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from seven of the included studies, 5076 were randomly assigned therapy (RRT), and ventilator-free and vasopressor-free days to
to the TXA treatment group, and 4968 were assigned to placebo. day 28. Results: We identified 13 RCTs, comprising 35,884 par-
In the TXA treatment group, 914 patients (18.0%) died, while ticipants. From six trials (34,450 participants) with a low risk of
961 patients (19.3%) died in the placebo group. There was no sig- bias, the risk ratio (RR) for 90-day mortality with balanced crys-
nificant difference between groups (RR, 0.93; 95% confidence in- talloids versus saline was 0.96 (95% confidence interval [CI], 0.91
terval, 0.86–1.01). No significant differences between the groups to 1.01; I = 12.1%); using vague priors, the posterior probability
2
in other important outcomes were observed. Conclusions: TXA that balanced crystalloids reduce mortality was 89.5%. The RRs
treatment demonstrated a tendency to reduce head trauma-re- of developing AKI and of being treated with RRT with balanced
lated deaths in the TBI population, with no significant incidence crystalloids versus saline were 0.96 (95% CI, 0.89 to 1.02) and
of thromboembolic events. TXA treatment may therefore be sug- 0.95 (95% CI, 0.81 to 1.11), respectively. Ventilator-free days
gested in the initial TBI care. (mean difference, 0.18 days; 95% CI, 20.45 to 0.81) and vaso-
pressor-free days (mean difference, 0.19 days; 95% CI, 20.14 to
Fluid resuscitation in Tactical Combat Casualty Care 0.51) were similar between groups. Conclusions: The estimated
TCCC Guidelines Change 21-01. 4 November 2021 effect of using balanced crystalloids versus saline in critically ill
Travis Deaton, MD; Jonathan Auten, DO; Richard Betzold, MD; adults ranges from a 9% relative reduction to a 1% relative in-
Frank Butler, MD; Terence Byrne, SOCM; Andre Cap, MD, PhD; crease in the risk of death, with a high probability that the average
Ben Donham, MD; Joseph DuBose, MD; Andrew D Fisher, MD, effect of using balanced crystalloids is to reduce mortality.
PA-C; James Hancock, MD; Victor Jourdain, MD; Ryan Knight,
MD; Lanny Littlejohn, MD; Matthew Martin, MD; Kevin Toland, Low titer group O whole blood resuscitation: military
SOIDC; Brendon Drew, DO experience from the point of injury
J Spec Oper Med. 21(4):126–137. Andrew D Fisher, MD, LP, Ethan A Miles, MD, Michael A Brous-
sard, MPAS, PA-C, Jason B Corley, MS, MT (ASCP) SBB, Ryan
Hemorrhagic shock in combat trauma remains the greatest life Knight, MD, Michael A Remley, NRP, SO-ATP, Andrew P Cap,
threat to casualties with potentially survivable injuries. Advances MD, PhD, Jennifer M Gurney, MD, Stacy A Shackelford, MD
in external hemorrhage control and the increasing use of dam- J Trauma Acute Care Surg. 2020;89(4):834–841.
age control resuscitation have demonstrated significant success in
decreasing mortality in combat casualties. Presently, an expand- Introduction: In the far forward combat environment, the use of
ing body of literature suggests that fluid resuscitation strategies whole blood is recommended for the treatment of hemorrhagic
for casualties in hemorrhagic shock that include the prehospital shock after injury. In 2016, US military special operations teams
use of cold-stored or fresh whole blood when available, or blood began receiving low titer group O whole blood (LTOWB) for use
components when whole blood is not available, are superior to at the point of injury (POI). This is a case series of the initial 15 pa-
crystalloid and colloid fluids. On the basis of this recent evidence, tients who received LTOWB on the battlefield. Methods: Patients
the Committee on Tactical Combat Casualty Care (TCCC) has were identified in the Department of Defense Trauma Registry,
conducted a review of fluid resuscitation for the combat casualty and charts were abstracted for age, sex, nationality, mechanism
who is in hemorrhagic shock and made the following new recom- of injury, injuries and physiologic criteria that triggered the trans-
mendations: (1) cold stored low-titer group O whole blood (CS- fusion, treatments at the POI, blood products received at the POI
LTOWB) has been designated as the preferred resuscitation fluid, and the damage-control procedures done by the first surgical
with fresh LTOWB identified as the first alternate if CS-LTOWB is team, next level of care, initial interventions by the second surgical
not available; (2) crystalloids and Hextend are no longer recom- team, Injury Severity Score, and 30-day survival. Descriptive sta-
mended as fluid resuscitation options in hemorrhagic shock; (3) tistics were used to characterize the clinical data when appropri-
target systolic blood pressure (SBP) resuscitation goals have been ate. Results: Of the 15 casualties, the mean age was 28, 50% were
redefined for casualties with and without traumatic brain injury US military, and 63% were gunshot wounds. Thirteen patients
(TBI) coexisting with their hemorrhagic shock; and (4) empiric survived to discharge, one died of wounds after arrival at the ini-
prehospital calcium administration is now recommended when- tial resuscitative surgical care, and two died prehospital. The mean
ever blood product resuscitation is required. Injury Severity Score was 21.31 (SD, 18.93). Eleven (68%) of the
causalities received additional blood products during evacuation/
Balanced crystalloids versus saline in critically ill role 2 and/or role 3. Vital signs were available for 10 patients from
adults—a systematic review with meta-analysis the prehospital setting and 9 patients upon arrival at the first sur-
Naomi E Hammond, PhD, Fernando G Zampieri, PhD, Gian gical capable facility. The mean systolic blood pressurewas 80.5
Luca Di Tanna, PhD, Tessa Garside, PhD, Derick Adigbli, PhD, prehospital and 117mmHg (p = 0.0002) at the first surgical fa-
Alexandre B Cavalcanti, MD, PhD, Flavia R Machado, MD, PhD, cility. The mean heart rate was 105 beats per minute prehospital
Sharon Micallef, BN, John Myburgh, PhD, Mahesh Ramanan, and 87.4 beats per minute (p = 0.075) at the first surgical facil-
MMed, Todd W Rice, MD, Matthew W Semler, MD, Paul J Young, ity. The mean hospital stay was 24 days. Conclusion: The use of
PhD, Balasubramanian Venkatesh, MD, Simon Finfer, MD, An- cold-stored LTOWB at POI is feasible during combat operations.
thony Delaney, PhD Further data are needed to validate and inform best practice for
NEJM Evid. 2022;1(2) POI transfusion.
Background: The comparative efficacy and safety of balanced Resuscitation with blood products in patients with
crystalloid solutions and saline for fluid therapy in critically ill trauma-related haemorrhagic shock receiving prehospital
adults remain uncertain. Methods: We systematically reviewed care (RePHILL): a multicentre, open-label, randomised,
randomized clinical trials (RCTs) comparing the use of balanced controlled, phase 3 trial
crystalloids with saline in critically ill adults. The primary out- Nicholas Crombie, Heidi A Doughty, Jonathan RB Bishop, Amisha
come was 90-day mortality after pooling data from low-risk-of- Desai, Emily F Dixon, James M Hancox, Mike J Herbert, Caroline
bias trials using a random-effects model. We also performed a Leech, Simon J Lewis, Mark R Nash, David N Naumann, Gemma
Bayesian meta-analysis to describe the primary treatment effect in Slinn, Hazel Smith, Iain M Smith, Rebekah K Wale, Alastair Wil-
probability terms. Secondary outcomes included the incidence of son, Natalie Ives, Gavin D Perkins; RePHILL collaborative group
acute kidney injury (AKI), new treatment with renal replacement
Lancet Haematol. 2020;9(4):e250–e261.

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