Trauma-Induced Coagulopathy—A Review of the Systematic Reviews: Is There Sufficient Evidence to Guide Clinical Transfusion Practice?

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Systematic reviews are accepted as a robust and less biased means of appraising and synthesizing results from high-quality studies. This report collated and summarized all the systematic review evidence relating to the diagnosis and management of trauma-related coagulopathy and transfusion, thereby covering the widest possible body of literature. We defined 4 key clinical questions: (1) What are the best methods of predicting and diagnosing trauma-related coagulopathy? (2) Which methods of clinical management correct coagulopathy? (3) Which methods of clinical management correct bleeding? and (4) What are the outcomes of transfusion in trauma? Thirty-seven systematic reviews were identified through searches of MEDLINE (1950–July 2010), EMBASE (1980–July 2010), The Cochrane Library (Issue 7, 2010), National Guidelines Clearing House, National Library for Health Guidelines Finder, and UKBTS SRI Transfusion Evidence Library (www.transfusionevidencelibrary.com). The evidence from the systematic review literature was scanty with many gaps, and we were not able to conclusively answer any of our 4 questions. Much more needs to be understood about how coagulopathy and bleeding in trauma are altered by transfusion practices and, most importantly, whether this translates into improved survival. There is a need for randomized controlled trials to answer these questions. The approach described in this report provides a framework for incorporating new evidence.

Section snippets

Methods

Relevant systematic reviews were identified from searches of MEDLINE (1950–July 2010), EMBASE (1980-July 2010), The Cochrane Library (Issue 7, 2010), National Guidelines Clearing House, National Library for Health Guidelines Finder, and the UKBTS SRI Transfusion Evidence Library (www.transfusionevidencelibrary.com). Searches of the databases were amplified by an additional search by author name of known experts in the field and by checking both the reference lists of studies identified and of

Results

The searches identified a total of 14 377 records, the majority of which were excluded because they were not a systematic review, or reported a nonrelevant topic, or did not include trauma patients. Overall, 340 articles underwent full-text review (Fig 1), of which 37 met the inclusion criteria and were included in this review (Table 1). The 37 reviews were published between 2000 and 2010, with more than half of the included data coming from 2007 to 2009. Most systematic reviews were published

Discussion

Half of all major trauma cases die within 24 hours of their injury,71 often from hemorrhagic shock. Many strategies for the management of hemorrhage have been proposed, but mortality rates have shown little change over time.2 We conducted a review of systematic reviews to critically evaluate the wider literature around bleeding, coagulation, and transfusion. The specific objectives were to inform and answer 4 key questions relating to coagulopathy and transfusion practice in trauma care. The

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    This work was supported by the National Institute for Health Research Programme Grant for Applied Research (RP-PG-0407-10036).

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