Page 144 - JSOM Spring 2023

guideline provides evidence-based recommendations for the man- Donald H Jenkins, Maxwell A Braverman, Caleb Mentzer, Guy
agement of massively and non-massively bleeding critically ill adult C Leonard, Lindsey L Perea, Courtney K Docherty, Julie A Dunn,
patients and identifies areas where further research is needed. Brittany Smoot, Matthew Martin, Jayraan Badiee, Alejandro J
Luis, Julie L Murray, Matthew R Noorbakhsh, James E Babo-
Prehospital lyophilized plasma transfusion for trauma- wice, Charles Mains, Robert Madayag, Haytham Kaafarani, Ava
induced coagulopathy in patients at risk for hemorrhagic Mokhtari, Annie Moore, Kathleen Madden, Allen Tanner II, Di-
shock: a randomized clinical trial ane Redmond, David J Millia, Amber Brandolino, Uyen Nguyen,
Daniel Jost, MD; Sabine Lemoine, MD; Frédéric Lemoine, CRA; Vernon Chinchilli, Scott Armen, John Porter
Clément Derkenne, MD; Sébastien Beaume, MD; Vincent La- Abstract presented at the 142nd meeting of the American Surgical
noë, CRA; Olga Maurin, MD; Emilie Louis-Delauriere, CRA; Association, Chicago, IL, April 7–9, 2022. https://meeting.american
Maëlle Delacote, MD; Pascal Dang-Minh, MD; Marilyn Franchin- surgical.org/program/2022/6.cgi
Frattini, MD; René Bihannic, PharmD; Dominique Savary, MD;
Albrice Levrat, MD; Clémence Baudouin, MD; Julie Trichereau, Objective: Currently, blood component therapy (BCT) is stan-
MD; Marina Salomé, CRA; Benoit Frattini, MD; Vivien Hong dard practice for the resuscitation of trauma patients, but recently
Tuan Ha, MD; Romain Jouffroy, MD; Edouard Seguineau, MD; whole blood (WB) transfusion has emerged as the resuscitation
Rudy Titreville, MD; Florian Roquet, MD, PhD; Olivier Stibbe, strategy of choice at select US trauma centers. Much of the data
MD; Benoit Vivien, MD, PhD; Catherine Verret, MD, PhD; Mi- regarding WB is limited to small prospective or retrospective stud-
chel Bignand, MD; Stéphane Travers, MD; Christophe Martinaud, ies which have failed to demonstrate a significant benefit of WB
MD, PhD; Michel Arock, MD, PhD; Mathieu Raux, MD, PhD; versus BCT. We hypothesized that the use of WB transfusion vs
Bertrand Prunet, MD, PhD; Sylvain Ausset, MD, PhD; Anne Sail- BCT alone would result in decreased mortality in trauma patients.
liol, MD, PhD; Jean-Pierre Tourtier,MD, PhD; Prehospital Lyo- Methods: We performed a multicenter (14 verified trauma cen-
philized Plasma (PREHO-PLYO) Study Group ters), prospective-observational study of patients who received
JAMA Netw Open. 2020;5(7):e2223619. WB vs BCT during their initial trauma resuscitation. We applied
a generalized linear mixed-effects model with a random effect (to
Importance: Blood transfusion is a mainstay of therapy for trau- control for center) and also controlled for age, sex, mechanism
ma-induced coagulopathy, but the optimal modalities for plasma of injury (MOI) and injury severity score (ISS). Trauma patients
transfusion in the prehospital setting remain to be defined. Ob- of any age who received a blood transfusion as part of their ini-
jective: To determine whether lyophilized plasma transfusion can tial resuscitation were included. Primary outcome was in-hospital
reduce the incidence of trauma-induced coagulopathy compared mortality and secondary outcomes included acute kidney injury
with standard care consisting of normal saline infusion. Design, (AKI), deep venous thrombosis (DVT), pulmonary complications,
setting, and participants: This randomized clinical trial was per- bleeding complications, and length of stay (LOS). Results: A total
formed at multiple centers in France involving prehospital medical of 1,623 trauma patients who sustained either penetrating (53%)
teams. Participants included 150 adults with trauma who were at or blunt (47%) injury were included. Of the 1,623 patients, 1,180
risk for hemorrhagic shock and associated coagulopathy between (73%) received at least one unit of WB while 443 (27%) received
April 1, 2016, and September 30, 2019, with a 28-day follow-up. only BCT. Median age was 40y (IQR 11-30), 83% were male and
Data were analyzed from November 1, 2019, to July 1, 2020. median ISS was 22 (IQR 11-30). Patients who received WB had
Intervention: Patients were randomized in a 1:1 ratio to receive a higher shock index (1.08 vs 0.94), more comorbid conditions,
either plasma or standard care with normal saline infusion (con- and more likely had a blunt MOI (all p < 0.05). After controlling
trol). Main outcomes and measures: The primary outcome was for center, age, sex, prehospital blood products, MOI, and ISS,
the international normalized ratio (INR) on arrival at the hospital. we found no differences in the rates of AKI, DVT/PE, pulmonary
Secondary outcomes included the need for massive transfusion and complications, or LOS between groups. Patients who received WB
30-day survival. As a safety outcome, prespecified adverse events were 9% less likely to experience a bleeding complication and
included thrombosis, transfusion-related acute lung injury, and were 48% less likely to die than those who received BCT alone
transfusion-associated circulatory overload. Results: Among 150 (p<0.0001). Conclusions: Compared with standard blood compo-
randomized patients, 134 were included in the analysis (median age, nent therapy, the use of whole blood transfusion resulted in a 48%
34 [IQR, 26–49] years; 110 men [82.1%]), with 68 in the plasma reduction in mortality in trauma patients. Our study supports the
group and 66 in the control group. Median INR values were 1.21 universal use of whole blood during the initial resuscitation of
(IQR, 1.12–1.49) in the plasma group and 1.20 (IQR, 1.10–1.39) in trauma patients who require a transfusion.
the control group (median difference, −0.01 [IQR, −0.09 to 0.08];
p = .88). The groups did not differ significantly in the need for Hypocalcemia as a predictor of mortality and transfusion.
massive transfusion (7 [10.3%] vs 4 [6.1%]; relative risk, 1.78 A scoping review of hypocalcemia in trauma and
[95% CI, 0.42-8.68]; p = .37) or 30-day survival (hazard ratio hemostatic resuscitation
for death, 1.07 [95% CI, 0.44-2.61]; p = .89). In the full inten- Shane Kronstedt, Nicholas Roberts, Ricky Ditzel, Justin Elder, Ai-
tion-to-treat population (n = 150), the groups did not differ in mee Steen, Kelsey Thompson, Justin Anderson, Jeffrey Siegler
the rates of any of the prespecified adverse events. Conclusions Transfusion. 2022;62 Suppl 1(Suppl 1):S158–S166.
and relevance: In this randomized clinical trial including severely
injured patients at risk for hemorrhagic shock and associated co- Background: Calcium plays an essential role in physiologic pro-
agulopathy, prehospital transfusion of lyophilized plasma was not cesses, including trauma’s “Lethal Diamond.” Thus, inadequate
associated with significant differences in INR values vs standard serum calcium in trauma patients exacerbates the effects of hem-
care with normal saline infusion. Nevertheless, these findings orrhagic shock secondary to traumatic injury and subsequently
show that lyophilized plasma transfusion is a feasible and safe poorer outcomes compared to those with adequate calcium levels.
procedure for this patient population. Evidence to date supports the consideration of calcium derange-
ments when assessing the risk of mortality and the need for blood
Whole blood vs blood component therapy for transfusion product transfusion in trauma patients. This review aims to fur-
in trauma patients: a prospective, multicenter study ther elucidate the predictive strength of this association for future
Joshua P Hazelton, Anna E Ssentongo, John S Oh, Paddy Ssen- treatment guidelines and clinical trials. Methods: Publications
tongo, Mark J Seamon, James P Byrne, Isabella G Armento, were collected on the relationship between i-Ca and the outcomes

142 | JSOM Volume 23, Edition 1 / Spring 2023