Transfusion: current and future challenges

Blood transfusion is an essential component of modern health services and its safety is still high on the agenda. A two-day symposium, ‘Transfusion 2012’ sponsored by Octapharma, aimed to address many of the current issues affecting blood services, both in the UK and overseas. The meeting, which is held every two years, brings together a wide range of expert speakers highlighting modern clinical transfusion practice and recent scientific developments, together with a review of current and future challenges for transfusion medicine. Setting the scene for the meeting Dr Archie Prentice, president of the Royal College of Pathologists, presented a whistle-stop tour of transfusion medicine history, including the early pioneering work of French physician Jean-Baptiste Denis in 1667, who famously infused the ‘blood of a gentle calf’ to a local man renowned for his violent behaviour and noted it had ‘a somewhat calming effect’. However, this success was short lived when his patient then experienced a great heat in his arms, followed by the passing of urine ‘as black as soot’, probably caused by the first ever haemolytic transfusion reaction. Moving on to the pioneering work of James Blundell, who performed the first successful human to human transfusions, Dr Prentice believed that this work had heralded the birth of blood transfusion therapy, an adventure which was still ongoing today and which is very much at the cutting edge of medicine.

Fuel to the Fire?

Major haemorrhage was the theme of the first session of ‘Transfusion 2012’, beginning with a presentation by Professor Walter Dzik, co-director of Massachusetts Blood Transfusion Service and renowned transfusion forwardthinker. Dealing particularly with the effects of major trauma, Prof. Dzik considered that trauma itself is a brutal, unexpected tragedy that spares no age group and which is a leading cause of death in those aged between 1 and 44 years. Examining some recent evidence of trauma survival in combat situations, Prof. Dzik believed that many mistakes had been made initially on how best to treat severe trauma, particularly in the use of high ratios of fresh frozen plasma (FFP) in relation to units of red cells transfused. ‘Does FFP improve survival or does survival only buy enough time to give the FFP’ was the intriguing question he posed. He eventually concluded that in his opinion, even though the military experience seemed to suggest otherwise, there was no significant benefit in giving high ratios of FFP and that it may even be detrimental, as it could be adding fuel to the flames in terms of its effect on the coagulation status of the patient. Another way of combating major haemorrhage in trauma namely the early deployment of tranexamic acid (TXA), was achieving some remarkable clinical trials results, as outlined by the next speaker, Professor Beverley Hunt, from Guys & St Thomas’ Hospital. Massive changes have occurred over recent years in how blood and blood products are used in major trauma to improve patient survival as a result of clinical trials. Prof. Hunt presented the latest findings of the ‘CRASH-2’ study, which was already yielding some important findings. CRASH-2 was a randomised controlled trial undertaken in 274 hospitals in 40 countries and included some 20,000 adult trauma cases. TXA was randomly assigned to patients within eight hours of injury and the results were impressive. Not only had the early use of TXA safely reduced the risk of death from bleeding but also had no adverse effects on patients and was relatively inexpensive to administer. The study concluded that TXA should be given as early as possible to bleeding trauma patients and that if this was implemented, it had the potential to save 120,000 lives globally every year – for example, in roadside trauma cases being administered by paramedics. Prof. Hunt was keen to stress, however, that the use of TXA would not reduce the use of blood in trauma cases, as those patients who did survive would very probably require later transfusions, adding that further work was already underway in the shape of CRASH-3, which was looking at the use of TXA in traumatic brain injury cases.