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Wadhwa H, Rohde M, Oquendo Y, Chen MJ, Tigchelaar SS, Bellino M, Bishop J, Gardner MJ. Interaction of preoperative chemoprophylaxis and tranexamic acid use does not affect transfusion in acetabular fracture surgery. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2024; 34:1025-1029. [PMID: 37865628 DOI: 10.1007/s00590-023-03763-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Accepted: 10/06/2023] [Indexed: 10/23/2023]
Abstract
PURPOSE While the effects of tranexamic acid (TXA) use on transfusion rates after acetabular fracture surgery are unclear, previous evidence suggests that holding deep vein thrombosis (DVT) chemoprophylaxis may improve TXA efficacy. This study examines whether holding DVT chemoprophylaxis in patients receiving TXA affects intraoperative and postoperative transfusion rates in acetabular fracture surgery. METHODS We reviewed electronic medical records (EMR) of 305 patients who underwent open reduction and internal fixation of acetabular fractures (AO/OTA 62) and stratified patients per the following perioperative treatment: (1) no intraoperative TXA (noTXA), (2) intraoperative TXA and no preoperative DVT prophylaxis (opTXA/noDVTP), or (3) intraoperative TXA and preoperative DVT prophylaxis (opTXA/opDVTP). The primary outcomes were need for intraoperative or postoperative transfusion. Risk factors for each primary outcome were assessed using multivariable regression. RESULTS Intraoperative or postoperative transfusion rates did not significantly differ between opTXA/opDVTP and opTXA/noDVTP groups (46.2% vs. 36%, p = 0.463; 15.4% vs. 28%, p = 0.181). Median units transfused did not differ between groups (2 ± 1 vs. 2 ± 1, p = 0.515; 2 ± 1 vs. 2 ± 0, p = 0.099). There was no association between preoperative DVT chemoprophylaxis and TXA with intraoperative or postoperative transfusions. EBL, preoperative hematocrit, and IV fluids were associated with intraoperative transfusions; age and Charlson Comorbidity Index (CCI) were associated with postoperative transfusions. CONCLUSION Our findings suggest holding DVT prophylaxis did not alter the effect of TXA on blood loss or need for transfusion.
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Affiliation(s)
- Harsh Wadhwa
- Department of Orthopaedic Surgery, Stanford School of Medicine, Stanford, CA, 94305, USA
| | - Matthew Rohde
- Department of Orthopaedic Surgery, Stanford School of Medicine, Stanford, CA, 94305, USA.
| | - Yousi Oquendo
- Department of Orthopaedic Surgery, Stanford School of Medicine, Stanford, CA, 94305, USA
| | - Michael J Chen
- Department of Orthopaedic Surgery, Stanford School of Medicine, Stanford, CA, 94305, USA
| | - Seth S Tigchelaar
- Department of Orthopaedic Surgery, Stanford School of Medicine, Stanford, CA, 94305, USA
| | - Michael Bellino
- Department of Orthopaedic Surgery, Stanford School of Medicine, Stanford, CA, 94305, USA
| | - Julius Bishop
- Department of Orthopaedic Surgery, Stanford School of Medicine, Stanford, CA, 94305, USA
| | - Michael J Gardner
- Department of Orthopaedic Surgery, Stanford School of Medicine, Stanford, CA, 94305, USA
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Huang YH, Lee TH. Effect of plasma transfusion on in-hospital mortality and morbidities in patients with spontaneous subarachnoid hemorrhage. Clin Neurol Neurosurg 2024; 237:108129. [PMID: 38277885 DOI: 10.1016/j.clineuro.2024.108129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 01/14/2024] [Accepted: 01/20/2024] [Indexed: 01/28/2024]
Abstract
OBJECTIVE Spontaneous subarachnoid hemorrhage (SAH) is a critical condition in which patients may require plasma transfusion during hospitalization. However, it remains unknown whether plasma administration has detrimental effects on the prognosis of SAH beyond the correction of coagulopathy or hypovolemia. This study aimed to analyze the association of plasma transfusion with in-hospital mortality and morbidities in patients with SAH. METHODS We retrospectively analyzed the data of 1689 adult patients with a primary diagnosis of spontaneous SAH. Differences in the clinical parameters were evaluated between patients who received plasma transfusion and those who did not. RESULTS Of 1689 patients, 158 (9.4%) received plasma transfusion. Statistical analysis revealed significant differences in pre-existing comorbidity prevalence between the two study groups. The post-SAH morbidities, including cerebral ischemic events (13.3% vs. 6.4%; p = 0.01), were more common in the plasma transfusion group, whereas the mortality rate was not different between the two study groups (p = 0.166). The mean duration of hospital stay was 19.3 ± 14.4 days and 15.1 ± 15.2 days for patients with and without plasma transfusion, respectively (p = 0.001). CONCLUSION Plasma transfusion following spontaneous SAH is not uncommon. Although the in-hospital mortality rate does not increase following plasma transfusion, cerebral ischemic events as well as other morbidities are more frequent in patients receiving plasma transfusion. Therefore, the indication for plasma transfusion following SAH needs careful weighing and should be further defined by well-controlled studies.
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Affiliation(s)
- Yu-Hua Huang
- Department of Neurosurgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Tsung-Han Lee
- Department of Neurosurgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan.
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Smith CJ, Valencia R, Sierra CM, Lopez M. The use of vitamin K for coagulopathy in critically ill children. Hosp Pract (1995) 2023; 51:262-266. [PMID: 37933498 DOI: 10.1080/21548331.2023.2277679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Accepted: 10/25/2023] [Indexed: 11/08/2023]
Abstract
OBJECTIVES Coagulopathy is associated with increased mortality in children in the intensive care unit (ICU). Recommended management of vitamin K-deficient coagulopathy is vitamin K administration. The goal of this study was to evaluate vitamin K administration for coagulopathy in critically ill children and determine a relationship between vitamin K dose and change in prothrombin time (PT) and international normalized ratio (INR). METHODS This retrospective cohort study reviewed electronic medical records of patients ≤17 years who received vitamin K for acute coagulopathy in the pediatric ICU from January 2013 to January 2021. Patients receiving vitamin K antagonists were excluded. Effectiveness data included change in PT/INR after vitamin K administration. Safety data included incidence of hypersensitivity or anaphylaxis. RESULTS A total of 310 patients (median age 6.8 years, range 22 days-17.7 years) received vitamin K. A median of three doses (range 1-8) and 0.14 mg/kg per dose (range 0.09-0.22 mg/kg) were given, most frequently intravenously (892/949, 94%). Most patients (304/310, 98%) had at least one risk factor for vitamin K deficiency. Mean PT/INR was 21.5/2.1 prior to vitamin K administration, which decreased by 4.4 (SD = 9.0, 95% CI 16.011 to 18.015, p < 0.001) and 0.5 (SD = 1.0, 95% CI 1.490 to 1.705, p < 0.001) to means of 17.0 and 1.6, respectively, after the first vitamin K dose. No linear relationship was found between vitamin K dose and change in PT/INR. No hypersensitivity or anaphylaxis occurred following vitamin K administration; 27% (84/310) of patients died. CONCLUSIONS Administration of vitamin K is effective and safe for the management of vitamin K-deficient coagulopathy in critically ill pediatric patients. Further study is needed to determine a relationship between vitamin K dose and change in PT/INR.
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Affiliation(s)
- Christina J Smith
- Department of Pharmacy, Loma Linda University Children's Hospital, Loma Linda, CA, USA
| | - Ryan Valencia
- Loma Linda University School of Pharmacy, Loma Linda, CA, USA
| | - Caroline M Sierra
- Department of Pharmacy Practice, Loma Linda University School of Pharmacy, Loma Linda, CA, USA
| | - Merrick Lopez
- Department of Pediatric Critical Care Medicine, Loma Linda University Children's Hospital, Loma Linda, CA, USA
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Kenmegne GR, Zou C, Lin Y, Yin Y, Huang S, Banneyake EL, Gunasekera IS, Fang Y. A prophylactic TXA administration effectively reduces the risk of intraoperative bleeding during open management of pelvic and acetabular fractures. Sci Rep 2023; 13:12570. [PMID: 37532829 PMCID: PMC10397234 DOI: 10.1038/s41598-023-39873-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Accepted: 08/01/2023] [Indexed: 08/04/2023] Open
Abstract
This study aimed to evaluate the efficacy of perioperative intravenous TXA in reducing blood loss in pelvic and acetabular fracture patients managed surgically. The study included 306 consecutive patients, divided as: group I, 157 patients who did not receive perioperative infusion of TXA and group II, 149 patients who received perioperative TXA. The perioperative blood test results and complication rates were compared between the two groups. The average perioperative hematocrit was higher during the preoperative period than during the first, second and third postoperative day in both groups. In the estimated blood loss between the two groups, there was a significant difference of 1391 (± 167.49) ml in group I and 725 (± 403.31) ml in group II respectively (p = 0.02). No significant difference was seen in the total of intraoperative transfusion units as well as in the total units of blood transfused. There was a reduced level of postoperative hemoglobin (9.28 ± 17.88 g/dl in group I and 10.06 ± 27.57 g/dl in group II compared to the values obtained in preoperative investigations (10.4 ± 2.37 g/dl in group I and 11.4 ± 2.08 g/dl in group II); with a significant difference in postoperative transfusion rates (p = 0.03). Therefore, the use of TXA effectively reduces the risk of intraoperative bleeding during open management of pelvic and acetabular fractures.
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Affiliation(s)
- Guy Romeo Kenmegne
- Department of Orthopedics, West China Hospital of Sichuan University, Chengdu, 610041, China
- Trauma center, West China Hospital of Sichuan University, Chengdu, 610041, China
| | - Chang Zou
- Department of Orthopedics, West China Hospital of Sichuan University, Chengdu, 610041, China
- Trauma center, West China Hospital of Sichuan University, Chengdu, 610041, China
| | - Yixiang Lin
- Department of Orthopedics, West China Hospital of Sichuan University, Chengdu, 610041, China
- Trauma center, West China Hospital of Sichuan University, Chengdu, 610041, China
| | - Yijie Yin
- Department of Orthopedics, West China Hospital of Sichuan University, Chengdu, 610041, China
- Trauma center, West China Hospital of Sichuan University, Chengdu, 610041, China
| | - Shenbo Huang
- Department of Orthopedics, West China Hospital of Sichuan University, Chengdu, 610041, China
- Trauma center, West China Hospital of Sichuan University, Chengdu, 610041, China
| | - Erandathie Lasanda Banneyake
- Department of Orthopedics, West China Hospital of Sichuan University, Chengdu, 610041, China
- Trauma center, West China Hospital of Sichuan University, Chengdu, 610041, China
| | - Imani Savishka Gunasekera
- Department of Orthopedics, West China Hospital of Sichuan University, Chengdu, 610041, China
- Trauma center, West China Hospital of Sichuan University, Chengdu, 610041, China
| | - Yue Fang
- Department of Orthopedics, West China Hospital of Sichuan University, Chengdu, 610041, China.
- Trauma center, West China Hospital of Sichuan University, Chengdu, 610041, China.
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Gelbard RB, Nahmias J, Byerly S, Ziesmann M, Stein D, Haut ER, Smith JW, Boltz M, Zarzaur B, Callum J, Cotton BA, Cripps M, Gunter OL, Holcomb JB, Kerby J, Kornblith LZ, Moore EE, Riojas CM, Schreiber M, Sperry JL, Yeh DD. Establishing a core outcomes set for massive transfusion: An Eastern Association for the Surgery of Trauma modified Delphi method consensus study. J Trauma Acute Care Surg 2023; 94:784-790. [PMID: 36727810 DOI: 10.1097/ta.0000000000003884] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND The management of severe hemorrhage has changed significantly over recent decades, resulting in a heterogeneous description of diagnosis, treatment, and outcomes in the literature, which is not suitable for data pooling. Therefore, we sought to develop a core outcome set (COS) to help guide future massive transfusion (MT) research and overcome the challenge of heterogeneous outcomes reporting. METHODS Massive transfusion content experts were invited to participate in a modified Delphi study. For Round 1, participants submitted a list of proposed core outcomes. In subsequent rounds, panelists used a 9-point Likert scale to score proposed outcomes for importance. Core outcomes consensus was defined as >85% of scores receiving 7 to 9 and <15% of scores receiving 1 to 3. Feedback and aggregate data were shared between rounds. RESULTS From an initial panel of 16 experts, 12 (75%) completed three rounds of deliberation to reevaluate variables not achieving predefined consensus criteria. A total of 64 items were considered, with 4 items achieving consensus for inclusion as core outcomes: blood products received in the first 6 hours, 6-hour mortality, time to mortality, and 24-hour mortality. CONCLUSION Through an iterative survey consensus process, content experts have defined a COS to guide future MT research. This COS will be a valuable tool for researchers seeking to perform new MT research and will allow future trials to generate data that can be used in pooled analyses with enhanced statistical power. LEVEL OF EVIDENCE Diagnostic Test or Criteria; Level V.
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Affiliation(s)
- Rondi B Gelbard
- From the Division of Trauma and Acute Care Surgery, Department of Surgery (R.B.G., J.B.H., J.K.), University of Alabama at Birmingham, Birmingham, Alabama; Division of Trauma, Burns and Surgical Critical Care (J.N.), University of California, Irvine, Orange, California; Department of Surgery (S.B.), University of Tennessee Health Science Campus, Memphis, Tennessee; Department of Surgery (M.Z.), University of Manitoba, Winnipeg, Manitoba, Canada; Department of Surgery (D.S.), R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine; Division of Acute Care Surgery, Department of Surgery (E.R.H.), Johns Hopkins University School of Medicine, Baltimore, Maryland; Department of Surgery (J.W.S.), University of Louisville School of Medicine, Louisville, Kentucky; Division of Trauma, Acute Care and Critical Care Surgery, Department of Surgery (M.B.), Penn State Hershey Medical Center, Hershey, Pennsylvania; Department of Surgery (B.Z.), University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin; Department of Pathology and Molecular Medicine (J.C.), School of Medicine, Queen's University, Kingston, Ontario, Canada; Department of Surgery (B.A.C.), University of Texas Health McGovern Medical School, Houston, Texas; Department of Surgery (M.C.), University of Colorado Hospital, Aurora, Colorado; Department of Surgery (O.L.G.), Division of Acute Care Surgery, Vanderbilt University Medical Center, Nashville, Tennessee; Department of Surgery (L.Z.K.), Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California; Ernest E Moore Shock Trauma Center at Denver Health (E.E.M., D.D.Y.), University of Colorado Denver, Denver, Colorado; Department of Surgery (C.M.R.), Brooke Army Medical Center, San Antonio, Texas; Department of Surgery (M.S.), Oregon Health and Science University, Portland, Oregon; and Department of Surgery (J.L.S.), UPMC Presbyterian, Pittsburgh, Pennsylvania
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Marchand LS, Sepehri A, Hannan ZD, Zaidi R, DuBose JJ, Morrison JJ, O'Toole RV, Slobogean GM. Resuscitative Endovascular Balloon Occlusion of the Aorta in Hemodynamically Unstable Patients With Pelvic Ring Injuries. J Orthop Trauma 2022; 36:74. [PMID: 34050079 DOI: 10.1097/bot.0000000000002191] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/24/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To evaluate the outcomes of patients with pelvic ring injuries managed with resuscitative endovascular balloon occlusion of the aorta (REBOA). DESIGN Retrospective case series. SETTING Academic, Level 1 trauma center in North America. PATIENTS Twenty-five patients with disruption of the pelvic ring and hemodynamic instability. INTERVENTION Placement of a REBOA device as an adjuvant treatment to trauma resuscitation. MAIN OUTCOME MEASURE Death and ischemic-related complications. RESULTS The average age of patients was 43 years (range: 17-85). Patients presented with a median lactate of 6.3 mmol/L, systolic blood pressure of 116 mm Hg, heart rate of 121 beats/minute, and injury severity score of 34. The median unit of packed red blood cells received through transfusion in the first 24 hours of hospital admission was 13 (interquartile range: 8-28). Young-Burgess injury patterns included fractures of the following types: 5 lateral compression (LC)-1, 1 LC-2, 8 LC-3, 4 anteroposterior compression-2, and 7 anteroposterior compression-3. Angiography and embolization were performed in 24 (96%) patients. Selective embolization occurred in 18 (72%) patients, with nonselective angiography of the iliac system occurring in 7 (24%) patients. There were 12 (48%) deaths, 7 (28%) patients requiring lower extremity fasciotomy, and 5 (20%) patients requiring lower extremity amputations, and there was 1 (4%) patient requiring thrombectomy. CONCLUSIONS REBOA use in pelvic ring injuries is rare and most frequently used in critically ill patients with polytrauma. Successful pelvic embolization can occur in concert with REBOA use; however, the severity of injury is associated with a high complication profile. In this series of 25 patients, in-hospital mortality was 48%. For those patients who survived, 54% experienced a major complication (fasciotomy, amputation, and deep infection). Further investigation is required to evaluate the role REBOA may play in managing these patients. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Lucas S Marchand
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, MD; and
| | - Aresh Sepehri
- University of British Columbia, Vancouver, BC, Canada
| | - Zachary D Hannan
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, MD; and
| | - Raza Zaidi
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, MD; and
| | - Joseph J DuBose
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, MD; and
| | - Jonathan J Morrison
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, MD; and
| | - Robert V O'Toole
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, MD; and
| | - Gerard M Slobogean
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, MD; and
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The efficiency and safety of intravenous tranexamic acid administration in open reduction and internal fixation of pelvic and acetabular fractures. Eur J Trauma Emerg Surg 2021; 48:351-356. [PMID: 33641043 DOI: 10.1007/s00068-021-01624-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2020] [Accepted: 02/16/2021] [Indexed: 10/22/2022]
Abstract
PURPOSE This study aimed to investigate the efficiency and safety of tranexamic acid use in open reduction and internal fixation of pelvis and acetabulum fractures. MATERIALS AND METHODS 73 consecutive patients were included. 1000 mg TXA was administered intravenously to all patients before surgery. The patients were evaluated on the basis of preoperative, postoperative first and third day hemoglobin-hematocrit values, amount of drainage collected, total blood loss, transfusion rates and complications. RESULTS Mean operative time was 120.1 min. Average decrease in hematocrit levels between preoperative and postoperative first day was 2.1 g/dL. Average collected blood from the drain was 177 mL. Mean total blood loss was 1137 mL. Transfusion rate of the patients was 21%. Mean transfused units was 0.9 units. Three patients died within 3 weeks after the operation due to myocardial infarction, acute kidney failure and pneumonia. There were no cases of symptomatic venous or pulmonary thromboembolism during the 90 days of follow-up. CONCLUSION Use of TXA in pelvic and acetabular fractures was found to be effective in reducing total blood loss, hemoglobin drop and transfusion rates without increasing venous and pulmonary thromboembolism in our series.
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Abstract
Massive transfusion protocol (MTP) with fresh-frozen plasma and packed red blood cells (PRBCs) in a 1:1 ratio is one of the most common resuscitative strategies used in patients with severe hemorrhage. There are no studies to date that examine the best postoperative hematocrit range as a marker for survival after MTP. We hypothesize a postoperative hematocrit dose-dependent survival benefit in patients receiving MTP. This was a 53-month retrospective analysis of patients with intra-abdominal injuries requiring surgery and transfusion of 10 units PRBCs or more at a single Level I trauma center. Groups were defined by postoperative hematocrit (less than 21, 21 to 29, 29.1 to 39, and 39 or more). Kaplan-Meier (KM) survival probability was calculated. One hundred fifty patients requiring operative abdominal explorations and 10 units PRBCs or more were identified. There were no significant differences in demographics between groups. When comparing postoperative hematocrit groups, relative to a hematocrit of less than 21 per cent in KM survival analysis, an overall survival advantage was only evident in patients transfused to hematocrits 29.1 to 39 per cent ( P < 0.03; odds ratio [OR], 0.284; 95% confidence interval [CI], 0.089 to 0.914). This survival advantage was not seen in the other groups (21 to 29: OR, 0.352; 95% CI, 0.103 to 1.195 or 39% or greater: OR, 0.107; 95% CI, 0.010 to 1.121). This is the first study to examine the impact of postoperative hematocrit as an indicator of survival after MTP in the trauma patient. Transfusion to hematocrits between 29.1 and 39 per cent conveyed a survival benefit, whereas resuscitation to supraphysiologic hematocrits 39 per cent or greater conveyed no additional survival benefit. This study highlights the need for judicious PRBC administration during MTP and its potential impact on survival in patients with postoperative supraphysiologic hematocrits.
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Cohen-Levy WB, Rush AJ, Goldstein JP, Sheu JI, Hernandez-Irizarry RC, Quinnan SM. Tranexamic acid with a pre-operative suspension of anticoagulation decreases operative time and blood transfusion in the treatment of pelvic and acetabulum fractures. INTERNATIONAL ORTHOPAEDICS 2020; 44:1815-1822. [DOI: 10.1007/s00264-020-04595-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Accepted: 04/27/2020] [Indexed: 12/18/2022]
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Briese T, Theisen C, Schliemann B, Raschke MJ, Lefering R, Weimann A. Shoulder injuries in polytraumatized patients: an analysis of the TraumaRegister DGU®. Eur J Trauma Emerg Surg 2020; 47:1921-1930. [PMID: 32221637 PMCID: PMC8629800 DOI: 10.1007/s00068-020-01340-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2019] [Accepted: 03/02/2020] [Indexed: 11/29/2022]
Abstract
Background The aim of the present study was to analyze the prevalence, epidemiology and relevance of shoulder injuries in polytraumatized patients in a large national trauma database. We hypothesize a high prevalence of shoulder injuries in traffic accidents and a high prevalence of concomitant injuries of the thorax leading to an aggravated clinical course and higher Injury Severity Score (ISS). Furthermore, we hypothesize an increased rate of surgical treatment with the severity of the injury. Materials and methods The retrospective analysis is based on the database (2002–2013) of the TraumaRegister DGU® and includes statistical data from 608 hospitals. The severity of injuries and trauma were scaled using the Abbreviated Injury Scale (AIS), and the Injury Severity Score (ISS), respectively. Patients with an ISS ≥ 16 were included in the study, and injuries were subdivided according to their anatomical involvement and analyzed with respect to the trauma mechanism and the resulting injuries. Results In this study, 54,076 cases of patients with an ISS ≥ 16 were analyzed. Shoulder injuries occurred in 15,115 patients (27.9%). Of these, 68.5% were caused by traffic accidents, especially in motorbike, bicycle, and pedestrian accidents. We found more shoulder injuries in blunt trauma mechanisms. Moreover, patients with shoulder injuries spent on average 1.7 more days on the intensive care unit (ICU), or intermediate care unit (IMCU), according to the severity of the injury, and had longer overall hospital stays (26.2 vs. 24.1 days) than patients without shoulder injuries. The overall ISS was increased in patients with shoulder injuries, whereas an increase of mortality could not be identified. Concomitant thoracic injuries occurred significantly more often in patients with shoulder injuries (82.9% vs. 69.6%). Injuries of the abdomen, pelvis, and lower extremity showed no correlation with shoulder injuries, whereas head and spine injuries showed a significant correlation. Conclusion Shoulder injuries are very common in polytraumatized patients. Together with their distinctive concomitant injuries, they have an aggravating impact on the clinical progress. Our data confirm the correlation with thoracic injuries. Furthermore, we identified an increased risk of shoulder injuries in motorbike, bicycle, and pedestrian accidents. An increase in mortality could not be identified.
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Affiliation(s)
- Thorben Briese
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Muenster, Albert-Schweitzer-Campus, Building W1, 48149, Muenster, Germany
| | - Christina Theisen
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Muenster, Albert-Schweitzer-Campus, Building W1, 48149, Muenster, Germany
- Department for Orthopedic Surgery, Schoen Clinic Duesseldorf, Am Heerdter Krankenhaus 2, 40549, Duesseldorf, Germany
| | - Benedikt Schliemann
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Muenster, Albert-Schweitzer-Campus, Building W1, 48149, Muenster, Germany
| | - Michael J Raschke
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Muenster, Albert-Schweitzer-Campus, Building W1, 48149, Muenster, Germany.
| | - Rolf Lefering
- IFOM, Institute for Research in Operative Medicine, University of Witten, Herdecke, Germany
| | - Andre Weimann
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Muenster, Albert-Schweitzer-Campus, Building W1, 48149, Muenster, Germany
- OCP-Muenster, Orthopedic, Trauma and Hand Surgery, Schaumburgstrasse 1, 48145, Muenster, Germany
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van Wessem KJP, Hietbrink F, Leenen LPH. Attenuation of MODS-related and ARDS-related mortality makes infectious complications a remaining challenge in the severely injured. Trauma Surg Acute Care Open 2020; 5:e000398. [PMID: 32154377 PMCID: PMC7046953 DOI: 10.1136/tsaco-2019-000398] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2019] [Revised: 01/11/2020] [Accepted: 01/18/2020] [Indexed: 12/02/2022] Open
Abstract
Introduction The recent decrease in multiple organ dysfunction syndrome (MODS)-associated and adult respiratory distress syndrome (ARDS)-associated mortality could be considered a success of improvements in trauma care. However, the incidence of infections remains high in patients with polytrauma, with high morbidity and hospital resources usage. Infectious complications might be a residual effect of the decrease in MODS-related/ARDS-related mortality. This study investigated the current incidence of infectious complications in polytrauma. Methods A 5.5-year prospective population-based cohort study included consecutive severely injured patients (age >15) admitted to a (Level-1) trauma center intensive care unit (ICU) who survived >48 hours. Demographics, physiologic and resuscitation parameters, multiple organ failure and ARDS scores, and infectious complications (pneumonia, fracture-related infection, meningitis, infections related to blood, wound, and urinary tract) were prospectively collected. Data are presented as median (IQR), p<0.05 was considered significant. Results 297 patients (216 (73%) men) were included with median age of 46 (27–60) years, median Injury Severity Score was 29 (22–35), 96% sustained blunt injuries. 44 patients (15%) died. One patient (2%) died of MODS and 1 died of ARDS. 134 patients (45%) developed 201 infectious complications. Pneumonia was the most common complication (50%). There was no difference in physiologic parameters on arrival in emergency department and ICU between patients with and without infectious complications. Patients who later developed infections underwent more often a laparotomy (32% vs 18%, p=0.009), had more often pelvic fractures (38% vs 25%, p=0.02), and received more blood products <8 hours. They had more often MODS (25% vs 13%, p=0.005), stayed longer on the ventilator (10 (5–15) vs 5 (2–8) days, p<0.001), longer in ICU (11 (6–17) vs 6 (3–10) days, p<0.001), and in hospital (30 (20–44) vs 16 (10–24) days, p<0.001). There was however no difference in mortality (12% vs 17%, p=0.41) between both groups. Conclusion 45% of patients developed infectious complications. These patients had similar mortality rates, but used more hospital resources. With low MODS-related and ARDS-related mortality, infections might be a residual effect, and are one of the remaining challenges in the treatment of patients with polytrauma. Level of evidence Level 3. Study type Population-based cohort study.
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Affiliation(s)
- Karlijn J P van Wessem
- Department of Trauma Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Falco Hietbrink
- Department of Trauma Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Luke P H Leenen
- Department of Trauma Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
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12
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Rajagopalan V, Chouhan RS, Pandia MP, Lamsal R, Rath GP. Effect of Intraoperative Blood Loss on Perioperative Complications and Neurological Outcome in Adult Patients Undergoing Elective Brain Tumor Surgery. J Neurosci Rural Pract 2019; 10:631-640. [PMID: 31831982 PMCID: PMC6906102 DOI: 10.1055/s-0039-3399487] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Background Major blood loss during neurosurgery can lead to several complications, including life-threatening hemodynamic instabilities. Studies addressing these complications in patients undergoing intracranial tumor surgery are limited. Materials and Methods During the study period, 456 patients who underwent elective craniotomy for brain tumor excision were categorized into four groups on the basis of estimated intraoperative blood volume loss: Group A (<20%), Group B (20-50%), Group C (>50-100%), and Group D (more than estimated blood volume). The occurrence of various perioperative complications was correlated with these groups to identify if there was any association with the amount of intraoperative blood loss. Results The average blood volume loss was 11% ± 5.3% in Group A, 29.8% ± 7.9% in Group B, 68.3% ± 13.5% in Group C, and 129.1% ± 23.9% in Group D. Variables identified as risk factors for intraoperative bleeding were female gender ( p < 0.001), hypertension ( p = 0.008), tumor size >5 cm ( p < 0.001), high-grade glioma ( p = 0.004), meningioma ( p < 0.001), mass effect ( p = 0.002), midline shift ( p = 0.014), highly vascular tumors documented on preoperative imaging ( p < 0.001), extended craniotomy approach ( p = 0.002), intraoperative colloids use >1,000 mL ( p < 0.001), intraoperative brain bulge ( p = 0.03), intraoperative appearance as highly vascular tumor ( p < 0.001), and duration of surgery >300 minutes ( p < 0.001). Conclusions Knowledge of these predictors may help anesthesiologists anticipate major blood loss during brain tumor surgery and be prepared to mitigate these complications to improve patient outcome.
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Affiliation(s)
- Vanitha Rajagopalan
- Department of Neuroanaesthesiology and Critical Care, All India Institute of Medical Sciences, New Delhi, India
| | - Rajendra Singh Chouhan
- Department of Neuroanaesthesiology and Critical Care, All India Institute of Medical Sciences, New Delhi, India
| | - Mihir Prakash Pandia
- Department of Neuroanaesthesiology and Critical Care, All India Institute of Medical Sciences, New Delhi, India
| | - Ritesh Lamsal
- Department of Neuroanaesthesiology and Critical Care, All India Institute of Medical Sciences, New Delhi, India
| | - Girija Prasad Rath
- Department of Neuroanaesthesiology and Critical Care, All India Institute of Medical Sciences, New Delhi, India
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Ki KK, Faddy HM, Flower RL, Dean MM. Packed Red Blood Cell Transfusion Modulates Myeloid Dendritic Cell Activation and Inflammatory Response In Vitro. J Interferon Cytokine Res 2019; 38:111-121. [PMID: 29565746 DOI: 10.1089/jir.2017.0099] [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: 12/14/2022] Open
Abstract
Transfusion of packed red blood cells (PRBCs) modulates patients' immune responses and clinical outcomes; however, the underpinning mechanism(s) remain unknown. The potential for PRBC to modulate myeloid dendritic cells (mDC) and blood DC antigen 3 was assessed using an in vitro transfusion model. In parallel, to model processes activated by viral or bacterial infection, toll-like receptor agonists polyinosinic:polycytidylic acid or lipopolysaccharide were added. Exposure to PRBC upregulated expression of CD83 and downregulated CD40 and CD80 on both DC subsets, and it suppressed production of interleukin (IL)-6, IL-8, IL-12, tumor necrosis factor-α, and interferon-gamma-inducible protein-10 by these cells. Similar effects were observed when modeling processes activated by concurrent infection. Furthermore, exposure to PRBC at date of expiry was associated with more pronounced effects in all assays. Our study suggests PRBC have an impact on recipient DC function, which may result in failure to establish an appropriate immune response, particularly in patients with underlying infection.
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Affiliation(s)
- Katrina K Ki
- 1 Research and Development Laboratory, The Australian Red Cross Blood Service , Kelvin Grove, Queensland, Australia .,2 School of Medicine, The University of Queensland , Brisbane, St. Lucia, Queensland, Australia
| | - Helen M Faddy
- 1 Research and Development Laboratory, The Australian Red Cross Blood Service , Kelvin Grove, Queensland, Australia .,2 School of Medicine, The University of Queensland , Brisbane, St. Lucia, Queensland, Australia
| | - Robert L Flower
- 1 Research and Development Laboratory, The Australian Red Cross Blood Service , Kelvin Grove, Queensland, Australia
| | - Melinda M Dean
- 1 Research and Development Laboratory, The Australian Red Cross Blood Service , Kelvin Grove, Queensland, Australia
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14
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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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15
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Sahin AS, Ozkan S. Treatment of Obstetric Hemorrhage with Fibrinogen Concentrate. Med Sci Monit 2019; 25:1814-1821. [PMID: 30852583 PMCID: PMC6421935 DOI: 10.12659/msm.914234] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2018] [Accepted: 01/03/2019] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Postpartum hemorrhage (PPH) is related to several factors but is frequently associated with coagulopathy with maternal mortality. Fibrinogen is a very important agent for bleeding. When its concentration is decreased, severe surgical blood loss may occur. Here, we investigate the association of postpartum bleeding characteristics with evolution of PPH in patients who were taking fibrinogen concentrate (FC). MATERIAL AND METHODS PPH patients' demographic parameters, outcome variables, and laboratory findings before and at ICU were recorded between January 2015 and July 2017. The duration of ICU stay and plasmapheresis, renal replacement therapy, maternal-fetal deaths, RBC, FFP, and PC replacement were calculated. RESULTS Group I: Fibrinogen levels were ≤150 mg/dl (n: 31), Group II: Fibrinogen levels were >151 mg/dl (n: 18). In the peroperative period, there was no difference between the 2 groups in terms of RBC, FFP, or PC transfussion. In intraoperative and ICU admission period, patients in Group I had higher INR, APTT, and PT values than in the other group. FC replacement according to fibrinogen level was given, ranging from to 1 to 6 gr in Group I and 1-2 gr in Group II intraoperatively and at ICU 2-8 gr FC was given in both groups. In the intraoperative and ICU admission period, blood transfusion requirements of patients after fibrinogen replacement were evaluated and there was no statistically significant difference between groups. There were no differrences between groups in duration of intensive care unit stay, hospital stay, and mechanical ventilation. CONCLUSIONS Adequate FC therapy prevents unnecessary RBC, FFP, and PC replacement and prevents complications and volume overload.
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Akbari E, Safari S, Hatamabadi H. The effect of fibrinogen concentrate and fresh frozen plasma on the outcome of patients with acute traumatic coagulopathy: A quasi-experimental study. Am J Emerg Med 2018; 36:1947-1950. [DOI: 10.1016/j.ajem.2018.02.018] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Revised: 02/16/2018] [Accepted: 02/21/2018] [Indexed: 10/18/2022] Open
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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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18
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Abstract
Anemia is a common condition and is diagnosed on laboratory assessment. It is defined by abnormally low hemoglobin concentration or decreased red blood cells. Several classification systems exist. Laboratory markers provide important information. Acute anemia presents with symptoms owing to acute blood loss; chronic anemia may present with worsening fatigue, dyspnea, lightheadedness, or chest pain. Specific treatments depend on the underlying anemia and etiology. Iron is an alternative treatment for patients with microcytic anemia owing to iron deficiency. Hyperbaric oxygen is an option for alternative rescue therapy. Most patients with chronic anemia may be discharged with follow-up if hemodynamically stable.
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Affiliation(s)
- Brit Long
- Department of Emergency Medicine, San Antonio Military Medical Center, 3841 Roger Brooke Drive, Fort Sam Houston, TX 78234, USA.
| | - Alex Koyfman
- Department of Emergency Medicine, The University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390, USA
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19
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Kasotakis G, Starr N, Nelson E, Sarkar B, Burke PA, Remick DG, Tompkins RG. Platelet transfusion increases risk for acute respiratory distress syndrome in non-massively transfused blunt trauma patients. Eur J Trauma Emerg Surg 2018; 45:671-679. [PMID: 29627883 DOI: 10.1007/s00068-018-0953-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Accepted: 04/03/2018] [Indexed: 12/30/2022]
Abstract
PURPOSE While damage control resuscitation is known to confer a survival advantage in severely injured patients, high-ratio blood component therapy should be initiated only in carefully selected trauma patients, due to the morbidity associated with blood product use. With this project, we aim to identify the effect of platelet transfusion in non-massively transfused bluntly injured patients. METHODS The Glue Grant database was retrospectively queried and severely injured blunt trauma patients who underwent non-massive transfusion were identified. Patients were divided into quartiles depending on platelet volume they were transfused in the first 48 h. Outcomes of interest included mortality; ventilator, Intensive Care Unit (ICU) and hospital length of stay (LOS); infectious and non-infectious complications. Multivariable regression models were fitted for these outcomes, controlling for age, pre-existing comorbidities, injury severity, acute physiologic derangement, neurologic injury burden, and other fluid and blood product resuscitation. RESULTS There was no difference in mortality, LOS, or the incidence of multi-organ failure and infectious complications. However, patients receiving ≥ 250 mL of platelets were more likely to develop acute respiratory distress syndrome (ARDS) compared to those who received < 250 mL [odds ratio 1.91 (95% CI 1.10-3.33, p = 0.022)]. CONCLUSIONS Pre-emptive platelet transfusion should be avoided in non-massively transfused blunt injury victims in the absence of true or functional thrombocytopenia, as it increases risk for ARDS with no survival benefit.
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Affiliation(s)
- George Kasotakis
- Division of Trauma, Acute Care Surgery and Surgical Critical Care, Boston University School of Medicine, 840 Harrison ave., Dowling 2 South, #2414, Boston, MA, 02118, USA.
| | - Nichole Starr
- Division of Trauma, Acute Care Surgery and Surgical Critical Care, Boston University School of Medicine, 840 Harrison ave., Dowling 2 South, #2414, Boston, MA, 02118, USA
| | - Erek Nelson
- Division of Trauma, Acute Care Surgery and Surgical Critical Care, Boston University School of Medicine, 840 Harrison ave., Dowling 2 South, #2414, Boston, MA, 02118, USA
| | - Bedabrata Sarkar
- Division of Trauma, Acute Care Surgery and Surgical Critical Care, Boston University School of Medicine, 840 Harrison ave., Dowling 2 South, #2414, Boston, MA, 02118, USA
| | - Peter Ashley Burke
- Division of Trauma, Acute Care Surgery and Surgical Critical Care, Boston University School of Medicine, 840 Harrison ave., Dowling 2 South, #2414, Boston, MA, 02118, USA
| | - Daniel George Remick
- Department of Pathology and Laboratory Medicine, Boston University School of Medicine, Boston, USA
| | - Ronald Gary Tompkins
- Division of Surgery, Science and Bioengineering, Massachusetts General Hospital, Harvard Medical School, Boston, USA
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20
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Hypothermia indices among severely injured trauma patients undergoing urgent surgery: A single-centred retrospective quality review and analysis. Injury 2018; 49:117-123. [PMID: 29183635 DOI: 10.1016/j.injury.2017.11.028] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2017] [Revised: 11/09/2017] [Accepted: 11/22/2017] [Indexed: 02/02/2023]
Abstract
BACKGROUND Hypothermia (<36°C) exacerbates trauma-induced coagulopathy and worsens morbidity and mortality among severely injured trauma patients; there is a paucity of published data describing how well trauma centres adhere to standards regarding measurement of temperature, and best practices for preventing and treating hypothermia. METHODS We completed a retrospective quality audit of all severely injured trauma patients (Injury Severity Score (ISS≥20)) who had urgent surgery at Sunnybrook Health Sciences Centre (SHSC) between 2010 and 2014. Information regarding temperature monitoring was evaluated over the course of the initial resuscitation and admission. Independent risk factors for in-hospital mortality were elucidated through a multivariable regression analysis. RESULTS Out of a total of 4492 trauma patients, 495 were severely-injured and went to the operating room (OPR) after being treated in the trauma bay (TB) at SHSC between 2010 and 2014. The majority of the patients were male (n=384, 77.6%) and had a blunt mechanism of injury (n=391, 79.0%). The median ISS score was 29 (interquartile range (IQR) 26, 35). Eighty-nine (17.9%) patients died; 26 (5.2%) of these patients died intra-operatively. Less than one fifth of patients (n=82,16.6%) received a temperature measurement during pre-hospital transport phase. Upon arrival to the TB, almost two-thirds (n=301, 60.8%) of patients had their temperature recorded and a similar proportion (n=175, 58.1%) of those patients were hypothermic (<36°C). In the OPR, close to 80% (n=389, 78.6%) of patients had their temperature measured on both arrival; almost 60% (n=223, 57.3%) were hypothermic on arrival. Almost all patients had their temperature measured upon arrival to the ICU or specialized ward (n=450, 98.3%). Warming initiatives were documented in only 36 (7.3%) patients in the TB, yet documented in almost all patients in OR (n=464, 93.7%). An increased risk of in-hospital mortality was correlated with not taking a temperature measurement in the TB (Odds Ratio (OR) 2.86 (95% Confidence Interval (CI) [1.64-4.99]) or OPR (OR 4.66 (95% CI [2.50-8.69]). CONCLUSIONS A majority of severely injured trauma patients are hypothermic well into the perioperative period after initial admission. An absence of having temperature measurement during initial hospitalization is associated with increased in-hospital mortality amongst this patient group. Quality improvement initiatives should aim to strive for ongoing temperature measurement as a key performance indicator and early prevention and treatment of hypothermia during initial resuscitation.
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Bomberg H, Volk T, Biedler A, Schneider SO. Impact of intraoperative blood salvage on monocyte subsets alteration and intracellular tumor necrosis factor-α production. J Biomed Mater Res A 2017; 106:815-821. [PMID: 29094483 DOI: 10.1002/jbm.a.36281] [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: 09/24/2017] [Revised: 10/23/2017] [Accepted: 10/27/2017] [Indexed: 11/09/2022]
Abstract
Intraoperative salvaged blood is used to reduce allogeneic blood transfusion in orthopedic surgery patients. However, salvaged blood reinfusion may lead to immune reactions. Salvaged and venous blood from 20 patients undergoing hip arthroplasty was processed. The salvaged samples were mixed with patients' venous blood and incubated in absence or presence of lipopolysaccharide. SAMPLES Venous: venous patient blood (n = 20). Native: mixed salvaged native blood (n = 20). Filtered: mixed salvaged leukocyte filtered blood (n = 20). Irradiated: mixed salvaged irradiated blood (n = 20). The frequency of the surface receptors CD14, HLA-DR, and intracellular tumor necrosis factor (TNF)-α on peripheral blood mononuclear cells was analyzed by fluorescence-activated cell sorting analysis. The frequency of unstimulated CD14low and CD14high cells as well as unstimulated HLA-DR and TNF-α positive monocytes was comparable between venous and filtered salvaged blood. However, native and irradiated salvaged blood increased compared with venous (p < 0.05) and filtered salvaged blood (p < 0.05) for unstimulated CD14low cells, HLA-DR, and TNF-α positive monocytes. Stimulated intracellular TNF-α positive monocytes were decreased in native, filtered, and irradiated salvaged blood compared with venous blood (p < 0.05). Processing perioperative salvaged blood with leukofiltration minimizes the influence on monocytes activation compared with native and irradiated salvaged blood. © 2017 Wiley Periodicals, Inc. J Biomed Mater Res Part A: 106A: 815-821, 2018.
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Affiliation(s)
- Hagen Bomberg
- Department of Anesthesiology, Intensive Care Medicine and Pain Medicine, Saarland University Medical Center, Homburg, Saar, Germany
| | - Thomas Volk
- Department of Anesthesiology, Intensive Care Medicine and Pain Medicine, Saarland University Medical Center, Homburg, Saar, Germany
| | - Andreas Biedler
- Department of Anesthesiology, Intensive Care Medicine and Pain Medicine, Saarland University Medical Center, Homburg, Saar, Germany
| | - Sven O Schneider
- Department of Anesthesiology, Intensive Care Medicine and Pain Medicine, Saarland University Medical Center, Homburg, Saar, Germany
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Zhang LM, Li R, Zhao XC, Zhang Q, Luo XL. Increased Transfusion of Fresh Frozen Plasma is Associated with Mortality or Worse Functional Outcomes After Severe Traumatic Brain Injury: A Retrospective Study. World Neurosurg 2017; 104:381-389. [DOI: 10.1016/j.wneu.2017.04.140] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Revised: 04/20/2017] [Accepted: 04/21/2017] [Indexed: 10/19/2022]
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Ki KK, Faddy HM, Flower RL, Dean MM. Platelet concentrates modulate myeloid dendritic cell immune responses. Platelets 2017; 29:373-382. [DOI: 10.1080/09537104.2017.1306045] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Katrina K. Ki
- Research and Development, The Australian Red Cross Blood Service, Brisbane, QLD, Australia
- School of Medicine, The University of Queensland, Brisbane, QLD, Australia
| | - Helen M. Faddy
- Research and Development, The Australian Red Cross Blood Service, Brisbane, QLD, Australia
- School of Medicine, The University of Queensland, Brisbane, QLD, Australia
| | - Robert L. Flower
- Research and Development, The Australian Red Cross Blood Service, Brisbane, QLD, Australia
| | - Melinda M. Dean
- Research and Development, The Australian Red Cross Blood Service, Brisbane, QLD, Australia
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Outcomes Related to the Use of Frozen Plasma or Pooled Solvent/Detergent-Treated Plasma in Critically Ill Children. Pediatr Crit Care Med 2017; 18:e215-e223. [PMID: 28350560 DOI: 10.1097/pcc.0000000000001149] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To determine if the use of fresh frozen plasma/frozen plasma 24 hours compared to solvent detergent plasma is associated with international normalized ratio reduction or ICU mortality in critically ill children. DESIGN This is an a priori secondary analysis of a prospective, observational study. Study groups were defined as those transfused with either fresh frozen plasma/frozen plasma 24 hours or solvent detergent plasma. Outcomes were international normalized ratio reduction and ICU mortality. Multivariable logistic regression was used to determine independent associations. SETTING One hundred one PICUs in 21 countries. PATIENTS All critically ill children admitted to a participating unit were included if they received at least one plasma unit during six predefined 1-week (Monday to Friday) periods. All children were exclusively transfused with either fresh frozen plasma/frozen plasma 24 hours or solvent detergent plasma. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS There were 443 patients enrolled in the study. Twenty-four patients (5%) were excluded because no plasma type was recorded; the remaining 419 patients were analyzed. Fresh frozen plasma/frozen plasma 24 hours group included 357 patients, and the solvent detergent plasma group included 62 patients. The median (interquartile range) age and weight were 1 year (0.2-6.4) and 9.4 kg (4.0-21.1), respectively. There was no difference in reason for admission, severity of illness score, pretransfusion international normalized ratio, or lactate values; however, there was a difference in primary indication for plasma transfusion (p < 0.001). There was no difference in median (interquartile range) international normalized ratio reduction, between fresh frozen plasma/frozen plasma 24 hours and solvent detergent plasma study groups, -0.2 (-0.4 to 0) and -0.2 (-0.3 to 0), respectively (p = 0.80). ICU mortality was lower in the solvent detergent plasma versus fresh frozen plasma/frozen plasma 24 hours groups, 14.5% versus 29.1%%, respectively (p = 0.02). Upon adjusted analysis, solvent detergent plasma transfusion was independently associated with reduced ICU mortality (odds ratio, 0.40; 95% CI, 0.16-0.99; p = 0.05). CONCLUSIONS Solvent detergent plasma use in critically ill children may be associated with improved survival. This hypothesis-generating data support a randomized controlled trial comparing solvent detergent plasma to fresh frozen plasma/frozen plasma 24 hours.
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Corral M, Ferko N, Hogan A, Hollmann SS, Gangoli G, Jamous N, Batiller J, Kocharian R. A hospital cost analysis of a fibrin sealant patch in soft tissue and hepatic surgical bleeding. CLINICOECONOMICS AND OUTCOMES RESEARCH 2016; 8:507-519. [PMID: 27703386 PMCID: PMC5036832 DOI: 10.2147/ceor.s112762] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Background Despite hemostat use, uncontrolled surgical bleeding is prevalent. Drawbacks of current hemostats include limitations with efficacy on first attempt and suboptimal ease-of-use. Evarrest® is a novel fibrin sealant patch that has demonstrated high hemostatic efficacy compared with standard of care across bleeding severities. The objective of this study was to conduct a hospital cost analysis of the fibrin sealant patch versus standard of care in soft tissue and hepatic surgical bleeding. Methods The analysis quantified the 30-day costs of each comparator from a hospital perspective. Published US unit costs were applied to resource use (ie, initial treatment, retreatment, operating time, hospitalization, transfusion, and ventilator) reported in four trials. A “surgical” analysis included resources clinically related to the hemostatic benefit of the fibrin sealant patch, whereas a “hospital” analysis included all resources reported in the trials. An exploratory subgroup analysis focused solely on coagulopathic patients defined by abnormal blood test results. Results The surgical analysis predicted cost savings of $54 per patient with the fibrin sealant patch compared with standard of care (net cost impact: −$54 per patient; sensitivity range: −$1,320 to $1,213). The hospital analysis predicted further cost savings with the fibrin sealant patch (net cost impact of −$2,846 per patient; sensitivity range: −$1,483 to −$5,575). Subgroup analyses suggest that the fibrin sealant patch may provide dramatic cost savings in the coagulopathic subgroup of $3,233 (surgical) and $9,287 (hospital) per patient. Results were most sensitive to operating time and product units. Conclusion In soft tissue and hepatic problematic surgical bleeding, the fibrin sealant patch may result in important hospital cost savings.
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Affiliation(s)
| | - Nicole Ferko
- Cornerstone Research Group, Burlington, ON, Canada
| | - Andrew Hogan
- Cornerstone Research Group, Burlington, ON, Canada
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Long B, Koyfman A. Red Blood Cell Transfusion in the Emergency Department. J Emerg Med 2016; 51:120-30. [PMID: 27262735 DOI: 10.1016/j.jemermed.2016.04.010] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2016] [Accepted: 04/09/2016] [Indexed: 01/28/2023]
Abstract
BACKGROUND Transfusion of red blood cells (RBCs) is the primary management of anemia, which affects 90% of critically ill patients. Anemia has been associated with a poor prognosis in various settings, including critical illness. Recent literature has shown a hemoglobin transfusion threshold of 7 g/dL to be safe. This review examines several aspects of transfusion. OBJECTIVE We sought to provide emergency physicians with an updated review of indications for RBC transfusion in the emergency department. DISCUSSION The standard hemoglobin transfusion threshold was 10 g/dL. However, the body shows physiologic compensatory adaptations to chronic anemia. Transfusion reactions and infections are rare but can have significant morbidity and mortality. Products stored for <21 days have the lowest risk of reaction and infection. A restrictive threshold of 7 g/dL is recommended in the new American Association of Blood Banks guidelines and multiple meta-analyses and supported in gastrointestinal bleeding, sepsis, critical illness, and trauma. Patients with active ischemia in acute coronary syndrome and neurologic injury require additional study. The physician must consider the patient's hemodynamic status, comorbidities, risks and benefits of transfusion, and clinical setting in determining the need for transfusion. CONCLUSIONS RBC transfusion is not without risks, including transfusion reaction, infection, and potentially increased mortality. The age of transfusion products likely has no effect on products before 21 days of storage. A hemoglobin level of 7 g/dL is safe in the setting of critical illness, sepsis, gastrointestinal bleeding, and trauma. The clinician must evaluate and transfuse based on the clinical setting and patient hemodynamic status rather than using a specific threshold.
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Affiliation(s)
- Brit Long
- Department of Emergency Medicine, San Antonio Military Medical Center, Fort Sam Houston, Texas
| | - Alex Koyfman
- Department of Emergency Medicine, The University of Texas Southwestern Medical Center, Dallas, Texas
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Smith SA, Livingston MH, Merritt NH. Early coagulopathy and metabolic acidosis predict transfusion of packed red blood cells in pediatric trauma patients. J Pediatr Surg 2016; 51:848-52. [PMID: 26960738 DOI: 10.1016/j.jpedsurg.2016.02.034] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Accepted: 02/07/2016] [Indexed: 11/30/2022]
Abstract
BACKGROUND Severely injured pediatric trauma patients often present to hospital with early coagulopathy and metabolic acidosis. These derangements are associated with poor outcomes, but it is unclear to what degree they predict transfusion of packed red blood cells (pRBC). METHODS We retrospectively identified pediatric trauma patients from a level 1 trauma center from 2006 to 2013. Inclusion criteria were age less than 18years, Injury Severity Score greater than 12, and pRBC transfusion within 24h of admission. RESULTS We identified 96 pediatric trauma patients who underwent pRBC transfusion within 24h of presentation to hospital. On admission, 43% of these patients had one or more signs of coagulopathy, and 81% had metabolic acidosis. Size of pRBC transfusion in the first 24h ranged from 3 to 177mL/kg (mean 29mL/kg), and nineteen patients (20%) underwent massive transfusion (>40ml/kg in 24h). Univariate analysis indicated that size of pRBC transfusion was associated with initial base excess (r=0.46), international normalized ratio (r=0.35), partial thromboplastin time (r=0.41), fibrinogen (r=0.46), and BIG score (Base deficit, INR, Glasgow Coma Scale (GCS), r=0.36). Platelet count, age, GCS, and direct versus referred presentation were not predictive. Multivariable linear regression confirmed that coagulopathy and metabolic acidosis remained predictive after adjusting for direct versus referred presentation (R(2)=0.30). CONCLUSIONS Early coagulopathy and metabolic acidosis predict size of pRBC transfusion among pediatric trauma patients. Further research is needed to develop massive transfusion protocols and guidelines for activation.
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Affiliation(s)
- Shane A Smith
- Division of General Surgery, Western University, London, Ontario, Canada
| | | | - Neil H Merritt
- Division of General Surgery, Western University, London, Ontario, Canada; Division of Pediatric Surgery, Western University, London, Ontario, Canada.
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Whiting P, Al M, Westwood M, Ramos IC, Ryder S, Armstrong N, Misso K, Ross J, Severens J, Kleijnen J. Viscoelastic point-of-care testing to assist with the diagnosis, management and monitoring of haemostasis: a systematic review and cost-effectiveness analysis. Health Technol Assess 2016. [PMID: 26215747 DOI: 10.3310/hta19580] [Citation(s) in RCA: 187] [Impact Index Per Article: 23.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Patients with substantive bleeding usually require transfusion and/or (re-)operation. Red blood cell (RBC) transfusion is independently associated with a greater risk of infection, morbidity, increased hospital stay and mortality. ROTEM (ROTEM® Delta, TEM International GmbH, Munich, Germany; www.rotem.de), TEG (TEG® 5000 analyser, Haemonetics Corporation, Niles, IL, USA; www.haemonetics.com) and Sonoclot (Sonoclot® coagulation and platelet function analyser, Sienco Inc., Arvada, CO) are point-of-care viscoelastic (VE) devices that use thromboelastometry to test for haemostasis in whole blood. They have a number of proposed advantages over standard laboratory tests (SLTs): they provide a result much quicker, are able to identify what part of the clotting process is disrupted, and provide information on clot formation over time and fibrinolysis. OBJECTIVES This assessment aimed to assess the clinical effectiveness and cost-effectiveness of VE devices to assist with the diagnosis, management and monitoring of haemostasis disorders during and after cardiac surgery, trauma-induced coagulopathy and post-partum haemorrhage (PPH). METHODS Sixteen databases were searched to December 2013: MEDLINE (OvidSP), MEDLINE In-Process and Other Non-Indexed Citations and Daily Update (OvidSP), EMBASE (OvidSP), BIOSIS Previews (Web of Knowledge), Science Citation Index (SCI) (Web of Science), Conference Proceedings Citation Index (CPCI-S) (Web of Science), Cochrane Database of Systematic Reviews (CDSR), Cochrane Central Register of Controlled Trials (CENTRAL), Database of Abstracts of Reviews of Effects (DARE), Health Technology Assessment (HTA) database, Latin American and Caribbean Health Sciences Literature (LILACS), International Network of Agencies for Health Technology Assessment (INAHTA), National Institute for Health Research (NIHR) HTA programme, Aggressive Research Intelligence Facility (ARIF), Medion, and the International Prospective Register of Systematic Reviews (PROSPERO). Randomised controlled trials (RCTs) were assessed for quality using the Cochrane Risk of Bias tool. Prediction studies were assessed using QUADAS-2. For RCTs, summary relative risks (RRs) were estimated using random-effects models. Continuous data were summarised narratively. For prediction studies, the odds ratio (OR) was selected as the primary effect estimate. The health-economic analysis considered the costs and quality-adjusted life-years of ROTEM, TEG and Sonoclot compared with SLTs in cardiac surgery and trauma patients. A decision tree was used to take into account short-term complications and longer-term side effects from transfusion. The model assumed a 1-year time horizon. RESULTS Thirty-one studies (39 publications) were included in the clinical effectiveness review. Eleven RCTs (n=1089) assessed VE devices in patients undergoing cardiac surgery; six assessed thromboelastography (TEG) and five assessed ROTEM. There was a significant reduction in RBC transfusion [RR 0.88, 95% confidence interval (CI) 0.80 to 0.96; six studies], platelet transfusion (RR 0.72, 95% CI 0.58 to 0.89; six studies) and fresh frozen plasma to transfusion (RR 0.47, 95% CI 0.35 to 0.65; five studies) in VE testing groups compared with control. There were no significant differences between groups in terms of other blood products transfused. Continuous data on blood product use supported these findings. Clinical outcomes did not differ significantly between groups. There were no apparent differences between ROTEM or TEG; none of the RCTs evaluated Sonoclot. There were no data on the clinical effectiveness of VE devices in trauma patients or women with PPH. VE testing was cost-saving and more effective than SLTs. For the cardiac surgery model, the cost-saving was £43 for ROTEM, £79 for TEG and £132 for Sonoclot. For the trauma population, the cost-savings owing to VE testing were more substantial, amounting to per-patient savings of £688 for ROTEM compared with SLTs, £721 for TEG, and £818 for Sonoclot. This finding was entirely dependent on material costs, which are slightly higher for ROTEM. VE testing remained cost-saving following various scenario analyses. CONCLUSIONS VE testing is cost-saving and more effective than SLTs, in both patients undergoing cardiac surgery and trauma patients. However, there were no data on the clinical effectiveness of Sonoclot or of VE devices in trauma patients. STUDY REGISTRATION This study is registered as PROSPERO CRD42013005623. FUNDING The NIHR Health Technology Assessment programme.
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Affiliation(s)
| | - Maiwenn Al
- Institute of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, the Netherlands
| | | | - Isaac Corro Ramos
- Institute of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, the Netherlands
| | | | | | - Kate Misso
- Kleijnen Systematic Reviews Ltd, York, UK
| | | | - Johan Severens
- Institute of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, the Netherlands
| | - Jos Kleijnen
- School for Public Health and Primary Care (CAPHRI), Maastricht University, Maastricht, the Netherlands
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Klauke N, Gräff I, Fleischer A, Boehm O, Guttenthaler V, Baumgarten G, Meybohm P, Wittmann M. Effects of prehospital hypothermia on transfusion requirements and outcomes: a retrospective observatory trial. BMJ Open 2016; 6:e009913. [PMID: 27029772 PMCID: PMC4823393 DOI: 10.1136/bmjopen-2015-009913] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVES Prehospital hypothermia is defined as a core temperature <36.0 °C and has been shown to be an independent risk factor for early death in patients with trauma. In a retrospective study, a possible correlation between the body temperature at the time of admission to the emergency room and subsequent in-hospital transfusion requirements and the in-hospital mortality rate was explored. SETTING This is a retrospective single-centre study at a primary care hospital in Germany. PARTICIPANTS 15,895 patients were included in this study. Patients were classified by admission temperature and transfusion rate. Excluded were ambulant patients and patients with missing data. PRIMARY AND SECONDARY OUTCOME MEASURES The primary outcome values were length of stay (LOS) in days, in-hospital mortality, the transferred amount of packed red blood cells (PRBCs), and admission to an intensive care unit. Secondary influencing variables were the patient's age and the Glasgow Coma Scale. RESULTS In 22.85% of the patients, hypothermia was documented. Hypothermic patients died earlier in the course of their hospital stay than non-hypothermic patients (p<0.001). The administration of 1-3 PRBC increased the LOS significantly (p<0.001) and transfused patients had an increased risk of death (p<0.001). Prehospital hypothermia could be an independent risk factor for mortality (adjusted OR 8.521; p=0.001) and increases the relative risk for transfusion by factor 2.0 (OR 2.007; p=0.002). CONCLUSIONS Low body temperature at hospital admission is associated with a higher risk of transfusion and death. Hence, a greater awareness of prehospital temperature management should be established.
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Affiliation(s)
- Nora Klauke
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
| | - Ingo Gräff
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
| | - Andreas Fleischer
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
| | - Olaf Boehm
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
| | - Vera Guttenthaler
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
| | - Georg Baumgarten
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
| | - Patrick Meybohm
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Frankfurt am Main, Frankfurt am Main, Germany
| | - Maria Wittmann
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
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Lewandowski LR, Weintrob AC, Tribble DR, Rodriguez CJ, Petfield J, Lloyd BA, Murray CK, Stinner D, Aggarwal D, Shaikh F, Potter BK. Early Complications and Outcomes in Combat Injury-Related Invasive Fungal Wound Infections: A Case-Control Analysis. J Orthop Trauma 2016; 30:e93-9. [PMID: 26360542 PMCID: PMC4761299 DOI: 10.1097/bot.0000000000000447] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVE Clinicians have anecdotally noted that combat-related invasive fungal wound infections (IFIs) lead to residual limb shortening, additional days and operative procedures before initial wound closure, and high early complication rates. We evaluated the validity of these observations and identified risk factors that may impact time to initial wound closure. DESIGN Retrospective review and case-control analysis. SETTING Military hospitals. PATIENTS/PARTICIPANTS US military personnel injured during combat operations (2009-2011). The IFI cases were identified based on the presence of recurrent, necrotic extremity wounds with mold growth in culture, and/or histopathologic fungal evidence. Non-IFI controls were matched on injury pattern and severity. In a supplemental matching analysis, non-IFI controls were also matched by blood volume transfused within 24 hours of injury. INTERVENTION None. MAIN OUTCOME MEASUREMENTS Amputation revision rate and loss of functional levels. RESULTS Seventy-one IFI cases (112 fungal-infected extremity wounds) were identified and matched to 160 control patients (315 non-IFI extremity wounds). The IFI wounds resulted in significantly more changes in amputation level (P < 0.001). Additionally, significantly (P < 0.001) higher number of operative procedures and longer duration to initial wound closure were associated with IFI. A shorter duration to initial wound closure was significantly associated with wounds lacking IFIs (Hazard ratio: 1.53; 95% confidence interval, 1.17-2.01). The supplemental matching analysis found similar results. CONCLUSIONS Our analysis indicates that IFIs adversely impact wound healing and patient recovery, requiring more frequent proximal amputation revisions and leading to higher early complication rates. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Louis R. Lewandowski
- Department of Orthopaedics, Walter Reed National Military Medical Center, Bethesda, MD 20814
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD 20814
| | - Amy C. Weintrob
- Department of Orthopaedics, Walter Reed National Military Medical Center, Bethesda, MD 20814
- Infectious Disease Clinical Research Program, Uniformed Services University of the Health Sciences, Bethesda, MD 20814
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc. Bethesda, MD 20817
| | - David R. Tribble
- Infectious Disease Clinical Research Program, Uniformed Services University of the Health Sciences, Bethesda, MD 20814
| | - Carlos J. Rodriguez
- Department of Orthopaedics, Walter Reed National Military Medical Center, Bethesda, MD 20814
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD 20814
| | - Joseph Petfield
- Department of Orthopaedics and Rehabilitation, San Antonio Military Medical Center, JBSA Fort Sam Houston, TX 78234
| | | | - Clinton K. Murray
- Infectious Disease Service, San Antonio Military Medical Center, 3551 Roger Brooke Drive #3600, JBSA Fort Sam Houston, TX 78234
| | - Daniel Stinner
- Department of Orthopaedics and Rehabilitation, San Antonio Military Medical Center, JBSA Fort Sam Houston, TX 78234
| | - Deepak Aggarwal
- Infectious Disease Clinical Research Program, Uniformed Services University of the Health Sciences, Bethesda, MD 20814
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc. Bethesda, MD 20817
| | - Faraz Shaikh
- Infectious Disease Clinical Research Program, Uniformed Services University of the Health Sciences, Bethesda, MD 20814
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc. Bethesda, MD 20817
| | - Benjamin K. Potter
- Department of Orthopaedics, Walter Reed National Military Medical Center, Bethesda, MD 20814
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD 20814
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Shander A, Ozawa S, Hofmann A. Activity-based costs of plasma transfusions in medical and surgical inpatients at a US hospital. Vox Sang 2016; 111:55-61. [DOI: 10.1111/vox.12386] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2015] [Revised: 12/17/2015] [Accepted: 01/13/2016] [Indexed: 11/30/2022]
Affiliation(s)
- A. Shander
- Department of Anesthesiology; Critical Care and Hyperbaric Medicine; Englewood Hospital and Medical Center; Englewood NJ USA
- Clinical Professor of Anesthesiology; Medicine and Surgery; Icahn School of Medicine at Mount Sinai; New York NY USA
- Institute for Bloodless Medicine and Patient Blood Management; Englewood Hospital & Medical Center; Englewood NJ USA
| | - S. Ozawa
- Institute for Bloodless Medicine and Patient Blood Management; Englewood Hospital & Medical Center; Englewood NJ USA
| | - A. Hofmann
- School of Surgery; Faculty of Medicine Dentistry and Health Sciences; University of Western Australia; Perth WA Australia
- Centre for Population Health Research; Curtin Health Innovation Research Institute; Curtin University; Perth WA Australia
- Institute of Anaesthesiology; University Hospital and University of Zurich; Zurich Switzerland
- Institute for Bloodless Medicine and Patient Blood Management; Englewood Hospital & Medical Center; Englewood NJ USA
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Effect of Intraoperative Red Blood Cell Transfusion on Postoperative Complications After Open Radical Cystectomy: Old Versus Fresh Stored Blood. Clin Genitourin Cancer 2015; 13:581-7. [PMID: 26165733 DOI: 10.1016/j.clgc.2015.06.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2015] [Revised: 06/08/2015] [Accepted: 06/09/2015] [Indexed: 11/22/2022]
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Corral M, Ferko N, Hollmann S, Broder MS, Chang E. Health and economic outcomes associated with uncontrolled surgical bleeding: a retrospective analysis of the Premier Perspectives Database. CLINICOECONOMICS AND OUTCOMES RESEARCH 2015; 7:409-21. [PMID: 26229495 PMCID: PMC4516034 DOI: 10.2147/ceor.s86369] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Background Bleeding remains a common occurrence in surgery. Data describing the burden of difficult-to-control bleeding and topical absorbable hemostat use are sparse. This study was conducted to estimate the clinical and economic impact that remains associated with uncontrolled surgical bleeding, even when hemostats are used during surgery. Methods This US retrospective analysis used the Premier Perspectives Database. Hospital discharges from 2012 were used to identify patients treated with hemostats during eight surgery types. Patients were included if they were ≥18 years, had an inpatient hospitalization with one of the eight surgeries, and received a hemostat on the day of surgery. Patients were stratified by procedure and presence or absence of major bleeding (uncontrolled) despite hemostat use. Outcomes were all-cause hospitalization costs, hemostat costs, length of stay, reoperation, and surgery-related complications (eg, mortality). Statistical significance was tested through chi-square or t-tests. Multivariate analyses were conducted for all-cause costs and length of stay using analysis of covariance. Results Among 25,048 procedures, major bleeding events occurred in 14,251 cases. Despite treatment with hemostats, major bleeding occurred in 32%–68% of cases. All-cause costs were significantly higher in patients with uncontrolled bleeding despite hemostat use versus controlled bleeding (US$24,203–$61,323 [uncontrolled], US$14,420–$45,593 [controlled]; P<0.001). Hemostat costs were significantly greater in the uncontrolled bleeding cohort for all surgery types except cystectomy and pancreatic surgery. Reoperation and mortality rates were significantly higher in the uncontrolled bleeding cohort in all surgical procedures except cystectomy and radical hysterectomy. Conclusion Uncontrolled intraoperative bleeding despite hemostat use is prevalent and associated with significantly higher hospital costs and worse clinical outcomes across several surgical procedures compared to controlled bleeding. There is an unmet need for newer hemostats that can more effectively control bleeding, improve outcomes, and reduce hospital resource use.
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Affiliation(s)
| | - Nicole Ferko
- Cornerstone Research Group, Burlington, ON, Canada
| | | | - Michael S Broder
- Partnership for Health Analytic Research, Beverly Hills, CA, USA
| | - Eunice Chang
- Partnership for Health Analytic Research, Beverly Hills, CA, USA
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Abstract
PURPOSE Trauma and complex cardiac surgery are associated with a high risk of bleeding complications. The difference in costs between patients who require bleeding control measures and those who do not is poorly understood. Our goal was to assess the cost of care and outcomes for patients in these settings. METHODS Patients >18 years of age, who were discharged between January 2010 and December 2012, were retrospectively identified in the Premier Hospital Database based on International Classification of Disease, Ninth Revision codes. These patients were categorized as having received blood products ("bleeding patients") or not ("nonbleeding patients"). Patients with costs and length of stay (LOS) of zero were excluded. Differences in treatment costs and outcomes were assessed using univariate analysis and multivariate modeling. FINDINGS Bleeding trauma patients (n = 8800) had a 150% higher total cost of care (P < 0.001; 146% after excluding costs of agents used for bleeding control, P < 0.001), an 81.3% longer hospital LOS (P < 0.001), and a 65.2% longer intensive care unit (ICU) LOS (P < 0.001) than nonbleeding patients (n = 53,727). Bleeding complex cardiac surgery patients (n = 82,832) had a 133.2% higher total cost of care (P < 0.001; 128.7% after excluding costs of agents used for bleeding control, P < 0.001), a 155.6% longer hospital LOS (P < 0.001), and an 89.3% longer ICU LOS (P < 0.001) than nonbleeding patients (n = 380,902). IMPLICATIONS Trauma and cardiac surgery patients who experienced bleeding and received allogeneic blood product transfusions had significantly worse outcomes, including longer LOS, greater inpatient mortality, and higher costs of care (even when excluding costs of agents used for bleeding control) than those who did not.
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Affiliation(s)
| | - Glenn Magee
- Premier Research Services, Charlotte, North Carolina
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Yuan Q, Wu X, Du ZY, Sun YR, Yu J, Li ZQ, Wu XH, Mao Y, Zhou LF, Hu J. Low-dose recombinant factor VIIa for reversing coagulopathy in patients with isolated traumatic brain injury. J Crit Care 2015; 30:116-20. [DOI: 10.1016/j.jcrc.2014.07.009] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2014] [Revised: 07/07/2014] [Accepted: 07/07/2014] [Indexed: 11/25/2022]
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Zheng Y, Lu C, Wei S, Li Y, Long L, Yin P. Association of red blood cell transfusion and in-hospital mortality in patients admitted to the intensive care unit: a systematic review and meta-analysis. Crit Care 2014; 18:515. [PMID: 25394759 PMCID: PMC4256753 DOI: 10.1186/s13054-014-0515-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2014] [Accepted: 08/28/2014] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION Previous research has debated whether red blood cell (RBC) transfusion is associated with decreased or increased mortality in patients admitted to the intensive care unit (ICU). We conducted a systematic review and meta-analysis to assess the relationship of RBC transfusion with in-hospital mortality in ICU patients. METHODS We carried out a literature search on Medline (1950 through May 2013), Web of Science (1986 through May 2013) and Embase (1980 through May 2013). We included all prospective and retrospective studies on the association between RBC transfusion and in-hospital mortality in ICU patients. The relative risk for the overall pooled effects was estimated by random effects model. Sensitivity analyses were conducted to assess potential bias. RESULTS The meta-analysis included 28,797 participants from 18 studies. The pooled relative risk for transfused versus nontransfused ICU patients was 1.431 (95% CI, 1.105 to 1.854). In sensitivity analyses, the pooled relative risk was 1.211 (95% CI, 0.975 to 1.505) if excluding studies without adjustment for confounders, 1.178 (95% CI, 0.937 to 1.481) if excluding studies with relative high risk of bias, and 0.901 (95% CI, 0.622 to 1.305) if excluding studies without reporting hazard ratio (HR) or relative risk (RR) as an effect size measure. Subgroup analyses revealed increased risks in studies enrolling patients from all ICU admissions (RR 1.513, 95%CI 1.123 to 2.039), studies without reporting information on leukoreduction (RR 1.851, 95%CI 1.229 to 2.786), studies reporting unadjusted effect estimates (RR 3.933, 95%CI 2.107 to 7.343), and studies using odds ratio as an effect measure (RR 1.465, 95%CI 1.049 to 2.045). Meta-regression analyses showed that RBC transfusion could decrease risk of mortality in older patients (slope coefficient -0.0417, 95%CI -0.0680 to -0.0154). CONCLUSIONS There is lack of strong evidence to support the notion that ICU patients who receive RBC transfusion have an increased risk of in-hospital death. In studies adjusted for confounders, we found that RBC transfusion does not increase the risk of in-hospital mortality in ICU patients. Type of patient, information on leukoreduction, statistical method, mean age of patient enrolled and publication year of the article may account for the disagreement between previous studies.
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Affiliation(s)
- Yi Zheng
- Department of Epidemiology and Biostatistics, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, 1037 Luoyu Road, Hongshan, Wuhan, China.
| | - Caihong Lu
- Department of ENT department, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1037 Luoyu Road, Hongshan, Wuhan, China.
| | - Shiqing Wei
- Department of Epidemiology and Biostatistics, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, 1037 Luoyu Road, Hongshan, Wuhan, China.
| | - Ye Li
- Department of Epidemiology and Biostatistics, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, 1037 Luoyu Road, Hongshan, Wuhan, China.
| | - Lu Long
- Department of Epidemiology and Biostatistics, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, 1037 Luoyu Road, Hongshan, Wuhan, China.
| | - Ping Yin
- Department of Epidemiology and Biostatistics, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, 1037 Luoyu Road, Hongshan, Wuhan, China.
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A multicenter, randomized clinical trial of IV iron supplementation for anemia of traumatic critical illness*. Crit Care Med 2014; 42:2048-57. [PMID: 24797376 DOI: 10.1097/ccm.0000000000000408] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVE To evaluate the efficacy of IV iron supplementation of anemic, critically ill trauma patients. DESIGN Multicenter, randomized, single-blind, placebo-controlled trial. SETTING Four trauma ICUs. PATIENTS Anemic (hemoglobin < 12 g/dL) trauma patients enrolled within 72 hours of ICU admission and with an expected ICU length of stay of more than or equal to 5 days. INTERVENTIONS Randomization to iron sucrose 100 mg IV or placebo thrice weekly for up to 2 weeks. MEASUREMENTS AND MAIN RESULTS A total of 150 patients were enrolled. Baseline iron markers were consistent with functional iron deficiency: 134 patients (89.3%) were hypoferremic, 51 (34.0%) were hyperferritinemic, and 64 (42.7%) demonstrated iron-deficient erythropoiesis as evidenced by an elevated erythrocyte zinc protoporphyrin concentration. The median baseline transferrin saturation was 8% (range, 2-58%). In the subgroup of patients who received all six doses of study drug (n = 57), the serum ferritin concentration increased significantly for the iron as compared with placebo group on both day 7 (808.0 ng/mL vs 457.0 ng/mL, respectively, p < 0.01) and day 14 (1,046.0 ng/mL vs 551.5 ng/mL, respectively, p < 0.01). There was no significant difference between groups in transferrin saturation, erythrocyte zinc protoporphyrin concentration, hemoglobin concentration, or packed RBC transfusion requirement. There was no significant difference between groups in the risk of infection, length of stay, or mortality. CONCLUSIONS Iron supplementation increased the serum ferritin concentration significantly, but it had no discernible effect on transferrin saturation, iron-deficient erythropoiesis, hemoglobin concentration, or packed RBC transfusion requirement. Based on these data, routine IV iron supplementation of anemic, critically ill trauma patients cannot be recommended (NCT 01180894).
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Schneider SO, Rensing H, Hartmann L, Grundmann U, Volk T, Biedler A. Impact of intraoperatively salvaged and washed blood on stimulated cytokine release in vitro. Transfusion 2014; 54:2782-90. [PMID: 25294235 DOI: 10.1111/trf.12781] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2013] [Revised: 05/21/2014] [Accepted: 06/02/2014] [Indexed: 12/31/2022]
Abstract
BACKGROUND Intraoperative blood salvage and processing it with commercially available devices is a widespread standard procedure to reduce allogeneic blood transfusion in patients undergoing major orthopedic surgery. The aim of this study was to investigate the impact of such processed blood on the immune system by measuring pro- and anti-inflammatory cytokines. STUDY DESIGN AND METHODS Salvaged blood from 20 patients undergoing hip arthroplasty was processed with a continuous autotransfusion system. One part of the processed blood was left without further treatment, one part was additionally leukoreduced, one part was irradiated, and one part was separated into its cellular and soluble fraction by centrifugation. Specimens from each part were mixed in vitro with venous blood from the patient in ratios of 3:1, 1:1, and 1:3 and incubated with endotoxin for 24 hours. Tumor necrosis factor (TNF)-α and interleukin (IL)-10 were measured in cell culture supernatants by enzyme-linked immunosorbent assay. RESULTS All parts of the salvaged blood were without a significant influence on TNF-α release. In contrast, IL-10 was significantly increased, independently of the admixtured salvaged blood being plain, additionally irradiated, or additionally leukoreduced. This IL-10 increase was also found with the cellular fraction of the plain salvaged blood, whereas the soluble fraction had no influence on IL-10 release. CONCLUSION Intraoperative salvaged blood is not immunologically inert. We observed a significant increase in the anti-inflammatory IL-10 response without affecting the proinflammatory TNF-α release. Neither leukofiltration nor gamma irradiation eliminated this effect that was limited only to the cellular fraction of the salvaged blood, suggesting red blood cells to be responsible for the observed immunomodulation.
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Affiliation(s)
- Sven Oliver Schneider
- Department for Anesthesiology, Critical Care Medicine and Pain Therapy, Saarland University Hospital, Homburg, Germany
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Patel SV, Kidane B, Klingel M, Parry N. Risks associated with red blood cell transfusion in the trauma population, a meta-analysis. Injury 2014; 45:1522-33. [PMID: 24975652 DOI: 10.1016/j.injury.2014.05.015] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2014] [Revised: 05/14/2014] [Accepted: 05/15/2014] [Indexed: 02/02/2023]
Abstract
INTRODUCTION A previous meta-analysis has found an association between red blood cell (RBC) transfusions and mortality in critically ill patients, but no review has focused on the trauma population only. OBJECTIVES To determine the association between RBC transfusion and mortality in the trauma population, with secondary outcomes of multiorgan failure (MOF) and acute respiratory distress syndrome (ARDS) or acute lung injury (ALI). DATA SOURCES EMBASE (1947-2012) and MEDLINE (1946-2012). STUDY ELIGIBILITY CRITERIA Randomized controlled trials and observational studies were to be included if they assessed the association between RBC transfusion and either the primary (mortality) or secondary outcomes (MOF, ARDS/ALI). PARTICIPANTS Trauma patients. EXPOSURE Red blood cell transfusion. METHODS A literature search was completed and reviewed in duplicate to identify eligible studies. Studies were included in the pooled analyses if an attempt was made to determine the association between RBC and the outcomes, after adjusting for important confounders. A random effects model was used for and heterogeneity was quantified using the I(2) statistic. Study quality was assessed using the Newcastle-Ottawa Scale. RESULTS 40 observational studies were included in the qualitative review. Including studies which adjusted for important confounders found the odds of mortality increased with each additional unit of RBC transfused (9 Studies, OR 1.07, 95%CI 1.04-1.10, I(2) 82.9%). The odds of MOF (3 studies, OR 1.08, 95%CI 1.02-1.14, I(2) 95.9%) and ARDS/ALI (2 studies, OR 1.06, 95%CI 1.03-1.10, I(2) 0%) also increased with each additional RBC unit transfused. CONCLUSIONS We have found an association between RBC transfusion and the primary and secondary outcomes, based on observational studies only. This represents the extent of the published literature. Further interventional studies are needed to clarify how limiting transfusion can affect mortality and other outcomes.
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Affiliation(s)
- Sunil V Patel
- London Health Sciences Centre, London, Ontario, Canada.
| | - Biniam Kidane
- London Health Sciences Centre, London, Ontario, Canada.
| | | | - Neil Parry
- London Health Sciences Centre, London, Ontario, Canada.
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Mitra B, Olaussen A, Cameron PA, O'Donohoe T, Fitzgerald M. Massive blood transfusions post trauma in the elderly compared to younger patients. Injury 2014; 45:1296-300. [PMID: 24560872 DOI: 10.1016/j.injury.2014.01.016] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2013] [Revised: 01/03/2014] [Accepted: 01/17/2014] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Older age and blood transfusion have both been independently associated with higher mortality post trauma and the combination is expected to be associated with catastrophic outcomes. Among patients who received a massive transfusion post trauma, we aimed to investigate mortality at hospital discharge of patients ≥65 years old and explore variables associated with poor outcomes. METHODS A retrospective review of registry data on all major trauma patients presenting to a level I trauma centre between 2006 and 2011 was conducted. Mortality at hospital discharge among patients ≥65 years old was compared to the younger cohort. A multivariable logistic regression model was constructed to determine independent risk-factors for mortality among older patients. RESULTS There were 51 (16.4%) patients of age ≥65 years who received a massive transfusion. There were 20 (39.2%) deaths, a proportion significantly higher than 55 (21.1%) deaths among younger patients (p<0.01). Pre-hospital GCS, the presence of acute traumatic coagulopathy and higher systolic blood pressure on presentation were independently associated with higher mortality. Age and volume of red cells transfused were not significantly associated with higher mortality. CONCLUSIONS Survival to hospital discharge was demonstrated in elderly patients receiving massive transfusions post trauma, even in the presence of multiple risk factors for mortality. Restrictive resuscitation or transfusion on the basis of age alone cannot be supported. Early aggressive resuscitation of elderly trauma patients along specific guidelines directed at the geriatric population is justified and may further improve outcomes.
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Affiliation(s)
- Biswadev Mitra
- Emergency & Trauma Centre, The Alfred Hospital, Australia; Department of Epidemiology & Preventive Medicine, Monash University, Australia; National Trauma Research Institute, The Alfred Hospital, Australia.
| | - Alexander Olaussen
- Emergency & Trauma Centre, The Alfred Hospital, Australia; Trauma Service, The Alfred Hospital, Australia
| | - Peter A Cameron
- Emergency & Trauma Centre, The Alfred Hospital, Australia; Department of Epidemiology & Preventive Medicine, Monash University, Australia; National Trauma Research Institute, The Alfred Hospital, Australia
| | - Tom O'Donohoe
- National Trauma Research Institute, The Alfred Hospital, Australia; Trauma Service, The Alfred Hospital, Australia
| | - Mark Fitzgerald
- National Trauma Research Institute, The Alfred Hospital, Australia; Trauma Service, The Alfred Hospital, Australia
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Rodriguez CJ, Weintrob AC, Shah J, Malone D, Dunne JR, Weisbrod AB, Lloyd BA, Warkentien TE, Murray CK, Wilkins K, Shaikh F, Carson ML, Aggarwal D, Tribble DR. Risk factors associated with invasive fungal infections in combat trauma. Surg Infect (Larchmt) 2014; 15:521-6. [PMID: 24821267 DOI: 10.1089/sur.2013.123] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND In recent years, invasive fungal infections (IFI) have complicated the clinical course of patients with combat-related injuries. Commonalities in injury patterns and characteristics among patients with IFI led to the development of a Joint Trauma System (JTS) clinical practice guideline (CPG) for IFI management. We performed a case-control study to confirm and further delineate risk factors associated with IFI development in combat casualties with the objective of generating data to refine the CPG and promote timelier initiation of treatment. METHODS Data were collected retrospectively for United States (U.S.) military personnel injured during deployment in Afghanistan from June 2009 through August 2011. Cases were identified as IFI based upon wound cultures with fungal growth and/or fungal elements seen on histology, in addition to the presence of recurrent wound necrosis. Controls were matched using date of injury (±3 mo) and injury severity score (±10). Risk factor parameters analyzed included injury circumstances, blood transfusion requirements, amputations after first operative intervention, and associated injuries. Data are expressed as multivariate odds ratios (OR; 95% confidence interval [CI]). RESULTS Seventy-six IFI cases were identified from 1,133 U.S. military personnel wounded in Afghanistan and matched to 150 controls. Parameters associated significantly with the development of IFI multivariate analysis were blast injuries (OR: 5.7; CI: 1.1-29.6), dismounted at time of injury (OR: 8.5; CI: 1.2-59.8); above the knee amputations (OR: 4.1; CI: 1.3-12.7), and large-volume packed red blood cell (PRBC; >20 U) transfusions within first 24 h (OR: 7.0; CI: 2.5-19.7). CONCLUSIONS Our analysis indicates that dismounted blast injuries, resulting in above the knee amputations, and requirement of large volume PRBC transfusions are independent predictors of IFI development. These data confirm all the preliminary risk factors, except for genitalia/perineal injuries, utilized by JTS in their IFI CPG. Model validation is necessary for further risk factor specification.
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The burden of infection in severely injured trauma patients and the relationship with admission shock severity. J Trauma Acute Care Surg 2014; 76:730-5. [PMID: 24487318 DOI: 10.1097/ta.0b013e31829fdbd7] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND Infection following severe injury is common and has a major impact on patient outcomes. The relationship between patient, injury, and physiologic characteristics with subsequent infections is not clearly defined. The objective of this study was to characterize the drivers and burden of all-cause infection in critical care trauma patients. METHODS A prospective cohort study of severely injured adult patients admitted to critical care was conducted. Data were collected prospectively on patient and injury characteristics, baseline physiology, coagulation profiles, and blood product use. Patients were followed up daily for infectious episodes and other adverse outcomes while in the hospital. RESULTS Three hundred patients (Injury Severity Score [ISS] >15) were recruited. In 48 hours or less, 29 patients (10%) died, leaving a cohort of 271. One hundred forty-one patients (52%) developed at least one infection. Three hundred four infections were diagnosed overall. Infection and noninfection groups were matched for age, sex, mechanism, and ISS. Infection rates were greater with any degree of admission shock and threefold higher in the most severely shocked cohort (p < 0.01). In multivariate analysis, base deficit (odds ratio [OR], 1.78, 95% confidence interval [CI], 1.48-1.94; p < 0.001) and lactate (OR, 1.36; 95% CI, 1.10-1.69; p = 0.05) were independently associated with the development of infection. Outcomes were significantly worse for the patients with infection. In multivariate logistic regression, infection was the only factor independently associated with multiple-organ failure (p < 0.001; OR, 15.4; 95% CI, 8.2-28.9; r = 0.402), ventilator-free days (p < 0.001; β, -4.48; 95% CI, -6.7 to -2.1; r = 0.245), critical care length of stay (p < 0.001; β, 13.2; 95% CI, 10.0-16.4; r = 0.466), and hospital length of stay (p < 0.001; β, 31.1; 95% CI, 24.0-38.2; r = 0.492). CONCLUSION Infectious complications are a burden for severely injured patients and occur early in the critical care stay. Severity of admission shock was predictive of infection and represents an opportunity for interventions to improve infectious outcomes. The incidence of infection may also have utility as an end point for clinical trials in trauma hemorrhage given the relationship with patient-experienced outcomes. LEVEL OF EVIDENCE Prognostic/epidemiologic study, level II.
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The use of higher platelet: RBC transfusion ratio in the acute phase of trauma resuscitation: a systematic review. Crit Care Med 2014; 41:2800-11. [PMID: 23982024 DOI: 10.1097/ccm.0b013e31829a6ecb] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
OBJECTIVE With the recognition of early coagulopathy, trauma resuscitation has shifted toward liberal platelet transfusions. The overall benefit of this strategy remains controversial. Our objective was to compare the effects of a liberal use of platelet (higher platelet:RBC ratios) with a conservative approach (lower ratios) in trauma resuscitation. DATA SOURCES We systematically searched Medline, Embase, Web of Science, Biosis, Cochrane Central, and Scopus. STUDY SELECTION Two independent reviewers selected randomized controlled trials and observational studies comparing two or more platelet:RBC ratios in trauma resuscitation. We excluded studies investigating the use of whole blood or hemostatic products. DATA EXTRACTION Two independent reviewers extracted data and assessed the risk of bias. Primary outcomes were early (in ICU or within 30 d) and late (in hospital or after 30 d) mortality. Secondary outcomes were multiple organ failure, lung injury, and sepsis. DATA SYNTHESIS From 6,123 citations, no randomized controlled trials were identified. We included seven observational studies (4,230 patients) addressing confounders through multivariable regression or propensity scores. Heterogeneity of studies precluded meta-analysis. Among the five studies including exclusively patients requiring massive transfusions, four observed a lower mortality with higher ratios. Two studies considering nonmassively bleeding patients observed no benefit of using higher ratios. Two studies evaluated the implementation of a massive transfusion protocol; only one study observed a decrease in mortality with higher ratios. Of the two studies at low risk of survival bias, one study observed a survival benefit. Three studies assessed secondary outcomes. One study observed an increase in multiple organ failure with higher ratios, whereas no study demonstrated an increased risk in lung injury or sepsis. CONCLUSIONS There is insufficient evidence to strongly support the use of a precise platelet:RBC ratio for trauma resuscitation, especially in nonmassively bleeding patients. Randomized controlled trials evaluating both the safety and efficacy of liberal platelet transfusions are warranted.
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Boone JD, Kim KH, Marques M, Straughn JM. Compliance rates and outcomes associated with a restrictive transfusion policy in gynecologic oncology patients. Gynecol Oncol 2014; 132:227-30. [DOI: 10.1016/j.ygyno.2013.10.019] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2013] [Revised: 10/14/2013] [Accepted: 10/19/2013] [Indexed: 10/26/2022]
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Magee G, Peters C, Zbrozek A. Analysis of Inpatient Use of Fresh Frozen Plasma and Other Therapies and Associated Outcomes in Patients with Major Bleeds from Vitamin K Antagonism. Clin Ther 2013; 35:1432-43. [DOI: 10.1016/j.clinthera.2013.07.331] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2013] [Revised: 06/11/2013] [Accepted: 07/17/2013] [Indexed: 10/26/2022]
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Magee G, Zbrozek A. Fluid overload is associated with increases in length of stay and hospital costs: pooled analysis of data from more than 600 US hospitals. CLINICOECONOMICS AND OUTCOMES RESEARCH 2013; 5:289-96. [PMID: 23836999 PMCID: PMC3699028 DOI: 10.2147/ceor.s45873] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
Background Fluid overload, including transfusion-associated circulatory overload (TACO), is a serious complication of fresh frozen plasma (FFP) transfusion. The incidence of fluid overload is underreported and its economic impact is unknown. An evaluation of fluid overload cases in US hospitals was performed to assess the impact of fluid overload on length and cost of hospital stay. Study design and methods Retrospective analysis was performed using a clinical and economic database covering >600 US hospitals. Data were collected for all inpatients discharged during 2010 who received ≥1 unit FFP during hospitalization. Incidence of fluid overload was determined through International Classification of Diagnosis (ICD-9) codes. Multivariate regression analysis was performed for primary outcome measures: hospital length of stay (LOS) and total hospital costs. Results Data were analyzed for 129,839 FFP-transfused patients, of whom 4,138 (3.2%) experienced fluid overload (including TACO). Multivariate analysis, adjusting for baseline characteristics, found that increased LOS and hospital costs were independently associated with fluid overload. Patients diagnosed with fluid overload had longer mean LOS (12.9 days versus 10.0 days; P < 0.001) and higher mean hospital cost per visit ($46,644 versus $32,582; P < 0.001) compared with patients without fluid overload. Conclusion For a population of US inpatients who received FFP during hospitalization, fluid overload was associated with a 29% increase in LOS and a $14,062 increase in hospital costs per visit. These findings suggest that the incidence of fluid overload in the general population is greater than historically reported. A substantial economic burden may be associated with fluid overload in the US.
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Affiliation(s)
- Glenn Magee
- Premier Research Services, Charlotte, NC, USA
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Agarwal N, Subramanian A, Pandey RM, Albert V, Karjee S, Arya V. An audit of fresh frozen plasma usage in a tertiary trauma care centre in north India. Indian J Hematol Blood Transfus 2013; 30:328-32. [PMID: 25435737 DOI: 10.1007/s12288-013-0265-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2011] [Accepted: 04/19/2013] [Indexed: 11/29/2022] Open
Abstract
Fresh frozen plasma (FFP) transfusion is a crucial part of management of trauma patients. There is a paucity of literature about the audit of appropriateness of FFP use in trauma patients. To evaluate and analyze the appropriateness of FFP transfusion practices for trauma patients. Prospectively compiled blood bank records of FFP transfusion practices over a period of 4 months from Augusts'08 through Deember'08 were retrospectively analyzed for 207 patients. The number of FFP units used in all these trauma patients were evaluated a propos the cause of injury, departments, type of surgery, presence of coagulopathy, bleeding, massive transfusion, length of hospital stay and patient outcome. Trauma scores such as Glasgow coma score and injury severity score were also calculated to estimate the severity of injury. The appropriateness of FFP transfusion was assessed according to the guidelines drafted by the College of American Pathologists. FFP transfusion for patients experiencing active bleeding, micro vascular bleeding, coagulopathy and/or massive transfusion, was deemed appropriate. Patients receiving FFP were categorized and individually correlated with the outcome. The influences of other variables which affect patient outcome were excluded using stepwise multivariate logistic regression analysis. p value < 0.05 were considered to be statistically significant. A total of 207 trauma patients were included in the study, 183 (88.4 %) males and 24 (11.6 %) females. The FFP use among neurosurgery patients was 46.9 %, general surgery patients 40.6 % and orthopedics 12.6 %. Appropriate use of FFP was 49.5 % according to the CAP guidelines. Trauma patients who required FFP as a part of treatment were categorized as; Patients who had bleeding alone (n = 40), bleeding with coagulopathy (n = 16), and coagulopathy alone (n = 43), and further correlated with the outcome and were found statistically insignificant. The prevalence of appropriate use of FFP at trauma centre was 49.5 %. The FFP use by neurosurgery:orthopedics:general surgery was 5:1:4. The highest appropriate FFP use was by Neurosurgery department (50.5 %). Assessing the pattern of usage and rate of misuse of FFP units, allows us to establish required strategies to improve the state of affairs.
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Affiliation(s)
- Neha Agarwal
- Department of Laboratory Medicine, Jai Prakash Narayan Apex Trauma centre, AIIMS, New Delhi, India
| | - Arulselvi Subramanian
- Department of Laboratory Medicine, Jai Prakash Narayan Apex Trauma centre, AIIMS, New Delhi, India ; Department of Blood Bank, Jai Prakash Narayan Apex Trauma centre, AIIMS, New Delhi, India
| | - Ravindra Mohan Pandey
- Department of Biostatistics, Jai Prakash Narayan Apex Trauma Centre, AIIMS, New Delhi, India
| | - Venencia Albert
- Department of Laboratory Medicine, Jai Prakash Narayan Apex Trauma centre, AIIMS, New Delhi, India
| | - Sulekha Karjee
- Department of Blood Bank, Jai Prakash Narayan Apex Trauma centre, AIIMS, New Delhi, India
| | - Vedanand Arya
- Department of Blood Bank, Jai Prakash Narayan Apex Trauma centre, AIIMS, New Delhi, India
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Nosocomial infections after severe trauma are associated with lower apolipoproteins B and AII. J Trauma Acute Care Surg 2013; 74:1067-73. [PMID: 23511146 DOI: 10.1097/ta.0b013e3182826be0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Infection after severe trauma is a significant cause of morbidity and mortality days to weeks after the initial injury. Apolipoproteins play important roles in host defense and circulating concentrations are altered by the acute inflammatory response. The purpose of this study was to determine if patients who acquire infection after severe trauma have significantly lower apolipoprotein levels than trauma patients who do not become infected. METHODS We conducted a case-control study on a prospectively identified cohort of adult patients admitted to our intensive care unit after severe trauma (Injury Severity Score ≥ 16). We compared plasma apolipoprotein levels between patients who acquired an infection within 30 days after trauma (cases) and those that remained infection free (controls). RESULTS Of 40 patients experiencing severe trauma, we identified 22 cases that developed an infection within 30 days after injury. Cases had significantly lower posttrauma plasma levels of apolipoprotein B (p = 0.02) and apolipoprotein AII (p = 0.02) compared with controls. Consistent with previous studies, cases also received greater volumes of crystalloid infusions (p < 0.01) and blood transfusions (p < 0.01). Cases also had a more profound inflammatory response as measured by interleukin 6 levels (p = 0.02). CONCLUSION Infection after severe trauma is associated with decreased circulating apolipoproteins as compared with uninfected controls. Profoundly decreased plasma apolipoproteins B and AII could potentially contribute to the impaired immunity after severe trauma. Apolipoproteins are potential targets for identifying those patients at risk of infection after trauma and for interventions aimed at preventing nosocomial infections. LEVEL OF EVIDENCE Prognostic study, level III.
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