Examining a Protocol for Transfusing Plasma to Severely Injured Patients

Examining a Protocol for Transfusing Plasma to Severely Injured Patients

Patients with a trauma-induced coagulopathy account for more than half of hemorrhagic deaths in the United States. About 25% of severely injured patients are already coagulopathic and thrombocytopenic upon arrival to trauma centers. Mortality rates have been shown to decrease in these patients when they receive higher ratios of plasma and platelets. “Early transfusion of red blood cells (RBCs) has been established as a core element of trauma resuscitation,” says Bryan A. Cotton, MD, MPH. “Most trauma centers store RBCs in their EDs, but few store plasma in their EDs. This makes it challenging to achieve high plasma-RBC ratios early during care, which in turn can worsen coagulopathy and increase patient mortality.” Expediting Plasma Delivery Over the past several years, more and more trauma centers have implemented massive transfusion (MT) protocols to ensure that severely injured patients receive higher plasma-RBC ratios early. “This was shown to markedly reduce the time to release of plasma, but the time to transfusion was still excessively long,” Dr. Cotton says. In an effort to expedite the delivery of plasma for patients requiring MT, some medical centers began keeping thawed plasma (TP) in their blood banks (BBs).   MT protocols vary throughout trauma centers in the U.S., but those reporting the most marked changes in survival are the ones that have implemented concurrent TP programs. Furthermore, trauma centers that develop TP programs concurrent with MT protocols have shown that they can reduce the time to first plasma transfusion and the overall number of blood components transfused. Testing a New Thawed Plasma Protocol In 2006, Dr. Cotton and colleagues began a TP program in their...

Tailoring Antiplatelet Treatment

Important advances have occurred in our understanding of the platelets’ role in arterial thrombosis. These advances have enabled the development of new antiplatelet therapies. Clinical trials have demonstrated the benefit of antiplatelet therapy in a diverse range of cardiovascular diseases (CVD), including acute myocardial infarction, unstable angina, and ischemic stroke. The market for antiplatelet therapies has grown in recent years for several reasons, including the: Aging population. Global increase in CVD incidence due to diabetes. Increased understanding of the role of antiplatelet therapy in the prevention and treatment of CVDs. Prasugrel and ticagrelor are two antiplatelet agents that have been recently approved by the FDA for use in conjunction with aspirin to treat patients with acute coronary artery syndromes. In phase III trials, these agents have been shown to significantly reduce adverse cardiovascular events when compared with clopidogrel therapy. These additions to the antiplatelet therapy class can make it more challenging for clinicians to decide on what is most appropriate and beneficial for their patients. There is no longer just one option for antiplatelet therapy. Clinicians must now consider the optimal antiplatelet therapy for each patient depending on their presentation, bleeding risk, and cost. Personalizing Approaches in Antiplatelet Treatment The unpredictable response to clopidogrel reported nearly a decade ago introduced us to the field of personalized antiplatelet therapy based on genetic and platelet function testing. The CYP2C19 loss-of-function allele is a major independent predictor of the pharmacodynamic and clinical response to clopidogrel in PCI patients. Guidelines and FDA recommendations suggest that patients who are poor metabolizers, according to CYP2C19 testing, should be switched to an alternate antiplatelet therapy. Genetic...