Does platelet administration affect mortality in elderly head-injured patients taking antiplatelet medications?

Department of Surgery, Wright State University Boonshoft School of Medicine, Dayton, OH 45409, USA.
The American surgeon (Impact Factor: 0.92). 11/2009; 75(11):1100-3.
Source: PubMed

ABSTRACT A significant portion of patients sustaining traumatic brain injury (TBI) take antiplatelet medications (aspirin or clopidogrel), which have been associated with increased morbidity and mortality. In an attempt to alleviate the risk of increased bleeding, platelet transfusion has become standard practice in some institutions. This study was designed to determine if platelet transfusion reduces mortality in patients with TBI on antiplatelet medications. Databases from two Level I trauma centers were reviewed. Patients with TBI 50 years of age or older with documented preinjury use of clopidogrel or aspirin were included in our cohort. Patients who received platelet transfusions were compared with those who did not to assess outcome differences between them. Demographics and other patient characteristics abstracted included Injury Severity Score, Glasgow Coma Scale, hospital length of stay, and warfarin use. Three hundred twenty-eight patients comprised the study group. Of these patients, 166 received platelet transfusion and 162 patients did not. Patients who received platelets had a mortality rate of 17.5 per cent (29 of 166), whereas those who did not receive platelets had a mortality rate of 16.7 per cent (27 of 162) (P = 0.85). Transfusion of platelets in patients with TBI using antiplatelet therapy did not reduce mortality.

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    ABSTRACT: Traumatic brain injuries are common and costly to hospital systems. Most of the guidelines on management of traumatic brain injuries are taken from the Brain Trauma Foundation Guidelines. This is a review of the current literature discussing the evolving practice of traumatic brain injury.
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    ABSTRACT: In recent years, a strong focus has been put on the need to assure early coagulation support in order to prevent and treat coagulopathy in patients with severe trauma, and to improve survival. Aggressive plasma administration with high plasma/ red blood cells ratio is increasingly used worldwide. However, plasma transfusion is associated with increased risks of multiple organ dysfunction syndrome (MODS), adult respiratory distress syndrome (ARDS) and infection, which may prolong hospital stay and the need for artificial ventilation. Moreover, in the majority of European hospitals plasma cannot be immediately available and therefore it has been reported a significant delay in coagulation support. This has lead to the proposal of using clotting factors as an alternative to plasma. However, strong evidence to define the best strategy is still missing, and the only published protocols are Institution-specific, thus depending on the local organization and the available resources. The Italian Trauma Centers Network (TUN) recently developed a treatment protocol aiming at shortening the interval before the onset of coagulation support and at reducing the use of plasma. We present this protocol-Early Coagulation Support (ECS) Protocol -and discuss its rationale. Its implications for the trauma-team workflow and hospital organization are also addressed. The ECS protocol must be considered as an integrated part of a comprehensive Damage Control Strategy. The impact of the ECS Protocol on blood products consumption, trauma mortality and morbidity as well as its financial aspects, will be strictly monitored by the TUN hospitals. Background Haemorrhage is the principal cause of death in the first few hours following severe injury. Coagulopathy is a frequent complication of haemorrhage and may occur in up to 25% of patients, even before hospital admission [1]. In recent years, international guidelines [2] that aim at preventing and treating trauma-induced coagulopathy (TIC), have been developed. However, due to the heterogeneous availability of haemocomponents and clotting factors in different countries and to the lack of sound data in the literature, there is not a widely agreed clinical strategy yet. Moreover, due to the aging population in western countries, elderly people with cardiovascular comorbidities and on antiplatelets agents or oral anticoagulants are increasingly represented. Therefore, a comprehensive protocol to treat the bleeding patients should also include strategies to quickly reverse the effect of these drugs. Any strategy should rapidly tackle acute traumatic coagulo-pathy through the early replacement of clotting factors. Haemostasis is critically dependent on fibrinogen as a substrate for clot formation. Fibrinogen is the single factor which is more and earlier affected in case of TIC. Many bleeding trauma patients with TIC present with a depletion of fibrinogen below levels currently recommended for therapeutic supplementation [2]. In a recent study, hypotension, increasing shock severity (as measured by the base deficit) and high degree of injury (ISS ≥25), were all associated with a reduction in fibrinogen levels [3]. Fibrinogen depletion is associated with poor outcomes and survival improves with the amounts of fibrinogen administered [4]. Plasma has traditionally been used as a source of fibrinogen. However, until few years ago plasma transfusion was not recommended in absence of a prolongation of PT or INR or fibrinogen decrease to less than 1.5 gr/L. More recently, retrospective evidence from both military [5] and civilian [6] practice suggested improved outcomes in patients with massive bleeding after the adoption of a massive-transfusion protocol (MTP), including the early administration of high-dose plasma therapy. Although the first reports based on the military experience suggested a 1:1 plasma/packed red
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