Damage-control resuscitation increases successful nonoperative management rates and survival after severe blunt liver injury

Shrestha, Binod Bade; Holcomb, John B.; Camp, Elizabeth A.; Junco, Deborah J. del; Cotton, Bryan A.; Albarado, Rondel; Gill, Brijesh S.; Kozar, Rosemary A.; Kao, Lillian S.; McNutt, Michelle K.; Moore, Laura J.; Love, Joseph D.; Tyson, George H.; Adams, Phillip R.; Khan, Saleem Ahmed; Wade, Charles E.

doi:10.1097/ta.0000000000000514

Cited by 76 publications

(52 citation statements)

References 33 publications

(35 reference statements)

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“…23,24 Energy-related neurochemical dysregulation in TBI + HS is likely a major factor contributing to worse neurologic outcomes. 25 Therefore, principles of damage-control resuscitation, which include permissive hypotension, 4,5,9 require further study in patients with TBI+HS, since a higher mean arterial pressure (>70-mm Hg) may result in better cerebral blood flow and cerebral mitochondrial function. 26 Speed of resuscitation may also be imperative for protecting brain function; animal models using a stepwise ratio-guided protocol with FFP (compared to a bolus protocol) have demonstrated a neuroprotective effect.…”

Section: Discussionmentioning

confidence: 99%

“…15,22,30,32,33 Ratio-guided resuscitation with fresh frozen plasma (FFP) may have beneficial effects for patients with TBI + HS, 15 including fewer inflammatory complications. 5,6,9 In experimental large animal studies, early administration of FFP reduced the size of brain lesions, decreased cerebral edema, and substantially attenuated the degree of neurological impairment. 32,34 Benefits of FFP resuscitation may be related to gene expression.…”

Section: Discussionmentioning

confidence: 99%

“…8 Application of DCR strategies has reduced mortality from HS and also seems to reduce the incidence and severity of complications such as organ failure and infection. 5,6,9 However, very little is known about the clinical implications of DCR for patients with TBI and HS, especially considering the coagulopathy that often accompanies TBI. 1,10–15 Additionally, there is virtually no data on how DCR affects neurologic status and outcomes with concomitant TBI.…”

Section: Introductionmentioning

confidence: 99%

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Outcomes after concomitant traumatic brain injury and hemorrhagic shock

Galvagno

Fox

Appana

et al. 2017

Journal of Trauma and Acute Care Surgery

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Background Often the clinician is faced with a diagnostic and therapeutic dilemma in patients with concomitant traumatic brain injury (TBI) and hemorrhagic shock (HS), as rapid deterioration from either can be fatal. Knowledge about outcomes following concomitant TBI and HS may help prioritize the emergent management of these patients. We hypothesized that patients with concomitant TBI and HS (TBI+HS) had worse outcomes and required more intensive care compared to patients with only one of these injuries. Methods This is a post-hoc analysis of the Pragmatic, Randomized Optimal Platelets and Plasma Ratios (PROPPR) trial. TBI was defined by a head abbreviated injury scale >2. HS was defined as a base excess ≤ −4 and/or shock index ≥ 0.9. The primary outcome for this analysis was mortality at 30 days. Logistic regression, using generalized estimating equations (GEE), was used to model categorical outcomes. Results 670 patients were included. Patients with TBI+HS had significantly higher lactate (median 6.3; IQR 4.7,9.2) compared to the TBI group (median 3.3; IQR 2.3,4). TBI+HS patients had higher activated prothrombin times and lower platelet counts. Unadjusted mortality was higher in the TBI+HS (51.6%) and TBI (50%) groups compared to the HS (17.5%) and neither group (7.7%). Adjusted odds of death in the TBI and TBI+HS groups were 8.2 (95% CI, 3.4–19.5) and 10.6 (95% CI, 4.8–23.2) times higher, respectively. Ventilator, ICU- and hospital-free days were lower in the TBI and TBI+HS groups compared to the other groups. Patients with TBI+HS or TBI had significantly greater odds of developing a respiratory complication compared to the neither group. Conclusions The addition of TBI to HS is associated with worse coagulopathy prior to resuscitation, and increased mortality. When controlling for multiple known confounders, the diagnosis of TBI alone or TBI+HS was associated with significantly greater odds of developing respiratory complications.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Outcomes after concomitant traumatic brain injury and hemorrhagic shock

Galvagno

Fox

Appana

et al. 2017

Journal of Trauma and Acute Care Surgery

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“…Shrestha et al have shown increased likelihood of successful non-operative management and survival in civilian patients with high grade liver injuries after blunt trauma. 64 In the military setting, soldiers injured in combat are also surviving with more severe injuries after implementation of DCR. 65 Based on these studies, the ACS TQIP Massive Transfusion in Trauma Guidelines recommend DCR in patients who meet MTP triggers (see comment 1) (Table 2)…”

Section: Pharmacologic Treatment Optionsmentioning

confidence: 99%

Optimal Fluid Therapy for Traumatic Hemorrhagic Shock

Chang¹,

Holcomb²

2017

Critical Care Clinics

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110

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The resuscitation of traumatic hemorrhagic shock has undergone a paradigm shift in the last 20 years with the advent of damage control resuscitation (DCR). Major principles of DCR include minimization of crystalloid, permissive hypotension, transfusion of a balanced ratio of blood products, and goal-directed correction of coagulopathy. In particular, plasma has replaced crystalloid as the primary means for volume expansion for traumatic hemorrhagic shock. Predicting which patient will require DCR by prompt and accurate activation of a massive transfusion protocol, however, remains a challenge.

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“…In addition, DCR may decrease the surgical hemostatic requirement in severely injured patients. A retrospective study showed an increase in the success rate of nonoperative management from 54 to 74% for grades IV and V severe blunt liver injury after the implementation of DCR [100]. DCR may herald the beginning of the end for DCS [98].…”

Section: Changes Of Surgical Strategy In Dcrmentioning

confidence: 99%

Damage control resuscitation: a practical approach for severely hemorrhagic patients and its effects on trauma surgery

Mizobata

2017

j intensive care

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Coagulopathy observed in trauma patients was thought to be a resuscitation-associated phenomenon. The replacement of lost and consumed coagulation factors was the mainstay in the resuscitation of hemorrhagic shock for many decades. Twenty years ago, damage control surgery (DCS) was implemented to challenge the coagulopathy of trauma. It consists of three steps: abbreviated surgery to control the hemorrhage and contamination, resuscitation in the intensive care unit (ICU), and planned re-operation with definitive surgery. The resuscitation strategy of DCS focused on the rapid reversal of acidosis and prevention of hypothermia through the first two steps. However, direct treatment of coagulopathy was not emphasized in DCS. Recently, better understanding of the pathophysiology of coagulopathy in trauma patients has led to the logical opinion that we should directly address this coagulopathy during major trauma resuscitation. Damage control resuscitation (DCR), the strategic approach to the trauma patient who presents in extremis, consists of balanced resuscitation, hemostatic resuscitation, and prevention of acidosis, hypothermia, and hypocalcemia. In balanced resuscitation, fluid administration is restricted and hypotension is allowed until definitive hemostatic measures begin. The administration of blood products consisting of fresh frozen plasma, packed red blood cells, and platelets, the ratio of which resembles whole blood, is recommended early in the resuscitation. DCR strategy is now the most beneficial measure available to address trauma-induced coagulopathy, and it can change the treatment strategy of trauma patients. DCS is now incorporated as a component of DCR. DCR as a structured intervention begins immediately after rapid initial assessment in the emergency room and progresses through the operating theater into the ICU in combination with DCS. By starting from ground zero with the performance of DCS, DCR allows the trauma surgeon to correct the coagulopathy of trauma. The effect of the reversal of coagulopathy in massively hemorrhagic patients may change the operative strategy with DCS.

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Damage-control resuscitation increases successful nonoperative management rates and survival after severe blunt liver injury

Abstract: Therapeutic/care management, level III.

Cited by 76 publications

References 33 publications

Outcomes after concomitant traumatic brain injury and hemorrhagic shock

Outcomes after concomitant traumatic brain injury and hemorrhagic shock

Optimal Fluid Therapy for Traumatic Hemorrhagic Shock

Damage control resuscitation: a practical approach for severely hemorrhagic patients and its effects on trauma surgery

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