Prehospital blood transfusion for haemorrhagic shock – Authors' reply

Abstract

We thank Michael Cardinale, Deborah del Junco, John Simpson, and their colleagues for their interest in the RePHILL trial. 1 Crombie N Doughty HA Bishop JRB et al. Resuscitation with blood products in patients with trauma-related haemorrhagic shock receiving prehospital care (RePHILL): a multicentre, open-label, randomised, controlled, phase 3 trial. Lancet Haematol. 2022; 9: 250-261 Summary Full Text Full Text PDF PubMed Scopus (17) Google Scholar We agree that there is variation in the characteristics of major trauma systems both within and between countries. 2 Sall L Hayward RD Fessler MM Edhayan E Between-hospital and between-neighbourhood variance in trauma outcomes: cross-sectional observational evidence from the Detroit metropolitan area. BMJ Open. 2018; 8e022090 Crossref Scopus (6) Google Scholar , 3 Miclau T Understanding trauma systems—a global need. OTA Int. 2019; 2: e010 Google Scholar The RePHILL trial occurred within the UK National Health Service major trauma system. 1 Crombie N Doughty HA Bishop JRB et al. Resuscitation with blood products in patients with trauma-related haemorrhagic shock receiving prehospital care (RePHILL): a multicentre, open-label, randomised, controlled, phase 3 trial. Lancet Haematol. 2022; 9: 250-261 Summary Full Text Full Text PDF PubMed Scopus (17) Google Scholar , 4 Smith IM Crombie N Bishop JR et al. RePHILL: protocol for a randomised controlled trial of pre-hospital blood product resuscitation for trauma. Transfus Med. 2018; 28: 346-356 Crossref PubMed Scopus (24) Google Scholar A paramedic-led ambulance resource typically arrives on scene within 10 min of an emergency call, with the prehospital critical care team usually arriving as a secondary response. In the RePHILL trial, 1 Crombie N Doughty HA Bishop JRB et al. Resuscitation with blood products in patients with trauma-related haemorrhagic shock receiving prehospital care (RePHILL): a multicentre, open-label, randomised, controlled, phase 3 trial. Lancet Haematol. 2022; 9: 250-261 Summary Full Text Full Text PDF PubMed Scopus (17) Google Scholar on average the prehospital critical care team arrived after a median of 26 min (IQR 19–37), compared with a median of 20 min (IQR 7–45) seen in the US-based PAMPer and COMBAT trials. 5 Pusateri AE Moore EE Moore HB et al. Association of prehospital plasma transfusion with survival in trauma patients with hemorrhagic shock when transport times are longer than 20 minutes: a post hoc analysis of the PAMPer and COMBAT clinical trials. JAMA Surg. 2020; 155e195085 Crossref PubMed Scopus (91) Google Scholar The time from the emergency call to arrival at the emergency department was also longer in the RePHILL trial (median 83 min [IQR 65–101] vs 59 min [IQR 27–97]). There were also differences in patient mix, with RePHILL having a lower proportion of patients with gunshot injuries than the PAMPer and COMBAT trials (2% vs 12%). The median injury severity scores were also higher in the RePHILL trial (36 [IQR 25–50 vs 22 [IQR 12–34]). Post-hoc analysis of the RePHILL trial found some evidence of an effect on episode mortality of time to treatment (p=0·01), but this did not seem to differ by treatment group (p=0·47 for the interaction term between episode mortality and time to treatment (appendix). 1 Crombie N Doughty HA Bishop JRB et al. Resuscitation with blood products in patients with trauma-related haemorrhagic shock receiving prehospital care (RePHILL): a multicentre, open-label, randomised, controlled, phase 3 trial. Lancet Haematol. 2022; 9: 250-261 Summary Full Text Full Text PDF PubMed Scopus (17) Google Scholar Prehospital blood transfusion for haemorrhagic shockWe read with great interest the phase 3 RePHILL trial,1 in which Nicholas Crombie and colleagues sought to evaluate the superiority of packed red blood cell (PRBC) and lyophilised plasma (LyoPlas) transfusion compared with 0·9% sodium chloride, using a composite endpoint of lactate clearance, or death, or both. This study failed to show the superiority of the early transfusion strategy, which in our opinion can be explained by several elements. Full-Text PDF Prehospital blood transfusion for haemorrhagic shockWe read with interest Nicholas Crombie and colleagues’ Article,1 which concluded that lyophilised plasma (LyoPlas) was not superior to 0·9% sodium chloride in the prehospital resuscitation of traumatic haemorrhage. However, we note that on average, trial treatments were initiated more than 56 min after the call to the emergency services. The mean time from injury to emergency call was not reported. In a study2 of 386 US military combat casualties with indications for prehospital transfusion, only blood products initiated within a median of 36 min after injury were associated with significant reductions in mortality. Full-Text PDF Prehospital blood transfusion for haemorrhagic shockIn a multicentre, randomised controlled trial, Nicholas Crombie and colleagues1 reported that prehospital use of packed red blood cells (PRBC) and lyophilised plasma (LyoPlas) transfusion was not superior to resuscitation with 0·9% sodium chloride alone for adult patients with haemorrhagic shock. The authors found no significant differences between groups in outcomes, which included mortality and impaired lactate clearance, and concluded that prehospital blood product transfusion did not reduce mortality for trauma-related haemorrhagic shock compared with sodium chloride. Full-Text PDF Resuscitation with blood products in patients with trauma-related haemorrhagic shock receiving prehospital care (RePHILL): a multicentre, open-label, randomised, controlled, phase 3 trialThe trial did not show that prehospital PRBC–LyoPlas resuscitation was superior to 0·9% sodium chloride for adult patients with trauma related haemorrhagic shock. Further research is required to identify the characteristics of patients who might benefit from prehospital transfusion and to identify the optimal outcomes for transfusion trials in major trauma. The decision to commit to routine prehospital transfusion will require careful consideration by all stakeholders. Full-Text PDF Open Access