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Fresh Whole Blood Use by Forward Surgical Teams in Afghanistan Is Associated with Improved Survival Compared to Component Therapy Without Platelets

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Fresh Whole Blood Use by Forward Surgical Teams in Afghanistan Is Associated with Improved Survival Compared to Component Therapy Without Platelets University of Nebraska - Lincoln DigitalCommons@University of Nebraska - Lincoln US Army Research U.S. Department of Defense 2013 Fresh Whole Blood Use by Forward Surgical Teams in Afghanistan is Associated with Improved Survival Compared to Component Therapy Without Platelets Shawn C. Nessen [email protected] Brian J. Eastridge Daniel Cronk Robert M. Craig Olle Berséus See next page for additional authors Follow this and additional works at: https://digitalcommons.unl.edu/usarmyresearch Nessen, Shawn C.; Eastridge, Brian J.; Cronk, Daniel; Craig, Robert M.; Berséus, Olle; Ellison, Richard; Remick, Kyle; Seery, Jason; Shah, Avani; and Spinella, Philip C., "Fresh Whole Blood Use by Forward Surgical Teams in Afghanistan is Associated with Improved Survival Compared to Component Therapy Without Platelets" (2013). US Army Research. 250. https://digitalcommons.unl.edu/usarmyresearch/250 This Article is brought to you for free and open access by the U.S. Department of Defense at DigitalCommons@University of Nebraska - Lincoln. It has been accepted for inclusion in US Army Research by an authorized administrator of DigitalCommons@University of Nebraska - Lincoln. Authors Shawn C. Nessen, Brian J. Eastridge, Daniel Cronk, Robert M. Craig, Olle Berséus, Richard Ellison, Kyle Remick, Jason Seery, Avani Shah, and Philip C. Spinella This article is available at DigitalCommons@University of Nebraska - Lincoln: https://digitalcommons.unl.edu/ usarmyresearch/250 ORIGINAL ARTICLE Fresh whole blood use by forward surgical teams in Afghanistan is associated with improved survival compared to component therapy without platelets Shawn C. Nessen, Brian J. Eastridge, Daniel Cronk, Robert M. Craig, Olle Berséus, Richard Ellison, Kyle Remick, Jason Seery, Avani Shah, and Philip C. Spinella INTRODUCTION BACKGROUND: In Afghanistan, a substantial portion of resuscitative combat surgery is performed by US Army With the end of combat operations in Iraq, attention to forward surgical teams (FSTs). Red blood cells (RBCs) Afghanistan has returned. There, a substantial portion of and fresh frozen plasma (FFP) are available at these resuscitative surgery has been performed by 20 personnel facilities, but platelets are not. FST personnel frequently US Army forward surgical teams (FSTs) or similar units. encounter high-acuity patient scenarios without the Many of these teams have been split to more widely dis- 1 ability to transfuse platelets. An analysis of the use of seminate surgical care platforms. FSTs doctrinally carry fresh whole blood (FWB) at FSTs therefore allows for an only 20 units of red blood cells (RBCs), but currently in evaluation of outcomes associated with this practice. Afghanistan they are augmented with fresh frozen plasma STUDY DESIGN AND METHODS: A retrospective (FFP) and some with cryoprecipitate. Platelets (PLTs) are 1-4 analysis was performed in prospectively collected data not available. The concept of damage control resuscita- from all transfused patients at six FSTs from December tion with the use of RBCs, FFP,and PLTs in balanced ratios 2005 to December 2010. Univariate analysis was per- that approximate those of whole blood has been sup- formed, followed by two separate propensity score ported by several recent publications in the military and 5-11 analyses. In-hospital mortality was predicted with the civilian trauma literature. Although these studies are use of a conditional logistic regression model that incor- retrospective in nature, the military has adopted a clinical porated these propensity scores. Subset analysis practice guideline recommending 1:1:1 unit ratios of these included evaluation of patients who received uncross- blood components. In addition, current theater clinical matched Type O FWB compared with those who practice guidelines recommend the use of fresh whole received type-specific FWB. blood (FWB) be reserved for “casualties who are antici- RESULTS: A total of 488 patients received a blood pated to require massive transfusion (10 or more units of transfusion. There were no significant differences in age, packed RBCs in 24 hr), for those with clinically significant sex, or Glasgow Coma Scale in those who received or did not receive FWB. Injury Severity Scores were higher in patients transfused FWB. In our adjusted analyses, patients who received RBCs and FFP with FWB had From the 212th Combat Support Hospital, Miseau, Germany; improved survival compared with those who received U.S. Army Institute of Surgical Research, Fort Sam Houston, RBCs and FFP without FWB. Of 94 FWB recipients, 46 Texas; Methodist Health System, Omaha, Nebraska; Walter Reed FWB recipients (49%) were given uncrossmatched Type National Military Medical Center, Bethesda, Maryland; O FWB, while 48 recipients (51%) received type-specific Department for Transfusion Medicine Örebro University FWB. There was no significant difference in mortality Hospital, Örebro, Sweden; Womack Army Medical Center, Fort between patients that received uncrossmatched Type O Bragg, North Carolina; Hospital of the University of and type-specific FWB. Pennsylvania, Philadelphia, Pennsylvania; Blood Systems CONCLUSIONS: The use of FWB in austere combat Research Institute, San Francisco, California; and Washington environments appears to be safe and is independently University in St Louis, Department of Pediatrics, St Louis, associated with improved survival to discharge when Missouri. compared with resuscitation with RBCs and FFP alone. Address reprint requests to: Shawn C. Nessen, CMR 403 Box Mortality was similar for patients transfused 4496, APO, AE 09059; e-mail: [email protected]. uncrossmatched Type O compared with ABO type- doi: 10.1111/trf.12044 specific FWB in an austere setting. TRANSFUSION 2013;53:107S-113S. Volume 53, January 2013 Supplement TRANSFUSION 107S NESSEN ET AL. shock or coagulopathy (e.g., bleeding with associated to mitigate survivor bias. Afghani patients with penetrat- metabolic acidosis, thrombocytopenia, or international ing head injuries with initial GCS of Յ7 were eliminated normalized ratio >1.5) when optimal component therapy as they were often treated expectantly. Statistical analysis (e.g., apheresis PLTs and FFP) is unavailable or stored was performed by an independent statistician. Univari- component therapy is not adequately resuscitating a ate analysis was performed with the use of SAS 9.1 (SAS patient with immediately life-threatening injuries.”12 Due Institute, Inc., Cary, NC). Two separate propensity score to the austerity of their environment, FST personnel fre- analyses were performed utilizing STATA 11.2 (StataCorp quently encounter high-acuity patient scenarios without LP, College Station, TX). Variables that were associated the ability to transfuse PLTs. The use of FWB in these loca- with the use of FWB in the univariate analysis were used tions therefore generates an opportunity to evaluate out- to calculate propensity scores. SBP at arrival to FST, comes associated with whole blood transfusions. Current arrival temperature, use of rFVIIa, total RBCs, and total US military doctrine states that FWB must be type specific FFP administered were used to calculate the propensity when transfused. In some remote settings where donors score that was the probability of receiving FWB. The bal- are limited, this is not possible, and uncrossmatched Type ancing property of the propensity scores was tested and O FWB is transfused as a last resort. The objective of this propensity scores were determined to be balanced in the study is to examine the association of FWB use versus FWB and non-FWB groups. The propensity scores were use of component therapy (RBCs and FFP) only, with used in the logistic regression model predicting death, in-hospital mortality in combat casualties admitted to adjusting for the ISSs and the Glasgow Coma Scores. The FSTs. Furthermore, we examine the association between propensity score was included as a continuous variable receipts of ABO type-specific FWB versus uncross- in the first model. In the second analysis, propensity matched Type O FWB on in-hospital mortality. scores were used to create strata or groups. Subjects were grouped into six strata based on similarity of propensity METHODS score and therefore have similar risk profile, without regard to outcome or receipt of FWB. Following stratifi- The Institutional Review Board of the US Army Medical cation, death in each group was predicted with the use of Research and Materiel Command approved the retro- a conditional logistic regression. Conditional logistic spective analysis of all admission performance improve- regression approach combines within-stratum effects ment data of a convenience sample of six FSTs from with between-stratum effects to estimate the overall FWB December 2005 to December 2010. These units were effect on death. chosen because they developed a comprehensive perfor- mance improvement plan that included collection of RESULTS data regarding blood transfusion. The data were prospec- tively collected by the individual FST units during the A total of 488 patients met inclusion criteria. They received 5-year study period. Blood product utilization, mecha- 2612 units of RBCs, 1566 units of FFP, and 416 units of nism of injury, type of injuries, number and type of sur- FWB. A total of 394 patients received blood transfusion gical procedures performed, and ultimate patient without receiving FWB and 94 patients received blood outcome were recorded. Demographic data including transfusions that included FWB. Table 1 indicates that patient status,
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