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Autologous Transfusion of Shed Pleural Blood in Trauma - a Register Study to Determine Applicability

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Autologous Transfusion of Shed Pleural Blood in Trauma - a Register Study to Determine Applicability Sahlgrenska academy Autologous transfusion of shed pleural blood in trauma - a register study to determine applicability Degree Project in Medicine Henrik Örtenwall Programme in Medicine, The Sahlgrenska Academy Gothenburg, Sweden, 2021 Supervisors: Dr. Ragnar Ang, trauma surgeon, SU Doc. Jenny Skytte-Larsson, anesthesiologist, FömedC Table of contents Abbreviations ............................................................................................................................. 3 Abstract ...................................................................................................................................... 4 Introduction ................................................................................................................................ 5 Aim ............................................................................................................................................. 6 Background ................................................................................................................................ 6 History ................................................................................................................................................. 6 Transfusion guidelines ........................................................................................................................ 9 Pros and cons of allogenic blood component transfusion ................................................................. 10 Pros and cons of autologous whole blood transfusion ...................................................................... 16 Previous research ............................................................................................................................... 17 Blood salvage .................................................................................................................................... 23 Material and Methods ............................................................................................................... 25 Results ...................................................................................................................................... 26 Prospective descriptive pilot study ........................................................................................... 28 Ethics ........................................................................................................................................ 30 Discussion ................................................................................................................................ 32 Limitations of the prospective study ................................................................................................. 37 Conclusion ................................................................................................................................ 40 Acknowledgements .................................................................................................................. 42 Populärvetenskaplig sammanfattning ...................................................................................... 43 Appendix .................................................................................................................................. 44 References ................................................................................................................................ 45 2 Abbreviations ABT Allogenic blood transfusion (from donor) aPTT Activated partial thromboplastin time Ca Calcium Cl Chloride CPD Citrate phosphorous dextrose CRP C-reactive protein DCR Damage Control Resuscitation DIC Disseminated Intravascular Coagulation DCS Damage Control Surgery ED Emergency Department FFP Fresh frozen plasma Hb Hemoglobin HTB Hemothorax blood HBV Hepatitis B virus HCT Hematocrit HCV Hepatitis C virus HES Hydroxyethyl starch HIV Human immunodeficiency virus HP Hemoperitoneum Il-6 Interleukin-6 INR International normalized ratio K Potassium Na Sodium NGO Non-Government Organization PCs Platelet concentrates PLT Platelets RBCs Red blood cells SU Sahlgrenska University hospital TNF Tumor necrosis factor WBC White blood cells 3 Abstract Background Direct autotransfusion of shed pleural blood in a trauma setting as an alternative to transfusion of banked blood in patients with (massive) traumatic hemothorax is a tested, working and well used methodology at some trauma centers throughout the world. Aim The aim of this study was to evaluate the usefulness of direct, whole blood, autotransfusion with hemothorax blood in trauma patients at Sahlgrenska University hospital (SU). Further, the aim was to summarize previous research in the field and analyze properties of blood retrieved from the pleural cavity (hemothorax) to appraise suitability for re-infusion. Method This was a register study of all patients treated with chest drain on the basis of suspected traumatic hemothorax/hemopneumothorax at the emergency department or trauma care unit at SU between 1st of January 2018 - 1st of October 2020. Inclusion criteria were chest tube insertion withing 24 hours of trauma, immediate draining >400 ml of blood followed by subsequent blood transfusion within 24h. Results A search in the journal database generated 158 hits with the ICD code GAA10 (insertion of chest drain) in combination with either S27.1 (hemothorax) or S27.2 (hemopneumothorax). 86 patients remained after excluding patients with pneumothorax, “old” hemothorax, non- trauma patients and referred out-of-county patients with tube thoracostomy already inserted. When the remaining patients were matched against the inclusion criteria, 24 patients remained that could have been treated with suggested method during the chosen time period (33 months) studied. Conclusion Less than one patient per month, admitted to SU, fulfilled the requirements necessary to utilize this technique. This low number, in combination with question marks regarding contamination and coagulation deterioration of hemothorax blood makes the technique more suitable as an emergency solution for mass-casualty situations than normal conditions until further research has clarified these uncertainties. Key words; hemothorax , trauma , autotransfusion , autologous blood transfusion 4 Introduction In Sweden, trauma is the leading cause of mortality between age 15 – 44 (1). Major bleeding in trauma constitutes an immediate threat to life. The treatment is to stop the bleeding and restore blood volume. In Swedish hospitals, the standard procedure to reestablish adequate blood volume in trauma patients is allogenic multicomponent blood transfusion. However, blood transfusion is not without risks, including those of disease transmission, incompatibility, and medical errors. One way to reduce the need of donated blood from blood banks is autotransfusion - the return of the patient’s own shed blood into the bloodstream. In the trauma setting, autotransfusion is already an established technique at trauma resuscitation centers, e.g., in South Africa, where the combination of extraordinary high rates of interpersonal violence and less than 1% active blood donors have resulted in autotransfusion becoming a lifesaving complement with the intravenous return of shed pleural and peritoneal blood (2-6). The student course manual for Advanced Trauma Life Support (ATLS) (7), published by the American College of Surgeons, suggest that “collection of shed blood for autotransfusion should be considered for any patient with a major hemothorax.” Furthermore, the author of the manual of Definitive Surgical Trauma Care (DSTC), Kenneth D. Boffard argues that; “In practical terms, bleeding from the chest seems ideal for immediate autotransfusion as contents of the thoracic cavity are sterile.”(5) Insufficient blood product supply from blood banks is rarely a problem in large Swedish hospitals, and commonly trauma patients immediately receive acute blood (blood group O negative erythrocytes) pending matched blood products. However, proper evaluation of pros and cons will help to determine whether autologous transfusion of shed pleural blood is an option should there be a blood product shortage, e.g., in a mass casualty situation. 5 The evaluation may also be of value to organizations acting on the field, far from regular blood banks, such as the military and different NGO’s (Medicin sans Frontiers - MSF, Red Cross etc.). Aim The aim of this study was to evaluate the usefulness of direct, whole blood, autotransfusion with hemothorax blood in trauma patients at Sahlgrenska University hospital (SU). The goal was to investigate how many patients that were treated with chest tube within 24 hours of trauma, immediately draining more than 400 ml of blood and in combination with subsequent blood transfusion, to evaluate the applicability of this method. Further, this study aimed to summarize what is known from published literature on the subject of autotransfusion with hemothorax blood (HTB) in trauma and determine unexplored areas in need of future research. As a part of this, we intended to conduct a prospective pilot study of shed pleural blood, analyzing its properties and appraise the suitability of re-infusion. The purpose is to demonstrate the risks and advantages of autologous HTB transfusion compared to allogenic transfusion in trauma patients, and in extension assess the possibility to introduce HTB autotransfusion as a complement to allogenic transfusion in trauma resuscitation at centers in Sweden. Background History The
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