Making thawed universal donor plasma available rapidly for massively bleeding trauma patients: experience from the Pragmatic, Randomized Optimal Platelets and Plasma Ratios (PROPPR) trial.

BACKGROUND: The Pragmatic, Randomized Optimal Platelets and Plasma Ratios (PROPPR) trial was a randomized clinical trial comparing survival after transfusion of two different blood component ratios for emergency resuscitation of traumatic massive hemorrhage. Transfusion services supporting the study were expected to provide thawed plasma, platelets, and red blood cells within 10 minutes of request. STUDY DESIGN AND METHODS: At the 12 Level 1 trauma centers participating in PROPPR, blood components transfused and delivery times were tabulated, with a focus on universal donor (UD) plasma management. The adequacy of site plans was assessed by comparing the bedside blood availability times to study goals and the new American College of Surgeons guidelines. RESULTS: Eleven of 12 sites were able to consistently deliver 6 units of thawed UD plasma to their trauma-receiving unit within 10 minutes and 12 units in 20 minutes. Three sites used blood group A plasma instead of AB for massive transfusion without complications. Approximately 4700 units of plasma were given to the 680 patients enrolled in the trial. No site experienced shortages of AB plasma that limited enrollment. Two of 12 sites reported wastage of thawed AB plasma approaching 25% of AB plasma prepared. CONCLUSION: Delivering UD plasma to massively hemorrhaging patients was accomplished consistently and rapidly and without excessive wastage in high-volume trauma centers. The American College of Surgeons Trauma Quality Improvement Program guidelines for massive transfusion protocol UD plasma availability are practicable in large academic trauma centers. Use of group A plasma in trauma resuscitation needs further study.

Safety of stress echocardiography supervised by registered nurses: results of a 2-year audit of 15,404 patients.

BACKGROUND: Stress echocardiography has traditionally been performed under the supervision of physicians. In the last decade, at some institutions, specially trained registered nurses have taken on the task of directly supervising and conducting these stress tests with appropriate physician involvement and assistance. METHODS: The safety of 15,404 stress echocardiograms that were performed under the direct supervision of registered nurses during a recent 2-year period was evaluated. RESULTS: The stress modality was treadmill exercise in 8592 (56%), dobutamine in 6755 (44%), and transesophageal atrial pacing in 57 (0.04%) patients. The mean age was 65 +/- 13 years, and 54% were male. A total of 55 patients (0.36%) had complications related to stress echocardiography, including 26 patients (0.18%) who were subsequently transferred to hospital. Complications included atrial fibrillation (n = 28, 0.18%), other supraventricular tachycardias (n = 9, 0.06%), sustained ventricular tachycardia (n = 4, 0.03%), and ventricular fibrillation (n = 2, 0.01%). Eight patients (0.05%) were hospitalized for markedly positive tests or prolonged chest pain and 4 patients (0.03%) for symptomatic hypotension. No patient had cardiac rupture or died. Complications were more common with dobutamine stress echocardiography (DSE) (47/6755; 0.7%) compared with exercise echocardiography (8/8592; 0.09%) or transesophageal atrial pacing stress echocardiography (0/57) (P < .0001). Arrhythmias were more commonly associated with DSE (39/6755, 0.58%) than exercise echocardiography (4/8592, 0.05%). Potentially life-threatening ventricular arrhythmias occurred in 6 of 6755 patients who underwent DSE (0.09%) and in none of the patients who underwent exercise echocardiography. Patients who underwent DSE were, on average, older, and had more comorbidities compared with those who underwent exercise echocardiography. CONCLUSIONS: Stress echocardiography, when supervised directly by specially trained registered nurses, can be performed safely; complications are uncommon (1/280 stress tests) and these complication rates are comparable with previously reported studies evaluating the safety of stress echocardiography supervised by physicians.

Ensuring timely completion of type and screen testing and the verification of ABO/Rh status for elective surgical patients.

CONTEXT: A blood bank can provide compatible blood for an elective surgical procedure, provided a blood sample is received by the laboratory with sufficient time to allow pretransfusion testing and acquire enough compatible red blood cell units. With the push for same-day admission surgical procedures, a patient's pretransfusion blood sample is often collected the morning of surgery. However, if blood is needed, compatible units might not be immediately available. OBJECTIVE: To define and improve the process of completing presurgical/preadmission type and screen testing and verifying the ABO/Rh status of scheduled surgical patients before they receive a transfusion. STUDY DESIGN: A list of surgical procedures that might necessitate blood transfusion was created. A checklist was used to ensure that the preoperative clinic nurse collects a baseline pretransfusion blood sample for type and screen testing from patients scheduled for a listed procedure. A new pretransfusion specimen was received on the day of surgery, if needed, so that a current specimen would be available for compatibility testing and to verify the accuracy of the patient's ABO/Rh status in case blood was requested. RESULTS: During the 1-year study period, 666 patients qualified for baseline type and screen testing. Cholecystectomy was the most commonly scheduled surgery. In 99% of cases, a baseline type and screen specimen was received in the laboratory at least 1 day before surgery. The interval between the preoperative clinic visit and date of surgery varied from same day (6 patients) to 3 months. CONCLUSION: Timely receipt of a presurgical specimen for type and screen testing and verification of a patient's ABO/Rh status can be ensured when clinical services collaborate and when the hospital blood utilization committee provides oversight to improve compliance.

The role of the nurse in clinical echocardiography.

Echocardiography plays an important role in the practice of clinical cardiology. As echocardiographic practice has evolved, the addition of nursing personnel to the echocardiography team has enhanced the assessment and diagnosis of cardiovascular disease. Specifically, nurses monitor patients during transesophageal and stress examinations and establish intravenous access for sonicated saline, microsphere contrast, and medication administration. We describe the involvement of nurses in the practice of clinical echocardiography.