Vox Sanguinis International Forum on the use of prehospital blood products and pharmaceuticals in the treatment of patients with traumatic haemorrhage

While specific practices and transported blood products vary around the world, most of the respondents in this International Forum transported at least one blood product for the transfusion to bleeding patients en route to the hospital. The most commonly carried product was RBCs, while the use of whole blood will likely increase given the recent reports of its successful use in the civilian setting, and because of the change in the AABB's Standards regulating its use. It will be interesting to see if plasma use in the prehospital setting becomes more widely used given today's enhanced appreciated of the coagulopathy of trauma and plasma's beneficial effect in reversing it, and if blood products are transported to the scene of injury by more vehicles, that is, not just predominantly in helicopters. It was not surprising that TXA is being widely administered as close to the time of injury as possible given its potential benefit in these patients. This International Forum highlights the importance of focusing attention on prehospital transfusion management with a need to further high‐quality research in this area to guide optimal resuscitation strategies.

In vitro Analysis of the Hemostatic Properties of Whole Blood Products Prepared with a Platelet-Sparing Leukoreduction Filter

Background

Warm fresh whole blood (WFWB) is an ideal resuscitation fluid for exsanguinating patients but there are myriad logistic and infectious issues associated with its use. Cold whole blood (CWB) may be an acceptable alternative to the reconstituted whole blood (RWB), the current standard of care. A leukoreduction filter has been developed which maintains platelet count while eliminating white blood cells but its effect on platelet function is unknown. We hypothesize that CWB will retain an acceptable functional coagulation profile after filtration and over time.

Study Design and Methods

WFWB and CWB samples were obtained from eight donors and four units of RWB were created. The quantitative and qualitative in vitro coagulation profiles of WFWB, RWB, and CWB over time were compared.

Results

Filtration was successful at removing white blood cells (5.5 ± 1.2 vs. 0.3 ± 0.3 × 10⁶/L) while retaining an adequate platelet count (172.0 ± 47.0 to 166.0 ± 42.3 × 10⁹/L) and hemoglobin concentration (13.7 ± 0.5 vs. 13.0 ± 0.7 g/dL). Rotational Thromboelastography (ROTEM) results revealed a similar clotting time (CT) before and after filtration (64.9 ± 5.1 vs. 64.1 ± 6.8 s) but a decreased maximum clot firmness (MCF) (58.6 ± 4.2 vs. 54.9 ± 4.6 mm). Platelet aggregation decreased substantially (28.8 ± 6.7 vs. 9.3 ± 2.1 ohm) immediately after filtration. CWB function continued to diminish over time.

Conclusion

CWB holds great promise as a surrogate for WFWB, but use of a platelet-sparing LR filter diminishes platelet function almost immediately after filtration.

Substance abuse and withdrawal in the intensive care unit. Contemporary issues

Because 36% of intentional injury victims are drug dependent, the association between drug abuse and violence, especially in urban settings, is high. Withdrawal syndromes in ICU patients confuse their clinical management, may be extremely difficult to diagnose, are often lethal, need to be suspected, and should be prophylaxed against; therefore, all ICU patients should be considered to be at high risk for drug or alcohol dependence, should be tested for evidence of such drugs, and should be interviewed (together with their family members) for the presence of drug dependence traits. Appropriate patients should be referred for formal evaluation and treatment. Withdrawal syndromes must be promptly recognized, differentiated from traumatic or metabolic deterioration, and immediately treated. As patients are unique, so is their drug dependence. Individualized withdrawal therapy, not a "one method fits all" approach, works best. The mainstay of most withdrawal therapy is supportive care and benzodiazepine therapy. Also, considering the high rate of multiple intoxicants present in trauma patients, withdrawal can occur from multiple agents in a single patient, further compounding these difficulties. Withdrawal from unusual substances, such as GHB, or from therapeutic interventions (e.g., prolonged opioid or benzodiazepine administration) also must be considered.

Improving the approach to organ donation: a review

Organ transplantation continues to be hindered by a limited supply of organs. A significant percentage of potential organ donors are lost to either medical failure or inability to obtain consent for donation. In a surgical intensive care unit (ICU) we have refocused our efforts toward aggressive resuscitation, directed by control of coagulopathy, invasive monitoring, and dedicated ICU management while implementing a rapid brain death determination protocol. Over a 6-year period the length of stay until the legal determination of brain death is made has been significantly shortened (12.0 vs. 3.4 hours; p < 0.05), as have associated charges despite this more aggressive approach. As a result, we have eliminated medical failures prior to donation (13% vs. 0%) and increased consent rates (44% vs. 71%; p < 0.05). These efforts have significantly improved the number of organs harvested per eligible donor (1.8 vs. 3.4; p < 0.05). In addition, the number of organs per actual donor has increased and is now markedly greater than the U.S. national average (4.7 vs. 3.7). We believe the approach presented, if widely applied, could potentially improve the current organ supply shortage.

An epizootic of blindness and encephalitis associated with a herpesvirus indistinguishable from equine herpesvirus I in a herd of alpacas and llamas

Blindness characterized by dilated unresponsive pupils and funduscopic evidence of varying degrees of vitritis, retinal vasculitis, retinitis, chorioretinitis, and optic neuritis developed in 21 alpacas and 1 llama within a 30-day period. The animals were part of a group of approximately 100 animals imported from Chile one year earlier. The animals had spent 6 months in quarantine and then, for the 6 months preceding the epizootic, were housed at an exotic animal import-export farm, where the disease developed. Four of the affected animals also had signs of neurologic dysfunction. A herpesvirus indistinguishable from equine herpesvirus I was isolated from 4 of the affected animals, and antibody titers diagnostic for equine herpesvirus I were demonstrated in the serum of all but one of the affected animals.

Carbon fibre reinforcement for chronic lateral ankle instability

Flexible carbon fibre implants have been used in 40 cases of chronic ankle instability. The carbon fibre implant permits retention of inversion, does not interfere with peroneal function and is simple to insert. Thirty-seven cases were available for review 46 months after surgery. In 35 cases normal stability had been restored, and 22 patients continued to have an excellent result when reviewed. In 13 cases the implant was subsequently removed, and where no other stabilizing operation was carried out instability recurred. The problems necessitating implant removal have been recognized, and the technique modified to prevent their recurring.

Carbon fibre used in the late reconstruction of rupture of the extensor mechanism of the knee

Carbon fibre may be used to repair rupture of the extensor mechanism of the knee when this involves either the patellar ligament or quadriceps tendon. The operative technique is described and the results in five patients are reviewed. This technique may be successful even after other forms of repair have failed.

Ligament induction by filamentous carbon fiber

On the basis of eight years of experimental and clinical investigations, the author recommends carbon fiber on a trial basis to patients with chronic ligamentous instability and where function has been severely compromised because of the injury.

Late repair of the calcaneal tendon with carbon fibre

Ruptures of the calcaneal tendon which present late may be repaired using carbon fibre to induce a neotendon. The operative technique is described and the results of five cases reviewed. The average muscle power obtained was 88% of normal, and the thickness of the neotendon was 148% of that of the normal side. It would appear that this tendon formation in man is comparable to that previously described in sheep.

Flexible carbon fibre in late ligamentous reconstruction for instability of the knee

Sixty-three knees with chronic ligamentous instability treated with flexible carbon fibre are reviewed. Assessment was by pre-operative and postoperative grading of function in work and sport, together with a subjective evaluation of the result based on stability. Fifteen knees had collateral repairs, seven had cruciate repairs and 41 had combined collateral and cruciate repairs. Overall, 71% of knees showed improvement in function and 67% had good or excellent results subjectively. Clinical examination did not correlate well with the patient's evaluation of the result. Nineteen unselected cases with intra-articular (cruciate) carbon fibre had arthroscopies. Infiltration of collagen tissues into the cruciate replacement was a slower process than at the extra-articular (collateral) site. There was no clinical or macroscopic evidence of synovitis but microscopically there was evidence of synovial irritation.

Aggressive surgical treatment of secondary spinal deformity in spina bifida children--is it worthwhile?

The results of sixty-five surgical corrections of secondary spinal deformities in spina bifida children are reported. Twenty-three patients had kyphectomies, and thirty-nine patients had anterior and posterior spinal fusions for scoliosis. There were three deaths. Patients in both groups showed functional improvement, though the effects on respiratory function were minimal. Patients with scoliosis should have their surgery before the curve reaches 100 degrees. Correction in these patients may have to be carried out very early if there is rapid curve progression. Kyphectomy ideally should be carried out between the ages of ten and fourteen years when bone size and quality are suitable for fixation.

Family reactions to surgical correction for kyphoscoliosis in spina bifida children: a preliminary report

The families of 11 children who had been operated for the correction of kyphosis and scoliosis not less than 12 months previously were visited. The anxieties and expectations of patients and parents were investigated and the results compared with a similar investigation in the schools of the children.

The role of flexible carbon-fibre implants as tendon and ligament substitutes in clinical practice. A preliminary report

The role of flexible carbon-fibre implants as substitutes for injured tendons and ligaments was investigated. These implants were simple to perform and were well tolerated by the patient. Repairs using carbon-fibres in 60 patients were successful, particularly in the almost insoluble problem of posterior cruciate laxity. The results in this report show that carbon-fibre implants have few disadvantages and have a future use in reconstructive procedures.

An assessment of filamentous carbon fibre for the treatment of tendon injury in the horse

The results of an assessment of carbon fibre for biological use are given, with particular reference to the clinical use of the material in the treatment of equine tendon injury. Biocompatability of the fibres is assessed using fibroblast cell cultures and replacement of normal tendon with carbon fibre prostheses in experimental animals. The rationale and technique for using this material in clinical cases of tendon injury in the racehorse are described. Results are given from 62 implant operations in a limited series of 40 horses.

The use of flexible carbon fibre in the repair of experimental large abdominal incisional hernias

Ventral hernia was induced surgically in sheep and either left unrepaired (5 animals), repaired with plastic mesh (20 animals) or with carbon fibre (20 animals). In unrepaired animals the hernia persisted. Three hernias recurred in the group repaired with plastic mesh, 2 as a consequence of sepsis. All the hernias repaired with carbon fibre remained sound over periods varying from 8 months to 2 years. There was a gradual invasion of the carbon fibres by collagenous tissue and thus a transition from one to the other of the stress of maintaining the abdominal wall intact.

The operative treatment of sacro-iliac subluxation and disruption of the symphysis pubis

A method of internal fixation of the disrupted symphysis publis is discribed which uses readily available AO plates and tools. Patients can be mobilized at 3 days and discharged within 2 weeks. This method of treatment represents a considerable saving in nursing time and a great improvement for the patient, who is usually free from pain after 1 week.

The repair of cruciate ligaments with flexible carbon fibre. A longer term study of the induction of new ligaments and of the fate of the implanted carbon

Carbon fibre appears to induce the formation of tendon in both animals and humans. Experiments have been conducted in sheep in which new anterior cruciate ligaments have been induced in response to the implantation of filamentous carbon fibre. Long-term studies indicate that the carbon fibre slowly breaks up at the site of implantation and later begins to appear in the regional lymph nodes.

Toxicity and residue studies in dairy animals with firemaster FF-1 (polybrominated biphenyls)

Two studies (one in Holstein calves and one in Holstein cows) were conducted to determine potential toxicity and residue levels following oral ingestion of polybrominated biphenyls (PBB). The material was FireMaster FF-1. Administration was by gelatin capsules. Doses in calves were 0.1, 1.0, 10, or 100 mg/kg body weight, while doses in cows were equivalent to 0.01, 0.1, 1.0, or 10 ppm in the diet. The calves were sacrificed after 2, 4, 6, or 12 weeks. The cows were fed 158 or 228 days, and were then in a recovery period for 182 or 112 days. In the calf study, signs of toxicity were observed only in animals fed 100 mg/kg-day. Administration of 10 mg/kg-day or less for up to 12 weeks caused no overt signs of toxicity. Histologic studies were conducted upon selected organs and tissues taken at time of sacrifice. The only treatment-induced lesions among animals fed 0.1 mg/kg-day were minimal lesions in the kidney and skin in the one calf fed at this level for 12 weeks. Treatment-induced lesions were present in the kidneys, skin, and/or liver from some animals fed levels of 1.0 mg/kg-day and above. The relative severity of these lesions was related to the level and length of exposure. Treatment-associated changes were observed in the testes of all males in this study. The hypospermatogenesis observed was consistent with the age of the animals due to prepuberal development of the testes. No clinical signs of toxicity or histologic changes attributed to PBB were observed in the cows. Two cows were pregnant at the initiation of the study and give birth to normal, healthy calves during the study. These calves grew normally and appeared healthy when sacrificed at about 6 months of age. Residue levels were quantitated as the hexabromobiphenyl isomer (BP-6) which is the major isomer present in the PBB mixture. Tissue residue levels in calves increased with dose and duration of administration of PBB with highest levels being found in the fat. At 100 mg/kg the levels in fat were about 6000 to 6300 ppm after 6 to 12 weeks. Residue levels of BP-6 in milk and fat of the cows also increased with dose and duration of administration. Maximum levels in milk were about 1/3 the levels in the diet. In general, the levels plateaued after about 4 to 6 weeks and did not go appreciably higher even though administration of the FireMaster FF-1 was continued. Maximum levels in fat were on the order of approximately 4.5 times the levels in the diet, except at the lowest dose level. Residues decreased in milk after administration of PBB was discontinued, but detectable levels were still present 6 months later. Residues were found in the calves born of treated cows indicating passage of the PBBs through the placental barrier and/or ingestion through the milk.

Biological reaction to carbon fiber implants: the formation and structure of a carbon-induced "neotendon"

In 43 young rabbits, the tendo Achilles and flexor digitorum longus tendon were excised and replaced by filamentous carbon fiber. Tendo-Achilles in controls was repaired by silk or nylon sutures or left without replacement. Concurrent excision of the posterior tibial nerve was performed in one group of the carbon-replacing tendo-Achilles operations. When fully functioning, carbon-induced "neotendon" rapidly developed from young fibroblastic tissue outgrowths of the loose mesenchymal tissue of the perineurium and adventitia of the blood vessels in the adjacent neurovascular bundle. Silk or nylon replacement of the excised Achilles tendon did not lead to successful production of a new substitute. Carbon fibers were unsatisfactory for replacement implants for the flexor digitorum longus tendons.

Potentially fatal asphyxia following a minor injury of the cervical spine

The case is reported of an elderly man with asymptomatic cervical spondylosis who sustained a minor hyperextension injury of the cervical spine when the brakes of a car were applied suddenly to avoid a collision. Within six hours marked swelling of the neck and severe dyspnoea developed, and a lateral radiograph showed the pharyngeal shadow displaced far forwards and a crack fracture of an anterior osteophyte. Tracheostomy and evacuation of a massive prevertebral haematoma were performed, with immediate relief. The case draws attention to the possibility of this serious complication of a "whiplash" type of injury.

Induction of tendon and ligament formation by carbon implants

Experiments have been performed on rabbits and sheep which demonstrate that pure carbon, in a flexible and filamentous form of great strength, can be used successfully to induce the formation of new tendons. A concept fundamentally different from that underlying the use of other artificial tendon replacements is involved, in which rapidly developing tendon-like tissue is induced to form around the implant. This gradually takes over the function of the implant. The early results in rabbits and the late results in sheep suggest that filamentous carbon may have a place in the replacement of the calcaneal tendon and the collateral ligaments of the knee.

A comparison of operative cholangiographic technique

The accuracy and postoperative morbidity of cannulation of the cystic duct in routine operative cholangiography were compared with those of needle puncture of the common bile duct. The results are comparable and a case is made for the simpler procedure of needle puncture of the common duct.

Stimulation of bone growth by periosteal stripping. A clinical study

Periosteal stripping in the long lower limb bones of thirty children with shortening after poliomyelitis was performed. All have been followed up for five years. A relative increase in length attributable to the periosteal stripping procedure was seen in the majority. The conclusions are that this simple procedure is indicated in minor degrees of limb inequality in growing children, but that the haphazare response precludes any accurate estimation of the final outcome of such a procedure.

Stablization of the spine in the surgical treatment of severe spinal tuberculosis in children

This is a 5- to 10-year survey of 160 children, all with severe surgically-treated spinal tuberculosis. The treatment consisted of: anterior spinal fusion alone, anterior with posterior fusion, posterior fusion alone and posterior with anterior fusion. The results indicate that in the less severe cases, where an abscess is not evident on plain radiographs, psoterior fusion alone can be of value in the growing spine. In severe cases, especially where an abscess is seen, the combined approaches give the best results. The risk of posterior fusion alone is an unsatisfactory, long term neurological outcome in too many patients. The combined procedure of anterior fusion with posterior fusion is the treatment of choice for all immature spines with this disease.

A hypothesis on some factors governing the behaviour of short segments of the small bowel

A hypothesis is advanced in which it is argued that variations in the extrinsic autonomic innervation of short small-bowel segments are responsible for the unpredictable behaviour of such segments. Experimental evidence is offered to substantiate the hypothesis.

Extensive cervical laminectomy. Long-term results

It has been possible to follow up 5 patients who underwent complete cervical laminectomy for cervical spondylotic myelopathy between 12 and 17 years ago. The operation was described by Rogers in 1961. Clinical examination findings, together with the radiological appearances, indicate that this procedure does not predispose to instability of the cervical spine. This relatively simple procedure achieved long-lasting improvement in the patients examined.

Proximal jejunal and distal ileal extrinsic innervation in the rabbit and dog

The varying patterns of motor behaviour of isolated and interposed jejunal and ileal segments in the rabbit and the dog previously reported (Jenkins and Macleod, 1970) were examined by selective denervation techniques. One hundred and twenty-three paired experiments were conducted on rabbits and 55 similar experiments were performed on dogs.

Length-matched paired segments of proximal jejunum and distal ileum were isolated and filled with saline at a constant rate. Segmental resistance to filling was regarded as an index of tone. The influence of vagotomy and of sympathectomy on the tone of the segments was studied in segments supplied by one or by two vessels.

Vagotomy caused a decrease in tone in the proximal jejunal segments, while sympathectomy had little effect. In segments of distal ileum sympathectomy resulted in segments behaving in a similar fashion, while vagotomy had an unpredictable effect on tone.

The results suggest a uniform distribution of the vagus to the whole length of the small bowel in the rabit and the dog, serving to maintain the tone of the bowel. It is deduced that sympathetic supply to the proximal jejunum isabsent in these animkals and is distributed to the distal ileum only in an irregular fashion.

The relevance of these observations to the clinical use of interposed small-bowel segments is considered.

A case of carcinoma of the colon in association with neurofibromatosis

A case is presented of neurofibromatosis of the large bowel associated with a primary adenocarcinoma of the colon. This is believed to be the first report of such an association.

Omental reinforcement of intestinal anastomoses. An experimental study in the rabbit

A series of end-to-end everting colonic anastomoses were performed in 95 rabbits in order to assess the value of omental reinforcement. The animals were divided into three groups: (a) control animals, (b) animals with anastomoses reinforced by a free omental graft, and (c) animals with anastomoses reinforced by an omental pedicle. Reinforcement with a free omental graft carried a prohibitive increase in mortality. The use of an omental pedicle appeared to strengthen the anastomosis against forced disruption in the immediate postoperative period but it did not improve the survival rates and it may carry long-term dangers. The explanation for these findings is discussed. It is our view that there is no place for omental reinforcement in colonic surgery.

Irritable hip in the adult

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