Page 16 - JSOM Winter 2021

TRANSFUSION REACTION to improve in-hospital trauma team performance as well as
the widely held belief of military training in general. Whole
The rate of non-infectious transfusion reaction is low. In a blood training should be viewed similarly. Coordinated and
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recent evaluation of 4,857 transfusion episodes approximately deliberate autologous blood labs with appropriate oversight
1% were associated with a serious reaction. Transfusion- can safely achieve the highest degree of realism with relatively
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associated circulatory overload was most common (~1%); low cost. 42,43 Armed services blood bank policies for donor
while transfusion-related acute lung injury, anaphylactic reac- allowance in autologous blood lab participants is still under
tion and hypotensive reactions all occurred in less than 0.1% of discussion.
transfusions. Other investigators evaluated emergency transfu-
sion of 5,203 units of type-O RBC to 480 trauma patients and
found that no acute hemolytic transfusion reactions occurred. PERFORMANCE IMPROVEMENT (PI) MONITORING
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Population of Interest
In the unlikely event of a prehospital transfusion reaction, 1. All patients who receive blood product transfusion within
immediately stop the unit being transfused. A different unit 3 hours of injury
must be obtained for transfusion if the casualty remains in 2. All patients who meet criteria for blood transfusion (severe
hemorrhagic shock. Symptoms of hemorrhagic and anaphy- traumatic injury: ISS ≥ 16 and ≥ 2 body regions injured
lactic shock are difficult to differentiate and hemorrhage is with AIS severity ≥ 2 AND SBP < 100 OR HR > 100 OR
the primary concern in most trauma patients. If hemorrhagic hematocrit < 32% OR pH < 7.25) within 3 hours of injury
shock is ruled out and anaphylaxis is a real concern, administer
0.3mL of 1:1000 epinephrine intramuscularly (IM), administer Intent (Outcome)
diphenhydramine 25mg IV or IM and consider methylpred- 1. LTOWB is used for prehospital resuscitation of casualties
nisolone (the FDA approved dose of methylprednisolone is with life-threatening injuries and hemodynamic instability
10–40mg IV over several minutes, with subsequent doses being (HR > 100 or SBP < 100).
determined by clinical response). Maintain the patient’s airway 2. For the population of interest, the first resuscitation fluid
as needed and administer IV fluids in cases of hypotension. In given after injury is a blood product, ideally cold-stored
cases of acute hemolytic reaction, administer diphenhydramine LTOWB.
25mg IV or IM, and consider 3% sodium chloride 250mL. 3. Casualties in hemorrhagic shock should receive whole
blood or blood products in the prehospital and en route
HYPOCALCEMIA care environment starting within 30 minutes of injury.
Calcium administration should be considered in all patients
undergoing en route care blood transfusion. The citrate preser- Performance/Adherence Metrics
vative in blood products can chelate calcium and contribute to 1. The number and percentage of patients in the population
hypotension in patients who have received blood products. of interest who receive WB transfusion prior to arrival at
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In 352 patients who were critically bleeding and required mas- first role of care.
sive transfusion, investigators found that hypocalcemia wors- 2. Number and percentage of patients in population of inter-
ened mortality. Patients generally had low ionized calcium est who received a blood product as the first resuscitation
concentration (mean = 0.88mmol/L) and had higher odds of fluid.
mortality (Odds Ratio = 1.25, 95% Confidence Interval 1.04– 3. Number and percentage of patients in population of inter-
1.52; p = 0.02). Admission hypocalcemia is further associated est who received cold-stored LTOWB as the first resuscita-
with mortality. Calcium concentration was measured in 591 tion fluid.
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trauma patients before administration of blood products. 4. Indication identified.
Those with an ionized calcium < 1 experienced higher mortal- 5. Pre and post vital signs measured.
ity (15.5%) compared to those with ionized calcium levels > 1 6. Calcium administration documented.
(mortality = 8.7%, p = 0.036). 7. Appropriate information collected for donor and recipient
exposure monitoring.
Trauma patients are often hypocalcemic without regard to
transfusion status, further suggesting that calcium adminis- Data Sources
tration may be beneficial .36,37 In 212 trauma patients with a • Patient Record (DD1380/DA4700 OP7)
mean Injury Severity Score (ISS) of 34; 64% were found to be • DoDTR
hypocalcemic (with calcium < 1.15mmol/L) and 10% were se-
verely hypocalcemic (< 0.9mmol/L). Hypocalcemia is common System Reporting and Frequency
in massive transfusion and associated with increased mortal- The above constitutes the minimum criteria for PI monitoring
ity .38,39 Although the mechanism of this effect is not completely of this CPG. System reporting frequency will be performed
understood, it is thought that acidemia related to tissue hypo- annually; additional PI monitoring and system reporting may
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perfusion may play a role. Administer one gram of calcium be performed as needed.
(30mL of 10% calcium gluconate or 10mL of 10% calcium
chloride) IV/IO before, during (using a secondary access point) The system review and data analysis will be performed by the
or immediately after the first unit of blood product. Re-dose JTS Chief and the JTS PI Improvement Branch.
1 gm of calcium IV/IO after every 4 units of blood products.
Responsibilities
It is the Unit Medical Director’s responsibility to ensure famil-
TRAINING
iarity, training, appropriate compliance and PI monitoring at
Execution of prehospital and en route care blood transfu- the local level with this CPG. Coordination with the Regional
sions requires sufficient training to adequately prepare. Con- Medical Director and Trauma Director is also essential in en-
ducting the most realistic training possible has been shown suring full spectrum compliance and PI monitoring along with

14 | JSOM Volume 21, Edition 4 / Winter 2021