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Sethapati VR, Pham TD, Quach T, Nguyen A, Le J, Cai W, Virk MS. Implementation and early outcomes with Pathogen Reduced Cryoprecipitated Fibrinogen Complex. Am J Clin Pathol 2024:aqae073. [PMID: 38967047 DOI: 10.1093/ajcp/aqae073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2024] [Accepted: 05/20/2024] [Indexed: 07/06/2024] Open
Abstract
OBJECTIVES Cryoprecipitated antihemophilic factor (cryo) has been used for fibrinogen replacement in actively bleeding patients, dysfibrinogenemia, and hypofibrinogenemia. Cryo has a shelf life of 4 to 6 hours after thawing and a long turnaround time in issuing the product, posing a major limitation of its use. Recently, the US Food and Drug Administration approved Pathogen Reduced Cryoprecipitated Fibrinogen Complex (INTERCEPT Fibrinogen Complex [IFC]) for the treatment of bleeding associated with fibrinogen deficiency, which can be stored at room temperature and has a shelf life of 5 days after thawing. METHODS We identified locations and specific end users with high cryoprecipitate utilization and waste. We partnered with our blood supplier to use IFC in these locations. We analyzed waste and turnaround time before and after implementation. RESULTS Operative locations had a waste rate that exceeded nonoperative locations (16.7% vs 3%) and were targeted for IFC implementation. IFC was added to our inventory to replace all cryo orders from adult operating rooms, and waste decreased to 2.2% in these locations. Overall waste of cryoprecipitated products across all locations was reduced from 8.8% to 2.4%. The turnaround time for cryoprecipitated products was reduced by 58% from 30.4 minutes to 14.6 minutes. CONCLUSIONS There has been a substantial decrease in waste with improved turnaround time after IFC implementation. This has improved blood bank logistics, improved efficiency of patient care, and reduced costly waste.
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Affiliation(s)
- V Rakesh Sethapati
- Department of Pathology, University of Arkansas for Medical Sciences, Little Rock, AR, US
| | - Tho D Pham
- Stanford Blood Center, Palo Alto, CA, US
| | - Thinh Quach
- Department of Pathology, Stanford University School of Medicine, Stanford, CA, US
| | - Anhthu Nguyen
- Department of Pathology, Stanford University School of Medicine, Stanford, CA, US
| | - Jimmy Le
- Department of Pathology, Stanford University School of Medicine, Stanford, CA, US
| | - Wei Cai
- Department of Pathology, Stanford University School of Medicine, Stanford, CA, US
| | - Mrigender Singh Virk
- Department of Pathology, Stanford University School of Medicine, Stanford, CA, US
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2
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Burnouf T, Epstein J, Faber JC, Smid WM. Stepwise options for preparing therapeutic plasma proteins from domestic plasma in low- and middle-income countries. Vox Sang 2024; 119:102-109. [PMID: 37872819 DOI: 10.1111/vox.13516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2023] [Revised: 08/06/2023] [Accepted: 08/09/2023] [Indexed: 10/25/2023]
Abstract
Industrial plasma fractionation, a complex and highly regulated technology, remains largely inaccessible to many low- and middle-income countries (LMICs). This, combined with the limited availability and high cost of plasma-derived medicinal products (PDMPs), creates deficiency of access to adequate treatment for patients in resource-limited countries, and leads to their suffering. Meanwhile, an increasing number of LMICs produce surplus plasma, as a by-product of red blood cell preparation from whole blood, that is discarded because of the lack of suitability for fractionation. This article reviews pragmatic technological options for processing plasma collected from LMICs into therapies and supports a realistic stepwise approach aligned with recent World Health Organization guidance and initiatives launched by the Working Party for Global Blood Safety of the International Society of Blood Transfusion. When industrial options based on contract or toll plasma fractionation programme and, even more, domestic fractionation facilities require larger volumes of quality plasma than is produced, alternative methods should be considered. In-bag minipool or small-scale production procedures implementable in blood establishments or national service centres are the only realistic options available to gradually reduce plasma wastage, provide safer treatments for patients currently treated with non-pathogen-reduced blood products and concurrently improve Good Manufacturing Practice (GMP) levels with minimum capital investment. As a next step, when the available volume of quality-assured plasma reaches the necessary thresholds, LMICs could consider engaging with an established fractionator in a fractionation agreement or a contract in support of a domestic fractionation facility to improve the domestic PDMP supply and patients' treatment.
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Affiliation(s)
- Thierry Burnouf
- Graduate Institute of Biomedical Materials and Tissue Engineering, College of Biomedical Engineering, Taipei Medical University, Taipei, Taiwan
- International PhD Program in Biomedical Engineering, College of Biomedical Engineering, Taipei Medical University, Taipei, Taiwan
| | | | - Jean-Claude Faber
- Association Luxembourgeoise des Hémophiles, Luxembourg City, Luxembourg
| | - W Martin Smid
- Sanquin Consulting Services, Amsterdam and Academic Institute IDTM, Groningen, The Netherlands
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3
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Dorken-Gallastegi A, Bokenkamp M, Argandykov D, Mendoza AE, Hwabejire JO, Saillant N, Fagenholz PJ, Kaafarani HMA, Velmahos GC, Parks JJ. Optimal dose of cryoprecipitate in massive transfusion following trauma. J Trauma Acute Care Surg 2024; 96:137-144. [PMID: 37335138 DOI: 10.1097/ta.0000000000004060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/21/2023]
Abstract
BACKGROUND While cryoprecipitate (Cryo) is commonly included in massive transfusion protocols for hemorrhagic shock, the optimal dose of Cryo transfusion remains unknown. We evaluated the optimal red blood cell (RBC) to RBC to Cryo ratio during resuscitation in massively transfused trauma patients. METHODS Adult patients in the American College of Surgeon Trauma Quality Improvement Program (2013-2019) receiving massive transfusion (≥4 U of RBCs, ≥1 U of fresh frozen plasma, and ≥1 U of platelets within 4 hours) were included. A unit of Cryo was defined as a pooled unit of 100 mL. The RBC:Cryo ratio was calculated for blood products transfused within 4 hours of presentation. The association between RBC:Cryo and 24-hour mortality was analyzed with multivariable logistic regression adjusting for the volume of RBC, plasma and platelet transfusions, global and regional injury severity, and other relevant variables. RESULTS The study cohort included 12,916 patients. Among those who received Cryo (n = 5,511 [42.7%]), the median RBC and Cryo transfusion volume within 4 hours was 11 U (interquartile range, 7-19 U) and 2 U (interquartile range, 1-3 U), respectively. Compared with no Cryo administration, only RBC:Cryo ratios ≤8:1 were associated with a significant survival benefit, while lower doses of Cryo (RBC:Cryo >8:1) were not associated with decreased 24-hour mortality. Compared with the maximum dose of Cryo administration (RBC:Cryo, 1:1-2:1), there was no difference in 24-hour mortality up to RBC:Cryo of 7:1 to 8:1, whereas lower doses of Cryo (RBC:Cryo, >8:1) were associated with significantly increased 24-hour mortality. CONCLUSION One pooled unit of Cryo (100 mL) per 7 to 8 U of RBCs could be the optimal dose of Cryo in trauma resuscitation that provides a significant survival benefit while avoiding unnecessary blood product transfusions. LEVEL OF EVIDENCE Prognostic and Epidemiologic; Level IV.
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Affiliation(s)
- Ander Dorken-Gallastegi
- From the Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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4
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Eid J, Stahl D. Blood Product Replacement for Postpartum Hemorrhage. Clin Obstet Gynecol 2023; 66:408-414. [PMID: 36730283 DOI: 10.1097/grf.0000000000000766] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Consideration for blood products replacement in postpartum hemorrhage should be given when blood loss exceeds 1.5 L or when an estimated 25% of blood has been lost. In cases of massive hemorrhage, standardized transfusion protocols have been shown to improve maternal morbidity and mortality. Most protocols recommend a balanced transfusion involving a 1:1:1 ratio of packed red blood cells, platelets, and fresh frozen plasma. Alternatives such as cryoprecipitate, fibrinogen concentrate, and prothrombin complex concentrates can be used in select clinical situations. Although transfusion of blood products can be lifesaving, it does have associated risks.
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Affiliation(s)
- Joe Eid
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, The Ohio State University Wexner Medical Center
| | - David Stahl
- Division of Critical Care Medicine, Department of Anesthesiology, The Ohio State University, Columbus, Ohio
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Curry N, Davenport R, Lucas J, Deary A, Benger J, Edwards A, Evans A, Foley C, Green L, Morris S, Thomas H, Brohi K, Stanworth SJ. The CRYOSTAT2 trial: The rationale and study protocol for a multi-Centre, randomised, controlled trial evaluating the effects of early high-dose cryoprecipitate in adult patients with major trauma haemorrhage requiring major haemorrhage protocol activation. Transfus Med 2023; 33:123-131. [PMID: 36321753 DOI: 10.1111/tme.12932] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Revised: 09/05/2022] [Accepted: 10/03/2022] [Indexed: 11/05/2022]
Abstract
OBJECTIVES To describe the protocol for a multinational randomised, parallel, superiority trial, in which patients were randomised to receive early high-dose cryoprecipitate in addition to standard major haemorrhage protocol (MHP), or Standard MHP alone. BACKGROUND Blood transfusion support for trauma-related major bleeding includes red cells, plasma and platelets. The role of concentrated sources of fibrinogen is less clear and has not been evaluated in large clinical trials. Fibrinogen is a key pro-coagulant factor that is essential for stable clot formation. A pilot trial had demonstrated that it was feasible to deliver cryoprecipitate as a source of fibrinogen within 90 min of admission. METHODS Randomisation was via opaque sealed envelopes held securely in participating Emergency Departments or transfusion laboratories. Early cryoprecipitate, provided as 3 pools (equivalent to 15 single units of cryoprecipitate or 6 g fibrinogen supplementation), was transfused as rapidly as possible, and started within 90 min of admission. Participants in both arms received standard treatment defined in the receiving hospital MHP. The primary outcome measure was all-cause mortality at 28 days. Symptomatic thrombotic events including venous thromboembolism and arterial thrombotic events (myocardial infarction, stroke) were collected from randomisation up to day 28 or discharge from hospital. EQ5D-5Land Glasgow Outcome Score were completed at discharge and 6 months. All analyses will be performed on an intention to treat basis, with per protocol sensitivity analysis. RESULTS The trial opened for recruitment in June 2017 and the final patient completed follow-up in May 2022. DISCUSSION This trial will provide firmer evidence to evaluate the effectiveness and cost-effectiveness of early high-dose cryoprecipitate alongside the standard MHP in major traumatic haemorrhage.
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Affiliation(s)
- Nicola Curry
- Oxford UniversityHospitals NHS Foundation Trust, Nuffield Orthopaedic Hospital, Oxford, UK
| | - Ross Davenport
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, UK
| | - Joanne Lucas
- NHS Blood and Transplant Clinical Trials Unit, Cambridge, UK
| | - Alison Deary
- NHS Blood and Transplant Clinical Trials Unit, Cambridge, UK
| | - Jonathan Benger
- Faculty of Health and Applied Sciences, University of the West of England, Bristol, UK
| | - Antoinette Edwards
- Trauma Audit and Research Network, Salford Royal Hospital, Northern Care Alliance NHS Foundation Trust, Salford, UK
| | - Amy Evans
- NHS Blood and Transplant Clinical Trials Unit, Cambridge, UK
| | - Claire Foley
- NHS Blood and Transplant Clinical Trials Unit, Cambridge, UK
| | - Laura Green
- Blizard Institute, Queen Mary University of London, London, UK
- NHS Blood and Transplant and Bart's Health NHS Trust, London, UK
| | - Stephen Morris
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Helen Thomas
- NHS Blood and Transplant Clinical Trials Unit, Bristol, UK
| | - Karim Brohi
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, UK
| | - Simon J Stanworth
- NHS Blood and Transplant and Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford, UK
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Hinton JV, Xing Z, Fletcher CM, Perry LA, Karamesinis A, Shi J, Ramson DM, Penny-Dimri JC, Liu Z, Coulson TG, Smith JA, Segal R, Bellomo R. Cryoprecipitate Transfusion After Cardiac Surgery. Heart Lung Circ 2023; 32:414-423. [PMID: 36528546 DOI: 10.1016/j.hlc.2022.11.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Revised: 11/14/2022] [Accepted: 11/16/2022] [Indexed: 12/23/2022]
Abstract
OBJECTIVES The association of cryoprecipitate transfusion with patient outcomes after cardiac surgery is unclear. We aimed to investigate the predictors of, and outcomes associated with, postoperative cryoprecipitate transfusion in cardiac surgery patients. METHODS We used the Medical Information Mart for Intensive Care III and IV databases. We included adults undergoing cardiac surgery, and propensity score matched cryoprecipitate-treated patients to controls. Using the matched cohort, we investigated the association of cryoprecipitate use with clinical outcomes. The primary outcome was in-hospital mortality. Secondary outcomes were infection, acute kidney injury, intensive care unit length of stay, hospital length of stay, and chest tube output at 2-hour intervals. RESULTS Of 12,043 eligible patients, 283 (2.35%) patients received cryoprecipitate. The median dose was 5.83 units (IQR 4.17-7.24) given at a median first transfusion time of 1.75 hours (IQR 0.73-4.46) after intensive care unit admission. After propensity scoring, we matched 195 cryoprecipitate recipients to 743 controls. Postoperative cryoprecipitate transfusion was not significantly associated with in-hospital mortality (odds ratio [OR] 1.10; 99% confidence interval [CI] 0.43-2.84; p=0.791), infection (OR 0.77; 99% CI 0.45-1.34; p=0.220), acute kidney injury (OR 1.03; 99% CI 0.65-1.62; p=0.876) or cumulative chest tube output (adjusted mean difference 8 hrs post transfusion, 11 mL; 99% CI -104 to 125; p=0.804). CONCLUSIONS Although cryoprecipitate was typically given to sicker patients with more bleeding, its administration was not associated with worse outcomes. Large, multicentred studies are warranted to further elucidate cryoprecipitate's safety profile and patterns of use in cardiac surgery.
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Affiliation(s)
- Jake V Hinton
- Department of Anaesthesia and Pain Management, Royal Melbourne Hospital, Melbourne, Vic, Australia.
| | - Zhongyue Xing
- Department of Anaesthesia and Pain Management, Royal Melbourne Hospital, Melbourne, Vic, Australia
| | - Calvin M Fletcher
- Department of Anaesthesiology and Perioperative Medicine, The Alfred Hospital, Melbourne, Vic, Australia
| | - Luke A Perry
- Department of Anaesthesia and Pain Management, Royal Melbourne Hospital, Melbourne, Vic, Australia; Department of Critical Care, University of Melbourne, Melbourne, Vic, Australia
| | - Alexandra Karamesinis
- Department of Anaesthesia and Pain Management, Royal Melbourne Hospital, Melbourne, Vic, Australia
| | - Jenny Shi
- Department of Anaesthesia and Pain Management, Royal Melbourne Hospital, Melbourne, Vic, Australia
| | - Dhruvesh M Ramson
- Department of Surgery, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Vic, Australia
| | - Jahan C Penny-Dimri
- Department of Surgery, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Vic, Australia
| | - Zhengyang Liu
- Department of Anaesthesia and Pain Management, Royal Melbourne Hospital, Melbourne, Vic, Australia
| | - Tim G Coulson
- Department of Anaesthesiology and Perioperative Medicine, The Alfred Hospital, Melbourne, Vic, Australia; Department of Critical Care, University of Melbourne, Melbourne, Vic, Australia
| | - Julian A Smith
- Department of Surgery, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Vic, Australia; Department of Cardiothoracic Surgery, Monash Health, Melbourne, Vic, Australia
| | - Reny Segal
- Department of Anaesthesia and Pain Management, Royal Melbourne Hospital, Melbourne, Vic, Australia; Department of Critical Care, University of Melbourne, Melbourne, Vic, Australia
| | - Rinaldo Bellomo
- Department of Critical Care, University of Melbourne, Melbourne, Vic, Australia; Department of Intensive Care, Royal Melbourne Hospital, Melbourne, Vic, Australia; Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Vic, Australia
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7
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Gammon RR, Al-Mozain N, Auron M, Bocquet C, Clem S, Gupta GK, Hensch L, Klein N, Lea NC, Mandal S, Pelletier P, Resheidat A, Yossi Schwartz J. Transfusion therapy of neonatal and paediatric patients: They are not just little adults. Transfus Med 2022; 32:448-459. [PMID: 36207985 DOI: 10.1111/tme.12921] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 08/01/2022] [Accepted: 09/11/2022] [Indexed: 11/28/2022]
Abstract
Patient blood management (PBM) strategies are needed in the neonate and paediatric population, given that haemoglobin thresholds used are often higher than recommended by evidence, with exposure of children to potential complications without meaningful benefit. A literature review was performed on the following topics: evidence-based transfusions of blood components and pharmaceutical agents. Other topics reviewed included perioperative coagulation assessment and perioperative PBM. The Transfusion and Anaemia Expertise Initiative (TAXI) consortium published a consensus statement addressing haemoglobin (Hb) transfusion threshold in multiple subsets of patients. A multicentre trial (PlaNeT-2) reported a higher risk of bleeding and death or serious new bleeding among infants who received platelet transfusion at a higher (50 000/μl) compared to a lower (25 000/μl) threshold. Recent data support the use of a restrictive transfusion threshold of 25 000/μl for prophylactic platelet transfusions in preterm neonates. The TAXI-CAB consortium mentioned that in critically ill paediatric patients undergoing invasive procedures outside of the operating room, platelet transfusion might be considered when the platelet count is less than or equal to 20 000/μl and there is no benefit of platelet transfusion when the platelet count is more than 50 000/μl. There are limited controlled studies in paediatric and neonatal population regarding plasma transfusion. Blood conservation strategies to minimise allogenic blood exposure are essential to positive patient outcomes neonatal and paediatric transfusion practices have changed significantly in recent years since randomised controlled trials were published to guide practice. Additional studies are needed in order to provide practice change recommendations.
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Affiliation(s)
| | - Nour Al-Mozain
- King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia.,Whittington Health NHS Trust, London, UK
| | | | - Christopher Bocquet
- Association for the Advancement of Blood and Biotherapies, Bethesda, Maryland, USA
| | - Sam Clem
- American Red Cross, Fort Wayne, Indiana, USA
| | - Gaurav K Gupta
- Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Lisa Hensch
- Baylor College of Medicine and Texas Children's Hospital, Houston, Texas, USA
| | - Norma Klein
- University of California, Davis, California, USA
| | | | | | | | - Ashraf Resheidat
- Baylor College of Medicine and Texas Children's Hospital, Houston, Texas, USA
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8
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Preparation and Storage of Cryoprecipitate Derived from Amotosalen and UVA-Treated Apheresis Plasma and Assessment of In Vitro Quality Parameters. Pathogens 2022; 11:pathogens11070805. [PMID: 35890049 PMCID: PMC9317929 DOI: 10.3390/pathogens11070805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 07/14/2022] [Accepted: 07/14/2022] [Indexed: 11/22/2022] Open
Abstract
Cryoprecipitate is a plasma-derived blood product, enriched for fibrinogen, factor VIII, factor XIII, and von Willebrand factor. Due to infectious risk, the use of cryoprecipitate in Central Europe diminished over the last decades. However, after the introduction of various pathogen-reduction technologies for plasma, cryoprecipitate production in blood centers is a feasible alternative to pharmaceutical fibrinogen concentrate with a high safety profile. In our study, we evaluated the feasibility of the production of twenty-four cryoprecipitate units from pools of two units of apheresis plasma pathogen reduced using amotosalen and ultraviolet light A (UVA) (INTERCEPT® Blood System). The aim was to assess the compliance of the pathogen-reduced cryoprecipitate with the European Directorate for the Quality of Medicines (EDQM) guidelines and the stability of coagulation factors after frozen (≤−25 °C) storage and five-day liquid storage at ambient temperature post-thawing. All pathogen-reduced cryoprecipitate units fulfilled the European requirements for fibrinogen, factor VIII and von Willebrand factor content post-preparation. After five days of liquid storage, content of these factors exceeded the minimum values in the European requirements and the content of other factors was sufficient. Our method of production of cryoprecipitate using pathogen-reduced apheresis plasma in a jumbo bag is feasible and efficient.
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Fibrinogen Supplementation for the Trauma Patient: Should You Choose Fibrinogen Concentrate Over Cryoprecipitate? J Trauma Acute Care Surg 2022; 93:453-460. [PMID: 35838235 DOI: 10.1097/ta.0000000000003728] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Trauma-induced coagulopathy is frequently associated with hypofibrinogenemia. Cryoprecipitate (Cryo), and fibrinogen concentrate (FC) are both potential means of fibrinogen supplementation. The aim of this study was to compare the outcomes of traumatic hemorrhagic patients who received fibrinogen supplementation using FC versus Cryo. METHODS We performed a 2-year (2016-2017) retrospective cohort analysis of the American College of Surgeons (ACS) Trauma Quality Improvement Program database. All adult trauma patients (≥18 years) who received FC or Cryo as an adjunct to resuscitation were included. Patients with bleeding disorders, chronic liver disease, and those on preinjury anticoagulants were excluded. Patients were stratified into those who received FC, and those who received Cryo. Propensity score matching (1:2) was performed. Outcome measures were transfusion requirements, major complications, hospital, and ICU lengths of stay (LOS), and mortality. RESULTS A matched cohort of 255 patients who received fibrinogen supplementation (85 in FC, 170 in Cryo) was analyzed. Overall, the mean age was 41 ± 19 years, 74% were male, 74% were white and median ISS was 26 [22-30]. Compared to the Cryo group, the FC group required less units of packed red blood cells (pRBC), fresh frozen plasma (FFP), and platelets, and had shorter in-hospital and ICU LOS. There were no significant differences between the two groups in terms of major in-hospital complications and mortality. CONCLUSIONS Fibrinogen supplementation in the form of FC for the traumatic hemorrhagic patient is associated with improved outcomes and reduced transfusion requirements as compared to Cryo. Further studies are required to evaluate the optimal method of fibrinogen supplementation in the resuscitation of trauma patients. LEVEL OF EVIDENCE III Therapeutic/Care Management.
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10
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Stanworth SJ, Dowling K, Curry N, Doughty H, Hunt BJ, Fraser L, Narayan S, Smith J, Sullivan I, Green L. A guideline for the haematological management of major haemorrhage: a British Society for Haematology Guideline. Br J Haematol 2022; 198:654-667. [PMID: 35687716 DOI: 10.1111/bjh.18275] [Citation(s) in RCA: 30] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 05/07/2022] [Accepted: 05/09/2022] [Indexed: 12/17/2022]
Affiliation(s)
- Simon J Stanworth
- Transfusion Medicine, NHS Blood and Transplant, Oxford, UK.,Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.,Radcliffe Department of Medicine, University of Oxford, and NIHR Oxford Biomedical Research Centre, Oxford, UK
| | - Kerry Dowling
- Transfusion Laboratory Manager, Southampton University Hospitals NHS Foundation Trust, Southampton, UK
| | - Nikki Curry
- Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.,Radcliffe Department of Medicine, University of Oxford, and NIHR Oxford Biomedical Research Centre, Oxford, UK
| | - Heidi Doughty
- Institute of Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK.,NIHR Surgical Reconstruction and Microbiology Research Centre, Birmingham, UK
| | - Beverley J Hunt
- Department of Haematology, Guy's and St Thomas's Hospital, London, UK
| | - Laura Fraser
- Transfusion Practitioner, NHS Lanarkshire, University Hospital Wishaw, Wishaw, UK.,National Services Scotland/Scottish National Blood Transfusion, Edinburgh, UK
| | - Shruthi Narayan
- Medical director, Serious Hazards of Transfusion, Manchester, UK
| | - Juliet Smith
- Lead Transfusion Practitioner, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Ian Sullivan
- Transfusion Laboratory Manager, Royal Cornwall Hospitals NHS Trust, Truro, UK
| | - Laura Green
- Transfusion Medicine, NHS Blood and Transplant, London, UK.,Barts Health NHS Trust, London, UK.,Blizzard Institute, Queen Mary University of London, London, UK
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11
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Nagrath M, Bince D, Rowsell C, Polintan D, Rezende-Neto J, Towler M. Porcine liver injury model to assess tantalum-containing bioactive glass powders for hemostasis. JOURNAL OF MATERIALS SCIENCE. MATERIALS IN MEDICINE 2022; 33:53. [PMID: 35670885 PMCID: PMC9174136 DOI: 10.1007/s10856-022-06674-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 05/18/2022] [Indexed: 06/15/2023]
Abstract
This study evaluates compositions of tantalum-containing mesoporous bioactive glass (Ta-MBG) powders using a porcine fatal liver injury model. The powders based on (80-x)SiO2-15CaO-5P2O5-xTa2O5 compositions with x = 0 (0Ta/Ta-free), 1 (1Ta), and 5 (5Ta) mol% were made using a sol-gel process. A class IV hemorrhage condition was simulated on the animals; hemodynamic data and biochemical analysis confirmed the life-threatening condition. Ta-MBGs were able to stop the bleeding within 10 min of their application while the bleeds in the absence of any intervention or in the presence of a commercial agent, AristaTM (Bard Davol Inc., Rhode Island, USA) continued for up to 45 min. Scanning electron microscopy (SEM) imaging of the blood clots showed that the presence of Ta-MBGs did not affect clot morphology. Rather, the connections seen between fibrin fibers of the blood clot and Ta-MBG powders point towards the powders' surfaces embracing fibrin. Histopathological analysis of the liver tissue showed 5Ta as the only composition reducing parenchymal hemorrhage and necrosis extent of the tissue after their application. Additionally, 5Ta was also able to form an adherent clot in worst-case scenario bleeding where no adherent clot was seen before the powder was applied. In vivo results from the present study agree with in vitro results of the previous study that 5Ta was the best Ta-MBG composition for hemostatic purposes. Graphical abstract.
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Affiliation(s)
- Malvika Nagrath
- Biomedical Engineering, Faculty of Engineering and Architectural Science (FEAS), Ryerson University, Toronto, M5B 2K3, ON, Canada.
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, M5B 1W8, ON, Canada.
| | - Danielle Bince
- Research Vivarium, St. Michael's Hospital, Toronto, M5B 1W8, ON, Canada
| | - Corwyn Rowsell
- Department of Laboratory Medicine, St. Michael's Hospital, Toronto, M5B 1W8, ON, Canada
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, M5S 1A1, ON, Canada
| | - Deanna Polintan
- Biomedical Engineering, Faculty of Engineering and Architectural Science (FEAS), Ryerson University, Toronto, M5B 2K3, ON, Canada
| | - Joao Rezende-Neto
- Trauma and Acute Care, General Surgery, St. Michael's Hospital, Toronto, M5B 1W8, ON, Canada
- Department of Surgery, University of Toronto, Toronto, M5S 1A1, ON, Canada
| | - Mark Towler
- Biomedical Engineering, Faculty of Engineering and Architectural Science (FEAS), Ryerson University, Toronto, M5B 2K3, ON, Canada
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, M5B 1W8, ON, Canada
- Department of Mechanical and Industrial Engineering, FEAS, Ryerson University, Toronto, M5B 2K3, ON, Canada
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12
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Cryoprecipitate use during massive transfusion: A propensity score analysis. Injury 2022; 53:1972-1978. [PMID: 35241286 DOI: 10.1016/j.injury.2022.02.039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Revised: 02/15/2022] [Accepted: 02/17/2022] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Cryoprecipitate is frequently administered as an adjunct to balanced transfusion in the setting of traumatic hemorrhage. However, civilian studies have not demonstrated a clear survival advantage, and prior observational studies noted selection bias when analyzing cryoprecipitate use. Additionally, due to the logistics involved in cryoprecipitate administration, it is inconsistently implemented alongside standardized massive transfusion protocols. This study aims to evaluate the effects of early cryoprecipitate administration on inpatient mortality in the setting of massive transfusion for exsanguinating trauma and to use propensity score analysis to minimize selection bias. METHODS The registry of an urban level 1 trauma center was queried for adult patients who received at least 6 units of packed red blood cells within 4 h of presentation. Univariate analysis, multiple logistic regression, and propensity score matching were performed. RESULTS 562 patients were identified. Patients with lower median RTS (6.86 (IQR 4.09-7.84) vs 7.6 (IQR 5.97-7.84), P<0.01), decreased Glasgow coma scale (12 (IQR 4-15) vs 15 (IQR 10-15), P<0.01), and increased lactate (7.5 (IQR 4.3-10.2) vs 4.9 (IQR 3.1-7.2), P<0.01) were more commonly administered cryoprecipitate. Mortality was greater among those who received cryoprecipitate (40.2% vs 23.7%, p<0.01) on univariate analysis. Neither multiple logistic regression (OR 0.917; 95% confidence interval 0.462-1.822; p = 0.805) nor propensity score matching (average treatment effect on the treated 2.3%, p = 0.77) revealed that cryoprecipitate administration was associated with a difference in inpatient mortality. CONCLUSIONS Patients receiving cryoprecipitate within 4 h of presentation were more severely injured at presentation and had increased inpatient mortality. Multivariable logistic regression and propensity score analysis failed to show that early administration of cryoprecipitate was associated with survival benefit for exsanguinating trauma patients. The prospect of definitively assessing the utility of cryoprecipitate in exsanguinating hemorrhage warrants prospective investigation.
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Hensley NB, Mazzeffi MA. Pro-Con Debate: Fibrinogen Concentrate or Cryoprecipitate for Treatment of Acquired Hypofibrinogenemia in Cardiac Surgical Patients. Anesth Analg 2021; 133:19-28. [PMID: 34127586 DOI: 10.1213/ane.0000000000005513] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Cryoprecipitate has been the gold standard for treating acquired hypofibrinogenemia in cardiac surgery for nearly 50 years. More recently, fibrinogen concentrate has been used off-label in the United States and is the standard in European countries and Canada to treat the acquired hypofibrinogenemia during cardiac surgery. Fibrinogen concentrate has multiple potential advantages including rapid reconstitution, greater dose predictability, viral inactivation during processing, and reduced transfusion-related adverse events. However, because fibrinogen concentrate lacks the other components contained in the cryoprecipitate, it may not be the "ideal" product for replacing fibrinogen in all cardiac surgical patients, particularly those with longer cardiopulmonary bypass duration. In this Pro-Con commentary article, we discuss the advantages and disadvantages of using fibrinogen concentrate and cryoprecipitate to treat acquired hypofibrinogenemia in cardiac surgical patients.
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Affiliation(s)
- Nadia B Hensley
- From the Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Michael A Mazzeffi
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, Maryland
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14
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Abstract
PURPOSE OF REVIEW Recent advances in the understanding of the pathophysiological processes associated with traumatic haemorrhage and trauma-induced coagulopathy (TIC) have resulted in improved outcomes for seriously injured trauma patients. However, a significant number of trauma patients still die from haemorrhage. This article reviews the role of fibrinogen in normal haemostasis, the effect of trauma and TIC on fibrinogen levels and current evidence for fibrinogen replacement in the management of traumatic haemorrhage. RECENT FINDINGS Fibrinogen is usually the first factor to reach critically low levels in traumatic haemorrhage and hypofibrinogenaemia after severe trauma is associated with increased risk of massive transfusion and death. It is postulated that the early replacement of fibrinogen in severely injured trauma patients can improve outcomes. There is, however, a paucity of evidence to support this, and in addition, there is little evidence to support or refute the effects of cryoprecipitate or fibrinogen concentrate for fibrinogen replacement. SUMMARY The important role fibrinogen plays in haemostasis and effective clot formation is clear. A number of pilot trials have investigated different strategies for fibrinogen replacement in severe trauma. These trials have formed the basis of several large-scale phase III trials, which, cumulatively will provide a firm evidence base to harmonise worldwide clinical management of severely injured trauma patients with major haemorrhage.
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15
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Shajan A, George N, Gilvaz S, Abraham SV. Afibrinogenemia Diagnosed During Pregnancy Successfully Managed with Targeted Cryoprecipitate Transfusion: A Case Report. J Obstet Gynaecol India 2021; 71:191-196. [PMID: 34149224 PMCID: PMC8166989 DOI: 10.1007/s13224-020-01389-3] [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: 05/18/2020] [Accepted: 10/21/2020] [Indexed: 10/23/2022] Open
Abstract
BACKGROUND We report a case of afibrinogenemia in a lady, which was detected for the first time during her pregnancy. CASE A 24-year-old G4A3 was referred as a case of vaginal bleeding, after a cervical cerclage at 14 weeks of gestation. Elastometry targeted correction of coagulopathy was done initially, and targeted cryoprecipitate transfusion was done to maintain her gestation. She underwent induced vaginal delivery at 34 weeks of gestation. Fourteen days postpartum, the mother and child were discharged home well. CONCLUSION Coagulation factor deficiency should be considered as a rare cause for RPL. Serum fibrinogen level of 50-100 mg/dl during pregnancy seems to be a safe and adequate target to maintain in pregnant patients with afibrinogenemia.
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Affiliation(s)
- Athulya Shajan
- Department of Obstetrics and Gynaecology, Jubilee Mission Medical College and Research Institute, Thrissur, Kerala India
| | - Neetha George
- Department of Obstetrics and Gynaecology, Jubilee Mission Medical College and Research Institute, Thrissur, Kerala India
| | - Sareena Gilvaz
- Department of Obstetrics and Gynaecology, Jubilee Mission Medical College and Research Institute, Thrissur, Kerala India
| | - Siju V. Abraham
- Department of Emergency Medicine, Jubilee Mission Medical College and Research Institute, Thrissur, Kerala India
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16
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Thomas KA, Shea SM, Spinella PC. Effects of pathogen reduction technology and storage duration on the ability of cryoprecipitate to rescue induced coagulopathies in vitro. Transfusion 2021; 61:1943-1954. [PMID: 33755208 PMCID: PMC8252673 DOI: 10.1111/trf.16376] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Revised: 02/19/2021] [Accepted: 03/09/2021] [Indexed: 12/16/2022]
Abstract
Background Fibrinogen concentrates and cryoprecipitate are currently used for fibrinogen supplementation in bleeding patients with dysfibrinogenemia. Both products provide an abundant source of fibrinogen but take greater than 10 min to prepare for administration. Fibrinogen concentrates lack coagulation factors (i.e., factor VIII [FVIII], factor XIII [FXIII], von Willebrand factor [VWF]) important for robust hemostatic function. Cryoprecipitate products contain these factors but have short shelf lives (<6 h). Pathogen reduction (PR) of cryoprecipitate would provide a shelf‐stable immediately available adjunct containing factors important for rescuing hemostatic dysfunction. Study Design and Methods Hemostatic adjunct study products were psoralen‐treated PR‐cryoprecipitated fibrinogen complex (PR‐Cryo FC), cryoprecipitate (Cryo), and fibrinogen concentrates (FibCon). PR‐Cryo FC and Cryo were stored for 10 days at 20–24°C. Adjuncts were added to coagulopathies (dilutional, 3:7 whole blood [WB]:normal saline; or lytic, WB + 75 ng/ml tissue plasminogen activator), and hemostatic function was assessed by rotational thromboelastometry and thrombin generation. Results PR of cryoprecipitate did not reduce levels of FVIII, FXIII, or VWF. PR‐Cryo FC rescued dilutional coagulopathy similarly to Cryo, while generating significantly more thrombin than FibCon, which also rescued dilutional coagulopathy. Storage out to 10 days at 20–24°C did not diminish the hemostatic function of PR‐Cryo FC. Discussion PR‐Cryo FC provides similar and/or improved hemostatic rescue compared to FibCon in dilutional coagulopathies, and this rescue ability is stable over 10 days of storage. In hemorrhaging patients, where every minute delay is associated with a 5% increase in mortality, the immediate availability of PR‐Cryo FC has the potential to improve outcomes.
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Affiliation(s)
- Kimberly A Thomas
- Department of Pediatrics, Division of Critical Care, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Susan M Shea
- Department of Pediatrics, Division of Critical Care, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Philip C Spinella
- Department of Pediatrics, Division of Critical Care, Washington University School of Medicine, St. Louis, Missouri, USA
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17
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Use of fibrinogen concentrate for trauma-related bleeding: A systematic-review and meta-analysis. J Trauma Acute Care Surg 2021; 89:1212-1224. [PMID: 32890340 DOI: 10.1097/ta.0000000000002920] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Trauma-induced coagulopathy contributes to significant morbidity and mortality in patients who experience trauma-related bleeding. This study aimed to synthesize the evidence supporting the efficacy and safety of preemptive and goal-directed fibrinogen concentrate (FC) in the management of trauma-related hemorrhage. METHODS PubMed, Medline, EMBASE, Web of Science, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, ClinicalTrials.gov, and the WHO International Clinical Trials Registry Platform were systematically searched. All trial designs, except individual case reports, which evaluated the preemptive or goal-directed use of FC for trauma-related bleeding/coagulopathy, in patients older than 16 years, were included in the systematic review. For the included randomized controlled trials comparing FC with control, meta-analysis was performed and a risk-of bias-assessment was completed using the Cochrane Methodology and Preferred Reporting Items Systematic Reviews and Meta-analysis guidelines. RESULTS A total of 2,743 studies were identified; 26 were included in the systematic review, and 5 randomized controlled trials (n = 238) were included in the meta-analysis. For the primary outcome of mortality, there was no statistically significant difference between the groups, with 22% and 23.4% in the FC and comparator arms, respectively (risk ratio, 1.00 [95% confidence interval, 0.39 to 2.56]; p = 0.99). In addition, there was no statistical difference between FC and control in packed red blood cell, fresh frozen plasma, or platelet transfusion requirements, and thromboembolic events. Overall, the quality of evidence was graded as low to moderate because of concerns with risk of bias, imprecision, and inconsistency. CONCLUSION Further high-quality, adequately powered studies are needed to assess the impact of FC in trauma, with a focus on administration as early as possible from the point of entry into the trauma system of care. LEVEL OF EVIDENCE Systematic review and Meta-analysis, level II.
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18
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Evans BA, Kamyszek RW, Piegore M, Stoner K, Fuller M, Welsby IJ, Mooberry M. Global sources of cryoprecipitate demonstrate variability in coagulant factor levels and functional hemostasis. Blood Coagul Fibrinolysis 2021; 32:87-102. [PMID: 33186132 DOI: 10.1097/mbc.0000000000000982] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Cryoprecipitate (cryo) is a plasma-derived blood product utilized during trauma resuscitation, surgery, and other major bleeding. Although local quality control metrics exist, inherent donor variability, and processing may confer differences in hemostatic effect between sources. The purposes of this study were to quantify procoagulant content in three global sources of cryo and evaluate their functional hemostatic effect. In this Institutional Review Board exempt study, 24 units of group A cryo from three different sources, American Red Cross single donor and pooled donor, Australian Red Cross single donor, Southwestern United States single donor, and Southwest pooled donor, were evaluated. Procoagulant factors were quantified from each source using ELISA and automated clot-based assays. Functional hemostasis was evaluated using rotational Thromboelastometry (ROTEM). Microparticles isolated from cryo units were enumerated and evaluated for cellular origin by flow cytometry, as well as their capacity to support thrombin generation. Southwestern United States single donor units demonstrated highest levels of fibrinogen, fibronectin, factor VIII, and von Willebrand factor in the selected units. In the coagulopathy model, successive doses from all cryo units were significantly correlated to decreasing coagulation time (P = 0.0100), and increasing maximum clot firmness (P = 0.0002) and alpha angle (P = 0.0009). Southwest pooled donor demonstrated significantly shorter coagulation time at all three doses (P = 0.02) than other sources. Microparticles support prothrombinase activity and thrombin generation. In this study of global cryo sources, procoagulant activity and in-vitro clot formation varied by source. This could be explained by variance in production and storage protocols. Further study is warranted to assess functional variance in cryo to optimize and standardize the use of cryo products.
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Affiliation(s)
- Brooke A Evans
- Department of Anesthesiology, Duke University School of Medicine, Durham
| | - Reed W Kamyszek
- Department of Anesthesiology, Duke University School of Medicine, Durham
| | - Mark Piegore
- UNC Department of Medicine, Hematology/Oncology, UNC Medical Center, Chapel Hill
| | | | | | - Ian J Welsby
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina, USA
| | - Micah Mooberry
- UNC Department of Medicine, Hematology/Oncology, UNC Medical Center, Chapel Hill
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19
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Winearls J, Wullschleger M, Wake E, McQuilten Z, Reade M, Hurn C, Ryan G, Trout M, Walsham J, Holley A, George S, Dyer W, McCullough J, Keijzers G, Fraser J, Presneill J, Campbell D. Fibrinogen Early In Severe Trauma studY (FEISTY): results from an Australian multicentre randomised controlled pilot trial. CRIT CARE RESUSC 2021; 23:32-46. [PMID: 38046391 PMCID: PMC10692540 DOI: 10.51893/2021.1.oa3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background: Haemorrhage is a major cause of death in severe trauma. Fibrinogen plays a critical role in maintaining haemostasis in traumatic haemorrhage, and early replacement using fibrinogen concentrate (FC) or cryoprecipitate (Cryo) is recommended by several international trauma guidelines. Limited evidence supports one product over the other, with widespread geographic and institutional variation in practice. Two previous trials have investigated the feasibility of rapid FC administration in severely injured trauma patients, with conflicting results. Objective: To compare the time to fibrinogen replacement using FC or Cryo in severely injured trauma patients with major haemorrhage and hypofibrinogenaemia. Design, setting, patients and interventions: A multicentre controlled pilot trial in which adult trauma patients with haemorrhage were randomly assigned (1:1) to receive FC or Cryo for fibrinogen replacement, guided by FIBTEM A5 (functional fibrinogen assessment at 5 minutes after clot formation, using rotational thromboelastometry). Main outcome measures: The primary outcome was time to commencement of fibrinogen replacement. Secondary outcomes included effects of the intervention on plasma fibrinogen levels and clinical outcomes including transfusion requirements and mortality. Results: Of the 100 randomly assigned patients, 62 were hypofibrinogenaemic and received the intervention (n = 37) or Cryo (n = 25). Median (interquartile range [IQR]) time to delivery of FC was 29 min (23-40 min) compared with 60 min (40-80 min) for Cryo (P = 0.0001). All 62 patients were hypofibrinogenaemic before receiving FC or Cryo (FC: median FIBTEM A5, 8 mm [IQR, 7-9 mm]; Cryo: median FIBTEM A5, 9 mm [IQR, 5-10 mm]). In the FC arm patients received a median of 3 g FC (IQR, 2-4 g), and in the Cryo arm patients received a median of 8 units of Cryo (IQR, 8-14 units). Restoration of fibrinogen levels was achieved in both arms after the intervention. Blood product transfusion, fluid resuscitation and thromboembolic complications were similar in both arms. Overall mortality was 15.3%, with more deaths in the FC arm. Conclusion: Fibrinogen replacement in severely injured trauma patients with major haemorrhage and hypofibrinogenaemia was achieved substantially faster using FC compared with Cryo. Fibrinogen levels increased appropriately using either product. The optimal method for replacing fibrinogen in traumatic haemorrhage is controversial. Our results will inform the design of a larger trial powered to assess patient-centred outcomes.
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Affiliation(s)
- James Winearls
- Intensive Care Unit, Gold Coast University Hospital, Gold Coast, QLD, Australia
- School of Medicine, University of Queensland, Brisbane, QLD, Australia
- School of Medical Sciences, Griffith University, Gold Coast, QLD, Australia
- St Andrews War Memorial Hospital Brisbane, QLD, Australia
| | | | - Elizabeth Wake
- Trauma Service, Gold Coast University Hospital, Gold Coast, QLD, Australia
| | - Zoe McQuilten
- Transfusion Research Unit, Monash University, Melbourne, VIC, Australia
- Monash Health, Melbourne, VIC, Australia
| | - Michael Reade
- Military Medicine and Surgery, Joint Health Command, Australian Defence Force
- Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
- Royal Brisbane and Women’s Hospital, Brisbane, QLD, Australia
| | - Catherine Hurn
- School of Medicine, University of Queensland, Brisbane, QLD, Australia
- Royal Brisbane and Women’s Hospital, Brisbane, QLD, Australia
| | - Glenn Ryan
- School of Medicine, University of Queensland, Brisbane, QLD, Australia
- Princess Alexandra Hospital, Brisbane, QLD, Australia
| | - Melita Trout
- Townsville Hospital, Townsville, QLD, Australia
- Faculty of Medicine, James Cook University, Townsville, QLD, Australia
| | - James Walsham
- School of Medicine, University of Queensland, Brisbane, QLD, Australia
- Princess Alexandra Hospital, Brisbane, QLD, Australia
| | - Anthony Holley
- School of Medicine, University of Queensland, Brisbane, QLD, Australia
- Royal Brisbane and Women’s Hospital, Brisbane, QLD, Australia
| | - Shane George
- School of Medicine, University of Queensland, Brisbane, QLD, Australia
- Emergency Department and Children’s Critical Care Service, Gold Coast University Hospital, Gold Coast, QLD, Australia
- Paediatric Critical Care Research Group, Child Health Research Centre, University of Queensland, Brisbane, QLD, Australia
| | | | - James McCullough
- Intensive Care Unit, Gold Coast University Hospital, Gold Coast, QLD, Australia
| | - Gerben Keijzers
- Intensive Care Unit, Gold Coast University Hospital, Gold Coast, QLD, Australia
- School of Medical Sciences, Griffith University, Gold Coast, QLD, Australia
- Faculty of Health Sciences and Medicine, Bond University, Gold Coast, QLD, Australia
| | - John Fraser
- School of Medicine, University of Queensland, Brisbane, QLD, Australia
- Critical Care Research Group, Prince Charles Hospital, Brisbane, QLD, Australia
| | - Jeffrey Presneill
- Intensive Care Unit, Royal Melbourne Hospital, Melbourne, VIC, Australia
- University of Melbourne, Melbourne, VIC, Australia
| | - Don Campbell
- Trauma Service, Gold Coast University Hospital, Gold Coast, QLD, Australia
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20
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Variations and obstacles in the use of coagulation factor concentrates for major trauma bleeding across Europe: outcomes from a European expert meeting. Eur J Trauma Emerg Surg 2021; 48:763-774. [PMID: 33399876 PMCID: PMC7782571 DOI: 10.1007/s00068-020-01563-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Accepted: 11/19/2020] [Indexed: 12/24/2022]
Abstract
Purpose Trauma is a leading cause of mortality, with major bleeding and trauma-induced coagulopathy (TIC) contributing to negative patient outcomes. Treatments for TIC include tranexamic acid (TXA), fresh frozen plasma (FFP), and coagulation factor concentrates (CFCs, e.g. prothrombin complex concentrates [PCCs] and fibrinogen concentrate [FCH]). Guidelines for TIC management vary across Europe and a clear definition of TIC is still lacking. Methods An advisory board involving European trauma experts was held on 02 February 2019, to discuss clinical experience in the management of trauma-related bleeding and recommendations from European guidelines, focusing on CFC use (mainly FCH). This review summarises the discussions, including TIC definitions, gaps in the guidelines that affect their implementation, and barriers to use of CFCs, with suggested solutions. Results A definition of TIC, which incorporates clinical (e.g. severe bleeding) and laboratory parameters (e.g. low fibrinogen) is suggested. TIC should be treated immediately with TXA and FCH/red blood cells; subsequently, if fibrinogen ≤ 1.5 g/L (or equivalent by viscoelastic testing), treatment with FCH, then PCC (if bleeding continues) is suggested. Fibrinogen concentrate, and not FFP, should be administered as first-line therapy for TIC. Several initiatives may improve TIC management, with improved medical education of major importance; generation of new and stronger data, simplified clinical practice guidance, and improved access to viscoelastic testing are also critical factors. Conclusions Management of TIC is challenging. A standard definition of TIC, together with initiatives to facilitate effective CFC administration, may contribute to improved patient care and outcomes.
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21
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Huisman EJ, Crighton GL. Pediatric Fibrinogen PART I-Pitfalls in Fibrinogen Evaluation and Use of Fibrinogen Replacement Products in Children. Front Pediatr 2021; 9:617500. [PMID: 33968842 PMCID: PMC8097151 DOI: 10.3389/fped.2021.617500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 02/26/2021] [Indexed: 11/13/2022] Open
Abstract
Fibrinogen is a key coagulation protein, playing a critical role in hemostasis. It is the first factor to decrease to critical levels during bleeding. Hypofibrinogenemia is an important risk factor for bleeding in clinical settings, including pediatric surgery. Yet, the optimal measurement of fibrinogen levels is subject to debate, as is the critical threshold for intervention. Fibrinogen replacement may be provided by cryoprecipitate and fibrinogen concentrate. Whilst both products contain fibrinogen, they are not equivalent, each has its own advantages and disadvantages, especially for pediatric use. Unfortunately, medical literature to support fibrinogen replacement in children is limited. In this article we review the current diagnostic tools to measure fibrinogen, with respect to their use in the pediatric critical care setting. Secondly, we evaluate the different fibrinogen replacement therapies, focusing on cryoprecipitate and fibrinogen concentrate and examine their individual product characteristics, associated risks and benefits, different dosing strategies and specific pitfalls for use in children. We summarize by highlighting current knowledge gaps and areas for future research.
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Affiliation(s)
- Elise J Huisman
- Department of Hematology, Erasmus Medical Center (MC)-Sophia Children's Hospital, Rotterdam, Netherlands.,Department of Clinical Chemistry and Blood Transfusion, Erasmus Medical Center (MC), Rotterdam, Netherlands.,Department of Transfusion Medicine, Sanquin Blood Supply, Amsterdam, Netherlands
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22
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Siemens K, Hunt BJ, Harris J, Nyman AG, Parmar K, Tibby SM. Individualized, Intraoperative Dosing of Fibrinogen Concentrate for the Prevention of Bleeding in Neonatal and Infant Cardiac Surgery Using Cardiopulmonary Bypass (FIBCON): A Phase 1b/2a Randomized Controlled Trial. Circ Cardiovasc Interv 2020; 13:e009465. [PMID: 33213194 DOI: 10.1161/circinterventions.120.009465] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Mediastinal bleeding is common following pediatric cardiopulmonary bypass surgery for congenital heart disease. Fibrinogen concentrate (FC) represents a potential therapy for preventing bleeding. METHODS We performed a single-center, phase 1b/2a, randomized controlled trial on infants 2.5 to 12 kg undergoing cardiopulmonary bypass surgery, aimed at (1) demonstrating the feasibility of an intraoperative point-of-care test, rotational thromboelastometry, to screen out patients at low risk of postoperative bleeding and then guide individualized FC dosing in high-risk patients and (2) determining the dose, safety, and efficacy of intraoperative FC supplementation. Screening occurred intraoperatively 1-hour before bypass separation using the rotational thromboelastometry variable fibrinogen thromboelastometry maximum clot firmness (FibTEM-MCF; fibrinogen contribution to clot firmness). If FibTEM-MCF ≥7 mm, patients entered the monitoring cohort. If FibTEM-MCF ≤6 mm, patients were randomized to receive FC/placebo (2:1 ratio). Individualized FC dose calculation included weight, bypass circuit volume, hematocrit, and intraoperative measured and desired FibTEM-MCF. The coprimary outcomes, measured 5 minutes post-FC administration were FibTEM-MCF (desired range, 8-13 mm) and fibrinogen levels (desired range, 1.5-2.5 g/L). Secondary outcomes were thrombosis and thrombosis-related major complications and postoperative 24-hour mediastinal blood loss. RESULTS We enrolled 111 patients (cohort, n=21; FC, n=60; placebo, n=30); mean (SD) age, 6.4 months (5.8); weight, 5.9 kg (2.0). Intraoperative rotational thromboelastometry screening effectively excluded low-risk patients, in that none in the cohort arm (FibTEM-MCF, ≥7 mm) demonstrated clinically significant early postoperative bleeding (>10 mL/kg per 4 hours). Among randomized patients, the median (range) FC administered dose was 114 mg/kg (51-218). Fibrinogen levels increased from a mean (SD) of 0.91 (0.22) to 1.7 g/L (0.41). The postdose fibrinogen range was 1.2 to 3.3 g/L (72% within the desired range). The corresponding FibTEM-MCF values were as follows: pre-dose, 5.3 mm (1.9); post-dose, 13 mm (3.2). Ten patients (8 FC and 2 placebo) exhibited 12 possible thromboses; none were clearly related to FC. There was an overall difference in mean (SD) 24-hour mediastinal drain loss: cohort, 12.6 mL/kg (6.4); FC, 11.6 mL/kg (5.2); placebo, 17.1 mL/kg (14.3; ANOVA P=0.02). CONCLUSIONS Intraoperative, individualized dosing of FC appears feasible. The need for individualized dosing is supported by the finding that a 4-fold variation in FC dose is required to achieve therapeutic fibrinogen levels. Registration: URL: https://eudract.ema.europa.eu/; Unique identifier: 2013-003532-68. URL: https://www.isrctn.com/; Unique identifier: 50553029.
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Affiliation(s)
- Kristina Siemens
- Department of Paediatric Intensive Care, Evelina London Children's Hospital, United Kingdom (K.S., J.H., A.G.N., S.M.T.)
| | - Beverley J Hunt
- Department of Haematology, St Thomas' Hospital, London, United Kingdom (B.J.H., K.P.)
| | - Julia Harris
- Department of Paediatric Intensive Care, Evelina London Children's Hospital, United Kingdom (K.S., J.H., A.G.N., S.M.T.)
| | - Andrew G Nyman
- Department of Paediatric Intensive Care, Evelina London Children's Hospital, United Kingdom (K.S., J.H., A.G.N., S.M.T.)
| | - Kiran Parmar
- Department of Haematology, St Thomas' Hospital, London, United Kingdom (B.J.H., K.P.)
| | - Shane M Tibby
- Department of Paediatric Intensive Care, Evelina London Children's Hospital, United Kingdom (K.S., J.H., A.G.N., S.M.T.)
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23
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Cushing MM, Haas T, Karkouti K, Callum J. Which is the preferred blood product for fibrinogen replacement in the bleeding patient with acquired hypofibrinogenemia-cryoprecipitate or fibrinogen concentrate? Transfusion 2020; 60 Suppl 3:S17-S23. [PMID: 32478877 DOI: 10.1111/trf.15614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Revised: 11/12/2019] [Accepted: 11/12/2019] [Indexed: 11/28/2022]
Abstract
The importance of the targeted treatment of acquired hypofibrinogenemia during hemorrhage with a concentrated fibrinogen product (either cryoprecipitate or fibrinogen concentrate) cannot be underestimated. Fibrinogen concentrate is a pathogen inactivated, pooled product that offers a highly purified single factor concentrate. Cryoprecipitate is a pooled product that comes with a spectrum of other coagulation factors which may further enhance (additional procoagulant effect) or even disturb (prothrombotic risk) hemostasis. The pros and cons of each product are discussed.
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Affiliation(s)
- Melissa M Cushing
- Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York, New York
| | - Thorsten Haas
- Department of Anesthesia, Zurich University Children's Hospital, Zurich, Switzerland
| | - Keyvan Karkouti
- Peter Munk Cardiac Centre, University Health Network, Toronto, Canada.,Department of Anesthesia and Pain Management, University Health Network, Sinai Health System, Women's College Hospital, University of Toronto, Toronto, Canada
| | - Jeannie Callum
- Department of Laboratory Medicine and Molecular Diagnostics, Sunnybrook Health Sciences Centre, Toronto, Canada.,Laboratory Medicine Program, University Health Network, Toronto, Canada.,Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Canada
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Nair PM, Rendo MJ, Reddoch-Cardenas KM, Burris JK, Meledeo MA, Cap AP. Recent advances in use of fresh frozen plasma, cryoprecipitate, immunoglobulins, and clotting factors for transfusion support in patients with hematologic disease. Semin Hematol 2020; 57:73-82. [PMID: 32892846 PMCID: PMC7384412 DOI: 10.1053/j.seminhematol.2020.07.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Indexed: 02/07/2023]
Abstract
Hematologic diseases include a broad range of acquired and congenital disorders, many of which affect plasma proteins that control hemostasis and immune responses. Therapeutic interventions for these disorders include transfusion of plasma, cryoprecipitate, immunoglobulins, or convalescent plasma-containing therapeutic antibodies from patients recovering from infectious diseases, as well as concentrated pro- or anticoagulant factors. This review will focus on recent advances in the uses of plasma and its derivatives for patients with acquired and congenital hematologic disorders.
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Affiliation(s)
- Prajeeda M. Nair
- United States Army Institute of Surgical Research, JBSA Fort Sam Houston, TX, USA
| | - Matthew J. Rendo
- San Antonio Military Medical Center, JBSA Fort Sam Houston, TX, USA
| | | | - Jason K. Burris
- San Antonio Military Medical Center, JBSA Fort Sam Houston, TX, USA
| | - Michael A. Meledeo
- United States Army Institute of Surgical Research, JBSA Fort Sam Houston, TX, USA
| | - Andrew P. Cap
- United States Army Institute of Surgical Research, JBSA Fort Sam Houston, TX, USA,Uniformed Services University, Bethesda, MD, USA,Corresponding author. Andrew P. Cap, MD, PhD, United States Army Institute of Surgical Research, 3650 Chambers Pass, JBSA Fort Sam Houston, TX 78234. Tel.: +1-210-539-4858 (office), +1-210-323-6908 (mobile)
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25
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Kim CH, Simmons SC, Wattar SF, Azad A, Pham HP. Potential impact of a delayed ADAMTS13 result in the treatment of thrombotic microangiopathy: an economic analysis. Vox Sang 2020; 115:433-442. [PMID: 32227485 DOI: 10.1111/vox.12912] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2019] [Revised: 01/23/2020] [Accepted: 02/24/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND A pre-plasma exchange ADAMTS13 measurement differentiates thrombotic thrombocytopenic purpura (TTP) from other forms of thrombotic microangiopathy (TMA). Given that many hospitals do not perform the ADAMTS13 assay in-house and that the turnaround time (TAT) differs among reference laboratories, we performed an analysis investigating the potential impact of a delay in obtaining the results on the healthcare system. METHODS An economic model was developed to estimate the impact of a delay in obtaining the pretreatment ADAMTS13 results on patients admitted with TMA with cost (US dollars) as the primary outcome. Incremental cost-effectiveness ratio (ICER) as a composite outcome was calculated from both cost and life days [LDs], an effectiveness surrogate marker. Model parameters were gathered from the medical literature, except for the institutional cost of the ADAMTS13 test. RESULTS In patients with TMA, during the 6-day study period, the incremental cost to the healthcare system ranged from approximately $4155 to $5123 for every 1-day delay in obtaining the pre-exchange ADAMTS13 results with virtually no change in the effectiveness marker. The ICER composite outcome established the cost-effectiveness of having a fast TAT for pre-exchange ADAMTS13 results. Probabilistic sensitivity analyses also confirmed the robustness of the model. CONCLUSIONS In patients with clinical presentations of TMAs, having a rapid TAT for pre-exchange ADAMTS13 measurement appeared to be cost-effective. If testing cannot be performed in-house, then our findings support the necessity of contracting with a reference laboratory that can reliably provide the result, preferably within 1 day of admission.
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Affiliation(s)
- Chong H Kim
- Department of Clinical Pharmacy, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Sierra C Simmons
- Department of Pathology, Michigan Pathology Specialists, Spectrum Health Hospitals, Grand Rapids, MI, USA
| | - Sarah F Wattar
- Department of Pathology, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Ameneh Azad
- Department of Pathology, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Huy P Pham
- Department of Pathology, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
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26
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Kim CH, Simmons SC, Wang D, Najafzadeh P, Azad A, Pham HP. An economic analysis of different treatments for bleeding in patients with acquired haemophilia. Vox Sang 2019; 115:192-199. [PMID: 31879973 DOI: 10.1111/vox.12877] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2019] [Revised: 11/07/2019] [Accepted: 11/30/2019] [Indexed: 01/19/2023]
Abstract
BACKGROUND Acquired haemophilia A (AHA), with potentially high risk of morbidity and mortality, occurs as a result of inhibitors against factor VIII. Bleeding due to AHA can be treated with activated prothrombin complex concentrate (aPCC), recombinant activated factor VII (rFVIIa) or recently, recombinant porcine-sequence factor VIII (rpFVIII). We extended our previous cost-effectiveness analysis (CEA) comparing rpFVIII against the available traditional options. METHODS For high-titred, haemorrhaging AHA patients treated with either aPCC, rFVIIa or rpFVIII, over the course of 6-days, a Markov simulation was conducted to evaluate the outcomes when these patients transitioned into any of the four following health states: (1) continuous bleeding, (2) thrombosis, (3) stop bleeding and (4) death, with states (2), (3) and (4) modelled as absorbing states. All model parameters were obtained from the medical literature, except the costs of aPCC, rFVIIa and the factor VIII assay, which came from our institutional data. RESULTS Excluding the cost of the initial treatment on day 0, the total subsequent treatment cost of rFVIIa was substantially more than the costs of aPCC and rpFVIII ($13 925 vs. $1778 vs. $6957, respectively). The average quality-adjusted life days (QALDs) gained from rpFVIII was lowest (4·89 vs. 4·9 for rFVIIa and 4·91 for aPCC). Overall, aPCC dominated the other two treatments. The model was determined to be robust across the tested ranges for all input variables. CONCLUSION Based on this economic model, for AHA patients with high titres who were bleeding, aPCC was the most cost-effective treatment option and may be considered for use if there is no clinical contraindication.
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Affiliation(s)
- Chong H Kim
- Department of Clinical Pharmacy, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Sierra C Simmons
- Department of Pathology, Michigan Pathology Specialists and Spectrum Health Hospitals, Grand Rapids, MI, USA
| | - Dandan Wang
- Department of Pathology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Parisa Najafzadeh
- Department of Pathology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Ameneh Azad
- Department of Pathology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Huy P Pham
- Department of Pathology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
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27
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Therapeutic Plasma Exchange in Guillain-Barre Syndrome and chronic inflammatory demyelinating polyradiculoneuropathy. Presse Med 2019; 48:338-346. [PMID: 31679897 DOI: 10.1016/j.lpm.2019.03.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Accepted: 03/05/2019] [Indexed: 12/28/2022] Open
Abstract
Therapeutic plasma exchange (TPE) has been used as a treatment modality in many autoimmune disorders, including neurological conditions, such as Guillain-Barre syndrome (GBS) and chronic inflammatory demyelinating polyradiculoneuropathy (CIDP). The American Society for Apheresis (ASFA) publishes its guidelines on the use of therapeutic apheresis every 3 years based on published evidence to assist physicians with both the medical and technical aspects of apheresis consults. The ASFA Guidelines included the use of TPE in both GBS and CIDP as an acceptable first-line therapy, either alone and/or in conjunction with other therapeutic modalities. In this article, we briefly reviewed GBS and CIDP, discussed the role of apheresis in these conditions as well as various technical aspects of the TPE procedure, such as apheresis calculation, number of volume exchange, replacement fluid, and management of potential complications.
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Pham HP, Staley EM, Schwartz J. Therapeutic plasma exchange – A brief review of indications, urgency, schedule, and technical aspects. Transfus Apher Sci 2019; 58:237-246. [DOI: 10.1016/j.transci.2019.04.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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29
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Fenderson JL, Meledeo MA, Rendo MJ, Peltier GC, McIntosh CS, Davis KW, Corley JB, Cap AP. Hemostatic characteristics of thawed, pooled cryoprecipitate stored for 35 days at refrigerated and room temperatures. Transfusion 2019; 59:1560-1567. [DOI: 10.1111/trf.15180] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2018] [Revised: 01/09/2019] [Accepted: 01/09/2019] [Indexed: 12/18/2022]
Affiliation(s)
- Joshua L. Fenderson
- Blood Research Program, US Army Institute of Surgical Research Fort Sam Houston Texas
| | - M. Adam Meledeo
- Blood Research Program, US Army Institute of Surgical Research Fort Sam Houston Texas
| | - Matthew J. Rendo
- Blood Research Program, US Army Institute of Surgical Research Fort Sam Houston Texas
| | - Grantham C. Peltier
- Blood Research Program, US Army Institute of Surgical Research Fort Sam Houston Texas
| | - Colby S. McIntosh
- Blood Research Program, US Army Institute of Surgical Research Fort Sam Houston Texas
| | - Kenneth W. Davis
- Blood Research Program, US Army Institute of Surgical Research Fort Sam Houston Texas
| | - Jason B. Corley
- Blood Research Program, US Army Institute of Surgical Research Fort Sam Houston Texas
| | - Andrew P. Cap
- Blood Research Program, US Army Institute of Surgical Research Fort Sam Houston Texas
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30
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Shah A, Collis RE. Managing obstetric haemorrhage: is it time for a more personalised approach? Anaesthesia 2019; 74:961-964. [PMID: 30950513 DOI: 10.1111/anae.14661] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/12/2019] [Indexed: 12/17/2022]
Affiliation(s)
- A Shah
- Nuffield Department of Anaesthesia, John Radcliffe Hospital, Oxford, UK.,Radcliffe Department of Medicine, University of Oxford, UK
| | - R E Collis
- Department of Anaesthetics, Cardiff and Vale University Health Board, Cardiff, UK
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31
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Logun MT, Dowling MB, Raghavan SR, Wallace ML, Schmiedt C, Stice S, Karumbaiah L. Expanding Hydrophobically Modified Chitosan Foam for Internal Surgical Hemostasis: Safety Evaluation in a Murine Model. J Surg Res 2019; 239:269-277. [PMID: 30884383 DOI: 10.1016/j.jss.2019.01.060] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Revised: 12/19/2018] [Accepted: 01/25/2019] [Indexed: 11/19/2022]
Abstract
BACKGROUND A novel injectable expanding foam based on hydrophobically modified chitosan (HM-CS) was developed to improve hemostasis during surgeries. HM-CS is an amphiphilic derivative of the natural biopolymer chitosan (CS); HM-CS has been shown to improve the natural hemostatic characteristics of CS, but its internal safety has not been systematically evaluated. The goal of this study was to compare the long-term in vivo safety of HM-CS relative to a commonly used fibrin sealant (FS), TISSEEL (Baxter). METHODS Sixty-four Sprague-Dawley rats (275-325 g obtained from Charles River Laboratories) were randomly assigned to control (n = 16) or experimental (n = 48) groups. Samples of the test materials (HM-CS [n = 16], CS [n = 16], and FS [n = 16]) applied to a nonlethal liver excision (0.4 ± 0.3 g of the medial lobe) in rats were left inside the abdomen to degrade. Animals were observed daily for signs of morbidity and mortality. Surviving animals were sacrificed at 1 and 6 wk; the explanted injury sites were microscopically assessed. RESULTS All animals (64/64) survived both the 1- and 6-wk time points without signs of morbidity. Histological examination showed a comparable pattern of degradation for the various test materials. FS remnants and significant adhesions to neighboring tissues were observed at 6 wk. Residual CS and HM-CS were observed at the 6 wk with fatty deposits at the site of injury. Minimal adhesions were observed for CS and HM-CS. CONCLUSIONS The internal safety observed in the HM-CS test group after abdominal implantation indicates that injectable HM-CS expanding foam may be an appropriate internal use hemostatic candidate.
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Affiliation(s)
- Meghan T Logun
- Regenerative Bioscience Center, University of Georgia, Athens, Georgia
| | | | - Srinivasa R Raghavan
- Department of Chemical and Biomolecular Engineering, University of Maryland, College Park, Maryland
| | - Mandy L Wallace
- Department of Small Animal Medicine and Surgery, College of Veterinary Medicine, University of Georgia, Athens, Georgia
| | - Chad Schmiedt
- Department of Small Animal Medicine and Surgery, College of Veterinary Medicine, University of Georgia, Athens, Georgia
| | - Steven Stice
- Regenerative Bioscience Center, University of Georgia, Athens, Georgia
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Cushing MM, Asmis LM, Harris RM, DeSimone RA, Hill S, Ivascu N, Haas T. Efficacy of a new pathogen-reduced cryoprecipitate stored 5 days after thawing to correct dilutional coagulopathy in vitro. Transfusion 2019; 59:1818-1826. [PMID: 30719724 DOI: 10.1111/trf.15157] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2018] [Revised: 12/27/2018] [Accepted: 12/29/2018] [Indexed: 12/29/2022]
Abstract
BACKGROUND Fibrinogen supplementation during bleeding restores clot strength and hemostasis. Cryoprecipitate, a concentrated source of fibrinogen, has prolonged preparation time for thawing, a short shelf life resulting in frequent wastage, and infectious disease risk. This in vitro study investigated the efficacy of a new pathogen-reduced cryoprecipitate thawed and stored at room temperature for 5 days (PR Cryo) to treat dilutional hypofibrinogenemia, compared to immediately thawed standard cryoprecipitate (Cryo) or fibrinogen concentrate (FC). STUDY DESIGN AND METHODS Ten phlebotomy specimens from healthy volunteers were diluted 1:1 with crystalloid and supplemented with PR Cryo and Cryo (at a dose replicating transfusion of two pooled doses [10 units]) and FC at a dose replicating 50 mg/kg. Changes in clot firmness (thromboelastometry) and in coagulation factor activity were assessed at baseline, after dilution, and after supplementation. RESULTS Clinical dosing was used, as described above, and consequently the FC dose contained 24% and 36% more fibrinogen versus PR Cryo and Cryo, respectively. At baseline, subjects had a median FIBTEM maximum clot firmness of 13.5 mm, versus 6.5 mm after 50% dilution (p = 0.005). After supplementation with PR Cryo, a median FIBTEM maximum clot firmness of 13 mm was observed versus 9.0 mm for Cryo (p = 0.005) or 16.5 mm for FC (p = 0.005). Median factor XIII was higher after PR Cryo (64.8%) versus Cryo (48.3%) (p = 0.005). Fibrinogen activity was higher after FC (269.0 mg/dL) versus PR Cryo (187.0 mg/dL; p = 0.005) or Cryo (193.5 mg/dL; p = 0.005); the difference between PR Cryo and Cryo supplementation (p = 0.445) was not significant. CONCLUSION PR Cryo used 5 days after thawing effectively restores clot strength after in vitro dilution.
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Affiliation(s)
- Melissa M Cushing
- Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York, New York.,Department of Anesthesiology, Weill Cornell Medicine, New York, New York
| | - Lars M Asmis
- Centre for Perioperative Thrombosis and Haemostasis, Zurich, Switzerland
| | - Rebecca M Harris
- Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York, New York
| | - Robert A DeSimone
- Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York, New York
| | - Shanna Hill
- Department of Anesthesiology, Weill Cornell Medicine, New York, New York
| | - Natalia Ivascu
- Department of Anesthesiology, Weill Cornell Medicine, New York, New York
| | - Thorsten Haas
- Department of Anaesthesia, Zurich University Children's Hospital, Zurich, Switzerland
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Kim CH, Simmons SC, Bui CM, Jiang N, Pham HP. aPCC vs. rFVIIa for the treatment of bleeding in patients with acquired haemophilia - a cost-effectiveness model. Vox Sang 2018; 114:63-72. [DOI: 10.1111/vox.12726] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Revised: 10/23/2018] [Accepted: 10/29/2018] [Indexed: 01/27/2023]
Affiliation(s)
- Chong H. Kim
- Department of Clinical Pharmacy; University of Colorado Anschutz Medical Campus; Aurora CO USA
| | | | | | - Ning Jiang
- Center for Family Life at Sunset Park; SCO Family of Services; Brooklyn NY USA
| | - Huy P. Pham
- Department of Pathology; Keck School of Medicine; University of Southern California; Los Angeles CA USA
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Marsden M, Benger J, Brohi K, Curry N, Foley C, Green L, Lucas J, Rossetto A, Stanworth S, Thomas H, Davenport R. Coagulopathy, cryoprecipitate and CRYOSTAT-2: realising the potential of a nationwide trauma system for a national clinical trial. Br J Anaesth 2018; 122:164-169. [PMID: 30686301 DOI: 10.1016/j.bja.2018.10.055] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Revised: 10/06/2018] [Accepted: 10/27/2018] [Indexed: 01/10/2023] Open
Affiliation(s)
- M Marsden
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, UK; Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, UK; Barts Health NHS Trust, London, UK.
| | - J Benger
- Faculty of Health and Applied Sciences, University of the West of England, Bristol, UK
| | - K Brohi
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, UK; Barts Health NHS Trust, London, UK
| | - N Curry
- Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK; Radcliffe Department of Medicine, University of Oxford, UK
| | - C Foley
- NHS Blood and Transplant, Clinical Trials Unit, Cambridge, UK
| | - L Green
- Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary, University of London, London, UK; Barts Health NHS Trust, London, UK
| | - J Lucas
- NHS Blood and Transplant, Clinical Trials Unit, Cambridge, UK
| | - A Rossetto
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, UK; Barts Health NHS Trust, London, UK
| | - S Stanworth
- Oxford NIHR BRC Haematology Theme, Oxford Centre for Haematology, University of Oxford, UK; NHS Blood and Transplant, Transfusion Medicine, Oxford, UK; Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK; Radcliffe Department of Medicine, University of Oxford, UK
| | - H Thomas
- NHS Blood and Transplant, Clinical Trials Unit, Bristol, UK; NHS Blood and Transplant, Transfusion Medicine, Oxford, UK
| | - R Davenport
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, UK; Barts Health NHS Trust, London, UK
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Pohlman TH, Fecher AM, Arreola-Garcia C. Optimizing transfusion strategies in damage control resuscitation: current insights. J Blood Med 2018; 9:117-133. [PMID: 30154676 PMCID: PMC6108342 DOI: 10.2147/jbm.s165394] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
From clinical and laboratory studies of specific coagulation defects induced by injury, damage control resuscitation (DCR) emerged as the most effective management strategy for hemorrhagic shock. DCR of the trauma patient who has sustained massive blood loss consists of 1) hemorrhage control; 2) permissive hypotension; and 3) the prevention and correction of trauma-induced coagulopathies, referred to collectively here as acute coagulopathy of trauma (ACOT). Trauma patients with ACOT have higher transfusion requirements, may eventually require massive transfusion, and are at higher risk of exsanguinating. Distinct impairments in the hemostatic system associated with trauma include acquired quantitative and qualitative platelet defects, hypocoagulable and hypercoagulable states, and dysregulation of the fibrinolytic system giving rise to hyperfibrinolysis or a phenomenon referred to as fibrinolytic shutdown. Furthermore, ACOT is a component of a systemic host defense dysregulation syndrome that bears several phenotypic features comparable with other acute systemic physiological insults such as sepsis, myocardial infarction, and postcardiac arrest syndrome. Progress in the science of resuscitation has been continuing at an accelerated rate, and clinicians who manage catastrophic blood loss may be incompletely informed of important advances that pertain to DCR. Therefore, we review recent findings that further characterize the pathophysiology of ACOT and describe the application of this new information to optimization of resuscitation strategies for the patient in hemorrhagic shock.
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Affiliation(s)
- Timothy H Pohlman
- Department of Surgery, Lutheran Hospital of Indiana, Fort Wayne, IN, USA,
| | - Alison M Fecher
- Department of Surgery, Lutheran Hospital of Indiana, Fort Wayne, IN, USA
| | - Cecivon Arreola-Garcia
- Department of Surgery, Section of Acute Care Surgery, Indiana University Health, Indianapolis, IN, USA
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Qadri SM, Eltringham-Smith LJ, Bhakta V, Sheffield WP. Thromboelastometry reveals similar hemostatic properties of purified fibrinogen and a mixture of purified cryoprecipitate protein components. Clin Chem Lab Med 2018; 56:e210-e213. [PMID: 29455186 DOI: 10.1515/cclm-2017-1136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Accepted: 01/25/2018] [Indexed: 11/15/2022]
Affiliation(s)
- Syed M Qadri
- Centre for Innovation, Canadian Blood Services, Hamilton, ON, Canada.,Department of Pathology and Molecular Medicine, McMaster University, Hamilton, ON, Canada
| | | | - Varsha Bhakta
- Centre for Innovation, Canadian Blood Services, Hamilton, ON, Canada
| | - William P Sheffield
- Centre for Innovation, Canadian Blood Services, Hamilton, ON, Canada.,Department of Pathology and Molecular Medicine, McMaster University, Hamilton, ON, Canada
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Onwukwe C, Maisha N, Holland M, Varley M, Groynom R, Hickman D, Uppal N, Shoffstall A, Ustin J, Lavik E. Engineering Intravenously Administered Nanoparticles to Reduce Infusion Reaction and Stop Bleeding in a Large Animal Model of Trauma. Bioconjug Chem 2018; 29:2436-2447. [PMID: 29965731 DOI: 10.1021/acs.bioconjchem.8b00335] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Bleeding from traumatic injury is the leading cause of death for young people across the world, but interventions are lacking. While many agents have shown promise in small animal models, translating the work to large animal models has been exceptionally difficult in great part because of infusion-associated complement activation to nanomaterials that leads to cardiopulmonary complications. Unfortunately, this reaction is seen in at least 10% of the population. We developed intravenously infusible hemostatic nanoparticles that were effective in stopping bleeding and improving survival in rodent models of trauma. To translate this work, we developed a porcine liver injury model. Infusion of the first generation of hemostatic nanoparticles and controls 5 min after injury led to massive vasodilation and exsanguination even at extremely low doses. In naïve animals, the physiological changes were consistent with a complement-associated infusion reaction. By tailoring the zeta potential, we were able to engineer a second generation of hemostatic nanoparticles and controls that did not exhibit the complement response at low and moderate doses but did at the highest doses. These second-generation nanoparticles led to cessation of bleeding within 10 min of administration even though some signs of vasodilation were still seen. While the complement response is still a challenge, this work is extremely encouraging in that it demonstrates that when the infusion-associated complement response is managed, hemostatic nanoparticles are capable of rapidly stopping bleeding in a large animal model of trauma.
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Affiliation(s)
- Chimdiya Onwukwe
- University of Maryland Baltimore County , 1000 Hilltop Circle, Baltimore , Maryland 21050 , United States
| | - Nuzhat Maisha
- University of Maryland Baltimore County , 1000 Hilltop Circle, Baltimore , Maryland 21050 , United States
| | - Mark Holland
- University of Maryland Baltimore County , 1000 Hilltop Circle, Baltimore , Maryland 21050 , United States
| | - Matt Varley
- Case Western Reserve University , 10900 Euclid Avenue , Cleveland , Ohio 44106 , United States
| | - Rebecca Groynom
- Case Western Reserve University , 10900 Euclid Avenue , Cleveland , Ohio 44106 , United States
| | - DaShawn Hickman
- Case Western Reserve University , 10900 Euclid Avenue , Cleveland , Ohio 44106 , United States
| | - Nishant Uppal
- Harvard Medical School , 25 Shattuck Street , Boston , Massachusetts 02115 , United States
| | - Andrew Shoffstall
- Case Western Reserve University , 10900 Euclid Avenue , Cleveland , Ohio 44106 , United States
| | - Jeffrey Ustin
- Case Western Reserve University , 10900 Euclid Avenue , Cleveland , Ohio 44106 , United States
| | - Erin Lavik
- University of Maryland Baltimore County , 1000 Hilltop Circle, Baltimore , Maryland 21050 , United States
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Novak A, Stanworth SJ, Curry N. Do we still need cryoprecipitate? Cryoprecipitate and fibrinogen concentrate as treatments for major hemorrhage - how do they compare? Expert Rev Hematol 2018; 11:351-360. [PMID: 29584463 DOI: 10.1080/17474086.2018.1458610] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
INTRODUCTION Major hemorrhage is a source of significant mortality and morbidity worldwide. Identification and characterization of coagulation impairment associated with major hemorrhage has suggested a key role for fibrinogen deficiency, however the optimum mode of replacement of fibrinogen remains unclear, and standardized major hemorrhage protocols may overlook context-dependent variations in individual patients' clotting derangement. Areas covered: This paper examines the current practice and evidence regarding the role of different modes of fibrinogen replacement in major hemorrhage in 3 distinct clinical settings: trauma, obstetric hemorrhage, and gastrointestinal hemorrhage with associated liver disease. A literature search was carried out electronically using Athens access to the National Health Service evidence health information resources, primarily PubMed and Google Scholar. Expert commentary: Two key questions need to be addressed. First, what is the role of concentrated fibrinogen (by comparison to no fibrinogen), and second, which concentrated source or product is more effective (or cost-effective)? Current practice and concept is derived largely from small pilot trials in the trauma setting, but results from larger studies are awaited. More comparative data on changes to clotting profiles in different groups of bleeding patients are needed to help delineate differences and guide interventional treatment studies.
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Affiliation(s)
- Alex Novak
- a Emergency Department , Oxford University Hospitals NHS Foundation Trust , Oxford , UK
| | - Simon J Stanworth
- b Department of Haematology , Oxford University Hospitals NHS Foundation Trust , Oxford , UK.,c NHS Blood and Transplant , John Radcliffe Hospital , Oxford , UK.,d Radcliffe Department of Medicine , University of Oxford , Oxford , UK.,e Oxford Biomedical Research Centre , NIHR Blood Theme , Oxford , UK
| | - Nicola Curry
- b Department of Haematology , Oxford University Hospitals NHS Foundation Trust , Oxford , UK.,e Oxford Biomedical Research Centre , NIHR Blood Theme , Oxford , UK
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Tkach EK, Mackley A, Brooks A, Kessler J, Paul DA. Cryoprecipitate transfusions in the neonatal intensive care unit: a performance improvement study to decrease donor exposure. Transfusion 2018; 58:1206-1209. [PMID: 29479718 DOI: 10.1111/trf.14555] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2017] [Revised: 11/22/2017] [Accepted: 12/29/2017] [Indexed: 12/01/2022]
Abstract
BACKGROUND The objective of this study was to determine if a change in cryoprecipitate transfusion policy impacts donor exposure and fibrinogen level in a neonatal intensive care unit (NICU) population. STUDY DESIGN AND METHODS The cryoprecipitate policy was changed from transfusing 10ml/kg to a maximum of 1 unit per transfusion in January 2013. Data were obtained via retrospective chart review of all infants receiving cryoprecipitate transfusions from January 2008 to February 2015 in the NICU at Christiana Hospital. RESULTS A total of 103 neonates received a total of 144 cryoprecipitate transfusions. Before the policy change, term babies were more likely to be exposed to more than one donor compared to preterm babies (75% vs. 6%, p < 0.01). After the policy change, no babies were exposed to greater than one donor per transfusion and there were similar increases in posttransfusion fibrinogen level as before the policy change. CONCLUSION Limiting cryoprecipitate transfusions to 1 unit per transfusion decreased donor exposure in infants without negatively impacting posttransfusion fibrinogen levels. This is especially evident in term neonates.
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Affiliation(s)
- Erin K Tkach
- Neonatology.,Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania
| | | | - Alison Brooks
- Blood Bank, Christiana Care Health System, Newark, Delaware
| | | | - David A Paul
- Neonatology.,Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania
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Bryan AW, Staley EM, Kennell T, Feldman AZ, Williams LA, Pham HP. Plasma Transfusion Demystified: A Review of the Key Factors Influencing the Response to Plasma Transfusion. Lab Med 2017; 48:108-112. [PMID: 28444398 DOI: 10.1093/labmed/lmx027] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
Many studies have suggested that inappropriate plasma usage is common. An important factor contributing to futile plasma administration in most patients is the nonlinear relationship between coagulation-factor levels and the volume of plasma transfused. In this review, a validated mathematical model and data from the literature will be used to illuminate 3 key properties of plasma transfusion. Those properties are as follows: the effect of plasma transfusion on international normalized ratio (INR) is transient; for the same volume of transfused plasma, a greater reduction in INR is observed at higher initial INRs; and the effect of plasma transfusion on INR correction (ie, the difference between initial and final INRs) diminishes as more plasma is transfused. Frequent misunderstanding of these properties may contribute to inappropriate plasma usage. Therefore, this review will assist physicians in navigating these common pitfalls. Stronger understanding of these principles may result in a reduction of inappropriate plasma transfusions, thus potentially enhancing patient safety and reducing healthcare costs.
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Affiliation(s)
- Allen W Bryan
- Department of Pathology, Division of Laboratory Medicine
| | | | - Timothy Kennell
- NIH Medical Scientist Training Program, University of Alabama at Birmingham
| | | | | | - Huy P Pham
- Department of Pathology, Division of Laboratory Medicine
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41
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Wong H, Curry N. Do we need cryoprecipitate in the era of fibrinogen concentrate and other specific factor replacement options? ACTA ACUST UNITED AC 2017. [DOI: 10.1111/voxs.12376] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
- H. Wong
- Department of Haematology; University of Oxford; Oxford UK
- Oxford Haemophilia & Thrombosis Centre; Oxford University Hospitals NHS Foundation Trust and Oxford NIHR BRC Blood Theme; Oxford UK
| | - N. Curry
- Oxford Haemophilia & Thrombosis Centre; Oxford University Hospitals NHS Foundation Trust and Oxford NIHR BRC Blood Theme; Oxford UK
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42
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Kim CH, Simmons SC, Williams LA, Staley EM, Zheng XL, Pham HP. ADAMTS13 test and/or PLASMIC clinical score in management of acquired thrombotic thrombocytopenic purpura: a cost-effective analysis. Transfusion 2017. [PMID: 28646526 DOI: 10.1111/trf.14230] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND The ADAMTS13 test distinguishes thrombotic thrombocytopenic purpura (TTP) from other thrombotic microangiopathies (TMAs). The PLASMIC score helps determine the pretest probability of ADAMTS13 deficiency. Due to inherent limitations of both tests, and potential adverse effects and cost of unnecessary treatments, we performed a cost-effectiveness analysis (CEA) investigating the benefits of incorporating an in-hospital ADAMTS13 test and/or PLASMIC score into our clinical practice. STUDY DESIGN AND METHODS A CEA model was created to compare four scenarios for patients with TMAs, utilizing either an in-house or a send-out ADAMTS13 assay with or without prior risk stratification using PLASMIC scoring. Model variables, including probabilities and costs, were gathered from the medical literature, except for the ADAMTS13 send-out and in-house tests, which were obtained from our institutional data. RESULTS If only the cost is considered, in-house ADAMTS13 test for patients with intermediate- to high-risk PLASMIC score is the least expensive option ($4,732/patient). If effectiveness is assessed as measured by the number of averted deaths, send-out ADAMTS13 test is the most effective. Considering the cost/effectiveness ratio, the in-house ADAMTS13 test in patients with intermediate- to high-risk PLASMIC score is the best option, followed by the in-house ADAMTS13 test without the PLASMIC score. CONCLUSIONS In patients with clinical presentations of TMAs, having an in-hospital ADAMTS13 test to promptly establish the diagnosis of TTP appears to be cost-effective. Utilizing the PLASMIC score further increases the cost-effectiveness of the in-house ADAMTS13 test. Our findings indicate the benefit of having a rapid and reliable in-house ADAMTS13 test, especially in the tertiary medical center.
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Affiliation(s)
- Chong H Kim
- Department of Clinical Pharmacy, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Sierra C Simmons
- Division of Laboratory Medicine, Department of Pathology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Lance A Williams
- Division of Laboratory Medicine, Department of Pathology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Elizabeth M Staley
- Division of Laboratory Medicine, Department of Pathology, University of Alabama at Birmingham, Birmingham, Alabama
| | - X Long Zheng
- Division of Laboratory Medicine, Department of Pathology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Huy P Pham
- Division of Laboratory Medicine, Department of Pathology, University of Alabama at Birmingham, Birmingham, Alabama
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43
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Winearls J, Wullschleger M, Wake E, Hurn C, Furyk J, Ryan G, Trout M, Walsham J, Holley A, Cohen J, Shuttleworth M, Dyer W, Keijzers G, Fraser JF, Presneill J, Campbell D. Fibrinogen Early In Severe Trauma studY (FEISTY): study protocol for a randomised controlled trial. Trials 2017; 18:241. [PMID: 28549445 PMCID: PMC5446750 DOI: 10.1186/s13063-017-1980-x] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2016] [Accepted: 05/06/2017] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Haemorrhage is a leading cause of death in severe trauma. Fibrinogen plays a critical role in maintaining haemostasis in traumatic haemorrhage. Early fibrinogen replacement is recommended by several international trauma guidelines using either fibrinogen concentrate (FC) or cryoprecipitate (Cryo). There is limited evidence to support one product over the other with widespread geographic and institutional variation in practice. This pilot trial is the first randomised controlled trial comparing FC to Cryo in traumatic haemorrhage. METHODS/DESIGN The Fibrinogen Early In Severe Trauma studY (FEISTY) is an exploratory, multicentre, randomised controlled trial comparing FC to Cryo for fibrinogen supplementation in traumatic haemorrhage. This trial will utilise thromboelastometry (ROTEM®) to guide and dose fibrinogen supplementation. The trial will recruit 100 trauma patients at four major trauma centres in Australia. Adult trauma patients with evidence of haemorrhage will be enrolled on arrival in the trauma unit and randomised to receiving fibrinogen supplementation with either FC or Cryo. The primary outcome is the differential time to fibrinogen supplementation. There are a number of predetermined secondary outcomes including: effects of the intervention on plasma fibrinogen levels, feasibility assessments and clinical outcomes including transfusion requirements and mortality. DISCUSSION The optimal method for replacing fibrinogen in traumatic haemorrhage is fiercely debated. In this trial the feasibility and efficacy of fibrinogen supplementation using FC will be compared to Cryo. The results of this pilot study will facilitate the design of a larger trial with sufficient power to address patient-centred outcomes. TRIAL REGISTRATION ClinicalTrials.gov, ID: NCT02745041 . Registered 4 May 2016.
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Affiliation(s)
- James Winearls
- Gold Coast University Hospital, Southport, QLD, Australia. .,School of Medicine, University of Queensland, St. Lucia, QLD, Australia. .,School of Medical Sciences, Griffith University, Nathan, QLD, Australia.
| | - Martin Wullschleger
- Gold Coast University Hospital, Southport, QLD, Australia.,School of Medical Sciences, Griffith University, Nathan, QLD, Australia
| | - Elizabeth Wake
- Gold Coast University Hospital, Southport, QLD, Australia
| | - Catherine Hurn
- School of Medicine, University of Queensland, St. Lucia, QLD, Australia.,Royal Brisbane and Women's Hospital, Herston, QLD, Australia
| | - Jeremy Furyk
- Emergency Research, Townsville Hospital, Douglas, QLD, Australia
| | - Glenn Ryan
- Princess Alexandra Hospital, Woolloongabba, QLD, Australia
| | | | - James Walsham
- School of Medicine, University of Queensland, St. Lucia, QLD, Australia.,Intensive Care Research, Princess Alexandra Hospital, Woolloongabba, QLD, Australia
| | - Anthony Holley
- School of Medicine, University of Queensland, St. Lucia, QLD, Australia.,Royal Brisbane and Women's Hospital, Herston, QLD, Australia
| | - Jeremy Cohen
- School of Medicine, University of Queensland, St. Lucia, QLD, Australia.,Royal Brisbane and Women's Hospital, Herston, QLD, Australia
| | - Megan Shuttleworth
- Menzies Health Institute Queensland, Griffith University, Nathan, QLD, Australia
| | - Wayne Dyer
- Australian Red Cross Blood Service, Melbourne, VIC, Australia
| | - Gerben Keijzers
- Gold Coast University Hospital, Southport, QLD, Australia.,School of Medical Sciences, Griffith University, Nathan, QLD, Australia.,School of Medicine, Bond University, Robina, QLD, Australia
| | - John F Fraser
- Critical Care Research Group, The Prince Charles Hospital and University of Queensland, Brisbane, QLD, Australia
| | - Jeffrey Presneill
- Intensive Care Unit, Royal Melbourne Hospital and University of Melbourne, Melbourne, VIC, Australia
| | - Don Campbell
- Gold Coast University Hospital, Southport, QLD, Australia
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