Shock Hemorrhagic Clinical Trial
Official title:
Interest of Pre-hospital Administration of Lyophilized Plasma to Prevent or Treat Coagulopathy Associated With Post-traumatic Hemorrhagic Shock (PREHO-PLYO Study )
In severe bleeding due to trauma, a decrease in coagulation factors maintains and promotes
bleeding. The plasma allows, through its contribution of coagulation factors, early
prevention or correction of this post-trauma induced coagulopathy. This study aims to measure
the effectiveness of pre-hospital FLYP administration in case of traumatic hemorrhagic shock,
in the occurrence or the treatment of a post traumatic induced coagulopathy.
Study Design
This is a randomized controlled multicenter open label study in two parallel groups.
Eligibility criteria : adult, victim of a hemorrhagic shock of traumatic origin with
[systolic blood pressure <70 mmHg] or Shock Index >1.1 The patients will receive either FLYP
either the usual treatment as given in the recommendations for best practice.
The primary endpoint is the International Normalized Ratio (INR) at hospital admission.
The study must confirm the link between causality of early administration of plasma in
improving post-traumatic coagulopathy. The study must show safe usage in out-of-hospital
situations and the ability of medical staff to meet the requirements of the health
authorities in terms of product use as well as in terms of traceability of the victims and
the treatment they received.
In severe bleeding due to trauma, a fall in coagulation factors maintains and promotes
bleeding. The plasma allows, through its contribution of coagulation factors, early
prevention or correction of this post-traumatic coagulopathy.
This labile blood product has so far only been used in armed conflicts by military medical
and surgical units deployed in External Operations (EXOP) to meet the logistical constraints
of the operating environment and the need to have, without delay, therapeutic plasma to treat
bleeding casualties. Unlike frozen plasma used in hospitals, FLYP is stored at room
temperature and is reconstituted in less than 6 mins.
In the civilian world, FLYP could be used by health institutions who have major logistical
difficulties which do not allow them to ensure a cold chain of sub-zero temperatures, or in
extreme emergency situations with the need for an immediate therapeutic plasma supply. In
this second indication, FLYP should be used until the fresh frozen plasma is thawed and
available. Its use in pre-hospital situations is also justified due to its immediate
availability and storage conditions.
FLYP is sterile and is in powder-form with a residual humidity not exceeding 2%. It is
packaged in a sterile and pyrogenic glass vial.
The main objective is to measure the effectiveness of pre-hospital FLYP administration in
case of traumatic hemorrhagic shock, in the occurrence or the treatment of a post traumatic
coagulopathy.
The secondary objectives consist in assessing the following outcomes :
(1) the need for massive transfusion (3) the ICU length of stay (4) the survival rate on day
30 (5) FLYP prehospital usability in civilian population (the compilation of technical and
logistical difficulties encountered with administration of FLYP) (6) the Prothrombin time
(PT) at hospital admission. Normal values for PT are 70 - 130%.
(7) the fibrinogen level at hospital admission (8) the variation in the level of PT, between
the pre-hospital setting and the hospital admission .
(9) the variation in the level of INR, between the pre-hospital setting and the hospital
admission .
(10) the variation in the fibrinogen level between the pre-hospital setting and the hospital
admission .
Method
The attribution of the experimental treatment (FLYP or saline), to each patient who will
receive a treatment numbered from 1 to 140, was carried out in advance using STATA 14.0
software.
Type of randomisation : randomisation in blocks of 2, stratified by center.
Treatments are allocated to participants in each "pre-hospital" center by ascending number.
Participants and investigators are therefore not blinded to the allocated treatment.However,
the statistical analysis is planned to be carried out as a blind study regarding knowledge of
the allocated treatment.
The planned experimental design is identical for each pre-hospital investigation centre.
Care of a patient in traumatic hemorrhagic shock is identical from one investigating centre
to another: it is based on formalized expert recommendations on hemorrhagic shock
resuscitation.
Determination of the number of subjects required
Coagulation factors were measured in a pre-after study in 2010 in the army in severely
traumatized patients. The "before" period consisted of an isotonic infusion of saline saline
chlorine, the "after" period of FLYP transfusion. In total, the inclusion of 124 patients
showed a significant difference between the two groups in terms of PT value. In the absence
of any other data available at the time of writing the protocol, we have brought the number
of subjects required to 140 (= 2X 70) according to a 10% in the follow-up.
There is no planned interim analysis.
The administration of the treatment in the study is stopped if any adverse event (AE) occurs
(abnormal clinical manifestation,...) and the offending experimental treatment is retained.
Usual care and corrective actions are continued in the field, during transport and at the
receiving hospital. An independent oversight committee meeting is organized to discuss the
stopping or the continuation of the study according to the nature of the AE.
Comparability of the 2 groups for the primary endpoint:
The median INR values are compared between the two groups, after adjustment on other
variables if necessary.
Comparability of the 2 groups for the secondary endpoints:
- Transfusion requirement will be judged by the number of units transfused after arrival
at the hospital: packed red blood cells (RBC), platelet concentrates, fibrinogen,
coagulation factors and plasma. The transfusion requirement will be measured over a
period of 24 to 48 hours.
- The median number of days in the ICU between the two groups will use the medians test
- Survival analysis up to 30 days will be based on the comparison of Kaplan-Meier curves,
by the log-rank test, and a Cox model to estimate the role of administration of FLYP on
survival, taking into account potential confounding factors.
- The usability of administering FLYP will be judged on the grounds of interruption or
non-administration of the experimental treatment, depending on the ability to respect
the procedure and the use of a Labile Blood Product according to the rules of good
practice.
- The average differential (pre-hospital -hospital) of coagulation parameters between the
two groups will be compared by an ANCOVA adjusted on other variables if needed.
INTERRUPTION OR STOPPING OF THE STUDY
The sponsor has the responsibility to report, to the national health authority , any serious
and unexpected adverse events attributable to the labile blood product of cell therapy and/or
protocol within 15 days (7 days in case of death and life-threatening situations).
In the case of occurrence of an incident, accident, or event, interruption of the study is
planned after analysis and decision by the hemovigilance and safety committee of the study.
RISKS
A full report on the risks, the description of incidents, accidents and adverse events will
be the subject of a chapter in the results section and also in the discussion.
FINANCING
Funding for the study is provided by the Health Department of the Army (promoter, following
the acceptance of the study in the context of Clinical research projects in the Health
service of armies).
DISCUSSION
The study must confirm the link between causality of early administration of plasma in
improving post-traumatic coagulopathy.
The study must show safe usage in out-of-hospital situations and the ability of medical staff
to meet the requirements of the health authorities in terms of product use as well as in
terms of traceability of the victims and the treatment they received.
CONCLUSION
This is the first study that aims to assess the usability and efficiency of FLYP in
prehospital situation.
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