The use of warm fresh whole blood transfusion in the austere setting: A civilian trauma experience.

BACKGROUND: Hemostatic resuscitation strategy using blood components with a balanced ratio is adopted in the civilian trauma setting. However, there is usually limited availability of blood components in the austere setting. Warm fresh whole blood (WFWB) has been used for trauma patients with life-threatening hemorrhage necessitating massive transfusions in the Okinawa Islands, Japan. The purpose of this study was to evaluate the safety and feasibility of WFWB use in the austere civilian trauma setting. METHODS: We conducted a retrospective cohort study between January 1999 and June 2019, including trauma patients who received WFWB within 24 hours of admission. Immediately after WFWB was collected from blood donors, the sample was typed and screened for transmissible infectious diseases. Approximately half of the study population received irradiated WFWB to prevent graft versus host disease. We evaluated the incidence of transfusion-associated adverse events. Transfusion requirements and patient outcomes were compared between early and late WFWB use. RESULTS: A total of 28 patients from three civilian institutions were eligible. Of those, 93% sustained blunt trauma. The median Injury Severity Score was 37 (interquartile range, 32-49). All patients required operative hemostatic intervention, and half of the patients required both operative and endovascular hemostatic interventions. Patients received a median of 1,800 mL WFWB transfusions from seven volunteer blood donors. None of our subjects developed hemolytic reactions, transmissible infectious diseases, or graft versus host disease. Early WFWB use (within 4 hours of admission) was associated with a significant reduction in platelet transfusion requirement compared with the late WFWB group in univariate analysis (16 units vs. 47 units, p = 0.002). CONCLUSION: Warm fresh whole blood use is safe and feasible in an austere civilian trauma setting. Prospective studies with larger cohorts are necessary to determine whether early WFWB use will affect patient outcomes, transfusion requirement, and treatment cost. LEVEL OF EVIDENCE: Therapeutic, Level IV.

A carbapenem-resistant clinical isolate of Aeromonas hydrophila in Japan harbouring an acquired gene encoding GES-24 ß-lactamase.

Several species of Aeromonas produce the enzyme CphA metallo-ß-lactamase. This study describes an isolate of Aeromonas hydrophila harbouring an acquired gene encoding the carbapenemase GES-24. This isolate was obtained from an inpatient in Okinawa, Japan, with no apparent record of travelling overseas. The minimum inhibitory concentrations of carbapenems against this isolate were 8 µg ml-1 for imipenem and 16 µg ml-1 for meropenem. Recombinant GES-24 hydrolyzed all of the tested ß-lactams, including imipenem and meropenem. The genomic environment surrounding blaGES-24 was intI1-blaGES-24-aac(6')-IIc-qacEdelta1-sulI-orfX-tetR-tetE. This is the first report of A. hydrophila producing a GES-type carbapenemase.

Resuscitative endovascular balloon occlusion of the aorta performed by emergency physicians for traumatic hemorrhagic shock: a case series from Japanese emergency rooms.

BACKGROUND: Resuscitative endovascular balloon occlusion of the aorta (REBOA), which has been increasingly used for the management of hemorrhagic shock, is a less invasive strategy for the management of patients with very severe hemorrhage. However, its effectiveness remains controversial. METHODS: This retrospective case series included trauma patients who underwent REBOA for hemorrhagic shock due to trauma in four Japanese tertiary care emergency centers from January 2013 to March 2017. Patients in cardiac arrest at the time of REBOA and those who underwent REBOA for nontraumatic causes during the study period were excluded. RESULTS: A total of 24 patients underwent REBOA during the study period. The median age was 52 years (interquartile range (IQR) 36.5-62.5), 17 (70.8%) of the patients were male, and 23 (95.8%) had blunt trauma. The 24-h survival was 50% (n = 12), and the in-hospital survival rate was 41.7% (10/24). In all cases, REBOA was performed in emergency rooms by emergency physicians without fluoroscopic guidance. Complications of REBOA were mesenteric ischemia (n = 1, 4.2%), ischemia of the lower extremities (n = 1, 4.2%), and placement of REBOA in thoracic aortic injury (n = 3, 12.5%). CONCLUSIONS: REBOA can be an effective and feasible tool for controlling massive hemorrhage due to trauma. However, caution should be exercised regarding complications including placement of REBOA in aortic injury and limb ischemia in cases where REBOA is performed in an emergency department setting with minimal or no support from trauma surgeons.