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Kumabe Y, Kalbas Y, Halvachizadeh S, Teuben M, Cesarovic N, Weisskopf M, Hülsmeier A, Hornemann T, Cinelli P, Pape HC, Pfeifer R. Occult hypoperfusion and changes of systemic lipid levels after severe trauma: an analysis in a standardized porcine polytrauma model. Eur J Trauma Emerg Surg 2024; 50:107-114. [PMID: 35819473 PMCID: PMC10924008 DOI: 10.1007/s00068-022-02039-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Accepted: 06/26/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND Occult hypoperfusion describes the absence of sufficient microcirculation despite normal vital signs. It is known to be associated with prolonged elevation of serum lactate and later complications in severely injured patients. We hypothesized that changes in circulating lipids are related to responsiveness to resuscitation. The purpose of this study is investigating the relation between responsiveness to resuscitation and lipidomic course after poly trauma. METHODS Twenty-five male pigs were exposed a combined injury of blunt chest trauma, liver laceration, controlled haemorrhagic shock, and femoral shaft fracture. After 1 h, animals received resuscitation and fracture stabilization. Venous blood was taken regularly and 233 specific lipids were analysed. Animals were divided into two groups based on serum lactate level at the end point as an indicator of responsiveness to resuscitation (<2 mmol/L: responder group (R group), ≧2 mmol/L: occult hypoperfusion group (OH group)). RESULTS Eighteen animals met criteria for the R group, four animals for the OH group, and three animals died. Acylcarnitines showed a significant increase at 1 h compared to baseline in both groups. Six lipid subgroups showed a significant increase only in R group at 2 h. There was no significant change at other time points. CONCLUSIONS Six lipid groups increased significantly only in the R group at 2 h, which may support the idea that they could serve as potential biomarkers to help us to detect the presence of occult hypoperfusion and insufficient resuscitation. We feel that further study is required to confirm the role and mechanism of lipid changes after trauma.
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Affiliation(s)
- Yohei Kumabe
- Department of Trauma, Institute for Clinical Chemistry, Zurich University Hospital, Zurich, Switzerland
- Department of Surgical Research, Harald Tscherne Laboratory for Orthopaedic and Trauma Research, Zurich University Hospital, Zurich, Switzerland
| | - Yannik Kalbas
- Department of Trauma, Institute for Clinical Chemistry, Zurich University Hospital, Zurich, Switzerland
- Department of Surgical Research, Harald Tscherne Laboratory for Orthopaedic and Trauma Research, Zurich University Hospital, Zurich, Switzerland
| | - Sascha Halvachizadeh
- Department of Trauma, Institute for Clinical Chemistry, Zurich University Hospital, Zurich, Switzerland
- Department of Surgical Research, Harald Tscherne Laboratory for Orthopaedic and Trauma Research, Zurich University Hospital, Zurich, Switzerland
| | - Michel Teuben
- Department of Trauma, Institute for Clinical Chemistry, Zurich University Hospital, Zurich, Switzerland
- Department of Surgical Research, Harald Tscherne Laboratory for Orthopaedic and Trauma Research, Zurich University Hospital, Zurich, Switzerland
| | - Nikola Cesarovic
- Department of Surgical Research, Harald Tscherne Laboratory for Orthopaedic and Trauma Research, Zurich University Hospital, Zurich, Switzerland
| | - Miriam Weisskopf
- Department of Surgical Research, Harald Tscherne Laboratory for Orthopaedic and Trauma Research, Zurich University Hospital, Zurich, Switzerland
| | - Andreas Hülsmeier
- Department of Trauma, Institute for Clinical Chemistry, Zurich University Hospital, Zurich, Switzerland
| | - Thorsten Hornemann
- Department of Trauma, Institute for Clinical Chemistry, Zurich University Hospital, Zurich, Switzerland
| | - Paolo Cinelli
- Department of Surgical Research, Harald Tscherne Laboratory for Orthopaedic and Trauma Research, Zurich University Hospital, Zurich, Switzerland
| | - Hans-Christoph Pape
- Department of Trauma, Institute for Clinical Chemistry, Zurich University Hospital, Zurich, Switzerland
- Department of Surgical Research, Harald Tscherne Laboratory for Orthopaedic and Trauma Research, Zurich University Hospital, Zurich, Switzerland
| | - Roman Pfeifer
- Department of Trauma, Institute for Clinical Chemistry, Zurich University Hospital, Zurich, Switzerland.
- Department of Surgical Research, Harald Tscherne Laboratory for Orthopaedic and Trauma Research, Zurich University Hospital, Zurich, Switzerland.
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Rayatdoost F, Grottke O. The Use of Large Animal Models in Trauma and Bleeding Studies. Hamostaseologie 2023; 43:360-373. [PMID: 37696297 DOI: 10.1055/a-2118-1431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/13/2023] Open
Abstract
BACKGROUND Major trauma often results in significant bleeding and coagulopathy, posing a substantial clinical burden. To understand the underlying pathophysiology and to refine clinical strategies to overcome coagulopathy, preclinical large animal models are often used. This review scrutinizes the clinical relevance of large animal models in hemostasis research, emphasizing challenges in translating findings into clinical therapies. METHODS We conducted a thorough search of PubMed and EMBASE databases from January 1, 2010, to December 31, 2022. We used specific keywords and inclusion/exclusion criteria centered on large animal models. RESULTS Our review analyzed 84 pertinent articles, including four animal species: pigs, sheep, dogs, and nonhuman primates (NHPs). Eighty-five percent of the studies predominantly utilized porcine models. Meanwhile, sheep and dogs were less represented, making up only 2.5% of the total studies. Models with NHP were 10%. The most frequently used trauma models involved a combination of liver injury and femur fractures (eight studies), arterial hemorrhage (seven studies), and a combination of hemodilution and liver injury (seven studies). A wide array of coagulation parameters were employed to assess the efficacy of interventions in hemostasis and bleeding control. CONCLUSIONS Recognizing the diverse strengths and weaknesses of large animal models is critical for trauma and hemorrhage research. Each model is unique and should be chosen based on how well it aligns with the specific scientific objectives of the study. By strategically considering each model's advantages and limitations, we can enhance our understanding of trauma and hemorrhage pathophysiology and further advance the development of effective treatments.
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Affiliation(s)
- Farahnaz Rayatdoost
- Department of Anaesthesiology, University Hospital RWTH Aachen, Aachen, Germany
| | - Oliver Grottke
- Department of Anaesthesiology, University Hospital RWTH Aachen, Aachen, Germany
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Oestreich MA, Seidel K, Bertrams W, Müller HH, Sassen M, Steinfeldt T, Wulf H, Schmeck B. Pulmonary inflammatory response and immunomodulation to multiple trauma and hemorrhagic shock in pigs. PLoS One 2022; 17:e0278766. [PMID: 36476845 PMCID: PMC9728855 DOI: 10.1371/journal.pone.0278766] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 10/31/2022] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Patients suffering from severe trauma experience substantial immunological stress. Lung injury is a known risk factor for the development of posttraumatic complications, but information on the long-term course of the pulmonary inflammatory response and treatment with mild hypothermia are scarce. AIM To investigate the pulmonary inflammatory response to multiple trauma and hemorrhagic shock in a porcine model of combined trauma and to assess the immunomodulatory properties of mild hypothermia. METHODS Following induction of trauma (blunt chest trauma, liver laceration, tibia fracture), two degrees of hemorrhagic shock (45 and 50%) over 90 (n = 30) and 120 min. (n = 20) were induced. Animals were randomized to hypothermia (33°C) or normothermia (38°C). We evaluated bronchoalveolar lavage (BAL) fluid and tissue levels of cytokines and investigated changes in microRNA- and gene-expression as well as tissue apoptosis. RESULTS We observed a significant induction of Interleukin (IL) 1β, IL-6, IL-8, and Cyclooxygenase-2 mRNA in lung tissue. Likewise, an increased IL-6 protein concentration could be detected in BAL-fluid, with a slight decrease of IL-6 protein in animals treated with hypothermia. Lower IL-10 protein levels in normothermia and higher IL-10 protein concentrations in hypothermia accompanied this trend. Tissue apoptosis increased after trauma. However, intervention with hypothermia did not result in a meaningful reduction of pro-inflammatory biomarkers or tissue apoptosis. CONCLUSION We observed signs of a time-dependent pulmonary inflammation and apoptosis at the site of severe trauma, and to a lower extent in the trauma-distant lung. Intervention with mild hypothermia had no considerable effect during 48 hours following trauma.
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Affiliation(s)
- Marc-Alexander Oestreich
- Institute for Lung Research, Universities of Giessen and Marburg Lung Center, German Center for Lung Research (DZL), Philipps University Marburg, Marburg, Germany
| | - Kerstin Seidel
- Vascular Biology Section, Evans Department of Medicine, Whitaker Cardiovascular Institute, Boston University School of Medicine, Boston, MA, United States of America
| | - Wilhelm Bertrams
- Institute for Lung Research, Universities of Giessen and Marburg Lung Center, German Center for Lung Research (DZL), Philipps University Marburg, Marburg, Germany
| | - Hans-Helge Müller
- Institute for Medical Bioinformatics and Biostatistics, Philipps-Universität Marburg, Marburg, Germany
| | - Martin Sassen
- Department of Anesthesia and Intensive Care Medicine, University Medical Center Gießen and Marburg, Philipps University Marburg, Marburg, Germany
- Center for Emergency Medicine, University Medical Center Gießen and Marburg, Philipps University Marburg, Marburg, Germany
| | - Thorsten Steinfeldt
- BG Unfallklinik Frankfurt am Main gGmbH, Department for Anesthesia, Intensive Care Medicine and Pain Therapy, Frankfurt am Main, Germany
| | - Hinnerk Wulf
- Department of Anesthesia and Intensive Care Medicine, University Medical Center Gießen and Marburg, Philipps University Marburg, Marburg, Germany
| | - Bernd Schmeck
- Institute for Lung Research, Universities of Giessen and Marburg Lung Center, German Center for Lung Research (DZL), Philipps University Marburg, Marburg, Germany
- Department of Pulmonary and Critical Care Medicine, University Medical Center Giessen and Marburg, German Center for Lung Research (DZL), Philipps University Marburg, Marburg, Germany
- Center for Synthetic Microbiology (SYNMIKRO), Philipps-University of Marburg, Marburg, Germany
- German Center for Infection Research (DZIF), Partner Site Giessen-Marburg-Langen, Marburg, Germany
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Halvachizadeh S, Kalbas Y, Teuben MPJ, Teuber H, Cesarovic N, Weisskopf M, Cinelli P, Pape HC, Pfeifer R. Effects of Occult Hypoperfusion on Local Circulation and Inflammation - An Analysis in a Standardized Polytrauma Model. Front Immunol 2022; 13:894270. [PMID: 35799796 PMCID: PMC9254728 DOI: 10.3389/fimmu.2022.894270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Accepted: 04/25/2022] [Indexed: 11/13/2022] Open
Abstract
IntroductionOccult hypoperfusion (OH) is defined as persistent lactic acidosis despite normalization of vital parameters following trauma. The aim of this study was to analyze the association of occult hypoperfusion with local circulation and inflammation of injured soft tissue in a porcine polytrauma model.MethodsThis experimental study was performed with male landrace pigs who suffered a standardized polytrauma, including a femoral fracture, blunt chest trauma, liver laceration and a mean arterial pressure (MAP) controlled hemorrhagic shock. One hour after induction of trauma, the animals were resuscitated with retrograde femoral nailing, liver packing and volume replacement. Animals were stratified into Group Norm (normalizing lactate levels after resuscitation) and Group occult hypoperfusion (OH) (persistent lactate levels above 2 mmol/l with normalizing vital parameters after resuscitation). Local circulation (oxygen saturation, hemoglobin amount, blood flow) was measured with optical sensors at the subcutaneous soft tissue at the fractured extremity as well as at the stomach and colon. Local inflammatory parameters [interleukin (IL) 6, 8, 10, and heat shock protein (HSP)] were analyzed in the subcutaneous tissue of the fractured extremity.ResultsGroup Norm (n = 19) and Group OH (n = 5) were comparable in baseline vital and laboratory parameters. The shock severity and total amount of blood loss were comparable among Group Norm and Group OH. Following resuscitation Group OH had significantly lower local relative hemoglobin amount at the injured soft tissue of the fractured extremity when compared with Group Norm (39.4, SD 5.3 vs. 63.9, SD 27.6 A.U., p = 0.031). The local oxygenation was significantly lower in Group OH compared to Group Norm (60.4, SD 4.6 vs. 75.8, SD 12.8, p = 0.049). Local IL-6 in the fatty tissue was significantly higher in Group OH (318.3, SD 326.6 [pg/ml]) when compared with Group Norm (73.9,SD 96.3[pg/ml], p = 0.03). The local circulation at the abdominal organs was comparable in both groups.ConclusionOH is associated with decreased local circulation and increased local inflammation at the injured soft tissue of the extremity in polytrauma. OH might reflect the severity of local soft tissue injuries, and guide treatment strategies.
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Affiliation(s)
- Sascha Halvachizadeh
- Department of Trauma, University Hospital Zurich, Zurich, Switzerland
- Harald Tscherne Research Laboratory, University of Zurich, Zurich, Switzerland
- *Correspondence: Sascha Halvachizadeh,
| | - Yannik Kalbas
- Department of Trauma, University Hospital Zurich, Zurich, Switzerland
- Harald Tscherne Research Laboratory, University of Zurich, Zurich, Switzerland
| | | | - Henrik Teuber
- Department of Trauma, University Hospital Zurich, Zurich, Switzerland
| | - Nikola Cesarovic
- Department of Health Sciences and Technology, Eidgenössische Technische Hochschule (ETH) Zurich, Zurich, Switzerland
| | - Miriam Weisskopf
- Center for Surgical Research, University Hospital Zurich, University Zurich, Zurich, Switzerland
| | - Paolo Cinelli
- Department of Trauma, University Hospital Zurich, Zurich, Switzerland
- Harald Tscherne Research Laboratory, University of Zurich, Zurich, Switzerland
| | - Hans-Christoph Pape
- Department of Trauma, University Hospital Zurich, Zurich, Switzerland
- Harald Tscherne Research Laboratory, University of Zurich, Zurich, Switzerland
| | - Roman Pfeifer
- Department of Trauma, University Hospital Zurich, Zurich, Switzerland
- Harald Tscherne Research Laboratory, University of Zurich, Zurich, Switzerland
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Dahlquist A, Elander Degerstedt L, von Oelreich E, Brännström A, Gustavsson J, P Arborelius U, Günther M. Blast polytrauma with hemodynamic shock, hypothermia, hypoventilation and systemic inflammatory response: description of a new porcine model. Eur J Trauma Emerg Surg 2022; 48:401-409. [PMID: 32862315 PMCID: PMC7456397 DOI: 10.1007/s00068-020-01476-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Accepted: 08/21/2020] [Indexed: 02/02/2023]
Abstract
PURPOSE In the past decade blast injuries have become more prevalent. Blast trauma may cause extensive injuries requiring improved early resuscitation and prevention of haemorrhage. Randomized prospective trials are logistically and ethically challenging, and large animal models are important for further research efforts. Few severe blast trauma models have been described, which is why we aimed to establish a comprehensive polytrauma model in accordance with the criteria of the Berlin definition of polytrauma and with a survival time of > 2 h. Multiple blast injuries to the groin and abdomen were combined with hypoperfusion, respiratory and metabolic acidosis, hypoventilation, hypothermia and inflammatory response. The model was compared to lung contusion and haemorrhage. METHODS 16 landrace swine (mean weight 60.5 kg) were randomized to "control" (n = 5), "chest trauma/hem" by lung contusion and class II haemorrhage (n = 5), and "blast polytrauma" caused by multiple blast injuries to the groin and abdomen, class II haemorrhage, lipopolysaccharide (LPS) infusion and hypothermia 32 °C (n = 6). RESULTS The blast polytrauma group had an Injury Severity Score of 57 which resulted in haemodynamic shock, hypothermia, respiratory and metabolic acidosis and inflammatory response. The chest trauma/hem group had an Injury Severity Score of 9 and less profound physiologic effects. Physiologic parameters presented a dose-response relationship corresponding to the trauma levels. CONCLUSION A comprehensive blast polytrauma model fulfilling the Berlin polytrauma criteria, with a high trauma load and a survival time of > 2 h was established. A severe, but consistent, injury profile was accomplished enabling the addition of experimental interventions in future studies, particularly of immediate resuscitation efforts including whole blood administration, trauma packing and haemostasis.
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Affiliation(s)
- Albin Dahlquist
- Department of Clinical Science and Education, Section of Anaesthesiology and Intensive Care, Södersjukhuset, Karolinska Institutet, Sjukhusbacken 10, S1, 118 83, Stockholm, Sweden
| | - Louise Elander Degerstedt
- Department of Clinical Science and Education, Section of Anaesthesiology and Intensive Care, Södersjukhuset, Karolinska Institutet, Sjukhusbacken 10, S1, 118 83, Stockholm, Sweden
| | - Erik von Oelreich
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Andreas Brännström
- Department of Clinical Science and Education, Section of Anaesthesiology and Intensive Care, Södersjukhuset, Karolinska Institutet, Sjukhusbacken 10, S1, 118 83, Stockholm, Sweden
| | - Jenny Gustavsson
- Department of Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Ulf P Arborelius
- Department of Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Mattias Günther
- Department of Clinical Science and Education, Section of Anaesthesiology and Intensive Care, Södersjukhuset, Karolinska Institutet, Sjukhusbacken 10, S1, 118 83, Stockholm, Sweden.
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McKinley TO, Childress P, Jewell E, Griffin KS, Wininger AE, Tucker A, Gremah A, Savaglio MK, Warden SJ, Fuchs RK, Natoli RM, Shively KD, Anglen JO, Gabriel Chu TM, Kacena MA. Bone Morphogenetic Protein-2 Rapidly Heals Two Distinct Critical Sized Segmental Diaphyseal Bone Defects in a Porcine Model. Mil Med 2021; 188:117-124. [PMID: 34557897 PMCID: PMC9825249 DOI: 10.1093/milmed/usab360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Revised: 08/11/2021] [Accepted: 08/20/2021] [Indexed: 01/12/2023] Open
Abstract
INTRODUCTION Segmental bone defects (SBDs) are devastating injuries sustained by warfighters and are difficult to heal. Preclinical models that accurately simulate human conditions are necessary to investigate therapies to treat SBDs. We have developed two novel porcine SBD models that take advantage of similarities in bone healing and immunologic response to injury between pigs and humans. The purpose of this study was to investigate the efficacy of Bone Morphogenetic Protein-2 (BMP-2) to heal a critical sized defect (CSD) in two novel porcine SBD models. MATERIALS AND METHODS Two CSDs were performed in Yucatan Minipigs including a 25.0-mm SBD treated with intramedullary nailing (IMN) and a 40.0-mm SBD treated with dual plating (ORIF). In control animals, the defect was filled with a custom spacer and a bovine collagen sponge impregnated with saline (IMN25 Cont, n = 8; ORIF40 Cont, n = 4). In experimental animals, the SBD was filled with a custom spacer and a bovine collage sponge impregnated with human recombinant BMP-2 (IMN25 BMP, n = 8; ORIF40 BMP, n = 4). Healing was quantified using monthly modified Radiographic Union Score for Tibia Fractures (mRUST) scores, postmortem CT scanning, and torsion testing. RESULTS BMP-2 restored bone healing in all eight IMN25 BMP specimens and three of four ORIF40 BMP specimens. None of the IMN25 Cont or ORIF40 Cont specimens healed. mRUST scores at the time of sacrifice increased from 9.2 (±2.4) in IMN25 Cont to 15.1 (±1.0) in IMN25 BMP specimens (P < .0001). mRUST scores increased from 8.2 (±1.1) in ORIF40 Cont to 14.3 (±1.0) in ORIF40 BMP specimens (P < .01). CT scans confirmed all BMP-2 specimens had healed and none of the control specimens had healed in both IMN and ORIF groups. BMP-2 restored 114% and 93% of intact torsional stiffness in IMN25 BMP and ORIF40 BMP specimens. CONCLUSIONS We have developed two porcine CSD models, including fixation with IMN and with dual-plate fixation. Porcine models are particularly relevant for SBD research as the porcine immunologic response to injury closely mimics the human response. BMP-2 restored healing in both CSD models, and the effects were evident within the first month after injury. These findings support the use of both porcine CSD models to investigate new therapies to heal SBDs.
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Affiliation(s)
- Todd O McKinley
- Department of Orthopaedic Surgery, Indiana University School of MedicineIndianapolis, IN 46202,USA
| | | | - Emily Jewell
- Hand Surgery Associates of Indiana, Indianapolis, IN 46260, USA
| | - Kaitlyn S Griffin
- Department of Obstetrics and Gynecology, University of Cincinnati School of Medicine, Cincinnati, OH 45267, USA
| | - Austin E Wininger
- Department of Orthopaedic Surgery, Methodist Hospital, Houston, TX 77030, USA
| | - Aamir Tucker
- Marian University College of Osteopathic Medicine, Indianapolis, IN 46222, USA
| | - Adam Gremah
- Marian University College of Osteopathic Medicine, Indianapolis, IN 46222, USA
| | - Michael K Savaglio
- Marian University College of Osteopathic Medicine, Indianapolis, IN 46222, USA
| | - Stuart J Warden
- Department of Physical Therapy, Indiana University School of Health and Human Sciences, Indianapolis, IN 46202, USA
| | - Robyn K Fuchs
- Department of Physical Therapy, Indiana University School of Health and Human Sciences, Indianapolis, IN 46202, USA
| | - Roman M Natoli
- Department of Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, IN 46202,USA
| | - Karl D Shively
- Department of Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | | | | | - Melissa A Kacena
- Department of Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, IN 46202, USA
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Halvachizadeh S, Teuben M, Lempert M, Kalbas Y, Cesarovic N, Lipiski M, Benninger E, Cinelli P, Pfeifer R, Pape HC. Protective effects of new femoral reaming techniques (Reamer irrigator aspirator, RIA I and II) on pulmonary function and posttraumatic contusion (CT morphology) - results from a standardized large animal model. Injury 2021; 52:26-31. [PMID: 33046248 DOI: 10.1016/j.injury.2020.10.027] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2020] [Revised: 10/01/2020] [Accepted: 10/05/2020] [Indexed: 02/02/2023]
Abstract
INTRODUCTION The effects of reaming for preparation of intramedullary fixation in long bone fractures have been widely studied. We compared pulmonary and systemic effects between conventional reaming with reamer irrigator aspirator and unreamed nailing in an acute porcine trauma model with a standardized femur fracture. MATERIALS AND METHODS In a standardized porcine model, (moderate blunt chest trauma, abdominal injury and femoral shaft fracture), the femur was submitted to intramedullary nailing after resuscitation and normalization of pulmonary function. The treatment groups included 3 reamer types (Group RFN: conventional reaming with Synream; group RIA1; reamer irrigator aspirator, version 2005; group RIA 2; reamer irrigator aspirator, version 2019) and were compared to unreamed femoral nailing (Group UFN). Pulmonary function measurements included arterial partial carbon-dioxide pressure (paCO2 [kPa]) (baseline, post reaming, 2,4,6 h) and volumetric measures of contusion in chest computer tomography (CT) (at 6 hrs.). Systemic inflammatory response was measured at baseline and every second hour until six hours after trauma. RESULTS This study included 24 male animals, mean weight 50.76 ± 4.1 kg n = 6 per group). Group RFN developed a significantly higher partial CO2 (pCO2) at one hour after reaming when compared with all other groups (7.4 ± 0.4 kPa versus 5.4 ± 0.6 RIA 1, 5.6 ± 0.4 RIA 2, and 5.5 ± 0.5 UFN, p < 0.001), along with a had lower pO2 (12.3 ± 1.3 kPa versus 17.2 ± 1.9 RIA 1, 17.4 ± 1.6 RIA 2, and 16.4 ± 0.7 UFN, p < 0.001) and the degree of pulmonary hyperdense changes in the CT analysis was higher in RFN (485.2 ± 98.5 cm3 versus 344.4 ± 74.4 cm3 RIA 1 and 335.2 ± 58.1 cm3 RIA 2, p < 0.01). The inflammatory reaction was lowest in both RIA groups when compared with group RFN or UFN (p < 0.001). CONCLUSION Both RIA 1 and RIA 2 protect the lung from reaming induced dysfunction and have no systemic inflammatory effects, while the negative effects were more sustained after reamed or unreamed nailing. Both RIA 1 and RIA II appear to be of value in terms of a Safe Definitive Surgery (SDS) strategy.
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Affiliation(s)
- Sascha Halvachizadeh
- University Hospital Zurich, Department of Trauma, Raemistrasse 100, 8091 Zurich, Switzerland; University of Zurich, University Hospital Zurich, Department of Surgical Research, Harald Tscherne Laboratory for Orthopaedic and Trauma research, Sternwartstrasse 14, 8091 Zurich, Switzerland.
| | - Michel Teuben
- University Hospital Zurich, Department of Trauma, Raemistrasse 100, 8091 Zurich, Switzerland; University of Zurich, University Hospital Zurich, Department of Surgical Research, Harald Tscherne Laboratory for Orthopaedic and Trauma research, Sternwartstrasse 14, 8091 Zurich, Switzerland.
| | - Max Lempert
- University Hospital Zurich, Department of Trauma, Raemistrasse 100, 8091 Zurich, Switzerland.
| | - Yannik Kalbas
- University Hospital Zurich, Department of Trauma, Raemistrasse 100, 8091 Zurich, Switzerland.
| | - Nikola Cesarovic
- University of Zurich, University Hospital Zurich, Department of Surgical Research, Harald Tscherne Laboratory for Orthopaedic and Trauma research, Sternwartstrasse 14, 8091 Zurich, Switzerland.
| | - Miriam Lipiski
- University of Zurich, University Hospital Zurich, Department of Surgical Research, Harald Tscherne Laboratory for Orthopaedic and Trauma research, Sternwartstrasse 14, 8091 Zurich, Switzerland.
| | - Emanuel Benninger
- Cantonal hospital Winterthur, Department of Orthopaedics and Trauma, Brauerstrasse 15, 8400 Winterthur, Switzerland.
| | - Paolo Cinelli
- University of Zurich, University Hospital Zurich, Department of Surgical Research, Harald Tscherne Laboratory for Orthopaedic and Trauma research, Sternwartstrasse 14, 8091 Zurich, Switzerland.
| | - Roman Pfeifer
- University Hospital Zurich, Department of Trauma, Raemistrasse 100, 8091 Zurich, Switzerland; University of Zurich, University Hospital Zurich, Department of Surgical Research, Harald Tscherne Laboratory for Orthopaedic and Trauma research, Sternwartstrasse 14, 8091 Zurich, Switzerland.
| | - Hans-Christoph Pape
- University Hospital Zurich, Department of Trauma, Raemistrasse 100, 8091 Zurich, Switzerland; University of Zurich, University Hospital Zurich, Department of Surgical Research, Harald Tscherne Laboratory for Orthopaedic and Trauma research, Sternwartstrasse 14, 8091 Zurich, Switzerland.
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Impact of Chest Trauma and Overweight on Mortality and Outcome in Severely Injured Patients. J Clin Med 2020; 9:jcm9092752. [PMID: 32858822 PMCID: PMC7564760 DOI: 10.3390/jcm9092752] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2020] [Revised: 08/11/2020] [Accepted: 08/16/2020] [Indexed: 01/08/2023] Open
Abstract
The morbidity and mortality of severely injured patients are commonly affected by multiple factors. Especially, severe chest trauma has been shown to be a significant factor in considering outcome. Contemporaneously, weight-associated endocrinological, haematological, and metabolic deviations from the norm seem to have an impact on the posttraumatic course. Therefore, the aim of this study was to determine the influence of body weight on severely injured patients by emphasizing chest trauma. A total of 338 severely injured patients were included. Multivariate regression analyses were performed on patients with severe chest trauma (AIS ≥ 3) and patients with minor chest trauma (AIS < 3). The influence of body weight on in-hospital mortality was evaluated. Of all the patients, 70.4% were male, the median age was 52 years (IQR 36–68), the overall Injury Severity Score (ISS) was 24 points (IQR 17–29), and a median BMI of 25.1 points (IQR 23–28) was determined. In general, chest trauma was associated with prolonged ventilation, prolonged ICU treatment, and increased mortality. For overweight patients with severe chest trauma, an independent survival benefit was found (OR 0.158; p = 0.037). Overweight seems to have an impact on the mortality of severely injured patients with combined chest trauma. Potentially, a nutritive advantage or still-unknown immunological aspects in these patients affecting the intensive treatment course could be argued.
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Traumatic injury pattern is of equal relevance as injury severity for experimental (poly)trauma modeling. Sci Rep 2019; 9:5706. [PMID: 30952899 PMCID: PMC6450898 DOI: 10.1038/s41598-019-42085-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Accepted: 03/21/2019] [Indexed: 01/02/2023] Open
Abstract
This study aims to elaborate the relevance of trauma severity and traumatic injury pattern in different multiple and/or polytrauma models by comparing five singular trauma to two different polytrauma (PT) models with high and one multiple trauma (MT) model with low injury-severity score (ISS). The aim is to provide a baseline for reducing animal harm according to 3Rs by providing less injury as possible in polytrauma modeling. Mice were randomly assigned to 10 groups: controls (Ctrl; n = 15), Sham (n = 15); monotrauma groups: hemorrhagic shock (HS; n = 15), thoracic trauma (TxT; n = 18), osteotomy with external fixation (Fx; n = 16), bilateral soft tissue trauma (bSTT; n = 16) or laparotomy (Lap; n = 16); two PT groups: PT I (TxT + HS + Fx; ISS = 18; n = 18), PT II (TxT + HS + Fx + Lap; ISS = 22; n = 18), and a MT group (TxT + HS + bSTT + Lap, ISS = 13; n = 18). Activity and mortality were assessed. Blood gas analyses and organ damage markers were determined after 6 h. Significant mortality occurred in TxT, PT and MT (11.7%). Activity decreased significantly in TxT, HS, both polytrauma and MT vs. Ctrl/Sham. PT-groups and MT had significantly decreased activity vs. bsTT, Lap or Fx. MT had significantly lower pCO2vs. Ctrl/Sham, Lap or bsTT. Transaminases increased significantly in PT-groups and MT vs. Ctrl, Sham or monotrauma. Traumatic injury pattern is of comparable relevance as injury severity for experimental multiple or (poly)trauma modeling.
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Eschbach D, Horst K, Sassen M, Andruszkow J, Mohr J, Debus F, Vogt N, Steinfeldt T, Hildebrand F, Schöller K, Uhl E, Wulf H, Ruchholtz S, Pape H, Frink M. Hypothermia does not influence liver damage and function in a porcine polytrauma model. Technol Health Care 2018; 26:209-221. [PMID: 28968251 DOI: 10.3233/thc-171043] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Previous studies revealed evidence that induced hypothermia attenuates ischemic organ injuries after severe trauma. In the present study, the effect of hypothermia on liver damage was investigated in a porcine long term model of multi-system injury, consisting of blunt chest trauma, penetrating abdominal trauma, musculoskeletal injury, and hemorrhagic shockMETHODS: In 30 pigs, a standardized polytrauma including blunt chest trauma, penetrating abdominal trauma, musculoskeletal injury, and hemorrhagic shock of 45% of total blood volume was induced. Following trauma, hypothermia of 33∘C was induced for 12 h and intensive care treatment was evaluated for 48 h. As outcome parameters, we assessed liver function and serum transaminase levels as well as a histopathological analysis of tissue samples. A further 10 animals served as controls. RESULTS Serum transaminase levels were increased at the end of the observation period following hypothermia without reaching statistical significance compared to normothermic groups. Liver function was preserved (p⩽ 0.05) after the rewarming period in hypothermic animals but showed no difference at the end of the observation period. In H&E staining, cell death was slightly increased hypothermic animals and caspase-3 staining displayed tendency towards more apoptosis in hypothermic group as well. CONCLUSIONS Induction of hypothermia could not significantly improve hepatic damage during the first 48 h following major trauma. Further studies focusing on multi-organ failure including a longer observation period are required to illuminate the impact of hypothermia on hepatic function in multiple trauma patients.
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Affiliation(s)
- D Eschbach
- Center for Orthopedics and Trauma Surgery, University Hospital Giessen and Marburg, Marburg, Germany
| | - K Horst
- Trauma Department, University of Aachen, Aachen, Germany
| | - M Sassen
- Department of Anesthesiology and Critical Care, University Hospital Giessen and Marburg, Marburg, Germany
| | - J Andruszkow
- Institute of Pathology, University of Aachen, Aachen, Germany
| | - J Mohr
- Department of Trauma Surgery, University of Magdeburg, Magdeburg, Germany
| | - F Debus
- Center for Orthopedics and Trauma Surgery, University Hospital Giessen and Marburg, Marburg, Germany
| | - N Vogt
- Department of Neurosurgery, University Hospital Giessen and Marburg, Giessen, Germany
| | - T Steinfeldt
- Department of Anesthesiology and Critical Care, Diakonie-Klinikum Schwäbisch Hall, Germany
| | - F Hildebrand
- Trauma Department, University of Aachen, Aachen, Germany
| | - K Schöller
- Department of Neurosurgery, University Hospital Giessen and Marburg, Giessen, Germany
| | - E Uhl
- Department of Neurosurgery, University Hospital Giessen and Marburg, Giessen, Germany
| | - H Wulf
- Department of Anesthesiology and Critical Care, University Hospital Giessen and Marburg, Marburg, Germany
| | - S Ruchholtz
- Center for Orthopedics and Trauma Surgery, University Hospital Giessen and Marburg, Marburg, Germany
| | - H Pape
- Department of Trauma, University of Zurich, Zurich, Switzerland
| | - M Frink
- Center for Orthopedics and Trauma Surgery, University Hospital Giessen and Marburg, Marburg, Germany
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Experimental Study of Thoracoabdominal Injuries Suffered from Caudocephalad Impacts Using Pigs. Appl Bionics Biomech 2018; 2018:2321053. [PMID: 29861783 PMCID: PMC5971294 DOI: 10.1155/2018/2321053] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2017] [Revised: 02/26/2018] [Accepted: 03/12/2018] [Indexed: 11/17/2022] Open
Abstract
To know the caudocephalad impact- (CCI-) induced injuries more clearly, 21 adult minipigs, randomly divided into three groups: control group (n = 3), group I (n = 9), and group II (n = 9), were used to perform the CCI experiments on a modified deceleration sled. Configured impact velocity was 0 m/s in the control group, 8 m/s in group I, and 11 m/s in group II. The kinematics and mechanical responses of the subjects were recorded and investigated. The functional change examination and the autopsies were carried out, with which the injuries were evaluated from the Abbreviated Injury Scale (AIS) and the Injury Severity Score (ISS). The subjects in group I and group II experienced the caudocephalad loading at the peak pelvic accelerations of 108.92 ± 58.87 g and 139.13 g ± 78.54 g, with the peak abdomen pressures, 41.24 ± 16.89 kPa and 63.61 ± 65.83 kPa, respectively. The injuries of the spleen, lung, heart, and spine were detected frequently among the tested subjects. The maximal AIS (MAIS) of chest injuries was 4 in group I and 5 in group II, while both the MAIS of abdomen injuries in group I and group II were 5. The ISS in group II was 52.71 ± 6.13, significantly higher than in group I, 26.67 ± 5.02 (p < 0.05). The thoracoabdomen CCI injuries and the mechanical response addressed presently may be useful to conduct both the prevention studies against military or civilian injuries.
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Wu XJ, Liu HM, Song XM, Zhao B, Leng Y, Wang EY, Zhan LY, Meng QT, Xia ZY. Penehyclidine hydrochloride inhibits TLR4 signaling and inflammation, and attenuates blunt chest trauma and hemorrhagic shock-induced acute lung injury in rats. Mol Med Rep 2018; 17:6327-6336. [PMID: 29488614 PMCID: PMC5928610 DOI: 10.3892/mmr.2018.8644] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2017] [Accepted: 01/11/2018] [Indexed: 12/12/2022] Open
Abstract
Blunt chest trauma with hemorrhagic shock (THS) frequently induces pulmonary inflammation that leads to acute lung injury (ALI). Penehyclidine hydrochloride (PHC) possesses anti‑inflammatory properties that may attenuate the systemic inflammatory response. The present study aimed to evaluate the molecular mechanism of PHC in modifying THS‑induced ALI in rats. Rats underwent either THS or a sham procedure. At 6 h subsequent to blunt chest trauma, arterial blood was drawn for blood gas and pro‑inflammatory factors analyses, and lung tissue samples were collected to examine pulmonary histopathological alterations, the wet/dry weight ratio, myeloperoxidase activity, and the protein expression levels of Toll-like receptor 4 (TLR4), phosphorylated (p‑)p38 mitogen‑activated protein kinase (MAPK), nuclear factor (NF)‑κB and activator protein‑1 (AP‑1). THS caused significant reductions in heart rate and mean arterial blood pressure, and was associated with significant increases in tumor necrosis factor‑α, interleukin (IL)‑6, IL‑1β, p‑p38MAPK, NF‑κB and AP‑1 activation, in addition to TLR4 expression, in the lung. PHC effectively attenuated THS‑induced ALI, and inhibited TLR4 expression, reduced the activation of p‑p38MAPK, NF‑κB and AP‑1, and downregulated the expression of pro‑inflammatory mediators. In conclusion, the results of the present study demonstrated that PHC may exert an anti‑inflammatory effect and attenuate THS‑induced ALI by inhibiting the TLR4 signaling pathway. These preclinical findings may offer a novel therapeutic strategy to restrict TLR4 overactivation in ALI.
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Affiliation(s)
- Xiao-Jing Wu
- Department of Anesthesiology, Renmin Hospital of Wuhan University, Wuhan, Hubei 430060, P.R. China
| | - Hui-Min Liu
- Department of Anesthesiology, Renmin Hospital of Wuhan University, Wuhan, Hubei 430060, P.R. China
| | - Xue-Min Song
- Department of Anesthesiology and Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan, Hubei 430071, P.R. China
| | - Bo Zhao
- Department of Anesthesiology, Renmin Hospital of Wuhan University, Wuhan, Hubei 430060, P.R. China
| | - Yan Leng
- Department of Anesthesiology, Renmin Hospital of Wuhan University, Wuhan, Hubei 430060, P.R. China
| | - E-You Wang
- Department of Anesthesiology, Renmin Hospital of Wuhan University, Wuhan, Hubei 430060, P.R. China
| | - Li-Ying Zhan
- Department of Anesthesiology, Renmin Hospital of Wuhan University, Wuhan, Hubei 430060, P.R. China
| | - Qing-Tao Meng
- Department of Anesthesiology, Renmin Hospital of Wuhan University, Wuhan, Hubei 430060, P.R. China
| | - Zhong-Yuan Xia
- Department of Anesthesiology, Renmin Hospital of Wuhan University, Wuhan, Hubei 430060, P.R. China
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Modeling Acute Traumatic Hemorrhagic Shock Injury: Challenges and Guidelines for Preclinical Studies. Shock 2017; 48:610-623. [DOI: 10.1097/shk.0000000000000901] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
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Wagner N, Franz N, Dieteren S, Perl M, Mörs K, Marzi I, Relja B. Acute Alcohol Binge Deteriorates Metabolic and Respiratory Compensation Capability After Blunt Chest Trauma Followed by Hemorrhagic Shock-A New Research Model. Alcohol Clin Exp Res 2017; 41:1559-1567. [PMID: 28715125 DOI: 10.1111/acer.13446] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2017] [Accepted: 07/07/2017] [Indexed: 12/20/2022]
Abstract
BACKGROUND The clinical relevance of blunt (thoracic) chest trauma (TxT) and hemorrhagic shock is indisputable due to the high prevalence of this injury type, as well as its close association with mortality and/or preventable deaths. Furthermore, there is an ongoing discussion about the influence of alcohol in trauma patients. Thus, we established a model of TxT followed by hemorrhagic shock with resuscitation (H/R) in alcohol-intoxicated rats. METHODS Depending on group allocation, 12 (subacute) or 2 (acute) hours before experimentation, the animals received a single oral dose of alcohol (ethanol [EtOH]) or saline (NaCl) followed by TxT, hemorrhagic shock (35 ± 3 mm Hg), and resuscitation (TxT + H/R). Arterial blood gas analyses and continuous monitoring of blood pressure were performed during the experimentation period. Survival during the experimentation procedure was determined. RESULTS Subacute and acute EtOH group exhibited lower baseline mean arterial blood pressure values compared with the corresponding NaCl group, respectively. Both EtOH groups showed lower maximal bleed-out volume, which was necessary to induce hemorrhagic shock compared to NaCl groups, and the recovery during the resuscitation period was attenuated. During the experimentation in all groups, a trend to acidic pH was observed. Acute EtOH group showed lowest pH values compared to all other groups. Higher pCO2 values were observed in both EtOH groups. All groups developed negative base excess and decreasing HCO3- values until the end of hemorrhagic shock and showed increasing base excess and HCO3- values during resuscitation. Significantly higher mortality rate was found in the acute EtOH group. CONCLUSIONS This study indicates that alcohol limits the metabolic and respiratory compensation capability, thereby promoting mortality.
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Affiliation(s)
- Nils Wagner
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Frankfurt, Goethe-University, Frankfurt am Main, Germany
| | - Niklas Franz
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Frankfurt, Goethe-University, Frankfurt am Main, Germany
| | - Scott Dieteren
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Frankfurt, Goethe-University, Frankfurt am Main, Germany
| | - Mario Perl
- BG-Trauma Center Murnau, Murnau, Germany
| | - Katharina Mörs
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Frankfurt, Goethe-University, Frankfurt am Main, Germany
| | - Ingo Marzi
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Frankfurt, Goethe-University, Frankfurt am Main, Germany
| | - Borna Relja
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Frankfurt, Goethe-University, Frankfurt am Main, Germany
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Eschbach D, Steinfeldt T, Hildebrand F, Frink M, Schöller K, Sassen M, Wiesmann T, Debus F, Vogt N, Uhl E, Wulf H, Ruchholtz S, Pape HC, Horst K. A porcine polytrauma model with two different degrees of hemorrhagic shock: outcome related to trauma within the first 48 h. Eur J Med Res 2015; 20:73. [PMID: 26338818 PMCID: PMC4559152 DOI: 10.1186/s40001-015-0162-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2015] [Accepted: 08/11/2015] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND An animal polytrauma model was developed, including trunk and extremity injuries combined with hemorrhagic shock and a prolonged post-traumatic phase. This could be useful for the assessment of different therapeutic approaches during intensive care therapy. METHODS A standardized polytrauma including lung contusion, liver laceration and lower leg fracture was applied in 25 pigs. They underwent controlled haemorrhage either with a blood volume loss of 45 % and a median arterial pressure (MAP) <30 mmHg/90 min (group L, n = 15) or a 50 % blood loss of and an MAP <25 mmHg/120 min (group H, n = 10). Five non-traumatized pigs served as a control (group C). Subsequently, intensive care treatment was given for an observational period of 48 h. RESULTS Both trauma groups showed signs of shock and organ injury (heart rate, MAP and lactate). The frequency of cardiopulmonary resuscitation (CPR) and lung injury was directly related to the severity of the haemorrhagic shock (CPR-group L: 4 of 15 pigs, group H: 4 of 10 pigs; Respiratory failure-group L: 3 of 13, group H: 3 of 9. There was no difference in mortality between trauma groups. CONCLUSION The present data suggest that our model reflects the mortality and organ failure of polytrauma in humans during shock and the intensive care period. This suggests that the experimental protocol could be useful for the assessment of therapeutic approaches during the post-traumatic period.
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Affiliation(s)
- D Eschbach
- Center for Orthopaedics and Trauma Surgery; University Hospital Giessen and Marburg, Marburg, Germany.
| | - T Steinfeldt
- Department of Anaesthesiology and Critical Care, University of Marburg, Marburg, Germany.
| | - F Hildebrand
- Trauma Department, University of Aachen, Aachen, Germany.
| | - M Frink
- Center for Orthopaedics and Trauma Surgery; University Hospital Giessen and Marburg, Marburg, Germany.
| | - K Schöller
- Department of Neurosurgery, University of Giessen, Giessen, Germany.
| | - M Sassen
- Department of Anaesthesiology and Critical Care, University of Marburg, Marburg, Germany.
| | - T Wiesmann
- Department of Anaesthesiology and Critical Care, University of Marburg, Marburg, Germany.
| | - F Debus
- Center for Orthopaedics and Trauma Surgery; University Hospital Giessen and Marburg, Marburg, Germany.
| | - N Vogt
- Department of Neurosurgery, University of Giessen, Giessen, Germany.
| | - E Uhl
- Department of Neurosurgery, University of Giessen, Giessen, Germany.
| | - H Wulf
- Department of Anaesthesiology and Critical Care, University of Marburg, Marburg, Germany.
| | - S Ruchholtz
- Center for Orthopaedics and Trauma Surgery; University Hospital Giessen and Marburg, Marburg, Germany.
| | - H C Pape
- Trauma Department, University of Aachen, Aachen, Germany.
| | - K Horst
- Trauma Department, University of Aachen, Aachen, Germany.
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Induced Hypothermia Does Not Harm Hemodynamics after Polytrauma: A Porcine Model. Mediators Inflamm 2015; 2015:829195. [PMID: 26170533 PMCID: PMC4481088 DOI: 10.1155/2015/829195] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2014] [Revised: 05/05/2015] [Accepted: 05/05/2015] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND The deterioration of hemodynamics instantly endangers the patients' life after polytrauma. As accidental hypothermia frequently occurs in polytrauma, therapeutic hypothermia still displays an ambivalent role as the impact on the cardiopulmonary function is not yet fully understood. METHODS We have previously established a porcine polytrauma model including blunt chest trauma, penetrating abdominal trauma, and hemorrhagic shock. Therapeutic hypothermia (34°C) was induced for 3 hours. We documented cardiovascular parameters and basic respiratory parameters. Pigs were euthanized after 15.5 hours. RESULTS Our polytrauma porcine model displayed sufficient trauma impact. Resuscitation showed adequate restoration of hemodynamics. Induced hypothermia had neither harmful nor major positive effects on the animals' hemodynamics. Though heart rate significantly decreased and mixed venous oxygen saturation significantly increased during therapeutic hypothermia. Mean arterial blood pressure, central venous pressure, pulmonary arterial pressure, and wedge pressure showed no significant differences comparing normothermic trauma and hypothermic trauma pigs during hypothermia. CONCLUSIONS Induced hypothermia after polytrauma is feasible. No major harmful effects on hemodynamics were observed. Therapeutic hypothermia revealed hints for tissue protective impact. But the chosen length for therapeutic hypothermia was too short. Nevertheless, therapeutic hypothermia might be a useful tool for intensive care after polytrauma. Future studies should extend therapeutic hypothermia.
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Abstract
INTRODUCTION Lyophilization may facilitate production of a safe, portable, easily storable, and transportable source of platelets for bleeding patients. The objective of this study was to examine the impact of lyophilized human and porcine platelets in a swine liver injury model of nonsurgical hemorrhage. METHODS Anesthetized pigs (40 kg) had a controlled 35% total blood volume bleed from the right jugular vein followed by cooling to 35°C and resuscitation with Ringer's lactate to achieve a 3:1 blood withdrawal resuscitation. Through a midline laparotomy, the liver was injured with two standardized 5 × 5-cm grids with lacerations 1 cm apart and 0.5 cm deep. After 2 min of uncontrolled hemorrhage, the animals were treated with placebo (n = 5), lyophilized human (n = 5, HP), or swine platelets (n = 5, SP). At 15 min, shed blood was calculated. The animals then underwent abdominal closure. At 48 h, the animals were killed for histopathologic evaluation of the lung, kidney, and heart. RESULTS Intraoperative blood loss at 15 min was significantly higher in the HP arm (SP: 4.9 ± 2.9 mL/kg, HP: 12.3 ± 4.7 mL/kg, and control: 6.1 ± 2.5 mL/kg; P = 0.013). Mortality at 48 h was 20% in all three arms, due to uncontrolled intra-abdominal bleeding. At the time the animals were killed, SP animals had a significantly higher hematocrit (SP: 22.0% ± 3.0%, HP: 15.1% ± 4.9%, and control: 13.9% ± 0.6%; P = 0.026). No significant difference was found in platelet count (SP: 319.3 ± 62.1 × 10(3)/µL, HP:361.5 ± 133.6 × 10(3)/µL, and control: 242.7 ± 42.5 × 10(3)/µL; P = 0.259). Histopathology of kidneys, lungs, and heart demonstrated no evidence of thromboembolic complications. CONCLUSION In this swine model of liver injury, human lyophilized platelets increased intraoperative blood loss. With the use of species-specific lyophilized platelets, however, this effect was abolished, with a decrease in blood loss at 48 h after injury.
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Horst K, Hildebrand F, Pfeifer R, Hübenthal S, Almahmoud K, Sassen M, Steinfeldt T, Wulf H, Ruchholtz S, Pape HC, Eschbach D. Impact of haemorrhagic shock intensity on the dynamic of alarmins release in porcine poly-trauma animal model. Eur J Trauma Emerg Surg 2015; 42:67-75. [PMID: 26038024 DOI: 10.1007/s00068-015-0504-1] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2014] [Accepted: 02/23/2015] [Indexed: 10/23/2022]
Abstract
PURPOSE Traumatic insults result in an altered inflammatory response, in which alarmins release has a central role. The impact of haemorrhagic shock intensity on the long-term kinetics of alarmins is not yet fully elucidated. We investigated these aspects in a combined trauma (chest, abdominal, and extremities injury) porcine model with different severities and durations of haemorrhagic shock. METHODS After induction of combined trauma (tibia fracture, lung contusion, and liver laceration), haemorrhagic shock was induced at different intensities: moderate haemorrhage (MH; n = 15): mean arterial pressure (MAP) <30 ± 5 mmHg [maximum loss of total blood volume (TBVmax): 45 %] for 90 min, and severe haemorrhage (SH; n = 10): MAP <25 ± 5 mmHg (TBVmax 50 %) for 120 min. Resuscitation was performed using a standardized crystalloid infusion protocol. Animals were mechanically ventilated and underwent ICU-monitoring for 48 h (MH) and 48.5 h (SH). Blood samples were collected over the clinical time course, and systemic levels of serum alarmins [High-Mobility Group Protein B-1 (HMGB-1) and Heat Shock Protein 70 (HSP70)] were measured using an ELISA kit. RESULTS Heart rate, systemic blood pressure, lactate, and base excess were significantly altered as a function of haemorrhagic shock in both trauma groups (MH and SH). Systemic HMGB-1 levels were significantly elevated in both trauma groups when compared to the sham group. Haemorrhagic shock severity and duration were positively correlated with HMGB-1 levels and compared to baseline values, concentrations remained significantly increased in SH when compared to MH. On the other hand, we observed a significant decrease in the systemic HSP70 levels of trauma groups (MH, and SH) when compared to the sham group, which was significantly decreased compared to baseline values in SH over the entire time course. CONCLUSION Our data show that haemorrhagic shock duration and severity affect the systemic levels of HMGB-1 and HSP70. This early alarmins release after trauma can be used to guide the treatment strategies (e.g. surgical procedures) of polytrauma patients.
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Affiliation(s)
- K Horst
- Department of Orthopaedic Trauma, Harald Tscherne Research Laboratory, University Hospital Aachen, Pauwelsstrasse 30, 52074, Aachen, Germany.
| | - F Hildebrand
- Department of Orthopaedic Trauma, Harald Tscherne Research Laboratory, University Hospital Aachen, Pauwelsstrasse 30, 52074, Aachen, Germany
| | - R Pfeifer
- Department of Orthopaedic Trauma, Harald Tscherne Research Laboratory, University Hospital Aachen, Pauwelsstrasse 30, 52074, Aachen, Germany
| | - S Hübenthal
- Department of Orthopaedic Trauma, Harald Tscherne Research Laboratory, University Hospital Aachen, Pauwelsstrasse 30, 52074, Aachen, Germany
| | - K Almahmoud
- Department of Orthopaedic Trauma, Harald Tscherne Research Laboratory, University Hospital Aachen, Pauwelsstrasse 30, 52074, Aachen, Germany
| | - M Sassen
- Department of Anaesthesiology, University Hospital Marburg, Marburg, Germany
| | - T Steinfeldt
- Department of Anaesthesiology, University Hospital Marburg, Marburg, Germany
| | - H Wulf
- Department of Anaesthesiology, University Hospital Marburg, Marburg, Germany
| | - S Ruchholtz
- Department of Hand, Traumatology and Reconstructive Surgery, University Hospital Marburg, Marburg, Germany
| | - H C Pape
- Department of Orthopaedic Trauma, Harald Tscherne Research Laboratory, University Hospital Aachen, Pauwelsstrasse 30, 52074, Aachen, Germany
| | - D Eschbach
- Department of Hand, Traumatology and Reconstructive Surgery, University Hospital Marburg, Marburg, Germany
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Valparaiso AP, Vicente DA, Bograd BA, Elster EA, Davis TA. Modeling acute traumatic injury. J Surg Res 2014; 194:220-32. [PMID: 25481528 DOI: 10.1016/j.jss.2014.10.025] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2014] [Revised: 10/16/2014] [Accepted: 10/17/2014] [Indexed: 11/26/2022]
Abstract
Acute traumatic injury is a complex disease that has remained a leading cause of death, which affects all ages in our society. Direct mechanical insult to tissues may result in physiological and immunologic disturbances brought about by blood loss, coagulopathy, as well as ischemia and reperfusion insults. This inappropriate response leads to an abnormal release of endogenous mediators of inflammation that synergistically contribute to the incidence of morbidity and mortality. This aberrant activation and suppression of the immune system follows a bimodal pattern, wherein activation of the innate immune responses is followed by an anti-inflammatory response with suppression of the adaptive immunity, which can subsequently lead secondary insults and multiple organ dysfunction. Traumatic injury rodent and swine models have been used to describe many of the underlying pathologic mechanisms, which have led to an improved understanding of the morbidity and mortality associated with critically ill trauma patients. The enigmatic immunopathology of the human immunologic response after severe trauma, however, has never more been apparent and there grows a need for a clinically relevant animal model, which mimics this immune physiology to enhance the care of the most severely injured. This has necessitated preclinical studies in a more closely related model system, the nonhuman primate. In this review article, we summarize animal models of trauma that have provided insight into the clinical response and understanding of cellular mechanisms involved in the onset and progression of ischemia-reperfusion injury as well as describe future treatment options using immunomodulation-based strategies.
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Affiliation(s)
- Apple P Valparaiso
- Department of Regenerative Medicine, Naval Medical Research Center, Silver Spring, Maryland; Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Diego A Vicente
- Department of Regenerative Medicine, Naval Medical Research Center, Silver Spring, Maryland; Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland; Department of Surgery, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Benjamin A Bograd
- Department of Regenerative Medicine, Naval Medical Research Center, Silver Spring, Maryland; Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland; Department of Surgery, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Eric A Elster
- Department of Regenerative Medicine, Naval Medical Research Center, Silver Spring, Maryland; Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland; Department of Surgery, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Thomas A Davis
- Department of Regenerative Medicine, Naval Medical Research Center, Silver Spring, Maryland; Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland.
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Induced hypothermia reduces the hepatic inflammatory response in a swine multiple trauma model. J Trauma Acute Care Surg 2014; 76:1425-32. [PMID: 24854311 DOI: 10.1097/ta.0000000000000224] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Mild therapeutic hypothermia following trauma has been introduced in several studies to reduce the posttraumatic inflammation and organ injury. In this study, we analyzed the effects of induced mild hypothermia (34°C) on the inflammation of the shock organs liver and kidney. METHODS In a porcine model of multiple trauma including blunt chest trauma, liver laceration, and hemorrhagic shock followed by fluid resuscitation, the influence of induced hypothermia on hepatic and renal damage and organ-specific inflammation were evaluated. A total of 40 pigs were randomly assigned to four groups, which were sham (anesthesia only) or trauma groups receiving either hypothermia or normothermia. The parameters analyzed were laboratory parameters (aspartate transaminase [AST], lactate dehydrogenase, urea, creatinine) as well as hepatic and renal cytokine expression determined by real-time polymerase chain reaction (interleukin 6 [IL-6], IL-8). Blinded analysis of histologic changes in the liver and kidney was performed. RESULTS Fifteen and a half hours following combined trauma, hepatic cytokine expression and liver damage were significantly increased in animals with normothermia compared with the respective sham group. Hypothermia, however, resulted in a fivefold reduced hepatic expression of IL-8 (mean ± SE, 2.4 ± 1.3; p = 0.01) when compared with the normothermic trauma group (IL-8, 12.8 ± 4.7). Accordingly, granulocyte infiltration and a histologic, semiquantitative score for liver injury were significantly higher in the normothermic trauma group. Serum AST levels raised significantly after trauma and normothermia compared with the respective sham group, while AST levels showed no difference from the sham groups in the hypothermic trauma group. In contrast, neither trauma nor hypothermia influenced the expression of IL-6 and IL-8 and tissue injury in the kidney. CONCLUSION Therapeutic hypothermia seems to attenuate the hepatic inflammatory response and the associated liver injury after severe trauma. Therefore, induced hypothermia might represent a potential therapeutic strategy to avoid posttraumatic organ dysfunction.
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Hildebrand F, Radermacher P, Ruchholtz S, Huber-Lang M, Seekamp A, Flohé S, van Griensven M, Andruszkow H, Pape HC. Relevance of induced and accidental hypothermia after trauma-haemorrhage-what do we know from experimental models in pigs? Intensive Care Med Exp 2014; 2:16. [PMID: 26266916 PMCID: PMC4512998 DOI: 10.1186/2197-425x-2-16] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2013] [Accepted: 04/06/2014] [Indexed: 12/17/2022] Open
Abstract
Recent experimental research has either focused on the role of accidental hypothermia as part of the lethal triad after trauma or tried to elucidate the effects of therapeutically induced hypothermia on the posttraumatic course. Induced hypothermia seems to reduce the mortality in experimental models of trauma-haemorrhage. As potential mechanisms, a decrease of cellular metabolism, beneficial effects on haemodynamic function and an attenuation of the inflammatory response have been described. However, negative side effects of hypothermia have to be considered, such as impairment of the coagulatory function and immunosuppressive effects. Furthermore, the optimal strategy for the induction of hypothermia (magnitude, duration, timing, cooling rate, etc.) and subsequent rewarming remains unclear. Nevertheless, this piece of information is essential before considering hypothermia as a treatment strategy for severely injured patients. This review aims to elaborate the differences between accidental and induced hypothermia and to summarize the current knowledge of the potential therapeutic use of induced hypothermia suggested in porcine models of trauma-haemorrhage.
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Affiliation(s)
- Frank Hildebrand
- Department of Orthopedic Trauma and Reconstructive Surgery and Harald Tscherne Laboratory, University of Aachen, Pauwelsstraße 30, Aachen, 52074, Germany,
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Abstract
The Combat Casualty Care research programme is an integrated suite of projects designed to address Defence Medical Services' research needs for casualty care. The programme covers a broad spectrum of topics ranging from the pathophysiological and immunological impact of military relevant injuries to the effects of these disturbances on the response to early treatment. Dstl Porton Down has a long history of studying military injuries and has developed models, both in vivo and physical, to address the research needs. The work is conducted in close collaboration with clinical colleagues at the Royal Centre for Defence Medicine who have direct experience of the clinical issues faced by combat casualties and insights into the potential clinical implications of emerging strategies. This article reviews progress in research areas spanning forward resuscitation, with a particular focus on blast-related injuries, trauma coagulopathy, effects of drugs on the response to haemorrhage and deployed research. A significant 'value added' component has been the underpinning of higher degrees for seconded military clinicians at Dstl Porton Down who have made a valuable contribution to the overall programme.
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Affiliation(s)
- Emrys Kirkman
- Biomedical Sciences Department, Dstl Porton Down, Salisbury, UK
| | - S Watts
- Biomedical Sciences Department, Dstl Porton Down, Salisbury, UK
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Keibl C, Kerbl M, Schlimp CJ. Comparison of Ringer's solution with 0.4% glucose or without in intraoperative infusion regimens for the prevention of hypoglycemia in juvenile pigs. Lab Anim 2014; 48:170-6. [PMID: 24496574 DOI: 10.1177/0023677213519088] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Juvenile pigs are prone to hypoglycemia, nevertheless they are commonly used in preclinical studies. The optimal perioperative fluid management with crystalloid solutions in such settings has not yet been studied. The aim of the current study was to correlate the perioperative fluid administration of Ringer's solution, with and without the addition of a minimal amount of glucose (0.4% glucose) to the blood glucose, and the incidence of perioperative hypoglycemia in 20 juvenile pigs (31.7 ± 5.2 kg) undergoing surgery for approximately one hour. Infusion of Ringer's solution without glucose (group Ri, n = 10) led to a significant decrease of the serum blood glucose level from 105.7 ± 27.1 mg/dL at baseline compared with 87.8 ± 31.7 mg/dL post surgery. The pigs (50%) in group Ri were observed to be hypoglycemic (<72 mg/dL). The second group received Ringer's solution containing a final concentration of 0.4% glucose (group Ri-Glu, n = 10) and showed a significant increase in blood glucose level from 104.4 ± 15.8 mg/dL at baseline compared with 122.3 ± 14.3 mg/dL post surgery. No animal in group Ri-Glu was observed to be hypoglycemic. In conclusion, we showed that even minor changes in perioperative crystalloid fluid management significantly influence blood glucose levels. In order to avoid hypoglycemia in juvenile pigs we recommend adding a minimal amount of glucose (0.4% final concentration) to the Ringer's solution given perioperatively during surgery of approximately one hour.
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Affiliation(s)
- C Keibl
- Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, AUVA Research Center, Austrian Cluster for Tissue Regeneration, Vienna, Austria
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Induced hypothermia does not impair coagulation system in a swine multiple trauma model. J Trauma Acute Care Surg 2013; 74:1014-20. [PMID: 23511139 DOI: 10.1097/ta.0b013e3182826edd] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Accidental hypothermia, acidosis, and coagulopathy represent the lethal triad in severely injured patients. Therapeutic hypothermia however is commonly used in transplantations, cardiac and neurosurgical surgery, or after cardiac arrest. However, the effects of therapeutic hypothermia on the coagulation system following multiple trauma need to be elucidated. METHODS In a porcine model of multiple trauma including blunt chest injury, liver laceration, and hemorrhagic shock followed by fluid resuscitation, the influence of therapeutic hypothermia on coagulation was evaluated. A total of 40 pigs were randomly assigned to sham (only anesthesia) or trauma groups receiving either hypothermia or normothermia. Each group consisted of 10 pigs. Analyzed parameters were cell count (red blood cells, platelets), pH, prothrombin time (PT), fibrinogen concentration, and analysis with ROTEM and Multiplate. RESULTS Trauma and consecutive fluid resuscitation resulted in impaired coagulation parameters (cell count, pH, PT, fibrinogen, ROTEM, and platelet function). During hypothermia, coagulation parameters measured at 37°C, such as PT, fibrinogen, thrombelastometry measurements, and platelet function, showed no significant differences between normothermic and hypothermic animals in both trauma groups. Additional analyses of thrombelastometry at 34°C during hypothermia showed significant differences for clotting time and clot formation time but not for maximum clot firmness. We were not able to detect macroscopic or petechial bleeding in both trauma groups. CONCLUSION Based on the results of the present study we suggest that mild hypothermia can be safely performed after stabilization following major trauma. Mild hypothermia has effects on the coagulation system but does not aggravate trauma-induced coagulopathy in our model. Before hypothermic treatment can be performed in the clinical setting, additional experiments with prolonged and deeper hypothermia to exclude detrimental effects are required.
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What's new in Shock? December 2012. Shock 2012; 38:575-6. [PMID: 23160519 DOI: 10.1097/shk.0b013e318278ae5f] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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