Daniel A González Padilla, José Daniel Subiela, Diego M Carrion, Francesco Esperto, Juan Gómez Rivas, Sinan Khadhouri, Guglielmo Mantica, Angelika Mattigk, Benjamin Pradere, Moisés Rodríguez Socarrás, Elena Segui Moya, Jeremy Yuen-Chun Teoh, Leonardo Tortolero-Blanco, Taha Uçar, Philipp Dahm
Evidence-based Medicine: Perceptions, Attitudes, and Skills Among European Urology Residents
European urology open science
rapid progress trauma care occurs results translational research promptly integrated clinical practice experience high volume severely injured casualties expedites process1 historically conditions converged times conflict improving care combat casualties subsequently civilian trauma patients12 severely injured casualties know lethal triad hypothermia acidosis coagulopathy present death imminent3 current teaching avoid reaching conditions using damage control surgery46 however conventional resuscitation practice damage control focuses rapid reversal acidosis prevention hypothermia surgical techniques focus controlling hemorrhage contamination direct treatment coagulopathy relatively neglected viewed byproduct resuscitation hemodilution hypothermia delayed blood banking logistics damage control resuscitation addresses entire lethal triad immediately upon admission combat hospital78 demonstrating severely injured coagulopathy trauma present admission recent studies brought back light importance treating disorder earlier stage912 reports lactated ringers solution normal saline increasing reperfusion injury leukocyte adhesion lead one conclude standard crystalloidbased resuscitation guidelines prehospital trauma life support phtls advanced trauma life support atls may worsen presenting acidosis coagulopathy severely injured trauma patients possibly increase ards sirs mof1317 safety withholding prbcs hemodynamically stable patients demonstrated18 risks associated blood transfusion well described1920 massive transfusion military civilian casualties associated increased risk death2123 taken together observations suggest severely injured may need resuscitative approach tailored specifically needs however even largest civilian academic trauma centers patients injuries outer limits survivability massively transfused 10 units rbcs first 24 hours uncommon constitute 1 2 patient population making difficult develop test new resuscitation concepts21 7 combat casualties require massive transfusion opportunity observe effects new resuscitation strategies combat hospitals iraq afghanistan military munitions used southwest asia inflict severe multisystem injuries combatants civilians patients frequently present american military medical personnel shortly wounded unlike civilian systems treatment coagulopathy often limited standard blood bank logistics iraq frequently immediate access prbcs thawed ab plasma rapid access apheresis platelets prepooled cryoprecipitate fresh whole blood rfviia indicated2429 thus opportunity formally evaluate immediate direct treatment coagulopathy trauma available trauma patients severely injured approximately 10 also represent majority inhospital trauma deaths considerable attention directed toward technical details damage control surgery reversing acidosis hypothermia present admission less attention directed toward reversing coagulopathy related blood loss present time clinical experience operation iraqi freedom operation enduring freedom suggests coagulopathy may present time admission significant resuscitative fluid given consequence acidosisinduced coagulation factor dysfunction coagulation factor consumption hypothermiainduced failure platelet activation failure recognize immediately address coagulopathy found severely injured patients linked several factors studies traumainduced coagulopathy measured laboratory changes happen icu dilution crystalloid prbcs concluded coagulopathy could fully explained resuscitation andor hypothermia30 goal shock resuscitation efforts past largely support blood pressure urine output reverse metabolic derangements associated ischemia associated acute blood loss3132 although goals obviously important studies supporting concept based controlled animal hemorrhage studies results evaluated randomized human trials3335 additionally potential benefits mitigating ischemiainduced reperfusion injury standard crystalloid resuscitation fully recognized1436 furthermore recent resuscitation studies overlooked importance integrated coherent prehospital ed icu shock resuscitation plan incorporates intravascular treatment coagulopathy3237 finally current generation clinicians taught use plasma resuscitation fluid38 agree current standard resuscitation methods appropriate policy approximately 90 trauma patients shock hypercoagulable injury3942 however approximately 10 casualties constitute seriously injured shock coagulopathic represent potentially preventable hemorrhagic deaths liquid plasma may optimal resuscitation fluid currently available4350 based 1 previous civilian clinical studies 2 recommendations international consensus conference early massive transfusion trauma51 3 considerable experience current war think patients high risk coagulopathy readily identified admission prompt simultaneous treatment hypothermia acidosis coagulopathy initiated hypothermia independent factor increased mortality trauma patients earlier focus active prevention treatment5254 application training equipment recommendations committee tactical combat casualty care joint theater trauma system made uncommon finding55 acidosis significantly impairs thrombin generation rates critical optimal coagulation function56 thus aggressively managed use tham volume loading blood components hemostasis obtained restoration normal blood lactate base deficit ph ultimate goal damage control resuscitation structured intervention begins immediately rapid initial assessment ed progresses icu efforts directed toward goal repeated point care testing use multiple blood products drugs readily available theater albeit new ratios amounts compared civilian practice damage control resuscitation efforts largely completed little resuscitation required icu achieving goal quickly may allow shift limited damage control surgery earlier definitive surgical interventions including sophisticated limb salvage techniques improved outcomes severely injured casualty damage control resuscitation consists two parts initiated within minutes arrival ed first resuscitation limited keep blood pressure approximately 90 mm hg preventing renewed bleeding recently clotted vessels1517395762 second intravascular volume restoration accomplished using thawed plasma primary resuscitation fluid least 11 12 ratio prbcs8104850 initial clinical experience shows ratios decrease mortality similarly injured casualties borgman et al unpublished data recombinant fviia occasionally used along early units red cells required throughout resuscitation casualties require continued resuscitation blood bank notified activate massive transfusion protocol deliver operating room 6 units plasma 6 units prbcs 6 packs platelets 10 units cryoprecipitate stored individual coolers50 severely injured group also receive fresh warm whole blood resuscitative fluid4763 additional coolers containing mix blood products provided needed massive transfusion order cancelled crystalloid use minimized serves mainly drug carrier keep lines open units blood products combat casualties requiring major resuscitation 1040 units blood products found little 5 l 8 l crystalloid utilized first 24 hours representing decrease least 50 compared current standard resuscitation practices using damage control resuscitation approach lack intraoperative coagulopathic bleeding remarkable allowing surgeons focus surgical bleeding patients treated fashion almost always arrive icu warm euvolemic nonacidotic normal inr minimal edema majority patients abnormalities lethal triad absent patients appear easily ventilated quickly extubated patients similar blood loss treated standard crystalloid resuscitation volumes blood component ratios admittedly anecdotal yet compelling observations cause us question use excessive crystalloid resuscitation begin formulate hypotheses tested demonstrate beneficial effects preemptive control coagulopathy14 first time us warfare data admitted trauma casualties current conflict southwest asia entered joint theater trauma registry jttr64 deployed combat research team sent theater first time since vietnam operating standards irb approval practiced united states data collected team along outcome data jttr allow analysis effects resuscitation thawed plasma fresh whole blood administration rfviia limited crystalloid additionally focused effort required describe mechanisms causing early coagulopathy trauma present admission clinical effects consequences damage control resuscitation measurable patient outcomes know saving severely injured soldiers reducing coagulopathy edema leads better outcomes ultimately whether creating blood exposure less soon sufficient data assess full benefits damage control resuscitation population critically injured matters past perceptive observation thoughtful discussion insightful analysis concerning medical care war experienced military medics surgeons scientists concert civilian colleagues generate recommendations new improved medical practice continuous modification experience research development produce new relevant information12