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Evaluation of Prehospital Blood Products to Attenuate Acute Coagulopathy of Trauma in a Model of Severe Injury and Shock in Anesthetized Pigs.

Watts S, Nordmann G, Brohi K, Midwinter M, Woolley T, Gwyther R, Wilson C, Poon H, Kirkman E - Shock (2015)

Bottom Line: Emergent clinical practice has started prehospital deployment of blood products (combined packed red blood cells and fresh frozen plasma [PRBCs:FFP], and alternatively PRBCs alone), but this is associated with significant logistical burden and some clinical risk.It is therefore imperative to establish whether prehospital use of blood products is likely to confer benefit.Furthermore, the amount of crystalloid may be reduced with potential benefit of reducing the extravasation effect and later tissue edema.

View Article: PubMed Central - PubMed

Affiliation: *CBR Division, Defence Science and Technology Laboratory, Defence Science and Technology Laboratory, Porton Down, Salisbury; †Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London; and ‡University of Birmingham, Birmingham, United Kingdom.

ABSTRACT
Acute trauma coagulopathy (ATC) is seen in 30% to 40% of severely injured casualties. Early use of blood products attenuates ATC, but the timing for optimal effect is unknown. Emergent clinical practice has started prehospital deployment of blood products (combined packed red blood cells and fresh frozen plasma [PRBCs:FFP], and alternatively PRBCs alone), but this is associated with significant logistical burden and some clinical risk. It is therefore imperative to establish whether prehospital use of blood products is likely to confer benefit. This study compared the potential impact of prehospital resuscitation with (PRBCs:FFP 1:1 ratio) versus PRBCs alone versus 0.9% saline (standard of care) in a model of severe injury. Twenty-four terminally anesthetised Large White pigs received controlled soft tissue injury and controlled hemorrhage (35% blood volume) followed by a 30-min shock phase. The animals were allocated randomly to one of three treatment groups during a 60-min prehospital evacuation phase: hypotensive resuscitation (target systolic arterial pressure 80 mmHg) using either 0.9% saline (group 1, n = 9), PRBCs:FFP (group 2, n = 9), or PRBCs alone (group 3, n = 6). Following this phase, an in-hospital phase involving resuscitation to a normotensive target (110 mmHg systolic arterial blood pressure) using PRBCs:FFP was performed in all groups. There was no mortality in any group. A coagulopathy developed in group 1 (significant increase in clot initiation and dynamics shown by TEG [thromboelastography] R and K times) that persisted for 60 to 90 min into the in-hospital phase. The coagulopathy was significantly attenuated in groups 2 and 3 (P = 0.025 R time and P = 0.035 K time), which were not significantly different from each other. Finally, the volumes of resuscitation fluid required was significantly greater in group 1 compared with groups 2 and 3 (P = 0.0067) (2.8 ± 0.3 vs. 1.9 ± 0.2 and 1.8 ± 0.3 L, respectively). This difference was principally due to a greater volume of saline used in group 1 (P = 0.001). Prehospital PRBCs:FFP or PRBCs alone may therefore attenuate ATC. Furthermore, the amount of crystalloid may be reduced with potential benefit of reducing the extravasation effect and later tissue edema.

No MeSH data available.


Related in: MedlinePlus

Effects of tissue injury, hemorrhagic shock, and resuscitation on OER, arterial oxygen content (Cao2), and mixed venous oxygen content (Cvo2) in three treatment groups. For more details, see legend to Figures 1 and 2. Mean values ± SEM.
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Figure 7: Effects of tissue injury, hemorrhagic shock, and resuscitation on OER, arterial oxygen content (Cao2), and mixed venous oxygen content (Cvo2) in three treatment groups. For more details, see legend to Figures 1 and 2. Mean values ± SEM.

Mentions: The degree of shock was evaluated by measuring changes in arterial base excess and lactate levels (Fig. 6). During hemorrhagic shock, there was a marked clinically and statistically significant fall in arterial ABE (P < 0.0001) and a rise in arterial lactate (P < 0.0001), without any significant difference between groups (P = 0.7787 and P = 0.8300, respectively). This was associated with a significant elevation in whole-body oxygen extraction ratio (OER; Fig. 7) from normal preinjury baseline levels in the range 0.25 to 0.30 to theoretical maximal levels in the range 0.78 to 0.80 (P < 0.0001). There were no significant differences in OER between groups (P = 0.254; Fig. 7). The high levels of OER persisted in all groups throughout the prehospital phase, whereas base excess continued to fall and lactate rose (P < 0001 and P < 0.0001). There was a trend for ABE to reach its nadir and lactate to reach its peak in group 2, whereas these variables continued to deteriorate in the other two groups; however, there were no significant differences between groups for either ABE (P = 0.3937) or lactate (P = 0.4330). Throughout the in-hospital phase, the trend for less negative ABE and lower lactate in group 2 persisted, although again this was not statistically significant (P = 0.1483 and P = 0.4720, respectively).


Evaluation of Prehospital Blood Products to Attenuate Acute Coagulopathy of Trauma in a Model of Severe Injury and Shock in Anesthetized Pigs.

Watts S, Nordmann G, Brohi K, Midwinter M, Woolley T, Gwyther R, Wilson C, Poon H, Kirkman E - Shock (2015)

Effects of tissue injury, hemorrhagic shock, and resuscitation on OER, arterial oxygen content (Cao2), and mixed venous oxygen content (Cvo2) in three treatment groups. For more details, see legend to Figures 1 and 2. Mean values ± SEM.
© Copyright Policy
Related In: Results  -  Collection

Show All Figures
getmorefigures.php?uid=PMC4498650&req=5

Figure 7: Effects of tissue injury, hemorrhagic shock, and resuscitation on OER, arterial oxygen content (Cao2), and mixed venous oxygen content (Cvo2) in three treatment groups. For more details, see legend to Figures 1 and 2. Mean values ± SEM.
Mentions: The degree of shock was evaluated by measuring changes in arterial base excess and lactate levels (Fig. 6). During hemorrhagic shock, there was a marked clinically and statistically significant fall in arterial ABE (P < 0.0001) and a rise in arterial lactate (P < 0.0001), without any significant difference between groups (P = 0.7787 and P = 0.8300, respectively). This was associated with a significant elevation in whole-body oxygen extraction ratio (OER; Fig. 7) from normal preinjury baseline levels in the range 0.25 to 0.30 to theoretical maximal levels in the range 0.78 to 0.80 (P < 0.0001). There were no significant differences in OER between groups (P = 0.254; Fig. 7). The high levels of OER persisted in all groups throughout the prehospital phase, whereas base excess continued to fall and lactate rose (P < 0001 and P < 0.0001). There was a trend for ABE to reach its nadir and lactate to reach its peak in group 2, whereas these variables continued to deteriorate in the other two groups; however, there were no significant differences between groups for either ABE (P = 0.3937) or lactate (P = 0.4330). Throughout the in-hospital phase, the trend for less negative ABE and lower lactate in group 2 persisted, although again this was not statistically significant (P = 0.1483 and P = 0.4720, respectively).

Bottom Line: Emergent clinical practice has started prehospital deployment of blood products (combined packed red blood cells and fresh frozen plasma [PRBCs:FFP], and alternatively PRBCs alone), but this is associated with significant logistical burden and some clinical risk.It is therefore imperative to establish whether prehospital use of blood products is likely to confer benefit.Furthermore, the amount of crystalloid may be reduced with potential benefit of reducing the extravasation effect and later tissue edema.

View Article: PubMed Central - PubMed

Affiliation: *CBR Division, Defence Science and Technology Laboratory, Defence Science and Technology Laboratory, Porton Down, Salisbury; †Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London; and ‡University of Birmingham, Birmingham, United Kingdom.

ABSTRACT
Acute trauma coagulopathy (ATC) is seen in 30% to 40% of severely injured casualties. Early use of blood products attenuates ATC, but the timing for optimal effect is unknown. Emergent clinical practice has started prehospital deployment of blood products (combined packed red blood cells and fresh frozen plasma [PRBCs:FFP], and alternatively PRBCs alone), but this is associated with significant logistical burden and some clinical risk. It is therefore imperative to establish whether prehospital use of blood products is likely to confer benefit. This study compared the potential impact of prehospital resuscitation with (PRBCs:FFP 1:1 ratio) versus PRBCs alone versus 0.9% saline (standard of care) in a model of severe injury. Twenty-four terminally anesthetised Large White pigs received controlled soft tissue injury and controlled hemorrhage (35% blood volume) followed by a 30-min shock phase. The animals were allocated randomly to one of three treatment groups during a 60-min prehospital evacuation phase: hypotensive resuscitation (target systolic arterial pressure 80 mmHg) using either 0.9% saline (group 1, n = 9), PRBCs:FFP (group 2, n = 9), or PRBCs alone (group 3, n = 6). Following this phase, an in-hospital phase involving resuscitation to a normotensive target (110 mmHg systolic arterial blood pressure) using PRBCs:FFP was performed in all groups. There was no mortality in any group. A coagulopathy developed in group 1 (significant increase in clot initiation and dynamics shown by TEG [thromboelastography] R and K times) that persisted for 60 to 90 min into the in-hospital phase. The coagulopathy was significantly attenuated in groups 2 and 3 (P = 0.025 R time and P = 0.035 K time), which were not significantly different from each other. Finally, the volumes of resuscitation fluid required was significantly greater in group 1 compared with groups 2 and 3 (P = 0.0067) (2.8 ± 0.3 vs. 1.9 ± 0.2 and 1.8 ± 0.3 L, respectively). This difference was principally due to a greater volume of saline used in group 1 (P = 0.001). Prehospital PRBCs:FFP or PRBCs alone may therefore attenuate ATC. Furthermore, the amount of crystalloid may be reduced with potential benefit of reducing the extravasation effect and later tissue edema.

No MeSH data available.


Related in: MedlinePlus