Joint Trauma System Clinical Practice Guideline (JTS CPG): Prehospital Blood Transfusion. 30 October 2020

What's new in whole blood resuscitation? In the trauma bay and beyond

PURPOSE OF REVIEW

Transfusion therapy commonly supports patient care during life-threatening injury and critical illness. Herein we examine the recent resurgence of whole blood (WB) resuscitation for patients in hemorrhagic shock following trauma and other causes of severe bleeding.

RECENT FINDINGS

A growing body of literature supports the use of various forms of WB for hemostatic resuscitation in military and civilian trauma practice. Different types of WB include warm fresh whole blood (FWB) principally used in the military and low titer O cold stored whole blood (LTOWB) used in a variety of military and civilian settings. Incorporating WB initial resuscitation alongside subsequent component therapy reduces aggregate blood product utilization and improves early mortality without adversely impacting intensive care unit length of stay or infection rate. Applications outside the trauma bay include prehospital WB and use in patients with nontraumatic hemorrhagic shock.

SUMMARY

Whole blood may be transfused as FWB or LTOWB to support a hemostatic approach to hemorrhagic shock management. Although the bulk of WB resuscitation literature has appropriately focused on hemorrhagic shock following injury, extension to other etiologies of severe hemorrhage will benefit from focused inquiry to address cost, efficacy, approach, and patient-centered outcomes.

Frequency of deployed emergency donor panel use prior to implementation of the low titre group O whole blood program

INTRODUCTION

The US military has frequently used a 'walking blood bank', formally known as an 'emergency donor panel' (EDP) to obtain warm fresh whole blood (WFWB) which is then immediately transfused into the casualty. We describe the frequency of EDP activation by the US military.

METHODS

We analysed data from 2007 to 2015 within the Department of Defense Trauma Registry for US, Coalition and US contractor casualties that received at least 1 unit of blood product within the first 24 hours and described the frequency of WFWB use.

RESULTS

There were 3474 casualties that met inclusion, of which, 290 casualties (8%) required activation of the EDP. The highest proportion of EDP events was in 2014, whereas the highest number of EDP events was in 2011. Median injury severity scores were higher in the recipients, compared with non-EDP recipients (29 vs 20), as were proportions with serious injuries to the abdomen (43% vs 19%) and extremities (77% vs 65%). The median number of units of all blood products, except for packed red blood cells, was higher for WFWB recipients. Of the WFWB recipients, the median was 5 units (IQR 2-10) with a maximum documented 144 units. There were four documented cases of EDP recipients receiving >100 units of WFWB with only one surviving to hospital discharge. During the study period, there were a total of 3102 (3%) units of WFWB transfused among a total of 104 288 total units.

CONCLUSIONS

We found nearly 1 in 11 casualties who received blood required activation of the EDP. Blood from the EDP accounted for 3% of all units transfused. These findings will enable future mission planning and medical training, especially for units with smaller, limited blood supplies. The lessons learned here can also enable mass casualty planning in civilian settings.

Preferential whole blood transfusion during the early resuscitation period is associated with decreased mortality and transfusion requirements in traumatically injured patients

Introduction

Whole blood (WB) transfusion represents a promising resuscitation strategy for trauma patients. However, a paucity of data surrounding the optimal incorporation of WB into resuscitation strategies persists. We hypothesized that traumatically injured patients who received a greater proportion of WB compared with blood product components during their resuscitative efforts would have improved early mortality outcomes and decreased transfusion requirements compared with those who received a greater proportion of blood product components.

Methods

Retrospective review from our Level 1 trauma center of trauma patients during their initial resuscitation (2019-2022) was performed. WB to packed red blood cell ratios (WB:RBC) were assigned to patients based on their respective blood product resuscitation at 1, 2, 3, and 24 hours from presentation. Multivariable regression models were constructed to assess the relationship of WB:RBC to 4 and 24-hour mortality, and 24-hour transfusion requirements.

Results

390 patients were evaluated (79% male, median age of 33 years old, 48% penetrating injury rate, and a median Injury Severity Score of 27). Overall mortality at 4 hours was 9%, while 24-hour mortality was 12%. A significantly decreased 4-hour mortality was demonstrated in patients who displayed a WB:RBC≥1 at 1 hour (5.9% vs. 12.3%; OR 0.17, p=0.015), 2 hours (5.5% vs. 13%; OR 0.16, p=0.019), and 3 hours (5.5% vs. 13%, OR 0.18, p<0.01), while a decreased 24-hour mortality was displayed in those with a WB:RBC≥1 at 24 hours (7.9% vs. 14.6%, OR 0.21, p=0.01). Overall 24-hour transfusion requirements were significantly decreased within the WB:RBC≥1 cohort (12.1 units vs. 24.4 units, p<0.01).

Conclusion

Preferential WB transfusion compared with a balanced transfusion strategy during the early resuscitative period was associated with a lower 4 and 24-hour mortality, as well as decreased 24-hour transfusion requirements, in trauma patients. Future prospective studies are warranted to determine the optimal use of WB in trauma.

Level of evidence

Level III/therapeutic.

Military Blood Supply and Distribution in USCENTCOM

In expeditionary environments, the consistent availability of blood for casualty care is imperative yet challenging. Responding to evidence and the specific needs of its expeditionary context, the US Central Command (USCENTCOM) prioritized supplying stored low titer O whole blood (LTOWB) to its units from March, 2023 onward. A strategy was devised to set minimal LTOWB on-hand supply benchmarks, determined by the number of operating beds and point of injury teams. This transition led to a 54% reduction in orders for packed red blood cells. As a countermove, the Armed Services Blood Program (ASBP) enhanced LTOWB production at a conversion rate 2:1 from packed red blood cell to LTOWB. Consequently, there was a decline in expired blood products, and fulfillment rates for blood requests are projected to reach 100% consistently. This paper delves into the intricacies of the expeditionary blood supply, the rationale behind the LTOWB transition, the devised allocation strategy, and the subsequent impacts of this change.

AI algorithm for personalized resource allocation and treatment of hemorrhage casualties

A deep neural network-based artificial intelligence (AI) model was assessed for its utility in predicting vital signs of hemorrhage patients and optimizing the management of fluid resuscitation in mass casualties. With the use of a cardio-respiratory computational model to generate synthetic data of hemorrhage casualties, an application was created where a limited data stream (the initial 10 min of vital-sign monitoring) could be used to predict the outcomes of different fluid resuscitation allocations 60 min into the future. The predicted outcomes were then used to select the optimal resuscitation allocation for various simulated mass-casualty scenarios. This allowed the assessment of the potential benefits of using an allocation method based on personalized predictions of future vital signs versus a static population-based method that only uses currently available vital-sign information. The theoretical benefits of this approach included up to 46% additional casualties restored to healthy vital signs and a 119% increase in fluid-utilization efficiency. Although the study is not immune from limitations associated with synthetic data under specific assumptions, the work demonstrated the potential for incorporating neural network-based AI technologies in hemorrhage detection and treatment. The simulated injury and treatment scenarios used delineated possible benefits and opportunities available for using AI in pre-hospital trauma care. The greatest benefit of this technology lies in its ability to provide personalized interventions that optimize clinical outcomes under resource-limited conditions, such as in civilian or military mass-casualty events, involving moderate and severe hemorrhage.

Training of medical students in the use of emergency whole blood collection and transfusion in the framework of a civilian walking blood

INTRODUCTION

In this report, we describe a training program in emergency whole blood collection and transfusion for medical students at the University of Bergen. The overall aim of the program is to improve the availability of early balanced blood transfusion for the treatment of patients with life-threatening bleeding in rural health care services.

STUDY DESIGN AND METHODS

The voluntary training program provides the knowledge needed to practice emergency whole blood transfusions and understand the system for emergency whole blood collection in the framework of a civilian walking blood bank (WBB). It includes theoretical and practical sessions. In-person teaching and web-based learning resources are provided. An anonymous survey of the students attending the training course in the autumn of 2022 and spring 2023 was performed.

RESULTS

128 of 178 students participated in the practical training. 88 of 128 (69%) responded to the survey. 82 (93%) performed blood typing, 71 (81%) performed donor interviews, 61 (69%) partially performed whole blood collection (up to blood in bag) and 27 (30%) participated in complete whole blood collection and performed autologous reinfusion. No complications occurred during training. The students reported that the training course increased their understanding of how to ensure access to emergency blood transfusion by the use of a WBB.

DISCUSSION

Structured theoretical and practical training in emergency whole blood collection and emergency transfusion is feasible and of interest to medical students. A multidisciplinary approach to student training in emergency whole blood collection and transfusion should be considered.

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

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.

Multicentre observational study on practice of prehospital management of hypotensive trauma patients: the SPITFIRE study protocol

INTRODUCTION

Major haemorrhage after injury is the leading cause of preventable death for trauma patients. Recent advancements in trauma care suggest damage control resuscitation (DCR) should start in the prehospital phase following major trauma. In Italy, Helicopter Emergency Medical Services (HEMS) assist the most complex injuries and deliver the most advanced interventions including DCR. The effect size of DCR delivered prehospitally on survival remains however unclear.

METHODS AND ANALYSIS

This is an investigator-initiated, large, national, prospective, observational cohort study aiming to recruit >500 patients in haemorrhagic shock after major trauma. We aim at describing the current practice of hypotensive trauma management as well as propose the creation of a national registry of patients with haemorrhagic shock.

PRIMARY OBJECTIVE

the exploration of the effect size of the variation in clinical practice on the mortality of hypotensive trauma patients. The primary outcome measure will be 24 hours, 7-day and 30-day mortality. Secondary outcomes include: association of prehospital factors and survival from injury to hospital admission, hospital length of stay, prehospital and in-hospital complications, hospital outcomes; use of prehospital ultrasound; association of prehospital factors and volume of first 24-hours blood product administration and evaluation of the prevalence of use, appropriateness, haemodynamic, metabolic and effects on mortality of prehospital blood transfusions.

INCLUSION CRITERIA

age >18 years, traumatic injury attended by a HEMS team including a physician, a systolic blood pressure <90 mm Hg or weak/absent radial pulse and a confirmed or clinically likely diagnosis of major haemorrhage. Prehospital and in-hospital variables will be collected to include key times, clinical findings, examinations and interventions. Patients will be followed-up until day 30 from admission. The Glasgow Outcome Scale Extended will be collected at 30 days from admission.

ETHICS AND DISSEMINATION

The study has been approved by the Ethics committee 'Comitato Etico di Area Vasta Emilia Centro'. Data will be disseminated to the scientific community by abstracts submitted to international conferences and by original articles submitted to peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT04760977.