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Hayakawa M, Tagami T, Kudo D, Ono K, Aoki M, Endo A, Yumoto T, Matsumura Y, Irino S, Sekine K, Ushio N, Ogura T, Nachi S, Irie Y, Hayakawa K, Ito Y, Okishio Y, Muronoi T, Kosaki Y, Ito K, Nakatsutsumi K, Kondo Y, Ueda T, Fukuma H, Saisaka Y, Tominaga N, Kurita T, Nakayama F, Shibata T, Kushimoto S. The Restrictive Red Blood Cell Transfusion Strategy for Critically Injured Patients (RESTRIC) trial: a cluster-randomized, crossover, non-inferiority multicenter trial of restrictive transfusion in trauma. J Intensive Care 2023; 11:34. [PMID: 37488591 PMCID: PMC10364403 DOI: 10.1186/s40560-023-00682-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 07/07/2023] [Indexed: 07/26/2023] Open
Abstract
BACKGROUND The efficacies of fresh frozen plasma and coagulation factor transfusion have been widely evaluated in trauma-induced coagulopathy management during the acute post-injury phase. However, the efficacy of red blood cell transfusion has not been adequately investigated in patients with severe trauma, and the optimal hemoglobin target level during the acute post-injury and resuscitation phases remains unclear. Therefore, this study aimed to examine whether a restrictive transfusion strategy was clinically non-inferior to a liberal transfusion strategy during the acute post-injury phase. METHODS This cluster-randomized, crossover, non-inferiority multicenter trial was conducted at 22 tertiary emergency medical institutions in Japan and included adult patients with severe trauma at risk of major bleeding. The institutions were allocated a restrictive or liberal transfusion strategy (target hemoglobin levels: 7-9 or 10-12 g/dL, respectively). The strategies were applied to patients immediately after arrival at the emergency department. The primary outcome was 28-day survival after arrival at the emergency department. Secondary outcomes included transfusion volume, complication rates, and event-free days. The non-inferiority margin was set at 3%. RESULTS The 28-day survival rates of patients in the restrictive (n = 216) and liberal (n = 195) strategy groups were 92.1% and 91.3%, respectively. The adjusted odds ratio for 28-day survival in the restrictive versus liberal strategy group was 1.02 (95% confidence interval: 0.49-2.13). Significant non-inferiority was not observed. Transfusion volumes and hemoglobin levels were lower in the restrictive strategy group than in the liberal strategy group. No between-group differences were noted in complication rates or event-free days. CONCLUSIONS Although non-inferiority of the restrictive versus liberal transfusion strategy for 28-day survival was not statistically significant, the mortality and complication rates were similar between the groups. The restrictive transfusion strategy results in a lower transfusion volume. TRIAL REGISTRATION NUMBER umin.ac.jp/ctr: UMIN000034405, registration date: 8 October 2018.
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Affiliation(s)
- Mineji Hayakawa
- Department of Emergency Medicine, Hokkaido University Hospital, N14W5 Kita-ku, Sapporo, 060-8648, Japan.
| | - Takashi Tagami
- Department of Emergency and Critical Care Medicine, Nippon Medical School Musashi Kosugi Hospital, Kawasaki, Japan
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Daisuke Kudo
- Division of Emergency and Critical Care Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Kota Ono
- Ono Biostat Consulting, Tokyo, Japan
| | - Makoto Aoki
- Department of Emergency Medicine, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Akira Endo
- Department of Acute Critical Care and Disaster Medicine, Tokyo Medical and Dental University Graduate School of Medicine, Tokyo, Japan
| | - Tetsuya Yumoto
- Department of Emergency, Critical Care, and Disaster Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Yosuke Matsumura
- Department of Intensive Care, Chiba Emergency Medical Centre, Chiba, Japan
| | - Shiho Irino
- Department of Emergency and Critical Care Medicine, Tokyo Saiseikai Central Hospital, Tokyo, Japan
| | - Kazuhiko Sekine
- Department of Emergency and Critical Care Medicine, Tokyo Saiseikai Central Hospital, Tokyo, Japan
| | - Noritaka Ushio
- Department of Emergency and Critical Care Medicine, Japan Red Cross Maebashi Hospital, Maebashi, Japan
| | - Takayuki Ogura
- Department of Emergency Medicine and Critical Care Medicine, Tochigi Prefectural Emergency and Critical Care Centre, Imperial Gift Foundation Saiseikai, Utsunomiya Hospital, Utsunomiya, Japan
| | - Sho Nachi
- Advanced Critical Care Centre, Gifu University Hospital, Gifu, Japan
| | - Yuhei Irie
- Department of Emergency and Critical Care Medicine, Fukuoka University Hospital, Fukuoka, Japan
| | - Katsura Hayakawa
- Advanced Emergency and Critical Care Centre, Saitama Red Cross Hospital, Saitama, Japan
| | - Yusuke Ito
- Senri Critical Care Medical Centre, Saiseikai Senri Hospital, Suita, Japan
| | - Yuko Okishio
- Department of Emergency and Critical Care Medicine, Wakayama Medical University, Wakayama, Japan
| | - Tomohiro Muronoi
- Department of Acute Care Surgery, Shimane University Faculty of Medicine, Izumo, Japan
| | - Yoshinori Kosaki
- Department of Emergency, Critical Care, and Disaster Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Kaori Ito
- Department of Surgery, Division of Acute Care Surgery, Teikyo University School of Medicine, Tokyo, Japan
| | - Keita Nakatsutsumi
- Trauma and Acute Critical Care Centre, Tokyo Medical and Dental University Hospital, Tokyo, Japan
| | - Yutaka Kondo
- Department of Emergency and Critical Care Medicine, Juntendo University Urayasu Hospital, Urayasu, Japan
| | - Taichiro Ueda
- Shock and Trauma Centre, Nippon Medical School Chiba Hokusoh Hospital, Inzai, Japan
| | - Hiroshi Fukuma
- Senshu Trauma and Critical Care Centre, Rinku General Medical Centre, Izumisano, Japan
| | - Yuichi Saisaka
- Emergency and Critical Care Centre, Kochi Health Sciences Centre, Kochi, Japan
| | - Naoki Tominaga
- Department of Emergency and Critical Care Medicine, Nippon Medical School, Tokyo, Japan
| | - Takeo Kurita
- Department of Emergency and Critical Care Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Fumihiko Nakayama
- Department of Emergency and Critical Care Medicine, Nippon Medical School Tama Nagayama Hospital, Tama, Japan
| | - Tomotaka Shibata
- Advanced Trauma, Emergency and Critical Care Centre, Oita University Hospital, Yufu, Japan
| | - Shigeki Kushimoto
- Division of Emergency and Critical Care Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
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Niemann M, Otto E, Eder C, Youssef Y, Kaufner L, Märdian S. Coagulopathy management of multiple injured patients - a comprehensive literature review of the European guideline 2019. EFORT Open Rev 2022; 7:710-726. [PMID: 36287131 PMCID: PMC9619392 DOI: 10.1530/eor-22-0054] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
The European guideline on the management of trauma-induced major bleeding and coagulopathy summarises the most relevant recommendations for trauma coagulopathy management. The management of trauma-induced major bleeding should interdisciplinary follow algorithms which distinguish between life-threatening and non-life-threatening bleeding. Point-of-care viscoelastic methods (VEM) assist target-controlled haemostatic treatment. Neither conventional coagulation assays nor VEM should delay treatment in life-threatening trauma-induced bleeding. Adjustments may be rational due to local circumstances, including the availability of blood products, pharmaceuticals, and employees.
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Affiliation(s)
- Marcel Niemann
- Charité – Universitätsmedizin Berlin, Center for Musculoskeletal Surgery, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany,Julius Wolff Institute for Biomechanics and Musculoskeletal Regeneration, Berlin Institute of Health at Charité – Universitätsmedizin Berlin, Berlin, Germany,Correspondence should be addressed to M Niemann;
| | - Ellen Otto
- Charité – Universitätsmedizin Berlin, Center for Musculoskeletal Surgery, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany,Julius Wolff Institute for Biomechanics and Musculoskeletal Regeneration, Berlin Institute of Health at Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Christian Eder
- Charité – Universitätsmedizin Berlin, Center for Musculoskeletal Surgery, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Yasmin Youssef
- Department of Orthopaedics, Trauma Surgery and Plastic Surgery, University Hospital Leipzig, Leipzig, Germany
| | - Lutz Kaufner
- Charité – Universitätsmedizin Berlin, Department of Anesthesiology and Intensive Care Medicine, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Sven Märdian
- Charité – Universitätsmedizin Berlin, Center for Musculoskeletal Surgery, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
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Hayakawa M, Tagami T, IIjima H, Kudo D, Sekine K, Ogura T, Yumoto T, Kondo Y, Endo A, Ito K, Matsumura Y, Kushimoto S. Restrictive transfusion strategy for critically injured patients (RESTRIC) trial: a study protocol for a cluster-randomised, crossover non-inferiority trial. BMJ Open 2020; 10:e037238. [PMID: 32895281 PMCID: PMC7478023 DOI: 10.1136/bmjopen-2020-037238] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
INTRODUCTION Resuscitation using blood products is critical during the acute postinjury period. However, the optimal target haemoglobin (Hb) levels have not been adequately investigated. With the restrictive transfusion strategy for critically injured patients (RESTRIC) trial, we aim to compare the restrictive and liberal red blood cell (RBC) transfusion strategies. METHODS AND ANALYSIS This is a cluster-randomised, crossover, non-inferiority trial of patients with severe trauma at 22 hospitals that have been randomised in a 1:1 ratio based on the use of a restrictive or liberal transfusion strategy with target Hb levels of 70-90 or 100-120 g/L, respectively, during the first year. Subsequently, after 1-month washout period, another transfusion strategy will be applied for an additional year. RBC transfusion requirements are usually unclear on arrival at the emergency department. Therefore, patients with severe bleeding, which could lead to haemorrhagic shock, will be included in the trial based on the attending physician's judgement. Each RBC transfusion strategy will be applied until 7 days postadmission to the hospital or discharge from the intensive care unit. The outcomes measured will include the 28-day survival rate after arrival at the emergency department (primary), the cumulative amount of blood transfused, event-free days and frequency of transfusion-associated lung injury and organ failure (secondary). Demonstration of the non-inferiority of restrictive transfusion will emphasise its clinical advantages. ETHICS AND DISSEMINATION The trial will be performed according to the Japanese and International Ethical guidelines. It has been approved by the Ethics Committee of each participating hospital and The Japanese Association for the Surgery of Trauma (JAST). Written informed consent will be obtained from all patients or their representatives. The results of the trial will be disseminated to the participating hospitals and board-certified educational institutions of JAST, submitted to peer-reviewed journals for publication, and presented at congresses. TRIAL REGISTRATION NUMBER UMIN Clinical Trials Registry; UMIN000034405. Registered 8 October 2018.
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Affiliation(s)
- Mineji Hayakawa
- Department of Emergency Medicine, Hokkaido University Hospital, Sapporo, Japan
| | - Takashi Tagami
- Department of Emergency and Critical Care Medicine, Nippon Medical School Musashikosugi Hospital, Kawasaki, Kanagawa, Japan
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Bunkyo-ku, Tokyo, Japan
| | | | - Daisuke Kudo
- Division of Emergency and Critical Care Medicine, Tohoku University School of Medicine, Sendai, Miyagi, Japan
| | - Kazuhiko Sekine
- Department of Emergency and Critical Care Medicine, Saiseikai Central Hospital, Minato-ku, Tokyo, Japan
| | - Takayuki Ogura
- Department of Emergency Medicine & Critical Care Medicine, Advanced Medical Emergency and Critical Care Center, Japan Red Cross Maebashi Hospital, Maebashi, Gunma, Japan
| | - Tetsuya Yumoto
- Emergency, Critical Care, and Disaster Medicine, Okayama University Graduate School of Medicine Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Yutaka Kondo
- Department of Emergency and Critical Care Medicine, Juntendo University Urayasu Hospital, Urayasu, Chiba, Japan
| | - Akira Endo
- Trauma and Acute Critical Care Centre, Medical Hospital of Tokyo Medical and Dental University, Bunkyo-ku, Tokyo, Japan
| | - Kaori Ito
- Department of Emergency Medicine, Division of Acute Care Surgery, Teikyo University School of Medicine Graduate School of Medicine, Itabashi-ku, Tokyo, Japan
| | - Yosuke Matsumura
- Department of Emergency and Critical Care Medicine, Chiba University Graduate School of Medicine, Chiba, Chiba, Japan
| | - Shigeki Kushimoto
- Division of Emergency and Critical Care Medicine, Tohoku University School of Medicine, Sendai, Miyagi, Japan
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Nguyen RK, Rizor JH, Damiani MP, Powers AJ, Fagnani JT, Monie DL, Cooper SS, Griffiths AD, Hellenthal NJ. The Impact of Anticoagulation on Trauma Outcomes : An National Trauma Data Bank Study. Am Surg 2020; 86:773-781. [PMID: 32730098 DOI: 10.1177/0003134820934419] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Increased prevalence of patients on anticoagulants and the advent of new therapies raise concern over how these patients fare if they sustain a traumatic injury. We investigated the role of prehospitalization anticoagulation therapy in trauma-related mortality and postacute disposition. METHODS A retrospective analysis was performed on patients who sustained traumatic injury identified in the 2017 National Trauma Data Bank (NTDB). Patients with and without anticoagulation therapy were analyzed to identify differences in demographics, injury type, Injury Severity Score (ISS), and trauma outcomes including hospital length of stay, ER, final hospital disposition, and mortality. Logistic regression was used to correlate anticoagulation to mortality and facility discharge. RESULTS Of the 1 000 596 patients included, 73 602 (7%) patients were on anticoagulants at the time of their trauma. Increased age was the strongest predictor for anticoagulation therapy (odds ratio 5.54, 95% CI 5.44-5.63), but being female and white were also independent predictors of anticoagulation (P < .001). Patients on anticoagulants had a significantly longer length of stay (5.11 days; 95% CI 5.06-5.15) than those who were not (4.37 days, 95% CI 4.36-4.39), were 2.20 times more likely to die (95% CI 2.12-2.28, P < .001), and were 2.77 times more likely to be discharged to a facility (95% CI 2.73-2.81, P < .001). Anticoagulation remained a significant predictor of worse trauma outcomes even when accounting for age and ISS in multivariate analysis. DISCUSSION Anticoagulation preceding trauma-related admission is associated with higher mortality and an increased likelihood of the need for a posthospital care facility.
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Affiliation(s)
- Rosalynn K Nguyen
- Department of Surgery, Bassett Healthcare Network, Cooperstown, NY, USA
| | - James H Rizor
- Department of Surgery, Bassett Healthcare Network, Cooperstown, NY, USA
| | - Michael P Damiani
- Department of Surgery, Bassett Healthcare Network, Cooperstown, NY, USA
| | - Andrew J Powers
- Department of Surgery, Bassett Healthcare Network, Cooperstown, NY, USA
| | - Jacob T Fagnani
- Department of Surgery, Bassett Healthcare Network, Cooperstown, NY, USA
| | - Daphne L Monie
- Department of Surgery, Bassett Healthcare Network, Cooperstown, NY, USA
| | - Shelby S Cooper
- Department of Surgery, Bassett Healthcare Network, Cooperstown, NY, USA
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5
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Barrera D, Sercy E, Orlando A, Mains CW, Madayag R, Carrick MM, Tanner A, Lieser M, Acuna D, Yon J, Bar-Or D. Associations of Antithrombotic Timing and Regimen with Ischemic Stroke and Bleeding Complications in Blunt Cerebrovascular Injury. J Stroke Cerebrovasc Dis 2020; 29:104804. [PMID: 32305279 DOI: 10.1016/j.jstrokecerebrovasdis.2020.104804] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Revised: 01/15/2020] [Accepted: 03/03/2020] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Blunt cerebrovascular injuries (BCVIs) are associated with long-term neurological effects. The first-line treatment for BCVIs is antithrombotics, but consensus on the optimal choice and timing of treatment is lacking. METHODS This was a retrospective study on patients aged at least 18 years admitted to 6 level 1 trauma centers between 1/1/2014 and 12/31/2017 with grade 1-4 BCVI and treated with antithrombotics. Differences in treatment practices were examined across the 6 centers. The primary outcome was ischemic stroke, and secondary outcomes were related to bleeding complications: blood transfusion and intracranial hemorrhage (ICH). Treatment characteristics examined were time to diagnosis and first computerized tomography angiography, time of total treatment course, time on each antithrombotic (anticoagulants, antiplatelets, combination), time from hospital arrival to antithrombotic initiation, and treatment interruption, i.e., treatment halted for a surgical procedure and restarted postoperatively. Chi-square, Fisher exact, Spearman's rank-order correlation, Wilcoxon rank-sum, Kruskal-Wallis, and Cox proportional hazards models with time-varying covariates were used to evaluate associations with the outcomes. RESULTS A total of 189 patients with BCVI were included. The median (IQR) time from arrival to antithrombotic initiation was 27 (8-61) hours, and 28% of patients had treatment interrupted. The ischemic stroke rate was 7.5% (n = 14), with most strokes (64%, n = 9) occurring between arrival and treatment initiation. Treatment interruption was associated with ischemic stroke (75% of patients with stroke had an interruption versus 24% of patients with no stroke; P < .01). Time on anticoagulants was not associated with ischemic stroke (P = .78), transfusion (P = .43), or ICH (P = .96). Similarly, time on antiplatelets (P = .54, P = .65, P = .60) and time on combination therapy (P = .96, P = .38, P = .57) were not associated with these outcomes. CONCLUSIONS The timing and consistency of antithrombotic administration are critical in preventing adverse outcomes in patients with BCVI. Most ischemic strokes in this study population occurred between arrival and antithrombotic initiation, representing events that may potentially be intervened upon by earlier treatment. Future studies should examine the safety of continuing treatment through surgical procedures.
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MESH Headings
- Adult
- Blood Transfusion
- Brain Injuries, Traumatic/diagnostic imaging
- Brain Injuries, Traumatic/drug therapy
- Brain Injuries, Traumatic/etiology
- Brain Ischemia/diagnostic imaging
- Brain Ischemia/etiology
- Brain Ischemia/therapy
- Cerebral Hemorrhage, Traumatic/diagnostic imaging
- Cerebral Hemorrhage, Traumatic/etiology
- Cerebral Hemorrhage, Traumatic/therapy
- Drug Administration Schedule
- Female
- Fibrinolytic Agents/administration & dosage
- Fibrinolytic Agents/adverse effects
- Humans
- Male
- Middle Aged
- Practice Patterns, Physicians'
- Retrospective Studies
- Risk Factors
- Stroke/diagnostic imaging
- Stroke/etiology
- Stroke/therapy
- Time Factors
- Time-to-Treatment
- Treatment Outcome
- United States
- Wounds, Nonpenetrating/diagnostic imaging
- Wounds, Nonpenetrating/drug therapy
- Wounds, Nonpenetrating/etiology
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Affiliation(s)
- Daniel Barrera
- Trauma Services Department, St. Anthony Hospital, Lakewood, Colorado
| | - Erica Sercy
- Trauma Research Department, St. Anthony Hospital, Lakewood, Colorado; Trauma Research Department, Swedish Medical Center, Englewood, Colorado; Trauma Research Department, Penrose Hospital, Colorado Springs, Colorado; Trauma Research Department, Medical City Plano, Plano, Texas; Trauma Research Department, Research Medical Center, Kansas City, Missouri; Trauma Research Department, Wesley Medical Center, Wichita, Kansas
| | - Alessandro Orlando
- Trauma Research Department, St. Anthony Hospital, Lakewood, Colorado; Trauma Research Department, Swedish Medical Center, Englewood, Colorado; Trauma Research Department, Penrose Hospital, Colorado Springs, Colorado; Trauma Research Department, Medical City Plano, Plano, Texas; Trauma Research Department, Research Medical Center, Kansas City, Missouri; Trauma Research Department, Wesley Medical Center, Wichita, Kansas
| | | | - Robert Madayag
- Trauma Services Department, St. Anthony Hospital, Lakewood, Colorado
| | | | - Allen Tanner
- Trauma Services Department, Penrose Hospital, Colorado Springs, Colorado
| | - Mark Lieser
- Trauma Services Department, Research Medical Center, Kansas City, Missouri
| | - David Acuna
- Trauma Services Department, Wesley Medical Center, Wichita, Kansas
| | - James Yon
- Trauma Services Department, Swedish Medical Center, Englewood, Colorado
| | - David Bar-Or
- Trauma Research Department, St. Anthony Hospital, Lakewood, Colorado; Trauma Research Department, Swedish Medical Center, Englewood, Colorado; Trauma Research Department, Penrose Hospital, Colorado Springs, Colorado; Trauma Research Department, Medical City Plano, Plano, Texas; Trauma Research Department, Research Medical Center, Kansas City, Missouri; Trauma Research Department, Wesley Medical Center, Wichita, Kansas.
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Oberladstätter D, Voelckel W, Bruckbauer M, Zipperle J, Grottke O, Ziegler B, Schöchl H. Idarucizumab in major trauma patients: a single centre real life experience. Eur J Trauma Emerg Surg 2019; 47:589-595. [PMID: 31555877 DOI: 10.1007/s00068-019-01233-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Accepted: 09/14/2019] [Indexed: 10/26/2022]
Abstract
INTRODUCTION Trauma care providers are facing an increasing number of elderly patients on direct oral anticoagulants prior to injury. For dabigatran etexilate (DAB), the specific antagonist idarucizumab (IDA) has been approved since 2015 as a reversal agent. However, only limited data regarding the use of IDA in trauma patients are available. METHODS We performed a retrospective analysis of trauma patients under DAB for whom IDA administration was deemed necessary to reverse DAB's antithrombotic effect. RESULTS A total of 15 (9 male) patients were treated with IDA during the study period. The mean age was 81 ± 10 years. Intracranial haemorrhage (n = 7) and long bone fractures (n = 5) were the most common types of injury. Three patients were diagnosed as polytrauma. In all but one patient, atrial fibrillation was the indication for DAB intake. The median dose of IDA was 2.5 g (IQR 2.5-5). IDA administration decreased DAB plasma levels from 112.4 (IQR 73.4-123.4) to 5 (IQR 4-12) ng/mL (p = 0.031), thrombin time from 114.8 ± 48.3 to 16.2 ± 0.5 s (p < 0.0001) and activated partial thromboplastin time form 45.4 ± 11.3 to 34.2 ± 7.0 s (p = 0.0025). No thromboembolic events or side effects attributed to IDA were observed. All patients survived until hospital discharge. CONCLUSIONS In trauma patients under DAB prior to injury, IDA decreased DAB plasma levels and normalized coagulation parameters. IDA appears to be safe, and no serious side effects were observed in this small cohort of patients.
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Affiliation(s)
- Daniel Oberladstätter
- Departement of Anaesthesiology and Intensive Care Medicine AUVA Trauma Centre Salzburg, Academic Teaching Hospital of the Paracelsus Medical University, Dr. Franz-Rehrl-Platz 5, 5020, Salzburg, Austria
| | - Wolfgang Voelckel
- Departement of Anaesthesiology and Intensive Care Medicine AUVA Trauma Centre Salzburg, Academic Teaching Hospital of the Paracelsus Medical University, Dr. Franz-Rehrl-Platz 5, 5020, Salzburg, Austria
| | - Martin Bruckbauer
- Departement of Anaesthesiology and Intensive Care Medicine AUVA Trauma Centre Salzburg, Academic Teaching Hospital of the Paracelsus Medical University, Dr. Franz-Rehrl-Platz 5, 5020, Salzburg, Austria
| | - Johannes Zipperle
- Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, AUVA Trauma Research Centre, Vienna, Austria
| | - Oliver Grottke
- Department of Anaesthesiology, RWTH Aachen University Hospital, Aachen, Germany
| | - Bernhard Ziegler
- Departement of Anaesthesiology and Intensive Care Medicine, University Hospital of Paracelsus Medical Private University, Salzburg, Austria
| | - Herbert Schöchl
- Departement of Anaesthesiology and Intensive Care Medicine AUVA Trauma Centre Salzburg, Academic Teaching Hospital of the Paracelsus Medical University, Dr. Franz-Rehrl-Platz 5, 5020, Salzburg, Austria. .,Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, AUVA Trauma Research Centre, Vienna, Austria.
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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. Crit Care 2019; 23:98. [PMID: 30917843 PMCID: PMC6436241 DOI: 10.1186/s13054-019-2347-3] [Citation(s) in RCA: 696] [Impact Index Per Article: 139.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Accepted: 02/06/2019] [Indexed: 12/24/2022] Open
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.
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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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Pearcy C, Almahmoud K, Jackson T, Hartline C, Cahill A, Spence L, Kim D, Olatubosun O, Todd SR, Campion EM, Burlew CC, Regner J, Frazee R, Michaels D, Dissanaike S, Stewart C, Foley N, Nelson P, Agrawal V, Truitt MS. Risky business? Investigating outcomes of patients undergoing urgent laparoscopic appendectomy on antithrombotic therapy. Am J Surg 2017; 214:1012-1015. [PMID: 28982518 DOI: 10.1016/j.amjsurg.2017.08.035] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2017] [Revised: 07/31/2017] [Accepted: 08/08/2017] [Indexed: 12/17/2022]
Abstract
INTRODUCTION The literature regarding outcomes in patients on irreversible antithrombotic therapy (IAT) undergoing urgent laparoscopic appendectomy is limited. The aim of this multicenter retrospective study was to examine the impact of prehospital IAT on outcomes in this population. METHODS From 2010 to 2014, seven institutions from the Southwest Surgical Multicenter Trials (SWSC MCT) group conducted a retrospective study to evaluate the clinical course of all patients on IAT who underwent urgent/emergent laparoscopic appendectomy. The IAT+ group was subdivided into IAT+ (Aspirin only) and IAT+ (Aspirin-Plavix). These groups were matched 1:1 to controls. The primary outcomes were estimated blood loss (EBL) and transfusion requirement. Secondary outcomes included infections (SSI - Surgical Site Infection, DSI - Deep Space Infection, and OSI - Organ Space Infection), hospital length of stay (HLOS), complications, 30-day readmissions, and mortality. RESULTS Out of the 2903 patients included in the study, 287 IAT+ patients were identified and matched in a 1:1 ratio to 287 IAT-patients. In the IAT+ vs IAT-analysis, no significant differences in EBL (p = 1.0), transfusion requirement during the preoperative (p = 0.5), intraoperative (p = 0.3) or postoperative periods (p = 0.5), infectious complications (SSI; p = 1.0, DSI; p = 1.0, and OSI; p = 0.1), overall complications (p = 0.3), HLOS (p = 0.7), 30-day readmission (p = 0.3), or mortality (p = 0.1) were noted. Similarly, outcomes in the IAT+ (Aspirin only) and IAT+ (Aspirin-Plavix) subgroups failed to demonstrate any significant differences when compared to controls. CONCLUSIONS Our analysis suggests that IAT is not associated with worse outcomes in urgent/emergent laparoscopic appendectomy. Prehospital use of IAT should not be used to delay laparoscopic appendectomy.
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Affiliation(s)
- Christopher Pearcy
- Department of Graduate Medical Education, Department of Surgery, Methodist Dallas Health System, Dallas, TX, USA
| | - Khalid Almahmoud
- Department of Graduate Medical Education, Department of Surgery, Methodist Dallas Health System, Dallas, TX, USA
| | - Theresa Jackson
- Department of Graduate Medical Education, Department of Surgery, Methodist Dallas Health System, Dallas, TX, USA
| | - Cassie Hartline
- Department of Graduate Medical Education, Department of Surgery, Methodist Dallas Health System, Dallas, TX, USA
| | - Anthony Cahill
- Department of Graduate Medical Education, Department of Surgery, Methodist Dallas Health System, Dallas, TX, USA
| | - Lara Spence
- Department of Graduate Medical Education, Department of Surgery, Harbor-UCLA Medical Center, Torrance, CA, USA
| | - Dennis Kim
- Department of Graduate Medical Education, Department of Surgery, Harbor-UCLA Medical Center, Torrance, CA, USA
| | - Oluwabukola Olatubosun
- Department of Graduate Medical Education, Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - S Rob Todd
- Department of Graduate Medical Education, Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Eric M Campion
- Department of Graduate Medical Education, Department of Surgery, University of Colorado, Aurora, CO, USA
| | - Clay Cothren Burlew
- Department of Graduate Medical Education, Department of Surgery, University of Colorado, Aurora, CO, USA
| | - Justin Regner
- Department of Graduate Medical Education, Department of Surgery, Baylor Scott and White Health - Central Texas, Temple, TX, USA
| | - Richard Frazee
- Department of Graduate Medical Education, Department of Surgery, Baylor Scott and White Health - Central Texas, Temple, TX, USA
| | - David Michaels
- Department of Graduate Medical Education, Department of Surgery, Texas Tech Health Sciences Center, Lubbock, TX, USA
| | - Sharmila Dissanaike
- Department of Graduate Medical Education, Department of Surgery, Texas Tech Health Sciences Center, Lubbock, TX, USA
| | - Collin Stewart
- Department of Graduate Medical Education, Department of Surgery, University of Nevada - Mountain View Surgery Residency, Las Vegas, NV, USA
| | - Neal Foley
- Department of Graduate Medical Education, Department of Surgery, University of Nevada - Mountain View Surgery Residency, Las Vegas, NV, USA
| | - Paul Nelson
- Department of Graduate Medical Education, Department of Surgery, University of Nevada - Mountain View Surgery Residency, Las Vegas, NV, USA
| | - Vaidehi Agrawal
- Clinical Research Institution, Methodist Dallas Health System, Dallas, TX, USA
| | - Michael S Truitt
- Department of Graduate Medical Education, Department of Surgery, Methodist Dallas Health System, Dallas, TX, USA.
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Hayakawa M, Maekawa K, Kushimoto S, Kato H, Sasaki J, Ogura H, Matsuoka T, Uejima T, Morimura N, Ishikura H, Hagiwara A, Takeda M, Kaneko N, Saitoh D, Kudo D, Kanemura T, Shibusawa T, Furugori S, Nakamura Y, Shiraishi A, Murata K, Mayama G, Yaguchi A, Kim S, Takasu O, Nishiyama K. Hyperfibrinolysis in severe isolated traumatic brain injury may occur without tissue hypoperfusion: a retrospective observational multicentre study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2017; 21:222. [PMID: 28830477 PMCID: PMC5568058 DOI: 10.1186/s13054-017-1811-1] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Accepted: 08/07/2017] [Indexed: 11/10/2022]
Abstract
BACKGROUND Hyperfibrinolysis is a critical complication in severe trauma. Hyperfibrinolysis is traditionally diagnosed via elevated D-dimer or fibrin/fibrinogen degradation product levels, and recently, using thromboelastometry. Although hyperfibrinolysis is observed in patients with severe isolated traumatic brain injury (TBI) on arrival at the emergency department (ED), it is unclear which factors induce hyperfibrinolysis. The present study aimed to investigate the factors associated with hyperfibrinolysis in patients with isolated severe TBI. METHODS We conducted a multicentre retrospective review of data for adult trauma patients with an injury severity score ≥ 16, and selected patients with isolated TBI (TBI group) and extra-cranial trauma (non-TBI group). The TBI group included patients with an abbreviated injury score (AIS) for the head ≥ 4 and an extra-cranial AIS < 2. The non-TBI group included patients with an extra-cranial AIS ≥ 3 and head AIS < 2. Hyperfibrinolysis was defined as a D-dimer level ≥ 38 mg/L on arrival at the ED. We evaluated the relationships between hyperfibrinolysis and injury severity/tissue injury/tissue perfusion in TBI patients by comparing them with non-TBI patients. RESULTS We enrolled 111 patients in the TBI group and 126 in the non-TBI group. In both groups, patients with hyperfibrinolysis had more severe injuries and received transfusion more frequently than patients without hyperfibrinolysis. Tissue injury, evaluated on the basis of lactate dehydrogenase and creatine kinase levels, was associated with hyperfibrinolysis in both groups. Among patients with TBI, the mortality rate was higher in those with hyperfibrinolysis than in those without hyperfibrinolysis. Tissue hypoperfusion, evaluated on the basis of lactate level, was associated with hyperfibrinolysis in only the non-TBI group. Although the increase in lactate level was correlated with the deterioration of coagulofibrinolytic variables (prolonged prothrombin time and activated partial thromboplastin time, decreased fibrinogen levels, and increased D-dimer levels) in the non-TBI group, no such correlation was observed in the TBI group. CONCLUSIONS Hyperfibrinolysis is associated with tissue injury and trauma severity in TBI and non-TBI patients. However, tissue hypoperfusion is associated with hyperfibrinolysis in non-TBI patients, but not in TBI patients. Tissue hypoperfusion may not be a prerequisite for the occurrence of hyperfibrinolysis in patients with isolated TBI.
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Affiliation(s)
- Mineji Hayakawa
- Emergency and Critical Care Center, Hokkaido University Hospital, N14W5, Kita-ku, Sapporo, 060-8648, Japan.
| | - Kunihiko Maekawa
- Emergency and Critical Care Center, Hokkaido University Hospital, N14W5, Kita-ku, Sapporo, 060-8648, Japan
| | - Shigeki Kushimoto
- Division of Emergency and Critical Care Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Hiroshi Kato
- Department of Critical Care and Traumatology, National Hospital Organization Disaster Medical Center, Tokyo, Japan
| | - Junichi Sasaki
- Department of Emergency & Critical Care Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Hiroshi Ogura
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Tetsuya Matsuoka
- Senshu Trauma and Critical Care Center, Rinku General Medical Center, Osaka, Japan
| | - Toshifumi Uejima
- Department of Emergency and Critical Care Medicine, Kinki University Faculty of Medicine, Osaka, Japan
| | - Naoto Morimura
- Department of Emergency and Critical Care Medicine, The University of Tokyo Hospital, Tokyo, Japan
| | - Hiroyasu Ishikura
- Department of Emergency and Critical Care Medicine, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Akiyoshi Hagiwara
- Department of Emergency Medicine and Critical Care, National Center for Global Health and Medicine, Tokyo, Japan
| | - Munekazu Takeda
- Department of Critical Care and Emergency Medicine, Tokyo Women's Medical University, Tokyo, Japan
| | - Naoyuki Kaneko
- Trauma and Emergency Center, Fukaya Red Cross Hospital, Saitama, Japan
| | - Daizoh Saitoh
- Division of Traumatology, Research Institute, National Defence Medical College, Saitama, Japan
| | - Daisuke Kudo
- Division of Emergency and Critical Care Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Takashi Kanemura
- Department of Critical Care and Traumatology, National Hospital Organization Disaster Medical Center, Tokyo, Japan
| | - Takayuki Shibusawa
- Department of Emergency & Critical Care Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Shintaro Furugori
- Department of Emergency Medicine, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Yoshihiko Nakamura
- Department of Emergency and Critical Care Medicine, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Atsushi Shiraishi
- Trauma and Acute Critical Care Medical Center, Tokyo Medical and Dental University Hospital of Medicine, Tokyo, Japan
| | - Kiyoshi Murata
- Trauma and Acute Critical Care Medical Center, Tokyo Medical and Dental University Hospital of Medicine, Tokyo, Japan
| | - Gou Mayama
- Department of Emergency Medicine and Critical Care, National Center for Global Health and Medicine, Tokyo, Japan
| | - Arino Yaguchi
- Department of Critical Care and Emergency Medicine, Tokyo Women's Medical University, Tokyo, Japan
| | - Shiei Kim
- Department of Emergency & Critical Care Medicine, Nippon Medical School, Tokyo, Japan
| | - Osamu Takasu
- Department of Emergency and Critical Care Medicine, Kurume University School of Medicine, Kurume, Japan
| | - Kazutaka Nishiyama
- Department of Emergency and Critical Care Medicine, Juntendo University Urayasu Hospital, Chiba, Japan
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