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Treffalls RN, DuBose JJ, Brenner M, Piccinini A, Inaba K, Scalea TM, Moore LJ, Kauvar DS. Outcomes Associated With Aortic Balloon Occlusion Time in Patients With Zone 1 Resuscitative Endovascular Balloon Occlusion of the Aorta. J Surg Res 2024; 296:256-264. [PMID: 38295713 DOI: 10.1016/j.jss.2023.12.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 12/08/2023] [Accepted: 12/29/2023] [Indexed: 03/19/2024]
Abstract
INTRODUCTION Resuscitative endovascular balloon occlusion of the aorta (REBOA) has the potential to cause clinically relevant systemic ischemic burden with long durations of aortic occlusion (AO). We aimed to examine the association between balloon occlusion time and clinical complications and mortality outcomes in patients undergoing zone 1 REBOA. METHODS A retrospective cohort analysis of American Association for the Surgery of Trauma Aortic Occlusion for Resuscitation in Trauma and Acuteregistry patients with Zone 1 REBOA between 2013 and 2022 was performed. Patients with cardiopulmonary resuscitation on arrival or who did not survive past the emergency department were excluded. Total AO times were categorized as follows: <15 min, 15-30 min, 31-60 min, and >60 min. Clinical and procedural variables and in-hospital outcomes were compared across groups using bivariate and multivariate regression analyses. RESULTS There were 327 cases meeting inclusion criteria (n = 51 < 15 min, 83 15-30 min, 98 31-60 min, and 95 > 60 min, respectively). AO >60 min had higher admission lactate (8 ± 6; P = 0.004) compared to all other time groups, but injury severity score, heart rate, and systolic blood pressure were similar. Group average times from admission to definitive hemorrhage control ranged from 82 to 103 min and were similar across groups (85 min in AO >60 group). Longer AO times were associated with greater red blood cell, fresh frozen plasma transfusions (P < 0.001), and vasopressor use (P = 0.001). Mortality was greatest in the >60 min group (73%) versus the <15 min, 15-30 min, and 31-60 min groups (53%, 43%, and 45%, P < 0.001). With adjustment for injury severity score, systolic blood pressure, and lactate, AO >60 min had greater mortality (OR 3.7, 95% CI 1.6-9.4; P < 0.001) than other AO duration groups. Among 153 survivors, AO >60 min had a higher rate of multiple organ failure (15.4%) compared to the other AO durations (0%, 0%, and 4%, P = 0.02). There were no differences in amputation rates (0.7%) or spinal cord ischemia (1.4%). acute kidney injury was seen in 41% of >60 min versus 21%, 27%, and 33%, P = 0.42. CONCLUSIONS Though greater preocclusion physiologic injury may have been present, REBOA-induced ischemic insult was correlated with poor patient outcomes, specifically, REBOA inflation time >60 min had higher rates of mortality and multiple organ failure. Minimizing AO duration should be prioritized, and AO should not delay achieving definitive hemostasis. Partial REBOA may be a solution to extend safe AO time and deserves further study.
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Affiliation(s)
| | - Joseph J DuBose
- Department of Surgery, University of Texas Dell School of Medicine, Austin, Texas
| | - Megan Brenner
- Department of Surgery, University of California Riverside, Riverside, California
| | - Alice Piccinini
- Department of Surgery, Los Angelos County + University of Southern California Hospital, Los Angelos, California
| | - Kenji Inaba
- Department of Surgery, Los Angelos County + University of Southern California Hospital, Los Angelos, California
| | - Thomas M Scalea
- R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, Maryland
| | - Laura J Moore
- Department of Surgery, University of Texas McGovern Medical School, Houston, Texas
| | - David S Kauvar
- Vascular Surgery Service, Brooke Army Medical Center, Houston, Texas; Department of Surgery, Uniformed Services University, Bethesda, Maryland.
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Liu T, Liu S, Shi Y, Zhang Z, Ding S, Hou K, Zhang W, Meng X, Li F. Electrospun nanofiber membranes for rapid liver hemostasis via N-alkylated chitosan doped chitosan/PEO. Int J Biol Macromol 2024; 258:128948. [PMID: 38143056 DOI: 10.1016/j.ijbiomac.2023.128948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Revised: 12/11/2023] [Accepted: 12/19/2023] [Indexed: 12/26/2023]
Abstract
The ideal hemostatic agents should be able to stop bleeding quickly and avoid secondary bleeding caused by adhesion with blood clots during dressing change. Herein, a hydrophobic electrospun nanofiber membrane was prepared for achieving hemostasis, rationally targeting both attributes, via doping N-alkylated chitosan (N-CS) grafted with octadecyl into chitosan/polyethylene oxide (PEO). In vitro and in vivo coagulation tests showed that CPNs doped with small amounts of N-CS (CPN31) could significantly shorten hemostasis time and promote the formation of more stable and stronger blood clots. In particular, the whole blood clotting time of CPN31 (58.8 ± 2.2 s) was significantly lower than that of chitosan/PEO (CPN0) nanofiber membrane (67 ± 3.5 s) and the medical sterile gauze (86.7 ± 0.6 s). Furthermore, due to the hemophobic nature of CPNs, blood wetting of the dressing was severely limited and blood can coagulated at the site of liver injury in rats, thus reducing blood loss and allowing rapid removal of the dressing without triggering secondary hemorrhage. The CPN31 exhibited excellent hemostasis properties, easy to remove, blood compatibility, biocompatibility and promoting fibroblast proliferation properties. This hydrophobic CPNs is a promising biological adhesive for hemorrhage control.
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Affiliation(s)
- Tao Liu
- Medical Support Technology Research Department, Academy of Military Sciences, People's Liberation Army, Tianjin 300161, China; Key Laboratory of Industrial Microbiology, Ministry of Education, College of Biotechnology, Tianjin University of Science and Technology, Tianjin 300457, China
| | - Shuhan Liu
- Key Laboratory of Industrial Microbiology, Ministry of Education, College of Biotechnology, Tianjin University of Science and Technology, Tianjin 300457, China
| | - Yihan Shi
- Medical Support Technology Research Department, Academy of Military Sciences, People's Liberation Army, Tianjin 300161, China
| | - Zhuoran Zhang
- General Hospital of Xinjiang Military Command, Xinjiang 830002, China
| | - Sheng Ding
- Medical Support Technology Research Department, Academy of Military Sciences, People's Liberation Army, Tianjin 300161, China
| | - Kexin Hou
- Medical Support Technology Research Department, Academy of Military Sciences, People's Liberation Army, Tianjin 300161, China
| | - Wen Zhang
- Shandong Academy of Pharmaceutical Sciences, Shandong Engineering Research Center of Novel Sustained and Controlled Release Formulations and Targeted Drug Delivery Systems, Jinan 250101, Shandong Province, China
| | - Xin Meng
- Key Laboratory of Industrial Microbiology, Ministry of Education, College of Biotechnology, Tianjin University of Science and Technology, Tianjin 300457, China.
| | - Fan Li
- Medical Support Technology Research Department, Academy of Military Sciences, People's Liberation Army, Tianjin 300161, China.
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Wang X, Yang X, Sun Z, Guo X, Teng Y, Hou S, Shi J, Lv Q. Progress in injectable hydrogels for the treatment of incompressible bleeding: an update. Front Bioeng Biotechnol 2024; 11:1335211. [PMID: 38264581 PMCID: PMC10803650 DOI: 10.3389/fbioe.2023.1335211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Accepted: 12/26/2023] [Indexed: 01/25/2024] Open
Abstract
Uncontrollable haemorrhage from deep, noncompressible wounds remains a persistent and intractable challenge, accounting for a very high proportion of deaths in both war and disaster situations. Recently, injectable hydrogels have been increasingly studied as potential haemostatic materials, highlighting their enormous potential for the management of noncompressible haemorrhages. In this review, we summarize haemostatic mechanisms, commonly used clinical haemostatic methods, and the research progress on injectable haemostatic hydrogels. We emphasize the current status of injectable hydrogels as haemostatic materials, including their physical and chemical properties, design strategy, haemostatic mechanisms, and application in various types of wounds. We discuss the advantages and disadvantages of injectable hydrogels as haemostatic materials, as well as the opportunities and challenges involved. Finally, we propose cutting-edge research avenues to address these challenges and opportunities, including the combination of injectable hydrogels with advanced materials and innovative strategies to increase their biocompatibility and tune their degradation profile. Surface modifications for promoting cell adhesion and proliferation, as well as the delivery of growth factors or other biologics for optimal wound healing, are also suggested. We believe that this paper will inform researchers about the current status of the use of injectable haemostatic hydrogels for noncompressible haemorrhage and spark new ideas for those striving to propel this field forward.
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Affiliation(s)
- Xiudan Wang
- Institution of Disaster and Emergency Medicine, Tianjin University, Tianjin, China
- Wenzhou Safety (Emergency) Institute of Tianjin University, Wenzhou, China
- Key Laboratory for Disaster Medicine Technology, Tianjin, China
| | - Xinran Yang
- Institution of Disaster and Emergency Medicine, Tianjin University, Tianjin, China
- Wenzhou Safety (Emergency) Institute of Tianjin University, Wenzhou, China
- Key Laboratory for Disaster Medicine Technology, Tianjin, China
| | - Zhiguang Sun
- Institution of Disaster and Emergency Medicine, Tianjin University, Tianjin, China
- Wenzhou Safety (Emergency) Institute of Tianjin University, Wenzhou, China
- Key Laboratory for Disaster Medicine Technology, Tianjin, China
| | - Xiaoqin Guo
- Institution of Disaster and Emergency Medicine, Tianjin University, Tianjin, China
- Key Laboratory for Disaster Medicine Technology, Tianjin, China
| | - Yanjiao Teng
- Institution of Disaster and Emergency Medicine, Tianjin University, Tianjin, China
- Wenzhou Safety (Emergency) Institute of Tianjin University, Wenzhou, China
- Key Laboratory for Disaster Medicine Technology, Tianjin, China
| | - Shike Hou
- Institution of Disaster and Emergency Medicine, Tianjin University, Tianjin, China
- Wenzhou Safety (Emergency) Institute of Tianjin University, Wenzhou, China
- Key Laboratory for Disaster Medicine Technology, Tianjin, China
| | - Jie Shi
- Institution of Disaster and Emergency Medicine, Tianjin University, Tianjin, China
- Wenzhou Safety (Emergency) Institute of Tianjin University, Wenzhou, China
- Key Laboratory for Disaster Medicine Technology, Tianjin, China
| | - Qi Lv
- Institution of Disaster and Emergency Medicine, Tianjin University, Tianjin, China
- Wenzhou Safety (Emergency) Institute of Tianjin University, Wenzhou, China
- Key Laboratory for Disaster Medicine Technology, Tianjin, China
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Webster S, Ritson JE, Barnard EBG. Abdominal aortic junctional tourniquet (AAJT-S): a systematic review of utility in military practice. BMJ Mil Health 2023:e002451. [PMID: 37400126 DOI: 10.1136/military-2023-002451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Accepted: 06/15/2023] [Indexed: 07/05/2023]
Abstract
INTRODUCTION Haemorrhage is the leading cause of potentially survivable death on the battlefield. Despite overall improvement in battlefield mortality, there has been no improvement in survival following non-compressible torso haemorrhage (NCTH). The abdominal aortic junctional tourniquet-stabilised (AAJT-S) is a potential solution that may address this gap in improving combat mortality. This systematic review examines the evidence base for the safety and utility of the AAJT-S for prehospital haemorrhage control in the combat setting. METHODS A systematic search of MEDLINE, Cumulated Index to Nursing and Allied Health Literature and Embase (inception to February 2022) was performed using exhaustive terms, in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline. The search was limited to English-language publications in peer-reviewed journals; grey literature was not included. Human, animal and experimental studies were included. Papers were reviewed by all authors to determine inclusion. Each study was assessed for level of evidence and bias. RESULTS 14 studies met the inclusion criteria: 7 controlled swine studies (total n=166), 5 healthy human volunteer cases series (total n=251), 1 human case report and 1 mannikin study. The AAJT-S was demonstrated to be effective at cessation of blood flow when tolerated in healthy human and animal studies. It was easy to apply by minimally trained individuals. Complications were observed in animal studies, most frequently ischaemia-reperfusion injury, which was dependent on application duration. There were no randomised controlled trials, and the overall evidence base supporting the AAJT-S was low. CONCLUSIONS There are limited data of safety and effectiveness of the AAJT-S. However, there is a requirement for a far-forward solution to improve NCTH outcomes, the AAJT-S is an attractive option and high-quality evidence is unlikely to be reported in the near future. Therefore, if this is implemented into clinical practice without a solid evidence base it will need a robust governance and surveillance process, similar to resuscitative endovascular balloon occlusion of the aorta, with regular audit of use.
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Affiliation(s)
- Stacey Webster
- Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine, Birmingham, UK
| | - J E Ritson
- Emergency Department, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - E B G Barnard
- Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine, Birmingham, UK
- Emergency Department, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
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