Four-factor prothrombin complex concentrate in adjunct to whole blood in trauma-related hemorrhage: Does whole blood replace the need for factors?

Abstract

BACKGROUND:The use of whole blood (WB) for the treatment of hemorrhagic shock and coagulopathy is increasing in civilian trauma patients. Four-factor prothrombin complex concentrate (4-PCC) in adjunct to component therapy showed improved outcomes in trauma patients.Our study aims to evaluate the outcomes of trauma patients who received 4-PCC and WB (4-PCC-WB) compared with WB alone. METHODS:We performed a 3-year (2015-2017) analysis of the American College of Surgeons-Trauma Quality Improvement Program database. All adult (age, ≥18 years) trauma patients who received WB were included. We excluded patients who were on preinjury anticoagulants. Patients were stratified into two groups, 4-PCC-WB versus WB alone, and matched in a 1:2 ratio using propensity score matching. Outcome measures were packed red blood cells, plasma, platelets, and cryoprecipitate transfused, in-hospital complications, hospital and intensive care unit (ICU) length of stay (LOS) among survivors, and mortality. RESULTS:A total of 252 patients (4-PCC-WB, 84; WB alone, 168) were matched. The mean ± SD age was 47 ± 21 years, 63% were males, median Injury Severity Score was 30 (21-40), and 87% had blunt injuries. Patients who received 4-PCC-WB had decreased requirement for packed red blood cell (8 U vs. 10 U, p = 0.04) and fresh frozen plasma (6 U vs. 8 U, p = 0.01) transfusion, lower rates of acute kidney injury (p = 0.03), and ICU LOS (5 days vs. 8 days, p = 0.01) compared with WB alone. There was no difference in the platelet transfusion (p = 0.19), cryoprecipitate transfusion (p = 0.37), hospital LOS (p = 0.72), and in-hospital mortality (p = 0.72) between the two groups. CONCLUSION:Our study demonstrates that the use of 4-PCC as an adjunct to WB is associated with a reduction in transfusion requirements and ICU LOS compared with WB alone in the resuscitation of trauma patients. Further studies are required to evaluate the role of PCC with WB in the resuscitation of trauma patients.

After 9,000 laparotomies for blunt trauma, resuscitation is becoming more balanced and time to intervention shorter: Evidence in action

“…Indeed, only 2.5% of blunt trauma patients in our study received WB in 2013 as compared with nearly five times that in 2016. This likely reflects the renewed interest in the benefits of WB resuscitation over blood component resuscitation recently demonstrated in the literature, including increased available hematocrit, and improved coagulation factor and platelet concentration and function 32–37 . Because previous work and our study have shown that balanced component therapy in ratios that mimic WB is associated with improved outcomes, transfusing WB may simply represent the logical end goal of trauma resuscitation practices.…”

“…This likely reflects the renewed interest in the benefits of WB resuscitation over blood component resuscitation recently demonstrated in the literature, including increased available hematocrit, and improved coagulation factor and platelet concentration and function. [32][33][34][35][36][37] Because previous work and our study have shown that balanced component therapy in ratios that mimic WB is associated with improved outcomes, transfusing WB may simply represent the logical end goal of trauma resuscitation practices. Future studies assessing the impact of the adoption of WB-based transfusion practices on a national scale are warranted.…”

Therapeutic Interventions and Outcomes in Civilian and Military Isolated Gunshot Wounds to the Head

“…The mortality was significantly lower in the military DoDTR population (23% vs 41%, P < 0.001). Military patients who survived had a discharge mean GCS of 14 (3)(4)(5)(6)(7)(8)(9)(10)(11)(12)(13)(14)(15). However, 32 (32.7%) of them had a discharge GCS < 9.…”

“…In a prospective observational study, the CENTER-TBI and OzENTER-TBI groups showed that positive fluid balance in the setting of TBI was associated with negative effects on outcome. 11 As resuscitation goals have adjusted and management has shifted toward balanced component replacement 12 and now whole blood therapy 13 and even whole blood with concentrated factor adjuncts, 14 these resuscitation strategies have allowed for a reduction in the volume of resuscitation that may have a beneficial effect on ICP and outcome after TBI.…”

Prothrombin complex concentrate (PCC) for treatment of trauma-induced coagulopathy: systematic review and meta-analyses

“…Across all nine observational studies, a total of 823 patients were included in the PCC treatment group (ranging from 9 to 234 patients per group). Two of the studies were multi-center with the remainder being single center [ 25 , 27 ]. The mean a 26 ge of the patients ranged from 36 to 51 years and the mean ISS from 23 to 50.…”