Effect of Plasma and Red Blood Cell Transfusions on Survival in Patients With Combat Related Traumatic Injuries

Plasma for prevention and treatment of glycocalyx degradation in trauma and sepsis

The endothelial glycocalyx, a gel-like layer that lines the luminal surface of blood vessels, is composed of proteoglycans, glycoproteins, and glycosaminoglycans. The endothelial glycocalyx plays an essential role in vascular homeostasis, and its degradation in trauma and sepsis can lead to microvascular dysfunction and organ injury. While there are no proven therapies for preventing or treating endothelial glycocalyx degradation, some initial literature suggests that plasma may have a therapeutic role in trauma and sepsis patients. Overall, the literature suggesting the use of plasma as a therapy for endothelial glycocalyx degradation is non-clinical basic science or exploratory. Plasma is an established therapy in the resuscitation of patients with hemorrhage for restoration of coagulation factors. However, plasma also contains other bioactive components, including sphingosine-1 phosphate, antithrombin, and adiponectin, which may protect and restore the endothelial glycocalyx, thereby helping to maintain or restore vascular homeostasis. This narrative review begins by describing the endothelial glycocalyx in health and disease: we discuss the overlapping disease mechanisms in trauma and sepsis that lead to its damage and introduce plasma transfusion as a potential therapy for prevention and treatment of endothelial glycocalyx degradation. Second, we review the literature on plasma as an exploratory therapy for endothelial glycocalyx degradation in trauma and sepsis. Third, we discuss the safety of plasma transfusion by reviewing the adverse events associated with plasma and other blood product transfusions, and we examine modern transfusion precautions that have enhanced the safety of plasma transfusion. We conclude that the literature proposes that plasma may have the potential to prevent and treat endothelial glycocalyx degradation in trauma and sepsis, indicating the need for further research.

Cryoprecipitate for the treatment of life-threatening hemorrhage in children

BACKGROUND

Hypofibrinogenemia is an important risk factor for poor outcomes in children with severe bleeding. There is a paucity of data on the impact of cryoprecipitate transfusion on outcomes in pediatric patients with life-threatening hemorrhage (LTH).

STUDY DESIGN AND METHODS

This secondary analysis of a multicenter prospective observational study of children with LTH investigated subjects who were categorized by receipt of cryoprecipitate during their resuscitation and according to the etiology of their bleeding: trauma, operative, and medical. Bivariate analysis was performed to identify variables associated with 6-h, 24-h, and 28-day mortality. Cox Hazard regression models were generated to adjust for potential confounders.

RESULTS

Cryoprecipitate was transfused to 33.9% (152/449) of children during LTH. The median (Interquartile range) time to cryoprecipitate administration was 108 (47-212) minutes. Children in the cryoprecipitate group were younger, more often female, with higher BMI and pre-LTH PRISM score and lower platelet counts. After adjusting for PRISM score, bleeding etiology, age, sex, RBC volume, platelet volume, antifibrinolytic use and cardiac arrest, cryoprecipitate administration was independently associated with lower 6-h mortality, Hazard Ratio (95% CI), 0.41 (0.19-0.89), (p = 0.02) and 24-h mortality, Hazard Ratio (95% CI), 0.46 (0.24-0.89), (p = 0.02).

CONCLUSION

Cryoprecipitate transfusion to children with LTH was associated with reduced early mortality. A prospective randomized trial is needed to determine if cryoprecipitate can improve outcomes in children with LTH.

[Surgical safety checklist for surgical interventions]

The review is devoted to mostly international data on patient safety during surgical procedures. The author emphasizes surgical safety checklist for surgical interventions as a tool developed by the WHO team. The principal objective of this document is protection of patients from harm following unintended misses and casual circumstances. The author tried to explain the basic principles and ideas underlying the checklist procedure. An importance of understanding the process by administration and surgical team is emphasized because its absence deprives this non-complicated and helpful procedure of necessary sense. The problems of patient safety in hospitals of the Russian Federation are also discussed.

Early Fresh Frozen Plasma Transfusion: Is It Associated With Improved Outcomes of Patients With Sepsis?

Background: So far, no study has investigated the effects of plasma transfusion in the patients with sepsis, especially in the terms of prognosis. Therefore, we aimed to explore the association of early fresh frozen plasma (FFP) transfusion with the outcomes of patients with sepsis.

Methods: We performed a cohort study using data extracted from the Medical Information Mart for Intensive Care III database (v1.4). External validation was obtained from the First Affiliated Hospital of Wenzhou Medical University, China. We adopted the Sepsis-3 criteria to extract the patients with sepsis and septic shock. The occurrence of transfusion during the first 3-days of intensive care unit (ICU) stay was regarded as early FFP transfusion. The primary outcome was 28-day mortality. We assessed the association of early FFP transfusion with the patient outcomes using a Cox regression analysis. Furthermore, we performed the sensitivity analysis, subset analysis, and external validation to verify the true strength of the results.

Results: After adjusting for the covariates in the three models, respectively, the significantly higher risk of death in the FFP transfusion group at 28-days [e.g., Model 2: hazard ratio (HR) = 1.361, P = 0.018, 95% CI = 1.054–1.756] and 90-days (e.g., Model 2: HR = 1.368, P = 0.005, 95% CI = 1.099–1.704) remained distinct. Contrarily, the mortality increased significantly with the increase of FFP transfusion volume. The outcomes of the patients with sepsis with hypocoagulable state after early FFP transfusion were not significantly improved. Similar results can also be found in the subset analysis of the septic shock cohort. The results of external validation exhibited good consistency.

Conclusions: Our study provides a new understanding of the rationale and effectiveness of FFP transfusion for the patients with sepsis. After recognizing the evidence of risk-benefit and cost-benefit, it is important to reduce the inappropriate use of FFP and avoid unnecessary adverse transfusion reactions.

Blood transfusions in gunshot-wound-related emergency department visits and hospitalizations in the United States

BACKGROUND

The United States (US) leads all high-income countries in gunshot wound (GSW) deaths. However, previous US studies have not evaluated the national blood transfusion utilization patterns in hospitalized GSW patients.

METHODS

Data from 2016 to 2017 were analyzed from the Nationwide Emergency Department Sample (NEDS) and Nationwide Inpatient Sample (NIS), the largest all-payer emergency department (ED) and inpatient databases, respectively. Using stratified probability sampling, weights were applied to generate nationally representative estimates. Multivariable Poisson-regression models were used to estimate prevalence ratios (PR) of blood transfusion.

RESULTS

There were 168,315 ED visits and 58,815 hospitalizations (age = 18-90 years) following a GSW. The majority of hospitalizations were men (88.5%), age 18-24 years (31.8%), and assault-related GSW (51.3%). Blacks had the largest proportion (48.7%) overall of all GSW hospitalizations; Whites accounted for the highest proportion of intentional self-harm injuries (72.4%). Blood transfusions occurred in 12.7% of hospitalizations (12.0% red blood cell [RBC], 4.9% plasma, and 2.5% platelet transfusions). Only 1.9% of cases were associated with transfusion of all three blood components. Hospitalizations with major/extreme severity of illness had significantly higher prevalence of transfusion versus those with mild/moderate severity [crude PR = 4.79 (95%CI:4.15-5.33, p < .001)]. Overall, 8.2% of hospitalizations with GSW died, of whom 26.8% required blood transfusions, which was significantly higher than survivors [crude PR = 2.34 (95%CI:2.10-2.61, p < .001)]. The vast majority (95%) of the transfusions among those who died were within 48 h since admission.

CONCLUSIONS

Gun-related violence is a public health emergency in the US, and GSWs are a source of significant mortality, blood utilization, and health care costs.

Systematic review of plasma/packed red blood cell ratio on survival in ruptured abdominal aortic aneurysms

BACKGROUND

The ideal perioperative fluid resuscitation for patients with ruptured abdominal aortic aneurysms (rAAAs) is unknown. It has been shown in trauma studies that a higher ratio of plasma and platelets to packed red blood cells confers a mortality benefit. Controversy remains whether this is true also in the rAAA population. The objective of the present study was to investigate the benefit of a greater ratio of plasma/packed red blood cells in patients with rAAAs.

METHODS

A health sciences librarian searched four electronic databases, including PubMed, Embase, Cochrane, and ClinicalTrials.gov, using concepts for the terms "fluid resuscitation," "survival," and "ruptured abdominal aortic aneurysm." Two reviewers independently screened the studies that were identified through the search strategy and read in full any study that was potentially relevant. Studies were included if they had compared the mortality of patients with rAAAs who had received a greater ratio of plasma to other component therapy with that of patients who had received a lower ratio. The risk of bias was assessed using the ROBINS-I (risk of bias in nonrandomized studies of interventions) validated tool, and evidence quality was rated using the GRADE (grades of recommendation assessment, development, and evaluation) profile. No data synthesis or meta-analysis was planned or performed, given the anticipated paucity of research on this topic and the high degree of heterogeneity of available studies.

RESULTS

Our search identified seven observational studies for inclusion in the present review. Of these seven studies, three found an associated decrease in mortality with a greater ratio of plasma to packed red blood cells. The remaining four found no significant differences. The overall risk of bias was serious, and the evidence quality was very low.

CONCLUSIONS

Overall, the findings from the available studies would suggest that for patients who have undergone open surgery for a rAAA, mortality tends to be decreased when the amount of plasma transfused perioperatively is similar to the amount of packed red blood cells. However, the included studies reported very low-quality evidence based solely on highly heterogeneous observational studies, and further research is warranted.

Effect of Low-Dose Supplementation of Arginine Vasopressin on Need for Blood Product Transfusions in Patients With Trauma and Hemorrhagic Shock: A Randomized Clinical Trial

Importance

Current therapies for traumatic blood loss focus on hemorrhage control and blood volume replacement. Severe hemorrhagic shock, however, is associated with a state of arginine vasopressin (AVP) deficiency, and supplementation of this hormone may decrease the need for blood products in resuscitation.

Objective

To determine whether low-dose supplementation of AVP in patients with trauma (hereinafter referred to as trauma patients) and with hemorrhagic shock decreases their need for transfused blood products during resuscitation.

Design, Setting, and Participants

This randomized, double-blind placebo-controlled clinical trial included adult trauma patients (aged 18-65 years) who received at least 6 U of any blood product within 12 hours of injury at a single urban level 1 trauma center from May 1, 2013, through May 31, 2017. Exclusion criteria consisted of prehospital cardiopulmonary resuscitation, emergency department thoracotomy, corticosteroid use, chronic renal insufficiency, coronary artery disease, traumatic brain injury requiring any neurosurgical intervention, pregnancy, prisoner status, or AVP administration before enrollment. Data were analyzed from May 1, 2013, through May 31, 2017, using intention to treat and per protocol.

Interventions

After administration of an AVP bolus (4 U) or placebo, participants received AVP (≤0.04 U/min) or placebo for 48 hours to maintain a mean arterial blood pressure of at least 65 mm Hg.

Main Outcomes

The primary outcome was total volume of blood product transfused. Secondary end points included total volume of crystalloid transfused, vasopressor requirements, secondary complications, and 30-day mortality.

Results

One hundred patients underwent randomization (49 to the AVP group and 51 to the placebo group). Patients were primarily young (median age, 27 years [interquartile range {IQR}, 22-25 years]) and male (n = 93) with penetrating trauma (n = 79). Cohort characteristics before randomization were well balanced. At 48 hours, patients who received AVP required significantly less blood products (median, 1.4 [IQR, 0.5-2.6] vs 2.9 [IQR, 1.1-4.8] L; P = .01) but did not differ in requirements for crystalloids (median, 9.9 [IQR, 7.9-13.0] vs 11.0 [8.9-15.0] L; P = .22) or vasopressors (median, 400 [IQR, 0-5900] vs 1400 [IQR, 200-7600] equivalent units; P = .22). Although the groups had similar rates of mortality (6 of 49 [12%] vs 6 of 51 [12%]; P = .94) and total complications (24 of 44 [55%] vs 30 of 47 [64%]; P = .37), the AVP group had less deep venous thrombosis (5 of 44 [11%] vs 16 of 47 [34%]; P = .02).

Conclusions and Relevance

Low-dose AVP during the resuscitation of trauma patients in hemorrhagic shock decreases blood product requirements. Additional research is necessary to determine whether including AVP improves morbidity or mortality.

Trial Registration

ClinicalTrials.gov identifier: NCT01611935.

Fibrinogen Protects Against Barrier Dysfunction Through Maintaining Cell Surface Syndecan-1 In Vitro

BACKGROUND

We have shown that fresh frozen plasma's (FFP) protection of pulmonary endothelial barrier integrity following hemorrhagic shock is due in part to restoration of endothelial syndecan-1. In the present study, we investigated the role of fibrinogen, a major component of FFP, as an endothelial protector and hypothesize that fibrinogen stabilizes cell surface syndecan-1 to restore endothelial barrier integrity.

METHODS

Pulmonary endothelial cells were incubated in FFP, fibrinogen, or lactated Ringers (LR) then immunostained with anti-syndecan-1 or fibrinogen and barrier integrity assessed. In some experiments, cells were exposed to fibrinogen depleted plasma.

RESULTS

Cell surface syndecan-1 was increased by FFP and fibrinogen compared with LR-treated cells while barrier integrity was augmented by FFP and fibrinogen compared with LR. The physiological concentration of 2.5 mg/mL fibrinogen was sufficient to increase cell surface syndecan-1. Colocalization and co-immunoprecipitation experiments demonstrated that fibrinogen associates with syndecan-1. Fibrinogen-deficient plasma was unable to augment sydnecan-1 immunostaining and lost its endothelial protective effect on barrier integrity.

CONCLUSION

These data suggest that in vitro, fibrinogen associated with cell surface syndecan-1 and enhanced endothelial barrier integrity.

Use of Combat Casualty Care Data to Assess the US Military Trauma System During the Afghanistan and Iraq Conflicts, 2001-2017

Importance

Although the Afghanistan and Iraq conflicts have the lowest US case-fatality rates in history, no comprehensive assessment of combat casualty care statistics, major interventions, or risk factors has been reported to date after 16 years of conflict.

Objectives

To analyze trends in overall combat casualty statistics, to assess aggregate measures of injury and interventions, and to simulate how mortality rates would have changed had the interventions not occurred.

Design, Setting, and Participants

Retrospective analysis of all available aggregate and weighted individual administrative data compiled from Department of Defense databases on all 56 763 US military casualties injured in battle in Afghanistan and Iraq from October 1, 2001, through December 31, 2017. Casualty outcomes were compared with period-specific ratios of the use of tourniquets, blood transfusions, and transport to a surgical facility within 60 minutes.

Main Outcomes and Measures

Main outcomes were casualty status (alive, killed in action [KIA], or died of wounds [DOW]) and the case-fatality rate (CFR). Regression, simulation, and decomposition analyses were used to assess associations between covariates, interventions, and individual casualty status; estimate casualty transitions (KIA to DOW, KIA to alive, and DOW to alive); and estimate the contribution of interventions to changes in CFR.

Results

In aggregate data for 56 763 casualties, CFR decreased in Afghanistan (20.0% to 8.6%) and Iraq (20.4% to 10.1%) from early stages to later stages of the conflicts. Survival for critically injured casualties (Injury Severity Score, 25-75 [critical]) increased from 2.2% to 39.9% in Afghanistan and from 8.9% to 32.9% in Iraq. Simulations using data from 23 699 individual casualties showed that without interventions assessed, CFR would likely have been higher in Afghanistan (15.6% estimated vs 8.6% observed) and Iraq (16.3% estimated vs 10.1% observed), equating to 3672 additional deaths (95% CI, 3209-4244 deaths), of which 1623 (44.2%) were associated with the interventions studied: 474 deaths (12.9%) (95% CI, 439-510) associated with the use of tourniquets, 873 (23.8%) (95% CI, 840-910) with blood transfusion, and 275 (7.5%) (95% CI, 259-292) with prehospital transport times.

Conclusions and Relevance

Our analysis suggests that increased use of tourniquets, blood transfusions, and more rapid prehospital transport were associated with 44.2% of total mortality reduction. More critically injured casualties reached surgical care, with increased survival, implying improvements in prehospital and hospital care.

Effects of whole blood leukoreduction on platelet function and hemostatic parameters

AIMS/OBJECTIVES

The aim of this study was to evaluate the hemostatic consequences of whole blood leukoreduction (LR).

BACKGROUND

Whole blood is being used for trauma resuscitation in the military, and an increasing number of civilian trauma centres across the nation. The benefits of LR, such as decreased infectious and transfusion-related complications, are well established, but the effects on hemostatic parameters remain a concern.

METHODS

Twenty-four units of whole blood were assigned to one of the four groups: non-leukoreduced (NLR), leukoreduced at 1 h and a height of 33 in. (LR-1), leukoreduced at 4 h and a height of 33 in. (LR-4(33)), or leukoreduced at 4 h and a height of 28 in. (LR-4(28)). Viscoelastic parameters, platelet aggregation, cell counts, physiological parameters and thrombin potential were evaluated immediately before and after LR, and on days 1, 7, 14 and 21 following LR.

RESULTS

The viscoelastic parameters and thrombin generation potential were unchanged between the groups. Platelet aggregation was reduced in the LR-1 group compared with NLR after 7 days. The LR-4(28) group also showed a trend of reduced platelet aggregation compared with NLR. Aggregation in LR-4(33) was similar to NLR throughout the storage time. Physiological and electrolyte changes over the whole blood storage period were not affected by LR.

CONCLUSION

Our study shows that whole blood can be LR at 4 h after collection and a height of 33 in. while maintaining platelet count and without altering platelet function and hemostatic performance.

Predictors of postinjury acute respiratory distress syndrome: Lung injury persists in the era of hemostatic resuscitation

BACKGROUND

Acute respiratory distress syndrome (ARDS) following trauma is historically associated with crystalloid and blood product exposure. Advances in resuscitation have occurred over the last decade, but their impact on ARDS is unknown. We sought to investigate predictors of postinjury ARDS in the era of hemostatic resuscitation.

METHODS

Data were prospectively collected from arrival to 28 days for 914 highest-level trauma activations who required intubation and survived more than 6 hours from 2005 to 2016 at a Level I trauma center. Patients with ratio of partial pressure of oxygen to fraction of inspired oxygen of 300 mmHg or less during the first 8 days were identified. Two blinded expert clinicians adjudicated all chest radiographs for bilateral infiltrates in the first 8 days. Those with left-sided heart failure detected were excluded. Multivariate logistic regression was used to define predictors of ARDS.

RESULTS

Of the 914 intubated patients, 63% had a ratio of partial pressure of oxygen to fraction of inspired oxygen of 300 or less, and 22% developed ARDS; among the ARDS cases, 57% were diagnosed early (in the first 24 hours), and 43% later. Patients with ARDS diagnosed later were more severely injured (ISS 32 vs. 20, p = 0.001), with higher rates of blunt injury (84% vs. 72%, p = 0.008), chest injury (58% vs. 36%, p < 0.001), and traumatic brain injury (72% vs. 48%, p < 0.001) compared with the no ARDS group. In multivariate analysis, head/chest Abbreviated Injury Score scores, crystalloid from 0 to 6 hours, and platelet transfusion from 0 to 6 hours and 7 to 24 hours were independent predictors of ARDS developing after 24 hours.

CONCLUSIONS

Blood and plasma transfusion were not independently associated with ARDS. However, platelet transfusion was a significant independent risk factor. The role of platelets warrants further investigation but may be mechanistically explained by lung injury models of pulmonary platelet sequestration with peripheral thrombocytopenia.

LEVEL OF EVIDENCE

Prognostic study, level IV.

Plasma-first resuscitation to treat haemorrhagic shock during emergency ground transportation in an urban area: a randomised trial

BACKGROUND

Plasma is integral to haemostatic resuscitation after injury, but the timing of administration remains controversial. Anticipating approval of lyophilised plasma by the US Food and Drug Administration, the US Department of Defense funded trials of prehospital plasma resuscitation. We investigated use of prehospital plasma during rapid ground rescue of patients with haemorrhagic shock before arrival at an urban level 1 trauma centre.

METHODS

The Control of Major Bleeding After Trauma Trial was a pragmatic, randomised, single-centre trial done at the Denver Health Medical Center (DHMC), which houses the paramedic division for Denver city. Consecutive trauma patients in haemorrhagic shock (defined as systolic blood pressure [SBP] ≤70 mm Hg or 71-90 mm Hg plus heart rate ≥108 beats per min) were assessed for eligibility at the scene of the injury by trained paramedics. Eligible patients were randomly assigned to receive plasma or normal saline (control). Randomisation was achieved by preloading all ambulances with sealed coolers at the start of each shift. Coolers were randomly assigned to groups 1:1 in blocks of 20 according to a schedule generated by the research coordinators. If the coolers contained two units of frozen plasma, they were defrosted in the ambulance and the infusion started. If the coolers contained a dummy load of frozen water, this indicated allocation to the control group and saline was infused. The primary endpoint was mortality within 28 days of injury. Analyses were done in the as-treated population and by intention to treat. This trial is registered with ClinicalTrials.gov, number NCT01838863.

FINDINGS

From April 1, 2014, to March 31, 2017, paramedics randomly assigned 144 patients to study groups. The as-treated analysis included 125 eligible patients, 65 received plasma and 60 received saline. Median age was 33 years (IQR 25-47) and median New Injury Severity Score was 27 (10-38). 70 (56%) patients required blood transfusions within 6 h of injury. The groups were similar at baseline and had similar transport times (plasma group median 19 min [IQR 16-23] vs control 16 min [14-22]). The groups did not differ in mortality at 28 days (15% in the plasma group vs 10% in the control group, p=0·37). In the intention-to-treat analysis, we saw no significant differences between the groups in safety outcomes and adverse events. Due to the consistent lack of differences in the analyses, the study was stopped for futility after 144 of 150 planned enrolments.

INTERPRETATION

During rapid ground rescue to an urban level 1 trauma centre, use of prehospital plasma was not associated with survival benefit. Blood products might be beneficial in settings with longer transport times, but the financial burden would not be justified in an urban environment with short distances to mature trauma centres.

FUNDING

US Department of Defense.

Platelet transfusions improve hemostasis and survival in a substudy of the prospective, randomized PROPPR trial

Transfusing platelets during massive hemorrhage is debated because of a lack of high-quality evidence concerning outcomes in trauma patients. The objective of this study was to examine the effect of platelet transfusions on mortality in severely injured trauma patients. This work analyzed PROPPR (Pragmatic, Randomized Optimal Platelet and Plasma Ratios) trial patients who received only the first cooler of blood products, which either did or did not contain platelets. Primary outcomes were all-cause mortality at 24 hours and 30 days and hemostasis. Secondary outcomes included cause of death, complications, and hospital-, intensive care unit (ICU)-, and ventilator-free days. Continuous variables were compared using Wilcoxon rank sum tests. Categorical variables were compared using Fisher's exact tests. There were 261 PROPPR patients who achieved hemostasis or died before receiving a second cooler of blood products (137 received platelets and 124 did not). Patients who received platelets also received more total plasma (median, 3 vs 2 U; P < .05) by PROPPR intervention design. There were no differences in total red blood cell transfusions between groups. After controlling for plasma volume, patients who received platelets had significantly decreased 24-hour (5.8% vs 16.9%; P < .05) and 30-day mortality (9.5% vs 20.2%; P < .05). More patients in the platelet group achieved hemostasis (94.9% vs 73.4%; P < .01), and fewer died as a result of exsanguination (1.5% vs 12.9%; P < .01). Patients who received platelets had a shorter time on mechanical ventilation (P < .05); however, no differences in hospital- or ICU-free days were observed. In conclusion, early platelet administration is associated with improved hemostasis and reduced mortality in severely injured, bleeding patients. This trial was registered at www.clinicaltrials.gov as # NCT01545232.

Platelet transfusion increases risk for acute respiratory distress syndrome in non-massively transfused blunt trauma patients

PURPOSE

While damage control resuscitation is known to confer a survival advantage in severely injured patients, high-ratio blood component therapy should be initiated only in carefully selected trauma patients, due to the morbidity associated with blood product use. With this project, we aim to identify the effect of platelet transfusion in non-massively transfused bluntly injured patients.

METHODS

The Glue Grant database was retrospectively queried and severely injured blunt trauma patients who underwent non-massive transfusion were identified. Patients were divided into quartiles depending on platelet volume they were transfused in the first 48 h. Outcomes of interest included mortality; ventilator, Intensive Care Unit (ICU) and hospital length of stay (LOS); infectious and non-infectious complications. Multivariable regression models were fitted for these outcomes, controlling for age, pre-existing comorbidities, injury severity, acute physiologic derangement, neurologic injury burden, and other fluid and blood product resuscitation.

RESULTS

There was no difference in mortality, LOS, or the incidence of multi-organ failure and infectious complications. However, patients receiving ≥ 250 mL of platelets were more likely to develop acute respiratory distress syndrome (ARDS) compared to those who received < 250 mL [odds ratio 1.91 (95% CI 1.10-3.33, p = 0.022)].

CONCLUSIONS

Pre-emptive platelet transfusion should be avoided in non-massively transfused blunt injury victims in the absence of true or functional thrombocytopenia, as it increases risk for ARDS with no survival benefit.

Lyophilized plasma attenuates vascular permeability, inflammation and lung injury in hemorrhagic shock

In severe trauma and hemorrhage the early and empiric use of fresh frozen plasma (FFP) is associated with decreased morbidity and mortality. However, utilization of FFP comes with the significant burden of shipping and storage of frozen blood products. Dried or lyophilized plasma (LP) can be stored at room temperature, transported easily, reconstituted rapidly with ready availability in remote and austere environments. We have previously demonstrated that FFP mitigates the endothelial injury that ensues after hemorrhagic shock (HS). In the current study, we sought to determine whether LP has similar properties to FFP in its ability to modulate endothelial dysfunction in vitro and in vivo. Single donor LP was compared to single donor FFP using the following measures of endothelial cell (EC) function in vitro: permeability and transendothelial monolayer resistance; adherens junction preservation; and leukocyte-EC adhesion. In vivo, using a model of murine HS, LP and FFP were compared in measures of HS- induced pulmonary vascular inflammation and edema. Both in vitro and in vivo in all measures of EC function, LP demonstrated similar effects to FFP. Both FFP and LP similarly reduced EC permeability, increased transendothelial resistance, decreased leukocyte-EC binding and persevered adherens junctions. In vivo, LP and FFP both comparably reduced pulmonary injury, inflammation and vascular leak. Both FFP and LP have similar potent protective effects on the vascular endothelium in vitro and in lung function in vivo following hemorrhagic shock. These data support the further development of LP as an effective plasma product for human use after trauma and hemorrhagic shock.

Perioperative bleeding management in pediatric patients

PURPOSE OF REVIEW

Managing the bleeding pediatric patient perioperatively can be extremely challenging. The primary goals include avoiding hypotension, maintaining adequate tissue perfusion and oxygenation, and maintaining hemostasis. Traditional bleeding management has consisted of transfusion of autologous blood products, however, there is strong evidence that transfusion-related side-effects are associated with increased morbidity and mortality in children. Especially concerning is the increased reported incidence of noninfectious adverse events such as transfusion-related acute lung injury, transfusion-related circulatory overload and transfusion-related immunomodulation. The current approach in perioperative bleeding management of the pediatric patient should focus on the diagnosis and treatment of anemia and coagulopathy with the transfusion of blood products only when clinically indicated and guided by goal-directed strategies.

RECENT FINDINGS

Current guidelines recommend that a comprehensive multimodal patient blood management strategy is critical in optimizing patient care, avoiding unnecessary transfusion of blood and blood product and limiting transfusion-related side-effects.

SUMMARY

This article will highlight current guidelines in perioperative bleeding management for our most vulnerable pediatric patients with emphasis on individualized targeted intervention using point-of-care testing and specific coagulation products.

Treatment of combined traumatic brain injury and hemorrhagic shock with fractionated blood products versus fresh whole blood in a rat model

INTRODUCTION

Treatment of combined traumatic brain injury and hemorrhagic shock, poses a particular challenge due to the possible conflicting consequences. While restoring diminished volume is the treatment goal for hypovolemia, maintaining adequate cerebral perfusion pressure and avoidance of secondary damage remains a treatment goal for the injured brain. Various treatment modalities have been proposed, but the optimal resuscitation fluid and goals have not yet been clearly defined. A growing body of evidence suggests that in hypovolemic shock, resuscitation with fresh whole blood (FWB) may be superior to component therapy without platelets (which are likely to be unavailable in the pre-hospital setting). Nevertheless, the effects of this approach have not been studied in the combined injury. Previously, in a rat model of combined injury we have found that mild resuscitation to MABP of 80 mmHg with FWB is superior to fluid resuscitation or aggressive resuscitation with FWB. In this study, we investigate the physiological and neurological outcomes in a rat model of combined traumatic brain injury (TBI) and hypovolemic shock, submitted to treatment with varying amounts of FWB, compared to similar resuscitation goals with fractionated blood products-red blood cells (RBCs) and plasma in a 1:1 ratio regimen.

MATERIALS AND METHODS

40 male Lewis rats were divided into control and treatment groups. TBI was inflicted by a free-falling rod on the exposed cranium. Hypovolemia was induced by controlled hemorrhage of 30% blood volume. Treatment groups were treated either with fresh whole blood or with RBC + plasma in a 1:1 ratio, achieving a resuscitation goal of a mean arterial blood pressure (MAP) of 80 mmHg at 15 min. MAP was assessed at 60 min, and neurological outcomes and mortality in the subsequent 24 h.

RESULTS

At 60 min, hemodynamic parameters were improved compared to controls, but not significantly different between treatment groups. Survival rates at 48 h were 100% for both of the mildly resuscitated groups (MABP 80 mmHg) with FWB and RBC + plasma. The best neurological outcomes were found in the group mildly resuscitated with FWB and were better when compared to resuscitation with RBC + plasma to the same MABP goal (FWB: Neurological Severity Score (NSS) 6 ± 2, RBC + plasma: NSS 10 ± 2, p = 0.02).

CONCLUSIONS

In this study, we find that mild resuscitation with goals of restoring MAP to 80 mmHg (which is lower than baseline) with FWB, provided better hemodynamic stability and survival. However, the best neurological outcomes were found in the group resuscitated with FWB. Thus, we suggest that resuscitation with FWB is a feasible modality in the combined TBI + hypovolemic shock scenario, and may result in improved outcomes compared to platelet-free component blood products.

Endothelial glycocalyx: basic science and clinical implications

The classic Starling principle proposed that microvascular fluid exchange was determined by a balance of hydrostatic and oncotic pressures relative to the vascular wall and this movement of water was regulated by gaps in the intercellular spaces. However, current literature on the endothelial glycocalyx (a jelly-like protective layer covering the luminal surface of the endothelium) has revised Starling's traditional concepts. This article aims to summarise the literature on the glycocalyx related to its basic science, clinical settings inciting injury, protective strategies and clinical perspectives. Perioperative damage to the glycocalyx structure can increase vascular permeability leading to interstitial fluid shifts, oedema, and increased surgical morbidity. Pathological shedding of the glycocalyx occurs in response to mechanical cellular stress, endotoxins, inflammatory mediators, atrial natriuretic peptide, ischaemia-reperfusion injury, free oxygen radicals and hyperglycaemia. Increased understanding of the endothelial glycocalyx may change perioperative fluid management, and therapeutic strategies aimed at its preservation may improve patient outcomes.

Comparison of the impact of applications of Targeted Transfusion Protocol and Massive Transfusion Protocol in trauma patients

Background

The current study assessed a recently developed resuscitation protocol for bleeding trauma patients called the Targeted Transfusion Protocol (TTP) and compared its results with those of the standard Massive Transfusion Protocol (MTP).

Methods

Per capita utilization of blood products such as packed red blood cells (RBCs), fresh frozen plasma (FFP), and platelet concentrates was compared along with mortality rates during two 6-month periods, one in 2011 (when the standard MTP was followed) and another in 2014 (when the TTP was used). In the TTP, patients were categorized into three groups based on the presence of head injuries, long bone fractures, or penetrating injuries involving the trunk, extremities, or neck who were resuscitated according to separate algorithms. All cases had experienced motor vehicle accidents and had injury severity scores over 16.

Results

No statistically significant differences were observed between the study groups at hospital admission. Per capita utilization of RBC (4.76 ± 0.92 vs. 3.37 ± 0.55; P = 0.037), FFP (3.71 ± 1.00 vs. 2.40 ± 0.52; P = 0.025), and platelet concentrate (1.18 ± 0.30 vs. 0.55 ± 0.18; P = 0.006) blood products were significantly lower in the TTP epoch. Mortality rates were similar between the two study periods (P = 0.74).

Conclusions

Introduction of the TTP reduced the requirements for RBCs, FFP, and platelet concentrates in severely injured trauma patients.

The pragmatic randomized optimal platelet and plasma ratios trial: what does it mean for remote damage control resuscitation?

BACKGROUND

Implications from the pragmatic, randomize, optimal platelet and plasma ratios (PROPPR) trial are critical for remote damage control resuscitation (DCR). Utilizing DCR principals in remote settings can combat early mortality from hemorrhage. Identifying the appropriate transfusion strategy is mandatory prior to adopting prehospital hemostatic resuscitation strategies.

STUDY DESIGN AND METHODS

The PROPPR study was examined in relation to the following questions: 1) Why is it important to have blood products in the prehospital setting?; 2) Which products should be investigated for prehospital hemostatic resuscitation?; 3) What is the appropriate ratio of blood product transfusion?; and 4) What are the appropriate indications for hemostatic resuscitation?

RESULTS

PROPPR demonstrates that early and balanced blood product transfusion ratios reduced mortality in all patients at 3 hours and death from exsanguination at 24 hours (p = 0.03). The median time to death from exsanguination was 2.3 hours, highlighting the need for point-of-injury DCR capabilities. A 1:1:1 transfusion ratio of plasma:platelets:packed red blood cells increased the percentage of patients achieving anatomic hemostasis (p = 0.006). PROPPR used the assessment of blood consumption score to identify patients likely to require ongoing hemostatic resuscitation. The critical administration threshold predicted patient mortality and identified patients likely to require ongoing hemostatic resuscitation.

CONCLUSION

A balanced resuscitation strategy demonstrates an early survival benefit, decreased death from exsanguination at 24 hours and a greater likelihood of achieving hemostasis in critically injured patients receiving a 1:1:1 ratio of plasma:platelets:PRBCs. This finding highlights the need to import DCR principals to remote locations.

Whole blood transfusion closest to the point-of-injury during French remote military operations

To improve the survival of combat casualties, interest in the earliest resort to whole blood (WB) transfusion on the battlefield has been emphasized. Providing volume, coagulation factors, plasma, and oxygenation capacity, WB appears actually as an ideal product severe trauma management. Whole blood can be collected in advance and stored for subsequent use, or can be drawn directly on the battlefield, once a soldier is wounded, from an uninjured companion and immediately transfused.Such concepts require a great control of risks at each step, especially regarding ABO mismatches, and transfusion-transmitted diseases. We present here the "warm and fresh" WB field transfusion program implemented among the French armed forces. We focus on the followed strategies to make it applicable on the battlefield, even during special operations and remote settings, and safe for recipients as well as for donors.

Incidence, risk factors, and mortality associated with acute respiratory distress syndrome in combat casualty care

BACKGROUND

The overall incidence and mortality of acute respiratory distress syndrome (ARDS) in civilian trauma settings have decreased over the past four decades; however, the epidemiology and impact of ARDS on modern combat casualty care are unknown. We sought to determine the incidence, risk factors, resource utilization, and mortality associated with ARDS in current combat casualty care.

METHODS

This was a retrospective review of mechanically ventilated US combat casualties within the Department of Defense Trauma Registry (formerly the Joint Theater Trauma Registry) during Operation Iraqi Freedom/Enduring Freedom (October 2001 to August 2008) for ARDS development, resource utilization, and mortality.

RESULTS

Of 18,329 US Department of Defense Trauma Registry encounters, 4,679 (25.5%) required mechanical ventilation; ARDS was identified in 156 encounters (3.3%). On multivariate logistic regression, ARDS was independently associated with female sex (odds ratio [OR], 2.62; 95% confidence interval [CI], 1.21-5.71; p = 0.02), higher military-specific Injury Severity Score (Mil ISS) (OR, 4.18; 95% CI, 2.61-6.71; p < 0.001 for Mil ISS ≥25 vs. <15), hypotension (admission systolic blood pressure <90 vs. ≥90 mm Hg; OR, 1.76; 95% CI, 1.07-2.88; p = 0.03), and tachycardia (admission heart rate ≥90 vs. <90 beats per minute; OR, 1.53; 95% CI, 1.06-2.22; p = 0.02). Explosion injury was not associated with increased risk of ARDS. Critical care resource utilization was significantly higher in ARDS patients as was all-cause hospital mortality (ARDS vs. no ARDS, 12.8% vs. 5.9%; p = 0.002). After adjustment for age, sex, injury severity, injury mechanism, Mil ISS, hypotension, tachycardia, and admission Glasgow Coma Scale score, ARDS remained an independent risk factor for death (OR, 1.99; 95% CI, 1.12-3.52; p = 0.02).

CONCLUSIONS

In this large cohort of modern combat casualties, ARDS risk factors included female sex, higher injury severity, hypotension, and tachycardia, but not explosion injury. Patients with ARDS also required more medical resources and were at greater risk of death compared with patients without ARDS. Thus, ARDS remains a significant complication in current combat casualty care.

LEVEL OF EVIDENCE

Prognostic/epidemiologic study, level III.

Adiponectin in Fresh Frozen Plasma Contributes to Restoration of Vascular Barrier Function After Hemorrhagic Shock

Hemorrhagic shock is the leading cause of preventable deaths in civilian and military trauma. Use of fresh frozen plasma (FFP) in patients requiring massive transfusion is associated with improved outcomes. FFP contains significant amounts of adiponectin, which is known to have vascular protective function. We hypothesize that FFP improves vascular barrier function largely via adiponectin. Plasma adiponectin levels were measured in 19 severely injured patients in hemorrhagic shock (HS). Compared with normal individuals, plasma adiponectin levels decreased to 49% in HS patients before resuscitation (P < 0.05) and increased to 64% post-resuscitation (but not significant). In a HS mouse model, we demonstrated a similar decrease in plasma adiponectin to 54% but a significant increase to 79% by FFP resuscitation compared with baseline (P < 0.05). HS disrupted lung vascular barrier function, leading to an increase in permeability. FFP resuscitation reversed these HS-induced effects. Immunodepletion of adiponectin from FFP abolished FFP's effects on blocking endothelial hyperpermeability in vitro, and on improving lung vascular barrier function in HS mice. Replenishment with adiponectin rescued FFP's effects. These findings suggest that adiponectin is an important component in FFP resuscitation contributing to the beneficial effects on vascular barrier function after HS.

Tactical damage control resuscitation in austere military environments

BACKGROUND

Despite the early uses of tourniquets and haemostatic dressings, blood loss still accounts for the vast majority of preventable deaths on the battlefield. Over the last few years, progress has been made in the management of such injuries, especially with the use of damage control resuscitation concepts. The early application of these procedures, on the field, may constitute the best opportunity to improve survival from combat injury during remote operations.

DATA SOURCES

Currently available literature relating to trauma-induced coagulopathy treatment and far-forward transfusion was identified by searches of electronic databases. The level of evidence and methodology of the research were reviewed for each article. The appropriateness for field utilisation of each medication was then discussed to take into account the characteristics of remote military operations.

CONCLUSIONS

In tactical situations, in association with haemostatic procedures (tourniquet, suture, etc), tranexamic acid should be the first medication used according to the current guidelines. The use of fibrinogen concentrate should also be considered for patients in haemorrhagic shock, especially if point-of-care (POC) testing of haemostasis or shock severity is available. If POC evaluation is not available, it seems reasonable to still administer this treatment after clinical assessment, particularly if the evacuation is delayed. In this situation, lyophilised plasma may also be given as a resuscitation fluid while respecting permissive hypotension. Whole blood transfusion in the field deserves special attention. In addition to the aforementioned treatments, if the field care is prolonged, whole blood transfusion must be considered if it does not delay the evacuation.

Implementation of a management protocol for massive bleeding reduces mortality in non-trauma patients: Results from a single centre audit

OBJECTIVE

To audit the impact upon mortality of a massive bleeding management protocol (MBP) implemented in our center since 2007.

DESIGN

A retrospective, single-center study was carried out. Patients transfused after MBP implementation (2007-2012, Group 2) were compared with a historical cohort (2005-2006, Group 1).

BACKGROUND

Massive bleeding is associated to high mortality rates. Available MBPs are designed for trauma patients, whereas specific recommendations in the medical/surgical settings are scarce.

PATIENTS

After excluding patients who died shortly (<6h) after MBP activation (n=20), a total of 304 were included in the data analysis (68% males, 87% surgical).

INTERVENTIONS

Our MBP featured goal-directed transfusion with early use of adjuvant hemostatic medications.

VARIABLES OF INTEREST

Primary endpoints were 24-h and 30-day mortality. Fresh frozen plasma-to-red blood cells (FFP:RBC) and platelet-to-RBC (PLT:RBC) transfusion ratios, time to first FFP unit and the proactive MBP triggering rate were secondary endpoints.

RESULTS

After MBP implementation (Group 2; n=222), RBC use remained stable, whereas FFP and hemostatic agents increased, when compared with Group 1 (n=82). Increased FFP:RBC ratio (p=0.053) and earlier administration of FFP (p=0.001) were also observed, especially with proactive MBP triggering. Group 2 patients presented lower rates of 24-h (0.5% vs. 7.3%; p=0.002) and 30-day mortality (15.9% vs. 30.2%; p=0.018) - the greatest reduction corresponding to non-surgical patients. Logistic regression showed an independent protective effect of MBP implementation upon 30-day mortality (OR=0.3; 95% CI 0.15-0.61).

CONCLUSIONS

These data suggest that the implementation of a goal-directed MBP for prompt and aggressive management of non-trauma, massive bleeding patients is associated to reduced 24-h and 30-day mortality rates.

Correlations of perioperative coagulopathy, fluid infusion and blood transfusions with survival prognosis in endovascular aortic repair for ruptured abdominal aortic aneurysm

BACKGROUND

Factors associated with survival prognosis among patients who undergo endovascular aortic repair (EVAR) for ruptured abdominal aortic aneurysms (rAAA) have not been sufficiently investigated. In the present study, we examined correlations between perioperative coagulopathy and 24-h and 30-day postoperative survival. Relationships between coagulopathy and the content of blood transfusions, volumes of crystalloid infusion and survival.

METHODS

This was a retrospective study of the medical records of all patients who underwent EVAR for rAAA at Chiba-Nishi General Hospital during the period from October 2013 to December 2015. Major coagulopathy was defined using the international normalized ratio or activated partial thromboplastin time (APTT) ratio of at least 1.5, or platelet count less than 50 × 10/l. We quantified the amounts of blood transfusions and crystalloid infusions administered from arrival to the hospital to admission to ICU following operations.

RESULTS

Coagulopathy among patients with rAAA was found to progress even after they had presented at the hospital. No statistically significant correlation between preoperative coagulopathy and mortality was found, although a significantly greater degree of postoperative coagulopathy was seen among patients who died both within 24-h and 30 days postoperatively. Among patients with postoperative coagulopathy, lesser quantities of fresh frozen plasma (FFP) compared with red cell concentrate (RCC) were used during the period from hospital arrival to postoperative ICU entry. In both groups of patients who did not survive after 24-h and 30 days, FFP was used less than RCC. Large transfusions of crystalloids administered during the periods from hospital arrival to surgery and from hospital arrival to the end of surgery were associated with postoperative incidence of major coagulopathy, death within 24-h, and death within 30 days.

CONCLUSION

Coagulopathy progressed during care in the emergency outpatient clinic and operations. Postoperative coagulopathy was associated with poorer outcomes. Smaller FFP/RCC ratios and larger volumes of crystalloid infusion were associated with development of coagulopathy and poorer prognosis of survival.

TRIAL REGISTRATION

This study is retrospectively registered in UMIN Clinical Trials Registry (Registration 19 April 2016, registered number is R000025334 UMIN000021978).

Damage control: The modern paradigm

It is more than 20 years since the term ‘Damage control’ was introduced to describe an emerging surgical strategy of abbreviated laparotomy for exsanguinating trauma patients. This strategy of temporisation and prioritisation of physiological recovery over completeness of anatomical repair was associated with improved survival in a subset of patients with combined major vascular and multiple visceral injuries. The ensuing years saw the rapid adoption of these principles as standard of care for massively injured and physiologically exhausted patients. Resuscitation of severely injured patients has changed significantly in the last decade with the emergence of a new resuscitation paradigm termed ‘damage control resuscitation’. Originating in combat support hospitals, damage control resuscitation emphasises the primacy of haemorrhage control while directly targeting the ‘lethal triad’ of coagulopathy, acidosis, and hypothermia. Integral to damage control resuscitation is the appropriate application of damage control surgery and together they constitute the modern damage control paradigm. This review aims to discuss the modern application of damage control resuscitation and damage control surgery and to review the evidence supporting its constituent components, as well as considering deficiencies in current knowledge and areas for future research.

[Multidisciplinary consensus document on the management of massive haemorrhage (HEMOMAS document)]

Massive haemorrhage is common and often associated with high morbidity and mortality. We perform a systematic review of the literature, with extraction of the recommendations from the existing evidences because of the need for its improvement and the management standardization. From the results we found, we wrote a multidisciplinary consensus document. We begin with the agreement in the definitions of massive haemorrhage and massive transfusion, and we do structured recommendations on their general management (clinical assessment of bleeding, hypothermia management, fluid therapy, hypotensive resuscitation and damage control surgery), blood volume monitoring, blood products transfusion (red blood cells, fresh frozen plasma, platelets and their best transfusion ratio), and administration of hemostatic components (prothrombin complex, fibrinogen, factor VIIa, antifibrinolytic agents).

Multidisciplinary consensus document on the management of massive haemorrhage (HEMOMAS document)

Massive haemorrhage is common and often associated with high morbidity and mortality. We perform a systematic review of the literature, with extraction of the recommendations from the existing evidences because of the need for its improvement and the management standardization. From the results we found, we wrote a multidisciplinary consensus document. We begin with the agreement in the definitions of massive haemorrhage and massive transfusion, and we do structured recommendations on their general management (clinical assessment of bleeding, hypothermia management, fluid therapy, hypotensive resuscitation and damage control surgery), blood volume monitoring, blood products transfusion (red blood cells, fresh frozen plasma, platelets and their best transfusion ratio), and administration of hemostatic components (prothrombin complex, fibrinogen, factor VIIa, antifibrinolytic agents).

All the bang without the bucks: Defining essential point-of-care testing for traumatic coagulopathy

BACKGROUND

Rapid assessment and treatment of coagulopathy reduces postinjury morbidity and mortality. Although thrombelastography (TEG) may be more accurate and efficient than conventional coagulation tests, it requires significant financial and personnel investments. We hypothesized that point-of-care international normalized ratio (POC INR) may provide a rapid and accurate alternative to TEG.

METHODS

A retrospective review of sequential trauma patients who underwent both POC INR and rapid TEG (r-TEG) testing upon presentation to a Level I trauma center from July 2012 to December 2013 was performed. POC INR was compared with r-TEG values (R value, K time, α angle, maximum amplitude, percent clot lysis in 30 minutes) and transfusion requirements. Vital signs, admission laboratory values, and injury severity were analyzed. POC INR and venous blood gas testing was performed in the emergency department. All results and Pearson correlations noted were significant if p < 0.05.

RESULTS

We identified 628 trauma patients with concomitant r-TEG and POC INR testing. Median Injury Severity Score (ISS) was 13, 20% arrived in shock (base value < -5), 21% were transfused, and 11% died. POC INR correlated with all r-TEG values, with stronger correlations for patients in shock. POC INR and r-TEG had similar correlations with blood products transfused at 4 hours and 24 hours, but only POC INR predicted substantial bleeding and massive transfusion. POC INR also correlated strongly with standard INR testing. POC INR test duration was less than 1 minute, compared with at least 30 minutes for r-TEG. Total cohort charges for POC INR were estimated at $21,980 versus $396,896 for r-TEG.

CONCLUSION

POC INR testing is faster and cheaper than r-TEG. In addition, POC INR correlates not only with r-TEG values but also with acute blood product transfusions. POC INR provides a practical alternative for rapid coagulopathy assessment in the trauma patient at institutions that lack TEG capability.

LEVEL OF EVIDENCE

Diagnostic study, level III. Therapeutic/care management study, level IV.

Making thawed universal donor plasma available rapidly for massively bleeding trauma patients: experience from the Pragmatic, Randomized Optimal Platelets and Plasma Ratios (PROPPR) trial

BACKGROUND

The Pragmatic, Randomized Optimal Platelets and Plasma Ratios (PROPPR) trial was a randomized clinical trial comparing survival after transfusion of two different blood component ratios for emergency resuscitation of traumatic massive hemorrhage. Transfusion services supporting the study were expected to provide thawed plasma, platelets, and red blood cells within 10 minutes of request.

STUDY DESIGN AND METHODS

At the 12 Level 1 trauma centers participating in PROPPR, blood components transfused and delivery times were tabulated, with a focus on universal donor (UD) plasma management. The adequacy of site plans was assessed by comparing the bedside blood availability times to study goals and the new American College of Surgeons guidelines.

RESULTS

Eleven of 12 sites were able to consistently deliver 6 units of thawed UD plasma to their trauma-receiving unit within 10 minutes and 12 units in 20 minutes. Three sites used blood group A plasma instead of AB for massive transfusion without complications. Approximately 4700 units of plasma were given to the 680 patients enrolled in the trial. No site experienced shortages of AB plasma that limited enrollment. Two of 12 sites reported wastage of thawed AB plasma approaching 25% of AB plasma prepared.

CONCLUSION

Delivering UD plasma to massively hemorrhaging patients was accomplished consistently and rapidly and without excessive wastage in high-volume trauma centers. The American College of Surgeons Trauma Quality Improvement Program guidelines for massive transfusion protocol UD plasma availability are practicable in large academic trauma centers. Use of group A plasma in trauma resuscitation needs further study.

Balanced ratio of plasma to packed red blood cells improves outcomes in massive transfusion: A large multicenter study

Resuscitation with the early administration of plasma can improve the survival of patients undergoing surgery or trauma patients who require massive transfusion. To ascertain the optimal ratio of fresh frozen plasma (FFP) to packed red blood cells (pRBCs) in massive transfusions, the records of 1,048 patients who received a massive transfusion at 20 hospitals were retrospectively reviewed. The patients were stratified into three groups according to the ratio of FFP to pRBCs. These were the low (<1:2.3), middle (1:2.3-0.75) and high (≥1:0.75) ratio groups. For 24-h treatment, the middle FFP:pRBC ratio led to a lower mortality rate (9.31%) compared with that in the low (11.83%) and high (11.44%) ratio groups (P=0.477). For 72-h treatment, the middle FFP:pRBC ratio also lead to the lowest mortality rate (7.25%), which was significantly lower than the ratios in the low (10.39%) and high (13.65%) ratio groups (P=0.007). The length of hospital stay, ICU stay, and FFP:pRBC ratio in 72 h were found to be significant associated with mortality. The optimal ratio of FFP to pRBCs of 1:2.3-0.75 in 72 h can improve the survival of patients undergoing massive transfusions.

Thawed and liquid plasma--what do we know?

There is increasing interest in the use of liquid or frozen plasma thawed and stored for extended periods (>24 h) to reduce wastage and to improve rapid availability of plasma in massive transfusion protocols advocating the early use of plasma in trauma by some centres. There is now a body of studies that have assessed individual coagulation factors during storage of thawed plasma. These show that factor VIII (FVIII) is the worst affected factor and that its activity is mainly lost during the first 24 h following thawing. However, for most factors studied, there is a continual decline during further storage. The few studies that have assessed thrombin generation in thawed plasma have shown variable results. Extended storage of plasma is associated with an increase in levels of DEHP in the component and could theoretically increase the risk of bacterial contamination, although the latter does not appear to have been an issue in countries that have adopted the use of thawed plasma. There are no clinical studies relating to the efficacy of extended-thawed plasma, and therefore, the potential reduction in its efficacy must be balanced with the clinical need for the component.

The natural history and effect of resuscitation ratio on coagulation after trauma: a prospective cohort study

OBJECTIVE

To investigate the natural history of coagulation factor perturbation after injury and identify longitudinal differences in clotting factor repletion by red blood cell:fresh frozen plasma (RBC:FFP) transfusion ratio.

BACKGROUND

Hemostatic transfusion ratios of RBC to FFP approaching 1:1 are associated with a survival advantage in traumatic hemorrhage, even in patients with normal coagulation studies.

METHODS

Plasma was prospectively collected from 336 trauma patients during their intensive care unit stay for up to 72 hours from February, 2005, to October, 2011. Standard coagulation studies as well as pro- and anticoagulant clotting factors were measured. RBC:FFP transfusion ratios were calculated at 6 hours after arrival and dichotomized into "low ratio" (RBC:FFP ≤ 1.5:1) and "high ratio" (RBC:FFP > 1.5:1) groups.

RESULTS

Factor-level measurements from 193 nontransfused patients provide an early natural history of clotting factor-level changes after injury. In comparison, 143 transfused patients had more severe injury, prolonged prothrombin time and partial thromboplastin time (PTT), and lower levels of both pro- and anticoagulants up to 24 hours. PTT was prolonged up to 12 hours and only returned to admission baseline at 48 hours in "high ratio" patients versus correction by 6 hours in "low ratio" patients. Better repletion of factors V, VIII, and IX was seen longitudinally, and both unadjusted and injury-adjusted survival was significantly improved in "low ratio" versus "high ratio" groups.

CONCLUSIONS

Resuscitation with a "low ratio" of RBC:FFP leads to earlier correction of coagulopathy, and earlier and prolonged repletion of some but not all procoagulant factors. This prospective evidence suggests hemostatic resuscitation as an interim standard of care for transfusion in critically injured patients pending the results of ongoing randomized study.

Inflammatory response to trauma: implications for coagulation and resuscitation

PURPOSE OF REVIEW

Recent studies have changed our understanding of the timing and interactions of the inflammatory processes and coagulation cascade following severe trauma. This review highlights this information and correlates its impact on the current clinical approach for fluid resuscitation and treatment of coagulopathy for trauma patients.

RECENT FINDINGS

Severe trauma is associated with a failure of multiple biologic emergency response systems that includes imbalanced inflammatory response, acute coagulopathy of trauma, and endovascular glycocalyx degradation with microcirculatory compromise. These abnormalities are all interlinked and related. Recent observations show that after severe trauma: proinflammatory and anti-inflammatory responses are concomitant, not sequential and resolution of the inflammatory response is an active process, not a passive one. Understanding these interrelated processes is considered extremely important for the development of future therapies for severe trauma in humans.

SUMMARY

Traumatic injuries continue to be a significant cause of mortality worldwide. Recent advances in understanding the mechanisms of end-organ failure, and modulation of the inflammatory response has important clinical implications regarding fluid resuscitation and treatment of coagulopathy.

Injured children are resistant to the adverse effects of early high volume crystalloid resuscitation

INTRODUCTION

Excessive crystalloid resuscitation of blunt injured adults is deleterious. We hypothesize that children, unlike adults, are resistant to the adverse effects of high volume resuscitation.

METHODS

We reviewed the trauma databases at two level-one trauma centers, including all children age 4-16years admitted following blunt trauma with an injury severity score (ISS) ≥15 to determine the relationship between crystalloid volume received and clinical outcomes.

RESULTS

A total of 384 children were included. After controlling for age, sex, AIS head, ISS, GCS on presentation, hemoglobin, blood transfusion, and surgical procedures in the first 24hours, crystalloid volume greater than 60ml/kg in the first 24hours was associated with increased length of stay (LOS) and need for mechanical ventilation. On univariate analysis, initial crystalloid volume of >60ml/kg was associated with anemia and thrombocytopenia. Volume of resuscitation was not associated with ARDS, ACS, MOF, urinary tract infection, or blood stream infection. However, these complications were exceedingly rare, with no children developing MOF.

CONCLUSIONS

Excessive crystalloid resuscitation was associated with increased hospital LOS and need for mechanical ventilation. Increased rates of other complications including ARDS, ACS, and MOF were not observed. Injured children appear relatively resistant to some of the adverse effects of early high volume fluid resuscitation.

Risks associated with red blood cell transfusion in the trauma population, a meta-analysis

INTRODUCTION

A previous meta-analysis has found an association between red blood cell (RBC) transfusions and mortality in critically ill patients, but no review has focused on the trauma population only.

OBJECTIVES

To determine the association between RBC transfusion and mortality in the trauma population, with secondary outcomes of multiorgan failure (MOF) and acute respiratory distress syndrome (ARDS) or acute lung injury (ALI).

DATA SOURCES

EMBASE (1947-2012) and MEDLINE (1946-2012).

STUDY ELIGIBILITY CRITERIA

Randomized controlled trials and observational studies were to be included if they assessed the association between RBC transfusion and either the primary (mortality) or secondary outcomes (MOF, ARDS/ALI).

PARTICIPANTS

Trauma patients.

EXPOSURE

Red blood cell transfusion.

METHODS

A literature search was completed and reviewed in duplicate to identify eligible studies. Studies were included in the pooled analyses if an attempt was made to determine the association between RBC and the outcomes, after adjusting for important confounders. A random effects model was used for and heterogeneity was quantified using the I(2) statistic. Study quality was assessed using the Newcastle-Ottawa Scale.

RESULTS

40 observational studies were included in the qualitative review. Including studies which adjusted for important confounders found the odds of mortality increased with each additional unit of RBC transfused (9 Studies, OR 1.07, 95%CI 1.04-1.10, I(2) 82.9%). The odds of MOF (3 studies, OR 1.08, 95%CI 1.02-1.14, I(2) 95.9%) and ARDS/ALI (2 studies, OR 1.06, 95%CI 1.03-1.10, I(2) 0%) also increased with each additional RBC unit transfused.

CONCLUSIONS

We have found an association between RBC transfusion and the primary and secondary outcomes, based on observational studies only. This represents the extent of the published literature. Further interventional studies are needed to clarify how limiting transfusion can affect mortality and other outcomes.

Application of damage control resuscitation strategies to patients with severe traumatic hemorrhage: review of plasma to packed red blood cell ratios at a single institution

When treating trauma patients with severe hemorrhage, massive transfusions are often needed. Damage control resuscitation strategies can be used for such patients, but an adequate fresh frozen plasma: packed red blood cell (FFP:PRBC) administration ratio must be established. We retrospectively reviewed the medical records of 100 trauma patients treated with massive transfusions from March 2010 to October 2012. We divided the patients into 2 groups according to the FFP:PRBC ratio: a high-ratio (≥0.5) and a low-ratio group (<0.5). The patient demographics, fluid and transfusion quantities, laboratory values, complications, and outcomes were analyzed and compared. There were 68 patients in the high-ratio and 32 in the low-ratio group. There were statistically significant differences between groups in the quantities of FFP, FFP:PRBC, platelets, and crystalloids administered, as well as the initial diastolic blood pressure. Bloodstream infections were noted only in the high-ratio group, and the difference was statistically significant (P=0.028). Kaplan-Meier plots revealed that the 24-hr survival rate was significantly higher in the high-ratio group (71.9% vs. 97.1%, P<0.001). In severe hemorrhagic trauma, raising the FFP:PRBC ratio to 0.5 or higher may increase the chances of survival. Efforts to minimize bloodstream infections during the resuscitation must be increased.