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Gaski IA, Naess PA, Baksaas-Aasen K, Skaga NO, Gaarder C. Achieving balanced transfusion early in critically bleeding trauma patients: an observational study exploring the effect of attending trauma surgical presence during resuscitation. Trauma Surg Acute Care Open 2023; 8:e001160. [PMID: 38020849 PMCID: PMC10660666 DOI: 10.1136/tsaco-2023-001160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Accepted: 10/13/2023] [Indexed: 12/01/2023] Open
Abstract
Background After 15 years of damage control resuscitation (DCR), studies still report high mortality rates for critically bleeding trauma patients. Adherence to massive hemorrhage protocols (MHPs) based on a 1:1:1 ratio of plasma, platelets, and red blood cells (RBCs) as part of DCR has been shown to improve outcomes. We wanted to assess MHP use in the early (6 hours from admission), critical phase of DCR and its impact on mortality. We hypothesized that the presence of an attending trauma surgeon during all MHP activations from 2013 would contribute to improving institutional resuscitation strategies and patient outcomes. Methods We conducted a retrospective analysis of all trauma patients receiving ≥10 RBCs within 6 hours of admission and included in the institutional trauma registry between 2009 and 2019. The cohort was divided in period 1 (P1): January 2009-August 2013, and period 2 (P2): September 2013-December 2019 for comparison of outcomes. Results A total of 141 patients were included, 81 in P1 and 60 in P2. Baseline characteristics were similar between the groups for Injury Severity Score, lactate, Glasgow Coma Scale, and base deficit. Patients in P2 received more plasma (16 units vs. 12 units; p<0.01), resulting in a more balanced plasma:RBC ratio (1.00 vs. 0.74; p<0.01), and platelets:RBC ratio (1.11 vs. 0.92; p<0.01). All-cause mortality rates decreased from P1 to P2, at 6 hours (22% to 8%; p=0.03), at 24 hours (36% vs 13%; p<0.01), and at 30 days (48% vs 30%, p=0.03), respectively. A stepwise logistic regression model predicted an OR of 0.27 (95% CI 0.08 to 0.93) for dying when admitted in P2. Conclusions Achieving balanced transfusion rates at 6 hours, facilitated by the presence of an attending trauma surgeon at all MHP activations, coincided with a reduction in all-cause mortality and hemorrhage-related deaths in massively transfused trauma patients at 6 hours, 24 hours, and 30 days. Level of evidence IV.
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Affiliation(s)
- Iver Anders Gaski
- Department of Traumatology, Oslo University Hospital Ulleval, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Paal Aksel Naess
- Department of Traumatology, Oslo University Hospital Ulleval, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | | | - Nils Oddvar Skaga
- Department of Anesthesiology, Oslo University Hospital Ullevål, Oslo, Norway
| | - Christine Gaarder
- Department of Traumatology, Oslo University Hospital Ulleval, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
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Ringen AH, Baksaas-Aasen K, Skaga NO, Wisborg T, Gaarder C, Naess PA. Close to zero preventable in-hospital deaths in pediatric trauma patients - An observational study from a major Scandinavian trauma center. Injury 2023; 54:183-188. [PMID: 35961867 DOI: 10.1016/j.injury.2022.07.043] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 07/13/2022] [Accepted: 07/26/2022] [Indexed: 02/02/2023]
Abstract
BACKGROUND In line with international trends, initial treatment of trauma patients has changed substantially over the last two decades. Although trauma is the leading cause of death and disability in children globally, in-hospital pediatric trauma related mortality is expected to be low in a mature trauma system. To evaluate the performance of a major Scandinavian trauma center we assessed treatment strategies and outcomes in all pediatric trauma patients over a 16-year period. METHODS A retrospective cohort study of all trauma patients under the age of 18 years admitted to a single institution from 1st of January 2003 to 31st of December 2018. Outcomes for two time periods were compared, 2003-2009 (Period 1; P1) and 2010-2018 (Period 2; P2). Deaths were further analyzed for preventability by the institutional trauma Mortality and Morbidity panel. RESULTS The study cohort consisted of 3939 patients. A total of 57 patients died resulting in a crude mortality of 1.4%, nearly one quarter of the study cohort (22.6%) was severely injured (Injury Severity Score > 15) and mortality in this group decreased from 9.7% in P1 to 4.1% in P2 (p<0.001). The main cause of death was brain injury in both periods, and 55 of 57 deaths were deemed non-preventable. The rate of emergency surgical procedures performed in the emergency department (ED) decreased during the study period. None of the 11 ED thoracotomies in non-survivors were performed after 2013. CONCLUSION A dedicated multidisciplinary trauma service with ongoing quality improvement efforts secured a low in-hospital mortality among severely injured children and a decrease in futile care. Deaths were shown to be almost exclusively non-preventable, pointing to the necessity of prioritizing prevention strategies to further decrease pediatric trauma related mortality.
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Affiliation(s)
- Amund Hovengen Ringen
- Department of Traumatology, Oslo University Hospital Ullevaal, Oslo, Norway; Department of Anesthesia, Oslo University Hospital Ullevaal, PB 4950 Nydalen, Oslo 0424, Norway; Department of Research & Development, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway; Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway.
| | - Kjersti Baksaas-Aasen
- Department of Traumatology, Oslo University Hospital Ullevaal, Oslo, Norway; Department of Anesthesia, Oslo University Hospital Ullevaal, PB 4950 Nydalen, Oslo 0424, Norway; Department of Research & Development, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway; Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Nils Oddvar Skaga
- Department of Anesthesia, Oslo University Hospital Ullevaal, PB 4950 Nydalen, Oslo 0424, Norway; Department of Research & Development, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway
| | - Torben Wisborg
- University of Tromsø, The Arctic University of Norway, Hammerfest, Norway; Department of Anesthesia and Intensive Care, Finnmark Health trust, Hammerfest Hospital, Hammerfest, Norway; Norwegian National Advisory Unit on Trauma, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway
| | - Christine Gaarder
- Department of Traumatology, Oslo University Hospital Ullevaal, Oslo, Norway; Department of Research & Development, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway; Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Paal Aksel Naess
- Department of Traumatology, Oslo University Hospital Ullevaal, Oslo, Norway; Department of Research & Development, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway; Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
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Vigstedt M, Baksaas-Aasen K, Henriksen HH, Maegele M, Stanworth S, Juffermans NP, Kolstadbråten KM, Naess PA, Brohi K, Gaarder C, Stensballe J, Johansson PI. Thrombelastography (TEG ® 6s) early amplitudes predict maximum amplitude in severely injured trauma patients. Scand J Clin Lab Invest 2022; 82:508-512. [PMID: 36073613 DOI: 10.1080/00365513.2022.2119599] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
Severely injured trauma patients are often coagulopathic and early hemostatic resuscitation is essential. Previous studies have revealed linear relationships between thrombelastography (TEG®) five- and ten-min amplitudes (A5 and A10), and maximum amplitude (MA), using TEG® 5000 technology. We aimed to investigate the performance of A5 and A10 in predicting low MA in severely injured trauma patients and identify optimal cut-off values for hemostatic intervention based on early amplitudes, using the cartridge-based TEG® 6s technology. Adult trauma patients with hemorrhagic shock were included in the iTACTIC randomized controlled trial at six European Level I trauma centers between 2016 and 2018. After admission, patients were randomized to hemostatic therapy guided by conventional coagulation tests (CCT) or viscoelastic hemostatic assays (VHA). Patients with available admission-TEG® 6s data were included in the analysis, regardless of treatment allocation. Low MA was defined as <55 mm for Kaolin TEG® and RapidTEG®, and <17 mm for TEG® functional fibrinogen (FF). One hundred eighty-seven patients were included. Median time to MA was 20 (Kaolin TEG®), 21 (RapidTEG®) and 12 (TEG® FF) min. For Kaolin TEG®, the optimal Youden index (YI) was at A5 < 36 mm (100/93% sensitivity/specificity) and A10 < 47 mm (100/96% sensitivity/specificity). RapidTEG® optimal YI was at A5 < 34 mm (98/92% sensitivity/specificity) and A10 < 45 mm (96/95% sensitivity/specificity). TEG® FF optimal YI was at A5 < 12 mm (97/93% sensitivity/specificity) and A10 < 15 mm (97/99% sensitivity/specificity). In summary, we found that TEG® 6s early amplitudes were sensitive and specific predictors of MA in severely injured trauma patients. Intervening on early amplitudes can save valuable time in hemostatic resuscitation.
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Affiliation(s)
- Martin Vigstedt
- Section for Transfusion Medicine, Capital Region Blood Bank, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | | | - Hanne H Henriksen
- Section for Transfusion Medicine, Capital Region Blood Bank, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Marc Maegele
- Cologne-Merheim Medical Centre, University of Witten/Herdecke, Cologne, Germany
| | - Simon Stanworth
- Oxford University Hospital NHS Trust, Oxford, UK.,NHS Blood and Transplant, Bristol, UK
| | - Nicole P Juffermans
- Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam University Medical Centres, Amsterdam, The Netherlands
| | | | - Pål A Naess
- Oslo University Hospital and University of Oslo, Oslo, Norway
| | - Karim Brohi
- Centre for Trauma Sciences, Queen Mary University of London, London, UK
| | | | - Jakob Stensballe
- Section for Transfusion Medicine, Capital Region Blood Bank, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.,Department of Anaesthesiology, Centre of Head and Orthopaedics, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Pär I Johansson
- Section for Transfusion Medicine, Capital Region Blood Bank, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
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Baksaas-Aasen K, Gall LS, Stensballe J, Juffermans NP, Curry N, Maegele M, Brooks A, Rourke C, Gillespie S, Murphy J, Maroni R, Vulliamy P, Henriksen HH, Pedersen KH, Kolstadbraaten KM, Wirtz MR, Kleinveld DJB, Schäfer N, Chinna S, Davenport RA, Naess PA, Goslings JC, Eaglestone S, Stanworth S, Johansson PI, Gaarder C, Brohi K. Viscoelastic haemostatic assay augmented protocols for major trauma haemorrhage (ITACTIC): a randomized, controlled trial. Intensive Care Med 2021; 47:49-59. [PMID: 33048195 PMCID: PMC7550843 DOI: 10.1007/s00134-020-06266-1] [Citation(s) in RCA: 133] [Impact Index Per Article: 44.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2020] [Accepted: 09/20/2020] [Indexed: 12/13/2022]
Abstract
PURPOSE Contemporary trauma resuscitation prioritizes control of bleeding and uses major haemorrhage protocols (MHPs) to prevent and treat coagulopathy. We aimed to determine whether augmenting MHPs with Viscoelastic Haemostatic Assays (VHA) would improve outcomes compared to Conventional Coagulation Tests (CCTs). METHODS This was a multi-centre, randomized controlled trial comparing outcomes in trauma patients who received empiric MHPs, augmented by either VHA or CCT-guided interventions. Primary outcome was the proportion of subjects who, at 24 h after injury, were alive and free of massive transfusion (10 or more red cell transfusions). Secondary outcomes included 28-day mortality. Pre-specified subgroups included patients with severe traumatic brain injury (TBI). RESULTS Of 396 patients in the intention to treat analysis, 201 were allocated to VHA and 195 to CCT-guided therapy. At 24 h, there was no difference in the proportion of patients who were alive and free of massive transfusion (VHA: 67%, CCT: 64%, OR 1.15, 95% CI 0.76-1.73). 28-day mortality was not different overall (VHA: 25%, CCT: 28%, OR 0.84, 95% CI 0.54-1.31), nor were there differences in other secondary outcomes or serious adverse events. In pre-specified subgroups, there were no differences in primary outcomes. In the pre-specified subgroup of 74 patients with TBI, 64% were alive and free of massive transfusion at 24 h compared to 46% in the CCT arm (OR 2.12, 95% CI 0.84-5.34). CONCLUSION There was no difference in overall outcomes between VHA- and CCT-augmented-major haemorrhage protocols.
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Affiliation(s)
| | - L S Gall
- Centre for Trauma Sciences, Queen Mary University of London, Blizard Institute, 4 Newark Street, London, E1 2AT, UK
| | - J Stensballe
- Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - N P Juffermans
- Amsterdam University Medical Centres, Amsterdam, The Netherlands
| | - N Curry
- Oxford University Hospital NHS Trust, Oxford, UK
| | - M Maegele
- Cologne-Merheim Medical Centre, University of Witten/Herdecke, Cologne, Germany
| | - A Brooks
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - C Rourke
- Centre for Trauma Sciences, Queen Mary University of London, Blizard Institute, 4 Newark Street, London, E1 2AT, UK
| | - S Gillespie
- Centre for Trauma Sciences, Queen Mary University of London, Blizard Institute, 4 Newark Street, London, E1 2AT, UK
| | - J Murphy
- Queen Mary University of London, London, UK
| | - R Maroni
- Queen Mary University of London, London, UK
| | - P Vulliamy
- Centre for Trauma Sciences, Queen Mary University of London, Blizard Institute, 4 Newark Street, London, E1 2AT, UK
| | - H H Henriksen
- Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - K Holst Pedersen
- Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | | | - M R Wirtz
- Amsterdam University Medical Centres, Amsterdam, The Netherlands
| | - D J B Kleinveld
- Amsterdam University Medical Centres, Amsterdam, The Netherlands
| | - N Schäfer
- Cologne-Merheim Medical Centre, University of Witten/Herdecke, Cologne, Germany
| | - S Chinna
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - R A Davenport
- Centre for Trauma Sciences, Queen Mary University of London, Blizard Institute, 4 Newark Street, London, E1 2AT, UK
| | - P A Naess
- Oslo University Hospital & University of Oslo, Oslo, Norway
| | - J C Goslings
- Amsterdam University Medical Centres, Amsterdam, The Netherlands
| | - S Eaglestone
- Centre for Trauma Sciences, Queen Mary University of London, Blizard Institute, 4 Newark Street, London, E1 2AT, UK
| | - S Stanworth
- Oxford University Hospital NHS Trust, Oxford, UK.,NHS Blood and Transplant, Bristol, UK
| | - P I Johansson
- Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - C Gaarder
- Oslo University Hospital & University of Oslo, Oslo, Norway
| | - K Brohi
- Centre for Trauma Sciences, Queen Mary University of London, Blizard Institute, 4 Newark Street, London, E1 2AT, UK.
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5
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Baksaas-Aasen K, Gall L, Eaglestone S, Rourke C, Juffermans NP, Goslings JC, Naess PA, van Dieren S, Ostrowski SR, Stensballe J, Maegele M, Stanworth SJ, Gaarder C, Brohi K, Johansson PI. iTACTIC - implementing Treatment Algorithms for the Correction of Trauma-Induced Coagulopathy: study protocol for a multicentre, randomised controlled trial. Trials 2017; 18:486. [PMID: 29047413 PMCID: PMC5648415 DOI: 10.1186/s13063-017-2224-9] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2017] [Accepted: 09/30/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Traumatic injury is the fourth leading cause of death globally. Half of all trauma deaths are due to bleeding and most of these will occur within 6 h of injury. Haemorrhagic shock following injury has been shown to induce a clotting dysfunction within minutes, and this early trauma-induced coagulopathy (TIC) may exacerbate bleeding and is associated with higher mortality and morbidity. In spite of improved resuscitation strategies over the last decade, current transfusion therapy still fails to correct TIC during ongoing haemorrhage and evidence for the optimal management of bleeding trauma patients is lacking. Recent publications describe increasing the use of Viscoelastic Haemostatic Assays (VHAs) in trauma haemorrhage; however, there is insufficient evidence to support their superiority to conventional coagulation tests (CCTs). METHODS/DESIGN This multicentre, randomised controlled study will compare the haemostatic effect of an evidence-based VHA-guided versus an optimised CCT-guided transfusion algorithm in haemorrhaging trauma patients. A total of 392 adult trauma patients will be enrolled at major trauma centres. Participants will be eligible if they present with clinical signs of haemorrhagic shock, activate the local massive haemorrhage protocol and initiate first blood transfusion. Enrolled patients will be block randomised per centre to either VHA-guided or CCT-guided transfusion therapy in addition to that therapy delivered as part of standard care, until haemostasis is achieved. Patients will be followed until discharge or 28 days. The primary endpoint is the proportion of subjects alive and free of massive transfusion (less than 10 units of red blood cells) at 24 h. Secondary outcomes include the effect of CCT- versus VHA-guided therapy on organ failure, total hospital and intensive care lengths of stay, health care resources needed and mortality. Surviving patients will be asked to complete a quality of life questionnaire (EuroQol EQ-5DTM) at day 90. DISCUSSION CCTs have traditionally been used to detect TIC and monitor response to treatment in traumatic major haemorrhage. The use of VHAs is increasing, but limited evidence exists to support the superiority of these technologies (or comparatively) for patient-centred outcomes. This knowledge gap will be addressed by this trial. TRIAL REGISTRATION ClinicalTrials.gov, ID: NCT02593877 . Registered on 15 October 2015. Trial sponsor Queen Mary University of London The contact person of the above sponsor organisation is: Dr. Sally Burtles, Director of Research Services and Business Development, Joint Research Management Office, QM Innovation Building, 5 Walden Street, London E1 2EF; phone: 020 7882 7260; Email: sponsorsrep@bartshealth.nhs.uk Trial sites Academic Medical Centre, Amsterdam, The Netherlands Kliniken der Stadt Köln gGmbH, Cologne, Germany Rigshospitalet (Copenhagen University Hospital), Copenhagen, Denmark John Radcliff Hospital, Oxford, United Kingdom Oslo University Hospital, Oslo, Norway The Royal London Hospital, London, United Kingdom Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, United Kingdom Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom Sites that are planning to start recruitment in mid/late 2017 Nottingham University Hospitals, Queen's Medical Centre, Nottingham, United Kingdom University of Kansas Hospital (UKH), Kansas City, MO, USA Protocol version: 3.0/14.03.2017 (Additional file 1).
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Affiliation(s)
| | - Lewis Gall
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, UK
| | - Simon Eaglestone
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, UK
| | - Claire Rourke
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, UK
| | - Nicole P Juffermans
- Department of Intensive Care Medicine, Academic Medical Center, Amsterdam, The Netherlands
| | - J Carel Goslings
- Trauma Unit, Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - Paal Aksel Naess
- Department of Traumatology, Oslo University Hospital, Oslo, Norway
| | - Susan van Dieren
- Trauma Unit, Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - Sisse Rye Ostrowski
- Section for Transfusion Medicine, Capital Region Blood Bank, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Jakob Stensballe
- Section for Transfusion Medicine, Capital Region Blood Bank, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Marc Maegele
- Department for Traumatology and Orthopedic Surgery, Cologne-Merheim Medical Centre, University of Witten/Herdecke, Cologne, Germany
| | - Simon J Stanworth
- NHS Blood and Transplant/Oxford University Hospital NHS Trust, John Radcliffe Hospital, Oxford, UK.,Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| | | | - Karim Brohi
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, UK
| | - Per I Johansson
- Section for Transfusion Medicine, Capital Region Blood Bank, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
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6
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Balvers K, van Dieren S, Baksaas-Aasen K, Gaarder C, Brohi K, Eaglestone S, Stanworth S, Johansson PI, Ostrowski SR, Stensballe J, Maegele M, Goslings JC, Juffermans NP. Combined effect of therapeutic strategies for bleeding injury on early survival, transfusion needs and correction of coagulopathy. Br J Surg 2017; 104:222-229. [PMID: 28079258 DOI: 10.1002/bjs.10330] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2016] [Revised: 04/10/2016] [Accepted: 08/25/2016] [Indexed: 11/08/2022]
Abstract
BACKGROUND The combined effects of balanced transfusion ratios and use of procoagulant and antifibrinolytic therapies on trauma-induced exsanguination are not known. The aim of this study was to investigate the combined effect of transfusion ratios, tranexamic acid and products containing fibrinogen on the outcome of injured patients with bleeding. METHODS A prospective multicentre observational study was performed in six level 1 trauma centres. Injured patients who received at least 4 units of red blood cells (RBCs) were analysed and divided into groups receiving a low (less than 1 : 1) or high (1 or more : 1) ratio of plasma or platelets to RBCs, and in receipt or not of tranexamic acid or fibrinogen products (fibrinogen concentrates or cryoprecipitate). Logistic regression models were used to assess the effect of transfusion strategies on the outcomes 'alive and free from massive transfusion' (at least 10 units of RBCs in 24 h) and early 'normalization of coagulopathy' (defined as an international normalized ratio of 1·2 or less). RESULTS A total of 385 injured patients with ongoing bleeding were included in the study. Strategies that were independently associated with an increased number of patients alive and without massive transfusion were a high platelet to RBC ratio (odds ratio (OR) 2·67, 95 per cent c.i. 1·24 to 5·77; P = 0·012), a high plasma to RBC ratio (OR 2·07, 1·03 to 4·13; P = 0·040) and treatment with tranexamic acid (OR 2·71, 1·29 to 5·71; P = 0·009). No strategies were associated with correction of coagulopathy. CONCLUSION A high platelet or plasma to RBC ratio, and use of tranexamic acid were associated with a decreased need for massive transfusion and increased survival in injured patients with bleeding. Early normalization of coagulopathy was not seen for any transfusion ratio, or for use of tranexamic acid or fibrinogen products.
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Affiliation(s)
- K Balvers
- Trauma Unit, Department of Surgery, Academic Medical Centre, Amsterdam, The Netherlands.,Department of Intensive Care Medicine, Academic Medical Centre, Amsterdam, The Netherlands
| | - S van Dieren
- Trauma Unit, Department of Surgery, Academic Medical Centre, Amsterdam, The Netherlands
| | - K Baksaas-Aasen
- Department of Traumatology, Oslo University Hospital, Oslo, Norway.,Department of Anaesthesiology, Oslo University Hospital, Oslo, Norway
| | - C Gaarder
- Department of Traumatology, Oslo University Hospital, Oslo, Norway
| | - K Brohi
- Trauma Sciences, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - S Eaglestone
- Trauma Sciences, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - S Stanworth
- National Health Service (NHS) Blood and Transplant/Oxford University Hospitals NHS Trust, John Radcliffe Hospital, and Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| | - P I Johansson
- Section for Transfusion Medicine, Capital Region Blood Bank, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - S R Ostrowski
- Section for Transfusion Medicine, Capital Region Blood Bank, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - J Stensballe
- Section for Transfusion Medicine, Capital Region Blood Bank, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - M Maegele
- Department for Traumatology and Orthopaedic Surgery, Cologne-Merheim Medical Centre, University of Witten/Herdecke, Cologne, Germany
| | - J C Goslings
- Trauma Unit, Department of Surgery, Academic Medical Centre, Amsterdam, The Netherlands
| | - N P Juffermans
- Department of Intensive Care Medicine, Academic Medical Centre, Amsterdam, The Netherlands
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