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Kasraian L, Naderi N, Hosseini M, Taheri Akerdi A, Paydar S, Abdolrahimzadeh Fard H. A novel scoring system for early prediction of massive transfusion requirement in trauma patients. Intern Emerg Med 2024; 19:1431-1438. [PMID: 38583098 DOI: 10.1007/s11739-024-03541-7] [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: 07/02/2023] [Accepted: 01/16/2024] [Indexed: 04/08/2024]
Abstract
Early resuscitation using blood products is critical for patients with severe hemorrhagic shock. We aimed to develop and validate a new scoring system, hemorrhagic shock transfusion prediction (HSTP) score, to predict the need for massive transfusion (MT) in these patients, compared to the widely used Assessment of Blood Consumption (ABC) score. Trauma patients admitted to Emtiaz Hospital in Iran from 2017 to 2021 were retrospectively included. Patients assigned a code 1 or 2 according to the Emergency severity index (ESI) triage system have been divided into MT and non-MT groups. MT was defined as receiving ≥ 10 units of packed cells (PCs) in 24 h. Demographic information, admission vital signs, and lab results available within 15 min were compared between the groups. A new predictive score was developed using logistic regression of statistically significant parameters. Out of 1029 patients, 651 (63.3%) required MT. An arrival, diastolic blood pressure < 79.5 mm Hg, absolute lymphocyte count > 1850/μL, base excess < - 4.25, and blood glucose > 156 mg/dL were independent predictors included in the HSTP score. The sensitivity and specificity were 74.36% and 53.87% for the HSTP score, compared to 31.03% and 76.16% for the ABC score. Moreover, the positive and negative predictive values were 77.88% and 49.03% for the HSTP score, versus 74.15% and 33.66% for ABC. The new scoring system demonstrated higher sensitivity and improved positive and negative predictive values compared to the ABC score. This score can assist physicians in making accurate transfusion decisions quickly, but further prospective studies are warranted to validate its clinical utility.
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Affiliation(s)
- Leila Kasraian
- Blood Transfusion Research Centre, Higher Institute for Research and Education in Transfusion Medicine, Shiraz, Iran
| | - Nima Naderi
- Anesthesiology and Critical Care Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Maryam Hosseini
- Truama Research Center, Shahid Rajaee (Emtiaz) Trauma Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Ali Taheri Akerdi
- Truama Research Center, Shahid Rajaee (Emtiaz) Trauma Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Shahram Paydar
- Truama Research Center, Shahid Rajaee (Emtiaz) Trauma Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Hossein Abdolrahimzadeh Fard
- Truama Research Center, Shahid Rajaee (Emtiaz) Trauma Hospital, Shiraz University of Medical Sciences, Shiraz, Iran.
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Zhou R, Li Z, Liu J, Qian D, Meng X, Guan L, Sun X, Li H, Yu M. Prediction of intraoperative red blood cell transfusion in valve replacement surgery: machine learning algorithm development based on non-anemic cohort. Front Cardiovasc Med 2024; 11:1344170. [PMID: 38486703 PMCID: PMC10937389 DOI: 10.3389/fcvm.2024.1344170] [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: 11/25/2023] [Accepted: 02/20/2024] [Indexed: 03/17/2024] Open
Abstract
Background Our study aimed to develop machine learning algorithms capable of predicting red blood cell (RBC) transfusion during valve replacement surgery based on a preoperative dataset of the non-anemic cohort. Methods A total of 423 patients who underwent valvular replacement surgery from January 2015 to December 2020 were enrolled. A comprehensive database that incorporated demographic characteristics, clinical conditions, and results of preoperative biochemistry tests was used for establishing the models. A range of machine learning algorithms were employed, including decision tree, random forest, extreme gradient boosting (XGBoost), categorical boosting (CatBoost), support vector classifier and logistic regression (LR). Subsequently, the area under the receiver operating characteristic curve (AUC), accuracy, recall, precision, and F1 score were used to determine the predictive capability of the algorithms. Furthermore, we utilized SHapley Additive exPlanation (SHAP) values to explain the optimal prediction model. Results The enrolled patients were randomly divided into training set and testing set according to the 8:2 ratio. There were 16 important features identified by Sequential Backward Selection for model establishment. The top 5 most influential features in the RF importance matrix plot were hematocrit, hemoglobin, ALT, fibrinogen, and ferritin. The optimal prediction model was CatBoost algorithm, exhibiting the highest AUC (0.752, 95% CI: 0.662-0.780), which also got relatively high F1 score (0.695). The CatBoost algorithm also showed superior performance over the LR model with the AUC (0.666, 95% CI: 0.534-0.697). The SHAP summary plot and the SHAP dependence plot were used to visually illustrate the positive or negative effects of the selected features attributed to the CatBoost model. Conclusions This study established a series of prediction models to enhance risk assessment of intraoperative RBC transfusion during valve replacement in no-anemic patients. The identified important predictors may provide effective preoperative interventions.
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Affiliation(s)
- Ren Zhou
- State Key Laboratory of Medical Genomics, National Research Center for Translational Medicine at Shanghai, Shanghai Institute of Hematology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Zhaolong Li
- Department of Cardiovascular Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jian Liu
- Department of Cardiovascular Surgery, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Dewei Qian
- Department of Cardiovascular Surgery, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xiangdong Meng
- Department of Cardiovascular Surgery, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Lichun Guan
- Department of Cardiovascular Surgery, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xinxin Sun
- Department of Cardiovascular Surgery, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China
| | - Haiqing Li
- Department of Cardiovascular Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Min Yu
- Department of Cardiovascular Surgery, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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Day DL, Ng K, Severino R, Ng-Kamstra J. Seeking a Relevant Description of Major Trauma Bleeding: Comparison of Four Major Bleeding Definitions. J Trauma Nurs 2024; 31:7-14. [PMID: 38193485 DOI: 10.1097/jtn.0000000000000762] [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: 01/10/2024]
Abstract
BACKGROUND The traditional definition of massive transfusion is 10 red blood cell units transfused within 24 hr. This definition has been faulted for excluding patients who die early from exsanguination. Alternative major bleeding definitions in the trauma literature include time-based (e.g., Resuscitation Intensity) and event based (e.g., Sharpe) transfusion thresholds. OBJECTIVE The study objective was to compare four definitions of major bleeding, including a modification to the Sharpe definition, on clinically relevant processes and outcomes. METHODS This is a retrospective cohort study of adult trauma patients admitted from the field to a Level I trauma center from 2014 to 2019. Data sources were the trauma registry, blood bank, and electronic medical records. Transfusion thresholds were defined as follows: Resuscitation Intensity-4 units of any combination of crystalloids, colloids, or blood products within the first 30 min of arrival; Sharpe-10 red blood cell units from trauma bay presentation to inpatient admission (a proxy for the interval of hemorrhage control); Modified Sharpe-10 units of any combination of blood products during the same interval. The study analysis consisted of descriptive statistics. RESULTS The cohort contained 187 subjects. Of 39 deaths, 28 (72%) occurred within 6 hr following arrival. Modified Sharpe captured 27 (96%) of these 28 subjects, whereas Resuscitation Intensity captured 20 (71%). Sharpe and the traditional definition each captured 22 subjects (79%). Modified Sharpe captured 17%-25% of deaths missed by the other definitions. CONCLUSION Modified Sharpe may optimally indicate major bleeding during trauma resuscitation.
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Affiliation(s)
- Darcy L Day
- Crisis/Rapid Response Program, Nursing Division (Ms Day), Division of Trauma (Ms Ng), Division of Surgical Critical Care (Mr Severino), and FRCSC General Surgery & Adult Critical Care Medicine, Trauma, Acute Care Surgery, and Surgical Critical Care, Department of Surgery (Dr Ng-Kamstra), The Queen's Medical Center, Honolulu, Hawaii; and Department of Surgery, John A. Burns School of Medicine, Honolulu, Hawaii (Dr Ng-Kamstra)
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Zhou R, Qian D, Li H, Wang Z, Shi S, Shen F, Cheng L, Yang D, Yu M. Clinical presentation and in-hospital outcomes of intraoperative red blood cell transfusion in non-anemic patients undergoing elective valve replacement. Front Cardiovasc Med 2022; 9:1053209. [DOI: 10.3389/fcvm.2022.1053209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2022] [Accepted: 11/07/2022] [Indexed: 11/24/2022] Open
Abstract
BackgroundIntraoperative transfusion is associated with adverse clinical outcomes in cardiac surgery. However, few studies have shown the impact of intraoperative red blood cell (RBC) transfusion on non-anemic patients undergoing cardiac surgery. We assessed the in-hospital clinical outcomes of non-anemic patients undergoing isolated valve replacements and investigated the predictors associated with intraoperative RBC transfusion.MethodsWe enrolled 345 non-anemic patients undergoing isolated valve replacements in our department from January 2015 to December 2019. The patients were stratified by the receipt of intraoperative RBC transfusion. Baseline characteristics were compared between groups and multiple logistic regression was used to identify the predictors for intraoperative RBC transfusion. The association between intraoperative RBC transfusion and in-hospital outcomes was also evaluated.ResultsIntraoperative RBC transfusion developed in 84 of the 345 enrolled patients (24.3%). Three independent predictors for intraoperative RBC transfusion of non-anemic patients undergoing isolated valve replacements were identified by multivariate logistic analysis, including female, iron deficiency and hemoglobin level. When the two groups were compared, a significant tendency of higher in-hospital mortality (6.0% vs. 1.1%, P = 0.033) and higher incidence of postoperative hypoxemia (9.5% vs. 2.7%, P = 0.007) were observed in the intraoperative RBC transfusion group. After adjustment, the presence of intraoperative RBC transfusion was associated with an increase in postoperative hypoxemia (OR = 3.36, 95% CI: 1.16–9.71, P = 0.026).ConclusionIntraoperative RBC transfusion was associated with poorer clinical outcomes in non-anemic adults undergoing isolated valve replacements, which significantly increased the risk of postoperative hypoxemia. The independent predictors of intraoperative RBC transfusion, such as iron deficiency and female, were identified, which may be helpful for risk assessment and perioperative management.
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Yazer MH, Cap AP, Glassberg E, Green L, Holcomb JB, Khan MA, Moore EE, Neal MD, Perkins GD, Sperry JL, Thompson P, Triulzi DJ, Spinella PC. Toward a more complete understanding of who will benefit from prehospital transfusion. Transfusion 2022; 62:1671-1679. [PMID: 35796302 DOI: 10.1111/trf.17012] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 06/14/2022] [Accepted: 06/17/2022] [Indexed: 12/11/2022]
Affiliation(s)
- Mark H Yazer
- Department of Pathology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Andrew P Cap
- U.S. Army Institute of Surgical Research, Department of Medicine, Uniformed Services University, Bethesda, Maryland, USA
| | - Elon Glassberg
- Israeli Defense Forces, Medical Corps, Israel; Azrieli Faculty of Medicine, Bar-Ilan University, Safed, Israel, The Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Laura Green
- Barts Health NHS Trust, London, UK.,Blizard Institute, Queen Mary, University of London, London, UK.,NHS Blood and Transplant, London, UK
| | - John B Holcomb
- Center for Injury Science, Department of Surgery, University of Alabama at Birmingham, Birmingham, USA
| | - Mansoor A Khan
- Department of Abdominal Surgery and Medicine, University Hospitals Sussex, Sussex, UK
| | - Ernest E Moore
- Department of Surgery, Ernest E Moore Shock Trauma Center at Denver Health, University of Colorado Denver, Denver, Colorado, USA
| | - Matthew D Neal
- Pittsburgh Trauma and Transfusion Medicine Research Center, Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Gavin D Perkins
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK; Critical Care Unit, Heartlands Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Jason L Sperry
- Division of Trauma and General Surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | | | - Darrell J Triulzi
- Department of Pathology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Philip C Spinella
- Departments of Surgery and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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Cheikhrouhou M, Guermazi S, Labbene I, Mahjoub S. Massive transfusion practices in Tunisia and protocol proposal. LA TUNISIE MEDICALE 2022; 100:149-155. [PMID: 35852250 PMCID: PMC9272547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
INTRODUCTION Massive transfusion (MT) is a life-saving therapy in situations of major hemorrhage awaiting radical haemostatic treatment. Poor management and control of this therapy may, however, compromise the patient's vital prognosis. The main aim of our study was to take stock of massive transfusion practices in Tunisia. The secondary aim was to propose a massive transfusion protocol. METHODS An analytical observational study based on a questionnaire was conducted. We targeted physicians brought in their clinical practice to use MT. RESULTS A total of 124 clinicians responded to the questionnaire. The majority (62%) were anesthesiologists or emergency physicians. More than half of the participants were residents (51%). The use of MT based on a clinical or biological score was only found for a minority (13%). The initial order was for the majority of participants (N=69) made up of red blood cell concentrates (RBC) and fresh frozen plasma (FFP). The FFP: RBC ratio was1:2 for 51% of the participants. A higher ratio was adopted by the rest. Respectively 23.5% and 9.6% of participants transfused platelets and fibrinogen concentrates without waiting for the result of biology. The use of tranexamic acid was systematically advocated by 60.5% of clinicians. The majority (86.3%) adopted a restrictive transfusion strategy (target hemoglobin between 7 and 9 g/dl). The latter was more adopted by the youngest physicians (92.1% of residents versus 55.6% of professors; p=0.008). CONCLUSIONS The professional practices of MT in Tunisia are heterogeneous. Given the lack of a clear institutionalized procedure which frames this therapy, a MT protocol has thus been proposed.
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Huo B, Hirsch GM, Doucette S, Herman CR, Gainer R, Mokhtar AT. Impact of Clopidogrel Stop Interval on Major Adverse Bleeding Events in Cardiac Surgery. CJC Open 2022; 4:12-19. [PMID: 35072023 PMCID: PMC8767124 DOI: 10.1016/j.cjco.2021.08.006] [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: 05/11/2021] [Accepted: 08/17/2021] [Indexed: 11/24/2022] Open
Abstract
Background Major societal guidelines recommend a 5-day stop interval before cardiac surgery for patients with acute coronary syndrome receiving clopidogrel. Yet, many such patients present with high acuity, generating surgeon inclination toward use of shorter stop intervals. Thus, this study aimed to determine the impact of the duration and timing of the interval of clopidogrel cessation on adverse bleeding events. Methods Patients who underwent cardiac surgery between 2009 and 2016 at a tertiary-care centre were included in this retrospective cohort study. Multivariable logistic regression models adjusted for clopidogrel stop interval, age, urgency of procedure, and procedure type were used to quantify the effect of clinically relevant baseline demographic characteristics on incidence of massive transfusion as well as hemorrhagic complication outcomes. Results A total of 5748 patients underwent cardiac surgery. In this cohort, 1743 patients (30.3%) received clopidogrel preoperatively, and 884 (50.7%) of these patients discontinued clopidogrel 5 days before presenting to the operating room. The administration of clopidogrel 1-2 days before surgery (odds ratio 1.97; 95% confidence interval: 1.18 to 3.29) was an independent predictor for massive transfusions and hemorrhagic complications (odds ratio 1.85; 95% confidence interval: 1.01 to 3.37). The 3-4 day group did not have an increased risk of major bleeding complications. The risk for both massive transfusions and hemorrhagic complications also increased with the urgency and complexity of surgery. Conclusion A clopidogrel stop interval of 3-4 days preoperatively was not associated with an increased risk for major bleeding complications.
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Zhu CS, Braverman M, Goddard S, McGinity AC, Pokorny D, Cotner-Pouncy T, Eastridge BJ, Epley S, Greebon LJ, Jonas RB, Liao L, Nicholson SE, Schaefer R, Stewart RM, Winckler CJ, Jenkins DH. Prehospital shock index and systolic blood pressure are highly specific for pediatric massive transfusion. J Trauma Acute Care Surg 2021; 91:579-583. [PMID: 33990534 DOI: 10.1097/ta.0000000000003275] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND While massive transfusion protocols (MTPs) are associated with decreased mortality in adult trauma patients, there is limited research on the impact of MTP on pediatric trauma patients. The purpose of this study was to compare pediatric trauma patients requiring massive transfusion with all other pediatric trauma patients to identify triggers for MTP activation in injured children. METHODS Using our level I trauma center's registry, we retrospectively identified all pediatric trauma patients from January 2015 to January 2018. Massive transfusion (MT) was defined as infusion of 40 mL/kg of blood products in the first 24 hours of admission. Patients missing prehospital vital sign data were excluded from the study. We retrospectively collected data including demographics, blood utilization, variable outcome data, prehospital vital signs, prehospital transport times, and Injury Severity Scores. Statistical significance was determined using Mann-Whitney U test and χ2 test. p Values of less than 0.05 were considered significant. RESULTS Thirty-nine (1.9%) of the 2,035 pediatric patients met the criteria for MT. All-cause mortality in MT patients was 49% (19 of 39 patients) versus 0.01% (20 of 1996 patients) in non-MT patients. The two groups significantly differed in Injury Severity Score, prehospital vital signs, and outcome data.Both systolic blood pressure (SBP) of <100 mm Hg and shock index (SI) of >1.4 were found to be highly specific for MT with specificities of 86% and 92%, respectively. The combination of SBP of <100 mm Hg and SI of >1.4 had a specificity of 94%. The positive and negative predictive values of SBP of <100 mm Hg and SI of >1.4 in predicting MT were 18% and 98%, respectively. Based on positive likelihood ratios, patients with both SBP of <100 mm Hg and SI of >1.4 were 7.2 times more likely to require MT than patients who did not meet both of these vital sign criteria. CONCLUSION Pediatric trauma patients requiring early blood transfusion present with lower blood pressures and higher heart rates, as well as higher SIs and lower pulse pressures. We found that SI and SBP are highly specific tools with promising likelihood ratios that could be used to identify patients requiring early transfusion. LEVEL OF EVIDENCE Therapeutic/care management, level V.
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Affiliation(s)
- Caroline S Zhu
- From the Department of Trauma and Emergency Surgery (C.S.Z., M.B., S.G., A.C.M., B.J.E., R.B.J., L.L., S.E.N., R.M.S., D.H.J.), University of Texas Health Science Center, San Antonio, Texas; Trauma Surgery (D.P.), Naval Medical Center Camp Lejeune, Camp Lejeune, North Carolina; University Hospital in San Antonio (T.C.-P., S.E.), Trauma Services; Department of Pathology (L.J.G.), University of Texas Health Science Center; Southwest Texas Regional Advisory Council (R.S.); and Department of Emergency Health Sciences (C.J.W.), University of Texas Health Science Center, San Antonio, Texas
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Cole E, Weaver A, Gall L, West A, Nevin D, Tallach R, O'Neill B, Lahiri S, Allard S, Tai N, Davenport R, Green L, Brohi K. A Decade of Damage Control Resuscitation: New Transfusion Practice, New Survivors, New Directions. Ann Surg 2021; 273:1215-1220. [PMID: 31651535 DOI: 10.1097/sla.0000000000003657] [Citation(s) in RCA: 74] [Impact Index Per Article: 24.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVE The aim of this study was to identify the effects of recent innovations in trauma major hemorrhage management on outcome and transfusion practice, and to determine the contemporary timings and patterns of death. BACKGROUND The last 10 years have seen a research-led change in hemorrhage management to damage control resuscitation (DCR), focused on the prevention and treatment of trauma-induced coagulopathy. METHODS A 10-year retrospective analysis of prospectively collected data of trauma patients who activated the Major Trauma Centre's major hemorrhage protocol (MHP) and received at least 1 unit of red blood cell transfusions (RBC). RESULTS A total of 1169 trauma patients activated the MHP and received at least 1 unit of RBC, with similar injury and admission physiology characteristics over the decade. Overall mortality declined from 45% in 2008 to 27% in 2017, whereas median RBC transfusion rates dropped from 12 to 4 units (massive transfusion rates from 68% to 24%). The proportion of deaths within 24 hours halved (33%-16%), principally with a fall in mortality between 3 and 24 hours (30%-6%). Survivors are now more likely to be discharged to their own home (57%-73%). Exsanguination is still the principal cause of early deaths, and the mortality associated with massive transfusion remains high (48%). Late deaths are now split between those due to traumatic brain injury (52%) and multiple organ dysfunction (45%). CONCLUSIONS There have been remarkable reductions in mortality after major trauma hemorrhage in recent years. Mortality rates continue to be high and there remain important opportunities for further improvements in these patients.
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Affiliation(s)
- Elaine Cole
- Blizard Institute, Queen Mary University of London, London, United Kingdom
| | - Anne Weaver
- Barts Health NHS Trust, London, United Kingdom
| | - Lewis Gall
- Blizard Institute, Queen Mary University of London, London, United Kingdom
| | - Anita West
- Barts Health NHS Trust, London, United Kingdom
| | | | | | | | | | | | - Nigel Tai
- Barts Health NHS Trust, London, United Kingdom
- Academic Departments of Military Surgery, Trauma and Anaesthesia, Royal Centre for Defence Medicine, Birmingham, United Kingdom
| | - Ross Davenport
- Blizard Institute, Queen Mary University of London, London, United Kingdom
- Barts Health NHS Trust, London, United Kingdom
| | - Laura Green
- Blizard Institute, Queen Mary University of London, London, United Kingdom
- Barts Health NHS Trust, London, United Kingdom
- NHS Blood and Transplant, London, United Kingdom
| | - Karim Brohi
- Blizard Institute, Queen Mary University of London, London, United Kingdom
- Barts Health NHS Trust, London, United Kingdom
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10
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Chang KW, Owen S, Gaspar M, Laffan M, Arachchillage DRJ. Outcome of Major Hemorrhage at a Major Cardiothoracic Center in Patients with Activated Major Hemorrhage Protocol versus Nonactivated Protocol. Semin Thromb Hemost 2021; 47:74-83. [PMID: 33525040 DOI: 10.1055/s-0040-1718869] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
This study aimed to determine the impact of major hemorrhage (MH) protocol (MHP) activation on blood administration and patient outcome at a UK major cardiothoracic center. MH was defined in patients (> 16 years) as those who received > 5 units of red blood cells (RBCs) in < 4 hours, or > 10 units in 24 hours. Data were collected retrospectively from patient electronic records and hospital transfusion databases recording issue of blood products from January 2016 to December 2018. Of 134 patients with MH, 24 had activated MHP and 110 did not have activated MHP. Groups were similar for age, sex, baseline hemoglobin, platelet count, coagulation screen, and renal function with no difference in the baseline clinical characteristics. The total number of red cell units (median and [IQR]) transfused was no different in the patients with activated (7.5 [5-11.75]) versus nonactivated (9 [6-12]) MHP (p = 0.35). Patients in the nonactivated MHP group received significantly higher number of platelet units (median: 3 vs. 2, p = 0.014), plasma (median: 4.5 vs. 1.5, p = 0.0007), and cryoprecipitate (median: 2 vs. 1, p = 0.008). However, activation of MHP was associated with higher mortality at 24 hours compared with patients with nonactivation of MHP (33.3 vs. 10.9%, p = 0.005) and 30 days (58.3 vs. 30.9%, p = 0.01). The total RBC and platelet (but not fresh frozen plasma [FFP]) units received were higher in deceased patients than in survivors. Increased mortality was associated with a higher RBC:FFP ratio. Only 26% of patients received tranexamic acid and these patients had higher mortality at 30 days but not at 24 hours. Deceased patients at 30 days had higher levels of fibrinogen than those who survived (median: 2.4 vs. 1.8, p = 0.01). Patients with activated MHP had significantly higher mortality at both 24 hours and 30 days despite lack of difference in the baseline characteristics of the patients with activated MHP versus nonactivated MHP groups. The increased mortality associated with a higher RBC:FFP ratio suggests dilutional coagulopathy may contribute to mortality, but higher fibrinogen at baseline was not protective.
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Affiliation(s)
- Kathryn W Chang
- Department of Haematology, Imperial College London, London, United Kingdom
| | - Steve Owen
- Department of Haematology, Royal Brompton Hospital, London, United Kingdom
| | - Michaela Gaspar
- Department of Haematology, Royal Brompton Hospital, London, United Kingdom
| | - Mike Laffan
- Department of Haematology, Imperial College London, London, United Kingdom
| | - Deepa R J Arachchillage
- Department of Haematology, Imperial College London, London, United Kingdom.,Department of Haematology, Royal Brompton Hospital, London, United Kingdom
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Neff LP, Beckwith MA, Russell RT, Cannon JW, Spinella PC. Massive Transfusion in Pediatric Patients. Clin Lab Med 2020; 41:35-49. [PMID: 33494884 DOI: 10.1016/j.cll.2020.10.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Massive transfusion in pediatric patients is infrequent but associated with much higher mortality than in adults. Blood transfusion and hematology has conceptualized ideas such as blood failure and the interplay of the blood-endothelium interface to understand coagulopathy in the context of hemorrhagic shock. Researchers are still searching for an appropriate definition of what constitutes a pediatric massive transfusion. There is no universally accepted protocol for massive transfusion and how to address the many complications that can arise. Pharmacologic adjuncts to resuscitation may prove beneficial in reducing coagulopathy during pediatric massive transfusion, but high-quality evidence has not yet emerged.
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Affiliation(s)
- Lucas P Neff
- Department of General Surgery, Section of Pediatric Surgery, Wake Forest University School of Medicine, 5th Floor, Watlington Hall, Medical Center Boulevard, Winston-Salem, NC 27157, USA.
| | - Michael Aaron Beckwith
- Division of Trauma and Acute Care Surgery, Department of Surgery, University of Alabama at Birmingham, 1922 7th Avenue South, KB 120, Birmingham, AL 35294, USA
| | - Robert T Russell
- Pediatric General Surgery, Division of Pediatric Surgery, Department of Surgery, University of Alabama at Birmingham, 1600 7th Avenue South, Lowder, Suite 300, Birmingham, AL 35233, USA
| | - Jeremy W Cannon
- Division of Traumatology, Surgical Critical Care, and Emergency Surgery, Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Penn Presbyterian Medical Center, 51 North 39th Street, Suite 120 MOB, Philadelphia, PA 19104, USA
| | - Philip C Spinella
- Division of Critical Care Medicine, Department of Pediatrics, The Washington University of Saint Louis, 4905 Children's Place, St Louis, MO 63110, USA
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12
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Evangelista ME, Gaffley M, Neff LP. Massive Transfusion Protocols for Pediatric Patients: Current Perspectives. J Blood Med 2020; 11:163-172. [PMID: 32547282 PMCID: PMC7247594 DOI: 10.2147/jbm.s205132] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Accepted: 04/24/2020] [Indexed: 01/03/2023] Open
Abstract
In adults, the use of balanced resuscitation and study of massive transfusion protocols have led to improved outcomes for patients and continues to be refined. In children, massive transfusion protocols require further development and study to assess efficacy. Standardization is needed as transfusions and activation of protocols still rely on physician discretion in most pediatric settings. Further research is required to define the pediatric trauma population that will benefit, when to activate these protocols and how to use adjuncts such as tranexamic acid or factor VII in resuscitation. In addition, future implementation of technology such as hemoglobin-based oxygen carriers to increase survival should be studied further in this subset of patients.
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Affiliation(s)
| | - Michaela Gaffley
- General Surgery, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Lucas P Neff
- Pediatric Surgery, Wake Forest School of Medicine, Winston-Salem, NC, USA
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Impact of high-dose norepinephrine during intra-hospital damage control resuscitation of traumatic haemorrhagic shock: A propensity-score analysis. Injury 2020; 51:1164-1171. [PMID: 31791590 DOI: 10.1016/j.injury.2019.11.037] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Revised: 11/17/2019] [Accepted: 11/23/2019] [Indexed: 02/02/2023]
Abstract
INTRODUCTION The use of norepinephrine (NE) during uncontrolled haemorrhagic shock (HS) has mostly been investigated in experimental studies. Clinical data including norepinephrine dose and its impact on fluid resuscitation and organ function are scarce. We hypothesized that there is great variability in NE use and that high doses of NE could lead to increased organ dysfunction as measured by the sequential organ failure assessment (SOFA). METHOD We included patients with HS (systolic blood pressure < 90 mmHg in severely injured patients) who required haemostasis surgery and a transfusion of more than 4 packed red blood cells (PRBC) in the first 6 h of admission and the used of norepinephrine infusion to maintain the blood pressure goal, between admission and the end of haemostasis surgery in a prospective trauma database. A ROC curve determined that, using Youden's criterion, a dose of NE ≥ 0.6 µg/kg/min was the optimal threshold associated with intrahospital mortality. Patients were compared according to this threshold in a propensity score (PS) model. In a generalized linear mixed model, we searched for independent factors associated with a SOFA ≥ 9 at 24 h RESULTS: A total of 89 patients were analysed. Fluid infusion rate ranged from 1.43 to 57.9 mL/kg/h and norepinephrine infusion rate from 0.1 to 2.8 µg/kg/min. The HDNE group received significantly less fluid than the LDNE group. This dose is associated with a higher SOFA score at 24h: 9 (7-10) vs. 7 (6-9) (p = 0.003). Factors independently associated with a SOFA score ≥ 9 at 24 h were maximal norepinephrine rate ≥ 0.6 µg/kg/min (OR 6.69, 95% CI 1.82 - 25.54; p = 0.004), non-blood resuscitation volume < 9 mL/kg/h (OR 3.98, 95% CI 1.14 - 13.95; p = 0.031) and lactate at admission ≥ 5 mmol/L (OR 5.27, 95% CI 1.48 - 18.77; p = 0.010) CONCLUSION: High dose of norepinephrine infusion is associated with deleterious effects as attested by a higher SOFA score at 24 h and likely hypovolemia as measured by reduced non-blood resuscitation volume. We did not find any significant difference in mortality over the long term.
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Schauer SG, Wheeler AR, April MD, Gale HL, Becker TE, Hill GJ, Borgman MA. An analysis of the pediatric casualties undergoing massive transfusion in Iraq and Afghanistan. Am J Emerg Med 2019; 38:895-899. [PMID: 31326199 DOI: 10.1016/j.ajem.2019.07.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2019] [Revised: 07/01/2019] [Accepted: 07/02/2019] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Existing data on pediatric massive transfusion as part of trauma resuscitation is limited. We report the characteristics of pediatric casualties associated with undergoing massive transfusion at US military treatment facilities during combat operations in Iraq and Afghanistan. METHODS We queried the Department of Defense Trauma Registry (DODTR) for all pediatric subjects admitted to US and Coalition fixed-facility hospitals in Iraq and Afghanistan from January 2007 to January 2016. We stratified subjects by Centers for Disease Control age groupings: <1, 1-4, 5-9, 10-14, and 15-17 years. We defined a massive transfusion as 40 mL/kg of total blood products or more. RESULTS From January 2007 through January 2016 there were 3439 pediatric casualties within the registry, of which 543 (15.7%) met criteria for receiving a massive transfusion. The median age of children undergoing massive transfusion was 9 years (IQR 5-12), male (73.4%), injured in Afghanistan (69.9%) and injured by explosives (60.4%). Compared to other pediatric casualties, subjects undergoing massive transfusion had higher composite injury severity scores (median 17 versus 9), higher incidence of tachycardia (86.8% versus 70.9%), increased incidence of hypotension (31.2% versus 7.5%), and decreased survival to hospital discharge (82.6% versus 91.6%). Specific to body regions, casualties undergoing massive transfusion more frequently had serious injuries to the head/neck (30.0% versus 22.8%), the thorax (22.8% versus 9.9%), abdomen (26.8% versus 6.9%), the extremities (42.1% versus 14.6%), while less frequently had serious injuries to the skin (5.3% versus 8.4%). All findings were significant. CONCLUSIONS Further research is needed to better translate the lessons learned from pediatric trauma care in the combat setting into the civilian setting in developed countries. LEVEL OF EVIDENCE 3.
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Affiliation(s)
- Steven G Schauer
- US Army Institute of Surgical Research, JBSA Fort Sam Houston, TX, USA; 59th Medical Wing, JBSA Lackland, TX, USA; Brooke Army Medical Center, JBSA Fort Sam Houston, TX, USA.
| | - Abigail R Wheeler
- US Army Institute of Surgical Research, JBSA Fort Sam Houston, TX, USA
| | | | - Hannah L Gale
- Brooke Army Medical Center, JBSA Fort Sam Houston, TX, USA
| | - Tyson E Becker
- Brooke Army Medical Center, JBSA Fort Sam Houston, TX, USA
| | - Guyon J Hill
- Madigan Army Medical Center, Joint Base Lewis McChord, Washington, USA
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Chen YC, Chuang CJ, Hsiao KY, Lin LC, Hung MS, Chen HW, Lee SC. Massive transfusion in upper gastrointestinal bleeding: a new scoring system. Ann Med 2019; 51:224-231. [PMID: 31050553 PMCID: PMC7877879 DOI: 10.1080/07853890.2019.1615122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
Abstract
Background: Massive transfusion in patients with upper gastrointestinal bleeding (UGIB) was not investigated. We developed a new scoring system to predict massive transfusion and to enhance care and early resource mobilization. Methods: Massive transfusion was defined as transfusion with ≥10 units of red blood cells within the first 24 h. Data were extracted from a 10-year, six-hospital database. Logistic regression was applied to derive a risk score for massive transfusion using data from 2006 to 2010, in 24,736 patients (developmental cohort). The score was then validated using data from 2011 to 2015 in 27,449 patients (validation cohort). Area under the receiver operating characteristic (AUROC) curve was performed to assess prediction accuracy. Results: Five characteristics were independently associated (p < .001) with massive transfusion: presence of band-form cells among white blood cells (band form >0), international normalized ratio (INR) >1.5, pulse >100 beats per minute or systolic blood pressure <100 mmHg (shock), haemoglobin <8.0 g/dL and endoscopic therapy. The new scoring system successfully discriminated well between UGIB patients requiring massive transfusion and those who did not in both cohorts (AUROC: 0.831, 95%CI: 0.827-0.836; AUROC: 0.822, 95% CI: 0.817-0.826, respectively). Conclusions: The new scoring system predicts massive transfusion requirement in patients with UGIB well. Key messages Massive transfusion is a life-saving management in massive upper gastrointestinal bleeding. How to identify patients requiring massive transfusion in upper gastrointestinal bleeding is poorly documented. Approximately 3.9% of upper gastrointestinal bleeding patients require massive transfusion. A new scoring system is developed to identify patients requiring massive transfusion with high accuracy.
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Affiliation(s)
- Yi-Chuan Chen
- a Department of Emergency Medicine , Chang Gung Memorial Hospital , Chiayi , Taiwan.,b Department of Nursing , Chang Gung University of Science and Technology, Chiayi Campus , Chiayi , Taiwan
| | - Chen-Ju Chuang
- a Department of Emergency Medicine , Chang Gung Memorial Hospital , Chiayi , Taiwan
| | - Kuang-Yu Hsiao
- a Department of Emergency Medicine , Chang Gung Memorial Hospital , Chiayi , Taiwan.,b Department of Nursing , Chang Gung University of Science and Technology, Chiayi Campus , Chiayi , Taiwan
| | - Leng-Chieh Lin
- a Department of Emergency Medicine , Chang Gung Memorial Hospital , Chiayi , Taiwan.,b Department of Nursing , Chang Gung University of Science and Technology, Chiayi Campus , Chiayi , Taiwan
| | - Ming-Szu Hung
- c Division of Thoracic Oncology, Department of Pulmonary and Critical Care Medicine , Chang Gung Memorial Hospital , Chiayi , Taiwan.,d College of Medicine, Chang Gung University , Taoyuan , Taiwan
| | - Huan-Wen Chen
- a Department of Emergency Medicine , Chang Gung Memorial Hospital , Chiayi , Taiwan
| | - Shung-Chieh Lee
- a Department of Emergency Medicine , Chang Gung Memorial Hospital , Chiayi , Taiwan
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Abstract
BACKGROUND Tranexamic acid (TXA) use in severe trauma remains controversial notably because of concerns of the applicability of the CRASH-2 study findings in mature trauma systems. The aim of our study was to evaluate the outcomes of TXA administration in severely injured trauma patients managed in a mature trauma care system. METHODS We performed a retrospective study of data prospectively collected in the TraumaBase registry (a regional registry collecting the prehospital and hospital data of trauma patients admitted in six Level I trauma centers in Paris Area, France). In hospital mortality was compared between patients having received TXA or not in the early phase of resuscitation among those presenting an unstable hemodynamic state. Propensity score for TXA administration was calculated and results were adjusted for this score. Hemodynamic instability was defined by the need of packed red blood cells (pRBC) transfusion and/or vasopressor administration in the emergency room (ER). RESULTS Among patients meeting inclusion criteria (n = 1,476), the propensity score could be calculated in 797, and survival analysis could be achieved in 684 of 797. Four hundred seventy (59%) received TXA, and 327 (41%) did not. The overall hospital mortality rate was 25.7%. There was no effect of TXA use in the whole population but mortality was lowered by the use of TXA in patients requiring pRBC transfusion in the ER (hazard ratio, 0.3; 95% confidence interval, 0.3-0.6). CONCLUSION The use of TXA in the management of severely injured trauma patients, in a mature trauma care system, was not associated with reduction in the hospital mortality. An independent association with a better survival was found in a selected population of patients requiring pRBC transfusion in the ER. LEVEL OF EVIDENCE Therapeutic study, level III.
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Tran A, Nemnom MJ, Lampron J, Matar M, Vaillancourt C, Taljaard M. Accuracy of massive transfusion as a surrogate for significant traumatic bleeding in health administrative datasets. Injury 2019; 50:318-323. [PMID: 30448330 DOI: 10.1016/j.injury.2018.11.014] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2018] [Revised: 10/22/2018] [Accepted: 11/06/2018] [Indexed: 02/02/2023]
Abstract
BACKGROUND Due to the challenge of identifying need for intervention in bleeding patients, there is a growing interest in prediction modeling. Massive transfusion (MT; 10 or more packed red cells in 24 h) is the most commonly studied dependent variable, serving as a surrogate for severe bleeding and its prediction guides the need for intervention. The critical administration threshold (CAT; 3 packed red cells in 1 h) has been proposed as an alternative. In this study, we aim to compare the classification accuracy of these two surrogates for hemorrhage-related outcomes in health administrative datasets. METHODS We performed a secondary analysis of major trauma patients from the prospectively collected Ottawa Trauma Registry, from September 2014 to September 2017. We conducted a logistic regression analysis utilizing need for hemostasis or hemorrhagic death as dependent variables. We compared classification accuracy in terms of sensitivity, specificity, positive predictive value, negative predictive value and AUC. CAT + and MT + status is not mutually exclusive. RESULTS We studied 890 major trauma patients, including 145 CAT + and 48 MT + patients. CAT + demonstrated a superior association for the composite outcome of 24-hour hemorrhage-related mortality and need for hemostasis (AUC 0.815 vs. 0.644, p < 0.0001). This performance was driven by a substantial difference in sensitivity, noted to be 70.0% (95% CI 62.1-77.9%) for CAT + but only 30.0% (95% CI 22.1-37.9%) for MT+. CAT + and MT + demonstrated specificities of 92.9% (95% CI 91.1-94.7%) and 98.9% (98.1-99.6%) respectively. CONCLUSION This study illustrates the concepts of survivorship and competing risk bias for massive transfusion. Utilizing a composite outcome of need for hemostasis and early hemorrhagic death, we demonstrate that CAT + is more accurate for identifying significantly bleeding patients.
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Affiliation(s)
- Alexandre Tran
- Department of Surgery, University of Ottawa, Ottawa, ON, Canada; Clinical Epidemiology Program, The Ottawa Hospital Research Institute, Ottawa, ON, Canada.
| | - Marie-Joe Nemnom
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, Ottawa, ON, Canada.
| | - Jacinthe Lampron
- Department of Surgery, University of Ottawa, Ottawa, ON, Canada.
| | - Maher Matar
- Department of Surgery, University of Ottawa, Ottawa, ON, Canada.
| | - Christian Vaillancourt
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, Ottawa, ON, Canada; Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada.
| | - Monica Taljaard
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, Ottawa, ON, Canada; School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada.
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Fabes J, Brunskill SJ, Curry N, Doree C, Stanworth SJ. Pro-coagulant haemostatic factors for the prevention and treatment of bleeding in people without haemophilia. Cochrane Database Syst Rev 2018; 12:CD010649. [PMID: 30582172 PMCID: PMC6517302 DOI: 10.1002/14651858.cd010649.pub2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND Some hospital patients may be at risk of or may present with major bleeding. Abnormalities of clotting (coagulation) are often recorded in these people, and the traditional management has been with transfusions of blood components, either to prevent bleeding (prophylactic) or to treat bleeding (therapeutic). There is growing interest in the use of targeted therapies with specific pro-coagulant haemostatic (causing bleeding to stop and to keep blood within a damaged blood vessel) factor concentrates in place of plasma. OBJECTIVES To assess the effects and safety of pro-coagulant haemostatic factors and factor concentrates in the prevention and treatment of bleeding in people without haemophilia. SEARCH METHODS We searched for randomised controlled trials (RCTs) in the Cochrane Central Register of Controlled Trials (2018, issue 3), MEDLINE (from 1948), Embase (from 1974), CINAHL (from 1938), PubMed (publications in process to 18 April 2018), PROSPERO, Transfusion Evidence Library (from 1950), LILACS (from 1980), IndMED (from 1985), KoreaMed (from 1934), Web of Science Conference Proceedings Citation Index (from 1990) and ongoing trial databases to 18 April 2018. SELECTION CRITERIA We included RCTs that compared intravenous administration of a pro-coagulant haemostatic factor concentrate, either with placebo, current best or standard treatment, or another pro-coagulant haemostatic factor concentrate for prevention or treatment of bleeding. There was no restriction on the types of participants. We excluded studies of desmopressin, tranexamic acid and aminocaproic acid and use of pro-coagulant haemostatic factors for vitamin K over-anticoagulation. DATA COLLECTION AND ANALYSIS We followed standard Cochrane methodological procedures. MAIN RESULTS We identified 31 RCTs with 2392 participants and 22 ongoing trials. There were 13 therapeutic RCTs that randomised 1057 participants (range from 20 to 249 participants) and 18 prophylactic trials that randomised 1335 participants (range 20 to 479 participants). The pro-coagulant haemostatic factor concentrate was fibrinogen in 23 trials, Factor XIII in seven trials and pro-thrombin complex concentrates (PCC) in one trial.Seventeen trials had industrial funding or support, eight studies either did not declare their funding or were unclear about their source of funding and six studies declared non-industrial funding sources.Certainty in the evidence and included study biasOur certainty in the evidence, using GRADE criteria, ranged from very low to high across all outcomes. We assessed most outcomes as being of low certainty. Risks of bias were a concern in many of the RCTs; randomisation methodology was unclear in 15 RCTs, with allocation concealment unclear in 14 RCTs and at high risk of bias in five RCTs. The blinding status of outcome assessors was unclear in 13 RCTs and at high risk of bias in five RCTs, although most outcomes in these trials were objective and not prone to observer bias. Study personnel were often unblinded or insufficient information was available to assess their level of blinding (five RCTs were at unclear risk and seven at high risk of bias).Primary outcomesAll-cause mortality was reported by 21 RCTs, arterial thromboembolic events by 22 RCTs, and venous thromboembolic events by 21 RCTs.Fibrinogen concentrate: prophylactic trials with inactive comparator (nine RCTs)The trials had heterogeneous clinical settings and outcome time points, so we did not pool the data. Compared to placebo, there was no evidence that prophylactic fibrinogen concentrate reduced all-cause mortality (4 RCTs; 248 participants). Compared to inactive comparators there was low- to moderate-quality evidence that prophylactic fibrinogen concentrate did not increase the risk of arterial or venous thromboembolic complications (7 RCTs; 398 participants).Fibrinogen concentrate: prophylactic trials with active comparator (two RCTs)There was no mortality or incidence of thromboembolic events in these two RCTs (with 57 participants).Fibrinogen concentrate: therapeutic trials with inactive comparator (eight RCTs)The trials had heterogeneous surgical settings and outcome time points, so we pooled data for subgroups only. Compared to an inactive comparator, there was no evidence (quality ranging from low to high) that fibrinogen concentrate reduced all-cause mortality in actively bleeding participants (7 RCTs; 724 participants). Compared to inactive comparators there was no evidence that the use of fibrinogen concentrate in active bleeding increased arterial (7 RCTs; 607 participants) or venous (6 RCTs; 562 participants) thromboembolic events.Fibrinogen concentrate: therapeutic trials with active comparator (four RCTs)We did not pool the outcome data, as they were not measured at comparable time points. Compared to other active pro-coagulant agents, there was no evidence (very low to moderate quality) that fibrinogen concentrate reduced all-cause mortality in actively bleeding participants (4 RCTs; 220 participants). There was no evidence that fibrinogen concentrate increased the risk of arterial (3 RCTs; 126 participants) or venous (4 RCTs; 220 participants) thromboembolic events.FactorXIII: Prophylactic trials with inactive comparator (six trials)The trials were heterogeneous in their surgical settings and time points for outcome analysis, so we pooled data for subgroups only. Compared to an inactive comparator, there was no evidence that prophylactic Factor XIII reduced all-cause mortality (5 RCTs; 414 participants). There was no evidence (very low to low quality) of a difference in the arterial or venous event rate between Factor XIII and inactive comparators (4 trials; 354 participants).FactorXIII: therapeutic trials with inactive comparator (one trial)There was no mortality or incidence of thromboembolic events in this trial.Prothrombin complex concentrate (PCC): prophylactic trials with inactive comparator (one trial)There was no evidence (moderate quality) that PCC reduced all-cause mortality (1 trial; 78 participants). No thromboembolic complications were reported in this trial. AUTHORS' CONCLUSIONS The paucity of good-quality comparable evidence precludes the drawing of conclusions for clinical practice. Further research is required to determine the risk-to-benefit ratio of these interventions. The sample sizes of future RCTs would need to be greatly increased to detect a reduction in mortality or thromboembolic events between treatment arms. To improve consistency in outcome reporting, the development of core outcome sets is essential and may help address a number of the limitations identified in this review.
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Affiliation(s)
- Jez Fabes
- John Radcliffe HospitalOxfordUKOX3 9DU
| | - Susan J Brunskill
- NHS Blood and TransplantSystematic Review InitiativeLevel 2, John Radcliffe HospitalHeadingtonOxfordOxonUKOX3 9BQ
| | - Nicola Curry
- Churchill HospitalOxford Haemophilia & Thrombosis CentreOld RoadHeadingtonOxfordUKOX3 7LE
| | - Carolyn Doree
- NHS Blood and TransplantSystematic Review InitiativeLevel 2, John Radcliffe HospitalHeadingtonOxfordOxonUKOX3 9BQ
| | - Simon J Stanworth
- Oxford University Hospitals NHS Foundation Trust and University of OxfordNational Institute for Health Research (NIHR) Oxford Biomedical Research CentreJohn Radcliffe Hospital, Headley WayHeadingtonOxfordUKOX3 9BQ
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Figueiredo S, Taconet C, Harrois A, Hamada S, Gauss T, Raux M, Duranteau J. How useful are hemoglobin concentration and its variations to predict significant hemorrhage in the early phase of trauma? A multicentric cohort study. Ann Intensive Care 2018; 8:76. [PMID: 29980953 PMCID: PMC6035120 DOI: 10.1186/s13613-018-0420-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Accepted: 06/21/2018] [Indexed: 12/15/2022] Open
Abstract
Background The diagnostic value of hemoglobin (Hb) for detecting a significant hemorrhage (SH) in the early phase of trauma remains controversial. The present study aimed to assess the abilities of Hb measurements taken at different times throughout trauma management to identify patients with SH. Methods All consecutive adult trauma patients directly admitted to six French level-1 trauma centers with at least one prehospital Hb measurement were analyzed. The abilities of the following variables to identify SH (≥ 4 units of red blood cells in the first 6 h and/or death related to uncontrolled bleeding within 24 h) were determined and compared to that of shock index (SI): Hb as measured with a point-of-care (POC) device by the prehospital team on scene (POC-Hbprehosp) and upon patient’s admission to the hospital (POC-Hbhosp), the difference between POC-Hbhosp and POC-Hbprehosp (DeltaPOC-Hb) and Hb as measured by the hospital laboratory on admission (Hb-Labhosp). Results A total of 6402 patients were included, 755 with SH and 5647 controls (CL). POC-Hbprehosp significantly predicted SH with an area under ROC curve (AUC) of 0.72 and best cutoff values of 12 g/dl for women and 13 g/dl for men. POC-Hbprehosp < 12 g/dl had 90% specificity to predict of SH. POC-Hbhosp and Hb-Labhosp (AUCs of 0.92 and 0.89, respectively) predicted SH better than SI (AUC = 0.77, p < 0.001); best cutoff values of POC-Hbhosp were 10 g/dl for women and 12 g/dl for men. DeltaPOC-Hb also predicted SH with an AUC of 0.77, a best cutoff value of − 2 g/dl irrespective of the gender. For a same prehospital fluid volume infused, DeltaPOC-Hb was significantly larger in patients with significant hemorrhage than in controls. Conclusions Challenging the classical idea that early Hb measurement is not meaningful in predicting SH, POC-Hbprehosp was able, albeit modestly, to predict significant hemorrhage. POC-Hbhosp had a greater ability to predict SH when compared to shock index. For a given prehospital fluid volume infused, the magnitude of the Hb drop was significantly higher in patients with significant hemorrhage than in controls. Electronic supplementary material The online version of this article (10.1186/s13613-018-0420-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- S Figueiredo
- Department of Anaesthesia and Critical Care, Assistance Publique - Hôpitaux de Paris, Hôpital Bicêtre, University Paris-Sud, 78 rue du Général Leclerc, 94275, Le Kremlin Bicêtre, France. .,Hôpitaux Universitaires Paris Sud, 94275, Le Kremlin Bicêtre, France.
| | - C Taconet
- Department of Anaesthesia and Critical Care, Assistance Publique - Hôpitaux de Paris, Hôpital Bicêtre, University Paris-Sud, 78 rue du Général Leclerc, 94275, Le Kremlin Bicêtre, France.,Hôpitaux Universitaires Paris Sud, 94275, Le Kremlin Bicêtre, France
| | - A Harrois
- Department of Anaesthesia and Critical Care, Assistance Publique - Hôpitaux de Paris, Hôpital Bicêtre, University Paris-Sud, 78 rue du Général Leclerc, 94275, Le Kremlin Bicêtre, France.,Hôpitaux Universitaires Paris Sud, 94275, Le Kremlin Bicêtre, France
| | - S Hamada
- Department of Anaesthesia and Critical Care, Assistance Publique - Hôpitaux de Paris, Hôpital Bicêtre, University Paris-Sud, 78 rue du Général Leclerc, 94275, Le Kremlin Bicêtre, France.,Hôpitaux Universitaires Paris Sud, 94275, Le Kremlin Bicêtre, France
| | - T Gauss
- Department of Anaesthesia and Critical Care, Beaujon Hospital, Hôpitaux Universitaires Paris-Nord Val-de-Seine, Assistance Publique - Hôpitaux de Paris, Clichy, France
| | - M Raux
- SSPI - Accueil des Polytraumatisés, Hôpital Universitaire Pitié Salpêtrière - Charles Foix, Assistance Publique - Hôpitaux de Paris, Paris, France.,INSERM UMR_S 1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Université Pierre et Marie Curie, Paris, France
| | - J Duranteau
- Department of Anaesthesia and Critical Care, Assistance Publique - Hôpitaux de Paris, Hôpital Bicêtre, University Paris-Sud, 78 rue du Général Leclerc, 94275, Le Kremlin Bicêtre, France.,Hôpitaux Universitaires Paris Sud, 94275, Le Kremlin Bicêtre, France
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Gauss T, Gayat E, Harrois A, Raux M, Follin A, Daban JL, Cook F, Hamada S, Attias A, Ausset S, Boutonnet M, Dhonneur G, Duranteau J, Langeron O, Mantz J, Paugam-Burtz C, Pirracchio R, Riou B, de St Maurice G, Vigué B, Bertho K, Chollet-Xemard C, Dolveck F, Michelland L, Reuter PG, Ricard-Hibon A, Richard O, Sapir D, Vivien B. Effect of early use of noradrenaline on in-hospital mortality in haemorrhagic shock after major trauma: a propensity-score analysis. Br J Anaesth 2018; 120:1237-1244. [DOI: 10.1016/j.bja.2018.02.032] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2017] [Revised: 01/19/2018] [Accepted: 03/01/2018] [Indexed: 10/17/2022] Open
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Early identification of patients requiring massive transfusion, embolization or hemostatic surgery for traumatic hemorrhage: A systematic review and meta-analysis. J Trauma Acute Care Surg 2018; 84:505-516. [DOI: 10.1097/ta.0000000000001760] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Brohi K, Eaglestone S. Traumatic coagulopathy and massive transfusion: improving outcomes and saving blood. PROGRAMME GRANTS FOR APPLIED RESEARCH 2017. [DOI: 10.3310/pgfar05190] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Introduction
Dysfunction of the coagulation system, termed trauma-induced coagulopathy (TIC), is a major problem in patients who bleed after injury. Trauma haemorrhage is considered one of the leading preventable causes of death worldwide. Deaths occur early and, despite the presence of trauma teams and large transfusions of blood products, outcomes remain poor.
Methods
We conducted a multimodal programme of work to develop our understanding of coagulopathy and its optimal management. We studied the epidemiology, management and health economics of trauma haemorrhage, including the provision of care during mass casualty events. We combined systematic reviews of the literature with a national study of trauma haemorrhage, its transfusion management and associated health-care costs. We further examined several point-of-care coagulation tools for their ability to diagnose coagulopathy and assess the response to blood component therapy. We progressively implemented our findings into practice and assessed the outcomes of trauma patients presenting to our major trauma centre. To examine different approaches to the provision of blood to casualties in a mass casualty event, we constructed a discrete event model based on data from the 2005 London bombings.
Key results
Our systematic reviews found little strong evidence for the existing diagnostic tools or the practice of delivery of blood components in trauma haemorrhage. Our national study recruited 442 patients in 22 hospitals and found that the 1-year mortality rate for massive haemorrhage approached 50%. Half of these deaths occurred in the first 24 hours after injury and half of these occurred in the first 4 hours. We identified this early time window as a period when the provision of blood component therapy was often below the recommended thresholds and blood component therapy was delivered inconsistently. Studying early TIC we determined that loss of fibrinogen and excessive fibrinolysis were key derangements. We were able to determine that rotational thromboelastometry could identify early coagulopathy within 5 minutes, a large improvement on laboratory tests. We were further able to show how existing damage control resuscitation regimens with high-dose plasma do not maintain haemostatic competency during haemorrhage. In total, the estimated cost of treating a major haemorrhage patient was £20,600 and the estimated cost of treating a massive haemorrhage patient was £24,000. Nationally, the estimated cost of trauma haemorrhage is £85M annually. In mass casualty situations, early results show that the only mutable factor that affects the provision of care to a large degree, in the initial phase of the response, is the level of blood stocks held in the receiving hospital.
Conclusions
This multimodal programme of work has led to new understandings of the epidemiology of trauma haemorrhage and its underlying mechanisms and clinical course. We have defined diagnostic tools and trigger thresholds for identification and management and increased our understanding of how blood component and other therapeutics affect coagulopathy and when they are likely to be most effective. This diagnostic work has been taken forward at an international level to produce new personalised guidelines for the management of trauma haemorrhage. The findings have had important therapeutic implications, which have led to important changes in practice that have been incorporated into new national and international guidelines.
Funding
The National Institute for Health Research Programme Grants for Applied Research programme.
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Affiliation(s)
- Karim Brohi
- Centre for Trauma Sciences, Blizard Institute, Barts and the London School of Medicine, Queen Mary University of London, London, UK
| | - Simon Eaglestone
- Centre for Trauma Sciences, Blizard Institute, Barts and the London School of Medicine, Queen Mary University of London, London, UK
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Delaney M, Stark PC, Suh M, Triulzi DJ, Hess JR, Steiner ME, Stowell CP, Sloan SR. Massive Transfusion in Cardiac Surgery: The Impact of Blood Component Ratios on Clinical Outcomes and Survival. Anesth Analg 2017; 124:1777-1782. [PMID: 28333704 DOI: 10.1213/ane.0000000000001926] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND Cardiac surgery is the most common setting for massive transfusion in medically advanced countries. Studies of massive transfusion after injury suggest that the ratios of administered plasma and platelets (PLT) to red blood cells (RBCs) affect mortality. Data from the Red Cell Storage Duration Study (RECESS), a large randomized trial of the effect of RBC storage duration in patients undergoing complex cardiac surgery, were analyzed retrospectively to investigate the association between blood component ratios used in massively transfused patients and subsequent clinical outcomes. METHODS Massive transfusion was defined as those who had ≥6 RBC units or ≥8 total blood components. For plasma, high ratio was defined as ≥1 plasma unit:1 RBC unit. For PLT transfusion, high ratio was defined as ≥0.2 PLT doses:1 RBC unit; PLT dose was defined as 1 apheresis PLT or 5 whole blood PLT equivalents. The clinical outcomes analyzed were mortality and the change in the Multiple Organ Dysfunction Score (ΔMODS) comparing the preoperative score with the highest composite score through the earliest of death, discharge, or day 7. Outcomes were compared between patients transfused with high and low ratios. Linear and Cox regression were used to explore relationships between predictors and continuous outcomes and time to event outcomes. RESULTS A total of 324 subjects met the definition of massive transfusion. In those receiving high plasma:RBC ratio, the mean (SE) 7- and 28-day ΔMODS was 1.24 (0.45) and 1.26 (0.56) points lower, (P = .007 and P = .024), respectively, than in patients receiving lower ratios. In patients receiving high PLT:RBC ratio, the mean (SE) 7- and 28-day ΔMODS were 1.55 (0.53) and 1.49 (0.65) points lower (P = .004 and P = .022), respectively. Subjects who received low-ratio plasma:RBC transfusion had excess 7-day mortality compared with those who received high ratio (7.2% vs 1.7%, respectively, P = .0318), which remained significant at 28 days (P = .035). The ratio of PLT:RBCs was not associated with differences in mortality. CONCLUSIONS This analysis found that in complex cardiac surgery patients who received massive transfusion, there was an association between the composition of blood products used and clinical outcomes. Specifically, there was less organ dysfunction in those who received high-ratio transfusions (plasma:RBCs and PLT:RBCs), and lower mortality in those who received high-ratio plasma:RBC transfusions.
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Affiliation(s)
- Meghan Delaney
- From the *Medical Division and Department of Laboratory Medicine, University of Washington, Seattle, Washington; †Center for Epidemiological and Statistical Research, New England Research Institutes (Data Coordinating Center), Watertown, Massachusetts; ‡Division of Transfusion Medicine, Department of Pathology, University of Pittsburgh, Pittsburgh, Pennsylvania; §Harborview Medical Center, Department of Laboratory Medicine and Division of Hematology, University of Washington, Seattle, Washington; ‖Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota; ¶Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; and #Department of Laboratory Medicine, Boston Children's Hospital and Department of Pathology, Harvard Medical School, Boston, Massachusetts
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Green L, Tan J, Grist C, Kaur M, MacCallum P. Aetiology and outcome of massive transfusion in two large London teaching hospitals over a 3-year period (2012-2014). Transfus Med 2017; 27 Suppl 5:342-347. [DOI: 10.1111/tme.12434] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2017] [Revised: 05/14/2017] [Accepted: 05/24/2017] [Indexed: 11/30/2022]
Affiliation(s)
- L. Green
- Department of Haematology; Barts Health NHS Trust; London UK
- Barts and the London School of Medicine and Dentistry; Queen Mary University of London; London UK
- NHS Blood and Transplant; London UK
| | - J. Tan
- Barts and the London School of Medicine and Dentistry; Queen Mary University of London; London UK
| | - C. Grist
- Department of Haematology; Barts Health NHS Trust; London UK
| | - M. Kaur
- Department of Haematology; Barts Health NHS Trust; London UK
| | - P. MacCallum
- Department of Haematology; Barts Health NHS Trust; London UK
- Barts and the London School of Medicine and Dentistry; Queen Mary University of London; London UK
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25
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Mclennan JV, Mackway-Jones KC, Horne ST, Body R. Predictors of massive blood transfusion: a Delphi Study to examine the views of experts. J ROY ARMY MED CORPS 2017; 163:259-265. [PMID: 28320917 DOI: 10.1136/jramc-2016-000702] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2016] [Revised: 10/30/2016] [Accepted: 10/31/2016] [Indexed: 11/03/2022]
Abstract
BACKGROUND Trauma patients requiring massive blood transfusion (MBT) have high morbidity and mortality: early and aggressive use of blood products during immediate resuscitation may improve survival. There is currently a lack of evidence to guide initial identification of these patients which is especially important in areas where plasma may need to be thawed. In the absence of this evidence, this study aimed to robustly evaluate expert opinion by using a Delphi process to identify predictors of massive transfusion. This process can be used to ensure that decision rules include variables that have clinical validity, which may improve translation of rules into clinical practice. METHODS An international panel of 35 experts was identified through expert advice against specific criteria. Military and civilian experts from the fields of emergency medicine, critical care, anaesthesia, prehospital care, haematology and general/trauma surgery were included. The Delphi Study was carried out over three rounds. Consensus level was predefined at 80%. RESULTS 195 statements were generated by the panel of which 97 (49.7%) achieved consensus at the 80% level by the end of round 3. Strikingly no clinical observations reached consensus individually. Metabolic acidosis of a base excess of -5.0 or worse, lactate >5 mmol/L and a low haematocrit on arrival were all considered predictive. Some patterns of injury, but few mechanisms of injury, were considered highly predictive of the need of MBT. CONCLUSIONS This Delphi process has produced a list of parameters that expert clinicians felt were predictive for MBT. This list can be used to inform the generation of decision rules. It is of note that many factors used in current decision rules were not valued by clinical experts-this may be a cause for poor uptake of those rules.
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Affiliation(s)
- Jacqueline V Mclennan
- Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine (Academia & Research), Medical Directorate, ICT Centre, Birmingham, UK.,Royal Stoke Hospital, University Hospital North Midlands NHS Trust, Staffordshire, UK
| | - K C Mackway-Jones
- Manchester University, Manchester, UK.,Emergency Department, Manchester Royal Infirmary, Manchester, UK
| | - S T Horne
- Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine (Academia & Research), Medical Directorate, ICT Centre, Birmingham, UK.,Emergency Department, Derriford Hospital, Plymouth, UK
| | - R Body
- Manchester University, Manchester, UK.,Emergency Department, Manchester Royal Infirmary, Manchester, UK
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26
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Experience of implementing a National pre-hospital Code Red bleeding protocol in Scotland. Injury 2017; 48:41-46. [PMID: 27641222 DOI: 10.1016/j.injury.2016.09.020] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2016] [Revised: 09/07/2016] [Accepted: 09/09/2016] [Indexed: 02/02/2023]
Abstract
INTRODUCTION The Scottish Transfusion and Laboratory Support in Trauma Group (TLSTG) have introduced a unified National pre-hospital Code Red protocol. This paper reports the results of a study aiming to establish whether current pre-hospital Code Red activation criteria for trauma patients successfully predict need for in hospital transfusion or haemorrhagic death, the current admission coagulation profile and Concentrated Red Cell (CRC): Fresh Frozen Plasma (FFP) ratio being used, and whether use of the protocol leads to increased blood component discards? METHODS Prospective cohort study. Clinical and transfusion leads for each of Scotland's pre-hospital services and their receiving hospitals agreed to enter data into the study for all trauma patients for whom a pre-hospital Code Red was activated. Outcome data collected included survival 24h after Code Red activation, survival to hospital discharge, death in the Emergency Department and death in hospital. RESULTS Between June 1st 2013 and October 31st 2015 there were 53 pre-hospital Code Red activations. Median Injury Severity Score (ISS) was 24 (IQR 14-37) and mortality 38%. 16 patients received pre-hospital blood. The pre-hospital Code Red protocol was sensitive for predicting transfusion or haemorrhagic death (89%). Sensitivity, specificity, positive and negative predictive values of the pre-hospital SBP <90mmHg component were 63%, 33%, 86% and 12%. 19% had an admission prothrombin time >14s and 27% had a fibrinogen <1.5g/L. CRC: FFP ratios did not drop to below 2:1 until 150min after arrival in the ED. 16 red cell units, 33 FFP and 6 platelets were discarded. This was not significantly increased compared to historical data. CONCLUSIONS A National pre-hospital Code Red protocol is sensitive for predicting transfusion requirement in bleeding trauma patients and does not lead to increased blood component discards. A significant number of patients are coagulopathic and there is a need to improve CRC: FFP ratios and time to transfusion support especially FFP provision. Training clinicians to activate pre-hospital Code Red earlier during the pre-hospital phase may give blood bank more time to thaw and prepare FFP and may improve FFP administration times and ratios so long as components are used upon their availability.
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27
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Noorman F, van Dongen TTCF, Plat MCJ, Badloe JF, Hess JR, Hoencamp R. Transfusion: -80°C Frozen Blood Products Are Safe and Effective in Military Casualty Care. PLoS One 2016; 11:e0168401. [PMID: 27959967 PMCID: PMC5154589 DOI: 10.1371/journal.pone.0168401] [Citation(s) in RCA: 65] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2016] [Accepted: 11/30/2016] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION The Netherlands Armed Forces use -80°C frozen red blood cells (RBCs), plasma and platelets combined with regular liquid stored RBCs, for the treatment of (military) casualties in Medical Treatment Facilities abroad. Our objective was to assess and compare the use of -80°C frozen blood products in combination with the different transfusion protocols and their effect on the outcome of trauma casualties. MATERIALS AND METHODS Hemovigilance and combat casualties data from Afghanistan 2006-2010 for 272 (military) trauma casualties with or without massive transfusions (MT: ≥6 RBC/24hr, N = 82 and non-MT: 1-5 RBC/24hr, N = 190) were analyzed retrospectively. In November 2007, a massive transfusion protocol (MTP; 4:3:1 RBC:Plasma:Platelets) for ATLS® class III/IV hemorrhage was introduced in military theatre. Blood product use, injury severity and mortality were assessed pre- and post-introduction of the MTP. Data were compared to civilian and military trauma studies to assess effectiveness of the frozen blood products and MTP. RESULTS No ABO incompatible blood products were transfused and only 1 mild transfusion reaction was observed with 3,060 transfused products. In hospital mortality decreased post-MTP for MT patients from 44% to 14% (P = 0.005) and for non-MT patients from 12.7% to 5.9% (P = 0.139). Average 24-hour RBC, plasma and platelet ratios were comparable and accompanying 24-hour mortality rates were low compared to studies that used similar numbers of liquid stored (and on site donated) blood products. CONCLUSION This report describes for the first time that the combination of -80°C frozen platelets, plasma and red cells is safe and at least as effective as standard blood products in the treatment of (military) trauma casualties. Frozen blood can save the lives of casualties of armed conflict without the need for in-theatre blood collection. These results may also contribute to solutions for logistic problems in civilian blood supply in remote areas.
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Affiliation(s)
- Femke Noorman
- Military Blood Bank, Ministry of Defense, Leiden, The Netherlands
- * E-mail: (FN); (TD)
| | - Thijs T. C. F. van Dongen
- Ministry of Defense and Department of Trauma, Division of Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands
- * E-mail: (FN); (TD)
| | | | - John F. Badloe
- Military Blood Bank, Ministry of Defense, Leiden, The Netherlands
| | - John R. Hess
- Transfusion Service, Harborview Medical Centre, Seattle, United States of America
| | - Rigo Hoencamp
- Ministry of Defense and Department of Surgery, Alrijne Medical Centre Leiderdorp, Leiden University Medical Centre, Leiden, the Netherlands
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Oldroyd JC, Venardos KM, Aoki NJ, Zatta AJ, McQuilten ZK, Phillips LE, Andrianopoulos N, Cooper DJ, Cameron PA, Isbister JP, Wood EM. Improving outcomes for hospital patients with critical bleeding requiring massive transfusion: the Australian and New Zealand Massive Transfusion Registry study methodology. BMC Res Notes 2016; 9:457. [PMID: 27716381 PMCID: PMC5052932 DOI: 10.1186/s13104-016-2261-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2016] [Accepted: 09/27/2016] [Indexed: 12/28/2022] Open
Abstract
Background The Australian and New Zealand (ANZ) Massive Transfusion (MT) Registry (MTR) has been established to improve the quality of care of patients with critical bleeding (CB) requiring MT (≥ 5 units red blood cells (RBC) over 4 h). The MTR is providing data to: (1) improve the evidence base for transfusion practice by systematically collecting data on transfusion practice and clinical outcomes; (2) monitor variations in practice and provide an opportunity for benchmarking, and feedback on practice/blood product use; (3) inform blood supply planning, inventory management and development of future clinical trials; and (4) measure and enhance translation of evidence into policy and patient blood management guidelines. The MTR commenced in 2011. At each participating site, all eligible patients aged ≥18 years with CB from any clinical context receiving MT are included using a waived consent model. Patient information and clinical coding, transfusion history, and laboratory test results are extracted for each patient’s hospital admission at the episode level. Results Thirty-two hospitals have enrolled and 3566 MT patients have been identified across Australia and New Zealand between 2011 and 2015. The majority of CB contexts are surgical, followed by trauma and gastrointestinal haemorrhage. Validation studies have verified that the definition of MT used in the registry correctly identifies 94 % of CB events, and that the median time of transfusion for the majority of fresh products is the ‘product event issue time’ from the hospital blood bank plus 20 min. Data linkage between the MTR and mortality databases in Australia and New Zealand will allow comparisons of risk-adjusted mortality estimates across different bleeding contexts, and between countries. Data extracts will be examined to determine if there are differences in patient outcomes according to transfusion practice. The ratios of blood components (e.g. FFP:RBC) used in different types of critical bleeding will also be investigated. Conclusions The MTR is generating data with the potential to have an impact on management and policy decision-making in CB and MT and provide benchmarking and monitoring tools for immediate application.
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Affiliation(s)
- J C Oldroyd
- Transfusion Research Unit, Department of Epidemiology and Preventive Medicine, Monash University, Clayton, VIC, 3004, Australia.
| | - K M Venardos
- Transfusion Research Unit, Department of Epidemiology and Preventive Medicine, Monash University, Clayton, VIC, 3004, Australia
| | - N J Aoki
- Transfusion Research Unit, Department of Epidemiology and Preventive Medicine, Monash University, Clayton, VIC, 3004, Australia
| | - A J Zatta
- Transfusion Research Unit, Department of Epidemiology and Preventive Medicine, Monash University, Clayton, VIC, 3004, Australia
| | - Z K McQuilten
- Transfusion Research Unit, Department of Epidemiology and Preventive Medicine, Monash University, Clayton, VIC, 3004, Australia.,Centre of Research Excellence for Patient Blood Management in Critical Illness and Trauma, Monash University, Clayton, VIC, 3004, Australia
| | - L E Phillips
- Transfusion Research Unit, Department of Epidemiology and Preventive Medicine, Monash University, Clayton, VIC, 3004, Australia
| | - N Andrianopoulos
- Transfusion Research Unit, Department of Epidemiology and Preventive Medicine, Monash University, Clayton, VIC, 3004, Australia
| | - D J Cooper
- Centre of Research Excellence for Patient Blood Management in Critical Illness and Trauma, Monash University, Clayton, VIC, 3004, Australia.,Department of Epidemiology and Preventive Medicine, Monash University, Clayton, VIC, 3004, Australia
| | - P A Cameron
- Emergency and Trauma Centre, The Alfred Hospital, Melbourne, VIC, 3004, Australia.,Department of Epidemiology and Preventive Medicine, Monash University, Clayton, VIC, 3004, Australia
| | - J P Isbister
- Department of Haematology, University of Sydney, Royal North Shore Hospital, St Leonard, Sydney, NSW, 2065, Australia
| | - E M Wood
- Transfusion Research Unit, Department of Epidemiology and Preventive Medicine, Monash University, Clayton, VIC, 3004, Australia
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Do lactate levels in the emergency department predict outcome in adult trauma patients? A systematic review. J Trauma Acute Care Surg 2016; 81:555-66. [DOI: 10.1097/ta.0000000000001156] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Recursive partitioning identifies greater than 4 U of packed red blood cells per hour as an improved massive transfusion definition. J Trauma Acute Care Surg 2016; 79:920-4. [PMID: 26680135 DOI: 10.1097/ta.0000000000000830] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Massive transfusion (MT) is classically defined as greater than 10 U of packed red blood cells (PRBCs) in 24 hours. This fails to capture the most severely injured patients. Extending the previous work of Savage and Rahbar, a rolling hourly rate-based definition of MT may more accurately define critically injured patients requiring early, aggressive resuscitation. METHODS The Prospective Observational Multicenter Major Trauma Transfusion (PROMMTT) trial collected data from 10 Level 1 trauma centers. Patients were placed into rate-based transfusion groups by maximal number of PRBCs transfused in any hour within the first 6 hours. A nonparametric analysis using classification trees partitioned data according to mortality at 24 hours using a predictor variable of maximum number PRBC units transfused in an hour. Dichotomous variables significant in previous scores and models as predictors of MT were used to identify critically ill patients: a positive finding on Focused Assessment with Sonography in Trauma (FAST) examination, Glasgow Coma Scale (GCS) score less than 8, heart rate greater than 120 beats/min, systolic blood pressure less than 90 mm Hg, penetrating mechanism of injury, international normalized ratio greater than 1.5, hemoglobin less than 11, and base deficit greater than 5. These critical indicators were then compared among the nodes of the classification tree. Patients omitted included those who did not receive PRBCs (n = 24) and those who did not have all eight critical indicators reported (n = 449). RESULTS In a population of 1,245 patients, the classification tree included 772 patients. Analysis by recursive partitioning showed increased mortality among patients receiving greater than 13 U/h (73.9%, p < 0.01). In those patients receiving less than or equal to 13 U/h, mortality was greater in patients who received more than 4 U/h (16.7% vs. 6.0%, p < 0.01) (Fig. 1). Nodal analysis showed that the median number of critical indicators for each node was 3 (2-4) (≤4 U/h), 4 (3-5) (>4 U/h and ≤13 U/h), and 5 (4-5.5) (>13 U/h). CONCLUSION A rate-based transfusion definition identifies a difference in mortality in patients who receive greater than 4 U/h of PRBCs. Redefining MT to greater than 4 U/h allows early identification of patients with a significant mortality risk who may be missed by the current definition. LEVEL OF EVIDENCE Prognostic/epidemiologic study, level III.
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Whiting P, Al M, Westwood M, Ramos IC, Ryder S, Armstrong N, Misso K, Ross J, Severens J, Kleijnen J. Viscoelastic point-of-care testing to assist with the diagnosis, management and monitoring of haemostasis: a systematic review and cost-effectiveness analysis. Health Technol Assess 2016. [PMID: 26215747 DOI: 10.3310/hta19580] [Citation(s) in RCA: 187] [Impact Index Per Article: 23.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Patients with substantive bleeding usually require transfusion and/or (re-)operation. Red blood cell (RBC) transfusion is independently associated with a greater risk of infection, morbidity, increased hospital stay and mortality. ROTEM (ROTEM® Delta, TEM International GmbH, Munich, Germany; www.rotem.de), TEG (TEG® 5000 analyser, Haemonetics Corporation, Niles, IL, USA; www.haemonetics.com) and Sonoclot (Sonoclot® coagulation and platelet function analyser, Sienco Inc., Arvada, CO) are point-of-care viscoelastic (VE) devices that use thromboelastometry to test for haemostasis in whole blood. They have a number of proposed advantages over standard laboratory tests (SLTs): they provide a result much quicker, are able to identify what part of the clotting process is disrupted, and provide information on clot formation over time and fibrinolysis. OBJECTIVES This assessment aimed to assess the clinical effectiveness and cost-effectiveness of VE devices to assist with the diagnosis, management and monitoring of haemostasis disorders during and after cardiac surgery, trauma-induced coagulopathy and post-partum haemorrhage (PPH). METHODS Sixteen databases were searched to December 2013: MEDLINE (OvidSP), MEDLINE In-Process and Other Non-Indexed Citations and Daily Update (OvidSP), EMBASE (OvidSP), BIOSIS Previews (Web of Knowledge), Science Citation Index (SCI) (Web of Science), Conference Proceedings Citation Index (CPCI-S) (Web of Science), Cochrane Database of Systematic Reviews (CDSR), Cochrane Central Register of Controlled Trials (CENTRAL), Database of Abstracts of Reviews of Effects (DARE), Health Technology Assessment (HTA) database, Latin American and Caribbean Health Sciences Literature (LILACS), International Network of Agencies for Health Technology Assessment (INAHTA), National Institute for Health Research (NIHR) HTA programme, Aggressive Research Intelligence Facility (ARIF), Medion, and the International Prospective Register of Systematic Reviews (PROSPERO). Randomised controlled trials (RCTs) were assessed for quality using the Cochrane Risk of Bias tool. Prediction studies were assessed using QUADAS-2. For RCTs, summary relative risks (RRs) were estimated using random-effects models. Continuous data were summarised narratively. For prediction studies, the odds ratio (OR) was selected as the primary effect estimate. The health-economic analysis considered the costs and quality-adjusted life-years of ROTEM, TEG and Sonoclot compared with SLTs in cardiac surgery and trauma patients. A decision tree was used to take into account short-term complications and longer-term side effects from transfusion. The model assumed a 1-year time horizon. RESULTS Thirty-one studies (39 publications) were included in the clinical effectiveness review. Eleven RCTs (n=1089) assessed VE devices in patients undergoing cardiac surgery; six assessed thromboelastography (TEG) and five assessed ROTEM. There was a significant reduction in RBC transfusion [RR 0.88, 95% confidence interval (CI) 0.80 to 0.96; six studies], platelet transfusion (RR 0.72, 95% CI 0.58 to 0.89; six studies) and fresh frozen plasma to transfusion (RR 0.47, 95% CI 0.35 to 0.65; five studies) in VE testing groups compared with control. There were no significant differences between groups in terms of other blood products transfused. Continuous data on blood product use supported these findings. Clinical outcomes did not differ significantly between groups. There were no apparent differences between ROTEM or TEG; none of the RCTs evaluated Sonoclot. There were no data on the clinical effectiveness of VE devices in trauma patients or women with PPH. VE testing was cost-saving and more effective than SLTs. For the cardiac surgery model, the cost-saving was £43 for ROTEM, £79 for TEG and £132 for Sonoclot. For the trauma population, the cost-savings owing to VE testing were more substantial, amounting to per-patient savings of £688 for ROTEM compared with SLTs, £721 for TEG, and £818 for Sonoclot. This finding was entirely dependent on material costs, which are slightly higher for ROTEM. VE testing remained cost-saving following various scenario analyses. CONCLUSIONS VE testing is cost-saving and more effective than SLTs, in both patients undergoing cardiac surgery and trauma patients. However, there were no data on the clinical effectiveness of Sonoclot or of VE devices in trauma patients. STUDY REGISTRATION This study is registered as PROSPERO CRD42013005623. FUNDING The NIHR Health Technology Assessment programme.
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Affiliation(s)
| | - Maiwenn Al
- Institute of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, the Netherlands
| | | | - Isaac Corro Ramos
- Institute of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, the Netherlands
| | | | | | - Kate Misso
- Kleijnen Systematic Reviews Ltd, York, UK
| | | | - Johan Severens
- Institute of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, the Netherlands
| | - Jos Kleijnen
- School for Public Health and Primary Care (CAPHRI), Maastricht University, Maastricht, the Netherlands
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O'Donnell JM, Nácul FE. Blood Products. SURGICAL INTENSIVE CARE MEDICINE 2016. [PMCID: PMC7123257 DOI: 10.1007/978-3-319-19668-8_35] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Perioperative hemorrhage, anemia, thrombocytopenia, and coagulopathy are common in the surgical intensive care unit. As a result, blood product transfusion occurs frequently. While red blood cell, plasma, and platelet transfusions have a lifesaving role in the resuscitation of patients with trauma and hemorrhagic shock, their application in other settings is under scrutiny. Current data would suggest a conservative approach be taken, thus avoiding unnecessary transfusion and associated potential adverse events. New and developmental products such as prothrombin complex concentrates offer appealing alternatives to traditional transfusion practice—potentially with fewer risks—however, further investigation into their safety and efficacy is required before practice change can take place.
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Affiliation(s)
- John M. O'Donnell
- Department of Surgical Critical Care; Lahey Hospital and Medical Center, Division of Surgery, Burlington, Massachusetts USA
| | - Flávio E. Nácul
- Surgical Critical Care Medicine, Pr�-Card�o Hospital, Critical Care Medicine, University Hospital, Federal University of Rio de Janeiro, Rio de Janeiro, Rio de Janeiro Brazil
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Green L, Knight M, Seeney FM, Hopkinson C, Collins PW, Collis RE, Simpson N, Weeks A, Stanworth SS. The epidemiology and outcomes of women with postpartum haemorrhage requiring massive transfusion with eight or more units of red cells: a national cross-sectional study. BJOG 2015; 123:2164-2170. [PMID: 26694742 DOI: 10.1111/1471-0528.13831] [Citation(s) in RCA: 67] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/24/2015] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To ascertain the incidence of massive transfusion (MT) in obstetrics in the UK, and describe its management and clinical outcomes. DESIGN A population-based cross-sectional study conducted through the UK Obstetric Surveillance System (UKOSS). SETTINGS All UK hospitals with consultant-led maternity units. POPULATION Any pregnant woman at ≥20 weeks of gestation receiving ≥8 units of red blood cells within 24 hours of giving birth, from July 2012 to June 2013. METHODS Prospective case identification through the monthly mailing of UKOSS. RESULTS We identified 181 women who had undergone MT, making the estimated incidence of MT associated with postpartum haemorrhage (PPH) 23 per 100 000 maternities (95% confidence interval 19-26) per year. The median estimated blood loss was 6 l (interquartile range 4.5-8.0 l). The majority of women presented outside working hours (63%), 40% had had previous caesarean sections and 3% had normal vaginal births without risk factors. The main cause for MT was uterine atony (40%) and the main mode of birth was caesarean section (69%). Of the 181 women, 15 received >20 units of red blood cells. In total, 45% of women underwent hysterectomy, and among all causes of PPH, placenta accreta had the highest hysterectomy rate. Two women died, 82% were admitted to intensive care/high-dependency units, and 28% developed major morbidities. CONCLUSION Massive transfusion due to PPH is associated with high rates of morbidity and hysterectomy. Clinical and research efforts should focus on approaches to recognise and optimise timely resuscitation and management of these severe cases. TWEETABLE ABSTRACT Massive transfusion due to postpartum haemorrhage is associated with high rates of morbidity and hysterectomy.
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Affiliation(s)
- L Green
- Barts Health NHS Trust & NHS Blood and Transplant, London, UK.,Blizzard Institute, Queen Mary University of London, London, UK
| | - M Knight
- National Perinatal Epidemiology Unit, University of Oxford, Oxford, UK
| | - F M Seeney
- Statistics and Clinical Studies, NHS Blood and Transplant, Bristol, UK
| | - C Hopkinson
- Statistics and Clinical Studies, NHS Blood and Transplant, Bristol, UK
| | - P W Collins
- Arthur Bloom Haemophilia Centre, Cardiff University, Cardiff, UK
| | - R E Collis
- Department of Anaesthetics, Cardiff and Vale University Health Board, Cardiff, UK
| | - Nab Simpson
- Department of Women's and Children's Health, University of Leeds, Leeds, UK
| | - A Weeks
- Department of Women's and Children's Health, University of Liverpool, Liverpool, UK
| | - S S Stanworth
- NHS Blood and Transplant, Oxford & Oxford University Hospitals NHS Trust, Oxford, UK
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Morris TP, White IR, Carpenter JR, Stanworth SJ, Royston P. Combining fractional polynomial model building with multiple imputation. Stat Med 2015; 34:3298-317. [PMID: 26095614 PMCID: PMC4871237 DOI: 10.1002/sim.6553] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2014] [Revised: 05/07/2015] [Accepted: 05/19/2015] [Indexed: 01/03/2023]
Abstract
Multivariable fractional polynomial (MFP) models are commonly used in medical research. The datasets in which MFP models are applied often contain covariates with missing values. To handle the missing values, we describe methods for combining multiple imputation with MFP modelling, considering in turn three issues: first, how to impute so that the imputation model does not favour certain fractional polynomial (FP) models over others; second, how to estimate the FP exponents in multiply imputed data; and third, how to choose between models of differing complexity. Two imputation methods are outlined for different settings. For model selection, methods based on Wald-type statistics and weighted likelihood-ratio tests are proposed and evaluated in simulation studies. The Wald-based method is very slightly better at estimating FP exponents. Type I error rates are very similar for both methods, although slightly less well controlled than analysis of complete records; however, there is potential for substantial gains in power over the analysis of complete records. We illustrate the two methods in a dataset from five trauma registries for which a prognostic model has previously been published, contrasting the selected models with that obtained by analysing the complete records only.
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Affiliation(s)
- Tim P. Morris
- Hub for Trials Methodology Research, MRC Clinical Trials Unit at UCLInstitute of Clinical Trials and MethodologyAviation House, 125 KingswayLondonWC2B 6NHU.K.
- Medical Statistics DepartmentLondon School of Hygiene & Tropical MedicineKeppel StLondonWC1E 7HTU.K.
| | - Ian R. White
- MRC Biostatistics UnitInstitute of Public HealthRobinson WayCambridgeCB2 0SRU.K.
| | - James R. Carpenter
- Hub for Trials Methodology Research, MRC Clinical Trials Unit at UCLInstitute of Clinical Trials and MethodologyAviation House, 125 KingswayLondonWC2B 6NHU.K.
- Medical Statistics DepartmentLondon School of Hygiene & Tropical MedicineKeppel StLondonWC1E 7HTU.K.
| | | | - Patrick Royston
- Hub for Trials Methodology Research, MRC Clinical Trials Unit at UCLInstitute of Clinical Trials and MethodologyAviation House, 125 KingswayLondonWC2B 6NHU.K.
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Rahbar MH, Ning J, Choi S, Piao J, Hong C, Huang H, Del Junco DJ, Fox EE, Rahbar E, Holcomb JB. A joint latent class model for classifying severely hemorrhaging trauma patients. BMC Res Notes 2015; 8:602. [PMID: 26498438 PMCID: PMC4620016 DOI: 10.1186/s13104-015-1563-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2014] [Accepted: 10/05/2015] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND In trauma research, "massive transfusion" (MT), historically defined as receiving ≥10 units of red blood cells (RBCs) within 24 h of admission, has been routinely used as a "gold standard" for quantifying bleeding severity. Due to early in-hospital mortality, however, MT is subject to survivor bias and thus a poorly defined criterion to classify bleeding trauma patients. METHODS Using the data from a retrospective trauma transfusion study, we applied a latent-class (LC) mixture model to identify severely hemorrhaging (SH) patients. Based on the joint distribution of cumulative units of RBCs and binary survival outcome at 24 h of admission, we applied an expectation-maximization (EM) algorithm to obtain model parameters. Estimated posterior probabilities were used for patients' classification and compared with the MT rule. To evaluate predictive performance of the LC-based classification, we examined the role of six clinical variables as predictors using two separate logistic regression models. RESULTS Out of 471 trauma patients, 211 (45 %) were MT, while our latent SH classifier identified only 127 (27 %) of patients as SH. The agreement between the two classification methods was 73 %. A non-ignorable portion of patients (17 out of 68, 25 %) who died within 24 h were not classified as MT but the SH group included 62 patients (91 %) who died during the same period. Our comparison of the predictive models based on MT and SH revealed significant differences between the coefficients of potential predictors of patients who may be in need of activation of the massive transfusion protocol. CONCLUSIONS The traditional MT classification does not adequately reflect transfusion practices and outcomes during the trauma reception and initial resuscitation phase. Although we have demonstrated that joint latent class modeling could be used to correct for potential bias caused by misclassification of severely bleeding patients, improvement in this approach could be made in the presence of time to event data from prospective studies.
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Affiliation(s)
- Mohammad H Rahbar
- Division of Clinical and Translational Sciences, Department of Internal Medicine, The University of Texas Medical School at Houston, The University of Texas Health Science Center at Houston, Fannin St, Houston, TX, USA. .,Division of Epidemiology, Human Genetics and Environmental Sciences, School of Public Health, The University of Texas Health Sciences Center at Houston, Pressler St, Houston, TX, USA.
| | - Jing Ning
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Holcombe Blvd, Houston, TX, USA.
| | - Sangbum Choi
- Division of Clinical and Translational Sciences, Department of Internal Medicine, The University of Texas Medical School at Houston, The University of Texas Health Science Center at Houston, Fannin St, Houston, TX, USA.
| | - Jin Piao
- Division of Biostatistics, School of Public Health, The University of Texas Health Sciences Center at Houston, Pressler St, Houston, TX, USA.
| | - Chuan Hong
- Division of Biostatistics, School of Public Health, The University of Texas Health Sciences Center at Houston, Pressler St, Houston, TX, USA.
| | - Hanwen Huang
- Epidemiology and Biostatistics, College of Public Health, University of Georgia, Buck Road, Athens, GA, 30602, USA.
| | - Deborah J Del Junco
- Division of Acute Care Surgery, Department of Surgery, Center for Translational Injury Research, The University of Texas Health Science Center at Houston, Fannin St, Houston, TX, USA.
| | - Erin E Fox
- Division of Acute Care Surgery, Department of Surgery, Center for Translational Injury Research, The University of Texas Health Science Center at Houston, Fannin St, Houston, TX, USA.
| | - Elaheh Rahbar
- Department of Biomedical Engineering, Wake Forest University, Winston-Salem, NC, USA.
| | - John B Holcomb
- Division of Acute Care Surgery, Department of Surgery, Center for Translational Injury Research, The University of Texas Health Science Center at Houston, Fannin St, Houston, TX, USA.
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Boutefnouchet T, Gregg R, Tidman J, Isaac J, Doughty H. Emergency red cells first: Rapid response or speed bump? The evolution of a massive transfusion protocol for trauma in a single UK centre. Injury 2015; 46:1772-8. [PMID: 26068644 DOI: 10.1016/j.injury.2015.05.046] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2014] [Revised: 05/07/2015] [Accepted: 05/21/2015] [Indexed: 02/02/2023]
Abstract
BACKGROUND Death from massive haemorrhage due to traumatic injury is potentially preventable after hospital admission using haemorrhage control and improved resuscitation techniques including massive transfusion protocols. Massive transfusion protocols (MTP) are an essential element of damage control resuscitation and provide a coordinated clinical pathology response to massive haemorrhage after hospital admission. The decision to activate and de-activate a MTP is based on a number of patient and local factors. The purpose of this before-and-after study was to determine the impact of modifying a protocol to include emergency red cells. In addition, we investigated whether massive transfusion prediction models could have been used to guide on-going transfusion support. METHODS Sequential MTP activations over three years, before and after protocol revision, were analysed. Percentage of MTP activation, component usage and outcome data were compared. Trauma associated severe haemorrhage (TASH) and assessment of blood consumption (ABC) scores were derived and receiver operating characteristic (ROC) analysis undertaken for an outcome defined as the use of >6 red cell units. RESULTS 52 MTP1 and 66 MTP2 activations arose from 216 and 495 major trauma cases, respectively. Protocol change significantly reduced the MTP activation rate (p=0.0006) from 24% to 13%, and the number of activations requiring >10 RCC increased from 13% to 36% (p=0.006). Average emergency red cells usage in the second cohort increased to 4 units. Survival, coagulation parameters, and time to MTP pack issue were all unaffected by the protocol revision. The TASH score showed an area under ROC (AUROC) of 0.88 ongoing transfusion requirements. CONCLUSION The change in protocol increased the use of emergency red cells but reduced MTP activation and use of multiple blood components. The TASH score appears to provide a useful predictive tool for ongoing transfusion support and may be of value for the trauma clinicians.
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Affiliation(s)
- Tarek Boutefnouchet
- Department of Trauma and Orthopaedic Surgery, University Hospital Birmingham NHS Foundation Trust, Edgbaston, Birmingham B15 2WB, UK.
| | - Richard Gregg
- Department of Haematology, University Hospital Birmingham NHS Foundation Trust, Edgbaston, Birmingham B15 2WB, UK
| | - Jane Tidman
- Department of Haematology, University Hospital Birmingham NHS Foundation Trust, Edgbaston, Birmingham B15 2WB, UK
| | - John Isaac
- Department of Haematology, University Hospital Birmingham NHS Foundation Trust, Edgbaston, Birmingham B15 2WB, UK
| | - Heidi Doughty
- NHS Blood and Transplant, Edgbaston, Birmingham B15 2TH, UK
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Campbell HE, Stokes EA, Bargo DN, Curry N, Lecky FE, Edwards A, Woodford M, Seeney F, Eaglestone S, Brohi K, Gray AM, Stanworth SJ. Quantifying the healthcare costs of treating severely bleeding major trauma patients: a national study for England. Crit Care 2015; 19:276. [PMID: 26148506 PMCID: PMC4517367 DOI: 10.1186/s13054-015-0987-5] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2015] [Accepted: 06/12/2015] [Indexed: 12/14/2022] Open
Abstract
INTRODUCTION Severely bleeding trauma patients are a small proportion of the major trauma population but account for 40% of all trauma deaths. Healthcare resource use and costs are likely to be substantial but have not been fully quantified. Knowledge of costs is essential for developing targeted cost reduction strategies, informing health policy, and ensuring the cost-effectiveness of interventions. METHODS In collaboration with the Trauma Audit Research Network (TARN) detailed patient-level data on in-hospital resource use, extended care at hospital discharge, and readmissions up to 12 months post-injury were collected on 441 consecutive adult major trauma patients with severe bleeding presenting at 22 hospitals (21 in England and one in Wales). Resource use data were costed using national unit costs and mean costs estimated for the cohort and for clinically relevant subgroups. Using nationally available data on trauma presentations in England, patient-level cost estimates were up-scaled to a national level. RESULTS The mean (95% confidence interval) total cost of initial hospital inpatient care was £19,770 (£18,177 to £21,364) per patient, of which 62% was attributable to ventilation, intensive care, and ward stays, 16% to surgery, and 12% to blood component transfusion. Nursing home and rehabilitation unit care and re-admissions to hospital increased the cost to £20,591 (£18,924 to £22,257). Costs were significantly higher for more severely injured trauma patients (Injury Severity Score ≥15) and those with blunt injuries. Cost estimates for England were £148,300,000, with over a third of this cost attributable to patients aged 65 years and over. CONCLUSIONS Severely bleeding major trauma patients are a high cost subgroup of all major trauma patients, and the cost burden is projected to rise further as a consequence of an aging population and as evidence continues to emerge on the benefits of early and simultaneous administration of blood products in pre-specified ratios. The findings from this study provide a previously unreported baseline from which the potential impact of changes to service provision and/or treatment practice can begin to be evaluated. Further studies are still required to determine the full costs of post-discharge care requirements, which are also likely to be substantial.
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Affiliation(s)
- Helen E Campbell
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Old Road Campus, Headington, Oxford, OX3 7LF, UK.
| | - Elizabeth A Stokes
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Old Road Campus, Headington, Oxford, OX3 7LF, UK.
| | - Danielle N Bargo
- Eli Lilly and Company Limited, Lilly House, Priestley Road, Basingstoke, Hampshire, RG24 9NL, UK.
| | - Nicola Curry
- Oxford Haemophilia and Thrombosis Centre, Oxford University Hospitals NHS Trust, Churchill Hospital, Oxford, OX3 7LE, UK.
| | - Fiona E Lecky
- Trauma Audit and Research Network, 3rd Floor Mayo Building, Salford Royal NHS Foundation Trust, Salford, M6 8HD, UK.
| | - Antoinette Edwards
- Trauma Audit and Research Network, 3rd Floor Mayo Building, Salford Royal NHS Foundation Trust, Salford, M6 8HD, UK.
| | - Maralyn Woodford
- Trauma Audit and Research Network, 3rd Floor Mayo Building, Salford Royal NHS Foundation Trust, Salford, M6 8HD, UK.
| | - Frances Seeney
- NHS Blood and Transplant Clinical Trials Unit, Fox Den Road, Stoke Gifford, Bristol, BS34 8RR, UK.
| | - Simon Eaglestone
- Blizard Institute, Barts and The London School of Medicine and Dentistry, The Blizard Building, 4 Newark Street, London, E1 2AT, UK.
| | - Karim Brohi
- Blizard Institute, Barts and The London School of Medicine and Dentistry, The Blizard Building, 4 Newark Street, London, E1 2AT, UK.
| | - Alastair M Gray
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Old Road Campus, Headington, Oxford, OX3 7LF, UK.
| | - Simon J Stanworth
- NHS Blood and Transplant and Oxford University Hospitals NHS Trust, John Radcliffe Hospital, Headley Way, Headington, Oxford, OX3 9BQ, UK.
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Sun Y, Jin ZK, Xu CX, Dang QL, Zhang LJ, Chen HN, Song YJ, Yang JC. Investigation of the current situation of massive blood transfusion in different surgical departments: a large multicenter study in China. Int J Clin Exp Med 2015; 8:9257-9265. [PMID: 26309583 PMCID: PMC4538122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2015] [Accepted: 05/28/2015] [Indexed: 06/04/2023]
Abstract
OBJECTIVE This study aims to learn about the current situation of surgical massive blood transfusion of different surgical departments in China's Tertiary hospitals, which could provide the basis for the formulation of guidelines on massive blood transfusion. METHOD A multicenter retrospective research on the application status of blood constituents during massive blood transfusion was conducted and a comparative analyses of survival and length of hospitalization in patients from different departments (trauma, cardiac surgery, obstetric conditions, or other common surgeries), were performed. RESULT In China, during massive blood transfusion the ratio of the dosage of fresh frozen plasma to the dosage of red blood cell suspension reached 1:1-2, while the dosage of platelet and cryoprecipitate appeared to be very small. The risk of in-hospital death were associated with the primary disease in patients receiving massive blood transfusion (Log-Rank P = 0.000), cardiac surgery and trauma patients who received massive blood transfusion have a higher risk of death rate. CONCLUSIONS Patients undergoing massive blood transfusion among different surgical departments have a certain difference in use of blood transfusion, mortality rate and the time of death. Our findings suggested that we should set up an independent transfusion program in cardiac surgery and trauma patients of massive blood transfusion.
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Affiliation(s)
- Yang Sun
- Department of Transfusion Medicine, The Third Affiliated Hospital of Medical College of Xi’an Jiaotong UniversityXi’an, China
| | - Zhan-Kui Jin
- The Second Department of Orthopaedics, The Third Affiliated Hospital of Medical College of Xi’an Jiaotong UniversityXi’an, China
| | - Cui-Xiang Xu
- Department of Shaanxi Provincial Center for Clinical Laboratory, The Third Affiliated Hospital of Medical College of Xi’an Jiaotong UniversityXi’an, China
| | - Qian-Li Dang
- Department of Dermatology, The Third Affiliated Hospital of Medical College of Xi’an Jiaotong UniversityXi’an, China
| | - Li-Jie Zhang
- Department of Transfusion Medicine, The Third Affiliated Hospital of Medical College of Xi’an Jiaotong UniversityXi’an, China
| | - Hong-Nan Chen
- Department of Laboratory, The Third Affiliated Hospital of Medical College of Xi’an Jiaotong UniversityXi’an, China
| | - Yao-Jun Song
- Department of Transfusion Medicine, The Third Affiliated Hospital of Medical College of Xi’an Jiaotong UniversityXi’an, China
| | - Jiang-Cun Yang
- Department of Transfusion Medicine, The Third Affiliated Hospital of Medical College of Xi’an Jiaotong UniversityXi’an, China
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Clearly defining pediatric massive transfusion: cutting through the fog and friction with combat data. J Trauma Acute Care Surg 2015; 78:22-8; discussion 28-9. [PMID: 25539199 DOI: 10.1097/ta.0000000000000488] [Citation(s) in RCA: 95] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Massive transfusion (MT) in pediatric patients remains poorly defined. Using the largest existing registry of transfused pediatric trauma patients, we sought a data-driven MT threshold. METHODS The Department of Defense Trauma Registry was queried from 2001 to 2013 for pediatric trauma patients (<18 years). Burns, drowning, isolated head injury, and missing Injury Severity Score (ISS) were excluded. MT was evaluated as a weight-based volume of all blood products transfused in the first 24 hours. Mortality at 24 hours and in the hospital was calculated for increasing transfusion volumes. Sensitivity and specificity curves for predicting mortality were used to identify an optimal MT threshold. Patients above and below this threshold (MT+ and MT-, respectively) were compared. RESULTS The Department of Defense Trauma Registry yielded 4,990 combat-injured pediatric trauma patients, of whom 1,113 were transfused and constituted the study cohort. Sensitivity and specificity for 24-hour and in-hospital mortality were optimal at 40.1-mL/kg and 38.6-mL/kg total blood products in the first 24 hours, respectively. With the use of a pragmatic threshold of 40 mL/kg, patients were divided into MT+ (n = 443) and MT- (n = 670). MT+ patients were more often in shock (68.1% vs. 47.0%, p < 0.001), hypothermic (13.0% vs. 3.4%, p < 0.001), coagulopathic (45.0% vs. 29.6%, p < 0.001), and thrombocytopenic (10.6% vs. 5.0%, p = 0.002) on presentation. MT+ patients had a higher ISS, more mechanical ventilator days, and longer intensive care unit and hospital stay. MT+ was independently associated with an increased 24-hour mortality (odds ratio, 2.50; 95% confidence interval, 1.28-4.88; p = 0.007) and in-hospital mortality (odds ratio, 2.58; 95% confidence interval, 1.70-3.92; p < 0.001). CONCLUSION Based on this large cohort of transfused combat-injured pediatric patients, a threshold of 40 mL/kg of all blood products given at any time in the first 24 hours reliably identifies critically injured children at high risk for early and in-hospital death. This evidence-based definition will provide a consistent framework for future research and protocol development in pediatric resuscitation. LEVEL OF EVIDENCE Diagnostic study, level II. Prognostic/epidemiologic study, level III.
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Yang JC, Sun Y, Xu CX, Dang QL, Li L, Xu YG, Song YJ, Yan H. Correlation between red blood cell transfusion volume and mortality in patients with massive blood transfusion: A large multicenter retrospective study. Exp Ther Med 2014; 9:137-142. [PMID: 25452789 PMCID: PMC4247322 DOI: 10.3892/etm.2014.2068] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2014] [Accepted: 10/23/2014] [Indexed: 11/25/2022] Open
Abstract
This study aimed to explore the correlation between red blood cell (RBC) transfusion volume and patient mortality in massive blood transfusion. A multicenter retrospective study was carried out on 1,601 surgical inpatients who received massive blood transfusion in 20 large comprehensive hospitals in China. According to RBC transfusion volume and duration, the patients were divided into groups as follows: 0–4, 5–9, 10–14, 15–19, 20–24, 25–29, 30–39 and ≥40 units within 24 or 72 h. Mortality in patients with different RBC transfusion volumes was analyzed. It was found that patient mortality increased with the increase in the volume of RBC transfusion when the total RBC transfusion volume was ≥10 units within 24 or 72 h. Survival analysis revealed significant differences in mortality according to the RBC transfusion volume (χ2=72.857, P<0.001). Logistic regression analysis revealed that RBC transfusion volume is an independent risk factor [odds ratio (OR) = 0.52; confidence interval (CI): 0.43–0.64; P<0.01] for the mortality of patients undergoing a massive blood transfusion. When RBCs were transfused at a volume of 5–9 units within 24 and 72 h, the mortality rate was the lowest, at 3.7 and 2.3% respectively. It is concluded that during massive blood transfusion in surgical inpatients, there is a correlation between RBC transfusion volume within 24 or 72 h and the mortality of the patients. Patient mortality increases with the increase in the volume of RBC transfusion. RBC transfusion volume, the length of stay at hospital and intensive care unit stay constitute the independent risk factors for patient mortality.
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Affiliation(s)
- Jiang-Cun Yang
- Department of Transfusion Medicine, The Third Affiliated Hospital of Medical College of Xi'an Jiaotong University, Xi'an, Shaanxi 710061, P.R. China
| | - Yang Sun
- Department of Transfusion Medicine, The Third Affiliated Hospital of Medical College of Xi'an Jiaotong University, Xi'an, Shaanxi 710061, P.R. China
| | - Cui-Xiang Xu
- Shaanxi Provincial Center for Clinical Laboratory, The Third Affiliated Hospital of Medical College of Xi'an Jiaotong University, Xi'an, Shaanxi 710061, P.R. China
| | - Qian-Li Dang
- Department of Dermatology, The Third Affiliated Hospital of Medical College of Xi'an Jiaotong University, Xi'an, Shaanxi 710061, P.R. China
| | - Ling Li
- Department of Laboratory, The Third Affiliated Hospital of Medical College of Xi'an Jiaotong University, Xi'an, Shaanxi 710061, P.R. China
| | - Yong-Gang Xu
- Department of Urology, The Third Affiliated Hospital of Medical College of Xi'an Jiaotong University, Xi'an, Shaanxi 710061, P.R. China
| | - Yao-Jun Song
- Department of Transfusion Medicine, The Third Affiliated Hospital of Medical College of Xi'an Jiaotong University, Xi'an, Shaanxi 710061, P.R. China
| | - Hong Yan
- Department of Epidemiology and Health Statistics, Medical College of Xi'an Jiaotong University, Xi'an, Shaanxi 710061, P.R. China
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Driessen A, Schäfer N, Albrecht V, Schenk M, Fröhlich M, Stürmer EK, Maegele M. Infrastructure and clinical practice for the detection and management of trauma-associated haemorrhage and coagulopathy. Eur J Trauma Emerg Surg 2014; 41:413-20. [PMID: 26037989 DOI: 10.1007/s00068-014-0455-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2014] [Accepted: 10/06/2014] [Indexed: 01/02/2023]
Abstract
PURPOSE Early detection and management of post-traumatic haemorrhage and coagulopathy have been associated with improved outcomes, but local infrastructures, logistics and clinical strategies may differ. METHODS To assess local differences in infrastructure, logistics and clinical management of trauma-associated haemorrhage and coagulopathy, we have conducted a web-based survey amongst the delegates to the 15th European Congress of Trauma and Emergency Surgery (ECTES) and the 2nd World Trauma (WT) Congress held in Frankfurt, Germany, 25-27 May 2014. RESULTS 446/1,540 delegates completed the questionnaire yielding a response rate of 29%. The majority specified to work as consultants/senior physicians (47.3%) in general (36.1%) or trauma/orthopaedic surgery (44.5%) of level I (70%) or level II (19%) trauma centres. Clinical assessment (>80%) and standard coagulation assays (74.6%) are the most frequently used strategies for early detection and monitoring of bleeding trauma patients with coagulopathy. Only 30% of the respondents declared to use extended coagulation assays to better characterise the bleeding and coagulopathy prompted by more individualised treatment concepts. Most trauma centres (69%) have implemented local protocols based on international and national guidelines using conventional blood products, e.g. packed red blood cell concentrates (93.3%), fresh frozen plasma concentrates (93.3%) and platelet concentrates (83%), and antifibrinolytics (100%). 89% considered the continuous intake of anticoagulants including "new oral anticoagulants" and platelet inhibitors as an increasing threat to bleeding trauma patients. CONCLUSIONS This study confirms differences in infrastructure, logistics and clinical practice for the detection and management of trauma-haemorrhage and trauma-associated coagulopathy amongst international centres. Ongoing work will focus on geographical differences.
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Affiliation(s)
- A Driessen
- Department of Orthopaedic Surgery, Traumatology and Sports Traumatology, Cologne-Merheim Medical Centre (CMMC), Witten/Herdecke University (Campus Cologne-Merheim), Ostmerheimerstr 200, 51109, Cologne, Germany,
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Yang JC, Sun Y, Xu CX, Dang QL, Li L, Xu YG, Song YJ, Yan H. Application status of blood constituents during massive blood transfusion in some regions of China. Int J Clin Exp Med 2014; 7:1775-1780. [PMID: 25126179 PMCID: PMC4132143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2014] [Accepted: 07/01/2014] [Indexed: 06/03/2023]
Abstract
OBJECTIVE This study aims to learn about the current situation of surgical massive blood transfusion in China's Class III general hospitals, which could provide the basis for the formulation of guidelines on massive blood transfusion. METHODS A multicenter retrospective research on the application status of blood constituents during massive blood transfusion was conducted and a comparative analysis on the distribution of the population infused with other blood constituents and the transfusion volume at different periods of time when red blood cells are infused in different units within 24 hours as well as on the blood applied for both the death group and survival group was made in this study. RESULTS In China, during massive blood transfusion the ratio of the dosage of fresh frozen plasma to the dosage of red blood cell suspension reached 1:1-2, while the dosage of platelet and cryocepitate appeared to be very small. CONCLUSION During massive blood transfusion, clinicians in 20 Chinese hospitals paid more attention to the infusion of fresh frozen plasma while making the infusion of red blood cells. However, they paid little attention to the supplement of platelet and cryocepitate.
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Affiliation(s)
- Jiang-Cun Yang
- Department of Transfusion Medicine, The Third Affiliated Hospital of Medical College of Xi’an Jiaotong UniversityXi’an, China
| | - Yang Sun
- Department of Transfusion Medicine, The Third Affiliated Hospital of Medical College of Xi’an Jiaotong UniversityXi’an, China
| | - Cui-Xiang Xu
- Department of Shaanxi Provincial Center for Clinical Laboratory, The Third Affiliated Hospital of Medical College of Xi’an Jiaotong UniversityXi’an, China
| | - Qian-Li Dang
- Department of Dermatology, The Third Affiliated Hospital of Medical College of Xi’an Jiaotong UniversityXi’an, China
| | - Ling Li
- Department of Laboratory, The Third Affiliated Hospital of Medical College of Xi’an Jiaotong UniversityXi’an, China
| | - Yong-Gang Xu
- Department of Urology, The Third Affiliated Hospital of Medical College of Xi’an Jiaotong UniversityXi’an, China
| | - Yao-Jun Song
- Department of Transfusion Medicine, The Third Affiliated Hospital of Medical College of Xi’an Jiaotong UniversityXi’an, China
| | - Hong Yan
- Department of Epidemiology and Health Statistics, Medical College of Xi’an Jiaotong UniversityXi’an, China
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Abstract
Trauma is a leading cause of death and disability. Hemorrhage is the major mechanism responsible for death during the first 24 hours following trauma. One quarter of severely injured patients present in the emergency room with acute coagulopathy of trauma and shock (ACOT). The drivers of ACOT are tissue hypoperfusion, inflammation, and activation of the neurohumoral system. ACOT is a result of protein C activation with cleavage of activated factor VIII and V and inhibition of plasminogen activator inhibitor-1 (PAI-1). The resuscitation-associated coagulopathy (RAC) is secondary to a combination of acidosis, hypothermia and dilution from intravenous blood and fluid therapy. RAC may further aggravate acidosis and hypoxia resulting in a vicious cycle. This review focuses on the biology of the trauma-associated coagulopathy, and reviews current therapeutic strategies.
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Affiliation(s)
- Pierre Noel
- Division of Hematology, Mayo College of Medicine, Phoenix, AZ 85054, USA.
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Identifying the bleeding trauma patient: predictive factors for massive transfusion in an Australasian trauma population. J Trauma Acute Care Surg 2013; 75:359-64. [PMID: 24089108 DOI: 10.1097/ta.0b013e31829e2248] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Military and civilian data would suggest that hemostatic resuscitation results in improved outcomes for exsanguinating patients. However, identification of those patients who are at risk of significant hemorrhage is not clearly defined. We attempted to identify factors that would predict the need for massive transfusion (MT) in an Australasian trauma population, by comparing those trauma patients who did receive massive transfusion with those who did not. METHODS Between 1985 and 2010, 1,686 trauma patients receiving at least 1 U of packed red blood cells were identified from our prospectively maintained trauma registry. Demographic, physiologic, laboratory, injury, and outcome variables were reviewed. Univariate analysis determined significant factors between those who received MT and those who did not. A predictive multivariate logistic regression model with backward conditional stepwise elimination was used for MT risk. Statistical analysis was performed using SPSS PASW. RESULTS MT patients had a higher pulse rate, lower Glasgow Coma Scale (GCS) score, lower systolic blood pressure, lower hemoglobin level, higher Injury Severity Score (ISS), higher international normalized ratio (INR), and longer stay. Initial logistic regression identified base deficit (BD), INR, and hemoperitoneum at laparotomy as independent predictive variables. After assigning cutoff points of BD being greater than 5 and an INR of 1.5 or greater, a further model was created. A BD greater than 5 and either INR of 1.5 or greater or hemoperitoneum was associated with 51 times increase in MT risk (odds ratio, 51.6; 95% confidence interval, 24.9-95.8). The area under the receiver operating characteristic curve for the model was 0.859. CONCLUSION From this study, a combination of BD, INR, and hemoperitoneum has demonstrated good predictability for MT. This tool may assist in the determination of those patients who might benefit from hemostatic resuscitation. LEVEL OF EVIDENCE Prognostic study, level III.
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