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Unmet Civilian Medical Need: When RBCs Are Not an Option

This article examines the unmet needs for resuscitation in resource-limited environments, such as trauma care in rural areas, emergency surgery, and critical access hospitals. It explores the potential for creating a functional, economical, and safe alternative to red blood cell transfusion to address these needs.

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Unmet Civilian Medical Need: When RBCs Are Not an Option

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  1. Unmet Civilian Medical Need: When RBCs Are Not an Option Donald Jenkins, MD Professor of Surgery University of Texas Health Science Center San Antonio, TX

  2. Disclosures None

  3. Acknowledgements • Mitch Cohen, UCSF • COL John Holcomb, ISR (Retired, Houston TX) • CAPT Frank Butler, CoTCCC • Dustin Smoot MD, Brian Kim MD, Martin Zielinski MD, Mohammad Khasawneh MBBS, Cathy Berns APRN, CNS, MS and Scott Zietlow MD, Mayo Clinic, Rochester • Jim Stubbs, MD and Lisa Button Mayo Clinic Rochester • Phil Spinella and Geir Strandenes, THOR • LTC Andre Cap USAISR • Rosemary Kozar and Shibani Pati • Elizabeth Waltman • Dani Cobb, Rachelle Jonas and Mark DeRosa

  4. Blood transfusion as a predictor of injury mortality • 1 in 400 injured people die • 1 in 50 of the hospitalized injured die • 20% of transfused injured die • 40% of injured who receive more than 10 U RBC die

  5. Hemorrhage and Shock • Sometimes it can be easy to spot • The longer in shock, the more likely to die • It takes a human being very little time to bleed to death • ~22 minutes from penetrating injury • This could be internal and/or external • ~28 minutes from blunt injury • Most often this is ‘hidden bleeding’ internally • Define Massive Transfusion • >10u PRBC 24 hrs vs 5u/60 minutes = same mortality

  6. Remote Damage Control Resuscitation • Austere/rural environment patients • Modified transfusion strategy • Different than those with scene/pre-hospital time < 30 minutes • Limited resources available • Lack of plasma availability • 40% of the population, 60% of the trauma mortality • Current treatment options for uncontrolled hemorrhage in this environment are very limited • >75% of combat fatalities occur in the field

  7. WISCONSIN CLINIC MINNESOTA HOSPITAL & CLINIC MANAGEMENT SERVICES AGREEMENT PHYSICIAN SERVICES AGREEMENT GOLD CROSS MAYO 1 IOWA 10 25 50 100 MILES

  8. Mayo HEMS Blood Product Use • Jan. 1, 2015 through May 31, 2016.  • Total transports (air and CC ground) during the time frame: 2968 • 323 patients received blood products (11%) • Plasma: 685 units • PRBC: 307 units • 1075 units total; 3.3 per pt transfused • 53 units that were started at the referring facility and we continued during transport • Nearly everyone of these patients got additional transfusion at the hospital

  9. Southwest Texas Regional Advisory Council for Trauma • 22 counties • 26,000 sq mi • 5 rotary wing HEMS organizations • 3 Level I trauma centers • Military • UTHSCSA/UHS • Adult • Pediatric

  10. Massive Transfusion in Trauma at UHS • In the last 18 months • 64 MTP activations for trauma • 40 yo blunt injured patients • BP < 90 • 76% mortality • Majority died within 24 hours (>90%) • First hematocrit 35% (Hgb > 10 g/dl) • 95% transported by ground

  11. Hypothesis Lack of adequate blood resuscitation in remote regions of STRAC Very high mortality in current MTP environment No agreed upon transfusion triggers No standard hemostatic resuscitation No early hemostatic resuscitation

  12. Oxygen Carrying Substitutes • Ideal characteristics • Lack of antigenicity • No transmissible disease • Room temperature storage • Long half-life • Long shelf-life • Good oxygen delivery • Avoid immunosuppression

  13. Indications • See introductory materials on ‘rural’ • Trauma care • Emergency surgery • Long term blood transfusions (anemias) • Organ preservation • Religious and ethnic groups • Critical access hospitals • Pre-hospital

  14. Other Considerations Military use Space travel Antarctica Surge stock piling for natural/man-made disasters Areas with endemic transfusion transmissible disease (Zika, HIV/AIDS)

  15. Other Considerations • Should help to decrease use of traditional blood products, preserving precious resource for those in greatest need • Avoid prior side effects: • Hypertension • Hemoglobinuria • Stroke • MI • Jaundice

  16. Summary Civilian trauma patients cared for in resource limited environments have unmet needs for resuscitation Creating a functional, economical and safe alternative to red cells for transfusion would be transformative in pre-hospital, ship board, critical access hospitals and in times of crisis and greatest need

  17. Thank You Donald H. Jenkins, MD, FACS Professor/Clinical, Division of Trauma and Emergency Surgery Vice Chair for Quality, Department of Surgery Betty and Bob Kelso Distinguished Chair in Burn and Trauma Surgery Associate Deputy Director, Military Health Institute The University of Texas Health Science Center at San Antonio 7703 Floyd Curl Drive San Antonio, TX 78229-3900 Phone: (210) 743-4130 Fax: (210) 702-6292 Jenkinsd4@uthscsa.edu

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