401
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Dzik WH, Blajchman MA, Fergusson D, Hameed M, Henry B, Kirkpatrick AW, Korogyi T, Logsetty S, Skeate RC, Stanworth S, MacAdams C, Muirhead B. Clinical review: Canadian National Advisory Committee on Blood and Blood Products--Massive transfusion consensus conference 2011: report of the panel. Crit Care 2011; 15:242. [PMID: 22188866 PMCID: PMC3388668 DOI: 10.1186/cc10498] [Citation(s) in RCA: 115] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
In June 2011 the Canadian National Advisory Committee on Blood and Blood Products sponsored an international consensus conference on transfusion and trauma. A panel of 10 experts and two external advisors reviewed the current medical literature and information presented at the conference by invited international speakers and attendees. The Consensus Panel addressed six specific questions on the topic of blood transfusion in trauma. The questions focused on: ratio-based blood resuscitation in trauma patients; the impact of survivorship bias in current research conclusions; the value of nonplasma coagulation products; the role of protocols for delivery of urgent transfusion; the merits of traditional laboratory monitoring compared with measures of clot viscoelasticity; and opportunities for future research. Key findings include a lack of evidence to support the use of 1:1:1 blood component ratios as the standard of care, the importance of early use of tranexamic acid, the expected value of an organized response plan, and the recommendation for an integrated approach that includes antifibrinolytics, rapid release of red blood cells, and a foundation ratio of blood components adjusted by results from either traditional coagulation tests or clot viscoelasticity or both. The present report is intended to provide guidance to practitioners, hospitals, and policy-makers.
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Affiliation(s)
- Walter H Dzik
- Blood Transfusion Service, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
| | - Morris A Blajchman
- Canadian Blood Services, Southern Ontario Region, Departments of Pathology and Medicine, McMaster University Medical Centre, 1200 Main Street West, Hamilton, Ontario, Canada L8N 3Z5
- NHLBI TMH Clinical Trials Network, Bethesda, MD, USA
| | - Dean Fergusson
- Department of Clinical Epidemiology, Ottawa Hospital Research Institute, Clinical Epidemiology Program, Faculty of Medicine, University of Ottawa, 6th Floor Critical Care Wing, Office W6119, 501 Smyth Road, Box 201, Ottawa, Ontario, Canada K1H 8L6
| | - Morad Hameed
- General Surgery Residency Program, Department of Surgery and Critical Care Medicine, University of British Columbia, Trauma Services, Vancouver General Hospital, 855 W 12 Avenue, Vancouver, British Columbia, Canada V5Z 1M9
| | - Blair Henry
- Sunnybrook Health Sciences Centre, Joint Centre for Bioethics, Department of Family and Community Medicine, University of Toronto, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Room H2-39, Toronto, Ontario, Canada M4N 3M5
| | - Andrew W Kirkpatrick
- Department of Critical Care Medicine and Surgery, University of Calgary, Regional Trauma Services, Foothills Medical Centre, 1403 29 St NW, Calgary, Alberta, Canada T2N 2T9
| | - Teresa Korogyi
- Emergency Department, Sunnybrook Health Sciences Center, 2075 Bayview Avenue, Toronto, Ontario, Canada M4N 3M5
| | - Sarvesh Logsetty
- Manitoba Firefighters' Burn Unit, University of Manitoba, GC401A, 820 Sherbrook Avenue, Winnipeg, Manitoba, Canada R3A1R9
| | - Robert C Skeate
- Canadian Blood Services Central Ontario Region, Department of Laboratory Medicine and Pathobiology, University of Toronto, 67 College Street, Toronto, Ontario, Canada M5G 2M1
| | - Simon Stanworth
- Department of Haematology, John Radcliffe Hospital, University of Oxford, UK
| | - Charles MacAdams
- Perioperative Blood Conservation Program Calgary Zone, Department of Anesthesia, Foothills Medical Centre, 1403 29th Street NW, Calgary, Alberta, Canada T2N 2T9
| | - Brian Muirhead
- Transfusion Practices Committee, Blood Conservation Servcies, Winnipeg Regional Health Authority, Department of Anesthesiology, University of Manitoba, 347 Cambridge Street, Winnipeg, Manitoba, Canada R3M 3E8
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402
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Abstract
Massive Transfusion is a part of Damage Control Resuscitation. The aim of transfusion therapy is to restore oxygen delivery to poorly perfused tissues and to treat the acute coagulopathy of trauma. The severity and complexity of modern injuries have led to the use of swift, protocol-driven care with the use of'Shock Packs' and management of metabolic complications. The proactive treatment of the coagulopathy has been termed Haemostatic Resuscitation. The delivery of this transfusion capability has required an increasingly sophisticated logistic and laboratory response. New operational capabilities have included cold chain solutions; laboratory management information systems; platelet apheresis and ROTEM. This investment in the massive transfusion capability has delivered rapid resuscitation. It has also enabled clinicians to direct individualised transfusion support following initial resuscitation i.e. goal directed therapy. Future technical solutions should further support the prehospital delivery of transfusion while addressing the logistic tail. However, the key to success is the knowledge and skills of frontline staff to deliver safe and appropriate blood transfusion.
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403
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Schaden E, Hoerburger D, Hacker S, Kraincuk P, Baron DM, Kozek-Langenecker S. Fibrinogen function after severe burn injury. Burns 2011; 38:77-82. [PMID: 22113102 DOI: 10.1016/j.burns.2010.12.004] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2010] [Revised: 11/14/2010] [Accepted: 12/05/2010] [Indexed: 01/07/2023]
Abstract
BACKGROUND Evidence regarding hypercoagulability in the first week after burn trauma is growing. This hypercoagulable state may partly be caused by increased fibrinogen levels. Rotational thrombelastometry offers a test which measures functional fibrinogen (FIBTEM(®)). To test the hypothesis that in patients with severe burn injury fibrinogen function changes over time, we simultaneously measured FIBTEM(®) and fibrinogen concentration early after burn trauma. METHODS After Ethics Committee approval consecutive patients with severe burn trauma admitted to the burn intensive care unit of the General Hospital of Vienna were included in the study. Blood examinations were done immediately and 12, 24 and 48 h after admission. At each time point fibrinogen level (Clauss) and 4 commercially available ROTEM(®) tests were performed. RESULTS 20 consecutive patients were included in the study. Fibrinogen level and FIBTEM(®) MCF were within the reference range until 24 h after burn trauma but increased significantly 48 h after trauma. There was a significant correlation between FIBTEM(®) MCF and fibrinogen level (R=0.714, p<0.001). CONCLUSION The results of this prospective observational clinical study show that fibrinogen function changes early after burn trauma and can be visualized by ROTEM(®) with the fibrinogen-sensitive FIBTEM(®) test.
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Affiliation(s)
- Eva Schaden
- Dept. of Anesthesiology, General Intensive Care and Pain Control, Medical University Of Vienna, Austria.
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404
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Haas T, Spielmann N, Mauch J, Madjdpour C, Speer O, Schmugge M, Weiss M. Comparison of thromboelastometry (ROTEM®) with standard plasmatic coagulation testing in paediatric surgery. Br J Anaesth 2011; 108:36-41. [PMID: 22086509 DOI: 10.1093/bja/aer342] [Citation(s) in RCA: 267] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Thromboelastometry (ROTEM(®)) might be useful to detect intraoperative coagulation disorders early in major paediatric surgery. This observational trial compares this technique to standard coagulation tests. METHODS Intraoperative blood sampling was obtained in children undergoing elective major surgery. At each time point, standard coagulation tests [activated partial thromboplastin time (aPTT), prothrombin time (PT), and fibrinogen level] and ROTEM(®) analyses (InTEM, ExTEM, and FibTEM) were performed simultaneously by trained hospital laboratory staff. RESULTS A total of 288 blood samples from 50 subjects were analysed. While there was a poor correlation between PT and aPTT to ExTEM clotting time (CT) and InTEM CT, respectively, a good correlation was detected between PT and aPTT to clot formation time, and a very good correlation between fibrinogen level and FibTEM assay (r=0.882, P<0.001). Notably, 64% of PT and 94% of aPTT measurements were outside the reference range, while impaired CT was observed in 13% and 6.3%, respectively. Standard coagulation test results were available after a median of 53 min [inter-quartile range (IQR): 45-63 min], whereas 10 min values of ROTEM(®) results were available online after 23 min (IQR: 21-24 min). CONCLUSIONS PT and aPTT cannot be interchangeably used with ROTEM(®) CT. Based on the results of ROTEM(®), recommended thresholds for PT and aPTT might overestimate the need for coagulation therapy. A good correlation was found between the fibrinogen level and the FibTEM assay. In addition, ROTEM(®) offered faster turnaround times.
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Affiliation(s)
- T Haas
- Department of Anaesthesia, University Children’s Hospital Zurich, Steinwiesstrasse 75, Zurich 8032, Switzerland.
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405
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The influence of coagulation and inflammation research on the improvement of polytrauma care. Eur J Trauma Emerg Surg 2011; 38:231-9. [DOI: 10.1007/s00068-011-0159-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2011] [Accepted: 10/16/2011] [Indexed: 10/15/2022]
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406
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Abstract
Massive bleeding accounts for more than 50% of all trauma-related deaths within the first 48h following hospital admission and it can significantly raise the mortality rate of any kind of surgery. Despite this great clinical relevance, evidence on the management of massive bleeding is surprisingly scarce, and its treatment is often based on empirical grounds. Successful treatment of massive haemorrhage depends on better understanding of the associated physiological changes as well as on good team work among the different specialists involved in the management of such a complex condition.
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Affiliation(s)
- Marco Marietta
- Dipartimento Integrato di Oncologia, Ematologia e Patologie dell'Apparto Respiratorio, U.O.C. di Ematologia, Azienda Ospedaliero-Universitaria di Modena, Italy.
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407
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Hasler RM, Nüesch E, Jüni P, Bouamra O, Exadaktylos AK, Lecky F. Systolic blood pressure below 110 mmHg is associated with increased mortality in penetrating major trauma patients: Multicentre cohort study. Resuscitation 2011; 83:476-81. [PMID: 22056618 DOI: 10.1016/j.resuscitation.2011.10.018] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2011] [Revised: 09/23/2011] [Accepted: 10/20/2011] [Indexed: 10/15/2022]
Abstract
INTRODUCTION Non-invasive systolic blood pressure (SBP) measurement is a commonly used triaging tool for trauma patients. A SBP of <90mmHg has represented the threshold for hypotension for many years, but recent studies have suggested redefining hypotension at lower levels. We therefore examined the association between SBP and mortality in penetrating trauma patients. METHODS We conducted a prospective cohort study in adult (≥16 years) penetrating trauma patients. Patients were admitted to hospitals belonging to the Trauma Audit and Research Network (TARN) between 2000 and 2009. The main outcome measure was the association between SBP and mortality at 30 days. Multivariate logistic regression models adjusted for the influence of age, gender, Injury Severity Score (ISS) and Glasgow Coma Score (GCS) on mortality were used. RESULTS 3444 patients with a median age of 30 years (IQR 22.5-41.4), SBP of 126mmHg (IQR 107-142), ISS of 9 (IQR 9-14) and GCS of 15 (IQR 15-15), were analysed. Multivariable logistic regression analysis adjusted for age, gender, severity of injury and level of consciousness showed a cut-off for SBP at <110mmHg, after which increased mortality was observed. Compared with the reference group with SBP 110-129mmHg, mortality was doubled at SBP 90-109mmHg, was four-fold higher at 70-89mmHg and 10-fold higher at <70mmHg. SBP values ≥150mmHg were associated with decreased mortality. CONCLUSION We recommend that penetrating trauma patients with a SBP<110mmHg are triaged to resuscitation areas within dedicated, appropriately specialised, high-level care trauma centres.
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Affiliation(s)
- Rebecca M Hasler
- Trauma Audit and Research Network, Health Sciences Research Group, School of Community Based Medicine, Manchester Academic Health Sciences Centre, University of Manchester, Salford Royal Hospital, Stott Lane, Salford M6 8HD, UK.
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408
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Ostrowski SR, Sørensen AM, Larsen CF, Johansson PI. Thrombelastography and biomarker profiles in acute coagulopathy of trauma: a prospective study. Scand J Trauma Resusc Emerg Med 2011; 19:64. [PMID: 22029598 PMCID: PMC3212903 DOI: 10.1186/1757-7241-19-64] [Citation(s) in RCA: 72] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2011] [Accepted: 10/26/2011] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Severe injury induces an acute coagulopathy associated with increased mortality. This study compared the Thrombelastography (TEG) and biomarker profiles upon admission in trauma patients. METHODS Prospective observational study of 80 trauma patients admitted to a Level I Trauma Centre. Data on demography, biochemistry including standard coagulation tests, hematology, transfusions, Injury Severity Score (ISS) and TEG were recorded. Retrospective analysis of thawed plasma/serum for biomarkers reflecting tissue injury (histone-complexed DNA fragments), sympathoadrenal activation (adrenaline, noradrenaline), coagulation activation/inhibition and fibrinolysis (sCD40L, protein C, activated Protein C, tissue-type plasminogen activator, plasminogen activator inhibitor-1, D-dimer, prothrombinfragment 1+2, plasmin/α2-antiplasmin complex, thrombin/antithrombin complex, tissue factor pathway inhibitor, antithrombin, von willebrand factor, factor XIII). Comparison of patients stratified according to ISS/TEG maximum clot strength. Linear regression analysis of variables associated with clot strength. RESULTS Trauma patients had normal (86%), hypercoagulable (11%) or hypocoagulable (1%) TEG clot strength; one had primary hyperfibrinolysis. Hypercoagulable patients had higher age, fibrinogen and platelet count (all p < 0.05), none had increased activated partial thromboplastin time (APTT) or international normalized ratio (INR) and none required massive transfusion (> 10 red blood cells the initial 24 h). Patients with normal or hypercoagulable TEG clot strength had comparable biomarker profiles, but the few patients with hypocoagulable TEG clot strength and/or hyperfibrinolysis had very different biomarker profiles.Increasing ISS was associated with higher levels of catecholamines, histone-complexed DNA fragments, sCD40L, activated protein C and D-dimer and reduced levels of non-activated protein C, antithrombin, fibrinogen and factor XIII (all p < 0.05). Fibrinogen and platelet count were associated independently with clot strength in patients with ISS ≤ 26 whereas only fibrinogen was associated independently with clot strength in patients with ISS > 26. In patients with ISS > 26, adrenaline and sCD40L were independently negatively associated with clot strength. CONCLUSIONS Trauma patients displayed different coagulopathies by TEG and variables independently associated with clot strength changed with ISS. In the highest ISS group, adrenaline and sCD40L were independently negatively associated with clot strength indicating that these may contribute to acute coagulopathy.
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Affiliation(s)
- Sisse R Ostrowski
- Section for Transfusion Medicine, Capital Region Blood Bank, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 9, DK-2100 Copenhagen, Denmark.
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409
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Abstract
Despite improved strategies in the treatment of polytraumatized patients the mortality rate of severely injured patients remains high. Thus, worldwide 5 million patients die due to trauma or trauma-related complications each year. As the majority of early trauma-related deaths are attributed to or caused by exsanguination the prevention and treatment of coagulopathy is of paramount significance. With the aim of developing guidelines and improve strategies to treat polytraumatized patients the multidisciplinary Task Force for Advanced Bleeding Care in Trauma was founded in 2005. Under consideration of new clinical studies, an updated version of the original publication from 2007 has recently been published. Based on a systematic review of published literature the recommendations were formed according to "Grading of Recommendations Assessment, Development and Evaluation" (GRADE). This publication summarizes the main recommendations with a special emphasis on revisions and new aspects.
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410
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Davenport R, Khan S. Management of major trauma haemorrhage: treatment priorities and controversies. Br J Haematol 2011; 155:537-48. [PMID: 22017416 DOI: 10.1111/j.1365-2141.2011.08885.x] [Citation(s) in RCA: 72] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
The severely injured trauma patient often arrives in the emergency department bleeding, coagulopathic and in need of a blood transfusion. The diagnosis and management of these patients has vastly improved with a better understanding of acute traumatic coagulopathy (ATC). In the emergency setting, traditional laboratory coagulation screens are of limited use in the diagnosis and management of life-threatening bleeding. Whole blood assays, such as thrombelastography (TEG) and rotational thrombelastometry (ROTEM) provide a rapid evaluation of clot formation, strength and lysis. Rapid diagnosis of ATC and aggressive haemostatic transfusion strategies utilizing early high doses of plasma are associated with improved outcomes in trauma. At present there is no accurate guide for transfusion in trauma, therefore blood and clotting products are administered on an empiric basis. Targeted transfusion therapy for major trauma haemorrhage based on comprehensive and rapid measures of coagulation e.g. TEG/ROTEM may lead to improved outcomes while optimizing blood utilization. Evidence for the clinical application of TEG and ROTEM in trauma is emerging with a number of studies evaluating their ability to diagnose coagulopathy early and facilitate goal-directed transfusion. This review explores current controversies and best practice in the diagnosis and management of major haemorrhage in trauma.
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Affiliation(s)
- Ross Davenport
- Trauma Sciences, Blizard Institute, Bart's and the London School of Medicine & Dentistry, Queen Mary University of London, London, UK.
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411
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Kozek-Langenecker S, Sørensen B, Hess JR, Spahn DR. Clinical effectiveness of fresh frozen plasma compared with fibrinogen concentrate: a systematic review. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2011; 15:R239. [PMID: 21999308 PMCID: PMC3334790 DOI: 10.1186/cc10488] [Citation(s) in RCA: 170] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/05/2011] [Revised: 08/23/2011] [Accepted: 10/14/2011] [Indexed: 12/14/2022]
Abstract
Introduction Haemostatic therapy in surgical and/or massive trauma patients typically involves transfusion of fresh frozen plasma (FFP). Purified human fibrinogen concentrate may offer an alternative to FFP in some instances. In this systematic review, we investigated the current evidence for the use of FFP and fibrinogen concentrate in the perioperative or massive trauma setting. Methods Studies reporting the outcome (blood loss, transfusion requirement, length of stay, survival and plasma fibrinogen level) of FFP or fibrinogen concentrate administration to patients in a perioperative or massive trauma setting were identified in electronic databases (1995 to 2010). Studies were included regardless of type, patient age, sample size or duration of patient follow-up. Studies of patients with congenital clotting factor deficiencies or other haematological disorders were excluded. Studies were assessed for eligibility, and data were extracted and tabulated. Results Ninety-one eligible studies (70 FFP and 21 fibrinogen concentrate) reported outcomes of interest. Few were high-quality prospective studies. Evidence for the efficacy of FFP was inconsistent across all assessed outcomes. Overall, FFP showed a positive effect for 28% of outcomes and a negative effect for 22% of outcomes. There was limited evidence that FFP reduced mortality: 50% of outcomes associated FFP with reduced mortality (typically trauma and/or massive bleeding), and 20% were associated with increased mortality (typically surgical and/or nonmassive bleeding). Five studies reported the outcome of fibrinogen concentrate versus a comparator. The evidence was consistently positive (70% of all outcomes), with no negative effects reported (0% of all outcomes). Fibrinogen concentrate was compared directly with FFP in three high-quality studies and was found to be superior for > 50% of outcomes in terms of reducing blood loss, allogeneic transfusion requirements, length of intensive care unit and hospital stay and increasing plasma fibrinogen levels. We found no fibrinogen concentrate comparator studies in patients with haemorrhage due to massive trauma, although efficacy across all assessed outcomes was reported in a number of noncomparator trauma studies. Conclusions The weight of evidence does not appear to support the clinical effectiveness of FFP for surgical and/or massive trauma patients and suggests it can be detrimental. Perioperatively, fibrinogen concentrate was generally associated with improved outcome measures, although more high-quality, prospective studies are required before any definitive conclusions can be drawn.
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Affiliation(s)
- Sibylle Kozek-Langenecker
- Department of Anaesthesia and Intensive Care, Evangelical Hospital Vienna, Hans-Sachs-Gasse 10-12, 1180-Vienna, Austria.
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412
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Holowaychuk MK, Monteith G. Ionized hypocalcemia as a prognostic indicator in dogs following trauma. J Vet Emerg Crit Care (San Antonio) 2011; 21:521-30. [DOI: 10.1111/j.1476-4431.2011.00675.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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413
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Pasquier P, Malgras B, Martinaud C, Auroy Y, Tourtier JP. Limb salvage in open tibia fractures: are prehospital time and tourniquet significant? THE JOURNAL OF TRAUMA 2011; 71:1093. [PMID: 21986759 DOI: 10.1097/ta.0b013e31822ac6c2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
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414
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Morrison GA, Chalmers RTA, Solomon C, Nimmo AF. Fibrinogen concentrate therapy guided by thromboelastometry as an alternative to fresh frozen plasma in major vascular surgery. J Cardiothorac Vasc Anesth 2011; 26:654-9. [PMID: 21955829 DOI: 10.1053/j.jvca.2011.07.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2011] [Indexed: 11/11/2022]
Affiliation(s)
- Gary A Morrison
- Department of Anaesthesia, Royal Infirmary of Edinburgh, Edinburgh, UK.
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415
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Nystrup KB, Windeløv NA, Thomsen AB, Johansson PI. Reduced clot strength upon admission, evaluated by thrombelastography (TEG), in trauma patients is independently associated with increased 30-day mortality. Scand J Trauma Resusc Emerg Med 2011; 19:52. [PMID: 21955460 PMCID: PMC3203039 DOI: 10.1186/1757-7241-19-52] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2011] [Accepted: 09/28/2011] [Indexed: 02/25/2023] Open
Abstract
INTRODUCTION Exsanguination due to uncontrolled bleeding is the leading cause of potentially preventable deaths among trauma patients. About one third of trauma patients present with coagulopathy on admission, which is associated with increased mortality and will aggravate bleeding in a traumatized patient. Thrombelastographic (TEG) clot strength has previously been shown to predict outcome in critically ill patients. The aim of the present study was to investigate this relation in the trauma setting. METHODS A retrospective study of trauma patients with an injury severity qualifying them for inclusion in the European Trauma Audit and Research Network (TARN) and a TEG analysis performed upon arrival at the trauma centre. RESULTS Eighty-nine patients were included. The mean Injury Severity Score (ISS) was 21 with a 30-day mortality of 17%. Patients with a reduced clot strength (maximal amplitude < 50 mm) evaluated by TEG, presented with a higher ISS 27 (95% CI, 20-34) vs. 19 (95% CI, 17-22), p = 0.006 than the rest of the cohort. Clot strength correlated with the amount of packed red blood cells (p = 0.01), fresh frozen plasma (p = 0.04) and platelet concentrates (p = 0.03) transfused during the first 24 hours of admission. Patients with low clot strength demonstrated increased 30-day mortality (47% vs. 10%, p < 0.001). By logistic regression analysis reduced clot strength was an independent predictor of increased mortality after adjusting for age and ISS. CONCLUSION Low clot strength upon admission is independently associated with increased 30-day mortality in trauma patients and it could be speculated that targeted interventions based on the result of the TEG analysis may improve patient outcome. Prospective randomized trials investigating this potential are highly warranted.
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Affiliation(s)
- Kristin B Nystrup
- Department of Clinical Immunology, Section for Transfusion Medicine, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
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416
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Nohé B, Ploppa A, Schmidt V, Unertl K. [Volume replacement in intensive care medicine]. Anaesthesist 2011; 60:457-64, 466-73. [PMID: 21350879 DOI: 10.1007/s00101-011-1860-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Volume substitution represents an essential component of intensive care medicine. The amount of fluid administered, the composition and the timing of volume replacement seem to affect the morbidity and mortality of critically ill patients. Although restrictive volume strategies bear the risk of tissue hypoperfusion and tissue hypoxia in hemodynamically unstable patients liberal strategies favour the development of avoidable hypervolemia with edema and resultant organ dysfunction. However, neither strategy has shown a consistent benefit. In order to account for the heavily varying oxygen demand of critically ill patients, a goal-directed, demand-adapted volume strategy is proposed. Using this strategy, volume replacement should be aligned to the need to restore tissue perfusion and the evidence of volume responsiveness. As the efficiency of volume resuscitation for correction of tissue hypoxia is time-dependent, preload optimization should be completed in the very first hours. Whether colloids or crystalloids are more suitable for this purpose is still controversially discussed. Nevertheless, a temporally limited use of colloids during the initial stage of tissue hypoperfusion appears to represent a strategy which uses the greater volume effect during hypovolemia while minimizing the risks for adverse reactions.
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Affiliation(s)
- B Nohé
- Klinik für Anaesthesiologie und Intensivmedizin, Universitätsklinikum Tübingen, Deutschland.
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417
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Schöchl H, Solomon C, Traintinger S, Nienaber U, Tacacs-Tolnai A, Windhofer C, Bahrami S, Voelckel W. Thromboelastometric (ROTEM) findings in patients suffering from isolated severe traumatic brain injury. J Neurotrauma 2011; 28:2033-41. [PMID: 21942848 DOI: 10.1089/neu.2010.1744] [Citation(s) in RCA: 96] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
Severe traumatic brain injury (sTBI) is often accompanied by coagulopathy and an increased risk of bleeding. To identify and successfully treat bleeding disorders associated with sTBI, rapid assessment of coagulation status is crucial. This retrospective study was designed to assess the potential role of whole-blood thromboelastometry (ROTEM(®), Tem International, Munich, Germany) in patients with isolated sTBI (abbreviated injury scale [AIS](head) ≥3 and AIS(extracranial) <3). Blood samples were obtained immediately following admission to the emergency room of the Trauma Centre Salzburg in Austria. ROTEM analysis (EXTEM, INTEM, and FIBTEM tests) and standard laboratory coagulation tests (prothrombin time index [PTI, percentage of normal prothrombin time], activated partial thromboplastin time [aPTT], fibrinogen concentration, and platelet count) were compared between survivors and non-survivors. Out of 88 patients with sTBI enrolled in the study, 66 survived and 22 died. PTI, fibrinogen, and platelet count were significantly higher in survivors (p<0.005). Accordingly, aPTT was shorter in this group (p<0.0001). ROTEM analysis revealed shorter clotting times in extrinsically activated thromboelastometric test (EXTEM) and intrinsically activated thromboelastometric test (INTEM) (p<0.001), shorter clot formation times in EXTEM and INTEM (p<0.0001), and higher maximum clot firmness in EXTEM, INTEM, and FIBTEM (p<0.01) in survivors compared with non-survivors. Logistic regression analysis revealed extrinsically activated thromboelastometric test with cytochalasin D (FIBTEM) MCF and aPTT to have the best predictive value for mortality. According to the degree of coagulopathy, non-survivors received more RBC (p=0.016), fibrinogen concentrate (p=0.01), and prothrombin complex concentrate (p<0.001) within 24 h of arrival in the emergency room. ROTEM testing appeared to offer an early signal of severe life-threatening sTBI. Further studies are warranted to confirm these results and to investigate the role of ROTEM in guiding coagulation therapy.
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Affiliation(s)
- Herbert Schöchl
- Ludwig Boltzmann Institute for Experimental and Clinical Traumatology and AUVA Research Centre, Vienna, Austria.
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418
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Consunji RJ, Serrato Marinas JPE, Aspuria Maddumba JR, Dela Paz DA. A profile of deaths among trauma patients in a university hospital: the Philippine experience. J Inj Violence Res 2011; 3:85-9. [PMID: 21498971 PMCID: PMC3134925 DOI: 10.5249/jivr.v3i2.39] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2009] [Accepted: 05/03/2010] [Indexed: 12/11/2022] Open
Abstract
Background: The Philippine General Hospital (PGH) is the pioneer in trauma care in the country, being the first to create a dedicated Trauma Service in 1989. The service has not conducted a review of its admissions and mortalities since 1992. The purpose of this study is to describe the mortality patterns of this service. Methods: A descriptive and retrospective 3-year review, covering January 2004 June 2007, was conducted using an electronic patient database. Review of patient records included: population demographics, mechanism of injury, length of stay prior to death, and the cause of death. Results: Of the 4947 patients admitted to the Division of Trauma during the study period, there were 231 (4.7%) deaths. The most common mechanisms of injuries were stab wounds (32.9 %), vehicular crashes (28.6 %), and gunshot wounds (25.5 %). Multiple organ failure/Sepsis (37.7 %) was the most frequent causes of death, followed by Exsanguinations (27.7 %), Central Nervous System failure (18.6 %) and other causes (10.8%). Forty four (66.7 %) of the 66 patients who died within the first 24 hours died from Exsanguinations, while 66 (61.1 %) of the 8 patients who died after 72 hours died from Multiple organ failure/Sepsis. Conclusions: Intentional causes of injury (i.e. penetrating interpersonal violence) caused the majority of trauma deaths in this series from the Philippine General Hospital. This highlights the need for prioritizing a public health approach to violence prevention in the Philippines. Further research must be conducted to identify risk factors for interpersonal violence. Early identification of lethal injuries that may cause exsanguinations and definitive control of hemorrhage should be the primary focus to prevent acute deaths, within 24 hours of admission. Further adjuncts to the definitive treatment of hemorrhage, the critical care of TBI and MOF/Sepsis are needed to reduce deaths occurring more than 72 hours after admission.
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Affiliation(s)
- Rafael J Consunji
- Division of Trauma, Department of Surgery, Philippine General Hospital, College of Medicine, University of the Philippines, Manila, Philippines.
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419
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Mateo J, Paniagua P, Koller T, Moral V, Fontcuberta J. Dextran and hydroxyethyl starch do not interfere with fibrinogen measurement if Clauss method with mechanical clot detection is used. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2011; 15:441. [PMID: 21958443 PMCID: PMC3334723 DOI: 10.1186/cc10304] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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420
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Abstract
Oxygen (O(2)) is the most frequently used pharmaceutical in anesthesiology and intensive care medicine: Every patient receives O(2) during surgery or during a stay in the intensive care unit. Hypoxia and hypoxemia of various origins are the most typical indications which are mentioned in the prescribing information of O(2): the goal of the administration of O(2) is either an increase of arterial O(2) partial pressure in order to treat hypoxia, or an increase of arterial O(2) content in order to treat hypoxemia. Most of the indications for O(2) administration were developed in former times and have seldom been questioned from that time on as the short-term side-effects of O(2) are usually considered to be of minor importance. As a consequence only a small number of controlled randomized studies exist, which can demonstrate the efficacy of O(2) in terms of evidence-based medicine. However, there is an emerging body of evidence that specific side-effects of O(2) result in a deterioration of the microcirculation. The administration of O(2) induces arteriolar constriction which will initiate a decline of regional O(2) delivery and subsequently a decline of tissue oxygenation. The aim of the manuscript presented is to discuss the significance of O(2) as a pharmaceutical in the clinical setting.
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421
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Tauber H, Innerhofer P, Breitkopf R, Westermann I, Beer R, El Attal R, Strasak A, Mittermayr M. Prevalence and impact of abnormal ROTEM ® assays in severe blunt trauma: results of the ‘Diagnosis and Treatment of Trauma-Induced Coagulopathy (DIA-TRE-TIC) study’. Br J Anaesth 2011; 107:378-87. [DOI: 10.1093/bja/aer158] [Citation(s) in RCA: 178] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
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422
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423
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Increasing concentrations of prothrombin complex concentrate induce disseminated intravascular coagulation in a pig model of coagulopathy with blunt liver injury. Blood 2011; 118:1943-51. [DOI: 10.1182/blood-2011-03-343046] [Citation(s) in RCA: 106] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Abstract
Despite increasing use of prothrombin complex concentrate (PCC) to treat hemorrhage-associated coagulopathy, few studies have investigated PCC in trauma, and there is a particular lack of safety data. This study was performed to evaluate PCC therapy in a porcine model of coagulopathy with blunt liver injury. Coagulopathy was induced in 27 anesthetized pigs by replacing approximately 70% blood volume with hydroxyethyl starch 130/0.4 and Ringer's lactate solution; erythrocytes were collected and retransfused. Ten minutes after trauma, animals randomly received PCC (35 or 50 IU/kg) or saline. Coagulation parameters including thromboelastometry, thrombin generation, and blood loss were monitored for 2 hours. Internal organs were examined macroscopically and histologically to determine the presence of emboli and assess liver injury. Total blood loss was significantly lower and survival was higher in both PCC groups versus the control group (P < .05). These outcomes appeared to be dose-independent. Thromboembolism was found in all animals treated with 50 IU/kg PCC; 44% also showed signs of disseminated intravascular coagulation. Liver injury was similar in all animals. In conclusion, 35 IU/kg PCC safely improved coagulation and attenuated blood loss. However, the higher dose of PCC (50 IU/kg) appeared to increase the risk of thromboembolism and disseminated intravascular coagulation.
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424
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Nascimento B, Rizoli S, Rubenfeld G, Fukushima R, Ahmed N, Nathens A, Lin Y, Callum J. Cryoprecipitate transfusion: assessing appropriateness and dosing in trauma. Transfus Med 2011; 21:394-401. [PMID: 21851429 DOI: 10.1111/j.1365-3148.2011.01098.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Originally developed for patients with congenital factor VIII deficiency, cryoprecipitate is currently largely used for acquired hypofibrinogenemia in the context of bleeding. However, scant evidence supports this indication and cryoprecipitate is commonly used outside guidelines. In trauma, the appropriate cryoprecipitate dose and its impact on plasma fibrinogen levels are unclear. OBJECTIVES The aims were to evaluate (i) the appropriateness of cryoprecipitate transfusion in trauma and (ii) the plasma fibrinogen response to cryoprecipitate transfusion during massive transfusion in trauma. METHODS Retrospective review (January 1998-June 2008) of indications, dose and plasma fibrinogen response to cryoprecipitate transfusion at a large teaching hospital. A fibrinogen of <1.0 g L(-1) within 2 and 6 h of transfusion was used for evaluating appropriateness. RESULTS Ten thousand five hundred and forty cryoprecipitate units were transfused in 1004 patients. Thirty-seven percent and 31% were used in cardiac surgery and trauma, respectively. In 394 events in trauma, 238 (60%) and 259 (66%) were considered appropriate using the 2- and 6-h cut-off criteria, respectively. In patients who did not receive plasma components 2 h prior to cryoprecipitate, a dose of 8.7 (± 1.7) units caused a mean increase in fibrinogen levels of 0.55 (± 0.24) g L(-1), or 0.06 g L(-1) per unit. CONCLUSIONS In our hospital, where transfusion guidelines are overseen by transfusion medicine specialists and technologists, and policies for rapid blood component and laboratory turnaround times exist, it is possible to achieve high rates of appropriateness for cryoprecipitate transfusion in trauma. The current recommended dose causes a modest increase in fibrinogen levels (0.55 g L(-1) ).
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Affiliation(s)
- B Nascimento
- Department of Critical Care & Clinical Pathology & Surgery, Sunnybrook Health Sciences Center, University of Toronto, Toronto, Ontario, Canada.
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425
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Díaz O, Esparza JM, Plaza M, Vila M. [Comments on the article "Hypotensive resuscitation of the polytrauma patient with hemorrhagic shock"]. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2011; 58:458-460. [PMID: 22046870 DOI: 10.1016/s0034-9356(11)70112-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
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426
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Le Noël A, Mérat S, Ausset S, De Rudnicki S, Mion G. [The damage control resuscitation concept]. ACTA ACUST UNITED AC 2011; 30:665-78. [PMID: 21764247 DOI: 10.1016/j.annfar.2011.05.016] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2010] [Accepted: 05/26/2011] [Indexed: 10/17/2022]
Abstract
OBJECTIVE Damage control is a strategy of care for bleeding trauma patients, involving minimal rescue surgery associated to perioperative resuscitation. The purpose of this review is to draw up a statement on current knowledge available on damage control. DATA SOURCES References were obtained from recent review articles, personal files, and Medline database research of English and French publications. All categories of articles on this topic have been selected. DATA SYNTHESIS Historical damage control surgery, that consist of abbreviated laparotomy with second-look after resuscitation, is now included in a wider concept called "damage control resuscitation", addressing the lethal triad (coagulopathy, hypothermia and acidosis) at an early phase. Care is focused on coagulopathy prevention. Early resuscitation, or damage control ground zero, has been improved: aggressive management of hypothermia, bleeding control techniques, permissive hypotension concept and early use of vasopressors. Transfusion practices also have evolved: early platelets and coagulation factors administration, use of hemostatic agents like recombinant FVIIa, whole blood transfusion, denote the damage control hematology. Progress in surgical practices and development of arteriographic techniques lead to wider indications of damage control strategy.
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Affiliation(s)
- A Le Noël
- Département d'anesthésie-réanimation, hôpital d'instruction des armées du Val-de-Grâce, 74, boulevard de Port-Royal, 75230 Paris cedex 05, France
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427
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Ogawa S, Szlam F, Chen EP, Nishimura T, Kim H, Roback JD, Levy JH, Tanaka KA. A comparative evaluation of rotation thromboelastometry and standard coagulation tests in hemodilution-induced coagulation changes after cardiac surgery. Transfusion 2011; 52:14-22. [PMID: 21756263 DOI: 10.1111/j.1537-2995.2011.03241.x] [Citation(s) in RCA: 121] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Coagulopathy after cardiopulmonary bypass (CPB) is caused by multiple perturbations in cellular and humoral elements of coagulation. A timely and comprehensive method to evaluate hemostasis would be helpful in the management of bleeding patients after CPB. The assessment of whole blood coagulation using rotation thromboelastometry (ROTEM) was compared to coagulation tests routinely performed during cardiac surgery. STUDY DESIGN AND METHODS Blood was obtained from 26 patients undergoing CPB surgery at baseline, at 60 minutes on CPB, at the end of CPB, and on admission to intensive care unit. ROTEM tests (extrinsically activated [EXTEM], intrinsically activated [INTEM], specific clot formation [FIBTEM]), prothrombin time, activated partial thromboplastin time, platelet (PLT) count, fibrinogen, prothrombin level, antithrombin level, and thrombin generation (TG) measurement were performed. RESULTS We observed strong correlations between FIBTEM-amplitude at 10 minutes (A10) and fibrinogen level (r=0.87; p<0.001) and between EXTEM/ INTEM-A10 variables and PLT count (r=0.72 and 0.67, respectively; p<0.001). Receiver operating characteristic analysis demonstrated that EXTEM-A10 and INTEM-A10 are predictive of thrombocytopenia below 80×10(9)/L (area under the curve [AUC], 0.83 and 0.82, respectively), and FIBTEM-A10 was highly predictive of fibrinogen level below 200 mg/dL (AUC, 0.96). There were only weak correlations found between TG peak and clot formation time of EXTEM or INTEM (r=0.30 and 0.29, respectively; p<0.05). CONCLUSION ROTEM variables demonstrated clinically relevant correlations with PLT counts and fibrinogen levels. In particular, decreasing levels of fibrinogen can be quickly determined (<15-20 min) using FIBTEM.
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Affiliation(s)
- Satoru Ogawa
- Department of Anesthesiology, Emory University School of Medicine, Atlanta, Georgia 30322, USA
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428
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Abstract
The coagulation system is a complex network of interacting proteins and cells with extensive sensitivity, amplification and control pathways. The system represents a delicate balance between procoagulant and anticoagulant as well as profibrinolytic and antifibrinolytic activities. Clinically relevant phenotypes, e.g. bleeding and thrombosis, occur immediately when this balance is no longer in equilibrium. A correct understanding of the complex coagulation pathophysiology in the perioperative setting is essential for an effective treatment. In a bleeding patient, patient's history, clinical findings, routine and advanced laboratory coagulation testing as well as point-of-care coagulation monitoring help to reliably and readily identify the underlying coagulation disorder. Modern coagulation management is proactive, individualized, balanced and follows clearly defined algorithms. Coagulopathic bleeding can be successfully controlled with specific interventions in the coagulation system.
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429
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Patanwala AE, Acquisto NM, Erstad BL. Prothrombin Complex Concentrate for Critical Bleeding. Ann Pharmacother 2011; 45:990-9. [DOI: 10.1345/aph.1q096] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Objective: To review the evidence supporting the use of prothrombin complex concentrate (PCC) as a hemostatic agent in individuals without hemophilia. Data Sources: Articles were identified through a search of Ovid/MEDLINE (up to April 2011) and Cochrane Central Register of Controlled Trials (up to April 2011). The search terms used were prothrombin complex concentrate, hemorrhage, and bleeding. Study Selection and Data Extraction: The search was limited to comparative studies. Bibliographies of retrieved articles were reviewed to obtain additional articles. The intent of the search was to identify original research comparing PCC to fresh frozen plasma (FFP) or recombinant factor VIIa for the management of bleeding in patients without hemophilia. Data Synthesis: PCCs are recommended as an alternative to FFP and recombinant factor VIIa for the treatment of serious or life-threatening bleeding related to vitamin K antagonist therapy. Studies in this setting have shown that PCCs are safe and effective and provide prompt reduction of international normalized ratio (INR) compared to FFP. However, most trials are uncontrolled, and the primary outcomes in these studies have been INR reduction rather than hemostatic effect. Other common off-label uses include coagulopathy due to hepatic failure and traumatic hemorrhage; however, there is insufficient evidence to support use of PCC in these settings. Advantages of PCC include the low drug volume required compared to FFP. The use of PCC may be associated with thromboembolic complications. Conclusions: PCC is a safe and effective alternative to FFP and provides rapid reversal of INR in patients on vitamin K antagonist therapy. These agents may be advantageous compared to FFP in patients with volume restrictions. Comparative trials are needed to compare the various PCC products, FPP, and recombinant factor VIIa with regard to clinically significant outcomes such as hemostatic effect.
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Affiliation(s)
| | - Nicole M Acquisto
- Department of Emergency Medicine, University of Rochester Medical Center, Rochester, NY
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430
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Current world literature. Curr Opin Anaesthesiol 2011; 24:224-33. [PMID: 21386670 DOI: 10.1097/aco.0b013e32834585d6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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431
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Nienaber U, Innerhofer P, Westermann I, Schöchl H, Attal R, Breitkopf R, Maegele M. The impact of fresh frozen plasma vs coagulation factor concentrates on morbidity and mortality in trauma-associated haemorrhage and massive transfusion. Injury 2011; 42:697-701. [PMID: 21392760 DOI: 10.1016/j.injury.2010.12.015] [Citation(s) in RCA: 112] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2010] [Revised: 11/18/2010] [Accepted: 12/16/2010] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Clinical observations together with recent research highlighted the role of coagulopathy in acute trauma care and early aggressive treatment has been shown to reduce mortality. METHODS Datasets from severely injured and bleeding patients with established coagulopathy upon emergency room (ER) arrival from two retrospective trauma databases, (i) TR-DGU (Germany) and (ii) Innsbruck Trauma Databank/ITB (Austria), that had received two different strategies of coagulopathy management during initial resuscitation, (i) fresh frozen plasma (FFP) without coagulation factor concentrates, and (ii) coagulation factor concentrates (fibrinogen and/or prothrombin complex concentrates) without FFP, were compared for morbidity, mortality and transfusion requirements using a matched-pair analysis approach. RESULTS There were no major differences in basic characteristics and physiological variables upon ER admission between the two cohorts that were matched. ITB patients had received substantially less packed red blood cell (pRBC) concentrates within the first 6h after admission (median 1.0 (IQR(25-75) 0-3) vs 7.5 (IQR(25-75) 4-12) units; p<0.005) and the first 24h as compared to TR-DGU patients (median 3 (IQR(25-75) 0-5) vs 12.5 (8-20) units; p<0.005). Overall mortality was comparable between both groups whilst the frequency for multi organ failure was significantly lower within the group that had received coagulation factor concentrates exclusively and no FFP during initial resuscitation (n=3 vs n=15; p=0.015). This translated into trends towards reduced days on ventilator whilst on ICU and shorter overall in-hospital length of stays (LOS). CONCLUSION Although there was no difference in overall mortality between both groups, significant differences with regard to morbidity and need for allogenic transfusion provide a signal supporting the management of acute post-traumatic coagulopathy with coagulation factor concentrates rather than with traditional FFP transfusions. Prospective and randomised clinical trials with sufficient patient numbers based upon this strategy are advocated.
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Affiliation(s)
- Ulrike Nienaber
- Institute for Research in Operative Medicine, University of Witten/Herdecke, Cologne, Germany
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432
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David JS, Marchal V, Levrat A, Inaba K. Which is the most effective strategy: early detection of coagulopathy with thromboelastometry or use of hemostatic factors or both? CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2011; 15:433; author reply 433. [PMID: 21672283 PMCID: PMC3218978 DOI: 10.1186/cc10224] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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433
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Solomon C, Traintinger S, Ziegler B, Hanke A, Rahe-Meyer N, Voelckel W, Schöchl H. Platelet function following trauma. A multiple electrode aggregometry study. Thromb Haemost 2011; 106:322-30. [PMID: 21655681 DOI: 10.1160/th11-03-0175] [Citation(s) in RCA: 148] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2011] [Accepted: 05/03/2011] [Indexed: 12/23/2022]
Abstract
Platelets play a central role in coagulation. Currently, information on platelet function following trauma is limited. We performed a retrospective analysis of patients admitted to the emergency room (ER) at the AUVA Trauma Centre, Salzburg, after sustaining traumatic injury. Immediately after admission to the ER, blood was drawn for blood cell counts, standard coagulation tests, and platelet function testing. Platelet function was assessed by multiplate electrode aggregometry (MEA) using adenosine diphosphate (ADPtest), collagen (COLtest) and thrombin receptor activating peptide-6 (TRAPtest) as activators. The thromboelastometric platelet component, measuring the contribution of platelets to the elasticity of the whole-blood clot, was assessed using the ROTEM device. The study included 163 patients, 79.7% were male, and the median age was 43 years. The median injury severity score was 18. Twenty patients (12.3%) died. Median platelet count was significantly lower among non-survivors than survivors (181,000/μl vs. 212,000/μl; p=0.01). Although platelet function defects were relatively minor, significant differences between survivors and non-survivors were observed in the ADPtest (94 vs. 79 U; p=0.0019), TRAPtest (136 vs. 115 U; p<0.0001), and platelet component (134 vs.103 MCEEXTEM - MCEFIBTEM; p=0.0012). Aggregometry values below the normal range for ADPtest and TRAPtest were significantly more frequent in non-survivors than in survivors (p=0.0017 and p=0.0002, respectively). Minor decreases in platelet function upon admission to the ER were a sign of coagulopathy accompanying increased mortality in patients with trauma. Further studies are warranted to confirm these results and investigate the role of platelet function in trauma haemostatic management.
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Affiliation(s)
- Cristina Solomon
- Department of Anaesthesiology and Intensive Care Medicine, AUVA Trauma Centre, Salzburg, Austria
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434
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Holzer T, Pellegrinelli G, Morel P, Toso C. Appendectomy during the third trimester of pregnancy in a 27-year old patient: case report of a "near miss" complication. Patient Saf Surg 2011; 5:11. [PMID: 21575272 PMCID: PMC3118102 DOI: 10.1186/1754-9493-5-11] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2011] [Accepted: 05/17/2011] [Indexed: 11/18/2022] Open
Abstract
The management of acute appendicitis during pregnancy is not fully established, especially regarding the choice between open and laparoscopic surgery during the third trimester. We report herein the case of a major uterine variecele hemorrhage during a laparoscopic appendectomy in a 27-year old pregnant patient at 33 weeks of amenorrhea. After conversion to a Pfannenstiel incision, the baby was delivered, the bleeding stopped and the appendectomy completed. While both mother and child fully recovered, this «near miss» complication underlines the challenges linked to the management of acute appendicitis during pregnancy. Based on a literature review, we propose an algorithm favoring the laparoscopic approach during the first and second trimesters, and the open approach during the third trimester (especially after the 26th week of amenorrhea). In case of unclear pre-operative diagnosis, a laparoscopy should be conducted even during the third trimester with a Mc Burney conversion when the diagnosis of appendicitis is confirmed.
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Affiliation(s)
- Thomas Holzer
- Abdominal and Transplant Surgery, University Hospitals of Geneva, Faculty of Medicine, University of Geneva, Geneva, Switzerland.
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435
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Hasler RM, Nuesch E, Jüni P, Bouamra O, Exadaktylos AK, Lecky F. Systolic blood pressure below 110 mm Hg is associated with increased mortality in blunt major trauma patients: multicentre cohort study. Resuscitation 2011; 82:1202-7. [PMID: 21632168 DOI: 10.1016/j.resuscitation.2011.04.021] [Citation(s) in RCA: 69] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2010] [Revised: 04/12/2011] [Accepted: 04/24/2011] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Non-invasive systolic blood pressure (SBP) measurement is often used in triaging trauma patients. Traditionally, SBP< 90 mm Hg has represented the threshold for hypotension, but recent studies have suggested redefining hypotension as SBP < 110 mm Hg. This study aims to examine the association of SBP with mortality in blunt trauma patients. METHODS This is an analysis of prospectively recorded data from adult (≥ 16 years) blunt trauma patients. Included patients presented to hospitals belonging to the Trauma Audit and Research Network (TARN) between 2000 and 2009. The primary outcome was the association of SBP and mortality rates at 30 days. Multivariate logistic regression models were used to adjust for the influence of age, gender, Injury Severity Score (ISS) and Glasgow Coma Score (GCS) on mortality. RESULTS 47,927 eligible patients presented to TARN hospitals during the study period. Sample demographics were: median age: 51.1 years (IQR=32.8-67.4); male 60% (n=28,694); median ISS 9 (IQR=8-10); median GCS 15 (IQR=15-15); and median SBP 135 mm Hg (IQR=120-152). We identified SBP< 110 mm Hg as a cut off for hypotension, where a significant increase in mortality was observed. Mortality rates doubled at < 100 mm Hg, tripled at < 90 mm Hg and were 5- to 6-fold at < 70 mm Hg, irrespective of age. CONCLUSION We recommend triaging adult blunt trauma patients with a SBP< 110 mm Hg to resuscitation areas within dedicated trauma units for close monitoring and appropriate management.
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Affiliation(s)
- Rebecca M Hasler
- Trauma Audit and Research Network (TARN), Health Sciences Research Group, School of Community Based Medicine, Manchester Academic Health Sciences Centre, University of Manchester, Salford Royal Hospital, Salford M6 8HD, UK.
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436
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Veljkovic D. Use fresh-frozen plasma in newborns, older infants and adolescents on the outcome of bleeding. ACTA ACUST UNITED AC 2011. [DOI: 10.1111/j.1751-2824.2011.01482.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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437
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Meyer MAS, Ostrowski SR, Windeløv NA, Johansson PI. Fibrinogen concentrates for bleeding trauma patients: what is the evidence? Vox Sang 2011; 101:185-90. [PMID: 21535437 DOI: 10.1111/j.1423-0410.2011.01478.x] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
INTRODUCTION A balanced transfusion of red blood cells, fresh frozen plasma and platelets are recommended for massively bleeding trauma patients. Fibrinogen concentrates could potentially lessen or replace the need for fresh frozen plasma and/or platelet transfusions. OBJECTIVE To provide a review of the literature covering the application of fibrinogen concentrates in trauma care. METHODS PubMed and Cochrane database search, 'fibrinogen' and ('concentrate' or 'trauma'), not 'congenital', 10 years. RESULTS Only four papers were identified. None were randomized controlled trials. The main conclusion of these papers was that administration of fibrinogen sometimes together with prothrombin complex concentrate might improve haemostasis in trauma patients resuscitated with synthetic colloids. CONCLUSION Evidence for the use of fibrinogen concentrate to trauma patients with massive bleeding is lacking. Well-designed prospective, randomized, double-blinded studies evaluating the effect of fibrinogen concentrate, as the only intervention, are urgently needed.
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Affiliation(s)
- M A S Meyer
- Section for Transfusion Medicine, Capital Regional Blood Bank, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.
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438
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Le ratio transfusionnel PFC/CGR 1/1 : un phénomène de mode basé sur des preuves ? ACTA ACUST UNITED AC 2011; 30:421-8. [DOI: 10.1016/j.annfar.2011.02.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2010] [Accepted: 02/09/2011] [Indexed: 11/22/2022]
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439
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Thorsen K, Ringdal KG, Strand K, Søreide E, Hagemo J, Søreide K. Clinical and cellular effects of hypothermia, acidosis and coagulopathy in major injury. Br J Surg 2011; 98:894-907. [PMID: 21509749 DOI: 10.1002/bjs.7497] [Citation(s) in RCA: 66] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/10/2011] [Indexed: 01/19/2023]
Abstract
BACKGROUND Hypothermia, acidosis and coagulopathy have long been considered critical combinations after severe injury. The aim of this review was to give a clinical update on this triad in severely injured patients. METHODS A non-systematic literature search on hypothermia, acidosis and coagulopathy after major injury was undertaken, with a focus on clinical data from the past 5 years. RESULTS Hypothermia (less than 35 °C) is reported in 1·6-13·3 per cent of injured patients. The occurrence of acidosis is difficult to estimate, but usually follows other physiological disturbances. Trauma-induced coagulopathy (TIC) has both endogenous and exogenous components. Endogenous acute traumatic coagulopathy is associated with shock and hypoperfusion. Exogenous effects of dilution from fluid resuscitation and consumption through bleeding and loss of coagulation factors further add to TIC. TIC is present in 10-34 per cent of injured patients, depending on injury severity, acidosis, hypothermia and hypoperfusion. More expedient detection of coagulopathy is needed. Thromboelastography may be a useful point-of-care measurement. Management of TIC is controversial, with conflicting reports on blood component therapy in terms of both outcome and ratios of blood products to other fluids, particularly in the context of civilian trauma. CONCLUSION The triad of hypothermia, acidosis and coagulopathy after severe trauma appears to be fairly rare but does carry a poor prognosis. Future research should define modes of early detection and targeted therapy.
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Affiliation(s)
- K Thorsen
- Department of Surgery, Stavanger University Hospital, Stavanger, Norway
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440
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Mitterlechner T, Innerhofer P, Streif W, Lödl M, Danninger T, Klima G, Hansson K, Fries D. Prothrombin complex concentrate and recombinant prothrombin alone or in combination with recombinant factor X and FVIIa in dilutional coagulopathy: a porcine model. J Thromb Haemost 2011; 9:729-37. [PMID: 21255250 DOI: 10.1111/j.1538-7836.2011.04211.x] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND This study was conducted to assess whether newly developed recombinant clotting factor concentrates enable the reversal of dilutional coagulopathy. METHODS In 50 anesthetized pigs, ~60% of the blood volume was withdrawn and replaced with hydroxyethyl starch. Pigs were randomized to receive either 200 mg kg(-1) fibrinogen (n = 10), fibrinogen and 35 IU kg(-1) prothrombin complex concentrate (PCC) (n = 10), fibrinogen and 4 mg kg(-1) recombinant human factor II (rhFII) concentrate (n = 10), fibrinogen and a three-factor combination (3F) of 4 mg kg(-1) rhFII, 0.006 mg kg(-1) recombinant human FVIIa and 0.32 mg kg(-1) recombinant human FX (n = 10), or saline (n = 10). Thereafter, a standardized liver laceration was performed to induce uncontrolled hemorrhage. Survival time and blood loss were determined, and standard coagulation tests and thrombelastometry were performed. RESULTS Fibrinogen combined with rhFII or PCC improved survival. Blood loss was significantly decreased in all groups as compared with the animals receiving saline. Clotting time was significantly shortened in the animals treated with fibrinogen and PCC, as well as in those treated with fibrinogen and 3F. One animal died after administration of fibrinogen and PCC. CONCLUSION Following hemodilution, a combination of fibrinogen and PCC, rhFII or 3F enhances coagulation and final clot strength. Mortality was reduced statistically significantly only in the animals treated with fibrinogen and rhFII or PCC, whereas administration of the combination of fibrinogen and PCC caused a fatal thromboembolic complication. The combination of fibrinogen and rhFII might be effective in reversing dilutional coagulopathy and may reduce blood loss in cases of dilutional coagulopathy.
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Affiliation(s)
- T Mitterlechner
- Department of Anesthesiology and Critical Care Medicine, Innsbruck Medical University, Innsbruck, Austria
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441
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Midwinter MJ, Woolley T. Resuscitation and coagulation in the severely injured trauma patient. Philos Trans R Soc Lond B Biol Sci 2011; 366:192-203. [PMID: 21149355 DOI: 10.1098/rstb.2010.0220] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Developments in the resuscitation of the severely injured trauma patient in the last decade have been through the increased understanding of the early pathophysiological consequences of injury together with some observations and experiences of recent casualties of conflict. In particular, the recognition of early derangements of haemostasis with hypocoagulopathy being associated with increased mortality and morbidity and the prime importance of tissue hypoperfusion as a central driver to this process in this population of patients has led to new resuscitation strategies. These strategies have focused on haemostatic resuscitation and the development of the ideas of damage control resuscitation and damage control surgery continuum. This in turn has led to a requirement to be able to more closely monitor the physiological status, of major trauma patients, including their coagulation status, and react in an anticipatory fashion.
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Affiliation(s)
- Mark J Midwinter
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, UK
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442
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Bonnet MP, Tesnière A, Mignon A. [Transfusion for post-partum haemorrhage: what's new in 2011?]. Transfus Clin Biol 2011; 18:129-32. [PMID: 21420343 DOI: 10.1016/j.tracli.2011.02.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2011] [Accepted: 02/12/2011] [Indexed: 11/28/2022]
Abstract
Post-partum haemorrhage is the first cause of maternal death in France. In addition to the treatment of the cause, its treatment consists in the association of procoagulant drugs and blood transfusion. At risk situations requiring blood transfusion are well identified. However, they are not found in one third of the actually transfused patients. Therefore, for all deliveries, the medical team should be prepared to face a post-partum haemorrhage and to transfuse. As post-partum haemorrhage onset is most frequently acute, it is rare to be able to base the transfusion decision on biological parameters such as haemoglobin concentration and / or coagulation tests. The recently defined policy of early use of fresh frozen plasma in order to better control the coagulopathy frequently associated with a large haemorrhage has not been established in obstetrical situations. However, it is recommended to apply it in large volume post-partum haemorrhage, with a fresh frozen plasma/red blood cells concentrate ratio between 1/1 and 1/2. The post-partum haemorrhage treatment may benefit from the use of drugs, the most frequently used being antifibrinolytics, such as tranexemic acid, which help to reduce the magnitude of post-partum haemorrhage. Conversely, activated factor VII use should be restricted to situations where all other conventional treatments failed, as a last attempt to avoid hysterectomy.
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Affiliation(s)
- M-P Bonnet
- Anesthésie-réanimation chirurgicale, maternité Port-Royal, hôpital Cochin, GHU Ouest, AP-HP, 27, rue du Faubourg-Saint-Jacques, 75014 Paris, France
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443
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Curry N, Hopewell S, Dorée C, Hyde C, Brohi K, Stanworth S. The acute management of trauma hemorrhage: a systematic review of randomized controlled trials. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2011; 15:R92. [PMID: 21392371 PMCID: PMC3219356 DOI: 10.1186/cc10096] [Citation(s) in RCA: 138] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/18/2010] [Revised: 12/15/2010] [Accepted: 03/09/2011] [Indexed: 12/13/2022]
Abstract
Introduction Worldwide, trauma is a leading cause of death and disability. Haemorrhage is responsible for up to 40% of trauma deaths. Recent strategies to improve mortality rates have focused on optimal methods of early hemorrhage control and correction of coagulopathy. We undertook a systematic review of randomized controlled trials (RCT) which evaluated trauma patients with hemorrhagic shock within the first 24 hours of injury and appraised how the interventions affected three outcomes: bleeding and/or transfusion requirements; correction of trauma induced coagulopathy and mortality. Methods Comprehensive searches were performed of MEDLINE, EMBASE, CENTRAL (The Cochrane Library Issue 7, 2010), Current Controlled Trials, ClinicalTrials.gov, the World Health Organization International Clinical Trials Registry Platform (ICTRP) and the National Health Service Blood and Transplant Systematic Review Initiative (NHSBT SRI) RCT Handsearch Database. Results A total of 35 RCTs were identified which evaluated a wide range of clinical interventions in trauma hemorrhage. Many of the included studies were of low methodological quality and participant numbers were small. Bleeding outcomes were reported in 32 studies; 7 reported significantly reduced transfusion use following a variety of clinical interventions, but this was not accompanied by improved survival. Minimal information was found on traumatic coagulopathy across the identified RCTs. Overall survival was improved in only three RCTs: two small studies and a large study evaluating the use of tranexamic acid. Conclusions Despite 35 RCTs there has been little improvement in outcomes over the last few decades. No clear correlation has been demonstrated between transfusion requirements and mortality. The global trauma community should consider a coordinated and strategic approach to conduct well designed studies with pragmatic endpoints.
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Affiliation(s)
- Nicola Curry
- NHS Blood and Transplant, Oxford Radcliffe Hospitals NHS Trust and University of Oxford, Headley Way, Oxford, OX3 9BQ, UK.
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444
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Schöchl H, Nienaber U, Maegele M, Hochleitner G, Primavesi F, Steitz B, Arndt C, Hanke A, Voelckel W, Solomon C. Transfusion in trauma: thromboelastometry-guided coagulation factor concentrate-based therapy versus standard fresh frozen plasma-based therapy. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2011; 15:R83. [PMID: 21375741 PMCID: PMC3219338 DOI: 10.1186/cc10078] [Citation(s) in RCA: 299] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/27/2010] [Revised: 12/11/2010] [Accepted: 03/04/2011] [Indexed: 01/04/2023]
Abstract
INTRODUCTION Thromboelastometry (TEM)-guided haemostatic therapy with fibrinogen concentrate and prothrombin complex concentrate (PCC) in trauma patients may reduce the need for transfusion of red blood cells (RBC) or platelet concentrate, compared with fresh frozen plasma (FFP)-based haemostatic therapy. METHODS This retrospective analysis compared patients from the Salzburg Trauma Centre (Salzburg, Austria) treated with fibrinogen concentrate and/or PCC, but no FFP (fibrinogen-PCC group, n = 80), and patients from the TraumaRegister DGU receiving ≥ 2 units of FFP, but no fibrinogen concentrate/PCC (FFP group, n = 601). Inclusion criteria were: age 18-70 years, base deficit at admission ≥ 2 mmol/L, injury severity score (ISS) ≥ 16, abbreviated injury scale for thorax and/or abdomen and/or extremity ≥ 3, and for head/neck < 5. RESULTS For haemostatic therapy in the emergency room and during surgery, the FFP group (ISS 35.5 ± 10.5) received a median of 6 units of FFP (range: 2, 51), while the fibrinogen-PCC group (ISS 35.2 ± 12.5) received medians of 6 g of fibrinogen concentrate (range: 0, 15) and 1200 U of PCC (range: 0, 6600). RBC transfusion was avoided in 29% of patients in the fibrinogen-PCC group compared with only 3% in the FFP group (P< 0.001). Transfusion of platelet concentrate was avoided in 91% of patients in the fibrinogen-PCC group, compared with 56% in the FFP group (P< 0.001). Mortality was comparable between groups: 7.5% in the fibrinogen-PCC group and 10.0% in the FFP group (P = 0.69). CONCLUSIONS TEM-guided haemostatic therapy with fibrinogen concentrate and PCC reduced the exposure of trauma patients to allogeneic blood products.
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Affiliation(s)
- Herbert Schöchl
- Ludwig Boltzmann Institute of Experimental and Clinical Traumatology, Donaueschingenstrasse 13, A-1200 Vienna, Austria
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445
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Surgical intensive care unit--the trauma surgery perspective. Langenbecks Arch Surg 2011; 396:429-46. [PMID: 21369845 DOI: 10.1007/s00423-011-0765-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2011] [Accepted: 02/21/2011] [Indexed: 01/04/2023]
Abstract
PURPOSE This review addresses and summarizes the key issues and unique specific intensive care treatment of adult patients from the trauma surgery perspective. MATERIALS AND METHODS The cornerstones of successful surgical intensive care management are fluid resuscitation, transfusion protocol and extracorporeal organ replacement therapies. The injury-type specific complications and unique pathophysiologic regulatory mechanisms of the traumatized patients influencing the critical care treatment are discussed. CONCLUSIONS Furthermore, the fundamental knowledge of the injury severity, understanding of the trauma mechanism, surgical treatment strategies and specific techniques of surgical intensive care are pointed out as essentials for a successful intensive care therapy.
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446
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Reed MJ, Lone N, Walsh TS. Resuscitation of the trauma patient: tell me a trigger for early haemostatic resuscitation please! CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2011; 15:126. [PMID: 21371347 PMCID: PMC3219305 DOI: 10.1186/cc10014] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
The management of trauma-related coagulopathy and haemorrhage is changing from a reactive strategy to a proactive early intervention with blood products and haemostatic agents. Although major haemorrhage and massive transfusion are associated with higher mortality, the pattern of this association with modern trauma care is poorly described. In addition, early predictors of massive transfusion, which might trigger a proactive haemostatic resuscitation strategy, are not currently available. We review recent literature relating to predictors of massive transfusions and the relationship between transfusion and mortality.
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Affiliation(s)
- Matthew J Reed
- Emergency Department, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh EH16 4SA, UK
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447
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Gopalan PD. What's new in critical care? SOUTHERN AFRICAN JOURNAL OF ANAESTHESIA AND ANALGESIA 2011. [DOI: 10.1080/22201173.2011.10872777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
- PD Gopalan
- Nelson R Mandela School of Medicine, University of Kwazulu-Natal
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448
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Hanke AA, Dellweg C, Schöchl H, Weber CF, Jüttner B, Johanning K, Görlinger K, Rahe-Meyer N, Kienbaum P. Potential of whole blood coagulation reconstitution by desmopressin and fibrinogen under conditions of hypothermia and acidosis – anin vitrostudy using rotation thrombelastometry. Scandinavian Journal of Clinical and Laboratory Investigation 2011; 71:292-8. [DOI: 10.3109/00365513.2011.561870] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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449
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Lier H, Böttiger BW, Hinkelbein J, Krep H, Bernhard M. Coagulation management in multiple trauma: a systematic review. Intensive Care Med 2011; 37:572-82. [PMID: 21318436 DOI: 10.1007/s00134-011-2139-y] [Citation(s) in RCA: 88] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2010] [Accepted: 01/21/2011] [Indexed: 01/17/2023]
Abstract
PURPOSE The management of trauma patients suffering from active bleeding has improved with a better understanding of trauma-induced coagulopathy. The aim of this manuscript is to give recommendations for coagulation management. METHODS A systematic literature search in the PubMed database was performed for articles published between January 2000 and August 2009. A total of 230 articles were included in the present systematic review. CONCLUSIONS The "coagulopathy of trauma" is a discrete disease which has a decisive influence on survival. Diagnosis and therapy of deranged coagulation should start immediately after admission to the emergency department. A specific protocol for massive transfusion should be introduced and continued. Loss of body temperature should be prevented and treated. Acidaemia should be prevented and treated by appropriate shock therapy. If massive transfusion is performed using fresh frozen plasma (FFP), a ratio of FFP to pRBC (packed red blood cells) of 1:2-1:1 should be achieved. Fibrinogen should be substituted at levels of <1.5 g/L. For patients suffering from active bleeding, permissive hypotension (i.e. mean arterial pressure ~65 mmHg) may be aimed for until surgical cessation of bleeding. This option is contraindicated in injuries of the central nervous system and in patients with coronary heart disease, or with known hypertension. Thrombelastography or -metry may be performed to guide coagulation diagnosis and substitution. Hypocalcaemia <0.9 mmol/L should be avoided and may be treated. For actively bleeding patients, pRBC may be given at haemoglobin <10 g/L (6.2 mmol/L) and haematocrit may be targeted at 30%.
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Affiliation(s)
- Heiko Lier
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Cologne, Cologne, Germany.
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450
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Five Drivers Shifting the Paradigm from Product‐Focused Transfusion Practice to Patient Blood Management. Oncologist 2011; 16 Suppl 3:3-11. [DOI: 10.1634/theoncologist.2011-s3-3] [Citation(s) in RCA: 82] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
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