1
|
Carlsen MIS, Brede JR, Medby C, Uleberg O. Transfusion practice in Central Norway - a regional cohort study in patients suffering from major haemorrhage. BMC Emerg Med 2024; 24:3. [PMID: 38185648 PMCID: PMC10773117 DOI: 10.1186/s12873-023-00918-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 12/11/2023] [Indexed: 01/09/2024] Open
Abstract
BACKGROUND In patients with major hemorrhage, balanced transfusions and limited crystalloid use is recommended in both civilian and military guidelines. This transfusion strategy is often applied in the non-trauma patient despite lack of supporting data. The aim of this study was to describe the current transfusion practice in patients with major hemorrhage of both traumatic and non-traumatic etiology in Central Norway, and discuss if transfusions are in accordance with appropriate massive transfusion protocols. METHODS In this retrospective observational cohort study, data from four hospitals in Central Norway was collected from 01.01.2017 to 31.12.2018. All adults (≥18 years) receiving massive transfusion (MT) and alive on admission were included. MT was defined as transfusion of ≥10 units of packed red blood cells (PRBC) within 24 hours, or ≥ 5 units of PRBC during the first 3 hours after admission to hospital. Clinical data was collected from the hospital blood bank registry (ProSang) and electronic patient charts (CareSuite PICIS). Patients undergoing cardiothoracic surgery or extracorporeal membrane oxygenation treatment were excluded. RESULTS A total of 174 patients were included in the study, of which 85.1% were non-trauma patients. Seventy-six per cent of all patients received plasma:PRBC in a ratio ≥ 1:2 (high ratio) and 59.2% of patients received platelets:PRBC in a ratio ≥ 1:2 (high ratio). 32.2% received a plasma:PRBC-ratio ≥ 1:1, and 23.6% platelet:PRBC-ratio ≥ 1:1. Median fluid infusion of crystalloids in all patients was 5750 mL. Thirty-seven per cent of all patients received tranexamic acid, 53.4% received calcium and fibrinogen concentrate was administered in 9.2%. CONCLUSIONS Most patients had a non-traumatic etiology. The majority was transfused with high ratios of plasma:PRBC and platelet:PRBC, but not in accordance with the aim of the local protocol (1:1:1). Crystalloids were administered liberally for both trauma and non-trauma patients. There was a lower use of hemostatic adjuvants than recommended in the local transfusion protocol. Awareness to local protocol should be increased.
Collapse
Affiliation(s)
- Marte Irene Skille Carlsen
- Department of Anesthesiology and Intensive Care Medicine, St Olav's University Hospital, Trondheim, Norway.
- Department of Traumatology, St. Olav's University Hospital, Trondheim, Norway.
| | - Jostein Rødseth Brede
- Department of Anesthesiology and Intensive Care Medicine, St Olav's University Hospital, Trondheim, Norway
- Department of Emergency Medicine and Pre-hospital Services, St Olav's University Hospital, Trondheim, Norway
- Department of Research and Development, Norwegian Air Ambulance Foundation, Oslo, Norway
| | - Christian Medby
- Department of Anesthesiology and Intensive Care Medicine, St Olav's University Hospital, Trondheim, Norway
- Department of Traumatology, St. Olav's University Hospital, Trondheim, Norway
- Norwegian Armed Forces Joint Medical Services, Sessvollmoen, Norway
| | - Oddvar Uleberg
- Department of Emergency Medicine and Pre-hospital Services, St Olav's University Hospital, Trondheim, Norway
- Department of Research and Development, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway
| |
Collapse
|
2
|
Sanderson BJ, Field JD, Kocaballi AB, Estcourt LJ, Magrabi F, Wood EM, Coiera E. Clinical decision support versus a paper-based protocol for massive transfusion: Impact on decision outcomes in a simulation study. Transfusion 2023; 63:2225-2233. [PMID: 37921017 DOI: 10.1111/trf.17580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 09/22/2023] [Accepted: 09/27/2023] [Indexed: 11/04/2023]
Abstract
BACKGROUND Management of major hemorrhage frequently requires massive transfusion (MT) support, which should be delivered effectively and efficiently. We have previously developed a clinical decision support system (CDS) for MT using a multicenter multidisciplinary user-centered design study. Here we examine its impact when administering a MT. STUDY DESIGN AND METHODS We conducted a randomized simulation trial to compare a CDS for MT with a paper-based MT protocol for the management of simulated hemorrhage. A total of 44 specialist physicians, trainees (residents), and nurses were recruited across critical care to participate in two 20-min simulated bleeding scenarios. The primary outcome was the decision velocity (correct decisions per hour) and overall task completion. Secondary outcomes included cognitive workload and System Usability Scale (SUS). RESULTS There was a statistically significant increase in decision velocity for CDS-based management (mean 8.5 decisions per hour) compared to paper based (mean 6.9 decisions per hour; p .003, 95% CI 0.6-2.6). There was no significant difference in the overall task completion using CDS-based management (mean 13.3) compared to paper-based (mean 13.2; p .92, 95% CI -1.2-1.3). Cognitive workload was statistically significantly lower using the CDS compared to the paper protocol (mean 57.1 vs. mean 64.5, p .005, 95% CI 2.4-12.5). CDS usability was assessed as a SUS score of 82.5 (IQR 75-87.5). DISCUSSION Compared to paper-based management, CDS-based MT supports more time-efficient decision-making by users with limited CDS training and achieves similar overall task completion while reducing cognitive load. Clinical implementation will determine whether the benefits demonstrated translate to improved patient outcomes.
Collapse
Affiliation(s)
- Brenton J Sanderson
- Department of Anaesthesia and Perioperative Medicine, Westmead Hospital, Sydney, Australia
| | - Jeremy D Field
- Department of Anaesthesia and Perioperative Medicine, Westmead Hospital, Sydney, Australia
| | - Ahmet B Kocaballi
- School of Computer Science, University of Technology, Sydney, Australia
| | | | - Farah Magrabi
- Centre for Health Informatics, Australian Institute of Health Innovation, Sydney, Australia
| | - Erica M Wood
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Department of Haematology, Monash Health, Melbourne, Australia
| | - Enrico Coiera
- Centre for Health Informatics, Australian Institute of Health Innovation, Sydney, Australia
| |
Collapse
|
3
|
Marshall C, Josephson CD, Leonard JC, Wisniewski SR, Leeper CM, Luther JF, Spinella PC. Blood component ratios in children with non-traumatic life-threatening bleeding. Vox Sang 2023; 118:68-75. [PMID: 36427061 DOI: 10.1111/vox.13382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 11/04/2022] [Accepted: 11/09/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND AND OBJECTIVES In paediatric trauma patients, there are limited prospective data regarding blood components and mortality, with some literature suggesting decreased mortality with high ratios of plasma and platelets to red blood cells (RBCs) in massive transfusions; however, most paediatric massive transfusions occur for non-traumatic aetiologies and few studies assess blood product ratios in these children. This study's objective was to evaluate whether high blood product ratios or low deficits conferred a survival benefit in children with non-traumatic life-threatening bleeding. MATERIALS AND METHODS This is a secondary analysis of the five-year, multicentre, prospective, observational massive transfusion epidemiology and outcomes in children study of children with life-threatening bleeding from US, Canadian and Italian medical centres. Primary interventions were plasma:RBC and platelets:RBC (high ratio ≥1:2 ml/kg) and plasma and platelet deficits. The primary outcome was mortality at 6 h, 24 h and 28 days. Multivariate logistic regression models were used to determine independent associations with mortality. RESULTS A total of 222 children were included from 24 medical centres: 145 children (median [interquartile range] age 2.1 years [0.3-11.8]) with operative bleeding and 77 (8.0 years [1.2-14.7]) with medical bleeding. In adjusted analyses, neither blood product ratios nor deficits were associated with mortality at 6 h, 24 h or 28 days. CONCLUSION This paper addresses a lack of prospective data in children regarding optimal empiric massive transfusion strategies in non-traumatic massive haemorrhage and in finding no decrease in mortality with high plasma or platelet to RBC ratios or lower deficits supports an exploratory analysis for mortality.
Collapse
Affiliation(s)
- Callie Marshall
- Department of Pediatrics, Washington University School of Medicine, St. Louis Children's Hospital, St. Louis, Missouri, USA
| | - Cassandra D Josephson
- Department of Oncology and Cancer and Blood Disorders Institute, Johns Hopkins University School of Medicine, Johns Hopkins All Children's Hospital, St. Petersburg, Florida, USA
| | - Julie C Leonard
- Department of Critical Care Medicine, The Ohio State University College of Medicine, Columbus, Ohio, USA
| | | | - Christine M Leeper
- Department of Pediatrics, University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - James F Luther
- University of Pittsburgh School of Public Health, Pittsburgh, Pennsylvania, USA
| | | | - Philip C Spinella
- Department of Pediatrics, Washington University School of Medicine, St. Louis Children's Hospital, St. Louis, Missouri, USA.,Department of Pediatrics, University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| |
Collapse
|
4
|
Dorken Gallastegi A, Secor JD, Maurer LR, Dzik WS, Saillant NN, Hwabejire JO, Fawley J, Parks J, Kaafarani HM, Velmahos GC. Role of Transfusion Volume and Transfusion Rate as Markers of Futility During Ultramassive Blood Transfusion in Trauma. J Am Coll Surg 2022; 235:468-480. [PMID: 35972167 DOI: 10.1097/xcs.0000000000000268] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Using a large national database, we evaluated the relationship between RBC transfusion volume, RBC transfusion rate, and in-hospital mortality to explore the presence of a futility threshold in trauma patients receiving ultramassive blood transfusion. STUDY DESIGN The ACS-TQIP 2013 to 2018 database was analyzed. Adult patients who received ultramassive blood transfusion (≥20 units of RBC/24 hours) were included. RBC transfusion volume and rate were captured at the only 2 time points available in TQIP (4 hours and 24 hours), or time of death, whichever came first. RESULTS Among 5,135 patients analyzed, in-hospital mortality rate was 62.1% (n = 3,190), and 4-hour and 24-hour mortality rates were 17.53% (n = 900) and 42.41% (n = 2,178), respectively. RBC transfusion volumes at 4 hours (area under the receiver operating characteristic curve [AUROC] 0.59 [95% CI 0.57 to 0.60]) and 24 hours (AUROC 0.59 [95% CI 0.57 to 0.60]) had low discriminatory ability for mortality and were inconclusive for futility. Mean RBC transfusion rates calculated within 4 hours (AUROC 0.65 [95% CI 0.63 to 0.66]) and 24 hours (AUROC 0.85 [95% CI 0.84 to 0.86]) had higher discriminatory ability than RBC transfusion volume. A futility threshold was not found for the mean RBC transfusion rate calculated within 4 hours. All patients with a final mean RBC transfusion rate of ≥7 U/h calculated within 24 hours of arrival experienced in-hospital death (n = 1,326); the observed maximum length of survival for these patients during the first 24 hours ranged from 24 hours for a rate of 7 U/h to 4.5 hours for rates ≥21 U/h. CONCLUSION RBC transfusion volume within 4 or 24 hours and mean RBC transfusion rate within 4 hours were not markers of futility. The observed maximum length of survival per mean RBC transfusion rate could inform resuscitation efforts in trauma patients receiving ongoing transfusion between 4 and 24 hours.
Collapse
Affiliation(s)
- Ander Dorken Gallastegi
- From the Division of Trauma, Emergency Surgery, and Surgical Critical Care (Dorken Gallastegi, Saillant, Hwabejire, Fawley, Parks, Kaafarani, Velmahos)
| | | | | | - Walter S Dzik
- Department of Pathology (Dzik), Massachusetts General Hospital & Harvard Medical School, Boston
- Blood Transfusion Service, Massachusetts General Hospital, Boston (Dzik)
| | - Noelle N Saillant
- From the Division of Trauma, Emergency Surgery, and Surgical Critical Care (Dorken Gallastegi, Saillant, Hwabejire, Fawley, Parks, Kaafarani, Velmahos)
| | - John O Hwabejire
- From the Division of Trauma, Emergency Surgery, and Surgical Critical Care (Dorken Gallastegi, Saillant, Hwabejire, Fawley, Parks, Kaafarani, Velmahos)
| | - Jason Fawley
- From the Division of Trauma, Emergency Surgery, and Surgical Critical Care (Dorken Gallastegi, Saillant, Hwabejire, Fawley, Parks, Kaafarani, Velmahos)
| | - Jonathan Parks
- From the Division of Trauma, Emergency Surgery, and Surgical Critical Care (Dorken Gallastegi, Saillant, Hwabejire, Fawley, Parks, Kaafarani, Velmahos)
| | - Haytham Ma Kaafarani
- From the Division of Trauma, Emergency Surgery, and Surgical Critical Care (Dorken Gallastegi, Saillant, Hwabejire, Fawley, Parks, Kaafarani, Velmahos)
| | - George C Velmahos
- From the Division of Trauma, Emergency Surgery, and Surgical Critical Care (Dorken Gallastegi, Saillant, Hwabejire, Fawley, Parks, Kaafarani, Velmahos)
| |
Collapse
|
5
|
Platelet Transfusion for Trauma Resuscitation. CURRENT TRAUMA REPORTS 2022. [DOI: 10.1007/s40719-022-00236-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Abstract
Purpose of Review
To review the role of platelet transfusion in resuscitation for trauma, including normal platelet function and alterations in behavior following trauma, blood product transfusion ratios and the impact of platelet transfusion on platelet function, platelet function assays, risks of platelet transfusion and considerations for platelet storage, and potential adjunct therapies and synthetic platelets.
Recent Findings
Platelets are a critical component of clot formation and breakdown following injury, and in addition to these hemostatic properties, have a complex role in vascular homeostasis, inflammation, and immune function. Evidence supports that platelets are activated following trauma with several upregulated functions, but under conditions of severe injury and shock are found to be impaired in their hemostatic behaviors. Platelets should be transfused in balanced ratios with red blood cells and plasma during initial trauma resuscitation as this portends improved outcomes including survival. Multiple coagulation assays can be used for goal-directed resuscitation for traumatic hemorrhage; however, these assays each have drawbacks in terms of their ability to measure platelet function. While resuscitation with balanced transfusion ratios is supported by the literature, platelet transfusion carries its own risks such as bacterial infection and lung injury. Platelet supply is also limited, with resource-intensive storage requirements, making exploration of longer-term storage options and novel platelet-based therapeutics attractive. Future focus on a deeper understanding of the biology of platelets following trauma, and on optimization of novel platelet-based therapeutics to maintain hemostatic effects while improving availability should be pursued.
Summary
While platelet function is altered following trauma, platelets should be transfused in balanced ratios during initial resuscitation. Severe injury and shock can impair platelet function, which can persist for several days following the initial trauma. Assays to guide resuscitation following the initial period as well as storage techniques to extend platelet shelf life are important areas of investigation.
Collapse
|
6
|
Sanderson BJ, Field JD, Estcourt LJ, Wood EM, Coiera EW. Massive transfusion experience, current practice and decision support: A survey of Australian and New Zealand anaesthetists. Anaesth Intensive Care 2021; 49:214-221. [PMID: 33951942 DOI: 10.1177/0310057x20974035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Massive transfusions guided by massive transfusion protocols are commonly used to manage critical bleeding, when the patient is at significant risk of morbidity and mortality, and multiple timely decisions must be made by clinicians. Clinical decision support systems are increasingly used to provide patient-specific recommendations by comparing patient information to a knowledge base, and have been shown to improve patient outcomes. To investigate current massive transfusion practice and the experiences and attitudes of anaesthetists towards massive transfusion and clinical decision support systems, we anonymously surveyed 1000 anaesthetists and anaesthesia trainees across Australia and New Zealand. A total of 228 surveys (23.6%) were successfully completed and 227 were analysed for a 23.3% response rate. Most respondents were involved in massive transfusions infrequently (88.1% managed five or fewer massive transfusion protocols per year) and worked at hospitals which have massive transfusion protocols (89.4%). Massive transfusion management was predominantly limited by timely access to point-of-care coagulation assessment and by competition with other tasks, with trainees reporting more significant limitations compared to specialists. The majority of respondents reported that they were likely, or very likely, both to use (73.1%) and to trust (85%) a clinical decision support system for massive transfusions, with no significant difference between anaesthesia trainees and specialists (P = 0.375 and P = 0.73, respectively). While the response rate to our survey was poor, there was still a wide range of massive transfusion experience among respondents, with multiple subjective factors identified limiting massive transfusion practice. We identified several potential design features and barriers to implementation to assist with the future development of a clinical decision support system for massive transfusion, and overall wide support for a clinical decision support system for massive transfusion among respondents.
Collapse
Affiliation(s)
- Brenton J Sanderson
- Centre for Health Informatics, Australian Institute of Health Innovation, Sydney, Australia.,Department of Anaesthesia and Perioperative Medicine, Westmead Hospital, Sydney, Australia
| | - Jeremy D Field
- Department of Anaesthesia and Perioperative Medicine, Westmead Hospital, Sydney, Australia
| | | | - Erica M Wood
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
| | - Enrico W Coiera
- Centre for Health Informatics, Australian Institute of Health Innovation, Sydney, Australia
| |
Collapse
|
7
|
Prittie J. The role of cryoprecipitate in human and canine transfusion medicine. J Vet Emerg Crit Care (San Antonio) 2021; 31:204-214. [PMID: 33751762 DOI: 10.1111/vec.13034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Revised: 05/27/2019] [Accepted: 07/02/2019] [Indexed: 12/20/2022]
Abstract
OBJECTIVE To evaluate the current role of cryoprecipitate in human and canine transfusion medicine. DATA SOURCES Human and veterinary scientific reviews and original studies found using PubMed and CAB Abstract search engines were reviewed. HUMAN DATA SYNTHESIS In the human critical care setting, cryoprecipitate is predominantly used for fibrinogen replenishment in bleeding patients with acute traumatic coagulopathy. Other coagulopathic patient cohorts for whom cryoprecipitate is recommended include those undergoing cardiovascular or obstetric procedures or patients bleeding from advanced liver disease. Preferential selection of cryoprecipitate versus fibrinogen concentrate (when available) is currently being investigated. Also a matter of ongoing debate is whether to administer this product as part of a fixed-dose massive hemorrhage protocol or to incorporate it into a goal-directed transfusion algorithm applied to the individual bleeding patient. VETERINARY DATA SYNTHESIS Although there are sporadic reports of the use of cryoprecipitate in dogs with heritable coagulopathies, there are few to no data pertaining to its use in acquired hypofibrinogenemic states. Low fibrinogen in dogs (as in people) has been documented with acute traumatic coagulopathy, advanced liver disease, and disseminated intravascular coagulation. Bleeding secondary to these hypocoagulable states may be amenable to cryoprecipitate therapy. Indications for preferential selection of cryoprecipitate (versus fresh frozen plasma) remain to be determined. CONCLUSIONS In the United States, cryoprecipitate remains the standard of care for fibrinogen replenishment in the bleeding human trauma patient. Its preferential selection for this purpose is the subject of several ongoing human clinical trials. Timely incorporation of cryoprecipitate into the transfusion protocol of the individual bleeding patient with hypofibrinogenemia may conserve blood products, mitigate adverse transfusion-related events, and improve patient outcomes. Cryoprecipitate is readily available, effective, and safe for use in dogs. The role of this blood product in clinical canine patients with acquired coagulopathy remains unknown.
Collapse
Affiliation(s)
- Jennifer Prittie
- Department of Emergency and Critical Care, Animal Medical Center, New York, New York
| |
Collapse
|
8
|
Cornero SG, Maegele M, Lefering R, Abbati C, Gupta S, Sammartano F, Cimbanassi S, Chiara O. Predictive Factors for Massive Transfusion in Trauma: A Novel Clinical Score from an Italian Trauma Center and German Trauma Registry. J Clin Med 2020; 9:jcm9103235. [PMID: 33050378 PMCID: PMC7601146 DOI: 10.3390/jcm9103235] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Revised: 09/29/2020] [Accepted: 10/02/2020] [Indexed: 11/17/2022] Open
Abstract
Early management of critical bleeding and coagulopathy can improve patient survival. The aim of our study was to identify independent predictors of critical bleeding and to build a clinical score for early risk stratification. A prospective analysis was performed on a cohort of trauma patients with at least one hypotensive episode during pre-hospital (PH) care or in the Emergency Department (ED). Patients who received massive transfusion (MT+) (≥4 blood units during the first hour) were compared to those who did not (MT−). Hemodynamics, Glagow Coma Score (GCS), diagnostics and blood tests were evaluated. Using multivariate analysis, we created and validated a predictive score for MT+ patients. The predictive score was validated on a matched cohort of patients of the German Trauma Registry TR-DGU. One hundred thirty-nine patients were included. Independent predictors of MT+ included a prehospital (PH) GCS of 3, PH administration of tranexamic acid, hypotension and tachycardia upon admission, coagulopathy and injuries with significant bleeding such as limb amputation, hemoperitoneum, pelvic fracture, massive hemothorax. The derived predictive score revealed an area under the curve (AUC) of 0.854. Massive transfusion is essential to damage control resuscitation. Altered GCS, unstable hemodynamics, coagulopathy and bleeding injuries can allow early identification of patients at risk for critical hemorrhage.
Collapse
Affiliation(s)
- Sara Giulia Cornero
- Trauma Team and General Surgery ASST Niguarda Milano, Department of Pathophysiology and Transplantation, University of Milano, 20125 Milano, Italy; (S.G.C.); (C.A.); (F.S.); (S.C.)
| | - Marc Maegele
- Cologne-Merheim Medical Center, Department for Trauma and Orthopedic Surgery, Institute for Research in Operative Medicine, University Witten/Herdecke, 51109 Köln, Germany; (M.M.); (R.L.)
| | - Rolf Lefering
- Cologne-Merheim Medical Center, Department for Trauma and Orthopedic Surgery, Institute for Research in Operative Medicine, University Witten/Herdecke, 51109 Köln, Germany; (M.M.); (R.L.)
| | - Claudia Abbati
- Trauma Team and General Surgery ASST Niguarda Milano, Department of Pathophysiology and Transplantation, University of Milano, 20125 Milano, Italy; (S.G.C.); (C.A.); (F.S.); (S.C.)
| | - Shailvi Gupta
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, MD 21201, USA;
| | - Fabrizio Sammartano
- Trauma Team and General Surgery ASST Niguarda Milano, Department of Pathophysiology and Transplantation, University of Milano, 20125 Milano, Italy; (S.G.C.); (C.A.); (F.S.); (S.C.)
| | - Stefania Cimbanassi
- Trauma Team and General Surgery ASST Niguarda Milano, Department of Pathophysiology and Transplantation, University of Milano, 20125 Milano, Italy; (S.G.C.); (C.A.); (F.S.); (S.C.)
| | - Osvaldo Chiara
- Trauma Team and General Surgery ASST Niguarda Milano, Department of Pathophysiology and Transplantation, University of Milano, 20125 Milano, Italy; (S.G.C.); (C.A.); (F.S.); (S.C.)
- Correspondence:
| |
Collapse
|
9
|
The effect of massive transfusion protocol implementation on the survival of trauma patients: a systematic review and meta-analysis. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2020; 18:434-445. [PMID: 32955420 DOI: 10.2450/2020.0065-20] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 03/15/2020] [Accepted: 06/22/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND Massive transfusion protocol (MTP) has been widely adopted for the care of bleeding trauma patients but its actual effectiveness is unclear. An earlier meta-analysis on the implementation of MTP for injured patients from 1990 to 2013 reported that only 2 out of 8 studies showed statistical improvement in survival. This study aimed to conduct an updated systematic review and meta-analysis to evaluate the effect of implementing an MTP on the mortality of trauma patients. MATERIALS AND METHODS MEDLINE, PubMed, Cochrane Library and Google scholar databases were systematically searched for relevant studies published from 1st January 2008 to 30th September 2019 using a combination of keywords and additional manual searching of reference lists. Inclusion criteria were: original study in English, study population including trauma patients, and comparison of mortality outcomes before and after institutional implementation of an MTP. Primary outcomes were 24-hour, 30-day, and overall mortality. RESULTS Fourteen studies met inclusion criteria, analysing outcomes from 3,201 trauma patients. There was a wide range of outcomes, patient populations, and process indicators utilised by the different authors. MTP significantly reduced the overall mortality for trauma patients (OR 0.71 [0.56-0.90]). No significant reduction was seen in either the 24-hour mortality (OR 0.81 [0.57-1.14]) or the 30-day mortality (OR 0.73 [0.46-1.16]). However, when mortality timing was unspecified, mortality was statistically reduced (OR 0.69 [0.55-0.86]). DISCUSSION The present study found a significant reduction in mortality following MTP implementation and thus it should be recommended to all institutions managing acutely injured patients. To better identify which elements of an MTP contribute to this effect, we encourage the use of standard nomenclature, indicators, protocols and patient populations in all future MTP studies.
Collapse
|
10
|
How well does your massive transfusion protocol perform? A scoping review of quality indicators. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2020; 18:423-433. [PMID: 32955419 DOI: 10.2450/2020.0082-20] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 04/05/2020] [Accepted: 05/02/2020] [Indexed: 12/25/2022]
Abstract
BACKGROUND Management of patients with major haemorrhage often requires urgent administration of multiple blood products, commonly termed a massive transfusion (MT). Clinical practice in these scenarios is supported in part by evidence-based MT guidelines, which typically recommend use of an MT protocol (MTP). MTPs aim to provide practical and specific interpretation of MT guidelines for local institutional use, outlining tasks and pre-configuration of blood product packs to be transfused to provide efficient and evidence-based transfusion management. Institutions can support this aim by the measurement of MTP performance and patient outcomes through collection of quality indicators (QI). Many international guidelines now recommend the routine collection of a range of QIs relating to MT/MTP; however, there is significant variation in procedures and no benchmarks or minimal evidence to guide practice. MATERIALS AND METHODS We conducted a scoping review to document and evaluate reported QIs for MTP. We conducted a search of CENTRAL, MEDLINE and EMBASE for published studies from inception until May 14, 2020, that reported at least one MTP QI and use of an MTP or equivalent protocol. Included studies were evaluated using a QI classification system based on current MT QI guidelines and the Donabedian QI framework. RESULTS We identified 107 eligible studies. Trauma patients were the most commonly evaluated group, and total blood products transfused and in-hospital mortality were the most commonly reported QIs. Reflecting the lack of international consensus and benchmarks, we found significant variability in the reporting of QIs, which often did not reflect guideline recommendations. DISCUSSION Our review highlights the importance of establishing international consensus on prioritised QIs with quantifiable targets that are important to the process of MT.
Collapse
|
11
|
Sun HW, Lee SB, Park SJ, Park CI, Kim JH. Effects of Massive Transfusion Protocol Implementation in Trauma Patients at a Level I Trauma Center. JOURNAL OF TRAUMA AND INJURY 2020. [DOI: 10.20408/jti.2020.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
|
12
|
Luckhurst CM, Saillant NN. Plasma: a Brief History, the Evidence, and Current Recommendations. CURRENT TRAUMA REPORTS 2020. [DOI: 10.1007/s40719-020-00181-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
|
13
|
Zhu CS, Cobb D, Jonas RB, Pokorny D, Rani M, Cotner-Pouncy T, Oliver J, Cap A, Cestero R, Nicholson SE, Eastridge BJ, Jenkins DH. Shock index and pulse pressure as triggers for massive transfusion. J Trauma Acute Care Surg 2019; 87:S159-S164. [PMID: 31246921 DOI: 10.1097/ta.0000000000002333] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
BACKGROUND Hemorrhage is the most common cause of preventable death in trauma patients. These mortalities might be prevented with prehospital transfusion. We sought to characterize injured patients requiring massive transfusion to determine the potential impact of a prehospital whole blood transfusion program. The primary goal of this analysis was to determine a method to identify patients at risk of massive transfusion in the prehospital environment. Many of the existing predictive models require laboratory values and/or sonographic evaluation of the patient after arrival at the hospital. Development of an algorithm to predict massive transfusion protocol (MTP) activation could lead to an easy-to-use tool for prehospital personnel to determine when a patient needs blood transfusion. METHODS Using our Level I trauma center's registry, we retrospectively identified all adult trauma patients from January 2015 to August 2017 requiring activation of the MTP. Patients who were younger than 18 years, older than 89 years, prisoners, pregnant women, and/or with nontraumatic hemorrhage were excluded from the study. We retrospectively collected data including demographics, blood utilization, variable outcome data (survival, length of stay, intensive care unit days, ventilator days), prehospital vital signs, prehospital transport times, and Injury Severity Score. The independent-samples t test and χ test were used to compare the group who died to the group who survived. p < 0.05 was considered significant. Based on age and mechanism of injury, relative risk of death was calculated. Graphs were generated using Microsoft Excel software to plot patient variables. RESULTS Our study population of 102 MTP patients had an average age of 42 years and average Injury Severity Score of 29, consisted of 80% males (82/102), and was 66% blunt trauma (67/102). The all-cause mortality was 67% (68/102). The positive predictive value of death for patients with pulse pressure of less than 45 and shock index of greater than 1 was 0.78 for all patients, but was 0.79 and 0.92 for blunt injury and elderly patients, respectively. CONCLUSIONS Our data demonstrate a high mortality rate in trauma patients who require MTP despite short transport times, indicating the need for early intervention in the prehospital environment. Given our understanding that the most severely injured patients in hemorrhagic shock require blood resuscitation, this study demonstrates that this subset of trauma patients requiring massive transfusion can be identified in the prehospital setting. We recommend using Emergency Medical Services pulse pressure in combination with shock index to serve as a trigger for initiation of prehospital whole blood transfusion. LEVEL OF EVIDENCE Therapeutic/care management, level V.
Collapse
Affiliation(s)
- Caroline S Zhu
- From the Department of Trauma and Emergency Surgery (C.S.Z., R.B.J., D.P., R.C., S.E.N., B.J.E., D.H.J.), University of Texas Health Science Center, San Antonio, Texas; Department of Surgery (D.C.), Louisiana State University School of Medicine, Baton Rouge, Louisiana; Department of Transplant Surgery (M.R.), University of Texas Health Science Center, San Antonio, Texas; Trauma Services (T.C.-P., J.O.), University Hospital in San Antonio, San Antonio, Texas; and US Army Institute of Surgical Research (A.C.), San Antonio, Texas
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
14
|
Abstract
Uncontrolled bleeding is the leading preventable cause of death in patients with multiple injuries. Currently, trauma-induced coagulopathy is seen as an independent disease entity influencing survival. Severely bleeding trauma patients are often treated with classical blood products in predefined ratios (damage control resuscitation). Viscoelasticity-based and target-oriented approaches could possibly be given priority. Viscoelasticity-based diagnostics and therapy enable the qualitative investigation of whole blood and provide therapeutically usable information on initiation, dynamics and sustainability of thrombus formation. Due to the ease of handling and timely results this lends itself as a point-of-care procedure. This article presents the clinical issues with using viscoelastic procedures and current expert recommendations taking the literature into consideration.
Collapse
|
15
|
Bell C, Prokopchuk-Gauk O, Cload B, Stirling A, Davis PJ. Optimum Accuracy of Massive Transfusion Protocol Activation: The Clinician's View. Cureus 2018; 10:e3688. [PMID: 30761240 PMCID: PMC6368427 DOI: 10.7759/cureus.3688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Massive transfusion protocols (MTP) aid in the efficient delivery of blood components to rapidly exsanguinating patients. Unfortunately, clinical gestalt and currently available clinical scoring systems lack the optimal accuracy to prevent blood product wastage (through over-activation), as well as individual patient morbidity and mortality (through under-activation). In order to help refine the MTP activation criteria and protocols, we surveyed clinicians on acceptable over- and under-activation rates for massive transfusions. Methods We surveyed Canadian content experts in their respective fields, using a snowball survey technique. Respondents were categorized into two groups: Group 1 was comprised of trauma and acute care specialists (TACS), while Group 2 was comprised of clinical and laboratory medicine specialists (CLMS). Between-group differences were examined using Fisher’s exact test and the likelihood ratio. Statistical significance was set at p < 0.05. Results We received responses from 35 clinicians in the TACS group and 10 clinicians in the CLMS group. About half (45.7%) of respondents in the TACS group considered an MTP overactivation rate of 5% - 10% acceptable (vs. 60% of the CLMS group; not significant (NS)). Approximately one-third (34.2%) of the respondents in the TACS group considered an MTP under-activation rate of less than 5% acceptable, whereas the majority (60%) of respondents in the CLMS group considered an under-activation rate of less than 5% acceptable (NS). A significantly greater proportion of respondents in the TACS group felt that an anticipated need for > 20 units of packed red blood cells within the next 24 hours was an acceptable criterion for MTP activation. Respondents in the CLMS group were more likely to consider “poor communication” as a reason for blood component wastage. Conclusion Similarities in acceptable MTP over- and under-activation rates were noted across specialties. Collaboration between involved parties is necessary for MTP protocol development to improve patient outcomes and reduce blood wastage.
Collapse
Affiliation(s)
- Chris Bell
- Internal Medicine, University of Saskatchewan College of Medicine, Saskatoon, CAN
| | - Oksana Prokopchuk-Gauk
- Pathology and Laboratory Medicine, University of Saskatchewan, Royal University Hospital, Saskatoon, CAN
| | - Bruce Cload
- Emergency Medicine, University of Saskatchewan, Royal University Hospital, Saskatoon, CAN
| | - Alena Stirling
- Anaesthesia, University of Saskatchewan, Royal University Hospital, Saskatoon, CAN
| | - Philip J Davis
- Emergency Medicine, University of Saskatchewan, Royal University Hospital, Saskatoon, CAN
| |
Collapse
|
16
|
Estebaranz-Santamaría C, Palmar-Santos AM, Pedraz-Marcos A. Massive transfusion triggers in severe trauma: Scoping review. Rev Lat Am Enfermagem 2018; 26:e3102. [PMID: 30517587 PMCID: PMC6280179 DOI: 10.1590/1518-8345.2574.3102] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Accepted: 10/08/2018] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVE to identify the predictive variables or the massive transfusion triggers in severely traumatized patients through the existing scales. METHOD a review of the literature was carried out using the Scoping Review method across the electronic databases CINAHL, MEDLINE, LILACS, the Cochrane and IBECS libraries, and the Google Scholar search tool. RESULTS in total, 578 articles were identified in the search and the 36 articles published in the last ten years were included, of which 29 were original articles and 7 review articles. From the analysis, scales for massive transfusion and their predictive triggers were examined. CONCLUSION the absence of universal criteria regarding the massive transfusion triggers in traumatized patients has led to the development of different scales, and the studies on their validation are considered relevant for the studies about when to initiate this strategy.
Collapse
|
17
|
Manduzio P. Transfusion-associated graft-versus-host disease: A concise review. Hematol Rep 2018; 10:7724. [PMID: 30542528 PMCID: PMC6240831 DOI: 10.4081/hr.2018.7724] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Accepted: 10/04/2018] [Indexed: 01/28/2023] Open
Abstract
Transfusion-associated graft-versushost disease (TA-GVHD) represents a rare fatal event observed in immunocompromised patients and immunocompetent individuals. The main clinical features of this transfusion reaction are pancitopenia and multiorgan failure (skin, liver, gut). The possible pathogenesis includes donor T lymphocyte proliferation in blood, their engraftment and host tissue attack. The purpose of this narrative review was analyzing the international guidelines for irradiation of cellular blood components to prevent TA-GVHD. A literature search was conducted using PubMed articles published between January 2000 to July 2018. American, Australian, British and Japanese transfusion guidelines have been compared regarding clinical indications. The contribution of manuscripts has been focused on recipients of Haematopoietic Stem Cell Transplantation, severe cellular immunodeficient patients, fetuses and neonates, immunocompentent individuals. Furthermore, 348 cases of TA-GVHD in the last five decades have been documented according to a recent systematic review. The standard of care to prevent this complication is gamma or x irradiation of cellular blood products. New treatments with pathogen inactivation appear safe and effective against proliferating white blood cells and T cells. Further clinical and biological studies are necessary to better characterize immunocompetence of T cells and select alternative preventive strategies.
Collapse
Affiliation(s)
- Palma Manduzio
- Diagnostic Department, Clinical Pathology, 'Augusto Murri' Civil Hospital of Fermo, Italy
| |
Collapse
|
18
|
Kelly JM, Rizoli S, Veigas P, Hollands S, Min A. Using rotational thromboelastometry clot firmness at 5 minutes (ROTEM ® EXTEM A5) to predict massive transfusion and in-hospital mortality in trauma: a retrospective analysis of 1146 patients. Anaesthesia 2018; 73:1103-1109. [PMID: 29658985 PMCID: PMC6120456 DOI: 10.1111/anae.14297] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/03/2018] [Indexed: 12/31/2022]
Abstract
Viscoelastic assays such as TEG® and ROTEM® are increasingly used to guide transfusion of blood products. The EXTEM assay maximum clot firmness (MCF) is a ROTEM measure available after 25–29 min used to guide early decisions. EXTEM A10, the clot firmness at 10 min, is an accepted early surrogate, but investigators differ on whether A5, the clot firmness at 5 min, is acceptable. We re‐examined this in a retrospective observational analysis of 1146 trauma patients in one centre who had ROTEM data recorded. A5 and A10 both correlated well with maximum clot firmness, with Pearson coefficients of r = 0.92 and r = 0.96, respectively. The correlations of A5, A10 and maximum clot firmness with requirement for massive transfusion were all similarly high, with c‐stats of 0.87, 0.89 and 0.90, respectively. The correlations with mortality were also similar but weaker, with c‐stats of 0.67, 0.69 and 0.69, respectively. Using a previously validated cut‐off of A5 < 35 mm to predict massive transfusion gave a sensitivity of 95%, specificity 83%, positive predictive value 9.3% and negative predictive value 100%. Using a value of A5 < 29 mm, for a pragmatic positive predictive value of 20%, gave a sensitivity of 67%, specificity 95% and negative predictive value 99%. Whether aiming for a high sensitivity or a strong predictive value, A5 was non‐inferior to A10 and actually missed fewer cases needing massive transfusion. A5 has similar utility to both A10 and maximum clot firmness as an early measure of clot firmness, and a low A5 value is strongly predictive of the need for massive transfusion.
Collapse
Affiliation(s)
- J M Kelly
- Department of Anaesthesia and Intensive Care, Queen Elizabeth Hospital, Birmingham, UK
| | - S Rizoli
- Trauma Department, St Michael's Hospital, Toronto, Canada
| | - P Veigas
- Trauma Department, St Michael's Hospital, Toronto, Canada
| | - S Hollands
- Institute for Clinical Evaluative Studies, University of Toronto, Canada
| | - A Min
- Royal College of Surgeons in Ireland, Dublin, Ireland
| |
Collapse
|
19
|
Blood Product Utilization Among Trauma and Nontrauma Massive Transfusion Protocols at an Urban Academic Medical Center. Anesth Analg 2017; 125:967-974. [DOI: 10.1213/ane.0000000000002253] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
|
20
|
Should All Massively Transfused Patients Be Treated Equally? An Analysis of Massive Transfusion Ratios in the Nontrauma Setting. Crit Care Med 2017; 45:1311-1316. [PMID: 28537938 DOI: 10.1097/ccm.0000000000002498] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Although balanced resuscitation has become integrated into massive transfusion practice, there is a paucity of evidence supporting the delivery of high ratios of plasma and platelet to RBCs in the nontrauma setting. This study investigated the administration of blood component ratios in the massively transfused nontrauma demographic. DESIGN Retrospective analysis of a prospective, observational cohort of massively bleeding patients. SETTING Surgical and critically ill patients at a tertiary medical center between 2011 and 2015. PATIENTS Massively transfused nontrauma patients. INTERVENTIONS Patients receiving plasma, platelet, and RBC transfusions were categorized into high and low ratio groups and analyzed for differences in characteristics and clinical outcomes. MEASUREMENTS AND MAIN RESULTS The primary outcome was 30-day mortality. Secondary outcomes included 48-hour mortality, hospital length of stay, ICU length of stay, and ventilator-free days. Among 601 massively transfused nontrauma patients, cardiothoracic surgery and gastrointestinal or hepato-pancreatico-biliary bleeds were the most common indications for massive transfusion. Higher fresh frozen plasma ratios (> 1:2) were not associated with increased 30-day mortality. A high platelets-to-packed RBCs ratio (> 1:2) was associated with decreased 48-hour mortality (10.5% vs 19.3%; p = 0.032), but not 30-day mortality. Fresh frozen plasma-to-packed RBCs and platelets-to-packed RBCs ratios were not associated with 30-day mortality hazard ratios after controlling for baseline characteristics and disease severity. CONCLUSIONS The benefits of higher ratios of fresh frozen plasma-to-packed RBCs and platelets-to-packed RBCs described in trials of trauma patients were not observed in this analysis of a nontrauma, massively transfused population. These data suggest that greater than 1:2 ratio transfusion in the setting of massive hemorrhage may not be appropriate for all patients, and that further research to guide appropriate resuscitation strategies in nontrauma patients is warranted.
Collapse
|
21
|
|
22
|
Nunn A, Fischer P, Sing R, Templin M, Avery M, Christmas AB. Improvement of Treatment Outcomes after Implementation of a Massive Transfusion Protocol: A Level I Trauma Center Experience. Am Surg 2017. [DOI: 10.1177/000313481708300429] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
We assessed the effectiveness of the implementation of an institutional massive transfusion protocol (MTP) for resuscitation with a 1:1:1 transfusion ratio of packed red blood cell (PRBC), fresh frozen plasma, and platelet units. In a Level I trauma center database, all trauma admissions (2004–2012) that received massive transfusions (≥10 units PRBCs in the first 24 hours) were reviewed retrospectively. Demographic data, transfusion ratios, and outcomes were compared before (PRE) and after (POST) MTP implementation in May 2008. Age, sex, and mechanism of injury were similar between 239 PRE and 208 POST trauma patients requiring massive transfusion. Transfusion ratios of fresh frozen plasma:PRBC and platelet:PRBC increased after MTP implementation. Among survivors, MTP implementation shortened hospital length of stay from 31 to 26 days (P = 0.04) and intensive care unit length of stay from 31 to 26 days (P = 0.02). Linear regression identified treatment after (versus before) implementation of MTP as an independent predictor of decreased ventilator days after adjusting for age, Glasgow Coma Scale, and chest Abbreviated Injury Score (P < 0.0001). Modest improvement in ratios likely does not account for all significant improvements in outcomes. Implementing a standardized protocol likely impacts automation, efficiency, and/or timeliness of product delivery.
Collapse
Affiliation(s)
- Andrew Nunn
- Division of Trauma and Surgical Critical Care, Department of Surgery, Carolinas HealthCare System, Charlotte, North Carolina
| | - Peter Fischer
- Division of Trauma and Surgical Critical Care, Department of Surgery, Carolinas HealthCare System, Charlotte, North Carolina
| | - Ronald Sing
- Division of Trauma and Surgical Critical Care, Department of Surgery, Carolinas HealthCare System, Charlotte, North Carolina
| | - Megan Templin
- Dickson Advanced Analytics, Carolinas Medical Center, Charlotte, North Carolina
| | - Michael Avery
- Dickson Advanced Analytics, Carolinas Medical Center, Charlotte, North Carolina
| | | |
Collapse
|
23
|
Prehospital shock index and pulse pressure/heart rate ratio to predict massive transfusion after severe trauma. J Trauma Acute Care Surg 2016; 81:713-22. [DOI: 10.1097/ta.0000000000001191] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
|
24
|
Etchill E, Sperry J, Zuckerbraun B, Alarcon L, Brown J, Schuster K, Kaplan L, Piper G, Peitzman A, Neal MD. The confusion continues: results from an American Association for the Surgery of Trauma survey on massive transfusion practices among United States trauma centers. Transfusion 2016; 56:2478-2486. [DOI: 10.1111/trf.13755] [Citation(s) in RCA: 58] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2015] [Revised: 04/25/2016] [Accepted: 04/26/2016] [Indexed: 12/26/2022]
Affiliation(s)
- Eric Etchill
- University of Pittsburgh School of Medicine; Pittsburgh Pennsylvania
| | - Jason Sperry
- University of Pittsburgh School of Medicine; Pittsburgh Pennsylvania
| | - Brian Zuckerbraun
- University of Pittsburgh School of Medicine; Pittsburgh Pennsylvania
| | - Louis Alarcon
- University of Pittsburgh School of Medicine; Pittsburgh Pennsylvania
| | - Joshua Brown
- University of Pittsburgh School of Medicine; Pittsburgh Pennsylvania
| | - Kevin Schuster
- Yale University School of Medicine; New Haven Connecticut
| | - Lewis Kaplan
- University of Pennsylvania Perelman School of Medicine and Philadelphia VA Medical Center; Philadelphia Pennsylvania
| | - Greta Piper
- New York University Medical Center; New York New York
| | - Andrew Peitzman
- University of Pittsburgh School of Medicine; Pittsburgh Pennsylvania
| | - Matthew D. Neal
- University of Pittsburgh School of Medicine; Pittsburgh Pennsylvania
| |
Collapse
|
25
|
Solomon C, Asmis LM, Spahn DR. Is viscoelastic coagulation monitoring with ROTEM or TEG validated? Scandinavian Journal of Clinical and Laboratory Investigation 2016; 76:503-7. [PMID: 27354213 PMCID: PMC5152534 DOI: 10.1080/00365513.2016.1200136] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Recent years have seen increasing worldwide interest in the use of viscoelastic coagulation monitoring tests, performed using devices such as ROTEM and TEG. The use of such tests to guide haemostatic therapy may help reduce transfusion of allogeneic blood products in bleeding patients and is supported in European guidelines for managing trauma and severe perioperative bleeding. In addition, viscoelastic tests form the basis of numerous published treatment algorithms. However, some publications have stated that viscoelastic tests are not validated. A specific definition of the term validation is lacking and regulatory requirements of the US Food and Drug Administration (FDA) and European Medicines Agency (EMA) have been fulfilled by ROTEM and TEG assays. Viscoelastic tests have been used in pivotal clinical trials, and they are approved for use in most of the world's countries. Provided that locally approved indications are adhered to, the regulatory framework for clinicians to use viscoelastic tests in routine clinical practice is in place.
Collapse
Affiliation(s)
- Cristina Solomon
- a Department of Anesthesiology, Perioperative Care and General Intensive Care , Paracelsus Medical University, Salzburg University Hospital , Salzburg , Austria , Ludwig Boltzmann Institute for Experimental and Clinical Traumatology and AUVA Research Centre , Vienna , Austria, and CSL Behring , Marburg , Germany
| | - Lars M Asmis
- b Coagulation Lab and Centre for Perioperative Thrombosis and Hemostasis , Unilabs , Zurich , Switzerland
| | - Donat R Spahn
- c Institute of Anesthesiology, University and University Hospital of Zurich , Zurich , Switzerland
| |
Collapse
|
26
|
Swiech A, Ausset S. Les produits sanguins labiles en 2016. MEDECINE INTENSIVE REANIMATION 2016. [DOI: 10.1007/s13546-016-1201-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
|
27
|
|
28
|
Giannoudi M, Harwood P. Damage control resuscitation: lessons learned. Eur J Trauma Emerg Surg 2016; 42:273-82. [PMID: 26847110 PMCID: PMC4886149 DOI: 10.1007/s00068-015-0628-3] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2015] [Accepted: 12/25/2015] [Indexed: 02/05/2023]
Abstract
BACKGROUND Damage control resuscitation describes an approach to the early care of very seriously injured patients. The aim is to keep the patient alive whilst avoiding interventions and situations that risk worsening their situation by driving the lethal triad of hypothermia, coagulopathy and acidosis or excessively stimulating the immune-inflammatory system. It is critical that the concepts and practicalities of this approach are understood by all those involved in the early management of trauma patients. This review aims to summarise this and discusses current knowledge on the subject. INTERVENTIONS Damage control resuscitation forms part of an overall approach to patient care rather than a specific intervention and has evolved from damage control surgery. It is characterised by early blood product administration, haemorrhage arrest and restoration of blood volume aiming to rapidly restore physiologic stability. The infusion of large volumes of crystalloid is no longer appropriate, instead the aim is to replace lost blood and avoid dilution and coagulopathy. In specific situations, permissive hypotension may also be of benefit, particularly in patients with severe haemorrhage from an arterial source. As rapid arrest of haemorrhage is so important, team-based protocols that deliver patients rapidly but safely, via CT scan where appropriate, to operating theatres or interventional radiology suites form a critical part of this process. CONCLUSIONS Given that interventions are so time dependent in the severely injured, it is likely that by further improving trauma systems and protocols, improvements in outcome can still be made. Further research work in this area will allow us to target these approaches more accurately to those patients who can benefit most.
Collapse
Affiliation(s)
- M Giannoudi
- Leeds General Infirmary, Clarendon Wing, Level A, Great George Street, Leeds, West Yorkshire, LS1 3EX, UK
| | - P Harwood
- Leeds General Infirmary, Clarendon Wing, Level A, Great George Street, Leeds, West Yorkshire, LS1 3EX, UK.
| |
Collapse
|
29
|
Abstract
Purpose Paediatric trauma is the leading cause of mortality in children. Paediatric trauma resuscitation is the first and foremost step towards a successful treatment and subsequent recovery. Significant advances have taken place in the last years in relation to this field of trauma care. Methods In this narrative review, we attempt to summarise the recent development in the concepts of fluid resuscitation, massive transfusion, permissive resuscitation, management of coagulopathy and use of tranexamic acid, literature pertaining to implementation of transfusion protocols in the paediatric population and education related to the paediatric trauma resuscitation. Results/Conclusions The current evidence although emerging is still sparse and high-quality studies are needed to shed more light on most of the above domains of resuscitation.
Collapse
|
30
|
Guerado E, Medina A, Mata MI, Galvan JM, Bertrand ML. Protocols for massive blood transfusion: when and why, and potential complications. Eur J Trauma Emerg Surg 2015; 42:283-95. [PMID: 26650716 DOI: 10.1007/s00068-015-0612-y] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2015] [Accepted: 11/23/2015] [Indexed: 12/31/2022]
Abstract
PURPOSE An update paper on massive bleeding after major trauma. A review of protocols to address massive bleeding, and its possible complications, including coagulation abnormalities, complications related to blood storage, immunosuppression and infection, lung injury associated with transfusion, and hypothermia is carried out. METHODS Literature review and discussion with authors' experience. RESULTS Massive bleeding is an acute life-threatening complication of major trauma, and consequently its prompt diagnosis and treatment is of overwhelming importance. Treatment requires rapid surgical management together with the massive infusion of colloid and blood. CONCLUSIONS Since massive transfusion provokes further problems in patients who are already severely traumatized and anaemic, once this course of action has been decided upon, a profound knowledge of its potential complications, careful monitoring and proper follow-up are all essential. To diagnose this bleeding, most authors favour, as the main first choice tool, a full-body CT scan (head to pelvis), in non-critical severe trauma cases. In addition, focused abdominal sonography for trauma (FAST, an acronym that highlights the necessity of rapid performance) is a very important diagnostic test for abdominal and thoracic bleeding. Furthermore, urgent surgical intervention should be undertaken for patients with significant free intraabdominal fluid and haemodynamic instability. Although the clinical situation and the blood haemoglobin concentration are the key factors considered in this rapid decision-making context, laboratory markers should not be based on a single haematocrit value, as its sensitivity to significant bleeding may be very low. Serum lactate and base deficit are very sensitive markers for detecting and monitoring the extent of bleeding and shock, in conjunction with repeated combined measurements of prothrombin time, activated partial thromboplastin time, fibrinogen and platelets.
Collapse
Affiliation(s)
- E Guerado
- Department of Orthopaedic Surgery and Traumatology, Hospital Costa del Sol, University of Malaga, Autovía A-7, Km 187, 29603, Marbella, Malaga, Spain.
| | - A Medina
- Department of Haematology, Hospital Costa del Sol, 29603, Marbella, Spain
| | - M I Mata
- Department of Haematology, Hospital Costa del Sol, 29603, Marbella, Spain
| | - J M Galvan
- Intensive Care Unit, Hospital Costa del Sol, 29603, Marbella, Spain
| | - M L Bertrand
- Department of Orthopaedic Surgery and Traumatology, Hospital Costa del Sol, University of Malaga, Autovía A-7, Km 187, 29603, Marbella, Malaga, Spain
| |
Collapse
|
31
|
Dzik WS, Ziman A, Cohen C, Pai M, Lozano M, Kaufman RM, Delaney M, Selleng K, Murphy MF, Hervig T, Yazer M. Survival after ultramassive transfusion: a review of 1360 cases. Transfusion 2015; 56:558-63. [DOI: 10.1111/trf.13370] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2015] [Revised: 08/31/2015] [Accepted: 08/31/2015] [Indexed: 11/27/2022]
Affiliation(s)
| | - Alyssa Ziman
- Department of Pathology and Laboratory Medicine, Division of Transfusion Medicine; UCLA Medical Center; Los Angeles California
| | - Claudia Cohen
- Lab Medicine and Pathology; University of Minnesota Medical Center; Minneapolis Minnesota
| | - Menaka Pai
- Medicine and Department of Pathology and Molecular Medicine; McMaster University; Hamilton Ontario Canada
| | - Miguel Lozano
- Hemotherapy and Hemostasis; University Clinic Hospital; Barcelona Spain
| | | | - Meghan Delaney
- Laboratory Medicine; University of Washington, and Puget Sound Blood Center; Seattle Washington
| | - Kathleen Selleng
- Institut for Immunology and Transfusion Medicine; Ernst-Moritz-Arndt-University; Greifswald Germany
| | | | - Tor Hervig
- Transfusion Medicine; Haukeland University Hospital; Bergen Norway
| | - Mark Yazer
- Institute for Transfusion Medicine; Pittsburgh Pennsylvania
| | | |
Collapse
|
32
|
Lynch AM, O'Toole TE, Respess M. Transfusion practices for treatment of dogs hospitalized following trauma: 125 cases (2008–2013). J Am Vet Med Assoc 2015; 247:643-9. [DOI: 10.2460/javma.247.6.643] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
|
33
|
Douglas WG, Uffort E, Denning D. Transfusion and Management of Surgical Patients with Hematologic Disorders. Surg Clin North Am 2015; 95:367-77. [DOI: 10.1016/j.suc.2014.11.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
|
34
|
Zeller MP, Al-Habsi KS, Golder M, Walsh GM, Sheffield WP. Plasma and Plasma Protein Product Transfusion: A Canadian Blood Services Centre for Innovation Symposium. Transfus Med Rev 2015; 29:181-94. [PMID: 25862281 DOI: 10.1016/j.tmrv.2015.03.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2015] [Revised: 03/12/2015] [Accepted: 03/13/2015] [Indexed: 12/27/2022]
Abstract
Plasma obtained via whole blood donation processing or via apheresis technology can either be transfused directly to patients or pooled and fractionated into plasma protein products that are concentrates of 1 or more purified plasma protein. The evidence base supporting clinical efficacy in most of the indications for which plasma is transfused is weak, whereas high-quality evidence supports the efficacy of plasma protein products in at least some of the clinical settings in which they are used. Transfusable plasma utilization remains composed in part of applications that fall outside of clinical practice guidelines. Plasma contains all of the soluble coagulation factors and is frequently transfused in efforts to restore or reinforce patient hemostasis. The biochemical complexities of coagulation have in recent years been rationalized in newer cell-based models that supplement the cascade hypothesis. Efforts to normalize widely used clinical hemostasis screening test values by plasma transfusion are thought to be misplaced, but superior rapid tests have been slow to emerge. The advent of non-vitamin K-dependent oral anticoagulants has brought new challenges to clinical laboratories in plasma testing and to clinicians needing to reverse non-vitamin K-dependent oral anticoagulants urgently. Current plasma-related controversies include prophylactic plasma transfusion before invasive procedures, plasma vs prothrombin complex concentrates for urgent warfarin reversal, and the utility of increased ratios of plasma to red blood cell units transfused in massive transfusion protocols. The first recombinant plasma protein products to reach the clinic were recombinant hemophilia treatment products, and these donor-free equivalents to factors VIII and IX are now being supplemented with novel products whose circulatory half-lives have been increased by chemical modification or genetic fusion. Achieving optimal plasma utilization is an ongoing challenge in the interconnected worlds of transfusable plasma, plasma protein products, and recombinant and engineered replacements.
Collapse
Affiliation(s)
- Michelle P Zeller
- Centre for Innovation, Medical Services and Innovation, Canadian Blood Services, Hamilton, Ottawa, Vancouver, Canada; Department of Medicine, McMaster University, Hamilton, Canada
| | - Khalid S Al-Habsi
- Centre for Innovation, Medical Services and Innovation, Canadian Blood Services, Hamilton, Ottawa, Vancouver, Canada; Department of Medicine, McMaster University, Hamilton, Canada
| | - Mia Golder
- Centre for Innovation, Medical Services and Innovation, Canadian Blood Services, Hamilton, Ottawa, Vancouver, Canada
| | - Geraldine M Walsh
- Centre for Innovation, Medical Services and Innovation, Canadian Blood Services, Hamilton, Ottawa, Vancouver, Canada
| | - William P Sheffield
- Centre for Innovation, Medical Services and Innovation, Canadian Blood Services, Hamilton, Ottawa, Vancouver, Canada; Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Canada.
| |
Collapse
|
35
|
Ilancheran A, Rahman F, Mitra B. Indications for blood transfusion following trauma - a pilot study. JOURNAL OF EMERGENCY MEDICINE, TRAUMA AND ACUTE CARE 2015. [DOI: 10.5339/jemtac.2015.4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Background: Indications for blood transfusion during trauma resuscitation remain poorly understood. This study aimed to objectively determine the range of factors that lead to initiation of blood transfusion during trauma resuscitation. Design and method: This was a prospective, observational pilot study. A questionnaire was distributed to all clinicians following any transfusion of packed red blood cells during trauma resuscitation. The questionnaire focused on the clinicians’ opinion regarding the indication for red cell transfusion. Results: Complete data on 37 individual episodes of transfusion initiation in the Emergency Department were collected. The most commonly used pre-hospital factors that influenced initiation of transfusion was a pre-hospital systolic blood pressure (SBP) of < 100 mm Hg (65%), pre-hospital tachycardia (38%) or estimated blood loss of >1 L (30%) by paramedics. On arrival to hospital, the activation of a massive transfusion protocol was the commonest indication for transfusion, followed by a positive FAST examination (43%), low systolic blood pressure (35%), tachycardia (32%) or pallor (35%). Blood tests to guide initiation of transfusion were less commonly used with 9 (24%) patients transfused for a low haemoglobin level and 6 (16%) patients transfused for coagulopathy. Conclusions: A combination of objective pre- and in-hospital vital signs, together with subjective indicators such as pallor and estimation of blood loss guided initiation of transfusion following injury.
Collapse
Affiliation(s)
- Arun Ilancheran
- Emergency & Trauma Centre, The Alfred Hospital, Monash University, Australia
| | - Fatima Rahman
- Emergency & Trauma Centre, The Alfred Hospital, Monash University, Australia
| | - Biswadev Mitra
- Emergency & Trauma Centre, The Alfred Hospital, Monash University, Australia
| |
Collapse
|
36
|
Brown JB, Guyette FX, Neal MD, Claridge JA, Daley BJ, Harbrecht BG, Miller RS, Phelan HA, Adams PW, Early BJ, Peitzman AB, Billiar TR, Sperry JL. Taking the Blood Bank to the Field: The Design and Rationale of the Prehospital Air Medical Plasma (PAMPer) Trial. PREHOSP EMERG CARE 2015; 19:343-50. [PMID: 25658881 DOI: 10.3109/10903127.2014.995851] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Hemorrhage and trauma induced coagulopathy remain major drivers of early preventable mortality in military and civilian trauma. Interest in the use of prehospital plasma in hemorrhaging patients as a primary resuscitation agent has grown recently. Trauma center-based damage control resuscitation using early and aggressive plasma transfusion has consistently demonstrated improved outcomes in hemorrhaging patients. Additionally, plasma has been shown to have several favorable immunomodulatory effects. Preliminary evidence with prehospital plasma transfusion has demonstrated feasibility and improved short-term outcomes. Applying state-of-the-art resuscitation strategies to the civilian prehospital arena is compelling. We describe here the rationale, design, and challenges of the Prehospital Air Medical Plasma (PAMPer) trial. The primary objective is to determine the effect of prehospital plasma transfusion during air medical transport on 30-day mortality in patients at risk for traumatic hemorrhage. This study is a multicenter cluster randomized clinical trial. The trial will enroll trauma patients with profound hypotension (SBP ≤ 70 mmHg) or hypotension (SBP 71-90 mmHg) and tachycardia (HR ≥ 108 bpm) from six level I trauma center air medical transport programs. The trial will also explore the effects of prehospital plasma transfusion on the coagulation and inflammatory response following injury. The trial will be conducted under exception for informed consent for emergency research with an investigational new drug approval from the U.S. Food and Drug Administration utilizing a multipronged community consultation process. It is one of three ongoing Department of Defense-funded trials aimed at expanding our understanding of the optimal therapeutic approaches to coagulopathy in the hemorrhaging trauma patient.
Collapse
|
37
|
Lahkar B, Saikia P, Bora BB. Haemangioma, thrombocytopenia and coagulopathy- kasabach merritt syndrome: an appraisal for anaesthesiologists. J Clin Diagn Res 2015; 9:UL01-2. [PMID: 25738066 DOI: 10.7860/jcdr/2015/10235.5406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2014] [Accepted: 08/29/2014] [Indexed: 11/24/2022]
Affiliation(s)
- Babita Lahkar
- Assistant Professor, Department of Anaesthesiology and Critical Care, Gauhati Medical College and Hospital , Guwahati, Assam, India
| | - Priyam Saikia
- Assistant Professor, Department of Anaesthesiology and Critical Care, Gauhati Medical College and Hospital , Guwahati, Assam, India
| | - Bikash Bhaskar Bora
- Post-Graduate Trainee, Department of Anaesthesiology and Critical Care, Gauhati Medical College and Hospital , Guwahati, Assam, India
| |
Collapse
|
38
|
Pitkänen H, Jouppila A, Mowinckel MC, Lemponen M, Patiwael S, Sandset PM, Lassila R, Brinkman HJM. Enhanced thrombin generation and reduced intact protein S in processed solvent detergent plasma. Thromb Res 2015; 135:167-74. [DOI: 10.1016/j.thromres.2014.10.020] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2014] [Revised: 10/23/2014] [Accepted: 10/27/2014] [Indexed: 11/16/2022]
|
39
|
Espinosa A, Seghatchian J. What is happening? The evolving role of the blood bank in the management of the bleeding patient: The impact of TEG as an early diagnostic predictor for bleeding. Transfus Apher Sci 2014; 51:105-10. [DOI: 10.1016/j.transci.2014.10.017] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
|
40
|
|