CT-based diagnostic algorithm to identify bowel and/or mesenteric injury in patients with blunt abdominal trauma.

OBJECTIVES: To develop a CT-based algorithm and evaluate its performance for the diagnosis of blunt bowel and/or mesenteric injury (BBMI) in patients with blunt abdominal trauma. METHODS: This retrospective study included a training cohort of 79 patients (29 with BBMI and 50 patients with blunt abdominal trauma without BBMI) and a validation cohort of 37 patients (13 patients with BBMI and 24 patients with blunt abdominal trauma without BBMI). CT examinations were blindly analyzed by two independent radiologists. For each CT sign, the kappa value, sensitivity, specificity, and accuracy were calculated. A diagnostic algorithm was built using a recursive partitioning model on the training cohort, and its performances were assessed on the validation cohort. RESULTS: CT signs with kappa value > 0.6 were extraluminal gas, hemoperitoneum, no or moderate bowel wall enhancement, and solid organ injury. CT signs yielding best accuracies in the training cohort were extraluminal gas (98%; 95% CI: 91-100), bowel wall defect (97%; 95% CI: 91-100), irregularity of mesenteric vessels (97%; 95% CI: 90-99), and mesenteric vessel extravasation (97%; 95% CI: 90-99). Using a recursive partitioning model, a decision tree algorithm including extraluminal gas and no/moderate bowel wall enhancement was built, achieving 86% sensitivity (95% CI: 74-99) and 96% specificity (95% CI: 91-100) in the training cohort and 92% sensitivity (95% CI: 78-97) and 88% specificity (95% CI: 74-100) in the validation cohort for the diagnosis of BBMI. CONCLUSIONS: An effective diagnostic algorithm was built to identify BBMI in patients with blunt abdominal trauma using only extraluminal gas and no/moderate bowel wall enhancement on CT examination. KEY POINTS: • A CT diagnostic algorithm that included extraluminal gas and no/moderate bowel wall enhancement was built for the diagnosis of surgical blunt bowel and/or mesenteric injury. • A decision tree combining only two reproducible CT signs has high diagnostic performance for the diagnosis of surgical blunt bowel and/or mesenteric injury.

Important Issues to Severe Trauma Survivors: A Qualitative Study.

OBJECTIVE: Identify issues that are important to severe trauma survivors up to 3 years after the trauma. BACKGROUND: Severe trauma is the first cause of disability-adjusted life years worldwide, yet most attention has focused on acute care and the impact on long-term health is poorly evaluated. METHOD: We conducted a large-scale qualitative study based on semi-structured phone interviews. Qualitative research methods involve the systematic collection, organization, and interpretation of conversations or textual data with patients to explore the meaning of a phenomenon experienced by individuals themselves. We randomly selected severe trauma survivors (abbreviated injury score ≥3 in at least 1 body region) who were receiving care in 6 urban academic level-I trauma centers in France between March 2015 and March 2018. We conducted double independent thematic analysis. Issues reported by patients were grouped into overarching domains by a panel of 5 experts in trauma care. Point of data saturation was estimated with a mathematical model. RESULTS: We included 340 participants from 3 months to 3 years after the trauma [median age: 41 years (Q1-Q3 24-54), median injury severity score: 17 (Q1-Q3 11-22)]. We identified 97 common issues that we grouped into 5 overarching domains: body and neurological issues (29 issues elicited by 277 participants), biographical disruption (23 issues, 210 participants), psychological and personality issues (21 issues, 147 participants), burden of treatment (14 issues, 145 participants), and altered relationships (10 issues, 87 participants). Time elapsed because the trauma, injury location, or in-hospital trauma severity did not affect the distribution of these domains across participants' answers. CONCLUSIONS: This qualitative study explored trauma survivors' experiences of the long-term effect of their injury and allowed for identifying a set of issues that they consider important, including dimensions that seem overlooked in trauma research. Our findings confirm that trauma is a chronic medical condition that demands new approaches to post-discharge and long-term care.

Blunt Traumatic Aortic Injury Management, a French TraumaBase Analytic Cohort.

OBJECTIVE: Blunt traumatic aortic injury (BTAI) in severe trauma patients is rare but potentially lethal. The aim of this work was to perform a current epidemiological analysis of the clinical and surgical management of these patients in a European country. METHODS: This was a multicentre, retrospective study using prospectively collected data from the French National Trauma Registry and the National Uniform Hospital Discharge Database from 10 trauma centres in France. The primary endpoint was the prevalence of BTAI. The secondary endpoints focused chronologically on injury characteristics, management, and patient outcomes. RESULTS: 209 patients were included with a mean age of 43 ± 19 years and 168 (80%) were men. The calculated prevalence of BTAI at hospital admission was 1% (162/15 094) (BTAI admissions/all trauma). The time to diagnosis increased with the severity of aortic injury and the clinical severity of the patients (grade 1: 94 [74, 143] minutes to grade 4: 154 [112, 202] minutes, p = .020). This delay seemed to be associated with the intensity of the required resuscitation. Sixty seven patients (32%) received no surgical treatment. Among those treated, 130 (92%) received endovascular treatment, 14 (10%) open surgery (two were combined), and 123 (85%) were treated within the first 24 hours. Overall mortality was 20% and the attributed cause of death was haemorrhagic shock (69%). Mortality was increased according to aortic injury severity, from 6% for grade 1 to 65% for grade 4 (p < .001). Twenty-six (18.3%) patients treated by endovascular aortic repair had complications. CONCLUSION: BTAI prevalence at hospital admission was low but occurred in severe high velocity trauma patients and in those with a high clinical suspicion of severe haemorrhage. The association of shock with high grade aortic injury and increasing time to diagnosis suggests a need to optimise early resuscitation to minimise the time to treatment. Endovascular treatment has been established as the reference treatment, accounting for more than 90% of interventional treatment options for BTAI.

Withholding and withdrawal of life-sustaining therapy in 8569 trauma patients: A multicentre, analytical registry study.

BACKGROUND: This study aimed to determine the prevalence of withholding or withdrawal of life-sustaining therapy (WLST) decisions in trauma ICU patients, using a large registry. We hypothesised that this prevalence is similar to that of the general population admitted to an ICU. As secondary aims, it sought to describe the trauma patients for whom the decision was made for WLST and the factors associated with this decision. DESIGN: This observational study assessed data from 14 French centres listed in the TraumaBaseTM registry. All trauma patients hospitalised for more than 48 h were pro-spectively included. RESULTS: Data from 8569 trauma patients, obtained from January 2016 to December 2018, were included in this study. A WLST decision was made in 6% of all cases. In the WLST group, 67% of the patients were older men (age: 62 versus 36, P  < 0.001); more often they had a prior medical history and higher median severity scores than the patients in the no WLST decision group; SAPS II 58 (46 to 69) versus 21 (13 to 35) and ISS 26 (22 to 24) versus 12 (5 to 22), P  < 0.001. Neurological status was strongly associated with WLST decisions. The geographic area of the ICUs affected the rate of the WLST decisions. The ICU mortality was 11% (n = 907) of which 47% (n = 422) were preceded by WLST decisions. Fourteen percent of WLST orders were not associated to the death. CONCLUSION: Among 8569 patients, medical history, trauma severity criteria, notably neurological status and geographical areas were associated with WLST. These regional differences deserve to be investigated in future studies.

Major bleeding complications in critically ill patients with COVID-19 pneumonia.

As patients with COVID-19 pneumonia admitted to intensive care unit (ICU) have high rates of thrombosis, high doses of thromboprophylaxis have been proposed. The associated bleeding risk remains unknown. We investigated major bleeding complications in ICU COVID-19 patients and we examined their relationship with inflammation and thromboprophylaxis. Retrospective monocentric study of consecutive adult patients admitted in ICU for COVID-19 pneumonia requiring mechanical ventilation. Data collected included demographics, anticoagulation status, coagulation tests and outcomes including major bleeding and thrombotic events. Among 56 ICU COVID-19 patients, 10 (18%) patients had major bleeding and 16 (29%) thrombotic events. Major bleeding occurred later than thrombosis after ICU admission [17(14-23) days versus 9(3-11) days respectively (p = 0.005)]. Fibrinogen concentration always decreased several days [4(3-5) days] before bleeding; D-dimers followed the same trend. All bleeding patients were treated with anticoagulants and anticoagulation was overdosed for 6 (60%) patients on the day of bleeding or the day before. In the whole cohort, overdose was measured in 22 and 78% of patients receiving therapeutic anticoagulation during fibrinogen increase and decrease respectively (p < 0.05). Coagulation disorders had biphasic evolution during COVID-19: first thrombotic events during initial hyperinflammation, then bleeding events once inflammation reduced, as confirmed by fibrinogen and D-dimers decrease. Most bleeding events complicated heparin overdose, promoted by inflammation decrease, suggesting to carefully monitor heparin during COVID-19. Thromboprophylaxis may be adapted to this biphasic evolution, with initial high doses reduced to standard doses once the high thrombotic risk period ends and fibrinogen decreases, to prevent bleeding events.

What are the differences in outcomes between simple and complicated FSF managed by early IMN?

PURPOSE: To compare the outcomes of simple versus complicated femoral shaft fracture (FSF) treated by early intramedullary nail. METHODS: Retrospective cohort study in level 1 trauma center including patients with FSF. Management consisted of intramedullary nailing (IMN) after adequate resuscitation within 24 h. Data were prospectively collected on admission (trauma base) consisted of demographics, biological parameters, associated injuries and injury severity score (ISS). Complicated fractures consisted of type C fracture or any type associated with bilateral femur fracture, floating knee, associated femoral neck fracture, dislocated hip, concomitant neurovascular injury. Simple fractures were Isolated type A and B fracture. Simple and complicated fracture groups were compared using stratification by ISS (ISS < 16; 16 ≤ ISS < 25; ISS ≥ 25). RESULTS: Inclusion of 191 consecutive patients: simple FSF (N = 109) versus complicated FSF (N = 82) (type 32C, n = 36; bilateral, n = 44; associated neck of femur fracture, n = 15; floating knee, n = 36; concomitant femoral artery injury, n = 3 or sciatic nerve injury, n = 7). Complicated fractures were associated with higher rate of associated injuries (thoracic, 56.1 vs. 40.4%, p = 0.04; head 25.6 vs 10.1%, p = 0.005) and ARDS (12.2% vs. 3.7%, p = 0.046); longer ICU stay (12.8 vs. 7.3 days, p = 0.019) and hospital stay (24.3 vs. 15.7 days, p < 0.001). After stratification, differences in morbidity between simple and complicated FSF were significant solely in range 16≤ISS < 25. Complicated fractures had longer operation duration (297 vs. 151 min, p < 0.001) due to additional IMN (tibial, humeral) requirements (24% vs. 1.8%, p < 0.001) and longer femoral IMN duration (133 vs. 104 min, p < 0.05). Pseudarthrosis was higher in complicated fracture group (9.6 vs. 3.7%, p = 0.002). CONCLUSION: Complicated femoral fractures are associated with higher morbidity, especially in less severely injured polytrauma, which eventually results in longer hospital stay. Patients with moderate ISS and complicated fracture may have an increased risk of ARDS.

Prevalence and risk factors for acute kidney injury among trauma patients: a multicenter cohort study.

BACKGROUND: Organ failure, including acute kidney injury (AKI), is the third leading cause of death after bleeding and brain injury in trauma patients. We sought to assess the prevalence, the risk factors and the impact of AKI on outcome after trauma. METHODS: We performed a retrospective analysis of prospectively collected data from a multicenter trauma registry. AKI was defined according to the risk, injury, failure, loss of kidney function and end-stage kidney disease (RIFLE) classification from serum creatinine only. Prehospital and early hospital risk factors for AKI were identified using logistic regression analysis. The predictive models were internally validated using bootstrapping resampling technique. RESULTS: We included 3111 patients in the analysis. The incidence of AKI was 13% including 7% stage R, 3.7% stage I and 2.3% stage F. AKI incidence rose to 42.5% in patients presenting with hemorrhagic shock; 96% of AKI occurred within the 5 first days after trauma. In multivariate analysis, prehospital variables including minimum prehospital mean arterial pressure, maximum prehospital heart rate, secondary transfer to the trauma center and data early collected after hospital admission including injury severity score, renal trauma, blood lactate and hemorrhagic shock were independent risk factors in the models predicting AKI. The model had good discrimination with area under the receiver operating characteristic curve of 0.85 (0.82-0.88) to predict AKI stage I or F and 0.80 (0.77-0.83) to predict AKI of all stages. Rhabdomyolysis severity, assessed by the creatine kinase peak, was an additional independent risk factor for AKI when it was forced into the model (OR 1.041 (1.015-1.069) per step of 1000 U/mL, p < 0.001). AKI was independently associated with a twofold increase in ICU mortality. CONCLUSIONS: AKI has an early onset and is independently associated with mortality in trauma patients. Its prevalence varies by a factor 3 according to the severity of injuries and hemorrhage. Prehospital and early hospital risk factors can provide good performance for early prediction of AKI after trauma. Hence, studies aiming to prevent AKI should target patients at high risk of AKI and investigate therapies early in the course of trauma care.

Development and validation of a pre-hospital "Red Flag" alert for activation of intra-hospital haemorrhage control response in blunt trauma.

BACKGROUND: Haemorrhagic shock is the leading cause of early preventable death in severe trauma. Delayed treatment is a recognized prognostic factor that can be prevented by efficient organization of care. This study aimed to develop and validate Red Flag, a binary alert identifying blunt trauma patients with high risk of severe haemorrhage (SH), to be used by the pre-hospital trauma team in order to trigger an adequate intra-hospital standardized haemorrhage control response: massive transfusion protocol and/or immediate haemostatic procedures. METHODS: A multicentre retrospective study of prospectively collected data from a trauma registry (Traumabase®) was performed. SH was defined as: packed red blood cell (RBC) transfusion in the trauma room, or transfusion ≥ 4 RBC in the first 6 h, or lactate ≥ 5 mmol/L, or immediate haemostatic surgery, or interventional radiology and/or death of haemorrhagic shock. Pre-hospital characteristics were selected using a multiple logistic regression model in a derivation cohort to develop a Red Flag binary alert whose performances were confirmed in a validation cohort. RESULTS: Among the 3675 patients of the derivation cohort, 672 (18%) had SH. The final prediction model included five pre-hospital variables: Shock Index ≥ 1, mean arterial blood pressure ≤ 70 mmHg, point of care haemoglobin ≤ 13 g/dl, unstable pelvis and pre-hospital intubation. The Red Flag alert was triggered by the presence of any combination of at least two criteria. Its predictive performances were sensitivity 75% (72-79%), specificity 79% (77-80%) and area under the receiver operating characteristic curve 0.83 (0.81-0.84) in the derivation cohort, and were not significantly different in the independent validation cohort of 2999 patients. CONCLUSION: The Red Flag alert developed and validated in this study has high performance to accurately predict or exclude SH.

Fibrinogen on Admission in Trauma score: Early prediction of low plasma fibrinogen concentrations in trauma patients.

BACKGROUND: Early recognition of low fibrinogen concentrations in trauma patients is crucial for timely haemostatic treatment and laboratory testing is too slow to inform decision-making. OBJECTIVE: To develop a simple clinical tool to predict low fibrinogen concentrations in trauma patients on arrival. DESIGN: Retrospective cohort study. SETTING: Three designated level 1 trauma centres in the Paris Region, from January 2011 to December 2013. PATIENTS: Patients admitted in accordance with national triage guidelines for major trauma and plasma fibrinogen concentration testing on admission. INTERVENTION: Construction of a clinical score [Fibrinogen on Admission in Trauma (FibAT) score] in a derivation cohort to predict fibrinogen plasma concentration 1.5 g l or less after multiple regressions. One point was given for each predictive factor. The score was the sum of all. Validation was performed in a separate validation cohort. MAIN OUTCOME MEASURE: Predictive accuracy of FibAT score. RESULTS: In total, 2936 patients were included, 2124 in the derivation cohort and 812 in the validation cohort. In the derivation cohort, a multivariate logistic model identified the following predictive factors for plasma fibrinogen concentrations 1.5 g l or less: age less than 33 years, prehospital heart rate more than 100 beats per minute, prehospital SBP less than 100 mmHg, blood lactate concentration on admission more than 2.5 mmol l, free intraabdominal fluid on sonography, decrease in haemoglobin concentration from prehospital to admission of more than 2 g dl, capillary haemoglobin concentration on admission less than 12 g dl and temperature on admission less than 36°C. The FibAT score had an area under the receiver operating characteristic curve of 0.87 [95% confidence interval (0.86 to 0.91)] in the derivation cohort and of 0.82 (95% confidence interval (0.86 to 0.91)] in the validation cohort to predict a low plasma fibrinogen. CONCLUSION: The FibAT score accurately predicts plasma fibrinogen levels 1.5 g l or less on admission in trauma patients. This easy-to-use score could allow early, goal-directed therapy to trauma patients.

Effect of RBC Transfusion on Sublingual Microcirculation in Hemorrhagic Shock Patients: A Pilot Study.

OBJECTIVES: The effects of RBC transfusion on microvascular perfusion are not well documented. We investigated the effect of RBC transfusion on sublingual microcirculation in hemorrhagic shock patients. DESIGN: Prospective, preliminary observational study. SETTINGS: A 28-bed, surgical ICU in a university hospital. PATIENTS: Fifteen hemorrhagic shock patients requiring RBC transfusion. INTERVENTION: Transfusion of one unit of RBCs. MEASUREMENTS AND MAIN RESULTS: The sublingual microcirculation was assessed with a Sidestream Dark Field imaging device before and after RBC transfusion. After transfusion of one unit of RBC, hemoglobin concentration increased from 8.5 g/dL (7.6-9.5 g/dL) to 9.6 g/dL (9.1-10.3 g/dL) g/dL (p = 0.02) but no effect on macrocirculatory parameters (arterial pressure, cardiac index, heart rate, and pulse pressure variations) was observed. Transfusion of RBC significantly increased microcirculatory flow index (from 2.3 [1.6-2.5] to 2.7 [2.6-2.9]; p < 0.003), the proportion of perfused vessels (from 79% [57-88%] to 92% [88-97%]; p < 0.004), and the functional capillary density (from 21 [19-22] to 24 [22-26] mm/mm; p = 0.003). Transfusion of RBC significantly decreased the flow heterogeneity index (from 0.51 [0.34-0.62] to 0.16 [0.04-0.29]; p < 0.001). No correlations were observed between other macrovascular parameters and microvascular changes after transfusion. The change in microvascular perfusion after transfusion correlated negatively with baseline microvascular perfusion. CONCLUSIONS: RBC transfusion improves sublingual microcirculation independently of macrocirculation and the hemoglobin level in hemorrhagic shock patients. The change in microvascular perfusion after transfusion correlated negatively with baseline microvascular perfusion. Evaluation of microcirculation perfusion is critical for optimization of microvascular perfusion and to define which patients can benefit from RBC transfusion during cardiovascular resuscitation.

Comparison of the Prognostic Significance of Initial Blood Lactate and Base Deficit in Trauma Patients.

BACKGROUND: Initial blood lactate and base deficit have been shown to be prognostic biomarkers in trauma, but their respective performances have not been compared. METHODS: Blood lactate levels and base deficit were measured at admission in trauma patients in three level 1 trauma centers. This was a retrospective analysis of prospectively acquired data. The association of initial blood lactate and base deficit with mortality was tested using receiver operating characteristics curve, logistic regression using triage scores (Revised Trauma Score and Mechanism Glasgow scale and Arterial Pressure score), and Trauma Related Injury Severity Score as a reference standard. The authors also used a reclassification method. RESULTS: The authors evaluated 1,075 trauma patients (mean age, 39 ± 18 yr, with 90% blunt and 10% penetrating injuries and a mortality of 13%). At admission, blood lactate was elevated in 425 (39%) patients and base deficit was elevated in 725 (67%) patients. Blood lactate was correlated with base deficit (R = 0.54; P < 0.001). Using logistic regression, blood lactate was a better predictor of death than base deficit when considering its additional predictive value to triage scores and Trauma Related Injury Severity Score. This result was confirmed using a reclassification method but only in the subgroup of normotensive patients (n = 745). CONCLUSIONS: Initial blood lactate should be preferred to base deficit as a biologic variable in scoring systems built to assess the initial severity of trauma patients.

Long-term prognosis after out-of-hospital resuscitation of cardiac arrest in trauma patients: prehospital trauma-associated cardiac arrest.

BACKGROUND: Although prehospital cardiac arrest (CA) remains associated with poor long-term outcome, recent studies show an improvement in the survival rate after prehospital trauma associated CA (TCA). However, data on the long-term neurological outcome of TCA, particularly from physician-staffed Emergency Medical Service (EMS), are scarce, and results reported have been inconsistent. The objective of this pilot study was to evaluate the long-term outcome of patients admitted to several trauma centres after a TCA. METHODS: This study is a retrospective database review of all patients from a multicentre prospective registry that experienced a TCA and had undergone successful cardiopulmonary resuscitation (CPR) prior their admission at the trauma centre. The primary end point was neurological outcome at 6 months among patients who survived to hospital discharge. RESULTS: 88 victims of TCA underwent successful CPR and were admitted to the hospital, 90% of whom were victims of blunt trauma. Of these 88 patients, 10 patients (11%; CI 95% 6% to 19%) survived to discharge: on discharge, 9 patients displayed a GCS of 15 and Cerebral Performance Categories (CPC) 1-2 and one patient had a GCS 7 and CPC of 3. Hypoxia was the most frequent cause of CA among survivors. 6-month follow-up was achieved for 9 patients of the 10 surviving patients. The 9 patients with a good outcome on hospital discharge had a CPC of 1 or 2 6 months post discharge. All returned to their premorbid family and social settings. CONCLUSIONS: Among patients admitted to hospital after successful CPR from TCA, hypoxia as the likely aetiology of arrest carried a more favourable prognosis. Most of the patients successfully resuscitated from TCA and surviving to hospital discharge had a good neurological outcome, suggesting that prehospital resuscitation may not be futile.

European trauma guideline compliance assessment: the ETRAUSS study.

INTRODUCTION: Haemorrhagic shock is the leading cause of preventable death in trauma patients. The 2013 European trauma guidelines emphasise a comprehensive, multidisciplinary, protocol-based approach to trauma care. The aim of the present Europe-wide survey was to compare 2015 practice with the 2013 guidelines. METHODS: A group of members of the Trauma and Emergency Medicine section of the European Society of Intensive Care Medicine developed a 50-item questionnaire based upon the core recommendations of the 2013 guidelines, employing a multistep approach. The questionnaire covered five fields: care structure and organisation, haemodynamic resuscitation targets, fluid management, transfusion and coagulopathy, and haemorrhage control. The sampling used a two-step approach comprising initial purposive sampling of eminent trauma care providers in each European country, followed by snowball sampling of a maximum number of trauma care providers. RESULTS: A total of 296 responses were collected, 243 (81 %) from European countries. Those from outside the European Union were excluded from the analysis. Approximately three-fourths (74 %) of responders were working in a designated trauma centre. Blunt trauma predominated, accounting for more than 90 % of trauma cases. Considerable heterogeneity was observed in all five core aspects of trauma care, along with frequent deviations from the 2013 guidelines. Only 92 (38 %) of responders claimed to comply with the recommended systolic blood pressure target, and only 81 (33 %) responded that they complied with the target pressure in patients with traumatic brain injury. Crystalloid use was predominant (n = 209; 86 %), and vasopressor use was frequent (n = 171, 76 %) but remained controversial. Only 160 respondents (66 %) declared that they used tranexamic acid always or often. CONCLUSIONS: This is the first European trauma survey, to our knowledge. Heterogeneity is significant across centres with regard to the clinical protocols for trauma patients and as to locally available resources. Deviations from guidelines are frequent, differ from region to region and are dependent upon specialty training. Further efforts are required to provide consensus guidelines and to improve their implementation across European countries.

Qualitative real-time analysis by nurses of sublingual microcirculation in intensive care unit: the MICRONURSE study.

INTRODUCTION: We aimed to determine i) the feasibility of nurses taking bedside measurements of microcirculatory parameters in real time in intensive care patients; and ii) whether such measurements would be comparable to those obtained by the classical delayed semi quantitative analysis made by a physician. METHODS: This prospective observational study was conducted in a university hospital and was approved by our local Institutional Review Board (IRB 00006477). After ICU admission and study inclusion, a set of measurements of macrocirculatory and microcirculatory parameters was taken by the nurse in charge of the patient every 4 h within the first 12 h after admission and before and after every hemodynamic therapeutic intervention. Seventy-four sublingual microvascular measurements were performed with incident dark field illumination (IDF) microscopy in 20 mechanically ventilated patients hospitalized in the ICU. RESULTS: There were no significant differences between the microvascular flow index (MFI) taken in real time by the nurses and the delayed evaluation by the physician. In fact, the nurses' real-time measurement of MFI demonstrated good agreement with the physician's delayed measurement. The mean difference between the two MFIs was -0.15, SD = 0.28. The nurses' real-time MFI assessment showed 97 % sensitivity (95 % CI: 84-99 %) and 95 % specificity (95 % CI: 84-99 %) at detecting a MFI <2.5 obtained by a physician upon delayed semiquantitative measurement. Concerning the density, 81 % of the paramedical qualitative density measurements corresponded with the automatized total vessel density (TVD) measurements. The nurses' real-time TVD assessment showed 77 % sensitivity (95 % CI: 46-95 %) and 100 % specificity (95 % CI: 89-100 %) at detecting a TVD <8 mm/mm(2). CONCLUSION: A real-time qualitative bedside evaluation of MFI by nurses showed good agreement with the conventional delayed analysis by physicians. The bedside evaluations of MFI and TVD were highly sensitive and specific for detecting impaired microvascular flow and low capillary density. These results suggest that this real-time technique could become part of ICU nurse routine surveillance and be implemented in algorithms for hemodynamic resuscitation in future clinical trials and regular practice. These results are an essential step to demonstrate whether these real-time measurements have a clinical impact in the management of ICU patients.

Fluid resuscitation and vasopressors in severe trauma patients.

PURPOSE OF REVIEW: To discuss the fluid resuscitation and the vasopressor support in severe trauma patients. RECENT FINDINGS: A critical point is to prevent a potential increase in bleeding by an overly aggressive resuscitative strategy. Indeed, large-volume fluid replacement may promote coagulopathy by diluting coagulation factors. Moreover, an excessive level of mean arterial pressure may induce bleeding by preventing clot formation. SUMMARY: Fluid resuscitation is the first-line therapy to restore intravascular volume and to prevent cardiac arrest. Thus, fluid resuscitation before bleeding control must be limited to the bare minimum to maintain arterial pressure to minimize dilution of coagulation factors and complications of over fluid resuscitation. However, a strategy of low fluid resuscitation needs to be handled in a flexible way and to be balanced considering the severity of the hemorrhage and the transport time. A target systolic arterial pressure of 80-90 mmHg is recommended until the control of hemorrhage in trauma patients without brain injury. In addition to fluid resuscitation, early vasopressor support may be required to restore arterial pressure and prevent excessive fluid resuscitation. It is crucial to find the best alchemy between fluid resuscitation and vasopressors, to consider hemodynamic monitoring and to establish trauma resuscitative protocols.

Cangrelor for cardiopulmonary bypass in patients with heparin-induced thrombocytopenia: it is not so easy.

Anticoagulation management for cardiopulmonary bypass (CPB) is challenging in patients with acute heparin-induced thrombocytopenia (HIT). The strategy of combining cangrelor intraoperatively with heparin for CPB anticoagulation is of increasing interest but exposes to specific unresolved problems. We report the case of a patient requiring surgical pulmonary embolectomy for pulmonary embolism at the very acute phase of HIT, with a high titre of anti-PF4/heparin antibodies and severe thrombocytopenia. For CPB management, cangrelor was administered in combination with heparin prescribed and monitored as usual. Surgery was successfully performed, but postoperatively, the patient developed a new thrombotic event. We discussed the specific problems associated with such strategy, including the dose of cangrelor and its monitoring, the management of the cell-saver, the risk of heparin rebound and the risk of platelet transfusion. These issues must be addressed before considering the combination of cangrelor and unfractionated heparin as a standard of care for CBP.

Comprehensive analysis of coagulation factor delivery strategies in a cohort of trauma patients.

PURPOSE: The 5th edition of The European recommendations for the management of major bleeding and coagulopathy following trauma leaves room for various coagulation factor administration strategies. The present study examines these strategies reporting prevalence and timing of administration, quantity dispensed, and transfusion ratios in French trauma centers and their compliance with recommendations alongside associated mortality data. METHODS: All adult patients, admitted directly to participating centers between 2011 and 2019, were extracted from a trauma registry. Two subpopulations were studied: severe hemorrhage (SH) and massive transfusion (MT) groups. RESULTS: A total of 19,396 patients were included, among whom 8.4% (1630) experienced SH and 3% (579) received MT. Within the first 24 hours, 10% received fresh frozen plasma (FFP), rising to 93% and 99% in the subgroups of patients experiencing SH and MT respectively. Only, 8% received fibrinogen concentrate (FC), increasing to 75% and 92% in subgroups SH and MT respectively. Co-administration of FFP and FC became the dominant strategy with 68% of patients at 6 h and 72% at 24 h in SH subgroup. In unadjusted data, mortality was systematically lower in groups that complied with recommendations, a lower mortality than expected was mostly observed in contrast to non-compliant subgroups. The per-patient compliance to studied recommendations was 21% and 22% in SH and MT subgroups. CONCLUSION: The main hemostatic strategy for major bleeding combined the administration of both FFP and FC, favoring an early additional supply of fibrinogen. Compliance with the recommendations was low in SH and MT subgroups.