gurney wb in combat casualty care - strac

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