An estimation of the burden of blood transfusion need and viability of red blood cells in the emergency medical services

Abstract

Background: Haemorrhagic shock patients are at risk of death, disseminated intravascular coagulation, hypoxic brain injury, global myocardial ischaemia and this risk is heightened among the young, old, or polytraumatised. The recommended definitive care is to stop the bleeding and to replace lost haemoglobin whilst providing supplemental oxygenation. Despite blood transfusion being a standard treatment of care for severe haemorrhagic shock, it is not used as a standard practice in the pre-hospital setting in South Africa. This could be due to a paucity in South African research regarding pre-hospital emergency blood transfusion (EBT), as many factors were to be considered. Objective: This research study in the Western Cape, South Africa, determined the viability of packed red blood cells in the pre-hospital setting by placing blood on ambulance vehicles, this study also determined the self-efficacy of emergency care practitioners (ECP) to administer an EBT and lastly, estimated the burden of need for EBT in the pre-hospital setting. Methods: The viability of Packed Red Blood Cells (PRBC) was determined by placing the blood in temperature-controlled fridges at the ambulance base as a Control, and the Treatment PRBC were transported. PRBC were transported in a cooler-box with ice-packs, and the cold-chain was monitored against the recommended transportation temperature range 1˚C – 10˚C. The PRBC were tested weekly for haemolysis. Questionnaires were given to EMS personnel to determine their self-efficacy about introducing blood as a resuscitation fluid. The estimation of the EBT need in the pre-hospital setting was done over a 2-month period by the advanced life support (ALS) ECP. This included patients who with penetrating injuries, displaying signs and symptoms of shock - class III or class IV (decompensated/irreversible). Results: The PRBC that were placed on ambulance vehicles indicated that they were <0.8% threshold after day 35. However several packs in the treatment group were ≥0.8% on day 42, while all packs in the control group were <0.8% on day 42. PRBC transported remained between 1˚C – 10˚C, although slight fluctuations. Questionnaire results indicated that ECP were confident in administering an EBT if required. A total of 12.8% of patients within the criteria used in this study was found, that could have been eligible for EBT. Conclusion: The viability of blood on ambulance vehicles remained within the acceptable ≤0.8% haemolysis level until the PRBC expiry on day 42, as per the Council of Europe Guidelines. PRBC were able to remain within the transportation temperature range according to the Clinical Guidelines of South Africa. The self-efficacy questionnaires given to ECP displayed confidence levels in their ability to administer blood, provided training is received. A significant percentage of 12.8% of patients could have made use of ERBC in the prehospital field, as ECP would have had the ability to bridge the time critical gap of a life-threatening probable mortality, before reaching the emergency department where blood would be administered We recommend that pre-hospital emergency blood transfusion be adopted as a standard practice in South Africa.