1
|
Bunch CM, Berquist M, Ansari A, McCoy ML, Langford JH, Brenner TJ, Aboukhaled M, Thomas SJ, Peck E, Patel S, Cancel E, Al-Fadhl MD, Zackariya N, Thomas AV, Aversa JG, Greene RB, Seder CW, Speybroeck J, Miller JB, Kwaan HC, Walsh MM. The Choice between Plasma-Based Common Coagulation Tests and Cell-Based Viscoelastic Tests in Monitoring Hemostatic Competence: Not an either-or Proposition. Semin Thromb Hemost 2022; 48:769-784. [PMID: 36174601 DOI: 10.1055/s-0042-1756302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
There has been a significant interest in the last decade in the use of viscoelastic tests (VETs) to determine the hemostatic competence of bleeding patients. Previously, common coagulation tests (CCTs) such as the prothrombin time (PT) and partial thromboplastin time (PTT) were used to assist in the guidance of blood component and hemostatic adjunctive therapy for these patients. However, the experience of decades of VET use in liver failure with transplantation, cardiac surgery, and trauma has now spread to obstetrical hemorrhage and congenital and acquired coagulopathies. Since CCTs measure only 5 to 10% of the lifespan of a clot, these assays have been found to be of limited use for acute surgical and medical conditions, whereby rapid results are required. However, there are medical indications for the PT/PTT that cannot be supplanted by VETs. Therefore, the choice of whether to use a CCT or a VET to guide blood component therapy or hemostatic adjunctive therapy may often require consideration of both methodologies. In this review, we provide examples of the relative indications for CCTs and VETs in monitoring hemostatic competence of bleeding patients.
Collapse
Affiliation(s)
- Connor M Bunch
- Department of Emergency Medicine, Henry Ford Hospital, Detroit, Michigan
| | - Margaret Berquist
- Department of Emergency Medicine, Saint Joseph Regional Medical Center, Mishawaka, Indiana
| | - Aida Ansari
- Department of Emergency Medicine, Saint Joseph Regional Medical Center, Mishawaka, Indiana
| | - Max L McCoy
- Department of Emergency Medicine, Saint Joseph Regional Medical Center, Mishawaka, Indiana
| | - Jack H Langford
- Department of Emergency Medicine, Saint Joseph Regional Medical Center, Mishawaka, Indiana
| | - Toby J Brenner
- Department of Emergency Medicine, Saint Joseph Regional Medical Center, Mishawaka, Indiana
| | - Michael Aboukhaled
- Department of Emergency Medicine, Saint Joseph Regional Medical Center, Mishawaka, Indiana
| | - Samuel J Thomas
- Department of Emergency Medicine, Saint Joseph Regional Medical Center, Mishawaka, Indiana
| | - Ethan Peck
- Department of Emergency Medicine, Saint Joseph Regional Medical Center, Mishawaka, Indiana
| | - Shivani Patel
- Department of Emergency Medicine, Saint Joseph Regional Medical Center, Mishawaka, Indiana
| | - Emily Cancel
- Department of Emergency Medicine, Saint Joseph Regional Medical Center, Mishawaka, Indiana
| | - Mahmoud D Al-Fadhl
- Indiana University School of Medicine, Notre Dame Campus, South Bend, Indiana
| | - Nuha Zackariya
- Indiana University School of Medicine, Notre Dame Campus, South Bend, Indiana
| | - Anthony V Thomas
- Indiana University School of Medicine, Notre Dame Campus, South Bend, Indiana
| | - John G Aversa
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Ryan B Greene
- Department of Interventional Radiology, St. Joseph Regional Medical Center, Mishawaka, Indiana
| | - Christopher W Seder
- Department of Cardiovascular and Thoracic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Jacob Speybroeck
- Department of Orthopedic Surgery, Case Western Medical Center, Cleveland, Ohio
| | - Joseph B Miller
- Department of Emergency Medicine, Henry Ford Hospital, Detroit, Michigan
| | - Hau C Kwaan
- Division of Hematology and Oncology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Mark M Walsh
- Department of Emergency Medicine, Saint Joseph Regional Medical Center, Mishawaka, Indiana.,Indiana University School of Medicine, Notre Dame Campus, South Bend, Indiana
| |
Collapse
|
2
|
Strauss R, Menchetti I, Perrier L, Blondal E, Peng H, Sullivan-Kwantes W, Tien H, Nathens A, Beckett A, Callum J, da Luz LT. Evaluating the Tactical Combat Casualty Care principles in civilian and military settings: systematic review, knowledge gap analysis and recommendations for future research. Trauma Surg Acute Care Open 2021; 6:e000773. [PMID: 34746434 PMCID: PMC8527149 DOI: 10.1136/tsaco-2021-000773] [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: 05/19/2021] [Accepted: 07/27/2021] [Indexed: 11/09/2022] Open
Abstract
OBJECTIVES The Tactical Combat Casualty Care (TCCC) guidelines detail resuscitation practices in prehospital and austere environments. We sought to review the content and quality of the current TCCC and civilian prehospital literature and characterize knowledge gaps to offer recommendations for future research. METHODS MEDLINE, EMBASE, CINAHL, and Cochrane Central Register of Controlled Trials were searched for studies assessing intervention techniques and devices used in civilian and military prehospital settings that could be applied to TCCC guidelines. Screening and data extraction were performed according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Quality appraisal was conducted using appropriate tools. RESULTS Ninety-two percent (n=57) of studies were observational. Most randomized trials had low risk of bias, whereas observational studies had higher risk of bias. Interventions of massive hemorrhage control (n=17) were wound dressings and tourniquets, suggesting effective hemodynamic control. Airway management interventions (n=7) had high success rates with improved outcomes. Interventions of respiratory management (n=12) reported low success with needle decompression. Studies assessing circulation (n=18) had higher quality of evidence and suggested improved outcomes with component hemostatic therapy. Hypothermia prevention interventions (n=2) were generally effective. Other studies identified assessed the use of extended focused assessment with sonography in trauma (n=3) and mixed interventions (n=2). CONCLUSIONS The evidence was largely non-randomized with heterogeneous populations, interventions, and outcomes, precluding robust conclusions in most subjects addressed in the review. Knowledge gaps identified included the use of blood products and concentrate of clotting factors in the prehospital setting. LEVEL OF EVIDENCE Systematic review, level III.
Collapse
Affiliation(s)
- Rachel Strauss
- Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Isabella Menchetti
- Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Laure Perrier
- Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Erik Blondal
- Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Henry Peng
- Defence Research and Development Canada, Toronto Research Centre, Toronto, Ontario, Canada
| | - Wendy Sullivan-Kwantes
- Defence Research and Development Canada, Toronto Research Centre, Toronto, Ontario, Canada
| | - Homer Tien
- Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Avery Nathens
- Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Andrew Beckett
- Department of Surgery, St Michael's Hospital, Toronto, Ontario, Canada
| | - Jeannie Callum
- Laboratory Medicine and Molecular Diagnostics, Kingston Health Sciences Centre, Kingston, Ontario, Canada
| | - Luis Teodoro da Luz
- Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| |
Collapse
|
3
|
Ziegler B, Bachler M, Haberfellner H, Niederwanger C, Innerhofer P, Hell T, Kaufmann M, Maegele M, Martinowitz U, Nebl C, Oswald E, Schöchl H, Schenk B, Thaler M, Treichl B, Voelckel W, Zykova I, Wimmer C, Fries D. Efficacy of prehospital administration of fibrinogen concentrate in trauma patients bleeding or presumed to bleed (FIinTIC): A multicentre, double-blind, placebo-controlled, randomised pilot study. Eur J Anaesthesiol 2021; 38:348-357. [PMID: 33109923 PMCID: PMC7969176 DOI: 10.1097/eja.0000000000001366] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Trauma-induced coagulopathy (TIC) substantially contributes to mortality in bleeding trauma patients. OBJECTIVE The aim of the study was to administer fibrinogen concentrate in the prehospital setting to improve blood clot stability in trauma patients bleeding or presumed to bleed. DESIGN A prospective, randomised, placebo-controlled, double-blinded, international clinical trial. SETTING This emergency care trial was conducted in 12 Helicopter Emergency Medical Services (HEMS) and Emergency Doctors' vehicles (NEF or NAW) and four trauma centres in Austria, Germany and Czech Republic between 2011 and 2015. PATIENTS A total of 53 evaluable trauma patients aged at least 18 years with major bleeding and in need of volume therapy were included, of whom 28 received fibrinogen concentrate and 25 received placebo. INTERVENTIONS Patients were allocated to receive either fibrinogen concentrate or placebo prehospital at the scene or during transportation to the study centre. MAIN OUTCOME MEASURES Primary outcome was the assessment of clot stability as reflected by maximum clot firmness in the FIBTEM assay (FIBTEM MCF) before and after administration of the study drug. RESULTS Median FIBTEM MCF decreased in the placebo group between baseline (before administration of study treatment) and admission to the Emergency Department, from a median of 12.5 [IQR 10.5 to 14] mm to 11 [9.5 to 13] mm (P = 0.0226), but increased in the FC Group from 13 [11 to 15] mm to 15 [13.5 to 17] mm (P = 0.0062). The median between-group difference in the change in FIBTEM MCF was 5 [3 to 7] mm (P < 0.0001). Median fibrinogen plasma concentrations in the fibrinogen concentrate Group were kept above the recommended critical threshold of 2.0 g l-1 throughout the observation period. CONCLUSION Early fibrinogen concentrate administration is feasible in the complex and time-sensitive environment of prehospital trauma care. It protects against early fibrinogen depletion, and promotes rapid blood clot initiation and clot stability. TRIAL REGISTRY NUMBERS EudraCT: 2010-022923-31 and ClinicalTrials.gov: NCT01475344.
Collapse
Affiliation(s)
- Bernhard Ziegler
- From the Department of Anaesthesiology, Perioperative Medicine and General Intensive Care Medicine, Paracelsus Medical University, Salzburg (BZ), Department of General and Surgical Critical Care Medicine, (MB, BS, DF ), Department of Anaesthesiology and Intensive Care Medicine (HH, PI, MK, EO, MT, BT), Department of Pediatrics, Pediatrics I, Intensive Care Unit, Medical University of Innsbruck, Innsbruck (CN), Department of Mathematics, Faculty of Mathematics, Computer Science and Physics, University of Innsbruck, Technikerstrasse, Austria (TH), Department of Trauma and Orthopedic Surgery, Cologne-Merheim Medical Center (CMMC), University Witten/Herdecke (UW/H), Campus Cologne-Merheim, Cologne, Germany (MM), Institute of Thrombosis and Haemostasis and the National Haemophilia Centre, The Chaim Sheba Medical Centre, Tel Hashomer, Israel (UM), Sportclinic Zillertal GmbH, Mayrhofen, Austria (CN), Department of Anaesthesiology and Intensive Care Medicine, AUVA Trauma Centre Salzburg, Academic Teaching Hospital of the Paracelsus Medical University, Salzburg, Austria (HS, WV), Department of Anesthesiology and Intensive Care, Liberec Regional Hospital, Liberec, Czech Republic (IZ), Christophorus 14, Niederöblarn, Austria (CW)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
4
|
Walsh M, Moore EE, Moore HB, Thomas S, Kwaan HC, Speybroeck J, Marsee M, Bunch CM, Stillson J, Thomas AV, Grisoli A, Aversa J, Fulkerson D, Vande Lune S, Sjeklocha L, Tran QK. Whole Blood, Fixed Ratio, or Goal-Directed Blood Component Therapy for the Initial Resuscitation of Severely Hemorrhaging Trauma Patients: A Narrative Review. J Clin Med 2021; 10:320. [PMID: 33477257 PMCID: PMC7830337 DOI: 10.3390/jcm10020320] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 01/15/2021] [Accepted: 01/15/2021] [Indexed: 12/21/2022] Open
Abstract
This narrative review explores the pathophysiology, geographic variation, and historical developments underlying the selection of fixed ratio versus whole blood resuscitation for hemorrhaging trauma patients. We also detail a physiologically driven and goal-directed alternative to fixed ratio and whole blood, whereby viscoelastic testing guides the administration of blood components and factor concentrates to the severely bleeding trauma patient. The major studies of each resuscitation method are highlighted, and upcoming comparative trials are detailed.
Collapse
Affiliation(s)
- Mark Walsh
- Notre Dame Campus, Indiana University School of Medicine, South Bend, IN 46617, USA; (M.W.); (J.S.); (M.M.); (C.M.B.); (J.S.); (A.V.T.); (A.G.)
- Departments of Emergency & Internal Medicine, Saint Joseph Regional Medical Center, Mishawaka, IN 46545, USA
| | - Ernest E. Moore
- Ernest E. Moore Shock Trauma Center, Denver Health, Denver, CO 80204, USA;
- Department of Surgery, University of Colorado Health Science Center, Denver, CO 80204, USA;
| | - Hunter B. Moore
- Department of Surgery, University of Colorado Health Science Center, Denver, CO 80204, USA;
| | - Scott Thomas
- Department of Trauma Surgery, Memorial Leighton Trauma Center, Beacon Health System, South Bend, IN 46601, USA;
| | - Hau C. Kwaan
- Division of Hematology and Oncology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA;
| | - Jacob Speybroeck
- Notre Dame Campus, Indiana University School of Medicine, South Bend, IN 46617, USA; (M.W.); (J.S.); (M.M.); (C.M.B.); (J.S.); (A.V.T.); (A.G.)
| | - Mathew Marsee
- Notre Dame Campus, Indiana University School of Medicine, South Bend, IN 46617, USA; (M.W.); (J.S.); (M.M.); (C.M.B.); (J.S.); (A.V.T.); (A.G.)
| | - Connor M. Bunch
- Notre Dame Campus, Indiana University School of Medicine, South Bend, IN 46617, USA; (M.W.); (J.S.); (M.M.); (C.M.B.); (J.S.); (A.V.T.); (A.G.)
| | - John Stillson
- Notre Dame Campus, Indiana University School of Medicine, South Bend, IN 46617, USA; (M.W.); (J.S.); (M.M.); (C.M.B.); (J.S.); (A.V.T.); (A.G.)
| | - Anthony V. Thomas
- Notre Dame Campus, Indiana University School of Medicine, South Bend, IN 46617, USA; (M.W.); (J.S.); (M.M.); (C.M.B.); (J.S.); (A.V.T.); (A.G.)
| | - Annie Grisoli
- Notre Dame Campus, Indiana University School of Medicine, South Bend, IN 46617, USA; (M.W.); (J.S.); (M.M.); (C.M.B.); (J.S.); (A.V.T.); (A.G.)
| | - John Aversa
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN 46202, USA;
| | - Daniel Fulkerson
- Department of Neurosurgery, Beacon Medical Group, South Bend, IN 46601, USA;
| | - Stefani Vande Lune
- Emergency Medicine Department, Navy Medicine Readiness and Training Command, Portsmouth, VA 23708, USA;
| | - Lucas Sjeklocha
- The R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD 21201, USA;
| | - Quincy K. Tran
- The R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD 21201, USA;
| |
Collapse
|
5
|
Napolitano LM. Hemostatic defects in massive transfusion: an update and treatment recommendations. Expert Rev Hematol 2021; 14:219-239. [PMID: 33267678 DOI: 10.1080/17474086.2021.1858788] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Acute hemorrhage is a global healthcare issue, and remains the leading preventable cause of death in trauma. Acute severe hemorrhage can be related to traumatic, peripartum, gastrointestinal, and procedural causes. Hemostatic defects occur early in patients requiring massive transfusion. Early recognition and treatment of hemorrhage and hemostatic defects are required to save lives and to achieve optimal patient outcomes. AREAS COVERED This review discusses current evidence and trials aimed at identifying the optimal treatment for hemostatic defects in hemorrhage and massive transfusion. Literature search included PubMed and Embase. EXPERT OPINION Patients with acute hemorrhage requiring massive transfusion commonly develop coagulopathy due to specific hemostatic defects, and accurate diagnosis and prompt correction are required for definitive hemorrhage control. Damage control resuscitation and massive transfusion protocols are optimal initial treatment strategies, followed by goal-directed individualized resuscitation using real-time coagulation monitoring. Distinct phenotypes exist in trauma-induced coagulopathy, including 'Bleeding' or 'Thrombotic' phenotypes, and hyperfibrinolysis vs. fibrinolysis shutdown. The trauma 'lethal triad' (hypothermia, coagulopathy, acidosis) has been updated to the 'lethal diamond' (including hypocalcemia). A number of controversies in optimal management exist, including whole blood vs. component therapy, use of factor concentrates vs. blood products, optimal use of tranexamic acid, and prehospital plasma and tranexamic acid administration.
Collapse
Affiliation(s)
- Lena M Napolitano
- Department of Surgery, University of Michigan Health System, University Hospital, Ann Arbor, Michigan, USA
| |
Collapse
|
6
|
Abstract
Hemorrhage is the leading cause of preventable death in combat trauma and the secondary cause of death in civilian trauma. A significant number of deaths due to hemorrhage occur before and in the first hour after hospital arrival. A literature search was performed through PubMed, Scopus, and Institute of Scientific Information databases for English language articles using terms relating to hemostatic agents, prehospital, battlefield or combat dressings, and prehospital hemostatic resuscitation, followed by cross-reference searching. Abstracts were screened to determine relevance and whether appropriate further review of the original articles was warranted. Based on these findings, this paper provides a review of a variety of hemostatic agents ranging from clinically approved products for human use to newly developed concepts with great potential for use in prehospital settings. These hemostatic agents can be administered either systemically or locally to stop bleeding through different mechanisms of action. Comparisons of current hemostatic products and further directions for prehospital hemorrhage control are also discussed.
Collapse
Affiliation(s)
- Henry T Peng
- Defence Research and Development Canada, Toronto Research Centre, 1133 Sheppard Avenue West, Toronto, ON, M3K 2C9, Canada.
| |
Collapse
|
7
|
Marsden M, Benger J, Brohi K, Curry N, Foley C, Green L, Lucas J, Rossetto A, Stanworth S, Thomas H, Davenport R. Coagulopathy, cryoprecipitate and CRYOSTAT-2: realising the potential of a nationwide trauma system for a national clinical trial. Br J Anaesth 2018; 122:164-169. [PMID: 30686301 DOI: 10.1016/j.bja.2018.10.055] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Revised: 10/06/2018] [Accepted: 10/27/2018] [Indexed: 01/10/2023] Open
Affiliation(s)
- M Marsden
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, UK; Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, UK; Barts Health NHS Trust, London, UK.
| | - J Benger
- Faculty of Health and Applied Sciences, University of the West of England, Bristol, UK
| | - K Brohi
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, UK; Barts Health NHS Trust, London, UK
| | - N Curry
- Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK; Radcliffe Department of Medicine, University of Oxford, UK
| | - C Foley
- NHS Blood and Transplant, Clinical Trials Unit, Cambridge, UK
| | - L Green
- Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary, University of London, London, UK; Barts Health NHS Trust, London, UK
| | - J Lucas
- NHS Blood and Transplant, Clinical Trials Unit, Cambridge, UK
| | - A Rossetto
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, UK; Barts Health NHS Trust, London, UK
| | - S Stanworth
- Oxford NIHR BRC Haematology Theme, Oxford Centre for Haematology, University of Oxford, UK; NHS Blood and Transplant, Transfusion Medicine, Oxford, UK; Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK; Radcliffe Department of Medicine, University of Oxford, UK
| | - H Thomas
- NHS Blood and Transplant, Clinical Trials Unit, Bristol, UK; NHS Blood and Transplant, Transfusion Medicine, Oxford, UK
| | - R Davenport
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, UK; Barts Health NHS Trust, London, UK
| | | |
Collapse
|
8
|
Yazer MH, Spinella PC, Allard S, Roxby D, So-Osman C, Lozano M, Gunn K, Shih AW, Stensballe J, Johansson PI, Bagge Hansen M, Maegele M, Doughty H, Crombie N, Jenkins DH, McGinity AC, Schaefer RM, Martinaud C, Shinar E, Strugo R, Chen J, Russcher H. Vox Sanguinis International Forum on the use of prehospital blood products and pharmaceuticals in the treatment of patients with traumatic hemorrhage. Vox Sang 2018; 113:816-830. [DOI: 10.1111/vox.12677] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
| | | | | | - D. Roxby
- SA Pathology Transfusion Medicine; Flinders Medical Centre; Flinders Drive Bedford Park SA 5042 Australia
| | | | | | - K. Gunn
- Department of Anaesthesia; Auckland City Hospital; 2 Park Road Grafton, Auckland 1023 New Zealand
| | - A. W. Shih
- Vancouver General Hospital; Department of Pathology and Laboratory Medicine; 855 West 12th Avenue Vancouver BC V5Z 1M9 Canada
| | - J. Stensballe
- Rigshospitalet; Section for Transfusion Medicine; Copenhagen University Hospital; Capital Region Blood Bank; Blegdamsvej 9 Copenhagen 2100 Denmark
| | - P. I. Johansson
- Rigshospitalet; Section for Transfusion Medicine; Copenhagen University Hospital; Capital Region Blood Bank; Blegdamsvej 9 Copenhagen 2100 Denmark
| | - M. Bagge Hansen
- Klinikchef; Rigshospitalet; Klinisk Immulogisk Afd. 2034, Blegdamsvej 9 2100 København Ø Denmark
| | - M. Maegele
- Department of Traumatology and Orthopedic Surgery; Cologne-Merheim Medical Center (CMMC); Institute for Research in Operative Medicine (IFOM); University Witten/Herdecke (UW/H); Ostmerheimerstr. 200 D-51109 Köln Germany
| | - H. Doughty
- NHS Blood and Transplant; Vincent Drive Birmingham UK
- Department of Clinical Traumatology; University Hospitals Birmingham NHS Foundation Trust; Birmingham UK
| | - N. Crombie
- University Hospitals Birmingham NHS Foundation Trust; Birmingham UK
- National Institute for Health Research SRMRC
| | - D. H. Jenkins
- Department of Surgery; UT Health San Antonio; 7703 Floyd Curl Dr San Antonio TX 78229 USA
| | - A. C. McGinity
- Department of Surgery; UT Health San Antonio; 7703 Floyd Curl Dr San Antonio TX 78229 USA
| | - R. M. Schaefer
- Research; Southwest Texas Regional Advisory Council; 7500 US-90 West San Antonio TX 78227 USA
| | - C. Martinaud
- Chief of Clinical Operations; French Military Blood Institute; 1 rue du Lieutenant Raoul Batany, 92 141 Clamart Cedex France
| | - E. Shinar
- Magen David Adom; Ramat Gan 5262100 Israel
| | - R. Strugo
- Magen David Adom; Yigal Alon 60 Tel Aviv 67062 Israel
| | - J. Chen
- Trauma and Combat Medicine Branch; Surgeon General's Headquarters; Israel Defense Force; Ramat Gan Israel
| | - H. Russcher
- Specialist Laboratory Medicine; Dep. Clinical Chemistry; Blood Transfusion Laboratory Erasmus MC; University Medical Center, Rotterdam; Dr. Molewaterplein 60 3015 GD Rotterdam The Netherlands
| |
Collapse
|
9
|
Knapp J, Pietsch U, Kreuzer O, Hossfeld B, Bernhard M, Lier H. Prehospital Blood Product Transfusion in Mountain Rescue Operations. Air Med J 2018; 37:392-399. [PMID: 30424860 DOI: 10.1016/j.amj.2018.08.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Revised: 07/08/2018] [Accepted: 08/24/2018] [Indexed: 12/13/2022]
Abstract
Severely injured patients with hemorrhage present major challenges for emergency medical services, especially during mountain rescue missions in which harsh environmental conditions and long out-of-hospital times are frequent. Because uncontrolled hemorrhage is the leading cause of death within the first 48 hours after severe trauma, initiating damage control resuscitation (DCR) as early as possible after severe trauma and exporting the concept of DCR to the out-of-hospital arena is pivotal for patient survival. Appropriate bleeding control, management of coagulopathy, and transfusion of blood products are core aspects of DCR. This review summarizes the available evidence on out-of-hospital blood product transfusion and the management of coagulopathy with a special focus on mountain rescue missions. An overview of upcoming trials and possible future trends in the management of coagulopathy during rescue operations is provided.
Collapse
Affiliation(s)
- Jürgen Knapp
- Department of Anaesthesiology and Pain Therapy, University Hospital of Bern, Bern, Switzerland; Air Zermatt, Emergency Medical Service, Zermatt, Switzerland.
| | - Urs Pietsch
- Air Zermatt, Emergency Medical Service, Zermatt, Switzerland; Department of Anaesthesiology and Intensive Care Medicine, Cantonal Hospital St Gallen, St Gallen, Switzerland
| | - Oliver Kreuzer
- Air Zermatt, Emergency Medical Service, Zermatt, Switzerland
| | - Björn Hossfeld
- Department of Anaesthesiology and Intensive Care Medicine, Armed Forces Hospital Ulm, Ulm, Germany; Task Force "Tactical Medicine" of the Scientific Working Group Emergency Medicine of the German Society of Anaesthesiology and Intensive Care Medicine, Nürnberg, Germany
| | - Michael Bernhard
- Emergency Department, University Hospital of Düsseldorf, Düsseldorf, Germany; Task Force "Trauma and Resuscitation Room Management" of the Scientific Working Group Emergency Medicine of the German Society of Anaesthesiology and Intensive Care Medicine, Nürnberg, Germany
| | - Heiko Lier
- Task Force "Tactical Medicine" of the Scientific Working Group Emergency Medicine of the German Society of Anaesthesiology and Intensive Care Medicine, Nürnberg, Germany; Department of Anaesthesiology and Postoperative Intensive Care Medicine, University of Cologne, Köln, Germany
| |
Collapse
|
10
|
Onwukwe C, Maisha N, Holland M, Varley M, Groynom R, Hickman D, Uppal N, Shoffstall A, Ustin J, Lavik E. Engineering Intravenously Administered Nanoparticles to Reduce Infusion Reaction and Stop Bleeding in a Large Animal Model of Trauma. Bioconjug Chem 2018; 29:2436-2447. [PMID: 29965731 DOI: 10.1021/acs.bioconjchem.8b00335] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Bleeding from traumatic injury is the leading cause of death for young people across the world, but interventions are lacking. While many agents have shown promise in small animal models, translating the work to large animal models has been exceptionally difficult in great part because of infusion-associated complement activation to nanomaterials that leads to cardiopulmonary complications. Unfortunately, this reaction is seen in at least 10% of the population. We developed intravenously infusible hemostatic nanoparticles that were effective in stopping bleeding and improving survival in rodent models of trauma. To translate this work, we developed a porcine liver injury model. Infusion of the first generation of hemostatic nanoparticles and controls 5 min after injury led to massive vasodilation and exsanguination even at extremely low doses. In naïve animals, the physiological changes were consistent with a complement-associated infusion reaction. By tailoring the zeta potential, we were able to engineer a second generation of hemostatic nanoparticles and controls that did not exhibit the complement response at low and moderate doses but did at the highest doses. These second-generation nanoparticles led to cessation of bleeding within 10 min of administration even though some signs of vasodilation were still seen. While the complement response is still a challenge, this work is extremely encouraging in that it demonstrates that when the infusion-associated complement response is managed, hemostatic nanoparticles are capable of rapidly stopping bleeding in a large animal model of trauma.
Collapse
Affiliation(s)
- Chimdiya Onwukwe
- University of Maryland Baltimore County , 1000 Hilltop Circle, Baltimore , Maryland 21050 , United States
| | - Nuzhat Maisha
- University of Maryland Baltimore County , 1000 Hilltop Circle, Baltimore , Maryland 21050 , United States
| | - Mark Holland
- University of Maryland Baltimore County , 1000 Hilltop Circle, Baltimore , Maryland 21050 , United States
| | - Matt Varley
- Case Western Reserve University , 10900 Euclid Avenue , Cleveland , Ohio 44106 , United States
| | - Rebecca Groynom
- Case Western Reserve University , 10900 Euclid Avenue , Cleveland , Ohio 44106 , United States
| | - DaShawn Hickman
- Case Western Reserve University , 10900 Euclid Avenue , Cleveland , Ohio 44106 , United States
| | - Nishant Uppal
- Harvard Medical School , 25 Shattuck Street , Boston , Massachusetts 02115 , United States
| | - Andrew Shoffstall
- Case Western Reserve University , 10900 Euclid Avenue , Cleveland , Ohio 44106 , United States
| | - Jeffrey Ustin
- Case Western Reserve University , 10900 Euclid Avenue , Cleveland , Ohio 44106 , United States
| | - Erin Lavik
- University of Maryland Baltimore County , 1000 Hilltop Circle, Baltimore , Maryland 21050 , United States
| |
Collapse
|
11
|
The use of fibrinogen concentrate for the management of trauma-related bleeding: a systematic review and meta-analysis. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2018; 15:318-324. [PMID: 28661856 DOI: 10.2450/2017.0094-17] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Accepted: 04/11/2017] [Indexed: 12/25/2022]
Abstract
Haemorrhage following injury is associated with significant morbidity and mortality. The role of fibrinogen concentrate in trauma-induced coagulopathy has been the object of intense research in the last 10 years and has been systematically analysed in this review. A systematic search of the literature identified six retrospective studies and one prospective one, involving 1,650 trauma patients. There were no randomised trials. Meta-analysis showed that fibrinogen concentrate has no effect on overall mortality (risk ratio: 1.07, 95% confidence interval: 0.83-1.38). Although the meta-analytic pooling of the current literature evidence suggests no beneficial effect of fibrinogen concentrate in the setting of severe trauma, the quality of data retrieved was poor and the final results of ongoing randomised trials will help to further elucidate the role of fibrinogen concentrate in traumatic bleeding.
Collapse
|
12
|
Bouzat P, Ageron FX, Charbit J, Bobbia X, Deras P, Nugues JBD, Escudier E, Marcotte G, Leone M, David JS. Modelling the association between fibrinogen concentration on admission and mortality in patients with massive transfusion after severe trauma: an analysis of a large regional database. Scand J Trauma Resusc Emerg Med 2018; 26:55. [PMID: 29986757 PMCID: PMC6038237 DOI: 10.1186/s13049-018-0523-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Accepted: 06/28/2018] [Indexed: 01/06/2023] Open
Abstract
Background The relationship between fibrinogen concentration and traumatic death has been poorly explored after severe trauma. Existing studies analysed this relationship in unselected trauma population, often considering fibrinogen concentration as a categorical variable. The aim of our study was to model the relationship between fibrinogen concentration and in-hospital mortality in severe trauma patients requiring massive transfusion using fibrinogen on admission as a continuous variable. Methods We designed a retrospective observational study based on prospectively collected data from 2009 to 2015 in seven French level-I trauma centres. All consecutive patients requiring a transfusion of at least 10 packed red blood cells (RBC) within 24 h were included. To assess the relationship between in-hospital death and fibrinogen concentration on admission, we performed generalized linear and additive models with death as a dependent variable. We also assessed the relationship between fibrinogen concentration below 1.5 g.L− 1 and potential predictors. Results Within the study period, 366 patients were included. A non-linear relationship was found between fibrinogen concentration and death. Graphical modelling of this relationship depicted a negative association between fibrinogen levels and death below a fibrinogen concentration of 1.5 g.L− 1. Predictors of low fibrinogen concentration (< 1.5 g.L− 1) were systolic blood pressure, Glasgow coma scale and haemoglobin concentration on admission. Conclusions A complex and robust approach for modelling the relationship between fibrinogen and mortality revealed a critical fibrinogen threshold of 1.5 g.L− 1 for severe trauma patients requiring massive transfusion. This trigger may guide the administration of procoagulant therapies in this context.
Collapse
Affiliation(s)
- Pierre Bouzat
- Grenoble Alps Trauma center, Department of anesthesiology and intensive care medicine, Grenoble University Hospital, F-38000, Grenoble, France. .,Grenoble Alps University, F-38000, Grenoble, France. .,Pôle d'Anesthésie-Réanimation, Hôpital Albert Michallon, 217, F-38043, Grenoble, BP, France.
| | - François-Xavier Ageron
- RENAU Northern French Alps Emergency Network, Public Health department, Annecy Hospital, F-74000, Annecy, France.,Department of emergency medicine and intensive care, Annecy Hospital, F-74000, Annecy, France
| | - Jonathan Charbit
- Department of anesthesiology and intensive care, Montpellier University Hospital, F-34000, Montpellier, France
| | - Xavier Bobbia
- Department of emergency medicine, Nimes University Hospital, F-30000, Nimes, France
| | - Pauline Deras
- Department of anesthesiology and intensive care, Montpellier University Hospital, F-34000, Montpellier, France
| | - Jennifer Bas Dit Nugues
- Grenoble Alps Trauma center, Department of anesthesiology and intensive care medicine, Grenoble University Hospital, F-38000, Grenoble, France
| | - Etienne Escudier
- Department of emergency medicine and intensive care, Annecy Hospital, F-74000, Annecy, France
| | - Guillaume Marcotte
- Department of anesthesiology and intensive care, Lyon-Edouard Herriot University Hospital, F-69000, Lyon, France
| | - Marc Leone
- Aix Marseille University, Nord Hospital, Department of anesthesiology and intensive medicine, APHM, F-13000, Marseille, France
| | - Jean-Stéphane David
- Hospices Civils de Lyon, Lyon-Sud University Hospital, Department of anesthesiology and intensive care, F-69495, Pierre-Bénite, France.,Claude Bernard Lyon 1 University, F-69008, Lyon, France
| |
Collapse
|
13
|
Lier H, Bernhard M, Knapp J, Buschmann C, Bretschneider I, Hossfeld B. [Approaches to pre-hospital bleeding management : Current overview on civilian emergency medicine]. Anaesthesist 2018; 66:867-878. [PMID: 28785773 DOI: 10.1007/s00101-017-0350-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Severe bleeding is a typical result of traumatic injuries. Hemorrhage is responsible for almost 50% of deaths within the first 6 h after trauma. Appropriate bleeding control and coagulation therapy depends on an integrated concept of local hemostasis by primary pressure with the hands, compression, and tourniquets accompanied by prevention of hypothermia, acidosis and hypocalcemia. Additionally, permissive hypotension is accepted for suitable patients and tranexamic acid should be administered early. Multiple publications prove that prehospital transfusion of blood products (e. g. red blood cells and plasma) and coagulation factors (e. g. fibrinogen) is feasible and safe, but only required for <5% of polytrauma patients in the civilian setting.
Collapse
Affiliation(s)
- H Lier
- Klinik für Anästhesiologie und Operative Intensivmedizin, Universitätsklinikum Köln (AöR), Kerpener Straße 62, 50937, Köln, Deutschland. .,Arbeitsgruppe "Taktische Medizin" des Arbeitskreises Notfallmedizin, Deutsche Gesellschaft für Anästhesiologie und Intensivmedizin, Nürnberg, Deutschland.
| | - M Bernhard
- Zentrale Notaufnahme, Universitätsklinikum Leipzig, Leipzig, Deutschland.,Arbeitsgruppe "Trauma- und Schockraummanagement" des Arbeitskreis Notfallmedizin, Deutschen Gesellschaft für Anästhesiologie und Intensivmedizin, Nürnberg, Deutschland
| | - J Knapp
- Klinik für Anästhesiologie und Schmerztherapie, Universitätsspital Bern, Bern, Schweiz.,Air Zermatt, Zermatt, Schweiz
| | - C Buschmann
- Institut für Rechtsmedizin, Charité - Universitätsmedizin Berlin, Berlin, Deutschland
| | - I Bretschneider
- Klinik für Anästhesiologie & Intensivmedizin, Bundeswehrkrankenhaus, Ulm, Deutschland
| | - B Hossfeld
- Klinik für Anästhesiologie & Intensivmedizin, Bundeswehrkrankenhaus, Ulm, Deutschland.,Arbeitsgruppe "Taktische Medizin" des Arbeitskreises Notfallmedizin, Deutsche Gesellschaft für Anästhesiologie und Intensivmedizin, Nürnberg, Deutschland
| |
Collapse
|
14
|
Abnormalities of laboratory coagulation tests versus clinically evident coagulopathic bleeding: results from the prehospital resuscitation on helicopters study (PROHS). Surgery 2017; 163:819-826. [PMID: 29289392 DOI: 10.1016/j.surg.2017.10.050] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2017] [Revised: 09/22/2017] [Accepted: 10/18/2017] [Indexed: 01/01/2023]
Abstract
BACKGROUND Laboratory-based evidence of coagulopathy (LC) is observed in 25-35% of trauma patients, but clinically-evident coagulopathy (CC) is not well described. METHODS Prospective observational study of adult trauma patients transported by helicopter from the scene to nine Level 1 trauma centers in 2015. Patients meeting predefined highest-risk criteria were divided into CC+ (predefined as surgeon-confirmed bleeding from uninjured sites or injured sites not controllable by sutures) or CC-. We used a mixed-effects, Poisson regression with robust error variance to test the hypothesis that abnormalities on rapid thrombelastography (r-TEG) and international normalized ratio (INR) were independently associated with CC+. RESULTS Of 1,019 highest-risk patients, CC+ (n=41, 4%) were more severely injured (median ISS 32 vs 17), had evidence of LC on r-TEG and INR, received more transfused blood products at 4 hours (37 vs 0 units), and had greater 30-day mortality (59% vs 12%) than CC- (n=978, 96%). The overall incidence of LC was 39%. 30-day mortality was 22% vs 9% in those with and without LC. In two separate models, r-TEG K-time >2.5 min (RR 1.3, 95% CI 1.1-1.7), r-TEG mA <55 mm (RR 2.5, 95% CI 2.0-3.2), platelet count <150 x 109/L (RR 1.2, 95% CI 1.1-1.3), and INR >1.5 (RR 5.4, 95% CI 1.8-16.3) were independently associated with CC+. A combined regression model was not generated because too few patients underwent both r-TEG and INR. CONCLUSION CC was rare compared to LC. CC was associated with poor outcomes and impairment of both clotting factor and platelet-mediated coagulation components.
Collapse
|
15
|
Winearls J, Reade M, Miles H, Bulmer A, Campbell D, Görlinger K, Fraser JF. Targeted Coagulation Management in Severe Trauma: The Controversies and the Evidence. Anesth Analg 2017; 123:910-24. [PMID: 27636575 DOI: 10.1213/ane.0000000000001516] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Hemorrhage in the setting of severe trauma is a leading cause of death worldwide. The pathophysiology of hemorrhage and coagulopathy in severe trauma is complex and remains poorly understood. Most clinicians currently treating trauma patients acknowledge the presence of a coagulopathy unique to trauma patients-trauma-induced coagulopathy (TIC)-independently associated with increased mortality. The complexity and incomplete understanding of TIC has resulted in significant controversy regarding optimum management. Although the majority of trauma centers utilize fixed-ratio massive transfusion protocols in severe traumatic hemorrhage, a widely accepted "ideal" transfusion ratio of blood to blood products remains elusive. The recent use of viscoelastic hemostatic assays (VHAs) to guide blood product replacement has further provoked debate as to the optimum transfusion strategy. The use of VHA to quantify the functional contributions of individual components of the coagulation system may permit targeted treatment of TIC but remains controversial and is unlikely to demonstrate a mortality benefit in light of the heterogeneity of the trauma population. Thus, VHA-guided algorithms as an alternative to fixed product ratios in trauma are not universally accepted, and a hybrid strategy starting with fixed-ratio transfusion and incorporating VHA data as they become available is favored by some institutions. We review the current evidence for the management of coagulopathy in trauma, the rationale behind the use of targeted and fixed-ratio approaches and explore future directions.
Collapse
Affiliation(s)
- James Winearls
- From the *Intensive Care Unit, Gold Coast University Hospital, Southport, Queensland, Australia; †Gold Coast University Hospital Critical Care Research Group, Queensland, Australia; ‡Joint Health Command, Australian Defence Force and Burns, Trauma and Critical Care Research Centre, University of Queensland, Brisbane, Queensland, Australia; §Heart Foundation Research Centre, School of Medicine, Griffith University, Gold Coast, Queensland, Australia; ∥Trauma Department, Gold Coast University Hospital, Queensland, Australia; ¶Department of Anesthesiology and Intensive Care Medicine, University Hospital Essen, University Duisburg-Essen, Essen, Germany; #Tem International GmbH, Munich, Germany; and **Critical Care Research Group, The Prince Charles Hospital and University of Queensland, Brisbane, Queensland, Australia
| | | | | | | | | | | | | |
Collapse
|
16
|
Maegele M. Coagulation factor concentrate-based therapy for remote damage control resuscitation (RDCR): a reasonable alternative? Transfusion 2017; 56 Suppl 2:S157-65. [PMID: 27100752 DOI: 10.1111/trf.13526] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2015] [Revised: 01/06/2016] [Accepted: 01/11/2016] [Indexed: 12/11/2022]
Abstract
The concept of remote damage control resuscitation (RDCR) is still in its infancy and there is significant work to be done to improve outcomes for patients with life-threatening bleeding secondary to injury. The prehospital phase of resuscitation is critical and if shock and coagulopathy can be rapidly minimized before hospital admission this will very likely reduce morbidity and mortality. The optimum transfusion strategy for these patients is still highly debated and the potential implications of the recently published pragmatic, randomize, optimal platelet, and plasma ratios trial (PROPPR) for RDCR have been reviewed. Identifying the appropriate transfusion strategy is mandatory before adopting prehospital hemostatic resuscitation strategies. An alternative approach is based on the early administration of coagulation factor concentrates combined with the antifibrinolytic tranexamic acid (TXA). The three major components to this approach in the context of RDCR target the following steps to achieve hemostasis: 1) stop (hyper)fibrinolysis; 2) support clot formation; and 3) increase thrombin generation. Strong evidence exists for the use of TXA. The data from the prospective fibrinogen in trauma induced coagulopathy (FIinTIC) study will inform on the prehospital use of fibrinogen in bleeding trauma patients. Deficits in thrombin generation may be addressed by the administration of prothrombin complex concentrates. Handheld point-of-care devices may be able to support and guide the prehospital and remote use of intravenous hemostatic agents including coagulation factor concentrates along with clinical presentation, assessment, and the extent of bleeding. Combinations may even be more effective for bleeding control. More studies are urgently needed.
Collapse
Affiliation(s)
- Marc Maegele
- Department of Traumatology, Orthopedic Surgery and Sportsmedicine, Cologne-Merheim Medical Center (CMMC) and the Institute for Research in Operative Medicine (IFOM), University of Witten/Herdecke, Cologne, Germany
| |
Collapse
|
17
|
Winearls J, Wullschleger M, Wake E, Hurn C, Furyk J, Ryan G, Trout M, Walsham J, Holley A, Cohen J, Shuttleworth M, Dyer W, Keijzers G, Fraser JF, Presneill J, Campbell D. Fibrinogen Early In Severe Trauma studY (FEISTY): study protocol for a randomised controlled trial. Trials 2017; 18:241. [PMID: 28549445 PMCID: PMC5446750 DOI: 10.1186/s13063-017-1980-x] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2016] [Accepted: 05/06/2017] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Haemorrhage is a leading cause of death in severe trauma. Fibrinogen plays a critical role in maintaining haemostasis in traumatic haemorrhage. Early fibrinogen replacement is recommended by several international trauma guidelines using either fibrinogen concentrate (FC) or cryoprecipitate (Cryo). There is limited evidence to support one product over the other with widespread geographic and institutional variation in practice. This pilot trial is the first randomised controlled trial comparing FC to Cryo in traumatic haemorrhage. METHODS/DESIGN The Fibrinogen Early In Severe Trauma studY (FEISTY) is an exploratory, multicentre, randomised controlled trial comparing FC to Cryo for fibrinogen supplementation in traumatic haemorrhage. This trial will utilise thromboelastometry (ROTEM®) to guide and dose fibrinogen supplementation. The trial will recruit 100 trauma patients at four major trauma centres in Australia. Adult trauma patients with evidence of haemorrhage will be enrolled on arrival in the trauma unit and randomised to receiving fibrinogen supplementation with either FC or Cryo. The primary outcome is the differential time to fibrinogen supplementation. There are a number of predetermined secondary outcomes including: effects of the intervention on plasma fibrinogen levels, feasibility assessments and clinical outcomes including transfusion requirements and mortality. DISCUSSION The optimal method for replacing fibrinogen in traumatic haemorrhage is fiercely debated. In this trial the feasibility and efficacy of fibrinogen supplementation using FC will be compared to Cryo. The results of this pilot study will facilitate the design of a larger trial with sufficient power to address patient-centred outcomes. TRIAL REGISTRATION ClinicalTrials.gov, ID: NCT02745041 . Registered 4 May 2016.
Collapse
Affiliation(s)
- James Winearls
- Gold Coast University Hospital, Southport, QLD, Australia. .,School of Medicine, University of Queensland, St. Lucia, QLD, Australia. .,School of Medical Sciences, Griffith University, Nathan, QLD, Australia.
| | - Martin Wullschleger
- Gold Coast University Hospital, Southport, QLD, Australia.,School of Medical Sciences, Griffith University, Nathan, QLD, Australia
| | - Elizabeth Wake
- Gold Coast University Hospital, Southport, QLD, Australia
| | - Catherine Hurn
- School of Medicine, University of Queensland, St. Lucia, QLD, Australia.,Royal Brisbane and Women's Hospital, Herston, QLD, Australia
| | - Jeremy Furyk
- Emergency Research, Townsville Hospital, Douglas, QLD, Australia
| | - Glenn Ryan
- Princess Alexandra Hospital, Woolloongabba, QLD, Australia
| | | | - James Walsham
- School of Medicine, University of Queensland, St. Lucia, QLD, Australia.,Intensive Care Research, Princess Alexandra Hospital, Woolloongabba, QLD, Australia
| | - Anthony Holley
- School of Medicine, University of Queensland, St. Lucia, QLD, Australia.,Royal Brisbane and Women's Hospital, Herston, QLD, Australia
| | - Jeremy Cohen
- School of Medicine, University of Queensland, St. Lucia, QLD, Australia.,Royal Brisbane and Women's Hospital, Herston, QLD, Australia
| | - Megan Shuttleworth
- Menzies Health Institute Queensland, Griffith University, Nathan, QLD, Australia
| | - Wayne Dyer
- Australian Red Cross Blood Service, Melbourne, VIC, Australia
| | - Gerben Keijzers
- Gold Coast University Hospital, Southport, QLD, Australia.,School of Medical Sciences, Griffith University, Nathan, QLD, Australia.,School of Medicine, Bond University, Robina, QLD, Australia
| | - John F Fraser
- Critical Care Research Group, The Prince Charles Hospital and University of Queensland, Brisbane, QLD, Australia
| | - Jeffrey Presneill
- Intensive Care Unit, Royal Melbourne Hospital and University of Melbourne, Melbourne, VIC, Australia
| | - Don Campbell
- Gold Coast University Hospital, Southport, QLD, Australia
| |
Collapse
|
18
|
Abstract
The resuscitation of traumatic hemorrhagic shock has undergone a paradigm shift in the last 20 years with the advent of damage control resuscitation (DCR). Major principles of DCR include minimization of crystalloid, permissive hypotension, transfusion of a balanced ratio of blood products, and goal-directed correction of coagulopathy. In particular, plasma has replaced crystalloid as the primary means for volume expansion for traumatic hemorrhagic shock. Predicting which patient will require DCR by prompt and accurate activation of a massive transfusion protocol, however, remains a challenge.
Collapse
Affiliation(s)
- Ronald Chang
- Center for Translational Injury Research, University of Texas Health Science Center, 6410 Fannin Street, Suite 1100, Houston, TX 77030, USA.
| | - John B Holcomb
- Department of Surgery, University of Texas Health Science Center, 6410 Fannin Street, Suite 1100, Houston, TX 77030, USA
| |
Collapse
|
19
|
Abstract
Haemorrhage in the setting of severe trauma is associated with significant morbidity and mortality. There is increasing awareness of the important role fibrinogen plays in traumatic haemorrhage. Fibrinogen levels fall precipitously in severe trauma and the resultant hypofibrinogenaemia is associated with poor outcomes. Hence, it has been postulated that early fibrinogen replacement in severe traumatic haemorrhage may improve outcomes, although, to date there is a paucity of high quality evidence to support this hypothesis. In addition there is controversy regarding the optimal method for fibrinogen supplementation. We review the current evidence regarding the role of fibrinogen in trauma, the rationale behind fibrinogen supplementation and discuss current research.
Collapse
|
20
|
Hayakawa M. Dynamics of fibrinogen in acute phases of trauma. J Intensive Care 2017; 5:3. [PMID: 34798699 PMCID: PMC8600928 DOI: 10.1186/s40560-016-0199-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2016] [Accepted: 12/17/2016] [Indexed: 11/10/2022] Open
Abstract
Fibrinogen is a unique precursor of fibrin and cannot be compensated for by other coagulation factors. If plasma fibrinogen concentrations are insufficient, hemostatic clots cannot be formed with the appropriate firmness. In severe trauma patients, plasma fibrinogen concentrations decrease earlier and more frequently than other coagulation factors, predicting massive bleeding and death. We review the mechanisms of plasma fibrinogen concentration decrease, which include coagulation activation-induced consumption, hyper-fibrino(geno)lysis-induced degradation, and dilution by infusion/transfusion. Understanding the mechanisms of plasma fibrinogen concentration decrease in severe trauma patients is crucial.
Collapse
|
21
|
Simmons J, Powell M. Acute traumatic coagulopathy: pathophysiology and resuscitation. Br J Anaesth 2016; 117:iii31-iii43. [DOI: 10.1093/bja/aew328] [Citation(s) in RCA: 91] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
|
22
|
David J, Imhoff E, Parat S, Augey L, Geay-Baillat MO, Incagnoli P, Tazarourte K. Intérêt de la thromboélastographie pour guider la correction de la coagulopathie post-traumatique : plus de MDS, moins de PSL ? Transfus Clin Biol 2016; 23:205-211. [DOI: 10.1016/j.tracli.2016.07.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2016] [Accepted: 07/19/2016] [Indexed: 01/28/2023]
|
23
|
Daniel Y, Habas S, Malan L, Escarment J, David JS, Peyrefitte S. Tactical damage control resuscitation in austere military environments. J ROY ARMY MED CORPS 2016; 162:419-427. [PMID: 27531659 DOI: 10.1136/jramc-2016-000628] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2016] [Revised: 06/30/2016] [Accepted: 07/01/2016] [Indexed: 11/04/2022]
Abstract
BACKGROUND Despite the early uses of tourniquets and haemostatic dressings, blood loss still accounts for the vast majority of preventable deaths on the battlefield. Over the last few years, progress has been made in the management of such injuries, especially with the use of damage control resuscitation concepts. The early application of these procedures, on the field, may constitute the best opportunity to improve survival from combat injury during remote operations. DATA SOURCES Currently available literature relating to trauma-induced coagulopathy treatment and far-forward transfusion was identified by searches of electronic databases. The level of evidence and methodology of the research were reviewed for each article. The appropriateness for field utilisation of each medication was then discussed to take into account the characteristics of remote military operations. CONCLUSIONS In tactical situations, in association with haemostatic procedures (tourniquet, suture, etc), tranexamic acid should be the first medication used according to the current guidelines. The use of fibrinogen concentrate should also be considered for patients in haemorrhagic shock, especially if point-of-care (POC) testing of haemostasis or shock severity is available. If POC evaluation is not available, it seems reasonable to still administer this treatment after clinical assessment, particularly if the evacuation is delayed. In this situation, lyophilised plasma may also be given as a resuscitation fluid while respecting permissive hypotension. Whole blood transfusion in the field deserves special attention. In addition to the aforementioned treatments, if the field care is prolonged, whole blood transfusion must be considered if it does not delay the evacuation.
Collapse
Affiliation(s)
- Yann Daniel
- Antenne médicale spécialisée, Base des Fusiliers Marins et des Commandos, Lanester, France
| | - S Habas
- Antenne médicale spécialisée, Base des Fusiliers Marins et des Commandos, Lanester, France
| | - L Malan
- Antenne médicale spécialisée, Base des Fusiliers Marins et des Commandos, Lanester, France
| | - J Escarment
- Hôpital d'Instruction des Armées Desgenettes, Lyon, France.,Direction Régionale du Service de Santé des Armées, Lyon, France
| | - J-S David
- Service d'Anesthésie Réanimation, Hôpital Edouard Herriot, Lyon, France.,Université Claude Bernard, Lyon, France
| | - S Peyrefitte
- Antenne médicale spécialisée, Base des Fusiliers Marins et des Commandos, Lanester, France
| |
Collapse
|
24
|
Schäfer N, Driessen A, Bauerfeind U, Fröhlich M, Ofir J, Stürmer EK, Maegele M. In vitro effects of different sources of fibrinogen supplementation on clot initiation and stability in a model of dilutional coagulopathy. Transfus Med 2016; 26:373-380. [PMID: 27506588 DOI: 10.1111/tme.12333] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2016] [Revised: 07/13/2016] [Accepted: 07/15/2016] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To analyse which fibrinogen source may improve coagulation using an in vitro 33% dilutional coagulopathy model. BACKGROUND Uncritical volume resuscitation in the context of trauma haemorrhage contributes to the iatrogenic arm of the acute trauma-induced coagulopathy through dilution and depletion of coagulation factors, with fibrinogen reaching critical levels first. MATERIALS AND METHODS By using an experimental model of 33% dilutional coagulopathy, we have analysed which fibrinogen source may exert superior effects on improving haemocoagulative capacities and correcting depleted fibrinogen levels. As fibrinogen sources, we supplemented (i) fresh frozen plasma (FFP), (ii) fibrinogen concentrate low-dose (Fiblow ) and (iii) fibrinogen concentrate high-dose (Fibhigh ), the latter both in the presence and absence of additional FXIII. RESULTS The dilution was associated with decreased haemoglobin and haematocrit levels. Fibrinogen supplementation with fibrinogen-containing formulations led to increased fibrinogen levels (FFP: 172·2 ± 17·4 mg dL-1 ; Fiblow : 211·5 ± 20·61 mg dL-1 ; Fibhigh : 255·8 ± 21·4 mg dL-1 ) than in a diluted-only sample (155·5 ± 19·7 mg dL-1 ). Extrinsically activated assay with tissue factor (EXTEM) clot formation times, α-angles and maximum clot firmness significantly improved in the groups of Fiblow + FXIII (79 ± 12·2 s; 74·3 ± 2·4°; 62 ± 2·3 mm), Fibhigh (70·8 ± 10·6 s; 76·2 ± 2·7°; 64·3 ± 2·3 mm) and Fibhigh + FXIII (69·8 ± 11·5 s; 77·5 ± 2·7°; 64·33 ± 2·5 mm) compared with the dilution groups (104·2 ± 19 s; 69·7 ± 2·9°; 56·5 ± 3·1 mm). In contrast, rotational thromboelastometric trace (ROTEM) measures of samples supplemented with FFP largely remained unchanged. CONCLUSION Fibrinogen concentrates corrected and improved haemodilution-induced changes in blood clotting in vitro. High-dose fibrinogen supplementation was associated with correction and improvement in clot dynamics and stability.
Collapse
Affiliation(s)
- N Schäfer
- The Institute for Research in Operative Medicine, Faculty of Health, Department of Medicine, Witten/Herdecke University, Cologne, Germany
| | - A Driessen
- The Institute for Research in Operative Medicine, Faculty of Health, Department of Medicine, Witten/Herdecke University, Cologne, Germany.,Department of Traumatology, Orthopaedic Surgery and Sports Traumatology, Cologne-Merheim Medical Centre (CMMC), Witten/Herdecke University, Cologne, Germany.,Department of Orthopaedic Surgery, University Hospital RWTH Aachen, Aachen, Germany
| | - U Bauerfeind
- Institute of Transfusion Medicine Cologne-Merheim Medical Centre (CMMC), Witten/Herdecke University, Cologne, Germany
| | - M Fröhlich
- The Institute for Research in Operative Medicine, Faculty of Health, Department of Medicine, Witten/Herdecke University, Cologne, Germany.,Department of Traumatology, Orthopaedic Surgery and Sports Traumatology, Cologne-Merheim Medical Centre (CMMC), Witten/Herdecke University, Cologne, Germany
| | - J Ofir
- The Institute for Research in Operative Medicine, Faculty of Health, Department of Medicine, Witten/Herdecke University, Cologne, Germany
| | - E K Stürmer
- The Institute for Research in Operative Medicine, Faculty of Health, Department of Medicine, Witten/Herdecke University, Cologne, Germany
| | - M Maegele
- Department of Traumatology, Orthopaedic Surgery and Sports Traumatology, Cologne-Merheim Medical Centre (CMMC), Witten/Herdecke University, Cologne, Germany.
| |
Collapse
|
25
|
Differential contributions of platelets and fibrinogen to early coagulopathy in a rat model of hemorrhagic shock. Thromb Res 2016; 141:58-65. [DOI: 10.1016/j.thromres.2016.03.007] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2016] [Revised: 03/02/2016] [Accepted: 03/05/2016] [Indexed: 11/20/2022]
|
26
|
|
27
|
Dudaryk R, Sheffy N, Hess JR. Changing Paradigms in Hemostatic Resuscitation: Timing, Extent, Economic Impact, and the Role of Factor Concentrates. CURRENT ANESTHESIOLOGY REPORTS 2016. [DOI: 10.1007/s40140-016-0143-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
|