Cesena experience in the management of trauma induced coagulopathy: where are we going?
DOI:
https://doi.org/10.7175/rhc.v4i3S.876Keywords:
Massive transfusion protocol (MTP), Trauma Center, ManagementAbstract
In recent years the management of the Trauma Center has witnessed the implementation of a significant change in the approach to critical bleeding and acute trauma-induced coagulopathy. The Trauma Center of “Bufalini” Hospital in Cesena has achieved a leading position in this system, especially with a multidisciplinary approach that has strongly influenced the organization of the Trauma Center. Thus, it is of particular interest the involvement of specialists in Transfusion Medicine within the Trauma Center: “Bufalini” Hospital was among the first in Italy to bring hematologists from Transfusion Medicine Department in the Trauma Team. This approach, which has led to very significant improvements in the way we manage polytrauma patients, is now spreading widely in other national centers. In 2009 the first Massive Transfusion Protocol (MTP) was implemented in the Trauma Center, with the aim of identifying patients at risk, improving the communication between different healthcare professionals and achieving a blood components fixed ratio. Transfusion support was part of the context of the Damage Control Resuscitation (DCR) based on the principles of permissive hypotension, Damage Control Surgery (DCS) and Haemostatic Resuscitation. Considering the major medical and scientific knowledge and new data available, in 2011 the “Bufalini” Hospital Working Group modified its MTP with the aim of obtaining a rapid diagnosis of hyperfibrinolisis, an early diagnosis of hypofibrinogenemia and reduce therapy with blood components. It has also been developed an algorithm for the proper interpretation of Point-Of-Care Device results (ROTEM®).
References
Brohi K, Cohen MJ, Davenport RA. Acute coagulopathy of trauma: mechanism, identification and effect. Curr Opin Crit Care 2007; 13: 680-5; http://dx.doi.org/10.1097/MCC.0b013e3282f1e78f
Brohi K, Singh J, Heron M, Coats T. Acute traumatic coagulopathy. J Trauma 2003; 54: 1127-30; http://dx.doi.org/10.1097/01.TA.0000069184.82147.06
Como JJ, Dutton RP, Scalea TM , Edelman BB, et al. Blood transfusion rates in the care of acute trauma. Transfusion 2004; 44: 809-13; http://dx.doi.org/10.1111/j.1537-2995.2004.03409.x
Davenport R, Curry N, Manson J, et al. Hemostatic effects of fresh frozen plasma may be maximal at red cell ratios of 1:2. J Trauma 2011; 70: 90-5; discussion 95-6; http://dx.doi.org/10.1097/TA.0b013e318202e486
Decreto della Giunta Regionale 23 del 2005. Disponibile online su: http://www.regione.emilia-romagna.it/agenziasan/aree/accred/accreditamento/requisiti_spec/emergenza_urg.pdf (ultimo accesso: marzo 2013)
Delibera di Giunta n. 1267/2002. Disponibile online su http://asr.regione.emilia-romagna.it/trauma/normativa/dgr_2002-1267.pdf (ultimo accesso: marzo 2013)
Dossett LA, Riesel JN, Griffin MR, et al. Prevalence and implications of preinjury warfarin use. An analysis of the National Trauma Databank. Arch Surg 2011; 146: 565-70; http://dx.doi.org/10.1001/archsurg.2010.313
Inaba K, Branco BC, Rhee P, et al. Impact of plasma transfusion in trauma patients who do not require massive transfusion. J Am Coll Surg 2010; 210: 957-65; http://dx.doi.org/10.1016/j.jamcollsurg.2010.01.031
Johansson P, Stensballe J. Effect of haemostatic control resuscitation on mortality in massively bleeding patients: a before and after study. Vox Sanguinis 2009; 96: 111-8; http://dx.doi.org/10.1111/j.1423-0410.2008.01130.x
Johansson PI, Bochsen L, Stensballe J, et al. Transfusion packages for massively bleeding patients: the effect on clot formation and stability as evaluated by Thrombelastograph (TEG). Transfus Apher Sci 2008; 39: 3-8; http://dx.doi.org/10.1016/j.transci.2008.05.012
Johansson PI, Stensballe J. Hemostatic resuscitation for massive bleeding: the paradigm of plasma and platelet: a review of the current literature. Transfusion 2010; 50: 701-10; http://dx.doi.org/10.1111/j.1537-2995.2009.02458.x
Legge n. 219 del 21 ottobre 2005 sulla “Nuova disciplina delle attività trasfusionali e della produzione nazionale degli emoderivati”
Maegele M, Lefering R, Yucel N, et al; AG Polytrauma of the German Trauma Society (DGU). Early coagulopathy in multiple injury: an analysis from the German Trauma Registry on 8724 patients. Injury 2007; 38: 298-304; http://dx.doi.org/10.1016/j.injury.2006.10.003
Manual of Optimal Blood Use. Disponibile online su: http://www.optimalblooduse.eu/_assets/pdf/blood_use_manual.pdf (ultimo accesso: marzo 2013)
Murthi SB, Stansbury LG, Hess JR. Blood and coagulation support in trauma. Blood Rev 2009; 23: 149-55; http://dx.doi.org/10.1016/j.blre.2008.12.001
Rossaint R, Bouillon B, Cerny V, et al; Task Force for Advanced Bleeding Care in Trauma. Management of bleeding following major trauma: an updated European guideline. Crit Care 2010; 14: R52; http://dx.doi.org/10.1186/cc8943
Schöchl H, Maegele M, Solomon C, et al. Early and individualized goal-directed therapy for trauma-induced coagulopathy. Scand J Trauma Resusc Emerg Med 2012; 20: 15; http://dx.doi.org/10.1186/1757-7241-20-15
Schöchl H, Nienaber U, Hofer G, et al. Goal-directed coagulation management of major trauma patients using thromboelastometry (ROTEM)-guided administration of fibrinogen concentrate and prothrombin complex concentrate. Crit Care 2010; 14: R55; http://dx.doi.org/10.1186/cc8948
Shakur H, Roberts I, Bautista R, et al; CRASH-2 trial collaborators. Effects of tranexamic acid and blood transfusion in trauma patients with significant haemorrhage (CRASH-2): a randomized, placebo-controlled trial. Lancet 2010; 376: 23-32; http://dx.doi.org/10.1016/S0140-6736(10)60835-5
Snyder CW, Weinberg JA, McGwin Get al. The relationship of blood product ratio to mortality: survival benefit or survival bias? J Trauma 2009; 66: 358-62; discussion 362-4; http://dx.doi.org/10.1097/TA.0b013e318196c3ac
Theusinger OM, Wanner GA, Emmert MY, et al. Hyperfibrinolisis diagnosed by rotational thromboelastometry (ROTEM) is associated with higher mortality in patients with severe trauma. Anesth Analg 2011; 113: 1003-12; http://dx.doi.org/10.1213/ANE.0b013e31822e183f
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