Reply to: is “Thrombin Burst” Now the Worst Option in Trauma?

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Reply:
The response by Dr Schöchl to our recent publication raises a number of interesting points for consideration. We reported that under hypercoagulable conditions, fresh frozen plasma (FFP) reduced thrombin generation in an ATIII-dependent manner; however under hypocoagulable conditions, FFP increased thrombin generation (1). This led us to conclude that FFP promotes recovery from shock and supports plasma homeostasis across the spectrum of coagulation derangements. Thus, our data enthusiastically agree with Dr Schöchl and colleague's support of balanced resuscitation strategies.
Based on observations presented in this paper, Dr Schöchl concluded that increasing thrombin generation is not considered a priority in the management of trauma-induced coagulopathy any longer. He goes on to question the use of recombinant factor VII (rFVII) and prothrombin complex concentrates (PCCs), specifically in light of reported complications associated with the use of rFVII (2). In addition, Schöchl et al. have previously reported that treatment with PCCs results in a prothrombotic state and therefore cautioned against their use in trauma patients (3). As he has previously stated, and we wish to reiterate, these products should be used judiciously, in the right patients at the right time. Our data here and previously have shown that a minority yet nonetheless substantial number of trauma patients present with low or exhausted thrombin generating potential (1, 4). In such patients, rFVII or PCCs could be of significant clinical value. However, the question that still needs to be definitively determined is who are these patients?
While we have advocated for the use of increased ratios of plasma to red blood cells in early resuscitation to mitigate the coagulopathy of trauma, the mechanisms by which increased plasma use is of benefit have yet to be fully defined in trauma patients (5). Our present study was just an initial step. Of more interest is the possible use of fresh whole blood, containing a full complement of clotting factors and functional platelets (6, 7). To paraphrase Dr Schöchl and colleagues, the whole may be greater than the sum of the parts (8).
Dr Schöchl points out that the community caring for patients with traumatic injuries has previously responded, perhaps too quickly to promising interventions. In contrast, we would like to point out that to wait for high quality, definitive data for the care of this population may be excessively conservative given the limited funding for trauma research and the difficulty of conducting large randomized trials in this population. Presently, it is the responsibility of each individual involved in the treatment of the patient to weigh the evidence, assess the risk and benefit of a treatment, and make clinical decisions (9, 10). Further, the community at large has the obligation to advocate for well-designed studies and definitive trials to support interventions provided to the patient with traumatic injuries. We strongly agree with Dr Schöchl that this must be done.
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