us army forward surgical team fresh whole blood …rdcr.org/wp-content/uploads/symp2012pdf/us army...

LTCP Shawn C. Nessen DO, FACS

DCCS, 212th Combat Support Hospital

Trauma Critical Care Surgeon

Landstuhl Regional Medical Center

US Army Forward Surgical

TeamFresh Whole Blood

onsdag 5. september 2012

541st Medical Detachment

Evaluate the effectiveness of resuscitation with and without FWB at Forward Surgical Teams in Afghanistan

OBJECTIVE



Afghanistan from 2006 to 2011

Forward Surgical Teams

Forward Operating Bases

10 or 20 personnel

RBCs

FFP

No platelets

FWB available

SETTING


490 patients given blood transfusions

4605 total units of blood products• 2622 units of RBCs• 1570 units of FFP• 416 units of FWB

94 Massive Blood Transfusions• 49 with FWB• 45 without FWB

94 Patients received Fresh Whole Blood

BACKGROUND



Temperature

Systolic blood pressure

Respiratory rate

Glasgow coma scale

Injury Severity score

Sex

Age

FST prospectively studied data from 206-2011

Blood product utilization

rF VIIa utilization

Mechanism of injury

Type of injury

Surgical procedures

Died of wounds

Nationality

Methods


Univariate analysis was performed to identify variables associated with FWB use.Variables associated with FWB were used to calculate propensity scores SBP Temperature rF VIIa Total RBCs and FFPTwo separate propensity score analysis were performed continuous variable stratificationDeath was the predicted using a conditional logistic regression model

Methods


RESULTS

Table 1: Admission Vitals and Lab data by Fresh Whole Blood (FWB) use Table 1: Admission Vitals and Lab data by Fresh Whole Blood (FWB) useTable 1: Admission Vitals and Lab data by Fresh Whole Blood (FWB) use

No FWB (n =396) FWB (n =94) p value

Age (yrs) 25.6 ± 11.5; 24.5(20,30); 372 28.05 ± 9.65; 25(22,30); 81 0.08

Male gender 377 (95.2) 90 (95.7) 1.00

GCS 13.7 ± 2.8; 15(14,15); 396 13.2 ± 3.4; 15(14,15); 93 0.15

ISS 19.6 ± 9.2; 16.5 (16, 25); 396 22.4 ± 8.9; 20 (16, 26); 94 0.008

Arrival SBP (mmHg) 110.1 ± 27.6; 110 (95,128); 390 99.9 ± 30.1; 97(80,123); 94 0.002

Arrival RR 22 ± 83; 21(16,26); 385 25.2 ± 9.7; 25(18,30); 94 0.004Arrival Temp (F)

97.6 ± 1.6; 97.7(96.9, 98.4);375 96.9 ± 2.1;97.1(96,97.9); 83 0.005

Continuous variables reported as mean ± SD; median (LowerQ, UpperQ); nContinuous variables reported as mean ± SD; median (LowerQ, UpperQ); nContinuous variables reported as mean ± SD; median (LowerQ, UpperQ); n

Categorical variables reported as n (%)Categorical variables reported as n (%)


Blood Product Use with FWB

Table 2: Blood Products Use by Fresh Whole Blood (FWB) useTable 2: Blood Products Use by Fresh Whole Blood (FWB) useTable 2: Blood Products Use by Fresh Whole Blood (FWB) use No FWB (n =396) FWB (n =94) p value

FWB (U) 0 4.4 ± 4; 3(2,6) <0.001Total PRBC (U) 4.6 ± 3.7; 4(2,6) 12.7 ± 9.4; 10 (6,16) <0.001Total Plasma (U) 2.6 ± 2.7 ; 2(0,4) 10 ±7.1; 8(5,12) <0.001Total Blood Products (U) 7.3 ± 5.8; 6 (3,10) 18.3 ±13.1;14(10,24) <0.001Factor VII given 23 (5.8) 24 (25.5) <0.001Massive Transfusion 46 (11.6) 49 (52.1) <0.001Continuous variables reported as mean ± SD ; median (LowerQ, UpperQ)Continuous variables reported as mean ± SD ; median (LowerQ, UpperQ)Continuous variables reported as mean ± SD ; median (LowerQ, UpperQ) Categorical variables reported as n (%)Categorical variables reported as n (%)


Admission Vital Signs and Trauma Scores

Table 4: Admission Vitals and Lab data by Death StatusTable 4: Admission Vitals and Lab data by Death StatusTable 4: Admission Vitals and Lab data by Death StatusTable 4: Admission Vitals and Lab data by Death Status

Alive (n =448) Dead (n =42) p value

Age (yrs) 25.9 ± 11; 25 (20, 30); 417 28.1 ± 13.3; 25 (21,30); 3628.1 ± 13.3; 25 (21,30); 36 0.25Male gender 426 (95.1) 41 (97.6) 0.71GCS 14.1 ± 2.3 ; 15 (14,15); 447 9.07 ± 4.8; 9 (3,15); 42 <0.001ISS 19.4 ± 8.6 ; 16 (16,25);448 27.8 ± 12.1; 25 (18, 32); 4227.8 ± 12.1; 25 (18, 32); 42 <0.001Arrival SBP (mmHg) 109.9 ± 26.8 ;110 (93,128);443 88.8 ± 37.1; 84 (78,106); 4188.8 ± 37.1; 84 (78,106); 41 <0.001Arrival RR 22.5 ± 8.4 ; 22 (16, 28); 438 23.7 ± 11.5 ;24 (17, 32); 4123.7 ± 11.5 ;24 (17, 32); 41 0.54Arrival Temp (F) 97.6 ± 1.6;97.8(97,98.6); 420 96.4±1.6;96.4(95.8, 97.4);3896.4±1.6;96.4(95.8, 97.4);38 <0.001Continuous variables reported as mean ± SD; median (LowerQ, UpperQ); nContinuous variables reported as mean ± SD; median (LowerQ, UpperQ); nContinuous variables reported as mean ± SD; median (LowerQ, UpperQ); nContinuous variables reported as mean ± SD; median (LowerQ, UpperQ); n

Categorical variables reported as n (%)Categorical variables reported as n (%)


Variables Associated with Death

Table 5: Blood Products Use by Death StatusTable 5: Blood Products Use by Death Status Alive (n =448) Dead (n =42) p value

FWB (U) 0.8 ± 2.2 ;0 (0,0);448 1.33 ± 4.6 ; 0 (0, 0);42 0.46Total PRBC (U) 5.8 ± 5.5 ;4 (2, 8); 448 10.1±10.3 ; 7(4 ,12); 42 0.01Total Plasma (U) 3.9 ± 4.5; 3(0,6); 448 5.9 ± 7.8;4 (1,6); 42 0.12Total Blood Products (U) 8.9 ± 8 ;7 (3, 12); 448 14.7±14 ;10 (6, 19) 42 0.01Factor VII given 39 (8.7) 8 (19.1) 0.049Massive Transfusion 79 (17.6) 16 (38.1) 0.007Continuous variables reported as mean ± SD ; median (LowerQ, UpperQ); nContinuous variables reported as mean ± SD ; median (LowerQ, UpperQ); nContinuous variables reported as mean ± SD ; median (LowerQ, UpperQ); n Categorical variables reported as n (%)Categorical variables reported as n (%)


Logistic Regression Predicting Effect of FWB on Death

Table 7: Propensity score used as continuous variable in logistic regression predicting effect of FWB on deathTable 7: Propensity score used as continuous variable in logistic regression predicting effect of Table 7: Propensity score used as continuous variable in logistic regression predicting effect of Table 7: Propensity score used as continuous variable in logistic regression predicting effect of

Outcome: Death Odds Ratio 95% CI p-value

FWB use 0.09 0.02, 0.53 0.007

Injury Severity Score 1.07 1.03, 1.11 <0.001

Glasgow Coma Score 0.71 0.65, 0.78 <0.001

Propensity score 9.12 1.35, 61.48 0.023

Arrival systolic blood pressure, arrival temperature, use of factor VIIa, total packed red blood cells and total plasma administered were used to calculate propensity scoreArrival systolic blood pressure, arrival temperature, use of factor VIIa, total packed red blood cells and total plasma administered were used to calculate propensity scoreArrival systolic blood pressure, arrival temperature, use of factor VIIa, total packed red blood cells and total plasma administered were used to calculate propensity scoreArrival systolic blood pressure, arrival temperature, use of factor VIIa, total packed red blood cells


Propensity Score Analysis Predicting Effect of FWB on Death

Table 8: Stratified Propensity score analysis predicting effect of use of FWB on death Table 8: Stratified Propensity score analysis predicting effect of use of FWB on death Table 8: Stratified Propensity score analysis predicting effect of use of FWB on death Table 8: Stratified Propensity score analysis predicting effect of use of FWB on death

Outcome: Death Odds Ratio 95% CI p-value

FWB use 0.11 0.02, 0.75 0.02

Injury Severity Score 1.06 1.01, 1.11 0.01

Glasgow Coma Score 0.71 0.63, 0.79 <0.001


Using logistic regression and propensity score analysis patients receiving RBCs and FFP with FWB had significantly higher survival than those who received RBCs and FFP alone.

Results


94 Patients received MBT

49 with FWB, RBCs, and FFP

DOW=8.16%

45 with RBCs and FFP

DOW=26.67%

P=0.025

Subset Analysis


94 patients received FWB51% was type Specific DOW=6.1%49% type O DOW=6.7%

Subset Analysis


Injury Severity Score

0

6,50

13,00

19,50

26,00

22,4525,820,15

All patientsMass transfused patientsFresh whole blood patients


Mechanism of Injury

47 %

2 %4 %1 %

46 % GunshotMotor Vehicle CollisionOtherBurnsBlast


Injury by Site4 %1 %5 %

6 %

12 %

1 %2 % 5 %

39 %

24 % AbdominalExtremityVascularUrologyGYNThoracicHead/NeckNeuroBurnOther



Damage Control ResuscitationDamage Control SurgeryEvacuation

Forward Surgical Teams



Surgical Support of Combat OperationsForward Surgical Team

20 Personnel

6 HMMWV

3 Tents

2 OR tables

30 Operations

Limited holding

20 units PRBCs

Maneuvers with a combat brigade

1 hour set up

Combat Support Hospital

84 Beds

8 OR Tables

36+ ICU beds

Large

Slow

Lab

X-ray

Trauma Center

Division support area


Combat Surgical Support



Prevents the Lethal Triad of Trauma

hypothermia

acidosis

coagulopathy

Minimize crystalloid

Transfuse RBC:FFP:PLTs 1:1:1

Damage Control Surgery

stops the bleeding

or it doesn’t

Damage Control Resuscitation



Corrects Trauma associated Coagulopathy

Present in 1/3 of combat wounded

blood loss

acidosis

hypothermia

consumption

fibrinolysis

dilution

Damage Control


Damage Control Resuscitation allows Damage Control Surgery

RBC:FFP:PLT=1:1:1

4 units RBC triggers DCR

10 units RBC=10 units FFP=10 pack PLTs

1 unit of Fresh Whole Blood

1 unit of RBCs

1 unit of FFP

130,000 to 350,000 PLTs per microliter

Damage Control Surgery


Historically Type O Fresh Whole Blood Transfused

Current Clinical Practice Guideline requires type specific FWB despite historical data

Patients in this study received type O and type specific blood with no difference in mortality

Difficult to determine blood transfusion reactions in this environment

Further study warranted

Type O Fresh Whole Blood


FWB can be safely transfused at Level II Surgical FacilitiesFWB is independently associated with survival compared to patients who only receive RBCs and FFP at Level II facilities

Conclusions


DCR in locations without PLTs should include FWB

FST personnel must be trained to transfuse FWB

All combat surgeons should be trained in DCR and DCS

Role II Facilities primary role is DCR and DCS

Role II facilities should have a minimum of 2 General Trauma Surgeons

All deploying personnel should be typed and screened pre-deployment

Deploying personnel should undergo standard blood donor testing

Type O blood may be used in emergency situations to prevent exsanguination

Recommendations


Questions


us army forward surgical team fresh whole blood …rdcr.org/wp-content/uploads/symp2012pdf/us army...

Documents