gurney wb in combat casualty care - strac
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Whole Blood in Combat Casualty Care
Jennifer Gurney, MD FACSCOL, MC, US Army
National Whole Blood Summit22 May 2019
“The opinions or assertions contained herein are the private views of the author and are not to be construed as official or as reflecting the views of the Departments of the Army, Air Force, Navy or the Department of Defense.”- No financial interests in items discussed
Disclaimers
Military Lessons LearnedØ Hemorrhage #1 cause of death on the
battlefield
J Trauma 2012
558“DOW”=In-Hospital
287 (51%) PS
4,596“KIA”=Pre-Hospital
976 (24%)Potentially Survivable
> 1 0 0 0Preventable Deaths from
BLEEDING ALONE!
6
Military Lessons LearnedØ Hemorrhage #1 cause of death on the
battlefieldØ Time Matters
The Golden Hour
Ø Evacuating urgent casualties to surgical care in 60 minutes or less helps save lives
Ø not all critically injured casualties will live for 60 minutes without hemorrhage control and blood
The Golden Hour
Military Lessons LearnedØ Hemorrhage #1 cause of death on the
battlefieldØ Time MattersØ Early transfusion saves lives
MINUTES MATTER
“Among medically evacuated US military combat causalities in Afghanistan, blood product transfusion prehospital or within minutes of injury was associated with greater 24-hour and 30-day survival than delayed transfusion or no transfusion.” Shackelford et al
JAMA 2017
Military Lessons LearnedØ Hemorrhage #1 cause of death on the
battlefieldØ Time MattersØ Early transfusion saves lives
MINUTES MATTER
Ø Product matters; needs to look like whole blood
…it should be whole blood
Military Lessons LearnedØ Whole blood saves lives
Is this a Cinderella Story?
Time matters Product matters
Whole Blood in the Combat Zone
Whole Blood in the Combat Zone
Ø Warm Fresh Whole Blood (WFWB)ü From Walking Blood Banksü Been used since 2002ü Not FDA-approved
Ø Low Titer Group O Whole Blood (LTOWB)1. From Low Titer Group O Donor (ROLO)2. Cold stored, FDA approved
Whole Blood in the Combat Zone
Ø Warm Fresh Whole Blood (WFWB)ü From Walking Blood Banksü Been used since 2002ü Not FDA-approved
Ø Low Titer Group O Whole Blood (LTOWB)1. Initial efforts: From Low Titer Group O
Donor (ROLO) – Rangers Lead the Way!2. Later adopted: Cold stored, FDA
approved CS-LTOWB
Low Titer Group O Whole Blood
Ø Newest addition to blood products
Ø First sent to theater in Nov. 2016
Ø Grew out of the Ranger Low Titer Group O WBB Concept (ROLO)Ø Always have available of LOTWB if from a
donor on the missionØ Training, training, training
Low Titer Group O Whole BloodØ Since introduction into CENTCOM; huge
demandØ All MEDEVAV units and Role 2 Forward
Surgical Teams have 2-10 units LTOWB
Ø Demand >> SupplyØ OIR WB WG, est. Nov 2017 to evaluate use
LTOWB use and increase supply
2
3326
40
24
46
59
198
1 3
2
2
0
10
20
30
40
50
60
70
JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC
# U
nits
LTOWB Transfused in 2017
OIR OFS
11 6 120
2 104
51
224
6 1327
5
10
6
2 33 26
40 2446
59
198
1
3 2
2
0102030405060708090
JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC
# U
nits
Total Whole Blood Transfused in 2017
OIR FWB OFS FWB
L – Logistically feasible
Ø Logistical Benefits in deployed settingØ CS-LTOWB simplifies the resuscitative
effort and shortens time to transfusion
Low Titer Group O Whole Blood
Ø Logistical Benefits in deployed settingØ CS-LTOWB simplifies the resuscitative
effort and shortens time to transfusion
Low Titer Group O Whole Blood
Further investigation isneeded regarding theclinical outcomes ofCS-LTOWB transfusionsand to further increaseCS-LTOWB shelf life
Whole Blood in the Combat ZoneØ Warm Fresh Whole Blood (WFWB)
ü From Walking Blood Banksü Been used since 2002ü Not FDA-approved
Ø Low Titer Group O Whole Blood (LTOWB)1. Initial efforts: From Low Titer Group O
Donor (ROLO) – Rangers Lead the Way!2. Later adopted: Cold stored, FDA
approved CS-LTOWB
Warm Fresh Whole BloodØ Used in combat zone for >17 years
ü Limited supply of componentsü No platelets at most Forward Surgical
Teamsü Focused Empiricism à better outcomes
Ø 2002-2019 >10,700 WFWB transfused
Warm Fresh Whole Blood
Ø Prescreened Donor Poolü Ready pool of eligible donorsü Pre-screening should be every 90 daysü Screened for TTD and titer levels
Pending DoDI à to ALL Service Members will get prescreened….
Warm Fresh Whole BloodØ TRAINING for WBB
ü Huge training commitment
Warm Fresh Whole BloodØ Prescreening Process
ü Huge training commitment
WBB Process – Resource Intensive
WBB Process – Resource Intensive
WBB Process – Resource Intensive
WBB Process – Resource Intensive
FWB Outcomes?
Mortality within 6 hours of Role 2 admission
The total sum of RBC-containing transfusions & sum of ALL transfusions
Adjusted to be independent of any effect of FWB on the competing risk of early (6 hr) injury mortality due to hemorrhage
FWB Patient Characteristicsn %
Hourly rate of RBC-containing unit transfusionsa, b
Low (0.33 to <1.71 units per hr) 59 26.7Medium-Low (1.71 to <2.88 units per hr) 62 28.1Medium-High (2.88 to 4.91 units per hr) 55 24.9High (>4.91 units per hr) 45 20.4
Shockc
Yes 143 64.7No 78 35.3
Dose of FWBLow 66 29.9High 155 70.1
Admission base deficit, median (IQR) -7 (-13, -4)Median (IQR) MAIS score, median (IQR), n=132 3 (2, 3)Median (IQR) Injury severity scoref, median (IQR), n=132 9 (5, 14)Time from point of injury to Role 2 facility, median (IQR), n=113 60 (35, 117)
How is FWB vs. no-FWB Associated with Outcomes? adjusted for matching and severity of head injury
Outcome Odds Ratio 95% Cl P value
6 hour mortality (7% vs 21%) 0.27 0.13 0.58 0.001
Subgroup with severe head injury 0.07 0.004 1.26 0.072Subgroup w/o severe head injury 0.35 0.15 0.79 0.011Low Dose of FWB (<33% of all RBCs) 0.73 0.28 1.89 0.515High Dose FWB (>33% of all RBCs) 0.14 0.04 0.51 0.003
Subgroup adjusted for 13 covariates 0.15 0.03 0.78 0.024
Sum total of RBC-containing units in those predicted to survive >6 hrs regardless of Rx
Did not differ, FWB group median=12
0.426
Sum total of all blood product unitsin those predicted to survive >6 hrs regardless of Rx
Did not differ, FWB group median=17 0.685
Conclusions
Advanced Resuscitative Care TCCC - 2019
Focuses on early whole blood
Military Use of WB in Deployed Environment
CS-LTOWB WFWB
WFWB improves 6 hour outcomes
Outcomes needed for CS-LTOWBDemand signal for CS-LTOWB is high
ASBP continues to support and increase supply
Questions
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