GSACEP Lecture Series: Thicker Than Water: Blood Product Resuscitation in the Operational Environment by Meaghan Keville, MD

Dr. Meaghan Keville, MD, is an emergency physician with Air Force Special Operations and currently a staff member at CSTARs Baltimore.  She shares her experience with blood resuscitation in the deployed environment and lessons that will be filtering to the civilian world in the future.

Transcript

Meaghan Keville: 1:02

Good morning everyone. My name is Megan cavil I'm an active duty, US Air Force em physician at the Center for sustainment of trauma and readiness skills at the our Adams Callie Shock Trauma Center in Baltimore, Maryland. Today, I'd like to take some time to talk about blood product usage and the operational environment, a fresh look at a topic that's been part of Operational Medicine for many years, what we use, why we use it, and a bit about the nuts and bolts of how to manage blood products outside of the hospital. I'd like to start by sharing a case with you from a recent deployment to get you thinking. I was part of a pair of two small surgical teams forward staged at a role to for a known high risk operation. We received the following information via radio call. There was an American soldier who had been shot multiple gunshot wounds with obvious paid penetrating injuries as you see listed for report. He'd initially lost consciousness but was now awake and talking. A tourniquet had been placed to the right arm. A sternal IO was placed and the above medications had been administered. The patient arrived to a role to approximately 17 minutes after injury via helicopter with two medics are somewhat impromptu team included a vascular surgeon, a transplant surgeon, an orthopedic surgeon, to CRNAs to emergency physicians, a nurse practitioner and an ICU nurse and addition the role to head to organic 18 Deltas. As we began her primary assessment, we found the following the tourniquet to the right arm and left leg with bilateral groins packed there were no current active bleeding. His airway was intact and he had a palpable pulse in the groin that was able to be assessed. There was no visible head injury. However, he was notably confused. He was brought in wrapped in a warming blanket. Or a secondary assessment was no more reassuring. Initial vital signs demonstrated a heart rate of 94 respirations of 24, an initial blood pressure of 73 over 23 and an O two set of 79% on room air. He was assessed to have approximately 11 gunshot wounds to the right chest, flank, lower abdomen, bilateral groins and left leg. As the resuscitation began, he was intubated receive bilateral chest tubes and a seven French sheath was placed in the right common femoral artery, he was prepared for damage control surgery. During this time, the walking blood bank was activated by the organic 18 Delta's seen here is their prep station. Thankfully, a thing of absolute perfection. From clean supplies ready at hand to the step by step reminders artistically created on some leftover packing Styrofoam. Our patient underwent exploratory laparotomy was zone one reboa placed times two for a total of 26 minutes of combined occlusion and partial occlusion time. The abdomen was packed to portions of small bowel or resected and a pelvic retroperitoneal hematoma was noted but not unroofed. At the role to I start results during his stay at the role two are shown here. Arrival ph 7.1 With lactate of 9.32 final rule to ICESat ph 7.2. Lactate 7.5. During his day there he received 37 units of whole blood between point of injury and arrival at rule 317 of which being warm, fresh whole blood from the walking blood bank. He was transported via fixed wing aircraft to a role three where he underwent initial evaluation and resuscitation. Here is his chest X ray on arrival. Here's his X ray of the abdomen with multiple fragments still present in the right upper quadrant and pelvis. Additionally, although difficult to see on this image, three Ebola which was left in place with balloon deflated can be appreciated traversing up towards the diaphragm. And lastly, here's his pelvis X ray. Again, with visible fragments and bilateral groins as well as deep in the pelvis. The reboa catheter can again be appreciated here. It was quickly identified that this patient would likely require more resuscitation than even the role three had the capability for the patient was taken back to the operating room and the walking blood bank was activated. Base wide via big voice announcement. Donors line up out the door and around the block to contribute over 150 units were drawn in less than a few hours. A second emergent exploratory laparotomy and wound wash out was performed. The pelvic hematoma was at this point unroofed and he was found to have bilateral iliac vein injuries. Ultimately, one common iliac ended up being ligated and the opposite external iliac was ligated as well. He remained intubated but stable in the ICU for the next two days. In the first 12 hours of his resuscitation, this patient received a total of 132 units of product combined 73 of these units were whole blood, multiple of them, oh positive, but untitled due to the shortage. Thankfully, he suffered none of the well known complications of severe multi trauma with massive transfusion, such as trolly arts or renal failure. He was transported back to the United States via Seacat. And shortly after excavated, I'm pleased to report that he has successfully completed rehab and return to his family and to active duty. This case is one example of how important a working knowledge of blood product utilization and logistics is in the operational environment to all providers. During the conflicts in Iraq and Afghanistan between 2003 and 2012 14%, of patients admitted to a rural three military treatment facility received a transfusion of at least one blood product. Of these 35% received massive transfusion, defined as greater than 10 units of red blood cells or whole blood in 24 hours. The proportion of transfused patients receiving massive transfusion reached approximately 50% by 2011. In parallel with increasing injury severity scores, use of blood product resuscitation, and decreased use of crystalloid and colloid use. Multiple studies have demonstrated that early blood product resuscitation provides the lowest mortality rates both early and late. The ABC or assessment of blood consumption score was developed out of Vanderbilt University as a simple way of predicting massive transfusion. Any two of the four components listed here is 75%, sensitive and 86% per specific for determining a massive transfusion event. A few other scores can also be helpful, but are slightly more complicated that TASH or trauma associated severe hemorrhage and McLaughlin scores can also be utilized but are slightly more complex and utilize laboratory values. Multiple studies in civilian literature suggest a shock index of greater than one to be indicative of a trauma patient that will likely require massive transfusion. A recent study by marinko at Al out of Madigan Army Medical Center and Scripps Mercy Hospital retrospectively reviewed the DoD trauma registry to demonstrate to them that a shock index of 0.8 is a significant predictor of the need for massive transfusion and emergency surgical procedures in the combat environment. As we move on to discuss the resuscitation of those sick trauma patients, I'll take a moment to step onto my favorite soapbox. The use of IV fluids for resuscitation can be traced back to 1831 during a particularly deadly cholera outbreak in London, although maybe a good thing for cholera patients, we've learned that for trauma patients sailing is not beneficial. I'm sure many of us can remember a time where a TLS recommended the administration of two liters of crystalloid prior to the administration of any blood product. How times have changed. The a TLS 10th edition now identifies that resuscitation with greater than 1.5 liters of crystalloid is associated with increased mortality dilutional coagulopathy, abdominal compartment syndrome, multiple organ failure and death and suggest limiting crystalloid use to no more than one leader during the initial resuscitation. My argument is that if blood is what's on the floor, it is what your patient needs. The Committee on tactical combat casualty care tends to agree. And their recommendations for choice of resuscitation fluid and the shock trauma patient are here. If you'll note options 1234 And five all involve some form of blood product. whole blood as a resuscitation fluid is not a new concept. Documented us dating back as early post World War Two and the Korean War as seen in this set of photos here. However, whole blood fell out of favor in the 1960s and 1970s, when separation of blood into its components became common practice in order to conserve blood as a resource and utilize only the components necessary. Although this was an effective method of improving storage times and decreasing waste, the change was not data driven. And there was little to no evidence to support therapeutic equivalence or superiority over her whole blood, particularly and the trauma patient population. However, there are many reasons as to why whole blood is an ideal choice for the resuscitation of the acutely ill trauma patient. For those math majors out there, here's a side by side comparison of whole blood versus component therapy composition. whole blood notably has higher MI, hemoglobin and hematocrit, higher platelet count and improve clotting in comparison to component therapy. Additionally, component therapy requires multiple different storage modes, and ultimately, patients receive various products for multiple different donors. Increasing overall inflammation and antibody presents an important consideration for future transfusion needs. To put it simply, for those of us that aren't as fond of public math, one can compare a single unit of whole blood to the combined component therapy volume, depending on your blood bank, roughly 300 ml per unit of extraneous crystalloid, or anticoagulant. Hopefully at this point, you might agree with me that blood products are the ideal choice of resuscitation and trauma patient, and that whole blood is the icing on that cake. But this may leave you with the question, how does blood get from the donor to my patient downrange? In short, it's a bit complicated. However, the armed services blood distribution system is a worldwide system for bringing blood products to those who need it. The logistics of this machine are beyond the scope of this discussion. However, let's take a closer look at the factors you should know as an end user. Wherever you find yourself if there is not a blood bank on site, blood will most likely arrive to you in a Columns box like seeing here, it can hold up to 30 units of blood with the appropriate 14 pounds or more of what ice or 15 units of fresh frozen plasma with its 20 to 30 pounds of pelleted dry ice. Both products can be kept at temperature for roughly 48 hours in this fashion. Although somewhat dependent on the outside temperature. The Golden Hour box is a means for transporting smaller amounts of product for shorter periods of time away from refrigeration. A few important points about the golden hour and minute boxes are that they must be frozen prior to use and require typically 24 hours of freeze time. They must be removed from the freezer and allowed to sit for 30 minutes before inserting any product. Once appropriately packed the box will maintain a temperature of one to six degrees for up to 72 hours. Golden Hour boxes can carry up to four units of PRBC or three units of FFP golden minute typically two units of product. important notes are that these containers do expire. You can check the expiration dates online using serial numbers and it is important not to use these containers without all insert components, they will be unlikely to maintain their temperature if they do not have all of the pieces. Blood Products storage should be carefully monitored downrange and without a blood bank. Keep in mind you may find yourself managing this daily temperature check should be monitored as well as stock expiration dates. Seen here is an example of the fridge freeze most commonly utilized. I've included the Air Force regulation for reference, but would presume each service likely has a similar similar one. Let's take a minute to deep dive on each of the products you might utilize and how you'll need to manage them in an operational environment. Codes stored whole blood is becoming the most frequently seen blood product downrange. It can be stored from one to six degrees Celsius and maintains its robust platelet function for up to 14 days. It can be utilized for up to 35 days depending on which preservative it has been drawn with. Some blood banks in the United States will cycle these units back to split into component therapy if not utilized within the first four 10 days to decrease wastage given packed red cells can be stored longer. We'll catch up on that in a minute. Fresh whole blood can either be stored at room temperature and used within 24 hours of collection and then destroyed if not used, or it can be refrigerated within eight hours of collection. After which point it is referred to as walking blood bank stored whole blood. A few words regarding the use of fresh whole blood at the time of the development of this lecture. Not all deploying personnel are currently required to be tighter to go downrange. Fresh whole blood low titer Oh whole blood is considered to have best when having a titer of less than one to 256 Anti A and anti B. This is something that J TTS is continuing to work on. However, it is important for those in leadership to consider those deploying to areas where this may be utilized must recognize that maintaining a battle roster with all deployed personnel as blood type can be life saving. Lastly, this process takes time even inexperienced hands and takes experienced hands to execute. Having supplies readily available for use and multiple trained personnel to manage the walking blood bank may also be life saving. packed red blood cells are still a mainstay of therapy and then trauma patient both in the United States and deployed. Depending on the preservative they can be stored for up to 35 days or 42 days and Refrigeration at one to six degrees Celsius. Typically see only a navy environment is also frozen red blood cells. Red blood cells that have been specifically treated and frozen with glycerol cryo precipitant that can be stored for up to 10 years at negative 65 degrees Celsius. Of note. When these red blood cells are ready for utilization, they must be thawed and rinsed in an automated process prior to transfusion that takes a few hours and some special equipment. AB plasma is classically considered the universal donor. However, it is now widely recognized that a plasma can in fact be considered universal. Since Group A individuals do not generally make high titer anti B antibodies and B red cells express the B antigen at such low depths density that they are much less susceptible to hemolysis than a red cells. fresh frozen plasma should be stored at minus 18 degrees Celsius or colder and when stored this way, can have a frozen shelf life of approximately a year. thawed plasma after being thought and a 37 degree water bath for approximately 30 minutes prior to transfusion has a shelf life of approximately five days. Liquid or never frozen plasma can be stored for up to 26 days or 40 days depending on its preservative. Freeze Dried plasma or French military freeze dried plasma is available to us special operations forces under an emergency use authorization from the FDA. You can see a vial in the bottom right corner of this slide. Pre reconstitution it has a two year shelf life. After reconstitution the shelf life is approximately four hours. currently in development is what you see in the top right corner freeze dried plasma made in the US that will not come in a glass bottle. You may find yourself wondering, how does a person create a 37 degree water bath for thawing frozen plasma in an operational environment. Thawing frozen plasma it takes time and it's somewhat unpredictable given one quarter of FFP units will be unusable when thawed due to broken packaging as a result of the freezing thawing process. For deployed teams have used many different methods, including everything from Emory heating elements, electric kettles and crackpots to accomplish this task, the favored device by far due to its ability to provide specific temperature control as well as its many different alternate uses is this cvwd There are two recent studies that looked at this problem in different ways. Mala do at Al's paper, feel the experience expedient thawing of fresh frozen plasma from transfusion in the year 2020 utilized only FFP and multiple different warmers to attempt to determine the most efficient one that does not affect the function of the plasma. Their results demonstrated that the superior solution with respect to timing was the Soviet immersion circulator requiring the shortest amount of time to repair the water and the N amount of time to thoughts similar to the clinical thar. This device maintained bath temperature accuracy as the clinical thar as well, even after adding in the two units of FFP. Additionally shown here are some selected images from the November 2020 military medicine article expeditionary immersion circulating heating device a promising technique for treating frostbite injuries and warming IV fluids in a forward deployed cold weather environment, demonstrating that the Soviet is not only helpful for the thawing of FFP, but also for warming blood and frostbitten extremities. In contrast to red cells and plasma platelets collected in theater by apheresis traditionally had been stored at room temperature under constant agitation for a maximum of five days. Refrigerated storage has been shown to better preserve platelet hemostatic function and clearly reduce the risk of bacterial growth. The major hazard of trans using room temperature stored platelets. Cold stored platelets have been proven effective in clinical trials and recently used successfully in combat trauma patients in the US that come area of operations, called soar, platelets and platelet additive solution or plasma retain function for at least 15 days and are compatible with blood warmers and a rapid infuser. For those of us, like myself, who have trouble keeping straight, all of the who gets what, when it comes to blood products. Here is a simple chart that keeps things straight as a reminder brought to you from the joint United Kingdom blood transfusion and tissue transplantation service. Here are a couple of final reminders for those of us that aren't typically the ones actually hanging the blood. Or if massive transfusion isn't a part of your daily practice. Early administration of calcium is recommended. One gram of calcium either 30 ml of 10% Calcium glucan eight or 10 mils of 10% Calcium Chloride IV or IO should be given to patients in hemorrhagic shock during or immediately after the transfusion of the first unit of blood product and with ongoing resuscitation after every four units of product. Ideally, ionized calcium should be monitored and serum and calcium should be given for an ionized calcium less than 1.2. Although it may not always be common practice in the United States, this is a reminder that it is acceptable and encouraged to spike blood tubing with blood products. Blood Products can also be administered with Plasma Light and normal saline. However, it is not recommended to accompany blood products with calcium containing fluids or hypotonic fluids. The importance of preventing hypothermia cannot be overemphasized. transfusing a trauma, patients with room temperature or cold fluids will only worsen the effects of trauma induced coagulopathy poor enzymatic function and DIC, expediting the arrival of your triage of death. However, finding fluid warmers with strong battery life, appropriate warming capabilities and flow rates that do not take up significant amounts of weight and cue at a reasonable cost continues to be a problem under investigation for the DOD. Shown here are a few examples of current available equipment. I strongly suggest becoming familiar with the equipment you will utilize when preparing for any downrange mission. Each of these has their own nuances and fail points that require mitigation. I leave you with a few parting words written by Captain J. S Mahone US Navy and his 1970 military medicine paper and in Korean into the nature of wounds resulting in killed in action in Vietnam, that I still believe ring true that American and Allied servicemen and women continue to receive the best hospital medical care possible, even in the worst of places. And that things like rapid use of whole blood rapid treatment either via transport of patient to hospital or hospital to patient. And the hard work of the people listening to this talk to continue to improve operational care every day brings service members willing to risk their lives home to their loved ones when they're injured. Thank you for your time and attention today. And with that open the floor to any questions