Blood Component Therapy and Coagulopathy in Trauma: A Systematic Review of the Literature from the Trauma Update Group.
BACKGROUND
Traumatic coagulopathy is thought to increase mortality and its treatment to reduce preventable deaths. However, there is still uncertainty in this field, and available literature results may have been overestimated.


METHODS
We searched the MEDLINE database using the PubMed platform. We formulated four queries investigating the prognostic weight of traumatic coagulopathy defined according to conventional laboratory testing, and the effectiveness in reducing mortality of three different treatments aimed at contrasting coagulopathy (high fresh frozen plasma/packed red blood cells ratios, fibrinogen, and tranexamic acid administration). Randomized controlled trials were selected along with observational studies that used a multivariable approach to adjust for confounding. Strict criteria were adopted for quality assessment based on a two-step approach. First, we rated quality of evidence according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria. Then, this rating was downgraded if other three criteria were not met: high reporting quality according to shared standards, absence of internal methodological and statistical issues not detailed by the GRADE system, and absence of external validity issues.


RESULTS
With few exceptions, the GRADE rating, reporting and methodological quality of observational studies was "very low", with frequent external validity issues. The only two randomized trials retrieved were, instead, of high quality. Only weak evidence was found for a relation between coagulopathy and mortality. Very weak evidence was found supporting the use of fibrinogen administration to reduce mortality in trauma. On the other hand, we found high evidence that the use of 1:1 vs. 1:2 high fresh frozen plasma/packed red blood cells ratios failed to obtain a 12% mortality reduction. This does not exclude lower mortality rates, which have not been investigated. The use of tranexamic acid in trauma was supported by "high" quality evidence according to the GRADE classification but was downgraded to "moderate" for external validity issues.


CONCLUSIONS
Tranexamic acid is effective in reducing mortality in trauma. The other transfusion practices we investigated have been inadequately studied in the literature, as well as the independent association between mortality and coagulopathy measured with traditional laboratory testing. Overall, in this field of research literature quality is poor.
Anesthesia and Intensive Care Operative Unit, "S. Martino" Hospital, Belluno, Italy.
Daniele
D
Poole
Department of Biopathology and Medical Biotechnologies (DIBIMED), Section of Anesthesia, Analgesia, Intensive Care, and Emergency, Policlinico "P. Giaccone", University of Palermo, Palermo, Italy.
Andrea
A
Cortegiani
Neurointensive Care Unit ASST Great Metropolitan "Niguarda" Hospital, Milan, Italy.
Arturo
A
Chieregato
Anaesthesia and Intensive Care Unit, Surgical and Severe Trauma Department, "Bufalini" Hospital, Cesena, Italy.
Emanuele
E
Russo
Anesthesia and Intensive Care, AO "Rummo", Benevento, Italy.
Concetta
C
Pellegrini
Anesthesia and Intensive Care, AO "Rummo", Benevento, Italy.
Elvio
E
De Blasio
UOC Intensive Care and Territorial Emergency Department, "Maggiore" Hospital, Bologna, Italy.
Francesca
F
Mengoli
Anesthesia and Intensive Care, AOU of Parma, Parma, Italy.
Annalisa
A
Volpi
Anesthesia and Intensive Care, AOU of Parma, Parma, Italy.
Silvia
S
Grossi
Departmental Structure of Anesthesia and Intensive Care for Orthopedic Surgery, AOU "Careggi", Florence, Italy.
Lara
L
Gianesello
Neuroanesthesia and Neurointensive Care, AOU "Careggi", CTO, Florence, Italy.
Vanni
V
Orzalesi
Neurointensive Care Unit ASST Great Metropolitan "Niguarda" Hospital, Milan, Italy.
Francesca
F
Fossi
Trauma Center Department, ASST Great Metropolitan Niguarda Hospital, Milan, Italy.
Osvaldo
O
Chiara
UOC Intensive Care and Territorial Emergency Department, "Maggiore" Hospital, Bologna, Italy.
Carlo
C
Coniglio
UOC Intensive Care and Territorial Emergency Department, "Maggiore" Hospital, Bologna, Italy.
Giovanni
G
Gordini
D000933:Antifibrinolytic Agents / Q000008:administration & dosage; D001778:Blood Coagulation Disorders / Q000175:diagnosis / Q000209:etiology* / Q000401:mortality / Q000628:therapy*; D016913:Blood Component Transfusion / Q000379:methods; D006801:Humans; D009026:Mortality; D010951:Plasma Exchange; D014148:Tranexamic Acid / Q000008:administration & dosage; D014947:Wounds and Injuries / Q000150:complications* / Q000401:mortality
D000933:Antifibrinolytic Agents; D014148:Tranexamic Acid
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