Dynamic use of fibrinogen under viscoelastic assessment results in reduced need for plasma and diminished overall transfusion requirements in severe trauma.
Dynamic use of fibrinogen under viscoelastic assessment results in reduced need for plasma and diminished overall transfusion requirements in severe trauma.
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DOI：
10.1097/ta.0000000000003624
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发表时间：
2022-08-01
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尽管创伤管理取得了进步，但一半的创伤死亡是继发于出血。目前，止血复苏策略包括按预先确定的固定比例（1:1:1）经验性输注血液制品，以治疗失血性休克并纠正创伤性凝血障碍（TIC）。在我们医院，实施以 ROTEMTM 粘弹性止血测定 (VHA) 为指导的复苏方案，形成了目标导向的方法。该研究的目的有两个，首先是分析输血实践随时间的变化，其次是确定这些变化对凝血参数和临床结果的影响。我们假设渐进式 VHA 的实施会导致纤维蛋白原浓缩物 (FC) 的施用量增加，并减少血液制品输注（尤其是血浆）的使用。共纳入135例严重创伤患者（2008年1月至2019年7月），所有患者均需要根据高能量损伤机制、出血严重程度和血流动力学不稳定进行TIC高风险初步评估。 2011 年我们首次修改输血方案后，随着时间的推移，输血管理发生了逐步变化。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，n = 28）、血浆和纤维蛋白原浓缩物（PF，n = 64）和仅纤维蛋白原浓缩物（F，n = 42）。各组之间的基线特征没有显着差异。随着时间的推移，ROTEMTM 的逐步实施导致 FC 的使用增加（p<0.001）。回归分析显示，F 组输注浓缩红细胞（p=0.005）、血浆（p<0.001）和血小板（p=0.011）显着减少。关于结局，F 患者的肺炎（p=0.019）和多器官衰竭（p<0.001）较少，其他结局没有显着差异。同样，总体死亡率也没有显着差异。然而，进一步分析比较 F 组仅因大出血而导致的特定死亡率与所有接受血浆的患者相比，其显着较低 (p=0.037)。实施基于 VHA 的算法产生了无血浆策略，增加了 FC 的使用，并显着减少了输注的浓缩红细胞。此外，我们观察到结果有所改善，但血栓并发症没有增加。回顾性队列研究IV
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 (TIC). At our hospital, the implementation of a resuscitation protocol guided by viscoelastic hemostatic assays (VHA) with ROTEMTM 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 TIC 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 transfusionalº management occurred over time. Three treatment groups were established, reflecting different stages in the evolution of our strategy: plasma (P, n=28), plasma and fibrinogen concentrate (PF, n=64) and only fibrinogen concentrate (F, n=42). There were no significant differences in baseline characteristics among groups. Progressive implementation of ROTEMTM 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 multi-organ 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. Additionally, we observed an improvement in outcomes without an increase in thrombotic complications. Retrospective cohort study IV