Blood Component Therapy and Coagulopathy in Trauma: A Systematic Review of the Literature from the Trauma Update Group

Abstract

BackgroundTraumatic coagulopathy is thought to increase mortality and its treatment to reduce preventable deaths. However, there is still uncertainty in this field, and available literature results may have been overestimated.MethodsWe searched the MEDLINE database using the PubMed platform. We formulated four queries investigating the prognostic weight of traumatic coagulopathy defined according to conventional laboratory testing, and the effectiveness in reducing mortality of three different treatments aimed at contrasting coagulopathy (high fresh frozen plasma/packed red blood cells ratios, fibrinogen, and tranexamic acid administration). Randomized controlled trials were selected along with observational studies that used a multivariable approach to adjust for confounding. Strict criteria were adopted for quality assessment based on a two-step approach. First, we rated quality of evidence according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria. Then, this rating was downgraded if other three criteria were not met: high reporting quality according to shared standards, absence of internal methodological and statistical issues not detailed by the GRADE system, and absence of external validity issues.ResultsWith few exceptions, the GRADE rating, reporting and methodological quality of observational studies was “very low”, with frequent external validity issues. The only two randomized trials retrieved were, instead, of high quality. Only weak evidence was found for a relation between coagulopathy and mortality. Very weak evidence was found supporting the use of fibrinogen administration to reduce mortality in trauma. On the other hand, we found high evidence that the use of 1:1 vs. 1:2 high fresh frozen plasma/packed red blood cells ratios failed to obtain a 12% mortality reduction. This does not exclude lower mortality rates, which have not been investigated. The use of tranexamic acid in trauma was supported by “high” quality evidence according to the GRADE classification but was downgraded to “moderate” for external validity issues.ConclusionsTranexamic acid is effective in reducing mortality in trauma. The other transfusion practices we investigated have been inadequately studied in the literature, as well as the independent association between mortality and coagulopathy measured with traditional laboratory testing. Overall, in this field of research literature quality is poor.

Use of low dose of rFVIIa (recombinant Factor VII activated) to control late bleeding after percutaneous dilational tracheostomy

“…It should be noted that although no specific guidelines for management of post‐PDT bleeding are available, the last version of the European Society of Anaesthesiology (ESA) guidelines for management of perioperative bleeding suggested that the use of rFVIIa could be considered for “bleeding which cannot be stopped by conventional, surgical or interventional radiological means and/or when comprehensive coagulation therapy fails” . In our case, correction of confounding factors (ie, acid‐base unbalance, hypocalcemia, hypothermia), administration of tranexamic acid, and correction of hypofibrinogenemia were performed according to guidelines, in association with a first platelet unit transfusion . However, these measures did not stop bleeding leading us to consider the use of rFVIIa.…”

“…13 In our case, correction of confounding factors (ie, acid-base unbalance, hypocalcemia, hypothermia), administration of tranexamic acid, and correction of hypofibrinogenemia were performed according to guidelines, in association with a first platelet unit transfusion. 13,14 However, these measures did not stop bleeding leading us to consider the use of rFVIIa. Since the administration of rFVIIa does not resolve the cause of bleeding per se, it should be considered as a "not specific" form of coagulation support.…”