Whole Blood Transfusion Research Articles

Does early transfusion of cold-stored whole blood reduce the need for component therapy in civilian trauma patients? A systematic review.

Civilian acute trauma care has advanced in recent decades; however, traumatic injury remains the leading cause of death in individuals aged 15 to 29 years in the United States and worldwide. Uncontrolled hemorrhage is the leading preventable cause of death in trauma patients, with up to half of these deaths occurring before reaching a medical facility. The timely application of hemorrhage control measures is critical to enhance the survivability of trauma patients and is one of the major challenges faced by medical providers in austere environments. The purpose of this review is to explore if early resuscitation with cold-stored whole blood therapy reduces the need for component therapy in the first 24 hours postinjury in the civilian population. Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we performed a systematic literature search in Medline, EMBASE, and Transfusion Evidence Library for studies reporting data on 24-hour blood product usage in trauma patients in hemorrhagic shock receiving initial therapy with whole blood. Two reviewers independently performed the selection of eligible studies. Of a total of 2,150 identified studies, 11 studies (n = 4,792) met the inclusion criteria. There was heterogeneity in the study design, interventions, and outcomes. Seven studies reported a statistically significant decrease in 24-hour transfusion requirements in the whole blood intervention group in comparison with the control component therapy group. Three studies reported no significant difference between the two groups. One of the studies reported an increase in 24-hour transfusion requirements in the whole blood group. Overall, there appears to be a decrease in component therapy use following initial resuscitation with whole blood in trauma patients with hemorrhagic shock. However, further research is needed to address this important practical question (PROSPERO registration no. CRD42023422173). Systematic Review; Level IV.

Whole blood to total transfusion volume ratio in injured children: A national database analysis.

Whole blood (WB) resuscitation is increasingly common in adult trauma centers and some pediatric trauma centers, as studies have noted its safety and potential superiority to component therapy (CT). Previous analyses have evaluated WB as a binary variable (any versus none), and little is known regarding the "dose response" of WB in relation to total transfusion volume (TTV) (WB/TTV ratio). Injured children younger than 18 years who received any blood transfusion within 4 hours of hospital arrival across 456 US trauma centers were included from the American College of Surgeons Trauma Quality Improvement Program database. The primary outcome was 24-hour mortality, and the secondary outcome was 4-hour mortality. Multivariate analysis was used to evaluate associations between WB administration and mortality and WB/TTV ratio and mortality. Of 4,323 pediatric patients included in final analysis, 88% (3,786) received CT only, and 12% (537) received WB with or without CT. Compared with the CT group, WB recipients were more likely to be in shock, according to pediatric age-adjusted shock index (71% vs. 60%) and had higher median (interquartile range) Injury Severity Score (26 [17-35] vs. 25 [16-24], p = 0.007). Any WB transfusion was associated with 42% decreased odds of mortality at 4 hours (adjusted odds ratio [aOR], 0.58 [95% confidence interval, 0.35-0.97]; p = 0.038) and 54% decreased odds of mortality at 24 hours (aOR, 0.46 [0.33-0.66]; p < 0.001). Each 10% increase in WB/TTV ratio was associated with a 9% decrease in 24-hour mortality (aOR, 0.91 [0.85-0.97]; p = 0.006). Subgroup analyses for age younger than 14 years and receipt of massive transfusion (>40 mL/kg) also showed statistically significant survival benefit for 24-hour mortality. In this retrospective American College of Surgeons Trauma Quality Improvement Program analysis, use of WB was independently associated with reduced 24-hour mortality in children; further, higher proportions of WB used over the total resuscitation (WB/TTV ratio) were associated with a stepwise increase in survival. Prognostic and Epidemiological; Level III.

Barriers and Challenges to Implementing Whole Blood Transfusion Protocols in Civilian Hospitals: A Systematic Review and Meta-Analysis.

Background: Whole blood is a product that contains all three blood components (plasma, red blood cells, and platelets). This systemic review and meta-analysis was conducted to identify barriers and obstacles to establishing whole blood transfusion protocols in civilian hospitals. Methods: The study was conducted using PRISMA guidelines with PROSPERO registration No. CRD42024519898. Traumatic patients who needed or received whole blood transfusion were included. A systematic literature review employed a comprehensive search strategy through the PubMed, Google Scholar, Web of Science, ScienceDirect, and ProQuest databases. Meta-analysis was utilized to analyze the outcomes. The risk of bias was assessed using the Newcastle-Ottawa Scale. Results: In total, 310 studies were identified, and 11 studies met the inclusion criteria. The following intervals were used to assess the prevalence of mortality: 6 h 12.15% (0.081, 95% CI [0.023, 0.139]), 24 h 14.08% (0.141, 95% CI [0.111, 0.171]), delayed mortality (28-30 days) 22.89% (0.284, 95% CI [0.207, 0.360]), and in-hospital 18.72%, with relative risk (0.176, 95% CI [0.114,0.238]). Conclusions: Traumatic patients can be effectively resuscitated and stabilized with whole blood transfusion (WBT), but it is essential to provide ongoing critical care, address logistical challenges, and prevent blood product wastage. We recommend utilizing WBT in the early stages of resuscitation for adult civilian trauma patients.

TXA combined with whole blood transfusion in trauma patients does not increase the risk of VTE but shock index does

IntroductionPrevious studies have demonstrated the benefits of tranexamic acid (TXA) administration in combination with packed red blood cell (PRBC) transfusion in trauma patients without increasing the risk of venous thromboembolism (VTE). However, the effect of TXA in combination with whole blood (WB) has not been studied. Injury, abbreviated injury severity scores (ISS and AIS) and the need for blood transfusions are historically associated with VTE. The objective of this study was to determine the relationship between VTE and the combination of TXA administration and transfusion of PRBCs vs. WB. MethodsOur institutional trauma registry was queried for trauma patients between 2015 and 2022 who received either WB ​+ ​TXA or PRBC ​+ ​TXA either prehospital or within 4 ​h of arrival. Multivariate analysis was utilized to determine independent risk factors for VTE, which were defined as either a deep vein thrombosis (DVT) or a pulmonary embolism (PE). Model covariates included age, mechanism of injury (MOI), ISS, lower extremity AIS, comorbid conditions, and shock index (SI). Additional outcomes analyzed were hospital length of stay (LOS), ICU LOS, and ventilator days. ResultsThree hundred and five patients had complete data and were included in the analysis. Of those, 251 received WB ​+ ​TXA and 54 received PRBC ​+ ​TXA. A total of 34 patients were found to have VTE event (11.1 ​%); 28 (11.2 ​%) and 6 (11.1 ​%) from the WB ​+ ​TXA and PRBC ​+ ​TXA groups, respectively. An elevated pre-hospital SI was independently associated with increased VTE rate (OR 1.85, 95 ​% CI 1.07–3.20). WB transfusion, TXA administration, ISS, and MOI did not influence the rate of VTE. ConclusionThese data demonstrate that the combination of WB ​+ ​TXA administered to trauma patients has no higher risk of VTE than patients who receive PRBC ​+ ​TXA, a comparison that has not been studied clinically to date. Despite the pro thrombotic state enhanced by TXA and the decreased dilutional coagulopathy seen in WB resuscitation, there was no increased risk of VTE compared to TXA ​+ ​PRBC. There is no evidence that TXA combined with whole blood transfusion is associated with an increased risk of VTE. However, higher pre-hospital SI was associated with an elevated rate of VTE. These clinical features provide insight into patients who may be at an increased risk of developing VTE and may benefit from targeted prevention strategies.

Association between whole blood ratio and risk of mortality in massively transfused trauma patients: retrospective cohort study

BackgroundAlthough whole blood (WB) transfusion was reported to improve survival in trauma patients with hemorrhagic shock, little is known whether a higher proportion of WB is associated with an improved survival. This study aimed to evaluate the association between whole blood ratio (WBR) and the risk of mortality in trauma patients requiring massive blood transfusion.MethodsWe performed a retrospective cohort study from the ACS-TQIP between 2020 and 2021. Patients were aged ≥ 18 years and received WB within 4 h of hospital arrival as a part of massive blood transfusion. Study patients were categorized into four groups based on the quartiles of WBR. Primary outcome was 24-h mortality and secondary outcome was 30-day mortality. Multivariable logistic regression analysis, fitted with generalized estimating equations, was performed to adjust for confounding factors and accounted for within-hospital clustering.ResultsA total of 4087 patients were eligible for analysis. The median age was 37 years (interquartile range [IQR]: 27–53 years), and 85.0% of patients were male. The median number of WB transfusions was 2.3 units (IQR 2.0–4.0 units), and the total transfusion volume was 4940 ml (IQR 3350–8504). When compared to the lowest WBR quartile, the highest WBR quartile had lower adjusted 24-h mortality (adjusted odds ratio [AOR]: 0.61, 95% confidence interval [CI]: 0.46–0.81) and 30-day mortality (AOR 0.58; 95% CI 0.45–0.75).ConclusionThe probability of mortality consistently decreased with higher WBR in trauma patients requiring massive blood transfusion.

The Efficacy of Whole Blood Resuscitation During Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) to Mitigate Post-occlusion Circulatory Collapse: A Translational Model in Large Swine.

Uncontrolled torso hemorrhage is the primary cause of potentially survivable deaths on the battlefield. Zone 1 Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA), in conjunction with damage control resuscitation, may be an effective management strategy for these patients in the prehospital or austere phase of their care. However, the effect of whole blood (WB) transfusion during REBOA on post-occlusion circulatory collapse is not fully understood. Yorkshire male swine (n = 6 per group, 70-90 kg) underwent a 40% volume-controlled hemorrhage. After a 10-minute hemorrhagic shock period, a REBOA balloon was inflated in Zone 1. Fifteen minutes after inflation, 0, 1, or 3 units (450 mL/unit) of autologous WB was infused through the left jugular vein. Thirty minutes after initial balloon inflation, the balloon was deflated slowly over 3 minutes. Following deflation, normal saline was administered (up to 3,000 mL) and swine were observed for 2 hours. Survival (primary outcome), hemodynamics, and blood gas values were compared among groups. Statistical significance was determined by log-rank test, one-way ANOVA, and repeated measures ANOVA. Survival rates were comparable between groups (P = .345) with 66% of control, 33% of the one-unit animals, and 50% of the 3-unit animals survived until the end of the study. Following WB infusion, both the 1-unit and the 3-unit groups had significantly higher blood pressure (P < .01), pulmonary artery pressure (P < .01), and carotid artery flow (P < .01) compared to the control group. WB transfusion during Zone 1 REBOA was not associated with increased short-term survival in this large animal model of severe hemorrhage. We observed no signal that WB transfusion may mitigate post-occlusion circulatory collapse. However, there was evidence of supra-normal blood pressures during WB transfusion.

Whole Blood and Blood Component Resuscitation in Trauma: Interaction and Association With Mortality.

To evaluate the interaction between whole blood (WB) and blood component resuscitation in relation to mortality after trauma. WB is increasingly available in civilian trauma resuscitation, and it is typically transfused concomitantly with blood components. The interaction between WB and blood component transfusions is unclear. Adult patients with trauma with a shock index >1 who received ≥4 combined units of red blood cells and/or WB within 4 hours across 501 U.S. trauma centers were included using the American College of Surgeons Trauma Quality Improvement Program database. The associations between (1) WB resuscitation and mortality, (2) WB to total transfusion volume ratio (WB:TTV) and mortality, and (3) balanced blood component transfusion in the setting of combined WB and component resuscitation and mortality were evaluated with multivariable analysis. A total of 12,275 patients were included (WB: 2884 vs component-only: 9391). WB resuscitation was associated with lower odds of 4-hour [adjusted odds ratio: 0.81 (0.68-0.97)], 24-hour, and 30-day mortality compared with component-only. Higher WB:TTV ratios were significantly associated with lower 4-hour, 24-hour, and 30-day mortality, with a 13% decrease in odds of 4-hour mortality for each 10% increase in the WB:TTV ratio [0.87 (95% CI: 0.80-0.94)]. Balanced blood component transfusion was associated with significantly lower odds of 4-hour [adjusted odds ratio: 0.45 (95% CI: 0.29-0.68)], 24-hour, and 30-day mortality in the setting of combined WB and blood component resuscitation. WB resuscitation, higher WB:TTV ratios, and balanced blood component transfusion in conjunction with WB were associated with lower mortality in patients with trauma presenting in shock requiring at least 4 units of red blood cells and/or WB transfusion within 4 hours of arrival.

Managing severe anaemia with a blood transfusion in a suspected IMHA case

This article discusses a challenging case from initial presentation, stabilisation and treatment to relapse. The case had an inconclusive diagnosis and differentials of hemangiosarcoma or immune-mediated haemolytic anaemia. The case progression included intensive medical management and a whole-blood transfusion with an excellent outcome. The patient, Patch (8-year-old male neutered Jack Russell Terrier), presented with history of lethargy and sudden onset of inappetence. Clinical symptoms alongside a MPCV 19%, RBC 0.25, haemoglobin 63, high platelets and borderline basophils.

Quantifying the benefit of whole blood on mortality in trauma patients requiring emergent laparotomy.

Whole blood (WB) transfusions in trauma represent an increasingly utilized resuscitation strategy in trauma patients. Previous reports suggest a probable mortality benefit with incorporating WB into massive transfusion protocols. However, questions surrounding optimal WB practices persist. We sought to assess the association between the proportion of WB transfused during the initial resuscitative period and its impact on early mortality outcomes for traumatically injured patients. We performed a retrospective analysis of severely injured patients requiring emergent laparotomy and ≥ 3 units of red blood cell containing products (WB or packed red blood cells) within the first hour from an ACS Level 1 Trauma Center (2019-2022). Patients were evaluated based on the proportion of WB they received compared to packed red blood cells during their initial resuscitation (high ratio cohort ≥50% WB vs low ratio cohort <50% WB). Multilevel Bayesian regression analyses were performed to calculate the posterior probabilities and risk ratios (RR) associated with a WB predominant resuscitation for early mortality outcomes. 266 patients were analyzed (81% male, mean age of 36 years old, 61% penetrating injury, mean ISS of 30). The mortality was 11% at 4-hours and 14% at 24-hours. The high ratio cohort demonstrated a 99% (RR 0.12; 95% CrI 0.02-0.53) and 99% (RR 0.22; 95% CrI 0.08-0.65) probability of decreased mortality at 4-hours and 24-hours, respectively, compared the low ratio cohort. There was a 94% and 88% probability of at least a 50% mortality relative risk reduction associated with the WB predominate strategy at 4 hours and 24 hours, respectively. Preferential transfusion of WB during the initial resuscitation demonstrated a 99% probability of being superior to component predominant resuscitations with regards to 4 and 24-hour mortality suggesting that WB predominant resuscitations may be superior for improving early mortality. Prospective, randomized trials should be sought. Therapeutic, Level III.

Effectiveness of blood transfusion to cats suffering flea infestation

Donation and transfusion of whole blood and its components in cats are relevant issues in veterinary practice. Blood transfusion to cats helps effectively treat anemia of diverse causes or at least stabilize a patient for further examinatons and searh of solutions for particular pathologies. Measures ensuring blood matching of donor and recipient cats must be conducted with the utmost care and thoroughness possible. At the very least, the blood group A/B/AB of both cats should be checked, and ideally further cross-sampling should be performed so as to detect Mik antigenes and other incompatibilities. Unlike dogs, cats have natural antibodies. Donor cats must be clinically healthy, vaccinated, 2–8 years old, weigh over 4 kg, with hematocrit over 30% (preferably more than 35%). Also, a donor cat should be examined for blood-transmitted infections, including feline leukemia virus (FeLV), feline immunodeficiency virus (FIV), and Mycoplasma haemofelis (pathogen of infectious feline anemia). The article presents clinical cases of using blood transfusion to treat feline anemia and results of the conducted laboratory studies, showing effectiveness of the performed medical procedures. After blood transfusion, the cats had positive dynamics in the general clinical state and increases in the main morphological blood parameters up to the norm or to values close to it. However, the issue of posthemorrhagic anemia requires more in-depth research in each separate case, particularly regarding the underlying case, since it can return the animal’s state and its main morphological blood parameters to the initial level, with no recovery, or at least long remission. It was found that whole-blood transfusion to the recipient animals with flea invasion increased the number of red blood cells, hemoglobin content, and hematocrit, which positively affected blood oxygenation and redox processes in the recipient animals, and accordingly their general clinical state.

TRANSFUSION AND INFUSION THERAPY FOR MASSIVE BLOOD LOSS. PART 3. PHYSIOLOGICAL PREREQUISITES AND LIMITATIONS WHEN USING PLASMA AND PLATELETS FOR HAEMOSTATIC RESUSCITATION

Haemotransfusion for massive bleeding (MB) should be used according to the principles of hemostatic resuscitation and simultaneously restore both oxygen transport (which we wrote about in detail in our previous publication) and compensate for the deficiency of coagulation factors and platelets. Coagulation factors (especially fibrinogen) and platelets are passively lost with the bleeding and are consumed during clot formation. Although the principles of haemostatic resuscitation are known and actively promoted already after a decade, the logistical problems with the availability of single-group fresh frozen plasma (FFP) and, even more so, platelets and cryoprecipitate at the stage of the beginning of resuscitation, are still not resolved. Poor logistics of blood product supply and organizational issues interfere with implementing the principles of haemostatic resuscitation into the routine clinical practice of treating MB in Ukraine. A deficiency of blood components at the initial stage of resuscitation pushes some doctors to transfuse crystalloid and even colloid solutions, which in MB can increase coagulopathy due to blood dilution. In this article, we present the pathophysiological rationale for early recovery of coagulation factors by performing balanced haemostatic transfusion therapy using FFP and cryoprecipitate. With MB, there is often a need for rapid correction of coagulopathy, and when the patient's blood group has not yet been determined, or when single-group FFP is still not ready for transfusion, then the urgent need for FFP transfusion from a universal AB donor (IV group). Creation of reserves of FFP from a universal donor AB (IV) is advisable in the admission of medical institutions, especially those where, in the case of MK or the numerous and mass occurrence of patients, the occurrence of a deficiency of FSP of another blood group is likely. In the absence of sufficient components and blood products containing coagulation factors and platelets, the possibility of transfusion of warm whole blood or cold whole blood should be considered.

Anticoagulant rodenticide poisoning in dogs: Retrospective analysis of clinical and laboratory diagnostic data

In this retrospective study, patient records of dogs suffering from poisoning with coumarin derivatives were evaluated to characterize the clinical appearance more precisely. Retrospective data analysis included 52 dogs with hemostaseologically proven anticoagulant rodenticide poisoning which were treated as inpatients at the Clinic for Small Animals between September 2011 and October 2018. In only 2 dogs (4%) the intake of poison could be observed with certainty. The most common clinical signs observed were reduced general behavior (79%), pallor of the mucosa (79%), anorexia (60%), and dyspnea/tachypnea (60%). In contrast, macroscopically visible internal and external bleedings occurred less frequently. Initially, all cases showed a highly altered prothrombin time and most patients a considerably prolonged activated partial thromboplastin time. Anemia was present in 75% of patients. All dogs included in the study received initially an intravenous treatment with 10 mg/kg vitamin K1. Pretreatment with 1 mg/kg prednisolone was given for prophylaxis of possible incompatibility reactions. No patient showed signs of anaphylactic reaction. Transfusions of whole blood or concentrated red cells were given to only 10 of the 52 animals; only one received 2 transfusions of erythrocytes. 94% of the animals could be discharged home for outpatient therapy after a median length of hospitalization of 3 days (1-9 days) with physiological or almost physiological coagulation test results. Anticoagulant rodenticide poisoning is often associated with non-specific symptoms and good prognosis if treated adequately. Coagulation diagnostics is always indicated in cases with unclear disorders. In life-threatening emergencies, immediate intravenous infusion of high-dose vitamin K1 is a very effective treatment and results in a rapid increase in coagulation factor activity.

Study of Whole blood in Frontline Trauma (SWiFT): implementation study protocol

IntroductionUncontrolled bleeding is a major cause of death for patients with major trauma. Current transfusion practices vary, and there is uncertainty about the optimal strategy. Whole blood (WB) transfusion, which...

Timing to First Whole Blood Transfusion and Survival Following Severe Hemorrhage in Trauma Patients

Civilian trauma centers have revived interest in whole-blood (WB) resuscitation for patients with life-threatening bleeding. However, there remains insufficient evidence that the timing of WB transfusion when given as an adjunct to a massive transfusion protocol (MTP) is associated with a difference in patient survival outcome. To evaluate whether earlier timing of first WB transfusion is associated with improved survival at 24 hours and 30 days for adult trauma patients presenting with severe hemorrhage. This retrospective cohort study used the American College of Surgeons Trauma Quality Improvement Program databank from January 1, 2019, to December 31, 2020, for adult patients presenting to US and Canadian adult civilian level 1 and 2 trauma centers with systolic blood pressure less than 90 mm Hg, with shock index greater than 1, and requiring MTP who received a WB transfusion within the first 24 hours of emergency department (ED) arrival. Patients with burns, prehospital cardiac arrest, deaths within 1 hour of ED arrival, and interfacility transfers were excluded. Data were analyzed from January 3 to October 2, 2023. Patients who received WB as an adjunct to MTP (earlier) compared with patients who had yet to receive WB as part of MTP (later) at any given time point within 24 hours of ED arrival. Primary outcomes were survival at 24 hours and 30 days. A total of 1394 patients met the inclusion criteria (1155 male [83%]; median age, 39 years [IQR, 25-51 years]). The study cohort included profoundly injured patients (median Injury Severity Score, 27 [IQR, 17-35]). A survival curve demonstrated a difference in survival within 1 hour of ED presentation and WB transfusion. Whole blood transfusion as an adjunct to MTP given earlier compared with later at each time point was associated with improved survival at 24 hours (adjusted hazard ratio, 0.40; 95% CI, 0.22-0.73; P = .003). Similarly, the survival benefit of earlier WB transfusion remained present at 30 days (adjusted hazard ratio, 0.32; 95% CI, 0.22-0.45; P < .001). In this cohort study, receipt of a WB transfusion earlier at any time point within the first 24 hours of ED arrival was associated with improved survival in patients presenting with severe hemorrhage. The survival benefit was noted shortly after transfusion. The findings of this study are clinically important as the earlier timing of WB administration may offer a survival advantage in actively hemorrhaging patients requiring MTP.

X-ray irradiation effectively inactivated lymphocytes in transfusion in vivo monitored by the bioluminescence transfusion-associated graft-versus-host disease model.

Transfusion of cold-stored whole blood is the preferred resuscitation method for trauma patients but may cause transfusion-associated graft-versus-host disease (TA-GVHD). Standard clinical practice to prevent this is to irradiate blood components with gamma-rays. X-ray irradiations are also a safe and effective alternative to gamma-ray irradiation. We established a visual mouse model of TA-GVHD to compare the viability and function of lymphocytes exposed to gamma- and x-ray irradiation. A haploidentical transplantation mouse model was established to simulate TA-GVHD with Balb/c mice as donors and hybrid F1 CB6 mice (Balb/c × C57) as recipients. Spleen cells from Tg-Fluc+ Balb/c mice were isolated and irradiated with gamma-rays and x-rays. Lymphocyte activation, apoptosis and proliferation post phorbol 1 2-myristate 1 3-acetate (PMA) stimulation were evaluated. After transfusion, we monitored Fluc+ lymphocytes daily by bioluminescence imaging. Recipients were euthanized on day 21, and tissues were examined pathologically and for inflammatory cytokines. The viability of gamma- or x-ray irradiated lymphocytes decreased significantly with slight changes in proliferation in vivo after transfusion. Compared with the non-irradiated group, both the gamma- and x-ray irradiated groups showed significantly decreased clinical scoring and inflammatory cytokine levels. The fluorescence intensity of the body and target organs was reduced after irradiation. No recipients acquired TA-GVHD after lymphocyte transfusion subjected to gamma- or x-rays, showing that x-rays inactivate as well as gamma rays and are suitable for irradiating whole blood.

Severe Traumatic Brain Injury Induced Coagulopathy in Pediatric: An Important Lesson with Literature Review

Children with coagulopathy had a greater mortality rate after moderate to severe traumatic brain injury (TBI). The purpose of the current study was to examine the most recent relevant literature in relation to the therapy of TIC in pediatric isolated severe TBI patients. A 5 years old boy presented to emergency department with decrease of consciousness after hit by a motorcycle. He was referred from the district hospital without proper stabilization within 3 hours after the injury. From the blood examination, hemoglobin level was 8.1 g/dl, base deficit -9.9mEq/L with PTT and aPTT no coagulation suggesting coagulopathy. Emergency non-contrast head computed tomography was performed and showed anterior skull base fracture with discontinuity in left squamous suture suggesting a diastases fracture with an air hypodensity lesion in left frontal area suggesting a pneumocephalus. There was also a hyperdense lesion with crescent shape in frontal and interhemispheric region suggesting subdural hematoma. Delayed operation for almost 6 hours was advocated due to transfusion of whole blood and fresh frozen plasma to correct coagulopathy. The operation was successful, the patient was survived but upon 2 years follow up, the patient still wasn’t able to perform normal daily activity. Localized injury at the brain manifesting in systemic coagulopathy requires special care. Several steps need to be evaluated before surgery but it should not delay the attempt of controlling the source of coagulopathy by it means lesion in the brain. Our case demonstrates the important of recognizing and managing coagulopathy in severe traumatic brain injury.

Maintaining a Whole Blood-Centered Transfusion Improves Survival in Hemorrhagic Resuscitation.

Whole blood (WB) transfusion has been shown to improve mortality in trauma resuscitation. The optimal ratio of packed red blood cells (pRBC) to WB in emergent transfusion has not been determined. We hypothesized that a low pRBC:WB transfusion ratio is associated with improved survival in trauma patients. We analyzed the 2021 Trauma Quality Improvement Program (TQIP) database to identify patients who underwent emergent surgery for hemorrhage control and were transfused within four hours of hospital arrival, excluding transfers or deaths in the emergency department. We stratified patients based on pRBC:WB ratios. The primary outcome was mortality at 24 hours. Logistic regression was performed to estimate odds of mortality among ratio groups compared to WB alone, adjusting for injury severity, time to intervention, and demographics. Our cohort included 17,562 patients; of those, 13,678 patients had only pRBC transfused and were excluded. FFP:pRBC ratio was balanced in all groups. Among those who received WB (n = 3,884), there was a significant increase in 24-hour mortality with higher pRBC:WB ratios (WB alone 5.2%, 1:1 10.9%, 2:1 11.8%, 3:1 14.9%, 4:1 20.9%, 5:1 34.1%, p = 0.0001). Using empirical cutpoint estimation we identified a 3:1 ratio or less as an optimal cutoff point. Adjusted odds ratios of 24-hour mortality for 4:1 and 5:1 groups were 2.85 (95% CI: 1.19 - 6.81) and 2.89 (95% CI: 1.29 - 6.49), respectively. Adjusted hazard ratios of 24-hour mortality were 2.83(95%CI: 1.18 - 6.77) for 3:1 ratio, 3.67(95%CI: 1.57 - 8.57) for 4:1 ratio, and 1.97(95%CI: 0.91 - 4.23) for 5:1 ratio. Our analysis shows that higher pRBC:WB ratios at 4 hours diminished survival benefits of WB in trauma resuscitation. Further efforts should emphasize this relationship to optimize trauma resuscitation protocols.

Effective Humanitarian Work: Teaching Medical Skill Sets in Ukraine.

The senior authors traveled to Ukraine to teach specific skills to Ukrainian physicians and other medical professionals, utilizing a 2-day ATLS course, workshops in point-of-care ultrasonography (POCUS), lectures and webinars on damage control resuscitation, damage control surgery, and transfusion of whole blood. The authors have focused on providing skill sets that Ukrainian doctors can utilize within their existing system to improve immediate patient care for casualties resulting from the unanticipated Russian invasion and improve outcomes. Given the resource limitations and differences of the Ukrainian healthcare systems, the authors believe Western-based professionals who come to Ukraine to help for short periods should resist the temptation to offer western solutions that may not work in Ukraine. Major improvements in Ukrainian health care will require long-term efforts in teaching but also need to include increased efforts to improve hospitals, clinics, staffing, education, supplies, and equipment. Those who travel to help in Ukraine can still teach short courses that provide skills that Ukrainian doctors and nurses can use within their existing healthcare system to improve the quality of patient care in the immediate period of crisis and hopefully improve outcomes in the near term. It is not a reasonable expectation to think that the delivery of 2-day courses such as ATLS or POCUS will significantly change the country-wide delivery of healthcare. This sort of practice change requires the engagement of medical and political leaders and a sustained reform effort over years, not days or weeks. Supportive countries and non-governmental organizations need to prepare for a long and extensive investment in improving Ukrainian healthcare.

Association Between Whole Blood Transfusion and Mortality Among Injured Pediatric Patients.

The aim of this study was to assess the association between whole blood (WB) and mortality among injured children who received immediate blood transfusion. The use of WB for transfusion therapy in trauma has been revisited, and recent studies have reported an association between WB and improved survival among adults. However, evidence of a similar association lacks in children. We performed a retrospective cohort study from the American College of Surgeons Trauma Quality Improvement Program (ACS-TQIP) between 2020 and 2021. Patients were aged less than or equal to 16 years and had immediate blood transfusion within 4 hours of hospital arrival. Survival at 24 hours and 30 days were compared after creating 1:1 propensity score-matched cohorts, matching for demographics, injury type, vital signs on admission, trauma severity scores, hemorrhage control procedures, hospital characteristics, and the need for massive transfusion. A total of 2729 patients were eligible for analysis. The median age was 14 years (interquartile range: 8-16 years); 1862 (68.2%) patients were male; and 1207 (44.2%) patients were White. A total of 319 (11.7%) patients received WB. After a 1:1 ratio propensity score matching, 318 matched pairs were compared. WB transfusion was associated with improved survival at 24 hours, demonstrating a 42% lower risk of mortality (hazard ratio, 0.58; 95% CI, 0.34-0.98; P =0.042) Similarly, the survival benefit associated with WB transfusion remained consistent at 30 days (hazard ratio, 0.65; 95% CI, 0.46-0.90; P =0.011). The use of WB was associated with improved survival among injured pediatric patients requiring immediate transfusion.

TRANSFUSION AND INFUSION THERAPY FOR MASSIVE BLOOD LOSS. PART 1, UNEXPECTED INTRAOPERATIVE HAEMORRHAGE

TRANSFUSION AND INFUSION THERAPY FOR MASSIVE BLOOD LOSS. PART 1, UNEXPECTED INTRAOPERATIVE HAEMORRHAGE