Injury, Int. J.

Care Injured 47 (2016) 1824–1827

Contents lists available at ScienceDirect

Injury
journal homepage: www.elsevier.com/locate/injury

Performance comparison of improvised prehospital blood warming

techniques and a commercial blood warmer
James Milligana , Anna Leea,b , Martin Gillc , Andrew Weatheralla,d , Chloe Tetlowa ,
Alan A. Garnera,*
a
CareFlight, NSW, Australia
b
Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Hong Kong, China
c
The Heart Centre for Children, The Children’s Hospital at Westmead, NSW, Australia
d
The Children’s Hospital at Westmead, NSW, Australia

A R T I C L E I N F O A B S T R A C T

Introduction: Prehospital transfusion of packed red blood cells (PRBC) may be life saving for hypovolaemic
Keywords: trauma patients. PRBCs should preferably be warmed prior to administration but practical prehospital
Prehospital
devices have only recently become available. The effectiveness of purpose designed prehospital warmers
Transfusion
Warming
compared with previously used improvised methods of warming has not previously been described.
Trauma Materials and methods: Expired units of PRBCs were randomly assigned to a warming method in a bench
study. Warming methods were exposure to body heat of an investigator, leaving the blood in direct
sunlight on a dark material, wrapping the giving set around gel heat pads or a commercial fluid warmer
(Belmont Buddy Lite). Methods were compared with control units that were run through the fluid circuit
with no active warming strategy.
Results: The mean temperature was similar for all methods on removal from the fridge (4.5
C). The mean
temperatures (degrees centigrade) for all methods were higher than the control group at the end of the
circuit (all P  0.001). For each method the mean (95% CI) temperature at the end of the circuit was; body
heat 17.2 (16.4–18.0), exposure to sunlight 20.2 (19.4–21.0), gel heat pads 18.8 (18.0–19.6), Buddy Lite 35.2
(34.5–36.0) and control group 14.7 (13.9–15.5).
Conclusions: All of the warming methods significantly warmed the blood but only the Buddy Lite reliably
warmed the blood to a near normal physiological level. Improvised warming methods therefore cannot
be recommended.
ã 2016 Elsevier Ltd. All rights reserved.

Introduction hypocalcaemia, acidosis, continued bleeding with consumption

Trauma is a leading cause of death with approximately 5 million
people worldwide dying from traumatic injury each year [1]. Early
trauma related death is associated with haemorrhage in approxi-
mately 30% of cases with a resulting emphasis on haemorrhage
control in trauma resuscitation [2]. In patients where haemorrhage
control is not possible or where blood loss has already exceeded
physiological reserves early transfusion of blood products is a
critical component of treatment. The incidence of coagulopathy
after major trauma is high and is an independent predictor of
mortality [3]. Key factors in the development of traumatic
coagulopathy include the injury severity, hypothermia,
* Corresponding author at: 4-6 Barden Street, Northmead, 2152, Australia.
E-mail address: alang@careflight.org (A.A. Garner).
of clotting factors, haemodilution from aggressive crystalloid
resuscitation and activation of fibrinolysis [4]. These factors can be
simplified and combined creating what is often referred to as the
trauma triad of death; coagulopathy, acidosis and hypothermia [5].
It is becoming increasingly common for emergency medical
services (EMS), particularly helicopter EMS (HEMS) to carry packed
red blood cells (PRBC) for prehospital transfusion in critical trauma
patients. CareFlight operates a rapid response physician staffed
HEMS in the greater Sydney area of New South Wales (NSW),
Australia and has carried PRBCs since 1986. In keeping with the
Australian National Blood Authority guidelines, these are stored in
a purpose designed cool box (Series 4-EMT 2l Credo System,
Minnesota Thermal Science, MN, USA) at 4
C with tight tempera-
ture regulation. The PRBC are typically used in patients with severe
injuries, with haemodynamic compromise and are generally
administered as a rapid bolus. These patients are already at risk

http://dx.doi.org/10.1016/j.injury.2016.05.038
0020-1383/ã 2016 Elsevier Ltd. All rights reserved.
 J. Milligan et al. / Injury, Int. J. Care Injured 47 (2016) 1824–1827
of developing traumatic coagulopathy and the use of rapidly
infused cold PRBCs may exacerbate the risk. Previous studies have
shown the rapid infusion of similar volumes of cold crystalloid
fluids will cause a drop in core body temperature of approximately
1.3
C [6]. This is a group already at risk of hypothermia, as was
demonstrated in previous studies showing 50% of major trauma
patients presented to the emergency department with a core
temperature of less than 36
C [7,8]. Post-traumatic hypothermia
has also been shown to be an independent predictor of mortality in
numerous retrospective and prospective studies [9–11].
The risk of exacerbating post traumatic hypothermia and
coagulopathy, and the previous lack of commercially available
portable blood warming devices have lead clinicians to use
various improvised methods to warm PRBCs prior to prehospital
transfusion. These methods include using the body heat of a
rescuer, leaving the blood in direct sunlight on a dark material
and wrapping the giving set around gel heat pads. We are not
aware of any previous reports validating the effectiveness or
safety of these techniques. Recently a commercial blood
warming device that is small enough to use prehospital became
available on the Australian market, the Buddy Lite (TM, Belmont
Instrument Corporation, MA, USA). We therefore proposed to
compare the effectiveness of common improvised methods with
this new commercial device, as there was no other available
comparable literature. The study was approved by the Sydney
Children’s Hospital Network Human Research Ethics Committee,
Australia.
Objective
To compare the change in temperature of PRBCs achieved by the
use of three improvised methods of blood warming (body heat,
direct sunlight and gel heat pad), a commercially available device
(Belmont Buddy Lite) and a control (no device or active warming
strategy) in a simulated pre-hospital environment.
Study design
Prospective randomized bench test study of blood warming
techniques (Belmont Buddy Lite, body heat, and direct sunlight and
gel pads) in a simulated pre-hospital environment.
Setting
This research was conducted at the Perfusion Laboratory at The
Children’s Hospital at Westmead, Sydney, Australia.
Methods
Donated units of PRBCs that had expired and could no longer be
used for human transfusion were used in this study. Units were
stored in a temperature controlled fridge at 4
C to simulate the
PRBCs coming directly from the temperature controlled cool box
used by our prehospital teams. Five study arms were assessed:
1. Body Heat Method: PRBCs were placed in either axilla of one of
the researchers for a period of five minutes prior to infusion.
2. Warming Gel Pad Method: The blood giving set was wrapped
around a thermal gel pad which had been activated at the start
of each test run. The distal section of the giving set was wrapped
around the gel pad 5 times to give maximal surface area contact
while replicating the pragmatic need for separation of the PRBC
unit and the patient as in prehospital clinical practice. The gel
pads are approximately 90 ml in volume, contain 88% sodium
acetate, 12% water and are activated by pressing a metal disk,
1825
Fig. 1. Belmont Buddy LiteTM. The battery is not included in this image.
generating an internal temperature of 54
C. (Kathmandu,
Melbourne, Victoria, Australia)
3. Direct Sunlight Method: PRBCs were placed on a black carbon
spinal board in direct sunlight for a period of five minutes prior
to infusion.
4. Belmont Buddy Lite (Fig. 1): PRBCs were delivered with this
battery-powered fluid warmer placed in line as per manufac-
turer’s instructions.
5. Control group (no active warming technique employed): PRBCs
were infused via the standard investigation giving set.
The order of methods was randomized using a computer
generated randomization sequence performed by one of the
investigators (AL) not involved in the laboratory experiment using
PASS software version 11 (NCSS, Kaysville, UT). A consecutive
numbered sealed opaque envelope was opened just before a bench
test occurred.
Blood was infused using a standardised giving set. A Baxter
Colleague 3 Volumetric Infusion Pump (Baxter, Deerfield, IL, USA)
within the circuit was used to regulate flow rates to ensure a
constant flow rate of 50 ml/min. Flow rates were confirmed with a
3/1600 Transonic flow probe (Transonic Systems, Inc., Ithaca, NY,
USA). This flow rate was chosen as it complies with maximum
recommended flow rates set by the manufacturers of the Belmont
Buddy Lite for fluids given at under 10
C.
The PRBCs were delivered via a standardised circuit as detailed
in Fig. 2. Following infusion through this standardised giving set,
the blood was delivered to a collection reservoir and subsequently
pumped through a heat exchanger, to allow re-cooling to 4
C, then
back to the collection bag for subsequent reuse. Units were re-used
to maximise experimental efficiency and reduce wastage.
Temperature was measured at three different points in the
standardised giving set and collection circuit using Capiox1 Leur
Thermisters (Terumo, Corporation, Tokyo, Japan).
1. Just distal to the collection bag
2. Prior to entering inline blood warming devices (where present)
3. Immediately distal to the giving set (prior to entering the
collection reservoir). This represented the temperature at which
blood would usually enter the patient’s circulation.
Ambient temperature was measured for all experimental runs
using an Esis, hygrochron temperature/humidity logger (Esis Pty
Ltd., Sydney, Australia). For the direct sunlight method the
temperature in the sunlight was also be recorded. Each of the
methods were tested three times with two units of blood used on
each run.
1826 J. Milligan et al. / Injury, Int. J. Care Injured 47 (2016) 1824–1827
Fig. 2. Standardised collection circuit.
Statistical analysis
The primary outcome was change in temperature (
C) from
baseline. The reliability of the each bench test was estimated using
the intra-class correlation coefficient (ICC). Analysis of variance
was used to compare simulated cool box storage temperature
between method groups. Changes in temperature over time were
analysed with the use of a mixed-effects regression, with method
group and time as fixed effects adjusting for duration of bench test
and simulated cool box storage temperature. In the mixed-effects
regression model, we used an exchangeable correlation structure
and adjusted for multiple bench tests of the donated bags of blood.
The effect of method was captured by the time-method interaction
and Wald tests were used to test for the significance of this. The
control (no device) group was considered the reference group for
comparisons, and the P values were Bonferroni-adjusted for
multiple comparisons. The mean temperature was reported with
either standard deviation (SD) or 95% confidence interval (95% CI).
All analyses were performed using STATA 14.0 (StataCorp, College
Station, TX, USA).
Results
Eight hundred and seven temperatures measurements were
record. The reliability of the bench test temperature measurements
was high (ICC = 0.985). The mean (SD) ambient temperature (
C) in
the laboratory during the runs was recorded at 23.4 (0.7) and
during the direct sunlight bench tests was 26.0 (3.3). The mean
(SD) cool box storage temperature (
C) was 4.5 (0.1), with no
difference between method groups (P = 0.42). The mean (95% CI)
temperatures at various sites in the circuit between method groups
are shown in Table 1.
Compared to control, the mean temperatures (
C) at site 1 in
the direct sunlight and body heat groups were higher, due to this
Table 1
Adjusted Mean (95% CI) temperatures (
C) at various sites in the circuit by method groups.
Method Location on the circuit
Below collection bag (site 1)
Control 9.4 (8.6–10.2)
Direct sunlight 18.0 (17.2–18.8)
Body heat 13.5 (12.8–12.3)
Gel pads 10.3 (9.5–11.0)
Buddy Lite 9.5 (8.8–10.3)
a
Temperature at site 3 minus site 1.
blood having already been exposed to active warming (mean
difference for direct sunlight 8.6, 95% CI 6.9–10.2, P < 0.001; body
heat 4.1, 95% CI 2.6–5.6, P < 0.001). Otherwise, there was no
difference in mean temperature (
C) at site 1 between the gel pad
group, the Buddy Lite group and control group (P = 0.99 and
P = 1.00, respectively). At site 3, the mean temperatures (
C) in all
groups were higher than the control group (all P < 0.001). The
change in all groups over that of the control group varied
according to type of method; it was significantly lower in direct
sunlight and body heat groups and higher in gel pads and Buddy
Lite groups (all P < 0.001).
Discussion
All of the blood warming methods investigated in this study
significantly warmed the blood when compared to the control.
However only the Buddy Lite warmed the blood to a near
physiologically normal level. The improvised methods of blood
warming are uncontrolled and could potentially lead to uneven
warming with an increased risk of haemolysis [12]. This may be
particularly true for high energy warming methods such as the use
of direct sunlight in Australian conditions. The suboptimal
warming displayed by the improvised methods and the potential
for harm makes it impossible to recommend these warming
methods for future use.
This study used a simulated pre-hospital environment in a
laboratory. The ambient temperature in the laboratory was
recorded at 23.4
C (SD 0.7). This was enough to significantly raise
the temperature of the blood in the control group to a mean
infusion temperature of 14.7
C (13.9–15.5) without any active
warming strategy. In the field, the magnitude and direction of
passive change in temperature will be dependent on the prevailing
prehospital environment and measures taken to insulate the
infusion lines from that environment.
Changea
Before device (site 2) Distal to device (site 3)
No device 14.7 (13.9–15.5) 5.3 (4.8–5.7)
No device 20.2 (19.4–21.0) 2.2 (1.7–2.7)
No device 17.2 (16.4–18.0) 3.7 (3.2–4.1)
15.3 (14.5–16.1) 18.8 (18.0–19.6) 8.5 (8.0–9.0)
14.9 (14.2–15.7) 35.2 (34.5–36.0) 25.7 (25.2–26.2)
 J. Milligan et al. / Injury, Int. J. Care Injured 47 (2016) 1824–1827
A volumetric infusion pump within the circuit was used to
regulate flow rates to ensure a constant flow rate of 50 ml/min. This
flow rate was chosen as it complies with maximum recommended
flow rates set by the manufacturers of the Belmont Buddy Lite for
fluids given at under 10
C. However in prehospital use no measure
of flow rate is made and mechanical pumps are generally not used
to control the rate of blood transfusion. Previous studies have
demonstrated it is possible to infuse fluids at rates much greater
than this. These rates are dependent on a number of factors but
rates in excess of 300 mls/min are achievable [13]. Even when
using an intraosseous access device flow rates approaching 100 ml/
min have been recorded [14]. Higher flow rates are likely to
adversely affect the performance of the methods that used an in-
line heating system; the gel pad and the Buddy Lite. Such infusion
rates may be outside of the manufacturer’s recommendations but
may be more representative of the rates used when trying to
resuscitate a critically injured trauma patient. Without this data we
cannot recommend the use of the Buddy Lite blood warmer at rates
in excess of 50 ml/min. Commercial units designed for high flow
rates are presently not relevant to prehospital use due to their size,
weight and requirement for a fixed power supply.
Donated blood that had expired was used in the study and the
circuit was designed to allow the blood to be collected and cooled
for reuse. The haemolysis rate was not measured and it is not clear
if this would have had any effect on the warming methods used.
However there was minimal variability in the results for each
method used with tight confidence intervals suggesting that
potential haemolysis had minimal effect on the measured result. A
significant haemolysis rate with any of the warming methods
would raise serious clinical concerns but was outside the scope of
this study. Measuring clinically relevant haemolysis accurately
would require non-expired blood presenting significant ethical
and logistical issues.
Further studies are required to determine the performance of
the Buddy Lite compared with other commercial fluid warmers
designed for prehospital use, and evaluating performance at flow
rates that may be more representative of PRBC administration in
the field in critically injured trauma patients.
Conclusion
All of the warming methods investigated in this study
significantly warmed the blood. However the Buddy Lite was
the only method which reliably warmed the blood to a near normal
physiological level. Improvised warming methods therefore
cannot be recommended. Further work is required to compare
1827
the performance of commercially available devices and at flow
rates that may be more representative of prehospital transfusion
practice.
Conflict of interest
All the authors declare that they have no conflict of interest.
Funding
The commercial device (Belmont Buddy Lite) evaluated was
obtained by the researchers under normal commercial arrange-
ments with the distributor. The distributor and manufacturer
provided no assistance, financial or otherwise in conduct of the
study and results were not disclosed to them prior to submission
for publication.
No external funding was obtained for the study.
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