The impact of a massive transfusion protocol (1:1:1) on major hepatic injuries: Does it increase abdominal wall closure rates?

Abstract

Background: Massive transfusion protocols (MTPs) using high plasma and platelet ratios for exsanguinating trauma patients are increasingly popular. Major liver injuries often require massive resuscitations and immediate hemorrhage control. Current published literature describes outcomes among patients with mixed patterns of injury. We sought to identify the effects of an MTP on patients with major liver trauma.Methods: Patients with grade 3, 4 or 5 liver injuries who required a massive blood component transfusion were analyzed. We compared patients with high plasma:red blood cell:platelet ratio (1:1:1) transfusions (2007)(2008)(2009)) with patients injured before the creation of an institutional MTP (2005MTP ( -2007.Results: Among 60 patients with major hepatic injuries, 35 (58%) underwent resuscitation after the implementation of an MTP. Patient and injury characteristics were similar between cohorts. Implementation of the MTP significantly improved plasma: red blood cell:platelet ratios and decreased crystalloid fluid resuscitation (p = 0.026). Rapid improvement in early acidosis and coagulopathy was superior with an MTP (p = 0.009). More patients in the MTP group also underwent primary abdominal fascial closure during their hospital stay (p = 0.021). This was most evident with grade 4 injuries (89% vs. 14%). The mean time to fascial closure was 4.2 days. The overall survival rate for all major liver injuries was not affected by an MTP (p = 0.61). Conclusion:The implementation of a formal MTP using high plasma and platelet ratios resulted in a substantial increase in abdominal wall approximation. This occurred concurrently to a decrease in the delivered volume of crystalloid fluid.Contexte : Les protocoles de transfusion massive (PTM) impliquant des rapports plasma:plaquettes élevés sont de plus en plus populaires pour traiter les patients atteints d'un traumatisme hémorragique. Les chirurgies majeures du foie requièrent souvent le déclenchement de protocoles de transfusion massive et une maîtrise immé-diate de l'hémorragie. La littérature actuelle décrit les résultats chez des patients victimes de divers types de traumatismes. Nous avons voulu mesurer les effets d'un PTM sur les patients ayant subi un traumatisme majeur au foie. Résultats : Sur 50 patients ayant subi des lésions hépatiques majeures, 35 (58 %) ont reçu des traitements de réanimation après la mise en place du PTM. Les caractéristiques propres aux patients et à leurs blessures étaient similaires entre les cohortes. L'application du PTM a significativement amélioré les rapports plasma:culots globulaires:plaquettes et réduit l'administration de cristalloïdes à des fins de réanimation liquidienne (p = 0,026). L'amélioration rapide de l'acidose naissante et de la coagulopathie a été meilleure avec le PTM (p = 0,009). Plus de patients du groupe soumis au PTM ont aussi subi une fermeture aponévrotique abdominale primaire durant leur séjour hospitalier (p = 0,021). Cela s'est surtout observé avec les lésions de grade 4 (89 % c. 14 %). Le délai moyen av...

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

“…22,23 The use of DCR during initial resuscitation has been associated with improved survival in the trauma population. 19,26 With the paradigm shift in resuscitation during the last decade and the frequency of liver injury, DCR's impact on severe liver injury should be explored. 16Y19,25 These studies have all evaluated the effect of DCR on the course of the injured patient, irrespective of type of injury.…”

Damage control surgery Concept

“…The recently published reports ( 2011) showed the clear benefi ts of DCS on survival in injured patients who have been managed with DCR compared to conventional resuscitation methods [33].Also, the stay length in ICU has increasingly been reduced in patients requiring DCS and managed with DCR [30].DCR implementation in a specifi cally selected patient who required emergency surgery for trauma has signifi cantly decreased the need for DCS laparotomy and reduced mortality and increased the rate of defi nitive surgery at the fi rst operation in level 1 trauma centre [34]. The shift towards performing complete surgery was associated with signifi cant reductions in health care costs and resources utilization.Additionally, important studies reported higher rates of primary abdominal closure in the context of DCR approach [35,36].More recently and related to continued advances in trauma care, the DCR strategies have reduced the need for surgical haemostasis in severe liver trauma (>20%) by the direct address of trauma-induced coagulopathy, increased the rate of defi nitive surgery and reduced the need for DCS approach in a critically injured patient [37].…”

Update from the Abdominal Compartment Society (WSACS) on intra-abdominal hypertension and abdominal compartment syndrome: past, present, and future beyond Banff 2017

“…The coincident evolution in resuscitation with hemostatic or balanced blood component resuscitation strategies [11][12][13][14] that limit use of crystalloid fluids are most probably also highly associated with a reduction in the prevalence of ACS (recognizing that excess crystalloid fluids are likely to be central in many cases of IAH/ACS) [15,16]. In support of these practices, a reduced incidence of open abdomens and ACS [17], and higher rates of abdominal closure with the adoption of damage control resuscitation and the use of negative pressure peritoneal therapy have been noted [18][19][20]. In 2017, the incidence of overt ACS is significantly lower than previous decades and may even been rare in some institutions.…”