I don't subscribe to any of those high-risk behaviors. I'm too lazy. So I was like, no problem there. So good morning. Thank you for inviting me here today. And the first thing I should say is, so we were actually known as United Blood Services for many, many years in the Valley here. We changed our name last year in September to Vitalant. I know most people say, think it's Vitalant, but I guess it's my duty to make sure that we get the right name pronunciation out there. So today I'm just gonna be talking about blood products and how those products can be utilized in master transfusion with their trauma patients. A lot of this is, I'm sure, very familiar to you. Hopefully I'll be able to provide some tidbits that's a little more interesting. Okay, so where's my advance? Oh, the big button, got it, okay. So information about me, that's okay. Since I only have 20 minutes, I think, I'm gonna do sort of an abridged version. So we'll talk about clinical applications of blood components. I'm gonna focus on the three most commonly used type, red cell, plasma, and platelet, because obviously cryoprecipitate is also being utilized in an adjunctive fashion sometimes, right? But I'm not gonna talk about that today. The next thing I'm gonna talk about is when to utilize OPAS versus O negative red cells. That is really near and dear to most blood bankers' heart because O negative RBCs are considered the most universal red blood cell type. And because of that, there's always a higher demand and supply is an issue. Then the next thing, we'll identify some new trends in blood component support for mass transfusion. And then lastly, I'll just take a quick look at some of the information that came out in the Las Vegas shooting regarding blood product usage. So this slide is very familiar to all of you here. This is just to set the context to tell you that for the lethal trial, associated trauma, you have very good means of mitigating the first two things, hypothermia and acidosis. But when it comes to coagulopathy, you are really relying on what we do, which is providing you with plasma-containing blood products to replenish the lost coagulation factors. There's also other things you can use, things like PCC, so pharmacologic kind of components that contain coagulation factors, but the most commonly used will still be plasma. So obviously, there's two types of coagulopathy associated with trauma. So there's acute, which happens very early on in about 25% of the patients. And so in these patients, when they develop this type of acute coagulopathy of trauma, there's actually a fourfold increase in mortality. So if you were to take these patients and you don't give them plasma-containing blood components in the very early phases, they're already at risk for significant morbidity and mortality, and then you take them to the next phase, where they start to get a lot of red cells or a lot of crystalloid fluids, where they get even more diluted. This just creates that vicious cycle. So that's still a reason why plasma has sort of become the darling right now in master transfusion and in trauma, because we know that with early infusion of plasma, you can actually prevent or stop some of these coagulopathies from occurring. So I'm gonna start with red cell. So red cell, whether it's in the setting of trauma or any other medical setting, the transfusion indication is truly for restoring the oxygen-carrying capacity. We really shouldn't be using it to restore volume. However, in this particular patient cohort, they're losing volume. So you're giving them oxygen-carrying capacity, and at the same time, you're giving them the volume back in an isotonic fashion, so it's kind of an added bonus. But outside of this setting, we really should not be giving red cell just to replenish volume. Most RBCs are collected and stored in additive solution. So there's a whole host of different anticoagulants and preservatives, and depending on what we use, the lifespan of that particular component varies. So we like to add additive solution because it gives us the longest shelf life of 42 days, and that really helps with inventory management and minimizing expiration and waste. So the effect of those, as you can see here, it's about four mil per kilogram, will lead to the rise of about one gram hemoglobin in an average adult. This, obviously, is calculated in a person who's not actively bleeding. So in your patient population, this goes out of the window. You're gonna have to use your clinical acumen and obviously some of your point-of-care testing to help you assess how the patient's doing and determine whether or not they need more red cell transfusions. This slide just summarizes some of the publications and studies that have been conducted in the last 10-plus years. It is really just to make the point that, once again, the main reason why we transfuse plasma for your patient population is to replenish the coagulation factors that's been lost during the bleeding episode. Okay, so the more plasma, the earlier you give, compared to red cells, that ratio, they tend to have better outcome. And then when you look on the flip side, which is what we were doing for probably 20, 30 years, 10 years ago, which is giving people a lot of crystalloid fluids to just bring the volume back up, well, when you look at that, the more crystalloid fluids you give as a ratio to red cell, they tend to do worse. So the other interesting thing about plasma is that there are actually some animal studies that have demonstrated some ability of plasma to restore and repair the endothelium that's been damaged. Exactly what those factors are, we don't know yet. So that's yet to be determined. But I do feel like there's something more to plasma than just the coagulation factor. And you know, there are some people who actually believe in some regenerative power of plasma, or even now people are using it to conduct some studies in patients who have Alzheimer's disease to see whether they can gain some of the cognitive skills back. So most plasma components that you are utilizing right now actually were collected as a liquid component and then frozen and then thawed upon demand. The main reason why we do that, it's because we can thaw plasma and keep it in the refrigerator for actually upwards of 10 years, depending on the storage condition. But in most setting, it's a one year storage period. So as you can see, we can stockpile plasma so that way we can have plenty of it. So usually plasma is not an issue when it comes to your need, right? Your blood bank generally don't call you and say, we don't have plasma. They'll say, you know what, we're running out of platelets, we're running out of red cell, but not plasma. It's because we can't keep it frozen. And then they'll thaw on demand. This is the interesting thing. Depending on how you label the thawed plasma, it's either good for 24 hours or five days. I'm hoping that most of your transfusion service at the hospital is converting them into five days because when you look at the in vitro activity, there's no difference. And in all the experience we have seen in clinical use, there's no difference. So the only difference is whether you have the comfort level and whether you do the conversion, the labeling. And then there's actually a type of plasma that's called liquid plasma, which is plasma that's collected in the liquid state and stored the entire period in the liquid state in the refrigerated environment. I'll talk a little more about that in a little bit. So we always focus on type O red cell as being the universal blood type. And that's because on O red cells, it lacks A and B antigens. So that means that when you transfuse these red cells to patients of any blood type, those red cells will not be attacked by the anti-A or anti-B substance in the patient. So when we look at plasma, it's just the flip of that. So for plasma, AB people are considered the universal donor. And the reason is because these people have A and B substance on the red cells, which means that their immune system will see that as native, and they will not form these naturally occurring anti-A and anti-B isoagglutinants. So that means that their plasma is essentially just full of coagulation factors, no anti-A, anti-B, and that can be transfused to anyone. So because it's the universal plasma type, it is the most desirable blood type for plasma. However, just as when we talk about type O, especially type O negative red cell, the supply demand is an issue. There is a huge imbalance. As you can see, the AB donor pool, it's only about 4% of the population. And you can see the request for distribution can be as high as 25%. So that large discrepancy is where the blood centers are having a hard time with right now. And that's why you'll see that I'm gonna be talking about the transition to maybe looking at alternative plasma type, which is type VIII. And we believe type VIII plasma can be safely transfused to as the initial resuscitative plasma. So I should make a very clear point. I'm not saying that you should use type VIII plasma for all your patients, for the entirety of the resuscitation. You should be using it at the very beginning when you do not know their ABO blood type, okay? So the reason why this is a safe alternative is because when you look at population statistic and the distribution, you'll realize most of the patients that are coming in just by chance are gonna be either type A or type O. So both of those patient type will be safe because they don't bear the B antigen on the red cells. So the only patients at risk will be your AB and your B patient. And that consists about 15% of the patient population. So in medicine, ideally, if we could get to zero risk, we always do. But reality is that sometimes you have to kind of take the balance of what you have and what kind of outcome you're trying to achieve. So about 15% of the patient may be at risk, but not every single patient who gets a plasma incompatible unit will experience a hemolytic transfusion reaction. So in 2015, there was a survey that was done looking at level one trauma centers, see what their comfort level is. And sure enough, actually, a lot of people started to convert, about 80%. They were keeping type A plasma as their initial resuscitated plasma. So for those of you out there that are either considering or are still a little hesitant about converting from AB plasma to type A plasma as your initial resuscitated plasma, I wanna show you two studies. So these are two studies that were conducted at level one trauma centers. In combination, they had about 600 patients, and these are all trauma patients. And at the time that they transfused them, they did not know the ABO blood type. So it was initial resuscitative plasma transfusion. And as you can see, there was zero report of hemolytic transfusion reaction. So that's very reassuring. And then the other caveat that I should point out is that neither of these centers took the extra effort to do any titering. So what we can do is we can take a unit plasma and we can titer to see how concentrated or how much anti-B there is in that particular unit. That's something you can do, but it's very time intensive, labor intensive. And to me, the benefit that you get, I don't really think justifies that, especially since these studies have demonstrated that. And in my personal experience, a lot of my trauma centers have converted to that, and I have yet to hear any hemolytic transfusion reaction coming from this. So the last thing is platelet. So platelet transfusion either could be for prevention of bleeding, which is obviously not in this scenario. For your patients who are actively bleeding, which means that they're losing platelet, they don't have enough platelets. And also because of the hypothermia, they're gonna have some platelet abnormality, they're not gonna be functioning as well. So with that combination, that's why you need platelet to be transfused, especially since platelets really play the critical factor in the entire hemostatic potential of the patient. So the other added bonus about platelets that most of the platelet is suspended in plasma. So now you're also getting some additional plasma being infused to the patient, right? So you're minimizing the dilution of coagulopathy at the same time. All right. So now we're gonna talk about when to use OPAS versus O-NIG red cells in an emergency situation. So overall in the US, about six to 7% of donors are O-NIG. So when we think about just type O people in general, it's the most common blood type. But when you go and look at, well, within that you subcategorize it to see how many of those O donors are actually O-negative. That's when you look at, when you see this statistics of six to seven, you see this statistics of six to 7%. It's extremely low, right? But the problem is, as you can see across our centers, we're collecting at a rate about close to 11%. And the reason for that is because we have to meet the demand. The demand on average is over 11%. Some of our hospitals are demanding about 25, 30% of O-NIG. Granted, some of these hospitals are rural hospitals. You know, they're far from the blood center. So they have, you know, less expertise. They feel more comfortable having the most universal blood type. The reason why we are able to get to this 11%, from a six to 7% donor base, it's because whenever our O-negative donor presented to us, if it's feasible, we will collect a double red cell from them. So that's the reason why we can get to that level. But the problem is, over time, as hospitals started implementing patient blood management, I'm sure you guys have all seen that the overall utilization of all blood component types has been down, taking a downward trend. However, O-negative RBC is going in just opposite direction because a lot of hospitals are adopting emergency transfusion protocol and adopting a mass transfusion protocol. And when they first adopt that, you know, just out of the comfort level and just in habit, they're going to put O-negative red cells or universal red cells, initial resuscitative red cell, regardless. So that's really creating a huge strain on the blood supply. Let's see. So the other thing is, you know, for our O-negative donor, when they come in to donate double RBC, every time they do that, they're losing twice as much iron as the person who's coming in to donate whole blood. And over time, we have actually come to acknowledge and realize that we're inadvertently making some of our donors iron deficient, especially the young donors. I don't know if you know, but about 30% of the nation's blood supply actually comes from high school blood donors. And the high school blood donors are the most at risk. They're young, they don't have the best diet, they're growing, they need a lot of nutrients. So the problem presents that at this point right now, we're actually testing ferritin for all of our 16 to 18 year old donors. And if they have a low ferritin, we're actually deferring the females for entire year and the males for six months. So in a way, you know, we are decreasing our donor base, right? Because we're trying to protect the donor. Because we're really in the place of protecting the donor and protecting the patient. And sometimes that's a pretty tough balancing act. And that's why we need clinicians help so that we can all come in and work on this problem together. So the indication for appropriate and necessary use of O-neg red cell, really it's the first bullet for you guys, your patient cohort, because your patient's gonna come in, you're not gonna know their blood type, right? They could be any age, any gender. So when they come in, if you have the ability, you should develop this and put it in your master transfusion protocol, which to say the highest risk patient that I wanna avoid giving O-pos red cells to are gonna be my females of reproductive potential. And the single reason for that is because if you have a female of reproductive potential coming in, you don't know their blood type, but turns out they're Rh negative. You give them Rh positive blood, they will likely form anti-D. And that anti-D isn't gonna harm them at that point. The problem is years down the line, they may get pregnant. And when they get pregnant, this anti-D may cross the placenta and cause HDFN, hemolytic disease of the newborn, right? If there is Rh positive fetus. And that can have some devastating consequences. So that's really, to me, the one absolute thing that you should really try to avoid giving, you know, like female of reproductive potential, Rh positive. However, these are general guidelines. When you run out of Rh negative blood, you should use Rh positive, because you know what? It's more important that you save a life than to think about the future. Because we have other ways of managing patients who have developed anti-D. And then whenever possible, you should get samples to your transfusion service as soon as possible, so that they can do the ABRH typing and antibody screen, because we wanna convert the patient to the negative blood type. One, because there are some studies that have demonstrated that when you transfuse patient, even with typo Rh cell, because there's some incompatibility, you know, in the plasma, there may be other soluble factors don't really have been characterized. There may be some long-term consequences that's not desirable. But the other thing is, I don't know if you have encountered this, when you give your patients a lot of old cells and their native blood type is not, oh, your blood bank sometimes will be like, I'm getting mixed field reaction. What do I do with this? Do I continue with type O? Do I convert them to the native blood type? A lot of questions come up on how you continue to support these patients. So we wanna avoid those. And of course, if you have the ability of knowing whether the patient has had either a history of anti-D formation or currently has anti-D, you want to avoid giving them Rh positive blood because you want to avoid any kind of potential hemolytic transfusion reaction. And lastly, if you have a patient female that you know is definitely Rh negative, then you should give them Rh negative blood. Once again, all of these rules can go out the window. If you run out of Rh negative blood, you will convert them to Rh positive. And the reason is because even in the worst case scenario, the patient has an anti-D, actively has an anti-D, most anti-Ds will cause extravascular hemolysis, which means that it's gonna happen slowly over days and weeks. It's not gonna be an acute intravascular hemolytic event that you think of associated with anti-A or anti-B. So in the grand scheme of things, it's a risk that's acceptable. So in case you're curious about the incidence of formation of anti-D after an exposure to Rh positive blood, it really varies depending on the patient population, you know, how healthy you are. So if you have a person who's completely healthy, immunocompetent, you expose them to a unit of Rh positive blood, so a large load of Rh antigen, then about up to 80% of them can form an anti-D. However, if you give the same amount to a hematologic patient who's immunocompromised, only up to 20% will develop anti-D. And similarly, in emergency transfusions, now here, emergency transfusion is not just for trauma patients, right? There could be other patient populations that require emergency transfusion. But whatever the underlying cause is, when they require emergency transfusion, it would appear that this particular population is somewhat acutely immunosuppressed because only about 20% of them develop anti-D. So the risk is about, I would say, 20% in your population in general. Okay, now we're going on to the new trends in transfusion support for massive hemorrhage. So the first thing I'm going to talk about is liquid plasma. Can I have a show of hands, how many of you are actually already using liquid plasma? Oh, I knew you guys would be. Okay, that's good. Oh, actually, you know what, not as many as I thought. Okay. Okay, you're using helicopters and ambulances and all of that. Yes. Yes. We're still trying to catch up. It's hard. There's a lot of competing priorities. Okay, so liquid plasma is something that's not new at all. You know, a lot of these things that I talk about, it's kind of like, you know, fashion, 20 years, they come into fashion again, right? So liquid plasma has been around for years and years and years. But the problem with liquid plasma is that the storage time is different because remember with frozen plasma, I can keep it in the freezer for up to a year and then thaw it on demand and use it whenever I want, right? So it's a better inventory method. For liquid plasma, it's kept in the liquid state for the entirety, whatever the maximum storage period, depending on the original blood component that was collected in the whole blood. And then the problem with liquid plasma also is that because it's not used a lot clinically, there's not a lot of good study out there to really demonstrate the coagulation profile. So, you know, there's some comfort level of, you know, using that, right? And then the thing is liquid plasma, since it's never been frozen and thawed, there are viable lymphocytes in there. So these viable lymphocytes have the potential to cause transfusion-associated graft-versus-host disease in the at-risk population. So that's another thing to consider. So which means that if you want to remove that risk, you have to irradiate this product. That's another added step. So it makes keeping liquid plasma in your facility a little more complicated. And then lastly, if you look at the package, essentially the package insert for blood components called the circular information, the use of liquid plasma is pretty limited at this time. Right now, it says it's indicated for initial treatment of massive hemorrhaging patients with significant coagulopathy. So technically, you're not supposed to use this product on any other patient population. But, you know, the reality is in a clinical setting, you can do what you want to do. But by regulation, we're not supposed to tell you to use it on anyone else. So there's really no good in vivo studies of liquid plasma. I found this pretty good in vitro study looking at the coagulation profile of liquid plasma from day one to day 30. And the nice thing is that, you know, they track the activity every day to see exactly where they were. So there's a lot of information here. Really not that important because I'm just going to summarize it. Pretty much day 15 is sort of that magical mark where things dramatically change. Because prior to that, you have more than 50% activity remaining, pretty much all the pro and the anti-coagulant factors, right, because we need a minimum of 30% of each factor in order to be hemostatic. So 50% is good. However, after day 15, you have some significant drop in your pretty important pro-coagulant factors like factor V, factor VII, and factor VIII. So really, to me, you know, if you're intending on using liquid plasma, is it really a good idea to use it up to its expiration date? I would say probably not. You know, if I have the ability to manage my inventory well, I would like to keep it under that. So in my experience, most institutions will use liquid plasma for up to 14 days because that just makes things easier, two weeks, you know, thinking about the expiration. And then my recommendation is that you should irradiate. And the reason why for liquid plasma you should irradiate is because there's really no other cells in there that you're concerned about, right? Irradiation-related damages to red cell platelet, it's not a thing. So to me, if you can get your liquid plasma, irradiate, as soon as you get it into your inventory, just leave it there for, you know, the entirety of the 14 days, that would be great. And, you know, restrictive use in massive bleeding patients. Obviously, if you have a patient in the hospital that needs plasma and you just are completely out, I would go to this. I would not ignore this. So I'm curious, how long do you keep your liquid plasma? 26 days. 26 days. Okay. So we've published a feature data on that. Oh, okay. I'll show it, yeah. Oh, great. I'm sure I will show our data. Okay, perfect. So I'm going to move on. Five, 30 day old liquid plasma. Right. But do you think that part of the outcome, better outcome you're observing is from the coagulation factor or perhaps other factors that we haven't identified that's... So we completely believe, like I said earlier, it's not really a factor. I think it is the repair of the interleaving of plasma and platelet-disposed tissue. Okay. We agree with that. Okay, great. It's always nice to have concurrence. Okay. So the next one I'm going to talk about is whole blood. So whole blood is really sort of like the striding star right now. We're getting a lot of requests from our level one trauma centers to implement whole blood transfusion. It's creating a huge challenge because in order to have whole blood available for this acute setting, right now it's limited to just type O whole blood, right? And as you know, I just talked about type O, even though it's being the most common, but Rh negative is the most desired and sort of the least common. So it's just been very difficult to manage those requests and still balancing out to have enough O red cell supply. So looking at the circulate information, currently, per the FDA, their definition is still very restrictive, which means that when you're trying to use whole blood, it must be ABO identical. And we know if that's the case, forget it. I mean, your patients, we don't know their blood type. We can't use it, right? So that's not possible. But obviously, that's a little bit outdated because the literature for the benefit of whole blood really came out of the military. And if you actually start to really deep dive a little bit and looking at whole blood and compare it to that component, you can see there's quite a lot of difference, which I for many years, we either ignored or just didn't think about. Very unfortunate. So there's actually three types of whole blood. What is truly available, I think, in a civilian setting as a reality, it's cold whole blood because there's a whole blood stored one to six degrees in the refrigerator up to its maximum expiration. Then you have what's called cold fresh whole blood. And this is cold whole blood used within 48 hours of collection. So that is very difficult to achieve in a civilian setting because it takes us about a day to a day and a half just to complete all the testing and the labeling and then getting the blood to your transfusion service. By the time it gets there, it's probably already two or three days old. So if you have a blood collection facility within your hospital on site to do the collection processing, labeling, you might be able to get to that. But it's still very challenging. And then the next one is the warm fresh whole blood, which is really only restricted to the military setting because they have a walking blood donor inventory pretty much because all the people that are on the base have been previously tested and they have very limited exposure to any kind of high-risk activity. So the time that they donate the blood, their sample is being collected, but there's no infectious disease testing results available. And that blood is already being transfused within 24 hours. So again, whole blood is not new at all. It's actually the very first blood product that was available to us before the invention of component therapy. So from World War II to Vietnam War, type O whole blood was used as the initial universal blood. However, in 1944, there were some reports saying that they're starting to see some hematotransfusion reaction from whole blood that contained high titer anti-A and anti-B. So from there, the military decided, okay, we're going to do some titering and then we're going to choose the ones that have low titer. And the way they defined it was a saline titer of anti-A or anti-B less than 250. So I want to point out a couple of things here. This is kind of a bluffing thing. So number one, saline titering is the least sensitive method. Number two, saline titering will only detect IgM antibodies. And as you know, anti-A, anti-B have both IgM and IgG component. Although the IgM is sort of the most feared because that's when the causes the acute intravascular hemolysis. So as you go and talk to your transfusion service and determine what titer is considered safe, you also have to talk about how you want to do the titer. Because if you look across literature, people are doing it differently. Some people are doing, you know, in gel. Some people are doing with an enhancement. So it's really important to know that, you know, sometimes you're not comparing apples to apples, right? So make sure you choose something that you feel comfortable with. And since then, they reported no hemotransfusion reaction. They recorded a transfusion of more than 500,000 units. And over time, the use of whole blood declined, I think mainly because of component therapy coming into, you know, favor. Because it made transfusing things a lot easier. And I think mostly when you think about in the hospital setting, it's going to be your medical patients that require transfusion. Either they're anemic or they're thrombocytopenic. They don't need everything else. They only need one of the, you know, three components. So I think that that really sort of like push whole blood outside and become, you know, less favorable. And, of course, the other thing is regulatory things coming in, such as the FDA saying, well, if you're going to transfuse whole blood, it has to be ABO-matched. And that's very difficult for a blood center to manufacture and for your transfusion service to keep up with just the right amount of ABO-matched whole blood to the right amount of patients. You're going to see a huge amount of waste. And then the other thing is, you know, the increase in crystallogram resuscitation and the perceived lack of platelet-sparing leukoreduction filters all contributed to some of the, I guess, loss in favoritism. So at present, whole blood is becoming the preferred blood component for massive hemorrhage patients. The Tactical Combat Casualty Care Committee in 2014 actually recommended this as the, you know, like initial preferred blood component to be transfused. So over time, the organization, professional organization that I belong to called the American Blood Bank Association have responded to that because we realize, you know, there's a clinical need. We can't, you know, just sort of like stay in our archaic time and say, well, this is what we're going to do. So in the latest ABB standard, as you can see here, they have changed the statement to allow recipients to receive ABO group-specific whole blood or low-titer group O whole blood when you don't know their blood type or when their blood type is not O. And then the caveat that follows that is that you have to have policies and procedures in place to determine what is considered low-titer and how much maximum volume of this low-titer O blood you can give to a patient that's either not a group O or ABO unknown and how do you monitor for any kind of adverse reaction. So those are all things that you have to consider before you embark on adopting whole blood. The benefits, as I said earlier, right, you know, we thought that maybe component therapy, if I just take my red cell, platelet, plasma, jam them together, it should be the same thing as whole blood. Not quite. So let's look at the bottom table first. As you can see on the left side, those are individual components, red cell, plasma, platelet. And in each of those components, there are quite a significant volume of anticoagulant added to the solution. So if you look at that in total, if we were to recapitulate whole blood from component therapy, you're going to have a total of 1,055 mil of anticoagulant-slash-preservative solution. While if you look on the right side for one unit of whole blood or the equivalent, you're going to get only 378 mil. So it's about three times as much anticoagulant, which means that you're going to be diluting your patient, right? And that's something that you want to avoid. Then the other thing is, interesting enough, you know, we have thought that well, maybe platelets are stored in the cold, doesn't work as well. But the reality is actually just the opposite. They work really well. They're very vigorous. They do a great job. They just don't live a long time. So compared to the ones that are stored at room temperature. So it's really, you know, a difference in like how aggressive they work and how long they last. And that kind of tug-of-war was, I think, won over by sort of the prophylactic transfusion population, the hematologic. So that's one thing. And then the limited storage time will limit storage lesion because for, you know, red cells, we'll store them up to like 42 days. But usually whole blood, it's not kept up to its expiration for use unless you guys do it differently. Depends on what it's preservative that you throw into, right? 25 or 36 days. Yeah. So you will use it up to its expiration for your whole blood. Absolutely. Interesting. At 14 days, I'll talk about it. At 14 days, we convert it to red cells. Yeah. So are you from? Oregon. Oh, Florida? Oregon. Oregon. Oh, okay. Okay, yeah. I'll show the data. Yeah. If you have the ability, that would be ideal. A lot of facilities don't have the ability to do the conversion on site. And logistically, it's really easy, right? So if you want to have it on your ambulance or on your helicopter, you just put it in the cooler. You don't have to worry about, okay, I'm going to have my red cells in the cooler, I'm going to have my platelet in, you know, ambient temperature transport, and I'm going to have my, you know, plasma frozen, and then I have to have a thar. It's just too complicated. So whole blood's great. Challenges. So for your transfusion service, it's going to be a dual inventory because remember, this is still restricted use for a massively hemorrhaging patient, right, not for just anybody. So they're going to have to manage that inventory. And then there's a cost associated with that because this is a component that most blood centers are not routinely producing, so we're going to have to change our policies and procedures so that we can manage that. And then also, you know, balancing out, collecting enough type O whole blood and not significantly impacting our old red cell inventory. And then as far as leukocytes are concerned, there are viable leukocytes, right, so you can do two things to reduce two of the risks. You can leukocyte reduce to reduce the risk of fibro reaction, to reduce the risk of L immunization. However, when you choose a leukocyte reduction filter, most of them out there will actually deplete the platelets. There's only one filter that's platelet sparing. So you'll have to think, do I want platelets to be in my whole blood, and do I care? Maybe I don't care because I'm just going to choose to use platelets. So that's a decision that you'll have to make. And then even after your leukocytes are reduced, there are still some residual viable leukocytes, even if there's just a couple. There's still the possibility that they can set a residence in a patient who is at risk and cause transfusions associated with GVHD. So in that scenario, you should think about irradiating. Then, of course, I talked about the lack of industry standard for what's considered low titer. You'll have to, like, determine that for your facility. And then, I mean, depending on who you talk to, you know, maybe more studies are still needed. I mean, there's plenty of studies in the military, but in a civilian setting, it's still kind of a relatively new product. Okay, I think I have just a minute left. So we're sitting in this hotel. You know, adjacent to us is the Mandalay Bay. And so October 1, 2017, that's where the shooting occurred. Across the street is where, you know, the site of the casualty. So it was pretty unfortunate. I remember getting a call at 11 a.m., and I never get a call at 11 a.m. from here, so I knew something was wrong. The gunman killed 58 people and injured almost 900 people, and about 600 people were brought to the hospital throughout the valley. So Sunrise Hospital, which is a Level 2 trauma center, about maybe, like, three or four miles from here, received most of the, you know, like, high-casualty patients. UMC, which is about six or seven miles away, they received some of the patients. There was some miscommunication. Anyway, overall, if you look within the first 14 hours, 500 blood components were transfused. This is very much, you know, in alignment with the biology of, you know, this type of trauma, right? You have acute bleeding. You need to transfuse those products early and quick. And you think after that, it's not going to be caused by that massive hemorrhage. So the blood centers, both us and the Red Cross, responded rapidly by sending about 700-plus components to all the hospitals throughout the valley. And this one, just to, you know, give you an idea, like, comparing the different massive casualty events, you know, in Vegas, Orlando, Paris, and to see how their component usage were similar or different. Obviously, there are differences everywhere. I mean, maybe part of it is that everyone's got a different protocol, right, for transfusing the patient. Perhaps, you know, the type of injury and how close the injury had occurred because in the Orlando shooting, it was within a club, so a lot of people had multiple gunshot wounds as opposed to this one. It was much farther away, so, you know, this sustained less number of gunshot wounds per patient. And then the other thing that was a potential reason for maybe why more red cell platelets were used here as compared to Paris is that they didn't have enough adequate tourniquet support. And a lot of the patients, about 60%, 70% of the patients were transported by civilians who really, you know, didn't have a lot of good training on how to stop the bleed. So that's what maybe some of the factors contributing to this. And I'm at the end. Did I meet my time? Perfect. Thank you.

blood transfusion

trauma patients

red cells

plasma

platelet

coagulopathy

whole blood transfusion