Large Transfusion Research Articles

Hypocalcemia in trauma patients: A narrative review

Hypothermia, acidosis, and coagulopathy together make up the trauma triad of death, which has been acknowledged as a key factor in the demise of trauma patients. Hypocalcemia has recently been added as the fourth element of the "diamond of death" in trauma. However, the effects of hypocalcemia in trauma patients have received insufficient attention from systematic reviews. The primary focus of this review will be the impact of hypocalcemia on the mortality rates among trauma victims. Regardless of a large transfusion, hypocalcemia can occur in trauma patients; this condition is known as "trauma-induced hypocalcemia". Hypocalcemia driven by trauma is multifaceted and linked to the fatal triad, which may worsen or even result in death. Our review showed an association between hypocalcemia and increased mortality. Recent data have introduced hypocalcemia integrated with the trauma lethal triad for predicting the prognosis and mortality of critically traumatized patients. However, the benefit of prophylactic calcium supplementation requires further study to support it.

Exploring the potential harm of varied blood storage on patients undergoing cardiovascular surgery.

Debate exists surrounding the optimal duration of red blood cell (RBC) storage. A hypothesis emerging from previous research suggests that exposure to fresh blood may be harmful to patients undergoing cardiac surgery. This study uses a large transfusion medicine database to explore the association between in-hospital mortality and red cell storage duration. This is an exploratory retrospective cohort study of all adult patients at Hamilton, Canada, over a 14-year period that received at least one allogeneic red cell transfusion during their hospitalization for cardiac surgery requiring bypass. The primary outcome for the study was in-hospital death. Analysis was performed using multivariate Cox regression modelling with time-dependent and time-independent covariates and stratification variables. Five models with varying definitions for short, intermediate and prolonged duration of RBC storage were tested. From March 2004 to December 2017, 11,205 patients met the inclusion criteria and were included in the regression analyses. No significant effect of short-duration red storage on patient mortality was observed in all statistical models, with the red cells stored for the longest duration as the reference group. When patients who received exclusively fresh (hazard ratio [HR] 1.040, 95% confidence interval [CI] 0.588-1.841, p-value = 0.893) and older aged (HR 1.038, 95% CI 0.769-1.1.402, p-value = 0.0801) RBCs were compared with those who received exclusively mid-age red cells as the reference, statistical significance was similarly not reached. Red cells stored for the shortest duration are not associated with increased risk of mortality among cardiac surgery patients.

Total Hip Arthroplasty in Patients with Idiopathic Thrombocytopenic Purpura

Background. There are no national clinical guidelines for the perioperative management of patients with idiopathic thrombocytopenia in hip arthroplasty. Most of the publications are presented in the context of general surgery, the distinguishing feature of which is the good achievement of hemostasis. However, it is impossible to achieve such a level of hemostasis with hip arthroplasty.
 The aim of the study was to evaluate the mid-term results of total hip arthroplasty in patients with primary idiopathic thrombocytopenia.
 Methods. Randomized monocenter clinical trial of 38 patients with idiopathic thrombocytopenia hip arthroplasty was performed. These patients was include in group I. As a control group, the outcomes of surgical treatment of 40 patients without thrombocytopenia over the same observation period were analyzed (group II). The mean follow-up period was 4.3 years. Exclusion criteria for the study were heparin-induced thrombocytopenia, a severe form of idiopathic thrombocytopenia in the acute stage with platelet counts less than 25109/L.
 Results. The average length of hospitalization was longer in patients with idiopathic thrombocytopenia (11.1 days). The results indicate a longer preoperative preparation, including the transfusion of hemocomponents with repeated monitoring of the parameters of the clinical blood test and coagulogram. There was no significant difference in the duration of the surgical intervention, but there were differences in the amount of intraoperative blood loss and the volume of blood transfusion. Among the patients of the group II, only 3 patients required intraoperative transfusion of one dose of erythrocyte suspension, patients of the group I more often underwent blood transfusion. In the group I, complications were noted in 5 patients, in the group II in one patient (p = 0.067), but the relative risk of complications was 5.2. Functional results 12 months after surgery didnt differ.
 Conclusions. The mid-term results of hip arthroplasty in patients with idiopathic thrombocytopenia are comparable to the results in patients of the general population. A distinctive feature of surgical intervention is an increase in the average volume of intraoperative blood loss and the need for a significantly larger transfusion of hemocomponents not only during the operation, but also in the preoperative period, which increases the duration of hospitalization.

Predictive modeling to create a proactive approach to patient blood management in the oncology population.

332 Background: Patient safety concerns that arose during COVID-19, related to blood shortages at a large oncological transfusion center, foregrounded the need for predictive modeling tools to optimize blood product inventory control. A maximum surgical blood ordering schedule (MSBOS), is a tool used to assist clinicians in predicting intraoperative blood usage based on retrospective historical data within an institution. Although MSBOS proves to be valuable, it is rudimentary in nature. Not only is data collection cumbersome but the data generated may not reflect current surgical practices and inter-patient variability may skew procedural averages. Predictive blood modeling is contingent generation of a digital health dashboard (DHB). DHB are electronically embedded in the electronic health record (EHR) to collect perioperative data. Coupling the generated informatics (patient demographics, diagnosis, laboratory results, procedural type, medications/supplements, surgeon) with machine learning allows for creation of patient-centered predictive blood modeling algorithms and better inventory control. Methods: To characterize blood use across various procedures at our institution, we engaged information technology specialists to create a Web Intelligence report by integrating data from both an EHR and a lab information system (LIS) into a single repository. Information obtained illuminated a master procedure list, blood product usage patterns, and characterized patient demographics during January - March, 2020. Data is continuously extracted to create a perpetually updated MSBOS while secondarily functioning to cultivate data for future predictive machine learning algorithms. Results: Data analysis demonstrated 5598 procedures were performed during the first quarter of 2020. Procedures not transfused with packed red blood cells (pRBCs) totaled to 4,156 and 1,442 had a greater than or equal to 10% probability of requiring pRBCs. Our current practices reflected our overall crossmatch to transfusion ratio ( C:T) was 5.4 to 1. Concerted collaboration, resulting in preparation of pre-surgical blood product orders according laboratory generated MSBOS schedule could decrease the C:T to 1.7 to 1. Additionally, high intraprocedural pRBCs variability was identified in current procedural subtypes. Conclusions: Traditionally generated MSBOS are functionally limited and may not be reflective of current surgical practices. Additionally, inter-patient variability may distort some procedural type guidance. Creating an integrated data report, eliminates some of the inherent limitations of traditional MSBOS. Moving forward, the cultivated data if coupled with machine learning has the potential to create transferable proprietary algorithms that proactively predict individual patient transfusion needs.

Place of birth and outcomes associated with large volume transfusion: an observational study

BackgroundGuidelines recommend that women at high risk of postpartum haemorrhage deliver at facilities able to handle heavy bleeding. However postpartum haemorrhage is often unexpected. This study aims to compare outcomes and health service use related to transfusion of ≥4 units of red blood cells between women delivering in tertiary and lower level hospitals.MethodsThe study population was women giving birth in public hospitals in New South Wales, Australia, between July 2006 and December 2010. Data were obtained from linked hospital, birth and blood bank databases. The exposure of interest was transfusion of four or more units of red cells during admission for delivery. Outcomes included maternal morbidity, length of stay, neonatal morbidity and need for other blood products or transfer to higher care. Multivariable regression models were developed to predict need of transfusion of ≥4 units of red cells using variables known early in pregnancy and those known by the birth admission.ResultsData were available for 231,603 births, of which 4309 involved a blood transfusion, with 1011 (0.4%) receiving 4 or more units. Women giving birth in lower level and/or smaller hospitals were more likely to receive ≥4 units of red cells. Women receiving ≥4 units in tertiary settings were more likely to receive other blood products and have longer hospital stays, but morbidity, readmission and hysterectomy rates were similar.Although 46% of women had no identifiable risk factors early in pregnancy, 20% of transfusions of ≥4 units occurred within this group. By the birth admission 70% of women had at least one risk factor for requiring ≥4 units of red cells.ConclusionsOverall outcomes for women receiving ≥4 units of red cells were comparable between tertiary and non-tertiary facilities. This is important given the inability of known risk factors to predict many instances of postpartum haemorrhage.

Prediction Of Transfusion Based On Machine Learning

The capacity to anticipate transfusions during a hospital stay may allow for more efficient blood supply management, as well as increased patient safety by assuring a sufficient supply of red blood cells (RBCs) for a specific patient. As a result, we tested the accuracy of four machine learning–based prediction algorithms for predicting transfusion, large transfusion, and the number of transfusions in hospitalized patients. Between January 2008 and June 2017, researchers conducted a retrospective observational study at three adult tertiary care institutions in Western Australia. The area under the curve for the receiver operating characteristics curve, the F1 score, and the average precision of the four machine learning algorithms used: artificial neural networks (NNs), logistic regression (LR), random forests (RFs), and gradient boosting (GB) trees were the primary outcome measures for the classification tasks. Transfusion of at least 1 unit of RBCs could be predicted quite correctly using our four prediction models (sensitivity for NN, LR, RF, and GB: 0.898, 0.894, 0.584, and 0.872, respectively; specificity: 0.958, 0.966, 0.964, 0.965). The four approaches were less successful in predicting large transfusion (sensitivity: 0.780, 0.721, 0.002, and 0.797 for ANN, LR, RF, and GB, respectively; specificity: 0.994, 0.995, 0.993, 0.995). As a result, the total number of packed RBCs transfused was likewise very inaccurately predicted. This study shows that the need for intra-hospital transfusion can be predicted with reasonable accuracy, but the number of RBC units transfused throughout a hospital stay is more difficult to predict.

Hemodynamics of different volumes of red blood cell transfusion in preterm infants.

Although many controversies exist regarding the risk of red blood cell (RBC) transfusions, half of preterm infants born at <32weeks of gestational age receive such transfusions because of anemia of prematurity. Because of the costs and risks associated with multiple transfusions, it has been suggested that a large transfusion volume reduces the number of transfusions. However, there have been persistent concerns that RBC transfusion might lead to volume overload. We examined the impacts of large (20mL/kg) compared to standard volume (15mL/kg) transfusions on the hemodynamic variables of stable, electively transfused, preterm infants, by serially measuring echocardiographic parameters and plasma B-type natriuretic peptide levels. A total of 39 infants born at <34weeks of gestation and aged >2weeks at the time of enrollment were randomly allocated to either a standard volume (15mL/kg) or a large volume (20mL/kg) group. Significant reductions in cardiac output and transient increases in plasma B-type natriuretic peptide levels were found after RBC transfusion in both the standard and large volume (20mL/kg) groups. However, these changes were not significantly different between the two groups. Large-volume transfusions could be tolerable in stable preterm infants with anemia.

Changes in the Coagulation Mechanism Following Wounding and Resuscitation with Stored Blood: A Study of Battle Casualties in Korea

1. The coagulation system was studied in eleven battle casualties immediately after they had been wounded and resuscitated and during the first days of their convalescence. 2. In general the clotting time was shorter than normal and the platelet count and fibrinogen concentration were greater than normal. Prothrombin activity as measured by the one-stage test averaged 50 per cent of normal immediately after resuscitation with large transfusions of stored blood. This defect corrected itself within one to three days, but about the fourth day prothrombin activity again was reduced to about 50 per cent of normal and thereafter recovered gradually. 3. The primary fall of prothrombin activity was not proved to be caused by a lack of prothrombin but appeared in some cases to be related to a lack of labile factor which may have been a consequence of large transfusions of stored blood deficient in the labile factor. The prothrombin time was not always corrected by addition of labile factor. The defect of the coagulation mechanism was never great enough to cause serious hemorrhage. A tendency to ooze was noted in patients who had received over 20 pints of blood in a short time. It is suggested that this may have been due to the presence of a great number of immature platelets in the circulation. No fibrinolytic reactions were observed. 4. The secondary fall of prothrombin activity was not due to the lack of prothrombin. The defect of the coagulation mechanism could be corrected by the addition of heated serum that was free of prothrombin, thrombin, labile factor, stable factor, and thromboplastic activity. The factor responsible for the correction of the coagulation defect was heat stable (56 C. for 30 minutes in the presence of oxalate) and was not absorbed by tricalcium phosphate gel. Of the known factors involved in the coagulation system, these two characteristics eliminate all except the platelet factor 3. This fall in prothrombin activity was not associated with any clinical hemorrhagic tendency.

Predicting Estimated Blood Loss and Transfusions in Gynecologic Surgery Using Artificial Neural Networks

This chapter explores valuating the efficacy of using artificial neural networks (ANNs) for predicting the estimated blood loss (EBL) and also transfusion requirements of myomectomy patients. All 146 myomectomy surgeries performed over a 6-year period from a single site are captured. Records were removed for various reasons, leaving 96 cases. Backpropagation and radial basis function ANN models were developed to predict EBL and perioperative transfusion needs along with a regression model. The single hidden layer backpropagation ANN models performed the best for both prediction problems. EBL was predicted on average within 127.33 ml of measured blood loss, and transfusions were predicted with 71.4% sensitivity and 85.4% specificity. A combined ANN ensemble model using the output of the EBL ANN as an input variable to the transfusion prediction ANN was developed and resulted in 100% sensitivity and 62.9% specificity. The preoperative identification of large EBL or transfusion need can assist caregivers in better planning for possible post-operative morbidity and mortality.

Mitigation strategies for anti-D alloimmunization by platelet transfusion in haematopoietic stem cell transplant patients: a survey of NCCN® centres.

D-negative patients are at risk of developing an alloantibody to D (anti-D) if exposed to D during transfusion. The presence of anti-D can lead to haemolytic transfusion reactions and haemolytic disease of the newborn. Anti-D alloimmunization can also complicate allogeneic haematopoietic stem cell transplantation (HSCT) with haemolysis and increased transfusion requirements. The goal of this study was to determine whether cancer centres have transfusion practices intended to prevent anti-D alloimmunization with special attention in patients considered for HSCT. To understand transfusion practices regarding D-positive platelets in D-negative patients with large transfusion needs, we surveyed the 28 cancer centres that are members of the National Comprehensive Cancer Network® (NCCN® ). Nineteen centres responded (68%). Most centres (79%) avoid transfusing D-positive platelets to RhD-negative patients when possible. Four centres (21%) avoid D-positive platelets only in D-negative women of childbearing age. If a D-negative patient receives a D-positive platelet transfusion, 53% of centres would consider treating with Rh immune globulin (RhIg) to prevent alloimmunization in women of childbearing age. Only one centre also gives RhIg to all D-negative patients who are HSCT candidates including adult men and women of no childbearing age. There is wide variation in platelet transfusion practices for supporting D-negative patients. The majority of centres do not have D-positive platelet transfusion policies focused on preventing anti-D alloimmunization specifically in patients undergoing HSCT. Multicentre, longitudinal studies are needed to understand the clinical implications of anti-D alloimmunization in HSCT patients.

Analysis on Factors Influencing Posttransfusion Effectiveness in Plasma Transfusion of 4423 Cases-Times

To investigate the related factors influencing plasma transfusion efficacy so as to improve the plasma transfusion efficiency. According to the clinical symptoms and the laboratorial results, the patients were divided into transfusion efficient and inefficient groups. A total of13090.8 units of plasma were transfused to 4423 patients. The clinical symptoms and the hemorrhage related index per- and pro-transfusion, plasma components sorts, storage time, and the dose of plasma (kg/ml) transfusion were analyzed. The largest transfusion volume of plasma were in intensive care unit (ICU) accounted for 30.36%, the largest blood plasma per patient transfusion was in cardiac surgery (3.96 U). The analysis of transfusion efficiency showed that in terms of patient age, there were difference in transfusion efficiency among the patients with different ages (P＜0.001). The effective transfusion rate in the group of age ＜18 was 53%, which was higher than that in group of age 18-60(41%) and group of age ＞60 (30%); in terms of sex, the effective transfusion rate in female group was higher than that in male group (42% vs 37%) (P＜0.001); in terms of transfusion plasma volume/body weight, there were differences in transfusion efficiency (P＞0.05). The multi-factor logistic regression analysis showed that there was no significant correlation among the plasma sorts, storage time of the plasma pre-transfusion and transfusion efficiency(P＞0.05). The analysis of the non-hemolytic fever reaction caused by plasma transfusion revealed that there was no statistical difference between the plasma and the leukocyte-depleted plasma groups (P＞0.05). The plasma transfusion effectiveness relates with age and sex, but not relates with the transfusion plasma voume/body weight, plasma sorts, and the duration of storage.

Placenta accreta and uterine rupture of unscarred uterus in patients with systemic lupus erythematosus with prolonged steroid exposure: a report of two cases

We experienced two cases of placental abnormalities or uterine rupture in patients with systemic lupus erythematosus (SLE), necessitating cesarean hysterectomy and leading to massive hemorrhage that required large transfusions. So we introduced the possibility of abnormal placentation and uterine rupture as well as preeclampsia, preterm labor, and fetal growth restriction needs to be considered in pregnant women with SLE who have been taking steroids, even if low dose, for prolonged periods and who do not have any other risk factors.

Point-of-care versus central testing of hemoglobin during large volume blood transfusion

BackgroundPoint-of-care (POC) hemoglobin testing has the potential to revolutionize massive transfusion strategies. No prior studies have compared POC and central laboratory testing of hemoglobin in patients undergoing massive transfusions.MethodsWe retrospectively compared the results of our point-of-care hemoglobin test (EPOC®) to our core laboratory complete blood count (CBC) hemoglobin test (Sysmex XE-5000™) in patients undergoing massive transfusion protocols (MTP) for hemorrhage. One hundred seventy paired samples from 90 patients for whom MTP was activated were collected at a single, tertiary care hospital between 10/2011 and 10/2017. Patients had both an EPOC® and CBC hemoglobin performed within 30 min of each other during the MTP. We assessed the accuracy of EPOC® hemoglobin testing using two variables: interchangeability and clinically significant differences from the CBC. The Clinical Laboratory Improvement Amendments (CLIA) proficiency testing criteria defined interchangeability for measurements. Clinically significant differences between the tests were defined by an expert panel. We examined whether these relationships changed as a function of the hemoglobin measured by the EPOC® and specific patient characteristics.ResultsFifty one percent (86 of 170) of paired samples’ hemoglobin results had an absolute difference of ≤7 and 73% (124 of 170) fell within ±1 g/dL of each other. The mean difference between EPOC® and CBC hemoglobin had a bias of − 0.268 g/dL (p = 0.002). When the EPOC® hemoglobin was < 7 g/dL, 30% of the hemoglobin values were within ±7, and 57% were within ±1 g/dL. When the measured EPOC® hemoglobin was ≥7 g/dL, 55% of the EPOC® and CBC hemoglobin values were within ±7, and 76% were within ±1 g/dL. EPOC® and CBC hemoglobin values that were within ±1 g/dL varied by patient population: 77% for cardiac surgery, 58% for general surgery, and 72% for non-surgical patients.ConclusionsThe EPOC® device had minor negative bias, was not interchangeable with the CBC hemoglobin, and was less reliable when the EPOC® value was < 7 g/dL. Clinicians must consider speed versus accuracy, and should check a CBC within 30 min as confirmation when the EPOC® hemoglobin is < 7 g/dL until further prospective trials are performed in this population.

P4736The Prognostic Impact of Volume Substitution on Cardiac Strain and the Development of Postoperative Atrial Fibrillation after Cardiac Surgery

Abstract Background Postoperative atrial fibrillation (POAF) represents a common complication after cardiac valve or coronary artery bypass surgery. Etiologically, multifactorial causes such as the patients' age, weight, comorbidities or local remodeling proved a strong association with this common arrhythmia. While strain of atrial tissue is known to induce atrial fibrillating impulses, less attention has been paid to potentially strain-promoting values during the peri- and post-operative period. Therefore, we aimed to determine the association of peri- and post-operative volume substitution on markers of cardiac strain and subsequently its impact on the promotion and development of POAF. Methods In this prospective observational study 271 patients undergoing elective cardiac surgery in our Medical University were enrolled (median age: 69 years [IQR: 60–75 years]; 195 [72%] male gender). Intra- and post-operative data was collected from anesthesiologic and intensive care unit protocols. Multivariate binary logistic regression analysis was used to identify the prognostic value of volume substitution on the development of POAF. Results A total of 123 (45.4%) individuals developed POAF. The average intra-operative transfusion volume was significantly elevated in the POAF subgroup (605.6ml [POAF] vs. 227.1ml [non-POAF]; p&lt;0.001). Moreover, the fluid balance within the first 24 hours after surgery was significantly higher in patients developing POAF (+1129.6 ml [POAF] vs. +544.9 ml [non-POAF]; p=0.044). We found that N-terminal pro brain natriuretic peptide (NT-proBNP) values were significantly elevated in patients that received any volume substitution (2860.0 pg/mL [Transfusion] vs. 1486.5 pg/mL [no-Transfusion]; p=0.002). In line with those results, the postoperative fluid balance was also found to have a direct and significant correlation with postoperative NT-ProBNP values (r=0.287, p=0.002). Of note, the amount of substituted volume proved to be a strong and independent predictor for POAF with an adjusted odds-ratio (OR) per one standard deviation (1-SD) of 2.49 (95% CI: 1.25–4.96; p=0.009). Conclusion Within the present analysis we were able to demonstrate that substitution of larger transfusion volumes presents a strong and independent predictor for the development of POAF. Via the observed distinct association with NT-proBNP values, it can reasonably be assumed that post-operative atrial fibrillating impulses are triggered via volume-induced cardiac strain.

Blood transfusion therapy for β-thalassemia major and hemoglobin E β-thalassemia: Adequacy, trends, and determinants in Sri Lanka.

Regular blood transfusion therapy still remains the cornerstone in the management of β-thalassemia. Although recommendations are clear for patients with β-thalassemia major, uniform transfusion guidelines are lacking for patients with hemoglobin E β-thalassemia. In this study, we aim to describe the adequacy, trends, and determinants of blood transfusion therapy in a large cohort of pediatric patients with β-thalassemia major and hemoglobin E β-thalassemia. This cross-sectional study was performed among all regularly transfused patents with β-thalassemia aged 2 to 18 years attending three large thalassemia centers in Sri Lanka. Data were collected using an interviewer-administered questionnaire, perusal of clinical records, and physical examination of patients by trained doctors. A total of 328 patients (male 47%) were recruited; 83% had β-thalassemia major, whereas 16% had hemoglobin E β-thalassemia. Sixty-one percent of patients had low pretransfusion hemoglobin levels (<9.0g/dL) despite receiving high transfusion volumes (>200mL/kg/year) by a majority (56%). Median pretransfusion hemoglobin was significantly lower in patients with hemoglobin E β-thalassemia compared with β-thalassemia major (P<0.001); however, there was no difference in requirement for high transfusion volumes over 200mL/kg/year in both groups (P=0.14). Hepatomegaly and splenomegaly were more common in hemoglobin E β-thalassemia and were associated with lower pretransfusion hemoglobin. Transfusion requirements were higher among patients with hepatitis C and in those who are underweight. Over 60% of regularly transfused patients with β-thalassemia have low pretransfusion hemoglobin levels despite receiving large transfusion volumes. Patients with hemoglobin E β-thalassemia are undertransfused and specific recommendations should be developed to guide transfusions in these patients.

In Response

In Response We appreciate the comments by Pivalizza and De Haan.1 As alluded to in their letter,1 anesthesiologists indeed were responsible for the majority of plasma transfusion orders at our institution during the study period. These occurred both intraoperatively (45%) and postoperatively (37%) in the intensive care unit, where the majority of our surgical intensive care units are staffed by anesthesiologists who have completed fellowship training in critical care.2 Regarding viscoelastic testing, our institution utilizes thromboelastography (TEG) but not universally for coagulation management decisions. Primarily, TEG is used in trauma, cardiac surgery, and solid-organ transplantation. Of those receiving plasma intraoperatively with a valid pretransfusion and posttransfusion international normalized ratio (INR), approximately 25% (795 patients) also had TEG data available both pretransfusion, defined as occurring within 1 hour of the first unit of plasma administered, and posttransfusion, defined as occurring within 6 hours after administration of the last unit of intraoperative plasma. We have recently published our experience with changes in TEG-derived R-time values after plasma transfusion and clinical outcomes for these patients.3 Concerning situations when the INR is not available, Supplemental Figure 1 shows that 3244 patients (29.7% of all adult patients receiving plasma over the study period of interest) were excluded for absence of either a pretransfusion or posttransfusion INR. Moreover, a total of 899 patients met criteria for massive transfusion over the study period as defined by ≥10 units of red blood cells administered within a single 24-hour period. This would represent approximately 8% of all patients who received plasma over the study period of interest, of which only a minority (approximately 5%) was directly related to trauma rather than other types of surgical insults. Of note, 643 (71.5%) were included in the current investigation, implying that they had qualifying pretransfusion and posttransfusion INR values available despite their large transfusion requirements. In light of the ongoing uncertainty regarding optimal plasma transfusion practices in nontrauma-related massive hemorrhage, additional investigations examining plasma transfusion practices in this broad cohort of massively transfused patients would certainly assist in advancing our understanding of clinical blood management decisions. Of particular interest, there is increasing evidence that optimal resuscitation strategies for patients with nontraumatic massive hemorrhage may differ from the trauma population. Specifically, delivery of high ratios of plasma to red blood cells, such as those given in protocol-driven fixed ratios, may not be associated with improved outcomes in this group.4,5 However, data are limited, and as such, optimal transfusion strategies for nontraumatic massive hemorrhage should be considered an area of research priority. Matthew A. Warner, MDDaryl J. Kor, MDDivision of Critical Care MedicineDepartment of Anesthesiology and Perioperative MedicineMayo ClinicRochester, MinnesotaDepartment of Anesthesiology and Perioperative MedicinePeriprocedural Outcomes, INformation and Transfusion Study GroupMayo ClinicRochester, Minnesota[email protected]

Colon Trauma: Evidence-Based Practices.

Colon injury is not uncommon and occurs in about a half of patients with penetrating hollow viscus injuries. Despite major advances in the operative management of penetrating colon wounds, there remains discussion regarding the appropriate treatment of destructive colon injuries, with a significant amount of scientific evidence supporting segmental resection with primary anastomosis in most patients without comorbidities or large transfusion requirement. Although literature is sparse concerning the management of blunt colon injuries, some studies have shown operative decision based on an algorithm originally defined for penetrating wounds should be considered in blunt colon injuries. The optimal management of colonic injuries in patients requiring damage control surgery (DCS) also remains controversial. Studies have recently reported that there is no increased risk compared with patients treated without DCS if fascial closure is completed on the first reoperation, or that a management algorithm for penetrating colon wounds is probably efficacious for colon injuries in the setting of DCS as well.

Traumatic coagulopathy and massive transfusion: improving outcomes and saving blood

IntroductionDysfunction of the coagulation system, termed trauma-induced coagulopathy (TIC), is a major problem in patients who bleed after injury. Trauma haemorrhage is considered one of the leading preventable causes of death worldwide. Deaths occur early and, despite the presence of trauma teams and large transfusions of blood products, outcomes remain poor.MethodsWe conducted a multimodal programme of work to develop our understanding of coagulopathy and its optimal management. We studied the epidemiology, management and health economics of trauma haemorrhage, including the provision of care during mass casualty events. We combined systematic reviews of the literature with a national study of trauma haemorrhage, its transfusion management and associated health-care costs. We further examined several point-of-care coagulation tools for their ability to diagnose coagulopathy and assess the response to blood component therapy. We progressively implemented our findings into practice and assessed the outcomes of trauma patients presenting to our major trauma centre. To examine different approaches to the provision of blood to casualties in a mass casualty event, we constructed a discrete event model based on data from the 2005 London bombings.Key resultsOur systematic reviews found little strong evidence for the existing diagnostic tools or the practice of delivery of blood components in trauma haemorrhage. Our national study recruited 442 patients in 22 hospitals and found that the 1-year mortality rate for massive haemorrhage approached 50%. Half of these deaths occurred in the first 24 hours after injury and half of these occurred in the first 4 hours. We identified this early time window as a period when the provision of blood component therapy was often below the recommended thresholds and blood component therapy was delivered inconsistently. Studying early TIC we determined that loss of fibrinogen and excessive fibrinolysis were key derangements. We were able to determine that rotational thromboelastometry could identify early coagulopathy within 5 minutes, a large improvement on laboratory tests. We were further able to show how existing damage control resuscitation regimens with high-dose plasma do not maintain haemostatic competency during haemorrhage. In total, the estimated cost of treating a major haemorrhage patient was £20,600 and the estimated cost of treating a massive haemorrhage patient was £24,000. Nationally, the estimated cost of trauma haemorrhage is £85M annually. In mass casualty situations, early results show that the only mutable factor that affects the provision of care to a large degree, in the initial phase of the response, is the level of blood stocks held in the receiving hospital.ConclusionsThis multimodal programme of work has led to new understandings of the epidemiology of trauma haemorrhage and its underlying mechanisms and clinical course. We have defined diagnostic tools and trigger thresholds for identification and management and increased our understanding of how blood component and other therapeutics affect coagulopathy and when they are likely to be most effective. This diagnostic work has been taken forward at an international level to produce new personalised guidelines for the management of trauma haemorrhage. The findings have had important therapeutic implications, which have led to important changes in practice that have been incorporated into new national and international guidelines.FundingThe National Institute for Health Research Programme Grants for Applied Research programme.

Cumulative erythrocyte damage in blood storage and relevance to massive transfusions: selective insights into serial morphological and biochemical findings.

Elucidating the precise mechanisms of cumulative red cell damages during storage and the potential harmful consequences after transfusion are achievable by exacting laboratory science and well-defined clinical studies in progress. Accordingly, for larger magnitude blood transfusions (i.e. 8-12 U in 24 hours), the quality of the stored blood and its characterisation are of special academic and clinical importance. Our main objectives in this review are to illuminate facets of the red cell storage lesion for prolonged storage (0-42 days) by concentrating on various hallmarks of the disorder: 1) identifying and characterising serial markers of the progressive lesion with respect to red cell dysmorphology, deformability, haemolytic fragility and dysfunction both in storage and the microcirculation; and 2) relevant biochemical findings of redox status correlated to oxidative stress of erythrocyte proteins. This is accomplished in part by reliance on advanced metabolomic and proteomic technologies using various sophisticated tools such as high pressure liquid chromatography in combination with mass spectrometry of proteins and small molecule metabolites. It is anticipated that these sophisticated methodologies and the experimental results therein shall lead to further advances in the quality improvement of red cell storage.

Reduction of transfusion requirements in pediatric craniosynostosis surgery by a new local hemostatic agent

Craniosynostosis surgery is often associated with severe perioperative bleeding especially due to venae emissariae, resulting in large transfusion amounts of packed red blood cells (PRBCs). Blood loss from venae emissariae is usually reduced by the usage of bone wax. SeraSeal is a new hemostatic agent which might help to reduce transfusion amounts if used additionally to bone wax. This study was designed with a retrospective control group (23 children), treated only with bone wax and a consecutive prospective verum group (12 children) treated additionally with SeraSeal. All children solely suffered from non-syndromic craniosynostosis, and were all treated by the same surgeons. Primary outcome variable was the volume of PRBC transfused during surgery. The numbers of PRBC transfusion was reduced significantly during the intraoperative period in the SeraSeal group (-44.5%, p<0.05) and also during the combination of the postoperative and intraoperative period (-59.3%, p<0.05). Our analysis suggests that SeraSeal has a strong potential to reduce transfusion requirements in pediatric craniosynostosis surgery. However, we acknowledge that due to small numbers our trial can only be seen as hypothesis generating pilot study. We suggest that the effect of SeraSeal should be assessed prospectively in other studies.