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Sethapati VR, Pham TD, Quach T, Nguyen A, Le J, Cai W, Virk MS. Implementation and early outcomes with Pathogen Reduced Cryoprecipitated Fibrinogen Complex. Am J Clin Pathol 2024:aqae073. [PMID: 38967047 DOI: 10.1093/ajcp/aqae073] [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: 03/29/2024] [Accepted: 05/20/2024] [Indexed: 07/06/2024] Open
Abstract
OBJECTIVES Cryoprecipitated antihemophilic factor (cryo) has been used for fibrinogen replacement in actively bleeding patients, dysfibrinogenemia, and hypofibrinogenemia. Cryo has a shelf life of 4 to 6 hours after thawing and a long turnaround time in issuing the product, posing a major limitation of its use. Recently, the US Food and Drug Administration approved Pathogen Reduced Cryoprecipitated Fibrinogen Complex (INTERCEPT Fibrinogen Complex [IFC]) for the treatment of bleeding associated with fibrinogen deficiency, which can be stored at room temperature and has a shelf life of 5 days after thawing. METHODS We identified locations and specific end users with high cryoprecipitate utilization and waste. We partnered with our blood supplier to use IFC in these locations. We analyzed waste and turnaround time before and after implementation. RESULTS Operative locations had a waste rate that exceeded nonoperative locations (16.7% vs 3%) and were targeted for IFC implementation. IFC was added to our inventory to replace all cryo orders from adult operating rooms, and waste decreased to 2.2% in these locations. Overall waste of cryoprecipitated products across all locations was reduced from 8.8% to 2.4%. The turnaround time for cryoprecipitated products was reduced by 58% from 30.4 minutes to 14.6 minutes. CONCLUSIONS There has been a substantial decrease in waste with improved turnaround time after IFC implementation. This has improved blood bank logistics, improved efficiency of patient care, and reduced costly waste.
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Affiliation(s)
- V Rakesh Sethapati
- Department of Pathology, University of Arkansas for Medical Sciences, Little Rock, AR, US
| | - Tho D Pham
- Stanford Blood Center, Palo Alto, CA, US
| | - Thinh Quach
- Department of Pathology, Stanford University School of Medicine, Stanford, CA, US
| | - Anhthu Nguyen
- Department of Pathology, Stanford University School of Medicine, Stanford, CA, US
| | - Jimmy Le
- Department of Pathology, Stanford University School of Medicine, Stanford, CA, US
| | - Wei Cai
- Department of Pathology, Stanford University School of Medicine, Stanford, CA, US
| | - Mrigender Singh Virk
- Department of Pathology, Stanford University School of Medicine, Stanford, CA, US
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Crochemore T, Görlinger K, Lance MD. Early Goal-Directed Hemostatic Therapy for Severe Acute Bleeding Management in the Intensive Care Unit: A Narrative Review. Anesth Analg 2024; 138:499-513. [PMID: 37977195 PMCID: PMC10852045 DOI: 10.1213/ane.0000000000006756] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/16/2023] [Indexed: 11/19/2023]
Abstract
This is a narrative review of the published evidence for bleeding management in critically ill patients in different clinical settings in the intensive care unit (ICU). We aimed to describe "The Ten Steps" approach to early goal-directed hemostatic therapy (EGDHT) using point-of-care testing (POCT), coagulation factor concentrates, and hemostatic drugs, according to the individual needs of each patient. We searched National Library of Medicine, MEDLINE for publications relevant to management of critical ill bleeding patients in different settings in the ICU. Bibliographies of included articles were also searched to identify additional relevant studies. English-language systematic reviews, meta-analyses, randomized trials, observational studies, and case reports were reviewed. Data related to study methodology, patient population, bleeding management strategy, and clinical outcomes were qualitatively evaluated. According to systematic reviews and meta-analyses, EGDHT guided by viscoelastic testing (VET) has been associated with a reduction in transfusion utilization, improved morbidity and outcome in patients with active bleeding. Furthermore, literature data showed an increased risk of severe adverse events and poor clinical outcomes with inappropriate prophylactic uses of blood components to correct altered conventional coagulation tests (CCTs). Finally, prospective, randomized, controlled trials point to the role of goal-directed fibrinogen substitution to reduce bleeding and the amount of red blood cell (RBC) transfusion with the potential to decrease mortality. In conclusion, severe acute bleeding management in the ICU is still a major challenge for intensive care physicians. The organized and sequential approach to the bleeding patient, guided by POCT allows for rapid and effective bleeding control, through the rational use of blood components and hemostatic drugs, since VET can identify specific coagulation disorders in real time, guiding hemostatic therapy with coagulation factor concentrates and hemostatic drugs with individual goals.
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Affiliation(s)
- Tomaz Crochemore
- From the Department of Critical Care, Hospital Vila Nova Star, São Paulo, Brazil
- Department of Critical Care, Hospital Israelita Albert Einstein, São Paulo, Brazil
- Werfen LATAM, São Paulo, Brazil
| | - Klaus Görlinger
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Essen, Essen, Germany
- TEM Innovations GmbH/Werfen PBM, Munich, Germany
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Curry N, Davenport R, Lucas J, Deary A, Benger J, Edwards A, Evans A, Foley C, Green L, Morris S, Thomas H, Brohi K, Stanworth SJ. The CRYOSTAT2 trial: The rationale and study protocol for a multi-Centre, randomised, controlled trial evaluating the effects of early high-dose cryoprecipitate in adult patients with major trauma haemorrhage requiring major haemorrhage protocol activation. Transfus Med 2023; 33:123-131. [PMID: 36321753 DOI: 10.1111/tme.12932] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Revised: 09/05/2022] [Accepted: 10/03/2022] [Indexed: 11/05/2022]
Abstract
OBJECTIVES To describe the protocol for a multinational randomised, parallel, superiority trial, in which patients were randomised to receive early high-dose cryoprecipitate in addition to standard major haemorrhage protocol (MHP), or Standard MHP alone. BACKGROUND Blood transfusion support for trauma-related major bleeding includes red cells, plasma and platelets. The role of concentrated sources of fibrinogen is less clear and has not been evaluated in large clinical trials. Fibrinogen is a key pro-coagulant factor that is essential for stable clot formation. A pilot trial had demonstrated that it was feasible to deliver cryoprecipitate as a source of fibrinogen within 90 min of admission. METHODS Randomisation was via opaque sealed envelopes held securely in participating Emergency Departments or transfusion laboratories. Early cryoprecipitate, provided as 3 pools (equivalent to 15 single units of cryoprecipitate or 6 g fibrinogen supplementation), was transfused as rapidly as possible, and started within 90 min of admission. Participants in both arms received standard treatment defined in the receiving hospital MHP. The primary outcome measure was all-cause mortality at 28 days. Symptomatic thrombotic events including venous thromboembolism and arterial thrombotic events (myocardial infarction, stroke) were collected from randomisation up to day 28 or discharge from hospital. EQ5D-5Land Glasgow Outcome Score were completed at discharge and 6 months. All analyses will be performed on an intention to treat basis, with per protocol sensitivity analysis. RESULTS The trial opened for recruitment in June 2017 and the final patient completed follow-up in May 2022. DISCUSSION This trial will provide firmer evidence to evaluate the effectiveness and cost-effectiveness of early high-dose cryoprecipitate alongside the standard MHP in major traumatic haemorrhage.
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Affiliation(s)
- Nicola Curry
- Oxford UniversityHospitals NHS Foundation Trust, Nuffield Orthopaedic Hospital, Oxford, UK
| | - Ross Davenport
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, UK
| | - Joanne Lucas
- NHS Blood and Transplant Clinical Trials Unit, Cambridge, UK
| | - Alison Deary
- NHS Blood and Transplant Clinical Trials Unit, Cambridge, UK
| | - Jonathan Benger
- Faculty of Health and Applied Sciences, University of the West of England, Bristol, UK
| | - Antoinette Edwards
- Trauma Audit and Research Network, Salford Royal Hospital, Northern Care Alliance NHS Foundation Trust, Salford, UK
| | - Amy Evans
- NHS Blood and Transplant Clinical Trials Unit, Cambridge, UK
| | - Claire Foley
- NHS Blood and Transplant Clinical Trials Unit, Cambridge, UK
| | - Laura Green
- Blizard Institute, Queen Mary University of London, London, UK
- NHS Blood and Transplant and Bart's Health NHS Trust, London, UK
| | - Stephen Morris
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Helen Thomas
- NHS Blood and Transplant Clinical Trials Unit, Bristol, UK
| | - Karim Brohi
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, UK
| | - Simon J Stanworth
- NHS Blood and Transplant and Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford, UK
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Effect of fibrinogen replacement therapy on bleeding outcomes and 1-year mortality in patients undergoing thoracic aortic surgery: a retrospective cohort study. J Anesth 2023; 37:119-129. [PMID: 36436075 DOI: 10.1007/s00540-022-03140-w] [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: 07/16/2022] [Accepted: 11/14/2022] [Indexed: 11/28/2022]
Abstract
PURPOSE This study aimed to examine the effect of fibrinogen replacement therapy with cryoprecipitate or fibrinogen concentrate on bleeding outcomes and 1-year mortality in patients undergoing thoracic aortic surgery. METHODS We retrospectively studied 439 consecutive patients who underwent thoracic aortic surgery with cardiopulmonary bypass between January 1st, 2010 and December 31st, 2019 and identified patients who received cryoprecipitate or fibrinogen concentrate (the fibrinogen replacement group) and those who did not (the control group). Multivariate analyses were performed to examine the associations of fibrinogen replacement therapy with perioperative major bleeding (i.e., excessive hemorrhage or blood transfusion), re-exploration for bleeding, and 1-year mortality. RESULTS There were 285 patients in the fibrinogen replacement group who received 2.2 ± 1.0 g of concentrated fibrinogen amount and 154 patients in the control group. The incidence of major bleeding in the fibrinogen replacement group was less than that in the control group in patients with fibrinogen level < 150 mg/dL during cardiopulmonary bypass (49.7% versus 74.6%, p = 0.0007, multivariate odds ratio; 0.33, 95% confidence intervals; 0.12-0.91, p = 0.03), but not in patients with fibrinogen level ≥ 150 mg/dL (25.0% versus 29.6%, p = 0.51). No significant difference was found in re-exploration for bleeding (1.0% versus 1.3%, p = 1.00) or 1-year mortality (10.4% versus 5.3%, multivariate Cox proportional-hazard ratio; 1.03, 95% confidence intervals; 0.82-1.31, p = 0.74) between the fibrinogen replacement group and the control group. CONCLUSIONS The results of this study indicate that 2-3 g of fibrinogen replacement reduces the incidence of major bleeding in patients with hypofibrinogenemia during cardiopulmonary bypass in thoracic aortic surgery.
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Niemann M, Otto E, Eder C, Youssef Y, Kaufner L, Märdian S. Coagulopathy management of multiple injured patients - a comprehensive literature review of the European guideline 2019. EFORT Open Rev 2022; 7:710-726. [PMID: 36287131 PMCID: PMC9619392 DOI: 10.1530/eor-22-0054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
The European guideline on the management of trauma-induced major bleeding and coagulopathy summarises the most relevant recommendations for trauma coagulopathy management. The management of trauma-induced major bleeding should interdisciplinary follow algorithms which distinguish between life-threatening and non-life-threatening bleeding. Point-of-care viscoelastic methods (VEM) assist target-controlled haemostatic treatment. Neither conventional coagulation assays nor VEM should delay treatment in life-threatening trauma-induced bleeding. Adjustments may be rational due to local circumstances, including the availability of blood products, pharmaceuticals, and employees.
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Affiliation(s)
- Marcel Niemann
- Charité – Universitätsmedizin Berlin, Center for Musculoskeletal Surgery, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany,Julius Wolff Institute for Biomechanics and Musculoskeletal Regeneration, Berlin Institute of Health at Charité – Universitätsmedizin Berlin, Berlin, Germany,Correspondence should be addressed to M Niemann;
| | - Ellen Otto
- Charité – Universitätsmedizin Berlin, Center for Musculoskeletal Surgery, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany,Julius Wolff Institute for Biomechanics and Musculoskeletal Regeneration, Berlin Institute of Health at Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Christian Eder
- Charité – Universitätsmedizin Berlin, Center for Musculoskeletal Surgery, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Yasmin Youssef
- Department of Orthopaedics, Trauma Surgery and Plastic Surgery, University Hospital Leipzig, Leipzig, Germany
| | - Lutz Kaufner
- Charité – Universitätsmedizin Berlin, Department of Anesthesiology and Intensive Care Medicine, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Sven Märdian
- Charité – Universitätsmedizin Berlin, Center for Musculoskeletal Surgery, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
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Clinical Benefits of Early Concurrent Use of Cryoprecipitate and Plasma Compared With Plasma Only in Bleeding Trauma Patients. Crit Care Med 2022; 50:1477-1485. [PMID: 35759689 DOI: 10.1097/ccm.0000000000005596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The effectiveness of cryoprecipitate (Cryo) in trauma has not been well established; the benefits of Cryo might have been overestimated in previous studies since the difference in the total amount of administered clotting factors was not considered. We aimed to evaluate the benefits of the concurrent use of Cryo in combination with fresh frozen plasma (FFP) for bleeding trauma patients. DESIGN Retrospective cohort study. SETTING The American College of Surgeons Trauma Quality Improvement Program database between 2015 and 2019. PATIENTS Patients who received greater than or equal to 5 units of packed RBCs and at least 1 unit of FFP within the first 4 hours after arrival to a hospital were included and dichotomized according to whether Cryo was used within the first 4 hours of hospital arrival. INTERVENTION None. MEASUREMENTS AND MAIN RESULTS The outcomes of patients treated with Cryo and FFP were compared with those treated with FFP only using propensity score-matching analysis. The dose of administered clotting factors in each group was balanced. The primary outcome was inhospital mortality, and the secondary outcome was the occurrence rate of adverse events. A total of 24,002 patients (Cryo+FFP group: 6,018; FFP only group: 17,984) were eligible for analysis, of whom 4,852 propensity score-matched pairs were generated. Significantly lower inhospital mortality (1,959 patients [40.4%] in the Cryo+FFP group vs 2,142 patients [44.1%] in the FFP only group; odds ratio [OR], 0.86; 95% CI, 0.79-0.93) was observed in the Cryo+FFP group; no significant difference was observed in the occurrence rate of adverse events (1,857 [38.3%] vs 1,875 [38.6%]; OR, 1.02; 95% CI, 0.94-1.10). Several sensitivity analyses showed similar results. CONCLUSIONS Cryo use combined with FFP was significantly associated with reduced mortality in bleeding trauma patients. Future randomized controlled trials are warranted to confirm these results.
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Stanworth SJ, Dowling K, Curry N, Doughty H, Hunt BJ, Fraser L, Narayan S, Smith J, Sullivan I, Green L. A guideline for the haematological management of major haemorrhage: a British Society for Haematology Guideline. Br J Haematol 2022; 198:654-667. [PMID: 35687716 DOI: 10.1111/bjh.18275] [Citation(s) in RCA: 30] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 05/07/2022] [Accepted: 05/09/2022] [Indexed: 12/17/2022]
Affiliation(s)
- Simon J Stanworth
- Transfusion Medicine, NHS Blood and Transplant, Oxford, UK.,Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.,Radcliffe Department of Medicine, University of Oxford, and NIHR Oxford Biomedical Research Centre, Oxford, UK
| | - Kerry Dowling
- Transfusion Laboratory Manager, Southampton University Hospitals NHS Foundation Trust, Southampton, UK
| | - Nikki Curry
- Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.,Radcliffe Department of Medicine, University of Oxford, and NIHR Oxford Biomedical Research Centre, Oxford, UK
| | - Heidi Doughty
- Institute of Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK.,NIHR Surgical Reconstruction and Microbiology Research Centre, Birmingham, UK
| | - Beverley J Hunt
- Department of Haematology, Guy's and St Thomas's Hospital, London, UK
| | - Laura Fraser
- Transfusion Practitioner, NHS Lanarkshire, University Hospital Wishaw, Wishaw, UK.,National Services Scotland/Scottish National Blood Transfusion, Edinburgh, UK
| | - Shruthi Narayan
- Medical director, Serious Hazards of Transfusion, Manchester, UK
| | - Juliet Smith
- Lead Transfusion Practitioner, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Ian Sullivan
- Transfusion Laboratory Manager, Royal Cornwall Hospitals NHS Trust, Truro, UK
| | - Laura Green
- Transfusion Medicine, NHS Blood and Transplant, London, UK.,Barts Health NHS Trust, London, UK.,Blizzard Institute, Queen Mary University of London, London, UK
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8
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Cryoprecipitate use during massive transfusion: A propensity score analysis. Injury 2022; 53:1972-1978. [PMID: 35241286 DOI: 10.1016/j.injury.2022.02.039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Revised: 02/15/2022] [Accepted: 02/17/2022] [Indexed: 02/02/2023]
Abstract
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.
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Curry N. Fibrinogen Replacement in Haemostatic Resuscitation: Dose, Laboratory Targets and Product Choice. Transfus Med Rev 2021; 35:104-107. [PMID: 34565636 DOI: 10.1016/j.tmrv.2021.06.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 06/05/2021] [Accepted: 06/12/2021] [Indexed: 10/20/2022]
Abstract
Fibrinogen is a key coagulation protein that is necessary for the formation of stable clots. Fibrinogen levels have been reported to be one of the first to fall during major haemorrhage reflecting consumption, dilution and fibrinogenolysis. Its role in acquired major haemorrhage, both in relation to the contribution it plays to the coagulopathy of major bleeding that can exacerbate bleeding and how effective fibrinogen supplementation can be at improving clinical outcomes, has received a great deal of attention over the last 10 - 15 years. This commentary focuses on just three of the more recent publications from the last 5 years that provide some of the evidence behind how we can think about fibrinogen as a haemostatic treatment for acquired major haemorrhage and how we can use the laboratory thresholds to guide therapy.
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Affiliation(s)
- Nicola Curry
- Oxford Haemophilia & Thrombosis Centre, Oxford University Hospitals NHS Foundation Trust, and Oxford University, NIHR BRC Haematology Theme, Oxford, UK.
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10
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Abstract
OBJECTIVES The management of acquired coagulopathy in multiple clinical settings frequently involves fibrinogen supplementation. Cryoprecipitate, a multidonor product, is widely used for the treatment of acquired hypofibrinogenemia following massive bleeding, but it has been associated with adverse events. We aimed to review the latest evidence on cryoprecipitate for treatment of bleeding. METHODS We conducted a narrative review of current literature on cryoprecipitate therapy, describing its history, formulations and preparation, and recommended dosing. We also reviewed guideline recommendations on the use of cryoprecipitate in bleeding situations and recent studies on its efficacy and safety. RESULTS Cryoprecipitate has a relatively high fibrinogen content; however, as it is produced by pooling fresh frozen donor plasma, the fibrinogen content per unit can vary considerably. Current guidelines suggest that cryoprecipitate use should be limited to treating hypofibrinogenemia in patients with clinical bleeding. Until recently, cryoprecipitate was deemed unsuitable for pathogen reduction, and potential safety concerns and lack of standardized fibrinogen content have led to some professional bodies recommending that cryoprecipitate is only indicated for the treatment of bleeding and hypofibrinogenemia in perioperative settings where fibrinogen concentrate is not available. While cryoprecipitate is effective in increasing plasma fibrinogen levels, data on its clinical efficacy are limited. CONCLUSIONS There is a lack of robust evidence to support the use of cryoprecipitate in bleeding patients, with few prospective, randomized clinical trials performed to date. Clinical trials in bleeding settings are needed to investigate the safety and efficacy of cryoprecipitate and to determine its optimal use and administration.
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Abstract
PURPOSE OF REVIEW Recent advances in the understanding of the pathophysiological processes associated with traumatic haemorrhage and trauma-induced coagulopathy (TIC) have resulted in improved outcomes for seriously injured trauma patients. However, a significant number of trauma patients still die from haemorrhage. This article reviews the role of fibrinogen in normal haemostasis, the effect of trauma and TIC on fibrinogen levels and current evidence for fibrinogen replacement in the management of traumatic haemorrhage. RECENT FINDINGS Fibrinogen is usually the first factor to reach critically low levels in traumatic haemorrhage and hypofibrinogenaemia after severe trauma is associated with increased risk of massive transfusion and death. It is postulated that the early replacement of fibrinogen in severely injured trauma patients can improve outcomes. There is, however, a paucity of evidence to support this, and in addition, there is little evidence to support or refute the effects of cryoprecipitate or fibrinogen concentrate for fibrinogen replacement. SUMMARY The important role fibrinogen plays in haemostasis and effective clot formation is clear. A number of pilot trials have investigated different strategies for fibrinogen replacement in severe trauma. These trials have formed the basis of several large-scale phase III trials, which, cumulatively will provide a firm evidence base to harmonise worldwide clinical management of severely injured trauma patients with major haemorrhage.
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Substitution of ROTEM FIBTEM A5 for A10 in trauma: an observational study building a case for more rapid analysis of coagulopathy. Eur J Trauma Emerg Surg 2021; 48:1077-1084. [PMID: 34136958 DOI: 10.1007/s00068-021-01652-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Accepted: 03/21/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE Rotational thromboelastometry (ROTEM®) allows guided blood product resuscitation to correct trauma-induced coagulopathy in bleeding trauma patients. FIBTEM amplitude at 10 min (A10) has been widely used to identify hypofibrinogenaemia; locally a threshold of < 11 mm has guided fibrinogen replacement. Amplitude at 5 min (A5) carries an inherent time advantage. The primary aim was to explore the relationship between FIBTEM A5 and A10 in a trauma. Secondary aim was to investigate the use of A5 as a surrogate for A10 within a fibrinogen-replacement algorithm. METHODS Retrospective observational cohort study of arrival ROTEM results from 1539 consecutive trauma patients at a Level 1 trauma centre in Australia. Consistency of agreement between FIBTEM A5 and A10 was assessed. A new fibrinogen replacement threshold was developed for A5 using the A5-A10 bias; this was clinically compared to the existing A10 threshold. RESULTS FIBTEM A5 displayed excellent consistency of agreement with A10. Intraclass correlation coefficient = 0.972 (95% confidence interval [CI] 0.969-0.974). Bias of A5 to A10 was - 1.49 (95% CI 1.43-1.56) mm. 19.34% patients met the original local threshold of A10 < 11 mm; 19.28% patients met the new, bias-adjusted threshold of A5 < 10 mm. CONCLUSION ROTEM FIBTEM A5 reliably predicts A10 in trauma. This further validates use of the A5 result over A10 allowing faster decision-making in time-critical resuscitation of trauma patients. A modification of -1 to the A10 threshold might be appropriate for use with the A5 value in trauma patients.
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Crighton GL, Huisman EJ. Pediatric Fibrinogen PART II-Overview of Indications for Fibrinogen Use in Critically Ill Children. Front Pediatr 2021; 9:647680. [PMID: 33968851 PMCID: PMC8097134 DOI: 10.3389/fped.2021.647680] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Accepted: 03/09/2021] [Indexed: 01/16/2023] Open
Abstract
Bleeding is frequently seen in critically ill children and is associated with increased morbidity and mortality. Fibrinogen is an essential coagulation factor for hemostasis and hypofibrinogenemia is an important risk factor for bleeding in pediatric and adult settings. Cryoprecipitate and fibrinogen concentrate are often given to critically ill children to prevent bleeding and improve fibrinogen levels, especially in the setting of surgery, trauma, leukemia, disseminated intravascular coagulopathy, and liver failure. The theoretical benefit of fibrinogen supplementation to treat hypofibrinogenemia appears obvious, yet the evidence to support fibrinogen supplementation in children is sparce and clinical indications are poorly defined. In addition, it is unknown what the optimal fibrinogen replacement product is in children and neonates or what the targets of treatment should be. As a result, there is considerable variability in practice. In this article we will review the current pediatric and applicable adult literature with regard to the use of fibrinogen replacement in different pediatric critical care contexts. We will discuss the clinical indications for fibrinogen supplementation in critically ill children and the evidence to support their use. We summarize by highlighting current knowledge gaps and areas for future research.
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Affiliation(s)
| | - Elise J. Huisman
- Department of Hematology, Erasmus MC–Sophia Children's Hospital, Rotterdam, Netherlands
- Department of Clinical Chemistry and Blood Transfusion, Erasmus MC, Rotterdam, Netherlands
- Department of Transfusion Medicine, Sanquin Blood Supply, Amsterdam, Netherlands
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Thomas KA, Shea SM, Spinella PC. Effects of pathogen reduction technology and storage duration on the ability of cryoprecipitate to rescue induced coagulopathies in vitro. Transfusion 2021; 61:1943-1954. [PMID: 33755208 PMCID: PMC8252673 DOI: 10.1111/trf.16376] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Revised: 02/19/2021] [Accepted: 03/09/2021] [Indexed: 12/16/2022]
Abstract
Background Fibrinogen concentrates and cryoprecipitate are currently used for fibrinogen supplementation in bleeding patients with dysfibrinogenemia. Both products provide an abundant source of fibrinogen but take greater than 10 min to prepare for administration. Fibrinogen concentrates lack coagulation factors (i.e., factor VIII [FVIII], factor XIII [FXIII], von Willebrand factor [VWF]) important for robust hemostatic function. Cryoprecipitate products contain these factors but have short shelf lives (<6 h). Pathogen reduction (PR) of cryoprecipitate would provide a shelf‐stable immediately available adjunct containing factors important for rescuing hemostatic dysfunction. Study Design and Methods Hemostatic adjunct study products were psoralen‐treated PR‐cryoprecipitated fibrinogen complex (PR‐Cryo FC), cryoprecipitate (Cryo), and fibrinogen concentrates (FibCon). PR‐Cryo FC and Cryo were stored for 10 days at 20–24°C. Adjuncts were added to coagulopathies (dilutional, 3:7 whole blood [WB]:normal saline; or lytic, WB + 75 ng/ml tissue plasminogen activator), and hemostatic function was assessed by rotational thromboelastometry and thrombin generation. Results PR of cryoprecipitate did not reduce levels of FVIII, FXIII, or VWF. PR‐Cryo FC rescued dilutional coagulopathy similarly to Cryo, while generating significantly more thrombin than FibCon, which also rescued dilutional coagulopathy. Storage out to 10 days at 20–24°C did not diminish the hemostatic function of PR‐Cryo FC. Discussion PR‐Cryo FC provides similar and/or improved hemostatic rescue compared to FibCon in dilutional coagulopathies, and this rescue ability is stable over 10 days of storage. In hemorrhaging patients, where every minute delay is associated with a 5% increase in mortality, the immediate availability of PR‐Cryo FC has the potential to improve outcomes.
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Affiliation(s)
- Kimberly A Thomas
- Department of Pediatrics, Division of Critical Care, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Susan M Shea
- Department of Pediatrics, Division of Critical Care, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Philip C Spinella
- Department of Pediatrics, Division of Critical Care, Washington University School of Medicine, St. Louis, Missouri, USA
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15
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Prittie J. The role of cryoprecipitate in human and canine transfusion medicine. J Vet Emerg Crit Care (San Antonio) 2021; 31:204-214. [PMID: 33751762 DOI: 10.1111/vec.13034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Revised: 05/27/2019] [Accepted: 07/02/2019] [Indexed: 12/20/2022]
Abstract
OBJECTIVE To evaluate the current role of cryoprecipitate in human and canine transfusion medicine. DATA SOURCES Human and veterinary scientific reviews and original studies found using PubMed and CAB Abstract search engines were reviewed. HUMAN DATA SYNTHESIS In the human critical care setting, cryoprecipitate is predominantly used for fibrinogen replenishment in bleeding patients with acute traumatic coagulopathy. Other coagulopathic patient cohorts for whom cryoprecipitate is recommended include those undergoing cardiovascular or obstetric procedures or patients bleeding from advanced liver disease. Preferential selection of cryoprecipitate versus fibrinogen concentrate (when available) is currently being investigated. Also a matter of ongoing debate is whether to administer this product as part of a fixed-dose massive hemorrhage protocol or to incorporate it into a goal-directed transfusion algorithm applied to the individual bleeding patient. VETERINARY DATA SYNTHESIS Although there are sporadic reports of the use of cryoprecipitate in dogs with heritable coagulopathies, there are few to no data pertaining to its use in acquired hypofibrinogenemic states. Low fibrinogen in dogs (as in people) has been documented with acute traumatic coagulopathy, advanced liver disease, and disseminated intravascular coagulation. Bleeding secondary to these hypocoagulable states may be amenable to cryoprecipitate therapy. Indications for preferential selection of cryoprecipitate (versus fresh frozen plasma) remain to be determined. CONCLUSIONS In the United States, cryoprecipitate remains the standard of care for fibrinogen replenishment in the bleeding human trauma patient. Its preferential selection for this purpose is the subject of several ongoing human clinical trials. Timely incorporation of cryoprecipitate into the transfusion protocol of the individual bleeding patient with hypofibrinogenemia may conserve blood products, mitigate adverse transfusion-related events, and improve patient outcomes. Cryoprecipitate is readily available, effective, and safe for use in dogs. The role of this blood product in clinical canine patients with acquired coagulopathy remains unknown.
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Affiliation(s)
- Jennifer Prittie
- Department of Emergency and Critical Care, Animal Medical Center, New York, New York
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16
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Winearls J, Wullschleger M, Wake E, McQuilten Z, Reade M, Hurn C, Ryan G, Trout M, Walsham J, Holley A, George S, Dyer W, McCullough J, Keijzers G, Fraser J, Presneill J, Campbell D. Fibrinogen Early In Severe Trauma studY (FEISTY): results from an Australian multicentre randomised controlled pilot trial. CRIT CARE RESUSC 2021; 23:32-46. [PMID: 38046391 PMCID: PMC10692540 DOI: 10.51893/2021.1.oa3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background: Haemorrhage is a major cause of death in severe trauma. Fibrinogen plays a critical role in maintaining haemostasis in traumatic haemorrhage, and early replacement using fibrinogen concentrate (FC) or cryoprecipitate (Cryo) is recommended by several international trauma guidelines. Limited evidence supports one product over the other, with widespread geographic and institutional variation in practice. Two previous trials have investigated the feasibility of rapid FC administration in severely injured trauma patients, with conflicting results. Objective: To compare the time to fibrinogen replacement using FC or Cryo in severely injured trauma patients with major haemorrhage and hypofibrinogenaemia. Design, setting, patients and interventions: A multicentre controlled pilot trial in which adult trauma patients with haemorrhage were randomly assigned (1:1) to receive FC or Cryo for fibrinogen replacement, guided by FIBTEM A5 (functional fibrinogen assessment at 5 minutes after clot formation, using rotational thromboelastometry). Main outcome measures: The primary outcome was time to commencement of fibrinogen replacement. Secondary outcomes included effects of the intervention on plasma fibrinogen levels and clinical outcomes including transfusion requirements and mortality. Results: Of the 100 randomly assigned patients, 62 were hypofibrinogenaemic and received the intervention (n = 37) or Cryo (n = 25). Median (interquartile range [IQR]) time to delivery of FC was 29 min (23-40 min) compared with 60 min (40-80 min) for Cryo (P = 0.0001). All 62 patients were hypofibrinogenaemic before receiving FC or Cryo (FC: median FIBTEM A5, 8 mm [IQR, 7-9 mm]; Cryo: median FIBTEM A5, 9 mm [IQR, 5-10 mm]). In the FC arm patients received a median of 3 g FC (IQR, 2-4 g), and in the Cryo arm patients received a median of 8 units of Cryo (IQR, 8-14 units). Restoration of fibrinogen levels was achieved in both arms after the intervention. Blood product transfusion, fluid resuscitation and thromboembolic complications were similar in both arms. Overall mortality was 15.3%, with more deaths in the FC arm. Conclusion: Fibrinogen replacement in severely injured trauma patients with major haemorrhage and hypofibrinogenaemia was achieved substantially faster using FC compared with Cryo. Fibrinogen levels increased appropriately using either product. The optimal method for replacing fibrinogen in traumatic haemorrhage is controversial. Our results will inform the design of a larger trial powered to assess patient-centred outcomes.
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Affiliation(s)
- James Winearls
- Intensive Care Unit, Gold Coast University Hospital, Gold Coast, QLD, Australia
- School of Medicine, University of Queensland, Brisbane, QLD, Australia
- School of Medical Sciences, Griffith University, Gold Coast, QLD, Australia
- St Andrews War Memorial Hospital Brisbane, QLD, Australia
| | | | - Elizabeth Wake
- Trauma Service, Gold Coast University Hospital, Gold Coast, QLD, Australia
| | - Zoe McQuilten
- Transfusion Research Unit, Monash University, Melbourne, VIC, Australia
- Monash Health, Melbourne, VIC, Australia
| | - Michael Reade
- Military Medicine and Surgery, Joint Health Command, Australian Defence Force
- Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
- Royal Brisbane and Women’s Hospital, Brisbane, QLD, Australia
| | - Catherine Hurn
- School of Medicine, University of Queensland, Brisbane, QLD, Australia
- Royal Brisbane and Women’s Hospital, Brisbane, QLD, Australia
| | - Glenn Ryan
- School of Medicine, University of Queensland, Brisbane, QLD, Australia
- Princess Alexandra Hospital, Brisbane, QLD, Australia
| | - Melita Trout
- Townsville Hospital, Townsville, QLD, Australia
- Faculty of Medicine, James Cook University, Townsville, QLD, Australia
| | - James Walsham
- School of Medicine, University of Queensland, Brisbane, QLD, Australia
- Princess Alexandra Hospital, Brisbane, QLD, Australia
| | - Anthony Holley
- School of Medicine, University of Queensland, Brisbane, QLD, Australia
- Royal Brisbane and Women’s Hospital, Brisbane, QLD, Australia
| | - Shane George
- School of Medicine, University of Queensland, Brisbane, QLD, Australia
- Emergency Department and Children’s Critical Care Service, Gold Coast University Hospital, Gold Coast, QLD, Australia
- Paediatric Critical Care Research Group, Child Health Research Centre, University of Queensland, Brisbane, QLD, Australia
| | | | - James McCullough
- Intensive Care Unit, Gold Coast University Hospital, Gold Coast, QLD, Australia
| | - Gerben Keijzers
- Intensive Care Unit, Gold Coast University Hospital, Gold Coast, QLD, Australia
- School of Medical Sciences, Griffith University, Gold Coast, QLD, Australia
- Faculty of Health Sciences and Medicine, Bond University, Gold Coast, QLD, Australia
| | - John Fraser
- School of Medicine, University of Queensland, Brisbane, QLD, Australia
- Critical Care Research Group, Prince Charles Hospital, Brisbane, QLD, Australia
| | - Jeffrey Presneill
- Intensive Care Unit, Royal Melbourne Hospital, Melbourne, VIC, Australia
- University of Melbourne, Melbourne, VIC, Australia
| | - Don Campbell
- Trauma Service, Gold Coast University Hospital, Gold Coast, QLD, Australia
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17
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de Lucena LS, Rodrigues RDR, Carmona MJC, Noronha FJD, Oliveira HP, Lima NM, Pinheiro RB, da Silva WA, Cavalcanti AB. Early administration of fibrinogen concentrate in patients with polytrauma with thromboelastometry suggestive of hypofibrinogenemia: A randomized feasibility trial. Clinics (Sao Paulo) 2021; 76:e3168. [PMID: 34755760 PMCID: PMC8552954 DOI: 10.6061/clinics/2021/e3168] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Accepted: 09/30/2021] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVE To evaluate the clinical effects of early administration of fibrinogen concentrate in patients with severe trauma and hypofibrinogenemia. METHODS We conducted an open randomized feasibility trial between December 2015 and January 2017 in patients with severe trauma admitted to the emergency department of a large trauma center. Patients presented with hypotension, tachycardia, and FIBTEM findings suggestive of hypofibrinogenemia. The intervention group received fibrinogen concentrate (50 mg/kg), and the control group did not receive early fibrinogen replacement. The primary outcome was feasibility assessed as the proportion of patients receiving the allocated treatment within 60 min after randomization. The secondary outcomes were transfusion requirements and other exploratory outcomes. Randomization was performed using sequentially numbered and sealed opaque envelopes. ClinicalTrials.gov: NCT02864875. RESULTS Thirty-two patients were randomized (16 in each group). All patients received the allocated treatment within 60 min after randomization (100%, 95% confidence interval, 86.7%-100%). The median length of intensive care unit stay was shorter in the intervention group (8 days, interquartile range [IQR] 5.75-10.0 vs. 11 days, IQR 8.5-16.0; p=0.02). There was no difference between the groups in other clinical outcomes. No adverse effects related to treatment were recorded in either group. CONCLUSION Early fibrinogen replacement with fibrinogen concentrate was feasible. Larger trials are required to properly evaluate clinical outcomes.
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Affiliation(s)
- Lucas Siqueira de Lucena
- Programa de Pos-graduacao em Anestesiologia, Ciencias Cirurgicas e Medicina Perioperatoria, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, BR
- Departamento de Anestesiologia, Hospital Universitario Walter Cantidio, Fortaleza, CE, BR
- Corresponding author. E-mail:
| | - Roseny dos Reis Rodrigues
- Programa de Pos-graduacao em Anestesiologia, Ciencias Cirurgicas e Medicina Perioperatoria, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Maria José Carvalho Carmona
- Programa de Pos-graduacao em Anestesiologia, Ciencias Cirurgicas e Medicina Perioperatoria, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Francisco José Diniz Noronha
- Programa de Pos-graduacao em Anestesiologia, Ciencias Cirurgicas e Medicina Perioperatoria, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Helenode Paiva Oliveira
- Programa de Pos-graduacao em Anestesiologia, Ciencias Cirurgicas e Medicina Perioperatoria, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Natalia Martins Lima
- Programa de Pos-graduacao em Anestesiologia, Ciencias Cirurgicas e Medicina Perioperatoria, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Rodrigo Brandão Pinheiro
- Programa de Pos-graduacao em Anestesiologia, Ciencias Cirurgicas e Medicina Perioperatoria, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Wallace Andrino da Silva
- Programa de Pos-graduacao em Anestesiologia, Ciencias Cirurgicas e Medicina Perioperatoria, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, BR
- Departamento de Anestesiologia, Hospital Universitario Onofre Lopes, Natal, RN, BR
| | - Alexandre Biasi Cavalcanti
- Programa de Pos-graduacao em Anestesiologia, Ciencias Cirurgicas e Medicina Perioperatoria, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, BR
- Instituto de Pesquisa Hcor, Sao Paulo, SP, BR
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18
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Park HS, Cho HS. Management of massive hemorrhage in pregnant women with placenta previa. Anesth Pain Med (Seoul) 2020; 15:409-416. [PMID: 33329843 PMCID: PMC7724116 DOI: 10.17085/apm.20076] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Accepted: 09/21/2020] [Indexed: 11/17/2022] Open
Abstract
Patients with placenta previa are at risk for intra- and postpartum massive blood loss as well as increased risk of placenta accreta, a type of abnormal placental implantation. This condition can lead to serious obstetric complications, including maternal mortality and morbidity. The risk factors for previa include prior cesarean section, multiparity, advanced maternal age, prior placenta previa history, prior uterine surgery, and smoking. The prevalence of previa parturients has increased due to the rising rates of cesarean section and advanced maternal age. For these reasons, we need to identify the risk factors for previa and identify adequate management strategies to respond to blood loss during surgery. This review evaluated the diagnosis of placenta previa and placenta accreta and assessed the risk factors for previa-associated bleeding prior to cesarean section. We then presented intraoperative anesthetic management and other interventions to control bleeding in patients with previa expected to experience massive hemorrhage and require transfusion.
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Affiliation(s)
- Hee-Sun Park
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hyun-Seok Cho
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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19
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Cushing MM, Haas T, Karkouti K, Callum J. Which is the preferred blood product for fibrinogen replacement in the bleeding patient with acquired hypofibrinogenemia-cryoprecipitate or fibrinogen concentrate? Transfusion 2020; 60 Suppl 3:S17-S23. [PMID: 32478877 DOI: 10.1111/trf.15614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Revised: 11/12/2019] [Accepted: 11/12/2019] [Indexed: 11/28/2022]
Abstract
The importance of the targeted treatment of acquired hypofibrinogenemia during hemorrhage with a concentrated fibrinogen product (either cryoprecipitate or fibrinogen concentrate) cannot be underestimated. Fibrinogen concentrate is a pathogen inactivated, pooled product that offers a highly purified single factor concentrate. Cryoprecipitate is a pooled product that comes with a spectrum of other coagulation factors which may further enhance (additional procoagulant effect) or even disturb (prothrombotic risk) hemostasis. The pros and cons of each product are discussed.
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Affiliation(s)
- Melissa M Cushing
- Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York, New York
| | - Thorsten Haas
- Department of Anesthesia, Zurich University Children's Hospital, Zurich, Switzerland
| | - Keyvan Karkouti
- Peter Munk Cardiac Centre, University Health Network, Toronto, Canada.,Department of Anesthesia and Pain Management, University Health Network, Sinai Health System, Women's College Hospital, University of Toronto, Toronto, Canada
| | - Jeannie Callum
- Department of Laboratory Medicine and Molecular Diagnostics, Sunnybrook Health Sciences Centre, Toronto, Canada.,Laboratory Medicine Program, University Health Network, Toronto, Canada.,Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Canada
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20
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Abstract
Hemorrhage is the leading cause of preventable death in combat trauma and the secondary cause of death in civilian trauma. A significant number of deaths due to hemorrhage occur before and in the first hour after hospital arrival. A literature search was performed through PubMed, Scopus, and Institute of Scientific Information databases for English language articles using terms relating to hemostatic agents, prehospital, battlefield or combat dressings, and prehospital hemostatic resuscitation, followed by cross-reference searching. Abstracts were screened to determine relevance and whether appropriate further review of the original articles was warranted. Based on these findings, this paper provides a review of a variety of hemostatic agents ranging from clinically approved products for human use to newly developed concepts with great potential for use in prehospital settings. These hemostatic agents can be administered either systemically or locally to stop bleeding through different mechanisms of action. Comparisons of current hemostatic products and further directions for prehospital hemorrhage control are also discussed.
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Affiliation(s)
- Henry T Peng
- Defence Research and Development Canada, Toronto Research Centre, 1133 Sheppard Avenue West, Toronto, ON, M3K 2C9, Canada.
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21
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Phillips JM, van den Anker JN, Ahmadzia HK. Next Generation Medical Management of Postpartum Hemorrhage. Curr Pharm Des 2020; 25:549-555. [PMID: 30894102 DOI: 10.2174/1381612825666190320155337] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Accepted: 03/18/2019] [Indexed: 11/22/2022]
Abstract
BACKGROUND Postpartum hemorrhage remains a significant contributor to morbidity and mortality of women of childbearing age worldwide. Trends in both incidence and severity of postpartum hemorrhage are increasing which makes it imperative to identify drugs that could target prevention and/or treatment of these postpartum hemorrhages for women living in high, middle and low-income countries. METHODS We have reviewed current advances in the medical management of postpartum hemorrhage focusing on non-uterotonic therapy. We specifically describe the use and mechanism of action of tranexamic acid (TXA) and fibrinogen concentrate. Furthermore, we address the existing data for using these medications in postpartum hemorrhage, highlighting both strengths and limitations. RESULTS This review describes a new generation of medications that are promising for the prevention and/or treatment of postpartum hemorrhage. For patients at risk for significant hemorrhage, TXA has been shown to reduce intraoperative blood loss and can be given as a prophylactic agent. For the treatment of postpartum hemorrhage, early use of TXA has the potential to reduce mortality. In addition, some data exists supporting the use of fibrinogen concentrate, though more studies are required to help formulate guidelines for its use. CONCLUSION A promising new approach for the management of severe postpartum hemorrhage is using medications that alter coagulation. More data are needed to describe ideal patient populations, dosing, the time of administration, and infusion rate.
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Affiliation(s)
- Jaclyn M Phillips
- The George Washington University, School of Medicine and Health Sciences, Washington, DC, United States
| | - John N van den Anker
- The George Washington University, School of Medicine and Health Sciences, Washington, DC, United States.,Children's National Medical Center, Washington, DC, United States
| | - Homa K Ahmadzia
- The George Washington University, School of Medicine and Health Sciences, Washington, DC, United States
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22
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Roy A, Stanford S, Nunn S, Alves S, Sargant N, Rangarajan S, Smith EA, Bell J, Dayal S, Cecil T, Tzivanakis A, Kruzhkova I, Solomon C, Knaub S, Moran B, Mohamed F. Efficacy of fibrinogen concentrate in major abdominal surgery - A prospective, randomized, controlled study in cytoreductive surgery for pseudomyxoma peritonei. J Thromb Haemost 2020; 18:352-363. [PMID: 31654548 PMCID: PMC7027898 DOI: 10.1111/jth.14665] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Revised: 10/18/2019] [Accepted: 10/22/2019] [Indexed: 01/12/2023]
Abstract
BACKGROUND Cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy for pseudomyxoma peritonei (PMP) is associated with excessive bleeding and acquired fibrinogen deficiency. Maintaining plasma fibrinogen may support hemostasis. OBJECTIVES To compare hemostatic efficacy and safety of human fibrinogen concentrate (HFC) vs cryoprecipitate as fibrinogen sources for bleeding patients with acquired fibrinogen deficiency undergoing PMP CRS. METHODS FORMA-05 was an off-label single-center, prospective, randomized, controlled phase 2 study. Patients undergoing PMP surgery with predicted intraoperative blood loss ≥2 L received human fibrinogen concentrate (HFC; 4 g) or cryoprecipitate (two pools of 5 units, containing approximately 4.0-4.6 g fibrinogen), repeated as needed. The primary endpoint was a composite of intraoperative and postoperative efficacy, graded using objective 4-point scales and adjudicated by an independent committee. RESULTS One hundred percent of patients receiving HFC (95% confidence interval: 83.9-100.0, n = 21) or cryoprecipitate (84.6-100.0, n = 22) achieved hemostatic success. HFC demonstrated noninferior efficacy (P = .0095; post hoc) and arrived in the operating room 46 minutes faster. There were significantly greater mean increases with HFC vs cryoprecipitate in plasma fibrinogen (0.78 vs 0.35 g/L; P < .0001) and FIBTEM A20 (3.33 vs 0.93 mm; P = .003). Factor XIII, factor VIII, and von Willebrand factor activity were maintained throughout surgery. Only red blood cells were transfused intraoperatively (median units: HFC group, 1.0; cryoprecipitate group, 0.5). Thromboembolic events were detected with cryoprecipitate only. Safety was otherwise comparable between groups. CONCLUSIONS Human fibrinogen concentrate was hemostatically efficacious in patients undergoing major abdominal PMP surgery, with a favorable safety profile. These results are relevant to other surgical settings where bleeding and acquired fibrinogen deficiency occur.
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Affiliation(s)
- Ashok Roy
- Basingstoke and North Hampshire HospitalBasingstokeUK
| | | | - Sean Nunn
- Basingstoke and North Hampshire HospitalBasingstokeUK
| | - Sue Alves
- Basingstoke and North Hampshire HospitalBasingstokeUK
| | - Nigel Sargant
- Basingstoke and North Hampshire HospitalBasingstokeUK
| | - Savita Rangarajan
- University Hospital Southampton NHS Foundation TrustUK
- KJ Somaiya AyurviharMumbaiIndia
| | | | - John Bell
- Basingstoke and North Hampshire HospitalBasingstokeUK
| | - Sanjeev Dayal
- Basingstoke and North Hampshire HospitalBasingstokeUK
| | - Tom Cecil
- Basingstoke and North Hampshire HospitalBasingstokeUK
| | | | | | | | | | - Brendan Moran
- Basingstoke and North Hampshire HospitalBasingstokeUK
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23
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Samukange WT, Gardarsdottir H, Leufkens HGM, Mantel-Teeuwisse AK. Selection of Blood, Blood Components, and Blood Products as Essential Medicines in 105 Low- and Middle-Income Countries. Transfus Med Rev 2019; 34:94-100. [PMID: 31761652 DOI: 10.1016/j.tmrv.2019.10.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Revised: 10/03/2019] [Accepted: 10/10/2019] [Indexed: 12/15/2022]
Abstract
Blood products of human origin are essential treatment options for several diseases, for example, hemophilia. We studied the alignment of national essential medicines lists (NEMLs) of low- and middle-income countries (LMICs) with the World Health Organization (WHO) Model List for the selection of blood products of human origin. The most recent versions of NEMLs from all LMICs were studied for the inclusion of blood products of human origin (blood and blood components, plasma products, and immunoglobulins). Data obtained from 105 NEMLs were compared to the 2017 WHO Model List. The median number of blood products of human origin on the NEMLs was 4 (range: 0-10). Immunoglobulins were most frequently included (73%). Blood and blood components were the least selected products (15%). The uptake of plasma products was around 50%. Nine countries did not have any blood products of human origin on their NEMLs. Some NEMLs included blood products not listed on the WHO Model List (albumin, hepatitis A immunoglobulin, and cryoprecipitate). We observed variation in selection according to WHO region, income level, and year of NEML update. Alignment of NEMLs with the WHO Model List varied greatly for different groups of blood products, ranging from good uptake for immunoglobulins, reasonable uptake for plasma products, to poor uptake for blood and blood components. This heterogeneity in selection and inclusion of blood products of human origin on NEMLs may be partly explained as being due to specific country characteristics, but some of it may not be explained. Policy makers need to rely on evidence in making decisions about which blood products to select, include, and remove on their NEMLs.
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Affiliation(s)
- Washington T Samukange
- Division of Pharmacoepidemiology & Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (UIPS), Faculty of Science, Utrecht University, Utrecht, the Netherlands; Paul Ehrlich Institut, Langen, Germany
| | - Helga Gardarsdottir
- Division of Pharmacoepidemiology & Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (UIPS), Faculty of Science, Utrecht University, Utrecht, the Netherlands
| | - Hubert G M Leufkens
- Division of Pharmacoepidemiology & Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (UIPS), Faculty of Science, Utrecht University, Utrecht, the Netherlands
| | - Aukje K Mantel-Teeuwisse
- Division of Pharmacoepidemiology & Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (UIPS), Faculty of Science, Utrecht University, Utrecht, the Netherlands.
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25
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Erdoes G, Koster A, Meesters MI, Ortmann E, Bolliger D, Baryshnikova E, Ahmed A, Lance MD, Ravn HB, Ranucci M, Heymann C, Agarwal S. The role of fibrinogen and fibrinogen concentrate in cardiac surgery: an international consensus statement from the Haemostasis and Transfusion Scientific Subcommittee of the European Association of Cardiothoracic Anaesthesiology. Anaesthesia 2019; 74:1589-1600. [DOI: 10.1111/anae.14842] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/14/2019] [Indexed: 12/23/2022]
Affiliation(s)
- G. Erdoes
- Department of Anaesthesiology and Pain Medicine Inselspital, Bern University Hospital University of Bern Switzerland
| | - A. Koster
- Institute for Anaesthesiology, Heart and Diabetes Centre NRW Ruhr‐University Bochum Bad Oeynhausen Germany
| | - M. I. Meesters
- Department of Anaesthesiology University Medical Centre Utrecht The Netherlands
| | - E. Ortmann
- Department of Anaesthesia Kerckhoff Heart and Lung Centre Bad Nauheim Germany
| | - D. Bolliger
- Department of Anaesthesia Surgical Intensive Care Prehospital Emergency Medicine, and Pain Therapy University Hospital Basel Switzerland
| | - E. Baryshnikova
- Department of Cardiovascular Anaesthesia and Intensive Care Unit IRCCS Policlinico San Donato Milan Italy
| | - A. Ahmed
- Department of Anaesthesia University Hospitals of Leicester NHS Trust LeicesterUK
| | - M. D. Lance
- Hamad Medical Corporation, HMC Anaesthesiology ICU and Peri‐operative Medicine Doha Qatar
| | - H. B. Ravn
- Department of Cardiothoracic Anaesthesiology Copenhagen University Hospital Copenhagen Denmark
| | - M. Ranucci
- Department of Cardiovascular Anaesthesia and Intensive Care Unit IRCCS Policlinico San Donato Milan Italy
| | - C. Heymann
- Department of Anaesthesia Intensive Care Medicine, Emergency Medicine and Pain Therapy Vivantes Klinikum im Friedrichshain Berlin Germany
| | - S. Agarwal
- Department of Anaesthesia Manchester University Hospitals Manchester UK
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Fenderson JL, Meledeo MA, Rendo MJ, Peltier GC, McIntosh CS, Davis KW, Corley JB, Cap AP. Hemostatic characteristics of thawed, pooled cryoprecipitate stored for 35 days at refrigerated and room temperatures. Transfusion 2019; 59:1560-1567. [DOI: 10.1111/trf.15180] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2018] [Revised: 01/09/2019] [Accepted: 01/09/2019] [Indexed: 12/18/2022]
Affiliation(s)
- Joshua L. Fenderson
- Blood Research Program, US Army Institute of Surgical Research Fort Sam Houston Texas
| | - M. Adam Meledeo
- Blood Research Program, US Army Institute of Surgical Research Fort Sam Houston Texas
| | - Matthew J. Rendo
- Blood Research Program, US Army Institute of Surgical Research Fort Sam Houston Texas
| | - Grantham C. Peltier
- Blood Research Program, US Army Institute of Surgical Research Fort Sam Houston Texas
| | - Colby S. McIntosh
- Blood Research Program, US Army Institute of Surgical Research Fort Sam Houston Texas
| | - Kenneth W. Davis
- Blood Research Program, US Army Institute of Surgical Research Fort Sam Houston Texas
| | - Jason B. Corley
- Blood Research Program, US Army Institute of Surgical Research Fort Sam Houston Texas
| | - Andrew P. Cap
- Blood Research Program, US Army Institute of Surgical Research Fort Sam Houston Texas
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Shah A, Collis RE. Managing obstetric haemorrhage: is it time for a more personalised approach? Anaesthesia 2019; 74:961-964. [PMID: 30950513 DOI: 10.1111/anae.14661] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/12/2019] [Indexed: 12/17/2022]
Affiliation(s)
- A Shah
- Nuffield Department of Anaesthesia, John Radcliffe Hospital, Oxford, UK.,Radcliffe Department of Medicine, University of Oxford, UK
| | - R E Collis
- Department of Anaesthetics, Cardiff and Vale University Health Board, Cardiff, UK
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Spahn DR, Bouillon B, Cerny V, Duranteau J, Filipescu D, Hunt BJ, Komadina R, Maegele M, Nardi G, Riddez L, Samama CM, Vincent JL, Rossaint R. The European guideline on management of major bleeding and coagulopathy following trauma: fifth edition. Crit Care 2019; 23:98. [PMID: 30917843 PMCID: PMC6436241 DOI: 10.1186/s13054-019-2347-3] [Citation(s) in RCA: 688] [Impact Index Per Article: 137.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Accepted: 02/06/2019] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Severe traumatic injury continues to present challenges to healthcare systems around the world, and post-traumatic bleeding remains a leading cause of potentially preventable death among injured patients. Now in its fifth edition, this document aims to provide guidance on the management of major bleeding and coagulopathy following traumatic injury and encourages adaptation of the guiding principles described here to individual institutional circumstances and resources. METHODS The pan-European, multidisciplinary Task Force for Advanced Bleeding Care in Trauma was founded in 2004, and the current author group included representatives of six relevant European professional societies. The group applied a structured, evidence-based consensus approach to address scientific queries that served as the basis for each recommendation and supporting rationale. Expert opinion and current clinical practice were also considered, particularly in areas in which randomised clinical trials have not or cannot be performed. Existing recommendations were re-examined and revised based on scientific evidence that has emerged since the previous edition and observed shifts in clinical practice. New recommendations were formulated to reflect current clinical concerns and areas in which new research data have been generated. RESULTS Advances in our understanding of the pathophysiology of post-traumatic coagulopathy have supported improved management strategies, including evidence that early, individualised goal-directed treatment improves the outcome of severely injured patients. The overall organisation of the current guideline has been designed to reflect the clinical decision-making process along the patient pathway in an approximate temporal sequence. Recommendations are grouped behind the rationale for key decision points, which are patient- or problem-oriented rather than related to specific treatment modalities. While these recommendations provide guidance for the diagnosis and treatment of major bleeding and coagulopathy, emerging evidence supports the author group's belief that the greatest outcome improvement can be achieved through education and the establishment of and adherence to local clinical management algorithms. CONCLUSIONS A multidisciplinary approach and adherence to evidence-based guidance are key to improving patient outcomes. If incorporated into local practice, these clinical practice guidelines have the potential to ensure a uniform standard of care across Europe and beyond and better outcomes for the severely bleeding trauma patient.
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Affiliation(s)
- Donat R. Spahn
- Institute of Anaesthesiology, University of Zurich and University Hospital Zurich, Raemistrasse 100, CH-8091 Zurich, Switzerland
| | - Bertil Bouillon
- Department of Trauma and Orthopaedic Surgery, Cologne-Merheim Medical Centre (CMMC), University of Witten/Herdecke, Ostmerheimer Strasse 200, D-51109 Cologne, Germany
| | - Vladimir Cerny
- Department of Anaesthesiology, Perioperative Medicine and Intensive Care, J.E. Purkinje University, Masaryk Hospital, Usti nad Labem, Socialni pece 3316/12A, CZ-40113 Usti nad Labem, Czech Republic
- Centre for Research and Development, University Hospital Hradec Kralove, Hradec Kralove, Czech Republic, Sokolska 581, CZ-50005 Hradec Kralove, Czech Republic
- Department of Anaesthesiology and Intensive Care Medicine, Faculty of Medicine in Hradec Kralove, Charles University, Simkova 870, CZ-50003 Hradec Kralove, Czech Republic
- Department of Anaesthesia, Pain Management and Perioperative Medicine, QE II Health Sciences Centre, Dalhousie University, Halifax, 10 West Victoria, 1276 South Park St, Halifax, NS B3H 2Y9 Canada
| | - Jacques Duranteau
- Department of Anaesthesia and Intensive Care, Hôpitaux Universitaires Paris Sud, University of Paris XI, Faculté de Médecine Paris-Sud, 78 rue du Général Leclerc, F-94275 Le Kremlin-Bicêtre Cedex, France
| | - Daniela Filipescu
- Department of Cardiac Anaesthesia and Intensive Care, C. C. Iliescu Emergency Institute of Cardiovascular Diseases, Sos Fundeni 256-258, RO-022328 Bucharest, Romania
| | - Beverley J. Hunt
- King’s College and Departments of Haematology and Pathology, Guy’s and St Thomas’ NHS Foundation Trust, Westminster Bridge Road, London, SE1 7EH UK
| | - Radko Komadina
- Department of Traumatology, General and Teaching Hospital Celje, Medical Faculty Ljubljana University, SI-3000 Celje, Slovenia
| | - Marc Maegele
- Department of Trauma and Orthopaedic Surgery, Cologne-Merheim Medical Centre (CMMC), Institute for Research in Operative Medicine (IFOM), University of Witten/Herdecke, Ostmerheimer Strasse 200, D-51109 Cologne, Germany
| | - Giuseppe Nardi
- Department of Anaesthesia and ICU, AUSL della Romagna, Infermi Hospital Rimini, Viale Settembrini, 2, I-47924 Rimini, Italy
| | - Louis Riddez
- Department of Surgery and Trauma, Karolinska University Hospital, S-171 76 Solna, Sweden
| | - Charles-Marc Samama
- Hotel-Dieu University Hospital, 1, place du Parvis de Notre-Dame, F-75181 Paris Cedex 04, France
| | - Jean-Louis Vincent
- Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Route de Lennik 808, B-1070 Brussels, Belgium
| | - Rolf Rossaint
- Department of Anaesthesiology, University Hospital Aachen, RWTH Aachen University, Pauwelsstrasse 30, D-52074 Aachen, Germany
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Cushing MM, Asmis LM, Harris RM, DeSimone RA, Hill S, Ivascu N, Haas T. Efficacy of a new pathogen-reduced cryoprecipitate stored 5 days after thawing to correct dilutional coagulopathy in vitro. Transfusion 2019; 59:1818-1826. [PMID: 30719724 DOI: 10.1111/trf.15157] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2018] [Revised: 12/27/2018] [Accepted: 12/29/2018] [Indexed: 12/29/2022]
Abstract
BACKGROUND Fibrinogen supplementation during bleeding restores clot strength and hemostasis. Cryoprecipitate, a concentrated source of fibrinogen, has prolonged preparation time for thawing, a short shelf life resulting in frequent wastage, and infectious disease risk. This in vitro study investigated the efficacy of a new pathogen-reduced cryoprecipitate thawed and stored at room temperature for 5 days (PR Cryo) to treat dilutional hypofibrinogenemia, compared to immediately thawed standard cryoprecipitate (Cryo) or fibrinogen concentrate (FC). STUDY DESIGN AND METHODS Ten phlebotomy specimens from healthy volunteers were diluted 1:1 with crystalloid and supplemented with PR Cryo and Cryo (at a dose replicating transfusion of two pooled doses [10 units]) and FC at a dose replicating 50 mg/kg. Changes in clot firmness (thromboelastometry) and in coagulation factor activity were assessed at baseline, after dilution, and after supplementation. RESULTS Clinical dosing was used, as described above, and consequently the FC dose contained 24% and 36% more fibrinogen versus PR Cryo and Cryo, respectively. At baseline, subjects had a median FIBTEM maximum clot firmness of 13.5 mm, versus 6.5 mm after 50% dilution (p = 0.005). After supplementation with PR Cryo, a median FIBTEM maximum clot firmness of 13 mm was observed versus 9.0 mm for Cryo (p = 0.005) or 16.5 mm for FC (p = 0.005). Median factor XIII was higher after PR Cryo (64.8%) versus Cryo (48.3%) (p = 0.005). Fibrinogen activity was higher after FC (269.0 mg/dL) versus PR Cryo (187.0 mg/dL; p = 0.005) or Cryo (193.5 mg/dL; p = 0.005); the difference between PR Cryo and Cryo supplementation (p = 0.445) was not significant. CONCLUSION PR Cryo used 5 days after thawing effectively restores clot strength after in vitro dilution.
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Affiliation(s)
- Melissa M Cushing
- Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York, New York.,Department of Anesthesiology, Weill Cornell Medicine, New York, New York
| | - Lars M Asmis
- Centre for Perioperative Thrombosis and Haemostasis, Zurich, Switzerland
| | - Rebecca M Harris
- Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York, New York
| | - Robert A DeSimone
- Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York, New York
| | - Shanna Hill
- Department of Anesthesiology, Weill Cornell Medicine, New York, New York
| | - Natalia Ivascu
- Department of Anesthesiology, Weill Cornell Medicine, New York, New York
| | - Thorsten Haas
- Department of Anaesthesia, Zurich University Children's Hospital, Zurich, Switzerland
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30
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Fujita H, Nishimura S, Sugiyama K. Evaluation of a Possible Effect of In-House Cryoprecipitate Transfusion on Outcome of Severe Upper Gastrointestinal Bleeding: A Retrospective Cohort Study. ACTA ACUST UNITED AC 2019. [DOI: 10.4236/ojbd.2019.91003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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31
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Ebihara T. Multiple Injury. Neurocrit Care 2019. [DOI: 10.1007/978-981-13-7272-8_11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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32
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Marsden M, Benger J, Brohi K, Curry N, Foley C, Green L, Lucas J, Rossetto A, Stanworth S, Thomas H, Davenport R. Coagulopathy, cryoprecipitate and CRYOSTAT-2: realising the potential of a nationwide trauma system for a national clinical trial. Br J Anaesth 2018; 122:164-169. [PMID: 30686301 DOI: 10.1016/j.bja.2018.10.055] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Revised: 10/06/2018] [Accepted: 10/27/2018] [Indexed: 01/10/2023] Open
Affiliation(s)
- M Marsden
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, UK; Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, UK; Barts Health NHS Trust, London, UK.
| | - J Benger
- Faculty of Health and Applied Sciences, University of the West of England, Bristol, UK
| | - K Brohi
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, UK; Barts Health NHS Trust, London, UK
| | - N Curry
- Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK; Radcliffe Department of Medicine, University of Oxford, UK
| | - C Foley
- NHS Blood and Transplant, Clinical Trials Unit, Cambridge, UK
| | - L Green
- Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary, University of London, London, UK; Barts Health NHS Trust, London, UK
| | - J Lucas
- NHS Blood and Transplant, Clinical Trials Unit, Cambridge, UK
| | - A Rossetto
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, UK; Barts Health NHS Trust, London, UK
| | - S Stanworth
- Oxford NIHR BRC Haematology Theme, Oxford Centre for Haematology, University of Oxford, UK; NHS Blood and Transplant, Transfusion Medicine, Oxford, UK; Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK; Radcliffe Department of Medicine, University of Oxford, UK
| | - H Thomas
- NHS Blood and Transplant, Clinical Trials Unit, Bristol, UK; NHS Blood and Transplant, Transfusion Medicine, Oxford, UK
| | - R Davenport
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, UK; Barts Health NHS Trust, London, UK
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Clinical pearls part 3: anaesthetic management of abnormally invasive placentation. Curr Opin Anaesthesiol 2018; 31:280-289. [PMID: 29652744 DOI: 10.1097/aco.0000000000000601] [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
PURPOSE OF REVIEW Abnormal placentation is a clinical condition seen increasingly in the pregnant population. It is associated with significant morbidity and mortality, which may be mitigated through robust multidisciplinary care for these patients. The role of maternal critical care for these patients has largely been ignored in the literature. RECENT FINDINGS Advances in pharmacological management of bleeding with recent publications of large multicentre trials in addition to new technologies in the management of massive obstetric haemorrhage (MOH) have revolutionized the management of abnormal placentation. These include the use of tranexamic acid, interventional radiology, cell saver technology, and point-of-care coagulation tests. The role of maternal critical care for the optimization of postoperative complications and physiological derangements has not been considered widely in the literature. This article summarizes the current evidence for interventions and suggests a protocol for the management of these high-risk patients. SUMMARY A robust protocol outlining the key elements of the management of placenta accreta, including optimizing postoperative care, should be in place to promote desired outcomes.
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Qadri SM, Eltringham-Smith LJ, Bhakta V, Sheffield WP. Thromboelastometry reveals similar hemostatic properties of purified fibrinogen and a mixture of purified cryoprecipitate protein components. Clin Chem Lab Med 2018; 56:e210-e213. [PMID: 29455186 DOI: 10.1515/cclm-2017-1136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Accepted: 01/25/2018] [Indexed: 11/15/2022]
Affiliation(s)
- Syed M Qadri
- Centre for Innovation, Canadian Blood Services, Hamilton, ON, Canada.,Department of Pathology and Molecular Medicine, McMaster University, Hamilton, ON, Canada
| | | | - Varsha Bhakta
- Centre for Innovation, Canadian Blood Services, Hamilton, ON, Canada
| | - William P Sheffield
- Centre for Innovation, Canadian Blood Services, Hamilton, ON, Canada.,Department of Pathology and Molecular Medicine, McMaster University, Hamilton, ON, Canada
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Curry N, Foley C, Wong H, Mora A, Curnow E, Zarankaite A, Hodge R, Hopkins V, Deary A, Ray J, Moss P, Reed MJ, Kellett S, Davenport R, Stanworth S. Early fibrinogen concentrate therapy for major haemorrhage in trauma (E-FIT 1): results from a UK multi-centre, randomised, double blind, placebo-controlled pilot trial. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2018; 22:164. [PMID: 29914530 PMCID: PMC6006766 DOI: 10.1186/s13054-018-2086-x] [Citation(s) in RCA: 60] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Accepted: 05/28/2018] [Indexed: 12/16/2022]
Abstract
Background There is increasing interest in the timely administration of concentrated sources of fibrinogen to patients with major traumatic bleeding. Following evaluation of early cryoprecipitate in the CRYOSTAT 1 trial, we explored the use of fibrinogen concentrate, which may have advantages of more rapid administration in acute haemorrhage. The aims of this pragmatic study were to assess the feasibility of fibrinogen concentrate administration within 45 minutes of hospital admission and to quantify efficacy in maintaining fibrinogen levels ≥ 2 g/L during active haemorrhage. Methods We conducted a blinded, randomised, placebo-controlled trial at five UK major trauma centres with adult trauma patients with active bleeding who required activation of the major haemorrhage protocol. Participants were randomised to standard major haemorrhage therapy plus 6 g of fibrinogen concentrate or placebo. Results Twenty-seven of 39 participants (69%; 95% CI, 52–83%) across both arms received the study intervention within 45 minutes of admission. There was some evidence of a difference in the proportion of participants with fibrinogen levels ≥ 2 g/L between arms (p = 0.10). Fibrinogen levels in the fibrinogen concentrate (FgC) arm rose by a mean of 0.9 g/L (SD, 0.5) compared with a reduction of 0.2 g/L (SD, 0.5) in the placebo arm and were significantly higher in the FgC arm (p < 0.0001) at 2 hours. Fibrinogen levels were not different at day 7. Transfusion use and thromboembolic events were similar between arms. All-cause mortality at 28 days was 35.5% (95% CI, 23.8–50.8%) overall, with no difference between arms. Conclusions In this trial, early delivery of fibrinogen concentrate within 45 minutes of admission was not feasible. Although evidence points to a key role for fibrinogen in the treatment of major bleeding, researchers need to recognise the challenges of timely delivery in the emergency setting. Future studies must explore barriers to rapid fibrinogen therapy, focusing on methods to reduce time to randomisation, using ‘off-the-shelf’ fibrinogen therapies (such as extended shelf-life cryoprecipitate held in the emergency department or fibrinogen concentrates with very rapid reconstitution times) and limiting the need for coagulation test-based transfusion triggers. Trial registration ISRCTN67540073. Registered on 5 August 2015.
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Affiliation(s)
- Nicola Curry
- Department of Haematology, Oxford Haemophilia & Thrombosis Centre, Churchill Hospital, Oxford University Hospitals NHS Trust, Oxford, UK. .,NIHR BRC Blood Theme, Oxford University, Oxford, UK.
| | - Claire Foley
- NHS Blood and Transplant Clinical Trials Unit, Cambridge, Bristol, UK
| | - Henna Wong
- Department of Haematology, Oxford Haemophilia & Thrombosis Centre, Churchill Hospital, Oxford University Hospitals NHS Trust, Oxford, UK.,NIHR BRC Blood Theme, Oxford University, Oxford, UK.,Nuffield Division of Clinical Laboratory Sciences, Radcliffe Department of Medicine, University of Oxford, John Radcliffe Hospital, Oxford, UK
| | - Ana Mora
- NHS Blood and Transplant Clinical Trials Unit, Cambridge, Bristol, UK
| | - Elinor Curnow
- NHS Blood and Transplant Clinical Trials Unit, Cambridge, Bristol, UK
| | - Agne Zarankaite
- NHS Blood and Transplant Clinical Trials Unit, Cambridge, Bristol, UK
| | - Renate Hodge
- NHS Blood and Transplant Clinical Trials Unit, Cambridge, Bristol, UK
| | - Valerie Hopkins
- NHS Blood and Transplant Clinical Trials Unit, Cambridge, Bristol, UK
| | - Alison Deary
- NHS Blood and Transplant Clinical Trials Unit, Cambridge, Bristol, UK
| | - James Ray
- Department of Emergency Medicine, John Radcliffe Hospital, Oxford, UK
| | - Phil Moss
- Department of Emergency Medicine, St. George's Hospital, London, UK
| | - Matthew J Reed
- Emergency Medicine Research Group Edinburgh (EMERGE), Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Suzanne Kellett
- Department of Anaesthetics, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Ross Davenport
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, UK
| | - Simon Stanworth
- Department of Haematology, Oxford Haemophilia & Thrombosis Centre, Churchill Hospital, Oxford University Hospitals NHS Trust, Oxford, UK.,NIHR BRC Blood Theme, Oxford University, Oxford, UK.,Nuffield Division of Clinical Laboratory Sciences, Radcliffe Department of Medicine, University of Oxford, John Radcliffe Hospital, Oxford, UK.,NHS Blood and Transplant, John Radcliffe Hospital, Oxford, UK
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Abstract
PURPOSE OF REVIEW Death from uncontrolled haemorrhage is one of the leading causes of trauma-related mortality and is potentially preventable. Advances in understanding the mechanisms of trauma-induced coagulopathy (TIC) have focused attention on the role of blood products and procoagulants in mitigating the sequelae of TIC and how these therapies can be improved. RECENT FINDINGS A host of preclinical and clinical studies have evaluated blood product availability and efficacy in trauma. Recently published randomized controlled trials have investigated the ratio of platelet:plasma:red cell transfusion and the role of early cryoprecipitate in trauma. Demand for readily available plasma has led to changes particularly in the use of thawed group A plasma. Furthermore, ex-vivo and early clinical work has demonstrated variations in the haemostatic activity of different plasma, platelet and whole blood products. A number of multicentre trials are in progress aiming to answer key questions regarding tranexamic acid, procoagulant factor and fibrinogen concentrates and their effect on trauma outcomes. SUMMARY There are promising results from ex-vivo studies in manufacturing and storage of blood products to optimize haemostatic activity and availability, particularly with alternative plasma and platelet products and whole blood. There is an urgent need for these products needs to be tested prospectively.
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Abstract
PURPOSE OF REVIEW To discuss the recent developments in and evolvement of next generation haemostatic resuscitation in bleeding trauma. RECENT FINDINGS Mortality from major trauma is a worldwide problem, and massive haemorrhage remains a major cause of potentially preventable deaths. Development of coagulopathy further increases trauma mortality emphasizing that coagulopathy is a key target in the phase of bleeding. The pathophysiology of coagulopathy in trauma reflects at least three distinct mechanisms that may be present isolated or coexist: acute traumatic coagulopathy, coagulopathy associated with the lethal triad, and consumptive coagulopathy. The concepts of 'damage control surgery' and 'damage control resuscitation' have been developed to ensure early control of bleeding and coagulopathy to improve outcome in bleeding trauma. Haemostatic resuscitation aims at controlling coagulopathy and consists of a ratio driven strategy aiming at 1 : 1 : 1, using tranexamic acid according to CRASH-2, and applying haemostatic monitoring enabling a switch to a goal-directed approach when bleeding slows. Haemostatic resuscitation is the mainstay of trauma resuscitation and is associated with improved survival. SUMMARY The next generation of haemostatic resuscitation aims at applying a ratio 1 : 1 : 1 driven strategy while using antifibrinolytics, haemostatic monitoring and avoiding critical fibrinogen deficiency by substitution.
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Novak A, Stanworth SJ, Curry N. Do we still need cryoprecipitate? Cryoprecipitate and fibrinogen concentrate as treatments for major hemorrhage - how do they compare? Expert Rev Hematol 2018; 11:351-360. [PMID: 29584463 DOI: 10.1080/17474086.2018.1458610] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
INTRODUCTION Major hemorrhage is a source of significant mortality and morbidity worldwide. Identification and characterization of coagulation impairment associated with major hemorrhage has suggested a key role for fibrinogen deficiency, however the optimum mode of replacement of fibrinogen remains unclear, and standardized major hemorrhage protocols may overlook context-dependent variations in individual patients' clotting derangement. Areas covered: This paper examines the current practice and evidence regarding the role of different modes of fibrinogen replacement in major hemorrhage in 3 distinct clinical settings: trauma, obstetric hemorrhage, and gastrointestinal hemorrhage with associated liver disease. A literature search was carried out electronically using Athens access to the National Health Service evidence health information resources, primarily PubMed and Google Scholar. Expert commentary: Two key questions need to be addressed. First, what is the role of concentrated fibrinogen (by comparison to no fibrinogen), and second, which concentrated source or product is more effective (or cost-effective)? Current practice and concept is derived largely from small pilot trials in the trauma setting, but results from larger studies are awaited. More comparative data on changes to clotting profiles in different groups of bleeding patients are needed to help delineate differences and guide interventional treatment studies.
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Affiliation(s)
- Alex Novak
- a Emergency Department , Oxford University Hospitals NHS Foundation Trust , Oxford , UK
| | - Simon J Stanworth
- b Department of Haematology , Oxford University Hospitals NHS Foundation Trust , Oxford , UK.,c NHS Blood and Transplant , John Radcliffe Hospital , Oxford , UK.,d Radcliffe Department of Medicine , University of Oxford , Oxford , UK.,e Oxford Biomedical Research Centre , NIHR Blood Theme , Oxford , UK
| | - Nicola Curry
- b Department of Haematology , Oxford University Hospitals NHS Foundation Trust , Oxford , UK.,e Oxford Biomedical Research Centre , NIHR Blood Theme , Oxford , UK
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Haas T, Cushing MM, Asmis LM. Comparison of the efficacy of two human fibrinogen concentrates to treat dilutional coagulopathy in vitro. Scandinavian Journal of Clinical and Laboratory Investigation 2018; 78:230-235. [DOI: 10.1080/00365513.2018.1437645] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Thorsten Haas
- Department of Anaesthesia, Zurich University Children’s Hospital, Zurich, Switzerland
| | - Melissa M. Cushing
- Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York, NY, USA
| | - Lars M. Asmis
- Centre for Perioperative Thrombosis and Haemostasis, Zurich, Switzerland
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Scharman CD, Burger D, Shatzel JJ, Kim E, DeLoughery TG. Treatment of individuals who cannot receive blood products for religious or other reasons. Am J Hematol 2017; 92:1370-1381. [PMID: 28815690 DOI: 10.1002/ajh.24889] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2017] [Revised: 08/12/2017] [Accepted: 08/14/2017] [Indexed: 01/04/2023]
Abstract
By virtue of their religious principles, Jehovah's Witnesses (JWs) generally object to receiving blood products, raising numerous ethical, legal, and medical challenges for providers who care for these patients, especially in the emergent setting. In this review, we discuss several areas relevant to the care of JWs, including the current literature on "bloodless" medical care in the setting of perioperative and intraoperative management, acute blood loss, trauma, pregnancy, and malignancy. We have found that medical and administrative efforts in the form of bloodless medicine and surgery programs can be instrumental in helping to reduce risks of morbidity and mortality in these patients. Planning prior to an anticipated event associated with blood loss or anemia (such as elective surgery, pregnancy, and chemotherapy) is critical. Specifically, bloodless medicine programs should prioritize vigilant early screening and management of anemias, early establishment of patient wishes regarding transfusion, and the incorporation of those wishes into multidisciplinary medical and surgical care. Although there are now a variety of human-based and nonhuman-based products available as transfusion alternatives, the degree and quality of evidence to support their use varies significantly between products and is also largely dependent on the clinical setting.
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Affiliation(s)
- Carlton D. Scharman
- Department of Internal Medicine; Oregon Health and Science University; Portland Oregon
| | - Debora Burger
- Patient Blood Management Program; Oregon Health and Science University; Portland Oregon
| | - Joseph J. Shatzel
- Division of Hematology and Medical Oncology; Oregon Health and Science University, Knight Cancer Institute; Portland Oregon
| | - Edward Kim
- School of Medicine; Oregon Health and Science University; Portland Oregon
| | - Thomas G. DeLoughery
- Division of Hematology and Medical Oncology; Oregon Health and Science University, Knight Cancer Institute; Portland Oregon
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41
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Wong H, Curry N. Do we need cryoprecipitate in the era of fibrinogen concentrate and other specific factor replacement options? ACTA ACUST UNITED AC 2017. [DOI: 10.1111/voxs.12376] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
- H. Wong
- Department of Haematology; University of Oxford; Oxford UK
- Oxford Haemophilia & Thrombosis Centre; Oxford University Hospitals NHS Foundation Trust and Oxford NIHR BRC Blood Theme; Oxford UK
| | - N. Curry
- Oxford Haemophilia & Thrombosis Centre; Oxford University Hospitals NHS Foundation Trust and Oxford NIHR BRC Blood Theme; Oxford UK
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McDonnell NJ, Browning R. How to replace fibrinogen in postpartum haemorrhage situations? (Hint: Don't use FFP!). Int J Obstet Anesth 2017; 33:4-7. [PMID: 29017741 DOI: 10.1016/j.ijoa.2017.08.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2017] [Revised: 08/23/2017] [Accepted: 08/28/2017] [Indexed: 10/18/2022]
Affiliation(s)
- N J McDonnell
- Department of Anaesthesia and Pain Medicine, King Edward Memorial Hospital, Perth, Western Australia, Australia; Department of Anaesthesia, St John of God Hospital Subiaco, Perth, Western Australia, Australia; School of Women's and Infants Health and School of Medicine and Pharmacology, University of Western Australia, Perth, Western Australia, Australia.
| | - R Browning
- Department of Anaesthesia and Pain Medicine, King Edward Memorial Hospital, Perth, Western Australia, Australia
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Winearls J, Wullschleger M, Wake E, Hurn C, Furyk J, Ryan G, Trout M, Walsham J, Holley A, Cohen J, Shuttleworth M, Dyer W, Keijzers G, Fraser JF, Presneill J, Campbell D. Fibrinogen Early In Severe Trauma studY (FEISTY): study protocol for a randomised controlled trial. Trials 2017; 18:241. [PMID: 28549445 PMCID: PMC5446750 DOI: 10.1186/s13063-017-1980-x] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2016] [Accepted: 05/06/2017] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Haemorrhage is a leading cause of death in severe trauma. Fibrinogen plays a critical role in maintaining haemostasis in traumatic haemorrhage. Early fibrinogen replacement is recommended by several international trauma guidelines using either fibrinogen concentrate (FC) or cryoprecipitate (Cryo). There is limited evidence to support one product over the other with widespread geographic and institutional variation in practice. This pilot trial is the first randomised controlled trial comparing FC to Cryo in traumatic haemorrhage. METHODS/DESIGN The Fibrinogen Early In Severe Trauma studY (FEISTY) is an exploratory, multicentre, randomised controlled trial comparing FC to Cryo for fibrinogen supplementation in traumatic haemorrhage. This trial will utilise thromboelastometry (ROTEM®) to guide and dose fibrinogen supplementation. The trial will recruit 100 trauma patients at four major trauma centres in Australia. Adult trauma patients with evidence of haemorrhage will be enrolled on arrival in the trauma unit and randomised to receiving fibrinogen supplementation with either FC or Cryo. The primary outcome is the differential time to fibrinogen supplementation. There are a number of predetermined secondary outcomes including: effects of the intervention on plasma fibrinogen levels, feasibility assessments and clinical outcomes including transfusion requirements and mortality. DISCUSSION The optimal method for replacing fibrinogen in traumatic haemorrhage is fiercely debated. In this trial the feasibility and efficacy of fibrinogen supplementation using FC will be compared to Cryo. The results of this pilot study will facilitate the design of a larger trial with sufficient power to address patient-centred outcomes. TRIAL REGISTRATION ClinicalTrials.gov, ID: NCT02745041 . Registered 4 May 2016.
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Affiliation(s)
- James Winearls
- Gold Coast University Hospital, Southport, QLD, Australia. .,School of Medicine, University of Queensland, St. Lucia, QLD, Australia. .,School of Medical Sciences, Griffith University, Nathan, QLD, Australia.
| | - Martin Wullschleger
- Gold Coast University Hospital, Southport, QLD, Australia.,School of Medical Sciences, Griffith University, Nathan, QLD, Australia
| | - Elizabeth Wake
- Gold Coast University Hospital, Southport, QLD, Australia
| | - Catherine Hurn
- School of Medicine, University of Queensland, St. Lucia, QLD, Australia.,Royal Brisbane and Women's Hospital, Herston, QLD, Australia
| | - Jeremy Furyk
- Emergency Research, Townsville Hospital, Douglas, QLD, Australia
| | - Glenn Ryan
- Princess Alexandra Hospital, Woolloongabba, QLD, Australia
| | | | - James Walsham
- School of Medicine, University of Queensland, St. Lucia, QLD, Australia.,Intensive Care Research, Princess Alexandra Hospital, Woolloongabba, QLD, Australia
| | - Anthony Holley
- School of Medicine, University of Queensland, St. Lucia, QLD, Australia.,Royal Brisbane and Women's Hospital, Herston, QLD, Australia
| | - Jeremy Cohen
- School of Medicine, University of Queensland, St. Lucia, QLD, Australia.,Royal Brisbane and Women's Hospital, Herston, QLD, Australia
| | - Megan Shuttleworth
- Menzies Health Institute Queensland, Griffith University, Nathan, QLD, Australia
| | - Wayne Dyer
- Australian Red Cross Blood Service, Melbourne, VIC, Australia
| | - Gerben Keijzers
- Gold Coast University Hospital, Southport, QLD, Australia.,School of Medical Sciences, Griffith University, Nathan, QLD, Australia.,School of Medicine, Bond University, Robina, QLD, Australia
| | - John F Fraser
- Critical Care Research Group, The Prince Charles Hospital and University of Queensland, Brisbane, QLD, Australia
| | - Jeffrey Presneill
- Intensive Care Unit, Royal Melbourne Hospital and University of Melbourne, Melbourne, VIC, Australia
| | - Don Campbell
- Gold Coast University Hospital, Southport, QLD, Australia
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Abstract
Haemorrhage in the setting of severe trauma is associated with significant morbidity and mortality. There is increasing awareness of the important role fibrinogen plays in traumatic haemorrhage. Fibrinogen levels fall precipitously in severe trauma and the resultant hypofibrinogenaemia is associated with poor outcomes. Hence, it has been postulated that early fibrinogen replacement in severe traumatic haemorrhage may improve outcomes, although, to date there is a paucity of high quality evidence to support this hypothesis. In addition there is controversy regarding the optimal method for fibrinogen supplementation. We review the current evidence regarding the role of fibrinogen in trauma, the rationale behind fibrinogen supplementation and discuss current research.
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Hasegawa A, Murakoshi T, Otsuki Y, Torii Y. Clinical course of disseminated intravascular coagulopathy-type amniotic fluid embolism: A report of three cases. J Obstet Gynaecol Res 2016; 42:1881-1885. [PMID: 27650060 DOI: 10.1111/jog.13142] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2016] [Revised: 06/26/2016] [Accepted: 07/17/2016] [Indexed: 11/26/2022]
Abstract
Amniotic fluid embolism (AFE) is a rare complication of pregnancy and its mortality rate is high. There have been few reports of AFE with presence of severe coagulopathy and incoagulable bleeding, and absence of cardiopulmonary symptoms or limited cardiopulmonary symptoms, followed by massive blood loss during delivery. Such cases have been referred to as disseminated intravascular coagulopathy-type AFE, and the characteristics of this condition have been presented previously. Here we report three cases that fulfilled the diagnostic characteristics of disseminated intravascular coagulopathy-type AFE.
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Affiliation(s)
- Akihiro Hasegawa
- Division of Perinatology, Fetal Diagnosis and Therapy, Maternal and Perinatal Care Center, Shizuoka, Japan
| | - Takeshi Murakoshi
- Division of Perinatology, Fetal Diagnosis and Therapy, Maternal and Perinatal Care Center, Shizuoka, Japan
| | - Yoshiro Otsuki
- Department of Pathology, Seirei Hamamatsu General Hospital, Shizuoka, Japan
| | - Yuichi Torii
- Division of Perinatology, Fetal Diagnosis and Therapy, Maternal and Perinatal Care Center, Shizuoka, Japan
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Pilot Randomized trial of Fibrinogen in Trauma Haemorrhage (PRooF-iTH): study protocol for a randomized controlled trial. Trials 2016; 17:327. [PMID: 27430210 PMCID: PMC4949907 DOI: 10.1186/s13063-016-1439-5] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2015] [Accepted: 06/28/2016] [Indexed: 01/28/2023] Open
Abstract
Background Haemorrhage remains a leading cause of morbidity and mortality in trauma patients. Fibrinogen is an essential endogenous component of haemostasis and the plasma level is associated with bleeding, transfusion and outcome. Fibrinogen concentrate is widely used to correct acquired hypofibrinogenaemia, recommended by several international guidelines for the treatment of trauma patients, but evidence is lacking regarding the treatment safety and efficacy. We aim to assess the efficacy and safety of an immediate pre-emptive first-line treatment with fibrinogen concentrate in patients with trauma haemorrhage in need of haemostatic resuscitation. Methods/Design This is a single-centre, randomized (1:1, active:placebo), placebo-controlled, double-blinded, investigator-initiated phase II trial. The trial population consists of 40 adult patients (>18 years) with traumatic, critical bleeding admitted to the Level 1 Trauma Centre at Rigshospitalet in Copenhagen, with immediate need for blood transfusion on arrival and an expected need for haemostatic resuscitation with multiple transfusions during the initial resuscitation. Patients will receive either pre-emptive administration of a bolus dose of 60–70 mg/kg fibrinogen concentrate (Riastap®) or placebo 0.9 % saline in equal volume to active treatment, both given as intravenous infusion blinded for the person administering the infusion. The primary end point is the change in thrombelastograph (TEG®) functional fibrinogen maximum amplitude in millimetres at 15 min after the intervention. The follow-up period on safety events and mortality will be until day 30. To detect a difference in the change from baseline to the 15-minute post-randomization measurement of 6–8 mm in TEG® functional fibrinogen maximum amplitude with a power of 0.90 and alpha of 0.05, we require 19 patients in each group. We have chosen to include 40 patients, 20 evaluable patients in each randomization group in case of attrition, in the present trial. Discussion Patients considered to be included in the trial will temporarily have a compromised consciousness because of the acute, critical bleeding related to trauma, so scientific guardians will co-sign the informed consent form. Next of kin and the patients’ general practitioner or the patients will co-sign as soon as possible. This trial will test whether immediate pre-emptive fibrinogen concentrate administered to adult trauma patients as first-line treatment of trauma haemorrhage will increase the clot strength as evaluated by thrombelastography, transfusion requirements and survival in patients receiving haemostatic resuscitation according to current standard of care. Trial registration EudraCT no. 2014-003978-16 (22/1 2015); ClinicalTrials.gov: NCT02344069. Registered on 14 January 2015. Trial protocol version 4.2 (23-12-2014).
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