06 Jul 09

Procalcitonin as a prognostic and diagnostic tool for septic complications after major trauma

Posted in Procalcitonin, Trauma at 16:18 by Laci

By G Castelli, C Pognani, M Cita, R Paladini

Critical Care Medicine 2009;37:1845-1849

The primary aim of this study was to investigate the diagnostic value of procalcitonin (PCT) and C-reactive protein (CRP) in septic complications after major trauma. A secondary aim was to determine whether there was a prognostic value of PCT for severity of injury, organ dysfunction, and sepsis.

Design
Prospective study.

Setting
Medical/surgical intensive care unit (ICU).

Patients
Ninety-four patients with consecutive trauma >=16 years who were admitted to the ICU for an expected stay of >24 hours.

Interventions
None.

Measurements
PCT and CRP were collected at admission and every day thereafter. The American College of Chest Physicians/Society of Critical Care Medicine Consensus Conference definition was used to identify sepsis criteria. The Sequential Organ Failure Assessment score was used to describe the severity of organ dysfunction. We retrospectively analyzed the occurrence of systemic inflammatory response syndrome and sepsis using the collected variables (criteria fulfilled at least during three continuous days).

Main results
Patients with trauma presented an early and significant increase in PCT at the moment of septic complications compared with concentrations measured 1 day before the diagnosis of sepsis: 0.85 vs. 3.32 ng/mL for PCT (p < 0.001) and 135 vs. 175 mg/L for CRP (p = not significant). The areas under the respective curve at admission in the diagnosis of sepsis were 0.787 (p < 0.001) and 0.489 for PCT and CRP, respectively.

Conclusion

PCT plasma reinduction marks possible septic complication during systemic inflammatory response syndrome after major trauma. In addition, high PCT concentration at admission after trauma in ICU patients indicates an increased risk of septic complications.

10 Oct 08

Early achievement of a 1:1 ratio of FFP:PRBC reduces mortality in patients receiving massive transfusion

Posted in Transfusion medicine, Trauma at 18:13 by Laci

By E A Gonzalez, J jastrow, J B Holcomb, L S Kao, F A Moore, R A Kozar

J Trauma 2008;64:247

We previously demonstrated that uncorrected coagulopathy in patients receiving massive transfusion was associated with increased mortality. Based on these findings we implemented early goal directed therapy beginning at the time of injury to approach an optimal plasma:PRBC ratio of 1:1. The aim of the current study was to evaluate mortality after implementation of this practice.

The ratio of blood products transfused affects mortality in patients receiving massive transfusions at a combat support hospital

Posted in Transfusion medicine, Trauma at 18:13 by Laci

By M A Borgman, P C Spinella, J G Perkins, K W Grathwohl, T Repine, A C Beekley, J Sebesta, D Jenkins et al

J Trauma 2007;63:805-813

Patients with severe traumatic injuries often present with coagulopathy and require massive transfusion. The risk of death from hemorrhagic shock increases in this population. To treat the coagulopathy of trauma, some have suggested early, aggressive correction using a 1:1 ratio of plasma to red blood cell (RBC) units.

Methods
We performed a retrospective chart review of 246 patients at a US Army combat support hospital, each of who received a massive transfusion (>=10 units of RBCs in 24 hours). Three groups of patients were constructed according to the plasma to RBC ratio transfused during massive transfusion. Mortality rates and the cause of death were compared among groups.

Results
For the low ratio group the plasma to RBC median ratio was 1:8 (interquartile range, 0:12–1:5), for the medium ratio group, 1:2.5 (interquartile range, 1:3.0–1:2.3), and for the high ratio group, 1:1.4 (interquartile range, 1:1.7–1:1.2) (p < 0.001). Median Injury Severity Score (ISS) was 18 for all groups (interquartile range, 14–25). For low, medium, and high plasma to RBC ratios, overall mortality rates were 65%, 34%, and 19%, (p < 0.001); and hemorrhage mortality rates were 92.5%, 78%, and 37%, respectively, (p < 0.001). Upon logistic regression, plasma to RBC ratio was independently associated with survival (odds ratio 8.6, 95% confidence interval 2.1–35.2).

Conclusions
In patients with combat-related trauma requiring massive transfusion, a high 1:1.4 plasma to RBC ratio is independently associated with improved survival to hospital discharge, primarily by decreasing death from hemorrhage. For practical purposes, massive transfusion protocols should utilize a 1:1 ratio of plasma to RBCs for all patients who are hypocoagulable with traumatic injuries.

22 Sep 07

Safety of rFVIIa in hemodynamically unstable polytrauma patients with traumatic brain injury

Posted in rFVIIa, Trauma at 18:03 by Laci

By Yoram Kluger, Bruno Riou, Rolf Rossaint, Sandro B Rizoli, Kenneth David Boffard, Philip Iau Tsau Choong, Brian Warren and Michael Tillinger

Critical Care 2007, 11:R85

Trauma is a leading cause of mortality and morbidity, with traumatic brain injury (TBI) and uncontrolled hemorrhage responsible for the majority of these deaths. Recombinant activated factor VIIa (rFVIIa) is being investigated as an adjunctive hemostatic treatment for bleeding refractory to conventional replacement therapy in trauma patients. TBI is a common component of polytrauma injuries. However, the combination of TBI with polytrauma injuries is associated with specific risk factors and treatment modalities somewhat different from those of polytrauma without TBI. Although rFVIIa treatment may offer added potential benefit for patients with combined TBI and polytrauma, its safety in this population has not yet been assessed. We conducted a post hoc sub analysis of patients with TBI and severe blunt polytrauma enrolled into a prospective, international, double-blind, randomized, placebo-controlled study.

Methods
A post hoc analysis of study data was performed for 143 patients with severe blunt trauma enrolled in a prospective, randomized, placebo-controlled study, evaluating the safety and efficacy of intravenous rFVIIa (200 + 100 + 100 μg/kg) or placebo, to identify patients with a computed tomography (CT) diagnosis of TBI. The incidences of ventilator-free days, intensive care unit-free days, and thromboembolic, serious, and adverse events within the 30-day study period were assessed in this cohort.

Results
Thirty polytrauma patients (placebo, n = 13; rFVIIa, n = 17) were identified as having TBI on CT. No significant differences in rates of mortality (placebo, n = 6, 46%, 90% confidence interval (CI): 22% to 71%; rFVIIa, n = 5, 29%, 90% CI: 12% to 56%; P = 0.19), in median numbers of intensive care unit-free days (placebo = 0, rFVIIa = 3; P = 0.26) or ventilator-free days (placebo = 0, rFVIIa = 10; P = 0.19), or in rates of thromboembolic adverse events (placebo, 15%, 90% CI: 3% to 51%; rFVIIa, 0%, 90% CI: 0% to 53%; P = 0.18) or serious adverse events (placebo, 92%, 90% CI: 68% to 98%; rFVIIa, 82%, 90% CI: 60% to 92%; P = 0.61) were observed between treatment groups.

Conclusion
The use of a total dose of 400 (200 + 100 + 100) μg/kg rFVIIa in this group of hemodynamically unstable polytrauma patients with TBI was not associated with an increased risk of mortality or with thromboembolic or adverse events.

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