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LaGrone LN, Stein D, Cribari C, Kaups K, Harris C, Miller AN, Smith B, Dutton R, Bulger E, Napolitano LM. American Association for the Surgery of Trauma/American College of Surgeons Committee on Trauma: Clinical protocol for damage-control resuscitation for the adult trauma patient. J Trauma Acute Care Surg 2024; 96:510-520. [PMID: 37697470 DOI: 10.1097/ta.0000000000004088] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/13/2023]
Abstract
ABSTRACT Damage-control resuscitation in the care of critically injured trauma patients aims to limit blood loss and prevent and treat coagulopathy by combining early definitive hemorrhage control, hypotensive resuscitation, and early and balanced use of blood products (hemostatic resuscitation) and the use of other hemostatic agents. This clinical protocol has been developed to provide evidence-based recommendations for optimal damage-control resuscitation in the care of trauma patients with hemorrhage.
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Affiliation(s)
- Lacey N LaGrone
- From the Department of Surgery (D.S.), University of Maryland, Baltimore, Maryland; Department of Surgery (L.N.L., C.C.), UCHealth, Loveland, Colorado; Department of Surgery (K.K), University of California San Francisco Fresno, San Francisco, California; Department of Surgery (C.H.), Tulane University, New Orleans, Louisiana; Orthopedic Surgery (A.N.M.), Washington University in St. Louis, St. Louis, Missouri; Department of Surgery (B.S.), University of Pennsylvania, Philadelphia, Pennsylvania; American Society of Anesthesiologists (R.D.), Anesthesia, Waco, Texas; Department of Surgery (E.B.), University of Washington, Seattle, Washington; and Department of Surgery (L.M.N.), University of Michigan, Ann Arbor, Michigan
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Philpott CD, Ernst NE, Makley AT, Wasky PR, Mueller EW. Case Report: Extended Duration Andexanet Alfa Infusion in a Surgical Trauma Patient. J Pharm Pract 2023; 36:1002-1007. [PMID: 35227117 DOI: 10.1177/08971900221078779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/20/2023]
Abstract
Background: Andexanet alfa (andexanet) is the only FDA-approved medication for reversal of apixaban and rivaroxaban anticoagulation for life-threatening or uncontrolled bleeding. Infusion modifications may be required in surgical patients undergoing prolonged operative intervention but have not previously been described. Case Report: A 78-year-old woman on rivaroxaban for atrial fibrillation was admitted to the trauma service for a mechanical fall, sustaining a T4 burst fracture with severe canal stenosis and spinal cord edema resulting in loss of strength and sensation in her legs. Clinically relevant rivaroxaban activity was verified with an elevated low molecular weight heparin anti-factor Xa assay, and laboratory confirmed coagulopathy was demonstrated by a prolonged prothrombin time, thromboelastography (TEG) R-time, and activated clotting time (ACT). The patient required urgent surgical intervention for spinal fixation. Given the expected prolonged duration of the procedure, standard dose andexanet was initiated with a prolonged infusion at half the standard rate during the operation. The procedure was successful and intraoperative TEGs demonstrated normalization of R-time and ACT throughout the procedure. The patient did not experience any complications postoperatively and successfully discharged to inpatient rehabilitation. Conclusion: Modifications to the andexanet infusion may be required in surgical patients requiring rivaroxaban reversal for a prolonged procedure. Further data are needed to determine the optimal approach to infusion modification.
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Affiliation(s)
- Carolyn D Philpott
- Clinical Pharmacy Specialist, Trauma, Surgery, Orthopedics, UC Health - University of Cincinnati Medical Center, Cincinnati, OH
| | - Neil E Ernst
- Clinical Pharmacy Specialist, Critical Care, UC Health - University of Cincinnati Medical Center, Cincinnati, OH
| | - Amy T Makley
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Peter R Wasky
- Department of Orthopaedics & Sports Medicine, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Eric W Mueller
- Clinical Pharmacy Specialist, Trauma, Surgery, Orthopedics, UC Health - University of Cincinnati Medical Center, Cincinnati, OH
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Barletta JF, Erstad BL. Dosing Medications for Coagulopathy Reversal in Patients with Extreme Obesity. J Emerg Med 2022; 63:541-550. [PMID: 35906122 DOI: 10.1016/j.jemermed.2022.04.036] [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: 02/17/2022] [Revised: 03/22/2022] [Accepted: 04/23/2022] [Indexed: 11/13/2022]
Abstract
BACKGROUND The reversal of anticoagulant or antiplatelet medications is a priority in the management of patients with severe injury with the goal of minimizing further bleeding without thrombotic complications. There are few studies, however, evaluating the dosing of reversal agents in the setting of trauma specific to patients with extreme obesity. Nevertheless, clinicians must still make decisions, balancing concerns of ongoing bleeding with excessive thrombosis. OBJECTIVES We describe the literature pertaining to dosing of medications used for the reversal of both drug-induced and trauma-related coagulopathy with the intent of providing a framework for clinicians to make dosing decisions in this challenging population. DISCUSSION Obesity is known to impact both the volume of distribution and the clearance of medications, but these changes are not usually linear with size nor are they uniform across drugs. Current strategies for dosing reversal agents in obesity include a capped dose (e.g., prothrombin complex concentrates), fixed dosages (e.g., andexanet alfa, idarucizumab, and tranexamic acid), and weight-based dosing (e.g., desmopressin). Extreme obesity, however, was not highly prevalent in the studies that have validated these dosing strategies. In fact, many of the clinical studies fail to report the average weight of the patients included. CONCLUSION Future studies should make efforts to increase reporting of patients with obesity included in clinical trials along with results stratified by weight class. In the meantime, doses listed in product labels should be used. Desmopressin should be dosed using either ideal body weight or a dose-capping strategy.
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Affiliation(s)
- Jeffrey F Barletta
- Department of Pharmacy Practice, College of Pharmacy, Midwestern University, Glendale
| | - Brian L Erstad
- Department of Pharmacy Practice and Science, College of Pharmacy, University of Arizona, Tucson, Arizona
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Bradshaw PG, Keegan S, Foertsch M, Yang GL, Ngwenya LB, Srinivasan V. Andexanet alfa after 4-factor PCC administration for intracranial hemorrhage: a case series. J Thromb Thrombolysis 2022; 54:295-300. [PMID: 35507109 DOI: 10.1007/s11239-022-02658-w] [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] [Accepted: 04/06/2022] [Indexed: 10/18/2022]
Abstract
The ongoing controversy regarding optimal reversal agent for factor Xa-inhibitors is mainly due to lack of comparative data of andexanet alfa (AA) to 4-factor prothrombin complex concentrate (4F-PCC), institutional formulary restrictions, and navigation of clinical scenarios involving patients clinically worsen despite initial reversal efforts. The combination use of 4F-PCC and AA has not been evaluated in clinical trials and the outcomes of such patients with FXA-inhibitor associated intracranial hemorrhage (ICH) are unknown. A total of five patients, including four outside hospital transfers, received 4F-PCC prior to AA for FXa-inhibitor associated ICH (n = 3 apixaban, n = 2 rivaroxaban; n = 4 ICH, n = 1 TBI). The doses of 4F-PCC ranged from 25 to 60 units/kg and were administered within a range of 1.5-4.2 h prior to AA. One patient required surgical intervention with craniotomy and three patients underwent external ventricular drain placement. Two of the five patients developed an ischemic or thromboembolic complication within one week from 4F-PCC and AA administration. This case series discusses multiple unique patient cases in which 4F-PCC and AA were both administered for FXa-inhibitor associated ICH. The results highlight the potentially increased thrombotic risk associated with combination use. Ongoing post-marketing data collection of real patient case scenarios are essential to the establishment of consensus guidelines on how to prioritize initial reversal efforts and manage these patients during the course of their bleed.
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Affiliation(s)
- Paige Garber Bradshaw
- Department of Pharmacy Services, University of Cincinnati Medical Center, Cincinnati, OH, USA. .,University of Cincinnati James L. Winkle College of Pharmacy, Cincinnati, OH, USA.
| | - Shaun Keegan
- Department of Pharmacy Services, University of Cincinnati Medical Center, Cincinnati, OH, USA.,University of Cincinnati James L. Winkle College of Pharmacy, Cincinnati, OH, USA
| | - Madeline Foertsch
- Department of Pharmacy Services, University of Cincinnati Medical Center, Cincinnati, OH, USA.,University of Cincinnati James L. Winkle College of Pharmacy, Cincinnati, OH, USA
| | - George L Yang
- University of Cincinnati Gardner Neuroscience Institute, Cincinnati, OH, USA.,Department of Neurosurgery, University of Cincinnati, Cincinnati, OH, USA
| | - Laura B Ngwenya
- University of Cincinnati Gardner Neuroscience Institute, Cincinnati, OH, USA.,Department of Neurosurgery, University of Cincinnati, Cincinnati, OH, USA
| | - Vasisht Srinivasan
- Department of Emergency Medicine, University of Washington School of Medicine, Seattle, USA
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Nederpelt C, Naar L, Meier K, van Wijck S, Krijnen P, Velmahos G, Kaafarani H, Rosenthal M, Schipper I. Treatment and outcomes of anticoagulated geriatric trauma patients with traumatic intracranial hemorrhage after falls. Eur J Trauma Emerg Surg 2022; 48:4297-4304. [PMID: 35267051 PMCID: PMC9532305 DOI: 10.1007/s00068-022-01938-7] [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: 08/22/2021] [Accepted: 02/20/2022] [Indexed: 11/24/2022]
Abstract
Introduction Emergency physicians and trauma surgeons are increasingly confronted with pre-injury direct oral anticoagulants (DOACs). The objective of this study was to assess if pre-injury DOACs, compared to vitamin K antagonists (VKA), or no oral anticoagulants is independently associated with differences in treatment, mortality and inpatient rehabilitation requirement. Methods We performed a review of the prospectively maintained institutional trauma registry at an urban academic level 1 trauma center. We included all geriatric patients (aged ≥ 65 years) with tICH after a fall, admitted between January 2011 and December 2018. Multivariable logistic regression analysis controlling for demographics, comorbidities, vital signs, and tICH types were performed to identify the association between pre-injury anticoagulants and reversal agent use, neurosurgical interventions, inhospital mortality, 3-day mortality, and discharge to inpatient rehabilitation. Results A total of 1453 tICH patients were included (52 DOAC, 376 VKA, 1025 control). DOAC use was independently associated with lower odds of receiving specific reversal agents [odds ratio (OR) 0.28, 95% confidence interval (CI) 0.15–0.54] than VKA patients. DOAC use was independently associated with requiring neurosurgical intervention (OR 3.14, 95% CI 1.36–7.28). VKA use, but not DOAC use, was independently associated with inhospital mortality, or discharge to hospice care (OR 1.62, 95% CI 1.15–2.27) compared to controls. VKA use was independently associated with higher odds of discharge to inpatient rehabilitation (OR 1.41, 95% CI 1.06–1.87) compared to controls. Conclusion Despite the higher neurosurgical intervention rates, patients with pre-injury DOAC use were associated with comparable rates of mortality and discharge to inpatient rehabilitation as patients without anticoagulation exposure. Future research should focus on risk assessment and stratification of DOAC-exposed trauma patients.
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Affiliation(s)
- Charlie Nederpelt
- Department of Trauma Surgery, Leiden University Medical Center, Leiden, The Netherlands. .,Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, MA, United States.
| | - Leon Naar
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, MA, United States
| | - Karien Meier
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, MA, United States
| | - Suzanne van Wijck
- Department of Trauma Surgery, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Pieta Krijnen
- Department of Trauma Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - George Velmahos
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, MA, United States
| | - Haytham Kaafarani
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, MA, United States
| | - Martin Rosenthal
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, MA, United States
| | - Inger Schipper
- Department of Trauma Surgery, Leiden University Medical Center, Leiden, The Netherlands
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