Massive Transfusion Protocol Activation Research Articles

Evaluation of the Potential for Improvement of Clinical Outcomes in Trauma Patients with Massive Hemorrhage by Maintaining a High Plasma-to-Red Blood Cell Ratio during the First Hour of Hospitalization.

Several reports indicate that early plasma transfusion may promote survival and reduce the incidence of traumatic coagulopathy in situations of massive bleeding. Consequently, it is recommended to maintain a plasma and RBC transfusion ratio between 1 : 1 and 1 : 2 at the start of admission. This retrospective study examined the effect of an early high plasma : RBC ratio on mortality rates by adopting a massive transfusion protocol (MTP) that forced an early and rapid issue of plasma products. Patients who received massive transfusions at a single trauma center between January 2014 and May 2020 were included in the study. A new protocol was established in January 2020, wherein a fixed amount of plasma was issued following MTP activation. Patients who underwent massive transfusions before and after the adoption of the new protocol were compared. In total, 1059 patients met the inclusion criteria. Fifty-one patients who underwent MTP were propensity score-matched with the patients who received a nonprotocolized massive transfusion. The MTP group had a higher plasma : RBC ratio at 1 h (0.8 vs. 0.2) and 4 h of hospitalization (1.1 vs. 0.6), with no significant between-group difference in the plasma : RBC ratio at 24 h of hospitalization. The MTP group had a lower 24 h mortality rate than the control group. There was no significant difference in the 30-day mortality. Using MTP to achieve a high plasma : RBC ratio in the early period of hospitalization appeared to affect 24-hour mortality; however, 30-day mortality did not change.

Assessment of Machine Learning Methods to Predict Massive Blood Transfusion in Trauma

BackgroundAccurately predicting which patients are most likely to benefit from massive transfusion protocol (MTP) activation may help patients while saving blood products and limiting cost. The purpose of this study is to explore the use of modern machine learning (ML) methods to develop and validate a model that can accurately predict the need for massive blood transfusion (MBT).MethodsThe institutional trauma registry was used to identify all trauma team activation cases between June 2015 and August 2019. We used an ML framework to explore multiple ML methods including logistic regression with forward and backward selection, logistic regression with lasso and ridge regularization, support vector machines (SVM), decision tree, random forest, naive Bayes, XGBoost, AdaBoost, and neural networks. Each model was then assessed using sensitivity, specificity, positive predictive value, and negative predictive value. Model performance was compared to that of existing scores including the Assessment of Blood Consumption (ABC) and the Revised Assessment of Bleeding and Transfusion (RABT).ResultsA total of 2438 patients were included in the study, with 4.9% receiving MBT. All models besides decision tree and SVM attained an area under the curve (AUC) of above 0.75 (range: 0.75–0.83). Most of the ML models have higher sensitivity (0.55–0.83) than the ABC and RABT score (0.36 and 0.55, respectively) while maintaining comparable specificity (0.75–0.81; ABC 0.80 and RABT 0.83).ConclusionsOur ML models performed better than existing scores. Implementing an ML model in mobile computing devices or electronic health record has the potential to improve the usability.

Massive Transfusion Protocol Adherence: Relationship to Trauma Patient Outcomes.

Ongoing evaluation of massive transfusion protocol adherence is critical to ensure better trauma patient outcomes. This quality improvement initiative aimed to determine provider adherence to a recently revised massive transfusion protocol and its relationship to clinical outcomes among trauma patients requiring massive transfusion. A retrospective, descriptive, correlational design was used to determine the association between provider adherence to a recently revised massive transfusion protocol and clinical outcomes in trauma patients with hemorrhage treated at a Level I trauma center from November 2018 to October 2020. Patient characteristics, provider massive transfusion protocol adherence, and patient outcomes were assessed. Patient characteristics and massive transfusion protocol adherence associations with 24-hr survival and survival to discharge were determined using bivariate statistical methods. A total of 95 trauma patients with massive transfusion protocol activation were evaluated. Of the 95, 71 (75%) survived the initial 24 hr following massive transfusion protocol activation and 65 (68%) survived to discharge. Based on protocol applicable items, the median massive transfusion protocol overall adherence rate per patient was 75% (IQR = 57.1-85.7) for the 65 survivors and 25% (IQR = 12.5-50.0) for the 21 nonsurvivors to discharge whose death occurred at least 1 hr after massive transfusion protocol activation (p < .001). Findings indicate the importance of ongoing evaluations of adherence to massive transfusion protocols in hospital trauma settings to target areas for improvement.

Predicting Early Versus Late In-Hospital Mortality in the Trauma Population.

This study aimed to evaluate non-survivors who were admitted to a level I trauma center but later died, in terms of predicting who would expire early vs late. This is a single-center study of Trauma Registry data, from July 3, 2016, to February 24, 2022. The inclusion criteria were based upon age (≥18years) and in-hospital mortality. 546 patients (mean age 58) were included in the analysis. Trauma patients who may experience an earlier death were those with increasing injury severity scores, activation of massive transfusion protocol, comorbid advanced directive limiting care, COPD, personality disorder, and ED death location. Patients were more likely to experience later in-hospital mortality, including those with increasing ICU stays, and comorbid dementia.

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

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

Shock Index for the Prediction of Interventions and Mortality in Patients With Blunt Thoracic Trauma

IntroductionShock index (SI) is a bedside simple scoring tool; however, it has not yet been tested in blunt thorax trauma (BTT). We sought to evaluate the prognostic value of SI for chest interventions (thoracostomy tube or thoracotomy), blood transfusion, and mortality in patients with BTT. We hypothesized that high SI is associated with worse outcomes in patients with BTT. MethodsWe conducted a retrospective analysis of all BTT patients (chest Abbreviated Injury Score [AIS] > 1) hospitalized in a level 1 trauma center between 2011 and 2020. Patients with AIS >1 for head or abdominal injuries and patients undergoing open reduction and internal fixation surgery or penetrating injuries were excluded. Patients were categorized into two groups (low SI <0.80 versus high SI ≥0.80) based on the receiver operating characteristic curve analysis. Multivariable regression analysis was performed to identify the predictors of mortality. ResultsA total of 1645 patients were admitted with BTT; of them, 24.5% had high SI. The mean age was 39.2 ± 15.2 y, and most were males (91%). Patients with high SI were younger, had sustained severer injuries, and required more chest interventions (P = 0.001), blood transfusion (P = 0.001), and massive transfusion protocol activation (P = 0.001) compared with low SI group. The overall in-hospital mortality rate was 2.6%, which was more in the high SI group (8.2% versus 0.8%; P = 0.001). SI significantly correlated with age (r = −0.281), injury severity score (r = 0.418), Glasgow Come Score on arrival (r = −0.377), Trauma and Injury Severity Score (r = −0.144), Revised Trauma Score (r = −0.219), serum lactate (r = 0.434), blood transfusion units (r = 0.418), and chest AIS (r = 0.066). SI was an independent predictor of mortality (odds ratio 3.506; 95% confidence interval 1.389-8.848; P = 0.008), and this effect persisted after adjustment for chest intervention (odds ratio 2.923; 95% confidence interval 1.146-7.455; P = 0.02). ConclusionsThe present study highlights the prognostic value of SI as a rapid bedside tool to predict the use of interventions and the risk of mortality in patients with BTT. The study findings help the emergency physicians for early and appropriate risk stratification and triaging of patients with BTT.

Outcomes of Cold-Stored, Low Titer Group O Whole Blood Transfusions in Non-Trauma Massive Transfusion Protocol Activations in Patients with Cirrhosis

Introduction: There has been significant debate on the best transfusion practices in cirrhotic patients with massive hemorrhage. As the liver is responsible for the synthesis of many proteins involved in coagulation and anticoagulation, cirrhosis can lead to multiple coagulation abnormalities. Portal hypertension, endothelial dysfunction, renal failure, and sepsis further contribute to increased bleeding tendency in cirrhosis. A growing area of interest is transfusion of cold-stored, low-titer Group O whole blood (LTOWB). The primary advantage of LTOWB versus component-based transfusion is that it provides a balanced resuscitation of all components that is closest to physiologic blood. Additionally, it contains lower quantities of anticoagulant and preservative solution compared to individual blood components. Previous studies suggest that LTOWB is at least equivalent if not superior to component therapy in resuscitation of life-threatening hemorrhage in trauma patients. The goal of the present study is to determine whether this positive effect is also observed in cirrhotic patients requiring activation of massive transfusion protocol (MTP) for non-traumatic bleeding. Methods: We retrospectively collected data from cirrhotic patients receiving MTP with at least one unit of LTOWB transfusion between January 2019 and November 2021. LTOWB is obtained from the American Red Cross and leukoreduced with a platelet sparing filter from Terumo (Lakewood, CO). It is stored for up to 14 days, and if unused is subsequently converted to red blood cells. Low titer is defined as < 1:256. Baseline samples were collected just prior to initiation of LTOWB MTP. Post-transfusion samples were collected 24 hours following the activation of the MTP. We describe the degree of anemia, thrombocytopenia, coagulopathy, and hemolysis before and after LTOWB MTPs. The difference between post-transfusion total bilirubin and pre-transfusion total bilirubin was used as a surrogate for hemolysis. Pre- and post-transfusion thromboelastography (TEG) was used to assess clot formation, clot strength, and fibrinolysis. Data are reported as mean ± standard deviation for normally distributed variables, or median with 1st and 3rd quartiles if non-normal. The Wilcoxon signed rank test was employed to test changes between pre-and post-transfusion parameters (p<0.05 considered statistically significant). Results: Of 810 patients who received LTOWB MTP between January 2019 and November 2021, 317 were for non-traumatic bleeding, and of these 61 patients had cirrhosis. Table 1 describes patient characteristics. The most common etiology of cirrhosis was alcohol-associated liver disease. The most common cause of bleeding was upper GI bleed, followed by procedural bleeding. 16.4% of the patients received LTOWB only, and 83.6% of patients received both LTOWB and component therapy. On average, patients received one unit of red blood cells and one unit of platelets in addition to 3 units of LTOWB. Table 2 shows outcome variables. Of the 61 patients who received LTOWB MTP, Hemoglobin significantly increased 1.7 g/dL (P <0.001). Similarly, INR and PTT significantly decreased following LTOWB MTP (P <0.01 for both). Interestingly, there was a 17.5 K/cu mm decrease in platelet count (P = 0.001). The total bilirubin, calcium, and fibrinogen levels were unaffected by LTOWB MTP. The TEG K time was significantly prolonged following LTOWB MTP, while the lysis time at 30 minutes was decreased (P <0.05). One patient had a transfusion reaction. Conclusions: To our knowledge, this is the first study examining LTOWB transfusion in non-trauma patients with cirrhosis. This proof of concept study suggests that LTOWB transfusion is a feasible option for this patient population. We observed a significant improvement in hemoglobin and PTT/INR, without observed signs of hemolysis. Our TEG results suggest decreased fibrinolysis following LTOWB MTP. An important limitation of this study is the lack of an appropriate control group. Ongoing work indicates that we will soon have enough data to compare our LTOWB versus component-only MTP cohorts. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

“You Get What You Need”: Early Results of BloodTrack System on Reducing Inefficiencies in Blood Product Allocation

Abstract Introduction/Objective The preparation of blood products allocated for massive transfusion protocol (MTP) activation and surgical cases consumes much time and energy of blood bank technologists. Often, these blood products are returned to the blood bank unused. Clinicians may activate the MTP preemptively to ensure the availability of blood products in case they are needed. Most blood products ordered for surgeries are placed on hold and not transfused. These returned units require additional inspections before they can be made available again. To reduce these inefficiencies, we implemented the BloodTrack [Haemonetics, Boston, MA] system, wherein blood products are stored in remote refrigerators and made available to clinicians near the patients’ bedside. Besides safeguarding units placed on hold for surgeries, we hypothesized that BloodTrack would provide greater visibility of available products in the emergency department (ED), thus reducing the rate of preemptive MTP activations. Methods/Case Report From March 2022 onwards, BloodTrack refrigerators with OnDemand software were active in the ED, operating room (OR), and two intensive care (ICU) units. We educated ED, OR, and ICU nurses on the appropriate use of BloodTrack. MTP activations were recorded from August 2021 to June 2022. Data on units allocated to OR patients by BloodTrack were collected from software-generated logs. Data on units allocated to OR patients by BloodTrack were collected from software-generated logs. Results (if a Case Study enter NA) Since its introduction in March, BloodTrack has dispensed 92 red blood cell units, which represents 12% of the total 766 units assigned. The remainder of 674 units were unused, and represent substantial savings in time otherwise spent re-instating them. Moreover, the rates of preemptive MTP activations trended downwards, from 28% (32/113) in the 7 months prior to implementation, to 13% (3/24) after implementation. Conclusion In conclusion, our implementation of BloodTrack has led to reduced MTP activations, improved efficiency of our blood product allocation process, and developed interdisciplinary care team integration.

First Massive Transfusion Protocol (MTP) Implementation Proposal in Egypt

Abstract Introduction/Objective Massive transfusion is often defined as transfusion of adults with 10 or more of packed red blood cells units in 24 hours period or transfusion of 4 or more units of packed red blood cells (PRBCs) in one hour when on-going need for more transfusion is foreseeable. Massive transfusion protocol in children is defined as transfusion of &amp;gt;40 mL/kg. Massive transfusion protocol (MTP) is a vital element of damage control resuscitation and provides a coordinated clinical response to hemorrhage in patients requiring massive blood transfusions after hospital admission. Hemorrhage is the most common cause of death within the first hour of arrival to the trauma center. Methods/Case Report This study aims to develop and establish the first massive protocol in Egypt to provide a consistent treatment for blood transfusion for trauma patients that will Reduce delay in ordering and administering blood products and Deliver a reasonable ratio of plasma to red blood cells. The protocol will be first implemented in a military hospital in Egypt. Developing the massive transfusion protocol will allow the practitioners to follow algorithm for rapid replacement of blood products using uncrossmatched packed red blood cells, Plasma, platelets and cryoprecipitate if necessary. Adopting the American Association of Blood Banks (AABB) and the American College of Surgeons (ACS) guidelines are the best practice around the world. The Protocol will be developed by multidisciplinary committee engagement, Blood bank, Diagnostic laboratory and Clinical care areas (OR, ER, ICU, OBS). Results (if a Case Study enter NA) The massive transfusion protocol ratio will be 3:2 (RBC: FFP) and one units of platelets for every 6 units of RBC. according to American College of Surgeons (ACS) guidelines the ratio should be 1:1 to 1:2 (RBC: FFP). The committee established defined criteria for MTP activation and termination. The delivery time of the blood products should be between 5-10 minutes. Administration of tranexamic acid to inhibit plasminogen activation and stabilize the clot. Conclusion The Developing and Implementing MTP in Egypt will provide reduction in mortality for trauma and uncontrolled hemorrhage patients. Once implemented, we will regularly evaluate the use and efficacy of the MTP to ensure positive patient outcomes., the MTP will be evaluated to ensure best practice.

Incidence of Red Cell Antibody Formation Following Massive Transfusion Protocol: Experience of a Single Institution.

Injured patients in hemorrhagic shock have a survival benefit with massive transfusion protocol (MTP). While there are many published studies on the transfusion management of massively bleeding patients, the risk of alloimmunization in patients that have received products during an MTP activation is relatively unknown. Therefore, we sought to determine the frequency of new antibody formation in MTP patients that received blood products from an uncrossmatched megapack. We conducted a retrospective data review of patients who underwent an MTP activation for trauma resuscitation between May 2014 and July 2020. Data were collected from patients who met the following criteria: MTP was activated, the patients received at least one unit of packed red blood cells, one unit of fresh frozen plasma, one unit of platelets, and had a repeat type and screen within 6 weeks of transfusion. These inclusion criteria resulted in 28 patients over the 6-year timeframe. Overall, the risk of alloimmunization secondary to MTP is 3.6% in our trauma patient population. The newly developed antibodies post-MTP are considered clinically significant, meaning they can cause hemolysis if exposed to donor red blood cells containing those antigens. Blood products should be given preferentially over crystalloids to acutely bleeding patients to prevent ischemic injury during an MTP activation despite the risk of alloimmunization. In our single-institution study, the alloimmunization rate in massive transfusions where patients receive uncrossmatched red blood cells is similar to those receiving crossmatched red blood cells.

Recognizing life-threatening bleeding in pediatric trauma: A standard for when to activate massive transfusion protocol.

Traumatic hemorrhage is the most common cause of preventable death in civilian and military trauma. Early identification of pediatric life-threatening hemorrhage is challenging. There is no accepted clinical critical administration threshold (CAT) in children for activating massive transfusion protocols. Children 0 to 17 years old who received any transfusion in the first 24 hours after injury between 2010 and 2019 were included. The type, volume, and time of administration for each product were recorded. The greatest volume of weight-adjusted products transfused within 1 hour was calculated. The cut point for the number of products that maximized sensitivity and specificity to predict in-hospital mortality, need for urgent surgery, and second life-threatening bleeding episode was determined using Youden's index. A binary variable (CAT+) was generated using this threshold for inclusion in a multivariable logistic regression model. In total, 287 patients were included. The median (interquartile range) age was 6 (2-14) years, 60% were males, 83% sustained blunt trauma, and the median (interquartile range) Injury Severity Score was 26 (17-35). The optimal cutoff to define CAT+ was >20 mL/kg of product; this optimized test characteristics for mortality (sensitivity, 70%; specificity, 77%), need for urgent hemorrhage control procedure (sensitivity, 65%; specificity, 74%). and second bleeding episode (sensitivity, 77%; specificity, 74%). There were 93 children (32%) who were CAT+. On multivariate regression, being CAT+ was associated with 3.4 increased odds of mortality (95% confidence interval, 1.67-6.89; p = 0.001) after controlling for age, hypotension, Injury Severity Score, and Glasgow Coma Scale. For every unit of product administered, there was a 10% increased risk of mortality (odds ratio, 1.1; p < 0.001). Transfusion of more than 20 mL/kg of any blood product within an hour should be used as a threshold for activating massive transfusion protocols in children. Children who meet this CAT are at high risk of mortality and need for interventions; this population may benefit from targeted, timely, and aggressive hemostatic resuscitation. Therapeutic/Care Management; Level III.

Prediction of massive transfusion with the Revised Assessment of Bleeding and Transfusion (RABT) score at Canadian level I trauma centers

BackgroundEarly damage control resuscitation and massive transfusion (MT) protocol activations improve outcomes in trauma patients with hemorrhagic shock, where scores to guide MT prediction are used including: the Assessment of Blood Consumption (ABC), Shock Index (SI), and Revised Assessment of Bleeding and Transfusion (RABT) scores. Our aim was to validate the RABT score in patients from two level I trauma centers in Canada. MethodsA retrospective review of adult patients meeting trauma team activation criteria receiving >1 unit of red blood cells (RBCs) within 24 h of admission, from 2015 to 2020, was conducted. A RABT score ≥ 2, ABC score ≥ 2, and Shock Index (SI) ≥ 1 was used to predict MT using both research (≥10 RBCs in 24 h) and clinical (≥3 RBCs in 3 h) definitions. Scores were assessed and compared using sensitivity, specificity, and the area under the receiver operating characteristic (AUROC). ResultsWe analyzed 514 patients with a mean age of 44.4 (19.2) years and a median injury severity score of 29 [18–38]. For both MT definitions, the RABT score trended towards higher sensitivity and lower specificity compared to ABC score and SI. For both research and clinical definitions of MT, the AUROC for the RABT score was not significantly higher (Research - RABT: 0.673 [0.610–0.735], ABC: 0.642 [0.551–0.734], SI 0.691 [0.625–0.757]; Clinical - RABT: 0.653 [0.608–0.698], ABC: 0.646 [0.600–0.691], SI 0.610 [0.559–0.660]). ConclusionThe RABT score is a valid tool for predicting the need for MTPs, performing similarly with a trend towards higher sensitivity when compared to the ABC score and SI.

Predictors of Transfusion in Trauma and Their Utility in the Prehospital Environment: A Scoping Review

Background: Hemorrhage is a leading cause of preventable mortality from trauma, necessitating resuscitation through blood product transfusions. Early and accurate identification of patients requiring transfusions in the prehospital setting may reduce delays in time to transfusion upon arrival to hospital, reducing mortality. The purpose of this study is to characterize existing literature on predictors of transfusion and analyze their utility in the prehospital context. Objectives: The objectives of this study are to characterize the existing quantity and quality of literature regarding predictor scores for transfusion in injured patients, and to analyze the utility of predictor scores for massive transfusions in the prehospital setting and identify prehospital predictor scores for future research. Methods: A search strategy was developed in consultation with information specialists. A literature search of OVID MEDLINE from 1946 to the present was conducted for primary studies evaluating the predictive ability of scoring systems or single variables in predicting transfusion in all trauma settings. Results: Of the 5,824 studies identified, 5,784 studies underwent title and abstract screening, 94 studies underwent full text review, and 72 studies were included in the final review. We identified 16 single variables and 52 scoring systems for predicting transfusion. Among single predictor variables, fluids administered and systolic blood pressure had the highest reported sensitivity (100%) and specificity (89%) for massive transfusion protocol (MTP) activation, respectively. Among scoring systems for transfusion, the Shock Index and Modified Shock Index had the highest reported sensitivity (96%), whereas the Pre-arrival Model had the highest reported specificity (95%) for MTP activation. Overall, 20 scores were identified as applicable to the prehospital setting, 25 scores were identified as potentially applicable, and 7 scores were identified as not applicable. Conclusions: We identified an extensive list of predictive single variables, validated scoring systems, and derived models for massive transfusion, presented their properties, and identified those with potential utility in the prehospital setting. By further validating applicable scoring tools in the prehospital setting, we may begin to administer more timely transfusions in the trauma population.

Overtransfusion of packed red blood cells during massive transfusion activation: a potential quality metric for trauma resuscitation

ObjectivesThe goal of this study was to explore the incidence of overtransfusion in trauma patients requiring massive transfusion protocol (MTP) activation and identify modifiable risk factors. We hypothesized that overtransfusion...

Platelet Transfusion and Outcomes After Massive Transfusion Protocol Activation for Major Trauma: A Retrospective Cohort Study.

Incorporation of massive transfusion protocols (MTPs) into acute major trauma care has reduced hemorrhagic mortality, but the threshold and timing of platelet transfusion in MTP are controversial. This study aimed to describe early (first 4 hours) platelet transfusion practice in a setting where platelet counts are available within 15 minutes and the effect of early platelet deployment on in-hospital mortality. Our hypothesis in this work was that platelet transfusion in resuscitation of severe trauma can be guided by rapid turnaround platelet counts without excess mortality. We examined MTP activations for all admissions from October 2016 to September 2018 to a Level 1 regional trauma center with a full trauma team activation. We characterized platelet transfusion practice by demographics, injury severity, and admission vital signs (as shock index: heart rate/systolic blood pressure) and laboratory results. A multivariable model assessed association between early platelet transfusion and mortality at 4 hours, 24 hours, and overall in-hospital, with P <.001. Of the 11,474 new trauma patients admitted over the study period, 469 (4.0%) were massively transfused (defined as ≥10 units of red blood cells [RBCs] in 24 hours, ≥5 units of RBC in 6 hour, ≥3 units of RBC in 1 hour, or ≥4 units of total products in 30 minutes). 250 patients (53.0%) received platelets in the first 4 hours, and most early platelet transfusions occurred in the first hour after admission (175, 70.0%). Platelet recipients had higher injury severity scores (mean ± standard deviation [SD], 35 ± 16 vs 28 ± 14), lower admission platelet counts (189 ± 80 × 10 9 /L vs 234 ± 80 × 10 9 /L; P < .001), higher admission shock index (heart rate/systolic blood pressure; 1.15 ± 0.46 vs 0.98 ± 0.36; P < .001), and received more units of red cells in the first 4 hours (8.7 ± 7.7 vs 3.3 ± 1.6 units), 24 hours (9 ± 9 vs 3 ± 2 units), and in-hospital (9 ± 8 vs 3 ± 2 units) than nonrecipients (all P < .001). We saw no difference in 4-hour (8% vs 7.8%; P = .4), 24-hour (16.4% vs 10.5%; P = .06), or in-hospital mortality (30.4% vs 23.7%; P = .1) between platelet recipients and nonrecipients. After adjustment for age, injury severity, head injury, and admission physiology/laboratory results, early platelet transfusion was not associated with 4-hour, 24-hour, or in-hospital mortality. In an advanced trauma care setting where platelet counts are available within 15 minutes, approximately half of massively transfused patients received early platelet transfusion. Early platelet transfusion guided by protocol-based clinical judgment and rapid-turnaround platelet counts was not associated with increased mortality.

Transfusion Ratios and Deficits in Injured Children With Life-Threatening Bleeding.

To assess the impact of plasma and platelet ratios and deficits in injured children with life-threatening bleeding. Secondary analysis of the MAssive Transfusion epidemiology and outcomes In Children study dataset, a prospective observational study of children with life-threatening bleeding events. Twenty-four childrens hospitals in the United States, Canada, and Italy. Injured children 0-17 years old who received greater than 40 mL/kg total blood products over 6 hours or were transfused under activation of massive transfusion protocol. Weight-adjusted blood product volumes received during the bleeding event were recorded. Plasma:RBC ratio (plasma/RBC weight-adjusted volume in mL/kg) and platelet:RBC ratio (platelet/RBC weight-adjusted volume in mL/kg) were analyzed. Plasma deficit was calculated as RBC mL/kg - plasma mL/kg; platelet deficit was calculated as RBC mL/kg - platelet mL/kg. Of 191 patients analyzed, median (interquartile range) age was 10 years (5-15 yr), 61% were male, 61% blunt mechanism, and median (interquartile range) Injury Severity Score was 29 (24-38). After adjusting for Pediatric Risk of Mortality score, cardiac arrest, use of vasoactive medications, and blunt mechanism, a high plasma:RBC ratio (> 1:2) was associated with improved 6-hour survival compared with a low plasma:RBC ratio (odds ratio [95% CI] = 0.12 [0.03-0.52]; p = 0.004). Platelet:RBC ratio was not associated with survival. After adjusting for age, Pediatric Risk of Mortality score, cardiac arrest, and mechanism of injury, 6-hour and 24-hour mortality were increased in children with greater plasma deficits (10% and 20% increased odds of mortality for every 10 mL/kg plasma deficit at 6 hr [p = 0.04] and 24 hr [p = 0.01], respectively); 24-hour mortality was increased in children with greater platelet deficits (10% increased odds of 24-hr mortality for every 10 mL/kg platelet deficit [p = 0.02)]). In injured children, balanced resuscitation may improve early survival according to this hypothesis generating study. Multicenter clinical trials are needed to assess whether clinicians should target ratios and deficits as optimal pediatric hemostatic resuscitation practice.

Trauma bay virtual reality-A game changer for ATLS instruction and assessment.

Medical educational research highlights the need for high-fidelity, multidisciplinary simulation training to teach complex decision-making skills, such as those taught in Advanced Trauma Life Support (ATLS). This approach is, however, expensive and time-intensive. Virtual reality (VR) education simulation may improve skill acquisition in a cost-effective and time-sensitive manner. We developed a novel trauma VR simulator (TVRSim) for providers to apply ATLS principles. We hypothesized in this pilot study that TVRSim could differentiate practitioner competency with increasing experience and would be well accepted. Providers at a Level I trauma center (acute care surgeons, novice (MS4 & PGY1), junior (PGY2 & 3), senior (PGY4-6) residents) ran a blunt, polytrauma VR code. Ten critical decision points were assessed: intubation, cricothyroidotomy, chest tube, intravenous access, focused abdominal sonography for trauma examination, pelvic binder, activation of massive transfusion protocol, administration of hypertonic saline, hyperventilation and decision to go to the operating room (OR). Learner assessment was based on frequency and time to correct decisions. Participant satisfaction was measured using validated surveys. All 31 providers intubated and obtained intravenous access. Novices and juniors frequently failed at hypertonic saline and hyperventilation decisions. Juniors often failed at cricothyroidotomy (60%) and OR (100%) decisions. Mean time to all decisions except going to the OR was longer for all groups compared to acute care surgeons. Mean number of decisions/min was significantly higher for surgeons and seniors compared to juniors and novices. Mortality was 92.3% for novices, 80% for juniors, 25% for seniors and 0% for the attendings. Participants found TVRSim comfortable, easy to use/interact with/performance enhancing, and helped develop skills and learning. In this pilot study using a sample of convenience, TVRSim was able to discern decision-making abilities among trainees with increasing experience. All trainees felt that the platform enhanced their performance and facilitated skill acquisition and learning. TVRSim could be a useful adjunct to teach and assess ATLS skills. Diagnostic Test or Criteria; Level IV.

Platelet-Lymphocyte and Neutrophil-Lymphocyte Ratio for Prediction of Hospital Outcomes in Patients with Abdominal Trauma.

Background The platelet-to-lymphocyte ratio (PLR) and neutrophil-to-lymphocyte ratio (NLR) reflect the patient inflammatory and immunity status. We investigated the role of on-admission PLR and NLR in predicting massive transfusion protocol (MTP) activation and mortality following abdominal trauma. Methods A 4-year retrospective analysis of all adult abdominal trauma patients was conducted. Patients were classified into survivors and nonsurvivors and low vs. high PLR. The discriminatory power for PLR and NLR to predict MTP and mortality was determined. Multivariate logistic regression analysis was performed for predictors of mortality. Results A total of 1199 abdominal trauma patients were included (18.7% of all the trauma admissions). Low PLR was associated with more severe injuries and greater rates of hospital complications including mortality in comparison to high PLR. On-admission PLR and NLR were higher in the survivors than in nonsurvivors (149.3 vs. 76.3 (p = 0.001) and 19.1 vs. 13.7 (p = 0.009), respectively). Only PLR significantly correlated with injury severity score, revised trauma score, TRISS, serum lactate, shock index, and FASILA score. Optimal cutoffs of PLR and NLR for predicting mortality were 98.5 and 18.5, respectively. The sensitivity and specificity of PLR were 81.3% and 61.1%, respectively, and 61.3% and 51.3%, respectively, for NLR. The AUROC for predicting MTP was 0.69 (95% CI: 0.655–0.743) for PLR and 0.55 (95% CI: 0.510–0.598) for NLR. To predict hospital mortality, the area under the curve (AUROC) for PLR was 0.77 (95% CI: 0.712–0.825) and 0.59 (95% CI: 0.529–0.650) for the NLR. On multivariate logistic regression analysis, the age, Glasgow Coma Scale, sepsis, injury severity score, and PLR were independent predictors of mortality. Conclusion On-admission PLR but not NLR helps early risk stratification and timely management and predicts mortality in abdominal trauma patients. Further prospective studies are required.

Implementation of a low-titer stored whole blood transfusion program for civilian trauma patients: Early experience and logistical challenges

Cold-stored low titer group O whole blood (LTOWB) is increasingly utilized in the initial resuscitation of exsanguinating trauma patients. We report on our early experience with LTOWB, focusing on logistics, implementation challenges, and outcomes. In February, 2019, LTOWB was incorporated into the massive transfusion protocol (MTP) activated for trauma patients in the emergency department (ED.) Up to 4 units of LTOWB were included in the MTP cooler, depending on availability, and were transfused prior to transfusion of any other blood products from the MTP cooler. Demographics, injury characteristics, and outcomes were obtained, and the logistics of LTOWB availability were reviewed. Over a 12-month period, MTP was activated for 74 trauma patients. Of those, 38 (51%) MTP included at least one unit of LTOWB, with 19/38 (50%) including 4 LTOWB units. A total of 177 units of LTOWB were purchased during the study period, and of those, 74 (42%) expired before use. Patients who received LTOWB had a similar mortality compared to those who received component therapy (39% vs. 47%; Odds Ratio [95% CI]: 0.7 [0.3, 2.0]; p=0.72,) however, they were able to achieve a significantly higher plasma:pRBC ratio during the duration of MTP activation (mean [SD] 0.8 [0.2] vs. 0.4 [0.4]; mean difference [95% CI]: 0.4 [0.2, 0.5]; p<0.01.) CONCLUSIONS: Our early experience with LTOWB transfusion demonstrates feasibility, but also highlights challenges with inventory management. These findings triggered changes to our protocol aiming at minimizing wastage. The use of LTOWB may yield a higher plasma:pRBC ratio early during the resuscitation period. Further investigation is required to explore whether this may yield a survival advantage. III (Therapeutic/Care Management).

The impact of the COVID-19 outbreak on activation of the massive transfusion protocol in the emergency department.

An outbreak of coronavirus disease 2019 (COVID-19) occurred in mid-May of 2021 in Taiwan. After 2 months of hard work, transmissions were successfully prevented and the number of newly confirmed COVID-19 cases fell remarkably. We evaluated the impact of this outbreak on the massive transfusion protocol (MTP) in the emergency department (ED) of a trauma centre. We retrospectively compared the activation and efficacy of MTP before, during and after the outbreak by analysing the clinical data relevant to MTP activations. There was no remarkable change in the average number of MTP triggers per month during the outbreak. The interval from an MTP trigger to the first unit of blood transfused at bedside was significantly increased during the outbreak compared to that before the outbreak (22.4min vs. 13.9 min, p< 0.001); while the 24-h survival rate decreased (57.1% vs. 71.1%, p= 0.938). There were no remarkable changes in blood unit return or wastage during the outbreak. The COVID-19 outbreak limitedly affected MTP activation and waste of blood products, but significantly increased the interval from an MTP trigger to the first unit of blood transfused at bedside.