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Baucom MR, Price AD, Whitrock JN, Hanseman D, Smith MP, Pritts TA, Goodman MD. Need for Blood Transfusion Volume Is Associated With Increased Mortality in Severe Traumatic Brain Injury. J Surg Res 2024; 301:163-171. [PMID: 38936245 DOI: 10.1016/j.jss.2024.04.087] [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: 11/20/2023] [Revised: 04/04/2024] [Accepted: 04/21/2024] [Indexed: 06/29/2024]
Abstract
INTRODUCTION Many patients suffering from isolated severe traumatic brain injury (sTBI) receive blood transfusion on hospital arrival due to hypotension. We hypothesized that increasing blood transfusions in isolated sTBI patients would be associated with an increase in mortality. METHODS We performed a trauma quality improvement program (TQIP) (2017-2019) and single-center (2013-2021) database review filtering for patients with isolated sTBI (Abbreviated Injury Scale head ≥3 and all other areas ≤2). Age, initial Glasgow Coma Score (GCS), Injury Severity Score (ISS), initial systolic blood pressure (SBP), mechanism (blunt/penetrating), packed red blood cells (pRBCs) and fresh frozen plasma (FFP) transfusion volume (units) within the first 4 h, FFP/pRBC ratio (4h), and in-hospital mortality were obtained from the TQIP Public User Files. RESULTS In the TQIP database, 9257 patients had isolated sTBI and received pRBC transfusion within the first 4 h. The mortality rate within this group was 47.3%. The increase in mortality associated with the first unit of pRBCs was 20%, then increasing approximately 4% per unit transfused to a maximum mortality of 74% for 11 or more units. When adjusted for age, initial GCS, ISS, initial SBP, and mechanism, pRBC volume (1.09 [1.08-1.10], FFP volume (1.08 [1.07-1.09]), and FFP/pRBC ratio (1.18 [1.08-1.28]) were associated with in-hospital mortality. Our single-center study yielded 138 patients with isolated sTBI who received pRBC transfusion. These patients experienced a 60.1% in-hospital mortality rate. Logistic regression corrected for age, initial GCS, ISS, initial SBP, and mechanism demonstrated no significant association between pRBC transfusion volume (1.14 [0.81-1.61]), FFP transfusion volume (1.29 [0.91-1.82]), or FFP/pRBC ratio (6.42 [0.25-164.89]) and in-hospital mortality. CONCLUSIONS Patients suffering from isolated sTBI have a higher rate of mortality with increasing amount of pRBC or FFP transfusion within the first 4 h of arrival.
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Affiliation(s)
- Matthew R Baucom
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Adam D Price
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Jenna N Whitrock
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Dennis Hanseman
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Maia P Smith
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Timothy A Pritts
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio
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Nellis M, Karam O, Aldave G, Rocque BG, Bauer DF. Scenario Decision-Making About Plasma and Platelet Transfusion for Intracranial Monitor Placement: Cross-Sectional Survey of Pediatric Intensivists and Neurosurgeons. Pediatr Crit Care Med 2024; 25:e205-e213. [PMID: 37966339 PMCID: PMC10994730 DOI: 10.1097/pcc.0000000000003414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2023]
Abstract
OBJECTIVES To report pediatric intensivists' and pediatric neurosurgeons' responses to case-based scenarios about plasma and platelet transfusions before intracranial pressure (ICP) monitor placement in children with severe traumatic brain injury (TBI). DESIGN Cross-sectional, electronic survey to evaluate reported plasma and platelet transfusion decisions in eight scenarios of TBI in which ICP monitor placement was indicated. SETTING Survey administered through the Pediatric Acute Lung Injury and Sepsis Investigators and the American Association of Neurologic Surgeons. SUBJECTS Pediatric intensivists and pediatric neurosurgeons. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS A total of 184 participants responded (85 identified as pediatric intensivists and 54 as pediatric neurosurgeons). In all eight scenarios, the majority of respondents reported that they would base their decision-making about plasma transfusion on international normalized ratio (INR) alone (60-69%), or platelet transfusion on platelet count alone (83-86%). Pediatric intensivists, as opposed to pediatric neurosurgeons, more frequently reported that they would have used viscoelastic testing in their consideration of plasma transfusion (32% vs. 7%, p < 0.001), as well as to guide platelet transfusions (29 vs. 8%, p < 0.001), for the case-based scenarios. For all relevant case-based scenarios, pediatric neurosurgeons in comparison with pediatric reported that they would use a lower median (interquartile range [IQR]) INR threshold for plasma transfusion (1.5 [IQR 1.4-1.7] vs. 2.0 [IQR 1.5-2.0], p < 0.001). Overall, in all respondents, the reported median platelet count threshold for platelet transfusion in the case-based scenario was 100 (IQR 50-100) ×10 9 /L, with no difference between specialties. CONCLUSIONS Despite little evidence showing efficacy, when we tested specialists' decision-making, we found that they reported using INR and platelet count in pediatric case-based scenarios of TBI undergoing ICP monitor placement. We also found that pediatric intensivists and pediatric neurosurgeons had differences in decision-making about the scenarios.
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Affiliation(s)
- Marianne Nellis
- Weill Cornell Medicine, Division of Pediatric Critical Care, Department of Pediatrics, New York, NY
| | - Oliver Karam
- Pediatric Critical Care Medicine, Department of Pediatrics, Yale Medicine, New Haven, CT, USA
| | - Guillermo Aldave
- Baylor College of Medicine (Texas Children’s Hospital), Division of Pediatric Neurosurgery, Houston, TX
| | - Brandon G. Rocque
- University of Alabama at Birmingham, Division of Pediatric Neurosurgery, Department of Neurosurgery, Birmingham, AL
| | - David F. Bauer
- Baylor College of Medicine (Texas Children’s Hospital), Division of Pediatric Neurosurgery, Houston, TX
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Silberberg A, Castro Méndez J, Torres SF, Fraire R, Siaba Serrate A, Kreutzer C, López Daneri M, Iolster T. Experiences of parents of children with hypoplastic left heart syndrome during their treatment: a qualitative study. Cardiol Young 2023; 33:2553-2558. [PMID: 37009758 DOI: 10.1017/s1047951123000677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/04/2023]
Abstract
AIM To investigate the opinion and personal experience of parents of children born with Hypoplastic Left Heart Syndrome and what advice they would give to other parents who have to decide between treatment options. METHODS We conducted a qualitative, descriptive and retrospective study by means of a survey directed to parents of children born with Hypoplastic Left Heart Syndrome in a tertiary hospital in Buenos Aires (Argentina). Their answers and data regarding medical procedures were analysed. RESULTS Parents of thirteen out of sixteen patients with Hypoplastic Left Heart Syndrome were surveyed. Norwood surgery had been performed in all the patients, many had received other procedures, and five had died. In relation to the decision-making process, sixty-one percent of parents would recommend other parents to remain at peace after having done everything possible and 54% would suggest to not feel guilt despite the final result. None of the parents would recommend rejecting surgical treatment and choosing comfort care. CONCLUSION The majority of parents of children with Hypoplastic Left Heart Syndrome would recommend continuing with the therapeutic effort in order to feel at peace and reduce feelings of guilt.
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Affiliation(s)
| | | | - Silvio F Torres
- Hospital Universitario Austral, Pilar, Buenos Aires, Argentina
| | - Rafael Fraire
- Hospital Universitario Austral, Pilar, Buenos Aires, Argentina
| | | | | | | | - Thomas Iolster
- Hospital Universitario Austral, Pilar, Buenos Aires, Argentina
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MacArthur TA, Vogel AM, Glasgow AE, Moody S, Kotagal M, Williams RF, Kayton ML, Alberto EC, Burd RS, Schroeppel TJ, Baerg JE, Munoz A, Rothstein WB, Boomer LA, Campion EM, Robinson C, Nygaard RM, Richardson CJ, Garcia DI, Streck CJ, Gaffley M, Petty JK, Ryan M, Pandya S, Russell RT, Yorkgitis BK, Mull J, Pence J, Santore MT, Klinkner DB, Safford SD, Trevilian T, Jensen AR, Mooney DP, Ketha B, Dassinger MS, Goldenberg-Sandau A, Falcone RA, Polites SF. Crystalloid volume is associated with short-term morbidity in children with severe traumatic brain injury: An Eastern Association for the Surgery of Trauma multicenter trial post hoc analysis. J Trauma Acute Care Surg 2023; 95:78-86. [PMID: 37072882 DOI: 10.1097/ta.0000000000004013] [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: 04/20/2023]
Abstract
OBJECTIVE This study examined differences in clinical and resuscitation characteristics between injured children with and without severe traumatic brain injury (sTBI) and aimed to identify resuscitation characteristics associated with improved outcomes following sTBI. METHODS This is a post hoc analysis of a prospective observational study of injured children younger than 18 years (2018-2019) transported from the scene, with elevated shock index pediatric-adjusted on arrival and head Abbreviated Injury Scale score of ≥3. Timing and volume of resuscitation products were assessed using χ 2t test, Fisher's exact t test, Kruskal-Wallis, and multivariable logistic regression analyses. RESULTS There were 142 patients with sTBI and 547 with non-sTBI injuries. Severe traumatic brain injury patients had lower initial hemoglobin (11.3 vs. 12.4, p < 0.001), greater initial international normalized ratio (1.4 vs. 1.1, p < 0.001), greater Injury Severity Score (25 vs. 5, p < 0.001), greater rates of ventilator (59% vs. 11%, p < 0.001) and intensive care unit (ICU) requirement (79% vs. 27%, p < 0.001), and more inpatient complications (18% vs. 3.3%, p < 0.001). Severe traumatic brain injury patients received more prehospital crystalloid (25% vs. 15%, p = 0.008), ≥1 crystalloid boluses (52% vs. 24%, p < 0.001), and blood transfusion (44% vs. 12%, p < 0.001) than non-sTBI patients. Among sTBI patients, receipt of ≥1 crystalloid bolus (n = 75) was associated with greater ICU need (92% vs. 64%, p < 0.001), longer median ICU (6 vs. 4 days, p = 0.027) and hospital stay (9 vs. 4 days, p < 0.001), and more in-hospital complications (31% vs. 7.5%, p = 0.003) than those who received <1 bolus (n = 67). These findings persisted after adjustment for Injury Severity Score (odds ratio, 3.4-4.4; all p < 0.010). CONCLUSION Pediatric trauma patients with sTBI received more crystalloid than those without sTBI despite having a greater international normalized ratio at presentation and more frequently requiring blood products. Excessive crystalloid may be associated with worsened outcomes, including in-hospital mortality, seen among pediatric sTBI patients who received ≥1 crystalloid bolus. Further attention to a crystalloid sparing, early transfusion approach to resuscitation of children with sTBI is needed. LEVEL OF EVIDENCE Therapeutic/Care Management; Level IV.
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Affiliation(s)
- Taleen A MacArthur
- Department of Surgery, Division of Pediatric Surgery (T.A.M., A.E.G., D.B.K., S.F.P.), Mayo Clinic, Rochester, Minnesota; Department of Pediatric Surgery (A.M.V.), Texas Children's Hospital, Houston, Texas; Division of Pediatric General and Thoracic Surgery (S.M., M.K., R.A.F.), Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Department of Surgery (R.F.W.), Le Bonheur Children's Hospital, Memphis, Tennessee; Jersey Shore University Medical Center (M.L.K.), Hackensack-Meridian Health Network, Neptune, New Jersey; Department of Pediatric Surgery (E.C.A., R.S.B.), Children's National Hospital, Washington, DC; UCHealth Memorial Hospital (T.J.S.), Pediatric Surgery, Colorado Springs, Colorado; Division of Pediatric Surgery (J.E.B., A.M.), Loma Linda University, Loma Linda, California; Department of Surgery, Virginia Commonwealth University (W.B.R., L.A.B.), Children's Hospital of Richmond, Richmond, Virginia; Department of Surgery (E.M.C., C.R.), Denver Health Medical Center, Denver, Colorado; Department of Surgery (R.M.N., C.J.R.), Hennepin Healthcare, Minneapolis, Minnesota; Department of Surgery (D.I.G., C.J.S.), The Medical University of South Carolina, Charleston, South Carolina; Department of Surgery (M.G., J.K.P.), Wake Forest Baptist Medical Center, Brenner Children's Hospital, Winston-Salem, North Carolina; Department of Surgery (M.R., S.P.), Children's Health Dallas, Dallas, Texas; Department of Pediatric Surgery, (R.T.R.), Children's of Alabama, Birmingham, Alabama; Department of Surgery (B.K.Y., J.M.), College of Medicine, University of Florida Jacksonville, Jacksonville, Florida; Department of Surgery (J.P.), Dayton Children's Hospital, Dayton, Ohio; Department of Surgery (M.T.S.), Children's Healthcare of Atlanta, Atlanta, Georgia; Department of Surgery (S.D.S., T.T.), Carilion Children's Hospital, Carilion Roanoke Memorial Hospital, Roanoke, Virginia; Department of Surgery (A.R.J.), Benioff Children's Hospital, University of California San Francisco, San Francisco, California; Department of Pediatric Surgery (D.P.M.), Boston Children's Hospital, Boston, Massachusetts; Department of Surgery (B.K., M.S.D.), Arkansas Children's Hospital, Little Rock, Arkansas; and Department of Surgery (A.G.-S.), Cooper University Hospital, Camden, New Jersey
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Raikot SR, Polites SF. Current management of pediatric traumatic brain injury. Semin Pediatr Surg 2022; 31:151215. [PMID: 36399949 DOI: 10.1016/j.sempedsurg.2022.151215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Yang Z, Simovic MO, Liu B, Burgess MB, Cap AP, DalleLucca JJ, Li Y. Indices of complement activation and coagulation changes in trauma patients. Trauma Surg Acute Care Open 2022; 7:e000927. [PMID: 36117727 PMCID: PMC9476135 DOI: 10.1136/tsaco-2022-000927] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Accepted: 08/10/2022] [Indexed: 11/26/2022] Open
Abstract
Objectives Early complementopathy and coagulopathy are shown often after trauma. However, the prevalence of any interplay between complement cascade (ComC) and coagulation cascade (CoaC) after trauma remains unclear. This study intended to explore whether complement-coagulation crosstalk exists, which may provide a reliable guide to clinical implications in trauma patients. Methods This single-center cohort study of trauma patients enrolled 100 patients along with 20 healthy volunteers. Blood samples from patients were collected at admission, 45, 90, 135 minutes, and 18 hours after admission. Demographic characteristics were recorded, blood levels of ComC and CoaC factors, and inflammatory cytokines were measured by ELISA, clot-based assays, or luminex multiplex assay, and partial thromboplastin (PT) and partial thromboplastin time (PTT) were assessed using a Behring blood coagulation system. Results Compared with the healthy controls, plasma levels of complement factors (C5b-9 and Bb) and 11 tested inflammatory cytokines increased in moderately and severely injured patients as early as 45 minutes after admission and sustained higher levels up to 18 hours after admission. C5b-9 correlated positively to patients’ hospital stay. In parallel, the consumption of coagulation factors I, II, X, and XIII was shown throughout the first 18 hours after admission in moderately and severely injured patients, whereas PT, PTT, D-dimer, factor VII, and factor VIII values significantly increased from the admission to 135 minutes in moderately and severely injured patients. Along with an inverse correlation between plasma Bb, factors I and II, a positive correlation between C5b-9, Bb, D-dimer, PT, and PTT was evident. Conclusions This study demonstrates trauma-induced early activation of plasma cascades including ComC, CoaC, and fibrinolytic cascade, and their correlation between plasma cascades in severe trauma patients. Our study suggests that the simultaneous modulation of plasma cascades might benefit clinical outcomes for trauma patients. Level of evidence Prospective study, level III.
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Affiliation(s)
- Zhangsheng Yang
- Department of Organ Function Support, US Army Institute of Surgical Research, Fort Sam Houston, Texas, USA
| | - Milomir O Simovic
- Department of Organ Function Support, US Army Institute of Surgical Research, Fort Sam Houston, Texas, USA
| | - Bin Liu
- Department of Organ Function Support, US Army Institute of Surgical Research, Fort Sam Houston, Texas, USA
| | - Matthew B Burgess
- Department of Organ Function Support, US Army Institute of Surgical Research, Fort Sam Houston, Texas, USA
| | - Andrew P Cap
- Department of Organ Function Support, US Army Institute of Surgical Research, Fort Sam Houston, Texas, USA
| | | | - Yansong Li
- Department of Organ Function Support, US Army Institute of Surgical Research, Fort Sam Houston, Texas, USA.,Trauma Research, UTHSCSA, San Antonio, Texas, USA.,Geneva Foundation, Tacoma, Washington, USA
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Association of Thromboelastography with Progression of Hemorrhagic Injury in Children with Traumatic Brain Injury. Neurocrit Care 2022; 38:326-334. [PMID: 35896767 DOI: 10.1007/s12028-022-01562-8] [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: 04/18/2022] [Accepted: 06/16/2022] [Indexed: 10/16/2022]
Abstract
INTRODUCTION Progression of hemorrhagic injury (PHI) in children with traumatic brain injury portends poor outcomes. The association between thromboelastography (TEG), functional coagulation assays, and PHI is not well characterized in children. METHODS This was a retrospective cohort study of children presenting with PHI at a pediatric level I academic trauma center from 2015 to 2020. Inclusion criteria were as follows: age less than 18 years, intracranial hemorrhage on admission head computed tomography scan, and admission rapid TEG assay and conventional coagulation tests. PHI was defined by the following radiographic criteria: any expansion of or new intracranial hemorrhage on subsequent head computed tomography scan. Rapid TEG values included Activated Clotting Time (ACT), alpha angle, maximum amplitude, and lysis at 30 min. Wilcoxon rank-sum test was used to assess baseline differences between groups with PHI and without PHI, including laboratory assays. Univariate analysis was performed to examine the association between variables of interest and PHI. Patients were dichotomized on the basis of this cut point to generate a "low ACT" group and a "high ACT" group. These variables were included in a multivariable logistic regression model to determine independent association with traumatic brain injury progression. RESULTS In total, 219 patients met criteria for analysis. In this cohort, the median (interquartile range [IQR]) age = 6 (2-12) years, median (IQR) Injury Severity Score = 21 (11-27), 68% were boys, and 69% sustained blunt injury. The rate of PHI was 25% (54). Median (IQR) time to PHI was 1 (0-4) days. Children with PHI had a higher Injury Severity Score (p < 0.001), lower Glasgow Coma Scale (p < 0.001), greater incidence of shock (p = 0.04), and lower admission hemoglobin (p = 0.02) compared with those without PHI. Children with PHI had a higher International Normalized Ratio (INR) and longer TEG-ACT; other TEG values (alpha angle, maximum amplitude, and lysis at 30 min) were not associated with PHI. In the logistic regression model accounting for other covariates associated with PHI, elevated ACT remained an independent predictor of progression (odds ratio = 2.25, 95% confidence interval 1.09-4.66; p = 0.03; area under the receiver operating characteristic curve = 0.76). After adjusting for confounders, INR fell out of the model and was not an independent predictor of progression (odds ratio = 1.32, 95% confidence interval 0.60-2.93; p = 0.49). CONCLUSIONS Although INR was elevated in children with PHI and has been associated with poor clinical outcomes, only admission TEG-ACT was independently associated with PHI. Further study is warranted to determine whether TEG-ACT reflects an actionable therapeutic target.
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El-Swaify ST, Refaat MA, Ali SH, Abdelrazek AEM, Beshay PW, Kamel M, Bahaa B, Amir A, Basha AK. Controversies and evidence gaps in the early management of severe traumatic brain injury: back to the ABCs. Trauma Surg Acute Care Open 2022; 7:e000859. [PMID: 35071780 PMCID: PMC8734008 DOI: 10.1136/tsaco-2021-000859] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2021] [Accepted: 12/10/2021] [Indexed: 11/04/2022] Open
Abstract
Traumatic brain injury (TBI) accounts for around 30% of all trauma-related deaths. Over the past 40 years, TBI has remained a major cause of mortality after trauma. The primary injury caused by the injurious mechanical force leads to irreversible damage to brain tissue. The potentially preventable secondary injury can be accentuated by addressing systemic insults. Early recognition and prompt intervention are integral to achieve better outcomes. Consequently, surgeons still need to be aware of the basic yet integral emergency management strategies for severe TBI (sTBI). In this narrative review, we outlined some of the controversies in the early care of sTBI that have not been settled by the publication of the Brain Trauma Foundation’s 4th edition guidelines in 2017. The topics covered included the following: mode of prehospital transport, maintaining airway patency while securing the cervical spine, achieving adequate ventilation, and optimizing circulatory physiology. We discuss fluid resuscitation and blood product transfusion as components of improving circulatory mechanics and oxygen delivery to injured brain tissue. An outline of evidence-based antiplatelet and anticoagulant reversal strategies is discussed in the review. In addition, the current evidence as well as the evidence gaps for using tranexamic acid in sTBI are briefly reviewed. A brief note on the controversial emergency surgical interventions for sTBI is included. Clinicians should be aware of the latest evidence for sTBI. Periods between different editions of guidelines can have an abundance of new literature that can influence patient care. The recent advances included in this review should be considered both for formulating future guidelines for the management of sTBI and for designing future clinical studies in domains with clinical equipoise.
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Affiliation(s)
| | - Mazen A Refaat
- Department of surgery, Ain Shams University Hospital, Cairo, Egypt
| | - Sara H Ali
- Department of surgery, Ain Shams University Hospital, Cairo, Egypt
| | | | | | - Menna Kamel
- Department of surgery, Ain Shams University Hospital, Cairo, Egypt
| | - Bassem Bahaa
- Department of surgery, Ain Shams University Hospital, Cairo, Egypt
| | - Abdelrahman Amir
- Department of surgery, Ain Shams University Hospital, Cairo, Egypt
| | - Ahmed Kamel Basha
- Department of neurosurgery, Ain Shams University Faculty of Medicine, Cairo, Egypt
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Delaney M, Karam O, Lieberman L, Steffen K, Muszynski JA, Goel R, Bateman ST, Parker RI, Nellis ME, Remy KE. What Laboratory Tests and Physiologic Triggers Should Guide the Decision to Administer a Platelet or Plasma Transfusion in Critically Ill Children and What Product Attributes Are Optimal to Guide Specific Product Selection? From the Transfusion and Anemia EXpertise Initiative-Control/Avoidance of Bleeding. Pediatr Crit Care Med 2022; 23:e1-e13. [PMID: 34989701 PMCID: PMC8769352 DOI: 10.1097/pcc.0000000000002854] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
OBJECTIVES To present consensus statements and supporting literature for plasma and platelet product variables and related laboratory testing for transfusions in general critically ill children from the Transfusion and Anemia EXpertise Initiative-Control/Avoidance of Bleeding. DESIGN Systematic review and consensus conference of international, multidisciplinary experts in platelet and plasma transfusion management of critically ill children. SETTING Not applicable. PATIENTS Critically ill pediatric patients at risk of bleeding and receiving plasma and/or platelet transfusions. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS A panel of 10 experts developed evidence-based and, when evidence was insufficient, expert-based statements for laboratory testing and blood product attributes for platelet and plasma transfusions. These statements were reviewed and ratified by the 29 Transfusion and Anemia EXpertise Initiative - Control/Avoidance of Bleeding experts. A systematic review was conducted using MEDLINE, EMBASE, and Cochrane Library databases, from inception to December 2020. Consensus was obtained using the Research and Development/University of California, Los Angeles Appropriateness Method. Results were summarized using the Grading of Recommendations Assessment, Development, and Evaluation method. We developed five expert consensus statements and two recommendations in answer to two questions: what laboratory tests and physiologic triggers should guide the decision to administer a platelet or plasma transfusion in critically ill children; and what product attributes are optimal to guide specific product selection? CONCLUSIONS The Transfusion and Anemia EXpertise Initiative-Control/Avoidance of Bleeding program provides some guidance and expert consensus for the laboratory and blood product attributes used for decision-making for plasma and platelet transfusions in critically ill pediatric patients.
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Affiliation(s)
- Meghan Delaney
- Division of Pathology & Laboratory Medicine, Children’s National Hospital; Department of Pathology & Pediatrics, The George Washington University Health Sciences, Washington, DC
| | - Oliver Karam
- Division of Pediatric Critical Care Medicine, Children’s Hospital of Richmond at VCU, Richmond, VA
| | - Lani Lieberman
- Department of Clinical Pathology, University Health Network Hospitals. Department of Laboratory Medicine & Pathobiology; University of Toronto, Toronto, Canada
| | - Katherine Steffen
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, Stanford University, Palo Alto, CA
| | - Jennifer A. Muszynski
- Department of Pediatrics, Division of Critical Care Medicine, Nationwide Children’s Hospital and the Ohio State University College of Medicine, Columbus, OH
| | - Ruchika Goel
- Division of Transfusion Medicine, Department of Pathology, Johns Hopkins University, Baltimore, MD
| | - Scot T. Bateman
- Division of Pediatric Critical Care, Department of Pediatrics, University of Massachusetts Medical School, Worcester, MA
| | - Robert I. Parker
- Emeritus, Renaissance School of Medicine, State University of New York at Stony Brook, Stony Brook, NY
| | - Marianne E. Nellis
- Pediatric Critical Care Medicine, NY Presbyterian Hospital-Weill Cornell Medicine, New York, NY
| | - Kenneth E. Remy
- Department of Pediatrics, Division of Critical Care Medicine, Washington University in St. Louis School of Medicine, St. Louis, MO
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10
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Russell R, Bauer DF, Goobie SM, Haas T, Nellis ME, Nishijima DK, Vogel AM, Lacroix J. Plasma and Platelet Transfusion Strategies in Critically Ill Children Following Severe Trauma, Traumatic Brain Injury, and/or Intracranial Hemorrhage: From the Transfusion and Anemia EXpertise Initiative-Control/Avoidance of Bleeding. Pediatr Crit Care Med 2022; 23:e14-e24. [PMID: 34989702 PMCID: PMC8849603 DOI: 10.1097/pcc.0000000000002855] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECTIVES To present consensus statements and supporting literature for plasma and platelet transfusions in critically ill children with severe trauma, traumatic brain injury, and/or intracranial hemorrhage from the Transfusion and Anemia EXpertise Initiative-Control/Avoidance of Bleeding. DESIGN Systematic review and consensus conference of international, multidisciplinary experts in platelet and plasma transfusion management of critically ill children. SETTING Not applicable. PATIENTS Critically ill neonates and children with severe trauma, traumatic brain injury, and/or intracranial hemorrhage. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS A panel of eight experts developed expert-based statements for plasma and platelet transfusions in critically ill neonates and children with severe trauma, traumatic brain injury, and/or intracranial hemorrhage. These statements were reviewed and ratified by the 29 Transfusion and Anemia EXpertise Initiative-Control/Avoidance of Bleeding experts. A systematic review was conducted using MEDLINE, EMBASE, and Cochrane Library databases, from inception to December 2020. Consensus was obtained using the Research and Development/University of California, Los Angeles Appropriateness Method. Results were summarized using the Grading of Recommendations Assessment, Development, and Evaluation method. We developed one good practice statement and six expert consensus statements. CONCLUSIONS The lack of evidence precludes proposing recommendations on monitoring of the coagulation system and on plasma and platelets transfusion in critically ill pediatric patients with severe trauma, severe traumatic brain injury, or nontraumatic intracranial hemorrhage.
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Affiliation(s)
- Robert Russell
- Pediatric General Surgery, Children's of Alabama, Birmingham, AL
| | - David F Bauer
- Pediatric Neurosurgery, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Susan M Goobie
- Harvard Medical School, Boston, MA
- Department of Anesthesiology, Critical Care & Pain Medicine, Boston Children's Hospital, Boston, MA
| | - Thorsten Haas
- Department of Pediatric Anesthesia, Zurich University Children's Hospital, Zurich, Switzerland
| | - Marianne E Nellis
- Division of Pediatric Critical Care Medicine, Weill Cornell Medicine, New York, NY
| | - Daniel K Nishijima
- Department of Emergency Medicine, CTSC Clinical Research Center and Trial Innovation Network, University of California Davis School of Medicine, Sacramento, CA
| | - Adam M Vogel
- Surgery and Pediatrics, Texas Children's Hospital and Baylor College of Medicine, Houston, TX
| | - Jacques Lacroix
- Division of Pediatric Critical Care, Department of Pediatrics, Sainte-Justine Hospital, Université de Montréal, Montreal, QC, Canada
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11
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Pajer HB, Asher AM, Leung D, Barnett RR, Joyner BL, Quinsey CS. Adherence to Guidelines for Managing Severe Traumatic Brain Injury in Children. Am J Crit Care 2021; 30:402-406. [PMID: 34467382 DOI: 10.4037/ajcc2021111] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Pediatric traumatic brain injury (TBI) protocols vary widely among institutions, despite the existence of published guidelines. This study seeks to identify significant differences in management of pediatric TBI across several institutions. Severe pediatric TBI protocols were collected from major US pediatric hospitals through direct communication with trauma staff. Of 24 institutions identified and contacted, 10 did not respond and 5 did not have a pediatric TBI protocol. Pediatric TBI protocols were successfully collected from 9 institutions. These 9 protocols were separated into treatment tiers analogous to those in the 2019 Society of Critical Care Medicine and World Federation of Pediatric Intensive and Critical Care Societies guidelines, and the intervention variables were identified and compared across the 9 institutions. First-line therapies were similar between institutions, including seizure prophylaxis, maintenance of normoglycemia and normothermia, and avoidance of hypoxia, hyponatremia, and hypotension. However, significant variation across institutions was found regarding timing of cerebrospinal fluid drainage, hyperventilation, and neuromuscular blockade. When included in institutional protocols, most therapies are in line with the 2019 guidelines, except for diversion of cerebrospinal fluid, hyperventilation, maintenance of cerebral perfusion pressure, and use of neuromuscular blocking agents. Although these variations may represent differences in style or preference, the optimal timing of these specific treatment variations should be studied to determine the impact of each protocol on clinical outcomes.
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Affiliation(s)
- Hengameh B. Pajer
- Hengameh B. Pajer is a medical student, Campbell University School of Osteopathic Medicine, Buis Creek, North Carolina
| | - Anthony M. Asher
- Anthony M. Asher is a medical student, University of North Carolina School of Medicine, Chapel Hill
| | - Dennis Leung
- Dennis Leung is a fellow, Department of Pediatric Critical Care, University of North Carolina, Chapel Hill
| | - Randaline R. Barnett
- Randaline R. Barnett is a resident, Department of Neurosurgery, University of North Carolina, Chapel Hill
| | - Benny L. Joyner
- Benny L. Joyner Jr is a professor, Department of Pediatric Critical Care, University of North Carolina, Chapel Hill
| | - Carolyn S. Quinsey
- Carolyn S. Quinsey is an assistant professor and associate program director, Department of Neurosurgery, University of North Carolina, Chapel Hill
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12
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Edwards TH, Rizzo JA, Pusateri AE. Hemorrhagic shock and hemostatic resuscitation in canine trauma. Transfusion 2021; 61 Suppl 1:S264-S274. [PMID: 34269447 DOI: 10.1111/trf.16516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 02/18/2021] [Accepted: 02/19/2021] [Indexed: 11/27/2022]
Abstract
Hemorrhage is a significant cause of death among military working dogs and in civilian canine trauma. While research specifically aimed at canine trauma is limited, many principles from human trauma resuscitation apply. Trauma with significant hemorrhage results in shock and inadequate oxygen delivery to tissues. This leads to aberrations in cellular metabolism, including anaerobic metabolism, decreased energy production, acidosis, cell swelling, and eventual cell death. Considering blood and endothelium as a single organ system, blood failure is a syndrome of endotheliopathy, coagulopathy, and platelet dysfunction. In severe cases following injury, blood failure develops and is induced by inadequate oxygen delivery in the presence of hemorrhage, tissue injury, and acute stress from trauma. Severe hemorrhagic shock is best treated with hemostatic resuscitation, wherein blood products are used to restore effective circulating volume and increase oxygen delivery to tissues without exacerbating blood failure. The principles of hemostatic resuscitation have been demonstrated in severely injured people and the authors propose an algorithm for applying this to canine patients. The use of plasma and whole blood to resuscitate severely injured canines while minimizing the use of crystalloids and colloids could prove instrumental in improving both mortality and morbidity. More work is needed to understand the canine patient that would benefit from hemostatic resuscitation, as well as to determine the optimal resuscitation strategy for these patients.
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Affiliation(s)
- Thomas H Edwards
- U.S. Army Institute of Surgical Research, Joint Base San Antonio - Fort Sam Houston, Texas, USA
| | - Julie A Rizzo
- U.S. Army Institute of Surgical Research, Joint Base San Antonio - Fort Sam Houston, Texas, USA.,Uniformed Services University of Health Sciences, Bethesda, Maryland, USA
| | - Anthony E Pusateri
- Naval Medical Research Unit San Antonio, Joint Base San Antonio - Fort Sam Houston, Texas, USA
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13
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Anderson TN, Farrell DH, Rowell SE. Fibrinolysis in Traumatic Brain Injury: Diagnosis, Management, and Clinical Considerations. Semin Thromb Hemost 2021; 47:527-537. [PMID: 33878779 DOI: 10.1055/s-0041-1722970] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Posttraumatic coagulopathy involves disruption of both the coagulation and fibrinolytic pathways secondary to tissue damage, hypotension, and inflammatory upregulation. This phenomenon contributes to delayed complications after traumatic brain injury (TBI), including intracranial hemorrhage progression and systemic disseminated intravascular coagulopathy. Development of an early hyperfibrinolytic state may result in uncontrolled bleeding and is associated with increased mortality in patients with TBI. Although fibrinolytic assays are not routinely performed in the assessment of posttraumatic coagulopathy, circulating biomarkers such as D-dimer and fibrin degradation products have demonstrated potential utility in outcome prediction. Unfortunately, the relatively delayed nature of these tests limits their clinical utility. In contrast, viscoelastic tests are able to provide a rapid global assessment of coagulopathy, although their ability to reliably identify disruptions in the fibrinolytic cascade remains unclear. Limited evidence supports the use of hypertonic saline, cryoprecipitate, and plasma to correct fibrinolytic disruption; however, some studies suggest more harm than benefit. Recently, early use of tranexamic acid in patients with TBI and confirmed hyperfibrinolysis has been proposed as a strategy to further improve clinical outcomes. Moving forward, further delineation of TBI phenotypes and the clinical implications of fibrinolysis based on phenotypic variation is needed. In this review, we summarize the clinical aspects of fibrinolysis in TBI, including diagnosis, treatment, and clinical correlates, with identification of targeted areas for future research efforts.
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Affiliation(s)
- Taylor N Anderson
- School of Medicine, Division of Trauma, Critical Care and Acute Care Surgery, Oregon Health and Science University, Portland, Oregon
| | - David H Farrell
- School of Medicine, Division of Trauma, Critical Care and Acute Care Surgery, Oregon Health and Science University, Portland, Oregon
| | - Susan E Rowell
- Department of Surgery, Duke University Medical Center, Durham, North Carolina
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14
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Mo YD, Delaney M. Transfusion in Pediatric Patients: Review of Evidence-Based Guidelines. Clin Lab Med 2021; 41:1-14. [PMID: 33494878 DOI: 10.1016/j.cll.2020.10.001] [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: 01/28/2023]
Abstract
Children require transfusion of blood components for a vast array of medical conditions, including acute hemorrhage, hematologic and nonhematologic malignancies, hemoglobinopathy, and allogeneic and autologous stem cell transplant. Evidence-based literature on pediatric transfusion practices is limited, particularly for non-red blood cell products, and many recommendations are extrapolated from studies in adult populations. Recognition of these knowledge gaps has led to increasing numbers of clinical trials focusing on children and establishment of pediatric transfusion working groups in recent years. This article reviews existing literature on pediatric transfusion therapy within the larger context of analogous data in adult populations.
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Affiliation(s)
- Yunchuan Delores Mo
- Transfusion Medicine, Children's National Hospital, 111 Michigan Avenue Northwest, Laboratory Administration, Suite 2100, Washington, DC 20010, USA.
| | - Meghan Delaney
- Pathology and Laboratory Medicine Division, Transfusion Medicine, Children's National Hospital, 111 Michigan Avenue Northwest, Laboratory Administration, Suite 2100, Washington, DC 20010, USA
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15
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Molloy S, Batchelor G, Mallett P, Thompson A, Bourke T, Fitzsimons A, Richardson J. Fifteen-minute consultation: Severe traumatic brain injury in paediatrics. Arch Dis Child Educ Pract Ed 2021; 106:9-17. [PMID: 33033077 DOI: 10.1136/archdischild-2019-318246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Revised: 04/14/2020] [Accepted: 05/24/2020] [Indexed: 11/03/2022]
Abstract
Paediatric traumatic brain injury (TBI) is a non-degenerative, acquired brain insult. Following a blow or penetrating trauma to the head, normal brain function is disrupted. If it occurs during the early stages of development, deficits may not immediately become apparent but unfold and evolve over time. We address the difficulties that arise when treating a child with severe TBI.
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Affiliation(s)
- Seana Molloy
- Paediatrics, Royal Belfast Hospital for Sick Children, Belfast, UK
| | - Gemma Batchelor
- General Paediatrics, Royal Belfast Hospital for Sick Children, Belfast, UK
| | - Peter Mallett
- Royal Belfast Hospital for Sick Children, Belfast, Northern Ireland, UK
| | - Andrew Thompson
- Paediatrics, Royal Belfast Hospital for Sick Children, Belfast, UK
| | - Thomas Bourke
- Paediatrics, Royal Belfast Hospital for Sick Children, Belfast, UK.,Centre for Medical Education, Queens University Belfast, Belfast, UK
| | - Andrew Fitzsimons
- Emergency Department, Royal Belfast Hospital for Sick Children, Belfast, Co Antrim, UK
| | - Julie Richardson
- Paediatric Intensive Care Unit, Royal Belfast Children's Hospital, Belfast, UK
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16
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Phillips R, Shahi N, Shirek G, Stevens J, Meier M, Recicar J, Lindberg DM, Kim J, Moulton S. Meaningful viscoelastic abnormalities in abusive and non-abusivepediatric trauma. J Pediatr Surg 2021; 56:397-400. [PMID: 33280852 DOI: 10.1016/j.jpedsurg.2020.10.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2020] [Accepted: 10/20/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND/PURPOSE There remains a lack of data on the utility of viscoelastic tests in managing abused patients. We hypothesize that abnormalities on admission thrombelastography (TEG) will differ in abused patients compared to those accidentally injured. METHODS Pediatric trauma patients (≤10 years old) who had an admission TEG at a Level I pediatric trauma center (2010-2020) were included and stratified into two cohorts: abuse versus accidental trauma. TEG abnormalities were based on the institution's normative values and compared between the groups. RESULTS Of 41 children included, 21 sustained abuse. Five abused patients and three accidentally injured patients died. Abused children showed a hypercoagulable pattern on viscoelastic testing with TEG when compared to those accidentally injured, as demonstrated by a short R-time (67% vs. 30%, p = 0.040) and an increased alpha angle (47% vs. 0%, p = 0.001). There was no significant difference in the MA and LY30 values between the two groups. In a multivariable model, only an abnormal alpha angle remained associated with abuse [odds ratio (OR) 0.17 (confidence intervals (CI) 0.02-0.92)]. In a separate multivariable model, only an abnormal MA was associated with mortality [OR 18.97 (CI 1.93-475.47), p = 0.025]. CONCLUSIONS Our data suggest that hemostasis is significantly different in abused children relative to those who are accidentally injured. TYPE OF STUDY Retrospective Comparative Study. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Ryan Phillips
- Division of Pediatric Surgery, Children's Hospital Colorado, Aurora, CO, USA; Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA.
| | - Niti Shahi
- Division of Pediatric Surgery, Children's Hospital Colorado, Aurora, CO, USA; Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Gabrielle Shirek
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Jenny Stevens
- Division of Pediatric Surgery, Children's Hospital Colorado, Aurora, CO, USA; Department of Surgery, Louisiana State University School of Medicine, New Orleans, LA, USA
| | - Maxene Meier
- The Center for Research in Outcomes for Children's Surgery, Center for Children's Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - John Recicar
- Division of Pediatric Surgery, Children's Hospital Colorado, Aurora, CO, USA; Division of Nursing, Children's Hospital Colorado, Aurora, CO, USA
| | - Daniel M Lindberg
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - John Kim
- Department of Pediatrics, Heart Institute, Children's Hospital Colorado, University of Colorado, School of Medicine, Aurora, CO, USA
| | - Steven Moulton
- Division of Pediatric Surgery, Children's Hospital Colorado, Aurora, CO, USA; Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
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17
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Hamele M, Aden JK, Borgman MA. Tranexamic acid in pediatric combat trauma requiring massive transfusions and mortality. J Trauma Acute Care Surg 2021; 89:S242-S245. [PMID: 32265388 DOI: 10.1097/ta.0000000000002701] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Tranexamic acid (TXA) has been demonstrated to decrease mortality in adult trauma, particularly in those with massive transfusions needs sustained in combat injury. Limited data are available for the efficacy of TXA in pediatric trauma patients outside of a single combat support hospital in Afghanistan. METHODS The Department of Defense Trauma Registry was queried for trauma patients younger than 18 years from Iraq and Afghanistan requiring 40 mL/kg or greater of blood product within 24 hours of injury. Burns and fatal head traumas were excluded. Primary outcome was in-hospital mortality. Secondary outcomes were hospital, ventilator, and intensive care unit-free days, as well as total blood product volume. RESULTS Among those pediatric patients receiving massive transfusions, those who received TXA were less likely to die in hospital (8.5% vs. 18.3%). Patients who received TXA and those who did not have similar hospital-free days (19 vs. 20), ventilator-free days (27 vs. 27), and intensive care unit-free days (25 vs. 24). Those who received TXA had higher 24-hour blood product administration (100 mL/kg vs. 75 mL/kg). None of our results rose to the level of statistical significance. The TXA administration significantly reduced odds of death on logistic regression (odds ratio, 0.35; 95% confidence interval, 0.123-0.995; p = 0.0488). CONCLUSION Use of TXA in pediatric patients with combat trauma requiring massive transfusions trended toward a significant improvement in in-hospital mortality (p = 0.055). This mortality benefit is similar to that seen in adult studies and a less well characterized cohort in another pediatric study suggesting TXA administration confers mortality benefit in massively transfused pediatric combat trauma victims. LEVEL OF EVIDENCE Evidence (retrospective cohort), Level IV.
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Affiliation(s)
- Mitchell Hamele
- From the Department of Pediatrics-Critical Care (M.H.), Tripler Army Medical Center, Honolulu, Hawaii; Brooke Army Medical Center Fort Sam Houston (J.K.A., M.A.B.), Houston, Texas; and Department of Pediatrics (M.H., M.A.B.), Uniformed Services University, Services University, Bethesda, Maryland
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18
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Crighton GL, Karam O, Nellis ME, Stanworth SJ. Editorial: Hemostatic Challenges in Pediatric Critical Care Medicine. Front Pediatr 2021; 9:697921. [PMID: 34322464 PMCID: PMC8311020 DOI: 10.3389/fped.2021.697921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 06/16/2021] [Indexed: 12/15/2022] Open
Affiliation(s)
- Gemma L Crighton
- Department of Haematology, Royal Children's Hospital, Melbourne, VIC, Australia
| | - Oliver Karam
- Division of Pediatric Critical Care Medicine, Children's Hospital of Richmond at VCU Richmond, Richmond, VA, United States
| | - Marianne E Nellis
- Division of Pediatric Critical Care Medicine, NY Presbyterian Hospital-Weill Cornell Medicine, New York, NY, United States
| | - Simon J Stanworth
- NHS Blood and Transplant; Oxford University Hospitals NHS Foundation Trust; Radcliffe Department of Medicine and Oxford BRC Haematology Theme, University of Oxford, Oxford, United Kingdom
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19
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Weber B, Lackner I, Braun CK, Kalbitz M, Huber-Lang M, Pressmar J. Laboratory Markers in the Management of Pediatric Polytrauma: Current Role and Areas of Future Research. Front Pediatr 2021; 9:622753. [PMID: 33816396 PMCID: PMC8010656 DOI: 10.3389/fped.2021.622753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Accepted: 02/19/2021] [Indexed: 11/13/2022] Open
Abstract
Severe trauma is the most common cause of mortality in children and is associated with a high socioeconomic burden. The most frequently injured organs in children are the head and thorax, followed by the extremities and by abdominal injuries. The efficient and early assessment and management of these injuries is essential to improve patients' outcome. Physical examination as well as imaging techniques like ultrasound, X-ray and computer tomography are crucial for a valid early diagnosis. Furthermore, laboratory analyses constitute additional helpful tools for the detection and monitoring of pediatric injuries. Specific inflammatory markers correlate with post-traumatic complications, including the development of multiple organ failure. Other laboratory parameters, including lactate concentration, coagulation parameters and markers of organ injury, represent further clinical tools to identify trauma-induced disorders. In this review, we outline and evaluate specific biomarkers for inflammation, acid-base balance, blood coagulation and organ damage following pediatric polytrauma. The early use of relevant laboratory markers may assist decision making on imaging tools, thus contributing to minimize radiation-induced long-term consequences, while improving the outcome of children with multiple trauma.
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Affiliation(s)
- Birte Weber
- Department of Traumatology, Hand-, Plastic- and Reconstructive Surgery, Center of Surgery, University of Ulm, Ulm, Germany
| | - Ina Lackner
- Department of Traumatology, Hand-, Plastic- and Reconstructive Surgery, Center of Surgery, University of Ulm, Ulm, Germany
| | - Christian Karl Braun
- Institute of Clinical and Experimental Trauma-Immunology, University Hospital of Ulm, Ulm, Germany.,Department of Pediatrics, University Medical Center Ulm, Ulm, Germany
| | - Miriam Kalbitz
- Department of Traumatology, Hand-, Plastic- and Reconstructive Surgery, Center of Surgery, University of Ulm, Ulm, Germany
| | - Markus Huber-Lang
- Institute of Clinical and Experimental Trauma-Immunology, University Hospital of Ulm, Ulm, Germany
| | - Jochen Pressmar
- Department of Traumatology, Hand-, Plastic- and Reconstructive Surgery, Center of Surgery, University of Ulm, Ulm, Germany
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20
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Neff LP, Beckwith MA, Russell RT, Cannon JW, Spinella PC. Massive Transfusion in Pediatric Patients. Clin Lab Med 2020; 41:35-49. [PMID: 33494884 DOI: 10.1016/j.cll.2020.10.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Massive transfusion in pediatric patients is infrequent but associated with much higher mortality than in adults. Blood transfusion and hematology has conceptualized ideas such as blood failure and the interplay of the blood-endothelium interface to understand coagulopathy in the context of hemorrhagic shock. Researchers are still searching for an appropriate definition of what constitutes a pediatric massive transfusion. There is no universally accepted protocol for massive transfusion and how to address the many complications that can arise. Pharmacologic adjuncts to resuscitation may prove beneficial in reducing coagulopathy during pediatric massive transfusion, but high-quality evidence has not yet emerged.
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Affiliation(s)
- Lucas P Neff
- Department of General Surgery, Section of Pediatric Surgery, Wake Forest University School of Medicine, 5th Floor, Watlington Hall, Medical Center Boulevard, Winston-Salem, NC 27157, USA.
| | - Michael Aaron Beckwith
- Division of Trauma and Acute Care Surgery, Department of Surgery, University of Alabama at Birmingham, 1922 7th Avenue South, KB 120, Birmingham, AL 35294, USA
| | - Robert T Russell
- Pediatric General Surgery, Division of Pediatric Surgery, Department of Surgery, University of Alabama at Birmingham, 1600 7th Avenue South, Lowder, Suite 300, Birmingham, AL 35233, 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, Penn Presbyterian Medical Center, 51 North 39th Street, Suite 120 MOB, Philadelphia, PA 19104, USA
| | - Philip C Spinella
- Division of Critical Care Medicine, Department of Pediatrics, The Washington University of Saint Louis, 4905 Children's Place, St Louis, MO 63110, USA
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21
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Sribnick EA, Wenger N, Nicol K, Tobias JD. Use of viscoelastic monitoring and prothrombin complex concentrate in a paediatric patient with polytrauma and severe traumatic brain injury. BMJ Case Rep 2020; 13:13/12/e236608. [PMID: 33318272 PMCID: PMC7737072 DOI: 10.1136/bcr-2020-236608] [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: 12/15/2022] Open
Abstract
Viscoelastic monitoring (VEM) tools, such as rotational thrombelastometry, have been used extensively to measure coagulopathy in adults but have received less attention in paediatric care. The presented case involves a 5-year-old boy who was brought to the emergency department after a motor vehicle collision with a Glasgow Coma Scale score of 6T and extensive injuries, including a subdural hematoma. VEM was used to monitor the patient's coagulopathy and to inform treatment measures by allowing real-time visualisation of the patient's coagulation status. VEM was additionally used to direct blood product replacement in preparation for neurosurgical intervention, and 4-factor prothrombin complex concentrate (PCC) was used to help reverse the coagulopathy. The patient underwent successful hemicraniectomy after improvement of his coagulopathy. In paediatrics, VEM and PCC are increasingly being used for post-trauma coagulopathy, and this case highlights their potential promise and the need for further research.
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Affiliation(s)
- Eric A Sribnick
- Department of Neurosurgery, Nationwide Children's Hospital, Columbus, Ohio, USA,Deparmtent of Neurosurgery, The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Nicole Wenger
- The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Kathleen Nicol
- Deaprtment of Pathology and Laboratory Medicine, Nationwide Children's Hospital, Columbus, Ohio, USA,Department of Pathology, The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Joseph D Tobias
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio, USA,Depatment of Anesthesiology and Pain Medicine, The Ohio State University College of Medicine, Columbus, Ohio, USA
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22
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Dense and dangerous: The tissue plasminogen activator-resistant fibrinolysis shutdown phenotype is due to abnormal fibrin polymerization. J Trauma Acute Care Surg 2020; 88:258-265. [PMID: 31999655 DOI: 10.1097/ta.0000000000002554] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Both hyperfibrinolysis and fibrinolysis shutdown can occur after severe trauma. The subgroup of trauma patients with fibrinolysis shutdown resistant to tissue plasminogen activator (t-PA)-mediated fibrinolysis have increased mortality. Fibrin polymerization and structure may influence fibrinolysis subgroups in trauma, but fibrin architecture has not been characterized in acutely injured subjects. We hypothesized that fibrin polymerization measured in situ will correlate with fibrinolysis subgroups. METHODS Blood samples were collected from trauma patients and noninjured controls. We selected samples across a range of fibrinolysis phenotypes (shutdown, physiologic, hyperfibrinolysis) and t-PA sensitivities (sensitive, physiologic, resistant) determined by thrombelastography. Plasma clots were created in situ with fluorescent fibrinogen and imaged using confocal microscopy for analysis of clot architecture in three dimensions. For each clot, we quantified the fiber resolvability, a metric of fiber distinctness or clarity, by mapping the variance of fluorescence intensity relative to background fluorescence. We also determined clot porosity by measuring the size and distribution of the gaps between fibrin fibers in three-dimensional space. We compared these measures across fibrinolysis subgroups. RESULTS Fiber resolvability was significantly lower in all trauma subgroups compared with controls (n = 35 and 5, respectively; p < 0.05). We observed markedly different patterns of fibrin architecture among trauma patients stratified by fibrinolysis subgroup. Subjects with t-PA-resistant fibrinolysis shutdown exhibited abnormal, densely packed fibrin clots nearly devoid of pores. Individuals with t-PA-hypersensitive fibrinolysis shutdown had highly irregular clots with pores as large as 2500 μm to 20,000 μm, versus 78 μm to 1250 μm in noninjured controls. CONCLUSION Fiber resolvability was significantly lower in trauma patients than controls, and subgroups of fibrinolysis differ in the porosity of the fibrin clot structure. The dense fibrin network in the t-PA-resistant group may prevent access to plasmin, suggesting a mechanism for thrombotic morbidity after injury.
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23
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Evangelista ME, Gaffley M, Neff LP. Massive Transfusion Protocols for Pediatric Patients: Current Perspectives. J Blood Med 2020; 11:163-172. [PMID: 32547282 PMCID: PMC7247594 DOI: 10.2147/jbm.s205132] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Accepted: 04/24/2020] [Indexed: 01/03/2023] Open
Abstract
In adults, the use of balanced resuscitation and study of massive transfusion protocols have led to improved outcomes for patients and continues to be refined. In children, massive transfusion protocols require further development and study to assess efficacy. Standardization is needed as transfusions and activation of protocols still rely on physician discretion in most pediatric settings. Further research is required to define the pediatric trauma population that will benefit, when to activate these protocols and how to use adjuncts such as tranexamic acid or factor VII in resuscitation. In addition, future implementation of technology such as hemoglobin-based oxygen carriers to increase survival should be studied further in this subset of patients.
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Affiliation(s)
| | - Michaela Gaffley
- General Surgery, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Lucas P Neff
- Pediatric Surgery, Wake Forest School of Medicine, Winston-Salem, NC, USA
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24
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Duque P, Mora L, Levy JH, Schöchl H. Pathophysiological Response to Trauma-Induced Coagulopathy: A Comprehensive Review. Anesth Analg 2020; 130:654-664. [PMID: 31633501 DOI: 10.1213/ane.0000000000004478] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Hypercoagulability can occur after severe tissue injury, that is likely related to tissue factor exposure and impaired endothelial release of tissue plasminogen activator (tPA). In contrast, when shock and hypoperfusion occur, activation of the protein C pathway and endothelial tPA release induce a shift from a procoagulant to a hypocoagulable and hyperfibrinolytic state with a high risk of bleeding. Both thrombotic and bleeding phenotypes are associated with increased mortality and are influenced by the extent and severity of tissue injury and degree of hemorrhagic shock. Response to trauma is a complex, dynamic process in which risk can shift from bleeding to thrombosis depending on the injury pattern, hemostatic treatment, individual responses, genetic predisposition, and comorbidities. Based on this body of knowledge, we will review and consider future directions for the management of severely injured trauma patients.
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Affiliation(s)
- Patricia Duque
- From the Anesthesiology and Critical Care Department, Gregorio Marañon Hospital, Madrid, Spain
| | - Lidia Mora
- Anesthesiology and Critical Care Department, Vall d´Hebron, Hospital, Barcelona, Spain
| | - Jerrold H Levy
- Departments of Anesthesiology and Critical Care, Duke University School of Medicine, Durham, North Carolina
| | - Herbert Schöchl
- Department of Anesthesiology and Intensive Care Medicine, AUVA Trauma Centre Salzburg, Academic Teaching Hospital of the Paracelsus Medical University, Salzburg, Austria.,Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, Vienna, Austria
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25
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Burggraf M, Polan C, Husen M, Mester B, Wegner A, Spodeck D, Dudda M, Kauther MD. Trauma induced clotting factor depletion in severely injured children: a single center observational study. World J Emerg Surg 2020; 15:31. [PMID: 32375899 PMCID: PMC7201748 DOI: 10.1186/s13017-020-00311-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Accepted: 04/22/2020] [Indexed: 01/09/2023] Open
Abstract
Background Coagulopathy following severe trauma contributes significantly to mortality. Impaired clotting factors have been observed in adult trauma patients, but in pediatric trauma victims their activity has not yet been investigated. Methods Sixteen pediatric trauma patients were evaluated according to the ISS and assigned to two cohorts. An additional control group (CO; n = 10) was formed. Routine coagulation parameters and the soluble clotting factors (F) were tested. Nonparametric data was analyzed using the Mann-Whitney U test. Results are reported as median and interquartile range. Results The ISS of severely (SI, n = 8) and mildly (MI, n = 8) injured children differed significantly (25 [19–28] vs. 5 [4–6]; p < 0.001). INR was elevated in the SI cohort only when compared to the CO (1.21 [1.04-1.58] vs. 0.96 [0.93-1.00]; p = 0.001). Differences between SI and MI were found for FII (67 [53-90] vs. 82 [76-114] %; p = 0.028), FV (76 [47-88] vs. 92 [82-99] %; p = 0.028), and FXIII (67 [62-87] vs. 90 [77-102] %; p = 0.021). Comparison of the SI with the CO (FII 122 [112-144] %; p < 0.001; FV 123 [100-142] %; p = 0.002; and FXIII 102 [79-115] %; p = 0.006) also revealed a reduction in the activity of these factors. Furthermore, fibrinogen (198 [80-242] vs. 296 [204-324] mg/dl; p = 0.034), FVII (71 [63-97] vs. 114 [100-152] %; p = 0.009), FIX (84 [67-103] vs. 110 [90-114] %; p = 0.043), and FX (70 [61-85] vs. 122 [96-140] %; p = 0.001) were reduced in the SI in comparison with the CO. Finally, FVIII was considerably, yet not significantly, increased in both patient cohorts (235 [91-320] % and 197 [164-238] %, respectively). Conclusions This study proves that children suffer a depletion of clotting factors following severe injury which basically reflects the findings for adult trauma patients. Attempts to correct the impaired clotting factor activity could be based on a specific hemostatic therapy involving administration of coagulation factors. Nevertheless, therapeutic implications need to be investigated in future studies.
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Affiliation(s)
- Manuel Burggraf
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Essen, University of Duisburg-Essen, Hufelandstr. 55, 45147, Essen, Germany.
| | - Christina Polan
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Essen, University of Duisburg-Essen, Hufelandstr. 55, 45147, Essen, Germany
| | - Martin Husen
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Essen, University of Duisburg-Essen, Hufelandstr. 55, 45147, Essen, Germany
| | - Bastian Mester
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Essen, University of Duisburg-Essen, Hufelandstr. 55, 45147, Essen, Germany
| | - Alexander Wegner
- Department of Orthopedics and Trauma Surgery, University Hospital Essen, University of Duisburg-Essen, Hufelandstr. 55, 45147, Essen, Germany
| | - Daniel Spodeck
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Essen, University of Duisburg-Essen, Hufelandstr. 55, 45147, Essen, Germany
| | - Marcel Dudda
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Essen, University of Duisburg-Essen, Hufelandstr. 55, 45147, Essen, Germany
| | - Max Daniel Kauther
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Essen, University of Duisburg-Essen, Hufelandstr. 55, 45147, Essen, Germany
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Abstract
Acute coagulopathy is prevalent in adult and pediatric trauma patients and is associated with increased morbidity and mortality. While reasonable hypotheses have been created to explain the underlying perturbations of adult trauma coagulopathy (i.e., tissue factor-related increase in thrombin generation, protein C activation, hypoperfusion, and hyperfibrinolysis), only a small number of studies have been performed to prove whether these mechanisms can likewise be detected in pediatric trauma patients. In addition, severe hypofibrinogenemia (<100 mg/dL) is a frequent finding in pediatric trauma patients (>20%). Although the probability of life-threatening coagulopathy is low with minor to moderate injury, it is present in almost all patients with an injury severity score >25, hypotension, hypothermia, and acidosis. As these multifactorial changes in hemostasis cannot be adequately and rapidly measured using standard laboratory testing, the use of viscoelastic measurements has been established in adult trauma management, but prospective studies in children are urgently needed. Apart from diagnostic challenges, several studies have focused on the impact of blood product ratios on the treatment of massively bleeding pediatric trauma patients. The majority of these studies were unable to show improved survival by using higher plasma to red blood cell ratios or higher platelet to red blood cells ratios, but there are no published randomized trials to definitively answer this question. A goal-directed transfusion protocol using viscoelastic tests together with early substitution with an antifibrinolytic and fibrinogen replacement is a promising alternative to traditional ratio-based interventions. Another crucial factor in treating trauma-induced coagulopathy is the early detection of hypofibrinogenemia, a common condition in massively transfused patients. Early treatment of hypofibrinogenemia is associated with improved morbidity and mortality in adults, but needs to be further studied in future pediatric trials. Pediatric trauma patients are not only threatened by coagulopathy-related bleeding but are also at higher risk for venous thromboembolism. Pediatric trauma patients with brain injury, central venous catheters, immobilization, or surgical procedures are at highest risk for developing a deep venous thrombosis. There are no specific pediatric guidelines established to prevent venous thromboembolism in children suffering from traumatic injury.
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Affiliation(s)
- Thorsten Haas
- Department of Pediatric Anesthesia, Zurich University Children's Hospital, Zurich, Switzerland
| | - Melissa M Cushing
- Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York, NY, United States
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28
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Stolla M, Zhang F, Meyer MR, Zhang J, Dong JF. Current state of transfusion in traumatic brain injury and associated coagulopathy. Transfusion 2019; 59:1522-1528. [PMID: 30980753 DOI: 10.1111/trf.15169] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Revised: 11/10/2018] [Accepted: 11/17/2018] [Indexed: 12/15/2022]
Abstract
Traumatic brain injury (TBI)-induced coagulopathy has long been recognized as a significant risk for poor outcomes in patients with TBI, but its pathogenesis remains poorly understood. As a result, current treatment options for the condition are limited and ineffective. The lack of information is most significant for the impact of blood transfusions on patients with isolated TBI and in the absence of confounding influences from trauma to the body and limbs and the resultant hemorrhagic shock. Here we discuss recent progress in understanding the pathogenesis of TBI-induced coagulopathy and the current state of blood transfusions for patients with TBI and associated coagulopathy.
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Affiliation(s)
- Moritz Stolla
- Bloodworks Research Institute, Seattle, Washington.,Division of Hematology, Department of Medicine, University of Washington, School of Medicine, Seattle, Washington
| | - Fangyi Zhang
- Department of Neurological Surgery, University of Washington School of Medicine, Seattle, Washington
| | - Michael R Meyer
- Department of Neurological Surgery, University of Washington School of Medicine, Seattle, Washington
| | - Jianning Zhang
- Tianjin Institute of Neurology, Tianjin, China.,Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Jing-Fei Dong
- Bloodworks Research Institute, Seattle, Washington.,Division of Hematology, Department of Medicine, University of Washington, School of Medicine, Seattle, Washington
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Gratz J, Güting H, Thorn S, Brazinova A, Görlinger K, Schäfer N, Schöchl H, Stanworth S, Maegele M. Protocolised thromboelastometric‐guided haemostatic management in patients with traumatic brain injury: a pilot study. Anaesthesia 2019; 74:883-890. [DOI: 10.1111/anae.14670] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/26/2019] [Indexed: 12/16/2022]
Affiliation(s)
- J. Gratz
- Department of Anaesthesia, Critical Care and Pain Medicine Medical University of Vienna Vienna Austria
| | - H. Güting
- Institute for Research in Operative Medicine University Witten/Herdecke CologneGermany
| | - S. Thorn
- Monash University Melbourne School of Public Health and Preventive MedicineMelbourneAustralia
| | - A. Brazinova
- Institute of Epidemiology Faculty of Medicine Comenius University Bratislava Bratislava Slokak Republic
| | - K. Görlinger
- Department of Anaesthesia and Intensive Care Medicine University Hospital Essen Germany
- TEM Innovations GmbH MunichGermany
| | - N. Schäfer
- Institute for Research in Operative Medicine University Witten/Herdecke CologneGermany
| | - H. Schöchl
- Department of Anaesthesia and Intensive Care Medicine AUVA Trauma Centre Salzburg Academic Teaching Hospital of the Paracelsus Medical University Salzburg Salzburg Austria
- Ludwig Boltzmann Institute for Experimental and Clinical Traumatology AUVA Trauma Research Centre Vienna Vienna Austria
| | - S. Stanworth
- Department of Haematology Radcliffe Department of Medicine Oxford University Hospitals NHS Foundation Trust University of Oxford UK
| | - M. Maegele
- Institute for Research in Operative Medicine University Witten/Herdecke CologneGermany
- Department of Traumatology and Orthopedic Surgery Cologne‐Merheim Medical Centre Cologne Germany
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Management of Pediatric Severe Traumatic Brain Injury: 2019 Consensus and Guidelines-Based Algorithm for First and Second Tier Therapies. Pediatr Crit Care Med 2019; 20:269-279. [PMID: 30830015 DOI: 10.1097/pcc.0000000000001737] [Citation(s) in RCA: 117] [Impact Index Per Article: 23.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To produce a treatment algorithm for the ICU management of infants, children, and adolescents with severe traumatic brain injury. DATA SOURCES Studies included in the 2019 Guidelines for the Management of Pediatric Severe Traumatic Brain Injury (Glasgow Coma Scale score ≤ 8), consensus when evidence was insufficient to formulate a fully evidence-based approach, and selected protocols from included studies. DATA SYNTHESIS Baseline care germane to all pediatric patients with severe traumatic brain injury along with two tiers of therapy were formulated. An approach to emergent management of the crisis scenario of cerebral herniation was also included. The first tier of therapy focuses on three therapeutic targets, namely preventing and/or treating intracranial hypertension, optimizing cerebral perfusion pressure, and optimizing partial pressure of brain tissue oxygen (when monitored). The second tier of therapy focuses on decompressive craniectomy surgery, barbiturate infusion, late application of hypothermia, induced hyperventilation, and hyperosmolar therapies. CONCLUSIONS This article provides an algorithm of clinical practice for the bedside practitioner based on the available evidence, treatment protocols described in the articles included in the 2019 guidelines, and consensus that reflects a logical approach to mitigate intracranial hypertension, optimize cerebral perfusion, and improve outcomes in the setting of pediatric severe traumatic brain injury.
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