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Byeon GJ, Yoon JU, Kim HJ, Choi EJ, Kim EJ, Park S, Park SJ, Heo W, Kim HY. The influence of circulating fibrinogen level on postoperative blood loss and blood transfusion in pediatric cardiac surgery: a retrospective observational study. Transl Pediatr 2022; 11:514-525. [PMID: 35558986 PMCID: PMC9085943 DOI: 10.21037/tp-21-236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Accepted: 07/13/2021] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Pediatric patients are at high risk of massive bleeding after cardiac surgery under cardiopulmonary bypass (CPB). Fibrinogen is essential for coagulation; however, pediatric patients with congenital heart disease (CHD) present abnormal fibrinogen function. The pre- and post-operative fibrinogen level may affect the bleeding and transfusion amount in patients undergoing cardiac surgery. However, the relationship between plasma fibrinogen levels and the bleeding and transfusion amount in pediatric cardiac surgery remains unclear. This study aimed to assess the association of pre-CPB fibrinogen levels (PreFib) and post-CPB fibrinogen levels (PostFib) with postoperative bleeding and transfusion volume in pediatric cardiac surgery. METHODS We reviewed the medical records of 375 newborns and infants who underwent cardiac surgery under CPB for CHD. The primary endpoint was the correlation of the PreFib and PostFib values, as well as their difference (FibGap), with the bleeding and transfusion amount within 24 postoperative hours. RESULTS There was no correlation of the PreFib, PostFib, and FibGap values with the bleeding and transfusion amounts at postoperative 24 hours. However, patients with PreFib and PostFib values of <150 and <100 mg/dL, respectively, showed a significantly higher frequency of postoperative platelet (PLT) transfusion. In patients with complex CHD, PreFib showed a weak negative correlation with the bleeding amount at postoperative 24 hours and the number of PLT-transfused patients. CONCLUSIONS Our findings suggest that in pediatric patients with CHD who cannot undergo point-of-care (POC) tests, those presenting PreFib and PostFib values of <150 and <100 mg/dL, respectively, have a significantly higher frequency of postoperative PLT transfusion.
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Affiliation(s)
- Gyeong-Jo Byeon
- Department of Anesthesia and Pain Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea.,Department of Anesthesia and Pain Medicine, School of Medicine, Pusan National University, Yangsan, Korea
| | - Ji-Uk Yoon
- Department of Anesthesia and Pain Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea.,Department of Anesthesia and Pain Medicine, School of Medicine, Pusan National University, Yangsan, Korea
| | - Hye-Jin Kim
- Department of Anesthesia and Pain Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Eun-Ji Choi
- Department of Dental Anesthesia and Pain Medicine, Pusan National University Dental Hospital, Yangsan, Korea
| | - Eun-Jung Kim
- Department of Dental Anesthesia and Pain Medicine, Pusan National University Dental Hospital, Yangsan, Korea.,Department of Dental Anesthesia and Pain Medicine, School of Dentistry, Pusan National University, Dental Research Institute, Yangsan, Korea
| | - Seyeon Park
- Department of Anesthesia and Pain Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Soon Ji Park
- Department of Anesthesia and Pain Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Wonjae Heo
- Department of Anesthesia and Pain Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Hee Young Kim
- Department of Anesthesia and Pain Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea
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2
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A review of treatments for non-compressible torso hemorrhage (NCTH) and internal bleeding. Biomaterials 2022; 283:121432. [DOI: 10.1016/j.biomaterials.2022.121432] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Revised: 01/26/2022] [Accepted: 02/17/2022] [Indexed: 12/12/2022]
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3
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Chang JC. Stroke Classification: Critical Role of Unusually Large von Willebrand Factor Multimers and Tissue Factor on Clinical Phenotypes Based on Novel "Two-Path Unifying Theory" of Hemostasis. Clin Appl Thromb Hemost 2020; 26:1076029620913634. [PMID: 32584600 PMCID: PMC7427029 DOI: 10.1177/1076029620913634] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2019] [Revised: 02/19/2020] [Accepted: 02/20/2020] [Indexed: 12/17/2022] Open
Abstract
Stroke is a hemostatic disease associated with thrombosis/hemorrhage caused by intracranial vascular injury with spectrum of clinical phenotypes and variable prognostic outcomes. The genesis of different phenotypes of stroke is poorly understood due to our incomplete understanding of hemostasis and thrombosis. These shortcomings have handicapped properly recognizing each specific stroke syndrome and contributed to controversy in selecting therapeutic agents. Treatment recommendation for stroke syndromes has been exclusively derived from the result of laborious and expensive clinical trials. According to newly proposed "two-path unifying theory" of in vivo hemostasis, intracranial vascular injury would yield several unique stroke syndromes triggered by 3 distinctly different thrombogenetic mechanisms depending upon level of intracranial intravascular injury and character of formed blood clots. Five major phenotypes of stroke occur via thrombogenetic paths: (1) transient ischemic attack due to focal endothelial damage limited to endothelial cells (ECs), (2) acute ischemic stroke due to localized ECs and subendothelial tissue (SET) damage extending up to the outer vascular wall, (3) thrombo-hemorrhagic stroke due to localized vascular damage involving ECs and SET and extending beyond SET to extravascular tissue, (4) acute hemorrhagic stroke due to major localized intracranial hemorrhage/hematoma into the brain tissue or space between the coverings of the brain associated with vascular anomaly or obtuse trauma, and (5) encephalopathic stroke due to disseminated endotheliopathy leading to microthrombosis within the brain. New classification of stroke phenotypes would assist in selecting rational therapeutic regimen for each stroke syndrome and designing clinical trials to improve clinical outcome.
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Affiliation(s)
- Jae C. Chang
- Department of Medicine, University of California Irvine School of Medicine, Irvine, CA, USA
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4
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Kyang LS, Howard A, Alzahrani NA, Morris DL. Case report: Intraoperative thrombosis cardiac arrest in extended right hepatectomy involving use of local haemostatic agent in intraoperative cell salvage (ICS) and administration of recombinant activated factor VII (rFVIIa). Int J Surg Case Rep 2019; 57:48-51. [PMID: 30901569 PMCID: PMC6429545 DOI: 10.1016/j.ijscr.2019.02.042] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Revised: 02/14/2019] [Accepted: 02/25/2019] [Indexed: 12/05/2022] Open
Abstract
Intractable intraoperative haemorrhage is a result of both surgical and coagulopathic (nonsurgical) components. There is increasing off-label use of rFVIIa for ceasing refractory bleeding aside from its application in patient with haemophilia. rFVIIa use may be associated with increased thromboembolic events according to some literature. The use of topical haemostatic agent in conjunction with ICS may potentially lead to systemic clot formation upon re-infusion of the chemical. Avoid use of cell saver suction while the surgical field is contaminated with topical clotting factors before irrigation with 0.9% sodium chloride.
Introduction In modern surgical era, local haemostatic agents and blood components such as recombinant activated factor VII (rFVIIa) have expanded surgeons’ armamentarium in controlling “surgical” and “nonsurgical bleeding”. We report a case of intraoperative thrombosis and cardiac arrest involving use of local haemostatic agent in intraoperative cell salvage and rFVIIa administration in extended right hepatectomy. Presentation of case A 46-year-old lady underwent extended right hepatectomy using cardiopulmonary bypass (CPB) and autotransfusion with ICS for metastatic gastrointestinal stromal tumour. She became extremely coagulopathic following weaning of CPB despite an array of fluid and blood products replacements. Decision to administer rFVIIa as a measure to arrest bleeding was unsuccessful. Extensive systemic thrombosis occurred which resulted in cardiac arrest and mortality. Discussion The thromboembolic event was unclear but likely multifactorial. Two important hypotheses were the administration of rFVIIa and use of local haemostatic agent in ICS. Conclusion Reported incidence of thromboembolism with use of rFVIIa in refractory bleeding is variable. More randomised controlled trials are needed to ascertain the efficacy and safety profile of the haemostatic agent. At present, off-label use of rFVIIa should be guided by the risk:benefit profile on a case-to-case basis. The authors also feel strongly against the use of local haemostatic gel in conjunction with ICS due to potential systemic circulation of the thrombin.
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Affiliation(s)
- Lee S Kyang
- Department of Surgery, St George Hospital, University of New South Wales, Sydney, New South Wales, Australia.
| | - Andrew Howard
- Department of Anaesthesia, St George Hospital, Sydney, New South Wales, Australia
| | - Nayef A Alzahrani
- Department of Surgery, St George Hospital, University of New South Wales, Sydney, New South Wales, Australia; College of Medicine, Al-Imam Mohammad Ibn Saud Islamic University (IMSIU), Riyadh, Saudi Arabia
| | - David L Morris
- Department of Surgery, St George Hospital, University of New South Wales, Sydney, New South Wales, Australia
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5
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Cheng CAY, Ho AMH. Use of Recombinant Activated Factor VII after Axillofemoral Bypass Grafting. Anaesth Intensive Care 2019; 34:375-8. [PMID: 16802495 DOI: 10.1177/0310057x0603400301] [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] [Indexed: 11/16/2022]
Abstract
Recombinant activated factor VII (rFVIIa) is a powerful prohaemostatic agent that theoretically predisposes to thrombosis after peripheral vascular surgery. We report the use of rFVIIa to reduce bleeding in a patient after axillofemoral bypass grafting for ruptured aorto-iliac pseudoaneurysm. Despite the increased risk of thrombosis, the patient made an uneventful recovery with preserved graft patency. The favourable result suggests that rFVIIa should be considered even in vascular surgical patients, if the risks of continued bleeding outweigh those of thrombosis. Better risk estimation is only possible if reports of rFVIIa use in vascular patients continue to appear and through controlled trials.
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Affiliation(s)
- C A Y Cheng
- Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, NT
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Phillips JB, Mohorn PL, Bookstaver RE, Ezekiel TO, Watson CM. Hemostatic Management of Trauma-Induced Coagulopathy. Crit Care Nurse 2018; 37:37-47. [PMID: 28765353 DOI: 10.4037/ccn2017476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Trauma-induced coagulopathy is a primary factor in many trauma-related fatalities. Management hinges upon rapid diagnosis of coagulation abnormalities and immediate administration of appropriate hemostatic agents. Use of crystalloids and packed red blood cells has traditionally been the core of trauma resuscitation, but current massive transfusion protocols include combination therapy with fresh frozen plasma and predefined ratios of platelets to packed red blood cells, limiting crystalloid administration. Hemostatic agents such as tranexamic acid, prothrombin complex concentrate, fibrinogen concentrate, and, in cases of refractory bleeding, recombinant activated factor VIIa may also be warranted. Goal-directed resuscitation using viscoelastic tools allows specific component-centered therapy based on individual clotting abnormalities that may limit blood product use and thromboembolic risks and may lead to reduced mortality. Because of the complex management of patients with trauma-induced coagulopathy, critical care nurses must be familiar with the pathophysiology, acute diagnostics, and pharmacotherapeutic options used to treat these patients.
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Affiliation(s)
- Janise B Phillips
- Janise B. Phillips is a critical care pharmacotherapy specialist, Department of Pharmacy Services, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates.,Phillip L. Mohorn is a critical care clinical pharmacy specialist, Department of Pharmacy, Spartanburg Medical Center, Spartanburg Regional Healthcare System, Spartanburg, South Carolina.,Rebecca E. Bookstaver is a critical care clinical pharmacist, Department of Pharmacy, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina.,Tanya O. Ezekiel is a clinical informatics pharmacist, Department of Pharmaceutical Services and Clinical Nutrition, Palmetto Health Richland, Columbia, South Carolina.,Christopher M. Watson is chief of surgery, medical director of the surgical-trauma ICU and surgical step down unit, and program director of the surgical critical care fellowship, Division of Trauma, Acute Care Surgery, and Surgical Critical Care, Palmetto Health Richland and the University of South Carolina School of Medicine, Columbia, South Carolina
| | - Phillip L Mohorn
- Janise B. Phillips is a critical care pharmacotherapy specialist, Department of Pharmacy Services, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates. .,Phillip L. Mohorn is a critical care clinical pharmacy specialist, Department of Pharmacy, Spartanburg Medical Center, Spartanburg Regional Healthcare System, Spartanburg, South Carolina. .,Rebecca E. Bookstaver is a critical care clinical pharmacist, Department of Pharmacy, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina. .,Tanya O. Ezekiel is a clinical informatics pharmacist, Department of Pharmaceutical Services and Clinical Nutrition, Palmetto Health Richland, Columbia, South Carolina. .,Christopher M. Watson is chief of surgery, medical director of the surgical-trauma ICU and surgical step down unit, and program director of the surgical critical care fellowship, Division of Trauma, Acute Care Surgery, and Surgical Critical Care, Palmetto Health Richland and the University of South Carolina School of Medicine, Columbia, South Carolina.
| | - Rebecca E Bookstaver
- Janise B. Phillips is a critical care pharmacotherapy specialist, Department of Pharmacy Services, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates.,Phillip L. Mohorn is a critical care clinical pharmacy specialist, Department of Pharmacy, Spartanburg Medical Center, Spartanburg Regional Healthcare System, Spartanburg, South Carolina.,Rebecca E. Bookstaver is a critical care clinical pharmacist, Department of Pharmacy, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina.,Tanya O. Ezekiel is a clinical informatics pharmacist, Department of Pharmaceutical Services and Clinical Nutrition, Palmetto Health Richland, Columbia, South Carolina.,Christopher M. Watson is chief of surgery, medical director of the surgical-trauma ICU and surgical step down unit, and program director of the surgical critical care fellowship, Division of Trauma, Acute Care Surgery, and Surgical Critical Care, Palmetto Health Richland and the University of South Carolina School of Medicine, Columbia, South Carolina
| | - Tanya O Ezekiel
- Janise B. Phillips is a critical care pharmacotherapy specialist, Department of Pharmacy Services, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates.,Phillip L. Mohorn is a critical care clinical pharmacy specialist, Department of Pharmacy, Spartanburg Medical Center, Spartanburg Regional Healthcare System, Spartanburg, South Carolina.,Rebecca E. Bookstaver is a critical care clinical pharmacist, Department of Pharmacy, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina.,Tanya O. Ezekiel is a clinical informatics pharmacist, Department of Pharmaceutical Services and Clinical Nutrition, Palmetto Health Richland, Columbia, South Carolina.,Christopher M. Watson is chief of surgery, medical director of the surgical-trauma ICU and surgical step down unit, and program director of the surgical critical care fellowship, Division of Trauma, Acute Care Surgery, and Surgical Critical Care, Palmetto Health Richland and the University of South Carolina School of Medicine, Columbia, South Carolina
| | - Christopher M Watson
- Janise B. Phillips is a critical care pharmacotherapy specialist, Department of Pharmacy Services, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates.,Phillip L. Mohorn is a critical care clinical pharmacy specialist, Department of Pharmacy, Spartanburg Medical Center, Spartanburg Regional Healthcare System, Spartanburg, South Carolina.,Rebecca E. Bookstaver is a critical care clinical pharmacist, Department of Pharmacy, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina.,Tanya O. Ezekiel is a clinical informatics pharmacist, Department of Pharmaceutical Services and Clinical Nutrition, Palmetto Health Richland, Columbia, South Carolina.,Christopher M. Watson is chief of surgery, medical director of the surgical-trauma ICU and surgical step down unit, and program director of the surgical critical care fellowship, Division of Trauma, Acute Care Surgery, and Surgical Critical Care, Palmetto Health Richland and the University of South Carolina School of Medicine, Columbia, South Carolina
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7
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Caspers M, Schäfer N, Fröhlich M, Bauerfeind U, Bouillon B, Mutschler M, Maegele M. How do external factors contribute to the hypocoagulative state in trauma-induced coagulopathy? - In vitro analysis of the lethal triad in trauma. Scand J Trauma Resusc Emerg Med 2018; 26:66. [PMID: 30111342 PMCID: PMC6094881 DOI: 10.1186/s13049-018-0536-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2018] [Accepted: 08/06/2018] [Indexed: 11/18/2022] Open
Abstract
Background External factors following trauma and iatrogenic intervention influence blood coagulation and particularly clot formation. In particular, three external factors (in detail dilution via uncritical volume replacement, acidosis and hypothermia), in combination, referred to as the “lethal triad”, substantially aggravate the hypocoagulative state after trauma. Contribution of these external factors to the resulting hypocoagulative state in trauma and especially their influence on primary haemostasis has still not been investigated systematically. This study aims to assess this contribution to the aggravating hypocoagulative state in trauma-induced coagulopathy (TIC) using an in vitro simulation assay. Emphasis is given to platelet contribution to clot formation and to the investigation of how platelet activation alters under the respective conditions. Methods To simulate the conditions of lethal triad in vitro, whole blood samples taken from five healthy volunteers were introduced to the respective conditions. Besides standard coagulation testing, thrombelastometric analysis and differentiated platelet mapping were performed. Results All three simulated conditions induced significant impairments of clot formation (clot formation time, CFT; α -angle) and propagation (maximum clot firmness, MCF; Diameter A5-A25), with the highest impact under hypothermia and dilution. Consistently, lethal triad resulted in an additive effect of all conditions. None of the simulated conditions induced a statistically relevant change in coagulation initiation assessed by EXTEM and FIBTEM thrombelastometry. Platelet contribution to clot formation decreased gradually under the respective conditions, reaching statistical significance for simulated dilution, and attaining its greatest extent under the conditions of lethal triad (Δtrias/baseline 0.59; p = 0.01). Consistent, reduced CD62 expression levels were observed under experimental acidosis (Δacidosis/baseline 0.32; p = 0.006), dilution (Δdilution/baseline 0.34; p = 0.01) and lethal triad (Δlethal triad/baseline 0.24; p = 0.01). Conclusion The respective external factors of lethal triad play a pivotal role in the development of coagulopathy, essentially influencing the kinetics of clot formation, and to a varying extent clot diameter, as measured by thrombelastometry. Moreover, impairment of platelet function under the conditions of lethal triad plays a key role in the pathophysiology of TIC, resulting in reduced responsiveness to stimulation with ADP that might also be present after trauma. Our data indicate that impairment of primary haemostasis contribute to the hypocoagulative state in TIC after trauma aggravated by external factors of lethal triad.
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Affiliation(s)
- Michael Caspers
- The Institute for Research in Operative Medicine, Faculty of Health, Department of Medicine, Witten/Herdecke University, Ostmerheimer Str. 200, 51109, Cologne, Germany. .,Department of Traumatology, Orthopaedic Surgery and Sports Traumatology, Cologne-Merheim Medical Centre (CMMC), Witten/Herdecke University, Campus Cologne-Merheim, Ostmerheimer Str. 200, 51109, Cologne, Germany.
| | - Nadine Schäfer
- The Institute for Research in Operative Medicine, Faculty of Health, Department of Medicine, Witten/Herdecke University, Ostmerheimer Str. 200, 51109, Cologne, Germany
| | - Matthias Fröhlich
- Department of Traumatology, Orthopaedic Surgery and Sports Traumatology, Cologne-Merheim Medical Centre (CMMC), Witten/Herdecke University, Campus Cologne-Merheim, Ostmerheimer Str. 200, 51109, Cologne, Germany
| | - Ursula Bauerfeind
- Department of Transfusion Medicine, Cologne-Merheim Medical Centre (CMMC), Witten/Herdecke University, Campus Cologne- Merheim, Ostmerheimer Str. 200, 51109, Cologne, Germany
| | - Bertil Bouillon
- Department of Traumatology, Orthopaedic Surgery and Sports Traumatology, Cologne-Merheim Medical Centre (CMMC), Witten/Herdecke University, Campus Cologne-Merheim, Ostmerheimer Str. 200, 51109, Cologne, Germany
| | - Manuel Mutschler
- Department of Traumatology, Orthopaedic Surgery and Sports Traumatology, Cologne-Merheim Medical Centre (CMMC), Witten/Herdecke University, Campus Cologne-Merheim, Ostmerheimer Str. 200, 51109, Cologne, Germany
| | - Marc Maegele
- The Institute for Research in Operative Medicine, Faculty of Health, Department of Medicine, Witten/Herdecke University, Ostmerheimer Str. 200, 51109, Cologne, Germany.,Department of Traumatology, Orthopaedic Surgery and Sports Traumatology, Cologne-Merheim Medical Centre (CMMC), Witten/Herdecke University, Campus Cologne-Merheim, Ostmerheimer Str. 200, 51109, Cologne, Germany
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8
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Payen JF, Berthet M, Genty C, Declety P, Garrigue-Huet D, Morel N, Bouzat P, Riou B, Bosson JL. Reduced mortality by meeting guideline criteria before using recombinant activated factor VII in severe trauma patients with massive bleeding. Br J Anaesth 2018; 117:470-476. [PMID: 28077534 DOI: 10.1093/bja/aew276] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/04/2016] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Management of trauma patients with severe bleeding has led to criteria before considering use of recombinant activated factor VII (rFVIIa), including haemoglobin >8 g dl-1, serum fibrinogen ≥1.0 g l-1, platelets >50,000 x 109 l-1, arterial pH ≥ 7.20, and body temperature ≥34 °C. We hypothesized that meeting these criteria is associated with improved outcomes. METHODS In this prospective cohort study of 26 French trauma centres, subjects were included if they received rFVIIa for persistent massive bleeding despite appropriate care after severe blunt and/or penetrating trauma. RESULTS After surgery and/or embolization as haemostatic interventions, 112 subjects received a first dose of 103 μg kg-1 rFVIIa (82-200) (median, 25th-75th percentile) at 420 min (285-647) post-trauma. Of these, 71 (63%) "responders" were still alive at 24h post-trauma and had their transfusion requirements reduced by > 2 packed red blood cell units after rFVIIa treatment. Mortality was 54% on day 30 post-trauma. There were 21%, 44% and 35% subjects who fulfilled 0-1, 2-3 or 4-5, respectively, of the guidelines before receiving rFVIIa. Survival at day 30 was 13%, 49% and 64% and the proportion of responders was 39%, 64% and 82%, when subjects fulfilled 0-1, 2-3 or 4-5 conditions, respectively (both P <0.01). CONCLUSIONS In actively bleeding trauma patients, meeting guideline criteria before considering rFVIIa was associated with lower mortality and a higher proportion of responders to the rFVIIa.
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Affiliation(s)
- J-F Payen
- Pôle Anesthésie Réanimation, CHU Grenoble Alpes, F-38000, Grenoble, France .,INSERM, U1216, F-38000 Grenoble, France.,Univ. Grenoble Alpes, Grenoble Institut des Neurosciences, GIN, F-38000 Grenoble, France
| | - M Berthet
- Pôle Anesthésie Réanimation, CHU Grenoble Alpes, F-38000, Grenoble, France
| | - C Genty
- Clinical Research Centre, INSERM 003, CHU Grenoble Alpes, F-38000, Grenoble, France.,Univ. Grenoble Alpes, CNRS-TIMC-IMAG UMR, 5525-ThEMAS, F-38000 Grenoble, France
| | - P Declety
- Pôle Anesthésie Réanimation, CHU Grenoble Alpes, F-38000, Grenoble, France
| | - D Garrigue-Huet
- Pôle Anesthésie Réanimation, CHU de Lille, F-59037, Lille, France
| | - N Morel
- Pôle Urgences SAMU SMUR, Groupe Hospitalier Pellegrin, CHU de Bordeaux, F-33076, Bordeaux, France
| | - P Bouzat
- Pôle Anesthésie Réanimation, CHU Grenoble Alpes, F-38000, Grenoble, France.,INSERM, U1216, F-38000 Grenoble, France.,Univ. Grenoble Alpes, Grenoble Institut des Neurosciences, GIN, F-38000 Grenoble, France
| | - B Riou
- Service d'accueil des Urgences, CHU Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, F-75651, Paris, France.,Sorbonne Universités, UPMC Univ. Paris 6, UMRS INSERM 1166, IHU ICAN, Paris, France
| | - J-L Bosson
- Clinical Research Centre, INSERM 003, CHU Grenoble Alpes, F-38000, Grenoble, France.,Univ. Grenoble Alpes, CNRS-TIMC-IMAG UMR, 5525-ThEMAS, F-38000 Grenoble, France
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9
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Endo A, Shiraishi A, Fushimi K, Murata K, Otomo Y. Outcomes of patients receiving a massive transfusion for major trauma. Br J Surg 2018; 105:1426-1434. [PMID: 29999518 DOI: 10.1002/bjs.10905] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Revised: 04/27/2018] [Accepted: 05/07/2018] [Indexed: 01/05/2023]
Abstract
BACKGROUND The benefits of high transfusion ratios (plasma to red blood cells and platelets to red blood cells) on survival in injured patients who receive massive transfusions remain uncertain. This study aimed to assess the association between transfusion ratios and adverse events and survival in patients undergoing massive transfusion for major trauma. METHODS A retrospective observational study was conducted on patients who had major trauma using a Japanese national administrative database. The associations between transfusion ratios and outcomes (in-hospital mortality and incidence of adverse events) were analysed using a non-linear logistic generalized additive model (GAM). In a logistic generalized estimating equation model, adjusted for patient and hospital-level confounders, transfusion ratios were included as continuous or categorical variables (low, transfusion ratio 0·75 or less; intermediate, over 0·75 to 1·25; high, over 1·25). RESULTS Some 1777 patients were included in the analysis, of whom 602 died in hospital. GAM plots of the transfusion ratios for in-hospital mortality demonstrated a downward convex unimodal curve. In-hospital mortality was similar with increasing transfusion ratios for plasma (adjusted odds ratio (OR) 1·13, 95 per cent c.i. 0·82 to 1·55; P = 0·446) and platelets (adjusted OR 0·84, 0·66 to 1·08; P = 0·171). Both plasma to red blood cell ratio (adjusted OR 1·77, 1·32 to 2·37; P < 0·001) and platelet to red blood cell ratio (adjusted OR 1·71, 1·35 to 2·15; P < 0·001) were significantly associated with a higher incidence of adverse events. No significant differences in in-hospital mortality were observed between the three transfusion categories (low, medium and high). CONCLUSION In this study, transfusion strategies with high plasma to red blood cell and platelet to red blood cell ratios did not have survival benefits, but were associated with an increase in adverse events.
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Affiliation(s)
- A Endo
- Trauma and Acute Critical Care Medical Centre, Tokyo Medical and Dental University Hospital of Medicine, Tokyo, Japan
| | - A Shiraishi
- Trauma and Acute Critical Care Medical Centre, Tokyo Medical and Dental University Hospital of Medicine, Tokyo, Japan.,Emergency and Trauma Centre, Kameda Medical Centre, Kamogawa, Japan
| | - K Fushimi
- Department of Health Policy and Informatics, Tokyo Medical and Dental University Graduate School of Medicine, Tokyo, Japan
| | - K Murata
- Trauma and Acute Critical Care Medical Centre, Tokyo Medical and Dental University Hospital of Medicine, Tokyo, Japan.,Shock Trauma and Emergency Medical Centre, Matsudo City Hospital, Matsudo, Japan
| | - Y Otomo
- Trauma and Acute Critical Care Medical Centre, Tokyo Medical and Dental University Hospital of Medicine, Tokyo, Japan
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10
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Ball CG, Grondin SC, Pasieka JL, Kirkpatrick AW, MacLean AR, Cantle P, Dixon E, Schneider P, Hamilton M. Examples of dramatic failures and their effectiveness in modern surgical disciplines: can we learn from our mistakes? J Comp Eff Res 2018; 7:709-720. [PMID: 29888953 DOI: 10.2217/cer-2017-0090] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Innovation can be variably defined, but when applied to healthcare is often considered to be the introduction of something new, whether an idea, method or device, into an unfilled void or needy environment. Despite the introduction of many positive surgical subspecialty altering concepts/devices however, epic failures are not uncommon. These failures can be dramatic in regards to both their human and economic costs. They can also be very public or more quiet in nature. As surgical leaders in our communities and advocates for patient safety and outcomes, it remains crucial that we meet new introductions in technology and patient care with a measured level of curiosity, skepticism and science-based conclusions. The aim of an expert committee was to identify the most dominant failures in technological innovation and/or dogmatic clinical beliefs within each major surgical subspecialty. In summary, this effort was pursued to highlight the past failures and remind surgeons to remain vigilant and appropriately skeptical with regard to the introduction of new innovations and clinical beliefs within our craft.
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Affiliation(s)
- Chad G Ball
- Department of Surgery, University of Calgary, Calgary, Alberta, Canada
| | - Sean C Grondin
- Department of Surgery, University of Calgary, Calgary, Alberta, Canada
| | - Janice L Pasieka
- Department of Surgery, University of Calgary, Calgary, Alberta, Canada
| | | | - Anthony R MacLean
- Department of Surgery, University of Calgary, Calgary, Alberta, Canada
| | - Paul Cantle
- Department of Surgery, University of Calgary, Calgary, Alberta, Canada
| | - Elijah Dixon
- Department of Surgery, University of Calgary, Calgary, Alberta, Canada
| | - Prism Schneider
- Department of Surgery, University of Calgary, Calgary, Alberta, Canada
| | - Mark Hamilton
- Department of Surgery, University of Calgary, Calgary, Alberta, Canada.,Department of Neurosciences, University of Calgary, Calgary, Alberta, Canada
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11
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Chaochankit W, Akaraborworn O, Sangthong B, Thongkhao K. Combination of blood lactate level with assessment of blood consumption (ABC) scoring system: A more accurate predictor of massive transfusion requirement. Chin J Traumatol 2018; 21:96-99. [PMID: 29605431 PMCID: PMC5911727 DOI: 10.1016/j.cjtee.2017.12.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2017] [Revised: 11/14/2017] [Accepted: 12/06/2017] [Indexed: 02/04/2023] Open
Abstract
PURPOSE Exsanguination is the most common leading cause of death in trauma patients. The massive transfusion (MT) protocol may influence therapeutic strategies and help provide blood components in timely manner. The assessment of blood consumption (ABC) score is a popular MT protocol but has low predictability. The lactate level is a good parameter to reflect poor tissue perfusion or shock states that can guide the management. This study aimed to modify the ABC scoring system by adding the lactate level for better prediction of MT. METHODS The data were retrospectively collected from 165 trauma patients following the trauma activated criteria at Songklanagarind Hospital from January 2014 to December 2014. The ABC scoring system was applied in all patients. The patients who had an ABC score ≥2 as the cut point for MT were defined as the ABC group. All patients who had a score ≥2 with a lactate level >4 mmol/dL were defined as the ABC plus lactate level (ABC + L) group. The prediction for the requirement of massive blood transfusion was compared between the ABC and ABC + L groups. The ability of ABC and ABC + L groups to predict MT was estimated by the area under the receiver operating characteristic curve (AUROC). RESULTS Among 165 patients, 15 patients (9%) required massive blood transfusion. There were no significant differences in age, gender, mechanism of injury or initial vital signs between the MT group and the non-MT group. The group that required MT had a higher Injury Severity Score and mortality. The sensitivity and specificity of the ABC scoring system in our institution were low (81%, 34%, AUC 0.573). The sensitivity and specificity were significantly better in the ABC + L group (92%, 42%, AUC = 0.745). CONCLUSION The ABC scoring system plus lactate increased the sensitivity and specificity compared with the ABC scoring system alone.
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Affiliation(s)
- Wongsakorn Chaochankit
- Department of Surgery, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand,Corresponding author.
| | - Osaree Akaraborworn
- Trauma Unit, Department of Surgery, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand
| | - Burapat Sangthong
- Trauma Unit, Department of Surgery, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand
| | - Komet Thongkhao
- Trauma Unit, Department of Surgery, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand
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12
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Schlimp CJ, Schöchl H. The role of fibrinogen in trauma-induced coagulopathy. Hamostaseologie 2017; 34:29-39. [DOI: 10.5482/hamo-13-07-0038] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2013] [Accepted: 10/18/2013] [Indexed: 12/18/2022] Open
Abstract
SummaryFibrinogen plays an essential role in clot formation and stability. Importantly it seems to be the most vulnerable coagulation factor, reaching critical levels earlier than the others during the course of severe injury. A variety of causes of fibrinogen depletion in major trauma have been identified, such as blood loss, dilution, consumption, hyperfibrinolysis, hypothermia and acidosis. Low concentrations of fibrinogen are associated with an increased risk of diffuse microvascular bleeding. Therefore, repeated measurements of plasma fibrinogen concentration are strongly recommended in trauma patients with major bleeding. Recent guidelines recommend maintaining plasma fibrinogen concentration at 1.5–2 g/l in coagulopathic patients. It has been shown that early fibrinogen substitution is associated with improved outcome.
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13
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Tomita E, Takase H, Tajima K, Suematsu Y. Change of coagulation after NovoSeven® use for bleeding during cardiac surgery. Asian Cardiovasc Thorac Ann 2017; 25:99-104. [PMID: 28114794 DOI: 10.1177/0218492317689901] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objectives Recombinant activated factor VII has been used for the treatment of hemophilia, factor VII deficiency, and Glanzmann's thrombasthenia. Off-label uses have recently been increasing, and there are reports that recombinant activated factor VII is effective for the treatment of excessive bleeding during or after cardiovascular surgery. We retrospectively reviewed the effectiveness of recombinant activated factor VII and its influence on the coagulation system as a treatment for uncontrollable bleeding during cardiovascular surgery. Methods Between April 2009 and May 2015, recombinant activated factor VII was used to treat uncontrollable bleeding during cardiovascular surgery in 17 patients at our hospital. The indications for recombinant activated factor VII administration were critical uncontrollable bleeding during surgery and normal platelet and fibrinogen levels. Results Blood loss significantly decreased in every case after recombinant activated factor VII administration ( p < 0.05). No adverse thromboembolic events were encountered. The prothrombin time-international normalized ratio, activated partial thromboplastin time, fibrin degradation product and D-dimer levels decreased significantly after recombinant activated factor VII administration. One day later, all blood coagulation test values were almost within the normal ranges. Conclusions Recombinant activated factor VII has a strong hemostatic action, but it is necessary to exclude surgical bleeding to exhibit the hemostatic effect. Administration that does not comply with the indications for recombinant activated factor VII may lead to serious complications such as thromboembolism. In properly selected patients, recombinant activated factor VII is an effective agent for the treatment of uncontrollable bleeding during cardiovascular surgery.
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Affiliation(s)
- Emi Tomita
- 1 Department of Anesthesiology, Tsukuba Memorial Hospital, Ibaraki, Japan
| | - Hajime Takase
- 1 Department of Anesthesiology, Tsukuba Memorial Hospital, Ibaraki, Japan
| | - Keiichi Tajima
- 1 Department of Anesthesiology, Tsukuba Memorial Hospital, Ibaraki, Japan
| | - Yoshihiro Suematsu
- 2 Department of Cardiovascular Surgery, Tsukuba Memorial Hospital, Ibaraki, Japan
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14
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Baxter MS, Schroeder WS, Cheng Y, Bernstein ZP. Diminished Response to Recombinant Factor Vila in a Patient with Idiopathic Thrombocytopenic Purpura. Ann Pharmacother 2016; 40:2053-8. [PMID: 17062831 DOI: 10.1345/aph.1h331] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Objective: To describe the hypotheses that may explain a diminished hemostatic response in a patient receiving multiple doses of recombinant coagulation factor Vila (rFVIIa) for off-label treatment of bleeding events. Case Summary: A 70-year-old female with a significant history of idiopathic thrombocytopenic purpura (ITP) was admitted for coronary artery bypass grafting surgery. The patient developed thrombocytopenia and persistent hemorrhage postoperatively that was refractory to conventional therapy for ITP. She experienced an initial hemostatic response to rFVIIa after receiving 3 doses. During her second trial of rFVIIa a few days later, the duration of hemostatic effect was approximately half that of the first. The patient then received rFVIIa almost daily over the following 9 days to which she remained unresponsive, ultimately resulting in death. All doses in this patient were 9.6 mg (101 μg/kg), except the last, which was 4.8 mg (50.5 μg/kg). Discussion: Several hypotheses may explain this patient's resistance to rFVIIa therapy. Two involve depletion of platelets or coagulation factors essential for rFVIIa efficacy. Another involves development of an antibody to rFVIIa. The last involves acidemia, which may interfere with the pharmacologic effect of rFVIIa. Conclusions: The combination of persistent thrombocytopenia and exhaustion of coagulation factors is the likely cause leading to resistance to rFVIIa therapy in this patient.
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Affiliation(s)
- Melissa S Baxter
- Department of Pharmacy Practice, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, Buffalo, NY 14221-1200, USA
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15
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Brenner B, Hoffman R, Balashov D, Shutluko E, Culić SD, Nizamoutdinova E. Control of Bleeding Caused by Thrombocytopenia Associated With Hematologic Malignancy: An Audit of the Clinical Use of Recombinant Activated Factor VII. Clin Appl Thromb Hemost 2016; 11:401-10. [PMID: 16244765 DOI: 10.1177/107602960501100406] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
This paper presents an analysis of 24 cases in which recombinant factor VIIa (rFVIIa) was used in the management of hemorrhage in patients with thrombocytopenia associated with hematologic malignancies. This is the largest case aggregation to date and focuses on preliminary experience in the off-label use of this hemostatic agent. Data were extracted from the international, Internet-based registry, www.haemostasis.com, accessed in September 2003. The search results were manually cross-checked against monthly summary reports. The physicians providing the cases were contacted individually to approve the use of their cases, supply any information missing from the database, and validate the data already held. Patients with acute myeloid leukemia, acute lymphoblastic leukemia, Hodgkin’s disease, non-Hodgkin’s lymphoma, Burkitt’s lymphoma, B-cell or T-cell lymphoma, or aplastic anemia received rFVIIa at total doses of between 18 and 1040 μg/kg body weight. Bleeding stopped in 11 of 24 (46%) patients, markedly decreased in 8 of 24 (33%) patients, and decreased in 4 of 24 (17%) patients. In most patients, the response was achieved within 2.5 hours of administration of rFVIIa. The use of rFVIIa was generally well tolerated—1 case of ischemic stroke was considered to be possibly related to rFVIIa administration, but this has yet to be confirmed. A review of these 24 cases submitted to the www.haemostasis.com database suggests that rFVIIa is beneficial in the management of hemorrhage in patients with thrombocytopenia and hematologic malignancies. This warrants further investigation in rigorously controlled clinical trials.
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Affiliation(s)
- Benjamin Brenner
- Thrombosis and Hemostasis Unit, Department of Hematology and Bone Marrow Transplantation, Rambam Medical Center, Haifa, Israel.
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16
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Abstract
Recombinant activated factor seven (rFVIIa) is a novel and emerging therapy for the acquired coagulopathy associated with massive bleeding and hemorrhagic shock. The intent of this paper is to review the mechanism of action of rFVIIa, to discuss the current state of evidence regarding the safety and efficacy of rFVIIa, and to offer guidance regarding its use in severely traumatized patients. No study has demonstrated a survival benefit in humans. rFVIIa, is safe to use in the setting of severe trauma associated with ongoing bleeding and acquired coagulopathy. Doses of 80—200 μg/kg may be used after correction of thrombocytopenia and acidosis. Hypothermia should be corrected in any traumatized patient, but should not be a barrier to its administration. Definitive evidence supporting the use of rFVIIa is lacking, but ongoing studies will delineate survival benefits, dosing regimens, and adverse events associated with its use.
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Affiliation(s)
- Eric Bruder
- Department of Emergency Medicine, Queen's University, Kingston, Ontario, Canada
| | - Daniel W Howes
- Department of Emergency Medicine, Queen's University, Kingston, Ontario, Canada,
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Rossaint R, Bouillon B, Cerny V, Coats TJ, Duranteau J, Fernández-Mondéjar E, Filipescu D, Hunt BJ, Komadina R, Nardi G, Neugebauer EAM, Ozier Y, Riddez L, Schultz A, Vincent JL, Spahn DR. The European guideline on management of major bleeding and coagulopathy following trauma: fourth edition. Crit Care 2016; 20:100. [PMID: 27072503 PMCID: PMC4828865 DOI: 10.1186/s13054-016-1265-x] [Citation(s) in RCA: 597] [Impact Index Per Article: 74.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Accepted: 03/11/2016] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Severe trauma continues to represent a global public health issue and mortality and morbidity in trauma patients remains substantial. A number of initiatives have aimed to provide guidance on the management of trauma patients. This document focuses on the management of major bleeding and coagulopathy following trauma and encourages adaptation of the guiding principles to each local situation and implementation within each institution. METHODS The pan-European, multidisciplinary Task Force for Advanced Bleeding Care in Trauma was founded in 2004 and included representatives of six relevant European professional societies. The group used a structured, evidence-based consensus approach to address scientific queries that served as the basis for each recommendation and supporting rationale. Expert opinion and current clinical practice were also considered, particularly in areas in which randomised clinical trials have not or cannot be performed. Existing recommendations were reconsidered and revised based on new scientific evidence and observed shifts in clinical practice; new recommendations were formulated to reflect current clinical concerns and areas in which new research data have been generated. This guideline represents the fourth edition of a document first published in 2007 and updated in 2010 and 2013. RESULTS The guideline now recommends that patients be transferred directly to an appropriate trauma treatment centre and encourages use of a restricted volume replacement strategy during initial resuscitation. Best-practice use of blood products during further resuscitation continues to evolve and should be guided by a goal-directed strategy. The identification and management of patients pre-treated with anticoagulant agents continues to pose a real challenge, despite accumulating experience and awareness. The present guideline should be viewed as an educational aid to improve and standardise the care of the bleeding trauma patients across Europe and beyond. This document may also serve as a basis for local implementation. Furthermore, local quality and safety management systems need to be established to specifically assess key measures of bleeding control and outcome. CONCLUSIONS A multidisciplinary approach and adherence to evidence-based guidance are key to improving patient outcomes. The implementation of locally adapted treatment algorithms should strive to achieve measureable improvements in patient outcome.
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Affiliation(s)
- Rolf Rossaint
- />Department of Anaesthesiology, University Hospital Aachen, RWTH Aachen University, Pauwelsstrasse 30, 52074 Aachen, Germany
| | - Bertil Bouillon
- />Department of Trauma and Orthopaedic Surgery, Witten/Herdecke University, Cologne-Merheim Medical Centre, Ostmerheimer Strasse 200, 51109 Cologne, Germany
| | - Vladimir Cerny
- />Department of Anaesthesiology, Perioperative Medicine and Intensive Care, J.E. Purkinje University, Masaryk Hospital, Usti nad Labem, Socialni pece 3316/12A, 40113 Usti nad Labem, Czech Republic
- />Department of Research and Development, Charles University in Prague, Faculty of Medicine in Hradec Kralove, Sokolska 581, 50005 Hradec Kralove, Czech Republic
- />Department of Anaesthesiology and Intensive Care, Charles University in Prague, Faculty of Medicine in Hradec Kralove, Sokolska 581, 50005 Hradec Kralove, Czech Republic
- />Department of Anaesthesia, Pain Management and Perioperative Medicine, Dalhousie University, Halifax, QE II Health Sciences Centre, 10 West Victoria, 1276 South Park St., Halifax, NS B3H 2Y9 Canada
| | - Timothy J. Coats
- />Emergency Medicine Academic Group, University of Leicester, University Road, Leicester, LE1 7RH UK
| | - Jacques Duranteau
- />Department of Anaesthesia and Intensive Care, Hôpitaux Universitaires Paris Sud, University of Paris XI, Faculté de Médecine Paris-Sud, 78 rue du Général Leclerc, 94275 Le Kremlin-Bicêtre, Cedex France
| | - Enrique Fernández-Mondéjar
- />Servicio de Medicina Intensiva, Complejo Hospitalario Universitario de Granada, ctra de Jaén s/n, 18013 Granada, Spain
| | - Daniela Filipescu
- />Department of Cardiac Anaesthesia and Intensive Care, C. C. Iliescu Emergency Institute of Cardiovascular Diseases, Sos Fundeni 256-258, 022328 Bucharest, Romania
| | - Beverley J. Hunt
- />King’s College, Departments of Haematology, Pathology and Lupus, Guy’s and St Thomas’ NHS Foundation Trust, Westminster Bridge Road, London, SE1 7EH UK
| | - Radko Komadina
- />Department of Traumatology, General and Teaching Hospital Celje, Oblakova 5, 3000 Celje, Slovenia
| | - Giuseppe Nardi
- />Shock and Trauma Centre, S. Camillo Hospital, Viale Gianicolense 87, 00152 Rome, Italy
| | - Edmund A. M. Neugebauer
- />Faculty of Health - School of Medicine, Witten/Herdecke University, Ostmerheimer Strasse 200, Building 38, 51109 Cologne, Germany
| | - Yves Ozier
- />Division of Anaesthesia, Intensive Care and Emergency Medicine, Brest University Hospital, Boulevard Tanguy Prigent, 29200 Brest, France
| | - Louis Riddez
- />Department of Surgery and Trauma, Karolinska University Hospital, 171 76 Solna, Sweden
| | - Arthur Schultz
- />Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, Lorenz Boehler Trauma Centre, Donaueschingenstrasse 13, 1200 Vienna, Austria
| | - Jean-Louis Vincent
- />Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Route de Lennik 808, 1070 Brussels, Belgium
| | - Donat R. Spahn
- />Institute of Anaesthesiology, University of Zurich and University Hospital Zurich, Raemistrasse 100, 8091 Zurich, Switzerland
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Abstract
Pelvic fractures carry a considerable risk for morbidity and mortality. Half or more of the early deaths in these patients have been attributed directly to haemorrhage. The transfusional requirements are four times higher for open pelvic fractures compared with a similar group of closed pelvic fractures. The loss of the tamponade effect by disruption of the pelvic soft tissues and the energy imparted play a central role in this potentially life threatening situation. We reported a case of open pelvic fracture in which persistent haemorrhage was stopped by giving recombinant activated coagulation factor VIIa as our last resort.
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19
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Gill R. Practical management of major blood loss. Anaesthesia 2014; 70 Suppl 1:54-7, e19-20. [DOI: 10.1111/anae.12915] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/21/2014] [Indexed: 12/22/2022]
Affiliation(s)
- R. Gill
- Shackleton Department of Anaesthesia; University Hospital Southampton; Southampton UK
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20
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Savan V, Willems A, Faraoni D, Van der Linden P. Multivariate model for predicting postoperative blood loss in children undergoing cardiac surgery: a preliminary study. Br J Anaesth 2014; 112:708-14. [DOI: 10.1093/bja/aet463] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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21
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Scarpelini S, Nascimento B, Tien H, Spencer Netto FAC, Tremblay L, Rizoli S. Overview on the use of recombinant factor VIIa in obstetrics and gynecology. ACTA ACUST UNITED AC 2014. [DOI: 10.1586/17474108.2.2.217] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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22
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Magon N, Babu KM, Kapur K, Chopra S, Joneja GS. Recombinant activated factor VII in post partum haemorrhage. Niger Med J 2013; 54:289-94. [PMID: 24403703 PMCID: PMC3883225 DOI: 10.4103/0300-1652.122328] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Post-partum haemorrhage (PPH) is a life-threatening obstetric complication and the leading cause of maternal death. Any bleeding that results in or could result in haemodynamic instability, if untreated, must be considered as PPH. There is no controversy about the need for prevention and treatment of PPH. The keystone of management of PPH entails first, non-invasive and nonsurgical methods and then invasive and surgical methods. However, mortality remains high. Therefore, new advancements in the treatment are most crucial. One such advancement has been the use of recombinant activated factor VII (rFVIIa) in PPH. First used 12 years back in PPH, this universal haemostatic agent has been effectively used in controlling PPH. The best available indicator of rFVIIa efficacy is the arrest of haemorrhage, which is judged by visual evidence and haemodynamic stabilization. It also reduces costs of therapy and the use of blood components in massive PPH. In cases of intractable PPH with no other obvious indications for hysterectomy, administration of rFVIIa should be considered before surgery. We share our experience in a series of cases of PPH, successfully managed using rFVIIa.
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Affiliation(s)
- Navneet Magon
- Department of Obstetrics and Gynecology, Air Force Hospital, Jorhat, India
| | - K. M. Babu
- Department of Obstetrics and Gynecology, Command Hospital (AF) Bangaluru, India
| | - Krishan Kapur
- Department of Obstetrics and Gynecology, Army Hospital (R and R) Delhi, India
| | - Sanjiv Chopra
- Department of Obstetrics and Gynecology, Military Hospital, Meerut, Uttar Pradesh, India
| | - Gurdarshan Singh Joneja
- Department of Obstetrics and Gynecology, Sikkim Manipal Medical College, Gangtok, Sikkim, India
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Abstract
PURPOSE OF REVIEW Early identification of shock and coagulopathy coupled with damage control resuscitation are central tenets of early trauma management. In traumatic injury, haemorrhage is responsible for almost 50% of deaths occurring within the first 24 h of injury and up to 80% of intraoperative trauma mortalities. Immediate haemorrhagic mortality constitutes the largest group of potentially preventable deaths in the initial 24-h period. This review will discuss the recent changes and advancement of early traumatic coagulopathy and the important role of substantial bleeding protocols (SBPs). RECENT FINDINGS Ho et al. examined survivor bias and determined when accounting for survivor bias improved survival outcome with higher fresh frozen plasma: red blood cell ratios. The PROMMTT study, a 10-centre observation trial, highlighted the variable nature of infusion, the importance of time and improved outcomes with higher product ratios. SUMMARY An SBP addresses the organizational issues necessary to respond to massive blood loss in an immediate and sustained manner. It reduces provider variability, facilitates staff communication and compliance, and simplifies the administration of predefined ratios of blood components. A transfusion subcommittee should be formed to directly address the complex issues of implementing a SBP system.
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25
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Fries D. The early use of fibrinogen, prothrombin complex concentrate, and recombinant-activated factor VIIa in massive bleeding. Transfusion 2013; 53 Suppl 1:91S-95S. [PMID: 23301979 DOI: 10.1111/trf.12041] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND Coagulopathy related to massive bleeding has a multifactorial aetiology. Coagulopathy is related to shock and blood loss including consumption of clotting factors and platelets and hemodilution. Additionally hyperfibrinolysis, hypothermia, acidosis, and metabolic changes affect the coagulation system. The aim of any hemostatic therapy is to control bleeding and minimize blood loss and transfusion requirements. Transfusion of allogeneic blood products as well as the presence of coagulopathy cause increased morbidity and mortality. STUDY DESIGN AND METHODS This paper presents a short review on new treatment strategies of coagulopathy, related to massive blood loss. RESULTS Paradigms are actively changing and there is still shortage of data. However, there is increasing experience and evidence that "target controlled algorithms" using point-of-care monitoring devices and coagulation factor concentrates are more effective compared to transfusion of fresh frozen plasma, independently of the individual clinical situation. CONCLUSION Future treatment of coagulopathy associated with massive bleeding can be based on an individualized point-of-care guided rational use of coagulation factor concentrates such as fibrinogen, prothrombin complex concentrate, and recombinant factor VIIa. The timely and rational use of coagulation factor concentrates may be more efficacious and safer than ratio-driven use of transfusion packages of allogeneic blood products.
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Affiliation(s)
- Dietmar Fries
- Department for General and Surgical Critical Care Medicine, Medical University Innsbruck, Innsbruck, Austria.
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Abstract
Trauma remains the leading cause of death, with bleeding as the primary cause of preventable mortality. When death occurs, it happens quickly, typically within the first 6 h after injury. The principal drivers of the acute coagulopathy of trauma have been characterized, but another group of patients with early evidence of coagulopathy both physiologically and mechanistically distinct from this systemic acquired coagulopathy has been identified. This distinct phenotype is present in 25% to 30% of patients with major trauma without being exposed to the traditional triggers and is associated with higher morbidity and a 4-fold increase in mortality. Despite improvements in the resuscitation of exsanguinating patients, one of the remaining keys is to expeditiously and reproducibly identify the patients most likely to require transfusion including massive transfusion with damage control resuscitation principles. Several predictive scoring systems/algorithms for transfusion including massive transfusion in both civilian and military trauma populations have been introduced. The models developed usually suggest combinations of physiologic, hemodynamic, laboratory, injury severity, and demographic triggers identified on the initial evaluation. Many use a combination of dichotomous variables that are readily accessible after the patient's arrival to the trauma bay, but others rely on time-consuming mathematical calculations and may thus have limited real-time application. Weighted and more sophisticated systems including higher numbers of variables perform superiorly. A common limitation to all models is their retrospective nature, and prospective validations are needed. Point-of-care viscoelastic testing may be an alternative to early recognize trauma-induced coagulopathy with the risk of ongoing hemorrhage and transfusion.
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[Management of penetrating abdominal trauma: what we need to know?]. ACTA ACUST UNITED AC 2013; 32:104-11. [PMID: 23402982 DOI: 10.1016/j.annfar.2012.12.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2012] [Accepted: 12/13/2012] [Indexed: 12/25/2022]
Abstract
Penetrating traumas are rare in France and mainly due to stabbing. Knives are less lethal than firearms. The initial clinical assessment is the cornerstone of hospital care. It remains a priority and can quickly lead to a surgical treatment first. Urgent surgical indications are hemorrhagic shock, evisceration and peritonitis. Dying patients should be immediately taken to the operating room for rescue laparotomy or thoracotomy. Ultrasonography and chest radiography are performed before damage control surgery for hemodynamic unstable critical patients. Stable patients are scanned by CT and in some cases may benefit from non-operative strategy. Mortality remains high, initially due to bleeding complications and secondarily to infectious complications. Early and appropriate surgery can reduce morbidity and mortality. Non-operative strategy is only possible in selected patients in trained trauma centers and with intensive supervision by experienced staff.
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Transfusion in trauma. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2012. [DOI: 10.1016/j.rcae.2012.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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Burad J, Bhakta P, Sharma J. Timely 'off-label' use of recombinant activated factor VII (NovoSeven(®)) can help in avoiding hysterectomy in intractable obstetric bleeding complicated with disseminated intravascular coagulation: A case report and review of the literature. Indian J Anaesth 2012; 56:69-71. [PMID: 22529425 PMCID: PMC3327077 DOI: 10.4103/0019-5049.93349] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Massive intra-operative bleeding is not an infrequent occurrence in obstetrics. Worldwide obstetric bleeding remains a major cause of morbidity and mortality. Conventional management of this bleeding consists of resuscitation with fluids, blood, surgical maneuvers, and embolisation of feeding blood vessels. But in most of cases, these measures appear to be ineffective in controlling bleeding. Recently, the 'off-label' use of the recombinant activated factor VII (rFVIIa) concentrate has emerged as promising treatment for such bleeding when conventional measures fail. We came across a similar scenario in which a young lady was admitted with per-vaginal bleeding due to abruptio placentae. In spite of usual surgical and medical interventions, she continued to bleed. rFVIIa was administered as a desperate measure to avoid hysterectomy and the bleeding could be stopped. She recovered successfully without any complication. Thus, the timely use of rFVIIa, hence, can be used to save life and fertility in cases of intractable obstetric bleeding.
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Affiliation(s)
- Jyoti Burad
- Department of Anaesthesia and Intensive Care, Sultan Qaboos University Hospital, Muscat, Oman
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32
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Guzzetta NA, Russell IA, Williams GD. Review of the Off-Label Use of Recombinant Activated Factor VII in Pediatric Cardiac Surgery Patients. Anesth Analg 2012; 115:364-78. [DOI: 10.1213/ane.0b013e31825aff10] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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Goksedef D, Panagopoulos G, Nassiri N, Levine RL, Hountis PG, Plestis KA. Intraoperative use of recombinant activated factor VII during complex aortic surgery. J Thorac Cardiovasc Surg 2012; 143:1198-204. [DOI: 10.1016/j.jtcvs.2012.01.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2011] [Revised: 11/23/2011] [Accepted: 01/04/2012] [Indexed: 10/14/2022]
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Changlani DK, Devendaran V, Murmu UC, Ganesan S, Varghese R, Kumar RS. Factor VII for excessive bleeding following congenital heart disease surgery. Asian Cardiovasc Thorac Ann 2012; 20:120-5. [DOI: 10.1177/0218492311433614] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Recombinant activated factor VII may be effective in patients with severe bleeding following congenital heart disease surgery requiring cardiopulmonary bypass. From August 2009 through June 2011, 13 patients (median age, 5 months) were given recombinant activated factor VII for severe bleeding after open heart surgery, preventing sternal closure 2 h after completion of cardiopulmonary bypass, or chest tube drainage >10 mLċ kg−1ċh−1 for 2 h. The median dose was 75 µgċ kg−1. The response was positive if postoperative bleeding decreased, permitting sternal closure in the operating room, or if there was > 50% decrease in chest tube drainage. The 3 patients who received factor VIIa in the operating room had successful sternal closure within 1 h. Of the 10 patients who received factor VIIa in the intensive care unit, drainage decreased to < 50% in 1 h in 6 cases, and a second dose was required in 4. None required surgical reexploration. There were 4 deaths, none was related to bleeding. Nine patients were discharged (median hospital stay, 29 days) and were doing well after 3 months. There were no thrombotic complications. Recombinant activated factor VII may be an effective rescue therapy for severe postoperative hemorrhage.
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Affiliation(s)
| | | | - Udaya Charan Murmu
- Department of Pediatric Cardiology, The Madras Medical Mission, Chennai, India
| | - Selvakumar Ganesan
- Department of Pediatric Cardiology, The Madras Medical Mission, Chennai, India
| | - Roy Varghese
- Department of Cardiac Surgery, The Madras Medical Mission, Chennai, India
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Magon N, Babu KM. Recombinant Factor VIIa in Post-partum Hemorrhage: A New Weapon in Obstetrician's Armamentarium. NORTH AMERICAN JOURNAL OF MEDICAL SCIENCES 2012; 4:157-62. [PMID: 22536557 PMCID: PMC3334254 DOI: 10.4103/1947-2714.94938] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Post-partum hemorrhage (PPH) is a life-threatening obstetric complication and the leading cause of maternal death. The usual manner for its management includes, first, noninvasive and nonsurgical methods, and, then invasive and surgical methods. However, mortality and morbidity related to PPH still remains unacceptably high, contributing to hysterectomy in at least 50% of cases. Early, effective, and preferably noninvasive treatments that can reduce maternal mortality and morbidity due to this entity are therefore essential. One of the most spectacular advancements in the control of PPH has been the use of recombinant activated factor (rFVIIa), both as initial and a life- and uterus-saving therapy. rFVIIa also reduces costs of therapy and use of blood components in massive PPH. In cases of intractable bleeding with no other obvious indications for hysterectomy, administration of rFVIIa should be considered before surgery. A MEDLINE search was done to review relevant articles in English literature on use of rFVIIa in PPH. Data were constructed and issues were reviewed from there. Our experience in a series of three cases of PPH, two of atonic and one of traumatic, successfully managed using rFVIIa is also shared.
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Affiliation(s)
- Navneet Magon
- Department of Obstetrics and Gynecology, Air Force Hospital, Nathu Singh Road, Kanpur Cantt., India
| | - KM Babu
- Department of Obstetrics and Gynecology, Air Force Hospital, Nathu Singh Road, Kanpur Cantt., India
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Maegele M, Brockamp T, Nienaber U, Probst C, Schoechl H, Görlinger K, Spinella P. Predictive Models and Algorithms for the Need of Transfusion Including Massive Transfusion in Severely Injured Patients. ACTA ACUST UNITED AC 2012; 39:85-97. [PMID: 22670126 DOI: 10.1159/000337243] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2012] [Accepted: 02/06/2012] [Indexed: 11/19/2022]
Abstract
BACKGROUND: Despite improvements on how to resuscitate exsanguinating patients, one remaining key to improve outcome is to expeditiously and reproducibly identify patients most likely to require transfusion including massive transfusion (MT). This work summarizes yet developed algorithms/scoring systems for transfusion including MT in civilian and military trauma populations. METHODS: A systematic search of evidence was conducted utilizing OVID/MEDLINE (1966 to present) and the 'Medical Algorithms Project'. RESULTS AND CONCLUSIONS: The models developed suggest combinations of physiologic, hemodynamic, laboratory, injury severity and demographic triggers identified on the initial evaluation of the bleeding trauma patient. Many approaches use a combination of dichotomous variables readily accessible after arrival but others rely on time-consuming calculations or complex algorithms and may have limited real-time application. Weighted and more sophisticated systems including higher numbers of variables perform superior. A common limitation to all models is their retrospective nature, and prospective validations are urgently needed. Point-of-care viscoelastic testing may be an alternative to these systems.
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Affiliation(s)
- Marc Maegele
- Department of Traumatology and Orthopedic Surgery, Germany
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Koh YR, Cho SJ, Yeom SR, Chang CL, Lee EY, Son HC, Kim HH. Evaluation of recombinant factor VIIa treatment for massive hemorrhage in patients with multiple traumas. Ann Lab Med 2012; 32:145-52. [PMID: 22389882 PMCID: PMC3289780 DOI: 10.3343/alm.2012.32.2.145] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2011] [Revised: 09/28/2011] [Accepted: 11/07/2011] [Indexed: 11/19/2022] Open
Abstract
Background Recent studies and case reports have shown that recombinant factor VIIa (rFVIIa) treatment is effective for reversing coagulopathy and reducing blood transfusion requirements in trauma patients with life-threatening hemorrhage. The purpose of this study is to evaluate the effect of rFVIIa treatment on clinical outcomes and cost effectiveness in trauma patients. Methods Between January 2007 and December 2010, we reviewed the medical records of patients who were treated with rFVIIa (N=18) or without rFVIIa (N=36) for life-threatening hemorrhage due to multiple traumas at the Emergency Department of Pusan National University Hospital in Busan, Korea. We reviewed patient demographics, baseline characteristics, initial vital signs, laboratory test results, and number of units transfused, and then analyzed clinical outcomes and 24-hr and 30-day mortality rates. Thromboembolic events were monitored in all patients. Transfusion costs and hospital stay costs were also calculated. Results In the rFVIIa-treated group, laboratory test results and clinical outcomes improved, and the 24-hr mortality rate decreased compared to that in the untreated group; however, 30-day mortality rate did not differ between the groups. Thromboembolic events did not occur in both groups. Transfusion and hospital stay costs in the rFVIIa-treated group were cost effective; however, total treatment costs, including the cost of rFVIIa, were not cost effective. Conclusions In our study, rFVIIa treatment was shown to be helpful as a supplementary drug to improve clinical outcomes and reduce the 24-hr mortality rate, transfusion and hospital stay costs, and transfusion requirements in trauma patients with life-threatening hemorrhage.
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Affiliation(s)
- Young Rae Koh
- Department of Laboratory Medicine, Pusan National University School of Medicine, Busan, Korea
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38
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Transfusion in trauma☆. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2012. [DOI: 10.1097/01819236-201240040-00009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Sorensen B, Fries D. Emerging treatment strategies for trauma-induced coagulopathy. Br J Surg 2011; 99 Suppl 1:40-50. [DOI: 10.1002/bjs.7770] [Citation(s) in RCA: 68] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Abstract
Background
Trauma-induced coagulopathy has a multifactorial aetiology. Coagulopathy is related to blood loss including consumption of clotting factors and platelets and haemodilution. Additionally hyperfibrinolysis, hypothermia, acidosis and metabolic changes affect the coagulation system.
Methods
This is a review of pathophysiology and new treatment strategies for trauma-induced coagulopathy.
Results
Paradigms are actively changing and there is still a shortage of data. The aim of any haemostatic therapy is to control bleeding and minimize blood loss and transfusion requirements. Transfusion of allogeneic blood products as well as trauma-induced coagulopathy cause increased morbidity and mortality. Current opinion is based on present studies and results from small case series, combined with findings from experimental studies in animals, in vitro studies and expert opinions, as opposed to large, randomized, placebo-controlled studies. A summary of new and emerging strategies, including medical infusion and blood products, to beneficially manipulate the coagulation system in the critically injured patient is suggested.
Conclusion
Future treatment of trauma-induced coagulopathy may be based on systemic antifibrinolytics, local haemostatics and individualized point-of-care-guided rational use of coagulation factor concentrates such as fibrinogen, prothrombin complex concentrate, recombinant factor VIIa and factor XIII. The authors speculate that timely and rational use of coagulation factor concentrates will be more efficacious and safer than ratio-driven use of transfusion packages of allogeneic blood products.
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Affiliation(s)
- B Sorensen
- Centre for Haemostasis and Thrombosis, Guy's and St Thomas' NHS Foundation Trust, St Thomas' Hospital, London, UK
| | - D Fries
- Department for General and Surgical Critical Care Medicine, Medical University Innsbruck, Innsbruck, Austria
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Kobayashi T, Nakabayashi M, Yoshioka A, Maeda M, Ikenoue T. Recombinant activated factor VII (rFVIIa/NovoSeven®) in the management of severe postpartum haemorrhage: initial report of a multicentre case series in Japan. Int J Hematol 2011; 95:57-63. [PMID: 22160834 DOI: 10.1007/s12185-011-0974-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2011] [Revised: 11/17/2011] [Accepted: 11/18/2011] [Indexed: 10/14/2022]
Abstract
Only a limited number of case reports documenting the off-label use of recombinant factor VIIa (rFVIIa) in Japanese patients with postpartum haemorrhage (PPH) have been published. Data on Japanese cases with severe PPH in which rFVIIa was administered were collected. Data of obstetric haemorrhage patients treated with rFVIIa between 2005 and 2010 were retrospectively collected throughout Japan. The data included patients' background information, blood product requirements, dose/timing of rFVIIa, and adverse effects. Treating clinicians subjectively assessed the effect of rFVIIa on bleeding at each administration using four categories: "Stopped", "Decreased", "Unchanged", and "Increased". A total of 25 women received rFVIIa for the treatment of obstetric haemorrhage in 18 institutions. After the final administration, bleeding was "stopped" in 16 patients (64%), "decreased" in eight patients (32%), and "unchanged" in one patient (4%). A significant reduction in blood product requirement was observed following the first rFVIIa administration. Hysterectomy was required in two patients (15.4%) after rFVIIa administration. Four asymptomatic thrombotic events were reported in three patients. These results suggest that rFVIIa can be a beneficial therapeutic option that can reduce blood loss and prevent hysterectomy in Japanese patients with massive obstetric bleeding.
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Affiliation(s)
- Takao Kobayashi
- Hamamatsu Medical Center, 328 Tomitsuka-cho, Naka-ku, Hamamatsu, Shizuoka 432-8580, Japan.
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Abstract
Massive Transfusion is a part of Damage Control Resuscitation. The aim of transfusion therapy is to restore oxygen delivery to poorly perfused tissues and to treat the acute coagulopathy of trauma. The severity and complexity of modern injuries have led to the use of swift, protocol-driven care with the use of'Shock Packs' and management of metabolic complications. The proactive treatment of the coagulopathy has been termed Haemostatic Resuscitation. The delivery of this transfusion capability has required an increasingly sophisticated logistic and laboratory response. New operational capabilities have included cold chain solutions; laboratory management information systems; platelet apheresis and ROTEM. This investment in the massive transfusion capability has delivered rapid resuscitation. It has also enabled clinicians to direct individualised transfusion support following initial resuscitation i.e. goal directed therapy. Future technical solutions should further support the prehospital delivery of transfusion while addressing the logistic tail. However, the key to success is the knowledge and skills of frontline staff to deliver safe and appropriate blood transfusion.
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Recombinant activated factor VIIa in a case of pregnancy with acute hepatic failure and massive blood loss. Med J Armed Forces India 2011; 67:390-3. [PMID: 27365859 DOI: 10.1016/s0377-1237(11)60096-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2010] [Accepted: 02/11/2011] [Indexed: 11/23/2022] Open
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Mitrophanov AY, Reifman J. Kinetic modeling sheds light on the mode of action of recombinant factor VIIa on thrombin generation. Thromb Res 2011; 128:381-90. [DOI: 10.1016/j.thromres.2011.05.013] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2010] [Revised: 05/05/2011] [Accepted: 05/10/2011] [Indexed: 11/29/2022]
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Alberca I, Asuero MS, Bóveda JL, Carpio N, Contreras E, Fernández-Mondéjar E, Forteza A, García-Erce JA, García de Lorenzo A, Gomar C, Gómez A, Llau JV, López-Fernández MF, Moral V, Muñoz M, Páramo JA, Torrabadella P, Quintana M, Sánchez C. [The "Seville" Consensus Document on Alternatives to Allogenic Blood Transfusion. Sociedades españolas de Anestesiología (SEDAR), Medicina Intensiva (SEMICYUC), Hematología y Hemoterapia (AEHH), Transfusión sanguínea (SETS) Trombosis y Hemostasia (SETH)]. Med Clin (Barc) 2011; 127 Suppl 1:3-20. [PMID: 17020674 DOI: 10.1157/13093075] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The Consensus Document on Alternatives to Allogenic Blood Transfusion (AABT) has been drawn up by a panel of experts from 5 scientific societies. The Spanish Societies of Anesthesiology (SEDAR), Critical Care Medicine and Coronary Units (SEMICYUC), Hematology and Hemotherapy (AEHH), Blood Transfusion (SETS) and Thrombosis and Hemostasis (SETH) have sponsored and participated in this Consensus Document. Alternatives to blood transfusion have been divided into pharmacological and non-pharmacological, with 4 modules and 12 topics. The main objective variable was the reduction of allogenic blood transfusions and/or the number of transfused patients. The extent to which this objective was achieved by each AABT was evaluated using the Delphi method, which classifies the grade of recommendation from A (supported by controlled studies) to E (non-controlled studies and expert opinion). The experts concluded that most of the indications for AABT were based on middle or low grades of recommendation, "C", "D", or "E", thus indicating the need for further controlled studies.
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45
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Haque A, Arnaud F, Teranishi K, Okada T, Kim B, Moon-Massat PF, Auker C, McCarron R, Freilich D, Scultetus AH. Pre-hospital resuscitation with HBOC-201 and rFVIIa compared to HBOC-201 alone in uncontrolled hemorrhagic shock in swine. ACTA ACUST UNITED AC 2011; 40:44-55. [PMID: 21806503 DOI: 10.3109/10731199.2011.585615] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
In a previous dose escalation study our group found that combining 90μg/kg rFVIIa with HBOC-201 reduced blood loss and improved physiologic parameters compared to HBOC alone. In this follow-up study in a swine liver injury model, we found that while there were no adverse hematology effects and trends observed in the previous study were confirmed, statistical significance could not be reached. Additional pre-clinical studies are indicated to identify optimal components of a multifunctional blood substitute for clinical use in trauma.
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Affiliation(s)
- Ashraful Haque
- Naval Medical Research Center, Operational and Undersea Medicine Directorate, NeuroTrauma Department, Silver Spring, MD 20910, USA.
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46
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Ragaller M. What's new in Emergencies, Trauma and Shock? Coagulation is in the focus! J Emerg Trauma Shock 2011; 3:1-3. [PMID: 20165713 PMCID: PMC2823136 DOI: 10.4103/0974-2700.58649] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Affiliation(s)
- Max Ragaller
- Department of Anesthesiology and Intensive Care Medicine, University Clinic Carl Gustav Carus, Dresden, Germany
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Yank V, Tuohy CV, Logan AC, Bravata DM, Staudenmayer K, Eisenhut R, Sundaram V, McMahon D, Olkin I, McDonald KM, Owens DK, Stafford RS. Systematic review: benefits and harms of in-hospital use of recombinant factor VIIa for off-label indications. Ann Intern Med 2011. [PMID: 21502651 DOI: 10.1059/0003-4819-154-8-201104190-00004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Recombinant factor VIIa (rFVIIa), a hemostatic agent approved for hemophilia, is increasingly used for off-label indications. PURPOSE To evaluate the benefits and harms of rFVIIa use for 5 off-label, in-hospital indications: intracranial hemorrhage, cardiac surgery, trauma, liver transplantation, and prostatectomy. DATA SOURCES Ten databases (including PubMed, EMBASE, and the Cochrane Library) queried from inception through December 2010. Articles published in English were analyzed. STUDY SELECTION Two reviewers independently screened titles and abstracts to identify clinical use of rFVIIa for the selected indications and identified all randomized, controlled trials (RCTs) and observational studies for full-text review. DATA EXTRACTION Two reviewers independently assessed study characteristics and rated study quality and indication-wide strength of evidence. DATA SYNTHESIS 16 RCTs, 26 comparative observational studies, and 22 noncomparative observational studies met inclusion criteria. Identified comparators were limited to placebo (RCTs) or usual care (observational studies). For intracranial hemorrhage, mortality was not improved with rFVIIa use across a range of doses. Arterial thromboembolism was increased with medium-dose rFVIIa use (risk difference [RD], 0.03 [95% CI, 0.01 to 0.06]) and high-dose rFVIIa use (RD, 0.06 [CI, 0.01 to 0.11]). For adult cardiac surgery, there was no mortality difference, but there was an increased risk for thromboembolism (RD, 0.05 [CI, 0.01 to 0.10]) with rFVIIa. For body trauma, there were no differences in mortality or thromboembolism, but there was a reduced risk for the acute respiratory distress syndrome (RD, -0.05 [CI, -0.02 to -0.08]). Mortality was higher in observational studies than in RCTs. LIMITATIONS The amount and strength of evidence were low for most outcomes and indications. Publication bias could not be excluded. CONCLUSION Limited available evidence for 5 off-label indications suggests no mortality reduction with rFVIIa use. For some indications, it increases thromboembolism.
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48
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Survival of trauma patients after massive red blood cell transfusion using a high or low red blood cell to plasma transfusion ratio*. Crit Care Med 2011; 39:1507-13. [DOI: 10.1097/ccm.0b013e31820eb517] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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49
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Yank V, Tuohy CV, Logan AC, Bravata DM, Staudenmayer K, Eisenhut R, Sundaram V, McMahon D, Olkin I, McDonald KM, Owens DK, Stafford RS. Systematic review: benefits and harms of in-hospital use of recombinant factor VIIa for off-label indications. Ann Intern Med 2011; 154:529-40. [PMID: 21502651 PMCID: PMC4102260 DOI: 10.7326/0003-4819-154-8-201104190-00004] [Citation(s) in RCA: 142] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Recombinant factor VIIa (rFVIIa), a hemostatic agent approved for hemophilia, is increasingly used for off-label indications. PURPOSE To evaluate the benefits and harms of rFVIIa use for 5 off-label, in-hospital indications: intracranial hemorrhage, cardiac surgery, trauma, liver transplantation, and prostatectomy. DATA SOURCES Ten databases (including PubMed, EMBASE, and the Cochrane Library) queried from inception through December 2010. Articles published in English were analyzed. STUDY SELECTION Two reviewers independently screened titles and abstracts to identify clinical use of rFVIIa for the selected indications and identified all randomized, controlled trials (RCTs) and observational studies for full-text review. DATA EXTRACTION Two reviewers independently assessed study characteristics and rated study quality and indication-wide strength of evidence. DATA SYNTHESIS 16 RCTs, 26 comparative observational studies, and 22 noncomparative observational studies met inclusion criteria. Identified comparators were limited to placebo (RCTs) or usual care (observational studies). For intracranial hemorrhage, mortality was not improved with rFVIIa use across a range of doses. Arterial thromboembolism was increased with medium-dose rFVIIa use (risk difference [RD], 0.03 [95% CI, 0.01 to 0.06]) and high-dose rFVIIa use (RD, 0.06 [CI, 0.01 to 0.11]). For adult cardiac surgery, there was no mortality difference, but there was an increased risk for thromboembolism (RD, 0.05 [CI, 0.01 to 0.10]) with rFVIIa. For body trauma, there were no differences in mortality or thromboembolism, but there was a reduced risk for the acute respiratory distress syndrome (RD, -0.05 [CI, -0.02 to -0.08]). Mortality was higher in observational studies than in RCTs. LIMITATIONS The amount and strength of evidence were low for most outcomes and indications. Publication bias could not be excluded. CONCLUSION Limited available evidence for 5 off-label indications suggests no mortality reduction with rFVIIa use. For some indications, it increases thromboembolism.
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50
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Končar IB, Davidović LB, Savić N, Sinđelić RB, Ilić N, Dragas M, Markovic M, Kostic D. Role of recombinant factor VIIa in the treatment of intractable bleeding in vascular surgery. J Vasc Surg 2011; 53:1032-7. [DOI: 10.1016/j.jvs.2010.07.075] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2009] [Revised: 05/05/2010] [Accepted: 07/18/2010] [Indexed: 02/05/2023]
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