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Original Article
March 2013

Association of Cryoprecipitate and Tranexamic Acid With Improved Survival Following Wartime Injury: Findings From the MATTERs II Study

Author Affiliations

Author Affiliations: National Institute of Health Research, New Queen Elizabeth Hospital (Dr Morrison), and The Academic Department of Military Surgery & Trauma, Royal Centre for Defence Medicine (Drs Morrison and Midwinter), Birmingham, and 144 Parachute Medical Squadron, 16 (Air Assault) Medical Regiment, Colchester (Dr Jansen), England; The US Army Institute of Surgical Research, Fort Sam Houston (Drs Morrison and Rasmussen), and 59th Medical Wing Science and Technology Office, Lackland Air Force Base (Dr Ross), San Antonio, Texas; and C-STARS Baltimore, R Adams Cowley Shock Trauma Center, Baltimore (Dr Dubose), and The Norman M. Rich Department of Surgery, the Uniformed Services University of the Health Sciences, Bethesda (Dr Rasmussen), Maryland.

JAMA Surg. 2013;148(3):218-225. doi:10.1001/jamasurg.2013.764
Abstract

Objective To quantify the impact of fibrinogen-containing cryoprecipitate in addition to the antifibrinolytic tranexamic acid on survival in combat injured.

Design Retrospective observational study comparing the mortality of 4 groups: tranexamic acid only, cryoprecipitate only, tranexamic acid and cryoprecipitate, and neither tranexamic acid nor cryoprecipitate. To balance comparisons, propensity scores were developed and added as covariates to logistic regression models predicting mortality.

Setting A Role 3 Combat Surgical Hospital in southern Afghanistan.

Patients A total of 1332 patients were identified from prospectively collected UK and US trauma registries who required 1 U or more of packed red blood cells and composed the following groups: tranexamic acid (n = 148), cryoprecipitate (n = 168), tranexamic acid/cryoprecipitate (n = 258), and no tranexamic acid/cryoprecipitate (n = 758).

Main Outcome Measure In-hospital mortality.

Results Injury Severity Scores were highest in the cryoprecipitate (mean [SD], 28.3 [15.7]) and tranexamic acid/cryoprecipitate (mean [SD], 26 [14.9]) groups compared with the tranexamic acid (mean [SD], 23.0 [19.2]) and no tranexamic acid/cryoprecipitate (mean [SD], 21.2 [18.5]) (P < .001) groups. Despite greater Injury Severity Scores and packed red blood cell requirements, mortality was lowest in the tranexamic acid/cryoprecipitate (11.6%) and tranexamic acid (18.2%) groups compared with the cryoprecipitate (21.4%) and no tranexamic acid/cryoprecipitate (23.6%) groups. Tranexamic acid and cryoprecipitate were independently associated with a similarly reduced mortality (odds ratio, 0.61; 95% CI, 0.42-0.89; P = .01 and odds ratio, 0.61; 95% CI, 0.40-0.94; P = .02, respectively). The combined tranexamic acid and cryoprecipitate effect vs neither in a synergy model had an odds ratio of 0.34 (95% CI, 0.20-0.58; P < .001), reflecting nonsignificant interaction (P = .21).

Conclusions Cryoprecipitate may independently add to the survival benefit of tranexamic acid in the seriously injured requiring transfusion. Additional study is necessary to define the role of fibrinogen in resuscitation from hemorrhagic shock.

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