The Reports of my Death are Greatly Exaggerated: An Evaluation of Futility Cut-Points in Massive Transfusion.

BACKGROUND: Following COVID and the subsequent blood shortage, several investigators evaluated futility cut-points in massive transfusion. We hypothesized that early, aggressive use of damage control resuscitation, including whole blood (WB), would demonstrate that these cut-points of futility were significantly underestimating potential survival among patients receiving >50 units of blood in the first four hours. METHODS: Adult trauma patients admitted from 11/2017-10/2021 who received emergency-release blood products in prehospital or ED setting were included. Deaths within 30 min of arrival were excluded. Total blood products were defined as total RBC, plasma, WB in the field and in the first 4 hours after arrival. Patients were first divided into those receiving ≤50 or > 50 units of blood in the first 4 hours. We then evaluated patients by whether they received any WB or received only component therapy (COMP). 30-day survival was evaluated for all included patients. RESULTS: 2,299 patients met inclusion (2,043 in ≤50 U, 256 in >50 U groups). While there were no differences in age or gender, the >50 U group was more likley to sustain penetrating injury (47 vs 30%, p < 0.05). Patients receiving >50 U of blood had lower field and arrival blood pressure and larger prehospital and ED resuscitation volumes (p < 0.05). Patients in the >50 U group had lower survival than those in the ≤50 cohort (31 vs 79%; p < 0.05). Patients who received WB (n = 1,291) had 43% increased odds of survival compared to those who received COMP (n = 1,008)(1.09-1.87, p = 0.009) as well as higher 30-day survival at transfusion volumes >50 U. CONCLUSION: Patient survival rates in patients receiving >50 units of blood in the first 4 hours of care are as high as 50-60%, with survival still at 15-25% after 100 units. While responsible blood stewardship is critical, futility should not be declared based on high transfusion volumes alone. LEVEL OF EVIDENCE: Level III, Retrospective comparative study without negative criteria.

Perforated Appendicitis: An Unintended Consequence During the Coronavirus-19 Pandemic.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic has had major clinical impact across the globe. Delayed presentation for medical emergencies has been noted by the medical community. There has been limited reporting on the impact for the care for emergent surgical conditions. We sought to describe the effect of the global pandemic on the presentation and outcomes for the most common urgent general surgery disease process, acute appendicitis. METHODS: We performed a retrospective review of patients admitted to the United States Naval Hospital Okinawa during the COVID-19 pandemic, from January 2020 to May 2020 (COVID cohort), and compared them to a historical cohort (pre-COVID cohort) over the prior 2 years. Demographics, clinical presentation data, and interventions were collected. RESULTS: Of the 80 patients with appendicitis, 20% presented perforated. Most patients were male (71%), presented with 1 day of symptoms and had a length of stay of 1 to 2 days. Comparing groups, 13% of the pre-COVID group vs. 31% of the COVID cohort presented perforated (P = .04), with a symptom duration of 1.6 vs. 2.7 days before presentation (P = .075), respectively. CONCLUSIONS: The COVID-19 pandemic and the global systematic response has impacted unrelated medical and surgical conditions. At our overseas military hospital with minimal disease burden, we observed a delay in presentation for acute appendicitis with a higher incidence of perforation. Patients should be empowered to continue to seek care for urgent and emergent medical and surgical conditions so that they are not harmed by fear of COVID-19 rather than by COVID-19 itself.

Transpacific Aeromedical Evacuation for a Ruptured Brain Arteriovenous Malformation During the COVID-19 Pandemic.

The COVID-19 pandemic has altered preexisting patient treatment algorithms and referral patterns, which has affected neurosurgical care worldwide. Brain arteriovenous malformations are complex vascular lesions that frequently present with intracerebral hemorrhage. Care for these patients is best performed at large medical centers by specialists with high volumes. The authors describe the care of a patient who presented in extremis to a resource-limited, community-sized military treatment facility (MTF) in Southeast Asia. In the MTF, the patient underwent emergent neurosurgical therapy. However, given newly implemented restrictions enacted to mitigate COVID-19 spread, local transfer for definitive care to a tertiary care facility was not possible. In order to attain definitive care for the patient, a transpacific aeromedical evacuation augmented with a critical care air transport team was utilized for transfer to a tertiary care, teaching hospital. This case demonstrates the safe treatment of a patient with hemorrhagic arteriovenous malformations and postoperative management under limited conditions in an MTF outside the CONUS. Given the unique circumstances and challenges the pandemic presented, the authors feel that this patient's outcome was only possible by leveraging all the capability military medicine has to offer.