1
|
Zadorozny EV, Lin HHS, Luther J, Wisniewski SR, Cotton BA, Fox EE, Harbrecht BG, Joseph BA, Moore EE, Ostenmayer DG, Patel MB, Schreiber MA, Tatebe LC, Todd SR, Wilson C, Gruen DS, Sperry JL, Martin-Gill C, Brown JB, Guyette FX. Prehospital Time Following Traumatic Injury Is Independently Associated With the Need for In-Hospital Blood and Early Mortality for Specific Injury Types. Air Med J 2024; 43:47-54. [PMID: 38154840 DOI: 10.1016/j.amj.2023.09.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Revised: 09/25/2023] [Accepted: 09/27/2023] [Indexed: 12/30/2023]
Abstract
OBJECTIVE Treating traumatic hemorrhage is time sensitive. Prehospital care and transport modes (eg, helicopter and ground) may influence in-hospital events. We hypothesized that prehospital time (on-scene time [OST] and total prehospital time [TPT]) and transport mode are associated with same-day transfusion and mortality. Furthermore, we sought to identify regions of anatomic injury that modify the relationship between prehospital time and outcomes in strata corresponding to transport types. METHODS We obtained prehospital, in-hospital, and trauma registry data from an 8-center cohort of adult nonburn trauma patients from 2017 to 2022 directly transported from the scene to the hospital and having an Injury Severity Score (ISS) > 9 for the Task Order 1 project of the Linking Investigators in Trauma and Emergency Services research network. We excluded patients missing prehospital times, patients < 18 years of age, patients from interfacility transfers, and recipients of prehospital blood. Our same-day outcomes were in-hospital transfusions within 4 hours and 24-hour mortality. Each outcome was adjusted using multivariable logistic regression for covariates of prehospital phases (OST and TPT), mode of transport (helicopter and ground), age, sex, ISS, Glasgow Coma Scale motor subscale score < 6, and field hypotension (systolic blood pressure < 90 mm Hg). We evaluated the association of prehospital time on outcomes for scene missions by transport mode across severe injury patterns defined by Abbreviated Injury Scale > 2 body regions. RESULTS Of 78,198 subjects, 34,504 were eligible for the study with a mean age of 47.6 ± 20.3 years, ISS of 18 ± 11, OST of 15.9 ± 9.5 minutes, and TPT of 48.7 ± 20.3 minutes. Adjusted for injury severity and demographic factors, transport type significantly modified the relationship between prehospital time and outcomes. The association of OST and TPT with the odds of 4-hour transfusion was absent for the ground emergency medical services (GEMS) cohort and present for the helicopter emergency medical services (HEMS) ambulance cohort, whereas these times were associated with decreased 24-hour mortality for both transport types. When stratifying by injury to most anatomic regions, OST and TPT were associated with a decreased need for 4-hour transfusions in the GEMS cohort. However, OST was associated with increased early transfusion only among patients with severe injuries of the thorax, and this association persisted after adjusting additionally for injury type (odds ratio [OR] = 1.03; 95% confidence interval [CI], 1.00-1.05; P = .02). The presence of polytrauma supported an association between prehospital time and decreased 24-hour mortality for the GEMS cohort (OST: OR = 0.97; 95% CI, 0.95-0.99; P < .01; TPT: OR = 0.99; 95% CI, 0.98-0.99; P = .02), whereas no injuries showed significant association of helicopter prehospital time on mortality after adjustment. CONCLUSION We determined that transport type affects the relationship between prehospital time and hospital outcomes (4-hour transfusion: positive relationship for HEMS and negative for GEMS, 24-hour mortality: negative for both transport types). Furthermore, we identified regions of anatomic injury that modify the relationship between prehospital time and outcomes in strata corresponding to transport types. Of these regions, most notable were severe isolated injuries to the thorax that supported a positive relationship between HEMS OST and 4-hour transfusions and polytrauma that showed a negative relationship between GEMS OST or TPT and 24-hour mortality after adjustment.
Collapse
Affiliation(s)
- Eva V Zadorozny
- Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA
| | - Hsing-Hua S Lin
- Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA
| | - James Luther
- Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA
| | | | - Brian A Cotton
- Department of Surgery, University of Houston School of Medicine, Houston, TX
| | - Erin E Fox
- Department of Surgery, University of Houston School of Medicine, Houston, TX
| | - Brian G Harbrecht
- Department of Surgery, University of Louisville School of Medicine, Louisville, KY
| | - Bellal A Joseph
- Department of Surgery, University of Arizona Tucson College of Medicine, Tucson, AZ
| | - Ernest E Moore
- Department of General Surgery, University of Colorado Denver Health, Denver, CO
| | - Daniel G Ostenmayer
- Department of Emergency Medicine, University of Houston School of Medicine, Houston, TX
| | - Mayur B Patel
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN
| | | | - Leah C Tatebe
- Department of General/Trauma Surgery, University of Texas Southwestern Medical School, Dallas, TX
| | - Samual R Todd
- Department of Trauma Surgery, Grady Memorial Hospital, Atlanta, GA
| | - Chad Wilson
- Department of Surgery, Baylor College of Medicine, Houston, TX
| | | | - Jason L Sperry
- Department of General/Trauma Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Christian Martin-Gill
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Joshua B Brown
- Department of General/Trauma Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Francis X Guyette
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA.
| |
Collapse
|
2
|
Morgan KM, Abou-Khalil E, Strotmeyer S, Richardson WM, Gaines BA, Leeper CM. Association of Prehospital Transfusion With Mortality in Pediatric Trauma. JAMA Pediatr 2023; 177:693-699. [PMID: 37213096 PMCID: PMC10203962 DOI: 10.1001/jamapediatrics.2023.1291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Accepted: 03/01/2023] [Indexed: 05/23/2023]
Abstract
Importance Optimal hemostatic resuscitation in pediatric trauma is not well defined. Objective To assess the association of prehospital blood transfusion (PHT) with outcomes in injured children. Design, Setting, and Participants This retrospective cohort study of the Pennsylvania Trauma Systems Foundation database included children aged 0 to 17 years old who received a PHT or emergency department blood transfusion (EDT) from January 2009 and December 2019. Interfacility transfers and isolated burn mechanism were excluded. Analysis took place between November 2022 and January 2023. Exposure Receipt of a blood product transfusion in the prehospital setting compared with the emergency department. Main Outcomes and Measures The primary outcome was 24-hour mortality. A 3:1 propensity score match was developed balancing for age, injury mechanism, shock index, and prehospital Glasgow Comma Scale score. A mixed-effects logistic regression was performed in the matched cohort further accounting for patient sex, Injury Severity Score, insurance status, and potential center-level heterogeneity. Secondary outcomes included in-hospital mortality and complications. Results Of 559 children included, 70 (13%) received prehospital transfusions. In the unmatched cohort, the PHT and EDT groups had comparable age (median [IQR], 47 [9-16] vs 14 [9-17] years), sex (46 [66%] vs 337 [69%] were male), and insurance status (42 [60%] vs 245 [50%]). The PHT group had higher rates of shock (39 [55%] vs 204 [42%]) and blunt trauma mechanism (57 [81%] vs 277 [57%]) and lower median (IQR) Injury Severity Score (14 [5-29] vs 25 [16-36]). Propensity matching resulted in a weighted cohort of 207 children, including 68 of 70 recipients of PHT, and produced well-balanced groups. Both 24-hour (11 [16%] vs 38 [27%]) and in-hospital mortality (14 [21%] vs 44 [32%]) were lower in the PHT cohort compared with the EDT cohort, respectively; there was no difference in in-hospital complications. Mixed-effects logistic regression in the postmatched group adjusting for the confounders listed above found PHT was associated with a significant reduction in 24-hour (adjusted odds ratio, 0.46; 95% CI, 0.23-0.91) and in-hospital mortality (adjusted odds ratio, 0.51; 95% CI, 0.27-0.97) compared with EDT. The number needed to transfuse in the prehospital setting to save 1 child's life was 5 (95% CI, 3-10). Conclusions and Relevance In this study, prehospital transfusion was associated with lower rates of mortality compared with transfusion on arrival to the emergency department, suggesting bleeding pediatric patients may benefit from early hemostatic resuscitation. Further prospective studies are warranted. Although the logistics of prehospital blood product programs are complex, strategies to shift hemostatic resuscitation toward the immediate postinjury period should be pursued.
Collapse
|
3
|
Prehospital Hemorrhage Control and Treatment by Clinicians: A Joint Position Statement. Ann Emerg Med 2023; 82:e1-e8. [PMID: 37349075 DOI: 10.1016/j.annemergmed.2023.03.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 03/10/2023] [Indexed: 06/24/2023]
|
4
|
Deeb AP, Guyette FX, Daley BJ, Miller RS, Harbrecht BG, Claridge JA, Phelan HA, Eastridge BJ, Joseph B, Nirula R, Vercruysse GA, Sperry JL, Brown JB. Time to early resuscitative intervention association with mortality in trauma patients at risk for hemorrhage. J Trauma Acute Care Surg 2023; 94:504-512. [PMID: 36728324 PMCID: PMC10038862 DOI: 10.1097/ta.0000000000003820] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Hemorrhage is the leading cause of preventable death after injury. Others have shown that delays in massive transfusion cooler arrival increase mortality, while prehospital blood product resuscitation can reduce mortality. Our objective was to evaluate if time to resuscitation initiation impacts mortality. METHODS We combined data from the Prehospital Air Medical Plasma (PAMPer) trial in which patients received prehospital plasma or standard care and the Study of Tranexamic Acid during Air and ground Medical Prehospital transport (STAAMP) trial in which patients received prehospital tranexamic acid or placebo. We evaluated the time to early resuscitative intervention (TERI) as time from emergency medical services arrival to packed red blood cells, plasma, or tranexamic acid initiation in the field or within 90 minutes of trauma center arrival. For patients not receiving an early resuscitative intervention, the TERI was calculated based on trauma center arrival as earliest opportunity to receive a resuscitative intervention and were propensity matched to those that did to account for selection bias. Mixed-effects logistic regression assessed the association of 30-day and 24-hour mortality with TERI adjusting for confounders. We also evaluated a subgroup of only patients receiving an early resuscitative intervention as defined above. RESULTS Among the 1,504 propensity-matched patients, every 1-minute delay in TERI was associated with 2% increase in the odds of 30-day mortality (adjusted odds ratio [aOR], 1.020; 95% confidence interval [CI], 1.006-1.033; p < 0.01) and 1.5% increase in odds of 24-hour mortality (aOR, 1.015; 95% CI, 1.001-1.029; p = 0.03). Among the 799 patients receiving an early resuscitative intervention, every 1-minute increase in TERI was associated with a 2% increase in the odds of 30-day mortality (aOR, 1.021; 95% CI, 1.005-1.038; p = 0.01) and 24-hour mortality (aOR, 1.023; 95% CI, 1.005-1.042; p = 0.01). CONCLUSION Time to early resuscitative intervention is associated with morality in trauma patients with hemorrhagic shock. Bleeding patients need resuscitation initiated early, whether at the trauma center in systems with short prehospital times or in the field when prehospital time is prolonged. LEVEL OF EVIDENCE Therapeutic/Care Management; Level III.
Collapse
Affiliation(s)
- Andrew-Paul Deeb
- From the Division of Trauma and General Surgery, Department of Surgery (A.-P.D., J.B.B.), and Department of Emergency Medicine (F.X.G.), University of Pittsburgh, Pittsburgh, Pennsylvania; Department of Surgery (B.J.D.), University of Tennessee Health Science Center, Knoxville, Tennessee; Department of Surgery (R.S.M.), John Peter Smith Health Network, Fort Worth, Texas; Department of Surgery (B.G.H.), University of Louisville, Louisville, Kentucky;Department of Surgery (J.A.C.), MetroHealth Medical Center/Case Western Reserve University, Cleveland, Ohio; Department of Surgery (H.A.P.), Louisiana State University Health Sciences Center-New Orleans, New Orleans, Louisiana; Department of Surgery (B.J.E.), University of Texas Health San Antonio, San Antonio, Texas; Department of Surgery (B.J., G.A.V.), University of Arizona, Tucson, Arizona; Department of Surgery (R.N.), University of Utah, Salt Lake City, Utah; Division of Trauma and General Surgery, Department of Surgery (J.L.S.), University of Pittsburgh, Pittsburgh, Pennsylvania
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
5
|
Berry C, Gallagher JM, Goodloe JM, Dorlac WC, Dodd J, Fischer PE. Prehospital Hemorrhage Control and Treatment by Clinicians: A Joint Position Statement. PREHOSP EMERG CARE 2023:1-15. [PMID: 36961935 DOI: 10.1080/10903127.2023.2195487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/26/2023]
Affiliation(s)
- Cherisse Berry
- Department of Surgery, New York University Grossman School of Medicine, New York, NY
| | | | - Jeffrey M Goodloe
- Department of Emergency Medicine, University of Oklahoma Health Sciences Center, Tulsa, OK
| | - Warren C Dorlac
- Department of Surgery, University of Colorado Health Loveland, Loveland, CO
| | - Jimm Dodd
- Stop the Bleed, American College of Surgeons, Chicago, IL
| | - Peter E Fischer
- Department of Surgery, University of Tennessee Health Science Center, Memphis, TN
| |
Collapse
|
6
|
Resuscitative practices and the use of low-titer group O whole blood in pediatric trauma. J Trauma Acute Care Surg 2023; 94:S29-S35. [PMID: 36156051 DOI: 10.1097/ta.0000000000003801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
ABSTRACT Increasing rates of penetrating trauma in the United States makes rapid identification of hemorrhagic shock, coagulopathy, and early initiation of balanced resuscitation in injured children of critical importance. Hemorrhagic shock begins early after injury and can be challenging to identify in children, as hypotension is a late sign that a child is on the verge of circulatory collapse and should be aggressively resuscitated. Recent data support shifting away from crystalloid and toward early resuscitation with blood products because of worse coagulopathy and clinical outcomes in injured patients resuscitated with crystalloid. Multicenter studies have found improved survival in injured children who receive balanced resuscitation with higher fresh frozen plasma: red blood cell ratios. Whole blood is an efficient way to achieve balanced resuscitation in critically injured children with limited intravenous access and decreased exposure to multiple donors. Administration of cold-stored, low-titer O-negative whole blood (LTOWB) appears to be safe in adults and children and may be associated with improved survival in children with life-threatening hemorrhage. Many pediatric centers use RhD-negative LTOWB for all female children because of the risk of hemolytic disease of the fetus and newborn (0-6%); however. there is a scarcity of LTOWB compared with the demand. Low risks of hemolytic disease of the fetus and newborn affecting a future pregnancy must be weighed against high mortality rates in delayed blood product administration in children in hemorrhagic shock. Survey studies involving key stakeholder's opinions on pediatric blood transfusion practices are underway. Existing pediatric-specific literature on trauma resuscitation is often limited and underpowered; multicenter prospective studies are urgently needed to define optimal resuscitation products and practices in injured children in an era of increasing penetrating trauma.
Collapse
|
7
|
Braverman MA, Smith AA, Ciaraglia AV, Radowsky JS, Schauer SG, Sams VG, Greebon LJ, Shiels MD, Jonas RB, Ngamsuntikul S, Waltman E, Epley E, Rose T, Bynum JA, Cap AP, Eastridge BJ, Stewart RM, Jenkins DH, Nicholson SE. The regional whole blood program in San Antonio, TX: A 3-year update on prehospital and in-hospital transfusion practices for traumatic and non-traumatic hemorrhage. Transfusion 2022; 62 Suppl 1:S80-S89. [PMID: 35748675 DOI: 10.1111/trf.16964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Revised: 05/16/2022] [Accepted: 05/17/2022] [Indexed: 11/30/2022]
Abstract
Low titer type O Rh-D + whole blood (LTO + WB) has become a first-line resuscitation medium for hemorrhagic shock in many centers around the World. Showing early effectiveness on the battlefield, LTO + WB is used in both the pre-hospital and in-hospital settings for traumatic and non-traumatic hemorrhage resuscitation. Starting in 2018, the San Antonio Whole Blood Collaborative has worked to provide LTO + WB across Southwest Texas, initially in the form of remote damage control resuscitation followed by in-hospital trauma resuscitation. This program has since expanded to include pediatric trauma resuscitation, obstetric hemorrhage, females of childbearing potential, and non-traumatic hemorrhage. The objective of this manuscript is to provide a three-year update on the successes and expansion of this system and outline resuscitation challenges in special populations.
Collapse
Affiliation(s)
| | - Allison A Smith
- Department of Surgery, UT Health San Antonio, San Antonio, Texas, USA
| | | | - Jason S Radowsky
- Department of Trauma and Acute Care Surgery, Brooke Army Medical Center, JBSA Fort Sam Houston, San Antonio, Texas, USA
| | - Steven G Schauer
- Department of Emergency Medicine, Brooke Army Medical Center, JBSA Fort Sam Houston, San Antonio, Texas, USA.,United States Army Institute of Surgical Research, JBSA Fort Sam Houston, San Antonio, Texas, USA
| | - Valerie G Sams
- Department of Trauma and Acute Care Surgery, Brooke Army Medical Center, JBSA Fort Sam Houston, San Antonio, Texas, USA
| | - Leslie J Greebon
- Department of Pathology, UT Health San Antonio, San Antonio, Texas, USA
| | | | | | | | | | - Eric Epley
- Southwest Texas Regional Advisory Council, San Antonio, Texas, USA
| | - Tracee Rose
- Southwest Texas Regional Advisory Council, San Antonio, Texas, USA
| | - James A Bynum
- United States Army Institute of Surgical Research, JBSA Fort Sam Houston, San Antonio, Texas, USA
| | - Andre P Cap
- United States Army Institute of Surgical Research, JBSA Fort Sam Houston, San Antonio, Texas, USA
| | - Brian J Eastridge
- Department of Surgery, UT Health San Antonio, San Antonio, Texas, USA
| | - Ronald M Stewart
- Department of Surgery, UT Health San Antonio, San Antonio, Texas, USA
| | - Donald H Jenkins
- Department of Surgery, UT Health San Antonio, San Antonio, Texas, USA
| | | | | |
Collapse
|
8
|
Del Junco DJ, Neal MD, Shackelford SA, Spinella PC, Guyette FX, Sperry JL, Lewis RJ, Yadav K. An adaptive platform trial for evaluating treatments in patients with life-threatening hemorrhage from traumatic injuries: Planning and execution. Transfusion 2022; 62 Suppl 1:S242-S254. [PMID: 35748672 DOI: 10.1111/trf.16982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 04/27/2022] [Accepted: 04/27/2022] [Indexed: 11/28/2022]
Affiliation(s)
| | - Matthew D Neal
- Department of Surgery and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | | | - Philip C Spinella
- Department of Surgery and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Francis X Guyette
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Jason L Sperry
- Department of Surgery and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Roger J Lewis
- Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, California, USA.,Department of Emergency Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California, USA.,Statistics and Software, Berry Consultants, LLC, Austin, Texas, USA
| | - Kabir Yadav
- Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, California, USA.,Department of Emergency Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| |
Collapse
|
9
|
Himmler A, Galarza Armijos ME, Naranjo JR, Patiño SGP, Sarmiento Altamirano D, Lazo NF, Pino Andrade R, Aguilar HS, Fernández de Córdova L, Augurto CC, Raykar N, Puyana JC, Salamea JC. Is the whole greater than the sum of its parts? The implementation and outcomes of a whole blood program in Ecuador. Trauma Surg Acute Care Open 2021; 6:e000758. [PMID: 34869909 PMCID: PMC8603278 DOI: 10.1136/tsaco-2021-000758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Accepted: 08/21/2021] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Hemorrhagic shock is a major cause of mortality in low-income and middle-income countries (LMICs). Many institutions in LMICs lack the resources to adequately prescribe balanced resuscitation. This study aims to describe the implementation of a whole blood (WB) program in Latin America and to discuss the outcomes of the patients who received WB. METHODS We conducted a retrospective review of patients resuscitated with WB from 2013 to 2019. Five units of O+ WB were made available on a consistent basis for patients presenting in hemorrhagic shock. Variables collected included gender, age, service treating the patient, units of WB administered, units of components administered, admission vital signs, admission hemoglobin, shock index, Revised Trauma Score in trauma patients, intraoperative crystalloid (lactated Ringer's or normal saline) and colloid (5% human albumin) administration, symptoms of transfusion reaction, length of stay, and in-hospital mortality. RESULTS The sample includes a total of 101 patients, 57 of which were trauma and acute care surgery patients and 44 of which were obstetrics and gynecology patients. No patients developed symptoms consistent with a transfusion reaction. The average shock index was 1.16 (±0.55). On average, patients received 1.66 (±0.80) units of WB. Overall mortality was 13.86% (14 of 101) in the first 24 hours and 5.94% (6 of 101) after 24 hours. DISCUSSION Implementing a WB protocol is achievable in LMICs. WB allows for more efficient delivery of hemostatic resuscitation and is ideal for resource-restrained settings. To our knowledge, this is the first description of a WB program implemented in a civilian hospital in Latin America. LEVEL OF EVIDENCE Level IV.
Collapse
Affiliation(s)
- Amber Himmler
- Department of Surgery, MedStar Georgetown University Hospital, Washington DC, District of Columbia, USA
| | - Monica Eulalia Galarza Armijos
- Department of Surgery, Hospital Vicente Corral Moscoso Cuenca, Cuenca, Ecuador
- College of Medicine, Universidad de Cuenca, Cuenca, Ecuador
| | - Jeovanni Reinoso Naranjo
- Department of Surgery, Hospital Vicente Corral Moscoso Cuenca, Cuenca, Ecuador
- College of Medicine, Universidad de Cuenca, Cuenca, Ecuador
| | | | - Doris Sarmiento Altamirano
- College of Medicine, University of Azuay, Cuenca, Ecuador
- Department of Surgery, Hospital Jose Carrasco Arteaga, Cuenca, Ecuador
| | - Nube Flores Lazo
- Department of Surgery, Hospital Vicente Corral Moscoso Cuenca, Cuenca, Ecuador
- College of Medicine, Universidad de Cuenca, Cuenca, Ecuador
| | - Raul Pino Andrade
- Department of Surgery, Hospital Vicente Corral Moscoso Cuenca, Cuenca, Ecuador
- College of Medicine, Universidad de Cuenca, Cuenca, Ecuador
| | - Hernán Sacoto Aguilar
- Department of Surgery, Hospital Vicente Corral Moscoso Cuenca, Cuenca, Ecuador
- College of Medicine, Universidad de Azuay, Cuenca, Ecuador
| | - Lenin Fernández de Córdova
- Department of Surgery, Hospital Vicente Corral Moscoso Cuenca, Cuenca, Ecuador
- College of Medicine, Universidad Católica de Cuenca, Cuenca, Ecuador
| | - Cecibel Cevallos Augurto
- Department of Surgery, Hospital Vicente Corral Moscoso Cuenca, Cuenca, Ecuador
- College of Medicine, Universidad de Cuenca, Cuenca, Ecuador
| | - Nakul Raykar
- Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Juan Carlos Puyana
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Juan Carlos Salamea
- Department of Surgery, Hospital Vicente Corral Moscoso Cuenca, Cuenca, Ecuador
- College of Medicine, Universidad de Azuay, Cuenca, Ecuador
| |
Collapse
|
10
|
Canton SP, Lutfi W, Daley BJ, Miller RS, Harbrecht BG, Claridge JA, Phelan HA, Guyette FX, Sperry JL, Brown JB. Lactate as a mediator of prehospital plasma mortality reduction in hemorrhagic shock. J Trauma Acute Care Surg 2021; 91:186-191. [PMID: 33797485 DOI: 10.1097/ta.0000000000003173] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Prehospital plasma transfusion in trauma reduces mortality. However, the underlying mechanism remains unclear. Reduction in shock severity may play a role. Lactate correlates with physiologic shock severity and mortality after injury. Our objective was to determine if prehospital plasma reduces lactate and if this contributes to the mortality benefit of plasma. METHODS Patients in the Prehospital Air Medical Plasma trial in the upper quartile of injury severity (Injury Severity Score, >30) were included to capture severe shock. Trial patients were randomized to prehospital plasma or standard care resuscitation (crystalloid ± packed red blood cells). Regression determined the associations between admission lactate, 30-day mortality, and plasma while adjusting for demographics, prehospital crystalloid, time, mechanism, and injury characteristics. Causal mediation analysis determined what proportion of the effect of plasma on mortality is mediated by lactate reduction. RESULTS A total of 125 patients were included. The plasma group had a lower adjusted admission lactate than standard of care group (coefficient, -1.64; 95% confidence interval [CI], -2.96 to -0.31; p = 0.02). Plasma was associated with lower odds of 30-day mortality (odds ratio [OR], 0.27; 95% CI, 0.08-0.90; p = 0.03). When adding lactate to this model, the effect of plasma on 30-day mortality was no longer significant (OR, 0.36; 95% CI, 0.07-1.88; p = 0.23), while lactate was associated with mortality (OR, 1.74 per 1 mmol/L increase; 95% CI, 1.10-2.73; p = 0.01). Causal mediation demonstrated 35.1% of the total effect of plasma on 30-day mortality was mediated by the reduction in lactate among plasma patients. CONCLUSION Prehospital plasma is associated with reduced 30-day mortality and lactate in severely injured patients. More than one third of the effect of plasma on mortality is mediated by a reduction in lactate. Thus, reducing the severity of hemorrhagic shock appears to be one mechanism of prehospital plasma benefit. Further study should elucidate other mechanisms and if a dose response exists. LEVEL OF EVIDENCE Therapeutic, level II.
Collapse
Affiliation(s)
- Stephen P Canton
- From the Division of Trauma and General Surgery, Department of Surgery (S.P.C., J.L.S., J.B.B.), University of Pittsburgh Medical Center, Pittsburgh; Department of Surgery (W.L.), University of Pennsylvania, Philadelphia, Pennsylvania; Department of Surgery (B.J.D.), University of Tennessee Health Science Center, Knoxville, Tennessee; Department of Surgery (R.S.M.), John Peter Smith Health Network, Fort Worth, Texas; Department of Surgery (B.G.H.), University of Louisville, Louisville, Kentucky; Department of Surgery (J.A.C.), MetroHealth Medical Center/Case Western Reserve University, Cleveland, Ohio; Department of Surgery (H.A.P.), Louisiana State University Health Sciences Center-New Orleans, New Orleans, Los Angeles; and Department of Emergency Medicine (F.X.G.), University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | | | | | | | | | | | | | | | | | | |
Collapse
|
11
|
Reitz KM, Gruen DS, Guyette F, Brown JB, Yazer MH, Vodovotz Y, Johanssen PI, Stensballe J, Daley B, Miller RS, Harbrecht BG, Claridge J, Phelan HA, Neal MD, Zuckerbraun BS, Sperry JL. Age of thawed plasma does not affect clinical outcomes or biomarker expression in patients receiving prehospital thawed plasma: a PAMPer secondary analysis. Trauma Surg Acute Care Open 2021; 6:e000648. [PMID: 33634214 PMCID: PMC7880105 DOI: 10.1136/tsaco-2020-000648] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 01/13/2021] [Accepted: 01/25/2021] [Indexed: 12/26/2022] Open
Abstract
Background Prehospital plasma administration during air medical transport reduces the endotheliopathy of trauma, circulating pro-inflammatory cytokines, and 30-day mortality among traumatically injured patients at risk of hemorrhagic shock. No clinical data currently exists evaluating the age of thawed plasma and its association with clinical outcomes and biomarker expression post-injury. Methods We performed a secondary analysis from the prehospital plasma administration randomized controlled trial, PAMPer. We dichotomized the age of thawed plasma creating three groups: standard-care, YOUNG (day 0-1) plasma, and OLD (day 2-5) plasma. We generated HRs and 95% CIs for mortality. Among all patients randomized to plasma, we compared predicted biomarker values at hospital admission (T0) and 24 hours later (T24) controlling for key difference between groups with a multivariable linear regression. Analyses were repeated in a severely injured subgroup. Results Two hundred and seventy-one patients were randomized to standard-care and 230 to plasma (40% YOUNG, 60% OLD). There were no clinically or statistically significant differences in demographics, injury, admission vital signs, or laboratory values including thromboelastography between YOUNG and OLD. Compared with standard-care, YOUNG (HR 0.66 (95% CI 0.41 to 1.07), p=0.09) and OLD (HR 0.64 (95% CI 0.42 to 0.96), p=0.03) plasma demonstrated reduced 30-day mortality. Among those randomized to plasma, plasma age did not affect mortality (HR 1.04 (95% CI 0.60 to 1.82), p=0.90) and/or adjusted serum markers by plasma age at T0 or T24 (p>0.05). However, among the severely injured subgroup, OLD plasma was significantly associated with increased adjusted inflammatory and decreased adjusted endothelial biomarkers at T0. Discussion Age of thawed plasma does not result in clinical outcome or biomarker expression differences in the overall PAMPer study cohort. There were biomarker expression differences in those patients with severe injury. Definitive investigation is needed to determine if the age of thawed plasma is associated with biomarker expression and outcome differences following traumatic injury. Level of evidence II.
Collapse
Affiliation(s)
- Katherine M Reitz
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Danielle S Gruen
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Frances Guyette
- Emergency Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Joshua B Brown
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Mark H Yazer
- Department of Pathology, University of Pittsburgh and the Institute for Transfusion Medicine, Pittsburgh, Pennsylvania, USA
| | - Yoram Vodovotz
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Pär I Johanssen
- Capital Region Blood Bank, Section for Transfusion Medicine, University of Copenhagen, Kobenhavn, Denmark
| | - Jakob Stensballe
- Capital Region Blood Bank, Section for Transfusion Medicine, University of Copenhagen, Kobenhavn, Denmark
| | - Brian Daley
- The University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Richard S Miller
- Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | | | | | - Herb A Phelan
- Surgery, The University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Matthew D Neal
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Brian S Zuckerbraun
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Jason L Sperry
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| |
Collapse
|
12
|
Salamea-Molina JC, Himmler AN, Valencia-Angel LI, Ordoñez CA, Parra MW, Caicedo Y, Guzmán-Rodríguez M, Orlas C, Granados M, Macia C, García A, Serna JJ, Badiel M, Puyana JC. Whole blood for blood loss: hemostatic resuscitation in damage control. Colomb Med (Cali) 2020; 51:e4044511. [PMID: 33795899 PMCID: PMC7968429 DOI: 10.25100/cm.v51i4.4511] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Revised: 11/25/2020] [Accepted: 12/18/2020] [Indexed: 12/23/2022] Open
Abstract
Hemorrhagic shock and its complications are a major cause of death among trauma patients. The management of hemorrhagic shock using a damage control resuscitation strategy has been shown to decrease mortality and improve patient outcomes. One of the components of damage control resuscitation is hemostatic resuscitation, which involves the replacement of lost blood volume with components such as packed red blood cells, fresh frozen plasma, cryoprecipitate, and platelets in a 1:1:1:1 ratio. However, this is a strategy that is not applicable in many parts of Latin America and other low-and-middle-income countries throughout the world, where there is a lack of well-equipped blood banks and an insufficient availability of blood products. To overcome these barriers, we propose the use of cold fresh whole blood for hemostatic resuscitation in exsanguinating patients. Over 6 years of experience in Ecuador has shown that resuscitation with cold fresh whole blood has similar outcomes and a similar safety profile compared to resuscitation with hemocomponents. Whole blood confers many advantages over component therapy including, but not limited to the transfusion of blood with a physiologic ratio of components, ease of transport and transfusion, less volume of anticoagulants and additives transfused to the patient, and exposure to fewer donors. Whole blood is a tool with reemerging potential that can be implemented in civilian trauma centers with optimal results and less technical demand.
Collapse
Affiliation(s)
- Juan Carlos Salamea-Molina
- Hospital Vicente Corral Moscoso, Division of Trauma and Acute Care Surgery, Cuenca, Ecuador
- Universidad del Azuay, Escuela de Medicina. Cuenca, Ecuador
| | - Amber Nicole Himmler
- Medstar Georgetown University Hospital, Department of Surgery, Washington, D.C., USA
- Washington Hospital Center. Washington, D.C., USA
| | - Laura Isabel Valencia-Angel
- Universidad Industrial de Santander, Department of Surgery, Bucaramanga, Colombia
- Hospital Manuela Beltrán, Department of Surgery, Socorro, Colombia
| | - Carlos A Ordoñez
- Fundación Valle del Lili, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia
- Universidad Icesi, Cali, Colombia
| | - Michael W Parra
- Broward General Level I Trauma Center, Department of Trauma Critical Care, Fort Lauderdale, FL - USA
| | - Yaset Caicedo
- Fundación Valle del Lili, Centro de Investigaciones Clínicas (CIC), Cali, Colombia
| | - Mónica Guzmán-Rodríguez
- Universidad de Chile, Facultad de Medicina, Instituto de Ciencias Biomédicas, Santiago de Chile, Chile
| | - Claudia Orlas
- Brigham & Women's Hospital, Department of Surgery, Center for Surgery and Public Health, Boston, USA
- Harvard Medical School & Harvard T.H., Chan School of Public Health, Boston - USA
| | | | - Carmenza Macia
- Fundación Valle del Lili, Blood Bank and Transfusion Service, Cali, Colombia
| | - Alberto García
- Fundación Valle del Lili, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia
- Universidad Icesi, Cali, Colombia
| | - José Julián Serna
- Fundación Valle del Lili, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia
- Universidad Icesi, Cali, Colombia
- Hospital Universitario del Valle, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia
| | | | | |
Collapse
|
13
|
Gruen DS, Guyette FX, Brown JB, Okonkwo DO, Puccio AM, Campwala IK, Tessmer MT, Daley BJ, Miller RS, Harbrecht BG, Claridge JA, Phelan HA, Neal MD, Zuckerbraun BS, Yazer MH, Billiar TR, Sperry JL. Association of Prehospital Plasma With Survival in Patients With Traumatic Brain Injury: A Secondary Analysis of the PAMPer Cluster Randomized Clinical Trial. JAMA Netw Open 2020; 3:e2016869. [PMID: 33057642 PMCID: PMC7563075 DOI: 10.1001/jamanetworkopen.2020.16869] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
IMPORTANCE Prehospital plasma administration improves survival in injured patients at risk for hemorrhagic shock and transported by air ambulance. Traumatic brain injury (TBI) is a leading cause of death following trauma, but few early interventions improve outcomes. OBJECTIVE To assess the association between prehospital plasma and survival in patients with TBI. DESIGN, SETTING, AND PARTICIPANTS The Prehospital Air Medical Plasma (PAMPer) trial was a pragmatic, multicenter, phase 3, cluster randomized clinical trial involving injured patients who were at risk for hemorrhagic shock during air medical transport to a trauma center. The trial was conducted at 6 US sites with 9 level-I trauma centers (comprising 27 helicopter emergency services bases). The original trial analyzed 501 patients, including 230 patients who were randomized to receive plasma and 271 randomized to standard care resuscitation. This secondary analysis of a predefined subgroup included patients with TBI. Data analysis was performed from October 2019 to February 2020. INTERVENTIONS Patients were randomized to receive standard care fluid resuscitation or 2 units of thawed plasma. MAIN OUTCOMES AND MEASURES The primary outcome was mortality at 30 days. Patients with TBI were prespecified as a subgroup for secondary analysis and for measurement of markers of brain injury. The 30-day survival benefit of prehospital plasma in subgroups with and without TBI as diagnosed by computed tomography was characterized using Kaplan-Meier survival analysis and Cox proportional hazard regression. RESULTS In total, 166 patients had TBI (median [interquartile range] age, 43.00 [25.00-59.75] years; 125 men [75.3%]). When compared with the 92 patients who received standard care, the 74 patients with TBI who received prehospital plasma had improved 30-day survival even after adjustment for multiple confounders and assessment of the degree of brain injury with clinical variables and biomarkers (hazard ratio [HR], 0.55; 95% CI, 0.33-0.94; P = .03). Receipt of prehospital plasma was associated with improved survival among patients with TBI with a prehospital Glasgow Coma Scale score of less than 8 (HR, 0.56; 95% CI, 0.35-0.91) and those with polytrauma (HR, 0.50; 95% CI, 0.28-0.89). Patients with TBI transported from the scene of injury had improved survival following prehospital plasma administration (HR, 0.45; 95% CI, 0.26-0.80; P = .005), whereas patients who were transferred from an outside hospital showed no difference in survival for the plasma intervention (HR, 1.00; 95% CI, 0.33-3.00; P = .99). CONCLUSIONS AND RELEVANCE These findings are exploratory, but they suggest that receipt of prehospital plasma is associated with improved survival in patients with computed tomography-positive TBI. The prehospital setting may be a critical period to intervene in the care of patients with TBI. Future studies are needed to confirm the clinical benefits of early plasma resuscitation following TBI and concomitant polytrauma. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT01818427.
Collapse
Affiliation(s)
- Danielle S. Gruen
- Department of Surgery and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
- Pittsburgh Trauma Research Center, Pittsburgh, Pennsylvania
| | - Francis X. Guyette
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Joshua B. Brown
- Department of Surgery and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
- Pittsburgh Trauma Research Center, Pittsburgh, Pennsylvania
| | - David O. Okonkwo
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Ava M. Puccio
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Insiyah K. Campwala
- Department of Surgery and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
- Pittsburgh Trauma Research Center, Pittsburgh, Pennsylvania
| | - Matthew T. Tessmer
- Department of Surgery and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
- Pittsburgh Trauma Research Center, Pittsburgh, Pennsylvania
| | - Brian J. Daley
- Department of Surgery, University of Tennessee Health Science Center, Knoxville
| | - Richard S. Miller
- Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | | | - Jeffrey A. Claridge
- MetroHealth Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - Herb A. Phelan
- Department of Surgery, University of Texas Southwestern, Dallas
| | - Matthew D. Neal
- Department of Surgery and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
- Pittsburgh Trauma Research Center, Pittsburgh, Pennsylvania
| | - Brian S. Zuckerbraun
- Department of Surgery and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
- Pittsburgh Trauma Research Center, Pittsburgh, Pennsylvania
| | - Mark H. Yazer
- Department of Pathology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Timothy R. Billiar
- Department of Surgery and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
- Pittsburgh Trauma Research Center, Pittsburgh, Pennsylvania
| | - Jason L. Sperry
- Department of Surgery and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
- Pittsburgh Trauma Research Center, Pittsburgh, Pennsylvania
| |
Collapse
|
14
|
Massive transfusion and the response to prehospital plasma: It is all in how you define it. J Trauma Acute Care Surg 2020; 89:43-50. [PMID: 32118820 DOI: 10.1097/ta.0000000000002639] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND A recent analysis derived from the Prehospital Air Medical Plasma trial data set demonstrated no significant independent plasma survival benefit in those who required massive transfusion (≥10 units of red cells in 24 hours). The definition of massive transfusion has evolved over time to minimize bias and predict those at highest risk of death. We sought to characterize the definition of massive transfusion, their associated mortality risks and the survival benefit associated with prehospital plasma. METHODS A secondary analysis was performed using data from a recent prehospital plasma trial. Patients transferred directly from the scene were characterized. We defined historic massive transfusion using ≥10 units red cells in 24 hours and critical administration threshold (CAT) as ≥3 units per hour in the first hour (CAT1hr) or in any of the first 4 hours (CAT4hr) from arrival. The primary outcome was 30-day mortality. Kaplan-Meier analysis and Cox hazard regression were used to characterize the survival benefit of prehospital plasma. RESULTS There were a total of 390 enrolled patients who were transferred from the scene and represent the study cohort. Overall, 126 patients were positive for the CAT1hr metric, 183 patients were positive for the CAT4hr metric and 84 patients were positive for historic massive transfusion metric. The overall study mortality rate for those patients who met each transfusion definition was 13.1%, 17.4% and 10.0%, respectively. The CAT4hr metric had the lowest potential for survival bias. Kaplan-Meier survival analysis demonstrated a prehospital plasma survival benefit in the patients who were CAT4hr positive. CONCLUSION The current analysis demonstrates the superior utility of the CAT4hr definition with optimization of survival bias while conserving mortality risk prediction. This transfusion definition was associated with a prehospital plasma survival benefit and may be the most appropriate definition of massive transfusion for pragmatic studies which focus on hemorrhagic shock. LEVEL OF EVIDENCE Epidemiologic, Level II.
Collapse
|
15
|
Accelerating availability of clinically-relevant parameter estimates from thromboelastogram point-of-care device. J Trauma Acute Care Surg 2020; 88:654-660. [PMID: 32032282 DOI: 10.1097/ta.0000000000002608] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Modeling approaches offer a novel way to detect and predict coagulopathy in trauma patients. A dynamic model, built and tested on thromboelastogram (TEG) data, was used to generate a virtual library of over 160,000 simulated RapidTEGs. The patient-specific parameters are the initial platelet count, platelet activation rate, thrombus growth rate, and lysis rate (P(0), k1, k2, and k3, respectively). METHODS Patient data from both STAAMP (n = 182 patients) and PAMPer (n = 111 patients) clinical trials were collected. A total of 873 RapidTEGs were analyzed. One hundred sixteen TEGs indicated maximum amplitude (MA) below normal and 466 TEGs indicated lysis percent above normal. Each patient's TEG response was compared against the virtual library of TEGs to determine library trajectories having the least sum-of-squared error versus the patient TEG up to each specified evaluation time ∈ (3, 4, 5, 7.5, 10, 15, 20 minutes). Using 10 nearest-neighbor trajectories, a logistic regression was performed to predict if the patient TEG indicated MA below normal (<50 mm), lysis percent 30 minutes after MA (LY30) greater than 3%, and/or blood transfusion need using the parameters from the dynamic model. RESULTS The algorithm predicts abnormal MA values using the initial 3 minutes of RapidTEG data with a median area under the curve of 0.95, and improves with more data to 0.98 by 10 minutes. Prediction of future platelet and packed red blood cell transfusion based on parameters at 4 and 5 minutes, respectively, provides equivalent predictions to the traditional TEG parameters in significantly less time. Dynamic model parameters could not predict abnormal LY30 or future fresh-frozen plasma transfusion. CONCLUSION This analysis could be incorporated into TEG software and workflow to quickly estimate if the MA would be below or above threshold value within the initial minutes following a TEG, along with an estimate of what blood products to have on hand. LEVEL OF EVIDENCE Therapeutic/Care Management: Level IV.
Collapse
|
16
|
Severity of hemorrhage and the survival benefit associated with plasma: Results from a randomized prehospital plasma trial. J Trauma Acute Care Surg 2020; 88:141-147. [PMID: 31688793 DOI: 10.1097/ta.0000000000002530] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Recent randomized clinical trial evidence demonstrated a survival benefit with the use of prehospital plasma in patients at risk of hemorrhagic shock. We sought to characterize the survival benefit associated with prehospital plasma relative to the blood transfusion volume over the initial 24 hours. We hypothesized that the beneficial effects of prehospital plasma would be most robust in those with higher severity of hemorrhage. METHODS We performed a prespecified secondary analysis using data derived from a prospective randomized prehospital plasma trial. Blood component transfusion volumes were recorded over the initial 24 hours. Massive transfusion (MT) was defined a priori as receiving ≥10 units of red cells in 24 hours. We characterized the 30-day survival benefit of prehospital plasma and the need for MT and overall 24-hour red cell transfusion volume utilizing Kaplan-Meier survival analysis and Cox proportional hazard regression. RESULTS There were 501 patients included in this analysis with 230 randomized to prehospital plasma with 104 patients requiring MT. Mortality in patients who received MT were higher compared with those that did not (MT vs. NO-MT, 42% vs. 26%, p = 0.001). Kaplan-Meier survival curves demonstrated early separation in the NO-MT subgroup (log rank p = 0.008) with no survival benefit found in the MT group (log rank p = 0.949). Cox regression analysis verified these findings. When 24-hour red cell transfusion was divided into quartiles, there was a significant independent association with 30-day survival in patients who received 4 to 7 units (hazard ratio, 0.33, 95% confidence interval, 0.14-0.80, p = 0.013). CONCLUSION The survival benefits of prehospital plasma was demonstrated only in patients with red cell requirements below the transfusion level of MT. Patients who received 4 to 7 units of red cells demonstrated the most robust independent survival benefit attributable to prehospital plasma transfusion. Prehospital plasma may be most beneficial in those patients with moderate transfusion requirements and mortality risk. LEVEL OF EVIDENCE Therapeutic, Level I.
Collapse
|
17
|
Implementation of a prehospital air medical thawed plasma program: Is it even feasible? J Trauma Acute Care Surg 2020; 87:1077-1081. [PMID: 31205211 DOI: 10.1097/ta.0000000000002406] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
BACKGROUND The Prehospital Air Medical Plasma (PAMPer) trial demonstrated a 30-day survival benefit among hypotensive trauma patients treated with prehospital plasma during air medical transport. We characterized resources, costs and feasibility of air medical prehospital plasma program implementation. METHODS We performed a secondary analysis using data derived from the recent PAMPer trial. Intervention patients received thawed plasma (5-day shelf life). Unused plasma units were recycled back to blood bank affiliates, when possible. Distribution method and capability of recycling varied across sites. We determined the status of plasma units deployed, utilized, wasted, and returned. We inventoried thawed plasma use and annualized costs for distribution and recovery. RESULTS The PAMPer trial screened 7,275 patients and 5,103 plasma units were deployed across 22 air medical bases during a 42-month period. Only 368 (7.2%) units of this total thawed plasma pool were provided to plasma randomized PAMPer patients. Of the total plasma pool, 3,716 (72.8%) units of plasma were returned to the blood bank with the potential for transfusion prior to expiration and 1,019 (20.0%) thawed plasma units were deemed wasted for this analysis. The estimated average annual cost of implementation of a thawed plasma program per air medical base at an average courier distance would be between US $24,343 and US $30,077, depending on the ability to recycle plasma and distance of courier delivery required. CONCLUSION A prehospital plasma program utilizing thawed plasma is resource intensive. Plasma waste can be minimized depending on trauma center and blood bank specific logistics. Implementation of a thawed plasma program can occur with financial cost. Products with a longer shelf life, such as liquid plasma or freeze-dried plasma, may provide a more cost-effective prehospital product relative to thawed plasma. LEVEL OF EVIDENCE Therapeutic, level III.
Collapse
|
18
|
Gruen DS, Brown JB, Guyette FX, Vodovotz Y, Johansson PI, Stensballe J, Barclay DA, Yin J, Daley BJ, Miller RS, Harbrecht BG, Claridge JA, Phelan HA, Neal MD, Zuckerbraun BS, Billiar TR, Sperry JL. Prehospital plasma is associated with distinct biomarker expression following injury. JCI Insight 2020; 5:135350. [PMID: 32229722 DOI: 10.1172/jci.insight.135350] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Accepted: 03/25/2020] [Indexed: 12/11/2022] Open
Abstract
BACKGROUNDPrehospital plasma improves survival in severely injured patients transported by air ambulance. We hypothesized that prehospital plasma would be associated with a reduction in immune imbalance and endothelial damage.METHODSWe sampled blood from 405 trauma patients enrolled in the Prehospital Air Medical Plasma (PAMPer) trial upon hospital admission (0 hours) and 24 hours post admission across 6 U.S. sites. We assayed samples for 21 inflammatory mediators and 7 markers associated with endothelial function and damage. We performed hierarchical clustering analysis (HCA) of these biomarkers of the immune response and endothelial injury. Regression analysis was used to control for differences across study and to assess any association with prehospital plasma resuscitation.RESULTSHCA distinguished two patient clusters with different injury patterns and outcomes. Patients in cluster A had greater injury severity and incidence of blunt trauma, traumatic brain injury, and mortality. Cluster A patients that received prehospital plasma showed improved 30-day survival. Prehospital plasma did not improve survival in cluster B patients. In an adjusted analysis of the most seriously injured patients, prehospital plasma was associated with an increase in adiponectin, IL-1β, IL-17A, IL-23, and IL-17E upon admission, and a reduction in syndecan-1, TM, VEGF, IL-6, IP-10, MCP-1, and TNF-α, and an increase in IL-33, IL-21, IL-23, and IL-17E 24 hours later.CONCLUSIONPrehospital plasma may ameliorate immune dysfunction and the endotheliopathy of trauma. These effects of plasma may contribute to improved survival in injured patients.TRIAL REGISTRATIONNCT01818427.FUNDINGDepartment of Defense; National Institutes of Health, U.S. Army.
Collapse
Affiliation(s)
- Danielle S Gruen
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Pittsburgh Trauma Research Center, Division of Trauma and Acute Care Surgery, Pittsburgh, Pennsylvania, USA
| | - Joshua B Brown
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Pittsburgh Trauma Research Center, Division of Trauma and Acute Care Surgery, Pittsburgh, Pennsylvania, USA
| | | | - Yoram Vodovotz
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Pittsburgh Trauma Research Center, Division of Trauma and Acute Care Surgery, Pittsburgh, Pennsylvania, USA.,Department of Computational and Systems Biology, and.,Center for Inflammation and Regeneration Modeling, McGowan Institute for Regenerative Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | | | - Jakob Stensballe
- Section for Transfusion Medicine, Capital Region Blood Bank, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.,Department of Anesthesia and Trauma Center, Centre of Head and Orthopaedics, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.,Emergency Medical Services, The Capital Region of Denmark, Denmark
| | - Derek A Barclay
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Pittsburgh Trauma Research Center, Division of Trauma and Acute Care Surgery, Pittsburgh, Pennsylvania, USA
| | - Jinling Yin
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Pittsburgh Trauma Research Center, Division of Trauma and Acute Care Surgery, Pittsburgh, Pennsylvania, USA
| | - Brian J Daley
- Department of Surgery, University of Tennessee Health Science Center, Knoxville, Tennessee, USA
| | - Richard S Miller
- Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Brian G Harbrecht
- Department of Surgery, University of Louisville, Louisville, Kentucky, USA
| | - Jeffrey A Claridge
- MetroHealth Medical Center, Case Western Reserve University, Cleveland, Ohio, USA
| | - Herb A Phelan
- Department of Surgery, University of Texas Southwestern, Dallas, Texas, USA
| | - Matthew D Neal
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Pittsburgh Trauma Research Center, Division of Trauma and Acute Care Surgery, Pittsburgh, Pennsylvania, USA
| | - Brian S Zuckerbraun
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Pittsburgh Trauma Research Center, Division of Trauma and Acute Care Surgery, Pittsburgh, Pennsylvania, USA
| | - Timothy R Billiar
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Pittsburgh Trauma Research Center, Division of Trauma and Acute Care Surgery, Pittsburgh, Pennsylvania, USA
| | - Jason L Sperry
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Pittsburgh Trauma Research Center, Division of Trauma and Acute Care Surgery, Pittsburgh, Pennsylvania, USA.,Department of Critical Care, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | | |
Collapse
|
19
|
Pusateri AE, Moore EE, Moore HB, Le TD, Guyette FX, Chapman MP, Sauaia A, Ghasabyan A, Chandler J, McVaney K, Brown JB, Daley BJ, Miller RS, Harbrecht BG, Claridge JA, Phelan HA, Witham WR, Putnam AT, Sperry JL. Association of Prehospital Plasma Transfusion With Survival in Trauma Patients With Hemorrhagic Shock When Transport Times Are Longer Than 20 Minutes: A Post Hoc Analysis of the PAMPer and COMBAT Clinical Trials. JAMA Surg 2020; 155:e195085. [PMID: 31851290 DOI: 10.1001/jamasurg.2019.5085] [Citation(s) in RCA: 133] [Impact Index Per Article: 33.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Importance Both military and civilian clinical practice guidelines include early plasma transfusion to achieve a plasma to red cell ratio approaching 1:1 to 1:2. However, it was not known how early plasma should be given for optimal benefit. Two recent randomized clinical trials were published, with apparently contradictory results. The Prehospital Air Medical Plasma (PAMPer) clinical trial showed a nearly 30% reduction in mortality with plasma transfusion in the prehospital environment, while the Control of Major Bleeding After Trauma (COMBAT) clinical trial showed no survival improvement. Objective To facilitate a post hoc combined analysis of the COMBAT and PAMPer trials to examine questions that could not be answered by either clinical trial alone. We hypothesized that prehospital transport time influenced the effects of prehospital plasma on 28-day mortality. Design, Setting, and Participants A total of 626 patients in the 2 clinical trials were included. Patients with trauma and hemorrhagic shock were randomly assigned to receive either standard care or 2 U of thawed plasma followed by standard care in the prehospital environment. Data analysis was performed between September 2018 and January 2019. Interventions Prehospital transfusion of 2 U of plasma compared with crystalloid-based resuscitation. Main Outcomes and Measures The main outcome was 28-day mortality. Results In this post hoc analysis of 626 patients (467 men [74.6%] and 159 women [25.4%]; median [interquartile range] age, 42 [27-57] years) who had trauma with hemorrhagic shock, a Cox regression analysis showed a significant overall survival benefit for plasma (hazard ratio [HR], 0.65; 95% CI, 0.47-0.90; P = .01) after adjustment for injury severity, age, and clinical trial cohort (COMBAT or PAMPer). A significant association with prehospital transport time was detected (from arrival on scene to arrival at the trauma center). Increased mortality was observed in patients in the standard care group when prehospital transport was longer than 20 minutes (HR, 2.12; 95% CI, 1.05-4.30; P = .04), while increased mortality was not observed in patients in the prehospital plasma group (HR, 0.78; 95% CI, 0.40-1.51; P = .46). No serious adverse events were associated with prehospital plasma transfusion. Conclusions and Relevance These data suggest that prehospital plasma is associated with a survival benefit when transport times are longer than 20 minutes and that the benefit-risk ratio is favorable for use of prehospital plasma. Trial Registration ClinicalTrials.gov identifiers: NCT01838863 (COMBAT) and NCT01818427 (PAMPer).
Collapse
Affiliation(s)
- Anthony E Pusateri
- US Army Institute of Surgical Research, JBSA-Fort Sam Houston, San Antonio, Texas
| | - Ernest E Moore
- Department of Surgery, School of Medicine, University of Colorado Denver, Aurora
| | - Hunter B Moore
- Department of Surgery, School of Medicine, University of Colorado Denver, Aurora
| | - Tuan D Le
- US Army Institute of Surgical Research, JBSA-Fort Sam Houston, San Antonio, Texas
| | - Francis X Guyette
- Division of Emergency Medicine, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Michael P Chapman
- Department of Radiology, School of Medicine, University of Colorado Denver, Aurora
| | - Angela Sauaia
- Department of Health Systems, Management, and Policy, School of Public Health, University of Colorado Denver, Aurora
| | - Arsen Ghasabyan
- Department of Surgery, School of Medicine, University of Colorado Denver, Aurora
| | - James Chandler
- Department of Surgery, School of Medicine, University of Colorado Denver, Aurora
| | - Kevin McVaney
- Department of Emergency Medicine, School of Medicine, University of Colorado Denver, Aurora
| | - Joshua B Brown
- Division of Trauma and General Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Brian J Daley
- Department of Surgery, University of Tennessee Health Science Center, Knoxville
| | - Richard S Miller
- Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Brian G Harbrecht
- Department of Surgery, University of Louisville, Louisville, Kentucky
| | - Jeffrey A Claridge
- MetroHealth Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - Herb A Phelan
- Department of Surgery, Parkland Memorial Hospital, University of Texas Southwestern, Dallas
| | | | - A Tyler Putnam
- Altoona Hospital, University of Pittsburgh Medical Center, Altoona, Pennsylvania
| | - Jason L Sperry
- Division of Trauma and General Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| |
Collapse
|
20
|
Jost D, Lemoine S, Lemoine F, Lanoe V, Maurin O, Derkenne C, Franchin Frattini M, Delacote M, Seguineau E, Godefroy A, Hervault N, Delhaye L, Pouliquen N, Louis-Delauriere E, Trichereau J, Roquet F, Salomé M, Verret C, Bihannic R, Jouffroy R, Frattini B, Hong Tuan Ha V, Dang-Minh P, Travers S, Bignand M, Martinaud C, Garrabe E, Ausset S, Prunet B, Sailliol A, Tourtier JP. French lyophilized plasma versus normal saline for post-traumatic coagulopathy prevention and correction: PREHO-PLYO protocol for a multicenter randomized controlled clinical trial. Trials 2020; 21:106. [PMID: 31969168 PMCID: PMC6977230 DOI: 10.1186/s13063-020-4049-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Accepted: 01/06/2020] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Post-trauma bleeding induces an acute deficiency in clotting factors, which promotes bleeding and hemorrhagic shock. However, early plasma administration may reduce the severity of trauma-induced coagulopathy (TIC). Unlike fresh frozen plasma, which requires specific hospital logistics, French lyophilized plasma (FLYP) is storable at room temperature and compatible with all blood types, supporting its use in prehospital emergency care. We aim to test the hypothesis that by attenuating TIC, FLYP administered by prehospital emergency physicians would benefit the severely injured civilian patient at risk for hemorrhagic shock. METHODS/DESIGN This multicenter randomized clinical trial will include adults severely injured and at risk for hemorrhagic shock, with a systolic blood pressure < 70 mmHg or a Shock Index > 1.1. Two parallel groups of 70 patients will receive either FLYP or normal saline in addition to usual treatment. The primary endpoint is the International Normalized Ratio (INR) at hospital admission. Secondary endpoints are transfusion requirement, length of stay in the intensive care unit, survival rate at day 30, usability and safety related to FLYP use, and other biological coagulation parameters. CONCLUSION With this trial, we aim to confirm the efficacy of FLYP in TIC and its safety in civilian prehospital care. The study results will contribute to optimizing guidelines for treating hemorrhagic shock in civilian settings. TRIAL REGISTRATION ClinicalTrials.gov, NCT02736812. Registered on 13 April 2016. The trial protocol has been approved by the French ethics committee (CPP 3342) and the French Agency for the Safety of Medicines and Health Products (IDRCB 2015-A00866-43).
Collapse
Affiliation(s)
- Daniel Jost
- Paris Fire Brigade Medical Emergency Department, 1 place Jules Renard, 75017, Paris, France.
| | - Sabine Lemoine
- Paris Fire Brigade Medical Emergency Department, 1 place Jules Renard, 75017, Paris, France
| | - Frederic Lemoine
- Paris Fire Brigade Medical Emergency Department, 1 place Jules Renard, 75017, Paris, France
| | - Vincent Lanoe
- Paris Fire Brigade Medical Emergency Department, 1 place Jules Renard, 75017, Paris, France
| | - Olga Maurin
- Paris Fire Brigade Medical Emergency Department, 1 place Jules Renard, 75017, Paris, France
| | - Clément Derkenne
- Paris Fire Brigade Medical Emergency Department, 1 place Jules Renard, 75017, Paris, France
| | | | - Maëlle Delacote
- Paris Fire Brigade Medical Emergency Department, 1 place Jules Renard, 75017, Paris, France
| | - Edouard Seguineau
- Paris Fire Brigade Medical Emergency Department, 1 place Jules Renard, 75017, Paris, France
| | - Anne Godefroy
- Paris Fire Brigade Medical Emergency Department, 1 place Jules Renard, 75017, Paris, France
| | - Nicolas Hervault
- Paris Fire Brigade Medical Emergency Department, 1 place Jules Renard, 75017, Paris, France
| | - Ludovic Delhaye
- Paris Fire Brigade Medical Emergency Department, 1 place Jules Renard, 75017, Paris, France
| | - Nicolas Pouliquen
- Paris Fire Brigade Medical Emergency Department, 1 place Jules Renard, 75017, Paris, France
| | - Emilie Louis-Delauriere
- Department of Education, Research and Innovation, Service de Santé des Armées, 1 Place Alphonse Laveran, 75230, Paris, France
| | - Julie Trichereau
- Paris Fire Brigade Medical Emergency Department, 1 place Jules Renard, 75017, Paris, France
| | - Florian Roquet
- Paris Fire Brigade Medical Emergency Department, 1 place Jules Renard, 75017, Paris, France
| | - Marina Salomé
- Paris Fire Brigade Medical Emergency Department, 1 place Jules Renard, 75017, Paris, France
| | - Catherine Verret
- Department of Education, Research and Innovation, Service de Santé des Armées, 1 Place Alphonse Laveran, 75230, Paris, France
| | - René Bihannic
- Paris Fire Brigade Medical Emergency Department, 1 place Jules Renard, 75017, Paris, France
| | - Romain Jouffroy
- Paris Fire Brigade Medical Emergency Department, 1 place Jules Renard, 75017, Paris, France
| | - Benoit Frattini
- Paris Fire Brigade Medical Emergency Department, 1 place Jules Renard, 75017, Paris, France
| | - Vivien Hong Tuan Ha
- Paris Fire Brigade Medical Emergency Department, 1 place Jules Renard, 75017, Paris, France
| | - Pascal Dang-Minh
- Paris Fire Brigade Medical Emergency Department, 1 place Jules Renard, 75017, Paris, France
| | - Stéphane Travers
- Paris Fire Brigade Medical Emergency Department, 1 place Jules Renard, 75017, Paris, France
- French Military Health Service, Val de Grâce military hospital, 1, Place Alphonse Laveran, 75230, Paris, France
| | - Michel Bignand
- Paris Fire Brigade Medical Emergency Department, 1 place Jules Renard, 75017, Paris, France
| | - Christophe Martinaud
- French Military Health Service, Val de Grâce military hospital, 1, Place Alphonse Laveran, 75230, Paris, France
- French army blood transfusion center, 1 Rue du Lieutenant Raoul Batany, 92140, Clamart, France
| | - Eliane Garrabe
- French Military Health Service, Val de Grâce military hospital, 1, Place Alphonse Laveran, 75230, Paris, France
- French army blood transfusion center, 1 Rue du Lieutenant Raoul Batany, 92140, Clamart, France
| | - Sylvain Ausset
- French Military Health Service, Val de Grâce military hospital, 1, Place Alphonse Laveran, 75230, Paris, France
- Department of Anesthesiology and Intensive Care, Percy military teaching hospital, 101 avenue Henri Barbusse, BP 406, 92141, Clamart, Cedex, France
| | - Bertrand Prunet
- Paris Fire Brigade Medical Emergency Department, 1 place Jules Renard, 75017, Paris, France
- French Military Health Service, Val de Grâce military hospital, 1, Place Alphonse Laveran, 75230, Paris, France
| | - Anne Sailliol
- French Military Health Service, Val de Grâce military hospital, 1, Place Alphonse Laveran, 75230, Paris, France
- French army blood transfusion center, 1 Rue du Lieutenant Raoul Batany, 92140, Clamart, France
- French Military Research Institute, 1 place Valérie Andre, BP 73, 91223, Brétigny sur Orge, France
| | - Jean Pierre Tourtier
- Paris Fire Brigade Medical Emergency Department, 1 place Jules Renard, 75017, Paris, France
- French Military Health Service, Val de Grâce military hospital, 1, Place Alphonse Laveran, 75230, Paris, France
- Department of Anaesthesiology and Intensive Care, Begin military teaching hospital, 94160, Saint-Mande, France
| |
Collapse
|
21
|
Pusateri AE, Butler FK, Shackelford SA, Sperry JL, Moore EE, Cap AP, Taylor AL, Homer MJ, Hoots WK, Weiskopf RB, Davis MR. The need for dried plasma - a national issue. Transfusion 2019; 59:1587-1592. [PMID: 30980738 DOI: 10.1111/trf.15261] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Accepted: 11/06/2018] [Indexed: 01/10/2023]
Abstract
Recent studies have demonstrated that early transfusion of plasma or RBCs improves survival in patients with severe trauma and hemorrhagic shock. Time to initiate transfusion is the critical factor. It is essential that transfusion begin in the prehospital environment when transport times are longer than approximately 15 to 20 minutes. Unfortunately, logistic constraints severely limit the use of blood products in the prehospital setting, especially in military, remote civilian, and mass disaster circumstances, where the need can be most acute. US military requirements for logistically supportable blood products are projected to increase dramatically in future conflicts. Although dried plasma products have been available and safely used in a number of countries for over 20 years, there is no dried plasma product commercially available in the United States. A US Food and Drug Administration-approved dried plasma is urgently needed. Considering the US military, disaster preparedness, and remote civilian trauma perspectives, this is an urgent national health care issue.
Collapse
Affiliation(s)
- Anthony E Pusateri
- US Army Institute of Surgical Research, JBSA Fort Sam Houston, San Antonio, Texas
| | - Frank K Butler
- Committee on Tactical Combat Casualty Care, Joint Trauma System, Defense Center of Excellence for Trauma, JBSA, Fort Sam Houston
| | - Stacy A Shackelford
- Joint Trauma System, Defense Center of Excellence for Trauma, JBSA Fort Sam Houston, San Antonio, Texas
| | - Jason L Sperry
- Department of Surgery and Critical Care, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Ernest E Moore
- Department of Surgery, Denver Health Medical Center, Denver, Colorado
| | - Andrew P Cap
- US Army Institute of Surgical Research, JBSA Fort Sam Houston, San Antonio, Texas
| | | | - Mary J Homer
- US Department of Health and Human Services (BARDA), Washington, DC
| | - W Keith Hoots
- National Institutes of Health (NHLBI), Bethesda, Maryland
| | | | - Michael R Davis
- US Army Medical Research and Materiel Command, Fort Detrick, Maryland
| |
Collapse
|
22
|
Overresuscitation with plasma is associated with sustained fibrinolysis shutdown and death in pediatric traumatic brain injury. J Trauma Acute Care Surg 2019; 85:12-17. [PMID: 29443859 DOI: 10.1097/ta.0000000000001836] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Elevated International Normalized Ratio (INR) is a marker of poor outcome but not necessarily bleeding or clinical coagulopathy in injured children. Conversely, children with traumatic brain injury (TBI) tend to be hypercoagulable based on rapid thromboelastography (rTEG) parameters. Many clinicians continue to utilize INR as a treatment target. METHODS Prospective observational study of severely injured children age < 18 with rTEG on arrival and daily thereafter for up to 7 days. Standard rTEG definitions of hyperfibrinolysis (LY30 ≥ 3), fibrinolysis shutdown (SD) (LY30 ≤ 0.8), and normal (LY30 = 0.9-2.9) were applied. The first 24-hour blood product transfusion volumes were documented. Abbreviated Injury Scale score ≥ 3 defined severe TBI. Sustained SD was defined as two consecutive rTEG with SD and no subsequent normalization. Primary outcomes were death and functional disability, based on functional independence measure score assessed at discharge. RESULTS One hundred one patients were included: median age, 8 years (interquartile range, 4-12 years); Injury Severity Score, 25 (16-30); 72% blunt mechanism; 47% severe TBI; 16% mortality; 45% discharge disability. Neither total volume nor any single product volume transfused (mL/kg; all p > 0.1) differed between TBI and non-TBI groups. On univariate analysis, transfusion of packed red blood cells (p = 0.016), plasma (p < 0.001), and platelets (p = 0.006) were associated with sustained SD; however, in a regression model that included all products (mL/kg) and controlled for severe TBI (head Abbreviated Injury Scale score ≥ 3), admission INR, polytrauma, and clinical bleeding, only plasma remained an independent predictor of sustained SD (odds ratio, 1.17; p = 0.031). Patients with both severe TBI and plasma transfusion had 100% sustained SD, 75% mortality, and 100% disability in survivors. Admission INR was elevated in TBI patients, but did not correlate with rTEG activated clotting time (p = NS) and was associated with sustained SD (p = 0.006). CONCLUSION Plasma transfusion is independently associated with sustained fibrinolysis SD. Severe TBI is also associated with sustained SD; the combined effect of plasma transfusion and severe TBI is associated with extremely poor prognosis. Plasma transfusion should not be targeted to INR thresholds but rather to rTEG activated clotting time and clinical bleeding. LEVEL OF EVIDENCE Prognostic and epidemiological study, level III.
Collapse
|
23
|
Prehospital Blood Product and Crystalloid Resuscitation in the Severely Injured Patient. Ann Surg 2019; 273:358-364. [DOI: 10.1097/sla.0000000000003324] [Citation(s) in RCA: 75] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
24
|
Are on-scene blood transfusions by a helicopter emergency medical service useful and safe? A multicentre case–control study. Eur J Emerg Med 2019; 26:128-132. [DOI: 10.1097/mej.0000000000000516] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
25
|
MacDonald RD. Articles That May Change Your Practice: Prehospital Plasma. Air Med J 2019; 38:12-13. [PMID: 30711076 DOI: 10.1016/j.amj.2018.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Accepted: 10/16/2018] [Indexed: 06/09/2023]
|
26
|
|
27
|
Tonglet ML, Swerts F, Mathonet PY, Moens D, D'Orio V, Ghuysen A. Pre-hospital transfusion of red blood cells in civilian trauma patients: what's next? Transfus Med 2018; 28:457. [PMID: 30338606 DOI: 10.1111/tme.12564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2017] [Revised: 07/29/2018] [Accepted: 09/27/2018] [Indexed: 11/30/2022]
Affiliation(s)
- M L Tonglet
- Centre Hospitalier Universitaire de Liège, Liege, Belgium
| | - F Swerts
- Centre Hospitalier Universitaire de Liège, Liege, Belgium
| | - P Y Mathonet
- Centre Hospitalier Universitaire de Liège, Liege, Belgium
| | - D Moens
- Centre Hospitalier Universitaire de Liège, Liege, Belgium
| | - V D'Orio
- Centre Hospitalier Universitaire de Liège, Liege, Belgium
| | - A Ghuysen
- Centre Hospitalier Universitaire de Liège, Liege, Belgium
| |
Collapse
|
28
|
Seheult JN, Anto V, Alarcon LH, Sperry JL, Triulzi DJ, Yazer MH. Clinical outcomes among low-titer group O whole blood recipients compared to recipients of conventional components in civilian trauma resuscitation. Transfusion 2018; 58:1838-1845. [DOI: 10.1111/trf.14779] [Citation(s) in RCA: 90] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Revised: 05/07/2018] [Accepted: 05/07/2018] [Indexed: 12/20/2022]
Affiliation(s)
| | | | - Louis H. Alarcon
- Department of Surgery; University of Pittsburgh
- Department of Critical Care Medicine; University of Pittsburgh
| | - Jason L. Sperry
- Department of Surgery; University of Pittsburgh
- Department of Critical Care Medicine; University of Pittsburgh
| | - Darrell J. Triulzi
- Department of Pathology; University of Pittsburgh
- The Institute for Transfusion Medicine; Pittsburgh Pennsylvania
| | - Mark H. Yazer
- Department of Pathology; University of Pittsburgh
- The Institute for Transfusion Medicine; Pittsburgh Pennsylvania
| |
Collapse
|
29
|
Yazer MH, Spinella PC, Allard S, Roxby D, So-Osman C, Lozano M, Gunn K, Shih AWY, Stensballe J, Johansson PI, Bagge Hansen M, Maegele M, Doughty H, Crombie N, Jenkins DH, McGinity A, Schaefer RM, Martinaud C, Shinar E, Strugo R, Chen J, Russcher H. Vox Sanguinis International Forum on the use of prehospital blood products and pharmaceuticals in the treatment of patients with traumatic haemorrhage. Vox Sang 2018; 113:701-706. [PMID: 30144091 DOI: 10.1111/vox.12678] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
While specific practices and transported blood products vary around the world, most of the respondents in this International Forum transported at least one blood product for the transfusion to bleeding patients en route to the hospital. The most commonly carried product was RBCs, while the use of whole blood will likely increase given the recent reports of its successful use in the civilian setting, and because of the change in the AABB's Standards regulating its use. It will be interesting to see if plasma use in the prehospital setting becomes more widely used given today's enhanced appreciated of the coagulopathy of trauma and plasma's beneficial effect in reversing it, and if blood products are transported to the scene of injury by more vehicles, that is, not just predominantly in helicopters. It was not surprising that TXA is being widely administered as close to the time of injury as possible given its potential benefit in these patients. This International Forum highlights the importance of focusing attention on prehospital transfusion management with a need to further high‐quality research in this area to guide optimal resuscitation strategies.
Collapse
Affiliation(s)
- M H Yazer
- Department of Pathology, University of Pittsburgh, Pittsburgh, PA, USA
| | - P C Spinella
- Pediatric Critical Care Translational Research Program, Department of Pediatrics, Washington University in St Louis School of Medicine, St Louis, MO, USA
| | - S Allard
- Clinical, NHS Blood and Transplant, NHSBT, London, UK
| | - D Roxby
- SA Pathology Transfusion Service, Flinders Medical Centre, Bedford Park, SA, Australia
| | - C So-Osman
- Department of Transfusion Medicine, Sanquin Bloodbank, Leiden, The Netherlands.,Department of Internal Medicine, Groene Hart Hospital, Gouda, The Netherlands
| | - M Lozano
- Department of Hemotherapy and Hemostasis, Hospital Clinic, Barcelona, Spain
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
30
|
Naumann DN, Doughty H, Cotton BA. No gains with plasma-first resuscitation in urban settings? Lancet 2018; 392:255-256. [PMID: 30032982 DOI: 10.1016/s0140-6736(18)31565-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Accepted: 07/02/2018] [Indexed: 12/11/2022]
Affiliation(s)
- David N Naumann
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Queen Elizabeth Hospital Birmingham, Birmingham, UK.
| | | | - Bryan A Cotton
- Center for Translational Injury Research, Department of Surgery, The McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, TX, USA
| |
Collapse
|
31
|
Sperry JL, Guyette FX, Brown JB, Yazer MH, Triulzi DJ, Early-Young BJ, Adams PW, Daley BJ, Miller RS, Harbrecht BG, Claridge JA, Phelan HA, Witham WR, Putnam AT, Duane TM, Alarcon LH, Callaway CW, Zuckerbraun BS, Neal MD, Rosengart MR, Forsythe RM, Billiar TR, Yealy DM, Peitzman AB, Zenati MS. Prehospital Plasma during Air Medical Transport in Trauma Patients at Risk for Hemorrhagic Shock. N Engl J Med 2018; 379:315-326. [PMID: 30044935 DOI: 10.1056/nejmoa1802345] [Citation(s) in RCA: 499] [Impact Index Per Article: 83.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND After a person has been injured, prehospital administration of plasma in addition to the initiation of standard resuscitation procedures in the prehospital environment may reduce the risk of downstream complications from hemorrhage and shock. Data from large clinical trials are lacking to show either the efficacy or the risks associated with plasma transfusion in the prehospital setting. METHODS To determine the efficacy and safety of prehospital administration of thawed plasma in injured patients who are at risk for hemorrhagic shock, we conducted a pragmatic, multicenter, cluster-randomized, phase 3 superiority trial that compared the administration of thawed plasma with standard-care resuscitation during air medical transport. The primary outcome was mortality at 30 days. RESULTS A total of 501 patients were evaluated: 230 patients received plasma (plasma group) and 271 received standard-care resuscitation (standard-care group). Mortality at 30 days was significantly lower in the plasma group than in the standard-care group (23.2% vs. 33.0%; difference, -9.8 percentage points; 95% confidence interval, -18.6 to -1.0%; P=0.03). A similar treatment effect was observed across nine prespecified subgroups (heterogeneity chi-square test, 12.21; P=0.79). Kaplan-Meier curves showed an early separation of the two treatment groups that began 3 hours after randomization and persisted until 30 days after randomization (log-rank chi-square test, 5.70; P=0.02). The median prothrombin-time ratio was lower in the plasma group than in the standard-care group (1.2 [interquartile range, 1.1 to 1.4] vs. 1.3 [interquartile range, 1.1 to 1.6], P<0.001) after the patients' arrival at the trauma center. No significant differences between the two groups were noted with respect to multiorgan failure, acute lung injury-acute respiratory distress syndrome, nosocomial infections, or allergic or transfusion-related reactions. CONCLUSIONS In injured patients at risk for hemorrhagic shock, the prehospital administration of thawed plasma was safe and resulted in lower 30-day mortality and a lower median prothrombin-time ratio than standard-care resuscitation. (Funded by the U.S. Army Medical Research and Materiel Command; PAMPer ClinicalTrials.gov number, NCT01818427 .).
Collapse
Affiliation(s)
- Jason L Sperry
- From the Division of Trauma and General Surgery, Department of Surgery (J.L.S., J.B.B., L.H.A., B.S.Z., M.D.N., M.R.R., R.M.F., T.R.B., A.B.P., M.S.Z.), and the Departments of Emergency Medicine (F.X.G., C.W.C., D.M.Y.) and Critical Care Medicine (B.J.E.-Y., P.W.A.), University of Pittsburgh Medical Center, and the Department of Pathology, University of Pittsburgh and Institute for Transfusion Medicine (M.H.Y., D.J.T.), Pittsburgh, and University of Pittsburgh Medical Center, Altoona Hospital, Altoona (A.T.P.) - all in Pennsylvania; the Department of Surgery, University of Tennessee Health Science Center, Knoxville (B.J.D.), and the Department of Surgery, Vanderbilt University Medical Center, Nashville (R.S.M.) - both in Tennessee; the Department of Surgery, University of Louisville, Louisville, KY (B.G.H.); MetroHealth Medical Center, Case Western Reserve University, Cleveland (J.A.C.); and the Department of Surgery, University of Texas Southwestern, Parkland Memorial Hospital, Dallas (H.A.P.) and Texas Health Harris Methodist Hospital (W.R.W.) and the John Peter Smith Health Network (T.M.D.), Fort Worth - all in Texas
| | - Francis X Guyette
- From the Division of Trauma and General Surgery, Department of Surgery (J.L.S., J.B.B., L.H.A., B.S.Z., M.D.N., M.R.R., R.M.F., T.R.B., A.B.P., M.S.Z.), and the Departments of Emergency Medicine (F.X.G., C.W.C., D.M.Y.) and Critical Care Medicine (B.J.E.-Y., P.W.A.), University of Pittsburgh Medical Center, and the Department of Pathology, University of Pittsburgh and Institute for Transfusion Medicine (M.H.Y., D.J.T.), Pittsburgh, and University of Pittsburgh Medical Center, Altoona Hospital, Altoona (A.T.P.) - all in Pennsylvania; the Department of Surgery, University of Tennessee Health Science Center, Knoxville (B.J.D.), and the Department of Surgery, Vanderbilt University Medical Center, Nashville (R.S.M.) - both in Tennessee; the Department of Surgery, University of Louisville, Louisville, KY (B.G.H.); MetroHealth Medical Center, Case Western Reserve University, Cleveland (J.A.C.); and the Department of Surgery, University of Texas Southwestern, Parkland Memorial Hospital, Dallas (H.A.P.) and Texas Health Harris Methodist Hospital (W.R.W.) and the John Peter Smith Health Network (T.M.D.), Fort Worth - all in Texas
| | - Joshua B Brown
- From the Division of Trauma and General Surgery, Department of Surgery (J.L.S., J.B.B., L.H.A., B.S.Z., M.D.N., M.R.R., R.M.F., T.R.B., A.B.P., M.S.Z.), and the Departments of Emergency Medicine (F.X.G., C.W.C., D.M.Y.) and Critical Care Medicine (B.J.E.-Y., P.W.A.), University of Pittsburgh Medical Center, and the Department of Pathology, University of Pittsburgh and Institute for Transfusion Medicine (M.H.Y., D.J.T.), Pittsburgh, and University of Pittsburgh Medical Center, Altoona Hospital, Altoona (A.T.P.) - all in Pennsylvania; the Department of Surgery, University of Tennessee Health Science Center, Knoxville (B.J.D.), and the Department of Surgery, Vanderbilt University Medical Center, Nashville (R.S.M.) - both in Tennessee; the Department of Surgery, University of Louisville, Louisville, KY (B.G.H.); MetroHealth Medical Center, Case Western Reserve University, Cleveland (J.A.C.); and the Department of Surgery, University of Texas Southwestern, Parkland Memorial Hospital, Dallas (H.A.P.) and Texas Health Harris Methodist Hospital (W.R.W.) and the John Peter Smith Health Network (T.M.D.), Fort Worth - all in Texas
| | - Mark H Yazer
- From the Division of Trauma and General Surgery, Department of Surgery (J.L.S., J.B.B., L.H.A., B.S.Z., M.D.N., M.R.R., R.M.F., T.R.B., A.B.P., M.S.Z.), and the Departments of Emergency Medicine (F.X.G., C.W.C., D.M.Y.) and Critical Care Medicine (B.J.E.-Y., P.W.A.), University of Pittsburgh Medical Center, and the Department of Pathology, University of Pittsburgh and Institute for Transfusion Medicine (M.H.Y., D.J.T.), Pittsburgh, and University of Pittsburgh Medical Center, Altoona Hospital, Altoona (A.T.P.) - all in Pennsylvania; the Department of Surgery, University of Tennessee Health Science Center, Knoxville (B.J.D.), and the Department of Surgery, Vanderbilt University Medical Center, Nashville (R.S.M.) - both in Tennessee; the Department of Surgery, University of Louisville, Louisville, KY (B.G.H.); MetroHealth Medical Center, Case Western Reserve University, Cleveland (J.A.C.); and the Department of Surgery, University of Texas Southwestern, Parkland Memorial Hospital, Dallas (H.A.P.) and Texas Health Harris Methodist Hospital (W.R.W.) and the John Peter Smith Health Network (T.M.D.), Fort Worth - all in Texas
| | - Darrell J Triulzi
- From the Division of Trauma and General Surgery, Department of Surgery (J.L.S., J.B.B., L.H.A., B.S.Z., M.D.N., M.R.R., R.M.F., T.R.B., A.B.P., M.S.Z.), and the Departments of Emergency Medicine (F.X.G., C.W.C., D.M.Y.) and Critical Care Medicine (B.J.E.-Y., P.W.A.), University of Pittsburgh Medical Center, and the Department of Pathology, University of Pittsburgh and Institute for Transfusion Medicine (M.H.Y., D.J.T.), Pittsburgh, and University of Pittsburgh Medical Center, Altoona Hospital, Altoona (A.T.P.) - all in Pennsylvania; the Department of Surgery, University of Tennessee Health Science Center, Knoxville (B.J.D.), and the Department of Surgery, Vanderbilt University Medical Center, Nashville (R.S.M.) - both in Tennessee; the Department of Surgery, University of Louisville, Louisville, KY (B.G.H.); MetroHealth Medical Center, Case Western Reserve University, Cleveland (J.A.C.); and the Department of Surgery, University of Texas Southwestern, Parkland Memorial Hospital, Dallas (H.A.P.) and Texas Health Harris Methodist Hospital (W.R.W.) and the John Peter Smith Health Network (T.M.D.), Fort Worth - all in Texas
| | - Barbara J Early-Young
- From the Division of Trauma and General Surgery, Department of Surgery (J.L.S., J.B.B., L.H.A., B.S.Z., M.D.N., M.R.R., R.M.F., T.R.B., A.B.P., M.S.Z.), and the Departments of Emergency Medicine (F.X.G., C.W.C., D.M.Y.) and Critical Care Medicine (B.J.E.-Y., P.W.A.), University of Pittsburgh Medical Center, and the Department of Pathology, University of Pittsburgh and Institute for Transfusion Medicine (M.H.Y., D.J.T.), Pittsburgh, and University of Pittsburgh Medical Center, Altoona Hospital, Altoona (A.T.P.) - all in Pennsylvania; the Department of Surgery, University of Tennessee Health Science Center, Knoxville (B.J.D.), and the Department of Surgery, Vanderbilt University Medical Center, Nashville (R.S.M.) - both in Tennessee; the Department of Surgery, University of Louisville, Louisville, KY (B.G.H.); MetroHealth Medical Center, Case Western Reserve University, Cleveland (J.A.C.); and the Department of Surgery, University of Texas Southwestern, Parkland Memorial Hospital, Dallas (H.A.P.) and Texas Health Harris Methodist Hospital (W.R.W.) and the John Peter Smith Health Network (T.M.D.), Fort Worth - all in Texas
| | - Peter W Adams
- From the Division of Trauma and General Surgery, Department of Surgery (J.L.S., J.B.B., L.H.A., B.S.Z., M.D.N., M.R.R., R.M.F., T.R.B., A.B.P., M.S.Z.), and the Departments of Emergency Medicine (F.X.G., C.W.C., D.M.Y.) and Critical Care Medicine (B.J.E.-Y., P.W.A.), University of Pittsburgh Medical Center, and the Department of Pathology, University of Pittsburgh and Institute for Transfusion Medicine (M.H.Y., D.J.T.), Pittsburgh, and University of Pittsburgh Medical Center, Altoona Hospital, Altoona (A.T.P.) - all in Pennsylvania; the Department of Surgery, University of Tennessee Health Science Center, Knoxville (B.J.D.), and the Department of Surgery, Vanderbilt University Medical Center, Nashville (R.S.M.) - both in Tennessee; the Department of Surgery, University of Louisville, Louisville, KY (B.G.H.); MetroHealth Medical Center, Case Western Reserve University, Cleveland (J.A.C.); and the Department of Surgery, University of Texas Southwestern, Parkland Memorial Hospital, Dallas (H.A.P.) and Texas Health Harris Methodist Hospital (W.R.W.) and the John Peter Smith Health Network (T.M.D.), Fort Worth - all in Texas
| | - Brian J Daley
- From the Division of Trauma and General Surgery, Department of Surgery (J.L.S., J.B.B., L.H.A., B.S.Z., M.D.N., M.R.R., R.M.F., T.R.B., A.B.P., M.S.Z.), and the Departments of Emergency Medicine (F.X.G., C.W.C., D.M.Y.) and Critical Care Medicine (B.J.E.-Y., P.W.A.), University of Pittsburgh Medical Center, and the Department of Pathology, University of Pittsburgh and Institute for Transfusion Medicine (M.H.Y., D.J.T.), Pittsburgh, and University of Pittsburgh Medical Center, Altoona Hospital, Altoona (A.T.P.) - all in Pennsylvania; the Department of Surgery, University of Tennessee Health Science Center, Knoxville (B.J.D.), and the Department of Surgery, Vanderbilt University Medical Center, Nashville (R.S.M.) - both in Tennessee; the Department of Surgery, University of Louisville, Louisville, KY (B.G.H.); MetroHealth Medical Center, Case Western Reserve University, Cleveland (J.A.C.); and the Department of Surgery, University of Texas Southwestern, Parkland Memorial Hospital, Dallas (H.A.P.) and Texas Health Harris Methodist Hospital (W.R.W.) and the John Peter Smith Health Network (T.M.D.), Fort Worth - all in Texas
| | - Richard S Miller
- From the Division of Trauma and General Surgery, Department of Surgery (J.L.S., J.B.B., L.H.A., B.S.Z., M.D.N., M.R.R., R.M.F., T.R.B., A.B.P., M.S.Z.), and the Departments of Emergency Medicine (F.X.G., C.W.C., D.M.Y.) and Critical Care Medicine (B.J.E.-Y., P.W.A.), University of Pittsburgh Medical Center, and the Department of Pathology, University of Pittsburgh and Institute for Transfusion Medicine (M.H.Y., D.J.T.), Pittsburgh, and University of Pittsburgh Medical Center, Altoona Hospital, Altoona (A.T.P.) - all in Pennsylvania; the Department of Surgery, University of Tennessee Health Science Center, Knoxville (B.J.D.), and the Department of Surgery, Vanderbilt University Medical Center, Nashville (R.S.M.) - both in Tennessee; the Department of Surgery, University of Louisville, Louisville, KY (B.G.H.); MetroHealth Medical Center, Case Western Reserve University, Cleveland (J.A.C.); and the Department of Surgery, University of Texas Southwestern, Parkland Memorial Hospital, Dallas (H.A.P.) and Texas Health Harris Methodist Hospital (W.R.W.) and the John Peter Smith Health Network (T.M.D.), Fort Worth - all in Texas
| | - Brian G Harbrecht
- From the Division of Trauma and General Surgery, Department of Surgery (J.L.S., J.B.B., L.H.A., B.S.Z., M.D.N., M.R.R., R.M.F., T.R.B., A.B.P., M.S.Z.), and the Departments of Emergency Medicine (F.X.G., C.W.C., D.M.Y.) and Critical Care Medicine (B.J.E.-Y., P.W.A.), University of Pittsburgh Medical Center, and the Department of Pathology, University of Pittsburgh and Institute for Transfusion Medicine (M.H.Y., D.J.T.), Pittsburgh, and University of Pittsburgh Medical Center, Altoona Hospital, Altoona (A.T.P.) - all in Pennsylvania; the Department of Surgery, University of Tennessee Health Science Center, Knoxville (B.J.D.), and the Department of Surgery, Vanderbilt University Medical Center, Nashville (R.S.M.) - both in Tennessee; the Department of Surgery, University of Louisville, Louisville, KY (B.G.H.); MetroHealth Medical Center, Case Western Reserve University, Cleveland (J.A.C.); and the Department of Surgery, University of Texas Southwestern, Parkland Memorial Hospital, Dallas (H.A.P.) and Texas Health Harris Methodist Hospital (W.R.W.) and the John Peter Smith Health Network (T.M.D.), Fort Worth - all in Texas
| | - Jeffrey A Claridge
- From the Division of Trauma and General Surgery, Department of Surgery (J.L.S., J.B.B., L.H.A., B.S.Z., M.D.N., M.R.R., R.M.F., T.R.B., A.B.P., M.S.Z.), and the Departments of Emergency Medicine (F.X.G., C.W.C., D.M.Y.) and Critical Care Medicine (B.J.E.-Y., P.W.A.), University of Pittsburgh Medical Center, and the Department of Pathology, University of Pittsburgh and Institute for Transfusion Medicine (M.H.Y., D.J.T.), Pittsburgh, and University of Pittsburgh Medical Center, Altoona Hospital, Altoona (A.T.P.) - all in Pennsylvania; the Department of Surgery, University of Tennessee Health Science Center, Knoxville (B.J.D.), and the Department of Surgery, Vanderbilt University Medical Center, Nashville (R.S.M.) - both in Tennessee; the Department of Surgery, University of Louisville, Louisville, KY (B.G.H.); MetroHealth Medical Center, Case Western Reserve University, Cleveland (J.A.C.); and the Department of Surgery, University of Texas Southwestern, Parkland Memorial Hospital, Dallas (H.A.P.) and Texas Health Harris Methodist Hospital (W.R.W.) and the John Peter Smith Health Network (T.M.D.), Fort Worth - all in Texas
| | - Herb A Phelan
- From the Division of Trauma and General Surgery, Department of Surgery (J.L.S., J.B.B., L.H.A., B.S.Z., M.D.N., M.R.R., R.M.F., T.R.B., A.B.P., M.S.Z.), and the Departments of Emergency Medicine (F.X.G., C.W.C., D.M.Y.) and Critical Care Medicine (B.J.E.-Y., P.W.A.), University of Pittsburgh Medical Center, and the Department of Pathology, University of Pittsburgh and Institute for Transfusion Medicine (M.H.Y., D.J.T.), Pittsburgh, and University of Pittsburgh Medical Center, Altoona Hospital, Altoona (A.T.P.) - all in Pennsylvania; the Department of Surgery, University of Tennessee Health Science Center, Knoxville (B.J.D.), and the Department of Surgery, Vanderbilt University Medical Center, Nashville (R.S.M.) - both in Tennessee; the Department of Surgery, University of Louisville, Louisville, KY (B.G.H.); MetroHealth Medical Center, Case Western Reserve University, Cleveland (J.A.C.); and the Department of Surgery, University of Texas Southwestern, Parkland Memorial Hospital, Dallas (H.A.P.) and Texas Health Harris Methodist Hospital (W.R.W.) and the John Peter Smith Health Network (T.M.D.), Fort Worth - all in Texas
| | - William R Witham
- From the Division of Trauma and General Surgery, Department of Surgery (J.L.S., J.B.B., L.H.A., B.S.Z., M.D.N., M.R.R., R.M.F., T.R.B., A.B.P., M.S.Z.), and the Departments of Emergency Medicine (F.X.G., C.W.C., D.M.Y.) and Critical Care Medicine (B.J.E.-Y., P.W.A.), University of Pittsburgh Medical Center, and the Department of Pathology, University of Pittsburgh and Institute for Transfusion Medicine (M.H.Y., D.J.T.), Pittsburgh, and University of Pittsburgh Medical Center, Altoona Hospital, Altoona (A.T.P.) - all in Pennsylvania; the Department of Surgery, University of Tennessee Health Science Center, Knoxville (B.J.D.), and the Department of Surgery, Vanderbilt University Medical Center, Nashville (R.S.M.) - both in Tennessee; the Department of Surgery, University of Louisville, Louisville, KY (B.G.H.); MetroHealth Medical Center, Case Western Reserve University, Cleveland (J.A.C.); and the Department of Surgery, University of Texas Southwestern, Parkland Memorial Hospital, Dallas (H.A.P.) and Texas Health Harris Methodist Hospital (W.R.W.) and the John Peter Smith Health Network (T.M.D.), Fort Worth - all in Texas
| | - A Tyler Putnam
- From the Division of Trauma and General Surgery, Department of Surgery (J.L.S., J.B.B., L.H.A., B.S.Z., M.D.N., M.R.R., R.M.F., T.R.B., A.B.P., M.S.Z.), and the Departments of Emergency Medicine (F.X.G., C.W.C., D.M.Y.) and Critical Care Medicine (B.J.E.-Y., P.W.A.), University of Pittsburgh Medical Center, and the Department of Pathology, University of Pittsburgh and Institute for Transfusion Medicine (M.H.Y., D.J.T.), Pittsburgh, and University of Pittsburgh Medical Center, Altoona Hospital, Altoona (A.T.P.) - all in Pennsylvania; the Department of Surgery, University of Tennessee Health Science Center, Knoxville (B.J.D.), and the Department of Surgery, Vanderbilt University Medical Center, Nashville (R.S.M.) - both in Tennessee; the Department of Surgery, University of Louisville, Louisville, KY (B.G.H.); MetroHealth Medical Center, Case Western Reserve University, Cleveland (J.A.C.); and the Department of Surgery, University of Texas Southwestern, Parkland Memorial Hospital, Dallas (H.A.P.) and Texas Health Harris Methodist Hospital (W.R.W.) and the John Peter Smith Health Network (T.M.D.), Fort Worth - all in Texas
| | - Therese M Duane
- From the Division of Trauma and General Surgery, Department of Surgery (J.L.S., J.B.B., L.H.A., B.S.Z., M.D.N., M.R.R., R.M.F., T.R.B., A.B.P., M.S.Z.), and the Departments of Emergency Medicine (F.X.G., C.W.C., D.M.Y.) and Critical Care Medicine (B.J.E.-Y., P.W.A.), University of Pittsburgh Medical Center, and the Department of Pathology, University of Pittsburgh and Institute for Transfusion Medicine (M.H.Y., D.J.T.), Pittsburgh, and University of Pittsburgh Medical Center, Altoona Hospital, Altoona (A.T.P.) - all in Pennsylvania; the Department of Surgery, University of Tennessee Health Science Center, Knoxville (B.J.D.), and the Department of Surgery, Vanderbilt University Medical Center, Nashville (R.S.M.) - both in Tennessee; the Department of Surgery, University of Louisville, Louisville, KY (B.G.H.); MetroHealth Medical Center, Case Western Reserve University, Cleveland (J.A.C.); and the Department of Surgery, University of Texas Southwestern, Parkland Memorial Hospital, Dallas (H.A.P.) and Texas Health Harris Methodist Hospital (W.R.W.) and the John Peter Smith Health Network (T.M.D.), Fort Worth - all in Texas
| | - Louis H Alarcon
- From the Division of Trauma and General Surgery, Department of Surgery (J.L.S., J.B.B., L.H.A., B.S.Z., M.D.N., M.R.R., R.M.F., T.R.B., A.B.P., M.S.Z.), and the Departments of Emergency Medicine (F.X.G., C.W.C., D.M.Y.) and Critical Care Medicine (B.J.E.-Y., P.W.A.), University of Pittsburgh Medical Center, and the Department of Pathology, University of Pittsburgh and Institute for Transfusion Medicine (M.H.Y., D.J.T.), Pittsburgh, and University of Pittsburgh Medical Center, Altoona Hospital, Altoona (A.T.P.) - all in Pennsylvania; the Department of Surgery, University of Tennessee Health Science Center, Knoxville (B.J.D.), and the Department of Surgery, Vanderbilt University Medical Center, Nashville (R.S.M.) - both in Tennessee; the Department of Surgery, University of Louisville, Louisville, KY (B.G.H.); MetroHealth Medical Center, Case Western Reserve University, Cleveland (J.A.C.); and the Department of Surgery, University of Texas Southwestern, Parkland Memorial Hospital, Dallas (H.A.P.) and Texas Health Harris Methodist Hospital (W.R.W.) and the John Peter Smith Health Network (T.M.D.), Fort Worth - all in Texas
| | - Clifton W Callaway
- From the Division of Trauma and General Surgery, Department of Surgery (J.L.S., J.B.B., L.H.A., B.S.Z., M.D.N., M.R.R., R.M.F., T.R.B., A.B.P., M.S.Z.), and the Departments of Emergency Medicine (F.X.G., C.W.C., D.M.Y.) and Critical Care Medicine (B.J.E.-Y., P.W.A.), University of Pittsburgh Medical Center, and the Department of Pathology, University of Pittsburgh and Institute for Transfusion Medicine (M.H.Y., D.J.T.), Pittsburgh, and University of Pittsburgh Medical Center, Altoona Hospital, Altoona (A.T.P.) - all in Pennsylvania; the Department of Surgery, University of Tennessee Health Science Center, Knoxville (B.J.D.), and the Department of Surgery, Vanderbilt University Medical Center, Nashville (R.S.M.) - both in Tennessee; the Department of Surgery, University of Louisville, Louisville, KY (B.G.H.); MetroHealth Medical Center, Case Western Reserve University, Cleveland (J.A.C.); and the Department of Surgery, University of Texas Southwestern, Parkland Memorial Hospital, Dallas (H.A.P.) and Texas Health Harris Methodist Hospital (W.R.W.) and the John Peter Smith Health Network (T.M.D.), Fort Worth - all in Texas
| | - Brian S Zuckerbraun
- From the Division of Trauma and General Surgery, Department of Surgery (J.L.S., J.B.B., L.H.A., B.S.Z., M.D.N., M.R.R., R.M.F., T.R.B., A.B.P., M.S.Z.), and the Departments of Emergency Medicine (F.X.G., C.W.C., D.M.Y.) and Critical Care Medicine (B.J.E.-Y., P.W.A.), University of Pittsburgh Medical Center, and the Department of Pathology, University of Pittsburgh and Institute for Transfusion Medicine (M.H.Y., D.J.T.), Pittsburgh, and University of Pittsburgh Medical Center, Altoona Hospital, Altoona (A.T.P.) - all in Pennsylvania; the Department of Surgery, University of Tennessee Health Science Center, Knoxville (B.J.D.), and the Department of Surgery, Vanderbilt University Medical Center, Nashville (R.S.M.) - both in Tennessee; the Department of Surgery, University of Louisville, Louisville, KY (B.G.H.); MetroHealth Medical Center, Case Western Reserve University, Cleveland (J.A.C.); and the Department of Surgery, University of Texas Southwestern, Parkland Memorial Hospital, Dallas (H.A.P.) and Texas Health Harris Methodist Hospital (W.R.W.) and the John Peter Smith Health Network (T.M.D.), Fort Worth - all in Texas
| | - Matthew D Neal
- From the Division of Trauma and General Surgery, Department of Surgery (J.L.S., J.B.B., L.H.A., B.S.Z., M.D.N., M.R.R., R.M.F., T.R.B., A.B.P., M.S.Z.), and the Departments of Emergency Medicine (F.X.G., C.W.C., D.M.Y.) and Critical Care Medicine (B.J.E.-Y., P.W.A.), University of Pittsburgh Medical Center, and the Department of Pathology, University of Pittsburgh and Institute for Transfusion Medicine (M.H.Y., D.J.T.), Pittsburgh, and University of Pittsburgh Medical Center, Altoona Hospital, Altoona (A.T.P.) - all in Pennsylvania; the Department of Surgery, University of Tennessee Health Science Center, Knoxville (B.J.D.), and the Department of Surgery, Vanderbilt University Medical Center, Nashville (R.S.M.) - both in Tennessee; the Department of Surgery, University of Louisville, Louisville, KY (B.G.H.); MetroHealth Medical Center, Case Western Reserve University, Cleveland (J.A.C.); and the Department of Surgery, University of Texas Southwestern, Parkland Memorial Hospital, Dallas (H.A.P.) and Texas Health Harris Methodist Hospital (W.R.W.) and the John Peter Smith Health Network (T.M.D.), Fort Worth - all in Texas
| | - Matthew R Rosengart
- From the Division of Trauma and General Surgery, Department of Surgery (J.L.S., J.B.B., L.H.A., B.S.Z., M.D.N., M.R.R., R.M.F., T.R.B., A.B.P., M.S.Z.), and the Departments of Emergency Medicine (F.X.G., C.W.C., D.M.Y.) and Critical Care Medicine (B.J.E.-Y., P.W.A.), University of Pittsburgh Medical Center, and the Department of Pathology, University of Pittsburgh and Institute for Transfusion Medicine (M.H.Y., D.J.T.), Pittsburgh, and University of Pittsburgh Medical Center, Altoona Hospital, Altoona (A.T.P.) - all in Pennsylvania; the Department of Surgery, University of Tennessee Health Science Center, Knoxville (B.J.D.), and the Department of Surgery, Vanderbilt University Medical Center, Nashville (R.S.M.) - both in Tennessee; the Department of Surgery, University of Louisville, Louisville, KY (B.G.H.); MetroHealth Medical Center, Case Western Reserve University, Cleveland (J.A.C.); and the Department of Surgery, University of Texas Southwestern, Parkland Memorial Hospital, Dallas (H.A.P.) and Texas Health Harris Methodist Hospital (W.R.W.) and the John Peter Smith Health Network (T.M.D.), Fort Worth - all in Texas
| | - Raquel M Forsythe
- From the Division of Trauma and General Surgery, Department of Surgery (J.L.S., J.B.B., L.H.A., B.S.Z., M.D.N., M.R.R., R.M.F., T.R.B., A.B.P., M.S.Z.), and the Departments of Emergency Medicine (F.X.G., C.W.C., D.M.Y.) and Critical Care Medicine (B.J.E.-Y., P.W.A.), University of Pittsburgh Medical Center, and the Department of Pathology, University of Pittsburgh and Institute for Transfusion Medicine (M.H.Y., D.J.T.), Pittsburgh, and University of Pittsburgh Medical Center, Altoona Hospital, Altoona (A.T.P.) - all in Pennsylvania; the Department of Surgery, University of Tennessee Health Science Center, Knoxville (B.J.D.), and the Department of Surgery, Vanderbilt University Medical Center, Nashville (R.S.M.) - both in Tennessee; the Department of Surgery, University of Louisville, Louisville, KY (B.G.H.); MetroHealth Medical Center, Case Western Reserve University, Cleveland (J.A.C.); and the Department of Surgery, University of Texas Southwestern, Parkland Memorial Hospital, Dallas (H.A.P.) and Texas Health Harris Methodist Hospital (W.R.W.) and the John Peter Smith Health Network (T.M.D.), Fort Worth - all in Texas
| | - Timothy R Billiar
- From the Division of Trauma and General Surgery, Department of Surgery (J.L.S., J.B.B., L.H.A., B.S.Z., M.D.N., M.R.R., R.M.F., T.R.B., A.B.P., M.S.Z.), and the Departments of Emergency Medicine (F.X.G., C.W.C., D.M.Y.) and Critical Care Medicine (B.J.E.-Y., P.W.A.), University of Pittsburgh Medical Center, and the Department of Pathology, University of Pittsburgh and Institute for Transfusion Medicine (M.H.Y., D.J.T.), Pittsburgh, and University of Pittsburgh Medical Center, Altoona Hospital, Altoona (A.T.P.) - all in Pennsylvania; the Department of Surgery, University of Tennessee Health Science Center, Knoxville (B.J.D.), and the Department of Surgery, Vanderbilt University Medical Center, Nashville (R.S.M.) - both in Tennessee; the Department of Surgery, University of Louisville, Louisville, KY (B.G.H.); MetroHealth Medical Center, Case Western Reserve University, Cleveland (J.A.C.); and the Department of Surgery, University of Texas Southwestern, Parkland Memorial Hospital, Dallas (H.A.P.) and Texas Health Harris Methodist Hospital (W.R.W.) and the John Peter Smith Health Network (T.M.D.), Fort Worth - all in Texas
| | - Donald M Yealy
- From the Division of Trauma and General Surgery, Department of Surgery (J.L.S., J.B.B., L.H.A., B.S.Z., M.D.N., M.R.R., R.M.F., T.R.B., A.B.P., M.S.Z.), and the Departments of Emergency Medicine (F.X.G., C.W.C., D.M.Y.) and Critical Care Medicine (B.J.E.-Y., P.W.A.), University of Pittsburgh Medical Center, and the Department of Pathology, University of Pittsburgh and Institute for Transfusion Medicine (M.H.Y., D.J.T.), Pittsburgh, and University of Pittsburgh Medical Center, Altoona Hospital, Altoona (A.T.P.) - all in Pennsylvania; the Department of Surgery, University of Tennessee Health Science Center, Knoxville (B.J.D.), and the Department of Surgery, Vanderbilt University Medical Center, Nashville (R.S.M.) - both in Tennessee; the Department of Surgery, University of Louisville, Louisville, KY (B.G.H.); MetroHealth Medical Center, Case Western Reserve University, Cleveland (J.A.C.); and the Department of Surgery, University of Texas Southwestern, Parkland Memorial Hospital, Dallas (H.A.P.) and Texas Health Harris Methodist Hospital (W.R.W.) and the John Peter Smith Health Network (T.M.D.), Fort Worth - all in Texas
| | - Andrew B Peitzman
- From the Division of Trauma and General Surgery, Department of Surgery (J.L.S., J.B.B., L.H.A., B.S.Z., M.D.N., M.R.R., R.M.F., T.R.B., A.B.P., M.S.Z.), and the Departments of Emergency Medicine (F.X.G., C.W.C., D.M.Y.) and Critical Care Medicine (B.J.E.-Y., P.W.A.), University of Pittsburgh Medical Center, and the Department of Pathology, University of Pittsburgh and Institute for Transfusion Medicine (M.H.Y., D.J.T.), Pittsburgh, and University of Pittsburgh Medical Center, Altoona Hospital, Altoona (A.T.P.) - all in Pennsylvania; the Department of Surgery, University of Tennessee Health Science Center, Knoxville (B.J.D.), and the Department of Surgery, Vanderbilt University Medical Center, Nashville (R.S.M.) - both in Tennessee; the Department of Surgery, University of Louisville, Louisville, KY (B.G.H.); MetroHealth Medical Center, Case Western Reserve University, Cleveland (J.A.C.); and the Department of Surgery, University of Texas Southwestern, Parkland Memorial Hospital, Dallas (H.A.P.) and Texas Health Harris Methodist Hospital (W.R.W.) and the John Peter Smith Health Network (T.M.D.), Fort Worth - all in Texas
| | - Mazen S Zenati
- From the Division of Trauma and General Surgery, Department of Surgery (J.L.S., J.B.B., L.H.A., B.S.Z., M.D.N., M.R.R., R.M.F., T.R.B., A.B.P., M.S.Z.), and the Departments of Emergency Medicine (F.X.G., C.W.C., D.M.Y.) and Critical Care Medicine (B.J.E.-Y., P.W.A.), University of Pittsburgh Medical Center, and the Department of Pathology, University of Pittsburgh and Institute for Transfusion Medicine (M.H.Y., D.J.T.), Pittsburgh, and University of Pittsburgh Medical Center, Altoona Hospital, Altoona (A.T.P.) - all in Pennsylvania; the Department of Surgery, University of Tennessee Health Science Center, Knoxville (B.J.D.), and the Department of Surgery, Vanderbilt University Medical Center, Nashville (R.S.M.) - both in Tennessee; the Department of Surgery, University of Louisville, Louisville, KY (B.G.H.); MetroHealth Medical Center, Case Western Reserve University, Cleveland (J.A.C.); and the Department of Surgery, University of Texas Southwestern, Parkland Memorial Hospital, Dallas (H.A.P.) and Texas Health Harris Methodist Hospital (W.R.W.) and the John Peter Smith Health Network (T.M.D.), Fort Worth - all in Texas
| |
Collapse
|
32
|
Assessment of prehospital hemorrhage and airway care using a simulation model. J Trauma Acute Care Surg 2018; 85:S27-S32. [DOI: 10.1097/ta.0000000000001800] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
33
|
Abstract
Damage control surgery is a combination of temporizing surgical interventions to arrest hemorrhage and control infectious source, with goal directed resuscitation to restore normal physiology. The convention of damage control surgery largely arose following the discovery of the lethal triad of hypothermia, acidosis, and coagulopathy, with the goal of Damage Control Surgery (DCS) is to avoid the initiation of this "bloody vicious cycle" or to reverse its progression. While hypothermia and acidosis are generally corrected with resuscitation, coagulopathy remains a challenging aspect of DCS, and is exacerbated by excessive crystalloid administration. This chapter focuses on resuscitative principles in the four settings of trauma care: the prehospital setting, emergency department, operating room, and intensive care unit including historical perspectives, resuscitative methods, controversies, and future directions. Each setting provides unique challenges with specific goals of care.
Collapse
|
34
|
Naumann DN, Hancox JM, Raitt J, Smith IM, Crombie N, Doughty H, Perkins GD, Midwinter MJ. What fluids are given during air ambulance treatment of patients with trauma in the UK, and what might this mean for the future? Results from the RESCUER observational cohort study. BMJ Open 2018; 8:e019627. [PMID: 29362272 PMCID: PMC5786144 DOI: 10.1136/bmjopen-2017-019627] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
OBJECTIVES We investigated how often intravenous fluids have been delivered during physician-led prehospital treatment of patients with hypotensive trauma in the UK and which fluids were given. These data were used to estimate the potential national requirement for prehospital blood products (PHBP) if evidence from ongoing trials were to report clinical superiority. SETTING The Regional Exploration of Standard Care during Evacuation Resuscitation (RESCUER) retrospective observational study was a collaboration between 11 UK air ambulance services. Each was invited to provide up to 5 years of data and total number of taskings during the same period. PARTICIPANTS Patients with hypotensive trauma (systolic blood pressure <90 mm Hg or absent radial pulse) attended by a doctor. PRIMARY AND SECONDARY OUTCOME MEASURES The primary outcome was the number of patients with hypotensive trauma given prehospital fluids. Secondary outcomes were types and volumes of fluids. These data were combined with published data to estimate potential national eligibility for PHBP. RESULTS Of 29 037 taskings, 729 (2.5%) were for patients with hypotensive trauma attended by a physician. Half were aged 21-50 years; 73.4% were male. A total of 537 out of 729 (73.7%) were given fluids. Five hundred and ten patients were given a single type of fluid; 27 received >1 type. The most common fluid was 0.9% saline, given to 486/537 (90.5%) of patients who received fluids, at a median volume of 750 (IQR 300-1500) mL. Three per cent of patients received PHBP. Estimated projections for patients eligible for PHBP at these 11 services and in the whole UK were 313 and 794 patients per year, respectively. CONCLUSIONS One in 40 air ambulance taskings were manned by physicians to retrievepatients with hypotensive trauma. The most common fluid delivered was 0.9% saline. If evidence justifies universal provision of PHBP, approximately 800 patients/year would be eligible in the UK, based on our data combined with others published. Prospective investigations are required to confirm or adjust these estimations.
Collapse
Affiliation(s)
- David N Naumann
- NIHR Surgical Reconstruction and Microbiology Research Centre, Queen Elizabeth Hospital, Birmingham, UK
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - James M Hancox
- NIHR Surgical Reconstruction and Microbiology Research Centre, Queen Elizabeth Hospital, Birmingham, UK
- West Midlands Ambulance Service NHS Foundation Trust, Brierley Hill, UK
- Midlands Air Ambulance Charity, Stourbridge, West Midlands, UK
| | - James Raitt
- Thames Valley Air Ambulance, RAF Benson, Oxfordshire, UK
| | - Iain M Smith
- NIHR Surgical Reconstruction and Microbiology Research Centre, Queen Elizabeth Hospital, Birmingham, UK
| | - Nicholas Crombie
- NIHR Surgical Reconstruction and Microbiology Research Centre, Queen Elizabeth Hospital, Birmingham, UK
| | | | | | - Mark J Midwinter
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
- School of Biomedical Sciences, Faculty of Medicine, University of Queensland, Brisbane, Australia
| |
Collapse
|
35
|
Smith IM, Crombie N, Bishop JR, McLaughlin A, Naumann DN, Herbert M, Hancox JM, Slinn G, Ives N, Grant M, Perkins GD, Doughty H, Midwinter MJ. RePHILL: protocol for a randomised controlled trial of pre-hospital blood product resuscitation for trauma. Transfus Med 2017; 28:346-356. [PMID: 29193548 DOI: 10.1111/tme.12486] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2017] [Revised: 10/16/2017] [Accepted: 10/17/2017] [Indexed: 12/20/2022]
Abstract
OBJECTIVES To describe the 'Resuscitation with Pre-HospItaL bLood products' trial (RePHILL) - a multi-centre randomised controlled trial of pre-hospital blood product (PHBP) administration vs standard care for traumatic haemorrhage. BACKGROUND PHBP are increasingly used for pre-hospital trauma resuscitation despite a lack of robust evidence demonstrating superiority over crystalloids. Provision of PHBP carries additional logistical and regulatory implications, and requires a sustainable supply of universal blood components. METHODS RePHILL is a multi-centre, two-arm, parallel group, open-label, phase III randomised controlled trial currently underway in the UK. Patients attended by a pre-hospital emergency medical team, with traumatic injury and hypotension (systolic blood pressure <90 mmHg or absent radial pulse) believed to be due to traumatic haemorrhage are eligible. Exclusion criteria include age <16 years, blood product receipt on scene prior to randomisation, Advanced Medical Directive forbidding blood product administration, pregnancy, isolated head injury and prisoners. A total of 490 patients will be recruited in a 1 : 1 ratio to receive either the intervention (up to two units of red blood cells and two units of lyophilised plasma) or the control (up to four boluses of 250 mL 0.9% saline). The primary outcome measure is a composite of failure to achieve lactate clearance of ≥20%/h over the first 2 hours after randomisation and all-cause mortality between recruitment and discharge from the primary receiving facility to non-acute care. Secondary outcomes include pre-hospital time, coagulation indices, in-hospital transfusion requirements and morbidity. RESULTS Pilot study recruitment began in December 2016. Approval to proceed to the main trial was received in June 2017. Recruitment is expected to continue until 2020. CONCLUSIONS RePHILL will provide high-quality evidence regarding the efficacy and safety of PHBP resuscitation for trauma.
Collapse
Affiliation(s)
- I M Smith
- NIHR Surgical Reconstruction and Microbiology Research Centre, University of Birmingham, Birmingham, UK
| | - N Crombie
- NIHR Surgical Reconstruction and Microbiology Research Centre, University of Birmingham, Birmingham, UK.,Department of Anaesthesia, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.,West Midlands Ambulance Service Medical Emergency Response Incident Team, Brierley Hill, UK.,Midlands Air Ambulance, Stourbridge, UK
| | - J R Bishop
- NIHR Surgical Reconstruction and Microbiology Research Centre, University of Birmingham, Birmingham, UK.,Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - A McLaughlin
- NIHR Surgical Reconstruction and Microbiology Research Centre, University of Birmingham, Birmingham, UK
| | - D N Naumann
- NIHR Surgical Reconstruction and Microbiology Research Centre, University of Birmingham, Birmingham, UK
| | - M Herbert
- Department of Haematology, Royal Wolverhampton Hospitals NHS Trust, Wolverhampton, UK
| | - J M Hancox
- NIHR Surgical Reconstruction and Microbiology Research Centre, University of Birmingham, Birmingham, UK.,Midlands Air Ambulance, Stourbridge, UK
| | - G Slinn
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - N Ives
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - M Grant
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - G D Perkins
- West Midlands Ambulance Service Medical Emergency Response Incident Team, Brierley Hill, UK.,Warwick Clinical Trials Unit, University of Warwick, Coventry, UK.,Critical Care Unit, Heart of England NHS Foundation Trust, Birmingham, UK
| | - H Doughty
- NHS Blood and Transplant, Birmingham, UK
| | - M J Midwinter
- NIHR Surgical Reconstruction and Microbiology Research Centre, University of Birmingham, Birmingham, UK.,School of Biomedical Sciences, University of Queensland, Brisbane, Queensland, Australia
| | | |
Collapse
|
36
|
Prehospital plasma resuscitation associated with improved neurologic outcomes after traumatic brain injury. J Trauma Acute Care Surg 2017; 83:398-405. [PMID: 28538641 DOI: 10.1097/ta.0000000000001581] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Trauma-related hypotension and coagulopathy worsen secondary brain injury in patients with traumatic brain injuries (TBIs). Early damage control resuscitation with blood products may mitigate hypotension and coagulopathy. Preliminary data suggest resuscitation with plasma in large animals improves neurologic function after TBI; however, data in humans are lacking. METHODS We retrospectively identified all patients with multiple injuries age >15 years with head injuries undergoing prehospital resuscitation with blood products at a single Level I trauma center from January 2002 to December 2013. Inclusion criteria were prehospital resuscitation with either packed red blood cells (pRBCs) or thawed plasma as sole colloid resuscitation. Patients who died in hospital and those using anticoagulants were excluded. Primary outcomes were Glasgow Outcomes Score Extended (GOSE) and Disability Rating Score (DRS) at dismissal and during follow-up. RESULTS Of 76 patients meeting inclusion criteria, 53% (n = 40) received prehospital pRBCs and 47% (n = 36) received thawed plasma. Age, gender, injury severity or TBI severity, arrival laboratory values, and number of prehospital units were similar (all p > 0.05). Patients who received thawed plasma had an improved neurologic outcome compared to those receiving pRBCs (median GOSE 7 [7-8] vs. 5.5 [3-7], p < 0.001). Additionally, patients who received thawed plasma had improved functionality compared to pRBCs (median DRS 2 [1-3.5] vs. 9 [3-13], p < 0.001). Calculated GOSE and DRS scores during follow-up, median 6 [5-7] months, demonstrated increased function in those resuscitated with thawed plasma compared to pRBCs by both median GOSE (8 [7-8] vs. 6 [6-7], p < 0.001) and DRS (0 [0-1] vs. 4 [2-8], p < 0.001). CONCLUSION In critically injured trauma patients with TBI, early resuscitation with thawed plasma is associated with improved neurologic and functional outcomes at discharge and during follow-up compared to pRBCs alone. These preliminary data support the further investigation and use of plasma in the resuscitation of critically injured TBI patients. LEVEL OF EVIDENCE Therapeutic, level V.
Collapse
|
37
|
Abstract
The resuscitation of traumatic hemorrhagic shock has undergone a paradigm shift in the last 20 years with the advent of damage control resuscitation (DCR). Major principles of DCR include minimization of crystalloid, permissive hypotension, transfusion of a balanced ratio of blood products, and goal-directed correction of coagulopathy. In particular, plasma has replaced crystalloid as the primary means for volume expansion for traumatic hemorrhagic shock. Predicting which patient will require DCR by prompt and accurate activation of a massive transfusion protocol, however, remains a challenge.
Collapse
Affiliation(s)
- Ronald Chang
- Center for Translational Injury Research, University of Texas Health Science Center, 6410 Fannin Street, Suite 1100, Houston, TX 77030, USA.
| | - John B Holcomb
- Department of Surgery, University of Texas Health Science Center, 6410 Fannin Street, Suite 1100, Houston, TX 77030, USA
| |
Collapse
|
38
|
Air Medical Administration of Tranexamic Acid. J Trauma Nurs 2017; 24:30-33. [DOI: 10.1097/jtn.0000000000000259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
|
39
|
Pusateri AE, Given MB, Macdonald VW, Homer MJ. Comprehensive US government program for dried plasma development. Transfusion 2016; 56 Suppl 1:S16-23. [PMID: 27001356 PMCID: PMC7169678 DOI: 10.1111/trf.13331] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Transfusion of plasma early after severe injury has been associated with improved survival. There are significant logistic factors that limit the ability to deliver plasma where needed in austere environments, such as the battlefield or during a significant civilian emergency. While some countries have access to more logistically supportable dried plasma, there is no such product approved for use in the United States. There is a clear need for a Food and Drug Administration (FDA)‐approved dried plasma for military and emergency‐preparedness uses, as well as for civilian use in remote or austere settings. The Department of Defense (DoD) and Biomedical Advanced Research and Development Authority are sponsoring development of three dried plasma products, incorporating different technologic approaches and business models. At the same time, the DoD is sponsoring prospective, randomized clinical studies on the prehospital use of plasma. These efforts are part of a coordinated program to provide a dried plasma for military and civilian applications and to produce additional information on plasma use so that, by the time we have an FDA‐approved dried plasma, we will better understand how to use it.
Collapse
Affiliation(s)
| | | | - Victor W Macdonald
- US Army Medical Materiel Development Activity, US Army Medical Materiel Command, Fort Detrick, Maryland
| | - Mary J Homer
- Biomedical Advanced Research and Development Authority, Office of the Assistant Secretary for Preparedness and Response, US Department of Health and Human Services, Washington, DC
| |
Collapse
|
40
|
Janelle GM, Shore-Lesserson L, Smith CE, Levy JH, Shander A. What Is the PROPPR Transfusion Strategy in Trauma Resuscitation? Anesth Analg 2016; 122:1216-9. [PMID: 26991624 DOI: 10.1213/ane.0000000000001105] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Gregory M Janelle
- From the *Department of Anesthesiology, University of Florida, Gainesville, Florida; †Department of Anesthesiology, Hofstra Northshore-LIJ School of Medicine, Hempstead, New York; ‡Department of Anesthesiology, Case Western Reserve University, Cleveland, Ohio; Departments of §Anesthesiology and ‖Surgery, Duke University, Durham, North Carolina; and ¶Department of Anesthesiology, Englewood Hospital and Medical Center, Englewood, New Jersey
| | | | | | | | | |
Collapse
|
41
|
Wang H, Umejiego J, Robinson RD, Schrader CD, Leuck J, Barra M, Buca S, Shedd A, Bui A, Zenarosa NR. A Derivation and Validation Study of an Early Blood Transfusion Needs Score for Severe Trauma Patients. J Clin Med Res 2016; 8:591-7. [PMID: 27429680 PMCID: PMC4931805 DOI: 10.14740/jocmr2598w] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/26/2016] [Indexed: 01/11/2023] Open
Abstract
Background There is no existing adequate blood transfusion needs determination tool that Emergency Medical Services (EMS) personnel can use for prehospital blood transfusion initiation. In this study, a simple and pragmatic prehospital blood transfusion needs scoring system was derived and validated. Methods Local trauma registry data were reviewed retrospectively from 2004 through 2013. Patients were randomly assigned to derivation and validation cohorts. Multivariate logistic regression was used to identify the independent approachable risks associated with early blood transfusion needs in the derivation cohort in which a scoring system was derived. Sensitivity, specificity, and area under the receiver operational characteristic (AUC) were calculated and compared using both the derivation and validation data. Results A total of 24,303 patients were included with 12,151 patients in the derivation and 12,152 patients in the validation cohorts. Age, penetrating injury, heart rate, systolic blood pressure, and Glasgow coma scale (GCS) were risks predictive of early blood transfusion needs. An early blood transfusion needs score was derived. A score > 5 indicated risk of early blood transfusion need with a sensitivity of 83% and a specificity of 80%. A sensitivity of 82% and a specificity of 80% were also found in the validation study and their AUC showed no statistically significant difference (AUC of the derivation = 0.87 versus AUC of the validation = 0.86, P > 0.05). Conclusions An early blood transfusion scoring system was derived and internally validated to predict severe trauma patients requiring blood transfusion during prehospital or initial emergency department resuscitation.
Collapse
Affiliation(s)
- Hao Wang
- Department of Emergency Medicine, Integrative Emergency Services, John Peter Smith Health Network, 1500 S. Main St., Fort Worth, TX 76104, USA
| | - Johnbosco Umejiego
- Department of Emergency Medicine, Integrative Emergency Services, John Peter Smith Health Network, 1500 S. Main St., Fort Worth, TX 76104, USA
| | - Richard D Robinson
- Department of Emergency Medicine, Integrative Emergency Services, John Peter Smith Health Network, 1500 S. Main St., Fort Worth, TX 76104, USA
| | - Chet D Schrader
- Department of Emergency Medicine, Integrative Emergency Services, John Peter Smith Health Network, 1500 S. Main St., Fort Worth, TX 76104, USA
| | - JoAnna Leuck
- Department of Emergency Medicine, Integrative Emergency Services, John Peter Smith Health Network, 1500 S. Main St., Fort Worth, TX 76104, USA
| | - Michael Barra
- Department of Emergency Medicine, Integrative Emergency Services, John Peter Smith Health Network, 1500 S. Main St., Fort Worth, TX 76104, USA
| | - Stefan Buca
- Department of Emergency Medicine, Integrative Emergency Services, John Peter Smith Health Network, 1500 S. Main St., Fort Worth, TX 76104, USA
| | - Andrew Shedd
- Department of Emergency Medicine, Integrative Emergency Services, John Peter Smith Health Network, 1500 S. Main St., Fort Worth, TX 76104, USA
| | - Andrew Bui
- Department of Emergency Medicine, Integrative Emergency Services, John Peter Smith Health Network, 1500 S. Main St., Fort Worth, TX 76104, USA
| | - Nestor R Zenarosa
- Department of Emergency Medicine, Integrative Emergency Services, John Peter Smith Health Network, 1500 S. Main St., Fort Worth, TX 76104, USA
| |
Collapse
|
42
|
Briggs A, Askari R. Damage control resuscitation. Int J Surg 2016; 33:218-221. [PMID: 27107662 DOI: 10.1016/j.ijsu.2016.03.064] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2016] [Revised: 02/29/2016] [Accepted: 03/03/2016] [Indexed: 11/30/2022]
Affiliation(s)
- Alexandra Briggs
- Brigham and Women's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Reza Askari
- Brigham and Women's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA.
| |
Collapse
|
43
|
Dudaryk R, Sheffy N, Hess JR. Changing Paradigms in Hemostatic Resuscitation: Timing, Extent, Economic Impact, and the Role of Factor Concentrates. CURRENT ANESTHESIOLOGY REPORTS 2016. [DOI: 10.1007/s40140-016-0143-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
|