05 Feb Improving Transfusion Practice May Reduce Mortality From Hemorrhage
MedicalResearch.com Interview with:
Dr. Ross Davenport
Dr Ross Davenport PhD
Post doctoral clinical academic working at the Royal London Hospital
Queen Mary University of London
MedicalResearch: What is the background for this study? What are the main findings?
Dr. Davenport: Bleeding is the leading cause of preventable death in trauma. Globally, bleeding following injury is estimated to be responsible for over two million deaths per year. Current treatment strategies focus on the rapid delivery of red blood cells, plasma and other clotting products. However, the logistics of providing the correct quantities in the right proportion during the first minutes and hours of emergency care can be extremely challenging.
Our UK NIHR-funded study, conducted at the Centre for Trauma Sciences – Queen Mary University of London, estimates that nearly 5,000 trauma patients sustain major haemorrhage in England and Wales each year and that one-third of those die. The research spotlights how delays in blood transfusion practices may contribute to this high death rate.
The rapid and consistent delivery of blood, plasma, platelets and other clotting products to trauma patients is essential to maintain clotting during haemorrhage, and in previous research from both civilian and military studies, has been shown to halve mortality. Overall, only two per cent of all patients with massive haemorrhage received what might be considered the optimal transfusion of a high dose of clotting products in conjunction with red blood cells during the first hour of arrival within the Emergency Department.
The study, published this week in the British Journal of Surgery, is the first to describe patterns of blood use and outcomes from major trauma haemorrhage on a national level. Looking at 22 hospitals in England and Wales, our research team studied 442 patients who had experienced major trauma haemorrhage as a result of their injuries.
Mortality from bleeding tended to occur early, with nearly two-thirds of all deaths in the first 24 hours. An unexpectedly high number of deaths (7.9 per cent) occurred once the patient left hospital, the reasons for which are unclear.
The average time to transfusion of red blood cells was longer than expected, at 41 minutes. Administration of specific blood components to aid with blood clotting such as plasma, platelets and cryoprecipitate was significantly delayed, on average 2-3 hours after admission.
The incidence of major haemorrhage increased markedly in patients over 65 years, who were twice as likely to suffer massive haemorrhage as a result of an injury compared to younger groups. The causes for this increased incidence were unclear and the researchers say further investigation is needed to examine the role of associated medical problems and prescribed medication. Transfusion procedures may also need to be adapted for older patients.
Study limitations include the data not being complete for all patients, such as timings of transfusions. The study was also undertaken at an early stage in national trauma network reorganization.
MedicalResearch: What should clinicians and patients take away from your report?
Dr. Davenport: This study tells us about the challenges of early delivery and administration of blood to a group of patients with life-threatening injuries. There is a clear opportunity for clinicians to improve the delivery of blood and clotting products during resuscitation for major haemorrhage. NHS Blood and Transplant were collaborators in this study and are currently looking at ways to improve the availability of blood components. This includes promoting and assessing different types of plasma, such as extended pre-thawed or liquid plasma, which would be more readily available for timely use. This area of the optimal products remains a high-priority for NHSBT and indeed all Blood Transfusion Services.
MedicalResearch: What recommendations do you have for future research as a result of this study?
Dr. Davenport: The rapid delivery of the right mix of blood components in an emergency environment is extremely challenging. Some transfusion components have to be thawed and at present aren’t always available for the patient quickly enough. We need more research into clotting products that can be readily available along with techniques and devices to control bleeding earlier – even at the scene of injury.
The Centre for Trauma Sciences has started a new five year European wide clinical trial (iTACTIC) which aims to improve outcomes for patients who need massive transfusions. iTACTIC is designed to find out if a rapid, detailed blood clotting test (Viscoelastic Haemostatic Assay – VHA) can be used to identify Trauma Induced Coagulopathy (TIC) early and to guide a massive transfusion protocol for that individual patient’s needs. The study will compare the outcomes of patients treated using the conventional blood transfusion strategy with the outcomes of patients treated using a personalised blood transfusion strategy guided by VHA.
MedicalResearch: Is there anything else you would like to add?
Dr. Davenport: C4TS has been investigating TIC for many years, and a summary of our research findings in bleeding and coagulopathy to date can be found on our website.
The study was a collaboration of researchers from QMUL, UK Trauma Audit & Research Network (TARN) and NHS Blood and Transplant, funded by the National Institute for Health Research (NIHR) under its Programme Grants for Applied Research Programme (RP-PG-0407-10036).
Citation:
Mortality from trauma haemorrhage and opportunities for improvement in transfusion practice’ S. J. Stanworth, R. Davenport, N. Curry, F. Seeney, S. Eaglestone, A. Edwards, K. Martin, S Allard, M. Woodford, F. E. Lecky and K. Brohi , British Journal of Surgery 2016.
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Dr Ross Davenport PhD (2016). Improving Transfusion Practice May Reduce Mortality From Hemorrhage
Last Updated on February 6, 2016 by Marie Benz MD FAAD