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Schmulevich D, Geng Z, Joergensen SM, McLauchlan NR, Winter E, Zone A, Bishop KE, Hinkle A, Holland S, Cacchione PZ, Fox EE, Abella BS, Meador CL, Wade CE, Hynes AM, Cannon JW. Real-time performance improvement optimizes damage control resuscitation best practice adherence: Results of a pilot prospective observational study. Transfusion 2024. [PMID: 39072759 DOI: 10.1111/trf.17970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Revised: 07/03/2024] [Accepted: 07/07/2024] [Indexed: 07/30/2024]
Abstract
BACKGROUND Maintaining balanced blood product ratios during damage control resuscitation (DCR) is independently associated with improved survival. We hypothesized that real-time performance improvement (RT-PI) would increase adherence to DCR best practice. STUDY DESIGN AND METHODS From December 2020-August 2021, we prospectively used a bedside RT-PI tool to guide DCR in severely injured patients surviving at least 30 min. RT-PI study patients were compared to contemporary control patients at our institution and historic PROMMTT study patients. A subset of patients transfused ≥6 U red blood cells (RBC) in 6 h (MT+) was also identified. The primary endpoint was percentage time in a high ratio range (≥3:4) of plasma (PLAS):RBC and platelet (PLT):RBC over 6 h. Secondary endpoints included time to massive transfusion protocol activation, time to calcium and tranexamic acid (TXA) dosing, and cumulative 6-h ratios. RESULTS Included patients (n = 772) were 35 (24-51) years old with an Injury Severity Score of 27 (17-38) and 42% had penetrating injuries. RT-PI (n = 10) patients spent 96% of the 6-h resuscitation in a high PLAS:RBC range, no different versus CONTROL (n = 87) (96%) but more than PROMMTT (n = 675) (25%, p < .001). In the MT+ subgroup, optimal PLAS:RBC and PLT:RBC were maintained for the entire 6 h in RT-PI (n = 4) versus PROMMTT (n = 391) patients for both PLAS (p < .001) and PLT ratios (p < .001). Time to TXA also improved significantly in RT-PI versus CONTROL patients (27 min [22-31] vs. 51 min [29-98], p = .035). CONCLUSION In this prospective study, RT-PI was associated with optimized DCR. Multicenter validation of this novel approach to optimizing DCR implementation is warranted.
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Affiliation(s)
- Daniela Schmulevich
- Division of Traumatology, Surgical Critical Care, and Emergency Surgery, Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio, USA
| | - Zhi Geng
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Sarah M Joergensen
- Penn Acute Research Collaboration (PARC), Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Nathaniel R McLauchlan
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Eric Winter
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Alea Zone
- Penn Acute Research Collaboration (PARC), Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Kathleen E Bishop
- Penn Acute Research Collaboration (PARC), Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Alyson Hinkle
- Department of Nursing, Penn Presbyterian Medical Center, Penn Medicine, Philadelphia, Pennsylvania, USA
| | - Sara Holland
- Department of Nursing, Penn Presbyterian Medical Center, Penn Medicine, Philadelphia, Pennsylvania, USA
| | - Pamela Z Cacchione
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Nursing, Penn Presbyterian Medical Center, Penn Medicine, Philadelphia, Pennsylvania, USA
- Department of Family and Community Health, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, USA
| | - Erin E Fox
- Center for Translational Injury Research, Department of Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Benjamin S Abella
- Penn Acute Research Collaboration (PARC), Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Emergency Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | | | - Charles E Wade
- Center for Translational Injury Research, Department of Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Allyson M Hynes
- Division of Traumatology, Surgical Critical Care, and Emergency Surgery, Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jeremy W Cannon
- Division of Traumatology, Surgical Critical Care, and Emergency Surgery, Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Penn Acute Research Collaboration (PARC), Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
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Tang WR, Wu CH, Yang TH, Yen YT, Hung KS, Wang CJ, Shan YS. Impact of trauma teams on high grade liver injury care: a two-decade propensity score approach study in Taiwan. Sci Rep 2023; 13:5429. [PMID: 37012308 PMCID: PMC10070483 DOI: 10.1038/s41598-023-32760-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2022] [Accepted: 04/01/2023] [Indexed: 04/05/2023] Open
Abstract
High-grade liver laceration is a common injury with bleeding as the main cause of death. Timely resuscitation and hemostasis are keys to the successful management. The impact of in-hospital trauma system on the quality of resuscitation and management in patients with traumatic high-grade liver laceration, however, was rarely reported. We retrospectively reviewed the impact of team-based approach on the quality and outcomes of high-grade traumatic liver laceration in our hospital. Patients with traumatic liver laceration between 2002 and 2020 were enrolled in this retrospective study. Inverse probability of treatment weighting (IPTW)-adjusted analysis using the propensity score were performed. Outcomes before the trauma team establishment (PTTE) and after the trauma team establishment (TTE) were compared. A total of 270 patients with liver trauma were included. After IPTW adjustment, interval between emergency department arrival and managements was shortened in the TTE group with a median of 11 min (p < 0.001) and 28 min (p < 0.001) in blood test reports and duration to CT scan, respectively. Duration to hemostatic treatments in the TTE group was also shorter by a median of 94 min in patients receiving embolization (p = 0.012) and 50 min in those undergoing surgery (p = 0.021). The TTE group had longer ICU-free days to day 28 (0.0 vs. 19.0 days, p = 0.010). In our study, trauma team approach had a survival benefit for traumatic high-grade liver injury patients with 65% reduction of risk of death within 72 h (Odds ratio (OR) = 0.35, 95% CI = 0.14-0.86) and 55% reduction of risk of in-hospital mortality (OR = 0.45, 95% CI = 0.23-0.87). A team-based approach might contribute to the survival benefit in patients with traumatic high-grade liver laceration by facilitating patient transfer from outside the hospital, through the diagnostic examination, and to the definitive hemostatic procedures.
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Affiliation(s)
- Wen-Ruei Tang
- Department of Surgery, College of Medicine, National Cheng Kung University Hospital, National Cheng Kung University, Tainan, Taiwan
| | - Chun-Hsien Wu
- Division of General Surgery, Department of Surgery, College of Medicine, National Cheng Kung University Hospital, National Cheng Kung University, Tainan, Taiwan
- Division of Trauma, Department of Surgery, College of Medicine, National Cheng Kung University Hospital, National Cheng Kung University, 138 Sheng-Li Road, Tainan, Taiwan, 704
| | - Tsung-Han Yang
- Division of Trauma, Department of Surgery, College of Medicine, National Cheng Kung University Hospital, National Cheng Kung University, 138 Sheng-Li Road, Tainan, Taiwan, 704
| | - Yi-Ting Yen
- Division of Trauma, Department of Surgery, College of Medicine, National Cheng Kung University Hospital, National Cheng Kung University, 138 Sheng-Li Road, Tainan, Taiwan, 704
| | - Kuo-Shu Hung
- Division of Trauma, Department of Surgery, College of Medicine, National Cheng Kung University Hospital, National Cheng Kung University, 138 Sheng-Li Road, Tainan, Taiwan, 704
| | - Chih-Jung Wang
- Division of Trauma, Department of Surgery, College of Medicine, National Cheng Kung University Hospital, National Cheng Kung University, 138 Sheng-Li Road, Tainan, Taiwan, 704.
| | - Yan-Shen Shan
- Division of General Surgery, Department of Surgery, College of Medicine, National Cheng Kung University Hospital, National Cheng Kung University, Tainan, Taiwan
- Institute of Clinical Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan
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3
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Vlaar APJ. Blood transfusion: the search for the sweet spot. Intensive Care Med 2022; 48:1218-1221. [PMID: 35794273 DOI: 10.1007/s00134-022-06799-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/22/2022] [Indexed: 12/01/2022]
Affiliation(s)
- Alexander P J Vlaar
- Department of Intensive Care Medicine, Amsterdam UMC, Room, C3-430, Meibergdreef 9, location AMC, 1105 AZ, Amsterdam, The Netherlands. .,Laboratory of Experimental Intensive Care and Anesthesiology (L.E.I.C.A.), Amsterdam UMC, Location AMC, Amsterdam, The Netherlands.
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4
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Tejiram S, Sen S, Romanowski KS, Greenhalgh DG, Palmieri TL. Examining 1:1 vs. 4:1 Packed Red Blood Cell to Fresh Frozen Plasma Ratio Transfusion During Pediatric Burn Excision. J Burn Care Res 2021; 41:443-449. [PMID: 31912141 DOI: 10.1093/jbcr/iraa001] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Blood transfusions following major burn injury are common due to operative losses, blood sampling, and burn physiology. While massive transfusion improves outcomes in adult trauma patients, literature examining its effect in critically ill children is limited. The study purpose was to prospectively compare outcomes of major pediatric burns receiving a 1:1 vs. 4:1 packed red blood cell to fresh frozen plasma transfusion strategy during massive burn excision. Children with >20% total body surface area burns were randomized to a 1:1 or 4:1 packed red blood cell/fresh frozen plasma transfusion ratio during burn excision. Parameters examined include patient demographics, burn size, pediatric risk of mortality (PRISM) scores, pediatric logistic organ dysfunction scores, laboratory values, total blood products transfused, and the presence of blood stream infections or pneumonia. A total of 68 children who met inclusion criteria were randomized into two groups (n = 34). Mean age, PRISM scores, estimated blood loss (600 ml (400-1175 ml) vs. 600 ml (300-1150 ml), P = 0.68), ventilator days (5 vs. 9, P = 0.47), and length of stay (57 vs. 60 days, P = 0.24) had no difference. No differences in frequency of blood stream infection (20 vs. 18, P = 0.46) or pneumonia events (68 vs. 116, P = 0.08) were noted. On multivariate analysis, only total body surface area burn size, inhalation injury, and PRISM scores (P < 0.05) were significantly associated with infections.
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Affiliation(s)
- Shawn Tejiram
- Shriners Hospitals for Children Northern California and the Firefighters Burn Institute Regional Burn Center, Department of Surgery, University of California, Davis, Sacramento, California
| | - Soman Sen
- Shriners Hospitals for Children Northern California and the Firefighters Burn Institute Regional Burn Center, Department of Surgery, University of California, Davis, Sacramento, California
| | - Kathleen S Romanowski
- Shriners Hospitals for Children Northern California and the Firefighters Burn Institute Regional Burn Center, Department of Surgery, University of California, Davis, Sacramento, California
| | - David G Greenhalgh
- Shriners Hospitals for Children Northern California and the Firefighters Burn Institute Regional Burn Center, Department of Surgery, University of California, Davis, Sacramento, California
| | - Tina L Palmieri
- Shriners Hospitals for Children Northern California and the Firefighters Burn Institute Regional Burn Center, Department of Surgery, University of California, Davis, Sacramento, California
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Hemostatic potential of cold-stored non-leukoreduced whole blood over time: An assessment of platelet function and thrombin generation for optimal shelf life. J Trauma Acute Care Surg 2021; 89:429-434. [PMID: 32467473 DOI: 10.1097/ta.0000000000002799] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES Cold-stored low-titer whole blood (WB) is becoming increasingly used as the preferred product for initial hemorrhagic shock resuscitation. The purpose of this study was to identify whether the current 21-day shelf life is the optimal duration for storage of WB, maintaining hemostatic efficacy. METHODS Five units of fresh low-titer group O WB (non-leukoreduced) were acquired from our regional blood center. These units were stored at 4°C for up to 21 days as per current clinical storage guidelines in our emergency department. Hemostatic parameters were measured in vitro at 0 days, 7 days, 14 days, and 21 days. Assessments of hemostatic potential included cell count, rapid thrombelastography (r-TEG) and kaolin thrombelastography (TEG), multiplate impedance aggregometry, and calibrated automated thrombogram (CAT). Univariate analysis, including one-way analysis of variance with repeated measures, was performed (STATA 12.1). RESULTS Compared with baseline product (0 days), both platelet count and platelet function of WB showed sharp decreases at 7 days and again at 14 days. Platelet function deterioration was noted by r-TEG c (MA), TEG-MA, and multiplate arachidonic acid and adenosine diphosphate (all p < 0.001). With respect to clot initiation, r-TEG ACT and TEG R-time were similar over the 21-day shelf life (p = 0.058 and p = 0.620, respectively). Thrombin generation assessed by CAT demonstrated stable endogenous thrombin potential over the course of storage (p = 0.162), but increased peak thrombin generation and quicker time to peak generation after 7 days. CONCLUSION While the platelet function of WB degrades significantly at 7 days (and again at 14 days), clot initiation remains stable over time, and thrombin generation appears to be improved at 7 days. This study supports a current storage limit for cold-stored, low-titer WB of 14 days.
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Ordoñez CA, Parra MW, Serna JJ, Rodríguez-Holguin F, García A, Salcedo A, Caicedo Y, Padilla N, Pino LF, Hadad AG, Herrera MA, Millán M, Quintero-Barrera L, Hernández-Medina F, Ferrada R, Brenner M, Rasmussen T, Scalea T, Ivatury R, Holcomb JB. Damage control resuscitation: REBOA as the new fourth pillar. COLOMBIA MEDICA (CALI, COLOMBIA) 2020; 51:e4014353. [PMID: 33795897 PMCID: PMC7968430 DOI: 10.25100/cm.v51i4.4353] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Damage Control Resuscitation (DCR) seeks to combat metabolic decompensation of the severely injured trauma patient by battling on three major fronts: Permissive Hypotension, Hemostatic Resuscitation, and Damage Control Surgery (DCS). The aim of this article is to perform a review of the history of DCR/DCS and to propose a new paradigm that has emerged from the recent advancements in endovascular technology: The Resuscitative Balloon Occlusion of the Aorta (REBOA). Thanks to the advances in technology, a bridge has been created between Pre-hospital Management and the Control of Bleeding described in Stage I of DCS which is the inclusion and placement of a REBOA. We have been able to show that REBOA is not only a tool that aids in the control of hemorrhage, it is also a vital tool in the hemodynamic resuscitation of a severely injured blunt and/or penetrating trauma patient. That is why we propose a new paradigm “The Fourth Pillar”: Permissive Hypotension, Hemostatic Resuscitation, Damage Control Surgery and REBOA.
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Affiliation(s)
- Carlos A Ordoñez
- Fundación Valle del Lili. Division of Trauma and Acute Care Surgery, Department of Surgery. Cali, Colombia.,Universidad del Valle, Facultad de Salud, Escuela de Medicina. Cali, Colombia.,Universidad Icesi, Cali, Colombia
| | - Michael W Parra
- Broward General Level I Trauma Center, Department of Trauma Critical Care, Fort Lauderdale, FL - USA
| | - José Julián Serna
- Fundación Valle del Lili. Division of Trauma and Acute Care Surgery, Department of Surgery. Cali, Colombia.,Universidad del Valle, Facultad de Salud, Escuela de Medicina. Cali, Colombia.,Universidad Icesi, Cali, Colombia.,Hospital Universitario del Valle, Division of Trauma and Acute Care Surgery, Department of Surgery. Cali, Colombia
| | - Fernando Rodríguez-Holguin
- Fundación Valle del Lili. Division of Trauma and Acute Care Surgery, Department of Surgery. Cali, Colombia
| | - Alberto García
- Fundación Valle del Lili. Division of Trauma and Acute Care Surgery, Department of Surgery. Cali, Colombia.,Universidad del Valle, Facultad de Salud, Escuela de Medicina. Cali, Colombia.,Universidad Icesi, Cali, Colombia
| | - Alexander Salcedo
- Fundación Valle del Lili. Division of Trauma and Acute Care Surgery, Department of Surgery. Cali, Colombia.,Universidad del Valle, Facultad de Salud, Escuela de Medicina. Cali, Colombia.,Universidad Icesi, Cali, Colombia
| | - Yaset Caicedo
- Fundación Valle del Lili, Centro de Investigaciones Clínicas (CIC), Cali, Colombia
| | - Natalia Padilla
- Fundación Valle del Lili, Centro de Investigaciones Clínicas (CIC), Cali, Colombia
| | - Luis Fernando Pino
- Universidad del Valle, Facultad de Salud, Escuela de Medicina. Cali, Colombia.,Hospital Universitario del Valle, Division of Trauma and Acute Care Surgery, Department of Surgery. Cali, Colombia
| | - Adolfo González Hadad
- Universidad del Valle, Facultad de Salud, Escuela de Medicina. Cali, Colombia.,Hospital Universitario del Valle, Division of Trauma and Acute Care Surgery, Department of Surgery. Cali, Colombia.,Centro Médico Imbanaco, Cali, Colombia
| | - Mario Alain Herrera
- Universidad del Valle, Facultad de Salud, Escuela de Medicina. Cali, Colombia.,Hospital Universitario del Valle, Division of Trauma and Acute Care Surgery, Department of Surgery. Cali, Colombia
| | - Mauricio Millán
- Universidad Icesi, Cali, Colombia.,Fundación Valle del Lili, Division of Transplant Surgery, Department of Surgery, Cali, Colombia
| | - Laureano Quintero-Barrera
- Universidad del Valle, Facultad de Salud, Escuela de Medicina. Cali, Colombia.,Centro Médico Imbanaco, Cali, Colombia
| | - Fabian Hernández-Medina
- Universidad del Valle, Facultad de Salud, Escuela de Medicina. Cali, Colombia.,Hospital Universitario del Valle, Division of Trauma and Acute Care Surgery, Department of Surgery. Cali, Colombia
| | - Ricardo Ferrada
- Universidad del Valle, Facultad de Salud, Escuela de Medicina. Cali, Colombia.,Centro Médico Imbanaco, Cali, Colombia
| | - Megan Brenner
- University of California, Department of Surgery Riverside University Health Systems . Riverside , CA , USA
| | - Todd Rasmussen
- Uniformed Services University, F. Edward Hebert School of Medicine, Department of Surgery, Bethesda, Maryland. USA
| | - Thomas Scalea
- University of Maryland, Department of Surgery, School of Medicine, Baltimore, MD USA
| | - Rao Ivatury
- Professor Emeritus Virginia Commonwealth University, Richmond, VA, USA
| | - John B Holcomb
- University of Alabama Center for Injury Science, Department of Surgery, Birmingham. AL, USA
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Phillips AR, Tran L, Foust JE, Liang NL. Systematic review of plasma/packed red blood cell ratio on survival in ruptured abdominal aortic aneurysms. J Vasc Surg 2020; 73:1438-1444. [PMID: 33189763 DOI: 10.1016/j.jvs.2020.10.027] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 10/10/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND The ideal perioperative fluid resuscitation for patients with ruptured abdominal aortic aneurysms (rAAAs) is unknown. It has been shown in trauma studies that a higher ratio of plasma and platelets to packed red blood cells confers a mortality benefit. Controversy remains whether this is true also in the rAAA population. The objective of the present study was to investigate the benefit of a greater ratio of plasma/packed red blood cells in patients with rAAAs. METHODS A health sciences librarian searched four electronic databases, including PubMed, Embase, Cochrane, and ClinicalTrials.gov, using concepts for the terms "fluid resuscitation," "survival," and "ruptured abdominal aortic aneurysm." Two reviewers independently screened the studies that were identified through the search strategy and read in full any study that was potentially relevant. Studies were included if they had compared the mortality of patients with rAAAs who had received a greater ratio of plasma to other component therapy with that of patients who had received a lower ratio. The risk of bias was assessed using the ROBINS-I (risk of bias in nonrandomized studies of interventions) validated tool, and evidence quality was rated using the GRADE (grades of recommendation assessment, development, and evaluation) profile. No data synthesis or meta-analysis was planned or performed, given the anticipated paucity of research on this topic and the high degree of heterogeneity of available studies. RESULTS Our search identified seven observational studies for inclusion in the present review. Of these seven studies, three found an associated decrease in mortality with a greater ratio of plasma to packed red blood cells. The remaining four found no significant differences. The overall risk of bias was serious, and the evidence quality was very low. CONCLUSIONS Overall, the findings from the available studies would suggest that for patients who have undergone open surgery for a rAAA, mortality tends to be decreased when the amount of plasma transfused perioperatively is similar to the amount of packed red blood cells. However, the included studies reported very low-quality evidence based solely on highly heterogeneous observational studies, and further research is warranted.
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Affiliation(s)
- Amanda R Phillips
- Division of Vascular Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa.
| | - Lillian Tran
- Division of Vascular Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | | | - Nathan L Liang
- Division of Vascular Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa
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Massive transfusion and the response to prehospital plasma: It is all in how you define it. J Trauma Acute Care Surg 2020; 89:43-50. [PMID: 32118820 DOI: 10.1097/ta.0000000000002639] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND A recent analysis derived from the Prehospital Air Medical Plasma trial data set demonstrated no significant independent plasma survival benefit in those who required massive transfusion (≥10 units of red cells in 24 hours). The definition of massive transfusion has evolved over time to minimize bias and predict those at highest risk of death. We sought to characterize the definition of massive transfusion, their associated mortality risks and the survival benefit associated with prehospital plasma. METHODS A secondary analysis was performed using data from a recent prehospital plasma trial. Patients transferred directly from the scene were characterized. We defined historic massive transfusion using ≥10 units red cells in 24 hours and critical administration threshold (CAT) as ≥3 units per hour in the first hour (CAT1hr) or in any of the first 4 hours (CAT4hr) from arrival. The primary outcome was 30-day mortality. Kaplan-Meier analysis and Cox hazard regression were used to characterize the survival benefit of prehospital plasma. RESULTS There were a total of 390 enrolled patients who were transferred from the scene and represent the study cohort. Overall, 126 patients were positive for the CAT1hr metric, 183 patients were positive for the CAT4hr metric and 84 patients were positive for historic massive transfusion metric. The overall study mortality rate for those patients who met each transfusion definition was 13.1%, 17.4% and 10.0%, respectively. The CAT4hr metric had the lowest potential for survival bias. Kaplan-Meier survival analysis demonstrated a prehospital plasma survival benefit in the patients who were CAT4hr positive. CONCLUSION The current analysis demonstrates the superior utility of the CAT4hr definition with optimization of survival bias while conserving mortality risk prediction. This transfusion definition was associated with a prehospital plasma survival benefit and may be the most appropriate definition of massive transfusion for pragmatic studies which focus on hemorrhagic shock. LEVEL OF EVIDENCE Epidemiologic, Level II.
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Puzio TJ, Kalkwarf K, Cotton BA. Predicting the need for massive transfusion in the prehospital setting. Expert Rev Hematol 2020; 13:983-989. [PMID: 32746651 DOI: 10.1080/17474086.2020.1803735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Massive transfusion (MT) prediction scores allowed for the early identification of patients with massive hemorrhage likely to require large volumes of blood products. Despite their utility, very few MT scoring systems have shown promise in the pre-hospital setting due to their complexity and resource limitations. AREAS COVERED Pub med database was utilized to identify supporting literature for this review which discusses the importance of blood-based resuscitation and highlights the utility of scoring systems to predict the need of massive transfusion. MTP scoring systems effective in the prehospital setting are specifically discussed. EXPERT OPINION Massive transfusions scores are useful in alerting hospitals to the severity of trauma patients and organizing resources necessary for appropriate patient care but should not completely replace clinical . The opportunity exists to extend their use to the pre-hospital setting to allow for even earlier notification and to triage patients to trauma centers best able to treat severely injured.
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Affiliation(s)
- Thaddeus J Puzio
- Department of Surgery and the Center for Translational Injury Research, University of Texas Health Science Center , Houston, TX, USA
| | - Kyle Kalkwarf
- Department of Surgery, University of Arkansas Medical Sciences , Little Rock, AR, USA
| | - Bryan A Cotton
- Department of Surgery and the Center for Translational Injury Research, University of Texas Health Science Center , Houston, TX, USA
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10
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Effect of fibrinogen concentrate administration on early mortality in traumatic hemorrhagic shock: A propensity score analysis. J Trauma Acute Care Surg 2020; 88:661-670. [PMID: 32068718 DOI: 10.1097/ta.0000000000002624] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Fibrinogen concentrate is widely used in traumatic hemorrhagic shock despite weak evidence in the literature. The aim of the study was to evaluate the effect of fibrinogen concentrate administration within the first 6 hours on 24-hour all-cause mortality in traumatic hemorrhagic shock using a causal inference approach. METHODS Observational study from a French multicenter prospective trauma registry was performed. Hemorrhagic shock was defined as transfusion of four or more red blood cell units within the first 6 hours after admission. The confounding variables for the outcome (24-hour all-cause mortality) and treatment allocation (fibrinogen concentrate administration within the first 6 hours) were chosen by a Delphi method. The propensity score was specified with a data-adaptive algorithm and a doubly-robust approach with inverse proportionality of treatment weighting allowed to compute the average treatment effect. Sensitivity analyses were performed. RESULTS Of 14,336 patients in the registry during the study period, 1,027 in hemorrhagic shock were analyzed (758 receiving fibrinogen concentrate within 6 hours and 269 not receiving fibrinogen concentrate). The average treatment effect, expressed as a risk difference, was -0.031 (95% confidence interval, -0.084 to 0.021). All sensitivity analysis confirmed the results. CONCLUSIONS Fibrinogen concentrate administration within the first 6 hours of a traumatic hemorrhagic shock did not decrease 24-hour all-cause mortality. LEVEL OF EVIDENCE Prognostic, level III.
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11
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Meneses E, Boneva D, McKenney M, Elkbuli A. Massive transfusion protocol in adult trauma population. Am J Emerg Med 2020; 38:2661-2666. [PMID: 33071074 DOI: 10.1016/j.ajem.2020.07.041] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 07/07/2020] [Accepted: 07/15/2020] [Indexed: 10/23/2022] Open
Abstract
BACKGROUND Acute blood loss in trauma requires quick identification and action to restore circulating volume and save the patient. Massive transfusion protocols (MTPs) have become standard at Trauma Centers, in order to rapidly deliver blood products to bleeding patients. This literature review presents current standards of transfusion ratios, as well as insights into adjuncts during massive transfusions. METHODS PubMED was searched for articles from 2005 to 2020 on MTPs, the article were assessed for single vs. multi-institutional, mechanism of injury, type of MTP, timing in which blood products should be administered, timing of delivery of blood products to trauma bay, pre-hospital treatment and adjuncts, and outcomes. RESULTS Eleven studies addressed transfusion ratios. Seven studies looked at timing of blood products. Nine studies addressed MTP pre-hospital treatment and adjuncts. Prior to 2015, studies supported the benefits of a balanced transfusion ratio, which was then confirmed by the PROPPR randomized controlled trial. The shorter the time to blood product delivery the better the outcomes. New advances in technology have allowed us to measure different patterns of coagulation, allowing more individualized approaches to the bleeding patient. CONCLUSION Current massive transfusion protocols should utilize between 1:1:1 and 1:1:2 ratios of the 3 main products; plasma, platelets, and red blood cells. Massive transfusion protocols are effective in decreasing mortality. Better resuscitation efforts were seen when blood products were readily available in the trauma bay when the patient arrived and the faster the replacement of blood, the better the outcomes.
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Affiliation(s)
- Evander Meneses
- Department of Surgery, Division of Trauma and Surgical Critical Care, Kendall Regional Medical Center, Miami, FL, USA
| | - Dessy Boneva
- Department of Surgery, Division of Trauma and Surgical Critical Care, Kendall Regional Medical Center, Miami, FL, USA; Department of Surgery, University of South Florida, Tampa, FL, USA
| | - Mark McKenney
- Department of Surgery, Division of Trauma and Surgical Critical Care, Kendall Regional Medical Center, Miami, FL, USA; Department of Surgery, University of South Florida, Tampa, FL, USA
| | - Adel Elkbuli
- Department of Surgery, Division of Trauma and Surgical Critical Care, Kendall Regional Medical Center, Miami, FL, USA.
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Mortality in civilian trauma patients and massive blood transfusion treated with high vs low plasma: red blood cell ratio. Systematic review and meta-analysis. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2020. [DOI: 10.1097/cj9.0000000000000161] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Introduction: Massive bleeding in civilian trauma patients leads to dilutional coagulopathy. Transfusion with high plasma: red blood cell (RBC) ratio has been effective in reducing mortality in war trauma patients. However, in civilian trauma the evidence is controversial.
Objective: To assess the impact on mortality of high vs low plasma: RBC ratio transfusion, in civilian trauma patients with massive bleeding.
Methods: A systematic review and meta-analysis, including observational studies and clinical trials, was conducted. Databases were systemically searched for relevant studies between January 2007 and June 2019. The main outcome was early (24-hours) and late (30-day) mortality. Fixed and random effects models were used.
Results: Out of 1295 studies identified, 33 were selected: 2 clinical trials and 31 observational studies. The analysis of observational trials showed both decreased early mortality (odds ratio [OR] 0.67; 95% confidence interval [CI], 0.60–0.75) and late mortality (OR 0.79; 95% CI, 0.71–0.87) with the use of high plasma:RBC ratio transfusion, but there were no differences when clinical trials were evaluated (OR 0.89; 95% CI, 0.64–1.26). The exclusion of patients who died within the first 24hours was a source of heterogeneity. The Injury Severity Score (ISS) altered the association between high plasma: RBC ratio and mortality, with a reduced protective effect when the ISS was high.
Conclusion: The use of high vs low plasma: RBC ratio transfusion, in patients with massive bleeding due to civil trauma, has a protective effect on early and late mortality in observational studies. The exclusion of patients who died within the first 24 hours was a source of heterogeneity.
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Shlaifer A, Siman-Tov M, Radomislensky I, Peleg K, Klein Y, Glassberg E, Yitzhak A. The impact of prehospital administration of freeze-dried plasma on casualty outcome. J Trauma Acute Care Surg 2020; 86:108-115. [PMID: 30358770 DOI: 10.1097/ta.0000000000002094] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Hemorrhage is the most common preventable cause of death in both civilian and military trauma. There is no consensus regarding the appropriate fluid resuscitation protocol. Plasma, as a resuscitative fluid, has substantial benefits as a volume expander, owing to its relatively high oncotic pressure and its positive effect on trauma-induced coagulopathy by replenishing the lost coagulation factors, rather than diluting the casualty's remaining factors. The Israel Defense Force Medical Corps decided to use freeze-dried plasma (FDP) as the fluid of choice for casualties in hemorrhagic shock in the prehospital setting. The aim of our study is to compare the differences of coagulation, perfusion measurements, resource utilization, and outcome between casualties receiving FDP to casualties who did not receive FDP in the prehospital setting. METHODS This is a retrospective matched cohort study based on two groups of casualties (those treated with FDP vs. those without FDP treatment). The control group was compiled in three steps of precision for age, sex, mechanism of injury and maximum level of severity for each nine injured body regions. Data were collected from the IDF Trauma Registry and The National Israel Trauma Registry. RESULTS The study group comprised 48 casualties receiving FDP and 48 controls with no differences in demographic, evacuation time, and injury characteristics. The FDP group demonstrated a lower level of hemoglobin (12.7 gr/dzl) (odds ratio [OR], 3.11; 95% confidence interval [CI], 1.10-8.80), lower level of international normalized ratio (1.1) (OR, 3.09; 95% CI, 1.04-9.14), and lower level of platelets (230 × 109/L) (OR, 3.06; 95% CI, 1.16-8.06). No other differences were found between the two groups. CONCLUSION The use of FDP in the prehospital setting has logistic benefits and a positive effect on coagulation profile, with no other significant effects. Future studies need to be performed on larger groups to verify trends or nullify our hypotheses. LEVEL OF EVIDENCE Therapeutic, level IV.
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Affiliation(s)
- Amir Shlaifer
- From the The Israel Defense Forces Medical Corps, Tel-Hashomer, Israel (S.A., G.E., Y.A.); Israel National Center for Trauma and Emergency Medicine (S.-T.M., R.I., P.K.), Gertner Institute for Epidemiology and Public Health Policy, Tel-Hashomer, Israel; Department of Disaster Management (P.K.), School of Public Health, Tel Aviv University, Tel Aviv, Israel; Division of Trauma and Emergency Surgery, Department of Surgery (K.Y.), Sheba Medical Center, Ramat-Gan, Israel; The Uniformed Services (G.E.), University of the Health Sciences, Bethesda, MD and Bar-Ilan University Faculty of Medicine (G.E.), Safed, Israel
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14
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Mechanism, frequency, transfusion and outcome of severe trauma in coagulopathic paediatric patients. Eur J Trauma Emerg Surg 2020; 48:153-161. [PMID: 32448940 PMCID: PMC7245642 DOI: 10.1007/s00068-020-01398-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Accepted: 05/16/2020] [Indexed: 01/22/2023]
Abstract
Purpose Acute traumatic coagulopathy can result in uncontrolled haemorrhage responsible for the majority of early deaths after adult trauma. Data on the frequency, transfusion practice and outcome of severe trauma haemorrhage in paediatric patients are inconsistent. Methods Datasets from paediatric trauma patients were retrieved from the registry of the German trauma society (TR-DGU®) between 2009 and 2016. Coagulopathy was defined by a Quick’s value < 70% (INR (international normalized ratio) > 1.4) and/or thrombocytes ≤ 100 k upon emergency room admission. Children were grouped according to age in 4 different groups (A: 1–5, B: 6–10, C: 11–15 and D: 16–17 years). Prevalence of coagulopathy was assessed. Demographics, injury severity, haemostatic management including transfusions and mortality were described. Results 5351 primary admitted children ≤ 17 years with an abbreviated injury scale (AIS) ≥ 3 and complete datasets were included. The prevalence of coagulopathy was 13.7% (733/5351). The majority of the children sustained blunt trauma (more than 90% independent of age group) and a combination of traumatic brain injury (TBI) and any other trauma in more than 60% (A, C, D) and in 53.8% in group B. Coagulopathy occurred the most among the youngest (A: 18.2%), followed by all other age groups with approximately 13%. Overall mortality was the highest in the youngest (A: 40.9%) and among the youngest patients with traumatic brain injury (A: 71.4% and B: 47.1%). Transfusion of packed red blood cells (pRBCs) and fresh frozen plasma (FFPs) occurred almost in a 2:1 ratio (or less) across all age subgroups. Conclusion Traumatic haemorrhage in association with coagulopathy and severe shock is a major challenge in paediatric trauma across all age groups. Electronic supplementary material The online version of this article (10.1007/s00068-020-01398-x) contains supplementary material, which is available to authorized users.
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da Luz LT, Shah PS, Strauss R, Mohammed AA, D'Empaire PP, Tien H, Nathens AB, Nascimento B. Does the evidence support the importance of high transfusion ratios of plasma and platelets to red blood cells in improving outcomes in severely injured patients: a systematic review and meta-analyses. Transfusion 2019; 59:3337-3349. [PMID: 31614006 PMCID: PMC6900194 DOI: 10.1111/trf.15540] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Revised: 08/13/2019] [Accepted: 08/21/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND Deaths by exsanguination in trauma are preventable with hemorrhage control and resuscitation with allogeneic blood products (ABPs). The ideal transfusion ratio is unknown. We compared efficacy and safety of high transfusion ratios of FFP:RBC and PLT:RBC with low ratios in trauma. STUDY DESIGN AND METHODS Medline, Embase, Cochrane, and Controlled Clinical Trials Register were searched. Observational and randomized data were included. Risk of bias was assessed using validated tools. Primary outcome was 24-h and 30-day mortality. Secondary outcomes were exposure to ABPs and improvement of coagulopathy. Meta-analysis was conducted using a random-effects model. Strength and evidence quality were graded using GRADE profile RESULTS: 55 studies were included (2 randomized and 53 observational), with low and moderate risk of bias, respectively, and overall low evidence quality. The two RCTs showed no mortality difference (odds ratio [OR], 1.35; 95% confidence interval [CI], 0.40-4.59). Observational studies reported lower mortality in high FFP:RBCs ratio (OR, 0.38 [95% CI, 0.22-0.68] for 1:1 vs. <1:1; OR, 0.42 [95% CI, 0.22-0.81] for 1:1.5 vs. <1:1.5; and OR, 0.47 [95% CI, 0.31-0.71] for 1:2 vs. <1:2, respectively). Meta-analyses in observational studies showed no difference in exposure to ABPs. No data on coagulopathy for meta-analysis was identified. CONCLUSIONS Meta-analyses in observational studies suggest survival benefit and no difference in exposure to ABPs. No survival benefit in RCTs was identified. These conflicting results should be interpreted with caution. Studies are mostly observational, with relatively small sample sizes, nonrandom treatment allocation, and high potential for confounding. Further research is warranted.
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Affiliation(s)
| | - Prakesh S. Shah
- Department of PediatricsMount Sinai HospitalTorontoOntarioCanada
| | - Rachel Strauss
- Department SurgerySunnybrook Health Sciences CentreTorontoOntarioCanada
| | | | - Pablo Perez D'Empaire
- Department Anesthesia, Sunnybrook Health Sciences CentreUniversity of TorontoTorontoOntarioCanada
| | - Homer Tien
- Department SurgerySunnybrook Health Sciences CentreTorontoOntarioCanada
| | - Avery B. Nathens
- Department SurgerySunnybrook Health Sciences CentreTorontoOntarioCanada
| | - Barto Nascimento
- Department SurgerySunnybrook Health Sciences CentreTorontoOntarioCanada
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Kam CW, Law PKJ, Lau HWJ, Ahmad R, Tse CLJ, Cheng M, Lee KB, Lee KY. The 10 commandments of exsanguinating pelvic fracture management. HONG KONG J EMERG ME 2019. [DOI: 10.1177/1024907919869501] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Background:Unstable pelvic fractures are highly lethal injuries.Objective:The review aims to summarize the landmark management changes in the past two decades.Methods:Structured review based on pertinent published literatures on severe pelvic fracture was performed.Results:Ten key management points were identified.Conclusion:These 10 recommendations help diminish and prevent the mortality. (1) Before the ABCDE management, preparedness, protection, and decision are essential to optimize patient outcome and to conserve resources. (2) Do not rock the pelvis to check stability, avoid logrolling but prophylactic pelvic binder can be life-saving. (3) Computed tomography scanner can be the tunnel to death for hemodynamically unstable patients. (4) Correct application of pelvic binder at the greater trochanter level to achieve the most effective compression. (5) Choose the suitable binder (BEST does not exist, always look for BETTER) to facilitate body examination and therapeutic intervention. (6) Massive transfusion protocol is only a temporizing measure to sustain the circulation for life maintenance. (7) Damage control operation aims to promptly stop the bleeding to restore the physiology by combating the trauma lethal triad to be followed by definitive anatomical repair. (8) Protocol-driven teamwork management expedites the completion of the multi-phase therapy including external pelvic fixation, pre-peritoneal pelvic packing, and angio-embolization, preceded by laparotomy when indicated. (9) Resuscitation endovascular balloon occlusion of aorta can reduce the pelvic bleeding while awaiting hospital transfer or operation theater access. (10) Operation is the definitive therapy for trauma but prevention is the best treatment, comprising primary, secondary, and tertiary levels.
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Affiliation(s)
- Chak Wah Kam
- Cluster Trauma Advisory Committee, Tuen Mun Hospital, Tuen Mun, Hong Kong
| | | | | | - Rashidi Ahmad
- EM Unit, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | | | - Mina Cheng
- Department of Surgery, Queen Elizabeth Hospital, Kowloon, Hong Kong
| | - Kin Bong Lee
- Department of Orthopaedics, Queen Elizabeth Hospital, Kowloon, Hong Kong
| | - Kin Yan Lee
- Department of Surgery, Queen Elizabeth Hospital, Kowloon, Hong Kong
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Sex-based differences in transfusion need after severe injury: Findings of the PROPPR study. Surgery 2019; 165:1122-1127. [PMID: 30871812 DOI: 10.1016/j.surg.2018.12.023] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Revised: 11/21/2018] [Accepted: 12/12/2018] [Indexed: 11/21/2022]
Abstract
BACKGROUND Women are underrepresented in trauma research, and aggregated results of clinical trials may mask effects that differ by sex. It is unclear whether women respond differently to severe hemorrhage compared with men. We sought to evaluate sex-based differences in outcomes after severe trauma with hemorrhage. METHODS We performed a secondary analysis of the Pragmatic Randomized Optimal Platelet and Plasma Ratios trial. Trauma patients predicted to require massive transfusion were randomized to a 1:1:1 vs 1:1:2 plasma to platelet to red blood cell transfusion ratio. Analysis was performed according to sex, controlling for clinical characteristics and transfusion arm. RESULTS A total of 134 women and 546 men were analyzed. In multivariable analysis, there was no difference in mortality at 24 hours (hazard ratio for women 0.64, 95% confidence interval 0.34-1.23, P = .18) or in time to hemostasis (hazard ratio 1.10, 95% confidence interval 0.84-1.42, P = .49) by sex. We observed no difference between sexes in volume of blood products transfused during active hemorrhage. However, after anatomic hemostasis, women received lower volumes of all products, with a 38% reduction in fresh frozen plasma (mean ratio 0.62 (95% confidence interval 0.43-0.89, P = .01), 49% reduction in platelets (mean ratio 0.51, 95% confidence interval 0.33-0.79, P < .01) and 49% reduction in volume of red blood cells (mean ratio 0.51, 95% confidence interval 0.33-0.79, P < .01). CONCLUSION Mortality and time to hemostasis of trauma patients with hemorrhage did not differ by sex. Although there was no difference in transfusion requirement during active hemorrhage, once hemostasis was achieved, women received fewer units of all blood products than men. Further research is required to determine whether women exhibit differences in coagulation during and after severe traumatic hemorrhage.
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Coccolini F, Pizzilli G, Corbella D, Sartelli M, Agnoletti V, Agostini V, Baiocchi GL, Ansaloni L, Catena F. Pre-hospital plasma in haemorrhagic shock management: current opinion and meta-analysis of randomized trials. World J Emerg Surg 2019; 14:6. [PMID: 30815028 PMCID: PMC6377767 DOI: 10.1186/s13017-019-0226-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Accepted: 02/07/2019] [Indexed: 01/12/2023] Open
Abstract
Background Trauma-induced coagulopathy is one of the most difficult issues to manage in severely injured patients. The plasma efficacy in treating haemorrhagic-shocked patients is well known. The debated issue is the timing at which it should be administered. Few evidences exist regarding the effects on mortality consequent to the use of plasma alone given in pre-hospital setting. Recently, two randomized trials reported interesting and discordant results. The present paper aims to analyse data from those two randomized trials in order to obtain more univocal results. Methods A systematic review with meta-analysis of randomized controlled trials (RCTs) of pre-hospital plasma vs. usual care in patients with haemorrhagic shock. Results Two high-quality RCTs have been included with 626 patients (295 in plasma and 331 in usual care arm). Twenty-four-hour mortality seems to be reduced in pre-hospital plasma group (RR = 0.69; 95% CI = 0.48–0.99). Pre-hospital plasma has no significant effect on 1-month mortality (RR = 0.86; 95% CI = 0.68–1.11) as on acute lung injury and on multi-organ failure rates (OR = 1.03; 95% CI = 0.71–1.50, and OR = 1.30; 95% CI = 0.92–1.86, respectively). Conclusions Pre-hospital plasma infusion seems to reduce 24-h mortality in haemorrhagic shock patients. It does not seem to influence 1-month mortality, acute lung injury and multi-organ failure rates. Level of evidence: Level I Study type: Systematic review with Meta-analysis
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Affiliation(s)
- Federico Coccolini
- 1General, Emergency and Trauma Surgery, Bufalini Hospital, Viale Ghirotti 268, 47521 Cesena, Italy
| | | | - Davide Corbella
- 3ICU department, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | | | | | - Vanessa Agostini
- 5Transfusional and Immunohaematological disorders department, Bufalini hospital, Cesena, Italy
| | - Gian Luca Baiocchi
- 6Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Luca Ansaloni
- 1General, Emergency and Trauma Surgery, Bufalini Hospital, Viale Ghirotti 268, 47521 Cesena, Italy
| | - Fausto Catena
- 7Emergency surgery department, Parma University Hospital, Parma, Italy
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Khasne RW, Kulkarni PA, Kulkarni AP. Landmark Papers on Blood and Component Transfusion Therapy in the Critically Ill: A Critical Analysis. Indian J Crit Care Med 2019; 23:S207-S211. [PMID: 31656380 PMCID: PMC6785815 DOI: 10.5005/jp-journals-10071-23254] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
How to cite this article: Khasne RW, Kulkarni PA, Kulkarni AP. Landmark Papers on Blood and Component Transfusion Therapy in the Critically Ill: A Critical Analysis. Indian J Crit Care Med 2019;23(Suppl 3):S207–S211.
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Affiliation(s)
| | - Pradnya Atul Kulkarni
- Blood Bank, Department of Pathology, KJ Somaiya Hospital, Mumbai, Maharashtra, India
| | - Atul P Kulkarni
- Division of Critical Care Medicine, Department of Anesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
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20
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Givergis R, Munnangi S, Fayaz M Fomani K, Boutin A, Zapata LC, Angus LDG. Evaluation of massive transfusion protocol practices by type of trauma at a level I trauma center. Chin J Traumatol 2018; 21:261-266. [PMID: 29776837 PMCID: PMC6235793 DOI: 10.1016/j.cjtee.2018.01.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Revised: 01/08/2018] [Accepted: 03/08/2018] [Indexed: 02/04/2023] Open
Abstract
PURPOSE To evaluate massive transfusion protocol practices by trauma type at a level I trauma center. METHODS A retrospective analysis was performed on a sample of 76 trauma patients with MTP activation between March 2010 and January 2015 at a regional trauma center. Patient demographics, transfusion practices, and clinical outcomes were compared by type of trauma sustained. RESULTS Penetrating trauma patients who required MTP activation were significantly younger, had lower injury severity score (ISS), higher probability of survival (POS), decreased mortality, and higher Glasgow Coma scale (GCS) compared to blunt trauma patients. Overall, the mortality rate was 38.16%. The most common injury sustained among blunt trauma patients was head injury (36.21%), whereas the majority of the penetrating trauma patients sustained abdominal injuries (55.56%). Although the admission coagulation parameters and timing of coagulopathy were not significantly different between the two groups of patients, a significantly higher proportion of penetrating trauma patients received high plasma content therapy relative to blunt trauma patients (p < 0.01). CONCLUSION Despite the use of the same MTP for all injured patients requiring massive transfusion, significant differences existed between blunt trauma patients and penetrating trauma patients. These differences in transfusion characteristics and outcomes following MTP activation underscore the complexity of implementing MTPs and warrant vigilant transfusion practices to improve outcomes in trauma patients.
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Affiliation(s)
- Roshan Givergis
- Department of Emergency Medicine, Nassau University Medical Center, East Meadow, NY, USA
| | - Swapna Munnangi
- Department of Emergency Medicine, Nassau University Medical Center, East Meadow, NY, USA,Corresponding author.
| | | | - Anthony Boutin
- Department of Emergency Medicine, Nassau University Medical Center, East Meadow, NY, USA
| | - Luis Carlos Zapata
- Department of Emergency Medicine, Nassau University Medical Center, East Meadow, NY, USA
| | - LD George Angus
- Department of Surgery, Nassau University Medical Center, East Meadow, NY, USA
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21
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Payen JF, Berthet M, Genty C, Declety P, Garrigue-Huet D, Morel N, Bouzat P, Riou B, Bosson JL. Reduced mortality by meeting guideline criteria before using recombinant activated factor VII in severe trauma patients with massive bleeding. Br J Anaesth 2018; 117:470-476. [PMID: 28077534 DOI: 10.1093/bja/aew276] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/04/2016] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Management of trauma patients with severe bleeding has led to criteria before considering use of recombinant activated factor VII (rFVIIa), including haemoglobin >8 g dl-1, serum fibrinogen ≥1.0 g l-1, platelets >50,000 x 109 l-1, arterial pH ≥ 7.20, and body temperature ≥34 °C. We hypothesized that meeting these criteria is associated with improved outcomes. METHODS In this prospective cohort study of 26 French trauma centres, subjects were included if they received rFVIIa for persistent massive bleeding despite appropriate care after severe blunt and/or penetrating trauma. RESULTS After surgery and/or embolization as haemostatic interventions, 112 subjects received a first dose of 103 μg kg-1 rFVIIa (82-200) (median, 25th-75th percentile) at 420 min (285-647) post-trauma. Of these, 71 (63%) "responders" were still alive at 24h post-trauma and had their transfusion requirements reduced by > 2 packed red blood cell units after rFVIIa treatment. Mortality was 54% on day 30 post-trauma. There were 21%, 44% and 35% subjects who fulfilled 0-1, 2-3 or 4-5, respectively, of the guidelines before receiving rFVIIa. Survival at day 30 was 13%, 49% and 64% and the proportion of responders was 39%, 64% and 82%, when subjects fulfilled 0-1, 2-3 or 4-5 conditions, respectively (both P <0.01). CONCLUSIONS In actively bleeding trauma patients, meeting guideline criteria before considering rFVIIa was associated with lower mortality and a higher proportion of responders to the rFVIIa.
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Affiliation(s)
- J-F Payen
- Pôle Anesthésie Réanimation, CHU Grenoble Alpes, F-38000, Grenoble, France .,INSERM, U1216, F-38000 Grenoble, France.,Univ. Grenoble Alpes, Grenoble Institut des Neurosciences, GIN, F-38000 Grenoble, France
| | - M Berthet
- Pôle Anesthésie Réanimation, CHU Grenoble Alpes, F-38000, Grenoble, France
| | - C Genty
- Clinical Research Centre, INSERM 003, CHU Grenoble Alpes, F-38000, Grenoble, France.,Univ. Grenoble Alpes, CNRS-TIMC-IMAG UMR, 5525-ThEMAS, F-38000 Grenoble, France
| | - P Declety
- Pôle Anesthésie Réanimation, CHU Grenoble Alpes, F-38000, Grenoble, France
| | - D Garrigue-Huet
- Pôle Anesthésie Réanimation, CHU de Lille, F-59037, Lille, France
| | - N Morel
- Pôle Urgences SAMU SMUR, Groupe Hospitalier Pellegrin, CHU de Bordeaux, F-33076, Bordeaux, France
| | - P Bouzat
- Pôle Anesthésie Réanimation, CHU Grenoble Alpes, F-38000, Grenoble, France.,INSERM, U1216, F-38000 Grenoble, France.,Univ. Grenoble Alpes, Grenoble Institut des Neurosciences, GIN, F-38000 Grenoble, France
| | - B Riou
- Service d'accueil des Urgences, CHU Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, F-75651, Paris, France.,Sorbonne Universités, UPMC Univ. Paris 6, UMRS INSERM 1166, IHU ICAN, Paris, France
| | - J-L Bosson
- Clinical Research Centre, INSERM 003, CHU Grenoble Alpes, F-38000, Grenoble, France.,Univ. Grenoble Alpes, CNRS-TIMC-IMAG UMR, 5525-ThEMAS, F-38000 Grenoble, France
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Abstract
INTRODUCTION Balanced resuscitation of plasma, platelets, and red blood cells is now recognized as improving outcomes in traumatic bleeding in adults. The correct approach in children has yet to be determined. METHODS We performed a systematic review of the literature into transfusion protocols in traumatic hemorrhage in children by conducting an article search of significant databases to identify relevant articles. Studies of interest included interventional trials with comparisons relating to the transfusion of blood including blood component therapy. The search identified 422 articles of interest, the abstracts of which were independently reviewed by 2 authors for inclusion in the trial. This revealed 35 articles, the full texts of which were reviewed. There were no randomized controlled trials and 4 nonrandomized trials with a further 21 articles that were deemed relevant. The data were insufficient for meta-analysis, and so a descriptive analysis was performed. RESULTS There were 4 main trials. Two trials were small (approximately 100 patients) nonrandomized trials into pediatric hemorrhage managed as per a massive transfusion protocol or at physician discretion. One was a retrospective analysis of pediatric trauma patients who received red blood cell transfusion with differing platelet ratios, and one was a trauma database review of component ratios in hemorrhaging children. All 4 trials found increased ratios had no effect on mortality. DISCUSSION As well as blood component therapy, adjunctive therapies used in the management of bleeding children are discussed. These include tranexamic acid, viscoelastic hemostatic assays, factor VIIa, and fibrinogen use. CONCLUSIONS There is little evidence for improved outcomes using component-based transfusion in a rigid 1:1:1 strategy in children. A goal-directed approach using viscoelastic hemostatic assay-guided treatment with early institution of tranexamic acid and fibrinogen replacement is considered the way forward.
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Affiliation(s)
| | - Claire Furyk
- Australian and New Zealand College of Anaesthetists, Melbourne, Australia
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Prehospital Blood Product Administration Opportunities in Ground Transport ALS EMS – A Descriptive Study. Prehosp Disaster Med 2018; 33:230-236. [DOI: 10.1017/s1049023x18000274] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
AbstractIntroductionHemorrhage remains the major cause of preventable death after trauma. Recent data suggest that earlier blood product administration may improve outcomes. The purpose of this study was to determine whether opportunities exist for blood product transfusion by ground Emergency Medical Services (EMS).MethodsThis was a single EMS agency retrospective study of ground and helicopter responses from January 1, 2011 through December 31, 2015 for adult trauma patients transported from the scene of injury who met predetermined hemodynamic (HD) parameters for potential transfusion (heart rate [HR]≥120 and/or systolic blood pressure [SBP]≤90).ResultsA total of 7,900 scene trauma ground transports occurred during the study period. Of 420 patients meeting HD criteria for transfusion, 53 (12.6%) had a significant mechanism of injury (MOI). Outcome data were available for 51 patients; 17 received blood products during their emergency department (ED) resuscitation. The percentage of patients receiving blood products based upon HD criteria ranged from 1.0% (HR) to 5.9% (SBP) to 38.1% (HR+SBP). In all, 74 Helicopter EMS (HEMS) transports met HD criteria for blood transfusion, of which, 28 patients received prehospital blood transfusion. Statistically significant total patient care time differences were noted for both the HR and the SBP cohorts, with HEMS having longer time intervals; no statistically significant difference in mean total patient care time was noted in the HR+SBP cohort.ConclusionsIn this study population, HD parameters alone did not predict need for ED blood product administration. Despite longer transport times, only one-third of HEMS patients meeting HD criteria for blood administration received prehospital transfusion. While one-third of ground Advanced Life Support (ALS) transport patients manifesting HD compromise received blood products in the ED, this represented 0.2% of total trauma transports over the study period. Given complex logistical issues involved in prehospital blood product administration, opportunities for ground administration appear limited within the described system.MixFM, ZielinskiMD, MyersLA, BernsKS, LukeA, StubbsJR, ZietlowSP, JenkinsDH, SztajnkrycerMD. Prehospital blood product administration opportunities in ground transport ALS EMS – a descriptive study. Prehosp Disaster Med. 2018;33(3):230–236.
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Mclennan JV, Mackway-Jones KC, Smith JE. Prediction of massive blood transfusion in battlefield trauma: Development and validation of the Military Acute Severe Haemorrhage (MASH) score. Injury 2018; 49:184-190. [PMID: 28988805 DOI: 10.1016/j.injury.2017.09.029] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2017] [Accepted: 09/28/2017] [Indexed: 02/02/2023]
Abstract
BACKGROUND The predominant cause of preventable trauma death is bleeding, and many of these patients need resuscitation with massive blood transfusion. In resource-constrained environments, early recognition of such patients can improve planning and reduce wastage of blood products. No existing decision rule is sufficiently reliable to predict those patients requiring massive blood transfusion. This study aims to produce a decision rule for use on arrival at hospital for patients sustaining battlefield trauma. METHODS A retrospective database analysis was undertaken using the UK Joint Theatre Trauma Registry to provide a derivation and validation dataset. Regression analysis of potential predictive factors was performed. Predictive factors were analysed through multi-logistic regression analysis to build predictive models; sensitivity and specificity of these models was assessed, and the best fit models were analysed in the validation dataset. RESULTS A decision rule was produced using a combination of injury pattern, clinical observations and pre-hospital data. The proposed rule, using a score of 3 or greater, demonstrated a sensitivity of 82.7% and a specificity of 88.8% for prediction of massive blood transfusion, with an AUROC of 0.93 (95% CI 0.91-0.95). CONCLUSIONS We have produced a decision tool with improved accuracy compared to any previously described tools that can be used to predict blood transfusion requirements in the military deployed hospital environment.
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Affiliation(s)
- Jacqueline V Mclennan
- Manchester University, Oxford Rd, Manchester, M13 9PL, UK; Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine (Academia & Research), Medical Directorate, ICT Centre, Birmingham Research Park, Vincent Drive, Edgbaston, Birmingham, B15 2SQ, UK; Royal Stoke University Hospital, University Hospital North Midlands, Stoke on Trent, Staffordshire, ST4 6QG, UK.
| | - Kevin C Mackway-Jones
- Royal Stoke University Hospital, University Hospital North Midlands, Stoke on Trent, Staffordshire, ST4 6QG, UK; Manchester Royal Infirmary, Oxford Rd, Manchester, M13 9WL, UK
| | - Jason E Smith
- Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine (Academia & Research), Medical Directorate, ICT Centre, Birmingham Research Park, Vincent Drive, Edgbaston, Birmingham, B15 2SQ, UK; Emergency Department, Derriford Hospital, Plymouth, PL6 8DH, UK
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Kunitake RC, Kornblith LZ, Cohen MJ, Callcut RA. Trauma Early Mortality Prediction Tool (TEMPT) for assessing 28-day mortality. Trauma Surg Acute Care Open 2018; 3:e000131. [PMID: 29766125 PMCID: PMC5887834 DOI: 10.1136/tsaco-2017-000131] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Revised: 11/05/2017] [Accepted: 11/14/2017] [Indexed: 01/08/2023] Open
Abstract
Background Prior mortality prediction models have incorporated severity of anatomic injury quantified by Abbreviated Injury Severity Score (AIS). Using a prospective cohort, a new score independent of AIS was developed using clinical and laboratory markers present on emergency department presentation to predict 28-day mortality. Methods All patients (n=1427) enrolled in an ongoing prospective cohort study were included. Demographic, laboratory, and clinical data were recorded on admission. True random number generator technique divided the cohort into derivation (n=707) and validation groups (n=720). Using Youden indices, threshold values were selected for each potential predictor in the derivation cohort. Logistic regression was used to identify independent predictors. Significant variables were equally weighted to create a new mortality prediction score, the Trauma Early Mortality Prediction Tool (TEMPT) score. Area under the curve (AUC) was tested in the validation group. Pairwise comparison of Trauma Injury Severity Score (TRISS), Revised Trauma Score, Glasgow Coma Scale, and Injury Severity Score were tested against the TEMPT score. Results There was no difference between baseline characteristics between derivation and validation groups. In multiple logistic regression, a model with presence of traumatic brain injury, increased age, elevated systolic blood pressure, decreased base excess, prolonged partial thromboplastin time, increased international normalized ratio (INR), and decreased temperature accurately predicted mortality at 28 days (AUC 0.93, 95% CI 0.90 to 0.96, P<0.001). In the validation cohort, this score, termed TEMPT, predicted 28-day mortality with an AUC 0.94 (95% CI 0.92 to 0.97). The TEMPT score preformed similarly to the revised TRISS score for severely injured patients and was highly predictive in those having mild to moderate injury. Discussion TEMPT is a simple AIS-independent mortality prediction tool applicable very early following injury. TEMPT provides an AIS-independent score that could be used for early identification of those at risk of doing poorly following even minor injury. Level of evidence Level II.
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Affiliation(s)
- Ryan C Kunitake
- Department of Surgery, University of California, San Francisco, California, USA
| | - Lucy Z Kornblith
- Department of Surgery, University of California, San Francisco, California, USA
| | - Mitchell Jay Cohen
- Department of Surgery, Denver Health Medical Center, Denver, Colorado, USA
| | - Rachael A Callcut
- Department of Surgery, University of California, San Francisco, California, USA
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Abstract
Damage control surgery (DCS) began as an adjunct approach to hemorrhage control, seeking to facilitate the body's innate clotting ability when direct repair or ligation was impossible, but it has since become a valuable instrument for a broader collection of critically ill surgical patients in whom metabolic dysfunction is the more immediate threat to life than imminent exsanguination. Modern damage control is a strategy that combines the principles of DCS with those of damage control resuscitation. When used correctly, damage control may improve survival in previously unsalvageable patients; when used incorrectly, it can subject patients to imprudent risk and contribute to morbidity. This review discusses the evolution of damage control in both concept and practice, summarizing available literature and experience to guide patient selection, medical decision-making, and strategy implementation throughout the preoperative, intraoperative, and early postoperative periods.
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Affiliation(s)
- Brian C Beldowicz
- Division of Military, Department of Emergency Medicine, Uniformed Services University of the Health Sciences, Sacramento, California
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Kyle T, Greaves I, Beynon A, Whittaker V, Brewer M, Smith J. Ionised calcium levels in major trauma patients who received blood en route to a military medical treatment facility. Emerg Med J 2017; 35:176-179. [PMID: 29175878 DOI: 10.1136/emermed-2017-206717] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2017] [Revised: 10/13/2017] [Accepted: 11/01/2017] [Indexed: 11/04/2022]
Abstract
BACKGROUND Hypocalcaemia is a common metabolic derangement in critically ill patients. Blood transfusion can also contribute to depleted calcium levels. The aims of this study were to identify the incidence of hypocalcaemia in military trauma patients receiving blood products en route to a deployed hospital facility and to determine if intravenous calcium, given during the prehospital phase, has an effect on admission calcium levels. METHODS This was a retrospective review of patients transported by the UK Medical Emergency Response Team in Afghanistan between January 2010 and December 2014 who were treated with blood products in the prehospital setting. Total units of blood products administered, basic demographics, Injury Severity Score and trauma type were collected. Ionised serum calcium levels on admission to hospital were compared between those who received blood products without prehospital intravenous calcium supplemental therapy (non-treatment) and patients who were treated with 10 mL of intravenous calcium chloride (10%) concurrently with blood products (treatment). RESULTS The study included 297 patients; 237 did not receive calcium and 60 did. The incidence of hypocalcaemia in the non-treatment group was 70.0% (n=166) compared with 28.3% (n=17) in the treatment group. Serum calcium levels were significantly different between the groups (1.03 mmol/L vs 1.25 mmol/L, difference 0.22 mmol/L, 95% CI 0.15 to 0.27). In the non-treatment group, 26.6% (n=63) had calcium levels within the normal range compared with 41.7% (n=25) in those who received calcium. There was a dose response of calcium level to blood products with a significant decrease in calcium levels as the volume of blood products increased. CONCLUSION Trauma patients who received blood products were at high risk of hypocalcaemia. Aggressive management of these patients with intravenous calcium during transfusion may be required.
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Affiliation(s)
- Tony Kyle
- Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine (Research and Academia), Birmingham, UK.,Institute of Learning Research & Innovation, James Cook University Hospital, Middlebrough, UK
| | - Ian Greaves
- Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine (Research and Academia), Birmingham, UK.,Emergency Department, James Cook University Hospital, Middlesbrough, UK
| | - Anthony Beynon
- Emergency Department, Derriford Hospital, Plymouth, UK.,Defence Medical Group South West, Derriford Hospital, Plymouth, UK
| | - Vicky Whittaker
- Health and Social Care Institute, Teesside University, Middlesbrough, North Yorkshire, UK
| | - Mike Brewer
- Department of Biomedical Science, 16 Medical Regiment, Colchester, UK
| | - Jason Smith
- Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine (Research and Academia), Birmingham, UK.,Emergency Department, Derriford Hospital, Plymouth, UK
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Yang JC, Wang QS, Dang QL, Sun Y, Xu CX, Jin ZK, Ma T, Liu J. Investigation of the status quo of massive blood transfusion in China and a synopsis of the proposed guidelines for massive blood transfusion. Medicine (Baltimore) 2017; 96:e7690. [PMID: 28767599 PMCID: PMC5626153 DOI: 10.1097/md.0000000000007690] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
The aim of this study was to provide an overview of massive transfusion in Chinese hospitals, identify the important indications for massive transfusion and corrective therapies based on clinical evidence and supporting experimental studies, and propose guidelines for the management of massive transfusion. This multiregion, multicenter retrospective study involved a Massive Blood Transfusion Coordination Group composed of 50 clinical experts specializing in blood transfusion, cardiac surgery, anesthesiology, obstetrics, general surgery, and medical statistics from 20 tertiary general hospitals across 5 regions in China. Data were collected for all patients who received ≥10 U red blood cell transfusion within 24 hours in the participating hospitals from January 1 2009 to December 31 2010, including patient demographics, pre-, peri-, and post-operative clinical characteristics, laboratory test results before, during, and after transfusion, and patient mortality at post-transfusion and discharge. We also designed an in vitro hemodilution model to investigate the changes of blood coagulation indices during massive transfusion and the correction of coagulopathy through supplement blood components under different hemodilutions. The experimental data in combination with the clinical evidence were used to determine the optimal proportion and timing for blood component supplementation during massive transfusion. Based on the findings from the present study, together with an extensive review of domestic and international transfusion-related literature and consensus feedback from the 50 experts, we drafted the guidelines on massive blood transfusion that will help Chinese hospitals to develop standardized protocols for massive blood transfusion.
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Affiliation(s)
- Jiang-Cun Yang
- Department of Transfusion Medicine, Shaanxi Provincial People's Hospital, Xi’an
| | - Qiu-Shi Wang
- Department of Transfusion Medicine, Shengjing Hospital of China Medical University, Shenyang
| | - Qian-Li Dang
- Department of Dermatology, Shaanxi Provincial People's Hospital, Xi’an
| | - Yang Sun
- Department of Transfusion Medicine, Shaanxi Provincial People's Hospital, Xi’an
| | - Cui-Xiang Xu
- Shaanxi Provincial Center for Clinical Laboratory
| | - Zhan-Kui Jin
- Department of Orthopaedics, Shaanxi Provincial People's Hospital, Xi’an, China
| | - Ting Ma
- Department of Transfusion Medicine, Shaanxi Provincial People's Hospital, Xi’an
| | - Jing Liu
- Division of Transfusion Medicine, Johns Hopkins University, School of Medicine, Baltimore, MD
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Damage control resuscitation in patients with severe traumatic hemorrhage: A practice management guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg 2017; 82:605-617. [PMID: 28225743 DOI: 10.1097/ta.0000000000001333] [Citation(s) in RCA: 262] [Impact Index Per Article: 37.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND The resuscitation of severely injured bleeding patients has evolved into a multi-modal strategy termed damage control resuscitation (DCR). This guideline evaluates several aspects of DCR including the role of massive transfusion (MT) protocols, the optimal target ratio of plasma (PLAS) and platelets (PLT) to red blood cells (RBC) during DCR, and the role of recombinant activated factor VII (rVIIa) and tranexamic acid (TXA). METHODS Using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology, a subcommittee of the Practice Management Guidelines (PMG) Section of EAST conducted a systematic review using MEDLINE and EMBASE. Articles in English from1985 through 2015 were considered in evaluating four PICO questions relevant to DCR. RESULT A total of 37 studies were identified for analysis, of which 31 met criteria for quantitative meta-analysis. In these studies, mortality decreased with use of an MT/DCR protocol vs. no protocol (OR 0.61, 95% CI 0.43-0.87, p = 0.006) and with a high ratio of PLAS:RBC and PLT:RBC (relatively more PLAS and PLT) vs. a low ratio (OR 0.60, 95% CI 0.46-0.77, p < 0.0001; OR 0.44, 95% CI 0.28-0.71, p = 0.0003). Mortality and blood product use were no different with either rVIIa vs. no rVIIa or with TXA vs. no TXA. CONCLUSION DCR can significantly improve outcomes in severely injured bleeding patients. After a review of the best available evidence, we recommend the use of a MT/DCR protocol in hospitals that manage such patients and recommend that the protocol target a high ratio of PLAS and PLT to RBC. This is best achieved by transfusing equal amounts of RBC, PLAS, and PLT during the early, empiric phase of resuscitation. We cannot recommend for or against the use of rVIIa based on the available evidence. Finally, we conditionally recommend the in-hospital use of TXA early in the management of severely injured bleeding patients.
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Utilizing Group-based Trajectory Modeling to Understand Patterns of Hemorrhage and Resuscitation. Ann Surg 2017; 264:1135-1141. [PMID: 26727091 DOI: 10.1097/sla.0000000000001555] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The purpose of this study was to describe variations in blood-based resuscitation in an injured cohort. We hypothesize that distinct transfusion trajectories are present. BACKGROUND Retrospective studies of hemorrhage utilize the concept of massive transfusion, where a set volume of blood is required. Patterns of hemorrhage vary and massive transfusion does little to describe these differences. METHODS Patients were prospectively included from June 2012 to 2013. Time of transfusion for each packed red blood cell (PRBC) transfused was recorded, in minutes, for all patients. Additional measures included demographic and injury data, admission laboratory values, and vital signs and outcomes including mortality, tempo of transfusion, and operative requirements. Group-based trajectory modeling was utilized to describe transfusion trajectories throughout the cohort. RESULTS Three hundred sixteen patients met the inclusion criteria. Among them, 72% were men and median age was 35 years (interquartile range [IQR] 24-50), median injury severity score was 13 (IQR 9-22), median 24-hour transfusion volume was 4 units of PRBCs (IQR 2-8), and mortality was 14%. Six transfusion trajectories were identified. Among the patients, 35% received negligible transfusions (group 1). Groups 2 and 3 received greater than 15 units PRBCs-the former as early resuscitation, whereas the latter intermittently throughout the day. Groups 4 and 5 had similar small resuscitations with distinct demographic differences. Group 6 suffered blunt injuries and required rapid resuscitation. CONCLUSIONS Traditional definitions of massive transfusion are broad and imprecise. In cohorts of severely injured patients, there are distinct, identifiable transfusion trajectories. Identification of subgroups is important in understanding clinical course and to anticipate resuscitative and therapeutic needs.
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31
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Gurney JM, Holcomb JB. Blood Transfusion from the Military’s Standpoint: Making Last Century’s Standard Possible Today. CURRENT TRAUMA REPORTS 2017. [DOI: 10.1007/s40719-017-0083-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Wijaya R, Cheng HMG, Chong CK. The use of massive transfusion protocol for trauma and non-trauma patients in a civilian setting: what can be done better? Singapore Med J 2017; 57:238-41. [PMID: 27211577 DOI: 10.11622/smedj.2016088] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
INTRODUCTION Massive transfusion protocol (MTP) is increasingly used in civilian trauma cases to achieve better haemostatic resuscitation in patients requiring massive blood transfusions (MTs), with improved survival outcomes. However, in non-trauma patients, evidence for MTP is lacking. This study aims to assess the outcomes of a newly established MTP in a civilian setting, for both trauma and non-trauma patients, in an acute surgical care unit. METHODS A retrospective cohort analysis was performed on 46 patients for whom MTP was activated in Changi General Hospital, Singapore. The patients were categorised into trauma and non-trauma groups. Assessment of Blood Consumption (ABC) score was used to identify MTP trauma patients and analyse over-activation rates. RESULTS Only 39.1% of all cases with MTP activation eventually received MTs; 39.8% of the MTs were for non-trauma patients. Mean fresh frozen plasma to packed red blood cells (pRBC) ratio achieved with MTP was 0.741, while mean platelet to pRBC ratio was 0.213. The 24-hour mortality rate for all patients who received an MT upon MTP activation was 33.3% (trauma vs. non-trauma group: 45.5% vs. 14.3%). The ABC scoring system used for trauma patients had a sensitivity and specificity of 81.8% and 41.2%, respectively. CONCLUSION MTP may be used for both trauma and non-trauma patients in acute care surgery. Scoring systems to predict the need for an MT, improved compliance to predefined transfusion ratios and regular reviews of the MTP are necessary to optimise MTPs and to improve the outcomes of patients receiving MTs.
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Affiliation(s)
- Ramesh Wijaya
- Department of General Surgery, Changi General Hospital, Singapore
| | | | - Chee Keong Chong
- Department of General Surgery, Changi General Hospital, Singapore
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Khouadja H, Rouissi W, Mahjoub M, Sakhri J, Beletaifa D, Jazia KB. [Transfusion strategy for patients with severe postpartum hemorrhage: a retrospective study of 47 cases]. Pan Afr Med J 2017; 25:169. [PMID: 28292131 PMCID: PMC5326027 DOI: 10.11604/pamj.2016.25.169.7095] [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: 05/18/2015] [Accepted: 07/12/2016] [Indexed: 11/11/2022] Open
Abstract
INTRODUCTION Postpartum haemorrhage is the leading cause of maternal morbidity and mortality worldwide. It requires a multidisciplinary approach. Transfusion strategy is essential, playing a key role in maternal prognosis. This study aims to determine FFP/RBC ratio (plasma frais congelé/concentrés de globules rouges; fresh frozen plasma/red blood cells) during the treatment of serious postpartum haemorrhages. METHODS We conducted a retrospective study at a Maternity Referral Center (level III) in eastern Tunisia over a period of 4 years (2009-2012). All parturients admitted due to severe postpartum bleeding requiring transfusion of more than 4 Units of RBC during the first 3 hours or of more than 10 Units of RBC during the first 24 hours of treatment were included in the study. RESULTS 47 parturients were enrolled in our study. The diagnosis of PPH was made on the basis of vaginal bleeding in 28 cases and following cesarean section in 19 cases. Preoperative hemoglobin level was of 6.3 g/dl. Transfusion ratio (FFP/RBC) was 1/0.7. CONCLUSION During tratment transfusion ratio was greater than that indicated in the existing guidelines stating an early and massive administration of FFP with a FFP/RBC ratio ranging between 1/2 and 1/1. Fibrinogen (Fbg) and tranexamic acid should be administered as early as possible. The use of recombinant activated factor VII (rFVIIa) should remain the ultimate treatment option.
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Affiliation(s)
- Hosni Khouadja
- Service Anesthésie Réanimation chirurgicale, Centre Hospitalo-Universitaire Farhat Hached Sousse-Tunisie; Unité de Recherche UR12SP32, CHU Farhat Hached, Sousse, Tunisie
| | - Wissem Rouissi
- Service Anesthésie Réanimation chirurgicale, Centre Hospitalo-Universitaire Farhat Hached Sousse-Tunisie
| | - Mohamed Mahjoub
- Service d'Hygiène Hospitalière. Centre Hospitalo-Universitaire Farhat Hached Sousse, Tunisie
| | - Jaballah Sakhri
- Unité de Recherche UR12SP32, CHU Farhat Hached, Sousse, Tunisie
| | - Dhafer Beletaifa
- Service Anesthésie Réanimation chirurgicale, Centre Hospitalo-Universitaire Farhat Hached Sousse-Tunisie
| | - Khaled Ben Jazia
- Service Anesthésie Réanimation chirurgicale, Centre Hospitalo-Universitaire Farhat Hached Sousse-Tunisie
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Ruseckaite R, McQuilten ZK, Oldroyd JC, Richter TH, Cameron PA, Isbister JP, Wood EM. Descriptive characteristics and in-hospital mortality of critically bleeding patients requiring massive transfusion: results from the Australian and New Zealand Massive Transfusion Registry. Vox Sang 2017; 112:240-248. [DOI: 10.1111/vox.12487] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2016] [Revised: 11/10/2016] [Accepted: 12/10/2016] [Indexed: 11/29/2022]
Affiliation(s)
- R. Ruseckaite
- Department of Epidemiology and Preventive Medicine; Monash University; Melbourne Vic. Australia
| | - Z. K. McQuilten
- Department of Epidemiology and Preventive Medicine; Monash University; Melbourne Vic. Australia
| | - J. C. Oldroyd
- Department of Epidemiology and Preventive Medicine; Monash University; Melbourne Vic. Australia
| | - T. H. Richter
- Department of Epidemiology and Preventive Medicine; Monash University; Melbourne Vic. Australia
| | - P. A. Cameron
- Department of Epidemiology and Preventive Medicine; Monash University; Melbourne Vic. Australia
- Emergency and Trauma Centre; The Alfred Hospital; Melbourne Vic. Australia
| | - J. P. Isbister
- Department of Haematology; Royal North Shore Hospital; University of Sydney; St Leonards NSW Australia
| | - E. M Wood
- Department of Epidemiology and Preventive Medicine; Monash University; Melbourne Vic. Australia
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Can Early Aggressive Administration of Fresh Frozen Plasma Improve Outcomes in Patients with Severe Blunt Trauma?--A Report by the Japanese Association for the Surgery of Trauma. Shock 2017; 45:495-501. [PMID: 26863127 PMCID: PMC4854180 DOI: 10.1097/shk.0000000000000536] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Background: This study investigated the effect of a high ratio of fresh frozen plasma (FFP) to red blood cells (RBCs) within the first 6 and 24 h after admission on mortality in patients with severe, blunt trauma. Methods: This retrospective observational study included 189 blunt trauma patients with an Injury Severity Score (ISS) ≥16 requiring RBC transfusions within the first 24 h. Receiver operating characteristic (ROC) curve analysis was performed to calculate cut-off values of the FFP/RBC ratio for outcome. The patients were then divided into two groups according to the cut-off value. Patient survival was compared between groups using propensity score matching (PSM). Results: The area under the ROC curve was 0.57, and the FFP/RBC ratio was 1.0 at maximum sensitivity (0.57) and specificity (0.67). All patients were then divided into two groups (FFP/RBC ratio ≥1 or <1) and analyzed using PSM and inverse probability of treatment weighting (IPTW). The unadjusted hazard ratio (HR) was 0.44, and the adjusted HR was 0.29. The HR was 0.38 by PSM and 0.41 by IPTW. The survival rate was significantly higher in patients with an FFP/RBC ratio ≥1 within the first 6 h. Conclusions: Severe blunt trauma patients transfused with an FFP/RBC ratio ≥1 within the first 6 h had an HR of about 0.4. The transfusion of an FFP/RBC ratio ≥1 within the first 6 h was associated with the outcomes of blunt trauma patients with ISS ≥16 who need a transfusion within 24 h.
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Association of Blood Component Ratio With Clinical Outcomes in Patients After Trauma and Massive Transfusion: A Systematic Review. Adv Emerg Nurs J 2017; 38:157-68. [PMID: 27139137 DOI: 10.1097/tme.0000000000000103] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Component ratios that mimic whole blood may produce survival benefit in patients massively transfused after trauma; other outcomes have not been reviewed. The purpose of this review was to systematically analyze studies where clinical outcomes were compared on the basis of the component ratios administered during massive transfusion in adult patients after trauma. PubMed, CINAHL, and MEDLINE (Ovid) were searched for studies published in English between 2007 and 2015, performed at Level I or major trauma centers. Twenty-one studies were included in the analysis. We used an adapted 9-item instrument to assess bias risk. The average bias score for the studies was 2.86 ± 1.39 out of 16, indicating a low bias risk. The most common bias sources were lack of data about primary outcomes and adverse events. Those who received high ratios experienced not only greater survival benefit but also higher rates of multiple-organ failure; all other clinical outcomes findings were equivocal.
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Mizobata Y. Damage control resuscitation: a practical approach for severely hemorrhagic patients and its effects on trauma surgery. J Intensive Care 2017; 5:4. [PMID: 34798697 PMCID: PMC8600903 DOI: 10.1186/s40560-016-0197-5] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2016] [Accepted: 12/17/2016] [Indexed: 02/07/2023] Open
Abstract
Coagulopathy observed in trauma patients was thought to be a resuscitation-associated phenomenon. The replacement of lost and consumed coagulation factors was the mainstay in the resuscitation of hemorrhagic shock for many decades. Twenty years ago, damage control surgery (DCS) was implemented to challenge the coagulopathy of trauma. It consists of three steps: abbreviated surgery to control the hemorrhage and contamination, resuscitation in the intensive care unit (ICU), and planned re-operation with definitive surgery. The resuscitation strategy of DCS focused on the rapid reversal of acidosis and prevention of hypothermia through the first two steps. However, direct treatment of coagulopathy was not emphasized in DCS. Recently, better understanding of the pathophysiology of coagulopathy in trauma patients has led to the logical opinion that we should directly address this coagulopathy during major trauma resuscitation. Damage control resuscitation (DCR), the strategic approach to the trauma patient who presents in extremis, consists of balanced resuscitation, hemostatic resuscitation, and prevention of acidosis, hypothermia, and hypocalcemia. In balanced resuscitation, fluid administration is restricted and hypotension is allowed until definitive hemostatic measures begin. The administration of blood products consisting of fresh frozen plasma, packed red blood cells, and platelets, the ratio of which resembles whole blood, is recommended early in the resuscitation. DCR strategy is now the most beneficial measure available to address trauma-induced coagulopathy, and it can change the treatment strategy of trauma patients. DCS is now incorporated as a component of DCR. DCR as a structured intervention begins immediately after rapid initial assessment in the emergency room and progresses through the operating theater into the ICU in combination with DCS. By starting from ground zero with the performance of DCS, DCR allows the trauma surgeon to correct the coagulopathy of trauma. The effect of the reversal of coagulopathy in massively hemorrhagic patients may change the operative strategy with DCS.
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Postoperative Management of Composite Tissue Graft Transplantation. ANESTHESIA AND PERIOPERATIVE CARE FOR ORGAN TRANSPLANTATION 2017. [PMCID: PMC7120326 DOI: 10.1007/978-1-4939-6377-5_47] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Composite tissue allotransplantation (CTA) is the transplantation of body structures such as the limbs, larynx, abdominal wall, tendons, and face. This chapter discusses the general and specific postoperative management of patients following CTA.
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Galganski LA, Greenhalgh DG, Sen S, Palmieri TL. Randomized Comparison of Packed Red Blood Cell-to-Fresh Frozen Plasma Transfusion Ratio of 4. J Burn Care Res 2017; 38:194-201. [DOI: 10.1097/bcr.0000000000000468] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Abstract
Peripartum hemorrhage (PPH) is a frequent obstetric emergency situation with increasing incidence in the last decades. It requires a fast, coordinated and interdisciplinary management. This life-threatening situation is often recognized too late and not adequately treated (too little is done too late); therefore, it is important to be aware of the most important risk factors for PPH known as the 4 Ts (i.e. tonus, trauma, tissue and thrombin). Due to the special patient population there is only little evidence-based data on hemostatic therapy in this situation; therefore, the currently available studies on the therapy of PPH is discussed.
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Tanaka H, Katsuragi S, Osato K, Hasegawa J, Nakata M, Murakoshi T, Yoshimatsu J, Sekizawa A, Kanayama N, Ishiwata I, Ikeda T. Efficacy of transfusion with fresh-frozen plasma:red blood cell concentrate ratio of 1 or more for amniotic fluid embolism with coagulopathy: a case-control study. Transfusion 2016; 56:3042-3046. [PMID: 27805263 DOI: 10.1111/trf.13856] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2016] [Revised: 08/05/2016] [Accepted: 08/05/2016] [Indexed: 12/24/2022]
Abstract
BACKGROUND The Japan Association of Obstetricians and Gynecologists (JAOG) recommends transfusion with a fresh-frozen plasma (FFP):red blood cell (RBC) ratio of 1 or more in postpartum hemorrhage. However, no global consensus exists concerning this, and little is known regarding the impact of FFP:RBC ratio on maternal mortality. This study evaluates the efficacy of transfusion with FFP:RBC ratio of 1 or more for amniotic fluid embolism (AFE) with coagulopathy. STUDY DESIGN AND METHODS The Maternal Death Exploratory Committee, established by the JAOG, conducted this retrospective nationwide case-control study in Japan. Women with AFE and coagulopathy were included in the study and were stratified into survival and death groups. Obstetric variables and therapy methods (hysterectomy, uterine artery embolism, and transfusion with FFP:RBC ratio ≥ 1) were compared between the survival and death groups. RESULTS A total of 54 women had AFE and coagulopathy (death group, n = 22; survival group, n = 32). Only nine (40.9%) women in the death group were transfused with FFP:RBC ratio of 1 or more, whereas 29 (90.6%) women in the survival group were transfused with FFP:RBC ratio of 1 or more. FFP:RBC ratio of 1 or more was found to be associated with better survival rate (adjusted odds ratio, 28.32; 95% confidence interval, 4.26-188.37). No difference was found in obstetric variables, hysterectomy, and uterine artery embolism between survival and death groups. CONCLUSION Transfusion with FFP:RBC ratio of 1 or more is associated with higher survival rate in women with AFE with coagulopathy.
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Affiliation(s)
- Hiroaki Tanaka
- Department of Obstetrics and Gynecology, Mie University School of Medicine, Mie, Japan
| | - Shinji Katsuragi
- Department of Obstetrics and Gynecology, Sakakibara Heart Institute
| | - Kazuhiro Osato
- Department of Obstetrics and Gynecology, Mie University School of Medicine, Mie, Japan
| | - Junichi Hasegawa
- Department of Obstetrics and Gynecology, Showa University School of Medicine
| | - Masahiko Nakata
- Department of Obstetrics and Gynecology, Toho University Omori Medical Center, Tokyo, Japan
| | - Takeshi Murakoshi
- Division of Perinatology, Maternal and Perinatal Care Center, Seirei Hamamatsu General Hospital, Shizuoka, Japan
| | - Jun Yoshimatsu
- Division of Maternal Fetal Medicine and Gynecology, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Akihiko Sekizawa
- Department of Obstetrics and Gynecology, Showa University School of Medicine
| | - Naohiro Kanayama
- Department of Obstetrics and Gynecology, Hamamatsu University School of Medicine, Shizuoka, Japan
| | - Isamu Ishiwata
- Ishiwata Obstetrics and Gynecology Hospital, Ibaraki, Japan
| | - Tomoaki Ikeda
- Department of Obstetrics and Gynecology, Mie University School of Medicine, Mie, Japan
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Adiponectin in Fresh Frozen Plasma Contributes to Restoration of Vascular Barrier Function After Hemorrhagic Shock. Shock 2016; 45:50-54. [PMID: 26263440 DOI: 10.1097/shk.0000000000000458] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Hemorrhagic shock is the leading cause of preventable deaths in civilian and military trauma. Use of fresh frozen plasma (FFP) in patients requiring massive transfusion is associated with improved outcomes. FFP contains significant amounts of adiponectin, which is known to have vascular protective function. We hypothesize that FFP improves vascular barrier function largely via adiponectin. Plasma adiponectin levels were measured in 19 severely injured patients in hemorrhagic shock (HS). Compared with normal individuals, plasma adiponectin levels decreased to 49% in HS patients before resuscitation (P < 0.05) and increased to 64% post-resuscitation (but not significant). In a HS mouse model, we demonstrated a similar decrease in plasma adiponectin to 54% but a significant increase to 79% by FFP resuscitation compared with baseline (P < 0.05). HS disrupted lung vascular barrier function, leading to an increase in permeability. FFP resuscitation reversed these HS-induced effects. Immunodepletion of adiponectin from FFP abolished FFP's effects on blocking endothelial hyperpermeability in vitro, and on improving lung vascular barrier function in HS mice. Replenishment with adiponectin rescued FFP's effects. These findings suggest that adiponectin is an important component in FFP resuscitation contributing to the beneficial effects on vascular barrier function after HS.
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Ex vivo recapitulation of trauma-induced coagulopathy and preliminary assessment of trauma patient platelet function under flow using microfluidic technology. J Trauma Acute Care Surg 2016; 80:440-9. [PMID: 27082706 DOI: 10.1097/ta.0000000000000915] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND Relevant to trauma-induced coagulopathy diagnostics, microfluidic assays allow controlled hemodynamics for testing of platelet and coagulation function using whole blood. METHODS Hemodilution or hyperfibrinolysis was studied under flow with modified healthy whole blood. Furthermore, platelet function was also measured using whole blood from trauma patients admitted to a Level I trauma center. Platelet deposition was measured with PPACK-inhibited blood perfused over collagen surfaces at a wall shear rate of 200 s, whereas platelet/fibrin deposition was measured with corn trypsin inhibitor-treated blood perfused over tissue factor (TF)/collagen. RESULTS In hemodilution studies, PPACK-treated blood displayed almost no platelet deposition when diluted to 10% hematocrit with saline, platelet-poor plasma, or platelet-rich plasma. Using similar dilutions, platelet/fibrin deposition was essentially absent for corn trypsin inhibitor-treated blood perfused over TF/collagen. To mimic hyperfibrinolysis during trauma, exogenous tissue plasminogen activator (50 nM) was added to blood before perfusion over TF/collagen. At both venous and arterial flows, the generation and subsequent lysis of fibrin were detectable within 6 minutes, with lysis blocked by addition of the plasmin inhibitor, ε-aminocaproic acid. Microfluidic assay of PPACK-inhibited whole blood from trauma patients revealed striking defects in collagen response and secondary platelet aggregation in 14 of 21 patients, whereas platelet hyperfunction was detected in three of 20 patients. CONCLUSION Rapid microfluidic detection of (1) hemodilution-dependent impairment of clotting, (2) clot instability because of lysis, (3) blockade of fibrinolysis, or (4) platelet dysfunction during trauma may provide novel diagnostic opportunities to predict trauma-induced coagulopathy risk.
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Tekindur S, Yetim M, Kilickaya O. Risk of transfusion-related acute lung injury after blood products transfusions. Am J Emerg Med 2016; 34:1674-5. [PMID: 27269954 DOI: 10.1016/j.ajem.2016.04.048] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2016] [Accepted: 04/26/2016] [Indexed: 10/21/2022] Open
Affiliation(s)
- Sukru Tekindur
- Gulhane Military Medical Academy (GMMA) Department of Anesthesiology and Reanimation, Ankara, Turkey
| | | | - Oguz Kilickaya
- Gulhane Military Medical Academy (GMMA) Department of Anesthesiology and Reanimation, Ankara, Turkey
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Arslan A, Flax L, Fraser R, Kanter M, Simon R, Caputo ND. Twenty-four-hour packed red blood cell requirement is the strongest independent prognostic marker of mortality in ED trauma patients. Am J Emerg Med 2016; 34:1121-4. [DOI: 10.1016/j.ajem.2016.03.036] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2015] [Revised: 03/10/2016] [Accepted: 03/14/2016] [Indexed: 11/24/2022] Open
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Smith SA, Livingston MH, Merritt NH. Early coagulopathy and metabolic acidosis predict transfusion of packed red blood cells in pediatric trauma patients. J Pediatr Surg 2016; 51:848-52. [PMID: 26960738 DOI: 10.1016/j.jpedsurg.2016.02.034] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Accepted: 02/07/2016] [Indexed: 11/30/2022]
Abstract
BACKGROUND Severely injured pediatric trauma patients often present to hospital with early coagulopathy and metabolic acidosis. These derangements are associated with poor outcomes, but it is unclear to what degree they predict transfusion of packed red blood cells (pRBC). METHODS We retrospectively identified pediatric trauma patients from a level 1 trauma center from 2006 to 2013. Inclusion criteria were age less than 18years, Injury Severity Score greater than 12, and pRBC transfusion within 24h of admission. RESULTS We identified 96 pediatric trauma patients who underwent pRBC transfusion within 24h of presentation to hospital. On admission, 43% of these patients had one or more signs of coagulopathy, and 81% had metabolic acidosis. Size of pRBC transfusion in the first 24h ranged from 3 to 177mL/kg (mean 29mL/kg), and nineteen patients (20%) underwent massive transfusion (>40ml/kg in 24h). Univariate analysis indicated that size of pRBC transfusion was associated with initial base excess (r=0.46), international normalized ratio (r=0.35), partial thromboplastin time (r=0.41), fibrinogen (r=0.46), and BIG score (Base deficit, INR, Glasgow Coma Scale (GCS), r=0.36). Platelet count, age, GCS, and direct versus referred presentation were not predictive. Multivariable linear regression confirmed that coagulopathy and metabolic acidosis remained predictive after adjusting for direct versus referred presentation (R(2)=0.30). CONCLUSIONS Early coagulopathy and metabolic acidosis predict size of pRBC transfusion among pediatric trauma patients. Further research is needed to develop massive transfusion protocols and guidelines for activation.
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Affiliation(s)
- Shane A Smith
- Division of General Surgery, Western University, London, Ontario, Canada
| | | | - Neil H Merritt
- Division of General Surgery, Western University, London, Ontario, Canada; Division of Pediatric Surgery, Western University, London, Ontario, Canada.
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Combat: Initial Experience with a Randomized Clinical Trial of Plasma-Based Resuscitation in the Field for Traumatic Hemorrhagic Shock. Shock 2016; 44 Suppl 1:63-70. [PMID: 25784527 DOI: 10.1097/shk.0000000000000376] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The existing evidence shows great promise for plasma as the first resuscitation fluid in both civilian and military trauma. We embarked on the Control of Major Bleeding After Trauma (COMBAT) trial with the support of the Department of Defense to determine if plasma-first resuscitation yields hemostatic and survival benefits. The methodology of the COMBAT study represents not only 3 years of development work but also the integration of nearly two decades of technical experience with the design and implementation of other clinical trials and studies. Herein, we describe the key features of the study design, critical personnel and infrastructural elements, and key innovations. We will also briefly outline the systems engineering challenges entailed by this study. The COMBAT trial is a randomized, placebo-controlled, semiblinded, prospective, phase IIB clinical trial conducted in a ground ambulance fleet based at a level I trauma center and part of a multicenter collaboration. The primary objective of the COMBAT trial is to determine the efficacy of field resuscitation with plasma first compared with standard of care (normal saline). To date, we have enrolled 30 subjects in the COMBAT study. The ability to achieve intervention with a hemostatic resuscitation agent in the closest possible temporal proximity to injury is critical and represents an opportunity to forestall the evolution of the "bloody vicious cycle." Thus, the COMBAT model for deploying plasma in first-response units should serve as a model for randomized clinical trials of other hemostatic resuscitative agents.
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Briggs A, Askari R. Damage control resuscitation. Int J Surg 2016; 33:218-221. [PMID: 27107662 DOI: 10.1016/j.ijsu.2016.03.064] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2016] [Revised: 02/29/2016] [Accepted: 03/03/2016] [Indexed: 11/30/2022]
Affiliation(s)
- Alexandra Briggs
- Brigham and Women's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Reza Askari
- Brigham and Women's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA.
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Abstract
The resuscitation of the injured patient continues to be a highly debated topic. Multiple studies have been performed with the intent to determine the optimal strategy to combat, and ultimately prevent, trauma induced coagulopathy. This chapter discusses the risks and benefits of resuscitation protocols utilizing plasma. Plasma is the aqueous portion of blood that contains coagulation factors, fibrinolytic proteins, albumin, immunoglobulins, and up to 6000 other proteins. Multiple methods of collection and storage have been developed, each one affecting the plasma and its proteins differently. Once collected, plasma can be frozen for storage. If frozen within 8 h, the product is labelled as fresh frozen plasma (FFP). If frozen more than 6 h, but less than 24 h, it is labelled as plasma frozen within 24 h (FP24). When FFP and FP24 are mobilized from the blood bank, they are thawed in a water bath to create thawed plasma (TP) which can be stored in liquid form for up to 4 days prior to transfusion. Liquid plasma (LQP) is derived from whole blood and is never frozen. It can be stored for up to 30 days by some reports prior to transfusion. Each of these forms of plasma has been extensively studied for efficacy of coagulation and are all useful in the resuscitation of a traumatically injured patient. There is much more than coagulation factors in plasma that are useful to patients. Studies looking at the endotheliopathy associated with hemorrhagic shock have shown a decrease in the inflammatory response, promotion of endothelial repair, and decreased edema. Transfusion protocols utilizing plasma at the time of presentation have shown a decrease in the amount of blood products transfused, as well as an improvement in mortality. Transfusion ratios of platelets–red blood cells–plasma units in a 1:1:1 ratio have shown a significant improvement in mortality at 3 h post-admission over 1:1:2. There has not been an increase in the incidence of adverse events with the increase usage of plasma. The early administration of plasma to the massively hemorrhaging traumatically injured patient improves mortality, decreases total blood product usage, and promotes the resolution of trauma induced endotheliopathy without increasing adverse events.
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Affiliation(s)
- Eduardo Gonzalez
- Dept of Surgery & Trauma Research Center, Univ of Colorado School of Medicine, Aurora, Colorado USA
| | - Hunter B. Moore
- Dept of Surgery & Trauma Research Center, Univ of Colorado School of Medicine, Aurora, Colorado USA
| | - Ernest E. Moore
- Dept of Surgery & Trauma Research Center, Univ of Colorado Sch of Med&Denver Healt, Denver, Colorado USA
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Ogura T, Lefor AK, Masuda M, Kushimoto S. Modified traumatic bleeding severity score: early determination of the need for massive transfusion. Am J Emerg Med 2016; 34:1097-101. [PMID: 27021127 DOI: 10.1016/j.ajem.2016.02.072] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Revised: 02/28/2016] [Accepted: 02/29/2016] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Determination of the need for massive transfusion (MT) is essential for early activation of a MT protocol. The Traumatic Bleeding Severity Score (TBSS) predicts the need for MT accurately, but takes time to determine because systolic blood pressure after a 1000mL of crystalloid infusion is used. The aim of this study is to determine the how well the Modified TBSS (age, sonography, pelvic fracture, serum lactate and systolic blood pressure on arrival) predicts the need for MT (accuracy). METHODS This is a single-center retrospective study of trauma patients (Injury Severity Score ≧16) admitted between 2010 and 2014. The TBSS, the Trauma Associated Severe Hemorrhage (TASH) Score, and the Modified TBSS were calculated. MT is defined as ≧10 U packed red blood cell transfusion within 24hours of injury, and the predictive value of the need for MT was compared by area under the receiver operating characteristic curve (AUC) analysis among three scores. RESULTS Three hundred patients were enrolled, and MT given to 25% of patients. Although the AUC of the TBSS was higher than that of the TASH score (0.956 vs 0.912, P=.006) and the Modified TBSS (0.956 vs 0.915, P=.001), there was no difference between the AUC of the Modified TBSS and the TASH score. The Modified TBSS has high accuracy, within an AUC >0.9. CONCLUSION The predictive value of the Modified TBSS of the need for MT is still high and is equivalent to the TASH score. The Modified TBSS is calculated earlier in resuscitation than the original TBSS.
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Affiliation(s)
- Takayuki Ogura
- Advanced Medical Emergency Department & Critical Care Center, Japan Red Cross Maebashi Hospital, Japan.
| | | | - Mamoru Masuda
- Advanced Medical Emergency Department & Critical Care Center, Japan Red Cross Maebashi Hospital, Japan.
| | - Shigeki Kushimoto
- Division of Emergency Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan.
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