Impact of Policy Change on US Army Combat Transfusion Practices

United States Army Institute of Surgical Research, Fort Sam Houston, Texas 78234, USA.
The Journal of trauma (Impact Factor: 2.96). 07/2010; 69 Suppl 1(Supplement):S75-80. DOI: 10.1097/TA.0b013e3181e44952
Source: PubMed


BACKGROUND: Clinical practice guidelines (CPGs) are used to keep providers up-to-date with the most recent literature and to guide in decision making. Adherence is typically improved although many have a muted impact. In March 2006, the US Army issued a damage control resuscitation CPG, encouraging 1:1 plasma:red blood cell (RBC) transfusions and limiting crystalloid use. The objective of this study was to determine whether the CPG was associated with a change in the transfusion practices in combat-wounded patients.

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    • "The MTP published by Dirks et al. resulted in a significant increase in PC transfusion without any improvement in the survival rate [55]. Similar results were reported by Simmons et al., who observed that the introduction of new clinical practice guidelines forcing early platelet transfusion resulted in no survival benefit [54]. Thus, platelet transfusion in a fixed predefined ratio carries the potential for wasting valuable resources and the risk of complications (e.g. "
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    ABSTRACT: Severe trauma-related bleeding is associated with high mortality. Standard coagulation tests provide limited information on the underlying coagulation disorder. Whole-blood viscoelastic tests such as rotational thromboelastometry or thrombelastography offer a more comprehensive insight into the coagulation process in trauma. The results are available within minutes and they provide information about the initiation of coagulation, the speed of clot formation, and the quality and stability of the clot. Viscoelastic tests have the potential to guide coagulation therapy according to the actual needs of each patient, reducing the risks of over- or under-transfusion. The concept of early, individualized and goal-directed therapy is explored in this review and the AUVA Trauma Hospital algorithm for managing trauma-induced coagulopathy is presented.
    Scandinavian Journal of Trauma Resuscitation and Emergency Medicine 02/2012; 20(1):15. DOI:10.1186/1757-7241-20-15 · 2.03 Impact Factor
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    • "Development of early coagulopathy after trauma is an independent predictor of poor outcome. Growing recognition of early coagulopathy after injury has led to renewed emphasis on early blood product administration in the injured patient with bleeding[101,102]. "
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    ABSTRACT: There is renewed interest in blood product use for resuscitation stimulated by recent military experience and growing recognition of the limitations of large-volume crystalloid resuscitation. An editorial review of recent reports published by investigators from the United States and Europe is presented. There is little prospective data in this area. Despite increasing sophistication of trauma care systems, hemorrhage remains the major cause of early death after injury. In patients receiving massive transfusion, defined as 10 or more units of packed red blood cells in the first 24 hours after injury, administration of plasma and platelets in a ratio equivalent to packed red blood cells is becoming more common. There is a clear possibility of time dependent enrollment bias. The early use of multiple types of blood products is stimulated by the recognition of coagulopathy after reinjury which may occur as many as 25% of patients. These patients typically have large-volume tissue injury and are acidotic. Despite early enthusiasm, the value of administration of recombinant factor VIIa is now in question. Another dilemma is monitoring of appropriate component administration to control coagulopathy. In patients requiring large volumes of blood products or displaying coagulopathy after injury, it appears that early and aggressive administration of blood component therapy may actually reduce the aggregate amount of blood required. If recombinant factor VIIa is given, it should be utilized in the fully resuscitated patient. Thrombelastography is seeing increased application for real-time assessment of coagulation changes after injury and directed replacement of components of the clotting mechanism.
    Scandinavian Journal of Trauma Resuscitation and Emergency Medicine 11/2010; 18(1):63. DOI:10.1186/1757-7241-18-63 · 2.03 Impact Factor
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    ABSTRACT: Platelets play a central role in coagulation. Currently, information on platelet function following trauma is limited. We performed a retrospective analysis of patients admitted to the emergency room (ER) at the AUVA Trauma Centre, Salzburg, after sustaining traumatic injury. Immediately after admission to the ER, blood was drawn for blood cell counts, standard coagulation tests, and platelet function testing. Platelet function was assessed by multiplate electrode aggregometry (MEA) using adenosine diphosphate (ADPtest), collagen (COLtest) and thrombin receptor activating peptide-6 (TRAPtest) as activators. The thromboelastometric platelet component, measuring the contribution of platelets to the elasticity of the whole-blood clot, was assessed using the ROTEM device. The study included 163 patients, 79.7% were male, and the median age was 43 years. The median injury severity score was 18. Twenty patients (12.3%) died. Median platelet count was significantly lower among non-survivors than survivors (181,000/μl vs. 212,000/μl; p=0.01). Although platelet function defects were relatively minor, significant differences between survivors and non-survivors were observed in the ADPtest (94 vs. 79 U; p=0.0019), TRAPtest (136 vs. 115 U; p<0.0001), and platelet component (134 vs.103 MCEEXTEM - MCEFIBTEM; p=0.0012). Aggregometry values below the normal range for ADPtest and TRAPtest were significantly more frequent in non-survivors than in survivors (p=0.0017 and p=0.0002, respectively). Minor decreases in platelet function upon admission to the ER were a sign of coagulopathy accompanying increased mortality in patients with trauma. Further studies are warranted to confirm these results and investigate the role of platelet function in trauma haemostatic management.
    Thrombosis and Haemostasis 06/2011; 106(2):322-30. DOI:10.1160/TH11-03-0175 · 4.98 Impact Factor
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