Page 143 - JSOM Spring 2023

Background: Time to treatment matters in traumatic haemorrhage Donald H, MD; Braverman, Maxwell A, DO; Mentzer, Caleb,
but the optimal prehospital use of blood in major trauma remains DO; Leonard, Guy C, BS; Perea, Lindsey L, DO; Docherty,
uncertain. We investigated whether use of packed red blood cells Courtney K, DO; Dunn, Julie A, MD; Smoot, Brittany, BS; Mar-
(PRBC) and lyophilised plasma (LyoPlas) was superior to use of tin, Matthew J, MD; Badiee, Jayraan, MPH; Luis, Alejandro J,
0.9% sodium chloride for improving tissue perfusion and reduc- MD; Murray, Julie L, BSN, RN; Noorbakhsh, Matthew R, MD;
ing mortality in trauma-related haemorrhagic shock. Methods: Babowice, James E, DO; Mains, Charles MD; Madayag, Robert
Resuscitation with pre-hospital blood products (RePHILL) is a M, MD; Kaafarani, Haytham MA, MD, MPH; Mokhtari, Ava K,
multicentre, allocation concealed, open-label, parallel group, ran- MD; Moore, Sarah A, MD; Madden, Kathleen, MD; Tanner, Allen
domised, controlled, phase 3 trial done in four civilian prehos- 2nd, MD; Redmond, Diane, MSN; Millia, David J, MD; Bran-
pital critical care services in the UK. Adults (age ≥16 years) with dolino, Amber, MS; Nguyen, Uyen, BS; Chinchilli, Vernon, PhD;
trauma-related haemorrhagic shock and hypotension (defined as Armen, Scott B, MD; Porter, John M, MD
systolic blood pressure <90mmHg or absence of palpable radial Ann Surg. 2022:276(4):579–588.
pulse) were assessed for eligibility by prehospital critial care teams.
Eligible participants were randomly assigned to receive either up Objective: The aim of this study was to identify a mortality ben-
to two units each of PRBC and LyoPlas or up to 1L of 0.9% so- efit with the use of whole blood (WB) as part of the resuscita-
dium chloride administered through the intravenous or intraosse- tion of bleeding trauma patients. Background: Blood component
ous route. Sealed treatment packs which were identical in external therapy (BCT) is the current standard for resuscitating trauma
appearance, containing PRBC–LyoPlas or 0.9% sodium chloride, patients, with WB emerging as the blood product of choice. We
were prepared by blood banks and issued to participating sites ac- hypothesized that the use of WB versus BCT alone would result
cording to a randomisation schedule prepared by the coordinating in decreased mortality. Methods: We performed a 14-center, pro-
centre (1:1 ratio, stratified by site). The primary outcome was a spective observational study of trauma patients who received WB
composite of episode mortality or impaired lactate clearance, or versus BCT during their resuscitation. We applied a generalized
both, measured in the intention-to-treat population. This study is linear mixed-effects model with a random effect and controlled
completed and registered with ISRCTN.com, ISRCTN62326938. for age, sex, mechanism of injury (MOI), and injury severity score.
Findings: From Nov 29, 2016, to Jan 2, 2021, prehospital critical All patients who received blood as part of their initial resuscita-
care teams randomly assigned 432 participants to PRBC–LyoPlas tion were included. Primary outcome was mortality, and second-
(n=209) or to 0.9% sodium chloride (n=223). Trial recruitment ary outcomes included acute kidney injury, deep vein thrombosis/
was stopped before it achieved the intended sample size of 490 pulmonary embolism, pulmonary complications, and bleeding
participants due to disruption caused by the COVID-19 pandemic. complications. Results: A total of 1623 [WB: 1180 (74%), BCT:
The median follow-up was 9 days (IQR 1 to 34) for participants 443(27%)] patients who sustained penetrating (53%) or blunt
in the PRBC–LyoPlas group and 7 days (0 to 31) for people in (47%) injury were included. Patients who received WB had a
the 0.9% sodium chloride group. Participants were mostly white higher shock index (0.98 vs 0.83), more comorbidities, and more
(62%) and male (82%), had a median age of 38 years (IQR 26 to blunt MOI (all p<0.05). After controlling for center, age, sex, MOI,
58), and were mostly involved in a road traffic collision (62%) and injury severity score, we found no differences in the rates of
with severe injuries (median injury severity score 36, IQR 25 to acute kidney injury, deep vein thrombosis/pulmonary embolism
50). Before randomisation, participants had received on average or pulmonary complications. WB patients were 9% less likely to
430mL crystalloid fluids and tranexamic acid (90%). The com- experience bleeding complications and were 48% less likely to die
posite primary outcome occurred in 128 (64%) of 199 partici- than BCT patients (p<0.0001). Conclusions: Compared with BCT,
pants randomly assigned to PRBC–LyoPlas and 136 (65%) of the use of WB was associated with a 48% reduction in mortality
210 randomly assigned to 0.9% sodium chloride (adjusted risk in trauma patients. Our study supports the use of WB use in the
difference –0.025% [95% CI –9.0 to 9.0], p=0.996). The rates resuscitation of trauma patients.
of transfusion-related complications in the first 24 hr after ED
arrival were similar across treatment groups (PRBC–LyoPlas 11 Transfusion strategies in bleeding critically ill adults: a
clinical practice guideline from the European Society of
[7%] of 148 compared with 0.9% sodium chloride nine [7%] of
137, adjusted relative risk 1.05 [95% CI 0.46–2.42]). Serious ad- Intensive Care Medicine
verse events included acute respiratory distress syndrome in nine Alexander PJ Vlaar, Joanna C Dionne, Sanne de Bruin, Marije Wi-
(6%) of 142 patients in the PRBC–LyoPlas group and three (2%) jnberge, S Jorinde Raasveld, Frank EHP van Baarle, Massimo An-
of 130 in 0.9% sodium chloride group, and two other unexpected tonelli, Cecile Aubron, Jacques Duranteau, Nicole P Juffermans,
serious adverse events, one in the PRBC-LyoPlas (cerebral infarct) Jens Meier, Gavin J Murphy, Riccardo Abbasciano, Marcella CA
and one in the 0.9% sodium chloride group (abnormal liver func- Müller, Marcus Lance, Nathan D Nielsen, Herbert Schöchl, Bev-
tion test). There were no treatment-related deaths. Interpretation: erley J Hunt, Maurizio Cecconi, Simon Oczkowski
The trial did not show that prehospital PRBC–LyoPlas resuscita- Intensive Care Med. 2021;47(12):1368–1392.
tion was superior to 0.9% sodium chloride for adult patients with
trauma related haemorrhagic shock. Further research is required Purpose: To develop evidence-based clinical practice recommenda-
to identify the characteristics of patients who might benefit from tions regarding transfusion practices and transfusion in bleeding
prehospital transfusion and to identify the optimal outcomes for critically ill adults. Methods: A taskforce involving 15 international
transfusion trials in major trauma. The decision to commit to rou- experts and 2 methodologists used the GRADE approach to guide-
tine prehospital transfusion will require careful consideration by line development. The taskforce addressed three main topics: trans-
all stakeholders. Funding: National Institute for Health Research fusion support in massively and non-massively bleeding critically
Efficacy and Mechanism Evaluation. ill patients (transfusion ratios, blood products, and point of care
testing) and the use of tranexamic acid. The panel developed and
Use of cold-stored whole blood is associated with answered structured guideline questions using the population, in-
improved mortality in hemostatic resuscitation of major tervention, comparison, and outcomes (PICO) format. Results: The
bleeding: a multicenter study taskforce generated 26 clinical practice recommendations (2 strong
recommendations, 13 conditional recommendations, 11 no rec-
Hazelton, Joshua P, DO; Ssentongo, Anna E, DrPh, MPH; Oh, ommendation), and identified 10 PICOs with insufficient evidence
John S, MD; Ssentongo, Paddy, MD, PhD; Seamon, Mark J, MD;
Byrne, James P, MD, PhD; Armento, Isabella G, BS; Jenkins, to make a recommendation. Conclusions: This clinical practice

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