Change of transfusion and treatment paradigm in major trauma patients

Abstract

Trauma promotes trauma-induced coagulopathy, which requires urgent treatment with fixed-ratio transfusions of red blood cells, fresh frozen plasma and platelet concentrates, or goal-directed administration of coagulation factors based on viscoelastic testing. This retrospective observational study compared two time periods before (2005-2007) and after (2012-2014) the implementation of changes in trauma management protocols which included: use of goal-directed coagulation management; admission of patients to designated trauma centres; whole-body computed tomography scanning on admission; damage control surgery; permissive hypotension; restrictive fluid resuscitation; and administration of tranexamic acid. The incidence of massive transfusion (≥ 10 units of red blood cells from emergency department arrival until intensive care unit admission) was compared with the predicted incidence according to the trauma associated severe haemorrhage score. All adult (≥ 16 years) trauma patients primarily admitted to the University Hospital Zürich with an injury severity score ≥ 16 were included. In 2005-2007, the observed and trauma associated severe haemorrhage score that predicted the incidence of massive transfusion were identical, whereas in 2012-2014 the observed incidence was less than half that predicted (3.7% vs. 7.5%). Compared to 2005-2007, the proportion of patients transfused with red blood cells and fresh frozen plasma was significantly lower in 2012-2014 in both the emergency department (43% vs. 17%; 31% vs. 6%, respectively), and after 24 h (53% vs. 27%; 37% vs. 16%, respectively). The use of tranexamic acid and coagulation factor XIII also increased significantly in the 2012-2014 time period. Implementation of a revised trauma management strategy, which included goal-directed coagulation management, was associated with a reduced incidence of massive transfusion and a reduction in the transfusion of red blood cells and fresh frozen plasma.

Impact of Early Thromboelastography-Directed Therapy in Trauma Resuscitation

“…Schochl et al [19] similarly demonstrated a reduction in PRBCs as well as PLs in TEG directed resuscitation with fibrinogen concentrate and prothrombin concentrate complex. More recently, Stein et al [20] also demonstrated a reduction in PRBCs and FFP during the period after TEG implementation, and noted a significantly higher rate in use of TXA (similar to our study) and coagulation factor XIII during that period. With regards to the higher use of PLs in our study, we experienced difficulty in extracting data pertinent to the history of antiplatelet use prior to trauma from patients' charts.…”

“…Our study results demonstrate that after TEG implementation, despite an initial increase in the use of FFP and PL during the first 4 h of trauma resuscitation, an overall reduction in the use of PRBCs and FFP was observed during the first 24 h similar to other studies [11,19,20]. In the study by Gonzales et al [11], patients randomized to either MTP goal directed by visco-elastic test or by CCTs.…”

Towards a systematic approach for (de)implementation of patient blood management strategies

“…This is also emphasised by literature on how to effectively implement PBM programmes (Farmer et al, ; Australia, ; Fischer et al, ; Meybohm et al, ,b). However, in several studies on the implementation of PBM programmes, both these processes are not described (Holt et al, ; Kopanidis et al, ; Loftus et al, ; Meybohm et al, ; Rineau et al, ; Rineau et al, ; Stein et al, ). Therefore, researchers should be challenged to generate knowledge on effective implementation strategies.…”

Impact of a goal-directed factor-based coagulation management on thromboembolic events following major trauma

“…Predefined coagulation algorithms were introduced to tackle this issue and to guide the haemostatic management of clinicians at the emergency department [5,6]. Such coagulation algorithms were proven to reduce the incidence of massive transfusion [7], the transfusion of allogeneic blood products [3,5,7] and to improve survival rate [6] of patients following major trauma. Beneficial effects of a factorbased coagulation management have been reported for patients following trauma, as well as in the early identification and individualized treatment of coagulopathy in major obstetric haemorrhage [8].…”