The impact of blood product ratio and procoagulant therapy on the development of thromboembolic events in severely injured hemorrhaging trauma patients

Abstract

INTRODUCTION Transfusion therapy in hemorrhaging trauma patients is associated with the development of thromboembolic events. It is unknown whether current resuscitation strategies, including large volumes of plasma and early administration of procoagulant therapy, increases this risk. METHODS A systematic search was conducted in MEDLINE, PubMed, and Embase. Studies were screened by two independent reviewers and included if they reported on thromboembolic events in patients with severe trauma (injury severity score ≥16) who received transfusion of at least 1 unit of red blood cells. The ratio by which blood products were transfused, as well as use of procoagulant or antifibrinolytic medication, was recorded. RESULTS A total of 40 studies with 11.074 bleeding trauma patients were included, in which 1.145 thromboembolic events were reported, yielding an incidence of 10% thromboembolic events. In studies performing routine screening for thromboembolic complications, the incidence ranged from 12% to 23%. The risk of thromboembolic events was increased after administration of tranexamic acid (TXA; odds ratio [OR], 2.6; 95% confidence interval [CI], 1.7‐4.1; p < 0.001) and fibrinogen concentrate (OR, 2.1; 95% CI, 1.0‐4.2; p = 0.04). Blood product ratio, the use of prothrombin complex concentrate or recombinant factor VIIa were not associated with thromboembolic events. CONCLUSION This systematic review identified an incidence of thromboembolic events of 10% in severely injured bleeding trauma patients. The use of TXA and fibrinogen concentrate was associated with the development of thromboembolic complications.

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“…Similarly, the ideal, fibrinogen dose and target level are not clear. Observational studies in trauma suggest a relation with low levels and mortality; conversely a possible association between higher fibrinogen levels and mortality [42] as well as with thrombosis [43]. More evidence is need regarding empirical and lab-based supplementation before a recommendation for or against early fibrinogen can be made; at the present time, either approach is justifiable on theoretical grounds.…”

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“… 111 Studies show that the patients received tranexamic acid can significantly reduce the fibrinolytic activity and not increase the risk of VTE, even TEG, or other blood coagulation indexes within 24 h of admission shows the coming state of hypercoagulation status. 3 , 112 But a recent systemic review 113 indicated the use of tranexamic acid and fibrinogen concentrate was associated with the development of thromboembolic complications.…”

Tranexamsäure zur Blutungsprophylaxe bei Trauma und orthopädischen Eingriffen – Standard oder individualisierte Anwendung?

“…Interessanterweise zeigte sich kein Unterschied in der Transfusionshäufigkeit zwischen der mit TXA und der ohne TXA behandelten Patientengruppe [ 45 ]. Trotz Kritik an methodischen Schwächen der Studie [ 4 , 38 ] sowie Hinweisen auf eine erhöhte Inzidenz von VTE in anderen Studien [ 22 , 37 , 57 ] etablierte sich die Dosierung von 1 g TXA als i.v.-Bolus und einer kontinuierlichen Gabe von 1 g i.v. über 8 h in verschiedenen Leitlinien und Empfehlungen [ 6 , 39 , 43 , 51 ] im Sinne einer frühen bzw.…”