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Bartoszko J, Peer M, Grewal D, Ansari S, Callum J, Karkouti K. Delayed cold-stored vs. room temperature stored platelet transfusions in bleeding adult cardiac surgery patients-a randomized multicentre pilot study (PLTS-1). Pilot Feasibility Stud 2024; 10:90. [PMID: 38879518 PMCID: PMC11179374 DOI: 10.1186/s40814-024-01518-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2024] [Accepted: 06/06/2024] [Indexed: 06/19/2024] Open
Abstract
BACKGROUND Platelets stored at 1-6 °C are hypothesized to be more hemostatically active than standard room temperature platelets (RTP) stored at 20-24 °C. Recent studies suggest converting RTP to cold-stored platelets (Delayed Cold-Stored Platelets, DCSP) may be an important way of extending platelet lifespan and increasing platelet supply while also activating and priming platelets for the treatment of acute bleeding. However, there is little clinical trial data supporting the efficacy and safety of DCSP compared to standard RTP. METHODS This protocol details the design of a multicentre, two-arm, parallel-group, randomized, active-control, blinded, internal pilot trial to be conducted at two cardiac surgery centers in Canada. The study will randomize 50 adult (≥ 18 years old) patients undergoing at least moderately complex cardiac surgery with cardiopulmonary bypass and requiring platelet transfusion to receive either RTP as per standard of care (control group) or DCSP (intervention group). Patients randomized to the intervention group will receive ABO-identical, buffy-coat, pathogen-reduced, platelets in platelet additive solution maintained at 22 °C for up to 4 days then placed at 4 °C for a minimum of 24 h, with expiration at 14 days after collection. The duration of the intervention is from the termination of cardiopulmonary bypass to 24 h after, with a maximum of two doses of DCSP. Thereafter, all patients will receive RTP. The aim of this pilot is to assess the feasibility of a future RCT comparing the hemostatic effectiveness of DCSP to RTP (defined as the total number of allogeneic blood products transfused within 24 h after CPB) as well as safety. Specifically, the feasibility objectives of this pilot study are to determine (1) recruitment of ≥ 15% eligible patients per center per month); (2) appropriate platelet product available for ≥ 90% of patients randomized to the cold-stored platelet group; (3) Adherence to randomization assignment (> 90% of patients administered assigned product). DISCUSSION DCSP represents a promising logistical solution to address platelet supply shortages and a potentially more efficacious option for the management of active bleeding. No prospective clinical studies on this topic have been conducted. This proposed internal pilot study will assess the feasibility of a larger definitive study. TRIAL REGISTRATION NCT06147531 (clinicaltrials.gov).
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Affiliation(s)
- Justyna Bartoszko
- Department of Anesthesia and Pain Management, Sinai Health System, Women's College Hospital, University Health Network, Toronto, ON, Canada.
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada.
- Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada.
| | - Miki Peer
- Department of Anesthesia and Pain Management, Sinai Health System, Women's College Hospital, University Health Network, Toronto, ON, Canada
| | - Deep Grewal
- Department of Anesthesia and Pain Management, Sinai Health System, Women's College Hospital, University Health Network, Toronto, ON, Canada
- Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada
| | - Saba Ansari
- Department of Anesthesia and Pain Management, Sinai Health System, Women's College Hospital, University Health Network, Toronto, ON, Canada
- Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada
| | - Jeannie Callum
- University of Toronto Quality in Utilization, Education and Safety in Transfusion Research Program, Toronto, ON, Canada
- Department of Pathology and Molecular Medicine, Kingston Health Sciences Centre and Queen's University, Kingston, ON, Canada
| | - Keyvan Karkouti
- Department of Anesthesia and Pain Management, Sinai Health System, Women's College Hospital, University Health Network, Toronto, ON, Canada
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada
- Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada
- Interdepartmental Division of Critical Care, Department of Medicine, University of Toronto, Toronto, ON, Canada
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2
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Apelseth TO, Raza S, Callum J, Ipe T, Blackwood B, Akhtar A, Hess JR, Marks DC, Brown B, Delaney M, Wendel S, Stanworth SJ. A review and analysis of outcomes in randomized clinical trials of plasma transfusion in patients with bleeding or for the prevention of bleeding: The BEST collaborative study. Transfusion 2024; 64:1116-1131. [PMID: 38623793 DOI: 10.1111/trf.17835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 03/26/2024] [Accepted: 03/28/2024] [Indexed: 04/17/2024]
Abstract
BACKGROUND Previous systematic reviews have revealed an inconsistency of outcome definitions as a major barrier in providing evidence-based guidance for the use of plasma transfusion to prevent or treat bleeding. We reviewed and analyzed outcomes in randomized controlled trials (RCTs) to provide a methodology for describing and classifying outcomes. STUDY DESIGN AND METHODS RCTs involving transfusion of plasma published after 2000 were identified from a prior review (Yang 2012) and combined with an updated systematic literature search of multiple databases (July 1, 2011 to January 17, 2023). Inclusion of publications, data extraction, and risk of bias assessments were performed in duplicate. (PROSPERO registration number is: CRD42020158581). RESULTS In total, 5579 citations were identified in the new systematic search and 22 were included. Six additional trials were identified from the previous review, resulting in a total of 28 trials: 23 therapeutic and five prophylactic studies. An increasing number of studies in the setting of major bleeding such as in cardiovascular surgery and trauma were identified. Eighty-seven outcomes were reported with a mean of 11 (min-max. 4-32) per study. There was substantial variation in outcomes used with a preponderance of surrogate measures for clinical effect such as laboratory parameters and blood usage. CONCLUSION There is an expanding literature on plasma transfusion to inform guidelines. However, considerable heterogeneity of reported outcomes constrains comparisons. A core outcome set should be developed for plasma transfusion studies. Standardization of outcomes will motivate better study design, facilitate comparison, and improve clinical relevance for future trials of plasma transfusion.
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Affiliation(s)
- Torunn O Apelseth
- Department of Immunology and Transfusion Medicine, Haukeland University Hospital, Bergen, Norway
- Faculty of Medicine, University of Bergen, Bergen, Norway
- Norwegian Armed Forces Joint Medical Services, Oslo, Norway
| | - Sheharyar Raza
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Canada
| | - Jeannie Callum
- Department of Pathology and Molecular Medicine, Kingston Health Sciences Centre and Queen's University, Kingston, Canada
| | - Tina Ipe
- Our Blood Institute, Oklahoma City, Oklahoma, USA
- Department of Pathology, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Bronagh Blackwood
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University, Belfast, UK
| | | | - John R Hess
- Department of Laboratory Medicine and Pathology, University of Washington School of Medicine, Seattle, Washington, USA
| | - Denese C Marks
- Research and Development, Australian Red Cross Lifeblood, Sydney, Australia
| | - Bethany Brown
- American Red Cross, Medical and Scientific Office, Washington, DC, USA
| | | | | | - Simon J Stanworth
- NHSBT, Oxford University Hospitals NHS Trust; Blood Transfusion Research Unit (BTRU), University of Oxford, Oxford, UK
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3
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Bottiger B, Klapper J, Fessler J, Shaz BH, Levy JH. Examining Bleeding Risk, Transfusion-related Complications, and Strategies to Reduce Transfusions in Lung Transplantation. Anesthesiology 2024; 140:808-816. [PMID: 38345894 DOI: 10.1097/aln.0000000000004829] [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: 03/13/2024]
Abstract
Blood product transfusions for bleeding management in lung transplantation affect recipient outcomes. Interventions are needed to reduce perioperative bleeding risk and optimize outcomes.
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Affiliation(s)
- Brandi Bottiger
- Department of Anesthesiology, Cardiothoracic Anesthesiology Division, Duke University Medical Center, Durham, North Carolina
| | - Jacob Klapper
- Department of Cardiothoracic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Julien Fessler
- Department of Anesthesiology, Hôpital Foch, Suresnes, France
| | - Beth H Shaz
- Department of Pathology, Duke University Medical Center, Durham, North Carolina
| | - Jerrold H Levy
- Department of Anesthesiology, Cardiothoracic Anesthesiology Division, Duke University Medical Center, Durham, North Carolina
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Juffermans NP, Gözden T, Brohi K, Davenport R, Acker JP, Reade MC, Maegele M, Neal MD, Spinella PC. Transforming research to improve therapies for trauma in the twenty-first century. Crit Care 2024; 28:45. [PMID: 38350971 PMCID: PMC10865682 DOI: 10.1186/s13054-024-04805-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2023] [Accepted: 01/11/2024] [Indexed: 02/15/2024] Open
Abstract
Improvements have been made in optimizing initial care of trauma patients, both in prehospital systems as well as in the emergency department, and these have also favorably affected longer term outcomes. However, as specific treatments for bleeding are largely lacking, many patients continue to die from hemorrhage. Also, major knowledge gaps remain on the impact of tissue injury on the host immune and coagulation response, which hampers the development of interventions to treat or prevent organ failure, thrombosis, infections or other complications of trauma. Thereby, trauma remains a challenge for intensivists. This review describes the most pressing research questions in trauma, as well as new approaches to trauma research, with the aim to bring improved therapies to the bedside within the twenty-first century.
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Affiliation(s)
- Nicole P Juffermans
- Department of Intensive Care, Erasmus Medical Center, Rotterdam, The Netherlands.
- Laboratory of Translational Intensive Care, Erasmus Medical Center, Rotterdam, The Netherlands.
| | - Tarik Gözden
- Laboratory of Translational Intensive Care, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Karim Brohi
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, UK
| | - Ross Davenport
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, UK
| | - Jason P Acker
- Canadian Blood Services, Innovation and Portfolio Management, Edmonton, AB, Canada
- Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, AB, Canada
| | - Michael C Reade
- Medical School, University of Queensland, Brisbane, QLD, Australia
- Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia
| | - Marc Maegele
- Department of Trauma and Orthopedic Surgery Cologne-Merheim Medical Center Institute of Research, Operative Medicine University Witten-Herdecke, Cologne, Germany
| | - Matthew D Neal
- Trauma and Transfusion Medicine Research Center, Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Philip C Spinella
- Trauma and Transfusion Medicine Research Center, Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
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5
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Brown JB, Schreiber M, Moore EE, Jenkins DH, Bank EA, Gurney JM. Commentary on gaps in prehospital trauma care: education and bioengineering innovations to improve outcomes in hemorrhage and traumatic brain injury. Trauma Surg Acute Care Open 2024; 9:e001122. [PMID: 38196935 PMCID: PMC10773423 DOI: 10.1136/tsaco-2023-001122] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Accepted: 08/23/2023] [Indexed: 01/11/2024] Open
Abstract
Hemorrhage remains the leading cause of preventable death on the battlefield and the civilian arena. Many of these deaths occur in the prehospital setting. Traumatic brain injury also represents a major source of early mortality and morbidity in military and civilian settings. The inaugural HERETIC (HEmostatic REsuscitation and Trauma Induced Coagulopathy) Symposium convened a multidisciplinary panel of experts in prehospital trauma care to discuss what education and bioengineering advancements in the prehospital space are necessary to improve outcomes in hemorrhagic shock and traumatic brain injury. The panel identified several promising technological breakthroughs, including field point-of-care diagnostics for hemorrhage and brain injury and unique hemorrhage control options for non-compressible torso hemorrhage. Many of these technologies exist but require further advancement to be feasibly and reliably deployed in a prehospital or combat environment. The panel discussed shifting educational and training paradigms to clinical immersion experiences, particularly for prehospital clinicians. The panel discussed an important balance between pushing traditionally hospital-based interventions into the field and developing novel intervention options specifically for the prehospital environment. Advancing prehospital diagnostics may be important not only to allow more targeted applications of therapeutic options, but also to identify patients with less urgent injuries that may not need more advanced diagnostics, interventions, or transfer to a higher level of care in resource-constrained environments. Academia and industry should partner and prioritize some of the promising advances identified with a goal to prepare them for clinical field deployment to optimize the care of patients near the point of injury.
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Affiliation(s)
- Joshua B Brown
- Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Martin Schreiber
- Surgery, Oregon Health and Science University, Portland, Oregon, USA
| | - Ernest E Moore
- Surgery, Ernest E Moore Shock Trauma Center at Denver Health, University of Colorado Denver, Denver, Colorado, USA
| | - Donald H Jenkins
- Surgery, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - Eric A Bank
- Harris County Emergency Services District No 48, Katy, Texas, USA
| | - Jennifer M Gurney
- Defense Committees on Trauma, Joint Trauma System, JBSA Fort Sam Houston, San Antonio, Texas, USA
- Department of Surgery, San Antonio Military Health System, San Antonio, Texas, USA
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6
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Pichon TJ, White NJ, Pun SH. ENGINEERED INTRAVENOUS THERAPIES FOR TRAUMA. CURRENT OPINION IN BIOMEDICAL ENGINEERING 2023; 27:100456. [PMID: 37456984 PMCID: PMC10343715 DOI: 10.1016/j.cobme.2023.100456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/18/2023]
Abstract
Trauma leading to severe hemorrhage and shock on average kills patients within 3 to 6 hours after injury. With average prehospital transport times reaching 1-6 hours in low- to middle-income countries, stopping the bleeding and reversing hemorrhagic shock is vital. First-generation intravenous hemostats rely on traditional drug delivery platforms, such as self-assembling systems, fabricated nanoparticles, and soluble polymers due to their active targeting, biodistribution, and safety. We discuss some challenges translating these therapies to patients, as very few have successfully made it through preclinical evaluation in large-animals, and none have translated to the clinic. Finally, we discuss the physiology of hemorrhagic shock, highlight a new low volume resuscitant (LVR) PEG-20k, and end with considerations for the rational design of LVRs.
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Affiliation(s)
- Trey J. Pichon
- Department of Bioengineering and Molecular Engineering and Sciences Institute, University of Washington, 3720 15 Avenue NE, Box 355061, Seattle, Washington 98105, United States
- Resuscitation Engineering Science Unit (RESCU), Harborview Research and Training Building, Seattle, Washington 98104, United States
| | - Nathan J. White
- Department of Emergency Medicine, University of Washington School of Medicine, Seattle, Washington 98105, United States
- Resuscitation Engineering Science Unit (RESCU), Harborview Research and Training Building, Seattle, Washington 98104, United States
| | - Suzie H. Pun
- Department of Bioengineering and Molecular Engineering and Sciences Institute, University of Washington, 3720 15 Avenue NE, Box 355061, Seattle, Washington 98105, United States
- Resuscitation Engineering Science Unit (RESCU), Harborview Research and Training Building, Seattle, Washington 98104, United States
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7
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Lammers D, Rokayak O, Uhlich R, Sensing T, Baird E, Richman J, Holcomb JB, Jansen J. Balanced resuscitation and earlier mortality end points: bayesian post hoc analysis of the PROPPR trial. Trauma Surg Acute Care Open 2023; 8:e001091. [PMID: 37575614 PMCID: PMC10414081 DOI: 10.1136/tsaco-2023-001091] [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: 01/16/2023] [Accepted: 07/23/2023] [Indexed: 08/15/2023] Open
Abstract
Introduction The Pragmatic Randomized Optimal Platelet and Plasma Ratios (PROPPR) trial failed to demonstrate a mortality difference for hemorrhaging patients receiving a balanced (1:1:1) vs a 1:1:2 resuscitation at 24 hours and 30 days. Recent guidelines recommend earlier mortality end points for hemorrhage-control trials, and the use of contemporary statistical methods. The aim of this post hoc analysis of the PROPPR trial was to evaluate the impact of a balanced resuscitation strategy at early resuscitation time points using a Bayesian analytical framework. Methods Bayesian hierarchical models were created to assess mortality differences at the 1, 3, 6, 12, 18, and 24 hours time points between study cohorts. Posterior probabilities and Bayes factors were calculated for each time point. Results A 1:1:1 resuscitation displayed a 96%, 99%, 94%, 92%, 96%, and 94% probability for mortality benefit at 1, 3, 6, 12, 18, and 24 hours, respectively, when compared with a 1:1:2 approach. Associated Bayes factors for each respective time period were 21.2, 142, 14.9, 11.4, 26.4, and 15.5, indicating 'strong' to 'decisive' supporting evidence in favor of balanced transfusions. Conclusion This analysis provides evidence in support that a 1:1:1 resuscitation has a high probability of mortality benefit when compared with a 1:1:2 strategy, especially at the newly defined more proximate time points during the resuscitative period. Researchers should consider using Bayesian approaches, along with more proximate end points when assessing hemorrhage-related mortality, for the analysis of future clinical trials. Level of evidence Level III/Therapeutic.
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Affiliation(s)
- Daniel Lammers
- Division of Trauma and Acute Care Surgery, The University of Alabama at Birmingham Hospital, Birmingham, Alabama, USA
| | - Omar Rokayak
- Division of Trauma and Acute Care Surgery, The University of Alabama at Birmingham Hospital, Birmingham, Alabama, USA
| | - Rindi Uhlich
- Division of Trauma and Acute Care Surgery, The University of Alabama at Birmingham Hospital, Birmingham, Alabama, USA
| | - Thomas Sensing
- Division of Trauma and Acute Care Surgery, The University of Alabama at Birmingham Hospital, Birmingham, Alabama, USA
| | - Emily Baird
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Joshua Richman
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - John B Holcomb
- Division of Trauma and Acute Care Surgery, The University of Alabama at Birmingham Hospital, Birmingham, Alabama, USA
| | - Jan Jansen
- Division of Trauma and Acute Care Surgery, The University of Alabama at Birmingham Hospital, Birmingham, Alabama, USA
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8
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Levy JH, Connors JM. Evaluation and management of oral anticoagulant bleeding: quid didicimus? (what have we learned?). J Thromb Haemost 2023; 21:460-462. [PMID: 36858792 DOI: 10.1016/j.jtha.2022.11.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Accepted: 11/24/2022] [Indexed: 03/02/2023]
Affiliation(s)
- Jerrold H Levy
- Departments of Anesthesiology, Critical Care, and Surgery, Duke University School of Medicine, Durham, North Carolina, USA.
| | - Jean M Connors
- Department of Medicine, Hematology Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Courtwright AM, Devarajan J, Fritz AV, Martin AK, Wilkey B, Subramani S, Cassara CM, Tawil JN, Miltiades AN, Boisen ML, Bottiger BA, Pollak A, Gelzinis TA. Cardiothoracic Transplant Anesthesia: Selected Highlights: Part I-Lung Transplantation. J Cardiothorac Vasc Anesth 2023; 37:884-903. [PMID: 36868904 DOI: 10.1053/j.jvca.2023.01.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Accepted: 01/22/2023] [Indexed: 01/30/2023]
Affiliation(s)
| | | | - Ashley Virginia Fritz
- Division of Cardiovascular and Thoracic Anesthesiology, Mayo Clinic, Jacksonville, FL
| | | | - Barbara Wilkey
- Department of Anesthesiology, University of Colorado, Aurora, CO
| | - Sudhakar Subramani
- Department of Anesthesiology, University of Iowa Hospitals & Clinics, Iowa City, IA
| | - Christopher M Cassara
- Department of Anesthesiology, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Justin N Tawil
- Department of Anesthesiology, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Andrea N Miltiades
- Department of Anesthesiology, Columbia University Medical Center, New York, NY
| | - Michael L Boisen
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Brandi A Bottiger
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Angela Pollak
- Department of Anesthesiology, Duke University, Durham, NC
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10
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Biffi A, Porcu G, Castellini G, Napoletano A, Coclite D, D’Angelo D, Fauci AJ, Iacorossi L, Latina R, Salomone K, Iannone P, Gianola S, Chiara O, Medici A, Mazzola A, Coniglio C, De Blasio E, Flego G, Geraci M, Maccauro G, Rampoldi A, Santolini F, Tacconi C, Tugnoli G, Stocchetti N, Fabbri A, Ruggeri MP, Seta MD, Pizzarelli S, Cammarano RR. Systemic hemostatic agents initiated in trauma patients in the pre-hospital setting: a systematic review. Eur J Trauma Emerg Surg 2022; 49:1259-1270. [DOI: 10.1007/s00068-022-02185-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Accepted: 11/24/2022] [Indexed: 12/23/2022]
Abstract
Abstract
Purpose
The effect of systemic hemostatic agents initiated during pre-hospital care of severely injured patients with ongoing bleeding or traumatic brain injury (TBI) remains controversial. A systematic review and meta-analysis was therefore conducted to assess the effectiveness and safety of systemic hemostatic agents as an adjunctive therapy in people with major trauma and hemorrhage or TBI in the context of developing the Italian National Institute of Health guidelines on major trauma integrated management.
Methods
PubMed, Embase, and Cochrane Library databases were searched up to October 2021 for studies that investigated pre-hospital initiated treatment with systemic hemostatic agents. The certainty of evidence was evaluated with the Grading of Recommendations Assessment, Development, and Evaluation approach, and the quality of each study was determined with the Cochrane risk-of-bias tool. The primary outcome was overall mortality, and secondary outcomes included cause-specific mortality, health-related quality of life, any adverse effects and blood product use, hemorrhage expansion, and patient-reported outcomes.
Results
Five trials of tranexamic acid (TXA) met the inclusion criteria for this meta-analysis. With a high certainty of evidence, when compared to placebo TXA reduced mortality at 24 h (relative risk = 0.83, 95% confidence interval = 0.73–0.94) and at 1 month among trauma patients (0.91, 0.85–0.97). These results depend on the subgroup of patients with significant hemorrhage because in the subgroup of TBI there are no difference between TXA and placebo. TXA also reduced bleeding death and multiple organ failure whereas no difference in health-related quality of life.
Conclusion
Balancing benefits and harms, TXA initiated in the pre-hospital setting can be used for patients experiencing major trauma with significant hemorrhage since it reduces the risk of mortality at 24 h and one month with no difference in terms of adverse effects when compared to placebo. Considering the subgroup of severe TBI, no difference in mortality rate was found at 24 h and one month. These results highlight the need to conduct future studies to investigate the role of other systemic hemostatic agents in the pre-hospital settings.
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11
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Roberts B, Green L, Ahmed V, Latham T, O'Boyle P, Yazer MH, Cardigan R. Modelling the outcomes of different red blood cell transfusion strategies for the treatment of traumatic haemorrhage in the prehospital setting in the United Kingdom. Vox Sang 2022; 117:1287-1295. [PMID: 36102164 PMCID: PMC9825834 DOI: 10.1111/vox.13359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 07/01/2022] [Accepted: 08/22/2022] [Indexed: 01/18/2023]
Abstract
BACKGROUND AND OBJECTIVES The limited supply and increasing demand of group O RhD-negative red blood cells (RBCs) have resulted in other transfusion strategies being explored by blood services that carry potential risks but may still provide an overall benefit to patients. Our aim was to analyse the potential economic benefits of prehospital transfusion (PHT) against no PHT. MATERIALS AND METHODS The impact of three PHT strategies (RhD-negative RBC, RhD-positive RBC and no transfusion) on quality-adjusted-life-years (QALYs) of all United Kingdom trauma patients in a given year and the subset of patients considered most at risk (RhD-negative females <50 years old), was modelled. RESULTS For the entire cohort and the subset of patients, transfusing RhD-negative RBCs generated the most QALYs (141,899 and 2977, respectively), followed by the RhD-positive RBCs (141,879.8 and 2958.8 respectively), and no prehospital RBCs (119,285 and 2503 respectively). The QALY difference between RhD-negative and RhD-positive policies was smaller (19.2, both cohorts) than RhD-positive and no RBCs policies in QALYs term (22,600 all cohort, 470 for a subset), indicating that harms from transfusing RhD-positive RBCs are lower than harms associated with no RBC transfusion. A survival increase from PHT of 0.02% (entire cohort) and 0.7% (subset cohort) would still make the RhD-positive strategy better in QALYs terms than no PHT. CONCLUSION While the use of RhD-positive RBCs carries risks, the benefits measured in QALYs are higher than if no PHT are administered, even for women of childbearing potential. Group O RhD-positive RBCs could be considered when there is a national shortage of RhD-negative RBCs.
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Affiliation(s)
- Barnaby Roberts
- Department of Health and Social CareHealth Protection AnalysisLondonUK
| | - Laura Green
- Blizard InstituteQueen Mary University of LondonLondonUK,NHS Blood and TransplantLondonUK,Barts Health NHS TrustLondonUK
| | - Venus Ahmed
- Department of Health and Social CareHealth Protection AnalysisLondonUK
| | | | - Peter O'Boyle
- Department of Health and Social CareHealth Protection AnalysisLondonUK
| | - Mark H. Yazer
- Department of PathologyUniversity of PittsburghPittsburghPennsylvaniaUSA
| | - Rebecca Cardigan
- NHS Blood and TransplantLondonUK,Department of HaematologyUniversity of CambridgeCambridgeUK
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12
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Yazer MH, Cap AP, Glassberg E, Green L, Holcomb JB, Khan MA, Moore EE, Neal MD, Perkins GD, Sperry JL, Thompson P, Triulzi DJ, Spinella PC. Toward a more complete understanding of who will benefit from prehospital transfusion. Transfusion 2022; 62:1671-1679. [PMID: 35796302 DOI: 10.1111/trf.17012] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 06/14/2022] [Accepted: 06/17/2022] [Indexed: 12/11/2022]
Affiliation(s)
- Mark H Yazer
- Department of Pathology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Andrew P Cap
- U.S. Army Institute of Surgical Research, Department of Medicine, Uniformed Services University, Bethesda, Maryland, USA
| | - Elon Glassberg
- Israeli Defense Forces, Medical Corps, Israel; Azrieli Faculty of Medicine, Bar-Ilan University, Safed, Israel, The Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Laura Green
- Barts Health NHS Trust, London, UK.,Blizard Institute, Queen Mary, University of London, London, UK.,NHS Blood and Transplant, London, UK
| | - John B Holcomb
- Center for Injury Science, Department of Surgery, University of Alabama at Birmingham, Birmingham, USA
| | - Mansoor A Khan
- Department of Abdominal Surgery and Medicine, University Hospitals Sussex, Sussex, UK
| | - Ernest E Moore
- Department of Surgery, Ernest E Moore Shock Trauma Center at Denver Health, University of Colorado Denver, Denver, Colorado, USA
| | - Matthew D Neal
- Pittsburgh Trauma and Transfusion Medicine Research Center, Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Gavin D Perkins
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK; Critical Care Unit, Heartlands Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Jason L Sperry
- Division of Trauma and General Surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | | | - Darrell J Triulzi
- Department of Pathology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Philip C Spinella
- Departments of Surgery and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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13
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Tolles J, Beiling M, Schreiber MA, Del Junco DJ, McMullan JT, Guyette FX, Wang H, Jansen JO, Meurer WJ, Mainali S, Yadav K, Lewis RJ. An adaptive platform trial for evaluating treatments in patients with life-threatening hemorrhage from traumatic injuries: Rationale and proposal. Transfusion 2022; 62 Suppl 1:S231-S241. [PMID: 35732508 DOI: 10.1111/trf.16957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Revised: 04/29/2022] [Accepted: 05/04/2022] [Indexed: 11/30/2022]
Affiliation(s)
- Juliana Tolles
- Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, California, USA.,Department of Emergency Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California, USA.,Berry Consultants, LLC, Austin, Texas, USA
| | - Marissa Beiling
- Division of Trauma, Critical Care & Acute Care Surgery, Department of Surgery, Oregon Health & Science University, Portland, Oregon, USA
| | - Martin A Schreiber
- Division of Trauma, Critical Care & Acute Care Surgery, Department of Surgery, Oregon Health & Science University, Portland, Oregon, USA
| | - Deborah J Del Junco
- Joint Trauma System, Defense Health Agency, Joint Base San Antonio Fort Sam Houston, San Antonio, Texas, USA.,Department of Emergency Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Jason T McMullan
- Department of Emergency Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Francis X Guyette
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Henry Wang
- Department of Emergency Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Jan O Jansen
- Center for Injury Science, University of Alabama at Birmingham, Birmingham, Alabama, USA.,Division of Trauma & Acute Care Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - William J Meurer
- Berry Consultants, LLC, Austin, Texas, USA.,Department of Emergency Medicine, University of Michigan, Ann Arbor, Michigan, USA.,Department of Neurology, University of Michigan, Ann Arbor, Michigan, USA
| | - Shraddha Mainali
- Department of Neurology, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Kabir Yadav
- Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, California, USA.,Department of Emergency Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Roger J Lewis
- Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, California, USA.,Department of Emergency Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California, USA.,Berry Consultants, LLC, Austin, Texas, USA
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14
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Levy JH, Faraoni D, Almond CS, Baumann-Kreuziger L, Bembea MM, Connors JM, Dalton HJ, Davies R, Dumont LJ, Griselli M, Karkouti K, Massicotte MP, Teruya J, Thiagarajan RR, Spinella PC, Steiner ME. Consensus Statement: Hemostasis Trial Outcomes in Cardiac Surgery and Mechanical Support. Ann Thorac Surg 2022; 113:1026-1035. [PMID: 34826386 DOI: 10.1016/j.athoracsur.2021.09.080] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 08/08/2021] [Accepted: 09/27/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND Research evaluating hemostatic agents for the treatment of clinically significant bleeding has been hampered by inconsistency and lack of standardized primary clinical trial outcomes. Clinical trials of hemostatic agents in both cardiac surgery and mechanical circulatory support, such as extracorporeal membrane oxygenation and ventricular assist devices, are examples of studies that lack implementation of universally accepted outcomes. METHODS A subgroup of experts convened by the National Heart, Lung, and Blood Institute and the US Department of Defense developed consensus recommendations for primary outcomes in cardiac surgery and mechanical circulatory support. RESULTS For cardiac surgery the primary efficacy endpoint of total allogeneic blood products (units vs mL/kg for pediatric patients) administered intraoperatively and postoperatively through day 5 or hospital discharge is recommended. For mechanical circulatory support outside the perioperative period the recommended primary outcome for extracorporeal membrane oxygenation is a 5-point ordinal score of thrombosis and bleeding severity adapted from the Common Terminology Criteria for Adverse Events version 5.0. The recommended primary endpoint for ventricular assist device is freedom from disabling stroke (Common Terminology Criteria for Adverse Events AE ≥ grade 3) through day 180. CONCLUSIONS The proposed composite risk scores could impact the design of upcoming clinical trials and enable comparability of future investigations. Harmonizing and disseminating global consensus definitions and management guidelines can also reduce patient heterogeneity that would confound standardized primary outcomes in future research.
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Affiliation(s)
- Jerrold H Levy
- Division Cardiothoracic Anesthesiology and Critical Care, Departments of Anesthesiology and Surgery (Cardiothoracic), Duke University School of Medicine, Durham, North Carolina.
| | - David Faraoni
- Division of Cardiac Anesthesia, Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Christopher S Almond
- Heart Failure Service, Cardiac Anticoagulation Service, Lucile Packard Children's Hospital Stanford, Stanford University School of Medicine, Palo Alto, California
| | | | - Melania M Bembea
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jean M Connors
- Hematology Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Heidi J Dalton
- INOVA Heart and Vascular Institute; Department of Pediatrics, INOVA Fairfax Medical Center, Falls Church, Virginia
| | - Ryan Davies
- Department of Cardiovascular and Thoracic Surgery, University of Texas Southwestern Medical Center and Children's Health, Dallas, Texas
| | - Larry J Dumont
- Vitalant Research Institute, Denver, Colorado; Department of Pathology, University of Colorado Medical School, Denver, Colorado; Department of Pathology and Laboratory Medicine, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| | - Massimo Griselli
- Division of Pediatric Cardiovascular Surgery, University of Minnesota, Minneapolis, Minnesota
| | - Keyvan Karkouti
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
| | - M Patricia Massicotte
- Division of Cardiology, Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Jun Teruya
- Division of Transfusion Medicine and Coagulation, Department of Pathology and Immunology, Pediatrics and Medicine, Texan Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Ravi R Thiagarajan
- Cardiac Intensive Care Unit, Boston Children's Hospital, Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Philip C Spinella
- Division of Critical Care, Department of Pediatrics, Washington University School of Medicine, St Louis, Missouri
| | - Marie E Steiner
- Divisions of Hematology and Critical Care, Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota
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15
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Cholette JM, Muszynski JA, Ibla JC, Emani S, Steiner ME, Vogel AM, Parker RI, Nellis ME, Bembea MM. Plasma and Platelet Transfusions Strategies in Neonates and Children Undergoing Cardiac Surgery With Cardiopulmonary Bypass or Neonates and Children Supported by Extracorporeal Membrane Oxygenation: From the Transfusion and Anemia EXpertise Initiative-Control/Avoidance of Bleeding. Pediatr Crit Care Med 2022; 23:e25-e36. [PMID: 34989703 PMCID: PMC8769357 DOI: 10.1097/pcc.0000000000002856] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [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 the recommendations and consensus statements with supporting literature for plasma and platelet transfusions in critically ill neonates and children undergoing cardiac surgery with cardiopulmonary bypass or supported by extracorporeal membrane oxygenation 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 following cardiopulmonary bypass or supported by extracorporeal membrane oxygenation. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS A panel of nine experts developed evidence-based and, when evidence was insufficient, expert-based statements for plasma and platelet transfusions in critically ill neonates and children following cardiopulmonary bypass or supported by extracorporeal membrane oxygenation. 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, two recommendations, and three expert consensus statements. CONCLUSIONS Whereas viscoelastic testing and transfusion algorithms may be considered, in general, evidence informing indications for plasma and platelet transfusions in neonatal and pediatric patients undergoing cardiac surgery with cardiopulmonary bypass or those requiring extracorporeal membrane oxygenation support is lacking.
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Affiliation(s)
- Jill M Cholette
- Department of Pediatrics, University of Rochester Golisano Children's Hospital, Rochester, NY
| | - Jennifer A Muszynski
- Department of Pediatrics, Division of Critical Care Medicine, Nationwide Children's Hospital, Columbus, OH
| | - Juan C Ibla
- Division of Cardiac Anesthesia, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital and Harvard Medical School, Boston, MA
| | - Sitaram Emani
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, MA
| | - Marie E Steiner
- Divisions of Critical Care and Hematology, Department of Pediatrics, University of Minnesota Masonic Children's Hospital, Minneapolis, MN
| | - Adam M Vogel
- Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital and Baylor College of Medicine, Houston, TX
| | - Robert I Parker
- Professor Emeritus, Department of Pediatrics, Hematology/Oncology, Renaissance School of Medicine, SUNY at Stony Brook, Stony Brook, NY
| | - Marianne E Nellis
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, NY Presbyterian Hospital - Weill Cornell Medicine, New York, NY
| | - Melania M Bembea
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
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16
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Jensen DM, Barkun A, Cave D, Gralnek IM, Jutabha R, Laine L, Lau JYW, Saltzman JR, Soetikno R, Sung JJ. Acute gastrointestinal bleeding: proposed study outcomes for new randomised controlled trials. Aliment Pharmacol Ther 2021; 54:616-626. [PMID: 34288017 PMCID: PMC9385213 DOI: 10.1111/apt.16483] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Revised: 05/10/2021] [Accepted: 06/02/2021] [Indexed: 12/29/2022]
Abstract
BACKGROUND Acute gastrointestinal bleeding (GIB) remains a common cause of hospitalisation. However, interpretation and comparisons of published studies in GIB have been hampered by disparate study methodology. AIMS To make recommendations about outcome measures to be used in future randomised controlled trials (RCTs) of patients with acute bleeding from any GI source (nonvariceal UGI, variceal, small bowel, or colon) and suggest new RCTs in acute GIB for future peer-reviewed funding. METHODS As part of a National Institutes of Health conference entitled "Hemostatic Outcomes in Clinical Trials", a group of GIB experts performed targeted critical reviews of available evidence with the goal of proposing a bleeding outcome that could potentially be applied to different disciplines. In addition, the panel sought to develop a clinically meaningful primary endpoint specifically for acute GIB, potentially allowing a more contemporary regrouping of clinically relevant outcomes. RESULTS The primary endpoint proposed was a composite outcome of further bleeding within 30 days after randomisation leading to red blood cell transfusion, urgent intervention (repeat endoscopy; interventional radiology or surgery), or death. Secondary outcomes may include the individual components of the primary outcome, length of hospitalisation, serious adverse events, and health care resource utilisation. CONCLUSION The proposed endpoint may help move the GIB field forward by focusing on the most clinically relevant outcomes for patients with acute GIB of all types and informing study design and importance of sample size determination for future RCTs in GIB.
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Affiliation(s)
- Dennis M. Jensen
- Division of Gastroenterology, Department of Medicine, David Geffen School of Medicine at UCLA and VA Greater Los Angeles Healthcare System Los Angeles, CA
| | - Alan Barkun
- Division of Gastroenterology, McGill University and the McGill University Health Centre Montréal, Québec, Canada
| | - David Cave
- UMass Memorial Medical Center, Worcester MA
| | - Ian M. Gralnek
- Rappaport Faculty of Medicine Technion Israel Institute of Technology, Haifa Israel, Ellen and Pinchas Mamber Institute of Gastroenterology and Hepatology Emek Medical Center, Afula, Israel
| | - Rome Jutabha
- Division of Gastroenterology and Hepatology, Keck Hospital of University of Southern California, Los Angeles, CA
| | - Loren Laine
- Yale School of Medicine, New Haven CT; VA Connecticut Healthcare System, West Haven, CT
| | | | | | - Roy Soetikno
- University of California, San Francisco, Department of Medicine, San Francisco, CA
| | - Joseph J.Y. Sung
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
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17
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Mayer SA, Frontera JA, Jankowitz B, Kellner CP, Kuppermann N, Naik BI, Nishijima DK, Steiner T, Goldstein JN. Recommended Primary Outcomes for Clinical Trials Evaluating Hemostatic Agents in Patients With Intracranial Hemorrhage: A Consensus Statement. JAMA Netw Open 2021; 4:e2123629. [PMID: 34473266 DOI: 10.1001/jamanetworkopen.2021.23629] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE In patients with acute spontaneous or traumatic intracranial hemorrhage, early hemostasis is thought to be critical to minimize ongoing bleeding. However, research evaluating hemostatic therapies has been hampered by a lack of standardized clinical trial outcome measures. OBJECTIVE To identify appropriate primary outcomes for phase 2 and 3 clinical trials of therapies aimed at reducing acute intracranial bleeding. EVIDENCE REVIEW A comprehensive review of all previous clinical trials of hemostatic therapy for intracranial bleeding was performed, and studies measuring the frequency, risk factors, and association of intracranial bleeding with outcome of hemorrhage growth were included. FINDINGS A hierarchy of 3 outcome measures is recommended, with the first choice being a global patient-centered clinical outcome scale measured 30 to 180 days after the event; the second, a combined clinical and radiographic end point associating hemorrhage expansion with a poor patient-centered outcome at 24 hours or later; and the third, a radiographic measure of hemorrhage expansion at 24 hours alone. Additional recommendations stress the importance of separating various subtypes of bleeding when possible, early treatment within a standardized treatment window, and the routine use of computerized planimetry comparing continuous measures of absolute and relative hemorrhage growth as either a primary or secondary end point. CONCLUSIONS AND RELEVANCE Standardization of outcome measures in studies of intracranial bleeding and hemostatic therapy will support comparative effectiveness research and meta-analysis, with the goal of accelerating the translation of research into clinical practice. The 3 outcome measures proposed in this consensus statement could help this process.
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Affiliation(s)
- Stephan A Mayer
- Departments of Neurology and Neurosurgery, Westchester Medical Center Health, New York Medical College, Valhalla
| | | | - Brian Jankowitz
- Department of Neurosurgery, Cooper University Health Care, Camden, New Jersey
| | | | - Nathan Kuppermann
- Departments of Emergency Medicine and Pediatrics, University of California, Davis School of Medicine, UC Davis Health, Sacramento
| | - Bhiken I Naik
- Department of Anesthesiology and Neurological Surgery, University of Virginia, Charlottesville
| | - Daniel K Nishijima
- Department of Emergency Medicine, University of California, Davis School of Medicine, UC Davis Health, Sacramento
| | - Thorsten Steiner
- Department of Neurology, Klinikum Frankfurt Höchst, Frankfurt, Germany
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Joshua N Goldstein
- Department of Emergency Medicine, Massachusetts General Hospital, Boston
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