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Abstract
Hemorrhage is the leading cause of preventable deaths in trauma patients. After presenting a brief history of hemorrhagic shock resuscitation, this article discusses damage control resuscitation and its adjuncts. Massively bleeding patients in hypovolemic shock should be treated with damage control resuscitation principles including limited crystalloid, whole blood or balance blood component transfusion to permissive hypotension, preventing hypothermia, and stopping bleeding as quickly as possible.
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52
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Ramsey G. Blood component transfusions in mass casualty events. Vox Sang 2017; 112:648-659. [PMID: 28891209 DOI: 10.1111/vox.12564] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Revised: 07/06/2017] [Accepted: 07/10/2017] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND OBJECTIVES Planning transfusion needs in mass casualty events (MCE) is critical for disaster preparedness. Published data on blood component usage were analysed to seek correlative factors and usage rates. MATERIALS AND METHODS English-language medical publications since 1980 were searched for MCEs with numbers of patient admissions and transfused RBCs. Reports were excluded from natural disasters or with total RBC use <50 units. Statistical analysis employed Mann-Whitney U-tests and Spearman's rank correlations. RESULTS In 24 reports, the average units per admission were 3·06 RBCs, 2·13 plasmas and 0·37 platelet doses. Five RBCs per admission would have sufficed for 87% of events. Transfusion needs involving bombings correlated with admissions (P ≤ 0·03). In the formula (massive-transfusion patients in MCE) times X = (total units for all MCE patients), the average X was 35 for RBCs (correlation P = 0·01), 17 for plasma (P = 0·10) and five for platelet doses (P = 0·06). From 67% to 84% of all components used were given in the first 24 h (event medians). CONCLUSIONS Blood component use in MCEs correlated with numbers of patients admitted or receiving massive transfusion. More current data are needed to better reflect emerging trauma care practices and refine predictive models of transfusion needs.
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Affiliation(s)
- G Ramsey
- Department of Pathology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA.,Department of Pathology, Northwestern Memorial Hospital, Chicago, IL, USA.,Blood Bank, Northwestern Memorial Hospital, Chicago, IL, USA
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53
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Bommiasamy AK, Schreiber MA. Damage control resuscitation: how to use blood products and manage major bleeding in trauma. ACTA ACUST UNITED AC 2017. [DOI: 10.1111/voxs.12353] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- A. K. Bommiasamy
- Department of Surgery; Oregon Health & Science University; Portland OR USA
| | - M. A. Schreiber
- Department of Surgery; Oregon Health & Science University; Portland OR USA
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54
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Maegele M. [Modern coagulation management in bleeding trauma patients : Point-of-care guided administration of coagulation factor concentrates and hemostatic agents]. Med Klin Intensivmed Notfmed 2017; 114:400-409. [PMID: 28849255 DOI: 10.1007/s00063-017-0337-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2017] [Revised: 07/12/2017] [Accepted: 08/01/2017] [Indexed: 01/25/2023]
Abstract
BACKGROUND Uncontrolled bleeding with trauma-induced coagulopathy (TIC) is still the leading cause of preventable death following severe multiple injury. Rapid diagnosis and treatment are associated with improved outcome. Early individualized goal-directed therapy and the use of point-of-care technology may be superior to empiric and ratio-based therapies with conventional blood products. MATERIALS AND METHODS Selective review of the literature considering current recommendations/expert opinion for coagulation management in bleeding trauma patients via individualized goal-directed therapy and the use of viscoelastic point-of-care (ROTEM®)-guided substitution of coagulation factor concentrates and hemostatic agents. RESULTS The administration of fibrinogen concentrate in bleeding trauma patients may be considered if ROTEM®-FIBTEM A10 < 10 mm (FIBTEM A5 < 9 mm; FIBTEM MCF < 12 mm) and EXTEM A10 < 45 mm (EXTEM A5 < 35 mm; EXTEM MCF < 55 mm); the administration of prothrombin complex concentrate (PCC) may be considered if signs of delayed coagulation initiation (ROTEM®-EXTEM CT > 80 s). At this stage, no concluding statement can be made for monitoring or treatment guidance with factor XIII by using point-of-care technology. Viscoelastic assays display high sensitivity and specificity for the detection of hyperfibrinolysis with subsequent administration of an antifibrinolytic. CONCLUSIONS Individualized therapeutic concepts based upon viscoelastic point-of-care (ROTEM®) assays present an alternative to empiric and ratio-based therapies with conventional blood products in bleeding trauma patients and may be associated with reduced need for allogenic blood products and morbidity.
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Affiliation(s)
- Marc Maegele
- Klinik für Orthopädie, Unfallchirurgie und Sporttraumatologie, Kliniken der Stadt Köln-Merheim, Universität Witten/Herdecke (UW/H), Campus Köln-Merheim, Ostmerheimerstr. 200, 51109, Köln, Deutschland. .,Institut für Forschung in der Operativen Medizin (IFOM), Haus 38, Universität Witten/Herdecke (UW/H), Campus Köln-Merheim, Ostmerheimerstr. 200, 51109, Köln, Deutschland.
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55
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Planinsic RM, Raval JS, Gorantla VS. Anesthesia and Perioperative Care in Reconstructive Transplantation. Anesthesiol Clin 2017; 35:523-538. [PMID: 28784224 DOI: 10.1016/j.anclin.2017.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Reconstructive transplantation of vascularized composite allografts (VCAs), such as upper extremity, craniofacial, abdominal, lower extremity, or genitourinary transplants, has emerged as a cutting-edge specialty, with more than 50 programs in the United States and 30 programs across the world performing these procedures. Most VCAs involve complicated technical planning and preparation, protracted surgery, and complex immunosuppressive or immunomodulatory protocols, each associated with unique anesthesiology challenges. This article outlines key procedural, patient, and protocol-related aspects of VCA relevant to anesthesiology management with the goal of ensuring patient safety and optimizing surgical, immunologic, and functional outcomes.
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Affiliation(s)
- Raymond M Planinsic
- Department of Anesthesiology, University of Pittsburgh Medical Center, 200 Lothrop Street, Suite C-200, Pittsburgh, PA 15213, USA.
| | - Jay S Raval
- Division of Transfusion Medicine, Department of Pathology and Laboratory Medicine, Transfusion Medicine Service, Hematopoietic Progenitor Cell Laboratory, University of North Carolina at Chapel Hill, 101 Manning Drive, Suite C3162, Chapel Hill, NC 27514, USA
| | - Vijay S Gorantla
- Departments of Surgery, Ophthalmology and Bioengineering, US Air Force, Wake Forest Institute for Regenerative Medicine, Wake Forest Baptist Medical Center, Richard H. Dean Biomedical Building, 391 Technology Way, Winston Salem, NC 27101, USA.
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56
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Fahy AS, Thiels CA, Polites SF, Parker M, Ishitani MB, Moir CR, Berns K, Stubbs JR, Jenkins DH, Zietlow SP, Zielinski MD. Prehospital blood transfusions in pediatric trauma and nontrauma patients: a single-center review of safety and outcomes. Pediatr Surg Int 2017; 33:787-792. [PMID: 28547532 DOI: 10.1007/s00383-017-4092-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/09/2017] [Indexed: 11/24/2022]
Abstract
PURPOSE Prehospital transfusions are a novel yet increasingly accepted intervention in the adult population as part of remote damage control resuscitation, but prehospital transfusions remain controversial in children. Our purpose was to review our pediatric prehospital transfusion experience over 12 years to describe the safety of prehospital transfusion in appropriately triaged trauma and nontrauma patients. METHODS Children (<18 years) transfused with packed red blood cells (pRBC) or plasma during transport to a single regional academic medical center between 2002 and 2014 were identified. Admission details, in-hospital clinical course, and outcomes were analyzed. RESULTS 28 children were transfused during transport; median age was 8.9 ± 7 years and 15 patients were male (54%). Most patients required at least one additional unit of blood products during their hospitalization (79%), and/or required operative intervention (53%), endoscopy (7%), or died during their hospitalization (14%). Comparison of trauma patients (n = 16) and nontrauma patients (n = 12) revealed that nontrauma patients were younger, more anemic, more coagulopathy on admission, and required more ongoing transfusion in the hospital. Trauma patients were more likely to need operative intervention. No patient had a transfusion reaction. CONCLUSION Remote damage control prehospital transfusions of blood products were safe in this small group of appropriately triaged pediatric patients. Further studies are needed to determine if outcomes are improved and to devise a rigorous protocol for this prehospital intervention for critically ill pediatric patients.
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Affiliation(s)
- Aodhnait S Fahy
- Department of General Surgery, Mayo Clinic, 200 1st Street SW, Rochester, MN, 55901, USA
| | - Cornelius A Thiels
- Department of General Surgery, Mayo Clinic, 200 1st Street SW, Rochester, MN, 55901, USA
| | - Stephanie F Polites
- Department of General Surgery, Mayo Clinic, 200 1st Street SW, Rochester, MN, 55901, USA
| | - Maile Parker
- Department of General Surgery, Mayo Clinic, 200 1st Street SW, Rochester, MN, 55901, USA
| | - Michael B Ishitani
- Division of Pediatric Surgery, Mayo Clinic, 200 1st Street SW, Rochester, MN, 55901, USA
| | - Christopher R Moir
- Division of Pediatric Surgery, Mayo Clinic, 200 1st Street SW, Rochester, MN, 55901, USA
| | - Kathleen Berns
- Mayo Clinic Medical Transport, Mayo Clinic, 200 1st Street SW, Rochester, MN, 55901, USA
| | - James R Stubbs
- Division of Laboratory Medicine, Blood Banking and Transfusion, Mayo Clinic, 200 1st Street SW, Rochester, MN, 55901, USA
| | - Donald H Jenkins
- Division of Trauma, Critical Care and General Surgery, Mayo Clinic, 200 1st Street SW, Rochester, MN, 55901, USA
| | - Scott P Zietlow
- Division of Trauma, Critical Care and General Surgery, Mayo Clinic, 200 1st Street SW, Rochester, MN, 55901, USA.,Mayo Clinic Medical Transport, Mayo Clinic, 200 1st Street SW, Rochester, MN, 55901, USA
| | - Martin D Zielinski
- Division of Trauma, Critical Care and General Surgery, Mayo Clinic, 200 1st Street SW, Rochester, MN, 55901, USA.
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57
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Holcomb JB, Swartz MD, DeSantis SM, Greene TJ, Fox EE, Stein DM, Bulger EM, Kerby JD, Goodman M, Schreiber MA, Zielinski MD, O’Keeffe T, Inaba K, Tomasek JS, Podbielski JM, Appana S, Yi M, Wade CE. Multicenter observational prehospital resuscitation on helicopter study. J Trauma Acute Care Surg 2017; 83:S83-S91. [PMID: 28383476 PMCID: PMC5562146 DOI: 10.1097/ta.0000000000001484] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Earlier use of in-hospital plasma, platelets, and red blood cells (RBCs) has improved survival in trauma patients with severe hemorrhage. Retrospective studies have associated improved early survival with prehospital blood product transfusion (PHT). We hypothesized that PHT of plasma and/or RBCs would result in improved survival after injury in patients transported by helicopter. METHODS Adult trauma patients transported by helicopter from the scene to nine Level 1 trauma centers were prospectively observed from January to November 2015. Five helicopter systems had plasma and/or RBCs, whereas the other four helicopter systems used only crystalloid resuscitation. All patients meeting predetermined high-risk criteria were analyzed. Patients receiving PHT were compared with patients not receiving PHT. Our primary analysis compared mortality at 3 hours, 24 hours, and 30 days, using logistic regression to adjust for confounders and site heterogeneity to model patients who were matched on propensity scores. RESULTS Twenty-five thousand one hundred eighteen trauma patients were admitted, 2,341 (9%) were transported by helicopter, of which 1,058 (45%) met the highest-risk criteria. Five hundred eighty-five of 1,058 patients were flown on helicopters carrying blood products. In the systems with blood available, prehospital median systolic blood pressure (125 vs 128) and Glasgow Coma Scale (7 vs 14) was significantly lower, whereas median Injury Severity Score was significantly higher (21 vs 14). Unadjusted mortality was significantly higher in the systems with blood products available, at 3 hours (8.4% vs 3.6%), 24 hours (12.6% vs 8.9%), and 30 days (19.3% vs 13.3%). Twenty-four percent of eligible patients received a PHT. A median of 1 unit of RBCs and plasma were transfused prehospital. Of patients receiving PHT, 24% received only plasma, 7% received only RBCs, and 69% received both. In the propensity score matching analysis (n = 109), PHT was not significantly associated with mortality at any time point, although only 10% of the high-risk sample were able to be matched. CONCLUSION Because of the unexpected imbalance in systolic blood pressure, Glasgow Coma Scale, and Injury Severity Score between systems with and without blood products on helicopters, matching was limited, and the results of this study are inconclusive. With few units transfused to each patient and small outcome differences between groups, it is likely large, multicenter, randomized studies will be required to detect survival differences in this important population. LEVEL OF EVIDENCE Level II.
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Affiliation(s)
- John B. Holcomb
- Center for Translational Injury Research, Division of Acute Care Surgery, Department of Surgery, Medical School, University of Texas Health Science Center at Houston, Houston, TX
| | - Michael D. Swartz
- Center for Translational Injury Research, Division of Acute Care Surgery, Department of Surgery, Medical School, University of Texas Health Science Center at Houston, Houston, TX
- Department of Biostatistics, School of Public Health, University of Texas Health Science Center at Houston
| | - Stacia M. DeSantis
- Department of Biostatistics, School of Public Health, University of Texas Health Science Center at Houston
| | - Thomas J. Greene
- Department of Biostatistics, School of Public Health, University of Texas Health Science Center at Houston
| | - Erin E. Fox
- Center for Translational Injury Research, Division of Acute Care Surgery, Department of Surgery, Medical School, University of Texas Health Science Center at Houston, Houston, TX
| | - Deborah M. Stein
- R Adams Cowley Shock Trauma Center, Program in Trauma, University of Maryland School of Medicine, Baltimore, MD
| | - Eileen M. Bulger
- Division of Trauma and Critical Care, Department of Surgery, School of Medicine, University of Washington, Seattle, WA
| | - Jeffrey D. Kerby
- Division of Trauma, Burns and Surgical Critical Care, Department of Surgery, School of Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Michael Goodman
- Division of Trauma/Critical Care, Department of Surgery, College of Medicine, University of Cincinnati, Cincinnati, OH
| | - Martin A. Schreiber
- Division of Trauma, Critical Care and Acute Care Surgery, School of Medicine, Oregon Health & Science University, Portland, OR
| | | | | | | | - Jeffrey S. Tomasek
- Center for Translational Injury Research, Division of Acute Care Surgery, Department of Surgery, Medical School, University of Texas Health Science Center at Houston, Houston, TX
| | - Jeanette M. Podbielski
- Center for Translational Injury Research, Division of Acute Care Surgery, Department of Surgery, Medical School, University of Texas Health Science Center at Houston, Houston, TX
| | - Savitri Appana
- Department of Biostatistics, School of Public Health, University of Texas Health Science Center at Houston
| | - Misung Yi
- Department of Biostatistics, School of Public Health, University of Texas Health Science Center at Houston
| | - Charles E. Wade
- Center for Translational Injury Research, Division of Acute Care Surgery, Department of Surgery, Medical School, University of Texas Health Science Center at Houston, Houston, TX
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58
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Spinella PC, Pidcoke HF, Strandenes G, Hervig T, Fisher A, Jenkins D, Yazer M, Stubbs J, Murdock A, Sailliol A, Ness PM, Cap AP. Whole blood for hemostatic resuscitation of major bleeding. Transfusion 2017; 56 Suppl 2:S190-202. [PMID: 27100756 DOI: 10.1111/trf.13491] [Citation(s) in RCA: 107] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2015] [Revised: 12/02/2015] [Accepted: 12/17/2015] [Indexed: 01/15/2023]
Abstract
Recent combat experience reignited interest in transfusing whole blood (WB) for patients with life-threatening bleeding. US Army data indicate that WB transfusion is associated with improved or comparable survival compared to resuscitation with blood components. These data complement randomized controlled trials that indicate that platelet (PLT)-containing blood products stored at 4°C have superior hemostatic function, based on reduced bleeding and improved functional measures of hemostasis, compared to PLT-containing blood products at 22°C. WB is rarely available in civilian hospitals and as a result is rarely transfused for patients with hemorrhagic shock. Recent developments suggest that impediments to WB availability can be overcome, specifically the misconceptions that WB must be ABO specific, that WB cannot be leukoreduced and maintain PLTs, and finally that cold storage causes loss of PLT function. Data indicate that the use of low anti-A and anti-B titer group O WB is safe as a universal donor, WB can be leukoreduced with PLT-sparing filters, and WB stored at 4°C retains PLT function during 15 days of storage. The understanding that these perceived barriers are not insurmountable will improve the availability of WB and facilitate its use. In addition, there are logistic and economic advantages of WB-based resuscitation compared to component therapy for hemorrhagic shock. The use of low-titer group O WB stored for up to 15 days at 4°C merits further study to compare its efficacy and safety with current resuscitation approaches for all patients with life-threatening bleeding.
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Affiliation(s)
- Philip C Spinella
- Division of Critical Care, Department of Pediatrics, Washington University in St Louis, St Louis, Missouri.,U.S. Army Institute of Surgical Research, JBSA-Fort Sam Houston, Texas
| | - Heather F Pidcoke
- U.S. Army Institute of Surgical Research, JBSA-Fort Sam Houston, Texas
| | - Geir Strandenes
- Norwegian Naval Special Operations Commando, Bergen, Norway.,Department of Immunology and Transfusion Medicine, Haukeland University Hospital, Bergen, Norway
| | - Tor Hervig
- Department of Immunology and Transfusion Medicine, Haukeland University Hospital, Bergen, Norway
| | | | - Donald Jenkins
- Department of Surgery, College of Medicine, Medical Director, Trauma Center, Mayo Clinic, Rochester, Minnesota
| | - Mark Yazer
- Department of Pathology, University of Pittsburgh and the Institute for Transfusion Medicine, Pittsburgh, Pennsylvania
| | - James Stubbs
- Department of Laboratory Medicine and Pathology, Division of Transfusion Medicine, Mayo Clinic, Rochester, Minnesota
| | - Alan Murdock
- Department of Surgery, University of Pittsburgh, and Division of Trauma, Allegheny General Hospital, Pittsburgh, Pennsylvania
| | - Anne Sailliol
- French Military Blood Transfusion Center, Clamart, France
| | - Paul M Ness
- Transfusion Medicine Division, Department of Pathology, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Andrew P Cap
- U.S. Army Institute of Surgical Research, JBSA-Fort Sam Houston, Texas
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59
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Subramani K, Lu S, Warren M, Chu X, Toque HA, Caldwell RW, Diamond MP, Raju R. Mitochondrial targeting by dichloroacetate improves outcome following hemorrhagic shock. Sci Rep 2017; 7:2671. [PMID: 28572638 PMCID: PMC5453974 DOI: 10.1038/s41598-017-02495-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2016] [Accepted: 04/12/2017] [Indexed: 12/16/2022] Open
Abstract
Hemorrhagic shock is a leading cause of death in people under the age of 45 and accounts for almost half of trauma-related deaths. In order to develop a treatment strategy based on potentiating mitochondrial function, we investigated the effect of the orphan drug dichloroacetate (DCA) on survival in an animal model of hemorrhagic shock in the absence of fluid resuscitation. Hemorrhagic shock was induced in rats by withdrawing 60% of the blood volume and maintaining a hypotensive state. The studies demonstrated prolonged survival of rats subjected to hemorrhagic injury (HI) when treated with DCA. In separate experiments, using a fluid resuscitation model we studied mitochondrial functional alterations and changes in metabolic networks connected to mitochondria following HI and treatment with DCA. DCA treatment restored cardiac mitochondrial membrane potential and tissue ATP in the rats following HI. Treatment with DCA resulted in normalization of several metabolic and molecular parameters including plasma lactate and p-AMPK/AMPK, as well as Ach-mediated vascular relaxation. In conclusion we demonstrate that DCA can be successfully used in the treatment of hemorrhagic shock in the absence of fluid resuscitation; therefore DCA may be a good candidate in prolonged field care following severe blood loss.
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Affiliation(s)
- Kumar Subramani
- Department of Laboratory Sciences, Augusta University, Augusta, GA, 30912, United States of America
| | - Sumin Lu
- Department of Laboratory Sciences, Augusta University, Augusta, GA, 30912, United States of America
| | - Marie Warren
- Department of Laboratory Sciences, Augusta University, Augusta, GA, 30912, United States of America
| | - Xiaogang Chu
- Department of Laboratory Sciences, Augusta University, Augusta, GA, 30912, United States of America
| | - Haroldo A Toque
- Department of Pharmacology and Toxicology, Augusta University, Augusta, GA, 30912, United States of America
| | - R William Caldwell
- Department of Pharmacology and Toxicology, Augusta University, Augusta, GA, 30912, United States of America
| | - Michael P Diamond
- Department of Obstetrics and Gynaecology, Augusta University, Augusta, GA, 30912, United States of America
| | - Raghavan Raju
- Department of Laboratory Sciences, Augusta University, Augusta, GA, 30912, United States of America. .,Department of Surgery, Augusta University, Augusta, GA, 30912, United States of America. .,Department of Biochemistry and Molecular Biology, Augusta University, Augusta, GA, 30912, United States of America.
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60
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Maegele M, Nardi G, Schöchl H. Hemotherapy algorithm for the management of trauma-induced coagulopathy: the German and European perspective. Curr Opin Anaesthesiol 2017; 30:257-264. [PMID: 28085709 DOI: 10.1097/aco.0000000000000433] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
PURPOSE OF REVIEW This review presents a synopsis of best current knowledge with reference to the updated German and European guidelines and recommendations on the management of severe trauma hemorrhage and trauma-induced coagulopathy as well as a viscoelastic-based treatment algorithm based upon international expert consensus to trigger the administration of hemostatic agents and blood products. RECENT FINDINGS Uncontrolled hemorrhage and trauma-induced coagulopathy are the major causes for preventable death after trauma and early detection and aggressive management have been associated with improved outcomes. However, best practice to treat this newly defined entity is still under debate. In the acute phase, the clinical management usually follows the 'Damage Control Resuscitation' concept, which advocates the empiric administration of blood products in predefined and fixed ratios. As an alternative, several European but also a few US trauma centers have instituted the concept of 'Goal-directed Coagulation Therapy' based upon results obtained from early point-of-care viscoelastic testing. SUMMARY Current guidelines urge for the implementation of evidence-based local protocols and algorithms including clinical quality and safety management systems together with parameters to assess key measures of bleeding control and outcome.
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Affiliation(s)
- Marc Maegele
- aDepartment for Trauma and Orthopedic Surgery, Cologne-Merheim Medical Center (CMMC) bInstitute for Research in Operative Medicine (IFOM), University Witten/Herdecke (UW/H), Köln, Germany cDepartment for Anesthesiology and Intensive Care Medicine, Ospedali di Rimini e Riccione, AUSL della Romagna, Rimini, Italy dDepartment for Anesthesiology and Intensive Care Medicine, AUVA Trauma Hospital, Salzburg, Austria
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Goal-directed Hemostatic Resuscitation of Trauma-induced Coagulopathy: A Pragmatic Randomized Clinical Trial Comparing a Viscoelastic Assay to Conventional Coagulation Assays. Ann Surg 2017; 263:1051-9. [PMID: 26720428 DOI: 10.1097/sla.0000000000001608] [Citation(s) in RCA: 412] [Impact Index Per Article: 58.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Massive transfusion protocols (MTPs) have become standard of care in the management of bleeding injured patients, yet strategies to guide them vary widely. We conducted a pragmatic, randomized clinical trial (RCT) to test the hypothesis that an MTP goal directed by the viscoelastic assay thrombelastography (TEG) improves survival compared with an MTP guided by conventional coagulation assays (CCA). METHODS This RCT enrolled injured patients from an academic level-1 trauma center meeting criteria for MTP activation. Upon MTP activation, patients were randomized to be managed either by an MTP goal directed by TEG or by CCA (ie, international normalized ratio, fibrinogen, platelet count). Primary outcome was 28-day survival. RESULTS One hundred eleven patients were included in an intent-to-treat analysis (TEG = 56, CCA = 55). Survival in the TEG group was significantly higher than the CCA group (log-rank P = 0.032, Wilcoxon P = 0.027); 20 deaths in the CCA group (36.4%) compared with 11 in the TEG group (19.6%) (P = 0.049). Most deaths occurred within the first 6 hours from arrival (21.8% CCA group vs 7.1% TEG group) (P = 0.032). CCA patients required similar number of red blood cell units as the TEG patients [CCA: 5.0 (2-11), TEG: 4.5 (2-8)] (P = 0.317), but more plasma units [CCA: 2.0 (0-4), TEG: 0.0 (0-3)] (P = 0.022), and more platelets units [CCA: 0.0 (0-1), TEG: 0.0 (0-0)] (P = 0.041) in the first 2 hours of resuscitation. CONCLUSIONS Utilization of a goal-directed, TEG-guided MTP to resuscitate severely injured patients improves survival compared with an MTP guided by CCA and utilizes less plasma and platelet transfusions during the early phase of resuscitation.
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63
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Mador B, Nascimento B, Hollands S, Rizoli S. Blood transfusion and coagulopathy in geriatric trauma patients. Scand J Trauma Resusc Emerg Med 2017; 25:33. [PMID: 28356162 PMCID: PMC5371241 DOI: 10.1186/s13049-017-0374-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2016] [Accepted: 03/15/2017] [Indexed: 12/02/2022] Open
Abstract
Background Trauma resuscitation has undergone a paradigm shift with new emphasis on the early use of blood products and increased proportions of plasma and platelets. However, it is unclear how this strategy is applied or how effective it is in the elderly population. The study aim is to identify differences in transfusion practices and the coagulopathy of trauma in the elderly. Methods Data was prospectively collected on all consecutive patients that met trauma activation criteria at a Level I trauma centre. Data fields included patient demographics, co-morbidities, injury and resuscitation data, laboratory values, thromboelastography (TEG) results, and outcome measures. Elderly patients were defined as those 55 and older. Propensity-score matched analysis was completed for patients receiving blood product transfusion. Patients were matched by gender, mechanism, injury severity score (ISS), head injury, and time from injury. Results Total of 628 patients were included, of which 142 (23%) were elderly. Elderly patients were more likely to be female (41% vs. 24%), suffer blunt mechanism of trauma (96% vs. 80%), have higher ISS scores (mean 25.4 vs. 21.6) and mortality (19% vs. 8%). Elderly patients were significantly more likely to receive a blood transfusion (42% vs. 30%), specifically for red cells and plasma. Propensity-matched analysis resulted in no difference in red cell transfusion or mortality. Despite the broad similarities between the matched cohorts, trauma coagulopathy as measured by TEG was less commonly observed in the elderly. Discussion Our results suggest that elderly trauma patients are more likely to receive blood products when admitted to a trauma centre, though this may be attributed to under-triage. The results also suggest an altered coagulopathic response to traumatic injury which is partially influenced by increased anticoagulant and antiplatelet medication use in the geriatric population. Conclusion It is not clear whether the acute coagulopathy of trauma is equivalent in geriatric patients, and further study is therefore warranted.
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Affiliation(s)
- Brett Mador
- Department of Surgery, University of Alberta, 205 - 3017 66 St NW, Edmonton, AB, T6K 4B2, Canada.
| | - Bartolomeu Nascimento
- Department of Surgery, Sunnybrook Health Sciences Centre, 2075 Bayview Ave, Room H171, Toronto, ON, M4N 3M5, Canada
| | - Simon Hollands
- Institute for Clinical Evaluative Sciences, Sunnybrook Health Sciences Centre, 2075 Bayview Ave, Toronto, ON, M4N 3M5, Canada
| | - Sandro Rizoli
- Department of Surgery, St. Michael's Hospital, 30 Bond Street, 3-074 Donnelly Wing, Toronto, ON, M5B 1W8, Canada
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Abstract
Trauma centers and a third-party payer within Michigan built a regional collaborative quality initiative. Hallmarks of the collaborative are standardized data collection, annual data validation visits, face-to-face collaborative meetings, and dedication to performance improvement. The Michigan Trauma Quality Improvement Program has shown measurable improvement in patient outcomes, resource use, and compliance with processes of care.
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Affiliation(s)
- Mark R Hemmila
- Department of Surgery, University of Michigan Medical School, North Campus Research Complex, Building 16, Room 139E, 2800 Plymouth Road, Ann Arbor, MI 48109-2800, USA.
| | - Jill L Jakubus
- Department of Surgery, University of Michigan Medical School, North Campus Research Complex, Building 16, Room 139E, 2800 Plymouth Road, Ann Arbor, MI 48109-2800, USA
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Raval JS, Gorantla VS, Shores JT, Lee WPA, Planinsic RM, Rollins-Raval MA, Brandacher G, King KE, Losee JE, Kiss JE. Blood product utilization in human upper-extremity transplantation: challenges, complications, considerations, and transfusion protocol conception. Transfusion 2017; 57:606-612. [PMID: 28297082 DOI: 10.1111/trf.14009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2016] [Revised: 11/06/2016] [Accepted: 11/06/2016] [Indexed: 01/27/2023]
Abstract
BACKGROUND Upper-extremity transplantation (UET) is a reality. Immunologic, functional, and graft survival outcomes have been encouraging. However, these complex reconstructions have unique considerations that pose distinct challenges. Transplant programs have reported morbidity and mortality due to significant intraoperative blood losses, but similar data are scant during other phases of recovery. We report experience from two centers on complete blood component demands and utilization with UET. STUDY DESIGN AND METHODS Inpatient medical records of UET recipients from intraoperative (time from initiation of transplant surgery to exit from the operative suite) and postoperative (exit from the operative suite to discharge from the hospital) phases were retrospectively reviewed. RESULTS Six patients received various UETs and mean (±SD) postoperative hospital stay was 46 (±14.4) days. Mean (±SD) intraoperative blood unit utilization was 14.8 (±10.2) red blood cells (RBCs), 10.5 (±11.8) plasma, 0.8 (±1.2) platelets (PLTs), and 0.3 (±0.8) cryoprecipitate units. Mean postoperative blood unit utilization was 9.3 (±10.4) RBCs, 5.3 (±6.7) plasma, 1.2 (±2.0) PLTs, and 0.7 (±1.6) cryoprecipitate units. Both intraoperative and postoperative blood utilization for unilateral versus bilateral transplant were different, but not significantly so. However, total inpatient blood use in bilateral transplants was significantly greater than in unilateral transplants. CONCLUSION Substantial blood loss may occur in UET and require transfusion of many blood components, primarily RBCs and plasma. We propose an UET transfusion protocol and suggest that centers preparing to perform these transplants should actively engage the transfusion medicine service to ensure availability and access to appropriate blood components for the entire hospitalizations of these unique patients.
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Affiliation(s)
- Jay S Raval
- Department of Pathology and Laboratory Medicine, University of North Carolina, Chapel Hill, North Carolina
| | - Vijay S Gorantla
- Department of Plastic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Jaimie T Shores
- Department of Plastic and Reconstructive Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - W P Andrew Lee
- Department of Plastic and Reconstructive Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Raymond M Planinsic
- Department of Anesthesiology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Marian A Rollins-Raval
- Department of Pathology and Laboratory Medicine, University of North Carolina, Chapel Hill, North Carolina
| | - Gerald Brandacher
- Department of Plastic and Reconstructive Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Karen E King
- Department of Pathology, Johns Hopkins University, Baltimore, Maryland
| | - Joseph E Losee
- Department of Plastic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Joseph E Kiss
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania.,The Institute for Transfusion Medicine, Pittsburgh, Pennsylvania
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66
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Dias JD, Haney EI, Mathew BA, Lopez-Espina CG, Orr AW, Popovsky MA. New-Generation Thromboelastography: Comprehensive Evaluation of Citrated and Heparinized Blood Sample Storage Effect on Clot-Forming Variables. Arch Pathol Lab Med 2017; 141:569-577. [DOI: 10.5858/arpa.2016-0088-oa] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Context.—
Thromboelastography (TEG) is a whole blood, real-time analyzer measuring the viscoelastic properties of the hemostasis process and allowing for individualized goal-directed therapy. However, routine use of TEG requires validation of sample storage effect on clot parameters.
Objectives.—
To establish the minimum time required for equilibration time and the maximum time for sample storage for all commercially available TEG tests for the new-generation TEG 6s and to determine how those times compare with the older generation TEG 5000.
Design.—
Citrated and heparinized whole blood samples obtained from 20 healthy donors were analyzed for clot parameters at multiple time points for both the TEG 6s and the TEG 5000. Samples were activated with the citrated multichannel cartridge or the platelet-mapping cartridge in the TEG 6s or with recalcified kaolin in the TEG 5000.
Results.—
All blood samples yielded TEG parameter results within reference ranges and had a tendency toward hypercoagulable profiles with increased storage time. Sample storage resulted in increased platelet inhibition with significant differences at 4 hours in the platelet-mapping cartridge (arachidonic acid percentage of inhibition, P = .002; adenosine diphosphate percentage of inhibition, P = .02).
Conclusions.—
For nonemergent cases or in a central laboratory setting, all tests provided reliable results for up to 4 hours in the citrated multichannel cartridge and for 3 hours for platelet function information in the platelet-mapping cartridge. In emergent/urgent situations in which the sample needs to be run immediately, RapidTEG and functional fibrinogen tests may be preferred.
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Affiliation(s)
| | | | | | | | | | - Mark A. Popovsky
- From the Department of Clinical Marketing, Haemonetics SA, Signy, Switzerland (Dr Dias); the Department of Scientific Research & Development, Haemonetics Corporation, Rosemont, Illinois (Mss Haney and Mathew and Mr Lopez-Espina); and the Department of Medical & Clinical Affairs, Haemonetics Corporation, Braintree, Massachusetts (Mr Orr and Dr Popovsky). Mr Orr is now with Anika Therapeutics Inc,
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67
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Leeper CM, Gaines BA. Viscoelastic hemostatic assays in the management of the pediatric trauma patient. Semin Pediatr Surg 2017; 26:8-13. [PMID: 28302286 DOI: 10.1053/j.sempedsurg.2017.01.004] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Viscoelastic hemostatic assays (VHA), such as TEG and ROTEM, are whole blood tests that depict functional coagulation both numerically and graphically. The development of rapid VHA technology, which allows for the first data points to result within minutes of test initiation, has increased the utility of these tests in the treatment of trauma patients. Both adult and pediatric centers have integrated VHAs into trauma resuscitation and transfusion protocols. Literature regarding the use of VHAs for injured children is limited. Here, we discuss the mechanics and interpretation of VHAs as well as the use of VHAs in data-driven resuscitation of pediatric trauma patients. Novel research on fibrinolysis states after injury as well as hypercoagulable state diagnosed with VHAs are presented.
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Affiliation(s)
- Christine M Leeper
- Department of Surgery, University of Pittsburgh School of Medicine, Children's Hospital of Pittsburgh of UPMC, 7th Floor, Faculty Pavilion, One Children's Hospital Dr, 4401 Penn Ave, Pittsburgh, Pennsylvania 15224
| | - Barbara A Gaines
- Department of Surgery, University of Pittsburgh School of Medicine, Children's Hospital of Pittsburgh of UPMC, 7th Floor, Faculty Pavilion, One Children's Hospital Dr, 4401 Penn Ave, Pittsburgh, Pennsylvania 15224.
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Sakamoto Y, Koami H, Miike T. Monitoring the coagulation status of trauma patients with viscoelastic devices. J Intensive Care 2017; 5:7. [PMID: 34798696 PMCID: PMC8600748 DOI: 10.1186/s40560-016-0198-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2016] [Accepted: 12/17/2016] [Indexed: 11/17/2022] Open
Abstract
Coagulopathy is a physiological response to massive bleeding that frequently occurs after severe trauma and is an independent predictive factor for mortality. Therefore, it is very important to grasp the coagulation status of patients with severe trauma quickly and accurately in order to establish the therapeutic strategy. Judging from the description in the European guidelines, the importance of viscoelastic devices in understanding the disease condition of patients with traumatic coagulopathy has been widely recognized in Europe. In the USA, the ACS TQIP Massive Transfusion in Trauma Guidelines proposed by the American College of Surgeons in 2013 presented the test results obtained by the viscoelastic devices, TEG® 5000 and ROTEM®, as the standard for transfusion or injection of blood plasma, cryoprecipitate, platelet concentrate, or anti-fibrinolytic agents in the treatment strategy for traumatic coagulopathy and hemorrhagic shock. However, some studies have reported limitations of these viscoelastic devices. A review in the Cochrane Library published in 2015 pointed out the presence of biases in the abovementioned reports in trauma patients and the absence of a quality study in this field thus far. A quality study on the relationship between traumatic coagulopathy and viscoelastic devices is needed.
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Affiliation(s)
- Yuichiro Sakamoto
- Department of Emergency and Critical Care Medicine, Faculty of Medicine, Saga University, 5-1-1 Nabeshima, Saga City, Saga, 849-8501, Japan.
| | - Hiroyuki Koami
- Department of Emergency and Critical Care Medicine, Faculty of Medicine, Saga University, 5-1-1 Nabeshima, Saga City, Saga, 849-8501, Japan
| | - Toru Miike
- Department of Emergency and Critical Care Medicine, Faculty of Medicine, Saga University, 5-1-1 Nabeshima, Saga City, Saga, 849-8501, Japan
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69
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Air Medical Administration of Tranexamic Acid. J Trauma Nurs 2017; 24:30-33. [DOI: 10.1097/jtn.0000000000000259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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70
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Development and validation of a prehospital prediction model for acute traumatic coagulopathy. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:371. [PMID: 27846895 PMCID: PMC5111191 DOI: 10.1186/s13054-016-1541-9] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/30/2016] [Accepted: 10/20/2016] [Indexed: 12/22/2022]
Abstract
Background Acute traumatic coagulopathy (ATC) is a syndrome of early, endogenous clotting dysfunction that afflicts up to 30% of severely injured patients, signaling an increased likelihood of all-cause and hemorrhage-associated mortality. To aid identification of patients within the likely therapeutic window for ATC and facilitate study of its mechanisms and targeted treatment, we developed and validated a prehospital ATC prediction model. Methods Construction of a parsimonious multivariable logistic regression model predicting ATC — defined as an admission international normalized ratio >1.5 — employed data from 1963 severely injured patients admitted to an Oregon trauma system hospital between 2008 and 2012 who received prehospital care but did not have isolated head injury. The prediction model was validated using data from 285 severely injured patients admitted to a level 1 trauma center in Seattle, WA, USA between 2009 and 2013. Results The final Prediction of Acute Coagulopathy of Trauma (PACT) score incorporated age, injury mechanism, prehospital shock index and Glasgow Coma Score values, and prehospital cardiopulmonary resuscitation and endotracheal intubation. In the validation cohort, the PACT score demonstrated better discrimination (area under the receiver operating characteristic curve 0.80 vs. 0.70, p = 0.032) and likely improved calibration compared to a previously published prehospital ATC prediction score. Designating PACT scores ≥196 as positive resulted in sensitivity and specificity for ATC of 73% and 74%, respectively. Conclusions Our prediction model uses routinely available and objective prehospital data to identify patients at increased risk of ATC. The PACT score could facilitate subject selection for studies of targeted treatment of ATC. Electronic supplementary material The online version of this article (doi:10.1186/s13054-016-1541-9) contains supplementary material, which is available to authorized users.
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72
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Prehospital shock index and pulse pressure/heart rate ratio to predict massive transfusion after severe trauma. J Trauma Acute Care Surg 2016; 81:713-22. [DOI: 10.1097/ta.0000000000001191] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
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Ten year maturation period in a level-I trauma center, a cohort comparison study. Eur J Trauma Emerg Surg 2016; 43:685-690. [PMID: 27629235 PMCID: PMC5629235 DOI: 10.1007/s00068-016-0722-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2016] [Accepted: 09/06/2016] [Indexed: 12/05/2022]
Abstract
Purpose Many changes have been made to improve trauma care. Improved trauma team response and usage of a hybrid resuscitation room are examples of how this trauma center has developed. The aim was to assess how the outcome of the trauma population was influenced by the maturation. Methods A cohort comparison, between June 2004–July 2005 and 2014, was performed. All adult trauma patients with an Injury Severity Score (ISS) >15 were included. Variables collected were: patient demographics, mechanism of trauma, total prehospital time, pre- and inhospital trauma scores, vital signs, blood values and interventions, and physician staffed helicopter emergency medical services (P-HEMS) involvement and outcome. Results From June 2004 to July 2005 219, patients were admitted, and for the year 2014, this was 282 patients. The 2014 cohort was significantly older (mean age of 53.6 ± 23.8 vs 45.6 ± 22.7 years). The mean RTS did not differ. P-HEMS assists increased to 116 (13.5 %). The number of CT scans, blood transfusion, and acute trauma surgical interventions decreased. Mean LOS, ICU admission, and ICU LOS did not differ. The mortality rate, however, decreased by 7.0 %, observed and predicted survival was significantly different in favour of the 2014 cohort, with a Z-score of 4.25. Conclusion An increase in age is seen, though trauma scores remain comparable. The number of blood products transfused and acute trauma surgical interventions performed declines. Mortality significantly decreased and a significant difference in observed and predicted survival is seen. Showing improved trauma care in our hospital, in favour of the second period.
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Etchill E, Sperry J, Zuckerbraun B, Alarcon L, Brown J, Schuster K, Kaplan L, Piper G, Peitzman A, Neal MD. The confusion continues: results from an American Association for the Surgery of Trauma survey on massive transfusion practices among United States trauma centers. Transfusion 2016; 56:2478-2486. [DOI: 10.1111/trf.13755] [Citation(s) in RCA: 58] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2015] [Revised: 04/25/2016] [Accepted: 04/26/2016] [Indexed: 12/26/2022]
Affiliation(s)
- Eric Etchill
- University of Pittsburgh School of Medicine; Pittsburgh Pennsylvania
| | - Jason Sperry
- University of Pittsburgh School of Medicine; Pittsburgh Pennsylvania
| | - Brian Zuckerbraun
- University of Pittsburgh School of Medicine; Pittsburgh Pennsylvania
| | - Louis Alarcon
- University of Pittsburgh School of Medicine; Pittsburgh Pennsylvania
| | - Joshua Brown
- University of Pittsburgh School of Medicine; Pittsburgh Pennsylvania
| | - Kevin Schuster
- Yale University School of Medicine; New Haven Connecticut
| | - Lewis Kaplan
- University of Pennsylvania Perelman School of Medicine and Philadelphia VA Medical Center; Philadelphia Pennsylvania
| | - Greta Piper
- New York University Medical Center; New York New York
| | - Andrew Peitzman
- University of Pittsburgh School of Medicine; Pittsburgh Pennsylvania
| | - Matthew D. Neal
- University of Pittsburgh School of Medicine; Pittsburgh Pennsylvania
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76
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Briggs A, Askari R. Damage control resuscitation. Int J Surg 2016; 33:218-221. [PMID: 27107662 DOI: 10.1016/j.ijsu.2016.03.064] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2016] [Revised: 02/29/2016] [Accepted: 03/03/2016] [Indexed: 11/30/2022]
Affiliation(s)
- Alexandra Briggs
- Brigham and Women's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Reza Askari
- Brigham and Women's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA.
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77
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Kemp Bohan PM, Yonge JD, Schreiber MA. Update on the Massive Transfusion Guidelines on Hemorrhagic Shock: After the Wars. CURRENT SURGERY REPORTS 2016. [DOI: 10.1007/s40137-016-0137-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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78
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Horst J, Leonard JC, Vogel A, Jacobs R, Spinella PC. A survey of US and Canadian hospitals' paediatric massive transfusion protocol policies. Transfus Med 2016; 26:49-56. [PMID: 26833998 DOI: 10.1111/tme.12277] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2015] [Revised: 11/25/2015] [Accepted: 07/23/2015] [Indexed: 12/14/2022]
Abstract
BACKGROUND Trauma is the leading cause of death in children >1 year of age, with haemorrhage as the most common cause of medically preventable deaths. While massive transfusion protocols (MTPs) have been investigated and used in adults to reduce death from haemorrhage, there are a paucity of published data on MTP practices and outcomes in children. This study aimed to survey current MTP policies and the frequency of activation at paediatric care centres. STUDY DESIGN AND METHODS We conducted a survey of MTPs at hospitals in the United States and Canada, including children's general hospitals, children's specialty hospitals and children's units in general hospitals. We collected information on how the MTP is activated, what therapeutics are given, frequency of its use, and how it is audited for compliance. RESULTS Forty-six survey responses were analysed. Physician discretion was the most common activation criteria (89%). A majority of sites (78%) targeted a 'high' (≥1 : 2) ratio of plasma to red blood cells (RBC). Fifteen percent of sites use antifibrinolytics in their MTPs. Eighty nine percent of sites have type-O RBC units and 48% of sites had thawed plasma units stored in an immediately available location. CONCLUSION There is a wide variation in MTPs among paediatric hospitals with regard to both activation criteria and products administered. This underscores the need for future prospective studies to determine the most effective resuscitation methods for paediatric populations to improve outcomes and therapeutic safety for massive bleeding.
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Affiliation(s)
- J Horst
- Division of Emergency Medicine, Department of Paediatrics, Washington University School of Medicine, St Louis, Missouri, USA
| | - J C Leonard
- Section of Emergency Medicine, Department of Paediatrics, Nationwide Children's Hospital and the Ohio State University, Columbus, Ohio, USA
| | - A Vogel
- Division of Paediatric Surgery, Department of Surgery, Washington University School of Medicine, St Louis, Missouri, USA
| | - R Jacobs
- Division of Critical Care, Department of Paediatrics, Washington University School of Medicine, St Louis, Missouri, USA
| | - P C Spinella
- Division of Critical Care, Department of Paediatrics, Washington University School of Medicine, St Louis, Missouri, USA
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