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Ho JW, Dawood ZS, Taylor ME, Liggett MR, Jin G, Jaishankar D, Nadig SN, Bharat A, Alam HB. THE NEUROENDOTHELIAL AXIS IN TRAUMATIC BRAIN INJURY: MECHANISMS OF MULTIORGAN DYSFUNCTION, NOVEL THERAPIES, AND FUTURE DIRECTIONS. Shock 2024; 61:346-359. [PMID: 38517237 DOI: 10.1097/shk.0000000000002307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2024]
Abstract
ABSTRACT Severe traumatic brain injury (TBI) often initiates a systemic inflammatory response syndrome, which can potentially culminate into multiorgan dysfunction. A central player in this cascade is endotheliopathy, caused by perturbations in homeostatic mechanisms governed by endothelial cells due to injury-induced coagulopathy, heightened sympathoadrenal response, complement activation, and proinflammatory cytokine release. Unique to TBI is the potential disruption of the blood-brain barrier, which may expose neuronal antigens to the peripheral immune system and permit neuroinflammatory mediators to enter systemic circulation, propagating endotheliopathy systemically. This review aims to provide comprehensive insights into the "neuroendothelial axis" underlying endothelial dysfunction after TBI, identify potential diagnostic and prognostic biomarkers, and explore therapeutic strategies targeting these interactions, with the ultimate goal of improving patient outcomes after severe TBI.
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Affiliation(s)
- Jessie W Ho
- Department of Surgery, Division of Trauma Surgery and Critical Care, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Zaiba Shafik Dawood
- Department of Surgery, Division of Trauma Surgery and Critical Care, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Meredith E Taylor
- Department of Surgery, Division of Organ Transplant, and Comprehensive Transplant Center, Feinberg School of Medicine, Northwestern University Chicago, Illinois
| | - Marjorie R Liggett
- Department of Surgery, Division of Trauma Surgery and Critical Care, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Guang Jin
- Department of Surgery, Division of Trauma Surgery and Critical Care, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Dinesh Jaishankar
- Department of Surgery, Division of Organ Transplant, and Comprehensive Transplant Center, Feinberg School of Medicine, Northwestern University Chicago, Illinois
| | - Satish N Nadig
- Department of Surgery, Division of Organ Transplant, and Comprehensive Transplant Center, Feinberg School of Medicine, Northwestern University Chicago, Illinois
| | - Ankit Bharat
- Department of Surgery, Division of Thoracic Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Hasan B Alam
- Department of Surgery, Division of Trauma Surgery and Critical Care, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
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Pigott A, Rudloff E. Traumatic Brain Injury-A Review of Intravenous Fluid Therapy. Front Vet Sci 2021; 8:643800. [PMID: 34307515 PMCID: PMC8299062 DOI: 10.3389/fvets.2021.643800] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 06/09/2021] [Indexed: 11/13/2022] Open
Abstract
This manuscript will review intravenous fluid therapy in traumatic brain injury. Both human and animal literature will be included. Basic treatment recommendations will also be discussed.
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Affiliation(s)
- Armi Pigott
- BluePearl Specialty + Emergency Pet Hospital, Glendale, WI, United States
| | - Elke Rudloff
- BluePearl Specialty + Emergency Pet Hospital, Glendale, WI, United States
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Pati S, Fennern E, Holcomb JB, Barry M, Trivedi A, Cap AP, Martin MJ, Wade C, Kozar R, Cardenas JC, Rappold JF, Spiegel R, Schreiber MA. Treating the endotheliopathy of SARS-CoV-2 infection with plasma: Lessons learned from optimized trauma resuscitation with blood products. Transfusion 2021; 61 Suppl 1:S336-S347. [PMID: 34269437 PMCID: PMC8446992 DOI: 10.1111/trf.16452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 03/30/2021] [Indexed: 11/29/2022]
Affiliation(s)
- Shibani Pati
- Department of Lab MedicineUniversity of California San Francisco School of MedicineSan FranciscoCaliforniaUSA
| | - Erin Fennern
- Department of SurgeryMount Sinai Icahn School of MedicineNew YorkNew YorkUSA
| | | | - Mark Barry
- Department of SurgeryUniversity of California San Francisco School of MedicineSan FranciscoCaliforniaUSA
| | - Alpa Trivedi
- Department of Lab MedicineUniversity of California San Francisco School of MedicineSan FranciscoCaliforniaUSA
| | - Andrew P. Cap
- U.S. Army Institute of Surgical ResearchJBSA‐FT Sam HoustonSan AntonioTexasUSA
| | | | - Charles Wade
- Department of Surgery McGovern School of MedicineUniversity of Texas Health Science CenterHoustonTexasUSA
| | - Rosemary Kozar
- Department of SurgeryUniversity of MarylandBaltimoreMarylandUSA
| | - Jessica C. Cardenas
- Department of Surgery McGovern School of MedicineUniversity of Texas Health Science CenterHoustonTexasUSA
| | - Joseph F. Rappold
- Department of Surgery Maine Medical CenterTufts University School of MedicinePortlandMaineUSA
| | - Renee Spiegel
- Department of SurgeryElmhurst Hospital CenterElmhurstNew YorkUSA
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Mok G, Hoang R, Khan MW, Pannell D, Peng H, Tien H, Nathens A, Callum J, Karkouti K, Beckett A, da Luz LT. Freeze-dried plasma for major trauma - Systematic review and meta-analysis. J Trauma Acute Care Surg 2021; 90:589-602. [PMID: 33507025 PMCID: PMC7899224 DOI: 10.1097/ta.0000000000003012] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2020] [Revised: 10/16/2020] [Accepted: 10/17/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND Treatment of acute trauma coagulopathy has shifted toward rapid replacement of coagulation factors with frozen plasma (FP). There are logistic difficulties in providing FP. Freeze-dried plasma (FDP) may have logistical advantages including easier storage and rapid preparation time. This review assesses the feasibility, efficacy, and safety of FDP in trauma. STUDY DESIGN AND METHODS Studies were searched from Medline, Embase, Cochrane Controlled Trials Register, ClinicalTrials.gov, and Google Scholar. Observational and randomized controlled trials (RCTs) assessing FDP use in trauma were included. Trauma animal models addressing FDP use were also included. Bias was assessed using validated tools. Primary outcome was efficacy, and secondary outcomes were feasibility and safety. Meta-analyses were conducted using random-effect models. Evidence was graded using Grading of Recommendations Assessment, Development, and Evaluation profile. RESULTS Twelve human studies (RCT, 1; observational, 11) and 15 animal studies were included. Overall, studies demonstrated moderate risk of bias. Data from two studies (n = 119) were combined for meta-analyses for mortality and transfusion of allogeneic blood products (ABPs). For both outcomes, no difference was identified. For mortality, pooled odds ratio was 0.66 (95% confidence interval, 0.29-1.49), with I2 = 0%. Use of FDP is feasible, and no adverse events were reported. Animal data suggest similar results for coagulation and anti-inflammatory profiles for FP and FDP. CONCLUSION Human data assessing FDP use in trauma report no difference in mortality and transfusion of ABPs in patients receiving FDP compared with FP. Data from animal trauma studies report no difference in coagulation factor and anti-inflammatory profiles between FP and FDP. Results should be interpreted with caution because most studies were observational and have heterogeneous population (military and civilian trauma) and a moderate risk of bias. Well-designed prospective observational studies or, preferentially, RCTs are warranted to answer FDP's effect on laboratory (coagulation factor levels), transfusion (number of ABPs), and clinical outcomes (organ dysfunction, length of stay, and mortality). LEVEL OF EVIDENCE Systematic review and meta-analysis, level IV.
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5
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Dinsdale RJ, Hazeldine J, Al Tarrah K, Hampson P, Devi A, Ermogenous C, Bamford AL, Bishop J, Watts S, Kirkman E, Dalle Lucca JJ, Midwinter M, Woolley T, Foster M, Lord JM, Moiemen N, Harrison P. Dysregulation of the actin scavenging system and inhibition of DNase activity following severe thermal injury. Br J Surg 2019; 107:391-401. [PMID: 31502663 PMCID: PMC7079039 DOI: 10.1002/bjs.11310] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Revised: 05/21/2019] [Accepted: 06/08/2019] [Indexed: 01/25/2023]
Abstract
Background Circulating cell‐free DNA (cfDNA) is not found in healthy subjects, but is readily detected after thermal injury and may contribute to the risk of multiple organ failure. The hypothesis was that a postburn reduction in DNase protein/enzyme activity could contribute to the increase in cfDNA following thermal injury. Methods Patients with severe burns covering at least 15 per cent of total body surface area were recruited to a prospective cohort study within 24 h of injury. Blood samples were collected from the day of injury for 12 months. Results Analysis of blood samples from 64 patients revealed a significant reduction in DNase activity on days 1–28 after injury, compared with healthy controls. DNase protein levels were not affected, suggesting the presence of an enzyme inhibitor. Further analysis revealed that actin (an inhibitor of DNase) was present in serum samples from patients but not those from controls, and concentrations of the actin scavenging proteins gelsolin and vitamin D‐binding protein were significantly reduced after burn injury. In a pilot study of ten military patients with polytrauma, administration of blood products resulted in an increase in DNase activity and gelsolin levels. Conclusion The results of this study suggest a novel biological mechanism for the accumulation of cfDNA following thermal injury by which high levels of actin released by damaged tissue cause a reduction in DNase activity. Restoration of the actin scavenging system could therefore restore DNase activity, and reduce the risk of cfDNA‐induced host tissue damage and thrombosis.
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Affiliation(s)
- R J Dinsdale
- Scar Free Foundation, Birmingham Centre for Burns Research, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.,Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
| | - J Hazeldine
- National Institute for Health Research Surgical Reconstruction and Microbiology Research Centre, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.,Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
| | - K Al Tarrah
- Scar Free Foundation, Birmingham Centre for Burns Research, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.,Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
| | - P Hampson
- Scar Free Foundation, Birmingham Centre for Burns Research, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.,Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
| | - A Devi
- Scar Free Foundation, Birmingham Centre for Burns Research, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.,Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
| | - C Ermogenous
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
| | - A L Bamford
- Scar Free Foundation, Birmingham Centre for Burns Research, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - J Bishop
- National Institute for Health Research Surgical Reconstruction and Microbiology Research Centre, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - S Watts
- Chemical, Biological and Radiological (CBR) Division, Defence Science and Technology Laboratory, Porton Down, Salisbury, UK
| | - E Kirkman
- Chemical, Biological and Radiological (CBR) Division, Defence Science and Technology Laboratory, Porton Down, Salisbury, UK
| | - J J Dalle Lucca
- Translational Medical Division, Department of Chemical and Biological Technologies, Defense Threat Reduction Agency, Fort Belvoir, Virginia, USA
| | - M Midwinter
- School of Biomedical Sciences, University of Queensland, Brisbane, Queensland, Australia
| | - T Woolley
- ICT Centre, Birmingham Research Park, Birmingham, UK.,Chemical, Biological and Radiological (CBR) Division, Defence Science and Technology Laboratory, Porton Down, Salisbury, UK
| | - M Foster
- National Institute for Health Research Surgical Reconstruction and Microbiology Research Centre, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.,Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
| | - J M Lord
- Scar Free Foundation, Birmingham Centre for Burns Research, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.,National Institute for Health Research Surgical Reconstruction and Microbiology Research Centre, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.,Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
| | - N Moiemen
- Scar Free Foundation, Birmingham Centre for Burns Research, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.,Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
| | - P Harrison
- Scar Free Foundation, Birmingham Centre for Burns Research, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.,Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
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A systematic review of large animal models of combined traumatic brain injury and hemorrhagic shock. Neurosci Biobehav Rev 2019; 104:160-177. [PMID: 31255665 DOI: 10.1016/j.neubiorev.2019.06.024] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Revised: 06/17/2019] [Accepted: 06/19/2019] [Indexed: 01/08/2023]
Abstract
Traumatic brain injury (TBI) and severe blood loss (SBL) frequently co-occur in human trauma, resulting in high levels of mortality and morbidity. Importantly, each of the individual post-injury cascades is characterized by complex and potentially opposing pathophysiological responses, complicating optimal resuscitation and therapeutic approaches. Large animal models of poly-neurotrauma closely mimic human physiology, but a systematic literature review of published models has been lacking. The current review suggests a relative paucity of large animal poly-neurotrauma studies (N = 52), with meta-statistics revealing trends for animal species (exclusively swine), characteristics (use of single biological sex, use of juveniles) and TBI models. Although most studies have targeted blood loss volumes of 35-45%, the associated mortality rates are much lower relative to Class III/IV human trauma. This discrepancy may result from potentially mitigating experimental factors (e.g., mechanical ventilation prior to or during injury, pausing/resuming blood loss based on physiological parameters, administration of small volume fluid resuscitation) that are rarely associated with human trauma, highlighting the need for additional work in this area.
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7
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Abstract
Dried plasma provides an alternative for early plasma transfusion in the resuscitation of hemorrhagic shock in environments where fresh frozen plasma is not immediately available. It is produced by freeze-drying or spray-drying liquid or thawed plasma. It is shelf-stable for prolonged periods, can be stored at room temperature, and is easy to transport, reconstitute, and administer. It was widely used in WWII but fell out of favor due to the risk of infectious disease transmission. The German and French experiences with lyophilized plasma are the most extensive and show a good track record of efficacy and safety. Recent studies show many beneficial effects of dried plasma in the treatment of shock in large animal models. Currently, no FDA-licensed product is available in the USA, but several are under development.
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Affiliation(s)
- Philip C. Spinella
- School of Medicine, Washington University in St. Louis, St. Louis, MO USA
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Glushakova OY, Glushakov AV, Yang L, Hayes RL, Valadka AB. Intracranial Pressure Monitoring in Experimental Traumatic Brain Injury: Implications for Clinical Management. J Neurotrauma 2019; 37:2401-2413. [PMID: 30595079 DOI: 10.1089/neu.2018.6145] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Traumatic brain injury (TBI) is often associated with long-term disability and chronic neurological sequelae. One common contributor to unfavorable outcomes is secondary brain injury, which is potentially treatable and preventable through appropriate management of patients in the neurosurgical intensive care unit. Intracranial pressure (ICP) is currently the predominant neurological-specific physiological parameter used to direct the care of severe TBI (sTBI) patients. However, recent clinical evidence has called into question the association of ICP monitoring with improved clinical outcome. The detailed cellular and molecular derangements associated with intracranial hypertension (IC-HTN) and their relationship to injury phenotype and neurological outcomes are not completely understood. Various animal models of TBI have been developed, but the clinical applicability of ICP monitoring in the pre-clinical setting has not been well-characterized. Linking basic mechanistic studies in translational TBI models with investigation of ICP monitoring that more faithfully replicates the clinical setting will provide clinical investigators with a more informed understanding of the pathophysiology of IC-HTN, thus facilitating development of improved therapies for sTBI patients.
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Affiliation(s)
- Olena Y Glushakova
- Department of Neurosurgery, Virginia Commonwealth University, Richmond, Virginia, USA
| | | | - Likun Yang
- Department of Neurosurgery, The 101st Hospital of Chinese People's Liberation Army, Xuxi, Jiangsu, China
| | - Ronald L Hayes
- Department of Neurosurgery, Virginia Commonwealth University, Richmond, Virginia, USA.,Banyan Biomarkers, Inc., Alachua, Florida, USA
| | - Alex B Valadka
- Department of Neurosurgery, Virginia Commonwealth University, Richmond, Virginia, USA
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9
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Challenges to producing novel therapies - dried plasma for use in trauma and critical care. Transfusion 2019; 59:837-845. [DOI: 10.1111/trf.14985] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Accepted: 09/19/2018] [Indexed: 12/31/2022]
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10
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Weykamp M, Nikolian VC, Dennahy IS, Higgins GA, Georgoff PE, Remmer H, Ghandour MH, Alam HB. Rapid valproic acid-induced modulation of the traumatic proteome in a porcine model of traumatic brain injury and hemorrhagic shock. J Surg Res 2018; 228:84-92. [PMID: 29907235 DOI: 10.1016/j.jss.2018.02.046] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2017] [Revised: 01/10/2018] [Accepted: 02/22/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND Histone deacetylase inhibitors such as valproic acid (VPA) improve survival in lethal models of hemorrhagic shock and polytrauma. Although VPA is known to modulate transcription, its ability to reduce mortality within minutes of administration suggests involvement of a rapid, posttranslational mechanism. We hypothesized that VPA treatment would cause proteomic changes within minutes of treatment including quantitative and/or posttranslational differences in structural and/or effector proteins. MATERIALS AND METHODS We used a porcine model of traumatic brain injury (computer-controlled cortical impact, 12 mm depth) and hemorrhagic shock (40% hemorrhage). Animals were kept in shock for 2 h and randomized to two groups (n = 3): normal saline (volume = 3:1 hemorrhage volume) or normal saline + VPA (150 mg/kg, single dose). Peripheral blood mononuclear cells were collected at baseline, postshock, and postresuscitation. Intracellular protein profiles were assessed using 1 dimensional gel electrophoresis, liquid chromatography, mass spectrometry, and analyzed with Ingenuity Pathway Analysis software. RESULTS Animals treated with VPA demonstrated significant proteomic changes. Quantitative differences were found in over 200 proteins including effector, regulatory, and structural proteins in critical cell signaling pathways. Posttranslational modification analysis demonstrated differential VPA-induced acetylation of lysine residues in histone and nonhistone proteins. Pathway analysis correlated these changes with significant increases in numerous prosurvival and cytoskeletal intracellular pathways, including Rho GTPase signaling (P = 1.66E-11), integrin signaling (P = 4.19E-21), and a decrease in Rho guanosine nucleotide dissociation inhibitor signaling (P = 4.83E-12). CONCLUSIONS In a porcine model of severe injuries, a single dose of VPA is associated with protective changes in the proteome that are measurable within minutes of treatment.
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Affiliation(s)
- Michael Weykamp
- Department of Surgery, University of Michigan Medical School, Ann Arbor, Michigan
| | - Vahagn C Nikolian
- Department of Surgery, University of Michigan Medical School, Ann Arbor, Michigan
| | - Isabel S Dennahy
- Department of Surgery, University of Michigan Medical School, Ann Arbor, Michigan
| | - Gerald A Higgins
- Department of Computational Medicine and Bioinformatics, University of Michigan Medical School, Ann Arbor, Michigan
| | - Patrick E Georgoff
- Department of Surgery, University of Michigan Medical School, Ann Arbor, Michigan
| | - Henriette Remmer
- Department of Biological Chemistry, University of Michigan Medical School, Ann Arbor, Michigan
| | - Mohamed H Ghandour
- Department of Surgery, University of Michigan Medical School, Ann Arbor, Michigan
| | - Hasan B Alam
- Department of Surgery, University of Michigan Medical School, Ann Arbor, Michigan.
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Dekker SE, Nikolian VC, Sillesen M, Bambakidis T, Schober P, Alam HB. Different resuscitation strategies and novel pharmacologic treatment with valproic acid in traumatic brain injury. J Neurosci Res 2018; 96:711-719. [PMID: 28742231 PMCID: PMC5785554 DOI: 10.1002/jnr.24125] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2017] [Revised: 07/06/2017] [Accepted: 07/06/2017] [Indexed: 12/28/2022]
Abstract
Traumatic brain injury (TBI) is a leading cause of death in young adults, and effective treatment strategies have the potential to save many lives. TBI results in coagulopathy, endothelial dysfunction, inflammation, cell death, and impaired epigenetic homeostasis, ultimately leading to morbidity and/or mortality. Commonly used resuscitation fluids such as crystalloids or colloids have several disadvantages and might even be harmful when administered in large quantities. There is a need for next-generation treatment strategies (especially in the prehospital setting) that minimize cellular damage, improve survival, and enhance neurological recovery. Pharmacologic treatment with histone deacetylase inhibitors, such as valproic acid, has shown promising results in animal studies of TBI and may therefore be an excellent example of next-generation therapy. This review briefly describes traditional resuscitation strategies for TBI combined with hemorrhagic shock and describes preclinical studies on valproic acid as a new pharmacologic agent in the treatment of TBI. It finally discusses limitations and future directions on the use of histone deacetylase inhibitors for the treatment of TBI.
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Affiliation(s)
- Simone E. Dekker
- Department of Surgery, University of Michigan Hospital, Ann Arbor, Michigan, USA
- Department of Neurological Surgery, Case Western Reserve University, Cleveland, Ohio, USA
- Department of Anesthesiology, Institute for Cardiovascular Research, VU University Medical Center, Amsterdam, the Netherlands
| | - Vahagn C. Nikolian
- Department of Surgery, University of Michigan Hospital, Ann Arbor, Michigan, USA
| | - Martin Sillesen
- Department of Surgical Gastroenterology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark; Institute for Inflammation Research, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Ted Bambakidis
- Department of Surgery, University of Michigan Hospital, Ann Arbor, Michigan, USA
| | - Patrick Schober
- Department of Anesthesiology, Institute for Cardiovascular Research, VU University Medical Center, Amsterdam, the Netherlands
| | - Hasan B. Alam
- Department of Surgery, University of Michigan Hospital, Ann Arbor, Michigan, USA
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12
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Pati S, Peng Z, Wataha K, Miyazawa B, Potter DR, Kozar RA. Lyophilized plasma attenuates vascular permeability, inflammation and lung injury in hemorrhagic shock. PLoS One 2018; 13:e0192363. [PMID: 29394283 PMCID: PMC5796727 DOI: 10.1371/journal.pone.0192363] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Accepted: 01/21/2018] [Indexed: 11/18/2022] Open
Abstract
In severe trauma and hemorrhage the early and empiric use of fresh frozen plasma (FFP) is associated with decreased morbidity and mortality. However, utilization of FFP comes with the significant burden of shipping and storage of frozen blood products. Dried or lyophilized plasma (LP) can be stored at room temperature, transported easily, reconstituted rapidly with ready availability in remote and austere environments. We have previously demonstrated that FFP mitigates the endothelial injury that ensues after hemorrhagic shock (HS). In the current study, we sought to determine whether LP has similar properties to FFP in its ability to modulate endothelial dysfunction in vitro and in vivo. Single donor LP was compared to single donor FFP using the following measures of endothelial cell (EC) function in vitro: permeability and transendothelial monolayer resistance; adherens junction preservation; and leukocyte-EC adhesion. In vivo, using a model of murine HS, LP and FFP were compared in measures of HS- induced pulmonary vascular inflammation and edema. Both in vitro and in vivo in all measures of EC function, LP demonstrated similar effects to FFP. Both FFP and LP similarly reduced EC permeability, increased transendothelial resistance, decreased leukocyte-EC binding and persevered adherens junctions. In vivo, LP and FFP both comparably reduced pulmonary injury, inflammation and vascular leak. Both FFP and LP have similar potent protective effects on the vascular endothelium in vitro and in lung function in vivo following hemorrhagic shock. These data support the further development of LP as an effective plasma product for human use after trauma and hemorrhagic shock.
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Affiliation(s)
- Shibani Pati
- Department of Laboratory Medicine, University of California San Francisco, San Francisco, California, United States of America
| | - Zhanglong Peng
- Department of Anesthesia, University of Texas Health Science Center at Houston, Houston, Texas, United States of America
| | - Katherine Wataha
- Department of Laboratory Medicine, University of California San Francisco, San Francisco, California, United States of America
| | - Byron Miyazawa
- Department of Laboratory Medicine, University of California San Francisco, San Francisco, California, United States of America
| | - Daniel R Potter
- Department of Laboratory Medicine, University of California San Francisco, San Francisco, California, United States of America
| | - Rosemary A Kozar
- Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland, United States of America
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13
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Improvement of Blood-Brain Barrier Integrity in Traumatic Brain Injury and Hemorrhagic Shock Following Treatment With Valproic Acid and Fresh Frozen Plasma. Crit Care Med 2017; 46:e59-e66. [PMID: 29095204 DOI: 10.1097/ccm.0000000000002800] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVE Combined traumatic brain injury and hemorrhagic shock are highly lethal. Following injuries, the integrity of the blood-brain barrier can be impaired, contributing to secondary brain insults. The status of the blood-brain barrier represents a potential factor impacting long-term neurologic outcomes in combined injuries. Treatment strategies involving plasma-based resuscitation and valproic acid therapy have shown efficacy in this setting. We hypothesize that a component of this beneficial effect is related to blood-brain barrier preservation. DESIGN Following controlled traumatic brain injury, hemorrhagic shock, various resuscitation and treatment strategies were evaluated for their association with blood-brain barrier integrity. Analysis of gene expression profiles was performed using Porcine Gene ST 1.1 microarray. Pathway analysis was completed using network analysis tools (Gene Ontology, Ingenuity Pathway Analysis, and Parametric Gene Set Enrichment Analysis). SUBJECTS Female Yorkshire swine were subjected to controlled traumatic brain injury and 2 hours of hemorrhagic shock (40% blood volume, mean arterial pressure 30-35 mmHg). INTERVENTIONS Subjects were resuscitated with 1) normal saline, 2) fresh frozen plasma, 3) hetastarch, 4) fresh frozen plasma + valproic acid, or 5) hetastarch + valproic acid (n = 5 per group). After 6 hours of observation, brains were harvested for evaluation. MEASUREMENTS AND MAIN RESULTS Immunofluoroscopic evaluation of the traumatic brain injury site revealed significantly increased expression of tight-junction associated proteins (zona occludin-1, claudin-5) following combination therapy (fresh frozen plasma + valproic acid and hetastarch + valproic acid). The extracellular matrix protein laminin was found to have significantly improved expression with combination therapies. Pathway analysis indicated that valproic acid significantly modulated pathways involved in endothelial barrier function and cell signaling. CONCLUSIONS Resuscitation with fresh frozen plasma results in improved expression of proteins essential for blood-brain barrier integrity. The addition of valproic acid provides significant improvement to these protein expression profiles. This is likely secondary to activation of key pathways related to endothelial functions.
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14
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Prehospital plasma resuscitation associated with improved neurologic outcomes after traumatic brain injury. J Trauma Acute Care Surg 2017; 83:398-405. [PMID: 28538641 DOI: 10.1097/ta.0000000000001581] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Trauma-related hypotension and coagulopathy worsen secondary brain injury in patients with traumatic brain injuries (TBIs). Early damage control resuscitation with blood products may mitigate hypotension and coagulopathy. Preliminary data suggest resuscitation with plasma in large animals improves neurologic function after TBI; however, data in humans are lacking. METHODS We retrospectively identified all patients with multiple injuries age >15 years with head injuries undergoing prehospital resuscitation with blood products at a single Level I trauma center from January 2002 to December 2013. Inclusion criteria were prehospital resuscitation with either packed red blood cells (pRBCs) or thawed plasma as sole colloid resuscitation. Patients who died in hospital and those using anticoagulants were excluded. Primary outcomes were Glasgow Outcomes Score Extended (GOSE) and Disability Rating Score (DRS) at dismissal and during follow-up. RESULTS Of 76 patients meeting inclusion criteria, 53% (n = 40) received prehospital pRBCs and 47% (n = 36) received thawed plasma. Age, gender, injury severity or TBI severity, arrival laboratory values, and number of prehospital units were similar (all p > 0.05). Patients who received thawed plasma had an improved neurologic outcome compared to those receiving pRBCs (median GOSE 7 [7-8] vs. 5.5 [3-7], p < 0.001). Additionally, patients who received thawed plasma had improved functionality compared to pRBCs (median DRS 2 [1-3.5] vs. 9 [3-13], p < 0.001). Calculated GOSE and DRS scores during follow-up, median 6 [5-7] months, demonstrated increased function in those resuscitated with thawed plasma compared to pRBCs by both median GOSE (8 [7-8] vs. 6 [6-7], p < 0.001) and DRS (0 [0-1] vs. 4 [2-8], p < 0.001). CONCLUSION In critically injured trauma patients with TBI, early resuscitation with thawed plasma is associated with improved neurologic and functional outcomes at discharge and during follow-up compared to pRBCs alone. These preliminary data support the further investigation and use of plasma in the resuscitation of critically injured TBI patients. LEVEL OF EVIDENCE Therapeutic, level V.
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Early resuscitation with lyophilized plasma provides equal neuroprotection compared with fresh frozen plasma in a large animal survival model of traumatic brain injury and hemorrhagic shock. J Trauma Acute Care Surg 2017; 81:1080-1087. [PMID: 27893618 DOI: 10.1097/ta.0000000000001204] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Combined traumatic brain injury (TBI) and hemorrhagic shock (HS) is highly lethal. In previous models of combined TBI + HS, we showed that early resuscitation with fresh frozen plasma (FFP) improves neurologic outcomes. Delivering FFP, however, in austere environments is difficult. Lyophilized plasma (LP) is a logistically superior alternative to FFP, but data are limited regarding its efficacy for treatment of TBI. We conducted this study to determine the safety and long-term outcomes of early treatment with LP in a large animal model of TBI + HS. METHODS Adult anesthetized swine underwent TBI and volume-controlled hemorrhage (40% blood volume) concurrently. After 2 hours of shock, animals were randomized (n = 5 per /group) to FFP or LP (1× shed blood) treatment. Serial blood gases were drawn, and thromboelastography was performed on citrated, kaolin-activated whole-blood samples. Five hours after treatment, packed red blood cells were administered, and animals recovered. A 32-point Neurologic Severity Score was assessed daily for 30 days (0 = normal, 32 = most severe injury). Cognitive functions were tested by training animals to retrieve food from color-coded boxes. Brain lesion size was measured on serial magnetic resonance imaging, and an autopsy was performed at 30 days. RESULTS The severity of shock and the degree of resuscitation were similar in both groups. Administration of FFP and LP was well tolerated with no differences in reversal of shock or thromboelastography parameters. Animals in both groups displayed the worst Neurologic Severity Score on postoperative Day 1 with rapid recovery and return to baseline within 7 days of injury. Lesion size on Day 3 in FFP-treated animals was 645 ± 85 versus 219 ± 20 mm in LP-treated animals (p < 0.05). There were no differences in cognitive functions or delayed treatment-related complications. CONCLUSIONS Early treatment with LP in TBI + HS is safe and provides neuroprotection that is comparable to FFP.
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Georgoff PE, Nikolian VC, Halaweish I, Chtraklin K, Bruhn PJ, Eidy H, Rasmussen M, Li Y, Srinivasan A, Alam HB. Resuscitation with Lyophilized Plasma Is Safe and Improves Neurological Recovery in a Long-Term Survival Model of Swine Subjected to Traumatic Brain Injury, Hemorrhagic Shock, and Polytrauma. J Neurotrauma 2017; 34:2167-2175. [PMID: 28228060 DOI: 10.1089/neu.2016.4859] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
We have shown previously that fresh frozen plasma (FFP) and lyophilized plasma (LP) decrease brain lesion size and improve neurological recovery in a swine model of traumatic brain injury (TBI) and hemorrhagic shock (HS). In this study, we examine whether these findings can be validated in a clinically relevant model of severe TBI, HS, and polytrauma. Female Yorkshire swine were subjected to TBI (controlled cortical impact), hemorrhage (40% volume), grade III liver and splenic injuries, rib fracture, and rectus abdominis crush. The animals were maintained in a state of shock (mean arterial pressure 30-35 mm Hg) for 2 h, and then randomized to resuscitation with normal saline (NS), FFP, or LP (n = 5 swine/group). Animals were recovered and monitored for 30 d, during which time neurological recovery was assessed. Brain lesion sizes were measured via magnetic resonance imaging (MRI) on post-injury days (PID) three and 10. Animals were euthanized on PID 30. The severity of shock and response to resuscitation was similar in all groups. When compared with NS-treated animals, plasma-treated animals (FFP and LP) had significantly lower neurologic severity scores (PID 1-7) and a faster return to baseline neurological function. There was no significant difference in brain lesion sizes between groups. LP treatment was well tolerated and similar to FFP. In this clinically relevant large animal model of severe TBI, HS, and polytrauma, we have shown that plasma-based resuscitation strategies are safe and result in neurocognitive recovery that is faster than recovery after NS-based resuscitation.
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Affiliation(s)
- Patrick E Georgoff
- 1 Department of Surgery, Section of Neuroradiology, University of Michigan , Ann Arbor, Michigan
| | - Vahagn C Nikolian
- 1 Department of Surgery, Section of Neuroradiology, University of Michigan , Ann Arbor, Michigan
| | - Ihab Halaweish
- 1 Department of Surgery, Section of Neuroradiology, University of Michigan , Ann Arbor, Michigan
| | - Kiril Chtraklin
- 1 Department of Surgery, Section of Neuroradiology, University of Michigan , Ann Arbor, Michigan
| | - Peter J Bruhn
- 1 Department of Surgery, Section of Neuroradiology, University of Michigan , Ann Arbor, Michigan
| | - Hassan Eidy
- 1 Department of Surgery, Section of Neuroradiology, University of Michigan , Ann Arbor, Michigan
| | - Monica Rasmussen
- 1 Department of Surgery, Section of Neuroradiology, University of Michigan , Ann Arbor, Michigan
| | - Yongqing Li
- 1 Department of Surgery, Section of Neuroradiology, University of Michigan , Ann Arbor, Michigan
| | - Ashok Srinivasan
- 2 Department of Radiology, Section of Neuroradiology, University of Michigan , Ann Arbor, Michigan
| | - Hasan B Alam
- 1 Department of Surgery, Section of Neuroradiology, University of Michigan , Ann Arbor, Michigan
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Prevalence and Impact of Admission Acute Traumatic Coagulopathy on Treatment Intensity, Resource Use, and Mortality: An Evaluation of 956 Severely Injured Children and Adolescents. J Am Coll Surg 2017; 224:625-632. [DOI: 10.1016/j.jamcollsurg.2016.12.046] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2016] [Accepted: 12/19/2016] [Indexed: 11/23/2022]
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Genét GF, Bentzer P, Ostrowski SR, Johansson PI. Resuscitation with Pooled and Pathogen-Reduced Plasma Attenuates the Increase in Brain Water Content following Traumatic Brain Injury and Hemorrhagic Shock in Rats. J Neurotrauma 2016; 34:1054-1062. [PMID: 27626366 DOI: 10.1089/neu.2016.4574] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
Traumatic brain injury and hemorrhagic shock is associated with blood-brain barrier (BBB) breakdown and edema formation. Recent animal studies have shown that fresh frozen plasma (FFP) resuscitation reduces brain swelling and improves endothelial function compared to isotonic NaCl (NS). The aim of this study was to investigate whether pooled and pathogen-reduced plasma (OctaplasLG® [OCTA]; Octapharma, Stockholm, Sweden) was comparable to FFP with regard to effects on brain water content, BBB permeability, and plasma biomarkers of endothelial glycocalyx shedding and cell damage. After fluid percussion brain injury, hemorrhage (20 mL/kg), and 90-min shock, 48 male Sprague-Dawley rats were randomized to resuscitation with OCTA, FFP, or NS (n = 16/group). Brain water content (wet/dry weight) and BBB permeability (transfer constant for 51Cr-EDTA) were measured at 24 h. Plasma osmolality, oncotic pressure, and biomarkers of systemic glycocalyx shedding (syndecan-1) and cell damage (histone-complexed DNA) were measured at 0 and 23 h. At 24 h, brain water content was 80.44 ± 0.39%, 80.82 ± 0.82%, and 81.15 ± 0.86% in the OCTA, FFP, and NS groups (lower in OCTA vs. NS; p = 0.026), with no difference in BBB permeability. Plasma osmolality and oncotic pressures were highest in FFP and OCTA resuscitated, and osmolality was further highest in OCTA versus FFP (p = 0.027). In addition, syndecan-1 was highest in FFP and OCTA resuscitated (p = 0.010). These results suggest that pooled solvent-detergent (SD)-treated plasma attenuates the post-traumatic increase in brain water content, and that this effect may, in part, be explained by a high crystalloid and colloid osmotic pressure in SD-treated plasma.
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Affiliation(s)
- Gustav Folmer Genét
- 1 Section for Transfusion Medicine, Capital Region Blood Bank, Rigshospitalet, University of Copenhagen , Copenhagen, Denmark
| | - Peter Bentzer
- 2 Department of Anesthesia and Intensive Care, Helsingborg Hospital , Helsingborg and Lund University, Lund, Sweden
| | - Sisse Rye Ostrowski
- 1 Section for Transfusion Medicine, Capital Region Blood Bank, Rigshospitalet, University of Copenhagen , Copenhagen, Denmark
| | - Pär Ingemar Johansson
- 1 Section for Transfusion Medicine, Capital Region Blood Bank, Rigshospitalet, University of Copenhagen , Copenhagen, Denmark .,3 Department of Surgery, Center for Translational Injury Research, CeTIR, University of Texas Medical School at Houston , Houston, Texas
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Baimukanova G, Miyazawa B, Potter DR, Muench MO, Bruhn R, Gibb SL, Spinella PC, Cap AP, Cohen MJ, Pati S. Platelets regulate vascular endothelial stability: assessing the storage lesion and donor variability of apheresis platelets. Transfusion 2016; 56 Suppl 1:S65-75. [PMID: 27001364 DOI: 10.1111/trf.13532] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2015] [Revised: 01/09/2016] [Accepted: 01/09/2016] [Indexed: 12/15/2022]
Abstract
BACKGROUND In current blood banking practices, platelets (PLTs) are stored in plasma at 22°C, with gentle agitation for up to 5 days. To date, the effects of storage and donor variability on PLT regulation of vascular integrity are not known. STUDY DESIGN AND METHODS In this study, we examined the donor variability of leukoreduced fresh (Day 1) or stored (Day 5) PLTs on vascular endothelial barrier function in vitro and in vivo. In vitro, PLT effects on endothelial cell (EC) monolayer permeability were assessed by analyzing transendothelial electrical resistances (TEER). PLT aggregation, a measure of hemostatic potential, was analyzed by impedance aggregometry. In vivo, PLTs were investigated in a vascular endothelial growth factor A (VEGF-A)-induced vascular permeability model in NSG mice, and PLT circulation was measured by flow cytometry. RESULTS Treatment of endothelial monolayers with fresh Day 1 PLTs resulted in an increase in EC barrier resistance and decreased permeability in a dose-dependent manner. Subsequent treatment of EC monolayers with Day 5 PLTs demonstrated diminished vasculoprotective effects. Donor variability was noted in all measures of PLT function. Day 1 PLT donors were more variable in their effects on TEER than Day 5 PLTs. In mice, while all PLTs regardless of storage time demonstrated significant protection against VEGF-A-induced vascular leakage, Day 5 PLTs exhibited reduced protection when compared to Day 1 PLTs. Day 1 PLTs demonstrated significant donor variability against VEGF-A-challenged vascular leakage in vivo. Systemic circulating levels of Day 1 PLTs were higher than those of Day 5 PLTs CONCLUSIONS In vitro and in vivo, Day 1 PLTs are protective in measures of vascular endothelial permeability. Donor variability is most prominent in Day 1 PLTs. A decrease in the protective effects is found with storage of the PLT units between Day 1 and Day 5 at 22°C, thereby suggesting that Day 5 PLTs are diminished in their ability to attenuate vascular endothelial permeability.
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Affiliation(s)
| | - Byron Miyazawa
- Department of Surgery, University of California at San Francisco, San Francisco, California
| | | | | | - Roberta Bruhn
- Blood Systems Research Institute, San Francisco, California
| | - Stuart L Gibb
- Blood Systems Research Institute, San Francisco, California
| | - Philip C Spinella
- Division of Critical Care Medicine, Department of Pediatrics, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Andrew P Cap
- US Army Institute of Surgical Research (USAISR), JBSA-FT Sam Houston, Texas
| | - Mitchell J Cohen
- Department of Surgery, University of California at San Francisco, San Francisco, California
| | - Shibani Pati
- Blood Systems Research Institute, San Francisco, California.,Department of Laboratory Medicine, University of California at San Francisco, San Francisco, California
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Pusateri AE, Given MB, Schreiber MA, Spinella PC, Pati S, Kozar RA, Khan A, Dacorta JA, Kupferer KR, Prat N, Pidcoke HF, Macdonald VW, Malloy WW, Sailliol A, Cap AP. Dried plasma: state of the science and recent developments. Transfusion 2016; 56 Suppl 2:S128-39. [DOI: 10.1111/trf.13580] [Citation(s) in RCA: 65] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2015] [Revised: 01/30/2016] [Accepted: 02/15/2016] [Indexed: 12/25/2022]
Affiliation(s)
| | | | | | | | - Shibani Pati
- Blood Systems Research Institute; San Francisco California
| | | | - Abdul Khan
- Velico Medical, Inc.; Beverly Massachusetts
| | | | | | - Nicolas Prat
- French Armed Forces Institute of Biomedical Research (IRBA) Bretigny-sur-Orge; France
| | | | - Victor W. Macdonald
- US Army Medical Materiel Development Activity; US Army Medical Research and Materiel Command; Fort Detrick Maryland
| | - Wilbur W. Malloy
- Congressionally Directed Medical Research Programs; US Army Medical Research and Materiel Command; Fort Detrick Maryland
| | - Anne Sailliol
- Centre de Transfusion Sanguine des Armées; Clamart CEDEX France
| | - Andrew P. Cap
- US Army Institute of Surgical Research; Fort Sam Houston Texas
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Fresh frozen plasma reduces edema in skeletal muscle following combined limb ischemia-reperfusion injury and hemorrhagic shock in rats. J Trauma Acute Care Surg 2016; 79:S110-5. [PMID: 26406422 DOI: 10.1097/ta.0000000000000752] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Exsanguination from extremity vascular injuries is the most common potentially survivable injury on the battlefield. Advances in treatment have dramatically improved survival, increasing the need to address associated morbidities including ischemia-reperfusion injury and extremity compartment syndrome. Despite advances, hemorrhagic shock (HS) requiring fluid resuscitation is common. Plasma-based resuscitation for the treatment of HS has been shown to reduce edema and injury in tissues other than muscle. The objective of this study was to determine if fresh frozen plasma (FFP) resuscitation offered protection in a rat model of combined HS and skeletal muscle ischemia-reperfusion injury. METHODS Anesthetized Sprague-Dawley rats underwent 37.5% arterial hemorrhage, producing HS, followed by 3 hours of tourniquet application. Animals were not resuscitated or resuscitated with either FFP (equal to the shed blood volume) or lactated Ringer's solution (three times shed volume) after 30 minutes of ischemia. They were euthanized 24 hours later, and their muscles were analyzed for edema (wet weight-dry weight). Routine histology was performed on muscle cross-sections stained with hematoxylin and eosin and graded using a semiquantitative grading system. RESULTS All animals developed HS; the mortality rate was 50% in no resuscitation rats. FFP reduced edema by 13% (p = 0.02) compared with lactated Ringer's solution. Pathology scores were not different between treatment groups. CONCLUSION FFP resuscitation reduces edema following muscle injury, decreasing the risk of developing extremity compartment syndrome.
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Zhang C, Chen J, Lu H. Expression of aquaporin-4 and pathological characteristics of brain injury in a rat model of traumatic brain injury. Mol Med Rep 2015; 12:7351-7. [PMID: 26459070 PMCID: PMC4626127 DOI: 10.3892/mmr.2015.4372] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2014] [Accepted: 08/04/2015] [Indexed: 11/06/2022] Open
Abstract
Aquaporin 4 (AQP4) is a widely distributed membrane protein, which is found in glial cells, ependymocytes and capillary endothelial cells in the brain, and particularly in the choroid plexus. AQP4 is a key regulator of water metabolism, and changes in its expression following brain injury are associated with pathological changes in the damaged side of the brain; however, the effects of brain injury on AQP4 and injury‑induced pathological changes in the contralateral non‑damaged side of the brain remain to be fully elucidated. In the present study, male Sprague‑Dawley rats were subjected to traumatic brain injury (TBI) and changes in brain water content, the expression of AQP4 expression and pathological characteristics in the damaged and contralateral non‑damaged sides of the brain were examined. In the damaged side of the brain, vasogenic edema appeared first, followed by cellular edema. The aggravated cellular edema in the damaged side of the brain resulted in two periods of peak edema severity. Pathological changes in the contralateral non‑damaged side of the brain occurred later than those in the damaged side; cellular edema appeared first, followed by vasogenic edema, which was alleviated earlier than the cellular edema. AQP4 was downregulated during vasogenic edema, and upregulated during cellular edema. Taken together, these results suggested that the downregulation of AQP4 was a result of vasogenic edema and that the upregulation of AQP4 may have induced cellular edema.
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Affiliation(s)
- Chengcheng Zhang
- Department of Radiology, Affiliated Haikou Hospital, Xiangya School of Medicine, Central South University, Haikou, Hainan 570208, P.R. China
| | - Jianqiang Chen
- Department of Radiology, Affiliated Haikou Hospital, Xiangya School of Medicine, Central South University, Haikou, Hainan 570208, P.R. China
| | - Hong Lu
- Department of Radiology, Affiliated Haikou Hospital, Xiangya School of Medicine, Central South University, Haikou, Hainan 570208, P.R. China
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Fresh frozen plasma and spray-dried plasma mitigate pulmonary vascular permeability and inflammation in hemorrhagic shock. J Trauma Acute Care Surg 2015; 78:S7-S17. [PMID: 26002267 DOI: 10.1097/ta.0000000000000630] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND In retrospective and prospective observational studies, fresh frozen plasma (FFP) has been associated with a survival benefit in massively transfused trauma patients. A dry plasma product, such as spray-dried plasma (SDP), offers logistical advantages over FFP. Recent studies on FFP have demonstrated that FFP modulates systemic vascular stability and inflammation. The effect of SDP on these measures has not been previously examined. This study compares SDP with FFP using in vitro assays of endothelial function and in vivo assays of lung injury using a mouse model of hemorrhagic shock (HS) and trauma. METHODS FFP, SDP, and lactated Ringer's (LR) solution were compared in vitro using assays of endothelial cell (EC) permeability, cytokine production and content, gene expression, as well as tight and adherens junction stability. All resuscitation products were also compared in a murine model of HS. Mean arterial pressures and physiologic measures were assessed. Pulmonary vascular permeability was measured using tagged dextran. Lung tissues were stained for CD68, VE-cadherin, and occludin. RESULTS Treatment of ECs with FFP and SDP, but not LR, preserved the integrity of EC monolayers in vitro and resulted in similar EC gene expression patterns and cytokine/growth factor production. FFP and SDP also reduced HS-induced pulmonary vascular permeability in vivo to the same extent. In mice with HS, mean arterial pressures and base excess were corrected by both FFP and SDP to levels observed in sham-treated mice. Treatment after HS with FFP and SDP but not LR solution reduce alveolar wall thickening, leukocyte infiltration, and the breakdown of EC junctions, as measured by staining for VE-cadherin, and occludin. CONCLUSION Both FFP and SDP similarly modulate pulmonary vascular integrity, permeability, and inflammation in vitro and in vivo in a murine model of HS and trauma.
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Halaweish I, Bambakidis T, He W, Linzel D, Chang Z, Srinivasan A, Dekker SE, Liu B, Li Y, Alam HB. Early resuscitation with fresh frozen plasma for traumatic brain injury combined with hemorrhagic shock improves neurologic recovery. J Am Coll Surg 2015; 220:809-19. [PMID: 25907868 DOI: 10.1016/j.jamcollsurg.2015.01.057] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2014] [Revised: 01/23/2015] [Accepted: 01/27/2015] [Indexed: 11/30/2022]
Abstract
BACKGROUND We have shown that early administration of fresh frozen plasma (FFP) reduces the size of brain lesions 6 hours after injury in a large animal model of traumatic brain injury (TBI) and hemorrhagic shock (HS). To examine long-term outcomes, we hypothesized that early treatment with FFP would result in faster neurologic recovery and better long-term outcomes in a combined TBI and HS model. STUDY DESIGN Anesthetized Yorkshire swine underwent combined TBI and volume-controlled hemorrhage (40% blood volume). After 2 hours of shock, animals were randomized (n = 5/group) to normal saline (3× shed blood) or FFP (1× shed blood) treatment. A neurologic severity score was assessed for 30 days. Magnetic resonance imaging of the brain was performed at days 3, 10, and 24. Cognitive function was tested by training animals to retrieve food from color-coded boxes. RESULTS Neurologic impairment was lower and speed of recovery was considerably faster in the FFP-treated animals. There was a trend toward a smaller lesion size in FFP-treated animal at days 3 and 10, but this did not reach statistical significance. Both groups reached baseline performance on the cognitive testing; however, FFP-treated animals were able to participate, on average, 8 days earlier due to quicker recovery. CONCLUSIONS This is the first study to demonstrate the beneficial effects of FFP treatment in a long-term survival model of combined TBI and HS. Our data show that early treatment with FFP substantially attenuates the degree of neurologic impairment, improves the rate of recovery, and preserves the cognitive functions.
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Affiliation(s)
- Ihab Halaweish
- Department of Surgery, University of Michigan Hospital, Ann Arbor, MI
| | - Ted Bambakidis
- Department of Surgery, University of Michigan Hospital, Ann Arbor, MI
| | - Wei He
- Department of Cardiothoracic Surgery, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Durk Linzel
- Department of Emergency Medicine, Flevoziekenhuis Hospital, Almere, The Netherlands
| | - Zhigang Chang
- Department of Surgical Critical Care, Beijing Hospital Ministry of Health, Beijing, China
| | - Ashok Srinivasan
- Department of Radiology, Section of Neuroradiology, University of Michigan Hospital, Ann Arbor, MI
| | - Simone E Dekker
- Department of Anesthesiology, VU University Medical Center, Institute for Cardiovascular Research, Amsterdam, The Netherlands
| | - Baoling Liu
- Department of Surgery, University of Michigan Hospital, Ann Arbor, MI
| | - Yongqing Li
- Department of Surgery, University of Michigan Hospital, Ann Arbor, MI
| | - Hasan B Alam
- Department of Surgery, University of Michigan Hospital, Ann Arbor, MI.
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Sillesen M, Jin G, Johansson PI, Alam HB. Resuscitation speed affects brain injury in a large animal model of traumatic brain injury and shock. Scand J Trauma Resusc Emerg Med 2014; 22:46. [PMID: 25116886 PMCID: PMC4143574 DOI: 10.1186/s13049-014-0046-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2014] [Accepted: 08/04/2014] [Indexed: 01/09/2023] Open
Abstract
Background Optimal fluid resuscitation strategy following combined traumatic brain injury (TBI) and hemorrhagic shock (HS) remain controversial and the effect of resuscitation infusion speed on outcome is not well known. We have previously reported that bolus infusion of fresh frozen plasma (FFP) protects the brain compared with bolus infusion of 0.9% normal saline (NS). We now hypothesize reducing resuscitation infusion speed through a stepwise infusion speed increment protocol using either FFP or NS would provide neuroprotection compared with a high speed resuscitation protocol. Methods 23 Yorkshire swine underwent a protocol of computer controlled TBI and 40% hemorrhage. Animals were left in shock (mean arterial pressure of 35 mmHg) for two hours prior to resuscitation with bolus FFP (n = 5, 50 ml/min) or stepwise infusion speed increment FFP (n = 6), bolus NS (n = 5, 165 ml/min) or stepwise infusion speed increment NS (n = 7). Hemodynamic variables over a 6-hour observation phase were recorded. Following euthanasia, brains were harvested and lesion size as well as brain swelling was measured. Results Bolus FFP resuscitation resulted in greater brain swelling (22.36 ± 1.03% vs. 15.58 ± 2.52%, p = 0.04), but similar lesion size compared with stepwise resuscitation. This was associated with a lower cardiac output (CO: 4.81 ± 1.50 l/min vs. 5.45 ± 1.14 l/min, p = 0.03). In the NS groups, bolus infusion resulted in both increased brain swelling (37.24 ± 1.63% vs. 26.74 ± 1.33%, p = 0.05) as well as lesion size (3285.44 ± 130.81 mm3 vs. 2509.41 ± 297.44 mm3, p = 0.04). This was also associated with decreased cardiac output (NS: 4.37 ± 0.12 l/min vs. 6.35 ± 0.10 l/min, p < 0.01). Conclusions In this clinically relevant model of combined TBI and HS, stepwise resuscitation protected the brain compared with bolus resuscitation.
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Affiliation(s)
| | | | | | - Hasan B Alam
- Department of Surgery, University of Michigan Hospital, 2920 Taubman Center/5331, 1500 E, Medical Center Drive, Ann Arbor 48109, MI, USA.
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