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Strada AM, Suarez G, Luo-Owen X, Tabrizi MB, Rosenthal MG, Stevens WT, Lum SS, Mukherjee K. Pragmatic O-Positive Whole-blood RandoMizaTion in male trauma Patients (POWeR-MTP). Eur J Trauma Emerg Surg 2025; 51:175. [PMID: 40237834 PMCID: PMC12003594 DOI: 10.1007/s00068-025-02848-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2025] [Accepted: 03/23/2025] [Indexed: 04/18/2025]
Abstract
PURPOSE Hemorrhage is a significant cause of trauma-related death. Low-titer O-positive whole blood (LTOWB) is an alternative to component therapy (CT) [packed red blood cells (PRBC) and fresh frozen plasma (FFP)]. We evaluated if LTOWB reduces transfusion requirement or mortality. METHODS Adult male trauma activations requiring uncrossmatched transfusion in the emergency department underwent nonblinded 24-hour block randomization to receive uncrossmatched LTOWB or CT in the emergency department (ED). Female patients, children, and known prisoners were excluded. If LTOWB was not available, CT was used. Primary outcome was transfusion requirement in patients surviving ≥ 24 h, with a subset analysis for patients undergoing hemorrhage control interventions (HCI). Dichotomous variables were evaluated with Chi-Square testing and continuous outcomes with Student's T-test. RESULTS Overall, 199 patients were randomized (52 LTOWB, 147 CT); 36 patients (12 LTOWB, 24 CT) were excluded post-randomization for mortality within 24 h. The remaining 40 LTOWB and 123 CT patient cohorts had similar age, Glasgow Coma Scale, Injury Severity Score, heart rate, systolic blood pressure, and temperature. LTOWB patients received 1.4 ± 0.75 LTOWB units. LTOWB patients trended toward less transfusion (PRBC [3.8 ± 5.6 vs. 5.7 ± 6.2 units, p = 0.077], FFP [2.3 ± 3.8 vs. 3.5 ± 4.3 units, p = 0.088], and CRYO [0.13 ± 0.34 vs. 0.28 ± 0.68 units, p = 0.061]). Mortality was similar (LTOWB:10.2% [4/39] vs. CT:10.5% [13/123], p = 0.956). LTOWB patients undergoing HCI had less transfusion than CT patients (PRBC [3.9 ± 5.1 vs. 7.4 ± 7.2 units, p = 0.013]; in the HCI cohort the differences were even more pronounced when severe traumatic brain injury (TBI) deaths were excluded (PRBC [3.0 ± 3.6 vs. 7.4 ± 7.2 units, p < 0.001], FFP [2.1 ± 2.3 vs. 4.5 ± 5.2 units, p = 0.005]). CONCLUSION LTOWB is associated with reduced PRBC transfusion in patients undergoing HCI, and a trend toward decreased PRBC, FFP, and CRYO transfusion in all patients. TRIAL REGISTRATION ClinicalTrials.gov (NCT05081063), posted 10/18/2021.
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Affiliation(s)
- Anthony M Strada
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Gus Suarez
- Loma Linda University School of Medicine, Loma Linda, CA, USA
| | - Xian Luo-Owen
- Division of Acute Care Surgery, Loma Linda University Health, 11175 Campus Street, Loma Linda, CA, CP 21111, 92350, USA
| | - Maryam B Tabrizi
- Division of Acute Care Surgery, Loma Linda University Health, 11175 Campus Street, Loma Linda, CA, CP 21111, 92350, USA
| | - Martin G Rosenthal
- Division of Acute Care Surgery, Loma Linda University Health, 11175 Campus Street, Loma Linda, CA, CP 21111, 92350, USA
| | - Wesley T Stevens
- Department of Pathology, Loma Linda University Health, Loma Linda, CA, USA
| | - Sharon S Lum
- Division of Surgical Oncology, Loma Linda University Health, Loma Linda, CA, USA
| | - Kaushik Mukherjee
- Division of Acute Care Surgery, Loma Linda University Health, 11175 Campus Street, Loma Linda, CA, CP 21111, 92350, USA.
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Hamed AA, Shuib SM, Elhusein AM, Fadlalmola HA, Higazy OA, Mohammed IH, Mohamed BS, Abdelmalik M, Al-Sayaghi KM, Saeed AAM, Hegazy SM, Albalawi S, Alrashidi A, Abdallah M. Efficacy and Safety of Prehospital Blood Transfusion in Traumatized Patients: A Systematic Review and Meta-Analysis. Prehosp Disaster Med 2024; 39:324-334. [PMID: 39676718 DOI: 10.1017/s1049023x24000621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2024]
Abstract
BACKGROUND Approximately five million individuals have traumatic injuries annually. Implementing prehospital blood-component transfusion (PHBT), encompassing packed red blood cells (p-RBCs), plasma, or platelets, facilitates early hemostatic volume replacement following trauma. The lack of uniform PHBT guidelines persists, relying on diverse parameters and physician experience. AIM This study aims to evaluate the efficacy of various components of PHBT, including p-RBCs and plasma, on mortality and hematologic-related outcomes in traumatic patients. METHODS A comprehensive search strategy was executed to identify pertinent literature comparing the transfusion of p-RBCs, plasma, or a combination of both with standard resuscitation care in traumatized patients. Eligible studies underwent independent screening, and pertinent data were systematically extracted. The analysis employed pooled risk ratios (RR) for dichotomous outcomes and mean differences (MD) for continuous variables, each accompanied by their respective 95% confidence intervals (CI). RESULTS Forty studies were included in the qualitative analysis, while 26 of them were included in the quantitative analysis. Solely P-RBCs alone or combined with plasma showed no substantial effect on 24-hour or long-term mortality (RR = 1.13; 95% CI, 0.68 - 1.88; P = .63). Conversely, plasma transfusion alone exhibited a 28% reduction in 24-hour mortality with a RR of 0.72 (95% CI, 0.53 - 0.99; P = .04). In-hospital mortality and length of hospital stay were mostly unaffected by p-RBCs or p-RBCs plus plasma, except for a notable three-day reduction in length of hospital stay with p-RBCs alone (MD = -3.00; 95% CI, -5.01 to -0.99; P = .003). Hematological parameter analysis revealed nuanced effects, including a four-unit increase in RBC requirements with p-RBCs (MD = 3.95; 95% CI, 0.69 - 7.21; P = .02) and a substantial reduction in plasma requirements with plasma transfusion (MD = -0.73; 95% CI, -1.28 to -0.17; P = .01). CONCLUSION This study revealed that plasma transfusion alone was associated with a substantial decrease in 24-hour mortality. Meanwhile, p-RBCs alone or combined with plasma did not significantly impact 24-hour or long-term mortality. In-hospital mortality and length of hospital stay were generally unaffected by p-RBCs or p-RBCs plus plasma, except for a substantial reduction in length of hospital stay with p-RBCs alone.
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Affiliation(s)
| | | | - Amal Mohamed Elhusein
- College of Applied Medical Science, Department of Nursing, University of Bisha, Saudi Arabia
| | - Hammad Ali Fadlalmola
- Nursing College, Department of Community Health Nursing, Taibah University, Saudi Arabia
| | | | | | | | - Mohammed Abdelmalik
- Al-Rayan Private College of Health Sciences and Nursing, Al Madinah Al Munawarah, Saudi Arabia
| | | | | | - Samya Mohamed Hegazy
- College of Applied Medical Sciences, Nursing Department, Al Jouf University, Saudi Arabia
| | - Saud Albalawi
- Ministry of Health, Al Badrani Healthcare Center, Almadinah AlMinawwarah, Saudi Arabia
| | - Abdullah Alrashidi
- Ministry of Health, General Director Infection Control, Almadinah AlMinawwarah, Saudi Arabia
| | - Mohamed Abdallah
- Al-Rayan Private College of Health Sciences and Nursing, Al Madinah Al Munawarah, Saudi Arabia
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Plodr M, Chalusova E. Current trends in the management of out of hospital cardiac arrest (OHCA). Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2024; 168:105-116. [PMID: 38441422 DOI: 10.5507/bp.2024.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Accepted: 02/27/2024] [Indexed: 06/16/2024] Open
Abstract
Sudden cardiac arrest remains a relevant problem with a significant number of deaths worldwide. Although survival rates have more than tripled over the last 20 years (4% in 2001 vs. 14% in 2020), survival rates with good neurological outcomes remain persistently low, representing a major socioeconomic problem. Every minute of delay from patient collapse to start cardiopulmonary resuscitation (CPR) and early defibrillation reduces the chance of survival by approximately 10-12%. Therefore, the time to treatment is a crucial factor in the prognosis of patients with out-of-hospital cardiac arrest (OHCA). Research teams working in the pre-hospital setting are therefore looking for ways to improve the transmission of information from the site of an emergency event and to make it easier for emergency medical dispatch centres (EMDC) to recognise life-threatening conditions with minimal deviation. For emergency unit procedures already at the scene of the event, methods are being sought to efficiently and temporarily replace a non-functioning cardiopulmonary system. In the case of traumatic cardiac arrest (TCA), the focus is mainly on effective affecting non-compressible haemorrhage.
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Affiliation(s)
- Michal Plodr
- Department of Emergency Medicine and Military General Medicine, Military Faculty of Medicine, University of Defence, Hradec Kralove, Czech Republic
- Emergency Medical Services of the Hradec Kralove Region, Hradec Kralove, Czech Republic
| | - Eva Chalusova
- Department of Emergency Medicine and Military General Medicine, Military Faculty of Medicine, University of Defence, Hradec Kralove, Czech Republic
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Clements TW, Van Gent JM, Menon N, Roberts A, Sherwood M, Osborn L, Hartwell B, Refuerzo J, Bai Y, Cotton BA. Use of Low-Titer O-Positive Whole Blood in Female Trauma Patients: A Literature Review, Qualitative Multidisciplinary Analysis of Risk/Benefit, and Guidelines for Its Use as a Universal Product in Hemorrhagic Shock. J Am Coll Surg 2024; 238:347-357. [PMID: 37930900 DOI: 10.1097/xcs.0000000000000906] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2023]
Abstract
BACKGROUND Whole blood transfusion is associated with benefits including improved survival, coagulopathy, and decreased transfusion requirements. The majority of whole blood transfusion is in the form of low-titer O-positive whole blood (LTOWB). Practice at many trauma centers withholds the use of LTOWB in women of childbearing potential due to concerns of alloimmunization. The purpose of this article is to review the evidence for LTOWB transfusion in female trauma patients and generate guidelines for its application. STUDY DESIGN Literature and evidence for LTOWB transfusion in hemorrhagic shock are reviewed. The rates of alloimmunization and subsequent obstetrical outcomes are compared to the reported outcomes of LTOWB vs other resuscitation media. Literature regarding patient experiences and preferences in regards to the risk of alloimmunization is compared to current trauma practices. RESULTS LTOWB has shown improved outcomes in both military and civilian settings. The overall risk of alloimmunization for Rhesus factor (Rh) - female patients in hemorrhagic shock exposed to Rh + blood is low (3% to 20%). Fetal outcomes in Rh-sensitized patients are excellent compared to historical standards, and treatment options continue to expand. The majority of female patients surveyed on the risk of alloimmunization favor receiving Rh + blood products to improve trauma outcomes. Obstetrical transfusion practices have incorporated LTOWB with excellent results. CONCLUSIONS The use of whole blood resuscitation in trauma is associated with benefits in the resuscitation of severely injured patients. The rate at which severely injured, Rh-negative patients develop anti-D antibodies is low. Treatments for alloimmunized pregnancies have advanced, with excellent results. Fears of alloimmunization in female patients are likely overstated and may not warrant the withholding of whole blood resuscitation. The benefits of whole blood resuscitation likely outweigh the risks of alloimmunization.
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Affiliation(s)
- Thomas W Clements
- From the Departments of Surgery (Clements, Van Gent, Cotton), McGovern Medical School, Houston, Texas
| | - Jan-Michael Van Gent
- From the Departments of Surgery (Clements, Van Gent, Cotton), McGovern Medical School, Houston, Texas
| | - Neethu Menon
- Obstetrics, Gynecology, and Reproductive Sciences, McGovern Medical School (Menon, Roberts, Refuerzo), McGovern Medical School, Houston, Texas
| | - Aaron Roberts
- Obstetrics, Gynecology, and Reproductive Sciences, McGovern Medical School (Menon, Roberts, Refuerzo), McGovern Medical School, Houston, Texas
| | | | - Lesley Osborn
- Emergency Medicine (Osborn), McGovern Medical School, Houston, Texas
| | - Beth Hartwell
- Gulf Coast Regional Blood Center, Houston, Texas (Hartwell)
| | - Jerrie Refuerzo
- Obstetrics, Gynecology, and Reproductive Sciences, McGovern Medical School (Menon, Roberts, Refuerzo), McGovern Medical School, Houston, Texas
| | - Yu Bai
- Pathology and Laboratory Medicine (Bai), McGovern Medical School, Houston, Texas
| | - Bryan A Cotton
- From the Departments of Surgery (Clements, Van Gent, Cotton), McGovern Medical School, Houston, Texas
- Center for Translational Injury Research, Houston, Texas (Cotton)
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Tadlock MD, Edson TD, Cancio JM, Flieger DM, Wickard AS, Grimsley B, Gustafson CG, Yelon JA, Jeng JC, Gurney JM. War at Sea: Burn Care Challenges-Past, Present and Future. EUROPEAN BURN JOURNAL 2023; 4:605-630. [PMID: 39600029 PMCID: PMC11571863 DOI: 10.3390/ebj4040041] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/14/2023] [Revised: 11/30/2023] [Accepted: 12/05/2023] [Indexed: 11/29/2024]
Abstract
Throughout history, seafarers have been exposed to potential thermal injuries during naval warfare; however, injury prevention, including advances in personal protective equipment, has saved lives. Thankfully, burn injuries have decreased over time, which has resulted in a significant clinical skills gap. Ships with only Role 1 (no surgical capability) assets have worse outcomes after burn injury compared to those with Role 2 (surgical capability) assets. To prepare for future burn care challenges during a war at sea, Military Medicine must re-learn the lessons of World War I and World War II. Burn injuries do not occur in isolation during war and are associated with concomitant traumatic injuries. To care for burn casualties at sea, there is an urgent need to increase the availability of whole blood and dried plasma, resuscitation fluids that were ubiquitous throughout the naval force during World War II for both hemorrhagic and burn shock resuscitation. Furthermore, those providing trauma care at sea require formal burn care training and skills sustainment experiences in the clinical management of Burn, Trauma, and Critical Care patients. While burn education, training, and experience must be improved, modern high-energy weapons systems and anti-ship ballistic missiles necessitate concurrent investments in prevention, countermeasures, and personal protective equipment to decrease the likelihood of burn injury and damage resulting from these attacks.
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Affiliation(s)
- Matthew D. Tadlock
- Department of Surgery, Naval Medical Center, San Diego, CA 92134, USA; (A.S.W.); (B.G.)
- 1st Medical Battalion, 1st Marine Logistics Group, Camp Pendleton, CA 92058, USA;
| | - Theodore D. Edson
- 1st Medical Battalion, 1st Marine Logistics Group, Camp Pendleton, CA 92058, USA;
| | - Jill M. Cancio
- U.S. Army Burn Center, U.S. Army Institute of Surgical Research, Ft. Sam Houston, San Antonio, TX 78234, USA;
| | - Dana M. Flieger
- Navy Medicine Readiness and Training Command, Camp Lejeune, NC 28547, USA;
| | - Aaron S. Wickard
- Department of Surgery, Naval Medical Center, San Diego, CA 92134, USA; (A.S.W.); (B.G.)
| | - Bailey Grimsley
- Department of Surgery, Naval Medical Center, San Diego, CA 92134, USA; (A.S.W.); (B.G.)
| | | | - Jay A. Yelon
- Navy Medical Operational Command, University of Pennsylvania, Philadelphia, PA 19104, USA;
| | - James C. Jeng
- Division of Trauma Critical Care, Acute Care & Burn Surgery, Department of Surgery, University of California Irvine, Orange, CA 92868, USA;
| | - Jennifer M. Gurney
- Joint Trauma System, DoD Center of Excellence for Trauma, Joint Base San Antonio-Fort Sam, Houston, TX 78234, USA;
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Cooper JL, Sharp CR, Boyd CJ, Claus MA, Rossi G. The hemostatic profile of cold-stored whole blood from non-greyhound and greyhound dogs over 42 days. Front Vet Sci 2023; 10:1135880. [PMID: 36937016 PMCID: PMC10019821 DOI: 10.3389/fvets.2023.1135880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Accepted: 02/08/2023] [Indexed: 03/06/2023] Open
Abstract
Objectives To compare the hemostatic characteristics of cold-stored whole blood (CSWB) from non-greyhound dogs (NGD) and greyhound dogs (GD) over 42 days of storage, notably, platelet closure time (PCT) (NGD only), manual platelet count (PLT) (GD only), ellagic acid (INTEM) and tissue factor activated (EXTEM) rotational thromboelastometry, prothrombin (PT) and activated partial thromboplastin time (aPTT), fibrinogen concentration (FIB), and the activities of factors (F) FII, FV, FVII, FVIII, FIX, FX, FXIII antigen (FXIII:Ag), and von Willebrand factor antigen (vWF:Ag). Design Whole blood from 10 NGD and 10 GD, was refrigerated in CPD blood bags at 4°C for 42 days. Blood was analyzed before refrigeration (day 0) and at day 1 (d1), 3, 5, 7, 10, 14, 17, 21, 24, 28, 31, 35, 38, and 42. Multivariate linear mixed effects models were created to evaluate coagulation parameters over time and compare NGD and GD. Data are summarized as estimated marginal means with 95% confidence intervals. Significance was set at P < 0.05. Results The PCT for all NGD CSWB was above the device limit by d7. The PLT for GD CSWB did not change during storage. The mean alpha-angle for INTEM and EXTEM decreased to <50% of baseline at d38 and d31 for NGD, and d31 and d17 for GD CSWB. The mean maximum clot firmness (MCF) for INTEM and EXTEM reduced to <50% of baseline at d42 and d28 for both GD and NGD. PT and aPTT for NGD and GD increased over time. For NGD CSWB, the mean FVIII and vWF:Ag activities decreased to <50% of baseline at d7 and d28, respectively, and FIB reached 0.982 g/dL by d24. For GD CSWB, FVIII, FXIII:Ag and FV activities decreased to <50% of baseline by d3, d38, and d38, respectively, and FIB was 0.982 g/dL at baseline. Alpha-angle and MCF for both INTEM and EXTEM, and activities for FII, FV, FIX, FXIII:Ag were significantly lower, and vWF:Ag was significantly higher overall in GD CSWB compared with NGD. A significant difference in the pattern of change over time was detected between NGD and GD in EXTEM alpha-angle, INTEM and EXTEM MCF, FII, and FVIII activities. Conclusions The in vitro viscoelastic parameters of GD and NGD CSWB declines over 42 days, but numerous hemostatic parameters (INTEM and EXTEM alpha-angle and MCF, activity of FII, FV, FV, FVII, FIX, FX, FXIII:Ag, vWF:Ag, and FIB) remain within 50% of baseline for more than 14 days. CSWB from GD compared to NGD has reduced hemostatic activity overall, but a similar pattern of decline for most parameters over time.
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Affiliation(s)
- James L. Cooper
- School of Veterinary Medicine, Murdoch University, Murdoch, WA, Australia
| | - Claire R. Sharp
- School of Veterinary Medicine, Murdoch University, Murdoch, WA, Australia
- *Correspondence: Claire R. Sharp
| | - Corrin J. Boyd
- School of Veterinary Medicine, Murdoch University, Murdoch, WA, Australia
| | - Melissa A. Claus
- School of Veterinary Medicine, Murdoch University, Murdoch, WA, Australia
- Perth Veterinary Specialists, Osborne Park, WA, Australia
| | - Gabriel Rossi
- School of Veterinary Medicine, Murdoch University, Murdoch, WA, Australia
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Hegde S, Zheng Y, Cancelas JA. Novel blood derived hemostatic agents for bleeding therapy and prophylaxis. Curr Opin Hematol 2022; 29:281-289. [PMID: 35942861 PMCID: PMC9547927 DOI: 10.1097/moh.0000000000000737] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PURPOSE OF REVIEW Hemorrhage is a major cause of preventable death in trauma and cancer. Trauma induced coagulopathy and cancer-associated endotheliopathy remain major therapeutic challenges. Early, aggressive administration of blood-derived products with hypothesized increased clotting potency has been proposed. A series of early- and late-phase clinical trials testing the safety and/or efficacy of lyophilized plasma and new forms of platelet products in humans have provided light on the future of alternative blood component therapies. This review intends to contextualize and provide a critical review of the information provided by these trials. RECENT FINDINGS The beneficial effect of existing freeze-dried plasma products may not be as high as initially anticipated when tested in randomized, multicenter clinical trials. A next-generation freeze dried plasma product has shown safety in an early phase clinical trial and other freeze-dried plasma and spray-dried plasma with promising preclinical profiles are embarking in first-in-human trials. New platelet additive solutions and forms of cryopreservation or lyophilization of platelets with long-term shelf-life have demonstrated feasibility and logistical advantages. SUMMARY Recent trials have confirmed logistical advantages of modified plasma and platelet products in the treatment or prophylaxis of bleeding. However, their postulated increased potency profile remains unconfirmed.
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Affiliation(s)
- Shailaja Hegde
- Hoxworth Blood Center, University of Cincinnati Academic Health Center
| | - Yi Zheng
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Jose A Cancelas
- Hoxworth Blood Center, University of Cincinnati Academic Health Center
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
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Taylor AL, Corley JB, Cap AP, Swingholm MT, Nance ET, Gonzales R, Gurney JM, Shackelford S, Hebert JC, Hughes JD, Royster K, Hestilow GA, Cordrick CL, Hoiles J, Whitlock K, Whitacre R, Pederson B. The U.S. Armed Services Blood Program support to U.S. Central Command 2014-2021: Transformation of combat trauma resuscitation through blood product innovation and expansion of blood availability far forward. Transfusion 2022; 62 Suppl 1:S167-S176. [PMID: 35748678 DOI: 10.1111/trf.16951] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Revised: 04/20/2022] [Accepted: 04/21/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND The United States Armed Services Blood Program (ASBP) faced complex blood supply challenges during two decades of military operations in the U.S. Central Command (CENTCOM) and through an adaptive, responsive, and agile system, gained valuable insights on blood product usage in combat casualty care. STUDY DESIGN AND METHODS A retrospective review of blood product introduction and utilization trends was compiled from ASBP data collected during CENTCOM operations from 2014 through 2021. RESULTS During the study period, several blood products were introduced to the CENTCOM area of operations including Low Titer O Whole Blood (LTOWB), Cold-Stored Platelets (CSP), Liquid Plasma (LP), and French Freeze Dried Plasma (FDP) manufactured from U.S. sourced donor plasma, all while expanding Walking Blood Bank capabilities. There was a gradual substitution of component therapy for whole blood; blood utilization peaked in 2017. Transfusion of Fresh Whole Blood (FWB) from Walking Blood Banks decreased as fully pre-tested LTOWB was supplied by the ASBP. LTOWB was initially supplied in citrate-phosphate-dextrose (CPD) anticoagulant (21-day shelf life) but was largely replaced with LTOWB in citrate-phosphate-dextrose-adenine (CPDA-1) anticoagulant (35-day shelf life) by 2019. Implementation of prehospital transfusion and expansion of surgical and resuscitation teams led to an increase in the number of sites receiving blood. DISCUSSION ASBP introduced new products to its inventory in order to meet changing blood product demands driven by changes in the Joint Trauma System Clinical Practice Guidelines and operational demands. These products were adopted into clinical practice with a resultant evolution in transfusion strategies.
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Affiliation(s)
- Audra L Taylor
- Armed Services Blood Program Division, Defense Health Agency, Falls Church, Virginia, USA
| | - Jason B Corley
- U.S. Army Medical Command, Army Blood Program, San Antonio, Texas, USA
| | - Andrew P Cap
- Army Institute of Surgical Research Army Blood Program, San Antonio, Texas, USA
| | | | - Erika T Nance
- Armed Services Blood Program Division, Defense Health Agency, Falls Church, Virginia, USA
| | | | - Jennifer M Gurney
- Army Institute of Surgical Research Army Blood Program, San Antonio, Texas, USA
| | | | - Jeffrey C Hebert
- Bureau of Medicine & Surgery, Navy Blood Program, Falls Church, Virginia, USA
| | | | - Karen Royster
- Armed Services Blood Program Division, Defense Health Agency, Falls Church, Virginia, USA
| | - George A Hestilow
- Air Force Medical Readiness Agency, Air Force Blood Program, San Antonio, Texas, USA
| | - Colleen L Cordrick
- Center for Laboratory Medicine Services, Defense Health Agency, Falls Church, Virginia, USA
| | | | | | - Robin Whitacre
- Armed Services Blood Program Division, Defense Health Agency, Falls Church, Virginia, USA
| | - Becky Pederson
- Air Force Medical Readiness Agency, Air Force Blood Program, San Antonio, Texas, USA
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Martinaud C, Fleuriot E, Pasquier P. Implementation of Low Titer Whole Blood for French overseas operations: O positive or negative products in massive hemorrhage? Transfus Clin Biol 2022; 29:164-167. [DOI: 10.1016/j.tracli.2022.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Revised: 02/20/2022] [Accepted: 02/22/2022] [Indexed: 11/26/2022]
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10
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Gurney JM, Staudt AM, Del Junco DJ, Shackelford SA, Mann-Salinas EA, Cap AP, Spinella PC, Martin MJ. Whole blood at the tip of the spear: A retrospective cohort analysis of warm fresh whole blood resuscitation versus component therapy in severely injured combat casualties. Surgery 2022; 171:518-525. [PMID: 34253322 DOI: 10.1016/j.surg.2021.05.051] [Citation(s) in RCA: 52] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 05/26/2021] [Accepted: 05/31/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Death from uncontrolled hemorrhage occurs rapidly, particularly among combat casualties. The US military has used warm fresh whole blood during combat operations owing to clinical and operational exigencies, but published outcomes data are limited. We compared early mortality between casualties who received warm fresh whole blood versus no warm fresh whole blood. METHODS Casualties injured in Afghanistan from 2008 to 2014 who received ≥2 red blood cell containing units were reviewed using records from the Joint Trauma System Role 2 Database. The primary outcome was 6-hour mortality. Patients who received red blood cells solely from component therapy were categorized as the non-warm fresh whole blood group. Non- warm fresh whole blood patients were frequency-matched to warm fresh whole blood patients on identical strata by injury type, patient affiliation, tourniquet use, prehospital transfusion, and average hourly unit red blood cell transfusion rates, creating clinically unique strata. Multilevel mixed effects logistic regression adjusted for the matching, immortal time bias, and other covariates. RESULTS The 1,105 study patients (221 warm fresh whole blood, 884 non-warm fresh whole blood) were classified into 29 unique clinical strata. The adjusted odds ratio of 6-hour mortality was 0.27 (95% confidence interval 0.13-0.58) for the warm fresh whole blood versus non-warm fresh whole blood group. The reduction in mortality increased in magnitude (odds ratio = 0.15, P = .024) among the subgroup of 422 patients with complete data allowing adjustment for seven additional covariates. There was a dose-dependent effect of warm fresh whole blood, with patients receiving higher warm fresh whole blood dose (>33% of red blood cell-containing units) having significantly lower mortality versus the non-warm fresh whole blood group. CONCLUSION Warm fresh whole blood resuscitation was associated with a significant reduction in 6-hour mortality versus non-warm fresh whole blood in combat casualties, with a dose-dependent effect. These findings support warm fresh whole blood use for hemorrhage control as well as expanded study in military and civilian trauma settings.
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Affiliation(s)
- Jennifer M Gurney
- US Army Institute of Surgical Research, San Antonio, TX; Joint Trauma System, San Antonio, TX; Uniformed Services University of the Health Sciences, Bethesda, MD.
| | | | | | - Stacy A Shackelford
- Joint Trauma System, San Antonio, TX; Uniformed Services University of the Health Sciences, Bethesda, MD
| | | | - Andrew P Cap
- US Army Institute of Surgical Research, San Antonio, TX; Uniformed Services University of the Health Sciences, Bethesda, MD
| | - Philip C Spinella
- Department of Surgery, Washington University School of Medicine, St. Louis, MO
| | - Matthew J Martin
- Uniformed Services University of the Health Sciences, Bethesda, MD; Department of Surgery, Scripps Mercy Hospital, San Diego, CA. https://twitter.com/docmartin22
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Hinojosa-Laborde C, Hudson IL, Ross E, Xiang L, Ryan KL. Pathophysiology of Hemorrhage as It Relates to the Warfighter. Physiology (Bethesda) 2022; 37:141-153. [PMID: 35001653 PMCID: PMC8977138 DOI: 10.1152/physiol.00028.2021] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Saving lives of wounded military Warfighters often depends on the ability to resolve or mitigate the pathophysiology of hemorrhage, specifically diminished oxygen delivery to vital organs that leads to multi-organ failure and death. However, caring for hemorrhaging patients on the battlefield presents unique challenges that extend beyond applying a tourniquet and giving a blood transfusion, especially when battlefield care must be provided for a prolonged period. This review will describe these challenges and potential strategies for treating hemorrhage on the battlefield in a prolonged casualty care situation.
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Affiliation(s)
| | - Ian L Hudson
- U.S. Army Institute of Surgical Research, JBSA Fort Sam Houston, TX, United States
| | - Evan Ross
- U.S. Army Institute of Surgical Research, JBSA Fort Sam Houston, TX, United States
| | - Lusha Xiang
- U.S. Army Institute of Surgical Research, JBSA Fort Sam Houston, TX, United States
| | - Kathy L Ryan
- U.S. Army Institute of Surgical Research, JBSA Fort Sam Houston, TX, United States
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Clarke EE, Hamm J, Fisher AD, April MD, Long BJ, Mdaki KS, Hill R, Bynum JA, Schauer SG. Trends in Prehospital Blood, Crystalloid, and Colloid Administration in Accordance With Changes in Tactical Combat Casualty Care Guidelines. Mil Med 2021; 187:e1265-e1270. [PMID: 34935982 DOI: 10.1093/milmed/usab461] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 10/12/2021] [Accepted: 11/08/2021] [Indexed: 11/12/2022] Open
Abstract
INTRODUCTION Hemorrhage is the leading threat to the survival of battlefield casualties. This study aims to investigate the types of fluids and blood products administered in prehospital trauma encounters to discover the effectiveness of Tactical Combat Casualty Care (TCCC) recommendations. MATERIALS AND METHODS This is a secondary analysis of a previously described dataset from the Department of Defense Trauma Registry with a focus on prehospital fluid and blood administration in conjunction with changes in the TCCC guidelines. We collected demographic information on each patient. We categorized receipt of each fluid type and blood product as a binary variable for each casualty and evaluated trends over 2007-2020 both unadjusted and controlling for injury severity and mechanism of injury. RESULTS Our original dataset comprised 25,897 adult casualties from January 1, 2007 through March 17, 2020. Most (97.3%) of the casualties were male with a median age of 25. Most (95.5%) survived to hospital discharge, and 12.2% of the dataset received fluids of any kind. Medical personnel used crystalloids in 7.4% of encounters, packed red blood cells in 2.0%, and whole blood in 0.5% with very few receiving platelets or freeze-dried plasma. In the adjusted model, we noted significant year-to-year increases in intravenous fluid administration from 2014 to 2015 and 2018 to 2019, with significant decreases noted in 2008-2009, 2010-2012, and 2015-2016. We noted no significant increases in Hextend used, but we did note significant decreases in 2010-2012. For any blood product, we noted significant increases from 2016 to 2017, with decreases noted in 2009-2013, 2015-2016, and 2017-2018. Overall, we noted a general spike in all uses in 2011-2012 that rapidly dropped off 2012-2013. Crystalloids consistently outpaced the use of blood products. We noted a small upward trend in all blood products from 2017 to 2019. CONCLUSIONS Changes in TCCC guidelines did not immediately translate into changes in prehospital fluid administration practices. Crystalloid fluids continue to dominate as the most commonly administered fluid even after the 2014 TCCC guidelines changed to use of blood products over crystalloids. There should be future studies to investigate the reasons for delay in guideline implementation and efforts to improve adherence.
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Affiliation(s)
| | - James Hamm
- Soldier Recovery Brigade, National Capital Region, Walter Reed, MD, USA
| | - Andrew D Fisher
- University of New Mexico School of Medicine, Albuquerque, NM 87106, USA.,Texas Army National Guard, Austin, TX, USA
| | - Michael D April
- 40th FRSD, Forward Resuscitative Surgical Team, Fort Carson, CO 80193, USA.,Department of Emergency Medicine, Brooke Army Medical Center, JBSA Fort Sam Houston, TX 78234, USA
| | - Brit J Long
- Department of Military and Emergency Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA.,Department of Emergency Medicine, Brooke Army Medical Center, JBSA Fort Sam Houston, TX 78234, USA
| | - Kennedy S Mdaki
- US Army Institute of Surgical Research, JBSA Fort Sam Houston, TX 78234, USA
| | - Ronnie Hill
- US Army Institute of Surgical Research, JBSA Fort Sam Houston, TX 78234, USA
| | - James A Bynum
- US Army Institute of Surgical Research, JBSA Fort Sam Houston, TX 78234, USA
| | - Steven G Schauer
- Department of Military and Emergency Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA.,Department of Emergency Medicine, Brooke Army Medical Center, JBSA Fort Sam Houston, TX 78234, USA.,US Army Institute of Surgical Research, JBSA Fort Sam Houston, TX 78234, USA
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Strauss R, Menchetti I, Perrier L, Blondal E, Peng H, Sullivan-Kwantes W, Tien H, Nathens A, Beckett A, Callum J, da Luz LT. Evaluating the Tactical Combat Casualty Care principles in civilian and military settings: systematic review, knowledge gap analysis and recommendations for future research. Trauma Surg Acute Care Open 2021; 6:e000773. [PMID: 34746434 PMCID: PMC8527149 DOI: 10.1136/tsaco-2021-000773] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Accepted: 07/27/2021] [Indexed: 11/09/2022] Open
Abstract
OBJECTIVES The Tactical Combat Casualty Care (TCCC) guidelines detail resuscitation practices in prehospital and austere environments. We sought to review the content and quality of the current TCCC and civilian prehospital literature and characterize knowledge gaps to offer recommendations for future research. METHODS MEDLINE, EMBASE, CINAHL, and Cochrane Central Register of Controlled Trials were searched for studies assessing intervention techniques and devices used in civilian and military prehospital settings that could be applied to TCCC guidelines. Screening and data extraction were performed according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Quality appraisal was conducted using appropriate tools. RESULTS Ninety-two percent (n=57) of studies were observational. Most randomized trials had low risk of bias, whereas observational studies had higher risk of bias. Interventions of massive hemorrhage control (n=17) were wound dressings and tourniquets, suggesting effective hemodynamic control. Airway management interventions (n=7) had high success rates with improved outcomes. Interventions of respiratory management (n=12) reported low success with needle decompression. Studies assessing circulation (n=18) had higher quality of evidence and suggested improved outcomes with component hemostatic therapy. Hypothermia prevention interventions (n=2) were generally effective. Other studies identified assessed the use of extended focused assessment with sonography in trauma (n=3) and mixed interventions (n=2). CONCLUSIONS The evidence was largely non-randomized with heterogeneous populations, interventions, and outcomes, precluding robust conclusions in most subjects addressed in the review. Knowledge gaps identified included the use of blood products and concentrate of clotting factors in the prehospital setting. LEVEL OF EVIDENCE Systematic review, level III.
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Affiliation(s)
- Rachel Strauss
- Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Isabella Menchetti
- Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Laure Perrier
- Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Erik Blondal
- Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Henry Peng
- Defence Research and Development Canada, Toronto Research Centre, Toronto, Ontario, Canada
| | - Wendy Sullivan-Kwantes
- Defence Research and Development Canada, Toronto Research Centre, Toronto, Ontario, Canada
| | - Homer Tien
- Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Avery Nathens
- Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Andrew Beckett
- Department of Surgery, St Michael's Hospital, Toronto, Ontario, Canada
| | - Jeannie Callum
- Laboratory Medicine and Molecular Diagnostics, Kingston Health Sciences Centre, Kingston, Ontario, Canada
| | - Luis Teodoro da Luz
- Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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