The use of massive transfusion protocol for trauma and non-trauma patients in a civilian setting: what can be done better?

Effective use of the hybrid emergency Department system in the treatment of non-traumatic critical care diseases

BACKGROUND

The hybrid emergency room (ER) system can provide resuscitation, computed tomography imaging, endovascular treatment, and emergency surgery, without transferring the patient. However, although several reports have demonstrated the effectiveness of the hybrid ER for trauma conditions, only a few case reports have demonstrated its usefulness for non-traumatic critical diseases. In this observational cohort study, we aimed to identify endogenous diseases that may benefit from treatment in the hybrid ER.

METHODS

We retrospectively reviewed the clinical characteristics of patients with non-traumatic conditions treated in a hybrid ER between August 2017 and July 2022 at our institution. Patients who underwent surgery, endoscopy, or interventional radiology (IR) in the hybrid ER were selected and pathophysiologically divided into a bleeding and non-bleeding group. The rate of shock or cardiac arrest, blood transfusion, and death within 24 h of admission or in-hospital death were compared among the groups using Fisher's exact test. Multivariable logistic regression analysis was performed to confirm the relationships among in-hospital mortality, transfusion, and hemorrhagic conditions in patients who underwent endoscopy and IR.

RESULTS

Among the 726 patients with non-traumatic conditions treated in a hybrid ER system, 50 (6.9%) experienced cardiac arrest at or before admission to the hybrid ER, 301 (41.5%) were in shock, 126 (17.4%) received blood transfusions, 42 (5.8%) died within 24 h of admission to the hybrid ER, and 141 (19.4%) died in the hospital. Emergency surgery was performed in 39 patients (7 in the bleeding group and 32 in the non-bleeding group). Significantly more blood transfusions were administered in the bleeding group (71.4% vs. 18.8%, P = 0.01); there were no significant differences in the rate of shock or cardiac arrest, death within 24 h, or in-hospital death between groups. Endoscopy was performed in 122 patients (80 in the bleeding group and 42 in the non-bleeding group). The bleeding group had a significantly higher rate of shock or cardiac arrest (87.5% vs. 66.7%, P = 0.008) and rate of blood transfusion (62.5% vs. 4.8%, P < 0.0001); there was no significant difference in death within 24 h and in-hospital death between groups. IR was performed in 100 patients (68 in the bleeding group and 32 in the non-bleeding group). Significantly more blood transfusions were administered in the hemorrhage group (67.7% vs. 12.5%, P < 0.0001); there was no difference in the rate of shock or cardiac arrest, death within 24 h, or in-hospital death between groups. Multivariable analysis in patients who underwent endoscopy showed a trend toward more in-hospital deaths in non-hemorrhagic conditions than in hemorrhagic conditions (odds ratio = 3.8, 95% confidence interval: 0.88-17, P = 0.073); however, no significant relationship with in-hospital death was observed for any of the adjusted variables.

CONCLUSION

Among endogenous diseases treated in the hybrid ER, there is a possible association between in-hospital mortality and hemorrhagic conditions. Future studies are needed to focus on diseases to demonstrate the effectiveness of the hybrid ER.

Blood Lost: A Retrospective Review of Blood Wastage from a Massive Transfusion Protocol in a Tertiary Paediatric Hospital

BACKGROUND

The paediatric massive transfusion protocol (MTP) is activated in the paediatric population for both trauma and non-trauma related indications. While it helps to improve the efficiency and efficacy of the delivery of blood products, it can also result in increased wastage. We aimed to evaluate the wastage rates from our paediatric MTP activations from 2013 to 2018.

METHOD

As part of an audit, we retrospectively reviewed the records of the paediatric patients who had MTP activations. We collected the following data: reason for MTP activation, weight of patient, number of cycles of MTP required, blood products used, blood products wasted, deviation from our institution's recommended MTP blood product ratio, and reason for wastage.

RESULT

We had 26 paediatric MTP activations within the audit period. There was an overall wastage rate of 1.5%, with wastage occurring in 3 out of 26 patients. The reason for all wastage was demise of the patient. Most patients' transfusion ratios deviated from our institution's MTP protocol.

CONCLUSION

Our wastage rates are low likely because of clear MTP activation guidelines and a flexible MTP workflow.

Acute Kidney Injury Risk in Patients Treated with Vancomycin Combined with Meropenem or Cefepime

Background: No previous studies have determined the incidence of acute kidney injury (AKI) in trauma patients treated with vancomycin + meropenem (VM) versus vancomycin + cefepime (VC). The purpose of this study was to fill this gap. Methods: A series of 99 patients admitted to an American College of Surgeons-verified level 1 trauma center over a two-year period who received VC or VM for >48 hours were reviewed retrospectively. Exclusion criteria were existing renal dysfunction or on renal replacement therapy. The primary outcome was AKI as defined by a rise in serum creatinine (SCr) to 1.5 times baseline. Multi-variable analysis was performed to control for factors associated with AKI (age, obesity, gender, length of stay [LOS], nephrotoxic agent(s), and baseline SCr), with significance defined as p < 0.05. Results: The study population was 50 ± 19 years old, 76% male, with a median LOS of 21 [range 15-39] days, and baseline SCr of 0.9 ± 0.2 mg/dL. Antibiotics, diabetes mellitus, and Injury Severity Score were independent predictors of AKI (odds ratio [OR] 4.4; 95% confidence interval [CI] 1.4-12; OR 9.3; 95% CI 1-27; OR 1.2; 95% CI 1.023-1.985, respectively). The incidence of AKI was higher with VM than VC (10/26 [38%] versus 14/73 [19.1%]; p = 0.049). Conclusions: The renal toxicity of vancomycin is potentiated by meropenem relative to cefepime in trauma patients. We recommend caution when initiating vancomycin combination therapy, particularly with meropenem.

Massive transfusion protocols in nontrauma patients: A systematic review and meta-analysis

BACKGROUND

Massive bleeding is a major cause of death both in trauma and nontrauma patients. In trauma patients, the implementation of massive transfusion protocols (MTP) led to improved outcomes. However, the majority of patients with massive bleeding are nontrauma patients.

OBJECTIVES

To assess if the implementation of MTP in nontrauma patients with massive bleeding leads to improved survival.

DATA SOURCES

National Library of Medicine's Medline database (PubMed).

STUDY ELIGIBILITY CRITERIA

Original research articles in English language investigating MTP in nontrauma patients.

PARTICIPANTS

Nontrauma patients with massive bleeding 18 years or older.

INTERVENTION

Transfusion according to MTP versus off-protocol.

STUDY APPRAISAL AND SYNTHESIS METHODS

Systematic literature review using PubMed. Outcomes assessed were mortality and transfused blood products. Studies that compared mortality of MTP and non-MTP groups were included in meta-analysis using Mantel-Haenszel random effect models.

RESULTS

A total of 252 abstracts were screened. Of these, 12 studies published 2007 to 2017 were found to be relevant to the topic, including 2,475 patients. All studies were retrospective and comprised different patient populations. Most frequent indications for massive transfusion were perioperative, obstetrical and gastrointestinal bleeding, as well as vascular emergencies. Four of the five studies that compared the number of transfused blood products in MTP and non-MTP groups revealed no significant difference. Meta-analysis revealed no significant effect of MTP on the 24-hour mortality (odds ratio 0.42; 95% confidence interval 0.01-16.62; p = 0.65) and a trend toward lower 1-month mortality (odds ratio 0.56; 95% confidence interval 0.30-1.07; p = 0.08).

LIMITATIONS

Heterogeneous patient populations and MTP in the studies included.

CONCLUSION

There is limited evidence that the implementation of MTP may be associated with decreased mortality in nontrauma patients. However, patient characteristics, as well as the indication and definition of MTP were highly heterogeneous in the available studies. Further prospective investigation into this topic is warranted.

LEVEL OF EVIDENCE

Systematic review and meta-analysis, level III.

RBC Transfusion Strategies in the ICU: A Concise Review

OBJECTIVES

To critically assess available high-level clinical studies regarding RBC transfusion strategies, with a focus on hemoglobin transfusion thresholds in the ICU.

DATA SOURCES

Source data were obtained from a PubMed literature review.

STUDY SELECTION

English language studies addressing RBC transfusions in the ICU with a focus on the most recent relevant studies.

DATA EXTRACTION

Relevant studies were reviewed and the following aspects of each study were identified, abstracted, and analyzed: study design, methods, results, and implications for critical care practice.

DATA SYNTHESIS

Approximately 30-50% of ICU patients receive a transfusion during their hospitalization with anemia being the indication for 75% of transfusions. A significant body of clinical research evidence supports using a restrictive transfusion strategy (e.g., hemoglobin threshold < 7 g/dL) compared with a more liberal approach (e.g., hemoglobin threshold < 10 g/dL). A restrictive strategy (hemoglobin < 7 g/dL) is recommended in patients with sepsis and gastrointestinal bleeds. A slightly higher restrictive threshold is recommended in cardiac surgery (hemoglobin < 7.5 g/dL) and stable cardiovascular disease (hemoglobin < 8 g/dL). Although restrictive strategies are generally supported in hematologic malignancies, acute neurologic injury, and burns, more definitive studies are needed, including acute coronary syndrome. Massive transfusion protocols are the mainstay of treatment for hemorrhagic shock; however, the exact RBC to fresh frozen plasma ratio is still unclear. There are also emerging complimentary practices including nontransfusion strategies to avoid and treat anemia and the reemergence of whole blood transfusion.

CONCLUSIONS

The current literature supports the use of restrictive transfusion strategies in the majority of critically ill populations. Continued studies of optimal transfusion strategies in various patient populations, coupled with the integration of novel complementary ICU practices, will continue to enhance our ability to treat critically ill patients.

Optimum Accuracy of Massive Transfusion Protocol Activation: The Clinician's View

Background

Massive transfusion protocols (MTP) aid in the efficient delivery of blood components to rapidly exsanguinating patients. Unfortunately, clinical gestalt and currently available clinical scoring systems lack the optimal accuracy to prevent blood product wastage (through over-activation), as well as individual patient morbidity and mortality (through under-activation). In order to help refine the MTP activation criteria and protocols, we surveyed clinicians on acceptable over- and under-activation rates for massive transfusions.

Methods

We surveyed Canadian content experts in their respective fields, using a snowball survey technique. Respondents were categorized into two groups: Group 1 was comprised of trauma and acute care specialists (TACS), while Group 2 was comprised of clinical and laboratory medicine specialists (CLMS). Between-group differences were examined using Fisher’s exact test and the likelihood ratio. Statistical significance was set at p < 0.05.

Results

We received responses from 35 clinicians in the TACS group and 10 clinicians in the CLMS group. About half (45.7%) of respondents in the TACS group considered an MTP overactivation rate of 5% - 10% acceptable (vs. 60% of the CLMS group; not significant (NS)). Approximately one-third (34.2%) of the respondents in the TACS group considered an MTP under-activation rate of less than 5% acceptable, whereas the majority (60%) of respondents in the CLMS group considered an under-activation rate of less than 5% acceptable (NS). A significantly greater proportion of respondents in the TACS group felt that an anticipated need for > 20 units of packed red blood cells within the next 24 hours was an acceptable criterion for MTP activation. Respondents in the CLMS group were more likely to consider “poor communication” as a reason for blood component wastage.

Conclusion

Similarities in acceptable MTP over- and under-activation rates were noted across specialties. Collaboration between involved parties is necessary for MTP protocol development to improve patient outcomes and reduce blood wastage.

Changes in plasma unit distributions to hospitals over a 10-year period

BACKGROUND

There are many influences on a hospital's demand for plasma. Pharmaceuticals are now being administered for many indications instead of plasma, although trauma resuscitation now emphasizes increased and early intervention with plasma. This multinational study evaluated changes in blood center plasma unit distributions over a 10-year period.

STUDY DESIGN AND METHODS

Data on the total number and the ABO groups of plasma unit distributions were obtained from nine American blood collectors (ABCs) and nine national or provincial blood services (NPBS) from 2007 through 2016. Plasma distributions to trauma hospitals by five ABCs and four NPBS were also analyzed.

RESULTS

The overall number of plasma unit distributions from ABCs decreased by 23.1% from 2007 to 2016, but the relative proportion of distributed AB plasma units increased during the same period. The NPBS (excluding the Japanese Red Cross [JRC]) also had a 35.4% decrease in the overall number of plasma unit distributions with an increase in the relative proportion of AB plasma distributions between 2007 and 2016. The JRC, however, reported an increase in the overall number of plasma distributions by 13.5% in 2016 compared to 2007. The proportion of low-titer A plasma distributions increased to 1.6% of total plasma distributions by ABCs in 2016. There was a trend of distributing increasing proportions of group AB plasma units to trauma hospitals over the 10-year period.

CONCLUSION

Although the number of plasma unit distributions has decreased at many blood collectors over time, the proportion of AB units has increased at both ABCs and NPBS.

Anesthesia and Perioperative Care in Reconstructive Transplantation

Reconstructive transplantation of vascularized composite allografts (VCAs), such as upper extremity, craniofacial, abdominal, lower extremity, or genitourinary transplants, has emerged as a cutting-edge specialty, with more than 50 programs in the United States and 30 programs across the world performing these procedures. Most VCAs involve complicated technical planning and preparation, protracted surgery, and complex immunosuppressive or immunomodulatory protocols, each associated with unique anesthesiology challenges. This article outlines key procedural, patient, and protocol-related aspects of VCA relevant to anesthesiology management with the goal of ensuring patient safety and optimizing surgical, immunologic, and functional outcomes.

[Efficacy of high versus low plasma: red blood cell ratio resuscitation in patients with severe trauma requiring massive blood transfusion: a meta-analysis]

OBJECTIVE

To evaluate the efficacy of high (≥1:2) and low (<1:2) plasma: red blood cell (RBC) ratio resuscitation in patients with severe trauma requiring massive blood transfusion.

METHODS

The databases including the Cochrane Library, Pubmed, Web of Science, and EMBASE were systemically searched for relevant studies published between January, 2009 and April, 2016. The selection of studies, assessment of methodological quality and data extraction were performed by two researchers independently according to the inclusion and exclusion criteria. The main endpoint was 24-h mortality, 30-day mortality and 24-h survival rate.

RESULTS

Five observational studies reporting outcomes of 1024 patients were included in this meta-analysis. Four studies documented civilian cases and one study had a military setting. No significant differences were found in the Injury Severity Score (ISS) between patient groups receiving high and low plasma: RBC ratio resuscitation. Compared with the low-ratio group, the patients with high-ratio resuscitation showed a significant reduction in the 24-h mortality rate (OR=0.35, 95%CI [0.25, 0.48], P<0.000 01) and the 30-day mortality rate (OR=0.55, 95%CI [0.41, 0.75], P=0.0001). An increased survival rate was observed in patients receiving high plasma: RBC ratio resuscitation within the initial 24 h following the trauma (HR=2.34, 95%CI [1.46, 3.73], P=0.00001).

CONCLUSION

Raising the plasma: RBC ratio to 0.5 or higher may decrease the mortality rate of the patients with severe trauma who need massive blood transfusion.