Harmful or Physiologic: Diagnosing Fibrinolysis Shutdown in a Trauma Cohort With Rotational Thromboelastometry.

BACKGROUND: Despite its central role in early trauma coagulopathy, abnormal fibrinolysis continues to be poorly understood. Excessive fibrinolysis is a known contributor to mortality. Recent studies with thromboelastography (TEG) suggest decreased fibrinolysis (or shutdown) may be just as harmful. Considering the broad use of 2 different viscoelastic assays, which are not interchangeable, we proposed for the first time to define and characterize fibrinolysis shutdown using rotational thromboelastometry (ROTEM). METHODS: Retrospective cohort study of severely injured patients with admission ROTEM. Shutdown was defined by the best Youden index value of the maximum lysis. Fibrinolysis phenotypes were physiologic, hyperfibrinolysis, and shutdown. Multivariable logistic regression evaluated association between Injury Severity Score and the fibrinolysis phenotypes, and the association among shutdown phenotype with mortality, blood transfusion, and thrombotic events. RESULTS: Five hundred fifty patients were included. Maximum lysis <3.5% was selected to define shutdown. Predominant phenotype was physiologic (70.7%), followed by shutdown (25.6%) and hyperfibrinolysis (3.6%). Shutdown patients had higher Injury Severity Score, lower base excess, and required more transfusions than physiologic group. Shutdown was associated with acidosis (base excess: odds ratio [OR] for a 1 mEq/L increase, 0.93; 95% confidence interval [CI], 0.88-0.98; P = .0094) and the combination of clotting derangements, higher clot firmness (maximum clot formation: OR for a 2 mm increase, 1.8; 95% CI, 1.5-2.27; P < .0001), lower fibrinogen (OR for a 0.5 g/dL decrease, 1.47; 95% CI, 1.18-1.84; P = .0006), and poor clot formation dynamics (clot formation time: OR for a 5 seconds increase, 1.25; 95% CI, 1.15-1.36; P < .0001). Fibrinolysis shutdown was not independently associated with mortality (OR, 0.61; 95% CI, 0.28-1.33; P = .21), massive transfusion (OR, 2.14; 95% CI, 0.79-5.74; P = .1308), or thrombotic events (OR, 1.08; 95% CI, 0.37-3.15; P = .874). Shutdown was associated with increased 24-hour transfusion (OR, 2.24; 95% CI, 1.24-4.04; P = .007). CONCLUSIONS: Despite higher injury burden, evidence of shock, and greater need for blood transfusions, early fibrinolysis shutdown was not associated with mortality, suggesting that it could represent an adaptive physiologic response to life-threatening trauma.

Efficacy and safety of the drugs used to reverse direct oral anticoagulants: a systematic review and meta-analysis.

BACKGROUND: Direct oral anticoagulants (DOACs) are effective and safe for prophylaxis and treatment of thromboembolic phenomena. However, managing DOACs during bleeding emergencies is challenging. A systematic review and meta-analysis was conducted on studies addressing efficacy and safety of the drugs used for reversal of DOACs. STUDY DESIGN AND METHODS: Medline, Embase, Cochrane Library, and ClinicalTrials.gov were searched up to September 2016. Studies that examined clinical and laboratory effects of drugs used to reverse DOACs were included. Risk of bias was assessed using Newcastle-Ottawa scale and Cochrane Collaboration tool. Primary and secondary outcomes assessed were reversal of clinical bleeding, clotting assays, and safety, respectively. Overall effect estimates were pooled, and clinical and statistical heterogeneity were assessed. Meta-analysis was conducted using random-effects model. RESULTS: Four cohort studies in bleeding patients (n = 230) and eight randomized controlled trials in healthy volunteers (n = 381) were included, both with moderate risk of bias. Reversal of clotting assays in healthy volunteers was frequently reported, demonstrating that prothrombin complex concentrate (PCC) reversed prothrombin time (PT) and endogenous thrombin potential (ETP) substantially. For PT, pooled mean difference was 1.68 seconds (95% confidence interval [CI], -0.33 to 3.70 sec; p < 0.01; I2  = 97%). For ETP, pooled mean difference was 2.16 seconds (95% CI, 0.57 to 3.75 sec; p < 0.01; I2  =  98%). Andexanet alfa and idarucizumab both reverse clotting assays. No important safety concerns were identified. CONCLUSIONS: Clotting assays are partially reversed by PCC in healthy volunteers. Idarucizumab and andexanet alfa have solid laboratory reversal effect and potential to be clinically efficacious and safe. However, clinical evidence is still lacking for all agents.

Catecholamines as outcome markers in isolated traumatic brain injury: the COMA-TBI study.

BACKGROUND: Elevated catecholamine levels might be associated with unfavorable outcome after traumatic brain injury (TBI). We investigated the association between catecholamine levels in the first 24 h post-trauma and functional outcome in patients with isolated moderate-to-severe TBI. METHODS: A cohort of 174 patients who sustained isolated blunt TBI was prospectively enrolled from three Level-1 Trauma Centers. Epinephrine (Epi) and norepinephrine (NE) concentrations were measured at admission (baseline), 6, 12 and 24 h post-injury. Outcome was assessed at 6 months by the extended Glasgow Outcome Scale (GOSE) score. Fractional polynomial plots and logistic regression models (fixed and random effects) were used to study the association between catecholamine levels and outcome. Effect size was reported as the odds ratio (OR) associated with one logarithmic change in catecholamine level. RESULTS: At 6 months, 109 patients (62.6%) had an unfavorable outcome (GOSE 5-8 vs. 1-4), including 51 deaths (29.3%). Higher admission levels of Epi were associated with a higher risk of unfavorable outcome (OR, 2.04, 95% CI: 1.31-3.18, p = 0.002) and mortality (OR, 2.86, 95% CI: 1.62-5.01, p = 0.001). Higher admission levels of NE were associated with higher risk of unfavorable outcome (OR, 1.59, 95% CI: 1.07-2.35, p = 0.022) but not mortality (OR, 1.45, 95% CI: 0.98-2.17, p = 0.07). There was no relationship between the changes in Epi levels over time and mortality or unfavorable outcome. Changes in NE levels with time were statistically associated with a higher risk of mortality, but the changes had no relation to unfavorable outcome. CONCLUSIONS: Elevated circulating catecholamines, especially Epi levels on hospital admission, are independently associated with functional outcome and mortality after isolated moderate-to-severe TBI.

Current use of live tissue training in trauma: a descriptive systematic review.

BACKGROUND: Growing public concern for animal welfare, advances in computerized simulation and economic barriers have drawn a critical eye to the use of live tissue training (LTT) in trauma skills acquisition. As a consequence, other simulation methods have replaced LTT, for example, in the Advanced Trauma Life Support (ATLS) course. Owing to the lack of clear conclusions in the literature, we conducted a systematic review to determine the value of LTT alone and in comparison to other simulation methods in trauma. METHODS: We performed a systematic review of the literature considering observational studies and randomized controlled trials (RCTs) that examined LTT in trauma exclusively or compared with other simulation methods. Independently and in duplicate, we adjudicated studies for inclusion and data abstraction. We assessed the quality and risk of bias. RESULTS: Twelve studies met our inclusion criteria: 2 RCTs and 10 prospective cohort studies. Eight and 4 studies were performed in the military and in the civilian settings, respectively. Anesthetized swine were used in 8 studies and goats in 1. The cohort studies involved LTT alone. Different adjunctive training modalities were included: mannequins in 6 studies, cadavers in 2, computer simulation in 1, video presentations in 2 and wound moulage scenarios in 1. The overall methodological quality was moderate as per the Newcastle-Ottawa score (mean 6.0 ± 0, possible range 1-9). The 2 RCTs did not demonstrate adequate random sequence generation and allocation concealment. CONCLUSION: There is limited evidence that other types of simulation are better than LTT. Data on training effects of LTT versus other simulations on outcomes are lacking.

CONTEXTE: Les préoccupations croissantes du public envers le bien-être des animaux, le perfectionnement des dispositifs de simulation informatisés et les contraintes budgétaires ont remis en question la formation sur tissus vivant (FTV) pour l'acquisition des compétences en traumatologie. Par conséquent, d'autres méthodes de simulation ont remplacé la FTV, par exemple, le cours ATLS (Advanced Trauma Life Support ­ Cours avancé de réanimation des polytraumatisés). Étant donné l'absence de conclusions claires dans la littérature, nous avons procédé à une revue systématique afin de comparer la valeur de la FTV seule à celle d'autres méthodes de simulation en traumatologie. MÉTHODES: Nous avons procédé à une revue systématique de la littérature, plus particulièrement des études d'observation et des essais randomisés et contrôlés (ERC) portant exclusivement sur la FTV en traumatologie ou en comparaison avec d'autres méthodes de simulation. De manière indépendante et dupliquée, nous avons sélectionné les études à inclure et nous en avons extrait les données. Nous avons évalué la qualité et le risque de biais. RÉSULTANTS: Douze études répondaient aux critères d'inclusion : 2 ERC et 10 études de cohorte prospectives. Huit et 4 études ont été effectuées dans des contextes militaires et civils, respectivement. Des porcs anesthésiés ont été utilisés pour 8 études et des chèvres pour une étude. Les études de cohorte ne concernaient que la FTV. Les différentes modalités de formation complémentaires incluaient : mannequins dans 6 études, cadavres dans 2 études, simulation par ordinateur dans 1 étude, présentations vidéo dans 2 études et scénarios de moulage de plaies dans 1 étude. La qualité méthodologique globale s'est révélée modérée selon le score Newcastle­Ottawa (moyenne 6,0 ± 0, éventail de valeurs possibles 1­9). Les 2 ERC ne disposaient pas de séquences aléatoires adéquates et l'attribution des traitement n'y était pas effectuée à l'insu. CONCLUSION: Les preuves dont on dispose pour déterminer si d'autres types de simulation sont préférables à la FTV sont limitées. On manque de données comparatives concernant les effets de la FTV sur l'issue des interventions par rapport à d'autres types de simulations.

Perioperatively acquired disorders of coagulation.

PURPOSE OF REVIEW: To provide an overview of acquired coagulopathies that can occur in various perioperative clinical settings. Also described are coagulation disturbances linked to antithrombotic medications and currently available strategies to reverse their antithrombotic effects in situations of severe hemorrhage. RECENT FINDINGS: Recent studies highlight the link between low fibrinogen and decreased fibrin polymerization in the development of acquired coagulopathy. Particularly, fibrin(ogen) deficits are observable after cardiopulmonary bypass in cardiac surgery, on arrival at the emergency room in trauma patients, and with ongoing bleeding after child birth. Regarding antithrombotic therapy, although new oral anticoagulants offer the possibility of efficacy and relative safety compared with vitamin K antagonists, reversal of their anticoagulant effect with nonspecific agents, including prothrombin complex concentrate, has provided conflicting results. Specific antidotes, currently being developed, are not yet licensed for clinical use, but initial results are promising. SUMMARY: Targeted hemostatic therapy aims to correct coagulopathies in specific clinical settings, and reduce the need for allogeneic transfusions, thus preventing massive transfusion and its deleterious outcomes. Although there are specific guidelines for reversing anticoagulation in patients treated with antiplatelet agents or warfarin, there is currently little evidence to advocate comprehensive recommendations to treat drug-induced coagulopathy associated with new oral anticoagulants.

Effect of thromboelastography (TEG®) and rotational thromboelastometry (ROTEM®) on diagnosis of coagulopathy, transfusion guidance and mortality in trauma: descriptive systematic review.

INTRODUCTION: The understanding of coagulopathies in trauma has increased interest in thromboelastography (TEG®) and thromboelastometry (ROTEM®), which promptly evaluate the entire clotting process and may guide blood product therapy. Our objective was to review the evidence for their role in diagnosing early coagulopathies, guiding blood transfusion, and reducing mortality in injured patients. METHODS: We considered observational studies and randomized controlled trials (MEDLINE, EMBASE, and Cochrane databases) to February 2014 that examined TEG®/ROTEM® in adult trauma patients. We extracted data on demographics, diagnosis of early coagulopathies, blood transfusion, and mortality. We assessed methodologic quality by using the Newcastle-Ottawa scale (NOS) for observational studies and QUADAS-2 tool for diagnostic accuracy studies. RESULTS: Fifty-five studies (12,489 patients) met inclusion criteria, including 38 prospective cohort studies, 15 retrospective cohort studies, two before-after studies, and no randomized trials. Methodologic quality was moderate (mean NOS score, 6.07; standard deviation, 0.49). With QUADAS-2, only three of 47 studies (6.4%) had a low risk of bias in all domains (patient selection, index test, reference standard and flow and timing); 37 of 47 studies (78.8%) had low concerns regarding applicability. Studies investigated TEG®/ROTEM® for diagnosis of early coagulopathies (n = 40) or for associations with blood-product transfusion (n = 25) or mortality (n = 24). Most (n = 52) were single-center studies. Techniques examined included rapid TEG® (n =12), ROTEM® (n = 18), TEG® (n = 23), or both TEG® and rapid TEG® (n = 2). Many TEG®/ROTEM® measurements were associated with early coagulopathies, including some (hypercoagulability, hyperfibrinolysis, platelet dysfunction) not assessed by routine screening coagulation tests. Standard measures of diagnostic accuracy were inconsistently reported. Many abnormalities predicted the need for massive transfusion and death, but predictive performance was not consistently superior to routine tests. One observational study suggested that a ROTEM®-based transfusion algorithm reduced blood-product transfusion, but TEG®/ROTEM®-based resuscitation was not associated with lower mortality in most studies. CONCLUSIONS: Limited evidence from observational data suggest that TEG®/ROTEM® tests diagnose early trauma coagulopathy and may predict blood-product transfusion and mortality in trauma. Effects on blood-product transfusion, mortality, and other patient-important outcomes remain unproven in randomized trials.

Effect of a fixed-ratio (1:1:1) transfusion protocol versus laboratory-results-guided transfusion in patients with severe trauma: a randomized feasibility trial.

BACKGROUND: Hemorrhage coupled with coagulopathy remains the leading cause of preventable in-hospital deaths among trauma patients. Use of a transfusion protocol with a predefined ratio of 1:1:1 (1 each of red blood cells [RBC], frozen plasma [FP] and platelets) has been associated with improved survival in retrospective studies in military and civilian settings, but such a protocol has its challenges and may increase the risk of respiratory complications. We conducted a randomized controlled trial to assess the feasibility of a 1:1:1 transfusion protocol and its effect on mortality and complications among patients with severe trauma. METHODS: We included 78 patients seen in a tertiary trauma centre between July 2009 and October 2011 who had hypotension and bleeding and were expected to need massive transfusion (≥ 10 RBC units in 24 h). We randomly assigned them to either the fixed-ratio (1:1:1) transfusion protocol (n = 40) or to a laboratory-results-guided transfusion protocol (control; n = 38). The primary outcome, feasibility, was assessed in terms of blood product ratios and plasma wastage. Safety was measured based on 28-day mortality and survival free of acute respiratory distress syndrome. RESULTS: Overall, a transfusion ratio of 1:1:1 was achieved in 57% (21/37) of patients in the fixed-ratio group, as compared with 6% (2/32) in the control group. A ratio of 1:1 (RBC:FP) was achieved in 73% (27/37) in the fixed-ratio group and 22% (7/32) in the control group. Plasma wastage was higher with the intervention protocol (22% [86/390] of FP units v. 10% [30/289] in the control group). The 28-day mortality and number of days free of acute respiratory distress syndrome were statistically similar between the groups. INTERPRETATION: The fixed-ratio transfusion protocol was feasible in our study, but it was associated with increased plasma wastage. Larger randomized trials are needed to evaluate the efficacy of such a protocol in trauma care. TRIAL REGISTRATION: ClinicalTrials.gov, no. NCT00945542.

Vitamin K-dependent coagulation factor deficiency in trauma: a comparative analysis between international normalized ratio and thromboelastography.

BACKGROUND: The use of international normalized ratio (INR) to diagnose vitamin K-dependent coagulation factor (VitK-CF) deficiency in trauma has limitations (inability to predict bleeding and long turnaround times). Thromboelastography (TEG) assesses the entire coagulation process. With TEG, reaction time (TEG-R) is used to assess global coagulation factor activity and takes less than 10 minutes. We assessed the ability of TEG-R to detect VitK-CF deficiency in trauma, compared to the INR. STUDY DESIGN AND METHODS: A total of 219 trauma patients with INR, TEG, and all VitK-CF measured at admission were included. Demographics and laboratory tests, drugs, blood transfusions, and severity scores were analyzed. Specificity, sensitivity, positive predictive value (PPV), and negative predictive value (NPV) of INR (≥1.3 and ≥1.5) and TEG-R (>8 min) to diagnose VitK-CF deficits (≤50%) were calculated. Secondary outcomes included time to INR and TEG results. RESULTS: Overall, TEG-R performed worse than INR. TEG-R had a sensitivity of 33% (95% CI, 16%-55%), specificity of 95% (95% CI, 91%-98%), PPV of 47% (95% CI, 23%-72%), and NPV of 92% (95% CI, 87%-95%). An INR of 1.5 or greater had a sensitivity of 67% (95% CI, 45%-84%), specificity of 98% (95% CI, 96%-99.7%), PPV of 84% (95% CI, 60%-97%), and NPV of 96% (95% CI, 92%-98%). An INR of 1.3 or greater also had better sensitivity, PPV, and NPV. For patients on warfarin, the times to INR results and TEG completion were 58 (±23) and 92 (±40) minutes (p=0.07), respectively. TEG-R was abnormal in only one patient on warfarin. CONCLUSION: Our study suggests that TEG-R is not superior at identifying VitK-CF deficiency compared to INR in trauma.

Design and preliminary results of a pilot randomized controlled trial on a 1:1:1 transfusion strategy: the trauma formula-driven versus laboratory-guided study.

BACKGROUND: Retrospective reviews have recently shown an survival benefit for adopting a resuscitation strategy that transfuses plasma and platelets at a near 1:1 ratio with red blood cells (RBCs). However, a randomized controlled trial on the topic is lacking. We report on the design and preliminary results of our ongoing randomized control pilot trial (ClinicalTrial.gov NCT00945542). METHODS: This is a 2-year feasibility randomized control trial at a single tertiary trauma center. Bleeding trauma patients were randomized to either a laboratory-driven or a formula-driven (1 plasma:1 platelet:1 RBC) transfusion protocols. Feasibility was assessed by analyzing for ability to enroll patients, appropriate activation of transfusion protocols, time to transfusion of each type of blood product, laboratory turnaround time, ratio of blood products transfused, and wastage of blood products. RESULTS: From July 6, 2009, to May 31, 2010, n = 18 patients were randomized and included in the study. Issues that we noted were the need to do postrandomization exclusions, the need to have rapid and accurate predictors of massive bleeding to enroll patients quickly, and the need to have waived consent for study participation. As well, we noted that the logistics of administering 1:1:1 were formidable and required rapid access to thawed plasma. Similarly, challenges in the control arm of such a study included the turnaround time for obtaining laboratory results. CONCLUSION: Despite major challenges, our initial experience suggests that with an organized system, it is possible to prospectively randomize massively bleeding trauma patients. The accomplishment of high ratios of plasma to RBCs is challenging with current thawing methods and unavailability of thawed plasma in Canada. Longer shelf-life for plasma and faster plasma thawing microwaves should overcome some of these obstacles. For a laboratory-guided transfusion protocol, massive transfusion protocols should be in place with faster turnaround time for coagulation tests. Finally, further research on predictors of massive transfusion is needed.

Clotting factor deficiency in early trauma-associated coagulopathy.

BACKGROUND: Coagulopathic bleeding is a leading cause of in-hospital death after injury. A recently proposed transfusion strategy calls for early and aggressive frozen plasma transfusion to bleeding trauma patients, thus addressing trauma-associated coagulopathy (TAC) by transfusing clotting factors (CFs). This strategy may dramatically improve survival of bleeding trauma patients. However, other studies suggest that early TAC occurs by protein C activation and is independent of CF deficiency. This study investigated whether CF deficiency is associated with early TAC. METHODS: This is a prospective observational cohort study of severely traumatized patients (Injury Severity Score ≥ 16) admitted shortly after injury, receiving minimal fluids and no prehospital blood. Blood was assayed for CF levels, thromboelastography, and routine coagulation tests. Critical CF deficiency was defined as ≤ 30% activity of any CF. RESULTS: Of 110 patients, 22 (20%) had critical CF deficiency: critically low factor V level was evident in all these patients. International normalized ratio, activated prothrombin time, and, thromboelastography were abnormal in 32%, 36%, and 35%, respectively, of patients with any critically low CF. Patients with critical CF deficiency suffered more severe injuries, were more acidotic, received more blood transfusions, and showed a trend toward higher mortality (32% vs. 18%, p = 0.23). Computational modeling showed coagulopathic patients had pronounced delays and quantitative deficits in generating thrombin. CONCLUSIONS: Twenty percent of all severely injured patients had critical CF deficiency on admission, particularly of factor V. The observed factor V deficit aligns with current understanding of the mechanisms underlying early TAC. Critical deficiency of factor V impairs thrombin generation and profoundly affects hemostasis.

Disseminated intravascular coagulopathy in the first 24 hours after trauma: the association between ISTH score and anatomopathologic evidence.

BACKGROUND: Recent studies questioned "classical" concepts in trauma care, including whether disseminated intravascular coagulation (DIC) occurs in trauma. The knowledge on trauma DIC is limited to few studies built on diagnosing DIC with laboratory-based scores. This study explores whether DIC diagnosed by the well-established ISTH (International Society for Thrombosis and Hemostasis) score is corroborated by anatomopathologic findings. METHODS: Prospective observational cohort study of severely injured (ISS ≥ 16) patients. DIC was diagnosed by the ISTH score throughout the first 24 hours after trauma. All organs surgically removed within 24 hours of trauma were reviewed by two independent pathologists. All autopsy reports were reviewed. RESULTS: Of 423 patients enrolled, ∼11% had "overt DIC" and 85% had "suggestive of non-overt DIC" scores throughout the 24 hours after trauma. "Overt DIC" patients had higher mortality and worse bleeding, receiving more blood and plasma transfusions. One hundred and sixteen patients underwent surgery within 24 hours of trauma, and all 40 excised organs were reviewed by two pathologists. Twenty-seven autopsies reports were reviewed. No anatomopathologic evidence of DIC was identified in the first 24 hours, even after additional histochemical staining. d-dimer was universally elevated after trauma. Common DIC features: platelet count, fibrinogen, clotting time, and factor VIII drop were mostly absent. CONCLUSIONS: d-dimer has a disproportional participation in trauma DIC scores. Within 24 hours of trauma, most severely injured patients have DIC scores "suggestive for" or of "overt DIC" but no anatomopathologic evidence of DIC. Considering pathologic findings as the gold standard diagnosis, then DIC is exceptionally uncommon and the ISTH score should not be used for trauma.

Clinical review: Fresh frozen plasma in massive bleedings - more questions than answers.

Fresh frozen plasma (FFP) is indicated for the management of massive bleedings. Recent audits suggest physician knowledge of FFP is inadequate and half of the FFP transfused in critical care is inappropriate. Trauma is among the largest consumers of FFP. Current trauma resuscitation guidelines recommend FFP to correct coagulopathy only after diagnosed by laboratory tests, often when overt dilutional coagulopathy already exists. The evidence supporting these guidelines is limited and bleeding remains a major cause of trauma-related death. Recent studies demonstrated that coagulopathy occurs early in trauma. A novel early formula-driven haemostatic resuscitation proposes addressing coagulopathy early in massive bleedings with FFP at a near 1:1 ratio with red blood cells. Recent retrospective reports suggest such strategy significantly reduces mortality, and its use is gradually expanding to nontraumatic bleedings in critical care. The supporting studies, however, have bias limiting the interpretation of the results. Furthermore, logistical considerations including need for immediately available universal donor AB plasma, short life after thawing, potential waste and transfusion-associated complications have challenged its implementation. The present review focuses on FFP transfusion in massive bleeding and critically appraises the evidence on formula-driven resuscitation, providing resources to allow clinicians to develop informed opinion, given the current deficient and conflicting evidence.

A comparative study of viscoelastic hemostatic assays and conventional coagulation tests in trauma patients receiving fibrinogen concentrate.

BACKGROUND: Both thrombelastography (TEG) and rotational thromboelastometry (ROTEM) have been investigated for diagnosis of coagulopathy and guidance of resuscitation in trauma and surgery. Given similarities between the two systems, it is important to determine whether one is superior to the other and how comparable they are to conventional coagulation tests (CCTs). Therefore, we conducted a comparative study of functional fibrinogen and coagulation assays using TEG and ROTEM and CCTs to determine their capability to monitor coagulation profiles, diagnose coagulopathy and predict blood transfusion requirements in trauma patients. METHODS: Blood samples were collected from 45 patients at admission and during 48-h hospitalization as part of a randomized control trial on early fibrinogen replacement in trauma. Functional fibrinogen (FF) TEG, ROTEM FIBTEM and EXTEM, and CCTs were performed and compared. RESULTS: We found significant differences between the placebo and fibrinogen groups over hospitalization time in FF TEG MA, ROTEM CT, MCF and LI30. FF TEG MA and ROTEM FIBTEM MCF mirrored plasma fibrinogen profiles, reached a maximum difference between the two groups 1-3 h after fibrinogen administration. In comparison, CCTs detected minimal hemostatic changes by fibrinogen treatment. TEG and ROTEM showed various degrees of correlations with CCTs. TEG MA and ROTEM MCF provided better predictions for plasma and RBC transfusions than CCTs, but poor accuracy for cryoprecipitate transfusion. Both TEG and ROTEM well predicted hypofibrinogenemia (fibrinogen concentration < 1 g/L), but poorly detected coagulopathy (INR ≥ 1.2). CONCLUSIONS: TEG and ROTEM detected increases in clot strength following early use of fibrinogen. ROTEM also detected changes in coagulation time and clot lysis. Both were better than CCTs for monitoring coagulation profiles and predicting transfusion requirements.

Cosmiatria: Uma análise do mercado brasileiro / Cosmiatry: An analysis of the Brazilian market

Introdução: O mercado de procedimento estéticos cresce exponencialmente no Brasil. Tal crescimento tem despertado o interesse de várias categorias profissionais. A decisão de praticar no setor deve considerar as oportunidades de mercado da localidade na qual se pretende atuar. Entretanto, a área carece de análises comparativas documentando prováveis diferenças regionais no país. O objetivo do estudo é descrever as diferenças de mercado em procedimentos estéticos entre os estados e regiões brasileiras. Um índice de potencial consumo de cosmiatria (IPCC) é calculado para tal análise comparativa. Método: Estudo transversal envolvendo prestadores de procedimentos estéticos não cirúrgicos no Brasil. Buscas no Google®-Google Maps® foram conduzidas usando termoschave e entrevistas telefônicas realizadas para obter informações sobre categorias profissionais, tipo de provedores e serviços oferecidos. Valores preditivos positivos foram obtidos para todas as estratégias de busca e usados para estimar o número total de provedores. O tamanho da população e a renda per capita foram considerados para o cálculo dos IPCCs para os estados brasileiros. Resultados: São Paulo, Minas Gerais e Rio de Janeiro apresentaram os maiores IPCCs, sendo 524, 210 e 180, respectivamente. Roraima teve um IPCC de 14, o mais baixo do país. A Região Sudeste apresentou, em média, o maior IPCC (242) entre todas as regiões brasileiras. Conclusão: Considerando o tamanho da população e a renda, a Região Sudeste apresenta as maiores oportunidades de mercado em procedimentos estéticos não cirúrgicos no Brasil. Nossos achados podem ser de interesse para profissionais de saúde e investidores que atuam ou pretendem atuar no setor.

Introduction: The aesthetic procedure market is growing exponentially in Brazil. This growth has aroused the interest of several professional categories. The decision to practice in the sector must consider the market opportunities in the location in which you intend to operate. However, the area lacks comparative analyses documenting probable regional differences in the country. The objective of the study is to describe market differences in aesthetic procedures between Brazilian states and regions. An index of potential cosmetic consumption (IPCC) is calculated for such a comparative analysis. Method: Cross-sectional study involving providers of nonsurgical aesthetic procedures in Brazil. Searches on Google Maps® were conducted using key terms, and telephone interviews were conducted to obtain information on professional categories, types of providers, and services offered. Positive predictive values were obtained for all search strategies and used to estimate the total number of providers. Population size and per capita income were considered to calculate the IPCCs for Brazilian states. Results: São Paulo, Minas Gerais, and Rio de Janeiro presented the highest IPCCs, being 524, 210, and 180, respectively. Roraima had an IPCC of 14, the lowest in the country. The Southeast Region presented, on average, the highest IPCC (242) among all Brazilian regions. Conclusion: Considering population size and income, the Southeast Region presents the greatest market opportunities for nonsurgical aesthetic procedures in Brazil. Our findings may be of interest to healthcare professionals and investors who work or intend to work in the sector.

Thromboelastography and Thromboelastometry in Assessment of Fibrinogen Deficiency and Prediction for Transfusion Requirement: A Descriptive Review.

Fibrinogen is crucial for the formation of blood clot and clinical outcomes in major bleeding. Both Thromboelastography (TEG) and Rotational Thromboelastometry (ROTEM) have been increasingly used to diagnose fibrinogen deficiency and guide fibrinogen transfusion in trauma and surgical bleeding patients. We conducted a comprehensive and comparative review on the technologies and clinical applications of two typical functional fibrinogen assays using TEG (FF TEG) and ROTEM (FIBTEM) for assessment of fibrinogen level and deficiency, and prediction of transfusion requirement. Clot strength and firmness of FF TEG and ROTEM FIBTEM were the most used parameters, and their associations with fibrinogen levels as measured by Clauss method ranged from 0 to 0.9 for FF TEG and 0.27 to 0.94 for FIBTEM. A comparison of the interchangeability and clinical performance of the functional fibrinogen assays using the two systems showed that the results were correlated, but are not interchangeable between the two systems. It appears that ROTEM FIBTEM showed better associations with the Clauss method and more clinical use for monitoring fibrinogen deficiency and predicting transfusion requirements including fibrinogen replacement than FF TEG. TEG and ROTEM functional fibrinogen tests play important roles in the diagnosis of fibrinogen-related coagulopathy and guidance of transfusion requirements. Despite the fact that high-quality evidence is still needed, the two systems are likely to remain popular for the hemostatic management of bleeding patients.

Blood transfusion and coagulopathy in geriatric trauma patients.

BACKGROUND: Trauma resuscitation has undergone a paradigm shift with new emphasis on the early use of blood products and increased proportions of plasma and platelets. However, it is unclear how this strategy is applied or how effective it is in the elderly population. The study aim is to identify differences in transfusion practices and the coagulopathy of trauma in the elderly. METHODS: Data was prospectively collected on all consecutive patients that met trauma activation criteria at a Level I trauma centre. Data fields included patient demographics, co-morbidities, injury and resuscitation data, laboratory values, thromboelastography (TEG) results, and outcome measures. Elderly patients were defined as those 55 and older. Propensity-score matched analysis was completed for patients receiving blood product transfusion. Patients were matched by gender, mechanism, injury severity score (ISS), head injury, and time from injury. RESULTS: Total of 628 patients were included, of which 142 (23%) were elderly. Elderly patients were more likely to be female (41% vs. 24%), suffer blunt mechanism of trauma (96% vs. 80%), have higher ISS scores (mean 25.4 vs. 21.6) and mortality (19% vs. 8%). Elderly patients were significantly more likely to receive a blood transfusion (42% vs. 30%), specifically for red cells and plasma. Propensity-matched analysis resulted in no difference in red cell transfusion or mortality. Despite the broad similarities between the matched cohorts, trauma coagulopathy as measured by TEG was less commonly observed in the elderly. DISCUSSION: Our results suggest that elderly trauma patients are more likely to receive blood products when admitted to a trauma centre, though this may be attributed to under-triage. The results also suggest an altered coagulopathic response to traumatic injury which is partially influenced by increased anticoagulant and antiplatelet medication use in the geriatric population. CONCLUSION: It is not clear whether the acute coagulopathy of trauma is equivalent in geriatric patients, and further study is therefore warranted.