Platelet transfusions reduce fibrinolysis but do not restore platelet function during trauma hemorrhage

Vulliamy, Paul; Gillespie, Scarlett; Gall, Lewis; Green, Laura; Brohi, Karim; Davenport, Ross

doi:10.1097/ta.0000000000001520

Cited by 56 publications

(74 citation statements)

References 30 publications

(31 reference statements)

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“…CS‐LTOWB not only simplifies the resuscitative effort by not requiring thawing or cross‐matching, but it also is space‐efficient and shortens time to transfusion, which may contribute to improved survival . Also, CS‐LTOWB delivers platelets much farther forward than has been previously possible, due to increased storage duration; early platelet transfusion has been associated with improved survival . Lastly, CS‐LTOWB has over a century of proven safety; hundreds of thousands of units of CS‐LTOWB were transfused during the wars of the 20th Century with few reported adverse reactions.…”

Section: Discussionmentioning

confidence: 99%

“…LTOWB also has the advantage of being the most logistically feasible in the far forward environment; it only requires refrigeration compared to a balanced component transfusion strategy that not only requires refrigeration, but a freezer, incubator, and thawer as well. Clinically LTOWB: (1) is a more concentrated product than 1:1:1 CT resuscitation; (2) has better oxygen carrying capacity than CT; (3) has a plasma coagulation profile better than FFP; and (4) has cold platelets making it more hemostatic than warm platelets while carrying a lower bacterial infectious risk . Given the challenges of the battlefield, a simple, safe, efficient, and effective option for resuscitation is best.…”

Section: Whole Blood Is the Optimal Resuscitation Fluid For The Hemormentioning

confidence: 99%

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The use of whole blood in US military operations in Iraq, Syria, and Afghanistan since the introduction of low‐titer Type O whole blood: feasibility, acceptability, challenges

et al. 2018

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BACKGROUND Hemorrhage is the leading cause of preventable death in military and civilian traumatic injury. Blood product resuscitation improves survival. Low‐titer Type O Whole Blood (LTOWB) was recently re‐introduced to the combat theater as a universal resuscitation product for hemorrhagic shock. This study assessed the utilization patterns of LTOWB compared to warm fresh whole blood (WFWB) and blood component therapy (CT) in US Military Operations in Iraq/Syria and Afghanistan known as Operation Inherent Resolve (OIR) and Operation Freedom's Sentinel (OFS) respectively. We hypothesized LTOWB utilization would increase over time given its advantages. STUDY DESIGN AND METHODS Using the Theater Medical Data Store, patients receiving blood products between January 2016 and December 2017 were identified. Product utilization ratios (PUR) for LTOWB, WFWB, and CT were compared across Area of Operations (AORs), medical treatment facilities (Role 2 vs. Role 3), and time. PUR was defined as number of blood products transfused/(number of blood products transfused + number of blood products wasted). RESULTS The overall PUR for all blood products was 17.4%; the LTOWB PUR was 14.3%. Over the study period, the total number of blood products transfused increased 133%. Although the total whole blood (WB) increased from 2.1% to 6.6% of all products transfused, WFWB use remained at 2% while LTOWB transfusions increased from 0.5% to 4%. Transfusion of LTOWB occurred more in austere Role 2 facilities compared to Role 3 hospitals. CONCLUSIONS LTOWB transfusion is feasible in austere, far‐forward environments. Further investigation is needed regarding the safety, clinical outcomes, and drivers of LTOWB transfusions.

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Section: Discussionmentioning

confidence: 99%

Section: Whole Blood Is the Optimal Resuscitation Fluid For The Hemormentioning

confidence: 99%

The use of whole blood in US military operations in Iraq, Syria, and Afghanistan since the introduction of low‐titer Type O whole blood: feasibility, acceptability, challenges

et al. 2018

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“…Furthermore, the dangers of excessive platelet transfusions for intracranial bleeding were suggested in the PATCH-3 study in which empiric platelet transfusion in hemorrhagic stroke patients was associated with increased mortality [20]. While platelet count predicts outcome, transfusing platelets based on platelet count to “normalize” platelet count does not seem to improve outcomes, and may even harm patients, if the internal environment is hostile [21]. The appropriate transfusion trigger for platelets in injured patients remains to be elucidated but goal-directed platelet transfusions with TEG MA have been associated with a reduction in platelet transfusions and a reduction in mortality in patients undergoing massive transfusion [7,22,23].…”

Section: Discussionmentioning

confidence: 99%

Platelet adenosine diphosphate receptor inhibition provides no advantage in predicting need for platelet transfusion or massive transfusion

Stettler

Moore

et al. 2017

Surgery

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Introduction Thrombelastography Platelet Mapping (TEG-PM) is a useful assay to assess antiplatelet therapy. Inhibited response to the ADP receptor on platelets occurs early following injury but recent work suggests this alteration occurs even with minor trauma. However, the utility of TEG-PM, specifically the percent of ADP receptor inhibition (%ADP-INH), in predicting outcomes and guiding platelet transfusion in trauma-induced coagulopathy (TIC) remains unknown. We assessed the role of %ADP-INH in predicting survival, requirement for massive transfusion or platelet transfusion in patients at risk for TIC. Methods TEG-PM was assessed in 303 trauma activation patients from 2014–2016 and in 89 healthy volunteers. %ADP-INH is presented as median and interquartile range (IQR). We compared the area under the receiver operating characteristic curve (AUROC) of %ADP-INH, platelet count, and rTEG Maximum amplitude (MA) for in-hospital mortality, massive transfusion (>10 RBC or death/6 hours, and platelet transfusion (>0 platelet units or death/6hrs). Results Overall, 35 (11.5%) patient died, 27 (8.9%) required massive transfusion and 46, platelet transfusions (15.2%). Median %ADP-INH was 42.5% (IQR: 22.4–69.1%), compared to 4.3 % (IQR: 0–13.5%) in healthy volunteers (p<0.0001). Patients that died, had a massive transfusion, or platelet transfusion had higher %ADP-INH than those that did not (p<0.05 for all). However, %ADP-INH did not add significantly to the predictive performance of MA or platelet count for any of the three outcomes, after adjustment for confounders. Subgroup analyses by severe traumatic brain injury, severe injury and requirement of RBCs showed similar results. Conclusion ADP receptor inhibition did not add predictive value to predicting mortality, massive transfusion, or platelet transfusion. Thus, the role of TEG-PM as a solitary tool to guide platelet transfusions in trauma requires continued refinement.

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“…In contrast, Vulliamy et al 25 used data from a single center in the ACIT trial to show that platelet administration did not improve either platelet count or aggregation but did improve viscoelastic test parameters of fibrinolysis. Although this suggests that transfused platelets could still be beneficial after degranulation and release of procoagulant contents, even if not for their primary hemostatic capabilities, the study did not comment on clinical outcomes after platelet transfusion.…”

Section: Discussionmentioning

confidence: 99%

“…25,26 These observations likely reflect both the well-described storage lesions that affect transfused platelet number and function and the differential removal from the circulation by adhesion to the site of injury of better-functioning platelets in injured patients. 27,28 The recently completed PROPPR trial provided an opportunity to examine a subset of severely injured patients who were prospectively randomized to receive early platelets or not.…”

Section: Introductionmentioning

confidence: 99%

Platelet transfusions improve hemostasis and survival in a substudy of the prospective, randomized PROPPR trial

Xu²,

et al. 2018

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Key Points• Early platelet administration is associated with improved hemostasis and reduced mortality in severely injured, bleeding trauma patients.Transfusing platelets during massive hemorrhage is debated because of a lack of high-quality evidence concerning outcomes in trauma patients. The objective of this study was to examine the effect of platelet transfusions on mortality in severely injured trauma patients. This work analyzed PROPPR (Pragmatic, Randomized Optimal Platelet and Plasma Ratios) trial patients who received only the first cooler of blood products, which either did or did not contain platelets. Primary outcomes were all-cause mortality at 24 hours and 30 days and hemostasis.Secondary outcomes included cause of death, complications, and hospital-, intensive care unit (ICU)-, and ventilator-free days. Continuous variables were compared using Wilcoxon rank sum tests. Categorical variables were compared using Fisher's exact tests. There were 261 PROPPR patients who achieved hemostasis or died before receiving a second cooler of blood products (137 received platelets and 124 did not). Patients who received platelets also received more total plasma (median, 3 vs 2 U; P , .05) by PROPPR intervention design.There were no differences in total red blood cell transfusions between groups. After controlling for plasma volume, patients who received platelets had significantly decreased 24-hour (5.8% vs 16.9%; P , .05) and 30-day mortality (9.5% vs 20.2%; P , .05). More patients in the platelet group achieved hemostasis (94.9% vs 73.4%; P , .01), and fewer died as a result of exsanguination (1.5% vs 12.9%; P , .01). Patients who received platelets had a shorter time on mechanical ventilation (P , .05); however, no differences in hospital-or ICU-free days were observed. In conclusion, early platelet administration is associated with improved hemostasis and reduced mortality in severely injured, bleeding patients. This trial was registered at www.clinicaltrials.gov as # NCT01545232.

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Platelet transfusions reduce fibrinolysis but do not restore platelet function during trauma hemorrhage

Abstract: Therapeutic, level III.

Cited by 56 publications

References 30 publications

The use of whole blood in US military operations in Iraq, Syria, and Afghanistan since the introduction of low‐titer Type O whole blood: feasibility, acceptability, challenges

The use of whole blood in US military operations in Iraq, Syria, and Afghanistan since the introduction of low‐titer Type O whole blood: feasibility, acceptability, challenges

Platelet adenosine diphosphate receptor inhibition provides no advantage in predicting need for platelet transfusion or massive transfusion

Platelet transfusions improve hemostasis and survival in a substudy of the prospective, randomized PROPPR trial

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