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Xu X, Zhang Y, Tang B, Yu X, Huang Y. Association between perioperative plasma transfusion and in-hospital mortality in patients undergoing surgeries without massive transfusion: A nationwide retrospective cohort study. Front Med (Lausanne) 2023; 10:1130359. [PMID: 36873874 PMCID: PMC9975265 DOI: 10.3389/fmed.2023.1130359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Accepted: 01/30/2023] [Indexed: 02/17/2023] Open
Abstract
Background An aggressive plasma transfusion is associated with a decreased mortality in traumatic patients requiring massive transfusion (MT). However, it is controversial whether non-traumatic or non-massively transfused patients can benefit from high doses of plasma. Methods We performed a nationwide retrospective cohort study using data from Hospital Quality Monitoring System, which collected anonymized inpatient medical records from 31 provinces in mainland China. We included the patients who had at least one record of surgical procedure and received red blood cell transfusion on the day of surgery from 2016 to 2018. We excluded those receiving MT or diagnosed with coagulopathy at admission. The exposure variable was the total volume of fresh frozen plasma (FFP) transfused, and the primary outcome was in-hospital mortality. The relationship between them was assessed using multivariable logistic regression model adjusting 15 potential confounders. Results A total of 69319 patients were included, and 808 died among them. A 100-ml increase in FFP transfusion volume was associated with a higher in-hospital mortality (odds ratio 1.05, 95% confidence interval 1.04-1.06, p < 0.001) after controlling for the confounders. FFP transfusion volume was also associated with superficial surgical site infection, nosocomial infection, prolonged length of hospital stay, ventilation time, and acute respiratory distress syndrome. The significant association between FFP transfusion volume and in-hospital mortality was extended to the subgroups of cardiac surgery, vascular surgery, and thoracic or abdominal surgery. Conclusions A higher volume of perioperative FFP transfusion was associated with an increased in-hospital mortality and inferior postoperative outcomes in surgical patients without MT.
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Affiliation(s)
- Xiaohan Xu
- Department of Anesthesiology, Chinese Academy of Medical Sciences & Peking Union Medical College Hospital, Beijing, China
| | - Yuelun Zhang
- Medical Research Center, Chinese Academy of Medical Sciences & Peking Union Medical College Hospital, Beijing, China
| | - Bo Tang
- Department of Anesthesiology, Chinese Academy of Medical Sciences & Peking Union Medical College Hospital, Beijing, China
| | - Xuerong Yu
- Department of Anesthesiology, Chinese Academy of Medical Sciences & Peking Union Medical College Hospital, Beijing, China
| | - Yuguang Huang
- Department of Anesthesiology, Chinese Academy of Medical Sciences & Peking Union Medical College Hospital, Beijing, China
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Utility of viscoelastic hemostatic assay to guide hemostatic resuscitation in trauma patients: a systematic review. World J Emerg Surg 2022; 17:48. [PMID: 36100918 PMCID: PMC9472418 DOI: 10.1186/s13017-022-00454-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Accepted: 09/05/2022] [Indexed: 11/15/2022] Open
Abstract
Objective Viscoelastic hemostatic assay (VHA) provides a graphical representation of a clot’s lifespan and reflects the real time of coagulation. It has been used to guide trauma resuscitation; however, evidence of the effectiveness of VHAs is still limited. This systematic review aims to summarize the published evidence to evaluate the VHA-guided strategy in resuscitating trauma patients. Methods The PubMed, Embase, and Web of Science databases were searched from their inception to December 13, 2021. Randomized controlled trials (RCTs) or observational studies comparing VHA-guided transfusion to controls in resuscitating trauma patients were included in this systematic review. Results Of the 7743 records screened, ten studies, including two RCTs and eight observational studies, met the inclusion criteria. There was great heterogeneity concerning study design, enrollment criterion, VHA device, VHA-guided strategy, and control strategy. Thrombelastography (TEG) was used as a guiding tool for transfusion in eight studies, and rotational thromboelastometry (ROTEM), and TEG or ROTEM were used in the other two studies. The overall risk of bias assessment was severe or mild in RCTs and was severe or moderate in observational studies. The main outcomes reported from the included studies were blood transfusion (n = 10), mortality (n = 10), hospital length of stay (LOS) (n = 7), intensive care unit LOS (n = 7), and cost (n = 4). The effect of the VHA-guided strategy was not always superior to the control. Most of the studies did not find significant differences in the transfusion amount of red blood cells (n = 7), plasma (n = 5), platelet (n = 7), cryoprecipitate/fibrinogen (n = 7), and mortality (n = 8) between the VHA-guided group and control group. Notable, two RCTs showed that the VHA-guided strategy was superior or equal to the conventional coagulation test-guided strategy in reducing mortality, respectively. Conclusion Although some studies demonstrated VHA-guided strategy probable benefit in reducing the need for blood transfusion and mortality when resuscitating trauma patients, the evidence is still not robust. The quality of evidence was primarily downgraded by the limited number of included studies and great heterogeneity and severe risk of bias in these. Further studies are strongly recommended. Supplementary Information The online version contains supplementary material available at 10.1186/s13017-022-00454-8.
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Kojima M, Endo A, Shiraishi A, Shoko T, Otomo Y, Coimbra R. Association between the plasma-to-red blood cell ratio and survival in geriatric and non-geriatric trauma patients undergoing massive transfusion: a retrospective cohort study. J Intensive Care 2022; 10:2. [PMID: 35016735 PMCID: PMC8753889 DOI: 10.1186/s40560-022-00595-7] [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: 11/15/2021] [Accepted: 01/04/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The benefits of a high plasma-to-red blood cell (RBC) ratio on the survival of injured patients who receive massive transfusions remain unclear, especially in older patients. We aimed to investigate the interaction of age with the plasma-to-RBC ratio and clinical outcomes of trauma patients. METHODS In this retrospective study conducted from 2013 to 2016, trauma patients who received massive transfusions were included. Using a generalized additive model (GAM),we assessed how the plasma-to-RBC ratio and age affected the in-hospital mortality rates. The association of the plasma-to-RBC ratio [low (< 0.5), medium (0.5-1.0), and high (≥ 1.0)] with in-hospital mortality and the incidence of adverse events were assessed for the overall cohort and for patients stratified into non-geriatric (16-64 years) and geriatric (≥ 65 years) groups using logistic regression analyses. RESULTS In total, 13,894 patients were included. The GAM plot of the plasma-to-RBC ratio for in-hospital mortality demonstrated a downward convex unimodal curve for the entire cohort. The low-transfusion ratio group was associated with increased odds of in-hospital mortality in the non-geriatric cohort [odds ratio 1.38, 95% confidence interval (CI) 1.22-1.56]; no association was observed in the geriatric group (odds ratio 0.84, 95% CI 0.62-1.12). An increase in the transfusion ratio was associated with a higher incidence of adverse events in the non-geriatric and geriatric groups. CONCLUSION The association of the non-geriatric age category and plasma-to-RBC ratio for in-hospital mortality was clearly demonstrated. However, the relationship between the plasma-to-RBC ratio with mortality among geriatric patients remains inconclusive.
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Affiliation(s)
- Mitsuaki Kojima
- Emergency and Critical Care Medicine, Tokyo Women's Medical University Adachi Medical Center, 4-33-1 Kohoku, Adachi-ku, Tokyo, Japan. .,Trauma and Acute Critical Care Medical Center, Tokyo Medical and Dental University Hospital, 1-5-45 Yushima, Bunkyo-ku, Tokyo, Japan.
| | - Akira Endo
- Trauma and Acute Critical Care Medical Center, Tokyo Medical and Dental University Hospital, 1-5-45 Yushima, Bunkyo-ku, Tokyo, Japan
| | - Atsushi Shiraishi
- Emergency and Trauma Center, Kameda Medical Center, 929 Higashicho, Kamogawa, Chiba, Japan
| | - Tomohisa Shoko
- Emergency and Critical Care Medicine, Tokyo Women's Medical University Adachi Medical Center, 4-33-1 Kohoku, Adachi-ku, Tokyo, Japan
| | - Yasuhiro Otomo
- Trauma and Acute Critical Care Medical Center, Tokyo Medical and Dental University Hospital, 1-5-45 Yushima, Bunkyo-ku, Tokyo, Japan
| | - Raul Coimbra
- Comparative Effectiveness and Clinical Outcomes Research Center-CECORC, Riverside University Health System Medical Center, 26520 Cactus Ave., Moreno Valley, CA, USA
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4
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Vulliamy P, Kornblith LZ, Kutcher ME, Cohen MJ, Brohi K, Neal MD. Alterations in platelet behavior after major trauma: adaptive or maladaptive? Platelets 2021; 32:295-304. [PMID: 31986948 PMCID: PMC7382983 DOI: 10.1080/09537104.2020.1718633] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Revised: 01/01/2020] [Accepted: 01/14/2020] [Indexed: 12/14/2022]
Abstract
Platelets are damage sentinels of the intravascular compartment, initiating and coordinating the primary response to tissue injury. Severe trauma and hemorrhage induce profound alterations in platelet behavior. During the acute post-injury phase, platelets develop a state of impaired ex vivo agonist responsiveness independent of platelet count, associated with systemic coagulopathy and mortality risk. In patients surviving the initial insult, platelets become hyper-responsive, associated with increased risk of thrombotic events. Beyond coagulation, platelets constitute part of a sterile inflammatory response to injury: both directly through release of immunomodulatory molecules, and indirectly through modifying behavior of innate leukocytes. Both procoagulant and proinflammatory aspects have implications for secondary organ injury and multiple-organ dysfunction syndromes. This review details our current understanding of adaptive and maladaptive alterations in platelet biology induced by severe trauma, mechanisms underlying these alterations, potential platelet-focused therapies, and existing knowledge gaps and their research implications.
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Affiliation(s)
- Paul Vulliamy
- Centre for Trauma Sciences, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, E1 2AT, United Kingdom
| | - Lucy Z. Kornblith
- Department of Surgery, Zuckerberg San Francisco General Hospital and the University of California, San Francisco, San Francisco, California
| | - Matthew E. Kutcher
- Division of Trauma, Critical Care, and Acute Care Surgery, University of Mississippi Medical Center, Jackson, Mississippi
| | - Mitchell J. Cohen
- Department of Surgery, University of Colorado, Aurora, Colorado
- Ernest E Moore Shock Trauma Center at Denver Health, Denver, Colorado
| | - Karim Brohi
- Centre for Trauma Sciences, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, E1 2AT, United Kingdom
| | - Matthew D. Neal
- Division of Trauma and Acute Care Surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, PA
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5
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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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6
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Spahn DR, Bouillon B, Cerny V, Duranteau J, Filipescu D, Hunt BJ, Komadina R, Maegele M, Nardi G, Riddez L, Samama CM, Vincent JL, Rossaint R. The European guideline on management of major bleeding and coagulopathy following trauma: fifth edition. Crit Care 2019; 23:98. [PMID: 30917843 PMCID: PMC6436241 DOI: 10.1186/s13054-019-2347-3] [Citation(s) in RCA: 688] [Impact Index Per Article: 137.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Accepted: 02/06/2019] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Severe traumatic injury continues to present challenges to healthcare systems around the world, and post-traumatic bleeding remains a leading cause of potentially preventable death among injured patients. Now in its fifth edition, this document aims to provide guidance on the management of major bleeding and coagulopathy following traumatic injury and encourages adaptation of the guiding principles described here to individual institutional circumstances and resources. METHODS The pan-European, multidisciplinary Task Force for Advanced Bleeding Care in Trauma was founded in 2004, and the current author group included representatives of six relevant European professional societies. The group applied a structured, evidence-based consensus approach to address scientific queries that served as the basis for each recommendation and supporting rationale. Expert opinion and current clinical practice were also considered, particularly in areas in which randomised clinical trials have not or cannot be performed. Existing recommendations were re-examined and revised based on scientific evidence that has emerged since the previous edition and observed shifts in clinical practice. New recommendations were formulated to reflect current clinical concerns and areas in which new research data have been generated. RESULTS Advances in our understanding of the pathophysiology of post-traumatic coagulopathy have supported improved management strategies, including evidence that early, individualised goal-directed treatment improves the outcome of severely injured patients. The overall organisation of the current guideline has been designed to reflect the clinical decision-making process along the patient pathway in an approximate temporal sequence. Recommendations are grouped behind the rationale for key decision points, which are patient- or problem-oriented rather than related to specific treatment modalities. While these recommendations provide guidance for the diagnosis and treatment of major bleeding and coagulopathy, emerging evidence supports the author group's belief that the greatest outcome improvement can be achieved through education and the establishment of and adherence to local clinical management algorithms. CONCLUSIONS A multidisciplinary approach and adherence to evidence-based guidance are key to improving patient outcomes. If incorporated into local practice, these clinical practice guidelines have the potential to ensure a uniform standard of care across Europe and beyond and better outcomes for the severely bleeding trauma patient.
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Affiliation(s)
- Donat R. Spahn
- Institute of Anaesthesiology, University of Zurich and University Hospital Zurich, Raemistrasse 100, CH-8091 Zurich, Switzerland
| | - Bertil Bouillon
- Department of Trauma and Orthopaedic Surgery, Cologne-Merheim Medical Centre (CMMC), University of Witten/Herdecke, Ostmerheimer Strasse 200, D-51109 Cologne, Germany
| | - Vladimir Cerny
- Department of Anaesthesiology, Perioperative Medicine and Intensive Care, J.E. Purkinje University, Masaryk Hospital, Usti nad Labem, Socialni pece 3316/12A, CZ-40113 Usti nad Labem, Czech Republic
- Centre for Research and Development, University Hospital Hradec Kralove, Hradec Kralove, Czech Republic, Sokolska 581, CZ-50005 Hradec Kralove, Czech Republic
- Department of Anaesthesiology and Intensive Care Medicine, Faculty of Medicine in Hradec Kralove, Charles University, Simkova 870, CZ-50003 Hradec Kralove, Czech Republic
- Department of Anaesthesia, Pain Management and Perioperative Medicine, QE II Health Sciences Centre, Dalhousie University, Halifax, 10 West Victoria, 1276 South Park St, Halifax, NS B3H 2Y9 Canada
| | - Jacques Duranteau
- Department of Anaesthesia and Intensive Care, Hôpitaux Universitaires Paris Sud, University of Paris XI, Faculté de Médecine Paris-Sud, 78 rue du Général Leclerc, F-94275 Le Kremlin-Bicêtre Cedex, France
| | - Daniela Filipescu
- Department of Cardiac Anaesthesia and Intensive Care, C. C. Iliescu Emergency Institute of Cardiovascular Diseases, Sos Fundeni 256-258, RO-022328 Bucharest, Romania
| | - Beverley J. Hunt
- King’s College and Departments of Haematology and Pathology, Guy’s and St Thomas’ NHS Foundation Trust, Westminster Bridge Road, London, SE1 7EH UK
| | - Radko Komadina
- Department of Traumatology, General and Teaching Hospital Celje, Medical Faculty Ljubljana University, SI-3000 Celje, Slovenia
| | - Marc Maegele
- Department of Trauma and Orthopaedic Surgery, Cologne-Merheim Medical Centre (CMMC), Institute for Research in Operative Medicine (IFOM), University of Witten/Herdecke, Ostmerheimer Strasse 200, D-51109 Cologne, Germany
| | - Giuseppe Nardi
- Department of Anaesthesia and ICU, AUSL della Romagna, Infermi Hospital Rimini, Viale Settembrini, 2, I-47924 Rimini, Italy
| | - Louis Riddez
- Department of Surgery and Trauma, Karolinska University Hospital, S-171 76 Solna, Sweden
| | - Charles-Marc Samama
- Hotel-Dieu University Hospital, 1, place du Parvis de Notre-Dame, F-75181 Paris Cedex 04, France
| | - Jean-Louis Vincent
- Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Route de Lennik 808, B-1070 Brussels, Belgium
| | - Rolf Rossaint
- Department of Anaesthesiology, University Hospital Aachen, RWTH Aachen University, Pauwelsstrasse 30, D-52074 Aachen, Germany
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Endo A, Shiraishi A, Fushimi K, Murata K, Otomo Y. Outcomes of patients receiving a massive transfusion for major trauma. Br J Surg 2018; 105:1426-1434. [PMID: 29999518 DOI: 10.1002/bjs.10905] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Revised: 04/27/2018] [Accepted: 05/07/2018] [Indexed: 01/05/2023]
Abstract
BACKGROUND The benefits of high transfusion ratios (plasma to red blood cells and platelets to red blood cells) on survival in injured patients who receive massive transfusions remain uncertain. This study aimed to assess the association between transfusion ratios and adverse events and survival in patients undergoing massive transfusion for major trauma. METHODS A retrospective observational study was conducted on patients who had major trauma using a Japanese national administrative database. The associations between transfusion ratios and outcomes (in-hospital mortality and incidence of adverse events) were analysed using a non-linear logistic generalized additive model (GAM). In a logistic generalized estimating equation model, adjusted for patient and hospital-level confounders, transfusion ratios were included as continuous or categorical variables (low, transfusion ratio 0·75 or less; intermediate, over 0·75 to 1·25; high, over 1·25). RESULTS Some 1777 patients were included in the analysis, of whom 602 died in hospital. GAM plots of the transfusion ratios for in-hospital mortality demonstrated a downward convex unimodal curve. In-hospital mortality was similar with increasing transfusion ratios for plasma (adjusted odds ratio (OR) 1·13, 95 per cent c.i. 0·82 to 1·55; P = 0·446) and platelets (adjusted OR 0·84, 0·66 to 1·08; P = 0·171). Both plasma to red blood cell ratio (adjusted OR 1·77, 1·32 to 2·37; P < 0·001) and platelet to red blood cell ratio (adjusted OR 1·71, 1·35 to 2·15; P < 0·001) were significantly associated with a higher incidence of adverse events. No significant differences in in-hospital mortality were observed between the three transfusion categories (low, medium and high). CONCLUSION In this study, transfusion strategies with high plasma to red blood cell and platelet to red blood cell ratios did not have survival benefits, but were associated with an increase in adverse events.
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Affiliation(s)
- A Endo
- Trauma and Acute Critical Care Medical Centre, Tokyo Medical and Dental University Hospital of Medicine, Tokyo, Japan
| | - A Shiraishi
- Trauma and Acute Critical Care Medical Centre, Tokyo Medical and Dental University Hospital of Medicine, Tokyo, Japan.,Emergency and Trauma Centre, Kameda Medical Centre, Kamogawa, Japan
| | - K Fushimi
- Department of Health Policy and Informatics, Tokyo Medical and Dental University Graduate School of Medicine, Tokyo, Japan
| | - K Murata
- Trauma and Acute Critical Care Medical Centre, Tokyo Medical and Dental University Hospital of Medicine, Tokyo, Japan.,Shock Trauma and Emergency Medical Centre, Matsudo City Hospital, Matsudo, Japan
| | - Y Otomo
- Trauma and Acute Critical Care Medical Centre, Tokyo Medical and Dental University Hospital of Medicine, Tokyo, Japan
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8
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Kasotakis G, Starr N, Nelson E, Sarkar B, Burke PA, Remick DG, Tompkins RG. Platelet transfusion increases risk for acute respiratory distress syndrome in non-massively transfused blunt trauma patients. Eur J Trauma Emerg Surg 2018; 45:671-679. [PMID: 29627883 DOI: 10.1007/s00068-018-0953-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Accepted: 04/03/2018] [Indexed: 12/30/2022]
Abstract
PURPOSE While damage control resuscitation is known to confer a survival advantage in severely injured patients, high-ratio blood component therapy should be initiated only in carefully selected trauma patients, due to the morbidity associated with blood product use. With this project, we aim to identify the effect of platelet transfusion in non-massively transfused bluntly injured patients. METHODS The Glue Grant database was retrospectively queried and severely injured blunt trauma patients who underwent non-massive transfusion were identified. Patients were divided into quartiles depending on platelet volume they were transfused in the first 48 h. Outcomes of interest included mortality; ventilator, Intensive Care Unit (ICU) and hospital length of stay (LOS); infectious and non-infectious complications. Multivariable regression models were fitted for these outcomes, controlling for age, pre-existing comorbidities, injury severity, acute physiologic derangement, neurologic injury burden, and other fluid and blood product resuscitation. RESULTS There was no difference in mortality, LOS, or the incidence of multi-organ failure and infectious complications. However, patients receiving ≥ 250 mL of platelets were more likely to develop acute respiratory distress syndrome (ARDS) compared to those who received < 250 mL [odds ratio 1.91 (95% CI 1.10-3.33, p = 0.022)]. CONCLUSIONS Pre-emptive platelet transfusion should be avoided in non-massively transfused blunt injury victims in the absence of true or functional thrombocytopenia, as it increases risk for ARDS with no survival benefit.
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Affiliation(s)
- George Kasotakis
- Division of Trauma, Acute Care Surgery and Surgical Critical Care, Boston University School of Medicine, 840 Harrison ave., Dowling 2 South, #2414, Boston, MA, 02118, USA.
| | - Nichole Starr
- Division of Trauma, Acute Care Surgery and Surgical Critical Care, Boston University School of Medicine, 840 Harrison ave., Dowling 2 South, #2414, Boston, MA, 02118, USA
| | - Erek Nelson
- Division of Trauma, Acute Care Surgery and Surgical Critical Care, Boston University School of Medicine, 840 Harrison ave., Dowling 2 South, #2414, Boston, MA, 02118, USA
| | - Bedabrata Sarkar
- Division of Trauma, Acute Care Surgery and Surgical Critical Care, Boston University School of Medicine, 840 Harrison ave., Dowling 2 South, #2414, Boston, MA, 02118, USA
| | - Peter Ashley Burke
- Division of Trauma, Acute Care Surgery and Surgical Critical Care, Boston University School of Medicine, 840 Harrison ave., Dowling 2 South, #2414, Boston, MA, 02118, USA
| | - Daniel George Remick
- Department of Pathology and Laboratory Medicine, Boston University School of Medicine, Boston, USA
| | - Ronald Gary Tompkins
- Division of Surgery, Science and Bioengineering, Massachusetts General Hospital, Harvard Medical School, Boston, USA
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9
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Pagano MB, Metcalf RA, Hess JR, Reyes J, Perkins JD, Montenovo MI. A high plasma: red blood cell transfusion ratio during liver transplantation is associated with decreased blood utilization. Vox Sang 2018; 113:268-274. [DOI: 10.1111/vox.12634] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2017] [Revised: 12/11/2017] [Accepted: 12/12/2017] [Indexed: 11/26/2022]
Affiliation(s)
- M. B. Pagano
- Laboratory Medicine; Transfusion Medicine Division; University of Washington; Seattle WA USA
| | - R. A. Metcalf
- Pathology, Transfusion Services; University of Utah and ARUP; Salt Lake City UT USA
| | - J. R. Hess
- Laboratory Medicine; Transfusion Medicine Division; University of Washington; Seattle WA USA
| | - J. Reyes
- Surgery; Transplant Surgery Division; University of Washington; Seattle WA USA
| | - J. D. Perkins
- Surgery; Transplant Surgery Division; University of Washington; Seattle WA USA
| | - M. I. Montenovo
- Surgery; Transplant Surgery Division; University of Washington; Seattle WA USA
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10
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Mesar T, Larentzakis A, Dzik W, Chang Y, Velmahos G, Yeh DD. Association Between Ratio of Fresh Frozen Plasma to Red Blood Cells During Massive Transfusion and Survival Among Patients Without Traumatic Injury. JAMA Surg 2017; 152:574-580. [PMID: 28273299 DOI: 10.1001/jamasurg.2017.0098] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Hemostatic resuscitation has been shown to be beneficial for patients with trauma, but there is little evidence that it is equally beneficial for bleeding patients without trauma. The practice of a high transfusion ratio of fresh frozen plasma (FFP) to red blood cells (RBCs) has spread to other surgical and medical fields. Objective To identify whether ratio-based resuscitation in patients without trauma is associated with improved survival. Design, Setting, and Participants This study is a retrospective review of all massive transfusions provided in an urban academic hospital from January 1, 2009, through December 31, 2012. Massive transfusion was defined as the transfusion of at least 10 U of RBCs in the first 24 hours after a patient's admission to the operating room, emergency department, or intensive care unit. All patients who received massive transfusions within the study period and survived more than 30 minutes after hospital arrival were counted (n=865). Patients were grouped into those with trauma and those without trauma. Sources of data included the Research Patient Data Registry, patients' medical records, and blood bank records. All data collection occurred between April 26, 2013, and April 26, 2015. Data analysis took place from April 27, 2015, and June 22, 2016. Main Outcomes and Measures Examination of FFP:RBC transfusion ratios for patients without trauma. Results There were 865 massive transfusion events that occurred within 4 years, transfusing 16 569 U of RBCs, 13 933 U of FFP, 5228 U of cryoprecipitate, and 22 635 U of platelets. Most of these transfusions were received by patients without trauma (767 [88.7%]), by men (582 [67.3%]), and for intraoperative bleeding (544 [62.9%]). The FFP:RBC ratios of survivors and nonsurvivors were nearly identical: the ratio for survivors was 1:1.5 (interquartile range [IQR], 1:1.1-1:2.2) and for nonsurvivors was 1:1.4 (IQR, 1:1.1-1:1.9; P = .43). Among the 767 patients without trauma, there was no difference in the adjusted odds ratio (aOR) for 30-day mortality when comparing the high FFP:RBC ratio vs the low FFP:RBC ratio subgroups (aOR, 1.10; 95% CI, 0.72-1.70; P = .65). In vascular surgery, the aOR for death favored the high FFP:RBC ratio subgroup (aOR, 0.16; 95% CI, 0.03-0.79; P = .02). However, in general surgery and medicine, the aOR for death favored the low FFP:RBC ratio subgroup; general surgery: aOR, 4.27 (95% CI, 1.28-14.22; P = .02); medicine: aOR, 8.48 (95% CI, 1.50-47.75; P = .02). Conclusions and Relevance High FFP:RBC transfusion ratios are applied mostly to patients without trauma, who account for nearly 90% of all massive transfusion events. Thirty-day survival was not significantly different in patients who received a high FFP:RBC ratio compared with those who received a low ratio.
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Affiliation(s)
- Tomaz Mesar
- Division of Trauma, Department of Surgery, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital and Harvard Medical School, Boston
| | - Andreas Larentzakis
- Division of Trauma, Department of Surgery, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital and Harvard Medical School, Boston
| | - Walter Dzik
- Department of Pathology and Transfusion Medicine, Massachusetts General Hospital and Harvard Medical School, Boston
| | - Yuchiao Chang
- Department of Medicine, Massachusetts General Hospital, Boston
| | - George Velmahos
- Division of Trauma, Department of Surgery, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital and Harvard Medical School, Boston
| | - Daniel Dante Yeh
- Division of Trauma, Department of Surgery, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital and Harvard Medical School, Boston
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Maegele M. Coagulation factor concentrate-based therapy for remote damage control resuscitation (RDCR): a reasonable alternative? Transfusion 2017; 56 Suppl 2:S157-65. [PMID: 27100752 DOI: 10.1111/trf.13526] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2015] [Revised: 01/06/2016] [Accepted: 01/11/2016] [Indexed: 12/11/2022]
Abstract
The concept of remote damage control resuscitation (RDCR) is still in its infancy and there is significant work to be done to improve outcomes for patients with life-threatening bleeding secondary to injury. The prehospital phase of resuscitation is critical and if shock and coagulopathy can be rapidly minimized before hospital admission this will very likely reduce morbidity and mortality. The optimum transfusion strategy for these patients is still highly debated and the potential implications of the recently published pragmatic, randomize, optimal platelet, and plasma ratios trial (PROPPR) for RDCR have been reviewed. Identifying the appropriate transfusion strategy is mandatory before adopting prehospital hemostatic resuscitation strategies. An alternative approach is based on the early administration of coagulation factor concentrates combined with the antifibrinolytic tranexamic acid (TXA). The three major components to this approach in the context of RDCR target the following steps to achieve hemostasis: 1) stop (hyper)fibrinolysis; 2) support clot formation; and 3) increase thrombin generation. Strong evidence exists for the use of TXA. The data from the prospective fibrinogen in trauma induced coagulopathy (FIinTIC) study will inform on the prehospital use of fibrinogen in bleeding trauma patients. Deficits in thrombin generation may be addressed by the administration of prothrombin complex concentrates. Handheld point-of-care devices may be able to support and guide the prehospital and remote use of intravenous hemostatic agents including coagulation factor concentrates along with clinical presentation, assessment, and the extent of bleeding. Combinations may even be more effective for bleeding control. More studies are urgently needed.
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Affiliation(s)
- Marc Maegele
- Department of Traumatology, Orthopedic Surgery and Sportsmedicine, Cologne-Merheim Medical Center (CMMC) and the Institute for Research in Operative Medicine (IFOM), University of Witten/Herdecke, Cologne, Germany
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12
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Poole D, Cortegiani A, Chieregato A, Russo E, Pellegrini C, De Blasio E, Mengoli F, Volpi A, Grossi S, Gianesello L, Orzalesi V, Fossi F, Chiara O, Coniglio C, Gordini G. Blood Component Therapy and Coagulopathy in Trauma: A Systematic Review of the Literature from the Trauma Update Group. PLoS One 2016; 11:e0164090. [PMID: 27695109 PMCID: PMC5047588 DOI: 10.1371/journal.pone.0164090] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2016] [Accepted: 09/18/2016] [Indexed: 12/27/2022] Open
Abstract
Background Traumatic coagulopathy is thought to increase mortality and its treatment to reduce preventable deaths. However, there is still uncertainty in this field, and available literature results may have been overestimated. Methods We searched the MEDLINE database using the PubMed platform. We formulated four queries investigating the prognostic weight of traumatic coagulopathy defined according to conventional laboratory testing, and the effectiveness in reducing mortality of three different treatments aimed at contrasting coagulopathy (high fresh frozen plasma/packed red blood cells ratios, fibrinogen, and tranexamic acid administration). Randomized controlled trials were selected along with observational studies that used a multivariable approach to adjust for confounding. Strict criteria were adopted for quality assessment based on a two-step approach. First, we rated quality of evidence according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria. Then, this rating was downgraded if other three criteria were not met: high reporting quality according to shared standards, absence of internal methodological and statistical issues not detailed by the GRADE system, and absence of external validity issues. Results With few exceptions, the GRADE rating, reporting and methodological quality of observational studies was “very low”, with frequent external validity issues. The only two randomized trials retrieved were, instead, of high quality. Only weak evidence was found for a relation between coagulopathy and mortality. Very weak evidence was found supporting the use of fibrinogen administration to reduce mortality in trauma. On the other hand, we found high evidence that the use of 1:1 vs. 1:2 high fresh frozen plasma/packed red blood cells ratios failed to obtain a 12% mortality reduction. This does not exclude lower mortality rates, which have not been investigated. The use of tranexamic acid in trauma was supported by “high” quality evidence according to the GRADE classification but was downgraded to “moderate” for external validity issues. Conclusions Tranexamic acid is effective in reducing mortality in trauma. The other transfusion practices we investigated have been inadequately studied in the literature, as well as the independent association between mortality and coagulopathy measured with traditional laboratory testing. Overall, in this field of research literature quality is poor.
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Affiliation(s)
- Daniele Poole
- Anesthesia and Intensive Care Operative Unit, “S. Martino” Hospital, Belluno, Italy
- * E-mail:
| | - Andrea Cortegiani
- Department of Biopathology and Medical Biotechnologies (DIBIMED), Section of Anesthesia, Analgesia, Intensive Care, and Emergency, Policlinico “P. Giaccone”, University of Palermo, Palermo, Italy
| | - Arturo Chieregato
- Neurointensive Care Unit ASST Great Metropolitan “Niguarda” Hospital, Milan, Italy
| | - Emanuele Russo
- Anaesthesia and Intensive Care Unit, Surgical and Severe Trauma Department, “Bufalini” Hospital, Cesena, Italy
| | | | | | - Francesca Mengoli
- UOC Intensive Care and Territorial Emergency Department, “Maggiore” Hospital, Bologna, Italy
| | - Annalisa Volpi
- Anesthesia and Intensive Care, AOU of Parma, Parma, Italy
| | - Silvia Grossi
- Anesthesia and Intensive Care, AOU of Parma, Parma, Italy
| | - Lara Gianesello
- Departmental Structure of Anesthesia and Intensive Care for Orthopedic Surgery, AOU “Careggi”, Florence, Italy
| | - Vanni Orzalesi
- Neuroanesthesia and Neurointensive Care, AOU “Careggi”, CTO, Florence, Italy
| | - Francesca Fossi
- Neurointensive Care Unit ASST Great Metropolitan “Niguarda” Hospital, Milan, Italy
| | - Osvaldo Chiara
- Trauma Center Department, ASST Great Metropolitan Niguarda Hospital, Milan, Italy
| | - Carlo Coniglio
- UOC Intensive Care and Territorial Emergency Department, “Maggiore” Hospital, Bologna, Italy
| | - Giovanni Gordini
- UOC Intensive Care and Territorial Emergency Department, “Maggiore” Hospital, Bologna, Italy
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The survival impact of plasma to red blood cell ratio in massively transfused non-trauma patients. Eur J Trauma Emerg Surg 2016; 43:393-398. [PMID: 27117790 DOI: 10.1007/s00068-016-0674-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2015] [Accepted: 04/15/2016] [Indexed: 01/24/2023]
Abstract
PURPOSE High ratios of Plasma to Packed Red Blood Cells (FFP:PRBC) improve survival in massively transfused trauma patients. We hypothesized that non-trauma patients also benefit from this transfusion strategy. METHODS Non-trauma patients requiring massive transfusion from November 2003 to September 2011 were reviewed. Logistic regression was performed to identify independent predictors of mortality. The population was stratified using two FFP:PRBC ratio cut-offs (1:2 and 1:3) and adjusted mortality derived. RESULTS Over 8 years, 29 % (260/908) of massively transfused surgical patients were non-trauma patients. Mortality decreased with increasing FFP:PRBC ratios (45 % for ratio ≤1:8, 33 % for ratio >1:8 and ≤1:3, 27 % for ratio >1:3 and ≤1:2 and 25 % for ratio >1:2). Increasing FFP:PRBC ratio independently predicted survival (AOR [95 % CI]: 1.91 [1.35-2.71]; p < 0.001). Patients achieving a ratio >1:3 had improved survival (AOR [95 % CI]: 3.24 [1.24-8.47]; p = 0.016). CONCLUSION In non-trauma patients undergoing massive transfusion, increasing FFP:PRBC ratio was associated with improved survival. A ratio >1:3 significantly improved survival probability.
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Rossaint R, Bouillon B, Cerny V, Coats TJ, Duranteau J, Fernández-Mondéjar E, Filipescu D, Hunt BJ, Komadina R, Nardi G, Neugebauer EAM, Ozier Y, Riddez L, Schultz A, Vincent JL, Spahn DR. The European guideline on management of major bleeding and coagulopathy following trauma: fourth edition. Crit Care 2016; 20:100. [PMID: 27072503 PMCID: PMC4828865 DOI: 10.1186/s13054-016-1265-x] [Citation(s) in RCA: 597] [Impact Index Per Article: 74.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Accepted: 03/11/2016] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Severe trauma continues to represent a global public health issue and mortality and morbidity in trauma patients remains substantial. A number of initiatives have aimed to provide guidance on the management of trauma patients. This document focuses on the management of major bleeding and coagulopathy following trauma and encourages adaptation of the guiding principles to each local situation and implementation within each institution. METHODS The pan-European, multidisciplinary Task Force for Advanced Bleeding Care in Trauma was founded in 2004 and included representatives of six relevant European professional societies. The group used a structured, evidence-based consensus approach to address scientific queries that served as the basis for each recommendation and supporting rationale. Expert opinion and current clinical practice were also considered, particularly in areas in which randomised clinical trials have not or cannot be performed. Existing recommendations were reconsidered and revised based on new scientific evidence and observed shifts in clinical practice; new recommendations were formulated to reflect current clinical concerns and areas in which new research data have been generated. This guideline represents the fourth edition of a document first published in 2007 and updated in 2010 and 2013. RESULTS The guideline now recommends that patients be transferred directly to an appropriate trauma treatment centre and encourages use of a restricted volume replacement strategy during initial resuscitation. Best-practice use of blood products during further resuscitation continues to evolve and should be guided by a goal-directed strategy. The identification and management of patients pre-treated with anticoagulant agents continues to pose a real challenge, despite accumulating experience and awareness. The present guideline should be viewed as an educational aid to improve and standardise the care of the bleeding trauma patients across Europe and beyond. This document may also serve as a basis for local implementation. Furthermore, local quality and safety management systems need to be established to specifically assess key measures of bleeding control and outcome. CONCLUSIONS A multidisciplinary approach and adherence to evidence-based guidance are key to improving patient outcomes. The implementation of locally adapted treatment algorithms should strive to achieve measureable improvements in patient outcome.
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Affiliation(s)
- Rolf Rossaint
- />Department of Anaesthesiology, University Hospital Aachen, RWTH Aachen University, Pauwelsstrasse 30, 52074 Aachen, Germany
| | - Bertil Bouillon
- />Department of Trauma and Orthopaedic Surgery, Witten/Herdecke University, Cologne-Merheim Medical Centre, Ostmerheimer Strasse 200, 51109 Cologne, Germany
| | - Vladimir Cerny
- />Department of Anaesthesiology, Perioperative Medicine and Intensive Care, J.E. Purkinje University, Masaryk Hospital, Usti nad Labem, Socialni pece 3316/12A, 40113 Usti nad Labem, Czech Republic
- />Department of Research and Development, Charles University in Prague, Faculty of Medicine in Hradec Kralove, Sokolska 581, 50005 Hradec Kralove, Czech Republic
- />Department of Anaesthesiology and Intensive Care, Charles University in Prague, Faculty of Medicine in Hradec Kralove, Sokolska 581, 50005 Hradec Kralove, Czech Republic
- />Department of Anaesthesia, Pain Management and Perioperative Medicine, Dalhousie University, Halifax, QE II Health Sciences Centre, 10 West Victoria, 1276 South Park St., Halifax, NS B3H 2Y9 Canada
| | - Timothy J. Coats
- />Emergency Medicine Academic Group, University of Leicester, University Road, Leicester, LE1 7RH UK
| | - Jacques Duranteau
- />Department of Anaesthesia and Intensive Care, Hôpitaux Universitaires Paris Sud, University of Paris XI, Faculté de Médecine Paris-Sud, 78 rue du Général Leclerc, 94275 Le Kremlin-Bicêtre, Cedex France
| | - Enrique Fernández-Mondéjar
- />Servicio de Medicina Intensiva, Complejo Hospitalario Universitario de Granada, ctra de Jaén s/n, 18013 Granada, Spain
| | - Daniela Filipescu
- />Department of Cardiac Anaesthesia and Intensive Care, C. C. Iliescu Emergency Institute of Cardiovascular Diseases, Sos Fundeni 256-258, 022328 Bucharest, Romania
| | - Beverley J. Hunt
- />King’s College, Departments of Haematology, Pathology and Lupus, Guy’s and St Thomas’ NHS Foundation Trust, Westminster Bridge Road, London, SE1 7EH UK
| | - Radko Komadina
- />Department of Traumatology, General and Teaching Hospital Celje, Oblakova 5, 3000 Celje, Slovenia
| | - Giuseppe Nardi
- />Shock and Trauma Centre, S. Camillo Hospital, Viale Gianicolense 87, 00152 Rome, Italy
| | - Edmund A. M. Neugebauer
- />Faculty of Health - School of Medicine, Witten/Herdecke University, Ostmerheimer Strasse 200, Building 38, 51109 Cologne, Germany
| | - Yves Ozier
- />Division of Anaesthesia, Intensive Care and Emergency Medicine, Brest University Hospital, Boulevard Tanguy Prigent, 29200 Brest, France
| | - Louis Riddez
- />Department of Surgery and Trauma, Karolinska University Hospital, 171 76 Solna, Sweden
| | - Arthur Schultz
- />Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, Lorenz Boehler Trauma Centre, Donaueschingenstrasse 13, 1200 Vienna, Austria
| | - Jean-Louis Vincent
- />Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Route de Lennik 808, 1070 Brussels, Belgium
| | - Donat R. Spahn
- />Institute of Anaesthesiology, University of Zurich and University Hospital Zurich, Raemistrasse 100, 8091 Zurich, Switzerland
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16
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Llau JV, Acosta FJ, Escolar G, Fernández-Mondéjar E, Guasch E, Marco P, Paniagua P, Páramo JA, Quintana M, Torrabadella P. [Multidisciplinary consensus document on the management of massive haemorrhage (HEMOMAS document)]. ACTA ACUST UNITED AC 2015; 63:e1-e22. [PMID: 26688462 DOI: 10.1016/j.redar.2015.11.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2015] [Accepted: 05/17/2015] [Indexed: 12/23/2022]
Abstract
Massive haemorrhage is common and often associated with high morbidity and mortality. We perform a systematic review of the literature, with extraction of the recommendations from the existing evidences because of the need for its improvement and the management standardization. From the results we found, we wrote a multidisciplinary consensus document. We begin with the agreement in the definitions of massive haemorrhage and massive transfusion, and we do structured recommendations on their general management (clinical assessment of bleeding, hypothermia management, fluid therapy, hypotensive resuscitation and damage control surgery), blood volume monitoring, blood products transfusion (red blood cells, fresh frozen plasma, platelets and their best transfusion ratio), and administration of hemostatic components (prothrombin complex, fibrinogen, factor VIIa, antifibrinolytic agents).
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Affiliation(s)
- J V Llau
- Anestesia y Reanimación, Hospital Clínico Universitario de Valencia, Valencia, España
| | - F J Acosta
- Anestesia y Reanimación, Hospital Universitario Virgen de la Arrixaca, El Palmar, Murcia, España
| | - G Escolar
- Hemoterapia y Hematología, Hospital Clínic i Provincial de Barcelona, Barcelona, España
| | - E Fernández-Mondéjar
- Servicio de Cuidados Críticos y Urgencias, Hospital Universitario Virgen de las Nieves; Instituto de Investigación Biosanitaria ibs.Granada, Granada, España.
| | - E Guasch
- Anestesia y Reanimación, Hospital Universitario La Paz, Madrid, España
| | - P Marco
- Hemoterapia y Hematología, Hospital General de Alicante, Alicante, España
| | - P Paniagua
- Anestesia y Reanimación, Hospital de la Santa Creu i Sant Pau, Barcelona, España
| | - J A Páramo
- Hematología y Hemoterapia, Clínica Universidad de Navarra, Pamplona, España
| | - M Quintana
- Medicina Intensiva, Hospital Universitario La Paz, Madrid, España
| | - P Torrabadella
- Unidad de Cuidados Intensivos, Hospital Germans Trias i Pujol, Badalona, Barcelona, España
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Coagulopathy and transfusion strategies in trauma. Overwhelmed by literature, supported by weak evidence. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2015; 14:3-7. [PMID: 26674832 DOI: 10.2450/2015.0244-15] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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18
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Llau JV, Acosta FJ, Escolar G, Fernández-Mondéjar E, Guasch E, Marco P, Paniagua P, Páramo JA, Quintana M, Torrabadella P. Multidisciplinary consensus document on the management of massive haemorrhage (HEMOMAS document). Med Intensiva 2015; 39:483-504. [PMID: 26233588 DOI: 10.1016/j.medin.2015.05.002] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2015] [Revised: 05/14/2015] [Accepted: 05/17/2015] [Indexed: 12/30/2022]
Abstract
Massive haemorrhage is common and often associated with high morbidity and mortality. We perform a systematic review of the literature, with extraction of the recommendations from the existing evidences because of the need for its improvement and the management standardization. From the results we found, we wrote a multidisciplinary consensus document. We begin with the agreement in the definitions of massive haemorrhage and massive transfusion, and we do structured recommendations on their general management (clinical assessment of bleeding, hypothermia management, fluid therapy, hypotensive resuscitation and damage control surgery), blood volume monitoring, blood products transfusion (red blood cells, fresh frozen plasma, platelets and their best transfusion ratio), and administration of hemostatic components (prothrombin complex, fibrinogen, factor VIIa, antifibrinolytic agents).
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Affiliation(s)
- J V Llau
- Anestesia y Reanimación, Hospital Clínico Universitario de Valencia, Valencia, España
| | - F J Acosta
- Anestesia y Reanimación, Hospital Universitario Virgen de la Arrixaca, El Palmar, Murcia, España
| | - G Escolar
- Hemoterapia y Hematología, Hospital Clínic i Provincial de Barcelona, Barcelona, España
| | - E Fernández-Mondéjar
- Servicio de Cuidados Críticos y Urgencias, Hospital Universitario Virgen de las Nieves; Instituto de Investigación Biosanitaria ibs.Granada, Granada, España.
| | - E Guasch
- Anestesia y Reanimación, Hospital Universitario La Paz, Madrid, España
| | - P Marco
- Hemoterapia y Hematología, Hospital General de Alicante, Alicante, España
| | - P Paniagua
- Anestesia y Reanimación, Hospital de la Santa Creu i Sant Pau, Barcelona, España
| | - J A Páramo
- Hematología y Hemoterapia, Clínica Universidad de Navarra, Pamplona, España
| | - M Quintana
- Medicina Intensiva, Hospital Universitario La Paz, Madrid, España
| | - P Torrabadella
- Unidad de Cuidados Intensivos, Hospital Germans Trias i Pujol, Badalona, Barcelona, España
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Boutefnouchet T, Gregg R, Tidman J, Isaac J, Doughty H. Emergency red cells first: Rapid response or speed bump? The evolution of a massive transfusion protocol for trauma in a single UK centre. Injury 2015; 46:1772-8. [PMID: 26068644 DOI: 10.1016/j.injury.2015.05.046] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2014] [Revised: 05/07/2015] [Accepted: 05/21/2015] [Indexed: 02/02/2023]
Abstract
BACKGROUND Death from massive haemorrhage due to traumatic injury is potentially preventable after hospital admission using haemorrhage control and improved resuscitation techniques including massive transfusion protocols. Massive transfusion protocols (MTP) are an essential element of damage control resuscitation and provide a coordinated clinical pathology response to massive haemorrhage after hospital admission. The decision to activate and de-activate a MTP is based on a number of patient and local factors. The purpose of this before-and-after study was to determine the impact of modifying a protocol to include emergency red cells. In addition, we investigated whether massive transfusion prediction models could have been used to guide on-going transfusion support. METHODS Sequential MTP activations over three years, before and after protocol revision, were analysed. Percentage of MTP activation, component usage and outcome data were compared. Trauma associated severe haemorrhage (TASH) and assessment of blood consumption (ABC) scores were derived and receiver operating characteristic (ROC) analysis undertaken for an outcome defined as the use of >6 red cell units. RESULTS 52 MTP1 and 66 MTP2 activations arose from 216 and 495 major trauma cases, respectively. Protocol change significantly reduced the MTP activation rate (p=0.0006) from 24% to 13%, and the number of activations requiring >10 RCC increased from 13% to 36% (p=0.006). Average emergency red cells usage in the second cohort increased to 4 units. Survival, coagulation parameters, and time to MTP pack issue were all unaffected by the protocol revision. The TASH score showed an area under ROC (AUROC) of 0.88 ongoing transfusion requirements. CONCLUSION The change in protocol increased the use of emergency red cells but reduced MTP activation and use of multiple blood components. The TASH score appears to provide a useful predictive tool for ongoing transfusion support and may be of value for the trauma clinicians.
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Affiliation(s)
- Tarek Boutefnouchet
- Department of Trauma and Orthopaedic Surgery, University Hospital Birmingham NHS Foundation Trust, Edgbaston, Birmingham B15 2WB, UK.
| | - Richard Gregg
- Department of Haematology, University Hospital Birmingham NHS Foundation Trust, Edgbaston, Birmingham B15 2WB, UK
| | - Jane Tidman
- Department of Haematology, University Hospital Birmingham NHS Foundation Trust, Edgbaston, Birmingham B15 2WB, UK
| | - John Isaac
- Department of Haematology, University Hospital Birmingham NHS Foundation Trust, Edgbaston, Birmingham B15 2WB, UK
| | - Heidi Doughty
- NHS Blood and Transplant, Edgbaston, Birmingham B15 2TH, UK
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Chay J, Koh M, Tan HH, Ng J, Ng HJ, Chia N, Kuperan P, Tan J, Lew E, Tan LK, Koh PL, Desouza KA, Bin Mohd Fathil S, Kyaw PM, Ang AL. A national common massive transfusion protocol (MTP) is a feasible and advantageous option for centralized blood services and hospitals. Vox Sang 2015; 110:36-50. [PMID: 26178308 DOI: 10.1111/vox.12311] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2014] [Revised: 05/29/2015] [Accepted: 06/08/2015] [Indexed: 12/12/2022]
Abstract
BACKGROUND A common national MTP was jointly implemented in 2011 by the national blood service (Blood Services Group) and seven participating acute hospitals to provide rapid access to transfusion support for massively haemorrhaging patients treated in all acute care hospitals. METHODS Through a systematic clinical workflow, blood components are transfused in a ratio of 1:1:1 (pRBC: whole blood-derived platelets: FFP), together with cryoprecipitate for fibrinogen replacement. The composition of components for the MTP is fixed, although operational aspects of the MTP can be adapted by individual hospitals to suit local hospital workflow. The MTP could be activated in support of any patient with critical bleeding and at risk of massive transfusion, including trauma and non-trauma general medical, surgical and obstetric patients. RESULTS There were 434 activations of the MTP from October 2011 to October 2013. Thirty-nine per cent were for trauma patients, and 30% were for surgical patients with heavy intra-operative bleeding, with 25% and 6% for patients with gastrointestinal bleeding and peri-partum haemorrhage, respectively. Several hospitals reported reduction in mean time between request and arrival of blood. Mean transfusion ratio achieved was one red cell unit: 0·8 FFP units: 0·8 whole blood-derived platelet units: 0·4 units of cryoprecipitate. Although cryoprecipitate usage more than doubled after introduction of MTP, there was no significant rise in overall red cells, platelet and FFP usage following implementation. CONCLUSION This successful collaboration shows that shared transfusion protocols are feasible and potentially advantageous for hospitals sharing a central blood provider.
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Affiliation(s)
- J Chay
- Blood Services Group, Health Sciences Authority, Singapore City, Singapore
| | - M Koh
- Blood Services Group, Health Sciences Authority, Singapore City, Singapore
| | - H H Tan
- Blood Services Group, Health Sciences Authority, Singapore City, Singapore
| | - J Ng
- Department of Surgery, Singapore General Hospital, Singapore City, Singapore
| | - H J Ng
- Department of Haematology, Singapore General Hospital, Singapore City, Singapore
| | - N Chia
- Department of Anaesthesiology, Khoo Teck Puat Hospital, Singapore City, Singapore
| | - P Kuperan
- Department of Haematology, Tan Tock Seng Hospital, Singapore City, Singapore
| | - J Tan
- Department of Anaesthesiology, Tan Tock Seng Hospital, Singapore City, Singapore
| | - E Lew
- Department of Anaesthesiology, KK Woman's & Children's Hospital, Singapore City, Singapore
| | - L K Tan
- Department of Haematology, National University Hospital, Singapore City, Singapore
| | - P L Koh
- Paediatrics, National University Hospital, Singapore City, Singapore
| | - K A Desouza
- Department of Anaesthesiology, Changi General Hospital, Singapore City, Singapore
| | - S Bin Mohd Fathil
- Department of Anaethesiology, Jurong Health Services, Singapore City, Singapore
| | - P M Kyaw
- Blood Services Group, Health Sciences Authority, Singapore City, Singapore
| | - A L Ang
- Blood Services Group, Health Sciences Authority, Singapore City, Singapore
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Mirski MA, Frank SM, Kor DJ, Vincent JL, Holmes DR. Restrictive and liberal red cell transfusion strategies in adult patients: reconciling clinical data with best practice. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2015; 19:202. [PMID: 25939346 PMCID: PMC4419449 DOI: 10.1186/s13054-015-0912-y] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Red blood cell (RBC) transfusion guidelines correctly promote a general restrictive transfusion approach for anemic hospitalized patients. Such recommendations have been derived from evaluation of specific patient populations, and it is important to recognize that engaging a strict guideline approach has the potential to incur harm if the clinician fails to provide a comprehensive review of the patient’s physiological status in determining the benefit and risks of transfusion. We reviewed the data in support of a restrictive or a more liberal RBC transfusion practice, and examined the quality of the datasets and manner of their interpretation to provide better context by which a physician can make a sound decision regarding RBC transfusion therapy. Reviewed studies included PubMed-cited (1974 to 2013) prospective randomized clinical trials, prospective subset analyses of randomized studies, nonrandomized controlled trials, observational case series, consecutive and nonconsecutive case series, and review articles. Prospective randomized clinical trials were acknowledged and emphasized as the best-quality evidence. The results of the analysis support that restrictive RBC transfusion practices appear safe in the hospitalized populations studied, although patients with acute coronary syndromes, traumatic brain injury and patients at risk for brain or spinal cord ischemia were not well represented in the reviewed studies. The lack of quality data regarding the purported adverse effects of RBC transfusion at best suggests that restrictive strategies are no worse than liberal strategies under the studied protocol conditions, and RBC transfusion therapy in the majority of instances represents a marker for greater severity of illness. The conclusion is that in the majority of clinical settings a restrictive RBC transfusion strategy is cost-effective, reduces the risk of adverse events specific to transfusion, and introduces no harm. In anemic patients with ongoing hemorrhage, with risk of significant bleeding, or with concurrent ischemic brain, spinal cord, or myocardium, the optimal hemoglobin transfusion trigger remains unknown. Broad-based adherence to guideline approaches of therapy must respect the individual patient condition as interpreted by comprehensive clinical review.
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Affiliation(s)
- Marek A Mirski
- Johns Hopkins Medical Institutions, 1800 Orleans Street, Phipps 455b, Baltimore, MD, 21287, USA.
| | - Steven M Frank
- Johns Hopkins Medical Institutions, 1800 Orleans Street, Phipps 455b, Baltimore, MD, 21287, USA.
| | - Daryl J Kor
- Mayo Clinic College of Medicine, 200 First Street SW, Rochester, MN, 55905, USA.
| | - Jean-Louis Vincent
- Erasme Hospital, Free University of Brussels, Route de Lennik 808, 1070, Bruxelles, Belgium.
| | - David R Holmes
- Mayo Clinic College of Medicine, 200 First Street SW, Rochester, MN, 55905, USA.
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Cardigan R, Green L. Thawed and liquid plasma--what do we know? Vox Sang 2015; 109:1-10. [PMID: 25833464 DOI: 10.1111/vox.12251] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2014] [Revised: 12/16/2014] [Accepted: 12/16/2014] [Indexed: 12/21/2022]
Abstract
There is increasing interest in the use of liquid or frozen plasma thawed and stored for extended periods (>24 h) to reduce wastage and to improve rapid availability of plasma in massive transfusion protocols advocating the early use of plasma in trauma by some centres. There is now a body of studies that have assessed individual coagulation factors during storage of thawed plasma. These show that factor VIII (FVIII) is the worst affected factor and that its activity is mainly lost during the first 24 h following thawing. However, for most factors studied, there is a continual decline during further storage. The few studies that have assessed thrombin generation in thawed plasma have shown variable results. Extended storage of plasma is associated with an increase in levels of DEHP in the component and could theoretically increase the risk of bacterial contamination, although the latter does not appear to have been an issue in countries that have adopted the use of thawed plasma. There are no clinical studies relating to the efficacy of extended-thawed plasma, and therefore, the potential reduction in its efficacy must be balanced with the clinical need for the component.
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Affiliation(s)
| | - L Green
- NHS Blood & Transplant, and Barts Health NHS Trust and Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
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Does resuscitation with plasma increase the risk of venous thromboembolism? J Trauma Acute Care Surg 2015; 78:39-43; discussion 43-4. [PMID: 25539201 DOI: 10.1097/ta.0000000000000480] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Resuscitation with blood products improves survival in patients with traumatic hemorrhage. However, the risk of venous thromboembolic (VTE) complications associated with fresh frozen plasma (FFP) resuscitation is unknown. We hypothesized that a higher ratio of FFP to packed red blood cells (PRBCs) given during acute resuscitation increases the risk of VTE independent of severity of injury and shock. METHODS The records of patients admitted from April 2007 to December 2011 who had surveillance lower extremity duplex ultrasounds were retrospectively reviewed. Patients who received at least 1 U of PRBCs within 24 hours of admission were included. Patients who died without VTE were excluded. The relationship between FFP and VTE was evaluated using logistic regression. RESULTS A total of 381 patients met inclusion criteria, of whom 77 (20.2%) developed VTE. In patients who required less than 4 U of PRBCs, increasing units of FFP were associated with an increasing risk for VTE, with each unit of FFP having an adjusted odds ratio of 1.27 (95% confidence interval, 1.04-1.54, p = 0.015). Conversely, in patients who required four or greater units of PRBCs, FFP in equal or greater ratios than PRBCs was not associated with VTE. CONCLUSION Each unit of FFP increased VTE risk by 25% in patients who required less than 4 U of PRBCs. In patients who required 4 U or greater PRBCs, FFP administration conferred no increased risk of VTE. This suggests that FFP should be used cautiously when early hemodynamic stability can be achieved with less than 4 U of PRBCs. LEVEL OF EVIDENCE Care management study, level III.
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Driessen A, Schäfer N, Bauerfeind U, Kaske S, Fromm-Dornieden C, Stuermer EK, Maegele M. Functional capacity of reconstituted blood in 1:1:1 versus 3:1:1 ratios: a thrombelastometry study. Scand J Trauma Resusc Emerg Med 2015; 23:2. [PMID: 25571924 PMCID: PMC4296528 DOI: 10.1186/s13049-014-0080-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2014] [Accepted: 12/16/2014] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Different transfusion ratio concepts of packed red blood cells (pRBCs), fresh frozen plasma (FFP) and platelets (PLTs) have been implemented in trauma care, but the optimal ratios are still discussed. In this study the hemostatic potential of two predefined ratios was assessed by using an in vitro thrombelastometric approach. Furthermore, age effects of reconstituted blood were analyzed. METHODS Whole blood (WB) of voluntary donors was separated into pRBCs, FFP and PLTs and reconstituted into the ratios 1:1:1 and 3:1:1 at day 1, 4, 14, and 24. Standard blood count, electrolytes and coagulation proteins were quantified. The functional coagulation in ratio- and age-specific groups was evaluated using rotational thromboelastometry (ROTEM). RESULTS Several coagulation factors reduced significantly in the 3:1:1 ratio and were consistent with increased INR, decelerated clot formation times and A10 (amplitude 10 minutes after clotting time (CT)), flattened α-angle during the EXTEM and diminished MCF for distinct time points during the INTEM, FIBTEM and APTEM assays. With rising age of pRBCs the pH, sodium and potassium reached non-physiological levels. CONCLUSION Under standardized in vitro conditions the higher amount of pRBCs in the 3:1:1 ratio diluted coagulation factors significantly on the expense of its functional coagulation capacity as revealed by ROTEM results. Thus, the coagulation functionality of the 1:1:1 ratio predominated.
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Affiliation(s)
- Arne Driessen
- Institute for Research in Operative Medicine, Faculty of Health, Department of Medicine, Witten/Herdecke University, Ostmerheimer Str. 200, D-51109, Cologne, Germany. .,Department of Traumatology, Orthopaedic Surgery and Sports Traumatology, Cologne-Merheim Medical Centre (CMMC), Witten/Herdecke University, Campus Cologne-Merheim, Ostmerheimer Str. 200, D-51109, Cologne, Germany.
| | - Nadine Schäfer
- Institute for Research in Operative Medicine, Faculty of Health, Department of Medicine, Witten/Herdecke University, Ostmerheimer Str. 200, D-51109, Cologne, Germany.
| | - Ursula Bauerfeind
- Institute of Transfusion Medicine Cologne-Merheim Medical Centre (CMMC), Witten/Herdecke University, Campus Cologne-Merheim, Cologne (Germany), Ostmerheimer Str. 200, D-51109, Cologne, Germany.
| | - Sigune Kaske
- Department of Traumatology, Orthopaedic Surgery and Sports Traumatology, Cologne-Merheim Medical Centre (CMMC), Witten/Herdecke University, Campus Cologne-Merheim, Ostmerheimer Str. 200, D-51109, Cologne, Germany.
| | - Carolin Fromm-Dornieden
- Institute for Research in Operative Medicine, Faculty of Health, Department of Medicine, Witten/Herdecke University, Ostmerheimer Str. 200, D-51109, Cologne, Germany.
| | - Ewa K Stuermer
- Institute for Research in Operative Medicine, Faculty of Health, Department of Medicine, Witten/Herdecke University, Ostmerheimer Str. 200, D-51109, Cologne, Germany.
| | - Marc Maegele
- Department of Traumatology, Orthopaedic Surgery and Sports Traumatology, Cologne-Merheim Medical Centre (CMMC), Witten/Herdecke University, Campus Cologne-Merheim, Ostmerheimer Str. 200, D-51109, Cologne, Germany.
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Blood wastage reduction: a 10-year observational evaluation in a large teaching institution in France. Eur J Anaesthesiol 2014; 30:250-5. [PMID: 23535198 DOI: 10.1097/eja.0b013e32835fadcf] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
CONTEXT Blood transfusion has increased significantly during the last decade and blood wastage reduction is a medical and economic challenge in hospital practice and for institutional quality, particularly in the ICU and operating theatre. OBJECTIVE To evaluate the impact of multiple strategies in one hospital to reduce red blood cell wastage. DESIGN Multicentre, prospective, comparative, observational study. SETTING Over 10 years, the study was conducted over two time periods. During the first period (2000 to 2003), information was given to medical professionals about blood wastage, and audits (reasons for wastage) were performed, in a large teaching institution (more than 4% wastage in 1999). The second period (2004 to 2010) was designed to analyse the impact of seven strategies intended to minimise blood wastage. Blood wastage reduction in the local centre was compared with regional (64 institutions) and national centres (1470 institutions). Reduction was compared using the Mann-Kendall non-parametric trend test. PATIENTS Local centre (22,572 transfused patients, Nîmes, France), regional centre (South France, 64 institutions, 208,525 transfused patients) and national centres (France, 1470 institutions). INTERVENTIONS Medical and surgical procedures. MAIN OUTCOME MEASURES The primary end-point was to describe the percentage of blood wastage for two periods in a local centre. The secondary objective was to compare the percentage of blood wastage in the local centre with wastage at regional and national centres. RESULTS Over the 10 year study period the percentage of blood wastage in the local centre decreased, with a significant reduction in the second period, from more than 4% (1999) to less than 1% (2010; P < 0.05). Blood wastage at regional and national centres was never less than 1%. Inadequate containers for transport, absence of a temperature analyser in the ICU and inadequate intraoperative blood strategies (excessive orders of blood) were the main causes of wastage. Correction of these points affected the outcome favourably in the second period, but transfusion information was poor in the first period. CONCLUSION Seven simple strategies (including transport containers with an effective temperature analyser and audits) decreased blood wastage, especially in the ICU and operating theatre.
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In vitro combinations of red blood cell, plasma and platelet components evaluated by thromboelastography. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2014; 12:491-6. [PMID: 24960655 DOI: 10.2450/2014.0285-13] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 10/23/2013] [Accepted: 10/25/2013] [Indexed: 12/27/2022]
Abstract
BACKGROUND Thromboelastography is increasingly used to evaluate coagulation in massively bleeding patients. The aim of this study was to investigate how different combinations of blood components affect in vitro whole blood clotting measured by thromboelastography. MATERIALS AND METHODS Packed red blood cells, plasma and platelets from fresh and old blood components were mixed in vitro, in proportions of 4:4:1, 5:5:2, 8:4:1 and 2:1:0, and analysed with thromboelastography. For the ratio 4:4:1 the experiment was done at both 37 °C and 32 °C. RESULTS Thromboelastography curves were within normal reference values for the blood component proportions of 4:4:1 and 5:5:2. For 8:4:1, the angle and maximal amplitude were reduced below normal values, indicating low levels of fibrinogen and/or platelets. For the 2:1:0 proportion, all parameters were affected resulting in severely impaired in vitro clot formation. The reaction-time, reflecting the coagulation factor-dependent, initial clot formation, was slightly increased at a low temperature. Prolonged storage of the components did not affect the curve. DISCUSSION With the introduction of guidelines on the management of massive bleeding it is important to have tools for the assessment of the new protocols. In vitro evaluation of mixtures of packed red blood cells, plasma and platelets by thromboelastography may be relevant in the prediction of in vivo clot formation and haemostasis.
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The use of higher platelet: RBC transfusion ratio in the acute phase of trauma resuscitation: a systematic review. Crit Care Med 2014; 41:2800-11. [PMID: 23982024 DOI: 10.1097/ccm.0b013e31829a6ecb] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
OBJECTIVE With the recognition of early coagulopathy, trauma resuscitation has shifted toward liberal platelet transfusions. The overall benefit of this strategy remains controversial. Our objective was to compare the effects of a liberal use of platelet (higher platelet:RBC ratios) with a conservative approach (lower ratios) in trauma resuscitation. DATA SOURCES We systematically searched Medline, Embase, Web of Science, Biosis, Cochrane Central, and Scopus. STUDY SELECTION Two independent reviewers selected randomized controlled trials and observational studies comparing two or more platelet:RBC ratios in trauma resuscitation. We excluded studies investigating the use of whole blood or hemostatic products. DATA EXTRACTION Two independent reviewers extracted data and assessed the risk of bias. Primary outcomes were early (in ICU or within 30 d) and late (in hospital or after 30 d) mortality. Secondary outcomes were multiple organ failure, lung injury, and sepsis. DATA SYNTHESIS From 6,123 citations, no randomized controlled trials were identified. We included seven observational studies (4,230 patients) addressing confounders through multivariable regression or propensity scores. Heterogeneity of studies precluded meta-analysis. Among the five studies including exclusively patients requiring massive transfusions, four observed a lower mortality with higher ratios. Two studies considering nonmassively bleeding patients observed no benefit of using higher ratios. Two studies evaluated the implementation of a massive transfusion protocol; only one study observed a decrease in mortality with higher ratios. Of the two studies at low risk of survival bias, one study observed a survival benefit. Three studies assessed secondary outcomes. One study observed an increase in multiple organ failure with higher ratios, whereas no study demonstrated an increased risk in lung injury or sepsis. CONCLUSIONS There is insufficient evidence to strongly support the use of a precise platelet:RBC ratio for trauma resuscitation, especially in nonmassively bleeding patients. Randomized controlled trials evaluating both the safety and efficacy of liberal platelet transfusions are warranted.
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Tapia NM, Suliburk J, Mattox KL. The initial trauma center fluid management of penetrating injury: a systematic review. Clin Orthop Relat Res 2013; 471:3961-73. [PMID: 23807449 PMCID: PMC3825889 DOI: 10.1007/s11999-013-3122-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Damage-control resuscitation is the prevailing trauma resuscitation technique that emphasizes early and aggressive transfusion with balanced ratios of red blood cells (RBCs), plasma (FFP), and platelets (Plt) while minimizing crystalloid resuscitation, which is a departure from Advanced Trauma Life Support (ATLS) guidelines. It is unclear whether the newer approach is superior to the approach recommended by ATLS. QUESTIONS/PURPOSES With these recent changes pervading resuscitation protocols, we performed a systematic review to determine if the shift in trauma resuscitation from ATLS guidelines to damage control resuscitation has improved mortality in patients with penetrating injuries. METHODS A systematic search of PubMed, the Cochrane Library, and the Current Controlled Trials Register was performed for studies comparing mortality in massively transfused penetrating trauma patients receiving either balanced ratios of blood transfusion per damage control resuscitation tenets or undergoing an alternate blood volume resuscitation strategy. Studies were deemed appropriate for inclusion if they had a Newcastle-Ottawa Scale score of 6 or greater as well as at least 30% penetrating trauma. Twenty studies that reported on a total of 12,154 patients were included. RESULTS Transfusion ratios varied widely, with 1:1 and 1:2 ratios of FFP:RBC most often defined as high ratios for purposes of comparison with other low ratio groups. Fourteen of 20 studies found significantly lower 30-day mortality when higher transfusion ratios of FFP, RBC, and/or Plt were used; six of 20 studies found mortality to be similar between higher and lower transfusion ratios. CONCLUSIONS Patients with penetrating injuries who require massive transfusion should be transfused early using balanced ratios of RBC, FFP, and Plt. Randomized, controlled trials are needed to determine optimal ratios for transfusion.
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Affiliation(s)
- Nicole M. Tapia
- Baylor College of Medicine, One Baylor Plaza, Suite 404D, Houston, TX 77030 USA
| | - James Suliburk
- Baylor College of Medicine, One Baylor Plaza, Suite 404D, Houston, TX 77030 USA
| | - Kenneth L. Mattox
- Baylor College of Medicine, One Baylor Plaza, Suite 404D, Houston, TX 77030 USA
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Allard S, Green L, Hunt BJ. How we manage the haematological aspects of major obstetric haemorrhage. Br J Haematol 2013; 164:177-88. [PMID: 24383841 DOI: 10.1111/bjh.12605] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Major obstetric haemorrhage (MOH) remains an important medical challenge worldwide, contributing to significant maternal morbidity and mortality. Prompt and appropriate management is essential if we are to improve outcomes and reduce substandard care that may result in adverse consequences. This review describes the current understanding of the pathophysiological aspects of MOH together with the principles of transfusion and haemostatic therapy, with emphasis on a coordinated multidisciplinary approach. We also highlight the current lack of evidence available from randomized controlled trials to inform best practice and the need to prioritize research in this key clinical area.
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Affiliation(s)
- Shubha Allard
- Barts Health NHS Trust & NHS Blood and Transplant, London, UK
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Moffat B, Vogt KN, Inaba K. The Shock Index: is it ready for primetime? CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2013; 17:196. [PMID: 24090407 PMCID: PMC4057433 DOI: 10.1186/cc13040] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The rapid and accurate prediction of the need for massive transfusion in bleeding trauma patients remains a challenge. Various models have been proposed to anticipate massive transfusion with variable success. The current study by Mutschler and colleagues proposes four classes of shock as defined by the Shock Index and examines its ability to predict the need for massive transfusion. This model demonstrates promise as a practical tool in acute decision-making for transfusion after injury.
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Tang N, Yin S, Sun Z, Pan Y. Time course of soluble P-selectin and von Willebrand factor levels in trauma patients: a prospective observational study. Scand J Trauma Resusc Emerg Med 2013; 21:70. [PMID: 24034700 PMCID: PMC3847632 DOI: 10.1186/1757-7241-21-70] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2013] [Accepted: 09/13/2013] [Indexed: 12/18/2022] Open
Abstract
Background Coagulopathy often develops in patients with serious trauma and is correlated with the clinical outcome. The contribution of platelet activity and endothelial dysfunction to trauma-induced coagulopathy remain to be defined. The purpose of this study was to investigate the time courses of soluble P-selectin (sPsel, an index of platelet activation) and von Willebrand factor (VWF, an index of endothelial dysfunction) in trauma patients and elucidate their relationship to coagulation parameter levels, the presence of coagulopathy, and patient outcome. Methods This prospective observational study, which took place in a university hospital intensive care unit (ICU), included 82 severely injured trauma patients. The sPsel, VWF antigen, protein C, and factor VII levels were measured and routine coagulation tests were performed upon admission to ICU and daily within the first week. The 30-day mortality rate was also determined. Results Thirty-seven (45.1%) patients developed coagulopathy upon admission to the ICU, and the 30-day mortality rate was 20.7% (n = 17). Both the admission sPsel and VWF levels were lower in patients with coagulopathy than in those without (p < 0.05) and were significantly correlated with the protein C and factor VII levels, respectively (all p < 0.05). The VWF levels were lower during the first 3 days and higher on day 7 after admission in nonsurvivors than in survivors (all p < 0.05). No significant differences in sPsel levels were found between nonsurvivors and survivors on each day during the first week. Conclusion In severely injured trauma patients in the ICU, lower levels of sPsel and VWF on admission were associated with the presence of coagulopathy and might not predict a better outcome. An increase in the VWF level at the end of the first week after admission to ICU was associated with increased 30-day mortality.
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Affiliation(s)
- Ning Tang
- Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430030, China.
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Emergency department blood transfusion: the first two units are free. J Surg Res 2013; 184:546-50. [PMID: 23578753 DOI: 10.1016/j.jss.2013.03.043] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2013] [Revised: 03/08/2013] [Accepted: 03/13/2013] [Indexed: 11/20/2022]
Abstract
INTRODUCTION Studies on blood product transfusions after trauma recommend targeting specific ratios to reduce mortality. Although crystalloid volumes as little as 1.5 L predict increased mortality after trauma, little data is available regarding the threshold of red blood cell (RBC) transfusion volume that predicts increased mortality. MATERIALS AND METHODS Data from a level I trauma center between January 2000 and December 2008 were reviewed. Trauma patients who received at least 100 mL RBC in the emergency department (ED) were included. Each unit of RBC was defined as 300 mL. Demographics, RBC transfusion volume, and mortality were analyzed in the nonelderly (<70 y) and elderly (≥70 y). Multivariate logistic regression was performed at various volume cutoffs to determine whether there was a threshold transfusion volume that independently predicted mortality. RESULTS A total of 560 patients received ≥100 mL RBC in the ED. Overall mortality was 24.3%, with 22.5% (104 deaths) in the nonelderly and 32.7% (32 deaths) in the elderly. Multivariate logistic regression demonstrated that RBC transfusion of ≥900 mL was associated with increased mortality in both the nonelderly (adjusted odds ratio 2.06, P = 0.008) and elderly (adjusted odds ratio 5.08, P = 0.006). CONCLUSIONS Although transfusion of greater than 2 units in the ED was an independent predictor of mortality, transfusion of 2 units or less was not. Interestingly, unlike crystalloid volume, stepwise increases in blood volume were not associated with stepwise increases in mortality. The underlying etiology for mortality discrepancies, such as transfusion ratios, hypothermia, or immunosuppression, needs to be better delineated.
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Abstract
Survival after severe traumatic shock can be complicated by a number of pathophysiologic processes that ensue after the initial trauma. One of these is trauma-induced coagulopathy (TIC) whose onset may occur before initial fluid resuscitation. The pathogenesis of TIC has not yet been fully elaborated, but evolving evidence appears to link severe tissue hypoxia and damage to the endothelium as key factors, which evolve into measurable structural and biochemical changes of the endothelium resulting in a coagulopathic state. This paper will provide a general review of these linkages and identify knowledge gaps as well as suggest new approaches and areas of investigation, which may both limit the development of TIC as well as produce insights into its pathophysiology. A better understanding of these issues will be necessary in order to advance the practice of remote damage control resuscitation.
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Affiliation(s)
- Kevin R Ward
- Department of Emergency Medicine, University of Michigan, Michigan Center for Integrative Research in Critical Care, Ann Arbor, MI 48109, USA.
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Elmer J, Wilcox SR, Raja AS. Massive transfusion in traumatic shock. J Emerg Med 2013; 44:829-38. [PMID: 23375220 DOI: 10.1016/j.jemermed.2012.11.025] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2012] [Revised: 07/03/2012] [Accepted: 11/05/2012] [Indexed: 01/31/2023]
Abstract
BACKGROUND Hemorrhage after trauma is a common cause of death in the United States and globally. The primary goals when managing traumatic shock are the restoration of oxygen delivery to end organs, maintenance of circulatory volume, and prevention of ongoing bleeding through source control and correction of coagulopathy. Achieving these goals may require massive transfusion of blood products. Although use of blood products may be lifesaving, dose-related adverse effects are well described. DISCUSSION Complications of massive transfusion include interdependent derangements such as coagulopathy, hypothermia, acidosis, and electrolyte abnormalities, as well as infectious and immunomodulatory phenomena. This article explores the pathogenesis, implications, prevention, and treatment of these complications through the use of massive transfusion protocols. Particular attention is given to the optimal ratio of blood products transfused in large volume resuscitation and prevention of secondary coagulopathy. CONCLUSIONS Observational data indicate that the development and use of a massive transfusion protocol may reduce the morbidity and mortality associated with large-volume resuscitation of patients with hemorrhagic shock. Such protocols should include a pre-defined ratio of packed red blood cells, fresh frozen plasma, and platelets transfused; most commonly, the ratio used is 1:1:1. Additionally, such protocols should monitor for and correct hypothermia, hypofibrinogenemia, and electrolyte disturbances such as hypocalcemia and hyperkalemia.
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Affiliation(s)
- Jonathan Elmer
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
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Lier H, Vorweg M, Hanke A, Görlinger K. Thromboelastometry guided therapy of severe bleeding. Essener Runde algorithm. Hamostaseologie 2013; 33:51-61. [PMID: 23258612 DOI: 10.5482/hamo-12-05-0011] [Citation(s) in RCA: 80] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2012] [Accepted: 11/27/2012] [Indexed: 01/08/2023] Open
Abstract
Both, severe haemorrhage and blood transfusion are associated with increased morbidity and mortality. Therefore, it is of particular importance to stop perioperative bleeding as fast and as possible to avoid unnecessary transfusion. Viscoelastic test (ROTEM® or TEG®) allow for early prediction of massive transfusion and goal-directed therapy with specific haemostatic drugs, coagulation factor concentrates, and blood products. Growing consensus points out, that plasma-based coagulation screening tests like aPTT and PT are inappropriate for monitoring coagulopathy or guide transfusion therapy. Increasing evidence of more than 5000 surgical or trauma patients points towards the beneficial effects of a thrombelastography or -metry based approach in diagnosis and goal-directed therapy of perioperative massive haemorrhage. The Essener Runde task force is a group of clinicians of various specialties (anaesthesiology, intensive care, haemostaseology, haematology, internal medicine, transfusion medicine, surgery) interested in perioperative coagulation management. The ROTEM diagnostic algorithm of the Essener Runde task force was created to standardise and simplify the interpretation of ROTEM® results in perioperative settings and to present their possible implications for therapeutic interventions in severe bleeding. To exemplify, this text mainly focuses on coagulation management in trauma.
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Affiliation(s)
- H Lier
- Department of Anaesthesiology and Intensive Care, Medicine University Hospital of Cologne, Kerpener Straße 62, 50937 Cologne, Germany.
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Assessment and management of massive bleeding: coagulation assessment, pharmacologic strategies, and transfusion management. Hematology 2012. [DOI: 10.1182/asheducation.v2012.1.522.3806896] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Abstract
This review details the current knowledge in massive hemorrhage with regard to the pathophysiology and laboratory assessment of the coagulation disturbance, the role of plasma and platelet transfusion, the role of pharmaceutical strategies, and the clinical value of having a massive transfusion protocol. The bulk of the recent medical literature on this topic stems from the study of military and civilian trauma; however, where applicable, reference to postcardiac and post-noncardiac surgery and postpartum hemorrhage will also be discussed.
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Stansbury LG, Hess AS, Thompson K, Kramer B, Scalea TM, Hess JR. The clinical significance of platelet counts in the first 24 hours after severe injury. Transfusion 2012; 53:783-9. [PMID: 22882316 DOI: 10.1111/j.1537-2995.2012.03828.x] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Admission platelet (PLT) counts are known to be associated with all-cause mortality for seriously injured patients admitted to a trauma center. The course of subsequent PLT counts, their implications, and the effects of PLT therapy are less well known. STUDY DESIGN AND METHODS Trauma center patients who were directly admitted from the scene of injury, received 1 or more units of uncrossmatched red blood cells in the first hour of care, survived for at least 15 minutes, and had a PLT count measured in the first hour were analyzed for the association of their admission and subsequent PLT counts in the first 24 hours with injury severity and hemorrhagic and central nervous system (CNS) causes of in-hospital mortality. RESULTS Over an 8.25-year period, 1292 of 45,849 direct trauma admissions met entry criteria. Admission PLT counts averaged 228×10(9) ±90×10(9) /L and decreased by 104×10(9) /L by the second hour and 1×10(9) /L each hour thereafter. The admission count was not related to time to admission. Each 1-point increase in the injury severity score was associated with a 1×10(9) /L decrease in the PLT count at all times in the first 24 hours of care. Admission PLT counts were strongly associated with hemorrhagic and CNS injury mortality and subsequent PLT counts. Effects of PLT therapy could not be ascertained. DISCUSSION Admission PLT counts in critically injured trauma patients are usually normal, decreasing after admission. Low PLT counts at admission and during the course of trauma care are strongly associated with mortality.
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Affiliation(s)
- Lynn G Stansbury
- Program in Trauma, Epidemiology, and Pathology, University of Maryland School of Medicine, Baltimore, Maryland, USA
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Callum JL, Rizoli S. Plasma transfusion for patients with severe hemorrhage: what is the evidence? Transfusion 2012; 52 Suppl 1:30S-7S. [PMID: 22578369 DOI: 10.1111/j.1537-2995.2012.03621.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
The following review will detail the current knowledge in massive hemorrhage with regard to the pathophysiology of the coagulation disturbance, the role of plasma, the role of alternatives to plasma, and the clinical value of having a massive transfusion protocol. The coagulation disturbance in trauma patients is more than just the result of consumption of clotting factors at sites of injury and dilution from the infusion of intravenous fluids and red blood cells (RBCs). Even before substantial amounts of fluid resuscitation and RBC transfusion, one-quarter of trauma patients already have abnormal coagulation variables. There is an apparent role for the activation of protein C, hypofibrinogenemia, and fibrin(gen)olysis in the coagulation disturbance after trauma and massive hemorrhage. None of these three disturbances would be completely mitigated by the use of plasma alone, suggesting that there may be an opportunity to improve care of these patients with alternative strategies, such as fibrinogen concentrates and antifibrinolytics. Despite numerous retrospective cohort studies evaluating 1:1 plasma to RBC formula-driven resuscitation, the overall clinical value of this approach is unclear. Studies have even raised concerns regarding a potential increase in morbidity associated with this approach, particularly for patients overtriaged to 1:1 where a massive transfusion is unlikely. We also do not have sufficient evidence to recommend either goal-directed therapy with thromboelastography or early use of fibrinogen replacement, with either cryoprecipitate or fibrinogen concentrates. We have high-quality data that argue against the role for recombinant Factor VIIa that should prompt removal of this strategy from existing protocols. In contrast, we have high-level evidence that all bleeding trauma patients should receive tranexamic acid as soon as possible after injury. This therapy must be included in hemorrhage protocols. If we are to improve the care of massively bleeding patients on a firm scientific ground, we will need large-scale randomized trials to delineate the role of coagulation replacement and the utility of laboratory monitoring. But even until these trials are completed, it is clear that a massive transfusion protocol is needed in all hospitals that manage bleeding patients, to ensure a prompt and coordinated response to hemorrhage.
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Affiliation(s)
- Jeannie L Callum
- Department of Clinical Pathology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada.
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Plasma/platelets/red blood cell ratio in the management of the bleeding traumatized patient: does it matter? Curr Opin Anaesthesiol 2012; 25:242-7. [PMID: 22227445 DOI: 10.1097/aco.0b013e32834fcc3e] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
PURPOSE OF REVIEW The scope of this review is to describe what is known about blood product ratios and their effects on acute trauma coagulopathy. Assessing how ratios matter to trauma patients is important to improve massive transfusion strategies. RECENT FINDINGS A growing body of evidence supports that high ratios of fresh frozen plasma and platelets to red blood cells improve survival of the massively bleeding traumatized patient. Acting quickly is also critical. Reducing transfusion delay can be achieved through massive transfusion protocol implementations, which incorporate local agreements with blood banks and 'trauma packs' in organized trauma systems. Thawed plasma and freeze-dried plasma allow immediate delivery of plasma. SUMMARY Fresh frozen plasma/platelet/red blood cell ratios matter to define the content of packs immediately available within the golden hour to the right, accurately screened trauma patients. Research is needed in developing novel transfusion approaches for massively bleeding patients.
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Pasquier P, Tourtier JP, Boutonnet M, Bourrilhon C, Ausset S. Pulmonary embolus in combat extremity injury: influence of the fresh frozen plasma to red blood cells ratio? J Trauma Acute Care Surg 2012; 72:1118. [PMID: 22491640 DOI: 10.1097/ta.0b013e31823e2850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Current World Literature. Curr Opin Anaesthesiol 2012; 25:260-9. [DOI: 10.1097/aco.0b013e3283521230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Schöchl H, Maegele M, Solomon C, Görlinger K, Voelckel W. Early and individualized goal-directed therapy for trauma-induced coagulopathy. Scand J Trauma Resusc Emerg Med 2012; 20:15. [PMID: 22364525 PMCID: PMC3306198 DOI: 10.1186/1757-7241-20-15] [Citation(s) in RCA: 165] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2011] [Accepted: 02/24/2012] [Indexed: 01/29/2023] Open
Abstract
Severe trauma-related bleeding is associated with high mortality. Standard coagulation tests provide limited information on the underlying coagulation disorder. Whole-blood viscoelastic tests such as rotational thromboelastometry or thrombelastography offer a more comprehensive insight into the coagulation process in trauma. The results are available within minutes and they provide information about the initiation of coagulation, the speed of clot formation, and the quality and stability of the clot. Viscoelastic tests have the potential to guide coagulation therapy according to the actual needs of each patient, reducing the risks of over- or under-transfusion. The concept of early, individualized and goal-directed therapy is explored in this review and the AUVA Trauma Hospital algorithm for managing trauma-induced coagulopathy is presented.
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Affiliation(s)
- Herbert Schöchl
- Ludwig Boltzmann Institute of Experimental and Clinical Traumatology, Vienna, Austria.
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