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Shang W, Cao Y, Li Y, Ma M, Che H, Xiao P, Yu Y, Kang H, Wang D. Effect of early hemostasis strategy on secondary post-traumatic sepsis in trauma hemorrhagic patients. Injury 2024; 55:111205. [PMID: 38006781 DOI: 10.1016/j.injury.2023.111205] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Revised: 11/02/2023] [Accepted: 11/12/2023] [Indexed: 11/27/2023]
Abstract
INTRODUCTION Fibrinogen and platelet, as the two main components of hemostatic resuscitation, are frequently administered in traumatic massive hemorrhage patients. It is reasonable to infer that they may have an impact on post-traumatic sepsis as more and more recognition of their roles in inflammation and immunity. This study aims to determine the association between the fibrinogen/platelet transfusion ratio during the first 24 h after trauma and the risk of the post- traumatic sepsis. METHODS We analyzed the data from the National Trauma Data Bank (NTDB). Subjects included the critically injured adult patients admitted to Level I/II trauma center from 2013 to 2017 who received fibrinogen and platelet supplementation and more than 10 units (about 4000 ml) packed red blood cells (pRBCs) during the first 24 h after trauma. Two parts of analyses were performed: (1) multivariable stepwise regression was used to determine the variables that influence the risk of post-traumatic sepsis; (2) propensity score matching (PSM), to compare the influences of different transfusion ratio between fibrinogen and platelet on the risk of sepsis and other outcomes after trauma. RESULTS 8 features were screened out by bi-directional multivariable stepwise logistic regression to predict the post-traumatic sepsis. They are age, sex, BMI, ISSabdomen, current smoker, COPD, Fib4h/24h and Fib/PLT24h. Fib/PLT24h was negatively related to sepsis (p < 0.05). A total of 1601 patients were included in the PSM cohort and grouped by Fib/PLT24h = 0.025 according to the fitting generalized additive model (GAM) model curve. The incidence of sepsis was significantly decreased in the high Fib/PLT group [3.3 % vs 9.4 %, OR = 0.33, 95 %CI (0.17-0.60)]; the length of stay in ICU and mechanical ventilation were both shortened as well [8 (IQR 2.00,17.00) vs 9 (IQR 3.00,19.25), p = 0.006 and 4 (IQR 2.00,10.00) vs 5 (IQR 2.00,14.00), p = 0.003, respectively. CONCLUSIONS Early and sufficient supplementation of fibrinogen was a convenient way contribute to reduce the risk of sepsis after trauma.
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Affiliation(s)
- Wei Shang
- Medical School of Chinese PLA, Beijing, China; Department of Blood Transfusion Medicine, the First Medical Centre, Chinese PLA General Hospital, Beijing, China
| | - Yuan Cao
- Emergency Department, the Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Yun Li
- Medical School of Chinese PLA, Beijing, China; Department of Critical Care Medicine, the First Medical Centre, Chinese PLA General Hospital, Beijing, China
| | - Mingzi Ma
- Department of Blood Transfusion, Shenyang Women's and Children's Hospital, Shenyang, China
| | - Hebin Che
- Medical Big Data Research Center, Chinese PLA General Hospital, Beijing, China
| | - Pan Xiao
- Department of Blood Transfusion Medicine, the First Medical Centre, Chinese PLA General Hospital, Beijing, China; Department of Blood Transfusion, Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Yang Yu
- Medical School of Chinese PLA, Beijing, China; Department of Blood Transfusion Medicine, the First Medical Centre, Chinese PLA General Hospital, Beijing, China
| | - Hongjun Kang
- Medical School of Chinese PLA, Beijing, China; Department of Critical Care Medicine, the First Medical Centre, Chinese PLA General Hospital, Beijing, China
| | - Deqing Wang
- Medical School of Chinese PLA, Beijing, China; Department of Blood Transfusion Medicine, the First Medical Centre, Chinese PLA General Hospital, Beijing, China.
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Ang D, Fakhry SM, Watts DD, Liu H, Morse JL, Armstrong J, Ziglar M, Restivo J, Plurad D, Kurek S, Gonzalez E, Pierre K. Data-Driven Blood Transfusion Thresholds for Severely Injured Patients During Blood Shortages. J Surg Res 2023; 291:17-24. [PMID: 37331188 PMCID: PMC10274455 DOI: 10.1016/j.jss.2023.05.028] [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: 02/16/2023] [Revised: 04/27/2023] [Accepted: 05/14/2023] [Indexed: 06/20/2023]
Abstract
INTRODUCTION Crises like the COVID-19 pandemic create blood product shortages. Patients requiring transfusions are placed at risk and institutions may need to judiciously administer blood during massive blood transfusions protocols (MTP). The purpose of this study is to provide data-driven guidance for the modification of MTP when the blood supply is severely limited. METHODS This is a retrospective cohort study of 47 Level I and II trauma centers (TC) within a single healthcare system whose patients received MTP from 2017 to 2019. All TC used a unifying MTP protocol for balanced blood product transfusions. The primary outcome was mortality as a function of volume of blood transfused and age. Hemoglobin thresholds and measures of futility were also estimated. Risk-adjusted analyses were performed using multivariable and hierarchical regression to account for confounders and hospital variation. RESULTS Proposed MTP maximum volume thresholds for three age groupings are as follows: 60 units for ages 16-30 y, 48 units for ages 31-55 y, and 24 units for >55 y. The range of mortality under the transfusion threshold was 30%-36% but doubled to 67-77% when the threshold was exceeded. Hemoglobin concentration differences relative to survival were clinically nonsignificant. Prehospital measures of futility were prehospital cardiac arrest and nonreactive pupils. In hospital risk factors of futility were mid-line shift on brain CT and cardiopulmonary arrest. CONCLUSIONS Establishing MTP threshold practices under blood shortage conditions, such as the COVID pandemic, could sustain blood availability by following relative thresholds for MTP use according to age groups and key risk factors.
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Affiliation(s)
- Darwin Ang
- Department of Surgery, University of South Florida, Tampa, Florida; College of Medicine, University of Central Florida, Orlando, Florida; Department of Trauma, HCA Florida Ocala Hospital, Ocala, Florida
| | - Samir M Fakhry
- Center for Trauma and Acute Care Surgery Research, Clinical Services Group, HCA Healthcare, Nashville, Tennessee
| | - Dorraine D Watts
- Center for Trauma and Acute Care Surgery Research, Clinical Services Group, HCA Healthcare, Nashville, Tennessee
| | - Huazhi Liu
- Department of Trauma, HCA Florida Ocala Hospital, Ocala, Florida
| | - Jennifer L Morse
- Center for Trauma and Acute Care Surgery Research, Clinical Services Group, HCA Healthcare, Nashville, Tennessee
| | - John Armstrong
- Department of Surgery, University of South Florida, Tampa, Florida
| | - Michele Ziglar
- HCA Healthcare Trauma Services, Clinical Operations Group, HCA Healthcare, Nashville, Tennessee
| | | | - David Plurad
- Department of Trauma, Riverside Community Hospital, Riverside, California
| | - Stanley Kurek
- Trauma Services, Chippenham Johnston Willis Medical Center, Richmond, Virginia
| | - Ernest Gonzalez
- Department of Trauma, St. David's South Austin Medical Center, Austin, Texas
| | - Kevin Pierre
- Department of Radiology, University of Florida, Gainesville, Florida.
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Beckermann J, Swartz H, Albright J, Street W, Martin S, Hagen C, Linnaus M, Ciresi D. Achieving optimal massive transfusion ratios: The trauma white board, whole blood, and liquid plasma. Real world low-tech solutions for a high stakes issue. Injury 2022; 53:2974-8. [PMID: 35791968 DOI: 10.1016/j.injury.2022.06.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2021] [Revised: 05/27/2022] [Accepted: 06/08/2022] [Indexed: 02/02/2023]
Abstract
BACKGROUND It is well established that achieving optimal ratios of packed red blood cells (PRBC) to fresh frozen plasma (FFP) to platelet ratios during massive transfusion leads to improved outcomes but is difficult to accomplish. METHODS Between September 2018 and May 2019 our level 2 trauma center implemented 3 new processes to optimize transfusion ratios during massive transfusion protocol (MTP). Two units of low titer group O whole blood (LTOWB) were added as the first step to our MTP. Second, a dry erase board whiteboard was attached to each fluid warmer for real time recording of transfusions. Last, liquid plasma was incorporated into our MTP. We performed a retrospective review evaluating PRBC:FFP ratios for patients who had the massive transfusion protocol initiated and received 4 or more units of blood. RESULTS A total of 50 patients had the massive transfusion protocol initiated and received 4 or more units of PRBCs and/or LTOWB within 4 h of arrival. There were 21 patients evaluated prior to protocol changes and 29 patients after the changes. In the study group mean age, sex, pulse, systolic blood pressure (SBP), and injury severity scale (ISS) on admission were not different. In the pre-protocol (preP) group 90% of patients were blunt trauma and in the post-protocol group (postP) 72% were blunt trauma, p = 0. 22. For the preP group the mean units of PRBCs was 7.6 units and FFP 4.7 units. PostP the mean units of PRBCs was 11.4 units and FFP 10.0 units. PRBC/FFP ratios were 1.7 preP and 1.2 postP, p = 0.0072. CONCLUSION The institution of whole blood, use of the trauma white board, and the addition of liquid plasma to our transfusion services have allowed us to approach a 1:1 transfusion ratio during the course of our massive transfusions.
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Singh L, Jain K, Jain A, Suri V, Sharma RR. Massive transfusion protocol: Need of the hour - A tertiary care centre experience. J Anaesthesiol Clin Pharmacol 2022; 38:423-427. [PMID: 36505206 PMCID: PMC9728422 DOI: 10.4103/joacp.joacp_476_20] [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] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 01/04/2021] [Accepted: 04/14/2021] [Indexed: 11/07/2022] Open
Abstract
Background and Aims Massive transfusion (MT) in critically ill patients during major volume losses can lead to serious adverse outcomes. Studies have reported that rampant red cell infusion for maintaining perfusion support has had detrimental effects on patients' short- and long-term survival rates. Evidence-based studies quote the importance of maintaining blood product ratio during massive hemorrhage and ensuring good outcomes with the least morbidity and mortality. Material and Methods It is an observational study to compare the ratio of usage of blood products and their role in the outcome of MT cases. Results A total of 70 patients (29 females and 41 males) who received MT were included in the study. There was no fixed ratio of packed red blood cells (PRBC) to blood components for patients with massive hemorrhage. The average ratio of PRBC: fresh frozen plasma (FFP):platelet concentrate (PC) was 1:0.9:0.6. However, blood component therapy with PRBC: FFP ratio between 1 and 2 was associated with a significant rise in post-acute phase hemoglobin value (P value = 0.018). Conclusion Appropriate blood component therapy during the acute bleeding phase in massively transfused patients can further decrease the transfusion demand and transfusion-related complications. There is a need to adhere to the MT protocol for the clinical areas requiring MT in the developing world too.
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Affiliation(s)
| | - Kajal Jain
- Department of Anaesthesiology and Intensive Care, PGIMER, Chandigarh, India
| | - Ashish Jain
- Department of Transfusion Medicine, PGIMER, Chandigarh, India
| | - Vanita Suri
- Department of Obstetrics and Gynaecology, PGIMER, Chandigarh, India
| | - Ratti Ram Sharma
- Department of Transfusion Medicine, PGIMER, Chandigarh, India,Address for correspondence: Prof. Ratti Ram Sharma, Department of Transfusion Medicine, PGIMER, Chandigarh, India. E-mail:
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Rijnhout TWH, Noorman F, van Waes OJF, van Bohemen M, Verhofstad MHJ, Hoencamp R. Massive transfusion protocols in the Netherlands. Consensus or confusion? Injury 2022; 53:49-53. [PMID: 34749909 DOI: 10.1016/j.injury.2021.10.034] [Citation(s) in RCA: 2] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 10/26/2021] [Accepted: 10/29/2021] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Transfusion strategy for trauma patients with massive haemorrhage is often incorporated in massive transfusion protocols (MTP). Albeit correct MTP use results in better patient outcome, research regarding the state of MTP knowledge is scarce. The objective of this study is therefore to assess knowledge of local MTP and massive transfusion strategy in the level 1 trauma centres in the Netherlands. Our hypothesis is that actual MTP knowledge is low and transfusion strategy differs. MATERIALS AND METHODS Surveys were sent out in January 2020 to all trauma and vascular surgeons, anaesthesiologists, emergency department physicians of the largest level 1 trauma centre (locally, n = 113) and to one trauma surgeon, emergency physician and anaesthesiologist in each of the nine other governmentally assigned level 1 trauma centres in the Netherlands (nationally, n = 27). The respondents were subdivided into a frequent user group (MTP usage ≥ 4 times in 2019) and a non-frequent user group (MTP usage < 4 in 2019). Data are expressed as numbers and percentages. RESULTS Response rate was (n = 48; 42%) for the local survey and (n = 14; 52%) for the national survey. Locally, (n = 23; 48%) and (n = 25; 52%) respondents were defined frequent and non-frequent users respectively and national respondents all as frequent users. In total, (n = 13; 27%) of local respondents were aware of the current local composition of the MTP. Respondents indicated to transfuse erythrocytes first, followed by plasma and platelets (local non-frequent users n = 23; 92%, local frequent users n = 21; 91% and national frequent users n = 13; 93%). The indication for platelet transfusion was units erythrocytes transfused (local non-frequent users n = 10; 40% frequent users locally n = 11; 48% and nationally n = 5; 36%) and clinical view (local non-frequent users n = 9; 36%, frequent users locally n = 8; 35% and n<5 nationally. Whereas few respondents claimed (n = 5; 21% non-frequent users locally and n <5 nationally) to transfuse platelets based on platelet counts. Viscoelastic haemostatic assays were performed during MTP, but only by frequent users. CONCLUSION The majority of physicians dealing with massive transfusion in trauma patients were not aware of the exact composition of the MTP and consensus regarding transfusion strategy and indication for platelet transfusion was low.
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Affiliation(s)
- Tim W H Rijnhout
- Department of Surgery, Alrijne Medical Centre, 2353 GA Leiderdorp, the Netherlands; Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Centre Rotterdam, 3000 CA Rotterdam, the Netherlands.
| | - Femke Noorman
- Military Blood Bank, Ministry of Defence, 3584 EZ Utrecht, the Netherlands.
| | - Oscar J F van Waes
- Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Centre Rotterdam, 3000 CA Rotterdam, the Netherlands.
| | - Michaela van Bohemen
- Department of Haematology, Erasmus MC, University Medical Centre Rotterdam, CE 3015 Rotterdam, the Netherlands.
| | - Michael H J Verhofstad
- Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Centre Rotterdam, 3000 CA Rotterdam, the Netherlands.
| | - Rigo Hoencamp
- Department of Surgery, Alrijne Medical Centre, 2353 GA Leiderdorp, the Netherlands; Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Centre Rotterdam, 3000 CA Rotterdam, the Netherlands; Defence Healthcare Organization, Ministry of Defence, 3584 AB Utrecht, the Netherlands; Department of Surgery, Leiden University Medical Centre, 2333 ZA Leiden, the Netherlands.
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Ninokawa S, Tatum D, Toraih E, Nordham K, Ghio M, Taghavi S, Guidry C, McGrew P, Schroll R, Harris C, Duchesne J. Elevated K/iCa ratio is an ancillary predictor for mortality in patients with severe hemorrhage: A decision tree analysis. Am J Surg 2021; 223:1187-1193. [PMID: 34930584 DOI: 10.1016/j.amjsurg.2021.12.011] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 11/22/2021] [Accepted: 12/07/2021] [Indexed: 01/23/2023]
Abstract
INTRODUCTION Trauma patients receiving massive transfusion protocol (MTP) are at risk of citrate-induced hypocalcemia and hyperkalemia. Here we evaluate potassium (K), ionized calcium (iCa), and K/iCa ratio as predictors of mortality. METHODS This retrospective study includes all adult trauma patients who received MTP within 1 h at our level I trauma center between 2014 and 2019. Receiver operating characteristic curve analysis assessed predictive accuracy of K/iCa ratio at admission on 120-day mortality. RESULTS Of 614 patients, 146 received MTP within 1 h and 38 expired. Patients who expired had higher K/iCa ratio than survivors (median [IQR] = 5.7 [3.8-7.2] vs 3.7 [3.1-4.9], p < 0.001). Area under the curve of K/iCa was 0.72 (95%CI = 0.62-0.82, p < 0.001) with sensitivity = 63.2% and specificity = 77.6%. At the optimum K/iCa cutoff (5.07), patients with high ratios had 4 times higher mortality risk (HR = 3.97, 95%CI = 1.89-8.32, p < 0.001). CONCLUSION Elevated K/iCa ratio was an independent predictor of mortality in trauma patients managed with MTP.
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Affiliation(s)
- Scott Ninokawa
- Tulane University School of Medicine, Department of Surgery, New Orleans, LA, USA.
| | - Danielle Tatum
- Tulane University School of Medicine, Department of Surgery, New Orleans, LA, USA; Our Lady of the Lake Regional Medical Center, Baton Rouge, LA, USA.
| | - Eman Toraih
- Tulane University School of Medicine, Department of Surgery, New Orleans, LA, USA; Genetics Unit, Department of Histology and Cell Biology, Faculty of Medicine, Suez Canal University, Ismailia, Egypt.
| | - Kristen Nordham
- Tulane University School of Medicine, Department of Surgery, New Orleans, LA, USA.
| | - Michael Ghio
- Tulane University School of Medicine, Department of Surgery, New Orleans, LA, USA.
| | - Sharven Taghavi
- Tulane University School of Medicine, Department of Surgery, New Orleans, LA, USA.
| | - Chrissy Guidry
- Tulane University School of Medicine, Department of Surgery, New Orleans, LA, USA.
| | - Patrick McGrew
- Tulane University School of Medicine, Department of Surgery, New Orleans, LA, USA.
| | - Rebecca Schroll
- Tulane University School of Medicine, Department of Surgery, New Orleans, LA, USA.
| | - Charles Harris
- Tulane University School of Medicine, Department of Surgery, New Orleans, LA, USA.
| | - Juan Duchesne
- Tulane University School of Medicine, Department of Surgery, New Orleans, LA, USA.
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Gatta LA, Lee PS, Gilner JB, Weber JM, Adkins L, Salinaro JR, Habib AS, Pabon-Ramos W, Strickland KC, Ronald J, Erkanli A, Mehdiratta JE, Grotegut CA, Secord AA. Placental uterine artery embolization followed by delayed hysterectomy for placenta percreta: A case series. Gynecol Oncol Rep 2021; 37:100833. [PMID: 34368412 PMCID: PMC8326725 DOI: 10.1016/j.gore.2021.100833] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Revised: 07/07/2021] [Accepted: 07/11/2021] [Indexed: 11/20/2022] Open
Abstract
Approximately 23% of women intending delayed hysterectomy for placenta accreta spectrum will have an unscheduled surgery. Targeted embolization for placenta accreta spectrum appears to be a safe and feasible adjunct to surgical management. Placental regression may contribute to discrepancy between intraoperative and pathology diagnoses in delayed hysterectomy. A multidisciplinary approach to placenta accreta spectrum is associated with a lower blood loss.
We describe outcomes of patients with suspected placenta percreta treated with placental uterine artery embolization (P-UAE) followed by delayed hysterectomy. This is a prospective case series of subjects from 2005 to 2018 with suspected placenta percreta who underwent P-UAE at the time of cesarean delivery followed by delayed hysterectomy. Both scheduled and unscheduled surgical cases were included. Maternal characteristics, surgical approaches, intra- and postoperative outcomes were abstracted from medical records. In total, twenty-two subjects were included. Median (interquartile range, IQR) delivery gestational age was 34.6 (31.9, 35.7) weeks, occurring as scheduled in 17 (77.3%) subjects and unscheduled in 5 (22.7%). Delayed hysterectomy was performed as scheduled in 17 (77.3%) subjects at a median (IQR) 40.5 (38.0, 44.0) days after delivery, and 5 (22.7%) subjects had a hysterectomy prior to scheduled date, median (IQR) 27.0 (17.0, 35.0) days after delivery. Indications for the 5 unscheduled hysterectomies included bleeding (n = 3) and suspected endometritis (n = 2). Three subjects (13.6%) received a blood transfusion (1, 3, 3 units) during delivery, and 7 (31.8%) were transfused during delayed hysterectomy (median [IQR] 2 [1,3] units). Three (13.6%) subjects had bladder resection at the time of hysterectomy; 1 (4.5%) had an unintentional cystotomy and 1 (4.5%) had a ureteral injury. P-UAE followed by delayed hysterectomy appears to be a safe and feasible, although appropriate patient selection and close surveillance are imperative, as 22.7% of patients underwent unscheduled hysterectomy.
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Affiliation(s)
- Luke A. Gatta
- Division of Maternal-Fetal Medicine, Duke University Hospital, Durham, NC, USA
- Corresponding author at: 2608 Erwin Road, Suite 220, Durham, NC 27705, USA.
| | - Paula S. Lee
- Division of Gynecologic Oncology, Duke Cancer Institute, Duke University Hospital, Durham, NC, USA
| | - Jennifer B. Gilner
- Division of Maternal-Fetal Medicine, Duke University Hospital, Durham, NC, USA
| | - Jeremy M. Weber
- Department of Biostatistics & Bioinformatics, Duke University Hospital, Durham, NC, USA
| | - LaMani Adkins
- Department of Obstetrics & Gynecology, Duke University Hospital, Durham, NC, USA
| | - Julia R. Salinaro
- Department of Obstetrics & Gynecology, Duke University Hospital, Durham, NC, USA
| | - Ashraf S. Habib
- Department of Anesthesiology, Duke University Hospital, Durham, NC, USA
| | - Waleska Pabon-Ramos
- Department of Radiology and Medicine, Duke University Hospital, Durham, NC, USA
| | | | - James Ronald
- Department of Radiology and Medicine, Duke University Hospital, Durham, NC, USA
| | - Alaattin Erkanli
- Department of Biostatistics & Bioinformatics, Duke University Hospital, Durham, NC, USA
| | | | - Chad A. Grotegut
- Division of Maternal-Fetal Medicine, Duke University Hospital, Durham, NC, USA
| | - Angeles Alvarez Secord
- Division of Gynecologic Oncology, Duke Cancer Institute, Duke University Hospital, Durham, NC, USA
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Cowan T, Weaver N, Whitfield A, Bell L, Sebastian A, Hurley S, King KL, Fischer A, Balogh ZJ. The epidemiology of overtransfusion of red cells in trauma resuscitation patients in the context of a mature massive transfusion protocol. Eur J Trauma Emerg Surg 2021; 48:2725-2730. [PMID: 33929562 PMCID: PMC9360094 DOI: 10.1007/s00068-021-01678-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Accepted: 04/19/2021] [Indexed: 11/24/2022]
Abstract
Purpose Packed red blood cell (PRBC) transfusion remains an integral part of trauma resuscitation and an independent predictor of unfavourable outcomes. It is often administered urgently based on clinical judgement. These facts put trauma patients at high risk of potentially dangerous overtransfusion. We hypothesised that trauma patients are frequently overtransfused and overtransfusion is associated with worse outcomes. Methods Trauma patients who received PRBCs within 24 h of admission were identified from the trauma registry during the period January 1 2011–December 31 2018. Overtransfusion was defined as haemoglobin concentration of greater than or equal to 110 g/L at 24 h post ED arrival (± 12 h). Demographics, injury severity, injury pattern, shock severity, blood gas values and outcomes were compared between overtransfused and non-overtransfused patients. Results From the 211 patients (mean age 45 years, 71% male, ISS 27, mortality 12%) who met inclusion criteria 27% (56/211) were overtransfused. Patients with a higher pre-hospital systolic blood pressure (112 vs 99 mmHg p < 0.01) and a higher initial haemoglobin concentration (132 vs 124 p = 0.02) were more likely to be overtransfused. Overtransfused patients received smaller volumes of packed red blood cells (5 vs 7 units p = 0.049), fresh frozen plasma (4 vs 6 units p < 0.01) and cryoprecipitate (6 vs 9 units p = 0.01) than non-overtransfused patients. Conclusion More than a quarter of patients in our cohort were potentially given more blood products than required without obvious clinical consequences. There were no clinically relevant associations with overtransfusion.
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Affiliation(s)
- Timothy Cowan
- Department of Emergency Medicine, John Hunter Hospital, Newcastle, NSW, Australia.,The University of Newcastle, Newcastle, NSW, 2310, Australia
| | - Natasha Weaver
- Hunter Medical Research Institute, Newcastle, NSW, Australia.,The University of Newcastle, Newcastle, NSW, 2310, Australia
| | - Alexander Whitfield
- Department of Emergency Medicine, John Hunter Hospital, Newcastle, NSW, Australia
| | - Liam Bell
- Department of Emergency Medicine, John Hunter Hospital, Newcastle, NSW, Australia
| | - Amanda Sebastian
- Department of Emergency Medicine, John Hunter Hospital, Newcastle, NSW, Australia
| | - Stephen Hurley
- Department of Emergency Medicine, John Hunter Hospital, Newcastle, NSW, Australia
| | - Kate L King
- Department of Traumatology, John Hunter Hospital, Newcastle, NSW, Australia
| | - Angela Fischer
- Department of Traumatology, John Hunter Hospital, Newcastle, NSW, Australia
| | - Zsolt J Balogh
- Department of Traumatology, John Hunter Hospital, Newcastle, NSW, Australia. .,The University of Newcastle, Newcastle, NSW, 2310, Australia.
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Lee YT, Bae BK, Cho YM, Park SC, Jeon CH, Huh U, Lee DS, Ko SH, Ryu DM, Wang IJ. Reverse shock index multiplied by Glasgow coma scale as a predictor of massive transfusion in trauma. Am J Emerg Med 2020; 46:404-409. [PMID: 33143960 DOI: 10.1016/j.ajem.2020.10.027] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [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: 06/11/2020] [Revised: 10/06/2020] [Accepted: 10/15/2020] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND AND PURPOSE Previous studies have identified that the reverse shock index multiplied by the Glasgow Coma Scale score (rSIG) is a good predictor of mortality in trauma patients. However, it is unknown if rSIG has utility as a predictor for massive transfusion (MT) in trauma patients. The present study evaluated the ability of rSIG to predict MT in trauma patients. METHODS This was a retrospective, observational study performed at a level 1 trauma center. Consecutive patients who presented to the trauma center emergency department between January 2016 and December 2018 were included. The predictive ability of rSIG for MT was assessed as our primary outcome measure. Our secondary outcome measures were the predictive ability of rSIG for coagulopathy, in-hospital mortality, and 24-h mortality. We compared the prognostic performance of rSIG with the shock index, age shock index, and quick Sequential Organ Failure Assessment. RESULTS In total, 1627 patients were included and 117 (7.2%) patients received MT. rSIG showed the highest area under the receiver operating characteristic (AUROC) curve (0.842; 95% confidence interval [CI], 0.806--0.878) for predicting MT. rSIG also showed the highest AUROC for predicting coagulopathy (0.769; 95% CI, 0.728-0.809), in-hospital mortality (AUROC 0.812; 95% CI, 0.772-0.852), and 24-h mortality (AUROC 0.826; 95% CI, 0.789-0.864). The sensitivity of rSIG for MT was 0.79, and the specificity of rSIG for MT was 0.77. All tools had a high negative predictive value and low positive predictive value. CONCLUSION rSIG is a useful, rapid, and accurate predictor for MT, coagulopathy, in-hospital mortality, and 24- h mortality in trauma patients.
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Affiliation(s)
- Young Tark Lee
- Department of Emergency Medicine, Pusan National University Hospital, 179, Gudeok-ro, Seo-gu, Busan 602-739, South Korea
| | - Byung Kwan Bae
- Department of Emergency Medicine, Pusan National University Hospital, 179, Gudeok-ro, Seo-gu, Busan 602-739, South Korea
| | - Young Mo Cho
- Department of Emergency Medicine, Pusan National University Hospital, 179, Gudeok-ro, Seo-gu, Busan 602-739, South Korea
| | - Soon Chang Park
- Department of Emergency Medicine, Pusan National University Hospital, 179, Gudeok-ro, Seo-gu, Busan 602-739, South Korea
| | - Chang Ho Jeon
- Department of Radiology, Pusan National University Hospital, 179, Gudeok-ro, Seo-gu, Busan 602-739, South Korea
| | - Up Huh
- Department of Thoracic and Cardiovascular Surgery, Pusan National University Hospital, 179, Gudeok-ro, Seo-gu, Busan 602-739, South Korea
| | - Dae-Sup Lee
- Department of Emergency Medicine, Pusan National University Yangsan Hospital, Beomeo-ri, Mulgeum-eup, Gyeongsangnam-do 626-770, South Korea
| | - Sung-Hwa Ko
- Department of Rehabilitation Medicine, Pusan National University Yangsan Hospital, Beomeo-ri, Mulgeum-eup, Gyeongsangnam-do 626-770, South Korea
| | - Dong-Man Ryu
- Department of Mechanical Engineering, Michigan State University, East Lansing, MI 48824, United States; Biomedical Research Institute, Pusan National University Hospital, 179, Gudeok-ro, Seo-gu, Busan 602-739, South Korea.
| | - Il Jae Wang
- Department of Emergency Medicine, Pusan National University Hospital, 179, Gudeok-ro, Seo-gu, Busan 602-739, South Korea; Biomedical Research Institute, Pusan National University Hospital, 179, Gudeok-ro, Seo-gu, Busan 602-739, South Korea.
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10
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Sehdev M, Grigorian A, Kuza C, Dolich M, Borazjani B, Lekawa M, Nahmias J. Comparing unbalanced and balanced ratios of blood products in massive transfusion to pediatric trauma patients: effects on mortality and outcomes. Eur J Trauma Emerg Surg 2020. [PMID: 32797258 DOI: 10.1007/s00068-020-01461-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Accepted: 08/05/2020] [Indexed: 01/26/2023]
Abstract
BACKGROUND The utilization and impact of various ratios of transfusions for pediatric trauma patients (PTPs) receiving a massive transfusion (MT) are unknown. Therefore, we sought to determine the risk for mortality in PTPs receiving an MT of ≥ 6 units of packed red blood cells (PRBC) within 24 h. We compared PRBC: plasma ratio of > 2:1 (Unbalanced Ratios, UR) versus ≤ 2:1 (Balanced Ratios, BR), hypothesizing decreased risk of mortality with BR. METHODS The Trauma Quality Improvement Program was queried (2014-2016) for PTPs receiving a MT. A multivariable logistic regression model was used to determine risk of mortality. RESULTS From 239 PTPs receiving an MT, 98 (41%) received an UR, whereas 141 (59%) received a BR. The median ratios, respectively, were 2.7:1 and 1.2:1. Compared to BR patients, UR patients had no differences in injury severity score (ISS), hypotension on admission, and intensive care unit stay (all p > 0.05). The mortality rates for BR and UR were similar (46.1% vs. 52.0%, p = 0.366). Controlling for age, ISS, and severe head injury, UR demonstrated similar risk of mortality compared to BR (p = 0.276). Additionally, ≥ 4:1 ratio versus ≤ 2:1 showed no difference in associated risk of mortality (p = 0.489). CONCLUSION In contrast to adult studies, this study demonstrated that MT ratios of > 2:1 and even ≥ 4:1 were associated with similar mortality compared to BR for PTPs. These results suggest pediatric MT resuscitation may not require strict BR as has been shown beneficial in adult trauma patients. Future prospective studies are needed to evaluate the optimal ratio for PTP MT resuscitation. LEVEL OF EVIDENCE III; Retrospective Care Management Study.
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11
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Meneses E, Boneva D, McKenney M, Elkbuli A. Massive transfusion protocol in adult trauma population. Am J Emerg Med 2020; 38:2661-2666. [PMID: 33071074 DOI: 10.1016/j.ajem.2020.07.041] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [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: 05/18/2020] [Revised: 07/07/2020] [Accepted: 07/15/2020] [Indexed: 10/23/2022] Open
Abstract
BACKGROUND Acute blood loss in trauma requires quick identification and action to restore circulating volume and save the patient. Massive transfusion protocols (MTPs) have become standard at Trauma Centers, in order to rapidly deliver blood products to bleeding patients. This literature review presents current standards of transfusion ratios, as well as insights into adjuncts during massive transfusions. METHODS PubMED was searched for articles from 2005 to 2020 on MTPs, the article were assessed for single vs. multi-institutional, mechanism of injury, type of MTP, timing in which blood products should be administered, timing of delivery of blood products to trauma bay, pre-hospital treatment and adjuncts, and outcomes. RESULTS Eleven studies addressed transfusion ratios. Seven studies looked at timing of blood products. Nine studies addressed MTP pre-hospital treatment and adjuncts. Prior to 2015, studies supported the benefits of a balanced transfusion ratio, which was then confirmed by the PROPPR randomized controlled trial. The shorter the time to blood product delivery the better the outcomes. New advances in technology have allowed us to measure different patterns of coagulation, allowing more individualized approaches to the bleeding patient. CONCLUSION Current massive transfusion protocols should utilize between 1:1:1 and 1:1:2 ratios of the 3 main products; plasma, platelets, and red blood cells. Massive transfusion protocols are effective in decreasing mortality. Better resuscitation efforts were seen when blood products were readily available in the trauma bay when the patient arrived and the faster the replacement of blood, the better the outcomes.
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Affiliation(s)
- Evander Meneses
- Department of Surgery, Division of Trauma and Surgical Critical Care, Kendall Regional Medical Center, Miami, FL, USA
| | - Dessy Boneva
- Department of Surgery, Division of Trauma and Surgical Critical Care, Kendall Regional Medical Center, Miami, FL, USA; Department of Surgery, University of South Florida, Tampa, FL, USA
| | - Mark McKenney
- Department of Surgery, Division of Trauma and Surgical Critical Care, Kendall Regional Medical Center, Miami, FL, USA; Department of Surgery, University of South Florida, Tampa, FL, USA
| | - Adel Elkbuli
- Department of Surgery, Division of Trauma and Surgical Critical Care, Kendall Regional Medical Center, Miami, FL, USA.
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12
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Fort AC, Zack-Guasp RA. Anesthesia for Patients with Extensive Trauma. Anesthesiol Clin 2020; 38:135-148. [PMID: 32008648 DOI: 10.1016/j.anclin.2019.10.012] [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] [Indexed: 11/26/2022]
Abstract
Trauma anesthesiology is a unique and growing subspecialty. With the growing number of adult and pediatric trauma centers in the United States, a thorough understanding of the early management of severely injured patients with trauma is an important aspect of anesthesia. Trauma anesthesiology requires the ability to adapt to different work environments, including the trauma bay, the operating room, and even the intensive care unit, where a patient room may require conversion to an operating suite for emergencies. This article provides a review of the anesthetic management for patients with extensive trauma, focusing on physiology, pharmacology, and bedside management.
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Affiliation(s)
- Alexander C Fort
- Department of Anesthesiology, Perioperative Medicine and Pain Management, University of Miami Miller School of Medicine, University of Miami, 1611 Northwest 12th Avenue, Suite C300, Miami, FL 33136, USA.
| | - Richard A Zack-Guasp
- Department of Anesthesiology, Bruce W. Carter Medical Center, Department of Veteran's Health Administration, 1201 Northwest 16th Street, Room B333, Miami, FL 33136, USA
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13
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Herman J, Park B, Awsare B, West F, Crittendon D, Evans L, Harach M, Karp J, Peedin A, LaNoue M, Goldsmith B, Warnick E, Baram M. Point-of-care versus central testing of hemoglobin during large volume blood transfusion. BMC Anesthesiol 2019; 19:240. [PMID: 31881989 PMCID: PMC6933896 DOI: 10.1186/s12871-019-0916-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Accepted: 12/19/2019] [Indexed: 11/10/2022] Open
Abstract
Background Point-of-care (POC) hemoglobin testing has the potential to revolutionize massive transfusion strategies. No prior studies have compared POC and central laboratory testing of hemoglobin in patients undergoing massive transfusions. Methods We retrospectively compared the results of our point-of-care hemoglobin test (EPOC®) to our core laboratory complete blood count (CBC) hemoglobin test (Sysmex XE-5000™) in patients undergoing massive transfusion protocols (MTP) for hemorrhage. One hundred seventy paired samples from 90 patients for whom MTP was activated were collected at a single, tertiary care hospital between 10/2011 and 10/2017. Patients had both an EPOC® and CBC hemoglobin performed within 30 min of each other during the MTP. We assessed the accuracy of EPOC® hemoglobin testing using two variables: interchangeability and clinically significant differences from the CBC. The Clinical Laboratory Improvement Amendments (CLIA) proficiency testing criteria defined interchangeability for measurements. Clinically significant differences between the tests were defined by an expert panel. We examined whether these relationships changed as a function of the hemoglobin measured by the EPOC® and specific patient characteristics. Results Fifty one percent (86 of 170) of paired samples’ hemoglobin results had an absolute difference of ≤7 and 73% (124 of 170) fell within ±1 g/dL of each other. The mean difference between EPOC® and CBC hemoglobin had a bias of − 0.268 g/dL (p = 0.002). When the EPOC® hemoglobin was < 7 g/dL, 30% of the hemoglobin values were within ±7, and 57% were within ±1 g/dL. When the measured EPOC® hemoglobin was ≥7 g/dL, 55% of the EPOC® and CBC hemoglobin values were within ±7, and 76% were within ±1 g/dL. EPOC® and CBC hemoglobin values that were within ±1 g/dL varied by patient population: 77% for cardiac surgery, 58% for general surgery, and 72% for non-surgical patients. Conclusions The EPOC® device had minor negative bias, was not interchangeable with the CBC hemoglobin, and was less reliable when the EPOC® value was < 7 g/dL. Clinicians must consider speed versus accuracy, and should check a CBC within 30 min as confirmation when the EPOC® hemoglobin is < 7 g/dL until further prospective trials are performed in this population.
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Affiliation(s)
- Justin Herman
- Department of Pulmonary and Critical Care Medicine, Thomas Jefferson University Hospital, 834 Walnut St Suite 650, Philadelphia, PA, 19107, USA
| | - Brian Park
- Department of Internal Medicine, Thomas Jefferson University Hospital, 1025 Walnut St Room 805, Philadelphia, PA, 19107, USA
| | - Bharat Awsare
- Department of Pulmonary and Critical Care Medicine, Thomas Jefferson University Hospital, 834 Walnut St Suite 650, Philadelphia, PA, 19107, USA
| | - Frances West
- Department of Pulmonary and Critical Care Medicine, Thomas Jefferson University Hospital, 834 Walnut St Suite 650, Philadelphia, PA, 19107, USA
| | - Denine Crittendon
- School of Population Health, Thomas Jefferson University, 901 Walnut St 10th Floor, Philadelphia, PA, 19107, USA
| | - Lilah Evans
- Department of Pathology, Thomas Jefferson University Hospital, 130 South 9th St Room 2109, Philadelphia, PA, 19107, USA
| | - Mary Harach
- Blood Bank and Transfusion Medicine, Thomas Jefferson University Hospital, 111 South 11th St, Philadelphia, PA, 19107, USA
| | - Julie Karp
- Blood Bank and Transfusion Medicine, Thomas Jefferson University Hospital, 111 South 11th St, Philadelphia, PA, 19107, USA
| | - Alexis Peedin
- Blood Bank and Transfusion Medicine, Thomas Jefferson University Hospital, 111 South 11th St, Philadelphia, PA, 19107, USA
| | - Marianna LaNoue
- School of Population Health, Thomas Jefferson University, 901 Walnut St 10th Floor, Philadelphia, PA, 19107, USA
| | - Barbara Goldsmith
- Department of Pathology, Thomas Jefferson University Hospital, 130 South 9th St Room 2109, Philadelphia, PA, 19107, USA
| | - Eugene Warnick
- Sidney Kimmel Medical College, Thomas Jefferson University, 1025 Walnut St, Philadelphia, PA, 19107, USA
| | - Michael Baram
- Department of Pulmonary and Critical Care Medicine, Thomas Jefferson University Hospital, 834 Walnut St Suite 650, Philadelphia, PA, 19107, USA.
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14
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Elkbuli A, Shaikh S, McKenney M, Boneva D. Life-threatening hemoperitoneum secondary to rupture of a uterine leiomyoma: A case report and review of the literature. Int J Surg Case Rep 2019; 61:51-55. [PMID: 31326857 PMCID: PMC6642253 DOI: 10.1016/j.ijscr.2019.07.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Accepted: 07/06/2019] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION While uterine leiomyomas are the most common pelvic tumors in females, resultant hemoperitoneum is an extremely rare and acute complication which requires emergent intervention and resuscitation. To date, less than one-hundred cases have been reported in the literature. PRESENTATION OF CASE We report a case of massive hemoperitoneum due to spontaneous rupture of a 20 cm pedunculated leiomyoma in a 74-year-old female who presented as a trauma alert. Rapidly declining hemodynamic status with an ultrasound consistent with extensive hemoperitoneum led to activation of the massive transfusion protocol and an emergent laparotomy. In the operating theater the laparotomy revealed 4 L of blood. She underwent a myomectomy and subsequently, an angiogram and embolization of a bleeding uterine artery. In all, she required transfusion of 26 units of blood. Post operatively she was discharged home on hospital day 13. DISCUSSION Near fatal hemoperitoneum secondary to a uterine leiomyoma may be due to traumatic or spontaneous rupture of an overlying vein or artery. Leiomyomas greater than 10 cm in size have an increased risk of rupturing. A significant amount of blood can accumulate in the peritoneum resulting in hypovolemic shock. CONCLUSION Acute complications of uterine leiomyomas requiring surgical intervention are exceptionally rare. Candidates for the massive transfusion protocol must be appropriately and timely identified. Additionally, because surgery is a potential treatment for hemorrhage control in leiomyoma-related hemoperitoneum, surgeons should be aware of such complications.
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Affiliation(s)
- Adel Elkbuli
- Department of Surgery, Kendall Regional Medical Center, Miami, FL, United States.
| | - Saamia Shaikh
- Department of Surgery, Kendall Regional Medical Center, Miami, FL, United States
| | - Mark McKenney
- Department of Surgery, Kendall Regional Medical Center, Miami, FL, United States; University of South Florida, Tampa, FL, United States
| | - Dessy Boneva
- Department of Surgery, Kendall Regional Medical Center, Miami, FL, United States; University of South Florida, Tampa, FL, United States
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15
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Shi W, Al-Sabti R, Burke PA, Gonzalez M, Mantilla-Rey N, Quillen K. Quality Management of massive transfusion protocol incorporating tranexamic acid adherence. Transfus Apher Sci 2018; 57:785-789. [PMID: 30455154 DOI: 10.1016/j.transci.2018.10.003] [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: 07/27/2018] [Revised: 09/22/2018] [Accepted: 10/16/2018] [Indexed: 11/16/2022]
Abstract
Massive transfusion protocols (MTP) vary at different institutions. We implemented an algorithm in the transfusion service to support our Level I trauma center in 2007 and periodically monitor MTP utilization as part of ongoing quality management. At the last review in 2013, median plasma: RBC ratio was 1:1.8. We undertook a retrospective 3-year review of MTP activations stratifying by trauma versus non-trauma indications, and blood component utilization of the massive transfusion (MT) cases, adding a review of tranexamic acid (TXA) administration to the audit. The median transfused plasma: RBC ratio was 1:1.9 in trauma MT, and 1:1.6 in the non-trauma MT cases. Non-trauma MT patients at our institution were significantly older and more coagulopathic at MTP initiation compared to trauma MT patients, received fewer RBC units (15.5 versus 20.2), and had higher mortality. TXA adherence increased over the 3-year period to 60% of all trauma MTP activations in 2017.
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Affiliation(s)
- Weiwei Shi
- Department of Pathology and Laboratory Medicine, Boston University Medical Center, Boston, MA, 02118, United States.
| | - Ram Al-Sabti
- Department of Pathology and Laboratory Medicine, Boston University Medical Center, Boston, MA, 02118, United States
| | - Peter A Burke
- Department of Surgery, Boston University Medical Center, United States
| | - Mauricio Gonzalez
- Department of Anesthesiology, Boston University Medical Center, United States
| | - Nelson Mantilla-Rey
- Department of Pathology and Laboratory Medicine, Boston University Medical Center, Boston, MA, 02118, United States
| | - Karen Quillen
- Department of Pathology and Laboratory Medicine, Boston University Medical Center, Boston, MA, 02118, United States
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16
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Margarido C, Ferns J, Chin V, Ribeiro T, Nascimento B, Barrett J, Herer E, Halpern S, Andrews L, Ballatyne G, Chapmam M, Gomes J, Callum J. Massive hemorrhage protocol activation in obstetrics: a 5-year quality performance review. Int J Obstet Anesth 2018; 38:37-45. [PMID: 30509680 DOI: 10.1016/j.ijoa.2018.10.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Revised: 09/24/2018] [Accepted: 10/13/2018] [Indexed: 11/19/2022]
Abstract
BACKGROUND A structured approach to hemorrhagic emergencies in obstetrics has gained popularity with the implementation of massive hemorrhage protocols. The trauma literature suggests that routine quality reviews should be in place to improve patient outcomes. The aim of this study was to develop quality indicators and assess compliance by the clinical team. METHODS A multidisciplinary team set the institutional quality indicators for the massive hemorrhage protocol review. A retrospective review of all obstetrical massive hemorrhage protocol activation events from September 2010 to January 2015 was performed. All protocol events occurred before the creation of the quality indicators. Data were retrieved from patient records. RESULTS There were 17 (0.09%) protocol activations for 19 790 deliveries during the study period. All 17 (100%) patients received at least one unit of red blood cells. Overactivation, defined as the transfusion of <2 units of red blood cells, occurred in two cases (12%). Common causes of non-compliance were: 24% (4/17) temperature monitoring, 18% (3/17) lactate measurement, 41% (7/17) arterial blood gas sampling, and 18% (3/17) hemoglobin maintenance within the target range of 55-95 g/L. Admission to intensive care and peripartum hysterectomy occurred in 12 and 5 cases (71% and 29%), respectively. CONCLUSIONS Suboptimal compliance was found in multiple areas, which may be attributable to the low frequency of activation of our massive haemorrhage protocol in obstetrics. The quality targets identified in this report can act as a basis for other institutions developing quality indicators to evaluate performance.
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Affiliation(s)
- C Margarido
- Department of Obstetrics Anaesthesia, Division of Obstetrical Anaesthesia, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.
| | - J Ferns
- Department of Obstetrics Anaesthesia, Division of Obstetrical Anaesthesia, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - V Chin
- Department of Transfusion Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - T Ribeiro
- Department of Obstetrics Anaesthesia, Division of Obstetrical Anaesthesia, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - B Nascimento
- Department of General Surgery, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - J Barrett
- Department of Obstetrics and Gynecology, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - E Herer
- Department of Obstetrics and Gynecology, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - S Halpern
- Department of Obstetrics Anaesthesia, Division of Obstetrical Anaesthesia, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - L Andrews
- Department of Women and Babies, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - G Ballatyne
- Department of Women and Babies, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - M Chapmam
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - J Gomes
- Department of Evaluative Clinical Sciences, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - J Callum
- Department of Transfusion Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
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17
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Givergis R, Munnangi S, Fayaz M Fomani K, Boutin A, Zapata LC, Angus LDG. Evaluation of massive transfusion protocol practices by type of trauma at a level I trauma center. Chin J Traumatol 2018; 21:261-266. [PMID: 29776837 PMCID: PMC6235793 DOI: 10.1016/j.cjtee.2018.01.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Revised: 01/08/2018] [Accepted: 03/08/2018] [Indexed: 02/04/2023] Open
Abstract
PURPOSE To evaluate massive transfusion protocol practices by trauma type at a level I trauma center. METHODS A retrospective analysis was performed on a sample of 76 trauma patients with MTP activation between March 2010 and January 2015 at a regional trauma center. Patient demographics, transfusion practices, and clinical outcomes were compared by type of trauma sustained. RESULTS Penetrating trauma patients who required MTP activation were significantly younger, had lower injury severity score (ISS), higher probability of survival (POS), decreased mortality, and higher Glasgow Coma scale (GCS) compared to blunt trauma patients. Overall, the mortality rate was 38.16%. The most common injury sustained among blunt trauma patients was head injury (36.21%), whereas the majority of the penetrating trauma patients sustained abdominal injuries (55.56%). Although the admission coagulation parameters and timing of coagulopathy were not significantly different between the two groups of patients, a significantly higher proportion of penetrating trauma patients received high plasma content therapy relative to blunt trauma patients (p < 0.01). CONCLUSION Despite the use of the same MTP for all injured patients requiring massive transfusion, significant differences existed between blunt trauma patients and penetrating trauma patients. These differences in transfusion characteristics and outcomes following MTP activation underscore the complexity of implementing MTPs and warrant vigilant transfusion practices to improve outcomes in trauma patients.
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Affiliation(s)
- Roshan Givergis
- Department of Emergency Medicine, Nassau University Medical Center, East Meadow, NY, USA
| | - Swapna Munnangi
- Department of Emergency Medicine, Nassau University Medical Center, East Meadow, NY, USA,Corresponding author.
| | | | - Anthony Boutin
- Department of Emergency Medicine, Nassau University Medical Center, East Meadow, NY, USA
| | - Luis Carlos Zapata
- Department of Emergency Medicine, Nassau University Medical Center, East Meadow, NY, USA
| | - LD George Angus
- Department of Surgery, Nassau University Medical Center, East Meadow, NY, USA
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18
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Tanaka H, Matsunaga S, Yamashita T, Okutomi T, Sakurai A, Sekizawa A, Hasegawa J, Terui K, Miyake Y, Murotsuki J, Ikeda T. A systematic review of massive transfusion protocol in obstetrics. Taiwan J Obstet Gynecol 2017; 56:715-8. [PMID: 29241907 DOI: 10.1016/j.tjog.2017.10.001] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/18/2017] [Indexed: 12/30/2022] Open
Abstract
Post-partum obstetric haemorrhage is a leading cause of mortality among Japanese women, generally treated with haemostatic measures followed by supplementary transfusion. Commonly used in the setting of severe trauma, massive transfusion protocols (MTPs), preparations of red blood cell concentrate (RBC) and fresh frozen plasma (FFP) with additional supplements, have proved effective in decreasing patient mortality following major obstetric bleeding events. Although promising, the optimal configuration of RBC and FFP utilized for obstetric bleeding needs to be verified. Here, we conducted a systematic literature review to define the optimal ratio of RBC to FFP for transfusion therapy during instances of obstetric bleeding. Our analysis extracted four retrospective, observational studies, all demonstrating that an FFP/RBC ratio of ≥1 was associated with improved patient outcomes following obstetric haemorrhage. We therefore conclude that, from the standpoint of haemostatic resuscitation, an FFP/RBC ratio of ≥1 is a necessary condition for optimal clinical management during MTP administration in the field of obstetrics. Hence, we further propose an optimized MTP strategy to be utilized in the setting of severe obstetric bleeding.
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19
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Dhillon NK, Smith EJT, Ko A, Harada MY, Yang AR, Patel KA, Barmparas G, Ley EJ. The risk factors of venous thromboembolism in massively transfused patients. J Surg Res 2017; 222:115-121. [PMID: 29273362 DOI: 10.1016/j.jss.2017.09.038] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2017] [Revised: 09/02/2017] [Accepted: 09/28/2017] [Indexed: 11/29/2022]
Abstract
BACKGROUND Massive transfusion protocols (MTPs) are necessary for hemodynamically unstable trauma patients with active bleeding. Thrombotic events have been associated with blood transfusion; however, the risk factors for the development of venous thromboembolism (VTE) in trauma patients receiving MTP are unknown. METHODS A retrospective review was conducted by reviewing the electronic medical records of all trauma patients admitted to a Level I trauma center who received MTP from 2011 to 2016. Data were collected on patient demographics, mechanism of injury, injury severity scores, quantity of blood products transfused during MTP activation, incidence of VTE, intensive care unit length of stay (LOS), hospital LOS, and ventilator days. The primary outcome was VTE. RESULTS Of the 59 patients who had MTP activated, 15 (25.4%) developed a VTE during their hospital admission. Patients who developed VTE were compared with those who did not. Age (40 y versus 35 y, P = 0.59), sex (60% versus 73% male, P = 0.52), and mechanism of injury (47% versus 59% blunt, P = 0.40) were similar. Intensive care unit LOS, hospital LOS, and ventilator days were longer in the patients who were diagnosed with a VTE. Multivariable analysis revealed an increase in the odds for developing a VTE with increasing packed red blood cell transfusion (adjusted odds ratio = 2.61, P = 0.03). CONCLUSIONS The risk for VTE in trauma patients requiring massive transfusion is proportional to the number of packed red blood cells transfused. Liberal screening protocols and maintenance of a high index of suspicion for VTE in these high-risk patients is justified.
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Affiliation(s)
- Navpreet K Dhillon
- Division of Trauma and Critical Care, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Eric J T Smith
- Division of Trauma and Critical Care, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Ara Ko
- Division of Trauma and Critical Care, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Megan Y Harada
- Division of Trauma and Critical Care, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Audrey R Yang
- Division of Trauma and Critical Care, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Kavita A Patel
- Division of Trauma and Critical Care, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Galinos Barmparas
- Division of Trauma and Critical Care, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Eric J Ley
- Division of Trauma and Critical Care, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California.
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Abstract
The resuscitation of traumatic hemorrhagic shock has undergone a paradigm shift in the last 20 years with the advent of damage control resuscitation (DCR). Major principles of DCR include minimization of crystalloid, permissive hypotension, transfusion of a balanced ratio of blood products, and goal-directed correction of coagulopathy. In particular, plasma has replaced crystalloid as the primary means for volume expansion for traumatic hemorrhagic shock. Predicting which patient will require DCR by prompt and accurate activation of a massive transfusion protocol, however, remains a challenge.
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Affiliation(s)
- Ronald Chang
- Center for Translational Injury Research, University of Texas Health Science Center, 6410 Fannin Street, Suite 1100, Houston, TX 77030, USA.
| | - John B Holcomb
- Department of Surgery, University of Texas Health Science Center, 6410 Fannin Street, Suite 1100, Houston, TX 77030, USA
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21
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Fredericks C, Kubasiak JC, Mentzer CJ, Yon JR. Massive transfusion: An update for the anesthesiologist. World J Anesthesiol 2017; 6:14-21. [DOI: 10.5313/wja.v6.i1.14] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2016] [Revised: 11/04/2016] [Accepted: 12/19/2016] [Indexed: 02/06/2023] Open
Abstract
Exsanguination from trauma, gastrointestinal bleeding, and obstetric hemorrhage remains a major source of mortality across the planet. Continued research into resuscitation strategies and evolving technology and blood product storage has allowed for patient to undergo very large volume transfusions, even to the point of replacing a patient’s blood volume several times over. As massive transfusions have become more common, more studies have been performed delineating the exact patient population that would benefit, start- and stop-points of transfusions, complications and avoidance of the same. We discuss these points and provide information and strategies for massive transfusion.
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Abstract
Obstetric hemorrhage accounts for 5% all deliveries in the United States and accounts for high maternal morbidity and mortality. Many hemorrhages are secondary to uterine atony and are quickly ameliorated with appropriate uterotonic use. However, for a subset of cases, severe hemorrhage may require advanced resuscitative techniques, and innovative procedural and surgical techniques. This article guides a provider through such a resuscitation.
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Affiliation(s)
- Arthur Jason Vaught
- Division of Maternal Fetal Medicine, Department of Gynecology and Obstetrics, The Johns Hopkins University School of Medicine, 600 North Wolfe Street, Phipps 228, Baltimore, MD 21287, USA.
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Abstract
OBJECTIVES We sought to assess ordering practices and quality of communication during massive transfusion at US level I trauma centers. METHODS An anonymous, web-based survey was distributed to blood banks supporting US level I trauma centers. Information gathered in the survey included demographics, utilization of and perceived level of support for computerized physician order entry (CPOE), frequency of order confusion, and nonprotocol ordering. Responses were analyzed using descriptive statistics. RESULTS Responses were received from 43 of 121 centers (35.5% response rate), with the majority completed by blood bank physicians (67.4%) and blood bank supervisors (25.6%). Allowable pathways for massive transfusion protocol (MTP) ordering included CPOE (48.8%), verbal/telephone (86.1%), and written (44.2%). The preferred method of MTP activation was verbal/telephone (86.1%). Initial activation of MTP was well communicated (97.6% agreement), but confusion associated with ongoing needs was reported to occur at least sometimes by 32.6%. CONCLUSIONS Although CPOE-based MTP ordering is offered by nearly half of US level I trauma centers, verbal/telephone ordering is by far the preferred mechanism. Our survey identifies confusion surrounding blood component needs during MTP resuscitation as an opportunity for practice improvement.
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Affiliation(s)
- Minh-Ha Tran
- From the University of California Irvine Health, School of Medicine, Irvine
| | | | - Sarah Harm
- University of Vermont College of Medicine, Burlington
| | | | - Mark Fung
- University of Vermont College of Medicine, Burlington
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Abstract
Massive transfusion practices were transformed during the 1970s without solid evidence supporting the use of component therapy. A manual literature search was performed for all references to the lethal triad, acute or early coagulopathy of trauma, fresh whole blood, and component transfusion therapy in massive trauma, and damage control resuscitation. Data from recent wars suggest traditional component therapy causes a nonhemostatic resuscitation worsening the propagation of the lethal triad hastening death. These same studies also indicate the advantage of fresh whole blood over component therapy even when administered in a 1:1:1 replacement ratio.
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Peralta R, Vijay A, El-Menyar A, Consunji R, Abdelrahman H, Parchani A, Afifi I, Zarour A, Al-Thani H, Latifi R. Trauma resuscitation requiring massive transfusion: a descriptive analysis of the role of ratio and time. World J Emerg Surg 2015; 10:36. [PMID: 26279672 PMCID: PMC4536606 DOI: 10.1186/s13017-015-0028-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2015] [Accepted: 07/23/2015] [Indexed: 11/10/2022] Open
Abstract
Objective We aimed to evaluate whether early administration of high plasma to red blood cells ratios influences outcomes in injured patients who received massive transfusion protocol (MTP). Methods A retrospective analysis was conducted at the only level 1 national trauma center in Qatar for all adult patients(≥18 years old) who received MTP (≥10 units) of packed red blood cell (PRBC) during the initial 24 h post traumatic injury. Data were analyzed with respect to FFB:PRBC ratio [(high ≥ 1:1.5) (HMTP) vs. (low < 1:1.5) (LMTP)] given at the first 4 h post-injury and also between (>4 and 24 h). Mortality, multiorgan failure (MOF) and infectious complications were studied as well. Results During the study period, a total of 4864 trauma patients were admitted to the hospital, 1.6 % (n = 77) of them met the inclusion criteria. Both groups were comparable with respect to initial pH, international normalized ratio, injury severity score, revised trauma score and development of infectious complications. However, HMTP was associated with lower crude mortality (41.9 vs. 78.3 %, p = 0.001) and lower rate of MOF (48.4 vs. 87.0 %, p = 0.001). The number of deaths was 3 times higher in LMTP in comparison to HMTP within the first 30 days (36 vs. 13 cases). The majority of deaths occurred within the first 24 h (80.5 % in LMTP and 69 % in HMTP) and particularly within the first 6 h (55 vs. 46 %). Conclusions Aggressive attainment of high FFP/PRBC ratios as early as 4 h post-injury can substantially improve outcomes in trauma patients.
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Affiliation(s)
- Ruben Peralta
- Trauma Surgery Section, Hamad Trauma Center, Hamad General Hospital, Doha, Qatar
| | - Adarsh Vijay
- Trauma Surgery Section, Hamad Trauma Center, Hamad General Hospital, Doha, Qatar
| | - Ayman El-Menyar
- Clinical Research, Trauma Surgery Section, Hamad General Hospital, HMC, PO Box 3050, Doha, Qatar ; Clinical Medicine, Weill Cornell Medical College, Doha, Qatar
| | - Rafael Consunji
- Trauma Surgery Section, Hamad Trauma Center, Hamad General Hospital, Doha, Qatar
| | - Husham Abdelrahman
- Trauma Surgery Section, Hamad Trauma Center, Hamad General Hospital, Doha, Qatar
| | - Ashok Parchani
- Trauma Surgery Section, Hamad Trauma Center, Hamad General Hospital, Doha, Qatar
| | - Ibrahim Afifi
- Trauma Surgery Section, Hamad Trauma Center, Hamad General Hospital, Doha, Qatar
| | - Ahmad Zarour
- Trauma Surgery Section, Hamad Trauma Center, Hamad General Hospital, Doha, Qatar ; Clinical Medicine, Weill Cornell Medical College, Doha, Qatar
| | - Hassan Al-Thani
- Trauma Surgery Section, Hamad Trauma Center, Hamad General Hospital, Doha, Qatar
| | - Rifat Latifi
- Trauma Surgery Section, Hamad Trauma Center, Hamad General Hospital, Doha, Qatar ; Department of Surgery, University of Arizona, Tucson, AZ USA
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Bawazeer M, Ahmed N, Izadi H, McFarlan A, Nathens A, Pavenski K. Compliance with a massive transfusion protocol (MTP) impacts patient outcome. Injury 2015; 46:21-8. [PMID: 25452004 DOI: 10.1016/j.injury.2014.09.020] [Citation(s) in RCA: 57] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2014] [Revised: 09/16/2014] [Accepted: 09/25/2014] [Indexed: 02/02/2023]
Abstract
BACKGROUND About 5% of civilian trauma requires massive transfusion. Protocolized resuscitation with blood products to achieve high plasma:RBC ratio has been advocated to improve survival. Our objectives were to measure compliance to our institutional MTP, to identify quality assurance activities that could improve protocol compliance and to determine if protocol compliance was related to patient outcome. METHODS The investigators determined 13 compliance criteria based upon our institutional protocol. We measured compliance in 72 consecutive MTP activations between January 2010 and September 2011 at a Level I trauma centre. Data elements were retrospectively retrieved from blood bank, trauma registry and clinical records. Patients were stratified into three groups based on compliance level, and mortality differences were compared. RESULTS Average compliance for the cohort (n=72) was 66%. The most common cause of non-compliance was failure to send a complete haemorrhage panel from the trauma bay (96%). Failure to monitoring blood work every 30min occurred in 89% of cases. Delay in activation and deactivation occurred in 50% and 50% respectively. Non-compliance to protocol-based administration of blood products happened in 47%. The cohort was stratified into three groups based on compliance, A: <60%, B: 60-80% and C: >80% (low, moderate and high compliance groups). There was no statistical significance with regard to median age, median ISS, ED SBP, ED GCS and AIS of the head/spine, chest and abdomen. The mortality rates in each group were 62%, 50% and 10% in the low, moderate and high compliance groups respectively. Mortality differences were compared using adjusted logistic regression. The OR for mortality between Groups A and B=1.1 [95% CI 0.258-4.687 (P=0.899)] while the OR for mortality between Groups C and B=0.02 [95% CI <0.001-0.855 (P=0.041)]. CONCLUSIONS Measures should be directed towards provider and system factors to improve compliance. In this study, there was an association between survival and higher level of compliance.
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Affiliation(s)
- M Bawazeer
- Trauma Program and Transfusion Medicine, Departments of Surgery and Laboratory Medicine, St. Michael's Hospital, University of Toronto, Canada.
| | - N Ahmed
- Trauma Program and Transfusion Medicine, Departments of Surgery and Laboratory Medicine, St. Michael's Hospital, University of Toronto, Canada.
| | - H Izadi
- Trauma Program and Transfusion Medicine, Departments of Surgery and Laboratory Medicine, St. Michael's Hospital, University of Toronto, Canada.
| | - A McFarlan
- Trauma Program and Transfusion Medicine, Departments of Surgery and Laboratory Medicine, St. Michael's Hospital, University of Toronto, Canada.
| | - A Nathens
- Trauma Program and Transfusion Medicine, Departments of Surgery and Laboratory Medicine, St. Michael's Hospital, University of Toronto, Canada.
| | - K Pavenski
- Trauma Program and Transfusion Medicine, Departments of Surgery and Laboratory Medicine, St. Michael's Hospital, University of Toronto, Canada.
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Leal-Noval SR, Casado M, Arellano-Orden V, Dusseck R, Bautista-Paloma J, Muñoz M, Naranjo-Izorieta J, Moreno AP, Cayuela A. Administration of fibrinogen concentrate for refractory bleeding in massively transfused, non-trauma patients with coagulopathy: a retrospective study with comparator group. BMC Anesthesiol 2014; 14:109. [PMID: 25489274 PMCID: PMC4258800 DOI: 10.1186/1471-2253-14-109] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2014] [Accepted: 11/12/2014] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND This retrospective, single centre study was conducted to investigate the efficacy of fibrinogen concentrate (FBNc) in decreasing blood requirements and reaching optimal fibrinogen level, in non-trauma, massively transfused, bleeding patients with coagulopathy. METHODS Over a 3-years period, all patients for whom a massive transfusion protocol was activated and had received ≥ 4 units of allogeneic blood components within a ≤ 4 h period, were included. Patients were classified according to whether they received FBNc or achieved an optimal fibrinogen level of ≥ 2 g/L within 24 h after FBNc administration. RESULTS Seventy-one patients received 2 [2,4] g of FBNc (FBNc group) and 72 did not (comparator group). FBNc was administered after transfusing 5 [5,9] blood component units, 3 [2,6] hours after massive transfusion protocol activation. Linear regression analysis showed that SOFA (AOR 0.75 [95% CI:0.08-1.43]) and admission fibrinogen level (AOR -2.7 [95% CI:-4.68 - -0.78]), but not FBNc administration, were independently associated with total transfused units. There was a significant inverse relation between both admission and target fibrinogen levels, and total transfused components. Logistic regression showed a direct relationship between admission fibrinogen level and achieving a target level ≥ 2 g/L (AOR 3.29 [95% CI;1.95-5.56]). No thromboembolic events associated with FBNc were observed. CONCLUSIONS In massively transfused, non-trauma patients with coagulopathy and refractory bleeding, late administration of low FBNc dosage was not associated with decreased blood transfusion or increased post-infusion fibrinogen level. Given that both fibrinogen upon admission and target fibrinogen levels were associated with decreased blood transfusion, earlier administration and higher doses of FBNc could be needed.
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Affiliation(s)
- Santiago R Leal-Noval
- Critical Care Division, Hospital Universitario "Virgen del Rocío" and Instituto de Biomedicina IBIS, Avenida Manuel Siurot s/n, 41013 Seville, Spain
| | - Manuel Casado
- Critical Care Division, Hospital Universitario "Virgen del Rocío" and Instituto de Biomedicina IBIS, Avenida Manuel Siurot s/n, 41013 Seville, Spain
| | - Victoria Arellano-Orden
- Critical Care Division, Hospital Universitario "Virgen del Rocío" and Instituto de Biomedicina IBIS, Avenida Manuel Siurot s/n, 41013 Seville, Spain
| | - Reginald Dusseck
- Critical Care Division, Hospital Universitario "Virgen del Rocío" and Instituto de Biomedicina IBIS, Avenida Manuel Siurot s/n, 41013 Seville, Spain
| | - Javier Bautista-Paloma
- Pharmacy Division, Hospital Universitario "Virgen del Rocío" and Instituto de Biomedicina IBIS, Avenida Manuel Siurot s/n, 41013 Seville, Spain
| | - Manuel Muñoz
- Transfusion Medicine, University of Málaga, Málaga, Spain
| | - José Naranjo-Izorieta
- Critical Care Division, Hospital Universitario "Virgen del Rocío" and Instituto de Biomedicina IBIS, Avenida Manuel Siurot s/n, 41013 Seville, Spain
| | - Antonio Puppo Moreno
- Critical Care Division, Hospital Universitario "Virgen del Rocío" and Instituto de Biomedicina IBIS, Avenida Manuel Siurot s/n, 41013 Seville, Spain
| | - Aurelio Cayuela
- Statistics and Design Division, Hospital del Valme, Seville, Spain
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Mauffrey C, Cuellar DO, Pieracci F, Hak DJ, Hammerberg EM, Stahel PF, Burlew CC, Moore EE. Strategies for the management of haemorrhage following pelvic fractures and associated trauma-induced coagulopathy. Bone Joint J 2014; 96-B:1143-54. [PMID: 25183582 DOI: 10.1302/0301-620x.96b9.33914] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Exsanguination is the second most common cause of death in patients who suffer severe trauma. The management of haemodynamically unstable high-energy pelvic injuries remains controversial, as there are no universally accepted guidelines to direct surgeons on the ideal use of pelvic packing or early angio-embolisation. Additionally, the optimal resuscitation strategy, which prevents or halts the progression of the trauma-induced coagulopathy, remains unknown. Although early and aggressive use of blood products in these patients appears to improve survival, over-enthusiastic resuscitative measures may not be the safest strategy. This paper provides an overview of the classification of pelvic injuries and the current evidence on best-practice management of high-energy pelvic fractures, including resuscitation, transfusion of blood components, monitoring of coagulopathy, and procedural interventions including pre-peritoneal pelvic packing, external fixation and angiographic embolisation.
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Affiliation(s)
- C Mauffrey
- Denver Health Medical Center, 655 Broadway, Suite 365 Denver, Colorado 80203, USA
| | - D O Cuellar
- Denver Health Medical Center, 655 Broadway, Suite 365 Denver, Colorado 80203, USA
| | - F Pieracci
- Denver Health Medical Center, 655 Broadway, Suite 365 Denver, Colorado 80203, USA
| | - D J Hak
- Denver Health Medical Center, 655 Broadway, Suite 365 Denver, Colorado 80203, USA
| | - E M Hammerberg
- Denver Health Medical Center, 655 Broadway, Suite 365 Denver, Colorado 80203, USA
| | - P F Stahel
- Denver Health Medical Center, 655 Broadway, Suite 365 Denver, Colorado 80203, USA
| | - C C Burlew
- Denver Health Medical Center, 655 Broadway, Suite 365 Denver, Colorado 80203, USA
| | - E E Moore
- Denver Health Medical Center, 655 Broadway, Suite 365 Denver, Colorado 80203, USA
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29
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Abstract
Bleeding is the second leading cause of death after trauma. Initial care of the patient with hemorrhage focuses on restoring circulating blood volume and reversing coagulopathy. Trauma and injury can initiate the coagulation cascade. Patients with massive bleeding should be resuscitated with goal-directed therapy. Hemostatic resuscitation in conjunction with ratio-based transfusion and massive transfusion protocols should be utilized while awaiting hemorrhage control. The military initiated massive transfusion protocols in the battlefield. We discuss the coagulation cascade, recent recommendations of goal-directed therapy, massive transfusion protocols, fixed ratios, and the future of transfusion medicine.
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Affiliation(s)
- Tara Ann Paterson
- Department of Anesthesiology, R Adams Cowley Shock Trauma Center, 22 South Greene Street, Baltimore, MD 21201, USA.
| | - Deborah Michelle Stein
- Department of Surgery, University of Maryland School of Medicine, R Adams Cowley Shock Trauma Center, 22 South Greene Street, Baltimore, MD 21201, USA
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30
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Bhangu A, Nepogodiev D, Doughty H, Bowley DM. Meta-analysis of plasma to red blood cell ratios and mortality in massive blood transfusions for trauma. Injury 2013; 44:1693-9. [PMID: 23021369 DOI: 10.1016/j.injury.2012.07.193] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2012] [Revised: 07/14/2012] [Accepted: 07/25/2012] [Indexed: 02/06/2023]
Abstract
BACKGROUND The current military paradigm for blood transfusion in major trauma favours high plasma:RBC ratios. This study aimed determine whether high plasma:red blood cell (RBC) ratios during massive transfusion for trauma decrease mortality, using meta-analysis of contemporaneous groups matched for injury severity score. METHODS A systemic review of the published literature for massive blood transfusions in trauma was performed. Patients were categorised into groups based on plasma:RBC transfusion ratios. Meta-analysis was only performed when there were no significant differences in Injury Severity Score (ISS) between ratio groups within studies. The main endpoint was 30-day mortality. RESULTS Six observational studies reporting outcomes for 1885 patients were included in this meta-analysis. Five studies were from civilian environments and one from a military setting. Ratio cut-offs at 1:2 were the most commonly reported, demonstrating a survival advantage with higher ratios (OR 0.49, 95% CI 0.31-0.80, p=0.004). Ratios≥1:2 showed a significant reduction in mortality compared to lower ratios (OR 0.56, 95% CI 0.40-0.78, p<0.001). Reducing the cut-off level was still protective (ratios between 1:2.5 and 1:4, OR 0.41), although the confidence interval was wide (0.16-1.00, p=0.05) and data heterogenous (I(2)=78%). Ratios of 1:1 were not proven to confer additional benefit beyond ratios of 1:2 (OR 0.50, 95% CI 0.37-0.68, p<0.001). CONCLUSIONS In groups matched for ISS, there was a survival benefit with high plasma:RBC resuscitation ratios. No additional benefits of 1:1 over 1:2 ratios were identified.
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Affiliation(s)
- Aneel Bhangu
- Academic Department of Military Surgery & Trauma, Royal Centre for Defence Medicine, Birmingham, UK
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31
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Nosanov L, Inaba K, Okoye O, Resnick S, Upperman J, Shulman I, Rhee P, Demetriades D. The impact of blood product ratios in massively transfused pediatric trauma patients. Am J Surg 2013; 206:655-60. [PMID: 24011571 DOI: 10.1016/j.amjsurg.2013.07.009] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.7] [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: 05/30/2013] [Revised: 07/26/2013] [Accepted: 07/28/2013] [Indexed: 11/18/2022]
Abstract
BACKGROUND Few studies have examined the impact of balanced resuscitation in pediatric trauma patients requiring massive transfusions. Adult data may not be generalizable to children. METHODS Retrospective analysis assessed patients seen at a level I trauma center between 2003 and 2010 aged ≤18 years requiring massive packed red blood cell (PRBC) transfusion, defined as transfusion of ≥50% total blood volume. After excluding mortalities in the first 24 hours, the impact of plasma and platelet ratios on mortality was evaluated. RESULTS Of 6,675 pediatric trauma patients, 105 were massively transfused (mean age, 12.4 ± 6.3 years; mean Injury Severity Score, 25.8 ± 11.4; mortality rate, 18.1%). All deceased patients sustained severe head injuries. Plasma/PRBC and platelet/PRBC ratios were not significantly associated with mortality. CONCLUSIONS In this study, higher plasma/PRBC and platelet/PRBC ratios were not associated with increased survival in children. The value of aggressive blood product transfusion for injured pediatric patients requires further prospective validation.
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Affiliation(s)
- Lauren Nosanov
- Department of Surgery, Keck School of Medicine, University of Southern California, LAC+USC Medical Center, 2051 Marengo Street, IPT, C5L100, Los Angeles, CA 90033, USA
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