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Unrecognized central venous catheter (CVC) infiltration is an uncommon but potentially life-threatening complication. For instance, a malpositioned subclavian line can infuse into the mediastinum, pleural cavity, or interstitial space of the neck. We present the case of a 30-year-old male with gunshot wounds to the right chest, resuscitated with an initially functional left subclavian CVC, which later infiltrated into the neck causing compression of the carotid sinus and consequent bradycardic arrest. Return of spontaneous circulation (ROSC) was achieved following intravenous epinephrine, cardiac massage, and emergency neck exploration and cervical fasciotomy. Our case highlights the importance of frequent reassessment of lines, especially those placed during fast-paced, high-intensity clinical situations. We recommend being mindful when using rapid transfusion devices as an interstitial catheter may not mount enough back pressure to trigger the systems alarm before significant tissue damage or compartment syndrome occurs.

Objectives Demand for rapid coagulation testing for massive transfusion events led to development of an emergency hemorrhage panel (EHP; hemoglobin, platelet count, prothrombin time/international normalized ratio, and fibrinogen), with laboratory turnaround time (TAT) of less than 20 minutes. Ten years on, we asked if current laboratory practices were meeting that TAT goal and differences were evident in TAT between the 2 major institutions in our system. Methods We identified EHPs ordered at our 2 largest hospitals, February 2, 2021, to July 17, 2022, comparing order to specimen draw time, specimen draw to specimen received time, laboratory analytic time, and total TAT results from emergency department and operating room. Site 1 houses a level I trauma center; site 2 includes tertiary care, transplant, and obstetrics services. Results In total, 1137 EHPs were recorded in our study period. Laboratory TAT was significantly faster at site 1 (~14 vs ~27 minutes, P <.01). Average laboratory TAT was under 20 minutes at site 1 but only for 50% of specimens at site 2. Outlier specimens were collection delays at site 1 and specimen processing delays at site 2. Conclusions The EHP can be performed as rapidly as described. However, compromises in laboratory location, available personnel, and processing differences can degrade performance. [ABSTRACT FROM AUTHOR]

Background: Exsanguination is the leading cause of preventable death in severe trauma. Immediate hemorrhage control and transfusion of blood products are critical to maintain oxygen delivery and address trauma-induced coagulopathy. While prehospital blood product transfusion (PHBT) is established in neighboring countries, the fragmented configuration of Germany's emergency medical service (EMS) infrastructure has delayed the adoption of widespread PHBT programmes. This review aims to provide an updated perspective on the evolution, international practices and research needs of PHBT within the German context. Methods: This narrative review is based on a PubMed search using the search terms "prehospital" and "blood*". From an initial 4738 articles, 333 were directly related to PHBT and were subjected to further detailed examination. The literature, including referenced studies, was categorized into areas such as history, rationale, international practices, and evidence, and analyzed for quality. Results: The benefit of early blood transfusion in major trauma has been established since WW1, explaining the efforts to initiate this lifesaving intervention as early as possible in the care pathway, including the prehospital field. Recent randomized trials have faced design and recruitment challenges, reflecting the complexity of the research question. These trials have yielded inconclusive results regarding the survival benefits of PHBT in civilian settings. This scenario raises doubts about the capability of randomized trials to resolve questions concerning survival advantages. Despite these difficulties, there is a discernible trend indicating potential improvements in patient outcomes. In Germany, the incidence of trauma-associated shock stands at 38 per 100,000 individuals per year. It is estimated that between 300 and 1800 patients annually possibly benefit from PHBT. Conclusion: Prehospital Blood Transfusion appears to be promising but identifying patient groups most likely to benefit as well as the most suitable blood products remain unresolved issues. In Germany PHBT programs are not yet widely established. Paradoxically, this situation, paired with the extensive German Trauma Registry, provides a prime opportunity for comprehensive prospective cohort studies, addressing the balance between PHBT benefits, logistical feasibility, and implementation strategies. Such studies are essential for establishing guidelines and integrating PHBT efficiently into German trauma care protocols. [ABSTRACT FROM AUTHOR]

Background: Evaluations of critical bleeding and massive transfusion have focused on traumatic hemorrhage. However, most critical bleeding in hospitalized patients occurs outside trauma. The purpose of this study was to provide an in‐depth description examining the critical administration threshold (CAT; ≥3 units red blood cells (RBCs) in a 1‐h period) occurrences in nontraumatic hemorrhage. This will assist in establishing the framework for future investigations in nontraumatic hemorrhage. Methods: This is an observational cohort study of adults experiencing critical bleeding defined as being CAT+ during hospitalization from 2016 to 2021 at a single academic institution. A CAT episode started with administration of the first qualifying RBC unit and ended at the time of completion of the last allogeneic unit prior to a ≥4‐h gap without subsequent transfusion. The primary goal was to describe demographic, clinical and transfusion characteristics of participants with nontraumatic critical bleeding. Results: 2433 patients suffered critical bleeding, most often occurring in the operating room (71.1%) followed by the intensive care unit (20.8%). 57% occurred on the initial day of hospitalization, with a median duration of 138 (36, 303) minutes. The median number of RBCs transfused during the episode was 5 (4, 8), with median total allogeneic units of 9 (4, 9). Hospital mortality was 19.2%. The most common cause of death was multi‐organ failure (50.3%), however death within 24 h was due to exsanguination (72.7%). Discussion: The critical administration threshold may be employed to identify critical bleeding in non‐trauma settings of life‐threatening hemorrhage, with a mortality rate of approximately 20%. [ABSTRACT FROM AUTHOR]

Background Study Design and Methods Results Discussion Massive transfusion with citrated blood products causes hypocalcemia, which is associated with mortality. Recognition of this problem has led to increased calcium administration; however, the optimal dosing is still unknown.This retrospective, single‐center study included level 1 trauma patients in 2019 and 2020 who underwent an operation within 12 h of arrival and received a transfusion. Preoperative and intraoperative administrations were totaled to calculate the ratio of administered calcium to the number of blood transfusions for each patient. The citrate content of each blood component was estimated to calculate a second ratio, the ratio of administered calcium to administered citrate. Receiver Operating Characteristic (ROC) curves were performed on both ratios to determine the optimal cutoff values for predicting severe hypocalcemia (ionized calcium <0.9 mmol/L) and hypercalcemia (>1.35 mmol/L) at the end of the intraoperative period.A total of 506 trauma activations were included, receiving a mean of 17.4 citrated blood products and 16.3 mmol of calcium (equivalent to 2400 mg of calcium chloride). No ratio was statistically significant in differentiating severely hypocalcemic patients from the rest. A calcium to blood ratio of 0.903 mmol of administered calcium per citrated blood product differentiated hypercalcemic patients from the rest.Quantifying received calcium and citrated blood products was insufficient to predict severe hypocalcemia, suggesting other contributions to hypocalcemia. We demonstrated an upper‐limit ratio for calcium administration in traumatic hemorrhage; however, further studies are required to determine what calcium dosing regimen results in the best outcomes. [ABSTRACT FROM AUTHOR]

Purpose Hypocalcemia is associated with increased mortality in trauma patients with hemorrhagic shock who require massive transfusion protocols (MTPs). Despite known risks of potentiating hypocalcemia with blood product administration, there is little research discussing appropriate calcium replacement. The purpose of this study was to evaluate the ability of a standardized calcium replacement protocol to reduce the incidence of hypocalcemia in trauma patients undergoing MTP. Methods This retrospective, single-center, pre-post study evaluated the use of a calcium replacement protocol during MTP. Adult trauma patients with MTP orders who received at least one "round" of product transfusion were included. Patients were excluded if their ionized calcium (iCa) levels were unavailable or they were transferred to a higher level of care within 4 hours of presentation. The primary outcome was incidence of hypocalcemia (iCa of <1.1 mg/dL) within 24 hours of MTP initiation. Secondary endpoints included the incidence of severe hypocalcemia (iCa of <0.9 mg/dL), time to first calcium dose, total calcium dose administered (mEq), resolution of hypocalcemia within 24 hours, hypercalcemia, adherence to the calcium replacement protocol, and mortality. Results The incidence of hypocalcemia within 24 hours was significantly lower in the postprotocol group (63% vs 95.2%; P = 0.006). There was not a significant difference in the incidence of severe hypocalcemia between the groups (39.1% vs 69.1%; P = 0.083). Time to first calcium dose was significantly shorter in postprotocol patients compared to preprotocol patients (median [interquartile range], 5.5 [0-21] minutes vs 43 [22.8-73] minutes; P < 0.0001), and postprotocol patients were administered more calcium during MTP (40.8 [27.2-54.4] mEq vs 27.2 [14-32.2] mEq; P = 0.005). Adherence to the protocol was seen in only 37% of patients in the postprotocol group. There was no difference in the rate of adverse events or overall mortality. Conclusion Trauma patients who received massive transfusion of blood products had a significantly lower incidence of hypocalcemia after a calcium replacement protocol was implemented. [ABSTRACT FROM AUTHOR]

Background and Objectives: Massive transfusion protocols (MTPs) are critical in managing haemorrhage, yet their utilization varies. There is lack of data on the utilization of MTPs in the Middle East and North Africa (MENA) region. This study aims to assess the degree of utilization of MTPs in the region. Materials and Methods: We conducted a survey to collect data on MTP use, inviting medical directors of transfusion services from various hospitals. Data were analysed to determine the prevalence of MTP utilization, their compositions, challenges in application and areas of future need. Results: Eighteen respondents participated, representing 11 countries in the region. Thirteen hospitals implemented MTP, and eight included paediatrics. Eleven institutions used more than one definition of massive haemorrhage, with the most common being ≥10 red blood cell (RBC) units transfused for adults and replacement of >50% total blood volume in paediatrics. The majority of sites with MTPs utilized 1:1:1 RBCs:platelets:plasma ratio (70%). Variations were observed in the types and blood groups of components used. Two sites utilized whole blood, while six are considering it for future use. Utilization of adjunctive agents and frequency of laboratory testing varied among the sites. Challenges included the lack of medical expertise in protocol development, adherence and paediatric application. The need assessment emphasized the need for developing regional guidelines, standardized protocols and training initiatives. Conclusion: Although several hospitals have adopted MTPs, variations exist in activation criteria, blood product ratios and monitoring. Challenges include the lack of medical expertise, protocol adherence and addressing paediatric needs. Standardizing protocols, enhancing training and paediatric application are crucial for improving massive transfusion management in the region. [ABSTRACT FROM AUTHOR]

Background Excessive requests for preoperative packed red cell (PRC) preparation have been noted, resulting in waste of blood products and higher costs in brain tumor surgery. The objectives of the present study were as follows: (1) the primary objective was to assess the effectiveness index of blood preparation and utilization; (2) the secondary objective was to explore factors associated with intraoperative PRC transfusion; and (3) the third objective was to identify the prevalence and analyze risk factors of massive transfusion.

BACKGROUND AND OBJECTIVE: We compared the overall clinical outcome in formula-based protocol (1:1:1) and thromboelastogram (TEG)-guided goal-based massive transfusion (MT) in the resuscitation of patients with hemorrhagic shock. MATERIALS AND METHODS: This was a retro-prospective case–control study conducted over a period of 2 years among the patients who received MT using a 1:1:1 fixed ratio protocol (controls, Group A) and goal-based protocol (cases, Group B) guided through TEG. Patients were matched for the type and severity of the clinical conditions. Utilization of blood components, clinical outcomes, transfusion-related complications, and total mortality rates were compared between the groups. RESULTS: There were 113 patients in the formula-based group and 109 patients in the goal-based transfusion group who were matched for injury severity scores. The total blood components utilized were 1867 and 1560, respectively, with a 17.7% reduction associated with the use of TEG. Patients were divided into normal, hypo, and hypercoagulable based on TEG, and a higher transfusion rate was associated with hypocoagulable TEG (942 vs. 610). The prothrombin time, activated partial thromboplastin time, R time, and K time had a significant positive correlation with the need to transfuse more than 20 blood components, whereas platelet count, base excess, alpha angle, MA, and CI had a negative correlation (r = 0.268, P < 0.001). At the end of goal-directed transfusion, 75% of the patients were free of transfusion support (vs. 65.4%) and only 6.9% of the patients had coagulopathy (vs. 31.8%) compared to formula-based resuscitation with a 10% reduction in mortality. CONCLUSION: TEG-guided goal-based approach helped to reduce blood component utilization with a reduced incidence of coagulopathy at the end of the MT while improving patient survival.

The reduction in the blood supply following the 2019 coronavirus pandemic has been exacerbated by the increased use of balanced resuscitation with blood components including whole blood in urban trauma centers. This reduction of the blood supply has diminished the ability of blood banks to maintain a constant supply to meet the demands associated with periodic surges of urban trauma resuscitation. This scarcity has highlighted the need for increased vigilance through blood product stewardship, particularly among severely bleeding trauma patients (SBTPs). This stewardship can be enhanced by the identification of reliable clinical and laboratory parameters which accurately indicate when massive transfusion is futile. Consequently, there has been a recent attempt to develop scoring systems in the prehospital and emergency department settings which include clinical, laboratory, and physiologic parameters and blood products per hour transfused as predictors of futile resuscitation. Defining futility in SBTPs, however, remains unclear, and there is only nascent literature which defines those criteria which reliably predict futility in SBTPs. The purpose of this review is to provide a focused examination of the literature in order to define reliable parameters of futility in SBTPs. The knowledge of these reliable parameters of futility may help define a foundation for drawing conclusions which will provide a clear roadmap for traumatologists when confronted with SBTPs who are candidates for the declaration of futility. Therefore, we systematically reviewed the literature regarding the definition of futile resuscitation for patients with trauma-induced hemorrhagic shock, and we propose a concise roadmap for clinicians to help them use well-defined clinical, laboratory, and viscoelastic parameters which can define futility. [ABSTRACT FROM AUTHOR]

Early resuscitation using blood products is critical for patients with severe hemorrhagic shock. We aimed to develop and validate a new scoring system, hemorrhagic shock transfusion prediction (HSTP) score, to predict the need for massive transfusion (MT) in these patients, compared to the widely used Assessment of Blood Consumption (ABC) score. Trauma patients admitted to Emtiaz Hospital in Iran from 2017 to 2021 were retrospectively included. Patients assigned a code 1 or 2 according to the Emergency severity index (ESI) triage system have been divided into MT and non-MT groups. MT was defined as receiving ≥ 10 units of packed cells (PCs) in 24 h. Demographic information, admission vital signs, and lab results available within 15 min were compared between the groups. A new predictive score was developed using logistic regression of statistically significant parameters. Out of 1029 patients, 651 (63.3%) required MT. An arrival, diastolic blood pressure < 79.5 mm Hg, absolute lymphocyte count > 1850/μL, base excess < − 4.25, and blood glucose > 156 mg/dL were independent predictors included in the HSTP score. The sensitivity and specificity were 74.36% and 53.87% for the HSTP score, compared to 31.03% and 76.16% for the ABC score. Moreover, the positive and negative predictive values were 77.88% and 49.03% for the HSTP score, versus 74.15% and 33.66% for ABC. The new scoring system demonstrated higher sensitivity and improved positive and negative predictive values compared to the ABC score. This score can assist physicians in making accurate transfusion decisions quickly, but further prospective studies are warranted to validate its clinical utility. [ABSTRACT FROM AUTHOR]

Blood transfusion is a common therapeutic intervention in hospitalized patients. There are numerous indications for transfusion, including anemia and coagulopathy with deficiency of single or multiple coagulation components such as platelets or coagulation factors. Nevertheless, the practice of transfusion in critically ill patients has been controversial mainly due to a lack of evidence and the need to consider the appropriate clinical context for transfusion. Further, transfusion carries many risk factors that must be balanced with benefits. Therefore, transfusion practice in ICU patients has constantly evolved, and we endeavor to present a contemporary review of transfusion practices in this population guided by clinical trials and expert guidelines. [ABSTRACT FROM AUTHOR]

Background: Thromboelastometry like ROTEM® is a point-of-care method used to assess the coagulation status of patients in a rapid manner being particularly useful in critical care settings, such as trauma, where quick and accurate assessment of coagulation can guide timely and appropriate treatment. Currently, this method is not yet comprehensively available with sparse data on its effectiveness in resuscitation rooms. The aim of this study was to assess the effect of early thromboelastometry on the probability of mass transfusions and mortality of severely injured patients. Methods: The TraumaRegister DGU® was retrospectively analyzed for severely injured patients (2011 until 2020) with information available regarding blood transfusions and Trauma-Associated Severe Hemorrhage (TASH) score components. Patients with an estimated risk of mass transfusion >2% were included in a matched-pair analysis. Cases with and without use of ROTEM® diagnostic were matched based on risk categories for mass transfusion. A total of 1722 patients with ROTEM® diagnostics could be matched with a non-ROTEM® patient with an identical risk category. Adult patients (≥16) admitted to a trauma center in Germany, Austria, or Switzerland with Maximum Abbreviated Injury Scale severity ≥3 were included. Results: A total of 83,798 trauma victims were identified after applying the inclusion and exclusion criteria. For 7740 of these patients, the use of ROTEM® was documented. The mean Injury Severity Score (ISS) in patients with ROTEM® was 24.3 compared to 19.7 in the non-ROTEM® group. The number of mass transfusions showed no significant difference (14.9% ROTEM® group vs. 13.4% non-ROTEM® group, p = 0.45). Coagulation management agents were given significantly more often in the ROTEM® subgroup. Mortality in the ROTEM® group was 4.1% less than expected (estimated mortality based on RISC II 34.6% vs. observed mortality 30.5% (n = 525)). In the non-ROTEM® group, observed mortality was 1.6% less than expected. Therefore, by using ROTEM® analysis, the expected mortality could be reduced by 2.5% (number needed to treat (NNT) 40; SMR of ROTEM® group: 1:0.88; SMR of non-ROTEM® group: 1:0.96; p = 0.081). Conclusions: Hemorrhage is still one of the leading causes of death of severely injured patients in the first hours after trauma. Early thromboelastometry can lead to a more targeted coagulation management, but is not yet widely available. This study demonstrated that ROTEM® was used for the more severely injured patients and that its use was associated with a less than expected mortality as well as a higher utilization of hemostatic products. [ABSTRACT FROM AUTHOR]

Background: Obstetric haemorrhage is a leading cause of maternal mortality worldwide. New concepts involving the pathophysiology of haemorrhage have been described and include early activation of both the protein C and fibrinolytic pathways. New tendencies in haemorrhage treatment include the use of haemostatic resuscitation. Massive transfusion protocols involve the early utilization of blood products and limit the traditional approach of early massive crystalloid based resuscitation. The evidence behind haemostatic resuscitation is still limited. Objective: To study the common indications, complications & outcome of massive transfusions in obstetrics hemorrhage and to study the different components of blood & their ratios used during obstetric hemorrhage. Methodology: This is a retrospective study done at ESIC-PGIMSR Rajajinagar, Bengaluru, in department of Obstetrics of gynaecology. Between Jan 2016 to Dec 2021, data of number of obstetric patients who underwent blood product transfusion in our institution was manually abstracted from our medical record sections and blood bank. The following parameters were reviewed- Type and number of blood component transfused; Underlying obstetric risk factor in each case; Indication for each blood component transfusion noted; Patients who had Massive Obstetric Haemorrhage were further analysed to estimate the ratio of components transfused. Results: In our study a total of 38 obstetric patients had undergone massive transfusions, (which was taken for patients who underwent > 5 transfusions in 24hrs). 60.5% of patients needed 4-6 transfusions in 24hrs, 15.8% patients needed 7-10 PRBC transfusion & 1 patient ( 2.6%) needed >10 transfusions. Among these the transfusion protocol of Ratio of PRBC: Platelet: Frozen plasma transfused showed that, only in 29% of the patients the Massive transfusion protocol was followed.60.5% patients who required massive transfusions developed Disseminated intravascular coagulation (DIC), 55% of them developed pulmonary oedema, 44.7% of them developed Transfusion related lung injury, 34.2% had hepatic failure and acute renal failure. Among 38 mothers who had massive transfusions, 4 mothers died in spite of massive transfusions. 23.7% of them had morbidities. Conclusion: Haemorrhage is the most common form of shock in obstetric practice and remains a major cause of maternal mortality worldwide. Haemostatic resuscitation has emerged as a new concept, albeit based on limited prospective data. Massive transfusion protocols could improve outcomes in the bleeding patient not only due to early blood product administration but also secondarily to an early and aggressive multidisciplinary intervention. [ABSTRACT FROM AUTHOR]

La prise en charge des victimes polytraumatisées est un défi majeur de santé publique. En France, les accidents de la route sont la quatrième cause de décès et les polytraumatismes restent le premier facteur d'années de vie perdues. Leur prise en charge est largement basée sur la transfusion sanguine, ciblant la coagulopathie aiguë du traumatisé. Les recommandations préconisent l'utilisation de concentrés de globules rouges, de plasma thérapeutique et de concentrés de plaquettes lors de transfusions massives. Les protocoles de transfusion massive visent à réduire les délais et à améliorer l'efficacité de la prise en charge. Les scores cliniques et les critères biologiques, dont la viscoélastométrie, aident à anticiper et à adapter les besoins transfusionnels. Les protocoles de transfusion massive, largement utilisés, présentent des variations dans leur contenu, leur ratio et leurs critères de déclenchement. Leur utilisation s'étend à d'autres indications que le traumatisme mais des défis subsistent en termes d'organisation, de composition des lots de transfusion et de gestion des gaspillages. Polytrauma is a major public health challenge. In France, road accidents rank fourth among causes of death, and polytraumas are the leading cause of years of life lost. Management is largely based on blood transfusion, targeting acute traumatic coagulopathy. Recommendations advocate the use of packed red blood cells, therapeutic plasma, and platelet concentrates during massive transfusions. Massive Transfusion Protocols aim to reduce delays and enhance efficiency in management. Clinical scores and biological criteria, such as viscoelastic tests, help anticipate transfusion needs. Although widely used, massive transfusion protocols exhibit variations in content, ratios, and triggering criteria. Their application extends beyond trauma, posing challenges in terms of organization, transfusion pack composition, and waste management. [ABSTRACT FROM AUTHOR]

Background Excessive requests for preoperative packed red cell (PRC) preparation have been noted, resulting in waste of blood products and higher costs in brain tumor surgery. The objectives of the present study were as follows: (1) the primary objective was to assess the effectiveness index of blood preparation and utilization; (2) the secondary objective was to explore factors associated with intraoperative PRC transfusion; and (3) the third objective was to identify the prevalence and analyze risk factors of massive transfusion. Methods A retrospective cohort study was done on patients who had undergone brain tumor operations. The effectiveness indexes of preoperative PRC preparation and intraoperative utilization were calculated as follows: the crossmatch to transfusion (C/T) ratio, transfusion probability (Tp), and transfusion index (Ti). Additionally, factors associated with intraoperative PRC transfusion and massive transfusion were analyzed. Results There were 1,708 brain tumor patients and overall C/T, Tp, and Ti were 3.27, 45.54%, and 1.10, respectively. Prevalence of intraoperative PRC transfusion was 44.8%, and meningioma, intraosseous/skull-based tumor, and tumor size were linked with massive transfusion. Conclusion Unnecessary preoperative blood component preparation for brain tumor surgery was noticed in routine practice. Exploring intraoperative transfusion variables has been challenged in optimizing crossmatch and actual use. [ABSTRACT FROM AUTHOR]

危機的出血への対応ガイドライン及び産科的危機出血の対応指針 2022 では看護師の役割として, 出血量の測定・ 記録や輸血の介助, 血液製剤の運搬・確認, 輸血部門との連絡などが挙げられている．緊急輸血が多い救急現場では 血液型情報や輸血歴の有無・血液伝播性感染症・宗教上の問題などの情報収集, 輸血同意書など治療と同時進行で行 う必要がある．緊急性が高いほど輸血関連インシデントや有害事象のリスクは高まるが, 安全かつ的確に業務を遂行 するためにはひとつひとつの行為がなぜ必要なのかを熟知し, そのための手間を惜しまないことが重要である． 近年タスクシフトやタスクシェアにより看護師は多くの役割を求められる．緊迫した状況で多くの役割を短時間か つ的確に行うためには日頃の準備が必要であり, マニュアル作成や多職種とシミュレーションを行うことが望ましい． 実際の現場では看護師の中にもコマンダーを置き看護師の役割遂行や多職種との連携を担うことが理想である． 本稿では緊急輸血・大量輸血時における看護のポイントや看護師のチーム医療における役割について述べる. [ABSTRACT FROM AUTHOR]

Summary: A vascular introducer sheath is often used for rapid volume replacement. However, common manipulations such as the addition of needleless connectors to infusion ports and the insertion of catheters or other devices through the introducer sheath may impede flow. In this study we utilised a rapid infuser to deliver room-temperature normal saline through two introducer sheath configurations with and without the addition of needleless connectors and the placement of catheters through the introducer sheaths. The maximal flow rate delivered by the rapid infuser was 1000 mL/min, which was observed with both introducer sheath sizes tested without additional resistive elements. However, with the addition of a needleless connector, flow rates through the introducer sheaths were substantially lower (64 (standard deviation (SD) 6) mL/min and 61 (SD 7) mL/min for the 8.5 Fr and 9 Fr introducers, respectively). Flow rates were also reduced when catheters were placed within the sheaths (298 (SD 9) mL/min with the 7 Fr catheter and 74 (SD 9) mL/min with the 8 Fr catheter placed in an 8.5 Fr sheath; 649 (SD 6) mL/min with the 7 Fr catheter and 356 (SD 14) mL/min with the 8 Fr catheter placed in the 9 Fr sheath). These findings indicated that both needleless connectors and the placement of catheters through vascular introducer sheaths substantially reduced potential flow rates. Even 'large' vascular introducer sheaths capable of delivering high flow rates could be rendered minimally effective for rapid fluid administration when used in this way. Clinicians should consider these impediments to flow when rapid fluid administration is required, and obtain alternative vascular access if necessary. [ABSTRACT FROM AUTHOR]

Purpose: This study aimed to examine the association of fibrinogen/fibrin degradation product (FDP) values in comparison with D-dimer and fibrinogen (Fib) values and the need for massive fresh frozen plasma (FFP) transfusion in patients with blunt trauma. Methods: This retrospective study included patients with blunt trauma aged ≥ 18 years who were transported directly to the tertiary care hospital between April, 2012, and March, 2021. Massive FFP transfusion was defined as a composite outcome of at least 10 units of FFP or death for any cause except for cerebral herniation, within 24 h after hospital arrival. We evaluated the diagnostic accuracy of predicting the need for massive FFP transfusions using FDP, D-dimer, and Fib levels at the time of hospital arrival. Results: A total of 2160 patients were eligible for the analysis, of which 167 fulfilled the criteria for the composite outcome. The area under the curve and 95% confidence interval for FDP, D-dimer, and Fib levels were 0.886 (0.865–0.906), 0.885 (0.865–0.906), and 0.771 (0.731–0.810), respectively. When the cutoff values of FDP and D-dimer were set at 90 μg/mL and 45 μg/mL, the sensitivity values were 77% and 78%, the positive predictive values were 28% and 27%, and the negative predictive values were both 98%, respectively. In contrast, the sensitivity of Fib was low regardless of the cutoff value. Conclusion: FDP and D-dimer levels at the time of hospital arrival showed a higher predictive accuracy for the need for massive FFP transfusion than Fib. [ABSTRACT FROM AUTHOR]

Haemorrhagic shock is frequent in critical care settings and responsible for a high mortality rate due to multiple organ dysfunction and coagulopathy. The management of critically ill patients with bleeding and shock is complex, and treatment of these patients must be rapid and definitive. The administration of large volumes of blood components leads to major physiological alterations which must be mitigated during and after bleeding. Early recognition of bleeding and coagulopathy, understanding the underlying pathophysiology related to specific disease states, and the development of individualised management protocols are important for optimal outcomes. This review describes the contemporary understanding of the pathophysiology of various types of coagulopathic bleeding; the diagnosis and management of critically ill bleeding patients, including major haemorrhage protocols and post-transfusion management; and finally highlights recent areas of opportunity to better understand optimal management strategies for managing bleeding in the intensive care unit (ICU). [ABSTRACT FROM AUTHOR]

This study aimed to assess whether the grade of contrast extravasation (CE) on CT scans was associated with massive transfusion (MT) requirements in pediatric blunt liver and/or spleen injuries (BLSI). This multicenter retrospective cohort study included pediatric patients (≤16 years old) who sustained BLSI between 2008 and 2019. MT was defined as transfusion of all blood products ≥40 mL/kg within the first 24 h of admission. Associations between CE and MT requirements were assessed using multivariate logistic regression analysis with cluster-adjusted robust standard errors to calculate the adjusted odds ratio (AOR). A total of 1407 children (median age: 9 years) from 83 institutions were included in the analysis. Overall, 199 patients (14 %) received MT. CT on admission revealed that 54 patients (3.8 %) had CE within the subcapsular hematoma, 100 patients (7.1 %) had intraparenchymal CE, and 86 patients (6.1 %) had CE into the peritoneal cavity among the overall cohort. Multivariate analysis, adjusted for age, sex, age-adjusted shock index, injury severity, and laboratory and imaging factors, showed that intraparenchymal CE and CE into the peritoneal cavity were significantly associated with the need for MT (AOR: 2.50; 95 % CI, 1.50–4.16 and AOR: 4.98; 95 % CI, 2.75–9.02, respectively both p < 0.001). The latter significant association persisted in the subgroup of patients with spleen and liver injuries. Active CE into the free peritoneal cavity on admission CT was independently associated with a greater probability of receiving MT in pediatric BLSI. The CE grade may help clinicians plan blood transfusion strategies. Level 4; Therapeutic/Care management. • What is currently known about this topic? The presence of contrast extravasation on CT is a warning sign of higher failure rates of non-operative management in pediatric blunt liver and spleen injuries. Patients with hepatic and splenic contrast blush on imaging were more likely to undergo intensive medical management. • What new information is contained in this article? Active contrast extravasation into the free peritoneal cavity on CT could be identified in children with blunt splenic and liver injury who are at risk of massive transfusion. The grade of contrast extravasation may help clinicians to plan blood transfusion strategies. [ABSTRACT FROM AUTHOR]

Injury remains a significant global health concern, with early major haemorrhage (MH) being a leading cause of preventable death. However, the absence of a standardised definition for MH hinders research comparability and optimal clinical decision-making.This scoping review aims to explore and categorise the published definitions of MH in adults following injury.A systematic search of the Medline (OVID) database and additional sources was conducted following established guidelines. Peer-reviewed articles published in English up to March 2023 were included if they related to injury, and critically unwell adult patients, and included reference to bleeding or haemorrhage.Out of 191 identified articles, 50 were included in the final analysis. These studies spanned from 2006 to 2023 and were conducted in various geographic locations. No consistent definition of MH was identified. Definitions of MH fell into six distinct categories: receipt of blood products, physiological parameters, scoring systems, clinical gestalt, observed bleeding (CT or clinical), and composite definitions. The ‘receipt of blood products’ category was the most frequent definition category, with massive transfusion (MT) ‘received’ being the most common definition of MH. Composite definitions and definitions involving the use of physiological parameters were also commonly employed.Our scoping review identified wide heterogeneity in the definition of MH following injury. The absence of a standardised definition for MH poses a significant challenge to both injury research and clinical practice. Addressing this gap is crucial in improving systems of trauma care and outcomes for critically bleeding patients.

Abstract Background In patients with major hemorrhage, balanced transfusions and limited crystalloid use is recommended in both civilian and military guidelines. This transfusion strategy is often applied in the non-trauma patient despite lack of supporting data. The aim of this study was to describe the current transfusion practice in patients with major hemorrhage of both traumatic and non-traumatic etiology in Central Norway, and discuss if transfusions are in accordance with appropriate massive transfusion protocols. Methods In this retrospective observational cohort study, data from four hospitals in Central Norway was collected from 01.01.2017 to 31.12.2018. All adults (≥18 years) receiving massive transfusion (MT) and alive on admission were included. MT was defined as transfusion of ≥10 units of packed red blood cells (PRBC) within 24 hours, or ≥ 5 units of PRBC during the first 3 hours after admission to hospital. Clinical data was collected from the hospital blood bank registry (ProSang) and electronic patient charts (CareSuite PICIS). Patients undergoing cardiothoracic surgery or extracorporeal membrane oxygenation treatment were excluded. Results A total of 174 patients were included in the study, of which 85.1% were non-trauma patients. Seventy-six per cent of all patients received plasma:PRBC in a ratio ≥ 1:2 (high ratio) and 59.2% of patients received platelets:PRBC in a ratio ≥ 1:2 (high ratio). 32.2% received a plasma:PRBC-ratio ≥ 1:1, and 23.6% platelet:PRBC-ratio ≥ 1:1. Median fluid infusion of crystalloids in all patients was 5750 mL. Thirty-seven per cent of all patients received tranexamic acid, 53.4% received calcium and fibrinogen concentrate was administered in 9.2%. Conclusions Most patients had a non-traumatic etiology. The majority was transfused with high ratios of plasma:PRBC and platelet:PRBC, but not in accordance with the aim of the local protocol (1:1:1). Crystalloids were administered liberally for both trauma and non-trauma patients. There was a lower use of hemostatic adjuvants than recommended in the local transfusion protocol. Awareness to local protocol should be increased.

Objective To analyze the value of plasmin-α2-plasmin inhibitor complex (PIC) and thrombin-antithrombin complex (TAT) for risk stratification of massive transfusion (MT) in patients with postpartum hemorrhage (PPH). Methods Clinical data and blood samples of patients with PPH in our hospital from January 2019 to December 2022 were retrospectively analyzed. MT (MT group, n=60) was defined as transfusion of red blood cells≥10 U within 24 h after delivery, and 3.25 ng/mL and PIC level>1.04 μg/mL were independent risk factors for MT after PPH. Conclusion Elevated TAT and PIC levels are independent predictors of MT in patients with PPH, and their combined predictive efficacy is better.

Background: Rotational thromboelastometry (ROTEM) allows targeted and individualised blood product replacement. Objectives: The study aimed to determine the impact of ROTEM‐guided transfusion on the clinical course of patients with acute massive haemorrhage in a regional Australian hospital. Methods/Materials: A retrospective review of all patients with acute massive haemorrhage that compared the characteristics, blood product use, and clinical outcomes of patients with massive haemorrhage before and after the introduction of ROTEM‐guided transfusion. Results: In per‐protocol analysis, the 31/97 (32%) with ROTEM‐guided transfusion used less packed red blood cells (median [interquartile range]: 6 [6–8] vs. 8 [6–12] units, p = 0.03) than patients whose transfusion was not ROTEM‐guided. They were also less likely to receive fresh frozen plasma (2/31 [6%] vs. 45/66 [68%], p < 0.0001) or platelets (2/31 [6%] vs. 31/66 [47%], p < 0.0001); they were, however, more likely to receive fibrinogen products (26/31 [84%] vs. 38/66 [58%], p = 0.01). Patients receiving ROTEM‐guided transfusion had lower in‐hospital mortality (6/31 [19%] vs. 20/66 [30%], odds ratio 0.55 [95% confidence interval]: 0.20–1.55, p = 0.26) although this did not achieve statistical significance in this small cohort. Conclusion: ROTEM‐guided massive transfusion of patients with acute haemorrhage in this regional Australian hospital led to a reduction in packed red blood cell, fresh frozen plasma, and platelet utilisation and may also have reduced mortality. [ABSTRACT FROM AUTHOR]

Background: In patients with major hemorrhage, balanced transfusions and limited crystalloid use is recommended in both civilian and military guidelines. This transfusion strategy is often applied in the non-trauma patient despite lack of supporting data. The aim of this study was to describe the current transfusion practice in patients with major hemorrhage of both traumatic and non-traumatic etiology in Central Norway, and discuss if transfusions are in accordance with appropriate massive transfusion protocols. Methods: In this retrospective observational cohort study, data from four hospitals in Central Norway was collected from 01.01.2017 to 31.12.2018. All adults (≥18 years) receiving massive transfusion (MT) and alive on admission were included. MT was defined as transfusion of ≥10 units of packed red blood cells (PRBC) within 24 hours, or ≥ 5 units of PRBC during the first 3 hours after admission to hospital. Clinical data was collected from the hospital blood bank registry (ProSang) and electronic patient charts (CareSuite PICIS). Patients undergoing cardiothoracic surgery or extracorporeal membrane oxygenation treatment were excluded. Results: A total of 174 patients were included in the study, of which 85.1% were non-trauma patients. Seventy-six per cent of all patients received plasma:PRBC in a ratio ≥ 1:2 (high ratio) and 59.2% of patients received platelets:PRBC in a ratio ≥ 1:2 (high ratio). 32.2% received a plasma:PRBC-ratio ≥ 1:1, and 23.6% platelet:PRBC-ratio ≥ 1:1. Median fluid infusion of crystalloids in all patients was 5750 mL. Thirty-seven per cent of all patients received tranexamic acid, 53.4% received calcium and fibrinogen concentrate was administered in 9.2%. Conclusions: Most patients had a non-traumatic etiology. The majority was transfused with high ratios of plasma:PRBC and platelet:PRBC, but not in accordance with the aim of the local protocol (1:1:1). Crystalloids were administered liberally for both trauma and non-trauma patients. There was a lower use of hemostatic adjuvants than recommended in the local transfusion protocol. Awareness to local protocol should be increased. [ABSTRACT FROM AUTHOR]

Background: Although transfusion management has improved during the last decade, orthotopic liver transplantation (OLT) has been associated with considerable blood transfusion requirements which poses some challenges in securing blood bank inventories. Defining the predictors of massive blood transfusion before surgery will allow the blood bank to better manage patients' needs without delays. We evaluated the predictors of intraoperative massive transfusion in OLT. Study Design and Methods: Data were collected on patients who underwent OLT between 2007 and 2017. Repeat OLTs were excluded. Analyzed variables included recipients' demographic and pretransplant laboratory variables, donors' data, and intraoperative variables. Massive transfusion was defined as intraoperative transfusion of ≥10 units of packed red blood cells (RBCs). Statistical analysis was performed using SPSS version 17.0. Results: The study included 970 OLT patients. The median age of patients was 57 (range: 16–74) years; 609 (62.7%) were male. RBCs, thawed plasma, and platelets were transfused intraoperatively to 782 (80.6%) patients, 831 (85.7%) patients, and 422 (43.5%) patients, respectively. Massive transfusion was documented in 119 (12.3%) patients. In multivariate analysis, previous right abdominal surgery, the recipient's hemoglobin, Model for End Stage Liver Disease (MELD) score, cold ischemia time, warm ischemia time, and operation time were predictive of massive transfusion. There was a direct significant correlation between the number of RBC units transfused and plasma (Pearson correlation coefficient r =.794) and platelets (r =.65). Discussion: Previous abdominal surgery, the recipient's hemoglobin, MELD score, cold ischemia time, warm ischemia time, and operation time were predictive of intraoperative massive transfusion in OLT. [ABSTRACT FROM AUTHOR]

BACKGROUND: The traditional definition of massive transfusion is 10 red blood cell units transfused within 24 hr. This definition has been faulted for excluding patients who die early from exsanguination. Alternative major bleeding definitions in the trauma literature include time-based (e.g., Resuscitation Intensity) and event based (e.g., Sharpe) transfusion thresholds. OBJECTIVE: The study objective was to compare four definitions of major bleeding, including a modification to the Sharpe definition, on clinically relevant processes and outcomes. METHODS: This is a retrospective cohort study of adult trauma patients admitted from the field to a Level I trauma center from 2014 to 2019. Data sources were the trauma registry, blood bank, and electronic medical records. Transfusion thresholds were defined as follows: Resuscitation Intensity--4 units of any combination of crystalloids, colloids, or blood products within the first 30 min of arrival; Sharpe--10 red blood cell units from trauma bay presentation to inpatient admission (a proxy for the interval of hemorrhage control); Modified Sharpe--10 units of any combination of blood products during the same interval. The study analysis consisted of descriptive statistics. RESULTS: The cohort contained 187 subjects. Of 39 deaths, 28 (72%) occurred within 6 hr following arrival. Modified Sharpe captured 27 (96%) of these 28 subjects, whereas Resuscitation Intensity captured 20 (71%). Sharpe and the traditional definition each captured 22 subjects (79%). Modified Sharpe captured 17%-25% of deaths missed by the other definitions. CONCLUSION: Modified Sharpe may optimally indicate major bleeding during trauma resuscitation. [ABSTRACT FROM AUTHOR]

Key questions in bleeding management are "Why does my patient bleed?" and "How to fix it?" To answer the first question, the high negative predictive value of viscoelastic testing can be used to identify coagulopathic bleeding. Accordingly, goal-directed bleeding management (GDBM) guided by viscoelastic testing has been shown to be an effective and essential part of the second pillar of patient blood management (PBM) with the aim to improve patients' outcomes and safety. Patient's medical and drug history - with a focus on medication with oral anticoagulants and antiplatelet drugs - are important in emergency, urgent, and elective surgery. Furthermore, risk scores have been developed and validated for traumatic and obstetric hemorrhage and can be helpful tools to predict severe hemorrhage and the need for massive transfusion. Acidosis, hypocalcemia, anemia, and hypothermia ("diamond of death in trauma") are important basic conditions for hemostasis and good predictors of coagulopathy and should be closely monitored by blood gas analysis and corrected in bleeding patients. Earlier time to hemostasis was associated with decreased mortality in trauma studies. Therefore, GDBM aims to stop the bleeding as soon as possible and avoid the main killers in blood transfusion: Transfusion-associated circulatory overload, transfusion-related acute lung injury, transfusion-related immune modulation, and thrombosis. Thromboelastometry-guided bleeding management follows the concepts of Good Medical Practice and Precision Medicine. Here, rotational thromboelastometry (ROTEM)-guided bleeding management algorithms are using a stepwise approach based on the sequence "Treat first what kills first:" (1) Fibrinolysis management, (2) clot firmness management, (3) thrombin generation management, and (4) avoidance of hypercoagulability and thrombosis. Here, thromboelastometry can not only identify patients with hypercoagulability and increased risk of thrombosis but also ROTEM-guided bleeding management can avoid thromboembolic complications, too. This may support the idea of personalized antithrombotic therapy guided by viscoelastic testing in the postoperative period. Finally, PBM is not about blood transfusion: It is about patients' outcomes. Accordingly, several meta-analyses based on more than 20 randomized controlled trials on the effect of viscoelastic testingguided perioperative bleeding management did not only demonstrate a significant reduction in transfusion requirements but also a significant reduction in mortality and postoperative acute kidney injury. The reduction in postoperative acute kidney injury again has a significant impact on long-term survival. Accordingly, recent PBM guidelines recommend the implementation of viscoelastic testing-guided bleeding management algorithms with a 1B or 1A recommendation. This is also addressed in the World Health Organization policy brief about the urgent need to implement PBM in all member states in a timely manner. However, even if the number of national activities is increasing, there is still a long way to go. [ABSTRACT FROM AUTHOR]

Background. In Europe, ambulances are increasingly being equipped with blood products for prehospital use. Available evidence on the early administration of blood products comes from military medicine and the Anglo-American medical literature; the evidence cannot be easily transferred to European countries. Objectives. This study assesses the incidence of patients with massive haemorrhage after trauma and the potential need for prehospital blood transfusions. Methods. Data reported by 37 German air rescue stations between 2015 and 2020 were retrospectively analysed to predict the need for massive transfusion. Results. A total of 320,347 helicopter emergency medical service (HEMS) missions were performed and involved 2982 patients with potential need for massive transfusion after trauma (approximately 13 transfusions per helicopter per year). Men were most affected (73%). The median age of patients was 38 years. Traffic accidents accounted for 59% of the cases. Most patients sustained multiple injuries including traumatic brain injuries (62%), as well as thoracic (54%), abdominal (39%), and extremity injuries (41%). The median "rSIG" (reversed shock index multiplied with the Glasgow Coma Scale) decreased from 4.31 to 3.78. Conclusions. Although the incidence of haemorrhagic trauma patients is low, the prehospital administration of blood products might be useful as a potentially life-saving bridging treatment until hospital admission. [ABSTRACT FROM AUTHOR]

Background: Definitions for massive transfusion (MT) vary widely between studies, contributing to challenges in interpretation of research findings and practice evaluation. In this first systematic review, we aimed to identify all MT definitions used in randomised controlled trials (RCTs) to date to inform the development of consensus definitions for MT. Methods: We systematically searched the following databases for RCTs from inception until 11 August 2022: MEDLINE, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), PubMed, Cumulative Index to Nursing and Allied Health Literature, and Transfusion Evidence Library. Ongoing trials were sought from CENTRAL, ClinicalTrials.gov, and World Health Organisation International Clinical Trials Registry Platform. To be eligible for inclusion, studies had to fulfil all the following three criteria: (1) be an RCT; (2) include an adult patient population with major bleeding who had received, or were anticipated to receive, an MT in any clinical setting; and (3) specify a definition for MT as an inclusion criterion or outcome measure. Results: Of the 8,458 distinct references identified, 30 trials were included for analysis (19 published, 11 ongoing). Trauma was the most common clinical setting in published trials, while for ongoing trials, it was obstetrics. A total of 15 different definitions of MT were identified across published and ongoing trials, varying greatly in cut-offs for volume transfused and time period. Almost all definitions specified the number of red blood cells (RBCs) within a set time period, with none including plasma, platelets or other haemostatic agents that are part of contemporary transfusion resuscitation. For completed trials, the most commonly used definition was transfusion of ≥ 10 RBC units in 24 h (9/19, all in trauma), while for ongoing trials it was 3–5 RBC units (n = 7), with the timing for transfusion being poorly defined, or in some trials not provided at all (n = 5). Conclusions: Transfusion of ≥ 10 RBC units within 24 h was the most commonly used definition in published RCTs, while lower RBC volumes are being used in ongoing RCTs. Any consensus definitions should reflect the need to incorporate different blood components/products for MT and agree on whether a 'one-size-fits-all' approach should be used across different clinical settings. [ABSTRACT FROM AUTHOR]

Abstract Background Previous studies have reported conflicting results regarding fresh frozen plasma (FFP)-to-red blood cell (RBC) ratio and platelet-to-RBC ratio on outcomes for massive transfusion for trauma. Moreover, nationwide data on massive transfusion practices for trauma in the real-world clinical setting are scarce. This study aimed to examine the nationwide practice patterns and trends in massive transfusion for trauma in Japan using a national administrative, inpatient database. Method We identified patients who underwent emergency hospitalization for trauma and received massive transfusion, defined as administration of at least 20 units of RBC within the first 2 days of admission, using the nationwide inpatient database, which covers approximately 90% of all tertiary emergency hospitals in Japan, between 2011 and 2020. Trends in the incidence and practice patterns of massive transfusion were described by calendar year. The association of practice patterns with mortality or adverse events was tested. Results A total of 3,530,846 trauma hospitalizations were identified, of which 5247 (0.15%) received massive transfusion. A significant declining trend was observed in the incidence of massive transfusion in trauma hospitalizations from 0.24% in 2011 to 0.10% in 2020 (P for trend

BackgroundThe utilization and impact of various ratios of transfusions for pediatric trauma patients (PTPs) receiving a massive transfusion (MT) are unknown. Therefore, we sought to determine the risk for mortality in PTPs receiving an MT of ≥ 6 units of packed red blood cells (PRBC) within 24 h. We compared PRBC: plasma ratio of > 2:1 (Unbalanced Ratios, UR) versus ≤ 2:1 (Balanced Ratios, BR), hypothesizing decreased risk of mortality with BR.MethodsThe Trauma Quality Improvement Program was queried (2014-2016) for PTPs receiving a MT. A multivariable logistic regression model was used to determine risk of mortality.ResultsFrom 239 PTPs receiving an MT, 98 (41%) received an UR, whereas 141 (59%) received a BR. The median ratios, respectively, were 2.7:1 and 1.2:1. Compared to BR patients, UR patients had no differences in injury severity score (ISS), hypotension on admission, and intensive care unit stay (all p > 0.05). The mortality rates for BR and UR were similar (46.1% vs. 52.0%, p = 0.366). Controlling for age, ISS, and severe head injury, UR demonstrated similar risk of mortality compared to BR (p = 0.276). Additionally, ≥ 4:1 ratio versus ≤ 2:1 showed no difference in associated risk of mortality (p = 0.489).ConclusionIn contrast to adult studies, this study demonstrated that MT ratios of > 2:1 and even ≥ 4:1 were associated with similar mortality compared to BR for PTPs. These results suggest pediatric MT resuscitation may not require strict BR as has been shown beneficial in adult trauma patients. Future prospective studies are needed to evaluate the optimal ratio for PTP MT resuscitation.Level of evidenceIII; Retrospective Care Management Study.

Abstract Background Definitions for massive transfusion (MT) vary widely between studies, contributing to challenges in interpretation of research findings and practice evaluation. In this first systematic review, we aimed to identify all MT definitions used in randomised controlled trials (RCTs) to date to inform the development of consensus definitions for MT. Methods We systematically searched the following databases for RCTs from inception until 11 August 2022: MEDLINE, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), PubMed, Cumulative Index to Nursing and Allied Health Literature, and Transfusion Evidence Library. Ongoing trials were sought from CENTRAL, ClinicalTrials.gov, and World Health Organisation International Clinical Trials Registry Platform. To be eligible for inclusion, studies had to fulfil all the following three criteria: (1) be an RCT; (2) include an adult patient population with major bleeding who had received, or were anticipated to receive, an MT in any clinical setting; and (3) specify a definition for MT as an inclusion criterion or outcome measure. Results Of the 8,458 distinct references identified, 30 trials were included for analysis (19 published, 11 ongoing). Trauma was the most common clinical setting in published trials, while for ongoing trials, it was obstetrics. A total of 15 different definitions of MT were identified across published and ongoing trials, varying greatly in cut-offs for volume transfused and time period. Almost all definitions specified the number of red blood cells (RBCs) within a set time period, with none including plasma, platelets or other haemostatic agents that are part of contemporary transfusion resuscitation. For completed trials, the most commonly used definition was transfusion of ≥ 10 RBC units in 24 h (9/19, all in trauma), while for ongoing trials it was 3–5 RBC units (n = 7), with the timing for transfusion being poorly defined, or in some trials not provided at all (n = 5). Conclusions Transfusion of ≥ 10 RBC units within 24 h was the most commonly used definition in published RCTs, while lower RBC volumes are being used in ongoing RCTs. Any consensus definitions should reflect the need to incorporate different blood components/products for MT and agree on whether a ‘one-size-fits-all’ approach should be used across different clinical settings.

Marfan syndrome (MS) is an autosomal dominant connective tissue disease associated with significant morbidity and mortality due to progressive dilatation of the thoracic aorta which can lead to aortic rupture. Survival from an aortic rupture is predicated on immediate organized and goal directed care by both surgical and anesthesia teams. This case highlights how coordinated care from a cardiac operating room team, including early preparation of autologous blood products, expeditious placement of intravascular access for rapid high volume transfusion, and intentional communication between anesthesia, perfusion, surgery and nursing during the resuscitation in the OR, can all lead to an improved outcome.

Background: Injured patients in hemorrhagic shock have a survival benefit with massive transfusion protocol (MTP). While there are many published studies on the transfusion management of massively bleeding patients, the risk of alloimmunization in patients that have received products during an MTP activation is relatively unknown. Therefore, we sought to determine the frequency of new antibody formation in MTP patients that received blood products from an uncrossmatched megapack. Materials and Methods: We conducted a retrospective data review of patients who underwent an MTP activation for trauma resuscitation between May 2014 and July 2020. Data were collected from patients who met the following criteria: MTP was activated, the patients received at least one unit of packed red blood cells, one unit of fresh frozen plasma, one unit of platelets, and had a repeat type and screen within 6 weeks of transfusion. These inclusion criteria resulted in 28 patients over the 6-year timeframe. Results: Overall, the risk of alloimmunization secondary to MTP is 3.6% in our trauma patient population. The newly developed antibodies post-MTP are considered clinically significant, meaning they can cause hemolysis if exposed to donor red blood cells containing those antigens. Discussion: Blood products should be given preferentially over crystalloids to acutely bleeding patients to prevent ischemic injury during an MTP activation despite the risk of alloimmunization. In our single-institution study, the alloimmunization rate in massive transfusions where patients receive uncrossmatched red blood cells is similar to those receiving crossmatched red blood cells. [ABSTRACT FROM AUTHOR]

Previous studies have shown that an elevated prehospital National Early Warning Score (preNEWS) is associated with increased levels of adverse outcomes in patients with trauma. However, whether preNEWS is a predictor of massive transfusion (MT) in patients with trauma is currently unknown. This study investigated the accuracy of preNEWS in predicting MT and hospital mortality among trauma patients. We analyzed adult trauma patients who were treated and transported by emergency medical services (EMS) between January 2018 and December 2019. The main exposure was the preNEWS calculated for the scene. The primary outcome was the predictive ability for MT, and the secondary outcome was 24 h mortality. We compared the prognostic performance of preNEWS with the shock index, modified shock index, and reverse shock index, and reverse shock index multiplied by Glasgow Coma Scale in the prehospital setting. In total, 41,852 patients were included, and 1456 (3.5%) received MT. preNEWS showed the highest area under the receiver operating characteristic (AUROC) curve for predicting MT (0.8504; 95% confidence interval [CI], 0.840–0.860) and 24 h mortality (AUROC 0.873; 95% CI, 0.863–0.883). The sensitivity of preNEWS for MT was 0.755, and the specificity of preNEWS for MT was 0.793. All indicies had a high negative predictive value and low positive predictive value. preNEWS is a useful, rapid predictor for MT and 24 h mortality. Calculation of preNEWS would be helpful for making the decision at the scene such as transfer straightforward to trauma center and advanced treatment. [ABSTRACT FROM AUTHOR]

Background: Previous studies have reported conflicting results regarding fresh frozen plasma (FFP)-to-red blood cell (RBC) ratio and platelet-to-RBC ratio on outcomes for massive transfusion for trauma. Moreover, nationwide data on massive transfusion practices for trauma in the real-world clinical setting are scarce. This study aimed to examine the nationwide practice patterns and trends in massive transfusion for trauma in Japan using a national administrative, inpatient database. Method: We identified patients who underwent emergency hospitalization for trauma and received massive transfusion, defined as administration of at least 20 units of RBC within the first 2 days of admission, using the nationwide inpatient database, which covers approximately 90% of all tertiary emergency hospitals in Japan, between 2011 and 2020. Trends in the incidence and practice patterns of massive transfusion were described by calendar year. The association of practice patterns with mortality or adverse events was tested. Results: A total of 3,530,846 trauma hospitalizations were identified, of which 5247 (0.15%) received massive transfusion. A significant declining trend was observed in the incidence of massive transfusion in trauma hospitalizations from 0.24% in 2011 to 0.10% in 2020 (P for trend < 0.001). The FFP-to-RBC ratio rose significantly from 0.77 in 2011 to 1.08 in 2020 (P for trend < 0.001), while the platelet-to-RBC ratio remained virtually unchanged from 0.71 in 2011 to 0.78 in 2020 (P for trend 0.060). Massive transfusion with lower FFP-to-RBC (< 0.75) and platelets-to-RBC ratio (< 1.00) were associated with increased in-hospital mortality compared with those ≥ 1.00, while there were linear increases in adverse events with increasing FFP and platelets ratios. Conclusions: This study demonstrated a declining trend in the incidence and a rise in higher FFP-to-RBC ratios in massive transfusion in association with patient outcomes for trauma from 2011 to 2020 in Japan. [ABSTRACT FROM AUTHOR]

Massive transfusion in obstetric catastrophes is to achieve surgical hemostasis while reducing the hypoperfusion complications. Aprospective observational study was conducted on subjects with obstetric hemorrhage requiring blood/blood product transfusions for 405 subjects out of 10063 subjects required transfusion (4.02% incidence).Association between massive transfusion and age ≥35 years was assessed using chi square test P value was <0.001 significant, similarly, irregular antenatal check-up was also found to be significant with P value 0.004. Association between previous LSCS and massive transfusion was found to be P value 0.017 significant and a significant association was found between platelet count & massive transfusion, blood loss & massive transfusion and shock and DIC with a P value of <0.001. [ABSTRACT FROM AUTHOR]

Introduction: Massive hemorrhage (MH) is the second determinant of initial mortality in trauma patients. Its treatment requires aggressive resuscitation with blood or its components. New therapeutic schemes have been postulated, within which massive transfusion (MT) stands out. To analyze the initial experience with the application of the TM protocol in adult trauma patients admitted to the Emergency Department of the Hospital de Clínicas "Dr Manuel Quintela." Materials and methods: A retrospective, observational, and descriptive study was carried out at the Hospital de Clínicas in the period from 1st February 2018 to 2020. Inclusion and exclusion criteria were established. Results: If we only include patients who suffered some type of trauma, the percentage of correct activation rose to 81.6% of the cases. When evaluating the mortality associated with the use of the protocol, it was shown to be significantly lower than in those in which the protocol was used without a clear indication, with a calculated p-value of 0.009. This reflects that there is an association between the need for MT and death. An association was demonstrated between the value of the Assessment of Blood Consumption (ABC) score and death (p = 0.013). Conclusion: Decreases morbidity and mortality in patients who are candidates for MT. Organizes the work group, assigning roles and establishing therapies. Appropriate the rational use of blood components, a finite and scarce good in the world such as blood donation. [ABSTRACT FROM AUTHOR]

BACKGROUND: Hypocalcemia is common in trauma patients receiving massive transfusion protocol and often leads to worsening coagulopathies. Despite the identified problem and recommendations for replacement, few institutions have implemented a standardized calcium replacement protocol. OBJECTIVE: This study aims to assess whether a revised massive transfusion protocol, including standardized calcium replacement, increases the incidence of calcium administration in trauma patients receiving massive transfusion protocol. METHODS: This quality improvement project used a retrospective pre-/postdesign to study the revision of the current facility's massive transfusion protocol to include calcium replacement and ionized calcium monitoring at an urban Level I academic trauma center. Pre- and postintervention data were collected from January 2022 through October 2022 to determine the number of times massive transfusion protocol was ordered, ionized calcium monitoring, and calcium administration rates. Feedback regarding the protocol was collected throughout the monitoring period and was utilized in the final analysis. RESULTS: A total of 40 patients received massive transfusion protocol, preintervention, 18 of 23 (78%) received calcium supplementation, postintervention, 15 of 16 (98%) were treated. The majority of protocol activations occurred in the trauma bay (79%) and postintervention; ionized calcium monitoring dropped by 14%. CONCLUSION: This study found that the addition of standardized calcium replacement improved administration rates of calcium in this patient population. Ongoing research will ensure the recommended changes improve the identified shortcomings and that patients maintain adequate ionized calcium levels with the current dosing parameters. [ABSTRACT FROM AUTHOR]

Introduction: Pancreas transplant is one of the UK's less commonly done solid abdominal organ transplants. The transplant is reputed for its high-risk postsurgical complications due to multiple patients, procedures, and immunological factors. For this reason, patients are habitually admitted to the intensive care unit for postlaparotomy care, physiological support, and graft function monitoring during their immediate postoperative course. Project Aim: This program evaluation analyzed the trend in critical care length of stay and organ support requirements for patients following whole pancreas transplantation. The aim was to use these baseline data as performance metrics to enable a safer transition and Plan-Do-Study-Act (PDSA) cycles in improving the delivery of enhanced recovery service. Design: A retrospective chart review was performed using records from Phillips IntelliSpace Critical Care and Anaesthesia system to evaluate the institutional outcomes of patients < 18 years admitted to intensive care following pancreas transplantation between January 1, 2018, and December 31, 2021. Islet-cell transplant recipients were excluded as there is a different postoperative recovery. Results: The data suggested that although patients require a higher level of observations, blood pressure management, blood gas, and glucose monitoring during their first week of transplant, these patients did not routinely require the full range of critical care support. Conclusion: The present evaluation reported the organ support requirements for these transplant recipients. The results will generate further interest in enhanced recovery and service evaluation projects to streamline the postoperative care of these patients from the operating theatre back to the transplant wards. [ABSTRACT FROM AUTHOR]

Abstract Background Management of bleeding trauma patients is still a difficult challenge. Massive transfusion (MT) requires resources to ensure the safety and timely delivery of blood products. Early prediction of MT need may be useful to shorten the time process of blood product preparation. The primary aim of this study was to assess the accuracy of shock index to predict the need for MT in adult patients with trauma. For the same population, we also assessed the accuracy of SI to predict mortality. Methods This systematic review and meta-analysis was performed in accordance with the PRISMA guidelines. We performed a systematic search on MEDLINE, Scopus, and Web of Science from inception to March 2022. Studies were included if they reported MT or mortality with SI recorded at arrival in the field or the emergency department. The risk of bias was assessed using the QUADAS-2. Results Thirty-five studies were included in the systematic review and meta-analysis, for a total of 670,728 patients. For MT the overall sensibility was 0.68 [0.57; 0.76], the overall specificity was 0.84 [0.79; 0.88] and the AUC was 0.85 [0.81; 0.88]. Positive and Negative Likelihood Ratio (LR+; LR−) were 4.24 [3.18–5.65] and 0.39 [0.29–0.52], respectively. For mortality the overall sensibility was 0.358 [0.238; 0.498] the overall specificity 0.742 [0.656; 0.813] and the AUC 0.553 (confidence region for sensitivity given specificity: [0.4014; 0.6759]; confidence region for specificity given sensitivity: [0.4799; 0.6332]). LR+ and LR− were 1.39 [1.36–1.42] and 0.87 [0.85–0.89], respectively. Conclusions Our study demonstrated that SI may have a limited role as the sole tool to predict the need for MT in adult trauma patients. SI is not accurate to predict mortality but may have a role to identify patients with a low risk of mortality.

Massive transfusion protocols (MTP) commonly result in severe hypocalcemia due to the calcium-binding affinity of citrate in blood components. The purpose of this study is to determine the optimal grams (g) of citrate to repletion calcium (Ca) milliequivalents (mEq) (Citrate:Ca) ratio to reduce 30-day mortality. This was a retrospective, single-centered, cohort study at a level 1 trauma center evaluating trauma and surgical patients in need of MTP activation from January 1, 2010–July 31, 2021. Patients with severe hypocalcemia at baseline, defined as ionized calcium (iCa) <0.9 mmol/L, were compared to patients without severe hypocalcemia. The primary endpoint was to determine the optimal ratio of grams of citrate to calcium mEq to reduce mortality in patients receiving a MTP. Secondary endpoints included mortality at 24 h and 30 days, blood components used in MTP, and type of calcium used. Overall, 501 patients were screened for inclusion. Of these patients, 193 were excluded, leaving 308 patients, of which 165 patients (53.6%) had an iCa <0.9 mmol/L within 24 h and 143 patients (46.4%) had iCa ≥0.9 mmol/L within 24 h. The ratio of Citrate:Ca for each patient was not significantly associated with mortality at 24 h (P = 0.79) or 30 days (P = 0.91) at a repletion Citrate:Ca ratio of median 1.97 (IQR 1.14–2.91). The rate of mortality was lowest at a Citrate:Ca of 2 in both <24-h mortality and 30-day mortality. There were no differences in 24 h or 30 day mortality based on repletion ratios seen in this study. A Citrate:Ca ratio between 2 and 3 in patients undergoing MTP was sufficient to obtain a normalized iCa within 24 h of MTP activation regardless of baseline iCa level. Further prospective studies will be needed to determine the optimal Citrate:Ca ratio. [ABSTRACT FROM AUTHOR]