Prehospital Whole Blood Transfusion Programs in Norway

Background: Prehospital management of severe hemorrhage has evolved significantly in Norwegian medical emergency services in the last 10 years. Treatment algorithms for severe bleeding were previously focused on restoration of the blood volume by administration of crystalloids and colloids, but now the national trauma system guidelines recommend early balanced transfusion therapy according to remote damage control resuscitation principles. Materials and Methods: This survey describes the implementation, utilization, and experience of the use of low titer group O whole blood (LTOWB) and blood components in air ambulance services in Norway. Medical directors from all air ambulance bases in Norway as well as the blood banks that support LTOWB were invited to participate. Results: Medical directors from all 13 helicopter emergency medical services (HEMS) bases, the 7 search and rescue (SAR) helicopter bases, and the 4 blood banks that support HEMS with LTOWB responded to the survey. All HEMS and SAR helicopter services carry LTOWB or blood components. Four of 20 (20%) HEMS bases have implemented LTOWB. A majority of services (18/20, 90%) have a preference for LTOWB, primarily because LTOWB enables early balanced transfusion and has logistical benefits in time-critical emergencies and during prolonged evacuations. Conclusion: HEMS services and blood banks report favorable experiences in the implementation and utilization of LTOWB. Prehospital balanced blood transfusion using whole blood is feasible in Norway.publishedVersio

Training of medical students in the use of emergency whole blood collection and transfusion in the framework of a civilian walking blood

Introduction: In this report, we describe a training program in emergency whole blood collection and transfusion for medical students at the University of Bergen. The overall aim of the program is to improve the availability of early balanced blood transfusion for the treatment of patients with life-threatening bleeding in rural health care services. Study Design and Methods: The voluntary training program provides the knowledge needed to practice emergency whole blood transfusions and understand the system for emergency whole blood collection in the framework of a civilian walking blood bank (WBB). It includes theoretical and practical sessions. In-person teaching and web-based learning resources are provided. An anonymous survey of the students attending the training course in the autumn of 2022 and spring 2023 was performed. Results: 128 of 178 students participated in the practical training. 88 of 128 (69%) responded to the survey. 82 (93%) performed blood typing, 71 (81%) performed donor interviews, 61 (69%) partially performed whole blood collection (up to blood in bag) and 27 (30%) participated in complete whole blood collection and performed autologous reinfusion. No complications occurred during training. The students reported that the training course increased their understanding of how to ensure access to emergency blood transfusion by the use of a WBB. Discussion: Structured theoretical and practical training in emergency whole blood collection and emergency transfusion is feasible and of interest to medical students. A multidisciplinary approach to student training in emergency whole blood collection and transfusion should be considered.publishedVersio

Implementation of a dual platelet inventory in a tertiary hospital during the COVID-19 pandemic enabling cold-stored apheresis platelets for treatment of actively bleeding patients

Background: To increase preparedness and mitigate the risk of platelet shortage without increasing the number of collections, we introduced a dual platelet inventory with cold-stored platelets (CSP) with 14-days shelf life for actively bleeding patients during the COVID-19 pandemic. Study design and methods: We collected apheresis platelet concentrates with blood type O or A. All patients receiving CSP units were included in a quality registry. Efficacy was evaluated by total blood usage and laboratory analysis of platelet count, hemoglobin, and TEG 6s global hemostasis assay. Feasibility was evaluated by monitoring inventory and a survey among laboratory staff. Results: From 17 March, 2020, to 31 December, 2021, we produced 276 CSP units and transfused 186 units to 92 patients. Main indication for transfusion was surgical bleeding (88%). No transfusion reactions were reported. 24-h post-transfusion patient survival was 96%. Total outdate in the study period was 33%. The majority (75%) of survey respondents answered that they had received sufficient information and training before CSP was implemented. Lack of information about bleeding status while issuing platelets, high workload, and separate storage location was described as main reasons for outdates. Discussion: CSP with 14-days shelf life is a feasible alternative for the treatment of patients with bleeding. Implementation of a dual platelet inventory requires thorough planning, including information and training of clinical and laboratory staff, continuous follow-up of practice and patients, and an easy-to-follow algorithm for use of CSP units. A dual platelet inventory may mitigate the risk of platelet shortage during a pandemic situation.publishedVersio

In vitro quality of cold and delayed cold-stored platelet concentrates from interim platelet units during storage for 21 days

Background and Objectives: Based on previous success using apheresis platelets, we wanted to investigate the in vitro quality and platelet function in continuously cold-stored and delayed cold-stored platelet concentrates (PCs) from interim platelet units (IPUs) produced by the Reveos system. Materials and Methods: We used a pool-and-split design to prepare 18 identical pairs of PCs. One unit was stored unagitated and refrigerated after production on day 1 (cold-stored). The other unit was stored agitated at room temperature until day 5 and then refrigerated (delayed cold-stored). Samples were taken after pool-and-split on day 1 and on days 5, 7, 14 and 21. Swirling was observed and haematology parameters, metabolism, blood gas, platelet activation and platelet aggregation were analysed for each sample point. Results: All PCs complied with European recommendations (EDQM 20th edition). Both groups had mean platelet content >200 × 109/unit on day 21. The pH remained above 6.4 for all sample points. Glucose concentration was detectable in every cold-stored unit on day 21 and in every delayed cold-stored unit on day 14. The cold-stored group showed a higher activation level before stimulation as measured by flow cytometry. The activation levels were similar in the two groups after stimulation. Both groups had the ability to form aggregates after cold storage and until day 21. Conclusion: Our findings suggest that PCs from IPUs are suitable for cold storage from day 1 until day 21 and delayed cold storage from day 5 until day 14.publishedVersio

Effect of leukoreduction and temperature on risk of bacterial growth in CPDA-1 whole blood: A study of Escherichia coli

Background Collection of non-leukoreduced citrate-phosphate-dextrose-adenine (CPDA-1) whole blood is performed in walking blood banks. Blood collected under field conditions may have increased risk of bacterial contamination. This study was conducted to examine the effects of WBC reduction and storage temperature on growth of Escherichia coli (ATCC® 25922™) in CPDA-1 whole blood. Methods CPDA-1 whole blood of 450 ml from 10 group O donors was inoculated with E. coli. Two hours after inoculation, the test bags were leukoreduced with a platelet-sparing filter. The control bags remained unfiltered. Each whole blood bag was then split into three smaller bags for further storage at 2–6°C, 20–24°C, or 33–37°C. Bacterial growth was quantified immediately, 2 and 3 h after inoculation, on days 1, 3, 7, and 14 for all storage temperatures, and on days 21 and 35 for storage at 2–6°C. Results Whole blood was inoculated with a median of 19.5 (range 12.0–32.0) colony-forming units per ml (CFU/ml) E. coli. After leukoreduction, a median of 3.3 CFU/ml (range 0.0–33.3) E. coli remained. In the control arm, the WBCs phagocytized E. coli within 24 h at 20–24°C and 33–37°C in 9 of 10 bags. During storage at 2–6°C, a slow self-sterilization occurred over time with and without leukoreduction. Conclusions Storage at 20–24°C and 33–37°C for up to 24 h before leukoreduction reduces the risk of E. coli-contamination in CPDA-1 whole blood. Subsequent storage at 2–6°C will further reduce the growth of E. coli.publishedVersio

Livro didático público paranaense "lingua portuguesa e literatura" : o professor-autor e o gênero discursivo

Orientadora: Profa. Dra. Iara Bemquerer CostaAutor não autorizou a divulgação do arquivo digitalTese (doutorado) - Universidade Federal do Paraná, Setor de Ciências Humanas, Letras e Artes, Programa de Pós-Graduação em Letras. Defesa: Curitiba, 23/04/2012Bibliografia: fls. 163-178Área de concentração :Resumo: Esta pesquisa descritivo-explicativa tem como objetivo averiguar a relacao dialogica entre o Livro Didatico Publico Paranaense \Lingua Portuguesa e Literatura. (LDP-PR) e os livros representantes do genero discursivo Livro Didatico de Lingua Portuguesa (LD-LP). A partir de uma perspectiva socio-historico-discursiva e empregando fontes bibliografica e documental, desenvolvemos esta pesquisa em duas etapas. Na primeira, procuramos efetuar uma reflexao teorica sobre os Generos Discursivos (BAKHTIN) e sobre como a abordagem sociointeracionista se apropria desta concepcao bakhtiniana e discute a questao da didatizacao dos generos (SCHNEUWLY e DOLZ). Na segunda, aplicamos estes pressupostos ao LDP-PR com o intuito de averiguar o encaminhamento didatico dado aos textos de generos discursivos empregados neste material didatico. A partir desta averiguacao do conteudo tematico do LDP-PR, realizada pelo trabalho com as praticas de leitura, escrita e oralidade, buscamos sustentacao para a analise deste LD como um exemplar do genero LD-LP. Nossos resultados mostram que o LDP-PR inova na escolha do conteudo tematico, mas mantem o estilo (marcado pelo emprego de discursos injuntivos, explicativos e expositivos) e a construcao composicional (de textualidade multimodal) tipicos do genero LD-LP. Creditamos a autoria multipla (constituida por professores da rede escolar), marcada pela experiencia reduzida e a merce da Secretaria de Estado da Educacao do Parana (SEED-PR) este apego ao genero consolidado.Abstract: This descriptive-explanatory research aims to investigate the dialogic relationship between the Parana‘s Public Textbook "Portuguese and Literature" (LDP-PR) and the representative books of the discursive genre of Portuguese Textbook (LP-LD). From a socio-historic-discursive perspective and by the use of bibliographical and documentary sources, we developed this research in two stages. In the first one, we carried out a theoretical reflection about the Discursive Genres (BAKHTIN) and how the social interactionist approach appropriates this Bakhtinian concept and discusses the issue of making genre educational (SCHNEUWLY and DOLZ). In the second one, we applied these assumptions to the LDP-PR with the intent of investigating the educational directions given to the texts of discursive genres employed in such a teaching materials. From this investigation of the LDP-PR‘s thematic contents, performed through the work with reading, writing and speaking skills practices, we sought support for the analysis of this LD as an exemplar of the LD-LP genre. Our results reveal that the LDP-PR innovates the choice of the thematic content but retains the style (marked by the use of injunctive, explanatory and expository discourses) and compositional construction (multimodal textuality) that is typical of the LD-LP genre. We attribute to the multiple authorship (made up of teachers from the public educational system), marked by limited experience and at the mercy of the Parana‘s State Department of Education (SEED-PR), this attachment to the consolidated genre

The Norwegian blood preparedness project: A whole blood program including civilian walking blood banks for early treatment of patients with life-threatening bleeding in municipal health care services, ambulance services, and rural hospitals

Background Civilian and military guidelines recommend early balanced transfusion to patients with life-threatening bleeding to improve survival. To provide the best care to patients with hemorrhagic shock in regions with reduced access to evacuation, blood preparedness must be ensured also on a municipal health care level. The primary aim of the Norwegian Blood Preparedness project is to enable rural hospitals, prehospital ambulance services, and municipal health care services to start early balanced blood transfusions for patients with life-threatening bleeding regardless of etiology. Study Design and Methods The project is designed based on three principles: (1) Early balanced transfusion should be provided for patients with life-threatening bleeding, (2) Management of an emergency requires a planned and rehearsed day-to-day system for blood preparedness, and (3) A decentralized system is needed to ensure local self-sufficiency in an emergency. We developed a system for education and training in blood-based resuscitation with a focus on the municipal health care service. Results In this publication, we describe the implementation of emergency whole blood collections from a preplanned civilian walking blood bank in the municipal health care service. This includes donor selection, whole blood collection, emergency transfusion and quality assessment of practice. Conclusion We conclude that implementation of a Whole Blood based emergency transfusion program is feasible on all health care levels and that a preplanned civilian walking blood bank should be considered in locations were prolonged transport-times may reduce access to blood transfusion for patients with life threatening bleeding.publishedVersio

Prehospital Whole Blood Transfusion Programs in Norway

Background: Prehospital management of severe hemorrhage has evolved significantly in Norwegian medical emergency services in the last 10 years. Treatment algorithms for severe bleeding were previously focused on restoration of the blood volume by administration of crystalloids and colloids, but now the national trauma system guidelines recommend early balanced transfusion therapy according to remote damage control resuscitation principles. Materials and Methods: This survey describes the implementation, utilization, and experience of the use of low titer group O whole blood (LTOWB) and blood components in air ambulance services in Norway. Medical directors from all air ambulance bases in Norway as well as the blood banks that support LTOWB were invited to participate. Results: Medical directors from all 13 helicopter emergency medical services (HEMS) bases, the 7 search and rescue (SAR) helicopter bases, and the 4 blood banks that support HEMS with LTOWB responded to the survey. All HEMS and SAR helicopter services carry LTOWB or blood components. Four of 20 (20%) HEMS bases have implemented LTOWB. A majority of services (18/20, 90%) have a preference for LTOWB, primarily because LTOWB enables early balanced transfusion and has logistical benefits in time-critical emergencies and during prolonged evacuations. Conclusion: HEMS services and blood banks report favorable experiences in the implementation and utilization of LTOWB. Prehospital balanced blood transfusion using whole blood is feasible in Norway

Implementation of a low-titre whole blood transfusion program in a civilian helicopter emergency medical service

Background: Early balanced transfusion is associated with improved outcome in haemorrhagic shock patients. This study describes the implementation and evaluates the safety of a whole blood transfusion program in a civilian helicopter emergency medical service (HEMS). Methods: This prospective observational study was performed over a 5-year period at HEMS-Bergen, Norway. Patients in haemorrhagic shock receiving out of hospital transfusion of low-titre Group O whole blood (LTOWB) or other blood components were included. Two LTOWB units were produced weekly and rotated to the HEMS for forward storage. The primary endpoints were the number of patients transfused, mechanisms of injury/illness, adverse events and survival rates. Informed consent covered patient pathway from time of emergency interventions to last endpoint and subsequent data handling/storage. Results: The HEMS responded to 5124 patients. Seventy-two (1.4%) patients received transfusions. Twenty patients (28%) were excluded due to lack of consent (16) or not meeting the inclusion criteria (4). Of the 52 (100%) patients, 48 (92%) received LTOWB, nine (17%) received packed red blood cells (PRBC), and nine (17%) received freeze-dried plasma. Of the forty-six (88%) patients admitted alive to hospital, 35 (76%) received additional blood transfusions during the first 24 h. Categories were blunt trauma 30 (58%), penetrating trauma 7 (13%), and nontrauma 15 (29%). The majority (79%) were male, with a median age of 49 (IQR 27–70) years. No transfusion reactions, serious complications or logistical challenges were reported. Overall, 36 (69%) patients survived 24 h, and 28 (54%) survived 30 days. Conclusions: Implementing a whole blood transfusion program in civilian HEMS is feasible and safe and the logistics around out of hospital whole blood transfusions are manageable.publishedVersio