Are we meeting current recommendations for the initial management of penetrating trauma? A preliminary analysis from a Colombian institutional registry
Keywords:
Mortality, Tranexamic acid, Blood coagulation disorders, Multiple trauma, Abdomen
Abstract
Introduction: To achieve minimal physiological goals in patients with penetrating thoracoabdominal trauma (TAPT) is essential to ensure adequate outcomes.
Objectives: To determine the success in meting basic standards at the end of damage control surgery in subjects with TAPT: (1) Monitoring and prevention of hyperfibrinolysis; (2) central temperature >35 °C; (3) platelet count >50,000/mm3 and serum fibrinogen >150mg/dl; (4) hemoglobin levels >7.5 mg/dl and base deficit <6.
Methods: Subjects >18 years old undergoing damage control surgery as a result of TAPT were prospectively collected at a referral center between October Oct-2012 and Dec-2014. Comparisons were done according to the Injury Severity Score (ISS) with a severity value indicator of >25. A p < 0.05 value was considered significant.
Results:106 subjects with TAPT were enrolled. Administration of tranexamic acid was only reported in 52.7% of the patients, particularly in the group with low severity scores [Group ISS < 25 36.3% vs. group ISS > 25 65.8%. OR 3.37 (95% CI 1.2-9.85); p = 0.01]. Although the temperature was reported in 91% of the cases, only 66.2-71.4% reached the recommended goal. Serum fibrinogen was measured in 59.5% of the cases and only 52% met the recommended level. The base deficit values of <6 at the end of surgery were only accomplished in 40-43.8% of the subjects, with a significantly lower probability in the more severe patients [53% vs. 35.9%. OR 2.04 (95% CI 1.2-6.02); p = 0.042].
Conclusions: A considerable proportion of patients with TAPT does not meet the current recommendations at the end of damage control surgery.
References
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28. González Cárdenas VH. Transfusión en trauma. Rev Colomb Anestesiol. 2012;40:287-92.
29. Müller MCA, Balvers K, Binnekade JM, Curry N, Stanworth S, Gaarder C, et al. Thromboelastometry an organ failure in trauma patients: a prospective cohort study. Crit Care. 2014;18:687.
30. Hunt H, Stanworth S, Curry N, Woolley T, Cooper C, Ukoumunne O, et al. Thromboelastography (TEG) and rotational thromboelastometry (ROTEM) for trauma induced coagulopathy in adult trauma patients with bleeding. Cochrane Database Syst Rev. 2015:CD010438.
31. Da Luz LT, Nascimento B, Shankarakutty AK, Rizoli S, Adhikari NK. Effect of thromboelastography (TEG ) and rotational thromboelastometry (ROTEM ) on diagnosis of coagulopathy, transfusion guidance and mortality in trauma: descriptive systematic review. Crit Care. 2014;18:518.
32. Schlimp CJ, Khadem A, Klotz A, Solomon C, Hochleitner G, Ponschab M, et al. Rapid measurement of fibrinogen concentration in whole blood using a steel ball coagulometer. J Trauma Acute Care Surg. 2015;78:830-6.
33. Ogawa S, Tanaka KA, Nakajima Y, Nakayama Y, Takeshita J, Arai M, et al. Fibrinogen measurements in plasma and whole blood: a performance evaluation study of the dry-hematology system. Anesth Analg. 2015;120:18-25.
34. Rossaint R, Bouillon B, Cerny V, Coats TJ, Duranteau J, Fernández-Mondéjar E, et al. The European guideline on management of major bleeding and coagulopathy following trauma: fourth edition. Crit Care. 2016;20:100.
35. Holcomb JB, del Junco DJ, Fox EE, Wade CE, Cohen MJ, Schreiber MA, et al. The prospective, observational, multicenter, major trauma transfusion (PROMMTT) study: comparative effectiveness of a time-varying treatment with competing risks. JAMA Surg. 2013;148:127-36.
2. Cause-specific mortality and morbidity. World Health Organization; 2009. p. 47-57. Available from: http://www.who.int/whosis/whostat/EN_WHS09_Table2.pdf.
3. Sørensen B, Larsen OH, Rea CJ, Tang M, Foley JH, Fenger-Eriksen C. Fibrinogen as a hemostatic agent. Semin Thromb Hemost. 2012;38:268-73.
4. Wang HE, Callaway CW, Peitzman AB, Tisherman SA. Admission hypothermia and outcome after major trauma. Crit Care Med. 2005;33:1296-301.
5. Spivey M, Parr MJ. Therapeutic approaches in trauma-induced coagulopathy. Minerva Anestesiol. 2005;71:281-9.
6. Hoyt DB, Bulger EM, Knudson MM, Morris J, Ierardi R, Sugerman HJ, et al. Death in the operating room: an analysis of a multi-center experience. J Trauma. 1994;37:426-32.
7. Curry N, Stanworth S, Hopewell S, Dorée C, Brohi K, Hyde C. Trauma-induced coagulopathy-a review of the systematic reviews: is there sufficient evidence to guide clinical transfusion practice? Transfus Med Rev. 2011;25:217-31, e2.
8. Egea-Guerrero JJ, Freire-Aragón MD, Serrano-Lázaro A, Quintana-Díaz M, Grupo de Trabajo de Trauma y Neurointensivismo de SEMICYUC. Resuscitative goals and new strategies in severe trauma patient resuscitation. Med Intensiva. 2014;38:502-12.
9. Schöchl H, Grassetto A, Schlimp CJ. Management of hemorrhage in trauma. J Cardiothorac Vasc Anesth. 2013;27 Suppl:S35-43.
10. Spahn DR. TEG®- or ROTEM®-based individualized goal-directed coagulation algorithms: don't wait-act now! Crit Care. 2014;18:637.
11. Baker SP, O'Neill B, Haddon W Jr, Long WB. The injury severity score: a method for describing patients with multiple injuries and evaluating emergency care. J Trauma. 1974;14:187-96.
12. Gillman LM, Ball CG, Panebianco N, Al-Kadi A, Kirkpatrick AW. Clinician performed resuscitative ultrasonography for the initial evaluation and resuscitation of trauma. Scand J Trauma Resusc Emerg Med. 2009;17:34.
13. Johnson JW, Gracias VH, Schwab CW, Reilly PM, Kauder DR, Shapiro MB, et al. Evolution in damage control for exsanguinating penetrating abdominal injury. J Trauma. 2001;51:261-9, discussion 269-71.
14. Nunez TC, Voskresensky IV, Dossett LA, Shinall R, Dutton WD, Cotton BA. Early prediction of massive transfusion in trauma: simple as ABC (assessment of blood consumption)? J Trauma. 2009;66:346-52.
15. Mitra B, Rainer TH, Cameron PA. Predicting massive blood transfusion using clinical scores post-trauma. Vox Sang. 2012;102:324-30.
16. CRASH-2 trial collaboratorsShakur H, Roberts I, Bautista R, Caballero J, Coats T, et al. Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage (CRASH-2): a randomised, placebo-controlled trial. Lancet. 2010;376:23-32.
17. Sihler KC, Napolitano LM. Massive transfusion: new insights. Chest. 2009;136:1654-67.
18. Kutcher ME, Howard BM, Sperry JL, Hubbard AE, Decker AL, Cuschieri J, et al. Evolving beyond the vicious triad: differential mediation of traumatic coagulopathy by injury, shock, and resuscitation. J Trauma Acut Care Surg. 2015;78:516-23.
19. Simmons JW, Pittet JF, Pierce B. Trauma-induced coagulopathy. Curr Anesthesiol Rep. 2014;4:189-99.
20. Newgard CD, Meier EN, McKnight B, Drennan IR, Richardson D, Brasel K, et al. Understanding traumatic shock: out-of-hospital hypotension with and without other physiologic compromise. J Trauma Acute Care Surg. 2015;78:342-51.
21. Dunne JR, Tracy JK, Scalea TM, Napolitano LM. Lactate and base deficit in trauma: does alcohol or drug use impair their predictive accuracy? J Trauma. 2005;58:959-66.
22. Cheddie S, Muckart DJJ, Hardcastle TC. Base deficit as an early marker of coagulopathy in trauma. S Afr J Surg. 2013;51:88-90.
23. Martin MJ, FitzSullivan E, Salim A, Brown CVR, Demetriades D, Long W.Discordance between lactate and base deficit in the surgical intensive care unit: which one do you trust? Am J Surg. 2006;191:625-30.
24. Polderman KH, Varon J. Do not drown the patient: appropriate fluid management in critical illness. Am J Emerg Med. 2015;33:448-50.
25. Dutton RP. Management of traumatic haemorrhage-the US perspective. Anaesthesia. 2015;70 Suppl 1:108-11, e38.
26. Levy JH, Goodnough LT. How I use fibrinogen replacement therapy in acquired bleeding. Blood. 2015;125:1387-93.
27. Moore HB, Moore EE, Gonzalez E, Chapman MP, Chin TL, Silliman CC, et al. Hyperfibrinolysis, physiologic fibrinolysis, and fibrinolysis shutdown: the spectrum of postinjury fibrinolysis and relevance to antifibrinolytic therapy. J Trauma Acute Care Surg. 2014;77:811-7, discussion 817.
28. González Cárdenas VH. Transfusión en trauma. Rev Colomb Anestesiol. 2012;40:287-92.
29. Müller MCA, Balvers K, Binnekade JM, Curry N, Stanworth S, Gaarder C, et al. Thromboelastometry an organ failure in trauma patients: a prospective cohort study. Crit Care. 2014;18:687.
30. Hunt H, Stanworth S, Curry N, Woolley T, Cooper C, Ukoumunne O, et al. Thromboelastography (TEG) and rotational thromboelastometry (ROTEM) for trauma induced coagulopathy in adult trauma patients with bleeding. Cochrane Database Syst Rev. 2015:CD010438.
31. Da Luz LT, Nascimento B, Shankarakutty AK, Rizoli S, Adhikari NK. Effect of thromboelastography (TEG ) and rotational thromboelastometry (ROTEM ) on diagnosis of coagulopathy, transfusion guidance and mortality in trauma: descriptive systematic review. Crit Care. 2014;18:518.
32. Schlimp CJ, Khadem A, Klotz A, Solomon C, Hochleitner G, Ponschab M, et al. Rapid measurement of fibrinogen concentration in whole blood using a steel ball coagulometer. J Trauma Acute Care Surg. 2015;78:830-6.
33. Ogawa S, Tanaka KA, Nakajima Y, Nakayama Y, Takeshita J, Arai M, et al. Fibrinogen measurements in plasma and whole blood: a performance evaluation study of the dry-hematology system. Anesth Analg. 2015;120:18-25.
34. Rossaint R, Bouillon B, Cerny V, Coats TJ, Duranteau J, Fernández-Mondéjar E, et al. The European guideline on management of major bleeding and coagulopathy following trauma: fourth edition. Crit Care. 2016;20:100.
35. Holcomb JB, del Junco DJ, Fox EE, Wade CE, Cohen MJ, Schreiber MA, et al. The prospective, observational, multicenter, major trauma transfusion (PROMMTT) study: comparative effectiveness of a time-varying treatment with competing risks. JAMA Surg. 2013;148:127-36.
How to Cite
1.
Ariza F, Sánchez BE, García AF, Raffán-Sanabria F, Quintana-Díaz M, Mejía-Mantilla JH. Are we meeting current recommendations for the initial management of penetrating trauma? A preliminary analysis from a Colombian institutional registry. Colomb. J. Anesthesiol. [Internet]. 2017 Jan. 1 [cited 2024 Jul. 2];45(1):39-45. Available from: https://www.revcolanest.com.co/index.php/rca/article/view/45
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2017-01-01
How to Cite
1.
Ariza F, Sánchez BE, García AF, Raffán-Sanabria F, Quintana-Díaz M, Mejía-Mantilla JH. Are we meeting current recommendations for the initial management of penetrating trauma? A preliminary analysis from a Colombian institutional registry. Colomb. J. Anesthesiol. [Internet]. 2017 Jan. 1 [cited 2024 Jul. 2];45(1):39-45. Available from: https://www.revcolanest.com.co/index.php/rca/article/view/45
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