The regional whole blood program in San Antonio, TX: A 3-year update on prehospital and in-hospital transfusion practices for traumatic and non-traumatic hemorrhage

A national database review of whole blood use among females of childbearing potential experiencing traumatic hemorrhage

INTRODUCTION

The use of low-titer O whole blood (LTOWB) for traumatic hemorrhage is growing. Most LTOWB for use in adults is RhD-positive, which presents potential risks to females of childbearing potential (FCP); however, data on practice patterns are lacking. We sought to assess the use of LTOWB among FCPs compared to similarly aged males in facilities with documented LTOWB capabilities.

METHODS

We compared FCP (females 15-50 years of age) to similarly aged males (or sex unclassified/undocumented) who were included in the Trauma Quality Improvement Program database from 2020 to 2022. This database records transfusion volumes administered within the first 4 h after admission and patient demographics. We compared LTOWB use among FCPs versus similarly aged males using descriptive, inferential, and multivariable statistics.

RESULTS

There were 79,298 that met inclusion for this analysis. There were 16,823 (21%) FCPs, of whom, 2759/16,823 (16%) received any volume of LTOWB compared to 16,310/62,475 (26%) of the males. Furthermore, among LTOWB recipients, the median (interquartile range) volume administered to FCPs was 1162 mL (500-1000) compared to 1352 mL (500-1000, p = .003) for males. In our multivariable logistic regression analysis, males had a higher odds for the receipt of LTOWB compared to FCPs (odds ratio 1.76, 95% confidence interval 1.68-1.84) after adjusting for age, mechanism of injury, and composite injury severity score. These findings persisted on sensitivity testing.

CONCLUSIONS

Males were more likely than FCPs to receive LTOWB during trauma resuscitation in unadjusted and adjusted analyses. The reasons for such differences require elucidation in future prospective studies.

What we do matters

Amidst all the bad news and divisiveness we are surrounded with every day, there are many reminders from our field that highlight that the things we do really do matter. The scope of this talk focuses on blood, but it is important to remember that the concepts discussed can be applied to all aspects of medical care. Level III evidence.

How do we implement a prehospital whole blood administration program for shock trauma patients on a statewide basis?

BACKGROUND

Since bleeding is a major cause of early mortality in trauma, there is continued interest in providing transfusion support as early as possible to trauma patients. Various approaches have been taken to accomplish this, including the rapid provision of blood products upon arrival at the hospital, as well as a variety of prehospital approaches. However, implementing prehospital blood availability statewide for use in all populations has been limited.

STUDY DESIGN AND METHODS

The program described for prehospital transfusion identifies a direct partnership between state EMS providers and the local blood center. Predictive modeling is compared to early outcome data of the first 100 patients who received whole blood from this program. Additional discussion contains key elements of the program, including planning, validation, and implementation.

RESULTS

Between May 2023 and July 2024, an average of 11 prehospital whole blood units were transfused per month against the projected average of 10-16 units administered per month, with the median time to transfusion of 29.2 min. The leading reason for blood administration was due to blunt trauma. Of the patients who were not in prehospital cardiac arrest prior to paramedic arrival or excluded for other reasons, approximately 95% survived to hospital discharge.

DISCUSSION

Implementation of prehospital whole blood across the state has demonstrated effectiveness early within the first year of the program. Continued process improvements will be implemented with statewide ground paramedic agency utilization of whole blood as well as expansion into aviation divisions for more expedient whole blood administration times.

Prehospital Trauma Compendium: Management of Injured Pregnant Patients- A Position Statement and Resource Document of NAEMSP

The assessment and management of critically injured pregnant trauma patients represents a high-risk, low-frequency event. One in every 12 pregnant patients experience physical trauma during their pregnancy, but only 0.1% experience major trauma with an injury severity score (ISS) greater than fifteen. It is crucial that emergency medical services (EMS) clinicians understand the anatomic and pathophysiologic changes that impact morbidity and mortality for pregnant trauma patients so they can effectively provide life-saving interventions and resuscitation for this patient population.

An Analysis of the Association of Whole Blood Transfusion With the Development of Acute Respiratory Distress Syndrome

OBJECTIVES

To determine the association of whole blood and other blood products (components, prothrombin complex concentrate, and fibrinogen concentrate) with the development of acute respiratory distress syndrome (ARDS) among blood recipients.

DESIGN

Retrospective cohort study.

SETTING

American College of Surgeons Trauma Quality Improvement Program (TQIP) database between 2020 and 2021.

PATIENTS

Patients 15 years old or older in the TQIP database between 2020 and 2022 who received at least one blood product.

INTERVENTIONS

We compared characteristics and blood product administration between patients who developed ARDS versus those who did not.

MEASUREMENTS AND MAIN RESULTS

There were 134,863 that met inclusion for this analysis. Within the included population, 1% (1927) was diagnosed with ARDS. The no ARDS group had a lower portion of serious injuries to the head/neck (31% vs. 46%), thorax (51% vs. 78%), abdomen (34% vs. 48%), and extremities (37% vs. 47%). The median composite Injury Severity Score was 21 (11-30) in the no ARDS group vs. 30 (22-41) in the ARDS group. Unadjusted survival of discharge was 74% in the no ARDS group vs. 61% in the ARDS group. In our multivariable model, we found that whole blood (unit odds ratio [uOR], 1.05; 95% CI, 1.02-1.07), male sex (odds ratio, 1.44; 95% CI, 1.28-1.63), arrival shock index (uOR, 1.03; 95% CI, 1.01-1.06), and composite Injury Severity Score (uOR, 1.03; 95% CI, 1.03-1.04) were associated with the development of ARDS. These persisted on sensitivity testing.

CONCLUSIONS

We found an association between whole blood and the development of ARDS among trauma patients who received blood transfusions. Contrary to previous studies, we found no association between ARDS and fresh frozen plasma administration. The literature would benefit from further investigation via prospective study designs.

Low-Titer O-Positive Whole Blood: Lessons From the Battlefield for Civilian Rural Hospitals

Low-titer O-positive whole blood was used extensively by the military during operations in Iraq and Afghanistan. Studies have consistently shown that this therapy is feasible, safe, and effective in the management of hemorrhagic shock in trauma patients, and it is now the standard of care across the US military Joint Trauma System. The military's success in using low-titer O-positive whole blood has renewed the practice in the civilian setting, with recent research confirming its safety and efficacy. In a few short years, use of this treatment for hemorrhagic shock has expanded to more than 80 US level I and level II trauma centers. However, its use is still relatively rare in the rural hospital setting. This article describes the benefits for patients, staff members, and the overall trauma system of using low-titer O-positive whole blood in rural hospitals.

Blood Product Administration in the Prehospital Setting: A Scoping Review

OBJECTIVES

Implementing prehospital blood products for treating hemorrhagic shock has been utilized globally in military and civilian settings. This review aims to compare various guidelines for using blood products, including the types of blood products, injuries, biomarkers (hemodynamic measurement) to indicate use, associated treatments and risks, and the logistical concerns of storage and wastage in the prehospital setting. Furthermore, it explores whether prehospital blood transfusions are beneficial and a safe treatment option.

METHODS

Data were collected using a systematic search and screening process of online databases CINAHL, Medline, and Scopus, as well as by creating a PRISMA flow diagram to screen articles using inclusion and exclusion criteria. Forty-five articles were screened, with twenty-five excluded, resulting in twenty articles in this scoping review.

RESULTS

The most frequently used blood product used was red blood cells, with twelve studies using either red blood cells alone or in combination with other products. Indications for blood use varied across services, but all aimed to address hemodynamic instability as a primary indication for blood transfusion. Eleven studies recorded no adverse reactions. Only one study reported chills and shivers; however, it was unclear if blood products were the cause. Nine studies avoided logistical issues of storage and wastage to create a feasible rotation system.

CONCLUSIONS

Prehospital blood was used in medical, trauma, and maternity-related hemorrhage. Many types of blood products are in use, ranging from component therapy to whole blood, with each protocol having different indications of use and treatment guidelines aimed at improving hemodynamic stability.

Prehospital Whole Blood Administration for Pediatric Gastrointestinal Hemorrhage: A Case Report

The management of gastrointestinal (GI) hemorrhage in a prehospital setting presents significant challenges, particularly in arresting the hemorrhage and initiating resuscitation. This case report introduces a novel instance of prehospital whole blood transfusion to an 8-year-old male with severe lower GI hemorrhage, marking a shift in prehospital pediatric care. The patient, with no previous significant medical history, presented with acute rectal bleeding, severe hypotension (systolic/diastolic blood pressure [BP] 50/30 mmHg), and tachycardia (148 bpm). Early intervention by Emergency Medical Services (EMS), including the administration of 500 mL (16 mL/kg) of whole blood, led to marked improvement in vital signs (BP 97/64 mmHg and heart rate 93 bpm), physiology, and physical appearance, underscoring the potential effectiveness of prehospital whole blood transfusion in pediatric GI hemorrhage. Upon hospital admission, a Meckel's diverticulum was identified as the bleeding source, and it was successfully surgically resected. The patient's recovery was ultimately favorable, highlighting the importance of rapid, prehospital intervention and the potential role of whole blood transfusion in managing acute pediatric GI hemorrhage. This case supports the notion of advancing EMS protocols to include interventions historically reserved for the hospital setting that may significantly impact patient outcomes from the field.

Prehospital Massive Transfusion for Resuscitation of an Entrapped Patient in a Rural Setting: A Case Report

Resuscitation of injured patients suffering from hemorrhagic shock with blood products in the prehospital environment is becoming more commonplace. However, blood product utilization is typically restricted and can be exhausted in the event of a prolonged entrapment. Delivery of large amounts of blood products to a scene is rare, particularly in rural settings. We present the case of a 26-year-old male who was entrapped in a motor vehicle for 144 min. First responders assessed the entrapped patient to be in hemorrhagic shock from lower extremities injuries. The Helicopter Emergency Medical Services team exhausted their supply of blood products shortly after arrival on scene. The local trauma center's Surgical Emergency Response Team (SERT) was requested to the scene. The preplanned response included seven units of blood components to provide massive transfusion at the point of injury and released directly to field responders by the blood bank. During extrication, the patient was given two units of packed red blood cells by initial responders with three more units of blood components from the SERT supply. During transfer to the hospital, the patient received an additional three units, and four units were transfused on initial trauma resuscitation in the hospital. He was found to have severe lower extremities injuries as the cause of his hemorrhage. The patient survived to hospital discharge. Delivery of large volumes of blood products to an entrapped patient with prolonged extrication time may be a lifesaving intervention. We advocate for integration of blood bank services and on scene physician guided resuscitation for prolonged extrications.

Assessing the one-month mortality impact of civilian-setting prehospital transfusion: A systematic review and meta-analysis

BACKGROUND

Based on convincing evidence for outcomes improvement in the military setting, the past decade has seen evaluation of prehospital transfusion (PHT) in the civilian emergency medical services (EMS) setting. Evidence synthesis has been challenging, due to study design variation with respect to both exposure (type of blood product administered) and outcome (endpoint definitions and timing). The goal of the current meta-analysis was to execute an overarching assessment of all civilian-arena randomized controlled trial (RCT) evidence focusing on administration of blood products compared to control of no blood products.

METHOD

The review structure followed the Cochrane group's Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA). Using the Transfusion Evidence Library (transfusionevidencelibrary.com), the multidatabase (e.g. PubMed, EMBASE) Harvard On-Line Library Information System (HOLLIS), and GoogleScholar, we accessed many databases and gray literature sources. RCTs of PHT in the civilian setting with a comparison group receiving no blood products with 1-month mortality outcomes were identified.

RESULTS

In assessing a single patient-centered endpoint-1-month mortality-we calculated an overall risk ratio (RR) estimate. Analysis of three RCTs yielded a model with acceptable heterogeneity (I2 = 48%, Q-test p = 0.13). Pooled estimate revealed civilian PHT results in a statistically nonsignificant (p = 0.38) relative mortality reduction of 13% (RR 0.87, 95% CI 0.63-1.19).

CONCLUSIONS

Current evidence does not demonstrate 1-month mortality benefit of civilian-setting PHT. This should give pause to EMS systems considering adoption of civilian-setting PHT programs. Further studies should not only focus on which formulations of blood products might improve outcomes but also focus on which patients are most likely to benefit from any form of civilian-setting PHT.

Implementation of a prehospital whole blood program: Lessons learned

Early blood administration by Emergency Medical Services (EMS) to patients suffering from hemorrhagic shock improves outcomes. Prehospital blood programs represent an invaluable resuscitation capability that directly addresses hemorrhagic shock and mitigates subsequent multiple organ dysfunction syndrome. Prehospital blood programs must be thoughtfully planned, have multiple safeguards, ensure adequate training and credentialing processes, and be responsible stewards of blood resources. According to the 2022 best practices model by Yazer et al, the four key pillars of a successful prehospital program include the following: (1) the rationale for the use and a description of blood products that can be transfused in the prehospital setting, (2) storage of blood products outside the hospital blood bank and how to move them to the patient in the prehospital setting, (3) prehospital transfusion criteria and administration personnel, and (4) documentation of prehospital transfusion and handover to the hospital team.  This concepts paper describes our operational experience using these four pillars to make Maryland's inaugural prehospital ground-based low-titer O-positive whole blood program successful. These lessons learned may inform other EMS systems as they establish prehospital blood programs to help improve outcomes and enhance mass casualty response.

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

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.

Impact of Transfused Citrate on Pathophysiology in Massive Transfusion

This narrative review article seeks to highlight the effects of citrate on physiology during massive transfusion of the bleeding patient.

DATA SOURCES

A limited library of curated articles was created using search terms including "citrate intoxication," "citrate massive transfusion," "citrate pharmacokinetics," "hypocalcemia of trauma," "citrate phosphate dextrose," and "hypocalcemia in massive transfusion." Review articles, as well as prospective and retrospective studies were selected based on their relevance for inclusion in this review.

STUDY SELECTION

Given the limited number of relevant studies, studies were reviewed and included if they were written in English. This is not a systematic review nor a meta-analysis.

DATA EXTRACTION AND SYNTHESIS

As this is not a meta-analysis, new statistical analyses were not performed. Relevant data were summarized in the body of the text.

CONCLUSIONS

The physiologic effects of citrate independent of hypocalcemia are poorly understood. While a healthy individual can rapidly clear the citrate in a unit of blood (either through the citric acid cycle or direct excretion in urine), the physiology of hemorrhagic shock can lead to decreased clearance and prolonged circulation of citrate. The so-called "Diamond of Death" of bleeding-coagulopathy, acidemia, hypothermia, and hypocalcemia-has a dynamic interaction with citrate that can lead to a death spiral. Hypothermia and acidemia both decrease citrate clearance while circulating citrate decreases thrombin generation and platelet function, leading to ionized hypocalcemia, coagulopathy, and need for further transfusion resulting in a new citrate load. Whole blood transfusion typically requires lower volumes of transfused product than component therapy alone, resulting in a lower citrate burden. Efforts should be made to limit the amount of citrate infused into a patient in hemorrhagic shock while simultaneously addressing the induced hypocalcemia.