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Krishna G, Aggarwal V, Singh I. Prospective Analysis of Coagulopathy Associated with Isolated Traumatic Brain Injury and Clinical Outcome. INDIAN JOURNAL OF NEUROSURGERY 2021. [DOI: 10.1055/s-0041-1728989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
Abstract
Introduction Traumatic brain injury (TBI) affects the coagulation pathway in a distinct way than does extracranial trauma. The extent of coagulation abnormalities varies from bleeding diathesis to disseminated thrombosis.
Design Prospective study.
Methods The study included 50 patients of isolated TBI with cohorts of moderate (MHI) and severe head injury (SHI). Coagulopathy was graded according to the values of parameters in single laboratory. The incidence of coagulopathy according to the severity of TBI and correlation with disseminated intravascular coagulation (DIC) score, platelets, prothrombin time (PT), activated partial thromboplastin time (APTT), D-dimer, and fibrinogen was observed. The comparison was also made between expired and discharged patients within each group. It also compared coagulation derailments with clinical presentation (Glasgow Coma Scale [GCS]) and outcome (Glasgow Outcome Scale [GOS]).
Results Road traffic accident was the primary (72%) mode of injury. Fifty-two percent had MHI and rest had SHI. Eighty-four percent of cases were managed conservatively. The mean GCS was 12.23 and 5.75 in MHI and SHI, respectively. Sixty-two percent of MHI and 96% of the patients with SHI had coagulation abnormalities. On statistical analysis, DIC score (p < 0.001) strongly correlated with the severity of head injury and GOS. PT and APTT were also significantly associated with the severity of TBI. In patients with moderate TBI, D-dimer and platelet counts showed association with clinical outcome. Fibrinogen levels did not show any statistical significance. The mean platelet counts remained normal in both the groups of TBI. The mean GOS was 1.54 and 4.62 in SHI and MHI, respectively.
Conclusion Coagulopathy is common in isolated TBI. The basic laboratory parameters are reliable predictors of coagulation abnormalities in TBI. Coagulopathy is directly associated with the severity of TBI, GCS, and poor outcome.
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Affiliation(s)
- Gopal Krishna
- Department of Neurosurgery, Pt. B.D. Sharma Postgraduate Institute of Medical Sciences, Rohtak, Haryana, India
| | - Varun Aggarwal
- Department of Neurosurgery, Pt. B.D. Sharma Postgraduate Institute of Medical Sciences, Rohtak, Haryana, India
| | - Ishwar Singh
- Department of Neurosurgery, Pt. B.D. Sharma Postgraduate Institute of Medical Sciences, Rohtak, Haryana, India
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Overresuscitation with plasma is associated with sustained fibrinolysis shutdown and death in pediatric traumatic brain injury. J Trauma Acute Care Surg 2019; 85:12-17. [PMID: 29443859 DOI: 10.1097/ta.0000000000001836] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Elevated International Normalized Ratio (INR) is a marker of poor outcome but not necessarily bleeding or clinical coagulopathy in injured children. Conversely, children with traumatic brain injury (TBI) tend to be hypercoagulable based on rapid thromboelastography (rTEG) parameters. Many clinicians continue to utilize INR as a treatment target. METHODS Prospective observational study of severely injured children age < 18 with rTEG on arrival and daily thereafter for up to 7 days. Standard rTEG definitions of hyperfibrinolysis (LY30 ≥ 3), fibrinolysis shutdown (SD) (LY30 ≤ 0.8), and normal (LY30 = 0.9-2.9) were applied. The first 24-hour blood product transfusion volumes were documented. Abbreviated Injury Scale score ≥ 3 defined severe TBI. Sustained SD was defined as two consecutive rTEG with SD and no subsequent normalization. Primary outcomes were death and functional disability, based on functional independence measure score assessed at discharge. RESULTS One hundred one patients were included: median age, 8 years (interquartile range, 4-12 years); Injury Severity Score, 25 (16-30); 72% blunt mechanism; 47% severe TBI; 16% mortality; 45% discharge disability. Neither total volume nor any single product volume transfused (mL/kg; all p > 0.1) differed between TBI and non-TBI groups. On univariate analysis, transfusion of packed red blood cells (p = 0.016), plasma (p < 0.001), and platelets (p = 0.006) were associated with sustained SD; however, in a regression model that included all products (mL/kg) and controlled for severe TBI (head Abbreviated Injury Scale score ≥ 3), admission INR, polytrauma, and clinical bleeding, only plasma remained an independent predictor of sustained SD (odds ratio, 1.17; p = 0.031). Patients with both severe TBI and plasma transfusion had 100% sustained SD, 75% mortality, and 100% disability in survivors. Admission INR was elevated in TBI patients, but did not correlate with rTEG activated clotting time (p = NS) and was associated with sustained SD (p = 0.006). CONCLUSION Plasma transfusion is independently associated with sustained fibrinolysis SD. Severe TBI is also associated with sustained SD; the combined effect of plasma transfusion and severe TBI is associated with extremely poor prognosis. Plasma transfusion should not be targeted to INR thresholds but rather to rTEG activated clotting time and clinical bleeding. LEVEL OF EVIDENCE Prognostic and epidemiological study, level III.
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Goyal K, Hazarika A, Khandelwal A, Sokhal N, Bindra A, Kumar N, Kedia S, Rath GP. Non- Neurological Complications after Traumatic Brain Injury: A Prospective Observational Study. Indian J Crit Care Med 2018; 22:632-638. [PMID: 30294128 PMCID: PMC6161576 DOI: 10.4103/ijccm.ijccm_156_18] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Introduction and Aims Recognizing and treating nonneurological complications occurring in traumatic brain injury (TBI) patients during intensive care unit (ICU) stay are challenging. The aim is to estimate various nonneurological complications in TBI patients. The secondary aim is to see the effect of these complications on ICU stay, disability, and mortality. Materials and Methods This was a prospective observational study at the neuro-ICU of a Level-I trauma center. A total of 154 TBI patients were enrolled. The period of the study was from admission to discharge from ICU or demise. Inclusion criteria were patients aged >16 years and patients with severe TBI (Glasgow coma score [GCS] ≤8). Nonneurological complications were frequent in TBI patients. Results We observed respiratory complications to be the most common (61%). Other complications, in the decreasing order, included dyselectrolytemia (46.1%), cardiovascular (34.4%), coagulopathy (33.1%), sepsis (26%), abdominal complications (17.5%), and acute kidney injury (AKI, 3.9%). The presence of systemic complications except AKI was found to be significantly associated with increased ICU stay. Most of the patients of AKI died early in ICU. Respiratory dysfunction was found to be independently associated with 3.05 times higher risk of worsening clinical condition (disability) (P < 0.018). The presence of cardiovascular complications during ICU stay (4.2 times, P < 0.005), AKI (24.7 times, P < 0.02), coagulopathy (3.13 times, P < 0.047), and GCS <6 (4.2 times, P < 0.006) of TBI was independently associated with significantly increased risk of ICU mortality. Conclusion TBI patients tend to have poor outcome due to concomitant nonneurological complications. These have significant bearing on ICU stay, disability, and mortality.
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Affiliation(s)
- Keshav Goyal
- Department of Neuroanaesthesiology and Critical Care, Jai Prakash Narayan Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Amarjyoti Hazarika
- Department of Anaesthesiology and Intensive Care, PGIMER, Chandigarh, India
| | - Ankur Khandelwal
- Department of Neuroanaesthesiology and Critical Care, Jai Prakash Narayan Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Navdeep Sokhal
- Department of Neuroanaesthesiology and Critical Care, Jai Prakash Narayan Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Ashish Bindra
- Department of Neuroanaesthesiology and Critical Care, Jai Prakash Narayan Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Niraj Kumar
- Department of Neuroanaesthesiology and Critical Care, Jai Prakash Narayan Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Shweta Kedia
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | - Girija P Rath
- Department of Neuroanaesthesiology and Critical Care, Jai Prakash Narayan Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
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Shrestha A, Joshi RM, Devkota UP. Contributing Factors for Coagulopathy in Traumatic Brain Injury. Asian J Neurosurg 2017; 12:648-652. [PMID: 29114277 PMCID: PMC5652089 DOI: 10.4103/ajns.ajns_192_14] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Context In traumatic brain injury patients, coagulation disorder causes secondary brain injury, thereby increasing mortality and morbidity. Aims The aim of this study is to identify the factors responsible for coagulopathy in traumatic brain injury. Settings and Design This prospective longitudinal study from June 2012 included 100 patients with moderate and severe head injury presenting to National Institute of Neurological and Allied Sciences, Kathmandu, over 1-year period. Subjects and Methods Patients were evaluated for the development of coagulopathy, defined as collectively three abnormal hemostatic parameters, and associated risk factors for coagulopathy. They were then analyzed for correlation with coagulopathy. Statistical Analysis Used SPSS version 16 was used for the analysis of data. For identification of contributing factors, a stepwise logistic regression analysis was performed, including the factors with P < 0.05 from the analysis. Results Among the 100 patients, coagulopathy was present in 63% of cohort. Forty-three patients had severe head injury, and 76.7% (n = 33) of them had coagulopathy compared to 52.7% (n = 30) in 57 patients with moderate head injury (P = 0.013). Statistically significant correlation with coagulopathy was present with polytrauma, severity of head injury, blood transfusion, surgical intervention, and Marshall's classification of CT of the head; however, stepwise logistic regression analysis showed that blood transfusion, surgical intervention, polytrauma, and severity of head injury were significant independent variables responsible for the development of coagulopathy. Conclusions Traumatic brain injury is complicated with coagulopathy in up to 63% of patients. Blood transfusion, surgical intervention, polytrauma, and severity of head injury are significant independent variables responsible for coagulopathy.
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Affiliation(s)
- Ajit Shrestha
- Department of Surgery, Neurosurgery Unit, Chitwan Medical College, Bharatpur, Nepal
| | - Ramesh Man Joshi
- Department of Neurological Surgery, National Institute of Neurological and Allied Sciences, Kathmandu, Nepal
| | - Upendra Prasad Devkota
- Department of Neurological Surgery, National Institute of Neurological and Allied Sciences, Kathmandu, Nepal
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Gupta G, Wadhwa C, Garg R, Dhaiya RS, Kaushal RK. Impact of Coagulation Profile on Outcome of Head Injury. J Clin Diagn Res 2016; 10:PC04-6. [PMID: 26894120 PMCID: PMC4740648 DOI: 10.7860/jcdr/2016/14638.7029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2015] [Accepted: 09/25/2015] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Worldwide, head injury is recognized as a major public health problem. Head injury patients often develop consumptive coagulopathy in the absence of other trauma or haemorrhages. The release of tissue factor from the damaged brain is postulated as the cause of coagulopathy. AIM To know the impact of coagulation profile derangements and their effect on the outcome of head injury patients. MATERIALS AND METHODS Fifty patients in the age group of 20-70 years admitted with isolated head injury were taken. Samples of complete haemogram (CBC), prothrombin time (PTI), partial thromboplastin time (PTK), D-Dimers and fibrinogen were taken within 24 hour of admission. Coagulopathy was defined as platelet counts < 100,000 cells/mm(2) and PTI >15 seconds or a DIC score more than 4. The outcome in each group was measured according to Glasgow outcome score. Coagulation abnormalities were analysed. RESULTS In case of severe head injury, p-values in patients who died with regard to DIC score, Prothrombin time and APTT were found to be significant (p< 0.05). For D-Dimers, fibrinogen and platelets counts the p-value was not significant. In case of moderate head injury, p-values in patients who died with regard to DIC score, platelet count, Prothrombin time, D-Dimer and APTT were found to be significant (0.05). For fibrinogen level it was insignificant. The mean DIC score and mean GOS in the severe head injury patients was significant (p<0.001). CONCLUSION Patients with isolated head injury are at risk of development of coagulation abnormalities, which is associated with poor outcome. Based on our results we also emphasize the importance of early diagnosis of coagulation abnormalities in isolated head injury patients.
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Affiliation(s)
- Gulzar Gupta
- Associate Professor, Department of Neurosurgery, Dayanand Medical College & Hospital, Ludhiana, Punjab, India
| | - Chetan Wadhwa
- Senior Resident, Department of Neurosurgery, Dayanand Medical College & Hospital, Ludhiana, Punjab, India
| | - Rajveer Garg
- Senior Resident, Department of Neurosurgery, Dayanand Medical College & Hospital, Ludhiana Punjab, India
| | - Ranbir S Dhaiya
- Ex Professor, Department of Surgery, PGIMS, Rohtak, Haryana, India
| | - Rakesh K Kaushal
- Professor and Head, Department of Neurosurgery, Dayanand Medical College & Hospital, Ludhiana, Punjab, India
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Schoeneberg C, Schilling M, Keitel J, Burggraf M, Hussmann B, Lendemans S. Mortality in severely injured children: experiences of a German level 1 trauma center (2002 - 2011). BMC Pediatr 2014; 14:194. [PMID: 25074319 PMCID: PMC4121010 DOI: 10.1186/1471-2431-14-194] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2014] [Accepted: 07/22/2014] [Indexed: 11/30/2022] Open
Abstract
Background Trauma in pediatric patients is a major cause of death. This study investigated differences between decedents and survivors. Furthermore, an analysis of preventable and potential preventable trauma deaths was conducted and errors in the acute trauma care were investigated. Methods All patients aged less than 16 years with an Injury Severity Score (ISS) ≥ 16 upon primary admission to the hospital between July 2002 and December 2011 were included in this study. Decedents were compared with survivors and an analysis of deceased children for preventable and potential preventable deaths was conducted. The acute trauma care was investigated regarding errors in treatment. Results Significant differences were found in Glasgow Coma Scale, Injury Severity Score, Revised Trauma Score, New ISS, Revised Injury Severity Classification, and Trauma and Injury Severity Score. Decedents had a worse head trauma with associated coagulopathy. The overall mortality rate was 13.4%. The majority of death occurred soon after arrival. No long term intensive care unit stay was found. No preventable but one potential preventable death was analyzed. Most errors occurred in fluid volume management and in a delay of starting the therapy for hemorrhage and coagulopathy. Prolonged preclinical rescue time and surgery time within the first 24 hours was found. Conclusions Head trauma is the determinant factor for mortality in severely injured pediatric patients. Death occurred shortly after arrival and long term intensive care stays might be an exception. In treatment of severely injured children volume management, hemorrhage and coagulopathy management, rescue time, and total surgery time should receive more attention.
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Affiliation(s)
- Carsten Schoeneberg
- Department of Trauma Surgery, University Hospital Essen, University Duisburg-Essen, Hufelandstraße 55, Essen, Germany.
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Christiaans SC, Duhachek-Stapelman AL, Russell RT, Lisco SJ, Kerby JD, Pittet JF. Coagulopathy after severe pediatric trauma. Shock 2014; 41:476-490. [PMID: 24569507 PMCID: PMC4024323 DOI: 10.1097/shk.0000000000000151] [Citation(s) in RCA: 91] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Trauma remains the leading cause of morbidity and mortality in the United States among children aged 1 to 21 years. The most common cause of lethality in pediatric trauma is traumatic brain injury. Early coagulopathy has been commonly observed after severe trauma and is usually associated with severe hemorrhage and/or traumatic brain injury. In contrast to adult patients, massive bleeding is less common after pediatric trauma. The classical drivers of trauma-induced coagulopathy include hypothermia, acidosis, hemodilution, and consumption of coagulation factors secondary to local activation of the coagulation system after severe traumatic injury. Furthermore, there is also recent evidence for a distinct mechanism of trauma-induced coagulopathy that involves the activation of the anticoagulant protein C pathway. Whether this new mechanism of posttraumatic coagulopathy plays a role in children is still unknown. The goal of this review is to summarize the current knowledge on the incidence and potential mechanisms of coagulopathy after pediatric trauma and the role of rapid diagnostic tests for early identification of coagulopathy. Finally, we discuss different options for treating coagulopathy after severe pediatric trauma.
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Affiliation(s)
- Sarah C Christiaans
- Department of Anesthesiology, University of Alabama at Birmingham, AL
- Department of Surgery, University of Alabama at Birmingham, AL
| | | | | | - Steven J Lisco
- Department of Anesthesiology, University of Nebraska Medical Center, NE
| | - Jeffrey D Kerby
- Department of Surgery, University of Alabama at Birmingham, AL
| | - Jean-François Pittet
- Department of Anesthesiology, University of Alabama at Birmingham, AL
- Department of Surgery, University of Alabama at Birmingham, AL
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Chhabra G, Sharma S, Subramanian A, Agrawal D, Sinha S, Mukhopadhyay AK. Coagulopathy as prognostic marker in acute traumatic brain injury. J Emerg Trauma Shock 2013; 6:180-5. [PMID: 23960374 PMCID: PMC3746439 DOI: 10.4103/0974-2700.115332] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2012] [Accepted: 10/04/2012] [Indexed: 11/08/2022] Open
Abstract
Context: Coagulopathy frequently occurs following traumatic brain injury (TBI) and usually occurs 6-72 hour post-trauma. The incidence and the probable risk factors for development of coagulopathy and poor outcome following TBI are largely unknown and vary considerably. Aims: To assess the incidence and probable risk factors for development of coagulopathy and to identify the risk factors for poor outcome in terms of median survival time following TBI. Materials and Methods: In this prospective study over two years, patients of isolated moderate and severe traumatic brain injury (GCS≤12) admitted to trauma center had coagulation profile (PT, APTT, thrombin time, fibrinogen and D-dimer), arterial lactate and ABG analysis done on day of admission and on day three. Coagulopathy was defined as prothrombin time (PT) or/and activated partial thromboplastin time (APTT) more than 1.5 times the normal control. Incidence of in-hospital mortality was assessed in all cases. Statistical Analysis: A stepwise logistic regression analysis was performed to identify risk factors for coagulopathy and mortality in these patients. Results: A total of 208 patients were enrolled in the study. The mean age was 32 ± 12 years and mean GCS was 7.1 ± 2.8. Coagulopathy was present in 46% (n = 96) of patients. Risk factors for development of coagulopathy were found out to be severity of head injury (OR: 2.81), elevated D-dimer (OR: 3.43), low hemoglobin (OR: 3.13), and effaced cisterns in the CT scan (OR: 2.72). Presence of coagulopathy (OR: 2.97) and severity of head injury (OR: 5.70) strongly predicted poor outcome, and were associated with a decreased median survival time. Conclusions: There is a high incidence of coagulopathy following TBI. The presence of coagulopathy as well as of severity of TBI are strong predictors of in-hospital mortality in these patients.
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Affiliation(s)
- Gaurav Chhabra
- Department of Laboratory Medicine, Jai Prakash Narayan Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
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Mertes PM, Baumann A, Audibert G. [Transfusion in neurosurgery]. Transfus Clin Biol 2008; 15:205-11. [PMID: 18930420 DOI: 10.1016/j.tracli.2008.09.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2008] [Accepted: 09/04/2008] [Indexed: 10/21/2022]
Abstract
In neurosurgery, the question of the optimal transfusion "trigger" remains a controversial matter. Regarding the brain, the current data are still incomplete, justifying the continuation of experimental and clinical studies. The existing expert advices are based on these rather poor data and would probably evolve after the completion of clinical studies in progress. In spine surgery, the situation is simpler and the transfusional stakes are quite similar to those of orthopedics and traumatology. With regard to hemostasis, standardized recommendations exist depending on the laboratory test results or the anticoagulant treatments of the patient.
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Affiliation(s)
- P-M Mertes
- Département d'anesthésie-réanimation, hôpital Central, CHU de Nancy, Nancy, France.
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Abstract
As of August 2007, 96 900 people are awaiting organ transplantation in the United States, while only 28 930 transplants were performed in 2006. With such a large gap between organ need and organ availability, it is inevitable that many will die while awaiting transplantation. This organ shortage has become a national public health crisis, and as a response, the United States Department of Health and Human Services launched the Organ Donation Breakthrough Collaborative, an ambitious campaign to dramatically increase the number of transplantable organs. One of the suggested strategies involves maximizing the number of organs obtained from the available cadaveric "brain dead'' donor pool by using donor management protocols that optimize and treat the profound physiological disturbances that are associated with brain death. The use of these standardized and aggressive donor management protocols has been shown to increase the number of transplanted organs and prevent the number of donors lost due to medical failures. A protocol-driven approach by a dedicated organ donor management team should be considered a key component of any program designed to bridge the gap between organ supply and demand.
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Affiliation(s)
- Joseph DuBose
- Division of Trauma and Critical Care at the Los Angeles County and University of Southern California Medical Center, Los Angeles, California, USA
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