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Moore HB, Moore EE, Neal MD, Sheppard FR, Kornblith LZ, Draxler DF, Walsh M, Medcalf RL, Cohen MJ, Cotton BA, Thomas SG, Leeper CM, Gaines BA, Sauaia A. Fibrinolysis Shutdown in Trauma: Historical Review and Clinical Implications. Anesth Analg 2019; 129:762-773. [PMID: 31425218 PMCID: PMC7340109 DOI: 10.1213/ane.0000000000004234] [Citation(s) in RCA: 79] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Despite over a half-century of recognizing fibrinolytic abnormalities after trauma, we remain in our infancy in understanding the underlying mechanisms causing these changes, resulting in ineffective treatment strategies. With the increased utilization of viscoelastic hemostatic assays (VHAs) to measure fibrinolysis in trauma, more questions than answers are emerging. Although it seems certain that low fibrinolytic activity measured by VHA is common after injury and associated with increased mortality, we now recognize subphenotypes within this population and that specific cohorts arise depending on the specific time from injury when samples are collected. Future studies should focus on these subtleties and distinctions, as hypofibrinolysis, acute shutdown, and persistent shutdown appear to represent distinct, unique clinical phenotypes, with different pathophysiology, and warranting different treatment strategies.
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Affiliation(s)
- Hunter B. Moore
- Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado
| | - Ernest E. Moore
- Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado
- Department of Surgery, Denver Health Medical Center, Denver, Colorado
| | - Matthew D. Neal
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | | | - Lucy Z. Kornblith
- Department of Surgery, San Francisco General Hospital, University of California San Francisco, San Francisco, California
| | - Dominik F. Draxler
- Australian Centre for Blood Diseases, Monash University, Melbourne, Australia
| | - Mark Walsh
- Department of Surgery, Memorial Hospital Trauma Center, Springfield, Illinois
- Department of Emergency Medicine, Memorial Hospital Trauma Center, Springfield, Illinois
| | - Robert L. Medcalf
- Australian Centre for Blood Diseases, Monash University, Melbourne, Australia
| | - Mitch J. Cohen
- Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado
- Department of Surgery, Denver Health Medical Center, Denver, Colorado
| | - Bryan A. Cotton
- Department of Surgery, Center for Translational Injury Research, The McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas
| | - Scott G. Thomas
- Department of Surgery, Memorial Hospital Trauma Center, Springfield, Illinois
- Department of Emergency Medicine, Memorial Hospital Trauma Center, Springfield, Illinois
| | - Christine M. Leeper
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Barbara A. Gaines
- Department of Surgery, Children’s Hospital of Pittsburgh of the University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Angela Sauaia
- Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado
- Division of Health Systems, Management, and Policy, University of Colorado School of Public Health, Aurora, Colorado
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Conhaim RL, Watson KE, Teodorescu M. Obstructive apnea causes microvascular perfusion maldistribution in the lungs of rats. Am J Physiol Regul Integr Comp Physiol 2019; 316:R21-R26. [PMID: 30403498 DOI: 10.1152/ajpregu.00243.2018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Obstructive sleep apnea (OSA) is associated with significant cardiovascular consequences, including pulmonary hypertension, yet little is known about its effects on pulmonary microvascular perfusion. To investigate effects of OSA on pulmonary microvascular perfusion, we clamped the tracheal cannulas of anesthetized, spontaneously breathing rats to simulate obstructive apnea. The clamp remained in place for 10 breaths before it was released to allow the animals to again breathe spontaneously. We repeated this protocol every 20 s until the rat experienced a total of five apneic episodes of 10 breaths each. We then infused into a femoral vein 108 fluorescent latex particles (4 µm diameter), which became trapped within the pulmonary microcirculation. We removed the lungs, allowed them to air-dry, and quantified the particle distributions in sections of the lungs using dispersion index (DI) analysis, a method we developed previously. The log of the DI (logDI) is a measure of perfusion maldistribution. Greater log(DI) values correspond to greater maldistribution. Apneic lungs had average logDI values of 1.28 (SD 0.24). Rats not subjected to apnea had average logDI values of 0.85 (SD 0.08) ( P ≤ 0.05). Rats that received latex particles 10 min or 24 h after apnea had average logDI values of 0.97 (SD 0.31) and 0.84 (SD 0.38), respectively (not significant). Our results demonstrate, for the first time, that a few apneic events produced significant, but temporary, perfusion maldistribution within the pulmonary microcirculation. Repeated nightly episodes of apnea over months and years may explain why human patients with OSA suffer from significantly greater cardiovascular disease than those without OSA.
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Affiliation(s)
- Robert L Conhaim
- William S. Middleton Memorial Veterans Hospital , Madison, Wisconsin.,Department of Surgery, University of Wisconsin School of Medicine and Public Health , Madison, Wisconsin
| | - Kal E Watson
- William S. Middleton Memorial Veterans Hospital , Madison, Wisconsin
| | - Mihaela Teodorescu
- William S. Middleton Memorial Veterans Hospital , Madison, Wisconsin.,Department of Medicine, University of Wisconsin School of Medicine and Public Health , Madison, Wisconsin
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Joslyn LR, Pienaar E, DiFazio RM, Suliman S, Kagina BM, Flynn JL, Scriba TJ, Linderman JJ, Kirschner DE. Integrating Non-human Primate, Human, and Mathematical Studies to Determine the Influence of BCG Timing on H56 Vaccine Outcomes. Front Microbiol 2018; 9:1898. [PMID: 30177934 PMCID: PMC6110197 DOI: 10.3389/fimmu.2018.01898] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Accepted: 07/31/2018] [Indexed: 12/21/2022] Open
Abstract
Background Acute lung injury (ALI) is characterized by suppressed fibrinolytic activity in bronchoalveolar lavage fluid (BALF) attributed to elevated plasminogen activator inhibitor-1 (PAI-1). Restoring pulmonary fibrinolysis by delivering tissue-type plasminogen activator (tPA), urokinase plasminogen activator (uPA), and plasmin could be a promising approach. Objectives To systematically analyze the overall benefit of fibrinolytic therapy for ALI reported in preclinical studies. Methods We searched PubMed, Embase, Web of Science, and CNKI Chinese databases, and analyzed data retrieved from 22 studies for the beneficial effects of fibrinolytics on animal models of ALI. Results Both large and small animals were used with five routes for delivering tPA, uPA, and plasmin. Fibrinolytics significantly increased the fibrinolytic activity both in the plasma and BALF. Fibrin degradation products in BALF had a net increase of 408.41 ng/ml vs controls (P < 0.00001). In addition, plasma thrombin–antithrombin complexes increased 1.59 ng/ml over controls (P = 0.0001). In sharp contrast, PAI-1 level in BALF decreased 21.44 ng/ml compared with controls (P < 0.00001). Arterial oxygen tension was improved by a net increase of 15.16 mmHg, while carbon dioxide pressure was significantly reduced (11.66 mmHg, P = 0.0001 vs controls). Additionally, fibrinolytics improved lung function and alleviated inflammation response: the lung wet/dry ratio was decreased 1.49 (P < 0.0001 vs controls), lung injury score was reduced 1.83 (P < 0.00001 vs controls), and BALF neutrophils were lesser (3 × 104/ml, P < 0.00001 vs controls). The mortality decreased significantly within defined study periods (6 h to 30 days for mortality), as the risk ratio of death was 0.2-fold of controls (P = 0.0008). Conclusion We conclude that fibrinolytic therapy may be effective pharmaceutic strategy for ALI in animal models.
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Affiliation(s)
- Louis R Joslyn
- Department of Chemical Engineering, University of Michigan, Ann Arbor, MI, United States.,Department of Microbiology and Immunology, University of Michigan Medical School, Ann Arbor, MI, United States
| | - Elsje Pienaar
- Department of Chemical Engineering, University of Michigan, Ann Arbor, MI, United States.,Department of Microbiology and Immunology, University of Michigan Medical School, Ann Arbor, MI, United States
| | - Robert M DiFazio
- Department of Microbiology and Molecular Genetics, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Sara Suliman
- South African Tuberculosis Vaccine Initiative and Institute of Infectious Disease and Molecular Medicine, Division of Immunology, Department of Pathology, University of Cape Town, Cape Town, South Africa
| | - Benjamin M Kagina
- South African Tuberculosis Vaccine Initiative and Institute of Infectious Disease and Molecular Medicine, Division of Immunology, Department of Pathology, University of Cape Town, Cape Town, South Africa
| | - JoAnne L Flynn
- Department of Microbiology and Molecular Genetics, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Thomas J Scriba
- South African Tuberculosis Vaccine Initiative and Institute of Infectious Disease and Molecular Medicine, Division of Immunology, Department of Pathology, University of Cape Town, Cape Town, South Africa
| | - Jennifer J Linderman
- Department of Chemical Engineering, University of Michigan, Ann Arbor, MI, United States
| | - Denise E Kirschner
- Department of Microbiology and Immunology, University of Michigan Medical School, Ann Arbor, MI, United States
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Ruthman CA, Festic E. Emerging therapies for the prevention of acute respiratory distress syndrome. Ther Adv Respir Dis 2015; 9:173-87. [PMID: 26002528 DOI: 10.1177/1753465815585716] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
The development of acute respiratory distress syndrome (ARDS) carries significant risk of morbidity and mortality. To date, pharmacological therapy has been largely ineffective for patients with ARDS. We present our personal review aimed at outlining current and future directions for the pharmacological prevention of ARDS. Several available risk-stratification or prediction score strategies for identification of patients at risk of ARDS have been reported. Although not ready for clinical everyday use, they are and will be instrumental in the ongoing and future trials of pharmacoprevention of ARDS.Several systemic medications established the potential role in ARDS prevention based on the preclinical studies and observational data. Due to potential for systemic adverse effects to neutralize any pharmacological benefits of systemic therapy, inhaled medications appear particularly attractive candidates for ARDS prevention. This is because of their direct delivery to the site of proposed action (lungs), while the pulmonary epithelial surface is still functional.We postulate that overall morbidity and mortality rates from ARDS in the future will be contingent upon decreasing the overall incidence of ARDS through effective identification of those at risk and early application of proven supportive care and pharmacological interventions.
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Affiliation(s)
- Carl A Ruthman
- Pulmonary and Critical Care, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL 32224, USA
| | - Emir Festic
- Pulmonary and Critical Care, Mayo Clinic, Jacksonville, FL, 32224 USA
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What’s New in Shock? June 2014. Shock 2014. [DOI: 10.1097/shk.0000000000000185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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