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Epstein A, Lim R, Johannigman J, Fox CJ, Inaba K, Vercruysse GA, Thomas RW, Martin MJ, Konstantyn G, Schwaitzberg SD. Putting Medical Boots on the Ground: Lessons from the War in Ukraine and Applications for Future Conflict with Near-Peer Adversaries. J Am Coll Surg 2023; 237:364-373. [PMID: 37459197 PMCID: PMC10344429 DOI: 10.1097/xcs.0000000000000707] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Revised: 03/17/2023] [Accepted: 03/20/2023] [Indexed: 04/25/2023]
Abstract
In the past 20 years of the Global War on Terror, the US has seen substantial improvements in its system of medical delivery in combat. However, throughout that conflict, enemy forces did not have parity with the weaponry, capability, or personnel of the US and allied forces. War against countries like China and Russia, who are considered near-peer adversaries in terms of capabilities, will challenge battlefield medical care in many different ways. This article reviews the experience of a medical team, Global Surgical and Medical Support Group, that has been providing assistance, training, medical support, and surgical support to Ukraine since the Russian invasion began in February 2022. The team has extensive experience in medicine, surgery, austere environments, conflict zones, and building partner nation capacities. This article compares and contrasts the healthcare systems of this war against the systems used during the Global War on Terror. The lessons learned here could help the US anticipate challenges and successfully plan for the provision of medical care in a future conflict against an adversary with capabilities close to its own.
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Affiliation(s)
- Aaron Epstein
- From the Global Surgical and Medical Support Group (GSMSG), Washington, DC (Epstein)
- Department of Surgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo - The State University of New York, Buffalo, NY (Epstein, Schwaitzberg)
- Department of Surgery, University of Oklahoma School of Medicine, Tulsa, OK (Lim)
- Department of Surgery, St Anthony Hospital, Lakewood, CO (Johannigman)
- Division of Vascular Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD (Johannigman)
- Department of Radiology, Memorial Healthcare System, Hollywood, FL (Fox)
- Division of Trauma and Surgical Critical Care, Department of Surgery, University of Southern California, Los Angeles, CA (Inaba)
- Department of Surgery, University of Michigan School of Medicine, Ann Arbor, MI (Vercruysse)
- West Virginia University School of Medicine Eastern Division, Martinsburg, WV (Thomas)
- Department of Surgery, University of Southern California Keck School of Medicine, Los Angeles, CA (Martin)
- Medical Service of the Armed Forces of Ukraine (Konstantyn)
- Department of General Surgery, Bohomolets National Medical University of Ukraine; Department of Military Surgery, Ukrainian Military Medical Academy, Kyiv, Ukraine (Konstantyn)
- Department of Biomedical Informatics, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo - The State University of New York, Buffalo, NY (Schwaitzberg)
| | - Robert Lim
- From the Global Surgical and Medical Support Group (GSMSG), Washington, DC (Epstein)
- Department of Surgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo - The State University of New York, Buffalo, NY (Epstein, Schwaitzberg)
- Department of Surgery, University of Oklahoma School of Medicine, Tulsa, OK (Lim)
- Department of Surgery, St Anthony Hospital, Lakewood, CO (Johannigman)
- Division of Vascular Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD (Johannigman)
- Department of Radiology, Memorial Healthcare System, Hollywood, FL (Fox)
- Division of Trauma and Surgical Critical Care, Department of Surgery, University of Southern California, Los Angeles, CA (Inaba)
- Department of Surgery, University of Michigan School of Medicine, Ann Arbor, MI (Vercruysse)
- West Virginia University School of Medicine Eastern Division, Martinsburg, WV (Thomas)
- Department of Surgery, University of Southern California Keck School of Medicine, Los Angeles, CA (Martin)
- Medical Service of the Armed Forces of Ukraine (Konstantyn)
- Department of General Surgery, Bohomolets National Medical University of Ukraine; Department of Military Surgery, Ukrainian Military Medical Academy, Kyiv, Ukraine (Konstantyn)
- Department of Biomedical Informatics, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo - The State University of New York, Buffalo, NY (Schwaitzberg)
| | - Jay Johannigman
- From the Global Surgical and Medical Support Group (GSMSG), Washington, DC (Epstein)
- Department of Surgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo - The State University of New York, Buffalo, NY (Epstein, Schwaitzberg)
- Department of Surgery, University of Oklahoma School of Medicine, Tulsa, OK (Lim)
- Department of Surgery, St Anthony Hospital, Lakewood, CO (Johannigman)
- Division of Vascular Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD (Johannigman)
- Department of Radiology, Memorial Healthcare System, Hollywood, FL (Fox)
- Division of Trauma and Surgical Critical Care, Department of Surgery, University of Southern California, Los Angeles, CA (Inaba)
- Department of Surgery, University of Michigan School of Medicine, Ann Arbor, MI (Vercruysse)
- West Virginia University School of Medicine Eastern Division, Martinsburg, WV (Thomas)
- Department of Surgery, University of Southern California Keck School of Medicine, Los Angeles, CA (Martin)
- Medical Service of the Armed Forces of Ukraine (Konstantyn)
- Department of General Surgery, Bohomolets National Medical University of Ukraine; Department of Military Surgery, Ukrainian Military Medical Academy, Kyiv, Ukraine (Konstantyn)
- Department of Biomedical Informatics, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo - The State University of New York, Buffalo, NY (Schwaitzberg)
| | - Charles J Fox
- From the Global Surgical and Medical Support Group (GSMSG), Washington, DC (Epstein)
- Department of Surgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo - The State University of New York, Buffalo, NY (Epstein, Schwaitzberg)
- Department of Surgery, University of Oklahoma School of Medicine, Tulsa, OK (Lim)
- Department of Surgery, St Anthony Hospital, Lakewood, CO (Johannigman)
- Division of Vascular Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD (Johannigman)
- Department of Radiology, Memorial Healthcare System, Hollywood, FL (Fox)
- Division of Trauma and Surgical Critical Care, Department of Surgery, University of Southern California, Los Angeles, CA (Inaba)
- Department of Surgery, University of Michigan School of Medicine, Ann Arbor, MI (Vercruysse)
- West Virginia University School of Medicine Eastern Division, Martinsburg, WV (Thomas)
- Department of Surgery, University of Southern California Keck School of Medicine, Los Angeles, CA (Martin)
- Medical Service of the Armed Forces of Ukraine (Konstantyn)
- Department of General Surgery, Bohomolets National Medical University of Ukraine; Department of Military Surgery, Ukrainian Military Medical Academy, Kyiv, Ukraine (Konstantyn)
- Department of Biomedical Informatics, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo - The State University of New York, Buffalo, NY (Schwaitzberg)
| | - Kenji Inaba
- From the Global Surgical and Medical Support Group (GSMSG), Washington, DC (Epstein)
- Department of Surgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo - The State University of New York, Buffalo, NY (Epstein, Schwaitzberg)
- Department of Surgery, University of Oklahoma School of Medicine, Tulsa, OK (Lim)
- Department of Surgery, St Anthony Hospital, Lakewood, CO (Johannigman)
- Division of Vascular Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD (Johannigman)
- Department of Radiology, Memorial Healthcare System, Hollywood, FL (Fox)
- Division of Trauma and Surgical Critical Care, Department of Surgery, University of Southern California, Los Angeles, CA (Inaba)
- Department of Surgery, University of Michigan School of Medicine, Ann Arbor, MI (Vercruysse)
- West Virginia University School of Medicine Eastern Division, Martinsburg, WV (Thomas)
- Department of Surgery, University of Southern California Keck School of Medicine, Los Angeles, CA (Martin)
- Medical Service of the Armed Forces of Ukraine (Konstantyn)
- Department of General Surgery, Bohomolets National Medical University of Ukraine; Department of Military Surgery, Ukrainian Military Medical Academy, Kyiv, Ukraine (Konstantyn)
- Department of Biomedical Informatics, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo - The State University of New York, Buffalo, NY (Schwaitzberg)
| | - Gary A Vercruysse
- From the Global Surgical and Medical Support Group (GSMSG), Washington, DC (Epstein)
- Department of Surgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo - The State University of New York, Buffalo, NY (Epstein, Schwaitzberg)
- Department of Surgery, University of Oklahoma School of Medicine, Tulsa, OK (Lim)
- Department of Surgery, St Anthony Hospital, Lakewood, CO (Johannigman)
- Division of Vascular Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD (Johannigman)
- Department of Radiology, Memorial Healthcare System, Hollywood, FL (Fox)
- Division of Trauma and Surgical Critical Care, Department of Surgery, University of Southern California, Los Angeles, CA (Inaba)
- Department of Surgery, University of Michigan School of Medicine, Ann Arbor, MI (Vercruysse)
- West Virginia University School of Medicine Eastern Division, Martinsburg, WV (Thomas)
- Department of Surgery, University of Southern California Keck School of Medicine, Los Angeles, CA (Martin)
- Medical Service of the Armed Forces of Ukraine (Konstantyn)
- Department of General Surgery, Bohomolets National Medical University of Ukraine; Department of Military Surgery, Ukrainian Military Medical Academy, Kyiv, Ukraine (Konstantyn)
- Department of Biomedical Informatics, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo - The State University of New York, Buffalo, NY (Schwaitzberg)
| | - Richard W Thomas
- From the Global Surgical and Medical Support Group (GSMSG), Washington, DC (Epstein)
- Department of Surgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo - The State University of New York, Buffalo, NY (Epstein, Schwaitzberg)
- Department of Surgery, University of Oklahoma School of Medicine, Tulsa, OK (Lim)
- Department of Surgery, St Anthony Hospital, Lakewood, CO (Johannigman)
- Division of Vascular Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD (Johannigman)
- Department of Radiology, Memorial Healthcare System, Hollywood, FL (Fox)
- Division of Trauma and Surgical Critical Care, Department of Surgery, University of Southern California, Los Angeles, CA (Inaba)
- Department of Surgery, University of Michigan School of Medicine, Ann Arbor, MI (Vercruysse)
- West Virginia University School of Medicine Eastern Division, Martinsburg, WV (Thomas)
- Department of Surgery, University of Southern California Keck School of Medicine, Los Angeles, CA (Martin)
- Medical Service of the Armed Forces of Ukraine (Konstantyn)
- Department of General Surgery, Bohomolets National Medical University of Ukraine; Department of Military Surgery, Ukrainian Military Medical Academy, Kyiv, Ukraine (Konstantyn)
- Department of Biomedical Informatics, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo - The State University of New York, Buffalo, NY (Schwaitzberg)
| | - Matthew J Martin
- From the Global Surgical and Medical Support Group (GSMSG), Washington, DC (Epstein)
- Department of Surgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo - The State University of New York, Buffalo, NY (Epstein, Schwaitzberg)
- Department of Surgery, University of Oklahoma School of Medicine, Tulsa, OK (Lim)
- Department of Surgery, St Anthony Hospital, Lakewood, CO (Johannigman)
- Division of Vascular Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD (Johannigman)
- Department of Radiology, Memorial Healthcare System, Hollywood, FL (Fox)
- Division of Trauma and Surgical Critical Care, Department of Surgery, University of Southern California, Los Angeles, CA (Inaba)
- Department of Surgery, University of Michigan School of Medicine, Ann Arbor, MI (Vercruysse)
- West Virginia University School of Medicine Eastern Division, Martinsburg, WV (Thomas)
- Department of Surgery, University of Southern California Keck School of Medicine, Los Angeles, CA (Martin)
- Medical Service of the Armed Forces of Ukraine (Konstantyn)
- Department of General Surgery, Bohomolets National Medical University of Ukraine; Department of Military Surgery, Ukrainian Military Medical Academy, Kyiv, Ukraine (Konstantyn)
- Department of Biomedical Informatics, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo - The State University of New York, Buffalo, NY (Schwaitzberg)
| | - Gumeniuk Konstantyn
- From the Global Surgical and Medical Support Group (GSMSG), Washington, DC (Epstein)
- Department of Surgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo - The State University of New York, Buffalo, NY (Epstein, Schwaitzberg)
- Department of Surgery, University of Oklahoma School of Medicine, Tulsa, OK (Lim)
- Department of Surgery, St Anthony Hospital, Lakewood, CO (Johannigman)
- Division of Vascular Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD (Johannigman)
- Department of Radiology, Memorial Healthcare System, Hollywood, FL (Fox)
- Division of Trauma and Surgical Critical Care, Department of Surgery, University of Southern California, Los Angeles, CA (Inaba)
- Department of Surgery, University of Michigan School of Medicine, Ann Arbor, MI (Vercruysse)
- West Virginia University School of Medicine Eastern Division, Martinsburg, WV (Thomas)
- Department of Surgery, University of Southern California Keck School of Medicine, Los Angeles, CA (Martin)
- Medical Service of the Armed Forces of Ukraine (Konstantyn)
- Department of General Surgery, Bohomolets National Medical University of Ukraine; Department of Military Surgery, Ukrainian Military Medical Academy, Kyiv, Ukraine (Konstantyn)
- Department of Biomedical Informatics, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo - The State University of New York, Buffalo, NY (Schwaitzberg)
| | - Steven D Schwaitzberg
- From the Global Surgical and Medical Support Group (GSMSG), Washington, DC (Epstein)
- Department of Surgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo - The State University of New York, Buffalo, NY (Epstein, Schwaitzberg)
- Department of Surgery, University of Oklahoma School of Medicine, Tulsa, OK (Lim)
- Department of Surgery, St Anthony Hospital, Lakewood, CO (Johannigman)
- Division of Vascular Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD (Johannigman)
- Department of Radiology, Memorial Healthcare System, Hollywood, FL (Fox)
- Division of Trauma and Surgical Critical Care, Department of Surgery, University of Southern California, Los Angeles, CA (Inaba)
- Department of Surgery, University of Michigan School of Medicine, Ann Arbor, MI (Vercruysse)
- West Virginia University School of Medicine Eastern Division, Martinsburg, WV (Thomas)
- Department of Surgery, University of Southern California Keck School of Medicine, Los Angeles, CA (Martin)
- Medical Service of the Armed Forces of Ukraine (Konstantyn)
- Department of General Surgery, Bohomolets National Medical University of Ukraine; Department of Military Surgery, Ukrainian Military Medical Academy, Kyiv, Ukraine (Konstantyn)
- Department of Biomedical Informatics, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo - The State University of New York, Buffalo, NY (Schwaitzberg)
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Braverman MA, Schauer SG, Ciaraglia A, Brigmon E, Smith AA, Barry L, Bynum J, Cap AD, Corral H, Fisher AD, Epley E, Jonas RB, Shiels M, Waltman E, Winckler C, Eastridge BJ, Stewart RM, Nicholson SE, Jenkins DH. The impact of prehospital whole blood on hemorrhaging trauma patients: A multi-center retrospective study. J Trauma Acute Care Surg 2023; 95:191-196. [PMID: 37012617 DOI: 10.1097/ta.0000000000003908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2023]
Abstract
BACKGROUND Whole blood (WB) use has become increasingly common in trauma centers across the United States for both in-hospital and prehospital resuscitation. We hypothesize that prehospital WB (pWB) use in trauma patients with suspected hemorrhage will result in improved hemodynamic status and reduced in-hospital blood product requirements. METHODS The institutional trauma registries of two academic level I trauma centers were queried for all patients from 2015-2019 who underwent transfusion upon arrival to the trauma bay. Patients who were dead on arrival or had isolated head injuries were excluded. Demographics, injury and shock characteristics, transfusion requirements, including massive transfusion protocol (MTP) (>10 U in 24 hours) and rapid transfusion (CAT3+) and outcomes were compared between pWB and non-pWB patients. Significantly different demographic, injury characteristics and pWB were included in univariate followed by stepwise logistic regression analysis to determine the relationship with shock index (SI). Our primary objective was to determine the relationship between pWB and improved hemodynamics or reduction in blood product utilization. RESULTS A total of 171 pWB and 1391 non-pWB patients met inclusion criteria. Prehospital WB patients had a lower median Injury Severity Score (17 vs. 21, p < 0.001) but higher prehospital SI showing greater physiologic disarray. Prehospital WB was associated with improvement in SI (-0.04 vs. 0.05, p = 0.002). Mortality and (LOS) were similar. Prehospital WB patients received fewer packed red blood cells, fresh frozen plasma, and platelets units across their LOS but total units and volumes were similar. Prehospital WB patients had fewer MTPs (22.6% vs. 32.4%, p = 0.01) despite a similar requirement of CAT3+ transfusion upon arrival. CONCLUSION Prehospital WB administration is associated with a greater improvement in SI and a reduction in MTP. This study is limited by its lack of power to detect a mortality difference. Prospective randomized controlled trials will be required to determine the true impact of pWB on trauma patients. LEVEL OF EVIDENCE Prognostic and Epidemiological; Level IV.
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Affiliation(s)
- Maxwell A Braverman
- From the Department of Surgery (M.A.B., A.C., E.B., E.S., A.A.S., L.B., H.C., R.B.J., B.J.E., R.M.S., S.E.N., D.H.J.), UT Health San Antonio; Department of Emergency Medicine (S.G.S.), Brooke Army Medical Center, United States Army Institute of Surgical Research (S.G.S., A.D.C., J.B.), JBSA Fort Sam Houston; Department of Surgery (A.D.F.), University of New Mexico School of Medicine, Albuquerque, New Mexico; Southwest Texas Regional Advisory Council (E.E.); Trauma Services (M.S.), University Hospital; South Texas Blood & Tissue Center (E.W.); and Department of Emergency Health Sciences (C.W.), UT Health, San Antonio, Texas
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Santangini MR, Leuckel SN, King KA, Cheves TA, Sweeney JD. In vitro comparison of CPD whole blood with conventional blood components. Transfus Apher Sci 2023; 62:103526. [PMID: 36041978 DOI: 10.1016/j.transci.2022.103526] [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: 05/27/2022] [Revised: 08/04/2022] [Accepted: 08/23/2022] [Indexed: 10/15/2022]
Abstract
INTRODUCTION Resuscitation of severely injured trauma patients is commonly performed using red blood cells in additive solution supplemented with plasma and platelet concentrates. There is an increasing interest in the use of low anti-A titer Group O whole blood (LTOWB) in the early management of the resuscitation. It is unclear whether clinical outcome is improved using this approach. METHODS Expired units of CPD-LTOWB were studied on Day 22 and expired units of thawed plasma on Day 6 and Day 7. LTOWB was assessed for hemoglobin content, clotting factor levels and platelet numbers and function using thromboelastography (TEG) and impedance aggregation. Assays of fibrinogen and FV, FVIII, FVII and FX were performed on the expired plasma. The LTOWB hemoglobin was compared to red cells in additive solution (AS-RBCs) and the clotting factor levels to those of expired thawed plasma. Platelet function was compared to fresh whole blood samples from healthy subjects. RESULTS LTOWB contained slightly more hemoglobin than the AS-RBCs (Medians, 66 v 59 G), and the plasma content of fibrinogen was similar. Other clotting factors were reduced by approximately 15% except for FVIII which was 30% less. Both TEG and impedance aggregometry showed evidence of residual platelet function despite the prolonged period of refrigerator storage. CONCLUSION LTOWB contains higher hemoglobin and adequate clotting factors, and residual platelet function is demonstrated indicating that this product would be expected to be at least equivalent to a single unit of each of the conventional components commonly used in trauma resuscitation.
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Affiliation(s)
| | - Stephanie N Leuckel
- Division of Trauma and Surgical Critical Care, Providence, RI, USA; Lifespan Academic Medical Center and the Alpert Medical School of Brown University, Providence, RI, USA
| | - Karen A King
- Department of Coagulation and Transfusion Medicine, Providence, RI, USA
| | - Tracey A Cheves
- Department of Coagulation and Transfusion Medicine, Providence, RI, USA
| | - Joseph D Sweeney
- Department of Coagulation and Transfusion Medicine, Providence, RI, USA; Lifespan Academic Medical Center and the Alpert Medical School of Brown University, Providence, RI, USA.
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Guo Y, Cheng N, Sun H, Hou J, Zhang Y, Wang D, Zhang W, Chen Z. Advances in the development and optimization strategies of the hemostatic biomaterials. Front Bioeng Biotechnol 2023; 10:1062676. [PMID: 36714615 PMCID: PMC9873964 DOI: 10.3389/fbioe.2022.1062676] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Accepted: 12/29/2022] [Indexed: 01/12/2023] Open
Abstract
Most injuries are accompanied by acute bleeding. Hemostasis is necessary to relieve pain and reduce mortality in these accidents. In recent years, the traditional hemostatic materials, including inorganic, protein-based, polysaccharide-based and synthetic materials have been widely used in the clinic. The most prominent of these are biodegradable collagen sponges (Helistat®, United States), gelatin sponges (Ethicon®, SURGIFOAM®, United States), chitosan (AllaQuixTM, ChitoSAMTM, United States), cellulose (Tabotamp®, SURGICEL®, United States), and the newly investigated extracellular matrix gels, etc. Although these materials have excellent hemostatic properties, they also have their advantages and disadvantages. In this review, the performance characteristics, hemostatic effects, applications and hemostatic mechanisms of various biomaterials mentioned above are presented, followed by several strategies to improve hemostasis, including modification of single materials, blending of multiple materials, design of self-assembled peptides and their hybrid materials. Finally, the exploration of more novel hemostatic biomaterials and relative coagulation mechanisms will be essential for future research on hemostatic methods.
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Affiliation(s)
- Yayuan Guo
- Faculty of Life Science, Northwest University, Xi’an, Shaanxi Province, China
| | - Nanqiong Cheng
- Faculty of Life Science, Northwest University, Xi’an, Shaanxi Province, China
| | - Hongxiao Sun
- Faculty of Life Science, Northwest University, Xi’an, Shaanxi Province, China
| | - Jianing Hou
- Faculty of Life Science, Northwest University, Xi’an, Shaanxi Province, China
| | - Yuchen Zhang
- Faculty of Life Science, Northwest University, Xi’an, Shaanxi Province, China
| | - Du Wang
- Faculty of Life Science, Northwest University, Xi’an, Shaanxi Province, China
| | - Wei Zhang
- Faculty of Life Science, Northwest University, Xi’an, Shaanxi Province, China,School of Medicine, Northwest University, Xi’an, Shaanxi Province, China
| | - Zhuoyue Chen
- Faculty of Life Science, Northwest University, Xi’an, Shaanxi Province, China,School of Medicine, Northwest University, Xi’an, Shaanxi Province, China,*Correspondence: Zhuoyue Chen,
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Transfusion management in the trauma patient. Curr Opin Crit Care 2022; 28:725-731. [PMID: 36226706 DOI: 10.1097/mcc.0000000000000992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
PURPOSE OF REVIEW Transfusion of blood products is lifesaving in the trauma ICU. Intensivists must be familiar with contemporary literature to develop the optimal transfusion strategy for each patient. RECENT FINDINGS A balanced ratio of red-blood cells to plasma and platelets is associated with improved mortality and has therefore become the standard of care for resuscitation. There is a dose-dependent relationship between units of product transfused and infections. Liquid and freeze-dried plasma are alternatives to fresh frozen plasma that can be administered immediately and may improve coagulation parameters more rapidly, though higher quality research is needed. Trauma induced coagulopathy can occur despite a balanced transfusion, and administration of prothrombin complex concentrate and cryoprecipitate may have a role in preventing this. In addition to balanced ratios, viscoelastic guidance is being increasingly utilized to individualize component transfusion. Alternatively, whole blood can be used, which has become the standard in military practice and is gaining popularity at civilian centers. SUMMARY Hemorrhagic shock is the leading cause of death in trauma. Improved resuscitation strategy has been one of the most important contemporary advancements in trauma care and continues to be a key area of clinical research.
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6
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Use of Cold-Stored Whole Blood is Associated with Improved Mortality in Hemostatic Resuscitation of Major Bleeding: A Multicenter Study. Ann Surg 2022; 276:579-588. [PMID: 35848743 DOI: 10.1097/sla.0000000000005603] [Citation(s) in RCA: 45] [Impact Index Per Article: 22.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The aim of this study was to identify a mortality benefit with the use of whole blood as part of the resuscitation of bleeding trauma patients. SUMMARY BACKGROUND DATA Blood component therapy (BCT) is the current standard for resuscitating trauma patients, with whole blood (WB) emerging as the blood product of choice. We hypothesized that the use of WB versus BCT alone would result in decreased mortality. METHODS We performed a 14-center, prospective-observational study of trauma patients who received WB versus BCT during their resuscitation. We applied a generalized linear mixed-effects model with a random effect and controlled for age, sex, mechanism of injury (MOI), and injury severity score (ISS). All patients who received blood as part of their initial resuscitation were included. Primary outcome was mortality and secondary outcomes included AKI, DVT/PE, pulmonary complications, and bleeding complications. RESULTS A total of 1,623 (WB: 1,180(74%), BCT: 443(27%)) patients who sustained penetrating (53%) or blunt (47%) injury were included. Patients who received WB had a higher shock index (0.98 vs. 0.83), more comorbidities, and more blunt MOI (all P<0.05). After controlling for center, age, sex, MOI, and ISS, we found no differences in the rates of AKI, DVT/PE or pulmonary complications. WB patients were 9% less likely to experience bleeding complications and were 48% less likely to die than BCT patients (P<0.0001). CONCLUSIONS Compared with BCT, the use of WB was associated with a 48% reduction in mortality in trauma patients. Our study supports the use of WB use in the resuscitation of trauma patients.
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7
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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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8
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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: 13] [Impact Index Per Article: 4.3] [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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9
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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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10
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Rice J, Bill JR, Razatos A, Marschner S. Platelet aggregation in whole blood is not impaired by a platelet-sparing leukoreduction filter and instead depends upon the presence of leukocytes. Transfusion 2021; 61 Suppl 1:S90-S100. [PMID: 34269461 DOI: 10.1111/trf.16521] [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: 12/29/2020] [Revised: 03/04/2021] [Accepted: 03/04/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Recent studies characterizing in vitro hemostatic properties of whole blood (WB) leukoreduced (LR) with a platelet-sparing filter have described subtle, if any, changes to viscoelastic clotting; however, reductions in platelet (PLT) content and impedance aggregometry (IA) responses have been noted. The effects of filtration of WB (i.e., filter-contact effects, reduction in platelet and leukocyte count) have not been rigorously investigated as to their individual impacts on platelet IA responses. STUDY DESIGN AND METHODS WB units from healthy donors were collected and characterized to assess the effects of platelet-sparing leukoreduction (LR) upon the in vitro hemostatic measures of platelet IA and thromboelastometry. Further characterization of platelet IA responses was carried out in WB samples to delineate the effects of platelet count and leukocyte presence/absence upon the response. RESULTS WB filtration reduced the platelet count and IA responses but had no impact on viscoelastic clotting measures in fresh WB. Experiments revealed that IA responses have a linear correlation with platelet count in both apheresis platelets and WB and that passage of platelets through the WB-LR filter has no impact upon the strength of this response. Further experiments in LR WB showed that addition of autologous leukocytes back to the platelets fully restored the platelet aggregation response to pre-filtration levels. CONCLUSION WB filtration results in platelet count reduction and leukocyte removal; however, platelet IA is not degraded by passage through the filter. Apparent declines in platelet IA responses can be fully attributed to the reduction in platelet count and the removal of leukocytes.
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Affiliation(s)
- Joseph Rice
- Terumo Blood and Cell Technologies, Inc., Lakewood, Colorado, USA
| | - Jerome R Bill
- Terumo Blood and Cell Technologies, Inc., Lakewood, Colorado, USA
| | - Anna Razatos
- Terumo Blood and Cell Technologies, Inc., Lakewood, Colorado, USA
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11
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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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12
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Duchesne J, Smith A, Lawicki S, Hunt J, Houghton A, Taghavi S, Schroll R, Jackson-Weaver O, Guidry C, Tatum D. Single Institution Trial Comparing Whole Blood vs Balanced Component Therapy: 50 Years Later. J Am Coll Surg 2020; 232:433-442. [PMID: 33348017 DOI: 10.1016/j.jamcollsurg.2020.12.006] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2020] [Accepted: 12/07/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Early close ratio transfusion with balanced component therapy (BCT) has been associated with improved outcomes in patients with severe hemorrhage; however, this modality is not comparable with whole blood (WB) constituents. We compared use of BCT vs WB to determine if one yielded superior outcomes in patients with severe hemorrhage. We hypothesized that WB would lead to reduced in-hospital mortality and blood product volume if given in the first 24 hours of admission. STUDY DESIGN This was a 1-year, single institution, prospective, observational study comparing BCT with WB in adult (18+y) trauma patients with active hemorrhage who required blood transfusion upon arrival at the emergency department. Primary endpoint was in-hospital mortality. Secondary endpoints included 24-hour transfusion volumes, in-hospital clinical outcomes, and complications. RESULTS A total of 253 patients were included; 71.1% received BCT and 29.9% WB. The WB cohort had significantly more penetrating trauma (64.4% vs 48.9%; p = 0.03) and higher Shock Index (1.12 vs 0.92; p = 0.04). WB patients received significantly fewer units of packed red blood cells (PRBCs) (p < 0.001) and fresh frozen plasma (FFP) (p = 0.04), with a lower incidence of ARDS (p = 0.03) and fewer ventilator days (p = 0.03). Kaplan Meier survival analysis revealed no difference in survival between the 2 transfusion strategies (p = 0.80). When adjusted for various markers of injury severity and critical illness in Cox regression analysis, WB remained unassociated with mortality (hazard ratio 1.25; 95% CI 0.60-2.58; p = 0.55). CONCLUSIONS There was no difference in survival rates when comparing BCT with WB. In the WB group, the incidence of ARDS, duration of mechanical ventilation, massive transfusion protocol (MTP) activation, and transfusion volumes were significantly reduced. Further research should be directed at analyzing whether there is a true hemorrhage-related pathophysiologic benefit of WB when compared with BCT.
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Affiliation(s)
- Juan Duchesne
- Tulane University School of Medicine, New Orleans, LA.
| | - Alison Smith
- Louisiana State University Health Sciences Center, New Orleans, LA
| | - Shaun Lawicki
- Louisiana State University Health Sciences Center, New Orleans, LA
| | - John Hunt
- Louisiana State University Health Sciences Center, New Orleans, LA
| | | | | | | | | | | | - Danielle Tatum
- Our Lady of the Lake Regional Medical Center, Baton Rouge, LA
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13
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Fresh whole blood from walking blood banks for patients with traumatic hemorrhagic shock: A systematic review and meta-analysis. J Trauma Acute Care Surg 2020; 89:792-800. [PMID: 32590558 DOI: 10.1097/ta.0000000000002840] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
BACKGROUND Whole blood is optimal for resuscitation of traumatic hemorrhage. Walking Blood Banks provide fresh whole blood (FWB) where conventional blood components or stored, tested whole blood are not readily available. There is an increasing interest in this as an emergency resilience measure for isolated communities and during crises including the coronavirus disease 2019 pandemic. We conducted a systematic review and meta-analysis of the available evidence to inform practice. METHODS Standard systematic review methodology was used to obtain studies that reported the delivery of FWB (PROSPERO registry CRD42019153849). Studies that only reported whole blood from conventional blood banking were excluded. For outcomes, odds ratios (ORs) and 95% confidence interval (CI) were calculated using random-effects modeling because of high risk of heterogeneity. Quality of evidence was assessed using the Grading of Recommendations, Assessment, Development, and Evaluation system. RESULTS Twenty-seven studies published from 2006 to 2020 reported >10,000 U of FWB for >3,000 patients (precise values not available for all studies). Evidence for studies was "low" or "very low" except for one study, which was "moderate" in quality. Fresh whole blood patients were more severely injured than non-FWB patients. Overall, survival was equivalent between FWB and non-FWB groups for eight studies that compared these (OR, 1.00 [95% CI, 0.65-1.55]; p = 0.61). However, the highest quality study (matched groups for physiological and injury characteristics) reported an adjusted OR of 0.27 (95% CI, 0.13-0.58) for mortality for the FWB group (p < 0.01). CONCLUSION Thousands of units of FWB from Walking Blood Banks have been transfused in patients following life-threatening hemorrhage. Survival is equivalent for FWB resuscitation when compared with non-FWB, even when patients were more severely injured. Evidence is scarce and of relative low quality and may underestimate potential adverse events. Whereas Walking Blood Banks may be an attractive resilience measure, caution is still advised. Walking Blood Banks should be subject to prospective evaluation to optimize care and inform policy. LEVEL OF EVIDENCE Systematic/therapeutic, level 3.
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14
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Chen HW, Belinskaya T, Zhang Z, Ching WM. Simple Detection of Hepatitis B Virus in Using Loop-Mediated Isothermal Amplification Method. Mil Med 2020; 184:e275-e280. [PMID: 30690497 DOI: 10.1093/milmed/usy421] [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: 05/10/2018] [Revised: 09/26/2018] [Accepted: 12/11/2018] [Indexed: 11/14/2022] Open
Abstract
INTRODUCTION US Military and civilian personnel regularly deploy to regions that are endemic for the Hepatitis B virus (HBV), including the Western Pacific, Africa, Eastern Mediterranean, Southeast Asia, and Europe. When patients have life-threatening injuries that require any blood component that is not immediately available, they are typically transfused with locally collected fresh whole blood from a walking blood bank. Currently, there is no simple and easy method for sensitively screening fresh blood in deployed theaters of conflict. MATERIALS AND METHODS In order to fill the gap, we have developed a loop-mediated isothermal amplification (LAMP) assay to detect the presence of HBV in blood products. The primers were designed to target the gene of the pre-Surface/Surface antigen region of HBV. The amplification reaction mixture was incubated at 60°C for 60 min. The amplicon can be detected by a handheld fluorescence tube scanner or an immune-chromatography test strip. RESULTS We were able to detect down to 10 copies of viral DNA by LAMP reaction for HBV DNA extracted from HBV-positive plasma. We also identified the optimal heat treatment condition (125°C for 10 min) for plasma specimens without requiring DNA extraction for the LAMP assay. The sensitivity of the assay was evaluated with polymerase chain reaction (PCR) confirmed HBV-positive samples. Using LAMP, we detected HBV in 107 out of 127 (84%) samples. CONCLUSION This LAMP assay has the potential to be used in resource-limited settings to improve the safety of locally collected blood in endemic regions.
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Affiliation(s)
- Hua-Wei Chen
- Naval Medical Research Center, 503 Robert Grant Avenue, Silver Spring, MD
| | - Tatyana Belinskaya
- Naval Medical Research Center, 503 Robert Grant Avenue, Silver Spring, MD
| | - Zhiwen Zhang
- Naval Medical Research Center, 503 Robert Grant Avenue, Silver Spring, MD
| | - Wei-Mei Ching
- Naval Medical Research Center, 503 Robert Grant Avenue, Silver Spring, MD.,Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD
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15
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Hulse W, Bahr TM, Morris DS, Richards DS, Ilstrup SJ, Christensen RD. Emergency-release blood transfusions after postpartum hemorrhage at the Intermountain Healthcare hospitals. Transfusion 2020; 60:1418-1423. [PMID: 32529673 DOI: 10.1111/trf.15903] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Revised: 04/14/2020] [Accepted: 04/17/2020] [Indexed: 12/28/2022]
Abstract
BACKGROUND Most low-risk obstetric patients do not have crossmatched blood available to treat unexpected postpartum hemorrhage. An emergency-release blood transfusion (ERBT) program is critical for hospitals with obstetrical services. We performed a retrospective analysis of obstetrical ERBTs administered in our multihospital system. DESIGN AND METHODS We collected data from the past 8 years at all Intermountain Healthcare hospitals on every ERBT after postpartum hemorrhage; logging circumstances, number and type of transfused products, and outcomes. RESULTS Eighty-nine women received ERBT following 224,035 live births, for an incidence of 3.97 transfused women/10,000 births. The most common causally-associated conditions were: uterine atony (40%), placental abruption/placenta previa (16%), retained placenta (11%), and uterine rupture (5%). The mean number of total units transfused was 7.9 (range 1-76). The mean number of red blood cells (RBCs) transfused was 4.8, the median 4, and SD was ±4.4. Massive transfusion protocols (MTPs) for trauma recommend using a ratio of 1:1:1 or 2:1:1 of RBC:FFP:Platelets, however the ratios varied widely for postpartum hemorrhage. Only 1.5% received a 1:1:1 ratio and 7.5% received a 2:1:1 ratio. Nineteen percent (17/89) of women underwent hysterectomy, 7% (6/89) had uterine artery embolization, 36% (32/89) had an intensive care unit admission, and 1% (1/89) died. CONCLUSION Emergency transfusion for postpartum hemorrhage occurred after 1/2500 births. Most women received less FFP and platelets than recommended for traumatic hemorrhage. A potentially better practice for postpartum hemorrhage would be a balanced ratio of blood products, transfusion of low-titer, group O, cold-stored, whole blood, or inclusion in a MTP.
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Affiliation(s)
- Whitley Hulse
- Division of Neonatology, Department of Pediatrics, University of Utah Health, Salt Lake City, Utah, USA
| | - Timothy M Bahr
- Division of Neonatology, Department of Pediatrics, University of Utah Health, Salt Lake City, Utah, USA
| | - David S Morris
- Trauma and General Surgery, Intermountain Medical Center, Murray, Utah, USA
| | - Douglas S Richards
- Division of Maternal/Fetal Medicine, University of Utah Health and Intermountain Medical Center, Murray, Utah, USA.,Women and Newborn's Clinical Program, Intermountain Healthcare, Murray, Utah, USA
| | - Sarah J Ilstrup
- Department of Pathology, Intermountain Healthcare Transfusion Services and Intermountain Medical Center, Murray, Utah, USA
| | - Robert D Christensen
- Division of Neonatology, Department of Pediatrics, University of Utah Health, Salt Lake City, Utah, USA.,Division of Maternal/Fetal Medicine, University of Utah Health and Intermountain Medical Center, Murray, Utah, USA.,Division of Hematology-Oncology, University of Utah Health, Salt Lake City, Utah, USA
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16
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Braverman MA, Smith A, Shahan CP, Axtman B, Epley E, Hitchman S, Waltman E, Winckler C, Nicholson SE, Eastridge BJ, Stewart RM, Jenkins DH. From battlefront to homefront: creation of a civilian walking blood bank. Transfusion 2020; 60 Suppl 3:S167-S172. [PMID: 32478857 DOI: 10.1111/trf.15694] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Revised: 01/17/2020] [Accepted: 01/17/2020] [Indexed: 01/24/2023]
Abstract
Hemorrhagic shock remains the leading cause of preventable death on the battlefield, despite major advances in trauma care. Early initiation of balanced resuscitation has been shown to decrease mortality in the hemorrhaging patient. To address transfusion limitations in austere environments or in the event of multiple casualties, walking blood banks have been used in the combat setting with great success. Leveraging the success of the region-wide whole blood program in San Antonio, Texas, we report a novel plan that represents a model response to mass casualty incidents.
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Affiliation(s)
| | - Alison Smith
- Department of Surgery, UT Health San Antonio, San Antonio, Texas
| | | | - Benjamin Axtman
- Department of Surgery, UT Health San Antonio, San Antonio, Texas
| | - Eric Epley
- Southwest Texas Regional Advisory Council, San Antonio, Texas
| | - Scott Hitchman
- Southwest Texas Regional Advisory Council, San Antonio, Texas
| | | | - Christopher Winckler
- Department of Emergency Health Services, UT Health San Antonio, San Antonio, Texas
| | | | | | - Ronald M Stewart
- Department of Surgery, UT Health San Antonio, San Antonio, Texas
| | - Donald H Jenkins
- Department of Surgery, UT Health San Antonio, San Antonio, Texas
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17
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Morris DS, Braverman MA, Corean J, Myers JC, Xenakis E, Ireland K, Greebon L, Ilstrup S, Jenkins DH. Whole blood for postpartum hemorrhage: early experience at two institutions. Transfusion 2020; 60 Suppl 3:S31-S35. [PMID: 32478935 DOI: 10.1111/trf.15731] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Revised: 02/07/2020] [Accepted: 02/08/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Death from postpartum hemorrhage (PPH) remains a significant preventable problem worldwide. Cold-stored, low-titer, type-O whole blood (LTOWB) is increasingly being used for resuscitation of injured patients, but it is uncommon in PPH patients, and it is unclear what its role may be in this population. STUDY DESIGN AND METHODS Brief report of the early experience of WB use for PPH in two institutions, one university hospital and one private hospital. RESULTS Different approaches have been implemented at the two institutions, one designed for emergency release, uncrossmatched transfusion of LTOWB as part of a massive transfusion protocol (MTP) and one for high-risk obstetric patients with known placental abnormalities. A total of 7 PPH patients have received a total of 17 units of LTOWB between the two institutions. No severe adverse transfusion reactions were observed clinically in either institution and the clinical outcomes were favorable in all cases. CONCLUSION In our early experience, LTOWB can be implemented for two different PPH clinical scenarios. Larger studies are needed to compare outcomes between LTOWB and traditional component resuscitation strategies.
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Affiliation(s)
- David S Morris
- Division of Trauma, Intermountain Medical Center, Murray, Utah
| | - Maxwell A Braverman
- Department of Surgery, University of Texas Health San Antonio, San Antonio, Texas
| | - Jessica Corean
- Division of Pathology, University of Utah, Salt Lake City, Utah
| | - John C Myers
- Department of Surgery, University of Texas Health San Antonio, San Antonio, Texas
| | - Elly Xenakis
- Department of Obstetrics and Gynecology, University of Texas Health San Antonio, San Antonio, Texas
| | - Kayla Ireland
- Department of Obstetrics and Gynecology, University of Texas Health San Antonio, San Antonio, Texas
| | - Leslie Greebon
- Department of Obstetrics and Gynecology, University of Texas Health San Antonio, San Antonio, Texas
| | - Sarah Ilstrup
- Division of Transfusion Medicine, Intermountain Medical Center, Salt Lake City, Utah
| | - Donald H Jenkins
- Department of Surgery, University of Texas Health San Antonio, San Antonio, Texas
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18
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Leibner E, Andreae M, Galvagno SM, Scalea T. Damage control resuscitation. Clin Exp Emerg Med 2020; 7:5-13. [PMID: 32252128 PMCID: PMC7141982 DOI: 10.15441/ceem.19.089] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2019] [Accepted: 12/10/2019] [Indexed: 01/24/2023] Open
Abstract
The United States Navy originally utilized the concept of damage control to describe the process of prioritizing the critical repairs needed to return a ship safely to shore during a maritime emergency. To pursue a completed repair would detract from the goal of saving the ship. This concept of damage control management in crisis is well suited to the care of the critically ill trauma patient, and has evolved into the standard of care. Damage control resuscitation is not one technique, but, rather, a group of strategies which address the lethal triad of coagulopathy, acidosis, and hypothermia. In this article, we describe this approach to trauma resuscitation and the supporting evidence base.
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Affiliation(s)
- Evan Leibner
- Department of Emergency Medicine, Institute of Critical Care Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Mark Andreae
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Samuel M Galvagno
- Program in Trauma, Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Thomas Scalea
- Program in Trauma, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
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19
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Howard JT, Kotwal RS, Stern CA, Janak JC, Mazuchowski EL, Butler FK, Stockinger ZT, Holcomb BR, Bono RC, Smith DJ. Use of Combat Casualty Care Data to Assess the US Military Trauma System During the Afghanistan and Iraq Conflicts, 2001-2017. JAMA Surg 2020; 154:600-608. [PMID: 30916730 DOI: 10.1001/jamasurg.2019.0151] [Citation(s) in RCA: 140] [Impact Index Per Article: 35.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Importance Although the Afghanistan and Iraq conflicts have the lowest US case-fatality rates in history, no comprehensive assessment of combat casualty care statistics, major interventions, or risk factors has been reported to date after 16 years of conflict. Objectives To analyze trends in overall combat casualty statistics, to assess aggregate measures of injury and interventions, and to simulate how mortality rates would have changed had the interventions not occurred. Design, Setting, and Participants Retrospective analysis of all available aggregate and weighted individual administrative data compiled from Department of Defense databases on all 56 763 US military casualties injured in battle in Afghanistan and Iraq from October 1, 2001, through December 31, 2017. Casualty outcomes were compared with period-specific ratios of the use of tourniquets, blood transfusions, and transport to a surgical facility within 60 minutes. Main Outcomes and Measures Main outcomes were casualty status (alive, killed in action [KIA], or died of wounds [DOW]) and the case-fatality rate (CFR). Regression, simulation, and decomposition analyses were used to assess associations between covariates, interventions, and individual casualty status; estimate casualty transitions (KIA to DOW, KIA to alive, and DOW to alive); and estimate the contribution of interventions to changes in CFR. Results In aggregate data for 56 763 casualties, CFR decreased in Afghanistan (20.0% to 8.6%) and Iraq (20.4% to 10.1%) from early stages to later stages of the conflicts. Survival for critically injured casualties (Injury Severity Score, 25-75 [critical]) increased from 2.2% to 39.9% in Afghanistan and from 8.9% to 32.9% in Iraq. Simulations using data from 23 699 individual casualties showed that without interventions assessed, CFR would likely have been higher in Afghanistan (15.6% estimated vs 8.6% observed) and Iraq (16.3% estimated vs 10.1% observed), equating to 3672 additional deaths (95% CI, 3209-4244 deaths), of which 1623 (44.2%) were associated with the interventions studied: 474 deaths (12.9%) (95% CI, 439-510) associated with the use of tourniquets, 873 (23.8%) (95% CI, 840-910) with blood transfusion, and 275 (7.5%) (95% CI, 259-292) with prehospital transport times. Conclusions and Relevance Our analysis suggests that increased use of tourniquets, blood transfusions, and more rapid prehospital transport were associated with 44.2% of total mortality reduction. More critically injured casualties reached surgical care, with increased survival, implying improvements in prehospital and hospital care.
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Affiliation(s)
- Jeffrey T Howard
- Department of Kinesiology, Health, and Nutrition, The University of Texas at San Antonio.,Department of Defense Joint Trauma System, Defense Health Agency, Joint Base San Antonio-Fort Sam Houston, Texas
| | - Russ S Kotwal
- Department of Defense Joint Trauma System, Defense Health Agency, Joint Base San Antonio-Fort Sam Houston, Texas.,Department of Military and Emergency Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland.,Texas A&M Health Science Center College of Medicine, College Station
| | - Caryn A Stern
- Department of Defense Joint Trauma System, Defense Health Agency, Joint Base San Antonio-Fort Sam Houston, Texas
| | - Jud C Janak
- Department of Defense Joint Trauma System, Defense Health Agency, Joint Base San Antonio-Fort Sam Houston, Texas
| | - Edward L Mazuchowski
- Department of Defense Joint Trauma System, Defense Health Agency, Joint Base San Antonio-Fort Sam Houston, Texas.,Armed Forces Medical Examiner System, Dover Air Force Base, Dover, Delaware
| | - Frank K Butler
- Department of Defense Joint Trauma System, Defense Health Agency, Joint Base San Antonio-Fort Sam Houston, Texas
| | - Zsolt T Stockinger
- Department of Defense Joint Trauma System, Defense Health Agency, Joint Base San Antonio-Fort Sam Houston, Texas.,Bureau of Medicine and Surgery, US Navy, Falls Church, Virginia
| | - Barbara R Holcomb
- US Army Medical Research and Materiel Command, Fort Detrick, Maryland
| | - Raquel C Bono
- Defense Health Agency, US Department of Defense, Falls Church, Virginia
| | - David J Smith
- Defense Health Agency, US Department of Defense, Falls Church, Virginia
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20
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Bahr TM, DuPont TL, Christensen TR, Rees T, O'Brien EA, Ilstrup SJ, Christensen RD. Evaluating emergency-release blood transfusion of newborn infants at the Intermountain Healthcare hospitals. Transfusion 2019; 59:3113-3119. [PMID: 31479169 DOI: 10.1111/trf.15495] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Revised: 07/06/2019] [Accepted: 07/08/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND An emergency-release blood transfusion (ERBT) protocol (uncrossmatched type O-negative red blood cells, AB plasma, AB platelets) is critical for neonatology practice. However, few reports of emergency transfusions are available. We conducted an ERBT quality improvement project as a basis for progress. STUDY DESIGN AND METHODS For each ERBT in the past 8 years, we logged indications, products, locations and timing of the transfusions, and outcomes. RESULTS One hundred forty-nine ERBTs were administered; 42% involved a single blood product, and 58% involved two or more. The incidence was 6.25 ERBT per 10,000 live births, with a higher rate (9.52 ERBT/10,000) in hospitals with a Level 3 neonatal intensive care unit (NICU) (p < 0.001). Seventy percent of ERBTs were administered in a NICU and 30% in a delivery room, operating room, or emergency department. Indications were abruption/previa (32.2%), congenital anemia (i.e., fetomaternal hemorrhage; 15.4%), umbilical cord accident (i.e., velamentous insertion; 15.0%), and bleeding/coagulopathy (12.8%). Fifty-eight percent of those with hemorrhage before birth did not have a hemoglobin value reported on the umbilical cord gas; thus, anemia was not recognized initially. None of the 149 ERBTs were administered using a blood warmer. The mortality rate of recipients was 35%. CONCLUSION Based on our findings, we recommend including a hemoglobin value with every cord blood gas after emergency delivery to rapidly identify fetal anemia. We also discuss two potential improvements for future testing: 1) the use of a warming device for massive transfusion of neonates and 2) the use of low-titer group O cold-stored whole blood for massive hemorrhage in neonates.
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Affiliation(s)
- Timothy M Bahr
- Division of Neonatology, Department of Pediatrics, University of Utah Health, Salt Lake City, Utah
| | - Tara L DuPont
- Division of Neonatology, Department of Pediatrics, University of Utah Health, Salt Lake City, Utah
| | | | - Terry Rees
- Intermountain Healthcare Transfusion Services and Department of Pathology Intermountain Medical Center, University of Utah Health, Salt Lake City, Utah
| | - Elizabeth A O'Brien
- Division of Neonatology, Department of Pediatrics, University of Utah Health, Salt Lake City, Utah.,Women and Newborn's Clinical Program, Intermountain Healthcare, University of Utah Health, Salt Lake City, Utah
| | - Sarah J Ilstrup
- Intermountain Healthcare Transfusion Services and Department of Pathology Intermountain Medical Center, University of Utah Health, Salt Lake City, Utah
| | - Robert D Christensen
- Division of Neonatology, Department of Pediatrics, University of Utah Health, Salt Lake City, Utah.,Women and Newborn's Clinical Program, Intermountain Healthcare, University of Utah Health, Salt Lake City, Utah.,Division of Hematology/Oncology, Department of Pediatrics, University of Utah Health, Salt Lake City, Utah
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Bahr TM, DuPont TL, Morris DS, Pierson SE, Esplin MS, Brown SM, O'Brien EA, Ilstrup SJ, Christensen RD. First report of using low‐titer cold‐stored type O whole blood in massive postpartum hemorrhage. Transfusion 2019; 59:3089-3092. [DOI: 10.1111/trf.15492] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Revised: 07/09/2019] [Accepted: 07/26/2019] [Indexed: 01/14/2023]
Affiliation(s)
- Timothy M. Bahr
- Division of Neonatology, Department of PediatricsUniversity of Utah Health Salt Lake City Utah
| | - Tara L. DuPont
- Division of Neonatology, Department of PediatricsUniversity of Utah Health Salt Lake City Utah
| | - David S. Morris
- Trauma and General SurgeryIntermountain Medical Center Salt Lake City Utah
| | - Spencer E. Pierson
- Department of Obstetrics and GynecologyIntermountain Medical Center Salt Lake City Utah
| | - Michael Sean Esplin
- Department of Obstetrics and GynecologyIntermountain Medical Center Salt Lake City Utah
- Women and Newborn's Clinical ProgramIntermountain Healthcare Salt Lake City Utah
- Department of Obstetrics and GynecologyUniversity of Utah Health Salt Lake City Utah
| | - Samuel M. Brown
- Divsion of Pulmonology, Department of Internal MedicineUniversity of Utah Health, and Shock/Trauma ICU, Intermountain Medical Center Salt Lake City Utah
| | - Elizabeth A. O'Brien
- Division of Neonatology, Department of PediatricsUniversity of Utah Health Salt Lake City Utah
- Women and Newborn's Clinical ProgramIntermountain Healthcare Salt Lake City Utah
| | - Sarah J. Ilstrup
- Intermountain Healthcare Transfusion Medicine Service and Department of Pathology Intermountain Medical Center Salt Lake City Utah
| | - Robert D. Christensen
- Division of Neonatology, Department of PediatricsUniversity of Utah Health Salt Lake City Utah
- Women and Newborn's Clinical ProgramIntermountain Healthcare Salt Lake City Utah
- Division of Hematology‐Oncology, Department of PediatricsUniversity of Utah Health Salt Lake City Utah
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Pivalizza EG, Stephens CT, Sridhar S, Gumbert SD, Rossmann S, Bertholf MF, Bai Y, Cotton BA. Whole Blood for Resuscitation in Adult Civilian Trauma in 2017: A Narrative Review. Anesth Analg 2019; 127:157-162. [PMID: 29771715 DOI: 10.1213/ane.0000000000003427] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
After a hiatus of several decades, the concept of cold whole blood (WB) is being reintroduced into acute clinical trauma care in the United States. Initial implementation experience and data grew from military medical applications, followed by more recent development and data acquisition in civilian institutions. Anesthesiologists, especially those who work in acute trauma facilities, are likely to be presented with patients either receiving WB from the emergency department or may have WB as a therapeutic option in massive transfusion situations. In this focused review, we briefly discuss the historical concept of WB and describe the characteristics of WB, including storage, blood group compatibility, and theoretical hemolytic risks. We summarize relevant recent retrospective military and preliminary civilian efficacy as well as safety data related to WB transfusion, and describe our experience with the initial implementation of WB transfusion at our level 1 trauma hospital. Suggestions and collective published experience from other centers as well as ours may be useful to those investigating such a program. The role of WB as a significant therapeutic option in civilian trauma awaits further prospective validation.
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Affiliation(s)
- Evan G Pivalizza
- From the Department of Anesthesiology, University of Texas Health McGovern Medical School, Houston, Texas
| | - Christopher T Stephens
- From the Department of Anesthesiology, University of Texas Health McGovern Medical School, Houston, Texas
| | - Srikanth Sridhar
- From the Department of Anesthesiology, University of Texas Health McGovern Medical School, Houston, Texas
| | - Sam D Gumbert
- From the Department of Anesthesiology, University of Texas Health McGovern Medical School, Houston, Texas
| | - Susan Rossmann
- Executive Staff, Gulf Coast Regional Blood Center, Houston, Texas
| | | | | | - Bryan A Cotton
- Surgery, University of Texas Health McGovern Medical School, Houston, Texas
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23
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Weymouth W, Long B, Koyfman A, Winckler C. Whole Blood in Trauma: A Review for Emergency Clinicians. J Emerg Med 2019; 56:491-498. [DOI: 10.1016/j.jemermed.2019.01.024] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Revised: 01/09/2019] [Accepted: 01/21/2019] [Indexed: 11/26/2022]
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24
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Amico F, Briggs G, Balogh ZJ. Transfused trauma patients have better outcomes when transfused with blood components from young donors. Med Hypotheses 2018; 122:141-146. [PMID: 30593399 DOI: 10.1016/j.mehy.2018.11.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Revised: 11/14/2018] [Accepted: 11/21/2018] [Indexed: 12/20/2022]
Abstract
The physiology of tissue healing and aging share common pathways. Both patient age and tissue healing are crucial factors predicting outcomes in trauma patients. The presented hypothesis focuses on the concept that transfused trauma patients have better outcomes when transfused with blood components from young donors. The age of the donor of a blood transfusion could affect recovery following a major traumatic insult and help avoid postinjury immune paralysis and its associated complications. The frequent transfusion of blood components to the severely injured trauma patient provides an opportunity for the recipient to benefit from the potentially favourable effect of blood originating from young donors. Different types of evidence support the presented hypothesis including work on soluble circulating factors, research on animal parabiontic models and epidemiological studies. Theories on the role of transfusion of cells, on bone marrow and on senolytics also represent grounds to elaborate pathways to test this hypothesis. The precise molecular mechanism underlying this hypothesis is uncertain. A beneficial effect on trauma patients following transfusion of blood could be due to a positive effect of blood donated from younger donors or instead to the lack of a negative effect possibly occurring when transfusing blood from older donors. Either way, identifying this mechanism would provide a powerful tool enhance long and short term recovery after trauma.
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Affiliation(s)
- Francesco Amico
- Department of Traumatology, John Hunter Hospital and University of Newcastle, Australia
| | - Gabrielle Briggs
- Department of Traumatology, John Hunter Hospital and University of Newcastle, Australia
| | - Zsolt J Balogh
- Department of Traumatology, John Hunter Hospital and University of Newcastle, Australia.
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25
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Enhanced platelet function in cold stored whole blood supplemented with resveratrol or cytochrome C. J Trauma Acute Care Surg 2018. [DOI: 10.1097/ta.0000000000001887] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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26
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Hickman DA, Pawlowski CL, Sekhon UDS, Marks J, Gupta AS. Biomaterials and Advanced Technologies for Hemostatic Management of Bleeding. ADVANCED MATERIALS (DEERFIELD BEACH, FLA.) 2018; 30:10.1002/adma.201700859. [PMID: 29164804 PMCID: PMC5831165 DOI: 10.1002/adma.201700859] [Citation(s) in RCA: 260] [Impact Index Per Article: 43.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/11/2017] [Revised: 06/18/2017] [Indexed: 05/03/2023]
Abstract
Bleeding complications arising from trauma, surgery, and as congenital, disease-associated, or drug-induced blood disorders can cause significant morbidities and mortalities in civilian and military populations. Therefore, stoppage of bleeding (hemostasis) is of paramount clinical significance in prophylactic, surgical, and emergency scenarios. For externally accessible injuries, a variety of natural and synthetic biomaterials have undergone robust research, leading to hemostatic technologies including glues, bandages, tamponades, tourniquets, dressings, and procoagulant powders. In contrast, treatment of internal noncompressible hemorrhage still heavily depends on transfusion of whole blood or blood's hemostatic components (platelets, fibrinogen, and coagulation factors). Transfusion of platelets poses significant challenges of limited availability, high cost, contamination risks, short shelf-life, low portability, performance variability, and immunological side effects, while use of fibrinogen or coagulation factors provides only partial mechanisms for hemostasis. With such considerations, significant interdisciplinary research endeavors have been focused on developing materials and technologies that can be manufactured conveniently, sterilized to minimize contamination and enhance shelf-life, and administered intravenously to mimic, leverage, and amplify physiological hemostatic mechanisms. Here, a comprehensive review regarding the various topical, intracavitary, and intravenous hemostatic technologies in terms of materials, mechanisms, and state-of-art is provided, and challenges and opportunities to help advancement of the field are discussed.
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Affiliation(s)
- DaShawn A Hickman
- Case Western Reserve University School of Medicine, Department of Pathology, Cleveland, Ohio 44106, USA
| | - Christa L Pawlowski
- Case Western Reserve University, Department of Biomedical Engineering, Cleveland, Ohio 44106, USA
| | - Ujjal D S Sekhon
- Case Western Reserve University, Department of Biomedical Engineering, Cleveland, Ohio 44106, USA
| | - Joyann Marks
- Case Western Reserve University, Department of Biomedical Engineering, Cleveland, Ohio 44106, USA
| | - Anirban Sen Gupta
- Case Western Reserve University, Department of Biomedical Engineering, Cleveland, Ohio 44106, USA
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27
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Initial safety and feasibility of cold-stored uncrossmatched whole blood transfusion in civilian trauma patients. J Trauma Acute Care Surg 2017; 81:21-6. [PMID: 27120323 DOI: 10.1097/ta.0000000000001100] [Citation(s) in RCA: 138] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND The transfusion of cold-stored uncrossmatched whole blood (WB) has not been extensively used in civilian trauma resuscitation. This report details the initial experience with the safety and feasibility of using WB in this setting after a change of practice at a Level 1 trauma center was instituted. METHODS Up to two units of uncrossmatched group O positive WB that was leukoreduced using a platelet-sparing filter from male donors were transfused to male trauma patients with hypotension secondary to bleeding. Hemolytic marker haptoglobin and reports of transfusion reactions in these patients were followed. Additionally, transfusion volumes and outcomes were compared to a historical cohort of male trauma patients who received at least one red blood cell (RBC) unit, but not WB, during the first 24 hours of admission. RESULTS There were 47 WB patients who were transfused with a mean (SD) of 1.74 (0.61) WB units. The median haptoglobin concentration on post-WB transfusion Day 1 was 25.1 (9.3) mg/dL in 7 of 30 non-group O recipients. No adverse reactions in temporal relation to the WB transfusions were reported. There were 145 male historical control patients identified who were resuscitated with component therapy; the median volume of incompatible plasma transfused to the WB versus component therapy group was not significantly different (1,000 vs. 800 mL, respectively; p = 0.38); the mean plasma:RBC (0.99 [0.47] vs. 0.77 [ 0.73], respectively; p = 0.006) and platelet:RBC (0.72 [0.40] vs. 0.51 [0.734], respectively; p < 0.0001) ratios were significantly higher in the WB group. CONCLUSION Transfusion of two units of cold-stored uncrossmatched WB is feasible and seems to be safe in civilian trauma resuscitation. Determining the efficacy of WB with regard to reducing the number of blood products transfused in the first 24 hours or improving recipient survival will require a larger randomized trial. LEVEL OF EVIDENCE Therapeutic study, level IV.
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Abstract
The resuscitation of traumatic hemorrhagic shock has undergone a paradigm shift in the last 20 years with the advent of damage control resuscitation (DCR). Major principles of DCR include minimization of crystalloid, permissive hypotension, transfusion of a balanced ratio of blood products, and goal-directed correction of coagulopathy. In particular, plasma has replaced crystalloid as the primary means for volume expansion for traumatic hemorrhagic shock. Predicting which patient will require DCR by prompt and accurate activation of a massive transfusion protocol, however, remains a challenge.
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Affiliation(s)
- Ronald Chang
- Center for Translational Injury Research, University of Texas Health Science Center, 6410 Fannin Street, Suite 1100, Houston, TX 77030, USA.
| | - John B Holcomb
- Department of Surgery, University of Texas Health Science Center, 6410 Fannin Street, Suite 1100, Houston, TX 77030, USA
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Noorman F, van Dongen TTCF, Plat MCJ, Badloe JF, Hess JR, Hoencamp R. Transfusion: -80°C Frozen Blood Products Are Safe and Effective in Military Casualty Care. PLoS One 2016; 11:e0168401. [PMID: 27959967 PMCID: PMC5154589 DOI: 10.1371/journal.pone.0168401] [Citation(s) in RCA: 65] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2016] [Accepted: 11/30/2016] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION The Netherlands Armed Forces use -80°C frozen red blood cells (RBCs), plasma and platelets combined with regular liquid stored RBCs, for the treatment of (military) casualties in Medical Treatment Facilities abroad. Our objective was to assess and compare the use of -80°C frozen blood products in combination with the different transfusion protocols and their effect on the outcome of trauma casualties. MATERIALS AND METHODS Hemovigilance and combat casualties data from Afghanistan 2006-2010 for 272 (military) trauma casualties with or without massive transfusions (MT: ≥6 RBC/24hr, N = 82 and non-MT: 1-5 RBC/24hr, N = 190) were analyzed retrospectively. In November 2007, a massive transfusion protocol (MTP; 4:3:1 RBC:Plasma:Platelets) for ATLS® class III/IV hemorrhage was introduced in military theatre. Blood product use, injury severity and mortality were assessed pre- and post-introduction of the MTP. Data were compared to civilian and military trauma studies to assess effectiveness of the frozen blood products and MTP. RESULTS No ABO incompatible blood products were transfused and only 1 mild transfusion reaction was observed with 3,060 transfused products. In hospital mortality decreased post-MTP for MT patients from 44% to 14% (P = 0.005) and for non-MT patients from 12.7% to 5.9% (P = 0.139). Average 24-hour RBC, plasma and platelet ratios were comparable and accompanying 24-hour mortality rates were low compared to studies that used similar numbers of liquid stored (and on site donated) blood products. CONCLUSION This report describes for the first time that the combination of -80°C frozen platelets, plasma and red cells is safe and at least as effective as standard blood products in the treatment of (military) trauma casualties. Frozen blood can save the lives of casualties of armed conflict without the need for in-theatre blood collection. These results may also contribute to solutions for logistic problems in civilian blood supply in remote areas.
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Affiliation(s)
- Femke Noorman
- Military Blood Bank, Ministry of Defense, Leiden, The Netherlands
- * E-mail: (FN); (TD)
| | - Thijs T. C. F. van Dongen
- Ministry of Defense and Department of Trauma, Division of Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands
- * E-mail: (FN); (TD)
| | | | - John F. Badloe
- Military Blood Bank, Ministry of Defense, Leiden, The Netherlands
| | - John R. Hess
- Transfusion Service, Harborview Medical Centre, Seattle, United States of America
| | - Rigo Hoencamp
- Ministry of Defense and Department of Surgery, Alrijne Medical Centre Leiderdorp, Leiden University Medical Centre, Leiden, the Netherlands
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30
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Swann JA, Hofmann LJ. The Reliability of Self-Reporting Blood Type: Helmet Patches, ID Tags, Tattoos, and Other Blood Type Identification. Am Surg 2016. [DOI: 10.1177/000313481608201210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Jacob A. Swann
- Department of Surgery William Beaumont Army Medical Center El Paso, Texas
| | - Luke J. Hofmann
- Department of Surgery William Beaumont Army Medical Center El Paso, Texas
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Kohli A, Chao E, Spielman D, Sugano D, Srivastava A, Dayama A, Lederman A, Stern M, Reddy SH, Teperman S, Stone ME. Factors Associated with Return to Work Postinjury: Can the Modified Rankin Scale be Used to Predict Return to Work? Am Surg 2016. [DOI: 10.1177/000313481608200210] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The ability to return to work (RTW) postinjury is one of the primary goals of rehabilitation. The modified Rankin Scale (mRS) is a validated simple scale used to assess the functional status of stroke patients during rehabilitation. We sought to determine the applicability of mRS in predicting RTW postinjury in a general trauma population. The trauma registry was queried for patients, aged 18 to 65 years, discharged from 2012 to 2013. A telephone interview for each patient included questions about employment status and physical ability to determine the mRS. Patients who had RTW postinjury were compared with those who had not (nRTW). Two hundred and thirty-four patients met the inclusion criteria. Of these, 171 (72.5%) patients RTW and 63 (26.7%) did nRTW. Patients who did nRTW were significantly older, had longer length of stay and higher rates of in-hospital complications. Multivariate analysis revealed that older patients were less likely to RTW (odds ratio = 0.961, P = 0.011) and patients with a modified Rankin score ≤2 were 15 times more likely to RTW (odds ratio = 14.932, P < 0.001). In conclusion, an mRS ≤2 was independently associated with a high likelihood of returning to work postinjury. This is the first study that shows applicability of the mRS for predicting RTW postinjury in a trauma population.
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Affiliation(s)
- Anirudh Kohli
- Department of Surgery, Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Edward Chao
- Department of Surgery, Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Daniel Spielman
- Department of Surgery, Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Dordaneh Sugano
- Department of Surgery, Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Abhishek Srivastava
- Department of Surgery, Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Anand Dayama
- Department of Surgery, Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Andrew Lederman
- Department of Physical Medicine and Rehabilitation, Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Michelle Stern
- Department of Physical Medicine and Rehabilitation, Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Srinivas H. Reddy
- Department of Surgery, Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Sheldon Teperman
- Department of Surgery, Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Melvin E. Stone
- Department of Surgery, Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, New York
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Lessons of war: Combat-related injury infections during the Vietnam War and Operation Iraqi and Enduring Freedom. J Trauma Acute Care Surg 2016; 79:S227-35. [PMID: 26406435 DOI: 10.1097/ta.0000000000000768] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Yazer MH, Glackin EM, Triulzi DJ, Alarcon LH, Murdock A, Sperry J. The effect of stationary versus rocked storage of whole blood on red blood cell damage and platelet function. Transfusion 2015; 56:596-604. [PMID: 26718322 DOI: 10.1111/trf.13448] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2015] [Revised: 09/30/2015] [Accepted: 10/17/2015] [Indexed: 11/29/2022]
Abstract
BACKGROUND Increasingly, cold-stored whole blood (WB) is being considered for the resuscitation of civilian trauma patients. It is unclear whether the WB should be agitated to enhance the function of the platelets (PLTs) or whether agitation will cause RBC damage. STUDY DESIGN AND METHODS WB units were collected by standard procedures using a PLT-sparing inline leukoreduction filter and stored between 1 and 6°C. On Storage Day 3 each unit was divided into 4 subunits that were stored under one of the following conditions for 21 days: unrocked, manually rocked once daily, continuously rocked end over end, or continuously rocked horizontally. From Day 3 to Day 10, hemolysis and the mechanical fragility index (MFI) for RBC injury were measured daily and again on Days 15 and 21 (n = 9-16 units tested each time). On Days 4 and 10, rapid thromboelastogram (rTEG) measurements were performed (n = 8-10 units tested each time). RESULTS Hemolysis and MFI increased significantly between Day 3 and Day 21 (p < 0.0001) for all RBC rocking conditions, as well as the unrocked units. Only the manually and horizontally rocked units demonstrated higher hemolysis (on Day 21) and MFI (starting on Day 10) compared to the unrocked units. Only the α-angle and maximum amplitude in the end-over-end rocked units increased significantly between Day 4 and Day 10. There were no significant differences between the rocked and unrocked units on Day 10 for any rTEG variable. CONCLUSIONS Rocking does not appear to enhance in vitro PLT activity in cold-stored WB and can lead to increased hemolysis.
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Affiliation(s)
- Mark H Yazer
- The Institute for Transfusion Medicine, Pittsburgh, Pennsylvania.,Department of Pathology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Emily M Glackin
- Department of Pathology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Darrell J Triulzi
- The Institute for Transfusion Medicine, Pittsburgh, Pennsylvania.,Department of Pathology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Louis H Alarcon
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Alan Murdock
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Jason Sperry
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
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Glassberg E, Nadler R, Erlich T, Klien Y, Kreiss Y, Kluger Y. A Decade of Advances in Military Trauma Care. Scand J Surg 2014; 103:126-131. [DOI: 10.1177/1457496914523413] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background: While combat casualty care shares many key concepts with civilian trauma systems, its unique features mandate certain practices that are distinct from the civilian ones. Methods: This is a review of the most current literature on combat casualty care, based on computer database searches for studies on combat casualty care and military medicine. Studies were selected for inclusion in this review based on their relevance and contribution. Results: Over the last decade, meticulous, international data collection and research efforts have led to significant improvements in military trauma care. Combat medicine has focused on the causes of preventable deaths and targeted on bleeding control and resuscitation strategies, as well as improved evacuation. En route care and forward surgical interventions have resulted in unprecedented low fatality rates and the saving of more lives. Conclusion: This overview of the developments in combat casualty care in recent years emphasizes medical practices that are characteristic of combat medicine, yet with the potential to save lives in other scenarios, as well.
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Affiliation(s)
- E. Glassberg
- Surgeon General’s Headquarters, Israel Defense Forces, Ramat Gan, Israel
| | - R. Nadler
- Surgeon General’s Headquarters, Israel Defense Forces, Ramat Gan, Israel
| | - T. Erlich
- Surgeon General’s Headquarters, Israel Defense Forces, Ramat Gan, Israel
| | - Y. Klien
- Department of General Surgery, Kaplan Medical Center, Rehovot, Israel
| | - Y. Kreiss
- Surgeon General’s Headquarters, Israel Defense Forces, Ramat Gan, Israel
- Department of Military Medicine, Hebrew University, Jerusalem, Israel
| | - Y. Kluger
- Department of General Surgery, Rambam Medical Center, Haifa, Israel
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36
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Strandenes G, Cap AP, Cacic D, Lunde THF, Eliassen HS, Hervig T, Spinella PC. Blood Far Forward--a whole blood research and training program for austere environments. Transfusion 2013; 53 Suppl 1:124S-130S. [PMID: 23301964 DOI: 10.1111/trf.12046] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
The Blood Far Forward (BFF) research program was established to conduct blood product efficacy and safety studies, donor performance studies, and research on optimal training methods to improve the safety of blood collection and transfusion performed by Norwegian Naval Special Operation Commando soldiers. The use of intravenous fluids for volume replacement during hemorrhagic shock is controversial, but it is currently the standard of care. In the far-forward environment, large volume resuscitation for massive bleeding is a great challenge. Crystalloid and colloid solutions add weight and bulk to the medic's kit, require temperature sensitive storage, and should be warmed before infusion to prevent hypothermia. Excessive use of these solutions causes a dilutional coagulopathy, acidosis, and potentially increased inflammatory injury compared with blood products. Type-specific whole blood from an uninjured combat companion on the other hand is almost always available. It is warm, replaces intravascular volume, and provides oxygen delivery and hemostatic capacity to prevent or treat shock and coagulopathy. Whole blood may be ideal for the resuscitation of combat casualties with hemorrhagic shock. BFF program pilot studies on use of platelet-sparing leukoreduction filters, whole blood transport tolerance, donor performance, and autologous reinfusion of 24-hour ambient temperature stored whole blood have been performed and suggest the feasibility of expanding whole blood use in resuscitation. If successful, the BFF program will change tactics, techniques, and procedures with a new lifesaving capability.
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