patients. METHODS Data were collected prospectively on patients who received prehospital transfusion (RBC + thawed plasma/Lyoplas or RCP) for traumatic hemorrhage from six prehospital services in England (2018-2020). Retrospective data on patients who transfused RBC from 2015 to 2018 were included for comparison. The association between transfusion arms and 24-h and 30-day mortality, adjusting for age, injury mechanism, age, prehospital heart rate and blood pressure, was evaluated using generalized estimating equations. RESULTS Out of 970 recruited patients, 909 fulfilled the study criteria (RBC + P = 391, RCP = 295, RBC = 223). RBC + P patients were older (mean age 42 vs 35 years for RCP and RBC), and 80% had a blunt injury (RCP = 52%, RBC = 56%). RCP and RBC + P were associated with lower odds of death at 24-h, compared to RBC alone (adjusted odds ratio [aOR] 0.69 [95%CI: 0.52; 0.92] and 0.60 [95%CI: 0.32; 1.13], respectively). The lower odds of death for RBC + P and RCP vs RBC were driven by penetrating injury (aOR 0.22 [95%CI: 0.10; 0.53] and 0.39 [95%CI: 0.20; 0.76], respectively). There was no association between RCP or RBC + P with 30-day survival vs RBC. CONCLUSION Prehospital plasma transfusion for penetrating injury was associated with lower odds of death at 24-h compared to RBC alone. Large trials are needed to confirm these findings.
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Affiliation(s)
- Harriet Tucker
- grid.4868.20000 0001 2171 1133Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, 4 Newark Street, London, E1 2AT UK
| | - Karim Brohi
- grid.4868.20000 0001 2171 1133Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, 4 Newark Street, London, E1 2AT UK ,grid.139534.90000 0001 0372 5777Barts Health NHS Trust, London, UK
| | - Joachim Tan
- grid.264200.20000 0000 8546 682XSt George’s University of London, London, UK
| | - Christopher Aylwin
- grid.426467.50000 0001 2108 8951St Mary’s Hospital, Imperial College NHS Foundation Trust, London, UK
| | - Roger Bloomer
- grid.429705.d0000 0004 0489 4320Kings College Hospital NHS Foundation Trust, London, UK
| | - Rebecca Cardigan
- grid.436365.10000 0000 8685 6563NHS Blood and Transplant, Cambridge, UK
| | - Ross Davenport
- grid.4868.20000 0001 2171 1133Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, 4 Newark Street, London, E1 2AT UK ,grid.139534.90000 0001 0372 5777Barts Health NHS Trust, London, UK
| | - Edward D. Davies
- grid.416204.50000 0004 0391 9602Royal Preston Hospital, Preston, UK
| | - Phillip Godfrey
- grid.411812.f0000 0004 0400 2812James Cook University Hospital, Middlesbrough, UK
| | - Rachel Hawes
- Newcastle Upon Tyne NHS Foundation Trust, Newcastle, UK ,Great North Air Ambulance, Stockton-on-Tees, UK
| | | | | | - Simon Stanworth
- grid.436365.10000 0000 8685 6563NHS Blood and Transplant, Cambridge, UK ,grid.4991.50000 0004 1936 8948Oxford University Hospital NHS Foundation Trust, Oxford, UK
| | - Julian Thompson
- grid.416201.00000 0004 0417 1173Southmead Hospital, Bristol, UK ,Great West Air Ambulance, Bristol, UK
| | - James Uprichard
- grid.264200.20000 0000 8546 682XSt George’s University Hospital NHS Foundation Trust, London, UK
| | - Simon Walsh
- grid.426467.50000 0001 2108 8951St Mary’s Hospital, Imperial College NHS Foundation Trust, London, UK ,Essex and Hertfordshire Air Ambulance Trust, Essex, UK
| | - Anne Weaver
- grid.139534.90000 0001 0372 5777Barts Health NHS Trust, London, UK
| | - Laura Green
- grid.4868.20000 0001 2171 1133Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, 4 Newark Street, London, E1 2AT UK ,grid.139534.90000 0001 0372 5777Barts Health NHS Trust, London, UK ,grid.436365.10000 0000 8685 6563NHS Blood and Transplant, Cambridge, UK
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5
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Bush K, Shea L, San Roman J, Pailloz E, Gaughan J, Porter J, Goldenberg-Sandau A. Whole Blood in Trauma Resuscitation: What is the Real Cost? J Surg Res 2022; 275:155-160. [DOI: 10.1016/j.jss.2022.01.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 12/30/2021] [Accepted: 01/29/2022] [Indexed: 10/18/2022]
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6
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Sivertsen J, Hervig T, Strandenes G, Kristoffersen EK, Braathen H, Apelseth TO. In vitro quality and hemostatic function of cold-stored CPDA-1 whole blood after repeated transient exposure to 28°C storage temperature. Transfusion 2022; 62 Suppl 1:S105-S113. [PMID: 35748681 PMCID: PMC9541954 DOI: 10.1111/trf.16970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Revised: 05/01/2022] [Accepted: 05/01/2022] [Indexed: 12/03/2022]
Abstract
Background Blood products are frequently exposed to room temperature or higher for longer periods than permitted by policy. We aimed to investigate if this resulted in a measurable effect on common quality parameters and viscoelastic hemostatic function of cold stored CPDA‐1 whole blood. Study Design and Methods 450 ml of whole blood from 16 O Rh(D) positive donors was collected in 63 ml of CPDA‐1 and stored cold. Eights bags were exposed to five weekly 4‐h long transient temperature changes to 28°C. Eight bags were stored continuously at 4°C as a control. Samples were collected at baseline on day 1, after the first cycle on day 1 and weekly before each subsequent cycle (day 7, 14, 21, 28 and 35). Hemolysis, hematological parameters, pH, glucose, lactate, potassium, thromboelastography, INR, APTT, fibrinogen, and factor VIII were measured. Results CPDA‐1 whole blood repeatedly exposed to 28°C did not show reduced quality compared to the control group on day 35. Two units in the test group had hemolysis of 1.1% and 1.2%, and two in the control group hemolysis of 0.8%. Remaining thromboelastography clot strength (MA) on day 35 was 51.7 mm (44.8, 58.6) in the test group and 46.1 (41.6, 50.6) in the control group (p = .023). Platelet count was better preserved in the test group (166.7 [137.8, 195.6] vs. 117.8 [90.3, 145.2], p = .018). One sample in the test group was positive for Cutibacterium acnes on day 35 + 6. Conclusion Hemolysis findings warrant further investigation. Other indicators of quality were not negatively affected.
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Affiliation(s)
- 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
| | - Tor Hervig
- Department of Immunology and Transfusion Medicine, Haukeland University Hospital, Bergen, Norway
| | - Geir Strandenes
- Department of Immunology and Transfusion Medicine, Haukeland University Hospital, Bergen, Norway
| | - Einar K Kristoffersen
- Department of Immunology and Transfusion Medicine, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Hanne Braathen
- Department of Immunology and Transfusion Medicine, Haukeland University Hospital, Bergen, Norway
| | - Torunn O Apelseth
- Department of Immunology and Transfusion Medicine, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Science, University of Bergen, Bergen, Norway.,Department of War Surgery and Emergency Medicine, Norwegian Armed Forces Joint Medical Services, Oslo, Norway
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7
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There and Back Again: The Once and Current Developments in Donor-Derived Platelet Products for Products for Hemostatic Therapy. Blood 2022; 139:3688-3698. [PMID: 35482959 DOI: 10.1182/blood.2021014889] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Accepted: 04/20/2022] [Indexed: 01/19/2023] Open
Abstract
Over 100 years ago, Duke transfused whole blood to a thrombocytopenic patient to raise the platelet count and prevent bleeding. Since then, platelet transfusions have undergone numerous modifications from whole blood-derived platelet-rich plasma to apheresis-derived platelet concentrates. Similarly, the storage time and temperature have changed. The mandate to store platelets for a maximum of 5-7 days at room temperature has been challenged by recent clinical trial data, ongoing difficulties with transfusion-transmitted infections, and recurring periods of shortages, further exacerbated by the COVID-19 pandemic. Alternative platelet storage approaches are as old as the first platelet transfusions. Cold-stored platelets may offer increased storage times (days) and improved hemostatic potential at the expense of reduced circulation time. Frozen (cryopreserved) platelets extend the storage time to years but require storage at -80 °C and thawing before transfusion. Lyophilized platelets can be powder-stored for years at room temperature and reconstituted within minutes in sterile water but are probably the least explored alternative platelet product to date. Finally, whole blood offers the hemostatic spectrum of all blood components but has challenges, such as ABO incompatibility. While we know more than ever before about the in vitro properties of these products, clinical trial data on these products are accumulating. The purpose of this review is to summarize the findings of recent preclinical and clinical studies on alternative, donor-derived platelet products.
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8
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Whole blood for transfusion in sub-Saharan Africa. THE LANCET GLOBAL HEALTH 2022; 10:e303-e304. [DOI: 10.1016/s2214-109x(22)00033-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Accepted: 01/26/2022] [Indexed: 11/19/2022] Open
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9
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Green L, Stanworth S, McQuilten Z, Lin V, Tucker H, Jackson B, Badawi M, Hindawi S, Chaurasia R, Patidar G, Pandey HC, Fasola F, Miyata S, Matsumoto M, Matsushita T, Rahimi-Levene N, Peer V, Pavenski K, Callum J, Thompson T, Murphy M, Staves J, Maegele M, Abeyakoon C, Rushford K, Wood E, Nuñez MA, Mellado S, Saa E, Triyono T, Pratomo B, Apelseth TO, Dunbar N. International Forum on the Management of Major Haemorrhage: Summary. Vox Sang 2022; 117:746-753. [PMID: 35050497 DOI: 10.1111/vox.13244] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 12/16/2021] [Indexed: 12/24/2022]
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10
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Huish S, Green L, Kempster C, Smethurst P, Wiltshire M, Prajapati C, Allen E, Cardigan R. A comparison of platelet function in cold-stored whole blood and platelet concentrates. Transfusion 2021; 61:3224-3235. [PMID: 34622949 DOI: 10.1111/trf.16657] [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: 02/22/2021] [Revised: 07/09/2021] [Accepted: 07/25/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND There is renewed interest in the use of whole blood (WB) for the resuscitation of trauma patients. Platelet function in stored WB compared to platelet concentrates is not well established and was assessed in vitro in this study. METHODS Leucocyte-depleted cold-stored WB (CS-WB) was prepared using a Terumo WB-SP Imuflex kit and held at 2-6°C alongside: (A) UK standard pooled platelets stored at 20-24°C (RT-PLTS), (B) pooled platelets stored at 2-6°C (CS-PLTS), and (C) platelet-rich plasma produced using the Terumo kit (CS-PRP), for 21 days. A series of in vitro assays were assessed platelet function. RESULTS Platelet count was retained to 57 ± 14% of starting number at day 21 in CS-WB. Over time, CS-WB platelets become more activated, with increased CD62P expression (day 1: 7 ± 3.7% vs. day 21: 59 ± 17.1%) and annexin V binding (day 1: 2 ± 0.2% vs. day 21: 21 ± 15.1%). For comparison, 18.6 ± 6% of platelets in RT-PLTS demonstrated CD62P expression at day 7, whereas annexin V binding in RT-PLTS at day 7 was 2.6 ± 0.5%. Over storage, aggregatory response to agonists decreased in all arms. Functional platelet microparticles increased steadily in CS-WB throughout storage. CONCLUSION During storage, platelet count reduced in CS-WB, whereas CD62P expression and annexin V binding increased. This was accompanied by a reduced aggregatory response, although compared to 7-day-old RT-PLTS, CS-WB maintained a maximal response to agonists for longer, suggesting that the shelf life for CS-WB can be considered for up to 21 days.
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Affiliation(s)
- Sian Huish
- Component Development Laboratory, NHS Blood and Transplant, Cambridge, UK
| | - Laura Green
- Department of Clinical, NHS Blood and Transplant, London, UK.,Blizzard Institute, Queen Mary University of London, London, UK.,Department of Haematology, Barts Health NHS Trust UK, London, UK
| | - Carly Kempster
- Component Development Laboratory, NHS Blood and Transplant, Cambridge, UK
| | - Peter Smethurst
- Component Development Laboratory, NHS Blood and Transplant, Cambridge, UK
| | - Michael Wiltshire
- Component Development Laboratory, NHS Blood and Transplant, Cambridge, UK
| | | | - Elisa Allen
- Statistics and Clinical Studies, NHS Blood and Transplant, Stoke Gifford, UK
| | - Rebecca Cardigan
- Component Development Laboratory, NHS Blood and Transplant, Cambridge, UK.,Department of Haematology, University of Cambridge, Cambridge, UK
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11
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Doughty H, Green L. Transfusion support during mass casualty events. Br J Anaesth 2021; 128:e75-e79. [PMID: 34503826 DOI: 10.1016/j.bja.2021.07.027] [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: 01/29/2021] [Revised: 06/17/2021] [Accepted: 07/12/2021] [Indexed: 12/24/2022] Open
Abstract
Transfusion support is an essential element of modern emergency healthcare. Blood services together with hospital transfusion teams are required to prepare for, and respond to, mass casualty events as part of wider healthcare emergency planning. Preparedness is a constant collaborative process that actively identifies and manages potential risks, to prevent such events becoming a 'disaster'. The aim of transfusion support during incidents is to provide sufficient and timely supply of blood components and diagnostic services, whilst maintaining support to other patients not involved in the event.
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Affiliation(s)
- Heidi Doughty
- NHS Blood and Transplant, UK; NIHR Surgical Reconstruction and Microbiology Research Centre, Birmingham, UK.
| | - Laura Green
- NHS Blood and Transplant, UK; Barts Health NHS Trust, London, UK; Blizzard Institute, Queen Mary University of London, London, UK
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12
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Schubert P, Chen Z, Bhakta V, Culibrk B, Wambolt R, Sheffield WP, Devine DV, McTaggart K. Cold-stored leukoreduced whole blood: Extending the time between donation and filtration has minimal impact on in vitro quality. Transfusion 2021; 61 Suppl 1:S131-S143. [PMID: 34269454 DOI: 10.1111/trf.16540] [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: 12/22/2020] [Revised: 05/21/2021] [Accepted: 05/28/2021] [Indexed: 12/26/2022]
Abstract
BACKGROUND Leukoreduced whole blood (LR-WB) has received renewed attention as alternative to component-based transfusion in trauma. According to the manufacturer's instructions, leukoreduction should be carried out within 8 h after collection. This study assessed impact of (1) WB collection bag, (2) LR filtration, and (3) timing of filtration on in vitro quality. STUDY DESIGN AND METHODS WB collected into different vendor bags was held at room temperature for <8 h or >16 h but <24 h prior to LR. In vitro quality was assessed before and after filtration, and throughout 3 weeks of storage at 4°C. Cell count and hemoglobin levels were determined by hematology analyzer, platelet activation, and responsiveness to ADP by surface expression of P-selectin by flow cytometry, hemolysis by HemoCue, and metabolic parameters by blood gas analyzer. Hemostatic properties were assessed by rotational thromboelastometry. Plasma protein activities and clotting times were determined by automated coagulation analyzer or quantitative immunoblotting. RESULTS Bag type had no impact on WB in vitro quality. LR by filtration had some impact, but is aligned with data in the literature. The time between donation and filtration resulted in some statistically significant differences in metabolic activity, platelet yield, platelet activation, and factor protein activity initially; however, these differences in in vitro quality attributes decreased throughout 21-day cold storage. CONCLUSION WB hold time showed only a minor impact on WB in vitro quality, so it may be possible for blood processing facilities to explore extended hold times prior to filtration in order to provide greater operational flexibility.
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Affiliation(s)
- Peter Schubert
- Centre for Innovation, Canadian Blood Services, Vancouver, Canada.,Centre for Blood Research, University of British Columbia, Vancouver, Canada.,Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, Canada
| | - Zhongming Chen
- Centre for Innovation, Canadian Blood Services, Vancouver, Canada.,Centre for Blood Research, University of British Columbia, Vancouver, Canada
| | - Varsha Bhakta
- Centre for Innovation, Canadian Blood Services, Hamilton, Canada
| | - Brankica Culibrk
- Centre for Innovation, Canadian Blood Services, Vancouver, Canada.,Centre for Blood Research, University of British Columbia, Vancouver, Canada
| | - Richard Wambolt
- Centre for Innovation, Canadian Blood Services, Vancouver, Canada
| | - William P Sheffield
- Centre for Innovation, Canadian Blood Services, Hamilton, Canada.,Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Canada
| | - Dana V Devine
- Centre for Innovation, Canadian Blood Services, Vancouver, Canada.,Centre for Blood Research, University of British Columbia, Vancouver, Canada.,Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, Canada
| | - Ken McTaggart
- Centre for Innovation, Canadian Blood Services, Ottawa, Canada
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13
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McCullagh J, Proudlove N, Tucker H, Davies J, Edmondson D, Lancut J, Maddison A, Weaver A, Davenport R, Green L. Making every drop count: reducing wastage of a novel blood component for transfusion of trauma patients. BMJ Open Qual 2021; 10:bmjoq-2021-001396. [PMID: 34244177 PMCID: PMC8268902 DOI: 10.1136/bmjoq-2021-001396] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 06/19/2021] [Indexed: 01/03/2023] Open
Abstract
Recent research demonstrates that transfusing whole blood (WB=red blood cells (RBC)+plasma+platelets) rather than just RBC (which is current National Health Service (NHS) practice) may improve outcomes for major trauma patients. As part of a programme to investigate provision of WB, NHS Blood and Transplant undertook a 2-year feasibility study to supply the Royal London Hospital (RLH) with (group O negative, 'O neg') leucodepleted red cell and plasma (LD-RCP) for transfusion of trauma patients with major haemorrhage in prehospital settings.Incidents requiring such prehospital transfusion occur randomly, with very high variation. Availability is critical, but O neg LD-RCP is a scarce resource and has a limited shelf life (14 days) after which it must be disposed of. The consequences of wastage are the opportunity cost of loss of overall treatment capacity across the NHS and reputational damage.The context was this feasibility study, set up to assess deliverability to RLH and subsequent wastage levels. Within this, we conducted a quality improvement project, which aimed to reduce the wastage of LD-RCP to no more than 8% (ie, 1 of the 12 units delivered per week).Over this 2-year period, we reduced wastage from a weekly average of 70%-27%. This was achieved over four improvement cycles. The largest improvement came from moving near-expiry LD-RCP to the emergency department (ED) for use with their trauma patients, with subsequent improvements from embedding use in ED as routine practice, introducing a dedicated LD-RCP delivery schedule (which increased the units ≤2 days old at delivery from 42% to 83%) and aligning this delivery schedule to cover two cycles of peak demand (Fridays and Saturdays).
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Affiliation(s)
- Josephine McCullagh
- NHS Higher Specialist Scientist Training (HSST), DClinSci Programme, The University of Manchester, Manchester, UK .,Pathology, Barts Health NHS Trust, London, UK
| | - Nathan Proudlove
- Alliance Manchester Business School, The University of Manchester, Manchester, UK
| | - Harriet Tucker
- Blizard Institute, Queen Mary, University of London, UK, London, UK
| | - Jane Davies
- Manufacturing and Development, NHS Blood and Transplant, Bristol, UK
| | - Dave Edmondson
- Manufacturing and Development, NHS Blood and Transplant, Bristol, UK
| | | | | | - Anne Weaver
- Major Trauma Centre, Barts Health NHS Trust, London, UK
| | - Ross Davenport
- Blizard Institute, Queen Mary, University of London, UK, London, UK.,Major Trauma Centre, Barts Health NHS Trust, London, UK
| | - Laura Green
- Pathology, Barts Health NHS Trust, London, UK.,Blizard Institute, Queen Mary, University of London, UK, London, UK.,Blood Component Department, NHS Blood and Transplant, London, UK
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14
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Clements T, McCoy C, Assen S, Cardenas J, Wade C, Meyer D, Cotton BA. The prehospital use of younger age whole blood is associated with an improved arrival coagulation profile. J Trauma Acute Care Surg 2021; 90:607-614. [PMID: 33405468 DOI: 10.1097/ta.0000000000003058] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Recent in vitro data have shown that the hemostatic profile of whole blood (WB) degrades significantly after 14 days, yet the optimal storage remains debated. We hypothesized that arrival coagulation studies would be improved in patients receiving younger WB in the prehospital setting. METHODS This study was approved by our institutional institutional review board. We evaluated all trauma patients who received prehospital blood products by our helicopter service between July 2017 and July 2019. "Young" WB was defined as 14 days or less. Patients who received at least 1 U of young WB were classified as YOUNG, while the remainder was classified as OLD. Continuous data are presented as medians (25th-75th interquartile range) with comparisons performed using Wilcoxon rank sum. Assessments of clinical hemostatic potential included arrival platelet cell count and rapid thrombelastography. Multivariate regression analysis was also performed (Stata 12.1; College Station, TX). RESULTS A total of 220 patients received prehospital WB during the study period. Of these, 153 patients received YOUNG WB, while 67 were transfused only OLD WB units. There were no differences in demographics, prehospital or arrival physiology, or Injury Severity Score among the two groups. The measures of clot initiation (activated clotting time) and kinetics (k time) were improved, as were the measures of clot acceleration/fibrinogen function (angle) and platelet function (maximum amplitude). As well, arrival platelet count was higher in the YOUNG cohort. No significant differences in postarrival transfusion were noted (p = 0.220). Multivariate analysis showed the greatest differences in maximum amplitude and α angle but failed to reach significance. CONCLUSION Previous in vitro data have suggested deterioration of platelet function in cold-stored WB after 14 days. The current study demonstrated decreased global hemostasis by clinically available laboratory tests, especially related to fibrinogen and platelet interactions on univariate, but not multivariate analysis. This did not translate into increased transfusion requirements. Further studies are needed to determine the optimal storage duration for cold-stored WB for transfusion in the bleeding trauma patient, as well as rule out the presence of confounding variables. LEVEL OF EVIDENCE Therapeutic, level IV.
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Affiliation(s)
- Thomas Clements
- From the Cumming School of Medicine (T.C., S.A.), University of Calgary; Center of Translational Injury Research and the Department of Surgery, McGovern Medical School (C.M., J.C., C.W., D.M., B.A.C.), University of Texas Health Science Center, Houston, Texas
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15
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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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16
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Quality of Platelets in Stored Whole Blood. Transfus Med Rev 2020; 34:234-241. [PMID: 33051112 DOI: 10.1016/j.tmrv.2020.09.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 09/09/2020] [Accepted: 09/10/2020] [Indexed: 12/29/2022]
Abstract
Transfusion of whole blood rather than blood components is gaining popularity. It is easy to use, with one transfusion product to administer rather than 3, and is held at one storage temperature. It only contains anticoagulant-preservative solution, while components contain various storage solutions, which in theory may induce dilution coagulopathy. In this review, the quality of platelets in stored whole blood is summarized. In cold-stored whole blood, the platelet count declines by 1% to 2% per day. The responsiveness to various agonists declines during the storage time, but this appears to have a limited impact on clotting time or on clot strength as measured with thromboelastography. Animal studies have confirmed that platelets from stored whole blood participate equally well in clot formation. The recovery of platelets in stored whole blood is acceptable during at least 15 days of storage. The survival of platelets after transfusion is only 1 day, but this is likely to be sufficient for the intended patient group requiring massive transfusions, as the platelets are rapidly consumed in the wound area. In addition to the logistic benefits, there are drawbacks, most importantly having a sufficiently large inventory with an acceptable outdating rate, particularly since massive transfusions are rare, while requiring a lot of whole blood. The positive experience of the United States military with whole blood transfusion is often brought forward for introduction in the civilian blood bank, but patients with trauma are only a small fraction of the civilian population requiring massive transfusions. It needs to be determined whether in the resourceful environment of the hospital, these patients benefit from whole blood transfusions. Optimization of whole blood storage, with focus on platelet quality, needs to be performed to allow extension of the storage time beyond 15 days to a point where the number of units in inventory and outdating can be balanced.
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17
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Rijnhout TWH, Noorman F, De Kort B, Zoodsma M, Hoencamp R. Prolonged (post-thaw) shelf life of -80°C frozen AB apheresis plasma. Transfusion 2020; 60:1846-1855. [PMID: 32692441 PMCID: PMC7497178 DOI: 10.1111/trf.15963] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 05/20/2020] [Accepted: 06/03/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND Early plasma transfusion is important in the treatment of patients with major hemorrhage. Prolonged shelf life of AB type frozen −80°C and cold‐stored (4°C) deep frozen plasma (DFP) will improve strategic stock management, minimize need for resupply, and make pre‐hospital implementation more feasible. METHODS AND MATERIALS Plasma products type AB of different age and origin (−30°C Fresh Frozen [(FFP], −80°C DFP [short (±1 year) and long (±7 year)] stored) were thawed (Day 0), stored at 4°C, and sampled on Days 7 and 14. Additionally, samples of plasma containing blood products (Octaplas LG®, whole blood and platelets) were compared for coagulation factor activity, phospholipid clotting time (PPL), and kaolin TEG during 4°C or 22°C storage. RESULTS Coagulation profiles of FFP, short‐ and long‐stored −80°C DFP were not significantly different after thaw. Cold storage did not affect fibrinogen, Protein C, and Antithrombin III activities whereas factor V, VII, VIII, and Protein S decreased in all blood products. After 14 days DFP still meets the guidelines for clinical use, except for Protein S (0.4 IU/mL). With exception of Octaplas LG®, phospholipid activity and TEG coagulation were similar between plasma containing blood components during storage. CONCLUSION AB DFP quality was unaffected by almost 7 years of frozen storage. Quality of thawed 14‐day stored AB DFP met, with exception of Protein S, all minimal guidelines which implies that its quality is sufficient for use in the (pre)‐hospital (military) environment for treatment of major hemorrhage.
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Affiliation(s)
- Tim W H Rijnhout
- Department of Surgery, Alrijne Medical Center, Leiderdorp, The Netherlands.,Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA Rotterdam, The Netherlands
| | - Femke Noorman
- Military Blood Bank, Ministry of Defense, Utrecht, The Netherlands
| | - Bob De Kort
- Military Blood Bank, Ministry of Defense, Utrecht, The Netherlands
| | - Margreet Zoodsma
- Military Blood Bank, Ministry of Defense, Utrecht, The Netherlands
| | - Rigo Hoencamp
- Department of Surgery, Alrijne Medical Center, Leiderdorp, The Netherlands.,Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA Rotterdam, The Netherlands.,Department of Surgery, Defense Healthcare Organization, Ministry of Defense, Utrecht, The Netherlands.,Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
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18
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Is Fresh Frozen Plasma Still Necessary for Management of Acute Traumatic Coagulopathy? CURRENT ANESTHESIOLOGY REPORTS 2020. [DOI: 10.1007/s40140-020-00397-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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19
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Haley NR, Hess JR. Whole blood: back to the future. Transfusion 2019; 59:3293-3294. [PMID: 31696552 DOI: 10.1111/trf.15579] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Accepted: 10/10/2019] [Indexed: 11/28/2022]
Affiliation(s)
| | - John R Hess
- Laboratory Medicine, University of Washington School of Medicine, Seattle, Washington
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