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Deras P, Villiet M, Manzanera J, Latry P, Schved JF, Capdevila X, Charbit J. Early coagulopathy at hospital admission predicts initial or delayed fibrinogen deficit in severe trauma patients. J Trauma Acute Care Surg 2014; 77:433-40. [DOI: 10.1097/ta.0000000000000314] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Abstract
Trauma is the leading cause of death among people under the age of 44. Hemorrhage is a major contributor to deaths related to trauma in the first 48 h. Accordingly, the management of these patients is a time-sensitive and critical affair that anesthesiologists responsible for surgical resuscitation will face. Coagulopathy associated with trauma exists in one-third of all severely injured patients upon presentation to the hospital. Trauma patients presenting with coagulopathy have significantly higher mortality. This trauma-induced coagulopathy (TIC) must be managed adroitly in the resuscitation of these patients. Recent advancements in our understanding of TIC have led to new protocols and therapy guidelines. Anesthesiologists must be aware of these to effectively manage this form of shock. TIC driven by a combination of endogenous biological processes, as well as iatrogenic causes, can ultimately lead to the lethal triad of hypothermia, acidemia, and coagulopathy. Providers should understand how to promptly diagnose TIC and be aware of the early indicators of massive transfusion. The use of common laboratory studies and patient vital signs serve as our current guide, but the importance of each is still under debate. Thromboelastography is a tool used often in the diagnosis of TIC and can be used to guide blood product transfusion. Certain pharmaceutical strategies and non-transfusion strategies also exist, which aid in the management of hemorrhagic shock. Damage control surgery, rewarming, tranexamic acid, and 1:1:1 transfusion protocols are promising methods used to treat the critically wounded. Though protocols have been developed, controversies still exist on the optimal resuscitation strategy.
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Affiliation(s)
- Jeffrey W. Simmons
- Trauma Section, Medical Simulation, Department of Anesthesiology, University of Alabama at Birmingham, 804 Jefferson Tower, 619 South 19th Street, Birmingham, AL 35249-6810, USA
| | - Jean-Francois Pittet
- Critical Care Division, Department of Anesthesiology, University of Alabama at Birmingham, 804 Jefferson Tower, 619 South 19th Street, Birmingham, AL 35249-6810, USA
| | - Bert Pierce
- Department of Anesthesiology, University of Alabama at Birmingham, 804 Jefferson Tower, 619 South 19th Street, Birmingham, AL 35249-6810, USA
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Recovery of fibrinogen concentrate after intraosseous application is equivalent to the intravenous route in a porcine model of hemodilution. J Trauma Acute Care Surg 2014; 76:1235-42. [PMID: 24747454 PMCID: PMC4888919 DOI: 10.1097/ta.0000000000000174] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
BACKGROUND Fibrinogen concentrate is increasingly considered as a hemostatic agent for trauma patients experiencing bleeding. Placing a venous access is sometimes challenging during severe hemorrhage. Intraosseous access may be considered instead. Studies of intraosseous infusion of coagulation factor concentrates are limited. We investigated in vivo recovery following intraosseous administration of fibrinogen concentrate and compared the results with intravenous administration. METHODS This study was performed on 12 pigs (mean [SD] body weight, 34.1 [2.8] kg). Following controlled blood loss (35 mL/kg) and fluid replacement with balanced crystalloid solution, intraosseous (n = 6) administration of fibrinogen concentrate (80 mg per kilogram of bodyweight) in the proximal tibia was compared with intravenous (n = 6) administration of the same dose (fibrinogen infusion time approximately 5 minutes in both groups). The following laboratory parameters were assessed: blood cell count, prothrombin time index, activated partial thromboplastin time, and plasma fibrinogen concentration (Clauss assay). Coagulation status was also assessed by thromboelastometry. RESULTS All tested laboratory parameters were comparable between the intraosseous and intravenous groups at baseline, hemodilution, and 30 minutes after fibrinogen concentrate administration. In vivo recovery of fibrinogen was also similar in the two groups (89% [23%] and 91% [22%], respectively). There were no significant between-group differences in any of the thromboelastometric parameters. Histologic examination indicated no adverse effects on the tissue surrounding the intraosseous administration site. CONCLUSION This study suggests that intraosseous administration of fibrinogen concentrate results in a recovery of fibrinogen similar to that of intravenous administration. The intraosseous route of fibrinogen concentrate could be a valuable alternative in situations where intravenous access is not feasible or would be time consuming. LEVEL OF EVIDENCE Prospective, randomized, therapeutic feasibility study in an animal model, level V.
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Jenkins DH, Rappold JF, Badloe JF, Berséus O, Blackbourne L, Brohi KH, Butler FK, Cap AP, Cohen MJ, Davenport R, DePasquale M, Doughty H, Glassberg E, Hervig T, Hooper TJ, Kozar R, Maegele M, Moore EE, Murdock A, Ness PM, Pati S, Rasmussen T, Sailliol A, Schreiber MA, Sunde GA, van de Watering LMG, Ward KR, Weiskopf RB, White NJ, Strandenes G, Spinella PC. Trauma hemostasis and oxygenation research position paper on remote damage control resuscitation: definitions, current practice, and knowledge gaps. Shock 2014; 41 Suppl 1:3-12. [PMID: 24430539 PMCID: PMC4309265 DOI: 10.1097/shk.0000000000000140] [Citation(s) in RCA: 108] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The Trauma Hemostasis and Oxygenation Research Network held its third annual Remote Damage Control Resuscitation Symposium in June 2013 in Bergen, Norway. The Trauma Hemostasis and Oxygenation Research Network is a multidisciplinary group of investigators with a common interest in improving outcomes and safety in patients with severe traumatic injury. The network's mission is to reduce the risk of morbidity and mortality from traumatic hemorrhagic shock, in the prehospital phase of resuscitation through research, education, and training. The concept of remote damage control resuscitation is in its infancy, and there is a significant amount of work that needs to be done to improve outcomes for patients with life-threatening bleeding secondary to injury. The prehospital phase of resuscitation is critical in these patients. If shock and coagulopathy can be rapidly identified and minimized before hospital admission, this will very likely reduce morbidity and mortality. This position statement begins to standardize the terms used, provides an acceptable range of therapeutic options, and identifies the major knowledge gaps in the field.
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Affiliation(s)
- Donald H Jenkins
- *Department of Surgery, Mayo Clinic, Rochester, Minnesota; †Department of Surgery, Temple University School of Medicine, Philadelphia, Pennsylvania; ‡Transfusion Medicine, Blood Banking (American Society of Clinical Pathology), Netherlands Military Blood Bank; §Department of Transfusion Medicine, Örebro University Hospital, Örebro, Sweden; ∥Commander, US Army Institute of Surgical Research, San Antonio, Texas; ¶Trauma Sciences, Barts and the London School of Medicine, and Trauma & Vascular Surgery at the Royal London Hospital, London, UK; **Committee on Tactical Combat Casualty Care, Joint Trauma System, Joint Base San Antonio, Texas; ††Coagulation and Blood Research, US Army Institute of Surgical Research, JBSA Fort Sam Houston, Texas; ‡‡Department of Surgery University of California-San Francisco, San Francisco, California; §§Centre for Trauma Sciences, Blizard Institute, Bart's & the London School of Medicine, Queen Mary University of London, London, UK; ∥∥Deployment Medicine International, Gig Harbor, Washington; ¶¶Transfusion Medicine NHS Blood and Transplant, Birmingham, UK; ***The Trauma & Combat Medicine Branch, Surgeon General's HQ, Israel Defense Forces, Ramat Gan; and †††Department of Military Medicine, Hebrew University, Jerusalem, Israel; ‡‡‡Blood Bank, Haukeland University Hospital, and Department of Clinical Science, University of Bergen, Norway; §§§UK Defence Medical Services, Anaesthetic Department, Frenchay Hospital, Bristol UK; ∥∥∥Department of Surgery, Memorial Hermann Hospital, University of Texas Medical School at Houston, Houston, Texas; ¶¶¶Department for Traumatology, Orthopedic Surgery and Sportsmedicine Cologne-Merheim Medical Center, Cologne, Germany; ****Vice Chairman for Research, Department of Surgery, University of Colorado Denver, Colorado; ††††Surgeon General for Trauma, Air Force Medical Operations Agency, Lackland AFB, Texas; and Division of Trauma and General Surgery, Unive
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Schlimp CJ, Voelckel W, Inaba K, Maegele M, Schöchl H. Impact of fibrinogen concentrate alone or with prothrombin complex concentrate (+/- fresh frozen plasma) on plasma fibrinogen level and fibrin-based clot strength (FIBTEM) in major trauma: a retrospective study. Scand J Trauma Resusc Emerg Med 2013; 21:74. [PMID: 24103457 PMCID: PMC3852540 DOI: 10.1186/1757-7241-21-74] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2013] [Accepted: 10/04/2013] [Indexed: 01/09/2023] Open
Abstract
Background Low plasma fibrinogen concentration is a predictor of poor outcome in major trauma patients. The role of fibrinogen concentrate for rapidly increasing fibrinogen plasma levels in severe trauma is not well defined. Methods In this retrospective study we included severe trauma patients treated with fibrinogen concentrate alone (FC group), fibrinogen concentrate with prothrombin complex concentrate (FC–PCC group) or fibrinogen concentrate with PCC and fresh frozen plasma (FC–PCC–FFP group). PCC was generally administered as the second step of intraoperative therapy, while FFP was only administered as a third step. All patients received ≥1 g fibrinogen concentrate within 24 hours. Plasma fibrinogen concentration and ROTEM parameters upon emergency room (ER) admission, intensive care unit (ICU) admission, and after 24 hours were analysed. Results Among 157 patients fulfilling the inclusion criteria, 83% were male; mean age was 44 years and median injury severity score (ISS) was 29. Standard coagulation tests reflected increasing severity of coagulopathy with increasing complexity of haemostatic therapy (highest severity in the FC–PCC–FFP group; p < 0.0001). Total 24-hour fibrinogen concentrate dose also increased with complexity of haemostatic therapy. Plasma fibrinogen concentration was maintained, with no significant difference between ER admission and ICU admission in all patient groups. FIBTEM clot firmness at 10 minutes (CA10) was similarly maintained, albeit with a small increase in the FC–PCC group. Fibrinogen concentration and FIBTEM CA10 were within the normal range in all groups at 24 hours. The ratio of fibrinogen concentrate to red blood cells (g:U) ranged between 0.7:1.0 and 1.0:1.0. Conclusion Fibrinogen concentrate therapy maintained fibrinogen concentration and FIBTEM CA10 during the initial phase of trauma care until ICU admission. After 24 hours, these parameters were comparable between the three groups and within the normal range for each of them. Further studies are warranted to investigate the effect of fibrinogen concentrate on clinical outcomes.
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Affiliation(s)
- Christoph J Schlimp
- Ludwig Boltzmann Institute of Experimental and Clinical Traumatology, AUVA Research Centre, Vienna, Austria.
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Davenport R, Brohi K. Fibrinogen depletion in trauma: early, easy to estimate and central to trauma-induced coagulopathy. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2013; 17:190. [PMID: 24063404 PMCID: PMC4056262 DOI: 10.1186/cc13021] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
Abstract
Fibrinogen is fundamental to hemostasis and falls rapidly in trauma hemorrhage,
although levels are not routinely measured in the acute bleeding episode. Prompt
identification of critically low levels of fibrinogen and early supplementation
has the potential to correct trauma-induced coagulation and improve outcomes.
Early estimation of hypofibrinogenemia is possible using surrogate markers of
shock and hemorrhage; for example, hemoglobin and base excess. Rapid replacement
with fibrinogen concentrate or cryoprecipitate should be considered a clinical
priority in major trauma hemorrhage.
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