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Schaefer JH, Lieschke F, Urban H, Bohmann FO, Gatzke F, Miesbach W. Feasibility and comparability of different platelet function tests in acute stroke with or without prior antiplatelet therapy. Front Neurol 2024; 15:1361751. [PMID: 38410198 PMCID: PMC10894916 DOI: 10.3389/fneur.2024.1361751] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2023] [Accepted: 01/30/2024] [Indexed: 02/28/2024] Open
Abstract
Background The clinical course of ischemic and hemorrhagic strokes can be influenced by the coagulation status of individual patients. The prior use of antiplatelet therapy (APT) such as acetylsalicylic acid (ASA) or P2Y12-antagonists has been inconsistently described as possibly increasing the risk of hemorrhagic transformation or expansion. Since clinical studies describing prior use of antiplatelet medication are overwhelmingly lacking specific functional tests, we aimed to implement testing in routine stroke care. Methods We used fluorescence-activated cell sorting (FACS) with antibodies against CD61 for thrombocyte identification and CD62p or platelet activation complex-1 (PAC-1) to determine platelet activation. Aggregometry and automated platelet functioning analyzer (PFA-200) were employed to test thrombocyte reactivity. FACS and aggregometry samples were stimulated in vitro with arachidonic acid (AA) and adenosine diphosphate (ADP) to measure increase in CD62p-/PAC-1-expression or aggregation, respectively. Results Between February and July 2023, 20 blood samples (n = 11 ischemic strokes; n = 7 hemorrhagic strokes; n = 2 controls) were acquired and analyzed within 24 h of symptom onset. N = 11 patients had taken ASA, n = 8 patients no APT and n = 1 ASA+clopidogrel. ASA intake compared to no APT was associated with lower CD62p expression after stimulation with AA on FACS analysis (median 15.8% [interquartile range {IQR} 12.6-37.2%] vs. 40.1% [IQR 20.3-56.3%]; p = 0.020), lower platelet aggregation (9.0% [IQR 7.0-12.0%] vs. 88.5% [IQR 11.8-92.0%]; p = 0.015) and longer time to plug formation with PFA-200 (248.0 s [IQR 157.0-297] vs. 121.5 s [IQR 99.8-174.3]; p = 0.027). Significant correlations were noted between AA-induced CD62p expression and aggregometry analysis (n = 18; ρ = 0.714; p < 0.001) as well as a negative correlation between CD62p increase and PFA clot formation time (n = 18; ρ = -0.613; p = 0.007). Sensitivity for ASA intake was highest for PFA (81.8% for values ≥155.5 s). The combination of ASA + clopidogrel also affected ADP-induced CD62p and PAC-1 expression. Conclusion In the clinical setting it is feasible to use differentiated platelet analytics to determine alterations caused by antiplatelet therapy. Among the tests under investigation, PFA-200 showed the highest sensitivity for the intake of ASA in stroke patients. FACS analysis on the other hand might be able to provide a more nuanced approach to altered platelet reactivity.
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Affiliation(s)
- Jan Hendrik Schaefer
- Department of Neurology, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany
| | - Franziska Lieschke
- Department of Neurology, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany
| | - Hans Urban
- Department of Neurology, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany
| | - Ferdinand O Bohmann
- Department of Neurology, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany
| | - Florian Gatzke
- Department of Internal Medicine II, Haemostaseology and Haemophilia Centre, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany
| | - Wolfgang Miesbach
- Department of Internal Medicine II, Haemostaseology and Haemophilia Centre, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany
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2
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Miles MVP, Hicks RC, Parmer H, Brown C, Edwards A, Stewart K, Gao L, Maxwell R. Traumatic brain injury patients with platelet inhibition receiving platelet transfusion demonstrate decreased need for neurosurgical intervention and decreased mortality. J Trauma Acute Care Surg 2022; 92:701-707. [PMID: 35320155 DOI: 10.1097/ta.0000000000003516] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Platelet dysfunction is known to occur in patients with traumatic brain injury (TBI), and the correction of platelet dysfunction may prevent hemorrhagic progression in TBI. Thromboelastography with platelet mapping (TEG-PM; Haemonetics) evaluates the degree of platelet function inhibition through the adenosine diphosphate (ADP) and arachidonic acid (AA) pathways. We hypothesized that ADP and AA inhibition would improve with the transfusion of platelets in patients with TBI. METHODS A retrospective review was conducted at a Level I trauma center of all patients presenting with TBI from December 2019 to December 2020. Per a practice management guideline, a platelet mapping assay was obtained on all patients with TBI upon admission. If ADP or AA was found to be inhibited (>60%), the patient was transfused 1 unit of platelets and a repeat platelet mapping assay was ordered. Demographic data, laboratory values, and outcomes were analyzed. RESULTS Over the 13-month study period, 453 patients with TBI underwent TEG-PM with a protocol adherence rate of 66.5% resulting in a total of 147 patients who received platelets for ADP and/or AA inhibition; of those, 107 underwent repeat TEG-PM after platelets were administered. With the administration of platelets, ADP (p < 0.0001), AA (p < 0.0001), and MA (p = 0.0002) all significantly improved. Of 330 patients with TBI not taking antiplatelet medications, 50.9% showed inhibition in ADP and/or AA. If AA or ADP inhibition was noted on admission, mortality was increased (p = 0.0108). If ADP improved with platelet administration, the need for neurosurgical intervention was noted to decrease (p = 0.0182). CONCLUSION Patients with TBI and platelet inhibition may benefit from the administration of platelets to correct platelet dysfunction. Thromboelastography with platelet mapping may be implemented in the initial workup of patients presenting with TBI to assess platelet dysfunction and provide prognostic information, which may guide treatment. LEVEL OF EVIDENCE Therapeutic / Care Management, level III.
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Affiliation(s)
- M Victoria P Miles
- From the Department of Surgery, University of Tennessee College of Medicine Chattanooga (M.V.P.M., R.C.H., H.P., R.M.), Chattanooga; University of Tennessee College of Medicine (C.B., A.E.), Memphis; Department of Surgery, Erlanger Health System (K.S.); and Department of Mathematics (L.G.), University of Tennessee Chattanooga, Chattanooga, Tennessee
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3
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Viscoelastic Hemostatic Assays: A Primer on Legacy and New Generation Devices. J Clin Med 2022; 11:jcm11030860. [PMID: 35160311 PMCID: PMC8836477 DOI: 10.3390/jcm11030860] [Citation(s) in RCA: 41] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Revised: 01/28/2022] [Accepted: 02/02/2022] [Indexed: 02/06/2023] Open
Abstract
Viscoelastic hemostatic assay (VHAs) are whole blood point-of-care tests that have become an essential method for assaying hemostatic competence in liver transplantation, cardiac surgery, and most recently, trauma surgery involving hemorrhagic shock. It has taken more than three-quarters of a century of research and clinical application for this technology to become mainstream in these three clinical areas. Within the last decade, the cup and pin legacy devices, such as thromboelastography (TEG® 5000) and rotational thromboelastometry (ROTEM® delta), have been supplanted not only by cartridge systems (TEG® 6S and ROTEM® sigma), but also by more portable point-of-care bedside testing iterations of these legacy devices (e.g., Sonoclot®, Quantra®, and ClotPro®). Here, the legacy and new generation VHAs are compared on the basis of their unique hemostatic parameters that define contributions of coagulation factors, fibrinogen/fibrin, platelets, and clot lysis as related to the lifespan of a clot. In conclusion, we offer a brief discussion on the meteoric adoption of VHAs across the medical and surgical specialties to address COVID-19-associated coagulopathy.
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4
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Maegele M. Coagulopathy and Progression of Intracranial Hemorrhage in Traumatic Brain Injury: Mechanisms, Impact, and Therapeutic Considerations. Neurosurgery 2021; 89:954-966. [PMID: 34676410 DOI: 10.1093/neuros/nyab358] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 07/31/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Traumatic brain injury (TBI) remains one of the most challenging health and socioeconomic problems of our times. Clinical courses may be complicated by hemostatic abnormalities either pre-existing or developing with TBI. OBJECTIVE To review frequencies, patterns, mechanisms, novel approaches to diagnostics, treatment, and outcomes of hemorrhagic progression and coagulopathy after TBI. METHODS Selective review of the literature in the databases Medline (PubMed) and Cochrane Reviews using different combinations of the relevant search terms was conducted. RESULTS Of the patients, 20% with isolated TBI display laboratory coagulopathy upon hospital admission with profound effect on morbidity and mortality. Preinjury use of antithrombotic agents may be associated with higher rates of hemorrhagic progression and delayed traumatic intracranial hemorrhage. Further testing may display various changes affecting platelet function/numbers, pro- and/or anticoagulant factors, and fibrinolysis as well as interactions between brain tissues, vascular endothelium, mechanisms of inflammation, and blood flow dynamics. The nature of hemostatic disruptions after TBI remains elusive but current evidence suggests the presence of both a hyper- and hypocoagulable state with possible overlap and lack of distinction between phases and states. More "global" hemostatic assays, eg, viscoelastic and thrombin generation tests, may provide more detailed and timely information on the overall hemostatic potential thereby allowing early "goal-directed" therapies. CONCLUSION Whether timely and targeted management of hemostatic abnormalities after TBI can protect against secondary brain injury and thereby improve outcomes remains elusive. Innovative technologies for diagnostics and monitoring offer windows of opportunities for precision medicine approaches to managing TBI.
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Affiliation(s)
- Marc Maegele
- Department of Trauma and Orthopaedic Surgery, Cologne-Merheim Medical Center, University Witten/Herdecke, Cologne, Germany.,Institute for Research in Operative Medicine, University Witten/Herdecke, Cologne, Germany.,Treatment Center for Traumatic Injuries, Third Affiliated Hospital of Southern Medical University, Guangzhou, China
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5
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Bradbury JL, Thomas SG, Sorg NR, Mjaess N, Berquist MR, Brenner TJ, Langford JH, Marsee MK, Moody AN, Bunch CM, Sing SR, Al-Fadhl MD, Salamah Q, Saleh T, Patel NB, Shaikh KA, Smith SM, Langheinrich WS, Fulkerson DH, Sixta S. Viscoelastic Testing and Coagulopathy of Traumatic Brain Injury. J Clin Med 2021; 10:jcm10215039. [PMID: 34768556 PMCID: PMC8584585 DOI: 10.3390/jcm10215039] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Revised: 10/24/2021] [Accepted: 10/27/2021] [Indexed: 12/14/2022] Open
Abstract
A unique coagulopathy often manifests following traumatic brain injury, leading the clinician down a difficult decision path on appropriate prophylaxis and therapy. Conventional coagulation assays—such as prothrombin time, partial thromboplastin time, and international normalized ratio—have historically been utilized to assess hemostasis and guide treatment following traumatic brain injury. However, these plasma-based assays alone often lack the sensitivity to diagnose and adequately treat coagulopathy associated with traumatic brain injury. Here, we review the whole blood coagulation assays termed viscoelastic tests and their use in traumatic brain injury. Modified viscoelastic tests with platelet function assays have helped elucidate the underlying pathophysiology and guide clinical decisions in a goal-directed fashion. Platelet dysfunction appears to underlie most coagulopathies in this patient population, particularly at the adenosine diphosphate and/or arachidonic acid receptors. Future research will focus not only on the utility of viscoelastic tests in diagnosing coagulopathy in traumatic brain injury, but also on better defining the use of these tests as evidence-based and/or precision-based tools to improve patient outcomes.
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Affiliation(s)
- Jamie L. Bradbury
- Department of Neurosurgery, Indiana University School of Medicine, Indianapolis, IN 46202, USA;
| | - Scott G. Thomas
- Department of Trauma Surgery, Memorial Hospital, South Bend, IN 46601, USA;
| | - Nikki R. Sorg
- Department of Emergency Medicine, Indiana University School of Medicine—South Bend, South Bend, IN 46617, USA; (N.R.S.); (A.N.M.); (S.R.S.)
| | - Nicolas Mjaess
- Department of Intensive Care Medicine, St. Joseph Regional Medical Center, Mishawaka, IN 46545, USA; (N.M.); (M.R.B.); (T.J.B.); (J.H.L.); (M.D.A.-F.); (Q.S.); (T.S.)
| | - Margaret R. Berquist
- Department of Intensive Care Medicine, St. Joseph Regional Medical Center, Mishawaka, IN 46545, USA; (N.M.); (M.R.B.); (T.J.B.); (J.H.L.); (M.D.A.-F.); (Q.S.); (T.S.)
| | - Toby J. Brenner
- Department of Intensive Care Medicine, St. Joseph Regional Medical Center, Mishawaka, IN 46545, USA; (N.M.); (M.R.B.); (T.J.B.); (J.H.L.); (M.D.A.-F.); (Q.S.); (T.S.)
| | - Jack H. Langford
- Department of Intensive Care Medicine, St. Joseph Regional Medical Center, Mishawaka, IN 46545, USA; (N.M.); (M.R.B.); (T.J.B.); (J.H.L.); (M.D.A.-F.); (Q.S.); (T.S.)
| | - Mathew K. Marsee
- Department of Otolaryngology, Portsmouth Naval Medical Center, Portsmouth, VA 23708, USA;
| | - Ashton N. Moody
- Department of Emergency Medicine, Indiana University School of Medicine—South Bend, South Bend, IN 46617, USA; (N.R.S.); (A.N.M.); (S.R.S.)
| | - Connor M. Bunch
- Department of Emergency Medicine, Indiana University School of Medicine—South Bend, South Bend, IN 46617, USA; (N.R.S.); (A.N.M.); (S.R.S.)
- Correspondence:
| | - Sandeep R. Sing
- Department of Emergency Medicine, Indiana University School of Medicine—South Bend, South Bend, IN 46617, USA; (N.R.S.); (A.N.M.); (S.R.S.)
| | - Mahmoud D. Al-Fadhl
- Department of Intensive Care Medicine, St. Joseph Regional Medical Center, Mishawaka, IN 46545, USA; (N.M.); (M.R.B.); (T.J.B.); (J.H.L.); (M.D.A.-F.); (Q.S.); (T.S.)
| | - Qussai Salamah
- Department of Intensive Care Medicine, St. Joseph Regional Medical Center, Mishawaka, IN 46545, USA; (N.M.); (M.R.B.); (T.J.B.); (J.H.L.); (M.D.A.-F.); (Q.S.); (T.S.)
| | - Tarek Saleh
- Department of Intensive Care Medicine, St. Joseph Regional Medical Center, Mishawaka, IN 46545, USA; (N.M.); (M.R.B.); (T.J.B.); (J.H.L.); (M.D.A.-F.); (Q.S.); (T.S.)
| | - Neal B. Patel
- Department of Neurosurgery, Memorial Hospital, South Bend, IN 46601, USA; (N.B.P.); (K.A.S.); (S.M.S.); (W.S.L.); (D.H.F.)
- Department of Neurosurgery, St. Joseph Regional Medical Center, Mishawaka, IN 46545, USA
| | - Kashif A. Shaikh
- Department of Neurosurgery, Memorial Hospital, South Bend, IN 46601, USA; (N.B.P.); (K.A.S.); (S.M.S.); (W.S.L.); (D.H.F.)
- Department of Neurosurgery, St. Joseph Regional Medical Center, Mishawaka, IN 46545, USA
| | - Stephen M. Smith
- Department of Neurosurgery, Memorial Hospital, South Bend, IN 46601, USA; (N.B.P.); (K.A.S.); (S.M.S.); (W.S.L.); (D.H.F.)
- Department of Neurosurgery, St. Joseph Regional Medical Center, Mishawaka, IN 46545, USA
| | - Walter S. Langheinrich
- Department of Neurosurgery, Memorial Hospital, South Bend, IN 46601, USA; (N.B.P.); (K.A.S.); (S.M.S.); (W.S.L.); (D.H.F.)
- Department of Neurosurgery, St. Joseph Regional Medical Center, Mishawaka, IN 46545, USA
| | - Daniel H. Fulkerson
- Department of Neurosurgery, Memorial Hospital, South Bend, IN 46601, USA; (N.B.P.); (K.A.S.); (S.M.S.); (W.S.L.); (D.H.F.)
- Department of Neurosurgery, St. Joseph Regional Medical Center, Mishawaka, IN 46545, USA
| | - Sherry Sixta
- Department of Trauma Surgery, Envision Physician Services, Plano, TX 75093, USA;
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6
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Riojas CM, Ekaney ML, Ross SW, Cunningham KW, Furay EJ, Brown CVR, Evans SL. Platelet Dysfunction after Traumatic Brain Injury: A Review. J Neurotrauma 2021; 38:819-829. [PMID: 33143502 DOI: 10.1089/neu.2020.7301] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Coagulopathy is a known sequela of traumatic brain injury (TBI) and can lead to increased morbidity and mortality. Platelet dysfunction has been identified as one of several etiologies of coagulopathy following TBI and has been associated with poor outcomes. Regardless of whether the platelet dysfunction occurs as a direct consequence of the injury or because of pre-existing medical comorbidities or medication use, accurate detection and monitoring of response to therapy is key to optimal patient care. Platelet transfusion has been proposed as a potential therapeutic intervention to treat platelet dysfunction, with several studies using platelet function assays to monitor response. The development of increasingly precise diagnostic testing is providing enhanced understanding of the specific derangement in the hemostatic process, allowing clinicians to provide patient-specific treatment plans. There is wide variability in the currently available literature on the incidence and clinical significance of platelet dysfunction following TBI, which creates challenges with developing evidence-based management guidelines. The relatively high prevalence of platelet inhibitor therapy serves as an additional confounding factor. In addition, the data are largely retrospective in nature. We performed a literature review to provide clarity on this clinical issue. We reviewed 348 abstracts, and included 97 manuscripts in our final literature review. Based on the currently available research, platelet dysfunction has been consistently demonstrated in patients with moderate-severe TBI. We recommend the use of platelet functional assays to evaluate patients with TBI. Platelet transfusion directed at platelet dysfunction may lead to improved clinical outcome. A randomized trial guided by implementation science could improve the applicability of these practices.
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Affiliation(s)
- Christina M Riojas
- FH "Sammy" Ross Trauma Center, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina, USA
| | - Michael L Ekaney
- FH "Sammy" Ross Trauma Center, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina, USA
| | - Samuel W Ross
- FH "Sammy" Ross Trauma Center, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina, USA
| | - Kyle W Cunningham
- FH "Sammy" Ross Trauma Center, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina, USA
| | - Elisa J Furay
- Dell Medical School, University of Texas at Austin, Austin, Texas, USA
| | - Carlos V R Brown
- Dell Medical School, University of Texas at Austin, Austin, Texas, USA
| | - Susan L Evans
- FH "Sammy" Ross Trauma Center, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina, USA
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7
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Spahn DR, Bouillon B, Cerny V, Duranteau J, Filipescu D, Hunt BJ, Komadina R, Maegele M, Nardi G, Riddez L, Samama CM, Vincent JL, Rossaint R. The European guideline on management of major bleeding and coagulopathy following trauma: fifth edition. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2019; 23:98. [PMID: 30917843 PMCID: PMC6436241 DOI: 10.1186/s13054-019-2347-3] [Citation(s) in RCA: 676] [Impact Index Per Article: 135.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Accepted: 02/06/2019] [Indexed: 12/24/2022]
Abstract
Background Severe traumatic injury continues to present challenges to healthcare systems around the world, and post-traumatic bleeding remains a leading cause of potentially preventable death among injured patients. Now in its fifth edition, this document aims to provide guidance on the management of major bleeding and coagulopathy following traumatic injury and encourages adaptation of the guiding principles described here to individual institutional circumstances and resources. Methods The pan-European, multidisciplinary Task Force for Advanced Bleeding Care in Trauma was founded in 2004, and the current author group included representatives of six relevant European professional societies. The group applied a structured, evidence-based consensus approach to address scientific queries that served as the basis for each recommendation and supporting rationale. Expert opinion and current clinical practice were also considered, particularly in areas in which randomised clinical trials have not or cannot be performed. Existing recommendations were re-examined and revised based on scientific evidence that has emerged since the previous edition and observed shifts in clinical practice. New recommendations were formulated to reflect current clinical concerns and areas in which new research data have been generated. Results Advances in our understanding of the pathophysiology of post-traumatic coagulopathy have supported improved management strategies, including evidence that early, individualised goal-directed treatment improves the outcome of severely injured patients. The overall organisation of the current guideline has been designed to reflect the clinical decision-making process along the patient pathway in an approximate temporal sequence. Recommendations are grouped behind the rationale for key decision points, which are patient- or problem-oriented rather than related to specific treatment modalities. While these recommendations provide guidance for the diagnosis and treatment of major bleeding and coagulopathy, emerging evidence supports the author group’s belief that the greatest outcome improvement can be achieved through education and the establishment of and adherence to local clinical management algorithms. Conclusions A multidisciplinary approach and adherence to evidence-based guidance are key to improving patient outcomes. If incorporated into local practice, these clinical practice guidelines have the potential to ensure a uniform standard of care across Europe and beyond and better outcomes for the severely bleeding trauma patient. Electronic supplementary material The online version of this article (10.1186/s13054-019-2347-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Donat R Spahn
- Institute of Anaesthesiology, University of Zurich and University Hospital Zurich, Raemistrasse 100, CH-8091, Zurich, Switzerland
| | - Bertil Bouillon
- Department of Trauma and Orthopaedic Surgery, Cologne-Merheim Medical Centre (CMMC), University of Witten/Herdecke, Ostmerheimer Strasse 200, D-51109, Cologne, Germany
| | - Vladimir Cerny
- Department of Anaesthesiology, Perioperative Medicine and Intensive Care, J.E. Purkinje University, Masaryk Hospital, Usti nad Labem, Socialni pece 3316/12A, CZ-40113, Usti nad Labem, Czech Republic.,Centre for Research and Development, University Hospital Hradec Kralove, Hradec Kralove, Czech Republic, Sokolska 581, CZ-50005, Hradec Kralove, Czech Republic.,Department of Anaesthesiology and Intensive Care Medicine, Faculty of Medicine in Hradec Kralove, Charles University, Simkova 870, CZ-50003, Hradec Kralove, Czech Republic.,Department of Anaesthesia, Pain Management and Perioperative Medicine, QE II Health Sciences Centre, Dalhousie University, Halifax, 10 West Victoria, 1276 South Park St, Halifax, NS, B3H 2Y9, Canada
| | - Jacques Duranteau
- Department of Anaesthesia and Intensive Care, Hôpitaux Universitaires Paris Sud, University of Paris XI, Faculté de Médecine Paris-Sud, 78 rue du Général Leclerc, F-94275, Le Kremlin-Bicêtre Cedex, France
| | - Daniela Filipescu
- Department of Cardiac Anaesthesia and Intensive Care, C. C. Iliescu Emergency Institute of Cardiovascular Diseases, Sos Fundeni 256-258, RO-022328, Bucharest, Romania
| | - Beverley J Hunt
- King's College and Departments of Haematology and Pathology, Guy's and St Thomas' NHS Foundation Trust, Westminster Bridge Road, London, SE1 7EH, UK
| | - Radko Komadina
- Department of Traumatology, General and Teaching Hospital Celje, Medical Faculty Ljubljana University, SI-3000, Celje, Slovenia
| | - Marc Maegele
- Department of Trauma and Orthopaedic Surgery, Cologne-Merheim Medical Centre (CMMC), Institute for Research in Operative Medicine (IFOM), University of Witten/Herdecke, Ostmerheimer Strasse 200, D-51109, Cologne, Germany
| | - Giuseppe Nardi
- Department of Anaesthesia and ICU, AUSL della Romagna, Infermi Hospital Rimini, Viale Settembrini, 2, I-47924, Rimini, Italy
| | - Louis Riddez
- Department of Surgery and Trauma, Karolinska University Hospital, S-171 76, Solna, Sweden
| | - Charles-Marc Samama
- Hotel-Dieu University Hospital, 1, place du Parvis de Notre-Dame, F-75181, Paris Cedex 04, France
| | - Jean-Louis Vincent
- Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Route de Lennik 808, B-1070, Brussels, Belgium
| | - Rolf Rossaint
- Department of Anaesthesiology, University Hospital Aachen, RWTH Aachen University, Pauwelsstrasse 30, D-52074, Aachen, Germany.
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8
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Trimmel H, Herzer G, Schöchl H, Voelckel WG. [Intensive care treatment of traumatic brain injury in multiple trauma patients : Decision making for complex pathophysiology]. Unfallchirurg 2019; 120:739-744. [PMID: 28389734 DOI: 10.1007/s00113-017-0344-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Traumatic brain injury (TBI) and hemorrhagic shock due to uncontrolled bleeding are the major causes of death after severe trauma. Mortality rates are threefold higher in patients suffering from multiple injuries and additionally TBI. Factors known to impair outcome after TBI, namely hypotension, hypoxia, hypercapnia, acidosis, coagulopathy and hypothermia are aggravated by the extent and severity of extracerebral injuries. The mainstays of TBI intensive care may be, at least temporarily, contradictory to the trauma care concept for multiple trauma patients. In particular, achieving normotension in uncontrolled bleeding situations, maintenance of normocapnia in traumatic lung injury and thromboembolic prophylaxis are prone to discussion. Due to an ongoing uncertainty about the definition of normotensive blood pressure values, a cerebral perfusion pressure-guided cardiovascular management is of key importance. In contrast, there is no doubt that early goal directed coagulation management improves outcome in patients with TBI and multiple trauma. The timing of subsequent surgical interventions must be based on the development of TBI pathology; therefore, intensive care of multiple trauma patients with TBI requires an ongoing and close cooperation between intensivists and trauma surgeons in order to individualize patient care.
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Affiliation(s)
- H Trimmel
- Abteilung für Anästhesie, Notfall- und Allgemeine Intensivmedizin und Karl-Landsteiner Institut für Notfallmedizin, Landesklinikum Wiener Neustadt, Wien, Österreich
- ÖAMTC Flugrettung, Wien, Österreich
| | - G Herzer
- Abteilung für Anästhesie, Notfall- und Allgemeine Intensivmedizin und Karl-Landsteiner Institut für Notfallmedizin, Landesklinikum Wiener Neustadt, Wien, Österreich
| | - H Schöchl
- Institut für Anästhesiologie und Intensivmedizin, AUVA Unfallkrankenhaus Salzburg, Dr.-Franz-Rehrl-Platz 5, 5010, Salzburg, Österreich
- Paracelsus Medizinische Privatuniversität Salzburg, Salzburg, Österreich
| | - W G Voelckel
- Institut für Anästhesiologie und Intensivmedizin, AUVA Unfallkrankenhaus Salzburg, Dr.-Franz-Rehrl-Platz 5, 5010, Salzburg, Österreich.
- ÖAMTC Flugrettung, Wien, Österreich.
- Universität Stavanger, Stavanger, Norwegen.
- Paracelsus Medizinische Privatuniversität Salzburg, Salzburg, Österreich.
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Maegele M, Schöchl H, Menovsky T, Maréchal H, Marklund N, Buki A, Stanworth S. Coagulopathy and haemorrhagic progression in traumatic brain injury: advances in mechanisms, diagnosis, and management. Lancet Neurol 2017; 16:630-647. [PMID: 28721927 DOI: 10.1016/s1474-4422(17)30197-7] [Citation(s) in RCA: 189] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Revised: 05/08/2017] [Accepted: 05/30/2017] [Indexed: 01/28/2023]
Abstract
Normal haemostasis depends on an intricate balance between mechanisms of bleeding and mechanisms of thrombosis, and this balance can be altered after traumatic brain injury (TBI). Impaired haemostasis could exacerbate the primary insult with risk of initiation or aggravation of bleeding; anticoagulant use at the time of injury can also contribute to bleeding risk after TBI. Many patients with TBI have abnormalities on conventional coagulation tests at admission to the emergency department, and the presence of coagulopathy is associated with increased morbidity and mortality. Further blood testing often reveals a range of changes affecting platelet numbers and function, procoagulant or anticoagulant factors, fibrinolysis, and interactions between the coagulation system and the vascular endothelium, brain tissue, inflammatory mechanisms, and blood flow dynamics. However, the degree to which these coagulation abnormalities affect TBI outcomes and whether they are modifiable risk factors are not known. Although the main challenge for management is to address the risk of hypocoagulopathy with prolonged bleeding and progression of haemorrhagic lesions, the risk of hypercoagulopathy with an increased prothrombotic tendency also warrants consideration.
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Affiliation(s)
- Marc Maegele
- Department for Trauma and Orthopaedic Surgery, Cologne-Merheim Medical Center, University Witten/Herdecke, Cologne, Germany; Institute for Research in Operative Medicine, University Witten/Herdecke, Cologne, Germany.
| | - Herbert Schöchl
- Department for Anaesthesiology and Intensive Care Medicine, AUVA Trauma Academic Teaching Hospital, Paracelsus Medical University Salzburg, Salzburg, Austria
| | - Tomas Menovsky
- Department for Neurosurgery, Antwerp University Hospital, University of Antwerp, Edegem, Belgium
| | - Hugues Maréchal
- Department of Anaesthesiology and Intensive Care Medicine, CRH La Citadelle, Liège, Belgium
| | - Niklas Marklund
- Department of Clinical Sciences, Division of Neurosurgery, University Hospital of Southern Sweden, Lund University, Lund, Sweden
| | - Andras Buki
- Department of Neurosurgery, The MTA-PTE Clinical Neuroscience MR Research Group, Janos Szentagothai Research Center, Hungarian Brain Research Program, University of Pécs, Pécs, Hungary
| | - Simon Stanworth
- NHS Blood and Transplant/Oxford University Hospitals NHS Foundation Trust, University of Oxford, John Radcliffe Hospital, Oxford, UK
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