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Schmulevich D, Geng Z, Joergensen SM, McLauchlan NR, Winter E, Zone A, Bishop KE, Hinkle A, Holland S, Cacchione PZ, Fox EE, Abella BS, Meador CL, Wade CE, Hynes AM, Cannon JW. Real-time performance improvement optimizes damage control resuscitation best practice adherence: Results of a pilot prospective observational study. Transfusion 2024. [PMID: 39072759 DOI: 10.1111/trf.17970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Revised: 07/03/2024] [Accepted: 07/07/2024] [Indexed: 07/30/2024]
Abstract
BACKGROUND Maintaining balanced blood product ratios during damage control resuscitation (DCR) is independently associated with improved survival. We hypothesized that real-time performance improvement (RT-PI) would increase adherence to DCR best practice. STUDY DESIGN AND METHODS From December 2020-August 2021, we prospectively used a bedside RT-PI tool to guide DCR in severely injured patients surviving at least 30 min. RT-PI study patients were compared to contemporary control patients at our institution and historic PROMMTT study patients. A subset of patients transfused ≥6 U red blood cells (RBC) in 6 h (MT+) was also identified. The primary endpoint was percentage time in a high ratio range (≥3:4) of plasma (PLAS):RBC and platelet (PLT):RBC over 6 h. Secondary endpoints included time to massive transfusion protocol activation, time to calcium and tranexamic acid (TXA) dosing, and cumulative 6-h ratios. RESULTS Included patients (n = 772) were 35 (24-51) years old with an Injury Severity Score of 27 (17-38) and 42% had penetrating injuries. RT-PI (n = 10) patients spent 96% of the 6-h resuscitation in a high PLAS:RBC range, no different versus CONTROL (n = 87) (96%) but more than PROMMTT (n = 675) (25%, p < .001). In the MT+ subgroup, optimal PLAS:RBC and PLT:RBC were maintained for the entire 6 h in RT-PI (n = 4) versus PROMMTT (n = 391) patients for both PLAS (p < .001) and PLT ratios (p < .001). Time to TXA also improved significantly in RT-PI versus CONTROL patients (27 min [22-31] vs. 51 min [29-98], p = .035). CONCLUSION In this prospective study, RT-PI was associated with optimized DCR. Multicenter validation of this novel approach to optimizing DCR implementation is warranted.
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Affiliation(s)
- Daniela Schmulevich
- Division of Traumatology, Surgical Critical Care, and Emergency Surgery, Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio, USA
| | - Zhi Geng
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Sarah M Joergensen
- Penn Acute Research Collaboration (PARC), Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Nathaniel R McLauchlan
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Eric Winter
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Alea Zone
- Penn Acute Research Collaboration (PARC), Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Kathleen E Bishop
- Penn Acute Research Collaboration (PARC), Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Alyson Hinkle
- Department of Nursing, Penn Presbyterian Medical Center, Penn Medicine, Philadelphia, Pennsylvania, USA
| | - Sara Holland
- Department of Nursing, Penn Presbyterian Medical Center, Penn Medicine, Philadelphia, Pennsylvania, USA
| | - Pamela Z Cacchione
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Nursing, Penn Presbyterian Medical Center, Penn Medicine, Philadelphia, Pennsylvania, USA
- Department of Family and Community Health, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, USA
| | - Erin E Fox
- Center for Translational Injury Research, Department of Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Benjamin S Abella
- Penn Acute Research Collaboration (PARC), Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Emergency Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | | | - Charles E Wade
- Center for Translational Injury Research, Department of Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Allyson M Hynes
- Division of Traumatology, Surgical Critical Care, and Emergency Surgery, Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jeremy W Cannon
- Division of Traumatology, Surgical Critical Care, and Emergency Surgery, Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Penn Acute Research Collaboration (PARC), Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
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Maier CL, Brohi K, Curry N, Juffermans NP, Mora Miquel L, Neal MD, Shaz BH, Vlaar APJ, Helms J. Contemporary management of major haemorrhage in critical care. Intensive Care Med 2024; 50:319-331. [PMID: 38189930 DOI: 10.1007/s00134-023-07303-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Accepted: 12/05/2023] [Indexed: 01/09/2024]
Abstract
Haemorrhagic shock is frequent in critical care settings and responsible for a high mortality rate due to multiple organ dysfunction and coagulopathy. The management of critically ill patients with bleeding and shock is complex, and treatment of these patients must be rapid and definitive. The administration of large volumes of blood components leads to major physiological alterations which must be mitigated during and after bleeding. Early recognition of bleeding and coagulopathy, understanding the underlying pathophysiology related to specific disease states, and the development of individualised management protocols are important for optimal outcomes. This review describes the contemporary understanding of the pathophysiology of various types of coagulopathic bleeding; the diagnosis and management of critically ill bleeding patients, including major haemorrhage protocols and post-transfusion management; and finally highlights recent areas of opportunity to better understand optimal management strategies for managing bleeding in the intensive care unit (ICU).
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Affiliation(s)
- Cheryl L Maier
- Department of Pathology and Laboratory Medicine, Center for Transfusion and Cellular Therapies, Emory University School of Medicine, Atlanta, GA, USA
| | - Karim Brohi
- Centre for Trauma Sciences, Queen Mary University of London, London, UK
| | - Nicola Curry
- Oxford Haemophilia and Thrombosis Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- Nuffield Department of Clinical and Laboratory Sciences, Radcliffe Department of Medicine, Oxford University, Oxford, UK
| | - Nicole P Juffermans
- Department of Intensive Care and Laboratory of Translational Intensive Care, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Lidia Mora Miquel
- Department of Anaesthesiology, Intensive Care and Pain Clinic, Vall d'Hebron Trauma, Rehabilitation and Burns Hospital, Autonomous University of Barcelona, Passeig de La Vall d'Hebron 119-129, 08035, Barcelona, Spain
| | - Matthew D Neal
- Trauma and Transfusion Medicine Research Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Beth H Shaz
- Department of Pathology, Duke University School of Medicine, Durham, NC, USA
| | | | - Julie Helms
- Service de Médecine Intensive-Réanimation, Department of Intensive Care, Nouvel Hôpital Civil, Université de Strasbourg (UNISTRA), 1, Place de L'Hôpital, 67091, Strasbourg Cedex, France.
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3
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Ohbe H, Tagami T, Endo A, Miyata S, Matsui H, Fushimi K, Kushimoto S, Yasunaga H. Trends in massive transfusion practice for trauma in Japan from 2011 to 2020: a nationwide inpatient database study. J Intensive Care 2023; 11:46. [PMID: 37853484 PMCID: PMC10585788 DOI: 10.1186/s40560-023-00685-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Accepted: 08/20/2023] [Indexed: 10/20/2023] Open
Abstract
BACKGROUND Previous studies have reported conflicting results regarding fresh frozen plasma (FFP)-to-red blood cell (RBC) ratio and platelet-to-RBC ratio on outcomes for massive transfusion for trauma. Moreover, nationwide data on massive transfusion practices for trauma in the real-world clinical setting are scarce. This study aimed to examine the nationwide practice patterns and trends in massive transfusion for trauma in Japan using a national administrative, inpatient database. METHOD We identified patients who underwent emergency hospitalization for trauma and received massive transfusion, defined as administration of at least 20 units of RBC within the first 2 days of admission, using the nationwide inpatient database, which covers approximately 90% of all tertiary emergency hospitals in Japan, between 2011 and 2020. Trends in the incidence and practice patterns of massive transfusion were described by calendar year. The association of practice patterns with mortality or adverse events was tested. RESULTS A total of 3,530,846 trauma hospitalizations were identified, of which 5247 (0.15%) received massive transfusion. A significant declining trend was observed in the incidence of massive transfusion in trauma hospitalizations from 0.24% in 2011 to 0.10% in 2020 (P for trend < 0.001). The FFP-to-RBC ratio rose significantly from 0.77 in 2011 to 1.08 in 2020 (P for trend < 0.001), while the platelet-to-RBC ratio remained virtually unchanged from 0.71 in 2011 to 0.78 in 2020 (P for trend 0.060). Massive transfusion with lower FFP-to-RBC (< 0.75) and platelets-to-RBC ratio (< 1.00) were associated with increased in-hospital mortality compared with those ≥ 1.00, while there were linear increases in adverse events with increasing FFP and platelets ratios. CONCLUSIONS This study demonstrated a declining trend in the incidence and a rise in higher FFP-to-RBC ratios in massive transfusion in association with patient outcomes for trauma from 2011 to 2020 in Japan.
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Affiliation(s)
- Hiroyuki Ohbe
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan.
- Division of Emergency and Critical Care Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan.
| | - Takashi Tagami
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
- Department of Emergency and Critical Care Medicine, Nippon Medical School Musashikosugi Hospital, Kawasaki, Kanagawa, Japan
| | - Akira Endo
- Department of Acute Critical Care Medicine, Tsuchiura Kyodo General Hospital, Tsuchiura, Japan
| | - Shigeki Miyata
- Central Blood Institute, Blood Service Headquarters, Japanese Red Cross Society, Tokyo, Japan
| | - Hiroki Matsui
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
| | - Kiyohide Fushimi
- Department of Health Policy and Informatics, Tokyo Medical and Dental University Graduate School, Tokyo, Japan
| | - Shigeki Kushimoto
- Division of Emergency and Critical Care Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Hideo Yasunaga
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
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Schoenmann N, Tannenbaum N, Hodgeman RM, Raju RP. Regulating mitochondrial metabolism by targeting pyruvate dehydrogenase with dichloroacetate, a metabolic messenger. Biochim Biophys Acta Mol Basis Dis 2023; 1869:166769. [PMID: 37263447 PMCID: PMC10776176 DOI: 10.1016/j.bbadis.2023.166769] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 05/20/2023] [Accepted: 05/26/2023] [Indexed: 06/03/2023]
Abstract
Dichloroacetate (DCA) is a naturally occurring xenobiotic that has been used as an investigational drug for over 50 years. Originally found to lower blood glucose levels and alter fat metabolism in diabetic rats, this small molecule was found to serve primarily as a pyruvate dehydrogenase kinase inhibitor. Pyruvate dehydrogenase kinase inhibits pyruvate dehydrogenase complex, the catalyst for oxidative decarboxylation of pyruvate to produce acetyl coenzyme A. Several congenital and acquired disease states share a similar pathobiology with respect to glucose homeostasis under distress that leads to a preferential shift from the more efficient oxidative phosphorylation to glycolysis. By reversing this process, DCA can increase available energy and reduce lactic acidosis. The purpose of this review is to examine the literature surrounding this metabolic messenger as it presents exciting opportunities for future investigation and clinical application in therapy including cancer, metabolic disorders, cerebral ischemia, trauma, and sepsis.
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Affiliation(s)
- Nick Schoenmann
- Department of Emergency Medicine, Medical College of Georgia, Augusta University, Augusta, GA, United States of America
| | - Nicholas Tannenbaum
- Department of Emergency Medicine, Medical College of Georgia, Augusta University, Augusta, GA, United States of America
| | - Ryan M Hodgeman
- Department of Emergency Medicine, Medical College of Georgia, Augusta University, Augusta, GA, United States of America
| | - Raghavan Pillai Raju
- Department of Pharmacology and Toxicology, Medical College of Georgia, Augusta University, Augusta, GA, United States of America.
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5
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Robinson A, Rech MA, DeChristopher PJ, Vaughn A, Rubino J, Bannister E, Moore ME, Chang K. Defining the optimal calcium repletion dosing in patients requiring activation of massive transfusion protocol. Am J Emerg Med 2023; 70:96-100. [PMID: 37245404 DOI: 10.1016/j.ajem.2023.05.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 04/24/2023] [Accepted: 05/12/2023] [Indexed: 05/30/2023] Open
Abstract
PURPOSE Massive transfusion protocols (MTP) commonly result in severe hypocalcemia due to the calcium-binding affinity of citrate in blood components. The purpose of this study is to determine the optimal grams (g) of citrate to repletion calcium (Ca) milliequivalents (mEq) (Citrate:Ca) ratio to reduce 30-day mortality. METHODS This was a retrospective, single-centered, cohort study at a level 1 trauma center evaluating trauma and surgical patients in need of MTP activation from January 1, 2010-July 31, 2021. Patients with severe hypocalcemia at baseline, defined as ionized calcium (iCa) <0.9 mmol/L, were compared to patients without severe hypocalcemia. The primary endpoint was to determine the optimal ratio of grams of citrate to calcium mEq to reduce mortality in patients receiving a MTP. Secondary endpoints included mortality at 24 h and 30 days, blood components used in MTP, and type of calcium used. RESULTS Overall, 501 patients were screened for inclusion. Of these patients, 193 were excluded, leaving 308 patients, of which 165 patients (53.6%) had an iCa <0.9 mmol/L within 24 h and 143 patients (46.4%) had iCa ≥0.9 mmol/L within 24 h. The ratio of Citrate:Ca for each patient was not significantly associated with mortality at 24 h (P = 0.79) or 30 days (P = 0.91) at a repletion Citrate:Ca ratio of median 1.97 (IQR 1.14-2.91). The rate of mortality was lowest at a Citrate:Ca of 2 in both <24-h mortality and 30-day mortality. CONCLUSIONS There were no differences in 24 h or 30 day mortality based on repletion ratios seen in this study. A Citrate:Ca ratio between 2 and 3 in patients undergoing MTP was sufficient to obtain a normalized iCa within 24 h of MTP activation regardless of baseline iCa level. Further prospective studies will be needed to determine the optimal Citrate:Ca ratio.
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Affiliation(s)
- Andrew Robinson
- Loyola University Medical Center, Department of Pharmacy, Maywood, IL, United States of America; Community Health South, Department of Pharmacy, Greenwood, IN, United States of America.
| | - Megan A Rech
- Loyola University Medical Center, Department of Pharmacy, Maywood, IL, United States of America; Loyola University Chicago, Stritch School of Medicine, Department of Emergency Medicine, Maywood, IL, United States of America
| | - Phillip J DeChristopher
- Loyola University Medical Center, Department of Pathology, Maywood, IL, United States of America
| | - Alex Vaughn
- Loyola University Chicago, Stritch School of Medicine, United States of America
| | - John Rubino
- Loyola University Medical Center, Department of Pharmacy, Maywood, IL, United States of America
| | - Erika Bannister
- Loyola University Chicago, Stritch School of Medicine, United States of America
| | - Mary E Moore
- Loyola University Chicago, Clinical Research Office, United States of America
| | - Kevin Chang
- Loyola University Medical Center, Department of Pharmacy, Maywood, IL, United States of America
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Kim JS, Casem CF, Baral E, Inaba K, Kuza CM. Narrative Review: Is There a Transfusion Cutoff Value After Which Nonsurvivability Is Inevitable in Trauma Patients Receiving Ultramassive Transfusion? Anesth Analg 2023; 137:354-364. [PMID: 37115716 DOI: 10.1213/ane.0000000000006504] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/29/2023]
Abstract
The institution of massive transfusion protocols (MTPs) has improved the timely delivery of large quantities of blood products and improves patient outcomes. In recent years, the cost of blood products has increased, compounded by significant blood product shortages. There is practical need for identification of a transfusion volume in trauma patients that is associated with increased mortality, or a threshold after which additional transfusion is futile and associated with nonsurvivability. This transfusion threshold is often described in the setting of an ultramassive transfusion (UMT). There are few studies defining what constitutes amount or outcomes associated with such large volume transfusion. The purpose of this narrative review is to provide an analysis of existing literature examining the effects of UMT on outcomes including survival in adult trauma patients and to determine whether there is a threshold transfusion limit after which mortality is inevitable. Fourteen studies were included in this review. The data examining the utility of UMT in trauma are of poor quality, and with the variability inherent in trauma patients, and the surgeons caring for them, no universally accepted cutoff for transfusion exists. Not surprisingly, there is a trend toward increasing mortality with increasing transfusions. The decision to continue transfusing is multifactorial and must be individualized, taking into consideration patient characteristics, institution factors, blood bank supply, and most importantly, constant reevaluation of the need for ongoing transfusion rather than blind continuous transfusion until the heart stops.
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Affiliation(s)
- Jennie S Kim
- From the Department of Surgery, University of Southern California Trauma and Acute Care Surgery, Los Angeles, California
| | - Christleen F Casem
- Department of Surgery, University of California San Francisco East Bay Surgery, Oakland, Californiaand
| | - Erika Baral
- Department of Anesthesiology, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Kenji Inaba
- From the Department of Surgery, University of Southern California Trauma and Acute Care Surgery, Los Angeles, California
| | - Catherine M Kuza
- Department of Anesthesiology, Keck School of Medicine of the University of Southern California, Los Angeles, California
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7
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Vollmer NJ, Leshko NA, Wilson CS, Gilbert BW. A Review of Thromboelastography for Nurses. Crit Care Nurse 2023; 43:29-37. [PMID: 37257875 DOI: 10.4037/ccn2023371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
BACKGROUND Thromboelastography is a viscoelastic test with multiple potential advantages over conventional coagulation tests in various disease states. Thromboelastography rapidly provides qualitative and quantitative information related to a patient's coagulation status. OBJECTIVE To describe recent studies of the use of thromboelastography in various clinical states and how thromboelastography is used in coagulation management. METHODS A literature review using the MEDLINE and PubMed databases was conducted. The updated methodology for integrated reviews by Whittemore and Knafl was followed. Coauthors evaluated separate areas that were independently reviewed by other coauthors to ensure appropriateness for inclusion. RESULTS The use of thromboelastography for various clinical conditions with challenging hemostatic profiles has increased. This integrative review covers the use of thromboelastography in patients with trauma, medication-induced coagulopathy, acute and chronic liver failure, and cardiothoracic surgery. Potential future directions are also discussed. DISCUSSION Thromboelastography has numerous potential benefits over conventional coagulation tests for assessing coagulation status in patients in various clinical states. Nurses can support clinical decisions to use the most appropriate test for their patients. CONCLUSIONS Each team member should be involved in assessing the usefulness of thromboelastography. Critical care nurses and the multidisciplinary team must identify patients in whom its use is warranted, interpret the results, and provide appropriate interventions in response to the results and clinical status of the patient.
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Affiliation(s)
- Nicholas J Vollmer
- Nicholas J. Vollmer is an emergency medicine and intensive care unit clinical pharmacy specialist at Mayo Clinic, Rochester, Minnesota
| | - Nicole A Leshko
- Nicole A. Leshko is a critical care pharmacist at Northwestern Memorial Hospital, Chicago, Illinois
| | - Charles S Wilson
- Charles S. Wilson Jr is a postgraduate year 2 critical care pharmacy resident at Wesley Medical Center, Wichita, Kansas
| | - Brian W Gilbert
- Brian W. Gilbert is an emergency medicine clinical pharmacy specialist and Residency Program Director for the Postgraduate Year 2 Critical Care Pharmacy program at Wesley Medical Center
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Horst JA, Spinella PC, Leonard JC, Josephson CD, Leeper CM. Cryoprecipitate for the treatment of life-threatening hemorrhage in children. Transfusion 2023; 63 Suppl 3:S10-S17. [PMID: 37070338 PMCID: PMC10364587 DOI: 10.1111/trf.17340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 01/16/2023] [Accepted: 01/16/2023] [Indexed: 04/19/2023]
Abstract
BACKGROUND Hypofibrinogenemia is an important risk factor for poor outcomes in children with severe bleeding. There is a paucity of data on the impact of cryoprecipitate transfusion on outcomes in pediatric patients with life-threatening hemorrhage (LTH). STUDY DESIGN AND METHODS This secondary analysis of a multicenter prospective observational study of children with LTH investigated subjects who were categorized by receipt of cryoprecipitate during their resuscitation and according to the etiology of their bleeding: trauma, operative, and medical. Bivariate analysis was performed to identify variables associated with 6-h, 24-h, and 28-day mortality. Cox Hazard regression models were generated to adjust for potential confounders. RESULTS Cryoprecipitate was transfused to 33.9% (152/449) of children during LTH. The median (Interquartile range) time to cryoprecipitate administration was 108 (47-212) minutes. Children in the cryoprecipitate group were younger, more often female, with higher BMI and pre-LTH PRISM score and lower platelet counts. After adjusting for PRISM score, bleeding etiology, age, sex, RBC volume, platelet volume, antifibrinolytic use and cardiac arrest, cryoprecipitate administration was independently associated with lower 6-h mortality, Hazard Ratio (95% CI), 0.41 (0.19-0.89), (p = 0.02) and 24-h mortality, Hazard Ratio (95% CI), 0.46 (0.24-0.89), (p = 0.02). CONCLUSION Cryoprecipitate transfusion to children with LTH was associated with reduced early mortality. A prospective randomized trial is needed to determine if cryoprecipitate can improve outcomes in children with LTH.
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Affiliation(s)
- Jennifer A Horst
- Department of Pediatrics, Washington University, St. Louis, Missouri, USA
| | - Philip C Spinella
- Department of Surgery and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Julie C Leonard
- Department of Pediatrics, Nationwide Children's Hospital and The Ohio State University, Columbus, Ohio, USA
| | - Cassandra D Josephson
- Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- The Cancer and Blood Disorders Institute, Johns Hopkins All Children's Hospital, St. Petersburg, Florida, USA
| | - Christine M Leeper
- Department of Surgery and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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Roquet F, Godier A, Garrigue-Huet D, Hanouz JL, Vardon-Bounes F, Legros V, Pirracchio R, Ausset S, Duranteau J, Vigué B, Hamada SR. Comprehensive analysis of coagulation factor delivery strategies in a cohort of trauma patients. Anaesth Crit Care Pain Med 2023; 42:101180. [PMID: 36460214 DOI: 10.1016/j.accpm.2022.101180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2022] [Revised: 09/18/2022] [Accepted: 11/01/2022] [Indexed: 11/30/2022]
Abstract
PURPOSE The 5th edition of The European recommendations for the management of major bleeding and coagulopathy following trauma leaves room for various coagulation factor administration strategies. The present study examines these strategies reporting prevalence and timing of administration, quantity dispensed, and transfusion ratios in French trauma centers and their compliance with recommendations alongside associated mortality data. METHODS All adult patients, admitted directly to participating centers between 2011 and 2019, were extracted from a trauma registry. Two subpopulations were studied: severe hemorrhage (SH) and massive transfusion (MT) groups. RESULTS A total of 19,396 patients were included, among whom 8.4% (1630) experienced SH and 3% (579) received MT. Within the first 24 hours, 10% received fresh frozen plasma (FFP), rising to 93% and 99% in the subgroups of patients experiencing SH and MT respectively. Only, 8% received fibrinogen concentrate (FC), increasing to 75% and 92% in subgroups SH and MT respectively. Co-administration of FFP and FC became the dominant strategy with 68% of patients at 6 h and 72% at 24 h in SH subgroup. In unadjusted data, mortality was systematically lower in groups that complied with recommendations, a lower mortality than expected was mostly observed in contrast to non-compliant subgroups. The per-patient compliance to studied recommendations was 21% and 22% in SH and MT subgroups. CONCLUSION The main hemostatic strategy for major bleeding combined the administration of both FFP and FC, favoring an early additional supply of fibrinogen. Compliance with the recommendations was low in SH and MT subgroups.
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Affiliation(s)
- Florian Roquet
- Département d'Anesthésie Réanimation, Assistance Publique-Hôpitaux de Paris, HEGP, Université de Paris, Paris, France; INSERM UMR 1153, Université de Paris, Paris, France.
| | - Anne Godier
- Département d'Anesthésie Réanimation, Assistance Publique-Hôpitaux de Paris, HEGP, Université de Paris, Paris, France; INSERM UMRS-1140, Université de Paris, Paris, France
| | | | - Jean-Luc Hanouz
- CHU de Caen, Département d'Anesthésie Réanimation, Caen, France
| | | | - Vincent Legros
- CHU de Reims, Département d'Anesthésie Réanimation, Reims, France
| | - Romain Pirracchio
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, CA, USA
| | | | - Jacques Duranteau
- Département d'Anesthésie Réanimation, CHU de Bicêtre, Le Kremlin Bicêtre, France
| | - Bernard Vigué
- Centre d'Étude et de Santé des Populations INSERM U 10-18, Université Paris-Saclay, Paris, France
| | - Sophie Rym Hamada
- Département d'Anesthésie Réanimation, Assistance Publique-Hôpitaux de Paris, HEGP, Université de Paris, Paris, France; Centre d'Étude et de Santé des Populations INSERM U 10-18, Université Paris-Saclay, Paris, France
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Smedley WA, Mabry CD, Collins T, Tabor J, Bowman S, Porter A, Young S, Klutts G, Deloach J, Bhavaraju A, Maxson T, Robertson RD, Holcomb JB, Kalkwarf KJ. Access to Immediately Available Balanced Blood Products in a Rural State's Trauma System. Am Surg 2023:31348231160836. [PMID: 36877979 DOI: 10.1177/00031348231160836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/08/2023]
Abstract
INTRODUCTION The Arkansas Trauma System was established by law more than a dozen years ago, and all participating trauma centers are required to maintain red blood cells. Since then, there has been a paradigm shift in resuscitating exsanguinating trauma patients. Damage Control Resuscitation with balanced blood products (or whole blood) and minimal crystalloid is now the standard of care. This project aimed to determine access to balanced blood products in our state's Trauma System (TS). METHODS A survey of all trauma centers in the Arkansas TS was conducted, and geospatial analysis was performed. Immediately Available Balanced Blood (IABB) was defined as at least 2 units (U) of thawed plasma (TP) or never frozen plasma (NFP), 4 units of red blood cells (RBCs), 2 units of fresh frozen plasma (FFP), and 1 unit of platelets or 2 units of whole blood (WB). RESULTS All 64 trauma centers in the state TS completed the survey. All level I, II, and III Trauma Centers (TCs) maintain RBC, plasma, and platelets, but only half of the level II and 16% of the level III TCs have thawed or never frozen plasma. A third of level IV TCs maintain only RBCs, while only 1 had platelets, and none had thawed plasma. 85% of people in our state are within 30 min of RBCs, almost two-thirds are within 30 min of plasma (TP, NFP, or FFP) and platelets, while only a third are within 30 min of IABB. More than 90% are within an hour of plasma and platelets, while only 60% are within that time from an IABB. The median drive times for Arkansas from RBC, plasma (TP, NFP, or FFP), platelets, and an immediately available and balanced blood bank are 19, 21, 32, and 59 minutes, respectively. A lack of thawed or non-frozen plasma and platelets are the most common limitations of IABB. One level III TC in the state maintains WB, which would alleviate the limited access to IABB. CONCLUSION Only 16% of the trauma centers in Arkansas can provide IABB, and only 61% of the population can reach IABB within 60 minutes. Opportunities exist to reduce the time to balanced blood products by selectively distributing WB, TP, or NFP to hospitals in our state trauma system.
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Affiliation(s)
- W Andrew Smedley
- Department of Surgery, 12215University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | | | - Terry Collins
- Department of Surgery, 12215University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Jeff Tabor
- Arkansas Trauma Communications Center, Little Rock, AR, USA
| | - Stephen Bowman
- Department of Surgery, 12215University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Austin Porter
- Department of Surgery, 12215University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Sean Young
- Department of Surgery, 12215University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Garret Klutts
- Department of Surgery, 12215University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Joseph Deloach
- Department of Surgery, 12215University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Avi Bhavaraju
- Department of Surgery, 12215University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Todd Maxson
- Department of Surgery, 12215University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Ronald D Robertson
- Department of Surgery, 12215University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - John B Holcomb
- Center for Injury Sciences, Division of Acute Care Surgery, 9967University of Alabama at Birmingham, Birmingham, AL, USA
| | - Kyle J Kalkwarf
- Department of Surgery, 12215University of Arkansas for Medical Sciences, Little Rock, AR, USA
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11
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Abstract
Massive trauma remains the leading cause of mortality among people aged younger than 45 years. In this review, we discuss the initial care and diagnosis of trauma patients followed by a comparison of resuscitation strategies. We discuss various strategies including use of whole blood and component therapy, examine viscoelastic techniques for management of coagulopathy, and consider the benefits and limitations of the resuscitation strategies and consider a series of questions that will be important for researchers to answer to provide the best and most cost-effective therapy for severely injured patients.
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Affiliation(s)
- Carter M Galbraith
- Division of Critical Care Medicine, Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, 619 19th Street South, JT 845, Birmingham, AL 35249, USA
| | - Brant M Wagener
- Division of Critical Care Medicine, University of Alabama at Birmingham, 901 19th Street South, PBMR 302, Birmingham, AL 35294, USA; Division of Molecular and Translational Biomedicine, Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, 901 19th Street South, PBMR 302, Birmingham, AL 35294, USA
| | - Athanasios Chalkias
- Department of Anesthesiology, University of Thessaly, Biopolis, Larisa 41500, Greece; Outcomes Research Consortium, Cleveland, OH 44195, USA
| | - Shahla Siddiqui
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, Boston, MA 02215, USA.
| | - David J Douin
- Department of Anesthesiology, University of Colorado School of Medicine, 12401 East 17th Avenue, 7th Floor, Aurora, CO 80045, USA.
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12
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Trauma Quality Improvement and Team Education: How Can We Better Optimize Our Training? CURRENT SURGERY REPORTS 2023. [DOI: 10.1007/s40137-023-00351-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/23/2023]
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13
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Transfusion Management in Trauma: What is Current Best Practice? CURRENT SURGERY REPORTS 2023. [DOI: 10.1007/s40137-023-00352-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
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14
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Platelet Transfusion for Trauma Resuscitation. CURRENT TRAUMA REPORTS 2022. [DOI: 10.1007/s40719-022-00236-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Abstract
Purpose of Review
To review the role of platelet transfusion in resuscitation for trauma, including normal platelet function and alterations in behavior following trauma, blood product transfusion ratios and the impact of platelet transfusion on platelet function, platelet function assays, risks of platelet transfusion and considerations for platelet storage, and potential adjunct therapies and synthetic platelets.
Recent Findings
Platelets are a critical component of clot formation and breakdown following injury, and in addition to these hemostatic properties, have a complex role in vascular homeostasis, inflammation, and immune function. Evidence supports that platelets are activated following trauma with several upregulated functions, but under conditions of severe injury and shock are found to be impaired in their hemostatic behaviors. Platelets should be transfused in balanced ratios with red blood cells and plasma during initial trauma resuscitation as this portends improved outcomes including survival. Multiple coagulation assays can be used for goal-directed resuscitation for traumatic hemorrhage; however, these assays each have drawbacks in terms of their ability to measure platelet function. While resuscitation with balanced transfusion ratios is supported by the literature, platelet transfusion carries its own risks such as bacterial infection and lung injury. Platelet supply is also limited, with resource-intensive storage requirements, making exploration of longer-term storage options and novel platelet-based therapeutics attractive. Future focus on a deeper understanding of the biology of platelets following trauma, and on optimization of novel platelet-based therapeutics to maintain hemostatic effects while improving availability should be pursued.
Summary
While platelet function is altered following trauma, platelets should be transfused in balanced ratios during initial resuscitation. Severe injury and shock can impair platelet function, which can persist for several days following the initial trauma. Assays to guide resuscitation following the initial period as well as storage techniques to extend platelet shelf life are important areas of investigation.
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15
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Deeb AP, Hoteit L, Li S, Guyette FX, Eastridge BJ, Nirula R, Vercruysse GA, O'Keeffe T, Joseph B, Neal MD, Sperry JL, Brown JB. Prehospital synergy: Tranexamic acid and blood transfusion in patients at risk for hemorrhage. J Trauma Acute Care Surg 2022; 93:52-58. [PMID: 35393385 PMCID: PMC9233003 DOI: 10.1097/ta.0000000000003620] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Growing evidence supports improved survival with prehospital blood products. Recent trials show a benefit of prehospital tranexamic acid (TXA) administration in select subgroups. Our objective was to determine if receiving prehospital packed red blood cells (pRBC) in addition to TXA improved survival in injured patients at risk of hemorrhage. METHODS We performed a secondary analysis of all scene patients from the Study of Tranexamic Acid during Air and ground Medical Prehospital transport trial. Patients were randomized to prehospital TXA or placebo. Some participating EMS services utilized pRBC. Four resuscitation groups resulted: TXA, pRBC, pRBC+TXA, and neither. Our primary outcome was 30-day mortality and secondary outcome was 24-hour mortality. Cox regression tested the association between resuscitation group and mortality while adjusting for confounders. RESULTS A total of 763 patients were included. Patients receiving prehospital blood had higher Injury Severity Scores in the pRBC (22 [10, 34]) and pRBC+TXA (22 [17, 36]) groups than the TXA (12 [5, 21]) and neither (10 [4, 20]) groups (p < 0.01). Mortality at 30 days was greatest in the pRBC+TXA and pRBC groups at 18.2% and 28.6% compared with the TXA only and neither groups at 6.6% and 7.4%, respectively. Resuscitation with pRBC+TXA was associated with a 35% reduction in relative hazards of 30-day mortality compared with neither (hazard ratio, 0.65; 95% confidence interval, 0.45-0.94; p = 0.02). No survival benefit was observed in 24-hour mortality for pRBC+TXA, but pRBC alone was associated with a 61% reduction in relative hazards of 24-hour mortality compared with neither (hazard ratio, 0.39; 95% confidence interval, 0.17-0.88; p = 0.02). CONCLUSION For injured patients at risk of hemorrhage, prehospital pRBC+TXA is associated with reduced 30-day mortality. Use of pRBC transfusion alone was associated with a reduction in early mortality. Potential synergy appeared only in longer-term mortality and further work to investigate mechanisms of this therapeutic benefit is needed to optimize the prehospital resuscitation of trauma patients. LEVEL OF EVIDENCE Therapeutic/Care Management; Level III.
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Affiliation(s)
- Andrew-Paul Deeb
- From the Division of Trauma and General Surgery, Department of Surgery (A.-P.D., L.H., S.L., M.D.N., J.L.S., J.B.B.), Department of Emergency Medicine (F.X.G.), University of Pittsburgh, Pittsburgh, Pennsylvania; Department of Surgery (B.J.E.), University of Texas Health San Antonio, San Antonio, Texas; Department of Surgery (R.N.), University of Utah, Salt Lake City, Utah; and Department of Surgery (G.A.V., T.O.K., B.J.), University of Arizona, Tucson, Arizona
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16
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Juárez-Vela R, Andrés-Esteban EM, Santolalla-Arnedo I, Ruiz de Viñaspre-Hernández R, Benito-Puncel C, Serrano-Lázaro A, Marcos-Neira P, López-Fernández A, Tejada-Garrido CI, Sánchez-González JL, Quintana-Díaz M, García-Erce JA. Epidemiology and Associated Factors in Transfusion Management in Intensive Care Unit. J Clin Med 2022; 11:jcm11123532. [PMID: 35743602 PMCID: PMC9225042 DOI: 10.3390/jcm11123532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Revised: 06/16/2022] [Accepted: 06/16/2022] [Indexed: 11/16/2022] Open
Abstract
Severe traumatic injury is one of the main global health issues which annually causes more than 5.8 million worldwide deaths. Uncontrolled haemorrhage is the main avoidable cause of death among severely injured individuals. Management of trauma patients is the greatest challenge in trauma emergency care, and its proper diagnosis and early management of bleeding trauma patients, including blood transfusion, are critical for patient outcomes. Aim: We aimed to describe the epidemiology of transfusion practices in severe trauma patients admitted into Spanish Intensive Care Units. Material and Methods: We performed a multicenter cross-sectional study in 111 Intensive Care Units across Spain. Adult patients with moderate or severe trauma were eligible. Distribution of frequencies was used for qualitative variables and the mean, with its 95% CI, for quantitative variables. Transfusion programmes, the number of transfusions performed, and the blood component transfused were recorded. Demographic variables, mortality rate, hospital stay, SOFA-score and haemoglobin levels were also gathered. Results: We obtained results from 109 patients. The most transfused blood component was packet red blood cells with 93.8% of total transfusions versus 43.8% of platelets and 37.5% of fresh plasma. The main criteria for transfusion were analytical criteria (43.75%), and acute anaemia with shock (18.75%) and without haemodynamic impact (18.75%). Conclusion: Clinical practice shows a ratio of red blood cells, platelets, and Fresh Frozen Plasma (FFP) of 2:1:1. It is necessary to implement Massive Transfusion Protocols as they appear to improve outcomes. Our study suggests that transfusion of RBC, platelets and FFP in a 2:1:1 ratio could be beneficial for trauma patients.
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Affiliation(s)
- Raúl Juárez-Vela
- Doctoral Programme in Medicine and Surgery, Faculty of Medicine, Autonomous University of Madrid, 28049 Madrid, Spain;
- GRUPAC, Department of Nursing, University of La Rioja, 26004 Logroño, Spain; (I.S.-A.); (R.R.d.V.-H.)
- Research Institute IdiPaz, 28029 Madrid, Spain;
| | - Eva María Andrés-Esteban
- Research Institute IdiPaz, 28029 Madrid, Spain;
- Department of Business Economics and Applied Economy, Faculty of Legal and Economic Sciences, Rey Juan Carlos University, 28933 Madrid, Spain
| | - Ivan Santolalla-Arnedo
- GRUPAC, Department of Nursing, University of La Rioja, 26004 Logroño, Spain; (I.S.-A.); (R.R.d.V.-H.)
| | | | | | | | - Pilar Marcos-Neira
- Intensive Care Unit, Hospital Germans Trias i Pujol, 08916 Badalona, Spain;
| | | | - Clara Isabel Tejada-Garrido
- GRUPAC, Department of Nursing, University of La Rioja, 26004 Logroño, Spain; (I.S.-A.); (R.R.d.V.-H.)
- Correspondence: (C.I.T.-G.); (M.Q.-D.)
| | | | - Manuel Quintana-Díaz
- Research Institute IdiPaz, 28029 Madrid, Spain;
- Intensive Care Unit, University Hospital of La Paz, 28046 Madrid, Spain;
- Correspondence: (C.I.T.-G.); (M.Q.-D.)
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17
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Ammann AM, Wallen TE, Delman AM, Turner KM, Salvator A, Pritts TA, Makley AT, Goodman MD. Low Volume Blood Product Transfusion Patterns And Ratios After Injury. Am J Surg 2022; 224:1319-1323. [DOI: 10.1016/j.amjsurg.2022.06.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Revised: 06/15/2022] [Accepted: 06/23/2022] [Indexed: 11/26/2022]
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18
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Blood Transfusion Reactions-A Comprehensive Review of the Literature including a Swiss Perspective. J Clin Med 2022; 11:jcm11102859. [PMID: 35628985 PMCID: PMC9144124 DOI: 10.3390/jcm11102859] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 05/12/2022] [Accepted: 05/17/2022] [Indexed: 01/28/2023] Open
Abstract
Blood transfusions have been the cornerstone of life support since the introduction of the ABO classification in the 20th century. The physiologic goal is to restore adequate tissue oxygenation when the demand exceeds the offer. Although it can be a life-saving therapy, blood transfusions can lead to serious adverse effects, and it is essential that physicians remain up to date with the current literature and are aware of the pathophysiology, initial management and risks of each type of transfusion reaction. We aim to provide a structured overview of the pathophysiology, clinical presentation, diagnostic approach and management of acute transfusion reactions based on the literature available in 2022. The numbers of blood transfusions, transfusion reactions and the reporting rate of transfusion reactions differ between countries in Europe. The most frequent transfusion reactions in 2020 were alloimmunizations, febrile non-hemolytic transfusion reactions and allergic transfusion reactions. Transfusion-related acute lung injury, transfusion-associated circulatory overload and septic transfusion reactions were less frequent. Furthermore, the COVID-19 pandemic has challenged the healthcare system with decreasing blood donations and blood supplies, as well as rising concerns within the medical community but also in patients about blood safety and transfusion reactions in COVID-19 patients. The best way to prevent transfusion reactions is to avoid unnecessary blood transfusions and maintain a transfusion-restrictive strategy. Any symptom occurring within 24 h of a blood transfusion should be considered a transfusion reaction and referred to the hemovigilance reporting system. The initial management of blood transfusion reactions requires early identification, immediate interruption of the transfusion, early consultation of the hematologic and ICU departments and fluid resuscitation.
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19
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Kalkwarf KJ, Cardenas JC, Wade CE, Cotton BA. Green Plasma has a Superior Hemostatic Profile Compared With Standard Color Plasma. Am Surg 2022; 88:1970-1975. [PMID: 35476552 DOI: 10.1177/00031348221096571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Limitations in available donors have dramatically reduced plasma availability over the past several decades, concurrent with increasing demand for some types of plasma. Plasma from female donors who are pregnant or taking oral contraceptives often has a green appearance, which frequently results in these units being discarded. This pilot study aimed to evaluate the hemostatic potential of green compared to standard-color plasma. MATERIALS AND METHODS Plasma from twelve blood group-matched female and twelve male donors was obtained from the local blood center. Six of the female and all of the male units of plasma had a normal appearance (STANDARD), while six of the female units were grossly green (GREEN). The hemostatic potential was evaluated by thrombelastography (TEG), calibrated automated thrombogram (CAT), and coagulation factor level measurements. Univariate analysis was performed using Wilcoxon Rank-Sum. RESULTS GREEN plasma was more procoagulant for all TEG values (r-value, k-time, angle, mA) when compared to STANDARD plasma. Differences were also observed in coagulation factor levels, with GREEN plasma having higher than STANDARD (factors II; VII, IX; X, XI, Protein S, and plasminogen); conversely, GREEN plasma had a longer lag time in CAT. DISCUSSION This pilot study demonstrates that female donors with green plasma have a superior hemostatic profile than standard plasma. GREEN plasma should be further investigated for its safety profile and hemostatic potential, so if it is found to be a safe and functionally non-inferior product, it should be actively re-introduced for transfusion in bleeding patients.
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Affiliation(s)
- Kyle J Kalkwarf
- Division of Trauma and Acute Care Surgery, Department of Surgery, 12215University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Jessica C Cardenas
- Center for Translational Injury Research, 12340University of Texas Health Science Center, Houston, TX, USA
| | - Charles E Wade
- Center for Translational Injury Research, 12340University of Texas Health Science Center, Houston, TX, USA
| | - Bryan A Cotton
- Department of Surgery, 12340University of Texas Health Science Center, Houston, TX, USA
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20
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Rangrass G. Whole blood use in trauma resuscitation: targeting prehospital transfusion. Curr Opin Anaesthesiol 2022; 35:146-149. [PMID: 35102044 DOI: 10.1097/aco.0000000000001099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Trauma resuscitation management has evolved over the years with a more nuanced understanding of the injured patient's physiologic state of shock. The purpose of this review is to discuss the role of whole blood administration in the prehospital setting in the resuscitation of the trauma patient. RECENT FINDINGS In traumatically injured patients, whole blood administration initiated in the prehospital setting may improve early shock severity, coagulopathy, and survival when used over traditional resuscitation fluids such as crystalloid administration or component therapy. SUMMARY The timing of resuscitation and its components deserve special attention when improving outcomes for trauma patients requiring massive transfusion.
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Affiliation(s)
- Govind Rangrass
- Anesthesia and Critical Care, University of Chicago Pritzker School of Medicine, Chicago, Illinois, USA
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21
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Williams J, Gustafson M, Bai Y, Prater S, Wade CE, Guillamondegui OD, Khan M, Brenner M, Ferrada P, Roberts D, Horer T, Kauvar D, Kirkpatrick A, Ordonez C, Perreira B, Priouzram A, Duchesne J, Cotton BA. Limitations of Available Blood Products for Massive Transfusion During Mass Casualty Events at US Level 1 Trauma Centers. Shock 2021; 56:62-69. [PMID: 33470606 PMCID: PMC8601667 DOI: 10.1097/shk.0000000000001719] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2019] [Revised: 12/26/2019] [Accepted: 01/04/2021] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Exsanguination remains a leading cause of preventable death in traumatically injured patients. To better treat hemorrhagic shock, hospitals have adopted massive transfusion protocols (MTPs) which accelerate the delivery of blood products to patients. There has been an increase in mass casualty events (MCE) worldwide over the past two decades. These events can overwhelm a responding hospital's supply of blood products. Using a computerized model, this study investigated the ability of US trauma centers (TCs) to meet the blood product requirements of MCEs. METHODS Cross-sectional survey data of on-hand blood products were collected from 16 US level-1 TCs. A discrete event simulation model of a TC was developed based on historic data of blood product consumption during MCEs. Each hospital's blood bank was evaluated across increasingly more demanding MCEs using modern MTPs to guide resuscitation efforts in massive transfusion (MT) patients. RESULTS A total of 9,000 simulations were performed on each TC's data. Under the least demanding MCE scenario, the median size MCE in which TCs failed to adequately meet blood product demand was 50 patients (IQR 20-90), considering platelets. Ten TCs exhaust their supply of platelets prior to red blood cells (RBCs) or plasma. Disregarding platelets, five TCs exhausted their supply of O- packed RBCs, six exhausted their AB plasma supply, and five had a mixed exhaustion picture. CONCLUSION Assuming a TC's ability to treat patients is limited only by their supply of blood products, US level-1 TCs lack the on-hand blood products required to adequately treat patients following a MCE. Use of non-traditional blood products, which have a longer shelf life, may allow TCs to better meet the blood product requirement needs of patients following larger MCEs.
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Affiliation(s)
- James Williams
- The Center for Translational Injury Research, The McGovern Medical School at the University of Texas Health Science Center, Houston, Texas
- Department of Surgery, The McGovern Medical School at the University of Texas Health Science Center, Houston, Texas
| | - Michael Gustafson
- Duke University Pratt School of Engineering, The McGovern Medical School at the University of Texas Health Science Center, Houston, Texas
| | - Yu Bai
- Pathology and Laboratory Medicine, The McGovern Medical School at the University of Texas Health Science Center, Houston, Texas
- Department of Emergency Medicine, The McGovern Medical School at the University of Texas Health Science Center, Houston, Texas
| | - Samuel Prater
- Department of Emergency Medicine, The McGovern Medical School at the University of Texas Health Science Center, Houston, Texas
- Department of Surgery, The Red Duke Trauma Institute at Memorial Hermann Hospital, Texas Medical Center, Houston, Texas
| | - Charles E. Wade
- The Center for Translational Injury Research, The McGovern Medical School at the University of Texas Health Science Center, Houston, Texas
- Department of Surgery, The McGovern Medical School at the University of Texas Health Science Center, Houston, Texas
| | | | - Mansoor Khan
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, UK
| | - Megan Brenner
- Department of Surgery, University of California Riverside, Riverside, California
| | - Paula Ferrada
- VCU Surgery Trauma, Critical Care and Emergency Surgery, Richmond, Virginia
| | - Derek Roberts
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Ottawa, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Tal Horer
- Department of Cardiothoracic and Vascular Surgery, Faculty of Life Science Örebro University Hospital and University, Örebro, Sweden
| | - David Kauvar
- Vascular Surgery Service, San Antonio Military Medical Center, San Antonio, Texas
| | - Andrew Kirkpatrick
- Regional Trauma Services Foothills Medical Centre, Calgary, Alberta, Canada
- Departments of Surgery, Critical Care Medicine, University of Calgary, Calgary, Alberta, Canada
- Canadian Forces Health Services, Calgary, Alberta, Canada
| | - Carlos Ordonez
- Fundación Valle del Lili, Division of Trauma and Acute Care Surgery, Department of Surgery, Universidad del Valle, Cali, Valle del Cauca, Colombia
| | - Bruno Perreira
- Department of Surgery and Surgical Critical Care, University of Campinas, Campinas, Brazil
| | - Artai Priouzram
- Department of Cardiothoracic and Vascular Surgery, Linköping University Hospital, Linköping, Sweden
| | - Juan Duchesne
- Division Chief Acute Care Surgery, Department of Surgery Tulane, New Orleans, Louisiana
| | - Bryan A. Cotton
- The Center for Translational Injury Research, The McGovern Medical School at the University of Texas Health Science Center, Houston, Texas
- Department of Surgery, The McGovern Medical School at the University of Texas Health Science Center, Houston, Texas
- Department of Surgery, The Red Duke Trauma Institute at Memorial Hermann Hospital, Texas Medical Center, Houston, Texas
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22
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It is time for TEG in pediatric trauma: unveiling meaningful alterations in children who undergo massive transfusion. Pediatr Surg Int 2021; 37:1613-1620. [PMID: 34533617 PMCID: PMC8445780 DOI: 10.1007/s00383-021-04944-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/01/2021] [Indexed: 11/04/2022]
Abstract
BACKGROUND Hemorrhage is the leading cause of preventable death in pediatric trauma patients. In adults, goal-directed thrombelastography (TEG) has been shown to reduce mortality when used to guide massive transfusion (MT) resuscitation. There remains a paucity of data on the utility of TEG in directing resuscitation of pediatric trauma patients. We hypothesize that abnormalities on admission TEG will differ in pediatric trauma patients who undergo MT, compared to those who do not. METHODS Pediatric patients (≤ 18 years) who were highest level trauma activations at two trauma centers from 2015 to 2018 were analyzed. We included patients who had admission TEGs and excluded those who did not. Patients were stratified into two groups: those who received MT (> 40 cc/kg total blood product within 6 h of admission) and those who did not. We defined TEG abnormalities based on each institution's normative values and compared TEG abnormalities between the groups. RESULTS Of 117 children included, 39 had MT. MT patients had higher injury severity scores (30 vs. 23, p = 0.0004), lactates levels (7.0 vs. 3.5, p < 0.001), base deficit levels ( - 12.2 vs. - 5.8, p < 0.001), and INR values (1.8 vs. 1.3, p < 0.001). MT patients had significantly shortened alpha-angles (35.9% vs. 15.4%, p = 0.023), maximum amplitude (MA) values (43.6% vs. 10.3%, p < 0.001), and significantly lower platelet counts (165 vs. 281, p < 0.001) compared to those who did not receive MT. There was no difference in the trends in R-time, LY30 (lysis or shutdown), or fibrinogen concentration between the groups. Logistic regression identified a decreased MA as a significant predictor for MT [OR 3.68 (CI 1.29-10.52)] CONCLUSIONS: Pediatric trauma patients who undergo MT are more likely to have lower alpha-angles and MA values, as well as lower platelet counts. These findings support the use of TEG to identify hemorrhaging pediatric trauma patients, who may benefit from cryoprecipitate and/or platelet transfusions. TEG provides real-time information on coagulation status, which may expedite the delivery of specific blood products during trauma resuscitation. LEVEL OF EVIDENCE LEVEL III: Type of study: Retrospective comparative study.
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23
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Sayce AC, Neal MD, Leeper CM. Viscoelastic monitoring in trauma resuscitation. Transfusion 2021; 60 Suppl 6:S33-S51. [PMID: 33089933 DOI: 10.1111/trf.16074] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 06/13/2020] [Accepted: 06/14/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND Traumatic injury results in both physical and physiologic insult. Successful care of the trauma patient depends upon timely correction of both physical and biochemical injury. Trauma-induced coagulopathy is a derangement of hemostasis and thrombosis that develops rapidly and can be fatal if not corrected. Viscoelastic monitoring (VEM) assays have been developed to provide rapid, accurate, and relatively comprehensive depictions of an individual's coagulation profile. VEM are increasingly being integrated into trauma resuscitation guidelines to provide dynamic and individualized guidance to correct coagulopathy. STUDY DESIGN AND METHODS We performed a narrative review of the search terms viscoelastic, thromboelastography, thromboelastometry, TEG, ROTEM, trauma, injury, resuscitation, and coagulopathy using PubMed. Particular focus was directed to articles describing algorithms for management of traumatic coagulopathy based on VEM assay parameters. RESULTS Our search identified 16 papers with VEM-guided resuscitation strategies in adult patients based on TEG, 12 such protocols in adults based on ROTEM, 1 protocol for children based on TEG, and 2 protocols for children based on ROTEM. CONCLUSIONS This review presents evidence to support VEM use to detect traumatic coagulopathy, discusses the role of VEM in trauma resuscitation, provides a summary of proposed treatment algorithms, and discusses pending questions in the field.
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Affiliation(s)
- Andrew C Sayce
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Matthew D Neal
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Christine M Leeper
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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Tantry US, Hartmann J, Neal MD, Schöechl H, Bliden KP, Agarwal S, Mason D, Dias JD, Mahla E, Gurbel PA. The role of viscoelastic testing in assessing peri-interventional platelet function and coagulation. Platelets 2021; 33:520-530. [PMID: 34369848 DOI: 10.1080/09537104.2021.1961709] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
We carried out a literature search in MEDLINE (PubMed) and EMBASE literature databases to provide a concise review of the role of viscoelastic testing in assessing peri-interventional platelet function and coagulation. The search identified 130 articles that were relevant for the review, covering the basic science of VHA and VHA in clinical settings including cardiac surgery, cardiology, neurology, trauma, non-cardiac surgery, obstetrics, liver disease, and COVID-19. Evidence from these articles is used to describe the important role of VHAs and platelet function testing in various peri-interventional setups. VHAs can help us to comprehensively assess the contribution of platelets and coagulation dynamics to clotting at the site-of-care much faster than standard laboratory measures. In addition to standard coagulation tests, VHAs are beneficial in reducing allogeneic transfusion requirements and bleeding, in predicting ischemic events, and improving outcomes in several peri-interventional care settings. Further focused studies are needed to confirm their utility in the peri-interventional case.
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Affiliation(s)
- Udaya S Tantry
- Sinai Center for Thrombosis Research and Drug Development, Sinai Hospital of Baltimore, Baltimore, MD, USA
| | - Jan Hartmann
- Medical Affairs and Clinical Development, Haemonetics Corporation, Boston, MA, USA
| | - Matthew D Neal
- Department of General Surgery, The University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Herbert Schöechl
- Department of Anesthesiology and Intensive Care Medicine, AUVA Trauma Centre Salzburg, Academic Teaching Hospital of the Paracelsus Medical University, Salzburg, Austria.,AUVA Trauma Research Centre, Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, Vienna, Austria
| | - Kevin P Bliden
- Sinai Center for Thrombosis Research and Drug Development, Sinai Hospital of Baltimore, Baltimore, MD, USA
| | - Seema Agarwal
- Department of Anaesthesia, Manchester University Foundation Trust, Manchester, UK
| | - Dan Mason
- Medical Affairs and Clinical Development, Haemonetics Corporation, Boston, MA, USA
| | - Joao D Dias
- Medical Affairs and Clinical Development, Haemonetics Corporation, Boston, MA, USA
| | - Elisabeth Mahla
- Department of Anaesthesiology and Intensive Care Medicine, Medical University of Graz, Graz, Austria
| | - Paul A Gurbel
- Sinai Center for Thrombosis Research and Drug Development, Sinai Hospital of Baltimore, Baltimore, MD, USA
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Abstract
OBJECTIVES The purpose of our study was to describe children with life-threatening bleeding. DESIGN We conducted a prospective observational study of children with life-threatening bleeding events. SETTING Twenty-four childrens hospitals in the United States, Canada, and Italy participated. SUBJECTS Children 0-17 years old who received greater than 40 mL/kg total blood products over 6 hours or were transfused under massive transfusion protocol were included. INTERVENTIONS Children were compared according bleeding etiology: trauma, operative, or medical. MEASUREMENTS AND MAIN RESULTS Patient characteristics, therapies administered, and clinical outcomes were analyzed. Among 449 enrolled children, 55.0% were male, and the median age was 7.3 years. Bleeding etiology was 46.1% trauma, 34.1% operative, and 19.8% medical. Prior to the life-threatening bleeding event, most had age-adjusted hypotension (61.2%), and 25% were hypothermic. Children with medical bleeding had higher median Pediatric Risk of Mortality scores (18) compared with children with trauma (11) and operative bleeding (12). Median Glasgow Coma Scale scores were lower for children with trauma (3) compared with operative (14) or medical bleeding (10.5). Median time from bleeding onset to first transfusion was 8 minutes for RBCs, 34 minutes for plasma, and 42 minutes for platelets. Postevent acute respiratory distress syndrome (20.3%) and acute kidney injury (18.5%) were common. Twenty-eight-day mortality was 37.5% and higher among children with medical bleeding (65.2%) compared with trauma (36.1%) and operative (23.8%). There were 82 hemorrhage deaths; 65.8% occurred by 6 hours and 86.5% by 24 hours. CONCLUSIONS Patient characteristics and outcomes among children with life-threatening bleeding varied by cause of bleeding. Mortality was high, and death from hemorrhage in this population occurred rapidly.
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Effect of emergency department fibrinogen testing on survival of trauma patients receiving blood transfusions. Blood Coagul Fibrinolysis 2021; 31:372-376. [PMID: 32618590 DOI: 10.1097/mbc.0000000000000924] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
: Fibrinogen is the first clotting factor to reach critically low levels during blood loss and its depletion is associated with coagulopathy, increased blood loss, transfusion requirements and mortality after trauma. However, direct measurements of fibrinogen concentration or function are not included in many Emergency Department (ED) trauma laboratory testing protocols. We hypothesized that including a test of fibrinogen concentration in the ED would be associated with increased survival for trauma patients requiring blood transfusions.To test this hypothesis, we performed a single-centre retrospective study of the effect of a resulted fibrinogen concentration measurement performed in the ED on survival of trauma patients receiving blood transfusions within the first 4 h of their hospital arrival. Multivariate logistic regression was used test the effect of a fibrinogen test on hospital survival after adjusting for the influence of INR, injury severity, lowest recorded blood pressure and blood transfusion intensity defined as the number of red blood cell units transfused in the first 4 h or care.Of 11 404 trauma registry individuals from 2016 to 2017, 843 (7.4%) received any blood transfusions within the first 4 h of ED care, of whom 635 (75.3%) had a documented fibrinogen concentration ordered and resulted. Multivariate logistic regression for hospital survival demonstrated a significant interaction effect between the presence of a fibrinogen test and transfusion intensity (Whole Model P < 0.0001, Interaction P = 0.035). Repeat analysis after stratifying for those individuals receiving more than 4 units of red blood cell units within 4 h of care found that the presence of a fibrinogen test was independently associated with survival only for those receiving more than 4 units [FIB test odds ratio for survival = 3.5 (1.0, 10.8), P = 0.03].Fibrinogen testing in the ED may be a valuable addition to resuscitation of the trauma patient receiving significant blood transfusions.
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If not now, when? The value of the MTP in managing massive bleeding. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2020; 18:415-418. [PMID: 32955418 DOI: 10.2450/2020.0275-20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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How well does your massive transfusion protocol perform? A scoping review of quality indicators. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2020; 18:423-433. [PMID: 32955419 DOI: 10.2450/2020.0082-20] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 04/05/2020] [Accepted: 05/02/2020] [Indexed: 12/25/2022]
Abstract
BACKGROUND Management of patients with major haemorrhage often requires urgent administration of multiple blood products, commonly termed a massive transfusion (MT). Clinical practice in these scenarios is supported in part by evidence-based MT guidelines, which typically recommend use of an MT protocol (MTP). MTPs aim to provide practical and specific interpretation of MT guidelines for local institutional use, outlining tasks and pre-configuration of blood product packs to be transfused to provide efficient and evidence-based transfusion management. Institutions can support this aim by the measurement of MTP performance and patient outcomes through collection of quality indicators (QI). Many international guidelines now recommend the routine collection of a range of QIs relating to MT/MTP; however, there is significant variation in procedures and no benchmarks or minimal evidence to guide practice. MATERIALS AND METHODS We conducted a scoping review to document and evaluate reported QIs for MTP. We conducted a search of CENTRAL, MEDLINE and EMBASE for published studies from inception until May 14, 2020, that reported at least one MTP QI and use of an MTP or equivalent protocol. Included studies were evaluated using a QI classification system based on current MT QI guidelines and the Donabedian QI framework. RESULTS We identified 107 eligible studies. Trauma patients were the most commonly evaluated group, and total blood products transfused and in-hospital mortality were the most commonly reported QIs. Reflecting the lack of international consensus and benchmarks, we found significant variability in the reporting of QIs, which often did not reflect guideline recommendations. DISCUSSION Our review highlights the importance of establishing international consensus on prioritised QIs with quantifiable targets that are important to the process of MT.
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Puzio TJ, Kalkwarf K, Cotton BA. Predicting the need for massive transfusion in the prehospital setting. Expert Rev Hematol 2020; 13:983-989. [PMID: 32746651 DOI: 10.1080/17474086.2020.1803735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Massive transfusion (MT) prediction scores allowed for the early identification of patients with massive hemorrhage likely to require large volumes of blood products. Despite their utility, very few MT scoring systems have shown promise in the pre-hospital setting due to their complexity and resource limitations. AREAS COVERED Pub med database was utilized to identify supporting literature for this review which discusses the importance of blood-based resuscitation and highlights the utility of scoring systems to predict the need of massive transfusion. MTP scoring systems effective in the prehospital setting are specifically discussed. EXPERT OPINION Massive transfusions scores are useful in alerting hospitals to the severity of trauma patients and organizing resources necessary for appropriate patient care but should not completely replace clinical . The opportunity exists to extend their use to the pre-hospital setting to allow for even earlier notification and to triage patients to trauma centers best able to treat severely injured.
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Affiliation(s)
- Thaddeus J Puzio
- Department of Surgery and the Center for Translational Injury Research, University of Texas Health Science Center , Houston, TX, USA
| | - Kyle Kalkwarf
- Department of Surgery, University of Arkansas Medical Sciences , Little Rock, AR, USA
| | - Bryan A Cotton
- Department of Surgery and the Center for Translational Injury Research, University of Texas Health Science Center , Houston, TX, USA
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Meneses E, Boneva D, McKenney M, Elkbuli A. Massive transfusion protocol in adult trauma population. Am J Emerg Med 2020; 38:2661-2666. [PMID: 33071074 DOI: 10.1016/j.ajem.2020.07.041] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 07/07/2020] [Accepted: 07/15/2020] [Indexed: 10/23/2022] Open
Abstract
BACKGROUND Acute blood loss in trauma requires quick identification and action to restore circulating volume and save the patient. Massive transfusion protocols (MTPs) have become standard at Trauma Centers, in order to rapidly deliver blood products to bleeding patients. This literature review presents current standards of transfusion ratios, as well as insights into adjuncts during massive transfusions. METHODS PubMED was searched for articles from 2005 to 2020 on MTPs, the article were assessed for single vs. multi-institutional, mechanism of injury, type of MTP, timing in which blood products should be administered, timing of delivery of blood products to trauma bay, pre-hospital treatment and adjuncts, and outcomes. RESULTS Eleven studies addressed transfusion ratios. Seven studies looked at timing of blood products. Nine studies addressed MTP pre-hospital treatment and adjuncts. Prior to 2015, studies supported the benefits of a balanced transfusion ratio, which was then confirmed by the PROPPR randomized controlled trial. The shorter the time to blood product delivery the better the outcomes. New advances in technology have allowed us to measure different patterns of coagulation, allowing more individualized approaches to the bleeding patient. CONCLUSION Current massive transfusion protocols should utilize between 1:1:1 and 1:1:2 ratios of the 3 main products; plasma, platelets, and red blood cells. Massive transfusion protocols are effective in decreasing mortality. Better resuscitation efforts were seen when blood products were readily available in the trauma bay when the patient arrived and the faster the replacement of blood, the better the outcomes.
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Affiliation(s)
- Evander Meneses
- Department of Surgery, Division of Trauma and Surgical Critical Care, Kendall Regional Medical Center, Miami, FL, USA
| | - Dessy Boneva
- Department of Surgery, Division of Trauma and Surgical Critical Care, Kendall Regional Medical Center, Miami, FL, USA; Department of Surgery, University of South Florida, Tampa, FL, USA
| | - Mark McKenney
- Department of Surgery, Division of Trauma and Surgical Critical Care, Kendall Regional Medical Center, Miami, FL, USA; Department of Surgery, University of South Florida, Tampa, FL, USA
| | - Adel Elkbuli
- Department of Surgery, Division of Trauma and Surgical Critical Care, Kendall Regional Medical Center, Miami, FL, USA.
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Callcut RA, Simpson KN, Baraniuk S, Fox EE, Tilley BC, Holcomb JB. Cost-effectiveness evaluation of the PROPPR trial transfusion protocols. Transfusion 2020; 60:922-931. [PMID: 32358836 PMCID: PMC7567498 DOI: 10.1111/trf.15784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Revised: 01/03/2020] [Accepted: 01/03/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND There have been no prior investigations of the cost effectiveness of transfusion strategies for trauma resuscitation. The Pragmatic, Randomized, Optimal Platelet and Plasma Ratios (PROPPR) study was a Phase III multisite, randomized trial in 680 subjects comparing the efficacy of 1:1:1 transfusion ratios of plasma and platelets to red blood cells with the 1:1:2 ratio. We hypothesized that 1:1:1 transfusion results in an acceptable incremental cost-effectiveness ratio, when estimated using patients' age-specific life expectancy and cost of care during the 30-day PROPPR trial period. STUDY DESIGN AND METHODS International Classification of Diseases, Ninth Revision codes were prospectively collected, and subjects were matched 1:2 to subjects in the Healthcare Utilization Program State Inpatient Data to estimate cost weights. We used a decision tree analysis, combined with standard costs and estimated years of expected survival to determine the cost effectiveness of the two treatments. RESULTS The 1:1:1 group had higher overall costs for the blood products but were more likely to achieve hemostasis and decreased hemorrhagic death by 24 hours (p = 0.006). For every 100 patients treated in the 1:1:1 group, eight more achieved hemostasis than in the 1:1:2 group. At 30 days, the total hospital cost per 100 patients was $5.6 million in the 1:1:1 group compared with $5.0 million in the 1:1:2 group. For each 100 patients, the 1:1:1 group had 218.5 more years of life expectancy. This was at a cost of $2994 per year gained. CONCLUSION The 1:1:1 transfusion ratio in severely injured hemorrhaging trauma patients is a very cost-effective strategy for increasing hemostasis and decreasing trauma deaths.
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Affiliation(s)
- Rachael A. Callcut
- Division of General Surgery, Department of Surgery, School of Medicine, University of California San Francisco, San Francisco, California
| | - Kit N. Simpson
- Department of Healthcare Leadership & Management, Medical University of South Carolina, Charleston, South Carolina
| | - Sarah Baraniuk
- Division of Biostatistics, School of Public Health, University of Texas Health Science Center at Houston, Houston, Texas
| | - Erin E. Fox
- Center for Translational Injury Research and Department of Surgery, University of Texas Health Science Center at Houston, Houston, Texas
| | - Barbara C. Tilley
- Division of Biostatistics, School of Public Health, University of Texas Health Science Center at Houston, Houston, Texas
| | - John B. Holcomb
- Division of Acute Care Surgery, Department of Surgery, Center for Injury Science, University of Alabama at Birmingham, Birmingham, Alabama
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The Evaluation of Trauma Care: The Comparison of 2 High-Level Pediatric Emergency Departments in the United States and Turkey. Pediatr Emerg Care 2020; 35:611-617. [PMID: 28419017 DOI: 10.1097/pec.0000000000001110] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE The purpose of the study is to compare the outcomes of pediatric trauma patients with motor vehicle crashes (MVCs) and motor vehicle versus pedestrian crashes (MPCs) at a level 1 pediatric trauma center in the United States and a pediatric trauma center in Turkey. METHODS The medical records of all pediatric MVC and MPC subjects presenting to the emergency departments (EDs) of a level 3 hospital in Turkey (Izmir Tepecik Training and Research Hospital [ITTRH]) and a level 1 pediatric trauma center in the United States (Children's Medical Center Dallas [CMCD]) over a 1-year period were reviewed. Data that were collected include patient demographics, prehospital report (mechanism of injury, mode of transportation), injury severity score (ISS), abbreviated injury scale score, Glasgow Coma Scale score, ED length of stay, ED interventions, ED and hospital disposition, and mortality. Patients with moderate (ISS, 5-15) and severe (ISS, >15) trauma scores were included in the study. RESULTS One hundred six patient charts from the ITTRH and 125 patient charts from the CMCD with moderate and severe ISS due to MVCs and MPCs were reviewed. Most of the patients were pedestrians (86%) in the ITTRH group and passengers (60%) in the CMCD group. The percentage of patients transferred by ambulance (ground or air) to the CMCD and the ITTRH was 97.9% and 85%, respectively. Fifteen percent of ITTRH patients and 2.1% of CMCD patients arrived by private vehicle. Emergency department arrival ISS and Glasgow Coma Scale were similar between the 2 hospitals (P > 0.05). The overall mortality rate in the study population was 8.8% (11/125) at the CMCD and 4.7% (5/106) at the ITTRH. (P = 0.223). Blood product utilization was significantly higher in the CMCD group compared with the ITTRH group (P = 0.005). The use of hypertonic saline/mannitol/hyperventilation in patients with significant head trauma and increased intracranial pressure was higher in the ITTRH group (P = 0.000). CONCLUSIONS This is the first study that compared pediatric trauma care and outcome at a level 1 pediatric trauma center in the United States and a pediatric hospital in Turkey. Our findings highlight the opportunities to improve pediatric trauma care in Turkey. Specifically, there is a need for national trauma registries, enhanced trauma education, and standardized trauma patient care protocols. In addition, efforts should be directed toward improving prehospital care through better integration within the health care system and physician participation in educating prehospital providers. Data and organized trauma care will be instrumental in system-wide improvement and developing appropriate injury-prevention strategies.
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Taniguchi H, Doi T, Abe T, Takeuchi I. Trauma severity associated with stress index in emergency settings: an observational prediction-and-validation study. Acute Med Surg 2020; 7:e493. [PMID: 33391764 PMCID: PMC7774291 DOI: 10.1002/ams2.493] [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: 09/03/2019] [Revised: 01/23/2020] [Accepted: 02/05/2020] [Indexed: 11/23/2022] Open
Abstract
Aim Early judgments for treating severe trauma patients are essential for life‐saving. Stress index (SI), obtained from a division of blood glucose level by serum potassium at arrival, might be useful for early prediction. However, the efficacy of SI was unknown. The purpose of this study was to identify and validate prediction models of severe trauma (ST) and the need for damage control operation (DCOP) and massive transfusion (MT) by using SI among trauma patients. Methods This study was a retrospective and prospective observational study. The prediction models were created by 1‐year retrospective data of 167 trauma patients. The prediction models were validated by 6 months of prospective data of 87 trauma patients. Results The prediction model for ST contained respiratory rate and SI as significant factors. The prediction model for DCOP contained SI. The prediction model for MT contained systolic blood pressure and SI. The correlation of probability of MT, ST, and DCOP was r = 0.70 (P < 0.001), r = 0.46 (P < 0.001), and r = 0.15 (P = 0.196), respectively. The predicted probability of MT, ST, and DCOP showed 0.93 (95% confidence interval [CI], 0.88–0.90) and 0.80 (95% CI, 0.74–0.86), and 0.79 (95% CI, 0.70–0.88). Conclusion We identified and validated our prediction models for ST and the need for DCOP and MT among trauma patients using SI as a main predictor. Our models indicated that fewer variables in an early phase of the treatment process can inform clinicians regarding how severe a patient is and which intervention is needed.
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Affiliation(s)
- Hayato Taniguchi
- Department of Emergency and Critical Care Medicine Yokosuka Kyousai Hospital Yokosuka Japan.,Department of Emergency Medicine Yokohama City University Graduate School of Medicine Yokohama Japan
| | - Tomoki Doi
- Department of Emergency and Critical Care Medicine Yokosuka Kyousai Hospital Yokosuka Japan.,Department of Emergency Medicine Yokohama City University Graduate School of Medicine Yokohama Japan
| | - Takeru Abe
- Department of Emergency Medicine Yokohama City University Graduate School of Medicine Yokohama Japan
| | - Ichiro Takeuchi
- Department of Emergency Medicine Yokohama City University Graduate School of Medicine Yokohama Japan
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Abstract
Health care professionals must understand the impact of blood product transfusions and transfusion therapy procedures to ensure high-quality patient care, positive outcomes, and wise use of resources in blood management programs. Understanding transfusions of blood and blood products is also important because of the number of treatments performed, which affects individual patients and health care system resources. This article reviews research findings to acquaint health care professionals with the most successful protocols for blood, blood product, and coagulation factor transfusions. Damage control resuscitation in bleeding trauma patients, protocols for patients without trauma who are undergoing surgical procedures that place them at risk for excessive bleeding, and protocols for patients with sepsis are addressed. Emerging research continues to help guide mass transfusion treatments (restrictive vs liberal, balanced, and goal-directed treatment). Although available study results provide some guidance, questions remain. Additional research by health care professionals is needed.
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Affiliation(s)
- Heather M Passerini
- Heather M. Passerini is Nurse Practitioner, Surgical and Trauma Intensive Care Unit, University of Virginia Medical Center, PO Box 801443, Charlottesville, VA 22908-1443
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Abstract
Evaluation of coagulation is vital in the care of the orthopaedic patients, particularly in the subspecialties of trauma, spine, arthroplasty, and revision surgery resulting from blood loss and coagulopathies. Although conventional tests (prothrombin time/international normalized ratio, activated partial thromboplastin time, platelet count, and fibrinogen) are most commonly used, others like thromboelastography (TEG) are also available to the orthopaedic surgeons. TEG is a blood test developed in the 1950s, which provides a snapshot of a patient's coagulation profile by evaluating clot formation and lysis. Recently, TEG has been used to assess traumatic coagulopathy. The coagulation parameters measured by the TEG are reaction time (R-time), time to reach a certain clot strength (K-value), speed of fibrin build up (α-angle), maximum clot amplitude, and percentage decrease of clot in 30 minutes (LY30). Using these values, traumatologists have developed a better, faster, and more accurate overview of a patient's resuscitation and more successfully direct blood product use. However, many orthopaedic surgeons-despite performing surgical procedures that risk notable blood loss and postoperative clotting complications-are unaware of the existence of the TEG blood test and the critical information it provides. Increasing awareness of the TEG among orthopaedic surgeons could have a notable effect on numerous aspects of musculoskeletal care.
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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.
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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
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Govil D, Pal D. Point-of-care Testing of Coagulation in Intensive Care Unit: Role of Thromboelastography. Indian J Crit Care Med 2019; 23:S202-S206. [PMID: 31656379 PMCID: PMC6785812 DOI: 10.5005/jp-journals-10071-23253] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
How to cite this article: Govil D, Pal D. Point-of-care Testing of Coagulation in Intensive Care Unit: Role of Thromboelastography. Indian J Crit Care Med 2019;23(Suppl 3):S202–S206.
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Affiliation(s)
- Deepak Govil
- Department of Critical Care Medicine, Medanta: The Medicity, Gurugram, Haryana, India
| | - Divya Pal
- Department of Critical Care Medicine, Medanta: The Medicity, Gurugram, Haryana, India
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Chin V, Cope S, Yeh CH, Thompson T, Nascimento B, Pavenski K, Callum J. Massive hemorrhage protocol survey: Marked variability and absent in one-third of hospitals in Ontario, Canada. Injury 2019; 50:46-53. [PMID: 30449459 DOI: 10.1016/j.injury.2018.11.026] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Revised: 11/05/2018] [Accepted: 11/09/2018] [Indexed: 02/02/2023]
Abstract
BACKGROUND Massive hemorrhage protocols (MHP) are critical to standardized delivery of timely, safe, and resource-effective coordinated care for patients with life-threatening bleeding. METHODS A standardized MHP survey was sent to all hospitals (n = 150) in Ontario with a transfusion service. This study aim was to determine the proportion of hospitals with an MHP and assess for variability. RESULTS The overall survey completion rate was 133 of 150 hospitals (89%) (remaining 17 providing negative affirmation that they did not have an MHP). An MHP was in place at 97 of 150 (65%) hospitals (60% of small (<5000 red cell units/year) vs. 91% of medium/large). A total of 10 different names of protocols were reported, with "Massive Transfusion Protocol" (68%) predominating. Activation criteria were present in 82 of 97 (85%); commonly activated based on volume of blood loss (70%). Blood work was drawn at the discretion of the physician (37%) or at predefined intervals (31%; majority every 60 min). Common routine laboratory tests performed were CBC (87%) and INR (84%). Fibrinogen testing was available at 88 (66%) of 133 reporting hospitals and part of the standard testing at 73 of 97 (75%) hospitals with an MHP. Median targets of hemostatic resuscitations, stated in the protocol at 49% of hospitals with an MHP, were: platelets >50 × 109/L, INR < 1.8, fibrinogen >1.5 g/L, and hemoglobin >70 g/L. Protocol required patient temperature monitoring in 65% and specified a reversal plan for patients on anticoagulants in 59%. At 36% of sites all patients are initially managed with O RhD negative blood. Overall, 61% of sites issue blood in predefined packs (vs. on demand). Hemostatic agents in protocols included: tranexamic acid (70%), prothombin complex concentrate (14%), fibrinogen concentrate (13%), and recombinant FVIIa (4%). Quality metrics were tracked in 32% of hospitals. CONCLUSIONS A third of hospitals lack formal MHPs, with the majority lacking in smaller hospitals. The survey results indicate that there is marked variability in all key aspects of the reported MHPs. This may be due to differences in hospital resources and personnel, lack of supporting evidence to dictate requirements, and differences in knowledge base of the individuals involved in protocol setting.
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Affiliation(s)
| | - Stephanie Cope
- Ontario Regional Blood Coordinating Network, Toronto, Canada
| | - Calvin Hsiung Yeh
- Division of Emergency Medicine, Department of Medicine, University of Toronto, Canada
| | - Troy Thompson
- Ontario Regional Blood Coordinating Network, Toronto, Canada
| | - Barto Nascimento
- Sunnybrook Health Sciences Centre, Toronto, Canada; Department of Surgery, Sunnybrook Health Sciences Centre, Canada
| | - Katerina Pavenski
- Laboratory Medicine and Pathology, University of Toronto, Canada; St. Michael's Hospital, Toronto, Canada
| | - Jeannie Callum
- Sunnybrook Health Sciences Centre, Toronto, Canada; Laboratory Medicine and Pathology, University of Toronto, Canada.
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Seheult JN, Anto VP, Farhat N, Stram MN, Spinella PC, Alarcon L, Sperry J, Triulzi DJ, Yazer MH. Application of a recursive partitioning decision tree algorithm for the prediction of massive transfusion in civilian trauma: the MTPitt prediction tool. Transfusion 2018; 59:953-964. [PMID: 30548461 DOI: 10.1111/trf.15078] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Revised: 10/29/2018] [Accepted: 10/30/2018] [Indexed: 11/29/2022]
Abstract
BACKGROUND A supervised machine learning algorithm was used to generate decision trees for the prediction of massive transfusion at a Level 1 trauma center. METHODS Trauma patients who received at least one unit of RBCs and/or low-titer group O whole blood between January 1, 2015, and December 31, 2017, were included. Massive transfusion was defined as the transfusion of 10 or more units of RBCs and/or low-titer group O whole blood in the first 24 hours of admission. A recursive partitioning algorithm was used to generate two decision trees for prediction of massive transfusion using a training data set (n = 550): the first, MTPitt, was based on demographic and clinical parameters, and the second, MTPitt+Labs, also included laboratory data. Decision tree performance was compared with the Assessment of Blood Consumption score and the Trauma Associated Severe Hemorrhage score. RESULTS The incidence of massive transfusion in the validation data set (n = 199) was 7.5%. The MTPitt decision tree had a higher balanced accuracy (81.4%) and sensitivity (86.7%) compared to an Assessment of Blood Consumption Score of 2 or higher (77.9% and 66.7%, respectively) and a Trauma Associated Severe Hemorrhage score of 9 or higher (75.0% and 73.3%, respectively), although the 95% confidence intervals overlapped. Addition of laboratory data to the MTPitt decision tree (MTPitt+Labs) resulted in a higher specificity and balanced accuracy compared to MTPitt without an increase in sensitivity. CONCLUSIONS The MTPitt decisions trees are highly sensitive tools for identifying patients who received a massive transfusion and do not require computational resources to be implemented in the trauma setting.
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Affiliation(s)
- Jansen N Seheult
- Department of Pathology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Vincent P Anto
- School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Nadim Farhat
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Michelle N Stram
- Department of Pathology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Philip C Spinella
- Department of Pediatrics, Division of Critical Care Medicine, Washington University in St. Louis, St Louis, Missouri
| | - Louis Alarcon
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania.,Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Jason Sperry
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania.,Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Darrell J Triulzi
- Department of Pathology, University of Pittsburgh, Pittsburgh, Pennsylvania.,The Institute for Transfusion Medicine, Pittsburgh, Pennsylvania
| | - Mark H Yazer
- Department of Pathology, University of Pittsburgh, Pittsburgh, Pennsylvania.,The Institute for Transfusion Medicine, Pittsburgh, Pennsylvania
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Caspers M, Maegele M, Fröhlich M. Current strategies for hemostatic control in acute trauma hemorrhage and trauma-induced coagulopathy. Expert Rev Hematol 2018; 11:987-995. [PMID: 30433835 DOI: 10.1080/17474086.2018.1548929] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Introduction: Despite advances in the treatment of severely injured patients that have resulted in overall improved outcomes, uncontrolled hemorrhage still represents the most common cause of preventable death following major injury. While addressing both endo- and exogenous factors that lead to an acute trauma-induced coagulopathy, massive transfusion plays a key role in managing bleeding trauma patients. However, the best practice for hemostatic control including massive transfusion in these patients is still under debate. Areas covered: This review summarizes the current knowledge and clinical practice for hemostatic control including massive transfusion for bleeding trauma patients. The recent literature was reviewed and extended by current guidelines and their underlying evidence was incorporated. Expert commentary: Treatment strategies for bleeding trauma patients are still an area of emerging scientific and clinical interest as advances are likely to translate into improved outcomes including survival. To date, damage control resuscitation principles with ratio-based transfusion of packed red blood cells, plasma and platelets still dominate as "gold standard" of care but goal-directed strategies guided either by conventional coagulation tests or viscoelastic assays may demonstrate a better characterization of the underlying coagulopathy thereby allowing individualized and targeted therapies.
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Affiliation(s)
- Michael Caspers
- a The Institute for Research in Operative Medicine, Faculty of Health, Department of Medicine , Witten/Herdecke University , Cologne , Germany.,b Department of Traumatology and Orthopaedic Surgery, Cologne-Merheim Medical Centre (CMMC) , Witten/Herdecke University , Cologne , Germany
| | - Marc Maegele
- a The Institute for Research in Operative Medicine, Faculty of Health, Department of Medicine , Witten/Herdecke University , Cologne , Germany.,b Department of Traumatology and Orthopaedic Surgery, Cologne-Merheim Medical Centre (CMMC) , Witten/Herdecke University , Cologne , Germany
| | - Matthias Fröhlich
- b Department of Traumatology and Orthopaedic Surgery, Cologne-Merheim Medical Centre (CMMC) , Witten/Herdecke University , Cologne , Germany
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Shi W, Al-Sabti R, Burke PA, Gonzalez M, Mantilla-Rey N, Quillen K. Quality Management of massive transfusion protocol incorporating tranexamic acid adherence. Transfus Apher Sci 2018; 57:785-789. [PMID: 30455154 DOI: 10.1016/j.transci.2018.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Revised: 09/22/2018] [Accepted: 10/16/2018] [Indexed: 11/16/2022]
Abstract
Massive transfusion protocols (MTP) vary at different institutions. We implemented an algorithm in the transfusion service to support our Level I trauma center in 2007 and periodically monitor MTP utilization as part of ongoing quality management. At the last review in 2013, median plasma: RBC ratio was 1:1.8. We undertook a retrospective 3-year review of MTP activations stratifying by trauma versus non-trauma indications, and blood component utilization of the massive transfusion (MT) cases, adding a review of tranexamic acid (TXA) administration to the audit. The median transfused plasma: RBC ratio was 1:1.9 in trauma MT, and 1:1.6 in the non-trauma MT cases. Non-trauma MT patients at our institution were significantly older and more coagulopathic at MTP initiation compared to trauma MT patients, received fewer RBC units (15.5 versus 20.2), and had higher mortality. TXA adherence increased over the 3-year period to 60% of all trauma MTP activations in 2017.
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Affiliation(s)
- Weiwei Shi
- Department of Pathology and Laboratory Medicine, Boston University Medical Center, Boston, MA, 02118, United States.
| | - Ram Al-Sabti
- Department of Pathology and Laboratory Medicine, Boston University Medical Center, Boston, MA, 02118, United States
| | - Peter A Burke
- Department of Surgery, Boston University Medical Center, United States
| | - Mauricio Gonzalez
- Department of Anesthesiology, Boston University Medical Center, United States
| | - Nelson Mantilla-Rey
- Department of Pathology and Laboratory Medicine, Boston University Medical Center, Boston, MA, 02118, United States
| | - Karen Quillen
- Department of Pathology and Laboratory Medicine, Boston University Medical Center, Boston, MA, 02118, United States
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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.
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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
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Pohlman TH, Fecher AM, Arreola-Garcia C. Optimizing transfusion strategies in damage control resuscitation: current insights. J Blood Med 2018; 9:117-133. [PMID: 30154676 PMCID: PMC6108342 DOI: 10.2147/jbm.s165394] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
From clinical and laboratory studies of specific coagulation defects induced by injury, damage control resuscitation (DCR) emerged as the most effective management strategy for hemorrhagic shock. DCR of the trauma patient who has sustained massive blood loss consists of 1) hemorrhage control; 2) permissive hypotension; and 3) the prevention and correction of trauma-induced coagulopathies, referred to collectively here as acute coagulopathy of trauma (ACOT). Trauma patients with ACOT have higher transfusion requirements, may eventually require massive transfusion, and are at higher risk of exsanguinating. Distinct impairments in the hemostatic system associated with trauma include acquired quantitative and qualitative platelet defects, hypocoagulable and hypercoagulable states, and dysregulation of the fibrinolytic system giving rise to hyperfibrinolysis or a phenomenon referred to as fibrinolytic shutdown. Furthermore, ACOT is a component of a systemic host defense dysregulation syndrome that bears several phenotypic features comparable with other acute systemic physiological insults such as sepsis, myocardial infarction, and postcardiac arrest syndrome. Progress in the science of resuscitation has been continuing at an accelerated rate, and clinicians who manage catastrophic blood loss may be incompletely informed of important advances that pertain to DCR. Therefore, we review recent findings that further characterize the pathophysiology of ACOT and describe the application of this new information to optimization of resuscitation strategies for the patient in hemorrhagic shock.
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Affiliation(s)
- Timothy H Pohlman
- Department of Surgery, Lutheran Hospital of Indiana, Fort Wayne, IN, USA,
| | - Alison M Fecher
- Department of Surgery, Lutheran Hospital of Indiana, Fort Wayne, IN, USA
| | - Cecivon Arreola-Garcia
- Department of Surgery, Section of Acute Care Surgery, Indiana University Health, Indianapolis, IN, USA
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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.
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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
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Rapid TEG efficiently guides hemostatic resuscitation in trauma patients. Surgery 2018; 164:489-493. [PMID: 29903508 DOI: 10.1016/j.surg.2018.04.029] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Revised: 03/31/2018] [Accepted: 04/25/2018] [Indexed: 12/20/2022]
Abstract
BACKGROUND Several thrombelastography functional assays have been developed to guide transfusion in injured patients, but how this acceleration of thrombelastography affects its ability to predict massive transfusion is unknown. The objective of this study is to compare citrated native, citrated kaolin, and citrated rapid thromboelastographies for their prediction of massive transfusion after trauma. We hypothesized that citrated native thrombelastography best predicts massive transfusion. METHODS Data were collected as part of a prospective study of trauma activation patients. All patients received citrated native, citrated kaolin, or citrated rapid thromboelastographies. Logistic regression was used to assess the predictive performance of different thrombelastography assays for massive transfusion. RESULTS Measurements for all three TEG activating systems was available for 343 patients; 57 (16.6%) required a massive transfusion. Compared to citrated rapid thromboelastographies, citrated kaolin thromboelastographies performed better for activated clotting time/rapid and citrated native thromboelastographies for maximum amplitude and angle. Yet, the 95% confidence intervals overlapped considerably, suggesting the citrated rapid thromboelastographies produced comparable results to the other assays for activated clotting time/reaction time, maximum amplitude, and angle. CONCLUSION There was substantial overlap in the performance of the different thrombelastography assays, suggesting citrated rapid thrombelastography is a quick and effective method to guide hemostatic resuscitation in trauma patients and does not perform inferiorly to the citrated native or citrated kaolin thrombelastography despite the addition of activation factors.
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Abstract
Exsanguination requires massive blood product replacement and termination of the bleeding source to prevent hemorrhagic shock and death. Massive transfusion protocols (MTPs) are algorithms that allow the health care team to quickly stabilize the bleeding patient and guide blood product administration. However, no national MTP guidelines or a standardized evaluation tool exist for collecting and reporting MTP-related data. The purpose of this article is to describe an original MTP evaluation tool, how it was used, barriers encountered, and a framework for reporting the MTP evaluation data. The evidence-based Broxton MTP Evaluation Tool was developed to evaluate the use of a newly implemented MTP via a retrospective review of electronic medical records (EMRs). Although the instrument itself worked well, barriers were encountered while reviewing the EMRs for the MTP evaluation. These barriers included no institutional entity was charged with tracking MTP activations, no searchable database was established to collect data concerning the MTP-activated patients, and no standard location in the EMR was designated for documenting the MTP activation. When devising protocols such as an MTP, a priori strategies should be developed for its implementation, documentation, and evaluation. Research is needed to determine best practices for evaluating an MTP to ensure positive patient outcomes with this protocol.
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Fu CY, Huang RY, Wang SY, Liao CH, Huang JF, Hsu YP, Lin CY, Kang SC. Concomitant external and internal hemorrhage: Challenges to managing patients with open pelvic fracture. Am J Emerg Med 2018; 36:1937-1942. [PMID: 29486990 DOI: 10.1016/j.ajem.2018.02.014] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2017] [Revised: 02/01/2018] [Accepted: 02/16/2018] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION Managing patients with open pelvic fractures continues to be challenging and requires a multidisciplinary approach. In this study, we examined the characteristics of patients with open pelvic fractures and strategies for managing such patients. MATERIALS AND METHODS The records of patients with open pelvic fractures from January 2010 to August 2016 were retrospectively reviewed. Emergency surgery was performed to control hemorrhaging in patients with an active external hemorrhage. Transcatheter arterial embolization (TAE) was used for definitive hemostasis. The relation between cause of death and timing of death was examined. We also compared the characteristics of surviving and non-surviving patients. Furthermore, patients who received both surgery and post-operative TAE were analyzed in detail. RESULTS In total, 42 patients with open pelvic fractures were enrolled in the study. The overall mortality rate among patients with open pelvic fractures was 26.2%. Patients whose deaths were related to hemorrhaging and associated injuries died significantly earlier than patients whose deaths were related to sepsis and multiple organ failure (1.3days vs. 12.3days, p<0.001). Sixteen patients (38.1%) received TAE for hemostasis, and their systolic blood pressure (SBP) improved significantly following TAE (from 88.4mmHg to 111.6mmHg, p<0.05). In the patients who received both surgery and post-operative TAE (n=8), the SBP increased significantly after surgery (from 58.8mmHg to 81.1mmHg, p<0.05). Similarly, the patients' SBP after TAE was significantly higher than their post-operative SBP (110.5mmHg vs. 81.1mmHg, p<0.05). CONCLUSION Active external hemorrhaging was initially controlled when managing patients with open pelvic fractures; however, most patients also required TAE for definitive hemorrhage control. Early TAE should be considered due to the high probability of concomitant internal and external hemorrhage. Close observation and further infection control are important following the hemostatic procedure.
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Affiliation(s)
- Chih-Yuan Fu
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taiwan
| | - Ruo-Yi Huang
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taiwan
| | - Shang-Yu Wang
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taiwan.
| | - Chien-Hung Liao
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taiwan
| | - Jen-Fu Huang
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taiwan.
| | - Yu-Pao Hsu
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taiwan.
| | - Chia-Yun Lin
- Department of Physical Medicine and Rehabilitation, Taipei Medical University Hospital, Taiwan
| | - Shih-Ching Kang
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taiwan.
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Aladegbami B, Choi PM, Keller MS, Vogel AM. A Pilot Study of Viscoelastic Monitoring in Pediatric Trauma: Outcomes and Lessons Learned. J Emerg Trauma Shock 2018; 11:98-103. [PMID: 29937638 PMCID: PMC5994857 DOI: 10.4103/jets.jets_150_16] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Background: Examine the characteristics and outcomes of pediatric trauma patients at risk for coagulopathy following implementation of viscoelastic monitoring. Materials and Methods: Injured children, aged <18 years, from September 7, 2014, to December 21, 2015, at risk for trauma-induced coagulopathy were identified from a single, level-1 American College of Surgeons verified pediatric trauma center. Patients were grouped by coagulation assessment: no assessment (NA), conventional coagulation testing alone (CCT), and conventional coagulation testing with rapid thromboelastography (rTEG). Coagulation assessment was provider preference with all monitoring options continuously available. Groups were compared and outcomes were evaluated including blood product utilization, Intensive Care Unit (ICU) utilization, duration of mechanical ventilation, and mortality. Results: A total of 155 patients were identified (NA = 78, CCT = 54, and rTEG = 23). There was no difference in age, gender, race, or mechanism. In practice, rTEG patients were more severely injured, more anemic, and received more blood products and crystalloid (P < 0.001). rTEG patients also had increased mortality with fewer ventilator and ICU-free days. Multivariate logistic regression and covariance analysis indicated that while rTEG use was not associated with mortality, it was associated with increased use of blood products, duration of mechanical ventilation, and ICU length of stay. Conclusions: Viscoelastic monitoring was infrequently performed, but utilized in more severely injured patients. Well-designed prospective studies in patients at high risk of coagulopathy are needed to evaluate goal-directed hemostatic resuscitation strategies in children.
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Affiliation(s)
- Bola Aladegbami
- Department of Surgery, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Pamela M Choi
- Department of Surgery, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Martin S Keller
- Department of Surgery, Division of Pediatric Surgery, St. Louis Children's Hospital, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Adam M Vogel
- Department of Surgery, Division of Pediatric Surgery, Baylor College of Medicine, Texas Childresn's Hospital, Houston, Texas 77030, USA
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Abstract
Hemorrhage is the leading cause of preventable deaths in trauma patients. After presenting a brief history of hemorrhagic shock resuscitation, this article discusses damage control resuscitation and its adjuncts. Massively bleeding patients in hypovolemic shock should be treated with damage control resuscitation principles including limited crystalloid, whole blood or balance blood component transfusion to permissive hypotension, preventing hypothermia, and stopping bleeding as quickly as possible.
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