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Niemann M, Otto E, Eder C, Youssef Y, Kaufner L, Märdian S. Coagulopathy management of multiple injured patients - a comprehensive literature review of the European guideline 2019. EFORT Open Rev 2022; 7:710-726. [PMID: 36287131 PMCID: PMC9619392 DOI: 10.1530/eor-22-0054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
The European guideline on the management of trauma-induced major bleeding and coagulopathy summarises the most relevant recommendations for trauma coagulopathy management. The management of trauma-induced major bleeding should interdisciplinary follow algorithms which distinguish between life-threatening and non-life-threatening bleeding. Point-of-care viscoelastic methods (VEM) assist target-controlled haemostatic treatment. Neither conventional coagulation assays nor VEM should delay treatment in life-threatening trauma-induced bleeding. Adjustments may be rational due to local circumstances, including the availability of blood products, pharmaceuticals, and employees.
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Affiliation(s)
- Marcel Niemann
- Charité – Universitätsmedizin Berlin, Center for Musculoskeletal Surgery, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany,Julius Wolff Institute for Biomechanics and Musculoskeletal Regeneration, Berlin Institute of Health at Charité – Universitätsmedizin Berlin, Berlin, Germany,Correspondence should be addressed to M Niemann;
| | - Ellen Otto
- Charité – Universitätsmedizin Berlin, Center for Musculoskeletal Surgery, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany,Julius Wolff Institute for Biomechanics and Musculoskeletal Regeneration, Berlin Institute of Health at Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Christian Eder
- Charité – Universitätsmedizin Berlin, Center for Musculoskeletal Surgery, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Yasmin Youssef
- Department of Orthopaedics, Trauma Surgery and Plastic Surgery, University Hospital Leipzig, Leipzig, Germany
| | - Lutz Kaufner
- Charité – Universitätsmedizin Berlin, Department of Anesthesiology and Intensive Care Medicine, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Sven Märdian
- Charité – Universitätsmedizin Berlin, Center for Musculoskeletal Surgery, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
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Pekrul I, Schachtner T, Zwißler B, Möhnle P. [Tranexamic acid for bleeding prophylaxis in orthopedic surgery and trauma-standard or customized therapy?]. Anaesthesist 2021; 70:515-521. [PMID: 33620508 PMCID: PMC8190014 DOI: 10.1007/s00101-021-00928-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/27/2021] [Indexed: 11/23/2022]
Abstract
The use of tranexamic acid (TXA) is established in the treatment of bleeding, especially of bleeding due to hyperfibrinolysis. In recent years the prophylactic use of TXA in trauma and orthopedic surgery has increased leading to open questions regarding potentially associated risks and a possible classification as off label use. The available literature provides a sound basis for the recommendation that TXA can be used in these indications provided that an individual risk assessment is done in patients with increased risks for thromboembolic complications. Although the prophylactic use of TXA in orthopedic surgery and trauma is not explicitly listed in the product characteristics, it should not be regarded as an off label use.
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Affiliation(s)
- Isabell Pekrul
- Klinik für Anaesthesiologie, Abteilung für Transfusionsmedizin, Zelltherapeutika und Hämostaseologie, Universität München (LMU), Marchioninistr. 15, 81377, München, Deutschland
| | - Thomas Schachtner
- Anästhesie und Intensivmedizin, Schön Klinik München Harlaching, München, Deutschland
| | - Bernhard Zwißler
- Klinik für Anaesthesiologie, Universität München (LMU), München, Deutschland
| | - Patrick Möhnle
- Klinik für Anaesthesiologie, Abteilung für Transfusionsmedizin, Zelltherapeutika und Hämostaseologie, Universität München (LMU), Marchioninistr. 15, 81377, München, Deutschland.
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3
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Savioli G, Ceresa IF, Caneva L, Gerosa S, Ricevuti G. Trauma-Induced Coagulopathy: Overview of an Emerging Medical Problem from Pathophysiology to Outcomes. MEDICINES (BASEL, SWITZERLAND) 2021; 8:16. [PMID: 33805197 PMCID: PMC8064317 DOI: 10.3390/medicines8040016] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Revised: 02/15/2021] [Accepted: 03/07/2021] [Indexed: 12/17/2022]
Abstract
Coagulopathy induced by major trauma is common, affecting approximately one-third of patients after trauma. It develops independently of iatrogenic, hypothermic, and dilutive causes (such as iatrogenic cause in case of fluid administration), which instead have a pejorative aspect on coagulopathy. Notwithstanding the continuous research conducted over the past decade on Trauma-Induced Coagulopathy (TIC), it remains a life-threatening condition with a significant impact on trauma mortality. We reviewed the current evidence regarding TIC diagnosis and pathophysiological mechanisms and summarized the different iterations of optimal TIC management strategies among which product resuscitation, potential drug administrations, and hemostatis-focused approaches. We have identified areas of ongoing investigation and controversy in TIC management.
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Affiliation(s)
- Gabriele Savioli
- Emergency Department, IRCCS Policlinico San Matteo, PhD University of Pavia, 27100 Pavia, Italy; (I.F.C.); (S.G.)
| | - Iride Francesca Ceresa
- Emergency Department, IRCCS Policlinico San Matteo, PhD University of Pavia, 27100 Pavia, Italy; (I.F.C.); (S.G.)
| | - Luca Caneva
- Anesthesia and Intensive Care, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy;
| | - Sebastiano Gerosa
- Emergency Department, IRCCS Policlinico San Matteo, PhD University of Pavia, 27100 Pavia, Italy; (I.F.C.); (S.G.)
| | - Giovanni Ricevuti
- Department of Drug Science, University of Pavia, 27100 Pavia, Italy;
- Saint Camillus International University of Health Sciences, 00152 Rome, Italy
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Use of fibrinogen concentrate for trauma-related bleeding: A systematic-review and meta-analysis. J Trauma Acute Care Surg 2021; 89:1212-1224. [PMID: 32890340 DOI: 10.1097/ta.0000000000002920] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Trauma-induced coagulopathy contributes to significant morbidity and mortality in patients who experience trauma-related bleeding. This study aimed to synthesize the evidence supporting the efficacy and safety of preemptive and goal-directed fibrinogen concentrate (FC) in the management of trauma-related hemorrhage. METHODS PubMed, Medline, EMBASE, Web of Science, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, ClinicalTrials.gov, and the WHO International Clinical Trials Registry Platform were systematically searched. All trial designs, except individual case reports, which evaluated the preemptive or goal-directed use of FC for trauma-related bleeding/coagulopathy, in patients older than 16 years, were included in the systematic review. For the included randomized controlled trials comparing FC with control, meta-analysis was performed and a risk-of bias-assessment was completed using the Cochrane Methodology and Preferred Reporting Items Systematic Reviews and Meta-analysis guidelines. RESULTS A total of 2,743 studies were identified; 26 were included in the systematic review, and 5 randomized controlled trials (n = 238) were included in the meta-analysis. For the primary outcome of mortality, there was no statistically significant difference between the groups, with 22% and 23.4% in the FC and comparator arms, respectively (risk ratio, 1.00 [95% confidence interval, 0.39 to 2.56]; p = 0.99). In addition, there was no statistical difference between FC and control in packed red blood cell, fresh frozen plasma, or platelet transfusion requirements, and thromboembolic events. Overall, the quality of evidence was graded as low to moderate because of concerns with risk of bias, imprecision, and inconsistency. CONCLUSION Further high-quality, adequately powered studies are needed to assess the impact of FC in trauma, with a focus on administration as early as possible from the point of entry into the trauma system of care. LEVEL OF EVIDENCE Systematic review and Meta-analysis, level II.
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Napolitano LM. Hemostatic defects in massive transfusion: an update and treatment recommendations. Expert Rev Hematol 2021; 14:219-239. [PMID: 33267678 DOI: 10.1080/17474086.2021.1858788] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Acute hemorrhage is a global healthcare issue, and remains the leading preventable cause of death in trauma. Acute severe hemorrhage can be related to traumatic, peripartum, gastrointestinal, and procedural causes. Hemostatic defects occur early in patients requiring massive transfusion. Early recognition and treatment of hemorrhage and hemostatic defects are required to save lives and to achieve optimal patient outcomes. AREAS COVERED This review discusses current evidence and trials aimed at identifying the optimal treatment for hemostatic defects in hemorrhage and massive transfusion. Literature search included PubMed and Embase. EXPERT OPINION Patients with acute hemorrhage requiring massive transfusion commonly develop coagulopathy due to specific hemostatic defects, and accurate diagnosis and prompt correction are required for definitive hemorrhage control. Damage control resuscitation and massive transfusion protocols are optimal initial treatment strategies, followed by goal-directed individualized resuscitation using real-time coagulation monitoring. Distinct phenotypes exist in trauma-induced coagulopathy, including 'Bleeding' or 'Thrombotic' phenotypes, and hyperfibrinolysis vs. fibrinolysis shutdown. The trauma 'lethal triad' (hypothermia, coagulopathy, acidosis) has been updated to the 'lethal diamond' (including hypocalcemia). A number of controversies in optimal management exist, including whole blood vs. component therapy, use of factor concentrates vs. blood products, optimal use of tranexamic acid, and prehospital plasma and tranexamic acid administration.
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Affiliation(s)
- Lena M Napolitano
- Department of Surgery, University of Michigan Health System, University Hospital, Ann Arbor, Michigan, USA
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Upadhyaya GK, Iyengar KP, Jain VK, Garg R. Evolving concepts and strategies in the management of polytrauma patients. J Clin Orthop Trauma 2021; 12:58-65. [PMID: 33716429 PMCID: PMC7920163 DOI: 10.1016/j.jcot.2020.10.021] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Revised: 10/04/2020] [Accepted: 10/12/2020] [Indexed: 02/07/2023] Open
Abstract
Major trauma is one of the leading causes of morbidity and mortality in young adults. The impact of disability on the quality of life and functionality in this younger population is worrisome. This remains a major public health concern across the globe. Immediate and early deaths account for nearly 80% of trauma deaths occurring within the first few hours of injury to the first few days, usually because of traumatic brain injury or major exsanguination and subsequently due to shock or hypoxia. Worldwide adoption of comprehensive trauma systems and evolving models of trauma care including prehospital interventions have led improvements in trauma and critical care over the last few decades. Resuscitation and damage control orthopaedics are two key pillars in the management of polytrauma patient. Trauma-related coagulopathy can be an emerging complication during resuscitation of such patients which should be recognized early so appropriate corrective measures can be undertaken. We describe the evolving models of care in the management of polytrauma and trauma associated coagulopathy.
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Affiliation(s)
- Gaurav K. Upadhyaya
- Department of Orthopaedics, All India Institute of Medical Sciences, Raebareli, UP, 229405, India
| | | | - Vijay Kumar Jain
- Department of Orthopaedics, Atal Bihari Vajpayee Institute of Medical Sciences, Dr Ram Manohar Lohia Hospital, New Delhi, 110001, India
- Corresponding author. Department of Orthopaedics, Atal Bihari Vajpayee Institute of Medical Sciences, Dr Ram Manohar Lohia Hospital, New Delhi, 110001, India.
| | - Rakesh Garg
- Department of Onco-Anaesthesiology and Palliative Medicine, Dr BRAIRCH, All India Institute of Medical Sciences, New Delhi, 110029, India
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Giordano V, Giannoudis VP, Giannoudis PV. Current trends in resuscitation for polytrauma patients with traumatic haemorrhagic shock. Injury 2020; 51:1945-1948. [PMID: 32829760 DOI: 10.1016/j.injury.2020.08.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Affiliation(s)
- Vincenzo Giordano
- Hospital Municipal Miguel Couto, Serviço de Ortopedia e Traumatologia Prof. Nova Monteiro - Rio de Janeiro - RJ - Brasil
| | - Vasileios P Giannoudis
- Academic Department of Trauma and Orthopaedics, School of Medicine, University of Leeds, United Kingdom
| | - Peter V Giannoudis
- Academic Department of Trauma and Orthopaedics, School of Medicine, University of Leeds, United Kingdom; NIHR Leeds Biomedical Research Center, Chapel Allerton Hospital, Leeds, United Kingdom.
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Bocci MG, Nardi G, Veronesi G, Rondinelli MB, Palma A, Fiore V, De Candia E, Bianchi M, Maresca M, Barelli R, Tersali A, Dell'Anna AM, De Pascale G, Cutuli SL, Mercurio G, Caricato A, Grieco DL, Antonelli M, Cingolani E. Data on the application of early coagulation support protocol in the management of major trauma patients. Data Brief 2019; 27:104768. [PMID: 31763415 PMCID: PMC6861613 DOI: 10.1016/j.dib.2019.104768] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Accepted: 10/31/2019] [Indexed: 11/08/2022] Open
Abstract
This article provides additional data on the application of early coagulation support protocol in the management of major trauma patients. Data come from a retrospective analysis reported in the article “Early coagulation support protocol: a valid approach in real-life management of major trauma patients. Results from two Italian centres” [1]. Data contain information about the relationship between differences in resource use and mortality outcomes, and patient demographic and clinical features at presentation. Furthermore, a comparison between resource consumption, the probability of multiple transfusions and the mortality outcomes among propensity-score matched patients is reported.
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Affiliation(s)
- Maria Grazia Bocci
- Dipartimento di Scienze dell'Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Istituto di Anestesiologia e Rianimazione, Università Cattolica del sacro Cuore, Rome, Italy
| | - Giuseppe Nardi
- UOC Anestesia e Rianimazione, Ospedale Infermi, Rimini, Italy
| | - Giovanni Veronesi
- Centro Ricerche in Epidemiologia e Medicina Preventiva, Dipartimento di Medicina Clinica e Sperimentale, Università degli Studi dell'Insubria, Varese, Italy
| | - Maria Beatrice Rondinelli
- UOC Medicina Trasfusionale e Cellule Staminali, Azienda Ospedaliera San Camillo Forlanini, Rome, Italy
| | - Antonella Palma
- UOC Anestesia e Rianimazione, CTO Azienda Ospedaliera dei Colli, Napoli, Italy
| | - Valentina Fiore
- UOC Anestesia e Rianimazione, Azienda Ospedaliera Vito Fazi, Lecce, Italy
| | - Erica De Candia
- UOS Malattie Emorragiche e Trombotiche, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Istituto di Medicina Interna e Geriatria, Università Cattolica del sacro Cuore, Rome, Italy
| | - Maria Bianchi
- UOC Emotrasfusione, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Istituto di Ematologia, Università Cattolica del sacro Cuore, Rome, Italy
| | - Maddalena Maresca
- UOC Emotrasfusione, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Istituto di Ematologia, Università Cattolica del sacro Cuore, Rome, Italy
| | - Roberta Barelli
- UOC Anestesia e Rianimazione, Ospedale San Giovanni Calibita Fatebenefratelli, Rome, Italy
| | - Alessandra Tersali
- Dipartimento di Scienze dell'Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Istituto di Anestesiologia e Rianimazione, Università Cattolica del sacro Cuore, Rome, Italy
| | - Antonio Maria Dell'Anna
- Dipartimento di Scienze dell'Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Istituto di Anestesiologia e Rianimazione, Università Cattolica del sacro Cuore, Rome, Italy
| | - Gennaro De Pascale
- Dipartimento di Scienze dell'Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Istituto di Anestesiologia e Rianimazione, Università Cattolica del sacro Cuore, Rome, Italy
| | - Salvatore Lucio Cutuli
- Dipartimento di Scienze dell'Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Istituto di Anestesiologia e Rianimazione, Università Cattolica del sacro Cuore, Rome, Italy
| | - Giovanna Mercurio
- Dipartimento di Scienze dell'Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Istituto di Anestesiologia e Rianimazione, Università Cattolica del sacro Cuore, Rome, Italy
| | - Anselmo Caricato
- Dipartimento di Scienze dell'Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Istituto di Anestesiologia e Rianimazione, Università Cattolica del sacro Cuore, Rome, Italy
| | - Domenico Luca Grieco
- Dipartimento di Scienze dell'Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Istituto di Anestesiologia e Rianimazione, Università Cattolica del sacro Cuore, Rome, Italy
| | - Massimo Antonelli
- Dipartimento di Scienze dell'Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Istituto di Anestesiologia e Rianimazione, Università Cattolica del sacro Cuore, Rome, Italy
| | - Emiliano Cingolani
- UOSD Shock e Trauma, Azienda Ospedaliera San Camillo Forlanini, Rome, Italy
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