Page 28 - Journal of Special Operations Medicine - Fall 2014

and his colleagues note that much of the resistance to rotational thromboelastometry (ROTEM) measurements
the use of far-forward fresh whole blood is the perceived rather than mortality as an outcome measure and included
risk associated with its use but that this risk may be less trauma patients who did not receive massive transfusions
than that associated with other life- saving interventions in the analysis. 83
undertaken in the prehospital combat environment, such
as surgical airways and endotracheal intubation. 38 As with whole blood collected in theater, the platelets
used for 1:1:1 resuscitation in the US Central Command
DCR With 1:1:1 Component Therapy (CENTCOM) are also not FDA approved. An FDA-
Brohi and colleagues documented that trauma-related approved blood product must be collected at a blood
coagulopathy was present in 25% of severely injured bank that has a Biologic License Application with the
blunt trauma patients brought to a large trauma center, FDA, fully certifying its standard operating procedures
70
even before significant fluid resuscitation. Coagulo- and quality control in accordance with FDA standards.
pathy has been documented in 38% of combat casualties All DoD blood centers in the continental United States
71
who require transfusion. Trauma-related coagulopathy meet these standards. Combat theater blood banking
is associated with a 3- to 6-fold increase in mortality. 71,72 practice approximates these standards insofar as possi-
A recent review of 3632 casualties in the Department ble but deviates in two important ways: (1) Retrospective
of Defense Trauma Registry (DoDTR) who received at transfusion-transmitted disease (TTD) testing is con-
least one blood product found that there was a 33% ducted on each unit of product collected, but this is not
incidence of coagulopathy (INR greater than or equal to done prospectively, so each unit is not virally “cleared”
1.5) and that coagulopathy was associated with a 5-fold prior to release to the patient; and (2) platelets are kept
73
increase in mortality. up to 7 days if cultures are negative. Mitigation mea-
sures include tracking of recipients and matching with
Both the prehospital resuscitation strategy recommended retrospective results to ensure proper care in the event
by ATLS at the onset of the Afghanistan conflict (2L of disease transmission; use of pedigreed donors (tested
of crystalloid) and the transfusion practices of many every 90 days) to minimize risk; and use of rapid tests
trauma centers at that time (which emphasized RBC ad- prior to release of products for transfusion (note that
ministration with relatively fewer units of plasma and these rapid tests are meant for screening, not blood do-
platelets) exacerbated the endogenous component of nor qualification: a positive result helps, but a negative
trauma-related coagulopathy by superimposing a dilu- result does not guarantee product safety). Thus, there
84
tional coagulopthy. Some civilian trauma centers began is currently no way to administer either the best option
46
to administer RBCs, plasma, and platelets in a 1:1:1 ra- (whole blood) or the second-best option (1:1:1 com-
tio to decrease iatrogenic coagulopathy. 46,74–76 ponent therapy) in Afghanistan using FDA- compliant
blood products.
A retrospective study of 694 massively transfused com-
bat casualties treated at the military hospital in Baghdad DCR With 1:1 Component Therapy
found that patients receiving a higher ratio of platelets to DCR with a 1:1 ratio of plasma to RBCs is the high-
RBCs had a 24-hour survival rate of 95% compared with est level of hemostatic resuscitation that can be accom-
a survival rate of 87% in patients with a medium platelet- plished in theater using FDA-compliant blood products.
to-RBC ratio and 64% for those with the lowest platelet-to- The major challenge to achieving full FDA compli-
62
RBC ratio. Cap and coauthors performed a retrospective ance is the inability to certify the TTD status of WB or
analysis of 414 combat casualties from Iraq who received apheresis platelets prior to transfusion. This is one of
massive transfusions (defined as 10 or more units of RBCs the major drivers for the DoD’s WB pathogen reduction
within 24 hours). This study found that resuscitation with technology program. 84
higher ratios of plasma and platelets to RBCs within the
first 6 hours was associated with improved 24-hour and DCR using higher ratios of plasma to RBCs has now
30-day survival in combat casualties. When platelets are been shown to improve survival in massively trans-
77
not available, a plasma-to-RBC ratio of 1:1.5 or greater is fused patients in both the military and civilian sec-
also associated with improved survival. 48,78 tors. 48,52,73–75,78,85–89 Increasing the plasma-to-RBC ratio
has a greater impact on outcomes for those casualties
DCR using 1:1:1 plasma, RBCs, and platelets is now who receive massive transfusions (more than 10 units
the standard of care for the US military for casualties of RBCs in the first 24 hours) compared with those
requiring resuscitation from hemorrhagic shock. 49,79,80 who receive smaller amounts of blood products. Fur-
90
DCR is also being used with increasing frequency in ci- ther, plasma has been shown to be of greater benefit
91
vilian trauma centers. 52,81,82 One study that questioned when administered early in resuscitation. It should be
the use of the term “hemostatic resuscitation” to refer noted that the definition of massive transfusion is cur-
to DCR as well as the value of the DCR approach used rently evolving from the 10 or more units of RBCs in

20 Journal of Special Operations Medicine Volume 14, Edition 3/Fall 2014