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Emergency sternal intraosseous access for warm fresh whole blood transfusion in damage control resuscitation
Christopher Kalhagen Bjerkvig1, Theodor Kaurin Fosse, Torunn Oveland Apelseth
1From the Department of Anaesthesia and Intensive Care (C.K.B., T.F., A.B.G.), Haukeland University Hospital, Bergen; Norwegian Navy Special Operations Commando (C.K.B., T.F., H.S.E., G.S.); Department of Immunology and Transfusion Medicine (T.O.P., J.S., H.B., H.S.E., G.S.), Haukeland University Hospital, Bergen, Norway; Coagulation and Blood Research (A.P.C.), US Army Institute of Surgical Research, JBSA Fort Sam Houston, Texas; Department of War Surgery and Emergency Medicine (G.S.), Norwegian Armed Forces Medical Services, Oslo, Norway. Clinical Institute 1, University of Bergen, Bergen Norway (C.K.B., T.K.F., A.B.G.).
Background:
Intraosseous (IO) vascular access is increasingly used as an emergency tool for achieving access to the systemic circulation in critically ill patients. The role of IO transfusion of blood in damage control resuscitation is however questionable due to possible inadequate flow rate and hemolysis. Some experts claim that IO transfusion is contraindicated. In this study, we have challenged this statement by looking at flow rates of autologous fresh whole blood reinfusion and hemolysis using two of the commonly used Food and Drug Administration-approved and Conformité Européenne (CE)-marked sternal needles. Additionally, the success rate of sternal access between the two devices is evaluated.
Methods:
Volunteer professional military personnel, were enrolled prospectively in a nonrandomized observational study design. We collected 450 mL of autologous whole blood from each participant. Participants were divided into the following three groups of 10: Tactically Advanced Lifesaving IO Needle (T.A.L.O.N.) IO, FAST1 IO, and intravenous group. The reinfusion was done by gravity only. Blood sampling was performed before blood collection and 30 minutes after reinfusion. Investigation of hemolysis was performed by measurements of haptoglobin and lactate dehydrogenase. Success rate was evaluated by correct aspiration of bone marrow.
Results:
Median reinfusion rate was 46.2 mL/min in the FAST1 group, 32.4 mL/min in the T.A.L.O.N. group, and 74.1 mL/min in the intravenous group. Blood samples from all participants were within normal ranges. There was no statistically significant difference in haptoglobin and lactate dehydrogenase between the groups. In the FAST1 group, 1 (9%) of 11 procedures failed. In the T.A.L.O.N. group, 4 (29%) of 14 procedures failed.
Conclusion:
Although preferable, achieving peripheral venous access in the bleeding patient is a major problem. Our findings suggest that fresh whole-blood transfusion through the IO route is safe, reliable, and provide sufficient flow for resuscitation.
Level Of Evidence:
Therapeutic/Care management study, level III.
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