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Tran Z, Assali MA, Shin B, Benharash P, Mukherjee K. Trends and clinical outcomes of abdominal compartment syndrome among intensive care hospitalizations. Surgery 2024; 176:485-491. [PMID: 38806334 DOI: 10.1016/j.surg.2024.04.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2024] [Revised: 03/14/2024] [Accepted: 04/08/2024] [Indexed: 05/30/2024]
Abstract
BACKGROUND Abdominal compartment syndrome has been shown to be a highly morbid condition among patients admitted to the intensive care unit. The present study sought to characterize trends as well as clinical and financial outcomes of patients with abdominal compartment syndrome. METHODS The 2010 to 2020 National Inpatient Sample was used to identify adults (≥18 years) admitted to the intensive care unit. Standard mean differences were obtained to demonstrate effect size with >0.1 denoting significance. Hospitals were divided into tertiles based on annual institutional intensive care unit admissions. Multivariable regression models were used to evaluate the association of abdominal compartment syndrome on outcomes. The primary endpoint was in-hospital mortality, while complications, costs, and length of stay were secondarily considered. RESULTS Of 11,804,585 patients, 19,644 (0.17%) developed abdominal compartment syndrome. Over the study period, the incidence of abdominal compartment syndrome (2010-0.19%, 2020-0.20%, P < .001) remained similar. Those with abdominal compartment syndrome were more commonly admitted for gastrointestinal (22.8% vs 8.4%) and cardiovascular (22.6% vs 14.9%) etiologies and were more frequently managed at urban teaching hospitals (77.7% vs 65.1%) as well as high-volume intensive care units (85.2% vs 79.1%) (all standard mean differences >0.1). After adjustment, abdominal compartment syndrome was associated with higher odds of mortality (adjusted odds ratio: 3.84, 95% confidence interval: 3.57-4.13, reference: non-abdominal compartment syndrome). Incremental length of stay (β: +5.0 days, 95% confidence interval: 4.2-5.8) and costs (β: $49.3K, 95% confidence interval: 45.3-53.4) were significantly higher in abdominal compartment syndrome compared to non-abdominal compartment syndrome. CONCLUSION Abdominal compartment syndrome, while an uncommon occurrence among intensive care unit patients, remains highly morbid with significant resource burden. Further work exploring factors to mitigate its clinical and financial burden is needed.
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Affiliation(s)
- Zachary Tran
- Department of Surgery, Loma Linda University Health, Loma Linda, CA; Cardiovascular Outcomes Research Laboratories, Division of Cardiac Surgery, Department of Surgery, University of California, Los Angeles, CA
| | - Marc Abou Assali
- Department of Surgery, Loma Linda University Health, Loma Linda, CA
| | - Brandon Shin
- Department of Surgery, Loma Linda University Health, Loma Linda, CA
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories, Division of Cardiac Surgery, Department of Surgery, University of California, Los Angeles, CA
| | - Kaushik Mukherjee
- Department of Surgery, Loma Linda University Health, Loma Linda, CA.
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Yang VB, Shu H, Shah MM, Zhao X, Muquit ST, Greenberg M, Whitman G, Cho SM, Kim BS, Shafiq B. Atraumatic Polycompartment Syndrome Secondary to Cardiogenic Shock: A Case Report. Cureus 2023; 15:e44519. [PMID: 37790054 PMCID: PMC10544627 DOI: 10.7759/cureus.44519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/31/2023] [Indexed: 10/05/2023] Open
Abstract
We report the case of a 53-year-old male who developed polycompartment syndrome (PCS) secondary to cardiogenic shock. After suffering a cardiac arrest, a self-perpetuating cycle of intra-abdominal hypertension (IAH) and vital organ damage led to abdominal compartment syndrome (AbCS), which then contributed to the precipitation of extremity compartment syndrome (CS) in bilateral thighs, legs, forearms, and hands. This report is followed by a review of the literature regarding the pathophysiology of this rare sequela of cardiogenic shock. While the progression from cardiogenic shock to AbCS and ultimately to PCS has been hypothesized, no prior case reports demonstrate this. Furthermore, this case suggests more generally that IAH may be a risk factor for extremity CS. Future studies should examine the potential interplay between IAH and extremity CS in patients at risk, such as polytrauma patients with tibial fractures.
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Affiliation(s)
- Victor B Yang
- Critical Care, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Henry Shu
- Orthopaedic Surgery, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Manuj M Shah
- General Surgery, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Xiyu Zhao
- Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Siam T Muquit
- Cardiology, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Marc Greenberg
- Orthopaedic Surgery, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Glenn Whitman
- Cardiac Surgery, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Sung-Min Cho
- Neurology, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Bo Soo Kim
- Critical Care, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Babar Shafiq
- Orthopaedic Surgery, Johns Hopkins University School of Medicine, Baltimore, USA
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3
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Norepinephrine and Vasopressin in Hemorrhagic Shock: A Focus on Renal Hemodynamics. Int J Mol Sci 2023; 24:ijms24044103. [PMID: 36835514 PMCID: PMC9967703 DOI: 10.3390/ijms24044103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Revised: 02/01/2023] [Accepted: 02/15/2023] [Indexed: 02/22/2023] Open
Abstract
During hemorrhagic shock, blood loss causes a fall in blood pressure, decreases cardiac output, and, consequently, O2 transport. The current guidelines recommend the administration of vasopressors in addition to fluids to maintain arterial pressure when life-threatening hypotension occurs in order to prevent the risk of organ failure, especially acute kidney injury. However, different vasopressors exert variable effects on the kidney, depending on the nature and dose of the substance chosen as follows: Norepinephrine increases mean arterial pressure both via its α-1-mediated vasoconstriction leading to increased systemic vascular resistance and its β1-related increase in cardiac output. Vasopressin, through activation of V1-a receptors, induces vasoconstriction, thus increasing mean arterial pressure. In addition, these vasopressors have the following different effects on renal hemodynamics: Norepinephrine constricts both the afferent and efferent arterioles, whereas vasopressin exerts its vasoconstrictor properties mainly on the efferent arteriole. Therefore, this narrative review discusses the current knowledge of the renal hemodynamic effects of norepinephrine and vasopressin during hemorrhagic shock.
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Manole RA, Ion D, Bolocan A, Păduraru DN, Andronic O. Risk factors for abdominal compartment syndrome in trauma – A review. ROMANIAN JOURNAL OF MILITARY MEDICINE 2022. [DOI: 10.55453/rjmm.2022.125.4.3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
" Background and Aim: Abdominal compartment syndrome is a life-threatening complication that can occur in trauma patients and greatly increase their mortality. Although there is a better scientific understanding of the general phenomena involved in the pathogenesis of this complication, the particular risk factors and their implications in the trauma patient population are yet to be deciphered. Methods: The authors conducted research through 3 electronic databases (PubMed, Scopus, and ScienceDirect) using the following search formula: “(ACS OR abdominal compartment syndrome) AND (*trauma*) AND (risk factor)”. Subsequently, additional search formulas were used, including the risk factors taken into consideration (i.e. “shock”, “hypotension”, “acidosis”, “base deficit”, ”coagulopathy”, “retroperitoneal hematoma”, “HOB elevation”, “fluid resuscitation”, “damage control laparotomy”). Results: Throughout the 41 articles analyzed in this paper, 7 risk factors transcended and were further discussed: head of bed elevation/patient positioning, fluid resuscitation, the “lethal triad” of acidosis hypothermia and coagulopathy, Damage Control Laparotomy, shock/hypotension, retroperitoneal hematoma and demographics (age, gender, and race). Conclusions: To summarize, many potential risk factors were evaluated for the envisagement of the present paper, but the ones that prevailed the most were excessive fluid resuscitation, shock/hypotension, retroperitoneal hematomas, and the lethal triad. Consistent with other studies, no connection was found between age, gender, or race and the development of ACS. Further studies should focus more on the likely involvement of damage control laparotomy and patient positioning, as well as hypocalcemia, in the unfolding of ACS in trauma patients"
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Fluid Management, Intra-Abdominal Hypertension and the Abdominal Compartment Syndrome: A Narrative Review. Life (Basel) 2022; 12:life12091390. [PMID: 36143427 PMCID: PMC9502789 DOI: 10.3390/life12091390] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Revised: 08/17/2022] [Accepted: 08/25/2022] [Indexed: 11/17/2022] Open
Abstract
Background: General pathophysiological mechanisms regarding associations between fluid administration and intra-abdominal hypertension (IAH) are evident, but specific effects of type, amount, and timing of fluids are less clear. Objectives: This review aims to summarize current knowledge on associations between fluid administration and intra-abdominal pressure (IAP) and fluid management in patients at risk of intra-abdominal hypertension and abdominal compartment syndrome (ACS). Methods: We performed a structured literature search from 1950 until May 2021 to identify evidence of associations between fluid management and intra-abdominal pressure not limited to any specific study or patient population. Findings were summarized based on the following information: general concepts of fluid management, physiology of fluid movement in patients with intra-abdominal hypertension, and data on associations between fluid administration and IAH. Results: We identified three randomized controlled trials (RCTs), 38 prospective observational studies, 29 retrospective studies, 18 case reports in adults, two observational studies and 10 case reports in children, and three animal studies that addressed associations between fluid administration and IAH. Associations between fluid resuscitation and IAH were confirmed in most studies. Fluid resuscitation contributes to the development of IAH. However, patients with IAH receive more fluids to manage the effect of IAH on other organ systems, thereby causing a vicious cycle. Timing and approach to de-resuscitation are of utmost importance, but clear indicators to guide this decision-making process are lacking. In selected cases, only surgical decompression of the abdomen can stop deterioration and prevent further morbidity and mortality. Conclusions: Current evidence confirms an association between fluid resuscitation and secondary IAH, but optimal fluid management strategies for patients with IAH remain controversial.
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Bioelectrical impedance analysis-guided fluid management promotes primary fascial closure after open abdomen: a randomized controlled trial. Mil Med Res 2021; 8:36. [PMID: 34099065 PMCID: PMC8180439 DOI: 10.1186/s40779-021-00329-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Accepted: 05/27/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Fluid overload (FO) after resuscitation is frequent and contributes to adverse outcomes among postinjury open abdomen (OA) patients. Bioelectrical impedance analysis (BIA) is a promising tool for monitoring fluid status and FO. Therefore, we sought to investigate the efficacy of BIA-directed fluid resuscitation among OA patients. METHODS A pragmatic, prospective, randomized, observer-blind, single-center trial was performed for all trauma patients requiring OA between January 2013 and December 2017 to a national referral center. A total of 140 postinjury OA patients were randomly assigned in a 1:1 ratio to receive either a BIA-directed fluid resuscitation (BIA) protocol that included fluid administration with monitoring of hemodynamic parameters and different degrees of interventions to achieve a negative fluid balance targeting the hydration level (HL) measured by BIA or a traditional fluid resuscitation (TRD) in which clinicians determined the fluid resuscitation regimen according to traditional parameters during 30 days of ICU management. The primary outcome was the 30-day primary fascial closure (PFC) rate. The secondary outcomes included the time to PFC, postoperative 7-day cumulative fluid balance (CFB) and adverse events within 30 days after OA. The Kaplan-Meier method and the log-rank test were utilized for PFC after OA. A generalized linear regression model for the time to PFC and CFB was built. RESULTS A total of 134 patients completed the trial (BIA, n = 66; TRD, n = 68). The BIA patients were significantly more likely to achieve PFC than the TRD patients (83.33% vs. 55.88%, P < 0.001). In the BIA group, the time to PFC occurred earlier than that of the TRD group by an average of 3.66 days (P < 0.001). Additionally, the BIA group showed a lower postoperative 7-day CFB by an average of 6632.80 ml (P < 0.001) and fewer complications. CONCLUSION Among postinjury OA patients in the ICU, the use of BIA-guided fluid resuscitation resulted in a higher PFC rate and fewer severe complications than the traditional fluid resuscitation strategy.
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Muller CR, Courelli V, Lucas A, Williams AT, Li JB, Dos Santos F, Cuddington CT, Moses SR, Palmer AF, Kistler EB, Cabrales P. Resuscitation from hemorrhagic shock after traumatic brain injury with polymerized hemoglobin. Sci Rep 2021; 11:2509. [PMID: 33510204 PMCID: PMC7843604 DOI: 10.1038/s41598-021-81717-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Accepted: 01/07/2021] [Indexed: 11/09/2022] Open
Abstract
Traumatic brain injury (TBI) is often accompanied by hemorrhage, and treatment of hemorrhagic shock (HS) after TBI is particularly challenging because the two therapeutic treatment strategies for TBI and HS often conflict. Ischemia/reperfusion injury from HS resuscitation can be exaggerated by TBI-induced loss of autoregulation. In HS resuscitation, the goal is to restore lost blood volume, while in the treatment of TBI the priority is focused on maintenance of adequate cerebral perfusion pressure and avoidance of secondary bleeding. In this study, we investigate the responses to resuscitation from severe HS after TBI in rats, using fresh blood, polymerized human hemoglobin (PolyhHb), and lactated Ringer's (LR). Rats were subjected to TBI by pneumatic controlled cortical impact. Shortly after TBI, HS was induced by blood withdrawal to reduce mean arterial pressure (MAP) to 35-40 mmHg for 90 min before resuscitation. Resuscitation fluids were delivered to restore MAP to ~ 65 mmHg and animals were monitored for 120 min. Increased systolic blood pressure variability (SBPV) confirmed TBI-induced loss of autoregulation. MAP after resuscitation was significantly higher in the blood and PolyhHb groups compared to the LR group. Furthermore, blood and PolyhHb restored diastolic pressure, while this remained depressed for the LR group, indicating a loss of vascular tone. Lactate increased in all groups during HS, and only returned to baseline level in the blood reperfused group. The PolyhHb group possessed lower SBPV compared to LR and blood groups. Finally, sympathetic nervous system (SNS) modulation was higher for the LR group and lower for the PolyhHb group compared to the blood group after reperfusion. In conclusion, our results suggest that PolyhHb could be an alternative to blood for resuscitation from HS after TBI when blood is not available, assuming additional testing demonstrate similar favorable results. PolyhHb restored hemodynamics and oxygen delivery, without the logistical constraints of refrigerated blood.
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Affiliation(s)
- Cynthia R Muller
- Department of Bioengineering, University of California San Diego, 9500 Gilman Dr. La Jolla, San Diego, CA, 92093-0412, USA
| | - Vasiliki Courelli
- Department of Bioengineering, University of California San Diego, 9500 Gilman Dr. La Jolla, San Diego, CA, 92093-0412, USA
| | - Alfredo Lucas
- Department of Bioengineering, University of California San Diego, 9500 Gilman Dr. La Jolla, San Diego, CA, 92093-0412, USA
| | - Alexander T Williams
- Department of Bioengineering, University of California San Diego, 9500 Gilman Dr. La Jolla, San Diego, CA, 92093-0412, USA
| | - Joyce B Li
- Department of Bioengineering, University of California San Diego, 9500 Gilman Dr. La Jolla, San Diego, CA, 92093-0412, USA
| | - Fernando Dos Santos
- Department of Anesthesiology and Critical Care, University of California San Diego, San Diego, CA, USA
| | - Clayton T Cuddington
- William G. Lowrie Department of Chemical and Biomolecular Engineering, The Ohio State University, Columbus, OH, USA
| | - Savannah R Moses
- William G. Lowrie Department of Chemical and Biomolecular Engineering, The Ohio State University, Columbus, OH, USA
| | - Andre F Palmer
- William G. Lowrie Department of Chemical and Biomolecular Engineering, The Ohio State University, Columbus, OH, USA
| | - Erik B Kistler
- Department of Anesthesiology and Critical Care, University of California San Diego, San Diego, CA, USA
| | - Pedro Cabrales
- Department of Bioengineering, University of California San Diego, 9500 Gilman Dr. La Jolla, San Diego, CA, 92093-0412, USA.
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Taniguchi T, Fujimoto Y, Yawata H, Horiguchi M, An B, Takegami T, Takashina K. Renal venous congestion following hemorrhagic shock due to traumatic liver injury. CEN Case Rep 2020; 10:178-183. [PMID: 33038002 DOI: 10.1007/s13730-020-00540-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Accepted: 09/24/2020] [Indexed: 11/25/2022] Open
Abstract
A 78-year-old woman who sustained traumatic liver injury with hemorrhagic shock was hospitalized. She was admitted to the ICU after blood transfusion and emergent angiography. AKI was observed on the following day. Blood transfusion was continued because initial assessment was prerenal AKI due to hypovolemia. Despite transfusion of blood products and administration of diuretics, aggravated renal dysfunction, and low urine output continued, resulting in respiratory failure due to pulmonary edema. Renal venous congestion was suspected as the primary cause of AKI, since IVC compression from a hematoma with IVC injury was observed on CT imaging captured on admission, and renal Doppler ultrasonography demonstrated an intermittent biphasic pattern of renal venous flow. It was finally concluded that renal venous congestion resulted from IVC compression, since urine output increased remarkably after RRT without additional diuretics, and follow-up CT and renal Doppler ultrasonography revealed improvements in IVC compression and renal venous flow pattern, respectively. Renal venous congestion has been often reported to be associated with acute decompensated heart failure and, to our knowledge, this is the first report to describe trauma-induced renal venous congestion. Trauma patients are at risk for renal venous congestion due to massive blood transfusion after recovery from hemorrhagic shock; therefore, if they develop AKI that cannot be explained by other etiologies, physicians should consider the possibility of trauma-induced renal venous congestion and perform renal Doppler ultrasonography.
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Affiliation(s)
- Tomoki Taniguchi
- Emergency Department, Japanese Red Cross Kyoto Daiichi Hospital, Kyoto, Japan.
| | - Yoshihiro Fujimoto
- Emergency Department, Japanese Red Cross Kyoto Daiichi Hospital, Kyoto, Japan
| | - Hironori Yawata
- Emergency Department, Japanese Red Cross Kyoto Daiichi Hospital, Kyoto, Japan
| | - Masahito Horiguchi
- Emergency Department, Japanese Red Cross Kyoto Daiichi Hospital, Kyoto, Japan
| | - Byongmun An
- Emergency Department, Japanese Red Cross Kyoto Daiichi Hospital, Kyoto, Japan
| | - Tetsuro Takegami
- Emergency Department, Japanese Red Cross Kyoto Daiichi Hospital, Kyoto, Japan
| | - Kenichiro Takashina
- Emergency Department, Japanese Red Cross Kyoto Daiichi Hospital, Kyoto, Japan
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Nederpelt CJ, El Hechi M, Parks J, Fawley J, Mendoza AE, Saillant N, King DR, Fagenholz PJ, Velmahos GC, Kaafarani HMA. The dose-dependent relationship between blood transfusions and infections after trauma: A population-based study. J Trauma Acute Care Surg 2020; 89:51-57. [PMID: 32102046 DOI: 10.1097/ta.0000000000002637] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVE The relationship between total transfusion volume and infection in the trauma patient remains unclear, especially at lower volumes of transfusion. We sought to quantify the cumulative, independent impact of transfusion within 24 hours of admission on the risk of infection in trauma patients. METHODS Using the Trauma Quality Improvement Program 2013 to 2016 database, we included all patients who received blood transfusions in the first 4 hours. Patients who were transferred or had incomplete/wrongly coded information on transfusion volume were excluded. Patients were divided into 20 cohorts based on the total blood product volume transfused in the first 24 hours. A composite infection variable (INF) was created, including surgical site infection, ventilator-associated pneumonia, urinary tract infection, central line associated blood stream infection, and sepsis. Univariate and stepwise multivariable logistic regression analyses were performed to study the relationship between blood transfusion and INF, controlling for demographics (e.g., age, sex), comorbidities (e.g., cirrhosis, diabetes, steroid use), severity of injury (e.g., vital signs on arrival, mechanism, Injury Severity Score), and operative and angiographic interventions. RESULTS Of 1,002,595 patients, 37,568 were included. The mean age was 42 ± 18.6 years, 74.6% were males, 68% had blunt trauma, and median Injury Severity Score was 25 [17-34]. Adjusting for all available confounders, odds of INF increased incrementally from 1.00 (reference, 0-2 units) to 1.23 (95% confidence interval, 1.11-1.37) for 4 units transfused to 4.89 (95% confidence interval, 2.72-8.80) for 40 units transfused. Each additional unit increased the odds of INF by 7.6%. CONCLUSION Transfusion of the bleeding trauma patient was associated with a dose-dependent increased risk of infectious complications. Trauma surgeons and anesthesiologists should resuscitate the trauma patient until prompt hemorrhage control while avoiding overtransfusion. LEVEL OF EVIDENCE Retrospective cohort study, Therapeutic IV.
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Affiliation(s)
- Charlie J Nederpelt
- From the Division of Trauma, Emergency Surgery and Surgical Critical Care (C.J.N., M.E.H., J.P., J.F., A.E.M., N.S., D.R.K., P.J.F., G.C.V., H.M.A.K.), Massachusetts General Hospital, Boston, Massachusetts; Department of Trauma Surgery (C.J.N.), Leiden University Medical Center, Leiden, The Netherlands; Harvard Medical School (J.P., J.F., A.E.M., N.S., D.R.K., P.J.F., G.C.V., H.M.A.K.), Cambridge; and Center for Outcomes and Patient Safety in Surgery (COMPASS) (H.M.A.K.), Massachusetts General Hospital, Boston, Massachusetts
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Spahn DR, Bouillon B, Cerny V, Duranteau J, Filipescu D, Hunt BJ, Komadina R, Maegele M, Nardi G, Riddez L, Samama CM, Vincent JL, Rossaint R. The European guideline on management of major bleeding and coagulopathy following trauma: fifth edition. Crit Care 2019; 23:98. [PMID: 30917843 PMCID: PMC6436241 DOI: 10.1186/s13054-019-2347-3] [Citation(s) in RCA: 688] [Impact Index Per Article: 137.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Accepted: 02/06/2019] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Severe traumatic injury continues to present challenges to healthcare systems around the world, and post-traumatic bleeding remains a leading cause of potentially preventable death among injured patients. Now in its fifth edition, this document aims to provide guidance on the management of major bleeding and coagulopathy following traumatic injury and encourages adaptation of the guiding principles described here to individual institutional circumstances and resources. METHODS The pan-European, multidisciplinary Task Force for Advanced Bleeding Care in Trauma was founded in 2004, and the current author group included representatives of six relevant European professional societies. The group applied a structured, evidence-based consensus approach to address scientific queries that served as the basis for each recommendation and supporting rationale. Expert opinion and current clinical practice were also considered, particularly in areas in which randomised clinical trials have not or cannot be performed. Existing recommendations were re-examined and revised based on scientific evidence that has emerged since the previous edition and observed shifts in clinical practice. New recommendations were formulated to reflect current clinical concerns and areas in which new research data have been generated. RESULTS Advances in our understanding of the pathophysiology of post-traumatic coagulopathy have supported improved management strategies, including evidence that early, individualised goal-directed treatment improves the outcome of severely injured patients. The overall organisation of the current guideline has been designed to reflect the clinical decision-making process along the patient pathway in an approximate temporal sequence. Recommendations are grouped behind the rationale for key decision points, which are patient- or problem-oriented rather than related to specific treatment modalities. While these recommendations provide guidance for the diagnosis and treatment of major bleeding and coagulopathy, emerging evidence supports the author group's belief that the greatest outcome improvement can be achieved through education and the establishment of and adherence to local clinical management algorithms. CONCLUSIONS A multidisciplinary approach and adherence to evidence-based guidance are key to improving patient outcomes. If incorporated into local practice, these clinical practice guidelines have the potential to ensure a uniform standard of care across Europe and beyond and better outcomes for the severely bleeding trauma patient.
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Affiliation(s)
- Donat R. Spahn
- Institute of Anaesthesiology, University of Zurich and University Hospital Zurich, Raemistrasse 100, CH-8091 Zurich, Switzerland
| | - Bertil Bouillon
- Department of Trauma and Orthopaedic Surgery, Cologne-Merheim Medical Centre (CMMC), University of Witten/Herdecke, Ostmerheimer Strasse 200, D-51109 Cologne, Germany
| | - Vladimir Cerny
- Department of Anaesthesiology, Perioperative Medicine and Intensive Care, J.E. Purkinje University, Masaryk Hospital, Usti nad Labem, Socialni pece 3316/12A, CZ-40113 Usti nad Labem, Czech Republic
- Centre for Research and Development, University Hospital Hradec Kralove, Hradec Kralove, Czech Republic, Sokolska 581, CZ-50005 Hradec Kralove, Czech Republic
- Department of Anaesthesiology and Intensive Care Medicine, Faculty of Medicine in Hradec Kralove, Charles University, Simkova 870, CZ-50003 Hradec Kralove, Czech Republic
- Department of Anaesthesia, Pain Management and Perioperative Medicine, QE II Health Sciences Centre, Dalhousie University, Halifax, 10 West Victoria, 1276 South Park St, Halifax, NS B3H 2Y9 Canada
| | - Jacques Duranteau
- Department of Anaesthesia and Intensive Care, Hôpitaux Universitaires Paris Sud, University of Paris XI, Faculté de Médecine Paris-Sud, 78 rue du Général Leclerc, F-94275 Le Kremlin-Bicêtre Cedex, France
| | - Daniela Filipescu
- Department of Cardiac Anaesthesia and Intensive Care, C. C. Iliescu Emergency Institute of Cardiovascular Diseases, Sos Fundeni 256-258, RO-022328 Bucharest, Romania
| | - Beverley J. Hunt
- King’s College and Departments of Haematology and Pathology, Guy’s and St Thomas’ NHS Foundation Trust, Westminster Bridge Road, London, SE1 7EH UK
| | - Radko Komadina
- Department of Traumatology, General and Teaching Hospital Celje, Medical Faculty Ljubljana University, SI-3000 Celje, Slovenia
| | - Marc Maegele
- Department of Trauma and Orthopaedic Surgery, Cologne-Merheim Medical Centre (CMMC), Institute for Research in Operative Medicine (IFOM), University of Witten/Herdecke, Ostmerheimer Strasse 200, D-51109 Cologne, Germany
| | - Giuseppe Nardi
- Department of Anaesthesia and ICU, AUSL della Romagna, Infermi Hospital Rimini, Viale Settembrini, 2, I-47924 Rimini, Italy
| | - Louis Riddez
- Department of Surgery and Trauma, Karolinska University Hospital, S-171 76 Solna, Sweden
| | - Charles-Marc Samama
- Hotel-Dieu University Hospital, 1, place du Parvis de Notre-Dame, F-75181 Paris Cedex 04, France
| | - Jean-Louis Vincent
- Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Route de Lennik 808, B-1070 Brussels, Belgium
| | - Rolf Rossaint
- Department of Anaesthesiology, University Hospital Aachen, RWTH Aachen University, Pauwelsstrasse 30, D-52074 Aachen, Germany
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Richman A, Burlew CC. Lessons from Trauma Care: Abdominal Compartment Syndrome and Damage Control Laparotomy in the Patient with Gastrointestinal Disease. J Gastrointest Surg 2019; 23:417-424. [PMID: 30276590 DOI: 10.1007/s11605-018-3988-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Accepted: 09/20/2018] [Indexed: 01/31/2023]
Affiliation(s)
- Aaron Richman
- Denver Health Medical Center, University of Colorado School of Medicine, 777 Bannock Street, MC 0206, Denver, CO, 80204, USA
| | - Clay Cothren Burlew
- Denver Health Medical Center, University of Colorado School of Medicine, 777 Bannock Street, MC 0206, Denver, CO, 80204, USA.
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Gray S, Christensen M, Craft J. The gastro-renal effects of intra-abdominal hypertension: Implications for critical care nurses. Intensive Crit Care Nurs 2018; 48:69-74. [PMID: 29937073 DOI: 10.1016/j.iccn.2018.06.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Revised: 04/16/2018] [Accepted: 06/01/2018] [Indexed: 12/29/2022]
Abstract
Intra-abdominal hypertension is classified as either primary or secondary - primary occurs due to intra-abdominal or retro-peritoneal pathophysiology, whereas secondary results in alterations in capillary fluid dynamics due to factors, such as massive fluid resuscitation and generalised inflammation. The renal and gastro-intestinal effects occur early in the progression of intra-abdominal hypertension, and may lead to poor patient outcomes if not identified. As a direct response to intra-abdominal hypertension, renal function is reduced with remarkable impairment from pressures of around 10 mmHg, oliguria developing at 15 mmHg and anuria developing at 30 mmHg. Intestinal micro-circulation is significantly reduced by up to 50% with intra-abdominal pressures as low as 15 mmHg. Mucosal and submucosal tissue hypo-perfusion causes considerable damage to the intestinal cells, potentially resulting in bacterial translocation, endotoxin release, sepsis and multiple organ failure. The critical care nurse plays an important role in the early identification of intra-abdominal hypertension however, without this essential knowledge base and comprehension of intra-abdominal hypertension, clinical signs and symptoms may go unnoticed or be misinterpreted as signs of other critical illnesses.
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Affiliation(s)
- Sherree Gray
- School of Nursing, Queensland University of Technology, Caboolture Campus, Caboolture, Queensland 4510, Australia.
| | - Martin Christensen
- Centre for Applied Nursing Research (CANR), Western Sydney University, South Western Sydney Local Health District (SWSLHD), Locked Bag 7103, Liverpool, NSW 1871, Australia.
| | - Judy Craft
- School of Biomedical Sciences, Queensland University of Technology, Caboolture Campus, Caboolture, Queensland 4510, Australia.
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Crochemore T, Savioli FA. Thromboelastometry-guided hemostatic therapy for hemorrhagic shock in the postoperative period of vascular surgery: a case report. J Med Case Rep 2018; 12:153. [PMID: 29859130 PMCID: PMC5984768 DOI: 10.1186/s13256-018-1661-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Accepted: 03/19/2018] [Indexed: 12/23/2022] Open
Abstract
Background Hemorrhagic shock is a medical emergency that often complicates vascular surgery and can lead to death. Hemorrhagic shock is characterized by hypoperfusion and hemodynamic abnormalities leading to the collapse of homeostasis due to massive blood loss. Early diagnosis is critical for a favorable outcome. Thromboelastometry has been considered an effective tool for bleeding management in critically ill patients. Thromboelastometry can guide transfusion therapy quickly, reducing the need for blood products. Therefore, it could be an alternative test to guide hemostatic therapy in complex cases of hemorrhagic shock as a result of vascular surgeries. We report our successful experience with a case of hemorrhagic shock in postoperative care in vascular surgery, in which bleeding management was guided by thromboelastometry and bleeding control was achieved with hemostatic drugs and coagulation factor concentrates. Case presentation We report a case of an 82-year-old Afro-Brazilian man who presented to the intensive care unit with hemorrhagic shock in the postoperative period of vascular surgery. He underwent surgery for correction of iliac artery aneurysm with endoleak. His laboratory tests revealed severe anemia (hemoglobin 7.4 mg/dL), metabolic acidosis (bicarbonate 10 mEq/L, pH 7.11), acute kidney injury (creatinine 3.1 mg/dL), thrombocytopenia (platelets count 83 × 103/mm3), hypofibrinogenemia (70 mg/dL), international nationalized ratio 1.95, activated partial thromboplastin time 64.5 seconds, and lactate 87 mmol/L. There was active bleeding in surgical site. Bleeding management was guided by thromboelastometry. The first test showed fulminant hyperfibrinolysis, which was corrected with the administration of tranexamic acid. The second thromboelastometry test showed improvement of hyperfibrinolysis but severe hypocoagulability. Fibrinogen concentrate, platelet apheresis, cryoprecipitate, and prothrombin complex concentrate were sequentially administrated. Thromboelastometry was completely corrected after 2 hours. Arteriography to evaluate mechanical cause of bleeding was normal. No more bleeding was identified, and neither was any further transfusion needed. He was discharged from the intensive care unit from the ward 3 days after admission. Conclusions Thromboelastometry may be considered a useful, feasible and safe tool to monitor and manage coagulopathy in patients with hemorrhagic shock. Moreover, it has the potential benefit of allowing rapid diagnosis, goal-directed therapy with hemostatic drugs and coagulation factor concentrates and thus, avoiding unnecessary blood component transfusion.
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Affiliation(s)
- Tomaz Crochemore
- Hospital Israelita Albert Einstein - Intensive Care Unit, Av. Albert Einstein, 627, Morumbi, São Paulo, SP, CEP: 05651-901, Brazil.
| | - Felicio A Savioli
- Hospital Israelita Albert Einstein - Intensive Care Unit, Av. Albert Einstein, 627, Morumbi, São Paulo, SP, CEP: 05651-901, Brazil
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Ramchandran S, Day LM, Line B, Buckland AJ, Passias P, Protopsaltis T, Bendo J, Huncke T, Errico TJ, Bess S. The Impact of Different Intraoperative Fluid Administration Strategies on Postoperative Extubation Following Multilevel Thoracic and Lumbar Spine Surgery: A Propensity Score Matched Analysis. Neurosurgery 2018; 85:31-40. [DOI: 10.1093/neuros/nyy226] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2017] [Accepted: 05/01/2018] [Indexed: 11/13/2022] Open
Affiliation(s)
- Subaraman Ramchandran
- Department of Orthopedic surgery, NYU Hospital for Joint Diseases, New York, New York
| | - Louis M Day
- Department of Orthopedic surgery, NYU Hospital for Joint Diseases, New York, New York
| | - Breton Line
- Department of Orthopedic surgery, Rocky Mountain Scoliosis and spine center, Denver, Colorado
| | - Aaron J Buckland
- Department of Orthopedic surgery, NYU Hospital for Joint Diseases, New York, New York
| | - Peter Passias
- Department of Orthopedic surgery, NYU Hospital for Joint Diseases, New York, New York
| | | | - John Bendo
- Department of Orthopedic surgery, NYU Hospital for Joint Diseases, New York, New York
| | - Tessa Huncke
- Department of Anesthesiology, NYU Hospital for Joint Diseases, New York, New York
| | - Thomas J Errico
- Department of Orthopedic surgery, NYU Hospital for Joint Diseases, New York, New York
| | - Shay Bess
- Department of Orthopedic surgery, Rocky Mountain Scoliosis and spine center, Denver, Colorado
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Nassoiy SP, Babu FS, LaPorte HM, Byron KL, Majetschak M. Effects of the Kv7 voltage-activated potassium channel inhibitor linopirdine in rat models of haemorrhagic shock. Clin Exp Pharmacol Physiol 2018; 45:10.1111/1440-1681.12958. [PMID: 29702725 PMCID: PMC6204121 DOI: 10.1111/1440-1681.12958] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Revised: 04/13/2018] [Accepted: 04/20/2018] [Indexed: 12/12/2022]
Abstract
Recently, we demonstrated that Kv7 voltage-activated potassium channel inhibitors reduce fluid resuscitation requirements in short-term rat models of haemorrhagic shock. The aim of the present study was to further delineate the therapeutic potential and side effect profile of the Kv7 channel blocker linopirdine in various rat models of severe haemorrhagic shock over clinically relevant time periods. Intravenous administration of linopirdine, either before (1 or 3 mg/kg) or after (3 mg/kg) a 40% blood volume haemorrhage, did not affect blood pressure and survival in lethal haemorrhage models without fluid resuscitation. A single bolus of linopirdine (3 mg/kg) at the beginning of fluid resuscitation after haemorrhagic shock transiently reduced early fluid requirements in spontaneously breathing animals that were resuscitated for 3.5 hours. When mechanically ventilated rats were resuscitated after haemorrhagic shock with normal saline (NS) or with linopirdine-supplemented (10, 25 or 50 μg/mL) NS for 4.5 hours, linopirdine significantly and dose-dependently reduced fluid requirements by 14%, 45% and 55%, respectively. Lung and colon wet/dry weight ratios were reduced with linopirdine (25/50 μg/mL). There was no evidence for toxicity or adverse effects based on measurements of routine laboratory parameters and inflammation markers in plasma and tissue homogenates. Our findings support the concept that linopirdine-supplementation of resuscitation fluids is a safe and effective approach to reduce fluid requirements and tissue oedema formation during resuscitation from haemorrhagic shock.
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Affiliation(s)
- Sean P. Nassoiy
- Burn and Shock Trauma Research Institute, Department of Surgery, Loyola University Chicago, Stritch School of Medicine
| | - Favin S. Babu
- Burn and Shock Trauma Research Institute, Department of Surgery, Loyola University Chicago, Stritch School of Medicine
| | - Heather M. LaPorte
- Burn and Shock Trauma Research Institute, Department of Surgery, Loyola University Chicago, Stritch School of Medicine
| | - Kenneth L. Byron
- Department of Molecular Pharmacology and Therapeutics, Loyola University Chicago, Stritch School of Medicine
| | - Matthias Majetschak
- Burn and Shock Trauma Research Institute, Department of Surgery, Loyola University Chicago, Stritch School of Medicine
- Department of Molecular Pharmacology and Therapeutics, Loyola University Chicago, Stritch School of Medicine
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Bundles of care for resuscitation from hemorrhagic shock and severe brain injury in trauma patients-Translating knowledge into practice. J Trauma Acute Care Surg 2018; 81:780-94. [PMID: 27389129 DOI: 10.1097/ta.0000000000001161] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Kemp Bohan P, Schreiber MA. Resuscitation. MANAGING DISMOUNTED COMPLEX BLAST INJURIES IN MILITARY & CIVILIAN SETTINGS 2018. [PMCID: PMC7122077 DOI: 10.1007/978-3-319-74672-2_5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Blast injuries can produce complex patterns of injury and can easily result in hemorrhagic shock. Adequate resuscitation of blast-injured patients is critical, as both under- and over-resuscitation can result in a number of fatal complications. Consideration must be given to the choice of resuscitative fluid, the volume of resuscitation, the timing of resuscitation relative to definitive surgical management, and the determination of endpoints at which resuscitation can be stopped. This chapter explores resuscitation of blast-injured patients, beginning in the prehospital phase with initial choice of fluid and continuing through definitive resuscitation at a higher echelon of care. Particular consideration is given to the effect of resuscitation on the unique physiologic derangements seen following blast injury. Drawing upon the enormous amount of literature on resuscitation from the recent coalition experiences in Iraq and Afghanistan, we advocate for the use of early hemostatic resuscitation with a high ratio of plasma, platelets, and packed red blood cells, with a transition to resuscitation guided by viscoelastic testing or coagulation status immediately following definitive control of hemorrhage.
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18
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Hylands M, Toma A, Beaudoin N, Frenette AJ, D’Aragon F, Belley-Côté É, Charbonney E, Møller MH, Laake JH, Vandvik PO, Siemieniuk RA, Rochwerg B, Lauzier F, Green RS, Ball I, Scales D, Murthy S, Kwong JSW, Guyatt G, Rizoli S, Asfar P, Lamontagne F. Early vasopressor use following traumatic injury: a systematic review. BMJ Open 2017; 7:e017559. [PMID: 29151048 PMCID: PMC5701980 DOI: 10.1136/bmjopen-2017-017559] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
OBJECTIVES Current guidelines suggest limiting the use of vasopressors following traumatic injury; however, wide variations in practice exist. Although excessive vasoconstriction may be harmful, these agents may help reduce administration of potentially harmful resuscitation fluids. This systematic review aims to compare early vasopressor use to standard resuscitation in adults with trauma-induced shock. DESIGN Systematic review. DATA SOURCES We searched MEDLINE, EMBASE, ClinicalTrials.gov and the Central Register of Controlled Trials from inception until October 2016, as well as the proceedings of 10 relevant international conferences from 2005 to 2016. ELIGIBILITY CRITERIA FOR SELECTING STUDIES Randomised controlled trials and controlled observational studies that compared the early vasopressor use with standard resuscitation in adults with acute traumatic injury. RESULTS Of 8001 citations, we retrieved 18 full-text articles and included 6 studies (1 randomised controlled trial and 5 observational studies), including 2 published exclusively in abstract form. Across observational studies, vasopressor use was associated with increased short-term mortality, with unadjusted risk ratios ranging from 2.31 to 7.39. However, the risk of bias was considered high in these observational studies because patients who received vasopressors were systematically sicker than patients treated without vasopressors. One clinical trial (n=78) was too imprecise to yield meaningful results. Two clinical trials are currently ongoing. No study measured long-term quality of life or cognitive function. CONCLUSIONS Existing data on the effects of vasopressors following traumatic injury are of very low quality according to the Grading of Recommendations, Assessment, Development and Evaluation methodology. With emerging evidence of harm associated with aggressive fluid resuscitation and, in selected subgroups of patients, with permissive hypotension, the alternatives to vasopressor therapy are limited. Observational data showing that vasopressors are part of usual care would provide a strong justification for high-quality clinical trials of early vasopressor use during trauma resuscitation. TRIAL REGISTRATION NUMBER CRD42016033437.
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Affiliation(s)
- Mathieu Hylands
- Department of Surgery, Université de Sherbrooke, Sherbrooke, Québec, Canada
| | - Augustin Toma
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - Nicolas Beaudoin
- Department of Anaesthesiology, Université de Sherbrooke, Sherbrooke, Québec, Canada
| | - Anne Julie Frenette
- Centre de recherche de l’Hôpital du Sacré-Coeur de Montréal, Université de Montréal, Montréal, Québec, Canada
| | - Frédérick D’Aragon
- Department of Anaesthesiology, Université de Sherbrooke, Sherbrooke, Québec, Canada
- Centre de recherche du CHU de Sherbrooke, Sherbrooke, Québec, Canada
| | - Émilie Belley-Côté
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, Université de Sherbrooke, Sherbrooke, Canada
| | - Emmanuel Charbonney
- Centre de recherche de l’Hôpital du Sacré-Coeur de Montréal, Université de Montréal, Montréal, Québec, Canada
| | | | - Jon Henrik Laake
- Department of Anaesthesiology, Oslo University Hospital, Rikshospitalet Medical Centre, Oslo, Norway
| | - Per Olav Vandvik
- Norwegian Knowledge Centre for the Health Services, Oslo, Norway
| | - Reed Alexander Siemieniuk
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - Bram Rochwerg
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - François Lauzier
- Centre de Recherche du CHU de Québec, Université Laval, Québec, Canada
| | - Robert S Green
- Department of Emergency Medicine and Critical Care Medicine, Dalhousie University, Halifax, Canada
| | - Ian Ball
- Department of Emergency Medicine and Critical Care Medicine, Queen’s University, Kingston, Canada
| | - Damon Scales
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Srinivas Murthy
- Department of Pediatrics and Critical Care Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Joey S W Kwong
- Center for Evidence-Based and Translational Medicine, Wuhan University, Wuhan, Hubei Province, China
| | - Gordon Guyatt
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - Sandro Rizoli
- Department of Trauma and Acute Care Surgery, St Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Pierre Asfar
- Centre Hospitalier Universitaire d’Angers, Angers, Pays de la Loire, France
| | - François Lamontagne
- Centre de recherche du CHU de Sherbrooke, Sherbrooke, Québec, Canada
- Department of Medicine, Université de Sherbrooke, Sherbrooke, Canada
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19
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Prevalence and mortality of abdominal compartment syndrome in severely injured patients: A systematic review. J Trauma Acute Care Surg 2017; 81:585-92. [PMID: 27398983 DOI: 10.1097/ta.0000000000001133] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Abdominal compartment syndrome (ACS) in severely injured patients is associated with high morbidity and mortality. Many efforts have been made to improve outcome of patients with ACS. A treatment algorithm for ACS patients was introduced on January 1, 2005 by the World Society of the Abdominal Compartment Syndrome. The aim of this study was to determine the prevalence and mortality rate of ACS among severely injured patients before and after January 1, 2005 using a systematic literature review. METHOD Databases of Embase, Medline (OvidSP), Web of Science, CINAHL, CENTRAL, PubMed publisher, and Google Scholar were searched for terms related to severely injured patients and ACS. Original studies reporting ACS in trauma patients were considered eligible. Data on study design, population, definitions, prevalence, and mortality rates were extracted. Pooled prevalence and mortality of ACS among severely injured patients were calculated for both time periods using inversed variance weighting assuming a random effects model. Tests for heterogeneity were applied. RESULTS A total of 80 publications were included. Prevalence of studies that finished enrolling patients before January 1, 2005 ranged from 0.5% to 36.4% and 0.0% to 28.0% in studies after that date. For severely injured patients admitted to the ICU, this range was 0.5% to 1.3% before 2005 and 0% in one publication in the second time period. For patients with visceral injuries, ACS prevalence ranged 1.0% to 20.0%; one study in the second time period reported 11.1%. The prevalence among severely injured patients who underwent trauma laparotomy ranged from 0.9% to 36.4% in the first time period. Two studies after January 1, 2005 reported ACS prevalence of 2.3% and 13.2%, respectively. The mortality rate in both time periods ranged between 0.0% and 100.0%. CONCLUSION The overall prevalence of ACS ranged from 0.0% to 36.4%. Future studies are needed to measure the effect of improved trauma care and effectiveness of the World Society of the Abdominal Compartment Syndrome Consensus Statements. LEVEL OF EVIDENCE Systematic review/meta-analysis, level III.
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Abstract
The development of organ dysfunction (OD) is related to the intensity and balance between trauma-induced simultaneous, opposite inflammatory responses. Early proinflammation via innate immune system activation may cause early OD, whereas antiinflammation, via inhibition of the adaptive immune system and apoptosis, may induce immunoparalysis, impaired healing, infections, and late OD. Patients discharged with low-level OD may develop the persistent inflammation-immunosuppression catabolism syndrome. Although the incidence of multiple organ failure has decreased over time, it remains morbid, lethal, and resource intensive. However, single OD, especially acute lung injury, remains frequent. Treatment is limited, and prevention remains the mainstay strategy.
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Affiliation(s)
- Angela Sauaia
- University of Colorado Denver, 655 Broadway #365, Denver, CO 80203, USA.
| | | | - Ernest E Moore
- Denver Health Medical Center, University of Colorado Denver, 655 Broadway #365, Denver, CO 80203, USA
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Hylands M, Toma A, Beaudoin N, Frenette AJ, D'Aragon F, Belley-Côté E, Hylander M, Lauzier F, Siemieniuk RA, Charbonney E, Kwong J, Laake JH, Guyatt G, Vandvik PO, Rochwerg B, Green R, Ball I, Scales D, Murthy S, Rizoli S, Asfar P, Lamontagne F. Vasopressor use following traumatic injury: protocol for a systematic review. BMJ Open 2017; 7:e014166. [PMID: 28246141 PMCID: PMC5337706 DOI: 10.1136/bmjopen-2016-014166] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
INTRODUCTION Worldwide, traumatic casualties are projected to exceed 8 million by year 2020. Haemorrhagic shock and brain injury are the leading causes of death following trauma. While intravenous fluids have traditionally been used to support organ perfusion in the setting of haemorrhage, recent investigations have suggested that restricting fluid therapy by tolerating more severe hypotension may improve survival. However, the safety of permissive hypotension remains uncertain, particularly among patients who have suffered a traumatic brain injury. Vasopressors preferentially vasoconstrict blood vessels that supply non-vital organs and capacitance vessels, thereby mobilising the unstressed blood volume. Used as fluid-sparing adjuncts, these drugs can complement resuscitative measures by correcting hypotension without diluting clotting factors or increasing the risk for tissue oedema. METHODS AND ANALYSIS We will identify randomised control trials comparing early resuscitation with vasopressors versus placebo or standard care in adults following traumatic injury. Data sources will include MEDLINE, EMBASE, CENTRAL, clinical trial registries and conference proceedings. Two reviewers will independently determine trial eligibility. For each included trial, we will conduct duplicate independent data extraction and risk of bias assessment. We will assess the overall quality of the data for each individual outcome using the GRADE approach. ETHICS AND DISSEMINATION We will report this review in accordance with the PRISMA statement. We will disseminate our findings at critical care and trauma conferences and through a publication in a peer-reviewed journal. We will also use this systematic review to create clinical guidelines (http://www.magicapp.org), which will be disseminated in a standalone publication. TRIAL REGISTRATION NUMBER CRD42016033437.
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Affiliation(s)
- Mathieu Hylands
- Department of Surgery, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Augustin Toma
- McMaster University, Clinical Epidemiology and Biostatistics, Hamilton, Ontario, Canada
| | - Nicolas Beaudoin
- Department of Anaesthesiology, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Anne-Julie Frenette
- Hôpital du Sacré-Coeur de Montréal, Université de Montréal, Montréal, Quebec, Canada
| | - Frederick D'Aragon
- Department of Anaesthesiology, Université de Sherbrooke, Sherbrooke, Quebec, Canada
- Centre de recherche du CHU de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Emilie Belley-Côté
- McMaster University, Clinical Epidemiology and Biostatistics, Hamilton, Ontario, Canada
- Department of Medicine, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Morten Hylander
- Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - François Lauzier
- Population Health and Optimal Health Practives Research Unit (Trauma—Emergency—Critical Care Medicine), Centre de Recherche du CHU de Québec—Université Laval, Quebec, Quebec, Canada
| | | | - Emmanuel Charbonney
- Hôpital du Sacré-Coeur de Montréal, Université de Montréal, Montréal, Quebec, Canada
| | - Joey Kwong
- Wuhan University, Center for Evidence-Based and Translational Medicine Zhongnan Hospital, Wuhan, China
| | | | - Gordon Guyatt
- McMaster University, Clinical Epidemiology and Biostatistics, Hamilton, Ontario, Canada
| | - Per Olav Vandvik
- Norwegian Knowledge Centre for the Health Services, Oslo, Norway
| | - Bram Rochwerg
- McMaster University, Clinical Epidemiology and Biostatistics, Hamilton, Ontario, Canada
| | - Robert Green
- Department of Critical care, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Ian Ball
- London Health Sciences Centre, London, Ontario, Canada
| | - Damon Scales
- Department of Critical Care, University of Toronto, Toronto, Ontario, Canada
| | - Srinivas Murthy
- Department of Paediatrics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Sandro Rizoli
- Division of General Surgery, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Pierre Asfar
- Centre Hospitalier Universitaire d'Angers, Angers, France
| | - François Lamontagne
- Centre de recherche du CHU de Sherbrooke, Sherbrooke, Quebec, Canada
- Department of Medicine, Université de Sherbrooke, Sherbrooke, Quebec, Canada
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22
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Kudo D, Yoshida Y, Kushimoto S. Permissive hypotension/hypotensive resuscitation and restricted/controlled resuscitation in patients with severe trauma. J Intensive Care 2017; 5:11. [PMID: 34798698 PMCID: PMC8600688 DOI: 10.1186/s40560-016-0202-z] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2016] [Accepted: 12/17/2016] [Indexed: 11/10/2022] Open
Abstract
Achieving a balance between organ perfusion and hemostasis is critical for optimal fluid resuscitation in patients with severe trauma. The concept of “permissive hypotension” refers to managing trauma patients by restricting the amount of resuscitation fluid and maintaining blood pressure in the lower than normal range if there is continuing bleeding during the acute period of injury. This treatment approach may avoid the adverse effects of early, high-dose fluid resuscitation, such as dilutional coagulopathy and acceleration of hemorrhage, but does carry the potential risk of tissue hypoperfusion. Current clinical guidelines recommend the use of permissive hypotension and controlled resuscitation. However, it is not mentioned which subjects would receive most benefit from this approach, when considering factors such as age, injury mechanism, setting, or the presence or absence of hypotension. Recently, two randomized clinical trials examined the efficacy of titrating blood pressure in younger patients with shock secondary to either penetrating or blunt injury; in both trials, overall mortality was not improved. Another two major clinical trials suggest that controlled resuscitation may be safe in patients with blunt injury in the pre-hospital setting and possibly lead to improved outcomes, especially in patients with pre-hospital hypotension. Some animal studies suggest that hypotensive resuscitation may improve outcomes in subjects with penetrating injury where bleeding occurs from only one site. On the other hand, hypotensive resuscitation in blunt trauma may worsen outcomes due to tissue hypoperfusion. The influence of these approaches on coagulation has not been sufficiently examined, even in animal studies. The effectiveness of permissive hypotension/hypotensive resuscitation and restricted/controlled resuscitation is still inconclusive, even when examining systematic reviews and meta-analyses. Further investigation is needed to elucidate the effectiveness of these approaches, so as to develop improved treatment strategies which take into account coagulopathy in the pathophysiology of trauma.
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Nassoiy SP, Byron KL, Majetschak M. Kv7 voltage-activated potassium channel inhibitors reduce fluid resuscitation requirements after hemorrhagic shock in rats. J Biomed Sci 2017; 24:8. [PMID: 28095830 PMCID: PMC5240358 DOI: 10.1186/s12929-017-0316-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2016] [Accepted: 01/10/2017] [Indexed: 12/24/2022] Open
Abstract
Background Recent evidence suggests that drugs targeting Kv7 channels could be used to modulate vascular function and blood pressure. Here, we studied whether Kv7 channel inhibitors can be utilized to stabilize hemodynamics and reduce resuscitation fluid requirements after hemorrhagic shock. Methods Anesthetized male Sprague-Dawley rats were instrumented with arterial and venous catheters for blood pressure monitoring, hemorrhage and fluid resuscitation. Series 1: Linopirdine (Kv7 channel blocker, 0.1–6 mg/kg) or retigabine (Kv7 channel activator, 0.1–12 mg/kg) were administered to normal animals. Series 2: Animals were hemorrhaged to a MAP of 25 mmHg for 30 min, followed by fluid resuscitation with normal saline (NS) to a MAP of 70 mmHg until t = 75 min. Animals were treated with single bolus injections of vehicle, linopirdine (1–6 mg/kg), XE-991 (structural analogue of linopirdine with higher potency for channel blockade, 1 mg/kg) prior to fluid resuscitation. Series 3: Animals were resuscitated with NS alone or NS supplemented with linopirdine (1.25–200 μg/mL). Data were analyzed with 2-way ANOVA/Bonferroni post-hoc testing. Results Series 1: Linopirdine transiently (10–15 min) and dose-dependently increased MAP by up to 15%. Retigabine dose-dependently reduced MAP by up to 60%, which could be reverted with linopirdine. Series 2: Fluid requirements to maintain MAP at 70 mmHg were 65 ± 34 mL/kg with vehicle, and 57 ± 13 mL/kg, 22 ± 8 mL/kg and 22 ± 11 mL/kg with intravenous bolus injection of 1, 3 and 6 mg/kg linopirdine, respectively. XE-991 (1 mg/kg), reduced resuscitation requirements comparable to 3 mg/kg linopirdine. Series 3: When resuscitation was performed with linopirdine-supplemented normal saline (NS), fluid requirements to stabilize MAP were 73 ± 12 mL/kg with NS alone and 72 ± 24, 61 ± 20, 36 ± 9 and 31 ± 9 mL/kg with NS supplemented with 1.25, 6.25, 12.5 and 200 μg/mL linopirdine, respectively. Conclusions Our data suggest that Kv7 channel blockers could be used to stabilize blood pressure and reduce fluid resuscitation requirements after hemorrhagic shock.
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Affiliation(s)
- Sean P Nassoiy
- Burn and Shock Trauma Research Institute, Department of Surgery, Loyola University Chicago, Stritch School of Medicine, 2160 S. 1st Avenue, Maywood, IL, 60153, USA
| | - Kenneth L Byron
- Department of Molecular Pharmacology and Therapeutics, Loyola University Chicago, Stritch School of Medicine, 2160 S. 1st Avenue, Maywood, IL, 60153, USA
| | - Matthias Majetschak
- Burn and Shock Trauma Research Institute, Department of Surgery, Loyola University Chicago, Stritch School of Medicine, 2160 S. 1st Avenue, Maywood, IL, 60153, USA. .,Department of Molecular Pharmacology and Therapeutics, Loyola University Chicago, Stritch School of Medicine, 2160 S. 1st Avenue, Maywood, IL, 60153, USA.
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Gupta B, Garg N, Ramachandran R. Vasopressors: Do they have any role in hemorrhagic shock? J Anaesthesiol Clin Pharmacol 2017; 33:3-8. [PMID: 28413267 PMCID: PMC5374828 DOI: 10.4103/0970-9185.202185] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
The priority in the management of patients with traumatic hemorrhagic shock is to control the bleeding with simultaneous volume resuscitation to maintain adequate tissue perfusion. Fluid replacement remains the mainstay of initial resuscitation in hemorrhagic shock. Traditionally, vasopressors are contraindicated in the early management of hemorrhagic shock due to their deleterious consequences, although vasopressors may have a role in resuscitation when vasoplegic shock ensues and blood pressure cannot be maintained by fluids alone. Use of vasopressors is not recommended according to the Advanced Trauma Life SupportR management principles. The role of vasopressors remains controversial with no clear guidelines on the timing, type, and dose of these drugs in hemorrhagic shock. Among vasopressors, norepinephrine and vasopressin have been used in the majority of the trials, although not many studies compare the effect of these two on long-term survival in trauma patients. This article reviews the pathophysiology of hemorrhagic shock, adverse effects of fluid resuscitation, and the various experimental and clinical studies on the use of vasopressors in the early phase of resuscitation in hemorrhagic shock.
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Affiliation(s)
- Babita Gupta
- JPN Apex Trauma Center, All India Institute of Medical Sciences, New Delhi, India
| | - Neha Garg
- Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India
| | - Rashmi Ramachandran
- Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India
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Rossaint R, Bouillon B, Cerny V, Coats TJ, Duranteau J, Fernández-Mondéjar E, Filipescu D, Hunt BJ, Komadina R, Nardi G, Neugebauer EAM, Ozier Y, Riddez L, Schultz A, Vincent JL, Spahn DR. The European guideline on management of major bleeding and coagulopathy following trauma: fourth edition. Crit Care 2016; 20:100. [PMID: 27072503 PMCID: PMC4828865 DOI: 10.1186/s13054-016-1265-x] [Citation(s) in RCA: 597] [Impact Index Per Article: 74.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Accepted: 03/11/2016] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Severe trauma continues to represent a global public health issue and mortality and morbidity in trauma patients remains substantial. A number of initiatives have aimed to provide guidance on the management of trauma patients. This document focuses on the management of major bleeding and coagulopathy following trauma and encourages adaptation of the guiding principles to each local situation and implementation within each institution. METHODS The pan-European, multidisciplinary Task Force for Advanced Bleeding Care in Trauma was founded in 2004 and included representatives of six relevant European professional societies. The group used a structured, evidence-based consensus approach to address scientific queries that served as the basis for each recommendation and supporting rationale. Expert opinion and current clinical practice were also considered, particularly in areas in which randomised clinical trials have not or cannot be performed. Existing recommendations were reconsidered and revised based on new scientific evidence and observed shifts in clinical practice; new recommendations were formulated to reflect current clinical concerns and areas in which new research data have been generated. This guideline represents the fourth edition of a document first published in 2007 and updated in 2010 and 2013. RESULTS The guideline now recommends that patients be transferred directly to an appropriate trauma treatment centre and encourages use of a restricted volume replacement strategy during initial resuscitation. Best-practice use of blood products during further resuscitation continues to evolve and should be guided by a goal-directed strategy. The identification and management of patients pre-treated with anticoagulant agents continues to pose a real challenge, despite accumulating experience and awareness. The present guideline should be viewed as an educational aid to improve and standardise the care of the bleeding trauma patients across Europe and beyond. This document may also serve as a basis for local implementation. Furthermore, local quality and safety management systems need to be established to specifically assess key measures of bleeding control and outcome. CONCLUSIONS A multidisciplinary approach and adherence to evidence-based guidance are key to improving patient outcomes. The implementation of locally adapted treatment algorithms should strive to achieve measureable improvements in patient outcome.
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Affiliation(s)
- Rolf Rossaint
- />Department of Anaesthesiology, University Hospital Aachen, RWTH Aachen University, Pauwelsstrasse 30, 52074 Aachen, Germany
| | - Bertil Bouillon
- />Department of Trauma and Orthopaedic Surgery, Witten/Herdecke University, Cologne-Merheim Medical Centre, Ostmerheimer Strasse 200, 51109 Cologne, Germany
| | - Vladimir Cerny
- />Department of Anaesthesiology, Perioperative Medicine and Intensive Care, J.E. Purkinje University, Masaryk Hospital, Usti nad Labem, Socialni pece 3316/12A, 40113 Usti nad Labem, Czech Republic
- />Department of Research and Development, Charles University in Prague, Faculty of Medicine in Hradec Kralove, Sokolska 581, 50005 Hradec Kralove, Czech Republic
- />Department of Anaesthesiology and Intensive Care, Charles University in Prague, Faculty of Medicine in Hradec Kralove, Sokolska 581, 50005 Hradec Kralove, Czech Republic
- />Department of Anaesthesia, Pain Management and Perioperative Medicine, Dalhousie University, Halifax, QE II Health Sciences Centre, 10 West Victoria, 1276 South Park St., Halifax, NS B3H 2Y9 Canada
| | - Timothy J. Coats
- />Emergency Medicine Academic Group, University of Leicester, University Road, Leicester, LE1 7RH UK
| | - Jacques Duranteau
- />Department of Anaesthesia and Intensive Care, Hôpitaux Universitaires Paris Sud, University of Paris XI, Faculté de Médecine Paris-Sud, 78 rue du Général Leclerc, 94275 Le Kremlin-Bicêtre, Cedex France
| | - Enrique Fernández-Mondéjar
- />Servicio de Medicina Intensiva, Complejo Hospitalario Universitario de Granada, ctra de Jaén s/n, 18013 Granada, Spain
| | - Daniela Filipescu
- />Department of Cardiac Anaesthesia and Intensive Care, C. C. Iliescu Emergency Institute of Cardiovascular Diseases, Sos Fundeni 256-258, 022328 Bucharest, Romania
| | - Beverley J. Hunt
- />King’s College, Departments of Haematology, Pathology and Lupus, Guy’s and St Thomas’ NHS Foundation Trust, Westminster Bridge Road, London, SE1 7EH UK
| | - Radko Komadina
- />Department of Traumatology, General and Teaching Hospital Celje, Oblakova 5, 3000 Celje, Slovenia
| | - Giuseppe Nardi
- />Shock and Trauma Centre, S. Camillo Hospital, Viale Gianicolense 87, 00152 Rome, Italy
| | - Edmund A. M. Neugebauer
- />Faculty of Health - School of Medicine, Witten/Herdecke University, Ostmerheimer Strasse 200, Building 38, 51109 Cologne, Germany
| | - Yves Ozier
- />Division of Anaesthesia, Intensive Care and Emergency Medicine, Brest University Hospital, Boulevard Tanguy Prigent, 29200 Brest, France
| | - Louis Riddez
- />Department of Surgery and Trauma, Karolinska University Hospital, 171 76 Solna, Sweden
| | - Arthur Schultz
- />Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, Lorenz Boehler Trauma Centre, Donaueschingenstrasse 13, 1200 Vienna, Austria
| | - Jean-Louis Vincent
- />Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Route de Lennik 808, 1070 Brussels, Belgium
| | - Donat R. Spahn
- />Institute of Anaesthesiology, University of Zurich and University Hospital Zurich, Raemistrasse 100, 8091 Zurich, Switzerland
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Llau JV, Acosta FJ, Escolar G, Fernández-Mondéjar E, Guasch E, Marco P, Paniagua P, Páramo JA, Quintana M, Torrabadella P. [Multidisciplinary consensus document on the management of massive haemorrhage (HEMOMAS document)]. ACTA ACUST UNITED AC 2015; 63:e1-e22. [PMID: 26688462 DOI: 10.1016/j.redar.2015.11.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2015] [Accepted: 05/17/2015] [Indexed: 12/23/2022]
Abstract
Massive haemorrhage is common and often associated with high morbidity and mortality. We perform a systematic review of the literature, with extraction of the recommendations from the existing evidences because of the need for its improvement and the management standardization. From the results we found, we wrote a multidisciplinary consensus document. We begin with the agreement in the definitions of massive haemorrhage and massive transfusion, and we do structured recommendations on their general management (clinical assessment of bleeding, hypothermia management, fluid therapy, hypotensive resuscitation and damage control surgery), blood volume monitoring, blood products transfusion (red blood cells, fresh frozen plasma, platelets and their best transfusion ratio), and administration of hemostatic components (prothrombin complex, fibrinogen, factor VIIa, antifibrinolytic agents).
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Affiliation(s)
- J V Llau
- Anestesia y Reanimación, Hospital Clínico Universitario de Valencia, Valencia, España
| | - F J Acosta
- Anestesia y Reanimación, Hospital Universitario Virgen de la Arrixaca, El Palmar, Murcia, España
| | - G Escolar
- Hemoterapia y Hematología, Hospital Clínic i Provincial de Barcelona, Barcelona, España
| | - E Fernández-Mondéjar
- Servicio de Cuidados Críticos y Urgencias, Hospital Universitario Virgen de las Nieves; Instituto de Investigación Biosanitaria ibs.Granada, Granada, España.
| | - E Guasch
- Anestesia y Reanimación, Hospital Universitario La Paz, Madrid, España
| | - P Marco
- Hemoterapia y Hematología, Hospital General de Alicante, Alicante, España
| | - P Paniagua
- Anestesia y Reanimación, Hospital de la Santa Creu i Sant Pau, Barcelona, España
| | - J A Páramo
- Hematología y Hemoterapia, Clínica Universidad de Navarra, Pamplona, España
| | - M Quintana
- Medicina Intensiva, Hospital Universitario La Paz, Madrid, España
| | - P Torrabadella
- Unidad de Cuidados Intensivos, Hospital Germans Trias i Pujol, Badalona, Barcelona, España
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Llau JV, Acosta FJ, Escolar G, Fernández-Mondéjar E, Guasch E, Marco P, Paniagua P, Páramo JA, Quintana M, Torrabadella P. Multidisciplinary consensus document on the management of massive haemorrhage (HEMOMAS document). Med Intensiva 2015; 39:483-504. [PMID: 26233588 DOI: 10.1016/j.medin.2015.05.002] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2015] [Revised: 05/14/2015] [Accepted: 05/17/2015] [Indexed: 12/30/2022]
Abstract
Massive haemorrhage is common and often associated with high morbidity and mortality. We perform a systematic review of the literature, with extraction of the recommendations from the existing evidences because of the need for its improvement and the management standardization. From the results we found, we wrote a multidisciplinary consensus document. We begin with the agreement in the definitions of massive haemorrhage and massive transfusion, and we do structured recommendations on their general management (clinical assessment of bleeding, hypothermia management, fluid therapy, hypotensive resuscitation and damage control surgery), blood volume monitoring, blood products transfusion (red blood cells, fresh frozen plasma, platelets and their best transfusion ratio), and administration of hemostatic components (prothrombin complex, fibrinogen, factor VIIa, antifibrinolytic agents).
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Affiliation(s)
- J V Llau
- Anestesia y Reanimación, Hospital Clínico Universitario de Valencia, Valencia, España
| | - F J Acosta
- Anestesia y Reanimación, Hospital Universitario Virgen de la Arrixaca, El Palmar, Murcia, España
| | - G Escolar
- Hemoterapia y Hematología, Hospital Clínic i Provincial de Barcelona, Barcelona, España
| | - E Fernández-Mondéjar
- Servicio de Cuidados Críticos y Urgencias, Hospital Universitario Virgen de las Nieves; Instituto de Investigación Biosanitaria ibs.Granada, Granada, España.
| | - E Guasch
- Anestesia y Reanimación, Hospital Universitario La Paz, Madrid, España
| | - P Marco
- Hemoterapia y Hematología, Hospital General de Alicante, Alicante, España
| | - P Paniagua
- Anestesia y Reanimación, Hospital de la Santa Creu i Sant Pau, Barcelona, España
| | - J A Páramo
- Hematología y Hemoterapia, Clínica Universidad de Navarra, Pamplona, España
| | - M Quintana
- Medicina Intensiva, Hospital Universitario La Paz, Madrid, España
| | - P Torrabadella
- Unidad de Cuidados Intensivos, Hospital Germans Trias i Pujol, Badalona, Barcelona, España
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Barmparas G, Ko A, Harada MY, Zaw AA, Murry JS, Smith EJT, Ashrafian S, Sun BJ, Ley EJ. Decreasing maintenance fluids in normotensive trauma patients may reduce intensive care unit stay and ventilator days. J Crit Care 2015; 31:201-5. [PMID: 26643858 DOI: 10.1016/j.jcrc.2015.09.030] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2015] [Revised: 08/22/2015] [Accepted: 09/05/2015] [Indexed: 11/28/2022]
Abstract
PURPOSE The purpose of the study is to determine if excessive fluid administration is associated with a prolonged hospital course and worse outcomes. MATERIALS AND METHODS In July 2013, all normotensive trauma patients admitted to the surgical intensive care unit (ICU) were administered crystalloids at 30 mL/h ("to keep open [TKO]") and were compared to patients admitted during the preceding 6 months who were placed on a rate between 125 mL/h to 150 mL/h (non-TKO). The primary outcomes were ICU, hospital, and ventilator days. RESULTS A total of 101 trauma patients met inclusion criteria: 56 (55.4%) in the TKO and 45 (44.6%) in the non-TKO group. Overall, the 2 groups were similar in regard to age, Injury Severity Score, Acute Physiology and Chronic Health Evaluation IV scores, and the need for mechanical ventilation. TKO had no effect on renal function compared to non-TKO with similarities in maximum hospital creatinine. TKO patients had lower ICU stay (2.7 ± 1.5 vs 4.1 ± 4.6 days; P = .03) and ventilator days (1.4 ± 0.5 vs 5.5 ± 4.8 days; P < .01). CONCLUSIONS A protocol that encourages admission basal fluid rate of TKO or 30 mL/h in normotensive trauma patients is safe, reduces fluid intake, and may be associated with a shorter intensive care unit course and fewer ventilator days.
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Affiliation(s)
- Galinos Barmparas
- Division of Trauma and Critical Care, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA.
| | - Ara Ko
- Division of Trauma and Critical Care, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA.
| | - Megan Y Harada
- Division of Trauma and Critical Care, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA.
| | - Andrea A Zaw
- Division of Trauma and Critical Care, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA.
| | - Jason S Murry
- Division of Trauma and Critical Care, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA.
| | - Eric J T Smith
- Division of Trauma and Critical Care, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA.
| | - Sogol Ashrafian
- Division of Trauma and Critical Care, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA.
| | - Beatrice J Sun
- Division of Trauma and Critical Care, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA.
| | - Eric J Ley
- Division of Trauma and Critical Care, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA.
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The effect of the abdominal perfusion pressure on visceral circulation in critically ill patients with multiorgan dysfunction. THE EGYPTIAN JOURNAL OF CRITICAL CARE MEDICINE 2015. [DOI: 10.1016/j.ejccm.2015.12.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Gazmuri RJ, Whitehouse K, Whittinghill K, Baetiong A, Radhakrishnan J. Vasopressin Infusion with Small-Volume Fluid Resuscitation during Hemorrhagic Shock Promotes Hemodynamic Stability and Survival in Swine. PLoS One 2015; 10:e0130134. [PMID: 26107942 PMCID: PMC4479576 DOI: 10.1371/journal.pone.0130134] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2015] [Accepted: 04/27/2015] [Indexed: 11/25/2022] Open
Abstract
Introduction Current management of hemorrhagic shock (HS) in the battlefield and civilian settings favors small-volume fluid resuscitation before controlling the source of bleeding. We investigated in a swine model of HS the effects of vasopressin infusion along with small-volume fluid resuscitation; with erythropoietin (EPO) and HS severity as additional factors. Methods HS was induced in 24 male domestic pigs (36 to 41 kg) by blood withdrawal (BW) through a right atrial cannula modeling spontaneous bleeding by a mono-exponential decay function. The initial 12 pigs received no fluids; the last 12 pigs received normal saline (NS) half the BW volume. Pigs were randomized 2:1 to receive intraosseously vasopressin (0.04 U/kg·min-1) or vehicle control from minute 7 to minute 210. Pigs assigned to vasopressin were further randomized 1:1 to receive EPO (1,200 U/kg) or vehicle control and 1:1 to have 65% or 75% BW of their blood volume. Shed blood was reinfused at 210 minutes and the pigs recovered from anesthesia. Results Survival at 72 hours was influenced by vasopressin and NS but not by EPO or % BW. Vasopressin with NS promoted the highest survival (8/8) followed by vasopressin without NS (3/8), NS without vasopressin (1/4), and neither treatment (0/4) with overall statistical significance (log-rank test, p = 0.009) and each subset different from vasopressin with NS by Holm-Sidak test. Vasopressin increased systemic vascular resistance whereas NS increased cardiac output. Conclusion Vasopressin infusion with small-volume fluid resuscitation during severe HS was highly effective enabling critical hemodynamic stabilization and improved 72 hour survival.
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Affiliation(s)
- Raúl J. Gazmuri
- Department of Medicine and Resuscitation Institute at Rosalind Franklin University of Medicine and Science, North Chicago, IL, United States of America
- Department of Physiology at Rosalind Franklin University of Medicine and Science, North Chicago, IL, United States of America
- Critical Care Medicine at Captain James A. Lovell Federal Health Care Center, North Chicago, IL, United States of America
- * E-mail:
| | - Kasen Whitehouse
- Department of Medicine and Resuscitation Institute at Rosalind Franklin University of Medicine and Science, North Chicago, IL, United States of America
| | - Karla Whittinghill
- Department of Medicine and Resuscitation Institute at Rosalind Franklin University of Medicine and Science, North Chicago, IL, United States of America
| | - Alvin Baetiong
- Department of Medicine and Resuscitation Institute at Rosalind Franklin University of Medicine and Science, North Chicago, IL, United States of America
| | - Jeejabai Radhakrishnan
- Department of Medicine and Resuscitation Institute at Rosalind Franklin University of Medicine and Science, North Chicago, IL, United States of America
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Strang SG, Van Imhoff DL, Van Lieshout EMM, D'Amours SK, Van Waes OJF. Identifying patients at risk for high-grade intra-abdominal hypertension following trauma laparotomy. Injury 2015; 46:843-8. [PMID: 25805553 DOI: 10.1016/j.injury.2014.12.020] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2014] [Revised: 12/04/2014] [Accepted: 12/19/2014] [Indexed: 02/02/2023]
Abstract
BACKGROUND Abdominal Compartment Syndrome (ACS) is an uncommon but deleterious complication after trauma laparotomy. Early recognition of patients at risk of developing ACS is crucial for their outcome. The aim of this study was to compare the characteristics of patients who developed high-grade intra-abdominal hypertension (IAH) (i.e., grade III or IV; intra-abdominal pressure, IAP >20 mm Hg) following an injury-related laparotomy versus those who did not (i.e., IAP ≤20 mm Hg). METHODS A retrospective analysis of consecutive trauma patients admitted to a level 1 trauma centre in Australia between January 1, 1995 and January 31, 2010 was performed. A comparison was made between characteristics of patients who developed high-grade IAH following trauma laparotomy versus those who did not. RESULTS A total of 567 patients (median age 31 years) were included in this study. Of these patients 10.2% (58/567) developed high-grade IAH of which 51.7% (30/58) developed ACS. Patients with high-grade IAH were older (p<0.001), had a higher Injury Severity Score (p<0.001), larger base deficit (p<0.001) and lower temperature at admission (p=0.011). In the first 24h of admission, patients with high-grade IAH received larger volumes of crystalloids (p<0.001), larger volumes of colloids (p<0.001) and more units of packed red blood cells (p<0.001). Following surgery prolonged prothrombin (p<0.001) and partial thromboplastin times (p<0.001) were seen. The patients with high-grade IAH suffered higher mortality rates (25.9% (15/58) vs. 12.2% (62/509); p=0.012). CONCLUSION Of all patients who underwent a trauma laparotomy, 10.2% developed high-grade IAH, which increases the risk of mortality. Patients with acidosis, coagulopathy, and hypothermia were especially at risk. In these patients, the abdomen should be left open until adequate resuscitation has been achieved, allowing for definitive surgery. LEVEL OF EVIDENCE This is a level III retrospective study.
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Affiliation(s)
- Steven G Strang
- Erasmus MC, University Medical Center Rotterdam, Trauma Research Unit Department of Surgery, Room H-822k, PO Box 2040, 3000 CA Rotterdam, The Netherlands
| | - Diederik L Van Imhoff
- Erasmus MC, University Medical Center Rotterdam, Trauma Research Unit Department of Surgery, Room H-822k, PO Box 2040, 3000 CA Rotterdam, The Netherlands
| | - Esther M M Van Lieshout
- Erasmus MC, University Medical Center Rotterdam, Trauma Research Unit Department of Surgery, Room H-822k, PO Box 2040, 3000 CA Rotterdam, The Netherlands
| | - Scott K D'Amours
- Department of Trauma, Liverpool Hospital and the University of New South Wales, Sydney, NSW, Australia
| | - Oscar J F Van Waes
- Erasmus MC, University Medical Center Rotterdam, Trauma Research Unit Department of Surgery, Room H-822k, PO Box 2040, 3000 CA Rotterdam, The Netherlands.
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Secondary abdominal compartment syndrome after complicated traumatic lower extremity vascular injuries. Eur J Trauma Emerg Surg 2015; 42:207-11. [PMID: 26038042 DOI: 10.1007/s00068-015-0524-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2014] [Accepted: 03/22/2015] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Secondary abdominal compartment syndrome (ACS) can occur in trauma patients without abdominal injuries. Surgical management of patients presenting with secondary ACS after isolated traumatic lower extremity vascular injury (LEVI) continues to evolve, and associated outcomes remain unknown. METHODS From January 2006 to September 2011, 191 adult trauma patients presented to the Ryder Trauma Center, an urban level I trauma center in Miami, Florida with traumatic LEVIs. Among them 10 (5.2 %) patients were diagnosed with secondary ACS. Variables collected included age, gender, mechanism of injury, and clinical status at presentation. Surgical data included vessel injury, technical aspects of repair, associated complications, and outcomes. RESULTS Mean age was 37.4 ± 18.0 years (range 16-66 years), and the majority of patients were males (8 patients, 80 %). There were 7 (70 %) penetrating injuries (5 gunshot wounds and 2 stab wounds), and 3 blunt injuries with mean Injury Severity Score (ISS) 21.9 ± 14.3 (range 9-50). Surgical management of LEVIs included ligation (4 patients, 40 %), primary repair (1 patient, 10 %), reverse saphenous vein graft (2 patients, 20 %), and PTFE interposition grafting (3 patients, 30 %). The overall mortality rate in this series was 60 %. CONCLUSIONS The association between secondary ACS and lower extremity vascular injuries carries high morbidity and mortality rates. Further research efforts should focus at identifying parameters to accurately determine resuscitation goals, and therefore, prevent such a devastating condition.
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Leberle R, Ernstberger A, Loibl M, Merkl J, Bunz M, Creutzenberg M, Trabold B. Association of high volumes of hydroxyethyl starch with acute kidney injury in elderly trauma patients. Injury 2015; 46:105-9. [PMID: 25240412 DOI: 10.1016/j.injury.2014.08.039] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2014] [Revised: 08/05/2014] [Accepted: 08/24/2014] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Initial fluid resuscitation in trauma is still controversial. Hydroxyethyl starch (HES), a commonly used fluid for resuscitation in trauma patients, has potential nephrotoxic effects. Advancing age is a known risk factor for acute kidney injury (AKI) in trauma patients. Therefore, the objective of this study was to evaluate the impact of large volumes of HES 130/0.4 on renal function in trauma patients, with a particular focus on the significance of age. METHODS A retrospective review of all patients admitted to the Trauma Centre of the University Hospital Regensburg from September 1, 2007 to December 31, 2012 was performed. This investigation used data from the TraumaRegister of the German Trauma Society (DGU®), including preclinical data from the prehospital emergency physician's protocol, the patient data management system of the intensive care units and the anaesthesia protocols of the emergency room and the operating room. AKI was evaluated according to the risk, injury, failure, loss, or end-stage kidney disease (RIFLE) criteria. The rate of AKI and the rate of renal replacement therapy (RRT) were compared between patients who received<2000ml HES 130/0.4 during the first 24h (L-HES) after trauma and patients who received≥2000ml HES 130/0.4 during the first 24h (H-HES) after trauma. An additional sub analysis of patients older than 59 years of age was performed. RESULTS A total of 260 patients were included. Although patients in the H-HES group showed a higher injury severity score, the incidence of AKI and RRT were comparable. Furthermore, the sub analysis of patients older than 59 years of age also demonstrated similar results regarding incidence of AKI and the rate of RRT. CONCLUSIONS Fluid resuscitation with more than 2000ml HES (130kD/0.4) during the first twenty four hours after trauma was not associated with an increased incidence of AKI or need for RRT in trauma patients compared to patients who were administered<2000ml HES (130kD/0.4). The analysis of patients older than 59 years of age did not demonstrate any difference in the incidence of AKI or the need for RRT.
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Affiliation(s)
- R Leberle
- Department of Anesthesiology, University Medical Center, Germany.
| | - A Ernstberger
- Department of Trauma Surgery, University Medical Center, Germany.
| | - M Loibl
- Department of Trauma Surgery, University Medical Center, Germany.
| | - J Merkl
- Department of Anesthesiology, University Medical Center, Germany.
| | - M Bunz
- Department of Anesthesiology, University Medical Center, Germany.
| | - M Creutzenberg
- Department of Anesthesiology, University Medical Center, Germany.
| | - B Trabold
- Department of Anesthesiology, University Medical Center, Germany.
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Novy E, Levy B. Choc hémorragique : aspects physiopathologiques et prise en charge hémodynamique. MEDECINE INTENSIVE REANIMATION 2015. [DOI: 10.1007/s13546-014-1014-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Borovnik-Lesjak V, Whitehouse K, Baetiong A, Miao Y, Currie BM, Velmurugan S, Radhakrishnan J, Gazmuri RJ. Effects of intraosseous erythropoietin during hemorrhagic shock in swine. PLoS One 2014; 9:e110908. [PMID: 25365317 PMCID: PMC4218716 DOI: 10.1371/journal.pone.0110908] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2014] [Accepted: 09/21/2014] [Indexed: 11/22/2022] Open
Abstract
Objective To determine whether erythropoietin given during hemorrhagic shock (HS) ameliorates organ injury while improving resuscitation and survival. Methods Three series of 24 pigs each were studied. In an initial series, 50% of the blood volume (BV) was removed in 30 minutes and normal saline (threefold the blood removed) started at minute 90 infusing each third in 30, 60, and 150 minutes with shed blood reinfused at minute 330 (HS-50BV). In a second series, the same HS-50BV protocol was used but removing an additional 15% of BV from minute 30 to 60 (HS-65BV). In a final series, blood was removed as in HS-65BV and intraosseous vasopressin given from minute 30 (0.04 U/kg min−1) until start of shed blood reinfusion at minute 150 (HS-65BV+VP). Normal saline was reduced to half the blood removed and given from minute 90 to 120 in half of the animals. In each series, animals were randomized 1∶1 to receive erythropoietin (1,200 U/kg) or control solution intraosseously after removing 10% of the BV. Results In HS-50BV, O2 consumption remained near baseline yielding minimal lactate increases, 88% resuscitability, and 60% survival at 72 hours. In HS-65BV, O2 consumption was reduced and lactate increased yielding 25% resuscitability. In HS-65BV+VP, vasopressin promoted hemodynamic stability yielding 92% resuscitability and 83% survival at 72 hours. Erythropoietin did not affect resuscitability or subsequent survival in any of the series but increased interleukin-10, attenuated lactate increases, and ameliorated organ injury based on lesser troponin I, AST, and ALT increases and lesser neurological deficits in the HS-65BV+VP series. Conclusions Erythropoietin given during HS in swine failed to alter resuscitability and 72 hour survival regardless of HS severity and concomitant treatment with fluids and vasopressin but attenuated acute organ injury. The studies also showed the efficacy of vasopressin and restrictive fluid resuscitation for hemodynamic stabilization and survival.
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Affiliation(s)
- Vesna Borovnik-Lesjak
- Resuscitation Institute at Rosalind Franklin University of Medicine and Science, North Chicago, Illinois, United States of America
| | - Kasen Whitehouse
- Resuscitation Institute at Rosalind Franklin University of Medicine and Science, North Chicago, Illinois, United States of America
| | - Alvin Baetiong
- Resuscitation Institute at Rosalind Franklin University of Medicine and Science, North Chicago, Illinois, United States of America
| | - Yang Miao
- Resuscitation Institute at Rosalind Franklin University of Medicine and Science, North Chicago, Illinois, United States of America
| | - Brian M. Currie
- Resuscitation Institute at Rosalind Franklin University of Medicine and Science, North Chicago, Illinois, United States of America
| | - Sathya Velmurugan
- Resuscitation Institute at Rosalind Franklin University of Medicine and Science, North Chicago, Illinois, United States of America
| | - Jeejabai Radhakrishnan
- Department of Medicine and Resuscitation Institute at Rosalind Franklin University of Medicine and Science, North Chicago, Illinois, United States of America
| | - Raúl J. Gazmuri
- Department of Medicine, Department of Physiology and Biophysics, and Resuscitation Institute at Rosalind Franklin University of Medicine and Science, and Critical Care Medicine at the Captain James A. Lovell Federal Health Care Center, North Chicago, Illinois, United States of America
- * E-mail:
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Patel SV, Kidane B, Klingel M, Parry N. Risks associated with red blood cell transfusion in the trauma population, a meta-analysis. Injury 2014; 45:1522-33. [PMID: 24975652 DOI: 10.1016/j.injury.2014.05.015] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2014] [Revised: 05/14/2014] [Accepted: 05/15/2014] [Indexed: 02/02/2023]
Abstract
INTRODUCTION A previous meta-analysis has found an association between red blood cell (RBC) transfusions and mortality in critically ill patients, but no review has focused on the trauma population only. OBJECTIVES To determine the association between RBC transfusion and mortality in the trauma population, with secondary outcomes of multiorgan failure (MOF) and acute respiratory distress syndrome (ARDS) or acute lung injury (ALI). DATA SOURCES EMBASE (1947-2012) and MEDLINE (1946-2012). STUDY ELIGIBILITY CRITERIA Randomized controlled trials and observational studies were to be included if they assessed the association between RBC transfusion and either the primary (mortality) or secondary outcomes (MOF, ARDS/ALI). PARTICIPANTS Trauma patients. EXPOSURE Red blood cell transfusion. METHODS A literature search was completed and reviewed in duplicate to identify eligible studies. Studies were included in the pooled analyses if an attempt was made to determine the association between RBC and the outcomes, after adjusting for important confounders. A random effects model was used for and heterogeneity was quantified using the I(2) statistic. Study quality was assessed using the Newcastle-Ottawa Scale. RESULTS 40 observational studies were included in the qualitative review. Including studies which adjusted for important confounders found the odds of mortality increased with each additional unit of RBC transfused (9 Studies, OR 1.07, 95%CI 1.04-1.10, I(2) 82.9%). The odds of MOF (3 studies, OR 1.08, 95%CI 1.02-1.14, I(2) 95.9%) and ARDS/ALI (2 studies, OR 1.06, 95%CI 1.03-1.10, I(2) 0%) also increased with each additional RBC unit transfused. CONCLUSIONS We have found an association between RBC transfusion and the primary and secondary outcomes, based on observational studies only. This represents the extent of the published literature. Further interventional studies are needed to clarify how limiting transfusion can affect mortality and other outcomes.
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Affiliation(s)
- Sunil V Patel
- London Health Sciences Centre, London, Ontario, Canada.
| | - Biniam Kidane
- London Health Sciences Centre, London, Ontario, Canada.
| | | | - Neil Parry
- London Health Sciences Centre, London, Ontario, Canada.
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McBeth PB, Sass K, Nickerson D, Ball CG, Kirkpatrick AW. A necessary evil? Intra-abdominal hypertension complicating burn patient resuscitation. J Trauma Manag Outcomes 2014; 8:12. [PMID: 25132864 PMCID: PMC4134468 DOI: 10.1186/1752-2897-8-12] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2013] [Accepted: 08/01/2014] [Indexed: 12/14/2022]
Abstract
Objective Severe burns are devastating injuries that result in considerable systemic inflammation and often require resuscitation with large volumes of fluid. The result of massive resuscitation is often raised intra-abdominal pressures leading to Intra-abdominal hypertension (IAH) and the secondary abdominal compartment syndrome. The objective of this study is to conduct (1) a 10 year retrospective study to investigate epidemiological factors contributing to burn injuries in Alberta, (2) to characterize fluid management and incidence of IAH and ACS and (3) to review fluid resuscitation with a goal to identify optimal strategies for fluid resuscitation. Design A comprehensive 10-year retrospective review of burn injuries from 1999. Outcome Measures Age, sex, date, mechanism of injury, location of incident, on scene vitals and GCS, type of transport to hospital and routing, ISS, presenting vitals and GCS, diagnoses, procedures, complications, hospital LOS, ICU LOS, and events surrounding the injury. Results One hundred and seventy five patients (79.4% M, 20.6% F) were identified as having traumatic burn injuries with a mean ISS score of 21.8 (±8.3). The mean age was 41.6 (±17.5) (range 14-94) years. Nearly half (49.7%) of patients suffered their injuries at home, 17.7% were related to industrial incidents and 14.3% were MVC related. One hundred and ten patients required ICU admission. ICU LOS 18.5 (±8.8) days. Hospital LOS 38.0 (±37.8) days. The mean extent of burn injury was 31.4 (±20.9) % TBSA. Nearly half of the patients suffered inhalational injuries (mild 12.5%, moderate 13.7%, severe 9.1%). Thirty-nine (22.2%) of patients died from their injuries. Routine IAP monitoring began in September, 2005 with 15 of 28 patients having at least two IAP measurements. The mean IAP was 16.5 (±5.7) cm H2O (range: 1-40) with an average of 58 (±97) IAP measurements per patient. Those patients with IAP monitoring had an average TBSA of 35.0 (±16.0)%, ISS of 47.5 (±7.5). The mean 48 hr fluid balance was 25.6 (±11.1)L exceeding predicted Parkland formula estimates by 86 (±32)%. Conclusions Further evaluation of IAP monitoring is needed to further characterize IAP and fluid resuscitation in patients with burn injuries.
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Affiliation(s)
- Paul B McBeth
- Departments of Surgery, Foothills Medical Centre, University of Calgary, Calgary, Alberta, Canada
| | - Kim Sass
- Departments of Surgery, Foothills Medical Centre, University of Calgary, Calgary, Alberta, Canada
| | - Duncan Nickerson
- Departments of Surgery, Foothills Medical Centre, University of Calgary, Calgary, Alberta, Canada
| | - Chad G Ball
- Departments of Surgery, Foothills Medical Centre, University of Calgary, Calgary, Alberta, Canada
| | - Andrew W Kirkpatrick
- Departments of Surgery, Foothills Medical Centre, University of Calgary, Calgary, Alberta, Canada ; Critical Care Medicine, Foothills Medical Centre, University of Calgary, Calgary, Alberta, Canada ; Regional Trauma Program, Foothills Medical Centre, University of Calgary, 1403 - 29th Street N.W., Calgary, Alberta, Canada
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Roger C, Muller L, Deras P, Louart G, Nouvellon E, Molinari N, Goret L, Gris J, Ripart J, de La Coussaye J, Lefrant J. Does the type of fluid affect rapidity of shock reversal in an anaesthetized-piglet model of near-fatal controlled haemorrhage? A randomized study. Br J Anaesth 2014; 112:1015-23. [DOI: 10.1093/bja/aet375] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
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Cherian A, Udupi BP. Acute coagulopathy of trauma: Mechanism, monitoring, management. World J Anesthesiol 2014; 3:111-118. [DOI: 10.5313/wja.v3.i1.111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2013] [Revised: 01/14/2014] [Accepted: 02/20/2014] [Indexed: 02/06/2023] Open
Abstract
Coagulopathy is a well-known consequence of trauma and is the most common cause of mortality in the young. However, its cause and management is still controversial. A new concept in the understanding of coagulopathy in trauma is the occurrence of Acute coagulopathy of trauma (ACoT). ACoT is associated with hypo perfusion and tissue trauma as seen in massive injury. The incidence of coagulopathy increases with injury scores and is associated with higher number of ventilator days, higher morbidity and mortality. The process of coagulation is better described by the cell based model with a central role for platelets rather than the older plasma based model. This shift in our understanding supports the theory that ACoT results from the endothelial release of thrombomodulin and activated protein C in the presence of hypoperfusion. This in turn leads on to a hyperfibrinolytic and hypocoagulable state. Viscoelastic hemostatic assays are replacing the older tests like prothrombin time in the assessment of coagulopathy. These tests are accurate, determine the need for transfusion and can be performed at the point of care. Damage control resuscitation includes newer concepts like permissive hypotension, increased use of plasma as a part of massive transfusion protocols and damage control surgery.
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Holodinsky JK, Roberts DJ, Ball CG, Blaser AR, Starkopf J, Zygun DA, Stelfox HT, Malbrain ML, Jaeschke RC, Kirkpatrick AW. Risk factors for intra-abdominal hypertension and abdominal compartment syndrome among adult intensive care unit patients: a systematic review and meta-analysis. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2013; 17:R249. [PMID: 24144138 PMCID: PMC4057241 DOI: 10.1186/cc13075] [Citation(s) in RCA: 126] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/10/2013] [Accepted: 09/25/2013] [Indexed: 02/08/2023]
Abstract
Introduction Although intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) are associated with substantial morbidity and mortality among critically ill adults, it remains unknown if prevention or treatment of these conditions improves patient outcomes. We sought to identify evidence-based risk factors for IAH and ACS in order to guide identification of the source population for future IAH/ACS treatment trials and to stratify patients into risk groups based on prognosis. Methods We searched electronic bibliographic databases (MEDLINE, EMBASE, PubMed, and the Cochrane Database from 1950 until January 21, 2013) and reference lists of included articles for observational studies reporting risk factors for IAH or ACS among adult ICU patients. Identified risk factors were summarized using formal narrative synthesis techniques alongside a random effects meta-analysis. Results Among 1,224 citations identified, 14 studies enrolling 2,500 patients were included. The 38 identified risk factors for IAH and 24 for ACS could be clustered into three themes and eight subthemes. Large volume crystalloid resuscitation, the respiratory status of the patient, and shock/hypotension were common risk factors for IAH and ACS that transcended across presenting patient populations. Risk factors with pooled evidence supporting an increased risk for IAH among mixed ICU patients included obesity (four studies; odds ratio (OR) 5.10; 95% confidence interval (CI), 1.92 to 13.58), sepsis (two studies; OR 2.38; 95% CI, 1.34 to 4.23), abdominal surgery (four studies; OR 1.93; 95% CI, 1.30 to 2.85), ileus (two studies; OR 2.05; 95% CI, 1.40 to 2.98), and large volume fluid resuscitation (two studies; OR 2.17; 95% CI, 1.30 to 3.63). Among trauma and surgical patients, large volume crystalloid resuscitation and markers of shock/hypotension and metabolic derangement/organ failure were risk factors for IAH and ACS while increased disease severity scores and elevated creatinine were risk factors for ACS in severe acute pancreatitis patients. Conclusions Although several IAH/ACS risk factors transcend across presenting patient diagnoses, some appear specific to the population under study. As our findings were somewhat limited by included study methodology, the risk factors reported in this study should be considered candidate risk factors until confirmed by a large prospective multi-centre observational study.
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Smorenberg A, Ince C, Groeneveld ABJ. Dose and type of crystalloid fluid therapy in adult hospitalized patients. Perioper Med (Lond) 2013; 2:17. [PMID: 24472418 PMCID: PMC3964340 DOI: 10.1186/2047-0525-2-17] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2012] [Accepted: 07/04/2013] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVE In this narrative review, an overview is given of the pros and cons of various crystalloid fluids used for infusion during initial resuscitation or maintenance phases in adult hospitalized patients. Special emphasis is given on dose, composition of fluids, presence of buffers (in balanced solutions) and electrolytes, according to recent literature. We also review the use of hypertonic solutions. METHODS We extracted relevant clinical literature in English specifically examining patient-oriented outcomes related to fluid volume and type. RESULTS A restrictive fluid therapy prevents complications seen with liberal, large-volume therapy, even though restrictive fluid loading with crystalloids may not demonstrate large hemodynamic effects in surgical or septic patients. Hypertonic solutions may serve the purpose of small volume resuscitation but carry the disadvantage of hypernatremia. Hypotonic solutions are contraindicated in (impending) cerebral edema, whereas hypertonic solutions are probably more helpful in ameliorating than in preventing this condition and improving outcome. Balanced solutions offer a better approach for plasma composition than unbalanced ones, and the evidence for benefits in patient morbidity and mortality is increasing, particularly by helping to prevent acute kidney injury. CONCLUSIONS Isotonic and hypertonic crystalloid fluids are the fluids of choice for resuscitation from hypovolemia and shock. The evidence that balanced solutions are superior to unbalanced ones is increasing. Hypertonic saline is effective in mannitol-refractory intracranial hypertension, whereas hypotonic solutions are contraindicated in this condition.
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Affiliation(s)
- Annemieke Smorenberg
- Department of Intensive Care, Erasmus Medical Centre, ‘s-Gravendijkwal 230, 3015, CE, Rotterdam, The Netherlands
| | - Can Ince
- Department of Intensive Care, Erasmus Medical Centre, ‘s-Gravendijkwal 230, 3015, CE, Rotterdam, The Netherlands
| | - AB Johan Groeneveld
- Department of Intensive Care, Erasmus Medical Centre, ‘s-Gravendijkwal 230, 3015, CE, Rotterdam, The Netherlands
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David JS, Spann C, Marcotte G, Reynaud B, Fontaine O, Lefèvre M, Piriou V. Haemorrhagic shock, therapeutic management. ACTA ACUST UNITED AC 2013; 32:497-503. [PMID: 23896213 DOI: 10.1016/j.annfar.2013.07.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
The management of a patient in post-traumatic haemorrhagic shock will meet different logics that will apply from the prehospital setting. This implies that the patient has beneficiated from a "Play and Run" prehospital strategy and was sent to a centre adapted to his clinical condition capable of treating all haemorrhagic lesions. The therapeutic goals will be to control the bleeding by early use of tourniquet, pelvic girdle, haemostatic dressing, and after admission to the hospital, the implementation of surgical and/or radiological techniques, but also to address all the factors that will exacerbate bleeding. These factors include hypothermia, acidosis and coagulopathy. The treatment of these contributing factors will be associated to concepts of low-volume resuscitation and permissive hypotension into a strategy called "Damage Control Resuscitation". Thus, the objective in situation of haemorrhagic shock will be to not exceed a systolic blood pressure of 90 mmHg (in the absence of severe head trauma) until haemostasis is achieved.
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Affiliation(s)
- J-S David
- Department of Anaesthesia and Intensive Care, Lyon Sud Hospital, Hospices Civils de Lyon, 69495 Pierre-Bénite cedex, France.
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Use of an abdominal reapproximation anchor (ABRA) system in a patient with abdominal compartment syndrome after severe burns: A case report. Burns 2013. [DOI: 10.1016/j.burns.2012.10.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Gao J, Zhou L, Ge Y, Lin S, Du J. Effects of different resuscitation fluids on pulmonary expression of aquaporin1 and aquaporin5 in a rat model of uncontrolled hemorrhagic shock and infection. PLoS One 2013; 8:e64390. [PMID: 23741323 PMCID: PMC3669317 DOI: 10.1371/journal.pone.0064390] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2013] [Accepted: 04/13/2013] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND To investigate the effects of fluids resuscitation on pulmonary expression of aquaporin1 and aquaporin5 in a rat model of uncontrolled hemorrhagic shock and infection. METHODS Sixty Sprague-Dawley rats were randomly assigned to five groups, sham operation group (Group C) and four treated groups: no fluid resuscitation group (Group NF), groups resuscitated with Lactated Ringer's (LR),7.5% NaCl (HTS) and Hydroxyl ethyl starch (HES) respectively. Three-phased uncontrolled hemorrhagic shock and infection model was used. Phase I: Massive hemorrhage with a mean arterial pressure of 35-40 mmHg for 60 min, and followed by infection of lipopolysaccharide. Then some animals were resuscitated with solutions mentioned above, until 90 min. Phase II: At hemorrhagic shock 90 minutes, phase II of 60 minutes began with hemostasis and returning of all the initial shed blood. Phase III: Observation phase for 3.5 hours. After phase III, arterial blood gas analysis and the survival rates of the rats were recorded, Wet-to-dry lung weight ratio, BALF protein, pulmonary permeability index, and expressions of aquaporin1 and aquaporin5 were tested. RESULTS The expressions of aquaporin1 and aquaporin5 were decreased in treatment groups comparing with sham operation group. Group HES and Group HTS decreased pulmonary vascular permeability and Wet-to-dry lung weight ratio, improved arterial blood gas analysis and survival rates, and attenuated the decreased pulmonary expression of aquaporin1 and aquaporin5 after the "two-hit", comparing with groups NF and LR,but these beneficial effects were blunted in group HTS. CONCLUSION The expression of aquaporin1 and aquaporin5 may play important roles in formation of pulmonary edema. Resuscitation with HTS and HES, especially HES can reduce lung injury after hemorrhagic shock, partly by up-regulating the expressions of aquaporin1 and aquaporin5.
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Affiliation(s)
- Ju Gao
- Department of Anesthesiology, Subei People's Hospital (Clinical Medical College of Yangzhou University), Yangzhou, Jiangsu Province, People's Republic of China.
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Intra-abdominal hypertension and the abdominal compartment syndrome: updated consensus definitions and clinical practice guidelines from the World Society of the Abdominal Compartment Syndrome. Intensive Care Med 2013; 39:1190-206. [PMID: 23673399 PMCID: PMC3680657 DOI: 10.1007/s00134-013-2906-z] [Citation(s) in RCA: 789] [Impact Index Per Article: 71.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2013] [Accepted: 03/18/2013] [Indexed: 02/06/2023]
Abstract
Purpose To update the World Society of the Abdominal Compartment Syndrome (WSACS) consensus definitions and management statements relating to intra-abdominal hypertension (IAH) and the abdominal compartment syndrome (ACS). Methods We conducted systematic or structured reviews to identify relevant studies relating to IAH or ACS. Updated consensus definitions and management statements were then derived using a modified Delphi method and the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) guidelines, respectively. Quality of evidence was graded from high (A) to very low (D) and management statements from strong RECOMMENDATIONS (desirable effects clearly outweigh potential undesirable ones) to weaker SUGGESTIONS (potential risks and benefits of the intervention are less clear). Results In addition to reviewing the consensus definitions proposed in 2006, the WSACS defined the open abdomen, lateralization of the abdominal musculature, polycompartment syndrome, and abdominal compliance, and proposed an open abdomen classification system. RECOMMENDATIONS included intra-abdominal pressure (IAP) measurement, avoidance of sustained IAH, protocolized IAP monitoring and management, decompressive laparotomy for overt ACS, and negative pressure wound therapy and efforts to achieve same-hospital-stay fascial closure among patients with an open abdomen. SUGGESTIONS included use of medical therapies and percutaneous catheter drainage for treatment of IAH/ACS, considering the association between body position and IAP, attempts to avoid a positive fluid balance after initial patient resuscitation, use of enhanced ratios of plasma to red blood cells and prophylactic open abdominal strategies, and avoidance of routine early biologic mesh use among patients with open abdominal wounds. NO RECOMMENDATIONS were possible regarding monitoring of abdominal perfusion pressure or the use of diuretics, renal replacement therapies, albumin, or acute component-parts separation. Conclusion Although IAH and ACS are common and frequently associated with poor outcomes, the overall quality of evidence available to guide development of RECOMMENDATIONS was generally low. Appropriately designed intervention trials are urgently needed for patients with IAH and ACS. Electronic supplementary material The online version of this article (doi:10.1007/s00134-013-2906-z) contains supplementary material, which is available to authorized users.
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Bouglé A, Harrois A, Duranteau J. Resuscitative strategies in traumatic hemorrhagic shock. Ann Intensive Care 2013; 3:1. [PMID: 23311726 PMCID: PMC3626904 DOI: 10.1186/2110-5820-3-1] [Citation(s) in RCA: 96] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2012] [Accepted: 12/01/2012] [Indexed: 01/06/2023] Open
Abstract
Managing trauma patients with hemorrhagic shock is complex and difficult. Despite our knowledge of the pathophysiology of hemorrhagic shock in trauma patients that we have accumulated during recent decades, the mortality rate of these patients remains high. In the acute phase of hemorrhage, the therapeutic priority is to stop the bleeding as quickly as possible. As long as this bleeding is uncontrolled, the physician must maintain oxygen delivery to limit tissue hypoxia, inflammation, and organ dysfunction. This process involves fluid resuscitation, the use of vasopressors, and blood transfusion to prevent or correct acute coagulopathy of trauma. The optimal resuscitative strategy is controversial. To move forward, we need to establish optimal therapeutic approaches with clear objectives for fluid resuscitation, blood pressure, and hemoglobin levels to guide resuscitation and limit the risk of fluid overload and transfusion.
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Affiliation(s)
- Adrien Bouglé
- Departement of Anesthesia and Intensive Care, Bicêtre Hospital, Hôpitaux universitaires Paris-Sud, Université Paris-Sud, Assistance Publique-Hôpitaux de Paris, 78, rue du Général Leclerc, 94275, Le Kremlin Bicêtre, France.
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Chen CH, Tsai PS, Huang CJ. Minocycline ameliorates lung and liver dysfunction in a rodent model of hemorrhagic shock/resuscitation plus abdominal compartment syndrome. J Surg Res 2012; 180:301-9. [PMID: 22591920 DOI: 10.1016/j.jss.2012.04.036] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2012] [Revised: 04/06/2012] [Accepted: 04/17/2012] [Indexed: 01/07/2023]
Abstract
BACKGROUND We sought to elucidate whether minocycline, a broad-spectrum tetracycline antibiotic with potent anti-inflammation capacity, could mitigate inflammatory response and organ dysfunction in the lungs and liver induced by hemorrhagic shock/resuscitation (HS) plus abdominal compartment syndrome (ACS). MATERIALS AND METHODS Adult male rats were randomized to receive HS plus ACS or HS plus ACS plus minocycline (denoted as the HS/A and HS/A-M group, respectively; n = 12). Sham-instrumentation groups were employed to serve as the controls. Hemorrhagic shock/resuscitation was induced by blood drawing (mean arterial pressure: 40-45 mm Hg for 60 min) followed by shed blood/saline mixture reinfusion. Subsequently, intra-abdominal pressure (IAP) was increased to 25 mm Hg by injecting air into the preplaced intraperitoneal latex balloon to induce ACS. Minocycline (20 mg/kg) was intravenously administered immediately after resuscitation. IAP was maintained at 25 mm Hg for 6 h. Then, all rats were euthanized. RESULTS The levels of polymorphonuclear leukocyte infiltration, the wet/dry weight ratio, and the concentrations of inflammatory molecules (e.g., chemokine, cytokine, and prostaglandin E2) in lung and liver tissues of the HS/A group were significantly higher than those of the HS/A-M groups (all P < 0.05). Moreover, the levels of lung dysfunction (assayed by arterial blood gas) and liver dysfunction (assayed by plasma concentrations of bilirubin, aspartate aminotransferase, and alaninine aminotransferase) of the HS/A group were significantly higher than those of the HS/A-M group (all P < 0.05). CONCLUSIONS Minocycline ameliorates inflammatory response and organ dysfunction in the lungs and liver induced by hemorrhagic shock/resuscitation plus abdominal compartment syndrome.
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Affiliation(s)
- Cay-Huyen Chen
- Department of Anesthesiology, Buddhist Tzu Chi General Hospital, Taipei Branch, Taipei, Taiwan; School of Medicine, Tzu Chi University, Hualien, Taiwan
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Shah SK, Jimenez F, Letourneau PA, Walker PA, Moore-Olufemi SD, Stewart RH, Laine GA, Cox CS. Strategies for modulating the inflammatory response after decompression from abdominal compartment syndrome. Scand J Trauma Resusc Emerg Med 2012; 20:25. [PMID: 22472164 PMCID: PMC3352320 DOI: 10.1186/1757-7241-20-25] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2011] [Accepted: 04/03/2012] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Management of the open abdomen is an increasingly common part of surgical practice. The purpose of this review is to examine the scientific background for the use of temporary abdominal closure (TAC) in the open abdomen as a way to modulate the local and systemic inflammatory response, with an emphasis on decompression after abdominal compartment syndrome (ACS). METHODS A review of the relevant English language literature was conducted. Priority was placed on articles published within the last 5 years. RESULTS/CONCLUSION Recent data from our group and others have begun to lay the foundation for the concept of TAC as a method to modulate the local and/or systemic inflammatory response in patients with an open abdomen resulting from ACS.
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Affiliation(s)
- Shinil K Shah
- Department of Pediatric Surgery, University of Texas Medical School at Houston, Houston, Texas, USA
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Arginine vasopressin: the future of pressure-support resuscitation in hemorrhagic shock. J Surg Res 2012; 178:321-9. [PMID: 22480832 DOI: 10.1016/j.jss.2012.02.062] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2011] [Revised: 02/01/2012] [Accepted: 02/29/2012] [Indexed: 11/21/2022]
Abstract
BACKGROUND Arginine vasopressin (AVP) is a key player in maintaining the intravascular volume and pressure during hemorrhagic shock. During the past 2 decades, animal studies, case reports, and reviews have documented the minimized blood loss and improved perfusion pressures in those receiving pressure support with AVP. MATERIALS AND METHODS A PubMed search of studies was conducted with the terms: "AVP," "arginine vasopressin," "antidiuretic hormone," "hemorrhagic shock," "hemorrhage," "circulatory shock," "fluid resuscitation," "trauma," "massive transfusion protocol," "physiology," "cerebral," "renal," "cardiac," "perfusion," "dose," and "hypotension." The studies were located by a search of a combination of these terms. Also, within-PubMed citations relating to the studies gathered from the initial search were explored. Reports discussing vasopressin in hemorrhagic states were considered. No predetermined limit was used to choose or exclude articles. RESULTS AVP is an important hormone in osmoregulation and blood pressure. During stress, such as hemorrhage, the levels have been shown to rapidly decrease. Furthermore numerous animal studies and limited human studies have shown that circulatory support with AVP is linked to improved outcomes. No large human prospective studies are available to guide its use at present, but some of its effectiveness seems to lie in its ability to increase calcium sensitivity in acidotic environs, thereby allowing for more effective maintenance of vascular tone than catecholamines. It also redirects blood from the periphery, creating a steal syndrome, and increases the oxygen supply to vital organs, minimizing blood loss, and allowing additional time for surgical repair. CONCLUSIONS With these encouraging data, there is hope that "pressure support" will be the "resuscitation" considered necessary for a patient's optimum survival.
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Joynt GM, Wai JKM. Intra-Abdominal Hypertension and Abdominal Compartment Syndrome – Making Progress? Anaesth Intensive Care 2012; 40:11-3. [DOI: 10.1177/0310057x1204000102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- G. M. Joynt
- Department of Anaesthesia and Intensive Care, Chinese University of Hong Kong and Intensive Care Unit, Prince of Wales Hospital, Shatin, Hong Kong
| | - J. K. M. Wai
- Department of Anaesthesia and Intensive Care, Chinese University of Hong Kong and Intensive Care Unit, Prince of Wales Hospital, Shatin, Hong Kong
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