Trauma-induced coagulopathy: impact of the early coagulation support protocol on blood product consumption, mortality and costs

Abstract

IntroductionHemorrhage is the principal cause of death in the first few hours following severe injury. Coagulopathy is a frequent complication of critical bleeding. A network of Italian trauma centers recently developed a protocol to prevent and treat trauma-induced coagulopathy. A pre-post cohort multicenter study was conducted to assess the impact of the early coagulation support (ECS) protocol on blood products consumption, mortality and treatment costs.MethodsWe prospectively collected data from all severely injured patients (Injury Severity Score (ISS) >15) admitted to two trauma centers in 2013 and compared these findings with the data for 2011. Patients transfused with at least 3 units of packed red blood cells (PRBCs) within 24 hours of an accident were included in the study. In 2011, patients with significant hemorrhaging were treated with early administration of plasma with the aim of achieving a high (≥1:2) plasma-to-PRBC ratio. In 2013, the ECS protocol was the treatment strategy. Outcome data, blood product consumption and treatment costs were compared between the two periods.ResultsThe two groups were well matched for demographics, injury severity (ISS: 32.9 in 2011 versus 33.6 in 2013) and clinical and laboratory data on admission. In 2013, a 40% overall reduction in PRBCs was observed, together with a 65% reduction in plasma and a 52% reduction in platelets. Patients in the ECS group received fewer blood products: 6.51 units of PRBCs versus 8.14 units. Plasma transfusions decreased from 8.98 units to 4.21 units (P <0.05), and platelets fell from 4.14 units to 2.53 units (P <0.05). Mortality in 2013 was 13.5% versus 20% in 2011 (13 versus 26 hospital deaths, respectively) (nonsignificant). When costs for blood components, factors and point-of-care tests were compared, a €76,340 saving in 2013 versus 2011 (23%) was recorded.ConclusionsThe introduction of the ECS protocol in two Italian trauma centers was associated with a marked reduction in blood product consumption, reaching statistical significance for plasma and platelets, and with a non-significant trend toward a reduction in early and 28-day mortality. The overall costs for transfusion and coagulation support (including point-of-care tests) decreased by 23% between 2011 and 2013.

Partial Zone II Resuscitative Endovascular Balloon Occlusion of the Aorta in Management of Multiple Trauma with Combined Abdominal and Pelvic Injury

“…A crystalloids solution infusion started and a pelvic binder was applied to prevent potential further injury. The patient was transported to the Emergency Department (ED) of Bufalini Hospital in Cesena, Italy while activating Trauma Team (TT) and Early Coagulation Support Protocol [19].…”

Fixed ratio versus goal-directed therapy in trauma

“…Nardi et al [91] recently published data from an Italian multicenter study on the impact of a newly established early coagulation support protocol, whereby coagulation is monitored via VETs. Initial treatment, comparable with the Copenhagen concept, was based on clinical signs of shock and on results of early blood gas analyses.…”

“…According to the new protocol, patients in shock received a standard dose of 2 g fibrinogen concentrate. Blood product consumption, mortality, and costs were compared before and after the initiation of the protocol, and a significant reduction in plasma and platelet concentrate transfusion (P < 0.05) and a trend toward decreased use of RBCs and decreased mortality were observed [91].…”

Impossible primary referral to the major trauma center of an integrated trauma system: a case of exsanguinating trauma treated in a Spoke hospital

“…HEMS doctor, which was one of the Intensive Care doctors used to be involved in the MTC by Trauma Team activation, carried on Trauma Leader role. Early Coagulative Support Protocol started and mechanical ventilation carried on by Anesthesiologists [9]. Surgeon obtained Damage Control hemostasis with surgical forceps in few minutes and gradually the direct compression was freed.…”