The National Blood Shortage-An Impetus for Change

Platelet-inspired synthetic nanoparticles improve hemostasis and hemodynamics in a rabbit model of abdominal hemorrhage

BACKGROUND

Early platelet transfusion is associated with reduced mortality in traumatic hemorrhage. However, platelet usage is severely limited because of the challenges of donor availability, platelet portability, and storage. Here, we report on a bioinspired synthetic platelet (SP) nanoconstruct that utilizes liposome surface-decoration with peptides that mimic injury site-specific platelet adhesion to von Willebrand Factor and collagen, and fibrinogen-mediated platelet aggregation. Synthetic platelet has previously shown promising hemostatic outcomes in vitro and in vivo. Here, we evaluated hemostasis and hemodynamic effects of SP in a rabbit model of abdominal hemorrhage.

METHODS

Twenty-three adult male New Zealand white rabbits (2.5-3.5 kg) were treated with either buffer, control particles (CPs), or SP. Under general anesthesia with invasive monitoring, rabbits underwent laparotomy with combined splenic and hepatic injury. Hemodynamics were monitored for 30 minutes and blood loss was quantified. Blood counts, aggregometry, catecholamine and platelet factor 4 (PF4) assays were performed at multiple timepoints. Analysis used analysis of variance and post hoc Tukey testing with α = 0.05.

RESULTS

Rabbits in the SP (n = 7) group had significantly lower weight-normalized blood loss compared with both buffer (n = 8) and CP (n = 8) animals (21.1 vs. 33.2 vs. 40.4 g/kg, p < 0.001). Synthetic platelet-treated animals had higher systolic blood pressure area under curve compared with buffer- and CP-treated animals (1567 vs. 1281 vs. 1109 mm Hg*min, p = 0.006), although post hoc differences were only significant for the SP/CP comparison ( p = 0.005). Platelet counts, catecholamine levels, PF4, and aggregometry were similar between groups.

CONCLUSION

Synthetic platelet treatment significantly reduced blood loss and improved hemodynamics in a rabbit abdominal hemorrhage model. Synthetic platelet has potential as an intravenous hemostatic platelet surrogate with donor-independent availability and scalable manufacture.

A Perioperative Blood Management Algorithm Aimed at Conservation of Platelets in Clinical Practice: The Role of the Anesthesiologist in Decision-Making

Platelet dysfunction and thrombocytopenia are associated with postoperative morbidity not only from modifiable preoperative factors but also from a lack of local patient blood management algorithms. In this regard, platelet transfusions have risen after the COVID-19 pandemic. Simultaneously, there has been a shortage of donors. It is logical, therefore, that each hospital should develop a triage tool, posting their algorithm on walls. Anesthesiologists should assist in planning a strategy to minimize blood transfusions while improving tissue oxygenation. A flowchart posted in each operating theatre may be customized per patient and hospital. Clinicians need reminders to draw a prothrombin time, fibrinogen, complete blood count every hour, and the appropriate threshold to transfuse. In summary, anesthesiologists are often unable to have a discussion with a patient until the preoperative day; thus, the onus falls on our surgical colleagues to reduce risk factors for coagulopathy or to delay surgery until after proper consultants have optimized a patient. The most important problems that an individual patient has ideally should be listed in a column where an anesthesiologist can write a timeline of key steps across a row, corresponding to each problem. If a handoff in the middle of the case is required, this handoff tool is superior to simply checking a box on an electronic medical record. In summary, in the operating suite, an anesthesiologist should emphasize the importance of a multidisciplinary approach. Continuing education, regular stakeholder meetings, and posters can assist in reinforcing algorithms in clinical practice.

Use of Kaolin-Impregnated Gauze Aids in Hemostasis and Blood Loss Mitigation in a Penetrating Injury to the Bladder and Small Bowel

Hemorrhage control can be technically challenging in penetrating injuries to the pelvis. In an era of decreased availability of blood, rapid hemostasis is critical to minimize blood loss, limit transfusions, and control contamination from hollow viscus injuries. QuikClot Control+® 12x12 Hemostatic Device(C+) (Teleflex Medical OEM, Plymouth, MN), a form of kaolin-impregnated gauze, maybe a helpful adjunct to ebb the flow of hemorrhage from large surface area wounds. We present a case in which C+ was utilized in the preperitoneal packing of a gunshot wound to the pelvis and aided in obtaining hemostasis while simultaneously allowing the team time to complete the remainder of the case. Though further large randomized control trials are required to identify the role of C+ in trauma laparotomy, it remains a tool in the surgeon's armamentarium when dealing with hemorrhage.

The patient perspective: The struggles of living with thalassemia as an adult

Today it has become the norm for individuals diagnosed with severe forms of thalassemia who have access to hypertransfusion regimens, chelation therapy, and annual surveillance to survive well beyond childhood. However, with this improvement in prognosis and subsequent transition to adult care, it has become apparent that most adult healthcare providers, including many adult hematologists and primary care providers, are ill-prepared to care for these patients and the complications that accompany their survival into adulthood. Collaborative efforts are needed to develop comprehensive approaches to contend with the challenges faced by adult patients to ensure they are properly managed and supported.

Surgical Management of Renal Cell Carcinoma with Inferior Vena Cava Tumor Thrombus

Most kidney cancers are primary renal cell carcinomas (RCC) of clear cell histology. RCC is unique in its ability to invade into contiguous veins - a phenomenon terms venous tumor thrombus. Surgical resection is indicated for most patients with RCC and an inferior vena cava (IVC) thrombus in the absence of metastatic disease. Resection also has an important role in selected patients with metastatic disease. In this review, we discuss the comprehensive management of the patient with RCC with IVC tumor thrombus, emphasizing a multidisciplinary approach to the surgical techniques and perioperative management.

Predicting Futility in Severely Injured Patients: Using Arrival Lab Values and Physiology to Support Evidence-Based Resource Stewardship

BACKGROUND

The recent pandemic exposed a largely unrecognized threat to medical resources, including daily available blood products. Some of the most severely injured patients who arrive in extremis consume tremendous resources yet succumb shortly after arrival. We sought to identify cut points available early in the patient's resuscitation that predicted 100% mortality.

STUDY DESIGN

Cut points were developed from a previously collected data set of all level 1 trauma patients admitted January 2010 to December 2016. Objective values available on or shortly after arrival were evaluated. Once generated, we then validated these variables against (1) a prospective data set November 2017 to October 2021 of severely injured patients and (2) a multicenter, randomized trial of hemorrhagic shock patients. Analyses were conducted using STATA 17.0 (College Station, TX), generating positive predictive value (PPV), negative predictive value, sensitivity, and specificity.

RESULTS

The development data set consisted of 9,509 patients (17% mortality), with 2,137 (24%) and 680 (24%) in the two validation data sets. Several combinations of arrival vitals and labs had 100% PPV. Patients undergoing CPR in the field or on arrival (with subsequent return of spontaneous circulation) required lower fibrinolysis LY-30 (30%) than those with systolic blood pressures of ≤50 (30 to 50%), ≤70 (80 to 90%), and ≤90 mmHg (90%). Using a combination of these validated variables, the Suspension of Transfusions and Other Procedures (STOP) criteria were developed, with each element predicting 100% mortality, allowing physicians to cease further resuscitative efforts.

CONCLUSIONS

The use of evidence-based STOP criteria provides cut points of futility to help guide early decisions for discontinuing aggressive treatment of severely injured patients arriving in extremis.

Demographics of first-time donors returning for donation during the pandemic: COVID-19 convalescent plasma versus standard blood product donors

BACKGROUND

Previous studies have demonstrated low first-time donor return rates (DRR) following catastrophic events. Little is known, however, about the influence of demographic factors on the DRR of first-time donors during the COVID-19 pandemic, including the unique motivation of COVID-19 convalescent plasma (CCP) donors as compared to non-CCP donors.

STUDY DESIGN AND METHODS

Thirteen blood collection organizations submitted deidentified data from first-time CCP and non-CCP donors returning for regular (non-CCP) donations during the pandemic. DRR was calculated as frequencies. Demographic factors associated with returning donors: race/ethnicity, gender, and generation (Gen Z: 19-24, Millennial: 25-40, Gen X: 41-56, and Boomer: ≥57 years old), within the CCP and non-CCP first-time cohorts were compared using chi-square test at p < .05 statistical significance.

RESULTS

From March 2020 through December 2021, there were a total of 44,274 first-time CCP and 980,201 first-time non-CCP donors. DRR were 14.6% (range 11.9%-43.3%) and 46.6% (range 10.0%-76.9%) for CCP and non-CCP cohorts, respectively. Age over 40 years (Gen X and Boomers), female gender, and White race were each associated with higher return in both donor cohorts (p < .001). For the non-CCP return donor cohort, the Millennial and Boomers were comparable.

CONCLUSION

The findings demonstrate differences in returning donor trends between the two donor cohorts. The motivation of a first-time CCP donor may be different than that of a non-CCP donor. Further study to improve first-time donor engagement would be worthwhile to expand the donor base with a focus on blood donor diversity emphasizing engagement of underrepresented minorities and younger donors.

Using trends and outliers in managing delayed transfusions

OBJECTIVES

To investigate if time to initiate a blood transfusion after an informative laboratory test could feasibly be used by the transfusion medicine service as a metric to monitor for transfusion delays.

BACKGROUND

Delayed transfusions may result in patient morbidity and mortality, but no standards for timely transfusion have been developed. Information technology tools could be implemented to identify gaps in provision of blood and to recognise areas of improvement.

MATERIALS AND METHODS

Data obtained from a children's hospital's data science platform and time from the release of laboratory results to the initiation of transfusions were calculated and weekly medians were used for trend analyses. Outlier events were obtained using locally estimated scatterplot smoothing and generalised extreme studentized deviate test.

RESULTS

Overall, the number of outlier events on the timing of transfusions based on patients' haemoglobin level and platelet count were small (n = 1 and n = 0 for 139 weeks, respectively). Investigation of these events for adverse clinical outcomes was non-significant.

CONCLUSIONS

Herein, we propose that the trends and outlier events could be further investigated and used to make decisions and implement protocols to improve patient care.