Prehospital blood transfusion for haemorrhagic shock

Abstract

We read with interest Nicholas Crombie and colleagues’ Article, 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 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 study 2 Shackelford SA del Junco DJ Powell-Dunford N et al. Association of prehospital blood product transfusion during medical evacuation of combat casualties in Afghanistan with acute and 30-day survival. JAMA. 2017; 318: 1581-1591 Crossref PubMed Scopus (219) Google Scholar 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. In addition to accounting for variations in the timing of treatment initiation, trials of resuscitative interventions for traumatic haemorrhage have been encouraged to consider potential time-limited effects on mortality. 3 Holcomb JB Moore EE Sperry JL et al. Evidence based and clinically relevant outcomes for hemorrhage control trauma trials. Ann Surg. 2021; 373: 395-401 Crossref Scopus (20) Google Scholar Despite the treatment delays, Crombie and colleagues reported a difference in 3-h mortality favouring PRBC–LyoPlas (–7%; p=0·08), although they did not report the corresponding difference for their primary (composite) outcome. 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 shock – Authors' replyWe thank Michael Cardinale, Deborah del Junco, John Simpson, and their colleagues for their interest in the RePHILL trial.1 We agree that there is variation in the characteristics of major trauma systems both within and between countries.2,3 The RePHILL trial occurred within the UK National Health Service major trauma system.1,4 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. 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