HPE CSL Managing Perioperative Bleeding handbook - Page 26

Trauma concentrate first line, PCC and FXIII) replacement in a cohort of major trauma patients. Significantly fewer patients in the coagulation factor concentrate group received massive transfusion and fewer patients received ‘rescue’ therapy by changing the treatment groups. However, the primary outcome, which was multi-organ failure, was not different between groups (the study was stopped at 50% recruitment). 8 One study compared a ROTEM-guided coagulation therapy based on coagulation factor concentrates (fibrinogen concentrate and PCC) with controls from the German Trauma Registry, treated with FFP. RBC and PC transfusions were avoided in significantly higher proportions of patients in the coagulation factor concentrate group. However, no difference in mortality was observed. 50 Conclusions It remains unclear whether early substitution of coagulation factor concentrate can improve outcome in major trauma-related bleeding. However, it has been clearly established that coagulation factor concentrates allow rapid and targeted supplementation of pro-coagulants, and that the administration of fibrinogen concentrate in cases of TIC effectively treats early and critical fibrinogen depletion. Thus, fibrinogen concentrate confers significant advantages in both safety and speed of administration over FFP transfusion for supplementation of fibrinogen. In addition, PCCs effectively increase the content of vitamin K-dependent coagulation factors and is clearly superior compared with FFP transfusion. 26 References 1 Krug EG, Sharma GK, Lozano R. The global burden of injuries. Am J Public Health 2000;90:523–6. 2 Sauaia A et al. Epidemiology of trauma deaths: a reassessment. J Trauma 1995;38:185–93. 3 Brohi K et al. Acute traumatic coagulopathy. J Trauma 2003;54:1127–30. 4 Holcomb JB et al; PROPPR Study Group. Transfusion of plasma, platelets, and red blood cells in a 1:1:1 vs a 1:1:2 ratio and mortality in patients with severe trauma: the PROPPR randomized clinical trial. JAMA 2015;313(5):471–82. 5 Balvers K et al; Targeted Action for Curing Trauma-Induced Coagulopathy (TACTIC) Collaborators. Combined effect of therapeutic strategies for bleeding injury on early survival, transfusion needs and correction of coagulopathy. Br J Surg 2017;104(3):222–9. 6 Schöchl H et al. Goal-directed coagulation management of major trauma patients using thromboelastometry (ROTEM)-guided administration of fibrinogen concentrate and prothrombin complex concentrate. Crit Care 2010;14(2):R55. 7 Stein P et al. Change of transfusion and treatment paradigm in major trauma patients. hospitalpharmacyeurope.com Anaesthesia 2017;72(11):1317–26. 8 Innerhofer P et al. Reversal of trauma-induced coagulopathy using first-line coagulation factor concentrates or fresh frozen plasma (RETIC): a single-centre, parallel-group, open-label, randomised trial. Lancet Haematol 2017;4(6):e258–e271. 9 Nardi G et al. Trauma-induced coagulopathy: impact of the early coagulation support protocol on blood product consumption, mortality and costs. Crit Care 2015;19:83. 10 Maegele M. Frequency, risk stratification and therapeutic management of acute post-traumatic coagulopathy. Vox Sang 2009;97(1):39–49. 11 Chambers LA, Chow SJ, Shaffer LE. Frequency and characteristics of coagulopathy in trauma patients treated with a low- or high-plasma-content massive transfusion protocol. Am J Clin Pathol 2011;136(3): 364–70. 12 Hagemo JS et al. Prevalence, predictors and outcome of hypofibrinogenaemia in trauma: a multicentre observational study. Crit Care 2014;18(2):R52. 13 McQuilten ZK et al. Fibrinogen is an independent predictor of mortality in major trauma patients: A five-year statewide cohort study. Injury 2017;48(5):1074–81. 14 Schöchl H et al. FIBTEM provides early prediction of massive transfusion in trauma. Crit Care 2011;15(6):R265. 15 Mosesson MW. Update on antithrombin I (fibrin). Thromb Haemost 2007;98(1):105–8. 16 Floccard B et al. Early coagulopathy in trauma patients: an on-scene and hospital admission study. Injury 2012;43(1):26–32. 17 Schlimp CJ et al. Estimation of plasma fibrinogen levels based on hemoglobin, base excess and Injury Severity Score upon emergency room admission. Crit Care 2013;17(4):R137. 18 Rossaint R et al. The European guideline on management of major bleeding and coagulopathy following trauma: fourth edition. Crit Care 2016;20:100. 19 Aubron C et al. Efficacy and safety of fibrinogen concentrate in trauma patients – a systematic review. J Crit Care 2014;29(3):471.e11–7. 20 Ponschab M et al. Haemostatic profile of reconstituted blood in a proposed 1:1:1 ratio of packed red blood cells, platelet concentrate and four different plasma preparations. Anaesthesia 2015;70(5): 528–36. 21 Theusinger OM et al. Relative concentrations of haemostatic factors and cytokines in solvent/ detergent-treated and fresh-frozen plasma. Br J Anaesth 2011;106(4):505–11. 22 Rourke C et al. Fibrinogen levels during trauma hemorrhage, response to replacement therapy, and association with patient outcomes. J Thromb Haemost 2012;10(7):1342–51. 23 Curry N et al. Early cryoprecipitate for major haemorrhage in trauma: a randomised controlled feasibility trial. Br J Anaesth 2015;115(1):76–83. 24 Sørensen B, Bevan D. A critical evaluation of cryoprecipitate for replacement of fibrinogen. Br J Haematol 2010;149(6):834–43. 25 Solomon C et al