BACKGROUND The objective of this study was to assess transfusion strategies and outcomes, stratified by the combat mortality index, of casualties treated by small surgical teams in Afghanistan. Resuscitation that included warm fresh whole blood (FWB) was compared to blood component resuscitation. STUDY DESIGN AND METHODS Casualties treated by a Role 2 surgical team in Afghanistan from 2008 to 2014 who received 1 or more units of red blood cells (RBCs) or FWB were included. Patients were excluded if they had incomplete data or length of stay less than 30 minutes. Patients were separated into two groups: 1) received FWB and 2) did not receive FWB; moreover, both groups potentially received plasma, RBCs, and platelets. The analysis was stratified by critically versus noncritically injured patients using the prehospital combat mortality index. Kaplan‐Meier plot, log‐rank test, and multivariable Cox regression were performed to compare survival. RESULTS In FWB patients, median units of FWB and total blood product were 4.0 (interquartile range [IQR], 2.0‐7.0) and 16.0 (IQR, 10.0‐28.0), respectively. The Kaplan‐Meier plot demonstrated that survival was similar between FWB (79.1%) and no‐FWB (74.5%) groups (p = 0.46); after stratifying patients by the combat mortality index, the risk of mortality was increased in the no‐FWB group (hazard ratio, 2.8; 95% confidence interval, 1.2‐6.4) compared to the FWB cohort. CONCLUSION In forward‐deployed environments, where component products are limited, FWB has logistical advantages and was associated with reduced mortality in casualties with a critical combat mortality index. Additional analysis is needed to determine if these effects of FWB are appreciable in all trauma patients or just in those with severe physiologic derangement.

The purpose of this study was to determine whether systemic inflammatory response syndrome (SIRS) and American Burn Association (ABA) criteria predict sepsis in the burn patient and develop a model representing the best combination of novel clinical sepsis predictors. A retrospective, case-controlled, within-patient comparison of burn patients admitted to a single intensive care unit from January 2005 to September 2010 was made. Blood culture results were paired with documented sepsis: positive-sick, negative-sick (collectively defined as sick), and negative-not sick. Data for all predictors were collected for the 72 hours before blood culture. Variables were evaluated using regression and area under the curve (AUC) analyses. Fifty-nine subjects represented 177 culture periods. SIRS criteria were not discriminative: 98% of the subjects met criteria. ABA sepsis criteria were different on the day before (P = .004). The six best-fit variables identified for the model included heart rate > 130 beats per min, mean arterial pressure < 60 mm Hg, base deficit < -6 mEq/L, temperature < 36°C, use of vasoactive medications, and glucose > 150 mg/dl. The model was significant in predicting positive-sick and sick, with an AUC of 0.775 (P < .001) and 0.714 (P < .001), respectively; comparatively, the ABA criteria AUC was 0.619 (P = .028) and 0.597 (P = .035), respectively. Usefulness of the ABA criteria to predict sepsis is limited to the day before blood culture is obtained. A significant contribution of this research is the identification of six novel sepsis predictors for the burn patient.

Background: Death from uncontrolled hemorrhage occurs rapidly, particularly among combat casualties. The US military has used warm fresh whole blood during combat operations owing to clinical and operational exigencies, but published outcomes data are limited. We compared early mortality between casualties who received warm fresh whole blood versus no warm fresh whole blood. Methods: Casualties injured in Afghanistan from 2008 to 2014 who received 2 red blood cell containing units were reviewed using records from the Joint Trauma System Role 2 Database. The primary outcome was 6-hour mortality. Patients who received red blood cells solely from component therapy were categorized as the nonewarm fresh whole blood group. None warm fresh whole blood patients were frequency-matched to warm fresh whole blood patients on identical strata by injury type, patient affiliation, tourniquet use, prehospital transfusion, and average hourly unit red blood cell transfusion rates, creating clinically unique strata. Multilevel mixed effects logistic regression adjusted for the matching, immortal time bias, and other covariates. Results: The 1,105 study patients (221 warm fresh whole blood, 884 nonewarm fresh whole blood) were classified into 29 unique clinical strata. The adjusted odds ratio of 6-hour mortality was 0.27 (95% confidence interval 0.13e0.58) for the warm fresh whole blood versus nonewarm fresh whole blood group. The reduction in mortality increased in magnitude (odds ratio ¼ 0.15, P ¼ .024) among the subgroup of 422 patients with complete data allowing adjustment for seven additional covariates. There was a dose-dependent effect of warm fresh whole blood, with patients receiving higher warm fresh whole blood dose (>33% of red blood cellecontaining units) having significantly lower mortality versus the nonewarm fresh whole blood group. Conclusion: Warm fresh whole blood resuscitation was associated with a significant reduction in 6-hour mortality versus nonewarm fresh whole blood in combat casualties, with a dose-dependent effect. These findings support warm fresh whole blood use for hemorrhage control as well as expanded study in military and civilian trauma settings.