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Lubkin DT, Mueck KM, Hatton GE, Brill JB, Sandoval M, Cardenas JC, Wade CE, Cotton BA. Does an early, balanced resuscitation strategy reduce the incidence of hypofibrinogenemia in hemorrhagic shock? Trauma Surg Acute Care Open 2024; 9:e001193. [PMID: 38596569 PMCID: PMC11002398 DOI: 10.1136/tsaco-2023-001193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2023] [Accepted: 03/20/2024] [Indexed: 04/11/2024] Open
Abstract
Objectives Some centers have recommended including concentrated fibrinogen replacement in massive transfusion protocols (MTPs). Given our center's policy of aggressive early balanced resuscitation (1:1:1), beginning prehospital, we hypothesized that our rates of hypofibrinogenemia may be lower than those previously reported. Methods In this retrospective cohort study, patients presenting to our trauma center November 2017 to April 2021 were reviewed. Patients were defined as hypofibrinogenemic (HYPOFIB) if admission fibrinogen <150 or rapid thrombelastography angle <60. Univariate and multivariable analyses assessed risk factors for HYPOFIB. Inverse probability of treatment weighting analyses assessed the relationship between cryoprecipitate administration and outcomes. Results Of 29 782 patients, 6618 level 1 activations, and 1948 patients receiving emergency release blood, <1%, 2%, and 7% were HYPOFIB. HYPOFIB patients were younger, had higher head Abbreviated Injury Scale value, and had worse coagulopathy and shock. HYPOFIB had lower survival (48% vs 82%, p<0.001), shorter time to death (median 28 (7, 50) vs 36 (14, 140) hours, p=0.012), and were more likely to die from head injury (72% vs 51%, p<0.001). Risk factors for HYPOFIB included increased age (OR (95% CI) 0.98 (0.96 to 0.99), p=0.03), head injury severity (OR 1.24 (1.06 to 1.46), p=0.009), lower arrival pH (OR 0.01 (0.001 to 0.20), p=0.002), and elevated prehospital red blood cell to platelet ratio (OR 1.20 (1.02 to 1.41), p=0.03). Among HYPOFIB patients, there was no difference in survival for those that received early cryoprecipitate (within 2 hours; 40 vs 47%; p=0.630). On inverse probability of treatment weighted analysis, early cryoprecipitate did not benefit the full cohort (OR 0.52 (0.43 to 0.65), p<0.001), nor the HYPOFIB subgroup (0.28 (0.20 to 0.39), p<0.001). Conclusions Low rates of hypofibrinogenemia were found in our center which treats hemorrhage with early, balanced resuscitation. Previously reported higher rates may be partially due to unbalanced resuscitation and/or delay in resuscitation initiation. Routine empiric inclusion of concentrated fibrinogen replacement in MTPs is not supported by the currently available data. Level of evidence Level III.
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Affiliation(s)
- David T Lubkin
- Surgery, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Krislynn M Mueck
- Surgery, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Gabrielle E Hatton
- Surgery, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Jason B Brill
- Surgery, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Mariela Sandoval
- Surgery, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Jessica C Cardenas
- Surgery, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Charles E Wade
- Surgery, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Bryan A Cotton
- Surgery, The University of Texas Health Science Center at Houston, Houston, Texas, USA
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Helsloot D, Fitzgerald M, Lefering R, Verelst S, Missant C. Trauma-induced disturbances in ionized calcium levels correlate parabolically with coagulopathy, transfusion, and mortality: a multicentre cohort analysis from the TraumaRegister DGU ®. Crit Care 2023; 27:267. [PMID: 37415194 PMCID: PMC10324195 DOI: 10.1186/s13054-023-04541-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Accepted: 06/22/2023] [Indexed: 07/08/2023] Open
Abstract
BACKGROUND To which extent trauma- induced disturbances in ionized calcium (iCa2+) levels have a linear relationship with adverse outcomes remains controversial. The goal of this study was to determine the association between the distribution and accompanying characteristics of transfusion-independent iCa2+ levels versus outcome in a large cohort of major trauma patients upon arrival at the emergency department. METHODS A retrospective observational analysis of the TraumaRegister DGU® (2015-2019) was performed. Adult major trauma patients with direct admission to a European trauma centre were selected as the study cohort. Mortality at 6 h and 24 h, in-hospital mortality, coagulopathy, and need for transfusion were considered as relevant outcome parameters. The distribution of iCa2+ levels upon arrival at the emergency department was calculated in relation to these outcome parameters. Multivariable logistic regression analysis was performed to determine independent associations. RESULTS In the TraumaRegister DGU® 30 183 adult major trauma patients were found eligible for inclusion. iCa2+ disturbances affected 16.4% of patients, with hypocalcemia (< 1.10 mmol/l) being more frequent (13.2%) compared to hypercalcemia (≥ 1.30 mmol/l, 3.2%). Patients with hypo- and hypercalcemia were both more likely (P < .001) to have severe injury, shock, acidosis, coagulopathy, transfusion requirement, and haemorrhage as cause of death. Moreover, both groups had significant lower survival rates. All these findings were most distinct in hypercalcemic patients. When adjusting for potential confounders, mortality at 6 h was independently associated with iCa2+ < 0.90 mmol/L (OR 2.69, 95% CI 1.67-4.34; P < .001), iCa2+ 1.30-1.39 mmol/L (OR 1.56, 95% CI 1.04-2.32, P = 0.030), and iCa2+ ≥ 1.40 mmol/L (OR 2.87, 95% CI 1.57-5.26; P < .001). Moreover, an independent relationship was determined for iCa2+ 1.00-1.09 mmol/L with mortality at 24 h (OR 1.25, 95% CI 1.05-1.48; P = .0011), and with in-hospital mortality (OR 1.29, 95% CI 1.13-1.47; P < .001). Both hypocalcemia < 1.10 mmol/L and hypercalcemia ≥ 1.30 mmol/L had an independent association with coagulopathy and transfusion. CONCLUSIONS Transfusion-independent iCa2+ levels in major trauma patients upon arrival at the emergency department have a parabolic relationship with coagulopathy, need for transfusion, and mortality. Further research is needed to confirm whether iCa2+ levels change dynamically and are more a reflection of severity of injury and accompanying physiological derangements, rather than an individual parameter that needs to be corrected as such.
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Affiliation(s)
- Dries Helsloot
- Department of Anaesthesia and Emergency Medicine, AZ Groeninge Hospital, President Kennedylaan 4, 8500, Kortrijk, Belgium.
- Department of Cardiovascular Sciences, KU Leuven University Campus Kulak, Etienne Sabbelaan 53, Box 7700, 8500, Kortrijk, Belgium.
- National Trauma Research Institute, Alfred Health and Monash University, Level 4, 89 Commercial Road, Melbourne, VIC, 3004, Australia.
| | - Mark Fitzgerald
- National Trauma Research Institute, Alfred Health and Monash University, Level 4, 89 Commercial Road, Melbourne, VIC, 3004, Australia
- Trauma Service, The Alfred Hospital, 55 Commercial Road, Melbourne, VIC, 3004, Australia
| | - Rolf Lefering
- Institute for Research in Operative Medicine (IFOM), Universität Witten/Herdecke, Ostmerheimer Str.200, Haus 38, 51109, Cologne, Germany
| | - Sandra Verelst
- Department of Emergency Medicine, UZ Leuven Hospital, Herestraat 49, 3000, Leuven, Belgium
- Department of Public Health and Primary Care, KU Leuven University, Herestraat 49, Box 7003, 3000, Leuven, Belgium
| | - Carlo Missant
- Department of Anaesthesia and Emergency Medicine, AZ Groeninge Hospital, President Kennedylaan 4, 8500, Kortrijk, Belgium
- Department of Cardiovascular Sciences, KU Leuven University Campus Kulak, Etienne Sabbelaan 53, Box 7700, 8500, Kortrijk, Belgium
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Han M, Lin W, Huang S, Lin Z, Li K. Association between plasma metal elements and platelet dysfunction in trauma-induced coagulopathy rat model. J Trace Elem Med Biol 2023; 79:127210. [PMID: 37229983 DOI: 10.1016/j.jtemb.2023.127210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Revised: 03/30/2023] [Accepted: 05/17/2023] [Indexed: 05/27/2023]
Abstract
BACKGROUND Disorders of metal elements and platelet dysfunction are common in patients with trauma-induced coagulopathy (TIC). AIM The aim of this study was to explore the potential role of plasma metal elements in platelet dysfunction in TIC. METHODS Thirty Sprague-Dawley rats were divided into control, hemorrhage shock (HS) and multiple injury (MI) groups. At timepoints of 0.5 and 3 h after trauma and being documented as HS 0.5 h, HS3 h, MI 0.5 h or MI3 h, blood samples were harvested for inductively coupled plasma mass spectrometer, conventional coagulation function and thromboelastograph. RESULTS The plasma zinc (Zn), vanadium (V) and cadmium (Ca) decreased initially in HS 0.5 h and recovered slightly in HS3 h, whereas their plasma concentrations continued to decrease from beginning till MI3 h (p < 0.05). In HS, plasma Ca, V and nickel were negatively correlated to the time taken to reach the initial formation (R), whereas R was positively correlated to plasms Zn, V, Ca and selenium in MI (p < 0.05). In MI, plasma Ca was positively correlated to maximum amplitude, and plasma V was positively correlated to platelet count (p < 0.05). CONCLUSION The plasma concentrations of Zn, V and Ca appeared to contribute to platelet dysfunction in HS 0.5 h, HS3 h, MI 0.5 h and MI3 h, which were trauma type sensitive.
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Affiliation(s)
- Ming Han
- Department of Microbiology and Immunology, Shantou University Medical College, Shantou, China; Department of Emergency, Shenzhen University General Hospital, Shenzhen University Clinical Medical Academy, Shenzhen, China
| | - Wenhao Lin
- Department of Emergency, Shenzhen University General Hospital, Shenzhen University Clinical Medical Academy, Shenzhen, China
| | - Sunhua Huang
- Department of General Surgery, Shanghai Eastern Hepatobiliary Surgery Hospital, Shanghai, China
| | - Zhexuan Lin
- Bio-analytical Laboratory, Shantou University Medical College, Shantou, China
| | - Kangsheng Li
- Department of Microbiology and Immunology, Shantou University Medical College, Shantou, China.
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Mi YH, Xu MY. Trauma-induced pulmonary thromboembolism: What's update? Chin J Traumatol 2022; 25:67-76. [PMID: 34404569 PMCID: PMC9039469 DOI: 10.1016/j.cjtee.2021.08.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 07/26/2021] [Accepted: 08/02/2021] [Indexed: 02/04/2023] Open
Abstract
Trauma-induced pulmonary thromboembolism is the second leading cause of death in severe trauma patients. Primary fibrinolytic hyperactivity combined with hemorrhage and consequential hypercoagulability in severe trauma patients create a huge challenge for clinicians. It is crucial to ensure a safe anticoagulant therapy for trauma patients, but a series of clinical issues need to be answered first, for example, what are the risk factors for traumatic venous thromboembolism? How to assess and determine the status of coagulation dysfunction of patients? When is the optimal timing to initiate pharmacologic prophylaxis for venous thromboembolism? What types of prophylactic agents should be used? How to manage the anticoagulation-related hemorrhage and to determine the optimal timing of restarting chemoprophylaxis? The present review attempts to answer the above questions.
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Borowko R, Vignon PO, Lutz N, Maillot A, Lefort H. [The lethal triad of hemorrhage]. REVUE DE L'INFIRMIÈRE 2021; 70:16-18. [PMID: 34446227 DOI: 10.1016/j.revinf.2021.06.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Coagulopathy, acidosis and hypothermia form the lethal triad in trauma patients with acute hemorrhage. The prevention of this chain reaction relies on an adapted management from the first care in pre-hospital situation: rapid arrest of bleeding, fight against hypothermia, limited vascular filling with an early recourse to vasoactive amines. Pre-hospital transfusion is still rare, whereas in the hospital, an adapted transfusion strategy can wait for or support a surgical or radiological hemostasis procedure.
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Affiliation(s)
- Rachel Borowko
- Structure des urgences, hôpital d'instruction des armées Legouest, rue des Frères-Lacretelle, 57000 Metz, France
| | - Pierre-Olivier Vignon
- Structure des urgences, hôpital d'instruction des armées Legouest, rue des Frères-Lacretelle, 57000 Metz, France
| | - Noémie Lutz
- Structure des urgences, hôpital d'instruction des armées Legouest, rue des Frères-Lacretelle, 57000 Metz, France
| | - Aline Maillot
- Structure des urgences, hôpital d'instruction des armées Legouest, rue des Frères-Lacretelle, 57000 Metz, France
| | - Hugues Lefort
- Structure des urgences, hôpital d'instruction des armées Legouest, rue des Frères-Lacretelle, 57000 Metz, France; Structure des urgences, hôpital d'instruction des armées Lavéran, 34 boulevard Lavéran, 13384 Marseille, France.
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Johannsen S, Brohi K, Johansson PI, Moore EE, Reinhold AK, Schöchl H, Shepherd JM, Slater B, Stensballe J, Zacharowski K, Meybohm P. Getting hit by the bus around the world - a global perspective on goal directed treatment of massive hemorrhage in trauma. Curr Opin Anaesthesiol 2021; 34:537-543. [PMID: 34074885 DOI: 10.1097/aco.0000000000001025] [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: 12/26/2022]
Abstract
PURPOSE OF REVIEW Major trauma remains one of the leading causes of death worldwide with traumatic brain injury and uncontrolled traumatic bleeding as the main determinants of fatal outcome. Interestingly, the therapeutic approach to trauma-associated bleeding and coagulopathy shows differences between geographic regions, that are reflected in different guidelines and protocols. RECENT FINDINGS This article summarizes main principles in coagulation diagnostics and compares different strategies for treatment of massive hemorrhage after trauma in different regions of the world. How would a bleeding trauma patient be managed if they got hit by the bus in the United States, United Kingdom, Germany, Switzerland, Austria, Denmark, Australia, or in Japan? SUMMARY There are multiple coexistent treatment standards for trauma-induced coagulopathy in different countries and different trauma centers. Most of them initially follow a protocol-based approach and subsequently focus on predefined clinical and laboratory targets.
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Affiliation(s)
- Stephan Johannsen
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Karim Brohi
- Centre for Trauma Sciences, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Pär I Johansson
- Section for Transfusion Medicine, Capital Region Blood Bank, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Ernest E Moore
- Department of Surgery, Ernest E Moore Shock Trauma Center at Denver Health, University of Colorado, Denver, Colorado, USA
| | - Ann-Kristin Reinhold
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Herbert Schöchl
- Department of Anaesthesiology and Intensive Care Medicine, AUVA Trauma Centre Salzburg, Academic Teaching Hospital of the Paracelsus Medical University, Salzburg
- Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, AUVA Trauma Research Centre, Vienna, Austria
| | - Joanna M Shepherd
- Centre for Trauma Sciences, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Ben Slater
- Department of Anaesthesia and Acute Pain Medicine, Melbourne Medical School, The University of Melbourne, Melbourne, Australia
| | - Jakob Stensballe
- Section for Transfusion Medicine, Capital Region Blood Bank, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Anesthesia and Trauma Center, Centre of Head and Orthopaedics, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Kai Zacharowski
- Department of Anaesthesiology, Intensive Care and Pain Therapy, University Hospital Frankfurt, Frankfurt/Main, Germany
| | - Patrick Meybohm
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Wuerzburg, Wuerzburg, Germany
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Casu S. Simplified treatment algorithm for the management of trauma-induced hemorrhage without viscoelastic testing. Trauma Surg Acute Care Open 2021; 6:e000779. [PMID: 34337159 PMCID: PMC8287615 DOI: 10.1136/tsaco-2021-000779] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Accepted: 07/02/2021] [Indexed: 11/30/2022] Open
Abstract
Uncontrolled bleeding after major trauma remains a significant cause of death, with up to a third of trauma patients presenting with signs of coagulopathy at hospital admission. Rapid correction of coagulopathy is therefore vital to improve mortality rates and patient outcomes in this population. Early and repeated monitoring of coagulation parameters followed by clear protocols to correct hemostasis is the recommended standard of care for bleeding trauma patients. However, although a number of treatment algorithms are available, these are frequently complex and can rely on the use of viscoelastic testing, which is not available in all treatment centers. We therefore set out to develop a concise and pragmatic algorithm to guide treatment of bleeding trauma patients without the use of point-of-care viscoelastic testing. The algorithm we present here is based on published guidelines and research, includes recommendations regarding treatment and dosing, and is simple and clear enough for even an inexperienced physician to follow. In this way, we have demonstrated that treatment protocols can be developed and adapted to the resources available, to offer clear and relevant guidance to the entire trauma team.
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Affiliation(s)
- Sebastian Casu
- Department of Emergency Medicine, Asklepios Hospital Wandsbek, Hamburg, Germany
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8
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The European Perspective on the Management of Acute Major Hemorrhage and Coagulopathy after Trauma: Summary of the 2019 Updated European Guideline. J Clin Med 2021; 10:jcm10020362. [PMID: 33478011 PMCID: PMC7835990 DOI: 10.3390/jcm10020362] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 12/09/2020] [Accepted: 12/14/2020] [Indexed: 12/16/2022] Open
Abstract
Non-controlled hemorrhage with accompanying trauma-induced coagulopathy (TIC) remains the most common cause of preventable death after multiple injury. Rapid identification followed by aggressive treatment is the key for improved outcomes. Treatment of trauma hemorrhage begins at the scene, with manual compression, the use of tourniquets and (non) commercial pelvic slings, and rapid transfer to an adequate trauma center. Upon hospital admission, coagulation monitoring and support are to be initiated immediately. Bleeding is controlled surgically following damage control principles. Modern coagulation management includes goal-oriented, individualized therapies, guided by point-of-care viscoelastic assays. Idarucizumab can be used as an antidote to the thrombin inhibitor dabigatran, andexanet alpha as an antidote to factor Xa inhibitors. This review summarizes the key recommendations of the 2019 updated European guideline on the management of major bleeding and coagulopathy following trauma. These evidence-based recommendations may form the backbone of algorithms adapted to local logistics and infrastructure.
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Scala E, Marcucci C. Massive Hemorrhage: The Role of Whole Blood Viscoelastic Assays. Hamostaseologie 2020; 40:515-523. [PMID: 33091949 DOI: 10.1055/a-1227-8050] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Viscoelastic whole blood tests are increasingly used to guide hemostatic therapy in bleeding patients in the perioperative, trauma, and obstetric settings. Compared with standard laboratory tests of hemostasis, they have a shorter turnaround time and provide simultaneous information on various aspects of clot formation and lysis. The two available brands TEG (thromboelastography) and ROTEM (rotational thromboelastometry) provide devices that are either manually operated or fully automated. The automation allows for the assays to be used as point-of-care tests increasing their usefulness in massively bleeding patients with rapidly changing hemostatic profiles. While the number of research papers on the subject and the number of published treatment algorithms increase rapidly, the influence of the use of these devices on patient outcome needs yet to be established. In this article, we first review the technology of these devices and the parameters provided by the assays. Next, we present the problems encountered when choosing cut-off values that trigger intervention. Furthermore, we discuss the studies examining their influence on clinical outcomes, and finally, we briefly highlight some of the most important limitations and pitfalls inherent to these assays.
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Affiliation(s)
- Emmanuelle Scala
- Department of Anesthesiology, Lausanne University Hospital, Lausanne, Switzerland
| | - Carlo Marcucci
- Department of Anesthesiology, Lausanne University Hospital, Lausanne, Switzerland.,Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
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Abstract
Physical trauma can affect any individual and is globally accountable for more than one in every ten deaths. Although direct severe kidney trauma is relatively infrequent, extrarenal tissue trauma frequently results in the development of acute kidney injury (AKI). Various causes, including haemorrhagic shock, rhabdomyolysis, use of nephrotoxic drugs and infectious complications, can trigger and exacerbate trauma-related AKI (TRAKI), particularly in the presence of pre-existing or trauma-specific risk factors. Injured, hypoxic and ischaemic tissues expose the organism to damage-associated and pathogen-associated molecular patterns, and oxidative stress, all of which initiate a complex immunopathophysiological response that results in macrocirculatory and microcirculatory disturbances in the kidney, and functional impairment. The simultaneous activation of components of innate immunity, including leukocytes, coagulation factors and complement proteins, drives kidney inflammation, glomerular and tubular damage, and breakdown of the blood-urine barrier. This immune response is also an integral part of the intense post-trauma crosstalk between the kidneys, the nervous system and other organs, which aggravates multi-organ dysfunction. Necessary lifesaving procedures used in trauma management might have ambivalent effects as they stabilize injured tissue and organs while simultaneously exacerbating kidney injury. Consequently, only a small number of pathophysiological and immunomodulatory therapeutic targets for TRAKI prevention have been proposed and evaluated.
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Adam EH, Fischer D. Plasma Transfusion Practice in Adult Surgical Patients: Systematic Review of the Literature. Transfus Med Hemother 2020; 47:347-359. [PMID: 33173453 DOI: 10.1159/000511271] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Accepted: 08/31/2020] [Indexed: 12/18/2022] Open
Abstract
Background Plasma transfusions are most commonly used therapeutically for bleeding or prophylactically in non-bleeding patients prior to invasive procedures or surgery. Although plasma transfusions generally seem to decline, plasma usage for indications that lack evidence of efficacy prevail. Summary There is wide international, interinstitutional, and interindividual variance regarding the compliance with guidelines based on published references, supported by appropriate testing. There is furthermore a profound lack of evidence from randomized controlled trials comparing the effect of plasma transfusion with that of other therapeutic interventions for most indications, including massive bleeding. The expected benefit of a plasma transfusion needs to be balanced carefully against the associated risk of adverse events. In light of the heterogeneous nature of bleeding conditions and their rapid evolvement over time, fibrinogen and factor concentrate therapy, directed at specific phases of coagulation identified by alternative laboratory assays, may offer advantages over conventional blood product ratio-driven resuscitation. However, their outcome benefit has not been demonstrated in well-powered prospective trials. This systematic review will detail the current evidence base for plasma transfusion in adult surgical patients.
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Affiliation(s)
- Elisabeth Hannah Adam
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe University, Frankfurt, Germany
| | - Dania Fischer
- Department of Anesthesiology, Heidelberg University Hospital, Heidelberg, Germany
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Orthopedic injuries in patients with multiple injuries: Results of the 11th trauma update international consensus conference Milan, December 11, 2017. J Trauma Acute Care Surg 2020; 88:e53-e76. [PMID: 32150031 DOI: 10.1097/ta.0000000000002407] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND In blunt trauma, orthopedic injuries are often associated with cerebral and torso injuries. The optimal timing for definitive care is a concern. The aim of the study was to develop evidence-based guidelines for damage-control orthopedic (DCO) and early total care (ETC) of pelvic and long-bone fractures, closed or open, and mangled extremities in adult trauma patients with and without associated injuries. METHODS The literature since 2000 to 2016 was systematically screened according to Preferred Reporting Items for Systematic Reviews and meta-analyses protocol. One hundred twenty-four articles were reviewed by a panel of experts to assign grade of recommendation and level of evidence using the Grading of recommendations Assessment, Development, and Evaluation system, and an International Consensus Conference, endorsed by several scientific societies was held. RESULTS The choice between DCO and ETC depends on the patient's physiology, as well as associated injuries. In hemodynamically unstable pelvic fracture patient, extraperitoneal pelvic packing, angioembolization, external fixation, C-clamp, and resuscitative endovascular balloon occlusion of the aorta are not mutually exclusive. Definitive reconstruction should be deferred until recovery of physiological stability. In long bone fractures, DCO is performed by external fixation, while ETC should be preferred in fully resuscitated patients because of better outcomes. In open fractures early debridement within 24 hours should be recommended and early closure of most grade I, II, IIIa performed. In mangled extremities, limb salvage should be considered for non-life-threatening injuries, mostly of upper limb. CONCLUSION Orthopedic priorities may be: to save a life: control hemorrhage by stabilizing the pelvis and femur fractures; to save a limb: treat soft tissue and vascular injuries associated with fractures, stabilize fractures, recognize, and prevent compartmental syndrome; to save functionality: treat dislocations, articular fractures, distal fractures. While DCO is the best initial treatment to reduce surgical load, ETC should be applied in stable or stabilized patients to accelerate the recovery of normal functions. LEVEL OF EVIDENCE Systematic review of predominantly level II studies, level II.
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Leal-Noval SR, Fernández Pacheco J, Casado Méndez M, Cuenca-Apolo D, Múñoz-Gómez M. Current perspective on fibrinogen concentrate in critical bleeding. Expert Rev Clin Pharmacol 2020; 13:761-778. [PMID: 32479129 DOI: 10.1080/17512433.2020.1776608] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
INTRODUCTION . Massive hemorrhage continues to be a treatable cause of death. Its management varies from prefixed ratio-driven administration of blood components to goal-directed therapy based on point-of-care testing and administration of coagulation factor concentrates. AREAS COVERED . We review the current role of fibrinogen concentrate (FC) for the management of massive hemorrhage, either administered without coagulation testing in life-threatening hemorrhage, or within an algorithm based on viscoelastic hemostatic assays and plasma fibrinogen level. We identified relevant guidelines, meta-analyzes, randomized controlled trials, and observational studies that included indications, dosage, and adverse effects of FC, especially thromboembolic events. EXPERT OPINION . Moderate- to high-grade evidence supports the use of FC for the treatment of severe hemorrhage in trauma and cardiac surgery; a lower grade of evidence is available for its use in postpartum hemorrhage and end-stage liver disease. Pre-emptive FC administration in non-bleeding patients is not recommended. FC should be administered early, in a goal-directed manner, guided by early amplitude of clot firmness parameters (A5- or A10-FIBTEM) or hypofibrinogenemia. Further investigation is required into the early use of FC, as well as its potential advantages over cryoprecipitate, and whether or not its administration at high doses leads to a greater risk of adverse events.
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Affiliation(s)
- Santiago R Leal-Noval
- Neuro Critical Care Department, University Hospital "Virgen Del Rocío" and Institute of Biomedicine "IBIS" , 41013, Seville, Spain
| | - Jose Fernández Pacheco
- Pharmacy and Statistics and Design, University Hospital "Virgen Del Rocío" and Institute of Biomedicine "IBIS" , 41013, Seville, Spain
| | - Manuel Casado Méndez
- Critical Care Department, University Hospital "Virgen Del Rocío" and Institute of Biomedicine "IBIS" , 41013, Seville, Spain
| | - Diego Cuenca-Apolo
- Critical Care Department, University Hospital "Virgen Del Rocío" and Institute of Biomedicine "IBIS" , 41013, Seville, Spain
| | - Manuel Múñoz-Gómez
- Department of Surgical Specialties, Biochemistry and Immunology, University of Málaga , 29071, Málaga, Spain
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Maegele M. The Diagnosis and Treatment of Acute Traumatic Bleeding and Coagulopathy. DEUTSCHES ARZTEBLATT INTERNATIONAL 2020; 116:799-806. [PMID: 31847951 DOI: 10.3238/arztebl.2019.0799] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Revised: 06/13/2019] [Accepted: 09/06/2019] [Indexed: 11/27/2022]
Abstract
BACKGROUND Uncontrolled bleeding with trauma-induced coagulopathy (TIC) is still the most common avoidable cause of death in multiple trauma. The aging of the population has led to an increasing number of bleeding trauma patients with pre-existing anticoagulation. Such patients are not treated uniformly, even in major trauma centers. METHODS This review is based on a selective search of the literature (Medline/PubMed, Cochrane Reviews) and summarizes current treatment recommendations, including those of the newly revised European trauma guidelines. RESULTS The treatment of traumatic hemorrhage begins at the site of the accident, with compression, tourniquets, pelvic binders, and rapid transport to a certified trauma center. The early use of tourniquets was shown to lessen the trans- fusion requirement (packed red blood cells: 2.0 ± 0.1 vs. 9.3 ± 0.6; p < 0.001; fresh frozen plasma concentrates: 1.4 ± 0.08 vs. 6.2 ± 0.4; p < 0.001), while external pelvic stabilization was shown to reduce mortality (19.1% vs. 33.3%). Upon the patient's arrival in the hospital, steps are taken to measure, monitor, and support clotting function. Bleeding is controlled surgically according to the principles of damage control. Modern clotting management consists of goal-oriented, individualized therapy, including the use of point-of-care viscoelastic test procedures. Idarucizumab can be used as an antidote to the thrombin inhibitor dabigatran, andexanet alpha as an antidote to factor Xa inhibitors. CONCLUSION The evidence-based treatment of patients with hemorrhage from severe trauma, in accordance with the existing guidelines, can improve the clinical outcome. Corresponding algorithms, adapted to local logistics and infrastructure, must be developed and implemented.
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Affiliation(s)
- Marc Maegele
- Department of Orthopedic Surgery, Trauma Surgery, and Sports Medicine, Cologne Merheim Medical Center, Witten/Herdecke University, Cologne
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Point-of-Care diagnostics of coagulation in the management of bleeding and transfusion in trauma patients. Curr Opin Anaesthesiol 2020; 33:246-252. [PMID: 32022729 DOI: 10.1097/aco.0000000000000836] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
PURPOSE OF REVIEW Trauma-associated bleeding and coagulopathy require timely identification, prevention, and effective treatment. The present review summarizes the recent literature around point-of-care (POC) coagulation tests, their usefulness in the management of trauma-induced coagulopathy (TIC), their impact on trauma patient outcomes, and the requirement of quality assurance. RECENT FINDINGS Best practice algorithms to manage TIC have been compiled in the 2019 European Guideline on the management of major bleeding and coagulopathy after trauma. Evidence supports the use of goal-directed approaches to manage TIC. POC coagulation tests can accelerate and tailor individualized therapies. Recent findings emphasize: the time sparing of POC tests in prehospital settings and the validity of POC measurements in extreme environments; the potential scalability of POC-guided TIC algorithms in burn injuries and the pediatric population; the need for careful considerations of strategies to monitor and reverse the effects of direct oral anticoagulants in major trauma. SUMMARY In contrast to an abundance of reviews and practical approaches to POC coagulation management in trauma patients, there is a scarcity of research in the field and large-scale clinical trials are urgently needed. The paneuropean multicenter trial Implementing Treatment Algorithms for the Correction of Trauma Induced Coagulopathy (iTACTIC) will inform on the potential of viscoelastic tests to augment transfusion protocols for better patient outcomes.
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[The TraumaRegister DGU® dataset, its development over 25 years and advances in the care of severely injured patients]. Unfallchirurg 2019; 121:794-801. [PMID: 30225633 DOI: 10.1007/s00113-018-0555-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND Since the publication in 1993, the dataset and documentation form of the TraumaRegister DGU® (TR-DGU) have continuously evolved. On the occasion of the 25th anniversary the authors have analyzed this evolution in order to reflect it in the light of medical progress in the treatment of the severely injured. MATERIAL AND METHODS Enrolled in the study were 5 reference data entry sheets from the years 1993, 1996, 2002, 2009 and 2016. Every piece of information (item) queried therein was entered into the study database, was categorized by topic and counted for further analysis. RESULTS The arrangement of the 4‑page data entry form has remained practically unchanged since 1993 and includes an average of 212 items. A total of 491 items were identified of which 64 were present throughout every dataset. Based on the average extent of the form this equals a proportion of approximately 30%. The dataset actually shows much more consistency than this number suggests because many changes can be traced back to a smarter design of the data entry form. Most items fell into the categories "results/diagnosis" (143 items/29.1%), "coagulation" (104/21.2%) and "surgical approach" (40/8.1%). Many items serve as raw data for the calculation of prognostic risk scores, such as the trauma and injury severity score (TRISS), the revised injury severity classification II (RISC II) and the trauma associated severe hemorrhage (TASH) score. Currently, nine scores can be calculated from the dataset. CONCLUSION The members of the working group TraumaRegister all actively participate in the treatment of severely injured patients. For 25 years this group has managed to unify the latest medical developments and well-established parameters within the TR-DGU dataset at a relatively constant degree of effort for documentation. Practice in place of theory is the driving force behind this development that serves quality assurance and research in the treatment of severely injured patients.
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Comparison of ROTEM parameters from venous and intraosseous blood. Sci Rep 2019; 9:3741. [PMID: 30842625 PMCID: PMC6403318 DOI: 10.1038/s41598-019-40412-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Accepted: 02/14/2019] [Indexed: 11/24/2022] Open
Abstract
Rotational thromboelastometry is recommended to guide haemostatic therapy in trauma-related coagulopathy. In the case of unsuccessful venepuncture, intraosseous access allows immediate administration of drugs and volume replacement. Feasibility of rotational thromboelastometry from intraosseous blood has not yet been investigated in humans. We performed rotational thromboelastometry and standard coagulation assays from intraosseous and intravenous blood samples in 19 volunteers and 4 patients undergoing general anaesthesia. Intraosseous access was performed either at the tibial bone or the proximal humerus. We observed visible clotting in the majority of the intraosseous samples. Only 13% of the probes allowed realization of rotational thromboelastometry. ROTEM parameters are reported as follows: shorter median clotting time (CT) in EXTEM, INTEM, and APTEM (53 vs. 68 s; 140 vs. 154 s; 54 vs. 62.5 s) and smaller median maximal clot firmness (MCF) in EXTEM and APTEM (56 vs. 63 mm; 55 vs. 62 mm) in intraosseous samples. We found no relevant differences in median MCF values in FIBTEM and INTEM (12 vs. 13 mm; 60 vs. 59 mm). Given the difficulties we faced during IO blood sampling in a study setting, we advise against ROTEM measurements out of IO blood for guidance of procoagulant therapy in emergency situations.
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Affiliation(s)
- C. Booth
- Barts Health NHS Trust; London UK
| | - S. Allard
- Barts Health NHS Trust; London UK
- NHS Blood and Transplant; London UK
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