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Lombardo S, Millar D, Jurkovich GJ, Coimbra R, Nirula R. Factor VIIa administration in traumatic brain injury: an AAST-MITC propensity score analysis. Trauma Surg Acute Care Open 2018; 3:e000134. [PMID: 29766126 PMCID: PMC5887758 DOI: 10.1136/tsaco-2017-000134] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2017] [Revised: 01/09/2018] [Accepted: 01/10/2018] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Recombinant factor VIIa (rFVIIa) has been used off-label as an adjunct in the reversal of warfarin therapy and management of hemorrhage after trauma. Only a handful of these reports are rigorous studies, from which results regarding safety and effectiveness have been mixed. There remains no clear consensus as to the role of rFVIIa in traumatic brain injury (TBI). METHODS Eleven level 1 trauma centers provided clinical data and head CT scans of patients with a Glasgow Coma Scale (GCS) score of ≤13 and radiographic evidence of TBI. A propensity score (PS) to receive rFVIIa in those surviving ≥2 days was calculated for each patient based on patient demographics, comorbidities, physiology, Injury Severity Score, admission GCS score, and treatment center. Patients receiving rFVIIa within 24 hours of admission were matched to patients who did not receive rFVIIa for outcomes assessment. Subgroup analysis evaluated patients with primary head injury with PS matching. RESULTS There were 4284 patient observations; 129 received rFVIIa. Groups were comparable after matching. No differences in mortality or morbidity were found. Improvement in GCS score from admission to discharge was less among those receiving rFVIIa (5.5 vs. 2.4; P value 0.001); however, there was no difference in average GCS score at discharge. No significant differences in outcomes were identified in patients with isolated TBI receiving rFVIIa. DISCUSSION rFVIIa in early management of TBI is not associated with a decreased risk of mortality or morbidity, and may negatively impact recovery and functional status at discharge in the severely injured patient with polytrauma. LEVEL OF EVIDENCE Level III. STUDY TYPE Therapeutic/care management.
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Affiliation(s)
- Sarah Lombardo
- Department of Surgery, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - D Millar
- Division of Trauma, Critical Care and Acute Care Surgery, Department of General Surgery, University of Cincinnati Medical Center, Cincinnati, Ohio, USA
| | - Gregory J Jurkovich
- Division of Trauma, Acute Care Surgery and Surgical Critical Care, Department of Surgery, University of California Davis School of Medicine, Sacramento, California, USA
| | - Raul Coimbra
- Division of Trauma, Surgical Critical Care and Burns, Department of Surgery, University of San Diego, San Diego, California, USA
| | - Ram Nirula
- Acute Care Surgery Section, Department of Surgery, University of Utah School of Medicine, Salt Lake City, Utah, USA
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Mica L, Simmen H, Werner CML, Plecko M, Keller C, Wirth SH, Sprengel K. Fresh frozen plasma is permissive for systemic inflammatory response syndrome, infection, and sepsis in multiple-injured patients. Am J Emerg Med 2016; 34:1480-5. [PMID: 27260556 DOI: 10.1016/j.ajem.2016.04.041] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2016] [Revised: 04/27/2016] [Accepted: 04/28/2016] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND The correction of coagulopathy with fresh frozen plasma (FFP) is one of the main issues in the treatment of multiple-injured patients. Infectious and septic complications contribute to an adverse outcome in multiple-injured patients. Here, we investigated the role of FFP in the development of inflammatory complications given within the first 48 hours. METHODS A total of 2033 patients with multiple injuries and an Injury Severity Score greater than 16 points and aged 16 years or older were included. The population was subdivided into 2 groups: those who received FFP and those who did not. The data were analyzed using SPSS version 22.0. Associations between the data were tested using Pearson correlation. Independent predictivity was analyzed by binary logistic regression and multivariate regression. Data were considered as significant if P<.05. RESULTS The prothrombin time at admission was significantly lower (68.5%±23.3% vs 81.8%±21.0% normal; P<.001) in the group receiving FFP. The application of FFP led to a more severe systemic inflammatory response syndrome (SIRS) grade (3.0±1.2 vs 2.2±1.4; P<.001), to a higher infection rate (48% vs 28%; P<.001), and to a higher sepsis rate (29% vs 13%; P<.001) in the patients receiving FFP. The correlations between SIRS and the incidence of infections and sepsis increased with the amount of FFP applied (P<.001). CONCLUSIONS Treatment with FFP of bleeding patients with multiple injuries enhances the risk of SIRS, infection, and sepsis; however, a multifactorial genesis has to be postulated.
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Affiliation(s)
- Ladislav Mica
- Division of Trauma Surgery, University Hospital of Zürich, 8091 Zürich, Switzerland.
| | - Hanspeter Simmen
- Division of Trauma Surgery, University Hospital of Zürich, 8091 Zürich, Switzerland
| | - Clément M L Werner
- Division of Trauma Surgery, University Hospital of Zürich, 8091 Zürich, Switzerland
| | - Michael Plecko
- Division of Trauma Surgery, University Hospital of Zürich, 8091 Zürich, Switzerland
| | | | | | - Kai Sprengel
- Division of Trauma Surgery, University Hospital of Zürich, 8091 Zürich, Switzerland
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Jokar TO, Khalil M, Rhee P, Kulvatunyou N, Pandit V, O'Keeffe T, Tang A, Joseph B. Ratio-based Resuscitation in Trauma Patients with Traumatic Brain Injury: Is There a Similar Effect? Am Surg 2016. [DOI: 10.1177/000313481608200322] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The use of 1:1:1 (packed red blood cells: fresh frozen plasma: platelets) transfusion ratio has been shown to improve survival in severely injured trauma patients. The aim of this study was to assess the outcomes in patients with traumatic brain injury (TBI) receiving 1:1:1 ratio-based blood product transfusion (RBT). We hypothesized that RBT improves survival in patients with TBI as only major injury. We performed a 3-year retrospective analysis of all patients with TBI as only major injury presenting to our Level I trauma center. Patients receiving blood transfusion were included. Patients were stratified into two groups: those who received RBT and those who did not receive RBT (No-RBT). The outcome measure was inhospital mortality. Multivariate logistic regression analysis was performed. A total of 189 patients were included of which 29 per cent (n = 55) received RBT. The mean age was 48 ± 24 years, median (range) Glasgow Coma Scale score was 12 (3–15), and median head abbreviated injury severity scale was 3 (3–5). The overall mortality rate was 28.5 per cent. Patients in the RBT group had a higher survival rate compared with the patients in the No-RBT group (83.6% vs 66.5%, P = 0.02). In conclusion, the survival benefit of RBT exists even in patients with TBI as major injury. Guidelines for the initial management of TBI patients should focus on the use of RBT. The beneficial effect of platelets in RBT among TBI patients requires further evaluation.
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Affiliation(s)
- Tahereh Orouji Jokar
- From the Division of Trauma, Critical Care, Burn and Emergency Surgery, Department of Surgery, University of Arizona, Tucson, Arizona
| | - Mazhar Khalil
- From the Division of Trauma, Critical Care, Burn and Emergency Surgery, Department of Surgery, University of Arizona, Tucson, Arizona
| | - Peter Rhee
- From the Division of Trauma, Critical Care, Burn and Emergency Surgery, Department of Surgery, University of Arizona, Tucson, Arizona
| | - Narong Kulvatunyou
- From the Division of Trauma, Critical Care, Burn and Emergency Surgery, Department of Surgery, University of Arizona, Tucson, Arizona
| | - Viraj Pandit
- From the Division of Trauma, Critical Care, Burn and Emergency Surgery, Department of Surgery, University of Arizona, Tucson, Arizona
| | - Terence O'Keeffe
- From the Division of Trauma, Critical Care, Burn and Emergency Surgery, Department of Surgery, University of Arizona, Tucson, Arizona
| | - Andrew Tang
- From the Division of Trauma, Critical Care, Burn and Emergency Surgery, Department of Surgery, University of Arizona, Tucson, Arizona
| | - Bellal Joseph
- From the Division of Trauma, Critical Care, Burn and Emergency Surgery, Department of Surgery, University of Arizona, Tucson, Arizona
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Joseph B, Aziz H, Pandit V, Hays D, Kulvatunyou N, Yousuf Z, Tang A, O'Keeffe T, Green D, Friese RS, Rhee P. Prothrombin complex concentrate versus fresh-frozen plasma for reversal of coagulopathy of trauma: is there a difference? World J Surg 2015; 38:1875-81. [PMID: 24798029 DOI: 10.1007/s00268-014-2631-y] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
INTRODUCTION The development of coagulopathy of trauma is multifactorial associated with hypoperfusion and consumption of coagulation factors. Previous studies have compared the role of factor replacement versus FPP for reversal of trauma coagulopathy. The purpose of our study was to determine the time to correction of coagulopathy and blood product requirement in patients who received PCC+FFP compared with patients who received FFP alone. METHODS We performed a retrospective analysis of a prospectively maintained database of all coagulopathic (INR ≥ 1.5) trauma patients presenting to our level I trauma center during a 2-years period (2011-2012). Patients were stratified into two groups: patients who received PCC+FFP and patients who received FFP alone. Patients in the two groups were matched in a 1:3 (PCC+FFP:FFP) ratio using propensity score matching for demographics, injury severity, vital parameters, and initial INR. The two groups were then compared for: correction of INR, time to correction of INR, thromboembolic complications, mortality, and cost of therapy. RESULTS A total of 252 were included in the analysis [PCC+FFP:63; FFP:189]. The mean age was 44 ± 20 years; 70 % were male, with a median ISS score of 27 [16-38]. PCC use was associated with an accelerated correction of INR (394 vs. 1,050 min; p 0.001), reduction in requirement of pack red blood cell (6.6 vs. 10 units; p 0.001) and FFP (2.8 vs. 3.9 units; p 0.01), and decline in mortality (23 vs. 28%; p 0.04). PCC+FFP use was associated with a higher cost of therapy ($1,470 ± 845 vs. 1,171 ± 949; p 0.01) but lower overall cost of transfusion ($7,110 ± 1,068 vs. 9,571 ± 1,524; p 0.01) compared with FFP therapy alone. CONCLUSIONS PCC in conjunction with FFP rapidly corrects INR in a matched cohort of trauma patients not on warfarin therapy compared with FFP therapy alone. The use of PCC as an adjunct to FFP therapy is associated with reduction of blood product requirement and also lowers overall cost.
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Affiliation(s)
- Bellal Joseph
- Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, University of Arizona, 1501 N. Campbell Avenue, Room 5411, P.O. Box 245063, Tucson, AZ, 85724, US,
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Joseph B, Pandit V, Khalil M, Kulvatunyou N, Aziz H, Tang A, O'Keeffe T, Hays D, Gries L, Lemole M, Friese RS, Rhee P. Use of Prothrombin Complex Concentrate as an Adjunct to Fresh Frozen Plasma Shortens Time to Craniotomy in Traumatic Brain Injury Patients. Neurosurgery 2015; 76:601-7; discussion 607. [DOI: 10.1227/neu.0000000000000685] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
AbstractBACKGROUND:The use of prothrombin complex concentrate (PCC) to reverse acquired (coagulopathy of trauma) and induced coagulopathy (preinjury warfarin use) is well defined.OBJECTIVE:To compare outcomes in patients with traumatic brain injury without warfarin therapy receiving PCC as an adjunct to fresh frozen plasma (FFP) therapy compared with patients receiving FFP therapy alone.METHODS:All patients with traumatic brain injury coagulopathy without warfarin therapy who received PCC (25 IU/kg) in conjunction with FFP or FFP alone at our Level I trauma center were reviewed. Coagulopathy was defined as an international normalized ratio >1.5. The groups (PCC + FFP vs FFP alone) were matched using propensity score matching on a 1:2 ratio for age, sex, Glasgow Coma Scale score, Injury Severity Score, head Abbreviated Injury Scale score, and international normalized ratio (INR) on presentation. The primary outcome measure was time to craniotomy. Secondary outcome measures were blood product requirements, cost of therapy, and mortality.RESULTS:A total of 1641 patients were reviewed, 222 of whom were included (PCC + FFP, 74; FFP, 148). The mean ± standard deviation age was 46.4 ± 21.7 years, the median (range) Glasgow Coma Scale score was 8 (3-12), and the mean ± standard deviation INR on presentation was 1.92 ± 0.6. PCC + FFP therapy was associated with an accelerated correction of INR (P = .001) and decrease in overall pack red blood cell (P = .035) and FFP (P = .041) administration requirement. Craniotomy was performed in 26.1% of patients (n = 58). Patients who received PCC + FFP therapy had faster time to craniotomy (P = .028) compared with patients who received FFP therapy alone.CONCLUSION:PCC as an adjunct to FFP decreases the time to craniotomy with faster correction of INR and concomitant decrease in the need for blood product requirement in patients with traumatic brain injury exclusive of prehospital warfarin therapy.
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Affiliation(s)
- Bellal Joseph
- Division of Trauma, Emergency Surgery, Critical Care, and Burns, Department of Surgery, University of Arizona, Tucson, Arizona
- Oral Presentation at the Surgical Forum, American College of Surgery, October 2013, Washington, DC
| | - Viraj Pandit
- Division of Trauma, Emergency Surgery, Critical Care, and Burns, Department of Surgery, University of Arizona, Tucson, Arizona
- Oral Presentation at the Surgical Forum, American College of Surgery, October 2013, Washington, DC
| | - Mazhar Khalil
- Division of Trauma, Emergency Surgery, Critical Care, and Burns, Department of Surgery, University of Arizona, Tucson, Arizona
- Oral Presentation at the Surgical Forum, American College of Surgery, October 2013, Washington, DC
| | - Narong Kulvatunyou
- Division of Trauma, Emergency Surgery, Critical Care, and Burns, Department of Surgery, University of Arizona, Tucson, Arizona
- Oral Presentation at the Surgical Forum, American College of Surgery, October 2013, Washington, DC
| | - Hassan Aziz
- Division of Trauma, Emergency Surgery, Critical Care, and Burns, Department of Surgery, University of Arizona, Tucson, Arizona
- Oral Presentation at the Surgical Forum, American College of Surgery, October 2013, Washington, DC
| | - Andrew Tang
- Division of Trauma, Emergency Surgery, Critical Care, and Burns, Department of Surgery, University of Arizona, Tucson, Arizona
- Oral Presentation at the Surgical Forum, American College of Surgery, October 2013, Washington, DC
| | - Terence O'Keeffe
- Division of Trauma, Emergency Surgery, Critical Care, and Burns, Department of Surgery, University of Arizona, Tucson, Arizona
- Oral Presentation at the Surgical Forum, American College of Surgery, October 2013, Washington, DC
| | - Daniel Hays
- Division of Trauma, Emergency Surgery, Critical Care, and Burns, Department of Surgery, University of Arizona, Tucson, Arizona
- Oral Presentation at the Surgical Forum, American College of Surgery, October 2013, Washington, DC
| | - Lynn Gries
- Division of Trauma, Emergency Surgery, Critical Care, and Burns, Department of Surgery, University of Arizona, Tucson, Arizona
- Oral Presentation at the Surgical Forum, American College of Surgery, October 2013, Washington, DC
| | - Michael Lemole
- Division of Trauma, Emergency Surgery, Critical Care, and Burns, Department of Surgery, University of Arizona, Tucson, Arizona
- Oral Presentation at the Surgical Forum, American College of Surgery, October 2013, Washington, DC
| | - Randall S. Friese
- Division of Trauma, Emergency Surgery, Critical Care, and Burns, Department of Surgery, University of Arizona, Tucson, Arizona
- Oral Presentation at the Surgical Forum, American College of Surgery, October 2013, Washington, DC
| | - Peter Rhee
- Division of Trauma, Emergency Surgery, Critical Care, and Burns, Department of Surgery, University of Arizona, Tucson, Arizona
- Oral Presentation at the Surgical Forum, American College of Surgery, October 2013, Washington, DC
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Moderate elevations in international normalized ratio should not lead to delays in neurosurgical intervention in patients with traumatic brain injury. J Trauma Acute Care Surg 2015; 77:846-50; discussion 851. [PMID: 25423533 DOI: 10.1097/ta.0000000000000459] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND The management of severe traumatic brain injury (TBI) frequently involves invasive intracranial monitoring or cranial surgery. In our institution, intracranial procedures are often deferred until an international normalized ratio (INR) of less than 1.4 is achieved. There is no evidence that a moderately elevated INR is associated with increased risk of bleeding in patients undergoing neurosurgical intervention (NI). Thrombelastography (TEG) provides a functional assessment of clotting and has been shown to better predict clinically relevant coagulopathy compared with INR. We hypothesized that in patients with TBI, an elevated INR would result in increased time to NI and would not be associated with coagulation abnormalities based on TEG. METHODS A secondary analysis of prospectively collected data was performed in trauma patients with intracranial hemorrhage that underwent NI (defined as cranial surgery or intracranial pressure monitoring) within 24 hours of arrival. Time from admission to NI was recorded. TEG and routine coagulation assays were obtained at admission. Patients were considered hypocoagulable based on INR if their admission INR was greater than 1.4 (high INR). Manufacturer-specified values were used to determine hypocoagulability for each TEG variable. RESULTS Sixty-one patients (median head Abbreviated Injury Scale [AIS] score, 5) met entry criteria, of whom 16% had high INR. Demographic, physiologic, and injury scoring data were similar between groups. The median time to NI was longer in patients with high INR (358 minutes vs. 184 minutes, p = 0.027). High-INR patients were transfused more plasma than patients with an INR of 1.4 or less (2 U vs. 0 U, p = 0.01). There was no association between an elevated INR and hypocoagulability based on TEG. CONCLUSION TBI patients with an admission INR of greater than 1.4 had a longer time to NI. The use of plasma transfusion to decrease the INR may have contributed to this delay. A moderately elevated INR was not associated with coagulation abnormalities based on TEG. Routine plasma transfusion to correct a moderately elevated INR before NI should be reexamined. LEVEL OF EVIDENCE Diagnostic study, level III.
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Kim B, Haque A, Arnaud FG, Teranishi K, Steinbach T, Auker CR, McCarron RM, Freilich D, Scultetus AH. Use of recombinant factor VIIa (rFVIIa) as pre-hospital treatment in a swine model of fluid percussion traumatic brain injury. J Emerg Trauma Shock 2014; 7:102-11. [PMID: 24812455 PMCID: PMC4013725 DOI: 10.4103/0974-2700.130880] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2013] [Accepted: 11/19/2013] [Indexed: 11/04/2022] Open
Abstract
CONTEXT Recombinant factor VIIa (rFVIIa) has been used as an adjunctive therapy for acute post-traumatic hemorrhage and reversal of iatrogenic coagulopathy in trauma patients in the hospital setting. However, investigations regarding its potential use in pre-hospital management of traumatic brain injury (TBI) have not been conducted extensively. AIMS In the present study, we investigated the physiology, hematology and histology effects of a single pre-hospital bolus injection of rFVIIa compared to current clinical practice of no pre-hospital intervention in a swine model of moderate fluid percussion TBI. MATERIALS AND METHODS Animals were randomized to receive either a bolus of rFVIIa (90 μg/kg) or nothing 15 minutes (T15) post-injury. Hospital arrival was simulated at T60, and animals were euthanized at experimental endpoint (T360). RESULTS Survival was 100% in both groups; baseline physiology parameters were similar, vital signs were comparable. Animals that received rFVIIa demonstrated less hemorrhage in subarachnoid space (P = 0.0037) and less neuronal degeneration in left hippocampus, pons, and cerebellum (P = 0.00009, P = 0.00008, and P = 0.251, respectively). Immunohistochemical staining of brain sections showed less overall loss of microtubule-associated protein 2 (MAP2) and less Flouro-Jade B positive cells in rFVIIa-treated animals. CONCLUSIONS Early pre-hospital administration of rFVIIa in this swine TBI model reduced neuronal necrosis and intracranial hemorrhage (ICH). These results merit further investigation of this approach in pre-hospital trauma care.
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Affiliation(s)
- Bobby Kim
- Department of Neuro Trauma, Naval Medical Research Center, Silver Spring, Maryland, USA
| | - Ashraful Haque
- Department of Neuro Trauma, Naval Medical Research Center, Silver Spring, Maryland, USA
| | - Françoise G Arnaud
- Department of Neuro Trauma, Naval Medical Research Center, Silver Spring, Maryland, USA ; Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Kohsuke Teranishi
- Department of Neuro Trauma, Naval Medical Research Center, Silver Spring, Maryland, USA
| | - Thomas Steinbach
- Department of Veterinary Pathology, Naval Medical Research Center, Silver Spring, Maryland, USA
| | - Charles R Auker
- Department of Neuro Trauma, Naval Medical Research Center, Silver Spring, Maryland, USA
| | - Richard M McCarron
- Department of Neuro Trauma, Naval Medical Research Center, Silver Spring, Maryland, USA ; Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Daniel Freilich
- Department of Neuro Trauma, Naval Medical Research Center, Silver Spring, Maryland, USA ; Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Anke H Scultetus
- Department of Neuro Trauma, Naval Medical Research Center, Silver Spring, Maryland, USA ; Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
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Epstein DS, Mitra B, O'Reilly G, Rosenfeld JV, Cameron PA. Acute traumatic coagulopathy in the setting of isolated traumatic brain injury: a systematic review and meta-analysis. Injury 2014; 45:819-24. [PMID: 24529718 DOI: 10.1016/j.injury.2014.01.011] [Citation(s) in RCA: 121] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2013] [Revised: 12/20/2013] [Accepted: 01/13/2014] [Indexed: 02/02/2023]
Abstract
BACKGROUND AND OBJECTIVES Acute traumatic coagulopathy (ATC) has been reported in the setting of isolated traumatic brain injury (iTBI) and associated with high mortality and poor outcomes. The aim of this systematic review was to examine the incidence and outcome of patients with ATC in the setting of iTBI. METHODS We conducted a search of the MEDLINE database and Cochrane library, focused on subject headings and keywords involving coagulopathy and TBI. Design and results of each study were described. Studies were assessed for heterogeneity and the pooled incidence of ATC in the setting of iTBI determined. Reported outcomes were described. RESULTS There were 22 studies selected for analysis. A statistically significant heterogeneity among the studies was observed (p<0.01). Using the random effects model the pooled proportion of patients with ATC in the setting of iTBI was 35.2% (95% CI: 29.0-41.4). Mortality of patients with ATC and iTBI ranged between 17% and 86%. Higher blood transfusion rates, longer hospital stays, longer ICU stays, decreased ventilator free days, higher rates of single and multiple organ failure and higher incidence of delayed injury and disability at discharge were reported among patients with ATC. CONCLUSIONS ATC is commonly associated with iTBI and almost uniformly associated with worse outcomes. Any disorder of coagulation above the normal range appears to be associated with worse outcomes and therefore a clinically important target for management. Earlier identification of patients with ATC and iTBI, for recruitment into prospective trials, presents avenues for further research.
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Affiliation(s)
- Daniel S Epstein
- Emergency & Trauma Centre, The Alfred Hospital, Melbourne, Australia; Department of Epidemiology & Preventive Medicine, Monash University, Melbourne, Australia
| | - Biswadev Mitra
- Emergency & Trauma Centre, The Alfred Hospital, Melbourne, Australia; Department of Epidemiology & Preventive Medicine, Monash University, Melbourne, Australia.
| | - Gerard O'Reilly
- Emergency & Trauma Centre, The Alfred Hospital, Melbourne, Australia; Department of Epidemiology & Preventive Medicine, Monash University, Melbourne, Australia
| | - Jeffrey V Rosenfeld
- Department of Epidemiology & Preventive Medicine, Monash University, Melbourne, Australia; Department of Surgery, Monash University, Melbourne, Australia; Department of Neurosurgery, The Alfred Hospital, Melbourne, Australia
| | - Peter A Cameron
- Emergency & Trauma Centre, The Alfred Hospital, Melbourne, Australia; Department of Epidemiology & Preventive Medicine, Monash University, Melbourne, Australia; Emergency Medicine, Hamad Medical Corporation, Doha, Qatar
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Frumkin K. Rapid reversal of warfarin-associated hemorrhage in the emergency department by prothrombin complex concentrates. Ann Emerg Med 2013; 62:616-626.e8. [PMID: 23829955 DOI: 10.1016/j.annemergmed.2013.05.026] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2012] [Revised: 05/23/2013] [Accepted: 05/29/2013] [Indexed: 10/26/2022]
Abstract
Life-threatening warfarin-associated hemorrhage is common, with a high mortality. In the United States, the most commonly used therapies--fresh frozen plasma and vitamin K--are slow and unpredictable and can result in volume overload. Outside of the United States, prothrombin complex concentrates are often used instead; these pooled plasma products reverse warfarin anticoagulation in minutes rather than hours. This article reviews the literature relating to warfarin reversal with fresh frozen plasma, prothrombin complex concentrates, and recombinant factor VIIa and provides elements for a management protocol based on this literature.
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Affiliation(s)
- Kenneth Frumkin
- Emergency Medicine Department, Naval Medical Center Portsmouth, VA.
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Maegele M. Coagulopathy after traumatic brain injury: incidence, pathogenesis, and treatment options. Transfusion 2013; 53 Suppl 1:28S-37S. [DOI: 10.1111/trf.12033] [Citation(s) in RCA: 107] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Affiliation(s)
- Marc Maegele
- Department of Trauma and Orthopedic Surgery; Institute for Research in Operative Medicine (IFOM); University of Witten/Herdecke, Cologne-Merheim Medical Center (CMMC); Cologne; Germany
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H-Y CS, Xuemei C, G KR, M BL, V HG, A SF, K FS. Thromboembolic risks of recombinant factor VIIa Use in warfarin-associated intracranial hemorrhage: a case-control study. BMC Neurol 2012; 12:158. [PMID: 23241423 PMCID: PMC3538560 DOI: 10.1186/1471-2377-12-158] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2012] [Accepted: 11/19/2012] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Recombinant factor VIIa (rFVIIa) may be used for rapid hemostasis in life-threatening hemorrhage. In warfarin-associated intracerebral hemorrhage (wICH), FVIIa use is controversial and may carry significant thromboembolic risks. We compared incidence of baseline thromboembolic risk factors and thromboembolism rates in wICH patients treated with additional rFVIIa to those treated with standard therapy of fresh frozen plasma (FFP) and vitamin K alone. METHODS We identified 45 consecutive wICH patients treated with additional rFVIIa over 5-year period, and 34 consecutive wICH patients treated with standard therapy alone as comparison group. We compared the incidence of post-hemorrhage cardiac and extra-cardiac thromboembolic complications between two treatment groups, and used logistic regression to adjust for significant confounders such as baseline thromboembolic risk factors. We performed secondary analysis comparing the quantity of FFP transfused between two treatment cohorts. RESULTS Both rFVIIa-treated and standard therapy-treated wICH patients had a high prevalence of pre-existing thromboembolic diseases including atrial fibrillation (73% vs 68%), deep venous thrombosis (DVT) or pulmonary embolism (PE) (22% vs 18%), coronary artery disease (CAD) (38% vs 32%), and abnormal electrocardiogram (EKG) (78% vs 85%). Troponin elevation following wICH was prevalent in both groups (47% vs 41%). Clinically significant myocardial infarction (MI), defined as troponin > 1.0 ng/dL, occurred in 13% of rFVIIa-treated and 6% of standard therapy-treated patients (p=0.52). Past history of CAD (p=0.0061) and baseline abnormal EKG (p=0.02) were independently associated with clinically significant MI following wICH while rFVIIa use was not. The incidences of DVT/PE (2% vs 9%; p=0.18) and ischemic stroke (2% vs 0%; p=0.38) were similar between two treatment groups. Recombinant FVIIa-treated patients had lower mean INR at 3 (p=0.0001) and 6 hours (p<0.0001) and received fewer units of FFP transfusion (3 vs 5; p=0.003). CONCLUSIONS Pre-existing thromboembolic risk factors as well as post-hemorrhage troponin elevation are prevalent in wICH patients. Clinically significant MI occurs in up to 13% of wICH patients. rFVIIa use was not associated with increased incidence of clinically significant MI or other venous or arterial thromboembolic events in this wICH cohort.
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Affiliation(s)
- Chou Sherry H-Y
- Department of Neurology, Brigham and Women's Hospital, Boston, MA, USA.
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Brown CVR, Sowery L, Curry E, Pharm D, Valadka AB, Glover CS, Grabarkewitz K, Green T, Hail S, Admire J. Recombinant Factor VIIa to Correct Coagulopathy in Patients with Traumatic Brain Injury Presenting to Outlying Facilities before Transfer to the Regional Trauma Center. Am Surg 2012. [DOI: 10.1177/000313481207800135] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Timely correction of coagulopathy in patients with traumatic brain injury (TBI) improves mortality. Recombinant, activated factor VII (VIIa) has been identified as an effective method to correct coagulopathy in patients with TBI. We performed a retrospective study (January 1, 2008–December 31, 2009) of all patients with TBI and coagulopathy (international normalized ratio (INR) > 1.5) transferred to our Level I trauma center. Twenty-three patients with coagulopathy and TBI were transferred to our trauma center, 100 per cent sustained a fall, and 100 per cent were taking warfarin at the time of injury. Ten patients received VIIa to correct coagulopathy before transfer, whereas 13 did not. The purpose of this study was to compare outcomes in patients who received VIIa with those who did not. When comparing the VIIa group with the no-VIIa group there was no difference in age, gender, Glasgow Coma Scale score, injury severity score, transfer time, or INR at outlying facility. Both groups received one unit of plasma before arrival at our trauma center; patients in the VIIa group received a single 1.2 mg dose of VIIa at the outlying facility. Upon arrival to our trauma center the VIIa group had a lower INR (1.0 vs 3.0, P = 0.02) and lower mortality (0% vs 39%, P = 0.03). In coagulopathic patients with TBI presenting to outlying institutions with limited resources to quickly provide plasma, VIIa efficiently corrects coagulopathy before transfer to definitive care at the regional trauma center. More rapid correction of coagulopathy with VIIa in this patient population may improve mortality.
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Affiliation(s)
- Carlos V. R. Brown
- University of Texas Southwestern—Austin, University Medical Center Brackenridge, Austin, Texas
| | - Lauren Sowery
- University of Texas Southwestern—Austin, University Medical Center Brackenridge, Austin, Texas
| | - Eardie Curry
- University of Texas Southwestern—Austin, University Medical Center Brackenridge, Austin, Texas
| | - D. Pharm
- University of Texas Southwestern—Austin, University Medical Center Brackenridge, Austin, Texas
| | - Alex B. Valadka
- University of Texas Southwestern—Austin, University Medical Center Brackenridge, Austin, Texas
| | | | | | - Terry Green
- Seton Southwest Healthcare Center, Austin, Texas
| | - Steve Hail
- Seton Medical Center Williamson, Round Rock, Texas
| | - John Admire
- University of Texas Southwestern—Austin, University Medical Center Brackenridge, Austin, Texas
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Yank V, Tuohy CV, Logan AC, Bravata DM, Staudenmayer K, Eisenhut R, Sundaram V, McMahon D, Olkin I, McDonald KM, Owens DK, Stafford RS. Systematic review: benefits and harms of in-hospital use of recombinant factor VIIa for off-label indications. Ann Intern Med 2011. [PMID: 21502651 DOI: 10.1059/0003-4819-154-8-201104190-00004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Recombinant factor VIIa (rFVIIa), a hemostatic agent approved for hemophilia, is increasingly used for off-label indications. PURPOSE To evaluate the benefits and harms of rFVIIa use for 5 off-label, in-hospital indications: intracranial hemorrhage, cardiac surgery, trauma, liver transplantation, and prostatectomy. DATA SOURCES Ten databases (including PubMed, EMBASE, and the Cochrane Library) queried from inception through December 2010. Articles published in English were analyzed. STUDY SELECTION Two reviewers independently screened titles and abstracts to identify clinical use of rFVIIa for the selected indications and identified all randomized, controlled trials (RCTs) and observational studies for full-text review. DATA EXTRACTION Two reviewers independently assessed study characteristics and rated study quality and indication-wide strength of evidence. DATA SYNTHESIS 16 RCTs, 26 comparative observational studies, and 22 noncomparative observational studies met inclusion criteria. Identified comparators were limited to placebo (RCTs) or usual care (observational studies). For intracranial hemorrhage, mortality was not improved with rFVIIa use across a range of doses. Arterial thromboembolism was increased with medium-dose rFVIIa use (risk difference [RD], 0.03 [95% CI, 0.01 to 0.06]) and high-dose rFVIIa use (RD, 0.06 [CI, 0.01 to 0.11]). For adult cardiac surgery, there was no mortality difference, but there was an increased risk for thromboembolism (RD, 0.05 [CI, 0.01 to 0.10]) with rFVIIa. For body trauma, there were no differences in mortality or thromboembolism, but there was a reduced risk for the acute respiratory distress syndrome (RD, -0.05 [CI, -0.02 to -0.08]). Mortality was higher in observational studies than in RCTs. LIMITATIONS The amount and strength of evidence were low for most outcomes and indications. Publication bias could not be excluded. CONCLUSION Limited available evidence for 5 off-label indications suggests no mortality reduction with rFVIIa use. For some indications, it increases thromboembolism.
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Bracey AW, Reyes MA, Chen AJ, Bayat M, Allison PM. How do we manage patients treated with antithrombotic therapy in the perioperative interval. Transfusion 2011; 51:2066-77. [PMID: 21517891 DOI: 10.1111/j.1537-2995.2011.03146.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Arthur W Bracey
- Department of Pathology, Texas Heart Institute at St Luke's Episcopal Hospital, Houston, Texas, USA.
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17
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Yank V, Tuohy CV, Logan AC, Bravata DM, Staudenmayer K, Eisenhut R, Sundaram V, McMahon D, Olkin I, McDonald KM, Owens DK, Stafford RS. Systematic review: benefits and harms of in-hospital use of recombinant factor VIIa for off-label indications. Ann Intern Med 2011; 154:529-40. [PMID: 21502651 PMCID: PMC4102260 DOI: 10.7326/0003-4819-154-8-201104190-00004] [Citation(s) in RCA: 142] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Recombinant factor VIIa (rFVIIa), a hemostatic agent approved for hemophilia, is increasingly used for off-label indications. PURPOSE To evaluate the benefits and harms of rFVIIa use for 5 off-label, in-hospital indications: intracranial hemorrhage, cardiac surgery, trauma, liver transplantation, and prostatectomy. DATA SOURCES Ten databases (including PubMed, EMBASE, and the Cochrane Library) queried from inception through December 2010. Articles published in English were analyzed. STUDY SELECTION Two reviewers independently screened titles and abstracts to identify clinical use of rFVIIa for the selected indications and identified all randomized, controlled trials (RCTs) and observational studies for full-text review. DATA EXTRACTION Two reviewers independently assessed study characteristics and rated study quality and indication-wide strength of evidence. DATA SYNTHESIS 16 RCTs, 26 comparative observational studies, and 22 noncomparative observational studies met inclusion criteria. Identified comparators were limited to placebo (RCTs) or usual care (observational studies). For intracranial hemorrhage, mortality was not improved with rFVIIa use across a range of doses. Arterial thromboembolism was increased with medium-dose rFVIIa use (risk difference [RD], 0.03 [95% CI, 0.01 to 0.06]) and high-dose rFVIIa use (RD, 0.06 [CI, 0.01 to 0.11]). For adult cardiac surgery, there was no mortality difference, but there was an increased risk for thromboembolism (RD, 0.05 [CI, 0.01 to 0.10]) with rFVIIa. For body trauma, there were no differences in mortality or thromboembolism, but there was a reduced risk for the acute respiratory distress syndrome (RD, -0.05 [CI, -0.02 to -0.08]). Mortality was higher in observational studies than in RCTs. LIMITATIONS The amount and strength of evidence were low for most outcomes and indications. Publication bias could not be excluded. CONCLUSION Limited available evidence for 5 off-label indications suggests no mortality reduction with rFVIIa use. For some indications, it increases thromboembolism.
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DeLoughery EP, Lenfesty B, DeLoughery TG. A retrospective case control study of recombinant factor VIIa in patients with intracranial haemorrhage caused by trauma. Br J Haematol 2011; 152:667-9. [DOI: 10.1111/j.1365-2141.2010.08437.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Solomon D, Kim B, Scultetus A, Arnaud F, Auker C, Freilich D, McCarron R. The effect of rFVIIa on pro- and anti-inflammatory cytokines in serum and cerebrospinal fluid in a swine model of traumatic brain injury. Cytokine 2011; 54:20-3. [PMID: 21251848 DOI: 10.1016/j.cyto.2010.12.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2010] [Revised: 12/15/2010] [Accepted: 12/16/2010] [Indexed: 10/18/2022]
Abstract
Traumatic brain injury (TBI) is associated with significant infectious and inflammatory complications. Though increasing evidence suggests that rFVIIa administration may be efficacious for the pre-hospital treatment of TBI, the FVIIa-tissue factor complex has been shown to be immunologically active. To date the cytokine response to rFVIIa administration for the treatment of TBI has not been evaluated. Twenty anesthetized immature Yorkshire swine underwent fluid percussion TBI. At 15 min following injury, animals were randomized to receive either 90 μg/kg rFVIIa (rFVIIa) or nothing. Animals were observed for 6 h and then euthanized. Plasma and cerebrospinal (CSF) samples were collected at 0 min and 360 min, and ELISA analysis of TNF-α, IL-1β and IL-10 was performed. Survival in both groups was 100%. Baseline cytokine concentrations were not statistically different between rFVIIa and control animals in plasma or CSF. Animals in both groups did not have significant changes in plasma cytokine concentrations following TBI. Control animals did not demonstrate significant changes from baseline of CSF cytokine concentrations following TBI. The administration of rFVIIa however, resulted in significant increases in CSF TNF-α concentration (232.0 pg/ml ± 75.9 vs 36.4 pg/ml ± 10.4, p = 0.036) and IL-10 concentration (10.7 pg/ml ± 0.6 vs 8.8 pg/ml ± 0.1, p = 0.015). IL-1β concentrations were not significantly changed over the experimental time course. These results suggest that rFVIIa administration for the treatment of TBI is not immunologically inert, and is associated with increased CSF concentrations of TNF-α and IL-10.
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Affiliation(s)
- Daniel Solomon
- Naval Medical Research Center, Operational and Undersea Medicine Directorate, NeuroTrauma Department, USA.
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Rama-Maceiras P, Ingelmo-Ingelmo I, Fàbregas-Julià N, Hernández-Palazón J. Rol del factor VII recombinante activado en pacientes neuroquirúrgicos y neurocríticos. Neurocirugia (Astur) 2011. [DOI: 10.1016/s1130-1473(11)70016-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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Scultetus A, Arnaud F, Kaplan L, Shander A, Philbin N, Rice J, McCarron R, Freilich D. Hemoglobin-based oxygen carrier (HBOC-201) and escalating doses of recombinant factor VIIa (rFVIIa) as a novel pre-hospital resuscitation fluid in a swine model of severe uncontrolled hemorrhage. ACTA ACUST UNITED AC 2010; 39:59-68. [PMID: 20645681 DOI: 10.3109/10731199.2010.501755] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Exsanguinating hemorrhage and unavailability of blood are major problems in pre-hospital trauma care. We investigated if combining rFVIIa with HBOC-201 reduces blood loss and improves physiologic parameters compared to HBOC alone. Swine underwent liver injury and were resuscitated with HBOC-201 alone or HBOC+90, 180 or 360 μg/kg rFVIIa before hospital arrival at 240 min; animals survived to 72 hours. Blood loss was reduced; MAP, CI, transcutaneous oxygen saturation, and 72-hour survival improved in the 90 and 180 μg/kg rFVIIa groups. Lactate was cleared faster in the HBOC+rFVIIa 90 μg/kg group. Verification in a large, well-powered study is indicated.
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Affiliation(s)
- Anke Scultetus
- Operational and Undersea Medicine Directorate, NeuroTrauma Department, Naval Medical Research Center, 503 Robert Grant Avenue, Silver Spring, MD 20910, USA.
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22
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McCunn M, Gordon EKB, Scott TH. Anesthetic concerns in trauma victims requiring operative intervention: the patient too sick to anesthetize. Anesthesiol Clin 2010; 28:97-116. [PMID: 20400043 DOI: 10.1016/j.anclin.2010.01.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Trauma is the third leading cause of death in the U.S. Timely acute care anesthetic management of patients following traumatic injury may improve outcome. Recognition of highly-mortal injuries to the brain, heart, lungs, liver, and pelvis should guide trauma-specific management strategies. Rapid intraoperative treatment of life-threatening conditions following injury includes the use of 'controlled-under resuscitation' of fluid administration until surgical hemorrhage control, early factor replacement in addition to transfusion of packed red blood cells, and use of adjuvant therapies such as recombinant factor VIIa. These treatment strategies, other recent developments in acute trauma resuscitation, and a review of associated co-existing medical conditions that may impact mortality, are presented.
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Affiliation(s)
- Maureen McCunn
- Department of Anesthesiology and Critical Care, University of Pennsylvania School of Medicine, Dulles 6, 3400 Spruce Street, Philadelphia, PA 19104, USA.
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Nishijima DK, Dager WE, Schrot RJ, Holmes JF. The efficacy of factor VIIa in emergency department patients with warfarin use and traumatic intracranial hemorrhage. Acad Emerg Med 2010; 17:244-51. [PMID: 20370756 DOI: 10.1111/j.1553-2712.2010.00666.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVES The objective was to compare outcomes in emergency department (ED) patients with preinjury warfarin use and traumatic intracranial hemorrhage (tICH) who did and did not receive recombinant activated factor VIIa (rFVIIa) for international normalized ratio (INR) reversal. METHODS This was a retrospective before-and-after study conducted at a Level 1 trauma center, with data from 1999 to 2009. Eligible patients had preinjury warfarin use and tICH on cranial computed tomography (CT) scan. Patients before (standard cohort) and after (rFVIIa cohort) implementation of a protocol for administering 1.2 mg of rFVIIa in the ED were reviewed. Glasgow Coma Scale (GCS) score, Revised Trauma Score (RTS), Injury Severity Score (ISS), INR, and Marshall score were collected. Outcome measures included mortality, thromboembolic complications, and INR normalization. RESULTS Forty patients (median age=80.5 years, interquartile range [IQR]=63.5-85) were included (20 in each cohort). Age, GCS score, ISS, RTS, initial INR, and Marshall score were similar (p>0.05) between the two cohorts. Survival was identical between cohorts (13 of 20, or 65.0%, 95% confidence interval [CI]=40.8% to 84.6%). There were no differences in rate of thromboembolic complications in the standard cohort (1 of 20, 5.0%, 95% CI=0.1% to 24.9%) than the rFVIIa cohort (4 of 20, 20.0%, 95% CI=5.7% to 43.7%; p=0.34). Time to normal INR was earlier in the rFVIIa cohort (mean=4.8 hours, 95% CI=3.0 to 6.7 hours) than in the standard cohort (mean=17.5 hours, 95% CI=12.5 to 22.6; p<0.001). CONCLUSIONS In patients with preinjury warfarin and tICH, use of rFVIIa was associated with a decreased time to normal INR. However, no difference in mortality was identified. Use of rFVIIa in patients on warfarin and tICH requires further study to demonstrate important patient-oriented outcomes.
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Affiliation(s)
- Daniel K Nishijima
- Department of Emergency Medicine, UC Davis School of Medicine, Davis, CA, USA.
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Abstract
PURPOSE OF REVIEW Recombinant factor VIIa (rFVIIa) and thromboelastography have acquired increasing importance in patients with severe bleeding and coagulopathy. This article reviews the current opinions regarding their use, with the purpose of clarifying the ambiguities that exist in dealing with trauma patients. RECENT FINDINGS Recent evidence encourages the early use of rFVIIa and thromboelastography in the severe trauma patient with hemorrhagic shock, as a component of the damage control strategy. rFVIIa may decrease short-term mortality and the rate of required blood components during resuscitation, with no apparent increase in thromboembolic complications. Thromboelastometry enables better and earlier recognition of the coagulopathy accompanying such trauma patients. In patients with traumatic brain injury and coagulopathy, rFVIIa may delay or even halt the need for surgery, with no proven decrease in mortality. In those who needed urgent neurosurgical intervention, rFVIIa may rapidly correct the coagulopathy, enabling earlier and safer surgical intervention. SUMMARY Thromboelastometry may guide the medical staff when and to whom rFVIIa could be administered. Evidence also encourages the use of rFVIIa in traumatic brain injury. More research is required to prove decreases in mortality using both thromboelastography and rFVIIa in trauma, with a focus on clear end points and goal-directed therapy.
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McQuay N, Cipolla J, Franges EZ, Thompson GE. The use of recombinant activated factor VIIa in coagulopathic traumatic brain injuries requiring emergent craniotomy: is it beneficial? J Neurosurg 2009; 111:666-71. [DOI: 10.3171/2009.4.jns081611] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
The role of recombinant activated factor VII (rFVIIa) in traumatic brain injury (TBI) has not been well established. This study evaluates the outcomes of using rFVIIa as first-line therapy in patients with a severe TBI requiring emergent craniotomy that are coagulopathic.
Methods
The authors retrospectively reviewed patients admitted between 2003 and 2006 to a Level I trauma center with a severe TBI requiring an emergency craniotomy. Eighteen patients with coagulopathy that was corrected using rFVIIa were identified. Variables evaluated included age, injury severity score, head abbreviated injury score, Glasgow Coma Scale score, international normalized ratio, time to operation, operative procedure, thromboembolic events, and death.
Results
The cohort consisted of 18 patients, predominantly male (55.6%) with a mean age of 80.5 years. The most common mechanism of injury was a fall. Coagulopathy was due to premorbid anticoagulants in 50% of the cohort. Time from admission to operation was 130 minutes. Coagulopathy reversal was complete in all 18 cases (100%). A high mortality rate (55.6%) was attributed to a high incidence of withdrawal of care (50%). The incidence of thromboembolic events was low (5.6%). Survivors, when compared with nonsurvivors, had a > 3-fold increase in postoperative Glasgow Coma Scale score for similar preoperative scores. A good functional outcome was achieved in 75% of survivors with a mean follow-up period of 4.2 months.
Conclusions
The use of rFVIIa in the correction of coagulopathy in patients having sustained severe TBI requiring emergency craniotomy appears to be safe and effective even among the elderly. This allows a shorter transit time to craniotomy. Its effects on mortality and long-term neurological outcome requires further investigation prospectively.
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Affiliation(s)
- Nathaniel McQuay
- 1Department of Surgery, University of Pennsylvania Health System, Trauma/Critica Division, St. Luke's Hosptial; and
| | - James Cipolla
- 1Department of Surgery, University of Pennsylvania Health System, Trauma/Critica Division, St. Luke's Hosptial; and
| | - Eleanor Z. Franges
- Department of Neurosurgery, St. Luke's Hospital, Bethlehem, Pennsylvania
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Ageno W, Garcia D, Aguilar MI, Douketis J, Finazzi G, Imberti D, Iorio A, Key NS, Lim W, Marietta M, Prisco D, Sarode R, Testa S, Tosetto A, Crowther M. Prevention and treatment of bleeding complications in patients receiving vitamin K antagonists, part 2: Treatment. Am J Hematol 2009; 84:584-8. [PMID: 19610020 DOI: 10.1002/ajh.21469] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
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Sfaihi Ben Mansour L, Thabet A, Aloulou H, Turki H, Chabchoub I, Mhiri F, Mnif Z, Ben Ali H, Kammoun T, Hachicha M. Déficit congénital en facteur VII de la coagulation, révélé par une hémorragie cérébrale. Arch Pediatr 2009; 16:1024-7. [DOI: 10.1016/j.arcped.2009.03.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2008] [Revised: 09/06/2008] [Accepted: 03/25/2009] [Indexed: 11/16/2022]
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Abstract
BACKGROUND This review summarizes promising approaches for the treatment of traumatic brain injury (TBI) that are in either preclinical or clinical trials. OBJECTIVE The pathophysiology underlying neurological deficits after TBI is described. An overview of select therapies for TBI with neuroprotective and neurorestorative effects is presented. METHODS A literature review of preclinical TBI studies and clinical TBI trials related to neuroprotective and neurorestorative therapeutic approaches is provided. RESULTS/CONCLUSION Nearly all Phase II/III clinical trials in neuroprotection have failed to show any consistent improvement in outcome for TBI patients. The next decade will witness an increasing number of clinical trials that seek to translate preclinical research discoveries to the clinic. Promising drug- or cell-based therapeutic approaches include erythropoietin and its carbamylated form, statins, bone marrow stromal cells, stem cells singularly or in combination or with biomaterials to reduce brain injury via neuroprotection and promote brain remodeling via angiogenesis, neurogenesis, and synaptogenesis with a final goal to improve functional outcome of TBI patients. In addition, enriched environment and voluntary physical exercise show promise in promoting functional outcome after TBI, and should be evaluated alone or in combination with other treatments as therapeutic approaches for TBI.
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Affiliation(s)
- Ye Xiong
- Henry Ford Health System, Department of Neurosurgery, Detroit, MI 48202, USA
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Use of Recombinant Factor VIIa to Facilitate Organ Donation in Trauma Patients with Devastating Neurologic Injury. J Am Coll Surg 2009; 208:120-5. [DOI: 10.1016/j.jamcollsurg.2008.09.027] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2008] [Revised: 09/19/2008] [Accepted: 09/24/2008] [Indexed: 11/18/2022]
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31
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Duchesne JC, Mathew KA, Marr AB, Pinsky MR, Barbeau JM, Mcswain NE. Current Evidence Based Guidelines for Factor VIIa Use in Trauma: The Good, the Bad, and the Ugly. Am Surg 2008. [DOI: 10.1177/000313480807401206] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Recombinant factor VII (rFVIIa) has arisen as an option for the control of life-threatening traumatic bleeding unresponsive to other means. The timing of administration, dosage, mortality, units of blood transfusion saved, risk of thrombotic events, and risk/benefits ratio are presently poorly defined. A Medline search from 1995 through March 2008 was conducted. All English language articles containing the terms “trauma” and “factor VII” or its variants were retrieved. Letters to the editor, animal studies, and general reviews were excluded. A total of 19 articles met inclusion criteria. These articles were then reviewed and stratified into three classes of evidence according to the quality assessment instrument developed by the Brain and Trauma Foundation. Levels of recommendation were developed. A total of 118 articles were identified. Only one Class I study was identified. This study demonstrated that three doses of rFVIIa given in blunt traumatic hemorrhage yielded a significant reduction of 2.6 of red blood cells used. These findings were not statistically significant for penetrating trauma patients. There was no reduction in mortality and no increase in thromboembolic events. Four Class II studies were identified; three showed a significant decrease of blood product usage and one demonstrated significant reductions in 24-hour and 30 day death from hemorrhage in patients receiving rFVIIa. The remaining 14 studies were Class III reviews of databases, registries, case series, and case reports. No identified study specifically addressed the cost/benefit analysis of rFVIIa usage in trauma hemorrhage. Utility of rFVIIa in trauma-associated hemorrhage remains controversial. There is Level I supporting the use of rFVIIa for blunt trauma patients only. There is no Class I evidence supporting decreased mortality or differences in thromboembolic events. Minimal effective dosing regimens and cost/benefit analyses have not yet been examined.
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Affiliation(s)
- Juan C. Duchesne
- Departments of Surgery and Anesthesiology, Tulane School of Medicine, New Orleans, Louisiana
| | - Kavitha A. Mathew
- Departments of Surgery and Anesthesiology, Tulane School of Medicine, New Orleans, Louisiana
| | - Alan B. Marr
- Departments of Surgery, Louisiana State University School of Medicine, New Orleans, Louisiana
| | - Michael R. Pinsky
- Departments of Surgery and Anesthesiology, Tulane School of Medicine, New Orleans, Louisiana
| | - James M. Barbeau
- Departments of Surgery, Louisiana State University School of Medicine, New Orleans, Louisiana
| | - Norman E. Mcswain
- Departments of Surgery and Anesthesiology, Tulane School of Medicine, New Orleans, Louisiana
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32
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Mertes PM, Baumann A, Audibert G. [Transfusion in neurosurgery]. Transfus Clin Biol 2008; 15:205-11. [PMID: 18930420 DOI: 10.1016/j.tracli.2008.09.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2008] [Accepted: 09/04/2008] [Indexed: 10/21/2022]
Abstract
In neurosurgery, the question of the optimal transfusion "trigger" remains a controversial matter. Regarding the brain, the current data are still incomplete, justifying the continuation of experimental and clinical studies. The existing expert advices are based on these rather poor data and would probably evolve after the completion of clinical studies in progress. In spine surgery, the situation is simpler and the transfusional stakes are quite similar to those of orthopedics and traumatology. With regard to hemostasis, standardized recommendations exist depending on the laboratory test results or the anticoagulant treatments of the patient.
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Affiliation(s)
- P-M Mertes
- Département d'anesthésie-réanimation, hôpital Central, CHU de Nancy, Nancy, France.
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