From the Department of Anesthesiolgy (M.B.L.), Bellvitge University Hospital L'Hospitalet de Llobregat; Department of Anesthesiology (J.M.C., C.S.I., M.D.l.R.E., G.P.C.), Parc Taulí University Hospital, Sabadell, Barcelona, Spain; Global Health, Division of Trauma and Surgery (A.M.V., J.C.P.), University of Pittsburgh, Pittsburgh, Pennsylvania; Department of General Surgery (A.C.S., S.N.S.), Parc Taulí University Hospital; and Department of Intensive Care (A.G.V.). Taulí University Hospital, Sabadell, Barcelona, Spain.
J Trauma Acute Care Surg. 2022 Aug 1;93(2):166-175. doi: 10.1097/TA.0000000000003624. Epub 2022 Mar 28.
Despite advances in trauma management, half of trauma deaths occur secondary to bleeding. Currently, hemostatic resuscitation strategies consist of empirical transfusion of blood products in a predefined fixed ratio (1:1:1) to both treat hemorrhagic shock and correct trauma-induced coagulopathy. At our hospital, the implementation of a resuscitation protocol guided by viscoelastic hemostatic assays (VHAs) with rotational thromboelastometry has resulted in a goal-directed approach. The objective of the study is twofold, first to analyze changes in transfusion practices overtime and second to identify the impact of these changes on coagulation parameters and clinical outcomes. We hypothesized that progressive VHA implementation results in a higher administration of fibrinogen concentrate (FC) and lower use of blood products transfusion, especially plasma.
A total of 135 severe trauma patients (January 2008 to July 2019), all requiring and initial assessment for high risk of trauma-induced coagulopathy based on high-energy injury mechanism, severity of bleeding and hemodynamic instability were included. After 2011 when we first modified the transfusion protocol, a progressive change in transfusional management occurred over time. Three treatment groups were established, reflecting different stages in the evolution of our strategy: plasma (P, n = 28), plasma and FC (PF, n = 64) and only FC (F, n = 42).
There were no significant differences in baseline characteristics among groups. Progressive implementation of rotational thromboelastometry resulted in increased use of FC over time ( p < 0.001). Regression analysis showed that group F had a significant reduction in transfusion of packed red blood cells ( p = 0.005), plasma ( p < 0.001), and platelets ( p = 0.011). Regarding outcomes, F patients had less pneumonia ( p = 0.019) and multiorgan failure ( p < 0.001), without significant differences for other outcomes. Likewise, overall mortality was not significantly different. However, further analysis comparing specific mortality due only to massive hemorrhage in the F group versus all patients receiving plasma, it was significantly lower ( p = 0.037).
Implementing a VHA-based algorithm resulted in a plasma-free strategy with higher use of FC and a significant reduction of packed red blood cells transfused. In addition, we observed an improvement in outcomes without an increase in thrombotic complications.
Therapeutic/Care Management; Level IV.
尽管创伤管理取得了进展，但仍有一半的创伤死亡是由出血引起的。目前，止血复苏策略包括根据经验以固定比例（1:1:1）输注血液制品，以治疗出血性休克和纠正创伤引起的凝血障碍。在我们医院，实施基于黏弹性止血检测（VHA）的复温方案，结合旋转血栓弹性测定法，已经实现了目标导向的方法。本研究的目的有两个，首先是分析随着时间的推移输血实践的变化，其次是确定这些变化对凝血参数和临床结果的影响。我们假设，随着 VHA 的逐步实施，纤维蛋白原浓缩物（FC）的使用会增加，而血液制品的输注，尤其是血浆的使用会减少。
共纳入 135 例严重创伤患者（2008 年 1 月至 2019 年 7 月），所有患者均因高能损伤机制、出血严重程度和血流动力学不稳定而需要接受初始评估，并存在高风险的创伤性凝血障碍。2011 年我们首次修改输血方案后，随着时间的推移，输血管理发生了渐进性变化。我们建立了三个治疗组，反映了我们策略演变的不同阶段：血浆（P 组，n=28）、血浆和 FC（PF 组，n=64）和仅 FC（F 组，n=42）。
各组间基线特征无显著差异。随着时间的推移，旋转血栓弹性测定法的逐步实施导致 FC 的使用增加（p<0.001）。回归分析显示，F 组的红细胞（p=0.005）、血浆（p<0.001）和血小板（p=0.011）输注量显著减少。关于结局，F 组的肺炎（p=0.019）和多器官衰竭（p<0.001）发生率较低，但其他结局无显著差异。同样，总死亡率也无显著差异。然而，进一步分析比较 F 组仅因大出血导致的特定死亡率与所有接受血浆的患者，其死亡率显著降低（p=0.037）。
实施基于 VHA 的算法可实现无血浆策略，FC 使用增加，输注红细胞减少。此外，我们观察到在不增加血栓并发症的情况下，结局得到改善。
治疗/护理管理；IV 级。
