Search

Haemorrhagic shock is a rare occurrence in emergency medicine but it can be associated with significant mortality. The purpose of this study was to evaluate the impact of a major haemorrhage protocol on patient management in Emergency Department Resuscitation Area., Methods: A single-centre study was conducted to compare two periods, before and after institution of a massive haemorrhage protocol including the use of massive transfusion orders and the availability of packed red blood cell concentrates prior to patient's admission. Two groups of patients (in both trauma and non-trauma settings) were defined: "before protocol" and "after protocol". The primary outcome was the median transfusion time for a unit of red blood cell concentrate., Results: Forty patients were included: 22 for the "pre-protocol" group and 18 for the "post-protocol" group. The two groups were balanced with baseline characteristics. This study showed a significantly reduced median transfusion time for a unit of red blood cell concentrate from 20min pre-protocol to 9min post-protocol. The time between patient's admission and transfusion of the first red blood cell concentrate was reduced but non-significantly from 71min to 36min., Conclusion: The major haemorrhage protocol optimised patient management by reducing the median transfusion time for red blood cell concentrates., (Copyright © 2018. Published by Elsevier Masson SAS.)

Objectives: The European trauma guidelines were developed to assist clinicians in the early phase of trauma management to diagnose and treat coagulopathy and bleeding. This study aimed to determine compliance with these European trauma guidelines in a French referral trauma centre., Methods: Medical charts of trauma patients with an injury severity score≥16 admitted between January 2013 and December 2014 were reviewed. Compliance with 21 recommendations in the first 24-hours of patient management was assessed., Results: There were 145 patients with median ISS of 34 [IQR 25-41]. A good level of compliance (i.e. applied in≥80% of patients) was identified for nine recommendations, inconsistent compliance (i.e. applied in 50 to 79% of patients) for six recommendations, including fibrinogen levels at hospital admission and achievement of a target mean arterial blood pressure (MAP)>80mmHg in patients with major bleeding and TBI (55.5%), and poor compliance (i.e. applied in<50% of patients) for another six recommendations. Poorly applied recommendations included early measurement of lactate or base deficit (32%), early administration of tranexamic acid (18%), and achievement of normocapnia in patients with TBI undergoing invasive ventilation (3%)., Conclusions: In a referral trauma centre, nine of the 21 evaluable recommendations in the European trauma guidelines were applied in≥80% of patients. Early diagnosis and treatment of trauma-related coagulopathy was identified as an area for significant practice improvement. In patients with TBI, efforts should be made to achieve the targeted MAP and to maintain normocapnia., (Copyright © 2018 Elsevier Masson SAS. All rights reserved.)

Plasma for direct therapeutic use is a fast-evolving blood component in terms of its production and presentation. More than a dozen forms are available worldwide, which is often overlooked since most countries apply policies making only one or very few forms available for treating patients in need. It is most often reserved for the same three clinical indications, i.e. overall clotting-factor deficiency, reversal of vitamin K antagonists in the context of active bleeding or prior to urgent surgery, and therapeutic plasma exchange. The level of evidence is often less robust than generally acknowledged for such major indications while novel indications are tending to emerge in medical and trauma settings. This short review explores classical views and new prospects opened up by novel presentations and statuses for therapeutic plasma., (Copyright © 2018 Elsevier Masson SAS. All rights reserved.)

Objectives: Transfusion-related adverse events (TRAE) can contribute to patient morbidity and mortality. In this brief narrative review, the strategies that clinicians can apply at the bedside to avoid TRAE are discussed., Methods: Strategies to avoid the following five types of TRAE were reviewed: transfusion-associated circulatory overload (TACO), transfusion-related acute lung injury (TRALI), transfusion-associated hypothermia (TAH), transfusion-related allergic reactions (TRAR) and acute haemolytic transfusion reactions (AHTR)., Results: Minimizing exposure to blood components is fundamental to TRAE avoidance. Pre-transfusion assessment can identify patients at risk of TACO, TRAR and TAH, and avoidance steps implemented. Preventive strategies for TACO include lower transfusion rate, 'one unit at a time' transfusion policy and possibly diuretic medication. Patients with past history of TRAR should preferably be given plasma-free blood components; anti-histamine medication prior to transfusion could be considered. TAH is common in the massive transfusion setting, particularly trauma patients. Warming of patients are key strategies to avoid TAH. Identification of patients at risk of TRALI is more opaque; however, any measures that limit pulmonary inflammation prior to transfusion may decrease the risk of TRALI. Causes of AHTR are commonly due to human error and failure to apply rigorous cross-checks of patient and issued RBC component blood groups., Conclusions: Beneficial strategies to avoid TRAE include judicious use of blood components, identification of high-risk patients, adherence to recommended clinical processes and awareness of TRAE pathophysiology. More evidence is warranted to better guide clinicians in the prevention of TRAE., (Copyright © 2018 Elsevier Masson SAS. All rights reserved.)

As a therapy or a support to other therapies, despite being largely beneficial to patients in general, transfusion it is not devoid of some risks. In a moderate number of cases, patients may manifest adverse reactions, otherwise referred to as transfusion-associated hazards (TAHs). The latest French 2016 haemovigilance report indicates that 93% of TAHs are minor (grade 1), 5.5% are moderate (grade 2) and 1.6% are severe (grade 3), with only five deaths (grade 4) being attributed to transfusion with relative certainty (imputability of level [or grade] 1 to 3). Health-care providers need to be well aware of the benefits and potential risks (to best evaluate and discuss the benefit-risk ratio), how to prevent TAHs, the overall costs and the availability of alternative therapeutic options. In high-income countries, most blood establishments (BEs) and hospital blood banks (HBBs) have developed tools for reporting and analysing at least severe transfusion reactions. With nearly two decades of haemovigilance, transfusion reaction databases should be quite informative, though there are four main caveats that prevent it from being fully efficient: (ai) reporting is mainly declarative and is thus barely exhaustive even in countries where it is mandatory by law; (aii) it is often difficult to differentiate between the different complications related to transfusion, diseases, comorbidities and other types of therapies in patients suffering from debilitating conditions; (aiii) there is a lack of consistency in the definitions used to describe and report some transfusion reactions, their severity and their likelihood of being related to transfusion; and (aiv) it is difficult to assess the imputability of a particular BC given to a patient who has previously received many BCs over a relatively short period of time. When compiling all available information published so far, it appears that TAHs can be analysed using different approaches: (bi) their pathophysiological nature; (bii) their severity; (biii) the onset scheme; (biv) a quality assessment (preventable or non-preventable); (bv) their impact on ongoing therapy. Moreover, TAHs can be reported either in a non-integrative or in an integrative way; in the latter case, presentation may also differ when issued by a blood establishment or a treating ward. At some point, a recapitulative document would be useful to gain a better understanding of TAHs in order to decrease their occurrence and severity and allow decision makers to determine action plans: this is what this review attempts to make. This review attempts to merge the different aspects, with a focus on the hospital side, i.e., how the most frequent TAHs can be avoided or mitigated., (Copyright © 2018 Elsevier Masson SAS. All rights reserved.)

Hospital-acquired anemia is common, especially in the most critically ill patients. It may be associated with poor patient outcomes. It may result from increased blood loss, impaired red cell production or reduced red cell life span. Multiple associated factors may contribute simultaneously or sequentially to the decrease in hemoglobin level. Some of them are related to the underlying disease and others are iatrogenic. Clinicians should be aware of the importance and consequences of iatrogenic anemia caused by diagnostic blood sampling. Strategies and measures to minimize iatrogenic blood loss should be prioritized. They may reduce the risk of developing anemia and then red blood cells transfusion requirement., (Copyright © 2016 Elsevier Masson SAS. All rights reserved.)

Hydrostatic pulmonary edema is a frequent and severe complication of blood transfusion. Recent epidemiological studies open the way for a better prevention of Transfusion-Associated Circulatory Overload. Preventive measures rely solely on the medical and nursing staff. Mitigation strategies include a careful identification of patients and conditions at-risk, a single-unit transfusion policy in patients with chronic anemia, the use of slow infusion rates, the careful monitoring of patient vital signs (particularly systemic arterial blood pressure). Peritransfusion IV diuretics use is likely to be helpful, although optimal prescribing patterns have not been defined., (Copyright © 2014 Elsevier Masson SAS. All rights reserved.)

Patients with end-stage liver disease have complex alterations that involve all components of hemostasis, with changes both in prohemostatic and in antihemostatic pathways. Routine haemostasis tests such as prothrombin time and platelet count are unable to reflect a bleeding tendency. Bleeding complications are much less related to abnormal hemostasis than previously thought, with portal hypertension playing a more critical role. Systematic prophylactic measures based upon the use of fresh frozen plasma and/or platelet concentrates to improve or correct the abnormalities of the routine coagulation tests are most often inappropriate and may occasionally be deleterious., (Copyright © 2013 Elsevier Masson SAS. All rights reserved.)

"Transfusion-related acute lung injury" (TRALI) is a post-transfusion lesional pulmonary edema, potentially severe, better defined since the conference of Toronto in 2004. The incidence of TRALI reported in France remains low in part because of its ignorance by physicians. The objective of our study was to evaluate retrospectively transfusion accidents with respiratory complications that occurred in Nancy University Hospital and reported to the haemovigilance between 1996 and 2006, from the software "Traceline" listing all the blood transfusion complications from signs observed. The analysis of the files has been performed by applying rigorously diagnostic criteria of Toronto. Forty-one cases of respiratory complications were found in 34,573 blood products. Ten cases of TRALI were diagnosed while only one case had been reported to the haemovigilance. The remaining nine cases were previously labeled transfusion-associated circulatory overload (TACO). No cases of TRALI have been identified in the ICU. Our work can find an incidence of TRALI 10 times greater than previously reported. Ignorance of TRALI and the lack of consensus definition before 2004 are not sufficient to explain these results. This study demonstrates the potential interest of database and computerized declaration system based on the symptoms observed. It highlights the vulnerability of the current haemovigilance too dependent on a single medical observer. Although TRALI are recognized as serious complications, sometimes requiring resuscitative care, our work was not isolated severe TRALI in ICU. Physician awareness of TRALI to the identification and to the declaration, including ICU should be continued. Finally, the diagnostic criteria for TRALI must be adapted to the ICU., (Copyright © 2013 Elsevier Masson SAS. All rights reserved.)

Recent changes in plasma transfusion practices for severe hemorrhage are largely related to the recognition of an early endogenous coagulopathy associated with traumatic injury. Observational and mostly retrospective data suggest improved survival rates with high-dose plasma therapy, up to a 1:1 ratio of fresh frozen plasma to packed red blood cells, but the quality of evidence is limited. Putting it into practice raises many issues (early identification of patients at risk of massive bleeding, extrapolation to non-trauma settings, alternative or adjunctive treatments, among others) that are discussed in this brief review., (Copyright © 2012 Elsevier Masson SAS. All rights reserved.)

A working group of the French National Hemovigilance Committee has been in charge of heightening awareness of Transfusion-Associated Circulatory Overload (TACO) among physicians and nurses. This multidisciplinary group has produced the present document that focuses on epidemiological data provided by the French haemovigilance network, physiopathology, diagnosis, treatment and specific actions that could prevent or minimize the risk of TACO., (Copyright © 2012 Elsevier Masson SAS. All rights reserved.)

Pulmonary oedema after transfusion of blood products may be hydrostatic (transfusion-associated circulatory overload [taco]) or exsudative (transfusion-related acute lung injury [trali]). Both conditions have been recognized as major hazards to transfusion recipients. Risk characterization is necessary to improve safety and to monitor trends in the national blood transfusion system. A collaborative multidisciplinary working group of the French National Hemovigilance Committee has proposed an analysis framework for case definitions and classification. The method relies on internationally used definitions and is adapted to the codification procedures used in the french transfusion incident reports electronic data management., (Copyright © 2010 Elsevier Masson SAS. All rights reserved.)

Transfusion-related acute lung injury (TRALI) is the inflammatory, exudative form and Transfusion-associated cardiac overload (TACO) is the hydrostatic, transudative form of transfusion-induced acute pulmonary edema. The distinction between these two entities may be difficult, but important because of different clinical management strategies and different implications. There is no unique diagnostic tool. The diagnostic search should gather several clinical information and may be helped by various techniques listed in this article.

In addition to more restrictive "transfusion triggers", presently available allogeneic blood conservation strategies in surgery include preoperative increase in red blood cells (RBC) mass, techniques or pharmaceutical agents that reduce blood loss, and perioperative blood salvage. Because of very important risk reduction in allogeneic blood, benefit/risk of preautologous blood donation (PAD) is quite questionable at this moment. Indeed, at this moment in France, we focus to avoid any transfusion (allogeneic and autologous blood). Therefore the most important techniques used are pharmacological: erythropoietin before surgery with a number of injections related to baseline Hb, and tranexamic acid during and after surgery. Cell saving is used only if bleeding is enough important like arthroplasty revisions. All blood conservation techniques carry their own efficiency limits, constraints and risks that, in addition to institutional considerations and individual patient characteristics are determinant to settle a blood conservation strategy. The choice of a technique should take into account (a) the delay before surgery, (b) the anticipated blood loss for the procedure that varies among institutions, (c) the tolerable blood loss without transfusion for the patient, and (d) the efficacy of the blood conservation technique in the given setting. Nevertheless, at this moment in France, it is quite important to notice that the risk of delay or lack of transfusion induces much more deaths that the transfusion itself during or after anesthesia [Anesthesiology 105, 1087-97].

Uncontrolled hemorrhage is the most common cause of potentially preventable death in massive trauma. In addition to the early identification of potential bleeding sources and angiographic embolisation or surgical bleeding control, in-hospital management will aim at maintain tissue oxygenation with volume replacement using crystalloids, colloids and RBC. In general, RBC transfusion is recommended to maintain hemoglobin between 7-10g/dL. The complex combination of clotting factors and platelets consumption, loss and dilution, shock, hypothermia, acidosis and colloid-induced hemostatic alterations leads to coagulopathic bleeding. Most guidelines recommend the use of FFP in significant bleeding complicated by coagulopathy (PT, aPTT >1.5 times control). Platelets should be administered to maintain a platelet count above 50 x 10(9)/L (100 x 10(9)/L in patients with traumatic brain injury). However, standard laboratory tests have poor correlation with in vivo coagulopathy and the test results are not rapidly available. Empiric guidelines derived from mathematical hemodilution models developed in elective surgery settings may not be appropriate for trauma settings where significant bleeding may have already occurred. Moreover, coagulopathy is frequently present on admission in severely injured patients. Recent litterature suggests that FFP and platelets should be given early and more often to injured patients requiring massive transfusion. The place of adjunctive hemostatic therapy is discussed.

In moderately anaemic patients, Autologous Blood Donation is much less effective than Erythropoïetin (EPO) at constituting a pre-operative RBC reserve. Indeed, the ability to give blood is limited or even impossible for anaemic individuals. EPO lowers the risks associated with autologous and allogeneic transfusions, while improving probably the quality of life of the patients. EPO therapy is efficient, in moderate anaemic patients, to reduce allogeneic transfusion when iron supplementation is associated. All blood conservation techniques carry their own efficiency limits, constraints and risks that, in addition to institutional considerations and individual patient characteristics, are determinant to settle a blood conservation strategy. But to optimise benefit/cost/effectiveness of this technique, it is important to take into account the delay before surgery, the anticipated blood loss for the procedure that varies among institutions and the tolerable blood loss without transfusion for the patient. To reduce the cost, a strategy according to baseline haematocrit and to blood loss has to be adapted at each patient. Furthermore, when the delay between the first EPO injection and the surgical procedure is sufficient, the number of injections can be easily reduced to obtain the same Ht the day prior to surgery.

The amount of transfused blood is related to blood loss calculated for the specific type of surgical procedure, transfusion hematocrit trigger and patient's red blood cell mass on the day before surgery. To optimise the benefit/cost and benefit/risk ratios of blood transfusion, a correct prescription must be done in accordance with the patient's red blood cell mass and surgical blood loss. Indeed, there is a clear need to define the appropriate uses of blood management methods and to seek new methods of improving perioperative blood management. The number of moderately anaemic patients undergoing surgery is currently thought to be 20%. Where transfusion requirements are estimated at two to three blood units, as for instance in the most common types of orthopaedic surgery, preoperative haemoglobin is the key factor governing transfusion needs. In this case, the simplest approach is to prescribe Epoetin Alfa subcutaneous at a dose of 600 IU/kg/week starting three weeks before the surgery. In addition, it is important in all cases to give concomitant iron supplements. Concomitant use of other methods to decrease allogeneic blood requirements is of no value. Obviously, the higher the haematocrit the day prior to surgery, the higher the patient's RBC mass and the greater the patient's permitted blood loss, decreasing the transfusion trigger. In this way, allogeneic blood loss is reduced, but without the need for the patient to attend the blood transfusion center and to undergo laboratory screening and testing of donated blood, and without the risk of inducing preoperative anaemia compared with sequential autologous blood donation. But, to optimise the benefit/cost ratio, we try to define precisely the patient populations likely to benefit from preoperative erythropoietin. Using different examples, management is proposed with algorithms.