Fixed ratio versus goal-directed therapy in trauma

Schöchl, Herbert; Maegele, Marc; Voelckel, Wolfgang G.

doi:10.1097/aco.0000000000000278

Cited by 38 publications

(30 citation statements)

References 87 publications

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“…Recent evidence suggests that this approach may also not be adequate to correct hypoperfusion or coagulopathy during the acute phase of trauma hemorrhage 31, 32. As an alternative, several European but also a few US trauma centers have instituted the concept of goal-directed coagulation therapy (GDCT) based upon results obtained from early POC viscoelastic testing assays 33 . Viscoelastic testing assays provide rapid information about the underlying deficiencies with particular focus on the different aspects of hemostasis such as initiation, dynamics and sustainability of clotting thus allowing targeted coagulation monitoring and therapy according to the individual's needs thereby supporting the innovative concept of precision medicine (Fig.…”

Section: Initial Coagulation Management Including Massive Transfusionmentioning

confidence: 99%

Updated concepts on the pathophysiology and the clinical management of trauma hemorrhage and coagulopathy

Maegele¹,

Huang

et al. 2017

Chinese Journal of Traumatology

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Uncontrolled hemorrhage and subsequent trauma-induced coagulopathy (TIC) are still the principle causes for preventable death after trauma and early detection and aggressive management have been associated with reduced mortality. Despite increasing knowledge about trauma resuscitation, best practice to treat this newly defined entity is still under debate. A synopsis of best current knowledge with reference to the updated European trauma guideline on the management of severe trauma hemorrhage and TIC is presented. The implementation of evidence-based local protocols and algorithms including clinical quality and safety management systems together with parameters to assess key measures of bleeding control and outcome is advocated.

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Section: Initial Coagulation Management Including Massive Transfusionmentioning

confidence: 99%

Updated concepts on the pathophysiology and the clinical management of trauma hemorrhage and coagulopathy

Maegele¹,

Huang

et al. 2017

Chinese Journal of Traumatology

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“…However, the ideal trauma MHP remains elusive, with considerable geographical and institutional variation [19, 20]. The three most commonly utilised MHP are: (1) high fixed-ratio blood product to packed red blood cell transfusion (PRBC) transfusion, (2) targeted blood product transfusion in response to viscoelastic haemostatic assay (VHA) results and (3) a hybrid approach utilising a high fixed ratio initially and subsequently transitioning to a VHA-guided approach [21, 22]. …”

Section: Introductionmentioning

confidence: 99%

Fibrinogen Early In Severe Trauma studY (FEISTY): study protocol for a randomised controlled trial

Winearls

Wullschleger

Wake

et al. 2017

Trials

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BackgroundHaemorrhage is a leading cause of death in severe trauma. Fibrinogen plays a critical role in maintaining haemostasis in traumatic haemorrhage. Early fibrinogen replacement is recommended by several international trauma guidelines using either fibrinogen concentrate (FC) or cryoprecipitate (Cryo). There is limited evidence to support one product over the other with widespread geographic and institutional variation in practice. This pilot trial is the first randomised controlled trial comparing FC to Cryo in traumatic haemorrhage.Methods/designThe Fibrinogen Early In Severe Trauma studY (FEISTY) is an exploratory, multicentre, randomised controlled trial comparing FC to Cryo for fibrinogen supplementation in traumatic haemorrhage. This trial will utilise thromboelastometry (ROTEM®) to guide and dose fibrinogen supplementation. The trial will recruit 100 trauma patients at four major trauma centres in Australia. Adult trauma patients with evidence of haemorrhage will be enrolled on arrival in the trauma unit and randomised to receiving fibrinogen supplementation with either FC or Cryo. The primary outcome is the differential time to fibrinogen supplementation. There are a number of predetermined secondary outcomes including: effects of the intervention on plasma fibrinogen levels, feasibility assessments and clinical outcomes including transfusion requirements and mortality.DiscussionThe optimal method for replacing fibrinogen in traumatic haemorrhage is fiercely debated. In this trial the feasibility and efficacy of fibrinogen supplementation using FC will be compared to Cryo. The results of this pilot study will facilitate the design of a larger trial with sufficient power to address patient-centred outcomes.Trial registrationClinicalTrials.gov, ID: NCT02745041. Registered 4 May 2016.Electronic supplementary materialThe online version of this article (doi:10.1186/s13063-017-1980-x) contains supplementary material, which is available to authorized users.

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“…[22][23][24][25][26] In Europe, on the other hand, VETs had been more commonly used and therefore the European approach to TXA was to give TXA more frequently following the CRASH-2 trial with subsequent utilization of VET GDCT resulting in a more "tailored" approach to TXA utilization in Europe than in the USA until recently. [27][28][29][30]…”

Section: Peer Review Critique and Post-crash-2 Nrctsmentioning

confidence: 99%

Tranexamic Acid for Trauma Resuscitation in the United States of America

Walsh

Thomas

Moore

et al. 2016

Semin Thromb Hemost

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The utilization of tranexamic acid (TXA) for the management of bleeding trauma patients has been a subject of much debate on both sides of the Atlantic and in Australia. As a result of the large randomized controlled study called the , there was an initial enthusiasm for the use of TXA to treat bleeding patients. However, the adoption of TXA in the United States was delayed by concerns of "knowledge and evidence gaps" of the CRASH-2 study and because of a lack of mechanistic rationale that would explain the survival benefit noted in the study. Subsequent nonrandomized controlled trials questioned the liberal use of TXA in trauma patients. This narrative review explores the historical as well as clinical and theoretical grounds for the more measured use of TXA in the United States and proposes a clinical and point-of-care guided utilization of TXA, blood components, and adjunctive hemostatic agents in bleeding trauma patients.

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Fixed ratio versus goal-directed therapy in trauma

Abstract: Individualized GDCT, guided by VET, offers several advantages over fixed ratio coagulation therapy. Studies comparing both hemostatic strategies are warranted.

Cited by 38 publications

References 87 publications

Updated concepts on the pathophysiology and the clinical management of trauma hemorrhage and coagulopathy

Updated concepts on the pathophysiology and the clinical management of trauma hemorrhage and coagulopathy

Fibrinogen Early In Severe Trauma studY (FEISTY): study protocol for a randomised controlled trial

Tranexamic Acid for Trauma Resuscitation in the United States of America

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