A descriptive analysis of the Canadian prehospital and transport transfusion (CAN-PATT) network

Objective Out-of-hospital blood transfusion (OHBT) is becoming increasingly common across the prehospital environment, yet there is significant variability in OHBT practices. The Canadian Prehospital and Transport Transfusion (CAN-PATT) network was established to collaborate, standardize, and evaluate the effectiveness of out-of-hospital blood transfusion (OHBT) across Canada. The objectives of this study are to describe the setting and organizational characteristics of CAN-PATT member organizations and to provide a cross-sectional examination of the current OHBT practices of CAN-PATT organizations. Methods This was a cross-sectional examination of all six critical care transport organizations that are involved in CAN-PATT network. Surveys were sent to identified leads from each organization. The survey focused on three main areas of interest: 1) critical care transport organizational service and coverage, 2) provider, and crew configurations, and 3) OHBT transfusion practices. Results All six surveys were completed and returned. There are a total of 30 critical care transport bases (19 rotor-wing, 20 fixed-wing and 6 land) across Canada and 11 bases have a blood-on-board program. Crew configurations very between organizations as either dual paramedic or paramedic/nurse teams. Median transport times range from 30 to 46 minutes for rotor-wing assets and 64 to 90 minutes for fixed-wing assets. Half of the CAN-PATT organizations started their out-of-hospital blood transfusion programs within the last three years. Most organizations carry at least two units of O-negative, K-negative red blood cells and some organizations also carry group A thawed plasma, fibrinogen concentrate and/or prothrombin complex concentrate. All organizations advocate for early administration of tranexamic acid for injured patients suspected of bleeding. All organizations return un-transfused blood components to their local transfusion medicine laboratory within a predefined timeframe to reduce wastage. Conclusions Variations in OHBT practices were identified and we have suggested considerations for standardization of transfusion practices and patient care as it relates to OHBT. This standardization will also enable a robust means of data collection to study and optimize outcomes of patients receiving OHBT. A fulsome description of the participating organizations within CAN-PATT should enhance interpretation of future OHBT studies that will be conducted by this network

Development of a national out-of-hospital transfusion protocol: a modified RAND Delphi study

Background: Early resuscitation with blood components or products is emerging as best practice in selected patients with trauma and medical patients; as a result, out-of-hospital transfusion (OHT) programs are being developed based on limited and often conflicting evidence. This study aimed to provide guidance to Canadian critical care transport organizations on the development of OHT protocols. Methods: The study period was July 2021 to June 2022. We used a modified RAND Delphi process to achieve consensus on statements created by the study team guiding various aspects of OHT in the context of critical care transport. Purposive sampling ensured representative distribution of participants in regard to geography and relevant clinical specialties. We conducted 2 written survey Delphi rounds, followed by a virtual panel discussion (round 3). Consensus was defined as a median score of at least 6 on a Likert scale ranging from 1 (“Definitely should not include”) to 7 (“Definitely should include”). Statements that did not achieve consensus in the first 2 rounds were discussed and voted on during the panel discussion. Results: Seventeen subject experts participated in the study, all of whom completed the 3 Delphi rounds. After the study process was completed, a total of 39 statements were agreed on, covering the following domains: general oversight and clinical governance, storage and transport of blood components and products, initiation of OHT, types of blood components and products, delivery and monitoring of OHT, indications for and use of hemostatic adjuncts, and resuscitation targets of OHT. Interpretation: This expert consensus document provides guidance on OHT best practices. The consensus statements should support efficient and safe OHT in national and international critical care transport programs. The transfusion of blood components such as red blood cells (RBCs) and plasma is increasingly common in prehospital and transport medicine.1–3 In addition, the potential benefits of out-of-hospital administration of whole blood or blood products such as fibrinogen and prothrombin complex concentrate in selected patients are being investigated. In this report, we use the umbrella term “out-of-hospital transfusion” (OHT) to refer to the transfusion of whole blood, blood components such as RBCs and plasma, or blood products such as fibrinogen and prothrombin complex concentrate. Although the increasing practice of OHT suggests general consensus on a likely clinical benefit, evidence regarding the effect of OHT on morbidity and mortality is limited and conflicting.2,4–6 The generalizability of the limited evidence is further complicated in that the feasibility and potential benefit of OHT are dependent on multiple regional factors such as geography, patient factors and health care configuration. For example, 2 secondary analyses of the data sets from the Prehospital Air Medical Plasma (PAMPer) and the Control of Major Bleeding After Trauma (COMBAT) clinical trials suggested that OHT was beneficial if transport times were greater than 20 minutes and that a benefit present in blunt trauma does not translate to a benefit in penetrating trauma.7,8 In addition, out-of-hospital management of acute hemorrhage extends beyond OHT and includes factors such as administration of tranexamic acid, avoidance of hypothermia and physical means of hemorrhage control where possible.9,10 Efficient and effective implementation of OHT requires a combination of medical and logistic considerations that span multiple specialties. This is particularly relevant in countries like Canada, with long transport times to tertiary care centres, and remote communities that have limited or no access to physicians or blood components and products at their local health care facilities.11 We invited an expert panel to provide expert opinions on out-of-hospital hemorrhage management and, in particular, OHT to develop national consensus recommendations to guide OHT practice and to begin to optimize the effectiveness and safety of OHT

Rapid Reduction in Use of Antidiabetic Medication after Laparoscopic Sleeve Gastrectomy: The Newfoundland and Labrador Bariatric Surgery Cohort (BaSCo) Study

BACKGROUND: Patients who have undergone bariatric surgery generally need fewer medications as they experience improvement in, or even resolution of, various medical conditions, including type 2 diabetes mellitus, hypertension, and dyslipidemia. Published data on changes in medication use after laparoscopic sleeve gastrectomy, a type of bariatric surgery that is growing in popularity, are limited. OBJECTIVE: To determine whether patients took fewer medications for management of type 2 diabetes, hypertension, and dyslipidemia after laparoscopic sleeve gastrectomy, relative to preprocedure medications. METHODS: In this prospective, single-centre cohort study, a nurse practitioner used standard medication reconciliation and study data-extraction forms to interview adult patients who had undergone laparoscopic sleeve gastrectomy and determine their medication use and pertinent demographic data. The data were analyzed using generalized estimating equations and standard statistical software. Outcome measures included changes in the use of antidiabetic, antihypertensive, and antilipemic medications at 1, 3, and 6 months after the surgery. RESULTS: A total of 65 patients who underwent laparoscopic sleeve gastrectomy between May 2011 and January 2014 met the study inclusion criteria. Before surgery, the 30 patients with type 2 diabetes were taking an average of 1.9 antidiabetic medications. One month after the procedure, 15 (50%) had discontinued all antidiabetic medications, with a further decline at 3 and 6 months (p < 0.001 at each time point). Among the patients who were taking antihypertensives (n = 48) and antilipemics (n = 33) before surgery, the decline in use occurred at a more modest rate, with 6 (12%) and 2 (6%), respectively, discontinuing these medication classes within 1 month, and 12 (25%) (p = 0.001) and 8 (24%) (p = 0.015) having discontinued by 6 months. CONCLUSIONS: These findings suggest that patients with a history of type 2 diabetes mellitus, hypertension, and/or dyslipidemia who undergo laparoscopic sleeve gastrectomy are less likely to require disease-specific medications shortly after surgery

Rapid Reduction in Use of Antidiabetic Medication after Laparoscopic Sleeve Gastrectomy: The Newfoundland and Labrador Bariatric Surgery Cohort (BaSCo) Study

ABSTRACTBackground: Patients who have undergone bariatric surgery generally need fewer medications as they experience improvement in, or even resolution of, various medical conditions, including type 2 diabetes mellitus, hypertension, and dyslipidemia. Published data on changes in medication use after laparoscopic sleeve gastrectomy, a type of bariatric surgery that is growing in popularity, are limited.Objective: To determine whether patients took fewer medications for management of type 2 diabetes, hypertension, and dyslipidemia after laparoscopic sleeve gastrectomy, relative to preprocedure medications.Methods: In this prospective, single-centre cohort study, a nurse practitioner used standard medication reconciliation and study dataextraction forms to interview adult patients who had undergone laparoscopic sleeve gastrectomy and determine their medication use and pertinent demographic data. The data were analyzed using generalized estimating equations and standard statistical software. Outcome measures included changes in the use of antidiabetic, antihypertensive, and antilipemic medications at 1, 3, and 6 months after the surgery.Results: A total of 65 patients who underwent laparoscopic sleeve gastrectomy between May 2011 and January 2014 met the study inclusion criteria. Before surgery, the 30 patients with type 2 diabetes were taking an average of 1.9 antidiabetic medications. One month after the procedure, 15 (50%) had discontinued all antidiabetic medications, with a further decline at 3 and 6 months (p &lt; 0.001 at each time point). Among the patients who were taking antihypertensives (n = 48) and antilipemics (n = 33) before surgery, the decline in use occurred at a more modest rate, with 6 (12%) and 2 (6%), respectively, discontinuing these medication classes within 1 month, and 12 (25%) (p = 0.001) and 8 (24%) (p = 0.015) having discontinued by 6 months.Conclusions: These findings suggest that patients with a history of type 2 diabetes mellitus, hypertension, and/or dyslipidemia who undergo laparoscopic sleeve gastrectomy are less likely to require disease-specific medications shortly after surgery.RÉSUMÉContexte : Les patients ayant subi une chirurgie bariatrique ont généralement besoin de moins en moins de médicaments au fur et à mesure qu’ils voient leurs différentes affections, notamment le diabète sucré de type 2, l’hypertension et la dyslipidémie, s’estomper ou même se résorber. Or, il existe peu d’études publiées sur les changements apportés à la pharmacothérapie des patients ayant subi une gastrectomie longitudinale laparoscopique, une chirurgie bariatrique de plus en plus utilisée.Objectif : Déterminer si les patients prennent moins de médicaments pour le traitement du diabète de type 2, de l’hypertension et de la dyslipidémie après avoir subi une gastrectomie longitudinale laparoscopique comparativement à leur situation avant l’opération.Méthodes : Dans cette étude de cohorte prospective menée dans un seul centre, un membre du personnel infirmier praticien a utilisé des formulaires standards de bilan comparatif des médicaments et d’extraction de données d’étude afin d’interroger des patients adultes ayant subi une gastrectomie longitudinale laparoscopique, et ce, dans le but de connaître leur consommation de médicaments ainsi que de recueillir des données démographiques pertinentes. Les données ont été analysées à l’aide d’équations d’estimation généralisées et d’un logiciel statistique courant. Les critères de jugement incluaient l’adaptation du traitement antidiabétique, antihypertenseur et hypolipémiant, un mois, trois mois et six mois après la chirurgie.Résultats : Au total, 65 patients ayant subi l’intervention chirurgicale entre mai 2011 et janvier 2014 ont été admis dans l’étude. Avant l’opération, les 30 patients atteints du diabète de type 2 prenaient en moyenne 1,9 antidiabétique. Un mois après la chirurgie, 15 (50 %) d’entre eux ont cessé de prendre des antidiabétiques, un chiffre qui a augmenté après le troisième et le sixième mois (p &lt; 0,001 à chaque point dans le temps). Parmi les patients qui prenaient des antihypertenseurs (n = 48) et des hypolipémiants (n = 33) avant l’intervention chirurgicale, un moins grand nombre a cessé de prendre ces médicaments. Seulement 6 (12 %) patients ont cessé les antihypertenseurs et 2 (6 %) patients ont cessé les hypolipémiants après un mois, puis 12 (25 %) (p = 0,001) et 8 (24 %) (p = 0,015) respectivement après six mois.Conclusions : Ces résultats laissent croire que les patients atteints du diabète sucré de type 2, d’hypertension ou de dyslipidémie qui subissent une gastrectomie longitudinale laparoscopique courent la chance de ne plus avoir besoin de médicaments pour traiter ces maladies, et ce, peu de temps après la chirurgie