Background
The increasing use of fresh blood group O whole blood in acute trauma medicine makes it important to reevaluate the issue of hemolytic reactions related to the transfusion of ...ABO‐incompatible plasma.
STUDY DESIGN AND METHODS
This review summarizes and evaluates published articles and case reports concerning hemolytic reactions in connection with the transfusion of group O whole blood or blood products to nongroup O recipients.
Results
In 1945‐1986, 15 nonmilitary publications reported hemolytic transfusion reactions with group O blood/blood products. All patients recovered except for two fatalities. Late in World War II and during the Korean and Vietnam wars and onward in Iraq and Afghanistan only “low anti‐A, anti‐B titer” group O whole blood has been used as universal blood. In spite of a large number of units transfused, there are no reports of hemolytic reactions. Twenty‐five publications report hemolytic reactions after transfusion of group O platelets to nongroup O recipients. In all patients but one, the titer of the implicated A‐ or B‐antibody was >100 (saline) or >400 (antiglobulin) and all cases with an infused volume of incompatible plasma <200 mL were related to anti‐A or anti‐B antiglobulin titers >1000.
Conclusion
In emergency lifesaving resuscitation, the risk of hemolytic transfusion reactions from transfusion of group O blood to nongroup O recipients constitutes risk that is outweighed by the benefits. A low titer of anti‐A/B will minimize the risk for a hemolytic reaction, particularly if the screening is repeated after an immunization episode, e.g., blood transfusion, vaccination, or pregnancy.
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BFBNIB, FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SBCE, SBMB, UL, UM, UPUK
Background
In Afghanistan, a substantial portion of resuscitative combat surgery is performed by US Army forward surgical teams (FSTs). Red blood cells (RBCs) and fresh frozen plasma (FFP) are ...available at these facilities, but platelets are not. FST personnel frequently encounter high‐acuity patient scenarios without the ability to transfuse platelets. An analysis of the use of fresh whole blood (FWB) at FSTs therefore allows for an evaluation of outcomes associated with this practice.
Study Design and Methods
A retrospective analysis was performed in prospectively collected data from all transfused patients at six FSTs from December 2005 to December 2010. Univariate analysis was performed, followed by two separate propensity score analyses. In‐hospital mortality was predicted with the use of a conditional logistic regression model that incorporated these propensity scores. Subset analysis included evaluation of patients who received uncrossmatched Type O FWB compared with those who received type‐specific FWB.
Results
A total of 488 patients received a blood transfusion. There were no significant differences in age, sex, or Glasgow Coma Scale in those who received or did not receive FWB. Injury Severity Scores were higher in patients transfused FWB. In our adjusted analyses, patients who received RBCs and FFP with FWB had improved survival compared with those who received RBCs and FFP without FWB. Of 94 FWB recipients, 46 FWB recipients (49%) were given uncrossmatched Type O FWB, while 48 recipients (51%) received type‐specific FWB. There was no significant difference in mortality between patients that received uncrossmatched Type O and type‐specific FWB.
Conclusions
The use of FWB in austere combat environments appears to be safe and is independently associated with improved survival to discharge when compared with resuscitation with RBCs and FFP alone. Mortality was similar for patients transfused uncrossmatched Type O compared with ABO type‐specific FWB in an austere setting.
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BFBNIB, FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SBCE, SBMB, UL, UM, UPUK
Whole Blood Transfusion Cap, Andrew P; Beckett, Andrew; Benov, Avi ...
Military medicine,
09/2018, Volume:
183, Issue:
suppl_2
Journal Article
Peer reviewed
Open access
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. Whole blood can be stored under refrigeration for up to 35 days, during which it retains acceptable hemostatic function, though supplementation with specific blood components, coagulation factors or other adjuncts may be necessary in some patients. Fresh whole blood can be collected from pre-screened donors in a walking blood bank to provide effective resuscitation when fully tested stored whole blood or blood components are unavailable and the need for transfusion is urgent. Available clinical data suggest that whole blood is at least equivalent if not superior to component therapy in the resuscitation of life-threatening hemorrhage. Low titer group O whole blood can be considered the standard of care in resuscitation of major hemorrhage.
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DOBA, IZUM, KILJ, NUK, ODKLJ, PILJ, PNG, SAZU, UILJ, UKNU, UL, UM, UPUK, VSZLJ
Women generally display lower tolerance to acute central hypovolemia than men. The measurement of compensatory reserve (CRM) is a novel metric that provides information about the sum total of all ...mechanisms that together work to compensate for the relative blood volume deficit. Hemodynamic decompensation occurs with depletion of the CRM (i.e., 0% CRM). In the present study, we hypothesized that the lower tolerance to progressive central hypovolemia reported in women can be explained by a faster reduction rate in CRM compared with men rather than sex differences in absolute integrated compensatory responses. Continuous, noninvasive measures of CRM were collected from 208 healthy volunteers (107 men and 85 women) who underwent progressive stepwise central hypovolemia induced by lower body negative pressure to the point of presyncope. Comparisons revealed shorter ( P < 0.01) times in female participants compared with male participants to reach 30% and 0% CRM. Similarly, the lower body negative pressure level, represented by the cumulative stress index, was less at 30% and 0% CRM in women compared with men ( P < 0.01). Changes in hemodynamic responses and frequency-domain data (oscillations in cerebral blood flow velocity and mean arterial blood pressure) were similar between men and women at 0% CRM ( P > 0.05). We conclude that compensatory responses to central hypovolemia in women were similar to men but were depleted at a faster rate compared with men. The earlier depletion of the compensatory reserve in women appears to be influenced by failure to maintain adequate cerebral oxygen delivery. NEW & NOTEWORTHY We compared hemodynamic and metabolic responses in men and women to experimentally controlled reductions in central blood volume at physiologically equivalent levels of compensatory reserve. We corroborated previous findings that females have lower tolerance to central hypovolemia than males but demonstrated for the first time that compensatory responses are similar. Our findings suggest lower tolerance to central hypovolemia in women results from reaching critical cerebral delivery of oxygen faster than men.
IMPORTANCE: Nonbattle injury (NBI) among deployed US service members increases the burden on medical systems and results in high rates of attrition, affecting the available force. The possible causes ...and trends of NBI in the Iraq and Afghanistan wars have, to date, not been comprehensively described. OBJECTIVES: To describe NBI among service members deployed to Iraq and Afghanistan, quantify absolute numbers of NBIs and proportion of NBIs within the Department of Defense Trauma Registry, and document the characteristics of this injury category. DESIGN, SETTING, AND PARTICIPANTS: In this retrospective cohort study, data from the Department of Defense Trauma Registry on 29 958 service members injured in Iraq and Afghanistan from January 1, 2003, through December 31, 2014, were obtained. Injury incidence, patterns, and severity were characterized by battle injury and NBI. Trends in NBI were modeled using time series analysis with autoregressive integrated moving average and the weighted moving average method. Statistical analysis was performed from January 1, 2003, to December 31, 2014. MAIN OUTCOMES AND MEASURES: Primary outcomes were proportion of NBIs and the changes in NBI over time. RESULTS: Among 29 958 casualties (battle injury and NBI) analyzed, 29 003 were in men and 955 were in women; the median age at injury was 24 years (interquartile range, 21-29 years). Nonbattle injury caused 34.1% of total casualties (n = 10 203) and 11.5% of all deaths (206 of 1788). Rates of NBI were higher among women than among men (63.2% 604 of 955 vs 33.1% 9599 of 29 003; P < .001) and in Operation New Dawn (71.0% 298 of 420) and Operation Iraqi Freedom (36.3% 6655 of 18 334) compared with Operation Enduring Freedom (29.0% 3250 of 11 204) (P < .001). A higher proportion of NBIs occurred in members of the Air Force (66.3% 539 of 810) and Navy (48.3% 394 of 815) than in members of the Army (34.7% 7680 of 22 154) and Marine Corps (25.7% 1584 of 6169) (P < .001). Leading mechanisms of NBI included falls (2178 21.3%), motor vehicle crashes (1921 18.8%), machinery or equipment accidents (1283 12.6%), blunt objects (1107 10.8%), gunshot wounds (728 7.1%), and sports (697 6.8%), causing predominantly blunt trauma (7080 69.4%). The trend in proportion of NBIs did not decrease over time, remaining at approximately 35% (by weighted moving average) after 2006 and approximately 39% by autoregressive integrated moving average. Assuming stable battlefield conditions, the autoregressive integrated moving average model estimated that the proportion of NBIs from 2015 to 2022 would be approximately 41.0% (95% CI, 37.8%-44.3%). CONCLUSIONS AND RELEVANCE: In this study, approximately one-third of injuries during the Iraq and Afghanistan wars resulted from NBI, and the proportion of NBIs was steady for 12 years. Understanding the possible causes of NBI during military operations may be useful to target protective measures and safety interventions, thereby conserving fighting strength on the battlefield.
Timely and optimal care can reduce mortality among critically injured combat casualties. US military Role 2 surgical teams were deployed to forward positions in Afghanistan on behalf of the ...battlefield trauma system. They received prehospital casualties, provided early damage control resuscitation and surgery, and rapidly transferred casualties to Role 3 hospitals for definitive care. A database was developed to capture Role 2 data.
A retrospective review and descriptive analysis were conducted of battle-injured casualties transported to US Role 2 surgical facilities in Afghanistan from February 2008 to September 2014. Casualties were analyzed by mortality status and location of death (pretransport, intratransport, or posttransport), military affiliation, transport time, injury type and mechanism, combat mortality index-prehospital (CMI-PH), and documented prehospital treatment.
Of 9,557 casualties (median age, 25.0 years; male, 97.4%), most (95.1%) survived to transfer from Role 2 facility care. Military affiliation included US coalition forces (37.4%), Afghanistan National Security Forces (23.8%), civilian/other forces (21.3%), Afghanistan National Police (13.5%), and non-US coalition forces (4.0%). Mortality differed by military affiliation (p < 0.001). Among fatalities, most were Afghanistan National Security Forces (30.5%) civilian/other forces (26.0%), or US coalition forces (25.2%). Of those categorized by CMI-PH, 40.0% of critical, 11.2% of severe, 0.8% of moderate, and less than 0.1% of mild casualties died. Most fatalities with CMI-PH were categorized as critical (66.3%) or severe (25.9%), whereas most who lived were mild (56.9%) or moderate (25.4%). Of all fatalities, 14.0% died prehospital (pretransport, 5.8%; intratransport, 8.2%), and 86.0% died at a Role 2 facility (posttransport). Of fatalities with documented transport times (median, 53.0 minutes), most (61.7%) were evacuated within 60 minutes.
Role 2 surgical team care has been an important early component of the battlefield trauma system in Afghanistan. Combat casualty care must be documented, collected, and analyzed for outcomes and trends to improve performance.
Therapeutic/Care Management, level IV.
Traumatic brain injury (TBI) is a major health issue for service members deployed and is more common in recent conflicts; however, a thorough understanding of risk factors and trends is not well ...described. This study aims to characterize the epidemiology of TBI in U.S. service members and the potential impacts of changes in policy, care, equipment, and tactics over the 15 years studied.
Retrospective analysis of U.S. Department of Defense Trauma Registry data (2002–2016) was performed on service members treated for TBI at Role 3 medical treatment facilities in Iraq and Afghanistan. Risk factors and trends in TBI were examined in 2021 using Joinpoint regression and logistic regression.
Nearly one third of 29,735 injured service members (32.4%) reaching Role 3 medical treatment facilities had TBI. The majority sustained mild (75.8%), followed by moderate (11.6%) and severe (10.6%) TBI. TBI proportion was higher in males than in females (32.6% vs 25.3%; p<0.001), in Afghanistan than in Iraq (43.8% vs 25.5%; p<0.001), and in battle than in nonbattle (38.6% vs 21.9%; p<0.001). Patients with moderate or severe TBI were more likely to have polytrauma (p<0.001). TBI proportion increased over time, primarily in mild TBI (p=0.02), slightly in moderate TBI (p=0.04), and most rapidly between 2005 and 2011, with a 2.48% annual increase.
One third of injured service members at Role 3 medical treatment facilities experienced TBI. Findings suggest that additional preventive measures may decrease TBI frequency and severity. Clinical guidelines for field management of mild TBI may reduce the burden on evacuation and hospital systems. Additional capabilities may be needed for military field hospitals.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
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