In this episode, I’ll discuss the 6th edition of the European guideline on management of major bleeding and coagulopathy following trauma.
The 6th edition of the European guideline on management of major bleeding and coagulopathy following trauma has recently been published in the Journal Critical Care.
While the majority of the recommendations are related to medical and surgical management, I found 7 recommendations that pharmacists should be aware of.
Recommendation 14
If a restricted volume replacement strategy does not achieve the target blood pressure, we recommend the administration of noradrenaline in addition to fluids to maintain target arterial pressure (Grade 1C).We recommend infusion of dobutamine in the presence of myocardial dysfunction (Grade 1C).
In the details explaining this recommendation the guideline authors acknowledge a study that also shows vasopressin bolus of 4 units IV followed by 0.04 units/min decreased the need for blood products in trauma patients. However vasopressin did not make it to the recommendation level since the authors wanted morbidity and mortality data to support use, which is not yet available in the literature.
Recommendation 15
We recommend that fluid therapy using a 0.9% sodium chloride or balanced crystalloid solution be initiated in the hypotensive bleeding trauma patient (Grade 1B).We recommend that hypotonic solutions such as Ringer’s lactate be avoided in patients with severe head trauma (Grade 1B).
We recommend that the use of colloids be restricted due to the adverse effects on haemostasis (Grade 1C).
Although lactated ringers is not typically thought of as hypotonic, a secondary analysis from a study of patients with traumatic brain injury that compared Ringer’s lactate and normal saline solutions associated Ringer’s lactate higher adjusted mortality.
Recommendation 23
We recommend that tranexamic acid (TXA) be administered to the trauma patient who is bleeding or at risk of significant bleeding as soon as possible, if feasible en route to the hospital, and within 3 h after injury at a loading dose of 1 g infused over 10 min, followed by an i.v. infusion of 1 g over 8 h (Grade 1A).We recommend that the administration of TXA not await results from a viscoelastic assessment (Grade 1B).
This recommendation takes into account data not just from the landmark CRASH-2 study but from several more recent studies that also support the use of TXA in trauma patients.
Recommendations 33, 34, and 35 cover reversal of oral anticoagulants. For each oral anticoagulant class, the guideline authors recommend reversal with agents that directly counter the anticoagulant’s mechanism of action. This means prothrombin complex concentrate plus vitamin K for warfarin, andexanet alfa for apixaban and rivaroxaban, and idarucizumab for dabigatran. In the case of lack of availability of andexanet alfa, the guideline authors recommend prothrombin complex concentrate.
Recommendation 37
We recommend early initiation of mechanical thromboprophylaxis with intermittent pneumatic compression (IPC) while the patient is immobile and has a bleeding risk (Grade 1C).We recommend combined pharmacological and IPC thromboprophylaxis within 24 h after bleeding has been controlled and until the patient is mobile (Grade 1B).
We do not recommend the use of graduated compression stockings for thromboprophylaxis (Grade 1C).
We do not recommend the routine use of inferior vena cava filters as thromboprophylaxis (Grade 1C).
In the supporting text for this recommendation the authors suggest that pharmacological VTE prophylaxis be initiated with either low molecular weight heparin, or in the case of patients with renal failure, low-dose unfractionated heparin.
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