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Cralley AL, Moore EE, Coleman JR, Vigneshwar N, Bartley M, Kissau D, Eitel A, Hom P, Mitra S, Ghasabyan A, Fragoso M, Guo Z, Deguchi H, Griffin JH, Cohen MJ, Silliman CC, Banerjee A, Hansen K, Sauaia A. Hemorrhagic shock and tissue injury provoke distinct components of trauma-induced coagulopathy in a swine model. Eur J Trauma Emerg Surg 2023; 49:1079-1089. [PMID: 36319860 PMCID: PMC10802987 DOI: 10.1007/s00068-022-02148-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Accepted: 10/14/2022] [Indexed: 03/02/2023]
Abstract
INTRODUCTION Tissue injury (TI) and hemorrhagic shock (HS) are the major contributors to trauma-induced coagulopathy (TIC). However, the individual contributions of these insults are difficult to discern clinically because they typically coexist. TI has been reported to release procoagulants, while HS has been associated with bleeding. We developed a large animal model to isolate TI and HS and characterize their individual mechanistic pathways. We hypothesized that while TI and HS are both drivers of TIC, they provoke different pathways; specifically, TI reduces time to clotting, whereas, HS decreases clot strength stimulates hyperfibrinolysis. METHODS After induction of general anesthesia, 50 kg male, Yorkshire swine underwent isolated TI (bilateral muscle cutdown of quadriceps, bilateral femur fractures) or isolated HS (controlled bleeding to a base excess target of - 5 mmol/l) and observed for 240 min. Thrombelastography (TEG), calcium levels, thrombin activatable fibrinolysis inhibitor (TAFI), protein C, plasminogen activator inhibitor 1 (PAI-1), and plasminogen activator inhibitor 1/tissue-type plasminogen activator complex (PAI-1-tPA) were analyzed at pre-selected timepoints. Linear mixed models for repeated measures were used to compare results throughout the model. RESULTS TI resulted in elevated histone release which peaked at 120 min (p = 0.02), and this was associated with reduced time to clot formation (R time) by 240 min (p = 0.006). HS decreased clot strength at time 30 min (p = 0.003), with a significant decline in calcium (p = 0.001). At study completion, HS animals had elevated PAI-1 (p = 0.01) and PAI-1-tPA (p = 0.04), showing a trend toward hyperfibrinolysis, while TI animals had suppressed fibrinolysis. Protein C, TAFI and skeletal myosin were not different among the groups. CONCLUSION Isolated injury in animal models can help elucidate the mechanistic pathways leading to TIC. Our results suggest that isolated TI leads to early histone release and a hypercoagulable state, with suppressed fibrinolysis. In contrast, HS promotes poor clot strength and hyperfibrinolysis resulting in hypocoagulability.
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Affiliation(s)
| | - Ernest E Moore
- Department of Surgery, University of Colorado, Aurora, CO, USA
- Department of Surgery, Ernest E. Moore Shock Trauma Center at Denver Health, Denver, CO, USA
| | - Julia R Coleman
- Department of Surgery, University of Colorado, Aurora, CO, USA
| | | | - Matt Bartley
- Department of Surgery, University of Colorado, Aurora, CO, USA
| | - Daniel Kissau
- Department of Surgery, University of Colorado, Aurora, CO, USA
| | - Andrew Eitel
- Department of Surgery, University of Colorado, Aurora, CO, USA
| | - Patrick Hom
- Department of Surgery, University of Colorado, Aurora, CO, USA
| | | | - Arsen Ghasabyan
- Department of Surgery, University of Colorado, Aurora, CO, USA
| | - Miguel Fragoso
- Department of Surgery, University of Colorado, Aurora, CO, USA
| | - Zihan Guo
- Department of Molecular Medicine, The Scripps Research Institute, La Jolla, CA, USA
| | - Hiroshi Deguchi
- Department of Molecular Medicine, The Scripps Research Institute, La Jolla, CA, USA
| | - John H Griffin
- Department of Molecular Medicine, The Scripps Research Institute, La Jolla, CA, USA
- Department of Medicine, University of California, San Diego, CA, USA
| | | | - Christopher C Silliman
- Vitalant Research Institute, Denver, CO, USA
- Department of Pediatrics, University of Colorado, Aurora, CO, USA
| | | | - Kirk Hansen
- Department of Proteomics and Metabolomics, University of Colorado, Aurora, CO, USA
| | - Angela Sauaia
- Department of Health Systems, Management and Policy, School of Public Health, University of Colorado Denver, Aurora, CO, USA
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Ask A, Eltringham-Smith L, Bhakta V, Donkor DA, Pryzdial EL, Sheffield WP. Spotlight on animal models of acute traumatic coagulopathy: An update. Transfus Apher Sci 2022; 61:103412. [DOI: 10.1016/j.transci.2022.103412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Brännström A, von Oelreich E, Degerstedt LE, Dahlquist A, Hånell A, Gustavsson J, Günther M. The swine as a vehicle for research in trauma-induced coagulopathy: Introducing principal component analysis for viscoelastic coagulation tests. J Trauma Acute Care Surg 2021; 90:360-368. [PMID: 33093294 DOI: 10.1097/ta.0000000000002997] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND Uncontrolled bleeding is the leading cause of potentially preventable deaths among trauma patients. Tissue injury and shock result in trauma-induced coagulopathy (TIC). There are still uncertainties regarding detection methods and best practice management for TIC, and a deeper understanding of the pathophysiology requires robust animal models. The applicability of swine in coagulation studies, particularly after trauma has not been sufficiently elucidated. We, therefore, evaluated the swine as a vehicle for TIC research in a selection of trauma modalities. METHODS Twenty-six landrace swine (3 females/23 males) (mean weight, 60.0 kg) were anesthetized and randomized to negative controls, receiving no manipulation (n = 5), positive controls by hemodilution (n = 5), pulmonary contusion without hemorrhage (n = 5), pulmonary contusion with hemorrhage (n = 5), and blast polytrauma with hypothermia, hypoperfusion, hypoventilation, and systemic inflammation (n = 6). A comprehensive coagulation panel was analyzed at baseline, 20 minutes and 120 minutes after trauma. RESULTS PT(INR), aPTT, thrombocytes, and fibrinogen did not change after trauma. D-dimer increased (p < 0.0001), prothrombin decreased (p < 0.05) and aPC decreased (p < 0.01) after polytrauma. PAI-1 decreased after pulmonary contusion with hemorrhage (p < 0.05). Positive controls displayed changes in PT(INR), thrombocytes, fibrinogen, prothrombin, aPC (p < 0.05). Principal Component Analysis of rotational thromboelastometry presented pathologic coagulation profiles in both polytrauma and positive control groups with vectors extending outside the 95% confidence interval, which were not detected in negative controls. CONCLUSION Coagulopathy was induced after severe porcine blast polytrauma, specifically detected in rotational thromboelastometry. A novel method for principal component analysis of viscoelastic tests was introduced which may increase the detection sensitivity and differentiation of TIC phenotypes and should be further investigated in trauma populations.
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Affiliation(s)
- Andreas Brännström
- From the Department of Clinical Science and Education (A.B., L.E.D., A.D., M.G.), Department of Physiology and Pharmacology (E.v.O.), and Department of Neuroscience (A.H., J.G.), Karolinska Institutet, Stockholm, Sweden
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Chowdary P, Hamid C, Slatter D, Morris R, Foley JH, Gomez K, Brodkin E, Fox TA, Gatt A, McVey JH. Impaired platelet-dependent thrombin generation associated with thrombocytopenia is improved by prothrombin complex concentrates in vitro. Res Pract Thromb Haemost 2020; 4:334-342. [PMID: 32110765 PMCID: PMC7040546 DOI: 10.1002/rth2.12310] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Revised: 12/06/2019] [Accepted: 12/12/2019] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Impaired thrombin generation (TG) in patients with acquired coagulopathy, is due to low coagulation factors and thrombocytopenia. The latter is typically treated with platelet transfusions and the former with plasma and occasionally with prothrombin complex concentrates (PCCs). We hypothesized that manipulating the concentrations of coagulation factors might result in restoration of platelet-dependent TG over and above that of simple replacement therapy. OBJECTIVE To investigate the influence of PCCs on impaired TG secondary to thrombocytopenia. METHODS TG was evaluated by thrombin generation assay using a thrombocytopenia model in which normal plasma samples with varying platelet counts (20-300 × 109/L) were spiked with PCCs (25%-150% increase in plasma PCC levels). RESULTS PCCs and platelets significantly increased TG in a dose-dependent manner in vitro. Two-way repeated measures of analysis of variance showed variance in peak height, area under the curve, time to peak, and velocity. This variance explained, respectively, by levels of PCC was 47, 59, 25 and 53%; by platelet count was 45, 28, 44, and 14%; by the combination was 80, 67, 70, and 62% variance; and a combination with additional interaction was 91, 84, 76, and 68%. TG at a platelet count 40 × 109/L with an approximate 25% increase in PCC concentration was similar to TG at 150 × 109/L. Similarly, patient samples spiked ex vivo with PCCs also showed highly significant improvements in TG. CONCLUSIONS Impaired TG of thrombocytopenia is improved by PCCs, supporting the need for additional studies in complex coagulopathies characterized by mild to moderate thrombocytopenia and abnormal coagulation.
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Affiliation(s)
- Pratima Chowdary
- Katharine Dormandy Haemophilia and Thrombosis CentreRoyal Free HospitalLondonUK
- Department of HaematologyUniversity College LondonLondonUK
| | - Colleen Hamid
- Katharine Dormandy Haemophilia and Thrombosis CentreRoyal Free HospitalLondonUK
- Department of HaematologyUniversity College LondonLondonUK
| | - David Slatter
- Department of BiochemistryUniversity of CambridgeCambridgeUK
| | | | - Jonathan H. Foley
- Katharine Dormandy Haemophilia and Thrombosis CentreRoyal Free HospitalLondonUK
| | - Keith Gomez
- Katharine Dormandy Haemophilia and Thrombosis CentreRoyal Free HospitalLondonUK
- Department of HaematologyUniversity College LondonLondonUK
| | - Edgar Brodkin
- Katharine Dormandy Haemophilia and Thrombosis CentreRoyal Free HospitalLondonUK
| | - Thomas A. Fox
- Katharine Dormandy Haemophilia and Thrombosis CentreRoyal Free HospitalLondonUK
- Department of HaematologyUniversity College LondonLondonUK
| | - Alex Gatt
- Department of PathologyFaculty of Medicine and SurgeryUniversity of MaltaMsidaMalta
| | - John H. McVey
- School of Biosciences & MedicineUniversity of SurreyGuildfordUK
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Kammerer T, Hulde N, Speck E, Hübner M, Crispin A, Zwissler B, Conzen P, von Dossow V, Schäfer ST, Hofmann-Kiefer K, Rehm M. Effects of balanced hydroxyethyl starch 6% (130/0.4) and albumin 5% on clot formation and glycocalyx shedding: Subgroup analysis of a prospective randomized trial. Thromb Res 2019; 183:111-118. [DOI: 10.1016/j.thromres.2019.10.020] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2019] [Revised: 09/13/2019] [Accepted: 10/21/2019] [Indexed: 12/22/2022]
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Abstract
PURPOSE OF REVIEW Uncontrolled bleeding in trauma secondary to a combination of surgical bleeding and trauma-induced complex coagulopathy is a leading cause of death. Prothrombin complex concentrates (PCCs), recombinant activated factor seven (rFVIIa) and recombinant human prothrombin act as procoagulants by increasing thrombin generation and fibrinogen concentrate aids stable clot formation. This review summarizes the current evidence for procoagulant use in the management of bleeding in trauma, and data and evidence gaps for routine clinical use. RECENT FINDINGS Retrospective and prospective studies of PCCs (±fibrinogen concentrate) have demonstrated a decreased time to correction of trauma coagulopathy and decreased red cell transfusion with no obvious effect on mortality or thromboembolic outcomes. PCCs in a porcine model of dilutional coagulopathy demonstrated a sustained increase in thrombin generation, unlike recombinant human prothrombin which showed a transient increase and has been studied only in animals. In other retrospective studies, there is a suggestion that lower doses of PCCs may be effective in the setting of acquired coagulopathy. SUMMARY There is increasing evidence that early correction of coagulopathy has survival benefits, and the use of procoagulants as first-line therapy has the potential benefit of rapid access and timely treatment. This requires confirmation in prospective studies.
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Recombinant human prothrombin (MEDI8111) combined with fibrinogen dose-dependently improved survival time and reduced blood loss in a porcine model of dilutional coagulopathy with uncontrolled bleeding. Blood Coagul Fibrinolysis 2019; 30:140-148. [PMID: 31090596 DOI: 10.1097/mbc.0000000000000812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
: Uncontrolled bleeding due to trauma and coagulopathy is an area with high unmet medical need and high mortality rate. Treatment recommendations focus on transfusion of blood components while optimal therapy to improve coagulation remains to be established. The haemostatic effect of 2, 4 and 8 mg/kg recombinant prothrombin (MEDI8111) co-administered with 100 mg/kg fibrinogen (n = 7-8) was investigated in a porcine model of dilutional coagulopathy with uncontrolled bleeding. Vehicle (n = 11), fibrinogen alone (100 mg/kg , n = 15) were included as controls. Dilutional coagulopathy was induced by replacing ∼75% of the blood volume with hydroxyethyl starch and a standardized liver incision was made followed by intravenous administration of study compounds. Survival time and blood loss were determined up to 120 min after liver incision. Rotational thromboelastometry (ROTEM EXTEM), prothrombin time (PT), thrombin--antithrombin complex and thrombin generation were measured at baseline, after dilution and 10, 40, 80 and 120 min after compound administration. Administration of MEDI8111+fibrinogen improved haemostasis, decreased blood loss and dose-dependently improved survival time compared to fibrinogen. All pigs receiving a dose of 8 mg/kg MEDI8111+fibrinogen, which restored normal prothrombin concentration, survived to the end of the experiment with close to normal haemostasis as measured by PT and ROTEM EXTEM CT. Administration of fibrinogen and MEDI8111 was sufficient to improve survival time and haemostasis in severely coagulopathic pigs. The dose-dependent haemostatic improvement observed with MEDI8111 administration suggests that prothrombin concentration was rate limiting for coagulation.
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Balendran CA, Lövgren A, Hansson KM, Nelander K, Olsson M, Johansson KJ, Brohi K, Fries D, Berggren A. Prothrombin time is predictive of low plasma prothrombin concentration and clinical outcome in patients with trauma hemorrhage: analyses of prospective observational cohort studies. Scand J Trauma Resusc Emerg Med 2017; 25:30. [PMID: 28292321 PMCID: PMC5348885 DOI: 10.1186/s13049-016-0332-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2016] [Accepted: 11/18/2016] [Indexed: 12/04/2022] Open
Abstract
Background Fibrinogen and prothrombin have been suggested to become rate limiting in trauma associated coagulopathy. Administration of fibrinogen is now recommended, however, the importance of prothrombin to patient outcome is unknown. Methods We have utilized two trauma patient databases (database 1 n = 358 and database 2 n = 331) to investigate the relationship of plasma prothrombin concentration on clinical outcome and coagulation status. Database 1 has been used to assess the relationship of plasma prothrombin to administered packed red blood cells (PRBC), clinical outcome and coagulation biomarkers (Prothrombin Time (PT), ROTEM EXTEM Coagulation Time (CT) and Maximum Clot Firmness (MCF)). ROC analyses have been performed to investigate the ability of admission coagulation biomarkers to predict low prothrombin concentration (database 1), massive transfusion and 24 h mortality (database 1 and 2). The importance of prothrombin was further investigated in vitro by PT and ROTEM assays in the presence of a prothrombin neutralizing monoclonal antibody and following step-wise dilution. Results Patients who survived the first 24 h had higher admission prothrombin levels compared to those who died (94 vs.67 IU/dL). Patients with lower transfusion requirements within the first 24 h (≤10 units of PRBCs) also had higher admission prothrombin levels compared to patients with massive transfusion demands (>10 units of PRBCs) (95 vs.62 IU/dL). Admission PT, in comparison to admission ROTEM EXTEM CT and MCF, was found to be a better predictor of prothrombin concentration <60 IU/dL (AUC 0.94 in database 1), of massive transfusion (AUC 0.92 and 0.81 in database 1 and 2 respectively) and 24 h mortality (AUC 0.90 and 0.78 in database 1 and 2, respectively). In vitro experiments supported a critical role for prothrombin in coagulation and demonstrated that PT and ROTEM EXTEM CT are sensitive methods to measure low prothrombin concentration. Discussion Our analyses suggest that prothrombin concentration at admission is predictive of mortality and transfusion and indicates that prothrombin and fibrinogen are rate limiting in coagulopathy. Conclusions Admission PT is predictive of low prothrombin concentration and clinical outcome. PT could therefore be used as a surrogate for prothrombin concentration and further evaluation of point-of-care devices for faster PT analysis is warranted.
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Affiliation(s)
- Clare A Balendran
- Personalised HealthCare and Biomarkers, Innovative Medicines and Early Development Biotech Unit, AstraZeneca, Pepparedsleden 1, Mölndal, 431 83, Sweden.
| | - Ann Lövgren
- Cardiovascular and Metabolic Diseases, Innovative Medicines and Early Development Biotech Unit, AstraZeneca, Pepparedsleden 1, Mölndal, 431 83, Sweden.,Present address: Leaflet Biotech Consulting, Jungfrudansen 8, 171 56, Solna, Sweden
| | - Kenny M Hansson
- Cardiovascular and Metabolic Diseases, Innovative Medicines and Early Development Biotech Unit, AstraZeneca, Pepparedsleden 1, Mölndal, 431 83, Sweden
| | - Karin Nelander
- Early Clinical Development, Innovative Medicines and Early Development Biotech Unit, AstraZeneca, Pepparedsleden 1, Mölndal, 431 83, Sweden
| | - Marita Olsson
- Early Clinical Development, Innovative Medicines and Early Development Biotech Unit, AstraZeneca, Pepparedsleden 1, Mölndal, 431 83, Sweden
| | - Karin J Johansson
- Cardiovascular and Metabolic Diseases, Innovative Medicines and Early Development Biotech Unit, AstraZeneca, Pepparedsleden 1, Mölndal, 431 83, Sweden
| | - Karim Brohi
- Centre for Trauma Sciences, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Dietmar Fries
- Department of General and Surgical Critical Care Medicine, Innsbruck Medical University, Innsbruck, Austria
| | - Anders Berggren
- Early Clinical Development, Innovative Medicines and Early Development Biotech Unit, AstraZeneca, Pepparedsleden 1, Mölndal, 431 83, Sweden
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