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Macdonald S, Fatovich D, Finn J, Litton E. Critical Illness Outside the Intensive Care Unit: Research Challenges in Emergency and Prehospital Settings. Crit Care Clin 2024; 40:609-622. [PMID: 38796231 DOI: 10.1016/j.ccc.2024.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2024]
Abstract
Patients with acute critical illness require prompt interventions, yet high-quality evidence supporting many investigations and treatments is lacking. Clinical research in this setting is challenging due to the need for immediate treatment and the inability of patients to provide informed consent. Attempts to obtain consent from surrogate decision-makers can be intrusive and lead to unacceptable delays to treatment. These problems may be overcome by pragmatic approaches to study design and the use of supervised waivers of consent, which is ethical and appropriate in situations where there is high risk of poor outcome and a paucity of proven effective treatment.
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Affiliation(s)
- Stephen Macdonald
- Centre for Clinical Research in Emergency Medicine, Harry Perkins Institute of Medical Research, Level 6, Rear 54 Murray Street, Perth, WA6000, Australia; Royal Perth Hospital, Victoria Square, Perth, WA6000, Australia; Medical School, University of Western Australia, 35 Stirling Highway, Perth, WA6009, Australia.
| | - Daniel Fatovich
- Centre for Clinical Research in Emergency Medicine, Harry Perkins Institute of Medical Research, Level 6, Rear 54 Murray Street, Perth, WA6000, Australia; Royal Perth Hospital, Victoria Square, Perth, WA6000, Australia; Medical School, University of Western Australia, 35 Stirling Highway, Perth, WA6009, Australia; East Metropolitan Health Service, 10 Murray Street, Perth, WA6000, Australia
| | - Judith Finn
- Prehospital, Resuscitation & Emergency Care Research Unit (PRECRU), Curtin University, Kent Street, Bentley, WA6102, Australia
| | - Edward Litton
- Medical School, University of Western Australia, 35 Stirling Highway, Perth, WA6009, Australia; Fiona Stanley Hospital, 11 Robin Warren Drive, Murdoch, WA6150, Australia
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Bolliger D, Ranucci M. Improved outcome with individualised antifibrinolytic therapy: what is the evidence? Br J Anaesth 2024; 132:1187-1189. [PMID: 38729743 DOI: 10.1016/j.bja.2024.03.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2024] [Accepted: 03/26/2024] [Indexed: 05/12/2024] Open
Abstract
Viscoelastic haemostatic testing (VHT) has been used to determine hyperfibrinolysis and hypofibrinolysis. When modified by addition of tissue plasminogen activator (tPA), VHT has been suggested to assess responses to antifibrinolytic therapy and to estimate the concentration of tranexamic acid in patients undergoing cardiac surgery. Despite some evidence that tPA-modified VHT might allow individualisation of antifibrinolytic therapy, further studies are warranted to prove its clinical benefit for postsurgical bleeding, transfusion of blood products, and thromboembolic events.
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Affiliation(s)
- Daniel Bolliger
- Clinic for Anaesthesia, Intermediate Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, University of Basel, Basel, Switzerland.
| | - Marco Ranucci
- Department of Cardiovascular Anesthesia and Intensive Care, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
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Yassi N, Zhao H, Churilov L, Wu TY, Ma H, Nguyen HT, Cheung A, Meretoja A, Mai DT, Kleinig T, Jeng JS, Choi PMC, Duc PD, Brown H, Ranta A, Spratt N, Cloud GC, Wang HK, Grimley R, Mahawish K, Cho DY, Shah D, Nguyen TMP, Sharma G, Yogendrakumar V, Yan B, Harrison EL, Devlin M, Cordato D, Martinez-Majander N, Strbian D, Thijs V, Sanders LM, Anderson D, Parsons MW, Campbell BCV, Donnan GA, Davis SM. Tranexamic acid versus placebo in individuals with intracerebral haemorrhage treated within 2 h of symptom onset (STOP-MSU): an international, double-blind, randomised, phase 2 trial. Lancet Neurol 2024; 23:577-587. [PMID: 38648814 DOI: 10.1016/s1474-4422(24)00128-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2024] [Revised: 03/18/2024] [Accepted: 03/18/2024] [Indexed: 04/25/2024]
Abstract
BACKGROUND Tranexamic acid, an antifibrinolytic agent, might attenuate haematoma growth after an intracerebral haemorrhage. We aimed to determine whether treatment with intravenous tranexamic acid within 2 h of an intracerebral haemorrhage would reduce haematoma growth compared with placebo. METHODS STOP-MSU was an investigator-led, double-blind, randomised, phase 2 trial conducted at 24 hospitals and one mobile stroke unit in Australia, Finland, New Zealand, Taiwan, and Viet Nam. Eligible participants had acute spontaneous intracerebral haemorrhage confirmed on non-contrast CT, were aged 18 years or older, and could be treated with the investigational product within 2 h of stroke onset. Using randomly permuted blocks (block size of 4) and a concealed pre-randomised assignment procedure, participants were randomly assigned (1:1) to receive intravenous tranexamic acid (1 g over 10 min followed by 1 g over 8 h) or placebo (saline; matched dosing regimen) commencing within 2 h of symptom onset. Participants, investigators, and treating teams were masked to group assignment. The primary outcome was haematoma growth, defined as either at least 33% relative growth or at least 6 mL absolute growth on CT at 24 h (target range 18-30 h) from the baseline CT. The analysis was conducted within the estimand framework with primary analyses adhering to the intention-to-treat principle. The primary endpoint and secondary safety endpoints (mortality at days 7 and 90 and major thromboembolic events at day 90) were assessed in all participants randomly assigned to treatment groups who did not withdraw consent to use any data. This study was registered with ClinicalTrials.gov, NCT03385928, and the trial is now complete. FINDINGS Between March 19, 2018, and Feb 27, 2023, 202 participants were recruited, of whom one withdrew consent for any data use. The remaining 201 participants were randomly assigned to either placebo (n=98) or tranexamic acid (n=103; intention-to-treat population). Median age was 66 years (IQR 55-77), and 82 (41%) were female and 119 (59%) were male; no data on race or ethnicity were collected. CT scans at baseline or follow-up were missing or of inadequate quality in three participants (one in the placebo group and two in the tranexamic acid group), and were considered missing at random. Haematoma growth occurred in 37 (38%) of 97 assessable participants in the placebo group and 43 (43%) of 101 assessable participants in the tranexamic acid group (adjusted odds ratio [aOR] 1·31 [95% CI 0·72 to 2·40], p=0·37). Major thromboembolic events occurred in one (1%) of 98 participants in the placebo group and three (3%) of 103 in the tranexamic acid group (risk difference 0·02 [95% CI -0·02 to 0·06]). By 7 days, eight (8%) participants in the placebo group and eight (8%) in the tranexamic acid group had died (aOR 1·08 [95% CI 0·35 to 3·35]) and by 90 days, 15 (15%) participants in the placebo group and 19 (18%) in the tranexamic acid group had died (aOR 1·61 [95% CI 0·65 to 3·98]). INTERPRETATION Intravenous tranexamic acid did not reduce haematoma growth when administered within 2 h of intracerebral haemorrhage symptom onset. There were no observed effects on other imaging endpoints, functional outcome, or safety. Based on our results, tranexamic acid should not be used routinely in primary intracerebral haemorrhage, although results of ongoing phase 3 trials will add further context to these findings. FUNDING Australian Government Medical Research Future Fund.
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Affiliation(s)
- Nawaf Yassi
- Department of Medicine and Neurology, Melbourne Brain Centre at The Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia; Population Health and Immunity Division, The Walter and Eliza Hall Institute of Medical Research, Parkville, VIC, Australia.
| | - Henry Zhao
- Department of Medicine and Neurology, Melbourne Brain Centre at The Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia
| | - Leonid Churilov
- Department of Medicine and Neurology, Melbourne Brain Centre at The Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia; Melbourne Medical School, University of Melbourne, Parkville, VIC, Australia
| | - Teddy Y Wu
- Department of Neurology, Christchurch Hospital, Christchurch, New Zealand
| | - Henry Ma
- Department of Medicine, School of Clinical Sciences, Monash University, Melbourne, VIC, Australia
| | - Huy-Thang Nguyen
- Department of Cerebrovascular Disease, 115 Hospital, Ho Chi Minh City, Viet Nam
| | - Andrew Cheung
- Department of Interventional Neuroradiology, Liverpool Hospital, Liverpool, NSW, Australia
| | - Atte Meretoja
- Department of Neurology, Helsinki University Hospital, Helsinki, Finland
| | - Duy Ton Mai
- Stroke Center, Bach Mai Hospital, Hanoi Medical University, VNU University of Medicine and Pharmacy, Hanoi, Viet Nam
| | - Timothy Kleinig
- Department of Neurology, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Jiann-Shing Jeng
- Stroke Centre and Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Philip M C Choi
- Department of Neuroscience, Box Hill Hospital, Eastern Health, Eastern Health Clinical School, Monash University, Box Hill, VIC, Australia
| | - Phuc Dang Duc
- Stroke Department, 103 Military Hospital, Hanoi, Viet Nam
| | - Helen Brown
- Department of Neurology, Princess Alexandra Hospital, Woolloongabba, QLD, Australia
| | - Annemarei Ranta
- Department of Medicine, University of Otago, Wellington, New Zealand
| | - Neil Spratt
- Department of Neurology, John Hunter Hospital, and School of Biomedical Sciences and Pharmacy, University of Newcastle, Newcastle, NSW, Australia
| | - Geoffrey C Cloud
- Department of Neurology, Alfred Hospital, Melbourne, VIC, Australia
| | - Hao-Kuang Wang
- Department of Neurosurgery, E-Da Hospital, I-Shou University, Yanchao, Taiwan
| | - Rohan Grimley
- Department of Medicine, Sunshine Coast University Hospital, Birtinya, QLD, Australia
| | - Karim Mahawish
- Department of Internal Medicine, Palmerston North Hospital, Palmerston North, New Zealand
| | - Der-Yang Cho
- Department of Neurosurgery, China Medical University Hospital, Taichung, Taiwan
| | - Darshan Shah
- Department of Neurology, Gold Coast University Hospital, Southport, QLD, Australia
| | | | - Gagan Sharma
- Department of Medicine and Neurology, Melbourne Brain Centre at The Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia
| | - Vignan Yogendrakumar
- Department of Medicine and Neurology, Melbourne Brain Centre at The Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia
| | - Bernard Yan
- Department of Medicine and Neurology, Melbourne Brain Centre at The Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia
| | - Emma L Harrison
- Department of Neurology, Princess Alexandra Hospital, Woolloongabba, QLD, Australia
| | - Michael Devlin
- Department of Neurology, Princess Alexandra Hospital, Woolloongabba, QLD, Australia
| | - Dennis Cordato
- Department of Interventional Neuroradiology, Liverpool Hospital, Liverpool, NSW, Australia
| | - Nicolas Martinez-Majander
- Department of Neurology, Helsinki University Hospital, Helsinki, Finland; Department of Neurology, University of Helsinki, Helsinki, Finland
| | - Daniel Strbian
- Department of Neurology, Helsinki University Hospital, Helsinki, Finland; Department of Neurology, University of Helsinki, Helsinki, Finland
| | - Vincent Thijs
- The Florey, Stroke Theme, Heidelberg, VIC, Australia; Department of Neurology, Austin Hospital, Heidelberg, VIC, Australia; Department of Medicine, University of Melbourne, Heidelberg, VIC, Australia
| | - Lauren M Sanders
- Department of Neurosciences, St Vincent's Hospital, Melbourne, VIC, Australia
| | | | - Mark W Parsons
- Department of Neurology, Liverpool Hospital, Liverpool, NSW, Australia
| | - Bruce C V Campbell
- Department of Medicine and Neurology, Melbourne Brain Centre at The Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia
| | - Geoffrey A Donnan
- Department of Medicine and Neurology, Melbourne Brain Centre at The Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia
| | - Stephen M Davis
- Department of Medicine and Neurology, Melbourne Brain Centre at The Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia
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Capece GE, Luyendyk JP, Poole LG. Fibrinolysis-Mediated Pathways in Acute Liver Injury. Semin Thromb Hemost 2024; 50:638-647. [PMID: 38395065 DOI: 10.1055/s-0044-1779738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/25/2024]
Abstract
Acute liver injury (ALI), that is, the development of reduced liver function in patients without preexisting liver disease, can result from a wide range of causes, such as viral or bacterial infection, autoimmune disease, or adverse reaction to prescription and over-the-counter medications. ALI patients present with a complex coagulopathy, characterized by both hypercoagulable and hypocoagulable features. Similarly, ALI patients display a profound dysregulation of the fibrinolytic system with the vast majority of patients presenting with a hypofibrinolytic phenotype. Decades of research in experimental acute liver injury in mice suggest that fibrinolytic proteins, including plasmin(ogen), plasminogen activators, fibrinolysis inhibitors, and fibrin(ogen), can contribute to initial hepatotoxicity and/or stimulate liver repair. This review summarizes major experimental findings regarding the role of fibrinolytic factors in ALI from the last approximately 30 years and identifies unanswered questions, as well as highlighting areas for future research.
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Affiliation(s)
- Gina E Capece
- Department of Pharmacology, Rutgers University Robert Wood Johnson Medical School, Piscataway, New Jersey
| | - James P Luyendyk
- Department of Pathobiology and Diagnostic Investigation, Michigan State University, East Lansing, Michigan
| | - Lauren G Poole
- Department of Pharmacology, Rutgers University Robert Wood Johnson Medical School, Piscataway, New Jersey
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Zhang M, Liu T. Efficacy and safety of tranexamic acid in acute traumatic brain injury: A meta-analysis of randomized controlled trials. Am J Emerg Med 2024; 80:35-43. [PMID: 38502985 DOI: 10.1016/j.ajem.2024.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Revised: 01/10/2024] [Accepted: 03/05/2024] [Indexed: 03/21/2024] Open
Abstract
INTRODUCTION Tranexamic acid (TXA) holds a pivotal role in the therapeutic approach to traumatic conditions. Nevertheless, its precise influence on diminishing mortality and limiting the progression of intracranial hemorrhage (ICH) during the treatment of traumatic brain injury (TBI) remains indeterminate. METHODS PubMed, EMBASE, Cochrane Library, and Web of Science were searched for randomized controlled trials that compared TXA and a placebo in adults with TBI up to September 31, 2023. Two authors independently abstracted the data and assessed the quality of evidence. Additionally, subgroup analyses were performed to assess outcomes with low heterogenety. RESULTS Our search strategy yielded 11,299 patients from 11 studies. The result showed that TXA had no effect on mortality (RR 0.93 [0.86, 1.00], p = 0.06; I2: 0%, p = 0.79), poor clinical outcomes (RR 0.92 [0.78, 1.09], p = 0.34; I2: 0%, p = 0.40), adverse events (RR 0.94 [0.83, 1.07], p = 0.34; I2: 48%, p = 0.10), vascular occlusive events (RR 0.85 [0.68, 1.06], p = 0.16; I2: 32%, p = 0.22), pulmonary embolism (RR 0.76 [0.47, 1.22], p = 0.26; I2: 0%, p = 0.83), seizure (RR 1.11 [0.92, 1.35], p = 0.27; I2: 0%, p = 0.49) and hemorrhagic complications (RR 0.78 [0.55, 1.09], p = 0.14; I2: 0%, p = 0.42). TXA might reduce the rate of hemorrhagic expansion (RR 0.83 [0.70, 0.99], p = 0.03; I2: 18%, p = 0.29) and mean hemorrhage volume (SMD -0.39 [-0.60, -0.18], p <0.001; I2: 44%, p = 0.13).When the time interval from symptom onset to treatment was <3 h, TXA reduced mean hemorrhage volume (SMD -0.51 [-0.81, -0.20], p = 0.001; I2: 0%, p = 0.94). CONCLUSIONS TXA did not elevate the risk of adverse event, however, the lack of reduction in mortality and the poor clinical outcomes constrain the value of clinical application. Early administration of TXA (within 3 h) may significantly decrease the likelihood of ICH growth in patients with TBI.
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Affiliation(s)
- Minzhi Zhang
- Department of Neurology, Tianjin Neurological Institute, Tianjin Medical University General Hospital, Tianjin, China
| | - Tao Liu
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China; Key Laboratory of Post Neuro-Injury Neuro-Repair and Regeneration in Central NervousSystem, Tianjin Neurological Institute, Tianjin Medical University General Hospital, Ministry of Education, Tianjin, China.
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Morrow GB, Flannery S, Charles PD, Heilig R, Feller T, McQuilten Z, Wake E, Ariens RAS, Winearls J, Mutch NJ, Fischer R, Laffan MA, Curry N. A novel method to quantify fibrin-fibrin and fibrin-α 2-antiplasmin cross-links in thrombi formed from human trauma patient plasma. J Thromb Haemost 2024; 22:1758-1771. [PMID: 38462220 DOI: 10.1016/j.jtha.2024.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Revised: 02/14/2024] [Accepted: 03/04/2024] [Indexed: 03/12/2024]
Abstract
BACKGROUND The widespread use of the antifibrinolytic agent, tranexamic acid (TXA), interferes with the quantification of fibrinolysis by dynamic laboratory assays such as clot lysis, making it difficult to measure fibrinolysis in many trauma patients. At the final stage of coagulation, factor (F)XIIIa catalyzes the formation of fibrin-fibrin and fibrin-α2-antiplasmin (α2AP) cross-links, which increases clot mechanical strength and resistance to fibrinolysis. OBJECTIVES Here, we developed a method to quantify fibrin-fibrin and fibrin-α2AP cross-links that avoids the challenges posed by TXA in determining fibrinolytic resistance in conventional assays. METHODS Fibrinogen alpha (FGA) chain (FGA-FGA), fibrinogen gamma (FGG) chain (FGG-FGG), and FGA-α2AP cross-links were quantified using liquid chromatography-mass spectrometry (LC-MS) and parallel reaction monitoring in paired plasma samples from trauma patients prefibrinogen and postfibrinogen replacement. Differences in the abundance of cross-links in trauma patients receiving cryoprecipitate (cryo) or fibrinogen concentrate (Fg-C) were analyzed. RESULTS The abundance of cross-links was significantly increased in trauma patients postcryo, but not Fg-C transfusion (P < .0001). The abundance of cross-links was positively correlated with the toughness of individual fibrin fibers, the peak thrombin concentration, and FXIII antigen (P < .05). CONCLUSION We have developed a novel method that allows us to quantify fibrin cross-links in trauma patients who have received TXA, providing an indirect measure of fibrinolytic resistance. Using this novel approach, we have avoided the effect of TXA and shown that cryo increases fibrin-fibrin and fibrin-α2AP cross-linking when compared with Fg-C, highlighting the importance of FXIII in clot formation and stability in trauma patients.
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Affiliation(s)
- Gael B Morrow
- School of Pharmacy and Life Sciences, Robert Gordon University, Aberdeen, United Kingdom; Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom; Aberdeen Cardiovascular and Diabetes Centre, School of Medicine, Medical Sciences and Nutrition, Institute of Medical Sciences, University of Aberdeen, Aberdeen, United Kingdom.
| | - Sarah Flannery
- Target Discovery Institute, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Philip D Charles
- Target Discovery Institute, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Raphael Heilig
- Target Discovery Institute, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Timea Feller
- Leeds Thrombosis Collective, Discovery and Translational Science Department, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, United Kingdom
| | - Zoe McQuilten
- Transfusion Research Unit, Monash University, Melbourne and Monash Health, Melbourne, Australia
| | - Elizabeth Wake
- Trauma Service, Gold Coast University Hospital, University of Queensland, Southport, Queensland, Australia; School of Medicine, University of Queensland, Southport, Queensland, Australia
| | - Robert A S Ariens
- Leeds Thrombosis Collective, Discovery and Translational Science Department, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, United Kingdom
| | - James Winearls
- School of Medicine, University of Queensland, Southport, Queensland, Australia; Intensive Care Unit, Gold Coast University Hospital, Southport, Queensland, Australia; Australia and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
| | - Nicola J Mutch
- Aberdeen Cardiovascular and Diabetes Centre, School of Medicine, Medical Sciences and Nutrition, Institute of Medical Sciences, University of Aberdeen, Aberdeen, United Kingdom
| | - Roman Fischer
- Target Discovery Institute, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Mike A Laffan
- Centre for Haematology, Imperial College London, London, United Kingdom
| | - Nicola Curry
- Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom; Oxford Haemophilia and Thrombosis Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
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7
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De Simone B, Chouillard E, Podda M, Pararas N, de Carvalho Duarte G, Fugazzola P, Birindelli A, Coccolini F, Polistena A, Sibilla MG, Kruger V, Fraga GP, Montori G, Russo E, Pintar T, Ansaloni L, Avenia N, Di Saverio S, Leppäniemi A, Lauretta A, Sartelli M, Puzziello A, Carcoforo P, Agnoletti V, Bissoni L, Isik A, Kluger Y, Moore EE, Romeo OM, Abu-Zidan FM, Beka SG, Weber DG, Tan ECTH, Paolillo C, Cui Y, Kim F, Picetti E, Di Carlo I, Toro A, Sganga G, Sganga F, Testini M, Di Meo G, Kirkpatrick AW, Marzi I, déAngelis N, Kelly MD, Wani I, Sakakushev B, Bala M, Bonavina L, Galante JM, Shelat VG, Cobianchi L, Mas FD, Pikoulis M, Damaskos D, Coimbra R, Dhesi J, Hoffman MR, Stahel PF, Maier RV, Litvin A, Latifi R, Biffl WL, Catena F. The 2023 WSES guidelines on the management of trauma in elderly and frail patients. World J Emerg Surg 2024; 19:18. [PMID: 38816766 DOI: 10.1186/s13017-024-00537-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Accepted: 02/26/2024] [Indexed: 06/01/2024] Open
Abstract
BACKGROUND The trauma mortality rate is higher in the elderly compared with younger patients. Ageing is associated with physiological changes in multiple systems and correlated with frailty. Frailty is a risk factor for mortality in elderly trauma patients. We aim to provide evidence-based guidelines for the management of geriatric trauma patients to improve it and reduce futile procedures. METHODS Six working groups of expert acute care and trauma surgeons reviewed extensively the literature according to the topic and the PICO question assigned. Statements and recommendations were assessed according to the GRADE methodology and approved by a consensus of experts in the field at the 10th international congress of the WSES in 2023. RESULTS The management of elderly trauma patients requires knowledge of ageing physiology, a focused triage, including drug history, frailty assessment, nutritional status, and early activation of trauma protocol to improve outcomes. Acute trauma pain in the elderly has to be managed in a multimodal analgesic approach, to avoid side effects of opioid use. Antibiotic prophylaxis is recommended in penetrating (abdominal, thoracic) trauma, in severely burned and in open fractures elderly patients to decrease septic complications. Antibiotics are not recommended in blunt trauma in the absence of signs of sepsis and septic shock. Venous thromboembolism prophylaxis with LMWH or UFH should be administrated as soon as possible in high and moderate-risk elderly trauma patients according to the renal function, weight of the patient and bleeding risk. A palliative care team should be involved as soon as possible to discuss the end of life in a multidisciplinary approach considering the patient's directives, family feelings and representatives' desires, and all decisions should be shared. CONCLUSIONS The management of elderly trauma patients requires knowledge of ageing physiology, a focused triage based on assessing frailty and early activation of trauma protocol to improve outcomes. Geriatric Intensive Care Units are needed to care for elderly and frail trauma patients in a multidisciplinary approach to decrease mortality and improve outcomes.
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Affiliation(s)
- Belinda De Simone
- Department of Emergency Minimally Invasive Surgery, Academic Hospital of Villeneuve St Georges, Villeneuve St Georges, France.
- Department of General Minimally Invasive Surgery, Infermi Hospital, AUSL Romagna, Rimini, Italy.
- General Surgery Department, American Hospital of Paris, Paris, France.
| | - Elie Chouillard
- General Surgery Department, American Hospital of Paris, Paris, France
| | - Mauro Podda
- Department of Surgical Science, Unit of Emergency Surgery, University of Cagliari, Cagliari, Italy
| | - Nikolaos Pararas
- 3rd Department of Surgery, Attikon General Hospital, National and Kapodistrian University of Athens (NKUA), Athens, Greece
| | | | - Paola Fugazzola
- Unit of General Surgery I, IRCCS San Matteo Hospital of Pavia, University of Pavia, Pavia, Italy
| | | | | | - Andrea Polistena
- Department of Surgery, Policlinico Umberto I Roma, Sapienza University, Rome, Italy
| | - Maria Grazia Sibilla
- Department of Surgery, Unit of General Surgery, University Hospital of Ferrara and University of Ferrara, Ferrara, Italy
| | - Vitor Kruger
- Division of Trauma Surgery, School of Medical Sciences, University of Campinas, Campinas, Brazil
| | - Gustavo P Fraga
- Division of Trauma Surgery, School of Medical Sciences, University of Campinas, Campinas, Brazil
| | - Giulia Montori
- Unit of General and Emergency Surgery, Vittorio Veneto Hospital, Via C. Forlanini 71, 31029, Vittorio Veneto, TV, Italy
| | - Emanuele Russo
- Department of Anesthesia, Level I, Trauma Center, Bufalini Hospital, Cesena, Italy
| | - Tadeja Pintar
- UMC Ljubljana and Medical Faculty Ljubljana, Ljubljana, Slovenia
| | - Luca Ansaloni
- New Zealand Blood Service, Christchurch, New Zealand
| | - Nicola Avenia
- Endocrine Surgical Unit - University of Perugia, Terni, Italy
| | - Salomone Di Saverio
- General Surgery Unit, Madonna del Soccorso Hospital, AST Ascoli Piceno, San Benedetto del Tronto, Italy
| | - Ari Leppäniemi
- Division of Emergency Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Andrea Lauretta
- Department of Surgical Oncology, Centro Di Riferimento Oncologico Di Aviano IRCCS, Aviano, Italy
| | - Massimo Sartelli
- Department of General Surgery, Macerata Hospital, Macerata, Italy
| | - Alessandro Puzziello
- Dipartimento di Medicina, Chirurgia e Odontoiatria, Campus Universitario di Baronissi (SA) - Università di Salerno, AOU San Giovanni di Dio e Ruggi di Aragona, Salerno, Italy
| | - Paolo Carcoforo
- Department of Surgery, Unit of General Surgery, University Hospital of Ferrara and University of Ferrara, Ferrara, Italy
| | - Vanni Agnoletti
- Department of Anesthesia, Level I, Trauma Center, Bufalini Hospital, Cesena, Italy
| | - Luca Bissoni
- Department of Anesthesia, Level I, Trauma Center, Bufalini Hospital, Cesena, Italy
| | - Arda Isik
- Istanbul Medeniyet University, Istanbul, Turkey
| | - Yoram Kluger
- Department of General Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Ernest E Moore
- Ernest E Moore Shock Trauma Center at Denver Health, University of Colorado, Denver, CO, USA
| | - Oreste Marco Romeo
- Bronson Methodist Hospital/Western Michigan University, Kalamazoo, MI, USA
| | - Fikri M Abu-Zidan
- Department of Surgery, College of Medicine and Health Sciences, United Arab Emirates University, Al‑Ain, United Arab Emirates
| | | | - Dieter G Weber
- Department of General Surgery, Royal Perth Hospital and The University of Western Australia, Perth, Australia
| | - Edward C T H Tan
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Ciro Paolillo
- Emergency Department, Ospedale Civile Maggiore, Verona, Italy
| | - Yunfeng Cui
- Department of Surgery, Tianjin Nankai Hospital, Nankai Clinical School of Medicine, Tianjin Medical University, Tianjin, China
| | - Fernando Kim
- University of Colorado Anschutz Medical Campus, Denver, CO, 80246, USA
| | - Edoardo Picetti
- Department of Anesthesia and Intensive Care, Parma University Hospital, Parma, Italy
| | - Isidoro Di Carlo
- Department of Surgical Sciences and Advanced Technologies, General Surgery Cannizzaro Hospital, University of Catania, Catania, Italy
| | - Adriana Toro
- Department of Surgical Sciences and Advanced Technologies, General Surgery Cannizzaro Hospital, University of Catania, Catania, Italy
| | - Gabriele Sganga
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University, Rome, Italy
| | - Federica Sganga
- Department of Geriatrics, Ospedale Sant'Anna, Ferrara, Italy
| | - Mario Testini
- Department of Precision and Regenerative Medicine and Ionian Area, Unit of Academic General Surgery, University of Bari "A. Moro", Bari, Italy
| | - Giovanna Di Meo
- Department of Precision and Regenerative Medicine and Ionian Area, Unit of Academic General Surgery, University of Bari "A. Moro", Bari, Italy
| | - Andrew W Kirkpatrick
- Departments of Surgery and Critical Care Medicine, University of Calgary, Foothills Medical Centre, Calgary, AB, Canada
| | - Ingo Marzi
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Frankfurt, Frankfurt, Germany
| | - Nicola déAngelis
- Unit of Colorectal and Digestive Surgery, DIGEST Department, Beaujon University Hospital, AP-HP, University of Paris Cité, Clichy, France
| | | | - Imtiaz Wani
- Department of Surgery, Government Gousia Hospital, DHS, Srinagar, India
| | - Boris Sakakushev
- General Surgery Department, Medical University, University Hospital St George, Plovdiv, Bulgaria
| | - Miklosh Bala
- Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Luigi Bonavina
- Division of General Surgery, IRCCS Policlinico San Donato, University of Milan, Milan, Italy
| | - Joseph M Galante
- Division of Trauma and Acute Care Surgery, Department of Surgery, University of California Davis, Sacramento, CA, USA
| | - Vishal G Shelat
- Department of General Surgery, Tan Tock Seng Hospital, Novena, Singapore
| | - Lorenzo Cobianchi
- Unit of General Surgery I, IRCCS San Matteo Hospital of Pavia, University of Pavia, Pavia, Italy
- Collegium Medicum, University of Social Sciences, Łodz, Poland
| | - Francesca Dal Mas
- Department of Management, Ca' Foscari University of Venice, Venice, Italy
- Collegium Medicum, University of Social Sciences, Łodz, Poland
| | - Manos Pikoulis
- Department of Surgical Science, Unit of Emergency Surgery, University of Cagliari, Cagliari, Italy
| | | | - Raul Coimbra
- Riverside University Health System Medical Center, Riverside, CA, USA
| | - Jugdeep Dhesi
- Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Melissa Red Hoffman
- Department of Surgery, University of North Carolina, Surgical Palliative Care Society, Asheville, NC, USA
| | - Philip F Stahel
- Department of Surgery, Brody School of Medicine, East Carolina University, Greenville, NC, USA
| | - Ronald V Maier
- Harborview Medical Center, University of Washington, Seattle, WA, USA
| | - Andrey Litvin
- Department of Surgical Diseases No. 3, Gomel State Medical University, University Clinic, Gomel, Belarus
| | - Rifat Latifi
- University of Arizona, Tucson, AZ, USA
- Abrazo Health West Campus, Goodyear, Tucson, AZ, USA
| | - Walter L Biffl
- Division of Trauma/Acute Care Surgery, Scripps Clinic Medical Group, La Jolla, CA, USA
| | - Fausto Catena
- Department of General and Emergency Surgery, Bufalini Hospital-Level 1 Trauma Center, AUSL Romagna, Cesena, Italy
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Castro-Delgado R, Garijo-Gonzalo G, Cuartas-Alvarez T. Tranexamic acid needs to be implemented in mass casualty incident protocols. Eur J Trauma Emerg Surg 2024:10.1007/s00068-024-02517-8. [PMID: 38801465 DOI: 10.1007/s00068-024-02517-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Accepted: 03/30/2024] [Indexed: 05/29/2024]
Affiliation(s)
- Rafael Castro-Delgado
- Faculty of Medicine and Health Sciences, Department of Medicine, University of Oviedo, Julián Clavería, 6, 33006, Oviedo, Spain.
- Health Research Institute of the Principality of Asturias (Research Group On Prehospital Care and Disasters, GIAPREDE), Health Service of the Principality of Asturias (SAMU-Asturias), Oviedo, Spain.
- RINVEMER-SEMES (Research Network On Prehospital Care-Spanish Society of Emergency Medicine), Madrid, Spain.
| | - Gracia Garijo-Gonzalo
- RINVEMER-SEMES (Research Network On Prehospital Care-Spanish Society of Emergency Medicine), Madrid, Spain
- Emergencias Osakidetza. Vasc Country, Madrid, Spain
| | - Tatiana Cuartas-Alvarez
- Health Research Institute of the Principality of Asturias (Research Group On Prehospital Care and Disasters, GIAPREDE), Health Service of the Principality of Asturias (SAMU-Asturias), Oviedo, Spain
- RINVEMER-SEMES (Research Network On Prehospital Care-Spanish Society of Emergency Medicine), Madrid, Spain
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9
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Wilson M, Stuart S, Lassiter B, Parker T, Martin C, Healy R, Treager C, Sulava E, Gower L, Fernandez P, Friedrich E. Pharmacokinetics of Tranexamic Acid (TXA) Delivered by Expeditious Routes in a Swine Model of Polytrauma and Hemorrhagic Shock. PREHOSP EMERG CARE 2024:1-9. [PMID: 38634701 DOI: 10.1080/10903127.2024.2342025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Accepted: 03/21/2024] [Indexed: 04/19/2024]
Abstract
OBJECTIVE Hemorrhage is the leading cause of preventable death in civilian trauma centers and on the battlefield. One of the emerging treatment options for hemorrhage in austere environments is tranexamic acid (TXA). However, the landscape is not amenable to the current delivery standard. This study compared the pharmacokinetics of TXA via a standard 10-minute intravenous infusion (IV infusion), intravenous rapid push over 10 s (IV push), and intramuscular injection (IM) in a swine polytrauma and hemorrhagic shock model (trauma group) compared to uninjured controls (control group). METHODS Thirty swine were randomized to the trauma or control group. Following anesthesia, the trauma group experienced a simulated blast injury and 40% controlled hemorrhage. Subjects in both groups were then randomized to receive 1 g/10 mL TXA via IV infusion, IV push, or IM. Animals were monitored for four hours with serial blood sampling. Serum TXA concentrations were measured by liquid chromatography with tandem mass spectrometry (LC-MS/MS) and analyzed. RESULTS The time to maximum TXA concentration (Tmax) was not affected by trauma in IV infusion or IV push, but was affected in the IM administration with Tmax significantly slower than the control group (p = 0.016). The minimum effective serum concentration of TXA (Ceff, 10 µg/mL) was reached in less than one minute with IV infusion and instantaneously with IV push. Despite lower bioavailability, the time to reach Ceff (Teff) was achieved via IM administration in less than 10 min for both groups (6.4 min trauma vs. 2.1 min control). CONCLUSIONS In austere prehospital environments, an alternative to intravenous infusion of a life-saving medication is desired. Administration of TXA via all three methods reached the level needed to cause substantial inhibition of fibrinolysis within 10 min. The IV push method showed similar pharmacokinetics to IV infusion of TXA but can be delivered quickly without sacrificing an access site for 10 min.
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Affiliation(s)
- Mallori Wilson
- Combat Trauma Research Group, Department of Emergency Medicine, Naval Medical Center Portsmouth, Portsmouth, Virginia
| | - Sean Stuart
- Combat Trauma Research Group, Department of Emergency Medicine, Naval Medical Center Portsmouth, Portsmouth, Virginia
- Department of Military and Emergency Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | | | - Timothy Parker
- Combat Trauma Research Group, Department of Emergency Medicine, Naval Medical Center Portsmouth, Portsmouth, Virginia
| | - Clyde Martin
- Combat Trauma Research Group, Department of Emergency Medicine, Naval Medical Center Portsmouth, Portsmouth, Virginia
| | - Robert Healy
- Combat Trauma Research Group, Department of Emergency Medicine, Naval Medical Center Portsmouth, Portsmouth, Virginia
| | - Christopher Treager
- Combat Trauma Research Group, Department of Emergency Medicine, Naval Medical Center Portsmouth, Portsmouth, Virginia
| | - Eric Sulava
- Combat Trauma Research Group, Department of Emergency Medicine, Naval Medical Center Portsmouth, Portsmouth, Virginia
| | - Lorie Gower
- General Dynamics Information Technology, Fairfax, Virginia
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10
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Hanna S, Montmayeur J, Vergnaud E, Orliaguet G. Prognosis and assessment of the predictive value of severity scores in paediatric abdominal trauma: A French national cohort study. Eur J Anaesthesiol 2024:00003643-990000000-00187. [PMID: 38769943 DOI: 10.1097/eja.0000000000002019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/22/2024]
Abstract
BACKGROUND Paediatric closed abdominal trauma is common, however, its severity and influence on survival are difficult to determine. No prognostic score integrating abdominal involvement exists to date in paediatrics. OBJECTIVES To evaluate the severity and short-term and medium-term prognosis of closed abdominal trauma in children, and the performance of severity scores in predicting mortality. DESIGN Retrospective, cohort, observational study. SETTING AND PARTICIPANTS Patients aged 0 to 18 years presenting at the trauma room of a French paediatric Level I Trauma Centre over the period 2015 to 2019 with an isolated closed abdominal trauma or as part of a polytrauma. MAIN OUTCOMES Primary outcome was the six months mortality. Secondary outcomes were related complications and therapeutic interventions, and performance for predicting mortality of the scores listed. Paediatric Trauma Score (PTS), Revised Trauma Score (RTS), Shock Index Paediatric Age-adjusted (SIPA) score, Reverse shock index multiplied by Glasgow Coma Scale score (rSIG), Base Deficit, International Normalised Ratio, and Glasgow Coma Scale (BIG), Injury Severity Score (ISS) and Trauma Score and the Injury Severity (TRISS) score. DATA COLLECTION Data collected include clinical, biological and CT scan data at admission, first 24 h management and prognosis. The PTS, RTS, SIPA, rSIG, BIG and ISS scores were calculated and mortality was predicted according to BIG score and TRISS methodology. RESULTS Of 1145 patients, 149 met the inclusion criteria and 12 (8.1%) died. Of the 12 deceased patients, 11 (91.7%) presented with severe head injury, 11 (91.7%) had blood products transfusion and 7 received tranexamic acid. ROC curves analysis concluded that PTS, RTS, rSIG and BIG scores accurately predict mortality in paediatric closed abdominal trauma with AUCs at least 0.92. The BIG score offered the best predictive performance for predicting mortality at a threshold of 24.8 [sensitivity 90%, specificity 92%, negative-predictive value (NPV) 99%, area under the curve (AUC) 0.93]. CONCLUSION PEVALPED is the first French study to evaluate the prognosis of paediatric closed abdominal trauma. The use of PTS, rSIG and BIG scores are relevant from the acute phase and the pathophysiological interest and accuracy of the BIG score make it a powerful tool for predicting mortality of closed abdominal trauma in children.
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Affiliation(s)
- Sidonie Hanna
- From the Department of Paediatric Anaesthesia and Intensive Care, Necker-Enfants Malades University Hospital, AP-HP Centre - University of Paris, France (SH, JM, EV, GO)
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11
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Haberkorn CJ, Severance CC, Wetmore NC, West WG, Ng PC, Cendali F, Pitotti C, Schauer SG, Maddry JK, Bebarta VS, Hendry-Hofer TB. Intramuscular administration of tranexamic acid in a large swine model of hemorrhage with hyperfibrinolysis. J Trauma Acute Care Surg 2024; 96:735-741. [PMID: 37962201 DOI: 10.1097/ta.0000000000004207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2023]
Abstract
BACKGROUND Traumatic injury with subsequent hemorrhage is one of the leading causes of mortality among military personnel and civilians alike. Posttraumatic hemorrhage accounts for 40% to 50% of deaths in severe trauma patients occurring secondary to direct vessel injury or the development of trauma-induced coagulopathy (TIC). Hyperfibrinolysis plays a major role in TIC and its presence increases a patient's risk of mortality. Early therapeutic intervention with intravenous (IV) tranexamic acid (TXA) prevents development of hyperfibrinolysis and subsequent TIC leading to decreased mortality. However, obtaining IV access in an austere environment can be challenging. In this study, we evaluated the efficacy of intramuscular (IM) versus IV TXA at preventing hyperfibrinolysis in a hemorrhaged swine. METHODS Yorkshire cross swine were randomized on the day of study to receive IM or IV TXA or no treatment. Swine were sedated, intubated, and determined to be hemodynamically stable before experimentation. Controlled hemorrhaged was induced by the removal of 30% total blood volume. After hemorrhage, swine were treated with 1,000 mg of IM or IV TXA. Control animals received no treatment. Thirty minutes post-TXA treatment, fibrinolysis was induced with a 50-mg bolus of tissue plasminogen activator. Blood samples were collected to evaluate blood TXA concentrations, blood gases, blood chemistry, and fibrinolysis. RESULTS Blood TXA concentrations were significantly different between administration routes at the early time points but were equivalent by 20 minutes after injection, remaining consistently elevated for up to 3 hours postadministration. Induction of fibrinolysis resulted in 87.18 ± 4.63% lysis in control animals, compared with swine treated with IM TXA, 1.96 ± 2.66% and 1.5 ± 0.42% lysis in the IV TXA group. CONCLUSION In the large swine model of hemorrhage with hyperfibrinolysis, IM TXA is bioequivalent and equally efficacious in preventing hyperfibrinolysis as IV TXA administration.
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Affiliation(s)
- Christopher J Haberkorn
- From the Department of Emergency Medicine (C.J.H.), University of Colorado Anschutz Medical Campus; Department of Critical Care (C.J.H.), Children's Hospital Colorado; Department of Emergency Medicine (C.C.S., N.C.W., W.G.W., C.P., V.S.B., T.B.H.-H.), University of Colorado Anschutz Medical Campus, Aurora, Colorado; Department of Emergency Medicine (P.C.N.), Brooke Army Medical Center, Ft Sam Houston, San Antonio, Texas; Department of Biochemistry and Molecular Biology (F.C.), University of Colorado Anschutz Medical Campus, Aurora, Colorado; Department of Emergency Medicine (S.G.S.), Uniformed Services University of the Health Sciences, Bethesda, Maryland; Departments of Anesthesiology (S.G.S.) and Emergency Medicine (S.G.S.), University of Colorado Anschutz Medical Campus, Aurora, Colorado; Uniformed Services University of the Health Sciences (J.K.M.), Bethesda, Maryland; and Brooke Army Medical Center (J.K.M.), JBSA, Fort Sam Houston, Texas
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12
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Barrett CD, Neal MD, Schoenecker JG, Medcalf RL, Myles PS. Tranexamic acid in trauma: After 3 hours from injury, when is it safe and effective to use again? Transfusion 2024; 64 Suppl 2:S11-S13. [PMID: 38461482 DOI: 10.1111/trf.17779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Revised: 02/22/2024] [Accepted: 02/26/2024] [Indexed: 03/12/2024]
Abstract
Tranexamic acid (TXA) has proven mortality benefit if used early after traumatic injury, likely related to a combination of bleeding reduction and other non-bleeding effects. If TXA is given more than 3 h after traumatic injury, there is a significant and paradoxical increased risk of death due to bleeding. TXA has level 1 evidence for use as a bleeding reduction agent in isolated orthopedic operations, but in polytrauma patients undergoing orthopedic operations, it is not clear if and when TXA is safe or effective once outside the 3-h window of proven trauma efficacy.
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Affiliation(s)
- Christopher D Barrett
- Department of Surgery, University of Nebraska Medical Center, Omaha, Nebraska, USA
- Department of Cellular and Integrative Physiology, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Matthew D Neal
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Jonathan G Schoenecker
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Robert L Medcalf
- Australian Centre for Blood Diseases, Monash University, Melbourne, Victoria, Australia
| | - Paul S Myles
- Department of Anaesthesiology and Perioperative Medicine, Alfred Hospital and Monash University, Melbourne, Victoria, Australia
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13
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Zöllner C. [Preoperative evaluation of adult patients before elective, non-cardiothoracic surgery : A joint recommendation of the German Society for Anesthesiology and Intensive Care Medicine, the German Society for Surgery and the German Society for Internal Medicine]. DIE ANAESTHESIOLOGIE 2024; 73:294-323. [PMID: 38700730 PMCID: PMC11076399 DOI: 10.1007/s00101-024-01408-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 03/26/2024] [Indexed: 05/09/2024]
Abstract
The 70 recommendations summarize the current status of preoperative risk evaluation of adult patients prior to elective non-cardiothoracic surgery. Based on the joint publications of the German scientific societies for anesthesiology and intensive care medicine (DGAI), surgery (DGCH), and internal medicine (DGIM), which were first published in 2010 and updated in 2017, as well as the European guideline on preoperative cardiac risk evaluation published in 2022, a comprehensive re-evaluation of the recommendation takes place, taking into account new findings, the current literature, and current guidelines of international professional societies. The revised multidisciplinary recommendation is intended to facilitate a structured and common approach to the preoperative evaluation of patients. The aim is to ensure individualized preparation for the patient prior to surgery and thus to increase patient safety. Taking into account intervention- and patient-specific factors, which are indispensable in the preoperative risk evaluation, the perioperative risk for the patient should be minimized and safety increased. The recommendations for action are summarized under "General Principles (A)," "Advanced Diagnostics (B)," and the "Preoperative Management of Continuous Medication (C)." For the first time, a rating of the individual measures with regard to their clinical relevance has been given in the present recommendation. A joint and transparent agreement is intended to ensure a high level of patient orientation while avoiding unnecessary preliminary examinations, to shorten preoperative examination procedures, and ultimately to save costs. The joint recommendation of DGAI, DGCH and DGIM reflects the current state of knowledge as well as the opinion of experts. The recommendation does not replace the individualized decision between patient and physician about the best preoperative strategy and treatment.
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Affiliation(s)
- Christian Zöllner
- Universitätsklinikum Hamburg-Eppendorf, Klinik und Poliklinik für Anästhesiologie, Zentrum für Anästhesiologie und Intensivmedizin, Martinistr. 52, 20246, Hamburg, Deutschland.
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14
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Rifkin WJ, Parker A, Bluebond-Langner R. Use of Tranexamic Acid in Gender-Affirming Mastectomy Reduces Rates of Postoperative Hematoma and Seroma. Plast Reconstr Surg 2024; 153:1002e-1010e. [PMID: 37399532 DOI: 10.1097/prs.0000000000010892] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/05/2023]
Abstract
BACKGROUND The established safety and efficacy of tranexamic acid (TXA) in minimizing perioperative blood loss has led to increased interest within plastic surgery. Prior studies have demonstrated decreased edema and ecchymosis and reduced rates of postoperative collection with administration of TXA; however, its use has not been reported in gender-affirming mastectomy. This represents the first study to evaluate the effects of TXA on postoperative outcomes in patients undergoing gender-affirming mastectomy. METHODS A single-center cohort study was performed analyzing all consecutive patients undergoing gender-affirming mastectomy with the senior author (R.B.-L.) between February of 2017 and October of 2022. Beginning in June of 2021, all patients received 1000 mg of TXA intravenously before incision and 1000 mg at the conclusion of the procedure. Patients were stratified according to intraoperative administration of TXA, with demographic characteristics, surgical characteristics, and postoperative outcomes compared between groups. RESULTS A total of 851 patients underwent gender-affirming mastectomy. Of these, 646 cases were performed without TXA, and 205 patients received intravenous TXA intraoperatively, as described previously. Patients who received TXA had significantly lower rates of seroma (20.5% versus 33.0%; P < 0.001) and hematoma (0.5% versus 5.7%; P = 0.002). There was no difference in rates of surgical-site infection ( P = 0.74). TXA use was not associated with increased rates of venous thromboembolism ( P = 0.42). CONCLUSIONS Intraoperative administration of TXA in patients undergoing gender-affirming mastectomy may safely reduce the risk of postoperative seroma and hematoma without increased risk of thromboembolic events. Additional data collection and prospective studies are warranted to corroborate these findings. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.
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Affiliation(s)
- William J Rifkin
- From the Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health
| | - Augustus Parker
- From the Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health
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15
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Dujardin RWG, Kleinveld DJB, van den Brom CE, Geeraedts LMG, Beijer E, Gaarder C, Brohi K, Stanworth S, Johansson PI, Stensballe J, Maegele M, Juffermans NP. Older females have increased mortality after trauma as compared with younger females and males, associated with increased fibrinolysis. J Trauma Acute Care Surg 2024; 96:831-837. [PMID: 38079234 DOI: 10.1097/ta.0000000000004235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/25/2024]
Abstract
INTRODUCTION Female sex may provide a survival benefit after trauma, possibly attributable to protective effects of estrogen. This study aimed to compare markers of coagulation between male and female trauma patients across different ages. METHODS Secondary analysis of a prospective cohort study that was conducted at six trauma centers. Trauma patients presenting with full trauma team activation were eligible for inclusion. Patients with a penetrating trauma or traumatic brain injury were excluded. Upon hospital arrival, blood was drawn for measurement of endothelial and coagulation markers and for rotational thromboelastometry measurement. Trauma patients were divided into four categories: males younger than 45 years, males 45 years or older, females younger than 45 years, and females 45 years or older. In a sensitivity analysis, patients between 45 and 55 years old were excluded to control for menopausal transitioning. Groups were compared with a Kruskal-Wallis test with Bonferroni correction. A logistic regression was performed to assess whether the independent effect of sex and age on mortality. RESULTS A total of 1,345 patients were available for analysis. Compared with the other groups, mortality was highest in females 45 years or older, albeit not independent from injury severity and shock. In the group of females 45 years or older, there was increased fibrinolysis, demonstrated by increased levels of plasmin-antiplasmin complexes with a concomitant decrease in α2-antiplasmin. Also, a modest decrease in coagulation factors II and X was observed. Fibrinogen levels were comparable between groups. The sensitivity analysis in 1,104 patients demonstrated an independent relationship between female sex, age 55 years or older, and mortality. Rotational thromboelastometry profiles did not reflect the changes in coagulation tests. CONCLUSION Female trauma patients past their reproductive age have an increased risk of mortality compared with younger females and males, associated with augmented fibrinolysis and clotting factor consumption. Rotational thromboelastometry parameters did not reflect coagulation differences between groups. LEVEL OF EVIDENCE Prognostic and Epidemiological; Level III.
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Affiliation(s)
- Romein W G Dujardin
- From the Laboratory of Experimental Intensive Care and Anesthesiology (R.W.G.D., D.J.B.K., C.E.v.d.B., E.B., N.P.J.), and Department of Intensive Care (R.W.G.D., C.E.v.d.B.), Amsterdam UMC, University of Amsterdam; OLVG Hospital, Department of Intensive Care Medicine (R.W.G.D., N.P.J.), Amsterdam; Erasmus MC, Department of Anesthesiology (D.J.B.K.), Rotterdam; Department of Anesthesiology (C.E.v.d.B., E.B.), Amsterdam UMC, Vrije Universiteit Amsterdam; Department of Surgery (L.M.G.G., E.B.), Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands; Department of Traumatology (C.G.), Oslo University Hospital, Oslo, Norway; Trauma Sciences (K.B.), Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom; NHS Blood and Transplant/Oxford University Hospital NHS Trust (S.S.), John Radcliffe Hospital, Oxford, United Kingdom; Radcliffe Department of Medicine (S.S.), University of Oxford, United Kingdom; Department of Anesthesiology and Trauma Center (P.I.J., J.S.), Center for Head and Orthopedics, and Section for Transfusion Medicine (P.I.J., J.S.), Capital Region Blood Bank, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark; and Department of Traumatology and Orthopedic Surgery (M.M.), Cologne-Merheim Medical Center, University of Witten/Herdecke, Cologne, Germany
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16
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Fouche PF, Stein C, Nichols M, Meadley B, Bendall JC, Smith K, Anderson D, Doi SA. Tranexamic Acid for Traumatic Injury in the Emergency Setting: A Systematic Review and Bias-Adjusted Meta-Analysis of Randomized Controlled Trials. Ann Emerg Med 2024; 83:435-445. [PMID: 37999653 DOI: 10.1016/j.annemergmed.2023.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 09/14/2023] [Accepted: 10/06/2023] [Indexed: 11/25/2023]
Abstract
STUDY OBJECTIVE Traumatic injury causes a significant number of deaths due to bleeding. Tranexamic acid (TXA), an antifibrinolytic agent, can reduce bleeding in traumatic injuries and potentially enhance outcomes. Previous reviews suggested potential TXA benefits but did not consider the latest trials. METHODS A systematic review and bias-adjusted meta-analysis were performed to assess TXA's effectiveness in emergency traumatic injury settings by pooling estimates from randomized controlled trials. Researchers searched Medline, Embase, and Cochrane Central for randomized controlled trials comparing TXA's effects to a placebo in emergency trauma cases. The primary endpoint was 1-month mortality. The methodological quality of the trials underwent assessment using the MASTER scale, and the meta-analysis applied the quality-effects method to adjust for methodological quality. RESULTS Seven randomized controlled trials met the set criteria. This meta-analysis indicated an 11% decrease in the death risk at 1 month after TXA use (odds ratio [OR] 0.89, 95% confidence interval [CI] 0.84 to 0.95) with a number needed to treat of 61 to avoid 1 additional death. The meta-analysis also revealed reduced 24-hour mortality (OR 0.76, 95% CI 0.65 to 0.88) for TXA. No compelling evidence of increased vascular occlusive events emerged (OR 0.96, 95% CI 0.73 to 1.27). Subgroup analyses highlighted TXA's effectiveness in general trauma versus traumatic brain injury and survival advantages when administered out-of-hospital versus inhospital. CONCLUSIONS This synthesis demonstrates that TXA use for trauma in emergencies leads to a reduction in 1-month mortality, with no significant evidence of problematic vascular occlusive events. Administering TXA in the out-of-hospital setting is associated with reduced mortality compared to inhospital administration, and less mortality with TXA in systemic trauma is noted compared with traumatic brain injury specifically.
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Affiliation(s)
| | - Christopher Stein
- Department of Emergency Medical Care, University of Johannesburg, Johannesburg, Gauteng, South Africa
| | - Martin Nichols
- Clinical Systems, New South Wales Ambulance, Rozelle, NSW, Australia
| | - Benjamin Meadley
- Department of Paramedicine, Monash University, Mulgrave, Victoria, Australia
| | - Jason C Bendall
- Clinical Systems, New South Wales Ambulance, Rozelle, NSW, Australia
| | | | | | - Suhail A Doi
- College of Medicine, Qatar University, Doha, Qatar
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Marous CL, Farhat OJ, Cefalu M, Rothschild MI, Alapati S, Wladis EJ. Effects of Preoperative Intravenous Versus Subcutaneous Tranexamic Acid on Postoperative Periorbital Ecchymosis and Edema Following Upper Eyelid Blepharoplasty: A Prospective, Randomized, Double-Blinded, Placebo-Controlled, Comparative Study. Ophthalmic Plast Reconstr Surg 2024:00002341-990000000-00379. [PMID: 38687303 DOI: 10.1097/iop.0000000000002633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2024]
Abstract
PURPOSE To compare the effects of preoperative tranexamic acid (TXA) administered intravenously (IV) versus subcutaneously on postoperative ecchymosis and edema in patients undergoing bilateral upper eyelid blepharoplasty. METHODS A prospective, double-blinded, placebo-controlled study of patients undergoing bilateral upper eyelid blepharoplasty at a single-center. Eligible participants were randomized to preoperatively receive either (1) 1 g of TXA in 100 ml normal saline IV, (2) 50 µl/ml of TXA in local anesthesia, or (3) no TXA. Primary outcomes included ecchymosis and edema at postoperative day 1 (POD1) and 7 (POD7). Secondary outcomes included operative time, pain, time until resuming activities of daily living, patient satisfaction, and adverse events. RESULTS By comparison (IV TXA vs. local subcutaneous TXA vs. no TXA), ecchymosis scores were significantly lower on POD1 (1.31 vs. 1.56 vs. 2.09, p = 0.02) and on POD7 (0.51 vs. 0.66 vs. 0.98, p = 0.04) among those that received TXA. By comparison (IV TXA vs. local subcutaneous TXA vs. no TXA), significant reductions in edema scores occurred in those that received TXA on POD1 (1.59 vs. 1.43 vs. 1.91, p = 0.005) and on POD7 (0.85 vs. 0.60 vs. 0.99, p = 0.04). By comparison (IV TXA vs. local subcutaneous TXA vs. no TXA) patients treated with intravenous and local subcutaneous TXA preoperatively were more likely to experience shorter operative times (10.8 vs. 11.8 vs. 12.9 minutes, p = 0.01), reduced time to resuming activities of daily livings (1.6 vs. 1.6 vs. 2.3 days, p < 0.0001), and higher satisfaction scores at POD1 (8.8 vs. 8.7 vs. 7.9, p = 0.0002). No adverse events occurred were reported. CONCLUSION In an analysis of 106 patients, preoperative TXA administered either IV or subcutaneously safely reduced postoperative ecchymosis and edema in patients undergoing upper eyelid blepharoplasty. While statistical superiority between intravenous versus local subcutaneous TXA treatment was not definitively identified, our results suggest clinical superiority with IV dosing.
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Affiliation(s)
- Charlotte L Marous
- Oculoplastic and Orbital Surgery, Wills Eye Hospital, Thomas Jefferson University, Philadelphia, Pennsylvania
- Ophthalmic Plastic Surgery, Department of Ophthalmology, Albany Medical College
| | - Omar J Farhat
- Ophthalmic Plastic Surgery, Department of Ophthalmology, Albany Medical College
| | - Matthew Cefalu
- Ophthalmic Plastic Surgery, Department of Ophthalmology, Albany Medical College
| | | | | | - Edward J Wladis
- Ophthalmic Plastic Surgery, Department of Ophthalmology, Albany Medical College
- Department of Otolaryngology and Head and Neck Surgery, Albany Medical College, Albany, New York, U.S.A
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18
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Long B, Gottlieb M. Emergency medicine updates: Lower gastrointestinal bleeding. Am J Emerg Med 2024; 81:62-68. [PMID: 38670052 DOI: 10.1016/j.ajem.2024.04.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Revised: 03/26/2024] [Accepted: 04/14/2024] [Indexed: 04/28/2024] Open
Abstract
INTRODUCTION Lower gastrointestinal bleeding (LGIB) is a condition commonly seen in the emergency department. Therefore, it is important for emergency medicine clinicians to be aware of the current evidence regarding the diagnosis and management of this disease. OBJECTIVE This paper evaluates key evidence-based updates concerning LGIB for the emergency clinician. DISCUSSION LGIB is most commonly due to diverticulosis or anorectal disease, though there are a variety of etiologies. The majority of cases resolve spontaneously, but patients can have severe bleeding resulting in hemodynamic instability. Initial evaluation should focus on patient hemodynamics, the severity of bleeding, and differentiating upper gastrointestinal bleeding from LGIB. Factors associated with LGIB include prior history of LGIB, age over 50 years, and presence of blood clots per rectum. Computed tomography angiography is the imaging modality of choice in those with severe bleeding to diagnose the source of bleeding and guide management when embolization is indicated. Among stable patients without severe bleeding, colonoscopy is the recommended modality for diagnosis and management. A transfusion threshold of 7 g/dL hemoglobin is recommended based on recent data and guidelines (8 g/dL in those with myocardial ischemia), though patients with severe bleeding and hemodynamic instability should undergo emergent transfusion. Anticoagulation reversal may be necessary. If bleeding does not resolve, embolization or endoscopic therapies are necessary. There are several risk scores that can predict the risk of adverse outcomes; however, these scores should not replace clinical judgment in determining patient disposition. CONCLUSIONS An understanding of literature updates can improve the care of patients with LGIB.
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Affiliation(s)
- Brit Long
- SAUSHEC, Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, TX, USA.
| | - Michael Gottlieb
- Department of Emergency Medicine Rush, University Medical Center, Chicago, IL, USA
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19
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Tan G, Li J, Xu J, Zhu Y, Zhang H. The efficacy and safety of different does of intravenous tranexamic acid on blood loss in fresh foot and ankle fractures: a prospective, randomized controlled study. BMC Musculoskelet Disord 2024; 25:274. [PMID: 38589854 PMCID: PMC11003133 DOI: 10.1186/s12891-024-07410-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Accepted: 04/02/2024] [Indexed: 04/10/2024] Open
Abstract
BACKGROUND There are a few studies on the effectiveness and safety of intravenous administration of tranexamic acid(TXA) in patients who underwent foot and ankle surgery, especially for preoperative hidden blood loss in patients with freshfoot and ankle fractures. Thus, the aim of this study was to investigate whether intravenous administration of different doses of TXA can effectively reduce perioperative blood loss and blood loss before surgery and to determine its safety. METHODS A total of 150 patients with fresh closed foot and ankle fractures from July 2021 to July 2023 were randomly divided into a control group (placebo controlled [PC]), standard-dose group (low-dose group [LD], 1 g/24 h; medium-dose group [MD], 2 g/24 h), and high-dose group (HD, 3 g/24 h; ultrahigh-dose group [UD], 4 g/24 h). After admission, all patients completed hematological examinations as soon as possible and at multiple other time points postsurgery. RESULTS There was a significant difference in the incidence of hidden blood loss before the operation between the TXA group and the control group, and the effect was greater in the overdose groups than in the standard-dose groups. There were significant differences in surgical blood loss (intraoperative and postoperative), postoperative HGB changes, and hidden blood loss among the groups. The TXA groups showed a significant decrease in blood loss compared to that of the control group, and the overdose groups had a more significant effect than the standard-dose groups. A total of 9 patients in the control group had early wound infection or poor healing, while only 1 patient in the other groups had this complication, and the difference among the groups was significant. No patients in any group suffered from late deep wound infection, cardiovascular or cerebrovascular events or symptomatic VTE. CONCLUSION This is the first study on whether TXA can reduce preoperative hidden blood loss in patients with freshfoot and ankle fractures. In our study, on the one hand, intravenous application of TXA after foot and ankle fractures as soon as possible can reduce preoperative blood loss and postoperative blood loss. On the other hand, TXA can also lower wound complications, and over-doses of TXA are more effective than standard doses. Moreover, overdoses of TXA do not increase the incidence of DVT.
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Affiliation(s)
- Gang Tan
- Department of Orthopaedics, West China Hospital of Sichuan University, No.37 of Guoxue lane, Wuhou District, Chengdu, Sichuan, 610041, China
- Department of Orthopaedics, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Jia Li
- Department of Orthopaedics, West China Hospital of Sichuan University, No.37 of Guoxue lane, Wuhou District, Chengdu, Sichuan, 610041, China
| | - Jing Xu
- Operating Room, West China School of Nursing, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Yongzhan Zhu
- Foshan Hospital of Traditional Chinese Medicine, Foshan, Guangdong, China.
| | - Hui Zhang
- Department of Orthopaedics, West China Hospital of Sichuan University, No.37 of Guoxue lane, Wuhou District, Chengdu, Sichuan, 610041, China.
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20
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Wu B, Lv K. Effect of tranexamic acid on postoperative blood loss. Br J Oral Maxillofac Surg 2024:S0266-4356(24)00078-0. [PMID: 38735769 DOI: 10.1016/j.bjoms.2024.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Revised: 02/17/2024] [Accepted: 04/03/2024] [Indexed: 05/14/2024]
Abstract
The aim of this article was to evaluate the efficacy of tranexamic acid (TXA) to reduce blood loss after maxillofacial fracture surgery. Clinical data were collected retrospectively on patients with unilateral fractures of the zygomaticomaxillary complex (ZMC) or mandibular condyle. Patients were then further divided into TXA and control groups according to whether or not TXA was used after surgery. The amount of postoperative blood loss was evaluated by negative pressure drainage volume. Data were statistically analysed. In patients with unilateral ZMC fractures, total postoperative blood loss in the TXA group was about 30 ml less than that in the control group (p = 0.006). It was significantly less on the first and second postoperative days. However, in patients with unilateral mandibular condylar fractures, there was no significant difference between the TXA and control groups (p = 0.917). TXA can reduce postoperative bleeding in patients with ZMC fractures, and the optimal usage time is on the first and second postoperative days. For patients with mandibular condylar fractures, TXA may not be used.
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Affiliation(s)
- Benxing Wu
- State Key Laboratory of Oral & Maxillofacial Reconstruction and Regeneration, Key Laboratory of Oral Biomedicine Ministry of Education, Hubei Key Laboratory of Stomatology, School & Hospital of Stomatology, Wuhan University.
| | - Kun Lv
- State Key Laboratory of Oral & Maxillofacial Reconstruction and Regeneration, Key Laboratory of Oral Biomedicine Ministry of Education, Hubei Key Laboratory of Stomatology, School & Hospital of Stomatology, Wuhan University; Department of Oral and Maxillofacial Surgery, School and Hospital of Stomatology, Wuhan University, Wuhan 430079, People's Republic of China.
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21
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Keeves J, Gadowski A, McKimmie A, Bagg MK, Antonic-Baker A, Hicks AJ, Clarke N, Brown A, McNamara R, Reeder S, Roman C, Jeffcote T, Romero L, Hill R, Ponsford JL, Lannin NA, O'Brien TJ, Cameron PA, Rushworth N, Fitzgerald M, Gabbe BJ, Cooper DJ. The Australian Traumatic Brain Injury Initiative: Systematic Review of the Effect of Acute Interventions on Outcome for People With Moderate-Severe Traumatic Brain Injury. J Neurotrauma 2024. [PMID: 38279797 DOI: 10.1089/neu.2023.0465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2024] Open
Abstract
The Australian Traumatic Brain Injury Initiative (AUS-TBI) is developing a data resource to enable improved outcome prediction for people with moderate-severe TBI (msTBI) across Australia. Fundamental to this resource is the collaboratively designed data dictionary. This systematic review and consultation aimed to identify acute interventions with potential to modify clinical outcomes for people after msTBI, for inclusion in a data dictionary. Standardized searches were implemented across bibliographic databases from inception through April 2022. English-language reports of randomized controlled trials (RCTs) evaluating any association between any acute intervention and clinical outcome in at least 100 patients with msTBI, were included. A predefined algorithm was used to assign a value to each observed association. Consultation with AUS-TBI clinicians and researchers formed the consensus process for interventions to be included in a single data dictionary. Searches retrieved 14,455 records, of which 124 full-length RCTs were screened, with 35 studies included. These studies evaluated 26 unique acute interventions across 21 unique clinical outcomes. Only 4 interventions were considered to have medium modifying value for any outcome from the review, with an additional 8 interventions agreed upon through the consensus process. The interventions with medium value were tranexamic acid and phenytoin, which had a positive effect on an outcome; and decompressive craniectomy surgery and hypothermia, which negatively affected outcomes. From the systematic review and consensus process, 12 interventions were identified as potential modifiers to be included in the AUS-TBI national data resource.
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Affiliation(s)
- Jemma Keeves
- Curtin Health Innovation Research Institute, Faculty of Health Sciences, Curtin University, Bentley, Western Australia, Australia
- Perron Institute for Neurological and Translational Science, Nedlands, Western Australlia, Australia
- School of Public Health and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Adelle Gadowski
- School of Public Health and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Ancelin McKimmie
- School of Public Health and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Matthew K Bagg
- Curtin Health Innovation Research Institute, Faculty of Health Sciences, Curtin University, Bentley, Western Australia, Australia
- Perron Institute for Neurological and Translational Science, Nedlands, Western Australlia, Australia
- Centre for Pain IMPACT, Neuroscience Research Australia, Sydney, New South Wales, Australia
- School of Health Sciences and Physiotherapy, University of Notre Dame Australia, Fremantle, Western Australia, Australia
| | - Ana Antonic-Baker
- Department of Neuroscience, Central Clinical School, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Amelia J Hicks
- Monash-Epworth Rehabilitation Research Centre, Epworth Healthcare, Melbourne, Victoria, Australia
- Turner Institute for Brain and Mental Health, School of Psychological Sciences, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Nyssa Clarke
- School of Public Health and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Alastair Brown
- Department of Critical Care Medicine, St Vincent's Hospital, Melbourne, Victoria, Australia
- Department of Intensive Care Medicine, Austin Hospital, Melbourne, Victoria, Australia
- Department of Intensive Care and Hyperbaric Medicine, The Alfred, Melbourne, Victoria, Australia
| | - Rob McNamara
- School of Medicine, Faculty of Health Sciences, Curtin University, Bentley, Western Australia, Australia
- Department of Intensive Care Medicine, Royal Perth Hospital, Perth, Western Australia, Australia
| | - Sandy Reeder
- School of Public Health and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Department of Neuroscience, Central Clinical School, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | | | - Toby Jeffcote
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Department of Intensive Care and Hyperbaric Medicine, The Alfred, Melbourne, Victoria, Australia
| | | | - Regina Hill
- Regina Hill Effective Consulting Pty. Ltd., Melbourne, Victoria, Australia
| | - Jennie L Ponsford
- Monash-Epworth Rehabilitation Research Centre, Epworth Healthcare, Melbourne, Victoria, Australia
- Turner Institute for Brain and Mental Health, School of Psychological Sciences, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Natasha A Lannin
- Department of Neuroscience, Central Clinical School, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Alfred Health, Melbourne, Victoria, Australia
| | - Terence J O'Brien
- Department of Neuroscience, Central Clinical School, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Peter A Cameron
- School of Public Health and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- National Trauma Research Institute, Melbourne, Victoria, Australia
- Emergency and Trauma Centre, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Nick Rushworth
- Brain Injury Australia, Sydney, New South Wales, Australia
| | - Melinda Fitzgerald
- Curtin Health Innovation Research Institute, Faculty of Health Sciences, Curtin University, Bentley, Western Australia, Australia
- Perron Institute for Neurological and Translational Science, Nedlands, Western Australlia, Australia
| | - Belinda J Gabbe
- School of Public Health and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Health Data Research UK, Swansea University Medical School, Swansea University, Singleton Park, United Kingdom
| | - D Jamie Cooper
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Department of Intensive Care and Hyperbaric Medicine, The Alfred, Melbourne, Victoria, Australia
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22
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Demetriou C, Eardley W, Rebeiz MC, Hing CB. National variation in guidance for the management of pregnant women presenting with major trauma. Ann R Coll Surg Engl 2024. [PMID: 38563081 DOI: 10.1308/rcsann.2024.0011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2024] Open
Abstract
INTRODUCTION The initial assessment of pregnant women presenting with significant injuries is more complicated than that of non-pregnant women because of physiological and anatomical changes, and the presence of the fetus. The aim of this study was to determine whether guidelines for the early management of severely injured pregnant women exist, which aspects of assessment/management they cover and to what extent there is national consistency. METHODS A freedom of information request was submitted to 125 acute National Health Service trusts in England and six in Wales. The trusts were asked to confirm whether they have a guideline for the management of major trauma in pregnant women presenting to the emergency department and what the guidelines were. RESULTS In total, 96.2% of trusts responded, of which 19% have a specific guideline and 7.9% have a generic guideline for assessing pregnant women in the emergency department, irrespective of injury severity. Of the responding trusts, 19.8% have a protocol that specifies when an obstetric trauma call should be put out by the emergency department and when a pregnant woman should be transferred to a major trauma centre for definitive management. Our results found that 69.8% routinely call obstetrics or gynaecology to the trauma call compared with 36.5% calling paediatrics. CONCLUSIONS The heterogeneity evident across trusts necessitates the establishment of national guidelines for the assessment of pregnant women with major trauma to standardise communication and delivery of care.
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Affiliation(s)
| | - W Eardley
- South Tees Hospitals NHS Foundation Trust, UK
| | - M-C Rebeiz
- St George's University Hospitals NHS Foundation Trust, UK
| | - C B Hing
- St George's University Hospitals NHS Foundation Trust, UK
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23
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Arsenault V, Lieberman L, Akbari P, Murto K. Canadian tertiary care pediatric massive hemorrhage protocols: a survey and comprehensive national review. Can J Anaesth 2024; 71:453-464. [PMID: 38057534 DOI: 10.1007/s12630-023-02641-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 06/27/2023] [Accepted: 07/09/2023] [Indexed: 12/08/2023] Open
Abstract
PURPOSE Hemorrhage is the leading cause of pediatric death in trauma and cardiac arrest during surgery. Adult studies report improved patient outcomes using massive hemorrhage protocols (MHPs). Little is known about pediatric MHP adoption in Canada. METHODS After waived research ethics approval, we conducted a survey of Canadian pediatric tertiary care hospitals to study MHP activations. Transfusion medicine directors provided hospital/patient demographic and MHP activation data. The authors extracted pediatric-specific MHP data from requested policy/procedure documents according to seven predefined MHP domains based on the literature. We also surveyed educational and audit tools. The analysis only included MHPs with pediatric-specific content. RESULTS The survey included 18 sites (100% response rate). Only 13/18 hospitals had pediatric-specific MHP content: eight were dedicated pediatric hospitals, two were combined pediatric/obstetrical hospitals, and three were combined pediatric/adult hospitals. Trauma was the most common indication for MHP activation (54%), typically based on a specific blood volume anticipated/transfused over time (10/13 sites). Transport container content was variable. Plasma and platelets were usually not in the first container. There was little emphasis on balanced plasma/platelet to red-blood-cell ratios, and most sites (12/13) rapidly incorporated laboratory-guided goal-directed transfusion. Transfusion thresholds were consistent with recent guidelines. All protocols used tranexamic acid and eight sites used an audit tool. DISCUSSION/CONCLUSION Pediatric MHP content was highly variable. Activation demographics suggest underuse in nontrauma settings. Our findings highlight the need for a consensus definition for pediatric massive hemorrhage, a validated pediatric MHP activation tool, and prospective assessment of blood component ratios. A national pediatric MHP activation repository would allow for quality improvement metrics.
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Affiliation(s)
- Valérie Arsenault
- Division of Transfusion Medicine, Department of Laboratory Medicine, University of Montreal, Montreal, QC, Canada
- Centre Hospitalier Universitaire (CHU) Sainte-Justine, Mother and Child Hospital of Montreal, Montreal, QC, Canada
| | - Lani Lieberman
- Department of Laboratory Medicine and Pathology, University of Toronto, Toronto, ON, Canada
- University Health Network, Toronto General Hospital, Toronto, ON, Canada
| | - Pegah Akbari
- Department of Physical Therapy, University of Toronto, Toronto, ON, Canada
| | - Kimmo Murto
- Department of Anesthesiology and Pain Medicine, University of Ottawa, Ottawa, ON, Canada.
- Children's Hospital of Eastern Ontario Research Institute, 401 Smyth Rd., Ottawa, ON, K1H 8L1, Canada.
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24
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Montano-Pedroso JC, Perini FV, Donizetti E, Oliveira LC, Rodrigues RDR, Rizzo SRCP, Rabello G, Langhi DM. Consensus of the Brazilian association of hematology, hemotherapy and cellular therapy on patient blood management: Antifibrinolytics. Hematol Transfus Cell Ther 2024; 46 Suppl 1:S40-S47. [PMID: 38555249 PMCID: PMC11069061 DOI: 10.1016/j.htct.2024.02.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2024] [Accepted: 02/18/2024] [Indexed: 04/02/2024] Open
Abstract
The use of strategies to reduce blood loss and transfusions is essential in the treatment of surgical patients, including in complex cardiac surgeries and those that use cardiopulmonary bypass. Antifibrinolytics, such as epsilon-aminocaproic acid (EACA) and tranexamic acid (TXA), are widely used in these procedures, as well as in other types of surgeries. These medicines are included in the World Health Organization (WHO) list of 'essential medicines'. Scientific evidence demonstrates the effectiveness of EACA in reducing bleeding and the need for transfusions in heart surgery. EACA is highly recommended for use in heart surgery by the American Society of Anesthesiology Task Force on Perioperative Blood Management. Regarding the safety of EACA, there is no robust evidence of any significant thrombotic potential. TXA has also been shown to be effective in reducing the use of blood transfusions in cardiac and non-cardiac surgeries and is considered safer than other antifibrinolytic agents. There is no evidence of any increased risk of thromboembolic events with TXA, but doses greater than 2 g per day have been associated with an increased risk of seizures. It is also important to adjust the dose in patients with renal impairment. In conclusion, antifibrinolytics, such as EACA and TXA, are effective in reducing blood loss and transfusion use in cardiac and non-cardiac surgeries, without causing serious adverse effects.
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Affiliation(s)
- Juan Carlos Montano-Pedroso
- Universidade Federal de São Paulo (Unifesp), São Paulo, SP, Brazil; Instituto de Assistência Médica do Servidor Público Estadual (Iamspe), São Paulo, SP, Brazil
| | - Fernanda Vieira Perini
- Grupo GSH - Gestor de Serviços de Hemoterapia, São Paulo, SP, Brazil; Associação Beneficente Síria HCOR, São Paulo, SP, Brazil
| | | | - Luciana Correa Oliveira
- Hemocentro de Ribeirão Preto, Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo (HCFMRP-USP), Ribeirão Preto, SP, Brazil
| | - Roseny Dos Reis Rodrigues
- Hospital Israelita Albert Einstein são Paulo, São Paulo, SP, Brazil; Faculdade de Medicina da Universidade de São Paulo (FM USP), São Paulo, SP, Brazil
| | | | - Guilherme Rabello
- Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (Incor - HCFMUSP), São Paulo, SP, Brazil.
| | - Dante Mario Langhi
- Escola Paulista de Medicina, Universidade Federal de São Paulo (EPM UNIFESP), São Paulo, SP, Brazil
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Oliveira LC, Montano-Pedroso JC, Perini FV, Dos Reis Rodrigues R, Donizetti E, Rizzo SRCP, Rabello G, Junior DML. Consensus of the Brazilian association of hematology, hemotherapy and cellular therapy on patient blood management: Management of critical bleeding. Hematol Transfus Cell Ther 2024; 46 Suppl 1:S60-S66. [PMID: 38553342 PMCID: PMC11069065 DOI: 10.1016/j.htct.2024.02.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2024] [Accepted: 02/18/2024] [Indexed: 05/07/2024] Open
Abstract
The management of major bleeding is a critical aspect of modern healthcare and it is imperative to emphasize the importance of applying Patient Blood Management (PBM) principles. Although transfusion support remains a vital component of bleeding control, treating severe bleeding goes beyond simply replacing lost blood. A more comprehensive, multidisciplinary approach is essential to optimize patient outcomes and minimize the risks associated with excessive transfusions.
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Affiliation(s)
- Luciana Correa Oliveira
- Hemocentro de Ribeirão Preto, Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo (HCFMRP-USP), Ribeirão Preto, SP, Brazil
| | - Juan Carlos Montano-Pedroso
- Universidade Federal de São Paulo (Unifesp), São Paulo, SP, Brazil; Instituto de Assistência Médica do Servidor Público Estadual (Iamspe), São Paulo, SP, Brazil
| | - Fernanda Vieira Perini
- Grupo GSH - Gestor de Serviços de Hemoterapia, São Paulo, SP, Brazil; Associação Beneficente Síria HCOR, São Paulo, SP, Brazil
| | - Roseny Dos Reis Rodrigues
- Hospital Israelita Albert Einstein são Paulo, São Paulo, SP, Brazil; Faculdade de Medicina da Universidade de São Paulo (FM USP), São Paulo, SP, Brazil
| | | | | | - Guilherme Rabello
- Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (Incor - HCFMUSP), São Paulo, SP, Brazil.
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Faraoni D, Fenger-Eriksen C. Dosing of tranexamic acid in trauma. Curr Opin Anaesthesiol 2024; 37:125-130. [PMID: 38390911 DOI: 10.1097/aco.0000000000001357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2024]
Abstract
PURPOSE OF REVIEW Tranexamic acid is routinely used as part of the management of traumatic bleeding. The dose recommendation in trauma was extrapolated from other clinical settings and the results of pragmatic randomized trials rather than pharmaco-kinetic and -dynamic evaluations. The review addresses current evidence on dosing of tranexamic acid in traumatized patients with a focus on efficacy, safety and risk-benefit profile. RECENT FINDINGS A majority, but not all, of existing randomized clinical trials reports a reduction in mortality and/or blood loss with tranexamic acid administration. Increasing dose above the general recommendation (1 g bolus + 1 g infusion/8 h intravenously) has not been shown to further increase efficacy and could potentially increase side effects. SUMMARY The benefit of tranexamic acid as adjuvant therapy in the management of bleeding trauma patients on mortality and transfusion requirements is clear and well documented, being most effective if given early and to patients with clinical signs of hemorrhagic shock. Recent reports suggest that in some patients presenting with a shutdown of their fibrinolytic pathway the administration of tranexamic acid could be associated with an increased risk of thromboembolic events and poor outcomes. A more personalized approach based on bedside assessment of fibrinolytic activation and pharmacokinetic-based dose regimen should be developed moving forward.
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Affiliation(s)
- David Faraoni
- Arthur S. Keats Division of Pediatric. Cardiovascular Anesthesia, Department of Anesthesiology, Perioperative and Pain Medicine, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - Christian Fenger-Eriksen
- Department of Anesthesiology and Department of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark
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Hough P, Nawrocki P, McCardell T, Parker G. Top 10 Tips on Safety From the Air Medical Transport Industry. Crit Care Nurs Q 2024; 47:143-151. [PMID: 38419177 DOI: 10.1097/cnq.0000000000000504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2024]
Abstract
The air medical transport industry places a high value on developing and maintaining a culture of safety due to the higher risk nature of its operations. The dynamic nature of response and transport, inherent risks involved with flight, lack of supporting resources, weather conditions, and austere nature of the transport environment are all factors that highlight the need for enhanced safety. As such, the air medical transport industry has developed a robust and unique approach to provider and patient safety involving many tactics not otherwise used in other areas of health care. This article describes some of the unique safety features and approaches that are commonplace in the air medical transport industry and proposes a means for these initiatives to other areas of the health care system.
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Affiliation(s)
- Peter Hough
- Allegheny General Hospital, Pittsburgh, Pennsylvania
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Kwon MA, Ji SM. Revolutionizing trauma care: advancing coagulation management and damage control anesthesia. Anesth Pain Med (Seoul) 2024; 19:73-84. [PMID: 38725162 PMCID: PMC11089294 DOI: 10.17085/apm.24038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2024] [Revised: 04/26/2024] [Accepted: 04/29/2024] [Indexed: 05/15/2024] Open
Abstract
Despite advances in emergency transfer systems and trauma medicine, the incidence of preventable deaths due to massive hemorrhage remains high. Recent immunological research has elucidated key mechanisms underlying trauma-induced coagulopathy in the early stages of trauma, including sympathoadrenal stimulation, shedding of the glycocalyx, and endotheliopathy. Consequently, the condition progresses to fibrinogen depletion, hyperfibrinolysis, and platelet dysfunction. Coexisting factors such as uncorrected acidosis, hypothermia, excessive crystalloid administration, and a history of anticoagulant use exacerbate coagulopathy. This study introduces damage-control anesthetic management based on recent insights into damage-control resuscitation, emphasizing the importance of rapid transport, timely bleeding control, early administration of antifibrinolytics and fibrinogen concentrates, and maintenance of calcium levels and body temperature. Additionally, this study discusses brain-protective strategies for trauma patients with brain injuries and the utilization of cartridge-based viscoelastic assays for goal-directed coagulation management in trauma settings. This comprehensive approach may provide potential insights for anesthetic management in the fast-paced field of trauma medicine.
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Affiliation(s)
- Min A Kwon
- Department of Anesthesiology and Pain Medicine, Dankook University Hospital, Cheonan, Korea
| | - Sung Mi Ji
- Department of Anesthesiology and Pain Medicine, Dankook University Hospital, Cheonan, Korea
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Christoffel J, Maegele M. Guidelines in trauma-related bleeding and coagulopathy: an update. Curr Opin Anaesthesiol 2024; 37:110-116. [PMID: 38390904 DOI: 10.1097/aco.0000000000001346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2024]
Abstract
PURPOSE OF REVIEW The diagnosis and treatment of patients with severe traumatic bleeding and subsequent trauma-induced coagulopathy (TIC) is still inconsistent, although the implementation of standardized algorithms/treatment pathways was repeatedly linked to improved outcome. Various evidence-based guidelines for these patients now exist, three of which have recently been updated. RECENT FINDINGS A synopsis of the three recently updated guidelines for diagnosis and treatment of seriously bleeding trauma patients with TIC is presented: (i) AWMF S3 guideline 'Polytrauma/Seriously Injured Patient Treatment' under the auspices of the German Society for Trauma Surgery; (ii) guideline of the European Society of Anesthesiology and Intensive Care (ESAIC) on the management of perioperative bleeding; and (iii) European guideline on the management of major bleeding and coagulopathy after trauma in its 6th edition (EU-Trauma). SUMMARY Treatment of trauma-related bleeding begins at the scene with local compression, use of tourniquets and pelvic binders and rapid transport to a certified trauma centre. After arrival at the hospital, measures to record, monitor and support coagulation function should be initiated immediately. Surgical bleeding control is carried out according to 'damage control' principles. Modern coagulation management includes individualized treatment based on target values derived from point-of-care viscoelastic test procedures.
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Affiliation(s)
- Jannis Christoffel
- Department for Trauma and Orthopaedic Surgery, Cologne-Merheim Medical Center (CMMC)
| | - Marc Maegele
- Department for Trauma and Orthopaedic Surgery, Cologne-Merheim Medical Center (CMMC)
- Institute for Research in Operative Medicine (IFOM), Witten/Herdecke University, Campus Cologne-Merheim, Cologne, Germany
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Kowalczyk JJ, Cecconi M, Butwick AJ. Evaluating tranexamic acid for the prevention and treatment of obstetric hemorrhage. Curr Opin Obstet Gynecol 2024; 36:88-96. [PMID: 38170626 DOI: 10.1097/gco.0000000000000935] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2024]
Abstract
PURPOSE OF REVIEW Tranexamic acid (TXA) has emerged as a promising pharmacological adjunct to treat and prevent postpartum hemorrhage (PPH). We provide an overview of TXA, including its pharmacology, key findings of randomized trials and observational studies, and critical patient safety information. RECENT FINDINGS Pharmacokinetic data indicate that TXA infusions result in peak plasma concentration within 3 min (range: 1-6.6 min). Ex-vivo pharmacodynamic data suggest that low-dose TXA (5 mg/kg) inhibits maximum lysis for at least 1 h. In predominantly developing countries, TXA has demonstrated a 19% reduction in the risk of bleeding-related death among patients with PPH. Based on high-quality randomized trials, TXA prophylaxis does not effectively reduce the risk of PPH during vaginal delivery and is likely ineffective in reducing the PPH risk during cesarean delivery. TXA exposure does not increase the risk of maternal thrombotic events. Maternal deaths have occurred from accidental intrathecal TXA injection from look-alike medication errors. SUMMARY TXA has shown promise as an important adjunct for PPH treatment, especially in low-resource settings. However, TXA is not recommended as PPH prophylaxis during vaginal or cesarean delivery. Patient safety initiatives should be prioritized to prevent maternal death from accidental intrathecal TXA injection.
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Affiliation(s)
- John J Kowalczyk
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Maurizio Cecconi
- Biomedical Sciences Department, Humanitas University
- Department of Anaesthesia and Intensive Care, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Alexander J Butwick
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, California, USA
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Van Gent JM, Clements TW, Cotton BA. Resuscitation and Care in the Trauma Bay. Surg Clin North Am 2024; 104:279-292. [PMID: 38453302 DOI: 10.1016/j.suc.2023.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/09/2024]
Abstract
Start balanced resuscitation early (pre-hospital if possible), either in the form of whole blood or 1:1:1 ratio. Minimize resuscitation with crystalloid to minimize patient morbidity and mortality. Trauma-induced coagulopathy can be largely avoided with the use of balanced resuscitation, permissive hypotension, and minimized time to hemostasis. Using protocolized "triggers" for massive and ultramassive transfusion will assist in minimizing delays in transfusion of products, achieving balanced ratios, and avoiding trauma induced coagulopathy. Once "audible" bleeding has been addressed, further blood product resuscitation and adjunct replacement should be guided by viscoelastic testing. Early transfusion of whole blood can reduce patient morbidity, mortality, decreases donor exposure, and reduces nursing logistics during transfusions. Adjuncts to resuscitation should be guided by laboratory testing and carefully developed, institution-specific guidelines. These include empiric calcium replacement, tranexamic acid (or other anti-fibrinolytics), and fibrinogen supplementation.
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Affiliation(s)
- Jan-Michael Van Gent
- The Red Duke Trauma Institute, Memorial Hermann Hospital, Houston, TX, USA; McGovern Medical School, University of Texas Health Science Center-Houston, Houston, TX, USA
| | - Thomas W Clements
- The Red Duke Trauma Institute, Memorial Hermann Hospital, Houston, TX, USA; McGovern Medical School, University of Texas Health Science Center-Houston, Houston, TX, USA
| | - Bryan A Cotton
- The Red Duke Trauma Institute, Memorial Hermann Hospital, Houston, TX, USA; McGovern Medical School, University of Texas Health Science Center-Houston, Houston, TX, USA; Center for Translational Injury Research, Houston, TX, USA.
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Gendler S, Gelikas S, Talmy T, Nadler R, Tsur AM, Radomislensky I, Bodas M, Glassberg E, Almog O, Benov A, Chen J. Predictors of Short-Term Trauma Laparotomy Outcomes in an Integrated Military-Civilian Health System: A 23-Year Retrospective Cohort Study. J Clin Med 2024; 13:1830. [PMID: 38610595 PMCID: PMC11012665 DOI: 10.3390/jcm13071830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2024] [Revised: 02/03/2024] [Accepted: 03/14/2024] [Indexed: 04/14/2024] Open
Abstract
Background: Trauma laparotomy (TL) remains a cornerstone of trauma care. We aimed to investigate prehospital measures associated with in-hospital mortality among casualties subsequently undergoing TLs in civilian hospitals. Methods: This retrospective cohort study cross-referenced the prehospital and hospitalization data of casualties treated by Israel Defense Forces-Medical Corps teams who later underwent TLs in civilian hospitals between 1997 and 2020. Results: Overall, we identified 217 casualties treated by IDF-MC teams that subsequently underwent a TL, with a mortality rate of 15.2% (33/217). The main mechanism of injury was documented as penetrating for 121/217 (55.8%). The median heart rate and blood pressure were within the normal limit for the entire cohort, with a low blood pressure predicting mortality (65 vs. 127, p < 0.001). In a multivariate analysis, prehospital endotracheal intubation (ETI), emergency department Glasgow coma scores of 3-8, and the need for a thoracotomy or bowel-related procedures were significantly associated with mortality (OR 6.8, p < 0.001, OR = 48.5, p < 0.001, and OR = 4.61, p = 0.002, respectively). Conclusions: Prehospital interventions introduced throughout the study period did not lead to an improvement in survival. Survival was negatively influenced by prehospital ETI, reinforcing previous observations of the potential deleterious effects of definitive airways on hemorrhaging trauma casualties. While a low blood pressure was a predictor of mortality, the median systolic blood pressure for even the sickest patients (ISS > 16) was within normal limits, highlighting the challenges in triage and risk stratification for trauma casualties.
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Affiliation(s)
- Sami Gendler
- Israel Defense Forces, Medical Corps, Tel Hashomer, Ramat Gan 5262504, Israel (J.C.)
| | - Shaul Gelikas
- Israel Defense Forces, Medical Corps, Tel Hashomer, Ramat Gan 5262504, Israel (J.C.)
- Department of Medicine, Sheba Medical Center, Tel-Hashomer 5262504, Israel
| | - Tomer Talmy
- Israel Defense Forces, Medical Corps, Tel Hashomer, Ramat Gan 5262504, Israel (J.C.)
| | - Roy Nadler
- Israel Defense Forces, Medical Corps, Tel Hashomer, Ramat Gan 5262504, Israel (J.C.)
| | - Avishai M. Tsur
- Israel Defense Forces, Medical Corps, Tel Hashomer, Ramat Gan 5262504, Israel (J.C.)
- Department of Medicine, Sheba Medical Center, Tel-Hashomer 5262504, Israel
| | - Irina Radomislensky
- The National Center for Trauma & Emergency Medicine Research, Gertner Institute for Epidemiology and Health Policy Research, Sheba Medical Center, Ramat Gan 5262100, Israel
| | - Moran Bodas
- The National Center for Trauma & Emergency Medicine Research, Gertner Institute for Epidemiology and Health Policy Research, Sheba Medical Center, Ramat Gan 5262100, Israel
- Department of Emergency & Disaster Management, School of Public Health, Faculty of Medicine, Tel-Aviv University, Tel-Aviv-Yafo 6139001, Israel
| | - Elon Glassberg
- Israel Defense Forces, Medical Corps, Tel Hashomer, Ramat Gan 5262504, Israel (J.C.)
- The Azrieli Faculty of Medicine, Bar-Ilan University, Safed 5290002, Israel
- The Uniformed Services, University of the Health Sciences, Bethesda, MD 20814, USA
| | - Ofer Almog
- Israel Defense Forces, Medical Corps, Tel Hashomer, Ramat Gan 5262504, Israel (J.C.)
- Department of Military Medicine, Faculty of Medicine, Hebrew University, Jerusalem 9112102, Israel
| | - Avi Benov
- Israel Defense Forces, Medical Corps, Tel Hashomer, Ramat Gan 5262504, Israel (J.C.)
- The Azrieli Faculty of Medicine, Bar-Ilan University, Safed 5290002, Israel
| | - Jacob Chen
- Israel Defense Forces, Medical Corps, Tel Hashomer, Ramat Gan 5262504, Israel (J.C.)
- Meir Medical Center, Kfar Saba 4428164, Israel
- Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv 69978, Israel
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Atallah O, Alrefaie K, Al Krinawe Y. Crucial trials in neurosurgery: a must-know for every neurosurgeon. Neurosurg Rev 2024; 47:126. [PMID: 38512522 PMCID: PMC10957582 DOI: 10.1007/s10143-024-02358-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Revised: 03/06/2024] [Accepted: 03/14/2024] [Indexed: 03/23/2024]
Affiliation(s)
- Oday Atallah
- Department of Neurosurgery, Hannover Medical School, Carl-Neuberg Street. Nr. 1, 30625, Hannover, Germany.
| | - Khadeja Alrefaie
- Faculty of Medicine, Royal College of Surgeons in Ireland, Busaiteen, Bahrain
| | - Yazeed Al Krinawe
- Department of Neurosurgery, Hannover Medical School, Carl-Neuberg Street. Nr. 1, 30625, Hannover, Germany
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Mukharjee S, B V D, S V B. Evaluation of management of CT scan proved solid organ injury in blunt injury abdomen-a prospective study. Eur J Trauma Emerg Surg 2024:10.1007/s00068-024-02501-2. [PMID: 38512418 DOI: 10.1007/s00068-024-02501-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Accepted: 03/11/2024] [Indexed: 03/23/2024]
Abstract
BACKGROUND Trauma especially road traffic injury is one of the major health-related issues throughout the world, especially in developing countries like India (Mattox 2022). Solid organ injury is the most common cause of morbidity and mortality in patients with blunt abdominal trauma. The non-operative management (NOM) is being consistently followed for hemodynamically stable patients with respect to solid organ injuries. This study aims to provide an evidence base for management modalities of solid organ injuries in blunt abdominal trauma. AIM The aim of this study is to evaluate the effectiveness of various treatment modalities for solid organ injury in blunt abdominal trauma. OBJECTIVES Evaluating the characteristics of blunt abdominal injury with respect to age and gender; distribution, mode of injury, most common organ injured, and severity of injury; effect of delay in getting treatment on the management outcome for patients with solid organ injury; evaluating the various modalities of treatment of CT-proven solid organ injury; incidence of complications in different modes of treatment. METHODS All patients aged more than 18 years and suffering from CT-proven solid organ injury secondary to blunt abdominal trauma between February 2021 and September 2022 were included in this prospective observational study. Sixty-five patients were enrolled in the study after meeting the inclusion criteria. Details such as age, gender, mechanism of injury, the time between injury to first hospital contact, presenting complaints, organ and grade of injury, Revised Trauma Score (RTS), Trauma Score and Injury Severity Score (TRISS), management, and outcomes were collected using self-designed pro forma and analyzed. Different modalities of treatment were evaluated and patients undergoing operative and non-operative management were compared. Patients in whom non-operative management failed were compared with patients with successful non-operative management. RESULTS The mean age of patients involved were 36.8 years with a male:female ratio of 7.125:1 and the most common age group affected being between 21 and 30 years. The most common mode of injury was noted to be road traffic accidents (72.3%). The most common presenting complaints were abdominal pain (64.6%) followed by chest pain (29.2%) and vomiting (13.8%). There was no significant relationship between latent period and type of intervention or failure of non-operative management. FAST positivity rate was noted to be 92.3%. Chronic alcoholism and bronchial asthma were significant predictors for patients undergoing upfront surgery (p = 0.003 and 0.006 respectively). The presence of pelvic and spine injury was statistically significant for predicting mortality in polytrauma patients (p = 0.003). Concurrent adrenal injury was found in 24.6% of patients but was not related to failure of non-operative management or mortality. RTS significantly predicts the multitude of organ involvement (p = 0.015). The liver was the most common organ injured (60%) followed by the spleen (52.3%) and the kidney (20%). The liver and the spleen (9.2%) were noted to be the most common organ combination involved. No specific organ or organ injury combination was noted to predict failure of non-operative management or mortality. But the multitude of organ involvement was statistically significant for predicting patients undergoing upfront surgery (p = 0.011). Out of 65 patients enrolled in the study, 7 patients (10.8%) underwent immediate surgery, and 58 patients (89.2%) underwent non-operative management. Among the 68 chosen for non-operative management, 6 patients (9.2%) failed non-operative management and 52 patients (80%) had success of non-operative management. A significant drop in hemoglobin (83.3%) on day 1 (66.6%) was seen to be the commonest reason for failure of non-operative management. The spleen was noted to be the most commonly involved organ intra-operatively (61.5%) followed by the liver (30.8%). Concordance between pre-operative and intra-operative grading of organ injuries was highest for liver and kidney injuries (100%) and lowest for pancreatic injuries (0%). Requirement of blood transfusion and liver injuries were significant factors for failure of non-operative management (p = 0.012 and 0.045 respectively). The presence of pancreatic leak was significant between the non-operated patients and patients operated upfront (p = 0.003). Mortality was noted to be 10.8% (7 patients) in our study. CONCLUSION Solid organ injury in blunt abdominal trauma is an important cause of morbidity and mortality. RTS was noted to be a good predictor for solid organ injury in blunt abdominal trauma. Pancreatic injuries are notorious for being under-staged on CT findings; hence, the need arises for multimodality imaging for suspected pancreatic injuries. Non-operative management is a successful modality of treatment for majority of patients suffering from multiple solid organ injuries in blunt abdominal trauma provided serial close monitoring of patient's clinical signs and hemoglobin is instituted along with the presence of an emergency surgery team.
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Affiliation(s)
- Sourodip Mukharjee
- General Surgery, Kasturba Medical College, Tiger Circle, Madhav Nagar, Manipal, 576104, Karnataka, India.
| | - Dinesh B V
- General Surgery, Kasturba Medical College, Tiger Circle, Madhav Nagar, Manipal, 576104, Karnataka, India
| | - Bharath S V
- General Surgery, Kasturba Medical College, Tiger Circle, Madhav Nagar, Manipal, 576104, Karnataka, India
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Tachino J, Seno S, Matsumoto H, Kitamura T, Hirayama A, Nakao S, Katayama Y, Ogura H, Oda J. Association between tranexamic acid administration and mortality based on the trauma phenotype: a retrospective analysis of a nationwide trauma registry in Japan. Crit Care 2024; 28:89. [PMID: 38504320 PMCID: PMC10953216 DOI: 10.1186/s13054-024-04871-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2023] [Accepted: 03/13/2024] [Indexed: 03/21/2024] Open
Abstract
BACKGROUND In trauma systems, criteria for individualised and optimised administration of tranexamic acid (TXA), an antifibrinolytic, are yet to be established. This study used nationwide cohort data from Japan to evaluate the association between TXA and in-hospital mortality among all patients with blunt trauma based on clinical phenotypes (trauma phenotypes). METHODS A retrospective analysis was conducted using data from the Japan Trauma Data Bank (JTDB) spanning 2019 to 2021. RESULTS Of 80,463 patients with trauma registered in the JTDB, 53,703 met the inclusion criteria, and 8046 (15.0%) received TXA treatment. The patients were categorised into eight trauma phenotypes. After adjusting with inverse probability treatment weighting, in-hospital mortality of the following trauma phenotypes significantly reduced with TXA administration: trauma phenotype 1 (odds ratio [OR] 0.68 [95% confidence interval [CI] 0.57-0.81]), trauma phenotype 2 (OR 0.73 [0.66-0.81]), trauma phenotype 6 (OR 0.52 [0.39-0.70]), and trauma phenotype 8 (OR 0.67 [0.60-0.75]). Conversely, trauma phenotypes 3 (OR 2.62 [1.98-3.47]) and 4 (OR 1.39 [1.11-1.74]) exhibited a significant increase in in-hospital mortality. CONCLUSIONS This is the first study to evaluate the association between TXA administration and survival outcomes based on clinical phenotypes. We found an association between trauma phenotypes and in-hospital mortality, indicating that treatment with TXA could potentially influence this relationship. Further studies are needed to assess the usefulness of these phenotypes.
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Affiliation(s)
- Jotaro Tachino
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, 2-15 Yamada-oka, Suita City, Osaka, Japan.
| | - Shigeto Seno
- Department of Bioinformatic Engineering, Graduate School of Information Science and Technology, Osaka University, 1-5 Yamada-oka, Suita City, Osaka, Japan
| | - Hisatake Matsumoto
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, 2-15 Yamada-oka, Suita City, Osaka, Japan
| | - Tetsuhisa Kitamura
- Division of Environmental Medicine and Population Sciences, Department of Social and Environmental Medicine, Osaka University Graduate School of Medicine, 2-2 Yamada-oka, Suita City, Osaka, Japan
| | - Atsushi Hirayama
- Public Health, Department of Social Medicine, Osaka University Graduate School of Medicine, 2-2 Yamada-oka, Suita City, Osaka, Japan
| | - Shunichiro Nakao
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, 2-15 Yamada-oka, Suita City, Osaka, Japan
| | - Yusuke Katayama
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, 2-15 Yamada-oka, Suita City, Osaka, Japan
| | - Hiroshi Ogura
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, 2-15 Yamada-oka, Suita City, Osaka, Japan
| | - Jun Oda
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, 2-15 Yamada-oka, Suita City, Osaka, Japan
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Cobler-Lichter MD, Delamater JM, Meizoso JP. Lost and found: how missing data connects TXA and outcomes in severely injured patients. Trauma Surg Acute Care Open 2024; 9:e001429. [PMID: 38464550 PMCID: PMC10921536 DOI: 10.1136/tsaco-2024-001429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/12/2024] Open
Affiliation(s)
- Michael D Cobler-Lichter
- DeWitt Daughtry Family Department of Surgery, Ryder Trauma Center, Jackson Memorial Hospital, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Jessica M Delamater
- DeWitt Daughtry Family Department of Surgery, Ryder Trauma Center, Jackson Memorial Hospital, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Jonathan P Meizoso
- DeWitt Daughtry Family Department of Surgery, Ryder Trauma Center, Jackson Memorial Hospital, University of Miami Miller School of Medicine, Miami, Florida, USA
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Culkin MC, Bele P, Georges AP, Santos P, Niziolek G, Kaplan LJ, Smith DH, Pascual JL. Dose-Dependent Tranexamic Acid Blunting of Penumbral Leukocyte Mobilization and Blood-Brain Barrier Permeability Following Traumatic Brain Injury: An In Vivo Murine Study. Neurocrit Care 2024:10.1007/s12028-024-01952-0. [PMID: 38443709 DOI: 10.1007/s12028-024-01952-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Accepted: 01/29/2024] [Indexed: 03/07/2024]
Abstract
BACKGROUND Early posttraumatic brain injury (TBI) tranexamic acid (TXA) may reduce blood-brain barrier (BBB) permeability, but it is unclear if this effect is fixed regardless of dose. We hypothesized that post-TBI TXA demonstrates a dose-dependent reduction of in vivo penumbral leukocyte mobilization, BBB microvascular permeability, and enhancement of neuroclinical recovery. METHODS CD1 male mice (n = 40) were randomly assigned to TBI by controlled cortical impact (injury [I]) or sham TBI (S), followed by intravenous bolus of either saline (placebo [P]) or TXA (15, 30, or 60 mg/kg). At 48 h, in vivo pial intravital microscopy visualized live penumbral BBB microvascular leukocytes and albumin leakage. Neuroclinical recovery was assessed by Garcia Neurological Test scores and animal weight changes at 24 h and 48 h after injury. RESULTS I + TXA60 reduced live penumbral leukocyte rolling compared with I + P (p < 0.001) and both lower TXA doses (p = 0.017 vs. I + TXA15, p = 0.012 vs. I + TXA30). Leukocyte adhesion was infrequent and similar across groups. Only I + TXA60 significantly reduced BBB permeability compared with that in the I + P (p = 0.004) group. All TXA doses improved Garcia Test scores relative to I + P at both 24 h and 48 h (p < 0.001 vs. I + P for all at both time points). Mean 24-h body weight loss was greatest in the I + P (- 8.7 ± 1.3%) group and lowest in the I + TXA15 (- 4.4 ± 1.0%, p = 0.051 vs. I + P) group. CONCLUSIONS Only higher TXA dosing definitively abrogates penumbral leukocyte mobilization, preserving BBB integrity post TBI. Some neuroclinical recovery is observed, even with lower TXA dosing. Better outcomes with higher dose TXA after TBI may occur secondary to blunting of leukocyte-mediated penumbral cerebrovascular inflammation.
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Affiliation(s)
- Matthew C Culkin
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, SICU Administration Office - 5 Founders Pavilion, 3400 Spruce Street, Philadelphia, PA, 19104, USA
- Center for Brain Injury and Repair, Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Priyanka Bele
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, SICU Administration Office - 5 Founders Pavilion, 3400 Spruce Street, Philadelphia, PA, 19104, USA
- Center for Brain Injury and Repair, Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Anastasia P Georges
- Center for Brain Injury and Repair, Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Department of Bioengineering, School of Engineering and Applied Science, University of Pennsylvania, Philadelphia, PA, USA
| | - Patricia Santos
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, SICU Administration Office - 5 Founders Pavilion, 3400 Spruce Street, Philadelphia, PA, 19104, USA
- Center for Brain Injury and Repair, Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Grace Niziolek
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, SICU Administration Office - 5 Founders Pavilion, 3400 Spruce Street, Philadelphia, PA, 19104, USA
| | - Lewis J Kaplan
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, SICU Administration Office - 5 Founders Pavilion, 3400 Spruce Street, Philadelphia, PA, 19104, USA
| | - Douglas H Smith
- Center for Brain Injury and Repair, Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Jose L Pascual
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, SICU Administration Office - 5 Founders Pavilion, 3400 Spruce Street, Philadelphia, PA, 19104, USA.
- Center for Brain Injury and Repair, Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
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Marangoni D, Gemito A, Milan S, Tognetto D. Oral tranexamic acid for acute management of active bleeding from iris microhemangiomatosis: A case report. Am J Ophthalmol Case Rep 2024; 33:102000. [PMID: 38318444 PMCID: PMC10839555 DOI: 10.1016/j.ajoc.2024.102000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 12/24/2023] [Accepted: 01/12/2024] [Indexed: 02/07/2024] Open
Abstract
Purpose to report a case of active intraocular bleeding caused by iris microhemangiomatosis managed with oral tranexamic acid. Observations an 80-year-old male was referred to our emergency department for acute intraocular bleeding. Eye exam showed filiform bleeding arising from a cluster of vascular tufts at the upper pupillary margin, which was consistent with a diagnosis of iris microhemangiomatosis. The bleeding had started 6 hours before and could not be halted by conservative maneuvers such as ocular compression and application of sympathomimetic drops. Oral tranexamic acid 500 mg was administered and led to prompt resolution of the hemorrhage within 60 minutes. The patient was monitored for 3 months and showed no recurrence of the hemorrhage. Conclusion and importance oral tranexamic acid may represent a viable option to manage active intraocular bleeding from iris microhemangiomatosis, facilitating rapid hemorrhage resolution.
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Affiliation(s)
- Dario Marangoni
- Eye Clinic, Department of Medical Surgical Sciences and Health, University of Trieste, 34129, Trieste, Italy
| | - Antonio Gemito
- Eye Clinic, Department of Medical Surgical Sciences and Health, University of Trieste, 34129, Trieste, Italy
| | - Serena Milan
- Eye Clinic, Department of Medical Surgical Sciences and Health, University of Trieste, 34129, Trieste, Italy
| | - Daniele Tognetto
- Eye Clinic, Department of Medical Surgical Sciences and Health, University of Trieste, 34129, Trieste, Italy
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Raska A, Kálmán K, Egri B, Csikós P, Beinrohr L, Szabó L, Tenekedjiev K, Nikolova N, Longstaff C, Roberts I, Kolev K, Wohner N. Synergism of red blood cells and tranexamic acid in the inhibition of fibrinolysis. J Thromb Haemost 2024; 22:794-804. [PMID: 38016517 DOI: 10.1016/j.jtha.2023.11.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 11/13/2023] [Accepted: 11/15/2023] [Indexed: 11/30/2023]
Abstract
BACKGROUND Postpartum hemorrhage (PPH) is the leading cause of maternal death worldwide. The World Maternal Antifibrinolytic trial showed that antifibrinolytic tranexamic acid (TXA) reduces PPH deaths. Maternal anemia increases the risk of PPH. The World Maternal Antifibrinolytic-2 trial is now assessing whether TXA can prevent PPH in women with anemia. Low red blood cell (RBC) counts promote fibrinolysis by altering fibrin structure and plasminogen activation. OBJECTIVES We explored interactions between RBCs and TXA in inhibiting fibrinolysis. METHODS We used global fibrinolytic assays (ball sedimentation and viscoelasticity) to monitor the lysis of fibrin containing plasminogen and tissue-type plasminogen activator. We applied a fluorogenic kinetic assay to measure plasmin generation in fibrin clots and scanning electron microscopy to study fibrin structure. RESULTS According to parallel-line bioassay analysis of the fibrin lysis-time data, the antifibrinolytic potency of 4-128 μM TXA was increased in the presence of 10% to 40% (v/v) RBCs. Global fibrinolysis assays showed that the joint effect of RBCs and TXA was about 15% larger than the sum of their individual effects in the inhibition of fibrinolysis. In plasminogen activation, TXA added the same increment of inhibition to the effect of RBCs at any cell count in the fibrin clot. Regarding fibrin structure, TXA thickened fibrin fibers, which impaired plasminogen activation, whereas RBCs promoted fine fibers that were more resistant to plasmin. CONCLUSIONS The antifibrinolytic potency of TXA is enhanced in fibrin formed in the presence of RBCs through inhibition of plasminogen activation and fibrin lysis, which correlates with modifications of fibrin structures.
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Affiliation(s)
- Alexandra Raska
- Department of Biochemistry and Molecular Biology, Semmelweis University, Budapest, Hungary; HCEMM-SU Thrombosis and Hemostasis Research Group, Department of Biochemistry, Semmelweis University, Budapest, Hungary
| | - Kata Kálmán
- Department of Biochemistry and Molecular Biology, Semmelweis University, Budapest, Hungary; HCEMM-SU Thrombosis and Hemostasis Research Group, Department of Biochemistry, Semmelweis University, Budapest, Hungary
| | - Barnabás Egri
- Department of Biochemistry and Molecular Biology, Semmelweis University, Budapest, Hungary
| | - Petra Csikós
- Department of Biochemistry and Molecular Biology, Semmelweis University, Budapest, Hungary
| | - László Beinrohr
- Department of Biochemistry and Molecular Biology, Semmelweis University, Budapest, Hungary
| | - László Szabó
- Department of Biochemistry and Molecular Biology, Semmelweis University, Budapest, Hungary; Plasma Chemistry Research Group, Institute of Materials and Environmental Chemistry, Research Centre for Natural Sciences, Budapest, Hungary
| | - Kiril Tenekedjiev
- Australian Maritime College, University of Tasmania, Tasmania, Australia; Nikola Vaptsarov Naval Academy, Varna, Bulgaria
| | - Natalia Nikolova
- Defence Science and Technology Group, Edinburgh, Adelaide, Australia; Australian Maritime College, University of Tasmania, Tasmania, Australia
| | - Colin Longstaff
- Biotherapeutics, Haemostasis Section, National Institute for Biological Standards and Control, South Mimms, Potters Bar, United Kingdom
| | - Ian Roberts
- London School Hygiene and Tropical Medicine, Clinical Trials Unit, London, United Kingdom
| | - Krasimir Kolev
- Department of Biochemistry and Molecular Biology, Semmelweis University, Budapest, Hungary
| | - Nikolett Wohner
- Department of Biochemistry and Molecular Biology, Semmelweis University, Budapest, Hungary; HCEMM-SU Thrombosis and Hemostasis Research Group, Department of Biochemistry, Semmelweis University, Budapest, Hungary.
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Lee JH, Ward KR. Blood failure: traumatic hemorrhage and the interconnections between oxygen debt, endotheliopathy, and coagulopathy. Clin Exp Emerg Med 2024; 11:9-21. [PMID: 38018069 PMCID: PMC11009713 DOI: 10.15441/ceem.23.127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2023] [Accepted: 09/28/2023] [Indexed: 11/30/2023] Open
Abstract
This review explores the concept of "blood failure" in traumatic injury, which arises from the interplay of oxygen debt, the endotheliopathy of trauma (EoT), and acute traumatic coagulopathy (ATC). Traumatic hemorrhage leads to the accumulation of oxygen debt, which can further exacerbate hemorrhage by triggering a cascade of events when severe. Such events include EoT, characterized by endothelial glycocalyx damage, and ATC, involving platelet dysfunction, fibrinogen depletion, and dysregulated fibrinolysis. To manage blood failure effectively, a multifaceted approach is crucial. Damage control resuscitation strategies such as use of permissive hypotension, early hemorrhage control, and aggressive transfusion of blood products including whole blood aim to minimize oxygen debt and promote its repayment while addressing endothelial damage and coagulation. Transfusions of red blood cells, plasma, and platelets, as well as the use of tranexamic acid, play key roles in hemostasis and countering ATC. Whole blood, whether fresh or cold-stored, is emerging as a promising option to address multiple needs in traumatic hemorrhage. This review underscores the intricate relationships between oxygen debt, EoT, and ATC and highlights the importance of comprehensive, integrated strategies in the management of traumatic hemorrhage to prevent blood failure. A multidisciplinary approach is essential to address these interconnected factors effectively and to improve patient outcomes.
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Affiliation(s)
- Jae Hyuk Lee
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Kevin R. Ward
- Department of Emergency Medicine, Max Harry Weil Institute for Critical Care Research and Innovation, University of Michigan, Ann Arbor, MI, USA
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, USA
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Goel R, Tiwari G, Varghese M, Bhalla K, Agrawal G, Saini G, Jha A, John D, Saran A, White H, Mohan D. Effectiveness of road safety interventions: An evidence and gap map. CAMPBELL SYSTEMATIC REVIEWS 2024; 20:e1367. [PMID: 38188231 PMCID: PMC10765170 DOI: 10.1002/cl2.1367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/09/2024]
Abstract
Background Road Traffic injuries (RTI) are among the top ten leading causes of death in the world resulting in 1.35 million deaths every year, about 93% of which occur in low- and middle-income countries (LMICs). Despite several global resolutions to reduce traffic injuries, they have continued to grow in many countries. Many high-income countries have successfully reduced RTI by using a public health approach and implementing evidence-based interventions. As many LMICs develop their highway infrastructure, adopting a similar scientific approach towards road safety is crucial. The evidence also needs to be evaluated to assess external validity because measures that have worked in high-income countries may not translate equally well to other contexts. An evidence gap map for RTI is the first step towards understanding what evidence is available, from where, and the key gaps in knowledge. Objectives The objective of this evidence gap map (EGM) is to identify existing evidence from all effectiveness studies and systematic reviews related to road safety interventions. In addition, the EGM identifies gaps in evidence where new primary studies and systematic reviews could add value. This will help direct future research and discussions based on systematic evidence towards the approaches and interventions which are most effective in the road safety sector. This could enable the generation of evidence for informing policy at global, regional or national levels. Search Methods The EGM includes systematic reviews and impact evaluations assessing the effect of interventions for RTI reported in academic databases, organization websites, and grey literature sources. The studies were searched up to December 2019. Selection Criteria The interventions were divided into five broad categories: (a) human factors (e.g., enforcement or road user education), (b) road design, infrastructure and traffic control, (c) legal and institutional framework, (d) post-crash pre-hospital care, and (e) vehicle factors (except car design for occupant protection) and protective devices. Included studies reported two primary outcomes: fatal crashes and non-fatal injury crashes; and four intermediate outcomes: change in use of seat belts, change in use of helmets, change in speed, and change in alcohol/drug use. Studies were excluded if they did not report injury or fatality as one of the outcomes. Data Collection and Analysis The EGM is presented in the form of a matrix with two primary dimensions: interventions (rows) and outcomes (columns). Additional dimensions are country income groups, region, quality level for systematic reviews, type of study design used (e.g., case-control), type of road user studied (e.g., pedestrian, cyclists), age groups, and road type. The EGM is available online where the matrix of interventions and outcomes can be filtered by one or more dimensions. The webpage includes a bibliography of the selected studies and titles and abstracts available for preview. Quality appraisal for systematic reviews was conducted using a critical appraisal tool for systematic reviews, AMSTAR 2. Main Results The EGM identified 1859 studies of which 322 were systematic reviews, 7 were protocol studies and 1530 were impact evaluations. Some studies included more than one intervention, outcome, study method, or study region. The studies were distributed among intervention categories as: human factors (n = 771), road design, infrastructure and traffic control (n = 661), legal and institutional framework (n = 424), post-crash pre-hospital care (n = 118) and vehicle factors and protective devices (n = 111). Fatal crashes as outcomes were reported in 1414 records and non-fatal injury crashes in 1252 records. Among the four intermediate outcomes, speed was most commonly reported (n = 298) followed by alcohol (n = 206), use of seatbelts (n = 167), and use of helmets (n = 66). Ninety-six percent of the studies were reported from high-income countries (HIC), 4.5% from upper-middle-income countries, and only 1.4% from lower-middle and low-income countries. There were 25 systematic reviews of high quality, 4 of moderate quality, and 293 of low quality. Authors' Conclusions The EGM shows that the distribution of available road safety evidence is skewed across the world. A vast majority of the literature is from HICs. In contrast, only a small fraction of the literature reports on the many LMICs that are fast expanding their road infrastructure, experiencing rapid changes in traffic patterns, and witnessing growth in road injuries. This bias in literature explains why many interventions that are of high importance in the context of LMICs remain poorly studied. Besides, many interventions that have been tested only in HICs may not work equally effectively in LMICs. Another important finding was that a large majority of systematic reviews are of low quality. The scarcity of evidence on many important interventions and lack of good quality evidence-synthesis have significant implications for future road safety research and practice in LMICs. The EGM presented here will help identify priority areas for researchers, while directing practitioners and policy makers towards proven interventions.
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Affiliation(s)
- Rahul Goel
- Transportation Research and Injury Prevention CentreIndian Institute of Technology DelhiNew DelhiIndia
| | - Geetam Tiwari
- Transportation Research and Injury Prevention CentreIndian Institute of Technology DelhiNew DelhiIndia
| | | | - Kavi Bhalla
- Department of Public Health SciencesUniversity of ChicagoChicagoIllinoisUSA
| | - Girish Agrawal
- Transportation Research and Injury Prevention CentreIndian Institute of Technology DelhiNew DelhiIndia
| | | | - Abhaya Jha
- Transportation Research and Injury Prevention CentreIndian Institute of Technology DelhiNew DelhiIndia
| | - Denny John
- Faculty of Life and Allied Health SciencesM S Ramaiah University of Applied Sciences, BangaloreKarnatakaIndia
| | | | | | - Dinesh Mohan
- Transportation Research and Injury Prevention CentreIndian Institute of Technology DelhiNew DelhiIndia
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LaGrone LN, Stein D, Cribari C, Kaups K, Harris C, Miller AN, Smith B, Dutton R, Bulger E, Napolitano LM. American Association for the Surgery of Trauma/American College of Surgeons Committee on Trauma: Clinical protocol for damage-control resuscitation for the adult trauma patient. J Trauma Acute Care Surg 2024; 96:510-520. [PMID: 37697470 DOI: 10.1097/ta.0000000000004088] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/13/2023]
Abstract
ABSTRACT Damage-control resuscitation in the care of critically injured trauma patients aims to limit blood loss and prevent and treat coagulopathy by combining early definitive hemorrhage control, hypotensive resuscitation, and early and balanced use of blood products (hemostatic resuscitation) and the use of other hemostatic agents. This clinical protocol has been developed to provide evidence-based recommendations for optimal damage-control resuscitation in the care of trauma patients with hemorrhage.
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Affiliation(s)
- Lacey N LaGrone
- From the Department of Surgery (D.S.), University of Maryland, Baltimore, Maryland; Department of Surgery (L.N.L., C.C.), UCHealth, Loveland, Colorado; Department of Surgery (K.K), University of California San Francisco Fresno, San Francisco, California; Department of Surgery (C.H.), Tulane University, New Orleans, Louisiana; Orthopedic Surgery (A.N.M.), Washington University in St. Louis, St. Louis, Missouri; Department of Surgery (B.S.), University of Pennsylvania, Philadelphia, Pennsylvania; American Society of Anesthesiologists (R.D.), Anesthesia, Waco, Texas; Department of Surgery (E.B.), University of Washington, Seattle, Washington; and Department of Surgery (L.M.N.), University of Michigan, Ann Arbor, Michigan
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43
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Richards JE, Stein DM, Scalea TM. Damage Control Resuscitation in Traumatic Hemorrhage: It Is More Than Fixing the Holes and Filling the Tank. Anesthesiology 2024; 140:586-598. [PMID: 37982159 DOI: 10.1097/aln.0000000000004750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2023]
Abstract
Damage control resuscitation is the foundation of hemorrhagic shock management and includes early administration of plasma, tranexamic acid, and limited crystalloid-containing products.
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Affiliation(s)
- Justin E Richards
- Department of Anesthesiology, University of Maryland School of Medicine; Program in Trauma, R Adams Cowley Shock Trauma Center, Baltimore, Maryland
| | - Deborah M Stein
- Department of Surgery, University of Maryland School of Medicine; Program in Trauma, R Adams Cowley Shock Trauma Center, Baltimore, Maryland
| | - Thomas M Scalea
- Department of Surgery, University of Maryland School of Medicine; Program in Trauma, R Adams Cowley Shock Trauma Center, Baltimore, Maryland
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44
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McQuilten ZK, Wood EM, Medcalf RL. When to use tranexamic acid for the treatment of major bleeding? J Thromb Haemost 2024; 22:581-593. [PMID: 37827378 DOI: 10.1016/j.jtha.2023.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Revised: 08/15/2023] [Accepted: 10/02/2023] [Indexed: 10/14/2023]
Abstract
Tranexamic acid (TXA) is an antifibrinolytic agent originally developed for the management of bleeding in the setting of postpartum hemorrhage (PPH). Over the last 15 years, there has been accumulating evidence on the use of TXA for the treatment of active bleeding in a variety of clinical contexts. Clinical trials have shown that the efficacy and safety of TXA for the treatment of bleeding differ according to the clinical context in which it is being administered, timing of administration, and dose. Early administration is important for efficacy, particularly in trauma and PPH. Further studies are needed to understand the mechanisms by which TXA provides benefit, optimal modes of administration and dosing, and its effect in some clinical settings, such as spontaneous intracerebral hemorrhage. There is no evidence that TXA increases the risk of thrombotic events in patients with major bleeding overall. However, there is evidence of increased risk of venous thrombosis in patients with gastrointestinal bleeding. There is also evidence of increased risk of seizures with the use of higher doses. This review summarizes the current evidence for the use of TXA for patients with active bleeding and highlights the importance of generating evidence of efficacy and safety of hemostatic interventions specific to the bleeding contexts-as findings from 1 clinical setting may not be generalizable to other contexts-and that of individual patient assessment for bleeding, thrombotic, and other risks, as well as important logistical and other practical considerations, to optimize care and outcomes in these settings.
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Affiliation(s)
- Zoe K McQuilten
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia; Department of Haematology, Monash Health, Melbourne, Victoria, Australia.
| | - Erica M Wood
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia; Department of Haematology, Monash Health, Melbourne, Victoria, Australia
| | - Robert L Medcalf
- Central Clinical School, Australian Centre for Blood Diseases, Monash University, Melbourne, Victoria, Australia
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45
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Facchetti G, Facchetti M, Schmal M, Lee R, Fiorelli S, Marzano TF, Lupi C, Daminelli F, Sbrana G, Massullo D, Marinangeli F. Prehospital Blood Transfusion in Helicopter Emergency Medical Services: An Italian Survey. Air Med J 2024; 43:140-145. [PMID: 38490777 DOI: 10.1016/j.amj.2023.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 10/17/2023] [Accepted: 11/12/2023] [Indexed: 03/17/2024]
Abstract
OBJECTIVE Hemorrhage remains the most common cause of preventable death after trauma. Prehospital blood product (PHBP) administration may improve outcomes. No data are available about PHBP use in Italian helicopter emergency medical services (HEMS). The primary aim of this survey was to establish the degree of PHBP used throughout Italy. The secondary aims were to evaluate the main indications for their use, the opinions about PHBPs, and users' experience. METHODS The study group performed a telephone/e-mail survey of all 56 Italian HEMS bases. The questions concerned whether PHBPs were used in their HEMS bases, the frequency of transfusions, the PHBP used, and the perceived benefits. RESULTS Four of 56 HEMS bases use PHBPs. Overall, 7% have prehospital access to packed red cells and only 1 to fresh plasma. In addition to blood product administration, 4 of 4 use tranexamic acid, and 3 of 4 also use fibrinogen. Seventy-five percent use PHBPs once a month and 25% once a week. The users' experience was that PHBPs are beneficial and lifesaving. CONCLUSION Only 4 of 56 HEMS in Italy use PHBPs. There is an absolute consensus among providers on the benefit of PHBPs despite the lack of evidence on PHBP use.
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Affiliation(s)
| | - Marilisa Facchetti
- Department Anesthesiology and Critical Care, University of L'Aquila, L'Aquila, Italy
| | - Mariette Schmal
- Jeugdgezondheidszorg Zuid-Holland West, Zoetermeer, Netherlands
| | - Ronan Lee
- European Patent Office, Team Surgery, Rijswijk, Netherlands
| | - Silvia Fiorelli
- Anesthesia and Intensive Care Medicine, Department of Clinical and Surgical Translational Medicine, Sant'Andrea Hospital, Sapienza University of Rome, Rome, Italy.
| | | | - Cristian Lupi
- HEMS Bologna, Department of Anesthesia, Intensive Care and Prehospital Emergency, Maggiore Hospital Carlo Alberto Pizzardi, Azienda Unità Sanitaria Locale Bologna, Bologna, Italy
| | - Francesco Daminelli
- HEMS Bergamo, Papa Giovanni XXIII Hospital, Agenzia Regionale Emergenza Urgenza Lombardia, Bergamo, Italy
| | - Giovanni Sbrana
- HEMS Grosseto, Emergency Department, Azienda Sanitaria Locale Toscana Sud Est, Grosseto, Italy
| | - Domenico Massullo
- Anesthesia and Intensive Care Medicine, Department of Clinical and Surgical Translational Medicine, Sant'Andrea Hospital, Sapienza University of Rome, Rome, Italy
| | - Franco Marinangeli
- Department Anesthesiology and Critical Care, University of L'Aquila, L'Aquila, Italy
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Madden K, Adili A. Cochrane in CORR ®: Pharmacological Interventions for the Prevention of Bleeding in People Undergoing Definitive Fixation or Joint Replacement for Hip, Pelvic and Long Bone Fractures. Clin Orthop Relat Res 2024; 482:423-430. [PMID: 38334435 PMCID: PMC10871791 DOI: 10.1097/corr.0000000000002987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Accepted: 01/04/2024] [Indexed: 02/10/2024]
Affiliation(s)
- Kim Madden
- Department of Surgery, McMaster University, Hamilton, Ontario, Canada
- Research Institute of St. Joseph’s Hamilton, Hamilton, Ontario, Canada
| | - Anthony Adili
- Department of Surgery, McMaster University, Hamilton, Ontario, Canada
- Research Institute of St. Joseph’s Hamilton, Hamilton, Ontario, Canada
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47
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Simovic MO, Bynum J, Liu B, Dalle Lucca JJ, Li Y. Impact of Immunopathy and Coagulopathy on Multi-Organ Failure and Mortality in a Lethal Porcine Model of Controlled and Uncontrolled Hemorrhage. Int J Mol Sci 2024; 25:2500. [PMID: 38473750 DOI: 10.3390/ijms25052500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Revised: 02/07/2024] [Accepted: 02/14/2024] [Indexed: 03/14/2024] Open
Abstract
Uncontrolled hemorrhage is a major preventable cause of death in patients with trauma. However, the majority of large animal models of hemorrhage have utilized controlled hemorrhage rather than uncontrolled hemorrhage to investigate the impact of immunopathy and coagulopathy on multi-organ failure (MOF) and mortality. This study evaluates these alterations in a severe porcine controlled and uncontrolled hemorrhagic shock (HS) model. Anesthetized female swine underwent controlled hemorrhage and uncontrolled hemorrhage by partial splenic resection followed with or without lactated Ringer solution (LR) or Voluven® resuscitation. Swine were surveyed 6 h after completion of splenic hemorrhage or until death. Blood chemistry, physiologic variables, systemic and tissue levels of complement proteins and cytokines, coagulation parameters, organ function, and damage were recorded and assessed. HS resulted in systemic and local complement activation, cytokine release, hypocoagulopathy, metabolic acidosis, MOF, and no animal survival. Resuscitation with LR and Voluven® after HS improved hemodynamic parameters (MAP and SI), metabolic acidosis, hyperkalemia, and survival but resulted in increased complement activation and worse coagulopathy. Compared with the LR group, the animals with hemorrhagic shock treated with Voluven® had worse dilutional anemia, coagulopathy, renal and hepatic dysfunction, increased myocardial complement activation and renal damage, and decreased survival rate. Hemorrhagic shock triggers early immunopathy and coagulopathy and appears associated with MOF and death. This study indicates that immunopathy and coagulopathy are therapeutic targets that may be addressed with a high-impact adjunctive treatment to conventional resuscitation.
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Affiliation(s)
- Milomir O Simovic
- US Army Institute of Surgical Research, Fort Sam Houston, TX 78234, USA
- The Geneva Foundation, Tacoma, WA 98402, USA
- Department of Surgery, University of Texas Health Science Center at San Antonio, San Antonio, TX 78229, USA
| | - James Bynum
- US Army Institute of Surgical Research, Fort Sam Houston, TX 78234, USA
- Department of Surgery, University of Texas Health Science Center at San Antonio, San Antonio, TX 78229, USA
| | - Bin Liu
- US Army Institute of Surgical Research, Fort Sam Houston, TX 78234, USA
| | | | - Yansong Li
- US Army Institute of Surgical Research, Fort Sam Houston, TX 78234, USA
- The Geneva Foundation, Tacoma, WA 98402, USA
- Department of Surgery, University of Texas Health Science Center at San Antonio, San Antonio, TX 78229, USA
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Strilchuk AW, Hur WS, Batty P, Sang Y, Abrahams SR, Yong ASM, Leung J, Silva LM, Schroeder JA, Nesbitt K, de Laat B, Moutsopoulos NM, Bugge TH, Shi Q, Cullis PR, Merricks EP, Wolberg AS, Flick MJ, Lillicrap D, Nichols TC, Kastrup CJ. Lipid nanoparticles and siRNA targeting plasminogen provide lasting inhibition of fibrinolysis in mouse and dog models of hemophilia A. Sci Transl Med 2024; 16:eadh0027. [PMID: 38381848 DOI: 10.1126/scitranslmed.adh0027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Accepted: 01/31/2024] [Indexed: 02/23/2024]
Abstract
Antifibrinolytic drugs are used extensively for on-demand treatment of severe acute bleeding. Controlling fibrinolysis may also be an effective strategy to prevent or lessen chronic recurring bleeding in bleeding disorders such as hemophilia A (HA), but current antifibrinolytics have unfavorable pharmacokinetic profiles. Here, we developed a long-lasting antifibrinolytic using small interfering RNA (siRNA) targeting plasminogen packaged in clinically used lipid nanoparticles (LNPs) and tested it to determine whether reducing plasmin activity in animal models of HA could decrease bleeding frequency and severity. Treatment with the siRNA-carrying LNPs reduced circulating plasminogen and suppressed fibrinolysis in wild-type and HA mice and dogs. In HA mice, hemostatic efficacy depended on the injury model; plasminogen knockdown improved hemostasis after a saphenous vein injury but not tail vein transection injury, suggesting that saphenous vein injury is a murine bleeding model sensitive to the contribution of fibrinolysis. In dogs with HA, LNPs carrying siRNA targeting plasminogen were as effective at stabilizing clots as tranexamic acid, a clinical antifibrinolytic, and in a pilot study of two dogs with HA, the incidence of spontaneous or excess bleeding was reduced during 4 months of prolonged knockdown. Collectively, these data demonstrate that long-acting antifibrinolytic therapy can be achieved and that it provides hemostatic benefit in animal models of HA.
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Affiliation(s)
- Amy W Strilchuk
- Michael Smith Laboratories, University of British Columbia, Vancouver V6T 1Z4, Canada
- Department of Biochemistry and Molecular Biology, University of British Columbia, Vancouver V6T 2A1, Canada
| | - Woosuk S Hur
- Department of Pathology and Laboratory Medicine and UNC Blood Research Center, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Paul Batty
- Department of Pathology and Molecular Medicine, Queen's University, Kingston, ON K7L 3N6, Canada
| | - Yaqiu Sang
- Department of Pathology and Laboratory Medicine and UNC Blood Research Center, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Sara R Abrahams
- Department of Pathology and Laboratory Medicine and UNC Blood Research Center, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Alyssa S M Yong
- Michael Smith Laboratories, University of British Columbia, Vancouver V6T 1Z4, Canada
| | - Jerry Leung
- Michael Smith Laboratories, University of British Columbia, Vancouver V6T 1Z4, Canada
- Department of Biochemistry and Molecular Biology, University of British Columbia, Vancouver V6T 2A1, Canada
| | - Lakmali M Silva
- National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD 20892, USA
| | - Jocelyn A Schroeder
- Blood Research Institute, Versiti, Milwaukee, WI 53226, USA
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI 53226, USA
| | - Kate Nesbitt
- Department of Pathology and Molecular Medicine, Queen's University, Kingston, ON K7L 3N6, Canada
| | - Bas de Laat
- Synapse Research Institute, Maastricht 6217 KM, Netherlands
| | - Niki M Moutsopoulos
- National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD 20892, USA
| | - Thomas H Bugge
- National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD 20892, USA
| | - Qizhen Shi
- Blood Research Institute, Versiti, Milwaukee, WI 53226, USA
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI 53226, USA
| | - Pieter R Cullis
- Department of Biochemistry and Molecular Biology, University of British Columbia, Vancouver V6T 2A1, Canada
| | - Elizabeth P Merricks
- Department of Pathology and Laboratory Medicine and UNC Blood Research Center, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Alisa S Wolberg
- Department of Pathology and Laboratory Medicine and UNC Blood Research Center, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Matthew J Flick
- Department of Pathology and Laboratory Medicine and UNC Blood Research Center, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - David Lillicrap
- Department of Pathology and Molecular Medicine, Queen's University, Kingston, ON K7L 3N6, Canada
| | - Timothy C Nichols
- Department of Pathology and Laboratory Medicine and UNC Blood Research Center, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Christian J Kastrup
- Michael Smith Laboratories, University of British Columbia, Vancouver V6T 1Z4, Canada
- Department of Biochemistry and Molecular Biology, University of British Columbia, Vancouver V6T 2A1, Canada
- Blood Research Institute, Versiti, Milwaukee, WI 53226, USA
- Departments of Surgery, Biochemistry, Biomedical Engineering, and Pharmacology and Toxicology, Medical College of Wisconsin, Milwaukee, WI 53226, USA
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Fitschen-Oestern S, Franke GM, Kirsten N, Lefering R, Lippross S, Schröder O, Klüter T, Müller M, Seekamp A. Does tranexamic acid have a positive effect on the outcome of older multiple trauma patients on antithrombotic drugs? An analysis using the TraumaRegister DGU ®. Front Med (Lausanne) 2024; 11:1324073. [PMID: 38444412 PMCID: PMC10912612 DOI: 10.3389/fmed.2024.1324073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Accepted: 01/22/2024] [Indexed: 03/07/2024] Open
Abstract
BackgroundAcute hemorrhage is one of the most common causes of death in multiple trauma patients. Due to physiological changes, pre-existing conditions, and medication, older trauma patients are more prone to poor prognosis. Tranexamic acid (TXA) has been shown to be beneficial in multiple trauma patients with acute hemorrhage in general. The relation of tranexamic acid administration on survival in elderly trauma patients with pre-existing anticoagulation is the objective of this study. Therefore, we used the database of the TraumaRegister DGU® (TR-DGU), which documents data on severely injured trauma patients.MethodsIn this retrospective analysis, we evaluated the TR-DGU data from 16,713 primary admitted patients with multiple trauma and age > =50 years from 2015 to 2019. Patients with pre-existing anticoagulation and TXA administration (996 patients, 6%), pre-existing anticoagulation without TXA administration (4,807 patients, 28.8%), without anticoagulation as premedication but TXA administration (1,957 patients, 11.7%), and without anticoagulation and TXA administration (8,953 patients, 53.6%) were identified. A regression analysis was performed to investigate the influence of pre-existing antithrombotic drugs and TXA on mortality. A propensity score was created in patients with pre-existing anticoagulation, and matching was performed for better comparability of patients with and without TXA administration.ResultsRetrospective trauma patients who underwent tranexamic acid administration were older and had a higher ISS than patients without tranexamic acid donation. Predicted mortality (according to the RISC II Score) and observed mortality were higher in the group with tranexamic acid administration. The regression analysis showed that TXA administration was associated with lower mortality rates within the first 24 h in older patients with anticoagulation as premedication. The propensity score analysis referred to higher fluid requirement, higher requirement of blood transfusion, and longer hospital stay in the group with tranexamic acid administration. There was no increase in complications. Despite higher transfusion volumes, the tranexamic acid group had a comparable all-cause mortality rate.ConclusionTXA administration in older trauma patients is associated with a reduced 24-h mortality rate after trauma, without increased risk of thromboembolic events. There is no relationship between tranexamic acid and overall mortality in patients with anticoagulation as premedication. Considering pre-existing anticoagulation, tranexamic acid may be recommended in elderly trauma patients with acute bleeding.
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Affiliation(s)
| | - Georg Maximilian Franke
- Department of Trauma Surgery, University Medical Center of Schleswig-Holstein, Kiel, Germany
| | - Nora Kirsten
- Department of Trauma Surgery, Hannover Medical School, Hannover, Germany
| | - Rolf Lefering
- Institute for Research in Operative Medicine (IFOM), University Witten/Herdecke, Cologne, Germany
| | - Sebastian Lippross
- Department of Trauma Surgery, University Medical Center of Schleswig-Holstein, Kiel, Germany
| | - Ove Schröder
- Department of Trauma Surgery, University Medical Center of Schleswig-Holstein, Kiel, Germany
| | - Tim Klüter
- Department of Trauma Surgery, University Medical Center of Schleswig-Holstein, Kiel, Germany
| | - Michael Müller
- Department of Trauma Surgery, University Medical Center of Schleswig-Holstein, Kiel, Germany
| | - Andreas Seekamp
- Department of Trauma Surgery, University Medical Center of Schleswig-Holstein, Kiel, Germany
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50
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Franchini M, Focosi D, Mannucci PM. Tranexamic Acid: An Evergreen Hemostatic Agent. Semin Thromb Hemost 2024. [PMID: 38335995 DOI: 10.1055/s-0044-1779632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/12/2024]
Abstract
Tranexamic acid (TXA) is an important antifibrinolytic agent, which inhibits plasminogen activation and fibrinolysis. Several controlled randomized trials have investigated the role of TXA in preventing or decreasing blood loss across different surgical interventions or medical conditions characterized by excessive bleeding, consistently documenting its effectiveness and safety. Although the first clinical use of TXA dates back to more than 60 years ago, TXA remains the focus of intense research. This narrative review summarizes the more recent results and indications on the clinical use of TXA.
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Affiliation(s)
- Massimo Franchini
- Department of Transfusion Medicine and Hematology, Carlo Poma Hospital, Mantua, Italy
| | - Daniele Focosi
- North-Western Tuscany Blood Bank, Pisa University Hospital, Italy
| | - Pier Mannuccio Mannucci
- Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico and University of Milan, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy
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