Limits...
Prehospital Blood Product Resuscitation for Trauma: A Systematic Review.

Smith IM, James RH, Dretzke J, Midwinter MJ - Shock (2016)

Bottom Line: No consistent physiological or biochemical benefit was identified, nor was there evidence of reduced in-hospital transfusion requirements.While PHBP resuscitation appears logical, the clinical literature is limited, provides only poor quality evidence, and does not demonstrate improved outcomes.No conclusions as to efficacy can be drawn.

View Article: PubMed Central - PubMed

Affiliation: *NIHR Surgical Reconstruction and Microbiology Research Centre, University of Birmingham †Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, ICT Centre, Edgbaston, Birmingham ‡205 (Scottish) Field Hospital, Govan, Glasgow §Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine, ICT Centre, Edgbaston, Birmingham //East Anglian Air Ambulance, Gambling Close, Norwich ¶Ministry of Defence Hospital Unit Derriford, Derriford Hospital, Plymouth, United Kingdom **Institute of Applied Health Research, University of Birmingham, Edgbaston, Birmingham, United Kingdom.

ABSTRACT

Introduction: Administration of high ratios of plasma to packed red blood cells is a routine practice for in-hospital trauma resuscitation. Military and civilian emergency teams are increasingly carrying prehospital blood products (PHBP) for trauma resuscitation. This study systematically reviewed the clinical literature to determine the extent to which the available evidence supports this practice.

Methods: Bibliographic databases and other sources were searched to July 2015 using keywords and index terms related to the intervention, setting, and condition. Standard systematic review methodology aimed at minimizing bias was used for study selection, data extraction, and quality assessment (protocol registration

Prospero: CRD42014013794). Synthesis was mainly narrative with random effects model meta-analysis limited to mortality outcomes.

Results: No prospective comparative or randomized studies were identified. Sixteen case series and 11 comparative studies were included in the review. Seven studies included mixed populations of trauma and non-trauma patients. Twenty-five of 27 studies provided only very low quality evidence. No association between PHBP and survival was found (OR for mortality: 1.29, 95% CI: 0.84-1.96, P = 0.24). A single study showed improved survival in the first 24 h. No consistent physiological or biochemical benefit was identified, nor was there evidence of reduced in-hospital transfusion requirements. Transfusion reactions were rare, suggesting the short-term safety of PHBP administration.

Conclusions: While PHBP resuscitation appears logical, the clinical literature is limited, provides only poor quality evidence, and does not demonstrate improved outcomes. No conclusions as to efficacy can be drawn. The results of randomized controlled trials are awaited.

No MeSH data available.


Related in: MedlinePlus

Forest plot of adjusted mortality.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
getmorefigures.php?uid=PMC4933578&req=5

Figure 4: Forest plot of adjusted mortality.

Mentions: Long-term mortality among PHBP recipients varied from 8% to 52% (Fig. 2A). This analysis included unpublished absolute survival data for one cohort study (35-i) (J. Brown. 2015, pers. comm. June 08). One study reported 67% mortality among six subjects, but was excluded from analysis due to 60% loss to follow-up (15). Early studies reported loss to follow-up of 18% (12) and 20% (14). Later studies either minimized such losses through design or improved record keeping or (particularly when published in abstract) had insufficient information to allow loss to follow-up to be assessed. In studies from military operations in Afghanistan survival of non-coalition casualties was reported up to point of transfer to host nation medical facilities (up to 47% of study population). Significant post-transfer mortality was considered unlikely as patients were only transferred once in established recovery (42, 43). The pooled mortality estimate of 32% (95% CI: 26%–38%) exceeds the 23% mortality reported in profoundly hypotensive (SBP < 90 mm Hg) trauma patients treated without PHBP (44, 45) and provides no obvious evidence of benefit. Meta-analysis of uncorrected mortality data was performed, using matched data where available. PHBP receipt was not associated with reduced mortality (OR for mortality: 1.29, 95% CI: 0.84–1.96) (Fig. 3A). Heterogeneity was substantial (I2 = 63%). Limiting the meta-analysis to matched studies provided no evidence of benefit (Fig. 3B). Only three studies reported mortality adjusted for confounders (Fig. 4A)(35, 36, 46). These were not combined statistically.


Prehospital Blood Product Resuscitation for Trauma: A Systematic Review.

Smith IM, James RH, Dretzke J, Midwinter MJ - Shock (2016)

Forest plot of adjusted mortality.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4933578&req=5

Figure 4: Forest plot of adjusted mortality.
Mentions: Long-term mortality among PHBP recipients varied from 8% to 52% (Fig. 2A). This analysis included unpublished absolute survival data for one cohort study (35-i) (J. Brown. 2015, pers. comm. June 08). One study reported 67% mortality among six subjects, but was excluded from analysis due to 60% loss to follow-up (15). Early studies reported loss to follow-up of 18% (12) and 20% (14). Later studies either minimized such losses through design or improved record keeping or (particularly when published in abstract) had insufficient information to allow loss to follow-up to be assessed. In studies from military operations in Afghanistan survival of non-coalition casualties was reported up to point of transfer to host nation medical facilities (up to 47% of study population). Significant post-transfer mortality was considered unlikely as patients were only transferred once in established recovery (42, 43). The pooled mortality estimate of 32% (95% CI: 26%–38%) exceeds the 23% mortality reported in profoundly hypotensive (SBP < 90 mm Hg) trauma patients treated without PHBP (44, 45) and provides no obvious evidence of benefit. Meta-analysis of uncorrected mortality data was performed, using matched data where available. PHBP receipt was not associated with reduced mortality (OR for mortality: 1.29, 95% CI: 0.84–1.96) (Fig. 3A). Heterogeneity was substantial (I2 = 63%). Limiting the meta-analysis to matched studies provided no evidence of benefit (Fig. 3B). Only three studies reported mortality adjusted for confounders (Fig. 4A)(35, 36, 46). These were not combined statistically.

Bottom Line: No consistent physiological or biochemical benefit was identified, nor was there evidence of reduced in-hospital transfusion requirements.While PHBP resuscitation appears logical, the clinical literature is limited, provides only poor quality evidence, and does not demonstrate improved outcomes.No conclusions as to efficacy can be drawn.

View Article: PubMed Central - PubMed

Affiliation: *NIHR Surgical Reconstruction and Microbiology Research Centre, University of Birmingham †Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, ICT Centre, Edgbaston, Birmingham ‡205 (Scottish) Field Hospital, Govan, Glasgow §Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine, ICT Centre, Edgbaston, Birmingham //East Anglian Air Ambulance, Gambling Close, Norwich ¶Ministry of Defence Hospital Unit Derriford, Derriford Hospital, Plymouth, United Kingdom **Institute of Applied Health Research, University of Birmingham, Edgbaston, Birmingham, United Kingdom.

ABSTRACT

Introduction: Administration of high ratios of plasma to packed red blood cells is a routine practice for in-hospital trauma resuscitation. Military and civilian emergency teams are increasingly carrying prehospital blood products (PHBP) for trauma resuscitation. This study systematically reviewed the clinical literature to determine the extent to which the available evidence supports this practice.

Methods: Bibliographic databases and other sources were searched to July 2015 using keywords and index terms related to the intervention, setting, and condition. Standard systematic review methodology aimed at minimizing bias was used for study selection, data extraction, and quality assessment (protocol registration

Prospero: CRD42014013794). Synthesis was mainly narrative with random effects model meta-analysis limited to mortality outcomes.

Results: No prospective comparative or randomized studies were identified. Sixteen case series and 11 comparative studies were included in the review. Seven studies included mixed populations of trauma and non-trauma patients. Twenty-five of 27 studies provided only very low quality evidence. No association between PHBP and survival was found (OR for mortality: 1.29, 95% CI: 0.84-1.96, P = 0.24). A single study showed improved survival in the first 24 h. No consistent physiological or biochemical benefit was identified, nor was there evidence of reduced in-hospital transfusion requirements. Transfusion reactions were rare, suggesting the short-term safety of PHBP administration.

Conclusions: While PHBP resuscitation appears logical, the clinical literature is limited, provides only poor quality evidence, and does not demonstrate improved outcomes. No conclusions as to efficacy can be drawn. The results of randomized controlled trials are awaited.

No MeSH data available.


Related in: MedlinePlus