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Linström M, Musekwa E, Nell EM, de Waard L, Chapanduka Z. The influence of hematological profiles on the transfusion management and mortality risk of mothers presenting to the obstetric unit of a South African tertiary medical facility. Transfusion 2024; 64:986-997. [PMID: 38661229 DOI: 10.1111/trf.17849] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Revised: 01/09/2024] [Accepted: 04/10/2024] [Indexed: 04/26/2024]
Abstract
BACKGROUND Laboratory results are frequently abnormal in pregnant mothers. Abnormalities usually relate to pregnancy or associated complications. Hematological abnormalities and age in pregnancy may increase the likelihood for transfusion and mortality. STUDY DESIGN AND METHODS Hematological profiles and transfusion history of pregnant mothers presenting to a tertiary hospital, were evaluated over 2 years. Age, anemia, leukocytosis and thrombocytopenia were assessed for transfusion likelihood. Iron deficiency and coagulation were assessed in transfused patients. Anemia, leukocytosis, thrombocytopenia, human immunodeficiency virus (HIV) and transfusion were assessed for mortality likelihood. RESULTS There were 12,889 pregnant mothers included. Mothers <19-years-old had the highest prevalence of anemia (31.5%) and proportion of transfusions (19%). The transfusion likelihood was increased in mothers with anemia (odds ratios [OR] = 6.41; confidence intervals at 95% [95% CI] 5.46-7.71), leukocytosis (OR = 2.35; 95% CI 2.00-2.76) or thrombocytopenia (OR = 2.71; 95% CI 2.21-3.33). Mothers with prolonged prothrombin times received twice as many blood products as their normal counterparts (p = .03) and those with iron deficiency anemia five times more blood products (p < .001). Increased likelihood for mortality was seen in patients with anemia (OR = 4.15, 95% CI 2.03-8.49), leukocytosis (OR = 2.68; 95% CI 1.19-6.04) and those receiving blood transfusion (OR = 3.6, 95% CI 1.75-7.47). DISCUSSION Adolescence, anemia, leukocytosis and thrombocytopenia expose mothers to a high risk for transfusion and/or mortality. These risk factors should promptly trigger management and referral of patients. Presenting hematological profiles are strong predictors of maternal outcome and transfusion risk.
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Affiliation(s)
- Michael Linström
- Division of Hematological Pathology, Department of Pathology, Stellenbosch University, Cape Town, South Africa
- Division of Hematopathology, National Health Laboratory Services, Tygerberg Hospital, Cape Town, South Africa
| | - Ernest Musekwa
- Division of Hematological Pathology, Department of Pathology, Stellenbosch University, Cape Town, South Africa
- Division of Hematopathology, National Health Laboratory Services, Tygerberg Hospital, Cape Town, South Africa
| | - Erica-Mari Nell
- Division of Hematological Pathology, Department of Pathology, Stellenbosch University, Cape Town, South Africa
- Division of Hematopathology, National Health Laboratory Services, Tygerberg Hospital, Cape Town, South Africa
| | - Liesl de Waard
- Department of Obstetrics and Gynecology, Stellenbosch University, Cape Town, South Africa
| | - Zivanai Chapanduka
- Division of Hematological Pathology, Department of Pathology, Stellenbosch University, Cape Town, South Africa
- Division of Hematopathology, National Health Laboratory Services, Tygerberg Hospital, Cape Town, South Africa
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Vaizer R, Leeper CM, Lu L, Josephson CD, Leonard JC, Brown JB, Spinella PC. Increased platelet to red blood cell transfusion ratio associated with acute kidney injury in children with life-threatening bleeding. Transfusion 2024; 64 Suppl 2:S62-S71. [PMID: 38511721 DOI: 10.1111/trf.17788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2023] [Revised: 03/06/2024] [Accepted: 03/06/2024] [Indexed: 03/22/2024]
Abstract
INTRODUCTION Transfusion may increase the risk of organ failure through immunomodulatory effects. The primary objective of this study was to assess for patient or transfusion-related factors that are independently associated with the risk of acute kidney injury (AKI) and acute respiratory distress syndrome (ARDS) in a cohort of children with life-threatening bleeding from all etiologies. METHODS In a secondary analysis of the prospective observational massive transfusion in children (MATIC) study, multivariable logistic regression was performed in an adjusted analysis to determine if blood product ratios or deficits were independently associated with AKI or ARDS in children with life-threatening bleeding. RESULTS There were 449 children included with a median (interquartile range, IQR) age of 7.3 years (1.7-14.7). Within 5 days of the life-threatening bleeding event, AKI occurred in 18.5% and ARDS occurred in 20.3% of the subjects. Every 10% increase in the platelet to red blood cell transfusion ratio is independently associated with a 12.7% increase in the odds of AKI (adjusted odds ratio 1.127; 95% confidence interval 1.025-1.239; p-value .013). Subjects with operative or medical etiologies were independently associated with an increased risk of AKI compared to those with traumatic injury. No transfusion-related variables were independently associated with the risk of developing ARDS. CONCLUSION The use of increased platelet to red blood cell transfusion ratios in children with life-threatening bleeding of any etiology may increase the risk of AKI but not ARDS. Prospective trials are needed to determine if increased platelet use in this cohort increases the risk of AKI to examine possible mechanisms.
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Affiliation(s)
- Rachel Vaizer
- Department of Pediatrics, Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Christine M Leeper
- Trauma and Transfusion Medicine Research Center, Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Liling Lu
- Trauma and Transfusion Medicine Research Center, Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Cassandra D Josephson
- Cancer and Blood Disorders Institute, Johns Hopkins All Children's Hospital, St. Petersburg, Florida, USA
- Departments of Oncology and Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Julie C Leonard
- Center for Injury Research and Policy, Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Joshua B Brown
- Trauma and Transfusion Medicine Research Center, Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Philip C Spinella
- Trauma and Transfusion Medicine Research Center, Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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Shackelford SA, Del Junco DJ, Mazuchowski EL, Kotwal RS, Remley MA, Keenan S, Gurney JM. The Golden Hour of Casualty Care: Rapid Handoff to Surgical Team is Associated With Improved Survival in War-injured US Service Members. Ann Surg 2024; 279:1-10. [PMID: 36728667 DOI: 10.1097/sla.0000000000005787] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To examine time from injury to initiation of surgical care and association with survival in US military casualties. BACKGROUND Although the advantage of trauma care within the "golden hour" after an injury is generally accepted, evidence is scarce. METHODS This retrospective, population-based cohort study included US military casualties injured in Afghanistan and Iraq, January 2007 to December 2015, alive at initial request for evacuation with maximum abbreviated injury scale scores ≥2 and documented 30-day survival status after injury. Interventions: (1) handoff alive to the surgical team, and (2) initiation of first surgery were analyzed as time-dependent covariates (elapsed time from injury) using sequential Cox proportional hazards regression to assess how intervention timing might affect mortality. Covariates included age, injury year, and injury severity. RESULTS Among 5269 patients (median age, 24 years; 97% males; and 68% battle-injured), 728 died within 30 days of injury, 68% within 1 hour, and 90% within 4 hours. Only handoffs within 1 hour of injury and the resultant timely initiation of emergency surgery (adjusted also for prior advanced resuscitative interventions) were significantly associated with reduced 24-hour mortality compared with more delayed surgical care (adjusted hazard ratios: 0.34; 95% CI: 0.14-0.82; P = 0.02; and 0.40; 95% CI: 0.20-0.81; P = 0.01, respectively). In-hospital waits for surgery (mean: 1.1 hours; 95% CI; 1.0-1.2) scarcely contributed ( P = 0.67). CONCLUSIONS Rapid handoff to the surgical team within 1 hour of injury may reduce mortality by 66% in US military casualties. In the subgroup of casualties with indications for emergency surgery, rapid handoff with timely surgical intervention may reduce mortality by 60%. To inform future research and trauma system planning, findings are pivotal.
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Affiliation(s)
| | | | - Edward L Mazuchowski
- Joint Trauma System, Defense Health Agency, Fort Sam Houston, TX
- Armed Forces Medical Examiner System, Defense Health Agency, Dover AFB, DE
| | - Russ S Kotwal
- Joint Trauma System, Defense Health Agency, Fort Sam Houston, TX
| | - Michael A Remley
- Joint Trauma System, Defense Health Agency, Fort Sam Houston, TX
| | - Sean Keenan
- Joint Trauma System, Defense Health Agency, Fort Sam Houston, TX
| | - Jennifer M Gurney
- Joint Trauma System, Defense Health Agency, Fort Sam Houston, TX
- US Army Institute of Surgical Research, Fort Sam Houston, TX
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Blais-Normandin I, Rymer T, Feenstra S, Burry A, Colavecchia C, Duncan J, Farrell M, Greene A, Gupta A, Huynh Q, Lawrence R, Lehto P, Lett R, Lin Y, Lyon B, McCarthy J, Nahirniak S, Nolan B, Peddle M, Prokopchuk-Gauk O, Sham L, Trojanowski J, Shih AW. Current state of technical transfusion medicine practice for out-of-hospital blood transfusion in Canada. Vox Sang 2023; 118:1086-1094. [PMID: 37794849 DOI: 10.1111/vox.13542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 09/11/2023] [Accepted: 09/18/2023] [Indexed: 10/06/2023]
Abstract
BACKGROUND AND OBJECTIVES Canadian out-of-hospital blood transfusion programmes (OHBTPs) are emerging, to improve outcomes of trauma patients by providing pre-hospital transfusion from the scene of injury, given prolonged transport times. Literature is lacking to guide its implementation. Thus, we sought to gather technical transfusion medicine (TM)-specific practices across Canadian OHBTPs. MATERIALS AND METHODS A survey was sent to TM representatives of Canadian OHBTPs from November 2021 to March 2022. Data regarding transport, packaging, blood components and inventory management were included and reported descriptively. Only practices involving Blood on Board programme components for emergency use were included. RESULTS OHBTPs focus on helicopter emergency medical service programmes, with some supplying fixed-wing aircraft and ground ambulances. All provide 1-3 coolers with 2 units of O RhD/Kell-negative red blood cells (RBCs) per cooler, with British Columbia trialling coolers with 2 units of pre-thawed group A plasma. Inventory exchanges are scheduled and blood components are returned to TM inventory using visual inspection and internal temperature data logger readings. Coolers are validated to storage durations ranging from 72 to 124 h. All programmes audit to manage wastage, though there is no consensus on appropriate benchmarks. All programmes have a process for documenting units issued, reconciliation after transfusion and for transfusion reaction reporting; however, training programmes vary. Common considerations included storage during extreme temperature environments, O-negative RBC stewardship, recipient notification, traceability, clinical practice guidelines co-reviewed by TM and a common audit framework. CONCLUSION OHBTPs have many similarities throughout Canada, where harmonization may assist in further developing standards, leveraging best practice and national coordination.
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Affiliation(s)
- Isabelle Blais-Normandin
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Tihiro Rymer
- Alberta Precision Labs, Transfusion and Transplantation Medicine, Edmonton, Alberta, Canada
| | - Shelley Feenstra
- Vancouver Coastal Health Authority, Vancouver, British Columbia, Canada
| | - Anne Burry
- Alberta Precision Labs, Transfusion and Transplantation Medicine, Edmonton, Alberta, Canada
| | | | - Jennifer Duncan
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- Vancouver Island Health Authority, Courtenay, British Columbia, Canada
| | - Michael Farrell
- Provincial Blood Coordinating Team, Nova Scotia Health Authority, Halifax, Nova Scotia, Canada
| | - Adam Greene
- British Columbia Emergency Health Services, Parksville, British Columbia, Canada
| | - Akash Gupta
- Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
| | - Queenie Huynh
- Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Robin Lawrence
- Saskatchewan Health Authority, Regina, Saskatchewan, Canada
| | - Paula Lehto
- Saskatchewan Health Authority, Saskatoon, Saskatchewan, Canada
| | - Ryan Lett
- Saskatchewan Health Authority, Regina, Saskatchewan, Canada
- Department of Anesthesiology, Regina, Saskatchewan, Canada
| | - Yulia Lin
- Vancouver Island Health Authority, Courtenay, British Columbia, Canada
- Saskatchewan Health Authority, Regina, Saskatchewan, Canada
| | - Bruce Lyon
- Alberta Precision Labs, Transfusion and Transplantation Medicine, Edmonton, Alberta, Canada
| | - Joanna McCarthy
- Alberta Precision Labs, Transfusion and Transplantation Medicine, Edmonton, Alberta, Canada
| | - Susan Nahirniak
- Alberta Precision Labs, Transfusion and Transplantation Medicine, Edmonton, Alberta, Canada
- Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, Alberta, Canada
| | - Brodie Nolan
- Provincial Blood Coordinating Team, Nova Scotia Health Authority, Halifax, Nova Scotia, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Emergency Medicine, Unity Health Toronto, Toronto, Ontario, Canada
| | - Michael Peddle
- Ornge, Mississauga, Ontario, Canada
- Division of Emergency Medicine, Western University, London, Ontario, Canada
| | - Oksana Prokopchuk-Gauk
- Saskatchewan Health Authority, Saskatoon, Saskatchewan, Canada
- Department of Pathology and Laboratory Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Lawrence Sham
- Vancouver Coastal Health Authority, Vancouver, British Columbia, Canada
| | - Jan Trojanowski
- Vancouver Coastal Health Authority, Vancouver, British Columbia, Canada
- Department of Emergency Medicine, Vancouver, British Columbia, Canada
- British Columbia Emergency Health Services, Vancouver, British Columbia, Canada
| | - Andrew W Shih
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- Vancouver Coastal Health Authority, Vancouver, British Columbia, Canada
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Muldowney M, Liu Z, Stansbury LG, Vavilala MS, Hess JR. Ultramassive Transfusion for Trauma in the Age of Hemostatic Resuscitation: A Retrospective Single-Center Cohort From a Large US Level-1 Trauma Center, 2011-2021. Anesth Analg 2023; 136:927-933. [PMID: 37058729 DOI: 10.1213/ane.0000000000006388] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/16/2023]
Abstract
BACKGROUND Uncontrolled bleeding is a leading cause of death in trauma. In the last 40 years, ultramassive transfusion (UMT; ≥20 units of red blood cells [RBCs]/24 hours) for trauma has been associated with 50% to 80% mortality; the question remains as to whether the increasing number of units transfused in urgent resuscitation is a marker of futility. We asked whether the frequency and outcomes of UMT have changed in the era of hemostatic resuscitation. METHODS We performed a retrospective cohort study of all UMTs in the first 24 hours of care over an 11-year period at a major US level-1 adult and pediatric trauma center. UMT patients were identified, and a dataset was built by linking blood bank and trauma registry data, then reviewing individual electronic health records. Success in achieving hemostatic proportions of blood products was estimated as (units of plasma + apheresis-platelets-in-plasma + cryoprecipitate-pools + whole blood]/[all units given] ≥0.5. Demographics, injury type (blunt or penetrating), severity (Injury Severity Score [ISS]), severity pattern (Abbreviated Injury Scale score for head [AIS-Head] ≥4), admitting laboratory, transfusion, selected emergency department interventions, and discharge status were assessed using χ2 tests of categorical association, the Student t-test of means, and multivariable logistic regression. P <.05 was considered significant. RESULTS Among 66,734 trauma admissions from April 6, 2011 to December 31, 2021, we identified 6288 (9.4%) who received any blood products in the first 24 hours, 159 of whom received UMT (0.23%; 154 aged 18-90 + 5 aged 9-17), 81% in hemostatic proportions. Overall mortality was 65% (n = 103); mean ISS = 40; median time to death, 6.1 hours. In univariate analyses, death was not associated with age, sex, or more RBC units transfused beyond 20 but was associated with blunt injury, increasing injury severity, severe head injury, and failure to receive hemostatic blood product ratios. Mortality was also associated with decreased pH and evidence of coagulopathy at admission, especially hypofibrinogenemia. Multivariable logistic regression showed severe head injury, admission hypofibrinogenemia and not receiving a hemostatic resuscitation proportion of blood products as independently associated with death. CONCLUSIONS One in 420 acute trauma patients at our center received UMT, a historically low rate. A third of these patients lived, and UMT was not itself a marker of futility. Early identification of coagulopathy was possible, and failure to give blood components in hemostatic ratios was associated with excess mortality.
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Affiliation(s)
- Maeve Muldowney
- From the Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington
| | - Zhinan Liu
- Harborview Injury Prevention Research Center, Harborview Medical Center, Seattle, Washington
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, Washington
| | - Lynn G Stansbury
- From the Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington
- Harborview Injury Prevention Research Center, Harborview Medical Center, Seattle, Washington
| | - Monica S Vavilala
- From the Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington
- Harborview Injury Prevention Research Center, Harborview Medical Center, Seattle, Washington
| | - John R Hess
- Harborview Injury Prevention Research Center, Harborview Medical Center, Seattle, Washington
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, Washington
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6
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Resuscitative practices and the use of low-titer group O whole blood in pediatric trauma. J Trauma Acute Care Surg 2023; 94:S29-S35. [PMID: 36156051 DOI: 10.1097/ta.0000000000003801] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
ABSTRACT Increasing rates of penetrating trauma in the United States makes rapid identification of hemorrhagic shock, coagulopathy, and early initiation of balanced resuscitation in injured children of critical importance. Hemorrhagic shock begins early after injury and can be challenging to identify in children, as hypotension is a late sign that a child is on the verge of circulatory collapse and should be aggressively resuscitated. Recent data support shifting away from crystalloid and toward early resuscitation with blood products because of worse coagulopathy and clinical outcomes in injured patients resuscitated with crystalloid. Multicenter studies have found improved survival in injured children who receive balanced resuscitation with higher fresh frozen plasma: red blood cell ratios. Whole blood is an efficient way to achieve balanced resuscitation in critically injured children with limited intravenous access and decreased exposure to multiple donors. Administration of cold-stored, low-titer O-negative whole blood (LTOWB) appears to be safe in adults and children and may be associated with improved survival in children with life-threatening hemorrhage. Many pediatric centers use RhD-negative LTOWB for all female children because of the risk of hemolytic disease of the fetus and newborn (0-6%); however. there is a scarcity of LTOWB compared with the demand. Low risks of hemolytic disease of the fetus and newborn affecting a future pregnancy must be weighed against high mortality rates in delayed blood product administration in children in hemorrhagic shock. Survey studies involving key stakeholder's opinions on pediatric blood transfusion practices are underway. Existing pediatric-specific literature on trauma resuscitation is often limited and underpowered; multicenter prospective studies are urgently needed to define optimal resuscitation products and practices in injured children in an era of increasing penetrating trauma.
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7
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Gebregiorgis HT, Hasan RA, Liu Z, Phuong J, Stansbury LG, Khan J, Tsang HC, Vavilala MS, Hess JR. Drivers of blood use in paediatric trauma: A retrospective cohort study. Transfus Med 2022; 32:383-393. [DOI: 10.1111/tme.12901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2022] [Revised: 06/29/2022] [Accepted: 07/26/2022] [Indexed: 11/28/2022]
Affiliation(s)
- Hermela T. Gebregiorgis
- Department of Anesthesiology and Pain Medicine Harborview Injury Prevention and Research Center, University of Washington (UW) School of Medicine (SOM) Seattle Washington USA
- University of Washington (UW) School of Pharmacy Seattle Washington USA
| | - Rida A. Hasan
- Department of Laboratory Medicine and Pathology UW School of Medicine (SOM) Seattle Washington USA
- Department of Pediatrics UW SOM Seattle Washington USA
| | - Zhinan Liu
- Department of Anesthesiology and Pain Medicine Harborview Injury Prevention and Research Center, University of Washington (UW) School of Medicine (SOM) Seattle Washington USA
| | - Jim Phuong
- Department of Anesthesiology and Pain Medicine Harborview Injury Prevention and Research Center, University of Washington (UW) School of Medicine (SOM) Seattle Washington USA
| | - Lynn G. Stansbury
- Department of Anesthesiology and Pain Medicine Harborview Injury Prevention and Research Center, University of Washington (UW) School of Medicine (SOM) Seattle Washington USA
- Department of Pediatrics UW SOM Seattle Washington USA
- Department of Anesthesiology and Pain Medicine UW SOM Seattle Washington USA
| | - Jenna Khan
- Department of Laboratory Medicine and Pathology UW School of Medicine (SOM) Seattle Washington USA
- Transfusion Medicine Service Dartmouth Hitchcock Medical Centre Hanover New Hampshire USA
| | - Hamilton C. Tsang
- Department of Laboratory Medicine and Pathology UW School of Medicine (SOM) Seattle Washington USA
| | - Monica S. Vavilala
- Department of Anesthesiology and Pain Medicine Harborview Injury Prevention and Research Center, University of Washington (UW) School of Medicine (SOM) Seattle Washington USA
- Department of Pediatrics UW SOM Seattle Washington USA
- Department of Anesthesiology and Pain Medicine UW SOM Seattle Washington USA
| | - John R. Hess
- Department of Anesthesiology and Pain Medicine Harborview Injury Prevention and Research Center, University of Washington (UW) School of Medicine (SOM) Seattle Washington USA
- Department of Laboratory Medicine and Pathology UW School of Medicine (SOM) Seattle Washington USA
- Transfusion Medicine Service Harborview Medical Centre Seattle Washington USA
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8
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Boye M, Py N, Libert N, Chrisment A, Pissot M, Dedome E, Martinaud C, Ausset S, Boutonnet M, De Rudnicki S, Pasquier P, Martinez T. Step by step transfusion timeline and its challenges in trauma: A retrospective study in a level one trauma center. Transfusion 2022; 62 Suppl 1:S30-S42. [PMID: 35781713 DOI: 10.1111/trf.16953] [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: 12/24/2021] [Revised: 03/30/2022] [Accepted: 04/01/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Hemorrhagic shock is the leading cause of preventable early death in trauma patients. Transfusion management is guided by international guidelines promoting early and aggressive transfusion strategies. This study aimed to describe transfusion timelines in a trauma center and to identify key points to performing early and efficient transfusions. METHODS This is a monocentric retrospective study of 108 severe trauma patients, transfused within the first 48 h and hospitalized in an intensive care unit between January 2017 and May 2019. RESULTS One hundred and eight patients were transfused with 1250 labile blood products. Half of these labile blood products were transfused within 3 h of admission and consumed by 26 patients requiring massive transfusion (≥4 red blood cells [RBC] within 1 h). Among these, the median delay from patient's admission to labile blood products prescription was -11 min (-34 to -1); from admission to delivery of labile blood products was 1 min (-20 to 16); and from admission to first transfusion was 20 min (7-37) for RBC, 26 min (13-38) for plasma, and 72 min (51-103) for platelet concentrates. The anticipated prescription of labile blood products and the use of massive transfusion packs and lyophilized plasma units were associated with earlier achievement of high transfusion ratios. CONCLUSION This study provides detailed data on the transfusion timelines and composition, from prescription to initial transfusion. Transfusion anticipation, use of preconditioned transfusion packs including platelets, and lyophilized plasma allow rapid and high-ratio transfusion practices in severe trauma patients.
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Affiliation(s)
- Matthieu Boye
- Federation of anesthesiology, intensive care unit, burns and operating theater, Percy Military Training Hospital, Clamart, France.,École du Val-de-Grâce, French Military Medical Service Academy, Paris, France
| | - Nicolas Py
- Federation of anesthesiology, intensive care unit, burns and operating theater, Percy Military Training Hospital, Clamart, France.,École du Val-de-Grâce, French Military Medical Service Academy, Paris, France
| | - Nicolas Libert
- Federation of anesthesiology, intensive care unit, burns and operating theater, Percy Military Training Hospital, Clamart, France
| | - Anne Chrisment
- Federation of anesthesiology, intensive care unit, burns and operating theater, Percy Military Training Hospital, Clamart, France
| | - Mathieu Pissot
- Federation of anesthesiology, intensive care unit, burns and operating theater, Percy Military Training Hospital, Clamart, France
| | | | - Christophe Martinaud
- École du Val-de-Grâce, French Military Medical Service Academy, Paris, France.,FMBI, French Military Blood Institute, Clamart, France
| | - Sylvain Ausset
- École du Val-de-Grâce, French Military Medical Service Academy, Paris, France.,FMHSS, French Military Health Service Schools, Lyon, France
| | - Mathieu Boutonnet
- Federation of anesthesiology, intensive care unit, burns and operating theater, Percy Military Training Hospital, Clamart, France.,École du Val-de-Grâce, French Military Medical Service Academy, Paris, France
| | - Stéphane De Rudnicki
- Federation of anesthesiology, intensive care unit, burns and operating theater, Percy Military Training Hospital, Clamart, France
| | - Pierre Pasquier
- Federation of anesthesiology, intensive care unit, burns and operating theater, Percy Military Training Hospital, Clamart, France.,École du Val-de-Grâce, French Military Medical Service Academy, Paris, France.,1ère Chefferie du Service de Santé, French Military Medical Service, Villacoublay, France
| | - Thibault Martinez
- Federation of anesthesiology, intensive care unit, burns and operating theater, Percy Military Training Hospital, Clamart, France
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9
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Aichholz PK, Lee SA, Farr CK, Tsang HC, Vavilala MS, Stansbury LG, Hess JR. Platelet Transfusion and Outcomes After Massive Transfusion Protocol Activation for Major Trauma: A Retrospective Cohort Study. Anesth Analg 2022; 135:385-393. [PMID: 35522847 DOI: 10.1213/ane.0000000000005982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Incorporation of massive transfusion protocols (MTPs) into acute major trauma care has reduced hemorrhagic mortality, but the threshold and timing of platelet transfusion in MTP are controversial. This study aimed to describe early (first 4 hours) platelet transfusion practice in a setting where platelet counts are available within 15 minutes and the effect of early platelet deployment on in-hospital mortality. Our hypothesis in this work was that platelet transfusion in resuscitation of severe trauma can be guided by rapid turnaround platelet counts without excess mortality. METHODS We examined MTP activations for all admissions from October 2016 to September 2018 to a Level 1 regional trauma center with a full trauma team activation. We characterized platelet transfusion practice by demographics, injury severity, and admission vital signs (as shock index: heart rate/systolic blood pressure) and laboratory results. A multivariable model assessed association between early platelet transfusion and mortality at 4 hours, 24 hours, and overall in-hospital, with P <.001. RESULTS Of the 11,474 new trauma patients admitted over the study period, 469 (4.0%) were massively transfused (defined as ≥10 units of red blood cells [RBCs] in 24 hours, ≥5 units of RBC in 6 hour, ≥3 units of RBC in 1 hour, or ≥4 units of total products in 30 minutes). 250 patients (53.0%) received platelets in the first 4 hours, and most early platelet transfusions occurred in the first hour after admission (175, 70.0%). Platelet recipients had higher injury severity scores (mean ± standard deviation [SD], 35 ± 16 vs 28 ± 14), lower admission platelet counts (189 ± 80 × 109/L vs 234 ± 80 × 109/L; P < .001), higher admission shock index (heart rate/systolic blood pressure; 1.15 ± 0.46 vs 0.98 ± 0.36; P < .001), and received more units of red cells in the first 4 hours (8.7 ± 7.7 vs 3.3 ± 1.6 units), 24 hours (9 ± 9 vs 3 ± 2 units), and in-hospital (9 ± 8 vs 3 ± 2 units) than nonrecipients (all P < .001). We saw no difference in 4-hour (8% vs 7.8%; P = .4), 24-hour (16.4% vs 10.5%; P = .06), or in-hospital mortality (30.4% vs 23.7%; P = .1) between platelet recipients and nonrecipients. After adjustment for age, injury severity, head injury, and admission physiology/laboratory results, early platelet transfusion was not associated with 4-hour, 24-hour, or in-hospital mortality. CONCLUSIONS In an advanced trauma care setting where platelet counts are available within 15 minutes, approximately half of massively transfused patients received early platelet transfusion. Early platelet transfusion guided by protocol-based clinical judgment and rapid-turnaround platelet counts was not associated with increased mortality.
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Affiliation(s)
- Pudkrong K Aichholz
- From the Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington
| | - Sarah A Lee
- Department of Anesthesiology, Critical Care, and Pain Medicine, Massachusetts General Hospital-Harvard University, Boston, Massachusetts
| | - Carly K Farr
- Department of Medicine, Division of Pulmonary Critical Care and Sleep Medicine, University of Washington, Seattle, Washington
| | - Hamilton C Tsang
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, Washington
| | - Monica S Vavilala
- From the Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington.,Harborview Injury Prevention and Research Center, Seattle, Washington
| | - Lynn G Stansbury
- From the Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington.,Harborview Injury Prevention and Research Center, Seattle, Washington
| | - John R Hess
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, Washington
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10
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Spinella PC, Leonard JC, Marshall C, Luther JF, Wisniewski SR, Josephson CD, Leeper CM. Transfusion Ratios and Deficits in Injured Children With Life-Threatening Bleeding. Pediatr Crit Care Med 2022; 23:235-244. [PMID: 35213410 DOI: 10.1097/pcc.0000000000002907] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To assess the impact of plasma and platelet ratios and deficits in injured children with life-threatening bleeding. DESIGN Secondary analysis of the MAssive Transfusion epidemiology and outcomes In Children study dataset, a prospective observational study of children with life-threatening bleeding events. SETTING Twenty-four childrens hospitals in the United States, Canada, and Italy. PATIENTS Injured children 0-17 years old who received greater than 40 mL/kg total blood products over 6 hours or were transfused under activation of massive transfusion protocol. INTERVENTION/EXPOSURE Weight-adjusted blood product volumes received during the bleeding event were recorded. Plasma:RBC ratio (plasma/RBC weight-adjusted volume in mL/kg) and platelet:RBC ratio (platelet/RBC weight-adjusted volume in mL/kg) were analyzed. Plasma deficit was calculated as RBC mL/kg - plasma mL/kg; platelet deficit was calculated as RBC mL/kg - platelet mL/kg. MEASUREMENTS AND MAIN RESULTS Of 191 patients analyzed, median (interquartile range) age was 10 years (5-15 yr), 61% were male, 61% blunt mechanism, and median (interquartile range) Injury Severity Score was 29 (24-38). After adjusting for Pediatric Risk of Mortality score, cardiac arrest, use of vasoactive medications, and blunt mechanism, a high plasma:RBC ratio (> 1:2) was associated with improved 6-hour survival compared with a low plasma:RBC ratio (odds ratio [95% CI] = 0.12 [0.03-0.52]; p = 0.004). Platelet:RBC ratio was not associated with survival. After adjusting for age, Pediatric Risk of Mortality score, cardiac arrest, and mechanism of injury, 6-hour and 24-hour mortality were increased in children with greater plasma deficits (10% and 20% increased odds of mortality for every 10 mL/kg plasma deficit at 6 hr [p = 0.04] and 24 hr [p = 0.01], respectively); 24-hour mortality was increased in children with greater platelet deficits (10% increased odds of 24-hr mortality for every 10 mL/kg platelet deficit [p = 0.02)]). CONCLUSIONS In injured children, balanced resuscitation may improve early survival according to this hypothesis generating study. Multicenter clinical trials are needed to assess whether clinicians should target ratios and deficits as optimal pediatric hemostatic resuscitation practice.
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Affiliation(s)
- Philip C Spinella
- Department of Surgery, University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
| | - Julie C Leonard
- Department of Emergency Medicine, The Ohio State University College of Medicine, Columbus, OH
| | - Callie Marshall
- Department of Pediatrics, Washington University School of Medicine St. Louis Children's Hospital, St. Louis, MO
| | - James F Luther
- University of Pittsburgh School of Public Health, Pittsburgh, PA
| | | | | | - Christine M Leeper
- Department of Surgery, University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
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11
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Liu Z, Ayyagari RC, Martinez Monegro EY, Stansbury LG, Arbabi S, Bulger EM, Vavilala MS, Hess JR. Blood component use and injury characteristics of acute trauma patients arriving from the scene of injury or as transfers to a large, mature US Level 1 trauma center serving a large, geographically diverse region. Transfusion 2021; 61:3139-3149. [PMID: 34632587 DOI: 10.1111/trf.16679] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Revised: 08/09/2021] [Accepted: 08/30/2021] [Indexed: 12/23/2022]
Abstract
BACKGROUND Advanced trauma care demands the timely availability of hemostatic blood products, posing special challenges for regional systems in geographically diverse areas. We describe acute trauma blood use by transfer status and injury characteristics at a large regional Level 1 trauma center. STUDY DESIGN AND METHODS We reviewed Harborview Medical Center (HMC) Trauma Registry, Transfusion Service, and electronic medical records on acute trauma patients for demographics, injury patterns, blood use, and in-hospital mortality, 2011-2019. RESULTS Among 47,471 patients (mean age 45.2 ± 23.0 years; 68.3% male; Injury Severity Score 12.6 ± 11.1), 4.7% died and 8547 (18%) received at least one blood component through HMC. Firearms injuries were the most often transfused (690/2596, 26.6%) and the most urgently (39.9% ≥3 units in <1 h; 40.6% ≥5 units in <4 h), and had the highest mortality (case-fatality, 12.2%) (all p < .001). From-scene patients were younger than transfers (42.9 ± 21.0 vs. 47.2 ± 24.4), predominated among firearms injuries (68.2% from-scene vs. 31.8% transfers), were more likely to receive blood (18.5% vs. 17.6%) more urgently (≥3 units first hour, 24.4% vs. 7.7%; ≥5 units first 4 h: 25.6% vs. 8.2%), were more likely to die of hemorrhage (15.5% vs. 4.3%) and from firearms injuries (310/1360, 22.8%) (all p < .001). DISCUSSION Early blood use, firearms injuries, and mortality were all greater among from-scene patients, and firearms injuries had worse outcomes despite greater and more urgent blood use, but the role of survivor bias for transfer patients must be clarified. Future research must identify strategies for providing local hemostatic transfusion support, particularly for firearms injuries.
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Affiliation(s)
- Zhinan Liu
- Harborview Injury Prevention and Research Center (HIPRC), Seattle, Washington, USA
| | - Rajiv C Ayyagari
- Harborview Injury Prevention and Research Center (HIPRC), Seattle, Washington, USA
| | - Edison Y Martinez Monegro
- Harborview Injury Prevention and Research Center (HIPRC), Seattle, Washington, USA.,San Juan Bautista School of Medicine, Cauguas, Puerto Rico
| | - Lynn G Stansbury
- Harborview Injury Prevention and Research Center (HIPRC), Seattle, Washington, USA.,Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington, USA
| | - Saman Arbabi
- Harborview Injury Prevention and Research Center (HIPRC), Seattle, Washington, USA.,Department of Surgery, University of Washington School of Medicine, Seattle, Washington, USA
| | - Eileen M Bulger
- Harborview Injury Prevention and Research Center (HIPRC), Seattle, Washington, USA.,Department of Surgery, University of Washington School of Medicine, Seattle, Washington, USA
| | - Monica S Vavilala
- Harborview Injury Prevention and Research Center (HIPRC), Seattle, Washington, USA.,Department of Surgery, University of Washington School of Medicine, Seattle, Washington, USA.,Department of Pediatrics, University of Washington, Seattle, Washington, USA
| | - John R Hess
- Harborview Injury Prevention and Research Center (HIPRC), Seattle, Washington, USA.,Department of Laboratory Medicine and Pathology, University of Washington, Seattle, Washington, USA.,Harborview Medical Center Transfusion Medicine Service, Harborview Transfusion Medicine Service, Seattle, Washington, USA
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12
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Siletz AE, Blair KJ, Cooper RJ, Nguyen NC, Lewis SJ, Fang A, Ward DC, Jackson NJ, Rodriguez T, Grotts J, Hwang J, Ziman A, Cryer HM. A pilot study of stored low titer group O whole blood + component therapy versus component therapy only for civilian trauma patients. J Trauma Acute Care Surg 2021; 91:655-662. [PMID: 34225348 PMCID: PMC8463449 DOI: 10.1097/ta.0000000000003334] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND This pilot assessed transfusion requirements during resuscitation with whole blood followed by standard component therapy (CT) versus CT alone, during a change in practice at a large urban Level I trauma center. METHODS This was a single-center prospective cohort pilot study. Male trauma patients received up to 4 units of cold-stored low anti-A, anti-B group O whole blood (LTOWB) as initial resuscitation followed by CT as needed (LTOWB + CT). A control group consisting of women and men who presented when LTOWB was unavailable, received CT only (CT group). Exclusion criteria included antiplatelet or anticoagulant medication and death within 24 hours. The primary outcome was total transfusion volume at 24 hours. Secondary outcomes were mortality, morbidity, and intensive care unit- and hospital-free days. RESULTS Thirty-eight patients received LTOWB, with a median of 2.0 (interquartile range [IQR] 1.0-3.0) units of LTOWB transfused. Thirty-two patients received CT only. At 24 hours after presentation, the LTOWB +CT group had received a median of 2,138 mL (IQR, 1,275-3,325 mL) of all blood products. The median for the CT group was 4,225 mL (IQR, 1,900-5,425 mL; p = 0.06) in unadjusted analysis. When adjusted for Injury Severity Score, sex, and positive Focused Assessment with Sonography for Trauma, LTOWB +CT group patients received 3307 mL of blood products, and CT group patients received 3,260 mL in the first 24 hours (p = 0.95). The adjusted median ratio of plasma to red cells transfused was higher in the LTOWB + CT group (0.85 vs. 0.63 at 24 hours after admission; p = 0.043. Adjusted mortality was 4.4% in the LTOWB + CT group, and 11.7% in the CT group (p = 0.19), with similar complications, intensive care unit-, and hospital-free days in both groups. CONCLUSION Beginning resuscitation with LTOWB results in equivalent outcomes compared with resuscitation with CT only. LEVEL OF EVIDENCE Therapeutic (Prospective study with 1 negative criterion, limited control of confounding factors), level III.
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Affiliation(s)
- Anaar E Siletz
- From the Department of Surgery (A.E.S., K.J.B., H.M.C.), Department of Emergency Medicine (R.J.C., N.C.N., J.H.), Department of Pathology and Laboratory Medicine, Division of Transfusion Medicine (A.F., D.C.W., A.Z.), Department of Medicine Statistics Core (N.J.J., T.R., J.G.), David Geffen School of Medicine at UCLA, Los Angeles; and College of Medicine (S.J.L.), Touro University California, Vallejo, California
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13
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Ruby KN, Harm SK, Dunbar NM. Risk of ABO-Incompatible Plasma From Non-ABO-Identical Components. Transfus Med Rev 2021; 35:118-122. [PMID: 34544619 DOI: 10.1016/j.tmrv.2021.06.006] [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: 05/26/2021] [Accepted: 06/12/2021] [Indexed: 01/16/2023]
Abstract
The last several decades have seen significant changes in the approach to resuscitation of bleeding patients. These include the adoption of ABO-incompatible plasma transfusion in the form of group A plasma and/or low titer group O whole blood for trauma patients of unknown ABO group. Studies to date have examined the impact of these practices on patient outcomes and clinical markers of hemolysis in recipients of ABO-incompatible plasma compared to those for whom the plasma is ABO-compatible. Risk for increased mortality and/or overt hemolysis appear to be low among recipients of ABO-incompatible plasma; however, nearly all of studies are retrospective and most have focused only on adult trauma patients so results may not be generalizable to other bleeding patients. Work continues to evaluate the role of various titer thresholds in decreasing hemolytic risk and opportunities remain to improve our understanding of anti-A and anti-B antibody interactions with complement/endothelium and identify strategies to minimize risk.
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Affiliation(s)
- Kristen N Ruby
- Department of Pathology and Laboratory Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA; Geisel School of Medicine at Dartmouth, Hanover, NH, USA
| | - Sarah K Harm
- Department of Pathology and Laboratory Medicine, University of Vermont Medical Center, Burlington, VT, USA; University of Vermont Larner College of Medicine, Burlington, VT, USA
| | - Nancy M Dunbar
- Department of Pathology and Laboratory Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA; Geisel School of Medicine at Dartmouth, Hanover, NH, USA.
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14
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Labarthe A, Mennecart T, Imfeld C, Lély P, Ausset S. Pre-hospital transfusion of post-traumatic hemorrhage: Medical and regulatory aspects. Transfus Clin Biol 2021; 28:391-396. [PMID: 34464713 DOI: 10.1016/j.tracli.2021.08.345] [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: 07/31/2021] [Accepted: 08/25/2021] [Indexed: 10/20/2022]
Abstract
Data of good methodological quality have recently become available to support prehospital use of transfusion in the severe trauma setting. Consistent with recent guidelines for the implementation of damage control resuscitation in the hospital in this setting and in the wake of numerous cohort study data from wartime medicine, they are now guided by recent guidelines for the use of freeze-dried plasma. The main difficulties to overcome in order to implement a practice are of a regulatory and logistic nature.
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Affiliation(s)
- A Labarthe
- French Military medical school, 331, avenue du Général-de-Gaulle, Bron, France
| | - T Mennecart
- French Military medical school, 331, avenue du Général-de-Gaulle, Bron, France
| | - C Imfeld
- French Military medical school, 331, avenue du Général-de-Gaulle, Bron, France
| | - P Lély
- French Military medical school, 331, avenue du Général-de-Gaulle, Bron, France
| | - S Ausset
- French Military medical school, 331, avenue du Général-de-Gaulle, Bron, France.
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15
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Stubbs J, Klompas A, Thalji L. Transfusion Therapy in Specific Clinical Situations. Transfus Med 2021. [DOI: 10.1002/9781119599586.ch11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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16
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Blood product needs and transfusion timelines for the multisite massive Paris 2015 terrorist attack: A retrospective analysis. J Trauma Acute Care Surg 2021; 89:496-504. [PMID: 32301884 DOI: 10.1097/ta.0000000000002729] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Hemorrhage is the leading cause of death after terrorist attack, and the immediacy of labile blood product (LBP) administration has a decisive impact on patients' outcome. The main objective of this study was to evaluate the transfusion patterns of the Paris terrorist attack victims, November 13, 2015. METHODS We performed a retrospective analysis including all casualties admitted to hospital, aiming to describe the transfusion patterns from admission to the first week after the attack. RESULTS Sixty-eight of 337 admitted patients were transfused. More than three quarters of blood products were consumed in the initial phase (until November 14, 11:59 PM), where 282 packed red blood cell (pRBC) units were transfused along with 201 plasma and 25 platelet units, to 55 patients (16% of casualties). Almost 40% of these LBPs (134 pRBC, 73 plasma, 8 platelet units) were transfused within the first 6 hours after the attack. These early transfusions were massive transfusion (MT) for 20 (6%) of 337 patients, and the average plasma/red blood cell ratio was 0.8 for MT patients who received 366 (72%) of 508 LBPs.The median time from admission to pRBC transfusion was 57 (25-108) minutes and 208 (52-430) minutes for MT and non-MT patients, respectively. These same time intervals were 119 (66-202) minutes and 222 (87-381) minutes for plasma and 225 (131-289) minutes and 198 (167-230) minutes for platelets. CONCLUSION Our data suggest that improving transfusion procedures in mass casualty setting should rely more on shortening the time to bring LBP to the bedside than in increasing the stockpile. LEVEL OF EVIDENCE Epidemiological study, Therapeutic IV.
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17
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Mortality in civilian trauma patients and massive blood transfusion treated with high vs low plasma: red blood cell ratio. Systematic review and meta-analysis. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2020. [DOI: 10.1097/cj9.0000000000000161] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Introduction: Massive bleeding in civilian trauma patients leads to dilutional coagulopathy. Transfusion with high plasma: red blood cell (RBC) ratio has been effective in reducing mortality in war trauma patients. However, in civilian trauma the evidence is controversial.
Objective: To assess the impact on mortality of high vs low plasma: RBC ratio transfusion, in civilian trauma patients with massive bleeding.
Methods: A systematic review and meta-analysis, including observational studies and clinical trials, was conducted. Databases were systemically searched for relevant studies between January 2007 and June 2019. The main outcome was early (24-hours) and late (30-day) mortality. Fixed and random effects models were used.
Results: Out of 1295 studies identified, 33 were selected: 2 clinical trials and 31 observational studies. The analysis of observational trials showed both decreased early mortality (odds ratio [OR] 0.67; 95% confidence interval [CI], 0.60–0.75) and late mortality (OR 0.79; 95% CI, 0.71–0.87) with the use of high plasma:RBC ratio transfusion, but there were no differences when clinical trials were evaluated (OR 0.89; 95% CI, 0.64–1.26). The exclusion of patients who died within the first 24hours was a source of heterogeneity. The Injury Severity Score (ISS) altered the association between high plasma: RBC ratio and mortality, with a reduced protective effect when the ISS was high.
Conclusion: The use of high vs low plasma: RBC ratio transfusion, in patients with massive bleeding due to civil trauma, has a protective effect on early and late mortality in observational studies. The exclusion of patients who died within the first 24 hours was a source of heterogeneity.
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18
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Abstract
OBJECTIVES Modern critical care amasses unprecedented amounts of clinical data-so called "big data"-on a minute-by-minute basis. Innovative processing of these data has the potential to revolutionize clinical prognostics and decision support in the care of the critically ill but also forces clinicians to depend on new and complex tools of which they may have limited understanding and over which they have little control. This concise review aims to provide bedside clinicians with ways to think about common methods being used to extract information from clinical big datasets and to judge the quality and utility of that information. DATA SOURCES We searched the free-access search engines PubMed and Google Scholar using the MeSH terms "big data", "prediction", and "intensive care" with iterations of a range of additional potentially associated factors, along with published bibliographies, to find papers suggesting illustration of key points in the structuring and analysis of clinical "big data," with special focus on outcomes prediction and major clinical concerns in critical care. STUDY SELECTION Three reviewers independently screened preliminary citation lists. DATA EXTRACTION Summary data were tabulated for review. DATA SYNTHESIS To date, most relevant big data research has focused on development of and attempts to validate patient outcome scoring systems and has yet to fully make use of the potential for automation and novel uses of continuous data streams such as those available from clinical care monitoring devices. CONCLUSIONS Realizing the potential for big data to improve critical care patient outcomes will require unprecedented team building across disparate competencies. It will also require clinicians to develop statistical awareness and thinking as yet another critical judgment skill they bring to their patients' bedsides and to the array of evidence presented to them about their patients over the course of care.
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19
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Dunbar NM, Yazer MH. Confusion surrounding trauma resuscitation and opportunities for clarification. Transfusion 2020; 60 Suppl 3:S142-S149. [DOI: 10.1111/trf.15710] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Revised: 01/02/2020] [Accepted: 01/28/2020] [Indexed: 12/12/2022]
Affiliation(s)
- Nancy M. Dunbar
- Department of Pathology and Laboratory MedicineDartmouth‐Hitchcock Medical Center Lebanon New Hampshire
| | - Mark H. Yazer
- Department of PathologyUniversity of Pittsburgh and Vitalant Pittsburgh Pennsylvania
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20
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Jost D, Lemoine S, Lemoine F, Lanoe V, Maurin O, Derkenne C, Franchin Frattini M, Delacote M, Seguineau E, Godefroy A, Hervault N, Delhaye L, Pouliquen N, Louis-Delauriere E, Trichereau J, Roquet F, Salomé M, Verret C, Bihannic R, Jouffroy R, Frattini B, Hong Tuan Ha V, Dang-Minh P, Travers S, Bignand M, Martinaud C, Garrabe E, Ausset S, Prunet B, Sailliol A, Tourtier JP. French lyophilized plasma versus normal saline for post-traumatic coagulopathy prevention and correction: PREHO-PLYO protocol for a multicenter randomized controlled clinical trial. Trials 2020; 21:106. [PMID: 31969168 PMCID: PMC6977230 DOI: 10.1186/s13063-020-4049-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Accepted: 01/06/2020] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Post-trauma bleeding induces an acute deficiency in clotting factors, which promotes bleeding and hemorrhagic shock. However, early plasma administration may reduce the severity of trauma-induced coagulopathy (TIC). Unlike fresh frozen plasma, which requires specific hospital logistics, French lyophilized plasma (FLYP) is storable at room temperature and compatible with all blood types, supporting its use in prehospital emergency care. We aim to test the hypothesis that by attenuating TIC, FLYP administered by prehospital emergency physicians would benefit the severely injured civilian patient at risk for hemorrhagic shock. METHODS/DESIGN This multicenter randomized clinical trial will include adults severely injured and at risk for hemorrhagic shock, with a systolic blood pressure < 70 mmHg or a Shock Index > 1.1. Two parallel groups of 70 patients will receive either FLYP or normal saline in addition to usual treatment. The primary endpoint is the International Normalized Ratio (INR) at hospital admission. Secondary endpoints are transfusion requirement, length of stay in the intensive care unit, survival rate at day 30, usability and safety related to FLYP use, and other biological coagulation parameters. CONCLUSION With this trial, we aim to confirm the efficacy of FLYP in TIC and its safety in civilian prehospital care. The study results will contribute to optimizing guidelines for treating hemorrhagic shock in civilian settings. TRIAL REGISTRATION ClinicalTrials.gov, NCT02736812. Registered on 13 April 2016. The trial protocol has been approved by the French ethics committee (CPP 3342) and the French Agency for the Safety of Medicines and Health Products (IDRCB 2015-A00866-43).
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Affiliation(s)
- Daniel Jost
- Paris Fire Brigade Medical Emergency Department, 1 place Jules Renard, 75017, Paris, France.
| | - Sabine Lemoine
- Paris Fire Brigade Medical Emergency Department, 1 place Jules Renard, 75017, Paris, France
| | - Frederic Lemoine
- Paris Fire Brigade Medical Emergency Department, 1 place Jules Renard, 75017, Paris, France
| | - Vincent Lanoe
- Paris Fire Brigade Medical Emergency Department, 1 place Jules Renard, 75017, Paris, France
| | - Olga Maurin
- Paris Fire Brigade Medical Emergency Department, 1 place Jules Renard, 75017, Paris, France
| | - Clément Derkenne
- Paris Fire Brigade Medical Emergency Department, 1 place Jules Renard, 75017, Paris, France
| | | | - Maëlle Delacote
- Paris Fire Brigade Medical Emergency Department, 1 place Jules Renard, 75017, Paris, France
| | - Edouard Seguineau
- Paris Fire Brigade Medical Emergency Department, 1 place Jules Renard, 75017, Paris, France
| | - Anne Godefroy
- Paris Fire Brigade Medical Emergency Department, 1 place Jules Renard, 75017, Paris, France
| | - Nicolas Hervault
- Paris Fire Brigade Medical Emergency Department, 1 place Jules Renard, 75017, Paris, France
| | - Ludovic Delhaye
- Paris Fire Brigade Medical Emergency Department, 1 place Jules Renard, 75017, Paris, France
| | - Nicolas Pouliquen
- Paris Fire Brigade Medical Emergency Department, 1 place Jules Renard, 75017, Paris, France
| | - Emilie Louis-Delauriere
- Department of Education, Research and Innovation, Service de Santé des Armées, 1 Place Alphonse Laveran, 75230, Paris, France
| | - Julie Trichereau
- Paris Fire Brigade Medical Emergency Department, 1 place Jules Renard, 75017, Paris, France
| | - Florian Roquet
- Paris Fire Brigade Medical Emergency Department, 1 place Jules Renard, 75017, Paris, France
| | - Marina Salomé
- Paris Fire Brigade Medical Emergency Department, 1 place Jules Renard, 75017, Paris, France
| | - Catherine Verret
- Department of Education, Research and Innovation, Service de Santé des Armées, 1 Place Alphonse Laveran, 75230, Paris, France
| | - René Bihannic
- Paris Fire Brigade Medical Emergency Department, 1 place Jules Renard, 75017, Paris, France
| | - Romain Jouffroy
- Paris Fire Brigade Medical Emergency Department, 1 place Jules Renard, 75017, Paris, France
| | - Benoit Frattini
- Paris Fire Brigade Medical Emergency Department, 1 place Jules Renard, 75017, Paris, France
| | - Vivien Hong Tuan Ha
- Paris Fire Brigade Medical Emergency Department, 1 place Jules Renard, 75017, Paris, France
| | - Pascal Dang-Minh
- Paris Fire Brigade Medical Emergency Department, 1 place Jules Renard, 75017, Paris, France
| | - Stéphane Travers
- Paris Fire Brigade Medical Emergency Department, 1 place Jules Renard, 75017, Paris, France
- French Military Health Service, Val de Grâce military hospital, 1, Place Alphonse Laveran, 75230, Paris, France
| | - Michel Bignand
- Paris Fire Brigade Medical Emergency Department, 1 place Jules Renard, 75017, Paris, France
| | - Christophe Martinaud
- French Military Health Service, Val de Grâce military hospital, 1, Place Alphonse Laveran, 75230, Paris, France
- French army blood transfusion center, 1 Rue du Lieutenant Raoul Batany, 92140, Clamart, France
| | - Eliane Garrabe
- French Military Health Service, Val de Grâce military hospital, 1, Place Alphonse Laveran, 75230, Paris, France
- French army blood transfusion center, 1 Rue du Lieutenant Raoul Batany, 92140, Clamart, France
| | - Sylvain Ausset
- French Military Health Service, Val de Grâce military hospital, 1, Place Alphonse Laveran, 75230, Paris, France
- Department of Anesthesiology and Intensive Care, Percy military teaching hospital, 101 avenue Henri Barbusse, BP 406, 92141, Clamart, Cedex, France
| | - Bertrand Prunet
- Paris Fire Brigade Medical Emergency Department, 1 place Jules Renard, 75017, Paris, France
- French Military Health Service, Val de Grâce military hospital, 1, Place Alphonse Laveran, 75230, Paris, France
| | - Anne Sailliol
- French Military Health Service, Val de Grâce military hospital, 1, Place Alphonse Laveran, 75230, Paris, France
- French army blood transfusion center, 1 Rue du Lieutenant Raoul Batany, 92140, Clamart, France
- French Military Research Institute, 1 place Valérie Andre, BP 73, 91223, Brétigny sur Orge, France
| | - Jean Pierre Tourtier
- Paris Fire Brigade Medical Emergency Department, 1 place Jules Renard, 75017, Paris, France
- French Military Health Service, Val de Grâce military hospital, 1, Place Alphonse Laveran, 75230, Paris, France
- Department of Anaesthesiology and Intensive Care, Begin military teaching hospital, 94160, Saint-Mande, France
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21
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Pape HC, Halvachizadeh S, Leenen L, Velmahos GD, Buckley R, Giannoudis PV. Timing of major fracture care in polytrauma patients - An update on principles, parameters and strategies for 2020. Injury 2019; 50:1656-1670. [PMID: 31558277 DOI: 10.1016/j.injury.2019.09.021] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES Sustained changes in resuscitation and transfusion management have been observed since the turn of the millennium, along with an ongoing discussion of surgical management strategies. The aims of this study are threefold: a) to evaluate the objective changes in resuscitation and mass transfusion protocols undertaken in major level I trauma centers; b) to summarize the improvements in diagnostic options for early risk profiling in multiply injured patients and c) to assess the improvements in surgical treatment for acute major fractures in the multiply injured patient. METHODS I. A systematic review of the literature (comprehensive search of the MEDLINE, Embase, PubMed, and Cochrane Central Register of Controlled Trials databases) and a concomitant data base (from a single Level I center) analysis were performed. Two authors independently extracted data using a pre-designed form. A pooled analysis was performed to determine the changes in the management of polytraumatized patients after the change of the millennium. II. A data base from a level I trauma center was utilized to test any effects of treatment changes on outcome. INCLUSION CRITERIA adult patients, ISS > 16, admission < less than 24 h post trauma. Exclusion: Oncological diseases, genetic disorders that affect the musculoskeletal system. Parameters evaluated were mortality, ICU stay, ICU complications (Sepsis, Pneumonia, Multiple organ failure). RESULTS I. From the electronic databases, 5141 articles were deemed to be relevant. 169 articles met the inclusion criteria and a manual review of reference lists of key articles identified an additional 22 articles. II. Out of 3668 patients, 2694 (73.4%) were male, the mean ISS was 28.2 (SD 15.1), mean NISS was 37.2 points (SD 17.4 points) and the average length of stay was 17.0 days (SD 18.7 days) with a mean length of ICU stay of 8.2 days (SD 10.5 days), and a mean ventilation time of 5.1 days (SD 8.1 days). Both surgical management and nonsurgical strategies have changed over time. Damage control resuscitation, dynamic analyses of coagulopathy and lactate clearance proved to sharpen the view of the worsening trauma patient and facilitated the prevention of further complications. The subsequent surgical care has become safer and more balanced, avoiding overzealous initial surgeries, while performing early fixation, when patients are physiologically stable or rapidly improving. Severe chest trauma and soft tissue injuries require further evaluation. CONCLUSIONS Multiple changes in management (resuscitation, transfusion protocols and balanced surgical care) have taken place. Moreover, improvement in mortality rates and complications associated with several factors were also observed. These findings support the view that the management of polytrauma patients has been substantially improved over the past 3 decades.
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Affiliation(s)
- H-C Pape
- Department of Trauma, University Hospital Zurich, University of Zurich, Raemistrasse 100, 8091, Zurich, Switzerland.
| | - S Halvachizadeh
- Department of Trauma, University Hospital Zurich, University of Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - L Leenen
- Department of Trauma, University Medical Centre Utrecht, Suite G04.228, Heidelberglaan 100, 3585 GA, Utrecht, the Netherlands.
| | - G D Velmahos
- Dept. of Trauma, Emergency Surgery and Critical Care, Harvard University, Mass. General Hospital, 55 Fruit St., Boston, MA, 02114, USA
| | - R Buckley
- Section of Orthopedic Trauma, University of Calgary, Foothills Medical Center, 0490 McCaig Tower, 3134 University Drive NW Calgary, Alberta, T2N 5A1, Canada.
| | - P V Giannoudis
- Trauma & Orthopaedic Surgery, Clarendon Wing, A Floor, Great George Street, Leeds General Infirmary University Hospital, University of Leeds, Leeds, LS1 3EX, UK.
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22
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Radowsky JS, DuBose JJ, Scalea TM, Miller C, Floccare DJ, Sikorski RA, MacKenzie CF, Hu P, Rock P, Galvagno SM. Handheld Tissue Oximetry for the Prehospital Detection of Shock and Need for Lifesaving Interventions: Technology in Search of an Indication? Air Med J 2019; 38:276-280. [PMID: 31248537 DOI: 10.1016/j.amj.2019.03.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Revised: 02/28/2019] [Accepted: 03/27/2019] [Indexed: 06/09/2023]
Abstract
Improved prehospital methods for assessing the need for lifesaving interventions (LSIs) are needed to gain critical lead time in the care of the injured. We hypothesized that threshold values using prehospital handheld tissue oximetry would detect occult shock and predict LSI requirements. This was a prospective observational study of adult trauma patients emergently transported by helicopter. Patients were monitored with a handheld tissue oximeter (InSpectra Spot Check; Hutchinson Technology Inc, Hutchinson, MN), continuous vital signs, and 21 laboratory measurements obtained both in the field with a portable analyzer and at the time of admission. Shock was defined as base excess ≥ 4 or lactate > 3 mmol/L. Eighty-eight patients were enrolled with a median Injury Severity Score of 16 (interquartile range, 5-29). The median hemoglobin saturation in the capillaries, venules, and arterioles (StO2) value for all patients was 82% (interquartile range, 76%-87%; range, 42%-98%). StO2 was abnormal (< 75%) in 18 patients (20%). Eight were hypotensive (9%) and had laboratory-confirmed evidence of occult shock. StO2 correlated poorly with shock threshold laboratory values (r = -0.17; 95% confidence interval, -0.33 to 1.0; P = .94). The area under the receiver operating curve was 0.51 (95% confidence interval, 0.39-0.63) for StO2 < 75% and laboratory-confirmed shock. StO2 was not associated with LSI need on admission when adjusted for multiple covariates, nor was it independently associated with death. Handheld tissue oximetry was not sensitive or specific for identifying patients with prehospital occult shock. These results do not support prehospital StO2 monitoring despite its inclusion in several published guidelines.
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Affiliation(s)
- Jason S Radowsky
- R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD
| | - Joseph J DuBose
- Center for Sustainment for Trauma and Readiness Skills, Baltimore, MD
| | - Thomas M Scalea
- R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD
| | | | - Douglas J Floccare
- Maryland Institute for Emergency Medical Services Systems, Baltimore, MD
| | - Robert A Sikorski
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Colin F MacKenzie
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD
| | - Peter Hu
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD
| | - Peter Rock
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD
| | - Samuel M Galvagno
- R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD.
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23
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Stansbury LG, Hess AS. Can we answer transfusion questions with retrospective data? Transfusion 2019; 59:1891-1893. [PMID: 31161671 DOI: 10.1111/trf.15321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Accepted: 04/09/2019] [Indexed: 11/26/2022]
Affiliation(s)
- Lynn G Stansbury
- Harborview Injury Prevention and Research Center, University of Washington, Seattle, WA
| | - Aaron S Hess
- Department of Anesthesiology, University of Wisconsin School of Medicine, Madison, WI
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Miyata S, Itakura A, Ueda Y, Usui A, Okita Y, Ohnishi Y, Katori N, Kushimoto S, Sasaki H, Shimizu H, Nishimura K, Nishiwaki K, Matsushita T, Ogawa S, Kino S, Kubo T, Saito N, Tanaka H, Tamura T, Nakai M, Fujii S, Maeda T, Maeda H, Makino S, Matsunaga S. TRANSFUSION GUIDELINES FOR PATIENTS WITH MASSIVE BLEEDING. ACTA ACUST UNITED AC 2019. [DOI: 10.3925/jjtc.65.21] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Shigeki Miyata
- Department of Clinical Laboratory Medicine, National Cerebral and Cardiovascular Center
| | - Atsuo Itakura
- Department of Obstetrics and Gynecology, Faculty of Medicine, Juntendo University
| | - Yuichi Ueda
- Nara Prefectural Hospital Organization, Nara Prefecture General Medical Center
| | - Akihiko Usui
- Department of Cardiac Surgery, Nagoya University Graduate School of Medicine
| | - Yutaka Okita
- Department of Cardiovascular Surgery, Kobe University
| | - Yoshihiko Ohnishi
- Operation Room, Anesthesiology, National Cerebral and Cardiovascular Center
| | - Nobuyuki Katori
- Department of Anesthesiology, Keio University School of Medicine
| | - Shigeki Kushimoto
- Division of Emergency and Critical Care Medicine, Tohoku University Graduate School of Medicine
| | - Hiroaki Sasaki
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center
| | | | - Kunihiro Nishimura
- Department of Statistics and Data Analysis, Dept of Preventive Medicine and Epidemiology, National Cerebral and Cardiovascular Center
| | | | | | - Satoru Ogawa
- Department of Anesthesiology, Kyoto Prefectural University of Medicine
| | | | | | - Nobuyuki Saito
- Shock and Trauma Center, Nippon Medical School Chiba Hokusoh Hospital
| | - Hiroshi Tanaka
- Department of Surgery, Division of Minimum Invasive Surgery, Kobe University
| | | | - Michikazu Nakai
- Department of Statistics and Data Analysis, Dept of Preventive Medicine and Epidemiology, National Cerebral and Cardiovascular Center
| | - Satoshi Fujii
- Department of Laboratory Medicine, Asahikawa Medical University
| | - Takuma Maeda
- Division of Transfusion Medicine, National Cerebral and Cardiovascular Center
| | - Hiroo Maeda
- Transfusion Medicine and Cell Therapy, Saitama Medical Center/Saitama Medical University
| | - Shintaro Makino
- Department of Obstetrics and Gynecology, Faculty of Medicine, Juntendo University
| | - Shigetaka Matsunaga
- Department of Obstetrics and Gynecology, Saitama Medical Center/Saitama Medical University
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Does a balanced transfusion ratio of plasma to packed red blood cells improve outcomes in both trauma and surgical patients? A meta-analysis of randomized controlled trials and observational studies. Am J Surg 2018; 216:342-350. [DOI: 10.1016/j.amjsurg.2017.08.045] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2017] [Revised: 08/21/2017] [Accepted: 08/30/2017] [Indexed: 01/08/2023]
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26
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Vitalis V, Carfantan C, Montcriol A, Peyrefitte S, Luft A, Pouget T, Sailliol A, Ausset S, Meaudre E, Bordes J. Early transfusion on battlefield before admission to role 2: A preliminary observational study during "Barkhane" operation in Sahel. Injury 2018; 49:903-910. [PMID: 29248187 DOI: 10.1016/j.injury.2017.11.029] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2017] [Revised: 11/10/2017] [Accepted: 11/22/2017] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Haemorrage is the leading cause of death after combat related injuries and bleeding management is the cornerstone of management of these casualties. French armed forces are deployed in Barkhane operation in the Sahel-Saharan Strip who represents an immense area. Since this constraint implies evacuation times beyond doctrinal timelines, an institutional decision has been made to deploy blood products on the battlefield and transfuse casualties before role 2 admission if indicated. The purpose of this study was to evaluate the transfusion practices on battlefield during the first year following the implementation of this policy. MATERIALS AND METHODS Prospective collection of data about combat related casualties categorized alpha evacuated to a role 2. Battlefield transfusion was defined as any transfusion of blood product (red blood cells, plasma, whole blood) performed by role 1 or Medevac team before admission at a role 2. Patients' characteristics, battlefield transfusions' characteristics and complications were analysed. RESULTS During the one year study, a total of 29 alpha casualties were included during the period study. Twenty-eight could be analysed, 7/28 (25%) being transfused on battlefield, representing a total of 22 transfusion episodes. The most frequently blood product transfused was French lyophilized plasma (FLYP). Most of transfusion episodes occurred during medevac. Compared to non-battlefield transfused casualties, battlefield transfused casualties suffered more wounded anatomical regions (median number of 3 versus 2, p = 0.04), had a higher injury severity score (median ISS of 45 versus 25, p = 0,01) and were more often transfused at role 2, received more plasma units and whole blood units. There was no difference in evacuation time to role 2 between patients transfused on battlefield and non-transfused patients. There was no complication related to battlefield transfusions. Blood products transfusion onset on battlefield ranged from 75 min to 192 min after injury. CONCLUSION Battlefield transfusion for combat-related casualties is a logistical challenge. Our study showed that such a program is feasible even in an extended area as Sahel-Saharan Strip operation theatre and reduces time to first blood product transfusion for alpha casualties. FLYP is the first line blood product on the battlefield.
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Affiliation(s)
- V Vitalis
- French Medical Unit, Medical Centre of Lyon, France
| | - C Carfantan
- French Military Medical Service, Operational Headquarters, France
| | - A Montcriol
- Sainte Anne Military Teaching Hospital, Anaesthesia and Intensive Care Unit, Toulon, France
| | - S Peyrefitte
- French Medical Unit, Naval Special Operations Commandos Command, Lanester, France
| | - A Luft
- French Military Medical Service, Operational Headquarters, France
| | - T Pouget
- French Military Blood Institute, Clamart, France
| | - A Sailliol
- French Military Blood Institute, Clamart, France
| | - S Ausset
- Percy Military Teaching Hospital, Anaesthesia and Intensive Care Unit, Clamart, France & Val de Grâce Military Academy, Paris, France
| | - E Meaudre
- Sainte Anne Military Teaching Hospital, Anaesthesia and Intensive Care Unit, Toulon, France
| | - J Bordes
- Sainte Anne Military Teaching Hospital, Anaesthesia and Intensive Care Unit, Toulon, France; 7th Paratrooper Forward Surgical Unit, France.
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Garrigue D, Godier A, Glacet A, Labreuche J, Kipnis E, Paris C, Duhamel A, Resch E, Bauters A, Machuron F, Renom P, Goldstein P, Tavernier B, Sailliol A, Susen S. French lyophilized plasma versus fresh frozen plasma for the initial management of trauma-induced coagulopathy: a randomized open-label trial. J Thromb Haemost 2018; 16:481-489. [PMID: 29274254 DOI: 10.1111/jth.13929] [Citation(s) in RCA: 55] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2017] [Indexed: 01/08/2023]
Abstract
Essentials An immediate supply of plasma in case of trauma-induced coagulopathy is required. The Traucc trial compared French Lyophilised Plasma (FLyP) and Fresh Frozen Plasma (FFP). FLyP achieved higher fibrinogen concentrations compared with FFP. FLyP led to a more rapid coagulopathy improvement than FFP. SUMMARY Background Guidelines recommend beginning hemostatic resuscitation immediately in trauma patients. We aimed to investigate if French lyophilized plasma (FLyP) was more effective than fresh frozen plasma (FFP) for the initial management of trauma-induced coagulopathy. Methods In an open-label, phase 3, randomized trial (NCT02750150), we enrolled adult trauma patients requiring an emergency pack of 4 plasma units within 6 h of injury. We randomly assigned patients to receive 4-FLyP units or 4-FFP units. The primary endpoint was fibrinogen concentration at 45 min after randomization. Secondary outcomes included time to transfusion, changes in hemostatic parameters at different time-points, blood product requirements and 30-day in-hospital mortality. Results Forty-eight patients were randomized (FLyP, n = 24; FFP, n = 24). FLyP reduced the time from randomization to transfusion of first plasma unit compared with FFP (median[IQR],14[5-30] vs. 77[64-90] min). FLyP achieved a higher fibrinogen concentration 45 min after randomization compared with FFP (baseline-adjusted mean difference, 0.29 g L-1 ; 95% confidence interval [CI], 0.08-0.49) and a greater improvement in prothrombin time ratio, factor V and factor II. The between-group differences in coagulation parameters remained significant at 6 h. FLyP reduced fibrinogen concentrate requirements. Thirty-day in-hospital mortality rate was 22% with FLyP and 29% with FFP. Conclusion FLyP led to a more rapid, pronounced and extended increase in fibrinogen concentrations and coagulopathy improvement compared with FFP in the initial management of trauma patients. FLyP represents an attractive option for trauma management, especially when facing logistical issues such as combat casualties or mass casualties related to terror attacks or disasters.
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Affiliation(s)
- D Garrigue
- CHU de Lille, Pôle d'Anesthésie-Réanimation, Lille, France
- CHU Lille, Pôle de l'Urgence, Lille, France
| | - A Godier
- Service d'Anesthésie-Réanimation, Fondation Ophtalmologique Adolphe de Rothschild, Paris, France
- NSERM, UMR-S1140, Université Paris Descartes, Sorbonne Paris Cité, Paris, France
| | - A Glacet
- CHU de Lille, Pôle d'Anesthésie-Réanimation, Lille, France
- CHU Lille, Pôle de l'Urgence, Lille, France
| | - J Labreuche
- Université Lille, CHU Lille, EA 2694 - Santé Publique: Épidémiologie et Qualité des Soins, Lille, France
| | - E Kipnis
- CHU de Lille, Pôle d'Anesthésie-Réanimation, Lille, France
- Université Lille, EA 7366, Lille, France
| | - C Paris
- CHU de Lille, Institut d'Hématologie-Transfusion, Lille, France
| | - A Duhamel
- Université Lille, CHU Lille, EA 2694 - Santé Publique: Épidémiologie et Qualité des Soins, Lille, France
| | - E Resch
- EFS Hauts de France, Lille, France
| | - A Bauters
- CHU de Lille, Institut d'Hématologie-Transfusion, Lille, France
| | - F Machuron
- Université Lille, CHU Lille, EA 2694 - Santé Publique: Épidémiologie et Qualité des Soins, Lille, France
| | - P Renom
- CHU de Lille, Institut d'Hématologie-Transfusion, Lille, France
| | - P Goldstein
- CHU de Lille, Pôle d'Anesthésie-Réanimation, Lille, France
- CHU Lille, Pôle de l'Urgence, Lille, France
| | - B Tavernier
- CHU de Lille, Pôle d'Anesthésie-Réanimation, Lille, France
| | - A Sailliol
- Centre de Transfusion Sanguine des Armées, Clamart, France
| | - S Susen
- CHU de Lille, Institut d'Hématologie-Transfusion, Lille, France
- Université Lille, Inserm, CHU Lille, U1011 - EGID, Lille, France
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Hess JR, Ramos PJ, Sen NE, Cruz-Cody VG, Tuott EE, Louzon MJ, Bulger EM, Arbabi S, Pagano MB, Metcalf RA. Quality management of a massive transfusion protocol. Transfusion 2017; 58:480-484. [DOI: 10.1111/trf.14443] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2017] [Revised: 09/29/2017] [Accepted: 10/13/2017] [Indexed: 12/16/2022]
Affiliation(s)
- John R. Hess
- Department of Laboratory Medicine; University of Washington; Seattle Washington
- Transfusion Service; Harborview Medical Center; Seattle Washington
| | - Patrick J. Ramos
- Office of the Medical Director; Harborview Medical Center; Seattle Washington
| | - Nina E. Sen
- Transfusion Service; Harborview Medical Center; Seattle Washington
| | | | - Erin E. Tuott
- Transfusion Service; Harborview Medical Center; Seattle Washington
| | - Max J. Louzon
- Transfusion Service; Harborview Medical Center; Seattle Washington
| | - Eileen M. Bulger
- Department of Surgery; University of Washington; Seattle Washington
| | - Saman Arbabi
- Department of Surgery; University of Washington; Seattle Washington
| | - Monica B. Pagano
- Department of Laboratory Medicine; University of Washington; Seattle Washington
- Transfusion Service; Harborview Medical Center; Seattle Washington
| | - Ryan A. Metcalf
- Department of Laboratory Medicine; University of Washington; Seattle Washington
- Transfusion Service; Harborview Medical Center; Seattle Washington
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Leukocyte filtration lesion impairs functional coagulation in banked whole blood. J Trauma Acute Care Surg 2017; 83:420-426. [PMID: 28452876 DOI: 10.1097/ta.0000000000001535] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Whole blood (WB) transfusion is a promising alternative to component therapy in hemostatic resuscitation. Use of banked WB requires filtration of white blood cells (leukoreduction) and an established shelf life during which WB retains coagulant capacities. The goal of this study was to define the time course of coagulation stability in leukoreduced compared to unfiltered WB under standard refrigeration conditions. METHODS Twelve WB units were donated by healthy volunteers after routine screening. Five units underwent standard leukocyte filtration and five did not. Two units were aliquoted into filtered and unfiltered samples, with platelets added to each sample on day 14. Units were stored at 4°C and sampled on days 0, 1, 2, 3, 4, 5, 6, 7, 10, 14, 21, 28, and 35 for immediate thromboelastography (TEG) analysis, and centrifuged and stored at -80°C for later calibrated automated thrombogram and coagulation factor assays. RESULTS K-dependent factors and fibrinogen were low normal, decreased slightly over 35 days and were similar between unfiltered and filtered units. Labile factors were better preserved in filtered units, although unfiltered units did not show impaired coagulation over 35 days. Filtered blood had delayed clot initiation on days 0, 1, and 2 as measured by TEG R (p < 0.021); slower clot progression (TEG α-angle) on days 0, 1, 2, 3, 4, 5, and 6 (p < 0.023); weaker final clot (TEG MA) on all days (p < 0.0001). Thrombin generation was delayed on day 28 (p = 0.046) and decreased on days 10, 21, 28, and 35 (p < 0.034). Addition of platelets to filtered WB rescued TEG MA. CONCLUSION Filtered WB had decreased functional clotting capacity and thrombin generation and may not be suitable for hemostatic resuscitation as the sole blood product. LEVEL OF EVIDENCE Therapeutic, level IV.
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Hess JR, Pagano MB, Barbeau JD, Johannson PI. Will pathogen reduction of blood components harm more people than it helps in developed countries? Transfusion 2017; 56:1236-41. [PMID: 27167359 DOI: 10.1111/trf.13512] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2015] [Revised: 12/24/2015] [Accepted: 12/31/2015] [Indexed: 12/17/2022]
Abstract
BACKGROUND Blood-borne infectious diseases are a major impediment to the provision of safe blood. Pathogen reduction (PR) technologies have been approved for the treatment of plasma and platelet (PLT) concentrates to reduce infectious complications and graft-versus-host disease but product potency is adversely affected STUDY DESIGN AND METHODS We reviewed published data describing PR technology for estimates of treated blood component physical and functional loss. These physical and functional losses were summed and projected onto measured effects of plasma and PLT dose in trauma resuscitation. The net benefits estimated as reduced infectious disease deaths were compared to net losses estimated as increased deaths from uncontrolled hemorrhage. RESULTS Transfusion-transmitted infectious diseases caused five or fewer acute deaths each year from 2009 through 2014 in the United States according to the Food and Drug Administration. In-hospital deaths from uncontrolled hemorrhage after trauma number more than 10,000 yearly and are reduced by 4% to 15% with concentrated blood product resuscitation. The loss of 20% of plasma potency and 30% of PLT potency to PR is likely to be associated with 400 extra trauma deaths each year. Trauma represents a small fraction, perhaps 15%, of all massively transfused individuals. CONCLUSIONS Resuscitation of massive hemorrhage may be limited by blood component potency as shown in our literature review and analysis. The safety-versus-potency trade involved with current blood plasma and PLT PR technology is likely to result in a net loss of life. Hemorrhagic risk from reduced blood product potency for patients with trauma and other indications for massive transfusion is an important consideration in risk-based decision making for implementing PR.
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Affiliation(s)
- John R Hess
- Department of Laboratory Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Monica B Pagano
- Department of Laboratory Medicine, University of Washington School of Medicine, Seattle, Washington
| | - James D Barbeau
- Department of Pathology, Brown University School of Medicine, Providence, Rhode Island
| | - Pär I Johannson
- Department of Transfusion Medicine, Rigshospitalet, Copenhagen, Denmark.,Department of Surgery, University of Texas Health Medical School, Houston, Texas
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Yonge JD, Schreiber MA. The pragmatic randomized optimal platelet and plasma ratios trial: what does it mean for remote damage control resuscitation? Transfusion 2017; 56 Suppl 2:S149-56. [PMID: 27100751 DOI: 10.1111/trf.13502] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2015] [Revised: 12/21/2015] [Accepted: 12/21/2015] [Indexed: 12/27/2022]
Abstract
BACKGROUND Implications from the pragmatic, randomize, optimal platelet and plasma ratios (PROPPR) trial are critical for remote damage control resuscitation (DCR). Utilizing DCR principals in remote settings can combat early mortality from hemorrhage. Identifying the appropriate transfusion strategy is mandatory prior to adopting prehospital hemostatic resuscitation strategies. STUDY DESIGN AND METHODS The PROPPR study was examined in relation to the following questions: 1) Why is it important to have blood products in the prehospital setting?; 2) Which products should be investigated for prehospital hemostatic resuscitation?; 3) What is the appropriate ratio of blood product transfusion?; and 4) What are the appropriate indications for hemostatic resuscitation? RESULTS PROPPR demonstrates that early and balanced blood product transfusion ratios reduced mortality in all patients at 3 hours and death from exsanguination at 24 hours (p = 0.03). The median time to death from exsanguination was 2.3 hours, highlighting the need for point-of-injury DCR capabilities. A 1:1:1 transfusion ratio of plasma:platelets:packed red blood cells increased the percentage of patients achieving anatomic hemostasis (p = 0.006). PROPPR used the assessment of blood consumption score to identify patients likely to require ongoing hemostatic resuscitation. The critical administration threshold predicted patient mortality and identified patients likely to require ongoing hemostatic resuscitation. CONCLUSION A balanced resuscitation strategy demonstrates an early survival benefit, decreased death from exsanguination at 24 hours and a greater likelihood of achieving hemostasis in critically injured patients receiving a 1:1:1 ratio of plasma:platelets:PRBCs. This finding highlights the need to import DCR principals to remote locations.
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Affiliation(s)
- John D Yonge
- Division of Trauma, Critical Care, & Acute Care Surgery, Oregon Health and Sciences University, Portland, Oregon
| | - Martin A Schreiber
- Division of Trauma, Critical Care, & Acute Care Surgery, Oregon Health and Sciences University, Portland, Oregon
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Abstract
Coagulopathy is common after injury and develops independently from iatrogenic, hypothermic, and dilutional causes. Despite considerable research on the topic over the past decade, trauma-induced coagulopathy (TIC) continues to portend poor outcomes, including decreased survival. We review the current evidence regarding the diagnosis and mechanisms underlying trauma induced coagulopathy and summarize the debates regarding optimal management strategy including product resuscitation, potential pharmacologic adjuncts, and targeted approaches to hemostasis. Throughout, we will identify areas of continued investigation and controversy in the understanding and management of TIC.
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Simmons J, Powell M. Acute traumatic coagulopathy: pathophysiology and resuscitation. Br J Anaesth 2016; 117:iii31-iii43. [DOI: 10.1093/bja/aew328] [Citation(s) in RCA: 91] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
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35
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Automated continuous vital signs predict use of uncrossed matched blood and massive transfusion following trauma. J Trauma Acute Care Surg 2016; 80:897-906. [DOI: 10.1097/ta.0000000000001047] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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Swiech A, Ausset S. Les produits sanguins labiles en 2016. MEDECINE INTENSIVE REANIMATION 2016. [DOI: 10.1007/s13546-016-1201-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Cohen MJ, Christie SA. New understandings of post injury coagulation and resuscitation. Int J Surg 2016; 33:242-245. [PMID: 27212591 DOI: 10.1016/j.ijsu.2016.05.037] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2016] [Accepted: 05/10/2016] [Indexed: 11/29/2022]
Abstract
Coagulopathy following injury is common and it predicts poor outcomes and increased mortality. For many decades, coagulopathy in trauma was considered as an iatrogenic phenomenon, and clinical practice focused on a resuscitation strategy using large volume crystalloid and packed red blood cells. The discovery of Acute Traumatic Coagulopathy as a distinct pathophysiologic state coupled with a transition towards balanced product resuscitation has fundamentally changed the paradigm of trauma care and represents one of the most active areas of current research in the field of trauma. In this review, we examine the development and current understanding of the mechanisms, implicated mediators, and physiology of Acute Traumatic Coagulopathy, with an emphasis on the role of the activated Protein C pathway. We will also review the state of resuscitation practice including the evidence for balanced product administration and the previously under-appreciated importance of platelet count and function. Importantly, we highlight ongoing knowledge deficits in traumatic coagulopathy and resuscitation as directions for future investigation in order to facilitate further insight into these rapidly evolving fields.
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Affiliation(s)
- Mitchell Jay Cohen
- Department of Surgery, San Francisco General Hospital and the University of California, San Francisco, San Francisco, CA, USA.
| | - S Ariane Christie
- Department of Surgery, San Francisco General Hospital and the University of California, San Francisco, San Francisco, CA, USA
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Comparison of Decision-Assist and Clinical Judgment of Experts for Prediction of Lifesaving Interventions. Shock 2016; 43:238-43. [PMID: 25394243 DOI: 10.1097/shk.0000000000000288] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Early recognition of hemorrhage during the initial resuscitation of injured patients is associated with improved survival in both civilian and military casualties. We tested a transfusion and lifesaving intervention (LSI) prediction algorithm in comparison with clinical judgment of expert trauma care providers. We collected 15 min of pulse oximeter photopletysmograph waveforms and extracted features to predict LSIs. We compared this with clinical judgment of LSIs by individual categories of prehospital providers, nurses, and physicians and a combined judgment of all three providers using the Area Under Receiver Operating Curve (AUROC). We obtained clinical judgment of need for LSI from 405 expert clinicians in135 trauma patients. The pulse oximeter algorithm predicted transfusion within 6 h (AUROC, 0.92; P < 0.003) more accurately than either physicians or prehospital providers and as accurately as nurses (AUROC, 0.76; P = 0.07). For prediction of surgical procedures, the algorithm was as accurate as the three categories of clinicians. For prediction of fluid bolus, the diagnostic algorithm (AUROC, 0.9) was significantly more accurate than prehospital providers (AUROC, 0.62; P = 0.02) and nurses (AUROC, 0.57; P = 0.04) and as accurate as physicians (AUROC, 0.71; P = 0.06). Prediction of intubation by the algorithm (AUROC, 0.92) was as accurate as each of the three categories of clinicians. The algorithm was more accurate (P < 0.03) for blood and fluid prediction than the combined clinical judgment of all three providers but no different from the clinicians in the prediction of surgery (P = 0.7) or intubation (P = 0.8). Automated analysis of 15 min of pulse oximeter waveforms predicts the need for LSIs during initial trauma resuscitation as accurately as judgment of expert trauma clinicians. For prediction of emergency transfusion and fluid bolus, pulse oximetry features were more accurate than these experts. Such automated decision support could assist resuscitation decisions, trauma team, and operating room and blood bank preparations.
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Helicopter In-flight Resuscitation with Freeze-dried Plasma of a Patient with a High-velocity Gunshot Wound to the Neck in Afghanistan - A Case Report. Prehosp Disaster Med 2015; 30:509-11. [PMID: 26323858 DOI: 10.1017/s1049023x15005014] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Massive hemorrhage with coagulopathy is one of the leading causes of preventable death in the battlefield. The development of freeze-dried plasma (FDP) allows for early treatment with coagulation-optimizing resuscitation fluid in the prehospital setting. This report describes the first prehospital use of FDP in a patient with carotid artery injury due to a high-velocity gunshot wound (HVGSW) to the neck. It also describes in-flight constitution and administration of FDP in a Medevac Helicopter. Early administration of FDP may contribute to hemodynamic stabilization and reduction in trauma-induced coagulopathy and acidosis. However, large-scale studies are needed to define the prehospital use of FDP and other blood products.
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Dunbar NM, Yazer MH. A possible new paradigm? A survey-based assessment of the use of thawed group A plasma for trauma resuscitation in the United States. Transfusion 2015; 56:125-9. [PMID: 26294248 DOI: 10.1111/trf.13266] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2015] [Revised: 07/06/2015] [Accepted: 07/07/2015] [Indexed: 01/02/2023]
Abstract
BACKGROUND Although evidence supporting this practice is limited, some centers use thawed group A plasma for the initial resuscitation of trauma patients. STUDY DESIGN AND METHODS To better understand the current use of plasma in trauma resuscitation, a survey was developed, validated, and distributed via e-mail to 121 American trauma centers. RESULTS A total of 61 responses were received. Most were from Level 1 trauma centers (56/61, 92%) in urban settings (47/61, 77%). Virtually all centers reported maintaining A thawed plasma inventory (59/61, 97%). Among the 56 Level 1 trauma center respondents, most keep thawed A immediately available (49/56, 88%) and many use group A plasma for trauma recipients of unknown ABO group (34/49, 69%). Half of the surveyed centers implemented this practice within the past year. The majority do not limit the amount of A plasma that can be administered to a patients of unknown ABO group (21/34, 62%), and most do not titer for anti-B (27/34, 79%). CONCLUSION The majority of Level 1 trauma centers maintain thawed plasma inventories and use group A plasma for trauma recipients of unknown ABO group. Most centers do not limit the amount of group A plasma used in this situation or titer the anti-B.
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Affiliation(s)
- Nancy M Dunbar
- Department of Pathology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire.,Department of Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Mark H Yazer
- The Institute for Transfusion Medicine, Pittsburgh, Pennsylvania.,Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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Peralta R, Vijay A, El-Menyar A, Consunji R, Abdelrahman H, Parchani A, Afifi I, Zarour A, Al-Thani H, Latifi R. Trauma resuscitation requiring massive transfusion: a descriptive analysis of the role of ratio and time. World J Emerg Surg 2015; 10:36. [PMID: 26279672 PMCID: PMC4536606 DOI: 10.1186/s13017-015-0028-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2015] [Accepted: 07/23/2015] [Indexed: 11/10/2022] Open
Abstract
Objective We aimed to evaluate whether early administration of high plasma to red blood cells ratios influences outcomes in injured patients who received massive transfusion protocol (MTP). Methods A retrospective analysis was conducted at the only level 1 national trauma center in Qatar for all adult patients(≥18 years old) who received MTP (≥10 units) of packed red blood cell (PRBC) during the initial 24 h post traumatic injury. Data were analyzed with respect to FFB:PRBC ratio [(high ≥ 1:1.5) (HMTP) vs. (low < 1:1.5) (LMTP)] given at the first 4 h post-injury and also between (>4 and 24 h). Mortality, multiorgan failure (MOF) and infectious complications were studied as well. Results During the study period, a total of 4864 trauma patients were admitted to the hospital, 1.6 % (n = 77) of them met the inclusion criteria. Both groups were comparable with respect to initial pH, international normalized ratio, injury severity score, revised trauma score and development of infectious complications. However, HMTP was associated with lower crude mortality (41.9 vs. 78.3 %, p = 0.001) and lower rate of MOF (48.4 vs. 87.0 %, p = 0.001). The number of deaths was 3 times higher in LMTP in comparison to HMTP within the first 30 days (36 vs. 13 cases). The majority of deaths occurred within the first 24 h (80.5 % in LMTP and 69 % in HMTP) and particularly within the first 6 h (55 vs. 46 %). Conclusions Aggressive attainment of high FFP/PRBC ratios as early as 4 h post-injury can substantially improve outcomes in trauma patients.
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Affiliation(s)
- Ruben Peralta
- Trauma Surgery Section, Hamad Trauma Center, Hamad General Hospital, Doha, Qatar
| | - Adarsh Vijay
- Trauma Surgery Section, Hamad Trauma Center, Hamad General Hospital, Doha, Qatar
| | - Ayman El-Menyar
- Clinical Research, Trauma Surgery Section, Hamad General Hospital, HMC, PO Box 3050, Doha, Qatar ; Clinical Medicine, Weill Cornell Medical College, Doha, Qatar
| | - Rafael Consunji
- Trauma Surgery Section, Hamad Trauma Center, Hamad General Hospital, Doha, Qatar
| | - Husham Abdelrahman
- Trauma Surgery Section, Hamad Trauma Center, Hamad General Hospital, Doha, Qatar
| | - Ashok Parchani
- Trauma Surgery Section, Hamad Trauma Center, Hamad General Hospital, Doha, Qatar
| | - Ibrahim Afifi
- Trauma Surgery Section, Hamad Trauma Center, Hamad General Hospital, Doha, Qatar
| | - Ahmad Zarour
- Trauma Surgery Section, Hamad Trauma Center, Hamad General Hospital, Doha, Qatar ; Clinical Medicine, Weill Cornell Medical College, Doha, Qatar
| | - Hassan Al-Thani
- Trauma Surgery Section, Hamad Trauma Center, Hamad General Hospital, Doha, Qatar
| | - Rifat Latifi
- Trauma Surgery Section, Hamad Trauma Center, Hamad General Hospital, Doha, Qatar ; Department of Surgery, University of Arizona, Tucson, AZ USA
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The traditional vs "1:1:1" approach debate on massive transfusion in trauma should not be treated as a dichotomy. Am J Emerg Med 2015; 33:1501-4. [PMID: 26184524 DOI: 10.1016/j.ajem.2015.06.065] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2015] [Revised: 06/22/2015] [Accepted: 06/25/2015] [Indexed: 11/21/2022] Open
Abstract
Traditional transfusion guidelines suggest that fresh frozen plasma (FFP) should be given based on laboratory or clinical evidence of coagulopathy or acute loss of 1 blood volume. This approach tends to result in a significant lag time between the first units of erythrocytes and FFP in trauma requiring massive transfusion. In severe trauma, observational studies have found an association between increased survival and aggressive use of FFP and platelets such that FFP:platelet:erythrocyte ratio approaches 1:1:1 to 2 from the first units of erythrocytes given. There are considerable concerns over either approach, and no randomized controlled trials have been published comparing the 2 approaches. Nowadays, trauma clinicans are incorporating the strenghts of both approaches and are no longer treating them as a dichotomy. Specifically, "1:1:1" proponents have devised 1:1:1 activation criteria to minimize unnecessary FFP and platelet transfusion and are prepared to deactivate the protocol as soon as patient is stabilized. Similarly, 1:1:1 skeptics are more mindful of the need to be proactive about trauma coagulopathy and the inherent delays in FFP administration in trauma patients.
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Stubbs JR, Zielinski MD, Berns KS, Badjie KS, Tauscher CD, Hammel SA, Zietlow SP, Jenkins D. How we provide thawed plasma for trauma patients. Transfusion 2015; 55:1830-7. [PMID: 26013588 DOI: 10.1111/trf.13156] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2014] [Revised: 04/08/2015] [Accepted: 04/08/2015] [Indexed: 12/21/2022]
Abstract
Almost 50% of trauma-related fatalities within the first 24 hours of injury are related to hemorrhage. Improved survival in severely injured patients has been demonstrated when massive transfusion protocols are rapidly invoked as part of a therapeutic approach known as damage control resuscitation (DCR). DCR incorporates the early use of plasma to prevent or correct trauma-induced coagulopathy. DCR often requires the transfusion of plasma before determination of the recipient's ABO group. Historically, group AB plasma has been considered the "universal donor" plasma product. At our facility, the number of AB plasma products produced on an annual basis was found to be inadequate to support the trauma service's DCR program. A joint decision was made by the transfusion medicine and trauma services to provide group A thawed plasma (TP) for in-hospital and prehospital DCR protocols. A description of the implementation of group A TP into the DCR program is provided as well as outcome data pertaining to the use of TP in trauma patients.
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Affiliation(s)
- James R Stubbs
- Department of Laboratory Medicine and Pathology, Division of Transfusion Medicine
| | | | - Kathleen S Berns
- Department of Medical Transport, Mayo Clinic, Rochester, Minnesota
| | - Karafa S Badjie
- Department of Laboratory Medicine and Pathology, Division of Transfusion Medicine
| | - Craig D Tauscher
- Department of Laboratory Medicine and Pathology, Division of Transfusion Medicine
| | - Scott A Hammel
- Department of Laboratory Medicine and Pathology, Division of Transfusion Medicine
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Galvagno SM, Hu P, Yang S, Gao C, Hanna D, Shackelford S, Mackenzie C. Accuracy of continuous noninvasive hemoglobin monitoring for the prediction of blood transfusions in trauma patients. J Clin Monit Comput 2015; 29:815-21. [PMID: 25753142 DOI: 10.1007/s10877-015-9671-1] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2014] [Accepted: 02/23/2015] [Indexed: 11/27/2022]
Abstract
Early detection of hemorrhagic shock is required to facilitate prompt coordination of blood component therapy delivery to the bedside and to expedite performance of lifesaving interventions. Standard physical findings and vital signs are difficult to measure during the acute resuscitation stage, and these measures are often inaccurate until patients deteriorate to a state of decompensated shock. The aim of this study is to examine a severely injured trauma patient population to determine whether a noninvasive SpHb monitor can predict the need for urgent blood transfusion (universal donor or additional urgent blood transfusion) during the first 12 h of trauma patient resuscitation. We hypothesize that trends in continuous SpHb, combined with easily derived patient-specific factors, can identify the immediate need for transfusion in trauma patients. Subjects were enrolled if directly admitted to the trauma center, >17 years of age, and with a shock index (heart rate/systolic blood pressure) >0.62. Upon admission, a Masimo Radical-7 co-oximeter sensor (Masimo Corporation, Irvine, CA) was applied, providing measurement of continuous non-invasive hemoglobin (SpHb) levels. Blood was drawn and hemoglobin concentration analyzed and conventional pulse oximetry photopletysmograph signals were continuously recorded. Demographic information and both prehospital and admission vital signs were collected. The primary outcome was transfusion of at least one unit of packed red blood cells within 24 h of admission. Eight regression models (C1-C8) were evaluated for the prediction of blood use by comparing area under receiver operating curve (AUROC) at different time intervals after admission. 711 subjects had continuous vital signs waveforms available, to include heart rate (HR), SpHb and SpO2 trends. When SpHb was monitored for 15 min, SpHb did not increase AUROC for prediction of transfusion. The highest ROC was recorded for model C8 (age, sex, prehospital shock index, admission HR, SpHb and SpO2) for the prediction of blood products within the first 3 h of admission. When data from 15 min of continuous monitoring were analyzed, significant improvement in AUROC occurred as more variables were added to the model; however, the addition of SpHb to any of the models did not improve AUROC significantly for prediction of blood use within the first 3 h of admission in comparison to analysis of conventional oximetry features. The results demonstrate that SpHb monitoring, accompanied by continuous vital signs data and adjusted for age and sex, has good accuracy for the prediction of need for transfusion; however, as an independent variable, SpHb did not enhance predictive models in comparison to use of features extracted from conventional pulse oximetry. Nor was shock index better than conventional oximetry at discriminating hemorrhaging and prediction of casualties receiving blood. In this population of trauma patients, noninvasive SpHb monitoring, including both trends and absolute values, did not enhance the ability to predict the need for blood transfusion.
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Affiliation(s)
- Samuel M Galvagno
- Department of Anesthesiology, University of Maryland School of Medicine, 22 South Greene Street, T1R83, Baltimore, MD, 21201, USA.
- Program in Trauma, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, USA.
| | - Peter Hu
- Department of Anesthesiology, University of Maryland School of Medicine, 22 South Greene Street, T1R83, Baltimore, MD, 21201, USA
- Program in Trauma, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Shiming Yang
- Department of Biomedical Engineering, University of Maryland, Baltimore County (UMBC), Baltimore, MD, USA
| | - Cheng Gao
- Program in Trauma, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, USA
| | - David Hanna
- University of Maryland School of Medicine, Baltimore, USA
| | - Stacy Shackelford
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
- Center for Sustainment in Trauma and Readiness Skills (Baltimore-CSTARS), United States Air Force, Baltimore, MD, USA
| | - Colin Mackenzie
- Department of Anesthesiology, University of Maryland School of Medicine, 22 South Greene Street, T1R83, Baltimore, MD, 21201, USA
- Program in Trauma, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, USA
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Automated prediction of early blood transfusion and mortality in trauma patients. J Trauma Acute Care Surg 2014; 76:1379-85. [PMID: 24854304 DOI: 10.1097/ta.0000000000000235] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Prediction of blood transfusion needs and mortality for trauma patients in near real time is an unrealized goal. We hypothesized that analysis of pulse oximeter signals could predict blood transfusion and mortality as accurately as conventional vital signs (VSs). METHODS Continuous VS data were recorded for direct admission trauma patients with abnormal prehospital shock index (SI = heart rate [HR] / systolic blood pressure) greater than 0.62. Predictions of transfusion during the first 24 hours and in-hospital mortality using logistical regression models were compared with DeLong's method for areas under receiver operating characteristic curves (AUROCs) to determine the optimal combinations of prehospital SI and HR, continuous photoplethysmographic (PPG), oxygen saturation (SpO2), and HR-related features. RESULTS We enrolled 556 patients; 37 received blood within 24 hours; 7 received more than 4 U of red blood cells in less than 4 hours or "massive transfusion" (MT); and 9 died. The first 15 minutes of VS signals, including prehospital HR plus continuous PPG, and SpO2 HR signal analysis best predicted transfusion at 1 hour to 3 hours, MT, and mortality (AUROC, 0.83; p < 0.03) and no differently (p = 0.32) from a model including blood pressure. Predictions of transfusion based on the first 15 minutes of data were no different using 30 minutes to 60 minutes of data collection. SI plus PPG and SpO2 signal analysis (AUROC, 0.82) predicted 1-hour to 3-hour transfusion, MT, and mortality no differently from pulse oximeter signals alone. CONCLUSION Pulse oximeter features collected in the first 15 minutes of our trauma patient resuscitation cohort, without user input, predicted early MT and mortality in the critical first hours of care better than the currently used VS such as combinations of HR and systolic blood pressure or prehospital SI alone. LEVEL OF EVIDENCE Therapeutic/prognostic study, level II.
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Abstract
While early plasma transfusion for the treatment of patients with ongoing major hemorrhage is widely accepted as part of the standard of care in the hospital setting, logistic constraints have limited its use in the out-of-hospital setting. Freeze-dried plasma (FDP), which can be stored at ambient temperatures, enables early treatment in the out-of-hospital setting. Point-of-injury plasma transfusion entails several significant advantages over currently used resuscitation fluids, including the avoidance of dilutional coagulopathy, by minimizing the need for crystalloid infusion, beneficial effects on endothelial function, physiological pH level, and better maintenance of intravascular volume compared with crystalloid-based solutions. The Israel Defense Forces Medical Corps policy is that plasma is the resuscitation fluid of choice for selected, severely wounded patients and has thus included FDP as part of its armamentarium for use at the point of injury by advanced life savers, across the entire military. We describe the clinical rationale behind the use of FDP at the point-of-injury, the drafting of the administration protocol now being used by Israel Defense Forces advanced life support providers, the process of procurement and distribution, and preliminary data describing the first casualties treated with FDP at the point of injury. It is our hope that others will be able to learn from our experience, thus improving trauma casualty care around the world.
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Simms ER, Hennings DL, Hauch A, Wascom J, Fontenot TE, Hunt JP, McSwain NE, Meade PC, Myers L, Duchesne JC. Impact of infusion rates of fresh frozen plasma and platelets during the first 180 minutes of resuscitation. J Am Coll Surg 2014; 219:181-8. [PMID: 24974265 DOI: 10.1016/j.jamcollsurg.2014.03.050] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2013] [Revised: 03/07/2014] [Accepted: 03/07/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND Whether high-ratio resuscitation (HRR) provides patients with survival advantage remains controversial. We hypothesized a direct correlation between HRR infusion rates in the first 180 minutes of resuscitation and survival. STUDY DESIGN This was a retrospective analysis of massively transfused trauma patients surviving more than 30 minutes and undergoing surgery at a level 1 trauma center. Mean infusion rates (MIR) of packed red blood cells (PRBC), fresh frozen plasma (FFP), and platelets (Plt) were calculated for length of intervention (emergency department [ED] time + operating room [OR] time). Patients were categorized as HRR (FFP:PRBC > 0.7, and/or Plts: PRBC > 0.7) vs low-ratio resuscitation (LRR). Student's t-tests and chi-square tests were used to compare survivors with nonsurvivors. Cox proportional hazards regression models and Kaplan-Meier curves were generated to evaluate the association between MIR for FFP:PRBC and Plt:PRBC and 180-minute survival. RESULTS There were 151 patients who met criteria: 121 (80.1%) patients survived 180 minutes (MIR:PRBC 71.9 mL/min, FFP 92.0 mL/min, Plt 3.5 mL/min) vs 30 (19.9%) who did not survive (MIR:PRBC 47.3 mL/min, FFP 33.7 mL/min, Plt 1.1 mL/min), p = 0.43, p < 0.0001 and p < 0.011, respectively. A Cox regression model evaluated PRBC rate, FFP rate, and Plt rate (mL/min) as mortality predictors within 180 minutes to assess if they significantly affected survival (hazard ratios 1.01 [p = 0.054], 0.97 [p < 0.0001], and 0.75 [p = 0.01], respectively). Another model used stepwise Cox regression including PRBC rate, FFP rate, and Plt rate (hazard ratios 1.00 [p = 0.85], 0.97 [p < 0.0001], and 0.88 [p = 0.24], respectively), as well as possible confounding variables. CONCLUSIONS This is the first study to examine effects of MIRs on survival. Further studies on the effects of narrow time-interval analysis for blood product resuscitation are warranted.
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Affiliation(s)
- Eric R Simms
- Department of Surgery, Tulane University School of Medicine, New Orleans, LA
| | - Dietric L Hennings
- Department of Surgery, Tulane University School of Medicine, New Orleans, LA
| | - Adam Hauch
- Department of Surgery, Tulane University School of Medicine, New Orleans, LA
| | - Julie Wascom
- Department of Surgery, Louisiana State University Health Sciences Center, New Orleans, LA
| | - Tatyana E Fontenot
- Department of Surgery, Tulane University School of Medicine, New Orleans, LA
| | - John P Hunt
- Department of Surgery, Louisiana State University Health Sciences Center, New Orleans, LA
| | - Norman E McSwain
- Department of Surgery, Tulane University School of Medicine, New Orleans, LA
| | - Peter C Meade
- Department of Surgery, Tulane University School of Medicine, New Orleans, LA
| | - Leann Myers
- Tulane University School of Public Health and Tropical Medicine, New Orleans, LA
| | - Juan C Duchesne
- Department of Surgery, Tulane University School of Medicine, New Orleans, LA; Department of Surgery, Louisiana State University Health Sciences Center, New Orleans, LA; North Oaks Shock/Trauma, Division of Trauma/Critical Care, Hammond, LA.
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Abstract
INTRODUCTION Most preventable trauma deaths are due to uncontrolled hemorrhage. METHODS In this article, we briefly describe the pathophysiology of the classical triad of death in trauma, namely, acidosis, hypothermia, and coagulopathy, and then suggest damage control resuscitation strategies to prevent and/or mitigate the effects of each in the bleeding patient. RESULTS Damage control resuscitation strategies include body rewarming, restrictive fluid administration, permissive hypotension, balanced blood product administration, and the implementation of massive transfusion protocols. CONCLUSION Resuscitating and correcting the coagulopathy of the exsanguinating trauma patient is essential to improve chances of survival.
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Affiliation(s)
- H M A Kaafarani
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital & Harvard Medical School, Boston, MA, USA
| | - G C Velmahos
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital & Harvard Medical School, Boston, MA, USA
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Jacob M, Kumar P. The challenge in management of hemorrhagic shock in trauma. Med J Armed Forces India 2014; 70:163-9. [PMID: 24843206 DOI: 10.1016/j.mjafi.2014.03.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2013] [Accepted: 03/02/2014] [Indexed: 12/29/2022] Open
Abstract
Transfusion and resuscitation practices in trauma have undergone a sea change over the past decade. New understanding of transfusion physiology and experiences in military trauma over the last decade has identified key factors taken as challenges in trauma. The most important challenge remains acute traumatic coagulopathy (ATC) which sets in early after a trauma and spirals the patient into shock and continued bleeding. World wide trauma is the leading cause of mortality. More than 6 million deaths occur due to trauma out of which 20% are due to uncontrollable bleeding. Out of the hospital admissions in trauma 20% develop coagulopathy. Mortality is three to four times higher in a patient with coagulopathy and thus prevention and correction of coagulopathy is the central goal of the management of hemorrhagic shock in trauma. Damage control resuscitation (DCR), a strategy combining the techniques of permissive hypotension, hemostatic resuscitation and damage control surgery has been widely adopted as the preferred method of resuscitation in patients with haemorrhagic shock. The over-riding goals of DCR are to mitigate metabolic acidosis, hypothermia and coagulopathy, This article looks at the importance of acute traumatic coagulopathy, its etiology, diagnosis, effects and resuscitation strategies to prevent it and to see the background behind this shift.
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Affiliation(s)
- Mathews Jacob
- Associate Professor, Department of Anaesthesiology and Critical Care, Armed Forces Medical College, Pune 411040, India
| | - Praveen Kumar
- Resident, Department of Anaesthesiology and Critical Care, Armed Forces Medical College, Pune 411040, India
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