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Fibrinogen-based versus fresh frozen plasma-based initial approach for trauma-induced coagulopathy correction : implications on overall blood-derived consumption
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Introdução: A hemorragia grave, a principal causa de morte evitável em doentes traumáticos, tem seu tratamento baseado na cirurgia e controlo da coagulopatia. A coagulopatia induzida pelo trauma (CIT) é uma entidade multifatorial, que ocorre frequentemente em contexto de trauma grave. Está associada ao aumento das necessidades de transfusão precoce, à falência multiorgânica e a alta mortalidade. A CIT é causada tanto pela coagulopatia traumática aguda (CTA) como pela coagulopatia associada à ressuscitação (CAR). A CTA é reconhecida como uma condição primária que é multifatorial e se desenvolve rapidamente em resposta à lesão tecidual e ao choque hemorrágico, resultando em hipoperfusão, lesão endotelial sistémica e hipocoaguabilidade. Esta coagulopatia inicial é potenciada pela CAR, que inclui mecanismos como perda directa ou consumo dos fatores da coagulação, acidémia, hipotermia, hipocalcémia e hemodiluição (por exemplo, secundária a sobre-ressuscitação com hemoderivados ou fluídoterapia). Estas três entidades (coagulopatia, acidémia e hipotermia) são denominadas de “círculo vicioso da coagulopatia”. O seu tratamento eficaz e precoce influencia directamente a mortalidade e outros outcomes clínicos. Nos últimos anos, a melhor estratégia inicial para o tratamento da CIT tem sido objeto de intenso debate, sendo que as mais recentes orientações europeias sobre o tratamento da coagulopatia do trauma recomendam duas estratégias possíveis para a abordagem inicial da mesma: PFC e unidade de concentrado eritrocitário (UCE), na proporção de 1 para 1 ou 1 para 2; ou concentrado de fibrinogénio e UCE. O aumento da compreensão sobre o papel da hipofibrinogenemia no trauma grave levou à hipótese de que a suplementação de fibrinogénio, alcançada inadequadamente através de PFC, diminuiria consumos de hemoderivados e potencialmente aumentaria a sobrevida. Associado a essa hipótese, o uso crescente de métodos viscoelásticos para avaliar a coagulação à cabeceira do doente tem vindo a sugerir cada vez mais uma estratégia baseada em fibrinogénio. Apesar desses recentes avanços, as recomendações baseadas em concentrado de fibrinogénio são atualmente suportadas por consensos de especialistas e requerem validação adicional. O objetivo deste trabalho é comparar as duas abordagens iniciais e a implicação destas no consumo total de hemoderivados (THD).
Introduction: Trauma-induced coagulopathy (TIC) is a multifactorial entity, occurring almost universally in severe trauma. TIC is associated with increased early transfusion requirements, the development of organ failure and high mortality. Effective and early treatment of TIC is important and affects early mortality of trauma patients, as other clinical endpoints. Treatment of TIC is, nowadays, anchored on two initial strategies: one based on fresh frozen plasma (FFP) and red-blood cells (RBC), and one based in fibrinogen concentrate and RBC, that requires further validation. The objective of this work is to compare the initial approach with FFP-based or fibrinogen-based therapy and the implication of those in the total consumption of blood products in trauma patients. Methods: This is an observational cohort retrospective study, where the administration of blood products in patients with major trauma between 2013 and 2017 admitted in a tertiary intensive care unit (ICU) of university teaching hospital was analyzed. From initial sample, 104 patients were allocated to either FFP group or fibrinogen group based on the main use of such BDP in each patient. The primary outcome was the difference of RBC and total Blood Products (BDP) administration at 24h between groups. Secondary outcomes were the impact of each strategy on ICU mortality, ICU length of stay and acute kidney injury. Results and Discussion: the consumption of total blood products at 24h, RBC at 6h and total consumption of RBC were statistically lower in the fibrinogen group (p<0.01, p=0.05, p=0.048 respectively). There was a statistically difference in urea values at 24h (p=0.002), which may indicate less organ dysfunction in fibrinogen group. There was no difference in ICU mortality, ICU length of stay between groups. Conclusion: the initial management with fibrinogen concentrate may decrease the consumption of total blood products, compared with FFP-based treatment, at 24h.
Introduction: Trauma-induced coagulopathy (TIC) is a multifactorial entity, occurring almost universally in severe trauma. TIC is associated with increased early transfusion requirements, the development of organ failure and high mortality. Effective and early treatment of TIC is important and affects early mortality of trauma patients, as other clinical endpoints. Treatment of TIC is, nowadays, anchored on two initial strategies: one based on fresh frozen plasma (FFP) and red-blood cells (RBC), and one based in fibrinogen concentrate and RBC, that requires further validation. The objective of this work is to compare the initial approach with FFP-based or fibrinogen-based therapy and the implication of those in the total consumption of blood products in trauma patients. Methods: This is an observational cohort retrospective study, where the administration of blood products in patients with major trauma between 2013 and 2017 admitted in a tertiary intensive care unit (ICU) of university teaching hospital was analyzed. From initial sample, 104 patients were allocated to either FFP group or fibrinogen group based on the main use of such BDP in each patient. The primary outcome was the difference of RBC and total Blood Products (BDP) administration at 24h between groups. Secondary outcomes were the impact of each strategy on ICU mortality, ICU length of stay and acute kidney injury. Results and Discussion: the consumption of total blood products at 24h, RBC at 6h and total consumption of RBC were statistically lower in the fibrinogen group (p<0.01, p=0.05, p=0.048 respectively). There was a statistically difference in urea values at 24h (p=0.002), which may indicate less organ dysfunction in fibrinogen group. There was no difference in ICU mortality, ICU length of stay between groups. Conclusion: the initial management with fibrinogen concentrate may decrease the consumption of total blood products, compared with FFP-based treatment, at 24h.
Descrição
Trabalho Final do Curso de Mestrado Integrado em Medicina, Faculdade de Medicina, Universidade de Lisboa, 2020
Palavras-chave
Coagulopatia induzida pelo trauma Plasma fresco congelado Fibrinogénio Hemoderivados Medicina intensiva