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Editor's Choice
  • Dixon A
  • Kenny JE
  • Buzzard L
  • Holcomb J
  • Bulger E
  • et al.
J Trauma Acute Care Surg. 2024 Feb 1;96(2):319-325 doi: 10.1097/TA.0000000000004096.
POPULATION:

Trauma patients 15 years of age or older, enrolled in the Pragmatic, Randomized Optimal Platelet and Plasma Ratios (PROPPR) trial, in 12 Level I trauma centers across North America (n= 629).

INTERVENTION:

Plasma, platelets, and red blood cells administered in a 1:1:1 ratio (n= 321).

COMPARISON:

Plasma, platelets, and red blood cells administered in a 1:1:2 ratio (n= 308).

OUTCOME:

This is a secondary analysis of the PROPPR trial. Syndecan-1, soluble thrombomodulin (sTM), and receptor for advanced glycation end products (RAGE) were quantified for each treatment group on admission and at 2 hours, 4 hours, 6 hours, 12 hours, 24 hours, 48 hours, and 72 hours. Patients were excluded if they did not survive longer than 3 hours or had data from fewer than two time points. Three hundred eight patients in the 1:1:1 group and 291 in the 1:1:2 group were analyzed. There were no statistically significant differences in syndecan-1, sTM, or RAGE between treatment groups at any time point. Patients who developed acute respiratory distress syndrome, acute kidney injury, and death had significantly elevated biomarker expression at most time points when compared with patients who did not develop these sequelae.

BACKGROUND:

Disruption of the vascular endothelium and endothelial glycocalyx (EG) has been described after severe trauma. Plasma has been suggested to restore microvascular integrity by preservation and repair of the EG. We sought to evaluate whether plasma administered in a 1:1:1 ratio was associated with less endothelial marker circulation than a 1:1:2 ratio.

METHODS:

This is a secondary analysis of the PROPPR trial, which investigated post-traumatic resuscitation with platelets, plasma, and red blood cells in a 1:1:1 ratio compared with a 1:1:2 ratio. Syndecan-1, soluble thrombomodulin (sTM), and receptor for advanced glycation end products (RAGE) were quantified for each treatment group on admission and at 2 hours, 4 hours, 6 hours, 12 hours, 24 hours, 48 hours, and 72 hours. Patients were excluded if they did not survive longer than 3 hours or had data from fewer than two time points.

RESULTS:

Three hundred eight patients in the 1:1:1 group and 291 in the 1:1:2 group were analyzed. There were no statistically significant differences in syndecan-1, sTM, or RAGE between treatment groups at any time point ( p > 0.05). Patients who developed acute respiratory distress syndrome, acute kidney injury, and death had significantly elevated biomarker expression at most time points when compared with patients who did not develop these sequelae ( p < 0.05).

CONCLUSION:

Administration of FFP in a 1:1:1 ratio does not consistently affect circulation of endothelial biomarkers following significant trauma when compared with a 1:1:2 ratio. The development of post-traumatic ARDS, AKI, and death was associated with increased endothelial biomarker circulation.

LEVEL OF EVIDENCE:

Therapeutic/Care Management; Level III.

Editor's Choice
  • Mullis BH
  • Mullis LS
  • Kempton LB
  • Virkus W
  • Slaven JE
  • et al.
J Orthop Trauma. 2024 Jan 1;38(1):18-24 doi: 10.1097/BOT.0000000000002696.
POPULATION:

Musculoskeletal trauma patients with planned surgery (n= 99).

INTERVENTION:

Liberal transfusion threshold of 7.0 g/dL (n= 49).

COMPARISON:

Conservative transfusion threshold of 5.5 g/dL (n= 50).

OUTCOME:

Overall, 46/49 (93.9%) of the liberal group had a transfusion versus 23/50 (46.0%) of the conservative group had a transfusion after resuscitation and after enrollment in this study. Following resuscitation and enrollment in the study, patients in the liberal group received a median of 1 unit of blood transfused (range 0–12) and patients in the conservative group received a median of 0 units of blood (range 0–14). Sixty-five patients completed 1- year follow-up. There was a significant association between a liberal transfusion strategy and higher rate of infection, with no difference in functional outcomes at 6 months or 1 year.

OBJECTIVES:

To determine whether it is safe to use a conservative packed red blood cell transfusion hemoglobin (Hgb) threshold (5.5 g/dL) compared with a liberal transfusion threshold (7.0 g/dL) for asymptomatic musculoskeletal injured trauma patients who are no longer in the initial resuscitative period.

METHODS:

Design: Prospective, randomized, multicenter trial.

SETTING:

Three level 1 trauma centers.

PATIENT SELECTION CRITERIA:

Patients aged 18-50 with an associated musculoskeletal injury with Hgb less than 9 g/dL or expected drop below 9 g/dL with planned surgery who were stable and no longer being actively resuscitated were randomized once their Hgb dropped below 7 g/dL to a conservative transfusion threshold of 5.5 g/dL versus a liberal threshold of 7.0 g/dL.

OUTCOME MEASURES AND COMPARISONS:

Postoperative infection, other post-operative complications and Musculoskeletal Functional Assessment scores obtained at baseline, 6 months, and 1 year were compared for liberal and conservative transfusion thresholds.

RESULTS:

Sixty-five patients completed 1 year follow-up. There was a significant association between a liberal transfusion strategy and higher rate of infection (P = 0.01), with no difference in functional outcomes at 6 months or 1 year. This study was adequately powered at 92% to detect a difference in superficial infection (7% for liberal group, 0% for conservative, P < 0.01) but underpowered to detect a difference for deep infection (14% for liberal group, 6% for conservative group, P = 0.2).

CONCLUSIONS:

A conservative transfusion threshold of 5.5 g/dL in an asymptomatic young trauma patient with associated musculoskeletal injuries leads to a lower infection rate without an increase in adverse outcomes and no difference in functional outcomes at 6 months or 1 year.

LEVEL OF EVIDENCE:

Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Editor's Choice
  • Gianola S
  • Castellini G
  • Biffi A
  • Porcu G
  • Napoletano A
  • et al.
Int J Emerg Med. 2023 Nov 30;16(1):87 doi: 10.1186/s12245-023-00563-4.
POPULATION:

Trauma patients with haemorrhagic shock (14 systematic reviews).

INTERVENTION:

Crystalloids, packed red blood cells, fresh frozen plasma, platelets, liquid plasma, lyophilized plasma, low titre 0-negative whole blood.

COMPARISON:

A comparison or combination of the above (including different ratios).

OUTCOME:

For crystalloids, inconsistent evidence of effectiveness in 28- to 30-day survival (primary endpoint) was found for the hypertonic saline/dextran group compared with isotonic fluid solutions with moderate certainty of evidence. Pre-hospital blood component infusion seems to reduce mortality, however, as the certainty of evidence ranges from very low to moderate, the authors are unable to provide evidence to support or reject its use. The blood component ratio was in favour of higher ratios among all comparisons considered with moderate to very low certainty of evidence. Results about the effects of whole blood are very uncertain due to limited and heterogeneous interventions in studies included in systematic reviews.

BACKGROUND:

The use of intravenous fluid therapy in patients with major trauma in prehospital settings is still controversial. We conducted an umbrella review to evaluate which is the best volume expansion in the resuscitation of a hemorrhagic shock to support the development of major trauma guideline recommendations.

METHODS:

We searched PubMed, Embase, and CENTRAL up to September 2022 for systematic reviews (SRs) investigating the use of volume expansion fluid on mortality and/or survival. Quality assessment was performed using AMSTAR 2 and the Certainty of the evidence was assessed with the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach.

RESULTS:

We included 14 SRs investigating the effects on mortality with the comparisons: use of crystalloids, blood components, and whole blood. Most SRs were judged as critically low with slight overlapping of primary studies and high consistency of results. For crystalloids, inconsistent evidence of effectiveness in 28- to 30-day survival (primary endpoint) was found for the hypertonic saline/dextran group compared with isotonic fluid solutions with moderate certainty of evidence. Pre-hospital blood component infusion seems to reduce mortality, however, as the certainty of evidence ranges from very low to moderate, we are unable to provide evidence to support or reject its use. The blood component ratio was in favor of higher ratios among all comparisons considered with moderate to very low certainty of evidence. Results about the effects of whole blood are very uncertain due to limited and heterogeneous interventions in studies included in SRs.

CONCLUSION:

Hypertonic crystalloid use did not result in superior 28- to 30-day survival. Increasing evidence supports the scientific rationale for early use of high-ratio blood components, but their use requires careful consideration. Preliminary evidence is very uncertain about the effects of whole blood and further high-quality studies are required.