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Abstract
Traumatic hemorrhage is the leading cause of preventable death after trauma. Early transfusion of plasma and balanced transfusion have been shown to optimize survival, mitigate the acute coagulopathy of trauma, and restore the endothelial glycocalyx. There are a myriad of plasma formulations available worldwide, including fresh frozen plasma, thawed plasma, liquid plasma, plasma frozen within 24 h, and lyophilized plasma (LP). Significant equipoise exists in the literature regarding the optimal plasma formulation. LP is a freeze-dried formulation that was originally developed in the 1930s and used by the American and British military in World War II. It was subsequently discontinued due to risk of disease transmission from pooled donors. Recently, there has been a significant amount of research focusing on optimizing reconstitution of LP. Findings show that sterile water buffered with ascorbic acid results in decreased blood loss with suppression of systemic inflammation. We are now beginning to realize the creation of a plasma-derived formulation that rapidly produces the associated benefits without logistical or safety constraints. This review will highlight the history of plasma, detail the various types of plasma formulations currently available, their pathophysiological effects, impacts of storage on coagulation factors in vitro and in vivo, novel concepts, and future directions.
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Vogt KN, Van Koughnett JA, Dubois L, Gray DK, Parry NG. The use of trauma transfusion pathways for blood component transfusion in the civilian population: a systematic review and meta-analysis. Transfus Med 2012; 22:156-66. [PMID: 22486885 DOI: 10.1111/j.1365-3148.2012.01150.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
This study was undertaken to determine if, amongst civilian trauma patients requiring massive transfusion (MT), the use of a formal trauma transfusion pathway (TTP), in comparison with transfusion without a TTP, is associated with a reduction in mortality, or changes in indices of coagulation, blood product utilisation and complications. A systematic review of three bibliographic databases, reference lists and conference proceedings was conducted. Studies were included if comparisons were made between patients receiving transfusion with and without a TTP. Data were extracted by two independent reviewers on population characteristics, transfusion strategies, blood product utilisation, indices of coagulation, clinical outcomes and complications. Data were pooled using a random effects model and heterogeneity explored. Seven observational studies met all eligibility criteria. Amongst 1801 patients requiring MT, TTPs were associated with a significant reduction in mortality (RR 0·69, 95% CI 0·55, 0·87). No significant increase in the mean number of PRBC transfused between TTP and control patients was seen (MD -1·17 95% CI -2·70, 0·36). When studies assessing only trauma patients were considered, TTPs were associated with a reduction in the mean number of units of plasma transfused (MD -2·63, 95% CI -4·24, -1·01). In summary, the use of TTPs appears to be associated with a reduction in mortality amongst trauma patients requiring MT without a clinically significant increase in the number of PRBC transfused and a potential reduction in plasma transfusion. Effects of TTPs on platelet transfusion, indices of coagulation and complications remain unclear. A randomised controlled trial is warranted.
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Affiliation(s)
- K N Vogt
- Department of Surgery, Schulich School of Medicine & Dentistry, University of Western Ontario, Canada.
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Burruss S, Andakyan A, Romanov S, Semiletova N, Cryer H. Effect of protein C gene mutation on coagulation and inflammation in hemorrhagic shock. J Surg Res 2011; 175:18-23. [PMID: 21962741 DOI: 10.1016/j.jss.2011.06.055] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2011] [Revised: 03/16/2011] [Accepted: 06/22/2011] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Trauma patients are at high risk of complications and death from coagulopathy and inflammatory organ failure. Recent evidence implicates protein C (PC) as a key mediator of this process. We hypothesized that a mutation in the PC gene would ameliorate the inflammatory and coagulopathic response to hemorrhagic shock (HS) and resuscitation. METHODS FHH wild type and PC mutant rats underwent controlled hemorrhage for 120 min with 70% of blood volume removed. Rats were resuscitated with Ringers lactate (2x shed blood volume) and shed blood. Animals were sacrificed 4 h post-HS. Controls were untreated naïve rats. RESULTS AST and NFkB lung protein levels were elevated similarly in both WT and mutants compared with naïve rats. Plasma fibrinogen levels decreased significantly with progression of HS compared with baseline (BL) levels and returned towards normal 4 h after resuscitation. PC activity was similar in both groups at BL (0.5 ± 0.08 versus 0.6 ± 0.14; P = 0.14) and decreased from BL by 53% ± 24% in WT (P =0.08), by 67% ± 11% in mutants (P = 0.03) at sacrifice, and was not different between groups (P = 0.29). CONCLUSIONS Our model of HS and resuscitation produced a hypocoaguable, hyperinflammatory state with increased levels of NFkB and decreased levels of fibrinogen and PC levels. The mutated PC did not appear to alter these responses in our model of HS and resuscitation.
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Affiliation(s)
- Sigrid Burruss
- Department of Surgery, University of California, Los Angeles, California, USA
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ZHANG CF, TAN T, LI JG, MA HY, CHEN ZC, DUAN CJ. Effect of Fresh Frozen Plasma on Endothelial Cell Migration Diminishes During Storage and Its Molecular Mechanisms*. PROG BIOCHEM BIOPHYS 2011. [DOI: 10.3724/sp.j.1206.2010.00596] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Duan C, Cao Y, Deng X, Wang W, Yang W, Liu X, Chen Z, Pati S, Kozar RA, Gonzalez EA, Wade CE, Holcomb JB, Ko TC. Increased transforming growth factor β contributes to deterioration of refrigerated fresh frozen plasma's effects in vitro on endothelial cells. Shock 2011; 36:54-9. [PMID: 21330944 PMCID: PMC3763495 DOI: 10.1097/shk.0b013e318214475e] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Resuscitation with fresh frozen plasma (FFP) is associated with improved outcomes after hemorrhagic shock. Many trauma centers are using thawed plasma that has been stored for up to 5 days at 4°C (refrigeration), yet the effect of refrigeration on FFP is relatively unknown. Previously, our group showed that refrigeration of FFP changed its coagulation factors and diminished its beneficial effects on endothelial cell (EC) function and resuscitation in an animal model of hemorrhagic shock. We hypothesize that growth factor composition of FFP is altered during refrigeration, leading to a diminished beneficial effect on EC. Transforming growth factor (TGF-β) is a potent inhibitor of EC migration and is released during refrigeration of platelets. We found increased TGF-β1 protein levels and greater activation of downstream mediators Smad2/3 during refrigeration of FFP. Both day 0 FFP (used on the same day after being thawed) and day 5 FFP (used after being thawed and refrigerated for 5 days) stimulated EC migration in vitro; however, the EC migration in day 5 FFP was significantly reduced. Inhibition of TGF-β type I receptor blocked FFP-induced Smad3 signaling in EC cells and restored the effectiveness of day 5 FFP on EC migration to a comparable level seen in day 0 FFP. These data suggest that the increased TGF-β levels during FFP refrigeration contribute to the deterioration of refrigerated FFP's effects on EC migration. This study identifies a novel molecular mechanism contributing to the reduced efficacy of refrigerated FFP.
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Affiliation(s)
- Chaojun Duan
- Department of Surgery, The University of Texas Health Science Center at Houston, Houston Texas 77030, USA
- Medical Research Center, Xiangya Hospital, Central South University, Changsha, Hunan 410008, China
| | - Yanna Cao
- Department of Surgery, The University of Texas Health Science Center at Houston, Houston Texas 77030, USA
| | - Xiyun Deng
- Department of Surgery, The University of Texas Health Science Center at Houston, Houston Texas 77030, USA
| | - Weiwei Wang
- Center for Translational Injury Research, The University of Texas Health Science Center at Houston, Houston Texas 77030, USA
| | - Wenli Yang
- Department of Surgery, The University of Texas Health Science Center at Houston, Houston Texas 77030, USA
| | - Xianghua Liu
- Department of Surgery, The University of Texas Health Science Center at Houston, Houston Texas 77030, USA
| | - Zhuchu Chen
- Medical Research Center, Xiangya Hospital, Central South University, Changsha, Hunan 410008, China
| | - Shibani Pati
- Department of Surgery, The University of Texas Health Science Center at Houston, Houston Texas 77030, USA
- Center for Translational Injury Research, The University of Texas Health Science Center at Houston, Houston Texas 77030, USA
| | - Rosemary A. Kozar
- Department of Surgery, The University of Texas Health Science Center at Houston, Houston Texas 77030, USA
- Center for Translational Injury Research, The University of Texas Health Science Center at Houston, Houston Texas 77030, USA
| | - Ernest A. Gonzalez
- Department of Surgery, The University of Texas Health Science Center at Houston, Houston Texas 77030, USA
- Department of Surgery, University of Texas Southwestern at Austin, Austin Texas 78701
| | - Charles E. Wade
- Department of Surgery, The University of Texas Health Science Center at Houston, Houston Texas 77030, USA
- Center for Translational Injury Research, The University of Texas Health Science Center at Houston, Houston Texas 77030, USA
| | - John B. Holcomb
- Department of Surgery, The University of Texas Health Science Center at Houston, Houston Texas 77030, USA
- Center for Translational Injury Research, The University of Texas Health Science Center at Houston, Houston Texas 77030, USA
| | - Tien C. Ko
- Department of Surgery, The University of Texas Health Science Center at Houston, Houston Texas 77030, USA
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Cheynel N, Gentil J, Freitz M, Rat P, Ortega Deballon P, Bonithon Kopp C. Abdominal and Pelvic Injuries Caused by Road Traffic Accidents: Characteristics and Outcomes in a French Cohort of 2,009 Casualties. World J Surg 2011; 35:1621-5. [DOI: 10.1007/s00268-011-1136-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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de Lloyd L, Bovington R, Kaye A, Collis R, Rayment R, Sanders J, Rees A, Collins P. Standard haemostatic tests following major obstetric haemorrhage. Int J Obstet Anesth 2011; 20:135-41. [DOI: 10.1016/j.ijoa.2010.12.002] [Citation(s) in RCA: 137] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2010] [Revised: 10/15/2010] [Accepted: 12/14/2010] [Indexed: 11/25/2022]
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Surgical intensive care unit--the trauma surgery perspective. Langenbecks Arch Surg 2011; 396:429-46. [PMID: 21369845 DOI: 10.1007/s00423-011-0765-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2011] [Accepted: 02/21/2011] [Indexed: 01/04/2023]
Abstract
PURPOSE This review addresses and summarizes the key issues and unique specific intensive care treatment of adult patients from the trauma surgery perspective. MATERIALS AND METHODS The cornerstones of successful surgical intensive care management are fluid resuscitation, transfusion protocol and extracorporeal organ replacement therapies. The injury-type specific complications and unique pathophysiologic regulatory mechanisms of the traumatized patients influencing the critical care treatment are discussed. CONCLUSIONS Furthermore, the fundamental knowledge of the injury severity, understanding of the trauma mechanism, surgical treatment strategies and specific techniques of surgical intensive care are pointed out as essentials for a successful intensive care therapy.
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Protective effects of fresh frozen plasma on vascular endothelial permeability, coagulation, and resuscitation after hemorrhagic shock are time dependent and diminish between days 0 and 5 after thaw. ACTA ACUST UNITED AC 2010; 69 Suppl 1:S55-63. [PMID: 20622621 DOI: 10.1097/ta.0b013e3181e453d4] [Citation(s) in RCA: 108] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Clinical studies have shown that resuscitation with fresh frozen plasma (FFP) is associated with improved outcome after severe hemorrhagic shock (HS). We hypothesized that in addition to its effects on hemostasis, FFP has protective and stabilizing effects on the endothelium that translate into diminished endothelial cell (EC) permeability and improved resuscitation in vivo after HS. We further hypothesized that the beneficial effects of FFP would diminish over 5 days of routine storage at 4 degrees C. METHODS EC permeability was induced by hypoxia and assessed by the passage of 70-kDa Dextran between monolayers. Thrombin generation time and coagulation factor levels or activity were assessed in FFP. An in vivo rat model of HS and resuscitation was used to determine the effects of FFP on hemodynamic stability. RESULTS Thawed FFP inhibits EC permeability in vitro by 10.2-fold. Protective effects diminish (to 2.5-fold) by day 5. Thrombin generation time is increased in plasma that has been stored between days 0 and 5. In vivo data show that day 0 FFP is superior to day 5 FFP in maintaining mean arterial pressure in rats undergoing HS with resuscitation. CONCLUSION Both in vitro and in vivo studies show that FFP has beneficial effects on endothelial permeability, vascular stability, and resuscitation in rats after HS. The benefits are independent of hemostasis and diminish between days 0 and 5 of storage.
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Sandadi S, Johannigman JA, Wong VL, Blebea J, Altose MD, Hurd WW. Recognition and management of major vessel injury during laparoscopy. J Minim Invasive Gynecol 2010; 17:692-702. [PMID: 20656569 DOI: 10.1016/j.jmig.2010.06.005] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2010] [Revised: 06/02/2010] [Accepted: 06/09/2010] [Indexed: 01/05/2023]
Abstract
Laparoscopy is one of the most commonly performed procedures in the United States. Injury to a major retroperitoneal vessel occurs in 0.3% to 1.0% of procedures, most commonly during laparoscopic entry while placing the Veress needle or primary trocar. Fatal outcome can be related to massive gas embolism or exsanguination. Recommended treatment for gas embolism can range from supportive measures to external chest compression and insertion of a central line to withdraw gas from the right side of the heart. Recommended treatment of major vessel injury with massive hemorrhage consists of rapid laparotomy and control of hemorrhage using direct pressure until a surgeon experienced in vascular procedures arrives. When a major vessel injury occurs in a surgical facility distant from a medical center and without an available surgeon with vascular experience, based on the trauma literature, we recommend temporary control of blood loss using abdominal packing and closure (i.e., "damage control surgery") and judicious resuscitation (i.e., "damage control resuscitation") before transportation to a medical center.
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Affiliation(s)
- Samith Sandadi
- Department of Obstetrics and Gynecology, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
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Current world literature. Curr Opin Anaesthesiol 2010; 23:283-93. [PMID: 20404787 DOI: 10.1097/aco.0b013e328337578e] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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