17/07/2021
Transfuser avant l'hôpital: Pas suffisant pour réduire la mortalité
Effect of Prehospital Red Blood Cell Transfusion on Mortality and Time of Death in Civilian Trauma Patients
Background:
Current management principles of hemorrhagic shock after trauma emphasize earlier transfusion therapy to prevent dilution of clotting factors and correct coagulopathy. London's Air Ambulance (LAA) was the first UK civilian prehospital service to routinely offer prehospital red blood cell (RBC) transfusion (phRTx). We investigated the effect of phRTx on mortality.
Methods:
Retrospective trauma database study comparing mortality before implementation with after implementation of phRTx in exsanguinating trauma patients. Univariate logistic regression was performed for the unadjusted association between phRTx and mortality was performed, and multiple logistic regression adjusting for potential confounders.
Results:
We identified 623 subjects with suspected major hemorrhage. We excluded 84 (13.5%) patients due to missing data on survival status. Overall 187 (62.3%) patients died in the before phRTx period and 143 (59.8%) died in the after phRTx group. There was no significant improvement in overall survival after the introduction of phRTx (P = 0.554). Examination of prehospital mortality demonstrated 126 deaths in the pre-phRTx group (42.2%) and 66 deaths in the RBC administered group (27.6%). There was a significant reduction in prehospital mortality in the group who received RBC (P < 0.001).
Conclusions:
phRTx was associated with increased survival to hospital, but not overall survival. The “delay death” effect of phRTx carries an impetus to further develop inhospital strategies to improve survival in severely bleeding patients.
DCR: Tout ne réduit pas la mortalité à l'hôpital ?
After 800 MTP Events, Mortality due To Hemorrhagic Shock Remains High And Unchanged Despite Several In-Hospital Hemorrhage Control Advancements
Duchesne, J et Al. SHOCK: May 27, 2021 doi: 10.1097/SHK.0000000000001817
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La mise en oeuvre de moyens adaptés d'hémostase comme le REBOA est proposé dans une stratégie de DCR conduite à l'hôpital. Pourtant cette publication ne milite pas pour une amélioration de la survie de patients présentants un trauma pénétrants et requérants une transfusion massive. Seules la pose de garrot et la transfusion de sang total permettent de réduire la mortalité dans un système de prise en charge adapté. La réalisation encore plus précoce pourrait être une solution.
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Background:
Numerous advancements in hemorrhage control and volume replacement that comprise damage control resuscitation (DCR) have been implemented in the last decade to reduce deaths from bleeding. We sought to determine the impact of DCR interventions on mortality over 12 years in a massive transfusion protocol (MTP) population. We hypothesized that mortality would be decreased in later years, which would have used more DCR interventions.
Study Design:
This was a retrospective review of all MTP patients treated at a large regional Level I trauma center from 2008–2019. Interventions by year of implementation examined included MTP 1:1 ratio (2009), liquid plasma (2010), tranexamic acid (2012), pre-hospital tourniquets (2013), REBOA/TEG (2017), satellite blood station (2018), and whole blood transfusion (2019). Relative risk and odds of mortality for DCR interventions were examined.
Results:
There were 824 MTP patients included. The cohort was primarily male (80.6%) injured by penetrating mechanism (68.1%) with median (IQR) age 31 years (23–44) and NISS 25 (16–34). Overall mortality was unchanged [(38.3% to 56.6%); P = 0.26]. Tourniquets (P = 0.02) and WB (P = 0.03) were associated with lower unadjusted mortality; only tourniquets remained significant after adjustment (OR:0.39;95%CI:0.17–0.89; P = 0.03).
Conclusions:
Despite lower mortality with use of tourniquets and WB, mortality rates due to hemorrhage have not improved at our high MTP volume institution, suggesting implementation of new in-hospital strategies is insufficient to reduce mortality. Future efforts should be directed towards moving hemorrhage control and effective resuscitation interventions to the injury scene.
Sang total: Oui, au - 1/3 des besoins transfusionnels
Whole blood at the tip of the spear: A retrospective cohort analysis of warm fresh whole blood resuscitation versus component therapy in severely injured combat casualties
Jennifer M Gurney J Et Al. Surgery. 2021 Jul 9;S0039-6060(21)00538-9.
Background:
Death from uncontrolled hemorrhage occurs rapidly, particularly among combat casualties. The US military has used warm fresh whole blood during combat operations owing to clinical and operational exigencies, but published outcomes data are limited. We compared early mortality between casualties who received warm fresh whole blood versus no warm fresh whole blood.
Methods:
Casualties injured in Afghanistan from 2008 to 2014 who received ≥2 red blood cell containing units were reviewed using records from the Joint Trauma System Role 2 Database. The primary outcome was 6-hour mortality. Patients who received red blood cells solely from component therapy were categorized as the non-warm fresh whole blood group. Non- warm fresh whole blood patients were frequency-matched to warm fresh whole blood patients on identical strata by injury type, patient affiliation, tourniquet use, prehospital transfusion, and average hourly unit red blood cell transfusion rates, creating clinically unique strata. Multilevel mixed effects logistic regression adjusted for the matching, immortal time bias, and other covariates.
Results:
The 1,105 study patients (221 warm fresh whole blood, 884 non-warm fresh whole blood) were classified into 29 unique clinical strata. The adjusted odds ratio of 6-hour mortality was 0.27 (95% confidence interval 0.13-0.58) for the warm fresh whole blood versus non-warm fresh whole blood group. The reduction in mortality increased in magnitude (odds ratio = 0.15, P = .024) among the subgroup of 422 patients with complete data allowing adjustment for seven additional covariates. There was a dose-dependent effect of warm fresh whole blood, with patients receiving higher warm fresh whole blood dose (>33% of red blood cell-containing units) having significantly lower mortality versus the non-warm fresh whole blood group.
Conclusion:
Warm fresh whole blood resuscitation was associated with a significant reduction in 6-hour mortality versus non-warm fresh whole blood in combat casualties, with a dose-dependent effect. These findings support warm fresh whole blood use for hemorrhage control as well as expanded study in military and civilian trauma settings.
09/07/2021
Immobilisation pelvienne avec un garrot et une samsplint
L'oxygène: Contrainte logistique à ne pas oublier pour demain
Oxygen Management During Collective Aeromedical Evacuation of 36 COVID-19 Patients With ARDS
Beaussac M. et Al. Mil Med. 2021 Jul 1;186(7-8):e667-e671.
Objective:
The ongoing coronavirus disease-2019 pandemic leads to the saturation of critical care facilities worldwide. Collective aeromedical evacuations (MEDEVACS) might help rebalance the demand and supply of health care. If interhospital transport of patients suffering from ARDS is relatively common, little is known about the specific challenges of collective medevac. Oxygen management in such context is crucial. We describe our experience with a focus on this resource.
Methods:
We retrospectively analyzed the first six collective medevac performed during the coronavirus disease-2019 pandemic by the French Military Health Service from March 17 to April 3, 2020. Oxygen management was compliant with international guidelines as well as aeronautical constraints and monitored throughout the flights. Presumed high O2 consumers were scheduled to board the last and disembark the first.
Results:
Thirty-six mechanically ventilated patients were successfully transported within Europe. The duration of onboard ventilation was 185 minutes (145-198.5 minutes), including the flight, the boarding and disembarking periods. Oxygen intake was 1,650 L per patient per flight (1,350-1,950 L patient per flight) and 564 L per patient per hour (482-675 L per patient-1 per hour) and surpassed our anticipation. As anticipated, presumed high O2 consumers had a reduced ventilation duration onboard. The estimations of oxygen consumptions were frequently overshot, and only two hypoxemia episodes occurred.
Conclusion:
Oxygen consumption was higher than expected, despite anticipation and predefined oxygen management measures, and encourages to a great caution in the processing of such collective medevac missions.
Kétamine: Pas assez utilisée en role 1 ?
Ketamine Use in Operation Enduring Freedom
Eric L. et Al. Mil Med. 2021 Jul 1;186(7-8):e720-e725
Introduction:
Ketamine is a dissociative anesthetic increasingly used in the prehospital and battlefield environment. As an analgesic, it has been shown to have comparable effects to opioids. In 2012, the Defense Health Board advised the Joint Trauma System to update the Tactical Combat Casualty Care Guidelines to include ketamine as an acceptable first line agent for pain control on the battlefield. The goal of this study was to investigate trends in the use of ketamine during Operation Enduring Freedom (OEF) and Operation Freedom's Sentinel (OFS) during the years 2011-2016.
Materials and methods:
A retrospective review of Department of Defense Trauma Registry (DoDTR) data was performed for all patients receiving ketamine during OEF/OFS in 2011-2016. Prevalence of ketamine use, absolute use, mechanism of injury, demographics, injury severity score, provider type, and co-administration rates of various medications and blood products were evaluated.
Results:
Total number of administrations during the study period was 866. Ketamine administration during OEF/OFS increased during the years 2011-2013 (28 patient administrations in 2011, 264 administrations in 2012, and 389 administrations in 2013). A decline in absolute use was noted from 2014 to 2016 (98 administrations in 2014, 41 administrations in 2015, and 46 administrations in 2016). The frequency of battlefield ketamine use increased from 0.4% to 11.3% for combat injuries sustained in OEF/OFS from 2011 to 2016. Explosives (51%) and penetrating trauma (39%) were the most common pattern of injury in which ketamine was administered. Ketamine was co-administered with fentanyl (34.4%), morphine (26.2%), midazolam (23.1%), tranexamic acid (12.3%), plasma (10.3%), and packed red blood cells (18.5%).
Extrait du texte:
" Registry data demonstrate that the majority of these administrations were initially documented at role III (785; 82%), and role IIb (164; 17%) facilitie"
Conclusions:
This study demonstrates increasing use of ketamine by the U.S. Military on the battlefield and effectiveness of clinical practice guidelines in influencing practice patterns.