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Nasca B, Reddy S, Furmanchuk A, Lundberg A, Kong N, Andrei AC, Theros J, Thomas A, Ingram M, Sanchez J, Slocum J, Stey AM. Hospital variation in adoption of balanced transfusion practices among injured patients requiring blood transfusions. Surgery 2024:S0039-6060(24)00460-4. [PMID: 39069394 DOI: 10.1016/j.surg.2024.06.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Revised: 05/30/2024] [Accepted: 06/19/2024] [Indexed: 07/30/2024]
Abstract
BACKGROUND This study sought to measure hospital variability in adoption of balanced transfusion following the Pragmatic, Randomized Optimal Platelet and Plasma Ratios (PROPPR) guidelines. We hypothesized hospital adoption rates of balanced transfusion would be low, and vary significantly among hospitals after controlling for patient, injury and hospital characteristics. STUDY DESIGN AND METHODS This was an observational cohort study of injured adult patients (≥16 years) in Trauma Quality Improvement Program hospitals 2016-2021. Inclusion criteria were hypotensive patients receiving one transfusion of packed red blood cells, fresh frozen plasma, platelets, or cryoprecipitate. Balanced transfusion was defined as ≥1 ratio of plasma to packed red blood cells or platelets to packed red blood cells or whole blood use at 4 hours. Hierarchical multivariable logistic regression quantified residual hospital-level variability in balanced transfusion rates after adjusting for patient and hospital characteristics. RESULTS Among 172,457 injured patients who received transfusions, 30,386 (17.6%) underwent balanced transfusion. Patient-level balanced transfusion rates were 11% in 2016, rose to 14.0% in 2019, and jumped up once whole blood transfusions were measured to 24.0% in 2020 and to 25.9% in 2021. Approximately 26% of the variability in balanced transfusion rates was attributable to the hospital. Verified level I hospitals had a 2.09 increased adjusted odds of balanced transfusion (95% CI 1.88-2.21) compared to nonverified hospitals. University teaching status had a 1.29 increased adjusted odds of balanced transfusion (95% CI 1.08-1.54) compared with community hospitals. Overall, 150 (23.5%) hospitals were high outliers (high performing) in balanced transfusion adoption and 124 (19.4%) hospitals were low outliers. CONCLUSION There was significant variability in hospital adoption of balanced transfusion.
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Affiliation(s)
- Brian Nasca
- Department of surgery, Albany Medical College, New York, NY
| | - Susheel Reddy
- Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Alona Furmanchuk
- Feinberg School of Medicine, Northwestern University, Chicago, IL
| | | | - Nan Kong
- Weldon School of Biomedical Engineering, Purdue University, West Lafayette, IN
| | | | - Jonathan Theros
- Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Arielle Thomas
- Department of surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Martha Ingram
- Department of surgery, Emory University, Atlanta, GA
| | - Joseph Sanchez
- Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - John Slocum
- Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Anne M Stey
- Feinberg School of Medicine, Northwestern University, Chicago, IL.
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2
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Oliveira LC, Montano-Pedroso JC, Perini FV, Dos Reis Rodrigues R, Donizetti E, Rizzo SRCP, Rabello G, Junior DML. Consensus of the Brazilian association of hematology, hemotherapy and cellular therapy on patient blood management: Management of critical bleeding. Hematol Transfus Cell Ther 2024; 46 Suppl 1:S60-S66. [PMID: 38553342 PMCID: PMC11069065 DOI: 10.1016/j.htct.2024.02.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2024] [Accepted: 02/18/2024] [Indexed: 05/07/2024] Open
Abstract
The management of major bleeding is a critical aspect of modern healthcare and it is imperative to emphasize the importance of applying Patient Blood Management (PBM) principles. Although transfusion support remains a vital component of bleeding control, treating severe bleeding goes beyond simply replacing lost blood. A more comprehensive, multidisciplinary approach is essential to optimize patient outcomes and minimize the risks associated with excessive transfusions.
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Affiliation(s)
- Luciana Correa Oliveira
- Hemocentro de Ribeirão Preto, Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo (HCFMRP-USP), Ribeirão Preto, SP, Brazil
| | - Juan Carlos Montano-Pedroso
- Universidade Federal de São Paulo (Unifesp), São Paulo, SP, Brazil; Instituto de Assistência Médica do Servidor Público Estadual (Iamspe), São Paulo, SP, Brazil
| | - Fernanda Vieira Perini
- Grupo GSH - Gestor de Serviços de Hemoterapia, São Paulo, SP, Brazil; Associação Beneficente Síria HCOR, São Paulo, SP, Brazil
| | - Roseny Dos Reis Rodrigues
- Hospital Israelita Albert Einstein são Paulo, São Paulo, SP, Brazil; Faculdade de Medicina da Universidade de São Paulo (FM USP), São Paulo, SP, Brazil
| | | | | | - Guilherme Rabello
- Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (Incor - HCFMUSP), São Paulo, SP, Brazil.
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3
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Gianola S, Castellini G, Biffi A, Porcu G, Napoletano A, Coclite D, D'Angelo D, Di Nitto M, Fauci AJ, Punzo O, Iannone P, Chiara O. Volume replacement in the resuscitation of trauma patients with acute hemorrhage: an umbrella review. Int J Emerg Med 2023; 16:87. [PMID: 38036955 PMCID: PMC10687916 DOI: 10.1186/s12245-023-00563-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Accepted: 10/26/2023] [Indexed: 12/02/2023] Open
Abstract
BACKGROUND The use of intravenous fluid therapy in patients with major trauma in prehospital settings is still controversial. We conducted an umbrella review to evaluate which is the best volume expansion in the resuscitation of a hemorrhagic shock to support the development of major trauma guideline recommendations. METHODS We searched PubMed, Embase, and CENTRAL up to September 2022 for systematic reviews (SRs) investigating the use of volume expansion fluid on mortality and/or survival. Quality assessment was performed using AMSTAR 2 and the Certainty of the evidence was assessed with the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. RESULTS We included 14 SRs investigating the effects on mortality with the comparisons: use of crystalloids, blood components, and whole blood. Most SRs were judged as critically low with slight overlapping of primary studies and high consistency of results. For crystalloids, inconsistent evidence of effectiveness in 28- to 30-day survival (primary endpoint) was found for the hypertonic saline/dextran group compared with isotonic fluid solutions with moderate certainty of evidence. Pre-hospital blood component infusion seems to reduce mortality, however, as the certainty of evidence ranges from very low to moderate, we are unable to provide evidence to support or reject its use. The blood component ratio was in favor of higher ratios among all comparisons considered with moderate to very low certainty of evidence. Results about the effects of whole blood are very uncertain due to limited and heterogeneous interventions in studies included in SRs. CONCLUSION Hypertonic crystalloid use did not result in superior 28- to 30-day survival. Increasing evidence supports the scientific rationale for early use of high-ratio blood components, but their use requires careful consideration. Preliminary evidence is very uncertain about the effects of whole blood and further high-quality studies are required.
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Affiliation(s)
- Silvia Gianola
- Unit of Clinical Epidemiology, IRCCS Istituto Ortopedico Galeazzi, Milan, Italy
| | - Greta Castellini
- Unit of Clinical Epidemiology, IRCCS Istituto Ortopedico Galeazzi, Milan, Italy
| | - Annalisa Biffi
- Department of Statistics and Quantitative Methods, National Centre for Healthcare Research and Pharmacoepidemiology, University of Milano-Bicocca, Milan, Italy
- Department of Statistics and Quantitative Methods, Unit of Biostatistics, Epidemiology and Public Health, University of Milano-Bicocca, Milan, Italy
| | - Gloria Porcu
- Department of Statistics and Quantitative Methods, National Centre for Healthcare Research and Pharmacoepidemiology, University of Milano-Bicocca, Milan, Italy
- Department of Statistics and Quantitative Methods, Unit of Biostatistics, Epidemiology and Public Health, University of Milano-Bicocca, Milan, Italy
| | - Antonello Napoletano
- Centro Nazionale Per L'Eccellenza Clinica, La Qualità E La Sicurezza Delle Cure, Istituto Superiore Di Sanità, Rome, Italy
| | - Daniela Coclite
- Centro Nazionale Per L'Eccellenza Clinica, La Qualità E La Sicurezza Delle Cure, Istituto Superiore Di Sanità, Rome, Italy
| | - Daniela D'Angelo
- Azienda Sanitaria Locale Roma/6, Via Borgo Garibaldi, 12 00041 Albano Laziale, Rome, Italy.
- CECRI Evidence-Based Practice Group for Nursing Scholarship: A JBI Affiliated Group, Rome, Italy.
| | - Marco Di Nitto
- Centro Nazionale Per L'Eccellenza Clinica, La Qualità E La Sicurezza Delle Cure, Istituto Superiore Di Sanità, Rome, Italy
| | - Alice Josephine Fauci
- Centro Nazionale Per L'Eccellenza Clinica, La Qualità E La Sicurezza Delle Cure, Istituto Superiore Di Sanità, Rome, Italy
| | - Ornella Punzo
- Centro Nazionale Per L'Eccellenza Clinica, La Qualità E La Sicurezza Delle Cure, Istituto Superiore Di Sanità, Rome, Italy
| | - Primiano Iannone
- Dipartimento Di Medicina Interna, Azienda USL, Ospedale Maggiore, Largo Nigrisoli 2, 40133, Bologna, Italy
| | - Osvaldo Chiara
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
- General Surgery and Trauma Team, ASST Grande Ospedale Metropolitano Niguarda, University of Milan, Milano, Piazza Ospedale Maggiore, Milan, Italy
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4
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Walsh D, Cunning C, Lee G, Boylan J, McLoughlin P. CAPILLARY LEAK AND EDEMA AFTER RESUSCITATION: THE POTENTIAL CONTRIBUTION OF REDUCED ENDOTHELIAL SHEAR STRESS CAUSED BY HEMODILUTION. Shock 2023; 60:487-495. [PMID: 37647080 DOI: 10.1097/shk.0000000000002215] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
Abstract
ABSTRACT Normal shear stress is essential for the normal structure and functions of the microcirculation. Hemorrhagic shock leads to reduced shear stress due to reduced tissue perfusion. Although essential for the urgent restoration of cardiac output and systemic blood pressure, large volume resuscitation with currently available solutions causes hemodilution, further reducing endothelial shear stress. In this narrative review, we consider how the use of currently available resuscitation solutions results in persistent reduction in endothelial shear stress, despite successfully increasing cardiac output and systemic blood pressure. We consider how this reduced shear stress causes (1) a failure to restore normal vasomotor function and normal tissue perfusion thus leading to persistent tissue hypoxia and (2) increased microvascular endothelial permeability resulting in edema formation and impaired organ function. We discuss the need for clinical research into resuscitation strategies and solutions that aim to quickly restore endothelial shear stress in the microcirculation to normal.
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Affiliation(s)
| | - Ciara Cunning
- Department of Clinical Biochemistry, Mater Misericordiae University Hospital, Dublin, Ireland
| | | | | | - Paul McLoughlin
- School of Medicine and Conway Institute, University College Dublin, Dublin, Ireland
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5
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Yao R, Yan D, Fu X, Deng Y, Xie X, Li N. The effects of plasma to red blood cells transfusion ratio on in-hospital mortality in patients with acute type A aortic dissection. Front Cardiovasc Med 2023; 10:1091468. [PMID: 37252125 PMCID: PMC10213885 DOI: 10.3389/fcvm.2023.1091468] [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: 11/07/2022] [Accepted: 04/26/2023] [Indexed: 05/31/2023] Open
Abstract
Background Blood transfusion is a frequent and necessary practice in acute type A aortic dissection (AAAD) patients, but the effect of plasma/red blood cells (RBCs) ratio on mortality remains unclear. The aim of this study is to investigate the association between plasma/RBCs transfusion ratio and in-hospital mortality in patients with AAAD. Methods Patients were admitted to Xiangya Hospital of Central South University from January 1, 2016 to December 31, 2021. Clinical parameters were recorded. Multivariate Cox regression model was used to analyze the association between transfusion and in-hospital mortality. We used the smooth curve fitting and segmented regression model to assess the threshold effect between plasma/RBCs transfusion ratio and in-hospital mortality in patients with AAAD. Results The volumes of RBCs [14.00 (10.12-20.50) unit] and plasma [19.25 (14.72-28.15) unit] transfused in non-survivors were significantly higher than in survivors [RBCs: 8.00 (5.50-12.00) unit]; plasma: [10.35 (6.50-15.22) unit]. Multivariate Cox regression analysis showed plasma transfusion was an independent risk factor of in-hospital mortality. Adjusted HR was 1.03 (95% CI: 0.96-1.11) for RBCs transfusion and 1.08 (95% CI: 1.03-1.13) for plasma transfusion. In the spline smoothing plot, mortality risk increased with plasma/RBCs transfusion ratio leveling up to the turning point 1. Optimal plasma/RBCs transfusion ratio with least mortality risk was 1. When the plasma/RBCs ratio was <1 (adjusted HR per 0.1 ratio: 0.28, 95% CI per 0.1 ratio: 0.17-0.45), mortality risk decreased with the increase of ratio. When the plasma/RBCs ratio was 1-1.5 (adjusted HR per 0.1 ratio: 2.73, 95% CI per 0.1 ratio:1.13-6.62), mortality risk increased rapidly with the increase of ratio. When the plasma/RBCs ratio was >1.5 (adjusted HR per 0.1 ratio: 1.09, 95% CI per 0.1 ratio:0.97-1.23), mortality risk tended to reach saturation, and increased non-significantly with the increase of ratio. Conclusion A 1:1 plasma/RBCs ratio was associated with the lowest mortality in the patients with AAAD. And non-linear relationship existed between plasma/RBCs ratio and mortality.
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Affiliation(s)
- Run Yao
- Department of Blood Transfusion, National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Clinical Transfusion Research Center, Central South University, Changsha, China
| | - Danyang Yan
- Department of Blood Transfusion, National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Clinical Transfusion Research Center, Central South University, Changsha, China
| | - Xiangjie Fu
- Department of Blood Transfusion, National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Clinical Transfusion Research Center, Central South University, Changsha, China
| | - Ying Deng
- Office, Ningxiang People's Hospital Affiliated to Hunan University of Traditional Chinese Medicine, Ningxiang, China
| | - Xi Xie
- Department of Blood Transfusion, National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Clinical Transfusion Research Center, Central South University, Changsha, China
| | - Ning Li
- Department of Blood Transfusion, National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Clinical Transfusion Research Center, Central South University, Changsha, China
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6
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Wyssusek KH, Wagner MK, Lee J, Okano S, Wullschleger M, van Zundert AA. Blood management practices during rapid transfer of urgent trauma patients pre- and post-implementation of ROTEM ®-guided transfusion. TRAUMA-ENGLAND 2023. [DOI: 10.1177/14604086231159687] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/07/2023]
Abstract
Objective The ‘Red Blanket’ protocol fast tracks trauma patients with severe blood loss to the designated trauma operating theatre directly from the hospital helipad or Emergency Department. This study aimed to assess the impact of patient blood management (PBM) strategies on severely injured trauma patients treated under the ‘Red Blanket’ protocol at a quaternary referral hospital. Methods This retrospective review was conducted on all urgent trauma cases that were treated under the ‘Red Blanket’ protocol in a ten-year period between January 2007 and December 2017. The use of blood products and patient outcomes was compared between the 3.5-year periods pre- and post-ROTEM® implementation on 30th June 2014 (Jan 2011-June 2014 versus July 2014-Dec 2017). Results During the study period, 120 trauma patients were treated under the ‘Red Blanket’ protocol at our institution. Intention to treat analysis showed a reduction in fresh frozen plasma usage following the introduction of ROTEM®-guided transfusion. Furthermore, subgroup analysis suggested reduced blood product usage in patients who survived. Conclusions Patient blood management is a coordinated package of systems and tools, including education, patient logistics, anaemia management, intraoperative cell salvage, rotational thromboelastometry and massive transfusion protocols that together conserve blood products and improve outcomes. The implementation of ROTEM®-guided transfusion demonstrated a reduction in fresh frozen plasma usage.
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Affiliation(s)
- Kerstin H. Wyssusek
- Department of Anesthesia & Perioperative Medicine, Royal Brisbane & Women's Hospital, St Herston, QLD, Australia
- School of Clinical Medicine, The University of Queensland, Herston, QLD, Australia
| | - Matthew K. Wagner
- Department of Anesthesia & Perioperative Medicine, Royal Brisbane & Women's Hospital, St Herston, QLD, Australia
- School of Clinical Medicine, The University of Queensland, Herston, QLD, Australia
| | - Julie Lee
- Department of Anesthesia & Perioperative Medicine, Royal Brisbane & Women's Hospital, St Herston, QLD, Australia
- School of Clinical Medicine, The University of Queensland, Herston, QLD, Australia
| | - Satomi Okano
- Statistics Unit, QIMR Berghofer Medical Research Institute, Herston, QLD, Australia
| | - Martin Wullschleger
- School of Clinical Medicine, The University of Queensland, Herston, QLD, Australia
- Department of Trauma Service, Royal Brisbane and Women’s Hospital, Herston, QLD, Australia
| | - André A. van Zundert
- Department of Anesthesia & Perioperative Medicine, Royal Brisbane & Women's Hospital, St Herston, QLD, Australia
- School of Clinical Medicine, The University of Queensland, Herston, QLD, Australia
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7
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Marshall C, Josephson CD, Leonard JC, Wisniewski SR, Leeper CM, Luther JF, Spinella PC. Blood component ratios in children with non-traumatic life-threatening bleeding. Vox Sang 2023; 118:68-75. [PMID: 36427061 DOI: 10.1111/vox.13382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 11/04/2022] [Accepted: 11/09/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND AND OBJECTIVES In paediatric trauma patients, there are limited prospective data regarding blood components and mortality, with some literature suggesting decreased mortality with high ratios of plasma and platelets to red blood cells (RBCs) in massive transfusions; however, most paediatric massive transfusions occur for non-traumatic aetiologies and few studies assess blood product ratios in these children. This study's objective was to evaluate whether high blood product ratios or low deficits conferred a survival benefit in children with non-traumatic life-threatening bleeding. MATERIALS AND METHODS This is a secondary analysis of the five-year, multicentre, prospective, observational massive transfusion epidemiology and outcomes in children study of children with life-threatening bleeding from US, Canadian and Italian medical centres. Primary interventions were plasma:RBC and platelets:RBC (high ratio ≥1:2 ml/kg) and plasma and platelet deficits. The primary outcome was mortality at 6 h, 24 h and 28 days. Multivariate logistic regression models were used to determine independent associations with mortality. RESULTS A total of 222 children were included from 24 medical centres: 145 children (median [interquartile range] age 2.1 years [0.3-11.8]) with operative bleeding and 77 (8.0 years [1.2-14.7]) with medical bleeding. In adjusted analyses, neither blood product ratios nor deficits were associated with mortality at 6 h, 24 h or 28 days. CONCLUSION This paper addresses a lack of prospective data in children regarding optimal empiric massive transfusion strategies in non-traumatic massive haemorrhage and in finding no decrease in mortality with high plasma or platelet to RBC ratios or lower deficits supports an exploratory analysis for mortality.
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Affiliation(s)
- Callie Marshall
- Department of Pediatrics, Washington University School of Medicine, St. Louis Children's Hospital, St. Louis, Missouri, USA
| | - Cassandra D Josephson
- Department of Oncology and Cancer and Blood Disorders Institute, Johns Hopkins University School of Medicine, Johns Hopkins All Children's Hospital, St. Petersburg, Florida, USA
| | - Julie C Leonard
- Department of Critical Care Medicine, The Ohio State University College of Medicine, Columbus, Ohio, USA
| | | | - Christine M Leeper
- Department of Pediatrics, University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - James F Luther
- University of Pittsburgh School of Public Health, Pittsburgh, Pennsylvania, USA
| | | | - Philip C Spinella
- Department of Pediatrics, Washington University School of Medicine, St. Louis Children's Hospital, St. Louis, Missouri, USA.,Department of Pediatrics, University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
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8
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Shah A, Kerner V, Stanworth SJ, Agarwal S. Major haemorrhage: past, present and future. Anaesthesia 2023; 78:93-104. [PMID: 36089857 PMCID: PMC10087440 DOI: 10.1111/anae.15866] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/29/2022] [Indexed: 12/15/2022]
Abstract
Major haemorrhage is a leading cause of morbidity and mortality worldwide. Successful treatment requires early recognition, planned responses, readily available resources (such as blood products) and rapid access to surgery or interventional radiology. Major haemorrhage is often accompanied by volume loss, haemodilution, acidaemia, hypothermia and coagulopathy (factor consumption and fibrinolysis). Management of major haemorrhage over the past decade has evolved to now deliver a 'package' of haemostatic resuscitation including: surgical or radiological control of bleeding; regular monitoring of haemostasis; advanced critical care support; and avoidance of the lethal triad of hypothermia, acidaemia and coagulopathy. Recent trial data advocate for a more personalised approach depending on the clinical scenario. Fresh frozen plasma should be given as early as possible in major trauma in a 1:1 ratio with red blood cells until the results of coagulation tests are available. Tranexamic acid is a cheap, life-saving drug and is advocated in major trauma, postpartum haemorrhage and surgery, but not in patients with gastrointestinal bleeding. Fibrinogen levels should be maintained > 2 g.l-1 in postpartum haemorrhage and > 1.5 g.l-1 in other haemorrhage. Improving outcomes after major traumatic haemorrhage is now driving research to include extending blood-product resuscitation into prehospital care.
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Affiliation(s)
- A Shah
- Nuffield Department of Clinical Neurosciences, University of Oxford, UK
| | - V Kerner
- Nuffield Department of Anaesthesia, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - S J Stanworth
- Radcliffe Department of Medicine, University of Oxford, UK
| | - S Agarwal
- Department of Anaesthesia, Manchester University NHS Foundation Trust, Manchester, UK
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9
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Stanworth SJ, Dowling K, Curry N, Doughty H, Hunt BJ, Fraser L, Narayan S, Smith J, Sullivan I, Green L. A guideline for the haematological management of major haemorrhage: a British Society for Haematology Guideline. Br J Haematol 2022; 198:654-667. [PMID: 35687716 DOI: 10.1111/bjh.18275] [Citation(s) in RCA: 30] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 05/07/2022] [Accepted: 05/09/2022] [Indexed: 12/17/2022]
Affiliation(s)
- Simon J Stanworth
- Transfusion Medicine, NHS Blood and Transplant, Oxford, UK.,Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.,Radcliffe Department of Medicine, University of Oxford, and NIHR Oxford Biomedical Research Centre, Oxford, UK
| | - Kerry Dowling
- Transfusion Laboratory Manager, Southampton University Hospitals NHS Foundation Trust, Southampton, UK
| | - Nikki Curry
- Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.,Radcliffe Department of Medicine, University of Oxford, and NIHR Oxford Biomedical Research Centre, Oxford, UK
| | - Heidi Doughty
- Institute of Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK.,NIHR Surgical Reconstruction and Microbiology Research Centre, Birmingham, UK
| | - Beverley J Hunt
- Department of Haematology, Guy's and St Thomas's Hospital, London, UK
| | - Laura Fraser
- Transfusion Practitioner, NHS Lanarkshire, University Hospital Wishaw, Wishaw, UK.,National Services Scotland/Scottish National Blood Transfusion, Edinburgh, UK
| | - Shruthi Narayan
- Medical director, Serious Hazards of Transfusion, Manchester, UK
| | - Juliet Smith
- Lead Transfusion Practitioner, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Ian Sullivan
- Transfusion Laboratory Manager, Royal Cornwall Hospitals NHS Trust, Truro, UK
| | - Laura Green
- Transfusion Medicine, NHS Blood and Transplant, London, UK.,Barts Health NHS Trust, London, UK.,Blizzard Institute, Queen Mary University of London, London, UK
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10
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Dynamic impact of transfusion ratios on outcomes in severely injured patients: Targeted machine learning analysis of the Pragmatic, Randomized Optimal Platelet and Plasma Ratios randomized clinical trial. J Trauma Acute Care Surg 2021; 89:505-513. [PMID: 32520897 DOI: 10.1097/ta.0000000000002819] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Massive transfusion protocols to treat postinjury hemorrhage are based on predefined blood product transfusion ratios followed by goal-directed transfusion based on patient's clinical evolution. However, it remains unclear how these transfusion ratios impact patient outcomes over time from injury. METHODS The Pragmatic, Randomized Optimal Platelet and Plasma Ratios (PROPPR) is a phase 3, randomized controlled trial, across 12 Level I trauma centers in North America. From 2012 to 2013, 680 severely injured patients required massive transfusion. We used semiparametric machine learning techniques and causal inference methods to augment the intent-to-treat analysis of PROPPR, estimating the dynamic relationship between transfusion ratios and outcomes: mortality and hemostasis at different timepoints during the first 24 hours after admission. RESULTS In the intention-to-treat analysis, the 1:1:1 group tended to have decreased mortality, but with no statistical significance. For patients in whom hemostasis took longer than 2 hours, the 1:1:1 ratio was associated with a higher probability of hemostasis, statistically significant from the 4 hour on. In the per-protocol, actual-transfusion-ratios-received analysis, during four successive time intervals, no significant association was found between the actual ratios and mortality. When comparing patient groups who received both high plasma/PRBC and high platelet/PRBC ratios to the group of low ratios in both, the relative risk of achieving hemostasis was 2.49 (95% confidence interval, 1.19-5.22) during the third hour after admission, suggesting a significant beneficial impact of higher transfusion ratios of plasma and platelets on hemostasis. CONCLUSION Our results suggest that the impact of transfusion ratios on hemostasis is dynamic. Overall, the transfusion ratios had no significant impact on mortality over time. However, receiving higher ratios of platelets and plasma relative to red blood cells hastens hemostasis in subjects who have yet to achieve hemostasis within 3 hours after hospital admission. LEVEL OF EVIDENCE Therapeutic IV.
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11
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Eksteen A, O'Dochartaigh D, Odenbach J, Douma MJ, O'Neill K, Anantha R, Bradley NL, Gauri A, Widder S. A gap analysis of the potential use of resuscitative endovascular balloon occlusion of the aorta (REBOA) in trauma at two major Canadian trauma centers. CAN J EMERG MED 2020; 23:36-44. [PMID: 33683614 DOI: 10.1007/s43678-020-00007-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2020] [Accepted: 07/31/2020] [Indexed: 10/22/2022]
Abstract
OBJECTIVE Uncontrolled hemorrhage poses significant morbidity and mortality among injured patients. Resuscitative endovascular balloon occlusion of the aorta (REBOA) utilizes a rapidly-administered minimally invasive transfemoral balloon catheter that is inflated for aortic occlusion, allowing for time to arrange definitive surgical or angiographic intervention. As indications for its use continue to evolve, this study sought to evaluate whether there is a potential need for REBOA implementation in two high-volume trauma centers in Edmonton. METHODS Patient data within our provincial trauma registry was reviewed between 2015 and 2017 to identify major trauma patients (Injury Severity Score ≥ 12). Patients eligible for REBOA included patients with blunt or penetrating trauma to the torso or pelvis, AND death prior to discharge; and patients taken to the operating room or interventional radiology suite within 4 h of arrival. Charts were reviewed to determine if patients met current conventional criteria for REBOA. RESULTS Out of 3415 trauma patients during our study period, 237 patients met the registry screen as potentially eligible for REBOA. After primary researcher review, 67 patients underwent full chart review and then 2 trauma surgeons determined that 38 (1.1% of the study population) met criteria for deploying REBOA. CONCLUSION A small but significant number of trauma patients at the two trauma centers were identified as potential candidates for REBOA use. Implementation of a REBOA program should be done in alignment with existing clinical practice guidelines and professional society recommendations.
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Affiliation(s)
- Alistair Eksteen
- Department of Emergency Medicine, Faculty of Medicine and Dentistry 2J2.00 WC Mackenzie Health Sciences Centre, University of Alberta, 8440 112 St. NW, Edmonton, AB, T6G 2R7, Canada.
| | - Domhnall O'Dochartaigh
- Alberta Health Services, Emergency, Edmonton, AB, Canada.,Shock Trauma Air Rescue Society (STARS), Edmonton, AB, Canada
| | - Jeff Odenbach
- Department of Emergency Medicine, Faculty of Medicine and Dentistry 2J2.00 WC Mackenzie Health Sciences Centre, University of Alberta, 8440 112 St. NW, Edmonton, AB, T6G 2R7, Canada
| | - Matthew J Douma
- Alberta Health Services, Emergency, Edmonton, AB, Canada.,Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada.,School of Nursing, Midwifery, and Health Systems, University College Dublin, Dublin, Ireland
| | - Kristin O'Neill
- Department of Emergency Medicine, Faculty of Medicine and Dentistry 2J2.00 WC Mackenzie Health Sciences Centre, University of Alberta, 8440 112 St. NW, Edmonton, AB, T6G 2R7, Canada.,Alberta Health Services, Emergency, Edmonton, AB, Canada.,Shock Trauma Air Rescue Society (STARS), Edmonton, AB, Canada.,Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada.,School of Nursing, Midwifery, and Health Systems, University College Dublin, Dublin, Ireland.,Department of Surgery, University of Alberta, Edmonton, AB, USA.,Department of Critical Care Medicine, University of British Columbia, Vancouver, Canada
| | - Ram Anantha
- Department of Surgery, University of Alberta, Edmonton, AB, USA
| | - Nori L Bradley
- Department of Surgery, University of Alberta, Edmonton, AB, USA.,Department of Critical Care Medicine, University of British Columbia, Vancouver, Canada
| | - Aliyah Gauri
- Department of Emergency Medicine, Faculty of Medicine and Dentistry 2J2.00 WC Mackenzie Health Sciences Centre, University of Alberta, 8440 112 St. NW, Edmonton, AB, T6G 2R7, Canada
| | - Sandy Widder
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada.,Department of Surgery, University of Alberta, Edmonton, AB, USA
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12
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Hübner M, Kusamura S, Villeneuve L, Al-Niaimi A, Alyami M, Balonov K, Bell J, Bristow R, Guiral DC, Fagotti A, Falcão LFR, Glehen O, Lambert L, Mack L, Muenster T, Piso P, Pocard M, Rau B, Sgarbura O, Somashekhar SP, Wadhwa A, Altman A, Fawcett W, Veerapong J, Nelson G. Guidelines for Perioperative Care in Cytoreductive Surgery (CRS) with or without hyperthermic IntraPEritoneal chemotherapy (HIPEC): Enhanced recovery after surgery (ERAS®) Society Recommendations - Part I: Preoperative and intraoperative management. Eur J Surg Oncol 2020; 46:2292-2310. [PMID: 32873454 DOI: 10.1016/j.ejso.2020.07.041] [Citation(s) in RCA: 85] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 07/14/2020] [Accepted: 07/28/2020] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Enhanced recovery after surgery (ERAS) pathways have been shown to considerably reduce complications, length of stay and costs after most of surgical procedures by standardised application of best evidence-based perioperative care. The aim was to elaborate dedicated recommendations for cytoreductive surgery (CRS) ± hyperthermic intraperitoneal chemotherapy (HIPEC) in a two-part series of guidelines based on expert consensus. The present part I of the guidelines highlights preoperative and intraoperative management. METHODS The core group assembled a multidisciplinary panel of 24 experts involved in peritoneal surface malignancy surgery representing the fields of general surgery (n = 12), gynaecological surgery (n = 6), and anaesthesia (n = 6). Experts systematically reviewed and summarized the available evidence on 72 identified perioperative care items, following the GRADE (grading of recommendations, assessment, development, evaluation) system. Final consensus (defined as ≥50%, or ≥70% of weak/strong recommendations combined) was reached by a standardised 2-round Delphi process, regarding the strength of recommendations. RESULTS Response rates were 100% for both Delphi rounds. Quality of evidence was evaluated high, moderate low and very low, for 15 (21%), 26 (36%), 29 (40%) and 2 items, respectively. Consensus was reached for 71/72(98.6%) items. Strong recommendations were defined for 37 items, No consensus could be reached regarding the preemptive use of fresh frozen plasma. CONCLUSION The present ERAS recommendations for CRS±HIPEC are based on a standardised expert consensus process providing clinicians with valuable guidance. There is an urgent need to produce high quality studies for CRS±HIPEC and to prospectively evaluate recommendations in clinical practice.
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Affiliation(s)
- Martin Hübner
- Department of Visceral Surgery, Lausanne University Hospital CHUV, University of Lausanne (UNIL), Switzerland.
| | - Shigeki Kusamura
- Peritoneal Surface Malignancy Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Laurent Villeneuve
- Clinical Research and Epidemiological Unit, Department of Public Health, Lyon University Hospital, EA 3738, University of Lyon, Lyon, France
| | - Ahmed Al-Niaimi
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Wisconsin School of Medicine and Public Health, Madison, USA
| | - Mohammad Alyami
- Department of General Surgery and Surgical Oncology, King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia
| | - Konstantin Balonov
- Department of Anesthesiology and Perioperative Medicine, Tufts Medical Center, Boston, USA
| | - John Bell
- Department of Anesthesiology, Basingstoke and North Hampshire Hospital, Basingstoke, UK
| | - Robert Bristow
- Department of Obstetrics and Gynecologic Oncology, University of California, Irvine School of Medicine, Orange, USA
| | - Delia Cortés Guiral
- Department of General Surgery (Peritoneal Surface Surgical Oncology). University Hospital Principe de Asturias, Alcalá de Henares, Madrid, Spain
| | - Anna Fagotti
- Fondazione Policlinico Universitario Agostino Gemelli, IRCCS, Catholic University of the Sacred Heart, 00168, Rome, Italy
| | - Luiz Fernando R Falcão
- Discipline of Anesthesiology, Pain and Critical Care Medicine, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Olivier Glehen
- Department of Digestive Surgery, Lyon University Hospital, EA 3738, University of Lyon, Lyon, France
| | - Laura Lambert
- Peritoneal Surface Malignancy Program, Section of Surgical Oncology, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, USA
| | - Lloyd Mack
- Department of Surgical Oncology, University of Calgary, Calgary, Alberta, Canada
| | - Tino Muenster
- Department of Anaesthesiology and Intensive Care Medicine. Hospital Barmherzige Brüder, Regensburg, Germany
| | - Pompiliu Piso
- Department of General and Visceral Surgery, Hospital Barmherzige Brüder, Regensburg, Germany
| | - Marc Pocard
- Department of Digestive Surgery, Lariboisière University Hospital, Paris, France
| | - Beate Rau
- Department of Surgery, Campus Virchow-Klinikum and Charité Campus Mitte, Charité-Universitätsmedizin Berlin, Germany
| | - Olivia Sgarbura
- Department of Surgical Oncology, Cancer Institute Montpellier (ICM), University of Montpellier, Montpellier, France
| | - S P Somashekhar
- Department of Surgical Oncology, Manipal Comprehensive Cancer Centre, Manipal Hospital, Bengaluru, India
| | - Anupama Wadhwa
- Department of Anesthesiology, University of California San Diego, La Jolla, CA, USA
| | - Alon Altman
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Manitoba, Winnipeg, Canada
| | - William Fawcett
- Anaesthesia and Pain Medicine, Royal Surrey County Hospital NHS Foundation Trust, Guildford, UK
| | - Jula Veerapong
- Department of Surgery, Division of Surgical Oncology, University of California San Diego, La Jolla, CA, USA
| | - Gregg Nelson
- Division of Gynecologic Oncology, Tom Baker Cancer Centre, University of Calgary, Calgary, Alberta, Canada
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13
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Leal-Noval SR, Fernández Pacheco J, Casado Méndez M, Cuenca-Apolo D, Múñoz-Gómez M. Current perspective on fibrinogen concentrate in critical bleeding. Expert Rev Clin Pharmacol 2020; 13:761-778. [PMID: 32479129 DOI: 10.1080/17512433.2020.1776608] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
INTRODUCTION . Massive hemorrhage continues to be a treatable cause of death. Its management varies from prefixed ratio-driven administration of blood components to goal-directed therapy based on point-of-care testing and administration of coagulation factor concentrates. AREAS COVERED . We review the current role of fibrinogen concentrate (FC) for the management of massive hemorrhage, either administered without coagulation testing in life-threatening hemorrhage, or within an algorithm based on viscoelastic hemostatic assays and plasma fibrinogen level. We identified relevant guidelines, meta-analyzes, randomized controlled trials, and observational studies that included indications, dosage, and adverse effects of FC, especially thromboembolic events. EXPERT OPINION . Moderate- to high-grade evidence supports the use of FC for the treatment of severe hemorrhage in trauma and cardiac surgery; a lower grade of evidence is available for its use in postpartum hemorrhage and end-stage liver disease. Pre-emptive FC administration in non-bleeding patients is not recommended. FC should be administered early, in a goal-directed manner, guided by early amplitude of clot firmness parameters (A5- or A10-FIBTEM) or hypofibrinogenemia. Further investigation is required into the early use of FC, as well as its potential advantages over cryoprecipitate, and whether or not its administration at high doses leads to a greater risk of adverse events.
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Affiliation(s)
- Santiago R Leal-Noval
- Neuro Critical Care Department, University Hospital "Virgen Del Rocío" and Institute of Biomedicine "IBIS" , 41013, Seville, Spain
| | - Jose Fernández Pacheco
- Pharmacy and Statistics and Design, University Hospital "Virgen Del Rocío" and Institute of Biomedicine "IBIS" , 41013, Seville, Spain
| | - Manuel Casado Méndez
- Critical Care Department, University Hospital "Virgen Del Rocío" and Institute of Biomedicine "IBIS" , 41013, Seville, Spain
| | - Diego Cuenca-Apolo
- Critical Care Department, University Hospital "Virgen Del Rocío" and Institute of Biomedicine "IBIS" , 41013, Seville, Spain
| | - Manuel Múñoz-Gómez
- Department of Surgical Specialties, Biochemistry and Immunology, University of Málaga , 29071, Málaga, Spain
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14
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Superior Survival Outcomes of a Polyethylene Glycol-20k Based Resuscitation Solution in a Preclinical Porcine Model of Lethal Hemorrhagic Shock. Ann Surg 2020; 275:e716-e724. [PMID: 32773641 DOI: 10.1097/sla.0000000000004070] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To compare early outcomes and 24-hour survival after LVR with the novel polyethylene glycol-20k-based crystalloid (PEG-20k), WB, or hextend in a preclinical model of lethal HS. BACKGROUND Posttraumatic HS is a major cause of preventable death. Current resuscitation strategies focus on restoring oxygen-carrying capacity (OCC) and coagulation with blood products. Our lab shows that PEG-20k is an effective non-sanguineous, LVR solution in acute models of HS through mechanisms targeting cell swelling-induced microcirculatory failure. METHODS Male pigs underwent splenectomy followed by controlled hemorrhage until lactate reached 7.5-8.5 mmol/L. They were randomized to receive LVR with PEG-20k, WB, or Hextend. Surviving animals were recovered 4 hours post-LVR. Outcomes included 24-hour survival rates, mean arterial pressure, lactate, hemoglobin, and estimated intravascular volume changes. RESULTS Twenty-four-hour survival rates were 100%, 16.7%, and 0% in the PEG-20k, WB, and Hextend groups, respectively (P = 0.001). PEG-20k significantly restored mean arterial press, intravascular volume, and capillary perfusion to baseline, compared to other groups. This caused complete lactate clearance despite decreased OCC. Neurological function was normal after next-day recovery in PEG-20k resuscitated pigs. CONCLUSION Superior early and 24-hour outcomes were observed with PEG-20k LVR compared to WB and Hextend in a preclinical porcine model of lethal HS, despite decreased OCC from substantial volume-expansion. These findings demonstrate the importance of enhancing microcirculatory perfusion in early resuscitation strategies.
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15
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Mortality in civilian trauma patients and massive blood transfusion treated with high vs low plasma: red blood cell ratio. Systematic review and meta-analysis. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2020. [DOI: 10.1097/cj9.0000000000000161] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Introduction: Massive bleeding in civilian trauma patients leads to dilutional coagulopathy. Transfusion with high plasma: red blood cell (RBC) ratio has been effective in reducing mortality in war trauma patients. However, in civilian trauma the evidence is controversial.
Objective: To assess the impact on mortality of high vs low plasma: RBC ratio transfusion, in civilian trauma patients with massive bleeding.
Methods: A systematic review and meta-analysis, including observational studies and clinical trials, was conducted. Databases were systemically searched for relevant studies between January 2007 and June 2019. The main outcome was early (24-hours) and late (30-day) mortality. Fixed and random effects models were used.
Results: Out of 1295 studies identified, 33 were selected: 2 clinical trials and 31 observational studies. The analysis of observational trials showed both decreased early mortality (odds ratio [OR] 0.67; 95% confidence interval [CI], 0.60–0.75) and late mortality (OR 0.79; 95% CI, 0.71–0.87) with the use of high plasma:RBC ratio transfusion, but there were no differences when clinical trials were evaluated (OR 0.89; 95% CI, 0.64–1.26). The exclusion of patients who died within the first 24hours was a source of heterogeneity. The Injury Severity Score (ISS) altered the association between high plasma: RBC ratio and mortality, with a reduced protective effect when the ISS was high.
Conclusion: The use of high vs low plasma: RBC ratio transfusion, in patients with massive bleeding due to civil trauma, has a protective effect on early and late mortality in observational studies. The exclusion of patients who died within the first 24 hours was a source of heterogeneity.
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16
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Deleu F, Deneux-Tharaux C, Chiesa-Dubruille C, Seco A, Bonnet M. A population-based analysis of French transfusion practices for women experiencing severe postpartum hemorrhage. Int J Obstet Anesth 2020; 42:11-19. [DOI: 10.1016/j.ijoa.2019.07.006] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2018] [Revised: 06/28/2019] [Accepted: 07/15/2019] [Indexed: 01/01/2023]
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17
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Abstract
Health care professionals must understand the impact of blood product transfusions and transfusion therapy procedures to ensure high-quality patient care, positive outcomes, and wise use of resources in blood management programs. Understanding transfusions of blood and blood products is also important because of the number of treatments performed, which affects individual patients and health care system resources. This article reviews research findings to acquaint health care professionals with the most successful protocols for blood, blood product, and coagulation factor transfusions. Damage control resuscitation in bleeding trauma patients, protocols for patients without trauma who are undergoing surgical procedures that place them at risk for excessive bleeding, and protocols for patients with sepsis are addressed. Emerging research continues to help guide mass transfusion treatments (restrictive vs liberal, balanced, and goal-directed treatment). Although available study results provide some guidance, questions remain. Additional research by health care professionals is needed.
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Affiliation(s)
- Heather M Passerini
- Heather M. Passerini is Nurse Practitioner, Surgical and Trauma Intensive Care Unit, University of Virginia Medical Center, PO Box 801443, Charlottesville, VA 22908-1443
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18
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da Luz LT, Shah PS, Strauss R, Mohammed AA, D'Empaire PP, Tien H, Nathens AB, Nascimento B. Does the evidence support the importance of high transfusion ratios of plasma and platelets to red blood cells in improving outcomes in severely injured patients: a systematic review and meta-analyses. Transfusion 2019; 59:3337-3349. [PMID: 31614006 PMCID: PMC6900194 DOI: 10.1111/trf.15540] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Revised: 08/13/2019] [Accepted: 08/21/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND Deaths by exsanguination in trauma are preventable with hemorrhage control and resuscitation with allogeneic blood products (ABPs). The ideal transfusion ratio is unknown. We compared efficacy and safety of high transfusion ratios of FFP:RBC and PLT:RBC with low ratios in trauma. STUDY DESIGN AND METHODS Medline, Embase, Cochrane, and Controlled Clinical Trials Register were searched. Observational and randomized data were included. Risk of bias was assessed using validated tools. Primary outcome was 24-h and 30-day mortality. Secondary outcomes were exposure to ABPs and improvement of coagulopathy. Meta-analysis was conducted using a random-effects model. Strength and evidence quality were graded using GRADE profile RESULTS: 55 studies were included (2 randomized and 53 observational), with low and moderate risk of bias, respectively, and overall low evidence quality. The two RCTs showed no mortality difference (odds ratio [OR], 1.35; 95% confidence interval [CI], 0.40-4.59). Observational studies reported lower mortality in high FFP:RBCs ratio (OR, 0.38 [95% CI, 0.22-0.68] for 1:1 vs. <1:1; OR, 0.42 [95% CI, 0.22-0.81] for 1:1.5 vs. <1:1.5; and OR, 0.47 [95% CI, 0.31-0.71] for 1:2 vs. <1:2, respectively). Meta-analyses in observational studies showed no difference in exposure to ABPs. No data on coagulopathy for meta-analysis was identified. CONCLUSIONS Meta-analyses in observational studies suggest survival benefit and no difference in exposure to ABPs. No survival benefit in RCTs was identified. These conflicting results should be interpreted with caution. Studies are mostly observational, with relatively small sample sizes, nonrandom treatment allocation, and high potential for confounding. Further research is warranted.
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Affiliation(s)
| | - Prakesh S. Shah
- Department of PediatricsMount Sinai HospitalTorontoOntarioCanada
| | - Rachel Strauss
- Department SurgerySunnybrook Health Sciences CentreTorontoOntarioCanada
| | | | - Pablo Perez D'Empaire
- Department Anesthesia, Sunnybrook Health Sciences CentreUniversity of TorontoTorontoOntarioCanada
| | - Homer Tien
- Department SurgerySunnybrook Health Sciences CentreTorontoOntarioCanada
| | - Avery B. Nathens
- Department SurgerySunnybrook Health Sciences CentreTorontoOntarioCanada
| | - Barto Nascimento
- Department SurgerySunnybrook Health Sciences CentreTorontoOntarioCanada
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19
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Roquet F, Neuschwander A, Hamada S, Favé G, Follin A, Marrache D, Cholley B, Pirracchio R. Association of Early, High Plasma-to-Red Blood Cell Transfusion Ratio With Mortality in Adults With Severe Bleeding After Trauma. JAMA Netw Open 2019; 2:e1912076. [PMID: 31553473 PMCID: PMC6763975 DOI: 10.1001/jamanetworkopen.2019.12076] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
IMPORTANCE Optimal transfusion management is crucial when treating patients with trauma. However, the association of an early, high transfusion ratio of fresh frozen plasma (FFP) to packed red blood cells (PRBC) with survival remains uncertain. OBJECTIVE To study the association of an early, high FFP-to-PRBC ratio with all-cause 30-day mortality in patients with severe bleeding after trauma. DESIGN, SETTING, AND PARTICIPANTS This cohort study analyzes the data included in a multicenter national French trauma registry, Traumabase, from January 2012 to July 2017. Traumabase is a prospective, active, multicenter adult trauma registry that includes all consecutive patients with trauma treated at 15 trauma centers in France. Overall, 897 patients with severe bleeding after trauma were identified using the following criteria: (1) received 4 or more units of PRBC during the first 6 hours or (2) died from hemorrhagic shock before receiving 4 units of PRBC. EXPOSURES Eligible patients were divided into a high-ratio group, defined as an FFP-to-PRBC ratio more than 1:1.5, and a low-ratio group, defined as an FFP-to-PRBC ratio of 1:1.5 or less. The ratio was calculated using the cumulative units of FFP and PRBC received during the first 6 hours of management. MAIN OUTCOMES AND MEASURES A Cox regression model was used to analyze 30-day survival with the transfusion ratio as a time-dependent variable to account for survivorship bias. RESULTS Of the 12 217 patients included in the registry, 897 (7.3%) were analyzed (median [interquartile range] age, 38 (29-54) years; 639 [71.2%] men). The median (interquartile range) injury severity score was 34 (22-48), and the overall 30-day mortality rate was 33.6% (301 patients). A total of 506 patients (56.4%) underwent transfusion with a high ratio and 391 (43.6%) with a low ratio. A high transfusion ratio was associated with a significant reduction in 30-day mortality (hazard ratio, 0.74; 95% CI, 0.58-0.94; P = .01). When only analyzing patients who had complete data, a high transfusion ratio continued to be associated with a reduction in 30-day mortality (hazard ratio, 0.57; 95% CI, 0.33-0.97; P = .04). CONCLUSIONS AND RELEVANCE In this analysis of the Traumabase registry, an early FFP-to-PRBC ratio of more than 1:1.5 was associated with increased 30-day survival among patients with severe bleeding after trauma. This result supports the use of early, high FFP-to-PRBC transfusion ratios in patients with severe trauma.
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Affiliation(s)
- Florian Roquet
- Service d’Anesthésie-réanimation, Hôpital Européen Georges-Pompidou, Assistance Publique–Hôpitaux de Paris, Paris, France
- Service de Biostatistique et Informatique Médicale, Unité INSERM UMR 1153, Université Paris Diderot, Paris, France
| | - Arthur Neuschwander
- Service d’Anesthésie-réanimation, Hôpital Européen Georges-Pompidou, Assistance Publique–Hôpitaux de Paris, Paris, France
| | - Sophie Hamada
- Service d’Anesthésie-réanimation, Centre Hospitalier Universitaire Bicêtre, Université Paris Sud, Assistance Publique–Hôpitaux de Paris, Le Kremlin Bicêtre, France
| | - Gersende Favé
- Service d’Anesthésie-réanimation, Hôpital Européen Georges-Pompidou, Assistance Publique–Hôpitaux de Paris, Paris, France
| | - Arnaud Follin
- Service d’Anesthésie-réanimation, Hôpital Européen Georges-Pompidou, Assistance Publique–Hôpitaux de Paris, Paris, France
| | - David Marrache
- Service d’Anesthésie-réanimation, Hôpital Européen Georges-Pompidou, Assistance Publique–Hôpitaux de Paris, Paris, France
| | - Bernard Cholley
- Service d’Anesthésie-réanimation, Hôpital Européen Georges-Pompidou, Assistance Publique–Hôpitaux de Paris, Paris, France
| | - Romain Pirracchio
- Service d’Anesthésie-réanimation, Hôpital Européen Georges-Pompidou, Assistance Publique–Hôpitaux de Paris, Paris, France
- Service de Biostatistique et Informatique Médicale, Unité INSERM UMR 1153, Université Paris Diderot, Paris, France
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20
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Seheult JN, Shaz B, Bravo M, Croxon H, Devine D, Doncaster C, Field S, Flanagan P, Germain M, Grégoire Y, Kamel H, Karafin M, Kelting N, Lewis M, O'Brien C, Murphy MF, Rossmann S, Sayers M, Shinar E, Takanashi M, Titlestad K, Yazer MH. Changes in plasma unit distributions to hospitals over a 10-year period. Transfusion 2018; 58:1012-1020. [PMID: 29405302 DOI: 10.1111/trf.14526] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Revised: 12/20/2017] [Accepted: 12/20/2017] [Indexed: 11/28/2022]
Abstract
BACKGROUND There are many influences on a hospital's demand for plasma. Pharmaceuticals are now being administered for many indications instead of plasma, although trauma resuscitation now emphasizes increased and early intervention with plasma. This multinational study evaluated changes in blood center plasma unit distributions over a 10-year period. STUDY DESIGN AND METHODS Data on the total number and the ABO groups of plasma unit distributions were obtained from nine American blood collectors (ABCs) and nine national or provincial blood services (NPBS) from 2007 through 2016. Plasma distributions to trauma hospitals by five ABCs and four NPBS were also analyzed. RESULTS The overall number of plasma unit distributions from ABCs decreased by 23.1% from 2007 to 2016, but the relative proportion of distributed AB plasma units increased during the same period. The NPBS (excluding the Japanese Red Cross [JRC]) also had a 35.4% decrease in the overall number of plasma unit distributions with an increase in the relative proportion of AB plasma distributions between 2007 and 2016. The JRC, however, reported an increase in the overall number of plasma distributions by 13.5% in 2016 compared to 2007. The proportion of low-titer A plasma distributions increased to 1.6% of total plasma distributions by ABCs in 2016. There was a trend of distributing increasing proportions of group AB plasma units to trauma hospitals over the 10-year period. CONCLUSION Although the number of plasma unit distributions has decreased at many blood collectors over time, the proportion of AB units has increased at both ABCs and NPBS.
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Affiliation(s)
- Jansen N Seheult
- Department of Pathology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Beth Shaz
- New York Blood Center, New York, New York
| | | | - Harry Croxon
- Irish Blood Transfusion Service, Dublin, Ireland
| | - Dana Devine
- Canadian Blood Services, Ottawa, Ontario, Canada
| | | | | | | | | | | | | | | | - Nancy Kelting
- Mississippi Valley Regional Blood Center, Davenport, Iowa
| | - Marc Lewis
- Gulf Coast Regional Blood Center, Houston, Texas
| | | | - Michael F Murphy
- NHS Blood & Transplant, and Oxford Biomedical Research Centre, Oxford, United Kingdom
| | | | | | - Eilat Shinar
- Magen David Adom, National Blood Services, Ramat Gan, Israel
| | | | | | - Mark H Yazer
- Department of Pathology, University of Pittsburgh, Pittsburgh, Pennsylvania.,The Institute for Transfusion Medicine, Pittsburgh, Pennsylvania
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