Transfusion
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Despite countless advancements in trauma care a survivability gap still exists in the prehospital setting. Military studies clearly identify hemorrhage as the leading cause of potentially survivable prehospital death. Shifting resuscitation from the hospital to the point of injury has shown great promise in decreasing mortality among the severely injured. ⋯ Transfusion at the scene within minutes of injury has the potential to save lives. As our utilization expands to our outlying network we expect to see a continued decrease in mortality among significantly injured trauma patients.
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Idarucizumab (IDA) is approved for emergency reversal of dabigatran; prothrombin complex concentrates (PCCs) are recommended in the absence of specific antidote. The combined effects of IDA and PCC in trauma-related bleeding are unknown. The efficacy and safety of combined IDA + PCC were assessed in a lethal porcine model of double trauma under dabigatran anticoagulation. ⋯ IDA and PCC are effective in treating trauma-related bleeding with dabigatran anticoagulation. IDA is preferable for emergency reversal of dabigatran, but PCC may be valuable when the anticoagulant is unknown.
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Case Reports
Use of intravenous immunoglobulin G to treat spontaneous heparin-induced thrombocytopenia.
Spontaneous heparin-induced thrombocytopenia (HIT) is a rare but serious prothrombotic syndrome characterized by thrombosis, thrombocytopenia, and strong platelet-activating HIT antibodies in the absence of heparin exposure, and is frequently characterized by a suboptimal response to standard therapies. Here, we present the first report of intravenous immunoglobulin G (IVIG) use in a patient with spontaneous HIT. ⋯ These results suggest that IVIG may be a useful adjunctive therapy in spontaneous HIT.
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Case Reports
Massive transfusion of low-titer cold-stored O-positive whole blood in a civilian trauma setting.
Based on the improved outcomes achieved with fresh whole blood in cases of military trauma as well as with 1:1:1 transfusion strategies for massive traumatic hemorrhage in civilian settings, there has been resurgent interest in using whole blood for civilian trauma patients. There have been reports of giving up to 4 units of low-titer cold-stored O-positive to these patients. This is the first modern report of a massive transfusion with unrestricted low-titer group O whole blood (LTOWB) use in a civilian trauma patient. ⋯ This is the first report of a massive transfusion for civilian trauma based on cold-stored whole blood in the recent era. While this patient suffered a tremendous burden of traumatic injury and his recovery is not yet complete, his LTOWB resuscitation was successful. Frequent monitoring of coagulation status with thrombelastography during utilization of LTOWB is indicated because the efficacy of its components (particularly platelets) is not yet fully understood.
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Anti-CD47 (Hu5F9-G4) is a human monoclonal immunoglobulin G (IgG)4 antibody that is in clinical trials to treat hematologic or solid malignancies. CD47, a glycoprotein expressed on all cells, binds to signal-regulatory protein α on macrophages and regulates phagocytosis. Blocking CD47 is thought to enhance phagocytosis and promote antitumor responses. Here, we evaluate drug interference in pretransfusion testing, determine mitigation strategies, and compare interference with anti-CD38 (Daratumumab). ⋯ Anti-CD47 (Hu5F9-G4) interferes with all phases of pretransfusion testing, including ABO reverse typing. To remove interference requires multiple RBC alloadsorptions and/or the use of monoclonal Gamma-clone anti-IgG in the indirect antiglobulin testing.