1
|
Barbosa Rengifo MM, Garcia AF, Gonzalez-Hada A, Mejia NJ. Evaluating the Shock Index, Revised Assessment of Bleeding and Transfusion (RABT), Assessment of Blood Consumption (ABC) and novel PTTrauma score to predict critical transfusion threshold (CAT) in penetrating thoracic trauma. Sci Rep 2024; 14:13395. [PMID: 38862533 PMCID: PMC11166957 DOI: 10.1038/s41598-024-62579-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2023] [Accepted: 05/20/2024] [Indexed: 06/13/2024] Open
Abstract
The shock index (SI) has been associated with predicting transfusion needs in trauma patients. However, its utility in penetrating thoracic trauma (PTTrauma) for predicting the Critical Administration Threshold (CAT) has not been well-studied. This study aimed to evaluate the prognostic value of SI in predicting CAT in PTTrauma patients and compare its performance with the Assessment of Blood Consumption (ABC) and Revised Assessment of Bleeding and Transfusion (RABT) scores. We conducted a prognostic type 2, single-center retrospective observational cohort study on patients with PTTrauma and an Injury Severity Score (ISS) > 9. The primary exposure was SI at admission, and the primary outcome was CAT. Logistic regression and decision curve analysis were used to assess the predictive performance of SI and the PTTrauma score, a novel model incorporating clinical variables. Of the 620 participants, 53 (8.5%) had more than one CAT. An SI > 0.9 was associated with CAT (adjusted OR 4.89, 95% CI 1.64-14.60). The PTTrauma score outperformed SI, ABC, and RABT scores in predicting CAT (AUC 0.867, 95% CI 0.826-0.908). SI is a valuable predictor of CAT in PTTrauma patients. The novel PTTrauma score demonstrates superior performance compared to existing scores, highlighting the importance of developing targeted predictive models for specific injury patterns. These findings can guide clinical decision-making and resource allocation in the management of PTTrauma.
Collapse
Affiliation(s)
- Mario Miguel Barbosa Rengifo
- Department of Surgery, Universidad del Valle, Cl. 4B #36-00, El Sindicato, Cali Valle del Cauca, Cali, Colombia.
- Department of Surgery and Clinical Research Center, Fundación Valle del Lili, Cali, Colombia.
- Universidad Icesi, Facultad de Ciencias de la Salud, Cali, Colombia.
| | - Alberto F Garcia
- Department of Surgery, Universidad del Valle, Cl. 4B #36-00, El Sindicato, Cali Valle del Cauca, Cali, Colombia
- Department of Surgery and Clinical Research Center, Fundación Valle del Lili, Cali, Colombia
- Universidad Icesi, Facultad de Ciencias de la Salud, Cali, Colombia
| | - Adolfo Gonzalez-Hada
- Department of Surgery, Universidad del Valle, Cl. 4B #36-00, El Sindicato, Cali Valle del Cauca, Cali, Colombia
| | - Nancy J Mejia
- Department of Surgery, Universidad del Valle, Cl. 4B #36-00, El Sindicato, Cali Valle del Cauca, Cali, Colombia
| |
Collapse
|
2
|
Brac L, Levrat A, Vacheron CH, Bouzat P, Delory T, David JS. Development and validation of the tic score for early detection of traumatic coagulopathy upon hospital admission: a cohort study. Crit Care 2024; 28:168. [PMID: 38762746 PMCID: PMC11102139 DOI: 10.1186/s13054-024-04955-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2024] [Accepted: 05/14/2024] [Indexed: 05/20/2024] Open
Abstract
BACKGROUND Critically injured patients need rapid and appropriate hemostatic treatment, which requires prompt identification of trauma-induced coagulopathy (TIC) upon hospital admission. We developed and validated the performance of a clinical score based on prehospital resuscitation parameters and vital signs at hospital admission for early diagnosis of TIC. METHODS The score was derived from a level-1 trauma center registry (training set). It was then validated on data from two other level-1 trauma centers: first on a trauma registry (retrospective validation set), and then on a prospective cohort (prospective validation set). TIC was defined as a PTratio > 1.2 at hospital admission. Prehospital (vital signs and resuscitation care) and admission data (vital signs and laboratory parameters) were collected. We considered parameters independently associated with TIC in the score (binomial logistic regression). We estimated the score's performance for the prediction of TIC. RESULTS A total of 3489 patients were included, and among these a TIC was observed in 22% (95% CI 21-24%) of cases. Five criteria were identified and included in the TIC Score: Glasgow coma scale < 9, Shock Index > 0.9, hemoglobin < 11 g.dL-1, prehospital fluid volume > 1000 ml, and prehospital use of norepinephrine (yes/no). The score, ranging from 0 and 9 points, had good performance for the identification of TIC (AUC: 0.82, 95% CI: 0.81-0.84) without differences between the three sets used. A score value < 2 had a negative predictive value of 93% and was selected to rule-out TIC. Conversely, a score value ≥ 6 had a positive predictive value of 92% and was selected to indicate TIC. CONCLUSION The TIC Score is quick and easy to calculate and can accurately identify patients with TIC upon hospital admission.
Collapse
Affiliation(s)
- Louis Brac
- Department of Intensive Care, Annecy-Genevois Hospital, Annecy, France.
| | - Albrice Levrat
- Department of Intensive Care, Annecy-Genevois Hospital, Annecy, France
| | - Charles-Hervé Vacheron
- Department of Anesthesia and Intensive Care, Groupe Hospitalier Sud, Hospices Civils de Lyon, Pierre Bénite, France
- Biostatistics Health Team, Biometrics and Evolutionary Biology Laboratory, Hospices Civils de Lyon, Lyon, France
| | - Pierre Bouzat
- Department of Anesthesia and Intensive Care, Grenoble-Alpes University Hospital, Grenoble, France
| | - Tristan Delory
- Annecy-Genevois Hospital, Annecy, France
- INSERM, Institut Pierre Louis d'Épidémiologie et de Santé Publique, Sorbonne Université, Paris, France
| | - Jean-Stéphane David
- Department of Anesthesia and Intensive Care, Lyon Sud Hospital, Hospices Civils de Lyon, Pierre-Bénite, France
- Research on Healthcare Performance (RESHAPE), INSERM U1290, University Claude Bernard Lyon 1, Lyon, France
| |
Collapse
|
3
|
Matsumoto S, Aoki M, Shimizu M, Funabiki T. A clinical prediction model for non-operative management failure in patients with high-grade blunt splenic injury. Heliyon 2023; 9:e20537. [PMID: 37842598 PMCID: PMC10568089 DOI: 10.1016/j.heliyon.2023.e20537] [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: 03/18/2023] [Revised: 09/17/2023] [Accepted: 09/28/2023] [Indexed: 10/17/2023] Open
Abstract
Background Nonoperative management (NOM) is the standard treatment for hemodynamically stable blunt splenic injury (BSI). However, NOM failure is a significant source of morbidity and mortality. We developed a clinical risk scoring system for NOM failure in BSI. Methods Data from the Japanese Trauma Data Bank from 2008 to 2018 were analyzed. Eligible patients were restricted to those who underwent NOM with high-grade BSI (Organ Injury Scale ≥3). The primary outcome was a predictive score for NOM failure based on risk estimation. Results There were 1651 patients included in this analysis, among whom 110 (6.7%) patients had NOM failure. Multivariate analysis identified seven variables associated with failed NOM: systolic blood pressure, Glasgow coma scale, Injury Severity Score, other concomitant abdominal injury, pelvic injury, high-grade BSI, and angioembolization. An eight-point predictive score was developed with a cut-off of greater than 5 points (specificity, 98.2%; sensitivity, 25.5%) with an area under the curve of 0.81. Conclusion The clinical predictive score had good ability to predict NOM failure and may help surgeons to make better decisions for BSI.
Collapse
Affiliation(s)
- Shokei Matsumoto
- Department of Trauma and Emergency Surgery, Saiseikai Yokohamashi Tobu Hospital, Japan
| | - Makoto Aoki
- Advanced Medical Emergency Department and Critical Care Center, Japan Red Cross Maebashi Hospital, Japan
| | - Masayuki Shimizu
- Department of Trauma and Emergency Surgery, Saiseikai Yokohamashi Tobu Hospital, Japan
| | - Tomohiro Funabiki
- Department of Emergency and Critical Care Medicine, Fujita Health University Hospital, Japan
| |
Collapse
|
4
|
Duclos G, Fleury M, Grosdidier C, Lakbar I, Antonini F, Lassale B, Arbelot C, Albaladejo P, Zieleskiewicz L, Leone M. Blood coagulation test abnormalities in trauma patients detected by sonorheometry: a retrospective cohort study. Res Pract Thromb Haemost 2023; 7:100163. [PMID: 37251493 PMCID: PMC10208882 DOI: 10.1016/j.rpth.2023.100163] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 03/17/2023] [Accepted: 04/03/2023] [Indexed: 05/31/2023] Open
Abstract
Background Traumatic hemorrhage guidelines include point-of-care viscoelastic tests as a standard of care. Quantra (Hemosonics) is a device based on sonic estimation of elasticity via resonance (SEER) sonorheometry to assess whole blood clot formation. Objectives Our study aimed to assess the ability of an early SEER evaluation to detect blood coagulation test abnormalities in trauma patients. Methods We conducted an observational retrospective cohort study with data collected at hospital admission of consecutive multiple trauma patients from September 2020 to February 2022 at a regional level 1 trauma center. We performed a receiving operator characteristic curve analysis to determine the ability of the SEER device to detect blood coagulation test abnormalities. Four values on the SEER device were analyzed: clot formation time, clot stiffness (CS), platelet contribution to CS, and fibrinogen contribution to CS. Results A total of 156 trauma patients were analyzed. The clot formation time value predicted an activated partial thromboplastin time ratio of >1.5 with an area under the curve (AUC) of 0.93 (95% CI, 0.86-0.99). The AUC of the CS value in detecting an international normalized ratio of prothrombin time of >1.5 was 0.87 (95% CI, 0.79-0.95). The AUC of fibrinogen contribution to CS to detect a fibrinogen concentration of <1.5 g/L was 0.87 (95% CI, 0.80-0.94). The AUC of platelet contribution to CS to detect a platelet concentration of <50 G/L was 0.99 (95% CI, 0.99-1.00). Conclusion Our results suggest that the SEER device may be useful for the detection of blood coagulation test abnormalities at trauma admission.
Collapse
Affiliation(s)
- Gary Duclos
- Service of Anesthesia and Intensive Care, Hôpital Nord, Aix-Marseille Université, Marseille, France
| | - Marie Fleury
- Service of Anesthesia and Intensive Care, Hôpital Nord, Aix-Marseille Université, Marseille, France
| | - Charlotte Grosdidier
- Service of Medical Biology, Hôpital Nord, Aix-Marseille Université, Marseille, France
| | - Ines Lakbar
- Service of Anesthesia and Intensive Care, Hôpital Nord, Aix-Marseille Université, Marseille, France
| | - François Antonini
- Service of Anesthesia and Intensive Care, Hôpital Nord, Aix-Marseille Université, Marseille, France
| | - Bernard Lassale
- French Establishment for Blood, Hôpital Nord, Aix-Marseille Université, Marseille, France
| | - Charlotte Arbelot
- Service of Anesthesia and Intensive Care, Hôpital Nord, Aix-Marseille Université, Marseille, France
| | - Pierre Albaladejo
- Department of Anesthesiology and Critical Care, Grenoble Alpes University Hospital, Grenoble, France
| | - Laurent Zieleskiewicz
- Service of Anesthesia and Intensive Care, Hôpital Nord, Aix-Marseille Université, Marseille, France
| | - Marc Leone
- Service of Anesthesia and Intensive Care, Hôpital Nord, Aix-Marseille Université, Marseille, France
| |
Collapse
|
5
|
|
6
|
Infrastructure, logistics and clinical practice management of acute trauma hemorrhage and coagulopathy: a survey across German trauma centers. Eur J Trauma Emerg Surg 2021; 48:4461-4472. [PMID: 34564733 DOI: 10.1007/s00068-021-01788-9] [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: 05/20/2021] [Accepted: 09/16/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE Early detection and management of acute trauma hemorrhage and coagulopathy have been associated with improved outcomes, but local infrastructure, logistics and clinical strategies may differ. METHODS To assess local differences in infrastructure, logistics and clinical management of acute trauma hemorrhage and coagulopathy we have conducted a web-based survey amongst clinicians working in DGU®-certified supraregional, regional and local trauma centers. RESULTS 137/1875 respondents completed the questionnaire yielding a response rate of 7.3%. The majority specified to work as head of department or senior consultant (95%) in trauma/orthopedic surgery (80%) of supraregional (38%), regional (34%) or local (27%) trauma centers. Conventional coagulation assays are most frequently used to monitor bleeding trauma patients. Only half of the respondents (53%) rely on extended coagulation tests, e.g. viscoelastic hemostatic assays. Tests to assess preinjury use of direct oral anticoagulants and platelet inhibitors are still not widely available and vary according to level of care. Conventional blood products are widely available but there remain differences between trauma centers of different level of care to access other hemostatic therapies, e.g. coagulation factor concentrates. Trauma centers of higher level of care are more likely to implement treatment protocols. CONCLUSION This survey confirms still existing differences in infrastructure, logistics and clinical practice management for the detection of acute trauma hemorrhage and coagulopathy amongst DGU®-certified supraregional, regional and local trauma centers. Further work is recommended to locally implement diagnostics, therapies and treatment algorithms compliant to current guidelines to ensure the best possible outcomes in bleeding trauma patients.
Collapse
|
7
|
Kleinveld DJB, van Amstel RBE, Wirtz MR, Geeraedts LMG, Goslings JC, Hollmann MW, Juffermans NP. Platelet-to-red blood cell ratio and mortality in bleeding trauma patients: A systematic review and meta-analysis. Transfusion 2021; 61 Suppl 1:S243-S251. [PMID: 34269443 PMCID: PMC8362120 DOI: 10.1111/trf.16455] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 01/18/2021] [Accepted: 01/18/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND In traumatic bleeding, transfusion practice has shifted toward higher doses of platelets and plasma transfusion. The aim of this systematic review was to investigate whether a higher platelet-to-red blood cell (RBC) transfusion ratio improves mortality without worsening organ failure when compared with a lower ratio of platelet-to-RBC. METHODS Pubmed, Medline, and Embase were screened for randomized controlled trials (RCTs) in bleeding trauma patients (age ≥16 years) receiving platelet transfusion between 1946 until October 2020. High platelet:RBC ratio was defined as being the highest ratio within an included study. Primary outcome was 24 hour mortality. Secondary outcomes were 30-day mortality, thromboembolic events, organ failure, and correction of coagulopathy. RESULTS In total five RCTs (n = 1757 patients) were included. A high platelet:RBC compared with a low platelet:RBC ratio significantly improved 24 hour mortality (odds ratio [OR] 0.69 [0.53-0.89]) and 30- day mortality (OR 0.78 [0.63-0.98]). There was no difference between platelet:RBC ratio groups in thromboembolic events and organ failure. Correction of coagulopathy was reported in five studies, in which platelet dose had no impact on trauma-induced coagulopathy. CONCLUSIONS In traumatic bleeding, a high platelet:RBC improves mortality as compared to low platelet:RBC ratio. The high platelet:RBC ratio does not influence thromboembolic or organ failure event rates.
Collapse
Affiliation(s)
- Derek J B Kleinveld
- Department of Intensive Care Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.,Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Rombout B E van Amstel
- Department of Intensive Care Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.,Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Mathijs R Wirtz
- Department of Intensive Care Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.,Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Leo M G Geeraedts
- Department of Trauma Surgery, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - J Carel Goslings
- Department of Trauma Surgery, OLVG Hospital, Amsterdam, The Netherlands
| | - Markus W Hollmann
- Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.,Department of Anesthesiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Nicole P Juffermans
- Department of Intensive Care Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.,Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.,Department of Intensive Care, OLVG Hospital, Amsterdam, The Netherlands
| |
Collapse
|
8
|
Demma J, Weiss D, Kedar A, Shussman N, Zamir G, Pikarsky A, Bala M. Splenic infarction complicated with abscess after pelvic trauma as the first presentation of patent foramen ovale - A case report. Trauma Case Rep 2021; 33:100479. [PMID: 34027002 PMCID: PMC8121688 DOI: 10.1016/j.tcr.2021.100479] [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] [Accepted: 04/17/2021] [Indexed: 11/29/2022] Open
Abstract
Hypercoagulability after trauma is a known entity. Following significant trauma, most guidelines advise anticoagulation treatment for venous thromboembolism (VTE) prophylaxis. VTE following minor trauma convoyed with arterial or systemic embolization dictate the need to search for uncommon source of thromboembolic complications. This is a report of an unusual case of pulmonary and systemic emboli complicated by splenic abscess following minor trauma in a patient with Diabetes Mellitus as the first presentation of patent foramen ovale (PFO).
Collapse
Affiliation(s)
- J Demma
- General Surgery and Traumatology Department, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - D Weiss
- General Surgery and Traumatology Department, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - A Kedar
- General Surgery and Traumatology Department, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - N Shussman
- General Surgery and Traumatology Department, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - G Zamir
- General Surgery and Traumatology Department, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - A Pikarsky
- General Surgery and Traumatology Department, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - M Bala
- General Surgery and Traumatology Department, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| |
Collapse
|
9
|
Hochart A, Momal R, Garrigue-Huet D, Drumez E, Susen S, Bijok B. Prothrombin Time ratio can predict mortality in severe pediatric trauma: Study in a French trauma center level 1. Am J Emerg Med 2020; 38:2041-2044. [PMID: 33142171 DOI: 10.1016/j.ajem.2020.06.075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Revised: 06/16/2020] [Accepted: 06/24/2020] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Injury results in more deaths in children than all other causes combined, but there is little data regarding the association of early coagulopathy on outcomes in pediatric patients with traumatic injuries. The aim of this study was to determine the optimal cut-off value for the Prothrombin Time ratio (PTr) and to show the diagnostic characteristics of the PTr to predict mortality. METHODS We retrospectively included during 4 years all patients less than 16 years old referred to our trauma center for traumatic injury with ISS ≥9. RESULTS A total of 272 children were included. Mean age was 9.4 ± 4.8 years and median ISS was 17 [interquartile range, 12 to 26]. Day 28 mortality was 6.7%. The optimal cut-off value in our population for predicting day 28 mortality was 1.24. Using this value, the sensitivity of PTr was 84%, specificity was 82%, positive likelihood ratio was 4.7, and negative likelihood ratio was 0.19. Early mortality (i.e., mortality at 24 h) was also well-predicted (1.0% versus 16.4%, p < .0001), as the need for massive transfuion. Similarly, patients with PTr ≥1.24 at admission presented with a higher rate of severe thoracic and abdominal trauma, higher ISS, higher likelihood of admission to an intensive care unit, longer hospitalization, and higher rate of significant procedure (e.g., surgery or embolization). CONCLUSIONS Trauma-induced coagulopathy defined only by a PTr ≥1.24 could be used as a severity predictive marker and as a sensitive, specific, quick, and easy to use tool for admission triage of pediatric patients.
Collapse
Affiliation(s)
- Audrey Hochart
- CHU Lille, Institut d'Hématologie et de Transfusion, F-59000 Lille, France.
| | - Romain Momal
- CHU de Lille, Pôle d'anesthésie-réanimation, Lille F-59000, France.
| | - Delphine Garrigue-Huet
- CHU de Lille, Pôle d'anesthésie-réanimation, Lille F-59000, France; CHU Lille, Pôle de l'Urgence, Lille F-59000, France.
| | - Elodie Drumez
- Univ. Lille, CHU Lille, Unité de biostatistiques, EA 2694, F-59000 Lille, France.
| | - Sophie Susen
- CHU Lille, Institut d'Hématologie et de Transfusion, F-59000 Lille, France.
| | - Benjamin Bijok
- CHU de Lille, Pôle d'anesthésie-réanimation, Lille F-59000, France; CHU Lille, Pôle de l'Urgence, Lille F-59000, France.
| |
Collapse
|
10
|
Protective effects of plasma products on the endothelial-glycocalyx barrier following trauma-hemorrhagic shock: Is sphingosine-1 phosphate responsible? J Trauma Acute Care Surg 2020; 87:1061-1069. [PMID: 31453986 DOI: 10.1097/ta.0000000000002446] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND Plasma is an important component of resuscitation after trauma and hemorrhagic shock (T/HS). The specific plasma proteins and the impact of storage conditions are uncertain. Utilizing a microfluidic device system, we studied the effect of various types of plasma on the endothelial barrier function following T/HS. METHODS Human umbilical vein endothelial cells (HUVEC) were cultured in microfluidic plates. The microfluidic plates were subjected to control or shock conditions (hypoxia/reoxygenation + epinephrine, 10 μM). Fresh plasma, 1 day thawed plasma, 5-day thawed plasma and lyophilized plasma were then added. Supplementation of sphingosine-1 phosphate (S-1P) was done in a subset of experiments. Effect on the endothelial glycocalyx was indexed by shedding of syndecan-1 and hyaluronic acid. Endothelial injury/activation was indexed by soluble thrombomodulin, tissue plasminogen activator, plasminogen activator inhibitor-1. Vascular permeability determined by the ratio of angiopoietin-2 to angiopoietin-1. Concentration of S-1P and adiponectin in the different plasma groups was measured. RESULTS Human umbilical vein endothelial cells exposed to shock conditions increased shedding of syndecan-1 and hyaluronic acid. Administration of the various types of plasma decreased shedding, except for 5-day thawed plasma. Shocked HUVEC cells demonstrated a profibrinolytic phenotype, this normalized with all plasma types except for 5-day thawed plasma. The concentration of S-1P was significantly less in the 5-day thawed plasma compared with the other plasma types. Addition of S-1P to 5-day thawed plasma returned the benefits lost with storage. CONCLUSION A biomimetic model of the microcirculation following T/HS demonstrated endothelial glycocalyx and endothelial cellular injury/activation as well as a profibrinolytic phenotype. These effects were abrogated by all plasma products except the 5-day thawed plasma. Plasma thawed longer than 5 days had diminished S1-P concentrations. Our data suggest that S1-P protein is critical to the protective effect of plasma products on the endothelial-glycocalyx barrier following T/HS.
Collapse
|
11
|
Lorenz B. Einfach und praktisch: Thrombelastographie. Notf Rett Med 2020. [DOI: 10.1007/s10049-020-00693-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
|
12
|
Wang YH, Liu CC, Cherng JH, Fan GY, Wang YW, Chang SJ, Hong ZJ, Lin YC, Hsu SD. Evaluation of Chitosan-based Dressings in a Swine Model of Artery-Injury-Related Shock. Sci Rep 2019; 9:14608. [PMID: 31601964 PMCID: PMC6787046 DOI: 10.1038/s41598-019-51208-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Accepted: 09/25/2019] [Indexed: 11/09/2022] Open
Abstract
Uncontrolled haemorrhage shock is the highest treatment priority for military trauma surgeons. Injuries to the torso area remain the greatest treatment challenge, since external dressings and compression cannot be used here. Bleeding control strategies may thus offer more effective haemostatic management in these cases. Chitosan, a linear polysaccharide derived from chitin, has been considered as an ideal material for bleeding arrest. This study evaluated the potential of chitosan-based dressings relative to commercial gauze to minimise femoral artery haemorrhage in a swine model. Stable haemostasis was achieved in animals treated with chitosan fibre (CF) or chitosan sponge (CS), resulting in stabilisation of mean arterial pressure and a substantially higher survival rate (100% vs. 0% for gauze). Pigs receiving treatment with CF or CS dressings achieved haemostasis within 3.25 ± 1.26 or 2.67 ± 0.58 min, respectively, significantly more rapidly than with commercial gauze (>100 min). Moreover, the survival of animals treated with chitosan-based dressings was dramatically prolonged (>180 min) relative to controls (60.92 ± 0.69 min). In summary, chitosan-based dressings may be suitable first-line treatments for uncontrolled haemorrhage on the battlefield, and require further investigation into their use as alternatives to traditional dressings in prehospital emergency care.
Collapse
Affiliation(s)
- Yao-Horng Wang
- Department of Veterinary Medicine, National Chung Hsing University, Taichung, Taiwan, R.O.C.,Department of Nursing, Yuanpei University of Medical Technology, Hsinchu, Taiwan, R.O.C
| | - Chuan-Chieh Liu
- Department of Cardiology, Cardinal Tien Hospital, Taipei, Taiwan, R.O.C
| | - Juin-Hong Cherng
- Department and Graduate Institute of Biology and Anatomy, National Defense Medical Center, Taipei, Taiwan, R.O.C.,Department of Gerontological Health Care, National Taipei University of Nursing and Health Sciences, Taipei, Taiwan, R.O.C
| | - Gang-Yi Fan
- Graduate Institute of Medical Sciences, National Defense Medical Center, Taipei, Taiwan, R.O.C
| | - Yi-Wen Wang
- Department and Graduate Institute of Biology and Anatomy, National Defense Medical Center, Taipei, Taiwan, R.O.C
| | - Shu-Jen Chang
- Division of Rheumatology/Immunology/Allergy, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, R.O.C
| | - Zhi-Jie Hong
- Division of Traumatology, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, R.O.C
| | - Yung-Chang Lin
- Department of Veterinary Medicine, National Chung Hsing University, Taichung, Taiwan, R.O.C
| | - Sheng-Der Hsu
- Division of Traumatology, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, R.O.C..
| |
Collapse
|
13
|
Kleinveld DJB, Wirtz MR, van den Brink DP, Maas MAW, Roelofs JJTH, Goslings JC, Hollmann MW, Juffermans NP. Use of a high platelet-to-RBC ratio of 2:1 is more effective in correcting trauma-induced coagulopathy than a ratio of 1:1 in a rat multiple trauma transfusion model. Intensive Care Med Exp 2019; 7:42. [PMID: 31346913 PMCID: PMC6658636 DOI: 10.1186/s40635-019-0242-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Accepted: 03/07/2019] [Indexed: 12/16/2022] Open
Abstract
Background Platelet dysfunction importantly contributes to trauma-induced coagulopathy (TIC). Our aim was to examine the impact of transfusing platelets (PLTs) in a 2:1 PLT-to-red blood cell (RBC) ratio versus the standard 1:1 ratio on transfusion requirements, correction of TIC, and organ damage in a rat multiple trauma transfusion model. Methods Mechanically ventilated male Sprague Dawley rats were traumatized by crush injury to the small intestine and liver and a fracture of the femur, followed by exsanguination until a mean arterial pressure (MAP) of 40 mmHg. Animals were randomly assigned to receive resuscitation in a high PLT dose (PLT to plasma to RBC in a ratio of 2:1:1) or a standard PLT dose (ratio of 1:1:1) until a MAP of 60 mmHg was reached (n = 8 per group). Blood samples were taken for biochemical and thromboelastometry (ROTEM) assessment. Organs were harvested for histopathology.Outcome measures were transfusion requirements needed to reach a pretargeted MAP, as well as ROTEM correction and organ failure. Results Trauma resulted in coagulopathy as assessed by deranged ROTEM results. Mortality rate was 19%, with all deaths occurring in the standard dose group. The severity of hypovolemic shock as assessed by lactate and base excess was not different in both groups. The volume of transfusion needed to reach the MAP target was lower in the high PLT dose group compared to the standard dose, albeit not statistically significant (p = 0.054). Transfusion with a high PLT dose resulted in significant stronger clot firmness compared to the standard dose at all time points following trauma, while platelet counts were similar. Organ failure as assessed by biochemical analysis and histopathology was not different between groups, nor were there any thromboembolic events recorded. Conclusions Resuscitation with a high (2:1) PLT-to-RBC ratio was more effective compared to standard (1:1) PLT-to-RBC ratio in treating TIC, with a trend towards reduced transfusion volumes. Also, high PLT dose did not aggravate organ damage. Transfusion strategies using higher PLT dose regiments might be a feasible treatment option in hemorrhaging trauma patients for the correction of TIC.
Collapse
Affiliation(s)
- Derek J B Kleinveld
- Department of Intensive Care Medicine, Amsterdam UMC, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.,Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam UMC, Amsterdam, The Netherlands.,Department of Trauma Surgery, Amsterdam UMC, Amsterdam, The Netherlands
| | - Mathijs R Wirtz
- Department of Intensive Care Medicine, Amsterdam UMC, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.,Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam UMC, Amsterdam, The Netherlands.,Department of Trauma Surgery, Amsterdam UMC, Amsterdam, The Netherlands
| | - Daan P van den Brink
- Department of Intensive Care Medicine, Amsterdam UMC, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - M Adrie W Maas
- Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam UMC, Amsterdam, The Netherlands
| | | | - J Carel Goslings
- Department of Trauma Surgery, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
| | - Markus W Hollmann
- Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam UMC, Amsterdam, The Netherlands.,Department of Anesthesiology, Amsterdam UMC, Amsterdam, The Netherlands
| | - Nicole P Juffermans
- Department of Intensive Care Medicine, Amsterdam UMC, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands. .,Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam UMC, Amsterdam, The Netherlands.
| |
Collapse
|
14
|
Vernon T, Morgan M, Morrison C. Bad blood: A coagulopathy associated with trauma and massive transfusion review. Acute Med Surg 2019; 6:215-222. [PMID: 31304022 PMCID: PMC6603326 DOI: 10.1002/ams2.402] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Accepted: 02/02/2019] [Indexed: 12/14/2022] Open
Abstract
Coagulopathy in trauma patients is a known contributor to death due to hemorrhage. In fact, it seen as frequently as 35% of the time. The complexity of the coagulopathy pathway requires a deliberate and planned approach. The methods used to assess and detect if a patient is coagulopathic remain challenging, but tools have been developed to assist the practitioner to effectively manage and even quickly reverse the coagulopathy. The purpose of this review is to educate trauma and emergency medicine staff on the currently available diagnostic tools to assess coagulopathy, to provide an overview of the coagulopathy pathway, as well as provide examples of how to intervene and treat coagulopathy, including the use of crew resource management during mass transfusion protocol activations.
Collapse
Affiliation(s)
- Tawnya Vernon
- Trauma ServicesPenn Medicine Lancaster General HealthLancasterPennsylvania
| | - Madison Morgan
- Trauma ServicesPenn Medicine Lancaster General HealthLancasterPennsylvania
| | - Chet Morrison
- Trauma ServicesPenn Medicine Lancaster General HealthLancasterPennsylvania
| |
Collapse
|
15
|
Goal-directed hemostatic resuscitation for trauma induced coagulopathy: Maintaining homeostasis. J Trauma Acute Care Surg 2019; 84:S35-S40. [PMID: 29334568 DOI: 10.1097/ta.0000000000001797] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
16
|
Bell C, Prokopchuk-Gauk O, Cload B, Stirling A, Davis PJ. Optimum Accuracy of Massive Transfusion Protocol Activation: The Clinician's View. Cureus 2018; 10:e3688. [PMID: 30761240 PMCID: PMC6368427 DOI: 10.7759/cureus.3688] [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] [Indexed: 11/23/2022] Open
Abstract
Background Massive transfusion protocols (MTP) aid in the efficient delivery of blood components to rapidly exsanguinating patients. Unfortunately, clinical gestalt and currently available clinical scoring systems lack the optimal accuracy to prevent blood product wastage (through over-activation), as well as individual patient morbidity and mortality (through under-activation). In order to help refine the MTP activation criteria and protocols, we surveyed clinicians on acceptable over- and under-activation rates for massive transfusions. Methods We surveyed Canadian content experts in their respective fields, using a snowball survey technique. Respondents were categorized into two groups: Group 1 was comprised of trauma and acute care specialists (TACS), while Group 2 was comprised of clinical and laboratory medicine specialists (CLMS). Between-group differences were examined using Fisher’s exact test and the likelihood ratio. Statistical significance was set at p < 0.05. Results We received responses from 35 clinicians in the TACS group and 10 clinicians in the CLMS group. About half (45.7%) of respondents in the TACS group considered an MTP overactivation rate of 5% - 10% acceptable (vs. 60% of the CLMS group; not significant (NS)). Approximately one-third (34.2%) of the respondents in the TACS group considered an MTP under-activation rate of less than 5% acceptable, whereas the majority (60%) of respondents in the CLMS group considered an under-activation rate of less than 5% acceptable (NS). A significantly greater proportion of respondents in the TACS group felt that an anticipated need for > 20 units of packed red blood cells within the next 24 hours was an acceptable criterion for MTP activation. Respondents in the CLMS group were more likely to consider “poor communication” as a reason for blood component wastage. Conclusion Similarities in acceptable MTP over- and under-activation rates were noted across specialties. Collaboration between involved parties is necessary for MTP protocol development to improve patient outcomes and reduce blood wastage.
Collapse
Affiliation(s)
- Chris Bell
- Internal Medicine, University of Saskatchewan College of Medicine, Saskatoon, CAN
| | - Oksana Prokopchuk-Gauk
- Pathology and Laboratory Medicine, University of Saskatchewan, Royal University Hospital, Saskatoon, CAN
| | - Bruce Cload
- Emergency Medicine, University of Saskatchewan, Royal University Hospital, Saskatoon, CAN
| | - Alena Stirling
- Anaesthesia, University of Saskatchewan, Royal University Hospital, Saskatoon, CAN
| | - Philip J Davis
- Emergency Medicine, University of Saskatchewan, Royal University Hospital, Saskatoon, CAN
| |
Collapse
|
17
|
Barelli S, Alberio L. The Role of Plasma Transfusion in Massive Bleeding: Protecting the Endothelial Glycocalyx? Front Med (Lausanne) 2018; 5:91. [PMID: 29721496 PMCID: PMC5915488 DOI: 10.3389/fmed.2018.00091] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2018] [Accepted: 03/22/2018] [Indexed: 12/20/2022] Open
Abstract
Massive hemorrhage is a leading cause of death worldwide. During the last decade several retrospective and some prospective clinical studies have suggested a beneficial effect of early plasma-based resuscitation on survival in trauma patients. The underlying mechanisms are unknown but appear to involve the ability of plasma to preserve the endothelial glycocalyx. In this mini-review, we summarize current knowledge on glycocalyx structure and function, and present data describing the impact of hemorrhagic shock and resuscitation fluids on glycocalyx. Animal studies show that hemorrhagic shock leads to glycocalyx shedding, endothelial inflammatory changes, and vascular hyper-permeability. In these animal models, plasma administration preserves glycocalyx integrity and functions better than resuscitation with crystalloids or colloids. In addition, we briefly present data on the possible plasma components responsible for these effects. The endothelial glycocalyx is increasingly recognized as a critical component for the physiological vasculo-endothelial function, which is destroyed in hemorrhagic shock. Interventions for preserving an intact glycocalyx shall improve survival of trauma patients.
Collapse
Affiliation(s)
- Stefano Barelli
- Division of Haematology and Central Haematology Laboratory, CHUV, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
| | - Lorenzo Alberio
- Division of Haematology and Central Haematology Laboratory, CHUV, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland.,Faculté de Biologie et Médecine, UNIL, University of Lausanne, Lausanne, Switzerland
| |
Collapse
|
18
|
Abstract
Traumatic hemorrhage is the leading cause of preventable death after trauma. Early transfusion of plasma and balanced transfusion have been shown to optimize survival, mitigate the acute coagulopathy of trauma, and restore the endothelial glycocalyx. There are a myriad of plasma formulations available worldwide, including fresh frozen plasma, thawed plasma, liquid plasma, plasma frozen within 24 h, and lyophilized plasma (LP). Significant equipoise exists in the literature regarding the optimal plasma formulation. LP is a freeze-dried formulation that was originally developed in the 1930s and used by the American and British military in World War II. It was subsequently discontinued due to risk of disease transmission from pooled donors. Recently, there has been a significant amount of research focusing on optimizing reconstitution of LP. Findings show that sterile water buffered with ascorbic acid results in decreased blood loss with suppression of systemic inflammation. We are now beginning to realize the creation of a plasma-derived formulation that rapidly produces the associated benefits without logistical or safety constraints. This review will highlight the history of plasma, detail the various types of plasma formulations currently available, their pathophysiological effects, impacts of storage on coagulation factors in vitro and in vivo, novel concepts, and future directions.
Collapse
|
19
|
Tonglet M, Lefering R, Minon JM, Ghuysen A, D’Orio V, Hildebrand F, Pape HC, Horst K. Prehospital identification of trauma patients requiring transfusion: results of a retrospective study evaluating the use of the trauma induced coagulopathy clinical score (TICCS) in 33,385 patients from the TraumaRegister DGU ®. Acta Chir Belg 2017. [PMID: 28639537 DOI: 10.1080/00015458.2017.1341148] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Identifying trauma patients that need emergent blood product transfusion is crucial. The Trauma Induced Coagulopathy Clinical Score (TICCS) is an easy-to-measure score developed to meet this medical need. We hypothesized that TICCS would assist in identifying patients that need a transfusion in a large cohort of severe trauma patients from the TraumaRegister DGU® (TR-DGU). MATERIALS AND METHODS A total of 33,385 severe trauma patients were extracted from the TR-DGU for retrospective analysis. The TICCS was adapted for the registry structure. Blood transfusion was defined as the use of at least one unit of red blood cells (RBC) during acute hospital treatment. RESULTS With an area under the receiving operating curve (AUC) of 0.700 (95% CI: 0.691-0.709), the TICCS appeared to be moderately discriminant for determining the need for RBC transfusion in the trauma population of the TR-DGU. A TICCS cut-off value of ≥12 yielded the best trade-off between true positives and false positives. The corresponding positive predictive value and negative predictive values were 48.4% and 89.1%, respectively. CONCLUSION This retrospective study confirms that the TICCS is a useful and simple score for discriminating between trauma patients with and without the need for emergent blood product transfusion.
Collapse
Affiliation(s)
- Martin Tonglet
- Department of Emergency, Liege University Hospital, Domaine du Sart Tilman, Liege, Belgium
| | - Rolf Lefering
- Department of Medicine, Institute for Research in Operative Medicine (IFOM), Faculty of Health, Witten/Herdecke University, Cologne, Germany
| | - Jean Marc Minon
- Department of Laboratory and Transfusion, CHR de la Citadelle, Liege, Belgium
| | - Alexandre Ghuysen
- Department of Emergency, Liege University Hospital, Domaine du Sart Tilman, Liege, Belgium
| | - Vincenzo D’Orio
- Department of Emergency, Liege University Hospital, Domaine du Sart Tilman, Liege, Belgium
| | - Frank Hildebrand
- Department of Orthopedic Trauma, RWTH Aachen University Hospital, Aachen, Germany
| | - Hans-Christoph Pape
- Department of Orthopedic Trauma, RWTH Aachen University Hospital, Aachen, Germany
| | - Klemens Horst
- Department of Orthopedic Trauma, RWTH Aachen University Hospital, Aachen, Germany
| |
Collapse
|
20
|
Kong T, Park JE, Park YS, Lee HS, You JS, Chung HS, Park I, Chung SP. Usefulness of serial measurement of the red blood cell distribution width to predict 28-day mortality in patients with trauma. Am J Emerg Med 2017; 35:1819-1827. [DOI: 10.1016/j.ajem.2017.06.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2017] [Revised: 06/02/2017] [Accepted: 06/05/2017] [Indexed: 10/19/2022] Open
|
21
|
Modeling Acute Traumatic Hemorrhagic Shock Injury: Challenges and Guidelines for Preclinical Studies. Shock 2017; 48:610-623. [DOI: 10.1097/shk.0000000000000901] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
|
22
|
Fröhlich M, Mutschler M, Caspers M, Nienaber U, Jäcker V, Driessen A, Bouillon B, Maegele M. Trauma-induced coagulopathy upon emergency room arrival: still a significant problem despite increased awareness and management? Eur J Trauma Emerg Surg 2017; 45:115-124. [PMID: 29170791 DOI: 10.1007/s00068-017-0884-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2017] [Accepted: 11/20/2017] [Indexed: 12/17/2022]
Abstract
PURPOSE Over the last decade, the pivotal role of trauma-induced coagulopathy has been described and principal drivers have been identified. We hypothesized that the increased knowledge on coagulopathy of trauma would translate into a more cautious treatment, and therefore, into a reduced overall incidence rate of coagulopathy upon ER admission. PATIENTS AND METHODS Between 2002 and 2013, 61,212 trauma patients derived from the TraumaRegister DGU® had a full record of coagulation parameters and were assessed for the presence of coagulopathy. Coagulopathy was defined by a Quick's value < 70% and/or platelet counts < 100,000/µl upon ER admission. For each year, the incidence of coagulopathy, the amount of pre-hospital administered i.v.-fluids and transfusion requirements were assessed. RESULTS Coagulopathy upon ER admission was present in 24.5% of all trauma patients. Within the years 2002-2013, the annual incidence of coagulopathy decreased from 35 to 20%. Even in most severely injured patients (ISS > 50), the incidence of coagulopathy was reduced by 7%. Regardless of the injury severity, the amount of pre-hospital i.v.-fluids declined during the observed period by 51%. Simultaneously, morbidity and mortality of severely injured patients were on the decrease. CONCLUSION During the 12 years observed, a substantial decline of coagulopathy has been observed. This was paralleled by a significant decrease of i.v.-fluids administered in the pre-hospital treatment. The reduced presence of coagulopathy translated into decreased transfusion requirements and mortality. Nevertheless, especially in the most severely injured patients, posttraumatic coagulopathy remains a frequent and life-threatening syndrome.
Collapse
Affiliation(s)
- Matthias Fröhlich
- Department of Trauma and Orthopedic Surgery, Cologne-Merheim Medical Centre (CMMC), University of Witten/Herdecke, Ostmerheimerstr.200, 51109, Cologne, Germany. .,Institute for Research in Operative Medicine (IFOM), Cologne Merheim Medical Center (CMMC), University of Witten/Herdecke, Ostmerheimerstr.200, 51109, Cologne, Germany.
| | - Manuel Mutschler
- Department of Trauma and Orthopedic Surgery, Cologne-Merheim Medical Centre (CMMC), University of Witten/Herdecke, Ostmerheimerstr.200, 51109, Cologne, Germany
| | - Michael Caspers
- Department of Trauma and Orthopedic Surgery, Cologne-Merheim Medical Centre (CMMC), University of Witten/Herdecke, Ostmerheimerstr.200, 51109, Cologne, Germany.,Institute for Research in Operative Medicine (IFOM), Cologne Merheim Medical Center (CMMC), University of Witten/Herdecke, Ostmerheimerstr.200, 51109, Cologne, Germany
| | - Ulrike Nienaber
- AUC-Academy for Trauma Surgery, Wilhelm-Hale Str. 46b, 80639, Munich, Germany
| | - Vera Jäcker
- Department of Trauma and Orthopedic Surgery, Cologne-Merheim Medical Centre (CMMC), University of Witten/Herdecke, Ostmerheimerstr.200, 51109, Cologne, Germany
| | - Arne Driessen
- Department of Orthopedics, RWTH Aachen University Hospital, Pauwelsstr. 30, 52074, Aachen, Germany
| | - Bertil Bouillon
- Department of Trauma and Orthopedic Surgery, Cologne-Merheim Medical Centre (CMMC), University of Witten/Herdecke, Ostmerheimerstr.200, 51109, Cologne, Germany
| | - Marc Maegele
- Department of Trauma and Orthopedic Surgery, Cologne-Merheim Medical Centre (CMMC), University of Witten/Herdecke, Ostmerheimerstr.200, 51109, Cologne, Germany.,Institute for Research in Operative Medicine (IFOM), Cologne Merheim Medical Center (CMMC), University of Witten/Herdecke, Ostmerheimerstr.200, 51109, Cologne, Germany
| | | |
Collapse
|
23
|
Baksaas-Aasen K, Gall L, Eaglestone S, Rourke C, Juffermans NP, Goslings JC, Naess PA, van Dieren S, Ostrowski SR, Stensballe J, Maegele M, Stanworth SJ, Gaarder C, Brohi K, Johansson PI. iTACTIC - implementing Treatment Algorithms for the Correction of Trauma-Induced Coagulopathy: study protocol for a multicentre, randomised controlled trial. Trials 2017; 18:486. [PMID: 29047413 PMCID: PMC5648415 DOI: 10.1186/s13063-017-2224-9] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2017] [Accepted: 09/30/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Traumatic injury is the fourth leading cause of death globally. Half of all trauma deaths are due to bleeding and most of these will occur within 6 h of injury. Haemorrhagic shock following injury has been shown to induce a clotting dysfunction within minutes, and this early trauma-induced coagulopathy (TIC) may exacerbate bleeding and is associated with higher mortality and morbidity. In spite of improved resuscitation strategies over the last decade, current transfusion therapy still fails to correct TIC during ongoing haemorrhage and evidence for the optimal management of bleeding trauma patients is lacking. Recent publications describe increasing the use of Viscoelastic Haemostatic Assays (VHAs) in trauma haemorrhage; however, there is insufficient evidence to support their superiority to conventional coagulation tests (CCTs). METHODS/DESIGN This multicentre, randomised controlled study will compare the haemostatic effect of an evidence-based VHA-guided versus an optimised CCT-guided transfusion algorithm in haemorrhaging trauma patients. A total of 392 adult trauma patients will be enrolled at major trauma centres. Participants will be eligible if they present with clinical signs of haemorrhagic shock, activate the local massive haemorrhage protocol and initiate first blood transfusion. Enrolled patients will be block randomised per centre to either VHA-guided or CCT-guided transfusion therapy in addition to that therapy delivered as part of standard care, until haemostasis is achieved. Patients will be followed until discharge or 28 days. The primary endpoint is the proportion of subjects alive and free of massive transfusion (less than 10 units of red blood cells) at 24 h. Secondary outcomes include the effect of CCT- versus VHA-guided therapy on organ failure, total hospital and intensive care lengths of stay, health care resources needed and mortality. Surviving patients will be asked to complete a quality of life questionnaire (EuroQol EQ-5DTM) at day 90. DISCUSSION CCTs have traditionally been used to detect TIC and monitor response to treatment in traumatic major haemorrhage. The use of VHAs is increasing, but limited evidence exists to support the superiority of these technologies (or comparatively) for patient-centred outcomes. This knowledge gap will be addressed by this trial. TRIAL REGISTRATION ClinicalTrials.gov, ID: NCT02593877 . Registered on 15 October 2015. Trial sponsor Queen Mary University of London The contact person of the above sponsor organisation is: Dr. Sally Burtles, Director of Research Services and Business Development, Joint Research Management Office, QM Innovation Building, 5 Walden Street, London E1 2EF; phone: 020 7882 7260; Email: sponsorsrep@bartshealth.nhs.uk Trial sites Academic Medical Centre, Amsterdam, The Netherlands Kliniken der Stadt Köln gGmbH, Cologne, Germany Rigshospitalet (Copenhagen University Hospital), Copenhagen, Denmark John Radcliff Hospital, Oxford, United Kingdom Oslo University Hospital, Oslo, Norway The Royal London Hospital, London, United Kingdom Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, United Kingdom Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom Sites that are planning to start recruitment in mid/late 2017 Nottingham University Hospitals, Queen's Medical Centre, Nottingham, United Kingdom University of Kansas Hospital (UKH), Kansas City, MO, USA Protocol version: 3.0/14.03.2017 (Additional file 1).
Collapse
Affiliation(s)
| | - Lewis Gall
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, UK
| | - Simon Eaglestone
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, UK
| | - Claire Rourke
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, UK
| | - Nicole P Juffermans
- Department of Intensive Care Medicine, Academic Medical Center, Amsterdam, The Netherlands
| | - J Carel Goslings
- Trauma Unit, Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - Paal Aksel Naess
- Department of Traumatology, Oslo University Hospital, Oslo, Norway
| | - Susan van Dieren
- Trauma Unit, Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - Sisse Rye Ostrowski
- Section for Transfusion Medicine, Capital Region Blood Bank, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Jakob Stensballe
- Section for Transfusion Medicine, Capital Region Blood Bank, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Marc Maegele
- Department for Traumatology and Orthopedic Surgery, Cologne-Merheim Medical Centre, University of Witten/Herdecke, Cologne, Germany
| | - Simon J Stanworth
- NHS Blood and Transplant/Oxford University Hospital NHS Trust, John Radcliffe Hospital, Oxford, UK.,Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| | | | - Karim Brohi
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, UK
| | - Per I Johansson
- Section for Transfusion Medicine, Capital Region Blood Bank, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| |
Collapse
|
24
|
Overexpression of miR-24 Is Involved in the Formation of Hypocoagulation State after Severe Trauma by Inhibiting the Synthesis of Coagulation Factor X. DISEASE MARKERS 2017; 2017:3649693. [PMID: 28694557 PMCID: PMC5488151 DOI: 10.1155/2017/3649693] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/22/2017] [Revised: 04/16/2017] [Accepted: 05/14/2017] [Indexed: 01/09/2023]
Abstract
BACKGROUND Dysregulation of microRNAs may contribute to the progression of trauma-induced coagulopathy (TIC). We aimed to explore the biological function that miRNA-24-3p (miR-24) might have in coagulation factor deficiency after major trauma and TIC. METHODS 15 healthy volunteers and 36 severe trauma patients (Injury Severity Score ≥ 16 were enrolled. TIC was determined as the initial international normalized ratio >1.5. The miR-24 expression and concentrations of factor X (FX) and factor XII in plasma were measured. In vitro study was conducted on L02 cell line. RESULTS The plasma miR-24 expression was significantly elevated by 3.17-fold (P = 0.043) in major trauma patients and reduced after 3 days (P < 0.01). The expression level was significantly higher in TIC than in non-TIC patients (P = 0.040). Multivariate analysis showed that the higher miR-24 expression was associated with TIC. The plasma concentration of FX in TIC patients was significantly lower than in the non-TIC ones (P = 0.030) and controls (P < 0.01). A negative correlation was observed between miR-24 and FX. miR-24 transduction significantly reduced the FX level in the supernatant of L02 cells (P = 0.030). CONCLUSIONS miR-24 was overexpressed in major trauma and TIC patients. The negative correlation of miR-24 with FX suggested the possibility that miR-24 might inhibit the synthesis of FX during TIC.
Collapse
|
25
|
Iapichino GE, Ponschab M, Cadamuro J, Süssner S, Gabriel C, Dieplinger B, Egger M, Schlimp CJ, Bahrami S, Schöchl H. Concentrated lyophilized plasma used for reconstitution of whole blood leads to higher coagulation factor activity but unchanged thrombin potential compared with fresh-frozen plasma. Transfusion 2017; 57:1763-1771. [DOI: 10.1111/trf.14123] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Revised: 02/13/2017] [Accepted: 02/13/2017] [Indexed: 11/29/2022]
Affiliation(s)
- Giacomo E. Iapichino
- Ludwig Boltzmann Institute for Experimental and Clinical Traumatology; Austrian Workers' Compensation Board (AUVA) Research Centre Vienna Austria
- Scuola di Specializzazione in Anestesia Rianimazione e Terapia Intensiva, Università degli Studi di Milano; Milan Italy
| | - Martin Ponschab
- Ludwig Boltzmann Institute for Experimental and Clinical Traumatology; Austrian Workers' Compensation Board (AUVA) Research Centre Vienna Austria
- Department of Anesthesiology and Intensive Care Medicine; AUVA Trauma Centre Linz, Academic Teaching Hospital of the Paracelsus Medical University; Salzburg Austria
| | - Janne Cadamuro
- Department of Laboratory Medicine; Paracelsus Medical University; Salzburg Austria
| | - Susanne Süssner
- Red Cross Blood Transfusion Service for Upper Austria; Linz Austria
| | | | - Benjamin Dieplinger
- Department of Laboratory Medicine; Konventhospital Barmherzige Brüder Linz; Linz Austria
| | - Margot Egger
- Department of Laboratory Medicine; Konventhospital Barmherzige Brüder Linz; Linz Austria
| | - Christoph J. Schlimp
- Ludwig Boltzmann Institute for Experimental and Clinical Traumatology; Austrian Workers' Compensation Board (AUVA) Research Centre Vienna Austria
| | - Soheyl Bahrami
- Ludwig Boltzmann Institute for Experimental and Clinical Traumatology; Austrian Workers' Compensation Board (AUVA) Research Centre Vienna Austria
| | - Herbert Schöchl
- Ludwig Boltzmann Institute for Experimental and Clinical Traumatology; Austrian Workers' Compensation Board (AUVA) Research Centre Vienna Austria
- Department of Anesthesiology and Intensive Care Medicine; AUVA Trauma Centre Salzburg, Academic Teaching Hospital of the Paracelsus Medical University; Salzburg Austria
| |
Collapse
|
26
|
Abstract
Following results from the CRASH-2 trial, tranexamic acid (TXA) gained considerable interest for the treatment of hemorrhage in trauma patients. Although TXA is effective at reducing mortality in patients presenting within 3 hours of injury, optimal dosing, timing of administration, mechanism, and pharmacokinetics require further elucidation. The concept of fibrinolysis shutdown in hemorrhagic trauma patients has prompted discussion of real-time viscoelastic testing and its potential role for appropriate patient selection. The results of ongoing clinical trials will help establish high-quality evidence for optimal incorporation of TXA in mature trauma networks in the United States and abroad.
Collapse
Affiliation(s)
- Ricardo J Ramirez
- Department of Surgery, Washington University School of Medicine, 660 South Euclid Avenue, St Louis, MO 63110, USA
| | - Philip C Spinella
- Department of Pediatrics, Washington University School of Medicine, St Louis, MO, USA
| | - Grant V Bochicchio
- Department of Surgery, Washington University School of Medicine, 660 South Euclid Avenue, St Louis, MO 63110, USA.
| |
Collapse
|
27
|
Nakamura Y, Ishikura H, Kushimoto S, Kiyomi F, Kato H, Sasaki J, Ogura H, Matsuoka T, Uejima T, Morimura N, Hayakawa M, Hagiwara A, Takeda M, Kaneko N, Saitoh D, Kudo D, Maekawa K, Kanemura T, Shibusawa T, Hagihara Y, Furugori S, Shiraishi A, Murata K, Mayama G, Yaguchi A, Kim S, Takasu O, Nishiyama K. Fibrinogen level on admission is a predictor for massive transfusion in patients with severe blunt trauma: Analyses of a retrospective multicentre observational study. Injury 2017; 48:674-679. [PMID: 28122682 DOI: 10.1016/j.injury.2017.01.031] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Revised: 12/09/2016] [Accepted: 01/10/2017] [Indexed: 02/02/2023]
Abstract
INTRODUCTION In the early phase of trauma, fibrinogen (Fbg) plays an important role in clot formation. However, to the best of our knowledge, few studies have analysed methods of predicting the need for massive transfusion (MT) based on Fbg levels using multiple logistic regression. Therefore, the present study aimed to evaluate whether Fbg levels on admission can be used to predict the need for MT in patients with trauma. METHODS We conducted a retrospective multicentre observational study. Patients with blunt trauma with ISS ≥16 who were admitted to 15 tertiary emergency and critical care centres in Japan participating in the J-OCTET were enrolled in the present study. MT was defined as the transfusion of packed red blood cells (PRBC) ≥10 units or death caused by bleeding within 24h after admission. Patients were divided into non-MT and MT groups. Multiple logistic-regression analysis was used to assess the predictive value of the variables age, sex, vital signs, Glasgow Coma Scale (GCS) score, and Fbg levels for MT. We also evaluated the discrimination threshold of MT prediction via receiver operating characteristic curve (ROC) analysis for each variable. RESULTS Higher heart rate (HR; per 10 beats per minutes [bpm]), systolic blood pressure (SBP; per 10mm Hg), GCS, and Fbg levels (per 10mg/dL) were independent predictors of MT (odds ratio [OR] 1.480, 95% confidence interval [CI] 1.326-1.668; OR 0.851, 95% CI 0.789-0.914; OR 0.907, 95% CI 0.855-0.962; and OR 0.931, 95% CI 0.898-0.963, respectively). The optimal cut-off values for HR, SBP, GCS, and Fbg levels were ≥100 bpm (sensitivity 62.4%, specificity 79.8%), ≤120mm Hg (sensitivity 61.5%, specificity 70.5%), ≤12 points (sensitivity 63.3%, specificity 63.6%), and ≤190mg/dL (sensitivity 55.1%, specificity 78.6%), respectively. CONCLUSIONS Our findings suggest that vital signs, GCS, and decreased Fbg levels can be regarded as predictors of MT. Therefore, future studies should consider Fbg levels when devising models for the prediction of MT.
Collapse
Affiliation(s)
- Yoshihiko Nakamura
- Department of Emergency and Critical Care Medicine, Faculty of Medicine, Fukuoka University, 7-45-1 Nanakuma, Jonan-ku, Fukuoka 814-0180, Japan.
| | - Hiroyasu Ishikura
- Department of Emergency and Critical Care Medicine, Faculty of Medicine, Fukuoka University, 7-45-1 Nanakuma, Jonan-ku, Fukuoka 814-0180, Japan.
| | - Shigeki Kushimoto
- Division of Emergency and Critical Care Medicine, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai 980-8574, Japan.
| | - Fumiaki Kiyomi
- Academia, Industry and Government Collaborative Research Institute of Translational Medicine for Life Innovation, Fukuoka University, 7-45-1 Nanakuma, Jonan-ku, Fukuoka 814-0180, Japan.
| | - Hiroshi Kato
- Department of Critical Care and Traumatology, National Hospital Organization Disaster Medical Center, 3256 Midori-cho, Tachikawa, Tokyo 190-0014, Japan.
| | - Junichi Sasaki
- Department of Emergency & Critical Care Medicine, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan.
| | - Hiroshi Ogura
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, 2-15 Yamadaoka, Suita, Osaka 565-0871, Japan.
| | - Tetsuya Matsuoka
- Senshu Trauma and Critical Care Center, Rinku General Medical Center, 2-23 Rinku Orai-kita Izumisano, Osaka 598-8577, Japan.
| | - Toshifumi Uejima
- Department of Emergency and Critical Care Medicine, Kinki University Faculty of Medicine, 377-2 Ohnohigashi, Osakasayama, Osaka 589-8511, Japan.
| | - Naoto Morimura
- Department of Emergency Medicine, Yokohama City University Graduate School of Medicine, 4-57 Urafunecho Minami-ku, Yokohama 232-0024, Japan.
| | - Mineji Hayakawa
- Emergency and Critical Care Center, Hokkaido University Hospital N14W5, Kita-ku, Sapporo 060-8648, Japan.
| | - Akiyoshi Hagiwara
- Department of Emergency Medicine and Critical Care, National Center For Global Health and Medicine, 1-21-1 Toyama, Shinjuku-ku, Tokyo 162-8655, Japan.
| | - Munekazu Takeda
- Department of Critical Care and Emergency Medicine, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo 162-8666, Japan.
| | - Naoyuki Kaneko
- Trauma and Emergency Center, Fukaya Red Cross Hospital, 5-8-1 Kamishiba-West, Fukaya, Saitama 366-0052, Japan.
| | - Daizoh Saitoh
- Division of Traumatology, Research Institute, National Defense Medical College, 3-2 Namiki, Tokorozawa-shi, Saitama 359-8513, Japan.
| | - Daisuke Kudo
- Division of Emergency and Critical Care Medicine, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai 980-8574, Japan.
| | - Kunihiko Maekawa
- Emergency and Critical Care Center, Hokkaido University Hospital N14W5, Kita-ku, Sapporo 060-8648, Japan.
| | - Takashi Kanemura
- Department of Critical Care and Traumatology, National Hospital Organization Disaster Medical Center, 3256 Midori-cho, Tachikawa, Tokyo 190-0014, Japan.
| | - Takayuki Shibusawa
- Department of Emergency & Critical Care Medicine, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan.
| | - Yasushi Hagihara
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, 2-15 Yamadaoka, Suita, Osaka 565-0871, Japan.
| | - Shintaro Furugori
- Department of Emergency and Critical Care Medicine, Kinki University Faculty of Medicine, 377-2 Ohnohigashi, Osakasayama, Osaka 589-8511, Japan.
| | - Atsushi Shiraishi
- Trauma and Acute Critical Care Medical Center, Tokyo Medical and Dental University Hospital of Medicine, 1-5-45, Yushima, Bunkyo, Tokyo 113-8510, Japan.
| | - Kiyoshi Murata
- Trauma and Acute Critical Care Medical Center, Tokyo Medical and Dental University Hospital of Medicine, 1-5-45, Yushima, Bunkyo, Tokyo 113-8510, Japan.
| | - Gou Mayama
- Department of Emergency Medicine and Critical Care, National Center For Global Health and Medicine, 1-21-1 Toyama, Shinjuku-ku, Tokyo 162-8655, Japan.
| | - Arino Yaguchi
- Department of Critical Care and Emergency Medicine, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo 162-8666, Japan.
| | - Shiei Kim
- Department of Emergency & Critical Care Medicine, Nippon Medical School, 1-1-5 Sendagi Bunkyo-Ku, Tokyo 113-8603, Japan.
| | - Osamu Takasu
- Department of Emergency and Critical Care Medicine, Kurume University School of Medicine, 67 Asahi-machi, Kurume, Fukuoka 830-0011, Japan.
| | - Kazutaka Nishiyama
- Department of Emergency and Critical Care Medicine, Juntendo University Urayasu Hospital, 2-1-1 Tomioka, Urayasu-shi, Chiba 279-0021, Japan.
| |
Collapse
|
28
|
Can Early Aggressive Administration of Fresh Frozen Plasma Improve Outcomes in Patients with Severe Blunt Trauma?--A Report by the Japanese Association for the Surgery of Trauma. Shock 2017; 45:495-501. [PMID: 26863127 PMCID: PMC4854180 DOI: 10.1097/shk.0000000000000536] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Background: This study investigated the effect of a high ratio of fresh frozen plasma (FFP) to red blood cells (RBCs) within the first 6 and 24 h after admission on mortality in patients with severe, blunt trauma. Methods: This retrospective observational study included 189 blunt trauma patients with an Injury Severity Score (ISS) ≥16 requiring RBC transfusions within the first 24 h. Receiver operating characteristic (ROC) curve analysis was performed to calculate cut-off values of the FFP/RBC ratio for outcome. The patients were then divided into two groups according to the cut-off value. Patient survival was compared between groups using propensity score matching (PSM). Results: The area under the ROC curve was 0.57, and the FFP/RBC ratio was 1.0 at maximum sensitivity (0.57) and specificity (0.67). All patients were then divided into two groups (FFP/RBC ratio ≥1 or <1) and analyzed using PSM and inverse probability of treatment weighting (IPTW). The unadjusted hazard ratio (HR) was 0.44, and the adjusted HR was 0.29. The HR was 0.38 by PSM and 0.41 by IPTW. The survival rate was significantly higher in patients with an FFP/RBC ratio ≥1 within the first 6 h. Conclusions: Severe blunt trauma patients transfused with an FFP/RBC ratio ≥1 within the first 6 h had an HR of about 0.4. The transfusion of an FFP/RBC ratio ≥1 within the first 6 h was associated with the outcomes of blunt trauma patients with ISS ≥16 who need a transfusion within 24 h.
Collapse
|
29
|
Oh KJ, Hong JS, Youm J, Cho SH, Jung EY. Can coagulopathy in post-partum hemorrhage predict maternal morbidity? J Obstet Gynaecol Res 2016; 42:1509-1518. [DOI: 10.1111/jog.13098] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Accepted: 06/11/2016] [Indexed: 11/30/2022]
Affiliation(s)
- Kyung Joon Oh
- Department of Obstetrics and Gynecology; Seoul National University Bundang Hospital; Gyeonggi Korea
| | - Joon-Seok Hong
- Department of Obstetrics and Gynecology; Seoul National University Bundang Hospital; Gyeonggi Korea
| | - Jina Youm
- Department of Obstetrics and Gynecology; Seoul National University College of Medicine; Seoul Korea
| | - Soo-hyun Cho
- Department of Obstetrics and Gynecology; Seoul National University Bundang Hospital; Gyeonggi Korea
| | - Eun Young Jung
- Department of Obstetrics and Gynecology; Seoul National University Bundang Hospital; Gyeonggi Korea
| |
Collapse
|
30
|
Damage Control Resuscitation and Surgery in a Forward Combat Setting. CURRENT TRAUMA REPORTS 2016. [DOI: 10.1007/s40719-016-0049-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
|
31
|
Early Trauma-Induced Coagulopathy is Associated with Increased Ventilator-Associated Pneumonia in Spinal Cord Injury Patients. Shock 2016; 45:502-5. [DOI: 10.1097/shk.0000000000000531] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
|
32
|
Komorowski AL, Li WF, Millan CA, Huang TS, Yong CC, Lin TS, Lin TL, Jawan B, Wang CC, Chen CL. Temporary abdominal closure and delayed biliary reconstruction due to massive bleeding in patients undergoing liver transplantation: an old trick in a new indication. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2016; 23:118-24. [PMID: 26692574 PMCID: PMC4764012 DOI: 10.1002/jhbp.311] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/24/2015] [Accepted: 12/17/2015] [Indexed: 12/27/2022]
Abstract
Background Massive bleeding during liver transplantation (LT) is difficult to manage surgical event. Perihepatic packing (PP) and temporary abdominal closure (TAC) with delayed biliary reconstruction (DBR) can be applied in these circumstances. Method A prospective database of LT in a major transplant center was analyzed to identify patients with massive uncontrollable bleeding during LT that was resolved by PP, TAC, and DBR. Results From January 2009 to July 2013, 20 (3.6%) of 547 patients who underwent LT underwent DBR. Mean intraoperative blood loss was 20,500 ml at the first operation. The DBR was performed with a mean of 55.2 h (16–110) after LT. Biliary reconstruction included duct‐to‐duct (n = 9) and hepatico‐jejunostomy (n = 11). Complications occurred in eight patients and included portal vein thrombosis, cholangitis, severe bacteremia, pneumonia. There was one in‐hospital death. In the follow‐up of 18 to 33 months we have seen one patient died 9 months after transplantation. The remaining 18 patients are alive and well. Conclusions In case of massive uncontrollable bleeding and bowel edema during LT, the combined procedures of PP, TAC, and DBR offer an alternatively surgical option to solve the tough situation.
Collapse
Affiliation(s)
- Andrzej L Komorowski
- Liver Transplantation Program and Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, 123 Ta-Pei Road, Niao-Song, Kaohsiung, 833, Taiwan.,Department of Surgical Oncology, Maria Skłodowska-Curie Memorial Cancer Centre and Institute of Oncology, Kraków, Poland
| | - Wei-Feng Li
- Liver Transplantation Program and Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, 123 Ta-Pei Road, Niao-Song, Kaohsiung, 833, Taiwan
| | - Carlos A Millan
- Liver Transplantation Program and Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, 123 Ta-Pei Road, Niao-Song, Kaohsiung, 833, Taiwan
| | - Tun-Sung Huang
- Liver Transplantation Program and Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, 123 Ta-Pei Road, Niao-Song, Kaohsiung, 833, Taiwan.,Department of Surgery, Mackay Memorial Hospital, Taipei, Taiwan
| | - Chee-Chien Yong
- Liver Transplantation Program and Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, 123 Ta-Pei Road, Niao-Song, Kaohsiung, 833, Taiwan
| | - Tsan-Shiun Lin
- Liver Transplantation Program and Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, 123 Ta-Pei Road, Niao-Song, Kaohsiung, 833, Taiwan
| | - Ting-Lung Lin
- Liver Transplantation Program and Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, 123 Ta-Pei Road, Niao-Song, Kaohsiung, 833, Taiwan
| | - Bruno Jawan
- Liver Transplantation Program and Department of Anesthesiology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Chih-Chi Wang
- Liver Transplantation Program and Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, 123 Ta-Pei Road, Niao-Song, Kaohsiung, 833, Taiwan. .,Department of Surgery, Chang Gung Memorial Hospital Chiayi, Chang Gung University College of Medicine, Kaohsiung, Taiwan.
| | - Chao-Long Chen
- Liver Transplantation Program and Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, 123 Ta-Pei Road, Niao-Song, Kaohsiung, 833, Taiwan
| |
Collapse
|
33
|
Albrecht V, Schäfer N, Stürmer EK, Driessen A, Betsche L, Schenk M, Maegele M. Practice management of acute trauma haemorrhage and haemostatic disorders across German trauma centres. Eur J Trauma Emerg Surg 2015; 43:201-214. [DOI: 10.1007/s00068-015-0608-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2015] [Accepted: 11/18/2015] [Indexed: 11/24/2022]
|
34
|
Stengel D, Rademacher G, Ekkernkamp A, Güthoff C, Mutze S. Emergency ultrasound-based algorithms for diagnosing blunt abdominal trauma. Cochrane Database Syst Rev 2015; 2015:CD004446. [PMID: 26368505 PMCID: PMC6464800 DOI: 10.1002/14651858.cd004446.pub4] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Ultrasonography (performed by means of a four-quadrant, focused assessment of sonography for trauma (FAST)) is regarded as a key instrument for the initial assessment of patients with suspected blunt abdominal and thoraco-abdominal trauma in the emergency department setting. FAST has a high specificity but low sensitivity in detecting and excluding visceral injuries. Proponents of FAST argue that ultrasound-based clinical pathways enhance the speed of primary trauma assessment, reduce the number of unnecessary multi-detector computed tomography (MDCT) scans, and enable quicker triage to surgical and non-surgical care. Given the proven accuracy, increasing availability of, and indication for, MDCT among patients with blunt abdominal and multiple injuries, we aimed to compile the best available evidence of the use of FAST-based assessment compared with other primary trauma assessment protocols. OBJECTIVES To assess the effects of diagnostic algorithms using ultrasonography including in FAST examinations in the emergency department in relation to the early, late, and overall mortality of patients with suspected blunt abdominal trauma. SEARCH METHODS The most recent search was run on 30th June 2015. We searched the Cochrane Injuries Group Specialised Register, The Cochrane Library, MEDLINE (OvidSP), EMBASE (OvidSP), ISI Web of Science (SCI-EXPANDED, SSCI, CPCI-S, and CPSI-SSH), clinical trials registers, and screened reference lists. Trial authors were contacted for further information and individual patient data. SELECTION CRITERIA We included randomised controlled trials (RCTs). Participants were patients with blunt torso, abdominal, or multiple trauma undergoing diagnostic investigations for abdominal organ injury. The intervention was diagnostic algorithms comprising emergency ultrasonography (US). The control was diagnostic algorithms without US examinations (for example, primary computed tomography (CT) or diagnostic peritoneal lavage (DPL)). Outcomes were mortality, use of CT or invasive procedures (DPL, laparoscopy, laparotomy), and cost-effectiveness. DATA COLLECTION AND ANALYSIS Two authors (DS and CG) independently selected trials for inclusion, assessed methodological quality, and extracted data. Methodological quality was assessed using the Cochrane Collaboration risk of bias tool. Where possible, data were pooled and relative risks (RRs), risk differences (RDs), and weighted mean differences, each with 95% confidence intervals (CIs), were calculated by fixed-effect or random-effects models as appropriate. MAIN RESULTS We identified four studies meeting our inclusion criteria. Overall, trials were of poor to moderate methodological quality. Few trial authors responded to our written inquiries seeking to resolve controversial issues and to obtain individual patient data. Strong heterogeneity amongst the trials prompted discussion between the review authors as to whether the data should or should not be pooled; we decided in favour of a quantitative synthesis to provide a rough impression about the effect sizes achievable with US-based triage algorithms. We pooled mortality data from three trials involving 1254 patients; the RR in favour of the FAST arm was 1.00 (95% CI 0.50 to 2.00). FAST-based pathways reduced the number of CT scans (random-effects model RD -0.52, 95% CI -0.83 to -0.21), but the meaning of this result was unclear. AUTHORS' CONCLUSIONS The experimental evidence justifying FAST-based clinical pathways in diagnosing patients with suspected abdominal or multiple blunt trauma remains poor. Because of strong heterogeneity between the trial results, the quantitative information provided by this review may only be used in an exploratory fashion. It is unlikely that FAST will ever be investigated by means of a confirmatory, large-scale RCT in the future. Thus, this Cochrane Review may be regarded as a review which provides the best available evidence for clinical practice guidelines and management recommendations. It can only be concluded from the few head-to-head studies that negative US scans are likely to reduce the incidence of MDCT scans which, given the low sensitivity of FAST (or reliability of negative results), may adversely affect the diagnostic yield of the trauma survey. At best, US has no negative impact on mortality or morbidity. Assuming that major blunt abdominal or multiple trauma is associated with 15% mortality and a CT-based diagnostic work-up is considered the current standard of care, 874, 3495, or 21,838 patients are needed per intervention group to demonstrate non-inferiority of FAST to CT-based algorithms with non-inferiority margins of 5%, 2.5%, and 1%, power of 90%, and a type-I error alpha of 5%.
Collapse
Affiliation(s)
- Dirk Stengel
- Unfallkrankenhaus BerlinCentre for Clinical Research, Department of Trauma and Orthopaedic SurgeryWarener Str 7BerlinGermany12683
| | - Grit Rademacher
- Unfallkrankenhaus BerlinDepartment of Diagnostic and Interventional RadiologyWarener Str 7BerlinGermany12683
| | - Axel Ekkernkamp
- University HospitalDepartment of Trauma and Reconstructive SurgeryFerdinand‐Sauerbruch‐StraßeGreifswaldGermany17475
| | - Claas Güthoff
- Unfallkrankenhaus BerlinCentre for Clinical Research, Department of Trauma and Orthopaedic SurgeryWarener Str 7BerlinGermany12683
| | - Sven Mutze
- Unfallkrankenhaus BerlinDepartment of Diagnostic and Interventional RadiologyWarener Str 7BerlinGermany12683
| | | |
Collapse
|
35
|
Helicopter In-flight Resuscitation with Freeze-dried Plasma of a Patient with a High-velocity Gunshot Wound to the Neck in Afghanistan - A Case Report. Prehosp Disaster Med 2015; 30:509-11. [PMID: 26323858 DOI: 10.1017/s1049023x15005014] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Massive hemorrhage with coagulopathy is one of the leading causes of preventable death in the battlefield. The development of freeze-dried plasma (FDP) allows for early treatment with coagulation-optimizing resuscitation fluid in the prehospital setting. This report describes the first prehospital use of FDP in a patient with carotid artery injury due to a high-velocity gunshot wound (HVGSW) to the neck. It also describes in-flight constitution and administration of FDP in a Medevac Helicopter. Early administration of FDP may contribute to hemodynamic stabilization and reduction in trauma-induced coagulopathy and acidosis. However, large-scale studies are needed to define the prehospital use of FDP and other blood products.
Collapse
|
36
|
Correction of acute traumatic coagulopathy with small-volume 7.5% NaCl adenosine, lidocaine, and Mg2+ occurs within 5 minutes: a ROTEM analysis. J Trauma Acute Care Surg 2015; 78:773-83. [PMID: 25807406 DOI: 10.1097/ta.0000000000000587] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Acute traumatic coagulopathy is a major contributor to mortality and morbidity following hemorrhagic shock. Our aim was to examine the effect of small-volume 7.5% NaCl with adenosine, lidocaine, and Mg (ALM) resuscitation on the timing of correction of coagulopathy in the rat model of severe hemorrhagic shock using ROTEM. METHODS Male rats (300-450 g, n = 64) were randomly assigned to (1) baseline, (2) sham, (3) bleed, (4) shock, (5) 7.5% NaCl for 5 minutes, (6) 7.5% NaCl with ALM for 5 minutes, (7) 7.5% NaCl for 60 minutes, or (8) 7.5% NaCl with ALM for 60 minutes (all n = 8). For resuscitation, 0.3-mL intravenous bolus of 7.5% NaCl was administered with and without ALM (n = 8 each group). Hemodynamics and coagulopathy were assessed. RESULTS After hemorrhage, prothrombin time (PT) and activated partial thromboplastin time (aPTT) increased approximately four to six times, and ROTEM indicated hypocoagulopathy. After 60-minute shock, no sustainable clots could form. 7.5% NaCl increased mean arterial pressure (MAP) to 46 ± 2 mm Hg at 5 minutes and generated a weak clot in EXTEM with hyperfibrinolysis in all tests. At 60 minutes, 7.5% NaCl failed to sustain MAP (43 ± 5 mm Hg) and generate a viable clot. In direct contrast, 7.5% NaCl with ALM at 5 minutes resuscitated MAP to 64 ± 3 mm Hg, corrected PT and aPTT, and generated fully formed EXTEM and FIBTEM clots. At 60 minutes, MAP was 69 ± 5 mm Hg, PT and aPTT were fully corrected, and α angle, clot amplitudes (A10, A30), as well as clot firmness and elasticity were not significantly different from baseline. ALM clot lysis at 60 minutes was significantly less than bleed, shock, or 7.5% NaCl, indicating protection against hyperfibrinolysis. CONCLUSION Small-volume 7.5% NaCl failed to resuscitate and correct coagulopathy. In contrast, 7.5% NaCl with ALM resuscitated MAP and corrected coagulopathy at 5 minutes, with further improvements at 60 minutes in clot kinetics, propagation, and firmness. ALM fully reversed hyperfibrinolysis to baseline. The possible mechanisms are discussed.
Collapse
|
37
|
Traumaassoziierte Gerinnungsstörung. Notf Rett Med 2015. [DOI: 10.1007/s10049-014-1972-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
|
38
|
McDaniel LM, Etchill EW, Raval JS, Neal MD. State of the art: massive transfusion. Transfus Med 2015; 24:138-44. [PMID: 24889805 DOI: 10.1111/tme.12125] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2014] [Revised: 03/17/2014] [Accepted: 04/25/2014] [Indexed: 11/27/2022]
Abstract
The aim of this article was to review recent developments in the resuscitation of both trauma and non-trauma patients in haemorrhagic shock. Strategies for the resuscitation of massively haemorrhaging patients and the use of massive transfusion protocols (MTPs) have been a major focus of the trauma literature over the past several years. The application of haemostatic resuscitation practices and MTPs to non-trauma populations has long been in practice, but has only recently been the subject of active research. Medline and PubMed were reviewed for 'massive transfusion' (MT) from 2012 to present. Non-English and paediatric articles were excluded. Articles were systematically reviewed for their relevance to MT. There were eight major areas of development identified. In recent MT literature, there was an increased focus on massively haemorrhaging non-trauma patients, the role of acute traumatic coagulopathy, the use of thromboelastography (TEG), and the impact of MTPs on blood product waste and efficiency of product delivery. Other developments included additional MT prediction tools and The PRospective Observational Multicenter Major Trauma Transfusion (PROMMTT) study. There was also interest in re-evaluating the clinical relevance of the current MT definition and identifying new foci for MT. These recent developments reflect efforts to better understand and manage non-traumatic haemorrhage and to address prior limitations in the trauma literature. Inevitably, new questions have been raised, which will likely direct ongoing and future research in MT.
Collapse
Affiliation(s)
- L M McDaniel
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | | | | | | |
Collapse
|
39
|
Brown JB, Neal MD, Guyette FX, Peitzman AB, Billiar TR, Zuckerbraun BS, Sperry JL. Design of the Study of Tranexamic Acid during Air Medical Prehospital Transport (STAAMP) Trial: Addressing the Knowledge Gaps. PREHOSP EMERG CARE 2015; 19:79-86. [PMID: 25076119 PMCID: PMC4623322 DOI: 10.3109/10903127.2014.936635] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Abstract Hemorrhage and coagulopathy remain major drivers of early preventable mortality in military and civilian trauma. The development of trauma-induced coagulopathy and hyperfibrinolysis is associated with poor outcomes. Interest in the use of tranexamic acid (TXA) in hemorrhaging patients as an antifibrinolytic agent has grown recently. Additionally, several reports describe immunomodulatory effects of TXA that may confer benefit independent of its antifibrinolytic actions. A large trial demonstrated a mortality benefit for early TXA administration in patients at risk for hemorrhage; however, questions remain about the applicability in developed trauma systems and the mechanism by which TXA reduces mortality. We describe here the rationale, design, and challenges of the Study of Tranexamic Acid during Air Medical Prehospital transport (STAAMP) trial. The primary objective is to determine the effect of prehospital TXA infusion during air medical transport on 30-day mortality in patients at risk of traumatic hemorrhage. This study is a multicenter, placebo-controlled, double-blind, randomized clinical trial. The trial will enroll trauma patients with hypotension and tachycardia from 4 level I trauma center air medical transport programs. It includes a 2-phase intervention, with a prehospital and in-hospital phase to investigate multiple dosing regimens. The trial will also explore the effects of TXA on the coagulation and inflammatory response following injury. The trial will be conducted under exception for informed consent for emergency research and thus required an investigational new drug approval from the U.S. Food and Drug Administration as well as a community consultation process. It was designed to address several existing knowledge gaps and research priorities regarding TXA use in trauma.
Collapse
|
40
|
Abstract
Trauma remains the leading cause of death with bleeding as the primary cause of preventable mortality during the first 24 h following trauma. When death occurs, it happens quickly, typically within the first 6 h after injury. One of four patients to arrive in the emergency department after trauma is already in the state of acute traumatic coagulopathy and shock. The principal drivers of acute traumatic coagulopathy have been characterized by tissue hypoperfusion, inflammation, and the acute activation of the neurohumoral system. Hypoperfusion leads to an activation of protein C with cleavage of activated factors V and VIII and the inhibition of plasminogen activator inhibitor 1 with subsequent hyperfibrinolysis. Endothelial damage and activation result in Weibel-Palade body degradation and glycocalyx shedding associated with autoheparinization. In contrast, there is an iatrogenic coagulopathy that occurs secondary to uncritical volume therapy leading to acidosis, hypothermia, and hemodilution. This coagulopathy then may be an integral part of the "vicious cycle" when combined with acidosis and hypothermia. The present article summarizes an update on the principal mechanisms and triggers of the coagulopathy of trauma including traumatic brain injury.
Collapse
|
41
|
Driessen A, Schäfer N, Albrecht V, Schenk M, Fröhlich M, Stürmer EK, Maegele M. Infrastructure and clinical practice for the detection and management of trauma-associated haemorrhage and coagulopathy. Eur J Trauma Emerg Surg 2014; 41:413-20. [PMID: 26037989 DOI: 10.1007/s00068-014-0455-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2014] [Accepted: 10/06/2014] [Indexed: 01/02/2023]
Abstract
PURPOSE Early detection and management of post-traumatic haemorrhage and coagulopathy have been associated with improved outcomes, but local infrastructures, logistics and clinical strategies may differ. METHODS To assess local differences in infrastructure, logistics and clinical management of trauma-associated haemorrhage and coagulopathy, we have conducted a web-based survey amongst the delegates to the 15th European Congress of Trauma and Emergency Surgery (ECTES) and the 2nd World Trauma (WT) Congress held in Frankfurt, Germany, 25-27 May 2014. RESULTS 446/1,540 delegates completed the questionnaire yielding a response rate of 29%. The majority specified to work as consultants/senior physicians (47.3%) in general (36.1%) or trauma/orthopaedic surgery (44.5%) of level I (70%) or level II (19%) trauma centres. Clinical assessment (>80%) and standard coagulation assays (74.6%) are the most frequently used strategies for early detection and monitoring of bleeding trauma patients with coagulopathy. Only 30% of the respondents declared to use extended coagulation assays to better characterise the bleeding and coagulopathy prompted by more individualised treatment concepts. Most trauma centres (69%) have implemented local protocols based on international and national guidelines using conventional blood products, e.g. packed red blood cell concentrates (93.3%), fresh frozen plasma concentrates (93.3%) and platelet concentrates (83%), and antifibrinolytics (100%). 89% considered the continuous intake of anticoagulants including "new oral anticoagulants" and platelet inhibitors as an increasing threat to bleeding trauma patients. CONCLUSIONS This study confirms differences in infrastructure, logistics and clinical practice for the detection and management of trauma-haemorrhage and trauma-associated coagulopathy amongst international centres. Ongoing work will focus on geographical differences.
Collapse
Affiliation(s)
- A Driessen
- Department of Orthopaedic Surgery, Traumatology and Sports Traumatology, Cologne-Merheim Medical Centre (CMMC), Witten/Herdecke University (Campus Cologne-Merheim), Ostmerheimerstr 200, 51109, Cologne, Germany,
| | | | | | | | | | | | | |
Collapse
|
42
|
Abstract
INTRODUCTION Admission hypocoagulability has been associated with negative outcomes after trauma. The purpose of this study was to determine the impact of hypercoagulability after trauma on the need for blood product transfusion and mortality. METHODS Injured patients meeting our level I trauma center's highest activation criteria had a thromboelastography (TEG) performed at admission, +1 h, +2 h, and +6 h using citrated blood. Hypercoagulability was defined as any TEG parameter in the hypercoagulable range, and hypocoagulability as any parameter in the hypocoagulable range. Patients were followed up prospectively throughout their hospital course. RESULTS A total of 118 patients were enrolled: 26.3% (n = 31) were hypercoagulable, 55.9% (n = 66) had a normal TEG profile, and 17.8% (n = 21) were hypocoagulable. After adjusting for differences in demographics and clinical data, hypercoagulable patients were less likely to require un-cross-matched blood (11.1% for hypercoagulable vs. 20.4% for normal vs. 45.7% for hypocoagulable, adjusted P = 0.004). Hypercoagulable patients required less total blood products, in particular, plasma at 6 h (0.1 [SD, 0.4] U for hypercoagulable vs. 0.7 [SD, 1.9] U for normal vs. 4.3 [SD, 6.3] U for hypocoagulable, adjusted P < 0.001) and 24 h (0.2 [SD, 0.6] U for hypercoagulable vs. 1.1 [SD, 2.9] U for normal vs. 8.2 [SD, 19.3] U for hypocoagulable, adjusted P < 0.001). Hypercoagulable patients had lower 24-h mortality (0.0% vs. 5.5% vs. 27.8%, adjusted P < 0.001) and 7-day mortality (0.0% vs. 5.5% vs. 36.1%, adjusted P < 0.001). Bleeding-related deaths were less likely in the hypercoagulable group (0.0% vs. 1.8% vs. 25.0%, adjusted P < 0.001). CONCLUSIONS Approximately a quarter of trauma patients presented in a hypercoagulable state. Hypercoagulable patients required less blood products, in particular plasma. They also had a lower 24-h and 7-day mortality and lower rates of bleeding-related deaths. Further evaluation of the mechanism responsible for the hypercoagulable state and its implications on outcome is warranted.
Collapse
|
43
|
Trentzsch H, Nienaber U, Behnke M, Lefering R, Piltz S. Female sex protects from organ failure and sepsis after major trauma haemorrhage. Injury 2014; 45 Suppl 3:S20-8. [PMID: 25284229 DOI: 10.1016/j.injury.2014.08.013] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Biological sex is considered a risk factor for adverse outcome after major trauma. We hypothesized that female sex is protective against organ failure, sepsis and mortality in patients with traumatic haemorrhage. PATIENTS AND METHODS We selected patients from TraumaRegister DGU(®) (TR-DGU) with primary admission for blunt trauma with an injury severity score ≥ 16 and an ICU stay ≥ 3 days that presented with relevant bleeding in the years 2007-2012. Relevant bleeding was defined as Abbreviated Injury Scale (AIS) ≥ 3 with an estimated blood loss exceeding 20%, any femoral shaft fracture, any pelvic clamp as surrogate for unstable pelvic fracture or the presence of at least one criteria of haemorrhagic shock: shock index of 0.8-1.4; base excess of -2.0 to -10.0 mmol/L; body temperature ≤ 34°C; transfusion of ≥ 4 units of packed red blood cells; application of recombinant activated factor VII; any embolization during trauma room phase and pre-hospital resuscitation volume ≥ 3000 ml or any catecholamine use during pre-hospital care in the absence of cardiopulmonary resuscitation. A total of 7560 males and 2774 females were selected and analyzed for sex differences. RESULTS Higher rates of multiple organ failure (24.4 vs. 21.3%, Odds ratio [OR] 1.19 (95% confidence interval [95%CI] 1.07-1.33), p=0.001*) and sepsis (16.5 vs. 11.3%, OR 1.55 (95%CI 1.35-1.77), p<0.001*) were observed in males. Organ function of lung, cardio-circulatory system, liver and kidney were better in females, however, there was no difference in mortality. Stratification by age group revealed that in particular age-group 16-44 years was related to improved organ function which may indicate effects of sex hormones in females at reproductive age. Increased rates of sepsis in males were observed throughout virtually all age groups starting at 16 years of age, except in age group 54-64 years. This may suggest suppressive effect of testosterone on immune function. CONCLUSIONS Our study supports the hypothesis that female sex is associated with improved organ function following traumatic injury and haemorrhagic shock, in particular in age groups that are at reproductive age. However, further studies are warranted before sex steroids can be deployed as therapeutic intervention in critically ill trauma patients.
Collapse
Affiliation(s)
- H Trentzsch
- Institute for Emergency Medicine and Management in Medicine (INM), University Hospital of Munich, Campus Innenstadt, Munich, Germany.
| | - U Nienaber
- Academy for Trauma Surgery (AUC), Munich, Germany
| | - M Behnke
- Department of Surgery, University Hospital of Munich, Campus Großhadern, Munich, Germany
| | - R Lefering
- Institute for Research in Operative Medicine (IFOM), University Witten/Herdecke, Campus Cologne-Merhein, Cologne, Germany
| | - S Piltz
- Department of Surgery, University Hospital of Munich, Campus Großhadern, Munich, Germany
| |
Collapse
|
44
|
Traumatic brain injury is not associated with coagulopathy out of proportion to injury in other body regions. J Trauma Acute Care Surg 2014; 77:67-72; discussion 72. [PMID: 24977757 DOI: 10.1097/ta.0000000000000255] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
BACKGROUND Coagulopathy following trauma is associated with poor outcomes. Traumatic brain injury has been associated with coagulopathy out of proportion to other body regions. We hypothesized that injury severity and shock determine coagulopathy independent of body region injured. METHODS We performed a prospective, multicenter observational study at three Level 1 trauma centers. Conventional coagulation tests (CCTs) and rapid thrombelastography (r-TEG) were used. Admission vital signs, base deficit (BD), CCTs, and r-TEG data were collected. The Abbreviated Injury Scale (AIS) score and Injury Severity Score (ISS) were obtained. Severe injury was defined as AIS score greater than or equal to 3 for each body region. Patients were grouped according to their dominant AIS region of injury. Dominant region of injury was defined as the single region with the highest AIS score. Patients with two or more regions with the same greatest AIS score and patients without a region with an AIS score greater than or equal to 3 were excluded. Coagulation parameters were compared between the dominant AIS region. Significant hypoperfusion was defined as BD greater than or equal to 6. RESULTS Of the 795 patients enrolled, 462 met criteria for grouping by dominant AIS region. Patients were predominantly white (59%), were male (75%), experienced blunt trauma (71%), and had a median ISS of 25 (interquartile range, 14-29). Patients with BD greater than or equal to 6 (n = 110) were hypocoagulable by CCT and r-TEG compared with patients with BD less than 6 (n = 223). Patients grouped by dominant AIS region showed no significant differences for any r-TEG or CCT parameter. Patients with BD greater than or equal to 6 demonstrated no difference in any r-TEG or CCT parameter between dominant AIS regions. CONCLUSION Coagulopathy results from a combination of tissue injury and shock independent of the dominant region of injury. With the use of AIS as a measure of injury severity, traumatic brain injury was not independently associated with more profound coagulopathy. LEVEL OF EVIDENCE Epidemiologic study, level III.
Collapse
|
45
|
Abstract
While early plasma transfusion for the treatment of patients with ongoing major hemorrhage is widely accepted as part of the standard of care in the hospital setting, logistic constraints have limited its use in the out-of-hospital setting. Freeze-dried plasma (FDP), which can be stored at ambient temperatures, enables early treatment in the out-of-hospital setting. Point-of-injury plasma transfusion entails several significant advantages over currently used resuscitation fluids, including the avoidance of dilutional coagulopathy, by minimizing the need for crystalloid infusion, beneficial effects on endothelial function, physiological pH level, and better maintenance of intravascular volume compared with crystalloid-based solutions. The Israel Defense Forces Medical Corps policy is that plasma is the resuscitation fluid of choice for selected, severely wounded patients and has thus included FDP as part of its armamentarium for use at the point of injury by advanced life savers, across the entire military. We describe the clinical rationale behind the use of FDP at the point-of-injury, the drafting of the administration protocol now being used by Israel Defense Forces advanced life support providers, the process of procurement and distribution, and preliminary data describing the first casualties treated with FDP at the point of injury. It is our hope that others will be able to learn from our experience, thus improving trauma casualty care around the world.
Collapse
|
46
|
Abstract
PURPOSE OF REVIEW To summarize our current understanding of the pathophysiology, diagnosis, and management of acute traumatic coagulopathy in children. RECENT FINDINGS Traumatic coagulopathy is a complex process that leads to global dysfunction of the endogenous coagulation system and results in worse outcomes and increased mortality. Although the cause is multifactorial, it is common in severely injured patients and is driven by significant tissue injury and hypoperfusion. Viscoelastic coagulation tests have been established as a rapid and reliable method to assess traumatic coagulopathy. Additionally, massive transfusion protocols have improved outcomes in adults, but limited studies in pediatrics have not shown any difference in mortality. SUMMARY Prospective studies are needed to determine how to best diagnose and manage acute traumatic coagulopathy in children.
Collapse
|
47
|
Christiaans SC, Duhachek-Stapelman AL, Russell RT, Lisco SJ, Kerby JD, Pittet JF. Coagulopathy after severe pediatric trauma. Shock 2014; 41:476-490. [PMID: 24569507 PMCID: PMC4024323 DOI: 10.1097/shk.0000000000000151] [Citation(s) in RCA: 91] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Trauma remains the leading cause of morbidity and mortality in the United States among children aged 1 to 21 years. The most common cause of lethality in pediatric trauma is traumatic brain injury. Early coagulopathy has been commonly observed after severe trauma and is usually associated with severe hemorrhage and/or traumatic brain injury. In contrast to adult patients, massive bleeding is less common after pediatric trauma. The classical drivers of trauma-induced coagulopathy include hypothermia, acidosis, hemodilution, and consumption of coagulation factors secondary to local activation of the coagulation system after severe traumatic injury. Furthermore, there is also recent evidence for a distinct mechanism of trauma-induced coagulopathy that involves the activation of the anticoagulant protein C pathway. Whether this new mechanism of posttraumatic coagulopathy plays a role in children is still unknown. The goal of this review is to summarize the current knowledge on the incidence and potential mechanisms of coagulopathy after pediatric trauma and the role of rapid diagnostic tests for early identification of coagulopathy. Finally, we discuss different options for treating coagulopathy after severe pediatric trauma.
Collapse
Affiliation(s)
- Sarah C Christiaans
- Department of Anesthesiology, University of Alabama at Birmingham, AL
- Department of Surgery, University of Alabama at Birmingham, AL
| | | | | | - Steven J Lisco
- Department of Anesthesiology, University of Nebraska Medical Center, NE
| | - Jeffrey D Kerby
- Department of Surgery, University of Alabama at Birmingham, AL
| | - Jean-François Pittet
- Department of Anesthesiology, University of Alabama at Birmingham, AL
- Department of Surgery, University of Alabama at Birmingham, AL
| |
Collapse
|
48
|
The coagulopathy of trauma. Eur J Trauma Emerg Surg 2014; 40:113-26. [DOI: 10.1007/s00068-014-0389-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2014] [Accepted: 02/20/2014] [Indexed: 10/25/2022]
|
49
|
Gerinnungsmanagement beim Polytrauma. Unfallchirurg 2014; 117:94. [DOI: 10.1007/s00113-013-2486-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
|
50
|
Pierce A, Pittet JF. Practical understanding of hemostasis and approach to the bleeding patient in the OR. Adv Anesth 2014; 32:1-21. [PMID: 25506124 DOI: 10.1016/j.aan.2014.08.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- Albert Pierce
- Department of Anesthesiology, University of Alabama at Birmingham
| | | |
Collapse
|