Current opinion in anaesthesiology
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Curr Opin Anaesthesiol · Apr 2016
Review Comparative StudyCoagulation management in trauma-associated coagulopathy: allogenic blood products versus coagulation factor concentrates in trauma care.
Coagulation management by transfusion of allogenic blood products and coagulation factors are competing concepts in current trauma care. ⋯ The collective of trauma patients is heterogeneous. Despite the lack of evidence, there are strong arguments for individualized patient treatment with coagulation factors for some indications and to abstain from the use of fresh frozen plasma. In patients with severe trauma and major bleeding, plasma, platelets, and red blood cells should be considered to be administered at a ratio of 1 : 1 : 1.
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Evidence-based fluid therapy is complicated by blurred boundaries toward other fields of therapy and the majority of trials not focusing on patient-relevant outcomes. Additionally, recent trials unsettled the faith in traditional concepts on fluid therapy. The article reviews the evidence on diagnosis and treatment of hypovolemia and discusses the use of balanced solutions and early goal-directed therapy (EGDT) in septic shock resuscitation. ⋯ Evidence-based fluid therapy includes a multifaceted diagnostic approach, the primary use of balanced crystalloids and early aggressive (septic) shock resuscitation.
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Curr Opin Anaesthesiol · Apr 2016
ReviewManagement of direct oral anticoagulants-associated bleeding in the trauma patient.
This article emphasizes the differentiated management of direct oral anticoagulants (DOACs)-associated bleeding in trauma patients to generate a severity adjusted treatment protocol. ⋯ The different pharmacological properties of DOACs are important for the management of trauma-induced bleeding. Comorbidities like renal impairment and liver dysfunction prolong their half-life. Patients with minor bleeding in stable clinical condition can be managed by a 'wait and see' approach. Moderate bleeding is suggested to be managed by a primarily conservative approach. In life-threatening bleeding, the administration of activated or nonactivated factor concentrates seems justified, together with supportive measures as part of an advanced management protocol. The administration of specific antidotes may be an alternative in the future. A monoclonal antibody to dabigatran (idarucizumab) has recently been approved by the Food and Drug Administration, whereas antidotes to Factor X activated inhibitors (andexanet and aripazine) are still under development. Sufficiently powered studies with clinical and safety outcome measures are still missing for all specific antidotes at this time.
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This article compares the strategy of a fixed transfusion ratio of plasma and platelet concentrates to red blood cells to reconstitute 'whole blood' with the concept of individualized goal-directed coagulation therapy (GDCT). ⋯ Individualized GDCT, guided by VET, offers several advantages over fixed ratio coagulation therapy. Studies comparing both hemostatic strategies are warranted.
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Trauma-induced coagulopathy (TIC) is a multifactorial, global failure of the coagulation system to sustain adequate haemostasis after trauma haemorrhage. Damage control resuscitation is associated with improved outcomes although the mechanisms of how it corrects TIC have yet to be fully characterized. Identification of predominant pathophysiological pathways in TIC is required to develop effective treatment algorithms for trauma haemorrhage. ⋯ Further advances in TIC treatment require an enhanced understanding of the dynamic changes in the equilibrium between pro and anticoagulant factors, downstream effectors, and the host response. Delineating the interaction between fibrinolysis, fibrinogen utilization, platelet activity, and thrombin generation may provide opportunity for targeted intervention.