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Nordham KD, Tatum D, Attia AS, Patel MB, Paramesh A, Duchesne JC, Nahmias J, Maiga AW, Peetz AB, Udekwu PO, Stiles A, Shell C, Stodghill JD, Maghsoudi T, Iacullo E, McLafferty B, Coonan E, Boudreau RM, Zimmerman SA, Shammassian B, Egodage T, Aramento I, Morris P, Metheny J, Farrell MS, Painter MD, McCabe OT, Spadafore P, Wong DTW, Serrano J, Sciarretta JD, Kim P, Hayton R, Gonzales D, Murry J, Meadows K, Jacobson LE, Williams JM, Bernard AC, Smith B, Morrissey SL, Patel N, Tabello D, Teicher E, Chowdhury SM, Ahmad F, Marcos BS, West MA, Jacome TH, Davis G, Marks JA, Rattigan D, Haan JM, Lightwine K, Matsushima K, Park S, Santos A, Shrestha K, Sawyer R, VandenBerg S, Jean RJ, Hicks RC, Lueckel S, Bugaev N, Abosena W, Alvarez C, Lieser MJ, McDonald H, Dumas RP, Fitzgerald CA, Terzian WTH, Tian Y, Mousafeiris V, Mulita F, Berne JD, Mederos DR, Smith AA, Taghavi S. Impact of catastrophic brain injury guidelines on organ donation rates: Results of an EAST multicenter trial. J Trauma Acute Care Surg 2024:01586154-990000000-00812. [PMID: 39327646 DOI: 10.1097/ta.0000000000004386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/28/2024]
Abstract
BACKGROUND One third of organ donors suffer catastrophic brain injury (CBI). There are no standard guidelines for the management of traumatic CBI prior to brain death, and not all trauma centers have institutional CBI guidelines. In addition, there is high variability in management between institutions with guidelines. Catastrophic brain injury guidelines vary and may include various combinations of hormone therapy, vasopressors, fluid resuscitation, and other practices. We hypothesized that centers with CBI guidelines have higher organ donation rates than those without. METHODS This prospective, observational EAST-sponsored multicenter trial included adult (18+ years old) traumatic-mechanism CBI patients at 33 level I and II trauma centers from January 2022 to May 2023. Catastrophic brain injury was defined as a brain injury causing loss of function above the brain stem and subsequent death. Cluster analysis with linear mixed-effects model including UNOS regions and hospital size by bed count was used to determine whether CBI guidelines are associated with organ donation. RESULTS A total of 790 CBI patients were included in this analysis. In unadjusted comparison, CBI guideline centers had higher rates of organ donation and use of steroids, whole blood, and hormone therapy. In a linear mixed-effects model, CBI guidelines were not associated with organ donation. Registered organ donor status, steroid hormones, and vasopressin were associated with increased relative risk of donation. CONCLUSION There is high variability in management of CBI, even at centers with CBI guidelines in place. While the use of institutional CBI guidelines was not associated with increased organ donation, guidelines in this study were not identical. Hormone replacement with steroids and vasopressin was associated with increased donation. Hormone resuscitation is a common feature of CBI guidelines. Further analysis of individual practices that increase organ donation after CBI may allow for more effective guidelines and an overall increase in donation to decrease the long waiting periods for organ transplant recipients. LEVEL OF EVIDENCE Prognostic; Level III.
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Affiliation(s)
- Kristen D Nordham
- From the Department of Surgery (K.D.N., D. Tatum, A.P., J.C.D., A.S.A., E.I., B.M., E.C., S.T.), Tulane University School of Medicine, New Orleans, Louisiana; Department of Surgery (K.D.N.), Harbor-UCLA Medical Center, Torrance, California; Department of Surgery (M.B.P., A.W.M., A.B.P.), Vanderbilt University Medical Center, Nashville, Tennessee; Department of Surgery (J.N., C.A.), University of California-Irvine, Orange, California; Department of Surgery (P.O.U., A. Stiles, C.S.), Wake Med, Raleigh, North Carolina; Department of Surgery (J.D. Stodghill, T.M.), Virginia Tech Carilion School of Medicine, Roanoke, Virginia; Department of Surgery (R.M.B., S.A.Z., B. Shammassian, A.A.S.), Louisiana State University Health, New Orleans, Louisiana;Department of Surgery (T.E., I.A., P.M., J. Metheny), Cooper Medical School of Rowan University, Camden, New Jersey; Department of Surgery (M.S.F., M.D.P.), Lehigh Valley Health Network, Allentown, Pennsylvania; Department of Surgery (O.T.M., P.S.), Valleywise Health Medical Center, Phoenix, Arizona; Department of Surgery (D.T.-W.W., J.S.), Arrowhead Regional Medical Center, Colton, California; Department of Surgery (J.D. Sciarretta, P.K.), Emory University School of Medicine, Atlanta, Georgia; Department of Surgery (R.H., D.G.), Loma Linda University Medical Center, Loma Linda, California; Department of Surgery (J. Murry, K. Meadows), UT Health Tyler, Tyler, Texas; Department of Surgery (L.E.J., J.M.W.), Ascension St. Vincent Hospital, Indianapolis, Indiana; Department of Surgery (A.C.B.), University of Kentucky Healthcare, Lexington, Kentucky;17 DeBusk College of Osteopathic Medicine (B. Smith), Lincoln Memorial University, Harrogate, Tennessee; Department of Surgery (S.L.M., N.P.), Conemaugh Memorial Medical Center, Johnstown, Pennsylvania; Department of Surgery (D. Tabello, E.T.), Inova Health System, Falls Church, Virginia; Department of Surgery (S.M.C., F.A.), King Saud Medical City, Riyadh, Saudi Arabia;Department of Surgery (B.S.M., M.A.W.), University of Minnesota, Minneapolis, Minnesota;22 Department of Surgery (T.H.J., G.D.), Our Lady of the Lake Regional Medical Center, Baton Rouge, Louisiana;23 Department of 'Surgery (J.A.M., D.R.), Thomas Jefferson University Hospital, Philadelphia, Pennsylvania;24 Department of Surgery (J.M.H., K.L.), Ascension Via Christi Hospitals Wichita, Wichita, Kansas;25 Department of Surgery (K. Matsushima, S.P.), Los Angeles General Medical Center, Los Angeles, California; Department of Surgery (A. Santos, K.S.), Texas Tech University Health Science Center; Department of Surgery (C.B.), Covenant Medical Center, Lubbock, Texas; Department of Surgery (R.S., S.V.), Bronson Methodist Hospital, Kalamazoo, Michigan; Department of Surgery (R.J.J., R.C.H.), College of Medicine Chattanooga, University of Tennessee, Chattanooga, Tennessee; Department of Surgery (S.L.), Warren Alpert Medical School at Brown University, Providence, Rhode Island; Department of Surgery (N.B., W.A.), Tufts Medical Center, Boston, Massachusetts; Department of Surgery (M.J.L., H.M.), Research Medical Center, Kansas City, Missouri; Department of Surgery (R.P.D., C.A.F.), University of Texas Southwestern Medical Center, Dallas, Texas; Department of Surgery (C.A.F.), Brody School of Medicine at East Carolina, Greenville, North Carolina; Department of Surgery (W.T.H.T., Y.T.), University of Nebraska Medical Center, Omaha, Nevada; Department of Surgery (V.M., F.M.), U General University Hospital of Patras, Pio, Greece; and Department of Surgery (J.D.B., D.R.M.), Broward Health Medical Center, Fort Lauderdale, Florida
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Walsh MM, Fox MD, Moore EE, Johnson JL, Bunch CM, Miller JB, Lopez-Plaza I, Brancamp RL, Waxman DA, Thomas SG, Fulkerson DH, Thomas EJ, Khan HA, Zackariya SK, Al-Fadhl MD, Zackariya SK, Thomas SJ, Aboukhaled MW. Markers of Futile Resuscitation in Traumatic Hemorrhage: A Review of the Evidence and a Proposal for Futility Time-Outs during Massive Transfusion. J Clin Med 2024; 13:4684. [PMID: 39200824 PMCID: PMC11355875 DOI: 10.3390/jcm13164684] [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: 06/12/2024] [Revised: 07/26/2024] [Accepted: 08/06/2024] [Indexed: 09/02/2024] Open
Abstract
The reduction in the blood supply following the 2019 coronavirus pandemic has been exacerbated by the increased use of balanced resuscitation with blood components including whole blood in urban trauma centers. This reduction of the blood supply has diminished the ability of blood banks to maintain a constant supply to meet the demands associated with periodic surges of urban trauma resuscitation. This scarcity has highlighted the need for increased vigilance through blood product stewardship, particularly among severely bleeding trauma patients (SBTPs). This stewardship can be enhanced by the identification of reliable clinical and laboratory parameters which accurately indicate when massive transfusion is futile. Consequently, there has been a recent attempt to develop scoring systems in the prehospital and emergency department settings which include clinical, laboratory, and physiologic parameters and blood products per hour transfused as predictors of futile resuscitation. Defining futility in SBTPs, however, remains unclear, and there is only nascent literature which defines those criteria which reliably predict futility in SBTPs. The purpose of this review is to provide a focused examination of the literature in order to define reliable parameters of futility in SBTPs. The knowledge of these reliable parameters of futility may help define a foundation for drawing conclusions which will provide a clear roadmap for traumatologists when confronted with SBTPs who are candidates for the declaration of futility. Therefore, we systematically reviewed the literature regarding the definition of futile resuscitation for patients with trauma-induced hemorrhagic shock, and we propose a concise roadmap for clinicians to help them use well-defined clinical, laboratory, and viscoelastic parameters which can define futility.
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Affiliation(s)
- Mark M. Walsh
- Futile Indicators for Stopping Transfusion in Trauma (FISTT) Collaborative Group, Indiana University School of Medicine—South Bend, South Bend, IN 46617, USA; (M.D.F.); (E.E.M.); (J.L.J.); (C.M.B.); (J.B.M.); (I.L.-P.); (R.L.B.); (D.A.W.); (S.G.T.); (D.H.F.); (E.J.T.); (H.A.K.); (S.K.Z.); (M.D.A.-F.); (S.K.Z.); (S.J.T.); (M.W.A.)
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Al-Fadhl MD, Karam MN, Chen J, Zackariya SK, Lain MC, Bales JR, Higgins AB, Laing JT, Wang HS, Andrews MG, Thomas AV, Smith L, Fox MD, Zackariya SK, Thomas SJ, Tincher AM, Al-Fadhl HD, Weston M, Marsh PL, Khan HA, Thomas EJ, Miller JB, Bailey JA, Koenig JJ, Waxman DA, Srikureja D, Fulkerson DH, Fox S, Bingaman G, Zimmer DF, Thompson MA, Bunch CM, Walsh MM. Traumatic Brain Injury as an Independent Predictor of Futility in the Early Resuscitation of Patients in Hemorrhagic Shock. J Clin Med 2024; 13:3915. [PMID: 38999481 PMCID: PMC11242176 DOI: 10.3390/jcm13133915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2024] [Revised: 06/08/2024] [Accepted: 06/26/2024] [Indexed: 07/14/2024] Open
Abstract
This review explores the concept of futility timeouts and the use of traumatic brain injury (TBI) as an independent predictor of the futility of resuscitation efforts in severely bleeding trauma patients. The national blood supply shortage has been exacerbated by the lingering influence of the COVID-19 pandemic on the number of blood donors available, as well as by the adoption of balanced hemostatic resuscitation protocols (such as the increasing use of 1:1:1 packed red blood cells, plasma, and platelets) with and without early whole blood resuscitation. This has underscored the urgent need for reliable predictors of futile resuscitation (FR). As a result, clinical, radiologic, and laboratory bedside markers have emerged which can accurately predict FR in patients with severe trauma-induced hemorrhage, such as the Suspension of Transfusion and Other Procedures (STOP) criteria. However, the STOP criteria do not include markers for TBI severity or transfusion cut points despite these patients requiring large quantities of blood components in the STOP criteria validation cohort. Yet, guidelines for neuroprognosticating patients with TBI can require up to 72 h, which makes them less useful in the minutes and hours following initial presentation. We examine the impact of TBI on bleeding trauma patients, with a focus on those with coagulopathies associated with TBI. This review categorizes TBI into isolated TBI (iTBI), hemorrhagic isolated TBI (hiTBI), and polytraumatic TBI (ptTBI). Through an analysis of bedside parameters (such as the proposed STOP criteria), coagulation assays, markers for TBI severity, and transfusion cut points as markers of futilty, we suggest amendments to current guidelines and the development of more precise algorithms that incorporate prognostic indicators of severe TBI as an independent parameter for the early prediction of FR so as to optimize blood product allocation.
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Affiliation(s)
- Mahmoud D Al-Fadhl
- Department of Medical Education, South Bend Campus, Indiana University School of Medicine, South Bend, IN 46617, USA
| | - Marie Nour Karam
- Department of Medical Education, South Bend Campus, Indiana University School of Medicine, South Bend, IN 46617, USA
| | - Jenny Chen
- Department of Medical Education, South Bend Campus, Indiana University School of Medicine, South Bend, IN 46617, USA
| | - Sufyan K Zackariya
- Department of Medical Education, South Bend Campus, Indiana University School of Medicine, South Bend, IN 46617, USA
| | - Morgan C Lain
- Department of Medical Education, South Bend Campus, Indiana University School of Medicine, South Bend, IN 46617, USA
| | - John R Bales
- Department of Medical Education, South Bend Campus, Indiana University School of Medicine, South Bend, IN 46617, USA
| | - Alexis B Higgins
- Department of Medical Education, South Bend Campus, Indiana University School of Medicine, South Bend, IN 46617, USA
| | - Jordan T Laing
- Department of Medical Education, South Bend Campus, Indiana University School of Medicine, South Bend, IN 46617, USA
| | - Hannah S Wang
- Department of Medical Education, South Bend Campus, Indiana University School of Medicine, South Bend, IN 46617, USA
| | - Madeline G Andrews
- Department of Medical Education, South Bend Campus, Indiana University School of Medicine, South Bend, IN 46617, USA
| | - Anthony V Thomas
- Department of Medical Education, South Bend Campus, Indiana University School of Medicine, South Bend, IN 46617, USA
| | - Leah Smith
- Department of Medical Education, South Bend Campus, Indiana University School of Medicine, South Bend, IN 46617, USA
| | - Mark D Fox
- Department of Medical Education, South Bend Campus, Indiana University School of Medicine, South Bend, IN 46617, USA
| | - Saniya K Zackariya
- Department of Internal Medicine, Saint Joseph Regional Medical Center, Mishawaka, IN 46545, USA
| | - Samuel J Thomas
- Department of Internal Medicine, Saint Joseph Regional Medical Center, Mishawaka, IN 46545, USA
| | - Anna M Tincher
- Department of Medical Education, South Bend Campus, Indiana University School of Medicine, South Bend, IN 46617, USA
| | - Hamid D Al-Fadhl
- Department of Medical Education, South Bend Campus, Indiana University School of Medicine, South Bend, IN 46617, USA
| | - May Weston
- Department of Internal Medicine, Saint Joseph Regional Medical Center, Mishawaka, IN 46545, USA
| | - Phillip L Marsh
- Department of Internal Medicine, Saint Joseph Regional Medical Center, Mishawaka, IN 46545, USA
| | - Hassaan A Khan
- Department of Internal Medicine, Saint Joseph Regional Medical Center, Mishawaka, IN 46545, USA
| | - Emmanuel J Thomas
- Department of Internal Medicine, Saint Joseph Regional Medical Center, Mishawaka, IN 46545, USA
| | - Joseph B Miller
- Department of Emergency Medicine, Henry Ford Hospital, Detroit, MI 48202, USA
| | - Jason A Bailey
- Department of Emergency Medicine, Elkhart General Hospital, Elkhart, IN 46515, USA
| | - Justin J Koenig
- Department of Trauma & Surgical Services, Memorial Hospital, South Bend, IN 46601, USA
| | - Dan A Waxman
- Department of Pathology and Laboratory Medicine, Indiana University School of Medicine, Indianapolis, IN 46601, USA
- Versiti Blood Center of Indiana, Indianapolis, IN 46208, USA
| | - Daniel Srikureja
- Department of Surgery, Memorial Hospital, South Bend, IN 46601, USA
| | - Daniel H Fulkerson
- Department of Trauma & Surgical Services, Memorial Hospital, South Bend, IN 46601, USA
- Department of Neurosurgery, Memorial Hospital, South Bend, IN 46601, USA
| | - Sarah Fox
- Department of Trauma & Surgical Services, Memorial Hospital, South Bend, IN 46601, USA
| | - Greg Bingaman
- Department of Trauma & Surgical Services, Memorial Hospital, South Bend, IN 46601, USA
| | - Donald F Zimmer
- Department of Emergency Medicine, Memorial Hospital, South Bend, IN 46601, USA
| | - Mark A Thompson
- Department of Surgery, Memorial Hospital, South Bend, IN 46601, USA
| | - Connor M Bunch
- Department of Emergency Medicine, Henry Ford Hospital, Detroit, MI 48202, USA
| | - Mark M Walsh
- Department of Internal Medicine, Saint Joseph Regional Medical Center, Mishawaka, IN 46545, USA
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Zarzycki M, Seddon D, Petrovic M, Morrison V. Supporting Individuals With an Acquired Brain Injury: An Interpretative Phenomenological Study Exploring the Everyday Lives of Caregivers. QUALITATIVE HEALTH RESEARCH 2024:10497323241242046. [PMID: 38884621 DOI: 10.1177/10497323241242046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/18/2024]
Abstract
Acquired brain injury (ABI) is one of the most common causes of disability and death globally. Support from informal caregivers is critical to the well-being and quality of life of people with ABI and supports the sustainability of global health and social care systems. This study presents an in-depth qualitative analysis of the experiences of eight British informal caregivers supporting someone with ABI. Semi-structured interviews were conducted with narratives transcribed verbatim and analysed using interpretative phenomenological analysis (IPA). Three superordinate themes were generated: making sense of brain injury; being consumed by caregiving; and, the changing self. These data highlight the impact of caregiving on the caregiver's illness perceptions and sense of self. By identifying negative and positive changes in the caregiver's sense of self, and dilemmas regarding the care recipient's behaviour, we address less understood aspects of caregiver experiences. Caregiving can pose both challenges to the caregiver's sense of identity and an opportunity for self-growth. Some caregivers exhibit resilience throughout their journey, with post-traumatic growth more apparent in the later stages of caregiving. Illness perceptions shape caregiver well-being and family dynamics and indicate the need to address stigmatisation and discrimination faced by ABI survivors and caregivers. Although some caregivers acquired positive meaning and enrichment from their caregiving, previously described challenges of ABI caregiving are supported. Overall, our findings support the need for timely psychological/mental health support for caregivers, caregiver education, and the provision of short breaks from caregiving.
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Affiliation(s)
- Mikołaj Zarzycki
- Department of Psychology, Liverpool Hope University, Liverpool, UK
| | - Diane Seddon
- School of Health Sciences, College of Medicine and Health, Bangor University, Bangor, UK
| | - Milica Petrovic
- Department of Psychology, Università Cattolica del Sacro Cuore, Milan, Italy
- Depression Research Centre of the German Depression Foundation, Department for Psychiatry, Psychosomatics and Psychotherapy, Goethe University, Frankfurt, Germany
| | - Val Morrison
- School of Psychology and Sports Science, College of Medicine and Health, Bangor University, Bangor, UK
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Breeze J, Whitford A, Gensheimer WG, Berg C. Physiological and radiological parameters predicting outcome from penetrating traumatic brain injury treated in the deployed military setting. BMJ Mil Health 2024; 170:228-231. [PMID: 36028282 DOI: 10.1136/military-2022-002118] [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: 03/16/2022] [Accepted: 08/07/2022] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Penetrating traumatic brain injury (TBI) is the most common cause of death in current military conflicts, and results in significant morbidity in survivors. Identifying those physiological and radiological parameters associated with worse clinical outcomes following penetrating TBI in the austere setting may assist military clinicians to provide optimal care. METHOD All emergency neurosurgical procedures performed at a Role 3 Medical Treatment Facility in Afghanistan for penetrating TBI between 01 January 2016 and 18 December 2020 were analysed. The odds of certain clinical outcomes (death and functional dependence post-discharge) occurring following surgery were matched to existing agreed preoperative variables described in current US and UK military guidelines. Additional physiological and radiological variables including those comprising the Rotterdam criteria of TBI used in civilian settings were additionally analysed to determine their potential utility in a military austere setting. RESULTS 55 casualties with penetrating TBI underwent surgery, all either by decompressive craniectomy (n=42) or craniotomy±elevation of skull fragments (n=13). The odds of dying in hospital attributable to TBI were greater with casualties with increased glucose on arrival (OR=70.014, CI=3.0399 to 1612.528, OR=70.014, p=0.008) or a mean arterial pressure <90 mm Hg (OR=4.721, CI=0.969 to 22.979, p=0.049). Preoperative hyperglycaemia was also associated with increased odds of being functionally dependent on others on discharge (OR=11.165, CI=1.905 to 65.427, p=0.007). Bihemispheric injury had greater odds of being functionally dependent on others at discharge (OR=5.275, CI=1.094 to 25.433, p=0.038). CONCLUSIONS We would recommend that consideration of these three additional preoperative clinical parameters (hyperglycaemia, hypotension and bihemispheric injury on CT) when managing penetrating TBI be considered in future updates of guidelines for deployed neurosurgical care.
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Affiliation(s)
- John Breeze
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, UK
- Department of Bioengineering, Imperial College London, London, UK
| | - A Whitford
- Gaza Barracks, Joint Hospital Group, Catterick, UK
| | - W G Gensheimer
- Warfighter Eye Center, Malcolm Grow Medical Clinics and Surgery Center Joint Base Andrews, Prince George's County, Maryland, USA
| | - C Berg
- Department of Neurosurgery, Wright-Patterson Air Force Base, Dayton, Ohio, USA
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