Abstract
BackgroundSevere traumatic injury and haemorrhagic shock are frequently associated with disruptions of coagulation function (such as trauma-induced coagulopathy TIC) and activation of inflammatory cascades. These pathologies may be exacerbated by current standard of care resuscitation protocols. Observational studies suggest early administration of plasma to severely-injured haemorrhaging patients may correct TIC, minimise inflammation, and improve survival. The proposed randomised clinical trial will evaluate the clinical effectiveness of pre-hospital plasma administration compared with standard- of-care crystalloid resuscitation in severely-injured patients with major traumatic haemorrhage.Methods/designThis is a prospective, randomized, open-label, non-blinded trial to determine the effect of pre-hospital administration of thawed plasma (TP) on mortality, morbidity, transfusion requirements, coagulation, and inflammatory response in severely-injured bleeding trauma patients. Two hundred and ten eligible adult trauma patients will be randomised to receive either two units of plasma, to be administered in-field, vs standard of care normal saline (NS). Main analyses will compare subjects allocated to TP to those allocated to NS, on an intention-to-treat basis. Primary outcome measure is all-cause 30-day mortality. Secondary outcome measures include coagulation and lipidomic/pro-inflammatory marker responses, volume of resuscitation fluids (crystalloid, colloid) and blood products administered, and major hospital outcomes (e.g. incidence of MSOF, length of ICU stay, length of hospital stay).DiscussionThis study is part of a US Department of Defense (DoD)-funded multi-institutional investigation, conducted independently of, but in parallel with, the University of Pittsburgh and University of Denver. Demonstration of significant reductions in mortality and coagulopathic/inflammatory-related morbidities as a result of pre-hospital plasma administration would be of considerable clinical importance for the management of haemorrhagic shock in both civilian and military populations.Trial registrationClinicalTrials.gov: NCT02303964 on 28 November 2014
Highlights
Severe traumatic injury and haemorrhagic shock are frequently associated with disruptions of coagulation function and activation of inflammatory cascades
Demonstration of significant reductions in mortality and coagulopathic/inflammatory-related morbidities as a result of pre-hospital plasma administration would be of considerable clinical importance for the management of haemorrhagic shock in both civilian and military populations
Benefit of early in-hospital use of thawed plasma (TP) to correct traumarelated coagulation dysfunction is weakly supported by several observational studies [2], but unsupported or contradicted by other studies [21, 27]
Summary
Benefit of early in-hospital use of TP to correct traumarelated coagulation dysfunction is weakly supported by several observational studies [2], but unsupported or contradicted by other studies [21, 27]. There are several limitations to this study: TP infusion cannot be blinded to prehospital providers ( subsequent healthcare professionals may not necessarily receive this information), variable scene–hospital transport times of 6–30 min, so that not all patients allocated to the TP arm will receive the full complement of two units of TP before hospital arrival, and the complexity of patient management in the field, which means that the prehospital period will be most vulnerable to missing data This trial, coupled with those at Pittsburgh and Denver sister institutions, will be among the first to test the hypothesis that prehospital plasma administration to severely injured patients is effective in reducing traumarelated mortality and coagulopathy. BDS is Professor of Anesthesiology at VCUMC and Principal Investigator of the PUPTH trial
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