1
|
Wang J, Chen J, Liu K, Zhang H, Wei Y, Suo L, Lan S, Wang Y, Luo C, Yao L. Anesthetic managements, morbidities and mortalities in retroperitoneal sarcoma patients experiencing perioperative massive blood transfusion. Front Oncol 2024; 14:1347248. [PMID: 38505594 PMCID: PMC10948446 DOI: 10.3389/fonc.2024.1347248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Accepted: 02/19/2024] [Indexed: 03/21/2024] Open
Abstract
Objective Given high risks of major bleeding during retroperitoneal sarcoma(RPS) surgeries, severe complications and deaths are common to see perioperatively. Thus, effective anesthetic management is the key point to ensuring the safety of patients. This study aimed to introduce anesthesia management and mortalities in RPS patients receiving massive blood transfusions during surgeries. Methods Records of RPS surgeries under general anesthesia from January 2016 through December 2021 were retrospectively retrieved from our database. Patients who received massive blood transfusions (MBT) exceeding 20 units in 24h duration of operations were finally included in this study. Demographics, modalities of anesthesia management, blood loss, transfusion, peri-anesthesia biochemical tests as well as morbidities and mortalities were collected. Risk factors of postoperative 60d mortality were determined through logistic regression in uni-and multi-variety analysis using the statistics software STATA 17.0. Results A total of 70 patients (male 31) were included. The mean age was 50.1 ± 15.8 years. All patients received combined resections of sarcoma with involved organs under general anesthesia. Mean operation time and anesthesia time were 491.7 ± 131.1mins and 553.9 ± 132.6mins, respectively. The median intraoperative blood loss was 7000ml (IQR 5500,10000ml). Median red blood cells (RBC) and fresh frozen plasma (FFP) transfusion were 25.3u (IQR 20,28u), and 2400ml (IQR 2000,3000ml), respectively. Other blood products infusions included prothrombin complex concentrate (PCCs), fibrinogen concentrate (FC), platelet(plt) and albumin(alb) in 82.9% (58/70), 88.6% (62/70), 81.4% (57/70) and 12.9% (9/70) of patients. The postoperative severe complication rate(Clavien-Dindo grade≥3a) was 35.7%(25/70). A total of 7 patients (10%) died during the postoperative 60-day period. BMI, volumes of crystalloid infusion in anesthesia, and hemoglobin and lactate levels at the termination of operation were found significantly associated with postoperative occurrence of death in univariate analysis. In logistic multivariate analysis, extended anesthesia duration was found associated with postoperative venous thrombosis embolism (VTE) and severe complication. The lactate level at the immediate termination of the operation was the only risk factor related to perioperative death (p<0.05). Conclusion RPS patients who endure MBT in surgeries face higher risks of death postoperatively, which needs precise and effective anesthesia management in high-volume RPS centers. Increased blood lactate levels might be predictors of postoperative deaths which should be noted.
Collapse
Affiliation(s)
- Jun Wang
- Department of Anesthesiology, Peking University International Hospital, Beijing, China
| | - Jun Chen
- Department of Retroperitoneal Tumor Surgery, Peking University International Hospital, Beijing, China
- Department of General Surgery, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Kunpeng Liu
- Department of Anesthesiology, Peking University International Hospital, Beijing, China
| | - Hua Zhang
- The Clinical Epidemiology Research Center, Peking University Third Hospital, Beijing, China
| | - Yue Wei
- Department of Anesthesiology, Peking University International Hospital, Beijing, China
| | - Libin Suo
- Department of Anesthesiology, Peking University International Hospital, Beijing, China
| | - Shuang Lan
- Department of Anesthesiology, Peking University International Hospital, Beijing, China
| | - Yanzhen Wang
- Department of Anesthesiology, Peking University International Hospital, Beijing, China
| | - Chenghua Luo
- Department of Retroperitoneal Tumor Surgery, Peking University International Hospital, Beijing, China
- Department of Retroperitoneal Tumor Surgery, Peking University People’s Hospital, Beijing, China
| | - Lan Yao
- Department of Anesthesiology, Peking University International Hospital, Beijing, China
| |
Collapse
|
2
|
Barrett L, Curry N, Abu-Hanna J. Experimental Models of Traumatic Injuries: Do They Capture the Coagulopathy and Underlying Endotheliopathy Induced by Human Trauma? Int J Mol Sci 2023; 24:11174. [PMID: 37446351 PMCID: PMC10343021 DOI: 10.3390/ijms241311174] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 07/03/2023] [Accepted: 07/05/2023] [Indexed: 07/15/2023] Open
Abstract
Trauma-induced coagulopathy (TIC) is a major cause of morbidity and mortality in patients with traumatic injury. It describes the spectrum of coagulation abnormalities that occur because of the trauma itself and the body's response to the trauma. These coagulation abnormalities range from hypocoagulability and hyperfibrinolysis, resulting in potentially fatal bleeding, in the early stages of trauma to hypercoagulability, leading to widespread clot formation, in the later stages. Pathological changes in the vascular endothelium and its regulation of haemostasis, a phenomenon known as the endotheliopathy of trauma (EoT), are thought to underlie TIC. Our understanding of EoT and its contribution to TIC remains in its infancy largely due to the scarcity of experimental research. This review discusses the mechanisms employed by the vascular endothelium to regulate haemostasis and their dysregulation following traumatic injury before providing an overview of the available experimental in vitro and in vivo models of trauma and their applicability for the study of the EoT and its contribution to TIC.
Collapse
Affiliation(s)
- Liam Barrett
- Division of Anaesthesia, Department of Medicine, University of Cambridge, Cambridge CB2 1TN, UK;
- Emergency Department, Cambridge University Hospitals NHS Foundation Trust, Cambridge CB2 0QQ, UK
| | - Nicola Curry
- Nuffield Division of Clinical Laboratory Sciences, Radcliffe Department of Medicine, University of Oxford, Oxford OX3 9DU, UK;
- Oxford Haemophilia and Thrombosis Centre, Oxford University Hospitals NHS Foundation Trust, Oxford OX3 7LD, UK
| | - Jeries Abu-Hanna
- Nuffield Division of Clinical Laboratory Sciences, Radcliffe Department of Medicine, University of Oxford, Oxford OX3 9DU, UK;
| |
Collapse
|
3
|
Windberger U, Dibiasi C, Lotz EM, Scharbert G, Reinbacher-Koestinger A, Ivanov I, Ploszczanski L, Antonova N, Lichtenegger H. The effect of hematocrit, fibrinogen concentration and temperature on the kinetics of clot formation of whole blood. Clin Hemorheol Microcirc 2020; 75:431-445. [PMID: 32390608 DOI: 10.3233/ch-190799] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Dynamic mechanical analysis of blood clots can be used to detect the coagulability of blood. OBJECTIVE We investigated the kinetics of clot formation by changing several blood components, and we looked into the clot "signature" at its equilibrium state by using viscoelastic and dielectric protocols. METHODS Oscillating shear rheometry, ROTEM, and a dielectro-rheological device was used. RESULTS In fibrinogen- spiked samples we found the classical high clotting ability: shortened onset, faster rate of clotting, and higher plateau stiffness. Electron microscopy explained the gain of stiffness. Incorporated RBCs weakened the clots. Reduction of temperature during the clotting process supported the development of high moduli by providing more time for fiber assembly. But at low HCT, clot firmness could be increased by elevating the temperature from 32 to 37°C. In contrast, when the fibrinogen concentration was modified, acceleration of clotting via temperature always reduced clot stiffness, whatever the initial fibrinogen concentration. Electrical resistance increased continuously during clotting; loss tangent (D) (relaxation frequency 249 kHz) decreased when clots became denser: fewer dipoles contributed to the relaxation process. The relaxation peak (Dmax) shifted to lower frequencies at higher platelet count. CONCLUSION Increasing temperature accelerates clot formation but weakens clots. Rheometry and ROTEM correlate well.
Collapse
Affiliation(s)
- U Windberger
- Center for Biomedical Research, Medical University Vienna, Vienna, Austria
| | - Ch Dibiasi
- Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Vienna, Austria
| | - E M Lotz
- Center for Biomedical Research, Medical University Vienna, Vienna, Austria
| | - G Scharbert
- Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Vienna, Austria
| | - A Reinbacher-Koestinger
- Institute of Fundamentals and Theory in Electrical Engineering, Graz University of Technology, Graz, Austria
| | - I Ivanov
- Institute of Mechanics, Bulgarian Academy of Science, Sofia, Bulgaria
| | - L Ploszczanski
- Department of Material Sciences and Process Engineering, Institute of Physics and Materials Science, University of Natural Resources and Life Sciences, Vienna, Austria
| | - N Antonova
- Institute of Mechanics, Bulgarian Academy of Science, Sofia, Bulgaria
| | - H Lichtenegger
- Department of Material Sciences and Process Engineering, Institute of Physics and Materials Science, University of Natural Resources and Life Sciences, Vienna, Austria
| |
Collapse
|
4
|
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.
Collapse
|
5
|
Abstract
The microvasculature plays a central role in the pathophysiology of hemorrhagic shock and is also involved in arguably all therapeutic attempts to reverse or minimize the adverse consequences of shock. Microvascular studies specific to hemorrhagic shock were reviewed and broadly grouped depending on whether data were obtained on animal or human subjects. Dedicated sections were assigned to microcirculatory changes in specific organs, and major categories of pathophysiological alterations and mechanisms such as oxygen distribution, ischemia, inflammation, glycocalyx changes, vasomotion, endothelial dysfunction, and coagulopathy as well as biomarkers and some therapeutic strategies. Innovative experimental methods were also reviewed for quantitative microcirculatory assessment as it pertains to changes during hemorrhagic shock. The text and figures include representative quantitative microvascular data obtained in various organs and tissues such as skin, muscle, lung, liver, brain, heart, kidney, pancreas, intestines, and mesentery from various species including mice, rats, hamsters, sheep, swine, bats, and humans. Based on reviewed findings, a new integrative conceptual model is presented that includes about 100 systemic and local factors linked to microvessels in hemorrhagic shock. The combination of systemic measures with the understanding of these processes at the microvascular level is fundamental to further develop targeted and personalized interventions that will reduce tissue injury, organ dysfunction, and ultimately mortality due to hemorrhagic shock. Published 2018. Compr Physiol 8:61-101, 2018.
Collapse
Affiliation(s)
- Ivo Torres Filho
- US Army Institute of Surgical Research, JBSA Fort Sam Houston, Texas, USA
| |
Collapse
|
6
|
Torres Filho IP, Torres LN, Valdez C, Salgado C, Cap AP, Dubick MA. Refrigerated platelets stored in whole blood up to 5 days adhere to thrombi formed during hemorrhagic hypotension in rats. J Thromb Haemost 2017; 15:163-175. [PMID: 27797452 DOI: 10.1111/jth.13556] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2016] [Accepted: 10/14/2016] [Indexed: 12/21/2022]
Abstract
Essentials In vivo function of platelets stored at various conditions was studied in normo- and hypotension. Refrigerated platelets stored up to 5 days performed as well as those stored at room temperature. Platelet adhesion and thrombus formation were higher in ruptured vessels of hemorrhaged animals. In vivo data suggest that refrigerated platelets are hemostatically effective during hypotension. SUMMARY Background There is renewed interest in the therapeutic use of cold-stored platelets for bleeding patients. However, critical information is absent or partially available in vitro. Therefore, thrombus formation and platelet adhesion were studied in vivo, in situ, using bleeding and thrombosis models in instrumented rats, and confocal intravital videomicroscopy. Objectives We tested the hypothesis that refrigerated (4 °C) platelets (stored for 24 h or 5 days) participated in thrombus formation as well as platelets stored at room temperature (RT, 22 °C). This hypothesis was tested in normovolemia and hemorrhagic hypotension. Methods & Results After fluorescently-labeled platelet infusion, endothelial injury and vessel rupture were laser-induced in cremaster microvessels and platelet adhesion in > 230 developing thrombi was evaluated. Blood samples were collected for biochemistry and coagulation assays while multiple systemic physiologic parameters were recorded. Hemorrhagic hypotension study animals were subjected to 40% hemorrhage, leading to hypotension and hemodilution, during in vivo platelet adhesion assessments. The fluorescence intensity associated with labeled platelet adherence provided a quantitative index of adhesion. Cold-stored platelets performed as well as those stored at RT in normovolemic animals. During hypotension, cold-stored platelets still performed as well as RT-stored platelets, whereas platelet adhesion and thrombus formation were increased relative to normovolemic animals, in bleeding model experiments. Conclusions We found the methodology suitable for evaluating platelet function in vivo after different storage conditions in fully monitored animals. Refrigerated platelets (stored up to 5 days) participated as well as RT-stored platelets in thrombi formed after hemorrhage, suggesting that refrigerated platelets are effective during hypotensive situations.
Collapse
Affiliation(s)
- I P Torres Filho
- Damage Control Resuscitation, US Army Institute of Surgical Research, Fort Sam Houston, TX, USA
| | - L N Torres
- Damage Control Resuscitation, US Army Institute of Surgical Research, Fort Sam Houston, TX, USA
| | - C Valdez
- Damage Control Resuscitation, US Army Institute of Surgical Research, Fort Sam Houston, TX, USA
| | - C Salgado
- Damage Control Resuscitation, US Army Institute of Surgical Research, Fort Sam Houston, TX, USA
| | - A P Cap
- Coagulation and Blood Research Program, US Army Institute of Surgical Research, Fort Sam Houston, TX, USA
| | - M A Dubick
- Damage Control Resuscitation, US Army Institute of Surgical Research, Fort Sam Houston, TX, USA
| |
Collapse
|
7
|
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.
Collapse
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
| |
Collapse
|
8
|
Litvinov RI, Weisel JW. What Is the Biological and Clinical Relevance of Fibrin? Semin Thromb Hemost 2016; 42:333-43. [PMID: 27056152 DOI: 10.1055/s-0036-1571342] [Citation(s) in RCA: 58] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
As our knowledge of the structure and functions of fibrinogen and fibrin has increased tremendously, several key findings have given some people a superficial impression that the biological and clinical significance of these clotting proteins may be less than earlier thought. Most strikingly, studies of fibrinogen knockout mice demonstrated that many of these mice survive to weaning and beyond, suggesting that fibrin(ogen) may not be entirely necessary. Humans with afibrinogenemia also survive. Furthermore, in recent years, the major emphasis in the treatment of arterial thrombosis has been on inhibition of platelets, rather than fibrin. In contrast to the initially apparent conclusions from these results, it has become increasingly clear that fibrin is essential for hemostasis; is a key factor in thrombosis; and plays an important biological role in infection, inflammation, immunology, and wound healing. In addition, fibrinogen replacement therapy has become a preferred, major treatment for severe bleeding in trauma and surgery. Finally, fibrin is a unique biomaterial and is used as a sealant or glue, a matrix for cells, a scaffold for tissue engineering, and a carrier and/or a vector for targeted drug delivery.
Collapse
Affiliation(s)
- Rustem I Litvinov
- Department of Cell and Developmental Biology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - John W Weisel
- Department of Cell and Developmental Biology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| |
Collapse
|
9
|
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.
Collapse
|
10
|
Fibrinogen Concentrate Does Not Suppress Endogenous Fibrinogen Synthesis in a 24-hour Porcine Trauma Model. Anesthesiology 2014; 121:753-64. [DOI: 10.1097/aln.0000000000000315] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Abstract
Background:
Fibrinogen concentrate may reduce blood loss after trauma. However, its effect on endogenous fibrinogen synthesis is unknown. The authors investigated the effect of exogenous human fibrinogen on endogenous fibrinogen metabolism in a 24-h porcine trauma model.
Methods:
Coagulopathy was induced in 20 German Landrace pigs by hemodilution and blunt liver injury. Animals were randomized to receive fibrinogen concentrate (100 mg/kg; infusion beginning 20 min postinjury and lasting approximately 10 min) or saline. Fibrinogen concentration, thromboelastometry, and quantitative reverse transcriptase polymerase chain reaction of fibrinogen genes in liver tissue samples were recorded. Internal organs were examined histologically for emboli.
Results:
Coagulation parameters were impaired and plasma fibrinogen concentrations were reduced before starting infusion of fibrinogen concentrate/saline. Twenty minutes after starting infusion, exogenous fibrinogen supplementation had increased plasma fibrinogen concentration versus controls (171 ± 19 vs. 63 ± 10 mg/dl [mean ± SD for Multifibren U]; 185 ± 30 vs. 41 ± 4 mg/dl [Thrombin reagent]; P < 0.05 for both comparisons). The between-group difference in plasma fibrinogen concentration diminished thereafter, with maximum concentrations in both groups observed at approximately 24 h, that is, during the acute-phase reaction after trauma. Fibrinogen supplementation did not down-regulate endogenous fibrinogen synthesis (no between-group differences in fibrinogen messenger RNA). Total postinjury blood loss was significantly lower in the fibrinogen group (1,062 ± 216 vs. 1,643 ± 244 ml; P < 0.001). No signs of thromboembolism were observed.
Conclusions:
Administration of human fibrinogen concentrate did not down-regulate endogenous porcine fibrinogen synthesis. The effect on plasma fibrinogen concentration was most pronounced at 20 min but nonsignificant at approximately 24 h.
Collapse
|
11
|
|