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Yamaguchi M, Sagara A, Nagayama Y, Morinaga J, Yamanouchi Y, Makino S, Matsunaga S, Tanaka H, Hasegawa J, Ikeda T, Sugiyama T, Kondoh E. Dynamic Computed Tomography Findings as Indicators of Uterine Artery Embolization in Postpartum Hemorrhage. JAMA Netw Open 2025; 8:e2512209. [PMID: 40408104 PMCID: PMC12102700 DOI: 10.1001/jamanetworkopen.2025.12209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2024] [Accepted: 03/22/2025] [Indexed: 05/26/2025] Open
Abstract
Importance Postpartum hemorrhage (PPH) remains the leading cause of maternal mortality globally. Although traditional management relies on blood loss quantification, identifying cases resistant to conventional treatment remains challenging, potentially delaying crucial interventions. Objective To determine the prevalence and clinical implications of PPH that is resistant to treatment showing arterial contrast extravasation on dynamic computed tomography (CT) (PRACE) and its association with intervention requirements. Design, Setting, and Participants A multicenter retrospective case-control study of PPH cases was conducted at 43 tertiary facilities across Japan, including 30 university hospitals, between January and December 2021. The study included patients with PPH who were either transported to the centers or who delivered there. Data analysis was performed from September 2023 to November 2024. Exposure A diagnosis of PPH, defined as blood loss exceeding 2000 mL or requiring more than 10 units of red blood cell transfusion. Main Outcomes and Measures The primary outcome was the prevalence of PRACE and its association with uterine artery embolization (UAE) requirement. Secondary outcomes included risk factors for severe coagulopathy (fibrinogen <150 mg/dL). Odds ratios (ORs) were estimated using multivariable logistic regression to evaluate the association between types of PPH (atonic uterus, tissue, and PRACE) and PPH severity. Results Among 352 patients (median [IQR] age, 33.0 [30.0-37.0] years; 211 [60.0%] primiparous), 205 (58.2%) underwent CT scans, with PRACE detected in 58 (32.2%) of evaluable cases. Patients with PRACE had significantly higher total blood loss (median [IQR], 3455 [2000-5070] mL vs 2500 [1500-2650] mL) and greater UAE requirement (50 of 58 patients [86.2%] vs 35 of 122 patients [28.7%]) compared with patients without PRACE. PRACE was the primary factor associated with the need for UAE (OR, 27.74; 95% CI, 10.52-83.14). Conclusions and Relevance In this retrospective case-control study of patients with severe PPH undergoing dynamic CT, PRACE represented a distinct and common pathology in severe PPH and was associated with the need for interventional procedures. These findings suggest that dynamic CT imaging should be considered as an essential diagnostic tool in managing treatment-resistant PPH cases.
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Affiliation(s)
- Munekage Yamaguchi
- Department of Obstetrics and Gynecology, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan
| | - Akihito Sagara
- Department of Obstetrics and Gynecology, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan
| | - Yasunori Nagayama
- Department of Diagnostic Radiology, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan
| | - Jun Morinaga
- Department of Clinical Investigation, Kumamoto University Hospital, Kumamoto, Japan
| | - Yoshinori Yamanouchi
- Department of Clinical Investigation, Kumamoto University Hospital, Kumamoto, Japan
| | - Shintaro Makino
- Department of Obstetrics and Gynecology, Juntendo University Faculty of Medicine, Tokyo, Japan
| | - Shigetaka Matsunaga
- Center for Maternal, Fetal and Neonatal Medicine, Saitama Medical Center, Saitama Medical University, Kawagoe, Japan
| | - Hiroaki Tanaka
- Department of Obstetrics and Gynecology, Mie University Graduate School of Medicine, Tsu, Japan
- Department of Obstetrics and Gynecology, Kumamoto General Hospital, Japan Community Health Care Organization, Kumamoto, Japan
| | - Junichi Hasegawa
- Department of Obstetrics and Gynecology, St Marianna University School of Medicine, Kawasaki, Japan
| | - Tomoaki Ikeda
- Department of Obstetrics and Gynecology, Mie University Graduate School of Medicine, Tsu, Japan
| | - Takashi Sugiyama
- Department of Obstetrics and Gynecology, School of Medicine, Ehime University, Matsuyama, Japan
| | - Eiji Kondoh
- Department of Obstetrics and Gynecology, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan
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Nieto-Calvache AJ, Otero AF, Nieto-Calvache AS, Aryananda R, Ortiz-Lizcano EI, Meade-Triviño P, Maya J, Sarria-Ortiz D, Muñoz-Córdoba L, Yanque-Robles O, Posadas A, Zea-Prado F, Burgos-Luna JM, Vasco M, Messa-Bryon A. Usefulness of a low-cost simulation model for teaching internal manual aortic compression. A survey-based mannequin evaluation. Int J Gynaecol Obstet 2024; 164:763-769. [PMID: 37872710 DOI: 10.1002/ijgo.15197] [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: 07/11/2023] [Revised: 09/22/2023] [Accepted: 09/28/2023] [Indexed: 10/25/2023]
Abstract
OBJECTIVE To evaluate the users' opinion on internal manual aortic compression (IMAC) training, using a low-cost simulation model. METHODS An educational strategy was designed to teach IMAC, which included: (1) guided reading of educational material and viewing an explanatory video of IMAC; (2) an introductory lecture with the anatomical considerations, documentation of the cessation of femoral arterial flow during IMAC, and real clinical cases in which this procedure was used; and (3) simulated practice of IMAC with a new low-cost manikin. The educational strategy was applied during three postpartum hemorrhage workshops in three Latin American countries and the opinions of the participants were measured with a survey. RESULTS Almost all of the participants in the IMAC workshop, including the simulation with the low-cost mannikin, highlighted the usefulness of the strategy (scores of 4/5 and 5/5 on the Likert scale) and would recommend it to colleagues. CONCLUSION We present a low-cost simulation model for IMAC as the basis of an educational strategy perceived as very useful by most participants. The execution of this strategy in other populations and its impact on postpartum hemorrhage management should be evaluated in further studies.
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Affiliation(s)
| | | | | | - Rozi Aryananda
- Dr. Soetomo Academic General Hospital, Universitas Airlangga, Surabaya, Indonesia
| | | | | | - Juliana Maya
- Facultad de Ciencias de la Salud, Programa de Medicina, Universidad Icesi, Cali, Colombia
| | | | - Laura Muñoz-Córdoba
- Fundación Valle del Lili, Centro de Investigaciones Clínicas, Cali, Colombia
| | | | - Alejandro Posadas
- Centro de Entrenamiento Quirúrgico en Obstetricia y Ginecología (CEQOG), México City, Mexico
| | | | | | - Mauricio Vasco
- Director simulación clínica, Facultad de medicina, Universidad CES, Medellín, Colombia
| | - Adriana Messa-Bryon
- Departamento de Ginecología y Obstetricia, Fundación Valle del Lili, Cali, Colombia
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Wohlgemut JM, Pisirir E, Stoner RS, Kyrimi E, Christian M, Hurst T, Marsh W, Perkins ZB, Tai NRM. Identification of major hemorrhage in trauma patients in the prehospital setting: diagnostic accuracy and impact on outcome. Trauma Surg Acute Care Open 2024; 9:e001214. [PMID: 38274019 PMCID: PMC10806521 DOI: 10.1136/tsaco-2023-001214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 12/24/2023] [Indexed: 01/27/2024] Open
Abstract
Background Hemorrhage is the most common cause of potentially preventable death after injury. Early identification of patients with major hemorrhage (MH) is important as treatments are time-critical. However, diagnosis can be difficult, even for expert clinicians. This study aimed to determine how accurate clinicians are at identifying patients with MH in the prehospital setting. A second aim was to analyze factors associated with missed and overdiagnosis of MH, and the impact on mortality. Methods Retrospective evaluation of consecutive adult (≥16 years) patients injured in 2019-2020, assessed by expert trauma clinicians in a mature prehospital trauma system, and admitted to a major trauma center (MTC). Clinicians decided to activate the major hemorrhage protocol (MHPA) or not. This decision was compared with whether patients had MH in hospital, defined as the critical admission threshold (CAT+): administration of ≥3 U of red blood cells during any 60-minute period within 24 hours of injury. Multivariate logistical regression analyses were used to analyze factors associated with diagnostic accuracy and mortality. Results Of the 947 patients included in this study, 138 (14.6%) had MH. MH was correctly diagnosed in 97 of 138 patients (sensitivity 70%) and correctly excluded in 764 of 809 patients (specificity 94%). Factors associated with missed diagnosis were penetrating mechanism (OR 2.4, 95% CI 1.2 to 4.7) and major abdominal injury (OR 4.0; 95% CI 1.7 to 8.7). Factors associated with overdiagnosis were hypotension (OR 0.99; 95% CI 0.98 to 0.99), polytrauma (OR 1.3, 95% CI 1.1 to 1.6), and diagnostic uncertainty (OR 3.7, 95% CI 1.8 to 7.3). When MH was missed in the prehospital setting, the risk of mortality increased threefold, despite being admitted to an MTC. Conclusion Clinical assessment has only a moderate ability to identify MH in the prehospital setting. A missed diagnosis of MH increased the odds of mortality threefold. Understanding the limitations of clinical assessment and developing solutions to aid identification of MH are warranted. Level of evidence Level III-Retrospective study with up to two negative criteria. Study type Original research; diagnostic accuracy study.
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Affiliation(s)
- Jared M Wohlgemut
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, UK
- Trauma Service, Royal London Hospital, Barts Health NHS Trust, London, UK
| | - Erhan Pisirir
- School of Electronic Engineering and Computer Science, Queen Mary University of London, London, UK
| | - Rebecca S Stoner
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, UK
- Trauma Service, Royal London Hospital, Barts Health NHS Trust, London, UK
| | - Evangelia Kyrimi
- School of Electronic Engineering and Computer Science, Queen Mary University of London, London, UK
| | | | | | - William Marsh
- School of Electronic Engineering and Computer Science, Queen Mary University of London, London, UK
| | - Zane B Perkins
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, UK
- Trauma Service, Royal London Hospital, Barts Health NHS Trust, London, UK
| | - Nigel R M Tai
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, UK
- Trauma Service, Royal London Hospital, Barts Health NHS Trust, London, UK
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Papa L, Maguire L, Thundiyil JG, Ladde JG, Miller SA. Age and sex differences in blood product transfusions and mortality in trauma patients at a level I trauma center. Heliyon 2023; 9:e18890. [PMID: 37583761 PMCID: PMC10424079 DOI: 10.1016/j.heliyon.2023.e18890] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 07/29/2023] [Accepted: 08/02/2023] [Indexed: 08/17/2023] Open
Abstract
Objectives Hemorrhage is a common complication of trauma. We evaluated age and sex differences in treatment with blood product transfusions and massive transfusions as well as in-hospital mortality following trauma at a Level 1 Trauma Center. Methods This cross-sectional study evaluated trauma data from a Level 1 trauma center registry from January 2013 to December 2017. The primary outcome was amount of blood products (packed red blood cells (PRBCs), plasma, platelets), and massive transfusion (MT) by biological sex and by age group: 16-24 (youth), 25-59 (middle age), and >=60 (older age) The secondary outcome was in-hospital mortality to hospital discharge. Results There were 13596 trauma patients in the registry, mean age was 48 years, 4589 (34%) female and 9007 (66%) male, and median ISS of 9. Male patients received significantly more PRBC transfusions than female patients within 4-hours 6.6% vs 4.4%, and 24-hours 6.7% vs 4.5% respectively. Older patients received significantly fewer PRBC transfusions within 4-hours and 24-hours than their younger counterparts, with 6.9% in the youth group, 6.8% in the middle age group, and 3.9% in the older group (p<0.001). When adjusted for injury severity, the odds of receiving a blood transfusion within 4 hours of injury was significantly lower in older females. Using multivariate analysis, predictors of mortality included (in order of significance) injury severity, older age, transfusion within 4 hours of injury, penetrating trauma, and male sex. Conclusion In this large trauma cohort, older female trauma patients were less likely to receive blood products compared to younger females and to their older male counterparts, even after adjusting for injury severity. Predictors of mortality included injury severity, older age, early transfusion, penetrating trauma, and male sex. Following trauma, older women appear vulnerable to undertreatment. Further study is needed to determine the reasons for these differences and their impact on patient outcomes.
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Affiliation(s)
- Linda Papa
- Department of Emergency Medicine, Orlando Regional Medical Center, Orlando, FL, USA
| | - Lindsay Maguire
- Department of Emergency Medicine, Orlando Regional Medical Center, Orlando, FL, USA
| | - Josef G. Thundiyil
- Department of Emergency Medicine, Orlando Regional Medical Center, Orlando, FL, USA
| | - Jay G. Ladde
- Department of Emergency Medicine, Orlando Regional Medical Center, Orlando, FL, USA
| | - Susan A. Miller
- Department of Emergency Medicine, Orlando Regional Medical Center, Orlando, FL, USA
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Liu LY, Nathan L, Sheen JJ, Goffman D. Review of Current Insights and Therapeutic Approaches for the Treatment of Refractory Postpartum Hemorrhage. Int J Womens Health 2023; 15:905-926. [PMID: 37283995 PMCID: PMC10241213 DOI: 10.2147/ijwh.s366675] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 02/03/2023] [Indexed: 06/08/2023] Open
Abstract
Refractory postpartum hemorrhage (PPH) affects 10-20% of patients with PPH when they do not respond adequately to first-line treatments. These patients require second-line interventions, including three or more uterotonics, additional medications, transfusions, non-surgical treatments, and/or surgical intervention. Multiple studies have suggested that patients with refractory PPH have different clinical characteristics and causes of PPH when compared to patients who respond to first-line agents. This review highlights current insights into therapeutic approaches for the management of refractory PPH. Early management of refractory PPH relies on both hypovolemic resuscitation and achievement of hemostasis, with an emphasis on early blood product replacement and massive transfusion protocols. Transfusion needs can be more rapidly and accurately identified through point-of-care tests such as thromboelastography. Medical therapies for the treatment of refractory PPH involve treatment of both uterine atony as well as the underlying coagulopathy, with the use of tranexamic acid and adjunct therapies such as factor replacement. The principles guiding the management of refractory PPH include restoring normal uterine and pelvic anatomy, through the evaluation and management of retained products of conception, uterine inversion, and obstetric lacerations. Intrauterine vacuum-induced hemorrhage control devices are novel methods for the treatment of refractory PPH secondary to uterine atony, in addition to other uterine-sparing surgical procedures that are under investigation. Resuscitative endovascular balloon occlusion of the aorta can be considered for cases of critical refractory PPH, to prevent or decrease ongoing blood loss while definitive surgical interventions are performed. Finally, for patients with critical hemorrhage resulting in hemorrhagic shock, damage control resuscitation (a staged surgical approach focused on restoring normal physiologic recovery and maximizing tissue oxygenation prior to proceeding with definitive surgical management) has been shown to successfully control refractory PPH, with an overall mortality decrease for obstetric patients.
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Affiliation(s)
- Lilly Y Liu
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, New York, NY, USA
| | - Lisa Nathan
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, New York, NY, USA
| | - Jean-Ju Sheen
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, New York, NY, USA
| | - Dena Goffman
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, New York, NY, USA
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Uchida K, Mizobata Y. Warning about potential incidents of critical hyperkalemia during massive transfusion protocol after the preservation period of red blood cell products was extended in Japan. Acute Med Surg 2023; 10:e882. [PMID: 37577335 PMCID: PMC10413817 DOI: 10.1002/ams2.882] [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: 04/06/2023] [Revised: 07/01/2023] [Accepted: 07/24/2023] [Indexed: 08/15/2023] Open
Abstract
Background Recently, the Japanese Red Cross Society approved extension of the preservation period of red blood cell products. Since then, we have already experienced two cases of critical hyperkalemia during massive transfusion protocol (MTP). Case Presentation Case 1, a 24-year-old man was stabbed in his right posterior chest. Although quick hemorrhage control was completed 35 min after arrival, his potassium level increased from 3.5 to 8.9 mEq/L within 40 min. Case 2, a 44-year-old man was transferred to our hospital after a car hit him. We immediately started resuscitation including MTP and opened his abdomen 24 min after arrival. His potassium level increased from 3.5 to 7.8 mEq/L within 38 min. Conclusion Although several other factors might be causing this rise in potassium, we consider the extended preservation periods of red blood cell products to be one cause of these unexpectedly rapid rises in potassium during MTP.
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Affiliation(s)
- Kenichiro Uchida
- Department of Traumatology and Critical Care Medicine, Graduate School of MedicineOsaka Metropolitan UniversityOsakaJapan
| | - Yasumitsu Mizobata
- Department of Traumatology and Critical Care Medicine, Graduate School of MedicineOsaka Metropolitan UniversityOsakaJapan
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Carballo F, Albillos A, Llamas P, Orive A, Redondo-Cerezo E, Rodríguez de Santiago E, Crespo J. Consensus document of the Spanish Society of Digestives Diseases and the Spanish Society of Thrombosis and Haemostasis on massive nonvariceal gastrointestinal bleeding and direct-acting oral anticoagulants. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2022; 114:375-389. [PMID: 35686480 DOI: 10.17235/reed.2022.8920/2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/13/2025]
Abstract
INTRODUCTION there is limited experience and understanding of massive nonvariceal gastrointestinal bleeding during therapy with direct-acting oral anticoagulants. OBJECTIVES to provide evidenced-based definitions and recommendations. METHODS a consensus document developed by the Spanish Society of Digestives Diseases and the Spanish Society of Thrombosis and Haemostasis using modified Delphi methodology. A panel was set up of 24 gastroenterologists with experience in gastrointestinal bleeding, and consensus building was assessed over three rounds. Final recommendations are based on a systematic review of the literature using the GRADE system. RESULTS panelist agreement was 91.53 % for all 30 items as a group, a percentage that was improved during rounds 2 and 3 for items where clinical experience is lower. Explicit disagreement was only 1.25 %. A definition of massive nonvariceal gastrointestinal bleeding in patients on direct-acting oral anticoagulants was established, and recommendations to optimize this condition's management were developed. CONCLUSION the approach to these critically ill patients must be multidisciplinary and protocolized, optimizing decisions for an early identification of the condition and patient stabilization according to the tenets of damage control resuscitation. Thus, consideration must be given to immediate anticoagulation reversal, preferentially with specific antidotes (idarucizumab for dabigatran and andexanet alfa for direct factor Xa inhibitors); hemostatic resuscitation, and bleeding point identification and management.
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Affiliation(s)
- Fernando Carballo
- Medicina de Aparato Digestivo, Hospital Clínico Universitario Virgen de la Arrixaca, España
| | - Agustín Albillos
- Gastroenterología y Hepatología, Hospital Universitario Ramón y Cajal
| | - Pilar Llamas
- Hematología, Hospital Universitario Fundación Jiménez Díaz
| | - Aitor Orive
- Aparato Digestivo, Hospital Universitario de Araba
| | | | | | - Javier Crespo
- Aparato Digestivo, Hospital Universitario Marqués de Valdecilla
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Selleng K, Greinacher A. 10 Years of Experience with the First Thawed Plasma Bank in Germany. Transfus Med Hemother 2021; 48:350-357. [PMID: 35082566 PMCID: PMC8739389 DOI: 10.1159/000519700] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Accepted: 09/10/2021] [Indexed: 10/01/2024] Open
Abstract
BACKGROUND Plasma is stored at -30°C, which requires thawing before transfusion, causing a time delay between ordering and issuing of at least 30 min. In case of bleeding emergencies, guidelines strongly recommend a 2:1 transfusion ratio of RBCs and plasma. In addition, each minute delay in issuing of blood products in bleeding emergencies increases the mortality risk. To provide plasma in time in bleeding emergencies, a thawed plasma bank was introduced in 2011. SUMMARY The thawed plasma bank of University Medicine Greifswald has provided 18,924 thawed stored plasma units between 2011 and 2020. The workflow in the laboratory as well as in the emergency room, the operating room, and the intensive care unit have been optimized by thawed stored plasma. In case of emergencies, the stress factor for the transfusion medicine laboratory staff has been reduced substantially. The thawed plasma bank allows to transfuse patients with massive transfusion demand at a 2:1 ratio of RBCs and plasma according to guidelines. To reduce storage time, we issue all plasma requests from the thawed plasma bank except for pediatric patients. This results in a median storage time in the thawed plasma bank of 24 h. The "just in time" availability of plasma within the entire hospital based on the thawed plasma bank has reduced precautionary ordering of plasma, and hereby the unnecessary use of plasma. After introduction of the thawed plasma bank, plasma usage decreased substantially by 24% within the first year and by 60% compared to 2019/2020. However, as the overall approach to using blood products has changed over the last 10 years due to the patient blood management initiative, quantification of the effects of the thawed plasma bank in reduction of plasma transfusion is difficult. KEY MESSAGES (1) A thawed plasma bank for the routine supply of blood products in a large hospital is feasible in Germany. (2) The thawed plasma bank allows to supply RBCs and plasma in a 2:1 ratio in bleeding emergencies. (3) The beneficial logistical effects of the thawed plasma bank are optimal if all plasma requests are supplied from the thawed plasma bank. This results in a median storage time of 24 h for thawed plasma.
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Affiliation(s)
- Kathleen Selleng
- Institut für Immunologie und Transfusionsmedizin, Abteilung Transfusionsmedizin, Universitätsmedizin Greifswald, Greifswald, Germany
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Management and outcomes of open pelvic fractures: An update. Injury 2021; 52:2738-2745. [PMID: 32139131 DOI: 10.1016/j.injury.2020.02.096] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Revised: 02/07/2020] [Accepted: 02/19/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND Open pelvic fractures remain challenging in terms of their management. The purpose of this narrative review was to evaluate the latest advances made in the management of these injuries and report on their clinical outcome. PATIENTS AND METHODS A literature review was undertaken focusing on studies that have been published on the management of open pelvic fractures between January 2005 and November 2019. Information extracted from each article include demographics, mechanism of injury, injury severity score (ISS), classification of pelvic ring fracture, classification of open soft tissue, specific injury zone classification, number of cases with hemodynamic instability, number of cases that received blood transfusions, amount of packed red blood cells transfused during the first 24 h, number of cases with anorectal trauma, urogenital injury, number of fecal diversional colostomies and laparotomies, angiographies and embolization, preperitoneal pelvic packings, length of stay in intensive care unit (ICU) and in hospital, and mortality. RESULTS Fifteen articles with 646 cases formed the basis of this review. The majority of patients were male adults (74.9%). The mean age was 35.1 years. The main mechanism of injury was road traffic accidents, accounting for 67.1% of the injuries. The mean ISS was 26.8. A mean of 13.5 units of PRBCs were administered the first 24 h. During the whole hospital stay, 79.3% of the patients required blood transfusions. Angiography and pelvic packing were performed in a range of 3%-44% and 13.3%-100% respectively. Unstable types of pelvic injuries were the majority (72%), whilst 32.7% of the cases were associated with anorectal trauma, and 32.6% presented with urogenital injuries. Bladder ruptures were the most reported urogenital injury. Fecal diversional colostomy was performed in 37.4% of the cases. The mean length of ICU stay was 12.5 days and the mean length of hospital stay was 53.0 days. The mean mortality rate was 23.7%. CONCLUSION Mortality following open pelvic fracture remains high despite the evolution of trauma management the last 2 decades. Sufficient blood transfusion, bleeding control, treatments of associated injuries, fracture fixation and soft tissue management remain essential for the reduction of mortality and improved outcomes.
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Clinical Results of a Massive Blood Transfusion Protocol for Postpartum Hemorrhage in a University Hospital in Japan: A Retrospective Study. ACTA ACUST UNITED AC 2021; 57:medicina57090983. [PMID: 34577906 PMCID: PMC8467345 DOI: 10.3390/medicina57090983] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Revised: 09/12/2021] [Accepted: 09/16/2021] [Indexed: 11/25/2022]
Abstract
Background and objectives: Massive postpartum hemorrhage (PPH) is the most common cause of maternal death worldwide. A massive transfusion protocol (MTP) may be used to provide significant benefits in the management of PPH; however, only a limited number of hospitals use MTP protocol to manage massive obstetric hemorrhages, especially in Japan. This study aimed to assess the clinical outcomes in patients in whom MTP was activated in our hospital. Materials and Methods: We retrospectively reviewed the etiology of PPH, transfusion outcomes, and laboratory findings among the patients treated with MTP after delivery in our hospital. Results: MTP was applied in 24 cases (0.7% of deliveries). Among them, MTP was activated within 2 h of delivery in 15 patients (62.5%). The median estimated blood loss was 5017 mL. Additional procedures to control bleeding were performed in 19 cases, including transarterial embolization (18 cases, 75%) and hysterectomy (1 case, 4.2%). The mean number of units of red blood cells, fresh frozen plasma, and platelets were 17.9, 20.2, and 20.4 units, respectively. The correlation coefficients of any two items among red blood cells, fresh frozen plasma, platelets, blood loss, and obstetrical disseminated intravascular coagulation score ranged from 0.757 to 0.892, indicating high levels of correlation coefficients. Although prothrombin time and activated partial thromboplastin time levels were significantly higher in the <150 mg/dL fibrinogen group than in the ≥150 mg/dL fibrinogen group at the onset of PPH, the amount of blood loss and blood transfusion were comparable between the two groups. Conclusions: Our MTP provides early access to blood products for patients experiencing severe PPH and could contribute to improving maternal outcomes after resuscitation in our hospital. Our study suggests the implementation of a hospital-specific MTP protocol to improve the supply and utilization of blood products to physicians managing major obstetric hemorrhage.
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Gaitanidis A, Sinyard RT, Nederpelt CJ, Maurer LR, Christensen MA, Mashbari H, Velmahos GC, Kaafarani HMA. Lower Mortality with Cryoprecipitate During Massive Transfusion in Penetrating but Not Blunt Trauma. J Surg Res 2021; 269:94-102. [PMID: 34537533 DOI: 10.1016/j.jss.2021.07.027] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Revised: 06/23/2021] [Accepted: 07/13/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Balanced blood product transfusion improves the outcomes of trauma patients with exsanguinating hemorrhage, but it remains unclear whether administering cryoprecipitate improves mortality. We aimed to examine the impact of early cryoprecipitate transfusion on the outcomes of the trauma patients needing massive transfusion (MT). METHODS All MT patients 18 years or older in the 2017 Trauma Quality Improvement Program (TQIP) were retrospectively reviewed. MT was defined as the transfusion of ≥10 units of blood within 24 hours. Propensity score analysis (PSA) was used to 1:1 match then compare patients who received and those who did not receive cryoprecipitate in the first 4 hours after injury. Outcomes included in-hospital mortality, 1-day mortality, in-hospital complications and transfusion needs at 24 hours. RESULTS Of 1,004,440 trauma patients, 1,454 MT patients received cryoprecipitate and 2,920 did not. After PSA, 877 patients receiving cryoprecipitate were matched to 877 patients who did not. In-hospital mortality was lower among patients who received cryoprecipitate (49.4% v. 54.9%, P = 0.022), as was 1-day mortality. Sub-analyses showed that mortality was lower with cryoprecipitate in patients with penetrating (37.5% versus. 48%, adjusted P = 0.008), but not blunt trauma (58.5% versus. 59.8%, adjusted P = 1.000). In penetrating trauma, the cryoprecipitate group also had lower 1-day mortality (21.8% versus. 38.6%, P <0.001) and a higher rate of hemorrhage control surgeries performed within 24 hours (71.4% versus. 63.3%, P = 0.018). CONCLUSIONS Cryoprecipitate in MT is associated with improved survival in penetrating, but not blunt, trauma. Randomized trials are needed to better define the role of cryoprecipitate in MT.
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Affiliation(s)
- Apostolos Gaitanidis
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts; Center for Outcomes & Patient Safety in Surgery (COMPASS), Massachusetts General Hospital, Boston, Massachusetts
| | - Robert T Sinyard
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts
| | - Charlie J Nederpelt
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts
| | - Lydia R Maurer
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts; Center for Outcomes & Patient Safety in Surgery (COMPASS), Massachusetts General Hospital, Boston, Massachusetts
| | - Mathias A Christensen
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts
| | - Hassan Mashbari
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts; Center for Outcomes & Patient Safety in Surgery (COMPASS), Massachusetts General Hospital, Boston, Massachusetts
| | - George C Velmahos
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts
| | - Haytham M A Kaafarani
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts; Center for Outcomes & Patient Safety in Surgery (COMPASS), Massachusetts General Hospital, Boston, Massachusetts.
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12
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Koller T, Kinast N, Castellanos AG, Garcia SP, Iglesias PP, Vintro XL, Arranz JM, Seto NV, García MVM, Moreno-Castaño AB, Aznar-Salatti J, Albaladejo GE, Diaz-Ricart M. Normalization of blood clotting characteristics using prothrombin complex concentrate, fibrinogen and FXIII in an albumin based fluid: experimental studies in thromboelastometry. Scand J Trauma Resusc Emerg Med 2021; 29:57. [PMID: 33836790 PMCID: PMC8035752 DOI: 10.1186/s13049-021-00867-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2020] [Accepted: 03/15/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Colloid fluids supplemented with adequate combinations of coagulation factor concentrates with the capability to restore coagulation could be a desirable future treatment component in massive transfusion. METHODS Starting from a coagulation factor and blood cell-free albumin solution we added Prothrombin Complex Concentrate, Fibrinogen Concentrate and Factor XIII in different combinations and concentrations to analyze their properties to restore thromboelastometry parameters without the use of plasma. Further analysis under the presence of platelets was performed for comparability to whole blood conditions. RESULTS Albumin solutions enriched with Fibrinogen Concentrate, Factor XIII and Prothrombin Complex Concentrate at optimized concentrations show restoring coagulation potential. Prothrombin Complex Concentrate showed sufficient thrombin formation for inducing fibrinogen polymerization. The combination of Prothrombin Complex Concentrate and Fibrinogen Concentrate led to the formation of a stable in vitro fibrin clot. Fibrinogen and Factor XIII showed excellent capacity to improve fibrin clot firmness expressed as Amplitude at 10 min and Maximal Clot Firmness. Fibrinogen alone, or in combination with Factor XIII, was able to restore normal Amplitude at 10 min and Maximal Clot Firmness values. In the presence of platelets, the thromboelastometry surrogate parameter for thrombin generation (Clotting Time) improves and normalizes when compared to whole blood. CONCLUSIONS Combinations of coagulation factor concentrates suspended in albumin solutions can restore thromboelastometry parameters in the absence of plasma. This kind of artificial colloid fluids with coagulation-restoring characteristics might offer new treatment alternatives for massive transfusion. TRIAL REGISTRATION Study registered at the institutional ethic committee "Institut de Recerca, Hospital Santa Creu i Sant Pau, with protocol number IIBSP-CFC-2013-165.
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Affiliation(s)
- Tobias Koller
- Hospital de la Santa Creu i San Pau, Universidad Autonoma de Barcelona, Departamento de Cirugía, Carrer de Sant Quintí, 89, 08041, Barcelona, Spain.
| | - Nadia Kinast
- Consorci Sanitari Alt Penedés-Garraf, Carrer de l'Espirall, s/n, Vilafranca del Penedés, Spain
| | | | - Sergio Perez Garcia
- Hospital de la Santa Creu i San Pau, Universidad Autonoma de Barcelona, Departamento de Cirugía, Carrer de Sant Quintí, 89, 08041, Barcelona, Spain
| | - Pilar Paniagua Iglesias
- Hospital de la Santa Creu i San Pau, Universidad Autonoma de Barcelona, Departamento de Cirugía, Carrer de Sant Quintí, 89, 08041, Barcelona, Spain
| | - Xavi León Vintro
- Hospital de la Santa Creu i San Pau, Universidad Autonoma de Barcelona, Departamento de Cirugía, Carrer de Sant Quintí, 89, 08041, Barcelona, Spain
| | - Jose Mateo Arranz
- Hospital de la Santa Creu i San Pau, Universidad Autonoma de Barcelona, Departamento de Cirugía, Carrer de Sant Quintí, 89, 08041, Barcelona, Spain
| | - Noelia Vilalta Seto
- Hospital de la Santa Creu i San Pau, Universidad Autonoma de Barcelona, Departamento de Cirugía, Carrer de Sant Quintí, 89, 08041, Barcelona, Spain
| | - Ma Victòria Moral García
- Hospital de la Santa Creu i San Pau, Universidad Autonoma de Barcelona, Departamento de Cirugía, Carrer de Sant Quintí, 89, 08041, Barcelona, Spain
| | - Ana Belén Moreno-Castaño
- Hematopathology, Pathology Department, CDB, Hospital Clinic, IDIBAPS, University of Barcelona, Barcelona, Spain
| | | | - Gines Escolar Albaladejo
- Hematopathology, Pathology Department, CDB, Hospital Clinic, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Maribel Diaz-Ricart
- Hematopathology, Pathology Department, CDB, Hospital Clinic, IDIBAPS, University of Barcelona, Barcelona, Spain
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13
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Kwon J, Lee JH, Hwang K, Heo Y, Cho HJ, Lee JCJ, Jung K. Systematic Preventable Trauma Death Rate Survey to Establish the Region-based Inclusive Trauma System in a Representative Province of Korea. J Korean Med Sci 2020; 35:e417. [PMID: 33372420 PMCID: PMC7769700 DOI: 10.3346/jkms.2020.35.e417] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Accepted: 10/15/2020] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Trauma mortality review is the first step in assessing the quality of the trauma treatment system and provides an important basis for establishing a regional inclusive trauma system. This study aimed to obtain a reliable measure of the preventable trauma death rate in a single province in Korea. METHODS From January to December 2017, a total of 500 sample cases of trauma-related deaths from 64 hospitals in Gyeonggi Province were included. All cases were evaluated for preventability and opportunities for improvement using a multidisciplinary panel review approach. RESULTS Overall, 337 cases were included in the calculation for the preventable trauma death rate. The preventable trauma death rate was estimated at 17.0%. The odds ratio was 3.97 folds higher for those who arrived within "1-3 hours" than those who arrived within "1 hour." When the final treatment institution was not a regional trauma center, the odds ratio was 2.39 folds higher than that of a regional trauma center. The most significant stage of preventable trauma death was the hospital stage, during which 86.7% of the cases occurred, of which only 10.3% occurred in the regional trauma center, whereas preventable trauma death was more of a problem at emergency medical institutions. CONCLUSION The preventable trauma death rate was slightly lower in this study than in previous studies, although several problems were noted during inter-hospital transfer; in the hospital stage, more problems were noted at emergency medical care facilities than at regional trauma centers. Further, several opportunities for improvements were discovered regarding bleeding control.
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Affiliation(s)
- Junsik Kwon
- Division of Trauma Surgery, Department of Surgery, Ajou University School of Medicine, Suwon, Korea
- Southern Gyeonggi Trauma Center, Ajou University Hospital, Suwon, Korea
| | - Jin Hee Lee
- National Emergency Medical Center, National Medical Center, Seoul, Korea
| | - Kyungjin Hwang
- Division of Trauma Surgery, Department of Surgery, Ajou University School of Medicine, Suwon, Korea
- Southern Gyeonggi Trauma Center, Ajou University Hospital, Suwon, Korea
| | - Yunjung Heo
- The Health Insurance Review & Assessment Service, Wonju, Korea
| | - Hang Joo Cho
- Department of Emergency Medicine, Uijeongbu St. Mary's Hospital, The Catholic University of Korea, Seoul, Korea
| | - John Cook Jong Lee
- Division of Trauma Surgery, Department of Surgery, Ajou University School of Medicine, Suwon, Korea
- Southern Gyeonggi Trauma Center, Ajou University Hospital, Suwon, Korea
| | - Kyoungwon Jung
- Division of Trauma Surgery, Department of Surgery, Ajou University School of Medicine, Suwon, Korea
- Southern Gyeonggi Trauma Center, Ajou University Hospital, Suwon, Korea.
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14
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Puzio TJ, Kalkwarf K, Cotton BA. Predicting the need for massive transfusion in the prehospital setting. Expert Rev Hematol 2020; 13:983-989. [PMID: 32746651 DOI: 10.1080/17474086.2020.1803735] [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: 10/23/2022]
Abstract
INTRODUCTION Massive transfusion (MT) prediction scores allowed for the early identification of patients with massive hemorrhage likely to require large volumes of blood products. Despite their utility, very few MT scoring systems have shown promise in the pre-hospital setting due to their complexity and resource limitations. AREAS COVERED Pub med database was utilized to identify supporting literature for this review which discusses the importance of blood-based resuscitation and highlights the utility of scoring systems to predict the need of massive transfusion. MTP scoring systems effective in the prehospital setting are specifically discussed. EXPERT OPINION Massive transfusions scores are useful in alerting hospitals to the severity of trauma patients and organizing resources necessary for appropriate patient care but should not completely replace clinical . The opportunity exists to extend their use to the pre-hospital setting to allow for even earlier notification and to triage patients to trauma centers best able to treat severely injured.
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Affiliation(s)
- Thaddeus J Puzio
- Department of Surgery and the Center for Translational Injury Research, University of Texas Health Science Center , Houston, TX, USA
| | - Kyle Kalkwarf
- Department of Surgery, University of Arkansas Medical Sciences , Little Rock, AR, USA
| | - Bryan A Cotton
- Department of Surgery and the Center for Translational Injury Research, University of Texas Health Science Center , Houston, TX, USA
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15
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Abstract
Massive transfusion protocol (MTP) with fresh-frozen plasma and packed red blood cells (PRBCs) in a 1:1 ratio is one of the most common resuscitative strategies used in patients with severe hemorrhage. There are no studies to date that examine the best postoperative hematocrit range as a marker for survival after MTP. We hypothesize a postoperative hematocrit dose-dependent survival benefit in patients receiving MTP. This was a 53-month retrospective analysis of patients with intra-abdominal injuries requiring surgery and transfusion of 10 units PRBCs or more at a single Level I trauma center. Groups were defined by postoperative hematocrit (less than 21, 21 to 29, 29.1 to 39, and 39 or more). Kaplan-Meier (KM) survival probability was calculated. One hundred fifty patients requiring operative abdominal explorations and 10 units PRBCs or more were identified. There were no significant differences in demographics between groups. When comparing postoperative hematocrit groups, relative to a hematocrit of less than 21 per cent in KM survival analysis, an overall survival advantage was only evident in patients transfused to hematocrits 29.1 to 39 per cent ( P < 0.03; odds ratio [OR], 0.284; 95% confidence interval [CI], 0.089 to 0.914). This survival advantage was not seen in the other groups (21 to 29: OR, 0.352; 95% CI, 0.103 to 1.195 or 39% or greater: OR, 0.107; 95% CI, 0.010 to 1.121). This is the first study to examine the impact of postoperative hematocrit as an indicator of survival after MTP in the trauma patient. Transfusion to hematocrits between 29.1 and 39 per cent conveyed a survival benefit, whereas resuscitation to supraphysiologic hematocrits 39 per cent or greater conveyed no additional survival benefit. This study highlights the need for judicious PRBC administration during MTP and its potential impact on survival in patients with postoperative supraphysiologic hematocrits.
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16
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Taniguchi H, Doi T, Abe T, Takeuchi I. Trauma severity associated with stress index in emergency settings: an observational prediction-and-validation study. Acute Med Surg 2020; 7:e493. [PMID: 33391764 PMCID: PMC7774291 DOI: 10.1002/ams2.493] [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: 09/03/2019] [Revised: 01/23/2020] [Accepted: 02/05/2020] [Indexed: 11/23/2022] Open
Abstract
Aim Early judgments for treating severe trauma patients are essential for life‐saving. Stress index (SI), obtained from a division of blood glucose level by serum potassium at arrival, might be useful for early prediction. However, the efficacy of SI was unknown. The purpose of this study was to identify and validate prediction models of severe trauma (ST) and the need for damage control operation (DCOP) and massive transfusion (MT) by using SI among trauma patients. Methods This study was a retrospective and prospective observational study. The prediction models were created by 1‐year retrospective data of 167 trauma patients. The prediction models were validated by 6 months of prospective data of 87 trauma patients. Results The prediction model for ST contained respiratory rate and SI as significant factors. The prediction model for DCOP contained SI. The prediction model for MT contained systolic blood pressure and SI. The correlation of probability of MT, ST, and DCOP was r = 0.70 (P < 0.001), r = 0.46 (P < 0.001), and r = 0.15 (P = 0.196), respectively. The predicted probability of MT, ST, and DCOP showed 0.93 (95% confidence interval [CI], 0.88–0.90) and 0.80 (95% CI, 0.74–0.86), and 0.79 (95% CI, 0.70–0.88). Conclusion We identified and validated our prediction models for ST and the need for DCOP and MT among trauma patients using SI as a main predictor. Our models indicated that fewer variables in an early phase of the treatment process can inform clinicians regarding how severe a patient is and which intervention is needed.
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Affiliation(s)
- Hayato Taniguchi
- Department of Emergency and Critical Care Medicine Yokosuka Kyousai Hospital Yokosuka Japan.,Department of Emergency Medicine Yokohama City University Graduate School of Medicine Yokohama Japan
| | - Tomoki Doi
- Department of Emergency and Critical Care Medicine Yokosuka Kyousai Hospital Yokosuka Japan.,Department of Emergency Medicine Yokohama City University Graduate School of Medicine Yokohama Japan
| | - Takeru Abe
- Department of Emergency Medicine Yokohama City University Graduate School of Medicine Yokohama Japan
| | - Ichiro Takeuchi
- Department of Emergency Medicine Yokohama City University Graduate School of Medicine Yokohama Japan
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17
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Fresh frozen plasma-to-red blood cell ratio is an independent predictor of blood loss in patients with neuromuscular scoliosis undergoing posterior spinal fusion. Spine J 2020; 20:369-379. [PMID: 31525470 DOI: 10.1016/j.spinee.2019.09.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Revised: 09/04/2019] [Accepted: 09/10/2019] [Indexed: 02/03/2023]
Abstract
PURPOSE In major trauma with massive blood loss, higher fresh frozen plasma (FFP)-to-red blood cell (RBC) ratios have been associated with improved morbidity and mortality. Our population of patients with neuromuscular scoliosis undergoing posterior spinal fusion (PSF) often lose volumes of blood considered massive, that is, half a blood volume in 3 hours. In this retrospective cohort study, we examined the association of FFP ratio with blood loss in this elective surgical population. METHODS Patients with neuromuscular scoliosis undergoing PSF with unit rod fixation were identified from our anesthesia cases database. The patients were divided into two groups: the low FFP group received FFP-to-RBC≤0.5, and the high FFP group received FFP-to-RBC>0.5. After controlling for a false discovery rate in the univariate analysis, a logistic and linear regression was performed to understand the contribution of the significant factors associated with increased blood loss. RESULTS Risk estimation showed that patients in the low FFP group were more likely to lose >120% blood volume (odds ratio, 3.87; 95% confidence interval, 2.03-7.38). Linear regression revealed that each unit of increase in FFP-to-RBC ratio was associated with a 27.5% (95% confidence interval, -43.12-11.89) mean reduction in blood volume loss. CONCLUSIONS In our retrospective study, we found that FFP-to-RBC ratio was significant independent predictor of blood loss in this group of complex spine patients undergoing PSF. Thus, in patients with neuromuscular scoliosis undergoing posterior spine fusion, use of higher ratio of FFP to RBC may decrease blood loss.
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18
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Yoon KW, Cho D, Lee DS, Gil E, Yoo K, Choi KJ, Park CM. Clinical impact of massive transfusion protocol implementation in non-traumatic patients. Transfus Apher Sci 2020; 59:102631. [DOI: 10.1016/j.transci.2019.07.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Revised: 07/08/2019] [Accepted: 07/12/2019] [Indexed: 12/27/2022]
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19
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Wang IJ, Bae BK, Park SW, Cho YM, Lee DS, Min MK, Ryu JH, Kim GH, Jang JH. Pre-hospital modified shock index for prediction of massive transfusion and mortality in trauma patients. Am J Emerg Med 2020; 38:187-190. [PMID: 30738590 DOI: 10.1016/j.ajem.2019.01.056] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Revised: 01/13/2019] [Accepted: 01/17/2019] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Modified shock index (MSI) is a useful predictor in trauma patients. However, the value of prehospital MSI (preMSI) in trauma patients is unknown. The aim of this study was to investigate the accuracy of preMSI in predicting massive transfusion (MT) and hospital mortality among trauma patients. METHODS This was a retrospective, observational, single-center study. Patients presenting consecutively to the trauma center between January 2016 and December 2017, were included. The predictive ability of both prehospital shock index (preSI) and preMSI for MT and hospital mortality was assessed by calculating the areas under the receiver operating characteristic curves (AUROCs). RESULTS A total of 1007 patients were included. Seventy-eight (7.7%) patients received MT, and 30 (3.0%) patients died within 24 h of admission to the trauma center. The AUROCs for predicting MT with preSI and preMSI were 0.773 (95% confidence interval [CI], 0.746-0.798) and 0.765 (95% CI, 0.738-0.791), respectively. The AUROCs for predicting 24-hour mortality with preSI and preMSI were 0.584 (95% CI, 0.553-0.615) and 0.581 (95% CI, 0.550-0.612), respectively. CONCLUSIONS PreSI and preMSI showed moderate accuracy in predicting MT. PreMSI did not have higher predictive power than preSI. Additionally, in predicting hospital mortality, preMSI was not superior to preSI.
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20
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Kang WS, Shin IS, Pyo JS, Ahn S, Chung S, Ki YJ, Seok J, Park CY, Lee S. Prognostic Accuracy of Massive Transfusion, Critical Administration Threshold, and Resuscitation Intensity in Assessing Mortality in Traumatic Patients with Severe Hemorrhage: a Meta-Analysis. J Korean Med Sci 2019; 34:e318. [PMID: 31880415 PMCID: PMC6935555 DOI: 10.3346/jkms.2019.34.e318] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2019] [Accepted: 11/01/2019] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND The aim of this study was to assess the prognostic value of massive transfusion (MT), critical administration threshold (CAT), and resuscitation intensity (RI) for the mortality of trauma patients with severe hemorrhage. METHODS Seventeen relevant articles were obtained by searching the PubMed databases through February 15, 2019. The estimated mortality rates and injury severity scores were obtained through a meta-analysis. In addition, diagnostic test accuracy (DTA) reviews were conducted to obtain the sensitivity, specificity, diagnostic odds ratio, and the summary receiver operating characteristic curve. RESULTS At 24 hours, the estimated mortality rates were 0.194, 0.126, and 0.168 in assessments using MT, CAT, and RI, respectively. In addition, the pooled sensitivity of CAT (0.89; 95% confidence interval [CI], 0.82-0.94) was significantly higher than that of MT (0.63; 95% CI, 0.57-0.68) and RI (0.69; 95% CI, 0.63-0.75). Overall, the pooled specificity of MT and CAT was 0.82 (95% CI, 0.80-0.83) and 0.85 (95% CI, 0.83-0.88), respectively, while the pooled sensitivity was 0.49 (95% CI, 0.44-0.54) and 0.50 (95% CI, 0.38-0.62), respectively. CONCLUSION CAT may be a more sensitive predictor for 24-hour mortality than other predictors. Furthermore, RI also appears to be a useful predictor for 24-hour mortality. Both MT and CAT showed high specificity for overall mortality.
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Affiliation(s)
- Wu Seong Kang
- Department of Trauma Surgery, Wonkwang University Hospital, Iksan, Korea
| | - In Soo Shin
- College of Education, Jeonju University, Jeonju, Korea
| | - Jung Soo Pyo
- Department of Pathology, Eulji University Hospital, Eulji University School of Medicine, Daejeon, Korea.
| | - Sora Ahn
- Department of Trauma Surgery, Wonkwang University Hospital, Iksan, Korea
| | - Seungwoo Chung
- Department of Trauma Surgery, Wonkwang University Hospital, Iksan, Korea
| | - Young Jun Ki
- Department of Trauma Surgery, Wonkwang University Hospital, Iksan, Korea
| | - Junepill Seok
- Department of Trauma Surgery, Wonkwang University Hospital, Iksan, Korea
| | - Chan Yong Park
- Department of Trauma Surgery, Wonkwang University Hospital, Iksan, Korea
| | - Sungdo Lee
- Trauma Center, Wonkwang University Hospital, Iksan, Korea.
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21
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Rijnhout TWH, Noorman F, Bek A, Zoodsma M, Hoencamp R. Massive transfusion in The Netherlands. Emerg Med J 2019; 37:65-72. [PMID: 31831587 DOI: 10.1136/emermed-2019-208665] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Revised: 10/16/2019] [Accepted: 10/25/2019] [Indexed: 12/25/2022]
Abstract
OBJECTIVES Massive transfusion protocols (MTPs) may improve survival in patients with uncontrolled haemorrhage. An MTP was introduced into the Dutch transfusion guidelines in 2011, the ninth edition of the advanced trauma life support course in 2012 and the third version of the European guideline in 2013. This is the first survey of MTPs in Dutch trauma centres. METHODS The aim of the study was to compare MTP strategies in level 1 trauma centres in The Netherlands, and with (inter)national guidelines. A contact in each government assigned level 1 trauma centre in The Netherlands and the Dutch Ministry of Defence was approached to share their MTPs and elucidate their protocol in a survey and oral follow-up interview. RESULTS All 11 level 1 trauma centres responded. The content of the packages and transfusion ratios (red blood cells/plasma/platelets) were 3:3:1, 5:5:1, 5:3:1, 2:3:1, 4:4:1, 5:2:1, 2:2:1 and 4:3:1. Tranexamic acid was used in all centres and an additional dose was administered in eight centres. Fibrinogen was given directly (n=4), with persistent bleeding (n=3), based on Clauss fibrinogen (n=3) or rotational thromboelastometry (n=1). All centres used additional medication in patients in the form of anticoagulants, but their use was ambiguous. CONCLUSION MTPs differed between institutes and guidelines. The discrepancies in transfusion ratios can be explained by (inter)national differences in preparation and volume of blood components and/or interpretation of the '1:1:1' guideline. We recommend updating MTPs every year using the latest guidelines and evaluating the level of evidence for treatment during massive transfusion.
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Affiliation(s)
- Tim W H Rijnhout
- Department of Surgery, Alrijne Hospital Leiderdorp, Leiderdorp, The Netherlands .,Trauma Research Unit Department of Surgery, University Medical Center Rotterdam, Erasmus MC, Rotterdam, The Netherlands
| | - Femke Noorman
- Military Blood Bank, Dutch Ministry of Defence, Utrecht, The Netherlands
| | - Annemarije Bek
- Military Blood Bank, Dutch Ministry of Defence, Utrecht, The Netherlands
| | - Margreet Zoodsma
- Military Blood Bank, Dutch Ministry of Defence, Utrecht, The Netherlands
| | - Rigo Hoencamp
- Department of Surgery, Alrijne Hospital Leiderdorp, Leiderdorp, The Netherlands.,Trauma Research Unit Department of Surgery, University Medical Center Rotterdam, Erasmus MC, Rotterdam, The Netherlands.,Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands.,Defence Healthcare Organization, Ministry of Defence, Utrecht, The Netherlands
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22
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Thurn L, Wikman A, Westgren M, Lindqvist PG. Massive blood transfusion in relation to delivery: incidence, trends and risk factors: a population‐based cohort study. BJOG 2019; 126:1577-1586. [DOI: 10.1111/1471-0528.15927] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/07/2019] [Indexed: 12/12/2022]
Affiliation(s)
- L Thurn
- Department of Obstetrics and Gynaecology CLINTECKarolinska University Hospital Stockholm Sweden
| | - A Wikman
- Department of Clinical Immunology and Transfusion Medicine Karolinska University Hospital and Karolinska Institutet Stockholm Sweden
| | - M Westgren
- Department of Obstetrics and Gynaecology CLINTECKarolinska University Hospital Stockholm Sweden
| | - PG Lindqvist
- Department of Clinical Sciences and Education Karolinska Institutet Stockholm Sweden
- Department of Obstetrics and Gynaecology Södersjukhuset Stockholm Sweden
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23
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van der Meij JE, Geeraedts LMG, Kamphuis SJM, Kumar N, Greenfield T, Tweeddale G, Rosenfeld D, D'Amours SK. Ten-year evolution of a massive transfusion protocol in a level 1 trauma centre: have outcomes improved? ANZ J Surg 2019; 89:1470-1474. [PMID: 31496010 PMCID: PMC6899724 DOI: 10.1111/ans.15416] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Revised: 07/25/2019] [Accepted: 07/29/2019] [Indexed: 12/13/2022]
Abstract
Background We aimed to evaluate the evolution and implementation of the massive transfusion protocol (MTP) in an urban level 1 trauma centre. Most data on this topic comes from trauma centres with high exposure to life‐threatening haemorrhage. This study examines the effect of the introduction of an MTP in an Australian level 1 trauma centre. Methods A retrospective study of prospectively collected data was performed over a 14‐year period. Three groups of trauma patients, who received more than 10 units of packed red blood cells (PRBC), were compared: a pre‐MTP group (2002–2006), an MTP‐I group (2006–2010) and an MTP‐II group (2010–2016) when the protocol was updated. Key outcomes were mortality, complications and number of blood products transfused. Results A total of 168 patients were included: 54 pre‐MTP patients were compared to 47 MTP‐I and 67 MTP‐II patients. In the MTP‐II group, fewer units of PRBC and platelets were administered within the first 24 h: 17 versus 14 (P = 0.01) and 12 versus 8 (P < 0.001), respectively. Less infections were noted in the MTP‐I group: 51.9% versus 31.9% (P = 0.04). No significant differences were found regarding mortality, ventilator days, intensive care unit and total hospital lengths of stay. Conclusion Introduction of an MTP‐II in our level 1 civilian trauma centre significantly reduced the amount of PRBC and platelets used during damage control resuscitation. Introduction of the MTP did not directly impact survival or the incidence of complications. Nevertheless, this study reflects the complexity of real‐life medical care in a level 1 civilian trauma centre.
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Affiliation(s)
| | - Leo M G Geeraedts
- Department of Surgery, Section Trauma Surgery, VU University Medical Centre, Amsterdam, The Netherlands
| | - Saskia J M Kamphuis
- Department of Hand and Plastic Surgery, Cantonal Hospital Winterthur, Zurich, Switzerland
| | - Nimmi Kumar
- Department of Trauma Services, Liverpool Hospital, Sydney, New South Wales, Australia
| | - Tony Greenfield
- Blood Bank Laboratory, Liverpool Hospital, Sydney, New South Wales, Australia
| | - Geoff Tweeddale
- Department of Anaesthesia, Liverpool Hospital, Sydney, New South Wales, Australia
| | - David Rosenfeld
- Department of Haematology, Liverpool Hospital, Sydney, New South Wales, Australia.,School of Medicine, Western Sydney University, Sydney, New South Wales, Australia
| | - Scott K D'Amours
- Department of Trauma Services, Liverpool Hospital, Sydney, New South Wales, Australia.,UNSW Medicine, The University of New South Wales, Sydney, New South Wales, Australia
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Roquet F, Neuschwander A, Hamada S, Favé G, Follin A, Marrache D, Cholley B, Pirracchio R. Association of Early, High Plasma-to-Red Blood Cell Transfusion Ratio With Mortality in Adults With Severe Bleeding After Trauma. JAMA Netw Open 2019; 2:e1912076. [PMID: 31553473 PMCID: PMC6763975 DOI: 10.1001/jamanetworkopen.2019.12076] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
IMPORTANCE Optimal transfusion management is crucial when treating patients with trauma. However, the association of an early, high transfusion ratio of fresh frozen plasma (FFP) to packed red blood cells (PRBC) with survival remains uncertain. OBJECTIVE To study the association of an early, high FFP-to-PRBC ratio with all-cause 30-day mortality in patients with severe bleeding after trauma. DESIGN, SETTING, AND PARTICIPANTS This cohort study analyzes the data included in a multicenter national French trauma registry, Traumabase, from January 2012 to July 2017. Traumabase is a prospective, active, multicenter adult trauma registry that includes all consecutive patients with trauma treated at 15 trauma centers in France. Overall, 897 patients with severe bleeding after trauma were identified using the following criteria: (1) received 4 or more units of PRBC during the first 6 hours or (2) died from hemorrhagic shock before receiving 4 units of PRBC. EXPOSURES Eligible patients were divided into a high-ratio group, defined as an FFP-to-PRBC ratio more than 1:1.5, and a low-ratio group, defined as an FFP-to-PRBC ratio of 1:1.5 or less. The ratio was calculated using the cumulative units of FFP and PRBC received during the first 6 hours of management. MAIN OUTCOMES AND MEASURES A Cox regression model was used to analyze 30-day survival with the transfusion ratio as a time-dependent variable to account for survivorship bias. RESULTS Of the 12 217 patients included in the registry, 897 (7.3%) were analyzed (median [interquartile range] age, 38 (29-54) years; 639 [71.2%] men). The median (interquartile range) injury severity score was 34 (22-48), and the overall 30-day mortality rate was 33.6% (301 patients). A total of 506 patients (56.4%) underwent transfusion with a high ratio and 391 (43.6%) with a low ratio. A high transfusion ratio was associated with a significant reduction in 30-day mortality (hazard ratio, 0.74; 95% CI, 0.58-0.94; P = .01). When only analyzing patients who had complete data, a high transfusion ratio continued to be associated with a reduction in 30-day mortality (hazard ratio, 0.57; 95% CI, 0.33-0.97; P = .04). CONCLUSIONS AND RELEVANCE In this analysis of the Traumabase registry, an early FFP-to-PRBC ratio of more than 1:1.5 was associated with increased 30-day survival among patients with severe bleeding after trauma. This result supports the use of early, high FFP-to-PRBC transfusion ratios in patients with severe trauma.
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Affiliation(s)
- Florian Roquet
- Service d’Anesthésie-réanimation, Hôpital Européen Georges-Pompidou, Assistance Publique–Hôpitaux de Paris, Paris, France
- Service de Biostatistique et Informatique Médicale, Unité INSERM UMR 1153, Université Paris Diderot, Paris, France
| | - Arthur Neuschwander
- Service d’Anesthésie-réanimation, Hôpital Européen Georges-Pompidou, Assistance Publique–Hôpitaux de Paris, Paris, France
| | - Sophie Hamada
- Service d’Anesthésie-réanimation, Centre Hospitalier Universitaire Bicêtre, Université Paris Sud, Assistance Publique–Hôpitaux de Paris, Le Kremlin Bicêtre, France
| | - Gersende Favé
- Service d’Anesthésie-réanimation, Hôpital Européen Georges-Pompidou, Assistance Publique–Hôpitaux de Paris, Paris, France
| | - Arnaud Follin
- Service d’Anesthésie-réanimation, Hôpital Européen Georges-Pompidou, Assistance Publique–Hôpitaux de Paris, Paris, France
| | - David Marrache
- Service d’Anesthésie-réanimation, Hôpital Européen Georges-Pompidou, Assistance Publique–Hôpitaux de Paris, Paris, France
| | - Bernard Cholley
- Service d’Anesthésie-réanimation, Hôpital Européen Georges-Pompidou, Assistance Publique–Hôpitaux de Paris, Paris, France
| | - Romain Pirracchio
- Service d’Anesthésie-réanimation, Hôpital Européen Georges-Pompidou, Assistance Publique–Hôpitaux de Paris, Paris, France
- Service de Biostatistique et Informatique Médicale, Unité INSERM UMR 1153, Université Paris Diderot, Paris, France
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A comparison of resuscitation intensity and critical administration threshold in predicting early mortality among bleeding patients: A multicenter validation in 680 major transfusion patients. J Trauma Acute Care Surg 2019; 85:691-696. [PMID: 29985236 DOI: 10.1097/ta.0000000000002020] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND To address deficiencies associated with the classic definition of massive transfusion (MT), critical administration threshold (CAT) and resuscitation intensity (RI) were developed to better quantify the overall severity of illness and predict the need for transfusions and early mortality. We sought to evaluate these as more appropriate replacements for MT in defining mortality risk in patients undergoing major transfusions. METHODS Patients predicted to receive MT at 12 Level I trauma centers were randomized in the Pragmatic, Randomized Optimal Platelet and Plasma Ratios (PROPPR) trial. MT of 10 U or greater red blood cell (RBC) in 24 hours; CAT+, 3 U or greater RBC in the first hour; and RI, total products in the first 30 minutes (1 U RBC, 1 U plasma, 1000 mL crystalloid, 500 mL colloid each valued at 1 U). Resuscitation intensity was evaluated as a continuous variable and dichotomized as RI4+, where RI is 4 U or greater. Each metric was evaluated for its ability to predict mortality at 3 hours, 6 hours, and 24 hours, and at 30 days. RESULTS Of the 680 patients, 301 patients met MT definition, 521 were CAT+, and 445 were RI4+. Of those that died, 23% never reached MT threshold, but all were captured by CAT+ and RI4+. The 3-hour (9% vs. 9%), 6-hour (14% vs. 14%), 24-hour (17% vs. 18%), and 30-day mortality rates (28% vs. 29%) were similar between CAT+ and RI4+ patients. When RI was evaluated as a continuous variable, each unit increase was associated with a 20% increase in hemorrhage-related mortality (odds ratio, 1.20; 95% confidence interval, 1.15-1.29; p < 0.05). CONCLUSION Both RI and CAT are valid surrogates for early mortality in patients undergoing major transfusion, capturing patients omitted by the MT definition. The CAT+ showed the best sensitivity; RI4+ demonstrated better specificity and good positive predictive values and negative predictive values. While CAT+ may be suited for patients receiving an RBC-dominant resuscitation, RI4+ is more comprehensive. RI can also be used as a continuous variable to provide quantitative as well as qualitative risk of death. LEVEL OF EVIDENCE Prognostic, level III.
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Hagisawa K, Kinoshita M, Takikawa M, Takeoka S, Saitoh D, Seki S, Sakai H. Combination therapy using fibrinogen γ-chain peptide-coated, ADP-encapsulated liposomes and hemoglobin vesicles for trauma-induced massive hemorrhage in thrombocytopenic rabbits. Transfusion 2019; 59:3186-3196. [PMID: 31257633 DOI: 10.1111/trf.15427] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Revised: 05/16/2019] [Accepted: 05/16/2019] [Indexed: 01/07/2023]
Abstract
BACKGROUND We previously developed substitutes for red blood cells (RBCs) and platelets (PLTs) for transfusion. These substitutes included hemoglobin vesicles (HbVs) and fibrinogen γ-chain (dodecapeptide HHLGGAKQAGDV, H12)-coated, adenosine diphosphate (ADP)-encapsulated liposomes [H12-(ADP)-liposomes]. Here, we examined the efficacy of combination therapy using these substitutes instead of RBC and PLT transfusion in a rabbit model with trauma-induced massive hemorrhage with coagulopathy. STUDY DESIGN AND METHODS Thrombocytopenia (PLT count approximately 40,000/μL) was induced in rabbits by repeated blood withdrawal and isovolemic transfusion with autologous RBCs. Thereafter, lethal hemorrhage was induced in rabbits by noncompressible penetrating liver injury. Subsequently, H12-(ADP)-liposomes with platelet-poor plasma (PPP), platelet-rich plasma (PRP), or PPP alone were administered to stop bleeding. Once achieving hemostasis, HbVs, allogenic RBCs, or 5% albumin were transfused into rabbits to rescue them from fatal anemia following massive hemorrhage. RESULTS Administration of H12-(ADP)-liposomes/PPP as well as PRP (but not PPP) effectively stopped liver bleeding (100% hemostasis). The subsequent administration with HbVs as well as RBCs after hemostasis markedly rescued rabbits from fatal anemia (75% and 70% survivals for 24 hr, respectively). In contrast, 5% albumin administration rescued none of the rabbits. CONCLUSION Combination therapy with H12-(ADP)-liposomes and HbVs may be effective for damage control resuscitation of trauma-induced massive hemorrhage.
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Affiliation(s)
- Kohsuke Hagisawa
- Departments of Physiology, National Defense Medical College, Saitama, Japan
| | - Manabu Kinoshita
- Department of Immunology and Microbiology, National Defense Medical College, Saitama, Japan
| | - Masato Takikawa
- Departments of Advanced Science and Engineering, Graduate School of Advanced Science and Engineering, Waseda University, Tokyo, Japan
| | - Shinji Takeoka
- Departments of Life Science and Medical Bioscience, Graduate School of Advanced Science and Engineering, Waseda University, Tokyo, Japan
| | - Daizoh Saitoh
- Division of Traumatology, National Defense Medical College Research Institute, Tokorozawa, Japan
| | - Shuhji Seki
- Department of Immunology and Microbiology, National Defense Medical College, Saitama, Japan
| | - Hiromi Sakai
- Department of Chemistry, Nara Medical University, Nara, Japan
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27
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Chen YC, Chuang CJ, Hsiao KY, Lin LC, Hung MS, Chen HW, Lee SC. Massive transfusion in upper gastrointestinal bleeding: a new scoring system. Ann Med 2019; 51:224-231. [PMID: 31050553 PMCID: PMC7877879 DOI: 10.1080/07853890.2019.1615122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
Abstract
Background: Massive transfusion in patients with upper gastrointestinal bleeding (UGIB) was not investigated. We developed a new scoring system to predict massive transfusion and to enhance care and early resource mobilization. Methods: Massive transfusion was defined as transfusion with ≥10 units of red blood cells within the first 24 h. Data were extracted from a 10-year, six-hospital database. Logistic regression was applied to derive a risk score for massive transfusion using data from 2006 to 2010, in 24,736 patients (developmental cohort). The score was then validated using data from 2011 to 2015 in 27,449 patients (validation cohort). Area under the receiver operating characteristic (AUROC) curve was performed to assess prediction accuracy. Results: Five characteristics were independently associated (p < .001) with massive transfusion: presence of band-form cells among white blood cells (band form >0), international normalized ratio (INR) >1.5, pulse >100 beats per minute or systolic blood pressure <100 mmHg (shock), haemoglobin <8.0 g/dL and endoscopic therapy. The new scoring system successfully discriminated well between UGIB patients requiring massive transfusion and those who did not in both cohorts (AUROC: 0.831, 95%CI: 0.827-0.836; AUROC: 0.822, 95% CI: 0.817-0.826, respectively). Conclusions: The new scoring system predicts massive transfusion requirement in patients with UGIB well. Key messages Massive transfusion is a life-saving management in massive upper gastrointestinal bleeding. How to identify patients requiring massive transfusion in upper gastrointestinal bleeding is poorly documented. Approximately 3.9% of upper gastrointestinal bleeding patients require massive transfusion. A new scoring system is developed to identify patients requiring massive transfusion with high accuracy.
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Affiliation(s)
- Yi-Chuan Chen
- a Department of Emergency Medicine , Chang Gung Memorial Hospital , Chiayi , Taiwan.,b Department of Nursing , Chang Gung University of Science and Technology, Chiayi Campus , Chiayi , Taiwan
| | - Chen-Ju Chuang
- a Department of Emergency Medicine , Chang Gung Memorial Hospital , Chiayi , Taiwan
| | - Kuang-Yu Hsiao
- a Department of Emergency Medicine , Chang Gung Memorial Hospital , Chiayi , Taiwan.,b Department of Nursing , Chang Gung University of Science and Technology, Chiayi Campus , Chiayi , Taiwan
| | - Leng-Chieh Lin
- a Department of Emergency Medicine , Chang Gung Memorial Hospital , Chiayi , Taiwan.,b Department of Nursing , Chang Gung University of Science and Technology, Chiayi Campus , Chiayi , Taiwan
| | - Ming-Szu Hung
- c Division of Thoracic Oncology, Department of Pulmonary and Critical Care Medicine , Chang Gung Memorial Hospital , Chiayi , Taiwan.,d College of Medicine, Chang Gung University , Taoyuan , Taiwan
| | - Huan-Wen Chen
- a Department of Emergency Medicine , Chang Gung Memorial Hospital , Chiayi , Taiwan
| | - Shung-Chieh Lee
- a Department of Emergency Medicine , Chang Gung Memorial Hospital , Chiayi , Taiwan
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28
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Fluid Management and Transfusion. Int Anesthesiol Clin 2019; 55:78-95. [PMID: 28598882 DOI: 10.1097/aia.0000000000000154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Abstract
Blood product transfusion capabilities are crucial for appropriate response to postpartum hemorrhage. Novel treatments are continually being sought to improve maternal morbidity and mortality associated with massive hemorrhage.
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Affiliation(s)
- Benjamin K Kogutt
- Department of Gynecology and Obstetrics, Division of Maternal Fetal Medicine, Johns Hopkins Hospital, Johns Hopkins University Medical Center, Baltimore, MD, United States.
| | - Arthur J Vaught
- Department of Gynecology and Obstetrics, Division of Maternal Fetal Medicine, Johns Hopkins Hospital, Johns Hopkins University Medical Center, Baltimore, MD, United States; Department of Surgery, Division of Surgical Critical Care, Johns Hopkins Hospital, Johns Hopkins University Medical Center, Baltimore, MD, United States
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30
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Küçüktaş P, Şahin İ, Çalışkan E, Kılınçel Ö. Düzce Üniversitesi Sağlık Uygulama Ve Araştırma Merkezi’nde Kan Ve Kan Bileşenlerinin Kliniklere Göre Kullanımlarının Değerlendirilmesi. KOCAELI ÜNIVERSITESI SAĞLIK BILIMLERI DERGISI 2019. [DOI: 10.30934/kusbed.460700] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Bell C, Prokopchuk-Gauk O, Cload B, Stirling A, Davis PJ. Optimum Accuracy of Massive Transfusion Protocol Activation: The Clinician's View. Cureus 2018; 10:e3688. [PMID: 30761240 PMCID: PMC6368427 DOI: 10.7759/cureus.3688] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Massive transfusion protocols (MTP) aid in the efficient delivery of blood components to rapidly exsanguinating patients. Unfortunately, clinical gestalt and currently available clinical scoring systems lack the optimal accuracy to prevent blood product wastage (through over-activation), as well as individual patient morbidity and mortality (through under-activation). In order to help refine the MTP activation criteria and protocols, we surveyed clinicians on acceptable over- and under-activation rates for massive transfusions. Methods We surveyed Canadian content experts in their respective fields, using a snowball survey technique. Respondents were categorized into two groups: Group 1 was comprised of trauma and acute care specialists (TACS), while Group 2 was comprised of clinical and laboratory medicine specialists (CLMS). Between-group differences were examined using Fisher’s exact test and the likelihood ratio. Statistical significance was set at p < 0.05. Results We received responses from 35 clinicians in the TACS group and 10 clinicians in the CLMS group. About half (45.7%) of respondents in the TACS group considered an MTP overactivation rate of 5% - 10% acceptable (vs. 60% of the CLMS group; not significant (NS)). Approximately one-third (34.2%) of the respondents in the TACS group considered an MTP under-activation rate of less than 5% acceptable, whereas the majority (60%) of respondents in the CLMS group considered an under-activation rate of less than 5% acceptable (NS). A significantly greater proportion of respondents in the TACS group felt that an anticipated need for > 20 units of packed red blood cells within the next 24 hours was an acceptable criterion for MTP activation. Respondents in the CLMS group were more likely to consider “poor communication” as a reason for blood component wastage. Conclusion Similarities in acceptable MTP over- and under-activation rates were noted across specialties. Collaboration between involved parties is necessary for MTP protocol development to improve patient outcomes and reduce blood wastage.
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Affiliation(s)
- Chris Bell
- Internal Medicine, University of Saskatchewan College of Medicine, Saskatoon, CAN
| | - Oksana Prokopchuk-Gauk
- Pathology and Laboratory Medicine, University of Saskatchewan, Royal University Hospital, Saskatoon, CAN
| | - Bruce Cload
- Emergency Medicine, University of Saskatchewan, Royal University Hospital, Saskatoon, CAN
| | - Alena Stirling
- Anaesthesia, University of Saskatchewan, Royal University Hospital, Saskatoon, CAN
| | - Philip J Davis
- Emergency Medicine, University of Saskatchewan, Royal University Hospital, Saskatoon, CAN
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Rosenfeld EH, Lau P, Cunningham ME, Zhang W, Russell RT, Naik-Mathuria B, Vogel AM. Defining Massive Transfusion in Civilian Pediatric Trauma With Traumatic Brain Injury. J Surg Res 2018; 236:44-50. [PMID: 30694778 DOI: 10.1016/j.jss.2018.10.053] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Revised: 09/25/2018] [Accepted: 10/30/2018] [Indexed: 11/29/2022]
Abstract
BACKGROUND The purpose of this study was to identify an optimal definition of massive transfusion in civilian pediatric trauma with severe traumatic brain injury (TBI) METHODS: Severely injured children (age ≤18 y) with severe TBI in the Trauma Quality Improvement Program research data sets 2015-2016 that received blood products were identified. Data were analyzed using descriptive statistics, Wilcoxon rank-sum, chi-square, and logistic regression. Continuous variables are presented as median (interquartile range). Massive transfusion thresholds were determined based on receiver operating curves and optimization of sensitivity and specificity RESULTS: Of the 460 included children, the mortality rate was 43%. There were no differences in demographics, heart rate at presentation, or injury severity score between children that lived or died. However, those who died had lower Glasgow coma scores (3 [3, 8] versus 3 [3, 3]; P < 0.01), were more likely to have had a penetrating injury (20% versus 11%; P < 0.01) and were more likely to be hypotensive for age (62% versus 34%; P < 0.01). Total blood products infused were greater in those who died (34 mL/kg/4-h [17, 65] versus 22 [12, 44]; P < 0.01). Sensitivity and specificity for delayed mortality was optimized at 40 mL/kg/4 h, and for the need for a hemorrhage control procedure at 50 mL/kg/4 h. These thresholds predicted delayed mortality (OR 2.12; 95% CI 1.28-3.50; P < 0.01) and the need for hemorrhage control procedures (5.47; 95% CI 2.82-10.61; P < 0.01) CONCLUSIONS: For children with TBI, a massive transfusion threshold of 40 mL/kg/4-h of total administered blood products may be used to identify at-risk patients, improve resource utilization, and guide future research methodology.
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Affiliation(s)
- Eric H Rosenfeld
- Department of Pediatric Surgery, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas
| | - Patricio Lau
- Department of Pediatric Surgery, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas
| | - Megan E Cunningham
- Department of Pediatric Surgery, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas
| | - Wei Zhang
- Department of Pediatric Surgery, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas
| | - Robert T Russell
- Department of Pediatric Surgery, Children's Hospital of Alabama, Birmingham, Alabama
| | - Bindi Naik-Mathuria
- Department of Pediatric Surgery, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas
| | - Adam M Vogel
- Department of Pediatric Surgery, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas.
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Margarido C, Ferns J, Chin V, Ribeiro T, Nascimento B, Barrett J, Herer E, Halpern S, Andrews L, Ballatyne G, Chapmam M, Gomes J, Callum J. Massive hemorrhage protocol activation in obstetrics: a 5-year quality performance review. Int J Obstet Anesth 2018; 38:37-45. [PMID: 30509680 DOI: 10.1016/j.ijoa.2018.10.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Revised: 09/24/2018] [Accepted: 10/13/2018] [Indexed: 11/19/2022]
Abstract
BACKGROUND A structured approach to hemorrhagic emergencies in obstetrics has gained popularity with the implementation of massive hemorrhage protocols. The trauma literature suggests that routine quality reviews should be in place to improve patient outcomes. The aim of this study was to develop quality indicators and assess compliance by the clinical team. METHODS A multidisciplinary team set the institutional quality indicators for the massive hemorrhage protocol review. A retrospective review of all obstetrical massive hemorrhage protocol activation events from September 2010 to January 2015 was performed. All protocol events occurred before the creation of the quality indicators. Data were retrieved from patient records. RESULTS There were 17 (0.09%) protocol activations for 19 790 deliveries during the study period. All 17 (100%) patients received at least one unit of red blood cells. Overactivation, defined as the transfusion of <2 units of red blood cells, occurred in two cases (12%). Common causes of non-compliance were: 24% (4/17) temperature monitoring, 18% (3/17) lactate measurement, 41% (7/17) arterial blood gas sampling, and 18% (3/17) hemoglobin maintenance within the target range of 55-95 g/L. Admission to intensive care and peripartum hysterectomy occurred in 12 and 5 cases (71% and 29%), respectively. CONCLUSIONS Suboptimal compliance was found in multiple areas, which may be attributable to the low frequency of activation of our massive haemorrhage protocol in obstetrics. The quality targets identified in this report can act as a basis for other institutions developing quality indicators to evaluate performance.
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Affiliation(s)
- C Margarido
- Department of Obstetrics Anaesthesia, Division of Obstetrical Anaesthesia, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.
| | - J Ferns
- Department of Obstetrics Anaesthesia, Division of Obstetrical Anaesthesia, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - V Chin
- Department of Transfusion Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - T Ribeiro
- Department of Obstetrics Anaesthesia, Division of Obstetrical Anaesthesia, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - B Nascimento
- Department of General Surgery, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - J Barrett
- Department of Obstetrics and Gynecology, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - E Herer
- Department of Obstetrics and Gynecology, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - S Halpern
- Department of Obstetrics Anaesthesia, Division of Obstetrical Anaesthesia, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - L Andrews
- Department of Women and Babies, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - G Ballatyne
- Department of Women and Babies, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - M Chapmam
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - J Gomes
- Department of Evaluative Clinical Sciences, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - J Callum
- Department of Transfusion Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
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Tahir Janjua MS, Agarwal S, Castresana MR. The value of institutional protocols and focused cardiac ultrasound during a case of ultramassive transfusion. Ann Card Anaesth 2018; 21:433-436. [PMID: 30333342 PMCID: PMC6206793 DOI: 10.4103/aca.aca_49_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
A 53-year-old female was admitted to the emergency department with an exsanguinating bleed from the rectum which was of unclear origin. In what could be considered an ultramassive transfusion, 60 units packed red blood cells, 23 units fresh frozen plasma, 20 units platelets, 6 units cryoprecipitate, 30 L of crystalloids, 2 L of colloids, and 4 g of tranexamic acid were transfused over the course of 7 h. An arterio-enteric fistula was diagnosed and treated by an interventional radiologist. The patient recovered rapidly thereafter without any major neurologic, pulmonary, cardiac, or hematologic complications.
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Affiliation(s)
- Muhammad Salman Tahir Janjua
- Department of Anesthesiology and Perioperative Medicine, Medical College of Georgia at Augusta University, Augusta, GA, USA
| | - Shvetank Agarwal
- Department of Anesthesiology and Perioperative Medicine, Medical College of Georgia at Augusta University, Augusta, GA, USA
| | - Manuel R Castresana
- Department of Anesthesiology and Perioperative Medicine, Medical College of Georgia at Augusta University, Augusta, GA, USA
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Abstract
Massive transfusion protocols (MTPs) allow practitioners to follow a prescribed algorithm for the rapid replacement of blood products during a massive hemorrhage. They function as an established protocol to provide consistent treatment. Once implemented, the MTP must be evaluated to ensure best practice. The purpose of this clinical improvement project was to formally evaluate the use and efficacy of an MTP during its first year of implementation. The specific aims were to (1) determine whether MTP activations were missed; (2) compare outcomes between those patients managed by the MTP and those who were not; and (3) provide recommendations to the institution's stakeholders. A retrospective medical record review was conducted with 101 electronic medical records of adult trauma patients treated over 1 year. Patients were identified to have experienced massive bleeding if their medical record contained 1 of 4 indicators: (1) transfusion of uncrossmatched blood; (2) tranexamic acid administration; (3) transfusion of 4 or more units of packed red blood cells (PRBCs) in 1 hr; and/or (4) transfusion of 10 or more units of PRBCs in 24 hr. While 58 patients experienced massive bleeding, only 16 (28%) were managed using the MTP. Although the non-MTP group received fewer transfused blood products due to higher initial and 24-hr hemoglobin levels, more deaths occurred in this group than in the MTP group. The recommendations were to (1) establish well-defined criteria for MTP activation based on the 4 indicators of massive bleeding and (2) regularly evaluate the use and efficacy of the MTP to ensure positive patient outcomes.
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Lui CT, Wong OF, Tsui KL, Kam CW, Li SM, Cheng M, Leung KKG. Predictive model integrating dynamic parameters for massive blood transfusion in major trauma patients: The Dynamic MBT score. Am J Emerg Med 2018; 36:1444-1450. [DOI: 10.1016/j.ajem.2018.01.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2017] [Revised: 01/03/2018] [Accepted: 01/03/2018] [Indexed: 10/18/2022] Open
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Humbrecht C, Kientz D, Gachet C. Platelet transfusion: Current challenges. Transfus Clin Biol 2018; 25:151-164. [PMID: 30037501 DOI: 10.1016/j.tracli.2018.06.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Accepted: 06/21/2018] [Indexed: 12/29/2022]
Abstract
Since the late sixties, platelet concentrates are transfused to patients presenting with severe thrombocytopenia, platelet function defects, injuries, or undergoing surgery, to prevent the risk of bleeding or to treat actual hemorrhage. Current practices differ according to the country or even in different hospitals and teams. Although crucial advances have been made during the last decades, questions and debates still arise about the right doses to transfuse, the use of prophylactic or therapeutic strategies, the nature and quality of PC, the storage conditions, the monitoring of transfusion efficacy and the microbiological and immunological safety of platelet transfusion. Finally, new challenges are emerging with potential new platelet products, including cold stored or in vitro produced platelets. The most debated of these points are reviewed.
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Affiliation(s)
- C Humbrecht
- Établissement français du sang grand est, 85-87, boulevard Lobau, 54064 Nancy cedex, France.
| | - D Kientz
- Établissement français du sang grand est, 85-87, boulevard Lobau, 54064 Nancy cedex, France
| | - C Gachet
- Établissement français du sang grand est, 85-87, boulevard Lobau, 54064 Nancy cedex, France.
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Doughty H, Apelseth TO, Sivertsen J, Annaniasen K, Hervig T. Massive transfusion: changing practice in a single Norwegian centre 2002-2015. Transfus Med 2018; 28:357-362. [DOI: 10.1111/tme.12529] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2018] [Revised: 03/27/2018] [Accepted: 03/28/2018] [Indexed: 11/27/2022]
Affiliation(s)
| | - T. O. Apelseth
- Department of Immunology and Transfusion Medicine; Haukeland University Hospital; Bergen Norway
- Laboratory of Clinical Biochemistry; Haukeland University Hospital; Bergen Norway
| | - J. Sivertsen
- Department of Immunology and Transfusion Medicine; Haukeland University Hospital; Bergen Norway
| | - K. Annaniasen
- Department of Immunology and Transfusion Medicine; Haukeland University Hospital; Bergen Norway
| | - T. Hervig
- Department of Immunology and Transfusion Medicine; Haukeland University Hospital; Bergen Norway
- Institute of Clinical Science; University of Bergen; Bergen Norway
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Chaochankit W, Akaraborworn O, Sangthong B, Thongkhao K. Combination of blood lactate level with assessment of blood consumption (ABC) scoring system: A more accurate predictor of massive transfusion requirement. Chin J Traumatol 2018; 21:96-99. [PMID: 29605431 PMCID: PMC5911727 DOI: 10.1016/j.cjtee.2017.12.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2017] [Revised: 11/14/2017] [Accepted: 12/06/2017] [Indexed: 02/04/2023] Open
Abstract
PURPOSE Exsanguination is the most common leading cause of death in trauma patients. The massive transfusion (MT) protocol may influence therapeutic strategies and help provide blood components in timely manner. The assessment of blood consumption (ABC) score is a popular MT protocol but has low predictability. The lactate level is a good parameter to reflect poor tissue perfusion or shock states that can guide the management. This study aimed to modify the ABC scoring system by adding the lactate level for better prediction of MT. METHODS The data were retrospectively collected from 165 trauma patients following the trauma activated criteria at Songklanagarind Hospital from January 2014 to December 2014. The ABC scoring system was applied in all patients. The patients who had an ABC score ≥2 as the cut point for MT were defined as the ABC group. All patients who had a score ≥2 with a lactate level >4 mmol/dL were defined as the ABC plus lactate level (ABC + L) group. The prediction for the requirement of massive blood transfusion was compared between the ABC and ABC + L groups. The ability of ABC and ABC + L groups to predict MT was estimated by the area under the receiver operating characteristic curve (AUROC). RESULTS Among 165 patients, 15 patients (9%) required massive blood transfusion. There were no significant differences in age, gender, mechanism of injury or initial vital signs between the MT group and the non-MT group. The group that required MT had a higher Injury Severity Score and mortality. The sensitivity and specificity of the ABC scoring system in our institution were low (81%, 34%, AUC 0.573). The sensitivity and specificity were significantly better in the ABC + L group (92%, 42%, AUC = 0.745). CONCLUSION The ABC scoring system plus lactate increased the sensitivity and specificity compared with the ABC scoring system alone.
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Affiliation(s)
- Wongsakorn Chaochankit
- Department of Surgery, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand,Corresponding author.
| | - Osaree Akaraborworn
- Trauma Unit, Department of Surgery, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand
| | - Burapat Sangthong
- Trauma Unit, Department of Surgery, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand
| | - Komet Thongkhao
- Trauma Unit, Department of Surgery, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand
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Abstract
Exsanguination requires massive blood product replacement and termination of the bleeding source to prevent hemorrhagic shock and death. Massive transfusion protocols (MTPs) are algorithms that allow the health care team to quickly stabilize the bleeding patient and guide blood product administration. However, no national MTP guidelines or a standardized evaluation tool exist for collecting and reporting MTP-related data. The purpose of this article is to describe an original MTP evaluation tool, how it was used, barriers encountered, and a framework for reporting the MTP evaluation data. The evidence-based Broxton MTP Evaluation Tool was developed to evaluate the use of a newly implemented MTP via a retrospective review of electronic medical records (EMRs). Although the instrument itself worked well, barriers were encountered while reviewing the EMRs for the MTP evaluation. These barriers included no institutional entity was charged with tracking MTP activations, no searchable database was established to collect data concerning the MTP-activated patients, and no standard location in the EMR was designated for documenting the MTP activation. When devising protocols such as an MTP, a priori strategies should be developed for its implementation, documentation, and evaluation. Research is needed to determine best practices for evaluating an MTP to ensure positive patient outcomes with this protocol.
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Abstract
Damage control surgery is a combination of temporizing surgical interventions to arrest hemorrhage and control infectious source, with goal directed resuscitation to restore normal physiology. The convention of damage control surgery largely arose following the discovery of the lethal triad of hypothermia, acidosis, and coagulopathy, with the goal of Damage Control Surgery (DCS) is to avoid the initiation of this "bloody vicious cycle" or to reverse its progression. While hypothermia and acidosis are generally corrected with resuscitation, coagulopathy remains a challenging aspect of DCS, and is exacerbated by excessive crystalloid administration. This chapter focuses on resuscitative principles in the four settings of trauma care: the prehospital setting, emergency department, operating room, and intensive care unit including historical perspectives, resuscitative methods, controversies, and future directions. Each setting provides unique challenges with specific goals of care.
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Terceros-Almanza LJ, García-Fuentes C, Bermejo-Aznárez S, Prieto Del Portillo IJ, Mudarra-Reche C, Domínguez-Aguado H, Viejo-Moreno R, Barea-Mendoza J, Gómez-Soler R, Casado-Flores I, Chico-Fernández M. Prediction of massive bleeding in a prehospital setting: validation of six scoring systems. Med Intensiva 2018; 43:131-138. [PMID: 29415812 DOI: 10.1016/j.medin.2017.12.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2017] [Revised: 12/08/2017] [Accepted: 12/12/2017] [Indexed: 12/01/2022]
Abstract
OBJECTIVE To validate the diagnostic ability of six different scores to predict massive bleeding in a prehospital setting. DESIGN Retrospective cohort. SETTING Prehospital attention of patients with severe trauma. SUBJECTS Subjects with more than 15 years, a history of severe trauma (defined by code 15 criteria), that were initially assisted in a prehospital setting by the emergency services between January 2010 and December 2015 and were then transferred to a level one trauma center in Madrid. VARIABLES To validate: 1. Trauma Associated Severe Haemorrhage Score. 2. Assessment of Blood Consumption Score. 3. Emergency Transfusión Score. 4. Índice de Shock. 5. Prince of Wales Hospital/Rainer Score. 6. Larson Score. RESULTS 548 subjects were studied, 76,8% (420) were male, median age was 38 (interquartile range [IQR]: 27-50). Injury Severity Score was 18 (IQR: 9-29). Blunt trauma represented 82,5% (452) of the cases. Overall, frequency of MB was 9,2% (48), median intensive care unit admission days was 2,1 (IQR: 0,8 - 6,2) and hospital mortality rate was 11,2% (59). Emergency Transfusión Score had the highest precisions (AUC 0,85), followed by Trauma Associated Severe Haemorrhage score and Prince of Wales Hospital/Rainer Score (AUC 0,82); Assessment of Blood Consumption Score was the less precise (AUC 0,68). CONCLUSION In the prehospital setting the application of any the six scoring systems predicts the presence of massive hemorrhage and allows the activation of massive transfusion protocols while the patient is transferred to a hospital.
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Affiliation(s)
- L J Terceros-Almanza
- Unidad de Trauma y Emergencias, Servicio de Medicina Intensiva, Hospital Universitario 12 de Octubre.
| | - C García-Fuentes
- Unidad de Trauma y Emergencias, Servicio de Medicina Intensiva, Hospital Universitario 12 de Octubre
| | - S Bermejo-Aznárez
- Unidad de Trauma y Emergencias, Servicio de Medicina Intensiva, Hospital Universitario 12 de Octubre
| | - I J Prieto Del Portillo
- Unidad de Trauma y Emergencias, Servicio de Medicina Intensiva, Hospital Universitario 12 de Octubre
| | - C Mudarra-Reche
- Unidad de Trauma y Emergencias, Servicio de Medicina Intensiva, Hospital Universitario 12 de Octubre
| | - H Domínguez-Aguado
- Unidad de Trauma y Emergencias, Servicio de Medicina Intensiva, Hospital Universitario 12 de Octubre
| | - R Viejo-Moreno
- Unidad de Trauma y Emergencias, Servicio de Medicina Intensiva, Hospital Universitario 12 de Octubre
| | - J Barea-Mendoza
- Unidad de Trauma y Emergencias, Servicio de Medicina Intensiva, Hospital Universitario 12 de Octubre
| | - R Gómez-Soler
- Servicio de Asistencia Municipal de Urgencia y Rescate - SAMUR-Protección Civil
| | - I Casado-Flores
- Servicio de Asistencia Municipal de Urgencia y Rescate - SAMUR-Protección Civil
| | - M Chico-Fernández
- Unidad de Trauma y Emergencias, Servicio de Medicina Intensiva, Hospital Universitario 12 de Octubre
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Bundles of care for resuscitation from hemorrhagic shock and severe brain injury in trauma patients-Translating knowledge into practice. J Trauma Acute Care Surg 2018; 81:780-94. [PMID: 27389129 DOI: 10.1097/ta.0000000000001161] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Nakao S, Ishikawa K, Ono H, Kusakabe K, Fujimura I, Ueno M, Idoguchi K, Mizushima Y, Matsuoka T. Radiological classification of retroperitoneal hematoma resulting from lumbar vertebral fracture. Eur J Trauma Emerg Surg 2018; 45:353-363. [PMID: 29368084 DOI: 10.1007/s00068-018-0907-x] [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: 03/10/2017] [Accepted: 01/12/2018] [Indexed: 12/30/2022]
Abstract
PURPOSE Lumbar vertebral fracture (LVF) infrequently produces massive retroperitoneal hematoma (RPH). This study aimed to systematically review the clinical and radiographic characteristics of RPH resulting from LVF. METHODS For 193 consecutive patients having LVF who underwent computed tomography (CT), demographic data, physiological conditions, and outcomes were reviewed from their medical records. Presence or absence of RPH, other bone fractures, or organ/vessel injury was evaluated in their CT images, and LVF or RPH, if present, was classified according to either the Orthopaedic Trauma Association classification or the concept of interfascial planes. RESULTS RPH resulting only or dominantly from LVF was found in 66 (34.2%) patients, whereas among the others, 64 (33.2%) had no RPH, 38 (19.7%) had RPH from other injuries, and 25 (13.0%) had RPH partly attributable to LVF. The 66 RPHs resulting only or dominantly from LVF were radiologically classified into mild subtype of minor median (n = 35), moderate subtype of lateral (n = 11), and severe subtypes of central pushing-up (n = 13) and combined (n = 7). Of the 20 patients with severe subtypes, 18 (90.0%) were in hemorrhagic shock on admission, and 6 (30.0%) were clinically diagnosed as dying due to uncontrollable RPH resulting from vertebral body fractures despite no anticoagulant medication. CONCLUSIONS LVF can directly produce massive RPH leading to hemorrhagic death. A major survey of such pathology should be conducted to establish appropriate diagnosis and treatment.
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Affiliation(s)
- Shota Nakao
- Senshu Trauma and Critical Care Center, Rinku General Medical Center, 2-23 Rinku-Ourai-Kita, Izumisano-shi, Osaka, 598-0048, Japan
| | - Kazuo Ishikawa
- Emergency Department, Seikeikai Hospital, 1-1-1 Minami-Yasui-cho, Sakai-ku, Sakai-shi, Osaka, 590-0064, Japan.
| | - Hidefumi Ono
- Senshu Trauma and Critical Care Center, Rinku General Medical Center, 2-23 Rinku-Ourai-Kita, Izumisano-shi, Osaka, 598-0048, Japan
| | - Kenji Kusakabe
- Senshu Trauma and Critical Care Center, Rinku General Medical Center, 2-23 Rinku-Ourai-Kita, Izumisano-shi, Osaka, 598-0048, Japan
| | - Ichiro Fujimura
- Senshu Trauma and Critical Care Center, Rinku General Medical Center, 2-23 Rinku-Ourai-Kita, Izumisano-shi, Osaka, 598-0048, Japan
| | - Masato Ueno
- Ueno Clinic, 265-1 Inaba-cho, Kishiwada-shi, Osaka, 596-0103, Japan
| | - Koji Idoguchi
- Senshu Trauma and Critical Care Center, Rinku General Medical Center, 2-23 Rinku-Ourai-Kita, Izumisano-shi, Osaka, 598-0048, Japan
| | - Yasuaki Mizushima
- Senshu Trauma and Critical Care Center, Rinku General Medical Center, 2-23 Rinku-Ourai-Kita, Izumisano-shi, Osaka, 598-0048, Japan
| | - Tetsuya Matsuoka
- Senshu Trauma and Critical Care Center, Rinku General Medical Center, 2-23 Rinku-Ourai-Kita, Izumisano-shi, Osaka, 598-0048, Japan
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Schroll R, Swift D, Tatum D, Couch S, Heaney JB, Llado-Farrulla M, Zucker S, Gill F, Brown G, Buffin N, Duchesne J. Accuracy of shock index versus ABC score to predict need for massive transfusion in trauma patients. Injury 2018; 49:15-19. [PMID: 29017765 DOI: 10.1016/j.injury.2017.09.015] [Citation(s) in RCA: 79] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2017] [Revised: 09/07/2017] [Accepted: 09/14/2017] [Indexed: 02/02/2023]
Abstract
BACKGROUND Various scoring systems have been developed to predict need for massive transfusion in traumatically injured patients. Assessments of Blood Consumption (ABC) score and Shock Index (SI) have been shown to be reliable predictors for Massive Transfusion Protocol (MTP) activation. However, no study has directly compared these two scoring systems to determine which is a better predictor for MTP activation. The primary objective was to determine whether ABC or SI better predicted the need for MTP in adult trauma patients with severe hemorrhage. METHODS This was a retrospective cohort study which included all injured patients who were trauma activations between January 1, 2009 and December 31, 2013 at an urban Level I trauma center. Patients <18 years old or with traumatic brain injury (TBI) were excluded. ABC and SI were calculated for each patient. MTP was defined as need for >10 units PRBC transfusion within 24h of emergency department arrival. Sensitivity, specificity, and area under the receiver operating characteristic curve (AUROC) were used to evaluate scoring systems' ability to predict effective MTP utilization. RESULTS A total of 645 patients had complete data for analysis. Shock Index ≥1 had sensitivity of 67.7% (95% CI 49.5%-82.6%) and specificity of 81.3% (95% CI 78.0%-84.3%) for predicting MTP, and ABC score ≥2 had sensitivity of 47.0% (95% CI 29.8%-64.9%) and specificity of 89.8% (95% CI 87.2%-92.1%). AUROC analyses showed SI to be the strongest predictor followed by ABC score with AUROC values of 0.83 and 0.74, respectively. SI had a significantly greater sensitivity (P=0.035), but a significantly weaker specificity (P<0.001) compared to ABC score. CONCLUSION ABC score and Shock Index can both be used to predict need for massive transfusion in trauma patients, however SI is more sensitive and requires less technical skill than ABC score.
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Affiliation(s)
| | - David Swift
- Tulane School of Medicine, New Orleans, LA, United States
| | - Danielle Tatum
- Our Lady of the Lake Regional Medical Center-Trauma Specialist Program, Baton Rouge, LA, United States
| | - Stuart Couch
- Tulane School of Medicine, New Orleans, LA, United States
| | | | | | - Shana Zucker
- Tulane School of Medicine, New Orleans, LA, United States
| | - Frances Gill
- Tulane School of Medicine, New Orleans, LA, United States
| | - Griffin Brown
- Tulane School of Medicine, New Orleans, LA, United States
| | | | - Juan Duchesne
- Tulane School of Medicine, New Orleans, LA, United States
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Siada SS, Davis JW, Kaups KL, Dirks RC, Grannis KA. Current outcomes of blunt open pelvic fractures: how modern advances in trauma care may decrease mortality. Trauma Surg Acute Care Open 2017; 2:e000136. [PMID: 29766121 PMCID: PMC5887774 DOI: 10.1136/tsaco-2017-000136] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Revised: 11/22/2017] [Accepted: 11/27/2017] [Indexed: 12/02/2022] Open
Abstract
Background Open pelvic fracture, caused by a blunt mechanism, is an uncommon injury with a high mortality rate. In 2008, evidence-based algorithm for managing pelvic fractures in unstable patients was published by the Western Trauma Association (WTA). The use of massive transfusion protocols has become widespread as has the availability and use of pelvic angiography. The purpose of this study was to evaluate the outcome of open pelvic fractures in association with related advances in trauma care. Methods A retrospective review was performed, at an American College of Surgeon verified level I trauma center, of patients with blunt open pelvic fractures from January 2010 to April 2016. The WTA algorithm, including massive transfusion protocol, and pelvic angiography were uniformly used. Data collected included injury severity score, demographic data, transfusion requirements, use of pelvic angiography, length of stay, and disposition. Data were compared with a similar study from 2005. Results During the study period, 1505 patients with pelvic fractures were analyzed; 87 (6%) patients had open pelvic fractures. Of these, 25 were from blunt mechanisms and made up the study population. Patients in both studies had similar injury severity scores, ages, Glasgow Coma Scale, and gender distributions. Use of angiography was higher (44% vs. 16%; P=0.011) and mortality was lower (16% vs. 45%; P=0.014) than in the 2005 study. Conclusions Changes in trauma care for patients with open blunt pelvic fracture include the use of an evidence-based algorithm, massive transfusion protocols and increased use of angioembolization. Mortality for open pelvic fractures has decreased with these advances. Level of evidence Level IV.
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Affiliation(s)
- Sammy S Siada
- Department of Surgery, Community Regional Medical Center, University of California, San Francisco-Fresno, Fresno, California, USA
| | - James W Davis
- Department of Surgery, Community Regional Medical Center, University of California, San Francisco-Fresno, Fresno, California, USA
| | - Krista L Kaups
- Department of Surgery, Community Regional Medical Center, University of California, San Francisco-Fresno, Fresno, California, USA
| | - Rachel C Dirks
- Department of Surgery, Community Regional Medical Center, University of California, San Francisco-Fresno, Fresno, California, USA
| | - Kimberly A Grannis
- Department of Surgery, Community Regional Medical Center, University of California, San Francisco-Fresno, Fresno, California, USA
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Foster JC, Sappenfield JW, Smith RS, Kiley SP. Initiation and Termination of Massive Transfusion Protocols: Current Strategies and Future Prospects. Anesth Analg 2017; 125:2045-2055. [PMID: 28857793 DOI: 10.1213/ane.0000000000002436] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
The advent of massive transfusion protocols (MTP) has had a significant positive impact on hemorrhaging trauma patient morbidity and mortality. Nevertheless, societal MTP guidelines and individual MTPs at academic institutions continue to circulate opposing recommendations on topics critical to MTPs. This narrative review discusses up-to-date information on 2 such topics, the initiation and termination of an MTP. The discussion for each begins with a review of the recommendations and supporting literature presented by MTP guidelines from 3 prominent societies, the American Society of Anesthesiologists, the American College of Surgeons, and the task force for Advanced Bleeding Care in Trauma. This is followed by an in-depth analysis of the main components within those recommendations. Societal recommendations on MTP initiation in hemorrhaging trauma patients emphasize the use of retrospectively validated massive transfusion (MT) prediction score, specifically, the Assessment of Blood Consumption and Trauma-Associated Severe Hemorrhage scores. Validation studies have shown that both scoring systems perform similarly. Both scores reliably identify patients that will not require an MT, while simultaneously overpredicting MT requirements. However, each scoring system has its unique advantages and disadvantages, and this review discusses how specific aspects of each scoring system can affect widespread applicability and statistical performance. In addition, we discuss the often overlooked topic of initiating MT in nontrauma patients and the specific tools physicians have to guide the MT initiation decision in this unique setting. Despite the serious complications that can arise with transfusion of large volumes of blood products, there is considerably less research pertinent to the topic of MTP termination. Societal recommendations on MTP termination emphasize applying clinical reasoning to identify patients who have bleeding source control and are adequately resuscitated. This review, however, focuses primarily on the recommendations presented by the Advanced Bleeding Care in Trauma's MTP guidelines that call for prompt termination of the algorithm-guided model of resuscitation and rapidly transitioning into a resuscitation model guided by laboratory test results. We also discuss the evidence in support of laboratory result-guided resuscitation and how recent literature on viscoelastic hemostatic assays, although limited, highlights the potential to achieve additional benefits from this method of resuscitation.
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Affiliation(s)
- John C Foster
- From the University of Florida College of Medicine, Gainesville, Florida
| | - Joshua W Sappenfield
- Department of Anesthesiology, University of Florida College of Medicine, Gainesville, Florida
| | - Robert S Smith
- Division of Acute Care Surgery, Department of Surgery, University of Florida College of Medicine, Gainesville, Florida
| | - Sean P Kiley
- Department of Anesthesiology, University of Florida College of Medicine, Gainesville, Florida
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Pecoraro F, Gloekler S, Mader CE, Roos M, Chaykovska L, Veith FJ, Cayne NS, Mangialardi N, Neff T, Lachat M. Mortality rates and risk factors for emergent open repair of abdominal aortic aneurysms in the endovascular era. Updates Surg 2017; 70:129-136. [PMID: 28913787 DOI: 10.1007/s13304-017-0488-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2017] [Accepted: 08/15/2017] [Indexed: 12/17/2022]
Abstract
The background of this paper is to report the mortality at 30 and 90 days and at mean follow-up after open abdominal aortic aneurysms (AAA) emergent repair and to identify predictive risk factors for 30- and 90-day mortality. Between 1997 and 2002, 104 patients underwent emergent AAA open surgery. Symptomatic and ruptured AAAs were observed, respectively, in 21 and 79% of cases. Mean patient age was 70 (SD 9.2) years. Mean aneurysm maximal diameter was 7.4 (SD 1.6) cm. Primary endpoints were 30- and 90-day mortality. Significant mortality-related risk factor identification was the secondary endpoint. Open repair trend and its related perioperative mortality with a per-year analysis and a correlation subanalysis to identify predictive mortality factor were performed. Mean follow-up time was 23 (SD 23) months. Overall, 30-day mortality was 30%. Significant mortality-related risk factors were the use of computed tomography (CT) as a preoperative diagnostic tool, AAA rupture, preoperative shock, intraoperative cardiopulmonary resuscitation (CPR), use of aortic balloon occlusion, intraoperative massive blood transfusion (MBT), and development of abdominal compartment syndrome (ACS). Previous abdominal surgery was identified as a protective risk factor. The mortality rate at 90 days was 44%. Significant mortality-related risk factors were AAA rupture, aortocaval fistula, peripheral artery disease (PAD), preoperative shock, CPR, MBT, and ACS. The mortality rate at follow-up was 45%. Correlation analysis showed that MBT, shock, and ACS are the most relevant predictive mortality factor at 30 and 90 days. During the transition period from open to endovascular repair, open repair mortality outcomes remained comparable with other contemporary data despite a selection bias for higher risk patients. MBT, shock, and ACS are the most pronounced predictive mortality risk factors.
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Affiliation(s)
- Felice Pecoraro
- Clinic for Cardiovascular Surgery, University Hospital Zurich, Zurich, Switzerland. .,Vascluar Surgery Unit, University Hospital "P. Giaccone", Via Liborio Giuffrè, 5, 90100, Palermo, Italy.
| | - Steffen Gloekler
- Department of Cardiology, University Hospital Bern, Bern, Switzerland
| | - Caecilia E Mader
- Department of Radiology, University Hospital Zurich, Zurich, Switzerland
| | - Malgorzata Roos
- Institute for Social- and Preventive Medicine, University of Zurich, Zurich, Switzerland
| | - Lyubov Chaykovska
- Clinic for Cardiovascular Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Frank J Veith
- Division of Vascular Surgery, New York University Medical Center, New York, NY, USA
| | - Neal S Cayne
- Division of Vascular Surgery, New York University Medical Center, New York, NY, USA
| | | | - Thomas Neff
- Department of Anesthesiology and Intensive Care Medicine, Cantonal Hospital of Muensterlingen, Muensterlingen, Switzerland
| | - Mario Lachat
- Clinic for Cardiovascular Surgery, University Hospital Zurich, Zurich, Switzerland
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Farooq N, Galiatsatos P, Aulakh JK, Higgins C, Martinez A. Massive transfusion practice in non-trauma related hemorrhagic shock. J Crit Care 2017; 43:65-69. [PMID: 28846895 DOI: 10.1016/j.jcrc.2017.08.033] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2017] [Revised: 08/17/2017] [Accepted: 08/19/2017] [Indexed: 10/19/2022]
Abstract
PURPOSE Evidence suggests that trauma patients with hemorrhagic shock requiring massive transfusion have improved outcomes if resuscitated with a prescribed massive transfusion protocol (MTP). However, there is limited data regarding the efficacy of MTP in non-trauma patients. METHODS This was a retrospective observational study of all patients who received a massive transfusion protocol for non-traumatic hemorrhagic shock over a four-year period. The primary outcome was in-patient hospital survival. We dichotomized recipients of MTP into survivors versus non-survivors, comparing outcomes of interest within the categories by nonparametric testing. Summary statistics expressed as median (interquartile range). RESULTS Fifty-nine patients were reviewed, with the median age of 59.0 (35.0-71.0) years old. Thirty-three (56%) patients survived. Survivors were younger, 57.0 (30.0-67.0) versus 64.0 (53.5-71.5) years old (p=0.047), and had lower Sequential Organ Failure Assessment scores (6.0 (3.0-8.0) versus11.5 (9.5-13.0); p=0.008). Patients on the medical service receiving MTP had an increased risk of mortality (odds ratio 4.26; p=0.02). CONCLUSION Over half of the patients receiving massive transfusion protocols for their non-trauma related hemorrhagic shock survived. Survivors were younger, were less acutely ill, and on non-medical services. Further research is needed to investigate best practice for transfusion in non-trauma related hemorrhagic shock.
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Affiliation(s)
- Nauman Farooq
- Department of Internal Medicine and Transfusion Medicine, St. Agnes Hospital, Baltimore, MD, United States
| | - Panagis Galiatsatos
- Critical Care Medicine Department, National Institutes of Health, Bethesda, MD, United States.
| | - Jasmine K Aulakh
- Division of Critical Care, St. Agnes Hospital, Baltimore, MD, United States
| | - Christopher Higgins
- Department of Internal Medicine and Transfusion Medicine, St. Agnes Hospital, Baltimore, MD, United States
| | - Anthony Martinez
- Division of Critical Care, St. Agnes Hospital, Baltimore, MD, United States
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Yang JC, Wang QS, Dang QL, Sun Y, Xu CX, Jin ZK, Ma T, Liu J. Investigation of the status quo of massive blood transfusion in China and a synopsis of the proposed guidelines for massive blood transfusion. Medicine (Baltimore) 2017; 96:e7690. [PMID: 28767599 PMCID: PMC5626153 DOI: 10.1097/md.0000000000007690] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
The aim of this study was to provide an overview of massive transfusion in Chinese hospitals, identify the important indications for massive transfusion and corrective therapies based on clinical evidence and supporting experimental studies, and propose guidelines for the management of massive transfusion. This multiregion, multicenter retrospective study involved a Massive Blood Transfusion Coordination Group composed of 50 clinical experts specializing in blood transfusion, cardiac surgery, anesthesiology, obstetrics, general surgery, and medical statistics from 20 tertiary general hospitals across 5 regions in China. Data were collected for all patients who received ≥10 U red blood cell transfusion within 24 hours in the participating hospitals from January 1 2009 to December 31 2010, including patient demographics, pre-, peri-, and post-operative clinical characteristics, laboratory test results before, during, and after transfusion, and patient mortality at post-transfusion and discharge. We also designed an in vitro hemodilution model to investigate the changes of blood coagulation indices during massive transfusion and the correction of coagulopathy through supplement blood components under different hemodilutions. The experimental data in combination with the clinical evidence were used to determine the optimal proportion and timing for blood component supplementation during massive transfusion. Based on the findings from the present study, together with an extensive review of domestic and international transfusion-related literature and consensus feedback from the 50 experts, we drafted the guidelines on massive blood transfusion that will help Chinese hospitals to develop standardized protocols for massive blood transfusion.
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Affiliation(s)
- Jiang-Cun Yang
- Department of Transfusion Medicine, Shaanxi Provincial People's Hospital, Xi’an
| | - Qiu-Shi Wang
- Department of Transfusion Medicine, Shengjing Hospital of China Medical University, Shenyang
| | - Qian-Li Dang
- Department of Dermatology, Shaanxi Provincial People's Hospital, Xi’an
| | - Yang Sun
- Department of Transfusion Medicine, Shaanxi Provincial People's Hospital, Xi’an
| | - Cui-Xiang Xu
- Shaanxi Provincial Center for Clinical Laboratory
| | - Zhan-Kui Jin
- Department of Orthopaedics, Shaanxi Provincial People's Hospital, Xi’an, China
| | - Ting Ma
- Department of Transfusion Medicine, Shaanxi Provincial People's Hospital, Xi’an
| | - Jing Liu
- Division of Transfusion Medicine, Johns Hopkins University, School of Medicine, Baltimore, MD
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