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Mathew SK, Le TD, Pusateri AE, Pinto DN, Carney BC, McLawhorn MM, Tejiram S, Travis TE, Moffatt LT, Shupp JW. Plasma Inclusive Resuscitation Is Not Associated With Coagulation Profile Changes in Burn Patients. J Surg Res 2024; 303:233-240. [PMID: 39378792 DOI: 10.1016/j.jss.2024.09.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2024] [Revised: 08/01/2024] [Accepted: 09/02/2024] [Indexed: 10/10/2024]
Abstract
INTRODUCTION Dynamically titrated crystalloids are the standard of care for burn shock resuscitation. There are theoretical concerns that the adjunctive use of allogeneic plasma may perturb the patient's coagulation and inflammation status deleteriously. It was hypothesized that plasma-inclusive resuscitation (PIR) would not be associated with prothrombotic changes relative to baseline after thermal injury. METHODS Patients admitted to a regional burn center who were treated with PIR as part of their burn resuscitation were enrolled. Whole blood samples were analyzed prospectively via rapid thromboelastography and rotational thromboelastometry to assess for coagulopathy at four time points throughout their acute burn resuscitation. The mixed-effect model for repeated measures followed by Tukey's post hoc test for comparisons was used to examine group differences. RESULTS There were 35 patients in the analysis. Most were male (74.3%) with a median age of 43 y (32-55), concomitant inhalation injury of 28.6%, total body surface area burn size of 34% (27%-48.5%), and the overall mortality of the cohort was 28.6%. There were no transfusion reactions or thrombotic events. There were no differences in thromboelastography or rotational thromboelastometry parameters overall or when stratified by mortality, total body surface area burn, and inhalation injury. There were no significant differences between the fibrinolytic phenotypes over time. CONCLUSIONS Data suggest that PIR was not associated with prothrombotic or lytic changes in burn patients relative to baseline. Further research is needed to confirm these findings and evaluate efficacy of PIR in acute burn resuscitation.
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Affiliation(s)
- Shane K Mathew
- Firefighters' Burn and Surgical Research Laboratory, MedStar Health Research Institute, Washington, District of Columbia
| | - Tuan D Le
- Firefighters' Burn and Surgical Research Laboratory, MedStar Health Research Institute, Washington, District of Columbia
| | | | - Desiree N Pinto
- Firefighters' Burn and Surgical Research Laboratory, MedStar Health Research Institute, Washington, District of Columbia
| | - Bonnie C Carney
- Firefighters' Burn and Surgical Research Laboratory, MedStar Health Research Institute, Washington, District of Columbia; Department of Surgery, Georgetown University School of Medicine, Washington, District of Columbia; Department of Biochemistry, Georgetown University School of Medicine, Washington, District of Columbia
| | - Melissa M McLawhorn
- Firefighters' Burn and Surgical Research Laboratory, MedStar Health Research Institute, Washington, District of Columbia
| | - Shawn Tejiram
- Firefighters' Burn and Surgical Research Laboratory, MedStar Health Research Institute, Washington, District of Columbia; The Burn Center, MedStar Washington Hospital Center, Washington, District of Columbia; Department of Surgery, Georgetown University School of Medicine, Washington, District of Columbia; Department of Plastic and Reconstructive Surgery, Georgetown University School of Medicine, Washington, District of Columbia
| | - Taryn E Travis
- Firefighters' Burn and Surgical Research Laboratory, MedStar Health Research Institute, Washington, District of Columbia; The Burn Center, MedStar Washington Hospital Center, Washington, District of Columbia; Department of Surgery, Georgetown University School of Medicine, Washington, District of Columbia; Department of Plastic and Reconstructive Surgery, Georgetown University School of Medicine, Washington, District of Columbia
| | - Lauren T Moffatt
- Firefighters' Burn and Surgical Research Laboratory, MedStar Health Research Institute, Washington, District of Columbia; Department of Surgery, Georgetown University School of Medicine, Washington, District of Columbia; Department of Biochemistry, Georgetown University School of Medicine, Washington, District of Columbia
| | - Jeffrey W Shupp
- Firefighters' Burn and Surgical Research Laboratory, MedStar Health Research Institute, Washington, District of Columbia; The Burn Center, MedStar Washington Hospital Center, Washington, District of Columbia; Department of Surgery, Georgetown University School of Medicine, Washington, District of Columbia; Department of Biochemistry, Georgetown University School of Medicine, Washington, District of Columbia; Department of Plastic and Reconstructive Surgery, Georgetown University School of Medicine, Washington, District of Columbia.
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Tucci M, Crighton G, Goobie SM, Russell RT, Parker RI, Haas T, Nellis ME, Vogel AM, Lacroix J, Stricker PA. Plasma and Platelet Transfusion Strategies in Critically Ill Children Following Noncardiac Surgery and Critically Ill Children Undergoing Invasive Procedures Outside the Operating Room: From the Transfusion and Anemia EXpertise Initiative-Control/Avoidance of Bleeding. Pediatr Crit Care Med 2022; 23:e50-e62. [PMID: 34989705 PMCID: PMC8769350 DOI: 10.1097/pcc.0000000000002858] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECTIVES To present consensus statements and supporting literature for plasma and platelet transfusions in critically ill children following noncardiac surgery and critically ill children undergoing invasive procedures outside the operating room from the Transfusion and Anemia EXpertise Initiative - Control/Avoidance of Bleeding. DESIGN Systematic review and consensus conference of international, multidisciplinary experts in platelet and plasma transfusion management of critically ill children. SETTING Not applicable. PATIENTS Critically ill children undergoing invasive procedures outside of the operating room or noncardiac surgery. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS A panel of 10 experts developed evidence-based and, when evidence was insufficient, expert-based statements for plasma and platelet transfusions in critically ill children following noncardiac surgery or undergoing invasive procedures outside of the operating room. These statements were reviewed and ratified by the 29 Transfusion and Anemia EXpertise Initiative-Control/Avoidance of Bleeding experts. A systematic review was conducted using MEDLINE, EMBASE, and Cochrane Library databases, from inception to December 2020. Consensus was obtained using the Research and Development/University of California, Los Angeles Appropriateness Method. Results were summarized using the Grading of Recommendations Assessment, Development, and Evaluation method. We developed eight expert consensus statements focused on the critically ill child following noncardiac surgery and 10 expert consensus statements on the critically ill child undergoing invasive procedures outside the operating room. CONCLUSIONS Evidence regarding plasma and platelet transfusion in critically ill children in this area is very limited. The Transfusion and Anemia EXpertise Initiative-Control/Avoidance of Bleeding Consensus Conference developed 18 pediatric specific consensus statements regarding plasma and platelet transfusion management in these critically ill pediatric populations.
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Affiliation(s)
- Marisa Tucci
- Department of Pediatrics, Sainte-Justine University Hospital, University of Montreal, Montreal, QC, Canada
| | - Gemma Crighton
- Department of Haematology, Royal Children’s Hospital, Melbourne, Australia
| | - Susan M. Goobie
- Boston Children’s Hospital, Dept. of Anesthesiology, Critical Care & Pain Medicine, Boston Children’s Hospital, Boston, USA
| | - Robert T. Russell
- Department of Surgery, Division of Pediatric Surgery, Children’s of Alabama, University of Alabama at Birmingham, Birmingham, Alabama
| | - Robert I. Parker
- Department of Pediatrics, Stony Brook University, Stony Brook, NY
| | - Thorsten Haas
- Department of Anesthesia, Zurich University Children’s Hospital, Zurich, Switzerland
| | - Marianne E. Nellis
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, NY Presbyterian Hospital – Weill Cornell Medicine, New York, NY, USA
| | - Adam M. Vogel
- Division of Pediatric Surgery, Surgery and Pediatrics Baylor College of Medicine Texas Children’s Hospital, Houston, Texas
| | - Jacques Lacroix
- Department of Pediatrics, University of Montreal, Montreal, QC, Canada
| | - Paul A. Stricker
- Department of Anesthesiology and Critical Care, The Children’s Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
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3
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Tejiram S, Sen S, Romanowski KS, Greenhalgh DG, Palmieri TL. Examining 1:1 vs. 4:1 Packed Red Blood Cell to Fresh Frozen Plasma Ratio Transfusion During Pediatric Burn Excision. J Burn Care Res 2021; 41:443-449. [PMID: 31912141 DOI: 10.1093/jbcr/iraa001] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Blood transfusions following major burn injury are common due to operative losses, blood sampling, and burn physiology. While massive transfusion improves outcomes in adult trauma patients, literature examining its effect in critically ill children is limited. The study purpose was to prospectively compare outcomes of major pediatric burns receiving a 1:1 vs. 4:1 packed red blood cell to fresh frozen plasma transfusion strategy during massive burn excision. Children with >20% total body surface area burns were randomized to a 1:1 or 4:1 packed red blood cell/fresh frozen plasma transfusion ratio during burn excision. Parameters examined include patient demographics, burn size, pediatric risk of mortality (PRISM) scores, pediatric logistic organ dysfunction scores, laboratory values, total blood products transfused, and the presence of blood stream infections or pneumonia. A total of 68 children who met inclusion criteria were randomized into two groups (n = 34). Mean age, PRISM scores, estimated blood loss (600 ml (400-1175 ml) vs. 600 ml (300-1150 ml), P = 0.68), ventilator days (5 vs. 9, P = 0.47), and length of stay (57 vs. 60 days, P = 0.24) had no difference. No differences in frequency of blood stream infection (20 vs. 18, P = 0.46) or pneumonia events (68 vs. 116, P = 0.08) were noted. On multivariate analysis, only total body surface area burn size, inhalation injury, and PRISM scores (P < 0.05) were significantly associated with infections.
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Affiliation(s)
- Shawn Tejiram
- Shriners Hospitals for Children Northern California and the Firefighters Burn Institute Regional Burn Center, Department of Surgery, University of California, Davis, Sacramento, California
| | - Soman Sen
- Shriners Hospitals for Children Northern California and the Firefighters Burn Institute Regional Burn Center, Department of Surgery, University of California, Davis, Sacramento, California
| | - Kathleen S Romanowski
- Shriners Hospitals for Children Northern California and the Firefighters Burn Institute Regional Burn Center, Department of Surgery, University of California, Davis, Sacramento, California
| | - David G Greenhalgh
- Shriners Hospitals for Children Northern California and the Firefighters Burn Institute Regional Burn Center, Department of Surgery, University of California, Davis, Sacramento, California
| | - Tina L Palmieri
- Shriners Hospitals for Children Northern California and the Firefighters Burn Institute Regional Burn Center, Department of Surgery, University of California, Davis, Sacramento, California
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Reddoch-Cardenas KM, Sharma U, Salgado CL, Cantu C, Darlington DN, Pidcoke HF, Bynum JA, Cap AP. Use of Specialized Pro-Resolving Mediators to Alleviate Cold Platelet Storage Lesion. Transfusion 2020; 60 Suppl 3:S112-S118. [PMID: 32478925 DOI: 10.1111/trf.15750] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Revised: 02/19/2020] [Accepted: 02/24/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND Cold-stored platelets are an attractive option for treatment of actively bleeding patients due to a reduced risk of septic complications and preserved hemostatic function compared to conventional room temperature-stored platelets. However, refrigeration causes increased platelet activation and aggregate formation. Specialized pro-resolving mediators (SPMs), cell signaling mediators biosynthesized from essential fatty acids, have been shown to modulate platelet function and activation. In this study, we sought to determine if SPMs could be used to inhibit cold-stored platelet activation. METHODS Platelets were collected from healthy donors (n = 4-7) and treated with SPMs (resolvin E1 [RvE1], maresin 1 [MaR1], and resolvin D2 [RvD2]) or vehicle (VEH; 0.1% EtOH). Platelets were stored without agitation in the cold and assayed on Days 0 and 7 of storage for platelet activation levels using flow cytometry, platelet count, aggregation response using impedance aggregometry, and nucleotide content using mass spectrometry. RESULTS Compared to VEH, SPM treatment inhibited GPIb shedding (all compounds), significantly reduced both PS exposure and activation of GPIIb/IIIa receptor (RvD2, MaR1), and preserved aggregation response to TRAP (RvD2, MaR1) after 7 days of storage. Similar to untreated cold-stored platelets, SPM-treated samples did not preserve platelet counts or block the release of P-Selectin. Nucleotide content was unaffected by SPM treatment in cold-stored platelets. CONCLUSIONS SPM treatment, particularly Mar1 and RvD2, led to reduced platelet activation and preserved platelet function after 7 days of storage in the cold. Future work is warranted to better elucidate the mechanism of action of SPMs on cold platelet function and activation.
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Affiliation(s)
- Kristin M Reddoch-Cardenas
- Coagulation and Blood Research Program, U.S. Army Institute of Surgical Research, Fort Sam Houston, Texas, USA
| | - Umang Sharma
- Coagulation and Blood Research Program, U.S. Army Institute of Surgical Research, Fort Sam Houston, Texas, USA
| | - Christi L Salgado
- Coagulation and Blood Research Program, U.S. Army Institute of Surgical Research, Fort Sam Houston, Texas, USA
| | - Carolina Cantu
- Coagulation and Blood Research Program, U.S. Army Institute of Surgical Research, Fort Sam Houston, Texas, USA
| | - Daniel N Darlington
- Coagulation and Blood Research Program, U.S. Army Institute of Surgical Research, Fort Sam Houston, Texas, USA
| | - Heather F Pidcoke
- Translational Medicine Institute, Colorado State University, Fort Collins, Colorado, USA
| | - James A Bynum
- Coagulation and Blood Research Program, U.S. Army Institute of Surgical Research, Fort Sam Houston, Texas, USA
| | - Andrew P Cap
- Coagulation and Blood Research Program, U.S. Army Institute of Surgical Research, Fort Sam Houston, Texas, USA
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5
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Huber J, Stanworth SJ, Doree C, Fortin PM, Trivella M, Brunskill SJ, Hopewell S, Wilkinson KL, Estcourt LJ. Prophylactic plasma transfusion for patients without inherited bleeding disorders or anticoagulant use undergoing non-cardiac surgery or invasive procedures. Cochrane Database Syst Rev 2019; 11:CD012745. [PMID: 31778223 PMCID: PMC6993082 DOI: 10.1002/14651858.cd012745.pub2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND In the absence of bleeding, plasma is commonly transfused to people prophylactically to prevent bleeding. In this context, it is transfused before operative or invasive procedures (such as liver biopsy or chest drainage tube insertion) in those considered at increased risk of bleeding, typically defined by abnormalities of laboratory tests of coagulation. As plasma contains procoagulant factors, plasma transfusion may reduce perioperative bleeding risk. This outcome has clinical importance given that perioperative bleeding and blood transfusion have been associated with increased morbidity and mortality. Plasma is expensive, and some countries have experienced issues with blood product shortages, donor pool reliability, and incomplete screening for transmissible infections. Thus, although the benefit of prophylactic plasma transfusion has not been well established, plasma transfusion does carry potentially life-threatening risks. OBJECTIVES To determine the clinical effectiveness and safety of prophylactic plasma transfusion for people with coagulation test abnormalities (in the absence of inherited bleeding disorders or use of anticoagulant medication) requiring non-cardiac surgery or invasive procedures. SEARCH METHODS We searched for randomised controlled trials (RCTs), without language or publication status restrictions in: Cochrane Central Register of Controlled Trials (CENTRAL; 2017 Issue 7); Ovid MEDLINE (from 1946); Ovid Embase (from 1974); Cumulative Index to Nursing and Allied Health Literature (CINAHL; EBSCOHost) (from 1937); PubMed (e-publications and in-process citations ahead of print only); Transfusion Evidence Library (from 1950); Latin American Caribbean Health Sciences Literature (LILACS) (from 1982); Web of Science: Conference Proceedings Citation Index-Science (CPCI-S) (Thomson Reuters, from 1990); ClinicalTrials.gov; and World Health Organization (WHO) International Clinical Trials Registry Search Platform (ICTRP) to 28 January 2019. SELECTION CRITERIA We included RCTs comparing: prophylactic plasma transfusion to placebo, intravenous fluid, or no intervention; prophylactic plasma transfusion to alternative pro-haemostatic agents; or different haemostatic thresholds for prophylactic plasma transfusion. We included participants of any age, and we excluded trials incorporating individuals with previous active bleeding, with inherited bleeding disorders, or taking anticoagulant medication before enrolment. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. MAIN RESULTS We included five trials in this review, all were conducted in high-income countries. Three additional trials are ongoing. One trial compared fresh frozen plasma (FFP) transfusion with no transfusion given. One trial compared FFP or platelet transfusion or both with neither FFP nor platelet transfusion given. One trial compared FFP transfusion with administration of alternative pro-haemostatic agents (factors II, IX, and X followed by VII). One trial compared the use of different transfusion triggers using the international normalised ratio measurement. One trial compared the use of a thromboelastographic-guided transfusion trigger using standard laboratory measurements of coagulation. Four trials enrolled only adults, whereas the fifth trial did not specify participant age. Four trials included only minor procedures that could be performed by the bedside. Only one trial included some participants undergoing major surgical operations. Two trials included only participants in intensive care. Two trials included only participants with liver disease. Three trials did not recruit sufficient participants to meet their pre-calculated sample size. Overall, the quality of evidence was low to very low across different outcomes according to GRADE methodology, due to risk of bias, indirectness, and imprecision. One trial was stopped after recruiting two participants, therefore this review's findings are based on the remaining four trials (234 participants). When plasma transfusion was compared with no transfusion given, we are very uncertain whether there was a difference in 30-day mortality (1 trial comparing FFP or platelet transfusion or both with neither FFP nor platelet transfusion, 72 participants; risk ratio (RR) 0.38, 95% confidence interval (CI) 0.13 to 1.10; very low-quality evidence). We are very uncertain whether there was a difference in major bleeding within 24 hours (1 trial comparing FFP transfusion vs no transfusion, 76 participants; RR 0.33, 95% CI 0.01 to 7.93; very low-quality evidence; 1 trial comparing FFP or platelet transfusion or both with neither FFP nor platelet transfusion, 72 participants; RR 1.59, 95% CI 0.28 to 8.93; very low-quality evidence). We are very uncertain whether there was a difference in the number of blood product transfusions per person (1 trial, 76 participants; study authors reported no difference; very low-quality evidence) or in the number of people requiring transfusion (1 trial comparing FFP or platelet transfusion or both with neither FFP nor platelet transfusion, 72 participants; study authors reported no blood transfusion given; very low-quality evidence) or in the risk of transfusion-related adverse events (acute lung injury) (1 trial, 76 participants; study authors reported no difference; very low-quality evidence). When plasma transfusion was compared with other pro-haemostatic agents, we are very uncertain whether there was a difference in major bleeding (1 trial; 21 participants; no events; very low-quality evidence) or in transfusion-related adverse events (febrile or allergic reactions) (1 trial, 21 participants; RR 9.82, 95% CI 0.59 to 162.24; very low-quality evidence). When different triggers for FFP transfusion were compared, the number of people requiring transfusion may have been reduced (for overall blood products) when a thromboelastographic-guided transfusion trigger was compared with standard laboratory tests (1 trial, 60 participants; RR 0.18, 95% CI 0.08 to 0.39; low-quality evidence). We are very uncertain whether there was a difference in major bleeding (1 trial, 60 participants; RR 0.33, 95% CI 0.01 to 7.87; very low-quality evidence) or in transfusion-related adverse events (allergic reactions) (1 trial; 60 participants; RR 0.33, 95% CI 0.01 to 7.87; very low-quality evidence). Only one trial reported 30-day mortality. No trials reported procedure-related harmful events (excluding bleeding) or quality of life. AUTHORS' CONCLUSIONS Review findings show uncertainty for the utility and safety of prophylactic FFP use. This is due to predominantly very low-quality evidence that is available for its use over a range of clinically important outcomes, together with lack of confidence in the wider applicability of study findings, given the paucity or absence of study data in settings such as major body cavity surgery, extensive soft tissue surgery, orthopaedic surgery, or neurosurgery. Therefore, from the limited RCT evidence, we can neither support nor oppose the use of prophylactic FFP in clinical practice.
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Affiliation(s)
- Jonathan Huber
- University Hospital Southampton NHS Foundation TrustShackleton Department of AnaesthesiaTremona RoadSouthamptonHampshireUKSo16 6YD
| | - Simon J Stanworth
- Oxford University Hospitals NHS Foundation Trust and University of OxfordNational Institute for Health Research (NIHR) Oxford Biomedical Research CentreJohn Radcliffe Hospital, Headley WayHeadingtonOxfordUKOX3 9BQ
| | - Carolyn Doree
- NHS Blood and TransplantSystematic Review InitiativeJohn Radcliffe HospitalOxfordUKOX3 9BQ
| | | | - Marialena Trivella
- University of OxfordCentre for Statistics in MedicineBotnar Research CentreWindmill RoadOxfordUKOX3 7LD
| | - Susan J Brunskill
- NHS Blood and TransplantSystematic Review InitiativeJohn Radcliffe HospitalOxfordUKOX3 9BQ
| | - Sally Hopewell
- University of OxfordNuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS)Botnar Research Centre, Windmill RoadOxfordOxfordshireUKOX3 7LD
| | - Kirstin L Wilkinson
- Southampton University NHS HospitalPaediatric and Adult Cardiothoracic AnaesthesiaTremona RoadSouthamptonUKSO16 6YD
| | - Lise J Estcourt
- NHS Blood and TransplantHaematology/Transfusion MedicineLevel 2, John Radcliffe HospitalHeadingtonOxfordUKOX3 9BQ
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Abstract
PURPOSE OF REVIEW Blood transfusion is ubiquitous in major burn injury. The present article describes recent research findings directly impacting blood transfusion strategies in major burn injury both in the operating room and the ICU. RECENT FINDINGS Transfusion strategies have been the focus of recent burn investigations. First, a randomized prospective trial encompassing both the ICU and operating room reported that a restrictive red blood cell transfusion threshold (7 g/dl) had equivalent outcomes to a traditional threshold (10 g/dl) for burns more than 20% in terms of mortality, infection, length of stay, duration of mechanical ventilation, and wound healing despite receiving significantly fewer transfusions. The second burn transfusion advance addresses coagulation. Although burn patients initially have elevated fibrinogen, thrombocytopenia and other coagulation disorders develop during excision. Blood product repletion should be based on measurements such as thromboelastography in addition to traditional tests. Finally, a recent randomized trial suggests that fresh-frozen plasma and platelets during burn excision more than 20% may decrease transfusion requirements. SUMMARY A restrictive transfusion practice during burn excision and grafting is well tolerated and effective in reducing the number of transfusions without increasing complications. Repletion of coagulation products should focus on measured deficits of platelets, fibrinogen, and factors.
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Young AE, Davies A, Bland S, Brookes S, Blazeby JM. Systematic review of clinical outcome reporting in randomised controlled trials of burn care. BMJ Open 2019; 9:e025135. [PMID: 30772859 PMCID: PMC6398699 DOI: 10.1136/bmjopen-2018-025135] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION Systematic reviews collate trial data to provide evidence to support clinical decision-making. For effective synthesis, there must be consistency in outcome reporting. There is no agreed set of outcomes for reporting the effect of burn care interventions. Issues with outcome reporting have been identified, although not systematically investigated. This study gathers empirical evidence on any variation in outcome reporting and assesses the need for a core outcome set for burn care research. METHODS Electronic searches of four search engines were undertaken from January 2012 to December 2016 for randomised controlled trials (RCTs), using medical subject headings and free text terms including 'burn', 'scald' 'thermal injury' and 'RCT'. Two authors independently screened papers, extracted outcomes verbatim and recorded the timing of outcome measurement. Duplicate outcomes (exact wording ± different spelling), similar outcomes (albumin in blood, serum albumin) and identical outcomes measured at different times were removed. Variation in outcome reporting was determined by assessing the number of unique outcomes reported across all included trials. Outcomes were classified into domains. Bias was reduced using five researchers and a patient working independently and together. RESULTS 147 trials were included, of which 127 (86.4%) were RCTs, 13 (8.8%) pilot studies and 7 (4.8%) RCT protocols. 1494 verbatim clinical outcomes were reported; 955 were unique. 76.8% of outcomes were measured within 6 months of injury. Commonly reported outcomes were defined differently. Numbers of unique outcomes per trial varied from one to 37 (median 9; IQR 5,13). No single outcome was reported across all studies demonstrating inconsistency of reporting. Outcomes were classified into 54 domains. Numbers of outcomes per domain ranged from 1 to 166 (median 11; IQR 3,24). CONCLUSIONS This review has demonstrated heterogeneity in outcome reporting in burn care research which will hinder amalgamation of study data. We recommend the development of a Core Outcome Set. PROSPERO REGISTRATION NUMBER CRD42017060908.
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Affiliation(s)
- Amber E Young
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Anna Davies
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | | | - Sara Brookes
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- Cancer Research UK Clinical Trials Unit (CRCTU), Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
| | - Jane M Blazeby
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
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8
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Hwu RS, Keller MS, Spinella PC, Baker D, Shi J, Leonard JC. Identifying potential predictive indicators of massive transfusion in pediatric trauma. TRAUMA-ENGLAND 2018. [DOI: 10.1177/1460408617721729] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- Ruth S Hwu
- Division of Pediatric Emergency Medicine, Washington University School of Medicine, St. Louis, MO, USA
- Division of Pediatric Emergency Medicine, Emory University Atlanta, GA, USA
| | - Martin S Keller
- Division of Pediatric Surgery, St. Louis Children’s Hospital, St. Louis, MO, USA
| | - Philip C Spinella
- Division of Critical Care Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - David Baker
- St. Louis Children’s Hospital, St. Louis, MO, USA
| | - Junxin Shi
- Nationwide Children’s Hospital, Columbus, OH, USA
| | - Julie C Leonard
- Division of Pediatric Emergency Medicine, Washington University School of Medicine, St. Louis, MO, USA
- Division of Pediatric Emergency Medicine, Nationwide Children’s Hospital, Columbus, OH, USA
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Evaluation of adenosine, lidocaine, and magnesium for enhancement of platelet function during storage. J Trauma Acute Care Surg 2017; 83:S9-S15. [PMID: 28383470 DOI: 10.1097/ta.0000000000001479] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND The combination of adenosine, lidocaine, and magnesium (Mg2+) (ALM) has demonstrated cardioprotective and resuscitative properties in models of cardiac arrest and hemorrhagic shock that are linked to reduction of metabolic demand. Platelets play a key role in resuscitation strategies for ATC but suffer from loss of function following storage in part owing to mitochondrial exhaustion. This study evaluates whether ALM also demonstrates protective properties in stored platelet preparations. METHODS Platelets were tested at (baseline, Day 5, Day 10, and Day 15) at 22°C (room temperature) or 4°C in 100% plasma and platelet additive solution. Adenosine, lidocaine, and magnesium treatment or its individual components (A, L, M, or combinations) were added directly to the minibags at baseline for storage. Measurements consisted of blood gas and chemistry analyses, thromboelastography, impedance aggregometry, and flow cytometry. RESULTS Blood gas and cell analysis, as well as flow cytometry measures, demonstrated only differences between temperature groups starting at Day 5 (p < 0.05) and no differences between treatment groups. Aggregation response to collagen (A only, M only, and ALM high dose) and thrombin receptor activation peptide (A + M, and ALM high dose) was significantly greater at Day 5 compared to respective 4°C (100% plasma) controls (p < 0.05). Thromboelastography analysis revealed significant preservation of all measures (reaction time, maximum amplitude, and angle) at Day 15 for 4°C-stored samples in 100% plasma in both controls (no ALM) and ALM treatment compared to room temperature (p < 0.05); no differences were observed between the ALM and control groups. CONCLUSIONS The mechanism of ALM's protective effect remains unclear; key cellular functions may be required to provide protection. In this study, improvements in collagen and thrombin receptor activation peptide aggregation were seen when compared to 4°C-stored plasma samples although no improvements were seen when compared to 4°C-stored platelet additive solution platelets. LEVEL OF EVIDENCE Therapeutic/care management, level II.
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10
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Dale EL, Hultman CS. Patient Safety in Burn Care: Application of Evidence-based Medicine to Improve Outcomes. Clin Plast Surg 2017; 44:611-618. [PMID: 28576250 DOI: 10.1016/j.cps.2017.02.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
This article reviews 5 areas in burn care that increasingly use evidence-based medicine to optimize quality and safety: resuscitation protocols, transfusion practices, vascular access, venous thromboembolic prophylaxis, and rational use of antibiotics.
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Affiliation(s)
- Elizabeth L Dale
- Division of Plastic/Burn Surgery, Shriners Hospital for Children, University of Cincinnati, 231 Albert Sabin Way, Academic Health Center, Cincinnati, OH 45267-0513, USA.
| | - Charles Scott Hultman
- Division of Plastic Surgery, Department of Surgery, University of North Carolina School of Medicine, Chapel Hill, NC, USA
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11
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Nonclinical Evaluation of the New Topical Hemostatic Agent TT-173 for Skin Grafting Procedures. J Burn Care Res 2017; 38:e824-e833. [PMID: 28157787 DOI: 10.1097/bcr.0000000000000497] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Blood loss during grafting surgery represents a major concern of this procedure and the development of hemostatic agents for this indication is highly desirable. TT-173 is the first biologically active treatment based on tissue factor instead of thrombin. This study sought to investigate the efficacy, systemic absorption, and toxicology of TT-173 in animal models to support clinical evaluation of the product in donor sites of patients subjected to skin grafting. Procoagulant efficacy of 148 μg of TT-173 was evaluated in pigs in presence and absence of anticoagulant treatment with unfractioned heparin. Systemic absorption was quantified and characterized in rats subjected to severe skin lesions with affectation of muscular plane using TT-173 radiolabeled with I. The same animal model was used to test the toxicology of a dose of 80 μg of the product. Application of TT-173 significantly reduced the bleeding time of donor sites, even under anticoagulant treatment. Systemic absorption was low; it was excreted through urine and did not concentrate in organs such as liver, lung, or spleen suggesting that the absorbed dose could correspond to degradation fragments without procoagulant activity. Finally, a dose of 80 μg of TT-173 did not cause analytical disturbances suggestive of intravascular coagulation or any other adverse reaction. Nonclinical data obtained suggest that TT-173 could be useful to reduce the blood loss associated to burns treatment and support the clinical evaluation of the product in donor sites of patients subjected to skin grafting.
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Hwu RS, Spinella PC, Keller MS, Baker D, Wallendorf M, Leonard JC. The effect of massive transfusion protocol implementation on pediatric trauma care. Transfusion 2016; 56:2712-2719. [PMID: 27572499 DOI: 10.1111/trf.13781] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2016] [Revised: 07/07/2016] [Accepted: 07/15/2016] [Indexed: 01/26/2023]
Abstract
BACKGROUND Massive transfusion protocols (MTPs) to address hemorrhage are understudied in children. The objective was to determine the effect of MTP implementation on outcomes of injured children. STUDY DESIGN AND METHODS This was a retrospective comparison of injured children before and after MTP implementation for children less than 18 years old who presented in 2005 to 2014 and received red blood cells (RBCs) within 24 hours of arrival. Children were divided into groups based on pre-/post-MTP implementation and subgrouped based on receipt of massive transfusion (≥40 mL/kg RBCs or ≥80 mL/kg total blood products at 24 hr from arrival). The primary outcome was in-hospital mortality and secondary outcomes were total blood product use, intensive care unit/ventilator/pressor-free days, composite morbidity, and Glasgow Outcome Score. RESULTS A total of 11,995 children presented for trauma care over 9 years; 235 received RBCs. A total of 120 were in the pre-MTP group and 115 in the post-MTP, of whom 26 and 17 received massive transfusion in the pre- and post-MTP groups, respectively; 11 had MTP activations. Children massively transfused after MTP received mean plasma:RBC and platelet (PLT):RBC ratios greater than 1:1 at both 6 and 24 hours with no significant difference in total admission blood product use. There was no difference in in-hospital mortality between pre- and post-MTP groups (24% vs. 19%) or massive transfusion subgroups (54% vs. 47%). There were no differences in secondary outcomes. CONCLUSIONS While we were not able to show improvements in outcome, MTP implementation led to higher plasma and PLT:RBC ratios without an associated change in blood product use or composite morbidity.
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Affiliation(s)
- Ruth S Hwu
- St Louis Children's Hospital.,Emory University School of Medicine, Atlanta, Georgia
| | - Philip C Spinella
- St Louis Children's Hospital.,Washington University in St Louis School of Medicine, St Louis, Missouri
| | - Martin S Keller
- St Louis Children's Hospital.,Washington University in St Louis School of Medicine, St Louis, Missouri
| | | | - Michael Wallendorf
- Washington University in St Louis School of Medicine, St Louis, Missouri
| | - Julie C Leonard
- St Louis Children's Hospital.,Washington University in St Louis School of Medicine, St Louis, Missouri.,Nationwide Children's Hospital, Columbus, Ohio
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Wu G, Zhuang M, Fan X, Hong X, Wang K, Wang H, Chen Z, Sun Y, Xia Z. Blood transfusions in severe burn patients: Epidemiology and predictive factors. Burns 2016; 42:1721-1727. [PMID: 27576934 DOI: 10.1016/j.burns.2016.06.002] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2015] [Revised: 03/20/2016] [Accepted: 06/02/2016] [Indexed: 11/17/2022]
Abstract
BACKGROUND Blood is a vital resource commonly used in burn patients; however, description of blood transfusions in severe burns is limited. The purpose of this study was to describe the epidemiology of blood transfusions and determine factors associated with increased transfusion quantity. METHODS This is a retrospective study of total 133 patients with >40% total body surface area (TBSA) burns admitted to the burn center of Changhai hospital from January 2008 to December 2013. The study characterized blood transfusions in severe burn patients. Univariate and Multivariate regression analyses were used to evaluate the association of clinical variables with blood transfusions. RESULTS The overall transfusion rate was 97.7% (130 of 133). The median amount of total blood (RBC and plasma), RBC and plasma transfusions was 54 units (Interquartile range (IQR), 20-84), 19 units (IQR, 4-37.8) and 28.5 units (IQR, 14.8-51.8), respectively. The number of RBC transfusion in and outside operation room was 7 (0, 14) and 11 (2, 20) units, and the number of plasma was 6 (0.5, 12) and 21 (11.5, 39.3) units. A median of one unit of blood was transfused per TBSA and an average of 4 units per operation was given in the series. The consumption of plasma is higher than that of RBC. On multivariate regression analysis, age, full-thickness TBSA and number of operations were significant independent predictors associated with the number of RBC transfusion, and coagulopathy and ICU length showed a trend toward RBC consumption. Predictors for increased plasma transfusion were female, high full-thickness TBSA burn and more operations. CONCLUSIONS Severe burn patients received an ample volume of blood transfusions. Fully understanding of predictors of blood transfusions will allow physicians to better optimize burn patients during hospitalization in an effort to use blood appropriately.
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Affiliation(s)
- Guosheng Wu
- Department of Burn Surgery, Changhai Hospital, The Second Military Medical University, Shanghai, People's Republic of China.
| | - Mingzhu Zhuang
- Department of Blood Transfusion, Changhai Hospital, The Second Military Medical University, Shanghai, People's Republic of China.
| | - Xiaoming Fan
- Department of Burn Surgery, Changhai Hospital, The Second Military Medical University, Shanghai, People's Republic of China.
| | - Xudong Hong
- Department of Burn Surgery, Changhai Hospital, The Second Military Medical University, Shanghai, People's Republic of China.
| | - Kangan Wang
- Department of Burn Surgery, Changhai Hospital, The Second Military Medical University, Shanghai, People's Republic of China.
| | - He Wang
- Department of Burn Surgery, Changhai Hospital, The Second Military Medical University, Shanghai, People's Republic of China.
| | - Zhengli Chen
- Department of Burn Surgery, Changhai Hospital, The Second Military Medical University, Shanghai, People's Republic of China.
| | - Yu Sun
- Department of Burn Surgery, Changhai Hospital, The Second Military Medical University, Shanghai, People's Republic of China.
| | - Zhaofan Xia
- Department of Burn Surgery, Changhai Hospital, The Second Military Medical University, Shanghai, People's Republic of China.
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Hwu RS, Keller MS, Spinella PC, Baker D, Tao Y, Leonard JC. Potential effects of high plasma to red blood cell ratio transfusion in pediatric trauma. TRAUMA-ENGLAND 2016. [DOI: 10.1177/1460408616645613] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective High ratio of plasma to red blood cells during massive transfusion is associated with improved survival of traumatic injuries in adults, but this has not been demonstrated in children. Our objective was to compare the outcome of children who received high (≥1:2) versus low (<1:2) plasma: red blood cells (P:R) ratios at 24 h from injury. Methods We conducted a retrospective chart review of children <18 years of age who presented to the emergency department over a 7-year period and received massive transfusion (≥40 ml/kg red blood cells or ≥80 ml/kg total blood products in 24 h). Our primary outcome of interest was in-hospital mortality. Results We identified 38 children who received massive transfusion. There was no significant difference in in-hospital mortality (45.8% vs. 64.3%) between the high (n = 24, median ratio 1:1.1) and low P:R ratio (n = 14, median 1:3.2) groups. In subset analyses, there was reduced mortality for high P:R patients with BIG score ≥24 (69.2% vs. 100%) and those taken to the operating room within 6 h of arrival (21.4% vs. 60.0%), respectively ( p < 0.05). There was a trend for improved survival in high P:R patients without severe traumatic brain injury (TBI) (0% vs. 40.0%). Conclusions This study suggests that high P:R transfusion may improve in-hospital survival of injured children at high risk of mortality and in children without severe TBI, supporting the need for large, multi-center studies.
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Affiliation(s)
- Ruth S Hwu
- Division of Pediatric Emergency Medicine, Emory University School of Medicine, USA
| | - Martin S Keller
- Division of Pediatric Surgery, St. Louis Children’s Hospital, USA
| | - Philip C Spinella
- Division of Critical Care Medicine, Washington University School of Medicine, USA
| | - David Baker
- Blood Bank Supervisor, St. Louis Children’s Hospital, USA
| | - Yu Tao
- Division of Biostatistics, Washington University School of Medicine in St. Louis, USA
| | - Julie C Leonard
- Division of Pediatric Emergency Medicine, Nationwide Children's Hospital, USA
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Henschke A, Lee R, Delaney A. Burns management in ICU: Quality of the evidence: A systematic review. Burns 2016; 42:1173-82. [PMID: 27268108 DOI: 10.1016/j.burns.2016.02.025] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2015] [Accepted: 02/23/2016] [Indexed: 11/30/2022]
Abstract
BACKGROUND The objective of this study was to assess the quality of readily available evidence regarding critical care aspects of the management of patients with severe burn injuries. METHOD PUBMED, EMBASE, Cochrane Databases and bibliographies of included studies and burns review articles were searched from inception of databases to end of February 2015. We included systematic reviews, randomised controlled trials (RCTs) and cohort studies with concurrent controls on the topics of (a) fluid resuscitation (b) analgesia (c) haemodynamic monitoring and targets (d) ventilation (e) blood transfusion. The quality of the studies was assessed using validated tools. RESULTS Fifty six studies fulfilled the inclusion criteria. Twenty three on fluid resuscitation, 22 on analgesia, nine on haemodynamic monitoring and two on ventilation. No studies were found on blood transfusion practice. There were ten systematic reviews, 38 RCTs and eight cohort studies with concurrent controls. The majority of studies were single centre trials with small numbers of patients, surrogate outcomes and high risk of bias. CONCLUSIONS There is very little high quality evidence to guide clinical practice in early management of the severely burnt patient. Eleven of 56 studies found in our search of critical care topics were of good methodological quality with low risk of bias.
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Affiliation(s)
- Alice Henschke
- Intensive Care Unit, Royal Prince Alfred Hospital, Camperdown, NSW 2050, Australia.
| | - Richard Lee
- Malcolm Fisher Department of Intensive Care Medicine, Royal North Shore Hospital, St Leonards, NSW 2065, Australia; Northern Clinical School, Sydney Medical School, University of Sydney, Sydney, Australia.
| | - Anthony Delaney
- Malcolm Fisher Department of Intensive Care Medicine, Royal North Shore Hospital, St Leonards, NSW 2065, Australia; Northern Clinical School, Sydney Medical School, University of Sydney, Sydney, Australia
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Glas GJ, Levi M, Schultz MJ. Coagulopathy and its management in patients with severe burns. J Thromb Haemost 2016; 14:865-74. [PMID: 26854881 DOI: 10.1111/jth.13283] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2015] [Accepted: 01/26/2016] [Indexed: 11/30/2022]
Abstract
Severe burn injury is associated with systemic coagulopathy. The changes in coagulation described in patients with severe burns resemble those found patients with sepsis or major trauma. Coagulopathy in patients with severe burns is characterized by procoagulant changes, and impaired fibrinolytic and natural anticoagulation systems. Both the timing of onset and the severity of hemostatic derangements are related to the severity of the burn. The exact pathophysiology and time course of coagulopathy are uncertain, but, at least in part, result from hemodilution and hypothermia. As the occurrence of coagulopathy in patients with severe burns is associated with increased comorbidity and mortality, coagulopathy could be seen as a potential therapeutic target. Clear guidelines for the treatment of coagulopathy in patients with severe burns are lacking, but supportive measures and targeted treatments have been proposed. Supportive measures are aimed at avoiding preventable triggers such as tissue hypoperfusion caused by shock, or hemodilution and hypothermia following the usually aggressive fluid resuscitation in these patients. Suggested targeted treatments that could benefit patients with severe burns include systemic treatment with anticoagulants, but sufficient randomized controlled trial evidence is lacking.
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Affiliation(s)
- G J Glas
- Laboratory of Experimental Intensive Care and Anesthesiology (L.E.I.C.A), Academic Medical Center, Amsterdam, the Netherlands
| | - M Levi
- Department of Medicine, Academic Medical Center, Amsterdam, the Netherlands
| | - M J Schultz
- Laboratory of Experimental Intensive Care and Anesthesiology (L.E.I.C.A), Academic Medical Center, Amsterdam, the Netherlands
- Department of Intensive Care, Academic Medical Center, Amsterdam, the Netherlands
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Bynum JA, Adam Meledeo M, Getz TM, Rodriguez AC, Aden JK, Cap AP, Pidcoke HF. Bioenergetic profiling of platelet mitochondria during storage: 4°C storage extends platelet mitochondrial function and viability. Transfusion 2016; 56 Suppl 1:S76-84. [DOI: 10.1111/trf.13337] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
- James A. Bynum
- US Army Institute of Surgical Research; JBSA-Fort Sam Houston Texas
| | - M. Adam Meledeo
- US Army Institute of Surgical Research; JBSA-Fort Sam Houston Texas
| | - Todd M. Getz
- US Army Institute of Surgical Research; JBSA-Fort Sam Houston Texas
| | | | - James K. Aden
- US Army Institute of Surgical Research; JBSA-Fort Sam Houston Texas
| | - Andrew P. Cap
- US Army Institute of Surgical Research; JBSA-Fort Sam Houston Texas
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18
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Horst J, Leonard JC, Vogel A, Jacobs R, Spinella PC. A survey of US and Canadian hospitals' paediatric massive transfusion protocol policies. Transfus Med 2016; 26:49-56. [PMID: 26833998 DOI: 10.1111/tme.12277] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2015] [Revised: 11/25/2015] [Accepted: 07/23/2015] [Indexed: 12/14/2022]
Abstract
BACKGROUND Trauma is the leading cause of death in children >1 year of age, with haemorrhage as the most common cause of medically preventable deaths. While massive transfusion protocols (MTPs) have been investigated and used in adults to reduce death from haemorrhage, there are a paucity of published data on MTP practices and outcomes in children. This study aimed to survey current MTP policies and the frequency of activation at paediatric care centres. STUDY DESIGN AND METHODS We conducted a survey of MTPs at hospitals in the United States and Canada, including children's general hospitals, children's specialty hospitals and children's units in general hospitals. We collected information on how the MTP is activated, what therapeutics are given, frequency of its use, and how it is audited for compliance. RESULTS Forty-six survey responses were analysed. Physician discretion was the most common activation criteria (89%). A majority of sites (78%) targeted a 'high' (≥1 : 2) ratio of plasma to red blood cells (RBC). Fifteen percent of sites use antifibrinolytics in their MTPs. Eighty nine percent of sites have type-O RBC units and 48% of sites had thawed plasma units stored in an immediately available location. CONCLUSION There is a wide variation in MTPs among paediatric hospitals with regard to both activation criteria and products administered. This underscores the need for future prospective studies to determine the most effective resuscitation methods for paediatric populations to improve outcomes and therapeutic safety for massive bleeding.
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Affiliation(s)
- J Horst
- Division of Emergency Medicine, Department of Paediatrics, Washington University School of Medicine, St Louis, Missouri, USA
| | - J C Leonard
- Section of Emergency Medicine, Department of Paediatrics, Nationwide Children's Hospital and the Ohio State University, Columbus, Ohio, USA
| | - A Vogel
- Division of Paediatric Surgery, Department of Surgery, Washington University School of Medicine, St Louis, Missouri, USA
| | - R Jacobs
- Division of Critical Care, Department of Paediatrics, Washington University School of Medicine, St Louis, Missouri, USA
| | - P C Spinella
- Division of Critical Care, Department of Paediatrics, Washington University School of Medicine, St Louis, Missouri, USA
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López-López J, Jané-Salas E, Santamaría A, González-Navarro B, Arranz-Obispo C, López R, Miquel I, Arias B, Sánchez P, Rincón E, Rodríguez JR, Rojas S, Murat J. TETIS study: evaluation of new topical hemostatic agent TT-173 in tooth extraction. Clin Oral Investig 2015; 20:1055-63. [PMID: 26374745 DOI: 10.1007/s00784-015-1586-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2014] [Accepted: 08/30/2015] [Indexed: 01/14/2023]
Affiliation(s)
- José López-López
- Department of Odontostomatology, School of Dentistry-Hospital Odontológico Universidad de Barcelona, Barcelona University, C/Feixa Llarga s/n, 08907, Hospitalet de Llobregat, Barcelona, Spain.
| | - Enric Jané-Salas
- Department of Odontostomatology, School of Dentistry-Hospital Odontológico Universidad de Barcelona, Barcelona University, C/Feixa Llarga s/n, 08907, Hospitalet de Llobregat, Barcelona, Spain
| | - Amparo Santamaría
- Hemostasia and Thrombosis Unit, Department of Hematology, Hospital Universitari Vall d'Hebrón, Barcelona, Spain
| | - Beatriz González-Navarro
- Department of Odontostomatology, School of Dentistry-Hospital Odontológico Universidad de Barcelona, Barcelona University, C/Feixa Llarga s/n, 08907, Hospitalet de Llobregat, Barcelona, Spain
| | - Carlos Arranz-Obispo
- Department of Odontostomatology, School of Dentistry-Hospital Odontológico Universidad de Barcelona, Barcelona University, C/Feixa Llarga s/n, 08907, Hospitalet de Llobregat, Barcelona, Spain
| | - Ramón López
- S.L. Parque Mediterráneo de la Tecnología, Thombotargets Europe, Castelldefels, Spain
| | - Ignasi Miquel
- S.L. Parque Mediterráneo de la Tecnología, Thombotargets Europe, Castelldefels, Spain
| | - Belén Arias
- S.L. Parque Mediterráneo de la Tecnología, Thombotargets Europe, Castelldefels, Spain
| | - Pilar Sánchez
- S.L. Parque Mediterráneo de la Tecnología, Thombotargets Europe, Castelldefels, Spain
| | - Esther Rincón
- S.L. Parque Mediterráneo de la Tecnología, Thombotargets Europe, Castelldefels, Spain
| | - Juan R Rodríguez
- S.L. Parque Mediterráneo de la Tecnología, Thombotargets Europe, Castelldefels, Spain
| | - Santiago Rojas
- S.L. Parque Mediterráneo de la Tecnología, Thombotargets Europe, Castelldefels, Spain
| | - Jesus Murat
- S.L. Parque Mediterráneo de la Tecnología, Thombotargets Europe, Castelldefels, Spain
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Acute blood loss during burn and soft tissue excisions: An observational study of blood product resuscitation practices and focused review. J Trauma Acute Care Surg 2015; 78:S39-47. [PMID: 26002262 DOI: 10.1097/ta.0000000000000627] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Many military and civilian centers have shifted to a damage-control resuscitation approach, focused on providing oxygen-carrying capacity while simultaneously mitigating coagulopathy with a balanced ratio of platelets and plasma to red blood cells. It is unclear to what degree this strategy is used during burn or soft tissue excision. Here, we characterized blood product transfusion during burn and soft tissue surgery and reviewed the published literature regarding intraoperative coagulation changes. We hypothesized that blood product resuscitation during burn and soft tissue excision is not hemostatic and would be insufficient to address hemorrhage-induced coagulopathy. METHODS Consented adult patients were enrolled into an institutional review board-approved prospective observational study. Number, component type, volume, and age of the blood products transfused were recorded during burn excision/grafting or soft tissue debridement. Component bags (packed red blood cells, fresh frozen plasma, platelets, and cryoprecipitate) were collected, and the remaining sample was harvested from the bag and tubing. Aliquots of 1/1,000th the original volume of each blood product were obtained and combined, producing an amalgam sample containing the same ratio of product transfused. Platelet count, rotational thromboelastometry, and impedance aggregometry were measured. Significance was set at p < 0.05. RESULTS Amalgamated transfusate samples produced abnormally weak clots (p ≤ 0.001) particularly if they did not contain platelets. Clot strength (48.8 [2.6] mm; reference range, 49-71 mm) for platelet-containing amalgams was below the lower limit of the reference range despite platelet-red blood cell ratios greater than 1:1. Platelet aggregation was abnormally low; transfused platelets were functionally inferior to native platelets. CONCLUSION Our study and focused review demonstrate that further work is needed to fully understand the needs of patients undergoing tissue excision. The three studies reviewed and the results of our observational work suggest that coagulopathy and thrombocytopenia may contribute to intraoperative hemorrhage. Blood product resuscitation during burn and soft tissue excision is not hemostatic. LEVEL OF EVIDENCE Epidemiologic study, level V.
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