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Aidikoff J, Trivedi D, Kwock R, Shafi H. How do I implement pathogen reduced Cryoprecipitated fibrinogen complex in a tertiary Hospital's blood Bank. Transfusion 2024. [PMID: 38979964 DOI: 10.1111/trf.17940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Revised: 06/19/2024] [Accepted: 06/20/2024] [Indexed: 07/10/2024]
Abstract
BACKGROUND Kaiser-Permanente Los Angeles Medical Center (LAMC) is a 560 licensed bed facility that provides regional cardiovascular services, including 1200 open heart surgeries annually. In 2021, LAMC explored alternative therapies to offset the impact of pandemic-driven cryo AHF shortages, and implemented Pathogen Reduced Cryoprecipitated Fibrinogen Complex (also known as INTERCEPT Fibrinogen Complex or IFC). IFC is approved to treat and control bleeding associated with fibrinogen deficiency. Unlike cryo AHF, IFC has 5-day post-thaw shelf life with potential operational and clinical benefits. The implementation steps and the operational advantages to the LAMC Blood Bank are described. STUDY DESIGN AND METHODS Eighteen months post-implementation, the institution reviewed their product implementation experience and compared IFC with cryo AHF with a retrospective review of transfusion service and cardiac post-op data. RESULTS IFC significantly decreased product wastage rates and order-to-issue time. It did not significantly impact post-op product utilization or hospital length of stay (LOS) in cardiac surgery patients when compared with cryo AHF. DISCUSSION Implementation of IFC provides improved product supply stability, shorter turnaround times, and reduced wastage.
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Affiliation(s)
- Jennifer Aidikoff
- Kaiser-Permanente, Los Angeles Medical Center, Los Angeles, California, USA
| | - Dhaval Trivedi
- Kaiser-Permanente, Los Angeles Medical Center, Los Angeles, California, USA
- Department of Cardiac Surgery, Southern California Permanente Medical Group, Los Angeles, California, USA
| | - Richard Kwock
- Department of Business Intelligence, Kaiser-Permanente, Los Angeles Medical Center, Los Angeles, California, USA
| | - Hedyeh Shafi
- Kaiser-Permanente, Los Angeles Medical Center, Los Angeles, California, USA
- Department of Pathology, Southern California Permanente Medical Group, Los Angeles, California, USA
- Department of Clinical Science or Health Systems, Kaiser Permanente Bernard J Tyson School of Medicine, Pasadena, California, USA
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Liu W, Guo Y, Xie J, Wu Y, Zhao D, Xing Z, Fu X, Zhou S, Zhang H, Wang X. Establishment and validation of a bad outcomes prediction model based on EEG and clinical parameters in prolonged disorder of consciousness. Front Hum Neurosci 2024; 18:1387471. [PMID: 38952644 PMCID: PMC11215084 DOI: 10.3389/fnhum.2024.1387471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2024] [Accepted: 06/04/2024] [Indexed: 07/03/2024] Open
Abstract
Objective This study aimed to explore the electroencephalogram (EEG) indicators and clinical factors that may lead to poor prognosis in patients with prolonged disorder of consciousness (pDOC), and establish and verify a clinical predictive model based on these factors. Methods This study included 134 patients suffering from prolonged disorder of consciousness enrolled in our department of neurosurgery. We collected the data of sex, age, etiology, coma recovery scales (CRS-R) score, complications, blood routine, liver function, coagulation and other laboratory tests, resting EEG data and follow-up after discharge. These patients were divided into two groups: training set (n = 107) and verification set (n = 27). These patients were divided into a training set of 107 and a validation set of 27 for this study. Univariate and multivariate regression analysis were used to determine the factors affecting the poor prognosis of pDOC and to establish nomogram model. We use the receiver operating characteristic (ROC) and calibration curves to quantitatively test the effectiveness of the training set and the verification set. In order to further verify the clinical practical value of the model, we use decision curve analysis (DCA) to evaluate the model. Result The results from univariate and multivariate logistic regression analyses suggested that an increased frequency of occurrence microstate A, reduced CRS-R scores at the time of admission, the presence of episodes associated with paroxysmal sympathetic hyperactivity (PSH), and decreased fibrinogen levels all function as independent prognostic factors. These factors were used to construct the nomogram. The training and verification sets had areas under the curve of 0.854 and 0.920, respectively. Calibration curves and DCA demonstrated good model performance and significant clinical benefits in both sets. Conclusion This study is based on the use of clinically available and low-cost clinical indicators combined with EEG to construct a highly applicable and accurate model for predicting the adverse prognosis of patients with prolonged disorder of consciousness. It provides an objective and reliable tool for clinicians to evaluate the prognosis of prolonged disorder of consciousness, and helps clinicians to provide personalized clinical care and decision-making for patients with prolonged disorder of consciousness and their families.
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Affiliation(s)
- Wanqing Liu
- Department of Neurosurgery, The Fifth Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yongkun Guo
- Department of Neurosurgery, The Fifth Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- Henan Engineering Research Center for Prevention and Treatment of Brain Injuries, Zhengzhou, China
- Henan Key Laboratory of Brain Science and Brain Computer Interface Technology, Zhengzhou, China
| | - Jingwei Xie
- Department of Neurosurgery, The Fifth Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- Henan Engineering Research Center for Prevention and Treatment of Brain Injuries, Zhengzhou, China
- Henan Key Laboratory of Brain Science and Brain Computer Interface Technology, Zhengzhou, China
| | - Yanzhi Wu
- Department of Neurosurgery, The Fifth Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Dexiao Zhao
- Department of Neurosurgery, The Fifth Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Zhe Xing
- Department of Neurosurgery, The Fifth Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Xudong Fu
- Department of Neurosurgery, The Fifth Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- Henan Engineering Research Center for Prevention and Treatment of Brain Injuries, Zhengzhou, China
- Henan Key Laboratory of Brain Science and Brain Computer Interface Technology, Zhengzhou, China
| | - Shaolong Zhou
- Department of Neurosurgery, The Fifth Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- Henan Engineering Research Center for Prevention and Treatment of Brain Injuries, Zhengzhou, China
- Henan Key Laboratory of Brain Science and Brain Computer Interface Technology, Zhengzhou, China
| | - Hengwei Zhang
- Department of Neurosurgery, The Fifth Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- Henan Engineering Research Center for Prevention and Treatment of Brain Injuries, Zhengzhou, China
- Henan Key Laboratory of Brain Science and Brain Computer Interface Technology, Zhengzhou, China
| | - Xinjun Wang
- Department of Neurosurgery, The Fifth Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- Henan Engineering Research Center for Prevention and Treatment of Brain Injuries, Zhengzhou, China
- Henan Key Laboratory of Brain Science and Brain Computer Interface Technology, Zhengzhou, China
- Department of Neurosurgery, The Third Affiliated Hospital of Zhengzhou University, Zhengzhou, China
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Alber S, Tanabe K, Hennigan A, Tregear H, Gilliland S. Year in Review 2023: Noteworthy Literature in Cardiothoracic Critical Care. Semin Cardiothorac Vasc Anesth 2024; 28:66-79. [PMID: 38669120 DOI: 10.1177/10892532241249582] [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] [Indexed: 04/28/2024]
Abstract
This article reviews noteworthy investigations and society recommendations published in 2023 relevant to the care of critically ill cardiothoracic surgical patients. We reviewed 3,214 articles to identify 18 publications that add to the existing literature across a variety of topics including resuscitation, nutrition, antibiotic management, extracorporeal membrane oxygenation (ECMO), neurologic care following cardiac arrest, coagulopathy and transfusion, steroids in pulmonary infections, and updated guidelines in the management of acute respiratory distress syndrome (ARDS).
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Morrow GB, Flannery S, Charles PD, Heilig R, Feller T, McQuilten Z, Wake E, Ariens RAS, Winearls J, Mutch NJ, Fischer R, Laffan MA, Curry N. A novel method to quantify fibrin-fibrin and fibrin-α 2-antiplasmin cross-links in thrombi formed from human trauma patient plasma. J Thromb Haemost 2024; 22:1758-1771. [PMID: 38462220 DOI: 10.1016/j.jtha.2024.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Revised: 02/14/2024] [Accepted: 03/04/2024] [Indexed: 03/12/2024]
Abstract
BACKGROUND The widespread use of the antifibrinolytic agent, tranexamic acid (TXA), interferes with the quantification of fibrinolysis by dynamic laboratory assays such as clot lysis, making it difficult to measure fibrinolysis in many trauma patients. At the final stage of coagulation, factor (F)XIIIa catalyzes the formation of fibrin-fibrin and fibrin-α2-antiplasmin (α2AP) cross-links, which increases clot mechanical strength and resistance to fibrinolysis. OBJECTIVES Here, we developed a method to quantify fibrin-fibrin and fibrin-α2AP cross-links that avoids the challenges posed by TXA in determining fibrinolytic resistance in conventional assays. METHODS Fibrinogen alpha (FGA) chain (FGA-FGA), fibrinogen gamma (FGG) chain (FGG-FGG), and FGA-α2AP cross-links were quantified using liquid chromatography-mass spectrometry (LC-MS) and parallel reaction monitoring in paired plasma samples from trauma patients prefibrinogen and postfibrinogen replacement. Differences in the abundance of cross-links in trauma patients receiving cryoprecipitate (cryo) or fibrinogen concentrate (Fg-C) were analyzed. RESULTS The abundance of cross-links was significantly increased in trauma patients postcryo, but not Fg-C transfusion (P < .0001). The abundance of cross-links was positively correlated with the toughness of individual fibrin fibers, the peak thrombin concentration, and FXIII antigen (P < .05). CONCLUSION We have developed a novel method that allows us to quantify fibrin cross-links in trauma patients who have received TXA, providing an indirect measure of fibrinolytic resistance. Using this novel approach, we have avoided the effect of TXA and shown that cryo increases fibrin-fibrin and fibrin-α2AP cross-linking when compared with Fg-C, highlighting the importance of FXIII in clot formation and stability in trauma patients.
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Affiliation(s)
- Gael B Morrow
- School of Pharmacy and Life Sciences, Robert Gordon University, Aberdeen, United Kingdom; Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom; Aberdeen Cardiovascular and Diabetes Centre, School of Medicine, Medical Sciences and Nutrition, Institute of Medical Sciences, University of Aberdeen, Aberdeen, United Kingdom.
| | - Sarah Flannery
- Target Discovery Institute, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Philip D Charles
- Target Discovery Institute, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Raphael Heilig
- Target Discovery Institute, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Timea Feller
- Leeds Thrombosis Collective, Discovery and Translational Science Department, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, United Kingdom
| | - Zoe McQuilten
- Transfusion Research Unit, Monash University, Melbourne and Monash Health, Melbourne, Australia
| | - Elizabeth Wake
- Trauma Service, Gold Coast University Hospital, University of Queensland, Southport, Queensland, Australia; School of Medicine, University of Queensland, Southport, Queensland, Australia
| | - Robert A S Ariens
- Leeds Thrombosis Collective, Discovery and Translational Science Department, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, United Kingdom
| | - James Winearls
- School of Medicine, University of Queensland, Southport, Queensland, Australia; Intensive Care Unit, Gold Coast University Hospital, Southport, Queensland, Australia; Australia and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
| | - Nicola J Mutch
- Aberdeen Cardiovascular and Diabetes Centre, School of Medicine, Medical Sciences and Nutrition, Institute of Medical Sciences, University of Aberdeen, Aberdeen, United Kingdom
| | - Roman Fischer
- Target Discovery Institute, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Mike A Laffan
- Centre for Haematology, Imperial College London, London, United Kingdom
| | - Nicola Curry
- Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom; Oxford Haemophilia and Thrombosis Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
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Keltner NM, Cushing MM, Haas T, Spinella PC. Analyzing and modeling massive transfusion strategies and the role of fibrinogen-How much is the patient actually receiving? Transfusion 2024; 64 Suppl 2:S136-S145. [PMID: 38433522 DOI: 10.1111/trf.17774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2023] [Revised: 02/14/2024] [Accepted: 02/15/2024] [Indexed: 03/05/2024]
Abstract
BACKGROUND Hemorrhage is a leading cause of preventable death in trauma, cardiac surgery, liver transplant, and childbirth. While emphasis on protocolization and ratio of blood product transfusion improves ability to treat hemorrhage rapidly, tools to facilitate understanding of the overall content of a specific transfusion strategy are lacking. Medical modeling can provide insights into where deficits in treatment could arise and key areas for clinical study. By using a transfusion model to gain insight into the aggregate content of massive transfusion protocols (MTPs), clinicians can optimize protocols and create opportunities for future studies of precision transfusion medicine in hemorrhage treatment. METHODS The transfusion model describes the individual round and aggregate content provided by four rounds of MTP, illustrating that the total content of blood elements and coagulation factor changes over time, independent of the patient's condition. The configurable model calculates the aggregate hematocrit, platelet concentration, percent volume plasma, total grams and concentration of citrate, percent volume anticoagulant and additive solution, and concentration of clotting factors: fibrinogen, factor XIII, factor VIII, and von Willebrand factor, provided by the MTP strategy. RESULTS Transfusion strategies based on a 1:1:1 or whole blood foundation provide between 13.7 and 17.2 L of blood products over four rounds. Content of strategies varies widely across all measurements based on base strategy and addition of concentrated sources of fibrinogen and other key clotting factors. DISCUSSION Differences observed between modeled transfusion strategies provide key insights into potential opportunities to provide patients with precision transfusion strategy.
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Affiliation(s)
| | - Melissa M Cushing
- Department of Pathology and Laboratory Medicine and Department of Anesthesiology, Weill Cornell Medicine, New York, New York, USA
| | - Thorsten Haas
- Department of Anesthesiology, University of Florida, College of Medicine, Gainesville, Florida, USA
| | - Philip C Spinella
- Department of Surgery and Critical Care Medicine, University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
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Kost GJ, Dohner J, Liu J, Ramos D, Haider N, Thalladi V. Web-accessible critical limits and critical values for urgent clinician notification. Clin Chem Lab Med 2024; 0:cclm-2024-0117. [PMID: 38641917 DOI: 10.1515/cclm-2024-0117] [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: 01/23/2024] [Accepted: 04/05/2024] [Indexed: 04/21/2024]
Abstract
OBJECTIVES To survey the World Wide Web for critical limits/critical values, assess changes in quantitative low/high thresholds since 1990-93, streamline urgent notification practices, and promote global accessibility. METHODS We identified Web-posted lists of critical limits/values at university hospitals. We compared 2023 to 1990-93 archived notification thresholds. RESULTS We found critical notification lists for 26 university hospitals. Laboratory disciplines ranged widely (1-10). The median number of tests was 62 (range 21-116); several posted policies. The breadth of listings increased. Statistically significant differences in 2023 vs. 1990 critical limits were observed for blood gas (pO2, pCO2), chemistry (glucose, calcium, magnesium), and hematology (hemoglobin, platelets, PTT, WBC) tests, and for newborn glucose, potassium, pO2, and hematocrit. Twenty hospitals listed ionized calcium critical limits, which have not changed. Fourteen listed troponin (6), troponin I (3), hs-TnI (3), or troponin T (2). Qualitative critical values expanded across disciplines, encompassing anatomic/surgical pathology. Bioterrorism agents were listed frequently, as were contagious pathogens, although only three hospitals listed COVID-19. Only one notification list detailed point-of-care tests. Two children's hospital lists were Web-accessible. CONCLUSIONS Urgent notifications should focus on life-threatening conditions. We recommend that hospital staff evaluate changes over the past three decades for clinical impact. Notification lists expanded, especially qualitative tests, suggesting that automation might improve efficiency. Sharing notification lists and policies on the Web will improve accessibility. If not dependent on the limited scope of secondary sources, artificial intelligence could enhance knowledge of urgent notification and critical care practices in the 21st Century.
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Affiliation(s)
- Gerald J Kost
- Department of Pathology and Laboratory Medicine, School of Medicine, Davis, CA, USA
- Point-of-Care Testing Center for Teaching and Research (POCT•CTR), Davis, CA, USA
- CEO, Knowledge Optimization, Davis, CA, USA
| | | | - Janet Liu
- University of California, Davis, CA, USA
| | - Dean Ramos
- University of California, Davis, CA, USA
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Hall KE, Tucker C, Dunn JA, Webb T, Watts SA, Kirkman E, Guillaumin J, Hoareau GL, Pidcoke HF. Breaking barriers in trauma research: A narrative review of opportunities to leverage veterinary trauma for accelerated translation to clinical solutions for pets and people. J Clin Transl Sci 2024; 8:e74. [PMID: 38715566 PMCID: PMC11075112 DOI: 10.1017/cts.2024.513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Revised: 03/20/2024] [Accepted: 03/25/2024] [Indexed: 08/10/2024] Open
Abstract
Trauma is a common cause of morbidity and mortality in humans and companion animals. Recent efforts in procedural development, training, quality systems, data collection, and research have positively impacted patient outcomes; however, significant unmet need still exists. Coordinated efforts by collaborative, translational, multidisciplinary teams to advance trauma care and improve outcomes have the potential to benefit both human and veterinary patient populations. Strategic use of veterinary clinical trials informed by expertise along the research spectrum (i.e., benchtop discovery, applied science and engineering, large laboratory animal models, clinical veterinary studies, and human randomized trials) can lead to increased therapeutic options for animals while accelerating and enhancing translation by providing early data to reduce the cost and the risk of failed human clinical trials. Active topics of collaboration across the translational continuum include advancements in resuscitation (including austere environments), acute traumatic coagulopathy, trauma-induced coagulopathy, traumatic brain injury, systems biology, and trauma immunology. Mechanisms to improve funding and support innovative team science approaches to current problems in trauma care can accelerate needed, sustainable, and impactful progress in the field. This review article summarizes our current understanding of veterinary and human trauma, thereby identifying knowledge gaps and opportunities for collaborative, translational research to improve multispecies outcomes. This translational trauma group of MDs, PhDs, and DVMs posit that a common understanding of injury patterns and resulting cellular dysregulation in humans and companion animals has the potential to accelerate translation of research findings into clinical solutions.
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Affiliation(s)
- Kelly E. Hall
- Department of Clinical Sciences, College of Veterinary Medicine & Biomedical Sciences, Colorado State University, Fort Collins, CO, USA
- Translational Trauma Research Alliance (TeTRA-Med), Fort Collins, CO, USA
| | - Claire Tucker
- Department of Clinical Sciences, College of Veterinary Medicine & Biomedical Sciences, Colorado State University, Fort Collins, CO, USA
- Translational Trauma Research Alliance (TeTRA-Med), Fort Collins, CO, USA
- One Health Institute, Office of the Vice President of Research and Department of Clinical Sciences, College of Veterinary Medicine & Biomedical Sciences, Colorado State University, Fort Collins, CO, USA
| | - Julie A. Dunn
- Translational Trauma Research Alliance (TeTRA-Med), Fort Collins, CO, USA
- Medical Center of the Rockies, University of Colorado Health North, Loveland, CO, USA
| | - Tracy Webb
- Department of Clinical Sciences, College of Veterinary Medicine & Biomedical Sciences, Colorado State University, Fort Collins, CO, USA
- Translational Trauma Research Alliance (TeTRA-Med), Fort Collins, CO, USA
| | - Sarah A. Watts
- Translational Trauma Research Alliance (TeTRA-Med), Fort Collins, CO, USA
- CBR Division, Medical and Trauma Sciences Porton Down, Salisbury, WI, UK
| | - Emrys Kirkman
- Translational Trauma Research Alliance (TeTRA-Med), Fort Collins, CO, USA
- CBR Division, Dstl Porton Down, Salisbury, WI, UK
| | - Julien Guillaumin
- Department of Clinical Sciences, College of Veterinary Medicine & Biomedical Sciences, Colorado State University, Fort Collins, CO, USA
- Translational Trauma Research Alliance (TeTRA-Med), Fort Collins, CO, USA
| | - Guillaume L. Hoareau
- Translational Trauma Research Alliance (TeTRA-Med), Fort Collins, CO, USA
- Emergency Medicine Department and Nora Eccles-Harrison Cardiovascular Research and Training Institute and Biomedical Engineering Department, University of Utah, Salt Lake City, UT, USA
| | - Heather F. Pidcoke
- Department of Clinical Sciences, College of Veterinary Medicine & Biomedical Sciences, Colorado State University, Fort Collins, CO, USA
- Translational Trauma Research Alliance (TeTRA-Med), Fort Collins, CO, USA
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Van Gent JM, Kaminski CW, Praestholm C, Pivalizza EG, Clements TW, Kao LS, Stanworth S, Brohi K, Cotton BA. Empiric Cryoprecipitate Transfusion in Patients with Severe Hemorrhage: Results from the US Experience in the International CRYOSTAT-2 Trial. J Am Coll Surg 2024; 238:636-643. [PMID: 38146823 DOI: 10.1097/xcs.0000000000000938] [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: 12/27/2023]
Abstract
BACKGROUND Hypofibrinogenemia has been shown to predict massive transfusion and is associated with higher mortality in severely injured patients. However, the role of empiric fibrinogen replacement in bleeding trauma patients remains controversial. We sought to determine the effect of empiric cryoprecipitate as an adjunct to a balanced transfusion strategy (1:1:1). STUDY DESIGN This study is a subanalysis of patients treated at the single US trauma center in a multicenter randomized controlled trial. Trauma patients (more than 15 years) were eligible if they had evidence of active hemorrhage requiring emergent surgery or interventional radiology, massive transfusion protocol (MTP) activation, and received at least 1 unit of blood. Transfer patients, those with injuries incompatible with life, or those injured more than 3 hours earlier were excluded. Patients were randomized to standard MTP (STANDARD) or MTP plus 3 pools of cryoprecipitate (CRYO). Primary outcomes included all-cause mortality at 28 days. Secondary outcomes were transfusion requirements, intraoperative and postoperative coagulation laboratory values, and quality-of-life measures (Glasgow outcome score-extended). RESULTS Forty-nine patients (23 in the CRYO group and 26 in the STANDARD group) were enrolled between May 2021 and October 2021. Time to randomization was similar between groups (14 vs 24 minutes, p = 0.676). Median time to cryoprecipitate was 41 minutes (interquartile range 37 to 48). There were no differences in demographics, arrival physiology, laboratory values, or injury severity. Intraoperative and ICU thrombelastography values, including functional fibrinogen, were similar between groups. There was no benefit to CRYO with respect to post-emergency department transfusions (intraoperative and ICU through 24 hours), complications, Glasgow outcome score, or mortality. CONCLUSIONS In this study of severely injured, bleeding trauma patients, empiric cryoprecipitate did not improve survival or reduce transfusion requirements. Cryoprecipitate should continue as an "on-demand" addition to a balanced transfusion strategy, guided by laboratory values and should not be given empirically.
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Affiliation(s)
- Jan-Michael Van Gent
- From the Departments of Surgery (Van Gent, Kaminski, Praestholm, Clements, Kao, Cotton)
| | - Carter W Kaminski
- From the Departments of Surgery (Van Gent, Kaminski, Praestholm, Clements, Kao, Cotton)
| | - Caroline Praestholm
- From the Departments of Surgery (Van Gent, Kaminski, Praestholm, Clements, Kao, Cotton)
| | - Evan G Pivalizza
- Anesthesiology (Pivalizza), McGovern Medical School, Houston, TX
| | - Thomas W Clements
- From the Departments of Surgery (Van Gent, Kaminski, Praestholm, Clements, Kao, Cotton)
| | - Lillian S Kao
- From the Departments of Surgery (Van Gent, Kaminski, Praestholm, Clements, Kao, Cotton)
- The Center for Translational Injury Research, Houston, TX (Kao, Cotton)
| | | | - Karim Brohi
- Department of Haematology, University of Oxford, UK (Brohi)
| | - Bryan A Cotton
- From the Departments of Surgery (Van Gent, Kaminski, Praestholm, Clements, Kao, Cotton)
- The Center for Translational Injury Research, Houston, TX (Kao, Cotton)
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Schmitt FCF, Schöchl H, Brün K, Kreuer S, Schneider S, Hofer S, Weber CF. [Update on point-of-care-based coagulation treatment : Systems, reagents, device-specific treatment algorithms]. DIE ANAESTHESIOLOGIE 2024; 73:110-123. [PMID: 38261018 PMCID: PMC10850202 DOI: 10.1007/s00101-023-01368-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 08/28/2023] [Indexed: 01/24/2024]
Abstract
Viscoelastic test (VET) procedures suitable for point-of-care (POC) testing are in widespread clinical use. Due to the expanded range of available devices and in particular due to the development of new test approaches and methods, the authors believe that an update of the current treatment algorithms is necessary. The aim of this article is to provide an overview of the currently available VET devices and the associated reagents. In addition, two treatment algorithms for the VET devices most commonly used in German-speaking countries are presented.
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Affiliation(s)
- Felix C F Schmitt
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 420, 69120, Heidelberg, Deutschland.
| | - Herbert Schöchl
- Ludwig Boltzmann Institut für Traumatologie, AUVA Research Center, Wien, Österreich
- Klinik für Anästhesiologie und Intensivmedizin, AUVA Unfallkrankenhaus, Salzburg, Österreich
| | - Kathrin Brün
- Klinik für Anästhesiologie, Intensivmedizin und Schmerztherapie, Universitätsklinikum des Saarlandes, Homburg, Deutschland
| | - Sascha Kreuer
- Klinik für Anästhesiologie, Intensivmedizin und Schmerztherapie, Universitätsklinikum des Saarlandes, Homburg, Deutschland
- Medizinische Fakultät, Universität des Saarlandes, Homburg, Deutschland
| | - Sven Schneider
- Klinik für Anästhesiologie, Intensivmedizin und Schmerztherapie, Universitätsklinikum des Saarlandes, Homburg, Deutschland
| | - Stefan Hofer
- Klinik für Anästhesiologie, Westpfalz-Klinikum Kaiserslautern, Kaiserslautern, Deutschland
| | - Christian F Weber
- Klinik für Anästhesiologie, Intensiv- und Notfallmedizin, Asklepios Klinik Wandsbek, Hamburg, Deutschland
- Klinik für Anästhesiologie, Intensivmedizin und Schmerztherapie, Universitätsklinikum Frankfurt, Frankfurt am Main, Deutschland
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10
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Bodnar D, Bosley E, Raven S, Williams S, Ryan G, Wullschleger M, Lam AK. The nature and timing of coagulation dysfunction in a cohort of trauma patients in the Australian pre-hospital setting. Injury 2024; 55:111124. [PMID: 37858445 DOI: 10.1016/j.injury.2023.111124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 09/11/2023] [Accepted: 10/12/2023] [Indexed: 10/21/2023]
Abstract
BACKGROUND Acute Traumatic Coagulopathy (ATC) is a complex pathological process that is associated with patient mortality and increased blood transfusion requirements. It is evident on hospital arrival, but there is a paucity of information about the nature of ATC and the characteristics of patients that develop ATC in the pre-hospital setting. The objective of this study was to describe the nature and timing of coagulation dysfunction in a cohort of injured patients and to report on patient and pre-hospital factors associated with the development of ATC in the field. METHODS This was a prospective observational study of a convenience sample of trauma patients. Patients had blood taken during the pre-hospital phase of care and evaluated for derangements in Conventional Coagulation Assays (CCA) and Rotational Thromboelastometry (ROTEM). Associations between coagulation derangement and pre-hospital factors and patient outcomes were evaluated. RESULTS A total of 216 patients who had either a complete CCA or ROTEM were included in the analysis. One hundred and eighty (83 %) of patients were male, with a median injury severity score of 17 [interquartile range (IQR) 10-27] and median age of 34 years [IQR = 25.0-52.0]. Hypofibrinogenemia was the predominant abnormality seen, (CCA Hypofibrinogenemia: 51/193, 26 %; ROTEM hypofibrinogenemia: 65/204, 32 %). Increased CCA derangement, the presence of ROTEM coagulopathy, worsening INR, worsening FibTEM and decreasing fibrinogen concentration, were all associated with both mortality and early massive transfusion. CONCLUSION Clinically significant, multifaceted coagulopathy develops early in the clinical course, with hypofibrinogenemia being the predominant coagulopathy. In keeping with the ED literature, pre-hospital coagulation dysfunction was associated with mortality and early massive transfusion. Further work is required to identify strategies to identify and guide the pre-hospital management of the coagulation dysfunction seen in trauma.
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Affiliation(s)
- Daniel Bodnar
- Office of the Medical Director, Queensland Ambulance Service, Brisbane, Australia; School of Medicine and Dentistry, Griffith University, Gold Coast, Australia; Emergency and Trauma Centre, Royal Brisbane and Women's Hospital, Herston, Australia; Emergency Department, Queensland Children's Hospital, South Brisbane, Australia; School of Medicine, University of Queensland, Brisbane, Australia.
| | - Emma Bosley
- Office of the Medical Director, Queensland Ambulance Service, Brisbane, Australia; School of Clinical Sciences, Queensland University of Technology, Brisbane, Australia
| | - Steven Raven
- Office of the Medical Director, Queensland Ambulance Service, Brisbane, Australia
| | - Sue Williams
- Pathology Queensland Central Transfusion Laboratory, Royal Brisbane and Women's Hospital, Herston, Australia
| | - Glenn Ryan
- School of Medicine, University of Queensland, Brisbane, Australia; Emergency Department, The Princess Alexandra Hospital, Woolloongabba, Australia
| | - Martin Wullschleger
- School of Medicine and Dentistry, Griffith University, Gold Coast, Australia; Trauma Service, Gold Coast University Hospital, Gold Coast, Australia
| | - Alfred K Lam
- School of Medicine and Dentistry, Griffith University, Gold Coast, Australia; School of Medicine, University of Queensland, Brisbane, Australia; Pathology Queensland, Gold Coast University Hospital, Gold Coast, Australia
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11
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Zipperle J, Schmitt FCF, Schöchl H. Point-of-care, goal-directed management of bleeding in trauma patients. Curr Opin Crit Care 2023; 29:702-712. [PMID: 37861185 DOI: 10.1097/mcc.0000000000001107] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2023]
Abstract
PURPOSE OF REVIEW The purpose of this review is to consider the clinical value of point-of-care (POC) testing in coagulopathic trauma patients with traumatic brain injury (TBI) and trauma-induced coagulopathy (TIC). RECENT FINDINGS Patients suffering from severe TBI or TIC are at risk of developing pronounced haemostatic disorders. Standard coagulation tests (SCTs) are insufficient to reflect the complexity of these coagulopathies. Recent evidence has shown that viscoelastic tests (VETs) identify haemostatic disorders more rapidly and in more detail than SCTs. Moreover, VET results can guide coagulation therapy, allowing individualised treatment, which decreases transfusion requirements. However, the impact of VET on mortality remains uncertain. In contrast to VETs, the clinical impact of POC platelet function testing is still unproven. SUMMARY POC SCTs are not able to characterise the complexity of trauma-associated coagulopathy. VETs provide a rapid estimation of underlying haemostatic disorders, thereby providing guidance for haemostatic therapy, which impacts allogenic blood transfusion requirements. The value of POC platelet function testing to identify platelet dysfunction and guide platelet transfusion is still uncertain.
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Affiliation(s)
- Johannes Zipperle
- Ludwig Boltzmann Institute for Traumatology, the Research Centre in Cooperation with AUVA, Vienna
| | - Felix C F Schmitt
- Department of Anaesthesiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Herbert Schöchl
- Ludwig Boltzmann Institute for Traumatology, the Research Centre in Cooperation with AUVA, Vienna
- Paracelsus Medical University, Salzburg, Austria
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12
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Thibeault F, Plourde G, Fellouah M, Ziegler D, Carrier FM. Preoperative fibrinogen level and blood transfusions in liver transplantation: A systematic review. Transplant Rev (Orlando) 2023; 37:100797. [PMID: 37778295 DOI: 10.1016/j.trre.2023.100797] [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: 07/24/2023] [Revised: 09/03/2023] [Accepted: 09/23/2023] [Indexed: 10/03/2023]
Abstract
BACKGROUND Orthotopic liver transplantation (OLT) is a major surgery often associated with significant bleeding. We conducted a systematic review to explore the association between preoperative fibrinogen level and intraoperative blood products transfusion, blood loss and clinical outcomes in patients undergoing OLT. METHODS We included observational studies conducted in patients undergoing an OLT mostly for end-stage liver disease that reported an association between the preoperative fibrinogen level and our outcomes of interest. Our primary outcome was the intraoperative red blood cell (RBC) transfusion requirements. Our secondary outcomes were intraoperative blood loss, intraoperative transfusion of any blood product, postoperative RBC transfusion, postoperative thrombotic or hemorrhagic complications, and mortality. We used a standardized search strategy. We reported our results mostly descriptively but conducted meta-analyses using random-effect models when judged feasible. RESULTS We selected 24 cohort studies reporting at least one of our outcomes. We found that a high preoperative fibrinogen level was associated with fewer intraoperative RBC and other blood products transfusions, and lower blood loss. We also found a lower overall survival in patients with a higher fibrinogen level (pooled hazard ratio [95% CI] of 1.50 [1.23 to 1.84]; 5 studies, n = 1012, I2 = 48%). Only one study formally explored a fibrinogen level threshold effect. Overall, reporting was heterogeneous, and risk of bias was variable mostly because of uncontrolled confounding. CONCLUSION A higher preoperative fibrinogen level was associated with fewer intraoperative RBC and other blood products transfusions, lower blood loss, and higher mortality. Further studies may help clarify observed associations and inform guidelines.
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Affiliation(s)
| | - Guillaume Plourde
- Department of Medicine, Critical Care service, Centre hospitalier de l'Université de Montréal (CHUM), Canada; Health evaluation and innovation hub, Centre de Recherche du CHUM, Canada; Department of Medicine, Université de Montréal, Canada
| | | | - Daniela Ziegler
- Library, Centre hospitalier de l'Université de Montréal (CHUM), Canada
| | - François Martin Carrier
- Department of Medicine, Critical Care service, Centre hospitalier de l'Université de Montréal (CHUM), Canada; Health evaluation and innovation hub, Centre de Recherche du CHUM, Canada; Department of Anesthesiology, Centre hospitalier de l'Université de Montréal (CHUM), Canada; Department of Anesthesiology and Pain Medicine, Université de Montréal, Canada.
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13
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Davenport R, Curry N, Fox EE, Thomas H, Lucas J, Evans A, Shanmugaranjan S, Sharma R, Deary A, Edwards A, Green L, Wade CE, Benger JR, Cotton BA, Stanworth SJ, Brohi K. Early and Empirical High-Dose Cryoprecipitate for Hemorrhage After Traumatic Injury: The CRYOSTAT-2 Randomized Clinical Trial. JAMA 2023; 330:1882-1891. [PMID: 37824155 PMCID: PMC10570921 DOI: 10.1001/jama.2023.21019] [Citation(s) in RCA: 23] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Accepted: 09/26/2023] [Indexed: 10/13/2023]
Abstract
Importance Critical bleeding is associated with a high mortality rate in patients with trauma. Hemorrhage is exacerbated by a complex derangement of coagulation, including an acute fibrinogen deficiency. Management is fibrinogen replacement with cryoprecipitate transfusions or fibrinogen concentrate, usually administered relatively late during hemorrhage. Objective To assess whether survival could be improved by administering an early and empirical high dose of cryoprecipitate to all patients with trauma and bleeding that required activation of a major hemorrhage protocol. Design, Setting, and Participants CRYOSTAT-2 was an interventional, randomized, open-label, parallel-group controlled, international, multicenter study. Patients were enrolled at 26 UK and US major trauma centers from August 2017 to November 2021. Eligible patients were injured adults requiring activation of the hospital's major hemorrhage protocol with evidence of active hemorrhage, systolic blood pressure less than 90 mm Hg at any time, and receiving at least 1 U of a blood component transfusion. Intervention Patients were randomly assigned (in a 1:1 ratio) to receive standard care, which was the local major hemorrhage protocol (reviewed for guideline adherence), or cryoprecipitate, in which 3 pools of cryoprecipitate (6-g fibrinogen equivalent) were to be administered in addition to standard care within 90 minutes of randomization and 3 hours of injury. Main Outcomes and Measures The primary outcome was all-cause mortality at 28 days in the intention-to-treat population. Results Among 1604 eligible patients, 799 were randomized to the cryoprecipitate group and 805 to the standard care group. Missing primary outcome data occurred in 73 patients (principally due to withdrawal of consent) and 1531 (95%) were included in the primary analysis population. The median (IQR) age of participants was 39 (26-55) years, 1251 (79%) were men, median (IQR) Injury Severity Score was 29 (18-43), 36% had penetrating injury, and 33% had systolic blood pressure less than 90 mm Hg at hospital arrival. All-cause 28-day mortality in the intention-to-treat population was 26.1% in the standard care group vs 25.3% in the cryoprecipitate group (odds ratio, 0.96 [95% CI, 0.75-1.23]; P = .74). There was no difference in safety outcomes or incidence of thrombotic events in the standard care vs cryoprecipitate group (12.9% vs 12.7%). Conclusions and Relevance Among patients with trauma and bleeding who required activation of a major hemorrhage protocol, the addition of early and empirical high-dose cryoprecipitate to standard care did not improve all cause 28-day mortality. Trial Registration ClinicalTrials.gov Identifier: NCT04704869; ISRCTN Identifier: ISRCTN14998314.
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Affiliation(s)
- Ross Davenport
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, United Kingdom
| | - Nicola Curry
- Nuffield Orthopedic Hospital, Oxford University Hospitals NHS Foundation Trust, Headington, Oxford, United Kingdom
| | - Erin E. Fox
- Center for Translational Injury Research, The University of Texas Health Science Center, Houston
| | - Helen Thomas
- NHS Blood and Transplant Clinical Trials Unit, Stoke Gifford, Bristol, United Kingdom
| | - Joanne Lucas
- NHS Blood and Transplant Clinical Trials Unit, Cambridge, United Kingdom
| | - Amy Evans
- NHS Blood and Transplant Clinical Trials Unit, Cambridge, United Kingdom
| | | | - Rupa Sharma
- NHS Blood and Transplant Clinical Trials Unit, Cambridge, United Kingdom
| | - Alison Deary
- NHS Blood and Transplant Clinical Trials Unit, Cambridge, United Kingdom
| | - Antoinette Edwards
- The Trauma Audit & Research Network, University of Manchester, Salford Royal NHS Foundation Trust, Salford, United Kingdom
| | - Laura Green
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, United Kingdom
| | - Charles E. Wade
- Center for Translational Injury Research, The University of Texas Health Science Center, Houston
| | - Jonathan R. Benger
- Faculty of Health and Applied Sciences, University of the West of England, Bristol, United Kingdom
| | - Bryan A. Cotton
- Center for Translational Injury Research, The University of Texas Health Science Center, Houston
| | - Simon J. Stanworth
- Radcliffe Department of Medicine, John Radcliffe Hospital, NHS Blood and Transplant and Oxford University Hospitals NHS Foundation Trust, University of Oxford, Headington, Oxford, United Kingdom
| | - Karim Brohi
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, United Kingdom
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14
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Gerard J, Van Gent JM, Cardenas J, Gage C, Meyer DE, Cox C, Wade CE, Cotton BA. Hypofibrinogenemia following injury in 186 children and adolescents: identification of the phenotype, current outcomes, and potential for intervention. Trauma Surg Acute Care Open 2023; 8:e001108. [PMID: 38020863 PMCID: PMC10649809 DOI: 10.1136/tsaco-2023-001108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2023] [Accepted: 10/06/2023] [Indexed: 12/01/2023] Open
Abstract
Objectives Recent studies evaluating fibrinogen replacement in trauma, along with newly available fibrinogen-based products, has led to an increase in debate on where products such as cryoprecipitate belong in our resuscitation strategies. We set out to define the phenotype and outcomes of those with hypofibrinogenemia and evaluate whether fibrinogen replacement should have a role in the initial administration of massive transfusion. Methods All patients <18 years of age presenting to our trauma center 11/17-4/21 were reviewed. We then evaluated all patients who received emergency-release and massive transfusion protocol (MTP) products. Patients were defined as hypofibrinogenemic (HYPOFIB) if admission fibrinogen <150 or rapid thrombelastography (r-TEG) angle <60 degrees. Our analysis sought to define risk factors for presenting with HYPOFIB, the impact on outcomes, and whether early replacement improved mortality. Results 4169 patients were entered into the trauma registry, with 926 level 1 trauma activations, of which 186 patients received emergency-release blood products during this time; 1%, 3%, and 10% were HYPOFIB, respectively. Of the 186 patients of interest, 18 were HYPOFIB and 168 were non-HYPOFIB. The HYPOFIB patients were significantly younger, had lower field and arrival Glasgow Coma Scale, had higher head Abbreviated Injury Scale, arrived with worse global coagulopathy, and died from brain injury. Non-HYPOFIB patients were more likely to have (+)focused assessment for the sonography of trauma on arrival, sustained severe abdominal injuries, and die from hemorrhage. 12% of patients who received early cryoprecipitate (0-2 hours) had higher mortality by univariate analysis (55% vs 31%, p=0.045), but no difference on multivariate analysis (OR 0.36, 95% CI 0.07 to 1.81, p=0.221). Those receiving early cryoprecipitate who survived after pediatric intensive care unit (PICU) admission had lower PICU fibrinogen and r-TEG alpha-angle values. Conclusion In pediatric trauma, patients with hypofibrinogenemia on admission are most likely younger and to have sustained severe brain injury, with an associated mortality of over 80%. Given the absence of bleeding-related deaths in HYPOFIB patients, this study does not provide evidence for the empiric use of cryoprecipitate in the initial administration of a massive transfusion protocol. Level of Evidence Level III - Therapeutic/Care Management.
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Affiliation(s)
- Justin Gerard
- Department of Surgery, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Jan-Michael Van Gent
- Department of Surgery, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Jessica Cardenas
- Department of Surgery, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Christian Gage
- Department of Surgery, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - David E Meyer
- Department of Surgery, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Charles Cox
- Department of Surgery, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Charles E Wade
- Surgery/Center for Injury Research, The University of Texas Health Science Center McGovern School of Medicine, Houston, Texas, USA
| | - Bryan A Cotton
- Department of Surgery, The University of Texas Health Science Center at Houston, Houston, Texas, USA
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15
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Gomez Builes JC, Baker AJ, Callum J, Barahi S, Bai J, Karkouti K, Nisenbaum R, Sholzberg M. Evaluation of the association of factor XIII at hospital arrival and outcomes in a cohort of severely injured patients. J Thromb Haemost 2023; 21:3085-3098. [PMID: 37453456 DOI: 10.1016/j.jtha.2023.07.002] [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: 03/05/2023] [Revised: 07/03/2023] [Accepted: 07/05/2023] [Indexed: 07/18/2023]
Abstract
BACKGROUND Severe traumatic bleeding depletes coagulation factor XIII (FXIII) and fibrinogen. However, the role of FXIII level in bleeding-related outcomes is unknown. OBJECTIVES To evaluate the association between FXIII levels at hospital arrival and critical administration threshold (≥3 red blood cell units in 1 hour within the first 24 hours), bleeding-related outcomes, death, and baseline characteristics. METHODS A retrospective cohort study was conducted in severely injured adult patients (Injury Severity Score of ≥22 or ≥2 red blood cell units transfused in 24 hours) admitted to a level 1 trauma center. Clinical and laboratory data were collected. Baseline FXIII antigen levels were measured in banked patient plasma. Multivariable logistic and linear regression models were used to estimate the association between FXIII levels, outcomes, and baseline characteristics. RESULTS Three hundred sixty-four of 1730 subjects admitted during a 2-year period were analyzed. Median age was 44 years (IQR, 27-62 years), and median Injury Severity Score was 29 (IQR, 22-34). FXIII levels were not associated with critical administration threshold (odds ratio [OR], 1.06; 95% CI, 0.97-1.17) or death (OR, 0.98; 95% CI, 0.90-1.07). FXIII was associated with major bleeding (OR, 1.10; 95% CI, 1.02-1.2) and massive transfusion (OR, 1.25; 95% CI, 1.08-1.44). Lower baseline FXIII levels were associated with arrival from a referring hospital (FXIII level, -0.07 U/mL; 95% CI, -0.11 to -0.03), hemoglobin (FXIII level, -0.05 U/mL; 95% CI, -0.07 to -0.03), fibrinogen level (FXIII level, -0.05 U/mL; 95% CI, -0.08 to -0.02), and platelet count (FXIII level, -0.02 U/mL; 95% CI, -0.04 to -0.008). CONCLUSIONS Baseline FXIII levels in severely injured patients were inconsistently associated with bleeding-related outcomes and mortality. However, their association with major bleeding warrants further investigation of the role of FXIII in massively transfused patients with trauma.
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Affiliation(s)
- Johana Carolina Gomez Builes
- Institute of Medical Sciences, University of Toronto, Toronto, Ontario, Canada; Department of Anesthesia and Pain Medicine, St. Michael's Hospital, Toronto, Ontario, Canada; Department of Anesthesia and Pain Medicine, University of Toronto, Toronto, Ontario, Canada. https://twitter.com/cgomezbuiles
| | - Andrew J Baker
- Institute of Medical Sciences, University of Toronto, Toronto, Ontario, Canada; Department of Anesthesia and Pain Medicine, St. Michael's Hospital, Toronto, Ontario, Canada; Department of Anesthesia and Pain Medicine, University of Toronto, Toronto, Ontario, Canada; Interdepartmental Division of Critical Care, University of Toronto, Toronto, Ontario, Canada; Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada
| | - Jeannie Callum
- Department of Pathology and Molecular Medicine, Kingston Health Sciences Centre, Kingston, Ontario, Canada; Department of Pathology and Molecular Medicine, Queen's University, Kingston, Ontario, Canada
| | - Sunti Barahi
- Department of Anesthesia and Pain Medicine, St. Michael's Hospital, Toronto, Ontario, Canada; Department of Anesthesia and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Johnny Bai
- Department of Anesthesia and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Keyvan Karkouti
- Department of Anesthesia and Pain Medicine, University of Toronto, Toronto, Ontario, Canada; Department of Anesthesia and Pain Management, University Health Network, Sinai Health System, and Women's College Hospital, Toronto, Ontario, Canada
| | - Rosane Nisenbaum
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada; MAP Centre for Urban Health Solutions, Toronto, Ontario, Canada; Applied Health Research Centre, Toronto, Ontario, Canada; Division of Biostatistics, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Michelle Sholzberg
- Institute of Medical Sciences, University of Toronto, Toronto, Ontario, Canada; Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada; Department of Hematology, St. Michael's Hospital, Toronto, Ontario, Canada; Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada.
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16
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Hughes MDG, Cussons S, Hanson BS, Cook KR, Feller T, Mahmoudi N, Baker DL, Ariëns R, Head DA, Brockwell DJ, Dougan L. Building block aspect ratio controls assembly, architecture, and mechanics of synthetic and natural protein networks. Nat Commun 2023; 14:5593. [PMID: 37696784 PMCID: PMC10495373 DOI: 10.1038/s41467-023-40921-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Accepted: 08/16/2023] [Indexed: 09/13/2023] Open
Abstract
Fibrous networks constructed from high aspect ratio protein building blocks are ubiquitous in nature. Despite this ubiquity, the functional advantage of such building blocks over globular proteins is not understood. To answer this question, we engineered hydrogel network building blocks with varying numbers of protein L domains to control the aspect ratio. The mechanical and structural properties of photochemically crosslinked protein L networks were then characterised using shear rheology and small angle neutron scattering. We show that aspect ratio is a crucial property that defines network architecture and mechanics, by shifting the formation from translationally diffusion dominated to rotationally diffusion dominated. Additionally, we demonstrate that a similar transition is observed in the model living system: fibrin blood clot networks. The functional advantages of this transition are increased mechanical strength and the rapid assembly of homogenous networks above a critical protein concentration, crucial for in vivo biological processes such as blood clotting. In addition, manipulating aspect ratio also provides a parameter in the design of future bio-mimetic and bio-inspired materials.
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Affiliation(s)
- Matt D G Hughes
- School of Physics and Astronomy, Faculty of Engineering and Physical Sciences, University of Leeds, Leeds, UK
| | - Sophie Cussons
- Astbury Centre for Structural Molecular Biology, University of Leeds, Leeds, UK
- School of Molecular and Cellular Biology, Faculty of Biological Sciences, University of Leeds, Leeds, UK
| | - Benjamin S Hanson
- School of Physics and Astronomy, Faculty of Engineering and Physical Sciences, University of Leeds, Leeds, UK
| | - Kalila R Cook
- School of Physics and Astronomy, Faculty of Engineering and Physical Sciences, University of Leeds, Leeds, UK
| | - Tímea Feller
- Leeds Institute of Cardiovascular and Metabolic Medicine, Faculty of Medicine and Health, University of Leeds, Leeds, UK
| | - Najet Mahmoudi
- ISIS Neutron and Muon Spallation Source, STFC Rutherford Appleton Laboratory, Oxfordshire, UK
| | - Daniel L Baker
- School of Physics and Astronomy, Faculty of Engineering and Physical Sciences, University of Leeds, Leeds, UK
| | - Robert Ariëns
- Leeds Institute of Cardiovascular and Metabolic Medicine, Faculty of Medicine and Health, University of Leeds, Leeds, UK
| | - David A Head
- School of Computing, Faculty of Engineering and Physical Science, University of Leeds, Leeds, UK
| | - David J Brockwell
- Astbury Centre for Structural Molecular Biology, University of Leeds, Leeds, UK
- School of Molecular and Cellular Biology, Faculty of Biological Sciences, University of Leeds, Leeds, UK
| | - Lorna Dougan
- School of Physics and Astronomy, Faculty of Engineering and Physical Sciences, University of Leeds, Leeds, UK.
- Astbury Centre for Structural Molecular Biology, University of Leeds, Leeds, UK.
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17
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Nathwani R, Proumen A, Blaine KP. Etiology and management of hypofibrinogenemia in trauma. Curr Opin Anaesthesiol 2023; 36:382-387. [PMID: 36994749 DOI: 10.1097/aco.0000000000001265] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/31/2023]
Abstract
PURPOSE OF REVIEW Fibrin polymerization is essential for stable clot formation in trauma, and hypofibrinogenemia reduces hemostasis in trauma. This review considers fibrinogen biology, the changes that fibrinogen undergoes after major trauma, and current evidence for lab testing and treatment. RECENT FINDINGS Fibrinogen is a polypeptide that is converted to fibrin by the action of thrombin. During trauma, fibrinogen levels are consumed and reduce within the first few hours because of consumption, dilution, and fibrinolysis. Fibrinogen levels usually rebound within 48 hours of injury and can contribute to thrombotic events. The Clauss fibrinogen assay is the gold standard test for fibrinogen levels, although viscoelastic hemostatic assays are often used when a lab delay is anticipated. An evidence-based threshold for fibrinogen replacement is not well established in the literature, but expert opinion recommends maintaining a level above 150 mg/dl. SUMMARY Hypofibrinogenemia is an important cause of nonanatomic bleeding in trauma. Despite multiple pathologic causes, the cornerstone of treatment remains fibrinogen replacement with cryoprecipitate or fibrinogen concentrates.
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Affiliation(s)
- Rajen Nathwani
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington
| | - Adrian Proumen
- State University of New York (SUNY) Upstate University Hospital, Syracuse, New York
| | - Kevin P Blaine
- Department of Anesthesiology and Perioperative Medicine, Oregon Health & Science University, UHN2, Portland, Orlando, USA
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18
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Pagnussatt Neto E, Lopes da Costa PD, Gurgel SJT, Schmidt Azevedo P, Modolo NSP, do Nascimento Junior P. Plasma Fibrinogen as a Predictor of Perioperative-Blood-Component Transfusion in Major-Nontraumatic-Orthopedic-Surgery Patients: A Cohort Study. Diagnostics (Basel) 2023; 13:diagnostics13050976. [PMID: 36900120 PMCID: PMC10001368 DOI: 10.3390/diagnostics13050976] [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: 01/18/2023] [Revised: 02/08/2023] [Accepted: 02/27/2023] [Indexed: 03/08/2023] Open
Abstract
There is a trend towards increased perioperative bleeding in patients with plasma fibrinogen levels < 200 mg/dL-1. This study aimed to assess whether there is an association between preoperative fibrinogen levels and perioperative blood-product transfusion up to 48 h after major orthopedic surgery. This cohort study included 195 patients who underwent primary or revision hip arthroplasty for nontraumatic etiologies. Plasma fibrinogen, blood count, coagulation tests, and platelet count were measured preoperatively. A plasma fibrinogen level of 200 mg/dL-1 was the cutoff value used to predict blood transfusion. The mean (SD) plasma fibrinogen level was 325 (83) mg/dL-1. Only thirteen patients had levels < 200 mg/dL-1, and only one of them received a blood transfusion, with an absolute risk of 7.69% (1/13; 95%CI: 1.37-33.31%). Preoperative plasma fibrinogen levels were not associated with the need for blood transfusion (p = 0.745). The sensitivity and the positive predictive value of plasma fibrinogen < 200 mg/dL-1 as a predictor of blood transfusion were 4.17% (95%CI: 0.11-21.12%) and 7.69% (95%CI: 1.12-37.99%), respectively. Test accuracy was 82.05% (95%CI: 75.93-87.17%), but positive and negative likelihood ratios were poor. Therefore, preoperative plasma fibrinogen level in hip-arthroplasty patients was not associated with the need for blood-product transfusion.
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Affiliation(s)
- Eugenio Pagnussatt Neto
- Department of Surgical Specialties and Anesthesiology, School of Medicine, Universidade Estadual Paulista (UNESP), Botucatu 18618-970, SP, Brazil
- São Vicente de Paulo Hospital, Passo Fundo 99010-112, RS, Brazil
- Correspondence: ; Tel.: +55-(54)-99975-7010
| | - Paula Daniele Lopes da Costa
- Department of Surgical Specialties and Anesthesiology, School of Medicine, Universidade Estadual Paulista (UNESP), Botucatu 18618-970, SP, Brazil
| | - Sanderland J. Tavares Gurgel
- Department of Surgical Specialties and Anesthesiology, School of Medicine, Universidade Estadual Paulista (UNESP), Botucatu 18618-970, SP, Brazil
| | - Paula Schmidt Azevedo
- Department of Internal Medicine, School of Medicine, Universidade Estadual Paulista (UNESP), Botucatu 18618-970, SP, Brazil
| | - Norma S. Pinheiro Modolo
- Department of Surgical Specialties and Anesthesiology, School of Medicine, Universidade Estadual Paulista (UNESP), Botucatu 18618-970, SP, Brazil
| | - Paulo do Nascimento Junior
- Department of Surgical Specialties and Anesthesiology, School of Medicine, Universidade Estadual Paulista (UNESP), Botucatu 18618-970, SP, Brazil
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Shock Index for Early Detection of Low Plasma Fibrinogen in Trauma: A Prospective Observational Cohort Pilot Study. J Clin Med 2023; 12:jcm12041707. [PMID: 36836242 PMCID: PMC9966073 DOI: 10.3390/jcm12041707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 02/10/2023] [Accepted: 02/17/2023] [Indexed: 02/23/2023] Open
Abstract
Shock index (a ratio between heart rate and systolic blood pressure) predicts transfusion requirements and the need for haemostatic resuscitation in severe trauma patients. In the present study, we aimed to determine whether prehospital and on-admission shock index values can be used to predict low plasma fibrinogen in trauma patients. Between January 2016 and February 2017, trauma patients admitted from the helicopter emergency medical service into two large trauma centres in the Czech Republic were prospectively assessed for demographic, laboratory and trauma-associated variables and shock index at scene, during transport and at admission to the emergency department. Hypofibrinogenemia defined as fibrinogen plasma level of 1.5 g·L-l was deemed as a cut-off for further analysis. Three hundred and twenty-two patients were screened for eligibility. Of these, 264 (83%) were included for further analysis. The hypofibrinogenemia was predicted by the worst prehospital shock index with the area under the receiver operating characteristics curve (AUROC) of 0.79 (95% CI 0.64-0.91) and by the admission shock index with AUROC of 0.79 (95% CI 0.66-0.91). For predicting hypofibrinogenemia, the prehospital shock index ≥ 1 has 0.5 sensitivity (95% CI 0.19-0.81), 0.88 specificity (95% CI 0.83-0.92) and a negative predictive value of 0.98 (0.96-0.99). The shock index may help to identify trauma patients at risk of hypofibrinogenemia early in the prehospital course.
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Richards J, Fedeles BT, Chow JH, Scalea T, Kozar R. Raising the bar on fibrinogen: a retrospective assessment of critical hypofibrinogenemia in severely injured trauma patients. Trauma Surg Acute Care Open 2023; 8:e000937. [PMID: 36726403 PMCID: PMC9884899 DOI: 10.1136/tsaco-2022-000937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Accepted: 07/04/2022] [Indexed: 01/26/2023] Open
Abstract
Objectives Fibrinogen depletion may occur at higher levels than historically referenced. We evaluated hypofibrinogenemia and associated mortality and multiple organ failure (MOF) after severe injury. Methods Retrospective investigation including 417 adult patients with Injury Severity Score (ISS) >15. Demographics and injury characteristics were collected. Fibrinogen within 30 minutes of admission was described: <150 mg/dL, 150 mg/dL to 200 mg/dL and >200 mg/dL. Primary outcome: 28-day mortality. Secondary outcomes: 28-day MOF and blood product transfusion. Multivariable logistic regression model evaluated association of fibrinogen categories on risk of death, after controlling for confounding variables. Results presented as OR and 95% CIs. Results Fibrinogen <150 mg/dL: 4.8%, 150 mg/dL to 200 mg/dL: 18.2%, >200 mg/dL: 77.0%. 28-day mortality: 15.6%. Patients with <150 mg/dL fibrinogen had over fourfold increased 28-day mortality risk (OR: 4.9, 95% CI 1.53 to 15.7) after adjusting for age, ISS and admission Glasgow Coma Scale. Patients with lower fibrinogen were more likely to develop MOF (p=0.04) and receive larger red blood cell transfusion volumes at 3 hours and 24 hours (p<0.01). Conclusions Fibrinogen <150 mg/dL is significantly associated with increased 28-day mortality. Patients with fibrinogen <150 mg/dL were more likely to develop MOF and required increased administration of blood products. The optimal threshold for critically low fibrinogen, the association with MOF and subsequent fibrinogen replacement requires further investigation. Level of evidence Level III.
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Affiliation(s)
- Justin Richards
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, Maryland, USA,R Adams Cowley Shock Trauma Center, Baltimore, Maryland, USA
| | - Benjamin T Fedeles
- Department of Anesthesiology and Critical Care Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Jonathan H Chow
- Department of Anesthesiology and Critical Care Medicine, The George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Thomas Scalea
- R Adams Cowley Shock Trauma Center, Baltimore, Maryland, USA,Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Rosemary Kozar
- R Adams Cowley Shock Trauma Center, Baltimore, Maryland, USA,Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
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21
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Vyshynska M, Dutko K. VASCULAR-PLATELET HEMOSTASIS OF INJURED PATIENTS: PROSPECTIVE OBSERVATIONAL STUDY. WIADOMOSCI LEKARSKIE (WARSAW, POLAND : 1960) 2023; 76:1511-1516. [PMID: 37622491 DOI: 10.36740/wlek202307101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/26/2023]
Abstract
OBJECTIVE The aim: We study vascular-platelet hemostasis peculiarities in patients with severe trauma. PATIENTS AND METHODS Materials and methods: We included 50 patients, who were divided into control (n=15) and study (n=35) groups. The control group included patients without traumatic injuries, study group - patients with severe trauma. The study group was divided into the I subgroup (patients received 1 g tranexamic acid IV at the prehospital stage), and the II subgroup (1 g tranexamic acid IV after hospital admission). RESULTS Results: The main changes in the I subgroup started on the 3rd day, while in the II subgroup - on the 1st day. Patients of both subgroups on the 1st and 3rd days had a normal number of platelets in venous blood, however, on the 3rd day, there was a decreasing level of discocytes whereas the level of discoechinocytes, spherocytes, spheroechinocytes, and the sum of active forms of platelets were increased in comparison with the control group (p<0.05). CONCLUSION Conclusions: The changes in vascular-platelet hemostasis in patients appeared in the I subgroup on the 3rd day, while in the II subgroup - on the 1st day. For the I subgroup was the decreasing level of discocytes, whereas the level of discoechinocytes, spherocytes, spheroechinocytes, and the sum of active forms of platelets were increased. For the II subgroup on the 1st day, there was an increasing sum of active forms of platelets, on the 3rd day - the level of discocytes was decreased, and levels of discoechinocytes, spherocytes, spheroechinocytes, and the sum of active forms of platelets were increased.
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Affiliation(s)
| | - Khrystyna Dutko
- DANYLO HALYTSKY LVIV NATIONAL MEDICAL UNIVERSITY, LVIV, UKRAINE
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22
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Gosselin AR, White NJ, Bargoud CG, Hanna JS, Tutwiler V. Hyperfibrinolysis drives mechanical instabilities in a simulated model of trauma induced coagulopathy. Thromb Res 2022; 220:131-140. [PMID: 36347079 PMCID: PMC10544892 DOI: 10.1016/j.thromres.2022.10.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 10/04/2022] [Accepted: 10/24/2022] [Indexed: 11/06/2022]
Abstract
INTRODUCTION Trauma induced coagulopathy (TIC) is common after severe trauma, increasing transfusion requirements and mortality among patients. TIC has several phenotypes, with primary hyperfibrinolysis being among the most lethal. We aimed to investigate the contribution of hypercoagulation, hemodilution, and fibrinolytic activation to the hyperfibrinolytic phenotype of TIC, by examining fibrin formation in a plasma-based model of TIC. We hypothesized that instabilities arising from TIC will be due primarily to increased fibrinolytic activation rather than hemodilution or tissue factor (TF) induced hypercoagulation. METHODS The influence of TF, hemodilution, fibrinogen consumption, tissue plasminogen activator (tPA), and the antifibrinolytic tranexamic acid (TXA) on plasma clot formation and structure were examined using rheometry, optical properties, and confocal microscopy. These were then compared to plasma samples from trauma patients at risk of developing TIC. RESULTS Combining TF-induced clot formation, 15 % hemodilution, fibrinogen consumption, and tPA-induced fibrinolysis, the clot characteristics and hyperfibrinolysis were consistent with primary hyperfibrinolysis. TF primarily increased fibrin polymerization rates and reduced fiber length. Hemodilution decreased clot optical density but had no significant effect on mechanical clot stiffness. TPA addition induced primary clot lysis as observed mechanically and optically. TXA restored mechanical clot formation but did not restore clot structure to control levels. Patients at risk of TIC showed increased clot formation, and lysis like that of our simulated model. CONCLUSIONS This simulated TIC plasma model demonstrated that fibrinolytic activation is a primary driver of instability during TIC and that clot mechanics can be restored, but clot structure remains altered with TXA treatment.
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Affiliation(s)
- Andrew R Gosselin
- Department of Biomedical Engineering, Rutgers -The State University of New Jersey, Piscataway, NJ, USA
| | - Nathan J White
- Department of Emergency Medicine, Resuscitation Engineering Science Unit, University of Washington School of Medicine, Seattle, WA, USA
| | - Christopher G Bargoud
- Department of Surgery, Rutgers-Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Joseph S Hanna
- Department of Surgery, Rutgers-Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Valerie Tutwiler
- Department of Biomedical Engineering, Rutgers -The State University of New Jersey, Piscataway, NJ, USA.
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23
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Duque P, Korte W. Factor XIII in the Acute Care Setting and Its Relevance in Obstetric Bleeding. Transfus Med Hemother 2022; 50:10-17. [PMID: 36818773 PMCID: PMC9912001 DOI: 10.1159/000526489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 08/06/2022] [Indexed: 11/25/2022] Open
Abstract
Background Major hemorrhage is one of the main causes of preventable mortality in either severe trauma, high-risk surgical patient, or the obstetric population. As underlined by the cell-based coagulation model, a resistant and stable clot is essential to prevent or to stop an ongoing bleeding. Coagulation factor XIII (FXIII) stabilizes the newly formed clot by cross-linking the fibrin monomers into a three-dimensional network and by impeding fibrinolysis. Thus, FXIII is an essential coagulation factor in the acutely bleeding patient. Summary Acquired FXIII deficiency is much more common than the inherited form. On the basis of acute tissue injury which leads to major bleeding, acquired FXIII deficiency is traditionally considered to be secondary to consumption. However, recent evidence in the field of obstetrics and high-risk surgery suggests that it might be an associated factor rather than a consequence of the bleeding, which would mean that early replacement of FXIII could potentially improve outcomes. However, FXIII measurement is not universally available. Assessing FXIII through viscoelastic assays seems feasible, though likely it is not yet accurate. Moreover, the target population at risk and the aimed FXIII level required to achieve hemostasis in each condition are yet to be defined. Key Messages FXIII should be assessed and replaced if necessary in the acutely bleeding patient. We recommend FXIII to be included in an escalating scheme of hemostatic therapies in the acute care setting.
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Affiliation(s)
- Patricia Duque
- Anesthesiology and Intensive Care Department, Gregorio Marañon Hospital, Madrid, Spain,*Patricia Duque,
| | - Wolfgang Korte
- Haemostasis and Haemophilia Center, St. Gallen, Switzerland
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24
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Morrow GB, Feller T, McQuilten Z, Wake E, Ariëns RAS, Winearls J, Mutch NJ, Laffan MA, Curry N. Cryoprecipitate transfusion in trauma patients attenuates hyperfibrinolysis and restores normal clot structure and stability: Results from a laboratory sub-study of the FEISTY trial. Crit Care 2022; 26:290. [PMID: 36163263 PMCID: PMC9511733 DOI: 10.1186/s13054-022-04167-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 09/13/2022] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Fibrinogen is the first coagulation protein to reach critical levels during traumatic haemorrhage. This laboratory study compares paired plasma samples pre- and post-fibrinogen replacement from the Fibrinogen Early In Severe Trauma studY (FEISTY; NCT02745041). FEISTY is the first randomised controlled trial to compare the time to administration of cryoprecipitate (cryo) and fibrinogen concentrate (Fg-C; Riastap) in trauma patients. This study will determine differences in clot strength and fibrinolytic stability within individuals and between treatment arms. METHODS Clot lysis, plasmin generation, atomic force microscopy and confocal microscopy were utilised to investigate clot strength and structure in FEISTY patient plasma. RESULTS Fibrinogen concentration was significantly increased post-transfusion in both groups. The rate of plasmin generation was reduced 1.5-fold post-transfusion of cryo but remained unchanged with Fg-C transfusion. Plasminogen activator inhibitor 1 activity and antigen levels and Factor XIII antigen were increased post-treatment with cryo, but not Fg-C. Confocal microscopy analysis of fibrin clots revealed that cryo transfusion restored fibrin structure similar to those observed in control clots. In contrast, clots remained porous with stunted fibres after infusion with Fg-C. Cryo but not Fg-C treatment increased individual fibre toughness and stiffness. CONCLUSIONS In summary, our data indicate that cryo transfusion restores key fibrinolytic regulators and limits plasmin generation to form stronger clots in an ex vivo laboratory study. This is the first study to investigate differences in clot stability and structure between cryo and Fg-C and demonstrates that the additional factors in cryo allow formation of a stronger and more stable clot.
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Affiliation(s)
- Gael B Morrow
- Nuffield Division of Clinical Laboratory Sciences, Radcliffe Department of Medicine, University of Oxford, Oxford, OX3 9DU, UK.
- Aberdeen Cardiovascular and Diabetes Centre, School of Medicine, Medical Sciences and Nutrition, Institute of Medical Sciences, University of Aberdeen, Aberdeen, UK.
| | - Timea Feller
- Leeds Thrombosis Collective, Discovery and Translational Science Department, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Zoe McQuilten
- Transfusion Research Unit, Melbourne and Monash Health, Monash University, Melbourne, Australia
| | - Elizabeth Wake
- Trauma Service, Gold Coast University Hospital, Southport, Australia
- School of Medicine and Dentistry, Griffith University, Gold Coast Campus, Southport, Australia
| | - Robert A S Ariëns
- Leeds Thrombosis Collective, Discovery and Translational Science Department, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - James Winearls
- School of Medicine and Dentistry, Griffith University, Gold Coast Campus, Southport, Australia
| | - Nicola J Mutch
- Aberdeen Cardiovascular and Diabetes Centre, School of Medicine, Medical Sciences and Nutrition, Institute of Medical Sciences, University of Aberdeen, Aberdeen, UK
| | - Mike A Laffan
- Centre for Haematology, Imperial College London, London, UK
- Oxford Haemophilia and Thrombosis Centre, NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Nicola Curry
- Nuffield Division of Clinical Laboratory Sciences, Radcliffe Department of Medicine, University of Oxford, Oxford, OX3 9DU, UK
- Oxford Haemophilia and Thrombosis Centre, NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
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Kunii M, Nakao S, Nakagawa Y, Shimazaki J, Ogura H. Impact of Pelvic Fracture Sites on Fibrinogen Depletion in Patients with Blunt Trauma: A Single-Center Cohort Study. J Clin Med 2022; 11:jcm11164689. [PMID: 36012927 PMCID: PMC9409758 DOI: 10.3390/jcm11164689] [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: 06/23/2022] [Revised: 08/09/2022] [Accepted: 08/10/2022] [Indexed: 11/25/2022] Open
Abstract
Background: We aimed to examine the association of pelvic fracture sites with the minimum fibrinogen level within 24 h after hospital arrival. Methods: We conducted a single-center cohort study using health records review. We included patients with pelvic fractures transported by ambulance to a tertiary-care hospital from January 2012 to December 2018 and excluded those transported from other hospitals or aged younger than 16 years. The pelvic fracture was diagnosed and confirmed by trauma surgeons and/or radiologists. We classified the fracture sites of the pelvis as ilium, pubis, ischium, acetabulum, sacrum, sacroiliac joint diastasis, and pubic symphysis diastasis, and each side was counted separately except for pubic symphysis diastasis. We performed linear regression analysis to evaluate the association between pelvic fracture sites and the minimum fibrinogen level within 24 h of arrival. Results: We analyzed 120 pelvic fracture patients. Their mean age was 47.3 years, and 69 (57.5%) patients were men. The median Injury Severity Score was 24, and in-hospital mortality was 10.8%. The mean minimum fibrinogen level within 24 h of arrival was 171.4 mg/dL. Among pelvic fracture sites, only sacrum fracture was statistically significantly associated with the minimum fibrinogen level within 24 h of arrival (estimate, −34.5; 95% CI, −58.6 to −10.4; p = 0.005). Conclusions: Fracture of the sacrum in patients with pelvic fracture was associated with lower minimum fibrinogen levels within 24 h of hospital arrival and the requirement of blood transfusion.
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26
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Barquero López M, Martínez Cabañero J, Muñoz Valencia A, Sáez Ibarra C, De la Rosa Estadella M, Campos Serra A, Gil Velázquez A, Pujol Caballé G, Navarro Soto S, Puyana JC. Dynamic use of fibrinogen under viscoelastic assessment results in reduced need for plasma and diminished overall transfusion requirements in severe trauma. J Trauma Acute Care Surg 2022; 93:166-175. [PMID: 35358159 PMCID: PMC9329202 DOI: 10.1097/ta.0000000000003624] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Despite advances in trauma management, half of trauma deaths occur secondary to bleeding. Currently, hemostatic resuscitation strategies consist of empirical transfusion of blood products in a predefined fixed ratio (1:1:1) to both treat hemorrhagic shock and correct trauma-induced coagulopathy. At our hospital, the implementation of a resuscitation protocol guided by viscoelastic hemostatic assays (VHAs) with rotational thromboelastometry has resulted in a goal-directed approach. The objective of the study is twofold, first to analyze changes in transfusion practices overtime and second to identify the impact of these changes on coagulation parameters and clinical outcomes. We hypothesized that progressive VHA implementation results in a higher administration of fibrinogen concentrate (FC) and lower use of blood products transfusion, especially plasma. METHODS A total of 135 severe trauma patients (January 2008 to July 2019), all requiring and initial assessment for high risk of trauma-induced coagulopathy based on high-energy injury mechanism, severity of bleeding and hemodynamic instability were included. After 2011 when we first modified the transfusion protocol, a progressive change in transfusional management occurred over time. Three treatment groups were established, reflecting different stages in the evolution of our strategy: plasma (P, n = 28), plasma and FC (PF, n = 64) and only FC (F, n = 42). RESULTS There were no significant differences in baseline characteristics among groups. Progressive implementation of rotational thromboelastometry resulted in increased use of FC over time ( p < 0.001). Regression analysis showed that group F had a significant reduction in transfusion of packed red blood cells ( p = 0.005), plasma ( p < 0.001), and platelets ( p = 0.011). Regarding outcomes, F patients had less pneumonia ( p = 0.019) and multiorgan failure ( p < 0.001), without significant differences for other outcomes. Likewise, overall mortality was not significantly different. However, further analysis comparing specific mortality due only to massive hemorrhage in the F group versus all patients receiving plasma, it was significantly lower ( p = 0.037). CONCLUSION Implementing a VHA-based algorithm resulted in a plasma-free strategy with higher use of FC and a significant reduction of packed red blood cells transfused. In addition, we observed an improvement in outcomes without an increase in thrombotic complications. LEVEL OF EVIDENCE Therapeutic/Care Management; Level IV.
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Affiliation(s)
- Marta Barquero López
- From the Department of Anesthesiolgy (M.B.L.), Bellvitge University Hospital L'Hospitalet de Llobregat; Department of Anesthesiology (J.M.C., C.S.I., M.D.l.R.E., G.P.C.), Parc Taulí University Hospital, Sabadell, Barcelona, Spain; Global Health, Division of Trauma and Surgery (A.M.V., J.C.P.), University of Pittsburgh, Pittsburgh, Pennsylvania; Department of General Surgery (A.C.S., S.N.S.), Parc Taulí University Hospital; and Department of Intensive Care (A.G.V.). Taulí University Hospital, Sabadell, Barcelona, Spain
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27
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Sulimai NH, Brown J, Lominadze D. Fibrinogen, Fibrinogen-like 1 and Fibrinogen-like 2 Proteins, and Their Effects. Biomedicines 2022; 10:biomedicines10071712. [PMID: 35885017 PMCID: PMC9313381 DOI: 10.3390/biomedicines10071712] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Revised: 07/11/2022] [Accepted: 07/13/2022] [Indexed: 12/05/2022] Open
Abstract
Fibrinogen (Fg) and its derivatives play a considerable role in many diseases. For example, increased levels of Fg have been found in many inflammatory diseases, such as Alzheimer’s disease, multiple sclerosis, traumatic brain injury, rheumatoid arthritis, systemic lupus erythematosus, and cancer. Although associations of Fg, Fg chains, and its derivatives with various diseases have been established, their specific effects and the mechanisms of actions involved are still unclear. The present review is the first attempt to discuss the role of Fg, Fg chains, its derivatives, and other members of Fg family proteins, such as Fg-like protein 1 and 2, in inflammatory diseases and their effects in immunomodulation.
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Affiliation(s)
- Nurul H. Sulimai
- Departments of Surgery, University of South Florida Morsani College of Medicine, Tampa, FL 33612, USA; (N.H.S.); (J.B.)
| | - Jason Brown
- Departments of Surgery, University of South Florida Morsani College of Medicine, Tampa, FL 33612, USA; (N.H.S.); (J.B.)
| | - David Lominadze
- Departments of Surgery, University of South Florida Morsani College of Medicine, Tampa, FL 33612, USA; (N.H.S.); (J.B.)
- Departments of Molecular Pharmacology and Physiology, University of South Florida Morsani College of Medicine, Tampa, FL 33612, USA
- Correspondence:
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28
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Ban Q, Zhang Y, Li Y, Cao D, Ye W, Zhan L, Wang D, Wang X. A point-of-care microfluidic channel-based device for rapid and direct detection of fibrinogen in whole blood. LAB ON A CHIP 2022; 22:2714-2725. [PMID: 35748483 DOI: 10.1039/d2lc00437b] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Hemorrhage is the leading cause of preventable death in civilian and battlefield traumatic injuries. Patients with severe traumatic hemorrhagic shock are more likely to be deficient in fibrinogen than those with other coagulation factors, and hypofibrinogenemia is an independent risk factor for mortality. Thus, rapid detection of fibrinogen levels is of great importance in these patients during damage control resuscitation. Plasma is used as an analyte in fibrinogen detection, which restricts the use of existing devices in emergencies. To meet the needs of on-site detection, we developed a point-of-care microfluidic channel-based device for direct measurement of fibrinogen concentration in whole blood. In our method, thrombin is dispersed on a reaction strip to initiate conversion of fibrinogen to fibrin. The permeability of the resulting blood clots depends on the fibrinogen level. A hydrophobic plastic protection flake between the reaction strip and a wicking strip is then removed to allow flow of unclotted blood. The rate of blood flow along the wicking strip was inversely related to the fibrinogen concentration. The whole process could be completed in as fast as 5 minutes for a whole blood sample size of 150 μL, and yielded accurate results ranging from 0 to 4 g L-1, which were unaffected by Ca2+, blood lipids, hematocrit, warfarin and tissue plasminogen activators (tPAs). Results using clinical whole blood samples were also highly consistent with those using an automatic coagulation analyzer, yielding a Pearson correlation coefficient of up to 0.919. This approach has potential for allowing rapid diagnosis of fibrinogen concentration in critically ill bleeding patients in different settings, thus helping to judge the suitability of fibrinogen replacement therapy (FRT) in cases of emergency bleeding and in patients at risk of thrombosis due to hyperfibrinogenemia.
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Affiliation(s)
- Qinan Ban
- Institute of Health Service and Transfusion Medicine, Beijing 100850, P. R. China.
- BGI College, Zhengzhou University, Henan, 450001, P. R. China
| | - Yulong Zhang
- Institute of Health Service and Transfusion Medicine, Beijing 100850, P. R. China.
| | - Yuxuan Li
- Institute of Health Service and Transfusion Medicine, Beijing 100850, P. R. China.
| | - Daye Cao
- Anbio (Xiamen) Biotechnology Co., Ltd, Xiamen, Fujian Province, 361028, P. R. China
| | - Weifeng Ye
- Center of Clinical Laboratory, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, P. R. China
| | - Linsheng Zhan
- Institute of Health Service and Transfusion Medicine, Beijing 100850, P. R. China.
- BGI College, Zhengzhou University, Henan, 450001, P. R. China
| | - Daming Wang
- Anbio (Xiamen) Biotechnology Co., Ltd, Xiamen, Fujian Province, 361028, P. R. China
- Suzhou Institute of Biomedical Engineering and Technology (SIBET), Chinese Academy of Sciences, Suzhou, Jiangsu Province, 215163, P. R. China.
| | - Xiaohui Wang
- Institute of Health Service and Transfusion Medicine, Beijing 100850, P. R. China.
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Comparison of Bacterial Risk in Cryo AHF and Pathogen Reduced Cryoprecipitated Fibrinogen Complex. Pathogens 2022; 11:pathogens11070744. [PMID: 35889990 PMCID: PMC9317717 DOI: 10.3390/pathogens11070744] [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: 06/21/2022] [Accepted: 06/23/2022] [Indexed: 12/04/2022] Open
Abstract
Until November 2020, cryoprecipitated antihaemophilic factor (cryo AHF) was the only United States Food and Drug Administration (FDA)-approved fibrinogen source to treat acquired bleeding. The post-thaw shelf life of cryo AHF is limited, in part, by infectious disease risk. Concerns over product wastage demand that cryo AHF is thawed as needed, with thawing times delaying the treatment of coagulopathic patients. In November 2020, the FDA approved Pathogen Reduced Cryoprecipitated Fibrinogen Complex for the treatment and control of bleeding, including massive hemorrhage, associated with fibrinogen deficiency. Pathogen Reduced Cryoprecipitated Fibrinogen Complex (also known as INTERCEPT® Fibrinogen Complex, IFC) has a five-day post-thaw room-temperature shelf life. Unlike cryo AHF, manufacturing of IFC includes broad spectrum pathogen reduction (Amotosalen + UVA), enabling this extended post-thaw shelf life. In this study, we investigated the risk of bacterial contamination persisting through the cryoprecipitation manufacturing process of cryo AHF and IFC. Experiments were performed which included spiking plasma with bacteria prior to cryoprecipitation, and bacterial survival was analyzed at each step of the manufacturing process. The results show that while bacteria survive cryo AHF manufacturing, IFC remains sterile through to the end of shelf life and beyond. IFC, with a five-day post-thaw shelf life, allows the product to be sustainably thawed in advance, facilitating immediate access to concentrated fibrinogen and other key clotting factors for the treatment of bleeding patients.
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30
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Richards JE, Fedeles BT. Coagulation Management in Trauma: Do We Need a Viscoelastic Hemostatic Assay? CURRENT ANESTHESIOLOGY REPORTS 2022. [DOI: 10.1007/s40140-022-00532-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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31
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George S, Wake E, Sweeny A, Campbell D, Winearls J. Rotational thromboelastometry in children presenting to an Australian major trauma centre: A retrospective cohort study. Emerg Med Australas 2022; 34:590-598. [PMID: 35203106 PMCID: PMC9542394 DOI: 10.1111/1742-6723.13939] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Revised: 01/09/2022] [Accepted: 01/29/2022] [Indexed: 12/22/2022]
Abstract
Objective This retrospective cohort study aims to describe patterns of rotational thromboelastometry (ROTEM™) results in paediatric trauma following the implementation of a ROTEM‐guided critical bleeding algorithm and major haemorrhage protocol (MHP). Methods This retrospective observational study was conducted in a tertiary trauma hospital in Queensland, Australia, where point‐of‐care ROTEM was introduced for paediatric patients in 2014. All children aged less than 18 years who had a ROTEM test during their presentation between January 2014 and December 2017 for a traumatic injury were included in the dataset. Other children with a record in the hospital's trauma registry in the same period were also screened for blood product usage. Data were collected for frequency of ROTEM testing, pathology and ROTEM results, blood product and antifibrinolytic use along with injury related data. Compliance with recommended treatment thresholds for detected coagulopathy was also reviewed. Results A total of 1039 children were listed in the trauma registry, including 167 children having a ROTEM test for trauma. Factors significantly associated with having a ROTEM test were older age, higher injury severity score (ISS >12) and penetrating injury. A result exceeding a treatment threshold was returned for 122 (73.1%) of 167 children, with hyperfibrinolysis identified in 88 (52.6%) of 167 and hypofibrinogenaemia identified in 54 (32.3%) of 167. Adherence with the recommended treatments for those children where a treatment threshold was exceeded was low in this cohort. Conclusion The use of ROTEM‐guided blood component replacement is an emerging practice in children for both traumatic and non‐traumatic bleeding. Targeted replacement of identified coagulation defects guided by rapid point‐of‐care testing is an emerging alternative to fixed‐ratio‐based protocols. Further research is required to validate treatment thresholds in the paediatric population and further investigate the clinical outcomes for patients as a result of early correction of trauma‐induced coagulopathy.
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Affiliation(s)
- Shane George
- Department of Emergency Medicine, Gold Coast University Hospital, Gold Coast, Queensland, Australia.,Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia.,School of Medicine, Griffith University, Gold Coast, Queensland, Australia
| | - Elizabeth Wake
- School of Medicine, Griffith University, Gold Coast, Queensland, Australia.,Trauma Service, Gold Coast University Hospital, Gold Coast, Queensland, Australia
| | - Amy Sweeny
- Department of Emergency Medicine, Gold Coast University Hospital, Gold Coast, Queensland, Australia.,School of Medicine, Griffith University, Gold Coast, Queensland, Australia.,Faculty of Medicine, Bond University, Gold Coast, Queensland, Australia
| | - Don Campbell
- Department of Emergency Medicine, Gold Coast University Hospital, Gold Coast, Queensland, Australia.,School of Medicine, Griffith University, Gold Coast, Queensland, Australia.,Trauma Service, Gold Coast University Hospital, Gold Coast, Queensland, Australia
| | - James Winearls
- Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia.,School of Medicine, Griffith University, Gold Coast, Queensland, Australia.,Intensive Care Unit, Gold Coast University Hospital, Gold Coast, Queensland, Australia.,Intensive Care Unit, St Andrew's War Memorial Hospital, Brisbane, Queensland, Australia
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Lu CH, Zheng ZH, Yeh TT, Yeh CC. Practice algorithm of rotational thromboelastometry-guided bleeding management in trauma and orthopedic surgery. JOURNAL OF MEDICAL SCIENCES 2022. [DOI: 10.4103/jmedsci.jmedsci_122_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Ho VK, Wong J, Martinez A, Winearls J. Trauma-induced coagulopathy: Mechanisms and clinical management. ANNALS OF THE ACADEMY OF MEDICINE, SINGAPORE 2022; 51:40-48. [PMID: 35091729 DOI: 10.47102/annals-acadmedsg.2020381] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
INTRODUCTION Trauma-induced coagulopathy (TIC) is a form of coagulopathy unique to trauma patients and is associated with increased mortality. The complexity and incomplete understanding of TIC have resulted in controversies regarding optimum management. This review aims to summarise the pathophysiology of TIC and appraise established and emerging advances in the management of TIC. METHODS This narrative review is based on a literature search (MEDLINE database) completed in October 2020. Search terms used were "trauma induced coagulopathy", "coagulopathy of trauma", "trauma induced coagulopathy pathophysiology", "massive transfusion trauma induced coagulopathy", "viscoelastic assay trauma induced coagulopathy", "goal directed trauma induced coagulopathy and "fibrinogen trauma induced coagulopathy'. RESULTS TIC is not a uniform phenotype but a spectrum ranging from thrombotic to bleeding phenotypes. Evidence for the management of TIC with tranexamic acid, massive transfusion protocols, viscoelastic haemostatic assays (VHAs), and coagulation factor and fibrinogen concentrates were evaluated. Although most trauma centres utilise fixed-ratio massive transfusion protocols, the "ideal" transfusion ratio of blood to blood products is still debated. While more centres are using VHAs to guide blood product replacement, there is no agreed VHA-based transfusion strategy. The use of VHA to quantify the functional contributions of individual components of coagulation may permit targeted treatment of TIC but remains controversial. CONCLUSION A greater understanding of TIC, advances in point-of-care coagulation testing, and availability of coagulation factors and fibrinogen concentrates allows clinicians to employ a more goal-directed approach. Still, hospitals need to tailor their approaches according to available resources, provide training and establish local guidelines.
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Affiliation(s)
- Vui Kian Ho
- Surgical Intensive Care, Division of Anaesthesiology, Singapore General Hospital, Singapore
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Hofer S, Schlimp CJ, Casu S, Grouzi E. Management of Coagulopathy in Bleeding Patients. J Clin Med 2021; 11:jcm11010001. [PMID: 35011742 PMCID: PMC8745606 DOI: 10.3390/jcm11010001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 12/10/2021] [Accepted: 12/14/2021] [Indexed: 02/06/2023] Open
Abstract
Early recognition of coagulopathy is necessary for its prompt correction and successful management. Novel approaches, such as point-of-care testing (POC) and administration of coagulation factor concentrates (CFCs), aim to tailor the haemostatic therapy to each patient and thus reduce the risks of over- or under-transfusion. CFCs are an effective alternative to ratio-based transfusion therapies for the correction of different types of coagulopathies. In case of major bleeding or urgent surgery in patients treated with vitamin K antagonist anticoagulants, prothrombin complex concentrate (PCC) can effectively reverse the effects of the anticoagulant drug. Evidence for PCC effectiveness in the treatment of direct oral anticoagulants-associated bleeding is also increasing and PCC is recommended in guidelines as an alternative to specific reversal agents. In trauma-induced coagulopathy, fibrinogen concentrate is the preferred first-line treatment for hypofibrinogenaemia. Goal-directed coagulation management algorithms based on POC results provide guidance on how to adjust the treatment to the needs of the patient. When POC is not available, concentrate-based management can be guided by other parameters, such as blood gas analysis, thus providing an important alternative. Overall, tailored haemostatic therapies offer a more targeted approach to increase the concentration of coagulation factors in bleeding patients than traditional transfusion protocols.
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Affiliation(s)
- Stefan Hofer
- Department of Anaesthesiology, Westpfalz-Klinikum Kaiserslautern, 67655 Kaiserlautern, Germany
- Correspondence: ; Tel.: +49-631-203-1030
| | - Christoph J. Schlimp
- Department of Anaesthesiology and Intensive Care, AUVA Trauma Hospital Linz, 4010 Linz, Austria;
- Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, AUVA Research Center, 1200 Vienna, Austria
| | - Sebastian Casu
- Emergency Department, Asklepios Hospital Wandsbek, 22043 Hamburg, Germany;
| | - Elisavet Grouzi
- Transfusion Service and Clinical Hemostasis, Saint Savvas Oncology Hospital, 115 22 Athens, Greece;
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Marik A, Philip J, Mallhi RS, Kushwaha N, Kumar S, Biswas AK, Yadav AK. Effect of prolonged storage at 2°C-6°C for 120 h on the coagulation factors of thawed cryoprecipitate: Can we extend its shelf life post thaw beyond 4 h? Asian J Transfus Sci 2021; 15:146-150. [PMID: 34908745 PMCID: PMC8628235 DOI: 10.4103/ajts.ajts_38_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Accepted: 11/13/2019] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Cryoprecipitate helps in replenishing important coagulation factors like fibrinogen, Factor VIII and von Willebrand factor without running the risk of volume overload. It is very useful in the treatment of trauma patients with active bleeding and works best when administered early. Extending the shelf life of thawed cryoprecipitate beyond 4 hours enables us to manage inventory better, reduces the burden of demand vs supply as well as minimizes wastage. It can also help in logistically supporting the transfusion services in making cryoprecipitate readily available in mass casualty scenarios (war, natural calamity) in remote locations by reducing the time required for thawing cryoprecipitate and the need for costly storage equipment. AIM: The aim of this study was to compare the levels of Factor VIII, Fibrinogen and von Willebrand factor on thawed cryoprecipitate after prolonged storage for 5 days at a temperature of 2-6°C. METHODOLOGY The above mentioned coagulation factors were analyzed in cryoprecipitate at the time of product thaw and again after 120 hours of 2 to 6°C storage using fully automated coagulation analyser (STA Compact Max). All parameters were expressed as Mean ± Standard deviation and were analyzed using paired t-test with level of significance, P < 0.05. RESULTS There was a significant decrease in the level of Factor VIII, whereas the levels of fibrinogen and von Willebrand Factor remained stable during the storage period. All the cryoprecipitate units retained factor activities above therapeutic range even after 5 days of storage at 2-6°C. CONCLUSION Although the levels of clotting factors are reduced during storage, they are still maintained above the therapeutic range. In scenarios where maintaining frozen cryoprecipitate inventory is a logistical challenge and emergency massive demands of cryoprecipitate are foreseen, the use of pre-thawed cryoprecipitate can be considered as a viable option.
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Affiliation(s)
- Arghyadeep Marik
- Department of Immunohematology and Blood Transfusion, Armed Forces Medical College, Pune, Maharashtra, India
| | - Joseph Philip
- Department of Immunohematology and Blood Transfusion, Armed Forces Medical College, Pune, Maharashtra, India
| | - Rajiv Singh Mallhi
- Department of Immunohematology and Blood Transfusion, INHS Aswini, Mumbai, Maharashtra, India
| | - Neerja Kushwaha
- Department of Immunohematology and Blood Transfusion, Armed Forces Medical College, Pune, Maharashtra, India
| | - Sudeep Kumar
- Department of Immunohematology and Blood Transfusion, Armed Forces Medical College, Pune, Maharashtra, India
| | - Amit Kumar Biswas
- Department of Immunohematology and Blood Transfusion, Armed Forces Medical College, Pune, Maharashtra, India
| | - Arvind Kumar Yadav
- Department of Immunohematology and Blood Transfusion, Armed Forces Medical College, Pune, Maharashtra, India
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Transfusion strategies in bleeding critically ill adults: a clinical practice guideline from the European Society of Intensive Care Medicine. Intensive Care Med 2021; 47:1368-1392. [PMID: 34677620 PMCID: PMC8532090 DOI: 10.1007/s00134-021-06531-x] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Accepted: 09/04/2021] [Indexed: 12/19/2022]
Abstract
Purpose To develop evidence-based clinical practice recommendations regarding transfusion practices and transfusion in bleeding critically ill adults. Methods A taskforce involving 15 international experts and 2 methodologists used the GRADE approach to guideline development. The taskforce addressed three main topics: transfusion support in massively and non-massively bleeding critically ill patients (transfusion ratios, blood products, and point of care testing) and the use of tranexamic acid. The panel developed and answered structured guideline questions using population, intervention, comparison, and outcomes (PICO) format. Results The taskforce generated 26 clinical practice recommendations (2 strong recommendations, 13 conditional recommendations, 11 no recommendation), and identified 10 PICOs with insufficient evidence to make a recommendation. Conclusions This clinical practice guideline provides evidence-based recommendations for the management of massively and non-massively bleeding critically ill adult patients and identifies areas where further research is needed. Supplementary Information The online version contains supplementary material available at 10.1007/s00134-021-06531-x.
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Fecher A, Stimpson A, Ferrigno L, Pohlman TH. The Pathophysiology and Management of Hemorrhagic Shock in the Polytrauma Patient. J Clin Med 2021; 10:jcm10204793. [PMID: 34682916 PMCID: PMC8541346 DOI: 10.3390/jcm10204793] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Revised: 10/14/2021] [Accepted: 10/15/2021] [Indexed: 11/16/2022] Open
Abstract
The recognition and management of life-threatening hemorrhage in the polytrauma patient poses several challenges to prehospital rescue personnel and hospital providers. First, identification of acute blood loss and the magnitude of lost volume after torso injury may not be readily apparent in the field. Because of the expression of highly effective physiological mechanisms that compensate for a sudden decrease in circulatory volume, a polytrauma patient with a significant blood loss may appear normal during examination by first responders. Consequently, for every polytrauma victim with a significant mechanism of injury we assume substantial blood loss has occurred and life-threatening hemorrhage is progressing until we can prove the contrary. Second, a decision to begin damage control resuscitation (DCR), a costly, highly complex, and potentially dangerous intervention must often be reached with little time and without sufficient clinical information about the intended recipient. Whether to begin DCR in the prehospital phase remains controversial. Furthermore, DCR executed imperfectly has the potential to worsen serious derangements including acidosis, coagulopathy, and profound homeostatic imbalances that DCR is designed to correct. Additionally, transfusion of large amounts of homologous blood during DCR potentially disrupts immune and inflammatory systems, which may induce severe systemic autoinflammatory disease in the aftermath of DCR. Third, controversy remains over the composition of components that are transfused during DCR. For practical reasons, unmatched liquid plasma or freeze-dried plasma is transfused now more commonly than ABO-matched fresh frozen plasma. Low-titer type O whole blood may prove safer than red cell components, although maintaining an inventory of whole blood for possible massive transfusion during DCR creates significant challenges for blood banks. Lastly, as the primary principle of management of life-threatening hemorrhage is surgical or angiographic control of bleeding, DCR must not eclipse these definitive interventions.
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Affiliation(s)
- Alison Fecher
- Division of Acute Care Surgery, Lutheran Hospital of Indiana, Fort Wayne, IN 46804, USA; (A.F.); (A.S.)
| | - Anthony Stimpson
- Division of Acute Care Surgery, Lutheran Hospital of Indiana, Fort Wayne, IN 46804, USA; (A.F.); (A.S.)
| | - Lisa Ferrigno
- Department of Surgery, UCHealth, University of Colorado-Denver, Aurora, CO 80045, USA;
| | - Timothy H. Pohlman
- Surgery Section, Woodlawn Hospital, Rochester, IN 46975, USA
- Correspondence:
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Curry N. Fibrinogen Replacement in Haemostatic Resuscitation: Dose, Laboratory Targets and Product Choice. Transfus Med Rev 2021; 35:104-107. [PMID: 34565636 DOI: 10.1016/j.tmrv.2021.06.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 06/05/2021] [Accepted: 06/12/2021] [Indexed: 10/20/2022]
Abstract
Fibrinogen is a key coagulation protein that is necessary for the formation of stable clots. Fibrinogen levels have been reported to be one of the first to fall during major haemorrhage reflecting consumption, dilution and fibrinogenolysis. Its role in acquired major haemorrhage, both in relation to the contribution it plays to the coagulopathy of major bleeding that can exacerbate bleeding and how effective fibrinogen supplementation can be at improving clinical outcomes, has received a great deal of attention over the last 10 - 15 years. This commentary focuses on just three of the more recent publications from the last 5 years that provide some of the evidence behind how we can think about fibrinogen as a haemostatic treatment for acquired major haemorrhage and how we can use the laboratory thresholds to guide therapy.
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Affiliation(s)
- Nicola Curry
- Oxford Haemophilia & Thrombosis Centre, Oxford University Hospitals NHS Foundation Trust, and Oxford University, NIHR BRC Haematology Theme, Oxford, UK.
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Innerhofer N, Treichl B, Rugg C, Fries D, Mittermayr M, Hell T, Oswald E, Innerhofer P. First-Line Administration of Fibrinogen Concentrate in the Bleeding Trauma Patient: Searching for Effective Dosages and Optimal Post-Treatment Levels Limiting Massive Transfusion-Further Results of the RETIC Study. J Clin Med 2021; 10:jcm10173930. [PMID: 34501379 PMCID: PMC8432065 DOI: 10.3390/jcm10173930] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2021] [Revised: 08/23/2021] [Accepted: 08/25/2021] [Indexed: 11/23/2022] Open
Abstract
Fibrinogen supplementation is recommended for treatment of severe trauma hemorrhage. However, required dosages and aimed for post-treatment fibrinogen levels remain a matter of discussion. Within the published RETIC study, adult patients suffering trauma-induced coagulopathy were randomly assigned to receive fibrinogen concentrate (FC) as first-line (n = 50) or crossover rescue (n = 20) therapy. Depending on bodyweight, a single dose of 3, 4, 5, or 6 g FC was administered and repeated if necessary (FibA10 < 9 mm). The dose-dependent response (changes in plasma fibrinogen and FibA10) was analyzed. Receiver operating characteristics (ROC) analysis regarding the need for massive transfusion and correlation analyses regarding fibrinogen concentrations and polymerization were performed. Median FC single doses amounted to 62.5 (57 to 66.66) mg·kg−1. One FC single-dose sufficiently corrected fibrinogen and FibA10 (median fibrinogen 213 mg·dL−1, median FibA10 11 mm) only in patients with baseline fibrinogen above 100 mg·dL−1 and FibA10 above 5 mm, repeated dosing was required in patients with lower baseline fibrinogen/FibA10. Fibrinogen increased by 83 or 107 mg·dL−1 and FibA10 by 4 or 4.5 mm after single or double dose of FC, respectively. ROC curve analysis revealed post-treatment fibrinogen levels under 204.5 mg·dL−1 to predict the need for massive transfusion (AUC 0.652; specificity: 0.667; sensitivity: 0.688). Baseline fibrinogen/FibA10 levels should be considered for FC dosing as only sufficiently corrected post-treatment levels limit transfusion requirements.
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Affiliation(s)
- Nicole Innerhofer
- Department of Anesthesiology and Intensive Care Medicine, Medical University of Innsbruck, 6020 Innsbruck, Austria; (B.T.); (C.R.); (D.F.); (M.M.); (E.O.); (P.I.)
- Correspondence: ; Tel.: +43-512-504-81077
| | - Benjamin Treichl
- Department of Anesthesiology and Intensive Care Medicine, Medical University of Innsbruck, 6020 Innsbruck, Austria; (B.T.); (C.R.); (D.F.); (M.M.); (E.O.); (P.I.)
| | - Christopher Rugg
- Department of Anesthesiology and Intensive Care Medicine, Medical University of Innsbruck, 6020 Innsbruck, Austria; (B.T.); (C.R.); (D.F.); (M.M.); (E.O.); (P.I.)
| | - Dietmar Fries
- Department of Anesthesiology and Intensive Care Medicine, Medical University of Innsbruck, 6020 Innsbruck, Austria; (B.T.); (C.R.); (D.F.); (M.M.); (E.O.); (P.I.)
| | - Markus Mittermayr
- Department of Anesthesiology and Intensive Care Medicine, Medical University of Innsbruck, 6020 Innsbruck, Austria; (B.T.); (C.R.); (D.F.); (M.M.); (E.O.); (P.I.)
| | - Tobias Hell
- Department of Mathematics, Faculty of Mathematics, Computer Science and Physics, University of Innsbruck, 6020 Innsbruck, Austria;
| | - Elgar Oswald
- Department of Anesthesiology and Intensive Care Medicine, Medical University of Innsbruck, 6020 Innsbruck, Austria; (B.T.); (C.R.); (D.F.); (M.M.); (E.O.); (P.I.)
| | - Petra Innerhofer
- Department of Anesthesiology and Intensive Care Medicine, Medical University of Innsbruck, 6020 Innsbruck, Austria; (B.T.); (C.R.); (D.F.); (M.M.); (E.O.); (P.I.)
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Peng HT, Nascimento B, Rhind SG, da Luz L, Beckett A. Evaluation of trauma-induced coagulopathy in the fibrinogen in the initial resuscitation of severe trauma trial. Transfusion 2021; 61 Suppl 1:S49-S57. [PMID: 34269460 DOI: 10.1111/trf.16488] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 03/31/2021] [Accepted: 04/01/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND Coagulopathic bleeding is frequently present after major trauma. However, trauma-induced coagulopathy (TIC) remains incompletely understood. This laboratory analysis of blood samples derived from our completed trial on fibrinogen in the initial resuscitation of severe trauma (FiiRST) was conducted to evaluate TIC and associated responses to fibrinogen replacement. STUDY DESIGN AND METHODS We conducted a retrospective evaluation of TIC in 45 FiiRST trial patients based on rotational thromboelastometry (ROTEM), international normalized ratio (INR), and biomarkers for hemostasis and endotheliopathy. Whole blood was analyzed by ROTEM. Plasma was analyzed for INR and biomarkers. RESULTS Overall, 19.0% and 30.0% of the FiiRST trial patients were coagulopathic on admission defined by EXTEM maximum clot firmness out of the range of 40-71 mm and INR >1.2, respectively. The FiiRST patients showed lower fibrinogen, factor II and V levels, protein C and antiplasmin activities, higher activated protein C, tissue plasminogen activator, d-dimer, and thrombomodulin concentrations at admission than healthy controls. Most of the biomarkers changed their activities during 48-h hospitalization, but were at abnormal levels even 48-h after admission. The fibrinogen treatment reduced hypofibrinogenemia and increased factor XIII level, but had no significant effects on other biomarkers levels. Limited development of endotheliopathy was indicated by syndean-1, thrombomodulin, and sE-selectin. CONCLUSIONS About 19%-30% of the trauma patients in the FiiRST trial were coagulopathic on hospital admission depending on the definition of TIC. Analyses of the TIC biomarkers demonstrated that hemostasis would not return to normal after 48-h hospitalization, and fibrinogen replacement improved hypofibrinogenemia.
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Affiliation(s)
- Henry T Peng
- Defence Research and Development Canada, Toronto Research Centre, Toronto, Ontario, Canada
| | | | - Shawn G Rhind
- Defence Research and Development Canada, Toronto Research Centre, Toronto, Ontario, Canada
| | - Luis da Luz
- Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Andrew Beckett
- Department of Surgery, St. Michael's Hospital, Toronto, Ontario, Canada.,Royal Canadian Medical Services, Ottawa, Ontario, Canada
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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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Song JC, Yang LK, Zhao W, Zhu F, Wang G, Chen YP, Li WQ. Chinese expert consensus on diagnosis and treatment of trauma-induced hypercoagulopathy. Mil Med Res 2021; 8:25. [PMID: 33840386 PMCID: PMC8040221 DOI: 10.1186/s40779-021-00317-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 03/25/2021] [Indexed: 11/29/2022] Open
Abstract
Trauma-induced coagulopathy (TIC) is caused by post-traumatic tissue injury and manifests as hypercoagulability that leads to thromboembolism or hypocoagulability that leads to uncontrollable massive hemorrhage. Previous studies on TIC have mainly focused on hemorrhagic coagulopathy caused by the hypocoagulable phenotype of TIC, while recent studies have found that trauma-induced hypercoagulopathy can occur in as many as 22.2-85.1% of trauma patients, in whom it can increase the risk of thrombotic events and mortality by 2- to 4-fold. Therefore, the Chinese People's Liberation Army Professional Committee of Critical Care Medicine and the Chinese Society of Thrombosis, Hemostasis and Critical Care, Chinese Medicine Education Association jointly formulated this Chinese Expert Consensus comprising 15 recommendations for the definition, pathophysiological mechanism, assessment, prevention, and treatment of trauma-induced hypercoagulopathy.
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Affiliation(s)
- Jing-Chun Song
- Department of Critical Care Medicine, the 908th Hospital of Joint Logistics Support Forces of Chinese PLA, Nanchang, 330002, China.
| | - Li-Kun Yang
- Department of Neurosurgery, the 904th Hospital of Joint Logistics Support Forces of Chinese PLA, Wuxi, 214044, Jiangsu, China
| | - Wei Zhao
- Division of Vascular and Interventional Radiology, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China
| | - Feng Zhu
- Department of Critical Care Medicine, Shanghai East Hospital, Tongji University, Shanghai, 200120, China
| | - Gang Wang
- Department of Critical Care Medicine, the Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710001, China
| | - Yao-Peng Chen
- Department of Blood Transfusion, the 923th Hospital of Joint Logistics Support Forces of Chinese PLA, Nanning, 530021, China
| | - Wei-Qin Li
- Department of Critical Care Medicine, General Hospital of Eastern Theater Command of Chinese PLA, Nanjing, 210002, China.
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Effect of emergency department fibrinogen testing on survival of trauma patients receiving blood transfusions. Blood Coagul Fibrinolysis 2021; 31:372-376. [PMID: 32618590 DOI: 10.1097/mbc.0000000000000924] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
: Fibrinogen is the first clotting factor to reach critically low levels during blood loss and its depletion is associated with coagulopathy, increased blood loss, transfusion requirements and mortality after trauma. However, direct measurements of fibrinogen concentration or function are not included in many Emergency Department (ED) trauma laboratory testing protocols. We hypothesized that including a test of fibrinogen concentration in the ED would be associated with increased survival for trauma patients requiring blood transfusions.To test this hypothesis, we performed a single-centre retrospective study of the effect of a resulted fibrinogen concentration measurement performed in the ED on survival of trauma patients receiving blood transfusions within the first 4 h of their hospital arrival. Multivariate logistic regression was used test the effect of a fibrinogen test on hospital survival after adjusting for the influence of INR, injury severity, lowest recorded blood pressure and blood transfusion intensity defined as the number of red blood cell units transfused in the first 4 h or care.Of 11 404 trauma registry individuals from 2016 to 2017, 843 (7.4%) received any blood transfusions within the first 4 h of ED care, of whom 635 (75.3%) had a documented fibrinogen concentration ordered and resulted. Multivariate logistic regression for hospital survival demonstrated a significant interaction effect between the presence of a fibrinogen test and transfusion intensity (Whole Model P < 0.0001, Interaction P = 0.035). Repeat analysis after stratifying for those individuals receiving more than 4 units of red blood cell units within 4 h of care found that the presence of a fibrinogen test was independently associated with survival only for those receiving more than 4 units [FIB test odds ratio for survival = 3.5 (1.0, 10.8), P = 0.03].Fibrinogen testing in the ED may be a valuable addition to resuscitation of the trauma patient receiving significant blood transfusions.
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Long E, Williams A, Babl FE, Kinmonth A, Tse WC, Palmer CS, Crighton G, Savoia H, Teague WJ, Nystrup KB. Changes in emergency department blood product use for major paediatric trauma following the implementation of a major haemorrhage protocol. Emerg Med Australas 2021; 33:966-974. [PMID: 33811442 DOI: 10.1111/1742-6723.13773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Revised: 03/05/2021] [Accepted: 03/12/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Fixed ratio blood product administration may improve outcomes in trauma patients with massive blood loss. The present study aimed to describe the impact of a major haemorrhage protocol (MHP) on the ratio of blood products administered for paediatric major trauma. METHODS Retrospective observational study in a state-designated paediatric major trauma centre in Melbourne, Australia. Children with major trauma who received blood products in the ED were identified from a hospital trauma registry. Blood product ratios before, during and after implementation of a hospital MHP were compared in consecutive 2 year blocks. RESULTS Over a 6 year period, 767 major trauma patients were identified, of whom 47 received blood products in the ED and were included in the analysis; 14 pre-MHP implementation, 24 during-MHP implementation and nine post-MHP implementation. No patients received blood products at a ratio of 1:1:1 for red blood cells:fresh frozen plasma:platelets, respectively, during any time period. In this cohort of predominantly blunt trauma, blood products were infrequently administered in the ED because of the low prevalence of massive blood loss. Coagulopathy and hypofibrinogenaemia were commonly observed, nearly half of included patients were managed operatively and one quarter did not survive their injuries. CONCLUSION The implementation of a MHP did not change the ratio of blood product administration in this cohort of patients because of the infrequency of massive blood loss. Future studies may focus on the impact of treating coagulopathy and hypofibrinogenaemia on patient-centred outcomes.
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Affiliation(s)
- Elliot Long
- Department of Emergency Medicine, The Royal Children's Hospital Melbourne, Melbourne, Victoria, Australia.,Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Victoria, Australia.,Centre for Integrated Critical Care, Department of Medicine and Radiology, Melbourne Medical School, Melbourne, Victoria, Australia
| | - Amanda Williams
- Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Victoria, Australia
| | - Franz E Babl
- Department of Emergency Medicine, The Royal Children's Hospital Melbourne, Melbourne, Victoria, Australia.,Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Victoria, Australia.,Centre for Integrated Critical Care, Department of Medicine and Radiology, Melbourne Medical School, Melbourne, Victoria, Australia
| | - Anne Kinmonth
- Department of Haematology, The Royal Children's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Wai Chung Tse
- Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
| | - Cameron S Palmer
- Trauma Service, The Royal Children's Hospital Melbourne, Melbourne, Victoria, Australia.,Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Gemma Crighton
- Department of Haematology, The Royal Children's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Helen Savoia
- Department of Haematology, The Royal Children's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Warwick J Teague
- Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Victoria, Australia.,Trauma Service, The Royal Children's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Kristin Brønnum Nystrup
- Paediatric Intensive Care Unit, The Royal Children's Hospital Melbourne, Melbourne, Victoria, Australia
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Savioli G, Ceresa IF, Caneva L, Gerosa S, Ricevuti G. Trauma-Induced Coagulopathy: Overview of an Emerging Medical Problem from Pathophysiology to Outcomes. MEDICINES (BASEL, SWITZERLAND) 2021; 8:16. [PMID: 33805197 PMCID: PMC8064317 DOI: 10.3390/medicines8040016] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Revised: 02/15/2021] [Accepted: 03/07/2021] [Indexed: 12/17/2022]
Abstract
Coagulopathy induced by major trauma is common, affecting approximately one-third of patients after trauma. It develops independently of iatrogenic, hypothermic, and dilutive causes (such as iatrogenic cause in case of fluid administration), which instead have a pejorative aspect on coagulopathy. Notwithstanding the continuous research conducted over the past decade on Trauma-Induced Coagulopathy (TIC), it remains a life-threatening condition with a significant impact on trauma mortality. We reviewed the current evidence regarding TIC diagnosis and pathophysiological mechanisms and summarized the different iterations of optimal TIC management strategies among which product resuscitation, potential drug administrations, and hemostatis-focused approaches. We have identified areas of ongoing investigation and controversy in TIC management.
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Affiliation(s)
- Gabriele Savioli
- Emergency Department, IRCCS Policlinico San Matteo, PhD University of Pavia, 27100 Pavia, Italy; (I.F.C.); (S.G.)
| | - Iride Francesca Ceresa
- Emergency Department, IRCCS Policlinico San Matteo, PhD University of Pavia, 27100 Pavia, Italy; (I.F.C.); (S.G.)
| | - Luca Caneva
- Anesthesia and Intensive Care, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy;
| | - Sebastiano Gerosa
- Emergency Department, IRCCS Policlinico San Matteo, PhD University of Pavia, 27100 Pavia, Italy; (I.F.C.); (S.G.)
| | - Giovanni Ricevuti
- Department of Drug Science, University of Pavia, 27100 Pavia, Italy;
- Saint Camillus International University of Health Sciences, 00152 Rome, Italy
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Factor XIII-A: An Indispensable "Factor" in Haemostasis and Wound Healing. Int J Mol Sci 2021; 22:ijms22063055. [PMID: 33802692 PMCID: PMC8002558 DOI: 10.3390/ijms22063055] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 03/09/2021] [Accepted: 03/11/2021] [Indexed: 02/06/2023] Open
Abstract
Factor XIII (FXIII) is a transglutaminase enzyme that catalyses the formation of ε-(γ-glutamyl)lysyl isopeptide bonds into protein substrates. The plasma form, FXIIIA2B2, has an established function in haemostasis, with fibrin being its principal substrate. A deficiency in FXIII manifests as a severe bleeding diathesis emphasising its crucial role in this pathway. The FXIII-A gene (F13A1) is expressed in cells of bone marrow and mesenchymal lineage. The cellular form, a homodimer of the A subunits denoted FXIII-A, was perceived to remain intracellular, due to the lack of a classical signal peptide for its release. It is now apparent that FXIII-A can be externalised from cells, by an as yet unknown mechanism. Thus, three pools of FXIII-A exist within the circulation: plasma where it circulates in complex with the inhibitory FXIII-B subunits, and the cellular form encased within platelets and monocytes/macrophages. The abundance of this transglutaminase in different forms and locations in the vasculature reflect the complex and crucial roles of this enzyme in physiological processes. Herein, we examine the significance of these pools of FXIII-A in different settings and the evidence to date to support their function in haemostasis and wound healing.
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Prittie J. The role of cryoprecipitate in human and canine transfusion medicine. J Vet Emerg Crit Care (San Antonio) 2021; 31:204-214. [PMID: 33751762 DOI: 10.1111/vec.13034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Revised: 05/27/2019] [Accepted: 07/02/2019] [Indexed: 12/20/2022]
Abstract
OBJECTIVE To evaluate the current role of cryoprecipitate in human and canine transfusion medicine. DATA SOURCES Human and veterinary scientific reviews and original studies found using PubMed and CAB Abstract search engines were reviewed. HUMAN DATA SYNTHESIS In the human critical care setting, cryoprecipitate is predominantly used for fibrinogen replenishment in bleeding patients with acute traumatic coagulopathy. Other coagulopathic patient cohorts for whom cryoprecipitate is recommended include those undergoing cardiovascular or obstetric procedures or patients bleeding from advanced liver disease. Preferential selection of cryoprecipitate versus fibrinogen concentrate (when available) is currently being investigated. Also a matter of ongoing debate is whether to administer this product as part of a fixed-dose massive hemorrhage protocol or to incorporate it into a goal-directed transfusion algorithm applied to the individual bleeding patient. VETERINARY DATA SYNTHESIS Although there are sporadic reports of the use of cryoprecipitate in dogs with heritable coagulopathies, there are few to no data pertaining to its use in acquired hypofibrinogenemic states. Low fibrinogen in dogs (as in people) has been documented with acute traumatic coagulopathy, advanced liver disease, and disseminated intravascular coagulation. Bleeding secondary to these hypocoagulable states may be amenable to cryoprecipitate therapy. Indications for preferential selection of cryoprecipitate (versus fresh frozen plasma) remain to be determined. CONCLUSIONS In the United States, cryoprecipitate remains the standard of care for fibrinogen replenishment in the bleeding human trauma patient. Its preferential selection for this purpose is the subject of several ongoing human clinical trials. Timely incorporation of cryoprecipitate into the transfusion protocol of the individual bleeding patient with hypofibrinogenemia may conserve blood products, mitigate adverse transfusion-related events, and improve patient outcomes. Cryoprecipitate is readily available, effective, and safe for use in dogs. The role of this blood product in clinical canine patients with acquired coagulopathy remains unknown.
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Affiliation(s)
- Jennifer Prittie
- Department of Emergency and Critical Care, Animal Medical Center, New York, New York
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Földesi M, Merkei Z, Ferenci T, Nardai G. Fibrinogen level at hospital admission after multiple injury correlates with BMI and is negatively associated with the need for transfusion and early multiple organ failure. Injury 2021; 52 Suppl 1:S15-S20. [PMID: 33436265 DOI: 10.1016/j.injury.2020.12.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Accepted: 12/03/2020] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Bleeding and coagulopathy are leading causes of morbidity and lethal outcome after multiple injuries. The pathophysiology of traumatic coagulopathy is under extensive investigations and recent results highlighted the central role of fibrinogen and the fibrin polymerisation process. Our goal was to investigate the factors influencing fibrinogen level and the consequences of hypofibrinogenaemia with clinical importance. METHODS We conducted a retrospective analysis enrolling adult patients admitted to the shock room of a tertiary trauma centre in Hungary. Beside coagulation values, demographic data, injury related, transfusion and outcome parameters were collected from the hospital electronic charts. Only patients with complete e-chart were involved into final analysis. Multivariate linear and proportional odds logistic regression models were used to model outcomes - admission fibrinogen and SOFA score - controlling for age, sex, BMI, ISS and lactic acidosis. RESULTS 54 patients were enrolled in final analysis. Among the parameters analysed, BMI was positively associated with fibrinogen level at admission (+0.23 g/l for every 5 unit of increase in BMI, 95% CI: 0.09-0.37, p=0.0021). Increased risk of transfusion was observed, if fibrinogen at admission was about 1.8 g/l or lower. Beside age and ISS, fibrinogen concentration was also a determinant of early organ failures as it negatively correlated with SOFA scores within 24 hours or care (OR=2.42, 95% CI: 1.05-5.62, for 1 g/l decrease, p=0.0388). CONCLUSIONS In our trauma cohort BMI seems to significantly influence fibrinogen level at admission. This result draws our attention to the possible differences of haemostasis process, and consequently different diagnostic and therapeutic thresholds in the management of obese trauma patients. Moderate hypofibrinogenaemia increases transfusion risk and beside ISS might be a prognostic factor of early MOF after multiple injuries.
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Affiliation(s)
- Marcell Földesi
- Dept. of Anaesthesiology and Intensive Care, Péterfy Hospital and Trauma Centre, Budapest, Hungary
| | - Zoltán Merkei
- Dept. of Anaesthesiology and Intensive Care, Péterfy Hospital and Trauma Centre, Budapest, Hungary
| | - Tamás Ferenci
- Physiological Research Controls Centre, Óbuda University, Budapest, Hungary; Department of Statistics, Corvinus University of Budapest, Budapest, Hungary
| | - Gábor Nardai
- Dept. of Anaesthesiology and Intensive Care, Péterfy Hospital and Trauma Centre, Budapest, Hungary.
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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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Morrow GB, Carlier MSA, Dasgupta S, Craigen FB, Mutch NJ, Curry N. Fibrinogen Replacement Therapy for Traumatic Coagulopathy: Does the Fibrinogen Source Matter? Int J Mol Sci 2021; 22:ijms22042185. [PMID: 33671748 PMCID: PMC7926643 DOI: 10.3390/ijms22042185] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 02/11/2021] [Accepted: 02/15/2021] [Indexed: 11/23/2022] Open
Abstract
Fibrinogen is the first coagulation protein to reach critically low levels during traumatic haemorrhage. There have been no differential effects on clinical outcomes between the two main sources of fibrinogen replacement: cryoprecipitate and fibrinogen concentrate (Fg-C). However, the constituents of these sources are very different. The aim of this study was to determine whether these give rise to any differences in clot stability that may occur during trauma haemorrhage. Fibrinogen deficient plasma (FDP) was spiked with fibrinogen from cryoprecipitate or Fg-C. A panel of coagulation factors, rotational thromboelastography (ROTEM), thrombin generation (TG), clot lysis and confocal microscopy were performed to measure clot strength and stability. Increasing concentrations of fibrinogen from Fg-C or cryoprecipitate added to FDP strongly correlated with Clauss fibrinogen, demonstrating good recovery of fibrinogen (r2 = 0.99). A marked increase in Factor VIII, XIII and α2-antiplasmin was observed in cryoprecipitate (p < 0.05). Increasing concentrations of fibrinogen from both sources were strongly correlated with ROTEM parameters (r2 = 0.78-0.98). Cryoprecipitate therapy improved TG potential, increased fibrinolytic resistance and formed more homogeneous fibrin clots, compared to Fg-C. In summary, our data indicate that cryoprecipitate may be a superior source of fibrinogen to successfully control bleeding in trauma coagulopathy. However, these different products require evaluation in a clinical setting.
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Affiliation(s)
- Gael B. Morrow
- Radcliffe Department of Medicine, University of Oxford, Oxford OX3 9DU, UK;
- Aberdeen Cardiovascular & Diabetes Centre, School of Medicine, Medical Sciences and Nutrition, Institute of Medical Sciences, University of Aberdeen, Aberdeen AB25 2ZD, UK; (M.S.A.C.); (S.D.); (F.B.C.); (N.J.M.)
| | - Molly S. A. Carlier
- Aberdeen Cardiovascular & Diabetes Centre, School of Medicine, Medical Sciences and Nutrition, Institute of Medical Sciences, University of Aberdeen, Aberdeen AB25 2ZD, UK; (M.S.A.C.); (S.D.); (F.B.C.); (N.J.M.)
| | - Sruti Dasgupta
- Aberdeen Cardiovascular & Diabetes Centre, School of Medicine, Medical Sciences and Nutrition, Institute of Medical Sciences, University of Aberdeen, Aberdeen AB25 2ZD, UK; (M.S.A.C.); (S.D.); (F.B.C.); (N.J.M.)
| | - Fiona B. Craigen
- Aberdeen Cardiovascular & Diabetes Centre, School of Medicine, Medical Sciences and Nutrition, Institute of Medical Sciences, University of Aberdeen, Aberdeen AB25 2ZD, UK; (M.S.A.C.); (S.D.); (F.B.C.); (N.J.M.)
| | - Nicola J. Mutch
- Aberdeen Cardiovascular & Diabetes Centre, School of Medicine, Medical Sciences and Nutrition, Institute of Medical Sciences, University of Aberdeen, Aberdeen AB25 2ZD, UK; (M.S.A.C.); (S.D.); (F.B.C.); (N.J.M.)
| | - Nicola Curry
- Radcliffe Department of Medicine, University of Oxford, Oxford OX3 9DU, UK;
- Oxford Haemophilia & Thrombosis Centre, NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford OX3 7LE, UK
- Correspondence: ; Tel.: +44-1865-225316
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