DESC Réanimation Ile de France Réanimation en traumatologie

10 avril 2018

Transfusion de produits sanguins chez le polytraumatisé

Dr Mathieu Boutonnet Réanimation – Hôpital d’Instruction des Armées Percy

Revuedelali*érature22études1980-2008

Revuedelali*érature22études1980-2008

De quoi meurent les traumatisés?

Du*onRP,etal.1997-2008.JTrauma2010;69:620–6.

30,0%18,5%

46,7%

0%10%20%30%40%50%60%70%80%90%100%

Autres

SDMV

Traumacranien

Hémorragie

65454traumaNsésadultessurvivant>15mnaprèsl’admissionde1997à2008

5500traumaNsésparan 3,4%dedécès

Causedudécès(%)

Délaiavantdécès(médiane)

Traumacrânien 51% 24h

Hémorragie 30% 2h

Sepsis/SDMV 10% 15jours

5500paNentsparanBalNmore,USA

Médianedesurviedeshémorragiques:2heures

Du*onRP,etal.1997-2008.JTrauma2010;69:620–6.

Triade létale

HypothermieT°<34°C

CoagulopathieTTetTCA>2N

AcidosepH<7,2

Lactate>5mM

MooreEE.etal.Americanjournalofsurgery1996;172:405-10

Hémorragie

Etatdechoc

Hypothermie

MooreEE.etal.Americanjournalofsurgery1996;172:405-10

Chirurgie

Anesthésie

Remplissage

Transfusion

Catécholamines

AgentshémostaNques

miracles

Réchauffer

Transfusion de CGR en urgence

• Risques:

• Hémolyseaiguë• IncompaAbilitéABO• Existenced’unanNcorpsirrégulier

• Allo-immunisaNon

BoisenML,etal.Anesthesiology2015;122:191–5.

Transfusion de CGR en urgence

• Risques:

• Hémolyseaiguë• UAlisaAond’ungroupecompaAble+++• IdenNficaNond’unanNcorpsirrégulier

• Allo-immunisaNon

BoisenML,etal.Anesthesiology2015;122:191–5.

Transfusion de CGR en urgence:

• Risques:• Hémolyseaigüe

• UNlisaNond’ungroupecompaNble• IdenNficaNond’unanNcorpsirrégulier

• Allo-immunisaNon

BoisenML,etal.Anesthesiology2015;122:191–5.

CGRO

Transfusion de CGR en urgence

• Risques:• Hémolyseaiguë

• Allo-immunisaNon• RespectduphénotypeRh-Kell• 5anNgènesRhprincipaux:D,C,E,cete

•  Risqued’alloimmunisaNonRh1:50%ensituaNon«stable»,10-33%ensituaNon«clinique»

BoisenML,etal.Anesthesiology2015;122:191–5.

CGRO

Transfusion de CGR en urgence

• Risques:• Hémolyseaiguë

• Allo-immunisaNon• RespectduphénotypeRh-Kell• 5anNgènesRhprincipaux:D,C,E,cete

•  Risqued’alloimmunisaNonRh1:50%ensituaNon«stable»,10-33%ensituaNon«clinique»

BoisenML,etal.Anesthesiology2015;122:191–5.

CGRO

Transfusion de CGR en urgence

• Risques:• Hémolyseaiguë

• Allo-immunisaNon• RespectduphénotypeRh-Kell• 5anNgènesRhprincipaux:D,C,E,cete

DeuxdéterminaAons:CGRisogroupesCGRO

Transfusion de CGR en urgence

RESEARCH Open Access

Management of bleeding and coagulopathyfollowing major trauma: an updated EuropeanguidelineDonat R Spahn1, Bertil Bouillon2, Vladimir Cerny3,4, Timothy J Coats5, Jacques Duranteau6,Enrique Fernández-Mondéjar7, Daniela Filipescu8, Beverley J Hunt9, Radko Komadina10, Giuseppe Nardi11,Edmund Neugebauer12, Yves Ozier13, Louis Riddez14, Arthur Schultz15, Jean-Louis Vincent16 and Rolf Rossaint17*

Abstract

Introduction: Evidence-based recommendations are needed to guide the acute management of the bleedingtrauma patient. When these recommendations are implemented patient outcomes may be improved.

Methods: The multidisciplinary Task Force for Advanced Bleeding Care in Trauma was formed in 2005 with theaim of developing a guideline for the management of bleeding following severe injury. This document representsan updated version of the guideline published by the group in 2007 and updated in 2010. Recommendationswere formulated using a nominal group process, the Grading of Recommendations Assessment, Development andEvaluation (GRADE) hierarchy of evidence and based on a systematic review of published literature.

Results: Key changes encompassed in this version of the guideline include new recommendations on theappropriate use of vasopressors and inotropic agents, and reflect an awareness of the growing number of patientsin the population at large treated with antiplatelet agents and/or oral anticoagulants. The current guideline alsoincludes recommendations and a discussion of thromboprophylactic strategies for all patients following traumaticinjury. The most significant addition is a new section that discusses the need for every institution to develop,implement and adhere to an evidence-based clinical protocol to manage traumatically injured patients. Theremaining recommendations have been re-evaluated and graded based on literature published since the lastedition of the guideline. Consideration was also given to changes in clinical practice that have taken place duringthis time period as a result of both new evidence and changes in the general availability of relevant agents andtechnologies.

Conclusions: A comprehensive, multidisciplinary approach to trauma care and mechanisms with which to ensurethat established protocols are consistently implemented will ensure a uniform and high standard of care acrossEurope and beyond.

IntroductionSevere trauma is one of the major health care issuesfaced by modern society, resulting in the annual deathof more than five million people worldwide, and thisnumber is expected to increase to more than eight mil-lion by 2020 [1]. Uncontrolled post-traumatic bleedingis the leading cause of potentially preventable death

among these patients [2,3]. Appropriate management ofthe massively bleeding trauma patient includes the earlyidentification of bleeding sources followed by promptmeasures to minimise blood loss, restore tissue perfu-sion and achieve haemodynamic stability.An awareness of the specific pathophysiology asso-

ciated with bleeding following traumatic injury by treat-ing physicians is essential. About one-third of allbleeding trauma patients present with a coagulopathyupon hospital admission [4-7]. This subset of patientshas a significantly increased incidence of multiple organ

* Correspondence: RRossaint@ukaachen.de17Department of Anaesthesiology, University Hospital Aachen, RWTH AachenUniversity, Pauwelsstrasse 30, D-52074 Aachen, GermanyFull list of author information is available at the end of the article

Spahn et al. Critical Care 2013, 17:R76http://ccforum.com/content/17/2/R76

© 2013 Spahn et al.; licensee BioMed Central Ltd This is an open access article distributed under the terms of the Creative CommonsAttribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction inany medium, provided the original work is properly cited.

QuelobjecNfd’hémoglobinémie?

7à9g/dL

Stratégie transfusionnelle classique (avant 2005)

2,52,01,51,00,50,00

20

40

60

80

100 CGR

VolumeplasmaAque

Volumeérythrocytaire

Massesanguine

%

Massesanguine

%FacteursdecoagulaAon

2,52,01,51,00,50,00

20

40

60

80

100

DiaposiNve:ProfYvesOzier

Stratégie : Le déclic

5293blessésdeguerreNov2003-Sept2005àBagdad246(4.6%)TM

BorgmanMA,JTrauma2007;63:805–13.

MortalitéglobaledesTM:28%

n=31

n=53

n=162

Stratégie - Haut ratio Plasma/CGR

22civiles4militaires

17enfaveurdeshautsraNos

5nonconcluantes

HoAM,etal.Anesthesiology2012

Stratégie transfusionnelle

BhanguA,etal.Injury.2013;44(12):1693–1699.

⬇50%delamortalité

DuranteauJ,etal.RecommandaNonssurlaréanimaNonduchochémorragique.Anesthésie&Réanima8on.2015;1(1):62–74.

S’affranchir du biais de survie Analyse au fil du temps

deBiasiAR,etal.Transfusion2011;51:1925-32

835paNentstransfusésenextrêmeurgence(SAUV)

TransfusionmassiveanNcipéeProtocole(packdeTM):délaimédianduplasma=40mn

TM(≥10CGR/24h):307(36,8%)

Mortalité:36%(301/835)49%d’hémorragieincontrolée

33%demortcérébrale9%deSDMV

deBiasiAR,etal.Transfusion2011;51:1925-32

Lowplasmadeficit CGR–plasma<2Moderateplasmadeficit

Highplasmadeficit CGR–plasma>6

835paNentstransfusésenextrêmeurgence(SAUV)

TransfusionmassiveanNcipéeProtocole(packdeTM):délaimédianduplasma=40mn

S’affranchir du biais de survie Analyse au fil du temps

DuranteauJ,etal.RecommandaNonssurlaréanimaNonduchochémorragique.Anesthésie&Réanima8on.2015;1(1):62–74.

Stratégie transfusionnelle - Plaquettes?

CapAP,etal.JTraumaAcuteCareSurg2012;73:S89-94

8618blessésdeguerre–414TM(10CGRen24h)avecuNlisaNondeplaque*esdebanque

JohanssonPI,etal.JEmergTraumaShock2012;5:120-5

10études–3602paNentsBénéficeglobal(moyen)del’ordrede20%à

l’apport«important»deplaque*es

Stratégie transfusionnelle - Plaquettes?

Synergie+++avecl’apportde

plasma

Holcombetal.AnnSurg2008;248:447-458

466TMdetraumatologiecivile16levelItraumacenterJuillet2005–Juin2006

îPltîPlasma

ìPltìPlasma

ìPltîPlasma

îPltìPlasma

Stratégie transfusionnelle - Plaquettes?

DuranteauJ,etal.RecommandaNonssurlaréanimaNonduchochémorragique.Anesthésie&Réanima8on.2015;1(1):62–74.

Stratégie transfusionnelle - Plaquettes?

905traumaNsésadultessurvivant>30mnaprèsl’admissionayantreçu≥1CGRdansles6premièresheureset≥3PSL(CGR,plasma,plaque*es)dansles24premièresheures25%dedécès

ns

Plaque*esPlasma

EtudedecohorteprospecNve10traumacenters34362traumaNsés1245recevant≥1CGRdansles6premièresheures21%dedécès

ns

Holcomb,J.B.JAMASurg2013;148(2):127-36.

The Prospective, Observational, Multicenter, Major Trauma Transfusion (PROMMTT) Study

RéducNondelamortalitéhospitalièreet

praNquetransfusionnelledes6premièresheures

The Prospective, Observational, Multicenter, Major Trauma Transfusion (PROMMTT) Study

RaAo Faible<1/2 Modéré>1/2à1/1 Elevé>1/1

Min31–6h HR p HR p

Plasma:CGR 1 Réf 0,42 <0,001 0,23 <0,001

Plq:CGR 1 Réf 0,66 0,16 0,37 0,04

Holcomb,J.B.JAMASurg2013;148(2):127-36.

Holcomb,J.B.JAMASurg2013;148(2):127-36.

Plasma Plaque*es

➡94%desdécèsdecausehémorragique<24h➡81%<6h,60%<3h➡médianede2,6heuresaprèsl’admission

The Prospective, Observational, Multicenter, Major Trauma Transfusion (PROMMTT) Study

De quoi meurent les polytraumatisés?

Holcomb,J.B.JAMASurg2013;148(2):127-36.

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Autre

Cardiaque

SDMV

Sepsis

Défaillancerespiratoire

Traumacranien

Hémorragie

905traumaNsésadultessurvivant>30mnaprèsl’admissionayantreçu≥1CGRdansles6premièresheureset≥3PSL(CGR,plasma,plaque*es)dansles24premièresheures25%dedécès

95 37 88 226n=

The Pragmatic, Randomized Optimal Platelet and Plasma Ratios (PROPPR) trial

HolcombJB,etal.JAMA2015;313:471–82.

12traumacenters2stratégiesraNo1:1:1ou1:1:2

The Pragmatic, Randomized Optimal Platelet and Plasma Ratios (PROPPR) trial

HolcombJB,etal.JAMA2015;313:471–82.

Plasmadécongeléàl’avancepourêtredisponibleenmoinsde10mn:

Délaiadmission-demande:9mnDélaidemande-arrivéeauxurgences:8mn

Accompagnéed’unecarteplasNfiéeindiquant“transfuserlesplaque*esenpremier”

The Pragmatic, Randomized Optimal Platelet and Plasma Ratios (PROPPR) trial

12,7%(1:1:1)vs17%(1:1:2) 22,4%(1:1:1)vs26,1%(1:1:2)

Mortalitéà24h Mortalitéà30jours

MortparexsanguinaNon9.2%vs14.6%

HolcombJB,etal.JAMA2015;313:471–82.

Causes des décès dans PROPPR

Agents hémostatiques miracles ? FVIIa

BoffardKD,RiouB,WarrenB,etal.RecombinantfactorVIIaasadjuncAvetherapyforbleedingcontrolinseverelyinjuredtraumapaAents:twoparallelrandomized,placebo-controlled,double-blindclinicaltrials.J Trauma 2005;59:8.Intérêtdansletraumafermé?RéducNondunombredeCGRtransfusésPasdedifférencedemortalité

Facteur VIIa

•  Expérienceaméricaineenmédecinedeguerre•  18638blessésdeguerreenregistrésde2003à2009•  2050transfusés(11%)•  506reçoiventduFVIIa(1/4)

Wade,C.E.JTrauma.2010;69:353–359

Facteur VIIa •  Traumatologiecivile•  EtudeCONTROL

•  100hôpitaux/20pays•  573paNents 481traumafermés 92traumapénétrants

HauserCJ,etal.JTrauma.2010;69:489-500

Agents hémostatiques miracles ?

Lancet2010

Lancet2010

Acide tranexamique

ShakurH,etal.Effectsoftranexamicacidondeath,vascularocclusiveevents,andbloodtransfusionintraumapaNentswithsignificanthaemorrhage(CRASH-2):arandomised,placebo-controlledtrial.Lancet2010;376:23-32

+de20000paNents274centres40pays

îDelamortalitéde10%

Données Françaises IDF

Critèresd’inclusion2011–2015Adultes(>16ans)6994admissionsprimairesTraumaCenterIDFGravité:4CGR<6hCGRenSAUVNADàl’admission

Boutonnetetal.JTraumaAcuteCareSurg.2018Mar12.

Données Françaises IDF

Boutonnetetal.JTraumaAcuteCareSurg.2018Mar12.

• Acidetranexamique•  Urgence+++àPréhospitalier•  Moinsde3heuresaprèsletraumaNsme•  1gen10minpuis1gsur8h

RESEARCH Open Access

Management of bleeding and coagulopathyfollowing major trauma: an updated EuropeanguidelineDonat R Spahn1, Bertil Bouillon2, Vladimir Cerny3,4, Timothy J Coats5, Jacques Duranteau6,Enrique Fernández-Mondéjar7, Daniela Filipescu8, Beverley J Hunt9, Radko Komadina10, Giuseppe Nardi11,Edmund Neugebauer12, Yves Ozier13, Louis Riddez14, Arthur Schultz15, Jean-Louis Vincent16 and Rolf Rossaint17*

Abstract

Introduction: Evidence-based recommendations are needed to guide the acute management of the bleedingtrauma patient. When these recommendations are implemented patient outcomes may be improved.

Methods: The multidisciplinary Task Force for Advanced Bleeding Care in Trauma was formed in 2005 with theaim of developing a guideline for the management of bleeding following severe injury. This document representsan updated version of the guideline published by the group in 2007 and updated in 2010. Recommendationswere formulated using a nominal group process, the Grading of Recommendations Assessment, Development andEvaluation (GRADE) hierarchy of evidence and based on a systematic review of published literature.

Results: Key changes encompassed in this version of the guideline include new recommendations on theappropriate use of vasopressors and inotropic agents, and reflect an awareness of the growing number of patientsin the population at large treated with antiplatelet agents and/or oral anticoagulants. The current guideline alsoincludes recommendations and a discussion of thromboprophylactic strategies for all patients following traumaticinjury. The most significant addition is a new section that discusses the need for every institution to develop,implement and adhere to an evidence-based clinical protocol to manage traumatically injured patients. Theremaining recommendations have been re-evaluated and graded based on literature published since the lastedition of the guideline. Consideration was also given to changes in clinical practice that have taken place duringthis time period as a result of both new evidence and changes in the general availability of relevant agents andtechnologies.

Conclusions: A comprehensive, multidisciplinary approach to trauma care and mechanisms with which to ensurethat established protocols are consistently implemented will ensure a uniform and high standard of care acrossEurope and beyond.

IntroductionSevere trauma is one of the major health care issuesfaced by modern society, resulting in the annual deathof more than five million people worldwide, and thisnumber is expected to increase to more than eight mil-lion by 2020 [1]. Uncontrolled post-traumatic bleedingis the leading cause of potentially preventable death

among these patients [2,3]. Appropriate management ofthe massively bleeding trauma patient includes the earlyidentification of bleeding sources followed by promptmeasures to minimise blood loss, restore tissue perfu-sion and achieve haemodynamic stability.An awareness of the specific pathophysiology asso-

ciated with bleeding following traumatic injury by treat-ing physicians is essential. About one-third of allbleeding trauma patients present with a coagulopathyupon hospital admission [4-7]. This subset of patientshas a significantly increased incidence of multiple organ

* Correspondence: RRossaint@ukaachen.de17Department of Anaesthesiology, University Hospital Aachen, RWTH AachenUniversity, Pauwelsstrasse 30, D-52074 Aachen, GermanyFull list of author information is available at the end of the article

Spahn et al. Critical Care 2013, 17:R76http://ccforum.com/content/17/2/R76

© 2013 Spahn et al.; licensee BioMed Central Ltd This is an open access article distributed under the terms of the Creative CommonsAttribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction inany medium, provided the original work is properly cited.

Acide tranexamique

L’hémorragie d’origine traumatique L’anémie qui tue vite

•  Letempscompte

•  LaquanNtédeplasmacompte•  LaquanNtédeplaque*escompte

•  Laprécocitédel’apportdeplasmaetdeplaque*escompte

•  …letauxd’hémoglobinecomptemoins,surtoutàlaphaseiniNale

•  Traitementprécocedelacoagulopathie:PFC:CGR=Aumoins1:2Plaquekesprécoces(dèsle4èmeCGR)Fibrinogène

•  ObjecNfs•  Hb:7à9g/dl,(10g/dlsiTC)•  Plq>50000/mm3,(>100000/mm3siTCoupoursuitedusaignement)•  Fibrinogène1,5–2g/l•  Calciumionisémonitoréetmaintenudanslesvaleursnormales

•  Nécessitédeme*reenplacedesprotocolesdetransfusionmassive46

RESEARCH Open Access

Management of bleeding and coagulopathyfollowing major trauma: an updated EuropeanguidelineDonat R Spahn1, Bertil Bouillon2, Vladimir Cerny3,4, Timothy J Coats5, Jacques Duranteau6,Enrique Fernández-Mondéjar7, Daniela Filipescu8, Beverley J Hunt9, Radko Komadina10, Giuseppe Nardi11,Edmund Neugebauer12, Yves Ozier13, Louis Riddez14, Arthur Schultz15, Jean-Louis Vincent16 and Rolf Rossaint17*

Abstract

Introduction: Evidence-based recommendations are needed to guide the acute management of the bleedingtrauma patient. When these recommendations are implemented patient outcomes may be improved.

Methods: The multidisciplinary Task Force for Advanced Bleeding Care in Trauma was formed in 2005 with theaim of developing a guideline for the management of bleeding following severe injury. This document representsan updated version of the guideline published by the group in 2007 and updated in 2010. Recommendationswere formulated using a nominal group process, the Grading of Recommendations Assessment, Development andEvaluation (GRADE) hierarchy of evidence and based on a systematic review of published literature.

Results: Key changes encompassed in this version of the guideline include new recommendations on theappropriate use of vasopressors and inotropic agents, and reflect an awareness of the growing number of patientsin the population at large treated with antiplatelet agents and/or oral anticoagulants. The current guideline alsoincludes recommendations and a discussion of thromboprophylactic strategies for all patients following traumaticinjury. The most significant addition is a new section that discusses the need for every institution to develop,implement and adhere to an evidence-based clinical protocol to manage traumatically injured patients. Theremaining recommendations have been re-evaluated and graded based on literature published since the lastedition of the guideline. Consideration was also given to changes in clinical practice that have taken place duringthis time period as a result of both new evidence and changes in the general availability of relevant agents andtechnologies.

Conclusions: A comprehensive, multidisciplinary approach to trauma care and mechanisms with which to ensurethat established protocols are consistently implemented will ensure a uniform and high standard of care acrossEurope and beyond.

IntroductionSevere trauma is one of the major health care issuesfaced by modern society, resulting in the annual deathof more than five million people worldwide, and thisnumber is expected to increase to more than eight mil-lion by 2020 [1]. Uncontrolled post-traumatic bleedingis the leading cause of potentially preventable death

among these patients [2,3]. Appropriate management ofthe massively bleeding trauma patient includes the earlyidentification of bleeding sources followed by promptmeasures to minimise blood loss, restore tissue perfu-sion and achieve haemodynamic stability.An awareness of the specific pathophysiology asso-

ciated with bleeding following traumatic injury by treat-ing physicians is essential. About one-third of allbleeding trauma patients present with a coagulopathyupon hospital admission [4-7]. This subset of patientshas a significantly increased incidence of multiple organ

* Correspondence: RRossaint@ukaachen.de17Department of Anaesthesiology, University Hospital Aachen, RWTH AachenUniversity, Pauwelsstrasse 30, D-52074 Aachen, GermanyFull list of author information is available at the end of the article

Spahn et al. Critical Care 2013, 17:R76http://ccforum.com/content/17/2/R76

© 2013 Spahn et al.; licensee BioMed Central Ltd This is an open access article distributed under the terms of the Creative CommonsAttribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction inany medium, provided the original work is properly cited.

Bibliographie

RESEARCH Open Access

Management of bleeding and coagulopathyfollowing major trauma: an updated EuropeanguidelineDonat R Spahn1, Bertil Bouillon2, Vladimir Cerny3,4, Timothy J Coats5, Jacques Duranteau6,Enrique Fernández-Mondéjar7, Daniela Filipescu8, Beverley J Hunt9, Radko Komadina10, Giuseppe Nardi11,Edmund Neugebauer12, Yves Ozier13, Louis Riddez14, Arthur Schultz15, Jean-Louis Vincent16 and Rolf Rossaint17*

Abstract

Introduction: Evidence-based recommendations are needed to guide the acute management of the bleedingtrauma patient. When these recommendations are implemented patient outcomes may be improved.

Methods: The multidisciplinary Task Force for Advanced Bleeding Care in Trauma was formed in 2005 with theaim of developing a guideline for the management of bleeding following severe injury. This document representsan updated version of the guideline published by the group in 2007 and updated in 2010. Recommendationswere formulated using a nominal group process, the Grading of Recommendations Assessment, Development andEvaluation (GRADE) hierarchy of evidence and based on a systematic review of published literature.

Results: Key changes encompassed in this version of the guideline include new recommendations on theappropriate use of vasopressors and inotropic agents, and reflect an awareness of the growing number of patientsin the population at large treated with antiplatelet agents and/or oral anticoagulants. The current guideline alsoincludes recommendations and a discussion of thromboprophylactic strategies for all patients following traumaticinjury. The most significant addition is a new section that discusses the need for every institution to develop,implement and adhere to an evidence-based clinical protocol to manage traumatically injured patients. Theremaining recommendations have been re-evaluated and graded based on literature published since the lastedition of the guideline. Consideration was also given to changes in clinical practice that have taken place duringthis time period as a result of both new evidence and changes in the general availability of relevant agents andtechnologies.

Conclusions: A comprehensive, multidisciplinary approach to trauma care and mechanisms with which to ensurethat established protocols are consistently implemented will ensure a uniform and high standard of care acrossEurope and beyond.

IntroductionSevere trauma is one of the major health care issuesfaced by modern society, resulting in the annual deathof more than five million people worldwide, and thisnumber is expected to increase to more than eight mil-lion by 2020 [1]. Uncontrolled post-traumatic bleedingis the leading cause of potentially preventable death

among these patients [2,3]. Appropriate management ofthe massively bleeding trauma patient includes the earlyidentification of bleeding sources followed by promptmeasures to minimise blood loss, restore tissue perfu-sion and achieve haemodynamic stability.An awareness of the specific pathophysiology asso-

ciated with bleeding following traumatic injury by treat-ing physicians is essential. About one-third of allbleeding trauma patients present with a coagulopathyupon hospital admission [4-7]. This subset of patientshas a significantly increased incidence of multiple organ

* Correspondence: RRossaint@ukaachen.de17Department of Anaesthesiology, University Hospital Aachen, RWTH AachenUniversity, Pauwelsstrasse 30, D-52074 Aachen, GermanyFull list of author information is available at the end of the article

Spahn et al. Critical Care 2013, 17:R76http://ccforum.com/content/17/2/R76

© 2013 Spahn et al.; licensee BioMed Central Ltd This is an open access article distributed under the terms of the Creative CommonsAttribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction inany medium, provided the original work is properly cited.

JAMA2015;313:471–82