Base excess determined within one hour of admission predicts mortality in patients with severe pelvic fractures and severe hemorrhagic shock

Comparison of shelf-stable and conventional resuscitation products in a canine model of hemorrhagic shock

BACKGROUND

Treatment of severe hemorrhagic shock typically involves hemostatic resuscitation with blood products. However, logistical constraints often hamper the wide distribution of commonly used blood products like whole blood. Shelf-stable blood products and blood substitutes are poised to be able to effectively resuscitate individuals in hemorrhagic shock when more conventional blood products are not readily available.

METHODS

Purpose-bred adult dogs (n = 6) were anesthetized, instrumented, and subjected to hemorrhagic shock (mean arterial pressure <50 mm Hg or 40% blood volume loss). Then each dog was resuscitated with one of five resuscitation products: (1) lactated ringers solution and hetastarch (LRS/Heta), (2) canine chilled whole blood (CWB), (3) fresh frozen plasma (FFP) and packed red blood cells (pRBC), (4) canine freeze-dried plasma (FDP) and hemoglobin-based oxygen carrier (HBOC), or (5) HBOC/FDP and canine lyophilized platelets (LyoPLT). Each dog was allowed to recover after the hemorrhage resuscitation event and was then subjected to another hemorrhage event and resuscitated with a different product until each dog was resuscitated with each product.

RESULTS

At the time when animals were determined to be out of shock as defined by a shock index <1, mean arterial pressure (mmHg) values (mean ± standard error) were higher for FFP/pRBC (n = 5, 83.7 ± 4.5) and FDP/HBOC+LyoPLT (n = 4, 87.8 ± 2.1) as compared with WB (n = 4, 66.0 ± 13.1). A transient increase in creatinine was seen in dogs resuscitated with HBOC and FDP. Albumin and base excess increased in dogs resuscitated with HBOC and FDP products compared with LRS/heta and CWB ( p < 0.01).

CONCLUSION

Combinations of shelf-stable blood products compared favorably to canine CWB for resolution of shock. Further research is needed to ascertain the reliability and efficacy of these shelf-stable combinations of products in other models of hemorrhage that include a component of tissue damage as well as naturally occurring trauma.

The impact of creatine kinase and base excess on the clinical outcome of crush injuries sustained during the Kahramanmaras/Turkey earthquakes on February 6, 2023

The aim of the study is to determine the usefulness of base excess (BE) and creatine kinase (CK) in predicting the extent of damage to the extremities, the need for hemodialysis, and the likelihood of mortality in crush injuries. Our study included patients who were affected by the earthquakes that occurred in Kahramanmaras/Turkey on February 6, 2023 and were diagnosed with crush injuries. The study was a retrospective observational study. We used chi-square test, independent sample t test, analysis of variance (ANOVA) to examine whether CK and BE values can be used to predict damage to the extremities, hemodialysis requirement, and mortality. A total of 299 patients were included in the study. A statistically significant relationship was found between BE and extremity damage, hemodialysis requirement, and mortality (P < .005). A statistically significant difference was also seen in terms of extremity damage and hemodialysis requirement with CK (P < .001), while there was no statistically significant difference seen in mortality (P = .204). BE may serve as a predictive biomarker for the development of extremities damage, hemodialysis requirement, and mortality. CK is not predictive of mortality.

Early correction of base deficit decreases late mortality in polytrauma

INTRODUCTION

Physiology-driven resuscitation has become the standard of care in severely injured patients. This has resulted in a decrease in acute deaths by hemorrhagic shock. With increased survival from hemorrhage, focus shifts towards death later during hospital stay. This population based cohort study investigated the association of initial physiology derangement correction and (late) mortality.

METHODS

Consecutive polytrauma patients aged > 15 years with deranged physiology who were admitted to a level-1 trauma center intensive care unit (ICU) from 2015 to 2021, and requiring surgical intervention < 24 h were included. Patients who acutely (< 48 h) died were excluded. Demographics, treatment, and outcome parameters were analyzed. Physiology was monitored by serial base deficits (BD) during the first 48 h. Correction of physiology was defined as BD return to normal values. Area under the curve (AUC) of BD in time was used as measurement for the correction of physiological derangement and related to mortality 3-6 days (early), and > 7 days (late).

RESULTS

Two hundred thirty-five patients were included with a median age of 44 years (70% male), and Injury Severity Score (ISS) of 33. Mortality rate was 16% (71% due to traumatic brain injury (TBI)). Median time to death was 11 (6-17) days; 71% died > 7 days after injury. There was no difference between the single base deficit measurements in the emergency department(ED), operating room (OR), nor ICU between patients who died and those who did not. However, patients who later died were more acidotic at 24 and 48 h after arrival, and had a higher AUC of BD in time. This was independent of time and cause of death.

CONCLUSION

Early physiological restoration based on serial BD measurements in the first 48 h after injury decreases late mortality.

Effect of C-Clamp Application on Hemodynamic Instability in Polytrauma Victims with Pelvic Fracture

Background and Objectives: C-clamp application may reduce mortality in patients with unstable pelvic fractures and hemodynamic instability. Decreasing C-clamp use over the past decades may have resulted from concerns about its effectiveness and safety. The purpose of this study was to document effective hemodynamic stabilization after C-clamp application by means of vital parameters (primary outcome parameter), and the subsequent effect on metabolic indices and volume management (secondary outcome parameters). Materials and Methods: C-clamp application was performed between 2014 and 2021 for n = 13 patients (50 ± 18 years) with unstable pelvic fractures and hemodynamic instability. Vital parameters, metabolic indices, volume management, and the correlation of factors and potential changes were analyzed. Results: After C-clamp application, increases were measured in systolic blood pressure (+15 mmHg; p = 0.0284) and mean arterial pressure (+12 mmHg; p = 0.0157), and a reduction of volume requirements (p = 0.0266) and bolus vasoactive medication needs (p = 0.0081) were observed. The earlier C-clamp application was performed, the greater the effect (p < 0.05; r > 0.6). Heart rate, shock index, and end-tidal CO2 were not significantly altered. The extent of base deficit, hemoglobin, and lactate did not correlate with changes in vital parameters. Conclusions: In the majority of hemodynamically unstable trauma patients not responding to initial fluid resuscitation and severe pelvic fracture, early C-clamp application had an additive effect on hemodynamic stabilization and reduction in volume substitution. Based on these findings, there is still a rationale for considering early C-clamp stabilization in this group of severely injured patients.

Methylene Blue to Neonatal Septic Shock treatment in neonate pigs. Clinics (Sao Paulo) 2022;77:100139. [PMID: 36459779 PMCID: PMC9706526 DOI: 10.1016/j.clinsp.2022.100139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0]

OBJECTIVE

The authors design an animal model of neonatal sepsis to analyze the treatment of neonatal septic shock with Methylene Blue (MB) in a swine model.

METHODS

The study design included twenty male newborn pigs divided into four groups: 1) The control group; 2) The sepsis group (induced with lipopolysaccharide); 3) The MB group, and 4) The MB-treated sepsis group. Septic shock was defined as Blood Pressure (BP) dropping 20% below the baseline value. Continuous Blood Pressure (BP), Nitric Oxide (NO) levels, cyclic Guanosine Monophosphate (cGMP), malondialdehyde acid, base excess, lactate, arterial blood gases, hematocrit, and echocardiography were analyzed.

RESULTS

The BP of the sepsis group treated with MB showed a slight improvement in the first hour after treatment; however, a significant difference was not observed compared to the untreated sepsis group. Besides hemodynamic stability, the current study did not show symptomatic pulmonary hypertension, suggesting that MB was safe in neonates and children. An improvement in Base Excel (BE) levels after MB administration in septic animals may indicate a possible improvement in microcirculation.

CONCLUSION

The MB improved biomarkers related to septic shock prognosis, although an improvement in the blood levels could not be detected. MB might be a beneficial drug for hemodynamic instability in infants.

The Influence of Alcohol on the Base Excess Parameter in Trauma Patients

BACKGROUND

The base excess (BE) parameter can be used as an indicator of mortality. However, study results on the influence of alcohol on the validity of BE as a prognostic parameter in alcohol-intoxicated patients are controversial. Thus, this study examined the hypothesis: An increasing blood alcohol level reduces the prognostic value of the BE parameter on mortality.

PATIENTS AND METHODS

In a retrospective analysis of the multicenter database of the TraumaRegister DGU, patients from 2015 to 2017 were grouped depending on their blood alcohol level (BAL) into a BAL+ and BAL- group. The hypothesis was verified using logistic regression with an assumed significance level of 1% (P < 0.01).

RESULTS

Eleven thousand eight hundred eighty-nine patients were included; 9,472 patients in the BAL- group and 2,417 patients in the BAL+ group. Analysis of the BE showed lower values in the BAL+ group (BAL-: -1.8 ± 4.4 mmol/L vs. BAL+: -3.4 ± 4.6 mmol/L). There is a trend toward lower BE levels when BAL increases. Assuming a linear relationship, then BE decreases by 0.6 points per mille alcohol (95% CI: 0.5-0.7; P < 0.001). The mortality rate was significantly lower in the BAL+ group (BAL-: 11.1% vs. BAL+: 7.9%). The logistic regression analysis showed a significant beneficial influence of BAL+ on the mortality rate (OR 0.706, 95% CI 0.530-0.941, P = 0.018). To analyze whether a low BE (≤-6 mmol/L) has different prognostic effects in patients with and without alcohol, logistic regression models were calculated. However, the effect of BE ≤ -6 mmol/L was similar in both models (regression coefficients in BAL-/+ patients: 0.379/0.393).

CONCLUSIONS

The data demonstrate an existing influence of alcohol on the BE parameter; however, this does not negatively affect the BE as a prognostic parameter at a threshold of ≤ -6 mmol/L.

Comparison of base excess, lactate and pH predicting 72-h mortality of multiple trauma

Objective

To compare the predictive values of base excess (BE), lactate and pH of admission arterial blood gas for 72-h mortality in patients with multiple trauma.

Methods

This was a secondary analysis based on a publicly shared trauma dataset from the Dryad database, which provided the clinical data of 3669 multiple trauma patients with ISS > = 16. The records of BE, lactate, pH and 72-h prognosis data without missing values were selected from this dataset and 2441 individuals were enrolled in the study. Logistic regression model was performed to calculate the odds ratios (ORs) of variables. Area under the curve (AUC) of receiver operating curve (ROC) was utilized to evaluate the predictive value of predictors for 72 h in-hospital mortality. Pairwise comparison of AUCs was performed using the Delong’s test.

Results

The statistically significant correlations were observed between BE and lactate (r = − 0.5861, p < 0.05), lactate and pH (r = − 0.5039, p < 0.05), and BE and pH (r = − 0.7433, p < 0.05). The adjusted ORs of BE, lactate and pH for 72-h mortality with the adjustment for factors including gender, age, ISS category were 0.872 (95%CI: 0.854–0.890), 1.353 (95%CI: 1.296–1.413) and 0.007 (95%CI: 0.003–0.016), respectively. The AUCs of BE, lactate and pH were 0.693 (95%CI: 0.675–0.712), 0.715 (95%CI: 0.697–0.733), 0.670 (95%CI: 0.651–0.689), respectively.

Conclusions

There are significant correlations between BE, lactate and pH of the admission blood gas, all of them are independent predictors of 72-h mortality for multiple trauma. Lactate may have the best predictive value, followed by BE, and finally pH.

Predictive ability and interobserver reliability of computed tomography findings for angioembolization in patients with pelvic fracture

BACKGROUND

The purpose of this study was to identify computed tomography (CT) findings that predict the need for angioembolization in patients with pelvic fracture.

METHODS

This retrospective cross-sectional study was performed between April 2006 and October 2015 at two urban emergency medical centers in Japan. The study included patients who underwent CT within 3 hours of arrival and were diagnosed with a pelvic fracture. The study outcome was undergoing angioembolization within 24 hours of arrival. Four independent readers blinded to all clinical information interpreted the CT scans for blush, thickness of retroperitoneal hematoma, and diameter and laterality of muscle swelling around the pelvis. Receiver operating characteristics analyses provided area under the receiver-operating characteristic curves (AUROC) and diagnostic indicators at the estimated thresholds including sensitivity, specificity, positive and negative predictive values and diagnostic odds ratio (DOR). The interobserver reliability of all radiographic findings was also evaluated.

RESULTS

Fifty-two of 244 eligible patients underwent angioembolization. The predictive ability in terms of DOR was relatively better with blush on CT scan (sensitivity, 0.57; specificity, 0.86; DOR, 8.05) than with laterality of muscle swelling of 12.9 mm or greater (sensitivity, 0.79; specificity, 0.55; DOR, 4.60; AUROC, 0.75) and thickness of retroperitoneal hematoma of 22.7 mm or greater (sensitivity, 0.65; specificity, 0.74; DOR, 5.39; AUROC, 0.73). The interobserver reliability of blush, laterality of muscle swelling, and thickness of retroperitoneal hematoma was 0.43, 0.54, and 0.70, respectively.

CONCLUSION

All of the tested CT findings failed to show both sufficient predictive ability and sufficient interobserver agreement. Further diagnostic accuracy studies to validate these findings or establish a prediction model incorporating these findings are expected.

LEVEL OF EVIDENCE

Diagnostic, level V.

Ethyl pyruvate ameliorates hepatic injury following blunt chest trauma and hemorrhagic shock by reducing local inflammation, NF-kappaB activation and HMGB1 release

BACKGROUND

The treatment of patients with multiple trauma including blunt chest/thoracic trauma (TxT) and hemorrhagic shock (H) is still challenging. Numerous studies show detrimental consequences of TxT and HS resulting in strong inflammatory changes, organ injury and mortality. Additionally, the reperfusion (R) phase plays a key role in triggering inflammation and worsening outcome. Ethyl pyruvate (EP), a stable lipophilic ester, has anti-inflammatory properties. Here, the influence of EP on the inflammatory reaction and liver injury in a double hit model of TxT and H/R in rats was explored.

METHODS

Female Lewis rats were subjected to TxT followed by hemorrhage/H (60 min, 35±3 mm Hg) and resuscitation/R (TxT+H/R). Reperfusion was performed by either Ringer`s lactated solution (RL) alone or RL supplemented with EP (50 mg/kg). Sham animals underwent all surgical procedures without TxT+H/R. After 2h, blood and liver tissue were collected for analyses, and survival was assessed after 24h.

RESULTS

Resuscitation with EP significantly improved haemoglobin levels and base excess recovery compared with controls after TxT+H/R, respectively (p<0.05). TxT+H/R-induced significant increase in alanine aminotransferase levels and liver injury were attenuated by EP compared with controls (p<0.05). Local inflammation as shown by increased gene expression of IL-6 and ICAM-1, enhanced ICAM-1 and HMGB1 protein expression and infiltration of the liver with neutrophils were also significantly attenuated by EP compared with controls after TxT+H/R (p<0.05). EP significantly reduced TxT+H/R-induced p65 activation in liver tissue. Survival rates improved by EP from 50% to 70% after TxT+H/R.

CONCLUSIONS

These data support the concept that the pronounced local pro-inflammatory response in the liver after blunt chest trauma and hemorrhagic shock is associated with NF-κB. In particular, the beneficial anti-inflammatory effects of ethyl pyruvate seem to be regulated by the HMGB1/NF-κB axis in the liver, thereby, restraining inflammatory responses and liver injury after double hit trauma in the rat.

Is arterial base deficit still a useful prognostic marker in trauma? A systematic review

BACKGROUND

Arterial base deficit (BD) has been widely used in trauma patients since 1960. However, trauma management has also evolved significantly in the last 2 decades. The first objective of this study was to systematically review the literature on the relationship between arterial BD as a prognostic marker for trauma outcomes (mortality, significant injuries, and major complications) in the acute setting. The second objective was to evaluate arterial BD as a prognosis marker, specifically, in the elderly and in patients with positive blood alcohol levels.

METHODS

MEDLINE, EMBASE, Scopus, Web of Science, Cochrane Central Register of Controlled Trials, and Cochrane Database of Systematic Reviews were searched from January 1, 1990, to August 6, 2015. Bibliographies of articles were also hand searched for relevant citations.

RESULTS

Thirty-four studies were included in this review. The studies consistently showed that a higher arterial BD was associated with increased mortality, significant injuries, and major complications. The threshold BD value of 6 mmol/L was also useful in discriminating for poorer outcomes. The presence of alcohol did not affect the ability of arterial BD to discriminate between major and minor injuries. Elderly patients had higher mortality in all arterial BD categories compared to the younger age group.

CONCLUSIONS

Despite the advances in trauma care in the last 2 decades, arterial BD remains a useful prognostic marker in trauma patients, even in elderly patients and in patients who had consumed alcohol. The threshold BD value of 6 mmol/L was useful to prognosticate poorer outcomes.

Management of Bleeding Pelvic Fractures

INTRODUCTION

In patients with severe pelvic fractures, exsanguinating hemorrhage represents the major cause of death within the first 24 h. Despite advances in management, the mortality rate in these patients remains significantly high. Recently, multiple treatment algorithms have been proposed for patients with severe pelvic fractures; however, the optimal modalities in particular in the hemodynamically unstable patient are still a matter of lively debate.This review article focuses on the recent body of knowledge on the different treatment options in patients with severe pelvic fractures and proposes the possible role of each modality in the management of these patients.

METHODS

The MEDLINE database was searched for medical literature addressing the management of severe pelvic fractures with specific attention given to recent, clinically relevant publications.

RESULTS

Angiography and embolization have emerged as excellent methods for addressing arterial bleeding. Mechanical pelvic stabilization and surgical hemostasis by pelvic packing, on the other hand, may effectively control venous bleeding and bleeding from the fractured bony surface. However, since there is no precise way to determine the major source of bleeding that is responsible for the hemodynamic instability, controversy remains over the timing and optimal order of angiography, mechanical pelvic stabilization, and packing.

CONCLUSIONS

The author's own approach to these patients includes angiographic embolization as a first-line treatment only in hemodynamically stable patients with an arterial blush seen in the computed tomography scan, indicating acute arterial bleeding. Hemodynamically unstable patients are immediately transferred to the operating room, where pelvic packing and mechanical stabilization of the pelvic ring are carried out. Optionally, a subsequent postoperative angio-embolization is performed if signs of further bleeding remain present.