A Paradigm Shift in Trauma Resuscitation

Kutcher, Matthew; Kornblith, Lucy Z.; Narayan, Raja R.; Curd, Vivian; Daley, Aaron; Redick, Brittney J.; Nelson, Mary F.; Fiebig, Eberhard; Cohen, Mitchell J.

doi:10.1001/jamasurg.2013.2911

Cited by 84 publications

(32 citation statements)

References 29 publications

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“…13,14 However, in the context of current evidence, disparate strategies to guide MTPs exist. 14,15 Although a retrospective study comparing a TEG-guided MTPs to a historic cohort supports the use of TEG to guide MTPs, 37 this has not been prospectively validated.…”

Section: Discussionmentioning

confidence: 99%

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Goal-directed Hemostatic Resuscitation of Trauma-induced Coagulopathy

et al. 2016

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Background Massive transfusion protocols (MTPs) have become standard of care in the management of bleeding injured patients, yet strategies to guide them vary widely. We conducted a pragmatic, randomized clinical trial (RCT) to test the hypothesis that an MTP goal directed by the viscoelastic assay thrombelastography (TEG) improves survival compared with an MTP guided by conventional coagulation assays (CCA). Methods This RCT enrolled injured patients from an academic level-1 trauma center meeting criteria for MTP activation. Upon MTP activation, patients were randomized to be managed either by an MTP goal directed by TEG or by CCA (ie, international normalized ratio, fibrinogen, platelet count). Primary outcome was 28-day survival. Results One hundred eleven patients were included in an intent-to-treat analysis (TEG = 56, CCA = 55). Survival in the TEG group was significantly higher than the CCA group (log-rank P = 0.032, Wilcoxon P = 0.027); 20 deaths in the CCA group (36.4%) compared with 11 in the TEG group (19.6%) (P = 0.049). Most deaths occurred within the first 6 hours from arrival (21.8% CCA group vs 7.1% TEG group) (P = 0.032). CCA patients required similar number of red blood cell units as the TEG patients [CCA: 5.0 (2–11), TEG: 4.5 (2–8)] (P = 0.317), but more plasma units [CCA: 2.0 (0–4), TEG: 0.0 (0–3)] (P = 0.022), and more platelets units [CCA: 0.0 (0–1), TEG: 0.0 (0–0)] (P = 0.041) in the first 2 hours of resuscitation. Conclusions Utilization of a goal-directed, TEG-guided MTP to resuscitate severely injured patients improves survival compared with an MTP guided by CCA and utilizes less plasma and platelet transfusions during the early phase of resuscitation.

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Section: Discussionmentioning

confidence: 99%

“…13 MTPs rely on abnormal values of CCA as triggers for transfusion of plasma, cryoprecipitate, and platelet units. 14 An alternative approach incorporates a VHA into MTPs to assess each stage of hemostasis, allowing for goal-directed treatment with blood products.…”

mentioning

confidence: 99%

Goal-directed Hemostatic Resuscitation of Trauma-induced Coagulopathy

et al. 2016

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“…Recently, there has been a shift toward reduced administration of crystalloid volume and use of blood products to achieve hemostasis and oxygen delivery while benefiting from the volume also provided by them. Kutcher et al (65) reported that systematization of such practices under an institutional MTP was associated with decreased blood product use, and when adjusting for age and injury characteristics, with a 5.6% reduction in mortality. MTPs are either based on fixed plasma:red blood cell (RBC), cryoprecipitate:RBC, and/or platelet (PLT):RBC ratios agreed upon institutions, or goal directed by viscoelastic point-of-care assays.…”

Section: Hemostasis Managementmentioning

confidence: 99%

“…The ratio of blood products at which this benefit is optimal remains a matter of debate. Based on recent data, what is certain is that coagulopathic trauma patients meeting criteria for massive transfusion benefit from early plasma and platelet administration, while being judicious with crystalloid administration (65). This benefit appears to be independent of the ratio of blood product used, as all studies that report improved outcomes with a particular ratio gave plasma and/or platelets earlier (68).…”

Section: Hemostasis Managementmentioning

confidence: 99%

Trauma-Induced Coagulopathy: An Institution’s 35 Year Perspective on Practice and Research

González

Moore

et al. 2014

Scand J Surg

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Introduction Injury is the second leading cause of death worldwide, and as much as 40% of injury-related mortality is attributed to uncontrollable hemorrhage. This persists despite establishment of regionalized trauma systems and advances in the management of severely injured patients. Trauma-induced coagulopathy has been identified as the most common preventable cause of postinjury mortality. Methods A review of the current literature was performed by collecting PUBMED references related to trauma-induced coagulopathy. Data were then critically analyzed and summarized based on the authors’ clinical and research perspective, as well as that reported by other institutions and researchers interested in trauma-induced coagulopathy. A particular focus was placed on those aspects of coagulopathy in which agreement among clinical and basic scientists is currently lacking; these include, pathophysiology, the role of blood components and factor therapy, and goal-directed assessment and management. Results Trauma-induced coagulopathy has been recognized in approximately one-third of trauma patients. There is a vast range of severity, and the emergence of viscoelastic assays, such as thrombelastography and rotational thromboelastogram, has refined its diagnosis and management, particularly through the establishment of goal-directed massive transfusion protocols. Despite advancements in the diagnosis and management of trauma-induced coagulopathy, much remains to be understood regarding its pathophysiology. The cell-based model of hemostasis has allowed for characterization of endothelial dysfunction, impaired thrombin generation, platelet dysfunction, fibrinolysis, endogenous anticoagulants such as protein-C, and antifibrinolytic proteins. These concepts collectively compose the contemporary, but still partial, understanding of trauma-induced coagulopathy. Conclusion Trauma-induced coagulopathy is a complex pathophysiological condition, of which some mechanisms have been characterized, but much remains to be understood in order to translate this knowledge into improved outcomes for the injured patient.

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“…Much of the focus of recent research has been on optimizing the ratio of blood product administration and minimizing the use of crystalloid. 1 However, it is the early and timely delivery of higher balanced ratios of plasma and platelets that allows for the achievement of the ultimate goal of DCR: the rapid restoration of circulating red cells, plasma proteins and platelets, while definitive control of bleeding is achieved. The protocolization of massive transfusion (MT) was developed with DCR and has been associated with decreased mortality, decreased multi-organ failure, and an overall decrease in the amount of product transfused.…”

Section: Introductionmentioning

confidence: 99%

Every minute counts

Meyer

Vincent

Fox

et al. 2017

Journal of Trauma and Acute Care Surgery

228

126

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BACKGROUND ACS-TQIP Best Practices recommends initial massive transfusion (MT) cooler delivery within 15 minutes of protocol activation, with a goal of 10 minutes. The current study sought to examine the impact of timing of first cooler delivery on patient outcomes. METHODS Patients predicted to receive MT at 12 level-1 trauma centers were randomized to two separate transfusion ratios as described in the PROPPR trial. ABC score or clinician gestalt prediction of MT was used to randomize patients and call for initial study cooler. In this planned sub-analysis, the time to MT protocol activation and time to delivery of the initial cooler were evaluated. The impact of these times on mortality and time to hemostasis were examined using both Wilcoxon rank sum and linear and logistic regression. RESULTS Among 680 patients, the median time from patient arrival to MT protocol activation was 9 minutes with a median time from MT activation call to delivery of first cooler of 8 minutes. An increase in both time to MT activation and time to arrival of first cooler were associated with prolonged time to achieving hemostasis (coef 1.09, p=0.001 and coef. 1.16, p < 0.001, respectively). Increased time to MT activation and time to arrival of first cooler were associated with increased mortality (OR 1.02, p=0.009 and OR 1.02, p = 0.012, respectively). Controlling for injury severity, physiology, resuscitation intensity, and treatment arm (1:1:1 vs. 1:1:2), increased time to arrival of first cooler was associated with an increased mortality at 24-hours (OR 1.05, p = 0.035) and 30-days (OR 1.05, p = 0.016). CONCLUSIONS Delays in MT protocol activation and delays in initial cooler arrival were associated with prolonged time to achieve hemostasis and an increase in mortality. Independent of products ratios, every minute from time of MT protocol activation to time of initial cooler arrival increases odds of mortality by 5%. LEVEL OF EVIDENCE Level II, Prognostic

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A Paradigm Shift in Trauma Resuscitation

Abstract: There has been a shift toward a reduced crystalloid volume and the recreation of whole blood from component products in resuscitation. These changes are associated with markedly improved outcomes and a new paradigm in the resuscitation of severely injured patients.

Cited by 84 publications

References 29 publications

Goal-directed Hemostatic Resuscitation of Trauma-induced Coagulopathy

Goal-directed Hemostatic Resuscitation of Trauma-induced Coagulopathy

Trauma-Induced Coagulopathy: An Institution’s 35 Year Perspective on Practice and Research

Every minute counts

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