Page 52 - JSOM Fall 2018

A Pilot Study of Four Intraosseous Blood Transfusion Strategies

4
Jonathan Auten* ; Julie B. Mclean, PhD, CTR ; Jean D. Kemp ; Paul J. Roszko ;
2
3
1
7
6
5
Grady A. Fortner ; Alyssa L. Krepela ; Alexandra C. Walchak, MS, CTR ;
8
9
Chemely M. Walker, CTR ; Travis G. Deaton ; Joanna E. Fishback 10

ABSTRACT
Background: Intraosseous (IO) access is used by military first IO blood transfusion can present technical challenges, because
responders administering fluids, blood, and medications. Cur­ medullary pressure is approximately one­third of systemic
rent IO transfusion strategies include gravity, pressure bags, pressure. To improve IO transfusion flow rates, the pressure
6
rapid transfusion devices, and manual push­pull through a gradient between bone and systemic circulation must be in­
three­way stopcock. In a swine model of hemorrhagic shock, creased. The existing literature has shown few associations
7
we compared flow rates among four different IO blood trans­ between increasing IO transfusion pressure gradients and sig­
fusion strategies. Methods: Nine Yorkshire swine were placed nificant clinical complications like pulmonary arterial fat em­
under general anesthesia. We removed 20 to 25mL/kg of each bolism, hemolysis, or coagulopathy. 1,8
animal’s estimated blood volume using flow of gravity. IO ac­
cess was obtained in the proximal humerus. We then autolo­ However, after a decade of use in combat settings, the broad
gously infused 10 to 15mL/kg of the animal’s estimated blood acceptance of IO blood transfusions in adult DCR is still ques­
9
volume through one of four randomly assigned treatment tioned. Clinical concern stems from foundational studies that
arms. Results: The average weight of the swine was 77.3kg used a skeletally immature swine model to determine the safety
(interquartile range, 72.7kg–88.8kg). Infusion rates were as of IO blood transfusions. 8,10,11 The bone density of a healthy
follows: gravity, 5mL/min; Belmont rapid infuser, 31mL/min; man 20 to 40 years old is roughly double that of skeletally
single­site pressure bag, 78mL/min; double­site pressure bag, immature swine used in those studies. 9,12 Bone density or me­
103mL/min; and push­pull technique, 109mL/min. No pulmo­ dia permeability is a critical physical property in Darcy’s law,
nary arterial fat emboli were noted. Conclusion: The optimal which describes the relationship of fluid flow through porous
13
IO transfusion strategy for injured Servicemembers appears media. Darcy’s law predicts increased transfusion pressures
to be single­site transfusion with a 10mL to 20mL flush of are required to maintain or improve flow rates with increasing
14
normal saline, followed immediately by transfusion under a bone densities and fluid viscosity. Current pressurized mili­
pressure bag. Further study, powered to detect differences in tary IO transfusion strategies include using gravity, pressure
flow rate and clinical complications. is required. bags, rapid­transfusion devices, and manual push­pull of a
syringe with a three­way stopcock. Although swine are an
1,7
Keywords: blood transfusion; operational medicine; intraos- established model for human bone and cardiovascular physiol­
seous infusion; intraosseous transfusion; hemorrhagic shock ogy, the clinical effects of different pressurized IO transfusion
strategies in skeletally mature adults is not fully understood
and requires further investigation. 9,15–17
Introduction
In this pilot study, we compared four different IO blood trans­
Intraosseous (IO) access is used by military first responders fusion strategies with varying degrees of transfusion pressure
administering fluids, blood, and medications during remote in a swine model with similar bone density to that of an adult
damage­controlled resuscitation (rDCR). Prehospital blood Military Servicemember. We hypothesized that increasing trans­
1
transfusions for severely battle­injured military personnel fusion pressures would lead to increased flow rates with nonsig­
have been associated with an improvement in mortality in nificant differences in rates of pulmonary arterial fat embolism,
the austere environment. Unfortunately, multisystem trauma, coagulopathy, and periosteal damage at the transfusion site.
2
such as dismounted complex blast injury, presents a vascular
access challenge to even the most seasoned medical teams at­
tempting to initiate rDCR. In cases where access is difficult, Methods
3
IO catheters provide a noncollapsible method that serves as All activities were approved by the Naval Medical Center
a bridge to therapy while preparations are made for central Ports mouth Institutional Animal Care and Use Committee
venous access. 4,5 and conducted in compliance with the Animal Welfare Act
*Correspondence to Naval Medical Center Portsmouth, Department of Emergency Medicine, 620 John Paul Jones Circle, Portsmouth, VA
23708; or jonathan.d.auten.mil@mail.mil
7
6
8
1 LCDR Auten, MC USN; Dr Mclean; LCDR Roszko, MC USN; LT Fortner, MC USN; LT Krepela, MC, USN; Ms Walchak; and Ms Walker
2
4
5
are at Naval Medical Center Portsmouth, Department of Emergency Medicine, Portsmouth, VA. LCDR Kemp, MC USN, is at Naval Medical
3
Center Portsmouth, Department of Pathology, Portsmouth, VA. CDR Deaton, MC USN, is at Naval Medical Center San Diego, Department of
9
Emergency Medicine, San Diego, CA. MAJ Fishback, VC, USA, is at Naval Medical Center Portsmouth, Clinical Investigations Department,
10
Portsmouth, VA.
50