Emergency transfusion support is an essential element of modern healthcare. Life-threatening anaemia and haemorrhage require timely red cell transfusion. Haematological support is also essential to reduce the risk of critical bleeding due to haemostatic failure. The context of this article is the organisational and clinical management of major haemorrhage which may require both. Major haemorrhage is a clinical emergency that rapidly results in morbidity and mortality.
Common causes include obstetric emergencies, gastrointestinal bleeding, major surgery, and trauma. Mortality is high unless actively managed with early haemorrhage control and resuscitation, especially in trauma. Recent conflicts have driven a paradigm shift in the use of blood and raised expectations in the wider healthcare community. In this short article, we consider recent developments and innovations in emergency transfusion and the challenges for the transfusion community.
Lessons from military healthcare, including the response to Mass Casualty Events (MCEs), have influenced civilian trauma practice, registries, and transfusion emergency preparedness. The principles are also applied, with modification, to other causes of life-threatening haemorrhage.
Table 1 lists examples of clinical and organisational innovation. Clinical guidance emphasises the recognition of the patient at risk of shock, early haemorrhage control, the use of tranexamic acid, and balanced blood-based resuscitation. This approach has improved survival. The emphasis on early intervention in trauma has stimulated an interest in pre-hospital haemorrhage control and transfusion.
Table 1. Examples of development and innovations in emergency transfusion
- Re-organisation of trauma systems and registries
- Damage control resuscitation with haemorrhage control and early use of transfusion
- Use of Major Haemorrhage Protocols and tranexamic acid
- Pre-hospital transfusion with improved cold chain management
- Non-medical authorisation for transfusion and wider scope of practice
- Component research and development
- Transfusion support to emergency and disaster planning
- Development in hemovigilance systems
- Application of human factors science
- International collaboration and multi-centre trials
Successful pre-hospital transfusion programmes have driven developments in cold chain and stock management. In addition, the challenge for the simple, speedy safe delivery of blood has driven a renewed interest in both group O whole blood and universal dried plasma. In turn, the simplification of the transfusion process enables the non-medical authorisation of blood transfusion.
The best-known recent developments in emergency transfusion are Major Haemorrhage Protocols (MHPs). These are site-specific protocols that outline the processes, people, blood components, and adjuncts required to treat a bleeding patient. The treatment algorithms pre-specify the order and ratios of blood, components, or products used to treat bleeding in different clinical contexts. Common to all is patient safety which demands secure safe sampling and testing for blood type before transfusion. Clinical response directs initial blood-based resuscitation rather than haematological testing.
However, subsequent treatment is ‘goal-directed’ and tailored using Near-patient testing and laboratory support. Activation of an MHP should trigger a timely well-rehearsed response; whereas over-activation is resource-intensive and may lead to blood wastage. It is a difficult call to make. Emergency transfusion is stressful for both clinical and laboratory staff. Sourcing and preparing components take time, when the clinician sees the patient in front of them and demands blood, the laboratory is often busy supporting other patients.
The advent of MHPs and pre-hospital transfusion challenges both hospitals and blood providers. The innovations may drive blood demand including a greater proportion of ‘universal’ components such as group O red cells and group AB plasma. These components are often in short supply. Treating a single critically ill patient with haemorrhage may rapidly drain local blood stock. Multiple casualties magnify the need for blood and often trigger a surge in donors. Careful and coordinated management of both emergency transfusion demand and supply is essential.
Managing demand requires agreed protocols and clinical commitment using the principles of Patient Blood Management (PBM). PBM interventions include reducing blood loss, timely access to surgery, optimising physiology, and tolerating lower transfusion targets. If transfusion must be prioritised, pre-prepared blood shortage plans support fair distribution of blood. The challenge for blood providers is to meet both immediate and future demand, especially following Major Incidents or MCEs.
Transfusion support for major incidents requires organisational preparation and working in partnership to be successful. Public engagement partnership includes public first aid programmes to “stop the bleeding” and high-readiness blood donor panels. Organisational developments for the transfusion teams include the application of transfusion triage.
The concept of clinical triage is well established in the context of multiple casualties. By analogy, transfusion triage prioritises blood allocation, sample handling and laboratory work-streams as well as donor selection. The purpose of triage is to ensure fair and appropriate allocation of resources by ensuring blood grouping and transfusion for those in most need.
Over-categorisation uses scarce resources and limits the availability of others. We have found that providing emergency blood and advice in the Emergency Department and a focus on human factors improves blood ordering and sample handling. The International Society for Blood Transfusion and others have also highlighted the value of Transfusion Practitioners in emergencies.
We all have a responsibility to meet the challenge of emergency transfusion, whether we are dealing with a critically ill individual or multiple casualties. Guidance is valuable. Humanitarian organisations provide the overarching framework for disaster planning for healthcare. More recently, the Council of Europe and WHO has advised on the continuity of blood supplies during emergencies. The advice reminds us of the importance of a national approach to policy and planning. However, a local level commitment is essential for timely response, organisational resilience, and data collection. The outcome data fed back to planners and hemovigilance systems should drive further service improvement, development, and research.
Emergency transfusion is transforming. It is an exciting topic that has stimulated an enormous international academic effort. The challenge is translating this research into locally sensitive practice that balances timely transfusion with safety and sufficiency.
Dr. Heidi Doughty, Dr Philos, FRCP, FRCPath, is a Consultant in Transfusion Medicine. She will be speaking at the Blood Transfusion Medicine conference at Medlab Middle East 2023.
This article appears in the latest issue of Omnia Health Magazine. Read the full issue online today.