Thanks to Karim for a heads up on this one. Just a quick post this time, but another paper looking at the use of tranexamic acid in trauma and in this case the potential synergistic effect of cryoprecipitate together with TXA in trauma patients.
So, what of the paper? What can it tell us about the management of traumatic coagulopathy in the resus room? Well, for starters, read the abstract below and follow this link for the full paper (if you have journal access) which is now available on the JAMA network.
[learn_more caption=”Who was studied?”] This paper is a military study based in Afghanistan looking at the care of NATO and Afghan nationals treated at Camp Bastion. This is important to note as Camp Bastion is a really unique place, great in that it is somewhere with lots of opportunity to do good research, but challenged by the issues of generalisability for the results.[/learn_more] [learn_more caption=”What about the study design?”] This is an observational study and much like MATTERS 1, it looks at what happened to patients treated in the hospital following major trauma. Care was dictated by the trauma teams, they then looked back to see if there was an association between different treatment regimes and mortality in patients who received more than one unit of blood.The 4 groups (totalling 1332 patients over 5 years) they looked at were.
- Those given TXA
- Those given TXA and Cryo
- Those just given Cryo
- Those given neither.
Now, as this was observational it is perhaps not surprising that these groups appear to be slightly different at baseline. Perhaps not in the way you’d expect (I was surprised to see that the group with the highest % of SBP<90 were the ones given neither for example), but they are different at face value and also statistically. Interesting that as it may well influence the results.
The thinking behind the study is that Cryoprecipitate is a rich source of Fibrinogen which is rapidly exhausted during major bleeding. If that is replaced in conjunction with TXA with inhibits Fibrinolysis then perhaps they can be synergistic in effect. Sounds good to me – but does it work in practice?
The main outcome in this study was mortality at hospital discharge.[/learn_more][learn_more caption=”What are the headline results here?”] Well, the authors state that mortality was lowest in the tranexamic acid/cryoprecipitate group(11.6%) and tranexamic acid (18.2%) groups compared with the cryoprecipitate (21.4%) and no tranexamic acid/cryoprecipitate (23.6%) groups. However, because of the differences at baseline there is a fair bit of statistical adjustment to arrive at these figures, and that is perhaps the greatest concern here. It’s good and interesting data to publish, but an intervention trial likle this really requires an RCT for us to see if there is a real benefit as opposed to an underlying basis through patient selection. [/learn_more]
So, another trial is another from the same group that put the MATTERS trial together. The results are really interesting but the design and setting limit the applicability to my practice. Perhaps we need to keep thinking but wait a little longer to see how this works in the civilian population. Back to you Karim….[blackbirdpie url=”https://twitter.com/karimbrohi/status/335288319216873472″]
So, let’s look at this with interest, and wait to see what CRYOSTAT tells us. Looking at the protocol I think it will give us the answer we need, but I’m not yet sure when we might see the findings.