Heat illness experience at BMH Shaibah, Basra, during Operation TELIC: May-July 2003.

This is an observational study of heat-related illness in UK Service Personnel deployed into summer conditions in Northern Kuwait and Southern Iraq. Among 622 hospitalisations reported during a 9-week period at the historical British Military Hospital, Shaibah, 303 consecutive admissions are reviewed in detail. Several clinical syndromes attributable to thermal stress were observed. These ranged from self-limiting debility to life-threatening failures of homeostasis, with 5.0% developing a critical care requirement. Hyponatraemia was a commonly occurring electrolyte disturbance by which, relative to the local reference range, a majority of heat-attributed admissions were affected. Reductions in measured serum sodium could be profound (<125 mmol/L in 20.1% of all heat-related casualties). Hypokalaemia was observed in half of cases, though only a minority were affected by severely low potassium (<2.5 mmol/L in 4.0%). Despite preventive measures prescribed on hospital discharge, illness and significant biochemical derangements could recur upon return to duties in the heat. We reiterate the need for primary prevention of heat illness wherever possible and importance of early, effective interventions to treat and protect Service Personnel from secondary injury. We also highlight the requirement for comprehensive assessment to inform prognostication and occupational decision-making in relation to extreme climatic heat, including aeromedical evacuation. We draw additional attention to the contribution of psychological factors in select cases and identify research questions to improve understanding of environment-induced incapacitation in general.

Sweet Corn Sentinel Monitoring for Lepidopteran Field-Evolved Resistance to Bt Toxins.

As part of an insect resistance management plan to preserve Bt transgenic technology, annual monitoring of target pests is mandated to detect susceptibility changes to Bt toxins. Currently Helicoverpa zea (Boddie) monitoring involves investigating unexpected injury in Bt crop fields and collecting larvae from non-Bt host plants for laboratory diet bioassays to determine mortality responses to diagnostic concentrations of Bt toxins. To date, this monitoring approach has not detected any significant change from the known range of baseline susceptibility to Bt toxins, yet practical field-evolved resistance in H. zea populations and numerous occurrences of unexpected injury occur in Bt crops. In this study, we implemented a network of 73 sentinel sweet corn trials, spanning 16 U.S. states and 4 Canadian provinces, for monitoring changes in H. zea susceptibility to Cry and Vip3A toxins by measuring differences in ear damage and larval infestations between isogenic pairs of non-Bt and Bt hybrids over three years. This approach can monitor susceptibility changes and regional differences in other ear-feeding lepidopteran pests. Temporal changes in the field efficacy of each toxin were evidenced by comparing our current results with earlier published studies, including baseline data for each Bt trait when first commercialized. Changes in amount of ear damage showed significant increases in H. zea resistance to Cry toxins and possibly lower susceptibility to Vip3a. Our findings demonstrate that the sentinel plot approach as an in-field screen can effectively monitor phenotypic resistance and document field-evolved resistance in target pest populations, improving resistance monitoring for Bt crops.

Vox Sanguinis International Forum on the use of prehospital blood products and pharmaceuticals in the treatment of patients with traumatic haemorrhage.

While specific practices and transported blood products vary around the world, most of the respondents in this International Forum transported at least one blood product for the transfusion to bleeding patients en route to the hospital. The most commonly carried product was RBCs, while the use of whole blood will likely increase given the recent reports of its successful use in the civilian setting, and because of the change in the AABB's Standards regulating its use. It will be interesting to see if plasma use in the prehospital setting becomes more widely used given today's enhanced appreciated of the coagulopathy of trauma and plasma's beneficial effect in reversing it, and if blood products are transported to the scene of injury by more vehicles, that is, not just predominantly in helicopters. It was not surprising that TXA is being widely administered as close to the time of injury as possible given its potential benefit in these patients. This International Forum highlights the importance of focusing attention on prehospital transfusion management with a need to further high­quality research in this area to guide optimal resuscitation strategies.

Massive transfusion: changing practice in a single Norwegian centre 2002-2015.

OBJECTIVES: To describe the change in massive transfusion (MT) practice in a single Norwegian centre throughout the period 2002-2015. BACKGROUND: MT support for traumatic haemorrhage has changed since the mid-2000s. However, life-threatening haemorrhage may occur in other clinical specialties. In 2007, Haukeland University Hospital (HUS) introduced a universal MT programme including education, Acute Transfusion Packages (ATPs) and thromboelastography. METHODS/MATERIALS: A retrospective review was performed of all MT episodes defined as ≥10 red cell concentrates (RCC) in 24 h. Episodes were identified using the laboratory information system. Patient records were reviewed manually for demographics, transfusion indication, haemostatic drugs and mortality. The ATPs contained six units RCC, six units Octaplas and two platelet concentrates (four buffy coats/apheresis in platelet additive solution (PAS)). RESULTS: A total of 410 episodes were identified in 410 patients. The mean patient age was 60 years (9-94), with a male predominance (64%); 87·1% of MT episodes were in support of surgery (cardiac services 42·7%; trauma 17·6%), and 29·8% of MTs involved platelet inhibitors, with 82·6% of these undergoing cardiac procedures. MT accounted for 2·8% of all RCCs and 3·4% of platelets issued. The mean ratio of blood components RCC: plasma: platelets changed from 1·0 : 0·37 : 0·39 in 2002-2006 (n = 149) to 1·0 : 0·79 : 0·85 in 2008-2015 (n = 241, P < 0·001). A sub-analysis showed that cardiac specialities used proportionally more plasma and platelets. CONCLUSION: The MT programme changed transfusion practice, resulting in greater use of plasma and platelets. MT was primarily used in major surgery. The practice in cardiac surgery may reflect changes in antiplatelet medication.

RePHILL: protocol for a randomised controlled trial of pre-hospital blood product resuscitation for trauma.

OBJECTIVES: To describe the 'Resuscitation with Pre-HospItaL bLood products' trial (RePHILL) - a multi-centre randomised controlled trial of pre-hospital blood product (PHBP) administration vs standard care for traumatic haemorrhage. BACKGROUND: PHBP are increasingly used for pre-hospital trauma resuscitation despite a lack of robust evidence demonstrating superiority over crystalloids. Provision of PHBP carries additional logistical and regulatory implications, and requires a sustainable supply of universal blood components. METHODS: RePHILL is a multi-centre, two-arm, parallel group, open-label, phase III randomised controlled trial currently underway in the UK. Patients attended by a pre-hospital emergency medical team, with traumatic injury and hypotension (systolic blood pressure <90 mmHg or absent radial pulse) believed to be due to traumatic haemorrhage are eligible. Exclusion criteria include age <16 years, blood product receipt on scene prior to randomisation, Advanced Medical Directive forbidding blood product administration, pregnancy, isolated head injury and prisoners. A total of 490 patients will be recruited in a 1 : 1 ratio to receive either the intervention (up to two units of red blood cells and two units of lyophilised plasma) or the control (up to four boluses of 250 mL 0.9% saline). The primary outcome measure is a composite of failure to achieve lactate clearance of ≥20%/h over the first 2 hours after randomisation and all-cause mortality between recruitment and discharge from the primary receiving facility to non-acute care. Secondary outcomes include pre-hospital time, coagulation indices, in-hospital transfusion requirements and morbidity. RESULTS: Pilot study recruitment began in December 2016. Approval to proceed to the main trial was received in June 2017. Recruitment is expected to continue until 2020. CONCLUSIONS: RePHILL will provide high-quality evidence regarding the efficacy and safety of PHBP resuscitation for trauma.

Freedom from frozen: the first British military use of lyophilised plasma in forward resuscitation.

Prehospital use of blood products may improve survival. However, transfusion support with frozen blood components is logistically burdensome and constrains the configuration of prehospital medical support. Alternatives to frozen plasma, including lyophilised plasma, offer the potential for advanced resuscitation in the prehospital environment. We describe the successful use of lyophilised plasma by a UK patrol in the prehospital environment during operations in Afghanistan in 2012 and reflect on recent military experience and the need for further developments.

Transfusion support by a UK Role 1 medical team: a 2-year experience from Afghanistan.

INTRODUCTION: This paper describes the clinical governance, training, equipment and infrastructure developed to enable a UK Role 1 medical team to deliver forward transfusion in Southern Afghanistan. The aim was to explore the utility and feasibility of forward blood transfusion by a Role 1 medical team in an austere military environment. METHODS: An audit of prospectively collected transfusion regulatory and cold chain data using standard-issue equipment and governance systems. TempIT tags were read before and after each mission to record blood storage temperature. Two years' data were analysed to review the use of blood products, cold chain compliance and equipment issues. RESULTS: Over 24 months, blood products were carried on over 1000 mission hours. Two clinical cases required transfusion and were successfully resuscitated. The team was able to correctly transport, store and deploy red cells and plasma on missions using standard Ministry of Defence (MOD) issue equipment. There were seven cold chain failures, all of which were addressed locally. Current cold chain and diagnostic equipment would require further optimisation for use at Role 1. CONCLUSIONS: An isolated Role 1 medical team can safely deliver blood transfusion on vehicle, helicopter or foot patrols. The transport and storage of blood created a large logistical burden for a relatively small clinical output. However, with further developments, this capability may have utility in contingency operations especially for isolated teams.

Early cryoprecipitate for major haemorrhage in trauma: a randomised controlled feasibility trial.

BACKGROUND: Low fibrinogen (Fg) concentrations in trauma haemorrhage are associated with poorer outcomes. Cryoprecipitate is the standard source for Fg administration in the UK and USA and is often given in the later stages of transfusion therapy. It is not known whether early cryoprecipitate therapy improves clinical outcomes. The primary aim of this feasibility study was to determine whether it was possible to administer cryoprecipitate, within 90 min of admission to hospital. Secondary aims were to evaluate laboratory measures of Fg and clinical outcomes including thrombotic events, organ failure, length of hospital stay and mortality. METHODS: This was an unblinded RCT, conducted at two civilian UK major trauma centres of adult trauma patients (age ≥16 yrs), with active bleeding and requiring activation of the major haemorrhage protocol. Participants were randomised to standard major haemorrhage therapy (STANDARD) (n=22), or to standard haemorrhage therapy plus two early pools of cryoprecipitate (CRYO) (n=21). RESULTS: 85% (95% CI: 69-100%) CRYO participants received cryoprecipitate within 90 min, median time 60 min (IQR: 57-76) compared with 108 min (67-147), CRYO and STANDARD arms respectively (P=0.002). Fg concentrations were higher in the CRYO arm and were maintained above 1.8 g litre(-1) at all time-points during active haemorrhage. All-cause mortality at 28 days was not significantly different (P=0.14). CONCLUSIONS: Early Fg supplementation using cryoprecipitate is feasible in trauma patients. This study supports the need for a definitive RCT to determine the effect of early Fg supplementation on mortality and other clinical outcomes. TRIAL REGISTRY NUMBER: ISRCTN55509212.

Deployed research.

The Role 3 Medical Treatment Facility (Field Hospital) in Camp Bastion (R3 Bastion) is acknowledged to be one of the busiest dedicated trauma facilities in the world. Casualties typically present with severe injuries and in physiological extremis. These casualties form a unique cohort representing the most relevant population to evaluate the effectiveness of treating battlefield injuries as academic clinicians and scientists interested in trauma seek to improve outcomes for such patients in the future. This article describes four separate but related research projects that have been undertaken in Camp Bastion, Afghanistan, over the last year. They traverse the spectrum of clinical research, ranging from data collection to a randomised control trial. The aim is to discuss some of the problems encountered and the solutions that made it possible to undertake research in a theatre of operations, thereby providing a starting point for others who may wish to initiate research in a similar environment.

Going for gold: blood planning for the London 2012 Olympic Games.

The Olympics is one of the largest sporting events in the world. Major events may be complicated by disruption of normal activity and major incidents. Health care and transfusion planners should be prepared for both. Previously, transfusion contingency planning has focused on seasonal blood shortages and pandemic influenzas. This article is the first published account of transfusion contingency planning for a major event. We describe the issues encountered and the lessons identified during transfusion planning for the London 2012 Olympics. Planning was started 18 months in advance and was led by a project team reporting to the Executive. Planning was based on three periods of Gamestime. The requirements were planned with key stakeholders using normal processes enhanced by service developments. Demand planning was based on literature review together with computer modelling. The aim was blood-stock sufficiency complimented by a high readiness donor panel to minimise waste. Plans were widely communicated and table-top exercised. Full transfusion services were maintained during both Games with all demands met. The new service improvements and high readiness donors worked well. Emergency command and control have been upgraded. Red cell concentrate (RCC) stock aged but wastage was not significantly increased. The key to success was: early planning, stakeholder engagement, service developments, integration of transfusion service planning within the wider health care community and conduct within an assurance framework.

Changes in blood transfusion practices in the UK role 3 medical treatment facility in Afghanistan, 2008-2011.

OBJECTIVE: To document blood component usage in the UK medical treatment facility, Afghanistan, over a period of 4 years; and to examine the relationship with transfusion capability, injury pattern and survival. BACKGROUND: Haemostatic resuscitation is now firmly established in military medical practice, despite the challenges of providing such therapy in austere settings. MATERIALS AND METHODS: Retrospective study of blood component use in service personnel admitted for trauma. Data were extracted from the UK Joint Theatre Trauma Registry. RESULTS: A total of 2618 patients were identified. Survival increased from 76 to 84% despite no change in injury severity. The proportion of patients receiving blood components increased from 13 to 32% per annum; 417 casualties received massive transfusion (≥10 units of RCC), the proportion increasing from 40 to 62%. Use of all blood components increased significantly in severely injured casualties, to a median (IQR) of 16 (9-25) units of red cell concentrate (P = 0·006), 15 (8-24) of plasma (P = 0·002), 2 (0-5) of platelets (P < 0·001) and 1 (0-3) of cryoprecipitate (P < 0·001). Cryoprecipitate (P = 0·009) and platelet use (P = 0·005) also increased in moderately injured casualties. CONCLUSIONS: The number of blood components transfused to individual combat casualties increased during the 4-year period, despite no change in injury severity or injury pattern. Survival also increased. Combat casualties requiring massive transfusion have a significantly higher chance of survival than civilian patients. Survival is the product of the entire system of care. However, we propose that the changes in military transfusion practice and capability have contributed to increased combat trauma survival.

Acute transfusion reactions: an update.

Over the last decade the use of blood products by the United Kingdom (UK) military has increased significantly; with the increase in transfusion comes an increased incidence of transfusion-related incidents. Acute transfusion reactions (ATRs) are a common consequence of transfusion, which vary widely in their severity and are likely to be under-reported, although reporting is a regulatory requirement. This paper discusses the importance of identifying ATRs and managing them appropriately. It introduces a flowchart (due to be incorporated in the next version of Joint Service Publication (JSP) 999, Clinical Guidelines for Operations (CGOs)), which is designed to assist the military multi-disciplinary team caring for patients in the operational environment.

A UK single-centre survey of red cell antibodies in adult patients undergoing liver transplantation.

BACKGROUND AND OBJECTIVES: Red cell antibodies may complicate blood provision and liver transplantation outcome. The aim of this survey was to document red cell antibodies in adults undergoing liver transplantation and make recommendations for clinical practice. MATERIALS AND METHODS: We completed a 10-year retrospective review of adults undergoing liver transplant, in a single UK centre using 4- to 6-weekly red cell antibody screening. RESULTS: Seven hundred and thirty seven patients were reviewed: 58 (7·9%) had antibodies. In 50 (6·8%) patients, the antibodies were clinically significant, and the commonest were Rhesus (49·5%) and Kell (11%). 33 patients had a single antibody, and the rest had multiple antibodies (range 2-5). Two-thirds of patients (38) had antibodies at presentation; 22% of these developed additional antibodies while on the waiting list or postoperatively. CONCLUSION: Consideration should be given to the proactive use of Rh- and K-typed blood in end-stage liver disease in order to reduce alloimmunization. In addition, regular antibody screening would enable staff to identify those with atypical antibodies and plan their transfusion support.

Blood and bombs: the demand and use of blood following the London Bombings of 7 July 2005--a retrospective review.

Mass casualty events (MCE) present health systems with a sudden demand on key services. The overall objective of this study was to describe the experience of the National Blood Service (NBS) following the largest UK MCE in recent times. Data was collated from the NBS database and directly from the hospitals involved. All data was collected immediately following the event and included: all blood components requested, issued and transfused in relation to the bombings, blood stock levels at the time and the injury profiles of the casualties transfused. The total NBS order from hospitals for the event was 1455 units of blood components. All requests were fulfilled, this included: 978 units of red cells (RC), 36 doses of platelets, 141 units of fresh frozen plasma (FFP) and 300 doses of cryoprecipitate. The amount of blood ordered was three times that initially used and the total number of RC transfused in treating all victims from admission to discharge was approximately 440 units. The greatest use of blood components was for those casualties who had sustained traumatic amputations amongst their injury profile. Published data with which to compare these results is lacking, although the RC use was similar to the initial mean individual usage described in previous military and civilian bombings. The overall implication for any blood service remains, there is now likely to be a far greater demand for plasma, platelets and cryoprecipitate in any future incidents involving victims suffering major haemorrhage.

Massive transfusion.

Massive Transfusion is a part of Damage Control Resuscitation. The aim of transfusion therapy is to restore oxygen delivery to poorly perfused tissues and to treat the acute coagulopathy of trauma. The severity and complexity of modern injuries have led to the use of swift, protocol-driven care with the use of'Shock Packs' and management of metabolic complications. The proactive treatment of the coagulopathy has been termed Haemostatic Resuscitation. The delivery of this transfusion capability has required an increasingly sophisticated logistic and laboratory response. New operational capabilities have included cold chain solutions; laboratory management information systems; platelet apheresis and ROTEM. This investment in the massive transfusion capability has delivered rapid resuscitation. It has also enabled clinicians to direct individualised transfusion support following initial resuscitation i.e. goal directed therapy. Future technical solutions should further support the prehospital delivery of transfusion while addressing the logistic tail. However, the key to success is the knowledge and skills of frontline staff to deliver safe and appropriate blood transfusion.