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Brigmon EP, Cirone J, Harrell K, Greebon L, Ngamsuntikul S, Mendoza A, Epley E, Eastridge B, Nicholson S, Jenkins DH. Walking blood bank: a plan to ensure self-sufficiency in an era of blood shortage. Trauma Surg Acute Care Open 2024; 9:e001151. [PMID: 38196930 PMCID: PMC10773437 DOI: 10.1136/tsaco-2023-001151] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Accepted: 10/03/2023] [Indexed: 01/11/2024] Open
Abstract
Mass casualty incidents and massive transfusion requirements continue to plague the USA with hemorrhage remaining the number one cause of death in trauma. The unfortunate reality of numerous mass shootings in Southwest Texas has led to the need for a way in which to provide blood during these events as rapidly as it is required. Multiple agencies within the Southwest Texas system have united to help provide this life-saving blood to people when they need it most. This effort began with the development of a system for safe, efficient, and now widespread use of whole blood in the region. After demonstrating the success of delivering large quantities of blood during the Uvalde shooting, we have begun to develop a walking blood bank that is similar to what the miliary uses on the battlefield. The concept behind this initiative is to have a cohort of whole blood donors who are preselected to join the program which is now dubbed 'Heroes in Arms'. These donors will be called upon to donate whole blood during a massive transfusion event. Their blood will be rapidly screened prior to transfusion to the patient. This blood will still undergo the normal rigorous testing and, should any potentially transmissible diseases by discovered post-transfusion, the individual who received that product will be treated accordingly. Given the low rate of transmissible disease among this preselected population, combined with rapid screening prior to transfusion, the risk of a person receiving a transmissible disease is insignificant in comparison to the benefit of having blood to transfuse during hemorrhage. This model is a promising collaborative effort to provide in a timely and sufficient blood product in cases of major need which will consequently minimize the number of traumatically injured civilian patients who die from hemorrhage.
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Affiliation(s)
- Erika Paola Brigmon
- Trauma and Emergency General Surgery, UT Health San Antonio, San Antonio, Texas, USA
| | - Justin Cirone
- Trauma and Emergency General Surgery, UT Health San Antonio, San Antonio, Texas, USA
| | - Kelly Harrell
- General Surgery, UT Health San Antonio, San Antonio, Texas, USA
| | - Leslie Greebon
- Transfusion Medicine Services and Laboratory, UT Health San Antonio, San Antonio, Texas, USA
| | | | - Adriene Mendoza
- South Texas Blood and Tissue Center, San Antonio, Texas, USA
| | - Eric Epley
- Southwest Texas Regional Advisory Council, San Antonio, Texas, USA
| | - Brian Eastridge
- Trauma and Emergency General Surgery, UT Health San Antonio, San Antonio, Texas, USA
| | - Susannah Nicholson
- Trauma and Emergency General Surgery, UT Health San Antonio, San Antonio, Texas, USA
| | - Donald H Jenkins
- Trauma and Emergency General Surgery, UT Health San Antonio, San Antonio, Texas, USA
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Smith AA, Alkhateb R, Braverman M, Shahan CP, Axtman B, Nicholson S, Greebon L, Eastridge B, Jonas RB, Stewart R, Schaefer R, Foster M, Jenkins D. Efficacy and Safety of Whole Blood Transfusion in Non-Trauma Patients. Am Surg 2023; 89:4934-4936. [PMID: 34592111 DOI: 10.1177/00031348211048831] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Whole blood (WB) transfusion for trauma patients with severe hemorrhage has demonstrated early successful outcomes compared to conventional component therapy. The objective of this study was to demonstrate WB transfusion in the non-trauma patient. Consecutive adult patients receiving WB transfusion at a single academic institution were reviewed from February 2018 to January 2020. Outcomes measured were mortality and transfusion-related reactions. A total of 237 patients who received WB were identified with 55 (23.2%) non-trauma patients. Eight patients (14.5%) received pre-hospital WB. The most common etiology of non-traumatic hemorrhage was gastrointestinal bleeding (43.6%, n = 24/55). Approximately half of the non-trauma patients (n = 28/55) received component therapy. Transfusion-related events occurred in 3 patients. This study demonstrated that non-trauma patients could receive WB transfusions safely with infrequent transfusion-related events. Future studies should focus on determining if outcomes are improved in non-trauma patients who receive WB transfusions and defining specific transfusion criteria for this population.
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Affiliation(s)
- Alison A Smith
- Department of Surgery, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - Rahaf Alkhateb
- Department of Pathology, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - Maxwell Braverman
- Department of Surgery, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - Charles P Shahan
- Department of Surgery, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - Benjamin Axtman
- Department of Surgery, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - Susannah Nicholson
- Department of Surgery, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - Leslie Greebon
- Department of Pathology, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - Brian Eastridge
- Department of Surgery, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - Rachelle B Jonas
- Department of Surgery, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - Ronald Stewart
- Department of Surgery, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - Randi Schaefer
- Southwest Texas Regional Advisory Council, San Antonio, TX, USA
| | - Mark Foster
- Department of Surgery, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
- Department of Emergency Medicine, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - Donald Jenkins
- Department of Surgery, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
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Myers JC, Braverman MA, Ciaraglia A, Alkhateb R, Barry L, Brooke Z, Chang J, Wang H, Elenes R, Hepburn B, Ireland K, Jonas R, Nelson J, Pedraza S, Song J, Nicholson S, Eastridge B, Stewart R, Greebon L, Xenakis E, Jenkins D. Risk factors for massive transfusion in obstetrical hemorrhage and consideration of a whole blood program. Transfusion 2023; 63 Suppl 3:S112-S119. [PMID: 37067378 DOI: 10.1111/trf.17331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Revised: 02/18/2023] [Accepted: 02/18/2023] [Indexed: 04/18/2023]
Abstract
BACKGROUND Postpartum hemorrhage (PPH) is one of the leading causes of obstetric complications. The goal of this study was to identify risk factors for obstetric (OB) massive transfusion (MT) and determine the feasibility of developing a low-titer group O RhD-positive whole blood (LTO + WB) protocol for OB hemorrhage. STUDY DESIGN AND METHODS A retrospective study of OB patients who received transfusion within 24 h. MT patients were those who received >3 U of pRBC within 1 h or > 10 U in 24 h. Patient demographics, OB history, comorbidities, blood type, antibody status, and known risk factors for PPH and maternal-fetal outcomes were compared. Logistic regression was used for univariate and multivariate analyses. RESULTS Of the 610 transfused OB patients, 12.0% (n = 73) required MT. Groups were well matched for body mass index (BMI), maternal comorbidities, and history of spontaneous vaginal deliveries. The incidence of the previous cesarean section was higher in the MT group. Exactly 93.9% of patients were RhD-positive and 3.77% of all patients possessed an antibody on pretransfusion testing. Patients with MT had a longer length of stay (LOS), higher rate of intensive care unit (ICU) admission, fetal death, and hysterectomy. Multivariate analysis found age >35, PPH, placenta percreta, accreta, and increta to be significant (p < .05) risk factors for MT. DISCUSSION Patients over 35 years and those with abnormal placentation are at increased risk of requiring MT. With a time to delivery of 2 days, potential MT patients can be identified early, and with a 94% rate of RhD-positive+, they are eligible to receive low-titer O whole blood (LTOWB) providing hemostatic resuscitation with reduced donor exposure.
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Affiliation(s)
- John C Myers
- Department of Surgery, UT Health San Antonio, San Antonio, Texas, USA
| | | | - Angelo Ciaraglia
- Department of Surgery, UT Health San Antonio, San Antonio, Texas, USA
| | - Rahaf Alkhateb
- Department of Pathology, UT Health San Antonio, San Antonio, Texas, USA
| | - Lauran Barry
- Department of Surgery, UT Health San Antonio, San Antonio, Texas, USA
| | - Zachary Brooke
- Department of Surgery, UT Health San Antonio, San Antonio, Texas, USA
| | - Jeffrey Chang
- Department of Obstetrics and Gynecology, UT Health San Antonio, San Antonio, Texas, USA
| | - Hanzhang Wang
- Department of Urology, UT Health San Antonio, San Antonio, Texas, USA
| | - Rafael Elenes
- Department of Anesthesia, UT Health San Antonio, San Antonio, Texas, USA
| | - Byron Hepburn
- Military Health Institute, UT Health San Antonio, San Antonio, Texas, USA
| | - Kayla Ireland
- Department of Obstetrics and Gynecology, UT Health San Antonio, San Antonio, Texas, USA
| | - Rachelle Jonas
- Department of Surgery, UT Health San Antonio, San Antonio, Texas, USA
| | - Jeremy Nelson
- Military Health Institute, UT Health San Antonio, San Antonio, Texas, USA
| | - Santiago Pedraza
- Department of Surgery, UT Health San Antonio, San Antonio, Texas, USA
| | - Jun Song
- Department of Obstetrics and Gynecology, UT Health San Antonio, San Antonio, Texas, USA
| | | | - Brian Eastridge
- Department of Surgery, UT Health San Antonio, San Antonio, Texas, USA
| | - Ronald Stewart
- Department of Surgery, UT Health San Antonio, San Antonio, Texas, USA
| | - Leslie Greebon
- Department of Pathology, UT Health San Antonio, San Antonio, Texas, USA
| | - Elly Xenakis
- Department of Obstetrics and Gynecology, UT Health San Antonio, San Antonio, Texas, USA
| | - Donald Jenkins
- Department of Surgery, UT Health San Antonio, San Antonio, Texas, USA
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Alkhateb R, Prajapati V, Daniels J, Greebon L. RhD negative women transfused RhD positive blood: Alloimmunization prophylaxis protocol and experiences. Am J Clin Pathol 2021. [DOI: 10.1093/ajcp/aqab191.343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Introduction/Objective
Preventing allomiunization from D-mismatched transfusions, i.e., transfusion RhD positive (RhD+) red blood cells (RBC) to an RhD negative (RhD–) individual, is not well established. We describe our hospital protocol and experiences managing RhD– young women who received emergency release D-mismatched transfusions.
Methods/Case Report
The pathologists evaluate all patients who received D-mismatched blood transfusions. The inclusion criteria for alloimmunization prophylaxis protocol include: RhD– females; <50 years old; No current or historical Anti-D; and received ≥1 unit of RhD+ blood.
The prophylaxis protocol depends on the RBC volume (RBCV) transfused. Patients who receive RBCV <20% of their total blood volume (TBV) are eligible to receive high dose RhIg, calculated based on the volume transfused. Those who received RBCV ≥20% of TBV would be eligible for red cell exchange (RBCX) followed by RhIg.
Results (if a Case Study enter NA)
Since 2016, four eligible patients received RhIg prophylaxis protocol and none met the criteria for RBCX. All the patients started the prophylaxis protocol within 24 hours of transfusion and completed it within 72 hours. One patient developed post treatment hemolysis and significant drop in hemoglobin requiring blood transfusion. Passive anti-D post treatment was confirmed in three patients, and one had passive anti C. Three of the four patients had follow up antibody screens >6 months post treatment that were negative for RhD alloimmunization.
Conclusion
Our therapeutic plan, the first well established protocol, involves identifying eligible patients based on set criteria and protocols. Our experience demonstrates that this protocol is effective in reducing/preventing RhD alloimmunization.
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Affiliation(s)
- R Alkhateb
- Pathology, University of Texas San Antonio, San Antonio, Texas, UNITED STATES
| | - V Prajapati
- Pathology, University of Texas San Antonio, San Antonio, Texas, UNITED STATES
| | - J Daniels
- Pathology, University of Texas San Antonio, San Antonio, Texas, UNITED STATES
| | - L Greebon
- Pathology, University of Texas San Antonio, San Antonio, Texas, UNITED STATES
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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: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [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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Newberry R, Winckler CJ, Luellwitz R, Greebon L, Xenakis E, Bullock W, Stringfellow M, Mapp J. Prehospital Transfusion of Low-Titer O + Whole Blood for Severe Maternal Hemorrhage: A Case Report. PREHOSP EMERG CARE 2019; 24:566-575. [PMID: 31550184 DOI: 10.1080/10903127.2019.1671562] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Introduction: Beginning in 2017, multiple stakeholders within the Southwest Texas Regional Advisory Council for Trauma collaborated to incorporate cold-stored low-titer O RhD-positive whole blood (LTO + WB) into all phases of their trauma system, including the prehospital phase of care. Although the program was initially focused on trauma resuscitation, it was expanded to included non-traumatic hemorrhagic shock patients that may benefit from whole blood resuscitation.Case Report: We report the case of a patient with severe maternal hemorrhage secondary to placenta accreta who received a prehospital transfusion of LTO + WB. We believe this to be the first reported case of post-partum hemorrhage resuscitated out of hospital with whole blood.Discussion: This case highlights the potential benefits of a prehospital whole blood program as well as the controversy surrounding a LTO + WB program that includes females of childbearing age.
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