To transfuse or not to transfuse: A challenging question in pre-hospital critical care

Healthcare professionals have a wide range of treatment options  when a patient suffers significant blood loss in a hospital setting, but the situation becomes a lot more complicated in the outside world. One of the key decisions to make is whether or not to transfuse blood and blood products.

Dr Victor Viersen of the Department of Anaesthesiology at the University of Amsterdam, The Netherlands, shares the example of a motorcyclist who was involved in a head-on collision with a car at a combined speed of around 120 kilometres per hour (almost 75 miles per hour). The patient had a severe pelvic injury, resulting in massive blood loss and no measurable blood pressure upon arrival.

“Luckily, we carry a cooler with blood products when attending emergencies,” says Dr Viersen. “I had the ability to provide two packed red blood cells, two thawed units of plasma and two grams of fibrinogen. So that’s almost a litre of volume that we could provide and, after we pushed that in, we had a blood pressure of 40 over 20 (mmHg). That’s how I managed, along with some crystalloid fluids – because I had run out of blood products – to get him to a hospital where he made a full neurological recovery.”

Mixed evidence

The necessity of pre-hospital transfusion was evident in this case; however, the results of clinical studies into the benefits of transfusion in a pre-clinical setting are not so evident. Some studies have demonstrated a benefit of transfusion on morbidity and mortality, whereas others have not. However, it is becoming apparent that transfusion is likely to have a role in a pre-hospital setting, but only in carefully selected patient groups and certain situations.

One such group was identified through a post hoc combined analysis of the Control of Major Bleeding After Trauma (COMBAT) and Prehospital Air Medical Plasma (PAMPer) trials, comprising a total of 626 patients with trauma and haemorrhagic shock.^1-3 Patients had been randomly assigned to receive either standard care or two units of thawed plasma followed by standard care in the pre-hospital setting. The PAMPer trial found a reduction in mortality of almost 30% with plasma transfusion in the pre-hospital setting, whereas the COMBAT trial found no survival improvement. In the post hoc combined analysis, in patients for whom the benefit–risk ratio was favourable for the use of pre-hospital plasma, pre-hospital plasma was associated with a survival benefit when transport times were longer than 20 minutes.

Looking at the recent randomised controlled trials on pre-hospital transfusion in general, it suggests that pre-hospital transfusion has no benefit. However, when looking more closely at the data, it is apparent that a lot of patients were transfused who, in hindsight, did not need a transfusion.

Ensuring optimal benefit

As Dr Viersen explains, “Pre-hospital transfusion could be beneficial, but not when given to any patients with hypotension and suspected bleeding. We are just not that good at predicting who needs transfusion.” This is an issue not least because blood products in general are costly, in short supply and desperately needed in other settings. However, as evidence emerges regarding those patients and situations where pre-hospital transfusion is most likely to be beneficial, efforts are under way to optimise its use and cost effectiveness.

Lyophilised plasma

Octapharma has been working on a solution to this dilemma. A study published on October 1, 2022 showed that a new freeze-dried (lyophilised) form of Octapharma’s pooled S/D treated human plasma– a unique pharmaceutical-grade human plasma for infusion – is a viable alternative to frozen plasma, offering a comparable quality profile with the tremendous logistical advantage of a relatively long shelf life at room temperature.⁴ In February 2023, medical authorities in Europe approved the lyophilised presentation of Octapharma’s pooled S/D treated human plasma for transfusion, also in a pre-hospital setting.

In February 2023, medical authorities in Europe approved the lyophilised presentation of Octapharma’s pooled S/D treated human plasma for transfusion in a pre-hospital setting. “Octapharma’s pooled S/D treated human plasma is already a trusted product in emergency situations where plasma resuscitation is indicated,” says Oliver Hegener, Vice President IBU Critical Care.

“Octapharma’s pooled S/D treated human plasma in lyophilised powder form, our new product, can be kept at room temperature in the emergency room or in the back of an ambulance for 24 months and deployed as needed. The product can be quickly reconstituted by simply adding the accompanying water. This makes it a much more flexible and efficient option for use in pre-hospital settings and for situations or in regions with austere infrastructure. We look forward to filling this gap in the treatment of severely injured patients.”

The decision to transfuse or not remains a challenging one to make, and Oliver’s team is working with leading experts in critical care and trauma to help healthcare professionals make more informed choices about when a transfusion is called for and which products to use. This includes a rich programme of educational courses, including masterclasses in bleeding management, workshops, congresses and tailored educational programmes such as octaCARE designed to provide medical practitioners with access to the insights and expertise of leading experts in their field.

References:

1. ^{Moore HB, Moore EE, Chapman MP, et al. Plasma-first resuscitation to treat haemorrhagic shock during emergency ground transportation in an urban area: a randomised trial. Lancet. 2018 Jul 28;392(10144):283-291. doi: 10.1016/S0140-6736(18)31553-8.Epub 2018 Jul 20. PMID: 30032977; PMCID: PMC6284829.}

2. ^{Sperry JL, Guyette FX, Brown JB, et al; PAMPer Study Group. Prehospital Plasma during Air Medical Transport in Trauma Patients at Risk for Hemorrhagic Shock. N Engl J Med. 2018 Jul 26;379(4):315-326. doi: 10.1056/NEJMoa1802345. PMID: 30044935.}

3. ^{Pusateri AE, Moore EE, Moore HB, et al. Association of Prehospital Plasma Transfusion With Survival in Trauma Patients With Hemorrhagic Shock When Transport Times Are Longer Than 20 Minutes: A Post Hoc Analysis of the PAMPer and COMBAT Clinical Trials. JAMA Surg. 2020 Feb 1;155(2):e195085. doi: 10.1001/jamasurg.2019.5085. Epub 2020 Feb 19. PMID: 31851290; PMCID: PMC6990948.}

4. ^{Heger A, Gruber G. Frozen and freeze-dried solvent/detergent treated plasma: Two different pharmaceutical formulations with comparable quality. Transfusion. 2022 Dec;62(12):2621-2630. doi: 10.1111/trf.17139. Epub 2022 Oct 1. PMID: 36181447.}