Bringing Packed Red Blood Cells to the Point of Combat Injury: Are We There Yet?Aytekin Ünlü1, Soner Yılmaz2, Özlem Yalçın3, Metin Uyanık4, Patrizio Petrone5, Rıza Aytaç Çetinkaya6, İbrahim Eker7, Murat Urkan1, Taner Özgürtaş8, İsmail Yaşar Avcı9, Nazif Zeybek1, Ali Cenk Aksu31University of Health Sciences, Gülhane Training and Research Hospital, Clinic of General Surgery, Ankara, Turkey
2University of Health Sciences, Gülhane Training and Research Hospital, Regional Blood and Training Center, Ankara, Turkey
3Koç University Faculty of Medicine, Laboratory of Hemorheology, Hemodynamics, and Vascular Biology, İstanbul, Turkey
4Çorlu State Hospital, Clinic of Biochemistry, Tekirdağ, Turkey
5NYU Winthrop Hospital, Clinic of Surgery, Mineola; New York Medical College, Valhalla, New York, USA; University of Las Palmas de Gran Canaria, Canary Islands, Spain
6University of Health Sciences, Sultan Abdulhamid Han Training and Research Hospital, Clinic of Infectious Diseases, İstanbul, Turkey
7Afyon Kocatepe University Faculty of Medicine, Department of Pediatric Hematology, Afyonkarahisar, Turkey
8University of Health Sciences, Gülhane Training and Research Hospital, Clinic of Biochemistry, Ankara, Turkey
9University of Health Sciences, Gülhane Training and Research Hospital, Clinic of Infectious Diseases and Clinical Microbiology, Ankara, Turkey
Objective: Hemorrhage is the leading cause of injury-related prehospital mortality. We investigated worst-case scenarios and possible requirements of the Turkish military. As we plan to use blood resources during casualty transport, the impact of transport-related mechanical stress on packed red blood cells (PRBCs) was analyzed.
Materials and Methods: The in vitro experiment was performed in the environmental test laboratories of ASELSAN®. Operational vibrations of potential casualty transport mediums such as Sikorsky helicopters, Kirpi® armored vehicles, and the NATO vibration standard MIL-STD- 810G software program were recorded. The most powerful mechanical stress, which was created by the NATO standard, was applied to 15 units of fresh (≤7 days) and 10 units of old (>7 days) PRBCs in a blood cooler box. The vibrations were simulated with a TDS v895 Medium- Force Shaker Device. On-site blood samples were analyzed at 0, 6, and 24 h for biochemical and biomechanical analyses.
Results: The mean (±standard deviation) age of fresh and old PRBCs was 4.9±2.2 and 32.8±11.8 days, respectively. Six-hour mechanical damage of fresh PRBCs was demonstrated by increased erythrocyte fragmentation rates (p=0.015), hemolysis rates (p=0.003), and supernatant potassium levels (p=0.003) and decreased hematocrit levels (p=0.015). Old PRBC hemolysis rates (p=0.015), supernatant potassium levels (p=0.015), and supernatant hemoglobin (p=0.015) were increased and hematocrit levels were decreased (p=0.015) within 6 h. Two (13%) units of fresh PRBCs and none of the old PRBCs were eligible for transfusion after 6 h of mechanical stress.
Conclusion: When an austere combat environment was simulated for 24 h, fresh and old PRBC hemolysis rates were above the quality criteria. Currently, the technology to overcome this mechanical damage does not seem to exist. In light of the above data, a new national project is being performed.
Keywords: Combat trauma, Blood transport, Prehospital transfusion, Hemolysis
Eritrosit Konsantrelerini Yaralanma Noktasına Götürmek: O Noktaya Ulaşabildik mi?Aytekin Ünlü1, Soner Yılmaz2, Özlem Yalçın3, Metin Uyanık4, Patrizio Petrone5, Rıza Aytaç Çetinkaya6, İbrahim Eker7, Murat Urkan1, Taner Özgürtaş8, İsmail Yaşar Avcı9, Nazif Zeybek1, Ali Cenk Aksu31University of Health Sciences, Gülhane Training and Research Hospital, Clinic of General Surgery, Ankara, Turkey
2University of Health Sciences, Gülhane Training and Research Hospital, Regional Blood and Training Center, Ankara, Turkey
3Koç University Faculty of Medicine, Laboratory of Hemorheology, Hemodynamics, and Vascular Biology, İstanbul, Turkey
4Çorlu State Hospital, Clinic of Biochemistry, Tekirdağ, Turkey
5NYU Winthrop Hospital, Clinic of Surgery, Mineola; New York Medical College, Valhalla, New York, USA; University of Las Palmas de Gran Canaria, Canary Islands, Spain
6University of Health Sciences, Sultan Abdulhamid Han Training and Research Hospital, Clinic of Infectious Diseases, İstanbul, Turkey
7Afyon Kocatepe University Faculty of Medicine, Department of Pediatric Hematology, Afyonkarahisar, Turkey
8University of Health Sciences, Gülhane Training and Research Hospital, Clinic of Biochemistry, Ankara, Turkey
9University of Health Sciences, Gülhane Training and Research Hospital, Clinic of Infectious Diseases and Clinical Microbiology, Ankara, Turkey
Amaç: Kan kayıpları, hastane öncesi dönemdeki yaralanmalara bağlı ölümlerin en sık sebebidir. Türk ordusu için en kötü senaryoları ve olası ihtiyaçları araştırdık. Çatışma alanından nakil esnasında kan kaynaklarını kullanmayı planladığımız için nakil işleminden kaynaklı mekanik stresin eritrosit konsantreleri üzerine etkisini analiz edilmiştir.
Gereç ve Yöntem: İn vitro çalışmalar ASELSAN®’ın dış ortam test laboratuvarlarında gerçekleştirildi. Çatışma alanında kan taşıma işleminde kullanılması muhtemel olan Sikorsky helikopteri ve Kirpi® araçlarının operasyonel vibrasyonları ve NATO MIL-STD-810G titreşim standart yazılımı kayıt altına alındı. NATO standardının en güçlü titreşime neden olduğu hesaplandı. Kan saklama çantası içindeki 15 ünite taze (≤7 gün) ve 10 ünite taze olmayan eritrosit konsantresi (>7 gün), NATO standardı olan mekanik strese maruz bırakıldı. Titreşim TDS v895 Medium-Force Shaker cihazı tarafından simüle edildi. Simülasyonun 0., 6. ve 24. saatinde biyokimyasal ve biyomekanik analiz için kan örnekleri alındı.
Bulgular: Taze ve taze olmayan eritrosit konsantreleri sırasıyla ortalama 4,9 [standart deviasyon (SD) ±2,2] ve 32,8 (SD ±11,8) günlüktü. Taze eritrosit konsantrelerinde 6. saatte gelişen mekanik hasar; artmış eritrosit fragmentasyonu (p=0,015), hemoliz oranı (p=0,003) ve supernatant potasyum (p=0,015) düzeyleri ile gösterildi. Taze olmayan eritrosit konsantrelerinin 6. saatte hemoliz oranı (p=0,015) ve supernatant potasyum düzeyi (p=0,015) yükselirken, hematokrit değerleri (p=0,015) düştü. İlk 6 saat içerisinde taze eritrosit konsantrelerinin 2’si (%13) transfüze edilebilir kalitede kalırken, taze olmayanların ise hiçbirisi uygun değildi.
Sonuç: Taze ve taze olmayan eritrosit konsantrelerinin hemoliz oranları, bu ürünleri muharebe sahasında taşıdığımızda, çoğunun kullanılamaz hale geleceğini göstermektedir. Halihazırda eritrositler üzerinde oluşan mekanik hasarlanmanın önüne geçebilecek bir teknoloji bulunmamaktadır. Yukarıdaki verilerin ışığı altında yeni bir ulusal proje gerçekleştirilmektedir.
Anahtar Kelimeler: Harp yaralanmaları, Kan taşınması, Hastane öncesi transfüzyon, Hemoliz
Aytekin Ünlü, Soner Yılmaz, Özlem Yalçın, Metin Uyanık, Patrizio Petrone, Rıza Aytaç Çetinkaya, İbrahim Eker, Murat Urkan, Taner Özgürtaş, İsmail Yaşar Avcı, Nazif Zeybek, Ali Cenk Aksu. Bringing Packed Red Blood Cells to the Point of Combat Injury: Are We There Yet?. Turk J Hematol. 2018; 35(3): 185-191
Corresponding Author: Soner Yılmaz, Türkiye |
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