French lyophilized plasma versus fresh frozen plasma for the initial management of trauma-induced coagulopathy: a randomized open-label trial

Essentials An immediate supply of plasma in case of trauma-induced coagulopathy is required. The Traucc trial compared French Lyophilised Plasma (FLyP) and Fresh Frozen Plasma (FFP). FLyP achieved higher fibrinogen concentrations compared with FFP. FLyP led to a more rapid coagulopathy improvement than FFP.

SUMMARY

Background Guidelines recommend beginning hemostatic resuscitation immediately in trauma patients. We aimed to investigate if French lyophilized plasma (FLyP) was more effective than fresh frozen plasma (FFP) for the initial management of trauma-induced coagulopathy. Methods In an open-label, phase 3, randomized trial (NCT02750150), we enrolled adult trauma patients requiring an emergency pack of 4 plasma units within 6 h of injury. We randomly assigned patients to receive 4-FLyP units or 4-FFP units. The primary endpoint was fibrinogen concentration at 45 min after randomization. Secondary outcomes included time to transfusion, changes in hemostatic parameters at different time-points, blood product requirements and 30-day in-hospital mortality. Results Forty-eight patients were randomized (FLyP, n = 24; FFP, n = 24). FLyP reduced the time from randomization to transfusion of first plasma unit compared with FFP (median[IQR],14[5-30] vs. 77[64-90] min). FLyP achieved a higher fibrinogen concentration 45 min after randomization compared with FFP (baseline-adjusted mean difference, 0.29 g L-1 ; 95% confidence interval [CI], 0.08-0.49) and a greater improvement in prothrombin time ratio, factor V and factor II. The between-group differences in coagulation parameters remained significant at 6 h. FLyP reduced fibrinogen concentrate requirements. Thirty-day in-hospital mortality rate was 22% with FLyP and 29% with FFP. Conclusion FLyP led to a more rapid, pronounced and extended increase in fibrinogen concentrations and coagulopathy improvement compared with FFP in the initial management of trauma patients. FLyP represents an attractive option for trauma management, especially when facing logistical issues such as combat casualties or mass casualties related to terror attacks or disasters.

[Is the research of posttransfusional alloantibodies still relevant?]

The decision of November 6th, 2006 defining the principles of best practices recommends that posttransfusional red cell alloantibodies research is performed after one to three months after. In the University hospital of Brest, the haemovigilance unit takes charge of sending the medical prescription within the required time and centralizing the results. We wished to estimate if the realization of this research still remains relevant.

METHODS

A prospective analysis was performed in 2015. We evaluated the realization rate, the red cell alloantibodies rate and the recipient adverse reactions with the diagnostic category: alloimmunization (delayed serological transfusion reaction, DSTR).

RESULTS

In 2015, 2162 prescriptions were sent to the 3271 transfused patients. One thousand and eighteen red cell alloantibodies research were done, i.e. a return rate of 61%. Among them, 12 alloantibodies appeared (0.9%) within an average of 56 days. Thirty-three other alloantibodies appeared and were discovered most frequently before a new transfusion. In 10 cases, a posttransfusional research was done that was negative. A survey was conducted among GHCOH members to describe the practices in these health institutions. Twelve questionnaires were analysed. Ten institutions performed a posttransfusional alloantibodies research by issuing a prescription at the patient's exit with a return rate between 0.14 and 16%; 1 institution has a centralized organization with a return rate of 68.3%; 1566 red cell alloantibodies research were performed and among them, 24 alloantibodies appeared (1.53%).

CONCLUSION

These results indicate that to be effective, the management of this biological test must be centralized. Despite this, the red cell alloantibodies rate remains very low (0.9 and 1.53%) and raises the question of the relevance of this systematic testing after transfusion, which is in any case mandatory before a new transfusion of red blood cells.

The Posidonia oceanica marine sedimentary record: A Holocene archive of heavy metal pollution

The study of a Posidonia oceanica mat (a peat-like marine sediment) core has provided a record of changes in heavy metal abundances (Fe, Mn, Ni, Cr, Cu, Pb, Cd, Zn, As and Al) since the Mid-Holocene (last 4470yr) in Portlligat Bay (NW Mediterranean). Metal contents were determined in P. oceanica. Both, the concentration records and the results of principal components analysis showed that metal pollution in the studied bay started ca. 2800yr BP and steadily increased until present. The increase in Fe, Cu, Pb, Cd, Zn and As concentrations since ca. 2800yr BP and in particular during Greek (ca. 2680-2465cal BP) and Roman (ca. 2150-1740cal BP) times shows an early anthropogenic pollution rise in the bay, which might be associated with large- and short-scale cultural and technological development. In the last ca. 1000yr the concentrations of heavy metals, mainly derived from anthropogenic activities, have significantly increased (e.g. from ~15 to 47μg g(-1) for Pb, ~23 to 95μg g(-1) for Zn and ~8 to 228μg g(-1) for As). Our study demonstrates for the first time the uniqueness of P. oceanica meadows as long-term archives of abundances, patterns, and trends of heavy metals during the Late Holocene in Mediterranean coastal ecosystems.

[Suitability of red blood cell transfusion: a multicenter study]

The purpose of this retrospective observational multicenter study was to assess appropriateness of red blood cell (RBC) transfusion, according to the French national guidelines (Agence française de sécurité sanitaire des produits de santé) published in 2002. Six hundred and thirty-nine RBC transfusions from nine institutions have been randomly selected and analysed. The data collected are issued from different specialities. Patients' characteristics, occurrences of transfusion, admission, pre-transfusion, post-transfusion and discharge haemoglobin concentrations have been collected. Two physicians (who are in charge) must evaluate the appropriateness of pre-transfusion, discharged haemoglobin concentrations, quantity and quality of transfused RBC. The mean pre-transfusion haemoglobin concentration was 7.89 ± 1.24, the median number of transfused RBC was two (extremes: 1-16), the mean discharge haemoglobin concentration was 10.14 ± 1.30 (-5 days after the end of transfusion). The pre-transfusion and discharge haemoglobin concentrations were higher if the patient presented a co-morbidity factor. Ninety-three percent of pre-transfusion and 79% of discharge haemoglobin concentrations are in accordance with the guidelines. According to the physicians, the RBC transfusions are too "precocious" when pre-transfusion haemoglobin concentration is above nine and the anaemia is asymptomatic. 50% of RBC transfusion with discharge haemoglobin concentration above 10 is not excessive. In case of acute anaemia, the pre-transfusion and discharge haemoglobin concentrations are higher and RBC transfusion excessive. In this study, the trigger haemoglobin concentration is "restrictive", but the target haemoglobin concentration is "liberal" with a high-discharge haemoglobin concentration. Inappropriate RBC transfusions are mainly due to over-transfusion.

Évaluation des connaissances médicales transfusionnelles dans 14 établissements publics de santé

This multi-centre study aimed to assess the knowledge in blood transfusion of medical staff in 14 state-run hospitals.

MATERIALS AND METHODS

A questionnaire was distributed to all potential prescribers of blood products. It contained 35 questions concerning various subjects: blood products, immuno-haematology, prescription of blood products, transfusion practice, interpretation of the final bedside controls. The rate of correct answers (RCA) was obtained for each question, for each subject, and for nine questions defined as essential for patient safety. A weighted score was also calculated by ranking each question between one and six according to its importance.

RESULTS

Six hundred and ninety four questionnaires were analysed (rate of return 15%). The RCA ranged from 14 to 89%, according to the questions. The RCA ranged from 47 to 78% for seven of the nine essential safety questions, and 82% and 83% for the two questions concerning the interpretation of incompatible final bedside controls: there were 9% of wrong answers, which validated an incompatible blood transfusion. The mean weighted score was 62%. Both the RCA and the weighted score were higher for those that regularly prescribe blood products than for that only prescribe them occasionally. There were no significant differences between hospitals.

CONCLUSION

This study has confirmed that medical staff have deficiencies in their knowledge of blood transfusion, deficiencies which are acknowledged by medical staff. These first results will help the members of the study group to develop and prioritize various actions to improve this state of affairs, and to follow the effects of the training given.

Desmopressin is not always effective in mild haemophilia A patients undergoing urological surgery: the need of standardized protocols

Desmopressin may be an efficient haemostatic treatment for mild A haemophiliacs because its infusion raises plasma factor VIII level. We report the use of desmopressin in five mild haemophilia A patients undergoing urological surgery. They all received a preoperative infusion (0.3 microg kg(-1), i.v.) 1 h before incision followed by repeated injections at 12- or 24-h intervals according to the severity of the procedure. Nevertheless, four patients presented a postoperative bleeding requiring again surgery performed for 3 of them under clotting factor concentrate instead of desmopressin. The occurrence of haemorrhage was not always correlated with particularly low plasma factor VIII level. Surgical management of urological procedures with desmopressin in mild haemophilia A patients requires standardized protocols.

[Platelet transfusion and allergic transfusion reactions: experiences at Lille Hospital over a four year period]

Among the immediate transfusion reactions caused by the utilization of blood products, those suggesting immuno-allergic mechanisms posed problems for frequency, gravity, laboratory diagnosis and safety. We report here the Lille Hospital's experience over a four-year period concerning these manifestations after platelet concentrate transfusion. Eight hundred and fifty-two immediate transfusion reactions have been declared, of which 230 were allergic, which appeared in 181 patients (27%). Among the most frequent clinical signs, rash was often described (158 cases: 68.7%); less frequent were respiratory problems such as dyspnea (34 cases: 14.8%) and hypotensive reactions (18 cases: 7.8%). Seven patients presented severe reactions (3%). Twenty percent of them presented multiple allergic reactions and in 43.2%, the recurrence was more serious than the initial problem in spite of preventive medication; the use of washed blood components was necessary. The age of platelet concentrates does not appear to play a part in provoking these events (67% of platelet concentrates had been collected within four days). These allergic transfusion reactions posed problems for those who prescribe medication, because they are frequent, sometimes serious, can recur and at present, the proposed medication prevention is not always efficient.

[Diagnostic difficulties of transfusion incidents due to bacterial contamination: report of two cases]

The French hemovigilance system has recently underlined the relative frequency of transfusion-associated bacterial sepsis and the necessity to remain constantly aware of this eventuality. We describe the experience of a hematology unit over a 18-month period: 189 acute transfusion reactions were registered and bacterial cultures of the implicated cellular blood products realized in 82 of them. A positive result was obtained in two cases. For both cases, clinical symptoms of transfusion reaction were limited to a lasting fever, and a skin rash occurred in aplastic patients with preexisting signs of sepsis. The causal relationship between this contamination and the transfusion reaction is difficult to establish. Clinical manifestations justifying a bacterial inquiry must therefore be more precisely defined, particularly in multitransfused patients.

[Impact of a quality approach for transfusion safety on prescription, circuit optimization, traceability]

The Quality Assessment Program undertaken at the Regional University Hospital of Lille benefits from previous experience making management of this project possible: continuing education, preliminary initiation into the quality approach, and existing reference systems. The aims are to master the rates of outdated and no longer efficient red cell concentrates, to control red cell concentrate delivery time, to validate the refrigeration line integrity and to ensure a flawless marking out process. The process studied is transverse, with those taking part in it belonging to several professional categories. The method will consist in a process identification, its description and characterization according to FMECA (Failure Mode Effects and Criticality Analysis), the creation of a new process and its improvement. Thus failures should be identified and classified hierachically. The corrective actions will consist in communication aids, an education program, blood product transport and blood depot reorganization, data processing improvement and medical equipment acquisition. Quality indicators are developed according to the objectives of the study, and progress indicators are developed as a periodical assessment of blood transfusion practice. This ambitious project relies on the involvement of Hospital Management and referent network. These referents facilitate the improvement processes for those taking part in this process.