Aspects of Transfusion Medicine

Author: David Roxby

Roxby, David, 2018 Aspects of Transfusion Medicine, Flinders University, College of Medicine and Public Health

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My thesis is based upon twelve of my recently published works (1-12) and focuses on four areas of Transfusion Medicine: development of a non-electrically powered intravenous fluid/blood warmer , the effect of age of transfused red cells on patient mortality (2-5), critical bleeding and massive transfusion (6-11), and use of rotational viscoelastometric testing (ROTEM) to identify patients with sepsis at risk of developing multi-organ failure (12). Development of a novel portable non-electrically powered intravenous fluid/blood warmer has the potential to provide significant benefits for the prevention of hypothermia in non-hospital settings in critically injured patients. In vitro studies of our patented prototype has proved successful in warming up to four units of red cells from 2-6ºC to 35-37ºC (1) and an in vivo clinical trial is nearing completion. The INFORM randomised controlled trial (RCT), the largest of its kind and associated subsequent meta-analysis of other RCTs are pivotal pieces of research that have provided substantial critical evidence that the age of transfused red cells has no effect on patient mortality (2-5). This provides a benchmark for standard of care in the management of blood banking and of patients requiring transfusion. Our on-going observational studies of transfusion practice in critical bleeding situations, introduction of a standardised massive transfusion response and ROTEM has seen changes in clinical practice and more appropriate use of different blood products at Flinders Medical Centre (6-11) during massive transfusions. Severe sepsis and associated decreased fibrinolysis are major causes of multi-organ failure and mortality. Currently there are a limited number of routine diagnostic tests that are useful in identifying septic patients at risk of developing multi-organ failure. ROTEM was clinically evaluated to determine its efficacy in identifying patients at increased risk of sepsis related multi-organ failure. The results clearly showed a significant inverse relationship with fibrinolysis and the degree of sepsis and associated severity of organ failure (12). My publications are either based on novel developmental work or prospective studies, while others are centred upon retrospective and observational studies. Observational studies and RCTs both have strengths and limitations; observational studies are often seen to have limitations that are mostly avoided by RCTs (13). However, observational studies may permit for example investigation of incidence, causes, and outcomes which could not be achieved through a RCT. Mann (14) argued that ‘qualitative studies can produce high quality information but all such studies can be influenced by known and unknown confounders’. Several articles do not support the claim that observational studies are inferior to RCTs (15, 16). According to Trentino et al (13) ‘the view that dismissing observational studies play no role in establishing causality is invalid’ especially in Transfusion Medicine when it is impossible, unethical or logistically impossible to undertake RCTs. The body of work covered by this thesis demonstrates how blood transfusion related research and critical evaluation of practices influences patient management and long-term outcomes.

Keywords: transfusion, age of blood, massive transfusion, critical bleeding
Subject: Medicine thesis

Thesis type: Doctor of Philosophy
Completed: 2018
School: College of Medicine and Public Health
Supervisor: A/Prof Bryone Kuss