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Bath MF, Kohler K, Hobbs L, Smith BG, Clark DJ, Kwizera A, Perkins Z, Marsden M, Davenport R, Davies J, Amoako J, Moonesinghe R, Weiser T, Leather AJM, Hardcastle T, Naidoo R, Nördin Y, Conway Morris A, Lakhoo K, Hutchinson PJ, Bashford T. Evaluating patient factors, operative management and postoperative outcomes in trauma laparotomy patients worldwide: a protocol for a global observational multicentre trauma study. BMJ Open 2024; 14:e083135. [PMID: 38580358 PMCID: PMC11002395 DOI: 10.1136/bmjopen-2023-083135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Accepted: 03/05/2024] [Indexed: 04/07/2024] Open
Abstract
INTRODUCTION Trauma contributes to the greatest loss of disability-adjusted life-years for adolescents and young adults worldwide. In the context of global abdominal trauma, the trauma laparotomy is the most commonly performed operation. Variation likely exists in how these patients are managed and their subsequent outcomes, yet very little global data on the topic currently exists. The objective of the GOAL-Trauma study is to evaluate both patient and injury factors for those undergoing trauma laparotomy, their clinical management and postoperative outcomes. METHODS We describe a planned prospective multicentre observational cohort study of patients undergoing trauma laparotomy. We will include patients of all ages who present to hospital with a blunt or penetrating injury and undergo a trauma laparotomy within 5 days of presentation to the treating centre. The study will collect system, patient, process and outcome data, following patients up until 30 days postoperatively (or until discharge or death, whichever is first). Our sample size calculation suggests we will need to recruit 552 patients from approximately 150 recruiting centres. DISCUSSION The GOAL-Trauma study will provide a global snapshot of the current management and outcomes for patients undergoing a trauma laparotomy. It will also provide insight into the variation seen in the time delays for receiving care, the disease and patient factors present, and patient outcomes. For current standards of trauma care to be improved worldwide, a greater understanding of the current state of trauma laparotomy care is paramount if appropriate interventions and targets are to be identified and implemented.
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Affiliation(s)
- Michael F Bath
- International Health Systems Group, Department of Engineering, University of Cambridge, Cambridge, UK
| | - Katharina Kohler
- International Health Systems Group, Department of Engineering, University of Cambridge, Cambridge, UK
- Department of Anaesthesia, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Laura Hobbs
- International Health Systems Group, Department of Engineering, University of Cambridge, Cambridge, UK
- Department of Anaesthesia, East and North Hertfordshire NHS Trust, Stevenage, UK
| | - Brandon George Smith
- International Health Systems Group, Department of Engineering, University of Cambridge, Cambridge, UK
| | - David J Clark
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Arthur Kwizera
- Department of Anesthesia, Makerere University, Kampala, Uganda
| | - Zane Perkins
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, UK
- Major Trauma Service, Royal London Hospital, Barts Health NHS Trust, London, UK
| | - Max Marsden
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, UK
- Academic Department of Military Surgery and Trauma, Research and Clinical Innovation, Defence Medical Services, Birmingham, UK
| | - Ross Davenport
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, UK
- Major Trauma Service, Royal London Hospital, Barts Health NHS Trust, London, UK
| | - Justin Davies
- Cambridge Colorectal Unit, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
- Department of Surgery, University of Cambridge, Cambridge, UK
| | - Joachim Amoako
- Department of Surgery, Korle Bu Teaching Hospital, Accra, Ghana
- University of Ghana Medical School, Accra, Ghana
| | - Ramani Moonesinghe
- National Clinical Director for Critical and Perioperative Care, NHS England, London, UK
| | - Thomas Weiser
- Department of Surgery, Stanford University, Palo Alto, California, USA
| | - Andy J M Leather
- School of Life Course and Population Sciences, King's College London, London, UK
| | - Timothy Hardcastle
- Department of Surgical Sciences, Mandela School of Medicine (NRMSM), University of KwaZulu-Natal, Durban, South Africa
- Trauma and Burns Unit, Inkosi Albert Luthuli Central Hospital, KwaZulu-Natal Department of Health, Durban, South Africa
| | - Ravi Naidoo
- Department of Surgery, Ngwelezana Hospital, Empangeni, South Africa
| | - Yannick Nördin
- Emergency Medical Care System (SAMU), Jalisco State, Mexico
| | - Andrew Conway Morris
- Division of Anaesthesia, Department of Medicine, University of Cambridge, Cambridge, UK
| | - Kokila Lakhoo
- Department of Paediatric Surgery, University of Oxford, Oxford, UK
| | - Peter John Hutchinson
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
- NIHR Global Health Research Group on Acquired Brain and Spine Injury, Cambridge, UK
| | - Tom Bashford
- International Health Systems Group, Department of Engineering, University of Cambridge, Cambridge, UK
- Department of Anaesthesia, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
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Schofield H, Lindsay C, Brohi K, Davenport R. Group B or not group B? An association between ABO, early mortality, and organ dysfunction in major trauma patients with shock. J Thromb Haemost 2024; 22:676-685. [PMID: 38070741 DOI: 10.1016/j.jtha.2023.11.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Revised: 10/14/2023] [Accepted: 11/22/2023] [Indexed: 12/29/2023]
Abstract
BACKGROUND ABO blood group alters coagulation profiles in the general population and may influence outcomes after trauma. The relationship between trauma-induced coagulopathy, severe injury with hemorrhagic shock, and survival with respect to ABO group is unknown. OBJECTIVES In severe hemorrhagic trauma, we aimed to characterize the association of ABO group with admission coagulation profiles, mortality, and immune-mediated complications. METHODS Clinical and laboratory variables were examined from severely injured adult patients enrolled in a perpetual observational cohort study at a UK Major Trauma Center. Univariate and multivariate analyses were performed to determine differences in clinical outcomes (mortality, organ dysfunction, and critical care support). In a shock subgroup, we performed an exploratory analysis of rotational thromboelastometry parameters and coagulation biomarkers. RESULTS In 1119 trauma patients, we found no difference in mortality between ABO groups. In patients with shock, 24-hour mortality was significantly lower in group B vs non-B groups (7% vs 16%, adjusted odds ratio [aOR], 0.19; P = .030), but there were increased rates of invasive ventilation (aOR, 3.34; P = .033), renal replacement therapy (aOR, 2.55; P = .037), and a trend for infection (aOR, 1.85; P = .067). Comparing patients with shock, group B vs non-B patients had 40% higher fibrinogen, 65% higher factor (F) VIII, 36% higher FIX, 20% higher FXIII, and 19% higher von Willebrand factor. CONCLUSION In this observational study limited by single time-point sampling and subgroup analysis of trauma hemorrhage with shock, group B patients have enhanced hemostatic capability associated with early survival but with increased risk of immune-mediated complications.
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Affiliation(s)
- Henry Schofield
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, United Kingdom; Barts Health National Health Service Trust, London, United Kingdom.
| | - Charlotte Lindsay
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, United Kingdom; Barts Health National Health Service Trust, London, United Kingdom
| | - Karim Brohi
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, United Kingdom; Barts Health National Health Service Trust, London, United Kingdom
| | - Ross Davenport
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, United Kingdom; Barts Health National Health Service Trust, London, United Kingdom
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Juffermans NP, Gözden T, Brohi K, Davenport R, Acker JP, Reade MC, Maegele M, Neal MD, Spinella PC. Transforming research to improve therapies for trauma in the twenty-first century. Crit Care 2024; 28:45. [PMID: 38350971 PMCID: PMC10865682 DOI: 10.1186/s13054-024-04805-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2023] [Accepted: 01/11/2024] [Indexed: 02/15/2024] Open
Abstract
Improvements have been made in optimizing initial care of trauma patients, both in prehospital systems as well as in the emergency department, and these have also favorably affected longer term outcomes. However, as specific treatments for bleeding are largely lacking, many patients continue to die from hemorrhage. Also, major knowledge gaps remain on the impact of tissue injury on the host immune and coagulation response, which hampers the development of interventions to treat or prevent organ failure, thrombosis, infections or other complications of trauma. Thereby, trauma remains a challenge for intensivists. This review describes the most pressing research questions in trauma, as well as new approaches to trauma research, with the aim to bring improved therapies to the bedside within the twenty-first century.
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Affiliation(s)
- Nicole P Juffermans
- Department of Intensive Care, Erasmus Medical Center, Rotterdam, The Netherlands.
- Laboratory of Translational Intensive Care, Erasmus Medical Center, Rotterdam, The Netherlands.
| | - Tarik Gözden
- Laboratory of Translational Intensive Care, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Karim Brohi
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, UK
| | - Ross Davenport
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, UK
| | - Jason P Acker
- Canadian Blood Services, Innovation and Portfolio Management, Edmonton, AB, Canada
- Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, AB, Canada
| | - Michael C Reade
- Medical School, University of Queensland, Brisbane, QLD, Australia
- Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia
| | - Marc Maegele
- Department of Trauma and Orthopedic Surgery Cologne-Merheim Medical Center Institute of Research, Operative Medicine University Witten-Herdecke, Cologne, Germany
| | - Matthew D Neal
- Trauma and Transfusion Medicine Research Center, Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Philip C Spinella
- Trauma and Transfusion Medicine Research Center, Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
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Gunn F, Stevenson R, Almuwallad A, Rossetto A, Vulliamy P, Brohi K, Davenport R. A comparative analysis of tranexamic acid dosing strategies in traumatic major hemorrhage. J Trauma Acute Care Surg 2024; 96:216-224. [PMID: 37872678 DOI: 10.1097/ta.0000000000004177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2023]
Abstract
INTRODUCTION Tranexamic acid (TXA) is a life-saving treatment for traumatic hemorrhage, but the optimal dosing regimen remains unknown. Different doses and treatment strategies have been proposed, including single bolus, repeated bolus, or bolus plus infusion. The aim of this study was to determine the effect of different TXA dosing strategies on clinical outcomes in bleeding trauma patients. METHODS Secondary analysis of a perpetual cohort study from a UK Level I trauma center. Adult patients who activated the local major hemorrhage protocol and received TXA were included. The primary outcome was 28-day mortality. Secondary outcomes were 24-hour mortality, multiple organ dysfunction syndrome, venous thromboembolism, and rotational thromboelastometry fibrinolysis. RESULTS Over an 11-year period, 525 patients were included. Three dosing groups were identified: 1 g bolus only (n = 317), 1 g bolus +1 g infusion over 8 hours (n = 80), and 2 g bolus (n = 128). Demographics and admission physiology were similar, but there were differences in injury severity (median Injury Severity Score, 25, 29, and 25); and admission systolic blood pressure (median Systolic Blood Pressure, 99, 108, 99 mm Hg) across the 1-g, 1 g + 1 g, and 2-g groups. 28-day mortality was 21% in each treatment group. The incidence of multiple organ dysfunction syndrome was significantly higher in the bolus plus infusion group (84%) vs. 1 g bolus (64%) and 2 g bolus (62%) group, p = 0.002, but on multivariable analysis was nonsignificant. Venous thromboembolism rates were similar in the 1-g bolus (4%), 2 g bolus (8%) and bolus plus infusion groups (7%). There was no difference in rotational thromboelastometry maximum lysis at 24 hours: 5% in both the 1-g and 2-g bolus groups vs. 4% in bolus plus infusion group. CONCLUSION Clinical outcomes and 24-hour fibrinolysis state were equivalent across three different dosing strategies of TXA. Single bolus administration is likely preferable to a bolus plus infusion regimen. LEVEL OF EVIDENCE Therapeutic/Care Management; Level III.
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Affiliation(s)
- Finn Gunn
- From the Centre for Trauma Sciences, Blizard Institute, Barts and the London School of Medicine and Dentistry (F.G., R.S., A.A., A.R., P.V., K.B., R.D.), Queen Mary University of London; Barts Health National Health Service Trust (P.V., K.B., R.D.), London; Greater Glasgow and Clyde National Health Service Scotland (F.G.), Scotland; School of Medicine, Dentistry and Nursing (F.G.), University of Glasgow, Glasgow, United Kingdom; and Emergency Medical Services Department (A.A.), Faculty of Applied Medical Sciences, Jazan University, Kingdom of Saudi Arabia
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Almuwallad A, Cole E, Rossetto A, Brohi K, Perkins Z, Davenport R. Nationwide analysis of prehospital tranexamic acid for trauma demonstrates systematic bias in adherence to treatment guidelines: a retrospective cohort study. Int J Surg 2023; 109:3796-3803. [PMID: 37720941 PMCID: PMC10720772 DOI: 10.1097/js9.0000000000000712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Accepted: 08/13/2023] [Indexed: 09/19/2023]
Abstract
BACKGROUND Prehospital (PH) tranexamic acid (TXA) improves survival from trauma haemorrhage. Injury mechanism, physiology, and sex demographics vary with patient age. The authors hypothesised that these factors influence TXA guideline compliance and examined national trends in PH use to identify any systematic biases in bleeding management. MATERIALS AND METHODS The UK Trauma Audit and Research Network data for TXA eligible patients admitted to major trauma centres were divided into two cohorts: 2013-2015 ( n =32 072) and 2017-2019 ( n =14 974). Patients were stratified by PH, emergency department or no TXA use. Logistic regression models explored interaction between PH variables and TXA administration. Results are presented as odds ratios with a 95% CI. RESULTS PH TXA use increased from 8% to 27% over time ( P <0.001). Only 3% of eligible patients who fell less than 2 m received PH TXA versus 63% with penetrating injuries ( P <0.001). Older patients eligible for PH TXA were less likely to receive it compared to younger patients [≥65 years old: 590 (13%) vs. <65 years old: 3361 (33%), P <0.001]. There was a significant interaction between age and sex with fewer older women receiving PH TXA. In shocked patients, one third of females compared to a fifth of men did not receive TXA ( P <0.001). There was a decrease in PH TXA use as age increased ( P <0.001). CONCLUSIONS Despite a threefold increase in use, treatment guidance for PH TXA is not universally applied. Older people, women, and patients with low energy injury mechanisms appear to be systematically under treated. Training and education for PH providers should address these potential treatment biases.
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Affiliation(s)
- Ateeq Almuwallad
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London
- Emergency Medical Services Department, Faculty of Applied Medical Sciences, Jazan University, Kingdom of Saudi Arabia
| | - Elaine Cole
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London
| | - Andrea Rossetto
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London
- Barts Health National Health Service Trust, London, UK
| | - Karim Brohi
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London
- Barts Health National Health Service Trust, London, UK
| | - Zane Perkins
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London
- Barts Health National Health Service Trust, London, UK
| | - Ross Davenport
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London
- Barts Health National Health Service Trust, London, UK
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Abstract
PURPOSE OF REVIEW The use of Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) to temporarily control bleeding and improve central perfusion in critically injured trauma patients remains a controversial topic. In the last decade, select trauma services around the world have gained experience with REBOA. We discuss the recent observational data together with the initial results of the first randomized control trial and provide a view on the next steps for REBOA in trauma resuscitation. RECENT FINDINGS While the observational data continue to be conflicting, the first randomized control trial signals that in the UK, in-hospital REBOA is associated with harm. Likely a result of delays to haemorrhage control, views are again split on whether to abandon complex interventions in bleeding trauma patients and to only prioritize transfer to the operating room or to push REBOA earlier into the post injury phase, recognizing that some patients will not survive without intervention. SUMMARY Better understanding of cardiac shock physiology provides a new lens in which to evaluate REBOA through. Patient selection remains a huge challenge. Invasive blood pressure monitoring, combined with machine learning aided decision support may assist clinicians and their patients in the future. The use of REBOA should not delay definitive haemorrhage control in those patients without impending cardiac arrest.
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Affiliation(s)
- Max Marsden
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, UK
- Academic Department of Military Surgery and Trauma, Research and Clinical Innovation, Birmingham
| | - Robert Lendrum
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, UK
- London's Air Ambulance
- Department of Perioperative Medicine, St. Bartholomew's Hospital, Barts Health NHS Trust, London, UK
| | - Ross Davenport
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, UK
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Davenport R, Curry N, Fox EE, Thomas H, Lucas J, Evans A, Shanmugaranjan S, Sharma R, Deary A, Edwards A, Green L, Wade CE, Benger JR, Cotton BA, Stanworth SJ, Brohi K. Early and Empirical High-Dose Cryoprecipitate for Hemorrhage After Traumatic Injury: The CRYOSTAT-2 Randomized Clinical Trial. JAMA 2023; 330:1882-1891. [PMID: 37824155 PMCID: PMC10570921 DOI: 10.1001/jama.2023.21019] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Accepted: 09/26/2023] [Indexed: 10/13/2023]
Abstract
Importance Critical bleeding is associated with a high mortality rate in patients with trauma. Hemorrhage is exacerbated by a complex derangement of coagulation, including an acute fibrinogen deficiency. Management is fibrinogen replacement with cryoprecipitate transfusions or fibrinogen concentrate, usually administered relatively late during hemorrhage. Objective To assess whether survival could be improved by administering an early and empirical high dose of cryoprecipitate to all patients with trauma and bleeding that required activation of a major hemorrhage protocol. Design, Setting, and Participants CRYOSTAT-2 was an interventional, randomized, open-label, parallel-group controlled, international, multicenter study. Patients were enrolled at 26 UK and US major trauma centers from August 2017 to November 2021. Eligible patients were injured adults requiring activation of the hospital's major hemorrhage protocol with evidence of active hemorrhage, systolic blood pressure less than 90 mm Hg at any time, and receiving at least 1 U of a blood component transfusion. Intervention Patients were randomly assigned (in a 1:1 ratio) to receive standard care, which was the local major hemorrhage protocol (reviewed for guideline adherence), or cryoprecipitate, in which 3 pools of cryoprecipitate (6-g fibrinogen equivalent) were to be administered in addition to standard care within 90 minutes of randomization and 3 hours of injury. Main Outcomes and Measures The primary outcome was all-cause mortality at 28 days in the intention-to-treat population. Results Among 1604 eligible patients, 799 were randomized to the cryoprecipitate group and 805 to the standard care group. Missing primary outcome data occurred in 73 patients (principally due to withdrawal of consent) and 1531 (95%) were included in the primary analysis population. The median (IQR) age of participants was 39 (26-55) years, 1251 (79%) were men, median (IQR) Injury Severity Score was 29 (18-43), 36% had penetrating injury, and 33% had systolic blood pressure less than 90 mm Hg at hospital arrival. All-cause 28-day mortality in the intention-to-treat population was 26.1% in the standard care group vs 25.3% in the cryoprecipitate group (odds ratio, 0.96 [95% CI, 0.75-1.23]; P = .74). There was no difference in safety outcomes or incidence of thrombotic events in the standard care vs cryoprecipitate group (12.9% vs 12.7%). Conclusions and Relevance Among patients with trauma and bleeding who required activation of a major hemorrhage protocol, the addition of early and empirical high-dose cryoprecipitate to standard care did not improve all cause 28-day mortality. Trial Registration ClinicalTrials.gov Identifier: NCT04704869; ISRCTN Identifier: ISRCTN14998314.
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Affiliation(s)
- Ross Davenport
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, United Kingdom
| | - Nicola Curry
- Nuffield Orthopedic Hospital, Oxford University Hospitals NHS Foundation Trust, Headington, Oxford, United Kingdom
| | - Erin E. Fox
- Center for Translational Injury Research, The University of Texas Health Science Center, Houston
| | - Helen Thomas
- NHS Blood and Transplant Clinical Trials Unit, Stoke Gifford, Bristol, United Kingdom
| | - Joanne Lucas
- NHS Blood and Transplant Clinical Trials Unit, Cambridge, United Kingdom
| | - Amy Evans
- NHS Blood and Transplant Clinical Trials Unit, Cambridge, United Kingdom
| | | | - Rupa Sharma
- NHS Blood and Transplant Clinical Trials Unit, Cambridge, United Kingdom
| | - Alison Deary
- NHS Blood and Transplant Clinical Trials Unit, Cambridge, United Kingdom
| | - Antoinette Edwards
- The Trauma Audit & Research Network, University of Manchester, Salford Royal NHS Foundation Trust, Salford, United Kingdom
| | - Laura Green
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, United Kingdom
| | - Charles E. Wade
- Center for Translational Injury Research, The University of Texas Health Science Center, Houston
| | - Jonathan R. Benger
- Faculty of Health and Applied Sciences, University of the West of England, Bristol, United Kingdom
| | - Bryan A. Cotton
- Center for Translational Injury Research, The University of Texas Health Science Center, Houston
| | - Simon J. Stanworth
- Radcliffe Department of Medicine, John Radcliffe Hospital, NHS Blood and Transplant and Oxford University Hospitals NHS Foundation Trust, University of Oxford, Headington, Oxford, United Kingdom
| | - Karim Brohi
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, United Kingdom
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Hannadjas I, James A, Davenport R, Lindsay C, Brohi K, Cole E. Prothrombin complex concentrate (PCC) for treatment of trauma-induced coagulopathy: systematic review and meta-analyses. Crit Care 2023; 27:422. [PMID: 37919775 PMCID: PMC10621181 DOI: 10.1186/s13054-023-04688-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 10/14/2023] [Indexed: 11/04/2023] Open
Abstract
BACKGROUND Trauma-induced coagulopathy (TIC) is common in trauma patients with major hemorrhage. Prothrombin complex concentrate (PCC) is used as a potential treatment for the correction of TIC, but the efficacy, timing, and evidence to support its use in injured patients with hemorrhage are unclear. METHODS A systematic search of published studies was performed on MEDLINE and EMBASE databases using standardized search equations. Ongoing studies were identified using clinicaltrials.gov. Studies investigating the use of PCC to treat TIC (on its own or in combination with other treatments) in adult major trauma patients were included. Studies involving pediatric patients, studies of only traumatic brain injury (TBI), and studies involving only anticoagulated patients were excluded. Primary outcomes were in-hospital mortality and venous thromboembolism (VTE). Pooled effects of PCC use were reported using random-effects model meta-analyses. Risk of bias was assessed for each study, and we used the Grading of Recommendations Assessment, Development, and Evaluation to assess the quality of evidence. RESULTS After removing duplicates, 1745 reports were screened and nine observational studies and one randomized controlled trial (RCT) were included, with a total of 1150 patients receiving PCC. Most studies used 4-factor-PCC with a dose of 20-30U/Kg. Among observational studies, co-interventions included whole blood (n = 1), fibrinogen concentrate (n = 2), or fresh frozen plasma (n = 4). Outcomes were inconsistently reported across studies with wide variation in both measurements and time points. The eight observational studies included reported mortality with a pooled odds ratio of 0.97 [95% CI 0.56-1.69], and five reported deep venous thrombosis (DVT) with a pooled OR of 0.83 [95% CI 0.44-1.57]. When pooling the observational studies and the RCT, the OR for mortality and DVT was 0.94 [95% CI 0.60-1.45] and 1.00 [95% CI 0.64-1.55] respectively. CONCLUSIONS Among published studies of TIC, PCCs did not significantly reduce mortality, nor did they increase the risk of VTE. However, the potential thrombotic risk remains a concern that should be addressed in future studies. Several RCTs are currently ongoing to further explore the efficacy and safety of PCC.
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Affiliation(s)
- Ioannis Hannadjas
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, England
| | - Arthur James
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, England.
- GRC 29, AP-HP, DMU DREAM, Department of Anaesthesiology and Critical Care, Pitié-Salpêtrière Hospital, Sorbonne University, 47-83 Boulevard de l'Hôpital, 75013, Paris, France.
| | - Ross Davenport
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, England
| | - Charlotte Lindsay
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, England
| | - Karim Brohi
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, England
| | - Elaine Cole
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, England
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Rossetto A, Torres T, Platton S, Vulliamy P, Curry N, Davenport R. A new global fibrinolysis capacity assay for the sensitive detection of hyperfibrinolysis and hypofibrinogenemia in trauma patients. J Thromb Haemost 2023; 21:2759-2770. [PMID: 37207863 DOI: 10.1016/j.jtha.2023.05.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2023] [Revised: 04/14/2023] [Accepted: 05/05/2023] [Indexed: 05/21/2023]
Abstract
BACKGROUND Conventional clotting tests are not expeditious enough to allow timely targeted interventions in trauma, and current point-of-care analyzers, such as rotational thromboelastometry (ROTEM), have limited sensitivity for hyperfibrinolysis and hypofibrinogenemia. OBJECTIVES To evaluate the performance of a recently developed global fibrinolysis capacity (GFC) assay in identifying fibrinolysis and hypofibrinogenemia in trauma patients. METHODS Exploratory analysis of a prospective cohort of adult trauma patients admitted to a single UK major trauma center and of commercially available healthy donor samples was performed. Lysis time (LT) was measured in plasma according to the GFC manufacturer's protocol, and a novel fibrinogen-related parameter (percentage reduction in GFC optical density from baseline at 1 minute) was derived from the GFC curve. Hyperfibrinolysis was defined as a tissue factor-activated ROTEM maximum lysis of >15% or LT of ≤30 minutes. RESULTS Compared to healthy donors (n = 19), non-tranexamic acid-treated trauma patients (n = 82) showed shortened LT, indicative of hyperfibrinolysis (29 minutes [16-35] vs 43 minutes [40-47]; p < .001). Of the 63 patients without overt ROTEM-hyperfibrinolysis, 31 (49%) had LT of ≤30 minutes, with 26% (8 of 31) of them requiring major transfusions. LT showed increased accuracy compared to maximum lysis in predicting 28-day mortality (area under the receiver operating characteristic curve, 0.96 [0.92-1.00] vs 0.65 [0.49-0.81]; p = .001). Percentage reduction in GFC optical density from baseline at 1 minute showed comparable specificity (76% vs 79%) to ROTEM clot amplitude at 5 minutes from tissue factor-activated ROTEM with cytochalasin D in detecting hypofibrinogenemia but correctly reclassified >50% of the patients with false negative results, leading to higher sensitivity (90% vs 77%). CONCLUSION Severe trauma patients are characterized by a hyperfibrinolytic profile upon admission to the emergency department. The GFC assay is more sensitive than ROTEM in capturing hyperfibrinolysis and hypofibrinogenemia but requires further development and automation.
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Affiliation(s)
- Andrea Rossetto
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, UK; Barts Health National Health Service Trust, London, UK.
| | - Tracy Torres
- Barts Health National Health Service Trust, London, UK
| | - Sean Platton
- Barts Health National Health Service Trust, London, UK
| | - Paul Vulliamy
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, UK; Barts Health National Health Service Trust, London, UK
| | - Nicola Curry
- Oxford Haemophilia & Thrombosis Centre, Oxford University Hospitals Foundation Trust, Oxford, UK
| | - Ross Davenport
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, UK; Barts Health National Health Service Trust, London, UK
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10
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Rossetto A, Wohlgemut JM, Brohi K, Davenport R. Sonorheometry versus rotational thromboelastometry in trauma: a comparison of diagnostic and prognostic performance. J Thromb Haemost 2023:S1538-7836(23)00391-4. [PMID: 37164268 DOI: 10.1016/j.jtha.2023.04.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 04/28/2023] [Accepted: 04/28/2023] [Indexed: 05/12/2023]
Abstract
BACKGROUND Rotational thromboelastometry (ROTEM) is used to rapidly identify trauma-induced coagulopathy (TIC) and direct targeted interventions in hemorrhaging trauma patients. A novel technology, Quantra® System, utilizes sonic estimation of elasticity via resonance (SEER) sonorheometry, avoids mechanical clot interference and may increase diagnostic accuracy, but there is limited data in bleeding major trauma patients. OBJECTIVES To compare the performance of Quantra vs ROTEM for rapid diagnosis of TIC and prediction of transfusion requirements and mortality. METHODS Samples were collected from adult trauma patients enrolled into a perpetual cohort study upon admission to a single Level 1 trauma center between 2020-2021. Samples were analyzed using Quantra, ROTEM, multiple electrode aggregometry and conventional coagulation assays. RESULTS Samples from 209 patients were analyzed. Correlations were strong between Quantra and ROTEM parameters (all p<0.001): r=0.90 for clot stiffness (CS) and EXTEM A5; r=0.85 for fibrinogen contribution to clot stiffness (FCS) and FIBTEM A5; and r=0.73 for platelet contribution to clot stiffness (PCS) and EXTEM-FIBTEM A5. While CS showed higher discrimination than EXTEM A5 in detecting TIC (INR >1.2, AUROC 0.83 vs 0.79, p=0.038), the ability of FCS to detect hypofibrinogenemia (fibrinogen <2g/L) was good, but lower than FIBTEM A5 (AUROC 0.79 vs 0.84, p=0.027). There was no difference between Quantra and ROTEM in detecting platelet count <150×109/L, predicting rapid transfusion or mortality at 6hr. CONCLUSION Quantra and ROTEM have similar diagnostic performance in evaluating TIC and predicting clinically relevant outcomes. Larger studies are required to determine the utility of Quantra for goal-directed treatment of TIC.
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Affiliation(s)
- Andrea Rossetto
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, United Kingdom; Barts Health National Health Service Trust, London, United Kingdom.
| | - Jared M Wohlgemut
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, United Kingdom; Barts Health National Health Service Trust, London, United Kingdom
| | - Karim Brohi
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, United Kingdom; Barts Health National Health Service Trust, London, United Kingdom
| | - Ross Davenport
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, United Kingdom; Barts Health National Health Service Trust, London, United Kingdom
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11
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Curry N, Davenport R, Lucas J, Deary A, Benger J, Edwards A, Evans A, Foley C, Green L, Morris S, Thomas H, Brohi K, Stanworth SJ. The CRYOSTAT2 trial: The rationale and study protocol for a multi-Centre, randomised, controlled trial evaluating the effects of early high-dose cryoprecipitate in adult patients with major trauma haemorrhage requiring major haemorrhage protocol activation. Transfus Med 2023; 33:123-131. [PMID: 36321753 DOI: 10.1111/tme.12932] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Revised: 09/05/2022] [Accepted: 10/03/2022] [Indexed: 11/05/2022]
Abstract
OBJECTIVES To describe the protocol for a multinational randomised, parallel, superiority trial, in which patients were randomised to receive early high-dose cryoprecipitate in addition to standard major haemorrhage protocol (MHP), or Standard MHP alone. BACKGROUND Blood transfusion support for trauma-related major bleeding includes red cells, plasma and platelets. The role of concentrated sources of fibrinogen is less clear and has not been evaluated in large clinical trials. Fibrinogen is a key pro-coagulant factor that is essential for stable clot formation. A pilot trial had demonstrated that it was feasible to deliver cryoprecipitate as a source of fibrinogen within 90 min of admission. METHODS Randomisation was via opaque sealed envelopes held securely in participating Emergency Departments or transfusion laboratories. Early cryoprecipitate, provided as 3 pools (equivalent to 15 single units of cryoprecipitate or 6 g fibrinogen supplementation), was transfused as rapidly as possible, and started within 90 min of admission. Participants in both arms received standard treatment defined in the receiving hospital MHP. The primary outcome measure was all-cause mortality at 28 days. Symptomatic thrombotic events including venous thromboembolism and arterial thrombotic events (myocardial infarction, stroke) were collected from randomisation up to day 28 or discharge from hospital. EQ5D-5Land Glasgow Outcome Score were completed at discharge and 6 months. All analyses will be performed on an intention to treat basis, with per protocol sensitivity analysis. RESULTS The trial opened for recruitment in June 2017 and the final patient completed follow-up in May 2022. DISCUSSION This trial will provide firmer evidence to evaluate the effectiveness and cost-effectiveness of early high-dose cryoprecipitate alongside the standard MHP in major traumatic haemorrhage.
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Affiliation(s)
- Nicola Curry
- Oxford UniversityHospitals NHS Foundation Trust, Nuffield Orthopaedic Hospital, Oxford, UK
| | - Ross Davenport
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, UK
| | - Joanne Lucas
- NHS Blood and Transplant Clinical Trials Unit, Cambridge, UK
| | - Alison Deary
- NHS Blood and Transplant Clinical Trials Unit, Cambridge, UK
| | - Jonathan Benger
- Faculty of Health and Applied Sciences, University of the West of England, Bristol, UK
| | - Antoinette Edwards
- Trauma Audit and Research Network, Salford Royal Hospital, Northern Care Alliance NHS Foundation Trust, Salford, UK
| | - Amy Evans
- NHS Blood and Transplant Clinical Trials Unit, Cambridge, UK
| | - Claire Foley
- NHS Blood and Transplant Clinical Trials Unit, Cambridge, UK
| | - Laura Green
- Blizard Institute, Queen Mary University of London, London, UK
- NHS Blood and Transplant and Bart's Health NHS Trust, London, UK
| | - Stephen Morris
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Helen Thomas
- NHS Blood and Transplant Clinical Trials Unit, Bristol, UK
| | - Karim Brohi
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, UK
| | - Simon J Stanworth
- NHS Blood and Transplant and Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford, UK
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12
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Hurndall KH, Merriman H, Leatherby R, Glasgow S, Davenport R. Vascular Interventions and Surgery in Trauma Audit (VISTA). BJS Open 2023; 7:7117405. [PMID: 37052934 PMCID: PMC10101046 DOI: 10.1093/bjsopen/zrad012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Accepted: 01/14/2023] [Indexed: 04/14/2023] Open
Affiliation(s)
- Katherine-Helen Hurndall
- Centre for Trauma Sciences, Blizzard Institute, Queen Mary University of London, London, UK
- Department of Vascular Surgery, The Royal Free Hospital, London, UK
| | - Hannah Merriman
- Department of Vascular Surgery, Glenfield Hospital, Leicester, UK
| | - Robert Leatherby
- Department of Vascular Surgery, Royal Bournemouth Hospital, Bournemouth, UK
| | - Simon Glasgow
- Imperial Vascular Unit, Imperial College Healthcare NHS Trust, St. Mary's Hospital, London, UK
| | - Ross Davenport
- Centre for Trauma Sciences, Blizzard Institute, Queen Mary University of London, London, UK
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13
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Curry NS, Davenport R, Wong H, Gaarder C, Johansson P, Juffermans NP, Maegele M, Stensballe J, Brohi K, Laffan M, Stanworth SJ. Traumatic coagulopathy in the older patient: analysis of coagulation profiles from the Activation of Coagulation and Inflammation in Trauma-2 (ACIT-2) observational, multicenter study. J Thromb Haemost 2023; 21:215-226. [PMID: 36700506 DOI: 10.1016/j.jtha.2022.11.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Revised: 10/19/2022] [Accepted: 11/04/2022] [Indexed: 01/26/2023]
Abstract
BACKGROUND Most studies describing traumatic coagulopathy have used data from patient cohorts with an average age of between 35 and 45 years. The last 10 years has seen a steep increase in the number of patients admitted with significant injury and bleeding who are older than the age of 65 years. Many coagulation protein levels alter significantly with normal aging, and it is possible that traumatic coagulopathy has a different signature with age. OBJECTIVES The aim of this study was to report the coagulation profiles, including standard and extended laboratory, as well as viscoelastic hemostatic assays, stratified according to age to explore age-related differences in hemostatic capability. METHODS In total, 1576 patients were analyzed from 6 European level 1 trauma centers. RESULTS As age increased, there was evidence of higher fibrinogen, greater thrombin generation, greater clotting factor consumption, and greater activation of fibrinolysis. Despite this, shock and severe injury led to the same pattern of changes within age groups: lower procoagulant factors (including fibrinogen), increased fibrinolysis, and higher levels of activated protein C. Thromboelastography and rotational thromboelastometry tests detected traumatic coagulopathy with prolongation of R/clotting time and reductions in clot amplitudes in each age cohort. Advancing age strongly correlated with higher fibrinogen levels and greater fibrinolysis. CONCLUSION Age-related coagulation changes are evident in injured patients. Broadly, similar patterns of coagulation abnormalities are seen across age groups following severe injury/shock, but thresholds for single clotting factors differ. Age-related differences may need to be considered when clinical treatments (eg, transfusion therapy) are indicated.
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Affiliation(s)
- Nicola S Curry
- Oxford Haemophilia and Thrombosis Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom; Radcliffe Department of Medicine, Oxford University, Oxford, United Kingdom.
| | - Ross Davenport
- Trauma Sciences, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
| | - Henna Wong
- Radcliffe Department of Medicine, Oxford University, Oxford, United Kingdom
| | | | - Pär Johansson
- Department of Anesthesiology and Trauma Center, and Section for Transfusion Medicine, Capital Region Blood Bank, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Nicole P Juffermans
- Department of Intensive Care Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Marc Maegele
- Department of Traumatology and Orthopaedic Surgery, Cologne-Merheim Medical Center, University of Witten/Herdecke, Cologne, Germany
| | - Jakob Stensballe
- Department of Anesthesiology and Trauma Center, and Section for Transfusion Medicine, Capital Region Blood Bank, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Karim Brohi
- Trauma Sciences, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
| | - Mike Laffan
- Imperial College and Hammersmith Hospital, London, United Kingdom
| | - Simon J Stanworth
- Radcliffe Department of Medicine, Oxford University, Oxford, United Kingdom; NHS Blood and Transplant, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
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14
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Tucker H, Brohi K, Tan J, Aylwin C, Bloomer R, Cardigan R, Davenport R, Davies ED, Godfrey P, Hawes R, Lyon R, McCullagh J, Stanworth S, Thompson J, Uprichard J, Walsh S, Weaver A, Green L. Association of red blood cells and plasma transfusion versus red blood cell transfusion only with survival for treatment of major traumatic hemorrhage in prehospital setting in England: a multicenter study. Crit Care 2023; 27:25. [PMID: 36650557 PMCID: PMC9847037 DOI: 10.1186/s13054-022-04279-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 12/14/2022] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND In-hospital acute resuscitation in trauma has evolved toward early and balanced transfusion resuscitation with red blood cells (RBC) and plasma being transfused in equal ratios. Being able to deliver this ratio in prehospital environments is a challenge. A combined component, like leukocyte-depleted red cell and plasma (RCP), could facilitate early prehospital resuscitation with RBC and plasma, while at the same time improving logistics for the team. However, there is limited evidence on the clinical benefits of RCP. OBJECTIVE To compare prehospital transfusion of combined RCP versus RBC alone or RBC and plasma separately (RBC + P) on mortality in trauma bleeding patients. METHODS Data were collected prospectively on patients who received prehospital transfusion (RBC + thawed plasma/Lyoplas or RCP) for traumatic hemorrhage from six prehospital services in England (2018-2020). Retrospective data on patients who transfused RBC from 2015 to 2018 were included for comparison. The association between transfusion arms and 24-h and 30-day mortality, adjusting for age, injury mechanism, age, prehospital heart rate and blood pressure, was evaluated using generalized estimating equations. RESULTS Out of 970 recruited patients, 909 fulfilled the study criteria (RBC + P = 391, RCP = 295, RBC = 223). RBC + P patients were older (mean age 42 vs 35 years for RCP and RBC), and 80% had a blunt injury (RCP = 52%, RBC = 56%). RCP and RBC + P were associated with lower odds of death at 24-h, compared to RBC alone (adjusted odds ratio [aOR] 0.69 [95%CI: 0.52; 0.92] and 0.60 [95%CI: 0.32; 1.13], respectively). The lower odds of death for RBC + P and RCP vs RBC were driven by penetrating injury (aOR 0.22 [95%CI: 0.10; 0.53] and 0.39 [95%CI: 0.20; 0.76], respectively). There was no association between RCP or RBC + P with 30-day survival vs RBC. CONCLUSION Prehospital plasma transfusion for penetrating injury was associated with lower odds of death at 24-h compared to RBC alone. Large trials are needed to confirm these findings.
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Affiliation(s)
- Harriet Tucker
- grid.4868.20000 0001 2171 1133Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, 4 Newark Street, London, E1 2AT UK
| | - Karim Brohi
- grid.4868.20000 0001 2171 1133Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, 4 Newark Street, London, E1 2AT UK ,grid.139534.90000 0001 0372 5777Barts Health NHS Trust, London, UK
| | - Joachim Tan
- grid.264200.20000 0000 8546 682XSt George’s University of London, London, UK
| | - Christopher Aylwin
- grid.426467.50000 0001 2108 8951St Mary’s Hospital, Imperial College NHS Foundation Trust, London, UK
| | - Roger Bloomer
- grid.429705.d0000 0004 0489 4320Kings College Hospital NHS Foundation Trust, London, UK
| | - Rebecca Cardigan
- grid.436365.10000 0000 8685 6563NHS Blood and Transplant, Cambridge, UK
| | - Ross Davenport
- grid.4868.20000 0001 2171 1133Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, 4 Newark Street, London, E1 2AT UK ,grid.139534.90000 0001 0372 5777Barts Health NHS Trust, London, UK
| | - Edward D. Davies
- grid.416204.50000 0004 0391 9602Royal Preston Hospital, Preston, UK
| | - Phillip Godfrey
- grid.411812.f0000 0004 0400 2812James Cook University Hospital, Middlesbrough, UK
| | - Rachel Hawes
- Newcastle Upon Tyne NHS Foundation Trust, Newcastle, UK ,Great North Air Ambulance, Stockton-on-Tees, UK
| | | | | | - Simon Stanworth
- grid.436365.10000 0000 8685 6563NHS Blood and Transplant, Cambridge, UK ,grid.4991.50000 0004 1936 8948Oxford University Hospital NHS Foundation Trust, Oxford, UK
| | - Julian Thompson
- grid.416201.00000 0004 0417 1173Southmead Hospital, Bristol, UK ,Great West Air Ambulance, Bristol, UK
| | - James Uprichard
- grid.264200.20000 0000 8546 682XSt George’s University Hospital NHS Foundation Trust, London, UK
| | - Simon Walsh
- grid.426467.50000 0001 2108 8951St Mary’s Hospital, Imperial College NHS Foundation Trust, London, UK ,Essex and Hertfordshire Air Ambulance Trust, Essex, UK
| | - Anne Weaver
- grid.139534.90000 0001 0372 5777Barts Health NHS Trust, London, UK
| | - Laura Green
- grid.4868.20000 0001 2171 1133Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, 4 Newark Street, London, E1 2AT UK ,grid.139534.90000 0001 0372 5777Barts Health NHS Trust, London, UK ,grid.436365.10000 0000 8685 6563NHS Blood and Transplant, Cambridge, UK
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15
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Wong J, Mellor J, Memon G, Baker H, Allu S, Amin F, Sukthankar A, Mather S, Davenport R. 1301 OUTCOMES FROM A PILOT PROJECT OFFERING FRAIL OLDER ADULTS LIVING WITH HIV A VIRTUAL MDT COMPREHENSIVE GERIATRIC ASSESSMENT. Age Ageing 2023. [DOI: 10.1093/ageing/afac322.101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
Abstract
Introduction
Advancements in HIV treatment has resulted in an ageing population in people living with HIV (PLWH). Increasing prevalence of frailty in older PLWH has been demonstrated, giving rise to multi-morbidities, polypharmacy and consequently, complex medical and social needs. Approximately 5650 people are living with HIV across Greater Manchester. With increasing patient complexity, a pathway was developed to help provide holistic care and improve quality of life for older adults living with HIV.
Methods
A pilot involving multi-disciplinary professionals from the hospital frailty, HIV and community teams was established. Patients were screened using the Clinical Frailty Scale and patients with a CFS ≥ 4 were referred for completion of a comprehensive geriatric assessment (CGA). Patients would then be discussed at the Frailty MDT meeting, where action plans were devised.
Results
47 patients were assessed between October 2020 to December 2021, with 30 eligible for review in the frailty clinic. Commonly reported issues were mobility n=26 (86.6%), pain n=23 (76.6%), low mood n= 14 (46.6%), memory issues n=3 (43.3%) and falls n=12 (40%). Following MDT recommendations, 8 (26.6%) referrals were completed for social care, 1 (3%) referral for safeguarding and 9 (30%) referrals for active case management community teams for co-ordination of care in the community. Deprescribing recommendations were suggested for 16 (53.3%) patients and new medicine recommendations made for 24 (80%) patients.
Conclusion
A collaborative MDT approach to managing older PLWH can facilitate formulation of action plans to address patients physical, psychological and social needs.
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Affiliation(s)
- J Wong
- Manchester University NHS Foundation Trust
| | - J Mellor
- Manchester University NHS Foundation Trust
| | - G Memon
- Manchester University NHS Foundation Trust
| | - H Baker
- Manchester University NHS Foundation Trust
| | - S Allu
- Manchester University NHS Foundation Trust
| | - F Amin
- Manchester University NHS Foundation Trust
| | | | - S Mather
- Manchester University NHS Foundation Trust
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16
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Davenport R, Weaver A, Green L. Prehospital blood transfusion: Can we agree on a standardised approach? Injury 2023; 54:1-2. [PMID: 36587956 DOI: 10.1016/j.injury.2022.12.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Affiliation(s)
- Ross Davenport
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, UK; Royal London Major Trauma Centre, Barts Health NHS Trust, London, UK
| | - Anne Weaver
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, UK; London's Air Ambulance, Royal London Hospital, London, UK; Royal London Major Trauma Centre, Barts Health NHS Trust, London, UK
| | - Laura Green
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, UK; NHS Blood & Transplant, London, UK; Royal London Major Trauma Centre, Barts Health NHS Trust, London, UK
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17
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Marsden M, Perkins Z, Marsh W, Christian M, Lyon R, Davenport R, Tai N. 3* Evaluation of an Artificial Intelligence (AI) system to augment clinical risk prediction of Trauma Induced Coagulopathy in the pre-hospital setting: a prospective observational study. BMJ Mil Health 2022. [DOI: 10.1136/bmjmilitary-2022-rsmabstracts.3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BackgroundThe potential of AI systems to support pre-hospital clinical decision-making in both military and civilian settings is significant. However, whilst such algorithms are increasingly available, far less attention has been paid to understanding the impact of such systems on clinical performance. This study had two aims; first, to compare the performance of expert clinicians against an AI system in a real-world clinical setting and second, to assess the impact of augmenting expert clinical prediction with an AI system.MethodsTwo civilian UK Air Ambulances were selected as surrogate settings relevant to military practice. We performed a prospective study over a six-month period where expert pre-hospital clinicians’ judgement of the risk of Trauma Induced Coagulopathy (TIC) in injured patients was assessed and compared to the performance of an AI system. Two TIC risk predictions were generated for every patient: an AI prediction and a human prediction. Measures of predictive performance included discrimination, calibration, and overall accuracy.ResultsOverall, 51 expert clinicians were enrolled in the study providing 184 patient interactions for analysis. The studied patients had a median age of 31 (range 16, 89), median injury severity score of 17 (IQR 9, 34), 75% were male, and 19% developed TIC.Aim 1: The AI system performed better than clinicians; higher discrimination [AUROC 0.87 (0.79, 0.95) versus 0.83 (0.74, 0.92)] better calibration [0.37 (-0.14, 0.89) versus -1.19 (-1.73, -0.65)] and more accurate [Brier Skill Score 0.34 (0.19, 0.48) versus 0.00 (-0.41, 0.30)].Aim 2: Risk prediction was better in all performance metrics when clinicians were assisted with the AI system [AUROC 0.88 (0.80, 0.95) versus 0.83 (0.74, 0.92)]ConclusionsAI systems can improve human risk prediction in the pre-hospital setting. In the military environment, where austerity and lack of senior clinical expertise may affect outcomes, the benefit of implementing predictive AI should be substantial.(*awarded First Place)
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18
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Cole E, Curry N, Davenport R. Sex discrimination after injury: is inequity in tranexamic acid administration just the tip of the iceberg? Br J Anaesth 2022; 129:144-147. [PMID: 35753808 DOI: 10.1016/j.bja.2022.05.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Revised: 05/13/2022] [Accepted: 05/14/2022] [Indexed: 11/02/2022] Open
Abstract
There is emerging evidence of inequalities in healthcare provision between women and men. Trauma care is no exception with a number of studies indicating lower levels of prioritisation for injured female patients. The antifibrinolytic drug tranexamic acid, reduced trauma deaths to a similar extent in females and males in the international Clinical Randomisation of an Antifibrinolytic in Significant Haemorrhage (CRASH) randomised controlled trials, but in real-world practice, national registry data shows females are less likely to receive tranexamic acid than males. Inequity in the provision of tranexamic acid may extend beyond sex (and gender), and further study is required to examine the effect of age and mechanism of injury differences between men and women in the decision to treat.
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Affiliation(s)
- Elaine Cole
- Centre for Trauma Sciences, Blizard Institute, Bart's & the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Nicola Curry
- Oxford Haemophilia & Thrombosis Centre, Oxford University Hospitals NHS Trust, Nuffield Orthopaedic Hospital, Oxford and Oxford University, Oxford, UK
| | - Ross Davenport
- Centre for Trauma Sciences, Blizard Institute, Bart's & the London School of Medicine and Dentistry, Queen Mary University of London, London, UK; Royal London Major Trauma Centre, Bart's Health NHS Trust, London, UK.
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19
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Marsden M, Perkins Z, Marsh W, Christian M, Lyon R, Davenport R, Tai N. 92 Evaluation of an Artificial Intelligence (AI) System to Augment Clinical Risk Prediction of Trauma Induced Coagulopathy: A Prospective Observational Study. Br J Surg 2022. [DOI: 10.1093/bjs/znac041.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Abstract
Introduction
The potential of AI systems to support pre-hospital clinical decision-making is significant. However, whilst such algorithms are increasingly available, far less attention has been paid to understanding the impact of such systems on clinical performance. This study had two aims; first, to compare the performance of expert clinicians against an AI system in a real-world clinical setting and second, to assess the impact of augmenting expert clinical prediction with an AI system.
Method
We performed a prospective study at two UK Air Ambulances services over a six-month period. Expert pre-hospital clinicians’ judgement of the risk of Trauma Induced Coagulopathy (TIC) in injured patients was assessed and compared to the performance of an AI system. Two TIC risk predictions were generated for every patient: an AI prediction and a human prediction.
Results
Overall, 51 expert clinicians were enrolled in the study providing 184 patient interactions for analysis.
Aim 1
The AI system performed better than clinicians; higher discrimination [AUROC 0.87 (0.79, 0.95) versus 0.83 (0.74, 0.92)] better calibration [0.37 (-0.14, 0.89) versus -1.19 (-1.73, -0.65)] and more accurate [Brier Skill Score 0.34 (0.19, 0.48) versus 0.00 (-0.41, 0.30)].
Aim 2
Risk prediction was better in all performance metrics when clinicians were assisted with the AI system [AUROC 0.88 (0.80, 0.95) versus 0.83 (0.74, 0.92)]
Conclusions
AI systems can improve human risk prediction in the pre-hospital setting. In settings of low resources where a lack of senior clinical expertise may affect outcomes, the benefit of implementing predictive AI is substantial.
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Affiliation(s)
- M. Marsden
- Centre for Trauma Sciences, Queen Mary University of London, London, United Kingdom
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, United Kingdom
| | - Z. Perkins
- Centre for Trauma Sciences, Queen Mary University of London, London, United Kingdom
| | - W. Marsh
- School of Electronical Engineering and Computer Sciences, Queen Mary University of London, London, United Kingdom
| | | | - R. Lyon
- Air Ambulance Kent Surrey Sussex, Redhill, United Kingdom
| | - R. Davenport
- Centre for Trauma Sciences, Queen Mary University of London, London, United Kingdom
| | - N. Tai
- Centre for Trauma Sciences, Queen Mary University of London, London, United Kingdom
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, United Kingdom
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20
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Tucker H, Avery P, Brohi K, Davenport R, Griggs J, Weaver A, Green L. Outcome measures used in clinical research evaluating prehospital blood component transfusion in traumatically injured bleeding patients: A systematic review. J Trauma Acute Care Surg 2021; 91:1018-1024. [PMID: 34254958 DOI: 10.1097/ta.0000000000003360] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Trial outcomes should be relevant to all stakeholders and allow assessment of interventions' efficacy and safety at appropriate timeframes. There is no consensus regarding outcome measures in the growing field of prehospital trauma transfusion research. Harmonization of future clinical outcome reporting is key to facilitate interstudy comparisons and generate cohesive, robust evidence to guide practice. The objective of this study was to evaluate outcome measures reported in prehospital trauma transfusion trials. METHODS Data Sources, Eligibility Criteria, Participants, and InterventionsWe conducted a scoping systematic review to identify the type, number, and definitions of outcomes reported in randomized controlled trials, and prospective and retrospective observational cohort studies investigating prehospital blood component transfusion in adult and pediatric patients with traumatic hemorrhage. Electronic database searching of PubMed, Embase, Web of Science, Cochrane, OVID, clinical trials.gov, and the Transfusion Evidence Library was completed in accordance with Preferred Reporting Items for Meta-analyses guidelines.Study Appraisal and Synthesis MethodsTwo review authors independently extracted outcome data. Unique lists of salutogenic (patient-reported health and wellbeing outcomes) and nonsalutogenic focused outcomes were established. RESULTS A total of 3,471 records were identified. Thirty-four studies fulfilled the inclusion criteria: 4 military (n = 1,566 patients) and 30 civilian (n = 14,398 patients), all between 2000 and 2020. Two hundred twelve individual non-patient-reported outcomes were identified, which collapsed into 20 outcome domains with varied definitions and timings. All primary outcomes measured effectiveness, rather than safety or complications. Sixty-nine percent reported mortality, with 11 different definitions. No salutogenic outcomes were reported. CONCLUSION There is heterogeneity in outcome reporting and definitions, an absence of patient-reported outcome, and an emphasis on clinical effectiveness rather than safety or adverse events in prehospital trauma transfusion trials. We recommend stakeholder consultation and a Delphi process to develop a clearly defined minimum core outcome set for prehospital trauma transfusion trials. LEVEL OF EVIDENCE Scoping systematic review, level III.
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Affiliation(s)
- Harriet Tucker
- From the Centre for Trauma Sciences, Blizard Institute (H.T., K.B., R.D., L.G.), Queen Mary University of London, London, United Kingdom; Southmead Hospital (P.A.), North Bristol NHS Trust, Bristol, United Kingdom; Learning and Development (P.A.), South Western Ambulance Service NHS Foundation Trust, Bristol, United Kingdom; Air Ambulance Kent Surrey Sussex (J.G., H.T.), Rochester, United Kingdom; Faculty of Health Sciences (J.G.), University of Surrey, Guildford, United Kingdom; London's Air Ambulance (A.W.), London, United Kingdom; Barts Health NHS Foundation Trust (K.B., R.D., A.W., L.G.), London, United Kingdom; and NHS Blood and Transplant (L.G.), London, United Kingdom
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21
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Vulliamy P, Marsden M, Carden R, Brohi K, Davenport R. SP9.1.7 Emergency Laparotomy for Trauma in the United Kingdom and Ireland: a Prospective Multicentre Study. Br J Surg 2021. [DOI: 10.1093/bjs/znab361.170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Abstract
Aims
Trauma patients requiring abdominal surgery have significant morbidity and mortality, but are not included in existing national audits of emergency laparotomy. The aim of this study was to examine processes of care and outcomes among trauma patients undergoing emergency abdominal surgery in the UK and Ireland.
Methods
A prospective trainee-led multicentre audit was conducted over six months from January 2019 across the national trauma system. Patients undergoing laparotomy or laparoscopy within 24 hours of injury were included. Subgroup analysis was conducted in those requiring major haemorrhage protocol (MHP) activation.
Results
The study included 363 patients from 34 hospitals (22 major trauma centres). The majority were young males with no co-morbidities who required surgery for control of bleeding (51%) or exploration of penetrating injuries (46%). Over 85% received consultant-led care in the emergency department (318/363) and operating theatre (321/363). The MHP subgroup made up 45% of the cohort but accounted for 97% of deaths and 79% of ICU days, with a mortality rate of 19% and a massive transfusion rate of 32%. Compared to non-MHP patients they had shorter times to theatre (122 vs 218 minutes, p < 0.001), higher rates of advanced prehospital care (60% vs 33%, p < 0.001) and higher rates of consultant-led care (95% vs 85%, p < 0.001).
Conclusion
The majority of trauma patients requiring emergency abdominal surgery receive consultant-delivered perioperative care which is appropriately tailored to patient risk profile. Despite this, mortality and resource utilization among high-risk patients remains substantial, justifying ongoing performance improvement initiatives and research into novel therapeutics.
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Affiliation(s)
- Paul Vulliamy
- Centre for Trauma Sciences, Queen Mary University of London, UK
| | - Max Marsden
- Centre for Trauma Sciences, Queen Mary University of London, UK
| | - Richard Carden
- Centre for Trauma Sciences, Queen Mary University of London, UK
| | - Karim Brohi
- Centre for Trauma Sciences, Queen Mary University of London, UK
| | - Ross Davenport
- Centre for Trauma Sciences, Queen Mary University of London, UK
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22
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Tucker H, Davenport R, Green L. The Role of Plasma Transfusion in Pre-Hospital Haemostatic Resuscitation. Transfus Med Rev 2021; 35:91-95. [PMID: 34593289 DOI: 10.1016/j.tmrv.2021.08.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Revised: 08/22/2021] [Accepted: 08/23/2021] [Indexed: 12/15/2022]
Abstract
Traumatic haemorrhage remains a major cause of preventable death and early haemostatic resuscitation is now a mainstay of treatment internationally. Recently, 2 randomized control trials (RCTs) - PAMPer (Prehospital Air Medical Plasma) and COMBAT (Control of Major Bleeding After Trauma), evaluating the effect of pre-hospital use of plasma on mortality provided conflicting results, raising important questions on the role of plasma resuscitation in pre-hospital environment. Both PAMPer (n = 501 patients) and COMBAT (n = 144 patients) trials were pragmatic RCTs that evaluated the effect of pre-hospital plasma transfusion (two units) versus standard of care on 28/30 days mortality in trauma patients who presented with clinical signs of haemorrhagic shock (defined as hypotension or tachycardia). The PAMPer trial showed that plasma transfusion reduced 30-day mortality compared with standard of care (23% vs 33%, 95% confidence interval -18.6; -1.0%; P = 0.03), while COMBAT trial showed no difference in 28-day survival. The post-hoc analyses of the 2 trials have suggested that the benefit of pre-hospital plasma transfusion may be greater for patients who are coagulopathic, have blunt injury and have a transport time from the scene of injury to the hospital of >20 minutes. In this review we evaluate strengths and limitations of the two trials and their differences and similarities, which may explain the conflicting results, as well as provide directions for future trials to better define the target population that would most benefit from pre-hospital plasma resuscitation. Further, considering the logistical challenges of carrying any blood components on an aircraft, cost/safety of plasma, and the scarcity of universal blood group donors, there is a need for a health economic evaluation of pre-hospital plasma transfusion in trauma patients, prior to this intervention becoming universal.
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Affiliation(s)
- Harriet Tucker
- Blizard Institute, Queen Mary University of London, London, UK
| | - Ross Davenport
- Blizard Institute, Queen Mary University of London, London, UK; Departmen of Trauma, Barts Health NHS Trust, London, UK
| | - Laura Green
- Blizard Institute, Queen Mary University of London, London, UK; Departmen of Trauma, Barts Health NHS Trust, London, UK; Blood Component division, NHS Blood and Transplant, London, UK.
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23
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McCullagh J, Proudlove N, Tucker H, Davies J, Edmondson D, Lancut J, Maddison A, Weaver A, Davenport R, Green L. Making every drop count: reducing wastage of a novel blood component for transfusion of trauma patients. BMJ Open Qual 2021; 10:bmjoq-2021-001396. [PMID: 34244177 PMCID: PMC8268902 DOI: 10.1136/bmjoq-2021-001396] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 06/19/2021] [Indexed: 01/03/2023] Open
Abstract
Recent research demonstrates that transfusing whole blood (WB=red blood cells (RBC)+plasma+platelets) rather than just RBC (which is current National Health Service (NHS) practice) may improve outcomes for major trauma patients. As part of a programme to investigate provision of WB, NHS Blood and Transplant undertook a 2-year feasibility study to supply the Royal London Hospital (RLH) with (group O negative, 'O neg') leucodepleted red cell and plasma (LD-RCP) for transfusion of trauma patients with major haemorrhage in prehospital settings.Incidents requiring such prehospital transfusion occur randomly, with very high variation. Availability is critical, but O neg LD-RCP is a scarce resource and has a limited shelf life (14 days) after which it must be disposed of. The consequences of wastage are the opportunity cost of loss of overall treatment capacity across the NHS and reputational damage.The context was this feasibility study, set up to assess deliverability to RLH and subsequent wastage levels. Within this, we conducted a quality improvement project, which aimed to reduce the wastage of LD-RCP to no more than 8% (ie, 1 of the 12 units delivered per week).Over this 2-year period, we reduced wastage from a weekly average of 70%-27%. This was achieved over four improvement cycles. The largest improvement came from moving near-expiry LD-RCP to the emergency department (ED) for use with their trauma patients, with subsequent improvements from embedding use in ED as routine practice, introducing a dedicated LD-RCP delivery schedule (which increased the units ≤2 days old at delivery from 42% to 83%) and aligning this delivery schedule to cover two cycles of peak demand (Fridays and Saturdays).
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Affiliation(s)
- Josephine McCullagh
- NHS Higher Specialist Scientist Training (HSST), DClinSci Programme, The University of Manchester, Manchester, UK .,Pathology, Barts Health NHS Trust, London, UK
| | - Nathan Proudlove
- Alliance Manchester Business School, The University of Manchester, Manchester, UK
| | - Harriet Tucker
- Blizard Institute, Queen Mary, University of London, UK, London, UK
| | - Jane Davies
- Manufacturing and Development, NHS Blood and Transplant, Bristol, UK
| | - Dave Edmondson
- Manufacturing and Development, NHS Blood and Transplant, Bristol, UK
| | | | | | - Anne Weaver
- Major Trauma Centre, Barts Health NHS Trust, London, UK
| | - Ross Davenport
- Blizard Institute, Queen Mary, University of London, UK, London, UK.,Major Trauma Centre, Barts Health NHS Trust, London, UK
| | - Laura Green
- Pathology, Barts Health NHS Trust, London, UK.,Blizard Institute, Queen Mary, University of London, UK, London, UK.,Blood Component Department, NHS Blood and Transplant, London, UK
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24
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McElroy L, Robinson L, Battle C, Laidlaw L, Teager A, de Bernard L, McGillivray J, Tsang K, Bell S, Leech C, Marsden M, Carden R, Challen K, Peck G, Hancorn K, Davenport R, Brohi K, Wilson MSJ. Use of a modified Delphi process to develop research priorities in major trauma. Eur J Trauma Emerg Surg 2021; 48:1453-1461. [PMID: 34132821 PMCID: PMC8208060 DOI: 10.1007/s00068-021-01722-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Accepted: 06/05/2021] [Indexed: 11/30/2022]
Abstract
Purpose The burden of major trauma within the UK is ever increasing. There is a need to establish research priorities within the field. Delphi methodology can be used to develop consensus opinion amongst a group of stakeholders. This can be used to prioritise clinically relevant, patient-centred research questions to guide future funding allocations. The aim of our study was to identify key future research priorities pertaining to the management of major trauma in the UK. Methods A three-phased modified Delphi process was undertaken. Phase 1 involved the submission of research questions by members of the trauma community using an online survey (Phase 1). Phases 2 and 3 involved two consecutive rounds of prioritisation after questions were subdivided into 6 subcategories: Brain Injury, Rehabilitation, Trauma in Older People, Pre-hospital, Interventional, and Miscellaneous (Phases 2 and 3). Cut-off points were agreed by consensus amongst the steering subcommittees. This established a final prioritised list of research questions. Results In phase 1, 201 questions were submitted by 65 stakeholders. After analysis and with consensus achieved, 186 questions were taken forward for prioritisation in phase 2 with 114 included in phase 3. 56 prioritised major trauma research questions across the 6 categories were identified with a clear focus on long-term patient outcomes. Research priorities across the patient pathway from roadside to rehabilitation were deemed of importance. Conclusions Consensus within the major trauma community has identified 56 key research questions across 6 categories. Dissemination of these questions to funding bodies to allow for the development of high-quality research is now required. There is a clear indication for targeted multi-centre multi-disciplinary research in major trauma.
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Affiliation(s)
- Luke McElroy
- Department of General Surgery, Forth Valley Royal Hospital, Larbert, FK5 4WR, UK.
| | - Lisa Robinson
- Rehabilitation Department, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Royal Victoria Infirmary, Newcastle Upon Tyne, NE1 4LP, UK
| | - Ceri Battle
- Physiotherapy Department, Morriston Hospital, Swansea, SA6 6NL, UK
| | | | | | | | | | - Kevin Tsang
- Division of Surgery, St Mary's Hospital, Imperial College London, Paddington, London, W2 1NY, UK
| | - Steve Bell
- Medical Directorate, North West Ambulance Service NHS Trust, Bolton, BL1 5DD, UK
| | - Caroline Leech
- University Hospitals Coventry and Warwickshire NHS Trust, Clifford Bridge Road, Walsgrave, Coventry, CV2 2DX, UK
| | - Max Marsden
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, UK
| | - Richard Carden
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, UK
| | - Kirsty Challen
- Lancashire Teaching Hospitals NHS Foundation Trust, Preston, PR2 9HT, UK
| | - George Peck
- Division of Surgery, St Mary's Hospital, Imperial College London, Paddington, London, W2 1NY, UK
| | - Kate Hancorn
- Trauma Service, Barts Health NHS Trust, The Royal London Hospital, Whitechapel, London, E1 1FR, UK
| | - Ross Davenport
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, UK
| | - Karim Brohi
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, UK
| | - Michael S J Wilson
- Department of General Surgery, Forth Valley Royal Hospital, Larbert, FK5 4WR, UK
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25
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Cole E, Weaver A, Gall L, West A, Nevin D, Tallach R, O'Neill B, Lahiri S, Allard S, Tai N, Davenport R, Green L, Brohi K. A Decade of Damage Control Resuscitation: New Transfusion Practice, New Survivors, New Directions. Ann Surg 2021; 273:1215-1220. [PMID: 31651535 DOI: 10.1097/sla.0000000000003657] [Citation(s) in RCA: 70] [Impact Index Per Article: 23.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVE The aim of this study was to identify the effects of recent innovations in trauma major hemorrhage management on outcome and transfusion practice, and to determine the contemporary timings and patterns of death. BACKGROUND The last 10 years have seen a research-led change in hemorrhage management to damage control resuscitation (DCR), focused on the prevention and treatment of trauma-induced coagulopathy. METHODS A 10-year retrospective analysis of prospectively collected data of trauma patients who activated the Major Trauma Centre's major hemorrhage protocol (MHP) and received at least 1 unit of red blood cell transfusions (RBC). RESULTS A total of 1169 trauma patients activated the MHP and received at least 1 unit of RBC, with similar injury and admission physiology characteristics over the decade. Overall mortality declined from 45% in 2008 to 27% in 2017, whereas median RBC transfusion rates dropped from 12 to 4 units (massive transfusion rates from 68% to 24%). The proportion of deaths within 24 hours halved (33%-16%), principally with a fall in mortality between 3 and 24 hours (30%-6%). Survivors are now more likely to be discharged to their own home (57%-73%). Exsanguination is still the principal cause of early deaths, and the mortality associated with massive transfusion remains high (48%). Late deaths are now split between those due to traumatic brain injury (52%) and multiple organ dysfunction (45%). CONCLUSIONS There have been remarkable reductions in mortality after major trauma hemorrhage in recent years. Mortality rates continue to be high and there remain important opportunities for further improvements in these patients.
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Affiliation(s)
- Elaine Cole
- Blizard Institute, Queen Mary University of London, London, United Kingdom
| | - Anne Weaver
- Barts Health NHS Trust, London, United Kingdom
| | - Lewis Gall
- Blizard Institute, Queen Mary University of London, London, United Kingdom
| | - Anita West
- Barts Health NHS Trust, London, United Kingdom
| | | | | | | | | | | | - Nigel Tai
- Barts Health NHS Trust, London, United Kingdom
- Academic Departments of Military Surgery, Trauma and Anaesthesia, Royal Centre for Defence Medicine, Birmingham, United Kingdom
| | - Ross Davenport
- Blizard Institute, Queen Mary University of London, London, United Kingdom
- Barts Health NHS Trust, London, United Kingdom
| | - Laura Green
- Blizard Institute, Queen Mary University of London, London, United Kingdom
- Barts Health NHS Trust, London, United Kingdom
- NHS Blood and Transplant, London, United Kingdom
| | - Karim Brohi
- Blizard Institute, Queen Mary University of London, London, United Kingdom
- Barts Health NHS Trust, London, United Kingdom
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26
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Almuwallad A, Cole E, Ross J, Perkins Z, Davenport R. The impact of prehospital TXA on mortality among bleeding trauma patients: A systematic review and meta-analysis. J Trauma Acute Care Surg 2021; 90:901-907. [PMID: 33605702 DOI: 10.1097/ta.0000000000003120] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Tranexamic acid (TXA) is an antifibrinolytic drug associated with improved survival among trauma patients with hemorrhage. Tranexamic acid is considered a primary hemostatic intervention in prehospital for treatment of bleeding alongside blood product transfusion. METHODS A systematic review and meta-analysis was conducted to investigate the impact of prehospital TXA on mortality among trauma patients with bleeding. A systematic search was conducted using the National Institute for Health and Care Excellence Healthcare Databases Advanced Search library which contain the following of databases: EMBASE, Medline, PubMed, BNI, EMCARE, and HMIC. Other databases searched included SCOPUS and the Cochrane Central Register for Clinical Trials Library. Quality assessment tools were applied among included studies; Cochrane Risk of Bias for randomized control trials and Newcastle-Ottawa Scale for cohort observational studies. RESULTS A total of 797 publications were identified from the initial database search. After removing duplicates and applying inclusion/exclusion criteria, four studies were included in the review and meta-analysis which identified a significant survival benefit in patients who received prehospital TXA versus no TXA. Three observational cohort and one randomized control trial were included into the review with a total of 2,347 patients (TXA, 1,169 vs. no TXA, 1,178). There was a significant reduction in 24 hours mortality; odds ratio (OR) of 0.60 (95% confidence interval [CI], 0.37-0.99). No statistical significant differences in 28 days to 30 days mortality; OR of 0.69 (95% CI, 0.47-1.02), or venous thromboembolism OR of 1.49 (95% CI, 0.90-2.46) were found. CONCLUSION This review demonstrates that prehospital TXA is associated with significant reductions in the early (24 hour) mortality of trauma patients with suspected or confirmed hemorrhage but no increase in the incidence of venous thromboembolism. LEVEL OF EVIDENCE Systematic review and meta-analysis. Level I.
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Affiliation(s)
- Ateeq Almuwallad
- From the Centre for Trauma Science, Blizard Institute (A.A., E.C., J.R., Z.P., R.D.), Queen Mary University, London, United Kingdom; and Emergency Medical Services Department, Faculty of Applied Medical Sciences (A.A.), Jazan University, Kingdom of Saudi Arabia
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27
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Grassin-Delyle S, Shakur-Still H, Picetti R, Frimley L, Jarman H, Davenport R, McGuinness W, Moss P, Pott J, Tai N, Lamy E, Urien S, Prowse D, Thayne A, Gilliam C, Pynn H, Roberts I. Pharmacokinetics of intramuscular tranexamic acid in bleeding trauma patients: a clinical trial. Br J Anaesth 2020; 126:201-209. [PMID: 33010927 DOI: 10.1016/j.bja.2020.07.058] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 07/13/2020] [Accepted: 07/24/2020] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Intravenous tranexamic acid (TXA) reduces bleeding deaths after injury and childbirth. It is most effective when given early. In many countries, pre-hospital care is provided by people who cannot give i.v. injections. We examined the pharmacokinetics of intramuscular TXA in bleeding trauma patients. METHODS We conducted an open-label pharmacokinetic study in two UK hospitals. Thirty bleeding trauma patients received a loading dose of TXA 1 g i.v., as per guidelines. The second TXA dose was given as two 5 ml (0·5 g each) i.m. injections. We collected blood at intervals and monitored injection sites. We measured TXA concentrations using liquid chromatography coupled to mass spectrometry. We assessed the concentration time course using non-linear mixed-effect models with age, sex, ethnicity, body weight, type of injury, signs of shock, and glomerular filtration rate as possible covariates. RESULTS Intramuscular TXA was well tolerated with only mild injection site reactions. A two-compartment open model with first-order absorption and elimination best described the data. For a 70-kg patient, aged 44 yr without signs of shock, the population estimates were 1.94 h-1 for i.m. absorption constant, 0.77 for i.m. bioavailability, 7.1 L h-1 for elimination clearance, 11.7 L h-1 for inter-compartmental clearance, 16.1 L volume of central compartment, and 9.4 L volume of the peripheral compartment. The time to reach therapeutic concentrations (5 or 10 mg L-1) after a single intramuscular TXA 1 g injection are 4 or 11 min, with the time above these concentrations being 10 or 5.6 h, respectively. CONCLUSIONS In bleeding trauma patients, intramuscular TXA is well tolerated and rapidly absorbed. CLINICAL TRIAL REGISTRATION 2019-000898-23 (EudraCT); NCT03875937 (ClinicalTrials.gov).
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Affiliation(s)
- Stanislas Grassin-Delyle
- Département de Biotechnologie de la Santé, Université Paris-Saclay, UVSQ, Inserm, Infection et inflammation, Montigny le Bretonneux, France; Département des Maladies des Voies Respiratoires, Hôpital Foch, Suresnes, France
| | - Haleema Shakur-Still
- Department of Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Roberto Picetti
- Department of Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Lauren Frimley
- Department of Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Heather Jarman
- Emergency Department Clinical Research Unit, St George's Hospital, London, UK
| | - Ross Davenport
- Emergency Department, The Royal London Hospital, London, UK
| | - William McGuinness
- Emergency Department Clinical Research Unit, St George's Hospital, London, UK
| | - Phil Moss
- Emergency Department Clinical Research Unit, St George's Hospital, London, UK
| | - Jason Pott
- Emergency Department, The Royal London Hospital, London, UK
| | - Nigel Tai
- Emergency Department, The Royal London Hospital, London, UK
| | - Elodie Lamy
- Département de Biotechnologie de la Santé, Université Paris-Saclay, UVSQ, Inserm, Infection et inflammation, Montigny le Bretonneux, France
| | - Saïk Urien
- Unité de Recherche Clinique, Inserm, Hôpital Cochin-Necker, Université Paris Descartes, Sorbonne-Paris Cité, Paris, France
| | - Danielle Prowse
- Department of Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Andrew Thayne
- Department of Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Catherine Gilliam
- Department of Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Harvey Pynn
- Department of Research and Clinical Innovation, Royal Centre for Defence Medicine, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Ian Roberts
- Department of Population Health, London School of Hygiene & Tropical Medicine, London, UK.
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28
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Avery P, Morton S, Tucker H, Green L, Weaver A, Davenport R. Whole blood transfusion versus component therapy in adult trauma patients with acute major haemorrhage. Emerg Med J 2020; 37:370-378. [PMID: 32376677 DOI: 10.1136/emermed-2019-209040] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Revised: 04/02/2020] [Accepted: 04/11/2020] [Indexed: 01/06/2023]
Abstract
OBJECTIVE In the era of damage control resuscitation of trauma patients with acute major haemorrhage, transfusion practice has evolved to blood component (component therapy) administered in a ratio that closely approximates whole blood (WB). However, there is a paucity of evidence supporting the optimal transfusion strategy in these patients. The primary objective was therefore to establish if there is an improvement in survival at 30 days with the use of WB transfusion compared with blood component therapy in adult trauma patients with acute major haemorrhage. METHODOLOGY A systematic literature search was performed on 15 December 2019 to identify studies comparing WB transfusion with component therapy in adult trauma patients and mortality at 30 days. Studies which did not report mortality were excluded. Methodological quality of included studies was interpreted using the Cochrane risk of bias tool, and rated using the Grading of Recommendations Assessment, Development and Evaluation approach. RESULTS Search of the databases identified 1885 records, and six studies met the inclusion criteria involving 3255 patients. Of the three studies reporting 30-day mortality (one randomised controlled trial (moderate evidence) and two retrospective (low and very low evidence, respectively)), only one study demonstrated a statistically significant difference between WB and component therapy, and two found no statistical difference. Two retrospective studies reporting in-hospital mortality found no statistical difference in unadjusted mortality, but both reported statistically significant logistic regression analyses demonstrating that those with a WB transfusion strategy were less likely to die. CONCLUSION Recognising the limitations of this systematic review relating to the poor-quality evidence and limited number of included trials, it does not provide evidence to support or reject use of WB transfusion compared with component therapy for adult trauma patients with acute major haemorrhage. PROSPERO REGISTRATION NUMBER CRD42019131406.
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Affiliation(s)
- Pascale Avery
- Emergency Department, North Bristol NHS Trust, Bristol, UK .,Trauma Sciences, Blizard Institute of Cell and Molecular Science, Queen Mary University of London, London, UK
| | - Sarah Morton
- Department of Anaesthesia, Imperial College Healthcare NHS Trust, London, UK
| | - Harriet Tucker
- Trauma Sciences, Blizard Institute of Cell and Molecular Science, Queen Mary University of London, London, UK.,Air Ambulance Kent Surrey Sussex, Kent, UK.,Emergency Department, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Laura Green
- Trauma Sciences, Blizard Institute of Cell and Molecular Science, Queen Mary University of London, London, UK.,Haematology Department, Barts Health NHS Trust, London, UK.,NHS Blood and Transplant, London, UK
| | - Anne Weaver
- Trauma Sciences, Blizard Institute of Cell and Molecular Science, Queen Mary University of London, London, UK.,Emergency Department, Barts Health NHS Trust, London, UK.,London's Air Ambulance, The Royal London Hospital, London, UK
| | - Ross Davenport
- Trauma Sciences, Blizard Institute of Cell and Molecular Science, Queen Mary University of London, London, UK.,Trauma and Vascular Surgery, Barts Health NHS Trust, London, UK
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29
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Curry N, Foley C, Wong H, Mora A, Curnow E, Zarankaite A, Hodge R, Hopkins V, Deary A, Ray J, Moss P, Reed MJ, Kellett S, Davenport R, Stanworth S. The application of a haemorrhage assessment tool in evaluating control of bleeding in a pilot trauma haemorrhage trial. Transfus Med 2019; 29:454-459. [PMID: 31680331 DOI: 10.1111/tme.12644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Revised: 08/22/2019] [Accepted: 10/06/2019] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To determine whether it was feasible to use a haemorrhage assessment tool (HAT) within a trauma trial and whether the data obtained could differentiate patients who had achieved haemostasis. BACKGROUND Major haemorrhage is one of the leading causes of death worldwide, affecting 40% of trauma patients. Clinical trials evaluating haemostatic interventions often use transfusion outcomes as a primary endpoint. Transfusion is highly dependent on local practice, limiting its reliability as a robust, transferable endpoint. METHODS A five-point HAT questionnaire was applied to participants enrolled into the EFIT-1 trial. This RCT evaluated the feasibility of administering a 6 g fibrinogen concentrate to patients with severe trauma haemorrhage. RESULTS Of participants, 98% completed a HAT; 75% participants had 'achieved haemostasis' at the time of tool completion, as determined by clinical acumen alone. HAT scores were able to differentiate which participants required transfusion after 3 h. Of participants, 56% were transfused red blood cells when they scored 0-2, compared to 17% with HAT scores between 3 and 5. CONCLUSION This study has confirmed the feasibility of using a HAT during the emergency care of patients suffering trauma haemorrhage, and future studies should be conducted to determine its value as an endpoint in haemostasis studies.
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Affiliation(s)
- N Curry
- Department of Haematology, Oxford University Hospitals NHS Trust, Oxford, UK.,NIHR BRC Blood Theme, Oxford University, Oxford, UK
| | - C Foley
- NHS Blood and Transplant Clinical Trials Unit, NHS Blood and Transplant, Cambridge and Bristol, UK
| | - H Wong
- Department of Haematology, Oxford University Hospitals NHS Trust, Oxford, UK.,NIHR BRC Blood Theme, Oxford University, Oxford, UK.,NHS Blood and Transplant, John Radcliffe Hospital, Oxford, UK
| | - A Mora
- NHS Blood and Transplant Clinical Trials Unit, NHS Blood and Transplant, Cambridge and Bristol, UK
| | - E Curnow
- NHS Blood and Transplant Clinical Trials Unit, NHS Blood and Transplant, Cambridge and Bristol, UK
| | - A Zarankaite
- NHS Blood and Transplant Clinical Trials Unit, NHS Blood and Transplant, Cambridge and Bristol, UK
| | - R Hodge
- NHS Blood and Transplant Clinical Trials Unit, NHS Blood and Transplant, Cambridge and Bristol, UK
| | - V Hopkins
- NHS Blood and Transplant Clinical Trials Unit, NHS Blood and Transplant, Cambridge and Bristol, UK
| | - A Deary
- NHS Blood and Transplant Clinical Trials Unit, NHS Blood and Transplant, Cambridge and Bristol, UK
| | - J Ray
- Department of Emergency Medicine, John Radcliffe Hospital, Oxford, UK
| | - P Moss
- Department of Emergency Medicine, St. George's Hospital, London, UK
| | - M J Reed
- Emergency Medicine Research Group Edinburgh (EMERGE), Royal Infirmary of Edinburgh, Edinburgh, UK
| | - S Kellett
- Department of Anaesthetics, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - R Davenport
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, UK
| | - S Stanworth
- Department of Haematology, Oxford University Hospitals NHS Trust, Oxford, UK.,NIHR BRC Blood Theme, Oxford University, Oxford, UK.,NHS Blood and Transplant, John Radcliffe Hospital, Oxford, UK
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Lendrum R, Perkins Z, Chana M, Marsden M, Davenport R, Grier G, Sadek S, Davies G. Reply to: Prehospital REBOA: Time to clearly define the relevant indications. Resuscitation 2019; 142:191-192. [PMID: 31181231 DOI: 10.1016/j.resuscitation.2019.05.031] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2019] [Accepted: 05/15/2019] [Indexed: 11/18/2022]
Affiliation(s)
- Robbie Lendrum
- Bart's Health NHS Trust, Royal London Hospital, Whitechapel, London, E1 1BB, United Kingdom; London's Air Ambulance, The Helipad, 17th Floor, Royal London Hospital, Whitechapel, London, E1 1BB, United Kingdom; NHS Lothian, Department of Anaesthesia, Critical Care and Pain Medicine, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh, EH16 4SA, United Kingdom.
| | - Zane Perkins
- Bart's Health NHS Trust, Royal London Hospital, Whitechapel, London, E1 1BB, United Kingdom; London's Air Ambulance, The Helipad, 17th Floor, Royal London Hospital, Whitechapel, London, E1 1BB, United Kingdom; Centre for Trauma Sciences, Queen Mary University of London, Research Office Ward 12D, 12th Floor, Royal London Hospital, Whitechapel, London, E1 1BB, United Kingdom
| | - Manik Chana
- The Institute of Pre-Hospital Care at London's Air Ambulance, The Helipad, 17th Floor, Royal London Hospital, Whitechapel, London, E1 1BB, United Kingdom
| | - Max Marsden
- Centre for Trauma Sciences, Queen Mary University of London, Research Office Ward 12D, 12th Floor, Royal London Hospital, Whitechapel, London, E1 1BB, United Kingdom; Academic Department of Military Surgery and Trauma, Royal Centre for Defense Medicine, Birmingham, United Kingdom
| | - Ross Davenport
- Bart's Health NHS Trust, Royal London Hospital, Whitechapel, London, E1 1BB, United Kingdom; Centre for Trauma Sciences, Queen Mary University of London, Research Office Ward 12D, 12th Floor, Royal London Hospital, Whitechapel, London, E1 1BB, United Kingdom
| | - Gareth Grier
- Bart's Health NHS Trust, Royal London Hospital, Whitechapel, London, E1 1BB, United Kingdom; London's Air Ambulance, The Helipad, 17th Floor, Royal London Hospital, Whitechapel, London, E1 1BB, United Kingdom; The Institute of Pre-Hospital Care at London's Air Ambulance, The Helipad, 17th Floor, Royal London Hospital, Whitechapel, London, E1 1BB, United Kingdom
| | - Samy Sadek
- Bart's Health NHS Trust, Royal London Hospital, Whitechapel, London, E1 1BB, United Kingdom; London's Air Ambulance, The Helipad, 17th Floor, Royal London Hospital, Whitechapel, London, E1 1BB, United Kingdom
| | - Gareth Davies
- Bart's Health NHS Trust, Royal London Hospital, Whitechapel, London, E1 1BB, United Kingdom; London's Air Ambulance, The Helipad, 17th Floor, Royal London Hospital, Whitechapel, London, E1 1BB, United Kingdom; Centre for Trauma Sciences, Queen Mary University of London, Research Office Ward 12D, 12th Floor, Royal London Hospital, Whitechapel, London, E1 1BB, United Kingdom
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Lendrum R, Perkins Z, Chana M, Marsden M, Davenport R, Grier G, Sadek S, Davies G. Pre-hospital Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) for exsanguinating pelvic haemorrhage. Resuscitation 2019; 135:6-13. [DOI: 10.1016/j.resuscitation.2018.12.018] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2018] [Accepted: 12/15/2018] [Indexed: 10/27/2022]
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Abstract
Trauma is a leading cause of death worldwide in persons under 44 years of age, and uncontrolled haemorrhage is the most common preventable cause of death in this patient group. The transfusion management of trauma haemorrhage is unrecognisable from 20 years ago. Changes in clinical practice have been driven primarily by an increased understanding of the pathophysiology of trauma-induced coagulopathy (TIC), which is associated with poor clinical outcomes, including a 3- to 4-fold increased risk of death. Targeting this coagulopathy alongside changes to surgical and anaesthetic practices (an overarching strategy known as damage control surgery/damage control resuscitation) has led to a significant reduction in mortality rates over the last two decades. This narrative review will discuss the transfusion practices that are currently used for trauma haemorrhage and the evidence that supports these practices.
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Affiliation(s)
- Nicola S Curry
- Oxford Haemophilia & Thrombosis Centre, Department of Haematology, Oxford University Hospitals NHS Trust, Churchill Hospital, Oxford, UK.,NIHR BRC, Blood Theme, Oxford Centre for Haematology, Oxford, UK
| | - Ross Davenport
- Centre for Trauma Sciences, Blizard Institute, Barts and the London School of Medicine & Dentistry, Queen Mary University of London, London, UK
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Marsden M, Benger J, Brohi K, Curry N, Foley C, Green L, Lucas J, Rossetto A, Stanworth S, Thomas H, Davenport R. Coagulopathy, cryoprecipitate and CRYOSTAT-2: realising the potential of a nationwide trauma system for a national clinical trial. Br J Anaesth 2018; 122:164-169. [PMID: 30686301 DOI: 10.1016/j.bja.2018.10.055] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Revised: 10/06/2018] [Accepted: 10/27/2018] [Indexed: 01/10/2023] Open
Affiliation(s)
- M Marsden
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, UK; Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, UK; Barts Health NHS Trust, London, UK.
| | - J Benger
- Faculty of Health and Applied Sciences, University of the West of England, Bristol, UK
| | - K Brohi
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, UK; Barts Health NHS Trust, London, UK
| | - N Curry
- Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK; Radcliffe Department of Medicine, University of Oxford, UK
| | - C Foley
- NHS Blood and Transplant, Clinical Trials Unit, Cambridge, UK
| | - L Green
- Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary, University of London, London, UK; Barts Health NHS Trust, London, UK
| | - J Lucas
- NHS Blood and Transplant, Clinical Trials Unit, Cambridge, UK
| | - A Rossetto
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, UK; Barts Health NHS Trust, London, UK
| | - S Stanworth
- Oxford NIHR BRC Haematology Theme, Oxford Centre for Haematology, University of Oxford, UK; NHS Blood and Transplant, Transfusion Medicine, Oxford, UK; Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK; Radcliffe Department of Medicine, University of Oxford, UK
| | - H Thomas
- NHS Blood and Transplant, Clinical Trials Unit, Bristol, UK; NHS Blood and Transplant, Transfusion Medicine, Oxford, UK
| | - R Davenport
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, UK; Barts Health NHS Trust, London, UK
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Curry NS, Davenport R, Pavord S, Mallett SV, Kitchen D, Klein AA, Maybury H, Collins PW, Laffan M. The use of viscoelastic haemostatic assays in the management of major bleeding: A British Society for Haematology Guideline. Br J Haematol 2018; 182:789-806. [PMID: 30073664 DOI: 10.1111/bjh.15524] [Citation(s) in RCA: 113] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Nicola S Curry
- Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.,NIHR BRC, Blood Theme, Oxford University, Oxford, UK
| | - Ross Davenport
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, UK
| | - Sue Pavord
- Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.,NIHR BRC, Blood Theme, Oxford University, Oxford, UK
| | - Susan V Mallett
- Department of Anaesthesia, Royal Free London NHS Foundation Trust, London, UK
| | | | - Andrew A Klein
- Department of Anaesthesia and Intensive Care, Royal Papworth Hospital, Cambridge, UK
| | - Helena Maybury
- Department of Obstetrics, Leicester Royal Infirmary, Leicester, UK
| | - Peter W Collins
- Department of Haematology, School of Medicine, Cardiff University, Cardiff, UK
| | - Mike Laffan
- Department of Haematology, Imperial College and Hammersmith Hospital, London, UK
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Curry N, Foley C, Wong H, Mora A, Curnow E, Zarankaite A, Hodge R, Hopkins V, Deary A, Ray J, Moss P, Reed MJ, Kellett S, Davenport R, Stanworth S. Early fibrinogen concentrate therapy for major haemorrhage in trauma (E-FIT 1): results from a UK multi-centre, randomised, double blind, placebo-controlled pilot trial. Crit Care 2018; 22:164. [PMID: 29914530 PMCID: PMC6006766 DOI: 10.1186/s13054-018-2086-x] [Citation(s) in RCA: 60] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Accepted: 05/28/2018] [Indexed: 12/16/2022]
Abstract
Background There is increasing interest in the timely administration of concentrated sources of fibrinogen to patients with major traumatic bleeding. Following evaluation of early cryoprecipitate in the CRYOSTAT 1 trial, we explored the use of fibrinogen concentrate, which may have advantages of more rapid administration in acute haemorrhage. The aims of this pragmatic study were to assess the feasibility of fibrinogen concentrate administration within 45 minutes of hospital admission and to quantify efficacy in maintaining fibrinogen levels ≥ 2 g/L during active haemorrhage. Methods We conducted a blinded, randomised, placebo-controlled trial at five UK major trauma centres with adult trauma patients with active bleeding who required activation of the major haemorrhage protocol. Participants were randomised to standard major haemorrhage therapy plus 6 g of fibrinogen concentrate or placebo. Results Twenty-seven of 39 participants (69%; 95% CI, 52–83%) across both arms received the study intervention within 45 minutes of admission. There was some evidence of a difference in the proportion of participants with fibrinogen levels ≥ 2 g/L between arms (p = 0.10). Fibrinogen levels in the fibrinogen concentrate (FgC) arm rose by a mean of 0.9 g/L (SD, 0.5) compared with a reduction of 0.2 g/L (SD, 0.5) in the placebo arm and were significantly higher in the FgC arm (p < 0.0001) at 2 hours. Fibrinogen levels were not different at day 7. Transfusion use and thromboembolic events were similar between arms. All-cause mortality at 28 days was 35.5% (95% CI, 23.8–50.8%) overall, with no difference between arms. Conclusions In this trial, early delivery of fibrinogen concentrate within 45 minutes of admission was not feasible. Although evidence points to a key role for fibrinogen in the treatment of major bleeding, researchers need to recognise the challenges of timely delivery in the emergency setting. Future studies must explore barriers to rapid fibrinogen therapy, focusing on methods to reduce time to randomisation, using ‘off-the-shelf’ fibrinogen therapies (such as extended shelf-life cryoprecipitate held in the emergency department or fibrinogen concentrates with very rapid reconstitution times) and limiting the need for coagulation test-based transfusion triggers. Trial registration ISRCTN67540073. Registered on 5 August 2015.
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Affiliation(s)
- Nicola Curry
- Department of Haematology, Oxford Haemophilia & Thrombosis Centre, Churchill Hospital, Oxford University Hospitals NHS Trust, Oxford, UK. .,NIHR BRC Blood Theme, Oxford University, Oxford, UK.
| | - Claire Foley
- NHS Blood and Transplant Clinical Trials Unit, Cambridge, Bristol, UK
| | - Henna Wong
- Department of Haematology, Oxford Haemophilia & Thrombosis Centre, Churchill Hospital, Oxford University Hospitals NHS Trust, Oxford, UK.,NIHR BRC Blood Theme, Oxford University, Oxford, UK.,Nuffield Division of Clinical Laboratory Sciences, Radcliffe Department of Medicine, University of Oxford, John Radcliffe Hospital, Oxford, UK
| | - Ana Mora
- NHS Blood and Transplant Clinical Trials Unit, Cambridge, Bristol, UK
| | - Elinor Curnow
- NHS Blood and Transplant Clinical Trials Unit, Cambridge, Bristol, UK
| | - Agne Zarankaite
- NHS Blood and Transplant Clinical Trials Unit, Cambridge, Bristol, UK
| | - Renate Hodge
- NHS Blood and Transplant Clinical Trials Unit, Cambridge, Bristol, UK
| | - Valerie Hopkins
- NHS Blood and Transplant Clinical Trials Unit, Cambridge, Bristol, UK
| | - Alison Deary
- NHS Blood and Transplant Clinical Trials Unit, Cambridge, Bristol, UK
| | - James Ray
- Department of Emergency Medicine, John Radcliffe Hospital, Oxford, UK
| | - Phil Moss
- Department of Emergency Medicine, St. George's Hospital, London, UK
| | - Matthew J Reed
- Emergency Medicine Research Group Edinburgh (EMERGE), Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Suzanne Kellett
- Department of Anaesthetics, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Ross Davenport
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, UK
| | - Simon Stanworth
- Department of Haematology, Oxford Haemophilia & Thrombosis Centre, Churchill Hospital, Oxford University Hospitals NHS Trust, Oxford, UK.,NIHR BRC Blood Theme, Oxford University, Oxford, UK.,Nuffield Division of Clinical Laboratory Sciences, Radcliffe Department of Medicine, University of Oxford, John Radcliffe Hospital, Oxford, UK.,NHS Blood and Transplant, John Radcliffe Hospital, Oxford, UK
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Abstract
This review summarizes the evolution of trauma resuscitation from a one-size-fits-all approach to one tailored to patient physiology. The most dramatic change is in the management of actively bleeding patients, with a balanced blood product-based resuscitation approach (avoiding crystalloids) and surgery focused on hemorrhage control, not definitive care. When hemostasis has been achieved, definitive resuscitation to restore organ perfusion is initiated. This approach is associated with decreased mortality, reduced duration of stay, improved coagulation profile, and reduced crystalloid/vasopressor use. This article focuses on the tools and methods used for trauma resuscitation in the acute phase of trauma care.
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Affiliation(s)
- Tim Harris
- Emergency Medicine, Barts Health NHS Trust, Queen Mary University of London, London, UK
| | - Ross Davenport
- Trauma Sciences, Blizard Institute, Queen Mary University of London, London, UK
| | - Matthew Mak
- Emergency Medicine, Barts Health NHS Trust, London, UK
| | - Karim Brohi
- Trauma and Neuroscience, Blizard Institute, Queen Mary University of London, London E1 2AT, UK; London's Air Ambulance, Barts Health NHS Trust, London, UK.
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Wong H, Pottle J, Curry N, Stanworth SJ, Brunskill SJ, Davenport R, Doree C. Strategies for use of blood products for major bleeding in trauma. Hippokratia 2017. [DOI: 10.1002/14651858.cd012635] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Henna Wong
- Churchill Hospital; Oxford Haemophilia & Thrombosis Centre; Oxford UK
| | - Jack Pottle
- University College London Hospitals NHS Foundation Trust; London UK
| | - Nicola Curry
- Churchill Hospital; Oxford Haemophilia & Thrombosis Centre; Oxford UK
| | - Simon J Stanworth
- Oxford University Hospitals NHS Foundation Trust and University of Oxford; National Institute for Health Research (NIHR) Oxford Biomedical Research Centre; John Radcliffe Hospital, Headley Way Headington Oxford UK OX3 9BQ
| | - Susan J Brunskill
- NHS Blood and Transplant; Systematic Review Initiative; Level 2, John Radcliffe Hospital Headington Oxford Oxon UK OX3 9BQ
| | - Ross Davenport
- Queen Mary University of London; Centre for Trauma Sciences - Blizard Institute; London UK
| | - Carolyn Doree
- NHS Blood and Transplant; Systematic Review Initiative; Level 2, John Radcliffe Hospital Headington Oxford Oxon UK OX3 9BQ
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38
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Affiliation(s)
- Lewis Gall
- Centre for Trauma Sciences, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
| | - Karim Brohi
- Centre for Trauma Sciences, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
| | - Ross Davenport
- Centre for Trauma Sciences, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
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Hann M, Alderton W, Davenport R, Williams P. Recent disclosures of clinical candidates: Highlights from the Society of Medicines Research Symposium. The National Heart and Lung Institute, London, U.K. - December 1, 2016. DRUG FUTURE 2017. [DOI: 10.1358/dof.2017.042.02.2592800] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Tarasev M, Chakraborty S, Light L, Davenport R. Impact of environment on Red Blood Cell ability to withstand mechanical stress. Clin Hemorheol Microcirc 2016; 64:21-33. [DOI: 10.3233/ch-152037] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- M. Tarasev
- Blaze Medical Devices, Ann Arbor, MI, USA
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Maegele M, Inaba K, Rizoli S, Veigas P, Callum J, Davenport R, Fröhlich M, Hess J. [Early viscoelasticity-based coagulation therapy for severely injured bleeding patients: Report of the consensus group on the consensus conference 2014 for formulation of S2k guidelines]. Anaesthesist 2016; 64:778-94. [PMID: 26136120 DOI: 10.1007/s00101-015-0040-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Although there is increasing interest in the use of a viscoelastic test procedure (ROTEM/TEG) for diagnostics and therapy guidance of severely injured and bleeding patients, currently no uniformly accepted guidelines exist for how this technology should be integrated into clinical treatment. In September 2014 an international multidisciplinary group of opinion leaders in the field of trauma-induced coagulopathy and other disciplines involved in the treatment of severely injured patients were assembled for a 2-day consensus conference in Philadelphia (USA). This panel included trauma/accident surgeons, general/abdominal surgeons, vascular surgeons, emergency/intensive care surgeons, hematologists, transfusion specialists, anesthesiologists, laboratory physicians, pathobiologists/pathophysiologists and the lay public. A total of nine questions regarding the impact of viscoelastic testing in the early treatment of trauma patients were developed prior to the conference by a panel consensus. Early use was defined as baseline viscoelastic test result thresholds obtained within the first minutes of hospital arrival, when conventional laboratory results are not yet available. The available data for each question were then reviewed in person using standardized presentations by the expert panel. A consensus summary document was then developed and reviewed by the panel in an open forum. Finally, a 2-round Delphi poll was administered to the panel of experts regarding viscoelastic thresholds for triggering the initiation of specific treatments including fibrinogen (concentrates), platelet concentrates, blood plasma products and prothrombin complex concentrates (PCC). This report summarizes the findings and recommendations of this consensus conference, which correspond to a S2k guideline according to the system of the Association of the Scientific Medical Societies in Germany (AWMF) and taking formal consensus findings including Delphi methods into consideration.
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Affiliation(s)
- M Maegele
- Klinik für Orthopädie, Unfallchirurgie und Sporttraumatologie, Kliniken der Stadt Köln-Merheim, Institut für Forschung in der Operativen Medizin (IFOM), Private Universität Witten/Herdecke (UW/H), Ostmerheimerstr. 200, 51109, Köln, Deutschland.
| | - K Inaba
- Division of Trauma and Surgical Critical Care, University of Southern California, Los Angeles, California, USA
| | - S Rizoli
- Departments of Surgery & Critical Care Medicine, St. Michael's Hospital and University of Toronto, Toronto, Ontario, Kanada
| | - P Veigas
- Department of Surgery, Sunnybrook Health Sciences Center and Institute of Medical Science, University of Toronto, Toronto, Ontario, Kanada
| | - J Callum
- Department of Clinical Pathology, Sunnybrook Health Sciences Center Toronto, Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Kanada
| | - R Davenport
- Centre for Trauma Sciences, Blizard Institute, Bart's and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - M Fröhlich
- Klinik für Orthopädie, Unfallchirurgie und Sporttraumatologie, Kliniken der Stadt Köln-Merheim, Institut für Forschung in der Operativen Medizin (IFOM), Private Universität Witten/Herdecke (UW/H), Ostmerheimerstr. 200, 51109, Köln, Deutschland
| | - J Hess
- Department of Laboratory Medicine, School of Medicine, University of Washington, Seattle, WA, USA
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Stanworth SJ, Davenport R, Curry N, Seeney F, Eaglestone S, Edwards A, Martin K, Allard S, Woodford M, Lecky FE, Brohi K. Mortality from trauma haemorrhage and opportunities for improvement in transfusion practice. Br J Surg 2016; 103:357-65. [DOI: 10.1002/bjs.10052] [Citation(s) in RCA: 83] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2015] [Revised: 06/15/2015] [Accepted: 10/12/2015] [Indexed: 12/18/2022]
Abstract
Abstract
Background
The aim of this study was to describe the prevalence, patterns of blood use and outcomes of major haemorrhage in trauma.
Methods
This was a prospective observational study from 22 hospitals in the UK, including both major trauma centres and smaller trauma units. Eligible patients received at least 4 units of packed red blood cells (PRBCs) in the first 24 h of admission with activation of the massive haemorrhage protocol. Case notes, transfusion charts, blood bank records and copies of prescription/theatre charts were accessed and reviewed centrally. Study outcomes were: use of blood components, critical care during hospital stay, and mortality at 24 h, 30 days and 1 year. Data were used to estimate the national trauma haemorrhage incidence.
Results
A total of 442 patients were identified during a median enrolment interval of 20 (range 7–24) months. Based on this, the national incidence of trauma haemorrhage was estimated to be 83 per million. The median age of patients in the study cohort was 38 years and 73·8 per cent were men. The incidence of major haemorrhage increased markedly in patients aged over 65 years. Thirty-six deaths within 24 h of admission occurred within the first 3 h. At 24 h, 79 patients (17·9 per cent) had died, but mortality continued to rise even after discharge. Patients who received a cumulative ratio of fresh frozen plasma to PRBCs of at least 1 : 2 had lower rates of death than those who received a lower ratio. There were delays in administration of blood. Platelets and cryoprecipitate were either not given, or transfused well after initial resuscitation.
Conclusion
There is a high burden of trauma haemorrhage that affects all age groups. Research is required to understand the reasons for death after the first 24 h and barriers to timely transfusion support.
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Affiliation(s)
- S J Stanworth
- NHS Blood and Transplant/Oxford University Hospitals NHS Trust, John Radcliffe Hospital, and Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| | - R Davenport
- Centre for Trauma Sciences, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - N Curry
- Department of Haematology, Churchill Hospital, Oxford University Hospitals NHS Trust, Oxford, UK
| | - F Seeney
- NHS Blood and Transplant, Statistics and Clinical Studies, Bristol, UK
| | - S Eaglestone
- Centre for Trauma Sciences, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - A Edwards
- Trauma Audit and Research, Academic Health Science Centre, Institute of Population Health, University of Manchester, Salford Royal Hospitals NHS Foundation Trust, Salford, UK
| | - K Martin
- NHS Blood and Transplant, Statistics and Clinical Studies, Bristol, UK
| | - S Allard
- University of Sheffield/University of Manchester/Salford Royal Hospitals NHS Foundation Trust, EMRiS Group, Health Services Research Section, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - M Woodford
- Trauma Audit and Research, Academic Health Science Centre, Institute of Population Health, University of Manchester, Salford Royal Hospitals NHS Foundation Trust, Salford, UK
| | - F E Lecky
- University of Sheffield/University of Manchester/Salford Royal Hospitals NHS Foundation Trust, EMRiS Group, Health Services Research Section, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - K Brohi
- Centre for Trauma Sciences, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
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Zinchenko R, Cole E, Glasgow S, Davenport R. Mild, moderate or severe lung injury after trauma: what are the early predictors? Scand J Trauma Resusc Emerg Med 2015. [PMCID: PMC4577783 DOI: 10.1186/1757-7241-23-s2-a8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Maegele M, Inaba K, Rizoli S, Veigas P, Callum J, Davenport R, Fröhlich M, Hess J. Frühe viskoelastizitätsbasierte Gerinnungstherapie bei blutenden Schwerverletzten. Notf Rett Med 2015. [DOI: 10.1007/s10049-015-0071-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Curry N, Rourke C, Davenport R, Beer S, Pankhurst L, Deary A, Thomas H, Llewelyn C, Green L, Doughty H, Nordmann G, Brohi K, Stanworth S. Early cryoprecipitate for major haemorrhage in trauma: a randomised controlled feasibility trial. Br J Anaesth 2015; 115:76-83. [PMID: 25991760 DOI: 10.1093/bja/aev134] [Citation(s) in RCA: 110] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/14/2015] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Low fibrinogen (Fg) concentrations in trauma haemorrhage are associated with poorer outcomes. Cryoprecipitate is the standard source for Fg administration in the UK and USA and is often given in the later stages of transfusion therapy. It is not known whether early cryoprecipitate therapy improves clinical outcomes. The primary aim of this feasibility study was to determine whether it was possible to administer cryoprecipitate, within 90 min of admission to hospital. Secondary aims were to evaluate laboratory measures of Fg and clinical outcomes including thrombotic events, organ failure, length of hospital stay and mortality. METHODS This was an unblinded RCT, conducted at two civilian UK major trauma centres of adult trauma patients (age ≥16 yrs), with active bleeding and requiring activation of the major haemorrhage protocol. Participants were randomised to standard major haemorrhage therapy (STANDARD) (n=22), or to standard haemorrhage therapy plus two early pools of cryoprecipitate (CRYO) (n=21). RESULTS 85% (95% CI: 69-100%) CRYO participants received cryoprecipitate within 90 min, median time 60 min (IQR: 57-76) compared with 108 min (67-147), CRYO and STANDARD arms respectively (P=0.002). Fg concentrations were higher in the CRYO arm and were maintained above 1.8 g litre(-1) at all time-points during active haemorrhage. All-cause mortality at 28 days was not significantly different (P=0.14). CONCLUSIONS Early Fg supplementation using cryoprecipitate is feasible in trauma patients. This study supports the need for a definitive RCT to determine the effect of early Fg supplementation on mortality and other clinical outcomes. TRIAL REGISTRY NUMBER ISRCTN55509212.
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Affiliation(s)
- N Curry
- Department of Haematology, Oxford University Hospitals NHS Trust, John Radcliffe Hospital, Oxford, UK
| | - C Rourke
- Centre for Trauma Sciences, Barts and the London School of Medicine & Dentistry, Queen Mary University of London, London, UK
| | - R Davenport
- Centre for Trauma Sciences, Barts and the London School of Medicine & Dentistry, Queen Mary University of London, London, UK
| | - S Beer
- Department of Haematology, Oxford University Hospitals NHS Trust, John Radcliffe Hospital, Oxford, UK
| | - L Pankhurst
- NHS Blood and Transplant Clinical Trials Unit, NHS Blood & Transplant, Cambridge and Bristol, UK
| | - A Deary
- NHS Blood and Transplant Clinical Trials Unit, NHS Blood & Transplant, Cambridge and Bristol, UK
| | - H Thomas
- NHS Blood and Transplant Clinical Trials Unit, NHS Blood & Transplant, Cambridge and Bristol, UK
| | - C Llewelyn
- NHS Blood and Transplant Clinical Trials Unit, NHS Blood & Transplant, Cambridge and Bristol, UK
| | - L Green
- Department of Haematology, Barts Health NHS Trust, London, UK
| | - H Doughty
- NHS Blood and Transplant, Birmingham, UK
| | - G Nordmann
- Plymouth Hospitals NHS Trust, Plymouth, UK The Academic Department of Military Anaesthesia and Critical Care, Royal Centre for Defence Medicine, Birmingham, UK
| | - K Brohi
- Centre for Trauma Sciences, Barts and the London School of Medicine & Dentistry, Queen Mary University of London, London, UK
| | - S Stanworth
- Department of Haematology, Oxford University Hospitals NHS Trust, John Radcliffe Hospital, Oxford, UK
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Brown K, Davenport R, Ward S. Effective and emerging strategies for utilizing structure in drug discovery. Cambridge, UK - March 19, 2015. DRUG FUTURE 2015. [DOI: 10.1358/dof.2015.040.04.2314768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Lumley R, Davenport R, Williams A. Most Scottish neurologists do not apply the 2010 McDonald criteria when diagnosing multiple sclerosis. J R Coll Physicians Edinb 2015; 45:23-6. [DOI: 10.4997/jrcpe.2015.106] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Khan S, Davenport R, Raza I, Glasgow S, De'Ath HD, Johansson PI, Curry N, Stanworth S, Gaarder C, Brohi K. Damage control resuscitation using blood component therapy in standard doses has a limited effect on coagulopathy during trauma hemorrhage. Intensive Care Med 2014; 41:239-47. [PMID: 25447807 DOI: 10.1007/s00134-014-3584-1] [Citation(s) in RCA: 112] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2014] [Accepted: 11/25/2014] [Indexed: 10/24/2022]
Abstract
OBJECTIVE To determine the effectiveness of blood component therapy in the correction of trauma-induced coagulopathy during hemorrhage. BACKGROUND Severe hemorrhage remains a leading cause of mortality in trauma. Damage control resuscitation strategies target trauma-induced coagulopathy (TIC) with the early delivery of high-dose blood components such as fresh frozen plasma (FFP) and platelet transfusions. However, the ability of these products to correct TIC during hemorrhage and resuscitation is unknown. METHODS This was an international prospective cohort study of bleeding trauma patients at three major trauma centers. A blood sample was drawn immediately on arrival and after 4, 8 and 12 packed red blood cell (PRBC) transfusions. FFP, platelet and cryoprecipitate use was recorded during these intervals. Samples were analyzed for functional coagulation and procoagulant factor levels. RESULTS One hundred six patients who received at least four PRBC units were included. Thirty-four patients (32 %) required a massive transfusion. On admission 40 % of patients were coagulopathic (ROTEM CA5 ≤ 35 mm). This increased to 58 % after four PRBCs and 81 % after eight PRBCs. On average all functional coagulation parameters and procoagulant factor concentrations deteriorated during hemorrhage. There was no clear benefit to high-dose FFP therapy in any parameter. Only combined high-dose FFP, cryoprecipitate and platelet therapy with a high total fibrinogen load appeared to produce a consistent improvement in coagulation. CONCLUSIONS Damage control resuscitation with standard doses of blood components did not consistently correct trauma-induced coagulopathy during hemorrhage. There is an important opportunity to improve TIC management during damage control resuscitation.
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Affiliation(s)
- Sirat Khan
- Centre for Trauma Sciences, Blizard Institute, Barts and the London School of Medicine, Queen Mary University of London, London, UK,
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