Transfusion medicine in trauma patients

Safety of Uncrossmatched ABO-Compatible RBCs in Alloimmunized Patients with Bleeding: Data from Two Decades: Results of a Systematic Analysis in 6,109 Patients

Introduction: Uncrossmatched ABO-compatible red blood cells (RBCs) are generally recommended in patients with life-threatening massive bleeding. There is little data regarding RBC transfusion when patients are transfused against clinically significant alloantibodies because compatible RBCs are not immediately available. Methods/Patients: All patients reviewed in this study (n = 6,109) required emergency blood transfusion and were treated at the Charité – Universitätsmedizin Berlin between 2001 and 2015. Primary uncrossmatched O Rh(D)-positive or -negative RBC units were immediately transfused prior to complete regulatory serological testing including determination of ABO group, Rhesus antigens, antibody screening, and crossmatching. Results: Without any significant change in the protocol of emergency transfusion of RBCs, a total of 63,373 RBC units were transfused in 6,109 patients. Antibody screening was positive in 413 patients (6.8%), and 19 of these patients received RBC units against clinically significant alloantibodies. None of these patients appeared to have developed significant hemolysis, and only one patient with anti-D seems to have developed signs of insignificant hemolysis following the transfusion of three Rh(D)-positive units. One patient who had anti-Jka received unselected units and did not develop a hemolytic transfusion reaction. Conclusion: Transfusion of uncrossmatched ABO-compatible RBCs against alloantibodies is highly safe in patients with life-threatening hemorrhage.

Uncrossmatched Blood Transfusion for Resuscitation Patients at the Emergency Department

BACKGROUND: Patients with uncontrolled blood loss often require immediate blood transfusion after the bleeding is stopped. If it is an emergency situation, blood that has not been tested for compatibility (uncrossmatched red blood cell [URBC] products) can be used. However, no studies have been conducted to evaluate the effectiveness of this protocol. AIM: The aim of the study is to evaluate the effectiveness of URBC transfusion in Srinagarind Hospital’s emergency department (ED). METHODS: This was a cross-sectional study that reviewed the medical records of ninty Thai patients over 18 years of age who received at least one unit of blood through URBC transfusion in the Srinagarind Hospital ED from September 2016 to August 2018. RESULTS: The average age of the patients was 47.23 ± 18.2 years, and 73.3% were male. A total of 149 units of URBC were provided, with 54.44% of recipients being trauma patients and 27.78% being gastrointestinal bleeding patients. The 24-h and in-hospital mortality rates were 58.89 and 72.22%, respectively. There were no cases of acute blood transfusion complications or inappropriate URBC transfusion. CONCLUSIONS: The transfusion of URBC necessary in patients with uncontrolled bleeding. No complications were found due to acute blood transfusion.

Potential Consequences of the Red Blood Cell Storage Lesion on Cardiac Electrophysiology

Background The red blood cell (RBC) storage lesion is a series of morphological, functional, and metabolic changes that RBCs undergo following collection, processing, and refrigerated storage for clinical use. Since the biochemical attributes of the RBC unit shifts with time, transfusion of older blood products may contribute to cardiac complications, including hyperkalemia and cardiac arrest. We measured the direct effect of storage age on cardiac electrophysiology and compared it with hyperkalemia, a prominent biomarker of storage lesion severity. Methods and Results Donor RBCs were processed using standard blood-banking techniques. The supernatant was collected from RBC units, 7 to 50 days after donor collection, for evaluation using Langendorff-heart preparations (rat) or human induced pluripotent stem cell-derived cardiomyocytes. Cardiac parameters remained stable following exposure to "fresh" supernatant from red blood cell units (day 7: 5.8±0.2 mM K+), but older blood products (day 40: 9.3±0.3 mM K+) caused bradycardia (baseline: 279±5 versus day 40: 216±18 beats per minute), delayed sinus node recovery (baseline: 243±8 versus day 40: 354±23 ms), and increased the effective refractory period of the atrioventricular node (baseline: 77±2 versus day 40: 93±7 ms) and ventricle (baseline: 50±3 versus day 40: 98±10 ms) in perfused hearts. Beating rate was also slowed in human induced pluripotent stem cell-derived cardiomyocytes after exposure to older supernatant from red blood cell units (-75±9%, day 40 versus control). Similar effects on automaticity and electrical conduction were observed with hyperkalemia (10-12 mM K+). Conclusions This is the first study to demonstrate that "older" blood products directly impact cardiac electrophysiology, using experimental models. These effects are likely caused by biochemical alterations in the supernatant from red blood cell units that occur over time, including, but not limited to hyperkalemia. Patients receiving large volume and/or rapid transfusions may be sensitive to these effects.

CE: A Review of Current Practice in Transfusion Therapy

: In the United States, roughly 4.5 million patients per year receive transfusions of various blood products. Despite the lifesaving benefits of transfusion therapy, it is an independent risk factor for infection, morbidity, and death in critically ill patients. It's important for nurses to understand the potential complications patients face when blood products are administered and to recognize that patients who have received blood products in the past remain at risk for delayed reactions, including immune compromise and infection. Here, the authors review the blood products that are commonly transfused; discuss potential complications of transfusion, as well as their associated signs and symptoms; and outline current recommendations for transfusion therapy that are widely supported in the medical and nursing literature.

Unmatched Type O RhD+ Red Blood Cells in Multiple Injured Patients

Background

Immediate supply of red blood cell (RBC) concentrates is crucial in the initial treatment of exsanguinating patients in the emergency room. General shortage of RhD- RBCs has led to protocols in which patients with unknown blood groups are initially transfused with group O, RhD+ RBCs. Limited data are available regarding the safety of such an approach.

Methods

Transfusion protocols for all multiple injured patients from the regional polytrauma database were retrospectively analyzed over a period of 5 years. Data on side effects were retrieved from the local safety update registry. Follow-up data were obtained from patients with identified RhD-incompatible transfusions.

Results

In total, 823 patients were registered as multiple injured in the database. An immediate transfusion of 259 units (mean number of units 4, range 1-6) group O, RhD+ RBCs was initiated in 62 of them. 14 of these patients were RhD- and received 60 units of RhD-incompatible RBCs in the emergency room. In the later course RhD- patients received additional 185 incompatible transfusions (13; 1-31). The overall seroconversion rate was 50%. No adverse outcome due to incompatible transfusion was observed.

Conclusions

Initial supply with group O, RhD+ RBCs in multiple injured patients appears to be safe. Significant numbers of RhD- units can be saved for use in other patients.

Acute haemolysis, DIC and renal failure after transfusion of uncross-matched blood during trauma resuscitation: illustrative case and literature review

AIMS/OBJECTIVES

The aims of this study were to report a patient with acute haemolytic transfusion reaction (HTR) after transfusing uncross-matched red blood cell (RBC) units and to identify the frequency of this complication.

BACKGROUND

Uncross-matched RBC units are commonly transfused in emergencies, but the frequency of acute HTR is unknown.

METHODS

We describe a male stabbing victim who received three units of uncross-matched RBC units complicated by acute intravascular HTR, disseminated intravascular coagulation (DIC) and renal failure. We identified 14 studies evaluating the frequency of acute HTR post-emergency transfusion of uncross-matched RBC units.

RESULTS

Acute HTR was shown by haemoglobinuria, free-plasma haemoglobin and methemalbumin, with anti-K and anti-Fy^a eluted from recipient red cells; acute DIC featured severe hypofibrinogenemia, thrombocytopenia, elevated fibrin D-dimer and multiple bilateral renal infarcts. Two of the three transfused units reacted with pre-existing RBC alloantibodies [anti-K (titre, 128), anti-Fy^a (titre, 512)], explained by transfusion 25 years earlier. Our literature review found the frequency of acute HTR following emergency transfusion of uncross-matched RBC units to be 2/3998 [0·06% (95% CI, 0·01-0·21%)].

CONCLUSIONS

Although emergency transfusion of uncross-matched blood is commonly practiced at trauma centres worldwide, with low risk of acute HTR (<1/1000), our well-documented patient case demonstrates the potential for acute HTR with severe complications.

Utilisation of Blood Components in Trauma Surgery: A Single-Centre, Retrospective Analysis before and after the Implementation of an Educative PBM Initiative

BACKGROUND

The aim of our single-centre retrospective study presented here is to further analyse the utilisation of allogeneic blood components within a 5-year observation period (2009-2013) in trauma surgery (15,457 patients) under the measures of an educational patient blood management (PBM) initiative.

METHODS

After the implementation of the PBM initiative in January 2012, the Institute of Transfusion Medicine und Transplantation Immunology educates surgeons and nurses at the Department of Trauma Surgery to avoid unnecessary blood transfusions. A standardised reporting system was used to document the utilisation of blood components carefully for the most frequent diagnoses and surgical interventions in trauma surgery. These measures served as basis for the implementation of an interdisciplinary systematic exchange of information to foster decision-making processes in favour of patient blood management.

RESULTS

Since January 2012, the proportion of patients who received a transfusion as well as the number of transfused red blood cell (RBC) (7.3%/6.4%; p = 0.02), fresh frozen plasma (FFP) (1.7%/1.3%; p < 0.05) and platelet (PLT) (1.0%/0.5%; p < 0.001) units were reduced as a result of our PBM initiative. However, among the transfused patients, the number of administered RBC, FFP and PLT units did not decrease significantly. Overall, patients who did not receive transfusions were younger than transfused patients (p = 0.001). The subgroup with the highest probability of blood transfusion administered included patients with intensive care and long-term ventilation (before/after implementation of PBM: RBC 81.5%/75.9%; FFP 33.3%/20.4%; PLT 24.1%/13.0%). Only a total of 60 patients of 531 patients suffering multiple traumas were massively transfused (before/after implementation of PBM: RBC 55.6%/49.8%; FFP 28.4%/20.4%; PLT 17.6%/8.9%).

CONCLUSION

According to our educational PBM initiative, at least the proportion of trauma patients who received allogeneic blood transfusions could be reduced significantly. However, in case of blood transfusions, the total consumption of RBC, FFP and PLT units remained stable in both time periods. This phenomenon might indicate that the actual need of blood transfusions rather depends on the severity of trauma-related blood loss, the coagulopathy rates or the complexity of the surgical intervention which mainly determines the intra-operative blood loss. Taken together, educational training sessions and systematic reporting systems are suitable measures to avoid unnecessary allogeneic blood transfusions and to continuously improve their restrictive application.

Prehospital Transfusion of Plasma and Red Blood Cells in Trauma Patients

Abstract Objective. Earlier use of plasma and red blood cells (RBCs) has been associated with improved survival in trauma patients with substantial hemorrhage. We hypothesized that prehospital transfusion (PHT) of thawed plasma and/or RBCs would result in improved patient coagulation status on admission and survival. Methods. Adult trauma patient records were reviewed for patient demographics, shock, coagulopathy, outcomes, and blood product utilization from September 2011 to April 2013. Patients arrived by either ground or two different helicopter companies. All patients transfused with blood products (either pre- or in-hospital) were included in the study. One helicopter system (LifeFlight, LF) had thawed plasma and RBCs while the other air (OA) and ground transport systems used only crystalloid resuscitation. Patients receiving PHT were compared with all other patients meeting entry criteria to the study cohort. All comparisons were adjusted in multilevel regression models. Results. A total of 8,536 adult trauma patients were admitted during the 20-month study period, of which 1,677 met inclusion criteria. They represented the most severely injured patients (ISS = 24 and mortality = 26%). There were 792 patients transported by ground, 716 by LF, and 169 on OA. Of the LF patients, 137 (19%) received prehospital transfusion. There were 942 units (244 RBCs and 698 plasma) placed on LF helicopters, with 1.9% wastage. PHT was associated with improved acid-base status on hospital admission, decreased use of blood products over 24 hours, a reduction in the risk of death in the sickest patients over the first 6 hours after admission, and negligible blood products wastage. In this small single-center pilot study, there were no differences in 24-hour (odds ratio 0.57, p = 0.117) or 30-day mortality (odds ratio 0.71, p = 0.441) between LF and OA. Conclusions. Prehospital plasma and RBC transfusion was associated with improved early outcomes, negligible blood products wastage, but not an overall survival advantage. Similar to the data published from the ongoing war, improved early outcomes are associated with placing blood products prehospital, allowing earlier infusion of life-saving products to critically injured patients.

Emergency uncrossmatched transfusion effect on blood type alloantibodies

BACKGROUND

Trauma patients receive emergency transfusions of unmatched Type O Rh-negative (Rh-) blood until matched blood is available. We hypothesized that patients given uncrossmatched blood may develop alloantibodies, placing them at risk for hemolytic transfusion reactions (HTRs).

METHODS

Data regarding alloantibody profiles and HTR occurrence were collected from the records of trauma patients at our university-based trauma center who received emergency uncrossmatched blood from July 2008 to August 2010.

RESULTS

A total of 132 patients received 1,570 units of packed red blood cells. Mean injury severity score was 28 ± 1.3. Forty-five (34%) patients died: 27 on hospital day 1; the remaining 18 had no evidence of HTR before death. Four Rh- female patients received Rh+ fresh frozen plasma, but none received Rh+ packed red blood cells. Three Rh- male patients received both Rh+ packed red blood cells and fresh frozen plasma, and one received Rh+ fresh frozen plasma. One patient developed anti-Rh D antibodies. None experienced HTR. One female patient had HTR from reactivation of anamnestic JK antibodies. Thirteen (33%) of 39 patients met criteria for HTR based on urinalysis and 29 (40%) of 72 patients tested met criteria for HTR based on hemoglobin and bilirubin values. Only one patient had confirmed HTR.

CONCLUSION

High rates of injury recidivism in trauma patients increase the likelihood of multiple blood transfusions during their lifetime. Rh- patients who receive Rh+ blood are at risk of developing anti-Rh antibodies, putting them at risk for HTR. The conservation of Rh- blood for use in female patients may be detrimental to Rh- male patients. Laboratory diagnostic criteria for HTR are nonspecific in the trauma population and should be used with caution.

Transfusion medicine in trauma patients: an update

In 2008, we reviewed the practical interface between transfusion medicine and the surgery and critical care of severely injured patients. Reviewed topics ranged from epidemiology of trauma to patterns of resuscitation to the problems of transfusion reactions. In the interim, trauma specialists have adopted damage control resuscitation and become much more knowledgeable and thoughtful about the use of blood products. This new understanding and the resulting changes in clinical practice have raised new concerns. In this update, we focus on which patients need damage control resuscitation, current views on the optimal form of damage control resuscitation with blood products, the roles of newer blood products, and appropriate transfusion triggers in the postinjury setting. We will also review the role of new technology in patient assessment, therapy and monitoring.

Clinical review: Canadian National Advisory Committee on Blood and Blood Products--Massive transfusion consensus conference 2011: report of the panel

In June 2011 the Canadian National Advisory Committee on Blood and Blood Products sponsored an international consensus conference on transfusion and trauma. A panel of 10 experts and two external advisors reviewed the current medical literature and information presented at the conference by invited international speakers and attendees. The Consensus Panel addressed six specific questions on the topic of blood transfusion in trauma. The questions focused on: ratio-based blood resuscitation in trauma patients; the impact of survivorship bias in current research conclusions; the value of nonplasma coagulation products; the role of protocols for delivery of urgent transfusion; the merits of traditional laboratory monitoring compared with measures of clot viscoelasticity; and opportunities for future research. Key findings include a lack of evidence to support the use of 1:1:1 blood component ratios as the standard of care, the importance of early use of tranexamic acid, the expected value of an organized response plan, and the recommendation for an integrated approach that includes antifibrinolytics, rapid release of red blood cells, and a foundation ratio of blood components adjusted by results from either traditional coagulation tests or clot viscoelasticity or both. The present report is intended to provide guidance to practitioners, hospitals, and policy-makers.