The European guideline on management of major bleeding and coagulopathy following trauma: sixth edition

BACKGROUND

Severe trauma represents a major global public health burden and the management of post-traumatic bleeding continues to challenge healthcare systems around the world. Post-traumatic bleeding and associated traumatic coagulopathy remain leading causes of potentially preventable multiorgan failure and death if not diagnosed and managed in an appropriate and timely manner. This sixth edition of the European guideline on the management of major bleeding and coagulopathy following traumatic injury aims to advise clinicians who care for the bleeding trauma patient during the initial diagnostic and therapeutic phases of patient management.

METHODS

The pan-European, multidisciplinary Task Force for Advanced Bleeding Care in Trauma included representatives from six European professional societies and convened to assess and update the previous version of this guideline using a structured, evidence-based consensus approach. Structured literature searches covered the period since the last edition of the guideline, but considered evidence cited previously. The format of this edition has been adjusted to reflect the trend towards concise guideline documents that cite only the highest-quality studies and most relevant literature rather than attempting to provide a comprehensive literature review to accompany each recommendation.

RESULTS

This guideline comprises 39 clinical practice recommendations that follow an approximate temporal path for management of the bleeding trauma patient, with recommendations grouped behind key decision points. While approximately one-third of patients who have experienced severe trauma arrive in hospital in a coagulopathic state, a systematic diagnostic and therapeutic approach has been shown to reduce the number of preventable deaths attributable to traumatic injury.

CONCLUSION

A multidisciplinary approach and adherence to evidence-based guidelines are pillars of best practice in the management of severely injured trauma patients. Further improvement in outcomes will be achieved by optimising and standardising trauma care in line with the available evidence across Europe and beyond.

Passive order auditing associated with reductions in red blood cell utilization: National blood shortage experience

BACKGROUND

Decreased blood collection during the Coronavirus Disease 2019 (COVID-19) pandemic resulted in long-term red blood cell (RBC) shortages in the United States. In an effort to conserve RBCs, the existing passive alert system for auditing inpatient transfusions was modified to activate at a lower hemoglobin threshold (6.5 g/dL instead of 7.0 g/dL for stable, nonbleeding inpatients) during a 9-month shortage at an academic medical center. Hemoglobin levels prior to RBC transfusions were compared for inpatients receiving RBC transfusions to determine whether RBC utilization changed during the intervention.

STUDY DESIGN AND METHODS

This retrospective study compared the number of single-unit RBC transfusions and hemoglobin levels prior to RBC transfusion among inpatients during the 9 months of the intervention (Period 2, 06/01/2021-2/28/2022) to the same period of the previous year (Period 1, 06/01/2020-2/28/2021).

RESULTS

Overall full unit RBC transfusions to inpatients decreased by 15% from 5182 to 4421. Of all transfusions, 50.3% and 49.8% were single-unit RBC transfusions in Period 1 and Period 2, respectively. The incidence rate difference and incidence rate ratio of single RBC units transfused per 1000 patient days were significantly decreased (p = 0.0007). The average pre-transfusion hemoglobin level significantly decreased from 7.18 g/dL to 7.05 g/dL (p = 0.0002), largely due to significant decreases in hemoglobin transfusion triggers for adult inpatient ward transfusions.

DISCUSSION

Modification of the passive alert system was associated with significantly decreased RBC utilization during a long-term RBC shortage. Modification of transfusion criteria recommended by passive alerts may be a feasible option to decrease RBC utilization at centers during long-term RBC shortages.

Management and outcomes of severe pelvic fractures in level I and II ACS verified trauma centers

BACKGROUND

The aim of this study was to evaluate the management strategies and outcomes of isolated severe pelvic fractures in level I and II ACS verified trauma centers.

METHODS

ACS-TQIP database study, including patients with blunt, isolated severe pelvic facture (AIS 3-5).

RESULTS

2629 level I and 1277 level II patients were included. Early blood product transfusion was significantly higher, pharmacological VTE prophylaxis significantly lower and ICU length of stay significantly longer in level II centers (p < 0.001). On multivariate analysis, treatment at level II centers was independently associated with increased overall complications, specifically ARDS, but not mortality.

CONCLUSIONS

In isolated severe pelvic fractures there was a significantly higher use of early blood products, less VTE pharmacological prophylaxis, longer ICU length of stay and higher overall complications and ARDS in level II centers. Blood product utilization and pharmacological VTE prophylaxis are potential areas of quality improvement in level II centers.

Red cell use in trauma

PURPOSE OF REVIEW

Red cell transfusions are commonly used in management of hemorrhage in trauma patients. The appropriate indications and criteria for transfusion are still debated. Here, we summarize the recent findings on the use of red cell transfusion in trauma setting.

RECENT FINDINGS

Recent evidence continues to support the long-established link between allogeneic transfusion and worse clinical outcomes, reinstating the importance of more judicious use of allogeneic blood and careful consideration of benefits versus risks when making transfusion decisions. Studies support restrictive transfusion strategies (often based on hemoglobin thresholds of 7-8 g/dl) in most patient populations, although some argue more caution in specific populations (e.g. patients with traumatic brain injury) and more studies are needed to determine if these patients benefit from less restrictive transfusion strategies. It should be remembered that anemia remains an independent risk factor for worse outcomes and red cell transfusion does not constitute a lasting treatment. Anemia should be properly assessed and managed based on the cause and using hematinic medications as indicated.

SUMMARY

Although the debate on hemoglobin thresholds for transfusion continues, clinicians should not overlook proper management of the underlying issue (anemia).