Hemostatic Resuscitation in Children.
TL;DR: The following selection of important publications address the current state of hemostatic resuscitation strategies in pediatric trauma patients as well as the remaining knowledge gaps and areas for further research.
About: This article is published in Transfusion Medicine Reviews.The article was published on 2021-08-26. It has received 2 citations till now. The article focuses on the topics: Resuscitation & Tranexamic acid.
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01 Sep 2022
TL;DR: In this article , a review of the general rules of paediatric anaesthesia practice for paediatric orthopaedic emergency anaesthesia management before specifying the different modalities specific to each case is presented.
Abstract: Les urgences orthopédiques pédiatriques regroupent principalement les lésions traumatiques et les infections ostéo-articulaires. La prise en charge de ces enfants nécessite une intervention chirurgicale, le plus souvent sous anesthésie générale. La majorité de ces urgences sont différables de quelques heures à quelques jours, ce qui permet d’optimiser le circuit de prise en charge (ambulatoire, en journée, équipe dédiée), tout en diminuant les risques anesthésiques et l’anxiété du patient et de ses parents. L’anesthésie pédiatrique reste une discipline anxiogène pour les anesthésistes. Sur le plan physiologique, on peut distinguer les enfants prépubères et les enfants post-pubères pour lesquels les prises en charge anesthésique et orthopédique rejoignent celles de l’adulte, quel que soit l’âge. Ainsi, dans cette mise au point, nous allons détailler les règles générales de la pratique de l’anesthésie pédiatrique pour la prise en charge anesthésique d’urgence orthopédique pédiatrique avant de préciser les différentes modalités spécifiques à chaque cas. Paediatric orthopaedic emergencies mainly include traumatic injuries and osteoarticular infections. The management of these children requires a surgical intervention with a general anaesthesia most often. The majority of these emergencies can be delayed from a few hours to a few days, which makes it possible to optimise the management (ambulatory, daytime, dedicated team) and to reduce the anaesthetic risks and the anxiety of the patient and his parents. Paediatric anaesthesia remains an anxiety-provoking discipline for anaesthesiologists. From a physiological point of view, a distinction can be made between pre-pubertal and post-pubertal children for whom the anaesthetic and orthopaedic management is the same as for adults, whatever their age. Thus, in this review, we will detail the general rules of paediatric anaesthesia practice for paediatric orthopaedic emergency anaesthesia management before specifying the different modalities specific to each case.
TL;DR: In this paper , the authors explored whether this phenomenon could be associated with an impact on factor VIII and IX levels in a mouse model using coagulation assays, Western blot analysis and immuno-staining.
Abstract: The most common clinical presentation of hemophilia A and hemophilia B is bleeding in large joints and striated muscles. It is unclear why bleeding has a predilection to affect joints and muscles. As muscles and joints are involved in intermittent movement, we explored whether this phenomenon could be associated with an impact on factor VIII and IX levels. Purified proteins and a mouse model were assessed using coagulation assays, Western blot analysis and immuno-staining. Movement caused an increase in thrombin activity and a decrease in factor VIII and factor IX activity. The decrease in factor VIII activity was more significant in the presence of thrombin and during movement. Under movement condition, sodium ions appeared to enhance the activity of thrombin that resulted in decreased factor VIII activity. Unlike factor VIII, the reduction in factor IX levels in the movement condition was thrombin-independent. High factor VIII levels were found to protect factor IX from degradation and vice versa. In mice that were in movement, factor VIII and IX levels decreased in the microcirculation of the muscle tissue compared with other tissues and to the muscle tissue at rest. Movement had no effect on von Willebrand factor levels. Movement induces reduction in factor VIII and IX levels. It enables an increase in the binding of sodium ions to thrombin leading to enhanced thrombin activity and augmented degradation of factor VIII. These data suggest a potential mechanism underlying the tendency of hemophilia patients to bleed in muscles and joints.
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TL;DR: Tranexamic acid safely reduced the risk of death in bleeding trauma patients in this study, and should be considered for use in bleed trauma patients.
2,557 citations
University of Texas Health Science Center at Houston1, Medical College of Wisconsin2, Oregon Health & Science University3, University of Washington4, University of California, San Francisco5, University of Tennessee Health Science Center6, University of Southern California7, University of Alabama at Birmingham8, University of Cincinnati9, University of Arizona10, University of Toronto11, University of Maryland, Baltimore12, Sunnybrook Health Sciences Centre13, American College of Surgeons14, National Institutes of Health15
TL;DR: In this article, the effectiveness and safety of transfusing patients with severe trauma and major bleeding using plasma, platelets, and red blood cells in a 1:1:1 ratio compared with a 1 :1:2 ratio was evaluated.
Abstract: Importance Severely injured patients experiencing hemorrhagic shock often require massive transfusion. Earlier transfusion with higher blood product ratios (plasma, platelets, and red blood cells), defined as damage control resuscitation, has been associated with improved outcomes; however, there have been no large multicenter clinical trials. Objective To determine the effectiveness and safety of transfusing patients with severe trauma and major bleeding using plasma, platelets, and red blood cells in a 1:1:1 ratio compared with a 1:1:2 ratio. Design, Setting, and Participants Pragmatic, phase 3, multisite, randomized clinical trial of 680 severely injured patients who arrived at 1 of 12 level I trauma centers in North America directly from the scene and were predicted to require massive transfusion between August 2012 and December 2013. Interventions Blood product ratios of 1:1:1 (338 patients) vs 1:1:2 (342 patients) during active resuscitation in addition to all local standard-of-care interventions (uncontrolled). Main Outcomes and Measures Primary outcomes were 24-hour and 30-day all-cause mortality. Prespecified ancillary outcomes included time to hemostasis, blood product volumes transfused, complications, incidence of surgical procedures, and functional status. Results No significant differences were detected in mortality at 24 hours (12.7% in 1:1:1 group vs 17.0% in 1:1:2 group; difference, −4.2% [95% CI, −9.6% to 1.1%]; P = .12) or at 30 days (22.4% vs 26.1%, respectively; difference, −3.7% [95% CI, −10.2% to 2.7%]; P = .26). Exsanguination, which was the predominant cause of death within the first 24 hours, was significantly decreased in the 1:1:1 group (9.2% vs 14.6% in 1:1:2 group; difference, −5.4% [95% CI, −10.4% to −0.5%]; P = .03). More patients in the 1:1:1 group achieved hemostasis than in the 1:1:2 group (86% vs 78%, respectively; P = .006). Despite the 1:1:1 group receiving more plasma (median of 7 U vs 5 U, P P Conclusions and Relevance Among patients with severe trauma and major bleeding, early administration of plasma, platelets, and red blood cells in a 1:1:1 ratio compared with a 1:1:2 ratio did not result in significant differences in mortality at 24 hours or at 30 days. However, more patients in the 1:1:1 group achieved hemostasis and fewer experienced death due to exsanguination by 24 hours. Even though there was an increased use of plasma and platelets transfused in the 1:1:1 group, no other safety differences were identified between the 2 groups. Trial Registration clinicaltrials.gov Identifier:NCT01545232
1,643 citations
TL;DR: There is a common and clinically important acute traumatic coagulopathy that is not related to fluid administration that is related to mortality and a coagulation screen is an important early test in severely injured patients.
Abstract: Background:Traumatic coagulopathy is thought to be caused primarily by fluid administration and hypothermia.Methods:A retrospective study was performed to determine whether coagulopathy resulting from the injury itself is a clinically important entity in severely injured patients.Results:One thousan
1,428 citations
University of Texas Health Science Center at Houston1, University of California, San Francisco2, Oregon Health & Science University3, University of Pittsburgh4, Medical College of Wisconsin5, University of Washington6, University of Cincinnati7, University of Texas Health Science Center at San Antonio8, University of Texas Southwestern Medical Center9, San Antonio Military Medical Center10
TL;DR: Higher plasma and platelet ratios early in resuscitation were associated with decreased mortality in patients who received transfusions of at least 3 units of blood products during the first 24 hours after admission, and among survivors at 24 hours, the subsequent risk of death by day 30 was not associated with plasma or Platelet ratios.
Abstract: Objective To relate in-hospital mortality to early transfusion of plasma and/or platelets and to time-varying plasma:red blood cell (RBC) and platelet:RBC ratios. Design Prospective cohort study documenting the timing of transfusions during active resuscitation and patient outcomes. Data were analyzed using time-dependent proportional hazards models. Setting Ten US level I trauma centers. Patients Adult trauma patients surviving for 30 minutes after admission who received a transfusion of at least 1 unit of RBCs within 6 hours of admission (n = 1245, the original study group) and at least 3 total units (of RBCs, plasma, or platelets) within 24 hours (n = 905, the analysis group). Main Outcome Measure In-hospital mortality. Results Plasma:RBC and platelet:RBC ratios were not constant during the first 24 hours (P Conclusions Higher plasma and platelet ratios early in resuscitation were associated with decreased mortality in patients who received transfusions of at least 3 units of blood products during the first 24 hours after admission. Among survivors at 24 hours, the subsequent risk of death by day 30 was not associated with plasma or platelet ratios.
843 citations
TL;DR: The use of TXA with blood component-based resuscitation following combat injury results in improved measures of coagulopathy and survival, a benefit that is most prominent in patients requiring massive transfusion.
Abstract: Objectives To characterize contemporary use of tranexamic acid (TXA) in combat injury and to assess the effect of its administration on total blood product use, thromboembolic complications, and mortality. Design Retrospective observational study comparing TXA administration with no TXA in patients receiving at least 1 unit of packed red blood cells. A subgroup of patients receiving massive transfusion (≥10 units of packed red blood cells) was also examined. Univariate and multivariate regression analyses were used to identify parameters associated with survival. Kaplan-Meier life tables were used to report survival. Setting A Role 3 Echelon surgical hospital in southern Afghanistan. Patients A total of 896 consecutive admissions with combat injury, of which 293 received TXA, were identified from prospectively collected UK and US trauma registries. Main Outcome Measures Mortality at 24 hours, 48 hours, and 30 days as well as the influence of TXA administration on postoperative coagulopathy and the rate of thromboembolic complications. Results The TXA group had lower unadjusted mortality than the no-TXA group (17.4% vs 23.9%, respectively; P = .03) despite being more severely injured (mean [SD] Injury Severity Score, 25.2 [16.6] vs 22.5 [18.5], respectively; P Conclusions The use of TXA with blood component–based resuscitation following combat injury results in improved measures of coagulopathy and survival, a benefit that is most prominent in patients requiring massive transfusion. Treatment with TXA should be implemented into clinical practice as part of a resuscitation strategy following severe wartime injury and hemorrhage.
652 citations