Administration of fibrinogen concentrate in exsanguinating trauma patients is associated with improved survival at 6 hours but not at discharge

Long-Term Safety Analysis of a Fibrinogen Concentrate (RiaSTAP®/Haemocomplettan® P)

Fibrinogen concentrate treatment is recommended for acute bleeding episodes in adult and pediatric patients with congenital and acquired fibrinogen deficiency. Previous studies have reported a low risk of thromboembolic events (TEEs) with fibrinogen concentrate use; however, the post-treatment TEE risk remains a concern. A retrospective evaluation of RiaSTAP®/Haemocomplettan® P (CSL Behring, Marburg, Germany) post-marketing data was performed (January 1986-June 2022), complemented by a literature review of published studies. Approximately 7.45 million grams of fibrinogen concentrate was administered during the review period. Adverse drug reactions (ADRs) were reported in 337 patients, and 81 (24.0%) of these patients experienced possible TEEs, including 14/81 (17.3%) who experienced fatal outcomes. Risk factors and the administration of other coagulation products existed in most cases, providing alternative explanations. The literature review identified 52 high-ranking studies with fibrinogen concentrate across various clinical areas, including 26 randomized controlled trials. Overall, a higher number of comparative studies showed lower rates of ADRs and/or TEEs in the fibrinogen group versus the comparison group(s) compared with those that reported higher rates or no differences between groups. Post-marketing data and clinical studies demonstrate a low rate of ADRs, including TEEs, with fibrinogen concentrate treatment. These findings suggest a favorable safety profile of fibrinogen concentrate, placing it among the first-line treatments effective for managing intraoperative hemostatic bleeding.

Dynamic structures and emerging trends in the management of major trauma: A bibliometric analysis of publications between 2012 and 2021

Objective

Major trauma is currently a global public health issue with a massive impact on health at both the individual and population levels. However, there are limited bibliometric analyses on the management of major trauma. Thus, in this study we aimed to identify global research trends, dynamic structures, and scientific frontiers in the management of major trauma between 2012 and 2021.

Methods

We searched the Web of Science Core Collection to access articles and reviews concerning the management of major traumas and conducted a bibliometric analysis using CiteSpace.

Results

Overall, 2,585 studies were screened and published by 403 institutions from 110 countries/regions. The most productive country and institution in this field of research were the USA and Monash University, respectively. Rolf Lefering was the most prolific researcher and Holcomb JB had the most co-citations. Injury published the highest number of articles, and the Journal of Trauma was the most co-cited journal. A dual-map overlay of the literature showed that the articles of most publications were confined to the areas of medicine/medical/clinical and neurology/sports/ophthalmology. Document clustering indicated severe traumatic brain injury, traumatic coagulopathy, and resuscitative endovascular balloon occlusion as the recent hot topics. The most recent burst keywords were "trauma management," "neurocritical care," "injury severity," and "emergency medical services."

Conclusion

The dynamic structures and emerging trends in the management of major trauma were extensively analyzed using CiteSpace, a visualization software. Based on the analysis, the following research hotspots emerged: management of severe traumatic brain injury and massive hemorrhage, neurocritical care, injury severity, and emergency medical service. Our findings provide pertinent information for future research and contribute toward policy making in this field.

Cryoprecipitate use during massive transfusion: A propensity score analysis

INTRODUCTION

Cryoprecipitate is frequently administered as an adjunct to balanced transfusion in the setting of traumatic hemorrhage. However, civilian studies have not demonstrated a clear survival advantage, and prior observational studies noted selection bias when analyzing cryoprecipitate use. Additionally, due to the logistics involved in cryoprecipitate administration, it is inconsistently implemented alongside standardized massive transfusion protocols. This study aims to evaluate the effects of early cryoprecipitate administration on inpatient mortality in the setting of massive transfusion for exsanguinating trauma and to use propensity score analysis to minimize selection bias.

METHODS

The registry of an urban level 1 trauma center was queried for adult patients who received at least 6 units of packed red blood cells within 4 h of presentation. Univariate analysis, multiple logistic regression, and propensity score matching were performed.

RESULTS

562 patients were identified. Patients with lower median RTS (6.86 (IQR 4.09-7.84) vs 7.6 (IQR 5.97-7.84), P<0.01), decreased Glasgow coma scale (12 (IQR 4-15) vs 15 (IQR 10-15), P<0.01), and increased lactate (7.5 (IQR 4.3-10.2) vs 4.9 (IQR 3.1-7.2), P<0.01) were more commonly administered cryoprecipitate. Mortality was greater among those who received cryoprecipitate (40.2% vs 23.7%, p<0.01) on univariate analysis. Neither multiple logistic regression (OR 0.917; 95% confidence interval 0.462-1.822; p = 0.805) nor propensity score matching (average treatment effect on the treated 2.3%, p = 0.77) revealed that cryoprecipitate administration was associated with a difference in inpatient mortality.

CONCLUSIONS

Patients receiving cryoprecipitate within 4 h of presentation were more severely injured at presentation and had increased inpatient mortality. Multivariable logistic regression and propensity score analysis failed to show that early administration of cryoprecipitate was associated with survival benefit for exsanguinating trauma patients. The prospect of definitively assessing the utility of cryoprecipitate in exsanguinating hemorrhage warrants prospective investigation.

Coagulopathy and Traumatic Brain Injury: Overview of New Diagnostic and Therapeutic Strategies

Coagulopathy is a common sequela of traumatic brain injury. Consumptive coagulopathy and secondary hyperfibrinolysis are associated with hypercoagulability. In addition, fibrinolytic pathways are hyperactivated as a result of vascular endothelial cell damage in the injured brain. Coagulation and fibrinolytic parameters change dynamically to reflect these pathologies. Fibrinogen is consumed and degraded after injury, with fibrinogen concentrations at their lowest 3-6 h after injury. Hypercoagulability causes increased fibrinolytic activity, and plasma levels of D-dimer increase immediately after traumatic brain injury, reaching a maximum at 3 h. Owing to disseminated intravascular coagulation in the presence of fibrinolysis, the bleeding tendency is highest within the first 3 h after injury, and often a condition called “talk and deteriorate” occurs. In neurointensive care, it is necessary to measure coagulation and fibrinolytic parameters such as fibrinogen and D-dimer routinely to predict and prevent the development of coagulopathy and its negative outcomes. Currently, the only evidence-based treatment for traumatic brain injury with coagulopathy is tranexamic acid in the subset of patients with mild-to-moderate traumatic brain injury. Coagulation and fibrinolytic parameters should be closely monitored, and treatment should be considered on a patient-by-patient basis.

A Multifunctional, Low-Volume Resuscitation Cocktail Improves Vital Organ Blood Flow and Hemostasis in a Pig Model of Polytrauma with Traumatic Brain Injury

The resuscitation of polytrauma with hemorrhagic shock and traumatic brain injury (TBI) is a balance between permissive hypotension and maintaining vital organ perfusion. There is no current optimal solution. This study tested whether a multifunctional resuscitation cocktail supporting hemostasis and perfusion could mitigate blood loss while improving vital organ blood flow during prolonged limited resuscitation. Anesthetized Yorkshire swine were subjected to fluid percussion TBI, femur fracture, catheter hemorrhage, and aortic tear. Fluid resuscitation was started when lactate concentration reached 3–4 mmol/L. Animals were randomized to one of five groups. All groups received hydroxyethyl starch solution and vasopressin. Low- and high-dose fibrinogen (FBG) groups additionally received 100 and 200 mg/kg FBG, respectively. A third group received TXA and low-dose FBG. Two control groups received albumin, with one also including TXA. Animals were monitored for up to 6 h. Blood loss was decreased and vital organ blood flow was improved with low- and high-dose fibrinogen compared to albumin controls, but survival was not improved. There was no additional benefit of high- vs. low-dose FBG on blood loss or survival. TXA alone decreased blood loss but had no effect on survival, and combining TXA with FBG provided no additional benefit. Pooled analysis of all groups containing fibrinogen vs. albumin controls found improved survival, decreased blood loss, and improved vital organ blood flow with fibrinogen delivery. In conclusion, a low-volume resuscitation cocktail consisting of hydroxyethyl starch, vasopressin, and fibrinogen concentrate improved outcomes compare to controls during limited resuscitation of polytrauma.

Staying on target: Maintaining a balanced resuscitation during damage-control resuscitation improves survival

BACKGROUND

Damage-control resuscitation (DCR) improves survival in severely bleeding patients. However, deviating from balanced transfusion ratios during a resuscitation may limit this benefit. We hypothesized that maintaining a balanced resuscitation during DCR is independently associated with improved survival.

METHODS

This was a secondary analysis of the Prospective Observational Multicenter Major Trauma Transfusion (PROMMTT) study. Patients receiving >3 U of packed red blood cells (PRBCs) during any 1-hour period over the first 6 hours and surviving beyond 30 minutes were included. Linear regression assessed the effect of percent time in a high-ratio range on 24-hour survival. We identified an optimal ratio and percent of time above the target ratio threshold by Youden's index. We compared patients with a 6-hour ratio above the target and above the percent time threshold (on-target) with all others (off-target). Kaplan-Meier analysis assessed the combined effect of blood product ratio and percent time over the target ratio on 24-hour and 30-day survival. Multivariable logistic regression identified factors independently associated with 24-hour and 30-day survival.

RESULTS

Of 1,245 PROMMTT patients, 524 met the inclusion criteria. Optimal targets were plasma/PRBC and platelet/PRBC of 0.75 (3:4) and ≥40% time spent over this threshold. For plasma/PRBC, on-target (n = 213) versus off-target (n = 311) patients were younger (median, 31 years; interquartile range, [22-50] vs. 40 [25-54]; p = 0.002) with similar injury burdens and presenting physiology. Similar patterns were observed for platelet/PRBC on-target (n = 116) and off-target (n = 408) patients. After adjusting for differences, on-target plasma/PRBC patients had significantly improved 24-hour (odds ratio, 2.25; 95% confidence interval, 1.20-4.23) and 30-day (odds ratio, 1.97; 95% confidence interval, 1.14-3.41) survival, while on-target platelet/PRBC patients did not.

CONCLUSION

Maintaining a high ratio of plasma/PRBC during DCR is independently associated with improved survival. Performance improvement efforts and prospective studies should capture time spent in a high-ratio range.

LEVEL OF EVIDENCE

Epidemiologic/prognostic study, level II; Therapeutic, level IV.

Use of fibrinogen concentrate for trauma-related bleeding: A systematic-review and meta-analysis

BACKGROUND

Trauma-induced coagulopathy contributes to significant morbidity and mortality in patients who experience trauma-related bleeding. This study aimed to synthesize the evidence supporting the efficacy and safety of preemptive and goal-directed fibrinogen concentrate (FC) in the management of trauma-related hemorrhage.

METHODS

PubMed, Medline, EMBASE, Web of Science, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, ClinicalTrials.gov, and the WHO International Clinical Trials Registry Platform were systematically searched. All trial designs, except individual case reports, which evaluated the preemptive or goal-directed use of FC for trauma-related bleeding/coagulopathy, in patients older than 16 years, were included in the systematic review. For the included randomized controlled trials comparing FC with control, meta-analysis was performed and a risk-of bias-assessment was completed using the Cochrane Methodology and Preferred Reporting Items Systematic Reviews and Meta-analysis guidelines.

RESULTS

A total of 2,743 studies were identified; 26 were included in the systematic review, and 5 randomized controlled trials (n = 238) were included in the meta-analysis. For the primary outcome of mortality, there was no statistically significant difference between the groups, with 22% and 23.4% in the FC and comparator arms, respectively (risk ratio, 1.00 [95% confidence interval, 0.39 to 2.56]; p = 0.99). In addition, there was no statistical difference between FC and control in packed red blood cell, fresh frozen plasma, or platelet transfusion requirements, and thromboembolic events. Overall, the quality of evidence was graded as low to moderate because of concerns with risk of bias, imprecision, and inconsistency.

CONCLUSION

Further high-quality, adequately powered studies are needed to assess the impact of FC in trauma, with a focus on administration as early as possible from the point of entry into the trauma system of care.

LEVEL OF EVIDENCE

Systematic review and Meta-analysis, level II.

Serum Glucose-To-Potassium Ratio as a Prognostic Predictor for Severe Traumatic Brain Injury

BACKGROUND

Initial management of severe traumatic brain injury is important and includes treatment decision-making and prediction of prognosis. We examined whether biomarkers at admission could be useful prognostic predictors. We focused on electrolytes and blood glucose, which can be measured easily at any facility and for which results can be obtained promptly, before those of other biomarkers, such as D-dimer.

METHODS

All trauma patients with head injuries treated at Chiba Hokusoh Hospital between 2014 and 2017 were investigated. Cases of multiple trauma accompanied by fatal trauma, hemorrhagic shock, or cardiopulmonary arrest, and pediatric cases, were excluded from this study. Blood gas data at the initial hospital visit were reviewed retrospectively. A poor outcome was defined as death during hospitalization or a vegetative state due to head injury. Factors related to poor outcomes were analyzed.

RESULTS

Of the 185 male and 79 female patients studied, 34 had poor outcomes. Poor outcome was significantly correlated with potassium (P = 0.003), glucose (P < 0.001), and glucose-to-potassium ratio (P < 0.001) at arrival. The odds ratio was 4.079 for a glucose-to-potassium ratio of ≥50.

CONCLUSIONS

We evaluated blood gas data at the initial hospital visit, as these results can be obtained more quickly than those of other biomarkers assessed previously. Serum glucose-to-potassium ratio at admission may be a potential predictor of prognosis for severe traumatic brain injury.

The impact of blood product ratio and procoagulant therapy on the development of thromboembolic events in severely injured hemorrhaging trauma patients

INTRODUCTION

Transfusion therapy in hemorrhaging trauma patients is associated with the development of thromboembolic events. It is unknown whether current resuscitation strategies, including large volumes of plasma and early administration of procoagulant therapy, increases this risk.

METHODS

A systematic search was conducted in MEDLINE, PubMed, and Embase. Studies were screened by two independent reviewers and included if they reported on thromboembolic events in patients with severe trauma (injury severity score ≥16) who received transfusion of at least 1 unit of red blood cells. The ratio by which blood products were transfused, as well as use of procoagulant or antifibrinolytic medication, was recorded.

RESULTS

A total of 40 studies with 11.074 bleeding trauma patients were included, in which 1.145 thromboembolic events were reported, yielding an incidence of 10% thromboembolic events. In studies performing routine screening for thromboembolic complications, the incidence ranged from 12% to 23%. The risk of thromboembolic events was increased after administration of tranexamic acid (TXA; odds ratio [OR], 2.6; 95% confidence interval [CI], 1.7-4.1; p < 0.001) and fibrinogen concentrate (OR, 2.1; 95% CI, 1.0-4.2; p = 0.04). Blood product ratio, the use of prothrombin complex concentrate or recombinant factor VIIa were not associated with thromboembolic events.

CONCLUSION

This systematic review identified an incidence of thromboembolic events of 10% in severely injured bleeding trauma patients. The use of TXA and fibrinogen concentrate was associated with the development of thromboembolic complications.

A retrospective register study comparing fibrinogen treated trauma patients with an injury severity score matched control group

BACKGROUND

Fibrinogen concentrate (FC) is frequently used to treat bleeding trauma patients, although the clinical effects are not well known. In this study we describe demographic and clinical outcome data in a cohort of trauma patients receiving FC, compared to a matched control group, who did not receive FC.

METHODS

This retrospective, single-center, observational study included adult trauma patients admitted to a level 1-trauma center in Sweden between January 2013 and June 2015. The study population consisted of patients to whom FC was administrated within 24 h (n = 138, "Fib+"). Patients with Injury Severity Score (ISS) > 49 and/or deceased within 1 h from arrival were excluded (n = 30). Controls (n = 108) were matched for age, gender and ISS ("Fib-"). Primary outcome was mortality (24 h-/30 days-/1 year-), and secondary outcomes were blood transfusions, thromboembolic events and organ failure.

RESULTS

The Fib+ group, despite having similar ISS as Fib-, had higher prevalence of penetrating trauma and lower Glasgow Coma Scale (GCS), indicating more severe injuries. Patients receiving FC had a higher mortality after 24 h/ 30 days/ 1 year compared to controls (Fib-). However, in a propensity score matched model, the differences in mortality between Fib+ and Fib- were no longer significant. Blood transfusions were more common in the Fib+ group, but no difference was observed in thromboembolic events or organ failure. In both groups, low as well as high P-fibrinogen levels at arrival were associated with increased mortality, with the lowest mortality observed at P-fibrinogen values of 2-3 g/l.

CONCLUSIONS

Despite equal ISS, patients receiving FC had a higher mortality compared to the control group, presumably associated to the fact that these patients were bleeding and physiologically deranged on arrival. When applying a propensity score matching approach, the difference in mortality between the groups was no longer significant. No differences were observed between the groups regarding thromboembolic events or organ failure, despite higher transfusion volumes in patients receiving FC.

Early administration of fibrinogen concentrate is associated with improved survival among severe trauma patients: a single-centre propensity score-matched analysis

Background

Fibrinogen plays an important role in haemostasis during the early phase of trauma, and low fibrinogen levels after severe trauma are associated with haemostatic impairment, massive bleeding, and poor outcomes. Aggressive fibrinogen supplementation may improve haemostatic function, as fibrinogen levels deteriorate before other routine coagulation parameters in this setting. Therefore, we evaluated whether early administration of fibrinogen concentrate (FC) was associated with improved survival in severe trauma patients.

Methods

This single-centre retrospective study evaluated patients with severe trauma (injury severity score ≥ 16) who were admitted to our emergency department between January 2010 and July 2018. The exclusion criteria included age < 18 years, cardiac arrest before emergency department arrival, cervical spinal cord injury not caused by a high-energy accident, and severe burn injuries. The FC and control groups included trauma patients who received and did not receive FC within 1 h after emergency department arrival, respectively. Propensity scores were used to balance the two groups based on the trauma and injury severity score (TRISS), heart rate at emergency department admission, and age. The primary outcome was the in-hospital survival rate.

Results

The propensity scoring model had a c-statistic of 0.734, the Hosmer-Lemeshow chi-squared value was 7.036 (degrees of freedom = 8), and the non-significant p value of 0.533 indicated a good model fit. The propensity score matching created 31 matched pairs of patients, who had appropriately balanced characteristics. The FC group had a significantly higher in-hospital survival rate than the control group (log-rank p = 0.013). The FC group also used significantly higher amounts of red blood cells and fresh frozen plasma within 6 h after emergency department admission. However, the two groups had similar transfusion amounts between 6 and 24 h after emergency department admission.

Conclusions

The present study revealed that early FC administration was associated with a favourable survival rate among severe trauma patients. Therefore, FC may be useful for the early management of trauma-induced coagulopathy and may improve outcomes in this setting.

The Effect of Fibrinogen on Blood Loss After Lumbar Surgery: A Double-Blind Randomized Clinical Trial

Background

Spinal surgeries often have a high risk of hemorrhage during and after surgery, thus most patients require blood transfusions and blood products. Fibrinogen is used in different forms to control hemorrhage.

Objectives

The present study aimed to evaluate the outcomes of prophylactic fibrinogen administration in reducing hemorrhage after lumbar surgery.

Methods

This was a randomized clinical trial conducted on 30 patients undergoing lumbar surgery. The levels of fibrinogen, as well as hemoglobin (HB), hematocrit (HCT), prothrombin time (PT), partial thromboplastin time (PTT), and INR, were assessed preoperatively as the baseline values. The patients were divided into two groups: intervention (N = 15) and control (N = 15) groups. The intervention group received 1 g fibrinogen dissolved in 50 cc distilled water with surgical incision and the control group received 50 cc distilled water with the surgical incision. At the end of the operation, the volume of hemorrhage transfused blood products (fresh frozen plasma, packed cell, and platelet) was measured. In addition, at 0, 6, and 24 hours after the end of surgery and transfer to recovery, serum levels of fibrinogen, HB, HCT, INR, PT, PTT, and hemovac drain volume were measured.

Results

The hemorrhage during and after the operation in the control group was significantly higher than that of the intervention group (P < 0.05). There were no significant differences between hemoglobin and serum level of fibrinogen before and after surgery between the two groups. The postoperative hypotension showed no significant difference between the two groups.

Conclusions

The findings showed the effectiveness of fibrinogen in reducing acute hemorrhage. Considering the adverse consequences of hemorrhage and coagulopathy in patients undergoing surgery, using fibrinogen as prophylaxis is recommended in surgeries with high risks of hemorrhage.

Hemostatic Management of Trauma-Induced Coagulopathy

Trauma-induced coagulopathy is a primary factor in many trauma-related fatalities. Management hinges upon rapid diagnosis of coagulation abnormalities and immediate administration of appropriate hemostatic agents. Use of crystalloids and packed red blood cells has traditionally been the core of trauma resuscitation, but current massive transfusion protocols include combination therapy with fresh frozen plasma and predefined ratios of platelets to packed red blood cells, limiting crystalloid administration. Hemostatic agents such as tranexamic acid, prothrombin complex concentrate, fibrinogen concentrate, and, in cases of refractory bleeding, recombinant activated factor VIIa may also be warranted. Goal-directed resuscitation using viscoelastic tools allows specific component-centered therapy based on individual clotting abnormalities that may limit blood product use and thromboembolic risks and may lead to reduced mortality. Because of the complex management of patients with trauma-induced coagulopathy, critical care nurses must be familiar with the pathophysiology, acute diagnostics, and pharmacotherapeutic options used to treat these patients.

The use of fibrinogen concentrate for the management of trauma-related bleeding: a systematic review and meta-analysis

Haemorrhage following injury is associated with significant morbidity and mortality. The role of fibrinogen concentrate in trauma-induced coagulopathy has been the object of intense research in the last 10 years and has been systematically analysed in this review. A systematic search of the literature identified six retrospective studies and one prospective one, involving 1,650 trauma patients. There were no randomised trials. Meta-analysis showed that fibrinogen concentrate has no effect on overall mortality (risk ratio: 1.07, 95% confidence interval: 0.83-1.38). Although the meta-analytic pooling of the current literature evidence suggests no beneficial effect of fibrinogen concentrate in the setting of severe trauma, the quality of data retrieved was poor and the final results of ongoing randomised trials will help to further elucidate the role of fibrinogen concentrate in traumatic bleeding.

Modelling the association between fibrinogen concentration on admission and mortality in patients with massive transfusion after severe trauma: an analysis of a large regional database

Background

The relationship between fibrinogen concentration and traumatic death has been poorly explored after severe trauma. Existing studies analysed this relationship in unselected trauma population, often considering fibrinogen concentration as a categorical variable. The aim of our study was to model the relationship between fibrinogen concentration and in-hospital mortality in severe trauma patients requiring massive transfusion using fibrinogen on admission as a continuous variable.

Methods

We designed a retrospective observational study based on prospectively collected data from 2009 to 2015 in seven French level-I trauma centres. All consecutive patients requiring a transfusion of at least 10 packed red blood cells (RBC) within 24 h were included. To assess the relationship between in-hospital death and fibrinogen concentration on admission, we performed generalized linear and additive models with death as a dependent variable. We also assessed the relationship between fibrinogen concentration below 1.5 g.L^− 1 and potential predictors.

Results

Within the study period, 366 patients were included. A non-linear relationship was found between fibrinogen concentration and death. Graphical modelling of this relationship depicted a negative association between fibrinogen levels and death below a fibrinogen concentration of 1.5 g.L^− 1. Predictors of low fibrinogen concentration (< 1.5 g.L^− 1) were systolic blood pressure, Glasgow coma scale and haemoglobin concentration on admission.

Conclusions

A complex and robust approach for modelling the relationship between fibrinogen and mortality revealed a critical fibrinogen threshold of 1.5 g.L^− 1 for severe trauma patients requiring massive transfusion. This trigger may guide the administration of procoagulant therapies in this context.

Adjuncts to Resuscitation

Damage control resuscitation has been increasingly adopted and practiced over the last decade. The concepts used are not new to this era of medicine but are novel in combination. This chapter will focus on adjuncts to damage control resuscitation (DCR) including massive transfusion protocols, the “other” tenets of damage control resuscitation, hypertonic saline, tranexamic acid, pharmacologic resuscitation, Factor VIIa, and prothrombin complex, and viscoelastic testing.

Damage control resuscitation in patients with severe traumatic hemorrhage: A practice management guideline from the Eastern Association for the Surgery of Trauma

BACKGROUND

The resuscitation of severely injured bleeding patients has evolved into a multi-modal strategy termed damage control resuscitation (DCR). This guideline evaluates several aspects of DCR including the role of massive transfusion (MT) protocols, the optimal target ratio of plasma (PLAS) and platelets (PLT) to red blood cells (RBC) during DCR, and the role of recombinant activated factor VII (rVIIa) and tranexamic acid (TXA).

METHODS

Using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology, a subcommittee of the Practice Management Guidelines (PMG) Section of EAST conducted a systematic review using MEDLINE and EMBASE. Articles in English from1985 through 2015 were considered in evaluating four PICO questions relevant to DCR.

RESULT

A total of 37 studies were identified for analysis, of which 31 met criteria for quantitative meta-analysis. In these studies, mortality decreased with use of an MT/DCR protocol vs. no protocol (OR 0.61, 95% CI 0.43-0.87, p = 0.006) and with a high ratio of PLAS:RBC and PLT:RBC (relatively more PLAS and PLT) vs. a low ratio (OR 0.60, 95% CI 0.46-0.77, p < 0.0001; OR 0.44, 95% CI 0.28-0.71, p = 0.0003). Mortality and blood product use were no different with either rVIIa vs. no rVIIa or with TXA vs. no TXA.

CONCLUSION

DCR can significantly improve outcomes in severely injured bleeding patients. After a review of the best available evidence, we recommend the use of a MT/DCR protocol in hospitals that manage such patients and recommend that the protocol target a high ratio of PLAS and PLT to RBC. This is best achieved by transfusing equal amounts of RBC, PLAS, and PLT during the early, empiric phase of resuscitation. We cannot recommend for or against the use of rVIIa based on the available evidence. Finally, we conditionally recommend the in-hospital use of TXA early in the management of severely injured bleeding patients.

Damage control resuscitation: a practical approach for severely hemorrhagic patients and its effects on trauma surgery

Coagulopathy observed in trauma patients was thought to be a resuscitation-associated phenomenon. The replacement of lost and consumed coagulation factors was the mainstay in the resuscitation of hemorrhagic shock for many decades. Twenty years ago, damage control surgery (DCS) was implemented to challenge the coagulopathy of trauma. It consists of three steps: abbreviated surgery to control the hemorrhage and contamination, resuscitation in the intensive care unit (ICU), and planned re-operation with definitive surgery. The resuscitation strategy of DCS focused on the rapid reversal of acidosis and prevention of hypothermia through the first two steps. However, direct treatment of coagulopathy was not emphasized in DCS.Recently, better understanding of the pathophysiology of coagulopathy in trauma patients has led to the logical opinion that we should directly address this coagulopathy during major trauma resuscitation. Damage control resuscitation (DCR), the strategic approach to the trauma patient who presents in extremis, consists of balanced resuscitation, hemostatic resuscitation, and prevention of acidosis, hypothermia, and hypocalcemia. In balanced resuscitation, fluid administration is restricted and hypotension is allowed until definitive hemostatic measures begin. The administration of blood products consisting of fresh frozen plasma, packed red blood cells, and platelets, the ratio of which resembles whole blood, is recommended early in the resuscitation.DCR strategy is now the most beneficial measure available to address trauma-induced coagulopathy, and it can change the treatment strategy of trauma patients. DCS is now incorporated as a component of DCR. DCR as a structured intervention begins immediately after rapid initial assessment in the emergency room and progresses through the operating theater into the ICU in combination with DCS. By starting from ground zero with the performance of DCS, DCR allows the trauma surgeon to correct the coagulopathy of trauma. The effect of the reversal of coagulopathy in massively hemorrhagic patients may change the operative strategy with DCS.

Acquired hypofibrinogenemia: current perspectives

Acquired hypofibrinogenemia is most frequently caused by hemodilution and consumption of clotting factors. The aggressive replacement of fibrinogen has become one of the core principles of modern management of massive hemorrhage. The best method for determining the patient's fibrinogen level remains controversial, and particularly in acquired dysfibrinogenemia, could have major therapeutic implications depending on which quantification method is chosen. This review introduces the available laboratory and point-of-care methods and discusses the relative advantages and limitations. It also discusses current strategies for the correction of hypofibrinogenemia.

In vitro effects of different sources of fibrinogen supplementation on clot initiation and stability in a model of dilutional coagulopathy

OBJECTIVES

To analyse which fibrinogen source may improve coagulation using an in vitro 33% dilutional coagulopathy model.

BACKGROUND

Uncritical volume resuscitation in the context of trauma haemorrhage contributes to the iatrogenic arm of the acute trauma-induced coagulopathy through dilution and depletion of coagulation factors, with fibrinogen reaching critical levels first.

MATERIALS AND METHODS

By using an experimental model of 33% dilutional coagulopathy, we have analysed which fibrinogen source may exert superior effects on improving haemocoagulative capacities and correcting depleted fibrinogen levels. As fibrinogen sources, we supplemented (i) fresh frozen plasma (FFP), (ii) fibrinogen concentrate low-dose (Fib_low ) and (iii) fibrinogen concentrate high-dose (Fib_high ), the latter both in the presence and absence of additional FXIII.

RESULTS

The dilution was associated with decreased haemoglobin and haematocrit levels. Fibrinogen supplementation with fibrinogen-containing formulations led to increased fibrinogen levels (FFP: 172·2 ± 17·4 mg dL^-1 ; Fib_low : 211·5 ± 20·61 mg dL^-1 ; Fib_high : 255·8 ± 21·4 mg dL^-1 ) than in a diluted-only sample (155·5 ± 19·7 mg dL^-1 ). Extrinsically activated assay with tissue factor (EXTEM) clot formation times, α-angles and maximum clot firmness significantly improved in the groups of Fib_low + FXIII (79 ± 12·2 s; 74·3 ± 2·4°; 62 ± 2·3 mm), Fib_high (70·8 ± 10·6 s; 76·2 ± 2·7°; 64·3 ± 2·3 mm) and Fib_high + FXIII (69·8 ± 11·5 s; 77·5 ± 2·7°; 64·33 ± 2·5 mm) compared with the dilution groups (104·2 ± 19 s; 69·7 ± 2·9°; 56·5 ± 3·1 mm). In contrast, rotational thromboelastometric trace (ROTEM) measures of samples supplemented with FFP largely remained unchanged.

CONCLUSION

Fibrinogen concentrates corrected and improved haemodilution-induced changes in blood clotting in vitro. High-dose fibrinogen supplementation was associated with correction and improvement in clot dynamics and stability.

Patterns of early resuscitation associated with mortality after penetrating injuries

BACKGROUND

Penetrating injuries are rare in European populations so their management represents a particular challenge. The aim was to assess early therapeutic aspects that are associated with favourable outcomes in patients with penetrating trauma.

METHODS

Patients with penetrating injuries documented from 2009 to 2013 in the TraumaRegister DGU® were analysed. Patients with a primary admission and an Injury Severity Score (ISS) of at least 9 were included. The Revised Injury Severity Classification (RISC) II score was used for mortality prediction, and a standardized mortality ratio (SMR) calculated per hospital. Hospitals with favourable outcome (SMR below 1) were compared with those with poor outcome (SMR 1 or more).

RESULTS

A total of 50 centres had favourable outcome (1242 patients; observed mortality rate 15.7 per cent) and 34 centres had poor outcome (918 patients; observed mortality rate 24.4 per cent). Predicted mortality rates according to RISC-II were 20.4 and 20.5 per cent respectively. Mean(s.d.) ISS values were 22(14) versus 21(14) (P = 0.121). Patients in the favourable outcome group had a significantly shorter time before admission to hospital and a lower intubation rate. They received smaller quantities of intravenous fluids on admission to the emergency room, but larger amounts of fresh frozen plasma, and were more likely to receive haemostatic agents. A higher proportion of patients in the favourable outcome group were treated in a level I trauma centre. Independent risk factors for hospital death following penetrating trauma identified by multivariable analysis included gunshot injury mechanism and treatment in non-level I centres.

CONCLUSION

Among penetrating traumas, gunshot injuries pose an independent risk of death. Treatment of penetrating trauma in a level I trauma centre was significantly and independently associated with lower hospital mortality.

Development of a scoring system based on conventional parameters to assess polytrauma patients: PolyTrauma Grading Score (PTGS)

BACKGROUND

The impact of conventional laboratory data to identify polytrauma patients at risk of complications is established. However, it has not been assessed in terms of prognostic accuracy for systemic complications (ARDS, organ failure). We therefore assessed the most predictive parameters for systemic complications and developed a scoring system for early grading of polytrauma patients.

METHODS

A population based trauma registry was used.

INCLUSION CRITERIA

age >16 years, Abbreviated Injury Score (AIS) of the abdomen or chest ≥ 3 points and treatment in an intensive care unit, or Injury Severity Score (ISS) ≥ 16 points. The primary endpoint was hospital mortality. Patients were graded according their risk of death: low risk of death (5-14% mortality), intermediate risk patients (15-39% mortality) and high risk (>40%). Routine clinical and laboratory parameters on admission were assessed to determine their specific relevance to describe the risk profile of the patient. Based on these data, a scoring system for the description of the clinical status was developed. Statistical analysis included uniand multivariate analysis.

RESULTS

11.436 patients were included, the mean ISS was 22.7 ± 11.2 points, 73% were male, and 95.6% had blunt injuries. The most sensitive parameters were found to be the following ones: systolic blood pressure, INR, thrombocytes, base deficit, NISS, packed red blood cells administered. The multivariate analysis revealed the following threshold levels: BP 76-90 mmHg: r = 0.249, OR 1.283: Base deficit 8-10 r = 0.474, OR 1.606; INR 1.4-2 r = 0.160, OR 1.174; NISS 35-39 r = 0.9, OR 2.46; pBRC 3-14: r = 0.671, OR 1.957. The following ranges of score values were found to be associated with different patient status: <6 points: stable patients; 6-11 points: borderline condition; >11 points: unstable patients. When using this score, 80.6% were stable, 14.6% in a borderline condition and 4.8% unstable.

CONCLUSION

We developed a scoring system to discriminate polytrauma patients on admission that are at risk of systemic complications. Systolic blood pressure, INR, thrombocytes, base deficit, NISS, packed red blood cells administered are able to provide a prognosis of patients at risk of posttraumatic complications. Further prospective studies should be performed to verify this new scoring system.

How I use fibrinogen replacement therapy in acquired bleeding

Fibrinogen is a critical protein for hemostasis and clot formation. However, transfusion guidelines have variable recommendations for maintaining fibrinogen levels in bleeding patients. An increasing number of studies support the practice of fibrinogen replacement therapy for acquired coagulopathies, and additional studies are underway. Fibrinogen therapy can be administered with cryoprecipitate or fibrinogen concentrates, and clinical practice varies according to their availability and licensing status. Fibrinogen concentrate therapy has been studied in animal models and clinical trials and supports the critical role of fibrinogen repletion in bleeding patients. Point-of-care testing will have an important role in guiding fibrinogen replacement for hemostatic therapy in clinical settings such as cardiovascular surgery, postpartum hemorrhage, and trauma. Fibrinogen therapy is an important component of a multimodal strategy for the treatment of coagulopathic bleeding.

Safety of fibrinogen concentrate: analysis of more than 27 years of pharmacovigilance data

Fibrinogen concentrate use as a haemostatic agent has been increasingly explored. This study evaluates spontaneous reports of potential adverse drug reactions (ADRs) that occurred during postmarketing pharmacovigilance of Haemocomplettan P/RiaSTAP, and reviews published safety data. This descriptive study analysed postmarketing safety reports recorded in the CSL Behring pharmacovigilance database from January 1986 to December 2013. A literature review of clinical studies published during the same period was performed. Commercial data indicated that 2,611,294 g of fibrinogen concentrate were distributed over the pharmacovigilance period, corresponding to 652,824 standard doses of 4 g each, across a range of clinical settings and indications. A total of 383 ADRs in 106 cases were reported (approximately 1 per 24,600 g or 6,200 standard doses). Events of special interest included possible hypersensitivity reactions in 20 cases (1 per 130,600 g or 32,600 doses), possible thromboembolic events in 28 cases (1 per 93,300 g or 23,300 doses), and suspected virus transmission in 21 cases (1 per 124,300 g or 31,000 doses). One virus transmission case could not be analysed due to insufficient data; for all other cases, a causal relationship was assessed as unlikely due to negative polymerase chain reaction tests and/or alternative explanations. The published literature revealed a similar safety profile. In conclusion, underreporting of ADRs is a known limitation of pharmacovigilance. However, the present assessment indicates that fibrinogen concentrate is administered across a range of indications, with few ADRs and a low thromboembolic event rate. Overall, fibrinogen concentrate showed a promising safety profile.

Risk stratification in trauma and haemorrhagic shock: scoring systems derived from the TraumaRegister DGU(®)

Scoring systems commonly attempt to reduce complex clinical situations into one-dimensional values by objectively valuing and combining a variety of clinical aspects. The aim is to allow for a comparison of selected patients or cohorts. To appreciate the true value of scoring systems in patients with multiple injuries it is necessary to understand the different purposes of quantifying the severity of specific injuries and overall trauma load, being: (1) clinical decision making; (2) triage; (3) planning of trauma systems and resources; (4) epidemiological and clinical research; (5) evaluation of outcome and trauma systems, including quality assessment; and (6) estimation of costs and allocation of resources. For the first two, easy-to estimate scores with immediate availability are necessary, mainly based on initial physiology. More sophisticated scores considering age, gender, injury pattern/severity and more are usually used for research and outcome evaluation, once the diagnostic and therapeutic process has been completed. For score development large numbers of data are necessary and thus, it appears as a logical consequence that large registries as the TraumaRegister DGU(®) of the German Trauma Society (TR-DGU) are used to derive and validate clinical scoring systems. A variety of scoring systems have been derived from this registry, the majority of them with focus on hospital mortality. The most important among these systems is probably the RISC score, which is currently used for quality assessment and outcome adjustment in the annual audit reports. This report summarizes the various scoring systems derived from the TraumaRegister DGU(®) over the recent years.

Fibrinogen concentrate for bleeding--a systematic review

Fibrinogen concentrate as part of treatment protocols increasingly draws attention. Fibrinogen substitution in cases of hypofibrinogenaemia has the potential to reduce bleeding, transfusion requirement and subsequently reduce morbidity and mortality. A systematic search for randomised controlled trials (RCTs) and non-randomised studies investigating fibrinogen concentrate in bleeding patients was conducted up to November 2013. We included 30 studies of 3480 identified (7 RCTs and 23 non-randomised). Seven RCTs included a total of 268 patients (165 adults and 103 paediatric), and all were determined to be of high risk of bias and none reported a significant effect on mortality. Two RCTs found a significant reduction in bleeding and five RCTs found a significant reduction in transfusion requirements. The 23 non-randomised studies included a total of 2825 patients, but only 11 of 23 studies included a control group. Three out of 11 found a reduction in transfusion requirements while mortality was reduced in two and bleeding in one. In the available RCTs, which all have substantial shortcomings, we found a significant reduction in bleeding and transfusions requirements. However, data on mortality were lacking. Weak evidence from RCTs supports the use of fibrinogen concentrate in bleeding patients, primarily in elective cardiac surgery, but a general use of fibrinogen across all settings is only supported by non-randomised studies with serious methodological shortcomings. It seems pre-mature to conclude whether fibrinogen concentrate has a routine role in the management of bleeding and coagulopathic patients. More RCTs are urgently warranted.

Trauma hemostasis and oxygenation research position paper on remote damage control resuscitation: definitions, current practice, and knowledge gaps

The Trauma Hemostasis and Oxygenation Research Network held its third annual Remote Damage Control Resuscitation Symposium in June 2013 in Bergen, Norway. The Trauma Hemostasis and Oxygenation Research Network is a multidisciplinary group of investigators with a common interest in improving outcomes and safety in patients with severe traumatic injury. The network's mission is to reduce the risk of morbidity and mortality from traumatic hemorrhagic shock, in the prehospital phase of resuscitation through research, education, and training. The concept of remote damage control resuscitation is in its infancy, and there is a significant amount of work that needs to be done to improve outcomes for patients with life-threatening bleeding secondary to injury. The prehospital phase of resuscitation is critical in these patients. If shock and coagulopathy can be rapidly identified and minimized before hospital admission, this will very likely reduce morbidity and mortality. This position statement begins to standardize the terms used, provides an acceptable range of therapeutic options, and identifies the major knowledge gaps in the field.

Efficacy and safety of fibrinogen concentrate in trauma patients--a systematic review

PURPOSE

Uncontrolled bleeding is the main preventable cause of death in severe trauma patients. Fibrinogen is the first coagulation factor to decrease during trauma-induced coagulopathy, suggesting that pharmacological replacement might assist early hemorrhage control. Several sources of fibrinogen are available; however, fibrinogen concentrate (FC) is not routinely used in trauma settings in most countries. The aim of this review is to summarize the available literature evaluating the use of FC in the management of severe trauma.

METHODS

Studies reporting the administration of FC in trauma patients published between January 2000 and April 2013 were identified from MEDLINE and from the Cochrane Library.

RESULTS

The systematic review identified 12 articles reporting FC usage in trauma patients: 4 case reports, 7 retrospective studies, and 1 prospective observational study. Three of these were not restricted to trauma patients.

CONCLUSIONS

Despite methodological flaws, some of the available studies suggested that FC administration may be associated with a reduced blood product requirement. Randomized trials are warranted to determine whether FC improves outcomes in prehospital management of trauma patients or whether FC is superior to another source of fibrinogen in early hospital management of trauma patients.

Transfusion strategies and development of acute respiratory distress syndrome in combat casualty care

BACKGROUND

Damage-control resuscitation (DCR) has been advocated to reduce mortality in military and civilian settings. However, DCR and excessive crystalloid resuscitation may be associated with a higher incidence of acute respiratory distress syndrome (ARDS). We sought to examine the impact of resuscitation strategies on ARDS development in combat casualty care.

METHODS

A retrospective review of Joint Theater Trauma Registry data on US combat casualties who received at least 1 U of blood product within the first 24 hours of care was performed, cross-referenced with the cohort receiving mechanical ventilation (n = 1,475). Massive transfusion (MT, ≥10 red blood cells [RBCs] and/or whole blood in 24 hours) and volume/ratios of plasma/RBC, platelet/RBC, and crystalloid/RBC (C/RBC, crystalloid liters/RBC units) were examined using bivariate/multivariate logistic regression and local regression analyses as ARDS risk factors, controlling for age, injury severity, admission systolic blood pressure, and Glasgow Coma Scale (GCS) score.

RESULTS

ARDS was identified in 95 cases (6.4%). MT was required in 550 (37.3%) of the analysis cohort. ARDS was more common in MT (46 of 550, 8.4%) versus no-MT cohort (49 of 925, 5.3%), but mortality was not different (17.4% MT vs. 16.3% no-MT). ARDS patients received significantly increased crystalloid of blood product volumes. Increased crystalloid resuscitation (C/RBC ratio > 1.5) occurred in 479 (32.7%) of 1,464 patients. Unadjusted mortality was significantly increased in the cohort with C/RBC ratio of 1.5 or less compared with those with greater than 1.5 (19.1% vs. 6.3%, p < 0.0001), but no difference in ARDS (6.5% vs. 6.6%) was identified. Platelet/RBC ratio did not impact on ARDS. Increasing plasma (odds ratio, 1.07; p = 0.0062) and crystalloid (odds ratio, 1.04; p = 0.041) volumes were confirmed as independent ARDS risk factors.

CONCLUSION

In modern combat casualty care, increased plasma and crystalloid infusion were identified as independent risk factors for ARDS. These findings support a practice of decreased plasma/crystalloid transfusion in trauma resuscitation once hemorrhage control is established to achieve the mortality benefit of DCR and ARDS prevention.

Estimation of plasma fibrinogen levels based on hemoglobin, base excess and Injury Severity Score upon emergency room admission

INTRODUCTION

Fibrinogen plays a key role in hemostasis and is the first coagulation factor to reach critical levels in massively bleeding trauma patients. Consequently, rapid estimation of plasma fibrinogen (FIB) is essential upon emergency room (ER) admission, but is not part of routine coagulation monitoring in many centers. We investigated the predictive ability of the laboratory parameters hemoglobin (Hb) and base excess (BE) upon admission, as well as the Injury Severity Score (ISS), to estimate FIB in major trauma patients.

METHODS

In this retrospective study, major trauma patients (ISS ≥16) with documented FIB analysis upon ER admission were eligible for inclusion. FIB was correlated with Hb, BE and ISS, alone and in combination, using regression analysis.

RESULTS

A total of 675 patients were enrolled (median ISS 27). FIB upon admission correlated strongly with Hb, BE and ISS. Multiple regression analysis showed that Hb and BE together predicted FIB (adjusted R2 = 0.46; loge(FIB) = 3.567 + 0.223.Hb - 0.007.Hb2 + 0.044.BE), and predictive strength increased when ISS was included (adjusted R2 = 0.51; loge(FIB) = 4.188 + 0.243.Hb - 0.008.Hb2 + 0.036.BE - 0.031.ISS + 0.0003.ISS2). Of all major trauma patients admitted with Hb <12 g/dL, 74% had low (<200 mg/dL) FIB and 54% had critical (<150 mg/dL) FIB. Of patients admitted with Hb <10 g/dL, 89% had low FIB and 73% had critical FIB. These values increased to 93% and 89%, respectively, among patients with an admission Hb <8 g/dL. Sixty-six percent of patients with only a weakly negative BE (<-2 mmol/L) showed low FIB. Of patients with BE <-6 mmol/L upon admission, 81% had low FIB and 63% had critical FIB. The corresponding values for BE <-10 mmol/L were 89% and 78%, respectively.

CONCLUSIONS

Upon ER admission, FIB of major trauma patients shows strong correlation with rapidly obtainable, routine laboratory parameters such as Hb and BE. These two parameters might provide an insightful and rapid tool to identify major trauma patients at risk of acquired hypofibrinogenemia. Early calculation of ISS could further increase the ability to predict FIB in these patients. We propose that FIB can be estimated during the initial phase of trauma care based on bedside tests.