REBOA resulted in the restoration of Qcarotid ("cerebrovascular resuscitation") at least as rapidly as retransfusion of shed blood, with equivalent 4-hour survival. Further studies of REBOA, to include mitigation of end-organ effects and longer follow-up, are needed.
The impact on outcomes resulting from crystalloids used with hemostatic close ratio resuscitation (HCRR) in intraoperative hemorrhage (IOH) has not been analyzed. We hypothesize a survival advantage in patients with IOH managed with a low-volume resuscitation (LVR) protocol during HCRR. A 4-year case-control study was conducted to determine the impact on mortality of LVR versus conventional resuscitation efforts (CRE) during HCRR. A total of 45 patients managed with a HCRR + LVR protocol (combination Hextend® and 3% hypertonic saline) and 55 historical cohorts managed with HCRR + CRE (lactated Ringer's) were included. Patient demographics, number of intraoperative units of packed red blood cells (PRBCs) and fresh-frozen plasma (FFP) received, and FFP:PRBC ratio were similar between groups. The mean intraoperative fluid volume was 0.76 L in the HCRR + LVR group versus 4.7 L in the HCRR + CRE group ( P = 0.003). In a linear regression model HCRR + LVR versus HCRR + CRE, mean trauma intensive care unit length of stay was ± versus 11 days ( P = 0.009); 30-day overall mortality was 11.1 versus 32.7 per cent ( P = 0.009); perioperative mortality was 2.2 to 10.9 per cent ( P = 0.13); and intensive care unit mortality 8.8 to 21.8 per cent ( P = 0.07). LVR protocol conveyed a survival benefit to patients undergoing HCRR (odds ratio for mortality, 0.07 [95% confidence interval 0.07–0.54]). This is the first civilian study to analyze the impact of LVR in patients managed with HCRR during IOH. Patients with IOH managed with HCRR and a predefined LVR protocol with Hextend® and 3 per cent hypertonic saline had an overall survival advantage and shorter trauma intensive care unit length of stay. LVR can be an effective alternative to CRE when used in combination with HCRR in patients with IOH.
Background Patients with severe tissue injury and tissue hypoperfusion can present with low fibrinogen levels and signs of hyperfibrinolysis. The role of damage control resuscitation (DCR) in addressing the hyperfibrinolytic aspect of trauma induced coagulopathy (TIC) is unknown. We hypothesize a survival advantage when DCR is used in TIC patients with severe tissue injury and low fibrinogen levels. Materials and methods This is a 2 years prospective observational study of TIC patients who received DCR. TIC was defined as initial base deficit = –6 in combination with ISS = 12. Low fibrinogen was considered when serum level <200 mg/dl. Patients were stratified into those with an injury severity score (ISS) <20, and those with an ISS = 20. Variables analyzed between groups included: initial serum fibrinogen, INR, base deficit, intraoperative FFP: PRBC ratio and mortality. Results Of 67 patients with TIC, 29 (43.2%) had ISS < 20, and 38 (56.7%) an ISS ≥ 20. Mean ISS was 13.9 vs 32.8 (p < 0.0001) for the ISS < 20 group vs the ISS ≥ 20 group respectively. Mean initial fibrinogen levels for the ISS < 20 group vs the ISS ≥ 20 group was 357.4 mg/dl vs 148.5 mg/dl (p = 0.0007). Intraoperative DCR with FFP: PRBC for the ISS < 20 group vs the ISS ≥ 20 group showed no statistical difference: 1 to 1.12 vs 1 to 1.3 (p = 0.12). Overall mortality after controlling for DCR in the ISS < 20 group was 29 and 73% in the ISS ≥ 20 group (p = 0.0007). In a stepwise logistic regression, low fibrinogen levels was associated with mortality, p = 0.01; OR 1.01 (1.23-11.55) with area under the receiver operating characteristic curve of 0.701. The correlation coefficient for ISS vs initial fibrinogen level was –0.5635 (p = 0.0001). Conclusion Overall mortality was significantly increased in patients who had an ISS . 20 with low fibrinogen level despite effective DCR. Given the correlated decrease in fibrinogen levels in patients with severe tissue injury, further investigation regarding potential benefits of antifibrinolytic agents in DCR needs further validation. How to cite this article Duchesne JC, Guidry C, Park TS, Simms E, Hoffman JRH, Bock JM, Wascom J, Barbeau J, Meade P, McSwain NE Jr. Impact of Low Fibrinogen Levels in the Puzzle of Trauma-induced Coagulopathy: Is This the Missing Link? Panam J Trauma Critical Care Emerg Surg 2013;2(2): 74-79.
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