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Littlejohn JB, Grenn EE, Carter KT, Palei AC, Spradley FT, Hosler JP, Hoang NH, Edwards KS, Kutcher ME. Increased platelet mitochondrial function correlates with clot strength in a rodent fracture model. J Trauma Acute Care Surg 2024; 96:378-385. [PMID: 37962216 PMCID: PMC10922128 DOI: 10.1097/ta.0000000000004204] [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: 11/15/2023]
Abstract
BACKGROUND Thromboelastographic measures of clot strength increase early after injury, portending higher risks for thromboembolic complications during recovery. Understanding the specific role of platelets is challenging because of a lack of clinically relevant measures of platelet function. Platelet mitochondrial respirometry may provide insight to global platelet function but has not yet been correlated with functional coagulation studies. METHODS Wistar rats underwent anesthesia and either immediate sacrifice for baseline values (n = 6) or (1) bilateral hindlimb orthopedic injury (n = 12), versus (2) sham anesthesia (n = 12) with terminal phlebotomy/hepatectomy after 24 hours. High-resolution respirometry was used to measure basal respiration, mitochondrial leak, maximal oxidative phosphorylation, and Complex IV activity in intact platelets; Complex I- and Complex II-driven respiration was measured in isolated liver mitochondria. Results were normalized to platelet number and protein mass, respectively. Citrated native thromboelastography (TEG) was performed in triplicate. RESULTS Citrated native TEG maximal amplitude was significantly higher (81.0 ± 3.0 vs. 73.3 ± 3.5 mm, p < 0.001) in trauma compared with sham rats 24 hours after injury. Intact platelets from injured rats had higher basal oxygen consumption (17.7 ± 2.5 vs. 15.1 ± 3.2 pmol O 2 /[s × 10 8 cells], p = 0.045), with similar trends in mitochondrial leak rate ( p = 0.19) when compared with sham animals. Overall, platelet basal respiration significantly correlated with TEG maximal amplitude ( r = 0.44, p = 0.034). As a control for sex-dependent systemic mitochondrial differences, females displayed higher liver mitochondria Complex I-driven respiration (895.6 ± 123.7 vs. 622.1 ± 48.7 mmol e - /min/mg protein, p = 0.02); as a control for systemic mitochondrial effects of injury, no liver mitochondrial respiration differences were seen. CONCLUSION Platelet mitochondrial basal respiration is increased after injury and correlates with clot strength in this rodent hindlimb fracture model. Several mitochondrial-targeted therapeutics exist in common use that are underexplored but hold promise as potential antithrombotic adjuncts that can be sensitively evaluated in this preclinical model.
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Affiliation(s)
| | - Emily Evans Grenn
- Department of Surgery, University of Mississippi Medical Center, Jackson, MS, USA
| | - Kristen T. Carter
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Ana C. Palei
- Department of Surgery, University of Mississippi Medical Center, Jackson, MS, USA
| | - Frank T. Spradley
- Department of Surgery, University of Mississippi Medical Center, Jackson, MS, USA
| | - Jonathan P. Hosler
- Department of Cell and Molecular Biology, University of Mississippi Medical Center, Jackson, MS, USA
| | - Ngoc H. Hoang
- Department of Pharmacology and Toxicology, University of Mississippi Medical Center, Jackson, MS, USA
| | - Kristin S. Edwards
- Department of Pharmacology and Toxicology, University of Mississippi Medical Center, Jackson, MS, USA
| | - Matthew E. Kutcher
- Department of Surgery, University of Mississippi Medical Center, Jackson, MS, USA
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Rayatdoost F, Grottke O. The Use of Large Animal Models in Trauma and Bleeding Studies. Hamostaseologie 2023; 43:360-373. [PMID: 37696297 DOI: 10.1055/a-2118-1431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/13/2023] Open
Abstract
BACKGROUND Major trauma often results in significant bleeding and coagulopathy, posing a substantial clinical burden. To understand the underlying pathophysiology and to refine clinical strategies to overcome coagulopathy, preclinical large animal models are often used. This review scrutinizes the clinical relevance of large animal models in hemostasis research, emphasizing challenges in translating findings into clinical therapies. METHODS We conducted a thorough search of PubMed and EMBASE databases from January 1, 2010, to December 31, 2022. We used specific keywords and inclusion/exclusion criteria centered on large animal models. RESULTS Our review analyzed 84 pertinent articles, including four animal species: pigs, sheep, dogs, and nonhuman primates (NHPs). Eighty-five percent of the studies predominantly utilized porcine models. Meanwhile, sheep and dogs were less represented, making up only 2.5% of the total studies. Models with NHP were 10%. The most frequently used trauma models involved a combination of liver injury and femur fractures (eight studies), arterial hemorrhage (seven studies), and a combination of hemodilution and liver injury (seven studies). A wide array of coagulation parameters were employed to assess the efficacy of interventions in hemostasis and bleeding control. CONCLUSIONS Recognizing the diverse strengths and weaknesses of large animal models is critical for trauma and hemorrhage research. Each model is unique and should be chosen based on how well it aligns with the specific scientific objectives of the study. By strategically considering each model's advantages and limitations, we can enhance our understanding of trauma and hemorrhage pathophysiology and further advance the development of effective treatments.
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Affiliation(s)
- Farahnaz Rayatdoost
- Department of Anaesthesiology, University Hospital RWTH Aachen, Aachen, Germany
| | - Oliver Grottke
- Department of Anaesthesiology, University Hospital RWTH Aachen, Aachen, Germany
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Zhong X, Du W, Zong Z, Jiang R, Jia Y, Ye Z, Yang H. Features of Coagulo-Fibrinolytic Derangement Due to Bleeding in Nonacclimatized Rabbits Acutely Exposed to High Altitude. High Alt Med Biol 2023; 24:68-75. [PMID: 36940102 DOI: 10.1089/ham.2022.0100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/21/2023] Open
Abstract
Zhong, Xin, Wenqiong Du, Zhaowen Zong, Renqing Jiang, Yijun Jia, Zhao Ye, and Haoyang Yang. Features of coagulo-fibrinolytic derangement due to bleeding in nonacclimatized rabbits acutely exposed to high altitude. High Alt Med Biol. 24:68-75, 2023. Background: The present study aimed to observe the time course of coagulo-fibrinolytic derangement due to bleeding in rabbits acutely exposed to high altitude (HA). Materials and Methods: Forty-eight rabbits were randomly divided into four groups and were subjected to minor bleeding at low altitude, major bleeding at low altitude, minor bleeding after acute exposure to HA, and major bleeding after acute exposure to HA. To produce minor and major bleeding, 10% and 30% of the total blood volume was removed, respectively. At designated time points, samples were taken for laboratory examination. Results: While minor bleeding at low altitude led to minor coagulo-fibrinolytic derangements, it led to complicated derangements at HA, which presented as an early hypercoagulable state and transition to hypocoagulable and hyperfibrinolytic states with lower clot firmness. Major bleeding at HA resulted in greater derangements of the R time, K values, the D-dimer concentration, the alpha angle, maximum amplitude, and the concentration of fibrinogen than were observed at low altitude. Conclusions: The extent of coagulo-fibrinolytic derangements due to bleeding in rabbits after acute exposure to HA was more severe and complicated than that at low altitude. Therefore, proper resuscitation should be applied based on these changes.
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Affiliation(s)
- Xin Zhong
- State Key Laboratory of Trauma, Burn and Combined Injury, Department for Combat Casualty Care Training, Training Base for Army Health Care and Department of Orthopedics, XinQiao Hospital, Army Medical University, Chongqing, China
| | - Wenqiong Du
- State Key Laboratory of Trauma, Burn and Combined Injury, Department for Combat Casualty Care Training, Training Base for Army Health Care and Department of Orthopedics, XinQiao Hospital, Army Medical University, Chongqing, China
| | - Zhaowen Zong
- State Key Laboratory of Trauma, Burn and Combined Injury, Department for Combat Casualty Care Training, Training Base for Army Health Care and Department of Orthopedics, XinQiao Hospital, Army Medical University, Chongqing, China
| | - Renqing Jiang
- State Key Laboratory of Trauma, Burn and Combined Injury, Department for Combat Casualty Care Training, Training Base for Army Health Care and Department of Orthopedics, XinQiao Hospital, Army Medical University, Chongqing, China
| | - Yijun Jia
- State Key Laboratory of Trauma, Burn and Combined Injury, Department for Combat Casualty Care Training, Training Base for Army Health Care and Department of Orthopedics, XinQiao Hospital, Army Medical University, Chongqing, China
| | - Zhao Ye
- State Key Laboratory of Trauma, Burn and Combined Injury, Department for Combat Casualty Care Training, Training Base for Army Health Care and Department of Orthopedics, XinQiao Hospital, Army Medical University, Chongqing, China
| | - Haoyang Yang
- State Key Laboratory of Trauma, Burn and Combined Injury, Department for Combat Casualty Care Training, Training Base for Army Health Care and Department of Orthopedics, XinQiao Hospital, Army Medical University, Chongqing, China
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4
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Oestreich MA, Seidel K, Bertrams W, Müller HH, Sassen M, Steinfeldt T, Wulf H, Schmeck B. Pulmonary inflammatory response and immunomodulation to multiple trauma and hemorrhagic shock in pigs. PLoS One 2022; 17:e0278766. [PMID: 36476845 PMCID: PMC9728855 DOI: 10.1371/journal.pone.0278766] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 10/31/2022] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Patients suffering from severe trauma experience substantial immunological stress. Lung injury is a known risk factor for the development of posttraumatic complications, but information on the long-term course of the pulmonary inflammatory response and treatment with mild hypothermia are scarce. AIM To investigate the pulmonary inflammatory response to multiple trauma and hemorrhagic shock in a porcine model of combined trauma and to assess the immunomodulatory properties of mild hypothermia. METHODS Following induction of trauma (blunt chest trauma, liver laceration, tibia fracture), two degrees of hemorrhagic shock (45 and 50%) over 90 (n = 30) and 120 min. (n = 20) were induced. Animals were randomized to hypothermia (33°C) or normothermia (38°C). We evaluated bronchoalveolar lavage (BAL) fluid and tissue levels of cytokines and investigated changes in microRNA- and gene-expression as well as tissue apoptosis. RESULTS We observed a significant induction of Interleukin (IL) 1β, IL-6, IL-8, and Cyclooxygenase-2 mRNA in lung tissue. Likewise, an increased IL-6 protein concentration could be detected in BAL-fluid, with a slight decrease of IL-6 protein in animals treated with hypothermia. Lower IL-10 protein levels in normothermia and higher IL-10 protein concentrations in hypothermia accompanied this trend. Tissue apoptosis increased after trauma. However, intervention with hypothermia did not result in a meaningful reduction of pro-inflammatory biomarkers or tissue apoptosis. CONCLUSION We observed signs of a time-dependent pulmonary inflammation and apoptosis at the site of severe trauma, and to a lower extent in the trauma-distant lung. Intervention with mild hypothermia had no considerable effect during 48 hours following trauma.
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Affiliation(s)
- Marc-Alexander Oestreich
- Institute for Lung Research, Universities of Giessen and Marburg Lung Center, German Center for Lung Research (DZL), Philipps University Marburg, Marburg, Germany
| | - Kerstin Seidel
- Vascular Biology Section, Evans Department of Medicine, Whitaker Cardiovascular Institute, Boston University School of Medicine, Boston, MA, United States of America
| | - Wilhelm Bertrams
- Institute for Lung Research, Universities of Giessen and Marburg Lung Center, German Center for Lung Research (DZL), Philipps University Marburg, Marburg, Germany
| | - Hans-Helge Müller
- Institute for Medical Bioinformatics and Biostatistics, Philipps-Universität Marburg, Marburg, Germany
| | - Martin Sassen
- Department of Anesthesia and Intensive Care Medicine, University Medical Center Gießen and Marburg, Philipps University Marburg, Marburg, Germany
- Center for Emergency Medicine, University Medical Center Gießen and Marburg, Philipps University Marburg, Marburg, Germany
| | - Thorsten Steinfeldt
- BG Unfallklinik Frankfurt am Main gGmbH, Department for Anesthesia, Intensive Care Medicine and Pain Therapy, Frankfurt am Main, Germany
| | - Hinnerk Wulf
- Department of Anesthesia and Intensive Care Medicine, University Medical Center Gießen and Marburg, Philipps University Marburg, Marburg, Germany
| | - Bernd Schmeck
- Institute for Lung Research, Universities of Giessen and Marburg Lung Center, German Center for Lung Research (DZL), Philipps University Marburg, Marburg, Germany
- Department of Pulmonary and Critical Care Medicine, University Medical Center Giessen and Marburg, German Center for Lung Research (DZL), Philipps University Marburg, Marburg, Germany
- Center for Synthetic Microbiology (SYNMIKRO), Philipps-University of Marburg, Marburg, Germany
- German Center for Infection Research (DZIF), Partner Site Giessen-Marburg-Langen, Marburg, Germany
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5
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Dixon A, Beiling M, Smith S, Behrens B, Appleman L, Rick E, Murphy J, Madtson B, McCully B, Goodman A, Kanlerd A, Schaller T, Subramanian S, Trivedi A, Pati S, Schreiber M. FFP maintains normal coagulation while Kcentra induces a hypercoagulable state in a porcine model of pulmonary contusion and hemorrhagic shock. J Trauma Acute Care Surg 2022; 93:124-129. [PMID: 35261373 DOI: 10.1097/ta.0000000000003584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Moderate injury can lead to a coagulopathy. Fresh frozen plasma (FFP) corrects coagulopathy by means of a balanced array of clotting factors. We sought to compare the late effects of FFP and a prothrombin complex concentrate (PCC) on the coagulopathy of trauma using a porcine model of pulmonary contusion (PC) and hemorrhagic shock (HS) designed to evaluate the organ protective effects of these treatments. METHODS Female Yorkshire swine (40-50 kg) were randomized to receive PC + HS or control (instrumented and uninjured). A blunt PC was created using a captive bolt gun. To induce HS, a liver crush injury was performed. Eighty minutes after injury, swine were treated with 25 U·kg-1 PCC, 1 U FFP, or 50 mL lactated Ringer's vehicle in a blinded manner. Arterial blood samples were drawn every 6 hours. Swine were euthanized 48 hours postinjury. Data were analyzed by Pearson χ2, analysis of variance and Kruskal-Wallis tests with Tukey's or Mann-Whitney U tests for post hoc analysis. RESULTS Twenty-seven swine received PC + HS, 3 groups of 9 per group received PCC, FFP, or vehicle. Nine were noninjured controls. When compared with control, PC + HS swine had significantly shortened R time at 6 hours, 36 hours, and 42 hours, decreased LY30 at 12 hours, shortened K time at 30 hours and reduced α angle at 42 hours. PC + HS swine showed significant differences between treatment groups in K and α angle at 3 hours, LY30 at 12 hours and 18 hours, and MA at 12 hours, 18 hours, and 30 hours. Post hoc analysis was significant for higher α angle in PCC versus vehicle at 3 hours, higher MA in vehicle versus PCC at 12 hours and 18 hours, and higher LY30 in PCC versus vehicle at 18 hours (p < 0.012) with no significant differences between FFP and vehicle. CONCLUSION Severe injury with HS induced a coagulopathy in swine. While FFP maintained normal coagulation following injury, PCC induced more rapid initial clot propagation in injured animals.
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Affiliation(s)
- Alexandra Dixon
- From the Department of Surgery (A.D., M.B., S.Sm., B.B., L.A., E.B., J.M., B.M., B.MC., A.G., A.K., T.S., S.Sa., M.S.) Oregon Health & Science University, Portland, Oregon; Department of Laboratory Medicine (A.T., S.P.), University of California San Francisco, San Francisco, California
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6
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Sloos PH, Maas MAW, Hollmann MW, Juffermans NP, Kleinveld DJB. The effect of shock duration on trauma-induced coagulopathy in a murine model. Intensive Care Med Exp 2022; 10:1. [PMID: 34993669 PMCID: PMC8738789 DOI: 10.1186/s40635-021-00428-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Accepted: 12/20/2021] [Indexed: 11/10/2022] Open
Abstract
Background Trauma-induced coagulopathy (TIC) is a life-threatening condition associated with high morbidity and mortality. TIC can present with different coagulation defects. In this study, the aim was to determine the effect of shock duration on TIC characteristics. We hypothesized that longer duration of shock leads to a more hypocoagulable rotational thromboelastometry (ROTEM) profile compared to a shorter duration of shock. Methods Male B57BL/6J(c) mice (n = 5–10 per group) were sedated and mechanically ventilated. Trauma was induced by bilateral lower limb fractures and crush injuries to the liver and small intestine. Shock was induced by blood withdrawals until a mean arterial pressure of 25–30 mmHg was achieved. Groups reflected trauma and shock for 30 min (TS30) and trauma and shock for 90 min (TS90). Control groups included ventilation only (V90) and trauma only (T90). Results Mice in the TS90 group had significantly increased base deficit compared to the V90 group. Mortality was 10% in the TS30 group and 30% in the TS90 group. ROTEM profile was more hypocoagulable, as shown by significantly lower maximum clot firmness (MCF) in the TS30 group (43.5 [37.5–46.8] mm) compared to the TS90 group (52.0 [47.0–53.0] mm, p = 0.04). ROTEM clotting time and parameters of clot build-up did not significantly differ between groups. Conclusions TIC characteristics change with shock duration. Contrary to the hypothesis, a shorter duration of shock was associated with decreased maximum clotting amplitudes compared to a longer duration of shock. The effect of shock duration on TIC should be further assessed in trauma patients. Supplementary Information The online version contains supplementary material available at 10.1186/s40635-021-00428-1.
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Affiliation(s)
- Pieter H Sloos
- Department of Intensive Care Medicine, Amsterdam UMC Location AMC, Amsterdam, The Netherlands.,Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam UMC Location AMC, Amsterdam, The Netherlands
| | - M Adrie W Maas
- Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam UMC Location AMC, Amsterdam, The Netherlands
| | - Markus W Hollmann
- Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam UMC Location AMC, Amsterdam, The Netherlands.,Department of Anaesthesiology, Amsterdam UMC Location AMC, Amsterdam, The Netherlands
| | - Nicole P Juffermans
- Department of Intensive Care Medicine, Amsterdam UMC Location AMC, Amsterdam, The Netherlands.,Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam UMC Location AMC, Amsterdam, The Netherlands.,Department of Intensive Care Medicine, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
| | - Derek J B Kleinveld
- Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam UMC Location AMC, Amsterdam, The Netherlands. .,Department of Intensive Care Medicine, Erasmus MC, Rotterdam, The Netherlands.
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7
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Durán-Rey D, Crisóstomo V, Sánchez-Margallo JA, Sánchez-Margallo FM. Systematic Review of Tissue-Engineered Vascular Grafts. Front Bioeng Biotechnol 2021; 9:771400. [PMID: 34805124 PMCID: PMC8595218 DOI: 10.3389/fbioe.2021.771400] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Accepted: 10/18/2021] [Indexed: 01/01/2023] Open
Abstract
Pathologies related to the cardiovascular system are the leading causes of death worldwide. One of the main treatments is conventional surgery with autologous transplants. Although donor grafts are often unavailable, tissue-engineered vascular grafts (TEVGs) show promise for clinical treatments. A systematic review of the recent scientific literature was performed using PubMed (Medline) and Web of Science databases to provide an overview of the state-of-the-art in TEVG development. The use of TEVG in human patients remains quite restricted owing to the presence of vascular stenosis, existence of thrombi, and poor graft patency. A total of 92 original articles involving human patients and animal models were analyzed. A meta-analysis of the influence of the vascular graft diameter on the occurrence of thrombosis and graft patency was performed for the different models analyzed. Although there is no ideal animal model for TEVG research, the murine model is the most extensively used. Hybrid grafting, electrospinning, and cell seeding are currently the most promising technologies. The results showed that there is a tendency for thrombosis and non-patency in small-diameter grafts. TEVGs are under constant development, and research is oriented towards the search for safe devices.
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Affiliation(s)
- David Durán-Rey
- Laparoscopy Unit, Jesús Usón Minimally Invasive Surgery Centre, Cáceres, Spain
| | - Verónica Crisóstomo
- Cardiovascular Unit, Jesús Usón Minimally Invasive Surgery Centre, Cáceres, Spain.,Centro de Investigacion Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, Madrid, Spain
| | - Juan A Sánchez-Margallo
- Bioengineering and Health Technologies Unit, Jesús Usón Minimally Invasive Surgery Centre, Cáceres, Spain
| | - Francisco M Sánchez-Margallo
- Centro de Investigacion Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, Madrid, Spain.,Scientific Direction, Jesús Usón Minimally Invasive Surgery Centre, Cáceres, Spain
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8
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Ghosh S, Krege W, Doerr B, Mischnik M, Pragst I, Dickneite G, Herzog E. Evaluation of the prothrombotic potential of four-factor prothrombin complex concentrate (4F-PCC) in animal models. PLoS One 2021; 16:e0258192. [PMID: 34614035 PMCID: PMC8494364 DOI: 10.1371/journal.pone.0258192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Accepted: 09/21/2021] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVES Acquired coagulopathy may be associated with bleeding risk. Approaches to restore haemostasis include administration of coagulation factor concentrates, but there are concerns regarding potential prothrombotic risk. The present study assessed the prothrombotic potential of four-factor prothrombin complex concentrate (4F-PCC) versus activated PCC (aPCC) and recombinant factor VIIa (rFVIIa), using three preclinical animal models. METHODS The first model was a modified Wessler model of venous stasis-induced thrombosis in rabbit, focusing on dilutional coagulopathy; the second model employed the same system but focused on direct oral anticoagulant reversal (i.e. edoxaban). The third model assessed the prothrombotic impact of 4F-PCC, aPCC and rFVIIa in a rat model of ferric chloride-induced arterial thrombosis. RESULTS In the first model, thrombi were observed at aPCC doses ≥10 IU/kg (therapeutic dose 100 IU/kg) and rFVIIa doses ≥50 μg/kg (therapeutic dose 90 μg/kg), but not 4F-PCC 50 IU/kg (therapeutic dose 50 IU/kg). The impact of 4F-PCC (up to 300 IU/kg) on thrombus formation was evident from 10 minutes post-administration, but not at 24 hours post-administration; this did not change with addition of tranexamic acid and/or fibrinogen concentrate. 4F-PCC-induced thrombus formation was lower after haemodilution versus non-haemodilution. In the second model, no prothrombotic effect was confirmed at 4F-PCC 50 IU/kg. The third model showed lower incidence of thrombus formation for 4F-PCC 50 IU/kg versus aPCC (50 U/kg) and rFVIIa (90 μg/kg). CONCLUSIONS These results suggest that 4F-PCC has a low thrombotic potential versus aPCC or rFVIIa, supporting the clinical use of 4F-PCC for the treatment of coagulopathy-mediated bleeding.
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Affiliation(s)
- Subhajit Ghosh
- Department of Pharmacology and Toxicology, CSL Behring GmbH, Marburg, Germany
| | - Wilfred Krege
- Department of Pharmacology and Toxicology, CSL Behring GmbH, Marburg, Germany
| | - Baerbel Doerr
- Department of Pharmacology and Toxicology, CSL Behring GmbH, Marburg, Germany
| | - Marcel Mischnik
- Department of Pharmacology and Toxicology, CSL Behring GmbH, Marburg, Germany
| | - Ingo Pragst
- Department of Clinical Research and Development, CSL Behring GmbH, Marburg, Germany
| | - Gerhard Dickneite
- Department of Pharmacology and Toxicology, CSL Behring GmbH, Marburg, Germany
| | - Eva Herzog
- Department of Pharmacology and Toxicology, CSL Behring GmbH, Marburg, Germany
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9
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Lower Extremity Duplex Ultrasound Screening Protocol for Moderate- and High-Risk Trauma Patients. J Surg Res 2019; 235:280-287. [DOI: 10.1016/j.jss.2018.10.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Revised: 08/26/2018] [Accepted: 10/02/2018] [Indexed: 11/17/2022]
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10
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A clinically relevant and bias-controlled murine model to study acute traumatic coagulopathy. Sci Rep 2018; 8:5783. [PMID: 29636535 PMCID: PMC5893580 DOI: 10.1038/s41598-018-24225-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2017] [Accepted: 03/20/2018] [Indexed: 12/30/2022] Open
Abstract
Acute traumatic coagulopathy (ATC) is an acute and endogenous mechanism triggered by the association of trauma and hemorrhage. Several animal models have been developed, but some major biases have not yet been identified. Our aim was to develop a robust and clinically relevant murine model to study this condition. Anesthetized adult Sprague Dawley rats were randomized into 4 groups: C, control; T, trauma; H, hemorrhage; TH, trauma and hemorrhage (n = 7 each). Trauma consisted of laparotomy associated with four-limb and splenic fractures. Clinical variables, ionograms, arterial and hemostasis blood tests were compared at 0 and 90 min. ATC and un-compensated shock were observed in group TH. In this group, the rise in prothrombin time and activated partial thromboplastin was 29 and 40%, respectively. Shock markers, compensation mechanisms and coagulation pathways were all consistent with human pathophysiology. The absence of confounding factors, such as trauma-related bleeding or dilution due to trans-capillary refill was verified. This ethic, cost effective and bias-controlled model reproduced the specific and endogenous mechanism of ATC and will allow to identify potential targets for therapeutics in case of trauma-related hemorrhage.
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11
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Modeling Acute Traumatic Hemorrhagic Shock Injury: Challenges and Guidelines for Preclinical Studies. Shock 2017; 48:610-623. [DOI: 10.1097/shk.0000000000000901] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
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12
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Dhillon NK, Smith EJT, Ko A, Harada MY, Yang AR, Patel KA, Barmparas G, Ley EJ. The risk factors of venous thromboembolism in massively transfused patients. J Surg Res 2017; 222:115-121. [PMID: 29273362 DOI: 10.1016/j.jss.2017.09.038] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2017] [Revised: 09/02/2017] [Accepted: 09/28/2017] [Indexed: 11/29/2022]
Abstract
BACKGROUND Massive transfusion protocols (MTPs) are necessary for hemodynamically unstable trauma patients with active bleeding. Thrombotic events have been associated with blood transfusion; however, the risk factors for the development of venous thromboembolism (VTE) in trauma patients receiving MTP are unknown. METHODS A retrospective review was conducted by reviewing the electronic medical records of all trauma patients admitted to a Level I trauma center who received MTP from 2011 to 2016. Data were collected on patient demographics, mechanism of injury, injury severity scores, quantity of blood products transfused during MTP activation, incidence of VTE, intensive care unit length of stay (LOS), hospital LOS, and ventilator days. The primary outcome was VTE. RESULTS Of the 59 patients who had MTP activated, 15 (25.4%) developed a VTE during their hospital admission. Patients who developed VTE were compared with those who did not. Age (40 y versus 35 y, P = 0.59), sex (60% versus 73% male, P = 0.52), and mechanism of injury (47% versus 59% blunt, P = 0.40) were similar. Intensive care unit LOS, hospital LOS, and ventilator days were longer in the patients who were diagnosed with a VTE. Multivariable analysis revealed an increase in the odds for developing a VTE with increasing packed red blood cell transfusion (adjusted odds ratio = 2.61, P = 0.03). CONCLUSIONS The risk for VTE in trauma patients requiring massive transfusion is proportional to the number of packed red blood cells transfused. Liberal screening protocols and maintenance of a high index of suspicion for VTE in these high-risk patients is justified.
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Affiliation(s)
- Navpreet K Dhillon
- Division of Trauma and Critical Care, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Eric J T Smith
- Division of Trauma and Critical Care, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Ara Ko
- Division of Trauma and Critical Care, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Megan Y Harada
- Division of Trauma and Critical Care, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Audrey R Yang
- Division of Trauma and Critical Care, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Kavita A Patel
- Division of Trauma and Critical Care, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Galinos Barmparas
- Division of Trauma and Critical Care, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Eric J Ley
- Division of Trauma and Critical Care, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California.
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Tissue injury suppresses fibrinolysis after hemorrhagic shock in nonhuman primates (rhesus macaque). J Trauma Acute Care Surg 2017; 82:750-757. [PMID: 28129263 DOI: 10.1097/ta.0000000000001379] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Hypoperfusion is associated with hyperfibrinolysis and early death from exsanguination, whereas tissue trauma is associated with hypofibrinolysis and delayed death from organ failure. We sought to elucidate the effects of injury patterns on fibrinolysis phenotypes using a nonhuman primate (NHP) model. METHODS NHPs were randomized to three injury groups (n = 8/group): 60 minutes severe pressure-targeted controlled hemorrhagic shock (HS); HS + soft tissue injury (HS+); or HS + soft tissue injury + femur fracture (HS++). Animals were resuscitated and monitored for 360 minutes. Blood samples were collected at baseline, end-of-shock, end-of-resuscitation (EOR), and T = 360 minutes for assessments of: severity of shock (lactate) and coagulation via prothrombin time, partial thromboplastin time, D-dimer, fibrinogen, antithrombin-III, von Willebrand factor, and viscoelastic testing (ROTEM). Results are reported as mean ± SEM; statistics: two-way analysis of variance and t-tests (significance: p < 0.05). RESULTS Blood loss, prothrombin time, partial thromboplastin time, antithrombin-III, fibrinogen, and von Willebrand factor were equivalent among groups and viscoelastic testing revealed few differences throughout the study. D-dimer increased approximately threefold, at EOR in the HS group, and at T = 360 minutes in the HS+ and HS++ groups (p < 0.05). At EOR, in the HS group compared with the HS+ and HS++ groups; the D-dimer-lactate ratio was twofold greater (2.2 ± 0.3 vs. 1.1 ± 0.3 and 1.1 ± 0.2, respectively; p < 0.05) and tissue factor-activated fibrin clot 30-minute lysis index was lower (98 ± 1% vs. 100 ± 0% and 100 ± 0%, respectively; p < 0.05). CONCLUSION NHPs in HS exhibit acute suppression of fibrinolysis in the presence of tissue injury. Additional assessments to more comprehensively evaluate the mechanisms linking tissue injury with the observed fibrinolysis shutdown response are warranted.
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Wu R, Peng LG, Zhao HM. Diverse coagulopathies in a rabbit model with different abdominal injuries. World J Emerg Med 2017; 8:141-147. [PMID: 28458760 DOI: 10.5847/wjem.j.1920-8642.2017.02.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Although coagulopathy can be very common in severe traumatic shock patients, the exact incidence and mechanism remain unclear. In this study, a traumatic shock rabbit model with special abdomen injuries was developed and evaluated by examining indicators of clotting and fibrinolysis. METHODS Forty New Zealand white rabbits were randomly divided into four groups: group 1 (sham), group 2 (hemorrhage), group 3 (hemorrhage-liver injury), and group 4 (hemorrhage-liver injury/intestinal injury-peritonitis). Coagulation was detected by thromboelastography before trauma (T0), at 1 hour (T1) and 4 hours (T2) after trauma. RESULTS Rabbits that suffered from hemorrhage alone did not differ in coagulation capacity compared with the sham group. The clot initiations (R times) of group 3 at T1 and T2 were both shorter than those of groups 1, 2, and 4 (P<0.05). In group 4, clot strength was decreased at T1 and T2 compared with those in groups 1, 2, and 3 (P<0.05), whereas the R time and clot polymerization were increased at T2 (P<0.05). The clotting angle significantly decreased in group 4 compared with groups 2 and 3 at T2 (P<0.05). CONCLUSION This study suggests that different abdominal traumatic shock show diverse coagulopathy in the early phase. Isolated hemorrhagic shock shows no obvious effect on coagulation. In contrast, blunt hepatic injury with hemorrhage shows hypercoagulability, whereas blunt hepatic injury with hemorrhage coupled with peritonitis caused by a ruptured intestine shows a tendency toward hypocoagulability.
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Affiliation(s)
- Ruo Wu
- Department of Emergency Medicine, Haikou People's Hospital Affiliated to Central South University, Haikou 570208, China
| | - Luo-Gen Peng
- Department of Emergency Medicine, the First Affiliated Hospital of Guangxi Medical University, Nanning 530021, China
| | - Hui-Min Zhao
- Department of Emergency Medicine, the First Affiliated Hospital of Guangxi Medical University, Nanning 530021, China
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Witowski NE, Lusczek ER, Determan CE, Lexcen DR, Mulier KE, Wolf A, Ostrowski BG, Beilman GJ. Metabolomic analysis of survival in carbohydrate pre-fed pigs subjected to shock and polytrauma. MOLECULAR BIOSYSTEMS 2016; 12:1638-52. [PMID: 26989839 PMCID: PMC5577932 DOI: 10.1039/c5mb00637f] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Hemorrhagic shock, a result of extensive blood loss, is a dominant factor in battlefield morbidity and mortality. Early rodent studies in hemorrhagic shock reported carbohydrate feeding prior to the induction of hemorrhagic shock decreased mortality. When repeated in our laboratory with a porcine model, carbohydrate pre-feed resulted in a 60% increase in death rate following hemorrhagic shock with trauma when compared to fasted animals (15/32 or 47% vs. 9/32 or 28%). In an attempt to explain the unexpected death rate for pre-fed animals, we further investigated the metabolic profiles of pre-fed non-survivors (n = 15) across 4 compartments (liver, muscle, serum, and urine) at specific time intervals (pre-shock, shock, and resuscitation) and compared them to pre-fed survivors (n = 17). As hypothesized, pre-fed pigs that died as a result of hemorrhage and trauma showed differences in their metabolic and physiologic profiles at all time intervals and in all compartments when compared to pre-fed survivors. Our data suggest that, although all animals were subjected to the same shock and trauma protocol, non-survivors exhibited altered carbohydrate processing as early as the pre-shock sampling point. This was evident in (for example) the higher levels of ATP and markers of greater anabolic activity in the muscle at the pre-shock time point. Based on the metabolic findings, we propose two mechanisms that connect pre-fed status to a higher death rate: (1) animals that die are more susceptible to opening of the mitochondrial permeability transition pore, a major factor in ischemia/reperfusion injury; and (2) loss of fasting-associated survival mechanisms in pre-fed animals.
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Affiliation(s)
- Nancy E Witowski
- Department of Surgery, University of Minnesota, Minneapolis, MN, USA.
| | | | | | - Daniel R Lexcen
- Department of Surgery, University of Minnesota, Minneapolis, MN, USA.
| | - Kristine E Mulier
- Department of Surgery, University of Minnesota, Minneapolis, MN, USA.
| | - Andrea Wolf
- Department of Surgery, University of Minnesota, Minneapolis, MN, USA.
| | | | - Greg J Beilman
- Department of Surgery, University of Minnesota, Minneapolis, MN, USA.
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Abstract
BACKGROUND Perturbations in coagulation function are common following trauma and are associated with poor clinical outcomes. Traditionally considered an iatrogenic process, it is now recognized that an acute coagulation dysfunction develops prior to medical intervention. The mechanisms underlying the development of this acute traumatic coagulopathy remain poorly understood. Preclinical animal research is a necessary adjunct to improve mechanistic understanding and management of this condition. This review aims to identify and evaluate existing animal models of traumatic coagulopathy for clinical relevance. METHODS A structured search of MEDLINE/PubMed was performed in September 2014 in accordance with the PRISMA guidelines. RESULTS A total of 62 relevant publications describing 27 distinct models of traumatic coagulopathy were identified. Porcine models predominated, and hemodilution in isolation or in combination with hypothermia and/or acidosis was the principal mechanism for inducing coagulopathy. Acute coagulation changes in response to tissue injury and hemorrhage were evident in five publications, and pathophysiological evaluation of postulated mechanisms was performed in three studies. CONCLUSIONS There are few clinically relevant animal models that reflect the contemporary understanding of traumatic coagulopathy. This relative deficiency highlights the need for further development of valid and reproducible animal models of trauma. Well-designed models will facilitate improved mechanistic understanding and development of targeted treatment strategies for traumatic coagulopathy.
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Lusczek ER, Vincent T, Lexcen D, Kulkarni V, Mulier K, Beilman G. Metabolic networks in a porcine model of trauma and hemorrhagic shock demonstrate different control mechanism with carbohydrate pre-feed. BMC Emerg Med 2015; 15:13. [PMID: 26130247 PMCID: PMC4486709 DOI: 10.1186/s12873-015-0038-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2014] [Accepted: 09/25/2014] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Treatment with oral carbohydrate prior to trauma and hemorrhage confers a survival benefit in small animal models. The impact of fed states on survival in traumatically injured humans is unknown. This work uses regulatory networks to examine the effect of carbohydrate pre-feeding on metabolic response to polytrauma and hemorrhagic shock in a clinically-relevant large animal model. METHODS Male Yorkshire pigs were fasted overnight (n = 64). Pre-fed animals (n = 32) received an oral bolus of Karo\textregistered\syrup before sedation. All animals underwent a standardized trauma, hemorrhage, and resuscitation protocol. Serum samples were obtained at set timepoints. Proton NMR was used to identify and quantify serum metabolites. Metabolic regulatory networks were constructed from metabolite concentrations and rates of change in those concentrations to identify controlled nodes and controlling nodes of the network. RESULTS Oral carbohydrate pre-treatment was not associated with survival benefit. Six metabolites were identified as controlled nodes in both groups: adenosine, cytidine, glycerol, hypoxanthine, lactate, and uridine. Distinct groups of controlling nodes were associated with controlled nodes; however, the composition of these groups depended on feeding status. CONCLUSIONS A common metabolic output, typically associated with injury and hypoxia, results from trauma and hemorrhagic shock. However, this output is directed by different metabolic inputs depending upon the feeding status of the subject. Nodes of the network that are related to mortality can potentially be manipulated for therapeutic effect; however, these nodes differ depending upon feeding status.
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Affiliation(s)
- Elizabeth R Lusczek
- Department of Surgery, University of Minnesota, 516 Delaware St. SE, Minneapolis, MN, 55455, USA.
| | - Tyrone Vincent
- Department of Electrical Engineering and Computer Science, Colorado School of Mines, 1610 Illinois St., Golden, CO, 80401, USA.
| | - Daniel Lexcen
- Medtronic Inc., 710 Medtronic Parkway NE, Minneapolis, MN, 55432, USA.
| | | | - Kristine Mulier
- Department of Surgery, University of Minnesota, 516 Delaware St. SE, Minneapolis, MN, 55455, USA.
| | - Greg Beilman
- Department of Surgery, University of Minnesota, 516 Delaware St. SE, Minneapolis, MN, 55455, USA.
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A four-compartment metabolomics analysis of the liver, muscle, serum, and urine response to polytrauma with hemorrhagic shock following carbohydrate prefeed. PLoS One 2015; 10:e0124467. [PMID: 25875111 PMCID: PMC4396978 DOI: 10.1371/journal.pone.0124467] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2014] [Accepted: 02/08/2015] [Indexed: 12/05/2022] Open
Abstract
Objective Hemorrhagic shock accompanied by injury represents a major physiologic stress. Fasted animals are often used to study hemorrhagic shock (with injury). A fasted state is not guaranteed in the general human population. The objective of this study was to determine if fed animals would exhibit a different metabolic profile in response to hemorrhagic shock with trauma when compared to fasted animals. Methods Proton (1H) NMR spectroscopy was used to determine concentrations of metabolites from four different compartments (liver, muscle, serum, urine) taken at defined time points throughout shock/injury and resuscitation. PLS-DA was performed and VIP lists established for baseline, shock and resuscitation (10 metabolites for each compartment at each time interval) on metabolomics data from surviving animals. Results Fed status prior to the occurrence of hemorrhagic shock with injury alters the metabolic course of this trauma and potentially affects mortality. The death rate for CPF animals is higher than FS animals (47 vs 28%). The majority of deaths occur post-resuscitation suggesting reperfusion injury. The metabolomics response to shock reflects priorities evident at baseline. FS animals raise the baseline degree of proteolysis to provide additional amino acids for energy production while CPF animals rely on both glucose and, to a lesser extent, amino acids. During early resuscitation levels of metabolites associated with energy production drop, suggesting diminished demand. Conclusions Feeding status prior to the occurrence of hemorrhagic shock with injury alters the metabolic course of this trauma and potentially affects mortality. The response to shock reflects metabolic priorities at baseline.
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Müller MCA, Balvers K, Binnekade JM, Curry N, Stanworth S, Gaarder C, Kolstadbraaten KM, Rourke C, Brohi K, Goslings JC, Juffermans NP. Thromboelastometry and organ failure in trauma patients: a prospective cohort study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2014; 18:687. [PMID: 25539910 PMCID: PMC4305250 DOI: 10.1186/s13054-014-0687-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/23/2014] [Accepted: 11/25/2014] [Indexed: 11/10/2022]
Abstract
INTRODUCTION Data on the incidence of a hypercoagulable state in trauma, as measured by thromboelastometry (ROTEM), is limited and the prognostic value of hypercoagulability after trauma on outcome is unclear. We aimed to determine the incidence of hypercoagulability after trauma, and to assess whether early hypercoagulability has prognostic value on the occurrence of multiple organ failure (MOF) and mortality. METHODS This was a prospective observational cohort study in trauma patients who met the highest trauma level team activation. Hypercoagulability was defined as a G value of ≥ 11.7 dynes/cm(2) and hypocoagulability as a G value of <5.0 dynes/cm(2). ROTEM was performed on admission and 24 hours later. RESULTS A total of 1,010 patients were enrolled and 948 patients were analyzed. Median age was 38 (interquartile range (IQR) 26 to 53), 77% were male and median injury severity score was 13 (IQR 8 to 25). On admission, 7% of the patients were hypercoagulable and 8% were hypocoagulable. Altogether, 10% of patients showed hypercoagulability within the first 24 hours of trauma. Hypocoagulability, but not hypercoagulability, was associated with higher sequential organ failure assessment scores, indicating more severe MOF. Mortality in patients with hypercoagulability was 0%, compared to 7% in normocoagulable and 24% in hypocoagulable patients (P <0.001). EXTEM CT, alpha and G were predictors for occurrence of MOF and mortality. CONCLUSIONS The incidence of a hypercoagulable state after trauma is 10% up to 24 hours after admission, which is broadly comparable to the rate of hypocoagulability. Further work in larger studies should define the clinical consequences of identifying hypercoagulability and a possible role for very early, targeted use of anticoagulants.
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Affiliation(s)
- Marcella C A Müller
- Department of Intensive Care Medicine, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
| | - Kirsten Balvers
- Department of Intensive Care Medicine, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands. .,Department of Surgery, Trauma Unit, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
| | - Jan M Binnekade
- Department of Intensive Care Medicine, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
| | - Nicola Curry
- National Health Service Blood and Transplant/Hematology, John Radcliffe Hospital, Headley Way, Oxford, OX3 9BQ, UK.
| | - Simon Stanworth
- National Health Service Blood and Transplant/Hematology, John Radcliffe Hospital, Headley Way, Oxford, OX3 9BQ, UK.
| | - Christine Gaarder
- Department of Traumatology, Oslo University Hospital, Ullevaal, Nydalen, N-0424, Oslo, Norway.
| | - Knut M Kolstadbraaten
- Department of Traumatology, Oslo University Hospital, Ullevaal, Nydalen, N-0424, Oslo, Norway.
| | - Claire Rourke
- Trauma Sciences, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University, Turner Street, London, E1 2AD, UK.
| | - Karim Brohi
- Trauma Sciences, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University, Turner Street, London, E1 2AD, UK.
| | - J Carel Goslings
- Department of Surgery, Trauma Unit, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
| | - Nicole P Juffermans
- Department of Intensive Care Medicine, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
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Abstract
The majority of injury combinations in multiply injured patients entail the chest, abdomen, and extremities. Numerous pig models focus on the investigation of posttraumatic pathophysiology, organ performance monitoring and on potential treatment options. Depending on the experimental question, previous authors have included isolated insults (controlled or uncontrolled hemorrhage, chest trauma) or a combination of these injuries (hemorrhage with abdominal trauma, chest trauma, traumatic brain injury, and/or long-bone fractures). Combined trauma models in pigs can provide a high level of clinical relevance, when they are properly designed and mimicking the clinical situation. Most of these models focus on the first hours after trauma, to assess the acute sequel of traumatic hemorrhage. However, hemorrhagic shock and the associated mass transfusion are also major causes for organ failure and mortality in the later clinical course. Thus, most models lack information on the pathomechanisms during the late posttraumatic phase. Studying new therapies only during the early phase is also not reflective of the clinical situation. Therefore, a longer observation period is required to study the effects of therapeutic approaches during intensive care treatment when using animal models. These long-term studies of combined trauma models will allow the development of valuable therapeutic approaches relevant for the later posttraumatic course. This review summarizes the existing porcine models and outlines the need for long-term models to provide real effective novel therapeutics for multiply injured patients to improve organ function and clinical outcome.
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Hatch Q, Debarros M, Eckert M, Satterly S, Nelson D, Porta R, Lesperance R, Long W, Martin M. Acute coagulopathy in a porcine venous hemorrhage and ischemia reperfusion model. Am J Surg 2014; 207:637-41; discussion 641. [PMID: 24791624 DOI: 10.1016/j.amjsurg.2013.12.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2013] [Revised: 12/17/2013] [Accepted: 12/17/2013] [Indexed: 11/25/2022]
Abstract
BACKGROUND Injury-related coagulopathy is a complex process. We analyzed coagulation in a swine model of shock using rotational thromboelastometry (ROTEM). METHODS Forty-eight swine underwent laparotomy, 35% hemorrhage, supraceliac aortic cross-clamp, then reperfusion and resuscitation. ROTEM measurements and standard labs were taken at baseline and 6 hours into resuscitation. RESULTS Clot formation time (98 vs 53 seconds, P = .001) and international normalized ratio (1.67 vs 1.01, P < .001) were prolonged after resuscitation. Maximum clot firmness (61 vs 72 mm, P < .001) and fibrinogen levels (94 vs 165, P < .001) declined significantly during resuscitation. Despite decreased fibrinogen levels, there was no significant increase in fibrinolysis as measured by maximum lysis (3.9% vs 3.8%, P = .99). CONCLUSIONS ROTEM demonstrated the development of an acute coagulopathy. The most significant impacts on coagulopathy were seen with clot initiation and fibrin polymerization. Clot strength decreased over time, although there was little impact on clot breakdown because of fibrinolysis.
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Affiliation(s)
- Quinton Hatch
- Department of Surgery, Madigan Army Medical Center, 9040-A Fitzsimmons Drive, Tacoma, WA 98431, USA
| | - Mia Debarros
- Department of Surgery, Madigan Army Medical Center, 9040-A Fitzsimmons Drive, Tacoma, WA 98431, USA
| | - Matthew Eckert
- Department of Surgery, Madigan Army Medical Center, 9040-A Fitzsimmons Drive, Tacoma, WA 98431, USA
| | - Steven Satterly
- Department of Surgery, Madigan Army Medical Center, 9040-A Fitzsimmons Drive, Tacoma, WA 98431, USA
| | - Daniel Nelson
- Department of Surgery, Madigan Army Medical Center, 9040-A Fitzsimmons Drive, Tacoma, WA 98431, USA
| | - Rees Porta
- Department of Surgery, Madigan Army Medical Center, 9040-A Fitzsimmons Drive, Tacoma, WA 98431, USA
| | - Richard Lesperance
- Department of Surgery, Madigan Army Medical Center, 9040-A Fitzsimmons Drive, Tacoma, WA 98431, USA
| | - William Long
- Department of Surgery, Legacy Emanuel Medical Center, 2801 N Gantenbein Avenue, Portland, OR 97227, USA
| | - Matthew Martin
- Department of Surgery, Madigan Army Medical Center, 9040-A Fitzsimmons Drive, Tacoma, WA 98431, USA; Department of Surgery, Legacy Emanuel Medical Center, 2801 N Gantenbein Avenue, Portland, OR 97227, USA.
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Hyperosmolar reconstituted lyophilized plasma is an effective low-volume hemostatic resuscitation fluid for trauma. J Trauma Acute Care Surg 2013; 75:369-75. [PMID: 23928743 DOI: 10.1097/ta.0b013e31829bb67c] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND We performed this study to optimize reconstituted lyophilized plasma (LP) into a minimal volume fluid that provides effective hemostatic resuscitation for trauma while minimizing logistical limitations. METHODS We performed a prospective, blinded animal study. Plasma was lyophilized following whole blood collection from anesthetized swine. The minimal volume needed for reconstitution was determined, and this solution was evaluated for safe infusion into the swine. Reconstituted LP was analyzed for electrolyte content, osmolarity, and coagulation factor activity. Twenty swine were anesthetized and subjected to a validated model of polytrauma and hemorrhagic shock (including a Grade V liver injury), then randomized to resuscitation with LP reconstituted to either 100% of the original plasma volume (100%LP) or the minimal volume LP fluid. Physiologic data were monitored, and blood loss and hematocrit were measured. Coagulation status was evaluated using thrombelastography. RESULTS The minimal volume of reconstituted LP safe for infusion in swine was 50% of the original plasma volume (50%LP). The 50%LP had higher electrolyte concentrations, osmolarity, and increased coagulation factor activity levels by volume compared with 100%LP (p < 0.05). Blood loss, hematocrit, mean arterial pressure, and heart rate did not differ between animals receiving 100%LP (n = 10) or 50%LP (n = 10) at any time point (p > 0.05). International normalized ratio and thrombelastography parameters were not different between groups (R time, α angle, or maximal amplitude, p > 0.05). CONCLUSION Resuscitation with 50%LP fluid was well tolerated and equally effective compared with 100%LP, with respect to physiologic and hemostatic properties. The smaller volume of fluid necessary to reconstitute hypertonic LP makes it logistically superior to 100%LP for first responders and may reduce adverse effects of large-volume resuscitation.
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Chapman BC, Moore EE, Barnett C, Stovall RT, Biffl WL, Burlew CC, Bensard DD, Jurkovich GJ, Pieracci FM. Hypercoagulability following blunt solid abdominal organ injury: when to initiate anticoagulation. Am J Surg 2013; 206:917-22; discussion 922-3. [PMID: 24112665 DOI: 10.1016/j.amjsurg.2013.07.024] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2013] [Revised: 07/27/2013] [Accepted: 07/31/2013] [Indexed: 11/17/2022]
Abstract
BACKGROUND The optimal time to initiate venous thromboembolism pharmacoprophylaxis after blunt abdominal solid organ injury is unknown. METHODS Postinjury coagulation status was characterized using thromboelastography (TEG) in trauma patients with blunt abdominal solid organ injuries; TEG was divided into 12-hour intervals up to 72 hours. RESULTS Forty-two of 304 patients (13.8%) identified underwent multiple postinjury thromboelastographic studies. Age (P = .45), gender (P = .45), and solid organ injury grade (P = .71) were similar between TEG and non-TEG patients. TEG patients had higher Injury Severity Scores compared with non-TEG patients (33.2 vs 18.3, respectively, P < .01). Among the TEG patients, the shear elastic modulus strength and maximum amplitude values began in the normal range within the first 12-hour interval after injury, increased linearly, and crossed into the hypercoagulable range at 48 hours (15.1 ± 1.9 Kd/cs and 57.6 ± 1.6 mm, respectively; P < .01, analysis of variance). CONCLUSIONS Patients sustaining blunt abdominal solid organ injuries transition to a hypercoagulable state approximately 48 hours after injury. In the absence of contraindications, pharmacoprophylaxis should be considered before this time for effective venous thromboembolism prevention.
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Affiliation(s)
- Brandon C Chapman
- Department of Surgery, Denver Health Medical Center, University of Colorado Health Sciences Center, 777 Bannock Street MC0206, Denver, CO 80206, USA
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Comparing clinical predictors of deep venous thrombosis versus pulmonary embolus after severe injury: a new paradigm for posttraumatic venous thromboembolism? J Trauma Acute Care Surg 2013; 74:1231-7; discussion 1237-8. [PMID: 23609272 DOI: 10.1097/ta.0b013e31828cc9a0] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The traditional paradigm is that deep venous thrombosis (DVT) and pulmonary embolus (PE) are different temporal phases of a single disease process, most often labeled as the composite end point venous thromboembolism (VTE). However, we theorize that after severe blunt injury, DVT and PE may represent independent thrombotic entities rather than different stages of a single pathophysiologic process and therefore exhibit different clinical risk factor profiles. METHODS We examined a large, multicenter prospective cohort of severely injured blunt trauma patients to compare clinical risk factors for DVT and PE, including indicators of injury severity, shock, resuscitation parameters, comorbidities, and VTE prophylaxis. Independent risk factors for each outcome were determined by cross-validated logistic regression modeling using advanced exhaustive model search procedures. RESULTS The study cohort consisted of 1,822 severely injured blunt trauma patients (median Injury Severity Score [ISS], 33; median base deficit, -9.5). Incidence of DVT and PE were 5.1% and 3.9%, respectively. Only 9 (5.7%) of 73 patients with a PE were also diagnosed with DVT. Independent risk factors associated with DVT include prophylaxis initiation within 48 hours (odds ratio [OR], 0.57; 95% confidence interval [CI], 0.36-0.90) and thoracic Abbreviated Injury Scale (AIS) score of 3 or greater (OR, 1.82; 95% CI, 1.12-2.95), while independent risk factors for PE were serum lactate of greater than 5 (OR, 2.33; 95% CI, 1.43-3.79) and male sex (OR, 2.12; 95% CI, 1.17-3.84). Both DVT and PE exhibited differing risk factor profiles from the classic composite end point of VTE. CONCLUSION DVT and PE exhibit differing risk factor profiles following severe injury. Clinical risk factors for diagnosis of DVT after severe blunt trauma include the inability to initiate prompt pharmacologic prophylaxis and severe thoracic injury, which may represent overall injury burden. In contrast, risk factors for PE are male sex and physiologic evidence of severe shock. We hypothesize that postinjury DVT and PE may represent a broad spectrum of pathologic thrombotic processes as opposed to the current conventional wisdom of peripheral thrombosis and subsequent embolus.
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Comparing clinical predictors of deep venous thrombosis versus pulmonary embolus after severe injury: A new paradigm for posttraumatic venous thromboembolism? J Trauma Acute Care Surg 2013. [DOI: 10.1097/01586154-201305000-00007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Hypercoagulability in porcine hemorrhagic shock is present early after trauma and resuscitation. J Surg Res 2011; 176:e9-11. [PMID: 22341341 DOI: 10.1016/j.jss.2011.12.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2011] [Revised: 11/29/2011] [Accepted: 12/01/2011] [Indexed: 11/23/2022]
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