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Greene NA, McIntosh CS, Meledeo MA, Reddoch-Cardenas KM. Hemostatic Evaluation of Refrigerated Whole Blood Stored 7 Days Post-Expiration. Mil Med 2024:usae187. [PMID: 38739474 DOI: 10.1093/milmed/usae187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Revised: 02/21/2024] [Accepted: 03/28/2024] [Indexed: 05/16/2024] Open
Abstract
INTRODUCTION The United States Army has shifted doctrine to focus on large-scale combat operations against peer to near-peer adversaries. Future conflicts could result in a limited supply chain, leaving medical providers with only expired blood products for treatment of hemorrhagic shock. This study evaluated quality, function, and safety metrics of whole blood stored for 1 week past regulated expiration (i.e., 35 days, in CPDA-1). MATERIALS AND METHODS Whole blood units (n = 6) were collected in citrate phosphate dextrose adenine-1 (CPDA-1) anticoagulant and stored refrigerated for up to 42 days. Units were sampled on days 35, 37, 39, and 42 of storage and evaluated for the following: complete blood count, blood metabolism and chemistries, clotting dynamics, and presence of bacteria. RESULTS The majority of evaluated parameters fell outside of normal clinical ranges beginning at day 35 of storage. At 42 days, blood pH was 6.58 ± 0.038, hemolysis was significantly increased (P = .037 vs day 35), and bacterial contamination was not evident. Glucose levels continuously dropped during extended storage. K+ was significantly increased at day 42 compared to day 35 (P = .010). A significant reduction in clot strength, factor V activity, and factor VIII activity was evident beginning at day 39 of storage. CONCLUSIONS Storage of whole blood out to 42 days results in a continuous decline in function, but further in vivo safety studies should be performed to determine if the benefits of expired blood outweigh the risks. Other methods to safely extend storage of whole blood that maintain hemostatic function and preserve safety should be investigated, with emphasis placed on methods that reduce potassium leak and/or hemolysis.
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Affiliation(s)
- Nicholas A Greene
- George Washington University School of Medicine and Health Sciences, Washington, DC 20052, USA
| | - Colby S McIntosh
- Blood and Shock Resuscitation Research Department, U.S. Army Institute of Surgical Research, Fort Sam Houston, TX 78234, USA
| | - Michael A Meledeo
- Blood and Shock Resuscitation Research Department, U.S. Army Institute of Surgical Research, Fort Sam Houston, TX 78234, USA
| | - Kristin M Reddoch-Cardenas
- Blood and Shock Resuscitation Research Department, U.S. Army Institute of Surgical Research, Fort Sam Houston, TX 78234, USA
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Li SR, Moheimani H, Herzig B, Kail M, Krishnamoorthi N, Wu J, Abdelhamid S, Scioscia J, Sung E, Rosengart A, Bonaroti J, Johansson PI, Stensballe J, Neal MD, Das J, Kar U, Sperry J, Billiar TR. High-dimensional proteomics identifies organ injury patterns associated with outcomes in human trauma. J Trauma Acute Care Surg 2023; 94:803-813. [PMID: 36787435 PMCID: PMC10205666 DOI: 10.1097/ta.0000000000003880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
Abstract
INTRODUCTION Severe traumatic injury with shock can lead to direct and indirect organ injury; however, tissue-specific biomarkers are limited in clinical panels. We used proteomic and metabolomic databases to identify organ injury patterns after severe injury in humans. METHODS Plasma samples (times 0, 24, and 72 hours after arrival to trauma center) from injured patients enrolled in two randomized prehospital trials were subjected to multiplexed proteomics (SomaLogic Inc., Boulder, CO). Patients were categorized by outcome: nonresolvers (died >72 hours or required ≥7 days of critical care), resolvers (survived to 30 days and required <7 days of critical care), and low Injury Severity Score (ISS) controls. Established tissue-specific biomarkers were identified through a literature review and cross-referenced with tissue specificity from the Human Protein Atlas. Untargeted plasma metabolomics (Metabolon Inc., Durham, NC), inflammatory mediators, and endothelial damage markers were correlated with injury biomarkers. Kruskal-Wallis/Mann-Whitney U tests with false discovery rate correction assessed differences in biomarker expression across outcome groups (significance; p < 0.1). RESULTS Of 142 patients, 78 were nonresolvers (median ISS, 30), 34 were resolvers (median ISS, 22), and 30 were low ISS controls (median ISS, 1). A broad release of tissue-specific damage markers was observed at admission; this was greater in nonresolvers. By 72 hours, nine cardiac, three liver, eight neurologic, and three pulmonary proteins remained significantly elevated in nonresolvers compared with resolvers. Cardiac damage biomarkers showed the greatest elevations at 72 hours in nonresolvers and had significant positive correlations with proinflammatory mediators and endothelial damage markers. Nonresolvers had lower concentrations of fatty acid metabolites compared with resolvers, particularly acyl carnitines and cholines. CONCLUSION We identified an immediate release of tissue-specific biomarkers with sustained elevation in the liver, pulmonary, neurologic, and especially cardiac injury biomarkers in patients with complex clinical courses after severe injury. The persistent myocardial injury in nonresolvers may be due to a combination of factors including metabolic stress, inflammation, and endotheliopathy.
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Affiliation(s)
- Shimena R Li
- From the Department of Surgery (S.L., H.M., B.H., M.K., N.K., J.W., S.A., J. Scioscia, E.S., A.R., J.B., M.N., U.K., J. Sperry, T.R.B.) and Pittsburgh Transfusion and Trauma Research Center (S.L., H.M., B.H., M.K., N.K., J.W., S.A., J. Scioscia, E.S., A.R., J.B., M.N., U.K., J. Sperry, T.R.B.), University of Pittsburgh, Pittsburgh; Lake Erie College of Osteopathic Medicine (B.H.), Erie, Pennsylvania; Department of Cardiology (J.W.), The Third Xiangya Hospital, Central South University, Changsha, China; Section for Transfusion Medicine (P.I.J., J. Stensballe), Capital Region Blood Bank, Rigshospitalet and Department of Anesthesia and Trauma Center (J. Stensballe), Centre of Head and Orthopaedics, Rigshospitalet, Copenhagen University Hospital, Copenhagen; Emergency Medical Services (J. Stensballe), The Capital Region of Denmark, Hillerød, Denmark; and Center for Systems Immunology, Departments of Immunology (J.D.) and Computational and Systems Biology (J.D.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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Wu J, Vodovotz Y, Abdelhamid S, Guyette FX, Yaffe MB, Gruen DS, Cyr A, Okonkwo DO, Kar UK, Krishnamoorthi N, Voinchet RG, Billiar IM, Yazer MH, Namas RA, Daley BJ, Miller RS, Harbrecht BG, Claridge JA, Phelan HA, Zuckerbraun BS, Johansson PI, Stensballe J, Morrissey JH, Tracy RP, Wisniewski SR, Neal MD, Sperry JL, Billiar TR. Multi-omic analysis in injured humans: Patterns align with outcomes and treatment responses. Cell Rep Med 2021; 2:100478. [PMID: 35028617 PMCID: PMC8715070 DOI: 10.1016/j.xcrm.2021.100478] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Revised: 08/18/2021] [Accepted: 11/23/2021] [Indexed: 12/16/2022]
Abstract
Trauma is a leading cause of death and morbidity worldwide. Here, we present the analysis of a longitudinal multi-omic dataset comprising clinical, cytokine, endotheliopathy biomarker, lipidome, metabolome, and proteome data from severely injured humans. A "systemic storm" pattern with release of 1,061 markers, together with a pattern suggestive of the "massive consumption" of 892 constitutive circulating markers, is identified in the acute phase post-trauma. Data integration reveals two human injury response endotypes, which align with clinical trajectory. Prehospital thawed plasma rescues only endotype 2 patients with traumatic brain injury (30-day mortality: 30.3 versus 75.0%; p = 0.0015). Ubiquitin carboxy-terminal hydrolase L1 (UCHL1) was identified as the most predictive circulating biomarker to identify endotype 2-traumatic brain injury (TBI) patients. These response patterns refine the paradigm for human injury, while the datasets provide a resource for the study of critical illness, trauma, and human stress responses.
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Affiliation(s)
- Junru Wu
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
- Pittsburgh Trauma Research Center, University of Pittsburgh, Pittsburgh, PA, USA
- Department of Cardiology & Center of Pharmacology, The 3rd Xiangya Hospital, Central South University, Changsha, China
- Eight-Year Program of Medicine, Xiangya School of Medicine, Central South University, Changsha, China
| | - Yoram Vodovotz
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
- Pittsburgh Trauma Research Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Sultan Abdelhamid
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
- Pittsburgh Trauma Research Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Francis X. Guyette
- Department of Emergency Medicine, Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Michael B. Yaffe
- Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology, Cambridge, MA, USA
- Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Danielle S. Gruen
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
- Pittsburgh Trauma Research Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Anthony Cyr
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
- Pittsburgh Trauma Research Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - David O. Okonkwo
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Upendra K. Kar
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
- Pittsburgh Trauma Research Center, University of Pittsburgh, Pittsburgh, PA, USA
| | | | | | - Isabel M. Billiar
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Mark H. Yazer
- The Institute for Transfusion Medicine, Pittsburgh, PA, USA
| | - Rami A. Namas
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
- Pittsburgh Trauma Research Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Brian J. Daley
- Department of Surgery, University of Tennessee Health Science Center, Knoxville, TN, USA
| | | | | | - Jeffrey A. Claridge
- Metro Health Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | - Herbert A. Phelan
- Department of Surgery, University of Texas Southwestern, Dallas, TX, USA
| | - Brian S. Zuckerbraun
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
- Pittsburgh Trauma Research Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Pär I. Johansson
- Section for Transfusion Medicine, Capital Region Blood Bank, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Jakob Stensballe
- Section for Transfusion Medicine, Capital Region Blood Bank, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Anesthesia and Trauma Center, Centre of Head and Orthopaedics, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Emergency Medical Services, The Capital Region of Denmark, Hillerød, Denmark
| | - James H. Morrissey
- Departments of Biological Chemistry & Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Russell P. Tracy
- Department of Pathology & Laboratory Medicine and Biochemistry, University of Vermont Larner College of Medicine, Colchester, VT, USA
| | | | - Matthew D. Neal
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
- Pittsburgh Trauma Research Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jason L. Sperry
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
- Pittsburgh Trauma Research Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Timothy R. Billiar
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
- Pittsburgh Trauma Research Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - PAMPer study group
- The PAMPer study group is detailed in Supplemental acknowledgments (Document S1)
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Weinberg DS, Narayanan AS, Moore TA, Vallier HA. Prolonged resuscitation of metabolic acidosis after trauma is associated with more complications. J Orthop Surg Res 2015; 10:153. [PMID: 26400732 PMCID: PMC4581441 DOI: 10.1186/s13018-015-0288-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2015] [Accepted: 09/05/2015] [Indexed: 01/03/2023] Open
Abstract
Background Optimal patterns for fluid management are controversial in the resuscitation of major trauma. Similarly, appropriate surgical timing is often unclear in orthopedic polytrauma. Early appropriate care (EAC) has recently been introduced as an objective model to determine readiness for surgery based on the resuscitation of metabolic acidosis. EAC is an objective treatment algorithm that recommends fracture fixation within 36 h when either lactate <4.0 mmol/L, pH ≥ 7.25, or base excess (BE) ≥−5.5 mmol/L. The aim of this study is to better characterize the relationship between post-operative complications and the time required for resuscitation of metabolic acidosis using EAC. Methods At an adult level 1 trauma center, 332 patients with major trauma (Injury Severity Score (ISS) ≥16) were prospectively treated with EAC. The time from injury to EAC resuscitation was determined in all patients. Age, race, gender, ISS, American Society of Anesthesiologists score (ASA), body mass index (BMI), outside hospital transfer status, number of fractures, and the specific fractures were also reviewed. Complications in the 6-month post-operative period were adjudicated by an independent multidisciplinary committee of trauma physicians and included infection, sepsis, pulmonary embolism, deep venous thrombosis, renal failure, multiorgan failure, pneumonia, and acute respiratory distress syndrome. Univariate analysis and binomial logistic regression analysis were used to compare complications between groups. Results Sixty-six patients developed complications, which was less than a historical cohort of 1,441 patients (19.9 % vs. 22.1 %). ISS (p < 0.0005) and time to EAC resuscitation (p = 0.041) were independent predictors of complication rate. A 2.7-h increase in time to resuscitation had odds for sustaining a complication equivalent to a 1-unit increase on the ISS. Conclusions EAC guidelines were safe, effective, and practically implemented in a level 1 trauma center. During the resuscitation course, increased exposure to acidosis was associated with a higher complication rate. Identifying the innate differences in the response, regulation, and resolution of acidosis in these critically injured patients is an important area for trauma research. Level of evidence Level 1: prognostic study.
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Affiliation(s)
- Douglas S Weinberg
- Department of Orthopaedic Surgery, MetroHealth Medical Center, Case Western Reserve University, 2500 MetroHealth Dr., Cleveland, OH, 44109, USA.
| | - Arvind S Narayanan
- Case Western Reserve University, School of Medicine, 10900 Euclid Avenue, Cleveland, OH, 44106, USA
| | - Timothy A Moore
- Department of Orthopaedic Surgery, MetroHealth Medical Center, Case Western Reserve University, 2500 MetroHealth Dr., Cleveland, OH, 44109, USA
| | - Heather A Vallier
- Department of Orthopaedic Surgery, MetroHealth Medical Center, Case Western Reserve University, 2500 MetroHealth Dr., Cleveland, OH, 44109, USA
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