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Jávor P, Donka T, Solli HS, Sándor L, Baráth B, Perényi D, Mohácsi Á, Török L, Hartmann P. Could exhaled methane be used as a possible indicator for hemodynamic changes in trauma induced hemorrhagic shock? Scientific basis supported by a case study. Injury 2024; 55 Suppl 3:111456. [PMID: 39300623 DOI: 10.1016/j.injury.2024.111456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 02/14/2024] [Accepted: 02/25/2024] [Indexed: 09/22/2024]
Abstract
INTRODUCTION Identification of severe blood loss and hemorrhagic shock in polytrauma patients poses a key challenge for trauma teams across the world, as there are just a few objective parameters, on which clinicians can rely. We investigated the relationship between exhaled air methane (CH4) concentration and blood loss in a polytrauma patient. Decreased blood flow in the superior mesenteric artery (SMA) is one of the first compensatory responses to blood loss. Gases produced by the anaerobic flora of the intestinal segment supplied by the SMA are the primary source of exhaled CH4, which diffuses through the intestinal microvessels into the circulation and is finally eliminated through the lungs. We hypothesized that diminution of exhaled CH4 indicates blood loss and tested our theory in a severely injured patient. METHODS Exhaled CH4 concentrations of a severely injured patient were measured using a photoacoustic spectroscope (PAS) attached to the exhalation side of the breathing circuit. The primary objective was to investigate the relationship between exhaled CH4 and conventional indicators of hemorrhage including hemoglobin (Hb) levels, base deficit (BD) values and vital parameters (heart rate and systolic blood pressure) in the early phase of in-hospital care (first 4 h). RESULTS A severely injured patient was admitted with unstable hemodynamic parameters and incomplete left lower limb amputation, (Injury Severity Score: 38, 74/36 mmHg, 76 bpm). At the time of arrival, considerably lower CH4 levels were detected (22,800 PAU) in the exhaled air. During the first 4 h fluid and massive blood resuscitation, the exhaled CH4 levels were continuously rising in parallel with Htc and Hb values. Corresponding to these changes, BD values displayed a decreasing tendency. DISCUSSION Our study was conducted to characterize the changes in exhaled air CH4 concentration in response to hemorrhagic shock and to provide data on a viable clinical use of an experimental technique. According to our results, the real-time detection of exhaled air CH4 concentration is an applicable and promising technique for the early detection of bleeding and hemorrhagic shock in severely injured patients. Further research on large sample size and refinement of the PAS technique is required.
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Affiliation(s)
- Péter Jávor
- Department of Traumatology, University of Szeged, Szeged, Hungary, Semmelweis street 6., Szeged, 6725 Hungary
| | - Tibor Donka
- National Academy of Scientist Education, Pacsirta str 31., Szeged, 6724 Hungary
| | - Hanne Sofie Solli
- Department of Traumatology, University of Szeged, Szeged, Hungary, Semmelweis street 6., Szeged, 6725 Hungary
| | - Lilla Sándor
- Department of Traumatology, University of Szeged, Szeged, Hungary, Semmelweis street 6., Szeged, 6725 Hungary
| | - Bálint Baráth
- Department of Traumatology, University of Szeged, Szeged, Hungary, Semmelweis street 6., Szeged, 6725 Hungary; Doctoral School of Multidisciplinary Medical Sciences, University of Szeged, Szeged, Hungary, Dóm square 9., Szeged, 6720 Hungary
| | - Domonkos Perényi
- National Academy of Scientist Education, Pacsirta str 31., Szeged, 6724 Hungary
| | - Árpád Mohácsi
- MTA - SZTE Research Group on Photoacoustic Spectroscopy, University of Szeged, Szeged Hungary, Dóm tér 9., Szeged, 6720 Hungary
| | - László Török
- Department of Traumatology, University of Szeged, Szeged, Hungary, Semmelweis street 6., Szeged, 6725 Hungary; Department of Sports Medicine, University of Szeged, Szeged, Hungary, Semmelweis utca 6., Szeged, 6725 Hungary
| | - Petra Hartmann
- Department of Traumatology, University of Szeged, Szeged, Hungary, Semmelweis street 6., Szeged, 6725 Hungary.
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Yamada Y, Abe T, Tanohata R, Ochiai H. Changes in coagulation factor XIII activity during resuscitation for hemorrhagic shock. J Rural Med 2024; 19:76-82. [PMID: 38655226 PMCID: PMC11033671 DOI: 10.2185/jrm.2023-028] [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: 08/02/2023] [Accepted: 11/28/2023] [Indexed: 04/26/2024] Open
Abstract
Objective Little is known about the coagulation activity of factor XIII (FXIII) during resuscitation for hemorrhagic shock and the effects of plasma transfusions. We performed a single-center observational study to evaluate the changes in FXIII activity during resuscitation for hemorrhagic shock. Patient and Methods Twenty-three adult patients with hemorrhagic shock were enrolled in this study. Blood samples were drawn upon arrival (T1), at the time of hemostasis completion (T2), and on day 2 (T3). Baseline and changes in FXIII activity and the proportion of patients with adequate levels of FXIII activity (FXIII activity >70%) were evaluated. The effects of plasma transfusion on these parameters were also investigated. Results At T1, the median (interquartile range) FXIII activity was 53% (47-85%), which did not increase (T1 vs. T3: 53% [47-85%] vs. 63% [52-70%], P=0.8766). The proportion of patients with adequate FXIII activity decreased throughout the resuscitation period (T1, T2, and T3: 30, 34, and 21%, respectively). Plasma transfusion did not affect FXIII activity (T1 vs. T2, 66.4% [23.4] vs. 70.0% [16.2%], P=0.3956; T2 vs. T3, 72.0% [19.5] vs. 63.5% [8.6%], P=0.1161) or the proportion of adequate levels of FXIII activity at 44% at T2 and 27% at T3. Conclusion FXIII activity is low during the early phase of a hemorrhagic shock. Even with plasma transfusion, FXIII levels were not adequately maintained throughout resuscitation.
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Affiliation(s)
- Yusuke Yamada
- Department of Emergency and Critical Care Medicine,
University of Miyazaki, Japan
- Yamada Clinic, Japan
| | - Tomohiro Abe
- Department of Emergency and Critical Care Medicine,
University of Miyazaki, Japan
- Cardiovascular Biology Research Program, Oklahoma Medical
Research Foundation, USA
| | - Rina Tanohata
- Department of Emergency and Critical Care Medicine,
University of Miyazaki, Japan
| | - Hidenobu Ochiai
- Department of Emergency and Critical Care Medicine,
University of Miyazaki, Japan
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Castro LUC, Otsuki DA, Sanches TR, Souza FL, Santinho MAR, da Silva C, Noronha IDL, Duarte-Neto AN, Gomes SA, Malbouisson LMS, Andrade L. Terlipressin combined with conservative fluid management attenuates hemorrhagic shock-induced acute kidney injury in rats. Sci Rep 2022; 12:20443. [PMID: 36443404 PMCID: PMC9705717 DOI: 10.1038/s41598-022-24982-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Accepted: 11/23/2022] [Indexed: 11/29/2022] Open
Abstract
Hemorrhagic shock (HS), a major cause of trauma-related mortality, is mainly treated by crystalloid fluid administration, typically with lactated Ringer's (LR). Despite beneficial hemodynamic effects, such as the restoration of mean arterial pressure (MAP), LR administration has major side effects, including organ damage due to edema. One strategy to avoid such effects is pre-hospitalization intravenous administration of the potent vasoconstrictor terlipressin, which can restore hemodynamic stability/homeostasis and has anti-inflammatory effects. Wistar rats were subjected to HS for 60 min, at a target MAP of 30-40 mmHg, thereafter being allocated to receive LR infusion at 3 times the volume of the blood withdrawn (liberal fluid management); at 2 times the volume (conservative fluid management), plus terlipressin (10 µg/100 g body weight); and at an equal volume (conservative fluid management), plus terlipressin (10 µg/100 g body weight). A control group comprised rats not subjected to HS and receiving no fluid resuscitation or treatment. At 15 min after fluid resuscitation/treatment, the blood previously withdrawn was reinfused. At 24 h after HS, MAP was higher among the terlipressin-treated animals. Terlipressin also improved post-HS survival and provided significant improvements in glomerular/tubular function (creatinine clearance), neutrophil gelatinase-associated lipocalin expression, fractional excretion of sodium, aquaporin 2 expression, tubular injury, macrophage infiltration, interleukin 6 levels, interleukin 18 levels, and nuclear factor kappa B expression. In terlipressin-treated animals, there was also significantly higher angiotensin II type 1 receptor expression and normalization of arginine vasopressin 1a receptor expression. Terlipressin associated with conservative fluid management could be a viable therapy for HS-induced acute kidney injury, likely attenuating such injury by modulating the inflammatory response via the arginine vasopressin 1a receptor.
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Affiliation(s)
- Leticia Urbano Cardoso Castro
- grid.11899.380000 0004 1937 0722Laboratory of Basic Science in Renal Diseases, Division of Nephrology, University of São Paulo School of Medicine, Av. Dr. Arnaldo, 455, 3º Andar, sala 3310, São Paulo, SP CEP 01246-903 Brazil
| | - Denise Aya Otsuki
- grid.11899.380000 0004 1937 0722Laboratory of Anesthesiology, Division of Anesthesiology, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Talita Rojas Sanches
- grid.11899.380000 0004 1937 0722Laboratory of Basic Science in Renal Diseases, Division of Nephrology, University of São Paulo School of Medicine, Av. Dr. Arnaldo, 455, 3º Andar, sala 3310, São Paulo, SP CEP 01246-903 Brazil
| | - Felipe Lima Souza
- grid.11899.380000 0004 1937 0722Laboratory of Cellular, Genetic, and Molecular Nephrology, Renal Division, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Mirela Aparecida Rodrigues Santinho
- grid.11899.380000 0004 1937 0722Laboratory of Basic Science in Renal Diseases, Division of Nephrology, University of São Paulo School of Medicine, Av. Dr. Arnaldo, 455, 3º Andar, sala 3310, São Paulo, SP CEP 01246-903 Brazil
| | - Cleonice da Silva
- grid.11899.380000 0004 1937 0722Laboratory of Cellular, Genetic, and Molecular Nephrology, Renal Division, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Irene de Lourdes Noronha
- grid.11899.380000 0004 1937 0722Laboratory of Cellular, Genetic, and Molecular Nephrology, Renal Division, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Amaro Nunes Duarte-Neto
- grid.11899.380000 0004 1937 0722Department of Pathology, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Samirah Abreu Gomes
- grid.11899.380000 0004 1937 0722Laboratory of Cellular, Genetic, and Molecular Nephrology, Renal Division, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Luiz-Marcelo Sá Malbouisson
- grid.11899.380000 0004 1937 0722Laboratory of Anesthesiology, Division of Anesthesiology, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Lucia Andrade
- grid.11899.380000 0004 1937 0722Laboratory of Basic Science in Renal Diseases, Division of Nephrology, University of São Paulo School of Medicine, Av. Dr. Arnaldo, 455, 3º Andar, sala 3310, São Paulo, SP CEP 01246-903 Brazil
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Juárez-Vela R, Andrés-Esteban EM, Santolalla-Arnedo I, Ruiz de Viñaspre-Hernández R, Benito-Puncel C, Serrano-Lázaro A, Marcos-Neira P, López-Fernández A, Tejada-Garrido CI, Sánchez-González JL, Quintana-Díaz M, García-Erce JA. Epidemiology and Associated Factors in Transfusion Management in Intensive Care Unit. J Clin Med 2022; 11:jcm11123532. [PMID: 35743602 PMCID: PMC9225042 DOI: 10.3390/jcm11123532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Revised: 06/16/2022] [Accepted: 06/16/2022] [Indexed: 11/16/2022] Open
Abstract
Severe traumatic injury is one of the main global health issues which annually causes more than 5.8 million worldwide deaths. Uncontrolled haemorrhage is the main avoidable cause of death among severely injured individuals. Management of trauma patients is the greatest challenge in trauma emergency care, and its proper diagnosis and early management of bleeding trauma patients, including blood transfusion, are critical for patient outcomes. Aim: We aimed to describe the epidemiology of transfusion practices in severe trauma patients admitted into Spanish Intensive Care Units. Material and Methods: We performed a multicenter cross-sectional study in 111 Intensive Care Units across Spain. Adult patients with moderate or severe trauma were eligible. Distribution of frequencies was used for qualitative variables and the mean, with its 95% CI, for quantitative variables. Transfusion programmes, the number of transfusions performed, and the blood component transfused were recorded. Demographic variables, mortality rate, hospital stay, SOFA-score and haemoglobin levels were also gathered. Results: We obtained results from 109 patients. The most transfused blood component was packet red blood cells with 93.8% of total transfusions versus 43.8% of platelets and 37.5% of fresh plasma. The main criteria for transfusion were analytical criteria (43.75%), and acute anaemia with shock (18.75%) and without haemodynamic impact (18.75%). Conclusion: Clinical practice shows a ratio of red blood cells, platelets, and Fresh Frozen Plasma (FFP) of 2:1:1. It is necessary to implement Massive Transfusion Protocols as they appear to improve outcomes. Our study suggests that transfusion of RBC, platelets and FFP in a 2:1:1 ratio could be beneficial for trauma patients.
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Affiliation(s)
- Raúl Juárez-Vela
- Doctoral Programme in Medicine and Surgery, Faculty of Medicine, Autonomous University of Madrid, 28049 Madrid, Spain;
- GRUPAC, Department of Nursing, University of La Rioja, 26004 Logroño, Spain; (I.S.-A.); (R.R.d.V.-H.)
- Research Institute IdiPaz, 28029 Madrid, Spain;
| | - Eva María Andrés-Esteban
- Research Institute IdiPaz, 28029 Madrid, Spain;
- Department of Business Economics and Applied Economy, Faculty of Legal and Economic Sciences, Rey Juan Carlos University, 28933 Madrid, Spain
| | - Ivan Santolalla-Arnedo
- GRUPAC, Department of Nursing, University of La Rioja, 26004 Logroño, Spain; (I.S.-A.); (R.R.d.V.-H.)
| | | | | | | | - Pilar Marcos-Neira
- Intensive Care Unit, Hospital Germans Trias i Pujol, 08916 Badalona, Spain;
| | | | - Clara Isabel Tejada-Garrido
- GRUPAC, Department of Nursing, University of La Rioja, 26004 Logroño, Spain; (I.S.-A.); (R.R.d.V.-H.)
- Correspondence: (C.I.T.-G.); (M.Q.-D.)
| | | | - Manuel Quintana-Díaz
- Research Institute IdiPaz, 28029 Madrid, Spain;
- Intensive Care Unit, University Hospital of La Paz, 28046 Madrid, Spain;
- Correspondence: (C.I.T.-G.); (M.Q.-D.)
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Divers TJ, Radcliffe RM, Cook VL, Bookbinder LC, Hurcombe SDA. Calculating and selecting fluid therapy and blood product replacements for horses with acute hemorrhage. J Vet Emerg Crit Care (San Antonio) 2022; 32:97-107. [PMID: 35044062 DOI: 10.1111/vec.13127] [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: 02/23/2017] [Revised: 08/14/2017] [Accepted: 10/17/2017] [Indexed: 11/30/2022]
Abstract
BACKGROUND Blood products, crystalloids, and colloid fluids are used in the medical treatment of severe hemorrhage in horses with a goal of providing sufficient blood flow and oxygen delivery to vital organs. The fluid treatments for hemorrhage will vary depending upon severity and duration and whether hemorrhage is controlled or uncontrolled. DESCRIPTION With acute and severe controlled hemorrhage, treatment is focused on rapidly increasing perfusion pressure and blood flow to vital organs. This can most easily be accomplished in field cases by the administration of hypertonic saline. If isotonic crystalloids are used for resuscitation, the volume administered should be at least as great as the estimated blood loss. Following crystalloid resuscitation, clinical signs, HCT, and laboratory evidence of tissue hypoxia may help determine the need for a whole blood transfusion. In uncontrolled hemorrhage, crystalloid resuscitation is often more conservative and is referred to as "permissive hypotension." The goal of "permissive hypotension" would be to provide enough perfusion pressure to vital organs such that function is maintained while keeping blood pressure below the normal range in the hope that clot formation will not be disrupted. Whole blood and fresh frozen plasma in addition to aminocaproic acid are indicated in most horses with severe uncontrolled hemorrhage. SUMMARY Blood transfusion is a life-saving treatment for severe hemorrhage in horses. No precise HCT serves as a transfusion trigger; however, an HCT < 15%, lack of appropriate clinical response, or significant improvement in plasma lactate following crystalloid resuscitation and loss of 25% or more of blood volume is suggestive of the need for whole blood transfusion. Mathematical formulas may be used to estimate the amount of blood required for transfusion following severe but controlled hemorrhage, but these are not very accurate and, in practice, transfusion volume should be approximately 40% of estimated blood loss. KEY POINTS Modest hemorrhage, <15% of blood volume (<12 mL/kg), can be fully compensated by physiological mechanisms and generally does not require fluid or blood product therapy. More severe hemorrhage, >25% of blood volume (> 20 mL/kg), often requires crystalloid or blood product replacement, while acute loss of greater than 30% (>24 mL/kg) of blood volume may result in hemorrhagic shock requiring resuscitation treatments Uncontrolled hemorrhage is a common occurrence in equine practice, and is most commonly associated with abdominal bleeding (eg, uterine artery rupture in mares). If the hemorrhage can be controlled such as by ligation of a bleeding vessel, then initial efforts to resuscitate the horse should focus on increasing perfusion pressure and blood flow to organs as quickly as possible with crystalloids or colloids while assessing need for whole blood transfusion. While fluid therapy is being administered every effort to physically control hemorrhage should be made using ligatures, application of compression, surgical methods, and local hemostatic agents like collagen-, gelatin-, and cellulose-based products, fibrin, yunnan baiyao (YB), and synthetic glues Although some synthetic colloids have been shown to be associated with acute kidney injury in people receiving resuscitation therapy,20 this undesirable effect in horses has not been reported.
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Affiliation(s)
- Thomas J Divers
- Department of Clinical Sciences, College of Veterinary Medicine, Cornell University, Ithaca, New York, USA
| | - Rolfe M Radcliffe
- Department of Clinical Sciences, College of Veterinary Medicine, Cornell University, Ithaca, New York, USA
| | - Vanessa L Cook
- Department of Large Animal Clinical Sciences, College of Veterinary Medicine, Michigan State University, East Lansing, Michigan, USA
| | - Lauren C Bookbinder
- Department of Clinical Sciences, College of Veterinary Medicine, Cornell University, Ithaca, New York, USA
| | - Samuel D A Hurcombe
- Emergency Surgery and Medicine, Cornell Ruffian Equine Specialists, Elmont, New York, USA
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Controlled Hemorrhage Sensitizes Angiotensin II-Elicited Hypertension through Activation of the Brain Renin-Angiotensin System Independently of Endoplasmic Reticulum Stress. OXIDATIVE MEDICINE AND CELLULAR LONGEVITY 2022; 2022:6371048. [PMID: 35069977 PMCID: PMC8776443 DOI: 10.1155/2022/6371048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 12/08/2021] [Indexed: 11/25/2022]
Abstract
Hemorrhagic shock is associated with activation of renin-angiotensin system (RAS) and endoplasmic reticulum stress (ERS). Previous studies demonstrated that central RAS activation produced by various challenges sensitizes angiotensin (Ang) II-elicited hypertension and that ERS contributes to the development of neurogenic hypertension. The present study investigated whether controlled hemorrhage could sensitize Ang II-elicited hypertension and whether the brain RAS and ERS mediate this sensitization. Results showed that hemorrhaged (HEM) rats had a significantly enhanced hypertensive response to a slow-pressor infusion of Ang II when compared to sham HEM rats. Treatment with either angiotensin-converting enzyme (ACE) 1 inhibitor, captopril, or ACE2 activator, diminazene, abolished the HEM-induced sensitization of hypertension. Treatment with the ERS agonist, tunicamycin, in sham HEM rats also sensitized Ang II-elicited hypertension. However, blockade of ERS with 4-phenylbutyric acid in HEM rats did not alter HEM-elicited sensitization of hypertension. Either HEM or ERS activation produced a greater reduction in BP after ganglionic blockade, upregulated mRNA and protein expression of ACE1 in the hypothalamic paraventricular nucleus (PVN), and elevated plasma levels of Ang II but reduced mRNA expression of the Ang-(1-7) receptor, Mas-R, and did not alter plasma levels of Ang-(1-7). Treatment with captopril or diminazene, but not phenylbutyric acid, reversed these changes. No treatments had effects on PVN protein expression of the ERS marker glucose-regulated protein 78. The results indicate that controlled hemorrhage sensitizes Ang II-elicited hypertension by augmenting RAS prohypertensive actions and reducing RAS antihypertensive effects in the brain, which is independent of ERS mechanism.
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Liu Y, Yao C, Wang Y, Liu X, Xu S, Liang L. Protective Effect of Crocin on Liver Function and Survival in Rats With Traumatic Hemorrhagic Shock. J Surg Res 2021; 261:301-309. [PMID: 33482612 DOI: 10.1016/j.jss.2020.12.027] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Revised: 11/13/2020] [Accepted: 12/04/2020] [Indexed: 12/31/2022]
Abstract
BACKGROUND This study investigated the underlying mechanism of crocin in protecting rats with traumatic hemorrhagic shock (THS) from liver injury. MATERIALS AND METHODS Eighty Sprague Dawley rats were randomly divided into four groups (n = 20), namely, Sham group, THS group, crocin group, and Sodium Acetate Ringer group. A rat model of THS was induced by hemorrhage from the left femur fracture. The effects of crocin on hemodynamics, cardiac output, blood gas, animal survival rate, and liver function in the rats with THS were determined, and its relationship with oxidative stress was also explored. RESULTS Crocin significantly improved the survival rate, hemodynamic parameters, increased tissue blood flow, and promoted the liver function of the THS rats. Further results indicated that crocin significantly inhibited oxidative stress in serum and liver tissue of THS rats, with increased levels of superoxide dismutase, catalase, and glutathione, and also reduced levels of malondialdehyde and myeloperoxidase levels. In addition, crocin greatly increased nuclear factor erythroid 2-related factor 2/heme oxygenase-1 level in liver tissues of THS rats. CONCLUSIONS The protective mechanism of crocin on the liver of THS rats may be attributed to its abilities to stabilize hemodynamics, improve cardiac output and blood gas, increase antioxidant enzyme activity, reduce serum liver enzyme levels, and promote nuclear factor erythroid 2-related factor 2/heme oxygenase-1 pathway, thereby reducing oxidative stress.
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Affiliation(s)
- Yang Liu
- Department of Emergency, Affiliated Hospital/Clinical Medical College of Chengdu University, Chengdu, People's Republic of China
| | - Caoyuan Yao
- Department of Respiratory and Critical Care Medicine, Yongchuan Hospital of Chongqing Medical University, Chongqing, People's Republic of China
| | - Yuan Wang
- Department of Emergency, Affiliated Hospital/Clinical Medical College of Chengdu University, Chengdu, People's Republic of China
| | - Xiaolin Liu
- Department of Emergency, Affiliated Hospital/Clinical Medical College of Chengdu University, Chengdu, People's Republic of China
| | - Shanggang Xu
- Department of Emergency, Affiliated Hospital/Clinical Medical College of Chengdu University, Chengdu, People's Republic of China
| | - Longbin Liang
- Department of Emergency, Affiliated Hospital/Clinical Medical College of Chengdu University, Chengdu, People's Republic of China.
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Bialkower M, Manderson CA, McLiesh H, Tabor RF, Garnier G. Paper Diagnostic for Direct Measurement of Fibrinogen Concentration in Whole Blood. ACS Sens 2020; 5:3627-3638. [PMID: 33095567 DOI: 10.1021/acssensors.0c01937] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The ability to diagnose and treat critically bleeding patients can save more than 2 million lives a year. Diagnosing hypofibrinogenemia is essential in these patients. Recently, with the development of new handheld diagnostics, fibrinogen concentration can be measured rapidly at the point of care. However, these diagnostics can only work with plasma and hence need blood cells to be separated before use. In this study, we demonstrate a handheld fibrinogen diagnostic that works with whole blood. The test works by (1) forming a premixed droplet of a whole blood sample and thrombin solution on a solid surface, (2) allowing it to clot, and (3) dropping a paper strip on top. The further that blood moves down the strip, the lower the fibrinogen concentration. The diagnostic can easily measure plasma fibrinogen concentrations below 1.6 g/L for blood samples with hematocrits between 40 and 50%. Furthermore, diluting blood samples not only increases the test's sensitivity but also eliminates the effect of hematocrit and thrombin inhibitors. The test can be completed in 3-4 min, making it suitable for diagnosing early hypofibrinogenemia and allowing for fibrinogen replacement therapy in critically bleeding patients.
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Affiliation(s)
- Marek Bialkower
- BioPRIA and Department of Chemical Engineering, Monash University, Clayton, VIC 3800, Australia
| | - Clare A. Manderson
- BioPRIA and Department of Chemical Engineering, Monash University, Clayton, VIC 3800, Australia
| | - Heather McLiesh
- BioPRIA and Department of Chemical Engineering, Monash University, Clayton, VIC 3800, Australia
| | - Rico F. Tabor
- School of Chemistry, Monash University, Clayton, VIC 3800, Australia
| | - Gil Garnier
- BioPRIA and Department of Chemical Engineering, Monash University, Clayton, VIC 3800, Australia
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Prehospital end-tidal CO2 as an early marker for transfusion requirement in trauma patients. Am J Emerg Med 2020; 45:254-257. [PMID: 33041114 DOI: 10.1016/j.ajem.2020.08.056] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 08/12/2020] [Accepted: 08/17/2020] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE Below normal end-tidal carbon dioxide measurement (ETCO2) is associated with worse outcomes in sepsis and trauma patients as compared to patients with normal ETCO2. We sought to determine if ETCO2 can be used in the prehospital setting to predict transfusion requirement, operative hemorrhage control, or mortality in the first 24 h after admission for trauma. METHODS This is a retrospective cohort study at a suburban, academic Level 1 Trauma Center. Patients were sequentially identified as prehospital trauma alerts from a single EMS system which requires, per policy, ETCO2 for all traumas. One year of prehospital data was collected and paired with hospital trauma registry data. Comparisons were made between ETCO2 values for patients who required transfusion, operative blood loss control, or who died, and those who did not. RESULTS Two hundred thirty-five trauma patients were transported via the study EMS system, of which 105 (44.7%) had documented ETCO2 values. Patient mean age was 60 (SD24) years with 59 (56.2%) male. Three patients were intubated prehospital and seven were intubated in the trauma bay. Mean prehospital ETCO2 for those who needed transfusion, surgery, or died (n = 11) was 25.7 (9.1) compared to 30.6 (7.8) for those who did not (p = 0.049). Optimal cutoff for our population was EtCO2 ≤ 27 with a sensitivity of 72.7% (95% CI 32-93) and specificity of 72.2% (62-81). CONCLUSION Below normal ETCO2 values were associated with increase need for transfusion, operative intervention, and death. Further study is warranted to determine if ETCO2 outperforms other predictors of severe trauma.
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Abstract
Fibrinogen is one of the first factors to fall to critically low levels in the blood in many coagulopathic events. Patients with hypofibrinogenemia are at a significantly greater risk of major hemorrhage and death. The rapid replacement of fibrinogen early on in hypofibrinogenemia may significantly improve outcomes for patients. Fibrinogen is present at concentrations between 2 and 4 g/L in the plasma of healthy people. However, hypofibrinogenemia is diagnosed when the fibrinogen level drops below 1.5-2 g/L. This review analyses different types of fibrinogen assays that can be used for diagnosing hypofibrinogenemia. The scientific mechanisms and limitations behind these tests are then presented. Additionally, the current state of clinical major hemorrhage protocols (MHPs) is presented and the structure, function and physiological role of fibrinogen is summarized.
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Affiliation(s)
- Marek Bialkower
- BioPRIA and Department of Chemical Engineering, Monash University, Clayton, Australia
| | - Gil Garnier
- BioPRIA and Department of Chemical Engineering, Monash University, Clayton, Australia
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11
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Capilupi MJ, Kerath SM, Becker LB. Vagus Nerve Stimulation and the Cardiovascular System. Cold Spring Harb Perspect Med 2020; 10:cshperspect.a034173. [PMID: 31109966 DOI: 10.1101/cshperspect.a034173] [Citation(s) in RCA: 83] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
The vagus nerve plays an important role in maintaining physiological homeostasis, which includes reflex pathways that regulate cardiac function. The link between vagus nerve activity and the high-frequency component of heart rate variability (HRV) has been well established, correlating with vagal tone. Recently, vagus nerve stimulation (VNS) has been investigated as a therapeutic for a multitude of diseases, such as treatment-resistant epilepsy, rheumatoid arthritis, Crohn's disease, and asthma. Because of the vagus nerve's innervation of the heart, VNS has been identified as a potential therapy for cardiovascular disorders, such as cardiac arrest, acute myocardial infarction, and stroke. Here, we review the current state of preclinical and clinical studies, as well as the potential application of VNS in relation to the cardiovascular system.
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Affiliation(s)
- Michael J Capilupi
- Department of Emergency Medicine, North Shore University Hospital, Northwell Health, Manhasset, New York 11030
| | - Samantha M Kerath
- Feinstein Institute for Medical Research, Northwell Health, Manhasset, New York 11030
| | - Lance B Becker
- Department of Emergency Medicine, North Shore University Hospital, Northwell Health, Manhasset, New York 11030.,Feinstein Institute for Medical Research, Northwell Health, Manhasset, New York 11030.,Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York 11549
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12
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Wang T, Wang Y, Xu T, Li L, Huo M, Li X, He Y, Lin Q, Mei B, Zhou X, Jiang B. Epidemiological and clinical characteristics of 3327 cases of traffic trauma deaths in Beijing from 2008 to 2017: a retrospective analysis. Medicine (Baltimore) 2020; 99:e18567. [PMID: 31895799 PMCID: PMC6946352 DOI: 10.1097/md.0000000000018567] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
We investigated the epidemiological and clinical characteristics deaths from road traffic injury (RTI) in Beijing, and provided evidence useful for the prevention of fatal traffic trauma and for the treatment of traffic-related injuries.We retrospectively reviewed death cases provided by the Beijing Red Cross Emergency Center on road traffic injury deaths from 2008 to 2017. We analyzed population characteristics, time distribution, distribution of transportation modes, intervals to death, locations and injured body parts.From 2008 to 2017, there were 3327 deaths from RTI recorded by the Beijing Red Cross Emergency Center, with mainly males among these deaths. The average age at death was 46.19 ± 17.43 years old (46.19, 0.43-100.24). In accidents with more detail recorded, pedestrians and people using nonmotorized transportation modes suffered the most fatalities (664/968, 68.60%). The most commonly injured body parts were the head (2569/3327, 77.22%), followed by the chest (180/3327, 5.41%), abdomen (130/3327, 3.91%), lower extremities (68/3327, 2.04%), pelvis (67/3327, 2.01%), spinal cord (31/3327, 0.93%), and upper extremities (26/3327, 0.78%). Burns accounted for 0.96% (32/3327), and unknown body parts were affected in 11.28% (365/3327). The average time interval from injury to death was 36.90 ± 89.57 h (36.90, 0-720); 46.7% (1554/3327) died within 10 minutes after injury; 9.02% (300/3327) died between 10 min and 1 hour; 30.33% (1009/3327) died between 1 hour and 3 days; 13.95% (464/3327) died between 3 and 30 days.In Beijing, RTI is a significant cause of preventable death, particularly among pedestrians and users of non-motorized vehicles. Head trauma was the most lethal cause of RTI deaths. Our findings suggested that interventions to prevent collisions and reduce injuries, and improved trauma treatment process and trauma rescue system could address a certain proportion of avoidable RTI deaths.
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Affiliation(s)
- Tianbing Wang
- Trauma Medicine Center
- Department of Trauma and Orthopedics, Peking University People's Hospital
| | - Yanhua Wang
- Trauma Medicine Center
- Department of Trauma and Orthopedics, Peking University People's Hospital
| | - Tingmin Xu
- Department of Trauma and Orthopedics, Peking University People's Hospital
| | | | | | - Xian Li
- Beijing Red Cross Emergency Center
| | - Yingdong He
- Biostatitics Department, School of Public Health
| | - Qiushi Lin
- Beijing International Center for Mathematical Research, Peking University
| | - Bingsong Mei
- Beijing Traffic Management Bureau, Beijing, China
| | - Xiaohua Zhou
- Biostatitics Department, School of Public Health
- Beijing International Center for Mathematical Research, Peking University
| | - Baoguo Jiang
- Trauma Medicine Center
- Department of Trauma and Orthopedics, Peking University People's Hospital
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13
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Bialkower M, McLiesh H, Manderson CA, Tabor RF, Garnier G. Rapid, hand-held paper diagnostic for measuring Fibrinogen Concentration in blood. Anal Chim Acta 2019; 1102:72-83. [PMID: 32043998 DOI: 10.1016/j.aca.2019.12.046] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Revised: 11/22/2019] [Accepted: 12/16/2019] [Indexed: 12/20/2022]
Abstract
Critical bleeding causes over 2 million deaths a year. Early hypofibrinogenemia is a strong predictor of mortality in critically bleeding patients. The early replenishment of fibrinogen can significantly improve outcomes. However, over replenishment can also be dangerous. Furthermore, there is no rapid, cheap, hand-held diagnostic that can aid critically bleeding patients in fibrinogen replacement therapy. In this study, we have developed a hand-held paper diagnostic that measures plasma fibrinogen concentrations. The diagnostic has the potential to be used as a point of care device both inside and outside of hospital settings. It can vastly reduce the time to treatment for fibrinogen replacement therapy. The diagnostic is a two-step process. First, thrombin and plasma are added onto horizontially-orientated paper strips where the fibrinogen is converted into fibrin, drastically increasing the plasma's hydrophobicity. Second, an aqueous blue dye is pipetted onto the strips and allowed to wick through the fibrin. The distance the blue dye wicks through the strip correlates precisely to the fibrinogen concentration. The diagnostic can provide results within a minute. It can distinguish low fibrinogen concentrations (ie. <2 g/L) from normal fibrinogen concentrations. It shows remarkable reproducibility between healthy individuals. It is unaffected by common blood conditions such as acidosis, blood alcohol, severe hypertriglyceridemia, severe haemolysis and warfarin administration. Finally, it is unaffected by humidity and can withstand cold temperatures.
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Affiliation(s)
- Marek Bialkower
- BioPRIA and Department of Chemical Engineering, Monash University, Australia
| | - Heather McLiesh
- BioPRIA and Department of Chemical Engineering, Monash University, Australia
| | - Clare A Manderson
- BioPRIA and Department of Chemical Engineering, Monash University, Australia
| | - Rico F Tabor
- School of Chemistry, Monash University, Clayton, Vic, 3800, Australia
| | - Gil Garnier
- BioPRIA and Department of Chemical Engineering, Monash University, Australia.
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Powell K, Shah K, Hao C, Wu YC, John A, Narayan RK, Li C. Neuromodulation as a new avenue for resuscitation in hemorrhagic shock. Bioelectron Med 2019; 5:17. [PMID: 32232106 PMCID: PMC7098257 DOI: 10.1186/s42234-019-0033-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Accepted: 09/23/2019] [Indexed: 02/07/2023] Open
Abstract
Hemorrhagic shock (HS), a major cause of early death from trauma, accounts for around 40% of mortality, with 33–56% of these deaths occurring before the patient reaches a medical facility. Intravenous fluid therapy and blood transfusions are the cornerstone of treating HS. However, these options may not be available soon after the injury, resulting in death or a poorer quality of survival. Therefore, new strategies are needed to manage HS patients before they can receive definitive care. Recently, various forms of neuromodulation have been investigated as possible supplementary treatments for HS in the prehospital phase of care. Here, we provide an overview of neuromodulation methods that show promise to treat HS, such as vagus nerve stimulation, electroacupuncture, trigeminal nerve stimulation, and phrenic nerve stimulation and outline their possible mechanisms in the treatment of HS. Although all of these approaches are only validated in the preclinical models of HS and are yet to be translated to clinical settings, they clearly represent a paradigm shift in the way that this deadly condition is managed in the future.
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Affiliation(s)
- Keren Powell
- Translational Brain Research Laboratory, Feinstein Institutes for Medical Research, Manhasset, NY USA
| | - Kevin Shah
- Department of Neurosurgery, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY USA
| | - Caleb Hao
- Translational Brain Research Laboratory, Feinstein Institutes for Medical Research, Manhasset, NY USA
| | - Yi-Chen Wu
- Translational Brain Research Laboratory, Feinstein Institutes for Medical Research, Manhasset, NY USA
| | - Aashish John
- Translational Brain Research Laboratory, Feinstein Institutes for Medical Research, Manhasset, NY USA
| | - Raj K Narayan
- Translational Brain Research Laboratory, Feinstein Institutes for Medical Research, Manhasset, NY USA
| | - Chunyan Li
- Translational Brain Research Laboratory, Feinstein Institutes for Medical Research, Manhasset, NY USA.,Department of Neurosurgery, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY USA.,Feinstein Institutes for Medical Research, 350 Community Drive, Manhasset, NY 11030 USA
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15
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Berry MJ, Darby JRT, O'Byrne DM, Dyson RM, Sixtus R, Holman SL, Abelentseva A, Bowler P, Stanbridge K, Morrison JL. Arginine vasopressin improves cerebral perfusion following controlled haemorrhage in adult ewes. J Physiol 2019; 597:4165-4173. [PMID: 31264222 DOI: 10.1113/jp277629] [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: 01/06/2019] [Accepted: 07/01/2019] [Indexed: 11/08/2022] Open
Abstract
KEY POINTS Traumatic haemorrhagic shock carries significant morbidity and mortality related to the severity and duration of tissue hypoperfusion, much of which occurs in the pre-hospital environment where therapy must be easy to use and would augment, not replace, local haemorrhage control measures. Vasopressor therapy use in haemorrhagic shock remains controversial. Potential benefits from improved blood pressure and tissue perfusion need to be weighed against possible harm from increased blood loss if haemorrhage is uncontrolled. We demonstrate that 20 IU I.M. vasopressin produces a progressive, sustained and clinically significant increase in blood pressure and carotid blood flow compared to 1 mg I.M. adrenaline or placebo in an animal model of controlled haemorrhagic shock. I.M. vasopressin may play a role in the early management of haemorrhagic shock by improving cerebral perfusion and haemodynamic stability; however, further studies are required to establish the potential benefit against the risk of exacerbating haemorrhage, if it is uncontrolled. ABSTRACT Haemorrhagic shock causes significant morbidity and mortality. Novel pre-hospital therapy to improve haemodynamic stability and cerebral perfusion may improve outcomes but remains controversial. In an ovine model of controlled haemorrhagic shock, the effects of early intramuscular arginine vasopressin (AVP), adrenaline or placebo on haemodynamic stability and cerebral perfusion were compared. Carotid pressure and flow catheters were placed in healthy, anaesthetized adult ewes. Frontal cortex cerebral oxygenation was measured using near infrared spectroscopy. Controlled, rapid, haemorrhage (∼30% estimated blood volume) was induced. Five minutes post-bleed a 1 ml intramuscular dose of 0.9% saline, adrenaline 1 mg or AVP 20 IU was administered. Carotid blood pressure and flow improved significantly in the AVP group over the first 30 min post-intervention. To emulate standard trauma care, 1 L of 0.9% saline was infused 30 min post-bleed followed by re-transfusion of the sheep's own blood at 60 min post-bleed. Carotid blood pressure and flow in the AVP group remained significantly higher post-crystalloid infusion, but this difference was lost post-blood transfusion. Data were analysed by two-way ANOVA with time, group as the main factors. When compared to saline or adrenaline, a single dose of intramuscular AVP resulted in a progressive and sustained increase in carotid artery blood pressure and flow with commensurate increase in cerebral oxygenation. Intramuscular AVP has potential as an emergency pre-hospital therapy following exsanguinating haemorrhage; however, further studies are required to investigate whether the benefit of improved perfusion pressure outweighs the risks of exacerbating ongoing bleeding.
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Affiliation(s)
- Mary J Berry
- Centre for Translational Physiology, University of Otago, Wellington, New Zealand
- Department of Paediatrics and Child Health, University of Otago, Wellington, New Zealand
| | - Jack R T Darby
- Early Origins of Adult Health Research Group, School of Pharmacy & Medical Sciences, University of South Australia, Adelaide, SA, Australia, 5001
| | - David M O'Byrne
- Centre for Translational Physiology, University of Otago, Wellington, New Zealand
| | - Rebecca M Dyson
- Centre for Translational Physiology, University of Otago, Wellington, New Zealand
- Department of Paediatrics and Child Health, University of Otago, Wellington, New Zealand
| | - Ryan Sixtus
- Centre for Translational Physiology, University of Otago, Wellington, New Zealand
- Department of Paediatrics and Child Health, University of Otago, Wellington, New Zealand
| | - Stacey L Holman
- Early Origins of Adult Health Research Group, School of Pharmacy & Medical Sciences, University of South Australia, Adelaide, SA, Australia, 5001
| | | | - Paul Bowler
- Defence Health Directorate, New Zealand Defence Force, Wellington, New Zealand
| | - Kate Stanbridge
- Defence Health Directorate, New Zealand Defence Force, Wellington, New Zealand
| | - Janna L Morrison
- Early Origins of Adult Health Research Group, School of Pharmacy & Medical Sciences, University of South Australia, Adelaide, SA, Australia, 5001
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Park JY, Kim MJ, Lee JG. Early Predictive Values for Severe Rhabdomyolysis in Blunt Trauma. JOURNAL OF TRAUMA AND INJURY 2019. [DOI: 10.20408/jti.2018.029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Affiliation(s)
- Jung Yun Park
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Myoung Jun Kim
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Jae Gil Lee
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
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17
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Briyal S, Gandhakwala R, Khan M, Lavhale MS, Gulati A. Alterations in endothelin receptors following hemorrhage and resuscitation by centhaquin. Physiol Res 2018; 67:S199-S214. [PMID: 29947540 DOI: 10.33549/physiolres.933856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Endothelin-1 (ET-1) acts on ET(A) and ET(B) receptors and has been implicated in hemorrhagic shock (shock). We determined effect of shock and resuscitation by hypertonic saline (saline) or centhaquin on ET(A) and ET(B) receptor expression. Rats were anesthetized, a pressure catheter was placed in the left femoral artery; blood was withdrawn from the right femoral artery to bring mean arterial pressure (MAP) to 35 mm Hg for 30 min, resuscitation was performed and 90 min later sacrificed to collect samples for biochemical estimations. Resuscitation with centhaquin decreased blood lactate and increased MAP. Protein levels of ET(A) or ET(B) receptor were unaltered in the brain, heart, lung and liver following shock or resuscitation. In the abdominal aorta, shock produced an increase (140 %) in ET(A) expression which was attenuated by saline and centhaquin; ET(B) expression was unaltered following shock but was increased (79 %) by centhaquin. In renal medulla, ET(A) expression was unaltered following shock, but was decreased (-61 %) by centhaquin; shock produced a decrease (-34 %) in ET(B) expression which was completely attenuated by centhaquin and not saline. Shock induced changes in ET(A) and ET(B) receptors in the aorta and renal medulla are reversed by centhaquin and may be contributing to its efficacy.
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Affiliation(s)
- S Briyal
- Chicago College of Pharmacy, Midwestern University, Downers Grove, IL, USA.
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Crochemore T, Savioli FA. Thromboelastometry-guided hemostatic therapy for hemorrhagic shock in the postoperative period of vascular surgery: a case report. J Med Case Rep 2018; 12:153. [PMID: 29859130 PMCID: PMC5984768 DOI: 10.1186/s13256-018-1661-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Accepted: 03/19/2018] [Indexed: 12/23/2022] Open
Abstract
Background Hemorrhagic shock is a medical emergency that often complicates vascular surgery and can lead to death. Hemorrhagic shock is characterized by hypoperfusion and hemodynamic abnormalities leading to the collapse of homeostasis due to massive blood loss. Early diagnosis is critical for a favorable outcome. Thromboelastometry has been considered an effective tool for bleeding management in critically ill patients. Thromboelastometry can guide transfusion therapy quickly, reducing the need for blood products. Therefore, it could be an alternative test to guide hemostatic therapy in complex cases of hemorrhagic shock as a result of vascular surgeries. We report our successful experience with a case of hemorrhagic shock in postoperative care in vascular surgery, in which bleeding management was guided by thromboelastometry and bleeding control was achieved with hemostatic drugs and coagulation factor concentrates. Case presentation We report a case of an 82-year-old Afro-Brazilian man who presented to the intensive care unit with hemorrhagic shock in the postoperative period of vascular surgery. He underwent surgery for correction of iliac artery aneurysm with endoleak. His laboratory tests revealed severe anemia (hemoglobin 7.4 mg/dL), metabolic acidosis (bicarbonate 10 mEq/L, pH 7.11), acute kidney injury (creatinine 3.1 mg/dL), thrombocytopenia (platelets count 83 × 103/mm3), hypofibrinogenemia (70 mg/dL), international nationalized ratio 1.95, activated partial thromboplastin time 64.5 seconds, and lactate 87 mmol/L. There was active bleeding in surgical site. Bleeding management was guided by thromboelastometry. The first test showed fulminant hyperfibrinolysis, which was corrected with the administration of tranexamic acid. The second thromboelastometry test showed improvement of hyperfibrinolysis but severe hypocoagulability. Fibrinogen concentrate, platelet apheresis, cryoprecipitate, and prothrombin complex concentrate were sequentially administrated. Thromboelastometry was completely corrected after 2 hours. Arteriography to evaluate mechanical cause of bleeding was normal. No more bleeding was identified, and neither was any further transfusion needed. He was discharged from the intensive care unit from the ward 3 days after admission. Conclusions Thromboelastometry may be considered a useful, feasible and safe tool to monitor and manage coagulopathy in patients with hemorrhagic shock. Moreover, it has the potential benefit of allowing rapid diagnosis, goal-directed therapy with hemostatic drugs and coagulation factor concentrates and thus, avoiding unnecessary blood component transfusion.
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Affiliation(s)
- Tomaz Crochemore
- Hospital Israelita Albert Einstein - Intensive Care Unit, Av. Albert Einstein, 627, Morumbi, São Paulo, SP, CEP: 05651-901, Brazil.
| | - Felicio A Savioli
- Hospital Israelita Albert Einstein - Intensive Care Unit, Av. Albert Einstein, 627, Morumbi, São Paulo, SP, CEP: 05651-901, Brazil
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Liu DX, Liu J, Zhang F, Zhang QY, Xie M, Zhu ZQ. Randomized Controlled Study on Safety and Feasibility of Transfusion Trigger Score of Emergency Operations. Chin Med J (Engl) 2016; 128:1801-8. [PMID: 26112723 PMCID: PMC4733710 DOI: 10.4103/0366-6999.159357] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Background: Due to the floating of the guideline, there is no evidence-based evaluation index on when to start the blood transfusion for patients with hemoglobin (Hb) level between 7 and 10 g/dl. As a result, the trigger point of blood transfusion may be different in the emergency use of the existing transfusion guidelines. The present study was designed to evaluate whether the scheme can be safely and effectively used for emergency patients, so as to be supported by multicenter and large sample data in the future. Methods: From June 2013 to June 2014, patients were randomly divided into the experimental group (Peri-operative Transfusion Trigger Score of Emergency [POTTS-E] group) and the control group (control group). The between-group differences in the patients’ demography and baseline information, mortality and blood transfusion-related complications, heart rate, resting arterial pressure, body temperature, and Hb values were compared. The consistency of red blood cell (RBC) transfusion standards of the two groups of patients with the current blood transfusion guideline, namely the compliance of the guidelines, utilization rate, and per-capita consumption of autologous RBC were analyzed. Results: During the study period, a total of 72 patients were recorded, and 65 of them met the inclusion criteria, which included 33 males and 32 females with a mean age of (34.8 ± 14.6) years. 50 underwent abdomen surgery, 4 underwent chest surgery, 11 underwent arms and legs surgery. There was no statistical difference between the two groups for demography and baseline information. There was also no statistical differences between the two groups in anesthesia time, intraoperative rehydration, staying time in postanesthetic care unit, emergency hospitalization, postoperative 72 h Acute Physiologic Assessment and Chronic Health Evaluation II scores, blood transfusion-related complications and mortality. Only the POTTS-E group on the 1st postoperative day Hb was lower than group control, P < 0.05. POTTS-E group was totally (100%) conformed to the requirements of the transfusion guideline to RBC infusion, which was higher than that of the control group (81.25%), P < 0.01. There were no statistical differences in utilization rates of autologous blood of the two groups; the utilization rates of allogeneic RBC, total allogeneic RBC and total RBC were 48.48%, 51.5%, and 75.7% in POTTS-E group, which were lower than those of the control group (84.3%, 84.3%, and 96.8%) P < 0.05 or P < 0.01. Per capita consumption of intraoperative allogeneic RBC, total allogeneic RBC and total RBC were 0 (0, 3.0), 2.0 (0, 4.0), and 3.1 (0.81, 6.0) in POTTS-E groups were all lower than those of control group (4.0 [2.0, 4.0], 4.0 [2.0, 6.0] and 5.8 [2.7, 8.2]), P < 0.05 or P < 0.001. Conclusions: Peri-operative Transfusion Trigger Score-E evaluation scheme is used to guide the application of RBC. There are no differences in the recent prognosis of patients with the traditional transfusion guidelines. This scheme is safe; Compared with doctor experience-based subjective assessment, the scoring scheme was closer to patient physiological needs for transfusion and more reasonable; Utilization rate and the per capita consumption of RBC are obviously declined, which has clinical significance and is feasible. Based on the abovementioned three points, POTTS-E scores scheme is safe, reasonable, and practicable and has the value for carrying out multicenter and large sample clinical researches.
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Affiliation(s)
| | | | | | | | | | - Zhao-Qiong Zhu
- Department of Anesthesiology, Affiliated Hospital of Zunyi Medical College, Zunyi, Guizhou 563000, China
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Kane I, Ong A, Orozco FR, Post ZD, Austin LS, Radcliff KE. Thromboelastography predictive of death in trauma patients. Orthop Surg 2015; 7:26-30. [PMID: 25708032 DOI: 10.1111/os.12158] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2014] [Accepted: 11/03/2014] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVES To determine if thromboelastography (TEG) is predictive of patient outcomes following traumatic injury. METHODS A retrospective review of 131 patients with pelvic trauma admitted to a Level II trauma center was conducted over four years from 1 January 2009 to 31 December 2012. Patients were identified retrospectively from a prospectively collected database of acute pelvic trauma (n = 372). Eligible patients were identified from billing/coding data as having fractures of the acetabulum, iliac wing or sacral alae. Patients with incomplete TEG data were excluded (n = 241), as were patients with pathological fractures. TEG clotting variables and traditional clotting variables were recorded. RESULTS Evaluation of TEG data revealed 41 patients with abnormal clotting times (TEG R). TEG R > 6 was an independent risk factor for death (OR, 16; 95%CI 5.4-53; P = 0.0001). The death rate was 52% in patients with TEG R values ≥6 (n = 13/25). There was no significant association between traditional clotting markers and death rate. CONCLUSIONS TEG reaction time value, representing the time of initial clot formation, was the only hematologic marker predictive of mortality in patients with pelvic trauma. Delay in reaction time was associated with a significantly increased death rate, independent of injury severity. The death rate association was not observed with traditional markers of clotting. Future prospective studies may be warranted to determine the presentation and significance of TEG abnormalities when resuscitating patients with orthopaedic trauma.
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Affiliation(s)
- Ian Kane
- New York Medical College, Valhalla, New York, USA; Rothman Institute of Orthopedics, Jefferson University Hospital, Philadelphia, Pennsylvania, USA
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