Whole Blood for Civilian Urban Trauma Resuscitation: Historical, Present, and Future Considerations.

Whole blood (WB) has been used for more than a century for far-forward combat resuscitation. Following the Iraq/Afghanistan combat, maritime, and austere environment use of WB for the resuscitation of severely hemorrhaging patients, there has been an increasing use of WB for the civilian urban resuscitation environment population. The impetus for this was not just improved outcomes in far-forward hospitals, which had different populations and different needs than the civilian urban population, but also an application of the lessons suggested by recent 1:1:1 plasma:platelets:packed red cells fixed-ratio studies for patients with massive transfusion needs. Mechanistic, logistic, and standardization concerns have been addressed and are evolving as the WB project advances. A small number of studies have been published on WB in the civilian urban trauma population. In addition, European experience with viscoelastic testing and resuscitation with fibrinogen and prothrombin complex concentrate has provided another viewpoint regarding the choice of resuscitation strategies for severely bleeding trauma patients in urban civilian environments. There are randomized controlled trials in process, which are testing the hypothesis that WB may be beneficial for the civilian urban population. Whether WB will improve mortality significantly is now a matter of intense study, and this commentary reviews the history, mechanistic foundations, and logistical aspects for the use of WB in the civilian trauma population.

Sustainable surgical resource initiative for Haiti: the SSRI-Haiti project.

In response to the 2010 earthquake and subsequent cholera epidemic, St Luke's Medical Center was established in Port-au-Prince, Haiti. Here, we describe its inception and evolution to include an intensive care unit and two operating rooms, as well as the staffing, training and experiential learning activities, which helped St Luke's become a sustainable surgical resource. We describe a three-phase model for establishing a sustainable surgical centre in Haiti (build facility and acquire equipment; train staff and perform surgeries; provide continued education and expansion including regular specialist trips) and we report a progressive increase in the number and complexity of cases performed by all-Haitian staff from 2012 to 2022. The results are generalised in the context of the 'delay framework' to global health along with a discussion of the application of this three-phase model to resource-limited environments. We conclude with a brief description of the formation of a remote surgical centre in Port-Salut, an unforeseen benefit of local competence and independence. Establishing sustainable and collaborative surgery centres operated by local staff accelerates the ability of resource-limited countries to meet high surgical burdens.

SHock-INduced Endotheliopathy (SHINE): A mechanistic justification for viscoelastography-guided resuscitation of traumatic and non-traumatic shock.

Irrespective of the reason for hypoperfusion, hypocoagulable and/or hyperfibrinolytic hemostatic aberrancies afflict up to one-quarter of critically ill patients in shock. Intensivists and traumatologists have embraced the concept of SHock-INduced Endotheliopathy (SHINE) as a foundational derangement in progressive shock wherein sympatho-adrenal activation may cause systemic endothelial injury. The pro-thrombotic endothelium lends to micro-thrombosis, enacting a cycle of worsening perfusion and increasing catecholamines, endothelial injury, de-endothelialization, and multiple organ failure. The hypocoagulable/hyperfibrinolytic hemostatic phenotype is thought to be driven by endothelial release of anti-thrombogenic mediators to the bloodstream and perivascular sympathetic nerve release of tissue plasminogen activator directly into the microvasculature. In the shock state, this hemostatic phenotype may be a counterbalancing, yet maladaptive, attempt to restore blood flow against a systemically pro-thrombotic endothelium and increased blood viscosity. We therefore review endothelial physiology with emphasis on glycocalyx function, unique biomarkers, and coagulofibrinolytic mediators, setting the stage for understanding the pathophysiology and hemostatic phenotypes of SHINE in various etiologies of shock. We propose that the hyperfibrinolytic phenotype is exemplified in progressive shock whether related to trauma-induced coagulopathy, sepsis-induced coagulopathy, or post-cardiac arrest syndrome-associated coagulopathy. Regardless of the initial insult, SHINE appears to be a catecholamine-driven entity which early in the disease course may manifest as hyper- or hypocoagulopathic and hyper- or hypofibrinolytic hemostatic imbalance. Moreover, these hemostatic derangements may rapidly evolve along the thrombohemorrhagic spectrum depending on the etiology, timing, and methods of resuscitation. Given the intricate hemochemical makeup and changes during these shock states, macroscopic whole blood tests of coagulative kinetics and clot strength serve as clinically useful and simple means for hemostasis phenotyping. We suggest that viscoelastic hemostatic assays such as thromboelastography (TEG) and rotational thromboelastometry (ROTEM) are currently the most applicable clinical tools for assaying global hemostatic function-including fibrinolysis-to enable dynamic resuscitation with blood products and hemostatic adjuncts for those patients with thrombotic and/or hemorrhagic complications in shock states.

Universal Anesthesia Machine: Clinical Application in an Austere, Resource-Limited Environment.

INTRODUCTION: In austere environments, the safe administration of anesthesia becomes challenging because of unreliable electrical sources, limited amounts of compressed gas, and insufficient machine maintenance capabilities. Such austere environments exist in battlefield medicine, in low- and middle-income countries (LMICs), and in areas struck by natural disasters. Whether in military operations or civilian settings, the Universal Anesthesia Machine (UAM) (Gradian Health Systems, New York, New York) is a draw-over device capable of providing safe and effective general anesthesia when external oxygen supplies or reliable electrical sources are limited. This brief report discusses a proof-of-concept observational study demonstrating the clinical utility of the UAM in a resource-limited area. MATERIALS AND METHODS: This observational study of 20 patients in Haiti who underwent general anesthesia using the UAM highlights the device's capability to deliver anesthesia intraoperatively in a resource-limited LMIC clinical setting. Preoxygenation was achieved with the UAM's draw-over oxygen supply. Patients received acetaminophen for analgesia, dexmedetomidine for preinduction anesthesia, and succinylcholine for paralysis. After induction, the UAM provided a mixture of oxygen and isoflurane for maintenance of anesthesia. Manual ventilation was performed using draw-over bellows until spontaneous ventilation recurred, when clinically appropriate, artificial airways were removed. Intraoperative medication was administered at the anesthesiologist's discretion. The institutional review board at the U.S. anesthesiologists' affiliated institution and the Haitian hospital approved this study; patients were consented in their native language. RESULTS: Two anesthesiologists used the UAM to deliver general anesthesia to 20 patients in a Haitian hospital without access to an external oxygen supply, reliable power grid, or opioids. The patients' average age was ~40 years, and 90% of them were male. Most of the cases were herniorrhaphy (50%) and hydrocelectomy (25%) surgeries. The median American Society of Anesthesiologists (ASA) score was 2; 45% of the patients had an ASA score of 1, and none had an ASA score >3. Of the 20 cases, 55% of patients received an endotracheal tube, and 40% received a laryngeal mask airway; for one patient, only a masked airway was used. Every patient was discharged on the day of the surgery. No complications occurred in the perioperative or 1-month follow-up period. CONCLUSION: The UAM can be used where a lack of resources and training exist because of its simple design, built-in oxygen concentrator, and capacity to revert from continuous-flow to draw-over anesthesia in the event of a power failure or if external oxygen supplies are unavailable. We believe the UAM addresses some of the shortcomings of modern anesthesia machines and has the potential to improve the delivery of safe general anesthesia in combat and austere scenarios. Further studies could consider different types of surgeries than those reported here and involve more complex patients. Studies involving alternative anesthetic agents and non-anesthesiologist personnel are also needed. Overall, this brief report detailing the use of the UAM following a natural disaster in a LMIC is proof of concept that the machine can provide reliable anesthesia for surgical procedures in austere and resource-limited environments, including disaster areas and modern combat zones.

Using critical care physicians to deliver anesthesia and boost surgical caseload in austere environments: the Critical Care General Anesthesia Syllabus (CC GAS).

BACKGROUND: Despite an often severe lack of surgeons and surgical equipment, the rate-limiting step in surgical care for the nearly five billion people living in resource-limited areas is frequently the absence of safe anesthesia. During disaster relief and surgical missions, critical care physicians (CCPs), who are already competent in complex airway and ventilator management, can help address the need for skilled anesthetists in these settings. METHODS: We provided a descriptive analysis that CCPs were trained to provide safe general anesthesia, monitored anesthesia care (MAC), and spinal anesthesia using a specifically designed and simple syllabus. RESULTS: Six CCPs provided anesthesia under the supervision of a board-certified anesthesiologist for 58 (32%) cases of a total of 183 surgical cases performed by a surgical mission team at St. Luc Hospital in Port-au-Prince, Haiti in 2013, 2017, and 2018. There were no reported complications. CONCLUSIONS: Given CCPs' competencies in complex airway and ventilator management, a CCP, with minimal training from a simple syllabus, may be able to act as an anesthesiologist-extender and safely administer anesthesia in the austere environment, increasing the number of surgical cases that can be performed. Further studies are necessary to confirm our observation.