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1.
Injury ; 2021 Oct 31.
Artigo em Inglês | MEDLINE | ID: mdl-34749909

RESUMO

INTRODUCTION: Transfusion strategy for trauma patients with massive haemorrhage is often incorporated in massive transfusion protocols (MTP). Albeit correct MTP use results in better patient outcome, research regarding the state of MTP knowledge is scarce. The objective of this study is therefore to assess knowledge of local MTP and massive transfusion strategy in the level 1 trauma centres in the Netherlands. Our hypothesis is that actual MTP knowledge is low and transfusion strategy differs. MATERIALS AND METHODS: Surveys were sent out in January 2020 to all trauma and vascular surgeons, anaesthesiologists, emergency department physicians of the largest level 1 trauma centre (locally, n = 113) and to one trauma surgeon, emergency physician and anaesthesiologist in each of the nine other governmentally assigned level 1 trauma centres in the Netherlands (nationally, n = 27). The respondents were subdivided into a frequent user group (MTP usage ≥ 4 times in 2019) and a non-frequent user group (MTP usage < 4 in 2019). Data are expressed as numbers and percentages. RESULTS: Response rate was (n = 48; 42%) for the local survey and (n = 14; 52%) for the national survey. Locally, (n = 23; 48%) and (n = 25; 52%) respondents were defined frequent and non-frequent users respectively and national respondents all as frequent users. In total, (n = 13; 27%) of local respondents were aware of the current local composition of the MTP. Respondents indicated to transfuse erythrocytes first, followed by plasma and platelets (local non-frequent users n = 23; 92%, local frequent users n = 21; 91% and national frequent users n = 13; 93%). The indication for platelet transfusion was units erythrocytes transfused (local non-frequent users n = 10; 40% frequent users locally n = 11; 48% and nationally n = 5; 36%) and clinical view (local non-frequent users n = 9; 36%, frequent users locally n = 8; 35% and n<5 nationally. Whereas few respondents claimed (n = 5; 21% non-frequent users locally and n <5 nationally) to transfuse platelets based on platelet counts. Viscoelastic haemostatic assays were performed during MTP, but only by frequent users. CONCLUSION: The majority of physicians dealing with massive transfusion in trauma patients were not aware of the exact composition of the MTP and consensus regarding transfusion strategy and indication for platelet transfusion was low.

2.
J Trauma Acute Care Surg ; 91(4): 759-771, 2021 10 01.
Artigo em Inglês | MEDLINE | ID: mdl-34225351

RESUMO

BACKGROUND: Platelet transfusion during major hemorrhage is important and often embedded in massive transfusion protocols. However, the optimal ratio of platelets to erythrocytes (platelet-rich plasma [PLT]/red blood cell [RBC] ratio) remains unclear. We hypothesized that high PLT/RBC ratios, as compared with low PLT/RBC ratios, are associated with improved survival in patients requiring massive transfusion. METHODS: Four databases (Pubmed, CINAHL, EMBASE, and Cochrane) were systematically screened for literatures published until January 21, 2021, to determine the effect of PLT/RBC ratio on the primary outcome measure mortality at 1 hour to 6 hours and 24 hours and at 28 days to 30 days. Studies comparing various PLT/RBC ratios were included in the meta-analysis. Secondary outcomes included intensive care unit length of stay and in-hospital length of stay and total blood component use. The study protocol was registered in PROSPERO under number CRD42020165648. RESULTS: The search identified a total of 8903 records. After removing the duplicates and second screening of title, abstract, and full text, a total of 59 articles were included in the analysis. Of these articles, 12 were included in the meta-analysis. Mortality at 1 hour to 6 hours, 24 hours, and 28 days to 30 days was significantly lower for high PLT/RBC ratios as compared with low PLT/RBC ratios. CONCLUSION: Higher PLT/RBC ratios are associated with significantly lower 1-hour to 6-hour, 24-hour, 28-day to 30-day mortalities as compared with lower PLT/RBC ratios. The optimal PLT/RBC ratio for massive transfusion in trauma patients is approximately 1:1. LEVEL OF EVIDENCE: Systematic review and meta-analysis, therapeutic Level III.


Assuntos
Transfusão de Eritrócitos/estatística & dados numéricos , Hemorragia/terapia , Transfusão de Plaquetas/estatística & dados numéricos , Plasma Rico em Plaquetas , Ferimentos e Lesões/terapia , Hemorragia/etiologia , Hemorragia/mortalidade , Mortalidade Hospitalar , Humanos , Tempo de Internação , Índices de Gravidade do Trauma , Resultado do Tratamento , Ferimentos e Lesões/complicações , Ferimentos e Lesões/diagnóstico , Ferimentos e Lesões/mortalidade
3.
Vox Sang ; 116(2): 167-174, 2021 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-32996604

RESUMO

Whole blood is the original blood preparation but disappeared from the blood bank inventories in the 1980s following the advent of component therapy. In the early 2000s, both military and civilian practice called for changes in the transfusion support for massive haemorrhage. The 'clear fluid' policy was abandoned and replaced by early balanced transfusion of platelets, plasma and red cells. Whole blood is an attractive alternative to multi-component therapy, which offers reduced hemodilution, lower donor exposure and simplified logistics. However, the potential for wider re-introduction of whole blood requires re-evaluation of haemolysins, storage conditions and shelf-life, the need for leucocyte depletion/ pathogen reduction and inventory management for blood providers. This review addresses these questions and calls for research to define the optimal whole blood product and the indications for its use.


Assuntos
Transfusão de Sangue , Humanos
4.
Transfusion ; 60(8): 1846-1855, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32692441

RESUMO

BACKGROUND: Early plasma transfusion is important in the treatment of patients with major hemorrhage. Prolonged shelf life of AB type frozen -80°C and cold-stored (4°C) deep frozen plasma (DFP) will improve strategic stock management, minimize need for resupply, and make pre-hospital implementation more feasible. METHODS AND MATERIALS: Plasma products type AB of different age and origin (-30°C Fresh Frozen [(FFP], -80°C DFP [short (±1 year) and long (±7 year)] stored) were thawed (Day 0), stored at 4°C, and sampled on Days 7 and 14. Additionally, samples of plasma containing blood products (Octaplas LG®, whole blood and platelets) were compared for coagulation factor activity, phospholipid clotting time (PPL), and kaolin TEG during 4°C or 22°C storage. RESULTS: Coagulation profiles of FFP, short- and long-stored -80°C DFP were not significantly different after thaw. Cold storage did not affect fibrinogen, Protein C, and Antithrombin III activities whereas factor V, VII, VIII, and Protein S decreased in all blood products. After 14 days DFP still meets the guidelines for clinical use, except for Protein S (0.4 IU/mL). With exception of Octaplas LG®, phospholipid activity and TEG coagulation were similar between plasma containing blood components during storage. CONCLUSION: AB DFP quality was unaffected by almost 7 years of frozen storage. Quality of thawed 14-day stored AB DFP met, with exception of Protein S, all minimal guidelines which implies that its quality is sufficient for use in the (pre)-hospital (military) environment for treatment of major hemorrhage.


Assuntos
Transfusão de Componentes Sanguíneos , Preservação de Sangue , Congelamento , Plasma/química , Plasma/metabolismo , Humanos , Fatores de Tempo
5.
Transfusion ; 60(9): 2079-2089, 2020 09.
Artigo em Inglês | MEDLINE | ID: mdl-32592423

RESUMO

BACKGROUND: Cryopreserved platelet products can be stored for years and are mainly used in military settings. Following thawing, cryopreserved platelets are activated, resulting in faster clot formation but reduced aggregation in vitro, rendering their efficacy in bleeding unknown. Also, concerns remain on the safety of these products. The aim was to investigate the efficacy and safety of cryopreserved platelets in a rat model of traumatic hemorrhage. STUDY DESIGN AND METHODS: After 1 hour of shock, rats (n = 13/group) were randomized to receive a balanced transfusion pack (1:1:1 red blood cell:plasma:platelet) made from syngeneic rat blood, containing either liquid stored platelets or cryopreserved platelets. Primary outcome was the transfusion volume required to obtain a mean arterial pressure (MAP) of 60 mmHg. Secondary outcomes were coagulation as assessed by thromboelastometry (ROTEM®) and organ failure as assessed by biochemistry and histopathology. RESULTS: The transfusion volume to obtain a MAP of 60 mmHg was lower in animals receiving cryopreserved platelets (5.4 [4.1-7.1] mL/kg) compared to those receiving liquid stored platelets (7.5 [6.4-8.5] mL/kg, p < 0.05). ROTEM® clotting times were shorter (45 [41-48] vs. 49 [45-53]sec, p < 0.05), while maximum clot firmness was slightly lower (68 [67-68] vs. 69 [69-71]mm, p < 0.01). Organ failure was similar in both groups. CONCLUSIONS: Use of cryopreserved platelets required less transfusion volume to reach a targeted MAP compared to liquid stored platelets, while organ injury was similar. These results provide a rationale for clinical trials with cryopreserved platelets in (traumatic) bleeding.


Assuntos
Plaquetas , Preservação de Sangue , Criopreservação , Hemorragia , Transfusão de Plaquetas , Ferimentos e Lesões , Animais , Plaquetas/citologia , Plaquetas/metabolismo , Modelos Animais de Doenças , Hemorragia/sangue , Hemorragia/etiologia , Hemorragia/terapia , Masculino , Ratos , Ferimentos e Lesões/sangue , Ferimentos e Lesões/complicações , Ferimentos e Lesões/terapia
6.
Transfus Apher Sci ; 59(3): 102789, 2020 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-32340813

RESUMO

The Dutch military uses frozen blood products for the treatment of bleeding trauma patients during military deployments. With -80 °C frozen blood products it is possible to follow operational demand while reducing the number of resupply transports and loss of products due to expiration. In this paper lessons learned are described on efficient blood management with -80 °C deep-frozen erythrocytes (DEC).


Assuntos
Bancos de Sangue/normas , Preservação de Sangue/métodos , Criopreservação/métodos , Eritrócitos/metabolismo , Humanos , Militares , Países Baixos
7.
Emerg Med J ; 37(2): 65-72, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31831587

RESUMO

OBJECTIVES: Massive transfusion protocols (MTPs) may improve survival in patients with uncontrolled haemorrhage. An MTP was introduced into the Dutch transfusion guidelines in 2011, the ninth edition of the advanced trauma life support course in 2012 and the third version of the European guideline in 2013. This is the first survey of MTPs in Dutch trauma centres. METHODS: The aim of the study was to compare MTP strategies in level 1 trauma centres in The Netherlands, and with (inter)national guidelines. A contact in each government assigned level 1 trauma centre in The Netherlands and the Dutch Ministry of Defence was approached to share their MTPs and elucidate their protocol in a survey and oral follow-up interview. RESULTS: All 11 level 1 trauma centres responded. The content of the packages and transfusion ratios (red blood cells/plasma/platelets) were 3:3:1, 5:5:1, 5:3:1, 2:3:1, 4:4:1, 5:2:1, 2:2:1 and 4:3:1. Tranexamic acid was used in all centres and an additional dose was administered in eight centres. Fibrinogen was given directly (n=4), with persistent bleeding (n=3), based on Clauss fibrinogen (n=3) or rotational thromboelastometry (n=1). All centres used additional medication in patients in the form of anticoagulants, but their use was ambiguous. CONCLUSION: MTPs differed between institutes and guidelines. The discrepancies in transfusion ratios can be explained by (inter)national differences in preparation and volume of blood components and/or interpretation of the '1:1:1' guideline. We recommend updating MTPs every year using the latest guidelines and evaluating the level of evidence for treatment during massive transfusion.


Assuntos
Transfusão de Sangue/métodos , Protocolos Clínicos/normas , Adulto , Transfusão de Sangue/instrumentação , Feminino , Hemorragia/terapia , Humanos , Masculino , Países Baixos , Ressuscitação/métodos , Inquéritos e Questionários
8.
Transfusion ; 58(10): 2430-2436, 2018 10.
Artigo em Inglês | MEDLINE | ID: mdl-30238464

RESUMO

BACKGROUND: Thromboelastography (TEG) is widely advocated as a rapid method for obtaining critical blood coagulation data to guide resuscitation, but the method suffers well-known limits in sensitivity, repeatability, and interpretability. STUDY DESIGN AND METHODS: Mixtures of fresh human blood components were prepared that represent the range of blood element concentrations seen in health and disease and after injury. These mixtures were tested in a TEG device after kaolin, tissue factor and phospholipid, or tissue factor and phospholipid with abciximab activation. The results were measured as reproducibility and nonlinear effects in regression analysis and evaluated for interpretability. RESULTS: Clot strength was associated with increased platelet (PLT) content and plasma fibrinogen concentration and content. Increasing hematocrit (Hct) reduced while increasing PLT or plasma concentration increased TEG clot strength. The abciximab dose used to block PLT activity did not fully inhibit the PLT contribution to clot strength. Clot strength is logarithmically correlated in the absence and linearly correlated to PLT concentration in the presence of abciximab. TEG clot strength with or without abciximab is dependent on Hct, PLT, and plasma (fibrinogen) concentrations in complex patterns. CONCLUSION: Interpretation of TEG variables is limited without knowledge of the concentration of the blood components present. When "normal" TEG values are known for a certain PLT-plasma-red blood cell concentration, the assay can be used to assess PLT and plasma function in coagulation. The TEG "functional fibrinogen" assay should be used only as a gross estimate of the fibrinogen concentration in whole blood.


Assuntos
Coagulação Sanguínea , Plaquetas/citologia , Fibrinogênio/análise , Tromboelastografia/métodos , Testes de Coagulação Sanguínea , Humanos , Ressuscitação , Tromboelastografia/normas
9.
PLoS One ; 11(12): e0168401, 2016.
Artigo em Inglês | MEDLINE | ID: mdl-27959967

RESUMO

INTRODUCTION: The Netherlands Armed Forces use -80°C frozen red blood cells (RBCs), plasma and platelets combined with regular liquid stored RBCs, for the treatment of (military) casualties in Medical Treatment Facilities abroad. Our objective was to assess and compare the use of -80°C frozen blood products in combination with the different transfusion protocols and their effect on the outcome of trauma casualties. MATERIALS AND METHODS: Hemovigilance and combat casualties data from Afghanistan 2006-2010 for 272 (military) trauma casualties with or without massive transfusions (MT: ≥6 RBC/24hr, N = 82 and non-MT: 1-5 RBC/24hr, N = 190) were analyzed retrospectively. In November 2007, a massive transfusion protocol (MTP; 4:3:1 RBC:Plasma:Platelets) for ATLS® class III/IV hemorrhage was introduced in military theatre. Blood product use, injury severity and mortality were assessed pre- and post-introduction of the MTP. Data were compared to civilian and military trauma studies to assess effectiveness of the frozen blood products and MTP. RESULTS: No ABO incompatible blood products were transfused and only 1 mild transfusion reaction was observed with 3,060 transfused products. In hospital mortality decreased post-MTP for MT patients from 44% to 14% (P = 0.005) and for non-MT patients from 12.7% to 5.9% (P = 0.139). Average 24-hour RBC, plasma and platelet ratios were comparable and accompanying 24-hour mortality rates were low compared to studies that used similar numbers of liquid stored (and on site donated) blood products. CONCLUSION: This report describes for the first time that the combination of -80°C frozen platelets, plasma and red cells is safe and at least as effective as standard blood products in the treatment of (military) trauma casualties. Frozen blood can save the lives of casualties of armed conflict without the need for in-theatre blood collection. These results may also contribute to solutions for logistic problems in civilian blood supply in remote areas.


Assuntos
Preservação de Sangue , Transfusão de Sangue/métodos , Criopreservação , Medicina Militar/métodos , Ferimentos e Lesões/terapia , Sistema ABO de Grupos Sanguíneos , Adolescente , Adulto , Afeganistão , Segurança do Sangue , Criança , Temperatura Baixa , Transfusão de Eritrócitos/métodos , Feminino , Mortalidade Hospitalar , Humanos , Masculino , Militares , Países Baixos , Plasma/metabolismo , Transfusão de Plaquetas/métodos , Estudos Retrospectivos , Adulto Jovem
10.
Transfusion ; 43(2): 157-64, 2003 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-12559010

RESUMO

BACKGROUND: RBCs can be frozen with either the high-glycerol method (HGM) or the low-glycerol method (LGM). To date, the use of frozen RBCs is hampered by a 24-hour outdating period after thawing. A closed washing system (ACP 215) may solve this problem. STUDY DESIGN AND METHODS: We compared the effects of high- (40%) and low-glycerol (19%) concentration, with and without freezing (at -80 degrees C for HGM, -196 degrees C for LGM) on the in vitro quality of RBCs after deglycerolization with the closed washing system and during storage at 4 degrees C in SAGM after thawing. RESULTS: Glycerol treatment by itself induced hemolysis during processing, which was more pronounced in HGM cells. The freeze-thaw-wash process decreased the stability of RBCs, particularly in LGM cells during storage after thawing. In contrast to LGM cells, in HGM cells no additional effect of freeze or thaw on stability of washed cells was seen during the first week of storage after thawing. Changes in osmotic resistance and cellular metabolism could not explain the observed differences in RBC stability. CONCLUSION: The closed washing system is able to process both high- and low-glycerol-treated RBCs. Stability after washing during cold storage in SAGM, as measured by hemolysis, is better for HGM cells as compared to LGM cells.


Assuntos
Preservação de Sangue/métodos , Criopreservação/métodos , Crioprotetores/farmacologia , Eritrócitos/citologia , Glicerol/farmacologia , Preservação de Sangue/normas , Criopreservação/normas , Relação Dose-Resposta a Droga , Transfusão de Eritrócitos/normas , Hemólise/efeitos dos fármacos , Humanos , Temperatura
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