Whole Blood Transfusion.

Whole blood is the preferred product for resuscitation of severe traumatic hemorrhage. It contains all the elements of blood that are necessary for oxygen delivery and hemostasis, in nearly physiologic ratios and concentrations. Group O whole blood that contains low titers of anti-A and anti-B antibodies (low titer group O whole blood) can be safely transfused as a universal blood product to patients of unknown blood group, facilitating rapid treatment of exsanguinating patients.

Successful perioperative management in a patient with factor XI deficiency.

Factor XI (FXI) deficiency is an autosomal disorder which manifests as bleeding of varying severity. While homozygotes typically experience more dramatic bleeding symptoms, heterozygotes may experience clinically significant bleeding following surgical procedures or trauma, and therefore the condition is not purely recessive. The clinical significance of FXI deficiency is complicated in that FXI levels do not correlate well with bleeding severity, and in fact the bleeding risk is variable even for an individual in response to different haemostatic challenges.

Analysis of breast cancer in young women in the Department of Defense (DOD) database.

Purpose: Breast tumors from young women under the age of 40 account for approximately 7% of cases and have a poor prognosis independent of established prognostic factors. We evaluated the patient population served by the Military Health System, where a disproportionate number of breast cancer cases in young women are seen and treated in a single universal coverage healthcare system.

Methods: The Military Health System Repository and the DoD Central Registration databases were used to identify female breast cancer patients diagnosed or treated at military treatment facilities from 1998 to 2007.

Lessons Learned for the Resuscitation of Traumatic Hemorrhagic Shock.

The lessons learned regarding the resuscitation of traumatic hemorrhagic shock are numerous and come from a better understanding of the epidemiology, pathophysiology, and experience in this population over 10-plus years of combat operations. We have now come to better understand that the greatest benefit in survival can come from improved treatment of hemorrhage in the prehospital phase of care. We have learned that there is an endogenous coagulopathy that occurs with severe traumatic injury secondary to oxygen debt and that classic resuscitation strategies for severe bleeding based on crystalloid or colloid solutions exacerbate coagulopathy and shock for those with life-threatening hemorrhage.

Timing and location of blood product transfusion and outcomes in massively transfused combat casualties.

Background: Hemostatic resuscitation using blood components in a 1:1:1 ratio of platelets:fresh frozen plasma:red blood cells (RBCs) is based on analyses of massive transfusion (MT, ≥10 RBC units in 24 hours). These 24-hour analyses are weakened by survival bias and do not describe the timing and location of transfusions. Mortality outcomes associated with early (first 6 hours) resuscitation incorporating platelets, for combat casualties requiring MT, have not been reported.

Research and analytics in combat trauma care: converting data and experience to practical guidelines.

Throughout history, wars have resulted in medical advancements, especially in trauma. Once clinical challenges are identified, they require documentation and analysis before changes to care are introduced. The wars in Afghanistan and Iraq led to the collection of clinically relevant data from the entire medical system into a formal trauma registry.

Factors associated with acute lung injury in combat casualties receiving massive blood transfusions: a retrospective analysis.

Purpose: We sought to determine if use of warm fresh whole blood (WFWB), rather than blood component therapy, alters rates of acute lung injury (ALI) in patients with trauma.

Materials And Methods: We retrospectively analyzed rates of ALI in patients undergoing massive blood transfusions while at a combat support hospital. Patients with ALI were compared with those not developing ALI with respect to demographics, trauma type, severity of illness, crystalloid volume given, and exposure to WFWB.

The association of blood component use ratios with the survival of massively transfused trauma patients with and without severe brain injury.

Background: The effect of blood component ratios on the survival of patients with traumatic brain injury (TBI) has not been studied.

Methods: A database of patients transfused in the first 24 hours after admission for injury from 22 Level I trauma centers over an 18-month period was queried to find patients who (1) met different definitions of massive transfusion (5 units red blood cell [RBC] in 6 hours vs. 10 units RBC in 24 hours), (2) received high or low ratios of platelets or plasma to RBC units (<1:2 vs.

Increased platelet:RBC ratios are associated with improved survival after massive transfusion.

Background: Several recent military and civilian trauma studies demonstrate that improved outcomes are associated with early and increased use of plasma-based resuscitation strategies. However, outcomes associated with platelet transfusions are poorly characterized. We hypothesized that increased platelet:red blood cells (RBC) ratios would decrease hemorrhagic death and improve survival after massive transfusion (MT).

Impact of improved combat casualty care on combat wounded undergoing exploratory laparotomy and massive transfusion.

Background: Studies have shown decreased mortality after improvements in combat casualty care, including increased fresh frozen plasma (FFP):red blood cell (RBC) ratios. The objective was to evaluate the evolution and impact of improved combat casualty care at different time periods of combat operations.

Methods: A retrospective review was performed at one combat support hospital in Iraq of patients requiring both massive transfusion (≥ 10 units RBC in 24 hours) and exploratory laparotomy.

Comparison of platelet transfusion as fresh whole blood versus apheresis platelets for massively transfused combat trauma patients (CME).

Background: At major combat hospitals, the military is able to provide blood products to include apheresis platelets (aPLT), but also has extensive experience using fresh whole blood (FWB). In massively transfused trauma patients, we compared outcomes of patients receiving FWB to those receiving aPLT.

Study Design And Methods: This study was a retrospective review of casualties at the military hospital in Baghdad, Iraq, between January 2004 and December 2006.

Use of recombinant factor VIIa in US military casualties for a five-year period.

Background: Two prospective randomized trauma trials have shown recombinant factor VIIa (rFVIIa) to be safe and to decrease transfusion requirements. rFVIIa is presently used in 22% of massively transfused civilian trauma patients. The US Military has used rFVIIa in combat trauma patients for five years, and two small studies of massively transfused patients described an association with improved outcomes.

Popliteal artery repair in massively transfused military trauma casualties: a pursuit to save life and limb.

Background: Popliteal artery war wounds can bleed severely and historically have high rates of amputation associated with ligation (72%) and repair (32%). More than before, casualties are now surviving the initial medical evacuation and presenting with severely injured limbs that prompt immediate limb salvage decisions in the midst of life-saving maneuvers. A modern analysis of current results may show important changes because previous limb salvage strategies were limited by the resuscitation and surgical techniques of their eras.

Evidence-based practice guidelines for plasma transfusion.

Background: There is little systematically derived evidence-based guidance to inform plasma transfusion decisions. To address this issue, the AABB commissioned the development of clinical practice guidelines to help direct appropriate transfusion of plasma.

Study Design And Methods: A systematic review (SR) and meta-analysis of randomized and observational studies was performed to quantify known benefits and harms of plasma transfusion in common clinical scenarios (see accompanying article).

An evaluation of the impact of apheresis platelets used in the setting of massively transfused trauma patients.

Introduction: Trauma is a major cause of morbidity and mortality worldwide. Of patients arriving to trauma centers, patients requiring massive transfusion (MT, >or=10 units in 24 hours) are a small patient subset but are at the highest risk of mortality. Transfusion of appropriate ratios of blood products to such patients has recently been an area of interest to both the civilian and military medical community.

Warm fresh whole blood is independently associated with improved survival for patients with combat-related traumatic injuries.

Background: Increased understanding of the pathophysiology of the acute coagulopathy of trauma has lead many to question the current transfusion approach to hemorrhagic shock. We hypothesized that warm fresh whole blood (WFWB) transfusion would be associated with improved survival in patients with trauma compared with those transfused only stored component therapy (CT).

Methods: We retrospectively studied US Military combat casualty patients transfused >or=1 unit of red blood cells (RBCs).

Increased plasma and platelet to red blood cell ratios improves outcome in 466 massively transfused civilian trauma patients.

Objective: To determine the effect of blood component ratios in massive transfusion (MT), we hypothesized that increased use of plasma and platelet to red blood cell (RBC) ratios would result in decreased early hemorrhagic death and this benefit would be sustained over the ensuing hospitalization.

Summary Background Data: Civilian guidelines for massive transfusion (MT > or =10 units of RBC in 24 hours) have typically recommend a 1:3 ratio of plasma:RBC, whereas optimal platelet:RBC ratios are unknown. Conversely, military data shows that a plasma:RBC ratio approaching 1:1 improves long term outcomes in MT combat casualties.

Massive transfusion and nonsurgical hemostatic agents.

Background: Hemorrhage in trauma is a significant challenge, accounting for 30% to 40% of all fatalities, second only to central nervous system injury as a cause of death. However, hemorrhagic death is the leading preventable cause of mortality in combat casualties and typically occurs within 6 to 24 hrs of injury. In cases of severe hemorrhage, massive transfusion may be required to replace more than the entire blood volume.

Increased mortality associated with the early coagulopathy of trauma in combat casualties.

Background: Recent civilian studies have documented a relationship between increased mortality and the presence of an early coagulopathy of trauma diagnosed in the emergency department (ED). We hypothesized that acute coagulopathy (international normalized ratio >/=1.5) in combat casualties was associated with increased injury severity and mortality as is seen in civilian trauma patients.

The ratio of fibrinogen to red cells transfused affects survival in casualties receiving massive transfusions at an army combat support hospital.

Background: To treat the coagulopathy of trauma, some have suggested early and aggressive use of cryoprecipitate as a source of fibrinogen. Our objective was to determine whether increased ratios of fibrinogen to red blood cells (RBCs) decreased mortality in combat casualties requiring massive transfusion.

Methods: We performed a retrospective chart review of 252 patients at a U.

Effect of plasma and red blood cell transfusions on survival in patients with combat related traumatic injuries.

Background: The amount and age of stored red blood cells (RBCs) are independent predictors of multiorgan failure and death in transfused critically ill patients. The independent effect of plasma transfusion on survival has not been evaluated. Our objective was to determine the independent effects of plasma and RBC transfusion on survival for patients with combat-related traumatic injuries receiving any blood products.

A reduction in clot formation rate and strength assessed by thrombelastography is indicative of transfusion requirements in patients with penetrating injuries.

Background: Bleeding is a major cause of death in patients with traumatic injuries. Recently, thrombelastography (TEG) has been suggested as an additional means of evaluating coagulation in trauma patients. We hypothesized that TEG data would aid in defining the coagulopathy of trauma in patients with penetrating traumatic injuries.

A predictive model for massive transfusion in combat casualty patients.

Background: Massive transfusion (MT) is associated with increased morbidity and mortality in severely injured patients. Early and aggressive use of blood products in these patients may correct coagulopathy, control bleeding, and improve outcomes. However, rapid identification of patients at risk for MT has been difficult.