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Lu H, Qiu Y, Sun X, Zhao Y. A nomogram for predicting short-term prognosis in severely traumatized patients with acute respiratory failure. Asian J Surg 2024:S1015-9584(24)00626-2. [PMID: 38604867 DOI: 10.1016/j.asjsur.2024.03.198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2024] [Accepted: 03/28/2024] [Indexed: 04/13/2024] Open
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2
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Combat Trauma-Related Acute Respiratory Distress Syndrome: A Scoping Review. Crit Care Explor 2022; 4:e0759. [DOI: 10.1097/cce.0000000000000759] [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] Open
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3
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Platelet Transfusion for Trauma Resuscitation. CURRENT TRAUMA REPORTS 2022. [DOI: 10.1007/s40719-022-00236-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Abstract
Purpose of Review
To review the role of platelet transfusion in resuscitation for trauma, including normal platelet function and alterations in behavior following trauma, blood product transfusion ratios and the impact of platelet transfusion on platelet function, platelet function assays, risks of platelet transfusion and considerations for platelet storage, and potential adjunct therapies and synthetic platelets.
Recent Findings
Platelets are a critical component of clot formation and breakdown following injury, and in addition to these hemostatic properties, have a complex role in vascular homeostasis, inflammation, and immune function. Evidence supports that platelets are activated following trauma with several upregulated functions, but under conditions of severe injury and shock are found to be impaired in their hemostatic behaviors. Platelets should be transfused in balanced ratios with red blood cells and plasma during initial trauma resuscitation as this portends improved outcomes including survival. Multiple coagulation assays can be used for goal-directed resuscitation for traumatic hemorrhage; however, these assays each have drawbacks in terms of their ability to measure platelet function. While resuscitation with balanced transfusion ratios is supported by the literature, platelet transfusion carries its own risks such as bacterial infection and lung injury. Platelet supply is also limited, with resource-intensive storage requirements, making exploration of longer-term storage options and novel platelet-based therapeutics attractive. Future focus on a deeper understanding of the biology of platelets following trauma, and on optimization of novel platelet-based therapeutics to maintain hemostatic effects while improving availability should be pursued.
Summary
While platelet function is altered following trauma, platelets should be transfused in balanced ratios during initial resuscitation. Severe injury and shock can impair platelet function, which can persist for several days following the initial trauma. Assays to guide resuscitation following the initial period as well as storage techniques to extend platelet shelf life are important areas of investigation.
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Abstract
Contemplating the future should be grounded in history. The rise of post-polio ICUs was inextricably related to mechanical ventilation. Critically ill patients who developed acute respiratory failure often had "congestive atelectasis" (ie, a term used to describe ARDS prior to 1967). Initial mechanical ventilation strategies for treating this condition and others inadvertently led to ventilator-induced lung injury. Both injurious ventilation and later use of overly cautious weaning practices resulted from both limited technology and understanding of ARDS and other aspects of critical illness. The resulting misperceptions, misconceptions, and missed opportunities took decades to rectify and in some instances still persist. This suggests a reluctance to acknowledge that all therapeutic strategies reflect the historical period in which they were developed and the corresponding limited understanding of ARDS pathophysiology at that time. We are at the threshold of a revolutionary moment in critical care. The confluence of enormous clinical data production, massive computing power, advances in understanding the biomolecular and genetic aspects of critical illness, and the emergence of neural networks will have enormous impact on how critical care is practiced in the decades to come. Therefore, it is imperative we understand the long-crooked path needed to reach the era of protective ventilation in order to avoid similar mistakes moving forward. The emerging era is as difficult to fathom as our current practices and technologies were to those practicing 60 years ago. This review explores the history of mechanical ventilation in treating ARDS, describes current protective ventilation strategies, and speculates how ARDS management might look 20 years from now.
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Affiliation(s)
- Richard H Kallet
- Department of Anesthesia and Perioperative Care, University of California, San Francisco at San Francisco General Hospital, San Francisco, California.
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5
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Predictors and outcomes of postoperative tracheostomy in patients undergoing acute type A aortic dissection surgery. BMC Cardiovasc Disord 2022; 22:94. [PMID: 35264113 PMCID: PMC8908588 DOI: 10.1186/s12872-022-02538-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 03/03/2022] [Indexed: 11/21/2022] Open
Abstract
Background Despite surgical advances, acute type A aortic dissection remains a life-threatening disease with high mortality and morbidity. Tracheostomy is usually used for patients who need prolonged mechanical ventilation in the intensive care unit (ICU). However, data on the risk factors for requiring tracheostomy and the impact of tracheostomy on outcomes in patients after Stanford type A acute aortic dissection surgery (AADS) are limited. Methods A retrospective single-institutional study including consecutive patients who underwent AADS between January 2016 and December 2019 was conducted. Patients who died intraoperatively were excluded. Univariate analysis and multivariate logistic regression analysis were used to identify independent risk factors for postoperative tracheostomy (POT). A nomogram to predict the probability of POT was constructed based on independent predictors and their beta-coefficients. The area under the receiver operating characteristic curve (AUC) was performed to assess the discrimination of the model. Calibration plots and the Hosmer–Lemeshow test were used to evaluate calibration. Clinical usefulness of the nomogram was assessed by decision curve analysis. Propensity score matching analysis was used to analyze the correlation between requiring tracheostomy and clinical prognosis. Results There were 492 patients included in this study for analysis, including 55 patients (11.2%) requiring tracheostomy after AADS. Compared with patients without POT, patients with POT experienced longer ICU and hospital stay and higher mortality. Age, cerebrovascular disease history, preoperative white blood cell (WBC) count and renal insufficiency, intraoperative amount of red blood cell (RBC) transfusion and platelet transfusion were identified as independent risk factors for POT. Our constructed nomogram had good discrimination with an AUC = 0.793 (0.729–0.856). Good calibration and clinical utility were observed through the calibration and decision curves, respectively. For better clinical application, we defined four intervals that stratified patients from very low to high risk for occurrence of POT. Conclusions Our study identified preoperative and intraoperative risk factors for POT and found that requiring tracheostomy was related to the poor outcomes in patients undergoing AADS. The established prediction model was validated with well predictive performance and clinical utility, and it may be useful for individual risk assessment and early clinical decision-making to reduce the incidence of tracheostomy.
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Tran A, Fernando SM, Brochard LJ, Fan E, Inaba K, Ferguson ND, Calfee CS, Burns KEA, Brodie D, McCredie VA, Kim DY, Kyeremanteng K, Lampron J, Slutsky AS, Combes A, Rochwerg B. Prognostic factors for development of acute respiratory distress syndrome following traumatic injury - a systematic review and meta-analysis. Eur Respir J 2021; 59:13993003.00857-2021. [PMID: 34625477 DOI: 10.1183/13993003.00857-2021] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 08/17/2021] [Indexed: 11/05/2022]
Abstract
PURPOSE To summarise the prognostic associations between various clinical risk factors and the development of the acute respiratory distress syndrome (ARDS) following traumatic injury. METHODS We conducted this review in accordance with the PRISMA and CHARMS guidelines. We searched six databases from inception through December 2020. We included English language studies describing the clinical risk factors associated with the development of post-traumatic ARDS, as defined by either the American-European Consensus Conference or the Berlin definition. We pooled adjusted odds ratios for prognostic factors using the random effects method. We assessed risk of bias using the QUIPS tool and certainty of findings using GRADE methodology. RESULTS We included 39 studies involving 5 350 927 patients. We identified the amount of crystalloid resuscitation as a potentially modifiable prognostic factor associated with the development of post-traumatic ARDS (adjusted odds ratio [aOR] 1.19 for each additional liter of crystalloid administered within first 6 h after injury, 95% CI 1.15 to 1.24, high certainty). Non-modifiable prognostic factors with a moderate or high certainty of association with post-traumatic ARDS included increasing age, non-Hispanic white race, blunt mechanism of injury, presence of head injury, pulmonary contusion, or rib fracture; and increasing chest injury severity. CONCLUSION We identified one important modifiable factor, the amount of crystalloid resuscitation within the first 24 h of injury, and several non-modifiable factors associated with development of post-traumatic ARDS. This information should support the judicious use of crystalloid resuscitation in trauma patients and may inform the development of a risk-stratification tools.
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Affiliation(s)
- Alexandre Tran
- Department of Surgery, University of Ottawa, Ottawa, ON, Canada .,School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada.,Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Shannon M Fernando
- Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada.,Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Laurent J Brochard
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.,Keenan Research Centre for Biomedical Science, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.,Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.,Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada
| | - Kenji Inaba
- Division of Acute Care Surgery, Department of Surgery, University of Southern California, Los Angeles, CA, USA
| | - Niall D Ferguson
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.,Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.,Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada
| | - Carolyn S Calfee
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Karen E A Burns
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.,Keenan Research Centre for Biomedical Science, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada.,Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Daniel Brodie
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY, USA.,Center for Acute Respiratory Failure, New York-Presbyterian Hospital, New York, NY, USA
| | - Victoria A McCredie
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.,Krembil Research Institute, Toronto Western Hospital, University Health Network, Toronto, ON, Canada
| | - Dennis Y Kim
- Department of Surgery, University of California Los Angeles, Los Angeles, CA, USA
| | - Kwadwo Kyeremanteng
- Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | | | - Arthur S Slutsky
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.,Keenan Research Centre for Biomedical Science, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada
| | - Alain Combes
- Institute of Cardiometabolism and Nutrition, Sorbonne Université, INSERM Unite Mixte de Recherche (UMRS) 1166, Paris, France.,Service de Médecine Intensive-Réanimation, Institut de Cardiologie, Assistance Publique-Hôpitaux de Paris (APHP), Hôpital Pitié-Salpêtrière, Paris, France
| | - Bram Rochwerg
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada.,Department of Medicine, Division of Critical Care, McMaster University, Hamilton, ON, Canada
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Cheng Q, Lai X, Yang L, Yang H, Luo Y. Serum CD5L predicts acute lung parenchymal injury and acute respiratory distress syndrome in trauma patients. Medicine (Baltimore) 2021; 100:e27219. [PMID: 34596119 PMCID: PMC8483880 DOI: 10.1097/md.0000000000027219] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 08/26/2021] [Indexed: 01/05/2023] Open
Abstract
Cluster of differentiation 5 antigen-like (CD5L), derived from alveolar epithelial cells partly, is a secreted protein. It is shown that CD5L is associated with lung inflammation and systemic inflammatory diseases, but the relationship between CD5L and trauma-related acute lung parenchymal injury (PLI), acute lung injury or acute respiratory distress syndrome (ARDS) is unclear. This study aims to explore the value of serum CD5L levels in predicting trauma-associated PLI/ARDS and its potential clinical significance.This is a prospective observational study, and a total of 127 trauma patients were recruited from the emergency department (ED), and among them, 81 suffered from PLI/ARDS within 24 hours after trauma, and 46 suffered from trauma without PLI/ARDS. Fifty healthy subjects from the medical examination center were also recruited as controls for comparison. The serum CD5L level was measured within 24 hours of admission. The receiver operating characteristic analysis and logistic regression analysis were used to identify the correlation between high CD5L and trauma associated-PLI/ARDS within 24 hours following trauma.The trauma associated-PLI/ARDS subjects showed a significantly higher level of serum CD5L on emergency department admission within 24 hours after trauma compared with its level in non-trauma associated-PLI/ARDS subjects and healthy subjects. The initial CD5L concentration higher than 150.3 ng/mL was identified as indicating a high risk of PLI/ARDS within 24 hours following trauma (95% confidence interval: 0.674-0.878; P < .001). Moreover, CD5L was an independent risk factor for trauma associated-PLI/ARDS within 24 hours following trauma.CD5L could predict PLI/ARDS within 24 hours following trauma.
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Affiliation(s)
- Qian Cheng
- Department of Laboratory Medicine, The First Affiliated Hospital of Chongqing Medical University, No. 1 Friendship Road, Yuzhong District, Chongqing, China
| | - Xiaofei Lai
- Department of Laboratory Medicine, The First Affiliated Hospital of Chongqing Medical University, No. 1 Friendship Road, Yuzhong District, Chongqing, China
| | - Liping Yang
- Department of Laboratory Medicine, Guangyuan Central Hospital, No. 16 Jingxiangzi Road, Lizhou District, Guangyuan City, Sichuan Province, China
| | - Huiqing Yang
- Department of Laboratory Medicine, The First Affiliated Hospital of Chongqing Medical University, No. 1 Friendship Road, Yuzhong District, Chongqing, China
| | - Yan Luo
- Department of Laboratory Medicine, The First Affiliated Hospital of Chongqing Medical University, No. 1 Friendship Road, Yuzhong District, Chongqing, China
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Kasotakis G, Stanfield B, Haines K, Vatsaas C, Alger A, Vaslef SN, Brooks K, Agarwal S. Acute Respiratory Distress Syndrome (ARDS) after trauma: Improving incidence, but increasing mortality. J Crit Care 2021; 64:213-218. [PMID: 34022661 DOI: 10.1016/j.jcrc.2021.05.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2020] [Revised: 05/04/2021] [Accepted: 05/05/2021] [Indexed: 01/24/2023]
Abstract
PURPOSE Acute Respiratory Distress Syndrome (ARDS) is an infrequent, yet morbid inflammatory complication in injury victims. With the current project we sought to estimate trends in incidence, determine outcomes, and identify risk factors for ARDS and related mortality. MATERIALS & METHODS The national Trauma Quality Improvement Program dataset (2010-2014) was queried. Demographics, injury characteristics and outcomes were compared between patients who developed ARDS and those who did not. Logistic regression models were fitted for the development of ARDS and mortality respectively, adjusting for relevant confounders. RESULTS In the studied 808,195 TQIP patients, incidence of ARDS decreased over the study years (3-1.1%, p < 0.001), but related mortality increased (18.-21%, p = 0.001). ARDS patients spent an additional 14.7 ± 10.3 days in the hospital, 9.7 ± 7.9 in the ICU, and 6.6 ± 9.4 on mechanical ventilation (all p < 0.001). Older age, male gender, African American race increased risk for ARDS. Age, male gender, lower GCS and higher ISS also increased mortality risk among ARDS patients. Several pre-existing comorbidities including chronic alcohol use, diabetes, smoking, and respiratory disease also increased risk. CONCLUSION Although the incidence of ARDS after trauma appears to be declining, mortality is on the rise.
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Affiliation(s)
- George Kasotakis
- Department of Surgery, Duke University School of Medicine, United States of America.
| | - Brent Stanfield
- Department of Surgery, Duke University School of Medicine, United States of America.
| | - Krista Haines
- Department of Surgery, Duke University School of Medicine, United States of America.
| | - Cory Vatsaas
- Department of Surgery, Duke University School of Medicine, United States of America.
| | - Amy Alger
- Department of Surgery, Duke University School of Medicine, United States of America.
| | - Steven N Vaslef
- Department of Surgery, Duke University School of Medicine, United States of America.
| | - Kelli Brooks
- Department of Surgery, Duke University School of Medicine, United States of America.
| | - Suresh Agarwal
- Department of Surgery, Duke University School of Medicine, United States of America.
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Pritts TA. Trauma, Metabolomics, Outcomes, and Secrets of the Sphinx. J Am Coll Surg 2021; 232:797-798. [PMID: 33896480 DOI: 10.1016/j.jamcollsurg.2021.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 02/09/2021] [Indexed: 10/21/2022]
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10
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Varipapa RJ, DiGiacomo E, Jamieson DB, Desale S, Sonti R. Fluid Balance Predicts Need for Intubation in Subjects With Respiratory Failure Initiated on High-Flow Nasal Cannula. Respir Care 2021; 66:566-572. [PMID: 33077679 PMCID: PMC9993983 DOI: 10.4187/respcare.07688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND High-flow nasal cannula (HFNC) has gained widespread use for acute hypoxemic respiratory failure on the basis of recent publications that demonstrated fewer intubations and perhaps lower mortality in certain situations. However, a subset of patients initiated on HFNC for respiratory failure ultimately do require intubation. Our goal was to identify patient-level features predictive of this outcome. METHODS This was a retrospective cohort study of subjects with hypoxemic respiratory failure treated with HFNC. Individuals were described as having succeeded (if weaned from HFNC) or failed (if they required intubation). A variety of easily measurable variables were evaluated for their ability to predict intubation risk, analyzed via a multivariate logistic regression model. RESULTS Of a total of 74 subjects, 42 succeeded and 32 failed. The mean ± SD net fluid balance in the first 24 h after HFNC initiation was significantly lower in the success group versus the failure group (-33 ± 80 mL/h vs 72 ± 117 mL/h; P < .01). An adjusted model found only fluid balance and the previously described respiratory rate (breathing frequency [f]) to oxygenation (ROX) index ([[Formula: see text]/[Formula: see text]]/f) at 12 h as significant predictors of successful weaning (negative fluid balance adjusted odds ratio 0.77 [95% CI 0.62-0.96] for -10 mL/h increments [P = .02]; ROX adjusted OR 1.72 [1.15-2.57], P < .01). CONCLUSIONS A negative fluid balance while on HFNC discriminated well between those who required intubation versus those who were successfully weaned.
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Affiliation(s)
- Robert J Varipapa
- Division of Pulmonary, Critical Care and Sleep Medicine, Medstar Georgetown University Hospital, Washington DC
| | - Erik DiGiacomo
- Division of Pulmonary, Critical Care and Sleep Medicine, Medstar Georgetown University Hospital, Washington DC
| | - Daniel B Jamieson
- Division of Pulmonary, Critical Care and Sleep Medicine, Medstar Georgetown University Hospital, Washington DC
| | - Sameer Desale
- Division of Pulmonary, Critical Care and Sleep Medicine, Medstar Georgetown University Hospital, Washington DC
| | - Rajiv Sonti
- Division of Pulmonary, Critical Care and Sleep Medicine, Medstar Georgetown University Hospital, Washington DC.
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Walsh SA, Hoyt BW, Rowe CJ, Dey D, Davis TA. Alarming Cargo: The Role of Exosomes in Trauma-Induced Inflammation. Biomolecules 2021; 11:biom11040522. [PMID: 33807302 PMCID: PMC8065643 DOI: 10.3390/biom11040522] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 03/26/2021] [Accepted: 03/29/2021] [Indexed: 12/11/2022] Open
Abstract
Severe polytraumatic injury initiates a robust immune response. Broad immune dysfunction in patients with such injuries has been well-documented; however, early biomarkers of immune dysfunction post-injury, which are critical for comprehensive intervention and can predict the clinical course of patients, have not been reported. Current circulating markers such as IL-6 and IL-10 are broad, non-specific, and lag behind the clinical course of patients. General blockade of the inflammatory response is detrimental to patients, as a certain degree of regulated inflammation is critical and necessary following trauma. Exosomes, small membrane-bound extracellular vesicles, found in a variety of biofluids, carry within them a complex functional cargo, comprised of coding and non-coding RNAs, proteins, and metabolites. Composition of circulating exosomal cargo is modulated by changes in the intra- and extracellular microenvironment, thereby serving as a homeostasis sensor. With its extensively documented involvement in immune regulation in multiple pathologies, study of exosomal cargo in polytrauma patients can provide critical insights on trauma-specific, temporal immune dysregulation, with tremendous potential to serve as unique biomarkers and therapeutic targets for timely and precise intervention.
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Affiliation(s)
- Sarah A. Walsh
- USU Walter Reed Surgery, Uniformed Services University, Bethesda, MD 20814, USA; (S.A.W.); (B.W.H.); (C.J.R.); (D.D.)
| | - Benjamin W. Hoyt
- USU Walter Reed Surgery, Uniformed Services University, Bethesda, MD 20814, USA; (S.A.W.); (B.W.H.); (C.J.R.); (D.D.)
| | - Cassie J. Rowe
- USU Walter Reed Surgery, Uniformed Services University, Bethesda, MD 20814, USA; (S.A.W.); (B.W.H.); (C.J.R.); (D.D.)
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD 20817, USA
| | - Devaveena Dey
- USU Walter Reed Surgery, Uniformed Services University, Bethesda, MD 20814, USA; (S.A.W.); (B.W.H.); (C.J.R.); (D.D.)
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD 20817, USA
| | - Thomas A. Davis
- USU Walter Reed Surgery, Uniformed Services University, Bethesda, MD 20814, USA; (S.A.W.); (B.W.H.); (C.J.R.); (D.D.)
- Correspondence:
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Natural and engineered chemokine (C-X-C motif) receptor 4 agonists prevent acute respiratory distress syndrome after lung ischemia-reperfusion injury and hemorrhage. Sci Rep 2020; 10:11359. [PMID: 32647374 PMCID: PMC7347544 DOI: 10.1038/s41598-020-68425-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Accepted: 06/24/2020] [Indexed: 12/31/2022] Open
Abstract
We compared therapeutic properties of natural and engineered chemokine (C-X-C motif) receptor 4 (CXCR4) agonists in a rat acute respiratory distress syndrome (ARDS) model utilizing the PaO2/FiO2-ratio as a clinically relevant primary outcome criterion. Ventilated rats underwent unilateral lung ischemia from t = 0–70 min plus hemorrhage to a mean arterial blood pressure (MAP) of 30 mmHg from t = 40–70 min, followed by reperfusion/fluid resuscitation until t = 300 min. Natural CXCR4 agonists (CXCL12, ubiquitin) and engineered CXCL12 variants (CXCL121, CXCL22, CXCL12K27A/R41A/R47A, CXCL12 (3–68)) were administered within 5 min of fluid resuscitation. Animals treated with vehicle or CXCL12 (3–68) reached criteria for mild and moderate ARDS between t = 90–120 min and t = 120–180 min, respectively, and remained in moderate ARDS until t = 300 min. Ubiquitin, CXCL12, CXCL121 and CXCL122 prevented ARDS development. Potencies of CXCL12/CXCL121/CXCL122 were higher than the potency of ubiquitin. CXCL12K27A/R41A/R47A was inefficacious. CXCL121 > CXCL12 stabilized MAP and reduced fluid requirements. CXCR4 agonists at doses that preserved lung function reduced histological injury of the post-ischemic lung and reduced mortality from 55 to 9%. Our findings suggest that CXCR4 protein agonists prevent development of ARDS and reduce mortality in a rat model, and that development of new engineered protein therapeutics with improved pharmacological properties for ARDS is possible.
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13
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Pape HC, Halvachizadeh S, Leenen L, Velmahos GD, Buckley R, Giannoudis PV. Timing of major fracture care in polytrauma patients - An update on principles, parameters and strategies for 2020. Injury 2019; 50:1656-1670. [PMID: 31558277 DOI: 10.1016/j.injury.2019.09.021] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES Sustained changes in resuscitation and transfusion management have been observed since the turn of the millennium, along with an ongoing discussion of surgical management strategies. The aims of this study are threefold: a) to evaluate the objective changes in resuscitation and mass transfusion protocols undertaken in major level I trauma centers; b) to summarize the improvements in diagnostic options for early risk profiling in multiply injured patients and c) to assess the improvements in surgical treatment for acute major fractures in the multiply injured patient. METHODS I. A systematic review of the literature (comprehensive search of the MEDLINE, Embase, PubMed, and Cochrane Central Register of Controlled Trials databases) and a concomitant data base (from a single Level I center) analysis were performed. Two authors independently extracted data using a pre-designed form. A pooled analysis was performed to determine the changes in the management of polytraumatized patients after the change of the millennium. II. A data base from a level I trauma center was utilized to test any effects of treatment changes on outcome. INCLUSION CRITERIA adult patients, ISS > 16, admission < less than 24 h post trauma. Exclusion: Oncological diseases, genetic disorders that affect the musculoskeletal system. Parameters evaluated were mortality, ICU stay, ICU complications (Sepsis, Pneumonia, Multiple organ failure). RESULTS I. From the electronic databases, 5141 articles were deemed to be relevant. 169 articles met the inclusion criteria and a manual review of reference lists of key articles identified an additional 22 articles. II. Out of 3668 patients, 2694 (73.4%) were male, the mean ISS was 28.2 (SD 15.1), mean NISS was 37.2 points (SD 17.4 points) and the average length of stay was 17.0 days (SD 18.7 days) with a mean length of ICU stay of 8.2 days (SD 10.5 days), and a mean ventilation time of 5.1 days (SD 8.1 days). Both surgical management and nonsurgical strategies have changed over time. Damage control resuscitation, dynamic analyses of coagulopathy and lactate clearance proved to sharpen the view of the worsening trauma patient and facilitated the prevention of further complications. The subsequent surgical care has become safer and more balanced, avoiding overzealous initial surgeries, while performing early fixation, when patients are physiologically stable or rapidly improving. Severe chest trauma and soft tissue injuries require further evaluation. CONCLUSIONS Multiple changes in management (resuscitation, transfusion protocols and balanced surgical care) have taken place. Moreover, improvement in mortality rates and complications associated with several factors were also observed. These findings support the view that the management of polytrauma patients has been substantially improved over the past 3 decades.
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Affiliation(s)
- H-C Pape
- Department of Trauma, University Hospital Zurich, University of Zurich, Raemistrasse 100, 8091, Zurich, Switzerland.
| | - S Halvachizadeh
- Department of Trauma, University Hospital Zurich, University of Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - L Leenen
- Department of Trauma, University Medical Centre Utrecht, Suite G04.228, Heidelberglaan 100, 3585 GA, Utrecht, the Netherlands.
| | - G D Velmahos
- Dept. of Trauma, Emergency Surgery and Critical Care, Harvard University, Mass. General Hospital, 55 Fruit St., Boston, MA, 02114, USA
| | - R Buckley
- Section of Orthopedic Trauma, University of Calgary, Foothills Medical Center, 0490 McCaig Tower, 3134 University Drive NW Calgary, Alberta, T2N 5A1, Canada.
| | - P V Giannoudis
- Trauma & Orthopaedic Surgery, Clarendon Wing, A Floor, Great George Street, Leeds General Infirmary University Hospital, University of Leeds, Leeds, LS1 3EX, UK.
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