Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_35_библиотеки_им_акад_М_И_Перельмана
.pdf
154
https://t.me/medicina_free
C. L. Riley and J. Dean
anesthesiologist) or emergency medicine physician. The team
provides hospital level care to patients in ight after recovering them from the battleeld in potentially non- permissive
areas (hostile) while transporting them to more denitive care
[3]. Anesthesiologists in France have been part of the disaster
response system for several decades and are a key element of
the French emergency medical service, Service d’Aide
Medicale Urgente (SAMU) [2]. Anesthesiologists are often
the lead clinician sent with SAMU to mass casualty events to
provide an advanced level of care near the site of the disaster
and coordinate with re and police. In this arrangement, prehospital disaster management and hospital disaster management are integrated [2].
Hemorrhage is the leading cause of potentially preventable mortality in MCEs [1, 4–7]. Mortality from terrorist
attacks increased 500% between 2000 and 2014. Although
mortality from terrorist attacks has dropped to 27% since
2014, terrorism is more widespread affecting more countries
than in 2014 [8]. While only modest numbers of patients following MCEs require transfusion, a small number of patients
with critical injuries and polytrauma will require immediate
transfusion as part of damage control resuscitation (DCR).
Damage control resuscitation is a resuscitation strategy to
prevent death from catastrophic hemorrhage and refers to US
military guidelines developed for combat casualties with
massive bleeding in Iraq and Afghanistan. DCR is well
described throughout trauma and resuscitation literature and
involves multiple interventions including earlier and balanced transfusion of plasma and platelets with initial red
blood cell (RBC) transfusion. DCR evolved from the earlier
concept of damage control surgery (DCS), the practice of
rapid and abbreviated surgery after initial resuscitation to
control bleeding and reduce infection risk by removing
debris, fecal matter, and body uids followed by continued
resuscitation and physiological stabilization in the intensive
care unit (ICU) [9]. Denitive surgical repair could be
deferred for several days as DCS emphasized avoiding the
lethal triad of acidosis, hypothermia, and coagulopathy.
However, direct treatment of coagulopathy was not a primary focus of DCS because coagulopathy had been presumed to be due primarily to initial resuscitation,
hemodilution, and hypothermia rather than the physiological
response to trauma and hemorrhage [10]. Damage control
resuscitation is a comprehensive approach (incorporating
DCS) from the point of trauma to denitive treatment to minimize blood loss, maintain tissue oxygenation, and correct
the lethal triad at the earliest moment after the occurrence of
trauma [9, 10]. Intravascular treatment of bleeding and coagulopathy are integral to damage control resuscitation, and
more recent DCR research has shown that prehospital initiation of resuscitation, including transfusion of packed RBCs,
thawed plasma, and platelets, decreases morbidity and mortality in trauma patients at risk of shock [11–15] (Fig.18.1).
The surge in demand for blood products during a mass
casualty event and the earlier and higher number of blood
products required for DCR demand that transfusion emergency preparedness be integrated into the medical emergency preparedness planning process [16, 17]. Effective and
timely deployment of blood products during natural and
man-made disasters and in military conict requires the integration of research from multiple specialties including industrial engineering and operations research, emergency
Fig. 18.1 Mass casualty
event at Bagram air base
2011– single operating room
used for two simultaneous
surgeries after a mass casualty
event (Photograph from
author’s private collection)
18 Blood Deployment inNatural Disasters andaMilitary inConict
https://t.me/medicina_free
155
preparedness, blood banking, transfusion medicine, as well
as emergency and trauma medicine. As anesthesiologists
assume larger roles in hospital and community emergency
preparedness, a basic understanding of blood transfusion
emergency preparedness across the continuum of care is
valuable.
The USBlood Supply System andCurrent
Challenges toSustainability andResiliency
Organization
The US blood supply system is comprised of many organizations with different structures and philosophies and all function to meet the nation’s blood needs for component therapy
and plasma. This chapter focuses on the collection of whole
blood for processing into component therapy (RBCs, plasma,
platelets, cryoprecipitate) used in transfusion because these
components are the primary therapies required in MCEs.
Although plasma collected by plasmapheresis can be used for
transfusion, this collection process is separate, and the plasma
collected is generally used as raw material to manufacture
plasma derivatives such as brinogen, Factor IX, anti-thrombin III, etc. The blood collection system in the USA is heterogeneous because it developed on the free market without
consideration of patient referral patterns [18]. Blood collection is performed by a network of federally regulated nonprot
organizations and supplied by donors that are all nancially
uncompensated volunteers. Nearly half of all blood is collected by the American Red Cross (ARC) collection centers.
The remainder of blood collection in areas not represented by
the ARC is performed by independent nonprot community
blood centers and hospital blood banks. Most geographical
areas are served by only one blood collection organization.
Although blood is collected from volunteers by nonprot collections centers, blood and its fractionated products are commodities with processing and distribution costs as well as a
uctuating “market price” depending on supply and demand.
Areas with high supply and low demand can export their oversupply to areas with high demand and lower supply through
blood resource sharing. “Spot” markets exist for urgent purchases where prices are based on current market supply and
immediate delivery. Blood collection centers compete on
blood component price for contracts to supply hospitals and
other health-care organizations [18].
Regulation
Blood centers are licensed and regulated by the USFood and
Drug Agency (FDA). Other Federal organizations involved
in maintaining the health and safety of the blood supply
include the Department of Health and Human Services
(DHHS), the Public Health Service (PHS), and the Centers
for Disease Control (CDC) providing direction, oversight,
and surveillance. The American Association of Blood Banks
(AABB) is a nonprot association that performs inspections
and accreditation of blood banks and blood centers; establishes standards for blood collection, processing, and storage; and participates in the National Blood Exchange
Program, facilitating movement of blood products from surplus areas to shortage areas.
Challenges intheUSBlood Supply System
Over the last decade, the demand for blood products has
decreased signicantly. Between 2009 and 2016, the number
of units of blood collected and distributed by the American
Red Cross decreased by >25% [19]. This decline is largely
due to several advances in clinical medical practice and hospital cost-containment efforts. Less invasive surgeries, pharmacological alternatives to transfusion, non-myeloablative
treatment of malignancies, and comprehensive patient blood
management strategies have reduced the demand for blood
[20]. Patient blood management has been motivated by the
need to improve blood safety and patient outcomes, preserve
the blood inventory, and constrain escalating hospital costs
[21]. Blood management strategies promote appropriate use
of blood components with the goal of minimizing their use
and promote transfusion alternatives.
Despite the decreased demand for blood products, the
number of blood centers collecting, processing, and distributing blood has remained nearly the same. Costs for these
blood centers have remained constant or increased. New testing for specic diseases and broader pathogen-reduction
technologies add production and testing costs to the blood
centers that are difcult to pass on to hospitals [22]. For
example, the emergence of the Zika virus in Puerto Rico
required development and implementation of additional testing at additional cost to blood centers. Additionally, blood
products from non-affected areas had to be transported to
Puerto Rico to maintain a safe blood supply prior to development of Zika testing. Other blood center cost increases
include more selective donor criteria, expensive information
systems for data analysis, and leukocyte reduction of RBCs.
All of this has made blood transfusion safer but also more
expensive. Hospital consolidation has shifted negotiating
power away from blood centers and kept blood component
prices low. Private and government insurers do not treat
blood as a distinct reimbursable product or service in hospitalized patients resulting in no direct linkage between hospital reimbursement and the true cost of providing blood
components. Approximately 80% of all transfusions occur in
hospitals.
156
https://t.me/medicina_free
C. L. Riley and J. Dean
The blood center response to these challenges has been
predictable but concerning for the ability of the US blood
supply system to remain resilient especially in the face of a
prolonged disaster. Many blood centers have removed excess
capacity by reducing collections to a minimum, reducing
staff, limiting availability of specialty blood products, and
reducing or eliminating uncompensated services like surveillance and education [23]. In response to the changing economic landscape of blood centers, the Department of Health
and Human Services (DHHS) contracted the RAND
Corporation to study the sustainability of the blood supply in
the United States.The RAND (Research ANd Development)
Corporation is an American nonprot global policy think
tank created in 1948 by Douglas Aircraft Company to offer
research and analysis to the USArmed Forces. Their report
Toward a Sustainable Blood Supply in the United States: An
Analysis of the Current System and Alternatives for the
Future [22] concluded that the current blood supply system
is robust, operating efciently most of the time, but that continued market contraction will likely result in more widespread shortages in the future. Recommendations for
improving the resiliency of the US blood supply include both
market solutions and government intervention. Their conclusions include the following:
1. Separate payments for blood products may mitigate pres-
sures on the blood system.
2. Assess emerging technologies for maximum benet and
incentivize the adoption of these technologies.
3. Develop a vision of appropriate levels of surge capacity.
4. Distinguish between the costs of maintaining a surge
capacity and the normal costs of doing business and
nance the surge capacity.
5. Build relationships across blood brokerages (ARC,
Armed Services Blood Program) to address short-term
and local shortages.
6. Implement emergency use authorizations by DHHS for
replacement supplies in the event of a shortage.
products require careful temperature control, and therefore
shipping blood products is costly with added weight of insulation and ice.
Armed Services Blood Program
Organization andRegulation
The US military maintains its own blood supply under the
Armed Services Blood Program (ASBP). The ASBP represents all three branches of military, and its components collect, process, store, transport, and transfuse blood to service
members and their families worldwide. Like civilian blood
centers, the ASBP is governed by the FDA guidelines for
maintaining safety and quality of blood products. The ASBP
also follows the standards, procedures, recommendations,
and guidelines of the AABB.Any service member receiving
blood or blood products in a combat area will receive blood
through the ASBP.Although the ASBP does work with the
ARC and other blood centers during civilian emergencies,
the two blood supplies are usually distinct. The ASBP sends
all blood collected at military blood donation centers (on
military bases and civilian locations) to two Armed Services
Whole Blood Processing Laboratories (ASWBPLs). Blood
reaches combat theater either by pre-positioning frozen
blood at Blood Product Depots or by sending blood and
blood components to Expeditionary Blood Transshipment
Systems which move the blood products to Blood Supply
Units in theater. From there, blood is moved in theater to
forward deployed surgical units, theater hospitals, USNavy
ships, and Allied/Coalition hospitals. Forward surgical units
and theater hospitals provide blood and blood products to
rst responders at the individual unit level [26].
Challenges intheJoint Service Blood Supply
Chain
Review of the literature also suggests that international
blood product sharing agreements could support longer-term
blood supply challenges such as infectious disease emergencies like Zika virus outbreak [24].
Other ongoing challenges to the blood supply include
donor dependence, perishability of blood products, and
costly transit. The size of the donor pool is dwindling due to
increased donor exclusions and the aging population.
Minorities are also underrepresented in the donor pool due to
higher donor deferral rates, mistrust of the medical community, and lack of awareness of the blood donation process and
the need for rare blood [25]. The shelf life of blood products
is short, and therefore there is great potential for waste which
further burdens the cost of producing the product. Blood
The military blood supply chain faces different challenges
especially in some operating environments. Large-scale
combat operations can potentially result in a signicant
demand surge for blood products while simultaneously
reducing freedom of movement for US forces and limiting
the capacity to transport blood products to forward operating
locations. A sustained conict successful at targeting critical
military infrastructure such as command centers, runways,
and fuel depots could limit the movement of blood into theater from donation centers. Blood stored in medical treatment facilities (MTFs) would become depleted interrupting
care to combat casualties [27]. The Defense Advanced
Research Projects Agency (DARPA) has focused on developing approaches to augment operational resiliency. Three
18 Blood Deployment inNatural Disasters andaMilitary inConict
https://t.me/medicina_free
157
principles of operational resiliency have been integrated in
the joint service blood supply chain. Fractionation enables
the scaling of elements within the supply chain to deploy
downrange as needs require. For example, a small expeditionary blood collection center could be deployed until a
larger capability was established or restored. Composition
enables tailoring capabilities to best suit the needs downrange. Although a deploying Army brigade may not have the
capability to thaw and process frozen blood, the Air Force
has a small deployable capability that offers these services.
The Air Force capability can be tasked to deploy with the
Army. Functional substitution enables amending current
capabilities with substitutes better suited for operational
needs such as stocking frozen packed red blood cells that
have a longer shelf life than packed red blood cells [27].
Transfusion Disaster Preparedness
Transfusion Disaster Plan
Transfusion support is critical in the health-care response to
MCEs, and every hospital should include transfusion disaster preparedness in its overall emergency planning. The overall goals of transfusion disaster preparedness should be
holistic and include the following aims [28]:
1. To protect the delivery of key products and services
2. To manage the incident within regulatory requirements
3. To strive for recovery of normal business as soon as
possible
4. To safeguard the health, safety, and welfare of staff and
donors
After September 11, 2001, the American Society of
Anesthesiologists (ASA) formed the Committee on Trauma
and Emergency Preparedness (COTEP). Recognizing the
unique skill set anesthesiologists have, COTEP collaborated
with different organizations to create a resource center for
anesthesiologists to learn about emergency preparedness.
COTEP developed the Emergency Preparedness Manual for
Anesthesia Department Organization and Management that
emphasizes the importance of care coordination within the
hospital in order to successfully manage the surge of patients
requiring intervention. Core concepts of any hospital emergency preparedness plan should include the following:
1. Integration– It is of private and public medical capabili-
ties with public health systems.
2. Medical preparedness– Increase the response capabilities
and surge capacities.
3. At-risk populations – Identify populations most at-risk
after an event and determine their needs.
4. Continuity of operations – Maintain adequate public
health and medical services.
More specic details should include process and outcome
objectives with identication of surveillance methods. Chain
of command and expected ow of information should be
determined including methods for communicating with the
public. Personnel response timing and phasing should be
established including clinical and administrative leaders.
Equipment needs should be identied. Anesthesiologists can
provide airway and resuscitation expertise in a rst responder
role in the emergency department as well as liaison with staff
in the operating room to facilitate appropriate operating
room utilization. Figure18.2 details a general checklist for
operating room readiness in a mass casualty event.
The AABB has developed a disaster operations handbook
to help blood centers, hospital blood banks, and transfusion
services respond to disasters affecting the blood supply or
the distribution of blood products [
intended to facilitate coordination among blood centers, hospital transfusion services, national blood organizations, and
government ofcials to determine the medical need for
blood, to establish transportation of blood from one facility
to another, and to communicate a common message to the
national blood community and the public about the status of
the blood supply in the disaster-affected area. The AABB
denes a disaster as any event that:
1. Suddenly requires a much larger amount of blood than
usual
2. Temporarily restricts/eliminates a blood collector’s ability to collect, test, process, and distribute blood
3. Temporarily restricts/prevents local population from
donating blood
4. Temporarily restricts/prevents use of available inventory
of blood products requiring immediate replacement
5. Creates a sudden inux of donors requiring accelerated
drawing of blood to meet an emergent need elsewhere
This denition of disaster is broad and focuses attention
on any disruption however brief to the blood supply chain.
The broad denition encourages early communication
between all points in the blood supply chain to ensure early
response to interruptions in blood product supply.
Communication up and down the blood supply chain is probably the single most important component of any transfusion
disaster preparedness plan and should include hospital physicians involved in emergency response. See Fig.18.3.
Another important element in any transfusion disaster pre-
paredness plan is a business continuity plan to prevent loss of
function if routine infrastructure is disrupted (computer networks, blood processing centers), maintain services through
event, and initiate disaster recovery [30]. Disaster plans should
29]. The handbook is
158
https://t.me/medicina_free
Fig. 18.2 Operating room
procedures for mass casualty–
management step by step (Reprinted
with permission of the American
Society of Anesthesiologists, 1061
American Lane, Schaumburg,
Illinois 60,173–4973)
C. L. Riley and J. Dean
be rehearsed [28, 29] regularly. Exercises can be simple tabletop exercises and do not require extensive simulation equipment. Low delity exercises can challenge current assumptions
and reveal inadequate or inefcient processes [28]. Previous
assumptions are based on past data and do not reect future
challenges so transfusion emergency planning should be
viewed as dynamic and iterative. For example, the last decade
has seen both a change in resuscitation and transfusion practice and increased lethality in many events including terrorist
attacks and mass shootings [1, 31].
R
DISASTER OPERATIONS HANDBOOK • OCTOBER 2008
18 Blood Deployment inNatural Disasters andaMilitary inConict
https://t.me/medicina_free
159
Fig. 18.3 Response plan
ow chart– this owchart
shows the bidirectional
communication ow for
transfusion response during a
disaster. ARC American Red
Cross, CDC Centers for
Disease Control, HHS Health
and Human Services, AABB
American Association of
Blood Banks, BCA Blood
Centers of America, ABC
America’s Blood Centers,
ASBP Armed Services Blood
Program, FDA Food and Drug
Administration
e
L
ABC
BCA
Assist
Affected
Blood
Collector
EVENT
Affected
Blood
Collector
AABB
F
k
s
a
T
1
l
e
v
ARC CDC
AABB
ASBP
HHS
o
r
c
e
Message to
Blood
Community
and Donors
Message
to Public
HHS
FDA
Level 2
Task
Force
ESPONSE PLAN FLOW CHART
Step 1.
Affected Blood Collector (BC) Assesses
Medical Need for Blood
Contact local hospital customers and emergency services to
determine impact of event, including:
•
Hospitals
Nature of emergency (e.g., disaster, terrorism)
Number of current and expected hospital admissions
•
Types of expected injuries
•
Potential effect on local donor base
•
Gather information on local blood inventory levels from both
BC and hospital customers.
Calculate the medical need for blood for a nonbiological event
based on three units of type O RBCs per current and expected
hospital admissions resulting from the event (see Event
Assessment Form).
Step 2.
Affected BC Contacts AABB
(ideally within 1 hour of event)
Contact AABB (use redundant communication channels in
order listed below):
Land line: (800) 458-9388
1.
Cell phone: (240) 994-6700
2.
E-mail: nbe@aabb.org
3.
Text message: (240) 994-6700
4.
Satellite phone: (254) 377-3726
5.
Report medical need and local blood inventories.
Step 3.
Step 4.
Interorganizational Task Force (TF)
Conference Call
AABB convenes a conference call with Level 1 TF members
(Level 2 TF members included if necessary–see page 42 for
a list of Level 1 and Level 2 TF member organizations).
TF determines national strategy and coordination efforts,
including:
Message to blood community/donors
1.
Transpor tation and coordination of blood to affected BC
2.
Next steps until event is resolved
3.
AABB communicates decisions to Level 2 TF members.
Implementation of Task Force
Recommendation
TF representatives communicate recommendations to their
respective constituencies.
TF distributes unified message to blood community and donors
(e.g., joint press releases).
TF coordinates message to the public with Department of
Health and Human Services (HHS).
Blood Supply Chain Management (BSCM)
Glasgow et al. [1] showed that there are relationships
between casualty statistics and RBC use but that reporting of
blood use is often inconsistent and incomplete. Understanding
how the blood supply chain operates during the surge conditions of an MCE is challenging because data collection and
experimentation are low priority during an event.
Furthermore, the blood supply chain is dynamic with irregular supply, stochastic demand, perishable commodities,
expensive and technical processing, and costly transportation. Operational research techniques offer an approach to
investigate this complex system as these techniques provide
models that can interact and experiment with the numerous
variables involved in the delivery of transfusion services during an MCE [32]. Operational research models can evaluate
BSCM along each of the four main processes: procurement,
production, inventory, and distribution [33]. Other models
can evaluate for efciency (minimize cost) and effectiveness
(minimize delivery time) and effects of pandemics on blood
supply regionally [34, 35]. Dynamic supply chain modeling
can consider adjustments inlocation and capacity of facilities at different time periods representing different periods of
an MCE. In-hospital MCE response modeling has shown
perceived hospital ability to manage MCEs to be overly optimistic and specically identied blood resources as a limiting factor in event response time [36] and recommend early
automatic restocking during an MCE to preserve red cell
160
https://t.me/medicina_free
C. L. Riley and J. Dean
supply. BSCM modeling offers additional techniques to prepare for MCEs that do not interrupt patient care and can consider the large number of variables that impact the complex
blood supply chain. This area of research is promising as
resuscitation and transfusion practices evolve, and MCE
planning must include supply of coagulation components
both in the hospital and prehospital response.
Transfusion Demand Forecasting andPlanning
The greatest challenge in transfusion disaster preparedness is
balancing demand and supply especially the demand for universal components such as group O RBCs in an
MCE.Transfusion services must assess the event and predict
the likelihood for extensive use of blood components and
rapidly obtain more components if necessary. Transfusion
demand planning is increasingly important for MCE planning, and the literature is evolving. Transfusion demand
planning has been informed by civilian MCEs globally as
well as by changing trends in trauma care. Evidence from
these global MCEs suggests only a modest number of MCE
victims admitted to the hospital require transfusion. The
mean blood use per patient is consistently calculated at
2–3units PRBC per patient or 6–7 units PRBC per moderately and severely injured patient. Most of that product is
transfused within the rst 6–12h [1, 28, 37, 38]. Blood use
reporting however is inconsistent following MCEs, and
reporting standardization would improve data validation.
Additionally, much of the data used to derive the above estimates was gathered before the introduction of damage control resuscitation. Blood use has changed over the last decade
with the increased use of hemostatic components [1] including in the prehospital period. While this may reduce the
demand on RBCs, there will likely be strain on supplies of
plasma, platelets, and cryoprecipitate in the future. A recent
attempt to correlate transfusion needs with injury mechanisms and severity found that while the demand for components correlated with the number of casualties, injury
mechanism was less useful in prediction of blood requirements [28, 31] possibly because response and evacuation
times for events were very different.
Early Blood Grouping andTransfusion Triage
Massive transfusion protocol use in treatment of hemorrhage
has led to increased demand for group O Rh negative RBCs
and AB plasma. Activation of massive transfusion protocols
for multiple patients in an MCE can quickly lead to a demand
that exceeds supply of universal components and hemostatic
components if these practices are not incorporated into local
demand planning. Transfusion triage of patients by age and
gender can identify patients that are able to receive alternative universal blood products (O Rh positive RBCs for all
men and women over 50years old). Use of anti-D immunoglobulin can also reduce the risk from alternative universal
blood products. The use of group A plasma in patients with
unknown blood type instead of group AB plasma has not
been shown to increase morbidity and mortality in patients
with group B blood [
have been used in lieu of group O platelets in patients with
unknown blood types. Although red cell contamination can
increase the risk of alloimmunization, platelet additive solutions may reduce the risk of hemolysis [40, 41]. Transfusion
triage also can identify patients in whom transfusion is not
immediately required. Early blood grouping of these less
acute patients can help preserve the supply of universal components [28]. It is important to mention that blood grouping
during an MCE increases the risk of ABO blood group
incompatible transfusion and any blood grouping plan should
include a clear emergency plan for identifying, sampling,
and labeling patients and their blood group. Glasgow etal.
32] described simulation modeling of deliberate RBC, and
[
emergency group O blood transfusion restriction during an
MCE increased overall patient treatment rates. Red blood
cell transfusion restriction especially in combination with
hemorrhage control, early use of tranexamic acid, and prehospital plasma transfusion offers another potential tool to
extend blood supply in an MCE.
39]. Similarly, group A and B platelets
Management ofBlood Donation andStock
Management of blood stock and blood donation during an
MCE is critical to disaster preparedness. Maintaining large
stock holdings leads to wastage due to perishability, but
insufcient stock may interrupt the ability to provide clinical
care to patients. Immediate demand for blood should be met
by existing stocks although this may require movement of
stock. Shortages should be expected during any unplanned
event, and blood shortage plans should be prepared. More
rural areas may not be able to depend on immediate stock. In
a prolonged MCE or an event with large numbers of casualties or an event in remote areas, replacement will be required.
Blood collection agencies should work closely with donors
to ensure continued supply of blood but also not overwhelm
the collection system during a disaster. After the World Trade
Center and Pentagon attacks on September 11, 2001, over
475,000 units of blood were collected of which only 258
were used [42]. Blood collection centers need to appeal to
that altruism during non-disaster periods to meet collection
targets that will ensure capacity when emergency events
occur. Most blood services prefer to hold sufcient replacement stock rather than accept emergency donations, but a
prolonged MCE may require a variety of approaches to
18 Blood Deployment inNatural Disasters andaMilitary inConict
https://t.me/medicina_free
161
restocking supplies including stock movement, use of an
emergency/high-readiness donor pool, increase collection
targets, adjustments in testing and processing, and support
from other blood services [16]. Transportation should also be
a consideration in blood stock planning. Interruption of usual
transportation modes and routes must be considered in contingency plans for continued re-supply. Emerging technologies such as aerial drone technology offer transportation
alternatives for delivery of blood products to austere or
remote locations. Any transportation alternative must consider the cold chain management required for blood products
to ensure safe use. Widespread use of aerial drones for a variety of tasks is accelerating the development of improved
drone capability with an associated reduction in cost. This
includes increased speed and increased payload capacity.
This technology holds promise for blood stock resupply in a
disaster [43].
Emergency Donors andWhole Blood
Development of blood component therapy focused primarily
on medical indications for transfusion therapy for specic
patient groups. Component therapy enables targeted treatment for patients with a single blood cell or factor deciency
as in sickle cell disease or hemophilia. Component therapy
also optimizes storage of a limited resource that is dependent
on volunteers for sourcing. In contrast to medical patients,
hemorrhaging patients become decient in all components
of blood, and our current balanced mass transfusion practice
attempts to replace all of these components.
The US military has been using whole blood transfusion
in resuscitation of severe traumatic hemorrhage since World
War I [44, 45]. Whole blood (WB) transfusion can provide
oxygen-carrying capacity to military personnel injured in
austere environments and has been used extensively during
the wars in Iraq and Afghanistan by the US military and
NATO Coalition Forces [44, 46–48]. The current US military
Joint Trauma System Clinical Practice Guideline (JTS CPG)
for whole blood transfusion provides guidelines for both
cold-stored whole blood (SWB) and fresh whole blood
(FWB) transfusion [49]. Whole blood in one of the anticoagulant citrate solutions is an FDA-approved product when it
is collected, stored, and tested for transfusion-transmitted
disease (TTD). It can be stored for 21–35days depending on
the citrate solution at 1–6°C and is referred to as SWB. The
hemostatic function of SWB is adequate and stable for the
rst 2weeks after collection but may require supplementation with other blood components (platelets, FFP) for adequate hemostasis after 2weeks. FWB refers to whole blood
collected on an emergency basis from a “walking blood
bank” (WBB), a group of pre-screened donors that respond
to an emergency call from the military treatment facility
(MTF). FWB can be stored at room temperature for up to
24h before it must be discarded. If refrigerated within 8h of
collection and submitted for complete transfusion-transmitted disease testing, FWB becomes SWB. FWB has full
hemostatic function and usually does not undergo full FDAapproved TTD testing prior to transfusion. For this reason,
FWB transfusion is not FDAwhen tested blood products are unavailable and the need for
transfusion is urgent [49]. See Fig.18.4 for a sample emergency donor panel questionnaire for FWB donor.
The most important safety factor when transfusing WB is
donor RBC compatibility with the recipient’s pre-formed
anti-A or anti-B antibodies. WB from group O donors contain RBCs compatible with all recipients, but the plasma in
group O WB may cause hemolysis if the anti-A or anti-B
antibody titers are high. This challenge can be addressed by
transfusing only same-group WB (A to A, B to B, AB to AB,
and O to O) or using low titer anti-A and anti-B group O WB
(LTOWB) [
donor WB, and low titer SWB is the preferred resuscitation
product for the prehospital treatment of patients in hemorrhagic shock [52]. If the situation permits, rapid infectious
disease testing (HIV, HBV, HCV) is performed on donor
specimens prior to transfusion, and retrospective samples on
all donors are sent for FDA-approved TTD testing.
Clinical data suggests that the use of WB to treat hemorrhage results in outcomes at least as favorable as those with
component therapy including RBCs, plasma, and platelets
[14]. WB mitigates some of the challenges of adequate stored
components and supplies hemostatic components with a
smaller anticoagulant load [53]. Infection risk in a properly
prescreened donor group appears to be low. The ASBP sponsored an epidemiological study to characterize transfusiontransmitted infection associated with emergently collected
blood product transfusion [54]. The study looked at 761
recipients of emergently collected blood product transfusion
and found no HIV or HBV transmission. One HCV transmission was identied. The study estimated the transfusiontransmitted infection prevalence in potential walking blood
bank donors to be 8 in 1000 for HCV and 4 in 1000 for
HBV.This non-zero risk requires a risk-benet analysis prior
to use of FWB by experienced clinicians capable of assessing risk of withholding transfusion. A robust “walking blood
bank” (WBB) with practiced collection and testing can provide a more agile and resilient emergency transfusion
response to a major incident especially in isolated regions.
The Immunology and Transfusion Medicine Department of
Haukeland University Hospital in Bergen, Norway, in collaboration with the Norwegian Naval Special Operation
Commando establishes a WBB for military settings. The collaboration led to a mass casualty event contingency plan for
the hospital that includes the use of low titer anti-A and antiB FWB from established or pre-tested blood group O donors
50, 51]. LTOWB is considered the universal
approved and is reserved for
162
https://t.me/medicina_free
C. L. Riley and J. Dean
[55]. The contingency plan was exercised in July 2018 when
a critically ill patient received over 200units of blood products, exhausting the supply of stored LTOWB.Collection of
FWB was considered the fastest way to obtain platelet-containing blood product for immediate transfusion [53].
Norway has geography and population density that pose
numerous transportation challenges especially in the long
winter periods. Blood transfusion programs are therefore
regional rather than national. Blood banks are run by local
and regional hospitals and blood stock is maintained to meet
usual hospital needs. This decentralized management of the
Norwegian blood supply is similar to the independent blood
center management of much of the US blood supply system.
Locally developed transfusion disaster preparedness plans
that include the development of a walking blood bank will
increase the resiliency and responsiveness of their blood supply especially in a major incident.
Fig. 18.4 Proposed eld emergency
donor panel questionnaire
(Reproduced with permission from
Wiley)
Future ofTransfusion Disaster Preparedness:
TheGolden Hour ofTrauma
Military trauma care has transformed civilian trauma care in
the last decade. Military practice has also impacted mass
casualty event planning in the civilian sector because current
trauma care is dependent on networks of rst responders
trained in damage control resuscitation, blood centers
responsive to the need for massive transfusion for major
hemorrhage, and experienced clinicians leading emergency
and surgical teams in triage and resource allocation for maximum treatment capability in a major incident. The development of trauma registries has facilitated collaborative
translational research that has improved overall survival in
trauma patients.
Emergency donor panels (EDPs) and whole blood, tourniquets and hemostatic dressings, and early tranexamic acid
18 Blood Deployment inNatural Disasters andaMilitary inConict
https://t.me/medicina_free
Fig. 18.4 (continued)
163
and hemostatic components are trauma practices that have
been incorporated into civilian trauma care in the last decade.
Despite the changes in trauma care and improvement in
overall trauma patient survival, the mortality for trauma
patients undergoing laparotomy that arrive at the emergency
department (ED) with hypotension has remained unchanged
and is approximately 48% [56].
Efforts to reduce that mortality risk are now focused on
early hemorrhage control in the prehospital period, sometimes referred to as the golden hour of trauma. Controlling
hemorrhage before a patient is in shock reduces the risk of
the lethal triad of acidosis, hypothermia, and coagulopathy.
Transfusion of pre-thawed plasma has been incorporated
into many ED transfusion stocks because it reduces plasma
thaw time and patients receive balanced transfusion ratio of
1:1 plasma to RBCs earlier. In 2018, the FDA granted emergency use authorization to the Department of Defense to use
pathogen-reduced leukocyte-depleted freeze-dried plasma.
Freeze-dried plasma, known as French FDP or French lyophilized plasma (FLYP) because it is manufactured by the
French Military Blood Institute, has been used in the
European Union (EU) for almost two decades. FLYP can be
stored at room temperature for 2years without deterioration
of coagulation factors, and the hemostatic properties of
FLYP are comparable to those of fresh frozen plasma [57,
58]. The immediate availability of FLYP translates to earlier
balanced transfusion of plasma and RBCs and may reduce
the need for massive transfusion in trauma patients [59]. The
storage capabilities of this product could potentially simplify
the supply chain challenges for plasma. Alternative storage
methods for blood components and development of synthetic
blood components (platelets and oxygen carrying molecules)
continue to be researched [60–62] with the goal of reducing
mortality from traumatic hemorrhage.
Summary
Transfusion capability is critical to the health-care response to
MCEs with the key challenge being to match supply and
demand. Hospitals and the community health-care services
should include transfusion planning in their emergency
preparedness plans. Review of historical events can provide
guidance for future planning, but each new event offers new
insight for transfusion management. Transfusion emergency
preparedness is necessary to provide a timely, safe, and sustainable blood supply. Transfusion emergency preparedness
plans need to include modeling frameworks to understand
Соседние файлы в папке Библиотека им академика М.И. Перельмана