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Fujiwara G, Okada Y, Ishii W, Echigo T, Shiomi N, Ohtsuru S. High Fresh Frozen Plasma to Red Blood Cell Ratio and Survival Outcomes in Blunt Trauma. JAMA Surg 2024:2822573. [PMID: 39167374 PMCID: PMC11339704 DOI: 10.1001/jamasurg.2024.3097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Accepted: 06/11/2024] [Indexed: 08/23/2024]
Abstract
Importance Current trauma-care protocols advocate early administration of fresh frozen plasma (FFP) in a ratio close to 1:1 with red blood cells (RBCs) to manage trauma-induced coagulopathy in patients with severe blunt trauma. However, the benefits of a higher FFP to RBC ratio have not yet been established. Objective To investigate the effectiveness of a high FFP to RBC transfusion ratio in the treatment of severe blunt trauma and explore the nonlinear relationship between the ratio of blood products used and patient outcomes. Design, Setting, and Participants This was a multicenter cohort study retrospectively analyzing data from the Japan Trauma Data Bank, including adult patients with severe blunt trauma without severe head injury (Injury Severity Score ≥16 and head Abbreviated Injury Scale <3) between 2019 and 2022. Exposures Patients were categorized into 2 groups based on the ratio of FFP to RBC: the high-FFP group (ratio >1) and the low-FFP group (ratio ≤1). Main Outcomes and Measures All-cause in-hospital mortality was the primary outcome. Additionally, the occurrence of transfusion-related adverse events was evaluated. Results Among the 1954 patients (median [IQR] age, 61 [41-77] years; 1243 male [63.6%]) analyzed, 976 (49.9%) had a high FFP to RBC ratio. Results from logistic regression, weighted by inverse probability treatment weighting, demonstrated an association between the group with a high-FFP ratio and lower in-hospital mortality (odds ratio, 0.73; 95% CI, 0.56-0.93) compared with a low-FFP ratio. Nonlinear trends were noted, suggesting a potential ceiling effect on transfusion benefits. Conclusions and Relevance In this cohort study, a high FFP to RBC ratio was associated with favorable survival in patients with severe blunt trauma. These outcomes highlight the importance of revising the current transfusion protocols to incorporate a high FFP to RBC ratio, warranting further research on optimal patient treatment.
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Affiliation(s)
- Gaku Fujiwara
- Department of Management of Technology and Intellectual Property, School of Public Health, Kyoto University, Kyoto, Japan
- Department of Pharmacoepidemiology, School of Public Health, Kyoto University, Kyoto, Japan
- Department of Neurosurgery, Japanese Red Cross Society Kyoto Daini Hospital, Kyoto, Japan
- Department of Primary Care and Emergency Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Yohei Okada
- Department of Preventive Services, School of Public Health, Kyoto University. Yoshidahonmachi, Sakyo-ku, Kyoto, Japan
- Health Services and Systems Research, Duke-NUS Medical School, National University of Singapore, Singapore
| | - Wataru Ishii
- Department of Emergency Medicine and Critical Care, Japanese Red Cross Society Kyoto Daini Hospital, Kyoto, Japan
| | - Tadashi Echigo
- Department of Emergency and Critical Care Medicine, Saiseikai Shiga Hospital, Shiga, Japan
| | - Naoto Shiomi
- Department of Critical and Intensive Care Medicine, Shiga University of Medical Science, Shiga, Japan
| | - Shigeru Ohtsuru
- Department of Primary Care and Emergency Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
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Ohbe H, Tagami T, Endo A, Miyata S, Matsui H, Fushimi K, Kushimoto S, Yasunaga H. Trends in massive transfusion practice for trauma in Japan from 2011 to 2020: a nationwide inpatient database study. J Intensive Care 2023; 11:46. [PMID: 37853484 PMCID: PMC10585788 DOI: 10.1186/s40560-023-00685-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Accepted: 08/20/2023] [Indexed: 10/20/2023] Open
Abstract
BACKGROUND Previous studies have reported conflicting results regarding fresh frozen plasma (FFP)-to-red blood cell (RBC) ratio and platelet-to-RBC ratio on outcomes for massive transfusion for trauma. Moreover, nationwide data on massive transfusion practices for trauma in the real-world clinical setting are scarce. This study aimed to examine the nationwide practice patterns and trends in massive transfusion for trauma in Japan using a national administrative, inpatient database. METHOD We identified patients who underwent emergency hospitalization for trauma and received massive transfusion, defined as administration of at least 20 units of RBC within the first 2 days of admission, using the nationwide inpatient database, which covers approximately 90% of all tertiary emergency hospitals in Japan, between 2011 and 2020. Trends in the incidence and practice patterns of massive transfusion were described by calendar year. The association of practice patterns with mortality or adverse events was tested. RESULTS A total of 3,530,846 trauma hospitalizations were identified, of which 5247 (0.15%) received massive transfusion. A significant declining trend was observed in the incidence of massive transfusion in trauma hospitalizations from 0.24% in 2011 to 0.10% in 2020 (P for trend < 0.001). The FFP-to-RBC ratio rose significantly from 0.77 in 2011 to 1.08 in 2020 (P for trend < 0.001), while the platelet-to-RBC ratio remained virtually unchanged from 0.71 in 2011 to 0.78 in 2020 (P for trend 0.060). Massive transfusion with lower FFP-to-RBC (< 0.75) and platelets-to-RBC ratio (< 1.00) were associated with increased in-hospital mortality compared with those ≥ 1.00, while there were linear increases in adverse events with increasing FFP and platelets ratios. CONCLUSIONS This study demonstrated a declining trend in the incidence and a rise in higher FFP-to-RBC ratios in massive transfusion in association with patient outcomes for trauma from 2011 to 2020 in Japan.
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Affiliation(s)
- Hiroyuki Ohbe
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan.
- Division of Emergency and Critical Care Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan.
| | - Takashi Tagami
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
- Department of Emergency and Critical Care Medicine, Nippon Medical School Musashikosugi Hospital, Kawasaki, Kanagawa, Japan
| | - Akira Endo
- Department of Acute Critical Care Medicine, Tsuchiura Kyodo General Hospital, Tsuchiura, Japan
| | - Shigeki Miyata
- Central Blood Institute, Blood Service Headquarters, Japanese Red Cross Society, Tokyo, Japan
| | - Hiroki Matsui
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
| | - Kiyohide Fushimi
- Department of Health Policy and Informatics, Tokyo Medical and Dental University Graduate School, Tokyo, Japan
| | - Shigeki Kushimoto
- Division of Emergency and Critical Care Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Hideo Yasunaga
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
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David JS, James A, Orion M, Selves A, Bonnet M, Glasman P, Vacheron CH, Raux M. Thromboelastometry-guided haemostatic resuscitation in severely injured patients: a propensity score-matched study. Crit Care 2023; 27:141. [PMID: 37055832 PMCID: PMC10103518 DOI: 10.1186/s13054-023-04421-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Accepted: 03/30/2023] [Indexed: 04/15/2023] Open
Abstract
BACKGROUND To accelerate the diagnosis and treatment of trauma-induced coagulopathy (TIC), viscoelastic haemostatic assays (VHA) are increasingly used worldwide, although their value is still debated, with a recent randomised trial showing no improvement in outcome. The objective of this retrospective study was to compare 2 cohorts of injured patients in which TIC was managed with either a VHA-based algorithm or a conventional coagulation test (CCT)-based algorithm. METHODS Data were retrieved from 2 registries and patients were included in the study if they received at least 1 unit of red blood cell in the first 24 h after admission. A propensity score, including sex, age, blunt vs. penetrating, systolic blood pressure, GCS, ISS and head AIS, admission lactate and PTratio, tranexamic acid administration, was then constructed. Primary outcome was the proportion of subjects who were alive and free of massive transfusion (MT) at 24 h after injury. We also compared the cost for blood products and coagulation factors. RESULTS From 2012 to 2019, 7250 patients were admitted in the 2 trauma centres, and among these 624 were included in the study (CCT group: 380; VHA group: 244). After propensity score matching, 215 patients remained in each study group without any significant difference in demographics, vital signs, injury severity, or laboratory analysis. At 24 h, more patients were alive and free of MT in the VHA group (162 patients, 75%) as compared to the CCT group (112 patients, 52%; p < 0.01) and fewer patients received MT (32 patients, 15% vs. 91 patients, 42%, p < 0.01). However, no significant difference was observed for mortality at 24 h (odds ratio 0.94, 95% CI 0.59-1.51) or survival at day 28 (odds ratio 0.87, 95% CI 0.58-1.29). Overall cost of blood products and coagulation factors was dramatically reduced in the VHA group as compared to the CCT group (median [interquartile range]: 2357 euros [1108-5020] vs. 4092 euros [2510-5916], p < 0.001). CONCLUSIONS A VHA-based strategy was associated with an increase of the number of patients alive and free of MT at 24 h together with an important reduction of blood product use and associated costs. However, that did not translate into an improvement in mortality.
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Affiliation(s)
- Jean-Stéphane David
- Department of Anesthesia and Intensive Care, Groupe Hospitalier Sud, Hospices Civils de Lyon (HCL), Pierre Bénite Cedex, France.
- Research on Healthcare Performance (RESHAPE), INSERM U1290, University Claude Bernard Lyon 1, Lyon, France.
| | - Arthur James
- GRC 29, AP-HP, DMU DREAM, Department of Anaesthesia and Intensive Care, Pitié-Salpêtrière Hospital, Sorbonne University, Paris, France
| | - Maxime Orion
- Department of Anesthesia and Intensive Care, Groupe Hospitalier Sud, Hospices Civils de Lyon (HCL), Pierre Bénite Cedex, France
| | - Agathe Selves
- GRC 29, AP-HP, DMU DREAM, Department of Anaesthesia and Intensive Care, Pitié-Salpêtrière Hospital, Sorbonne University, Paris, France
| | - Mélody Bonnet
- Department of Anesthesia and Intensive Care, Groupe Hospitalier Sud, Hospices Civils de Lyon (HCL), Pierre Bénite Cedex, France
| | - Pauline Glasman
- GRC 29, AP-HP, DMU DREAM, Department of Anaesthesia and Intensive Care, Pitié-Salpêtrière Hospital, Sorbonne University, Paris, France
| | - Charles-Hervé Vacheron
- Department of Anesthesia and Intensive Care, Groupe Hospitalier Sud, Hospices Civils de Lyon (HCL), Pierre Bénite Cedex, France
- Biometrics and Evolutionary Biology Laboratory, Biostatistics-Health Team, HCL, Villeurbanne, France
- Division of Public Health, Department of Biostatistics and Bioinformatics, Lyon, France
| | - Mathieu Raux
- INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale Et Clinique; AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, Site Pitié-Salpêtrière, Département d'Anesthésie Réanimation, Sorbonne Université, Paris, France
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Balancing enrollment and mortality in hemorrhage control trials: A secondary analysis of the PROPPR trial. J Trauma Acute Care Surg 2022; 92:1054-1060. [PMID: 35609292 DOI: 10.1097/ta.0000000000003550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Designing clinical trials on hemorrhage control requires carefully balancing the need for high enrollment numbers with the need of focusing on the sickest patients. The Pragmatic Randomized Optimal Platelet and Plasma Ratios (PROPPR) trial enrolled patients within 2 hours of arrival to the emergency department for a trial of injured patients at risk for massive transfusion. We conducted a secondary analysis to determine how time-to-randomization affected patient outcomes and the balance between enrollment and mortality. METHODS Patients from the Pragmatic Randomized Optimal Platelet and Plasma Ratios trial were compared based on 30-minute time to randomization intervals. Outcomes included 24-hour and 30-day mortality, time to hemostasis, adverse events, and operative procedures. Additional analyses were conducted based on treatment arm allocation, mechanism of injury, and variation in start time (arrival vs. randomization). RESULTS Randomization within 30 minutes of arrival was associated with higher injury severity (median Injury Severity Score, 29 vs. 26 overall; p < 0.01), lower systolic blood pressure (median, 91 vs. 102 mm Hg overall; p < 0.01), and increased penetrating mechanism (50% vs. 47% overall; p < 0.01). Faster time-to-randomization was associated with increased 24-hour (20% for 0- to 30 minute entry, 9% for 31-minute to 60-minute entry, 10% for 61-minute to 90-minute entry, 0% for 91-minute to 120-minute entry; p < 0.01) and 30-day mortality (p < 0.01). There were no significant associations between time-to-randomization and adverse event occurrence, operative interventions, or time to hemostasis. CONCLUSION Increasing time to randomization in this large multicenter randomized trial was associated with increased survival. Fastest randomization (within 0-30 minutes) was associated with highest 24-hour and 30-day mortality, but only 57% of patients were enrolled within this timeframe. Only 3% of patients were enrolled within the last 30-minute window (91-120 minutes), with none of them dying within the first 24 hours. For a more optimal balance between enrollment and mortality, investigators should consider shortening the time to randomization when planning future clinical trials of hemorrhage control interventions. LEVEL OF EVIDENCE Prognostic and Epidemiologic; Level II.
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Hamada SR, Garrigue D, Nougue H, Meyer A, Boutonnet M, Meaudre E, Culver A, Gaertner E, Audibert G, Vigué B, Duranteau J, Godier A, Abback PS, Audibert G, Gauss T, Geeraerts T, Harrois A, Langeron O, Leone M, Pottecher J, Stecken L, Hanouz JL. Impact of platelet transfusion on outcomes in trauma patients. Crit Care 2022; 26:49. [PMID: 35189930 PMCID: PMC8862339 DOI: 10.1186/s13054-022-03928-y] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Accepted: 02/10/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Trauma-induced coagulopathy includes thrombocytopenia and platelet dysfunction that impact patient outcome. Nevertheless, the role of platelet transfusion remains poorly defined. The aim of the study was 1/ to evaluate the impact of early platelet transfusion on 24-h all-cause mortality and 2/ to describe platelet count at admission (PCA) and its relationship with trauma severity and outcome.
Methods
Observational study carried out on a multicentre prospective trauma registry. All adult trauma patients directly admitted in participating trauma centres between May 2011 and June 2019 were included. Severe haemorrhage was defined as ≥ 4 red blood cell units within 6 h and/or death from exsanguination. The impact of PCA and early platelet transfusion (i.e. within the first 6 h) on 24-h all-cause mortality was assessed using uni- and multivariate logistic regression.
Results
Among the 19,596 included patients, PCA (229 G/L [189,271]) was associated with coagulopathy, traumatic burden, shock and bleeding severity. In a logistic regression model, 24-h all-cause mortality increased by 37% for every 50 G/L decrease in platelet count (OR 0.63 95% CI 0.57–0.70; p < 0.001). Regarding patients with severe hemorrhage, platelets were transfused early for 36% of patients. Early platelet transfusion was associated with a decrease in 24-h all-cause mortality (versus no or late platelets): OR 0.52 (95% CI 0.34–0.79; p < 0.05).
Conclusions
PCA, although mainly in normal range, was associated with trauma severity and coagulopathy and was predictive of bleeding intensity and outcome. Early platelet transfusion within 6 h was associated with a decrease in mortality in patients with severe hemorrhage. Future studies are needed to determine which doses of platelet transfusion will improve outcomes after major trauma.
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Lu CH, Zheng ZH, Yeh TT, Yeh CC. Practice algorithm of rotational thromboelastometry-guided bleeding management in trauma and orthopedic surgery. JOURNAL OF MEDICAL SCIENCES 2022. [DOI: 10.4103/jmedsci.jmedsci_122_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Rijnhout TWH, Duijst J, Noorman F, Zoodsma M, van Waes OJF, Verhofstad MHJ, Hoencamp R. Platelet to erythrocyte transfusion ratio and mortality in massively transfused trauma patients. A systematic review and meta-analysis. J Trauma Acute Care Surg 2021; 91:759-771. [PMID: 34225351 DOI: 10.1097/ta.0000000000003323] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Platelet transfusion during major hemorrhage is important and often embedded in massive transfusion protocols. However, the optimal ratio of platelets to erythrocytes (platelet-rich plasma [PLT]/red blood cell [RBC] ratio) remains unclear. We hypothesized that high PLT/RBC ratios, as compared with low PLT/RBC ratios, are associated with improved survival in patients requiring massive transfusion. METHODS Four databases (Pubmed, CINAHL, EMBASE, and Cochrane) were systematically screened for literatures published until January 21, 2021, to determine the effect of PLT/RBC ratio on the primary outcome measure mortality at 1 hour to 6 hours and 24 hours and at 28 days to 30 days. Studies comparing various PLT/RBC ratios were included in the meta-analysis. Secondary outcomes included intensive care unit length of stay and in-hospital length of stay and total blood component use. The study protocol was registered in PROSPERO under number CRD42020165648. RESULTS The search identified a total of 8903 records. After removing the duplicates and second screening of title, abstract, and full text, a total of 59 articles were included in the analysis. Of these articles, 12 were included in the meta-analysis. Mortality at 1 hour to 6 hours, 24 hours, and 28 days to 30 days was significantly lower for high PLT/RBC ratios as compared with low PLT/RBC ratios. CONCLUSION Higher PLT/RBC ratios are associated with significantly lower 1-hour to 6-hour, 24-hour, 28-day to 30-day mortalities as compared with lower PLT/RBC ratios. The optimal PLT/RBC ratio for massive transfusion in trauma patients is approximately 1:1. LEVEL OF EVIDENCE Systematic review and meta-analysis, therapeutic Level III.
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Affiliation(s)
- Tim W H Rijnhout
- From the Department of Surgery (T.W.H.R., R.H.), Alrijne Medical Center, Leiderdorp; Trauma Research Unit, Department of Surgery (T.W.H.R., O.J.F.vW., M.H.J.V., R.H.), Erasmus MC, University Medical Center Rotterdam, Rotterdam; Department of Anesthesiology and Pain Medicine (J.D.), Maastricht University Medical Center+, Maastricht; Military Blood Bank (F.N., M.Z.), Defense Healthcare Organization (R.H.), Ministry of Defense, Utrecht; and Department of Surgery (R.H.), Leiden University Medical Center, Leiden, The Netherlands
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Chou SH, Lin SY, Wu MH, Tien YC, Jong YJ, Liang WC, Lu YM, Shih CL, Lu CC. Intravenous Tranexamic Acid Reduces Blood Loss and Transfusion Volume in Scoliosis Surgery for Spinal Muscular Atrophy: Results of a 20-Year Retrospective Analysis. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18199959. [PMID: 34639259 PMCID: PMC8507662 DOI: 10.3390/ijerph18199959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Revised: 09/17/2021] [Accepted: 09/19/2021] [Indexed: 11/16/2022]
Abstract
Intravenous tranexamic acid (TXA) has been administered to reduce intraoperative blood loss in scoliosis surgery. However, the therapeutic effect of TXA on spinal muscular atrophy (SMA) scoliosis surgery is not well demonstrated. Therefore, this study aimed to assess the efficacy of intravenous TXA in SMA scoliosis surgery. From December 1993 to August 2020, 30 SMA patients who underwent scoliosis surgery (posterior fusion with fusion level of thoracic second or third to pelvis) were retrospectively enrolled and divided into the TXA group and non-TXA (control) group, with 15 patients in each group. Survey parameters were the amount of blood loss, blood transfusion, crystalloid transfusion volume, intubation time, and associated pulmonary complications (including pneumonia, pulmonary edema, and pulmonary atelectasis). The TXA group had significantly lesser blood loss than the control group (p = 0.011). Compared with the control group, the TXA group had significantly lower blood transfusion (p < 0.001), crystalloid volume (p = 0.041), and total transfusion volume (p = 0.005). In addition, the TXA group had fewer postoperative pulmonary complications, and patients with pulmonary complications were associated with a higher relative crystalloid volume and relative total transfusion volume (p = 0.003 and 0.022, respectively). In conclusion, TXA can be effective in reducing intraoperative blood loss and crystalloid fluid transfusions during scoliosis surgery in SMA patients, which may aid in reducing postoperative pulmonary complications.
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Affiliation(s)
- Shih-Hsiang Chou
- Department of Orthopaedic Surgery, Kaohsiung Medical University Hospital, Kaohsiung 807, Taiwan; (S.-H.C.); (S.-Y.L.); (Y.-C.T.); (Y.-M.L.)
- Orthopaedic Research Centre, Kaohsiung Medical University, Kaohsiung 807, Taiwan
- Regenerative Medicine and Cell Therapy Research Center, Kaohsiung Medical University, Kaohsiung 807, Taiwan
- Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung 807, Taiwan
| | - Sung-Yen Lin
- Department of Orthopaedic Surgery, Kaohsiung Medical University Hospital, Kaohsiung 807, Taiwan; (S.-H.C.); (S.-Y.L.); (Y.-C.T.); (Y.-M.L.)
- Orthopaedic Research Centre, Kaohsiung Medical University, Kaohsiung 807, Taiwan
- Regenerative Medicine and Cell Therapy Research Center, Kaohsiung Medical University, Kaohsiung 807, Taiwan
- Department of Orthopaedics, School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung 807, Taiwan
| | - Meng-Huang Wu
- Department of Orthopedics, Taipei Medical University Hospital, Taipei 11031, Taiwan;
- Department of Orthopaedics, School of Medicine, College of Medicine, Taipei Medical University, Taipei 11031, Taiwan
| | - Yin-Chun Tien
- Department of Orthopaedic Surgery, Kaohsiung Medical University Hospital, Kaohsiung 807, Taiwan; (S.-H.C.); (S.-Y.L.); (Y.-C.T.); (Y.-M.L.)
- Department of Orthopaedics, School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung 807, Taiwan
| | - Yuh-Jyh Jong
- Department of Pediatrics, Kaohsiung Medical University Hospital, Kaohsiung 807, Taiwan; (Y.-J.J.); (W.-C.L.)
- Department of Pediatrics, School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung 807, Taiwan
- Graduate Institute of Clinical Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung 807, Taiwan
- Department of Laboratory Medicine, Kaohsiung Medical University Hospital, Kaohsiung 807, Taiwan
| | - Wen-Chen Liang
- Department of Pediatrics, Kaohsiung Medical University Hospital, Kaohsiung 807, Taiwan; (Y.-J.J.); (W.-C.L.)
- Department of Pediatrics, School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung 807, Taiwan
| | - Yen-Mou Lu
- Department of Orthopaedic Surgery, Kaohsiung Medical University Hospital, Kaohsiung 807, Taiwan; (S.-H.C.); (S.-Y.L.); (Y.-C.T.); (Y.-M.L.)
- Department of Orthopaedics, School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung 807, Taiwan
| | - Chia-Lung Shih
- Clinical Medicine Research Center, Ditmanson Medical Foundation Chia-Yi Christian Hospital, Chia-Yi City 600, Taiwan;
| | - Cheng-Chang Lu
- Department of Orthopaedic Surgery, Kaohsiung Medical University Hospital, Kaohsiung 807, Taiwan; (S.-H.C.); (S.-Y.L.); (Y.-C.T.); (Y.-M.L.)
- Orthopaedic Research Centre, Kaohsiung Medical University, Kaohsiung 807, Taiwan
- Regenerative Medicine and Cell Therapy Research Center, Kaohsiung Medical University, Kaohsiung 807, Taiwan
- Department of Orthopaedics, School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung 807, Taiwan
- Department of Orthopaedics, Kaohsiung Municipal Siaogang Hospital, Kaohsiung Medical University, Kaohsiung 812, Taiwan
- Correspondence:
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Vulliamy P, Kornblith LZ, Kutcher ME, Cohen MJ, Brohi K, Neal MD. Alterations in platelet behavior after major trauma: adaptive or maladaptive? Platelets 2021; 32:295-304. [PMID: 31986948 PMCID: PMC7382983 DOI: 10.1080/09537104.2020.1718633] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Revised: 01/01/2020] [Accepted: 01/14/2020] [Indexed: 12/14/2022]
Abstract
Platelets are damage sentinels of the intravascular compartment, initiating and coordinating the primary response to tissue injury. Severe trauma and hemorrhage induce profound alterations in platelet behavior. During the acute post-injury phase, platelets develop a state of impaired ex vivo agonist responsiveness independent of platelet count, associated with systemic coagulopathy and mortality risk. In patients surviving the initial insult, platelets become hyper-responsive, associated with increased risk of thrombotic events. Beyond coagulation, platelets constitute part of a sterile inflammatory response to injury: both directly through release of immunomodulatory molecules, and indirectly through modifying behavior of innate leukocytes. Both procoagulant and proinflammatory aspects have implications for secondary organ injury and multiple-organ dysfunction syndromes. This review details our current understanding of adaptive and maladaptive alterations in platelet biology induced by severe trauma, mechanisms underlying these alterations, potential platelet-focused therapies, and existing knowledge gaps and their research implications.
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Affiliation(s)
- Paul Vulliamy
- Centre for Trauma Sciences, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, E1 2AT, United Kingdom
| | - Lucy Z. Kornblith
- Department of Surgery, Zuckerberg San Francisco General Hospital and the University of California, San Francisco, San Francisco, California
| | - Matthew E. Kutcher
- Division of Trauma, Critical Care, and Acute Care Surgery, University of Mississippi Medical Center, Jackson, Mississippi
| | - Mitchell J. Cohen
- Department of Surgery, University of Colorado, Aurora, Colorado
- Ernest E Moore Shock Trauma Center at Denver Health, Denver, Colorado
| | - Karim Brohi
- Centre for Trauma Sciences, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, E1 2AT, United Kingdom
| | - Matthew D. Neal
- Division of Trauma and Acute Care Surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, PA
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Johansson PI, Eriksen CF, Schmal H, Gaarder C, Pall M, Henriksen HH, Bovbjerg P, Lange T, Næss PA, Nielsen C, Kirkegaard H, Stensballe J. Efficacy and safety of iloprost in trauma patients with haemorrhagic shock-induced endotheliopathy-Protocol for the multicentre randomized, placebo-controlled, blinded, investigator-initiated shine-trauma trial. Acta Anaesthesiol Scand 2021; 65:551-557. [PMID: 33393084 PMCID: PMC7986208 DOI: 10.1111/aas.13776] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Accepted: 12/07/2020] [Indexed: 12/18/2022]
Abstract
BACKGROUND Traumatic injury accounts for 800 000 deaths in the European Union annually. The main causes of deaths in trauma patients are exsanguination and multiple organ failure (MOF). We have studied >1000 trauma patients and identified shock-induced endotheliopathy (SHINE), the pathophysiological mechanism responsible for MOF and high mortality. Pilot studies indicate that low-dose iloprost (1 ng/kg/min) improves endothelial functionality in critically ill patients suggesting this intervention may improve patient outcome in traumatic SHINE. MATERIAL AND METHODS This is a multicentre, randomized, blinded clinical investigator-initiated phase 2B trial in trauma patients with haemorrhagic shock-induced endotheliopathy. Patients are randomized 1:1 to 72 hours infusion of iloprost 1 ng/kg/min or Placebo (equal volume of saline). A total of 220 trauma patients will be included. The primary endpoint is the number of intensive care unit (ICU)-free days, within 28 days of admission. Secondary endpoints include 28- and 90-day all-cause mortality, hospital length of stay, vasopressor-free days in the intensive care unit (ICU) within 28 days, ventilator-free days in the ICU within 28 days, renal replacement-free days in the ICU within 28 days, number of serious adverse reactions and serious adverse events within the first 4 days of admission. DISCUSSION This trial will test the safety and efficacy of administration of iloprost vs placebo for 72 hours in trauma patients with haemorrhagic shock-induced endotheliopathy. Trial endpoints focus on the potential effect of iloprost to reduce the need for ICU stay secondary to mitigation of organ failure. TRIAL REGISTRATION SHINE-TRAUMA trial-EudraCT no. 2019-000936-24-Clinicaltrials.gov: NCT03903939 Ethics Committee no. H-19014482.
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Affiliation(s)
- Pär I. Johansson
- Capital Region Blood BankCopenhagen University Hospital – RigshospitaletCopenhagenDenmark
| | | | - Hagen Schmal
- Department of Orthopaedic SurgeryOdense University HospitalOdenseDenmark
| | | | - Marlene Pall
- Department of Anaesthesiology and Intensive Care VOdense University HospitalOdenseDenmark
| | - Hanne Hee Henriksen
- Capital Region Blood BankCopenhagen University Hospital – RigshospitaletCopenhagenDenmark
| | - Pernille Bovbjerg
- Department of Orthopaedic SurgeryOdense University HospitalOdenseDenmark
| | - Theis Lange
- Section of BiostatisticsUniversity of CopenhagenCopenhagenDenmark
| | - Pål Aksel Næss
- Department of TraumatologyOslo University HospitalOsloNorway
| | - Christian Nielsen
- Department of AnaesthesiologyAarhus University HospitalAarhusDenmark
| | - Hans Kirkegaard
- Research Center for Emergency MedicineAarhus University Hospital, and Aarhus UniversityAarhusDenmark
| | - Jakob Stensballe
- Capital Region Blood BankCopenhagen University Hospital – RigshospitaletCopenhagenDenmark
- Department of Anaesthesiology and TraumaCentre of Head and OrtopaedicsCopenhagen University Hospital – RigshospitaletCopenhagenDenmark
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11
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Kleinveld DJB, Botros L, Maas MAW, Kers J, Aman J, Hollmann MW, Juffermans NP. Bosutinib reduces endothelial permeability and organ failure in a rat polytrauma transfusion model. Br J Anaesth 2021; 126:958-966. [PMID: 33685634 PMCID: PMC8258973 DOI: 10.1016/j.bja.2021.01.032] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Revised: 01/17/2021] [Accepted: 01/17/2021] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Trauma-induced shock is associated with endothelial dysfunction. We examined whether the tyrosine kinase inhibitor bosutinib as an adjunct therapy to a balanced blood component resuscitation strategy reduces trauma-induced endothelial permeability, thereby improving shock reversal and limiting transfusion requirements and organ failure in a rat polytrauma transfusion model. METHODS Male Sprague-Dawley rats (n=13 per group) were traumatised and exsanguinated until a MAP of 40 mm Hg was reached, then randomised to two groups: red blood cells, plasma and platelets in a 1:1:1 ratio with either bosutinib or vehicle. Controls were randomised to sham (median laparotomy, no trauma) with bosutinib or vehicle. Organs were harvested for histology and wet/dry (W/D) weight ratio. RESULTS Traumatic injury resulted in shock, with higher lactate levels compared with controls. In trauma-induced shock, the resuscitation volume needed to obtain a MAP of 60 mm Hg was lower in bosutinib-treated animals (2.8 [2.7-3.2] ml kg-1) compared with vehicle (6.1 [5.1-7.2] ml kg-1, P<0.001). Lactate levels in the bosutinib group were 2.9 [1.7-4.8] mM compared with 6.2 [3.1-14.1] mM in the vehicle group (P=0.06). Bosutinib compared with vehicle reduced lung vascular leakage (W/D ratio of 5.1 [4.6-5.3] vs 5.7 [5.4-6.0] (P=0.046) and lung injury scores (P=0.027). CONCLUSIONS Bosutinib as an adjunct therapy to a balanced transfusion strategy reduced resuscitation volume, improved shock reversal, and reduced vascular leak and organ injury in a rat polytrauma model.
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Affiliation(s)
- Derek J B Kleinveld
- Department of Intensive Care Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands; Laboratory of Experimental Intensive Care and Anesthesiology, Department of Trauma Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands; Department of Trauma Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.
| | - Liza Botros
- Department of Pulmonary Diseases, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands; Department of Physiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - M Adrie W Maas
- Department of Intensive Care Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands; Laboratory of Experimental Intensive Care and Anesthesiology, Department of Trauma Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Jesper Kers
- Department of Pathology, Amsterdam Infection & Immunity Institute, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands; Department of Pathology, Leiden University Medical Center, University of Leiden, Leiden, The Netherlands; Van't Hoff Institute for Molecular Sciences (HIMS), University of Amsterdam, Amsterdam, The Netherlands; Ragon Institute of Massachusetts General Hospital, Massachusetts Institute of Technology and Harvard University, Cambridge, MA, USA
| | - Jurjan Aman
- Department of Pulmonary Diseases, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands; Department of Physiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Markus W Hollmann
- Laboratory of Experimental Intensive Care and Anesthesiology, Department of Trauma Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands; Department of Anesthesiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Nicole P Juffermans
- Laboratory of Experimental Intensive Care and Anesthesiology, Department of Trauma Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands; Department of Intensive Care Medicine, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
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12
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Baksaas-Aasen K, Gall LS, Stensballe J, Juffermans NP, Curry N, Maegele M, Brooks A, Rourke C, Gillespie S, Murphy J, Maroni R, Vulliamy P, Henriksen HH, Pedersen KH, Kolstadbraaten KM, Wirtz MR, Kleinveld DJB, Schäfer N, Chinna S, Davenport RA, Naess PA, Goslings JC, Eaglestone S, Stanworth S, Johansson PI, Gaarder C, Brohi K. Viscoelastic haemostatic assay augmented protocols for major trauma haemorrhage (ITACTIC): a randomized, controlled trial. Intensive Care Med 2021; 47:49-59. [PMID: 33048195 PMCID: PMC7550843 DOI: 10.1007/s00134-020-06266-1] [Citation(s) in RCA: 143] [Impact Index Per Article: 47.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2020] [Accepted: 09/20/2020] [Indexed: 12/13/2022]
Abstract
PURPOSE Contemporary trauma resuscitation prioritizes control of bleeding and uses major haemorrhage protocols (MHPs) to prevent and treat coagulopathy. We aimed to determine whether augmenting MHPs with Viscoelastic Haemostatic Assays (VHA) would improve outcomes compared to Conventional Coagulation Tests (CCTs). METHODS This was a multi-centre, randomized controlled trial comparing outcomes in trauma patients who received empiric MHPs, augmented by either VHA or CCT-guided interventions. Primary outcome was the proportion of subjects who, at 24 h after injury, were alive and free of massive transfusion (10 or more red cell transfusions). Secondary outcomes included 28-day mortality. Pre-specified subgroups included patients with severe traumatic brain injury (TBI). RESULTS Of 396 patients in the intention to treat analysis, 201 were allocated to VHA and 195 to CCT-guided therapy. At 24 h, there was no difference in the proportion of patients who were alive and free of massive transfusion (VHA: 67%, CCT: 64%, OR 1.15, 95% CI 0.76-1.73). 28-day mortality was not different overall (VHA: 25%, CCT: 28%, OR 0.84, 95% CI 0.54-1.31), nor were there differences in other secondary outcomes or serious adverse events. In pre-specified subgroups, there were no differences in primary outcomes. In the pre-specified subgroup of 74 patients with TBI, 64% were alive and free of massive transfusion at 24 h compared to 46% in the CCT arm (OR 2.12, 95% CI 0.84-5.34). CONCLUSION There was no difference in overall outcomes between VHA- and CCT-augmented-major haemorrhage protocols.
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Affiliation(s)
| | - L S Gall
- Centre for Trauma Sciences, Queen Mary University of London, Blizard Institute, 4 Newark Street, London, E1 2AT, UK
| | - J Stensballe
- Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - N P Juffermans
- Amsterdam University Medical Centres, Amsterdam, The Netherlands
| | - N Curry
- Oxford University Hospital NHS Trust, Oxford, UK
| | - M Maegele
- Cologne-Merheim Medical Centre, University of Witten/Herdecke, Cologne, Germany
| | - A Brooks
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - C Rourke
- Centre for Trauma Sciences, Queen Mary University of London, Blizard Institute, 4 Newark Street, London, E1 2AT, UK
| | - S Gillespie
- Centre for Trauma Sciences, Queen Mary University of London, Blizard Institute, 4 Newark Street, London, E1 2AT, UK
| | - J Murphy
- Queen Mary University of London, London, UK
| | - R Maroni
- Queen Mary University of London, London, UK
| | - P Vulliamy
- Centre for Trauma Sciences, Queen Mary University of London, Blizard Institute, 4 Newark Street, London, E1 2AT, UK
| | - H H Henriksen
- Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - K Holst Pedersen
- Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | | | - M R Wirtz
- Amsterdam University Medical Centres, Amsterdam, The Netherlands
| | - D J B Kleinveld
- Amsterdam University Medical Centres, Amsterdam, The Netherlands
| | - N Schäfer
- Cologne-Merheim Medical Centre, University of Witten/Herdecke, Cologne, Germany
| | - S Chinna
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - R A Davenport
- Centre for Trauma Sciences, Queen Mary University of London, Blizard Institute, 4 Newark Street, London, E1 2AT, UK
| | - P A Naess
- Oslo University Hospital & University of Oslo, Oslo, Norway
| | - J C Goslings
- Amsterdam University Medical Centres, Amsterdam, The Netherlands
| | - S Eaglestone
- Centre for Trauma Sciences, Queen Mary University of London, Blizard Institute, 4 Newark Street, London, E1 2AT, UK
| | - S Stanworth
- Oxford University Hospital NHS Trust, Oxford, UK.,NHS Blood and Transplant, Bristol, UK
| | - P I Johansson
- Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - C Gaarder
- Oslo University Hospital & University of Oslo, Oslo, Norway
| | - K Brohi
- Centre for Trauma Sciences, Queen Mary University of London, Blizard Institute, 4 Newark Street, London, E1 2AT, UK.
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13
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Wirtz MR, van den Brink DP, Roelofs JJTH, Goslings JC, Juffermans NP. Therapeutic application of recombinant human ADAMTS-13 improves shock reversal and coagulation status in a trauma hemorrhage and transfusion rat model. Intensive Care Med Exp 2020; 8:42. [PMID: 33336308 PMCID: PMC7746419 DOI: 10.1186/s40635-020-00328-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Accepted: 07/16/2020] [Indexed: 12/29/2022] Open
Abstract
INTRODUCTION In hemorrhaging trauma patients, the endothelium is activated, resulting in excessive endothelial synthesis of von Willebrand Factor (vWF), which may enhance micro-thrombi formation, resulting in obstruction of the microcirculation and endothelial injury, aggravating bleeding, as well as contributing to organ failure. Under normal conditions, vWF is cleaved by the metalloprotease ADAMTS-13. After trauma, ADAMTS-13 levels are reduced. OBJECTIVES To assess whether recombinant human ADAMTS-13 inhibits endothelial injury and organ failure in a rat trauma-transfusion model. METHODS Blood products were prepared from syngeneic rat blood according to blood bank standards. Polytrauma was induced in rats by crush injury to the intestines and liver and by fracture of the femur. The rats were hemorrhaged until a mean arterial pressure (MAP) of 40 mmHg was reached. Rats were randomized to receive transfusion of RBCs, FFPs, and platelets in a 1:1:1 ratio to achieve a MAP of 70 mmHg, with or without the addition of ADAMTS-13 (50 μg/kg). Blood samples were assessed for biochemistry and rotational thromboelastometry (ROTEM). Syndecan-1 and VE-cadherin levels were measured as a reflection of endothelial integrity. The amount of leakage of dextran-FITC from the vascular system to the parenchyma in lungs was quantified. To assess inflammation, IL-6 and IL-8 levels were determined. Organ damage was assessed by histopathology. RESULTS All rats were severely shocked, with no significant differences in shock parameters between groups. Rats treated with ADAMTS-13 showed signs of a more effective shock reversal (higher blood pressure, lower lactate levels) compared to controls. Also, ROTEM parameters of clot formation in rats receiving ADAMTS-13 improved compared to controls, which was mainly platelet-dependent. Syndecan-1 levels relative to baseline trended to be lower in ADAMTS-13 treated rats compared to controls (107 vs 149%, p = 0.08). ADAMTS-13 reduced albuminuria (1.7 vs 4.4 g/L, p < 0.01) and organ-specific inflammation (pulmonary IL-6 243 vs 369 pg/mL, p = 0.08; splenic IL-6 253 vs 307, p = 0.03) compared to controls, but did not improve histopathological scores. CONCLUSIONS The use of ADAMTS-13 in a rat trauma-transfusion model improves parameters of shock, platelet-driven coagulation, endothelial damage, and organ inflammation. These results suggest that ADAMTS-13 is important in mediating outcome of trauma. Whether ADAMTS-13 can be used as a therapeutic adjunct to treat bleeding trauma patients remains to be determined.
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Affiliation(s)
- Mathijs R Wirtz
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, location Academic Medical Center, Amsterdam, The Netherlands. .,Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam University Medical Centers, location Academic Medical Center, Amsterdam, The Netherlands. .,Department of Trauma Surgery, Amsterdam University Medical Centers, location Academic Medical Center, Amsterdam, The Netherlands.
| | - Daan P van den Brink
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, location Academic Medical Center, Amsterdam, The Netherlands.,Department of Trauma Surgery, Amsterdam University Medical Centers, location Academic Medical Center, Amsterdam, The Netherlands
| | - Joris J T H Roelofs
- Department of Pathology, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centers, location Academic Medical Center, Amsterdam, The Netherlands
| | - J Carel Goslings
- Department of Trauma Surgery, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
| | - Nicole P Juffermans
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, location Academic Medical Center, Amsterdam, The Netherlands.,Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam University Medical Centers, location Academic Medical Center, Amsterdam, The Netherlands
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14
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van den Brink DP, Wirtz MR, Neto AS, Schöchl H, Viersen V, Binnekade J, Juffermans NP. Effectiveness of prothrombin complex concentrate for the treatment of bleeding: A systematic review and meta-analysis. J Thromb Haemost 2020; 18:2457-2467. [PMID: 32638483 PMCID: PMC7589201 DOI: 10.1111/jth.14991] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Revised: 06/23/2020] [Accepted: 06/26/2020] [Indexed: 01/02/2023]
Abstract
Prothrombin complex concentrate (PCC) is increasingly being used as a treatment for major bleeding in patients who are not taking anticoagulants. The aim of this systematic review and meta-analysis is to evaluate the effectiveness of PCC administration for the treatment of bleeding in patients not taking anticoagulants. Studies investigating the effectivity of PCC to treat bleeding in adult patients and providing data on either mortality or blood loss were eligible. Data were pooled using Mantel-Haenszel random effects meta-analysis or inverse variance random effects meta-analysis. From 4668 identified studies, 17 observational studies were included. In all patient groups combined, PCC administration was not associated with mortality (odds ratio = 0.83; 95% confidence interval [CI], 0.66-1.06; P = .13; I2 = 0%). However, in trauma patients, PCC administration, in addition to fresh frozen plasma, was associated with reduced mortality (odds ratio = 0.64; CI, 0.46-0.88; P = .007; I2 = 0%). PCC administration was associated with a reduction in blood loss in cardiac surgery patients (mean difference: -384; CI, -640 to -128, P = .003, I2 = 81%) and a decreased need for red blood cell transfusions when compared with standard care across a wide range of bleeding patients not taking anticoagulants (mean difference: -1.80; CI, -3.22 to -0.38; P = .01; I2 = 92%). In conclusion, PCC administration was not associated with reduced mortality in the whole cohort but did reduce mortality in trauma patients. In bleeding patients, PCC reduced the need for red blood cell transfusions when compared with treatment strategies not involving PCC. In bleeding cardiac surgery patients, PCC administration reduced blood loss.
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Affiliation(s)
- Daan P. van den Brink
- Department of Intensive Care MedicineAmsterdam UMCAmsterdamThe Netherlands
- Laboratory of Experimental Intensive Care and AnesthesiologyAmsterdam UMCAmsterdamThe Netherlands
| | - Mathijs R. Wirtz
- Department of Intensive Care MedicineAmsterdam UMCAmsterdamThe Netherlands
- Laboratory of Experimental Intensive Care and AnesthesiologyAmsterdam UMCAmsterdamThe Netherlands
- Department of Trauma SurgeryAmsterdam UMCAmsterdamThe Netherlands
| | - Ary Serpa Neto
- Department of Intensive Care MedicineAmsterdam UMCAmsterdamThe Netherlands
- Department of Critical Care MedicineHospital Israelita Albert EinsteinSᾶo PauloBrazil
| | - Herbert Schöchl
- Department of Anesthesiology and Intensive Care MedicineAUVA Trauma Centre SalzburgAcademic Teaching Hospital of the Paracelsus Medical UniversitySalzburgAustria
- Institute for Experimental and Clinical TraumatologyAUVA Research CentreViennaAustria
| | - Victor Viersen
- Department of AnesthesiologyAmsterdam UMCAmsterdamThe Netherlands
| | - Jan Binnekade
- Department of Intensive Care MedicineAmsterdam UMCAmsterdamThe Netherlands
| | - Nicole P. Juffermans
- Department of Intensive Care MedicineAmsterdam UMCAmsterdamThe Netherlands
- Laboratory of Experimental Intensive Care and AnesthesiologyAmsterdam UMCAmsterdamThe Netherlands
- Department of Intensive Care MedicineOLVG HospitalAmsterdamThe Netherlands
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15
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Leighton JL, You D, Schneider P. Limiting Blood Loss in Orthopaedic Trauma: Strategies and Effects. Injury 2020; 51 Suppl 2:S123-S127. [PMID: 32467044 DOI: 10.1016/j.injury.2020.04.040] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 04/17/2020] [Accepted: 04/25/2020] [Indexed: 02/02/2023]
Abstract
Trauma is a major cause of mortality globally, with post-traumatic hemorrhage being the leading cause of death amongst trauma patients. In this paper, the authors review the underlying pathophysiology of trauma-related hemorrhagic shock, specifically the factors which contribute to the development of the acute coagulopathy of trauma shock (ACoTS). We then review the best available evidence for treatment strategies in the pre-hospital setting, as well as the in-hospital setting. Interventions that are strongly supported in the literature include utilization of a well-organized trauma system with direct transport to a designated trauma centre, the early use of tranexamic acid, and damage control orthopaedic surgical techniques and resuscitation protocols. Targeted resuscitation is an evolving field, with use of thromboelastography to guide resuscitation being a particularly promising area. Special trauma populations at particularly high risk are also reviewed, including the geriatric population, as well as unstable pelvic fractures, which are each at increased risk for poor outcomes, and deserve special attention. Major advances have been made in this important area, and ongoing research into the understanding and correction of ACoTS will continue to guide practice.
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Affiliation(s)
| | - Daniel You
- University of Calgary, Calgary, AB, Canada
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16
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Vulliamy P, Thaventhiran AJ, Davenport RA. What's new for trauma haemorrhage management? Br J Hosp Med (Lond) 2019; 80:268-273. [PMID: 31059346 DOI: 10.12968/hmed.2019.80.5.268] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Uncontrolled haemorrhage is the leading cause of preventable death from injury and is a major contributor to the global burden of disease. The majority of deaths resulting from bleeding occur within the first 3 hours of hospital admission, and the window for meaningful intervention is therefore extremely small. Resuscitative efforts during active bleeding should focus on maintaining haemostatic function with blood product transfusion and early administration of tranexamic acid. Achieving control of haemorrhage is the overarching treatment priority and may require temporising measures before definitive surgical or radiological intervention. This review summarizes the contemporary approaches to resuscitation of bleeding trauma patients, options for achieving haemorrhage control, and current areas of active research including organ protective resuscitation and suspended animation.
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Affiliation(s)
- Paul Vulliamy
- Clinical Lecturer and Specialist Registrar in General Surgery, Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London
| | - Anthony J Thaventhiran
- Clinical Research Fellow and Specialist Registrar in General Surgery, Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London
| | - Ross A Davenport
- Consultant Surgeon and Senior Lecturer, Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London E1 2AT
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17
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Cardenas JC. Mechanisms of Traumatic Hyperfibrinolysis and Implications for Antifibrinolytic Therapy. CURRENT TRAUMA REPORTS 2019. [DOI: 10.1007/s40719-019-00175-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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18
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da Luz LT, Shah PS, Strauss R, Mohammed AA, D'Empaire PP, Tien H, Nathens AB, Nascimento B. Does the evidence support the importance of high transfusion ratios of plasma and platelets to red blood cells in improving outcomes in severely injured patients: a systematic review and meta-analyses. Transfusion 2019; 59:3337-3349. [PMID: 31614006 PMCID: PMC6900194 DOI: 10.1111/trf.15540] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Revised: 08/13/2019] [Accepted: 08/21/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND Deaths by exsanguination in trauma are preventable with hemorrhage control and resuscitation with allogeneic blood products (ABPs). The ideal transfusion ratio is unknown. We compared efficacy and safety of high transfusion ratios of FFP:RBC and PLT:RBC with low ratios in trauma. STUDY DESIGN AND METHODS Medline, Embase, Cochrane, and Controlled Clinical Trials Register were searched. Observational and randomized data were included. Risk of bias was assessed using validated tools. Primary outcome was 24-h and 30-day mortality. Secondary outcomes were exposure to ABPs and improvement of coagulopathy. Meta-analysis was conducted using a random-effects model. Strength and evidence quality were graded using GRADE profile RESULTS: 55 studies were included (2 randomized and 53 observational), with low and moderate risk of bias, respectively, and overall low evidence quality. The two RCTs showed no mortality difference (odds ratio [OR], 1.35; 95% confidence interval [CI], 0.40-4.59). Observational studies reported lower mortality in high FFP:RBCs ratio (OR, 0.38 [95% CI, 0.22-0.68] for 1:1 vs. <1:1; OR, 0.42 [95% CI, 0.22-0.81] for 1:1.5 vs. <1:1.5; and OR, 0.47 [95% CI, 0.31-0.71] for 1:2 vs. <1:2, respectively). Meta-analyses in observational studies showed no difference in exposure to ABPs. No data on coagulopathy for meta-analysis was identified. CONCLUSIONS Meta-analyses in observational studies suggest survival benefit and no difference in exposure to ABPs. No survival benefit in RCTs was identified. These conflicting results should be interpreted with caution. Studies are mostly observational, with relatively small sample sizes, nonrandom treatment allocation, and high potential for confounding. Further research is warranted.
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Affiliation(s)
| | - Prakesh S. Shah
- Department of PediatricsMount Sinai HospitalTorontoOntarioCanada
| | - Rachel Strauss
- Department SurgerySunnybrook Health Sciences CentreTorontoOntarioCanada
| | | | - Pablo Perez D'Empaire
- Department Anesthesia, Sunnybrook Health Sciences CentreUniversity of TorontoTorontoOntarioCanada
| | - Homer Tien
- Department SurgerySunnybrook Health Sciences CentreTorontoOntarioCanada
| | - Avery B. Nathens
- Department SurgerySunnybrook Health Sciences CentreTorontoOntarioCanada
| | - Barto Nascimento
- Department SurgerySunnybrook Health Sciences CentreTorontoOntarioCanada
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19
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Abstract
PURPOSE OF REVIEW Uncontrolled bleeding in trauma secondary to a combination of surgical bleeding and trauma-induced complex coagulopathy is a leading cause of death. Prothrombin complex concentrates (PCCs), recombinant activated factor seven (rFVIIa) and recombinant human prothrombin act as procoagulants by increasing thrombin generation and fibrinogen concentrate aids stable clot formation. This review summarizes the current evidence for procoagulant use in the management of bleeding in trauma, and data and evidence gaps for routine clinical use. RECENT FINDINGS Retrospective and prospective studies of PCCs (±fibrinogen concentrate) have demonstrated a decreased time to correction of trauma coagulopathy and decreased red cell transfusion with no obvious effect on mortality or thromboembolic outcomes. PCCs in a porcine model of dilutional coagulopathy demonstrated a sustained increase in thrombin generation, unlike recombinant human prothrombin which showed a transient increase and has been studied only in animals. In other retrospective studies, there is a suggestion that lower doses of PCCs may be effective in the setting of acquired coagulopathy. SUMMARY There is increasing evidence that early correction of coagulopathy has survival benefits, and the use of procoagulants as first-line therapy has the potential benefit of rapid access and timely treatment. This requires confirmation in prospective studies.
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20
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Görlinger K, Pérez-Ferrer A, Dirkmann D, Saner F, Maegele M, Calatayud ÁAP, Kim TY. The role of evidence-based algorithms for rotational thromboelastometry-guided bleeding management. Korean J Anesthesiol 2019; 72:297-322. [PMID: 31096732 PMCID: PMC6676023 DOI: 10.4097/kja.19169] [Citation(s) in RCA: 108] [Impact Index Per Article: 21.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Accepted: 05/08/2019] [Indexed: 02/07/2023] Open
Abstract
Rotational thromboelastometry (ROTEM) is a point-of-care viscoelastic method and enables to assess viscoelastic profiles of whole blood in various clinical settings. ROTEM-guided bleeding management has become an essential part of patient blood management (PBM) which is an important concept in improving patient safety. Here, ROTEM testing and hemostatic interventions should be linked by evidence-based, setting-specific algorithms adapted to the specific patient population of the hospitals and the local availability of hemostatic interventions. Accordingly, ROTEM-guided algorithms implement the concept of personalized or precision medicine in perioperative bleeding management (‘theranostic’ approach). ROTEM-guided PBM has been shown to be effective in reducing bleeding, transfusion requirements, complication rates, and health care costs. Accordingly, several randomized-controlled trials, meta-analyses, and health technology assessments provided evidence that using ROTEM-guided algorithms in bleeding patients resulted in improved patient’s safety and outcomes including perioperative morbidity and mortality. However, the implementation of ROTEM in the PBM concept requires adequate technical and interpretation training, education and logistics, as well as interdisciplinary communication and collaboration.
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Affiliation(s)
- Klaus Görlinger
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Essen, University Duisburg-Essen, Essen, Germany.,Tem Innovations, Munich, Germany
| | - Antonio Pérez-Ferrer
- Department of Anesthesiology, Infanta Sofia University Hospital, San Sebastián de los Reyes, Madrid, Spain
| | - Daniel Dirkmann
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Fuat Saner
- Department of General, Visceral and Transplant Surgery, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Marc Maegele
- Department for Trauma and Orthopedic Surgery, CologneMerheim Medical Center (CMMC), Cologne, Germany.,Institute for Research in Operative Medicine (IFOM), University Witten/Herdecke (UW/H), Campus Cologne-Merheim, Cologne, Germany
| | - Ángel Augusto Pérez Calatayud
- Terapia Intensiva Adultos, Hospital de Especialidades del Niño y la Mujer, Coordinador Grupo Mexicano para el Estudio de la Medicina Intensiva, Colegio Mexicano de Especialistas en Obstetrica Critica (COMEOC), Queretarco, Mexico
| | - Tae-Yop Kim
- Department of Anesthesiology, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul, Korea
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González Posada MA, Biarnés Suñe A, Naya Sieiro JM, Salvadores de Arzuaga CI, Colomina Soler MJ. Damage Control Resuscitation in polytrauma patient. ACTA ACUST UNITED AC 2019; 66:394-404. [PMID: 31031044 DOI: 10.1016/j.redar.2019.03.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Revised: 02/13/2019] [Accepted: 03/18/2019] [Indexed: 11/30/2022]
Abstract
Haemorrhagic shock is one of the main causes of mortality in severe polytrauma patients. To increase the survival rates, a combined strategy of treatment known as Damage Control has been developed. The aims of this article are to analyse the actual concept of Damage Control Resuscitation and its three treatment levels, describe the best transfusion strategy, and approach the acute coagulopathy of the traumatic patient as an entity. The potential changes of this therapeutic strategy over the coming years are also described.
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Affiliation(s)
- M A González Posada
- Servicio de Anestesiología y Reanimación, Hospital Universitario Vall d'Hebron, Barcelona, España; Universidad Autónoma de Barcelona, Barcelona, España.
| | - A Biarnés Suñe
- Servicio de Anestesiología y Reanimación, Hospital Universitario Vall d'Hebron, Barcelona, España; Universidad Autónoma de Barcelona, Barcelona, España
| | - J M Naya Sieiro
- Servicio de Anestesiología y Reanimación, Hospital Universitario Vall d'Hebron, Barcelona, España
| | | | - M J Colomina Soler
- Servicio de Anestesiología y Reanimación, Hospital Universitario de Bellvitge, l'Hospitalet de Llobregat, Barcelona, España; Universidad Barcelona, Barcelona, España
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Juffermans NP, Wirtz MR, Balvers K, Baksaas‐Aasen K, van Dieren S, Gaarder C, Naess PA, Stanworth S, Johansson PI, Stensballe J, Maegele M, Goslings JC, Brohi K. Towards patient-specific management of trauma hemorrhage: the effect of resuscitation therapy on parameters of thromboelastometry. J Thromb Haemost 2019; 17:441-448. [PMID: 30609290 PMCID: PMC6850475 DOI: 10.1111/jth.14378] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Indexed: 12/16/2022]
Abstract
Essentials The response of thromboelastometry (ROTEM) parameters to therapy is unknown. We prospectively recruited hemorrhaging trauma patients in six level-1 trauma centres in Europe. Blood products and pro-coagulants prevent further derangement of ROTEM results. ROTEM algorithms can be used to treat and monitor trauma induced coagulopathy. SUMMARY: Background Rotational thromboelastometry (ROTEM) can detect trauma-induced coagulopathy (TIC) and is used in transfusion algorithms. The response of ROTEM to transfusion therapy is unknown. Objectives To determine the response of ROTEM profiles to therapy in bleeding trauma patients. Patients/Methods A prospective multicenter study in bleeding trauma patients (receiving ≥ 4 red blood cell [RBC] units) was performed. Blood was drawn in the emergency department, after administration of 4, 8 and 12 RBC units and 24 h post-injury. The response of ROTEM to plasma, platelets (PLTs), tranexamic acid (TXA) and fibrinogen products was evaluated in the whole cohort as well as in the subgroup of patients with ROTEM values indicative of TIC. Results Three hundred and nine bleeding and shocked patients were included. A mean dose of 3.8 g of fibrinogen increased FIBTEM CA5 by 5.2 mm (IQR: 4.1-6.3 mm). TXA administration decreased lysis by 5.4% (4.3-6.5%). PLT transfusion prevented further derangement of parameters of clot formation. The effect of PLTs on EXTEM ca5 values was more pronounced in patients with a ROTEM value indicative of TIC than in the whole cohort. Plasma transfusion decreased EXTEM clotting time by 3.1 s (- 10 s to 3.9 s) in the whole cohort and by 10.6 s (- 45 s to 24 s) in the subgroup of patients with a ROTEM value indicative of TIC. Conclusion The effects of therapy on ROTEM values were small, but prevented further derangement of test results. In patients with ROTEM values indicative of TIC, the efficacy of PLTs and plasma in correcting deranged ROTEM parameters is possibly more robust.
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Affiliation(s)
- Nicole P. Juffermans
- Department of Intensive Care MedicineAmsterdam UMCAcademic Medical CenterAmsterdamthe Netherlands
| | - Mathijs R. Wirtz
- Department of Intensive Care MedicineAmsterdam UMCAcademic Medical CenterAmsterdamthe Netherlands
| | - Kirsten Balvers
- Department of Intensive Care MedicineAmsterdam UMCAcademic Medical CenterAmsterdamthe Netherlands
- Trauma UnitDepartment of SurgeryAcademic Medical CenterAmsterdamthe Netherlands
| | - Kjersti Baksaas‐Aasen
- Department of TraumatologyOslo University HospitalOsloNorway
- Department of AnesthesiologyOslo University HospitalOsloNorway
| | - Susan van Dieren
- Department of Intensive Care MedicineAmsterdam UMCAcademic Medical CenterAmsterdamthe Netherlands
| | | | - Paul A. Naess
- Department of TraumatologyOslo University HospitalOsloNorway
| | - Simon Stanworth
- NHS Blood and Transplant/Oxford University Hospitals NHS TrustJohn Radcliffe HospitalOxfordUK
- Radcliffe Department of MedicineUniversity of OxfordOxfordUK
| | - Pär I. Johansson
- Department of Anesthesiology and Trauma CenterCenter for Head and Orthopedics, and Section for Transfusion MedicineCapital Region Blood BankCopenhagen University Hospital RigshospitaletCopenhagenDenmark
| | - Jakob Stensballe
- Department of Anesthesiology and Trauma CenterCenter for Head and Orthopedics, and Section for Transfusion MedicineCapital Region Blood BankCopenhagen University Hospital RigshospitaletCopenhagenDenmark
| | - Marc Maegele
- Department for Traumatology and Orthopedic SurgeryCologne‐Merheim Medical CenterUniversity of Witten/HerdeckeCologneGermany
| | - J. C. Goslings
- Trauma UnitDepartment of SurgeryAcademic Medical CenterAmsterdamthe Netherlands
| | - Karim Brohi
- Trauma SciencesBlizard InstituteBarts and the London School of Medicine and DentistryQueen Mary University of LondonLondonUK
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Caspers M, Maegele M, Fröhlich M. Current strategies for hemostatic control in acute trauma hemorrhage and trauma-induced coagulopathy. Expert Rev Hematol 2018; 11:987-995. [PMID: 30433835 DOI: 10.1080/17474086.2018.1548929] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Introduction: Despite advances in the treatment of severely injured patients that have resulted in overall improved outcomes, uncontrolled hemorrhage still represents the most common cause of preventable death following major injury. While addressing both endo- and exogenous factors that lead to an acute trauma-induced coagulopathy, massive transfusion plays a key role in managing bleeding trauma patients. However, the best practice for hemostatic control including massive transfusion in these patients is still under debate. Areas covered: This review summarizes the current knowledge and clinical practice for hemostatic control including massive transfusion for bleeding trauma patients. The recent literature was reviewed and extended by current guidelines and their underlying evidence was incorporated. Expert commentary: Treatment strategies for bleeding trauma patients are still an area of emerging scientific and clinical interest as advances are likely to translate into improved outcomes including survival. To date, damage control resuscitation principles with ratio-based transfusion of packed red blood cells, plasma and platelets still dominate as "gold standard" of care but goal-directed strategies guided either by conventional coagulation tests or viscoelastic assays may demonstrate a better characterization of the underlying coagulopathy thereby allowing individualized and targeted therapies.
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Affiliation(s)
- Michael Caspers
- a The Institute for Research in Operative Medicine, Faculty of Health, Department of Medicine , Witten/Herdecke University , Cologne , Germany.,b Department of Traumatology and Orthopaedic Surgery, Cologne-Merheim Medical Centre (CMMC) , Witten/Herdecke University , Cologne , Germany
| | - Marc Maegele
- a The Institute for Research in Operative Medicine, Faculty of Health, Department of Medicine , Witten/Herdecke University , Cologne , Germany.,b Department of Traumatology and Orthopaedic Surgery, Cologne-Merheim Medical Centre (CMMC) , Witten/Herdecke University , Cologne , Germany
| | - Matthias Fröhlich
- b Department of Traumatology and Orthopaedic Surgery, Cologne-Merheim Medical Centre (CMMC) , Witten/Herdecke University , Cologne , Germany
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Deng Q, Hao F, Wang Y, Guo C. Rotation thromboelastometry (ROTEM) enables improved outcomes in the pediatric trauma population. J Int Med Res 2018; 46:5195-5204. [PMID: 30200794 PMCID: PMC6300942 DOI: 10.1177/0300060518794092] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Objective We evaluated the role of rotation thromboelastometry (ROTEM) in managing acute traumatic coagulopathy in pediatric patients with trauma. Methods A retrospective cohort of pediatric patients with trauma from six institutes was studied during a 10-year period from 2007 to 2017. The associations between ROTEM-guided, goal-directed coagulation therapy and clinical outcomes were determined. Results Three hundred thirty-two pediatric patients (age < 15 years) who were treated with ROTEM-guided, goal-directed coagulation therapy were matched to 332 control pediatric patients with conventional plasmatic coagulation tests. The ROTEM protocol was associated with a significant reduction in the interval for admission to acute traumatic coagulopathy treatment, less plasma transfusions in the first 24 hours of admission, and a favorable coagulopathy recovery. Furthermore, the median number of total hospital days was significantly shorter for patients who had the ROTEM protocol than for control patients. Conclusions There are significant favorable outcomes, including rapid acute traumatic coagulopathy treatment and a lower 24-hour blood product requirement, following ROTEM-guided, goal-directed coagulation therapy among pediatric patients with blunt trauma.
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Affiliation(s)
- Qin Deng
- 1 Department of Pediatric General Surgery and Liver Transplantation, Children's Hospital, Chongqing Medical University, Chongqing, China
| | - Fabao Hao
- 1 Department of Pediatric General Surgery and Liver Transplantation, Children's Hospital, Chongqing Medical University, Chongqing, China.,2 Department of Neonatology, Children's Hospital, Chongqing Medical University, Chongqing, China
| | - Yongming Wang
- 1 Department of Pediatric General Surgery and Liver Transplantation, Children's Hospital, Chongqing Medical University, Chongqing, China.,2 Department of Neonatology, Children's Hospital, Chongqing Medical University, Chongqing, China
| | - Chunbao Guo
- 1 Department of Pediatric General Surgery and Liver Transplantation, Children's Hospital, Chongqing Medical University, Chongqing, China.,3 Ministry of Education Key Laboratory of Child Development and Disorders, Children's Hospital, Chongqing Medical University, Chongqing, China
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Abstract
PURPOSE OF REVIEW Hemorrhage remains the primary cause of preventable death on the battlefield and in civilian trauma. Hemorrhage control is multifactorial and starts with point-of-injury care. Surgical hemorrhage control and time from injury to surgery is paramount; however, interventions in the prehospital environment and perioperative period affect outcomes. The purpose of this review is to understand concepts and strategies for successful management of the bleeding military patient. Understanding the life-threatening nature of coagulopathy of trauma and implementing strategies aimed at full spectrum hemorrhage management from point of injury to postoperative care will result in improved outcomes in patients with life-threatening bleeding. RECENT FINDINGS Timely and appropriate therapies impact survival. Blood product resuscitation for life-threatening hemorrhage should either be with whole blood or a component therapy strategy that recapitulates the functionality of whole blood. The US military has transfused over 10 000 units of whole blood since the beginning of the wars in Iraq and Afghanistan. The well recognized therapeutic benefits of whole blood have pushed this therapy far forward into prehospital care in both US and international military forces. Multiple hemostatic adjuncts are available that are likely beneficial to the bleeding military patient; and other products and techniques are under active investigation. SUMMARY Lessons learned in the treatment of combat casualties will likely continue to have positive impact and influence and the management of hemorrhage in the civilian trauma setting.
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Cardenas JC, Zhang X, Fox EE, Cotton BA, Hess JR, Schreiber MA, Wade CE, Holcomb JB. Platelet transfusions improve hemostasis and survival in a substudy of the prospective, randomized PROPPR trial. Blood Adv 2018; 2:1696-1704. [PMID: 30030268 PMCID: PMC6058234 DOI: 10.1182/bloodadvances.2018017699] [Citation(s) in RCA: 104] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Accepted: 06/12/2018] [Indexed: 01/01/2023] Open
Abstract
Transfusing platelets during massive hemorrhage is debated because of a lack of high-quality evidence concerning outcomes in trauma patients. The objective of this study was to examine the effect of platelet transfusions on mortality in severely injured trauma patients. This work analyzed PROPPR (Pragmatic, Randomized Optimal Platelet and Plasma Ratios) trial patients who received only the first cooler of blood products, which either did or did not contain platelets. Primary outcomes were all-cause mortality at 24 hours and 30 days and hemostasis. Secondary outcomes included cause of death, complications, and hospital-, intensive care unit (ICU)-, and ventilator-free days. Continuous variables were compared using Wilcoxon rank sum tests. Categorical variables were compared using Fisher's exact tests. There were 261 PROPPR patients who achieved hemostasis or died before receiving a second cooler of blood products (137 received platelets and 124 did not). Patients who received platelets also received more total plasma (median, 3 vs 2 U; P < .05) by PROPPR intervention design. There were no differences in total red blood cell transfusions between groups. After controlling for plasma volume, patients who received platelets had significantly decreased 24-hour (5.8% vs 16.9%; P < .05) and 30-day mortality (9.5% vs 20.2%; P < .05). More patients in the platelet group achieved hemostasis (94.9% vs 73.4%; P < .01), and fewer died as a result of exsanguination (1.5% vs 12.9%; P < .01). Patients who received platelets had a shorter time on mechanical ventilation (P < .05); however, no differences in hospital- or ICU-free days were observed. In conclusion, early platelet administration is associated with improved hemostasis and reduced mortality in severely injured, bleeding patients. This trial was registered at www.clinicaltrials.gov as # NCT01545232.
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Affiliation(s)
- Jessica C Cardenas
- Division of Acute Care Surgery, Department of Surgery, McGovern School of Medicine
- Center for Translational Injury Research, and
| | - Xu Zhang
- Center for Translational and Clinical Studies, University of Texas Health Science Center, Houston, TX
| | - Erin E Fox
- Division of Acute Care Surgery, Department of Surgery, McGovern School of Medicine
- Center for Translational Injury Research, and
- Center for Translational and Clinical Studies, University of Texas Health Science Center, Houston, TX
| | - Bryan A Cotton
- Division of Acute Care Surgery, Department of Surgery, McGovern School of Medicine
- Center for Translational Injury Research, and
- Center for Translational and Clinical Studies, University of Texas Health Science Center, Houston, TX
| | - John R Hess
- Department of Laboratory Medicine, Harborview Medical Center, University of Washington, Seattle, WA; and
| | - Martin A Schreiber
- Division of Trauma, Critical Care and Acute Care Surgery, Department of Surgery, Oregon Health and Science University, Portland, OR
| | - Charles E Wade
- Division of Acute Care Surgery, Department of Surgery, McGovern School of Medicine
- Center for Translational Injury Research, and
- Center for Translational and Clinical Studies, University of Texas Health Science Center, Houston, TX
| | - John B Holcomb
- Division of Acute Care Surgery, Department of Surgery, McGovern School of Medicine
- Center for Translational Injury Research, and
- Center for Translational and Clinical Studies, University of Texas Health Science Center, Houston, TX
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Endo A, Shiraishi A, Fushimi K, Murata K, Otomo Y. Outcomes of patients receiving a massive transfusion for major trauma. Br J Surg 2018; 105:1426-1434. [PMID: 29999518 DOI: 10.1002/bjs.10905] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Revised: 04/27/2018] [Accepted: 05/07/2018] [Indexed: 01/05/2023]
Abstract
BACKGROUND The benefits of high transfusion ratios (plasma to red blood cells and platelets to red blood cells) on survival in injured patients who receive massive transfusions remain uncertain. This study aimed to assess the association between transfusion ratios and adverse events and survival in patients undergoing massive transfusion for major trauma. METHODS A retrospective observational study was conducted on patients who had major trauma using a Japanese national administrative database. The associations between transfusion ratios and outcomes (in-hospital mortality and incidence of adverse events) were analysed using a non-linear logistic generalized additive model (GAM). In a logistic generalized estimating equation model, adjusted for patient and hospital-level confounders, transfusion ratios were included as continuous or categorical variables (low, transfusion ratio 0·75 or less; intermediate, over 0·75 to 1·25; high, over 1·25). RESULTS Some 1777 patients were included in the analysis, of whom 602 died in hospital. GAM plots of the transfusion ratios for in-hospital mortality demonstrated a downward convex unimodal curve. In-hospital mortality was similar with increasing transfusion ratios for plasma (adjusted odds ratio (OR) 1·13, 95 per cent c.i. 0·82 to 1·55; P = 0·446) and platelets (adjusted OR 0·84, 0·66 to 1·08; P = 0·171). Both plasma to red blood cell ratio (adjusted OR 1·77, 1·32 to 2·37; P < 0·001) and platelet to red blood cell ratio (adjusted OR 1·71, 1·35 to 2·15; P < 0·001) were significantly associated with a higher incidence of adverse events. No significant differences in in-hospital mortality were observed between the three transfusion categories (low, medium and high). CONCLUSION In this study, transfusion strategies with high plasma to red blood cell and platelet to red blood cell ratios did not have survival benefits, but were associated with an increase in adverse events.
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Affiliation(s)
- A Endo
- Trauma and Acute Critical Care Medical Centre, Tokyo Medical and Dental University Hospital of Medicine, Tokyo, Japan
| | - A Shiraishi
- Trauma and Acute Critical Care Medical Centre, Tokyo Medical and Dental University Hospital of Medicine, Tokyo, Japan.,Emergency and Trauma Centre, Kameda Medical Centre, Kamogawa, Japan
| | - K Fushimi
- Department of Health Policy and Informatics, Tokyo Medical and Dental University Graduate School of Medicine, Tokyo, Japan
| | - K Murata
- Trauma and Acute Critical Care Medical Centre, Tokyo Medical and Dental University Hospital of Medicine, Tokyo, Japan.,Shock Trauma and Emergency Medical Centre, Matsudo City Hospital, Matsudo, Japan
| | - Y Otomo
- Trauma and Acute Critical Care Medical Centre, Tokyo Medical and Dental University Hospital of Medicine, Tokyo, Japan
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Early haemorrhage control and management of trauma-induced coagulopathy: the importance of goal-directed therapy. Curr Opin Crit Care 2018; 23:503-510. [PMID: 29059118 DOI: 10.1097/mcc.0000000000000466] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
PURPOSE OF REVIEW The aim of this study was to discuss the recent developments in trauma-induced coagulopathy and the evolvement of goal-directed therapy. RECENT FINDINGS Mortality from major trauma continues to be a worldwide problem, and massive haemorrhage remains a major cause in 40% of potentially preventable trauma deaths. Development of trauma-induced coagulopathy challenges 25-35% of the patients further increasing trauma mortality. The pathophysiology of coagulopathy in trauma reflects at least two distinct mechanisms: Acute traumatic coagulopathy, consisting of endogenous heparinization, activation of the protein C pathway, hyperfibrinolysis and platelet dysfunction, and resuscitation associated coagulopathy. Clear fluid resuscitation with crystalloids and colloids is associated with dilutional coagulopathy and poor outcome in trauma. Haemostatic resuscitation is now the backbone of trauma resuscitation using a ratio-driven strategy aiming at 1:1:1 of red blood cells, plasma and platelets while applying goal-directed therapy early and repeatedly to control trauma-induced coagulopathy. SUMMARY Trauma resuscitation should focus on early goal-directed therapy with use of viscoelastic haemostatic assays while initially applying a ratio 1:1:1 driven transfusion therapy (with red blood cells, plasma and platelets) in order to sustain normal haemostasis and control further bleeding.
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Abstract
PURPOSE OF REVIEW Although nonoperative management (NOM) is the safest option in most patients with liver and splenic injuries or splenic injuries, some cases still need operative intervention. The aim of this review is to address the most recent literature and the evidence it provides for indications and timing of operative treatment for liver and spleen injuries. RECENT FINDINGS There seems to be a decrease in publication rate on these topics over the last years, parallel to the acceptance of NOM as the 'gold standard', with little added to the existing body of evidence over the last 12-24 months. Most published studies are retrospective descriptions or comparisons with historical controls, some observational studies, but no randomized control trials (RCTs).There is a striking lack of high-level evidence for the optimal treatment of solid organ injuries. The role of angiographic embolization as an adjunct to the treatment of liver and spleen injuries is still a matter of discussion. SUMMARY Unstable patients with suspected ongoing bleeding from liver and spleen injuries or spleen injuries with inadequate effect of resuscitation should undergo immediate explorative laparotomy.More RCTs are needed to further determine the role of angiographic embolization and who can be safely be treated nonoperatively and who needs surgical intervention.
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Rossignol Y, Huet O, Chapalain X, Le Maguet P, Sparrow R, L'Her E, Le Niger C, Ozier Y, Aubron C. Compliance with the European trauma guidelines: An observational single centre study. Transfus Clin Biol 2018; 26:18-26. [PMID: 29936040 DOI: 10.1016/j.tracli.2018.05.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Accepted: 05/24/2018] [Indexed: 11/16/2022]
Abstract
OBJECTIVES The European trauma guidelines were developed to assist clinicians in the early phase of trauma management to diagnose and treat coagulopathy and bleeding. This study aimed to determine compliance with these European trauma guidelines in a French referral trauma centre. METHODS Medical charts of trauma patients with an injury severity score≥16 admitted between January 2013 and December 2014 were reviewed. Compliance with 21 recommendations in the first 24-hours of patient management was assessed. RESULTS There were 145 patients with median ISS of 34 [IQR 25-41]. A good level of compliance (i.e. applied in≥80% of patients) was identified for nine recommendations, inconsistent compliance (i.e. applied in 50 to 79% of patients) for six recommendations, including fibrinogen levels at hospital admission and achievement of a target mean arterial blood pressure (MAP)>80mmHg in patients with major bleeding and TBI (55.5%), and poor compliance (i.e. applied in<50% of patients) for another six recommendations. Poorly applied recommendations included early measurement of lactate or base deficit (32%), early administration of tranexamic acid (18%), and achievement of normocapnia in patients with TBI undergoing invasive ventilation (3%). CONCLUSIONS In a referral trauma centre, nine of the 21 evaluable recommendations in the European trauma guidelines were applied in≥80% of patients. Early diagnosis and treatment of trauma-related coagulopathy was identified as an area for significant practice improvement. In patients with TBI, efforts should be made to achieve the targeted MAP and to maintain normocapnia.
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Affiliation(s)
- Y Rossignol
- Department of Anaesthesiology and Surgical Intensive Care, Centre Hospitalier et Universitaire de Brest, Université de Bretagne Occidentale, 29200 Brest, France
| | - O Huet
- Department of Anaesthesiology and Surgical Intensive Care, Centre Hospitalier et Universitaire de Brest, Université de Bretagne Occidentale, 29200 Brest, France
| | - X Chapalain
- Department of Anaesthesiology and Surgical Intensive Care, Centre Hospitalier et Universitaire de Brest, Université de Bretagne Occidentale, 29200 Brest, France
| | - P Le Maguet
- Department of Anaesthesiology and Surgical Intensive Care, Centre Hospitalier et Universitaire de Brest, Université de Bretagne Occidentale, 29200 Brest, France
| | - R Sparrow
- Department of Epidemiology and Preventive Medicine, Monash University, 3004 Melbourne, Australia
| | - E L'Her
- Emergency Department, Centre Hospitalier et Universitaire de Brest, Université de Bretagne Occidentale, 29200 Brest, France; Medical Intensive Care Unit, Centre Hospitalier et Universitaire de Brest, Université de Bretagne Occidentale, 29200 Brest, France
| | - C Le Niger
- Haemovigilance Unit, Centre Hospitalier et Universitaire de Brest, Université de Bretagne Occidentale, 29200 Brest, France
| | - Y Ozier
- Department of Anaesthesiology and Surgical Intensive Care, Centre Hospitalier et Universitaire de Brest, Université de Bretagne Occidentale, 29200 Brest, France
| | - C Aubron
- Medical Intensive Care Unit, Centre Hospitalier et Universitaire de Brest, Université de Bretagne Occidentale, 29200 Brest, France; Department of Epidemiology and Preventive Medicine, Monash University, 3004 Melbourne, Australia.
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Abstract
Development and standardization of fibrinolysis methods have progressed more slowly than coagulation testing and routine high-throughput screening tests for fibrinolysis are still lacking. In laboratory research, a variety of approaches are available and are applied to understand the regulation of fibrinolysis and its contribution to the hemostatic balance. Fibrinolysis in normal blood is slow to develop. For practical purposes plasminogen activators can be added to clotting plasma, or euglobulin prepared to reduce endogenous inhibitors, but results are complicated by these manipulations. Observational studies to identify a 'fibrinolysis deficit' have concluded that excess fibrinolysis inhibitors, plasminogen activator inhibitor 1 (PAI-1) or thrombin-activatable fibrinolysis inhibitor (TAFI), zymogen or active enzyme, may be associated with an increased risk of thrombosis. However, results are not always consistent and problems of adequate standardization are evident with these inhibitors and also for measurement of fibrin degradation products (D-dimer). Few methods are available to investigate fibrinolysis under flow, or in whole blood, but viscoelastic methods (VMs) such as ROTEM and TEG do permit the contribution of cells, and importantly platelets, to be explored. VMs are used to diagnose clinical hyperfibrinolysis, which is associated with high mortality. There is a debate on the usefulness of VMs as a point-of-care test method, particularly in trauma. Despite the difficulties of many fibrinolysis methods, research on the fibrinolysis system, taking in wider interactions with hemostasis proteins, is progressing so that in future we may have more complete models and better diagnostic methods and therapeutics.
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Affiliation(s)
- C. Longstaff
- Biotherapeutics DivisionNational Institute for Biological Standards and ControlSouth MimmsUK
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The temporal response and mechanism of action of tranexamic acid in endothelial glycocalyx degradation. J Trauma Acute Care Surg 2018; 84:75-80. [PMID: 29040203 DOI: 10.1097/ta.0000000000001726] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND The endothelial glycocalyx (GCX) plays an important role in vascular barrier function. Damage to the GCX occurs due to a variety of causes including hypoxia, ischemia-reperfusion, stress-related sympathoadrenal activation, and inflammation. Tranexamic acid (TXA) may prevent GCX degradation. The therapeutic window for TXA administration and the mechanism of action has been under review. Membrane-anchored proteases (sheddases) are key components in endothelial cell biology including the regulation of vascular permeability. The effect of TXA administration on stress-related GCX damage, and the role of sheddases in this process was studied in a cell-based model. METHODS Confluent human umbilical vein endothelial cells (HUVEC) were exposed to hydrogen peroxide and/or epinephrine (EPI) to stimulate postshock reperfusion. TXA was added at various times after hydrogen peroxide (H2O2) and/or EPI exposure. GCX degradation was indexed by syndecan-1 and hyaluronic acid release. Activation of endothelial sheddases was indexed by A Disintegrin and Metalloproteinase-17 and matrix metalloproteinase-9 activity in culture supernatants. RESULTS Exposure of HUVEC to either/both EPI and H2O2 resulted in a cellular stress and GCX disruption demonstrated by increased levels of syndecan-1 shedding, hyaluronic acid release, tumor necrosis factor-α release. Shedding of these GCX components was associated with increased activity of both A Disintegrin and Metalloproteinase-17 and matrix metalloproteinase. Disruption of the GCX was further demonstrated via fluorescent imaging, which demonstrated disruption after exposure to either/both H2O2 and EPI. Early administration of either TXA or doxycycline resulted in preservation of the GCX. Late administration of TXA had no effect, whereas doxycycline had some residual protective effect. CONCLUSION Tranexamic acid as a serine protease inhibitor prevented GCX degradation via inhibition of endothelial sheddase activation. This effect was not apparent when TXA was administered greater than 60 minutes after "simulated" reperfusion. Our study supports the clinical practice of early TXA administration in the severely injured patient.
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Sinha R, Roxby D. Any changes in recent massive transfusion practices in a tertiary level institution? Transfus Apher Sci 2017; 56:558-562. [PMID: 28688890 DOI: 10.1016/j.transci.2017.05.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Revised: 05/10/2017] [Accepted: 05/12/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND & OBJECTIVES A previous review of transfusion practices in our institution between 1998 and 2008 showed a trend of high ratios of red cells (RC) to plasma (FFP) and platelets to RC towards the later years of review period. The aim of the study was to further evaluate transfusion practices in the form of blood product usage and outcomes following massive transfusion (MT) METHODS: All adult patients with critical bleeding who received a MT (defined as ≥10 units of RC in 24h) in 2008 and between January 2010 and December 2014 were identified. Blood and blood products transfused, in-hospital mortality, 24h and 90-day mortality were analysed for the period 2010-2014. Blood and blood product usage, massive transfusion protocol (MTP) activation and use of ROTEM between 2008 and 2014 were compared. RESULTS A total of 190 MT including surgical (52.1%), gastro-intestinal bleeding (25.3%), trauma (11.6%) and obstetric haemorrhage (5.8%) episodes were identified between 2010 and 2014. The overall in-hospital mortality was 26.7% with a significant difference in 24h (p=0.04) and 90-day mortality (p=0.02) between diagnostic groups. Comparing 2008 (n=33) and 2014 (n=23), there was no significant difference in median RC, FFP and platelet units, cryoprecipitate doses and RC:FFP ratio; however there was an increase in number of patients who used cryoprecipitate (54.5% vs 87%, p=0.01). CONCLUSION Aligned with haemostatic resuscitation, the trend continues in the form of increased use of plasma and higher RC:FFP transfusion ratios including an increase in number of patients receiving cryoprecipitate.
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Affiliation(s)
- Romi Sinha
- Flinders University, Department of Haematology and Genetic Pathology, School of Medicine, Bedford Park, SA 5042, Australia.
| | - David Roxby
- Flinders University, Department of Haematology and Genetic Pathology, School of Medicine, Bedford Park, SA 5042, Australia
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