Ten-year evolution of a massive transfusion protocol in a level 1 trauma centre: have outcomes improved?

Acquired Factor XIII Deficiency in Patients with Multiple Trauma

INTRODUCTION

Fibrin stabilizing factor (FXIII) plays a crucial role in blood clotting, tissue repair, and immune defense. FXIII deficiency after trauma can lead to prolonged wound healing due to persistent infections or coagulation disorders. The aim of this study was to describe the prevalence of acquired FXIII deficiency after trauma and to provide a description of the time-course changes of important coagulation parameters in relation to FXIII activity. In this context, patient characteristics, laboratory data, and treatment modalities were examined with respect to their influence on FXIII activity. Furthermore, the effects of in vitro administration of FXIII on clot firmness and outcomes in patients with severe traumatic brain injury were investigated.

PATIENTS AND METHODS

Two trauma cohorts (A and B) were examined prospectively in a two-center study, and another (cohort C) was examined retrospectively. In cohort A (trauma patients, n=880) routine laboratory tests were conducted, and FXIII activity was measured. In cohort B (polytrauma patients, n=26), additional clinical parameters were collected, and in-vitro FXIII administration and rotational thromboelastometry (ROTEM) analyses were performed. In cohort C (polytrauma patients with severe traumatic brain injury [sTBI], n=84), the impact of initially measured FXIII activity on clinical outcomes after sTBI was investigated using the modified Rankin Scale (mRS) at least 6 months after trauma.

RESULTS

The prevalence of FXIII activity <70% in cohort A was 12.4%, with significant differences in age, Hb, fibrinogen, and Hct levels, platelet count, aPTT, and INR (vs. prevalence of FXIII activity >70%). Cohort B showed a decrease in FXIII activity from 85% to 58% after 7 days. FXIII deficiency correlated with time after trauma, aPTT, and fibrinogen level, lactate, and Hb levels. In-vitro administration of FXIII showed a positive influence on clot firmness due to improved maximum clot firmness (MCF in FIBTEM) and reduced maximum lysis (ML in EXTEM). Finally, a significant difference in FXIII activity between patients after sTBI with good and poor clinical outcomes was observed 6 months after trauma.

CONCLUSION

We demonstrated that trauma-associated FXIII deficiency is a common coagulation disorder, with FXIII deficiency increasing further in the first 7 days after trauma, the period of early surgical care. In vitro administration of FXIII was able to demonstrate significant clot stabilizing effects. For trauma patients with sTBI, FXIII activity could serve as a prognostic parameter, as it differed significantly between patients with good and poor clinical outcomes.

Platelet to erythrocyte transfusion ratio and mortality in massively transfused trauma patients. A systematic review and meta-analysis

BACKGROUND

Platelet transfusion during major hemorrhage is important and often embedded in massive transfusion protocols. However, the optimal ratio of platelets to erythrocytes (platelet-rich plasma [PLT]/red blood cell [RBC] ratio) remains unclear. We hypothesized that high PLT/RBC ratios, as compared with low PLT/RBC ratios, are associated with improved survival in patients requiring massive transfusion.

METHODS

Four databases (Pubmed, CINAHL, EMBASE, and Cochrane) were systematically screened for literatures published until January 21, 2021, to determine the effect of PLT/RBC ratio on the primary outcome measure mortality at 1 hour to 6 hours and 24 hours and at 28 days to 30 days. Studies comparing various PLT/RBC ratios were included in the meta-analysis. Secondary outcomes included intensive care unit length of stay and in-hospital length of stay and total blood component use. The study protocol was registered in PROSPERO under number CRD42020165648.

RESULTS

The search identified a total of 8903 records. After removing the duplicates and second screening of title, abstract, and full text, a total of 59 articles were included in the analysis. Of these articles, 12 were included in the meta-analysis. Mortality at 1 hour to 6 hours, 24 hours, and 28 days to 30 days was significantly lower for high PLT/RBC ratios as compared with low PLT/RBC ratios.

CONCLUSION

Higher PLT/RBC ratios are associated with significantly lower 1-hour to 6-hour, 24-hour, 28-day to 30-day mortalities as compared with lower PLT/RBC ratios. The optimal PLT/RBC ratio for massive transfusion in trauma patients is approximately 1:1.

LEVEL OF EVIDENCE

Systematic review and meta-analysis, therapeutic Level III.

The clock is ticking: using in situ simulation to improve time to blood administration for bleeding trauma patients

INTRODUCTION

Massive hemorrhage protocols are widely used to facilitate the administration of blood components to bleeding trauma patients. Delays in this process are associated with worse patient outcomes. We used in situ simulation as a novel and iterative quality improvement technique to reduce the mean time between massive hemorrhage protocol activation and blood administration during actual trauma resuscitations.

METHODS

We completed monthly, risk-informed unannounced in situ trauma simulations at a Canadian Level 1 trauma centre. We identified three major latent safety threats: (1) massive hemorrhage protocol activation; (2) transport of blood components; and (3) situational awareness of team members. Process improvements for each latent safety threats were tested and implemented during subsequent in situ simulation sessions. We evaluated the effect of this simulation-based intervention on the care of patients before, during and after the intervention. Demographic, clinical and massive hemorrhage protocol data were collected. The primary outcome was mean time between massive hemorrhage protocol activation and blood administration during actual trauma resuscitations as analyzed using a two-sample t test.

RESULTS

Each group was similar in demographic and injury characteristics. The time from massive hemorrhage protocol activation to blood administration decreased from 11.6 min pre-intervention to 9.1 min post-intervention. This represented a significant reduction (2.5 min, 95% confidence interval, 0.03-5.08) following the in situ simulation-based quality improvement intervention.

CONCLUSIONS

A comprehensive, in situ simulation-based quality improvement project was associated with a significant reduction in the mean time between massive hemorrhage protocol activation and blood administration among injured patients. In situ simulation represents a novel approach to the identification and mitigation of latent safety threats during massive hemorrhage protocol activation.

The effect of massive transfusion protocol implementation on the survival of trauma patients: a systematic review and meta-analysis

BACKGROUND

Massive transfusion protocol (MTP) has been widely adopted for the care of bleeding trauma patients but its actual effectiveness is unclear. An earlier meta-analysis on the implementation of MTP for injured patients from 1990 to 2013 reported that only 2 out of 8 studies showed statistical improvement in survival. This study aimed to conduct an updated systematic review and meta-analysis to evaluate the effect of implementing an MTP on the mortality of trauma patients.

MATERIALS AND METHODS

MEDLINE, PubMed, Cochrane Library and Google scholar databases were systematically searched for relevant studies published from 1^st January 2008 to 30^th September 2019 using a combination of keywords and additional manual searching of reference lists. Inclusion criteria were: original study in English, study population including trauma patients, and comparison of mortality outcomes before and after institutional implementation of an MTP. Primary outcomes were 24-hour, 30-day, and overall mortality.

RESULTS

Fourteen studies met inclusion criteria, analysing outcomes from 3,201 trauma patients. There was a wide range of outcomes, patient populations, and process indicators utilised by the different authors. MTP significantly reduced the overall mortality for trauma patients (OR 0.71 [0.56-0.90]). No significant reduction was seen in either the 24-hour mortality (OR 0.81 [0.57-1.14]) or the 30-day mortality (OR 0.73 [0.46-1.16]). However, when mortality timing was unspecified, mortality was statistically reduced (OR 0.69 [0.55-0.86]).

DISCUSSION

The present study found a significant reduction in mortality following MTP implementation and thus it should be recommended to all institutions managing acutely injured patients. To better identify which elements of an MTP contribute to this effect, we encourage the use of standard nomenclature, indicators, protocols and patient populations in all future MTP studies.