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Barton CA, Oetken HJ, Hall NL, Kolesnikov M, Levins ES, Sutton T, Schreiber M. Whole blood versus balanced resuscitation in massive hemorrhage: six of one or half dozen of the other? J Trauma Acute Care Surg 2024:01586154-990000000-00708. [PMID: 38685202 DOI: 10.1097/ta.0000000000004366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2024]
Abstract
INTRODUCTION Whole blood (WB) resuscitation is increasingly used at trauma centers. Prior studies investigating outcomes in WB versus component-only (CO) resuscitation have been limited by small cohorts, low volumes of WB resuscitation, and unbalanced CO resuscitation. This study aimed to address these limitations using data from a high-volume Level I trauma center, which adopted a WB-first resuscitation paradigm in 2018. We hypothesized that the resuscitation method, WB or balanced CO, would have no impact on patient mortality. METHODS A single-center, retrospective cohort study of adults presenting as a trauma activation from July 2016 through July 2021 was performed. Receipt of 3 or more units of WB or packed red blood cells (RBC) within the first hour of resuscitation was required for inclusion. Patients were grouped into WB versus CO resuscitation and important clinical outcomes were compared. Mortality was evaluated with Kaplan-Meier analysis, log-rank testing, and multivariable Cox proportional hazards modeling. RESULTS There were 180 patients in the WB group and 170 patients in the CO group. Of the 180 WB patients, 110 (61%) received only WB during the first 24 hours. The WB group received a median of 5.0 units (IQR 4.0-8.0) of WB and CO group received a median of 6.0 units (IQR 4.0-11.8) of RBCs during the first 24 hours of resuscitation. In the CO group, median RBC/plasma and RBC/platelet ratios approximated 1:1:1. Groups were similar in clinicopathologic characteristics including age, injury severity score, mechanism of injury, and requirement for hemorrhage control interventions (WB 55% vs CO 59%, p = 0.60). Unadjusted survival was equivalent at 24 hours (p = 0.52) and 30 days (p = 0.70) between both groups on Kaplan-Meier analysis with log-rank testing. On multivariable Cox regression, WB resuscitation was not independently associated with improved survival after accounting for age, ISS, mechanism of injury, and receipt of hemorrhage control procedure (HR 0.85, 95% CI 0.61-1.19, p = 0.34). CONCLUSIONS Balanced CO resuscitation is associated with similar mortality outcomes to that of WB based resuscitation. LEVEL OF EVIDENCE Level IV; Therapeutic/Care Management.
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Affiliation(s)
- Cassie A Barton
- Department of Pharmacy, Oregon Health & Science University, Portland, OR
| | - Heath J Oetken
- Department of Pharmacy, Oregon Health & Science University, Portland, OR
| | - Nicolas L Hall
- Donald D. Trunkey Center for Civilian and Combat Casualty Care, Division of Trauma, Critical Care and Acute Care Surgery, Department of Surgery, Oregon Health & Science University, Portland, OR
| | - Michael Kolesnikov
- Donald D. Trunkey Center for Civilian and Combat Casualty Care, Division of Trauma, Critical Care and Acute Care Surgery, Department of Surgery, Oregon Health & Science University, Portland, OR
| | - Elizabeth S Levins
- Department of Pharmacy, Oregon Health & Science University, Portland, OR
| | - Thomas Sutton
- Donald D. Trunkey Center for Civilian and Combat Casualty Care, Division of Trauma, Critical Care and Acute Care Surgery, Department of Surgery, Oregon Health & Science University, Portland, OR
| | - Martin Schreiber
- Donald D. Trunkey Center for Civilian and Combat Casualty Care, Division of Trauma, Critical Care and Acute Care Surgery, Department of Surgery, Oregon Health & Science University, Portland, OR
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Kartika T, Mathews R, Migneco G, Bundy T, Kaempf AJ, Pfeffer M, DeLoughery TG, Moore K, Beardshear R, Oetken HJ, Case J, Hinds MT, McCarty OJT, Shatzel JJ, Zonies D, Zakhary B. Comparison of bleeding and thrombotic outcomes in veno-venous extracorporeal membrane oxygenation: Heparin versus bivalirudin. Eur J Haematol 2024; 112:566-576. [PMID: 38088062 PMCID: PMC11034845 DOI: 10.1111/ejh.14146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Revised: 11/22/2023] [Accepted: 11/27/2023] [Indexed: 01/17/2024]
Abstract
OBJECTIVES We aimed to evaluate thrombotic and hemorrhagic complications with heparin versus bivalirudin use in veno-venous extracorporeal membrane oxygenation (V-V ECMO). METHODS We performed a retrospective cohort study of adult patients placed on V-V ECMO with intravenous anticoagulation with either heparin or bivalirudin. Time to thrombotic event and major bleed were analyzed in addition to related outcomes. RESULTS We identified 95 patients placed on V-V ECMO: 61 receiving heparin, 34 bivalirudin. The bivalirudin group had a higher rate of severe COVID-19, higher BMI, and longer ECMO duration. Despite this, bivalirudin was associated with reduced risk of thrombotic event (HR 0.14, 95% CI 0.06-0.32, p < .001) and increased average lifespan of the circuit membrane lung (16 vs. 10 days, p = 0.004). While there was no difference in major bleeding, the bivalirudin group required fewer transfusions of packed red blood cells and platelets per 100 ECMO days (means of 13 vs. 39, p = 0.004; 5 vs. 19, p = .014, respectively). Lastly, the bivalirudin group had improved survival to ECMO decannulation in univariate analysis (median OS 53 vs. 26 days, p = .015). CONCLUSIONS In this real-world analysis of bivalirudin versus heparin, bivalirudin is a viable option for V-V ECMO and associated with lower risk of thrombotic complications and fewer transfusion requirements.
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Affiliation(s)
- Thomas Kartika
- Division of Hematology and Medical Oncology, Knight Cancer Institute, Oregon Health & Science University, Portland, OR USA
| | - Rick Mathews
- Department of Biomedical Engineering, Oregon Health & Science University, OR USA
| | - Gina Migneco
- Department of Pharmacy, Oregon Health & Science University, Portland, OR USA
| | - Taylor Bundy
- Department of Internal Medicine, Oregon Health & Science University, Portland, OR USA
| | - Andy J Kaempf
- Biostatistics Shared Resource, Knight Cancer Institute, Oregon Health & Science University, Portland, OR USA
| | - Michael Pfeffer
- Division of Hematology and Medical Oncology, Knight Cancer Institute, Oregon Health & Science University, Portland, OR USA
| | - Thomas G DeLoughery
- Division of Hematology and Medical Oncology, Knight Cancer Institute, Oregon Health & Science University, Portland, OR USA
| | - Kerry Moore
- Department of Pharmacy, Oregon Health & Science University, Portland, OR USA
| | - Rachel Beardshear
- Department of Pharmacy, Oregon Health & Science University, Portland, OR USA
| | - Heath J Oetken
- Department of Pharmacy, Oregon Health & Science University, Portland, OR USA
| | - Jonathan Case
- Department of Pharmacy, Oregon Health & Science University, Portland, OR USA
| | - Monica T Hinds
- Department of Biomedical Engineering, Oregon Health & Science University, OR USA
| | - Owen J T McCarty
- Department of Biomedical Engineering, Oregon Health & Science University, OR USA
| | - Joseph J Shatzel
- Division of Hematology and Medical Oncology, Knight Cancer Institute, Oregon Health & Science University, Portland, OR USA
- Department of Biomedical Engineering, Oregon Health & Science University, OR USA
| | - David Zonies
- Department of Surgery, Oregon Health & Science University, Portland, OR USA
| | - Bishoy Zakhary
- Division of Pulmonary and Critical Care Medicine, Oregon Health & Science University, Portland, OR USA
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Webb AJ, Oetken HJ, Plott AJ, Knapp C, Munger DN, Gibson E, Schreiber M, Barton CA. The impact of low-dose aspirin in the Brain Injury Guidelines on outcomes in traumatic brain injury: A retrospective cohort study. J Trauma Acute Care Surg 2023; 94:320-327. [PMID: 35999660 DOI: 10.1097/ta.0000000000003772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND Current Brain Injury Guidelines (BIG) characterize patients with intracranial hemorrhage taking antiplatelet or anticoagulant agents as BIG 3 (the most severe category) regardless of trauma severity. This study assessed the risk of in-hospital mortality or need for neurosurgery in patients taking low-dose aspirin who otherwise would be classified as BIG 1. METHODS This was a retrospective study at an academic level 1 trauma center. Patients were included if they were admitted with traumatic intracerebral hemorrhage and were evaluated by the BIG criteria. Exclusion criteria included indeterminate BIG status or patients with missing primary outcomes documentation. Patients were categorized as BIG 1, BIG 2, BIG 3, or BIG 1 on aspirin (patients with BIG 1 features taking low-dose aspirin). The primary endpoint was a composite of neurosurgical intervention and all-cause in-hospital mortality. Key secondary endpoints include rate of intracranial hemorrhage progression, and intensive care unit- and hospital-free days. RESULTS A total of 1,520 patients met the inclusion criteria. Median initial Glasgow Coma Scale was 14 (interquartile range [IQR], 12-15), Injury Severity Scale score was 17 (IQR, 10-25), and Abbreviated Injury Scale subscore head and neck (AIS Head ) was 3 (IQR, 3-4). The rate of the primary outcome for BIG 1, BIG 1 on aspirin, BIG 2, and BIG 3 was 1%, 2.2%, 1%, and 27%, respectively; the difference between BIG 1 on aspirin and BIG 3 was significant ( p < 0.001). CONCLUSION Patients taking low-dose aspirin with otherwise BIG 1-grade injuries experienced mortality and required neurosurgery significantly less often than other patients categorized as BIG 3. Inclusion of low-dose aspirin in the BIG criteria should be reevaluated. LEVEL OF EVIDENCE Therapeutic/Care Management; Level IV.
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Affiliation(s)
- Andrew J Webb
- From the Department of Pharmacy (A.J.W., H.J.O., C.A.B.), Oregon Health and Science University, Portland, Oregon; Department of Pharmacy (A.J.W.), Massachusetts General Hospital, Boston, Massachusetts; Department of Pharmacy (A.J.P.), University Hospital, Newark, New Jersey; Department of Surgery (C.K., E.G., M.S.), Oregon Health and Science University; and Department of Neurosurgery (D.N.M.), Oregon Health and Science University, Portland, Oregon
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Barton CA, Oetken HJ, Hall NL, Webb AJ, Hoops HE, Schreiber M. Incidence of traumatic intracranial hemorrhage expansion after stable repeat head imaging: A retrospective cohort study. Am J Surg 2022; 224:775-779. [DOI: 10.1016/j.amjsurg.2022.01.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Revised: 12/31/2021] [Accepted: 01/30/2022] [Indexed: 11/01/2022]
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Barton CA, Oetken HJ, Roberti GJ, Dewey EN, Goodman A, Schreiber M. Thromboelastography with platelet mapping: Limited predictive ability in detecting preinjury antiplatelet agent use. J Trauma Acute Care Surg 2021; 91:803-808. [PMID: 34695058 DOI: 10.1097/ta.0000000000003172] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Preinjury antiplatelet agent (APA) use in trauma patients can increase traumatic hemorrhage and worsen outcomes. Thromboelastography with platelet mapping (TEGPM) has characterized platelet function via arachidonic acid (AA) and adenosine diphosphate (ADP) inhibition in nontrauma settings, but limited data exist in the acute trauma population. METHODS A prospective observational study of adult trauma patients with suspected preinjury APA use who received TEGPM testing from 2017 to 2020 was performed. Patients on anticoagulants were excluded. Patients were grouped according to preinjury APA regimen: 81 mg or 325 mg of aspirin daily, 81 mg of aspirin and 75 mg of clopidrogrel daily, 75 mg of clopidrogrel daily, or no antiplatelet. Ability of TEGPM to detect APA use was assessed using predictive statistics and area under receiver operating characteristic curves (AUROCs). RESULTS A total of 824 patients were included with most patients taking 81 mg of aspirin (n = 558). Patients on no antiplatelet were younger and had higher baseline platelet counts, while patients on 75 mg of clopidrogrel were more likely to be admitted after ground level fall. All other baseline characteristics were balanced. Admission TEG values were similar between groups. Median AA inhibition was higher in patients on aspirin containing regimens (p < 0.0001). Median ADP inhibition was higher in patients on clopidogrel containing regimens and those taking 325 mg of aspirin (p < 0.0001). Arachidonic acid inhibition accurately detected preinjury APA use and aspirin use (AUROC, 0.89 and 0.84, respectively); however, ADP inhibition performed poorly (AUROC, 0.58). Neither AA nor ADP inhibition was able to discern specific APA regimens or rule out APA use entirely. CONCLUSION High AA inhibition accurately detects preinjury APA use in trauma patients. High ADP inhibition after trauma is common, limiting its utility to accurately identify preinjury APA use. Further study is needed to identify assays that can reliably detect and further characterize preinjury APA use in trauma populations. LEVEL OF EVIDENCE Diagnostic test, level II.
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Affiliation(s)
- Cassie A Barton
- From the Department of Pharmacy (C.A.B., H.J.O., G.J.R.), and Department of Surgery (E.N.D., A.G., M.S.), Oregon Health & Science University, Portland, Oregon
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