Centre for Trauma Sciences, Queen Mary University of London, Blizard Institute, London, United Kingdom.
Oslo University Hospital and University of Oslo, Oslo, Norway.
Anesthesiology. 2024 Nov 1;141(5):904-912. doi: 10.1097/ALN.0000000000005183.
Trauma hemorrhage induces a coagulopathy with a high associated mortality rate. The Implementing Treatment Algorithms for the Correction of Trauma Induced Coagulopathy (ITACTIC) randomized trial tested two goal-directed treatment algorithms for coagulation management: one guided by conventional coagulation tests and one by viscoelastic hemostatic assays (viscoelastic). The lack of a difference in 28-day mortality led the authors to hypothesize that coagulopathic patients received insufficient treatment to correct coagulopathy.
During ITACTIC, two sites were coenrolling patients into an ongoing prospective observational study, which included serial blood sampling at the same intervals as in ITACTIC. The subgroup in both studies had conventional and viscoelastic test results for each patient available for analysis. A goal-directed treatment was defined as one triggered by an ITACTIC algorithm. Coagulopathy was defined as rotational thromboelastometry EXTEM A5 less than 40 mm. The primary outcome was correction of coagulopathy by the 12th unit of erythrocyte transfusion during resuscitation.
Full viscoelastic and conventional coagulation test results were available for 133 patients. Of these patients, 71% were coagulopathic on admission, and 16% developed a coagulopathy during resuscitation. ITACTIC viscoelastic hemostatic assay group patients were more likely to receive goal-directed treatment than the standard group (76% vs. 47%; odds ratio, 3.73; 95% CI, 1.64 to 8.49; P = 0.002). However, only 54% of patients received goal-directed treatment, and only 20% corrected their coagulopathy (vs. 0% with empiric treatment alone; not significant). Median time to first goal-directed treatment was 68 (53 to 88) min for viscoelastic and 110 (77 to 123) min for standard (P = 0.005).
In ITACTIC, many bleeding trauma patients did not receive an indicated goal-directed treatment. Interventions arrived late during resuscitation and were only partially effective at correcting coagulopathy.
创伤性出血可导致凝血功能障碍，其死亡率较高。《实施创伤性凝血病治疗算法（ITACTIC）》随机试验测试了两种针对凝血管理的目标导向治疗算法：一种基于常规凝血试验，另一种基于黏弹性止血测定法（viscoelastic）。28 天死亡率无差异的结果促使作者假设凝血障碍患者接受的凝血障碍纠正治疗不足。
在 ITACTIC 期间，两个站点同时对一项正在进行的前瞻性观察性研究入组患者，该研究包括在 ITACTIC 相同时间间隔进行连续采血。两项研究中的亚组均为每位患者提供常规和黏弹性检测结果以供分析。目标导向治疗定义为根据 ITACTIC 算法触发的治疗。凝血障碍定义为旋转血栓弹性描记术 EXTEM A5 小于 40mm。主要结局是在复苏过程中输注第 12 单位红细胞时纠正凝血障碍。
共有 133 名患者的完整黏弹性和常规凝血检测结果可用。这些患者中，71%入院时存在凝血障碍，16%在复苏过程中发生凝血障碍。ITACTIC 黏弹性止血测定组患者比标准组更有可能接受目标导向治疗（76%比 47%；优势比，3.73；95%置信区间，1.64 至 8.49；P=0.002）。然而，只有 54%的患者接受了目标导向治疗，只有 20%的患者纠正了凝血障碍（而单独采用经验性治疗的患者则为 0%；无统计学意义）。黏弹性治疗组首次目标导向治疗的中位时间为 68（53 至 88）分钟，标准治疗组为 110（77 至 123）分钟（P=0.005）。
在 ITACTIC 中，许多出血性创伤患者未接受既定的目标导向治疗。干预措施在复苏过程中较晚到达，且仅部分有效纠正凝血障碍。
