FURTHER OBSERVATIONS ON THE RESULTS OF BLOOD TRANSFUSION IN WAR SURGERY: WITH SPECIAL REFERENCE TO THE RESULTS IN PRIMARY HEMORRHAGE

Prehospital Blood Product Transfusion in Mountain Rescue Operations

Severely injured patients with hemorrhage present major challenges for emergency medical services, especially during mountain rescue missions in which harsh environmental conditions and long out-of-hospital times are frequent. Because uncontrolled hemorrhage is the leading cause of death within the first 48 hours after severe trauma, initiating damage control resuscitation (DCR) as early as possible after severe trauma and exporting the concept of DCR to the out-of-hospital arena is pivotal for patient survival. Appropriate bleeding control, management of coagulopathy, and transfusion of blood products are core aspects of DCR. This review summarizes the available evidence on out-of-hospital blood product transfusion and the management of coagulopathy with a special focus on mountain rescue missions. An overview of upcoming trials and possible future trends in the management of coagulopathy during rescue operations is provided.

"Blood failure" time to view blood as an organ: how oxygen debt contributes to blood failure and its implications for remote damage control resuscitation

Hemorrhagic shock is both a local and systemic disorder. In the context of systemic effects, blood loss may lead to levels of reduced oxygen delivery (DO2 ) sufficient to cause tissue ischemia. Similar to other physiologic debts such as sleep, it is not possible to incur a significant oxygen debt and suffer no consequences for lack of timely repayment. While the linkage between oxygen debt and traditional organ failure (renal, hepatic, lung, and circulation) has been long recognized, we should consider failure in two additional linked and very dynamic organ systems, the endothelium and blood. These systems are very sensitive to oxygen debt and at risk for failing, having further implications on all other organ systems. The degree of damage to the endothelium is largely modulated by the degree of oxygen debt. Thus hypoperfusion is believed to begin a cascade of events leading to acute traumatic coagulopathy (ATC). This combination of oxygen debt driven endothelial damage and ATC might be considered collectively as "blood failure" due to the highly connected networks between these drivers. This article presents the implications of oxygen debt for remote damage control resuscitation strategies, such as permissive hypotension and hemostatic resuscitation. We review the impact of whole blood resuscitation and red blood cell efficacy in mitigation of oxygen debt. At last, this article recognizes the need for simple and durable, lightweight equipment that can detect the adequacy of tissue DO2 and thus patient needs for resuscitative care. Point-of-care lactate measuring may be a predictive tool for identifying high-risk trauma patients and occult shock because it provides information beyond that of vital signs and mechanism of injury as it may help predict the level of oxygen debt accumulation and need for resuscitation. Serial measurements may also be valuable as a tool in guiding resuscitative efforts.

The University of Toronto's lasting contribution to war surgery: how Maj. L. Bruce Robertson fundamentally transformed thinking toward blood transfusion during the First World War

SUMMARY

During the Great War, Canadian military surgeons produced some of the greatest innovations to improve survival on the battlefield. Arguably, the most important was bringing blood transfusion practice close to the edge of the battlefield to resuscitate the many casualties dying of hemorrhagic shock. Dr. L. Bruce Robertson of the Canadian Army Medical Corps was the pioneering surgeon from the University of Toronto who was able to demonstrate the benefit of blood transfusions near the front line and counter the belief that saline was the resuscitation fluid of choice in military medicine. Robertson would go on to survive the Great War, but would be taken early in life by influenza. Despite his life and career being cut short, Robertson's work is still carried on today by many military medical organizations who strive to bring blood to the wounded in austere and dangerous settings. This article has an Appendix, available at canjsurg.ca.

Blood transfusion at the time of the First World War--practice and promise at the birth of transfusion medicine

The centenary of the start of the First World War has stirred considerable interest in the political, social, military and human factors of the time and how they interacted to produce and sustain the material and human destruction in the 4 years of the war and beyond. Medical practice may appear distant and static and perhaps seems to have been somewhat ineffectual in the face of so much trauma and in the light of the enormous advances in medicine and surgery over the last century. However, this is an illusion of time and of course medical, surgical and psychiatric knowledge and procedures were developing rapidly at the time and the war years accelerated implementation of many important advances. Transfusion practice lay at the heart of resuscitation, and although direct transfusion from donor to recipient was still used, Geoffrey Keynes from Britain, Oswald Robertson from America and his namesake Lawrence Bruce Robertson from Canada, developed methods for indirect transfusion from donor to recipient by storing blood in bottles and also blood-banking that laid the foundation of modern transfusion medicine. This review explores the historical setting behind the development of blood transfusion up to the start of the First World War and on how they progressed during the war and afterwards. A fresh look may renew interest in how a novel medical speciality responded to the needs of war and of post-war society.

Blood far forward: Time to get moving!

In planning for future contingencies, current problems often crowd out historical perspective and planners often turn to technological solutions to bridge gaps between desired outcomes and the reality of recent experience. The US Military, North Atlantic Treaty Organization, and other allies are collectively taking stock of 10-plus years of medical discovery and rediscovery of combat casualty care after the wars in Iraq and Afghanistan. There has been undeniable progress in the treatment of combat wounded during the course of the conflicts in Southwest Asia, but continued efforts are required to improve hemorrhage control and provide effective prehospital resuscitation that treats both coagulopathy and shock. This article presents an appraisal of the recent evolution in medical practice in historical context and suggests how further gains in far forward resuscitation might be achieved using existing technology and methods based on whole-blood transfusion while research on new approaches continues.

THE DETERMINATION OF THE LENGTH OF LIFE OF TRANSFUSED BLOOD CORPUSCLES IN MAN

1. It is possible in mixtures of corpuscles of different groups to separate the corpuscles practically quantitatively by treating with a serum that agglutinates the corpuscles of one kind, leaving the others unagglutinated. 2. After a recipient has been transfused with blood of a group other than his own, specimens of his blood treated with a serum that will agglutinate his own corpuscles but not the transfused corpuscles show unagglutinated corpuscles in large numbers. 3. These unagglutinated corpuscles which appear in the recipien's blood after such a transfusion are the transfused corpuscles and their count is a quantitative indicator of the amount of transfused blood still in the recipient's circulation. 4. The life of the transfused corpuscle is long; it has been found to extend for 30 days and more. The beneficial results of transfusion are without doubt not due primarily to a stimulating effect on the bone marrow, but, it is reasonable to assume, to the functioning of the transfused blood corpuscles.

International blood collection and storage: clinical use of blood products

Human blood transfusion is the process of transferring blood or blood-based products from an individual into the circulatory system of another. From the theory of circulation of blood to the early practice of blood transfusion, transfusion medicine has been an important concept for many centuries. The practicality of transfusion, however, only became a possibility during and shortly after the Second World War. Today, blood and its derivatives play a critical role in worldwide health care systems, with blood components having direct clinical indications. Over the past several years worldwide organizations including the World Health Organization (WHO) have made a number of substantial improvements to the regulation of the worlds blood supply. This continuous supply plays a critical role throughout health care systems worldwide, with procedures for blood collection, processing, and storage now complex, standardised processes. As the areas of clinical validation of different disease states from blood-derived sources (i.e., disease biomarkers) move towards validation stages, the importance of controlled- and standardised-protocols is imperative.

Canadian Surgeons and the Introduction of Blood Transfusion in War Surgery

Canadian surgeons serving in the Canadian Army Medical Corps in the First World War were responsible for introducing transfusion in the management of war casualties to the British Army. They were uniquely placed to do so by a coincidence of circumstances. They were aware of developments occurring in the field of blood transfusion in the United States, which was at the time leading the research and development of transfusion as a therapeutic measure. The ties between Britain and Canada in 1914 were such that Canada entered the war immediately, and Canadians served closely with the British, volunteering promptly and in large numbers. Britain, by contrast with the United States, had little interest in or expertise with blood transfusion. Thus, Canadian surgeons went to war aware of the value of blood transfusion and with some who had actually learned how to use transfusion. They arrived to find no interest or expertise on the part of their British colleagues and had to work hard to convince them of the merits of blood transfusion in the management of hemorrhage. Their efforts were reinforced by the arrival in 1917 of American surgeons bringing their experience with transfusion. By war's end, blood transfusion was generally accepted as the treatment of choice for severe blood loss.

Personal view: crystalloid transfusion in acute gastrointestinal haemorrhage: is it beneficial? An historical perspective

The conventional management of acute gastrointestinal haemorrhage mandates early repletion of blood volume with crystalloids and blood, as part of the initial management, where there is evidence of hypovolaemia. Meanwhile there is a major trend towards a restrained use of fluid to raise blood pressure to near normal for the bleeding patient in trauma and similar emergencies. This divergence of view requires analysis. An Ovid/MEDLINE, Google and extensive literature search focused on the resuscitation and transfusion of bleeding trauma patients was performed. In addition to clear evidence from animal experiments that early restoration of blood volume perpetuates bleeding, there is considerable evidence in humans - both in war and civilian life - that rapid crystalloid infusion is harmful. I also report a personal series of benefit from restricted transfusion in acute upper gastrointestinal haemorrhage in humans. Given the lack of evidence of benefit for rapid blood volume repletion in acute gastrointestinal haemorrhage, there is need for controlled studies of the most appropriate approach to crystalloid transfusion in acute gastrointestinal bleeding.