Hemorrhagic Resuscitation Guided by Viscoelastography in Far-Forward Combat and Austere Civilian Environments: Goal-Directed Whole-Blood and Blood-Component Therapy Far from the Trauma Center

Modern approaches to resuscitation seek to bring patient interventions as close as possible to the initial trauma. In recent decades, fresh or cold-stored whole blood has gained widespread support in multiple settings as the best first agent in resuscitation after massive blood loss. However, whole blood is not a panacea, and while current guidelines promote continued resuscitation with fixed ratios of blood products, the debate about the optimal resuscitation strategy—especially in austere or challenging environments—is by no means settled. In this narrative review, we give a brief history of military resuscitation and how whole blood became the mainstay of initial resuscitation. We then outline the principles of viscoelastic hemostatic assays as well as their adoption for providing goal-directed blood-component therapy in trauma centers. After summarizing the nascent research on the strengths and limitations of viscoelastic platforms in challenging environmental conditions, we conclude with our vision of how these platforms can be deployed in far-forward combat and austere civilian environments to maximize survival.

Chronic ectopic pregnancy complicated by septicemic shock and disseminated intravascular coagulation

Disseminated intravascular coagulation is a life threatening complication of ectopic pregnancy. It results from washing out of all important procoagulants. This is basically a state of increased propensity for clot formation triggered by a variety of stimuli related to such diverse disorders as sepsis ,endothelial cell damage (heat stroke and shock), obstetrical complication (abruptio placenta, amniotic fluid embolism, severe preeclampsia and retained intrauterine dead foetus). A case of disseminated intravascular coagulation with septicemic shock following laprotomy for ectopic pregnancy is reported. She was treated by vasopressors, broad spectrum antibiotic and aggressive blood and blood component therapy.

Whole Blood Versus Conventional Blood Component Massive Transfusion Protocol Therapy in Civilian Trauma Patients

Background Military data demonstrating an improved survival rate with whole blood (WB) have led to a shift toward the use of WB in civilian trauma. The purpose of this study is to compare a low-titer group O WB (LTOWB) massive transfusion protocol (MTP) to conventional blood component therapy (BCT) MTP in civilian trauma patients. Methods Trauma patients 15 years or older who had MTP activations from February 2019 to December 2020 were included. Patients with a LTOWB MTP activation were compared to BCT MTP patients from a historic cohort. Results 299 patients were identified, 169 received LTOWB and 130 received BCT. There were no differences in age, gender, or injury type. The Injury Severity Score was higher in the BCT group (27 vs 25, P = .006). The LTOWB group had a longer transport time (33 min vs 26 min, P < .001) and a lower arrival temperature (35.8 vs 36.1, P < .001). Other hemodynamic parameters were similar between the groups. The LTOWB group had a lower in-hospital mortality rate compared to the BCT group (19.5% vs 30.0%, P = .035). There were no differences in total transfusion volumes at 4 hours and 24 hours. No differences were seen in transfusion reactions or hospital complications. Multivariable logistic regression identified ISS, age, and 24-hour transfusion volume as predictors of mortality. Discussion Resuscitating severely injured trauma patient with LTOWB is safe and may be associated with an improved survival.

Whole blood versus component therapy for haemostatic resuscitation of major bleeding: a protocol for a systematic review and meta-analysis

IntroductionThere is a renewed interest in the use of whole blood (WB) to manage patients with life-threatening bleeding. We aimed to estimate mortality and complications risk between WB and blood component therapy for haemostatic resuscitation of major bleeding.MethodsWe will conduct a systematic review and meta-analysis of studies published between 1 January 1980 and 1 January 2020, identified from PubMed and Scopus databases. Population will be patients who require blood transfusion (traumatic operative, obstetric and gastrointestinal bleeding). Intervention is WB transfusion such as fresh WB (WB unit stored for less than 48 hours), leukoreduced modified WB (with platelets removed during filtration), warm fresh WB (stored warm at 22°C for up to 8 hours and then for a maximum of an additional 24 hours at 4°C). The primary outcomes will be the 24-hour and 30-day survival rates (in-hospital mortality). Comparator is blood component therapy (red blood cells, fresh-frozen plasma and platelets given together in a 1:1:1 unit ratio). The Cochrane risk of bias tool for randomised controlled trials and Risk Of Bias In Non-randomised Studies - of Interventions (ROBINS-I) for observation studies will be used to assess the risk of bias of included studies. We will use random-effects models for the pooling of studies. Interstudy heterogeneity will be assessed by the Cochran Q statistic, where p<0.10 will be considered statistically significant and quantified by I2 statistic, where I2 ≥50% will indicate substantial heterogeneity. We will perform subgroup and meta-regression analyses to assess geographical differences and other study-level factors explaining variations in the reported mortality risk. Results will be reported as risk ratios and their 95% CIs.Ethics and disseminationNo ethics clearance is required as no primary data will be collected. The results will be presented at scientific conferences and published in a peer-reviewed journal.

Knowledge and practices of physicians on blood component therapy: a cross-sectional study from two tertiary hospitals in Nigeria

Introduction: Comprehension of blood component therapy (BCT) has profound impact on transfusion outcomes. Varia- tions from the standards in practices of BCT may jeopardize patient care. Aim: To assess the understanding and implementation of BCT by physicians. Methods: The study was carried out at two tertiary health care centres. It was a descriptive cross- sectional study using a self-administered, questionnaire comprising of 30 questions. Result: A total of 265 physicians responded from various clinical specialties. Physicians studied showed remarkable knowl- edge (98%) of BCT. Nevertheless, 92.8% of the respondents' were inclined to prescribing whole blood and the common- est reason given was ready availability at the blood bank. More than half of the respondents' have prescribed BCT with sedimented red cells and platelet concentrates being the most frequently prescribed blood components. Non-availability of blood components and cost implications were some of the identified limitations to the use of BCT. Conclusion: Majority of the physicians have a good knowledge concerning BCT. Nonetheless, there was a knowledge-prac- tice mismatch attributable to the unavailability of the various blood components limiting optimal practice of BCT. Strategies should be formulated to overcome these identified challenges to ensure quality transfusion services in our healthcare facil- ities. Keywords: Physicians; blood component therapy; blood transfusion; blood components; knowledge.

Blood component therapy, demographic and outcome feature of pediatric acute lymphoblastic leukemia

Introduction: Acute lymphoblastic leukemia (ALL) is the most common childhood malignancy, with an annual incidence rate of three to four cases per 100000 children. Most children with ALL frequently receive blood products including packed cells, platelets, fresh frozen plasma (FFP) and whole blood in the course of chemotherapy and these transfusions may affect ALL outcomes. Objectives: This study aimed to evaluate blood component therapy together with demographic and outcome features of pediatric ALL patients. Patients and Methods: Demographic information of 208 patients with pediatric ALL from February 2011 to August 2019 enrolled in this cross-sectional study. Data is gathered and rechecked from archive files and e-files of Motahari hospital. Results: The mean age of patients at diagnosis was 5.48±3.38 years and Pre-B ALL was the most common phenotype (94.3%). 130 Out of 208 patients were treated with the new protocol and 78 patients were treated with the BFM98 protocol. The majority of relapses were in the bone marrow. The average of received packed cell, platelet and FFP were 4.32±2.93, 5.97±7.09 and 5.29±6.6 units, respectively. The mean overall survival of patients was 3.42±2.58 years in 10 years. Conclusion: According to this study, most of the patients were 5 to 15 years old. Dominant subtype of disease was B-cell type. Most of the deaths were one to 6 years after diagnosis. The relapse rate was about 31% and most of them were in the bone marrow.

Viscoelastic Hemostatic Assays for Postpartum Hemorrhage

This article discusses the importance and effectiveness of viscoelastic hemostatic assays (VHAs) in assessing hemostatic competence and guiding blood component therapy (BCT) in patients with postpartum hemorrhage (PPH). In recent years, VHAs such as thromboelastography and rotational thromboelastometry have increasingly been used to guide BCT, hemostatic adjunctive therapy and prohemostatic agents in PPH. The three pillars of identifying hemostatic competence include clinical observation, common coagulation tests, and VHAs. VHAs are advantageous because they assess the cumulative contribution of all components of the blood throughout the entire formation of a clot, have fast turnaround times, and are point-of-care tests that can be followed serially. Despite these advantages, VHAs are underused due to poor understanding of correct technique and result interpretation, a paucity of widespread standardization, and a lack of large clinical trials. These VHAs can also be used in cases of uterine atony, preeclampsia, acute fatty liver of pregnancy, amniotic fluid embolism, placental abruption, genital tract trauma, surgical trauma, and inherited and prepartum acquired coagulopathies. There exists an immediate need for a point-of-care test that can equip obstetricians with rapid results on developing coagulopathic states. The use of VHAs in predicting and treating PPH, although in an incipient state, can fulfill this need.

An Update on Transfusion Related Immunomodulation (TRIM) in a Time of COVID- 19 Pandemic

Recipients' immune systems are triggered by blood and blood component therapy. Transfusion-related immunomodulation (TRIM) is a complicated immunological response to transfusion that results in immunosuppression. The mechanisms of TRIM include the presence of residual white blood cells and apoptotic cells, the infusion of immunosuppressive cytokines that are present in donor components or that occur during blood processing, the transfer of metabolically active growth factor-loaded particles and extracellular vesicles, and the presence of hemoglobin or extracellular vesicles binds to hemoglobin. TRIM variables include donor-specific factors and processing variables. TRIM can explain, at least partially, the controversial negative clinical results observed in patients with covid19. Many potential treatment methods have been used in clinical practice, including supportive interventions, immunomodulators, antiviral therapy, and infusion of convalescent plasma. Here, we summarize current potential treatments for COVID-19 infection-related diseases and discuss the clinical value of blood transfusion-related technologies for COVID-19 treatment in blood transfusion-related immune regulation.

Volume Resuscitation in the Acutely Hemorrhaging Patient: Historic Use to Current Applications

Acute hemorrhage in small animals results from traumatic and non-traumatic causes. This review seeks to describe current understanding of the resuscitation of the acutely hemorrhaging small animal (dog and cat) veterinary patient through evaluation of pre-clinical canine models of hemorrhage and resuscitation, clinical research in dogs and cats, and selected extrapolation from human medicine. The physiologic dose and response to whole blood loss in the canine patient is repeatable both in anesthetized and awake animals and is primarily characterized clinically by increased heart rate, decreased systolic blood pressure, and increased shock index and biochemically by increased lactate and lower base excess. Previously, initial resuscitation in these patients included immediate volume support with crystalloid and/or colloid, regardless of total volume, with a target to replace lost vascular volume and bring blood pressure back to normal. Newer research now supports prioritizing hemorrhage control in conjunction with judicious crystalloid administration followed by early consideration for administration of platelets, plasma and red blood during the resuscitation phase. This approach minimizes blood loss, ameliorates coagulopathy, restores oxygen delivery and correct changes in the glycocalyx. There are many hurdles in the application of this approach in clinical veterinary medicine including the speed with which the bleeding source is controlled and the rapid availability of blood component therapy. Recommendations regarding the clinical approach to volume resuscitation in the acutely hemorrhaging veterinary patient are made based on the canine pre-clinical, veterinary clinical and human literature reviewed.