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Jehan F, Zangbar B, Rafieezadeh A, Shnaydman I, Klein J, Con J, Prabhakaran K. Is there a need for fresh frozen plasma and platelet transfusion in trauma patients receiving submassive transfusion? Trauma Surg Acute Care Open 2024; 9:e001310. [PMID: 38737815 PMCID: PMC11086383 DOI: 10.1136/tsaco-2023-001310] [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: 11/20/2023] [Accepted: 04/09/2024] [Indexed: 05/14/2024] Open
Abstract
Background Blood transfusions have become a vital intervention in trauma care. There are limited data on the safety and effectiveness of submassive transfusion (SMT), that is defined as receiving less than 10 units packed red blood cells (PRBCs) in the first 24 hours. This study aimed to evaluate the efficacy and safety of fresh frozen plasma (FFP) and platelet transfusions in patients undergoing SMT. Methods This is a retrospective cohort, reviewing the Trauma Quality Improvement Program database spanning 3 years (2016 to 2018). Adult patients aged 18 years and older who had received at least 1 unit of PRBC within 24 hours were included in the study. We used a multivariate regression model to analyze the cut-off units of combined resuscitation (CR) (which included PRBCs along with at least one unit of FFP and/or platelets) that leads to survival improvement. Patients were then stratified into two groups: those who received PRBC alone and those who received CR. Propensity score matching was performed in a 1:1 ratio. Results The study included 85 234 patients. Based on the multivariate regression model, transfusion of more than 3 units of PRBC with at least 1 unit of FFP and/or platelets demonstrated improved mortality compared with PRBC alone. Among 66 319 patients requiring SMT and >3 units of PRBCs, 25 978 received PRBC alone, and 40 341 received CR. After propensity matching, 4215 patients were included in each group. Patients administered CR had a lower rate of complications (15% vs 26%), acute respiratory distress syndrome (3% vs 5%) and acute kidney injury (8% vs 11%). Rates of sepsis and venous thromboembolism were similar between the two groups. Multivariate regression analysis indicated that patients receiving 4 to 7 units of PRBC alone had significantly higher ORs for mortality than those receiving CR. Conclusion Trauma patients requiring more than 3 units of PRBCs who received CR with FFP and platelets experienced improved survival and reduced complications. Level of evidence Level III retrospective study.
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Affiliation(s)
- Faisal Jehan
- Surgery, Westchester Medical Center, Valhalla, New York, USA
| | - Bardiya Zangbar
- Surgery, Westchester Medical Center, Valhalla, New York, USA
| | | | - Ilya Shnaydman
- Surgery, Westchester Medical Center, Valhalla, New York, USA
| | - Joshua Klein
- Surgery, Westchester Medical Center, Valhalla, New York, USA
| | - Jorge Con
- Surgery, Westchester Medical Center, Valhalla, New York, USA
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Cornelius B, Thompson D, Kilgore P, Cvek U, Trutschl M, Samra N, Cornelius A. Air Medical Blood Transfusion as a Trigger of Massive Transfusion Protocol. Air Med J 2023; 42:353-357. [PMID: 37716807 PMCID: PMC10540275 DOI: 10.1016/j.amj.2023.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Revised: 04/19/2023] [Accepted: 05/14/2023] [Indexed: 09/18/2023]
Abstract
Air medical services can improve access to blood products at the point of injury. Studies have shown that early activation of mass transfusion protocols (MTPs) can improve the survival of trauma patients by up to 25%. There are several scoring systems to guide early activation, but the use of a single criterion has been elusive. Our study sought to determine if air medical administration of blood products was a risk factor for massive transfusion activation and utilization of prehospital vital signs for calculation of the shock index. In our retrospective study, we evaluated adult trauma patients transfused by helicopter emergency medical services (HEMS) and as a control all patients in our institution receiving the MTP. Our study found HEMS blood transfusion was not a reliable trigger for MTP, although the sample size may have limited our findings. We found that HEMS care resulted in an overall reduction in the volume of transfusion and an improvement in hemodynamic parameters upon trauma center arrival. HEMS transfusion and a higher rate of tranexamic acid administration may have contributed to these findings. Of note, the assessment of blood consumption score and shock index were nonspecific in the study populations.
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Affiliation(s)
- Brian Cornelius
- Graduate Program in Nurse Anesthesia, Texas Wesleyan University, Fort Worth, TX; Department of Anesthesia, John Peter Smith Hospital, Fort Worth, TX; Department of Anesthesia, Ochsner LSU Health, Shreveport, LA.
| | - Dennis Thompson
- Department of Emergency Medicine, Louisiana State University Health Sciences Center, Shreveport, LA
| | - Phillip Kilgore
- Laboratory for Advanced Biomedical Informatics, Department of Computer Science, Louisiana State University Shreveport, LA
| | - Urska Cvek
- Laboratory for Advanced Biomedical Informatics, Department of Computer Science, Louisiana State University Shreveport, LA
| | - Marjan Trutschl
- Laboratory for Advanced Biomedical Informatics, Department of Computer Science, Louisiana State University Shreveport, LA
| | - Navdeep Samra
- Department of Trauma and Surgical Critical Care, Louisiana State University Health Sciences Center, Shreveport, LA
| | - Angela Cornelius
- Department of Emergency Medicine, Louisiana State University Health Sciences Center, Shreveport, LA; Department of Emergency Medicine, John Peter Smith Hospital, Fort Worth, TX
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Thau MR, Liu T, Sathe NA, O’Keefe GE, Robinson BRH, Bulger E, Wade CE, Fox EE, Holcomb JB, Liles WC, Stanaway IB, Mikacenic C, Wurfel MM, Bhatraju PK, Morrell ED. Association of Trauma Molecular Endotypes With Differential Response to Transfusion Resuscitation Strategies. JAMA Surg 2023; 158:728-736. [PMID: 37099286 PMCID: PMC10134038 DOI: 10.1001/jamasurg.2023.0819] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Accepted: 12/12/2022] [Indexed: 04/27/2023]
Abstract
Importance It is not clear which severely injured patients with hemorrhagic shock may benefit most from a 1:1:1 vs 1:1:2 (plasma:platelets:red blood cells) resuscitation strategy. Identification of trauma molecular endotypes may reveal subgroups of patients with differential treatment response to various resuscitation strategies. Objective To derive trauma endotypes (TEs) from molecular data and determine whether these endotypes are associated with mortality and differential treatment response to 1:1:1 vs 1:1:2 resuscitation strategies. Design, Setting, and Participants This was a secondary analysis of the Pragmatic, Randomized Optimal Platelet and Plasma Ratios (PROPPR) randomized clinical trial. The study cohort included individuals with severe injury from 12 North American trauma centers. The cohort was taken from the participants in the PROPPR trial who had complete plasma biomarker data available. Study data were analyzed on August 2, 2021, to October 25, 2022. Exposures TEs identified by K-means clustering of plasma biomarkers collected at hospital arrival. Main Outcomes and Measures An association between TEs and 30-day mortality was tested using multivariable relative risk (RR) regression adjusting for age, sex, trauma center, mechanism of injury, and injury severity score (ISS). Differential treatment response to transfusion strategy was assessed using an RR regression model for 30-day mortality by incorporating an interaction term for the product of endotype and treatment group adjusting for age, sex, trauma center, mechanism of injury, and ISS. Results A total of 478 participants (median [IQR] age, 34.5 [25-51] years; 384 male [80%]) of the 680 participants in the PROPPR trial were included in this study analysis. A 2-class model that had optimal performance in K-means clustering was found. TE-1 (n = 270) was characterized by higher plasma concentrations of inflammatory biomarkers (eg, interleukin 8 and tumor necrosis factor α) and significantly higher 30-day mortality compared with TE-2 (n = 208). There was a significant interaction between treatment arm and TE for 30-day mortality. Mortality in TE-1 was 28.6% with 1:1:2 treatment vs 32.6% with 1:1:1 treatment, whereas mortality in TE-2 was 24.5% with 1:1:2 treatment vs 7.3% with 1:1:1 treatment (P for interaction = .001). Conclusions and Relevance Results of this secondary analysis suggest that endotypes derived from plasma biomarkers in trauma patients at hospital arrival were associated with a differential response to 1:1:1 vs 1:1:2 resuscitation strategies in trauma patients with severe injury. These findings support the concept of molecular heterogeneity in critically ill trauma populations and have implications for tailoring therapy for patients at high risk for adverse outcomes.
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Affiliation(s)
- Matthew R. Thau
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle
- Sepsis Center of Research Excellence—University of Washington (SCORE-UW), Seattle
| | - Ted Liu
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle
| | - Neha A. Sathe
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle
- Sepsis Center of Research Excellence—University of Washington (SCORE-UW), Seattle
| | - Grant E. O’Keefe
- Sepsis Center of Research Excellence—University of Washington (SCORE-UW), Seattle
- Department of Surgery, University of Washington, Seattle
| | | | - Eileen Bulger
- Department of Surgery, University of Washington, Seattle
| | - Charles E. Wade
- Center for Translational Injury Research, Division of Acute Care Surgery, Department of Surgery, University of Texas Health Science Center, Houston
| | - Erin E. Fox
- Center for Translational Injury Research, Division of Acute Care Surgery, Department of Surgery, University of Texas Health Science Center, Houston
| | | | - W. Conrad Liles
- Sepsis Center of Research Excellence—University of Washington (SCORE-UW), Seattle
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle
| | - Ian B. Stanaway
- Kidney Research Institute, University of Washington, Seattle
- Division of Nephrology, Department of Medicine, University of Washington, Seattle
| | - Carmen Mikacenic
- Sepsis Center of Research Excellence—University of Washington (SCORE-UW), Seattle
- Translational Immunology, Benaroya Research Institute, Seattle, Washington
| | - Mark M. Wurfel
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle
- Sepsis Center of Research Excellence—University of Washington (SCORE-UW), Seattle
| | - Pavan K. Bhatraju
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle
- Sepsis Center of Research Excellence—University of Washington (SCORE-UW), Seattle
| | - Eric D. Morrell
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle
- Sepsis Center of Research Excellence—University of Washington (SCORE-UW), Seattle
- Hospital and Specialty Medicine, VA Puget Sound Health Care System, Seattle, Washington
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Xu X, Zhang Y, Tang B, Yu X, Huang Y. Association between perioperative plasma transfusion and in-hospital mortality in patients undergoing surgeries without massive transfusion: A nationwide retrospective cohort study. Front Med (Lausanne) 2023; 10:1130359. [PMID: 36873874 PMCID: PMC9975265 DOI: 10.3389/fmed.2023.1130359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Accepted: 01/30/2023] [Indexed: 02/17/2023] Open
Abstract
Background An aggressive plasma transfusion is associated with a decreased mortality in traumatic patients requiring massive transfusion (MT). However, it is controversial whether non-traumatic or non-massively transfused patients can benefit from high doses of plasma. Methods We performed a nationwide retrospective cohort study using data from Hospital Quality Monitoring System, which collected anonymized inpatient medical records from 31 provinces in mainland China. We included the patients who had at least one record of surgical procedure and received red blood cell transfusion on the day of surgery from 2016 to 2018. We excluded those receiving MT or diagnosed with coagulopathy at admission. The exposure variable was the total volume of fresh frozen plasma (FFP) transfused, and the primary outcome was in-hospital mortality. The relationship between them was assessed using multivariable logistic regression model adjusting 15 potential confounders. Results A total of 69319 patients were included, and 808 died among them. A 100-ml increase in FFP transfusion volume was associated with a higher in-hospital mortality (odds ratio 1.05, 95% confidence interval 1.04-1.06, p < 0.001) after controlling for the confounders. FFP transfusion volume was also associated with superficial surgical site infection, nosocomial infection, prolonged length of hospital stay, ventilation time, and acute respiratory distress syndrome. The significant association between FFP transfusion volume and in-hospital mortality was extended to the subgroups of cardiac surgery, vascular surgery, and thoracic or abdominal surgery. Conclusions A higher volume of perioperative FFP transfusion was associated with an increased in-hospital mortality and inferior postoperative outcomes in surgical patients without MT.
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Affiliation(s)
- Xiaohan Xu
- Department of Anesthesiology, Chinese Academy of Medical Sciences & Peking Union Medical College Hospital, Beijing, China
| | - Yuelun Zhang
- Medical Research Center, Chinese Academy of Medical Sciences & Peking Union Medical College Hospital, Beijing, China
| | - Bo Tang
- Department of Anesthesiology, Chinese Academy of Medical Sciences & Peking Union Medical College Hospital, Beijing, China
| | - Xuerong Yu
- Department of Anesthesiology, Chinese Academy of Medical Sciences & Peking Union Medical College Hospital, Beijing, China
| | - Yuguang Huang
- Department of Anesthesiology, Chinese Academy of Medical Sciences & Peking Union Medical College Hospital, Beijing, China
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Lang E, Neuschwander A, Favé G, Abback PS, Esnault P, Geeraerts T, Harrois A, Hanouz JL, Kipnis E, Leone M, Legros V, Mellati N, Pottecher J, Hamada S, Pirracchio R. Clinical decision support for severe trauma patients: Machine learning based definition of a bundle of care for hemorrhagic shock and traumatic brain injury. J Trauma Acute Care Surg 2022; 92:135-143. [PMID: 34554136 DOI: 10.1097/ta.0000000000003401] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Deviation from guidelines is frequent in emergency situations, and this may lead to increased mortality. Probably because of time constraints, 55% is the greatest reported guidelines compliance rate in severe trauma patients. This study aimed to identify among all available recommendations a reasonable bundle of items that should be followed to optimize the outcome of hemorrhagic shocks (HSs) and severe traumatic brain injuries (TBIs). METHODS We first estimated the compliance with French and European guidelines using the data from the French TraumaBase registry. Then, we used a machine learning procedure to reduce the number of recommendations into a minimal set of items to be followed to minimize 7-day mortality. We evaluated the bundles using an external validation cohort. RESULTS This study included 5,924 trauma patients (1,414 HS and 4,955 TBI) between 2011 and August 2019 and studied compliance to 36 recommendation items. Overall compliance rate to recommendation items was 71.6% and 66.9% for HS and TBI, respectively. In HS, compliance was significantly associated with 7-day decreased mortality in univariate analysis but not in multivariate analysis (risk ratio [RR], 0.91; 95% confidence interval [CI], 0.90-1.17; p = 0.06). In TBI, compliance was significantly associated with decreased mortality in univariate and multivariate analysis (RR, 0.85; 95% CI, 0.75-0.92; p = 0.01). For HS, the bundle included 13 recommendation items. In the validation cohort, when this bundle was applied, patients were found to have a lower 7-day mortality rate (RR, 0.46; 95% CI, 0.27-0.63; p = 0.01). In TBI, the bundle included seven items. In the validation cohort, when this bundle was applied, patients had a lower 7-day mortality rate (RR, 0.55; 95% CI, 0.34-0.71; p = 0.02). DISCUSSION Using a machine-learning procedure, we were able to identify a subset of recommendations that minimizes 7-day mortality following traumatic HS and TBI. These two bundles remain to be evaluated in a prospective manner. LEVEL OF EVIDENCE Care Management, level II.
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Affiliation(s)
- Elodie Lang
- From the Department of Anesthesia and Critical Care Medicine, APHP Hopital Européen Georges Pompidou (E.L., A.N., G.F., S.H.); Department of Anesthesia and Critical Care Medicine, Hôpital Beaujon (P.S.A.), Clichy; Department of Anesthesia and Critical Care Medicine, Hia Sainte Anne (P.E.); Department of Anesthesia and Critical Care Medicine, Chu De Toulouse (T.G.), Toulouse; Department of Anesthesia and Critical Care Medicine, Chu De Bicêtre (A.H.), Le Kremlin Bicêtre France; Department of Anesthesia and Critical Care Medicine, Chu De Caen (J.-L.H.), Caen; Department of Anesthesia and Critical Care Medicine, Chu Lille (E.K.), Lille; Department of Anesthesia and Critical Care Medicine, Hopital Nord (M.L.), Marseille; Department of Anesthesia and Critical Care Medicine, Chu De Reims (V.L.), Reims; Department of Anesthesia and Critical Care Medicine, Chr Metz Thionville (N.M.), Metz; Department of Anesthesia and Critical Care Medicine, Chu Strasbourg (J.P.), Strasbourg, France; Department of Anesthesia and Critical Care Medicine, Zuckerberg San Francisco General Hospital and Trauma Center (R.P.), San Francisco, California
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Labarthe A, Mennecart T, Imfeld C, Lély P, Ausset S. Pre-hospital transfusion of post-traumatic hemorrhage: Medical and regulatory aspects. Transfus Clin Biol 2021; 28:391-396. [PMID: 34464713 DOI: 10.1016/j.tracli.2021.08.345] [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: 07/31/2021] [Accepted: 08/25/2021] [Indexed: 10/20/2022]
Abstract
Data of good methodological quality have recently become available to support prehospital use of transfusion in the severe trauma setting. Consistent with recent guidelines for the implementation of damage control resuscitation in the hospital in this setting and in the wake of numerous cohort study data from wartime medicine, they are now guided by recent guidelines for the use of freeze-dried plasma. The main difficulties to overcome in order to implement a practice are of a regulatory and logistic nature.
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Affiliation(s)
- A Labarthe
- French Military medical school, 331, avenue du Général-de-Gaulle, Bron, France
| | - T Mennecart
- French Military medical school, 331, avenue du Général-de-Gaulle, Bron, France
| | - C Imfeld
- French Military medical school, 331, avenue du Général-de-Gaulle, Bron, France
| | - P Lély
- French Military medical school, 331, avenue du Général-de-Gaulle, Bron, France
| | - S Ausset
- French Military medical school, 331, avenue du Général-de-Gaulle, Bron, France.
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7
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Sayce AC, Neal MD, Leeper CM. Viscoelastic monitoring in trauma resuscitation. Transfusion 2021; 60 Suppl 6:S33-S51. [PMID: 33089933 DOI: 10.1111/trf.16074] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 06/13/2020] [Accepted: 06/14/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND Traumatic injury results in both physical and physiologic insult. Successful care of the trauma patient depends upon timely correction of both physical and biochemical injury. Trauma-induced coagulopathy is a derangement of hemostasis and thrombosis that develops rapidly and can be fatal if not corrected. Viscoelastic monitoring (VEM) assays have been developed to provide rapid, accurate, and relatively comprehensive depictions of an individual's coagulation profile. VEM are increasingly being integrated into trauma resuscitation guidelines to provide dynamic and individualized guidance to correct coagulopathy. STUDY DESIGN AND METHODS We performed a narrative review of the search terms viscoelastic, thromboelastography, thromboelastometry, TEG, ROTEM, trauma, injury, resuscitation, and coagulopathy using PubMed. Particular focus was directed to articles describing algorithms for management of traumatic coagulopathy based on VEM assay parameters. RESULTS Our search identified 16 papers with VEM-guided resuscitation strategies in adult patients based on TEG, 12 such protocols in adults based on ROTEM, 1 protocol for children based on TEG, and 2 protocols for children based on ROTEM. CONCLUSIONS This review presents evidence to support VEM use to detect traumatic coagulopathy, discusses the role of VEM in trauma resuscitation, provides a summary of proposed treatment algorithms, and discusses pending questions in the field.
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Affiliation(s)
- Andrew C Sayce
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Matthew D Neal
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Christine M Leeper
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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Hervig TA, Doughty HA, Cardigan RA, Apelseth TO, Hess JR, Noorman F, Bohoněk M, Yazer MH, Lu J, Wendel S, Sparrow RL. Re-introducing whole blood for transfusion: considerations for blood providers. Vox Sang 2020; 116:167-174. [PMID: 32996604 DOI: 10.1111/vox.12998] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 08/11/2020] [Indexed: 12/31/2022]
Abstract
Whole blood is the original blood preparation but disappeared from the blood bank inventories in the 1980s following the advent of component therapy. In the early 2000s, both military and civilian practice called for changes in the transfusion support for massive haemorrhage. The 'clear fluid' policy was abandoned and replaced by early balanced transfusion of platelets, plasma and red cells. Whole blood is an attractive alternative to multi-component therapy, which offers reduced hemodilution, lower donor exposure and simplified logistics. However, the potential for wider re-introduction of whole blood requires re-evaluation of haemolysins, storage conditions and shelf-life, the need for leucocyte depletion/ pathogen reduction and inventory management for blood providers. This review addresses these questions and calls for research to define the optimal whole blood product and the indications for its use.
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Affiliation(s)
- Tor A Hervig
- Blood Bank, Haugesund hospital, Haugesund, Norway
| | | | | | - Torunn O Apelseth
- Department of Immunology and Transfusion Medicine, Haukeland University Hospital, Bergen, Norway
| | - John R Hess
- Laboratory Medicine, University of Washington, Seattle, WA, USA
| | - Femke Noorman
- Quality, Research and Development, Military Blood Bank, Leiden, Netherlands
| | - Miloš Bohoněk
- Hematology, Biochemistry and Blood Transfusion, Central Military Hospital Prague, Prague, Czech Republic
| | - Mark H Yazer
- Department of Pathology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jia Lu
- Defence Medical & Environmental Research Institute, DSO National Laboratories (Kent Ridge), Singapore City, Singapore
| | | | - Rosemary L Sparrow
- Epidemiology and Preventive Medicine, Monash University, Melbourne, Vic, Australia
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Adam EH, Fischer D. Plasma Transfusion Practice in Adult Surgical Patients: Systematic Review of the Literature. Transfus Med Hemother 2020; 47:347-359. [PMID: 33173453 DOI: 10.1159/000511271] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Accepted: 08/31/2020] [Indexed: 12/18/2022] Open
Abstract
Background Plasma transfusions are most commonly used therapeutically for bleeding or prophylactically in non-bleeding patients prior to invasive procedures or surgery. Although plasma transfusions generally seem to decline, plasma usage for indications that lack evidence of efficacy prevail. Summary There is wide international, interinstitutional, and interindividual variance regarding the compliance with guidelines based on published references, supported by appropriate testing. There is furthermore a profound lack of evidence from randomized controlled trials comparing the effect of plasma transfusion with that of other therapeutic interventions for most indications, including massive bleeding. The expected benefit of a plasma transfusion needs to be balanced carefully against the associated risk of adverse events. In light of the heterogeneous nature of bleeding conditions and their rapid evolvement over time, fibrinogen and factor concentrate therapy, directed at specific phases of coagulation identified by alternative laboratory assays, may offer advantages over conventional blood product ratio-driven resuscitation. However, their outcome benefit has not been demonstrated in well-powered prospective trials. This systematic review will detail the current evidence base for plasma transfusion in adult surgical patients.
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Affiliation(s)
- Elisabeth Hannah Adam
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe University, Frankfurt, Germany
| | - Dania Fischer
- Department of Anesthesiology, Heidelberg University Hospital, Heidelberg, Germany
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Wise RD, de Vasconcellos K, Gopalan D, Ahmed N, Alli A, Joubert I, Kabambi KF, Mathiva LR, Mdladla N, Mer M, Miller M, Mrara B, Omar S, Paruk F, Richards GA, Skinner D, von Rahden R. Critical Care Society of Southern Africa adult patient blood management guidelines: 2019 Round-table meeting, CCSSA Congress, Durban, 2018. SOUTHERN AFRICAN JOURNAL OF CRITICAL CARE 2020; 36:10.7196/SAJCC.2020.v36i1b.440. [PMID: 37415775 PMCID: PMC10321416 DOI: 10.7196/sajcc.2020.v36i1b.440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/28/2020] [Indexed: 07/08/2023] Open
Abstract
The CCSSA PBM Guidelines have been developed to improve patient blood management in critically ill patients in southern Africa. These consensus recommendations are based on a rigorous process by experts in the field of critical care who are also practicing in South Africa (SA). The process comprised a Delphi process, a round-table meeting (at the CCSSA National Congress, Durban, 2018), and a review of the best available evidence and international guidelines. The guidelines focus on the broader principles of patient blood management and incorporate transfusion medicine (transfusion guidelines), management of anaemia, optimisation of coagulopathy, and administrative and ethical considerations. There are a mix of low-middle and high-income healthcare structures within southern Africa. Blood products are, however, provided by the same not-for-profit non-governmental organisations to both private and public sectors. There are several challenges related to patient blood management in SA due most notably to a high incidence of anaemia, a frequent shortage of blood products, a small donor population, and a healthcare system under financial strain. The rational and equitable use of blood products is important to ensure best care for as many critically ill patients as possible. The summary of the recommendations provides key practice points for the day-to-day management of critically ill patients. A more detailed description of the evidence used to make these recommendations follows in the full clinical guidelines section.
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Affiliation(s)
- R D Wise
- Discipline of Anaesthesiology and Critical Care, School of Clinical Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - K de Vasconcellos
- Department of Critical Care, King Edward VIII Hospital, Durban; Discipline of Anaesthesiology and Critical Care, School of Clinical Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - D Gopalan
- Discipline of Anaesthesiology and Critical Care, School of Clinical Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - N Ahmed
- Surgical ICU, Tygerberg Academic Hospital; Department of Surgical Sciences and Department of Anaesthesiology and Critical Care, Stellenbosch University, Cape Town, South Africa
| | - A Alli
- Department of Anaesthesia, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - I Joubert
- Division of Critical Care, Department of Anaesthesia and Perioperative Medicine, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa
| | - K F Kabambi
- Department of Anaesthesia and Critical Care, Nelson Mandela Academic Hospital, Mthatha; Department of Surgery, Faculty of Health Sciences, Walter Sisulu University, Mthatha, South Africa
| | - L R Mathiva
- Intensive Care Unit, Chris Hani Baragwanath Academic Hospital and University of the Witwatersrand, Johannesburg, South Africa
| | - N Mdladla
- Dr George Mukhari Academic Hospital; Sefako Makgatho Health Sciences University, Pretoria, South Africa
| | - M Mer
- Department of Medicine, Divisions of Critical Care and Pulmonology, Charlotte Maxeke Johannesburg Academic Hospital and Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - M Miller
- Department of Anaesthesia and Peri-operative Medicine, Division of Critical Care, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa
| | - B Mrara
- Anaesthesia Department, Walter Sisulu University, Mthatha, South Africa
| | - S Omar
- Department of Critical Care, Chris Hani Baragwanath Academic Hospital and School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | - F Paruk
- Department of Critical Care, Steve Biko Academic Hospital and Critical Care, School of Medicine, University of Pretoria, South Africa
| | - G A Richards
- Department of Critical Care, Charlotte Maxeke Johannesburg Academic Hospital and University of the Witwatersrand, Johannesburg, South Africa
| | - D Skinner
- Department of Critical Care, King Edward VIII Hospital, Durban; Discipline of Anaesthesiology and Critical Care, School of Clinical Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - R von Rahden
- Private practice (Critical Care), Rodseth and Partners, Pietermaritzburg, South Africa
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Jost D, Lemoine S, Lemoine F, Lanoe V, Maurin O, Derkenne C, Franchin Frattini M, Delacote M, Seguineau E, Godefroy A, Hervault N, Delhaye L, Pouliquen N, Louis-Delauriere E, Trichereau J, Roquet F, Salomé M, Verret C, Bihannic R, Jouffroy R, Frattini B, Hong Tuan Ha V, Dang-Minh P, Travers S, Bignand M, Martinaud C, Garrabe E, Ausset S, Prunet B, Sailliol A, Tourtier JP. French lyophilized plasma versus normal saline for post-traumatic coagulopathy prevention and correction: PREHO-PLYO protocol for a multicenter randomized controlled clinical trial. Trials 2020; 21:106. [PMID: 31969168 PMCID: PMC6977230 DOI: 10.1186/s13063-020-4049-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Accepted: 01/06/2020] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Post-trauma bleeding induces an acute deficiency in clotting factors, which promotes bleeding and hemorrhagic shock. However, early plasma administration may reduce the severity of trauma-induced coagulopathy (TIC). Unlike fresh frozen plasma, which requires specific hospital logistics, French lyophilized plasma (FLYP) is storable at room temperature and compatible with all blood types, supporting its use in prehospital emergency care. We aim to test the hypothesis that by attenuating TIC, FLYP administered by prehospital emergency physicians would benefit the severely injured civilian patient at risk for hemorrhagic shock. METHODS/DESIGN This multicenter randomized clinical trial will include adults severely injured and at risk for hemorrhagic shock, with a systolic blood pressure < 70 mmHg or a Shock Index > 1.1. Two parallel groups of 70 patients will receive either FLYP or normal saline in addition to usual treatment. The primary endpoint is the International Normalized Ratio (INR) at hospital admission. Secondary endpoints are transfusion requirement, length of stay in the intensive care unit, survival rate at day 30, usability and safety related to FLYP use, and other biological coagulation parameters. CONCLUSION With this trial, we aim to confirm the efficacy of FLYP in TIC and its safety in civilian prehospital care. The study results will contribute to optimizing guidelines for treating hemorrhagic shock in civilian settings. TRIAL REGISTRATION ClinicalTrials.gov, NCT02736812. Registered on 13 April 2016. The trial protocol has been approved by the French ethics committee (CPP 3342) and the French Agency for the Safety of Medicines and Health Products (IDRCB 2015-A00866-43).
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Affiliation(s)
- Daniel Jost
- Paris Fire Brigade Medical Emergency Department, 1 place Jules Renard, 75017, Paris, France.
| | - Sabine Lemoine
- Paris Fire Brigade Medical Emergency Department, 1 place Jules Renard, 75017, Paris, France
| | - Frederic Lemoine
- Paris Fire Brigade Medical Emergency Department, 1 place Jules Renard, 75017, Paris, France
| | - Vincent Lanoe
- Paris Fire Brigade Medical Emergency Department, 1 place Jules Renard, 75017, Paris, France
| | - Olga Maurin
- Paris Fire Brigade Medical Emergency Department, 1 place Jules Renard, 75017, Paris, France
| | - Clément Derkenne
- Paris Fire Brigade Medical Emergency Department, 1 place Jules Renard, 75017, Paris, France
| | | | - Maëlle Delacote
- Paris Fire Brigade Medical Emergency Department, 1 place Jules Renard, 75017, Paris, France
| | - Edouard Seguineau
- Paris Fire Brigade Medical Emergency Department, 1 place Jules Renard, 75017, Paris, France
| | - Anne Godefroy
- Paris Fire Brigade Medical Emergency Department, 1 place Jules Renard, 75017, Paris, France
| | - Nicolas Hervault
- Paris Fire Brigade Medical Emergency Department, 1 place Jules Renard, 75017, Paris, France
| | - Ludovic Delhaye
- Paris Fire Brigade Medical Emergency Department, 1 place Jules Renard, 75017, Paris, France
| | - Nicolas Pouliquen
- Paris Fire Brigade Medical Emergency Department, 1 place Jules Renard, 75017, Paris, France
| | - Emilie Louis-Delauriere
- Department of Education, Research and Innovation, Service de Santé des Armées, 1 Place Alphonse Laveran, 75230, Paris, France
| | - Julie Trichereau
- Paris Fire Brigade Medical Emergency Department, 1 place Jules Renard, 75017, Paris, France
| | - Florian Roquet
- Paris Fire Brigade Medical Emergency Department, 1 place Jules Renard, 75017, Paris, France
| | - Marina Salomé
- Paris Fire Brigade Medical Emergency Department, 1 place Jules Renard, 75017, Paris, France
| | - Catherine Verret
- Department of Education, Research and Innovation, Service de Santé des Armées, 1 Place Alphonse Laveran, 75230, Paris, France
| | - René Bihannic
- Paris Fire Brigade Medical Emergency Department, 1 place Jules Renard, 75017, Paris, France
| | - Romain Jouffroy
- Paris Fire Brigade Medical Emergency Department, 1 place Jules Renard, 75017, Paris, France
| | - Benoit Frattini
- Paris Fire Brigade Medical Emergency Department, 1 place Jules Renard, 75017, Paris, France
| | - Vivien Hong Tuan Ha
- Paris Fire Brigade Medical Emergency Department, 1 place Jules Renard, 75017, Paris, France
| | - Pascal Dang-Minh
- Paris Fire Brigade Medical Emergency Department, 1 place Jules Renard, 75017, Paris, France
| | - Stéphane Travers
- Paris Fire Brigade Medical Emergency Department, 1 place Jules Renard, 75017, Paris, France
- French Military Health Service, Val de Grâce military hospital, 1, Place Alphonse Laveran, 75230, Paris, France
| | - Michel Bignand
- Paris Fire Brigade Medical Emergency Department, 1 place Jules Renard, 75017, Paris, France
| | - Christophe Martinaud
- French Military Health Service, Val de Grâce military hospital, 1, Place Alphonse Laveran, 75230, Paris, France
- French army blood transfusion center, 1 Rue du Lieutenant Raoul Batany, 92140, Clamart, France
| | - Eliane Garrabe
- French Military Health Service, Val de Grâce military hospital, 1, Place Alphonse Laveran, 75230, Paris, France
- French army blood transfusion center, 1 Rue du Lieutenant Raoul Batany, 92140, Clamart, France
| | - Sylvain Ausset
- French Military Health Service, Val de Grâce military hospital, 1, Place Alphonse Laveran, 75230, Paris, France
- Department of Anesthesiology and Intensive Care, Percy military teaching hospital, 101 avenue Henri Barbusse, BP 406, 92141, Clamart, Cedex, France
| | - Bertrand Prunet
- Paris Fire Brigade Medical Emergency Department, 1 place Jules Renard, 75017, Paris, France
- French Military Health Service, Val de Grâce military hospital, 1, Place Alphonse Laveran, 75230, Paris, France
| | - Anne Sailliol
- French Military Health Service, Val de Grâce military hospital, 1, Place Alphonse Laveran, 75230, Paris, France
- French army blood transfusion center, 1 Rue du Lieutenant Raoul Batany, 92140, Clamart, France
- French Military Research Institute, 1 place Valérie Andre, BP 73, 91223, Brétigny sur Orge, France
| | - Jean Pierre Tourtier
- Paris Fire Brigade Medical Emergency Department, 1 place Jules Renard, 75017, Paris, France
- French Military Health Service, Val de Grâce military hospital, 1, Place Alphonse Laveran, 75230, Paris, France
- Department of Anaesthesiology and Intensive Care, Begin military teaching hospital, 94160, Saint-Mande, France
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12
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May LA, Harrell KN, Bell CM, Basham-Saif A, Barker DE, Maxwell RA. Intraoperative Resuscitation by Specialized Trauma Nurse Clinicians Improves Adherence to Massive Transfusion Protocol. Am Surg 2020. [DOI: 10.1177/000313482008600120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
A massive transfusion protocol (MTP) was implemented at a Level I trauma center in 2007 for patients with massive blood loss. A goal ratio of plasma to pheresed platelets to packed red blood cells (PRBCs) of 1:1:1 was established. From 2007 to 2014, trauma nurse clinicians (TNCs) administered the MTP during initial resuscitation and anesthesia personnel administered the MTP intraoperatively. In 2015, TNCs began administering the MTP intraoperatively. This study evaluates intraoperative blood product ratios and crystalloid volume administered by anesthesia personnel or TNCs. A retrospective review of trauma registry patients requiring MTP from 2007 to 2017 was performed. Patient data were stratified according to MTP administration by either anesthesia personnel (2007–2015) or TNCs (2015–2017). Ninety-seven patients were included with 54 anesthesia patients and 44 TNC patients. Patients undergoing resuscitation by MTP administered by TNCs received less median crystalloid (3000 mL vs 1500 mL, P < 0.001). The ratio of plasma:PRBC (0.75 vs 0.93, P = 0.027) and platelets:PRBC (0.75 vs 1.04, P = 0.003) was found to be significantly closer to 1:1 for TNC patients. MTP intraoperative blood product administration by TNCs reduced the amount of infused crystalloid and improved adherence to MTP in achieving a 1:1:1 ratio of blood products.
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Affiliation(s)
- L. Andrew May
- University of Tennessee College of Medicine Chattanooga, Chattanooga, Tennessee
| | - Kevin N. Harrell
- University of Tennessee College of Medicine Chattanooga, Chattanooga, Tennessee
| | | | | | - Donald E. Barker
- University of Tennessee College of Medicine Chattanooga, Chattanooga, Tennessee
| | - Robert A. Maxwell
- University of Tennessee College of Medicine Chattanooga, Chattanooga, Tennessee
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13
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Fresh Low Titer O Whole Blood Transfusion in the Austere Medical Environment. Wilderness Environ Med 2019; 30:425-430. [PMID: 31694782 DOI: 10.1016/j.wem.2019.08.006] [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: 05/20/2019] [Revised: 07/06/2019] [Accepted: 08/13/2019] [Indexed: 11/23/2022]
Abstract
Massive hemorrhage is an immediate threat to life. The military developed the Tactical Combat Casualty Care guidelines to address the management of acute trauma, including administration of blood products. The guidelines have been expanded to include low titer O whole blood, which is in limited use by the military. This proposal describes how the transfusion of fresh whole blood might be applied to the remote civilian environment. In doing so, this life-saving intervention may be brought to the austere medical environment, allowing critically hemorrhaging patients to survive to reach definitive medical care.
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14
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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: 9] [Impact Index Per Article: 1.8] [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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15
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Fedorov A, Kondratov K, Kishenko V, Mikhailovskii V, Kudryavtsev I, Belyakova M, Sidorkevich S, Vavilova T, Kostareva A, Sirotkina O, Golovkin A. Application of high-sensitivity flow cytometry in combination with low-voltage scanning electron microscopy for characterization of nanosized objects during platelet concentrate storage. Platelets 2019; 31:226-235. [DOI: 10.1080/09537104.2019.1599337] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Affiliation(s)
- Anton Fedorov
- Institute of molecular biology and genetics, Almazov National Medical Research Centre, St. Petersburg, Russia
| | - Kirill Kondratov
- Institute of molecular biology and genetics, Almazov National Medical Research Centre, St. Petersburg, Russia
| | - Vasilii Kishenko
- Department of Laboratory Medicine and Genetics, Institute of Medical Education, Almazov National Medical Research Centre, St. Petersburg, Russia
| | - Vladimir Mikhailovskii
- Interdisciplinary Resource Center for Nanotechnology, Saint-Petersburg State University, St. Petersburg, Russia
| | - Igor Kudryavtsev
- Department of Fundamental Medicine, Far Eastern Federal University, Vladivostok, Russia
- Department of Immunology, Institute of Experimental Medicine, St. Petersburg, Russia
| | - Margarita Belyakova
- Department of blood transfusion, Almazov National Medical Research Centre, St. Petersburg, Russia
| | - Sergey Sidorkevich
- Department of blood transfusion, Almazov National Medical Research Centre, St. Petersburg, Russia
| | - Tatyana Vavilova
- Department of Laboratory Medicine and Genetics, Institute of Medical Education, Almazov National Medical Research Centre, St. Petersburg, Russia
| | - Anna Kostareva
- Institute of molecular biology and genetics, Almazov National Medical Research Centre, St. Petersburg, Russia
| | - Olga Sirotkina
- Department of Laboratory Medicine and Genetics, Institute of Medical Education, Almazov National Medical Research Centre, St. Petersburg, Russia
- Petersburg Nuclear Physics Institute named by B.P. Konstantinov of National Research Centre «Kurchatov Institute», Gatchina, Leningradskaya oblast, Russia
| | - Alexey Golovkin
- Institute of molecular biology and genetics, Almazov National Medical Research Centre, St. Petersburg, Russia
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16
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Massive transfusion in the pediatric population: A systematic review and summary of best-evidence practice strategies. J Trauma Acute Care Surg 2019; 86:744-754. [DOI: 10.1097/ta.0000000000002188] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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17
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Miyata S, Itakura A, Ueda Y, Usui A, Okita Y, Ohnishi Y, Katori N, Kushimoto S, Sasaki H, Shimizu H, Nishimura K, Nishiwaki K, Matsushita T, Ogawa S, Kino S, Kubo T, Saito N, Tanaka H, Tamura T, Nakai M, Fujii S, Maeda T, Maeda H, Makino S, Matsunaga S. TRANSFUSION GUIDELINES FOR PATIENTS WITH MASSIVE BLEEDING. ACTA ACUST UNITED AC 2019. [DOI: 10.3925/jjtc.65.21] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Shigeki Miyata
- Department of Clinical Laboratory Medicine, National Cerebral and Cardiovascular Center
| | - Atsuo Itakura
- Department of Obstetrics and Gynecology, Faculty of Medicine, Juntendo University
| | - Yuichi Ueda
- Nara Prefectural Hospital Organization, Nara Prefecture General Medical Center
| | - Akihiko Usui
- Department of Cardiac Surgery, Nagoya University Graduate School of Medicine
| | - Yutaka Okita
- Department of Cardiovascular Surgery, Kobe University
| | - Yoshihiko Ohnishi
- Operation Room, Anesthesiology, National Cerebral and Cardiovascular Center
| | - Nobuyuki Katori
- Department of Anesthesiology, Keio University School of Medicine
| | - Shigeki Kushimoto
- Division of Emergency and Critical Care Medicine, Tohoku University Graduate School of Medicine
| | - Hiroaki Sasaki
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center
| | | | - Kunihiro Nishimura
- Department of Statistics and Data Analysis, Dept of Preventive Medicine and Epidemiology, National Cerebral and Cardiovascular Center
| | | | | | - Satoru Ogawa
- Department of Anesthesiology, Kyoto Prefectural University of Medicine
| | | | | | - Nobuyuki Saito
- Shock and Trauma Center, Nippon Medical School Chiba Hokusoh Hospital
| | - Hiroshi Tanaka
- Department of Surgery, Division of Minimum Invasive Surgery, Kobe University
| | | | - Michikazu Nakai
- Department of Statistics and Data Analysis, Dept of Preventive Medicine and Epidemiology, National Cerebral and Cardiovascular Center
| | - Satoshi Fujii
- Department of Laboratory Medicine, Asahikawa Medical University
| | - Takuma Maeda
- Division of Transfusion Medicine, National Cerebral and Cardiovascular Center
| | - Hiroo Maeda
- Transfusion Medicine and Cell Therapy, Saitama Medical Center/Saitama Medical University
| | - Shintaro Makino
- Department of Obstetrics and Gynecology, Faculty of Medicine, Juntendo University
| | - Shigetaka Matsunaga
- Department of Obstetrics and Gynecology, Saitama Medical Center/Saitama Medical University
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18
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Affiliation(s)
- David R King
- From the Department of Surgery, Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, and the Department of Surgery, Harvard Medical School - both in Boston; and the U.S. Army Special Operations Command, Ft. Bragg, NC
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19
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Tahir Janjua MS, Agarwal S, Castresana MR. The value of institutional protocols and focused cardiac ultrasound during a case of ultramassive transfusion. Ann Card Anaesth 2018; 21:433-436. [PMID: 30333342 PMCID: PMC6206793 DOI: 10.4103/aca.aca_49_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
A 53-year-old female was admitted to the emergency department with an exsanguinating bleed from the rectum which was of unclear origin. In what could be considered an ultramassive transfusion, 60 units packed red blood cells, 23 units fresh frozen plasma, 20 units platelets, 6 units cryoprecipitate, 30 L of crystalloids, 2 L of colloids, and 4 g of tranexamic acid were transfused over the course of 7 h. An arterio-enteric fistula was diagnosed and treated by an interventional radiologist. The patient recovered rapidly thereafter without any major neurologic, pulmonary, cardiac, or hematologic complications.
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Affiliation(s)
- Muhammad Salman Tahir Janjua
- Department of Anesthesiology and Perioperative Medicine, Medical College of Georgia at Augusta University, Augusta, GA, USA
| | - Shvetank Agarwal
- Department of Anesthesiology and Perioperative Medicine, Medical College of Georgia at Augusta University, Augusta, GA, USA
| | - Manuel R Castresana
- Department of Anesthesiology and Perioperative Medicine, Medical College of Georgia at Augusta University, Augusta, GA, USA
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20
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Givergis R, Munnangi S, Fayaz M Fomani K, Boutin A, Zapata LC, Angus LDG. Evaluation of massive transfusion protocol practices by type of trauma at a level I trauma center. Chin J Traumatol 2018; 21:261-266. [PMID: 29776837 PMCID: PMC6235793 DOI: 10.1016/j.cjtee.2018.01.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Revised: 01/08/2018] [Accepted: 03/08/2018] [Indexed: 02/04/2023] Open
Abstract
PURPOSE To evaluate massive transfusion protocol practices by trauma type at a level I trauma center. METHODS A retrospective analysis was performed on a sample of 76 trauma patients with MTP activation between March 2010 and January 2015 at a regional trauma center. Patient demographics, transfusion practices, and clinical outcomes were compared by type of trauma sustained. RESULTS Penetrating trauma patients who required MTP activation were significantly younger, had lower injury severity score (ISS), higher probability of survival (POS), decreased mortality, and higher Glasgow Coma scale (GCS) compared to blunt trauma patients. Overall, the mortality rate was 38.16%. The most common injury sustained among blunt trauma patients was head injury (36.21%), whereas the majority of the penetrating trauma patients sustained abdominal injuries (55.56%). Although the admission coagulation parameters and timing of coagulopathy were not significantly different between the two groups of patients, a significantly higher proportion of penetrating trauma patients received high plasma content therapy relative to blunt trauma patients (p < 0.01). CONCLUSION Despite the use of the same MTP for all injured patients requiring massive transfusion, significant differences existed between blunt trauma patients and penetrating trauma patients. These differences in transfusion characteristics and outcomes following MTP activation underscore the complexity of implementing MTPs and warrant vigilant transfusion practices to improve outcomes in trauma patients.
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Affiliation(s)
- Roshan Givergis
- Department of Emergency Medicine, Nassau University Medical Center, East Meadow, NY, USA
| | - Swapna Munnangi
- Department of Emergency Medicine, Nassau University Medical Center, East Meadow, NY, USA,Corresponding author.
| | | | - Anthony Boutin
- Department of Emergency Medicine, Nassau University Medical Center, East Meadow, NY, USA
| | - Luis Carlos Zapata
- Department of Emergency Medicine, Nassau University Medical Center, East Meadow, NY, USA
| | - LD George Angus
- Department of Surgery, Nassau University Medical Center, East Meadow, NY, USA
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21
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Dargère M, Langlais ML, Gangloff C, Léostic C, Le Niger C, Ozier Y. Implementation and evaluation of a major haemorrhage protocol in the Emergency Department Resuscitation Area in the University-affiliated Hospital of Brest (France). Transfus Clin Biol 2018; 26:309-315. [PMID: 30262152 DOI: 10.1016/j.tracli.2018.08.160] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Accepted: 08/13/2018] [Indexed: 11/16/2022]
Abstract
Haemorrhagic shock is a rare occurrence in emergency medicine but it can be associated with significant mortality. The purpose of this study was to evaluate the impact of a major haemorrhage protocol on patient management in Emergency Department Resuscitation Area. METHODS A single-centre study was conducted to compare two periods, before and after institution of a massive haemorrhage protocol including the use of massive transfusion orders and the availability of packed red blood cell concentrates prior to patient's admission. Two groups of patients (in both trauma and non-trauma settings) were defined: "before protocol" and "after protocol". The primary outcome was the median transfusion time for a unit of red blood cell concentrate. RESULTS Forty patients were included: 22 for the "pre-protocol" group and 18 for the "post-protocol" group. The two groups were balanced with baseline characteristics. This study showed a significantly reduced median transfusion time for a unit of red blood cell concentrate from 20min pre-protocol to 9min post-protocol. The time between patient's admission and transfusion of the first red blood cell concentrate was reduced but non-significantly from 71min to 36min. CONCLUSION The major haemorrhage protocol optimised patient management by reducing the median transfusion time for red blood cell concentrates.
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Affiliation(s)
- M Dargère
- Emergency department, centre hospitalier regional universitaire de Brest, 29200 Brest, France
| | - M-L Langlais
- Emergency department, centre hospitalier regional universitaire de Brest, 29200 Brest, France
| | - C Gangloff
- Urgent Medical Aid Service (SAMU), centre hospitalier regional universitaire de Brest, 29200 Brest, France
| | - C Léostic
- French National Blood Service (EFS), centre hospitalier regional universitaire de Brest, 29200 Brest, France
| | - C Le Niger
- Centre hospitalier regional universitaire de Brest, 29200 Brest, France.
| | - Y Ozier
- Department of anaesthesiology and intensive care medicine, centre hospitalier regional universitaire de Brest, 29200 Brest, France
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22
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Does a balanced transfusion ratio of plasma to packed red blood cells improve outcomes in both trauma and surgical patients? A meta-analysis of randomized controlled trials and observational studies. Am J Surg 2018; 216:342-350. [DOI: 10.1016/j.amjsurg.2017.08.045] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2017] [Revised: 08/21/2017] [Accepted: 08/30/2017] [Indexed: 01/08/2023]
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23
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Abstract
PURPOSE OF REVIEW Death from uncontrolled haemorrhage is one of the leading causes of trauma-related mortality and is potentially preventable. Advances in understanding the mechanisms of trauma-induced coagulopathy (TIC) have focused attention on the role of blood products and procoagulants in mitigating the sequelae of TIC and how these therapies can be improved. RECENT FINDINGS A host of preclinical and clinical studies have evaluated blood product availability and efficacy in trauma. Recently published randomized controlled trials have investigated the ratio of platelet:plasma:red cell transfusion and the role of early cryoprecipitate in trauma. Demand for readily available plasma has led to changes particularly in the use of thawed group A plasma. Furthermore, ex-vivo and early clinical work has demonstrated variations in the haemostatic activity of different plasma, platelet and whole blood products. A number of multicentre trials are in progress aiming to answer key questions regarding tranexamic acid, procoagulant factor and fibrinogen concentrates and their effect on trauma outcomes. SUMMARY There are promising results from ex-vivo studies in manufacturing and storage of blood products to optimize haemostatic activity and availability, particularly with alternative plasma and platelet products and whole blood. There is an urgent need for these products needs to be tested prospectively.
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24
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Doughty H, Apelseth TO, Sivertsen J, Annaniasen K, Hervig T. Massive transfusion: changing practice in a single Norwegian centre 2002-2015. Transfus Med 2018; 28:357-362. [DOI: 10.1111/tme.12529] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2018] [Revised: 03/27/2018] [Accepted: 03/28/2018] [Indexed: 11/27/2022]
Affiliation(s)
| | - T. O. Apelseth
- Department of Immunology and Transfusion Medicine; Haukeland University Hospital; Bergen Norway
- Laboratory of Clinical Biochemistry; Haukeland University Hospital; Bergen Norway
| | - J. Sivertsen
- Department of Immunology and Transfusion Medicine; Haukeland University Hospital; Bergen Norway
| | - K. Annaniasen
- Department of Immunology and Transfusion Medicine; Haukeland University Hospital; Bergen Norway
| | - T. Hervig
- Department of Immunology and Transfusion Medicine; Haukeland University Hospital; Bergen Norway
- Institute of Clinical Science; University of Bergen; Bergen Norway
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25
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Flint AWJ, McQuilten ZK, Wood EM. Massive transfusions for critical bleeding: is everything old new again? Transfus Med 2018; 28:140-149. [PMID: 29607593 DOI: 10.1111/tme.12524] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Revised: 08/11/2017] [Accepted: 03/07/2018] [Indexed: 12/19/2022]
Abstract
Massive transfusion or major haemorrhage protocols have been widely adopted in the treatment of critically bleeding patients. Following evidence that higher ratios of transfused plasma and platelets to red blood cells may offer survival benefits in military trauma patients, these ratios are now commonly incorporated into massive transfusion protocols. They more closely resemble the effects of whole blood transfusion, which in the second half of last century was largely replaced by individual blood component transfusion based on laboratory-guided indicators. However, high-quality evidence to guide transfusion support for critically bleeding patients across the range of bleeding contexts is lacking, including for both trauma and non-trauma patients. More data on major haemorrhage support and clinical outcomes are needed to inform guidelines and practice.
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Affiliation(s)
- A W J Flint
- The Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,Transfusion Research Unit, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,Royal Australian Navy, Australian Defence Force, Canberra, Australian Capital Territory, Australia
| | - Z K McQuilten
- The Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,Transfusion Research Unit, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,Department of Clinical Haematology, Monash Health, Melbourne, Victoria, Australia
| | - E M Wood
- Transfusion Research Unit, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,Department of Clinical Haematology, Monash Health, Melbourne, Victoria, Australia
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26
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Affiliation(s)
- C. Booth
- Barts Health NHS Trust; London UK
| | - S. Allard
- Barts Health NHS Trust; London UK
- NHS Blood and Transplant; London UK
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Abstract
Damage control surgery is a combination of temporizing surgical interventions to arrest hemorrhage and control infectious source, with goal directed resuscitation to restore normal physiology. The convention of damage control surgery largely arose following the discovery of the lethal triad of hypothermia, acidosis, and coagulopathy, with the goal of Damage Control Surgery (DCS) is to avoid the initiation of this "bloody vicious cycle" or to reverse its progression. While hypothermia and acidosis are generally corrected with resuscitation, coagulopathy remains a challenging aspect of DCS, and is exacerbated by excessive crystalloid administration. This chapter focuses on resuscitative principles in the four settings of trauma care: the prehospital setting, emergency department, operating room, and intensive care unit including historical perspectives, resuscitative methods, controversies, and future directions. Each setting provides unique challenges with specific goals of care.
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Smith IM, James RH, Dretzke J, Midwinter MJ. Prehospital Blood Product Resuscitation for Trauma: A Systematic Review. Shock 2018; 46:3-16. [PMID: 26825635 PMCID: PMC4933578 DOI: 10.1097/shk.0000000000000569] [Citation(s) in RCA: 57] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Introduction: Administration of high ratios of plasma to packed red blood cells is a routine practice for in-hospital trauma resuscitation. Military and civilian emergency teams are increasingly carrying prehospital blood products (PHBP) for trauma resuscitation. This study systematically reviewed the clinical literature to determine the extent to which the available evidence supports this practice. Methods: Bibliographic databases and other sources were searched to July 2015 using keywords and index terms related to the intervention, setting, and condition. Standard systematic review methodology aimed at minimizing bias was used for study selection, data extraction, and quality assessment (protocol registration PROSPERO: CRD42014013794). Synthesis was mainly narrative with random effects model meta-analysis limited to mortality outcomes. Results: No prospective comparative or randomized studies were identified. Sixteen case series and 11 comparative studies were included in the review. Seven studies included mixed populations of trauma and non-trauma patients. Twenty-five of 27 studies provided only very low quality evidence. No association between PHBP and survival was found (OR for mortality: 1.29, 95% CI: 0.84–1.96, P = 0.24). A single study showed improved survival in the first 24 h. No consistent physiological or biochemical benefit was identified, nor was there evidence of reduced in-hospital transfusion requirements. Transfusion reactions were rare, suggesting the short-term safety of PHBP administration. Conclusions: While PHBP resuscitation appears logical, the clinical literature is limited, provides only poor quality evidence, and does not demonstrate improved outcomes. No conclusions as to efficacy can be drawn. The results of randomized controlled trials are awaited.
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Affiliation(s)
- Iain M Smith
- *NIHR Surgical Reconstruction and Microbiology Research Centre, University of Birmingham †Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, ICT Centre, Edgbaston, Birmingham ‡205 (Scottish) Field Hospital, Govan, Glasgow §Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine, ICT Centre, Edgbaston, Birmingham
- East Anglian Air Ambulance, Gambling Close, Norwich ¶Ministry of Defence Hospital Unit Derriford, Derriford Hospital, Plymouth, United Kingdom **Institute of Applied Health Research, University of Birmingham, Edgbaston, Birmingham, United Kingdom
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29
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Optimal Dose, Timing and Ratio of Blood Products in Massive Transfusion: Results from a Systematic Review. Transfus Med Rev 2018; 32:6-15. [DOI: 10.1016/j.tmrv.2017.06.003] [Citation(s) in RCA: 57] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2017] [Revised: 05/26/2017] [Accepted: 06/19/2017] [Indexed: 11/22/2022]
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30
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Smith IM, Crombie N, Bishop JR, McLaughlin A, Naumann DN, Herbert M, Hancox JM, Slinn G, Ives N, Grant M, Perkins GD, Doughty H, Midwinter MJ. RePHILL: protocol for a randomised controlled trial of pre-hospital blood product resuscitation for trauma. Transfus Med 2017; 28:346-356. [PMID: 29193548 DOI: 10.1111/tme.12486] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2017] [Revised: 10/16/2017] [Accepted: 10/17/2017] [Indexed: 12/20/2022]
Abstract
OBJECTIVES To describe the 'Resuscitation with Pre-HospItaL bLood products' trial (RePHILL) - a multi-centre randomised controlled trial of pre-hospital blood product (PHBP) administration vs standard care for traumatic haemorrhage. BACKGROUND PHBP are increasingly used for pre-hospital trauma resuscitation despite a lack of robust evidence demonstrating superiority over crystalloids. Provision of PHBP carries additional logistical and regulatory implications, and requires a sustainable supply of universal blood components. METHODS RePHILL is a multi-centre, two-arm, parallel group, open-label, phase III randomised controlled trial currently underway in the UK. Patients attended by a pre-hospital emergency medical team, with traumatic injury and hypotension (systolic blood pressure <90 mmHg or absent radial pulse) believed to be due to traumatic haemorrhage are eligible. Exclusion criteria include age <16 years, blood product receipt on scene prior to randomisation, Advanced Medical Directive forbidding blood product administration, pregnancy, isolated head injury and prisoners. A total of 490 patients will be recruited in a 1 : 1 ratio to receive either the intervention (up to two units of red blood cells and two units of lyophilised plasma) or the control (up to four boluses of 250 mL 0.9% saline). The primary outcome measure is a composite of failure to achieve lactate clearance of ≥20%/h over the first 2 hours after randomisation and all-cause mortality between recruitment and discharge from the primary receiving facility to non-acute care. Secondary outcomes include pre-hospital time, coagulation indices, in-hospital transfusion requirements and morbidity. RESULTS Pilot study recruitment began in December 2016. Approval to proceed to the main trial was received in June 2017. Recruitment is expected to continue until 2020. CONCLUSIONS RePHILL will provide high-quality evidence regarding the efficacy and safety of PHBP resuscitation for trauma.
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Affiliation(s)
- I M Smith
- NIHR Surgical Reconstruction and Microbiology Research Centre, University of Birmingham, Birmingham, UK
| | - N Crombie
- NIHR Surgical Reconstruction and Microbiology Research Centre, University of Birmingham, Birmingham, UK.,Department of Anaesthesia, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.,West Midlands Ambulance Service Medical Emergency Response Incident Team, Brierley Hill, UK.,Midlands Air Ambulance, Stourbridge, UK
| | - J R Bishop
- NIHR Surgical Reconstruction and Microbiology Research Centre, University of Birmingham, Birmingham, UK.,Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - A McLaughlin
- NIHR Surgical Reconstruction and Microbiology Research Centre, University of Birmingham, Birmingham, UK
| | - D N Naumann
- NIHR Surgical Reconstruction and Microbiology Research Centre, University of Birmingham, Birmingham, UK
| | - M Herbert
- Department of Haematology, Royal Wolverhampton Hospitals NHS Trust, Wolverhampton, UK
| | - J M Hancox
- NIHR Surgical Reconstruction and Microbiology Research Centre, University of Birmingham, Birmingham, UK.,Midlands Air Ambulance, Stourbridge, UK
| | - G Slinn
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - N Ives
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - M Grant
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - G D Perkins
- West Midlands Ambulance Service Medical Emergency Response Incident Team, Brierley Hill, UK.,Warwick Clinical Trials Unit, University of Warwick, Coventry, UK.,Critical Care Unit, Heart of England NHS Foundation Trust, Birmingham, UK
| | - H Doughty
- NHS Blood and Transplant, Birmingham, UK
| | - M J Midwinter
- NIHR Surgical Reconstruction and Microbiology Research Centre, University of Birmingham, Birmingham, UK.,School of Biomedical Sciences, University of Queensland, Brisbane, Queensland, Australia
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Abstract
INTRODUCTION Despite advances in trauma care, hemorrhage continues to be the leading cause of preventable mortality in trauma. The evidence to support its use in non-trauma patients is limited. We aim to report our experience with prehospital blood product transfusion. We hypothesize that it is safe, appropriately utilized, and that our protocol, which was designed for trauma patients, is adaptable to fit the needs of non-trauma patients. METHODS Patients transfused with blood products, packed red blood cells (pRBCs) or plasma, in the prehospital environment between 2002 and 2014 were included. Trauma patients were compared to non-trauma patients using descriptive statistics. RESULTS A total of 857 patients (n = 549 trauma and n = 308 non-trauma) were transfused with pRBCs (76 %, n = 654, mean 1.6 ± 1.1 units en route), plasma (53 %, n = 455, mean 1.7 ± 0.7 unit), or both (29 %, n = 252) during ground (12 %) or air (84 %) critical care transport. Mean age was 60.8 ± 21.6 years with 60.1 % (n = 515) males. Subsequently, in-hospital blood transfusions were performed in 80 % of patients, operations in 44 %, and endoscopy in 31 %. Five percent (n = 41) of patients did not require any of these interventions. Thirty-day mortality rate was 18 %, and one patient (<0.01 %) had a transfusion reaction. The majority of patients were non-trauma (n = 549, 64 %). Of the non-trauma patients, 219 (40 %) were surgical, 193 (35 %) gastrointestinal bleeds, and 137 (25 %) medical. CONCLUSION Both non-trauma and trauma patients require blood products for life threatening hemorrhage and the majority required further interventions. Further research on the benefits of transfusion among non-trauma patients is warranted.
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Prehospital plasma resuscitation associated with improved neurologic outcomes after traumatic brain injury. J Trauma Acute Care Surg 2017; 83:398-405. [PMID: 28538641 DOI: 10.1097/ta.0000000000001581] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Trauma-related hypotension and coagulopathy worsen secondary brain injury in patients with traumatic brain injuries (TBIs). Early damage control resuscitation with blood products may mitigate hypotension and coagulopathy. Preliminary data suggest resuscitation with plasma in large animals improves neurologic function after TBI; however, data in humans are lacking. METHODS We retrospectively identified all patients with multiple injuries age >15 years with head injuries undergoing prehospital resuscitation with blood products at a single Level I trauma center from January 2002 to December 2013. Inclusion criteria were prehospital resuscitation with either packed red blood cells (pRBCs) or thawed plasma as sole colloid resuscitation. Patients who died in hospital and those using anticoagulants were excluded. Primary outcomes were Glasgow Outcomes Score Extended (GOSE) and Disability Rating Score (DRS) at dismissal and during follow-up. RESULTS Of 76 patients meeting inclusion criteria, 53% (n = 40) received prehospital pRBCs and 47% (n = 36) received thawed plasma. Age, gender, injury severity or TBI severity, arrival laboratory values, and number of prehospital units were similar (all p > 0.05). Patients who received thawed plasma had an improved neurologic outcome compared to those receiving pRBCs (median GOSE 7 [7-8] vs. 5.5 [3-7], p < 0.001). Additionally, patients who received thawed plasma had improved functionality compared to pRBCs (median DRS 2 [1-3.5] vs. 9 [3-13], p < 0.001). Calculated GOSE and DRS scores during follow-up, median 6 [5-7] months, demonstrated increased function in those resuscitated with thawed plasma compared to pRBCs by both median GOSE (8 [7-8] vs. 6 [6-7], p < 0.001) and DRS (0 [0-1] vs. 4 [2-8], p < 0.001). CONCLUSION In critically injured trauma patients with TBI, early resuscitation with thawed plasma is associated with improved neurologic and functional outcomes at discharge and during follow-up compared to pRBCs alone. These preliminary data support the further investigation and use of plasma in the resuscitation of critically injured TBI patients. LEVEL OF EVIDENCE Therapeutic, level V.
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Prehospital Transfusion for Gastrointestinal Bleeding. Air Med J 2017; 36:315-319. [PMID: 29122112 DOI: 10.1016/j.amj.2017.06.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2017] [Accepted: 06/06/2017] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Gastrointestinal (GI) bleeding is a common medical emergency with significant morbidity and mortality. Many patients are coagulopathic, which may perpetuate bleeding. Remote damage control resuscitation, including early correction of coagulopathy and anemia, may benefit exsanguinating patients with GI bleeding. METHODS We conducted a retrospective review of patients with acute GI bleeding who received packed red blood cells (pRBC) and/or plasma during transportation to our institution between 2010 and 2014. A comparison group of patients who were not transfused en route was selected, and demographics, outcomes, and response to resuscitation were compared. RESULTS A total of 112 patients with GI bleeding received pRBC (82%, n = 92 pRBC, mean 1.7 ± 0.9 units), plasma (62%, n = 69, mean 1.7 ± 0.8 units) or both (44%, n = 49) en-route. The comparison group comprised 49 patients transported by helicopter who were not transfused en-route. Demographics, crystalloid resuscitation, transfusion prior to transfer, rate of intervention, ICU days, length of stay, and mortality were similar between groups. Patients transfused en route had a significant increase in hemoglobin from 8.3 ± 2.2 to 8.9 ± 2.1 (P = .03) and decrease in INR from 2.0 ± 1.0 to 1.6 ± 1.4 (P = .01), whereas those not transfused en route experienced stable hemoglobin (8.7 ± 2.8 to 9.4 ± 2.5; P = .21) and INR values (1.9 ± 1.0 to 1.6 ± 1.4; P = .32). Both groups had a significant improvement in hemodynamic parameters with resuscitation. CONCLUSION Prehospital damage control resuscitation with pRBC and/or plasma resulted in the improvement of hemodynamic instability, coagulopathy and anemia in patients with acute GI bleeding. Almost all patients required additional inpatient interventions and/or transfusions, suggesting that pre-hospital transfusion is being utilized for appropriately selected patients.
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Fredericks C, Kubasiak JC, Mentzer CJ, Yon JR. Massive transfusion: An update for the anesthesiologist. World J Anesthesiol 2017; 6:14-21. [DOI: 10.5313/wja.v6.i1.14] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2016] [Revised: 11/04/2016] [Accepted: 12/19/2016] [Indexed: 02/06/2023] Open
Abstract
Exsanguination from trauma, gastrointestinal bleeding, and obstetric hemorrhage remains a major source of mortality across the planet. Continued research into resuscitation strategies and evolving technology and blood product storage has allowed for patient to undergo very large volume transfusions, even to the point of replacing a patient’s blood volume several times over. As massive transfusions have become more common, more studies have been performed delineating the exact patient population that would benefit, start- and stop-points of transfusions, complications and avoidance of the same. We discuss these points and provide information and strategies for massive transfusion.
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虞 芳, 钟 涛, 武 钢. [Efficacy of high versus low plasma: red blood cell ratio resuscitation in patients with severe trauma requiring massive blood transfusion: a meta-analysis]. NAN FANG YI KE DA XUE XUE BAO = JOURNAL OF SOUTHERN MEDICAL UNIVERSITY 2017; 37:119-123. [PMID: 28109111 PMCID: PMC6765755 DOI: 10.3969/j.issn.1673-4254.2017.01.22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 10/13/2016] [Indexed: 06/06/2023]
Abstract
OBJECTIVE To evaluate the efficacy of high (≥1:2) and low (<1:2) plasma: red blood cell (RBC) ratio resuscitation in patients with severe trauma requiring massive blood transfusion. METHODS The databases including the Cochrane Library, Pubmed, Web of Science, and EMBASE were systemically searched for relevant studies published between January, 2009 and April, 2016. The selection of studies, assessment of methodological quality and data extraction were performed by two researchers independently according to the inclusion and exclusion criteria. The main endpoint was 24-h mortality, 30-day mortality and 24-h survival rate. RESULTS Five observational studies reporting outcomes of 1024 patients were included in this meta-analysis. Four studies documented civilian cases and one study had a military setting. No significant differences were found in the Injury Severity Score (ISS) between patient groups receiving high and low plasma: RBC ratio resuscitation. Compared with the low-ratio group, the patients with high-ratio resuscitation showed a significant reduction in the 24-h mortality rate (OR=0.35, 95%CI [0.25, 0.48], P<0.000 01) and the 30-day mortality rate (OR=0.55, 95%CI [0.41, 0.75], P=0.0001). An increased survival rate was observed in patients receiving high plasma: RBC ratio resuscitation within the initial 24 h following the trauma (HR=2.34, 95%CI [1.46, 3.73], P=0.00001). CONCLUSION Raising the plasma: RBC ratio to 0.5 or higher may decrease the mortality rate of the patients with severe trauma who need massive blood transfusion.
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Affiliation(s)
- 芳 虞
- />南方医科大学南方医院急诊科,广东 广州 510515Department of Emergency Medicine, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - 涛 钟
- />南方医科大学南方医院急诊科,广东 广州 510515Department of Emergency Medicine, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - 钢 武
- />南方医科大学南方医院急诊科,广东 广州 510515Department of Emergency Medicine, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
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Arslan A, Flax L, Fraser R, Kanter M, Simon R, Caputo ND. Twenty-four-hour packed red blood cell requirement is the strongest independent prognostic marker of mortality in ED trauma patients. Am J Emerg Med 2016; 34:1121-4. [DOI: 10.1016/j.ajem.2016.03.036] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2015] [Revised: 03/10/2016] [Accepted: 03/14/2016] [Indexed: 11/24/2022] Open
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Swiech A, Ausset S. Les produits sanguins labiles en 2016. MEDECINE INTENSIVE REANIMATION 2016. [DOI: 10.1007/s13546-016-1201-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Recurrent event frailty models reduced time-varying and other biases in evaluating transfusion protocols for traumatic hemorrhage. J Clin Epidemiol 2016; 77:52-59.e1. [PMID: 27134138 DOI: 10.1016/j.jclinepi.2016.03.029] [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: 03/09/2015] [Revised: 03/01/2016] [Accepted: 03/11/2016] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Transfusion research seeks to improve survival for severely injured and hemorrhaging patients using optimal plasma and platelet ratios over red blood cells (RBCs). However, most published studies comparing different ratios are plagued with serious bias and ignore time-varying effects. We applied joint recurrent event frailty models to increase validity and clinical utility. STUDY DESIGN AND SETTING Using the PRospective Observational Multicenter Major Trauma Transfusion study data, our joint random-effects models estimated the association of (1) clinical covariates with transfusion rate intensities and (2) varying plasma:RBC and platelet:RBC ratios with survival over the 24 hours after hospital admission. Along with survival time, baseline patient vital signs, laboratory values, and longitudinal data on types and volumes of transfusions were included. RESULTS Baseline systolic blood pressure, heart rate, pH, and hemoglobin were significantly associated with RBC transfusion rates. Increased transfusion rates (per hour) of plasma (P = 0.05), platelets (P < 0.001), or RBCs were associated with increased 24-hour mortality. Higher ratios of plasma:RBC (P = 0.107) and platelet:RBC (P < 0.001) were associated with reduced mortality in a time-varying pattern (P < 0.001). CONCLUSIONS The proposed joint analysis of transfusion rates and ratios offers a more valid statistical approach to evaluate survival effects in the presence of informative censoring by early death.
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Dudaryk R, Sheffy N, Hess JR. Changing Paradigms in Hemostatic Resuscitation: Timing, Extent, Economic Impact, and the Role of Factor Concentrates. CURRENT ANESTHESIOLOGY REPORTS 2016. [DOI: 10.1007/s40140-016-0143-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
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40
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The impact of increased plasma ratios in massively transfused trauma patients: a prospective analysis. Eur J Trauma Emerg Surg 2015; 42:519-525. [PMID: 26362535 DOI: 10.1007/s00068-015-0573-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2015] [Accepted: 09/02/2015] [Indexed: 10/23/2022]
Abstract
PURPOSE Transfusion ratios approaching 1:1 FFP:PRBC for trauma resuscitation have become the de facto standard of care. The aim of this study was to prospectively evaluate the effect of increasing ratios of FFP:PRBC transfusion on survival for massively transfused civilian trauma patients as well as determine if time to reach the target ratio had any effect on outcomes. METHODS This is a prospective, observational study of all trauma patients requiring a massive transfusion (≥10 PRBC in ≤24 h) at a level 1 trauma center over a 2.5-year period. The ratio of FFP:PRBC was tracked hourly up to 24 h post-initiation of massive transfusion. A logistic regression model was utilized to identify the ideal ratio associated with mortality prediction. A stepwise logistic regression was performed to identify independent predictors of mortality. RESULTS The study population was predominantly male (89 %) with a mean age of 34.8 ± 16. On admission, 22 % had a systolic blood pressure ≤90 mmHg, 47 % had a heart rate ≥120, and 25 % had a GCS ≤8. The overall mortality was 33 %. The ratio of FFP:PRBC ≥ 1:1.5 was the second most important independent predictor of mortality for this population (R (2) = 0.59). Survivors had a higher FFP:PRBC ratio at all times during the first 24 h of resuscitation. CONCLUSIONS Achieving a ratio of FFP:PRBC ≥ 1:1.5 after the initial 24 h of resuscitation significantly improves survival in massively transfused trauma patients compared to patients that achieved a ratio <1:1.5.
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Reynolds PS, Michael MJ, Cochran ED, Wegelin JA, Spiess BD. Prehospital use of plasma in traumatic hemorrhage (The PUPTH Trial): study protocol for a randomised controlled trial. Trials 2015. [PMID: 26220293 PMCID: PMC4518517 DOI: 10.1186/s13063-015-0844-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Background Severe traumatic injury and haemorrhagic shock are frequently associated with disruptions of coagulation function (such as trauma-induced coagulopathy TIC) and activation of inflammatory cascades. These pathologies may be exacerbated by current standard of care resuscitation protocols. Observational studies suggest early administration of plasma to severely-injured haemorrhaging patients may correct TIC, minimise inflammation, and improve survival. The proposed randomised clinical trial will evaluate the clinical effectiveness of pre-hospital plasma administration compared with standard- of-care crystalloid resuscitation in severely-injured patients with major traumatic haemorrhage. Methods/design This is a prospective, randomized, open-label, non-blinded trial to determine the effect of pre-hospital administration of thawed plasma (TP) on mortality, morbidity, transfusion requirements, coagulation, and inflammatory response in severely-injured bleeding trauma patients. Two hundred and ten eligible adult trauma patients will be randomised to receive either two units of plasma, to be administered in-field, vs standard of care normal saline (NS). Main analyses will compare subjects allocated to TP to those allocated to NS, on an intention-to-treat basis. Primary outcome measure is all-cause 30-day mortality. Secondary outcome measures include coagulation and lipidomic/pro-inflammatory marker responses, volume of resuscitation fluids (crystalloid, colloid) and blood products administered, and major hospital outcomes (e.g. incidence of MSOF, length of ICU stay, length of hospital stay). Discussion This study is part of a US Department of Defense (DoD)-funded multi-institutional investigation, conducted independently of, but in parallel with, the University of Pittsburgh and University of Denver. Demonstration of significant reductions in mortality and coagulopathic/inflammatory-related morbidities as a result of pre-hospital plasma administration would be of considerable clinical importance for the management of haemorrhagic shock in both civilian and military populations. Trial registration ClinicalTrials.gov: NCT02303964 on 28 November 2014
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Affiliation(s)
- Penny S Reynolds
- Department of Anesthesiology, Virginia Commonwealth University Medical Center, Richmond, VA, USA.
| | - Mary Jane Michael
- Department of Anesthesiology, Virginia Commonwealth University Medical Center, Richmond, VA, USA.
| | - Emily D Cochran
- Department of Anesthesiology, Virginia Commonwealth University Medical Center, Richmond, VA, USA.
| | - Jacob A Wegelin
- Department of Biostatistics, Virginia Commonwealth University, Richmond, VA, USA.
| | - Bruce D Spiess
- Department of Anesthesiology, Virginia Commonwealth University Medical Center, Richmond, VA, USA.
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Ning J, Rahbar MH, Choi S, Piao J, Hong C, Del Junco DJ, Rahbar E, Fox EE, Holcomb JB, Wang MC. Estimating the ratio of multivariate recurrent event rates with application to a blood transfusion study. Stat Methods Med Res 2015; 26:1969-1981. [PMID: 26160825 DOI: 10.1177/0962280215593974] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
In comparative effectiveness studies of multicomponent, sequential interventions like blood product transfusion (plasma, platelets, red blood cells) for trauma and critical care patients, the timing and dynamics of treatment relative to the fragility of a patient's condition is often overlooked and underappreciated. While many hospitals have established massive transfusion protocols to ensure that physiologically optimal combinations of blood products are rapidly available, the period of time required to achieve a specified massive transfusion standard (e.g. a 1:1 or 1:2 ratio of plasma or platelets:red blood cells) has been ignored. To account for the time-varying characteristics of transfusions, we use semiparametric rate models for multivariate recurrent events to estimate blood product ratios. We use latent variables to account for multiple sources of informative censoring (early surgical or endovascular hemorrhage control procedures or death). The major advantage is that the distributions of latent variables and the dependence structure between the multivariate recurrent events and informative censoring need not be specified. Thus, our approach is robust to complex model assumptions. We establish asymptotic properties and evaluate finite sample performance through simulations, and apply the method to data from the PRospective Observational Multicenter Major Trauma Transfusion study.
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Affiliation(s)
- Jing Ning
- 1 Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - Mohammad H Rahbar
- 2 Division of Clinical and Translational Sciences, Department of Internal Medicine, The University of Texas Medical School at Houston, Houston, USA.,3 Division of Epidemiology, Human Genetics and Environmental Sciences, School of Public Health, The University of Texas Health Sciences Center at Houston, Houston, USA
| | - Sangbum Choi
- 2 Division of Clinical and Translational Sciences, Department of Internal Medicine, The University of Texas Medical School at Houston, Houston, USA
| | - Jin Piao
- 4 Division of Biostatistics, School of Public Health, The University of Texas Health Sciences Center at Houston, Houston, USA
| | - Chuan Hong
- 4 Division of Biostatistics, School of Public Health, The University of Texas Health Sciences Center at Houston, Houston, USA
| | - Deborah J Del Junco
- 5 Center for Translational Injury Research, Division of Acute Care Surgery, Department of Surgery, The University of Texas Health Science Center at Houston, Houston, USA
| | - Elaheh Rahbar
- 6 Department of Biomedical Engineering, Wake Forest University, Winston-Salem, USA
| | - Erin E Fox
- 5 Center for Translational Injury Research, Division of Acute Care Surgery, Department of Surgery, The University of Texas Health Science Center at Houston, Houston, USA
| | - John B Holcomb
- 5 Center for Translational Injury Research, Division of Acute Care Surgery, Department of Surgery, The University of Texas Health Science Center at Houston, Houston, USA
| | - Mei-Cheng Wang
- 7 Department of Biostatistics, School of Public Health, Johns Hopkins University, Baltimore, USA
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Del Junco DJ, Bulger EM, Fox EE, Holcomb JB, Brasel KJ, Hoyt DB, Grady JJ, Duran S, Klotz P, Dubick MA, Wade CE. Collider bias in trauma comparative effectiveness research: the stratification blues for systematic reviews. Injury 2015; 46:775-80. [PMID: 25766096 PMCID: PMC4402274 DOI: 10.1016/j.injury.2015.01.043] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2014] [Revised: 01/02/2015] [Accepted: 01/26/2015] [Indexed: 02/02/2023]
Abstract
BACKGROUND Collider bias, or stratifying data by a covariate consequence rather than cause (confounder) of treatment and outcome, plagues randomised and observational trauma research. Of the seven trials of prehospital hypertonic saline in dextran (HSD) that have been evaluated in systematic reviews, none found an overall between-group difference in survival, but four reported significant subgroup effects. We hypothesised that an avoidable type of collider bias often introduced inadvertently into trauma comparative effectiveness research could explain the incongruous findings. METHODS The two most recent HSD trials, a single-site pilot and a multi-site pivotal study, provided data for a secondary analysis to more closely examine the potential for collider bias. The two trials had followed the a priori statistical analysis plan to subgroup patients by a post-randomisation covariate and well-established surrogate for bleeding severity, massive transfusion (MT), ≥ 10 unit of red blood cells within 24h of admission. Despite favourable HSD effects in the MT subgroup, opposite effects in the non-transfused subgroup halted the pivotal trial early. In addition to analyzing the data from the two trials, we constructed causal diagrams and performed a meta-analysis of the results from all seven trials to assess the extent to which collider bias could explain null overall effects with subgroup heterogeneity. RESULTS As in previous trials, HSD induced significantly greater increases in systolic blood pressure (SBP) from prehospital to admission than control crystalloid (p=0.003). Proportionately more HSD than control decedents accrued in the non-transfused subgroup, but with paradoxically longer survival. Despite different study populations and a span of over 20 years across the seven trials, the reported mortality effects were consistently null, summary RR=0.99 (p=0.864, homogeneity p=0.709). CONCLUSIONS HSD delayed blood transfusion by modifying standard triggers like SBP with no detectable effect on survival. The reported heterogeneous HSD effects in subgroups can be explained by collider bias that trauma researchers can avoid by improved covariate selection and data capture strategies.
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Affiliation(s)
- Deborah J Del Junco
- University of Texas Health Science Center, Department of Surgery, Houston, TX, United States.
| | - Eileen M Bulger
- University of Washington, Department of Surgery, Seattle, WA, United States
| | - Erin E Fox
- University of Texas Health Science Center, Department of Surgery, Houston, TX, United States
| | - John B Holcomb
- University of Texas Health Science Center, Department of Surgery, Houston, TX, United States
| | - Karen J Brasel
- Oregon Health & Science University, Department of Surgery, Portland, OR, United States
| | - David B Hoyt
- American College of Surgeons, Chicago, IL, United States
| | - James J Grady
- University of Connecticut Health Center, Institute for Clinical and Translational Science, Farmington, CT, United States
| | - Sarah Duran
- University of Texas Health Science Center, Department of Surgery, Houston, TX, United States
| | - Patricia Klotz
- University of Washington, Department of Surgery, Seattle, WA, United States
| | - Michael A Dubick
- U.S. Army Institute of Surgical Research, San Antonio, TX, United States
| | - Charles E Wade
- University of Texas Health Science Center, Department of Surgery, Houston, TX, United States
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Duranteau J, Asehnoune K, Pierre S, Ozier Y, Leone M, Lefrant JY. Recommandations sur la réanimation du choc hémorragique. ANESTHESIE & REANIMATION 2015. [DOI: 10.1016/j.anrea.2014.12.007] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
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Simms ER, Hennings DL, Hauch A, Wascom J, Fontenot TE, Hunt JP, McSwain NE, Meade PC, Myers L, Duchesne JC. Impact of infusion rates of fresh frozen plasma and platelets during the first 180 minutes of resuscitation. J Am Coll Surg 2014; 219:181-8. [PMID: 24974265 DOI: 10.1016/j.jamcollsurg.2014.03.050] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2013] [Revised: 03/07/2014] [Accepted: 03/07/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND Whether high-ratio resuscitation (HRR) provides patients with survival advantage remains controversial. We hypothesized a direct correlation between HRR infusion rates in the first 180 minutes of resuscitation and survival. STUDY DESIGN This was a retrospective analysis of massively transfused trauma patients surviving more than 30 minutes and undergoing surgery at a level 1 trauma center. Mean infusion rates (MIR) of packed red blood cells (PRBC), fresh frozen plasma (FFP), and platelets (Plt) were calculated for length of intervention (emergency department [ED] time + operating room [OR] time). Patients were categorized as HRR (FFP:PRBC > 0.7, and/or Plts: PRBC > 0.7) vs low-ratio resuscitation (LRR). Student's t-tests and chi-square tests were used to compare survivors with nonsurvivors. Cox proportional hazards regression models and Kaplan-Meier curves were generated to evaluate the association between MIR for FFP:PRBC and Plt:PRBC and 180-minute survival. RESULTS There were 151 patients who met criteria: 121 (80.1%) patients survived 180 minutes (MIR:PRBC 71.9 mL/min, FFP 92.0 mL/min, Plt 3.5 mL/min) vs 30 (19.9%) who did not survive (MIR:PRBC 47.3 mL/min, FFP 33.7 mL/min, Plt 1.1 mL/min), p = 0.43, p < 0.0001 and p < 0.011, respectively. A Cox regression model evaluated PRBC rate, FFP rate, and Plt rate (mL/min) as mortality predictors within 180 minutes to assess if they significantly affected survival (hazard ratios 1.01 [p = 0.054], 0.97 [p < 0.0001], and 0.75 [p = 0.01], respectively). Another model used stepwise Cox regression including PRBC rate, FFP rate, and Plt rate (hazard ratios 1.00 [p = 0.85], 0.97 [p < 0.0001], and 0.88 [p = 0.24], respectively), as well as possible confounding variables. CONCLUSIONS This is the first study to examine effects of MIRs on survival. Further studies on the effects of narrow time-interval analysis for blood product resuscitation are warranted.
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Affiliation(s)
- Eric R Simms
- Department of Surgery, Tulane University School of Medicine, New Orleans, LA
| | - Dietric L Hennings
- Department of Surgery, Tulane University School of Medicine, New Orleans, LA
| | - Adam Hauch
- Department of Surgery, Tulane University School of Medicine, New Orleans, LA
| | - Julie Wascom
- Department of Surgery, Louisiana State University Health Sciences Center, New Orleans, LA
| | - Tatyana E Fontenot
- Department of Surgery, Tulane University School of Medicine, New Orleans, LA
| | - John P Hunt
- Department of Surgery, Louisiana State University Health Sciences Center, New Orleans, LA
| | - Norman E McSwain
- Department of Surgery, Tulane University School of Medicine, New Orleans, LA
| | - Peter C Meade
- Department of Surgery, Tulane University School of Medicine, New Orleans, LA
| | - Leann Myers
- Tulane University School of Public Health and Tropical Medicine, New Orleans, LA
| | - Juan C Duchesne
- Department of Surgery, Tulane University School of Medicine, New Orleans, LA; Department of Surgery, Louisiana State University Health Sciences Center, New Orleans, LA; North Oaks Shock/Trauma, Division of Trauma/Critical Care, Hammond, LA.
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Cherian A, Udupi BP. Acute coagulopathy of trauma: Mechanism, monitoring, management. World J Anesthesiol 2014; 3:111-118. [DOI: 10.5313/wja.v3.i1.111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2013] [Revised: 01/14/2014] [Accepted: 02/20/2014] [Indexed: 02/06/2023] Open
Abstract
Coagulopathy is a well-known consequence of trauma and is the most common cause of mortality in the young. However, its cause and management is still controversial. A new concept in the understanding of coagulopathy in trauma is the occurrence of Acute coagulopathy of trauma (ACoT). ACoT is associated with hypo perfusion and tissue trauma as seen in massive injury. The incidence of coagulopathy increases with injury scores and is associated with higher number of ventilator days, higher morbidity and mortality. The process of coagulation is better described by the cell based model with a central role for platelets rather than the older plasma based model. This shift in our understanding supports the theory that ACoT results from the endothelial release of thrombomodulin and activated protein C in the presence of hypoperfusion. This in turn leads on to a hyperfibrinolytic and hypocoagulable state. Viscoelastic hemostatic assays are replacing the older tests like prothrombin time in the assessment of coagulopathy. These tests are accurate, determine the need for transfusion and can be performed at the point of care. Damage control resuscitation includes newer concepts like permissive hypotension, increased use of plasma as a part of massive transfusion protocols and damage control surgery.
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Abstract
Hemorrhage remains one of the leading causes of trauma-related deaths. Uncontrolled diffuse microvascular bleeding in the course of initial care is common, potentially resulting in exsanguination. Early and aggressive hemostatic intervention increases survival and reduces the incidence of massive transfusion. Thus, timely diagnosis of the underlying coagulation disorders is mandatory. It has been shown that standard coagulation tests do not sufficiently characterize trauma-induced coagulopathy (TIC). This has led to increasing interest in alternatives, such as the viscoelastic test, to diagnose TIC and to provide the basis for a goal-directed hemostatic therapy. The concept of damage control resuscitation (DCR) has been introduced widely in trauma patients with severe bleeding. This strategy addresses important confounders of the coagulation process such as hemodilution, hypothermia, and acidosis; DCR is based on a damage control surgical approach, permissive hypotension, and improvement of hemostatic competence. Many studies have shown benefit in mortality when using high ratios of fresh frozen plasma (FFP) to red blood cells (RBC) as early treatment. However, there is increased awareness that coagulation factor concentrate could be beneficial in the treatment of trauma-induced coagulopathy.
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Affiliation(s)
- Herbert Schöchl
- Department of Anaesthesiology and Intensive Care Medicine, AUVA Trauma Centre, Salzburg, Austria.
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Pidcoke HF, McFaul SJ, Ramasubramanian AK, Parida BK, Mora AG, Fedyk CG, Valdez-Delgado KK, Montgomery RK, Reddoch KM, Rodriguez AC, Aden JK, Jones JA, Bryant RS, Scherer MR, Reddy HL, Goodrich RP, Cap AP. Primary hemostatic capacity of whole blood: a comprehensive analysis of pathogen reduction and refrigeration effects over time. Transfusion 2013; 53 Suppl 1:137S-149S. [PMID: 23301966 PMCID: PMC4321786 DOI: 10.1111/trf.12048] [Citation(s) in RCA: 151] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Whole blood (WB) has been used in combat since World War I as it is readily available and replaces every element of shed blood. Component therapy has become standard; however, recent military successes with WB resuscitation have revived the debate regarding wider WB use. Characterization of optimal WB storage is needed. We hypothesized that refrigeration preserves WB function and that a pathogen reduction technology (PRT) based on riboflavin and ultraviolet light has no deleterious effect over 21 days of storage. STUDY DESIGN AND METHODS WB units were stored for 21 days either at 4°C or 22°C. Half of each temperature group underwent PRT, yielding four final treatment groups (n = 8 each): CON 4 (WB at 4°C); CON 22 (WB at 22°C); PRT 4 (PRT WB at 4°C); and PRT 22 (PRT WB at 22°C). Testing was at baseline, Days 1-7, 10, 14, and 21. Assays included coagulation factors; platelet activation, aggregation, and adhesion; and thromboelastography (TEG). RESULTS Prothrombin time (PT) and partial thromboplastin time increased over time; refrigeration attenuated the effects on PT (p ≤ 0.009). Aggregation decreased over time (p ≤ 0.001); losses were attenuated by refrigeration (p ≤ 0.001). Refrigeration preserved TEG parameters (p ≤ 0.001) and PRT 4 samples remained within normal limits throughout the study. Refrigeration in combination with PRT inhibited fibrinolysis (p ≤ 0.001) and microparticle formation (p ≤ 0.031). Cold storage increased shear-induced platelet aggregation and ristocetin-induced platelet agglutination (p ≥ 0.032), as well as GPIb-expressing platelets (p ≤ 0.009). CONCLUSION The in vitro hemostatic function of WB is largely unaffected by PRT treatment and better preserved by cold storage over 21 days. Refrigerated PRT WB may be suitable for trauma resuscitation. Clinical studies are warranted.
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Affiliation(s)
- Heather F Pidcoke
- US Army Institute of Surgical Research, Fort Sam Houston, Texas 78234-6315, USA
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