The Utility of Thromboelastography to Guide Blood Product Transfusion

2019 ◽  
Vol 152 (4) ◽  
pp. 407-422 ◽  
Author(s):  
Amy E Schmidt ◽  
Anna Karolina Israel ◽  
Majed A Refaai
Keyword(s):  
Liver Transplantation ◽  
Patient Management ◽  
Blood Product ◽  
Blood Product Transfusion ◽  
Blood Components ◽  
Blood Products ◽  
Case Scenario ◽  
Rotational Thromboelastometry ◽  
Coagulation Assays ◽  
Testing Technology

AbstractObjectivesTo provide an overview of the clot viscoelastic testing technology and to describe its utility in guiding blood product transfusions.MethodsA case scenario will be discussed as well as interpretation of thromboelastography (TEG) tracings. In addition, literature examining the utility of viscoelastic testing in guiding patient management and blood product transfusions will be reviewed.ResultsTEG/rotational thromboelastometry (ROTEM) is useful in evaluating clot kinetics in trauma and acutely bleeding patients. TEG/ROTEM parameters are reflective of values measured using standard coagulation assays; however, TEG/ROTEM parameters are more rapidly available and more costly. TEG and ROTEM are used in three main settings: cardiac surgery, liver transplantation, and trauma to assess global hemostasis and administration of blood products.ConclusionsTEG/ROTEM can be helpful in guiding resuscitation and blood product transfusion. Several studies have demonstrated a reduction in transfusion of blood components with TEG/ROTEM; however, other studies have suggested that TEG/ROTEM is not clinically effective in guiding transfusion.

scholarly journals Hypocalcemia in Military Casualties From Point of Injury to Surgical Teams in Afghanistan

2021 ◽  
Vol 186 (Supplement_1) ◽  
pp. 300-304
Author(s):  
Jeffrey R Conner ◽  
Linda C Benavides ◽  
Stacy A Shackelford ◽  
Jennifer M Gurney ◽  
Edward F Burke ◽  
...  
Keyword(s):  
Blood Product ◽  
Calcium Supplementation ◽  
Cohort Analysis ◽  
Blood Product Transfusion ◽  
Blood Products ◽  
Military Trauma ◽  
Retrospective Cohort Analysis ◽  
Increased Risk ◽  
Surgical Teams ◽  
Patterns Of Injury

ABSTRACT Introduction Hypocalcemia is a known sequela of citrated blood product transfusion. Civilian data suggest hypocalcemia on hospital admission is associated with worse outcomes. Initial calcium levels in military casualties have not previously been analyzed. The objective of this retrospective review aimed to assess the initial calcium levels in military trauma casualties at different Forward Surgical Teams (FST) locations in Afghanistan and describe the effects of prehospital blood product administration on arrival calcium levels. Materials and Methods This is a retrospective cohort analysis of military casualties arriving from point of injury to one of two FSTs in Afghanistan from August 2018 to February 2019 split into four locations. The primary outcome was incidence of hypocalcemia (ionized calcium < 1.20 mmol/L). Results There were 101 patients included; 55 (54.5%) experienced hypocalcemia on arrival to the FST with a mean calcium of 1.16 mmol/L (95% confidence interval [CI], 1.14 to 1.18). The predominant mechanism of injury consisted of blast patterns, 46 (45.5%), which conferred an increased risk of hypocalcemia compared to all other patterns of injury (odds ratio = 2.42, P = .042). Thirty-eight (37.6%) patients required blood product transfusion. Thirty-three (86.8%) of the patients requiring blood product transfusion were hypocalcemic on arrival. Mean initial calcium of patients receiving blood product was 1.13 mmol/L (95% CI, 1.08 to 1.18), which was significantly lower than those who did not require transfusion (P = .01). Eight (7.9%) of the patients received blood products before arrival, with 6/8 (75%) presenting with hypocalcemia. Conclusions Hypocalcemia develops rapidly in military casualties and is prevalent on admission even before transfusion of citrated blood products. Blast injuries may confer an increased risk of developing hypocalcemia. This data support earlier use of calcium supplementation during resuscitation.

Desmopressin Reduces Transfusion Needs after Surgery

2008 ◽  
Vol 109 (6) ◽  
pp. 1063-1076 ◽  
Author(s):  
Giuseppe Crescenzi ◽  
Giovanni Landoni ◽  
Giuseppe Biondi-Zoccai ◽  
Federico Pappalardo ◽  
Massimiliano Nuzzi ◽  
...  
Keyword(s):  
Blood Loss ◽  
Excess Mortality ◽  
Blood Product ◽  
Meta Analysis ◽  
Blood Product Transfusion ◽  
Blood Products ◽  
Hemostatic Agents ◽  
Randomized Controlled ◽  
Randomized Controlled Studies ◽  
Transfusion Requirements

Background Perioperative pathologic microvascular bleeding is associated with increased morbidity and mortality and could be reduced by hemostatic drugs. At the same time, safety concerns regarding existing hemostatic agents include excess mortality. Numerous trials investigating desmopressin have lacked power to detect a beneficial effect on transfusion of blood products. The authors performed a meta-analysis of 38 randomized, placebo-controlled trials (2,488 patients) investigating desmopressin in surgery and indicating at least perioperative blood loss or transfusion of blood products. Methods Pertinent studies were searched in BioMed Central, CENTRAL, and PubMed (updated May 1, 2008). Further hand or computerized searches involved recent (2003-2008) conference proceedings. Results In most of the included studies, 0.3 microg/kg desmopressin was used prophylactically over a 15- to 30-min period. In comparison with placebo, desmopressin was associated with reduced requirements of blood product transfusion (standardized mean difference = -0.29 [-0.52 to -0.06] units per patient; P = 0.01), which were more pronounced in the subgroup of noncardiac surgery and were without a statistically significant increase in thromboembolic adverse events (57/1,002 = 5.7% in the desmopressin group vs. 45/979 = 4.6% in the placebo group; P = 0.3). Conclusions Desmopressin slightly reduced blood loss (almost 80 ml per patient) and transfusion requirements (almost 0.3 units per patient) in surgical patients, without reduction in the proportion of patients who received transfusions. This meta-analysis suggests the importance of further large, randomized controlled studies using desmopressin in patients with or at risk of perioperative pathologic microvascular bleeding.

scholarly journals Effect of magnesium on rotational thromboelastometry (ROTEM) and total blood products requirement in patients undergoing liver transplantation

2012 ◽  
Vol 28 (2) ◽  
pp. 101-105 ◽  
Author(s):  
Mohamed A. Hammouda ◽  
Hisham S. Khedr ◽  
Mohamed A. Alrabiey ◽  
Ahmed M. AbdEl-Hamid ◽  
Ahmed M. AbdEl-Azim
Keyword(s):  
Liver Transplantation ◽  
Blood Products ◽  
Total Blood ◽  
Rotational Thromboelastometry

Prehospital Blood Product Administration Opportunities in Ground Transport ALS EMS – A Descriptive Study

2018 ◽  
Vol 33 (3) ◽  
pp. 230-236 ◽  
Author(s):  
Felicia M. Mix ◽  
Martin D. Zielinski ◽  
Lucas A. Myers ◽  
Kathy S. Berns ◽  
Anurahda Luke ◽  
...  
Keyword(s):  
Blood Transfusion ◽  
Patient Care ◽  
Blood Product ◽  
Life Support ◽  
Descriptive Study ◽  
Blood Product Transfusion ◽  
Trauma Patients ◽  
Blood Products ◽  
Total Patient ◽  
Significant Difference

AbstractIntroductionHemorrhage remains the major cause of preventable death after trauma. Recent data suggest that earlier blood product administration may improve outcomes. The purpose of this study was to determine whether opportunities exist for blood product transfusion by ground Emergency Medical Services (EMS).MethodsThis was a single EMS agency retrospective study of ground and helicopter responses from January 1, 2011 through December 31, 2015 for adult trauma patients transported from the scene of injury who met predetermined hemodynamic (HD) parameters for potential transfusion (heart rate [HR]≥120 and/or systolic blood pressure [SBP]≤90).ResultsA total of 7,900 scene trauma ground transports occurred during the study period. Of 420 patients meeting HD criteria for transfusion, 53 (12.6%) had a significant mechanism of injury (MOI). Outcome data were available for 51 patients; 17 received blood products during their emergency department (ED) resuscitation. The percentage of patients receiving blood products based upon HD criteria ranged from 1.0% (HR) to 5.9% (SBP) to 38.1% (HR+SBP). In all, 74 Helicopter EMS (HEMS) transports met HD criteria for blood transfusion, of which, 28 patients received prehospital blood transfusion. Statistically significant total patient care time differences were noted for both the HR and the SBP cohorts, with HEMS having longer time intervals; no statistically significant difference in mean total patient care time was noted in the HR+SBP cohort.ConclusionsIn this study population, HD parameters alone did not predict need for ED blood product administration. Despite longer transport times, only one-third of HEMS patients meeting HD criteria for blood administration received prehospital transfusion. While one-third of ground Advanced Life Support (ALS) transport patients manifesting HD compromise received blood products in the ED, this represented 0.2% of total trauma transports over the study period. Given complex logistical issues involved in prehospital blood product administration, opportunities for ground administration appear limited within the described system.MixFM, ZielinskiMD, MyersLA, BernsKS, LukeA, StubbsJR, ZietlowSP, JenkinsDH, SztajnkrycerMD. Prehospital blood product administration opportunities in ground transport ALS EMS – a descriptive study. Prehosp Disaster Med. 2018;33(3):230–236.

Blood product transfusion during air medical transport: A needs assessment

CJEM ◽  
2020 ◽  
Vol 22 (S2) ◽  
pp. S67-S73
Author(s):  
Russell D. MacDonald ◽  
Aliya Ramjaun
Keyword(s):  
Hemorrhagic Shock ◽  
Blood Product ◽  
Positive Impact ◽  
Blood Product Transfusion ◽  
Blood Products ◽  
Medical Systems ◽  
Number Of Patients ◽  
Medical Transport ◽  
Limited Supply ◽  
Physiologic Data

ABSTRACTObjectivesEarly administration of blood products to patients with hemorrhagic shock has a positive impact on morbidity and mortality. Smaller hospitals may have limited supply of blood, and air medical systems may not carry blood. The primary outcome is to quantify the number of patients meeting established physiologic criteria for blood product administration and to identify which patients receive and which ones do not receive it due to lack of availability locally.MethodsElectronic patient care records were used to identify a retrospective cohort of patients undergoing emergent air medical transport in Ontario, Canada, who are likely to require blood. Presenting problems for blood product administration were identified. Physiologic data were extracted with criteria for transfusion used to identify patients where blood product administration is indicated.ResultsThere were 11,520 emergent patient transports during the study period, with 842 (7.3%) where blood product administration was considered. Of these, 290 met established physiologic criteria for blood products, with 167 receiving blood, of which 57 received it at a hospital with a limited supply. The mean number of units administered per patient was 3.5. The remaining 123 patients meeting criteria did not receive product because none was unavailable.ConclusionIndications for blood product administration are present in 2.5% of patients undergoing time-sensitive air medical transport. Air medical services can enhance access to potentially lifesaving therapy in patients with hemorrhagic shock by carrying blood products, as blood may be unavailable or in limited supply locally in the majority of patients where it is indicated.

UK Helicopter Emergency Medical Services’ use of circulatory access devices, blood product transfusion and fluid warmers – a cross-sectional survey

Trauma ◽  
2018 ◽  
Vol 22 (1) ◽  
pp. 45-50
Author(s):  
Jonathan Morris ◽  
Simon Hughes
Keyword(s):  
Red Blood Cells ◽  
Blood Cells ◽  
Blood Product ◽  
Central Venous Access ◽  
Venous Access ◽  
Blood Product Transfusion ◽  
Blood Products ◽  
Central Venous ◽  
Packed Red Blood Cells ◽  
Warming Devices

Introduction The pre-hospital environment provides significant challenges to clinicians who wish to rapidly administer warmed blood products and fluids to patients with haemorrhagic shock. Large-bore circulatory access is required with the use of devices that will successfully warm cold blood with minimal impact on flow rates. Until now, no information has been available that defines UK Helicopter Emergency Medical Services’ (HEMS) use of circulatory access and fluid warming devices, nor the recent adoption of pre-hospital blood product transfusion. Methods A survey was sent to all 22 UK HEMS asking which circulatory access devices crews have available, whether blood products are being transfused and if fluid warming devices are used as part of their resuscitations. Results All services responded. All UK HEMS use peripheral intravenous cannulae and intraosseous access. In addition, seven use central venous catheters and three use large-bore peripheral access (the Arrow Rapid Infusion Catheter®). Three services use landmark technique alone to gain central venous access, whereas four use a combination of landmark and ultrasound-guided techniques. Different sites for central venous access are used: subclavian (seven services), internal jugular (four) and femoral (four). Fourteen services carry pre-hospital blood products of which six transfuse packed red blood cells; four transfuse packed red blood cells and fresh frozen plasma; four transfuse packed red blood cells and lyophilised plasma. Eight services carry no pre-hospital blood products. Seventeen HEMS use fluid warmers; 13 use the Belmont® buddy lite™ and four use the QinFlow Warrior. Conclusion The use of a variety of policies and range of equipment has evolved across UK HEMS, demonstrating a lack of consensus on best practice. This is the first study to record a complete picture of current UK HEMS practice with regard to the use of circulatory access devices, fluid warmers and blood product administration.

Preoperative factors as predictors of blood product transfusion requirements in orthotopic liver transplantation

2011 ◽  
Vol 21 (3) ◽  
pp. 254-259 ◽  
Author(s):  
Sina Ghaffaripour ◽  
Hilda Mahmoudi ◽  
Mohammad Khosravi ◽  
Mohammad Sahmeddini ◽  
Hossein Eghbal ◽  
...  
Keyword(s):  
Liver Transplantation ◽  
Orthotopic Liver Transplantation ◽  
Blood Product ◽  
Blood Product Transfusion ◽  
Transfusion Requirements ◽  
Preoperative Factors

Optimizing blood product utilization: A whole lot to gain and nothing to lose!

2021 ◽  
Vol 39 (15_suppl) ◽  
pp. e18669-e18669
Author(s):  
Adam F Binder ◽  
Katy Loos ◽  
Alexis Peedin ◽  
Julie Karp ◽  
Usama Gergis ◽  
...  
Keyword(s):  
Blood Product ◽  
Baseline Period ◽  
Unintended Consequences ◽  
P Value ◽  
Blood Product Transfusion ◽  
Inpatient Setting ◽  
Blood Products ◽  
Intervention Period ◽  
Post Intervention ◽  
Packed Red Blood Cells

e18669 Background: Transfusion stewardship is a vital part of managing patients with hematologic malignancies (HM). Blood products are limited resources and blood product transfusion (txn) is costly and poses complications. Randomized trials in different clinical settings have shown that a conservative txn strategy is not inferior to more liberal txn strategy. As a result, the AABB and ASCO have recommended following a conservative txn strategy in patients with cancer (hemoglobin (hg) <7-8g/dL and platelets (plt) <10K in stable non-bleeding patients). Here we report our early outpatient institution’s experience implementing a contemporary txn approach in patients with HM. Methods: We formed a multi-disciplinary team to analyze blood product utilization. Overutilization was defined as orders for multi-units, packed red blood cells (pRBC) for hg >8 or plt for plt >10K in stable non-bleeding patients. Patients’ charts were audited during the baseline period to understand practice patterns. Data were collected using Qlik database. The baseline period (May 1, 2019-Feb 29, 2020) was compared to the intervention period (March 1 – December 31, 2020). A root cause analysis was performed. When possible 2-sided paired T-test was performed. If not possible, descriptive statistics were performed. Three interventions were developed and implemented sequentially: March 2020 – Blood bank began real-time review of blood products overutilization. May 2020 – Electronic Medical Record txn order set was revised to reflect recommended best practices. October 2020 –Txn guidelines revised for patients with HM. Results: During the study period, there were 3,227 pRBC and 2,817 plt transfused units in the outpatient setting. Monthly pRBC txn decreased from (mean(SD)) 168.5 (16.6) to 154.2(16.4) (p value: 0.14). Monthly plt txn decreased from 166.5 (26.5) to 115.2 (26.2) (p value: 0.001). Rates of multi-unit orders decreased significantly. Average monthly multi-unit orders decreased for pRBC (pre-48.6(5.9);post-24.3(7.6);p value 0.00007) and plts (pre-67.4(11.8);post-21.3(23.3);p value: 0.0002). Average hb at time of txn in the pre- and post-intervention period was 7.47 and 7.22. The percentage of txn in which the indication for txn was hb <7, 7-8, >8 changed from 34.6% to 56.3%, 52.6% to 32.8%, and 12.8% to 10.9% respectively. There was no significant increase in admissions for bleeding or increase in number of outpatient visits during the study period. Conclusions: Over 10-months, we significantly reduced outpatient blood product. Robust quality improvement methodology, engaging key stakeholders, and changing the culture of outpatient management were keys to success. To date, we have not seen any unintended consequences of these changes. These results are encouraging, as outpatient transfusion stewardship is thought to be harder given concerns about patients not being monitored as closely as in the inpatient setting.

scholarly journals Neurosurgical applications of viscoelastic hemostatic assays

2017 ◽  
Vol 43 (5) ◽  
pp. E9 ◽  
Author(s):  
Svetlana Kvint ◽  
James Schuster ◽  
Monisha A. Kumar
Keyword(s):  
Perioperative Management ◽  
Blood Product ◽  
Major Surgery ◽  
Blood Product Transfusion ◽  
Thromboembolic Complications ◽  
Antithrombotic Agents ◽  
Complete Evaluation ◽  
Rotational Thromboelastometry ◽  
The Past ◽  
Rapid Reversal

Patients taking antithrombotic agents are very common in neurosurgical practice. The perioperative management of these patients can be extremely challenging especially as newer agents, with poorly defined laboratory monitoring and reversal strategies, become more prevalent. This is especially true with emergent cases in which rapid reversal of anticoagulation is required and the patient’s exact medical history is not available. With an aging patient population and the associated increase in diseases such as atrial fibrillation, it is expected that the use of these agents will continue to rise in coming years. Furthermore, thromboembolic complications such as deep venous thrombosis, pulmonary embolism, and myocardial infarction are common complications of major surgery. These trends, in conjunction with a growing understanding of the hemostatic process and its contribution to the pathophysiology of disease, stress the importance of the complete evaluation of a patient’s hemostatic profile in guiding management decisions. Viscoelastic hemostatic assays (VHAs), such as thromboelastography and rotational thromboelastometry, are global assessments of coagulation that account for the cellular and plasma components of coagulation. This FDA-approved technology has been available for decades and has been widely used in cardiac surgery and liver transplantation. Although VHAs were cumbersome in the past, advances in software and design have made them more accurate, reliable, and accessible to the neurosurgeon. VHAs have demonstrated utility in guiding intraoperative blood product transfusion, identifying coagulopathy in trauma, and managing postoperative thromboprophylaxis. The first half of this review aims to evaluate and assess VHAs, while the latter half seeks to appraise the evidence supporting their use in neurosurgical populations.

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