Massive transfusion and nonsurgical hemostatic agents:

Use of resuscitative endovascular balloon occlusion of the aorta (REBOA) for trauma and its performance in Japan over the past 18 years: a nationwide descriptive study

BACKGROUND

Resuscitative endovascular balloon occlusion of the aorta (REBOA) has been used to control massive hemorrhages. Although there is no consensus on the efficacy of REBOA, it remains an option as a bridging therapy in non-trauma centers where trauma surgeons are not available. To better understand the current landscape of REBOA application, we examined changes in its usage, target population, and treatment outcomes in Japan, where immediate hemostasis procedures sometimes cannot be performed.

METHODS

This retrospective observational study used the Japan Trauma Data Bank data. All cases in which REBOA was performed between January 2004 and December 2021 were included. The primary outcome was the in-hospital mortality rate. We analyzed mortality trends over time according to the number of cases, number of centers, severity of injury, and overall and subgroup mortality associated with REBOA usage. We performed a logistic analysis of mortality trends over time, adjusting for probability of survival based on the trauma and injury severity score.

RESULTS

Overall, 2557 patients were treated with REBOA and were deemed eligible for inclusion. The median age of the participants was 55 years, and male patients constituted 65.3% of the study population. Blunt trauma accounted for approximately 93.0% of the cases. The number of cases and facilities that used REBOA increased until 2019. While the injury severity score and revised trauma score did not change throughout the observation period, the hospital mortality rate decreased from 91.3 to 50.9%. The REBOA group without severe head or spine injuries showed greater improvement in mortality than the all-patient group using REBOA and all-trauma patient group. The greatest improvement in mortality was observed in patients with systolic blood pressure ≥ 80 mmHg. The adjusted odds ratios for hospital mortality steadily declined, even after adjusting for the probability of survival.

CONCLUSIONS

While there was no significant change in patient severity, mortality of patients treated with REBOA decreased over time. Further research is required to determine the reasons for these improvements in trauma care.

Surgical Science and the Evolution of Critical Care Medicine

Surgical science has driven innovation and inquiry across adult and pediatric disciplines that provide critical care regardless of location. Surgically originated but broadly applicable knowledge has been globally shared within the pages Critical Care Medicine over the last 50 years.

Coagulopathy management of multiple injured patients - a comprehensive literature review of the European guideline 2019

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.

Ex vivo study: is it possible to overcome the blurriness caused by holmium laser fragmentation of kidney stones?

Better endoscopic vision is mandatory for successful ureteroscopic stone operations to achieve shorter operating time. However, an important impairing factor for a good endoscopic view is the cloudiness of vision which was formed during laser fragmentation. Holmium laser fragmentation of calcium oxalate stones produces calcium carbonate solubility of which is dependent on pH, citrate, and phosphate. In this ex vivo research, the solubility of calcium carbonate has been investigated in solutions composed of various concentrations of citrate and phosphate buffered at different pH levels after laser fragmentation of calcium oxalate stones. Calcium oxalate stones were placed into the laboratory tubes filled with various concentrations of citrate-phosphate buffers with different pH values. Laser energy in dusting mode was applied to the stones and spectrophotometric measurement for optical density (OD) was calculated for each buffered solution for clarity comparison. In the first phase, solutions composed of four different molar concentrations of citrate-phosphate buffer (0.2, 0.3, 0.4 and 0.5 molars) at various pH levels were used. Then, the next phase of the study was designed to compare solutions demonstrating the lowest OD values with an isotonic saline solution. The results were most convenient at 0.5 molarity (pH = 6) followed by 0.4 molarity (pH = 7) in the first phase (OD values of 0.054 and 0.065, respectively). In the next phase, OD values of both buffered solutions were significantly lower than those of isotonic saline solution (p = 0). Two specific buffers have provided better optic visibility values after laser fragmentation supporting their use as an irrigation solution for the favor of less cloudiness.

Direct Peritoneal Resuscitation Improves Survival in a Murine Model of Combined Hemorrhage and Burn Injury

INTRODUCTION

Combined burn injury and hemorrhagic shock are a common cause of injury in wounded warfighters. Current protocols for resuscitation for isolated burn injury and isolated hemorrhagic shock are well defined, but the optimal strategy for combined injury is not fully established. Direct peritoneal resuscitation (DPR) has been shown to improve survival in rats after hemorrhagic shock, but its role in a combined burn/hemorrhage injury is unknown. We hypothesized that DPR would improve survival in mice subjected to combined burn injury and hemorrhage.

MATERIALS AND METHODS

Male C57/BL6J mice aged 8 weeks were subjected to a 7-second 30% total body surface area scald in a 90°C water bath. Following the scald, mice received DPR with 1.5 mL normal saline or 1.5 mL peritoneal dialysis solution (Delflex). Control mice received no peritoneal solution. Mice underwent a controlled hemorrhage shock via femoral artery cannulation to a systolic blood pressure of 25 mm Hg for 30 minutes. Mice were then resuscitated to a target blood pressure with either lactated Ringer's (LR) or a 1:1 ratio of packed red blood cells (pRBCs) and fresh frozen plasma (FFP). Mice were observed for 24 hours following injury.

RESULTS

Median survival time for mice with no DPR was 1.47 hours in combination with intravascular LR resuscitation and 2.08 hours with 1:1 pRBC:FFP. Median survival time significantly improved with the addition of intraperitoneal normal saline or Delflex. Mice that received DPR followed by 1:1 pRBC:FFP required less intravascular volume than mice that received DPR with LR, pRBC:FFP alone, and LR alone. Intraperitoneal Delflex was associated with higher levels of tumor necrosis factor alpha and macrophage inflammatory protein 1 alpha and lower levels of interleukin 10 and intestinal fatty acid binding protein. Intraperitoneal normal saline resulted in less lung injury 1 hour postresuscitation, but increased to similar severity of Delflex at 4 hours.

CONCLUSIONS

After a combined burn injury and hemorrhage, DPR leads to increased survival in mice. Survival was similar with the use of normal saline or Delflex. DPR with normal saline reduced the inflammatory response seen with Delflex and delayed the progression of acute lung injury. DPR may be a valuable strategy in the treatment of patients with combined burn injury and hemorrhage.

Damage control strategy in bleeding trauma patients

Hemorrhagic shock is a main cause of death in severe trauma patients. Bleeding trauma patients have coagulopathy on admission, which may even be aggravated by incorrectly directed resuscitation. The damage control strategy is a very urgent and essential aspect of management considering the acute coagulopathy of trauma and the physiological status of bleeding trauma patients. This strategy has gained popularity over the past several years. Patients in extremis cannot withstand prolonged definitive surgical repair. Therefore, an abbreviated operation, referred to as damage control surgery (DCS), is needed. In addition to DCS, the likelihood of survival should be maximized for patients in extremis by providing appropriate critical care, including permissive hypotension, hemostatic resuscitation, minimization of crystalloid use, early use of tranexamic acid, and avoidance of hypothermia and hypocalcemia. This review presents an overview of the evolving strategy of damage control in bleeding trauma patients.

Transfusion-Related Hypocalcemia After Trauma

BACKGROUND

Hypocalcemia is cited as a complication of massive transfusion. However, this is not well studied as a primary outcome in trauma patients. Our primary outcome was to determine if transfusion of packed red blood cells (pRBC) was an independent predictor of severe hypocalcemia (ionized calcium ≤ 3.6 mg/dL).

METHODS

Retrospective, single-center study (01/2004-12/2014) including all trauma patients ≥ 18 yo presenting to the ED with an ionized calcium (iCa) level drawn. Variables extracted included demographics, interventions, outcomes, and iCa. Regression models identified independent risk factors for severe hypocalcemia (SH).

RESULTS

Seven thousand four hundred and thirty-one included subjects, 716 (9.8%) developed SH within 48 h of admission. Median age: 39 (Range: 18-102), systolic blood pressure: 131 (IQR: 114-150), median Glasgow Coma Scale (GCS): 15 (IQR: 10-15), Injury Severity Score (ISS): 14 (IQR: 9-24). SH patients were more likely to have depressed GCS (13 vs 15, p < 0.0001), hypotension (23.2% vs 5.1%, p < 0.0001) and tachycardia (57.0% vs 41.9%, p < 0.0001) compared to non-SH patients. They also had higher emergency operative rate (71.8% vs 29%, p < 0.0001) and higher blood administration prior to minimum iCa [pRBC: (8 vs 0, p < 0.0001), FFP: (4 vs 0, p < 0.0001), platelet: (1 vs 0, p < 0.0001)]. Multivariable analysis revealed penetrating mechanism (AOR: 1.706), increased ISS (AOR: 1.029), and higher pRBC (AOR: 1.343) or FFP administered (AOR: 1.097) were independent predictors of SH. SH was an independent predictor of mortality (AOR: 2.658). Regression analysis identified a significantly higher risk of SH at pRBC + FFP administration of 4 units (AOR: 18.706, AUC:. 897 (0.884-0.909).

CONCLUSION

Transfusion of pRBC is an independent predictor of SH and is associated with increased mortality. The predicted probability of SH increases as pRBC + FFP administration increases.

The European guideline on management of major bleeding and coagulopathy following trauma: fifth edition

BACKGROUND

Severe traumatic injury continues to present challenges to healthcare systems around the world, and post-traumatic bleeding remains a leading cause of potentially preventable death among injured patients. Now in its fifth edition, this document aims to provide guidance on the management of major bleeding and coagulopathy following traumatic injury and encourages adaptation of the guiding principles described here to individual institutional circumstances and resources.

METHODS

The pan-European, multidisciplinary Task Force for Advanced Bleeding Care in Trauma was founded in 2004, and the current author group included representatives of six relevant European professional societies. The group applied a structured, evidence-based consensus approach to address scientific queries that served as the basis for each recommendation and supporting rationale. Expert opinion and current clinical practice were also considered, particularly in areas in which randomised clinical trials have not or cannot be performed. Existing recommendations were re-examined and revised based on scientific evidence that has emerged since the previous edition and observed shifts in clinical practice. New recommendations were formulated to reflect current clinical concerns and areas in which new research data have been generated.

RESULTS

Advances in our understanding of the pathophysiology of post-traumatic coagulopathy have supported improved management strategies, including evidence that early, individualised goal-directed treatment improves the outcome of severely injured patients. The overall organisation of the current guideline has been designed to reflect the clinical decision-making process along the patient pathway in an approximate temporal sequence. Recommendations are grouped behind the rationale for key decision points, which are patient- or problem-oriented rather than related to specific treatment modalities. While these recommendations provide guidance for the diagnosis and treatment of major bleeding and coagulopathy, emerging evidence supports the author group's belief that the greatest outcome improvement can be achieved through education and the establishment of and adherence to local clinical management algorithms.

CONCLUSIONS

A multidisciplinary approach and adherence to evidence-based guidance are key to improving patient outcomes. If incorporated into local practice, these clinical practice guidelines have the potential to ensure a uniform standard of care across Europe and beyond and better outcomes for the severely bleeding trauma patient.

Efficacy of a massive transfusion protocol for hemorrhagic trauma resuscitation

OBJECTIVES

New paradigm shifts in trauma resuscitation recommend that early reconstitution of whole blood ratios with massive transfusion protocols (MTP) may be associated with improved survival. We performed a preliminary study on the efficacy of MTP at an urban, Level 1 trauma center and its impact on resuscitation goals.

METHODS

A case-control study was performed on consecutive critically-ill trauma patients over the course of 1 year. The trauma captain designated patients as either MTP activation (cases) or routine care without MTP (controls) in matched, non-randomized fashion. Primary outcomes were: time to initial transfusion; number of total units of packed red blood cells (pRBC) and fresh frozen plasma (FFP) transfused; and ratio of pRBC to fresh frozen plasma (pRBC:FFP). Secondary outcomes were in-hospital mortality, and length of stay.

RESULTS

Out of 226 patients screened, we analyzed 58 patients meeting study criteria (32 MTP, 26 non-MTP). Study characteristics for the MTP and non-MTP groups were similar except age (34.0 vs. 45.85 years, p=0.015). MTP patients received blood products more expeditiously (41.7 minutes vs. 62.1 minutes, p=0.10), with more pRBC (5.19 vs 3.08 units, p=0.05), more FFP (0.19 vs 0.08 units, p<0.01), and had larger pRBC:FFP ratios (1.90 vs 0.52, p<0.01). Secondary outcomes did not differ significantly but the MTP group was associated with a trend for decreased hospital length of stay (p=0.08).

CONCLUSIONS

MTP resulted in clinically significant improvements in transfusion times and volumes. Further larger and randomized studies are warranted to validate these findings to optimize MTP protocols.

Damage control resuscitation: a practical approach for severely hemorrhagic patients and its effects on trauma surgery

Coagulopathy observed in trauma patients was thought to be a resuscitation-associated phenomenon. The replacement of lost and consumed coagulation factors was the mainstay in the resuscitation of hemorrhagic shock for many decades. Twenty years ago, damage control surgery (DCS) was implemented to challenge the coagulopathy of trauma. It consists of three steps: abbreviated surgery to control the hemorrhage and contamination, resuscitation in the intensive care unit (ICU), and planned re-operation with definitive surgery. The resuscitation strategy of DCS focused on the rapid reversal of acidosis and prevention of hypothermia through the first two steps. However, direct treatment of coagulopathy was not emphasized in DCS.Recently, better understanding of the pathophysiology of coagulopathy in trauma patients has led to the logical opinion that we should directly address this coagulopathy during major trauma resuscitation. Damage control resuscitation (DCR), the strategic approach to the trauma patient who presents in extremis, consists of balanced resuscitation, hemostatic resuscitation, and prevention of acidosis, hypothermia, and hypocalcemia. In balanced resuscitation, fluid administration is restricted and hypotension is allowed until definitive hemostatic measures begin. The administration of blood products consisting of fresh frozen plasma, packed red blood cells, and platelets, the ratio of which resembles whole blood, is recommended early in the resuscitation.DCR strategy is now the most beneficial measure available to address trauma-induced coagulopathy, and it can change the treatment strategy of trauma patients. DCS is now incorporated as a component of DCR. DCR as a structured intervention begins immediately after rapid initial assessment in the emergency room and progresses through the operating theater into the ICU in combination with DCS. By starting from ground zero with the performance of DCS, DCR allows the trauma surgeon to correct the coagulopathy of trauma. The effect of the reversal of coagulopathy in massively hemorrhagic patients may change the operative strategy with DCS.

The European guideline on management of major bleeding and coagulopathy following trauma: fourth edition

BACKGROUND

Severe trauma continues to represent a global public health issue and mortality and morbidity in trauma patients remains substantial. A number of initiatives have aimed to provide guidance on the management of trauma patients. This document focuses on the management of major bleeding and coagulopathy following trauma and encourages adaptation of the guiding principles to each local situation and implementation within each institution.

METHODS

The pan-European, multidisciplinary Task Force for Advanced Bleeding Care in Trauma was founded in 2004 and included representatives of six relevant European professional societies. The group used a structured, evidence-based consensus approach to address scientific queries that served as the basis for each recommendation and supporting rationale. Expert opinion and current clinical practice were also considered, particularly in areas in which randomised clinical trials have not or cannot be performed. Existing recommendations were reconsidered and revised based on new scientific evidence and observed shifts in clinical practice; new recommendations were formulated to reflect current clinical concerns and areas in which new research data have been generated. This guideline represents the fourth edition of a document first published in 2007 and updated in 2010 and 2013.

RESULTS

The guideline now recommends that patients be transferred directly to an appropriate trauma treatment centre and encourages use of a restricted volume replacement strategy during initial resuscitation. Best-practice use of blood products during further resuscitation continues to evolve and should be guided by a goal-directed strategy. The identification and management of patients pre-treated with anticoagulant agents continues to pose a real challenge, despite accumulating experience and awareness. The present guideline should be viewed as an educational aid to improve and standardise the care of the bleeding trauma patients across Europe and beyond. This document may also serve as a basis for local implementation. Furthermore, local quality and safety management systems need to be established to specifically assess key measures of bleeding control and outcome.

CONCLUSIONS

A multidisciplinary approach and adherence to evidence-based guidance are key to improving patient outcomes. The implementation of locally adapted treatment algorithms should strive to achieve measureable improvements in patient outcome.

Intraosseous access in trauma by air medical retrieval teams

Trauma accounts for a significant portion of overall mortality globally. Hemorrhage is the second major cause of mortality in the prehospital environment. Air medical retrieval services throughout the world have been developed to help improve the outcomes of patients suffering from a broad range of medical conditions, including trauma. These services often utilize intraosseous (IO) devices as an alternative means for access of both medically ill and traumatically injured patients in austere environments. However, studies have suggested that IO access cannot reach acceptable rates for massive transfusion. We review the subject to find the answer of whether IO access should be performed by air medical teams in the prehospital setting, or would central venous (CVC) access be more appropriate? We decided to assess the literature for capacity of IO access to meet resuscitation requirements in the prehospital management of trauma. We also decided to compare the insertion and complication characteristics of IO and CVC access.

[Prehospital resuscitation of patients with multiple injuries]

INTRODUCTION

Polytrauma is the leading cause of morbidity and mortality in young adults (aged 35-45 years). At 30-40%, traumatic hemorrhage is the most frequent preventable cause of death. Approximately every fourth patient with multiple injuries suffers from trauma-induced coagulopathy.

METHODS

The current knowledge of prehospital resuscitation of patients with multiple injuries based on a selective literature research and experience in a level I trauma center are presented.

RESULTS

Hemorrhagic shock is a clinical diagnosis and the recognition by the first responding emergency physician requires rapid evaluation of the accident situation, injury pattern and patient's hemodynamic status. In the future, tools will help to reliably estimate shock. Development of trauma-induced coagulopathy is multifactorial and is characterized by interaction of tissue damage, shock, hypothermia, acidosis and dilution. Preclinical therapy follows the concept of damage control resuscitation and involves bleeding hemostasis, permissive hypotension with a target systolic blood pressure between 80 and 90 mmHg (≥80 mmHg in presence of traumatic brain injury) by modest infusion of primarily crystalloid solutions, avoiding hypothermia and acidosis.

CONCLUSION

The current knowledge and therapy recommendations are presented.

Citrate metabolism and its complications in non-massive blood transfusions: association with decompensated metabolic alkalosis+respiratory acidosis and serum electrolyte levels

BACKGROUND AND OBJECTIVES

Metabolic alkalosis, which is a non-massive blood transfusion complication, is not reported in the literature although metabolic alkalosis dependent on citrate metabolism is reported to be a massive blood transfusion complication. The aim of this study was to investigate the effect of elevated carbon dioxide production due to citrate metabolism and serum electrolyte imbalance in patients who received frequent non-massive blood transfusions.

MATERIALS AND METHODS

Fifteen inpatients who were diagnosed with different conditions and who received frequent blood transfusions (10-30 ml/kg/day) were prospectively evaluated. Patients who had initial metabolic alkalosis (bicarbonate>26 mmol/l), who needed at least one intensive blood transfusion in one-to-three days for a period of at least 15 days, and whose total transfusion amount did not fit the massive blood transfusion definition (<80 ml/kg) were included in the study.

RESULTS

The estimated mean total citrate administered via blood and blood products was calculated as 43.2 ± 34.19 mg/kg/day (a total of 647.70 mg/kg in 15 days). Decompensated metabolic alkalosis+respiratory acidosis developed as a result of citrate metabolism. There was a positive correlation between cumulative amount of citrate and the use of fresh frozen plasma, venous blood pH, ionized calcium, serum-blood gas sodium and mortality, whereas there was a negative correlation between cumulative amount of citrate and serum calcium levels, serum phosphorus levels and amount of urine chloride.

CONCLUSION

In non-massive, but frequent blood transfusions, elevated carbon dioxide production due to citrate metabolism causes intracellular acidosis. As a result of intracellular acidosis compensation, decompensated metabolic alkalosis+respiratory acidosis and electrolyte imbalance may develop. This situation may contribute to the increase in mortality. In conclusion, it should be noted that non-massive, but frequent blood transfusions may result in certain complications.

GNPs-CS/KGM as hemostatic first aid wound dressing with antibiotic effect: in vitro and in vivo study

Ideal wound dressing materials should create a good healing environment, with immediate hemostatic effects and antimicrobial activity. In this study, chitosan/konjac glucomannan (CS/KGM) films embedded with gentamicin-loaded poly(dex-GMA/AAc) nanoparticles (giving GNP-CS/KGM films) were prepared as novel wound dressings. The results revealed that the modified CS/KGM films could be used as effective wound dressings and had significant hemostatic effects. With their microporous structure, the films could effectively absorb water from blood and trap blood cells. The gentamicinloaded poly(dex-GMA/AAc) nanoparticles (GNPs) also further promoted blood clotting, with their favorable water uptake capacity. Thus, the GNP-CS/KGM films had wound healing and synergistic effects that helped to stop bleeding from injuries, and also showed good antibiotic abilities by addition of gentamicin to the NPs. These GNPCS/KGM films can be considered as promising novel biodegradable and biocompatible wound dressings with hemostatic capabilities and antibiotic effects for treatment of external bleeding injuries.

Hemostatic resuscitation with plasma and platelets in trauma

Background:

Continued hemorrhage remains a major contributor of mortality in massively transfused patients and controversy regarding the optimal management exists although recently, the concept of hemostatic resuscitation, i.e., providing large amount of blood products to critically injured patients in an immediate and sustained manner as part of an early massive transfusion protocol has been introduced. The aim of the present review was to investigate the potential effect on survival of proactive administration of plasma and/or platelets (PLT) in trauma patients with massive bleeding.

Materials and Methods:

English databases were searched for reports of trauma patients receiving massive transfusion (10 or more red blood cell (RBC) within 24 hours or less from admission) that tested the effects of administration of plasma and/or PLT in relation to RBC concentrates on survival from January 2005 to November 2010. Comparison between highest vs lowest blood product ratios and 30-day mortality was performed.

Results:

Sixteen studies encompassing 3,663 patients receiving high vs low ratios were included. This meta-analysis of the pooled results revealed a substantial statistical heterogeneity (I² = 58%) and that the highest ratio of plasma and/or PLT or to RBC was associated with a significantly decreased mortality (OR: 0.49; 95% confidence interval: 0.43-0.57; P<0.0001) when compared with lowest ratio.

Conclusion:

Meta-analysis of 16 retrospective studies concerning massively transfused trauma patients confirms a significantly lower mortality in patients treated with the highest fresh frozen plasma (FFP) and/or PLT ratio when compared with the lowest FFP and/or PLT ratio. However, optimal ranges of FFP: RBC and PLT : RBC should be established in randomized controlled trials.

Coagulopathy in the intensive care unit

Coagulopathy is a potential problem for many critically ill patients, placing them at risk for hemorrhage. Critical illness activates both hemostasis and the inflammatory-immune system, leading to both physiological and potentially pathophysiological responses. Following complex surgery or trauma, patients are at high risk for development of problems such as thrombocytopenia and postoperative bleeding, challenging nurses to recognize and manage these problems. The clinical manifestations of coagulopathy may be obvious or occult, and correlation with the coagulation panel results is a complex process. Transfusion of blood and components has long been an important part of patient management, but is known to put patients at risk for transfusion-related complications. Current clinical practice guidelines provide blood conservation strategies and criteria to guide decisions on transfusion therapy.

Massive transfusion in traumatic shock

BACKGROUND

Hemorrhage after trauma is a common cause of death in the United States and globally. The primary goals when managing traumatic shock are the restoration of oxygen delivery to end organs, maintenance of circulatory volume, and prevention of ongoing bleeding through source control and correction of coagulopathy. Achieving these goals may require massive transfusion of blood products. Although use of blood products may be lifesaving, dose-related adverse effects are well described.

DISCUSSION

Complications of massive transfusion include interdependent derangements such as coagulopathy, hypothermia, acidosis, and electrolyte abnormalities, as well as infectious and immunomodulatory phenomena. This article explores the pathogenesis, implications, prevention, and treatment of these complications through the use of massive transfusion protocols. Particular attention is given to the optimal ratio of blood products transfused in large volume resuscitation and prevention of secondary coagulopathy.

CONCLUSIONS

Observational data indicate that the development and use of a massive transfusion protocol may reduce the morbidity and mortality associated with large-volume resuscitation of patients with hemorrhagic shock. Such protocols should include a pre-defined ratio of packed red blood cells, fresh frozen plasma, and platelets transfused; most commonly, the ratio used is 1:1:1. Additionally, such protocols should monitor for and correct hypothermia, hypofibrinogenemia, and electrolyte disturbances such as hypocalcemia and hyperkalemia.

Intraoperatives Gerinnungsmanagement

<b><i>Hintergrund: </i></b>Intraoperative Gerinnungsstörungen kommen bei großen Operationen häufig vor und können verschiedene, oft parallel auftretende Ursachen haben. Die Blutungsdynamik unter laufender Operation erfordert eine gute interdisziplinäre Zusammenarbeit sowie ein effektives Team- und Kontextmanagement. Geeignete diagnostische Methoden sind für ein rasches und zielgerichtetes Gerinnungsmanagement notwendig. <b><i>Methode: </i></b>Die Literatur bis April 2013 wurde selektiv, inklusive der neuen europäischen und deutschen anästhesiologischen Handlungsempfehlungen zum perioperativen Blutungsmanagement, berücksichtigt. <b><i>Ergebnisse: </i></b>Dilutionskoagulopathien zählen zu den häufigsten intraoperativen Gerinnungsstörungen, da bei Blutverlust zur Aufrechterhaltung der Makrozirkulation kolloidale oder kristalloide Lösungen infundiert bzw. Erythrozytenkonzentrate zur Oxygenierung transfundiert werden. Hypothermien, Azidosen, Hypocalciämien, Anämien, Hyperfibrinolysen, Medikamenteneinnahmen und Vorerkrankungen können die Koagulopathien verstärken. Fibrinogen ist der erste Faktor, der bei massiven Blutungen kritisch abfällt und substituiert werden muss. <b><i>Schlussfolgerungen: </i></b>Patientennahe diagnostische Verfahren eignen sich besonders zur Differenzierung von intraoperativen Gerinnungsstörungen und einer zielgerichteten Therapie. Faktorenkonzentrate stehen schneller als Gefrierplasmen (fresh frozen plasma, FFP) zur Verfügung und bilden häufig die Basis einer zielgerichteten Therapie. FFP enthalten alle Faktoren in einem physiologischen Verhältnis, allerdings unkonzentriert. Zu den Limitationen zählen neben geringerer Wirksamkeit die zeitaufwendige Vorbereitung und die nicht unerheblichen unerwünschten Wirkungen. Die Evidenzlage ist noch nicht ausreichend für eindeutige Empfehlungen.

Development of a simple algorithm to guide the effective management of traumatic cardiac arrest

BACKGROUND

Major trauma is the leading worldwide cause of death in young adults. The mortality from traumatic cardiac arrest remains high but survival with good neurological outcome from cardiopulmonary arrest following major trauma has been regularly reported. Rapid, effective intervention is required to address potential reversible causes of traumatic cardiac arrest if the victim is to survive. Current ILCOR guidelines do not contain a standard algorithm for management of traumatic cardiac arrest. We present a simple algorithm to manage the major trauma patient in actual or imminent cardiac arrest.

METHODS

We reviewed the published English language literature on traumatic cardiac arrest and major trauma management. A treatment algorithm was developed based on this and the experience of treatment of more than a thousand traumatic cardiac arrests by a physician - paramedic pre-hospital trauma service.

RESULTS

The algorithm addresses the need treat potential reversible causes of traumatic cardiac arrest. This includes immediate resuscitative thoracotomy in cases of penetrating chest trauma, airway management, optimising oxygenation, correction of hypovolaemia and chest decompression to exclude tension pneumothorax.

CONCLUSION

The requirement to rapidly address a number of potentially reversible pathologies in a short time period lends the management of traumatic cardiac arrest to a simple treatment algorithm. A standardised approach may prevent delay in diagnosis and treatment and improve current poor survival rates.

Effect of hemodilution on coagulation and recombinant factor VIIa efficacy in human blood in vitro

BACKGROUND

This study evaluates the effect of hemodilution by various common resuscitation fluids, and the efficacy of activated recombinant factor VII (rFVIIa) on coagulation parameters in human blood in vitro.

METHODS

Samples from normal healthy volunteers (n = 9) were hemodiluted from 0% to 90% with normal saline, or 0%, 40%, 60%, and 80% with 5% albumin, Hespan, Hextend, normal saline, or lactated Ringer's, and incubated at 37°C ± 1°C for 30 minutes with and without rFVIIa (1.26 μg/mL).

RESULTS

There was a strong correlation between the dilution of hemoglobin (Hb), platelets, or fibrinogen and coagulation parameters. Hemodilution 0% to 90% changed coagulation parameters (prothrombin time [PT], activated partial thromboplastin time [aPTT], and thromboelastography) in an exponential fashion; the greatest changes occurred after hemodilution lowered Hb <6 mg/dL, platelet count < 100,000/mm(3), and fibrinogen concentration <200 mg/dL. PT and aPTT were significantly prolonged after 60% and 80% dilution for all fluids. Hemodilution of 60% and 80% significantly decreased clot strength (maximum amplitude) and the kinetics of clot development (α angle) and increased the clot formation time (K). Hemodilution with Hextend and Hespan decreased maximum amplitude and α angle >5% albumin, lactated Ringer's, or normal saline. rFVIIa significantly improved PT at 60% and 80% dilutions, and aPTT at 80% dilution. There was a significant effect of dilution, but not fluid type, on the efficacy of rFVIIa to change PT and aPTT, and the onset of clotting (R).

CONCLUSIONS

We have strong in vitro evidence that Hb <6 mg/dL, platelet count <100,000/mm(3), and fibrinogen concentration <200 mg/dL can be used as indexes of hemodilution-induced coagulopathy. This study also shows that Hextend and Hespan tend to decrease the clotting ability >5% albumin or the crystalloids. rFVIIa significantly decreased PT at all dilutions and aPTT at the highest dilution. The effectiveness of rFVIIa on PT and aPTT was significantly affected by the degree of dilution, but not by the type of fluid.

[The damage control resuscitation concept]

OBJECTIVE

Damage control is a strategy of care for bleeding trauma patients, involving minimal rescue surgery associated to perioperative resuscitation. The purpose of this review is to draw up a statement on current knowledge available on damage control.

DATA SOURCES

References were obtained from recent review articles, personal files, and Medline database research of English and French publications. All categories of articles on this topic have been selected.

DATA SYNTHESIS

Historical damage control surgery, that consist of abbreviated laparotomy with second-look after resuscitation, is now included in a wider concept called "damage control resuscitation", addressing the lethal triad (coagulopathy, hypothermia and acidosis) at an early phase. Care is focused on coagulopathy prevention. Early resuscitation, or damage control ground zero, has been improved: aggressive management of hypothermia, bleeding control techniques, permissive hypotension concept and early use of vasopressors. Transfusion practices also have evolved: early platelets and coagulation factors administration, use of hemostatic agents like recombinant FVIIa, whole blood transfusion, denote the damage control hematology. Progress in surgical practices and development of arteriographic techniques lead to wider indications of damage control strategy.

Massive transfusion protocols for patients with substantial hemorrhage

Transfusion medicine for the resuscitation of patients with massive hemorrhage has recently advanced from reactive, supportive treatment with crystalloid and red blood cell therapy to use of standardized massive transfusion protocols (MTPs). Through MTPs, medical facilities are able to standardize the most effective posthemorrhage treatments and execute them rapidly while reducing potential waste of blood products. Damage control resuscitation is an example of an MTP, where patients are (1) allowed more permissive hypotension, (2) spared large volumes of crystalloid/colloid therapy (through low volume resuscitation), and (3) transfused with blood products preemptively using a balanced ratio of plasma and platelets to red blood cells. This focused approach improves the timely availability of blood components during resuscitation. However, the use of MTPs remains controversial. This review describes published experiences with MTPs and illustrates the potential value of several MTPs currently utilized by academic transfusion services.

Balanced massive transfusion ratios in multiple injury patients with traumatic brain injury

Introduction

Retrospective studies have demonstrated a potential survival benefit from transfusion strategies using an early and more balanced ratio between fresh frozen plasma (FFP) concentration and packed red blood cell (pRBC) transfusions in patients with acute traumatic coagulopathy requiring massive transfusions. These results have mostly been derived from non-head-injured patients. The aim of the present study was to analyze whether a regime using a high FFP:pRBC transfusion ratio (FFP:pRBC ratio >1:2) would be associated with a similar survival benefit in severely injured patients with traumatic brain injury (TBI) (Abbreviated Injury Scale (AIS) score, head ≥3) as demonstrated for patients without TBI requiring massive transfusion (≥10 U of pRBCs).

Methods

A retrospective analysis of severely injured patients from the Trauma Registry of the Deutsche Gesellschaft für Unfallchirurgie (TR-DGU) was conducted. Inclusion criteria were primary admission, age ≥16 years, severe injury (Injury Severity Score (ISS) ≥16) and massive transfusion (≥10 U of pRBCs) from emergency room to intensive care unit (ICU). Patients were subdivided into patients with TBI (AIS score, head ≥3) and patients without TBI (AIS score, head <3), as well as according to the transfusion ratio they had received: high FFP:pRBC ratio (FFP:pRBC ratio >1:2) and low FFP:pRBC ratio (FFP:pRBC ratio ≤1:2). In addition, morbidity and mortality between the two groups were compared.

Results

A total of 1,250 data sets of severely injured patients from the TR-DGU between 2002 and 2008 were analyzed. The mean patient age was 42 years, the majority of patients were male (72.3%), the mean ISS was 41.7 points (±15.4 SD) and the principal mechanism of injury was blunt force trauma (90%). Mortality was statistically lower in the high FFP:pRBC ratio groups versus the low FFP:pRBC ratio groups, regardless of the presence or absence of TBI and across all time points studied (P < 0.001). The frequency of sepsis and multiple organ failure did not differ among groups, except for sepsis in patients with TBI who received a high FFP:pRBC ratio transfusion. Other secondary end points such as ventilator-free days, length of stay in the ICU and overall in-hospital length of stay differed significantly between the two study groups, but not when only data for survivors were analyzed.

Conclusions

These results add more detailed knowledge to the concept of a high FFP:pRBC ratio during early aggressive resuscitation, including massive transfusion, to decrease mortality in severely injured patients both with and without accompanying TBI. Future research should be conducted with a larger number of patients to prove these results in a prospective study.

Clot-inducing minerals versus plasma protein dressing for topical treatment of external bleeding in the presence of coagulopathy

BACKGROUND

Previous studies identified WoundStat (WS, smectite) and Combat Gauze (CG, kaolin-coated gauze) as the most effective available agents for controlling arterial bleeding with potential utility in casualty care. Tissue sealant properties of WS suggested its potential advantage over clot-promoting CG for treating coagulopathic bleeding. This study compared the efficacy of CG and WS with a fibrinogen-based (FAST) dressing to control bleeding in coagulopathic animals.

METHODS

Coagulopathy was induced in pigs (n = 55, 35 kg) by ∼50% isovolemic hemodilution and hypothermia (core temperature, 33°C ± 0.5°C). A 6-mm arteriotomy was made in the femoral artery and free bleeding allowed for 30 seconds. A test agent (n = 13-15 per group) or control product (gauze, GZ, n = 12) was applied to the wounds and compressed with a Kerlix gauze for 2 minutes. Fluid resuscitation was given, titrated to a mean arterial pressure of 65 mm Hg. Animals were observed for 180 minutes or until death. Angiography using the computed tomography method was performed on survivors, and local tissues were collected for histology.

RESULTS

No differences were seen in baseline measures. Coagulopathy, confirmed by a 31% increase in prothrombin time and a 28% reduction in clotting strength (maximum amplitude, thrombelastography assay), was similar in all groups before injury. The average pretreatment blood loss was 11.9 mL/kg ± 0.4 mL/kg with no difference among groups. Posttreatment blood loss, however, was significantly different (p = 0.015) ranging from 18.2 mL/kg ± 8.8 mL/kg (FAST) to 63.3 mL/kg ± 10.2 mL/kg (GZ controls). Stable hemostasis was achieved in 10 of 13 (FAST), 5 of 15 (CG), 2 of 15 (WS), and 1 of 12 (GZ) animals in each group, resulting in significantly different survival rates (8-77%; p = 0.001). The average survival times were 145 (FAST), 119 (CG), 75 (WS), and 74 (GZ) minutes for different groups (p < 0.002). The outcomes with the FAST dressing were significantly better than with WS or GZ in this coagulopathic bleeding model. Essentially, no difference was found between WS and GZ control. Computed tomography images showed limited blood flow only through the vessels treated with FAST dressings. Histologic observations of the vessels indicated minimal damage with FAST and CG and greater injury with WS with some residues present on the tissues.

CONCLUSION

The tissue sealant property of WS is apparently mediated by clot formation in the wound; therefore, it was ineffective under coagulopathic conditions. CG was partially effective in maintaining blood pressure up to 1 hour after application. FAST dressing showed the highest efficacy because of the exogenous delivery of concentrated fibrinogen and thrombin to the wound, which bypasses coagulopathy and secures hemostasis.

Surgical Services and Transformation of Civil Hospital During “August War 2008” in Georgia

Structural transformation of a civil hospital into a military one during “August War 2008” (August 8–12) in Georgia is presented. Damage-control principles, such as hemorrhage control, liver-packing and abdominal tamponade, gastrointestinal tract resection without formation of anastomoses, and other temporary interventions were prioritized. This provided a chance to empty the hospital in a short period to provide the admission of an increased number of combat casualties. There were soldiers from Georgian troops, civilians, and captives of war. The number of total admitted patients was 739. Fifty-two patients were operated on in the surgery department. The following operations were carried out: removal of foreign bodies from the neck region, 6 cases; isolated thoracotomy, pulmorrhaphy, and drainage, 2 cases; laparotomy, hepatorrhaphy, gastrorrhaphy, splenectomy, resection of small intestine, and colostomy, 18 cases; combined operations (thoracotomy plus laparotomy), 9 cases; extended debridement and dressing of wounds, 11 cases; angiosurgical operations, 4 cases; and coloplasty, 2 cases. There were 2 cases of mortality, 1 case of rethoracotomy, and 3 cases of relaparotomy: 2 because of intracavital bleeding and 1 because of sanation.

Concentration-Dependent Effect of Hypocalcaemia on Mortality of Patients with Critical Bleeding Requiring Massive Transfusion: A Cohort Study

Mortality of patients with critical bleeding requiring massive transfusion is high. Although hypothermia, acidosis and coagulopathy have been well described as important determinants of mortality in patients with critical bleeding requiring massive transfusion, the risk factors and outcome associated with hypocalcaemia in these patients remain uncertain. This cohort study assessed the relationship between the lowest ionised calcium concentration during the 24-hour period of critical bleeding and the hospital mortality of 352 consecutive patients, while adjusting for diagnosis, acidosis, coagulation results, transfusion requirements and use of recombinant factor VIIa. Hypocalcaemia was common (mean concentrations 0.77 mmol/l, SD 0.19) and had a linear, concentration-dependent relationship with mortality (odds ratio [OR] 1.25 per 0.1 mmol/l decrement, 95% confidence interval [CI]: 1.04 to 1.52; P=0.02). Hypocalcaemia accounted for 12.5% of the variability and was more important than the lowest fibrinogen concentrations (10.8%), acidosis (7.9%) and lowest platelet counts (7.7%) in predicting hospital mortality. The amount of fresh frozen plasma transfused (OR 1.09 per unit, 95% CI: 1.02 to 1.17; P=0.02) and acidosis (OR 1.45 per 0.1 decrement, 95% CI: 1.19 to 1.72; P=0.01) were associated with the occurrence of severe hypocalcaemia (<0.8 mmol/l). In conclusion, ionised calcium concentrations had an inverse concentration-dependent relationship with mortality of patients with critical bleeding requiring massive transfusion. Both acidosis and the amount of fresh frozen plasma transfused were the main risk factors for severe hypocalcaemia. Further research is needed to determine whether preventing ionised hypocalcaemia can reduce mortality of patients with critical bleeding requiring massive transfusion.

Transfusion-transmissible viral infections among US military recipients of whole blood and platelets during Operation Enduring Freedom and Operation Iraqi Freedom

BACKGROUND

Current US military clinical practice guidelines permit emergency transfusions of non-Food and Drug Administration (FDA)-compliant freshly collected blood products in theaters of war. This investigation aimed to characterize the risks of transfusion-transmitted infections (TTIs) associated with battlefield transfusions of non-FDA-compliant blood products.

STUDY DESIGN AND METHODS

US Service members who received emergency transfusion products in Iraq and Afghanistan (March 1, 2002-September 30, 2007) were tested for hepatitis C virus (HCV), human immunodeficiency virus (HIV), and hepatitis B virus (HBV) infections using reposed pre- and posttransfusion sera. Selected regions of viral genomes from epidemiologically linked infected recipients and their donors were sequenced and compared.

RESULTS

Of 761 US Service members who received emergency transfusion products, 475 were tested for HCV, 472 for HIV, and 469 for HBV. One transfusion-transmitted HCV infection (incidence rate of 2.1/1000 persons) was identified. The pretransfusion numbers (prevalence per 1000 persons) were HCV-four (8/1000), HIV-zero (0/1000), chronic HBV-two (4 /1000), and naturally immune (antibody to HBV core antigen)-nine (19/1000).

CONCLUSION

One HCV TTI was determined to be associated with emergency blood product use. The pretransfusion HCV and HBV prevalence in transfusion recipients, themselves members of the potential donor population, indicates better characterization of the deployed force's actual donor population, and further investigations of the TTI prevalence in these donors are needed. These data will inform countermeasure development and clinical decision making.

Damage control in trauma and abdominal sepsis

Damage control surgery, initially formalized <20 yrs ago, was developed to overcome the poor outcomes in exsanguinating abdominal trauma with traditional surgical approaches. The core concepts for damage control of hemorrhage and contamination control with abbreviated laparotomy followed by resuscitation before definitive repair, although simple in nature, have led to an alteration in which emergent surgery is handled among a multitude of problems, including abdominal sepsis and battlefield surgery. With the aggressive resuscitation associated with damage control surgery, understanding of abdominal compartment syndrome has expanded. It is probably through avoiding this clinical entity that the greatest improvement in surgical outcomes for various emergent surgical problems has occurred in the past two decades. However, with its success, new problems have emerged, including increases in enterocutaneous fistulas and open abdomens. But as with any crisis, innovative strategies are being developed. New approaches to control of the open abdomen and reconstruction of the abdominal wall are being developed from negative pressure dressing therapies to acellular allograft meshes. With further understanding of new resuscitative strategies, the need for damage control surgery may decline, along with its concomitant complications, at the same time retaining the success that damage control surgery has brought to the critically ill trauma and general surgery patient in the past few years.

Comparison of platelet transfusion as fresh whole blood versus apheresis platelets for massively transfused combat trauma patients (CME)

BACKGROUND

At major combat hospitals, the military is able to provide blood products to include apheresis platelets (aPLT), but also has extensive experience using fresh whole blood (FWB). In massively transfused trauma patients, we compared outcomes of patients receiving FWB to those receiving aPLT.

STUDY DESIGN AND METHODS

This study was a retrospective review of casualties at the military hospital in Baghdad, Iraq, between January 2004 and December 2006. Patients requiring massive transfusion (≥10 units in 24 hr) were divided into two groups: those receiving FWB (n = 85) or aPLT (n = 284) during their resuscitation. Admission characteristics, resuscitation, and survival were compared between groups. Multivariate regression analyses were performed comparing survival of patients at 24 hours and at 30 days. Secondary outcomes including adverse events and causes of death were analyzed.

RESULTS

Unadjusted survival between groups receiving aPLT and FWB was similar at 24 hours (84% vs. 81%, respectively; p = 0.52) and at 30 days (60% versus 57%, respectively; p = 0.72). Multivariate regression failed to identify differences in survival between patients receiving PLT transfusions either as FWB or as aPLT at 24 hours or at 30 days.

CONCLUSIONS

Survival for massively transfused trauma patients receiving FWB appears to be similar to patients resuscitated with aPLT. Prospective trials will be necessary before consideration of FWB in the routine management of civilian trauma. However, in austere environments where standard blood products are unavailable, FWB is a feasible alternative.

The long term immunological response of swine after two exposures to a salmon thrombin and fibrinogen hemostatic bandage

Experimental salmon thrombin/fibrinogen dressings have been shown to provide effective hemostasis in severe hemorrhage situations. The hypothesis for this study was that swine would still remain healthy without coagulopathy six months after exposure to salmon thrombin/fibrinogen dressings. Initial exposure was by insertion of the salmon dressing into the peritoneal cavity. Three months after the initial exposure, the same animals were subjected to two full thickness dermal wounds on the dorsal surface. One wound was bandaged with the salmon thrombin/fibrinogen bandage and the other wound was dressed with a standard bandage. The animals were monitored for an additional three months. Blood was drawn every 14 days over the six months for immunological and coagulation function analysis. All of the animals (8 pigs) remained healthy during the six month period and the dermal wounds healed without incidence. Lymph nodes and spleen showed signs of normal immune response and Western blots showed development of antibodies against salmon fibrinogen, but none of the animals made antibodies that recognized any species of thrombin. Coagulation parameters (fibrinogen concentration, thrombin time, PT and aPTT) and hematological parameters remained normal over the course of the study when compared to initial values of the subject swine.