Benchmarking the incidence of organ failure after injury at trauma centers and nontrauma centers in the United States

Postinjury multiple organ failure in polytrauma: more frequent and potentially less deadly with less crystalloid

BACKGROUND

Recently, retrospective registry-based studies have reported the decreasing incidence and increasing mortality of postinjury multiple organ failure (MOF). We aimed to describe the current epidemiology of MOF following the introduction of haemostatic resuscitation.

METHODS

A 10-year prospective cohort study was undertaken at a Level-1 Trauma Centre-based ending in December 2015. Inclusion criteria age ≥ 16 years, Injury Severity Score (ISS) > 15, Abbreviated Injury Scale (AIS) Head < 3 and survived > 48 h. Demographics, physiological and shock resuscitation parameters were collected. The primary outcome was MOF defined by a Denver Score > 3.

SECONDARY OUTCOMES

intensive care unit length of stay (ICU LOS), ventilation days and mortality.

RESULTS

Three hundred and forty-seven patients met inclusion criteria (age 48 ± 20; ISS 30 ± 11, 248 (71%) were males and 23 (6.6%) patients died. The 74 (21%) MOF patients (maximum Denver Score: 5.5 ± 1.8; Duration; 5.6 ± 5.8 days) had higher ISS (32 ± 11 versus 29 ± 11) and were older (54 ± 19 versus 46 ± 20 years) than non-MOF patients. Mean daily Denver scores adjusted for age, sex, MOF and ISS did not change over time. Crystalloid usage decreased over the 10-year period (p value < 0.01) and PRBC increased (p value < 0.01). Baseline cumulative incidence of MOF at 28 days was 9% and competing risk analyses showed that incidence of MOF increased over time (subdistribution hazard ratio 1.14, 95% CI 1.04 to 1.23, p value < 0.01). Mortality risk showed no temporal change. ICU LOS increased over time (subdistribution hazard ratio 0.95, 95% CI 0.92 to 0.98, p value < 0.01). Ventilator days increased over time (subdistribution hazard ratio 0.94, 95% CI 0.9 to 0.97, p value < 0.01).

CONCLUSION

The epidemiology of MOF continues to evolve. Our prospective cohort suggests an ageing population with increasing incidence of MOF, particularly in males, with little changes in injury or shock parameters, who are being resuscitated with less crystalloids, stay longer on ICU without improvement in survival.

Epidemiology and outcomes of multiple organ dysfunction syndrome following pediatric trauma

BACKGROUND

Existing studies have found a low prevalence of multiple organ dysfunction syndrome (MODS) in pediatric trauma patients, typically applying adult criteria to single-center pediatric cohorts. We used pediatric criteria to determine the prevalence, risk factors, and outcomes of MODS among critically injured children in a national pediatric intensive care unit (PICU) database.

METHODS

We conducted a retrospective cohort study of PICU patients 1 month to 17 years with traumatic injury in the Virtual Pediatric Systems, LLC database from 2009 to 2017. We used International Pediatric Sepsis Consensus Conference criteria to identify MODS on Day 1 of PICU admission and estimated the risk of mortality and poor functional outcome (Pediatric Overall/Cerebral Performance Category ≥3 with ≥1 point worsening from baseline) for MODS and for each type of organ dysfunction using generalized linear Poisson regression adjusted for age, comorbidities, injury type and mechanism, and postoperative status.

RESULTS

Multiple organ dysfunction syndrome was present on PICU Day 1 in 23.1% of 37,177 trauma patients (n = 8,592), with highest risk among patients with injuries associated with drowning, asphyxiation, and abuse. Pediatric intensive care unit mortality was 20.1% among patients with MODS versus 0.5% among patients without MODS (adjusted relative risk, 32.3; 95% confidence interval, 24.1-43.4). Mortality ranged from 1.5% for one dysfunctional organ system to 69.1% for four or more organ systems and was highest among patients with hematologic dysfunction (43.3%) or renal dysfunction (29.6%). Death or poor functional outcome occurred in 46.7% of MODS patients versus 8.3% of patients without MODS (adjusted relative risk, 4.3; 95% confidence interval 3.4-5.3).

CONCLUSION

Multiple organ dysfunction syndrome occurs more frequently following pediatric trauma than previously reported and is associated with high risk of morbidity and mortality. Based on existing literature using identical methodology, both the prevalence and mortality associated with MODS are higher among trauma patients than the general PICU population. Consideration of early organ dysfunction in addition to injury severity may aid prognostication following pediatric trauma.

LEVEL OF EVIDENCE

Prognostic and Epidemiological; Level III.

Organ failure, aetiology and 7-day all-cause mortality among acute adult patients on arrival to an emergency department: a hospital-based cohort study

BACKGROUND

Organ failure is both a frequent and dangerous condition among adult patients on arrival to an emergency department (ED). The risk of an unfavourable outcome could depend on the underlying aetiology. Knowledge of the relation between aetiology and prognosis could improve the risk stratification at arrival.

OBJECTIVES

To describe the relation between organ failure, aetiology and prognosis through 7-day all-cause mortality.

METHODS

An observational three-year cohort study at the ED at Odense University Hospital, Denmark, including all acute adult patients.First-measured vital signs and laboratory values were included to evaluate the presence of the following organ failures: respiratory, coagulation, hepatic, circulatory, cerebral or renal.The primary outcome was 7-day all-cause mortality. Aetiological disease categories were based on primary discharge diagnoses. We described the association between 7-day mortality, aetiology category, site of organ failures and number of patients at risk.

RESULTS

Of 40 423 patients with a first-time visit at the ED, 5883(14.6%) had an organ failure on arrival. The median age was 69 (IQR 54-80), and 50% were men. The most frequent aetiology was infection (1495, 25.4%). Seven-day all-cause mortality ranged between aetiologies from 0.0% (95% confidence interval [CI], 0.0-14.2) allergy) to 45.6% (95% CI, 41.3-50.0) (cardiac). Combining aetiology and site of organ failure, 7-day all-cause mortality was the highest in the cardiac category, from 14.8% (95% CI, 4.2-3.7) with hepatic failure to 79.2% (95% CI, 73.6-84.1) with cerebral failure. The combination of infection and respiratory failure characterised most patients (n = 949).

CONCLUSION

Infection was the most prevalent aetiology, and 7-day all-cause mortality was highly associated with the site of organ failure and aetiology.

Changes in the incidence and outcome of multiple organ failure in emergency non-cardiac surgical admissions: a 10-year retrospective observational study

BACKGROUND

During the past decades, epidemiologic data of independent predictors of multiple organ failure (MOF), incidence, and mortality have changed. The aim of the study was to assess the potential changes in the incidence and outcomes of MOF for one decade (2008-2017). In addition, resource utilization was considered.

METHODS

Patients were eligible for inclusion if they were adults, admitted to the ICU between January 1, 2008 and December 31, 2017, and had complete data sets regarding MOF. MOF was defined as organ failure separately with and without central nervous system (CNS) failure. The onset of MOF was defined as being early (≤48 h of ICU admission) and late (>48 h after ICU admission).

RESULTS

Of a total of 13,270 patients enclosed in this study, 44.6% of the patients developed MOF with and 31.4% without CNS failure. MOF-related mortality decreased in patients with (adjusted IRR 0.972 [95% CI 0.948 to 0.996], P=0.022) and without (adjusted IRR 0.957 [95% CI 0.931 to 0.983], P=0.0013) CNS failure. In addition, the incidence (adjusted IRR 0.970 [95% CI 0.950 to 0.991], P=0.006) and mortality (adjusted IRR 0.968 [95% CI 0.940 to 0.996], P=0.025) of early-onset MOF decreased, while the incidence and mortality of late-onset MOF remained constant. The length of ICU (P=0.024) and hospital (P=0.032) stays decreased while the length of mechanical ventilation remained constant (P=0.41).

CONCLUSIONS

Despite all improvements in intensive care during the last decades, the incidence of late-onset MOF remains a resource-intensive, morbid, and lethal condition. More research on etiologies, signs of organ failure, and where and when to start treatment is needed to improve the prognosis of late-onset MOF.

Precious cargo: Modulation of the mesenteric lymph exosome payload after hemorrhagic shock

BACKGROUND

Trauma/hemorrhagic shock (T/HS) causes a release of proinflammatory mediators into the mesenteric lymph (ML) that may trigger a systemic inflammatory response and subsequent organ failure. Recently, we showed that exosomes in postshock ML are biologically active mediators of this inflammation. Because the specific inflammatory mediators in postshock ML exosomes have yet to be characterized, we hypothesized that T/HS would lead to a distinct ML proinflammatory exosome phenotype that could be identified by proteomic analysis. We further hypothesized that their regulation by the neuroenteric axis via the vagus nerve would modify this proinflammatory profile.

METHODS

Male rats underwent an established T/HS model including 60 minutes of HS followed by resuscitation. Mesenteric lymph was collected before HS (preshock) and after resuscitation (postshock). A subset of animals underwent cervical vagus nerve electrical stimulation (VNS) after the HS phase. Liquid chromatography with tandem mass spectroscopy (LC-MS/MS) followed by protein identification, label free quantification, and bioinformatic analysis was performed on exosomes from the pre-shock and post-shock phases in the T/HS and T/HS + vagus nerve electrical stimulation groups. Biological activity of exosomes was evaluated using a monocyte nuclear factor kappa B (NF-κB) activity assay.

RESULTS

ML exosomes express a distinct protein profile after T/HS with enrichment in pathways associated with cell signaling, cell death and survival, and the inflammatory response. Stimulation of the vagus nerve following injury attenuated the transition of ML exosomes to this T/HS-induced inflammatory phenotype with protein expression remaining similar to pre-shock. Monocyte NF-κB activity was increased after exposure to ML exosomes harvested after T/HS, while ML exosomes from preshock had no effect on monocyte NF-κB expression.

CONCLUSION

Postshock ML exosomes carry a distinct, proinflammatory protein cargo. Stimulating the vagus nerve prevents the T/HS-induced changes in ML exosome protein payload and suggests a novel mechanism by which the neuroenteric axis may limit the systemic inflammatory response after injury.

How to detect a polytrauma patient at risk of complications: A validation and database analysis of four published scales

Introduction

Early accurate assessment of the clinical status of severely injured patients is crucial for guiding the surgical treatment strategy. Several scales are available to differentiate between risk categories. They vary between expert recommendations and scores developed on the basis of patient data (level II). We compared four established scoring systems in regard to their predictive abilities for early (e.g., hemorrhage-induced mortality) versus late (Multiple Organ Failure (MOF), sepsis, late death) in-hospital complications.

Methods

A database from a level I trauma center was used. The inclusion criteria implied an injury severity score (ISS) of ≥16 points, primary admission, and a complete data set from admission to hospital-day 21. The following four scales were tested: the clinical grading scale (CGS; covers acidosis, shock, coagulation, and soft tissue injuries), the modified clinical grading scale (mCGS; covers CGS with modifications), the polytrauma grading score (PTGS; covers shock, coagulation, and ISS), and the early appropriate care protocol (EAC; covers acid–base changes). Admission values were selected from each scale and the following endpoints were compared: mortality, pneumonia, sepsis, death from hemorrhagic shock, and multiple organ failure.

Statistics

Shapiro-Wilk test for normal distribution, Pearson Chi square, odds ratios (OR) for all endpoints, 95% confidence intervals. Fitted, generalized linear models were used for prediction analysis. Krippendorff was used for comparison of CGS and mCGS. Alpha set at 0.05.

Results

In total, 3668 severely injured patients were included (mean age, 45.8±20 years; mean ISS, 28.2±15.1 points; incidence of pneumonia, 19.0%; incidence of sepsis, 14.9%; death from hem. shock, 4.1%; death from multiple organ failure (MOF), 1.9%; mortality rate, 26.8%). Our data show distinct differences in the prediction of complications, including mortality, for these scores (OR ranging from 0.5 to 9.1). The PTGS demonstrated the highest predictive value for any late complication (OR = 2.0), sepsis (OR = 2.6, p = 0.05), or pneumonia (OR = 2.0, p = 0.2). The EAC demonstrated good prediction for hemorrhage-induced early mortality (OR = 7.1, p<0.0001), but did not predict late complications (sepsis, OR = 0.8 and p = 0.52; pneumonia, OR = 1.1 and p = 0.7) CGS and mCGS are not comparable and should not be used interchangeably (Krippendorff α = 0.045).

Conclusion

Our data show that prediction of complications is more precise after using values that covers different physiological systems (coagulation, hemorrhage, acid–base changes, and soft tissue damage) when compared with using values of only one physiological system (e.g., acidosis). When acid–base changes alone were tested in terms of complications, they were predictive of complications within 72 hours but failed to predict late complications. These findings should be considered when performing early assessment of trauma patients or for the development of new scores.

Prevalence of organ failure and mortality among patients in the emergency department: a population-based cohort study

OBJECTIVES

The aim was to describe population-based incidence and emergency department-based prevalence and 1-year all-cause mortality of patients with new organ failure present at arrival.

DESIGN

This was a population-based cohort study of all citizens in four municipalities (population of 230 000 adults).

SETTING

Emergency department at Odense University Hospital, Denmark.

PARTICIPANTS

We included all adult patients who arrived from 1 April 2012 to 31 March 2015.

PRIMARY AND SECONDARY OUTCOME MEASURES

Organ failure was defined as a modified Sequential Organ Failure Assessment score≥2 within six possible organ systems: cerebral, circulatory, renal, respiratory, hepatic and coagulation.The primary outcome was prevalence of organ failure, and secondary outcomes were 0-7 days, 8-30 days and 31-365 days all-cause mortality.

RESULTS

We identified in total 175 278 contacts, of which 70 399 contacts were further evaluated for organ failure. Fifty-two per cent of these were women, median age 62 (IQR 42-77) years. The incidence of new organ failure was 1342/100 000 person-years, corresponding to 5.2% of all emergency department contacts.The 0-7-day, 8-30-day and 31-365-day mortality was 11.0% (95% CI: 10.2% to 11.8%), 5.6% (95% CI: 5.1% to 6.2%) and 13.2% (95% CI: 12.3% to 14.1%), respectively, if the patient had one or more new organ failures at first contact in the observation period, compared with 1.4% (95% CI: 1.3% to 1.6%), 1.2% (95% CI: 1.1% to 1.3%) and 5.2% (95% CI: 5.0% to 5.4%) for patients without. Seven-day mortality ranged from hepatic failure, 6.5% (95% CI: 4.9% to 8.6%), to cerebral failure, 33.8% (95% CI: 31.0% to 36.8%), the 8-30-day mortality ranged from cerebral failure, 3.9% (95% CI: 2.8% to 5.3%), to hepatic failure, 8.6% (95% CI: 6.6% to 10.8%) and 31-365-day mortality ranged from cerebral failure, 9.3% (95% CI: 7.6% to 11.2%), to renal failure, 18.2% (95% CI: 15.5% to 21.1%).

CONCLUSIONS

The study revealed an incidence of new organ failure at 1342/100 000 person-years and a prevalence of 5.2% of all emergency department contacts. One-year all-cause mortality was 29.8% among organ failure patients.

Prevalence and prognosis of acutely ill patients with organ failure at arrival to hospital: A systematic review

Introduction

Patients in an emergency department are diverse. Some are more seriously ill than others and some even arrive in multi-organ failure. Knowledge of the prevalence of organ failure and its prognosis in unselected patients is important from a diagnostic, hospital planning, and from a quality evaluation point of view, but is not reported systematically.

Objectives

To analyse the prevalence and prognosis of new onset organ failure in unselected acute patients at arrival to hospital.

Methods

A systematic review of studies of prevalence and prognosis of acutely ill patients with organ failure at arrival to hospital. We searched PubMed, Cochrane Library, Embase and Cinahl, and read references in included studies. Two authors decided independently on study eligibility and extracted data. Results were summarised qualitatively.

Results

Four studies were included with a total of 678,960 patients. The number of different organ failures reported in the studies ranged from one to six, and the settings were emergency departments and wards. The definitions of organ failure varied between studies. The prevalence of organ failure was 7%, 14%, 14%, and 23%, and in-hospital mortality was 5%, 11% and 15% respectively. The relative risk of in-hospital mortality for patients with organ failure compared to patients without organ failure varied from 2.58 to 8.65. Numbers of organ failures per 1,000 visits varied from 71 to 256.

Conclusion

The results of this review indicate that clinicians have good reasons to be alert when a patient arrives to the emergency department; as a state of organ failure seems both frequent and highly severe.

However, most studies identified were performed in patients after a diagnosis was established, and only very few studies were performed in unselected patients.

Systematic review registration number

PROSPERO: CRD42017060871.

Nicotinamide mononucleotide preserves mitochondrial function and increases survival in hemorrhagic shock

Hemorrhagic shock depletes nicotinamide adenine dinucleotide (NAD) and causes metabolic derangements that, in severe cases, cannot be overcome, even after restoration of blood volume and pressure. However, current strategies to treat acute blood loss do not target cellular metabolism. We hypothesized that supplemental nicotinamide mononucleotide (NMN), the immediate biosynthetic precursor to NAD, would support cellular energetics and enhance physiologic resilience to hemorrhagic shock. In a rodent model of decompensated hemorrhagic shock, rats receiving NMN displayed significantly reduced lactic acidosis and serum IL-6 levels, two strong predictors of mortality in human patients. In both livers and kidneys, NMN increased NAD levels and prevented mitochondrial dysfunction. Moreover, NMN preserved mitochondrial function in isolated hepatocytes cocultured with proinflammatory cytokines, indicating a cell-autonomous protective effect that is independent from the reduction in circulating IL-6. In kidneys, but not in livers, NMN was sufficient to prevent ATP loss following shock and resuscitation. Overall, NMN increased the time animals could sustain severe shock before requiring resuscitation by nearly 25% and significantly improved survival after resuscitation (P = 0.018), whether NMN was given as a pretreatment or only as an adjunct during resuscitation. Thus, we demonstrate that NMN substantially mitigates inflammation, improves cellular metabolism, and promotes survival following hemorrhagic shock.

Prevalence and prognosis of acutely ill patients with organ failure at arrival to hospital: protocol for a systematic review

BACKGROUND

Acutely ill patients are a heterogeneous group, and some of these suffer from organ failure. As the prognosis of organ failure improves with early treatment, it is important to identify these patients as early as possible. Most studies on organ failure have been performed in intensive care settings, or on selected groups of patients, where a high prevalence and mortality have been reported. Before patients arrive to the intensive care unit, or the general ward, most of them have passed through the emergency department (ED), where diagnosis and treatment has been initiated. The prevalence and prognosis of acutely ill patients, with organ failure, at arrival have been studied in some selected groups, but methods and results differ. This systematic review aims to identify, summarize, and analyze studies of prevalence and prognosis of new onset organ failure in acutely ill undifferentiated patients, at arrival to hospital. The result of the review will assist physicians working in an ED, when assessing patients' risk of organ failure and their associated prognosis.

METHODS

The information sources used are electronic databases, PubMed, Cochrane Library, EMBASE, and CINAHL; references in included studies and review articles; and authors' personal files. One author will perform the title and abstract screening and exclude obviously ineligible studies. By an independent full-text screening, two authors will decide on the eligibility for the remaining studies. Eligible studies will include an unselected group of acutely ill adult patients at arrival to hospital, with one or more organ failures (respiratory, renal, cerebral, circulatory, hepatic, or coagulation failure). Included studies will have assessed the prevalence or prognosis, defined as mortality or ICU transfer, of new onset organ failure. From included studies, bibliographical and study description data, patient characteristics, and data related to prevalence of organ failure and prognosis will be extracted. We will assess risk of bias in included studies using the Quality in Prognosis Studies tool for prognostic studies and the Newcastle-Ottawa Scale for observational studies. We expect heterogeneity and to conduct a qualitative synthesis of the results. If, however, heterogeneity is low, we will conduct a random effects meta-analysis stratified by basic study design.

DISCUSSION

This review will summarize and analyze studies of prevalence and prognosis of acutely ill patients, with organ failure at arrival to hospital, assist ED physicians assessing the risk of organ failure in unselected patients, and guide recommendations for further research.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42017060871.

Supplemental arginine vasopressin during the resuscitation of severe hemorrhagic shock preserves renal mitochondrial function

Arginine vasopressin (AVP), a hormone secreted by the posterior pituitary, plays a vital role in maintaining vasomotor tone during acute blood loss. We hypothesized that decompensated hemorrhagic shock is associated with decreased AVP stores and supplementation during resuscitation would improve both blood pressure and renal function. Using a decompensated hemorrhagic shock model, male Long-Evans rats were bled to mean arterial blood pressure (MAP) of 40mmHg and maintained until the MAP could not be sustained without fluid. Once 40% of the shed volume was returned in lactated Ringer’s (Severe Shock), animals were resuscitated over 60 minutes with 4x the shed volume in lactated Ringer’s (LR) or the same fluids with AVP (0.5 units/kg+ 0.03 units/kg/min). Animals (n = 6-9/group) were sacrificed before hemorrhage (Sham), at Severe Shock, following resuscitation (60R, 60R with AVP) or 18 hours post-resuscitation (18hr, 18hr with AVP). Blood samples were taken to measure AVP levels and renal function. Pituitaries were harvested and assayed for AVP. Kidney samples were taken to assess mitochondrial function, histology, and oxidative damage. Baseline pituitary AVP stores (30,364 ± 5311 pg/mg) decreased with severe shock and were significantly depressed post-resuscitation (13,910 ± 3016 pg/ml. p<0.05) and at 18hr (15,592 ±1169 pg/ml, p<0.05). Resuscitation with LR+AVP led to higher serum AVP levels at 60R (31±8 vs 79±12; p<0.01) with an improved MAP both at 60R (125±3 vs 77±7mmHg; p<0.01) and 18hr (82±6 vs 69±5mmHg;p<0.05). AVP supplementation preserved complex I respiratory capacity at 60R and both complex I and II function at 18hr (p<0.05). AVP was also associated with decreased reactive oxygen species at 60R (856±67 vs 622±48F RFU) and significantly decreased oxidative damage as measured by mitochondrial lipid peroxidation (0.9±0.1 vs 1.7±0.1 fold change, p<0.01) and nitrosylation (0.9±0.1 vs 1.4±0.2 fold change, p<0.05). With AVP, renal damage was mitigated at 60R and histologic architecture was conserved at 18 hours. In conclusion, pituitary and serum AVP levels decrease during severe hemorrhage and may contribute to the development of decompensated hemorrhagic shock. Supplementing exogenous AVP during resuscitation improves blood pressure, preserves renal mitochondrial function, and mitigates acute kidney injury.

Postinjury Inflammation and Organ Dysfunction

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.

Influence of intraoperative positive end-expiratory pressure level on pulmonary complications in emergency major trauma surgery

INTRODUCTION

Pulmonary complications have a major impact on the morbidity and mortality of critically ill patients with multiple trauma. Intraoperative protective ventilation with low tidal volume may prevent lung injury and infection, whereas the role of positive end-expiratory pressure (PEEP) levels is unclear. The aim of this study was to evaluate the influence of different intraoperative PEEP levels on incidence of pulmonary complications after emergency trauma surgery.

MATERIAL AND METHODS

We retrospectively analysed data of multiple trauma patients who underwent emergency surgery within 24 h after injury in our level I trauma centre (n = 86). On the basis of their intraoperative PEEP level, patients were divided into a low PEEP group with a PEEP of < 8 mbar and a high PEEP group with a PEEP of 8 mbar or higher.

RESULTS

Besides differences in body mass index and preoperative oxygenation, there were no differences in patients' baseline data. There was a significant difference between incidence of pneumonia within 7 days after trauma surgery, with an incidence 26.7% in the low PEEP group and 7.3% in the high PEEP group (p = 0.02). The low PEEP group had higher pulmonary infection scores at days 3 and 5 after surgery. Oxygenation was better in the higher PEEP group postoperatively. There was no difference with respect to the incidence of acute respiratory distress syndrome, the mortality up until hospital discharge or haemodynamic parameters between groups.

CONCLUSIONS

Higher PEEP levels were associated with perioperative improvement of oxygenation and a lower incidence of pneumonia, without impairment of haemodynamics. Additional studies should be initiated to confirm these observations.

Resveratrol Rescues Kidney Mitochondrial Function Following Hemorrhagic Shock

OBJECTIVE

Hemorrhagic shock may contribute to acute kidney injury (AKI) by profoundly altering renal mitochondrial function. Resveratrol (RSV), a naturally occurring sirtuin 1 (SIRT1) activator, has been shown to promote mitochondrial function and reduce oxidative damage in a variety of aging-related disease states. We hypothesized that RSV treatment during resuscitation would ameliorate kidney mitochondrial dysfunction and decrease oxidative damage following hemorrhagic shock.

METHODS

Using a decompensated hemorrhagic shock model, male Long-Evans rats (n = 6 per group) were killed prior to hemorrhage (sham), at severe shock, and following either lactated Ringer's (LR) resuscitation or LR + RSV resuscitation (RSV: 30 mg/kg). At each time point, blood samples were assayed for arterial blood gases, lactate, blood urea nitrogen, and serum creatinine. Mitochondria were also isolated from kidney samples in order to assess individual electron transport complexes (complexes I, II, and IV) using high-resolution respirometry. Total mitochondria reactive oxygen species were measured using fluorometry, and lipid peroxidation was assessed by measuring 4-hydroxynonenal by Western blot. Quantitative polymerase chain reaction was used quantify mRNA from peroxisome proliferator-activated receptor γ coactivator 1-α (PGC1-α) SIRT1, and proteins known to mitigate oxidative damage and promote mitochondrial biogenesis.

RESULTS

Resveratrol supplementation during resuscitation restored mitochondrial respiratory capacity and decreased mitochondrial reactive oxygen species and lipid peroxidation. Compared with standard LR resuscitation, RSV treatment significantly increased SIRT1 and PGC1-α expression and significantly increased both superoxide dismutase 2 and catalase expression. Although RSV was associated with decreased lactate production, pH, blood urea nitrogen, and serum creatinine values did not differ between resuscitation strategies.

CONCLUSIONS

Resuscitation with RSV significantly restored renal mitochondrial function and decreased oxidative damage following hemorrhagic shock.

Plasmatic isoforms of cytokeratin 18 and RAGE after severe trauma: a longitudinal cohort study

BACKGROUND

Life-threatening traumatic injuries lead to a complex inflammation-driven pathophysiology. Receptor of advanced glycation end product (RAGE) is a multiligand receptor of several endogenous alarmins, while cytokeratin 18 is a structural component of the filament of epithelial cells. Both proteins can be frequently found in plasma of patients with different diseases, whereby they have distinct underlying mechanism of formation. In this prospective observational study, we wanted to shed light on the kinetic of plasmatic RAGE and cytokeratin 18 isoforms after severe trauma, thereby also addressing the association of these markers with inflammation and their potential use as biomarkers.

METHODS

Plasma samples of 77 patients with severe multiple trauma as defined by an Injury Severity Score (ISS) 16 or greater were obtained from a local repository and levels of soluble RAGE, endogenous secretory RAGE, cytokeratin 18, cleaved cytokeratin 18, and interleukin 6 by enzyme-linked immunosorbent assay. Demographic and routine parameters of the cohort were extracted from an electronic patient data management system.

RESULTS

Both RAGE isoforms were transiently increased in plasma within 24 hours after trauma, while cytokeratin 18 levels were unchanged. Moreover, soluble RAGE concentrations in patients with thoracic injuries were higher compared with patients without injury, and both isoforms of RAGE discriminated between patients with most severe adult respiratory distress syndrome and patients with milder forms. In addition, cleaved and total cytokeratin 18 levels differ between patients with hepatic dysfunction and normal function, without possessing discriminatory power. RAGE and cytokeratin 18 isoforms correlated significantly but to a low extent with interleukin 6, while the isoforms of both parameters correlated to a high extent with one another.

CONCLUSION

The release of RAGE (but not cytokeratin 18) isoforms occurs early and transiently after trauma and is associated with the extent of injury and inflammatory response. RAGE and cytokeratin 18 isoforms have the potential to act as diagnostic or prognostic biomarkers of lung and hepatic dysfunction.

LEVEL OF EVIDENCE

Epidemiologic/prognostic study, level IV.

Cost-effectiveness of aspirin adjuvant therapy in early stage colorectal cancer in older patients

BACKGROUND & AIMS

Recent observational studies showed that post-operative aspirin use reduces cancer relapse and death in the earliest stages of colorectal cancer. We sought to evaluate the cost-effectiveness of aspirin as an adjuvant therapy in Stage I and II colorectal cancer patients aged 65 years and older.

METHODS

Two five-state Markov models were constructed separately for Stage I and II colorectal cancer using TreeAge Pro 2014. Two hypothetical cohorts of 10,000 individuals at a starting age of 65 years and with colorectal cancer in remission were put through the models separately. Cost-effectiveness of aspirin was evaluated against no treatment (Stage I and II) and capecitabine (Stage II) over a 20-year period from the United States societal perspective. Extensive one-way sensitivity analyses and multivariable Probabilistic Sensitivity Analyses (PSA) were performed.

RESULTS

In the base case analyses, aspirin was cheaper and more effective compared to other comparators in both stages. Sensitivity analyses showed that no treatment and capecitabine (Stage II only) can be cost-effective alternatives if the utility of taking aspirin is below 0.909, aspirin's annual fatal adverse event probability exceeds 0.57%, aspirin's relative risk of disease progression is 0.997 or more, or when capecitabine's relative risk of disease progression is less than 0.228. Probabilistic Sensitivity Analyses (PSA) further showed that aspirin could be cost-effective 50% to 80% of the time when the willingness-to-pay threshold was varied from USD 20,000 to USD 100,000.

CONCLUSION

Even with a modest treatment benefit, aspirin is likely to be cost-effective in Stage I and II colorectal cancer, thus suggesting a potential unique role in secondary prevention in this group of patients.