Pauline Deras

Early coagulopathy at hospital admission predicts initial or delayed fibrinogen deficit in severe trauma patients.

BACKGROUND Early detection of a fibrinogen deficit in the initial phase of trauma is a determinant for anticipating massive blood loss. Hemostatic impairment should rationally be associated with an overall depletion of clotting factors, leading to early coagulopathy. The main objective of this study was to evaluate whether the severity of coagulopathy at admission could predict an initial and delayed fibrinogen deficit during the initial management of severe trauma patients. METHODS All severe trauma patients admitted consecutively to our trauma center between January 2006 and December 2009 were retrospectively reviewed. The results of coagulation tests and plasma fibrinogen levels at admission were studied. Patients were grouped according to severity of coagulopathy at admission: prothrombin time ratio and/or activated partial thromboplastin time ratio of 1.50 or greater, between 1.49 and 1.20, or less than 1.20. Correlation between severity of coagulopathy at admission and initial or delayed fibrinogen deficit (fibrinogen level < 1.5 g/L) within the first 24 hours was established. RESULTS Of the 663 patients studied, 481 (72%) were male, and the mean (SD) Injury Severity Score (ISS) was 21.3 (17.6). At admission, 105 patients (20%) had severe coagulopathy, 215 (33%) had moderate coagulopathy, and 313 (47%) had no coagulopathy. The number of patients with a fibrinogen level less than 1.5 g/L at admission increased with the severity of coagulopathy: 87%, 29%, and 1%, respectively (p < 0.001). Corresponding rates for an initial fibrinogen level less than 1.0 g/L were 53%, 2%, 0.3%, respectively (p < 0.001). Moreover, severity of coagulopathy at admission was an independent risk factor of the occurrence of fibrinogen deficit within the first 24 hours (p < 0.001). CONCLUSION Early coagulopathy at admission in severe trauma patients was strongly associated with a fibrinogen deficit during initial management. In the absence of specific monitoring of fibrinogen, coagulopathy severity helps to guide fibrinogen replacement therapy. LEVEL OF EVIDENCE Prognostic and epidemiologic study, level III.

Fatal Pancreatic Injury due to Trauma after Successful Cardiopulmonary Resuscitation with Automatic Mechanical Chest Compression

Fatal Pancreatic Injury due to Trauma after Successful Cardiopulmonary Resuscitation with Automatic Mechanical Chest Compression Pauline Deras;Jonathan Manzanera;Ingrid Millet;Jonathan Charbit;Xavier Capdevila; Anesthesiology

Relationship between Obesity and Massive Transfusion Needs in Trauma Patients, and Validation of TASH Score in Obese Population: A Retrospective Study on 910 Trauma Patients

Background Prediction of massive transfusion (MT) is challenging in management of trauma patients. However, MT and its prediction were poorly studied in obese patients. The main objective was to assess the relationship between obesity and MT needs in trauma patients. The secondary objectives were to validate the Trauma Associated Severe Hemorrhage (TASH) score in predicting MT in obese patients and to use a grey zone approach to optimize its ability to predict MT. Methods and Findings An observational retrospective study was conducted in a Level I Regional Trauma Center Trauma in obese and non-obese patients. MT was defined as ≥10U of packed red blood cells in the first 24h and obesity as a BMI≥30kg/m². Between January 2008 and December 2012, 119 obese and 791 non-obese trauma patients were included. The rate of MT was 10% (94/910) in the whole population. The MT rate tended to be higher in obese patients than in non-obese patients: 15% (18/119, 95%CI 9‒23%) versus 10% (76/791, 95%CI 8‒12%), OR, 1.68 [95%CI 0.97‒2.92], p = 0.07. After adjusting for Injury Severity Score (ISS), obesity was significantly associated with MT rate (OR, 1.79[95%CI 1.00‒3.21], p = 0.049). The TASH score was higher in the obese group than in the non-obese group: 7(4–11) versus 5(2–10)(p<0.001). The area under the ROC curves of the TASH score in predicting MT was very high and comparable between the obese and non-obese groups: 0.93 (95%CI, 0.89‒0.98) and 0.94 (95%CI, 0.92‒0.96), respectively (p = 0.80). The grey zone ranged respectively from 10 to 13 and from 9 to 12 in obese and non obese patients, and allowed separating patients at low, intermediate or high risk of MT using the TASH score. Conclusions Obesity was associated with a higher rate of MT in trauma patients. The predictive performance of the TASH score and the grey zones were robust and comparable between obese and non-obese patients.

Assessment of Modification of Diet in Renal Disease Equation to Predict Reference Serum Creatinine Value in Severe Trauma Patients: Lessons From an Observational Study of 775 Cases.

Objective:We assessed the Modification of Diet in Renal Disease (MDRD) performance to predict serum creatinine (SCr) in severe trauma population and determined the best theoretical glomerular filtration rate (GFR) to use in this estimation. Background:Baseline SCr may be misestimated in severe trauma patients because of their specific demographic characteristics including renal hyperfiltration. However, the back-calculated MDRD equation is supposed to estimate SCr using a predetermined GFR of 75 mL/min/1.73 m2. Methods:All severe trauma patients with a normal SCr were retrospectively included between January 2005 and January 2011. For each patient, the lowest SCr (oSCr) observed during the first week was used to estimate the GFR. The median GFR in period 1 (2005–2006) was determined. The back-calculated MDRD performance was assessed in period 2 (2007–2011) to predict oSCr by agreement, precision, and accuracy using a GFR of 75 mL/min/1.73 m2 (eSCr75-MDRD) or the median GFR observed in period 1 (eSCrTRAUMA-MDRD). Results:A total of 775 patients were studied: mean age, 37.7 ± 17 years; mean Injury Severity Score, 19 ± 11; 75% of male. In period 1 (n = 243), median GFR was 121 mL/min/1.73 m2. In period 2 (n = 532), eSCrTRAUMA-MDRD demonstrated better agreement in predicting oSCr than eSCr75-MDRD (mean bias 2 vs 35 &mgr;mol/L; P < 0.001). Both precision (14 vs 39 &mgr;mol/L, respectively) and accuracy were significantly improved with eSCrTRAUMA-MDRD. Proportion of estimated SCr values that deviated less than 15%, 30%, or 50% was also higher with eSCrTRAUMA-MDRD (P < 0.001). Conclusions:The eSCr75-MDRD equation systematically overestimates oSCr of severe trauma patients. The eSCrTRAUMA-MDRD equation determined was statistically superior allowing more accurate qualification of acute kidney injury.

Diagnostic performance of prothrombin time point-of-care to detect acute traumatic coagulopathy on admission: experience of 522 cases in trauma center: DIAGNOSTIC PERFORMANCE OF PT POINT-OF-CARE IN TRAUMA

Early identification of acute traumatic coagulopathy is a key challenge during initial management to determine whether to initiate early hemostatic support. We assessed the performance of prothrombin time (PT) at point‐of‐care in trauma patients to detect moderate and severe coagulopathy on admission.

Clinical value of automated fibrin generation markers in patients with septic shock: a SepsiCoag ancillary study

An ancillary analysis to the SepsiCoag multicentric prospective observational study on patients entering an intensive care unit with septic shock evaluated the prognostic potential of fibrin generation markers (FGMs) tested at inclusion in the study, on survival at day 30. After centralization of samples, three automated FGMs were compared: D‐dimers (DDi), fibrin/fibrinogen degradation products (FDP) and fibrin monomers (FM). FM was the single FGM that was significantly higher in non‐surviving patients, area under the receiver‐operator characteristic curve (AUCROC): 0·617, P < 0·0001. Significantly higher International Society on Thrombosis and Haemostasis Disseminated Intravascular Coagulation (ISTH DIC) scores were calculated in non‐survivors using each of the three FGMs. A dose‐effect relationship was observed between ISTH DIC scores and non‐survival, with highest significance obtained using FM as the FGM. An overt DIC diagnosis using the ISTH DIC score calculated using FM was a predictor of non‐survival at day 30, independently from overt DIC diagnosis based on scores calculated using FDP or DDi. The AUCROC values testing the ability of the ISTH DIC score to predict non‐survival were 0·650, 0·624 and 0·602 using FM, DDi and FDP, respectively, as the FGM. In patients with septic shock, among the commercially‐available automated assays, automated FM is the FGM best related with late prognosis.

Influence of late fluid management on the outcomes of severe trauma patients: a retrospective analysis of 294 severely-injured patients ☆

BACKGROUND Liberal late fluid management (LFM) is associated with higher morbi-mortality in critically ill populations. The aim of the study was to assess the association between LFM and duration of mechanical ventilation in a severe trauma population. METHODS A retrospective analysis of consecutive patients with an ISS≥16 and a length of stay in the intensive care unit (ICU)≥7 days was performed. The conservative LFM group included patients with at least 2 consecutive days with a negative fluid balance between day 3 and day 7; other patients were allocated to the liberal LFM group. RESULTS 294 severely injured patients were included, 157 (53%) as conservative LFM and 137 (47%) as liberal LFM. The groups did not differ significantly in terms of baseline characteristics, severe injuries, severity criteria or transfusion needs. Liberal LFM was significantly associated with more ventilation days (11 vs 8.5days; P=0.02), less ventilator-free days at day 30 (19 vs 21days; P=0.03), longer ICU stay (19 vs 16days; P=0.03) and longer hospital stay (30 vs 25days; P=0.04). Mortality rates were comparable between groups (6%). Liberal LFM was significantly associated in multivariable analysis with a reduced number of ventilator-free days at day 30 (β=-2.14 [95% CI, -4.2 to -0.08], P=0.042). CONCLUSIONS Liberal LFM was associated with higher morbidity in severe trauma patients, longer duration of ventilation, and longer ICU and hospital stays. These results were observed despite similar severity on admission and early fluid management.