Page 79 - JSOM Spring 2023

fluids were routinely infused to massively bleeding patients, received an infusion of 1,400mL of unwashed blood collected
because neither the acidic nature of normal saline nor the po- from his chest wound at a Role 1 facility and who survived for
tentially beneficial effects of permissive hypotension had yet at least five days suggests the relative safety of infusing blood
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been appreciated. 9–12 from this site. Providers choosing to utilize an intervention
such as this should be aware of the potential high risk of mor-
Several studies have highlighted the survival disadvantages of bidity. They should consider this only when all other options
overzealous crystalloid resuscitation, as well as the survival are exhausted to salvage the resuscitation effort.
benefits of administering blood products compared to crys-
talloid. 15–31 Thus, the 2021 TCCC guidelines list the preferred What Trauma Medications Can Be
order of blood products for the resuscitation of patients in Infused with Blood in the Same Line?
hemorrhagic shock as cold stored LTOWB, pre-screened low
titer group O fresh whole blood, and then components in a Ideally, blood products should be infused by themselves. This
balanced ratio in so far as is possible. 13 is because it makes identifying the etiological agent of adverse
events that might occur during the infusion easier because only
Historically, the TCCC guidelines for treating a patient in one product was being administered. It is also because of the
hemorrhagic shock in which blood products were not (or risk that medications might damage the blood products or in-
were no longer) available recommended the use of Hextend terfere with the infusion. The co-administration of calcium, or
followed by crystalloid in 500mL boluses. However, it is not calcium-containing medications (including Lactated Ringer’s
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known “how much is too much” crystalloid before adverse solution) with blood products should be avoided due to the
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effects become apparent. Furthermore, once infused, the vol- potential for the calcium to overwhelm the citrate and lead
ume of crystalloid quickly equilibrates between the intra- and to clot formation. This could slow the infusion rate or per-
extravascular space, with 2/3 of the crystalloid volume rap- haps lead to embolic events in the patient. In fact, if calcium-
idly entering the extravascular space causing tissues to become containing medications are to be infused through the same line
edematous. This can hinder surgical hemostasis and wound as blood products, ideally these medications should be admin-
healing. Crystalloid rapidly exits the intravascular space and istered after the transfusions.
so its beneficial effect on the blood pressure is very transient
while the edema can be much longer lasting. In contrast, blood The effect of co-administering medications with blood prod-
products exert an oncotic pressure that draws fluid into the ucts has not been well studied. In a study where several an-
intravascular space. This thereby reduces the extent of edema algesic medications were mixed with RBCs, changes in RBC
formation and potentially improves the patient’s blood pres- parameters or drug concentrations over 30 days of stor-
sure for a longer period. Albumin, at 5% or preferably 25% age were not observed. However, the infusion properties of
concentration, also provides a source of oncotic pressure for the RBC unit (i.e., the flow of the infusion, was not inves-
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volume expansion. For these reasons, the current TCCC tigated). A systematic review of general laboratory studies
guidelines emphasize the first-line use of blood products and that investigated the co-administration of medications, which
do not provide the option of using Hextend or crystalloids if included the above mentioned study, found that it was gener-
blood products are not available. In considering the trade-off ally safe to co-administer antibiotics and opioids with RBCs.
between what a medic can carry and what is useful, crystal- However, that clinical correlation of the in vitro findings of
loids fail to deliver an effective cost/benefit ratio. these studies was required to establish the actual safety of this
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practice. Thus, there is scant evidence guiding the practice
of co- administering medications with transfusions. In reality,
Recycling Blood from a Wound
the administration of medications through the same line as the
Although it may seem reasonable to collect shed blood from transfusion in the field is inevitable; perhaps consider admin-
a wound and administer it to the patient, one must first con- istering the transfusion first followed by other medications if
sider the potential negative complications. Several studies have possible. Flush the line with a small volume (e.g., 10mL) of sa-
evaluated the infusion of blood collected from the abdominal line or Plasmalyte (but not Lactated Ringer’s solution) before
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cavity of injured patients. Most studies have found that the infusing more blood products after medication infusion.
combination of washing the blood before it is infused to re-
move debris, inflammatory mediators and bacteria, as well as Considerations Regarding Blood Donor
administering antibiotics to the recipient, does not lead to ad- Medication History
verse patient effects. 18–21 Since washing the blood is not prac-
tical in the field, and it is not clear how effective antibiotics There are many classes of prescription and over the counter
alone would be in preventing sepsis, this practice cannot be (OTC) medications that can lead to a deferral from donating
recommended. blood for various lengths of time. Germane to the collection of
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FWB in a battlefield setting are non-steroidal anti-inflammatory
Blood salvaged from a hemothorax has been shown to have drugs (NSAID) and testosterone replacement therapy (TRT).
lower hematocrit and lower platelet and fibrinogen concen-
trations compared to venous blood. It has also been shown NSAIDs such as aspirin and ibuprofen detrimentally affect
to have longer PT and PTT times, suggesting a depletion of platelet function. Acetaminophen also has some effect on
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coagulation factors. Furthermore, some in vitro experi- platelet function. Aspirin in particular is a potent inhibitor of
ments suggest that when blood salvaged from a hemothorax platelet function, thus civilian donors are not permitted to do-
is mixed with venous blood, coagulation is activated, which nate LTOWB or platelets by apheresis for several days after
could lead to unwanted thrombosis in the recipient. However, their last dose of an NSAID. 29,30 NSAIDs do not affect RBC or
clinical correlation of these findings is needed. 23,24 That said, a plasma function. Thus, when selecting a donor for FWB dona-
case report of an Afghani male who was shot in the chest and tion, ideally they would not have taken an NSAID for the past

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