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1.
Injury ; 2021 Oct 31.
Artigo em Inglês | MEDLINE | ID: mdl-34749909

RESUMO

INTRODUCTION: Transfusion strategy for trauma patients with massive haemorrhage is often incorporated in massive transfusion protocols (MTP). Albeit correct MTP use results in better patient outcome, research regarding the state of MTP knowledge is scarce. The objective of this study is therefore to assess knowledge of local MTP and massive transfusion strategy in the level 1 trauma centres in the Netherlands. Our hypothesis is that actual MTP knowledge is low and transfusion strategy differs. MATERIALS AND METHODS: Surveys were sent out in January 2020 to all trauma and vascular surgeons, anaesthesiologists, emergency department physicians of the largest level 1 trauma centre (locally, n = 113) and to one trauma surgeon, emergency physician and anaesthesiologist in each of the nine other governmentally assigned level 1 trauma centres in the Netherlands (nationally, n = 27). The respondents were subdivided into a frequent user group (MTP usage ≥ 4 times in 2019) and a non-frequent user group (MTP usage < 4 in 2019). Data are expressed as numbers and percentages. RESULTS: Response rate was (n = 48; 42%) for the local survey and (n = 14; 52%) for the national survey. Locally, (n = 23; 48%) and (n = 25; 52%) respondents were defined frequent and non-frequent users respectively and national respondents all as frequent users. In total, (n = 13; 27%) of local respondents were aware of the current local composition of the MTP. Respondents indicated to transfuse erythrocytes first, followed by plasma and platelets (local non-frequent users n = 23; 92%, local frequent users n = 21; 91% and national frequent users n = 13; 93%). The indication for platelet transfusion was units erythrocytes transfused (local non-frequent users n = 10; 40% frequent users locally n = 11; 48% and nationally n = 5; 36%) and clinical view (local non-frequent users n = 9; 36%, frequent users locally n = 8; 35% and n<5 nationally. Whereas few respondents claimed (n = 5; 21% non-frequent users locally and n <5 nationally) to transfuse platelets based on platelet counts. Viscoelastic haemostatic assays were performed during MTP, but only by frequent users. CONCLUSION: The majority of physicians dealing with massive transfusion in trauma patients were not aware of the exact composition of the MTP and consensus regarding transfusion strategy and indication for platelet transfusion was low.

2.
J Trauma Acute Care Surg ; 91(4): 759-771, 2021 10 01.
Artigo em Inglês | MEDLINE | ID: mdl-34225351

RESUMO

BACKGROUND: Platelet transfusion during major hemorrhage is important and often embedded in massive transfusion protocols. However, the optimal ratio of platelets to erythrocytes (platelet-rich plasma [PLT]/red blood cell [RBC] ratio) remains unclear. We hypothesized that high PLT/RBC ratios, as compared with low PLT/RBC ratios, are associated with improved survival in patients requiring massive transfusion. METHODS: Four databases (Pubmed, CINAHL, EMBASE, and Cochrane) were systematically screened for literatures published until January 21, 2021, to determine the effect of PLT/RBC ratio on the primary outcome measure mortality at 1 hour to 6 hours and 24 hours and at 28 days to 30 days. Studies comparing various PLT/RBC ratios were included in the meta-analysis. Secondary outcomes included intensive care unit length of stay and in-hospital length of stay and total blood component use. The study protocol was registered in PROSPERO under number CRD42020165648. RESULTS: The search identified a total of 8903 records. After removing the duplicates and second screening of title, abstract, and full text, a total of 59 articles were included in the analysis. Of these articles, 12 were included in the meta-analysis. Mortality at 1 hour to 6 hours, 24 hours, and 28 days to 30 days was significantly lower for high PLT/RBC ratios as compared with low PLT/RBC ratios. CONCLUSION: Higher PLT/RBC ratios are associated with significantly lower 1-hour to 6-hour, 24-hour, 28-day to 30-day mortalities as compared with lower PLT/RBC ratios. The optimal PLT/RBC ratio for massive transfusion in trauma patients is approximately 1:1. LEVEL OF EVIDENCE: Systematic review and meta-analysis, therapeutic Level III.


Assuntos
Transfusão de Eritrócitos/estatística & dados numéricos , Hemorragia/terapia , Transfusão de Plaquetas/estatística & dados numéricos , Plasma Rico em Plaquetas , Ferimentos e Lesões/terapia , Hemorragia/etiologia , Hemorragia/mortalidade , Mortalidade Hospitalar , Humanos , Tempo de Internação , Índices de Gravidade do Trauma , Resultado do Tratamento , Ferimentos e Lesões/complicações , Ferimentos e Lesões/diagnóstico , Ferimentos e Lesões/mortalidade
3.
Transfusion ; 60(8): 1846-1855, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32692441

RESUMO

BACKGROUND: Early plasma transfusion is important in the treatment of patients with major hemorrhage. Prolonged shelf life of AB type frozen -80°C and cold-stored (4°C) deep frozen plasma (DFP) will improve strategic stock management, minimize need for resupply, and make pre-hospital implementation more feasible. METHODS AND MATERIALS: Plasma products type AB of different age and origin (-30°C Fresh Frozen [(FFP], -80°C DFP [short (±1 year) and long (±7 year)] stored) were thawed (Day 0), stored at 4°C, and sampled on Days 7 and 14. Additionally, samples of plasma containing blood products (Octaplas LG®, whole blood and platelets) were compared for coagulation factor activity, phospholipid clotting time (PPL), and kaolin TEG during 4°C or 22°C storage. RESULTS: Coagulation profiles of FFP, short- and long-stored -80°C DFP were not significantly different after thaw. Cold storage did not affect fibrinogen, Protein C, and Antithrombin III activities whereas factor V, VII, VIII, and Protein S decreased in all blood products. After 14 days DFP still meets the guidelines for clinical use, except for Protein S (0.4 IU/mL). With exception of Octaplas LG®, phospholipid activity and TEG coagulation were similar between plasma containing blood components during storage. CONCLUSION: AB DFP quality was unaffected by almost 7 years of frozen storage. Quality of thawed 14-day stored AB DFP met, with exception of Protein S, all minimal guidelines which implies that its quality is sufficient for use in the (pre)-hospital (military) environment for treatment of major hemorrhage.


Assuntos
Transfusão de Componentes Sanguíneos , Preservação de Sangue , Congelamento , Plasma/química , Plasma/metabolismo , Humanos , Fatores de Tempo
4.
Transfusion ; 60(9): 2079-2089, 2020 09.
Artigo em Inglês | MEDLINE | ID: mdl-32592423

RESUMO

BACKGROUND: Cryopreserved platelet products can be stored for years and are mainly used in military settings. Following thawing, cryopreserved platelets are activated, resulting in faster clot formation but reduced aggregation in vitro, rendering their efficacy in bleeding unknown. Also, concerns remain on the safety of these products. The aim was to investigate the efficacy and safety of cryopreserved platelets in a rat model of traumatic hemorrhage. STUDY DESIGN AND METHODS: After 1 hour of shock, rats (n = 13/group) were randomized to receive a balanced transfusion pack (1:1:1 red blood cell:plasma:platelet) made from syngeneic rat blood, containing either liquid stored platelets or cryopreserved platelets. Primary outcome was the transfusion volume required to obtain a mean arterial pressure (MAP) of 60 mmHg. Secondary outcomes were coagulation as assessed by thromboelastometry (ROTEM®) and organ failure as assessed by biochemistry and histopathology. RESULTS: The transfusion volume to obtain a MAP of 60 mmHg was lower in animals receiving cryopreserved platelets (5.4 [4.1-7.1] mL/kg) compared to those receiving liquid stored platelets (7.5 [6.4-8.5] mL/kg, p < 0.05). ROTEM® clotting times were shorter (45 [41-48] vs. 49 [45-53]sec, p < 0.05), while maximum clot firmness was slightly lower (68 [67-68] vs. 69 [69-71]mm, p < 0.01). Organ failure was similar in both groups. CONCLUSIONS: Use of cryopreserved platelets required less transfusion volume to reach a targeted MAP compared to liquid stored platelets, while organ injury was similar. These results provide a rationale for clinical trials with cryopreserved platelets in (traumatic) bleeding.


Assuntos
Plaquetas , Preservação de Sangue , Criopreservação , Hemorragia , Transfusão de Plaquetas , Ferimentos e Lesões , Animais , Plaquetas/citologia , Plaquetas/metabolismo , Modelos Animais de Doenças , Hemorragia/sangue , Hemorragia/etiologia , Hemorragia/terapia , Masculino , Ratos , Ferimentos e Lesões/sangue , Ferimentos e Lesões/complicações , Ferimentos e Lesões/terapia
5.
Transfus Apher Sci ; 59(3): 102789, 2020 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-32340813

RESUMO

The Dutch military uses frozen blood products for the treatment of bleeding trauma patients during military deployments. With -80 °C frozen blood products it is possible to follow operational demand while reducing the number of resupply transports and loss of products due to expiration. In this paper lessons learned are described on efficient blood management with -80 °C deep-frozen erythrocytes (DEC).


Assuntos
Bancos de Sangue/normas , Preservação de Sangue/métodos , Criopreservação/métodos , Eritrócitos/metabolismo , Humanos , Militares , Países Baixos
6.
World J Surg ; 44(1): 124-133, 2020 01.
Artigo em Inglês | MEDLINE | ID: mdl-31535167

RESUMO

BACKGROUND: In the Netherlands, each year a three-day international multidisciplinary trauma masterclass is organized to provide the knowledge and skills needed to care for critically injured trauma patients. This study was designed to longitudinally evaluate the effect of the course on participant's self-assessment of their own ability and confidence to perform general and specific skills. METHODS: Between 2013 and 2016, all participants were invited to complete a questionnaire before and during follow-up. Participants were asked to self-assess their level of confidence to perform general skills (communication, teamwork, leadership) and specific skills. Mean scores were calculated, and mixed models were used to evaluate correlation. RESULTS: We asked 265 participants to participate. Response rate was 64% for the pre-questionnaire, 63% for the post-questionnaire and for 3 months, 1 year and 2 years, respectively, 40%, 30%, 20%. The surgical group showed a statistically significant increase in self-assessed confidence for general skills (3.82-4.20) and specific technical skills (3.01-3.83; p < 0.001). In the anesthetic group, self-assessed confidence increased significantly in general skills (3.72-4.26) and specific technical skills (3.33-4.08; p < 0.001). For both groups statistical significance remained during follow-up. CONCLUSIONS: This study demonstrated a sustained positive effect of a dedicated multidisciplinary trauma training curriculum on participant's self-assessed confidence to perform both general and specific technical skills necessary for the care of injured patients. Given the known association between confidence and competence, these findings provide evidence that dedicated trauma training curricula can provide positive lasting results. LEVEL OF EVIDENCE: This is a basic science paper and therefore does not require a level of evidence.


Assuntos
Anestesiologistas/educação , Competência Clínica , Cirurgia Geral/educação , Autoavaliação (Psicologia) , Cirurgiões/educação , Ferimentos e Lesões/cirurgia , Adulto , Feminino , Humanos , Masculino
7.
Emerg Med J ; 37(2): 65-72, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31831587

RESUMO

OBJECTIVES: Massive transfusion protocols (MTPs) may improve survival in patients with uncontrolled haemorrhage. An MTP was introduced into the Dutch transfusion guidelines in 2011, the ninth edition of the advanced trauma life support course in 2012 and the third version of the European guideline in 2013. This is the first survey of MTPs in Dutch trauma centres. METHODS: The aim of the study was to compare MTP strategies in level 1 trauma centres in The Netherlands, and with (inter)national guidelines. A contact in each government assigned level 1 trauma centre in The Netherlands and the Dutch Ministry of Defence was approached to share their MTPs and elucidate their protocol in a survey and oral follow-up interview. RESULTS: All 11 level 1 trauma centres responded. The content of the packages and transfusion ratios (red blood cells/plasma/platelets) were 3:3:1, 5:5:1, 5:3:1, 2:3:1, 4:4:1, 5:2:1, 2:2:1 and 4:3:1. Tranexamic acid was used in all centres and an additional dose was administered in eight centres. Fibrinogen was given directly (n=4), with persistent bleeding (n=3), based on Clauss fibrinogen (n=3) or rotational thromboelastometry (n=1). All centres used additional medication in patients in the form of anticoagulants, but their use was ambiguous. CONCLUSION: MTPs differed between institutes and guidelines. The discrepancies in transfusion ratios can be explained by (inter)national differences in preparation and volume of blood components and/or interpretation of the '1:1:1' guideline. We recommend updating MTPs every year using the latest guidelines and evaluating the level of evidence for treatment during massive transfusion.


Assuntos
Transfusão de Sangue/métodos , Protocolos Clínicos/normas , Adulto , Transfusão de Sangue/instrumentação , Feminino , Hemorragia/terapia , Humanos , Masculino , Países Baixos , Ressuscitação/métodos , Inquéritos e Questionários
8.
Injury ; 50(5): 1017-1027, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-30928164

RESUMO

BACKGROUND: Life-threatening haemorrhage accounts for 40% mortality in trauma patients worldwide. After bleeding control is achieved, circulating volume must be restored. Early in-hospital transfusion of blood components is already proven effective, but the scientific proof for the effectiveness of prehospital blood-component transfusion (PHBT) in trauma patients is still unclear. OBJECTIVE: To systematically review the evidence for effectiveness and safety of PHBT to haemorrhagic trauma patients. METHODS: CINAHL, Cochrane, EMBASE, and Pubmed were searched in the period from 1988 until August 1, 2018. Meta-analysis was performed for matched trauma patients receiving PHBT with the primary outcomes 24-hour mortality and long-term mortality. Secondary outcome measure was adverse events as a result of PHBT. RESULTS: Trauma patients who received PHBT with simultaneous use of packed red blood cells (pRBCs) and plasma showed a statistically significant reduction in long-term mortality (OR = 0.51; 95% CI, 0.36-0.71; P < 0.0001) but no difference in 24-hour mortality (OR = 0.47, 95% CI, 0.17-1.34; P = 0.16). PHBT with individual use of pRBCs showed no difference in long-term mortality (OR = 1.18; 95% CI, 0.93-1.49; P = 0.17) or 24-hour mortality (OR = 0.92; 95% CI, 0.46-1.85; P = 0.82). In a total of 1341 patients who received PHBT, 14 adverse events were reported 1.04%, 95% CI 0.57-1.75%. CONCLUSIONS: PHBT with simultaneous use of both pRBCs and plasma resulted in a significant reduction in the odds for long-term mortality. However, based on mainly poor quality evidence no hard conclusion can be drawn about a possible survival benefit for haemorrhagic trauma patients receiving PHBT. Overall, PHBT is safe but results of currently ongoing randomised controlled trials have to be awaited to demonstrate a survival benefit. STUDY TYPE: Systematic review and meta-analysis.


Assuntos
Transfusão de Sangue , Serviços Médicos de Emergência , Hemorragia/terapia , Ferimentos e Lesões/terapia , Transfusão de Sangue/mortalidade , Serviços Médicos de Emergência/métodos , Hemorragia/mortalidade , Humanos , Análise de Sobrevida , Tempo para o Tratamento , Ferimentos e Lesões/mortalidade
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