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Frelich M, Pavlicek J, Bursa F, Vodicka V, Salounova D, Sklienka P. Urinary tract trauma as a predictor of acute kidney injury in severely injured patients: A retrospective analysis of observational studies. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2024. [PMID: 39171720 DOI: 10.5507/bp.2024.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/23/2024] Open
Abstract
AIM The main objective of this study was to determine whether urinary trauma increases the risk of acute kidney injury (AKI) in patients with severe trauma. As a secondary objective, we assessed the reliability of neutrophil gelatinase-associated lipocalin (NGAL) in the early prediction of AKI in this patient population. METHODS Retrospective analysis of two prospective observational studies involving 179 adult patients with severe trauma (Injury Severity Score >16). NGAL levels were measured by taking a blood sample 24 h after admission. AKI was diagnosed according to the Kidney Disease Improving Global Outcomes (KDIGO) classification. RESULTS The overall incidence of AKI was 29%. Kidney or vascular injury was an independent risk factor for AKI (risk ratio [RR] = 3.1, 95% confidence interval [CI] 1.93-4.90). Trauma to urinary passages was also associated with an increased risk of AKI (RR = 4.2, 95% CI 2.70-6.46). Among patients without urinary tract injury, serum NGAL levels were significantly higher in trauma patients who developed AKI during the first 5 days in the intensive care unit (ICU) compared to patients without this organ dysfunction (214.6 µg/L [IQR 167.3] vs. 90.6 µg/L [IQR 58.4]; P<0.001). In patients with urinary tract trauma, there was no difference in the NGAL levels between the two groups (184.6 µg/L [IQR 139.9] vs. 118.3 µg/L [IQR 118.1]; P=0.216). NGAL was not a reliable predictor of AKI in patients with urinary trauma (AUC 0.660). CONCLUSION Urinary tract injury is associated with a significant increase in AKI in patients with severe trauma during the first 5 days of hospitalization in the intensive care unit. In these patients, NGAL is not a reliable predictor of the development of AKI.
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Affiliation(s)
- Michal Frelich
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Ostrava, Ostrava, Czech Republic
- Department of Intensive Medicine, Emergency Medicine and Forensic Studies, Faculty of Medicine, University of Ostrava, Ostrava, Czech Republic
| | - Jan Pavlicek
- Department of Pediatrics, University Hospital Ostrava and Faculty of Medicine, Ostrava University, Ostrava, Czech Republic
| | - Filip Bursa
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Ostrava, Ostrava, Czech Republic
- Department of Intensive Medicine, Emergency Medicine and Forensic Studies, Faculty of Medicine, University of Ostrava, Ostrava, Czech Republic
| | - Vojtech Vodicka
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Ostrava, Ostrava, Czech Republic
| | - Dana Salounova
- Department of Science and Research, Faculty of Medicine, University of Ostrava, Ostrava, Czech Republic
| | - Peter Sklienka
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Ostrava, Ostrava, Czech Republic
- Department of Intensive Medicine, Emergency Medicine and Forensic Studies, Faculty of Medicine, University of Ostrava, Ostrava, Czech Republic
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Ferrada P, Cannon JW, Kozar RA, Bulger EM, Sugrue M, Napolitano LM, Tisherman SA, Coopersmith CM, Efron PA, Dries DJ, Dunn TB, Kaplan LJ. Surgical Science and the Evolution of Critical Care Medicine. Crit Care Med 2023; 51:182-211. [PMID: 36661448 DOI: 10.1097/ccm.0000000000005708] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Surgical science has driven innovation and inquiry across adult and pediatric disciplines that provide critical care regardless of location. Surgically originated but broadly applicable knowledge has been globally shared within the pages Critical Care Medicine over the last 50 years.
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Affiliation(s)
- Paula Ferrada
- Division of Trauma and Acute Care Surgery, Department of Surgery, Inova Fairfax Hospital, Falls Church, VA
| | - Jeremy W Cannon
- Division of Trauma, Surgical Critical Care and Emergency Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Rosemary A Kozar
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Eileen M Bulger
- Division of Trauma, Burn and Critical Care Surgery, Department of Surgery, University of Washington at Seattle, Harborview, Seattle, WA
| | - Michael Sugrue
- Department of Surgery, Letterkenny University Hospital, County of Donegal, Ireland
| | - Lena M Napolitano
- Division of Acute Care Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Samuel A Tisherman
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Craig M Coopersmith
- Division of General Surgery, Department of Surgery, Emory University, Emory Critical Care Center, Atlanta, GA
| | - Phil A Efron
- Department of Surgery, Division of Critical Care, University of Florida, Gainesville, FL
| | - David J Dries
- Department of Surgery, University of Minnesota, Regions Healthcare, St. Paul, MN
| | - Ty B Dunn
- Division of Transplant Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Lewis J Kaplan
- Division of Trauma, Surgical Critical Care and Emergency Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Corporal Michael J. Crescenz VA Medical Center, Section of Surgical Critical Care, Surgical Services, Philadelphia, PA
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3
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Neidert LE, Morgan CG, Hathaway EN, Hemond PJ, Tiller MM, Cardin S, Glaser JJ. Effects of hemodilution on coagulation function during prolonged hypotensive resuscitation in a porcine model of severe hemorrhagic shock. Trauma Surg Acute Care Open 2023; 8:e001052. [PMID: 37213865 PMCID: PMC10193089 DOI: 10.1136/tsaco-2022-001052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Accepted: 04/27/2023] [Indexed: 05/23/2023] Open
Abstract
Background Although hemorrhage remains the leading cause of survivable death in casualties, modern conflicts are becoming more austere limiting available resources to include resuscitation products. With limited resources also comes prolonged evacuation time, leaving suboptimal prehospital field care conditions. When blood products are limited or unavailable, crystalloid becomes the resuscitation fluid of choice. However, there is concern of continuous crystalloid infusion during a prolonged period to achieve hemodynamic stability for a patient. This study evaluates the effect of hemodilution from a 6-hour prehospital hypotensive phase on coagulation in a porcine model of severe hemorrhagic shock. Methods Adult male swine (n=5/group) were randomized into three experimental groups. Non-shock (NS)/normotensive did not undergo injury and were controls. NS/permissive hypotensive (PH) was bled to the PH target of systolic blood pressure (SBP) 85±5 mm Hg for 6 hours of prolonged field care (PFC) with SBP maintained via crystalloid, then recovered. Experimental group underwent controlled hemorrhage to mean arterial pressure 30 mm Hg until decompensation (Decomp/PH), followed by PH resuscitation with crystalloid for 6 hours. Hemorrhaged animals were then resuscitated with whole blood and recovered. Blood samples were collected at certain time points for analysis of complete blood counts, coagulation function, and inflammation. Results Throughout the 6-hour PFC, hematocrit, hemoglobin, and platelets showed significant decreases over time in the Decomp/PH group, indicating hemodilution, compared with the other groups. However, this was corrected with whole blood resuscitation. Despite the appearance of hemodilution, coagulation and perfusion parameters were not severely compromised. Conclusions Although significant hemodilution occurred, there was minimal impact on coagulation and endothelial function. This suggests that it is possible to maintain the SBP target to preserve perfusion of vital organs at a hemodilution threshold in resource-constrained environments. Future studies should address therapeutics that can mitigate potential hemodilutional effects such as lack of fibrinogen or platelets. Level of evidence Not applicable-Basic Animal Research.
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Affiliation(s)
- Leslie E Neidert
- Expeditionary and Trauma Medicine, Naval Medical Research Unit San Antonio, JBSA-Fort Sam Houston, Texas, USA
| | - Clifford G Morgan
- Expeditionary and Trauma Medicine, Naval Medical Research Unit San Antonio, JBSA-Fort Sam Houston, Texas, USA
| | - Emily N Hathaway
- Division of Trauma, Brooke Army Medical Center, JBSA-Fort Sam Houston, Texas, USA
| | - Peter J Hemond
- Expeditionary and Trauma Medicine, Naval Medical Research Unit San Antonio, JBSA-Fort Sam Houston, Texas, USA
| | - Michael M Tiller
- Expeditionary and Trauma Medicine, Naval Medical Research Unit San Antonio, JBSA-Fort Sam Houston, Texas, USA
- Division of Trauma, Brooke Army Medical Center, JBSA-Fort Sam Houston, Texas, USA
| | - Sylvain Cardin
- Expeditionary and Trauma Medicine, Naval Medical Research Unit San Antonio, JBSA-Fort Sam Houston, Texas, USA
| | - Jacob J Glaser
- Expeditionary and Trauma Medicine, Naval Medical Research Unit San Antonio, JBSA-Fort Sam Houston, Texas, USA
- Trauma and Acute Care Surgery, Providence Regional Medical Center Everett, Everett, Washington, USA
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4
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Sartini S, Spadaro M, Cutuli O, Castellani L, Sartini M, Cristina ML, Canepa P, Tognoni C, Lo A, Canata L, Rosso M, Arboscello E. Does Antithrombotic Therapy Affect Outcomes in Major Trauma Patients? A Retrospective Cohort Study from a Tertiary Trauma Centre. J Clin Med 2022; 11:jcm11195764. [PMID: 36233632 PMCID: PMC9573302 DOI: 10.3390/jcm11195764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Revised: 08/24/2022] [Accepted: 09/26/2022] [Indexed: 11/16/2022] Open
Abstract
Antithrombotic therapy may affect outcomes in major trauma but its role is not fully understood. We aimed to investigate adverse outcomes among those with and without antithrombotic treatment in major trauma. Material and methods: This is a retrospective study conducted at the Emergency Department (ED) of the University Hospital of Genoa, a tertiary trauma center, including all major trauma between January 2019 and December 2020. Adverse outcomes were reviewed among those without antithrombotic treatment (Group 0), on antiplatelet treatment (Group 1), and on anticoagulant treatment (Group 2). Results: We reviewed 349 electronic charts for full analysis. Group 0 were n = 310 (88.8%), Group 1 were n = 26 (7.4%), and Group 2 were n = 13 (3.7%). In-hospital death and ICU admission, respectively, were: n = 16 (5.6%) and n = 81 (26%) in Group 0, none and n = 6 (25%) in Group 1, and n = 2 (15.8%) and n = 4 (30.8%) in Group 2 (p = 0.123-p = 0.874). Altered INR (OR 5.2) and increasing D-dimer levels (AUC: 0.81) correlated to increased mortality. Discussion: Group 2 showed higher mortality than Group 0 and Group 1, however Group 2 had fewer active treatments. Of clotting factors, only altered INR and elevated D-dimer levels were significantly correlated to adverse outcomes. Conclusions: Anticoagulant but not antiplatelet treatment seems to produce the worst outcomes in major trauma.
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Affiliation(s)
- Stefano Sartini
- Emergency Medicine Department, UOC MECAU, San Martino Policlinic University Hospital, Largo Rosanna Benzi 10, 16132 Genoa, Italy
- Correspondence: (S.S.); (M.S.); (M.L.C.)
| | - Marzia Spadaro
- Emergency Medicine Department, UOC MECAU, San Martino Policlinic University Hospital, Largo Rosanna Benzi 10, 16132 Genoa, Italy
| | - Ombretta Cutuli
- Emergency Medicine Department, UOC MECAU, San Martino Policlinic University Hospital, Largo Rosanna Benzi 10, 16132 Genoa, Italy
| | - Luca Castellani
- Emergency Medicine Department, UOC MECAU, San Martino Policlinic University Hospital, Largo Rosanna Benzi 10, 16132 Genoa, Italy
| | - Marina Sartini
- Department of Health Sciences, University of Genova, 16128 Genoa, Italy
- Hospital Hygiene Unit, Galliera Hospital, Via Alessandro Volta 8, 16128 Genoa, Italy
- Correspondence: (S.S.); (M.S.); (M.L.C.)
| | - Maria Luisa Cristina
- Department of Health Sciences, University of Genova, 16128 Genoa, Italy
- Hospital Hygiene Unit, Galliera Hospital, Via Alessandro Volta 8, 16128 Genoa, Italy
- Correspondence: (S.S.); (M.S.); (M.L.C.)
| | - Paolo Canepa
- Emergency Medicine Post-Graduate School, University of Genoa, Via Balbi 5, 16126 Genoa, Italy
| | - Chiara Tognoni
- Emergency Medicine Post-Graduate School, University of Genoa, Via Balbi 5, 16126 Genoa, Italy
| | - Agnese Lo
- Emergency Medicine Post-Graduate School, University of Genoa, Via Balbi 5, 16126 Genoa, Italy
| | - Lorenzo Canata
- Emergency Medicine Post-Graduate School, University of Genoa, Via Balbi 5, 16126 Genoa, Italy
| | - Martina Rosso
- School of Medicine, University of Genoa, Via Balbi 5, 16126 Genoa, Italy
| | - Eleonora Arboscello
- Emergency Medicine Department, UOC MECAU, San Martino Policlinic University Hospital, Largo Rosanna Benzi 10, 16132 Genoa, Italy
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5
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Meshkin D, Yazer MH, Dunbar NM, Spinella PC, Leeper CM. Low titer Group O whole blood utilization in pediatric trauma resuscitation: A National Survey. Transfusion 2022; 62 Suppl 1:S63-S71. [PMID: 35748128 DOI: 10.1111/trf.16979] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 01/12/2022] [Accepted: 01/21/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Renewed interest in low titer group O whole blood (LTOWB) transfusion has led to increased utilization in adult trauma centers; little is known regarding LTOWB use in pediatric centers. STUDY DESIGN AND METHODS A survey of LTOWB utilization at American pediatric level 1 trauma centers. RESULTS Responses were received from 43/72 (60%) centers. These institutions were primarily urban (84%) and pediatric-specific (58%). There were 16% (7/43) centers using LTOWB, 7% (3/43) imminently initiating an LTOWB program, 47% (20/43) with interest but no current plan to develop a LTOWB program, and 30% (13/43) with no immediate interest in an LTOWB program. For the hospitals actively or imminently using LTOWB, 70% (3/10) have a minimum recipient weight criterion, 60% (6/10) have a minimum age criterion, and 70% (7/10) restrict the maximum volume transfused. Before the patient's RhD type becomes known, 30% (3/10) use RhD negative LTOWB for males and females, 40% (4/10) use RhD positive LTOWB for males and RhD negative LTOWB for females, 20% (2/10) use RhD positive LTOWB for males and RhD negative RBCs for females, and 10% (1/10) use RhD positive LTOWB for both males and females. Maximum LTOWB storage duration was 14-35 days and units nearing expiration were used for non-trauma patients (40%), processed to RBC (40%), and/or discarded (40%). The most common barriers to implementation were concerns about inventory management (37%), wastage (35%), infrequent use (33%), cost (21%) and unclear efficacy (14%). CONCLUSION LTOWB utilization is increasing in pediatric level 1 trauma centers in the United States.
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Affiliation(s)
- Dana Meshkin
- School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Mark H Yazer
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Nancy M Dunbar
- Department of Pathology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - Philip C Spinella
- Department of Surgery and Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Christine M Leeper
- Department of Surgery and Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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6
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Ammann AM, Wallen TE, Delman AM, Turner KM, Salvator A, Pritts TA, Makley AT, Goodman MD. Low Volume Blood Product Transfusion Patterns And Ratios After Injury. Am J Surg 2022; 224:1319-1323. [DOI: 10.1016/j.amjsurg.2022.06.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Revised: 06/15/2022] [Accepted: 06/23/2022] [Indexed: 11/26/2022]
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7
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Cardigan R, Latham T, Weaver A, Yazer M, Green L. Estimating the risks of prehospital transfusion of D-positive whole blood to trauma patients who are bleeding in England. Vox Sang 2022; 117:701-707. [PMID: 35018634 PMCID: PMC9306525 DOI: 10.1111/vox.13249] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Revised: 12/21/2021] [Accepted: 12/22/2021] [Indexed: 01/13/2023]
Abstract
Background and Objectives D‐negative red cells are transfused to D‐negative females of childbearing potential (CBP) to prevent haemolytic disease of the foetus and newborn (HDFN). Transfusion of low‐titre group O whole blood (LTOWB) prehospital is gaining interest, to potentially improve clinical outcomes and for logistical benefits compared to standard of care. Enhanced donor selection requirements and reduced shelf‐life of LTOWB compared to red cells makes the provision of this product challenging. Materials and Methods A universal policy change to the use of D‐positive LTOWB across England was modelled in terms of risk of three specific harms occurring: risk of haemolytic transfusion reaction now or in the future, and the risk of HDFN in future pregnancies for all recipients or D‐negative females of CBP. Results The risk of any of the three harms occurring for all recipients was 1:14 × 103 transfusions (credibility interval [CI] 56 × 102–42 × 103) while for females of CBP it was 1:520 transfusions (CI 250–1700). The latter was dominated by HDFN risk, which would be expected to occur once every 5.7 years (CI 2.6–22.5). We estimated that a survival benefit of ≥1% using LTOWB would result in more life‐years gained than lost if D‐positive units were transfused exclusively. These risks would be lower, if D‐positive blood were only transfused when D‐negative units are unavailable. Conclusion These data suggest that the risk of transfusing RhD‐positive blood is low in the prehospital setting and must be balanced against its potential benefits.
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Affiliation(s)
- Rebecca Cardigan
- Clinical Services, NHS Blood and Transplant, Cambridge, UK.,Department of Haematology, University of Cambridge, Cambridge, UK
| | - Tom Latham
- Clinical Services, NHS Blood and Transplant, London, UK
| | - Anne Weaver
- Department of Emergency Medicine, Barts Health NHS Trust, London, UK
| | - Mark Yazer
- Department of Pathology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Laura Green
- Clinical Services, NHS Blood and Transplant, London, UK.,Department of Haematology, Barts Health NHS Trust, London, UK.,Blizard Institute, Queen Mary University of London, London, UK
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8
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Yazer MH. The Evolution of Blood Product Use in Trauma Resuscitation: Change Has Come. Transfus Med Hemother 2021; 48:377-380. [PMID: 35082569 PMCID: PMC8739388 DOI: 10.1159/000520011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 10/01/2021] [Indexed: 11/19/2022] Open
Affiliation(s)
- Mark H. Yazer
- Department of Pathology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Department of Pathology, Tel Aviv University, Tel Aviv, Israel
- Department of Clinical Immunology, University of Southern Denmark, Odense, Denmark
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9
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Fecher A, Stimpson A, Ferrigno L, Pohlman TH. The Pathophysiology and Management of Hemorrhagic Shock in the Polytrauma Patient. J Clin Med 2021; 10:4793. [PMID: 34682916 PMCID: PMC8541346 DOI: 10.3390/jcm10204793] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Revised: 10/14/2021] [Accepted: 10/15/2021] [Indexed: 11/16/2022] Open
Abstract
The recognition and management of life-threatening hemorrhage in the polytrauma patient poses several challenges to prehospital rescue personnel and hospital providers. First, identification of acute blood loss and the magnitude of lost volume after torso injury may not be readily apparent in the field. Because of the expression of highly effective physiological mechanisms that compensate for a sudden decrease in circulatory volume, a polytrauma patient with a significant blood loss may appear normal during examination by first responders. Consequently, for every polytrauma victim with a significant mechanism of injury we assume substantial blood loss has occurred and life-threatening hemorrhage is progressing until we can prove the contrary. Second, a decision to begin damage control resuscitation (DCR), a costly, highly complex, and potentially dangerous intervention must often be reached with little time and without sufficient clinical information about the intended recipient. Whether to begin DCR in the prehospital phase remains controversial. Furthermore, DCR executed imperfectly has the potential to worsen serious derangements including acidosis, coagulopathy, and profound homeostatic imbalances that DCR is designed to correct. Additionally, transfusion of large amounts of homologous blood during DCR potentially disrupts immune and inflammatory systems, which may induce severe systemic autoinflammatory disease in the aftermath of DCR. Third, controversy remains over the composition of components that are transfused during DCR. For practical reasons, unmatched liquid plasma or freeze-dried plasma is transfused now more commonly than ABO-matched fresh frozen plasma. Low-titer type O whole blood may prove safer than red cell components, although maintaining an inventory of whole blood for possible massive transfusion during DCR creates significant challenges for blood banks. Lastly, as the primary principle of management of life-threatening hemorrhage is surgical or angiographic control of bleeding, DCR must not eclipse these definitive interventions.
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Affiliation(s)
- Alison Fecher
- Division of Acute Care Surgery, Lutheran Hospital of Indiana, Fort Wayne, IN 46804, USA; (A.F.); (A.S.)
| | - Anthony Stimpson
- Division of Acute Care Surgery, Lutheran Hospital of Indiana, Fort Wayne, IN 46804, USA; (A.F.); (A.S.)
| | - Lisa Ferrigno
- Department of Surgery, UCHealth, University of Colorado-Denver, Aurora, CO 80045, USA;
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10
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Jänig C, Schmidbauer W, Willms AG, Maegele M, Matthes G, Grübl T, Jaekel C, Kollig E, Bieler D. Vorbereitung auf eine differenzierte Hämotherapie nach Trauma – Ergebnisse einer Befragung deutscher Kliniken. Notf Rett Med 2021. [DOI: 10.1007/s10049-021-00912-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Zusammenfassung
Hintergrund
Die unkontrollierte Blutung ist weiterhin eine führende potenziell vermeidbare Todesursache im Rahmen schwerer Verletzungen.
Ziel der Arbeit
Die vorliegende Arbeit hat zum Ziel, die Vorbereitung für eine differenzierte Hämotherapie im Rahmen der Schwerstverletztenbehandlung in Kliniken verschiedener Versorgungsstufen innerhalb der Struktur des TraumaNetzwerks der Deutschen Gesellschaft für Unfallchirurgie (DGU)® zu evaluieren.
Material und Methoden
Anhand einer Online-Umfrage wurden gezielt Diagnose- und Therapiestrategien sowie vorhandene Ressourcen innerhalb der Kliniken erfragt. Im Rahmen einer Subgruppenanalyse sollte festgestellt werden, ob es Unterschiede in Bezug auf infrastrukturelle Voraussetzungen und diagnostisches bzw. therapeutisches Vorgehen innerhalb der Versorgungsstufen des TraumaNetzwerks DGU® gibt.
Ergebnisse
Massivtransfusionsprotokolle (MTP) bestehen in 75 % der Kliniken. Die Aktivierung erfolgt i. d. R. durch den Trauma-Leader (62 %). In 63 % erfolgt die Aktivierung aufgrund einer Anforderung aus der Präklinik. Als Transfusionstrigger werden ein positives FAST (80 %) und ein Pulsdruck < 45 mm Hg (60 %) angegeben. In 50 % der Kliniken existiert kein starres Transfusionsverhältnis der einzelnen Blutkomponenten. Überregionale Traumazentren (ÜTZ) bekommen im Vergleich zu regionalen Traumazentren (RTZ) und lokalen Traumazentren (LTZ) angeforderte Blutprodukte frühzeitiger (p 0,025).
Diskussion
Der massive Blutverlust ist ein seltenes Ereignis, welches mit einer hohen Letalität vergesellschaftet sein kann. MTP bilden die Grundlage für eine frühe Therapie der traumainduzierten Koagulopathie und tragen zur Verbesserung der Überlebenschancen der Patienten bei. Es existiert ein deutlicher Unterschied in den diagnostischen und therapeutischen Möglichkeiten in den einzelnen Versorgungsebenen. ÜTZ verfügen mehrheitlich über die umfangreichsten Optionen, gefolgt von RTZ und LTZ.
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11
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Cruciani M, Franchini M, Mengoli C, Marano G, Pati I, Masiello F, Veropalumbo E, Pupella S, Vaglio S, Agostini V, Liumbruno GM. The use of whole blood in traumatic bleeding: a systematic review. Intern Emerg Med 2021; 16:209-220. [PMID: 32930966 DOI: 10.1007/s11739-020-02491-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Accepted: 09/01/2020] [Indexed: 12/11/2022]
Abstract
Hemostatic resuscitation is currently considered a standard of care for the management of life-threatening hemorrhage, but in some critical settings the access to high quantities of blood components is problematic. Whole blood (WB) transfusion has been proposed as an alternative modality for hemostatic resuscitation of traumatic major bleeding. To assess the efficacy and safety of WB in trauma-associated massive bleeding, we performed a systematic review of the literature. We selected studies comparing WB transfusions to transfusion of blood components (COMP) in massive trauma bleeding; both randomized clinical trial (RCT) and observational studies were considered. The outcomes were mortality (30-day/in-hospital and 24-h mortality) and adverse events/transfusion reactions. The effect sizes were crude odds ratio (OR), adjusted OR and hazard ratio (HR). The methodological quality of studies was assessed using the Cochrane Risk of Bias tool for RCTs, and the ROBIN-1 tool for observational studies. The overall quality of the available evidence was assessed with the GRADE system. One RCT (2 reports) and 6 cohort studies were included (3642 adult patients; 675 receiving WB, 2967 receiving COMP). Three studies were conducted in military setting, and 4 in civilian setting. In the overall analysis, 30-day/in-hospital and 24-h mortality did not differ significantly between groups (very low quality of the evidence due to high risk of bias, imprecision and inconsistency). After adjustment for baseline covariates in three cohort studies, the OR for mortality was significantly lower in WB recipients compared to COMP (OR 0.22; 95% CIs 0.10/0.45) (moderate grade of evidence). Adverse events and transfusion reactions were overlooked and not consistently reported. The available evidence does not allow to draw definite conclusions on the short-term and long-term efficacy and safety of WB transfusion compared to COMP transfusion. Further well designed research is needed.
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Affiliation(s)
- Mario Cruciani
- Italian National Blood Centre, Rome, Italy
- AULSS9 Scaligera, Infection Control Committee and Antibiotic Stewardship Programme, Verona, Italy
| | - Massimo Franchini
- Italian National Blood Centre, Rome, Italy.
- Department of Hematology and Transfusion Medicine, Carlo Poma Hospital, Mantua, Italy.
| | | | | | | | | | | | | | | | - Vanessa Agostini
- Italian National Blood Centre, Rome, Italy
- Immunohematology and Transfusion Service, IRCCS Policlinico San Martino, Genova, Italy
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12
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Plasma resuscitation with adjunctive peritoneal resuscitation reduces ischemic intestinal injury following hemorrhagic shock. J Trauma Acute Care Surg 2020; 89:649-657. [PMID: 32773670 DOI: 10.1097/ta.0000000000002847] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Impaired intestinal microvascular perfusion following resuscitated hemorrhagic shock (HS) leads to ischemia-reperfusion injury, microvascular dysfunction, and intestinal epithelial injury, which contribute to the development of multiple organ dysfunction syndrome in some trauma patients. Restoration of central hemodynamics with traditional methods alone often fails to fully restore microvascular perfusion and does not protect against ischemia-reperfusion injury. We hypothesized that resuscitation (RES) with fresh frozen plasma (FFP) alone or combined with direct peritoneal resuscitation (DPR) with 2.5% Delflex solution might improve blood flow and decrease intestinal injury compared with conventional RES or RES with DPR alone. METHODS Sprague-Dawley rats underwent HS (40% mean arterial pressure) for 60 minutes and were randomly assigned to a RES group (n = 8): sham, HS-crystalloid resuscitation (CR) (shed blood + two volumes CR), HS-CR-DPR (intraperitoneal 2.5% peritoneal dialysis fluid), HS-FFP (shed blood + two volumes FFP), and HS-DPR-FFP (intraperitoneal dialysis fluid + two volumes FFP). Laser Doppler flowmeter evaluation of the ileum, serum samples for fatty acid binding protein enzyme-linked immunosorbent assay, and hematoxylin and eosin (H&E) staining were used to assess intestinal injury and blood flow. p Values of <0.05 were considered significant. RESULTS Following HS, the addition of DPR to either RES modality improved intestinal blood flow. Four hours after resuscitated HS, FABP-2 (intestinal) and FABP-6 (ileal) were elevated in the CR group but reduced in the FFP and DPR groups. The H&E staining demonstrated disrupted intestinal villi in the FFP and CR groups, most significantly in the CR group. Combination therapy with FFP and DPR demonstrated negligible cellular injury in H&E graded samples and a significant reduction in fatty acid binding protein levels. CONCLUSION Hemorrhagic shock leads to ischemic-reperfusion injury of the intestine, and both FFP and DPR alone attenuated intestinal damage; combination FFP-DPR therapy alleviated most signs of organ injury. Resuscitation with FFP-DPR to restore intestinal blood flow following shock could be an essential method of reducing morbidity and mortality after trauma.
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Meléndez-Lugo JJ, Caicedo Y, Guzmán-Rodríguez M, Serna JJ, Ordoñez J, Angamarca E, García A, Pino LF, Quintero L, Parra MW, Ordoñez CA. Prehospital Damage Control: The Management of Volume, Temperature… and Bleeding! COLOMBIA MEDICA (CALI, COLOMBIA) 2020; 51:e4024486. [PMID: 33795898 PMCID: PMC7968431 DOI: 10.25100/cm.v51i4.4486] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Damage control resuscitation should be initiated as soon as possible after a trauma event to avoid metabolic decompensation and high mortality rates. The aim of this article is to assess the position of the Trauma and Emergency Surgery Group (CTE) from Cali, Colombia regarding prehospital care, and to present our experience in the implementation of the “Stop the Bleed” initiative within Latin America. Prehospital care is phase 0 of damage control resuscitation. Prehospital damage control must follow the guidelines proposed by the “Stop the Bleed” initiative. We identified that prehospital personnel have a better perception of hemostatic techniques such as tourniquet use than the hospital providers. The use of tourniquets is recommended as a measure to control bleeding. Fluid management should be initiated using low volume crystalloids, ideally 250 cc boluses, maintaining the principle of permissive hypotension with a systolic blood pressure range between 80- and 90-mm Hg. Hypothermia must be management using warmed blankets or the administration of intravenous fluids warmed prior to infusion. However, these prehospital measures should not delay the transfer time of a patient from the scene to the hospital. To conclude, prehospital damage control measures are the first steps in the control of bleeding and the initiation of hemostatic resuscitation in the traumatically injured patient. Early interventions without increasing the transfer time to a hospital are the keys to increase survival rate of severe trauma patients.
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Affiliation(s)
| | - Yaset Caicedo
- Fundación Valle del Lili, Centro de Investigaciones Clínicas (CIC), Cali, Colombia
| | - Mónica Guzmán-Rodríguez
- Universidad de Chile, Instituto de Ciencias Biomédicas, Facultad de Medicina, Santiago de Chile, Chile
| | - José Julián Serna
- Fundación Valle del Lili, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia.,Universidad del Valle, Facultad de Salud, Escuela de Medicina, Sección de Cirugía de Trauma y Emergencias, Cali Colombia.,Universidad Icesi, Cali, Colombia.,Hospital Universitario del Valle, Sección de Cirugía de Trauma y Emergencias, Cali, Colombia
| | - Juliana Ordoñez
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Sección de Cirugía de Trauma y Emergencias, Cali Colombia
| | | | - Alberto García
- Fundación Valle del Lili, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia.,Universidad del Valle, Facultad de Salud, Escuela de Medicina, Sección de Cirugía de Trauma y Emergencias, Cali Colombia.,Universidad Icesi, Cali, Colombia
| | - Luis Fernando Pino
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Sección de Cirugía de Trauma y Emergencias, Cali Colombia.,Hospital Universitario del Valle, Sección de Cirugía de Trauma y Emergencias, Cali, Colombia
| | - Laureano Quintero
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Sección de Cirugía de Trauma y Emergencias, Cali Colombia.,Centro Médico Imbanaco, Cali, Colombia
| | - Michael W Parra
- Broward General Level I Trauma Center, Department of Trauma Critical Care, Fort Lauderdale, FL, USA
| | - Carlos A Ordoñez
- Fundación Valle del Lili, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia.,Universidad del Valle, Facultad de Salud, Escuela de Medicina, Sección de Cirugía de Trauma y Emergencias, Cali Colombia.,Universidad Icesi, Cali, Colombia
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Bonanno AM, Graham TL, Wilson LN, Ross JD. Novel use of XSTAT 30 for mitigation of lethal non-compressible torso hemorrhage in swine. PLoS One 2020; 15:e0241906. [PMID: 33206692 PMCID: PMC7673511 DOI: 10.1371/journal.pone.0241906] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Accepted: 10/22/2020] [Indexed: 11/19/2022] Open
Abstract
Background Management of Non-Compressible Torso Hemorrhage (NCTH) consists primarily of aortic occlusion which has significant adverse outcomes, including ischemia-reperfusion injury, in prolonged field care paradigms. One promising avenue for treatment is through use of RevMedx XSTAT 30™ (an FDA approved sponge-based dressing utilized for extremity wounds). We hypothesized that XSTAT 30™ would effectively mitigate NCTH during a prolonged pre-hospital period with correctable metabolic and physiologic derangements. Methods and findings Twenty-four male swine (53±2kg) were anesthetized, underwent line placement, and splenectomy. Animals then underwent laparoscopic transection of 70% of the left lobe of the liver with hemorrhage for a period of 10min. They were randomized into three groups: No intevention (CON), XSTAT 30™-Free Pellets (FP), and XSTAT 30™-Bagged Pellets (BP). Animals were observed for a pre-hospital period of 180min. At 180min, animals underwent damage control surgery (DCS), balanced blood product resuscitation and removal of pellets followed by an ICU period of 5 hours. Postoperative fluoroscopy was performed to identify remaining pellets or bags. Baseline physiologic and injury characteristics were similar. Survival rates were significantly higher in FP and BP (p<0.01) vs CON. DCS was significantly longer in FP in comparison to BP (p = 0.001). Two animals in the FP group had pellets discovered on fluoroscopy following DCS. There was no significant difference in blood product or pressor requirements between groups. End-ICU lactates trended to baseline in both FP and BP groups. Conclusions While these results are promising, further study will be required to better understand the role for XSTAT in the management of NCTH.
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Affiliation(s)
- Alicia M. Bonanno
- Department of Surgery, Oregon Health and Science University, Portland, Oregon, United States of America
| | - Todd L. Graham
- Division of Trauma and Acute Care Surgery, Oregon Health and Science University, Portland, Oregon, United States of America
| | - Lauren N. Wilson
- Division of Trauma and Acute Care Surgery, Oregon Health and Science University, Portland, Oregon, United States of America
| | - James D. Ross
- Division of Trauma and Acute Care Surgery, Oregon Health and Science University, Portland, Oregon, United States of America
- Charles T. Dotter Department of Interventional Radiology, Oregon Health and Science University, Portland, Oregon, United States of America
- * E-mail:
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Fresh whole blood from walking blood banks for patients with traumatic hemorrhagic shock: A systematic review and meta-analysis. J Trauma Acute Care Surg 2020; 89:792-800. [PMID: 32590558 DOI: 10.1097/ta.0000000000002840] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
BACKGROUND Whole blood is optimal for resuscitation of traumatic hemorrhage. Walking Blood Banks provide fresh whole blood (FWB) where conventional blood components or stored, tested whole blood are not readily available. There is an increasing interest in this as an emergency resilience measure for isolated communities and during crises including the coronavirus disease 2019 pandemic. We conducted a systematic review and meta-analysis of the available evidence to inform practice. METHODS Standard systematic review methodology was used to obtain studies that reported the delivery of FWB (PROSPERO registry CRD42019153849). Studies that only reported whole blood from conventional blood banking were excluded. For outcomes, odds ratios (ORs) and 95% confidence interval (CI) were calculated using random-effects modeling because of high risk of heterogeneity. Quality of evidence was assessed using the Grading of Recommendations, Assessment, Development, and Evaluation system. RESULTS Twenty-seven studies published from 2006 to 2020 reported >10,000 U of FWB for >3,000 patients (precise values not available for all studies). Evidence for studies was "low" or "very low" except for one study, which was "moderate" in quality. Fresh whole blood patients were more severely injured than non-FWB patients. Overall, survival was equivalent between FWB and non-FWB groups for eight studies that compared these (OR, 1.00 [95% CI, 0.65-1.55]; p = 0.61). However, the highest quality study (matched groups for physiological and injury characteristics) reported an adjusted OR of 0.27 (95% CI, 0.13-0.58) for mortality for the FWB group (p < 0.01). CONCLUSION Thousands of units of FWB from Walking Blood Banks have been transfused in patients following life-threatening hemorrhage. Survival is equivalent for FWB resuscitation when compared with non-FWB, even when patients were more severely injured. Evidence is scarce and of relative low quality and may underestimate potential adverse events. Whereas Walking Blood Banks may be an attractive resilience measure, caution is still advised. Walking Blood Banks should be subject to prospective evaluation to optimize care and inform policy. LEVEL OF EVIDENCE Systematic/therapeutic, level 3.
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Chico-Fernández M, Barea-Mendoza JA, Pérez-Bárcena J, García-Sáez I, Quintana-Díaz M, Marina L, Mayor-García DM, Serviá-Goixart L, Jiménez-Moragas JM, Llompart-Pou JA. Concomitant Traumatic Brain Injury and Hemorrhagic Shock: Outcomes Using the Spanish Trauma ICU Registry (RETRAUCI). Am Surg 2020; 87:370-375. [PMID: 32993317 DOI: 10.1177/0003134820949990] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND To compare the main outcomes of trauma patients with and without traumatic brain injury (TBI), hemorrhagic shock, and the combination of both using data from the Spanish trauma intensive care unit (ICU) registry (RETRAUCI). METHODS Patients admitted to the participating ICUs from March 2015 to May 2019 were included in the study. The main outcomes were analyzed according to the presence of TBI, hemorrhagic shock, and/or both. Comparison of groups with quantitative variables was performed using the Kruskal-Wallis test, and differences between groups with categorical variables were compared using the Chi-square test or Fisher's exact test as appropriate. A P value <.05 was considered significant. RESULTS Overall, 310 patients (3.98%) were presented with TBI and hemorrhagic shock. Patients with TBI and hemorrhagic shock received more red blood cell (RBC) concentrates, fresh frozen plasma (FFP), a higher ratio FFP/RBC, and had a higher incidence of trauma-induced coagulopathy (60%) (P < .001). These patients had higher mortality (P < .001). Intracranial hypertension was the leading cause of death (50.4%). CONCLUSIONS Concomitant TBI and hemorrhagic shock occur in nearly 4% of trauma ICU patients. These patients required a higher amount of RBC concentrates and FFP and had an increased mortality.
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Affiliation(s)
- Mario Chico-Fernández
- UCI de Trauma y Emergencias, Servicio de Medicina Intensiva, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Jesús A Barea-Mendoza
- UCI de Trauma y Emergencias, Servicio de Medicina Intensiva, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Jon Pérez-Bárcena
- Servei de Medicina Intensiva, Hospital Universitari Son Espases, Institut d'Investigació Sanitària Illes Balears (IdISBa), Palma, Spain
| | - Iker García-Sáez
- Servicio de Medicina Intensiva, Hospital Universitario de Donostia, Donostia, Spain
| | | | - Luis Marina
- Servicio de Medicina Intensiva, Hospital Virgen de la Salud, Toledo, Spain
| | | | - Luis Serviá-Goixart
- Servei de Medicina Intensiva, Hospital Universitari Arnau de Vilanova, Universitat de Lleida, IRBLleida, Lleida, Spain
| | | | - Juan A Llompart-Pou
- Servei de Medicina Intensiva, Hospital Universitari Son Espases, Institut d'Investigació Sanitària Illes Balears (IdISBa), Palma, Spain
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Goggs R, Cremer S, Brooks MB. Evaluation of cytokine concentrations in a trehalose-stabilised lyophilised canine platelet product: a preliminary study. Vet Rec Open 2020; 7:e000366. [PMID: 32821395 PMCID: PMC7418665 DOI: 10.1136/vetreco-2019-000366] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2019] [Revised: 06/30/2020] [Accepted: 07/03/2020] [Indexed: 12/12/2022] Open
Abstract
Background Platelet transfusion is indicated for haemorrhage due to severe thrombocytopenia and for trauma associated coagulopathy. Febrile non-haemolytic transfusion reactions are a common complication of platelet transfusions in people and may be due to accumulated inflammatory cytokines. The present study aimed to determine the cytokine profile of a novel canine lyophilised platelet product following reconstitution, to assess the lyophilised platelets’ activation response to physiological platelet agonists and to compare the cytokine profiles of basal and stimulated canine lyophilised platelets. Methods Cell counts and biochemical analyses were conducted following reconstitution. Cytokine concentrations were measured with a canine-specific multiplex immunocapture assay and with an electrochemiluminescent ELISA. Aliquots of reconstituted product from three separate vials were activated for 10 minutes under non-stirred conditions using adenosine diphosphate, thrombin or convulxin and their cytokine concentrations compared with unactivated samples. Flow cytometry and light-transmission aggregometry were used to evaluate the product’s ability to express a procoagulant surface, degranulate and aggregate. Fresh platelet-rich plasma was used as a positive control. Results The product had a mean±SD particle count of 1.23±0.2×109/ml, contained platelets that expressed surface phosphatidylserine before agonist stimulation and was capable of aggregation in response to thrombin stimulation suggesting that the product may have haemostatic potential following in vivo administration. Cytokine concentrations measured by the immunocapture assay were generally low, while twofold to threefold increases relative to published intervals were noted for several cytokines using the ELISA. Concentrations of chemokine (C-X-C) motif ligand 8 and tumour necrosis factor-α were significantly increased as measured by the ELISA, but not by the immunocapture assay, while concentrations of KC-like were significantly increased as measured by the immunocapture assay. Stimulation with platelet agonists did not affect measured cytokine concentrations. Conclusion Further study of the effects of administration of this lyophilised platelet product is warranted.
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Affiliation(s)
- Robert Goggs
- Clinical Sciences, Cornell University College of Veterinary Medicine, Ithaca, New York, USA
| | - Signe Cremer
- Department of Veterinary Clinical Sciences, University of Copenhagen, Frederiksberg C, Denmark
| | - Marjory B Brooks
- Population Medicine and Diagnostic Sciences, Cornell University College of Veterinary Medicine, Ithaca, New York, USA
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Minimizing Time to Plasma Administration and Fresh Frozen Plasma Waste: A Multimodal Approach to Improve Massive Transfusion at a Level 1 Trauma Center. J Trauma Nurs 2020; 26:234-238. [PMID: 31503194 DOI: 10.1097/jtn.0000000000000460] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Massive transfusion protocols are part of damage control resuscitation for hemorrhaging trauma patients with the goal of returning the patient to hemodynamic stability. It is essential that patients receive blood products immediately and in the proper ratios. At our metropolitan Level 1 trauma center, we identified several challenges to deploying massive transfusion rapidly and within the recommended ratio guidelines. In 2016, we implemented a quality improvement project addressing 4 opportunities: fresh frozen plasma (FFP) bag breakage, plasma options, blood bank equipment, and multidisciplinary policy revision. Implementing packaging and shipping improvements, utilization of new products, and updating protocols have resulted in a 50% decrease in FFP bag breakage rates, a dramatic decrease in time for patients receiving massive transfusion to receive plasma products (mean time 3.5 min), and patients being administered the recommended ratio of blood products.
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Storch EK, Custer BS, Jacobs MR, Menitove JE, Mintz PD. Review of current transfusion therapy and blood banking practices. Blood Rev 2019; 38:100593. [PMID: 31405535 DOI: 10.1016/j.blre.2019.100593] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Revised: 07/08/2019] [Accepted: 07/23/2019] [Indexed: 01/28/2023]
Abstract
Transfusion Medicine is a dynamically evolving field. Recent high-quality research has reshaped the paradigms guiding blood transfusion. As increasing evidence supports the benefit of limiting transfusion, guidelines have been developed and disseminated into clinical practice governing optimal transfusion of red cells, platelets, plasma and cryoprecipitate. Concepts ranging from transfusion thresholds to prophylactic use to maximal storage time are addressed in guidelines. Patient blood management programs have developed to implement principles of patient safety through limiting transfusion in clinical practice. Data from National Hemovigilance Surveys showing dramatic declines in blood utilization over the past decade demonstrate the practical uptake of current principles guiding patient safety. In parallel with decreasing use of traditional blood products, the development of new technologies for blood transfusion such as freeze drying and cold storage has accelerated. Approaches to policy decision making to augment blood safety have also changed. Drivers of these changes include a deeper understanding of emerging threats and adverse events based on hemovigilance, and an increasing healthcare system expectation to align blood safety decision making with approaches used in other healthcare disciplines.
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Affiliation(s)
| | - Brian S Custer
- UCSF Department of Laboratory Medicine, Blood Systems Research Institute, USA.
| | - Michael R Jacobs
- Department of Pathology, Case Western Reserve University, USA; Department of Clinical Microbiology, University Hospitals Cleveland Medical Center, USA.
| | - Jay E Menitove
- Department of Pathology and Laboratory Medicine, University of Kansas Medical Center, USA
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Rubiano AM, Maldonado M, Montenegro J, Restrepo CM, Khan AA, Monteiro R, Faleiro RM, Carreño JN, Amorim R, Paiva W, Muñoz E, Paranhos J, Soto A, Armonda R, Rosenfeld JV. The Evolving Concept of Damage Control in Neurotrauma: Application of Military Protocols in Civilian Settings with Limited Resources. World Neurosurg 2019; 125:e82-e93. [PMID: 30659971 DOI: 10.1016/j.wneu.2019.01.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Revised: 01/02/2019] [Accepted: 01/05/2019] [Indexed: 10/27/2022]
Abstract
OBJECTIVE The aim of the present review was to describe the evolution of the damage control concept in neurotrauma, including the surgical technique and medical postoperative care, from the lessons learned from civilian and military neurosurgeons who have applied the concept regularly in practice at military hospitals and civilian institutions in areas with limited resources. METHODS The present narrative review was based on the experience of a group of neurosurgeons who participated in the development of the concept from their practice working in military theaters and low-resources settings with an important burden of blunt and penetrating cranial neurotrauma. RESULTS Damage control surgery in neurotrauma has been described as a sequential therapeutic strategy that supports physiological restoration before anatomical repair in patients with critical injuries. The application of the concept has evolved since the early definitions in 1998. Current strategies have been supported by military neurosurgery experience, and the concept has been applied in civilian settings with limited resources. CONCLUSION Damage control in neurotrauma is a therapeutic option for severe traumatic brain injury management in austere environments. To apply the concept while using an appropriate approach, lessons must be learned from experienced neurosurgeons who use this technique regularly.
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Affiliation(s)
- Andres M Rubiano
- Institute of Neurosciences and Neurosurgery, El Bosque University, Bogotá, Colombia; NIHR Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, UK; INUB MEDITECH Research Group, MEDITECH Foundation, Cali, Colombia; MEDITECH Foundation, Cali Valle, Colombia.
| | - Miguel Maldonado
- School of Medicine, Central Military Hospital, Nueva Granada Military University, Bogota, Colombia
| | - Jorge Montenegro
- NIHR Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, UK; Department of Research, INUB-MEDITECH Research Group, MEDITECH Foundation, Cali, Colombia; Puerto Asís Hospital, Puerto Asís, Colombia
| | - Claudia M Restrepo
- NIHR Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, UK; Department of Research, INUB-MEDITECH Research Group, MEDITECH Foundation, Cali, Colombia; Central Military Hospital, Nueva Granada Military University, Bogota, Colombia
| | - Ahsan Ali Khan
- NIHR Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, UK; Department of Research, INUB-MEDITECH Research Group, MEDITECH Foundation, Cali, Colombia; Department of Neurosurgery, Neurotrauma, and Global Surgery, MEDITECH Foundation, Barrow Neurological Institute, University of Cambridge, Cambridge, United Kingdom
| | - Ruy Monteiro
- Neurological Surgery Service, Hospital Municipal Miguel Couto, Río de Janeiro, Brazil
| | - Rodrigo M Faleiro
- Department of Neurosurgery, Hospital Sao Joao XXIII, Belo Horizonte, Minas Gerais, Brazil
| | - José N Carreño
- Neurointensive Care Unit, Santa Fe Foundation University Hospital, Bogotá, Colombia; Central Military Hospital, Nueva Granada Military University, Bogotá, Colombia
| | - Robson Amorim
- Emergency Neurosurgery Service, Hospital das Clínicas, University of São Paulo Medical School, Manaus, Brazil
| | - Wellingson Paiva
- Neurosurgical Intensive Care Unit, Department of Neurology, University of São Paulo, São Paulo, Brazil
| | - Erick Muñoz
- Neurological Surgery Service, Central Military Hospital, Nueva Granada Military University, Bogotá, Colombia
| | - Jorge Paranhos
- Intensive Care Unite and Neuroemergency Service, Santa Casa de Misericordia Hospital, São João del Rei-Minas Gerais, Brazil
| | - Alvaro Soto
- Neurosurgery Service, San Antonio Hospital, Pitalito, Huila, Colombia
| | - Rocco Armonda
- Department of Neuroendovascular Surgery, Med-Star Washington Hospital Center, Med-Star Georgetown University Hospital, Washington, DC, USA
| | - Jeffrey V Rosenfeld
- Department of Neurosurgery, Alfred Hospital, Melbourne, Australia; Department of Surgery, Monash University, Melbourne, Australia; Department of Surgery, F. Edward Hébert School of Medicine, Uniformed Services University, Bethesda, Maryland, USA
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Larsson A, Smekal D, Lipcsey M. Rapid testing of red blood cells, white blood cells and platelets in intensive care patients using the HemoScreen™ point-of-care analyzer. Platelets 2018; 30:1013-1016. [PMID: 30592636 DOI: 10.1080/09537104.2018.1557619] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Acute major bleeding is a condition that can be encountered in critically ill patients and may require rapid transfusions. To evaluate the need for packed red blood cells (RBCs) and platelets (PLTs), it is important to have rapid test results for RBC/hemoglobin and PLTs. Recently, PixCell Medical (Yokneam Ilit, Israel) introduced the HemoScreen™, an automated hematology analyzer. It is a point-of-care device that uses single sample cuvettes and image analysis of RBCs, PLTs and white blood cells (WBCs), performing a five-part differential count. The HemoScreen™ is the first portable differential count instrument that uses image analysis. We compared the RBC, PLT, and WBC test results of the HemoScreen™ with the Sysmex XN device. In the study we analyzed 104 samples from the cardiothoracic, neuro and general intensive care units. The HemoScreen™ technique showed good precision, with total coefficient of variation of 1-2% for RBCs and 3-5% for PLTs. Deming correlations between the HemoScreen and the Sysmex XN instrument analyzer: (WBCHemoScreen™ = 1.061* WBCSysmex - 0.644; r = 0.995), RBC (RBCHemoScreen™ = 0.998* RBCSysmex + 0.049; r = 0.993) for WBC and (PlateletsHemoScreen™ = 1.087* PlateletsSysmex - 14.80; r = 0.994) for PLT. The HemoScreen™ device provided rapid and accurate test results to evaluate the need for RBC and PLT transfusion. This new technology is promising given that it allows the analysis of WBCs, RBCs, and PLTs further out in the healthcare organization compared with laboratory infrastructure based on traditional cell counters.
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Affiliation(s)
- Anders Larsson
- Department of Medical Sciences, Clinical Chemistry, Uppsala University , Uppsala , Sweden
| | - David Smekal
- CIRRUS, UCPR, Anaesthesiology and Intensive care, Department of Surgical Sciences, Anesthesiology, Uppsala University , Uppsala , Sweden
| | - Miklos Lipcsey
- CIRRUS, Hedenstierna laboratory, Anaesthesiology and Intensive care, Department of Surgical Sciences, Anesthesiology, Uppsala University , Uppsala , Sweden
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Richards JE, Conti BM, Grissom TE. Care of the Severely Injured Orthopedic Trauma Patient: Considerations for Initial Management, Operative Timing, and Ongoing Resuscitation. Adv Anesth 2018; 36:1-22. [PMID: 30414633 DOI: 10.1016/j.aan.2018.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Affiliation(s)
- Justin E Richards
- Department of Anesthesiology, University of Maryland School of Medicine, R Adams Cowley Shock Trauma Center, 22 South Greene Street, Suite T1R77, Baltimore, MD 21201, USA
| | - Bianca M Conti
- Department of Anesthesiology, University of Maryland School of Medicine, R Adams Cowley Shock Trauma Center, 22 South Greene Street, Suite T1R77, Baltimore, MD 21201, USA
| | - Thomas E Grissom
- Department of Anesthesiology, University of Maryland School of Medicine, R Adams Cowley Shock Trauma Center, 22 South Greene Street, Suite T1R77, Baltimore, MD 21201, USA.
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Abstract
PURPOSE OF REVIEW Hemorrhage remains the primary cause of preventable death on the battlefield and in civilian trauma. Hemorrhage control is multifactorial and starts with point-of-injury care. Surgical hemorrhage control and time from injury to surgery is paramount; however, interventions in the prehospital environment and perioperative period affect outcomes. The purpose of this review is to understand concepts and strategies for successful management of the bleeding military patient. Understanding the life-threatening nature of coagulopathy of trauma and implementing strategies aimed at full spectrum hemorrhage management from point of injury to postoperative care will result in improved outcomes in patients with life-threatening bleeding. RECENT FINDINGS Timely and appropriate therapies impact survival. Blood product resuscitation for life-threatening hemorrhage should either be with whole blood or a component therapy strategy that recapitulates the functionality of whole blood. The US military has transfused over 10 000 units of whole blood since the beginning of the wars in Iraq and Afghanistan. The well recognized therapeutic benefits of whole blood have pushed this therapy far forward into prehospital care in both US and international military forces. Multiple hemostatic adjuncts are available that are likely beneficial to the bleeding military patient; and other products and techniques are under active investigation. SUMMARY Lessons learned in the treatment of combat casualties will likely continue to have positive impact and influence and the management of hemorrhage in the civilian trauma setting.
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