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Strosberg DS, Nguyen MC, Mostafavifar L, Mell H, Evans DC. Development of a Prehospital Tranexamic Acid Administration Protocol. PREHOSP EMERG CARE 2016; 20:462-6. [DOI: 10.3109/10903127.2015.1128033] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Balvers K, Saleh S, Zeerleder SS, Klinkspoor JH, Goslings JC, Juffermans NP. Are there any alternatives for transfusion of AB plasma as universal donor in an emergency release setting? Transfusion 2016; 56:1469-74. [DOI: 10.1111/trf.13527] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2015] [Revised: 01/03/2016] [Accepted: 01/05/2016] [Indexed: 11/30/2022]
Affiliation(s)
- Kirsten Balvers
- Trauma Unit, Department of Surgery; Academic Medical Center; Amsterdam the Netherlands
- Department of Intensive Care Medicine; Academic Medical Center; Amsterdam the Netherlands
| | - Sarah Saleh
- Trauma Unit, Department of Surgery; Academic Medical Center; Amsterdam the Netherlands
- Department of Intensive Care Medicine; Academic Medical Center; Amsterdam the Netherlands
| | - Sacha S. Zeerleder
- Department of Hematology; Academic Medical Center; Amsterdam the Netherlands
- Department of Immunopathology; Sanquin Research; Academic Medical Center; Amsterdam the Netherlands
| | - J. Henriette Klinkspoor
- Laboratory for General Clinical Chemistry; Academic Medical Center; Amsterdam the Netherlands
| | - J. Carel Goslings
- Trauma Unit, Department of Surgery; Academic Medical Center; Amsterdam the Netherlands
| | - Nicole P. Juffermans
- Department of Intensive Care Medicine; Academic Medical Center; Amsterdam the Netherlands
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Shander A, Ozawa S, Hofmann A. Activity-based costs of plasma transfusions in medical and surgical inpatients at a US hospital. Vox Sang 2016; 111:55-61. [DOI: 10.1111/vox.12386] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2015] [Revised: 12/17/2015] [Accepted: 01/13/2016] [Indexed: 11/30/2022]
Affiliation(s)
- A. Shander
- Department of Anesthesiology; Critical Care and Hyperbaric Medicine; Englewood Hospital and Medical Center; Englewood NJ USA
- Clinical Professor of Anesthesiology; Medicine and Surgery; Icahn School of Medicine at Mount Sinai; New York NY USA
- Institute for Bloodless Medicine and Patient Blood Management; Englewood Hospital & Medical Center; Englewood NJ USA
| | - S. Ozawa
- Institute for Bloodless Medicine and Patient Blood Management; Englewood Hospital & Medical Center; Englewood NJ USA
| | - A. Hofmann
- School of Surgery; Faculty of Medicine Dentistry and Health Sciences; University of Western Australia; Perth WA Australia
- Centre for Population Health Research; Curtin Health Innovation Research Institute; Curtin University; Perth WA Australia
- Institute of Anaesthesiology; University Hospital and University of Zurich; Zurich Switzerland
- Institute for Bloodless Medicine and Patient Blood Management; Englewood Hospital & Medical Center; Englewood NJ USA
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Bhattacharya B, Davis KA. Nuances in the Care of Emergent Splenic Injury in the Elderly Patient. CURRENT GERIATRICS REPORTS 2016. [DOI: 10.1007/s13670-016-0153-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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55
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Abstract
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.
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Affiliation(s)
- Patrick MacGoey
- East Midlands Major Trauma Centre, Queen’s Medical Centre, Nottingham, UK
| | - Christopher M Lamb
- East Midlands Major Trauma Centre, Queen’s Medical Centre, Nottingham, UK
| | - Alex P Navarro
- East Midlands Major Trauma Centre, Queen’s Medical Centre, Nottingham, UK
| | - Adam J Brooks
- East Midlands Major Trauma Centre, Queen’s Medical Centre, Nottingham, UK
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Peralta R, Vijay A, El-Menyar A, Consunji R, Afifi I, Mahmood I, Asim M, Latifi R, Al-Thani H. Early high ratio platelet transfusion in trauma resuscitation and its outcomes. Int J Crit Illn Inj Sci 2016; 6:188-193. [PMID: 28149824 PMCID: PMC5225762 DOI: 10.4103/2229-5151.195448] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
INTRODUCTION The optimal ratio of platelets (PLTs) to packed red blood cell (PRBC) in trauma patients requiring massive transfusion protocol (MTP) is still controversial. This report aims to describe the effect of attaining a high PLT:PRBC ratio (≥1:1.5) within 4 h postinjury on the outcomes of trauma patients receiving MTP. METHODS Over a 24-month period, records of all adult patients with traumatic injury who received MTP were retrospectively reviewed. Data were analyzed with respect to PLT:PRBC ratio ([high-MTP ≥1:1.5] [HMTP] vs. [low-MTP <1:1.5] [LMTP]) given within the first 4 h postinjury and also between (>4 and 24 h). Baseline demographic, clinical characteristics, complications, and outcomes were compared according to HMTP and LMTP. RESULTS Of the total 3244 trauma patients, PLT:PRBC ratio was attainable in 58 (1.2%) patients who fulfilled the inclusion criteria. The mean age was 32.3 ± 10.7 years; the majority were males (89.6%) with high mean Injury Severity Score (ISS): 31.9 ± 11.5 and Revise Trauma Score (RTS): 5.1 ± 2.2. There was no significant association between age, gender, type of injury, presenting hemoglobin, International Normalized Ratio, ISS, and RTS. The rate of ventilator-associated pneumonia (38.9% vs. 10.8%; P = 0.02) and wound infection (50% vs. 10.8%; P = 0.002) were significantly higher in the HMTP group. However, HMTP was associated with lower rate of multiple organ failure (MOF) (42.1% vs. 87.2%, P = 0.001) and mortality (36.8% vs. 84.6%, P = 0.001) within the first 30 days postinjury. CONCLUSIONS Our study revealed that early attainment of high PLT/PRBC ratio within 4 h postinjury is significantly associated with lower MOF and mortality in trauma patients.
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Affiliation(s)
- Ruben Peralta
- Department of Surgery, Trauma Surgery Section, Hamad Trauma Center, Hamad General Hospital, Doha, Qatar; University National Pedro Henriquez Urena, Department of Surgery, Santo Domingo, Dominican Republic, Doha, Qatar
| | - Adarsh Vijay
- Department of Surgery, Trauma Surgery Section, Hamad Trauma Center, Hamad General Hospital, Doha, Qatar
| | - Ayman El-Menyar
- Clinical Research, Trauma Surgery Section, Hamad General Hospital, Doha, Qatar; Internal Medicine, Weill Cornell Medical College, Doha, Qatar
| | - Rafael Consunji
- Department of Surgery, Trauma Surgery Section, Hamad Trauma Center, Hamad General Hospital, Doha, Qatar
| | - Ibrahim Afifi
- Department of Surgery, Trauma Surgery Section, Hamad Trauma Center, Hamad General Hospital, Doha, Qatar
| | - Ismail Mahmood
- Department of Surgery, Trauma Surgery Section, Hamad Trauma Center, Hamad General Hospital, Doha, Qatar
| | - Mohammed Asim
- Clinical Research, Trauma Surgery Section, Hamad General Hospital, Doha, Qatar
| | - Rifat Latifi
- Department of Surgery, Westchester Medical Center, New York Medical College, Valhalla, NY, USA; Department of Surgery, University of Arizona, Tucson, AZ, USA
| | - Hassan Al-Thani
- Department of Surgery, Trauma Surgery Section, Hamad Trauma Center, Hamad General Hospital, Doha, Qatar
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Giancarelli A, Birrer KL, Alban RF, Hobbs BP, Liu-DeRyke X. Hypocalcemia in trauma patients receiving massive transfusion. J Surg Res 2015; 202:182-7. [PMID: 27083965 DOI: 10.1016/j.jss.2015.12.036] [Citation(s) in RCA: 80] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2015] [Revised: 11/11/2015] [Accepted: 12/22/2015] [Indexed: 10/22/2022]
Abstract
BACKGROUND Massive transfusion protocol (MTP) is increasingly used in civilian trauma resuscitation. Calcium is vital for coagulation, but hypocalcemia commonly occurs during massive transfusion due to citrate and serum calcium chelation. This study was conducted to determine the incidence of hypocalcemia and severe hypocalcemia in trauma patients who receive massive transfusion and to compare characteristics of patients with severe versus nonsevere hypocalcemia. MATERIALS AND METHODS This was a retrospective study of trauma patients who received massive transfusion between January 2009 and November 2013. The primary outcome was the incidence of hypocalcemia (ionized calcium [iCa] < 1.12 mmol/L) and severe hypocalcemia (iCa < 0.90 mmol/L). Secondary outcomes included calcium monitoring, calcium replacement, and correction of coagulopathy. RESULTS There were 156 patients included; 152 (97%) experienced hypocalcemia, and 111 (71%) had severe hypocalcemia. Patients were stratified into iCa ≥ 0.90 (n = 45) and iCa < 0.90 (n = 111). There were no differences in demographics or baseline laboratories except the severe hypocalcemia group had higher baseline activated partial thromboplastin time (29.7 [23.7-50.9] versus 25.8 [22.3-35.9], P = 0.003), higher lactic acid (5.8 [4.1-9.8] versus 4.0 [3.1-7.8], P = 0.019), lower platelets (176 [108-237] versus 208 [169-272], P = 0.003), and lower pH (7.14 [6.98-7.28] versus 7.23 [7.14-7.33], P = 0.019). Mortality was higher in the severe hypocalcemia group (49% versus 24%, P = 0.007). Patients in the iCa < 0.90 group received more blood products (34 [23-58] versus 22 [18-30] units, P < 0.001), and calcium chloride (4 [2-7] versus 3 [1-4] g, P = 0.002), but there was no difference in duration of MTP or final iCa. Neither group reached a median iCa > 1.12. CONCLUSIONS Hypocalcemia is common during MTP, and vigilant monitoring is warranted. Research is needed to effectively manage hypocalcemia during massive transfusion.
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Affiliation(s)
- Amanda Giancarelli
- Department of Pharmacy, Orlando Regional Medical Center, Orlando, Florida.
| | - Kara L Birrer
- Department of Pharmacy, Orlando Regional Medical Center, Orlando, Florida
| | - Rodrigo F Alban
- Department of Surgical Education, Orlando Regional Medical Center, Orlando, Florida
| | - Brandon P Hobbs
- Department of Pharmacy, Orlando Regional Medical Center, Orlando, Florida
| | - Xi Liu-DeRyke
- Department of Pharmacy, Orlando Regional Medical Center, Orlando, Florida.
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Balvers K, Coppens M, van Dieren S, van Rooyen-Schreurs IHM, Klinkspoor HJ, Zeerleder SS, Baumann HM, Goslings JC, Juffermans NP. Effects of a hospital-wide introduction of a massive transfusion protocol on blood product ratio and blood product waste. J Emerg Trauma Shock 2015; 8:199-204. [PMID: 26604525 PMCID: PMC4626936 DOI: 10.4103/0974-2700.166597] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background: Massive transfusion protocols (MTPs) are increasingly used in the transfusion practice and are developed to provide the standardized and early delivery of blood products and procoagulant agents and to supply the transfusion of blood products in a well-balanced ratio. Aim: The aim of this study was to investigate the effect of a hospital-wide introduction of an MTP on blood product ratio and a waste of blood products. Materials and Methods: Retrospective analysis was performed to compare the transfusion practice in massive bleeding patients before and after the introduction of an MTP and between the use of an MTP and transfusion off-protocol. Massive bleeding was defined as an administration of ≥5 units of red blood cells (RBCs) within 12 h. Results: Of 547 massively transfused patients, 192 patients were included in the pre-MTP period and 355 patients in the MTP period. The ratio of RBC to fresh frozen plasma (FFP) and the platelets transfused shifted significantly toward 1:1:1 in the MTP period (P = 0.012). This was mainly caused by a shift in RBC: FFP ratio (P = 0.014). An increase in the waste of blood products was observed, most notably FFPs (P = 0.026). Extending the storage time after thawing reduced the waste of FFPs from 11% to 4%. Conclusion: Hospital-wide introduction of an MTP is an adequate way to achieve a well-balanced transfusion ratio of 1:1:1. This comes at the cost of an increase in the waste of FFPs, which is lowered after extending the duration of storage time after thawing.
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Affiliation(s)
- Kirsten Balvers
- Trauma Unit, Department of Surgery, Academic Medical Center, Bijlmer, Amsterdam, The Netherlands ; Department of Intensive Care Medicine, Academic Medical Center, Bijlmer, Amsterdam, The Netherlands
| | - Michiel Coppens
- Department of Vascular Medicine, Academic Medical Center, Bijlmer, Amsterdam, The Netherlands
| | - Susan van Dieren
- Clinical Research Unit, Academic Medical Center, Bijlmer, Amsterdam, The Netherlands
| | | | - Henriëtte J Klinkspoor
- Laboratory of Clinical Chemistry, Academic Medical Center, Bijlmer, Amsterdam, The Netherlands
| | - Sacha S Zeerleder
- Clinical Research Unit, Academic Medical Center, Bijlmer, Amsterdam, The Netherlands ; Department of Immunopathology, Sanquin Research, Academic Medical Center, Bijlmer, Amsterdam, The Netherlands
| | - Holger M Baumann
- Department of Anesthesiology, Academic Medical Center, Bijlmer, Amsterdam, The Netherlands
| | - J Carel Goslings
- Trauma Unit, Department of Surgery, Academic Medical Center, Bijlmer, Amsterdam, The Netherlands
| | - Nicole P Juffermans
- Department of Intensive Care Medicine, Academic Medical Center, Bijlmer, Amsterdam, The Netherlands
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The impact of increased plasma ratios in massively transfused trauma patients: a prospective analysis. Eur J Trauma Emerg Surg 2015; 42:519-525. [PMID: 26362535 DOI: 10.1007/s00068-015-0573-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2015] [Accepted: 09/02/2015] [Indexed: 10/23/2022]
Abstract
PURPOSE Transfusion ratios approaching 1:1 FFP:PRBC for trauma resuscitation have become the de facto standard of care. The aim of this study was to prospectively evaluate the effect of increasing ratios of FFP:PRBC transfusion on survival for massively transfused civilian trauma patients as well as determine if time to reach the target ratio had any effect on outcomes. METHODS This is a prospective, observational study of all trauma patients requiring a massive transfusion (≥10 PRBC in ≤24 h) at a level 1 trauma center over a 2.5-year period. The ratio of FFP:PRBC was tracked hourly up to 24 h post-initiation of massive transfusion. A logistic regression model was utilized to identify the ideal ratio associated with mortality prediction. A stepwise logistic regression was performed to identify independent predictors of mortality. RESULTS The study population was predominantly male (89 %) with a mean age of 34.8 ± 16. On admission, 22 % had a systolic blood pressure ≤90 mmHg, 47 % had a heart rate ≥120, and 25 % had a GCS ≤8. The overall mortality was 33 %. The ratio of FFP:PRBC ≥ 1:1.5 was the second most important independent predictor of mortality for this population (R (2) = 0.59). Survivors had a higher FFP:PRBC ratio at all times during the first 24 h of resuscitation. CONCLUSIONS Achieving a ratio of FFP:PRBC ≥ 1:1.5 after the initial 24 h of resuscitation significantly improves survival in massively transfused trauma patients compared to patients that achieved a ratio <1:1.5.
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Peralta R, Vijay A, El-Menyar A, Consunji R, Abdelrahman H, Parchani A, Afifi I, Zarour A, Al-Thani H, Latifi R. Trauma resuscitation requiring massive transfusion: a descriptive analysis of the role of ratio and time. World J Emerg Surg 2015; 10:36. [PMID: 26279672 PMCID: PMC4536606 DOI: 10.1186/s13017-015-0028-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2015] [Accepted: 07/23/2015] [Indexed: 11/10/2022] Open
Abstract
Objective We aimed to evaluate whether early administration of high plasma to red blood cells ratios influences outcomes in injured patients who received massive transfusion protocol (MTP). Methods A retrospective analysis was conducted at the only level 1 national trauma center in Qatar for all adult patients(≥18 years old) who received MTP (≥10 units) of packed red blood cell (PRBC) during the initial 24 h post traumatic injury. Data were analyzed with respect to FFB:PRBC ratio [(high ≥ 1:1.5) (HMTP) vs. (low < 1:1.5) (LMTP)] given at the first 4 h post-injury and also between (>4 and 24 h). Mortality, multiorgan failure (MOF) and infectious complications were studied as well. Results During the study period, a total of 4864 trauma patients were admitted to the hospital, 1.6 % (n = 77) of them met the inclusion criteria. Both groups were comparable with respect to initial pH, international normalized ratio, injury severity score, revised trauma score and development of infectious complications. However, HMTP was associated with lower crude mortality (41.9 vs. 78.3 %, p = 0.001) and lower rate of MOF (48.4 vs. 87.0 %, p = 0.001). The number of deaths was 3 times higher in LMTP in comparison to HMTP within the first 30 days (36 vs. 13 cases). The majority of deaths occurred within the first 24 h (80.5 % in LMTP and 69 % in HMTP) and particularly within the first 6 h (55 vs. 46 %). Conclusions Aggressive attainment of high FFP/PRBC ratios as early as 4 h post-injury can substantially improve outcomes in trauma patients.
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Affiliation(s)
- Ruben Peralta
- Trauma Surgery Section, Hamad Trauma Center, Hamad General Hospital, Doha, Qatar
| | - Adarsh Vijay
- Trauma Surgery Section, Hamad Trauma Center, Hamad General Hospital, Doha, Qatar
| | - Ayman El-Menyar
- Clinical Research, Trauma Surgery Section, Hamad General Hospital, HMC, PO Box 3050, Doha, Qatar ; Clinical Medicine, Weill Cornell Medical College, Doha, Qatar
| | - Rafael Consunji
- Trauma Surgery Section, Hamad Trauma Center, Hamad General Hospital, Doha, Qatar
| | - Husham Abdelrahman
- Trauma Surgery Section, Hamad Trauma Center, Hamad General Hospital, Doha, Qatar
| | - Ashok Parchani
- Trauma Surgery Section, Hamad Trauma Center, Hamad General Hospital, Doha, Qatar
| | - Ibrahim Afifi
- Trauma Surgery Section, Hamad Trauma Center, Hamad General Hospital, Doha, Qatar
| | - Ahmad Zarour
- Trauma Surgery Section, Hamad Trauma Center, Hamad General Hospital, Doha, Qatar ; Clinical Medicine, Weill Cornell Medical College, Doha, Qatar
| | - Hassan Al-Thani
- Trauma Surgery Section, Hamad Trauma Center, Hamad General Hospital, Doha, Qatar
| | - Rifat Latifi
- Trauma Surgery Section, Hamad Trauma Center, Hamad General Hospital, Doha, Qatar ; Department of Surgery, University of Arizona, Tucson, AZ USA
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Chay J, Koh M, Tan HH, Ng J, Ng HJ, Chia N, Kuperan P, Tan J, Lew E, Tan LK, Koh PL, Desouza KA, Bin Mohd Fathil S, Kyaw PM, Ang AL. A national common massive transfusion protocol (MTP) is a feasible and advantageous option for centralized blood services and hospitals. Vox Sang 2015; 110:36-50. [PMID: 26178308 DOI: 10.1111/vox.12311] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2014] [Revised: 05/29/2015] [Accepted: 06/08/2015] [Indexed: 12/12/2022]
Abstract
BACKGROUND A common national MTP was jointly implemented in 2011 by the national blood service (Blood Services Group) and seven participating acute hospitals to provide rapid access to transfusion support for massively haemorrhaging patients treated in all acute care hospitals. METHODS Through a systematic clinical workflow, blood components are transfused in a ratio of 1:1:1 (pRBC: whole blood-derived platelets: FFP), together with cryoprecipitate for fibrinogen replacement. The composition of components for the MTP is fixed, although operational aspects of the MTP can be adapted by individual hospitals to suit local hospital workflow. The MTP could be activated in support of any patient with critical bleeding and at risk of massive transfusion, including trauma and non-trauma general medical, surgical and obstetric patients. RESULTS There were 434 activations of the MTP from October 2011 to October 2013. Thirty-nine per cent were for trauma patients, and 30% were for surgical patients with heavy intra-operative bleeding, with 25% and 6% for patients with gastrointestinal bleeding and peri-partum haemorrhage, respectively. Several hospitals reported reduction in mean time between request and arrival of blood. Mean transfusion ratio achieved was one red cell unit: 0·8 FFP units: 0·8 whole blood-derived platelet units: 0·4 units of cryoprecipitate. Although cryoprecipitate usage more than doubled after introduction of MTP, there was no significant rise in overall red cells, platelet and FFP usage following implementation. CONCLUSION This successful collaboration shows that shared transfusion protocols are feasible and potentially advantageous for hospitals sharing a central blood provider.
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Affiliation(s)
- J Chay
- Blood Services Group, Health Sciences Authority, Singapore City, Singapore
| | - M Koh
- Blood Services Group, Health Sciences Authority, Singapore City, Singapore
| | - H H Tan
- Blood Services Group, Health Sciences Authority, Singapore City, Singapore
| | - J Ng
- Department of Surgery, Singapore General Hospital, Singapore City, Singapore
| | - H J Ng
- Department of Haematology, Singapore General Hospital, Singapore City, Singapore
| | - N Chia
- Department of Anaesthesiology, Khoo Teck Puat Hospital, Singapore City, Singapore
| | - P Kuperan
- Department of Haematology, Tan Tock Seng Hospital, Singapore City, Singapore
| | - J Tan
- Department of Anaesthesiology, Tan Tock Seng Hospital, Singapore City, Singapore
| | - E Lew
- Department of Anaesthesiology, KK Woman's & Children's Hospital, Singapore City, Singapore
| | - L K Tan
- Department of Haematology, National University Hospital, Singapore City, Singapore
| | - P L Koh
- Paediatrics, National University Hospital, Singapore City, Singapore
| | - K A Desouza
- Department of Anaesthesiology, Changi General Hospital, Singapore City, Singapore
| | - S Bin Mohd Fathil
- Department of Anaethesiology, Jurong Health Services, Singapore City, Singapore
| | - P M Kyaw
- Blood Services Group, Health Sciences Authority, Singapore City, Singapore
| | - A L Ang
- Blood Services Group, Health Sciences Authority, Singapore City, Singapore
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Pretrauma center red blood cell transfusion is associated with reduced mortality and coagulopathy in severely injured patients with blunt trauma. Ann Surg 2015; 261:997-1005. [PMID: 24670858 DOI: 10.1097/sla.0000000000000674] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To evaluate the association of pretrauma center (PTC) red blood cell (RBC) transfusion with outcomes in severely injured patients. BACKGROUND Hemorrhage remains a major driver of mortality. Little evidence exists supporting PTC interventions to mitigate this. METHODS Blunt injured patients in shock arriving at a trauma center within 2 hours of injury were included from the Glue Grant database. Subjects were dichotomized by PTC RBC transfusion. Outcomes included 24-hour mortality, 30-day mortality, and trauma-induced coagulopathy [(TIC), admission international normalized ratio >1.5]. Cox regression and logistic regression determined the association of PTC RBC transfusion with outcomes. To address baseline differences, propensity score matching was used. RESULTS Of 1415 subjects, 50 received PTC RBC transfusion. Demographics and injury severity score were similar. The PTC RBC group received 1.3 units of RBCs (median), and 52% were scene transports. PTC RBC transfusion was associated with a 95% reduction in odds of 24-hour mortality [odds ratio (OR) = 0.05; 95% confidence interval (CI), 0.01-0.48; P < 0.01], 64% reduction in the risk of 30-day mortality [hazard ratio = 0.36; 95% CI, 0.15-0.83; P = 0.02], and 88% reduction in odds of TIC (OR = 0.12; 95% CI, 0.02-0.79; P = 0.03). The matched cohort included 113 subjects (31% PTC RBC group). Baseline characteristics were similar. PTC RBC transfusion was associated with a 98% reduction in odds of 24-hour mortality (OR = 0.02; 95% CI, 0.01-0.69; P = 0.04), 88% reduction in the risk of 30-day mortality (hazard ratio = 0.12; 95% CI, 0.03-0.61; P = 0.01), and 99% reduction in odds of TIC (OR = 0.01; 95% CI, 0.01-0.95; P = 0.05). CONCLUSIONS PTC RBC administration was associated with a lower risk of 24-hour mortality, 30-day mortality, and TIC in severely injured patients with blunt trauma, warranting further prospective study.
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Stubbs JR, Zielinski MD, Berns KS, Badjie KS, Tauscher CD, Hammel SA, Zietlow SP, Jenkins D. How we provide thawed plasma for trauma patients. Transfusion 2015; 55:1830-7. [PMID: 26013588 DOI: 10.1111/trf.13156] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2014] [Revised: 04/08/2015] [Accepted: 04/08/2015] [Indexed: 12/21/2022]
Abstract
Almost 50% of trauma-related fatalities within the first 24 hours of injury are related to hemorrhage. Improved survival in severely injured patients has been demonstrated when massive transfusion protocols are rapidly invoked as part of a therapeutic approach known as damage control resuscitation (DCR). DCR incorporates the early use of plasma to prevent or correct trauma-induced coagulopathy. DCR often requires the transfusion of plasma before determination of the recipient's ABO group. Historically, group AB plasma has been considered the "universal donor" plasma product. At our facility, the number of AB plasma products produced on an annual basis was found to be inadequate to support the trauma service's DCR program. A joint decision was made by the transfusion medicine and trauma services to provide group A thawed plasma (TP) for in-hospital and prehospital DCR protocols. A description of the implementation of group A TP into the DCR program is provided as well as outcome data pertaining to the use of TP in trauma patients.
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Affiliation(s)
- James R Stubbs
- Department of Laboratory Medicine and Pathology, Division of Transfusion Medicine
| | | | - Kathleen S Berns
- Department of Medical Transport, Mayo Clinic, Rochester, Minnesota
| | - Karafa S Badjie
- Department of Laboratory Medicine and Pathology, Division of Transfusion Medicine
| | - Craig D Tauscher
- Department of Laboratory Medicine and Pathology, Division of Transfusion Medicine
| | - Scott A Hammel
- Department of Laboratory Medicine and Pathology, Division of Transfusion Medicine
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Analysis of risk classification for massive transfusion in severe trauma using the gray zone approach. Am J Emerg Med 2015; 33:1146-51. [PMID: 26032662 DOI: 10.1016/j.ajem.2015.05.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2014] [Revised: 04/20/2015] [Accepted: 05/11/2015] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND The Traumatic Bleeding Severity Score (TBSS) was developed to predict the need for massive transfusion (MT). The aim of this study is evaluation of clinical thresholds for activation of a MT protocol using the gray zone approach based on TBSS. METHODS This is a single-center retrospective study of trauma patients, admitted from 2010 to 2013. The TBSS on admission was calculated, and the accuracy of predicting MT was analyzed using area under the receiver operating characteristic curve. Risk classification for MT was made using sensitivity/specificity. The gray zone (indeterminate risk) was defined from a sensitivity of 95% to a specificity of 95%, patients were separated into MT and non-MT groups, and their clinical characteristics were compared. RESULTS A total of 264 patients were enrolled, with an area under the TBSS curve of 0.967 (95% confidence interval, 0.94-0.99). A TBSS of 10 points or less resulted in a sensitivity of 96.5% with 146 patients in this group, and 3.4% (5/146) of them received MT. A TBSS of 17 points or higher had a specificity of 97.8%, which included 72 patients, and 94.4% (68/72) of them received MT. Forty-six patients had a TBSS from 11 to 16 points (gray zone), and 26.1% (12/46) of them received MT. Comparing the MT group (12/46) and non-MT group (34/46), coagulopathy and extravasation on computed tomographic scan were more prevalent in the MT group. CONCLUSION The TBSS is highly accurate in predicting the need for MT, and a risk classification for needing MT was created based on TBSS.
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Balvers K, Wirtz MR, van Dieren S, Goslings JC, Juffermans NP. Risk factors for trauma-induced coagulopathy- and transfusion-associated multiple organ failure in severely injured trauma patients. Front Med (Lausanne) 2015; 2:24. [PMID: 25964951 PMCID: PMC4408845 DOI: 10.3389/fmed.2015.00024] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2015] [Accepted: 03/30/2015] [Indexed: 12/26/2022] Open
Abstract
Background Both trauma-induced coagulopathy (TIC) and transfusion strategies influence early outcome in hemorrhagic trauma patients. Their impact on late outcome is less well characterized. This study systematically reviews risk factors for TIC- and transfusion-associated multiple organ failure (MOF) in severely injured trauma patients. Materials and methods A systematic search was conducted in PubMed and Embase. Studies published from 1986 to 2013 on adult trauma patients with an injury severity score ≥16, investigating TIC or transfusion strategies with MOF as primary or secondary outcome, were eligible for inclusion. Results of the included studies were evaluated with meta-analyses of pooled data. Results In total, 50 studies were included with a total sample size of 63,586 patients. Due to heterogeneity of the study populations and outcome measures, results from 7 studies allowed for pooling of data. Risk factors for TIC-associated MOF were hypocoagulopathy, hemorrhagic shock, activated protein C, increased histone levels, and increased levels of markers of fibrinolysis on admission. After at least 24 h after admission, the occurrence of thromboembolic events was associated with MOF. Risk factors for transfusion-associated MOF were the administration of fluids and red blood cell units within 24 h post-injury, the age of red blood cells (>14 days) and a ratio of FFP:RBC ≥ 1:1 (OR 1.11, 95% CI 1.04–1.19). Conclusion Risk factors for TIC-associated MOF in severely injured trauma patients are early hypocoagulopathy and hemorrhagic shock, while a hypercoagulable state with the occurrence of thromboembolic events later in the course of trauma predisposes to MOF. Risk factors for transfusion-associated MOF include administration of crystalloids and red blood cells and a prolonged storage time of red blood cells. Future prospective studies investigating TIC- and transfusion-associated risk factors on late outcome are required.
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Affiliation(s)
- Kirsten Balvers
- Trauma Unit, Department of Surgery, Academic Medical Center , Amsterdam , Netherlands ; Department of Intensive Care, Academic Medical Center , Amsterdam , Netherlands
| | - Mathijs R Wirtz
- Trauma Unit, Department of Surgery, Academic Medical Center , Amsterdam , Netherlands ; Department of Intensive Care, Academic Medical Center , Amsterdam , Netherlands
| | - Susan van Dieren
- Clinical Research Unit, Academic Medical Center , Amsterdam , Netherlands
| | - J Carel Goslings
- Trauma Unit, Department of Surgery, Academic Medical Center , Amsterdam , Netherlands
| | - Nicole P Juffermans
- Department of Intensive Care, Academic Medical Center , Amsterdam , Netherlands
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Buehner M, Edwards MJ. Massive Transfusion Protocols in the Pediatric Trauma Patient: An Update. CURRENT SURGERY REPORTS 2015. [DOI: 10.1007/s40137-015-0092-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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Effect of transfusion of fresh frozen plasma on parameters of endothelial condition and inflammatory status in non-bleeding critically ill patients: a prospective substudy of a randomized trial. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2015; 19:163. [PMID: 25880761 PMCID: PMC4407778 DOI: 10.1186/s13054-015-0828-6] [Citation(s) in RCA: 56] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/06/2014] [Accepted: 02/20/2015] [Indexed: 12/22/2022]
Abstract
Introduction Much controversy exists on the effect of a fresh frozen plasma (FFP) transfusion on systemic inflammation and endothelial damage. Adverse effects of FFP have been well described, including acute lung injury. However, it is also suggested that a higher amount of FFP decreases mortality in trauma patients requiring a massive transfusion. Furthermore, FFP has an endothelial stabilizing effect in experimental models. We investigated the effect of fresh frozen plasma transfusion on systemic inflammation and endothelial condition. Methods A prospective predefined substudy of a randomized trial in coagulopathic non-bleeding critically ill patients receiving a prophylactic transfusion of FFP (12 ml/kg) prior to an invasive procedure. Levels of inflammatory cytokines and markers of endothelial condition were measured in paired samples of 33 patients before and after transfusion. The statistical tests used were paired t test or the Wilcoxon signed-rank test. Results At baseline, systemic cytokine levels were mildly elevated in critically ill patients. FFP transfusion resulted in a decrease of levels of TNF-α (from 11.3 to 2.3 pg/ml, P = 0.01). Other cytokines were not affected. FFP also resulted in a decrease in systemic syndecan-1 levels (from 675 to 565 pg/ml, P = 0.01) and a decrease in factor VIII levels (from 246 to 246%, P <0.01), suggestive of an improved endothelial condition. This was associated with an increase in ADAMTS13 levels (from 24 to 32%, P <0.01) and a concomitant decrease in von Willebrand factor (vWF) levels (from 474 to 423%, P <0.01). Conclusions A fixed dose of FFP transfusion in critically ill patients decreases syndecan-1 and factor VIII levels, suggesting a stabilized endothelial condition, possibly by increasing ADAMTS13, which is capable of cleaving vWF. Trial registrations Trialregister.nl NTR2262, registered 26 March 2010 and Clinicaltrials.gov NCT01143909, registered 14 June 2010.
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Zhao J, Pan G, Wang B, Zhang Y, You G, Wang Y, Gao D, Zhou H, Zhao L. A fresh frozen plasma to red blood cell transfusion ratio of 1:1 mitigates lung injury in a rat model of damage control resuscitation for hemorrhagic shock. Am J Emerg Med 2015; 33:754-9. [PMID: 25869022 DOI: 10.1016/j.ajem.2015.02.041] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2014] [Revised: 02/02/2015] [Accepted: 02/21/2015] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND We aimed to evaluate the effects of resuscitation with different ratios of fresh frozen plasma (FFP) to red blood cells (RBCs) on pulmonary inflammatory injury and to illuminate the beneficial effects of FFP on lung protection compared with lactated ringers (LR) using a rat model of hemorrhagic shock. METHODS Rats underwent pressure-controlled hemorrhage for 60 minutes and were then transfused with LR for initial resuscitation. Thereafter, the rats were transfused with varying ratios of FFP:RBC (1:4, 1:2, 1:1, and 2:1) or LR:RBC (1:1) to hold their mean arterial pressure (MAP) at 100 ± 3 mm Hg for 30 minutes. After 4 hours of observation, lung tissue was harvested to determine the wet/dry weight, myeloperoxidase levels, tumor necrosis factor α levels, macrophage inflammatory protein 2 (MIP-2) levels, inducible nitric oxide synthase activity, and the nuclear factor κB p65 DNA-binding activity. RESULTS With an increase in the FFP:RBC ratio, the volume of required RBC to maintain the target MAP decreased. The MAP value in each group was not significantly different during the whole experiment period. The values of the wet/dry weights and MIP-2 were significantly lower in the FFP:RBC = 1:1 group than the other groups (P < .05). All parameters detected above were predominantly lower in the FFP:RBC = 1:1 group than the FFP:RBC = 1:2 group and the LR:RBC = 1:1 group (P < .05). In addition, all parameter values were lower in the FFP:RBC = 1:1 group than in the FFP:RBC = 2:1 group, but only the wet/dry weight, myeloperoxidase, and MIP-2 values were significantly different (P < .05). CONCLUSIONS Resuscitation with a 1:1 ratio of FFP to RBC results in decreased lung inflammation. Compared with LR, FFP could further mitigate lung inflammatory injury.
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Affiliation(s)
- Jingxiang Zhao
- Institute of Transfusion Medicine, Academy of Military Medical Sciences, No. 27th Taiping Road, HaiDian, Beijing, China
| | - Guocheng Pan
- Department of Biological Engineering, College of Environment and Chemical Engineering, Yanshan University, Qinhuangdao, China
| | - Bo Wang
- Institute of Transfusion Medicine, Academy of Military Medical Sciences, No. 27th Taiping Road, HaiDian, Beijing, China
| | - Yuhua Zhang
- Institute of Transfusion Medicine, Academy of Military Medical Sciences, No. 27th Taiping Road, HaiDian, Beijing, China
| | - Guoxing You
- Institute of Transfusion Medicine, Academy of Military Medical Sciences, No. 27th Taiping Road, HaiDian, Beijing, China
| | - Ying Wang
- Institute of Transfusion Medicine, Academy of Military Medical Sciences, No. 27th Taiping Road, HaiDian, Beijing, China
| | - Dawei Gao
- Department of Biological Engineering, College of Environment and Chemical Engineering, Yanshan University, Qinhuangdao, China.
| | - Hong Zhou
- Institute of Transfusion Medicine, Academy of Military Medical Sciences, No. 27th Taiping Road, HaiDian, Beijing, China.
| | - Lian Zhao
- Institute of Transfusion Medicine, Academy of Military Medical Sciences, No. 27th Taiping Road, HaiDian, Beijing, China.
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Maciel JD, Gifford E, Plurad D, de Virgilio C, Bricker S, Bongard F, Neville A, Smith J, Putnam B, Kim D. The impact of a massive transfusion protocol on outcomes among patients with abdominal aortic injuries. Ann Vasc Surg 2015; 29:764-9. [PMID: 25725276 DOI: 10.1016/j.avsg.2014.11.024] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2014] [Revised: 11/14/2014] [Accepted: 11/25/2014] [Indexed: 01/12/2023]
Abstract
BACKGROUND Injuries of the abdominal aorta are uncommon and associated with a high mortality. The purpose of this study was to examine the impact of an institutional massive transfusion protocol (MTP) on outcomes in patients with injuries of the abdominal aorta. METHODS A 12.5-year retrospective analysis of a Level 1 trauma center database to identify patients with abdominal aortic injuries was conducted. Demographics, associated injuries and severity, operative procedures, resuscitation requirements, and outcomes were compared among patients before and after implementation of an MTP. RESULTS Of the 46 patients with abdominal aortic injuries, 29 (63%) were in the pre-MTP group and 17 (37%) were in the post-MTP group. The mean age of the entire cohort was 32 ± 17 years and the two most common mechanisms of injury were gunshot wounds (63%) followed by motor vehicle collisions (24%). Thirteen patients (28%) underwent an emergency department thoracotomy and 11 patients (24%) sustained concomitant inferior vena cava injuries. There was a significant reduction in the volume of pre- and intraoperative crystalloids administered between the pre- and post-MTP groups. Intraoperatively, the use of tranexamic acid was increased in the post-MTP group (P < 0.001). A statistically significant difference in achievement of a low packed red blood cells to fresh frozen plasma ratio was observed for the post- versus the pre-MTP group (88% vs. 30%, P = 0.015). Overall survival was improved among post- versus pre-MTP patients (47% vs. 14%, P = 0.03). CONCLUSIONS Abdominal aortic injuries continue to represent a challenge and remain associated with a high mortality. Modern improvements in damage control resuscitation techniques including implementation of an institutional MTP may improve outcomes in patients with these injuries.
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Affiliation(s)
- James D Maciel
- Department of Surgery, Harbor-UCLA Medical Center, Torrance, CA
| | - Edward Gifford
- Department of Surgery, Harbor-UCLA Medical Center, Torrance, CA
| | - David Plurad
- Department of Surgery, Harbor-UCLA Medical Center, Torrance, CA; Division of Trauma/Acute Care Surgery/Surgical Critical Care, Harbor-UCLA Medical Center, Torrance, CA
| | | | - Scott Bricker
- Department of Surgery, Harbor-UCLA Medical Center, Torrance, CA; Division of Trauma/Acute Care Surgery/Surgical Critical Care, Harbor-UCLA Medical Center, Torrance, CA
| | - Fred Bongard
- Department of Surgery, Harbor-UCLA Medical Center, Torrance, CA; Division of Trauma/Acute Care Surgery/Surgical Critical Care, Harbor-UCLA Medical Center, Torrance, CA
| | - Angela Neville
- Department of Surgery, Harbor-UCLA Medical Center, Torrance, CA; Division of Trauma/Acute Care Surgery/Surgical Critical Care, Harbor-UCLA Medical Center, Torrance, CA
| | - Jennifer Smith
- Department of Surgery, Harbor-UCLA Medical Center, Torrance, CA; Division of Trauma/Acute Care Surgery/Surgical Critical Care, Harbor-UCLA Medical Center, Torrance, CA
| | - Brant Putnam
- Department of Surgery, Harbor-UCLA Medical Center, Torrance, CA; Division of Trauma/Acute Care Surgery/Surgical Critical Care, Harbor-UCLA Medical Center, Torrance, CA
| | - Dennis Kim
- Department of Surgery, Harbor-UCLA Medical Center, Torrance, CA; Division of Trauma/Acute Care Surgery/Surgical Critical Care, Harbor-UCLA Medical Center, Torrance, CA.
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Time matters in 1: 1 resuscitations: concurrent administration of blood: plasma and risk of death. J Trauma Acute Care Surg 2015; 77:833-7; discussion 837-8. [PMID: 25051380 DOI: 10.1097/ta.0000000000000355] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The practice of 1:1 transfusion, administering packed red blood cells (PRBCs) with fresh frozen plasma (FFP), has been associated with improved survival. However, the reported ratios are the result of mathematical averages over 24 hours and do not necessarily represent concurrent administration. Using critical administration thresholds (CAT+) of more than 3 U of PRBC per hour to identify hemorrhaging patients, this study evaluates the effect of concurrent administration of PRBC/FFP on patient survival. METHODS CAT+ patients identified retrospectively were eligible for analysis. The exact time of administration of each unit of PRBC and FFP was calculated. Each PRBC was matched to a corresponding unit of FFP given within 5 minutes before or after. Ideal 1:1 ratios were calculated for each hour during the first day of admission. Hourly ratio groups were created (25%, 50%, 75% of transfusion opportunities) and evaluated as time-varying covariates. Cox proportional hazard ratio (HR) was used to determine risk of mortality, and Student's t test or Wilcoxon signed-rank test was used to compare groups. RESULTS A total of 169 patients were initially identified (70% with New Injury Severity Score [NISS] > 10), 77 of whom were CAT+. There were no clinical differences between the groups in this study. In terms of mortality, patients who reached the 1:1 ratio 25% of the transfusion opportunities had an HR of 8.806 (95% confidence interval [CI], 1.845-42.034). Patients meeting the 1:1 ratio 50% of the opportunities had an HR of 5.062 (95% CI, 1.115-22.982) while those meeting 75% of the opportunities had an HR of 1.888 (95% CI, 0.198-18.035). CONCLUSION CAT+ patients represent the trauma subset at highest risk of mortality and may benefit from a focused blood-based resuscitation. Patients who were able to meet the 1:1 ratio more often had a noticeable decrease in risk of death compared with those who achieved less than 1:1 transfusions. Administering FFP concurrently with PRBC is associated with a decrease in mortality in CAT+ patients. LEVEL OF EVIDENCE Prognostic study, level III; therapeutic study, level IV.
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Brown JB, Guyette FX, Neal MD, Claridge JA, Daley BJ, Harbrecht BG, Miller RS, Phelan HA, Adams PW, Early BJ, Peitzman AB, Billiar TR, Sperry JL. Taking the Blood Bank to the Field: The Design and Rationale of the Prehospital Air Medical Plasma (PAMPer) Trial. PREHOSP EMERG CARE 2015; 19:343-50. [PMID: 25658881 DOI: 10.3109/10903127.2014.995851] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Hemorrhage and trauma induced coagulopathy remain major drivers of early preventable mortality in military and civilian trauma. Interest in the use of prehospital plasma in hemorrhaging patients as a primary resuscitation agent has grown recently. Trauma center-based damage control resuscitation using early and aggressive plasma transfusion has consistently demonstrated improved outcomes in hemorrhaging patients. Additionally, plasma has been shown to have several favorable immunomodulatory effects. Preliminary evidence with prehospital plasma transfusion has demonstrated feasibility and improved short-term outcomes. Applying state-of-the-art resuscitation strategies to the civilian prehospital arena is compelling. We describe here the rationale, design, and challenges of the Prehospital Air Medical Plasma (PAMPer) trial. The primary objective is to determine the effect of prehospital plasma transfusion during air medical transport on 30-day mortality in patients at risk for traumatic hemorrhage. This study is a multicenter cluster randomized clinical trial. The trial will enroll trauma patients with profound hypotension (SBP ≤ 70 mmHg) or hypotension (SBP 71-90 mmHg) and tachycardia (HR ≥ 108 bpm) from six level I trauma center air medical transport programs. The trial will also explore the effects of prehospital plasma transfusion on the coagulation and inflammatory response following injury. The trial will be conducted under exception for informed consent for emergency research with an investigational new drug approval from the U.S. Food and Drug Administration utilizing a multipronged community consultation process. It is one of three ongoing Department of Defense-funded trials aimed at expanding our understanding of the optimal therapeutic approaches to coagulopathy in the hemorrhaging trauma patient.
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Holcomb JB, Tilley BC, Baraniuk S, Fox EE, Wade CE, Podbielski JM, del Junco DJ, Brasel KJ, Bulger EM, Callcut RA, Cohen MJ, Cotton BA, Fabian TC, Inaba K, Kerby JD, Muskat P, O'Keeffe T, Rizoli S, Robinson BRH, Scalea TM, Schreiber MA, Stein DM, Weinberg JA, Callum JL, Hess JR, Matijevic N, Miller CN, Pittet JF, Hoyt DB, Pearson GD, Leroux B, van Belle G. Transfusion of plasma, platelets, and red blood cells in a 1:1:1 vs a 1:1:2 ratio and mortality in patients with severe trauma: the PROPPR randomized clinical trial. JAMA 2015; 313:471-82. [PMID: 25647203 PMCID: PMC4374744 DOI: 10.1001/jama.2015.12] [Citation(s) in RCA: 1535] [Impact Index Per Article: 170.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
IMPORTANCE Severely injured patients experiencing hemorrhagic shock often require massive transfusion. Earlier transfusion with higher blood product ratios (plasma, platelets, and red blood cells), defined as damage control resuscitation, has been associated with improved outcomes; however, there have been no large multicenter clinical trials. OBJECTIVE To determine the effectiveness and safety of transfusing patients with severe trauma and major bleeding using plasma, platelets, and red blood cells in a 1:1:1 ratio compared with a 1:1:2 ratio. DESIGN, SETTING, AND PARTICIPANTS Pragmatic, phase 3, multisite, randomized clinical trial of 680 severely injured patients who arrived at 1 of 12 level I trauma centers in North America directly from the scene and were predicted to require massive transfusion between August 2012 and December 2013. INTERVENTIONS Blood product ratios of 1:1:1 (338 patients) vs 1:1:2 (342 patients) during active resuscitation in addition to all local standard-of-care interventions (uncontrolled). MAIN OUTCOMES AND MEASURES Primary outcomes were 24-hour and 30-day all-cause mortality. Prespecified ancillary outcomes included time to hemostasis, blood product volumes transfused, complications, incidence of surgical procedures, and functional status. RESULTS No significant differences were detected in mortality at 24 hours (12.7% in 1:1:1 group vs 17.0% in 1:1:2 group; difference, -4.2% [95% CI, -9.6% to 1.1%]; P = .12) or at 30 days (22.4% vs 26.1%, respectively; difference, -3.7% [95% CI, -10.2% to 2.7%]; P = .26). Exsanguination, which was the predominant cause of death within the first 24 hours, was significantly decreased in the 1:1:1 group (9.2% vs 14.6% in 1:1:2 group; difference, -5.4% [95% CI, -10.4% to -0.5%]; P = .03). More patients in the 1:1:1 group achieved hemostasis than in the 1:1:2 group (86% vs 78%, respectively; P = .006). Despite the 1:1:1 group receiving more plasma (median of 7 U vs 5 U, P < .001) and platelets (12 U vs 6 U, P < .001) and similar amounts of red blood cells (9 U) over the first 24 hours, no differences between the 2 groups were found for the 23 prespecified complications, including acute respiratory distress syndrome, multiple organ failure, venous thromboembolism, sepsis, and transfusion-related complications. CONCLUSIONS AND RELEVANCE Among patients with severe trauma and major bleeding, early administration of plasma, platelets, and red blood cells in a 1:1:1 ratio compared with a 1:1:2 ratio did not result in significant differences in mortality at 24 hours or at 30 days. However, more patients in the 1:1:1 group achieved hemostasis and fewer experienced death due to exsanguination by 24 hours. Even though there was an increased use of plasma and platelets transfused in the 1:1:1 group, no other safety differences were identified between the 2 groups. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01545232.
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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, Houston
| | - Barbara C Tilley
- Division of Biostatistics, School of Public Health, University of Texas Health Science Center, Houston
| | - Sarah Baraniuk
- Division of Biostatistics, School of Public Health, University of Texas Health Science Center, 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, 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, Houston
| | - Jeanette M Podbielski
- Center for Translational Injury Research, Division of Acute Care Surgery, Department of Surgery, Medical School, University of Texas Health Science Center, Houston
| | - Deborah J del Junco
- Center for Translational Injury Research, Division of Acute Care Surgery, Department of Surgery, Medical School, University of Texas Health Science Center, Houston
| | - Karen J Brasel
- Division of Trauma and Critical Care, Department of Surgery, Medical College of Wisconsin, Milwaukee22Dr Brasel is now with the Division of Trauma, Critical Care and Acute Care Surgery, School of Medicine, Oregon Health & Science University, Portland
| | - Eileen M Bulger
- Division of Trauma and Critical Care, Department of Surgery, School of Medicine, University of Washington, Seattle
| | - Rachael A Callcut
- Division of General Surgery, Department of Surgery, School of Medicine, University of California, San Francisco
| | - Mitchell Jay Cohen
- Division of General Surgery, Department of Surgery, School of Medicine, University of California, San Francisco
| | - Bryan A Cotton
- Center for Translational Injury Research, Division of Acute Care Surgery, Department of Surgery, Medical School, University of Texas Health Science Center, Houston
| | - Timothy C Fabian
- Division of Trauma and Surgical Critical Care, Department of Surgery, College of Medicine, University of Tennessee Health Science Center, Memphis
| | - Kenji Inaba
- Division of Trauma and Critical Care, University of Southern California, Los Angeles
| | - Jeffrey D Kerby
- Division of Trauma, Burns and Surgical Critical Care, Department of Surgery, School of Medicine, University of Alabama, Birmingham
| | - Peter Muskat
- Division of Trauma/Critical Care, Department of Surgery, College of Medicine, University of Cincinnati, Cincinnati, Ohio23Dr Muskat is now with the Division of General Surgery, Department of Surgery, School of Medicine, University of California, San Franc
| | - Terence O'Keeffe
- Division of Trauma, Critical Care and Emergency Surgery, Department of Surgery, University of Arizona, Tucson
| | - Sandro Rizoli
- Trauma and Acute Care Surgery, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Bryce R H Robinson
- Division of Trauma/Critical Care, Department of Surgery, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Thomas M Scalea
- R. Adams Cowley Shock Trauma Center, Program in Trauma, University of Maryland School of Medicine, Baltimore
| | - Martin A Schreiber
- Division of Trauma, Critical Care and Acute Care Surgery, School of Medicine, Oregon Health & Science University, Portland
| | - Deborah M Stein
- R. Adams Cowley Shock Trauma Center, Program in Trauma, University of Maryland School of Medicine, Baltimore
| | - Jordan A Weinberg
- Division of Trauma and Surgical Critical Care, Department of Surgery, College of Medicine, University of Tennessee Health Science Center, Memphis
| | - Jeannie L Callum
- Sunnybrook Research Institute, Department of Clinical Pathology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - John R Hess
- Department of Laboratory Medicine, School of Medicine, University of Washington, Seattle
| | - Nena Matijevic
- Center for Translational Injury Research, Division of Acute Care Surgery, Department of Surgery, Medical School, University of Texas Health Science Center, Houston
| | - Christopher N Miller
- Department of Emergency Medicine, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Jean-Francois Pittet
- Division of Critical Care and Perioperative Medicine, Department of Anesthesiology, School of Medicine, University of Alabama, Birmingham
| | | | - Gail D Pearson
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Brian Leroux
- Department of Biostatistics, School of Public Health, University of Washington, Seattle
| | - Gerald van Belle
- Department of Biostatistics, School of Public Health, University of Washington, Seattle21Department of Environmental and Occupational Health Sciences, School of Public Health, University of Washington, Seattle
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Brown JB, Sperry JL, Fombona A, Billiar TR, Peitzman AB, Guyette FX. Pre-trauma center red blood cell transfusion is associated with improved early outcomes in air medical trauma patients. J Am Coll Surg 2015; 220:797-808. [PMID: 25840537 DOI: 10.1016/j.jamcollsurg.2015.01.006] [Citation(s) in RCA: 125] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2014] [Revised: 01/16/2015] [Accepted: 01/17/2015] [Indexed: 12/25/2022]
Abstract
BACKGROUND Hemorrhage is the leading cause of survivable death in trauma and resuscitation strategies including early RBC transfusion have reduced this. Pre-trauma center (PTC) RBC transfusion is growing and preliminary evidence suggests improved outcomes. The study objective was to evaluate the association of PTC RBC transfusion with outcomes in air medical trauma patients. STUDY DESIGN We conducted a retrospective cohort study of trauma patients transported by helicopter to a Level I trauma center from 2007 to 2012. Patients receiving PTC RBC transfusion were matched to control patients (receiving no PTC RBC transfusion during transport) in a 1:2 ratio using a propensity score based on prehospital variables. Conditional logistic regression and mixed-effects linear regression were used to determine the association of PTC RBC transfusion with outcomes. Subgroup analysis was performed for scene transport patients. RESULTS Two-hundred and forty treatment patients were matched to 480 control patients receiving no PTC RBC transfusion. Pre-trauma center RBC transfusion was associated with increased odds of 24-hour survival (adjusted odds ratio [AOR] = 4.92; 95% CI, 1.51-16.04; p = 0.01), lower odds of shock (AOR = 0.28; 95% CI, 0.09-0.85; p = 0.03), and lower 24-hour RBC requirement (Coefficient -3.6 RBC units; 95% CI, -7.0 to -0.2; p = 0.04). Among matched scene patients, PTC RBC was also associated with increased odds of 24-hour survival (AOR = 6.31; 95% CI, 1.88-21.14; p < 0.01), lower odds of shock (AOR = 0.24; 95% CI, 0.07-0.80; p = 0.02), and lower 24-hour RBC requirement (Coefficient -4.5 RBC units; 95% CI, -8.3 to -0.7; p = 0.02). CONCLUSIONS Pre-trauma center RBC was associated with an increased probability of 24-hour survival, decreased risk of shock, and lower 24-hour RBC requirement. Pre-trauma center RBC appears beneficial in severely injured air medical trauma patients and prospective study is warranted as PTC RBC transfusion becomes more readily available.
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Affiliation(s)
- Joshua B Brown
- Division of General Surgery and Trauma, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Jason L Sperry
- Division of General Surgery and Trauma, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA.
| | - Anisleidy Fombona
- Division of General Surgery and Trauma, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Timothy R Billiar
- Division of General Surgery and Trauma, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Andrew B Peitzman
- Division of General Surgery and Trauma, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Francis X Guyette
- Department of Emergency Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA
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Okoye OT, Reddy H, Wong MD, Doane S, Resnick S, Karamanos E, Skiada D, Goodrich R, Inaba K. Large animal evaluation of riboflavin and ultraviolet light-treated whole blood transfusion in a diffuse, nonsurgical bleeding porcine model. Transfusion 2015; 55:532-43. [PMID: 25582335 DOI: 10.1111/trf.12894] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2014] [Revised: 07/31/2014] [Accepted: 08/11/2014] [Indexed: 11/25/2022]
Abstract
BACKGROUND The Mirasol system has been demonstrated to effectively inactivate white blood cells (WBCs) and reduce pathogens in whole blood in vitro. The purpose of this study was to compare the safety and efficacy of Mirasol-treated fresh whole blood (FWB) to untreated FWB in an in vivo model of surgical bleeding. STUDY DESIGN AND METHODS A total of 18 anesthetized pigs (40 kg) underwent a 35% total blood volume bleed, cooling to 33°C, and a standardized liver injury. Animals were then randomly assigned to resuscitation with either Mirasol-treated or untreated FWB, and intraoperative blood loss was measured. After abdominal closure, the animals were observed for 14 days, after which the animals were euthanized and tissues were obtained for histopathologic examination. Mortality, tissue near-infrared spectroscopy, red blood cell (RBC) variables, platelets (PLTs), WBCs, and coagulation indices were analyzed. RESULTS Total intraoperative blood loss was similar in test and control arms (8.3 ± 3.2 mL/kg vs. 7.7 ± 3.9 mL/kg, p = 0.720). All animals survived to Day 14. Trended values over time did not show significant differences-tissue oxygenation (p = 0.605), hemoglobin (p = 0.461), PLTs (p = 0.807), WBCs (p = 0.435), prothrombin time (p = 0.655), activated partial thromboplastin time (p = 0.416), thromboelastography (TEG)-reaction time (p = 0.265), or TEG-clot formation time (p = 0.081). Histopathology did not show significant differences between arms. CONCLUSIONS Mirasol-treated FWB did not impact survival, blood loss, tissue oxygen delivery, RBC indices, or coagulation variables in a standardized liver injury model. These data suggest that Mirasol-treated FWB is both safe and efficacious in vivo.
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Affiliation(s)
- Obi T Okoye
- Division of Trauma Surgery and Surgical Critical Care, Department of Surgery, Keck School of Medicine of University of Southern California, Los Angeles, California
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75
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Adult respiratory distress syndrome risk factors for injured patients undergoing damage-control laparotomy. J Trauma Acute Care Surg 2014; 77:886-91. [DOI: 10.1097/ta.0000000000000421] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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76
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Waters J. Role of the massive transfusion protocol in the management of haemorrhagic shock. Br J Anaesth 2014; 113 Suppl 2:ii3-8. [DOI: 10.1093/bja/aeu379] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Abstract
Evidence for changes in adult trauma management often precedes evidence for changes in pediatric trauma management. Many adult trauma centers have adopted damage-control resuscitation management strategies, which target the metabolic syndrome of acidosis, coagulopathy, and hypothermia often found in severe uncontrolled hemorrhage. Two key components of damage-control resuscitation are permissive hypotension, which is a fluid management strategy that targets a subnormal blood pressure, and hemostatic resuscitation, which is a transfusion strategy that targets coagulopathy with early blood product administration. Acceptance of damage-control resuscitation strategies is reflected in recent changes in the American College of Surgeons' Advanced Trauma Life Support curriculum; the most recent edition has decreased its initial fluid recommendation to 1 L from 2 L, and it now recommends early administration of blood products without specifying any specific ratio. These recommendations are not advocating permissive hypotension or hemostatic resuscitation directly but represent an initial step toward limiting fluid resuscitation and using blood products to treat coagulopathy earlier. Evidence for permissive hypotension exists in animal studies and few adult clinical trials. There is no evidence to support permissive hypotension strategies in pediatrics. Evidence for hemostatic resuscitation in adult trauma management is more comprehensive, and there are limited data to support its use in pediatric trauma patients with severe hemorrhage. Additional studies on the management of children with severe uncontrolled hemorrhage are needed.
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78
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Baraniuk S, Tilley BC, del Junco DJ, Fox EE, van Belle G, Wade CE, Podbielski JM, Beeler AM, Hess JR, Bulger EM, Schreiber MA, Inaba K, Fabian TC, Kerby JD, Cohen MJ, Miller CN, Rizoli S, Scalea TM, O’Keeffe T, Brasel KJ, Cotton BA, Muskat P, Holcomb JB. Pragmatic Randomized Optimal Platelet and Plasma Ratios (PROPPR) Trial: design, rationale and implementation. Injury 2014; 45:1287-95. [PMID: 24996573 PMCID: PMC4137482 DOI: 10.1016/j.injury.2014.06.001] [Citation(s) in RCA: 102] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2014] [Accepted: 06/01/2014] [Indexed: 02/02/2023]
Abstract
BACKGROUND Forty percent of in-hospital deaths among injured patients involve massive truncal haemorrhage. These deaths may be prevented with rapid haemorrhage control and improved resuscitation techniques. The Pragmatic Randomized Optimal Platelet and Plasma Ratios (PROPPR) Trial was designed to determine if there is a difference in mortality between subjects who received different ratios of FDA approved blood products. This report describes the design and implementation of PROPPR. STUDY DESIGN PROPPR was designed as a randomized, two-group, Phase III trial conducted in subjects with the highest level of trauma activation and predicted to have a massive transfusion. Subjects at 12 North American level 1 trauma centres were randomized into one of two standard transfusion ratio interventions: 1:1:1 or 1:1:2, (plasma, platelets, and red blood cells). Clinical data and serial blood samples were collected under Exception from Informed Consent (EFIC) regulations. Co-primary mortality endpoints of 24h and 30 days were evaluated. RESULTS Between August 2012 and December 2013, 680 patients were randomized. The overall median time from admission to randomization was 26min. PROPPR enrolled at higher than expected rates with fewer than expected protocol deviations. CONCLUSION PROPPR is the largest randomized study to enrol severely bleeding patients. This study showed that rapidly enrolling and successfully providing randomized blood products to severely injured patients in an EFIC study is feasible. PROPPR was able to achieve these goals by utilizing a collaborative structure and developing successful procedures and design elements that can be part of future trauma studies.
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Affiliation(s)
- Sarah Baraniuk
- Division of Biostatistics, School of Public Health, University of Texas Health Science Center at Houston
| | - Barbara C. Tilley
- Division of Biostatistics, School of Public Health, University of Texas Health Science Center at Houston
| | - Deborah J. del Junco
- Center for Translational Injury Research, Division of Acute Care Surgery, Department of Surgery, Medical School, 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
| | | | - 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
| | - 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
| | - Angela M. Beeler
- Center for Translational Injury Research, Division of Acute Care Surgery, Department of Surgery, Medical School, University of Texas Health Science Center at Houston
| | | | - Eileen M. Bulger
- Division of Trauma and Critical Care, Department of Surgery, School of Medicine, University of Washington
| | - Martin A. Schreiber
- Division of Trauma, Critical Care and Acute Care Surgery, School of Medicine, Oregon Health & Science University
| | - Kenji Inaba
- Division of Trauma and Critical Care, University of Southern California
| | - Timothy C. Fabian
- Division of Trauma and Surgical Critical Care, Department of Surgery, Medical School, University of Tennessee Health Science Center
| | - Jeffrey D. Kerby
- Division of Trauma, Burns and Surgical Critical Care, Department of Surgery, School of Medicine, University of Alabama at Birmingham
| | - Mitchell J. Cohen
- Division of General Surgery, Department of Surgery, School of Medicine, University of California San Francisco
| | | | - Sandro Rizoli
- Trauma and Acute Care Surgery, St Michael’s Hospital, University of Toronto
| | - Thomas M. Scalea
- R Adams Cowley Shock Trauma Center, Program in Trauma, University of Maryland School of Medicine
| | - Terence O’Keeffe
- Division of Trauma, Critical Care and Emergency Surgery, Department of Surgery, University of Arizona
| | - Karen J. Brasel
- Division of Trauma and Critical Care, Department of Surgery, Medical College of Wisconsin
| | - Bryan A. Cotton
- Center for Translational Injury Research, Division of Acute Care Surgery, Department of Surgery, Medical School, University of Texas Health Science Center at Houston
| | - Peter Muskat
- Division of Trauma/Critical Care, Department of Surgery, College of Medicine, University of Cincinnati
| | - 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
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Lamb C, MacGoey P, Navarro A, Brooks A. Damage control surgery in the era of damage control resuscitation. Br J Anaesth 2014; 113:242-9. [DOI: 10.1093/bja/aeu233] [Citation(s) in RCA: 116] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Kim Y, Lee K, Kim J, Kim J, Heo Y, Wang H, Lee K, Jung K. 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. J Korean Med Sci 2014; 29:1007-11. [PMID: 25045236 PMCID: PMC4101768 DOI: 10.3346/jkms.2014.29.7.1007] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2013] [Accepted: 04/24/2014] [Indexed: 11/20/2022] Open
Abstract
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.
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Affiliation(s)
- Younghwan Kim
- Department of Surgery, Ajou University School of Medicine, Suwon, Korea
| | - KiYoung Lee
- Department of Biomedical Informatics, Ajou University School of Medicine, Suwon, Korea
- Department of Biomedical Sciences, Graduate School, Ajou University School of Medicine, Suwon, Korea
| | - Jihyun Kim
- Department of Biomedical Informatics, Ajou University School of Medicine, Suwon, Korea
- Department of Biomedical Sciences, Graduate School, Ajou University School of Medicine, Suwon, Korea
| | - Jiyoung Kim
- Department of Surgery, Ajou University School of Medicine, Suwon, Korea
| | - Yunjung Heo
- Department of Medical Humanities and Social Medicine, Ajou University School of Medicine, Suwon, Korea
| | - Heejung Wang
- Department of Surgery, Ajou University School of Medicine, Suwon, Korea
| | - Kugjong Lee
- Department of Surgery, Ajou University School of Medicine, Suwon, Korea
| | - Kyoungwon Jung
- Department of Surgery, Ajou University School of Medicine, Suwon, Korea
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Martin DT, Schreiber MA. Modern resuscitation of hemorrhagic shock: what is on the horizon? Eur J Trauma Emerg Surg 2014; 40:641-56. [PMID: 26814779 DOI: 10.1007/s00068-014-0416-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2014] [Accepted: 05/23/2014] [Indexed: 12/24/2022]
Abstract
PURPOSE Mortality rates among the severely injured remain high. The successful treatment of hemorrhagic shock relies on expeditious control of bleeding through surgical ligation, packing, or endovascular techniques. An important secondary concern in hemorrhaging patients is how to respond to the lost blood volume. A single method that is able to adequately address all needs of the exsanguinating patient has not yet been agreed upon, despite a large growth of knowledge regarding the causative factors of traumatic shock. METHODS A review of relevent literature was performed. CONCLUSIONS Many different trials are currently underway to discriminate ways to improve outcomes in the severely injured and bleeding patient. This paper will review: (1) recent advances in our understanding of the effects hemorrhagic shock has on the coagulation cascade and vascular endothelium, (2) recent research findings that have changed resuscitation, and (3) resuscitation strategies that are not widely used but under active investigation.
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Affiliation(s)
- D T Martin
- Division of Trauma, Critical Care, and Acute Care Surgery, Department of Surgery, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, Mail Code L-611, Portland, OR, 97239, USA. .,Division of Trauma, Critical Care, and Acute Care Surgery, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, Mail Code L-611, Portland, OR, 97239, USA.
| | - M A Schreiber
- Division of Trauma, Critical Care, and Acute Care Surgery, Department of Surgery, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, Mail Code L-611, Portland, OR, 97239, USA. .,Division of Trauma, Critical Care, and Acute Care Surgery, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, Mail Code L-611, Portland, OR, 97239, USA.
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Holcomb JB, Donathan DP, Cotton BA, Del Junco DJ, Brown G, Wenckstern TV, Podbielski JM, Camp EA, Hobbs R, Bai Y, Brito M, Hartwell E, Duke JR, Wade CE. Prehospital Transfusion of Plasma and Red Blood Cells in Trauma Patients. PREHOSP EMERG CARE 2014; 19:1-9. [PMID: 24932734 DOI: 10.3109/10903127.2014.923077] [Citation(s) in RCA: 133] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Abstract Objective. Earlier use of plasma and red blood cells (RBCs) has been associated with improved survival in trauma patients with substantial hemorrhage. We hypothesized that prehospital transfusion (PHT) of thawed plasma and/or RBCs would result in improved patient coagulation status on admission and survival. Methods. Adult trauma patient records were reviewed for patient demographics, shock, coagulopathy, outcomes, and blood product utilization from September 2011 to April 2013. Patients arrived by either ground or two different helicopter companies. All patients transfused with blood products (either pre- or in-hospital) were included in the study. One helicopter system (LifeFlight, LF) had thawed plasma and RBCs while the other air (OA) and ground transport systems used only crystalloid resuscitation. Patients receiving PHT were compared with all other patients meeting entry criteria to the study cohort. All comparisons were adjusted in multilevel regression models. Results. A total of 8,536 adult trauma patients were admitted during the 20-month study period, of which 1,677 met inclusion criteria. They represented the most severely injured patients (ISS = 24 and mortality = 26%). There were 792 patients transported by ground, 716 by LF, and 169 on OA. Of the LF patients, 137 (19%) received prehospital transfusion. There were 942 units (244 RBCs and 698 plasma) placed on LF helicopters, with 1.9% wastage. PHT was associated with improved acid-base status on hospital admission, decreased use of blood products over 24 hours, a reduction in the risk of death in the sickest patients over the first 6 hours after admission, and negligible blood products wastage. In this small single-center pilot study, there were no differences in 24-hour (odds ratio 0.57, p = 0.117) or 30-day mortality (odds ratio 0.71, p = 0.441) between LF and OA. Conclusions. Prehospital plasma and RBC transfusion was associated with improved early outcomes, negligible blood products wastage, but not an overall survival advantage. Similar to the data published from the ongoing war, improved early outcomes are associated with placing blood products prehospital, allowing earlier infusion of life-saving products to critically injured patients.
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Abstract
PURPOSE OF REVIEW To summarize our current understanding of the pathophysiology, diagnosis, and management of acute traumatic coagulopathy in children. RECENT FINDINGS Traumatic coagulopathy is a complex process that leads to global dysfunction of the endogenous coagulation system and results in worse outcomes and increased mortality. Although the cause is multifactorial, it is common in severely injured patients and is driven by significant tissue injury and hypoperfusion. Viscoelastic coagulation tests have been established as a rapid and reliable method to assess traumatic coagulopathy. Additionally, massive transfusion protocols have improved outcomes in adults, but limited studies in pediatrics have not shown any difference in mortality. SUMMARY Prospective studies are needed to determine how to best diagnose and manage acute traumatic coagulopathy in children.
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84
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Acharya MR, Forward DP. (iv) The initial assessment and early management of patients with severe pelvic ring injuries. ACTA ACUST UNITED AC 2014. [DOI: 10.1016/j.mporth.2014.05.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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MacLeod JBA, Winkler AM, McCoy CC, Hillyer CD, Shaz BH. Early trauma induced coagulopathy (ETIC): prevalence across the injury spectrum. Injury 2014; 45:910-5. [PMID: 24438827 DOI: 10.1016/j.injury.2013.11.004] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2013] [Revised: 10/19/2013] [Accepted: 11/06/2013] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Newer studies have hypothesised about a coagulopathy that occurs early after trauma, early trauma induced coagulopathy, ETIC, and is defined by an elevated admission prothrombin time (PT). Also, referred to by some authors as acute traumatic coagulopathy, it has been most often studied in cohorts of severely injured or hypotensive patients. However, we wanted to prospectively investigate ETIC in a large all-comers cohort to confirm its prevalence across the entire spectrum of injury, to evaluate its risk pattern and to determine a possible relationship to reduced survival. METHODS We conducted a prospective cohort study at a Level I trauma centre from July 15, 2008 to November 15, 2009. Demographics, injury mechanism, time from injury and to hospital arrival, fluid and blood administration and vital signs were collected at hospital arrival and to the time of first blood sample collection for all patients admitted for 24h or longer. Our primary outcome was the incidence of mortality by the 28th hospital day, referred to as 28 day in-hospital mortality. RESULTS 701 patients were included in the final study cohort. There was 75.3% male, 25.7% penetrating, with a mean age of 39 years. The overall mortality was 7.3%. ETIC occurred in 114 patients (16.3%) and was found to be independently associated with death (odds of death (per 0.10s increase in PT): 1.10, p=0.001). ETIC patients, as a group, were more severely injured, had more hypotension and head injury and used more crystalloid and blood products than non-ETIC patients. However, even mildly injured patients, who had an ISS<16, normal RTS score, and no fluid resuscitation, had an ETIC prevalence of 11.7% (11/94). CONCLUSIONS ETIC is an early, primary post-injury coagulopathy that occurs in 16.3% of admitted trauma patients. It is associated with an increase in mortality, even when controlling for crystalloids, vital signs, injury severity and head injury. It can also be found in approximately 11% of mildly injured patients (patients without physiological derangement or blood product administration). Therefore, further elucidation of ETIC is strategic to impacting trauma patient outcome.
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Affiliation(s)
- Jana B A MacLeod
- Study completed while author at the Department of Surgery, Emory University School of Medicine, Atlanta, GA, United States; Karen Hospital, Department of Surgery, Nairobi, Kenya.
| | - Anne M Winkler
- Departments of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, GA, United States
| | - Cameron C McCoy
- Duke University, Surgical Residency, Department of Surgery, Durham, NC, United States
| | | | - Beth H Shaz
- Departments of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, GA, United States; New York Blood Center, New York, NY, United States
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Abstract
INTRODUCTION Most preventable trauma deaths are due to uncontrolled hemorrhage. METHODS In this article, we briefly describe the pathophysiology of the classical triad of death in trauma, namely, acidosis, hypothermia, and coagulopathy, and then suggest damage control resuscitation strategies to prevent and/or mitigate the effects of each in the bleeding patient. RESULTS Damage control resuscitation strategies include body rewarming, restrictive fluid administration, permissive hypotension, balanced blood product administration, and the implementation of massive transfusion protocols. CONCLUSION Resuscitating and correcting the coagulopathy of the exsanguinating trauma patient is essential to improve chances of survival.
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Affiliation(s)
- H M A Kaafarani
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital & Harvard Medical School, Boston, MA, USA
| | - G C Velmahos
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital & Harvard Medical School, Boston, MA, USA
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87
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Abstract
Hemorrhage remains one of the leading causes of trauma-related deaths. Uncontrolled diffuse microvascular bleeding in the course of initial care is common, potentially resulting in exsanguination. Early and aggressive hemostatic intervention increases survival and reduces the incidence of massive transfusion. Thus, timely diagnosis of the underlying coagulation disorders is mandatory. It has been shown that standard coagulation tests do not sufficiently characterize trauma-induced coagulopathy (TIC). This has led to increasing interest in alternatives, such as the viscoelastic test, to diagnose TIC and to provide the basis for a goal-directed hemostatic therapy. The concept of damage control resuscitation (DCR) has been introduced widely in trauma patients with severe bleeding. This strategy addresses important confounders of the coagulation process such as hemodilution, hypothermia, and acidosis; DCR is based on a damage control surgical approach, permissive hypotension, and improvement of hemostatic competence. Many studies have shown benefit in mortality when using high ratios of fresh frozen plasma (FFP) to red blood cells (RBC) as early treatment. However, there is increased awareness that coagulation factor concentrate could be beneficial in the treatment of trauma-induced coagulopathy.
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Affiliation(s)
- Herbert Schöchl
- Department of Anaesthesiology and Intensive Care Medicine, AUVA Trauma Centre, Salzburg, Austria.
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Sun W, Jeleniowski K, Zhao X, Shen P, Li D, Hammond JA. Thromboelastography (TEG)-Based Algorithm Reduces Blood Product Utilization in Patients Undergoing VAD Implant. J Card Surg 2014; 29:238-43. [PMID: 24734284 DOI: 10.1111/jocs.12302] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Wenyu Sun
- Department of Cardiovascular Surgery; Qilu Hospital, Shandong University; Jinan P.R. China
| | - Ken Jeleniowski
- Department of Perfusion; Hartford Hospital; Hartford Connecticut
| | - Xin Zhao
- Department of Cardiovascular Surgery; Qilu Hospital, Shandong University; Jinan P.R. China
| | - Peter Shen
- Department of Cytopathology; Hartford Hospital; Hartford Connecticut
| | - Dadong Li
- Department of Research Administration; Hartford Hospital; Hartford Connecticut
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Barbosa Neto JO, Breda de Moraes MF, Souza Nani R, Rocha Filho JA, Carvalho Carmona MJ. Hemostatic resuscitation in traumatic hemorrhagic shock: case report. Rev Bras Anestesiol 2014; 63:99-102. [PMID: 23438804 DOI: 10.1016/s0034-7094(13)70201-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2011] [Accepted: 04/05/2012] [Indexed: 10/26/2022] Open
Abstract
BACKGROUND AND OBJECTIVES The aim of this paper is to report a case in which the damage control resuscitation (DCR) approach was successfully used to promote hemostatic resuscitation in a polytraumatized patient with severe hemorrhagic shock. CASE REPORT Female patient, 32 years of age, with severe hemorrhagic shock due to polytrauma with hip fracture, who developed acidosis, coagulopathy, and hypothermia. During fluid resuscitation, the patient received blood products transfusion of fresh frozen plasma/packed red blood cells/platelet concentrate at a ratio of 1:1:1 and evolved intraoperatively with improvement in perfusion parameters without requiring vasoactive drugs. At the end of the operation, the patient was taken to the intensive care unit and discharged on the seventh postoperative day. CONCLUSION The ideal management of traumatic hemorrhagic shock is not yet established, but the rapid control of bleeding and perfusion recovery and well-defined therapeutic protocols are fundamental to prevent progression of coagulopathy and refractory shock.
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Affiliation(s)
- José Osvaldo Barbosa Neto
- Anesthesiologist at Department of Anesthesia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Brazil.
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Fibrinolysis greater than 3% is the critical value for initiation of antifibrinolytic therapy. J Trauma Acute Care Surg 2014; 75:961-7; discussion 967. [PMID: 24256667 DOI: 10.1097/ta.0b013e3182aa9c9f] [Citation(s) in RCA: 123] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND The acute coagulopathy of trauma is present in up to one third of patients by the time of admission, and the recent CRASH-2 and MATTERs trials have focused worldwide attention on hyperfibrinolysis as a component of acute coagulopathy of trauma. Thromboelastography (TEG) is a powerful tool for analyzing fibrinolyis, but a clinically relevant threshold for defining hyperfibrinolysis has yet to be determined. Recent data suggest that the accepted normal upper bound of 7.5% for 30-minute fibrinolysis (LY30) by TEG is inappropriate in severe trauma, as the risk of death rises at much lower levels of clot lysis. We wished to determine the validity of this hypothesis and establish a threshold value to treat fibrinolysis, based on prediction of massive transfusion requirement and risk of mortality. METHODS Patients with uncontrolled hemorrhage, meeting the massive transfusion protocol (MTP) criteria at admission (n = 73), represent the most severely injured trauma population at our center (median Injury Severity Score [ISS], 30; interquartile range, 20-38). Citrated kaolin TEG was performed at admission blood samples from this population, stratified by LY30, and evaluated for transfusion requirement and 28-day mortality. The same analysis was conducted on available field blood samples from all non-MTP trauma patients (n = 216) in the same period. These represent the general trauma population. RESULTS Within the MTP-activating population, the cohort of patients with LY30 of 3% or greater was shown to be at much higher risk for requiring a massive transfusion (90.9% vs. 30.5%, p = 0.0008) and dying of hemorrhage (45.5% vs. 4.8%, p = 0.0014) than those with LY30 less than 3%. Similar trends were seen in the general trauma population. CONCLUSION LY30 of 3% or greater defines clinically relevant hyperfibrinolysis and strongly predicts the requirement for massive transfusion and an increased risk of mortality in trauma patients presenting with uncontrolled hemorrhage. This threshold value for LY30 represents a critical indication for the treatment of fibrinolysis. LEVEL OF EVIDENCE Prognostic study, level III.
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Ball CG, Dente CJ, Shaz B, Wyrzykowski AD, Nicholas JM, Kirkpatrick AW, Feliciano DV. The impact of a massive transfusion protocol (1:1:1) on major hepatic injuries: does it increase abdominal wall closure rates? Can J Surg 2013; 56:E128-34. [PMID: 24067528 DOI: 10.1503/cjs.020412] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Massive transfusion protocols (MTPs) using high plasma and platelet ratios for exsanguinating trauma patients are increasingly popular. Major liver injuries often require massive resuscitations and immediate hemorrhage control. Current published literature describes outcomes among patients with mixed patterns of injury. We sought to identify the effects of an MTP on patients with major liver trauma. METHODS Patients with grade 3, 4 or 5 liver injuries who required a massive blood component transfusion were analyzed. We compared patients with high plasma:red blood cell:platelet ratio (1:1:1) transfusions (2007-2009) with patients injured before the creation of an institutional MTP (2005-2007). RESULTS Among 60 patients with major hepatic injuries, 35 (58%) underwent resuscitation after the implementation of an MTP. Patient and injury characteristics were similar between cohorts. Implementation of the MTP significantly improved plasma: red blood cell:platelet ratios and decreased crystalloid fluid resuscitation (p = 0.026). Rapid improvement in early acidosis and coagulopathy was superior with an MTP (p = 0.009). More patients in the MTP group also underwent primary abdominal fascial closure during their hospital stay (p = 0.021). This was most evident with grade 4 injuries (89% vs. 14%). The mean time to fascial closure was 4.2 days. The overall survival rate for all major liver injuries was not affected by an MTP (p = 0.61). CONCLUSION The implementation of a formal MTP using high plasma and platelet ratios resulted in a substantial increase in abdominal wall approximation. This occurred concurrently to a decrease in the delivered volume of crystalloid fluid.
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Affiliation(s)
- Chad G Ball
- The Department of Surgery, Emory University, Grady Memorial Hospital, Atlanta, Ga
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92
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Transfusion strategies and development of acute respiratory distress syndrome in combat casualty care. J Trauma Acute Care Surg 2013; 75:S238-46. [PMID: 23883915 DOI: 10.1097/ta.0b013e31829a8c71] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Damage-control resuscitation (DCR) has been advocated to reduce mortality in military and civilian settings. However, DCR and excessive crystalloid resuscitation may be associated with a higher incidence of acute respiratory distress syndrome (ARDS). We sought to examine the impact of resuscitation strategies on ARDS development in combat casualty care. METHODS A retrospective review of Joint Theater Trauma Registry data on US combat casualties who received at least 1 U of blood product within the first 24 hours of care was performed, cross-referenced with the cohort receiving mechanical ventilation (n = 1,475). Massive transfusion (MT, ≥10 red blood cells [RBCs] and/or whole blood in 24 hours) and volume/ratios of plasma/RBC, platelet/RBC, and crystalloid/RBC (C/RBC, crystalloid liters/RBC units) were examined using bivariate/multivariate logistic regression and local regression analyses as ARDS risk factors, controlling for age, injury severity, admission systolic blood pressure, and Glasgow Coma Scale (GCS) score. RESULTS ARDS was identified in 95 cases (6.4%). MT was required in 550 (37.3%) of the analysis cohort. ARDS was more common in MT (46 of 550, 8.4%) versus no-MT cohort (49 of 925, 5.3%), but mortality was not different (17.4% MT vs. 16.3% no-MT). ARDS patients received significantly increased crystalloid of blood product volumes. Increased crystalloid resuscitation (C/RBC ratio > 1.5) occurred in 479 (32.7%) of 1,464 patients. Unadjusted mortality was significantly increased in the cohort with C/RBC ratio of 1.5 or less compared with those with greater than 1.5 (19.1% vs. 6.3%, p < 0.0001), but no difference in ARDS (6.5% vs. 6.6%) was identified. Platelet/RBC ratio did not impact on ARDS. Increasing plasma (odds ratio, 1.07; p = 0.0062) and crystalloid (odds ratio, 1.04; p = 0.041) volumes were confirmed as independent ARDS risk factors. CONCLUSION In modern combat casualty care, increased plasma and crystalloid infusion were identified as independent risk factors for ARDS. These findings support a practice of decreased plasma/crystalloid transfusion in trauma resuscitation once hemorrhage control is established to achieve the mortality benefit of DCR and ARDS prevention.
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93
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Campion EM, Pritts TA, Dorlac WC, Nguyen AQ, Fraley SM, Hanseman D, Robinson BRH. Implementation of a military-derived damage-control resuscitation strategy in a civilian trauma center decreases acute hypoxia in massively transfused patients. J Trauma Acute Care Surg 2013; 75:S221-7. [PMID: 23883912 DOI: 10.1097/ta.0b013e318299d59b] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND Recent military experience supports a paradigm shift in shock resuscitation to damage-control resuscitation (DCR), which emphasizes a plasma-rich and crystalloid-poor approach to resuscitation. The effect of DCR on hypoxia after massive transfusion is unknown. We hypothesized that implementation of a military-derived DCR strategy in a civilian setting would lead to decreased acute hypoxia. METHODS A DCR strategy was implemented in 2007. We retrospectively reviewed patients receiving trauma surgeon operative intervention and 10 or more units of packed red blood cells (pRBCs) within 24 hours of injury at an adult Level I trauma center from 2001 to 2010. Demographic data, blood requirements, and PaO₂/FIO₂ ratios were analyzed. To evaluate evolving resuscitation strategies, we fit linear trend models to continuous variables and tested their slopes for statistical significance. RESULTS Two hundred sixteen patients met the study criteria, with a mean age of 35 ± 1.1 years and Injury Severity Score (ISS) of 31 ± 9.0. Of the patients, 80% were male, and 52% sustained penetrating injuries. Overall mortality was 32%. Overall mean pRBC and fresh frozen plasma (FFP) units infused in 24 hours were 23.2 ± 1.1 and 18.6 ± 1.1, respectively. Trends for patient age, sex, mechanism of injury, ISS, highest positive end-expiratory pressure, and mean total pRBC transfused over 24 hours were not statistically different from zero. An increasing trend in FFP and platelets transfused during the first 24 hours (p < 0.0001, p = 0.04, respectively) and a decrease in the pRBC/FFP ratio (p < 0.0001) were found. The amount of crystalloid infused during the initial 24 hours decreased with time (p < 0.0001). The lowest PaO₂/FIO₂ ratio recorded during the initial 24 hours increased during the study period (p = 0.01), indicating a statistically significant reduction in hypoxia. CONCLUSION A military-derived DCR strategy can be implemented in the civilian setting. DCR led to significant increases in FFP transfusion, decreases in crystalloid use, and acute hypoxia.
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Affiliation(s)
- Eric M Campion
- Institute for Military Medicine, Department of Surgery, University of Cincinnati, Cincinnati, Ohio, USA
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94
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Barbosa Neto JO, de Moraes MFB, Nani RS, Rocha Filho JA, Carmona MJC. Hemostatic resuscitation in traumatic hemorrhagic shock: case report. Braz J Anesthesiol 2013; 63:99-102. [PMID: 24565093 DOI: 10.1016/j.bjane.2012.03.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2011] [Accepted: 03/05/2012] [Indexed: 10/26/2022] Open
Abstract
BACKGROUND AND OBJECTIVES The aim of this paper is to report a case in which the damage control resuscitation (DCR) approach was successfully used to promote hemostatic resuscitation in a polytraumatized patient with severe hemorrhagic shock. CASE REPORT Female patient, 32 years of age, with severe hemorrhagic shock due to polytrauma with hip fracture, who developed acidosis, coagulopathy, and hypothermia. During fluid resuscitation, the patient received blood products transfusion of fresh frozen plasma/packed red blood cells/platelet concentrate at a ratio of 1:1:1 and evolved intraoperatively with improvement in perfusion parameters without requiring vasoactive drugs. At the end of the operation, the patient was taken to the intensive care unit and discharged on the seventh postoperative day CONCLUSION : The ideal management of traumatic hemorrhagic shock is not yet established, but the rapid control of bleeding and perfusion recovery and well-defined therapeutic protocols are fundamental to prevent progression of coagulopathy and refractory shock.
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Affiliation(s)
- José Osvaldo Barbosa Neto
- Anesthesiologist at Department of Anesthesia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (FMUSP).
| | - Marcos Fernando Breda de Moraes
- Resident Physician at Department of Anesthesia, Hospital das Clínicas, FMUSP; Specialization in Anesthesiology, Centro de Ensino e Treinamento, Sociedade Brasileira de Anestesiologia (SBA)
| | - Ricardo Souza Nani
- TSA; Anestheiologist, at Department of Anesthesia, Hospital das Clínicas, FMUSP
| | - Joel Avancini Rocha Filho
- TSA; Anestheiologist, at Department of Anesthesia, Hospital das Clínicas, FMUSP; PHD in Medical Sciences, FMUSP
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95
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David JS, Spann C, Marcotte G, Reynaud B, Fontaine O, Lefèvre M, Piriou V. Haemorrhagic shock, therapeutic management. ACTA ACUST UNITED AC 2013; 32:497-503. [PMID: 23896213 DOI: 10.1016/j.annfar.2013.07.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
The management of a patient in post-traumatic haemorrhagic shock will meet different logics that will apply from the prehospital setting. This implies that the patient has beneficiated from a "Play and Run" prehospital strategy and was sent to a centre adapted to his clinical condition capable of treating all haemorrhagic lesions. The therapeutic goals will be to control the bleeding by early use of tourniquet, pelvic girdle, haemostatic dressing, and after admission to the hospital, the implementation of surgical and/or radiological techniques, but also to address all the factors that will exacerbate bleeding. These factors include hypothermia, acidosis and coagulopathy. The treatment of these contributing factors will be associated to concepts of low-volume resuscitation and permissive hypotension into a strategy called "Damage Control Resuscitation". Thus, the objective in situation of haemorrhagic shock will be to not exceed a systolic blood pressure of 90 mmHg (in the absence of severe head trauma) until haemostasis is achieved.
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Affiliation(s)
- J-S David
- Department of Anaesthesia and Intensive Care, Lyon Sud Hospital, Hospices Civils de Lyon, 69495 Pierre-Bénite cedex, France.
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96
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Hagemo JS, Jørgensen JJ, Ostrowski SR, Holtan A, Gundersen Y, Johansson PI, Næss PA, Gaarder C. Changes in fibrinogen availability and utilization in an animal model of traumatic coagulopathy. Scand J Trauma Resusc Emerg Med 2013; 21:56. [PMID: 23867061 PMCID: PMC3726467 DOI: 10.1186/1757-7241-21-56] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2013] [Accepted: 06/30/2013] [Indexed: 12/26/2022] Open
Abstract
Background Impaired haemostasis following shock and tissue trauma is frequently detected in the trauma setting. These changes occur early, and are associated with increased mortality. The mechanism behind trauma-induced coagulopathy (TIC) is not clear. Several studies highlight the crucial role of fibrinogen in posttraumatic haemorrhage. This study explores the coagulation changes in a swine model of early TIC, with emphasis on fibrinogen levels and utilization of fibrinogen. Methods A total of 18 landrace pigs were anaesthetized and divided into four groups. The Trauma-Shock group (TS) were inflicted bilateral blast femoral fractures with concomitant soft tissue injury by a high-energy rifle shot to both hind legs, followed by controlled exsanguination. The Shock group (S) was exposed to shock by exsanguination, whereas a third group was exposed to trauma only (T). A fourth group (C) served as control. Physiological data, haematological measurements, blood gas analyses and conventional coagulation assays were recorded at baseline and repeatedly over 60 minutes. Thrombelastometry were performed by means of the tissue factor activated ExTEM assay and the platelet inhibiting FibTEM assay. Data were statistically analysed by repeated measurements analyses method. Results A significant reduction of fibrinogen concentration was observed in both the TS and S groups. INR increased significantly in the S group and differed significantly from the TS group. Maximum clot firmness (MCF) of the ExTEM assay was significantly reduced over time in both TS and S groups. In the FibTEM assay a significant shortening of the clotting time and an increase in MCF was observed in the TS group compared to the S group. Conclusion Despite a reduction in clotting capability measured by ExTEM MCF and a reduced fibrinogen concentration, extensive tissue trauma may induce an increased fibrin based clotting activity that attenuates the hypocoagulable tendency in exsanguinated animals.
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97
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Aggressive early crystalloid resuscitation adversely affects outcomes in adult blunt trauma patients: an analysis of the Glue Grant database. J Trauma Acute Care Surg 2013; 74:1215-21; discussion 1221-2. [PMID: 23609270 DOI: 10.1097/ta.0b013e3182826e13] [Citation(s) in RCA: 67] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Evidence suggests that aggressive crystalloid resuscitation is associated with significant morbidity in various clinical settings. We wanted to assess whether aggressive early crystalloid resuscitation adversely affects outcomes in adult blunt trauma patients. METHODS Data were derived from the Glue Grant database. Our primary outcome measure was all-cause in-hospital mortality. Secondary outcomes included days on mechanical ventilation; intensive care unit (ICU) and hospital length of stay (LOS); inflammatory (acute lung injury and adult respiratory distress syndrome, or multiple-organ failure) and resuscitation-related morbidity (abdominal and extremity compartment syndromes or acute renal failure) and nosocomial infections (ventilator-associated pneumonia, bloodstream, urinary tract, and surgical site infections). RESULTS In our sample of 1,754 patients, in-hospital mortality was not affected, but ventilator days (p < 0.001) as well as ICU (p = 0.009) and hospital (p = 0.002) LOS correlated strongly with the amount of crystalloids infused in the first 24 hours after injury. Amount of crystalloid resuscitation was also associated with the development of adult respiratory distress syndrome (p < 0.001), multiple-organ failure (p < 0.001), bloodstream (p = 0.001) and surgical site infections (p < 0.001), as well as abdominal (p < 0.001) and extremity compartment syndromes (p = 0.028) in a dose-dependent fashion, when age, Glasgow Coma Scale (GCS), severity of injury and acute physiologic derangement, comorbidities, as well as colloid and blood product transfusions were controlled for. CONCLUSION Crystalloid resuscitation is associated with a substantial increase in morbidity, as well as ICU and hospital LOS in adult blunt trauma patients.
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98
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Abstract
Trauma is the leading cause of death in young adults and acute blood loss contributes to a large portion of mortality in the early post-trauma period. The recognition of lethal triad of coagulopathy, hypothermia and acidosis has led to the concepts of damage control surgery and resuscitation. Recent experience with managing polytrauma victims from the Iraq and Afghanistan wars has led to a few significant changes in clinical practice. Simultaneously, transfusion practices in the civilian settings have also been extensively studied retrospectively and prospectively in the last decade. Early treatment of coagulopathy with a high ratio of fresh frozen plasma and platelets to packed red blood cells (FFP:platelet:RBC), prevention and early correction of hypothermia and acidosis, monitoring of hemostasis using point of care tests like thromoboelastometry, use of recombinant activated factor VII, antifibrinolytic drugs like tranexamic acid are just some of the emerging trends. Further studies, especially in the civilian trauma centers, are needed to confirm the lessons learned in the military environment. Identification of patients likely to need massive transfusion followed by immediate preventive and therapeutic interventions to prevent the development of coagulopathy could help in reducing the morbidity and mortality associated with uncontrolled hemorrhage in trauma patients.
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Affiliation(s)
- Sanjay M Bhananker
- Department of Anesthesiology and Pain Medicine, University of Washington School of Medicine, Seattle, WA, USA
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99
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Miller TE. New evidence in trauma resuscitation - is 1:1:1 the answer? Perioper Med (Lond) 2013; 2:13. [PMID: 24472306 PMCID: PMC3964329 DOI: 10.1186/2047-0525-2-13] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2012] [Accepted: 05/08/2013] [Indexed: 02/07/2023] Open
Abstract
Traumatic injury is a common problem, with over five million worldwide deaths from trauma per year. An estimated 10 to 20% of these deaths are potentially preventable with better control of bleeding. Damage control resuscitation involves early delivery of plasma and platelets as a primary resuscitation approach to minimize trauma-induced coagulopathy. Plasma, red blood cell and platelet ratios of 1:1:1 appear to be the best substitution for fresh whole blood; however, the current literature consists only of survivor bias-prone observational studies.
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Affiliation(s)
- Timothy E Miller
- Department of Anesthesiology, Duke University Medical Center, 5677 HAFS Building, Box 3094, Durham NC 27710, UK.
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100
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Abstract
Coagulopathy is frequently present in trauma. It is indicative of the severity of trauma and contributes to increased morbidity and mortality. Uncontrolled bleeding is the most frequent preventable cause of death in trauma patients reaching hospital alive. Coagulopathy in trauma has been long thought to develop as a result of hemodilution, acidosis, and hypothermia often related to resuscitation practices. However, altered coagulation tests are already present in 25–30% of severe trauma patients upon hospital arrival before resuscitation efforts. Acute coagulopathy associated with trauma (ACoT) has been recognized in recent years as a distinct entity associated with increased mortality, morbidity, and transfusion requirements. Transfusion and nontransfusion strategies aimed at correcting ACoT, particularly in patients with massive bleeding and massive transfusion, are currently available. Early administration of tranexamic acid to bleeding trauma patients safely reduces the risk of death. It has been proposed that early aggressive blood product transfusional management of ACoT with a red blood cell : plasma : platelets ratio close to 1 : 1 : 1 could result in decreased mortality from uncontrolled bleeding.
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Affiliation(s)
- Carolina Ruiz
- Departamento de Medicina Intensiva, Escuela de Medicina, Facultad de Medicina, Pontificia Universidad Católica de Chile, Marcoleta 367, 02399 Santiago, Chile
| | - Max Andresen
- Departamento de Medicina Intensiva, Escuela de Medicina, Facultad de Medicina, Pontificia Universidad Católica de Chile, Marcoleta 367, 02399 Santiago, Chile
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