Management of bleeding following major trauma: an updated European guideline

Electrospun Silk-ICG Composite Fibers and the Application toward Hemorrhage Control

In trauma and surgery, efficient hemorrhage control is crucial to avert fatal blood loss and increase the likelihood of survival. There is a significant demand for novel biomaterials capable of promptly and effectively managing bleeding. This study aimed to develop flexible biocomposite fibrous scaffolds with an electrospinning technique using silk fibroin (SF) and indocyanine green (ICG). The FDA-approved ICG dye has unique photothermal properties. The water permeability, degradability, and biocompatibility of Bombyx mori cocoon-derived SF make it promising for biomedical applications. While as-spun SF-ICG fibers were dissolvable in water, ethanol vapor treatment (EVT) effectively induced secondary structural changes to promote β-sheet formation. This resulted in significantly improved aqueous stability and mechanical strength of the fibers, thereby increasing their fluid uptake capability. The enhanced SF-ICG interaction effectively prevented ICG leaching from the composite fibers, enabling them to generate heat under NIR irradiation due to ICG's photothermal properties. Our results showed that an SF-ICG 0.4% fibrous matrix can uptake 473% water. When water was replaced by bovine blood, a 25 s NIR irradiation induced complete blood coagulation. However, pure silk did not have the same effect. Additionally, NIR irradiation of the SF-ICG fibers successfully stopped the flow of blood in an in vitro model that mimicked a damaged blood vessel. This novel breakthrough offers a biotextile platform poised to enhance patient outcomes across various medical scenarios, representing a significant milestone in functional biomaterials.

A multicenter study of DDAVP versus platelet transfusions for antiplatelet agent reversal in patients with traumatic brain injury

BACKGROUND

Antiplatelet agents have been shown to worsen outcomes following traumatic injury. Research on desmopressin (DDAVP) and platelet transfusion for antiplatelet reversal is limited. We aimed to evaluate the effect of these agents on patients taking pre-injury antiplatelet medications who experienced traumatic brain injury (TBI) after blunt trauma.

METHODS

This is a retrospective cohort study of adult trauma patients from 2014 to 2021 on aspirin and/or a P2Y12 inhibitor. Patients were stratified into groups based on if they received DDAVP, platelets, both agents, or neither.

RESULTS

Of 5525 included patients, 4696 (85.4%) were not reversed, 461 (8.4%) received platelets, 173 (3.1%) received DDAVP, and 172 (3.1%) received both reversals. There was no statistically significant difference in length of stay between, but patients who received platelets or both reversals were more likely to have hospital complications (p < 0.05), longer hospital length of stay (p < 0.001), and longer ICU length of stay (p < 0.001) compared to those who did not receive reversal. A subgroup analysis of patients with a head AIS of 4 or 5 confirmed these findings.

CONCLUSIONS

Patients who received platelets or both reversals had a longer length of hospital stay and length of ICU stay. It is difficult to recommend one treatment over another based on our results alone. Further studies are needed to help clarify the risks and benefits of reversal agents in this patient population.

Correlation of Internal Jugular Vein and Inferior Vena Cava Collapsibility Index with Direct Central Venous Pressure Measurement in Critically-ill Patients: An Observational Study

Background and aims

Prompt assessments and quick replacement of intravascular fluid are critical steps to resuscitate hypovolemic patients. Intravascular volume assessment by direct central venous pressure (CVP) measurement is an invasive, time-consuming, and labor-intensive procedure. Nowadays, bedside ultrasound-guided volume assessment of the internal jugular vein (IJV) or inferior vena cava (IVC) is commonly employed as a proxy for direct CVP.Therefore, we examined the strength of association between CVP and collapsibility index (CI) of the IJV and IVC for evaluating the volume status of critically ill patients.

Methods

Bedside USG-guided A-P diameter and cross-sectional area of the right IJV and IVC were measured, and their corresponding collapsibility indices were deduced. The results of the IJV and IVC indices were correlated with CVP.

Results

About 60 out of 70 enrolled patients were analyzed. The baseline clinical parameters of patients are shown in Table 1. For CSA and AP diameter, the correlations between CVP and IJV-CI at 0° were r = -0.107 (p = 0.001) and r = -0.092 (p = 0.001). Correlations between CVP and IJV-CI at 30° for CSA and diameter, however, were (r = -0.109, p = 0.001) and (r = -0.117, p = 0.001), respectively. Table 2 depicts the correlation between CVP and IVC-CI r = -0.503, p = 0.001 for CSA and r = -0.452, p = 0.001 for diameter.

Conclusion

The IVC and IJV collapsibility indices can be used in place of invasive CVP monitoring to assess fluid status in critically ill patients.

How to cite this article

Kumar A, Bharti AK, Hussain M, Kumar S, Kumar A. Correlation of Internal Jugular Vein and Inferior Vena Cava Collapsibility Index with Direct Central Venous Pressure Measurement in Critically-ill Patients: An Observational Study. Indian J Crit Care Med 2024;28(6):595-600.

Complex Traumatic Jejunal Perforation With Mesenteric Tear and Intussusception: A Case Report

Blunt abdominal trauma can result in a spectrum of injuries, ranging from superficial contusions to severe hollow viscus perforations. We present the case of a 52-year-old male involved in a bicycle-truck collision, leading to complex intra-abdominal injuries. The patient presented with acute abdominal pain and signs of peritonitis, prompting urgent diagnostic workup and surgical intervention. Imaging studies revealed pneumoperitoneum, free fluid, and multiple rib fractures indicative of significant trauma. Exploratory laparotomy unveiled a perforated jejunal loop with an associated mesenteric tear and intussusception, necessitating segmental bowel resection and repair. Histopathological analysis confirmed acute hemorrhagic inflammation consistent with traumatic perforation. This case highlights the challenges and complexities associated with blunt abdominal trauma, emphasizing the importance of prompt recognition, multidisciplinary management, and surgical intervention in optimizing patient outcomes.

The pathophysiology of pelvic ring injuries: a review

Traumatic pelvic ring injuries continue to represent a major challenge due to the high rates of post-injury mortality of around 30-40% in the peer-reviewed literature. The main root cause of potentially preventable mortality relates to the delayed recognition of the extent of retroperitoneal hemorrhage and post-injury coagulopathy. The understanding of the underlying pathophysiology of pelvic trauma is predicated by classification systems for grading of injury mechanism and risk stratification for developing post-injury coagulopathy with subsequent uncontrolled exsanguinating hemorrhage. This review article elaborates on the current understanding of the pathophysiology of severe pelvic trauma with a focus on the underlying mechanisms of retroperitoneal bleeding and associated adverse outcomes.

The epidemiology of pelvic ring fractures in Qatar

PURPOSE

This study aimed to determine the incidence of pelvic ring fractures and their associated epidemiological profile in Qatar.

METHODS

A retrospective cross-sectional study was performed at the only level I trauma centre in Qatar for patients diagnosed with pelvic ring fractures between January 2016 and December 2018. Age, sex, mechanism of injury, fracture classification and associated characteristics, mode of treatment, associated nerve injuries, and other complications were analyzed.

RESULTS

A total of 327 consecutive patients were included, with an average age of 32.6 years. Most of the included patients were males, 85% (279), with a male: female ratio of 6:1. The incidence of pelvic fractures was 3.887/100,000 across the three years. High-speed motor vehicle collisions (MVC) were the most common mechanism of injury (108, 33%), followed by falling from height (105, 32%). Young-Burgess lateral compression (LC) fracture type was the most frequent (224, 68.5%) and was associated with 25% of the entire mortalities. Nine (2.8%) cases were open fractures, and 12% (39) were deemed unstable. Around 29% of cases had associated injuries, with an overall mortality rate of 4.9% (16) observed. Most fractures were treated nonoperatively(n = 283,86.5%).

CONCLUSION

This study demonstrated the epidemiology of pelvic fractures in Qatar. MVC and work-related injuries were predominant in a younger cohort compared to the literature. Also, the mortality rate was lower than those reported in the literature. Therefore, well-trained surgeons and specialized trauma centres for treating these injuries are recommended.

Prophylactic cryoprecipitate transfusion in patients undergoing scoliosis surgery: A randomised-controlled trial

BACKGROUND

Scoliosis surgeries in adults often have a high risk of massive blood loss and significant transfusion of blood products during and after surgery. It is not known whether early cryoprecipitate therapy is useful in reducing blood loss and transfusion requirements. The objective of this randomised, prospective placebo control study was to evaluate whether prophylactic administration of cryoprecipitate would reduce blood loss and transfusion requirements during scoliosis surgery.

METHODS

Eighty adult patients scheduled to undergo elective scoliosis correction were randomly assigned to receive either ten units of cryoprecipitate before incision (cryo group) or an equivalent volume of 0.9% saline (placebo group). Blood loss, transfusion requirements, coagulation parameters and complications were assessed.

RESULTS

No significant differences were found in the volume of transfused blood products, intraoperative estimated blood loss between the intervention and placebo groups. Postoperative blood loss was significantly lower in the cry group when compared to the other group. During adult surgical correction of scoliosis, prophylactic administration of cryoprecipitate did not diminish the amount of transfused blood products or decrease intraoperative blood loss.

CONCLUSION

It could be concluded that the prophylactic administration of cryoprecipitate shows no differences in intraoperative blood loss and transfusion requirements during scoliosis surgery.

Arterial angioembolisation versus pre-peritoneal pelvic packing in haemodynamically unstable patients with complex pelvic fractures: a meta-analysis

INTRODUCTION

Angioembolisation (AE) and/or pre-peritoneal pelvic packing (PPP) may be necessary for patients with complex pelvic fractures who are haemodynamically unstable. However, it remains unclear whether AE or PPP should be performed as an initial intervention and ongoing debates exist. This meta-analysis aimed to compare AE versus PPP in haemodynamically unstable patients with acute pelvic fractures. The primary outcomes of interest were to compare in-hospital mortality rate and number of blood units transfused. Secondary outcomes included evaluating differences in the time from diagnosis to treatment, as well as the length of stay in the intensive care unit (ICU) and hospital.

METHODS

All clinically relevant studies comparing AE versus PPP in patients with complex pelvic fractures and haemodynamic instability were accessed. The 2020 PRISMA guidelines were followed. In September 2023, the following databases were accessed: PubMed, Web of Science, Google Scholar and Embase, without constraint.

RESULTS

Data from 320 patients were collected (AE: 174; PPP: 146). The mean age on admission was 47.4 ± 7.2 years. The mean Injury Severity Score (ISS) on admission was 43.5 + 5.4 points. Baseline comparability was observed in ISS (P = 0.5, Table 3) and mean age (P = 0.7, Table 3). No difference was reported in mortality rate (P = 0.2) or rate of blood units transfused (P = 0.3). AE had a longer mean time to the procedure of 44.6 min compared to PPP (P = 0.04). The mean length of ICU and hospital stay were similar in both groups.

CONCLUSION

Despite the longer mean time from admission to the procedure, no significant differences were found between AE and PPP in terms of in-hospital mortality, blood units transfused, or length of ICU, and hospital stay. These findings should be interpreted considering the limitations of the present study. High-quality comparative research is strongly warranted.

LEVEL OF EVIDENCE

Level IV, meta-analysis.

Successfully Managing Severe Anemia in a Trauma Patient Who Refused Blood Transfusion: A Case Report

BACKGROUND Surgical management in patients who undergo traumatic blood loss but who refuse blood transfusion can be challenging, but physicians and surgeons must comply with the wishes and beliefs of their patients. This report describes the management of severe anemia, with hemoglobin level of 2.5 g/dL, in a 71-year-old male Korean trauma patient who declined blood transfusion. CASE REPORT A 71-year-old man was admitted to hospital with severe blood loss following trauma. He declined blood transfusion due to his religious belief as a Jehovah's Witness. On day 4, the patient's hemoglobin level dropped from 7.7 to 3.9 g/dL. Despite the need for blood transfusion, the patient refused. Hence, therapeutic strategies, including crystalloid fluid resuscitation, bleeding control, vasopressor support, erythropoietin administration, supplementation with iron, folic acid, and vitamin B12, coagulopathy correction, oxygen consumption reduction, and mechanical ventilation were implemented. Following 16 days of supportive management, the hemoglobin reached 7.4 g/dL. However, it suddenly decreased on day 41 (2.5 g/dL) due to episodes of melena secondary to an actively bleeding gastric ulcer, which was successfully managed with endoscopic hemostasis. Despite increased vasopressor dosage and addition of vasopressin and hydrocortisone, the patient became unresponsive with persistent hypotension. Methylene blue was used as the final therapeutic agent. The patient responded well and subsequently recovered without blood transfusion. CONCLUSIONS This report has presented the clinical challenges of managing the case of a patient who requires but declines blood transfusion and has highlighted the approach to clinical care while respecting the wishes of the patient.

Indicators for the evaluation of musculoskeletal trauma systems: A scoping review and Delphi study

BACKGROUND

Trauma is a leading cause of mortality and morbidity, disproportionately affecting low- and middle-income countries. Musculoskeletal trauma results in the majority of post-traumatic morbidity and disability globally. The literature has reported many performance indicators relating to trauma care, but few specific to musculoskeletal injuries.

STUDY OBJECTIVES

The purpose of this study was to establish a practical list of performance indicators to evaluate and monitor the quality and equity of musculoskeletal trauma care delivery in health systems worldwide.

METHODS

A scoping review was performed that identified performance indicators related to musculoskeletal trauma care. Indicators were organized by phase of care (general, prevention, pre-hospital, hospital, post-hospital) within a modified Donabedian model (structure, process, outcome, equity). A panel of 21 experts representing 45 countries was assembled to identify priority indicators utilizing a modified Delphi approach.

RESULTS

The scoping review identified 1,206 articles and 114 underwent full text review. We included 95 articles which reported 498 unique performance indicators. Most indicators related to the hospital phase of care (n = 303, 60%) and structural characteristics (n = 221, 44%). Mortality (n = 50 articles) and presence of trauma registries (n = 16 articles) were the most frequently reported indicators. After 3 rounds of surveys our panel reached consensus on a parsimonious list of priority performance indicators. These focused on access to trauma care; processes and key resources for polytrauma triage, patient stabilization, and hemorrhage control; reduction and immobilization of fractures and dislocations; and management of compartment syndrome and open fractures.

CONCLUSIONS

The literature has reported many performance indicators relating to trauma care, but few specific to musculoskeletal injuries. To create quality and equitable trauma systems, musculoskeletal care must be incorporated into development plans with continuous monitoring and improvement. The performance indicators identified by our expert panel and organized in a modified Donabedian model can serve as a method for evaluating musculoskeletal trauma care.

Hydrogel-Forming Microneedles with Applications in Oral Diseases Management

Controlled drug delivery in the oral cavity poses challenges such as bacterial contamination, saliva dilution, and inactivation by salivary enzymes upon ingestion. Microneedles offer a location-specific, minimally invasive, and retentive approach. Hydrogel-forming microneedles (HFMs) have emerged for dental diagnostics and therapeutics. HFMs penetrate the stratum corneum, undergo swelling upon contact, secure attachment, and enable sustained transdermal or transmucosal drug delivery. Commonly employed polymers such as polyvinyl alcohol (PVA) and polyvinyl pyrrolidone are crosslinked with tartaric acid or its derivatives while incorporating therapeutic agents. Microneedle patches provide suture-free and painless drug delivery to keratinized or non-keratinized mucosa, facilitating site-specific treatment and patient compliance. This review comprehensively discusses HFMs' applications in dentistry such as local anesthesia, oral ulcer management, periodontal treatment, etc., encompassing animal experiments, clinical trials, and their fundamental impact and limitations, for example, restricted drug carrying capacity and, until now, a low number of dental clinical trial reports. The review explores the advantages and future perspectives of HFMs for oral drug delivery.

Comparative study of National Emergency X-Radiography Utilization Study (NEXUS) chest algorithm and extended focused assessment with sonography for trauma (E-FAST) in the early detection of blunt chest injuries in polytrauma patients

Introduction

Chest imaging plays a prominent role in the assessment of patients with blunt trauma. Selection of the right approach at the right time is fundamental in the management of patients with blunt chest trauma.[1] A reliable, economic, bedside, and rapidly accomplished screening test can be pivotal. [2].

Objective

The aim of this study was to compare the accuracy of extended- focused assessment with sonography for trauma (E-FAST) to that of the National Emergency X-Radiography Utilisation Study (NEXUS) chest algorithm in detecting blunt chest injuries.

Methods

This descriptive cross-sectional study included 50 polytrauma patients with blunt chest trauma from the emergency centre of Suez Canal University Hospital. E-FAST and computed tomography (CT) were conducted, followed by reporting of NEXUS criteria for all patients. Blinding of the E-FAST performer and CT reporter were confirmed. The results of both the NEXUS algorithm and E-FAST were compared with CT chest results.

Results

The NEXUS algorithm had 100% sensitivity and 15.3% specificity, and E-FAST had 70% sensitivity and 96.7% specificity, in the detection of pneumothorax.In the detection of hemothorax, the sensitivity and specificity of the NEXUS algorithm were 90% and 7.5%, respectively, whereas E-FAST had a lower sensitivity of 80% and a higher specificity of 97.5%.

Conclusion

E-FAST is highly specific for the detection of hemothorax, pneumothorax, and chest injuries compared with the NEXUS chest algorithm, which demonstrated the lowest specificity. However, the NEXUS chest algorithm showed a higher sensitivity than E-FAST and hence can be used effectively to rule out thoracic injury.

Association Between Neutrophil Density and Survival in Trauma Patients Admitted to the Intensive Care Unit; a Retrospective Cohort Study

Introduction

Altered immune responses, in particular neutrophil changes, are perceived to play a key role in immune responses to trauma. This study aimed to evaluate the association of neutrophil changes with patients' survival in severe multiple trauma cases.

Methods

The current retrospective cohort study was conducted using data from patients admitted in the intensive care unit (ICU) of a trauma center in Shiraz, Iran, between 2016 and 2021. Patients were divided into three groups (i.e., normal, neutropenia, and neutrophilia) based on neutrophil count at the time of ICU admission, and the association of neutrophil count with in-hospital mortality was analyzed.

Results

2176 patients with the mean age of 37.90 ± 18.57 years were evaluated (84.04% male). The median trauma severity based on injury severity score (ISS) in this series was 9 (4 -17). Patients were divided in to three groups of neutrophilia (n = 1805), normal (n = 357), and neutropenia (n = 14). There were not any significant differences between groups regarding age distribution (p = 0.634), gender (p = 0.544), and trauma severity (p = 0.197). The median survival times for the normal, neutropenia, and neutrophilia groups were 49 (IQR: 33 -47) days, 51 (IQR: 8- 51) days, and 38 (IQR: 26 - 52) days, respectively (p = 0.346). The log-rank test showed a statistically significant difference between the three groups adjustment for ISS (p ≤ 0.001). For each unit increase in ISS, the hazard ratio increased by 2%. In ISS 9-17, the hazard ratio increased by 11% compared to ISS<4. Also, in ISS>17, the hazard ratio increased by 76% compared to ISS<4 in ICU-hospitalized patients.

Conclusions

In general, the findings of the present study showed that the survival rate of patients in the normal group after ISS adjustment was higher than the other two groups. Also, the Cox model showed that the mortality risk ratio in the neutropenia group was 15 times higher than the normal group.

Myocardial infarction after craniotomy for asymptomatic meningioma

A man in his 40s with a history of coronary artery disease previously treated with a drug-eluting stent presented for elective craniotomy and resection of an asymptomatic but enlarging meningioma. During his craniotomy, he received desmopressin and tranexamic acid for surgical bleeding. Postoperatively, the patient developed chest pain and was found to have an ST-elevation myocardial infarction (MI). Because of the patient's recent neurosurgery, standard post-MI care was contraindicated and he was instead managed symptomatically in the intensive care unit. Echocardiogram on postoperative day 1 demonstrated no regional wall motion abnormalities and an ejection fraction of 60%. His presentation was consistent with thrombosis of his diagonal stent. He was transferred out of the intensive care unit on postoperative day 1 and discharged home on postoperative day 3.

A photoacoustic patch for three-dimensional imaging of hemoglobin and core temperature

Electronic patches, based on various mechanisms, allow continuous and noninvasive monitoring of biomolecules on the skin surface. However, to date, such devices are unable to sense biomolecules in deep tissues, which have a stronger and faster correlation with the human physiological status than those on the skin surface. Here, we demonstrate a photoacoustic patch for three-dimensional (3D) mapping of hemoglobin in deep tissues. This photoacoustic patch integrates an array of ultrasonic transducers and vertical-cavity surface-emitting laser (VCSEL) diodes on a common soft substrate. The high-power VCSEL diodes can generate laser pulses that penetrate >2 cm into biological tissues and activate hemoglobin molecules to generate acoustic waves, which can be collected by the transducers for 3D imaging of the hemoglobin with a high spatial resolution. Additionally, the photoacoustic signal amplitude and temperature have a linear relationship, which allows 3D mapping of core temperatures with high accuracy and fast response. With access to biomolecules in deep tissues, this technology adds unprecedented capabilities to wearable electronics and thus holds significant implications for various applications in both basic research and clinical practice.

A framework for the design and implementation of Stop the Bleed and public access trauma equipment programs

Traumatic injuries remain the leading cause of death for those under the age of 44 years old. Nearly a third of those who die from trauma do so from bleeding. Reducing death from severe bleeding requires training in the recognition and treatment of life-threatening bleeding, as well as programs to ensure immediate access to bleeding control resources. The Stop the Bleed (STB) initiative seeks to educate and empower people to be immediate responders and provide control of life-threatening bleeding until emergency medical services arrive. Well-planned and implemented STB programs will help ensure program effectiveness, minimize variability, and provide long-term sustainment. Comprehensive STB programs foster consistency, promote access to bleeding control education, contain a framework to guide the acquisition and placement of equipment, and promote the use of these resources at the time of a bleeding emergency. We leveraged the expertise and experience of the Stop the Bleed Education Consortium to create a resource document to help inform and guide STB program developers and implementers on the key areas for consideration when crafting strategy. These areas include (1) equipment selection, (2) logistics and kit placement, (3) educational program accessibility and implementation, and (4) program oversight, facilitation, and administration.

Cryoprecipitate transfusion in trauma patients attenuates hyperfibrinolysis and restores normal clot structure and stability: Results from a laboratory sub-study of the FEISTY trial

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.

Multi-center Retrospective Study of Factors Affecting Perioperative Transfusion of Packed Red Blood Cells for Pelvic Fracture Patients

Objective

To analyze the use of packed red blood cells (PRBCs) for patients with pelvic fracture and evaluate factors associated with PRBC transfusion for patients with pelvic fracture.

Methods

This retrospective cohort study collected 551 patients with pelvic fractures from six hospitals between September 1, 2012, and June 31, 2019. The age span of patients varied from 10 to 95 years old, and they were classified into two groups based on high‐energy pelvic fractures (HE‐PFs) or low‐energy pelvic fractures (LE‐PFs). The study's outcome was the use of PRBCs, fresh frozen plasma (FFP), and albumin. Demographic data, characteristics, laboratory tests, clinical treatment details, and clinical outcomes were compared between the two groups. Factors that were statistically associated with perioperative PRBCs in univariate analyses were included to conduct an optimal scale regression to determine the independent factors for perioperative PRBCs.

Results

A total of 551 patients were screened from six hospitals, and after inclusion and exclusion, 319 were finally included and finished the follow‐up from admission to discharge, while four patients died during hospitalization. Three hundred and nineteen patients were classified into two groups by their injury mechanisms. A total of 230/319 (72.1%) patients were classified into the HE‐PF group, and 89/319 (27.8%) patients were classified into the LE‐PF group. Patients in the HE‐PF group were transfused with 4.5 (3–8) units of PRBCs, 300 (0–600) ml of FFP, and 0 (0–30) g of albumin, while patients in the LE‐PF group were transfused with 3.5 (2–4.5) units of PRBCs, 0 (0–295) ml of FFP, and 0 (0–0) g of albumin (all P < 0.001). There were higher proportions of male patients and patients under 65 in the HE‐PF group (all P < 0.001). HE‐PF group patients were more severely injured and likely to take external fixation. The optimal scale regression revealed four significant factors associated with perioperative transfused PRBCs, which were patients on admission with hemorrhagic shock (importance = 0.283, P = 0.004), followed by fracture types identified by Tile classification (importance = 0.156, P < 0.001), hemoglobin levels below 70 g/L on admission (importance = 0.283, P = 0.004), followed by fracture types identified by Tile classification (importance = 0.156, P < 0.001), hemoglobin levels below 70 g/L on admission (importance = 0.148, P = 0.039), and methods of pelvic fixation (importance = 0.008, P = 0.026), ranked by the importance.

Conclusion

Patients with HE‐PFs had increased transfusions of PRBCs, FFP, and albumin, and hemorrhagic shock on admission, Tile classification, Hb levels, and stabilization methods were found to be associated with perioperative PRBCs.

Recurrent Carotid artery blow out in a head & neck patient

Introduction and importance

Carotid artery blowout syndrome is a rare complication of head and neck cancer treatment. It defines a rupture of the carotid artery wall through vessel wall necrosis. This is typically precipitated by radiotherapy, direct tumour invasion, or a combination of these factors. We describe a rare case of three consecutive carotid artery blowouts in a head and neck cancer patient.

Case presentation

A 58-year-old man with a history of T3NO hypopharyngeal squamous cell carcinoma (SCC) treated with chemotherapy and radiation presented with a four-month history of progressive dysphagia and right sided neck pain. Flexible nasendoscopy revealed laryngeal oedema and slough. A panendoscopy and biopsy showed no evidence of tumour recurrence. The patient was discharged and represented with worsening dyspnoea. He subsequently experienced a large volume hemorrhage necessitating ligation of his right external carotid artery. He underwent pharyngolaryngectomy indicated due to the extent of laryngeal radiation necrosis. Thereafter he suffered two additional acute carotid bleeds from his right common carotid necessitating ligation in theatre.

Clinical discussion and conclusion

This case report illustrates the key issues to be considered in patients with locally advanced hypopharyngeal squamous cell carcinoma and subsequent management of acute carotid blowout syndrome, which without prompt management, can be fatal.

•

Carotid artery rupture, or blowout, has a high morbidity and mortality.

•

Carotid blowout is a rare consequence of head and neck cancer treatment.

•

Radiotherapy is the main predisposing risk factor.

•

Acute carotid blowout requires prompt resuscitation and bleeding source control.

•

Definitive treatment includes endovascular occlusion, stenting or surgical ligation.

Pro-Con Debate: Viscoelastic Hemostatic Assays Should Replace Fixed Ratio Massive Transfusion Protocols in Trauma

Major trauma patients at risk of traumatic coagulopathy are commonly treated with early clotting factor replacement to maintain hemostasis and prevent microvascular bleeding. In the United States, trauma transfusions are often dosed by empiric, low-ratio massive transfusion protocols, which pair plasma and platelets in some ratio relative to the red cells, such as the "1:1:1" combination of 1 units of red cells, 1 unit of plasma, and 1 donor's worth of pooled platelets. Empiric transfusion increases the rate of overtransfusion when unnecessary blood products are administered based on a formula and not on at patient's hemostatic profile. Viscoelastic hemostatic assays (VHAs) are point-of-care hemostatic assays that provided detailed information about abnormal clotting pathways. VHAs are used at many centers to better target hemostatic therapies in trauma. This Pro/Con section will address whether VHA guidance should replace empiric fixed ratio protocols in major trauma.

Antifibrinolytics Are Not Associated With Reduced Blood Loss in Minimally-Invasive Endoscopic-Assisted Craniectomy for Repair of Single-Suture Craniosynostosis

ABSTRACT

Minimally-invasive endoscopic-assisted craniectomy (EAC) achieves similar functional and cosmetic outcomes, whereas reducing morbidity risk that is often associated with complex cranial vault reconstruction. Antifibrinolytics (AF) usage to limit blood loss and transfusion requirements during complex cranial vault reconstruction has been studied extensively; however, studies are limited for AF therapy in EAC. The aim of this single-center retrospective observational cohort pilot study was to evaluate whether the use of AF was associated with reduced blood loss in infants undergoing EAC. The authors hypothesized that there would be no difference in blood loss between patients who received AF and those that did not receive AF during EAC. Non-syndromic patients who underwent single-suture EAC were retrospectively evaluated. Primary outcome measure was intraoperative calculated blood loss (mL/kg). Secondary outcome measures included perioperative red blood cells transfusion volumes, number of blood donor exposures, and pediatric intensive care unit and total hospital length of stay. Study cohort demographic and outcome data were analyzed; Fisher exact test was used for categorical data, Student t test was used for continuous data. A P value of < 0.05 was considered statistically significant. Forty-nine EAC patients were included in the study with 34 patients in the AF cohort and 15 patients in the non-AF cohort. There were no significant differences in demographics between the 2 groups. Additionally, there was no significant difference in intraoperative calculated blood loss or any secondary outcome measure. In our single-suture EAC study cohorts, AF administration was not associated with a decrease in blood loss when compared to those that did not receive AF therapy.

Recent developments in mussel-inspired materials for biomedical applications

Over the decades, researchers have strived to synthesize and modify nature-inspired biomaterials, with the primary aim to address the challenges of designing functional biomaterials for regenerative medicine and tissue engineering. Among these challenges, biocompatibility and cellular interactions have been extensively investigated. Some of the most desirable characteristics for biomaterials in these applications are the loading of bioactive molecules, strong adhesion to moist areas, improvement of cellular adhesion, and self-healing properties. Mussel-inspired biomaterials have received growing interest mainly due to the changes in mechanical and biological functions of the scaffold due to catechol modification. Here, we summarize the chemical and biological principles and the latest advancements in production, as well as the use of mussel-inspired biomaterials. Our main focus is the polydopamine coating, the conjugation of catechol with other polymers, and the biomedical applications that polydopamine moieties are used for, such as matrices for drug delivery, tissue regeneration, and hemostatic control. We also present a critical conclusion and an inspired view on the prospects for the development and application of mussel-inspired materials.

Complications after intramedullary nail fixation of pathological versus non-pathological femoral shaft fractures: a retrospective cohort study in 233 patients

BACKGROUND

Postoperative adverse events after intramedullary nailing have been reported in patients with metastatic pathological and non-pathological femoral fractures. Other consequences to be considered are readmission and reoperation. Few studies have compared the risks of postoperative adverse events, reoperation, and readmission after intramedullary nailing of pathological and non-pathological femur fractures. This study was designed to test the hypothesis that patients with pathological femoral fractures had more adverse events, readmission, and reoperation following surgical fixation than non-pathological femoral fractures.

METHODS

This was a retrospective observational cohort study, conducted at an academic medical center in Thailand. The data from patients with femoral shaft fractures undergoing long intramedullary nailing, from June 1, 2006, to June 30, 2020, were included. Patients who had a pathological fracture from a primary bone tumor, metabolic bone disease, or inadequate/missing information were excluded. Patients with pathological fractures from metastatic bone disease were assigned to be the pathological group whereas those with traumatic fractures were assigned to be the non-pathological group. The primary outcome was the risk of inpatient adverse events as compared between the two groups. The secondary outcome was the risk of consequences after discharge as compared between the two groups. Outcomes were analyzed by using multivariate logistic regression analysis.

RESULTS

The total number of patients was 48 in the pathological fracture group and 185 in the non-pathological group. There were significantly higher rates of surgical and medical adverse events in patients with pathological fractures compared to patients with non-pathological fractures. After adjusting for potential confounding factors in multivariate regression analysis, patients with pathological fractures had higher odds of both adverse surgical (adjusted OR 2.43, 95 % CI 1.15-5.13) and medical adverse events (adjusted OR 2.81, 95 % CI 1.13-7.03).

CONCLUSIONS

Patients with metastatic pathological femoral shaft fractures undergoing intramedullary nailing were more likely to experience postoperative adverse events than patients with non-pathological fractures.

A performance comparison of the most commonly used minimally invasive monitors of cardiac output

BACKGROUND

Shock is common in critically ill and injured patients. Survival during shock is highly dependent on rapid restoration of tissue oxygenation with therapeutic goals based on cardiac output (CO) optimization. Despite the clinical availability of numerous minimally invasive monitors of CO, limited supporting performance data are available.

METHODS

Following approval of the University of Saskatchewan Animal Research Ethics Board, we assessed the performance and trending ability of PiCCOplus™, FloTrac™, and CardioQ-ODM™ across a range of CO states in pigs. In addition, we assessed the ability of invasive mean arterial blood pressure (iMAP) to follow changes in CO using a periaortic transit-time flow probe as the reference method. Statistical analysis was performed with function-fail, bias and precision, percent error, and linear regression at all flow, low-flow (> 1 standard deviation [SD] below the mean), and high-flow (> 1 SD above the mean) CO conditions.

RESULTS

We made a total of 116,957 paired CO measurements. The non-invasive CO monitors often failed to provide a CO value (CardioQ-ODM: 40.6% failed measurements; 99% confidence interval [CI], 38.5 to 42.6; FloTrac: 9.6% failed measurements; 99% CI, 8.7 to 10.5; PiCCOplus: 4.7% failed measurements; 99% CI, 4.5 to 4.9; all comparisons, P < 0.001). The invasive mean arterial pressure provided zero failures, failing less often than any of the tested CO monitors (all comparisons, P < 0.001). The PiCCOplus was most interchangeable with the flow probe at all flow states: PiCCOplus (20% error; 99% CI, 19 to 22), CardioQ-ODM (25% error; 99% CI, 23 to 27), FloTrac (34% error; 99% CI, 32 to 38) (all comparisons, P < 0.001). At low-flow states, CardioQ-ODM (43% error; 99% CI, 32 to 63) and Flotrac (45% error; 99% CI, 33 to 70) had similar interchangeability (P = 0.07), both superior to PiCCOplus (48% error; 99% CI, 42 to 60) (P < 0.001). Regarding CO trending, the CardioQ-ODM (correlation coefficient, 0.82; 99% CI, 0.81 to 0.83) was statistically superior to other monitors including iMAP, but at low flows iMAP (correlation coefficient, 0.58; 99% CI, 0.58 to 0.60) was superior to all minimally invasive CO monitors (all comparisons P < 0.001).

CONCLUSIONS

None of the minimally invasive monitors of CO performed well at all tested flows. Invasive mean arterial blood pressure most closely tracked CO change at critical flow states.

Platelet dysfunction in patients with traumatic intracranial hemorrhage: Do desmopressin and platelet therapy help or harm?

BACKGROUND

Pre-injury anti-platelet use has been associated with increased risk of progression of traumatic intracranial hemorrhage (TICH) and worse outcomes. VerifyNow® assays assess platelet inhibition due to aspirin/clopidogrel. This study assesses the outcomes of patients with TICH and platelet dysfunction treated with desmopressin and/or platelets.

METHODS

We performed a retrospective chart review of patients with mild TICH at a level 1 trauma center 1/1/2013-6/1/2016. Patients with documented platelet dysfunction who received desmopressin and/or platelets were compared to those who were untreated. Primary outcomes were progression of TICH and neurologic outcomes at discharge.

RESULTS

Of 565 patients with a mild TICH, 200 patients had evidence of platelet dysfunction (a positive VerifyNow® assay). Patients had similar baseline demographics, injury characteristics, and rate of TICH progression; but patients who received desmopressin and/or platelets had worse Glasgow Outcomes Score at discharge.

CONCLUSION

Treatment of patients with mild TICH and platelet dysfunction with desmopressin and/or platelets did not affect TICH progression but correlated with worse neurologic status at discharge.

Goals for Collaborative Management of Obstetric Hemorrhage

Hemorrhage remains a leading cause of preventable maternal morbidity and mortality worldwide and in the United States. Postpartum hemorrhage is the number one cause of severe morbidity during hospitalization for birth, despite hospital, state, and national initiatives. In addition, studies show that more than 90% of maternal deaths related to obstetric hemorrhage are preventable. This article reviews relevant physiologic changes of pregnancy that may have an impact on hemorrhage management and describes collaborative approaches for management of hemorrhage in this unique population.

Massive Hemorrhage Protocol Application and Teamwork Skills

OBJECTIVE

Massive hemorrhages (MHs) are rare but serious complications of pediatric trauma and obstetric cases. This study aimed to evaluate the impact of interprofessional simulation to improve adherence to a MH protocol (MHP), teamwork skills and confidence levels during a hemorrhagic crisis situation.Methods: This was a pre-post experimental study conducted at a tertiary care mother-child simulation center. Pediatric emergency and obstetric teams were submitted to simulated trauma and postpartum MH scenarios. Training consisted of two case scenarios followed by debriefing sessions and a lecture on the MHP. The primary outcome was adherence to MHP processes (checklist) measured prior to and 2 weeks following training sessions. Other outcomes were the measure of teamwork skills (Mayo High Performance Teamwork Scale) and confidence of the participants.

RESULTS

Sixty-two health care professionals were involved in eight interprofessional teams. Mean scores for adherence to the MHP improved from 19.1 in the pretraining phase to 25.8 in the posttraining phase (difference of 6.7; 95% confidence interval [CI] = 4.4 to 8.9). Mean scores pertaining to teamwork skills also improved significantly between pre- and posttraining phases (difference = 3.9; 95% CI = 1.5 to 6.4). Confidence questionnaires showed significant improvements in the posttraining phase (difference = 6.9; 95% CI = 5.3 to 8.3).

CONCLUSIONS

Targeted training involving simulation and protocol review improved participant adherence to MHP processes and teamwork skills. Confidence levels improved across all disciplines.

Comparison between intraoperative bleeding score and ROTEM® measurements to assess coagulopathy during major pediatric surgery

PURPOSE

Intraoperative bleeding should be regularly assessed visually to guide coagulation management. Whereas viscoelastic testing with ROTEM® measurement has been proven to be useful in detecting coagulopathies, the visual assessment is not standardized. This study therefore aims to compare a standardized visual assessment with ROTEM® results.

METHODS

A 5-point bleeding score was created and applied in a recently published randomized controlled trial in major pediatric non-cardiac surgery. This score assesses overall bleeding tendency and the occurrence of diffuse bleeding, aqueous bleeding, bleeding outside the operative field, and the ability to control bleeding. Validity of this score was tested by post hoc comparison to the results of simultaneously performed ROTEM® measurements.

RESULTS

Signs of coagulopathic bleeding were assessed at 183 time points. Mild to moderate bleeding intensity was judged at 103 time points, in 42 % abnormal ROTEM® traces were obtained simultaneously. When severe bleeding was scored, abnormal ROTEM values occurred in 58 %, and FIBTEM-values were significantly lower than in the "no bleeding group". Altogether, the correlation between bleeding score and ROTEM® measurements was not significant.

CONCLUSIONS

The standardized visual assessment did not correlate well with ROTEM® measurements, suggesting that it is not useful to detect coagulopathy. Trial registry number: ClinicalTrials.gov identifier No. NCT01487837.

Design and Development of a Hemorrhagic Trauma Simulator for Lower Limbs: A Pilot Study

One of the main preventable leading causes of death after a trauma injury is the hemorrhagic shock. Therefore, it is extremely important to learn how to control hemorrhages. In this paper, a hemorrhagic trauma simulator for lower limb has been developed and a pilot study has been accomplished to trail the simulator. Four different bleeding scenarios have been tested per participant, gathering information about the manual pressure exerted to control the bleeding. Data, altogether, from 54 hemorrhagic scenarios managed by final year medical students and doctors were gathered. Additionally, a post-simulation questionnaire, related to the usability of the simulator, was completed. All the participants managed to control the simulated bleeding scenarios, but the pressure exerted to control the four different scenarios is different depending if the trainee is a student or a doctor, especially in deep venous hemorrhages. This research has highlighted the different approach to bleeding control treatment between medical students and doctors. Moreover, this pilot study demonstrated the need to deliver a more effective trauma treatment teaching for hemorrhagic lesions and that hemorrhagic trauma simulators can be used to train and evaluate different scenarios.

Slounase, a Batroxobin Containing Activated Factor X Effectively Enhances Hemostatic Clot Formation and Reducing Bleeding in Hypocoagulant Conditions in Mice

Uncontrolled bleeding associated with trauma and surgery is the leading cause of preventable death. Batroxobin, a snake venom-derived thrombin-like serine protease, has been shown to clot fibrinogen by cleaving fibrinopeptide A in a manner distinctly different from thrombin, even in the presence of heparin. The biochemical properties of batroxobin and its effect on coagulation have been well characterized in vitro. However, the efficacy of batroxobin on hemostatic clot formation in vivo is not well studied due to the lack of reliable in vivo hemostasis models. Here, we studied the efficacy of batroxobin and slounase, a batroxobin containing activated factor X, on hemostatic clot composition and bleeding using intravital microcopy laser ablation hemostasis models in micro and macro vessels and liver puncture hemostasis models in normal and heparin-induced hypocoagulant mice. We found that prophylactic treatment in wild-type mice with batroxobin, slounase and activated factor X significantly enhanced platelet-rich fibrin clot formation following vascular injury. In heparin-treated mice, batroxobin treatment resulted in detectable fibrin formation and a modest increase in hemostatic clot size, while activated factor X had no effect. In contrast, slounase treatment significantly enhanced both platelet recruitment and fibrin formation, forming a stable clot and shortening bleeding time and blood loss in wild-type and heparin-treated hypocoagulant mice. Our data demonstrate that, while batroxobin enhances fibrin formation, slounase was able to enhance hemostasis in normal mice and restore hemostasis in hypocoagulant conditions via the enhancement of fibrin formation and platelet activation, indicating that slounase is more effective in controlling hemorrhage.

Synthetic platelet microgels containing fibrin knob B mimetic motifs enhance clotting responses

Native platelets are crucial players in wound healing. Key to their role is the ability of their surface receptor GPIIb/IIIa to bind fibrin at injury sites, thereby promoting clotting. When platelet activity is impaired as a result of traumatic injury or certain diseases, uncontrolled bleeding can result. To aid clotting and tissue repair in cases of poor platelet activity, our lab has previously developed synthetic platelet-like particles capable of promoting clotting and improving wound healing responses. These are constructed by functionalizing highly deformable hydrogel microparticles (microgels) with fibrin-binding ligands including a fibrin-specific whole antibody or a single-domain variable fragment. To improve the translational potential of these clotting materials, we explored the use of fibrin-binding peptides as cost-effective, robust, high-specificity alternatives to antibodies. Herein, we present the development and characterization of soft microgels decorated with the peptide AHRPYAAK that mimics fibrin knob 'B' and targets fibrin hole 'b'. These "Fibrin-Affine Microgels with Clotting Yield" (FAMCY) were found to significantly increase clot density in vitro and decrease bleeding in a rodent trauma model in vivo. These results indicate that FAMCYs are capable of recapitulating the platelet-mimetic properties of previous designs while utilizing a less costly, more translational design.

Portuguese Consensus and Recommendations for Acquired Coagulopathic Bleeding Management (CCBM)

We aimed to determine how Portuguese physicians handle major bleeding. We also aim to establish global diagnostic and therapeutic recommendations to be followed in clinical practice by using a step-wise approach of evidence generation. This study followed a three-step process: a steering committee desk review, a Delphi technique, an expert panel meeting. A modified 3-round Delphi including 31 statements was performed. Questions were answered in a five-point Likert-type scale. Consensus threshold was established as a percentage of agreement among participants ≥90% in the first round, and ≥85% in the second and third rounds. The level of consensus achieved by panelists was discussed with the scientific committee (January-2020). Fifty-one physicians participated in the study (compliance rate >90%). Analyzing the three rounds, consensus was reached on 20 items (64.5%) in the first, 4/11 items (36.4%) in the second and 6/7 items (85.7%) in the third. One statement about administration of clotting factor concentrates for bleeding control did not reach consensus. A high level of consensus was reached toward the need for implementing Patient Blood Management strategies in Portuguese hospitals, reduce exposure to allogeneic blood components, to use goal directed therapies for acquired bleeding management, and the need for evaluating blood transfusion indirect costs. A final version with 12 recommendations was built, according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE). Our results provide critically appraised and updated evidence on bleeding coagulopathies management in Portugal. Additional studies, mainly about indirect costs of blood transfusion, are needed.

Trauma-Induced Coagulopathy: Overview of an Emerging Medical Problem from Pathophysiology to Outcomes

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.

Pathogen reduction of whole blood: Supplementing fibrinogen partly corrects clot formation in a massive transfusion model

BACKGROUND

The use of whole blood (WB) to treat trauma patients is becoming more common. Similar to the treatment of individual components, pathogen inactivation (PI) technologies are available to treat WB. The impact of PI on WB function is not well understood. This study investigated the impact of PI of WB with riboflavin/ultraviolet (UV) light on its hemostatic function by modeling transfusion scenarios for trauma patients and assessing transfusion efficacy by rotational thromboelastometry (ROTEM). As fibrinogen is affected by PI of WB, the effect of fibrinogen supplementation commonly used in trauma patients was also analyzed in this model.

STUDY DESIGN AND METHODS

Trauma transfusion scenarios were simulated by mixing untreated WB or WB treated with the Mirasol PI technology (riboflavin/UV) in different ratios with hemodiluted blood, and the thromboelasticity was monitored by ROTEM. The impact of supplementation with the fibrinogen concentrate RiaSTAP was investigated in this model.

RESULTS

Pathogen-inactivated WB (PI-WB) showed decreased activity in the hemostatic profile compared to the untreated control. Hemodiluted blood at a hematocrit (hct) of 20%, which was reconstituted with PI-WB or untreated WB, exhibited increased alpha values, maximum clot firmness, and clot formation time. Simulating transfusion scenarios by blood replacement with PI-WB resulted in a significant difference in ROTEM parameters between reconstituted PI-treated and -untreated WB (p ≥ .05). The effect of PI treatment waned when PI-WB was enriched with fibrinogen.

CONCLUSION

ROTEM investigations suggest that PI treatment has a negative impact on WB clot formation unless fibrinogen supplementation is used.

The role of cryoprecipitate in human and canine transfusion medicine

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.

[Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in gastric cancer]

BACKGROUND

Gastric cancer with peritoneal metastases is associated with an extremely poor prognosis. Developed multimodal treatment concepts, which include a combination of perioperative systemic treatment and cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (HIPEC), show promising results with respect to improvement of the long-term survival.

METHODS

This article contains a review of the literature of published studies on the topic of gastric cancer and peritoneal metastasis.

RESULTS

The prognosis of patients with gastric cancer peritoneal carcinomatosis shows an extremely limited median survival of 7 months under palliative second-line systemic treatment. The median survival time increased to 12 months with cytoreductive surgery and in combination with HIPEC showed a positive effect on survival in individual studies.

EXPERT OPINION

Treatment recommendations for patients with peritoneal metastases of gastric cancer should be carried out by experts in surgical reference centers.

Fibrinogen Replacement Therapy for Traumatic Coagulopathy: Does the Fibrinogen Source Matter?

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.

Management of Pelvic Ring Injury Patients With Hemodynamic Instability

Pelvic ring injuries (PRI) are among the most difficult injuries to deal with in orthopedic trauma. When these injuries are accompanied by hemodynamic instability their management becomes significantly more complex. A methodical assessment and expeditious triage are required for these patients followed by adequate resuscitation. A major triage decision is whether these patients should undergo arterial embolization in the angiography suit or prompt packing and pelvic stabilization in the operating room. Patient characteristics, fracture type and injury characteristics are taken into consideration in the decision-making process. In this review we discuss the acute evaluation, triage and management of PRIs associated with hemodynamic instability. An evidence based and protocol driven approach is necessary in order to achieve optimal outcomes in these patients.

New approach to the risk variables for administration of fibrinogen in patients with postpartum hemorrhage by using cluster analysis

OBJECTIVE

To analyze all the variables in women who received fibrinogen for postpartum hemorrhage (PPH) using hierarchical cluster analysis, to provide greater insight into the risk variables involved in these women.

METHODS

This retrospective study of women with at least 500 mL of bleeding at birth or during the postpartum period and treated with fibrinogen was conducted at the Department of Obstetrics and Gynecology, Atatürk University School of Medicine from January 2013 to January 2018. Data on the women were obtained from medical records and various risk variables were recorded and analyzed using hierarchical cluster analysis.

RESULTS

A total of 114 women with PPH were included in the study. Based on a dendrogram, three main clusters of similar quality variables were created: 1) gravida, parity, age, cervical/vaginal hematoma, laparotomy, hypogastric artery ligation, uterine artery embolization, uterine artery ligation, uterine atony, distance from outer center, lowest hemoglobin, preoperative platelets, endometritis, preoperative white blood cells; 2) lowest fibrinogen, highest fibrinogen, type of birth, placenta invasion anomaly, Bakri balloon tamponade, postpartum hysterectomy, preoperative activated partial thromboplastin time (APTT), preoperative international normalized ratio (INR), placental abruption, in-utero ex fetus; 3) postoperative APTT, postoperative INR, maternal mortality, erythrocyte transfusion, plasma transfusion, hospital stay time, disseminated intravascular coagulation/HELLP syndrome, highest hemoglobin, blood group, postoperative platelets, platelet transfusion, pre-eclampsia/eclampsia, fibrinogen extract.

CONCLUSION

According to the cluster analysis, we should keep fibrinogen extract in the foreground especially in the treatment of hemorrhage in patients with variable conditions. As a result, we can determine whether fibrinogen extract, which has a high economic cost, should be kept at each center. We can also direct which patient will be referred in accordance with the referral steps.

Use of Low-Dose Recombinant Factor Ⅶa for Uncontrolled Perioperative Bleeding

BACKGROUND

Recombinant activated factor VIIa (rFVIIa) is a prohemostatic agent initially approved for use in hemophilia patients and has also been used for a diverse range of off-label indications in the context of massive uncontrolled blood loss; however, no convincing evidence exists regarding the optimal dose of rFVIIa to treat uncontrolled bleeding in surgical patients.

AIM

To evaluate the effects and safety of a very low dose of rFⅦa in patients with uncontrolled perioperative bleeding in the surgical intensive care unit (ICU).

METHODS

55 patients from Beijing Hospital, who received rFⅦa between July 2004 and November 2018 for uncontrolled perioperative bleeding were included. The controls were matched for age, sex, severity, and operation type. The baseline demographics, survival, changes in bleeding and transfusion, coagulation parameters and complications were analyzed.

RESULTS

A low dose of rFⅦa (2.0∼3.6 mg, with a median dose of 39.02 μg/kg) appears to be effective in controlling massive hemorrhage (with an effective rate of 74.55%), and can reduce volume of red blood cell transfusion, improve coagulation status, while has a relatively low risk of thromboembolic complications (3.6%).

CONCLUSION

In patients with uncontrolled perioperative bleeding, a low dose of rFⅦa could be used when traditional methods are ineffective.

Platelet Transfusion After Traumatic Intracranial Hemorrhage in Patients on Antiplatelet Agents

BACKGROUND

With an aging population, the number of patients on antiplatelet medications and traumatic brain injury (TBI) is increasing. Our study aimed to evaluate the role of platelet transfusion on outcomes after traumatic intracranial bleeding (IB) in these patients.

METHODS

We analyzed our prospectively maintained TBI database from 2014 to 2016. We included all isolated TBI patients with an IB, who were on preinjury antiplatelet agents and excluded patients taking anticoagulants. Outcome measures included the progression of IB, neurosurgical intervention, and mortality. Regression analysis was performed.

RESULTS

A total of 343 patients met the inclusion criteria. Mean age was 58 ± 11 y, 58% were men, and median injury severity score was 15 (10-24). Distribution of antiplatelet agents was as follows: aspirin (60%) and clopidogrel (35%). Overall, 74% patients received platelet transfusion after admission with a median number of two platelet units. After controlling for confounders, patients who received one unit of pooled platelets had no difference in progression of IB (odds ratio [OR]: 0.98, [0.6-1.9], P = 0.41), need for neurosurgical intervention (OR: 1.09, [0.7-2.5], P = 0.53), and mortality (OR: 0.84, [0.6-1.8], P = 0.51). However, patients who received two units of pooled platelets had lower rate of progression of IB (OR: 0.69, [0.4-0.8], P = 0.02), the need for neurosurgical intervention (OR: 0.81, [0.3-0.9], P = 0.03), and mortality (OR: 0.84, [0.5-0.9], P = 0.04). Both groups were compared with those who did not receive platelet transfusion.

CONCLUSIONS

The use of two units of platelet may decrease the risk of IB progression, neurosurgical intervention, and mortality in patients on preinjury antiplatelet agents and TBI. Further studies should focus on developing protocols for platelet transfusion to improve outcomes in these patients.

LEVEL OF EVIDENCE

Level III prognostic.

Fibrinogen Diagnostics in Major Hemorrhage

Fibrinogen is one of the first factors to fall to critically low levels in the blood in many coagulopathic events. Patients with hypofibrinogenemia are at a significantly greater risk of major hemorrhage and death. The rapid replacement of fibrinogen early on in hypofibrinogenemia may significantly improve outcomes for patients. Fibrinogen is present at concentrations between 2 and 4 g/L in the plasma of healthy people. However, hypofibrinogenemia is diagnosed when the fibrinogen level drops below 1.5-2 g/L. This review analyses different types of fibrinogen assays that can be used for diagnosing hypofibrinogenemia. The scientific mechanisms and limitations behind these tests are then presented. Additionally, the current state of clinical major hemorrhage protocols (MHPs) is presented and the structure, function and physiological role of fibrinogen is summarized.

Change in Hematocrit during Trauma Assessment Predicts Bleeding Even with Ongoing Fluid Resuscitation

This study tests the hypothesis that a change in hematocrit (ΔHct) during initial trauma work-up is as reliable as conventional vital signs for detecting bleeding, even with ongoing fluid resuscitation. Consecutive trauma patients admitted to a Level I trauma center receiving two Hct measurements during initial resuscitation between January 2010 and January 2011 were stratified based on estimated blood loss greater than 250 mL (bleeding) or nonbleeding. Sensitivity, specificity, and receiver operating characteristic curves were calculated for systolic blood pressure (SBP), heart rate, base deficit, and ΔHct. In 168 (72%) nonbleeding versus 64 (28%) bleeding patients, age and gender were similar. Arrival SBP was highly specific (90 to 99%) but poorly sensitive (13 to 31%) for detecting bleeding. Combinations of vital signs increased specificity, albeit at the expense of sensitivity. For bleeding versus nonbleeding patients (all receiving resuscitation fluid), ΔHct was 9.0 versus 1.8, ΔHct/liter was 4.8 versus 1.5, and ΔHct/liter/hour was 2.8 vs 0.6 (all P < 0.001). Only SBP (area under the curve [AUC] 0.608 to 0.695) and ΔHct (AUC 0.731 to 0.921) were significant for identifying bleeding with ΔHct 6 or greater being the best predictor (sensitivity 89%, specificity 95%, AUC 0.921). During ongoing fluid resuscitation of a trauma victim, ΔHct is the single most reliable indicator of continuing blood loss. A ΔHct 6 or greater during initial resuscitation is highly suspicious for ongoing blood loss, but even lesser changes have predictive value. Altogether, these results support the idea that fluid shifts are rapid after hemorrhage and Hct can be valuable during initial trauma assessment.

Risk factors for blood transfusion in traumatic and postpartum hemorrhage patients: Analysis of the CRASH-2 and WOMAN trials

BACKGROUND

Hemorrhage is a leading cause of death after trauma and childbirth. In response to severe hemorrhage, bleeding patients often receive transfusions of red blood cells, plasma, platelets, or other blood components. We examined risk factors for transfusion in acute severe bleeding in two trials of over 20,000 patients to better understand factors associated with transfusion likelihood.

STUDY DESIGN AND METHODS

We conducted a cohort analysis of data from the CRASH-2 and WOMAN trials, two multinational trials that recruited patients with traumatic and postpartum hemorrhage, respectively. For each trial, we examined the effect of 10 factors on blood transfusion likelihood. Univariate and multivariate Poisson regressions were used to analyze the relationship between risk factors and blood transfusion.

RESULTS

Of the 20,207 traumatic hemorrhage patients, 10,232 (51%) received blood components. Of the 20,060 women with postpartum hemorrhage, 10,958 (55%) received blood components. For patients who suffered from traumatic hemorrhage, those greater than three hours from injury to hospitalization were more likely to be transfused (ARR 1.37; 95% CI, 1.20-1.56). Postpartum hemorrhage patients had an increased likelihood of transfusion if they gave birth outside the hospital (ARR 1.30; 95% CI 1.22-1.39), gave birth more than three hours before hospitalization (ARR 1.09; 95% CI 1.01-1.17), had a Caesarean section (ARR 1.16; 95% CI 1.08-1.25), and if they had any identifiable causes of hemorrhage other than uterine atony.

CONCLUSION

Several risk factors are associated with an increased likelihood of transfusion in traumatic and postpartum hemorrhage patients. Altering modifiable factors, by reducing time from injury or childbirth to hospitalization, for example, might be able to reduce transfusions and their complications.

TRIAL REGISTRATION

CRASH-2 is registered as ISRCTN86750102, ClinicalTrials.gov NCT00375258 and South African Clinical Trial Register DOH-27-0607-1919. WOMAN is registered as ISRCTN76912190, ClinicalTrials.gov NCT00872469, PACTR201007000192283, and EudraCT number 2008-008441-38.