Variations and obstacles in the use of coagulation factor concentrates for major trauma bleeding across Europe: outcomes from a European expert meeting

Authors: Cerny, V., Maegele, M., Agostini, V., Fries, D., Leal-Noval, S. R., Nardai, G., Nardi, G., Ostlund, A., and Schöchl, H.

Publication: Eur. J Trauma Emerg. Surg. ; 1-12. January 2021

Affiliations: Department of Anesthesiology, Perioperative Medicine and Intensive Care, JE Purkinje University, Usti Nad Labem, Masaryk Hospital, Prague, Czech Republic. Department of Trauma and Orthopedic Surgery, Institute for Research in Operative Medicine (IFOM), University Witten/Herdecke, Cologne-Merheim Medical Center (CMMC), Cologne, Germany ; IRCCS Ospedale Policlinico San Martino, Genova, Italy ; Department for General and Surgical Critical Care Medicine, Medical University Innsbruck, Innsbruck, Austria ; Critical Care Division, University Hospital ‘Virgen del Rocio’, Seville, Spain ; Péterfy Sándor Str. Hospital and Trauma Center, Budapest, Hungary ; Department of Anesthesia and Intensive Care, Rimini Hospital, Rimini, Italy ; Perioperative Medicine and Intensive Care, Karolinska University Hospital Solna, Stockholm, Sweden ; AUVA Trauma Centre Salzburg, Salzburg, Austria.

Abstract: PURPOSE: Trauma is a leading cause of mortality, with major bleeding and trauma-induced coagulopathy (TIC) contributing to negative patient outcomes. Treatments for TIC include tranexamic acid (TXA), fresh frozen plasma (FFP), and coagulation factor concentrates (CFCs, e.g., prothrombin complex concentrates [PCCs] and fibrinogen concentrate [FCH]). Guidelines for TIC management vary across Europe and a clear definition of TIC is still lacking. METHODS: An advisory board involving European trauma experts was held on 02 February 2019, to discuss clinical experience in the management of trauma-related bleeding and recommendations from European guidelines, focusing on CFC use (mainly FCH). This review summarises the discussions, including TIC definitions, gaps in the guidelines that affect their implementation, and barriers to use of CFCs, with suggested solutions. RESULTS: A definition of TIC, which incorporates clinical (e.g. severe bleeding) and laboratory parameters (e.g. low fibrinogen) is suggested. TIC should be treated immediately with TXA and FCH/red blood cells; subsequently, if fibrinogen ≤ 1.5 g/L (or equivalent by viscoelastic testing), treatment with FCH, then PCC (if bleeding continues) is suggested. Fibrinogen concentrate, and not FFP, should be administered as first-line therapy for TIC. Several initiatives may improve TIC management, with improved medical education of major importance; generation of new and stronger data, simplified clinical practice guidance, and improved access to viscoelastic testing are also critical factors. CONCLUSIONS: Management of TIC is challenging. A standard definition of TIC, together with initiatives to facilitate effective CFC administration, may contribute to improved patient care and outcomes.