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Laou E, Papagiannakis N, Papadopoulou A, Choratta T, Sakellakis M, Ippolito M, Pantazopoulos I, Cortegiani A, Chalkias A. Effects of Vasopressin Receptor Agonists during the Resuscitation of Hemorrhagic Shock: A Systematic Review and Meta-Analysis of Experimental and Clinical Studies. J Pers Med 2023; 13:1143. [PMID: 37511756 PMCID: PMC10381354 DOI: 10.3390/jpm13071143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 07/10/2023] [Accepted: 07/14/2023] [Indexed: 07/30/2023] Open
Abstract
BACKGROUND The clinical impact of vasopressin in hemorrhagic shock remains largely unknown. OBJECTIVE This systematic review and meta-analysis was designed to investigate the effects of vasopressin receptor agonists during the resuscitation of hemorrhagic shock. METHODS A systematic search of PubMed (MEDLINE), Scopus, and PubMed Central was conducted for relevant articles. Experimental (animal) and clinical studies were included. The primary objective was to investigate the correlation of vasopressin receptor agonist use with mortality and various hemodynamic parameters. RESULTS Data extraction was possible in thirteen animal studies and two clinical studies. Differences in risk of mortality between patients who received a vasopressin receptor agonist were not statistically significant when compared to those who were not treated with such agents [RR (95% CI): 1.17 (0.67, 2.08); p = 0.562; I2 = 50%]. The available data were insufficient to conduct a meta-analysis assessing the effect of vasopressin receptor agonists on hemodynamics. Drawing safe conclusions from animal studies was challenging, due to significant heterogeneity in terms of species and dosage of vasopressin receptor agonists among studies. CONCLUSIONS Differences in risk of mortality between patients who received a vasopressin receptor agonist were not statistically significant when compared to those who were not treated with such agents after hemorrhagic shock. More data are needed to deduce certain conclusions.
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Affiliation(s)
- Eleni Laou
- Department of Anesthesiology, Agia Sophia Children's Hospital, 15773 Athens, Greece
| | - Nikolaos Papagiannakis
- First Department of Neurology, Eginition University Hospital, Medical School, National and Kapodistrian University of Athens, 11528 Athens, Greece
| | - Androniki Papadopoulou
- Department of Anesthesiology, G. Gennimatas General Hospital, 54635 Thessaloniki, Greece
| | - Theodora Choratta
- Department of General Surgery, Metaxa Hospital, 18537 Piraeus, Greece
| | - Minas Sakellakis
- Department of Medical Oncology, Metropolitan Hospital, 18547 Piraeus, Greece
| | - Mariachiara Ippolito
- Department of Surgical, Oncological and Oral Science (Di.Chir.On.S.), University of Palermo, 90133 Palermo, Italy
| | - Ioannis Pantazopoulos
- Department of Emergency Medicine, Faculty of Medicine, University of Thessaly, 41500 Larisa, Greece
| | - Andrea Cortegiani
- Department of Surgical, Oncological and Oral Science (Di.Chir.On.S.), University of Palermo, 90133 Palermo, Italy
| | - Athanasios Chalkias
- Department of Anesthesiology, Faculty of Medicine, University of Thessaly, 41500 Larisa, Greece
- Institute for Translational Medicine and Therapeutics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104-5158, USA
- Outcomes Research Consortium, Cleveland, OH 44195, USA
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Hogarty JP, Jones ME, Jassal K, Hogarty DT, Mitra B, Udy AA, Fitzgerald MC. Review article: Early steroid administration for traumatic haemorrhagic shock: A systematic review. Emerg Med Australas 2023; 35:6-13. [PMID: 36347522 PMCID: PMC10100146 DOI: 10.1111/1742-6723.14129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Accepted: 10/10/2022] [Indexed: 11/11/2022]
Abstract
Haemorrhagic shock after trauma is a leading cause of death worldwide, particularly in young individuals. Despite advances in trauma systems and resuscitation strategies, mortality from haemorrhagic shock has not declined over the previous two decades. A proportion of shocked trauma patients may experience a deficiency of cortisol relative to the severity of their injury. The benefit of exogenous steroid administration in patients suffering haemorrhagic shock as a result of injury is unclear. A systematic review of four databases (Ovid Medline, Ovid Embase, Cochrane, Scopus) was undertaken. Inclusion and exclusion criteria were pre-determined and two reviewers independently screened the articles with disagreements arbitrated by a third reviewer. The primary outcome variable was 28-day mortality. Quality of studies were assessed using the Cochrane-risk-of-bias (RoB 2) tool. Of the 2919 studies yielded by the search strategy, 1274 duplicates were removed and 1645 screened on title and abstract. After the full text of 33 studies were assessed, two articles were included. Both studies were over 30 years old with small numbers of participants and with primary outcomes not including mortality. Of the data available, no statistically significant difference in mortality was detected. Hospital length of stay, reversal of shock or adverse events were not reported. Both studies were at risk of bias. There are no high quality or recent studies in the English literature investigating the use of steroids for haemorrhagic shocked trauma patients. PROSPERO: CRD42021239656.
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Affiliation(s)
- Joseph P Hogarty
- Trauma Service, The Alfred Hospital, Melbourne, Victoria, Australia.,National Trauma Research Institute, Melbourne, Victoria, Australia
| | - Morgan E Jones
- Trauma Service, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Karishma Jassal
- Trauma Service, The Alfred Hospital, Melbourne, Victoria, Australia.,National Trauma Research Institute, Melbourne, Victoria, Australia
| | - Daniel T Hogarty
- Trauma Service, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Biswadev Mitra
- Trauma Service, The Alfred Hospital, Melbourne, Victoria, Australia.,National Trauma Research Institute, Melbourne, Victoria, Australia.,Emergency and Trauma Centre, The Alfred Hospital, Melbourne, Victoria, Australia.,School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Andrew A Udy
- Department of Hyperbaric and Intensive Care Medicine, The Alfred Hospital, Melbourne, Victoria, Australia.,Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
| | - Mark C Fitzgerald
- Trauma Service, The Alfred Hospital, Melbourne, Victoria, Australia.,National Trauma Research Institute, Melbourne, Victoria, Australia
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Serum levels of copeptin predict adverse outcomes and improve risk prediction of TRISS and MGAP scores in patients with multiple trauma: A single-center prospective cohort study. J Trauma Acute Care Surg 2023; 94:336-343. [PMID: 36121260 DOI: 10.1097/ta.0000000000003793] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND Multiple trauma deserves early prognostication and stratification. Copeptin, a precursor of vasopressin, is produced in response to stress. We examined the association between serum levels of copeptin and mortality risk in patients with multiple trauma. We aimed to also enhance the previously established Trauma-Related Injury Severity Score (TRISS) and Mechanism, GCS, Age, and Arterial Pressure (MGAP) score with the additional consideration of copeptin levels. METHODS This single-center prospective cohort study enrolled patients who presented to the emergency department with potential major injuries. The serum levels of copeptin were measured, and the correlation to clinical severity in terms of 30-day mortality and requirement of intensive care management was analyzed. By combining copeptin levels with TRISS or MGAP, comparison between performance of the original models with the copeptin-enhanced models was performed via discrimination, calibration, and reclassification analyses. RESULTS There was a significant increase in copeptin levels in patients who died within 30 days (median 644.4 pg/L, interquartile range [472.5, 785.9]) or were admitted to intensive care units (233.8 pg/L, [105.7, 366.4]), compared with those who survived (37.49 pg/L, [17.88, 77.68]). Adding the natural log of copeptin levels to the established TRISS and MGAP models improved the AUC of TRISS from 0.89 to 0.96, and that of MGAP from 0.82 to 0.95. Both calibrations as measured by Brier's scores and reclassification as measured by net reclassification improvement or integrated discrimination improvement demonstrated significant improvements. A Web-based calculator was built to generate predicted mortality rates of various models for convenient clinical use. CONCLUSION Admission serum copeptin levels were correlated with clinical severity in multiple trauma. Coupling copeptin with preexisting trauma severity scores improved prediction accuracy. Copeptin shows promise as a novel biomarker for the prediction of trauma outcome. LEVEL OF EVIDENCE Prognostic and Epidemiologic; Level III.
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DeSpain K, Rosenfeld CR, Huebinger R, Wang X, Jay JW, Radhakrishnan RS, Wolf SE, Song J. Carotid smooth muscle contractility changes after severe burn. Sci Rep 2021; 11:18094. [PMID: 34508162 PMCID: PMC8433376 DOI: 10.1038/s41598-021-97732-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Accepted: 08/25/2021] [Indexed: 11/17/2022] Open
Abstract
Severe burns result in cardiovascular dysfunction, but responses in the peripheral vasculature are unclear. We hypothesize that severe burns disturb arterial contractility through acute changes in adrenergic and cholinergic receptor function. To address this, we investigated the changes in carotid artery contractility and relaxation following a severe burn. Thirty-four adult Sprague–Dawley male rats received a 40% total body surface area (TBSA) scald burn and fluid resuscitation using the Parkland formula. Control animals received sham burn procedure. Animals were serially euthanized between 6 h and 14 days after burn and endothelium-intact common carotid arteries were used for ex vivo force/relaxation measurements. At 6 h after burn, carotid arteries from burned animals demonstrated a > 50% decrease in cumulative dose-responses to norepinephrine (p < 0.05) and to 10−7 M angiotensin II (p < 0.05). Notably, pre-constricted carotid arteries also demonstrated reduced relaxation responses to acetylcholine (p < 0.05) 6 h after burn, but not to sodium nitroprusside. Histologic examination of cross-sectional planes revealed significant increases in carotid artery wall thickness in burned rats at 6 h versus 3 days, with increased collagen expression in tunica media at 3 days (p < 0.05). Carotid artery dysfunction occurs within 6 h after severe burn, demonstrating decreased sensitivity to adrenergic- and angiotensin II-induced vasoconstriction and acetylcholine-induced relaxation.
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Affiliation(s)
- Kevin DeSpain
- Department of Kinesiology, University of Texas Arlington, Arlington, TX, USA
| | | | - Ryan Huebinger
- Department of Pediatrics, UT Southwestern Medical Center, Dallas, TX, USA
| | - Xiaofu Wang
- Department of Surgery, University of Texas Medical Branch, 301 University Blvd., Galveston, TX, 77555-0644, USA
| | - Jayson W Jay
- Department of Surgery, University of Texas Medical Branch, 301 University Blvd., Galveston, TX, 77555-0644, USA
| | - Ravi S Radhakrishnan
- Department of Surgery, Shriners Hospitals for Children - Galveston, Galveston, TX, USA.,Department of Surgery, University of Texas Medical Branch, 301 University Blvd., Galveston, TX, 77555-0644, USA
| | - Steven E Wolf
- Department of Surgery, Shriners Hospitals for Children - Galveston, Galveston, TX, USA.,Department of Surgery, University of Texas Medical Branch, 301 University Blvd., Galveston, TX, 77555-0644, USA
| | - Juquan Song
- Department of Surgery, University of Texas Medical Branch, 301 University Blvd., Galveston, TX, 77555-0644, USA.
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Plasma resuscitation with adjunctive peritoneal resuscitation reduces ischemic intestinal injury following hemorrhagic shock. J Trauma Acute Care Surg 2020; 89:649-657. [PMID: 32773670 DOI: 10.1097/ta.0000000000002847] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Impaired intestinal microvascular perfusion following resuscitated hemorrhagic shock (HS) leads to ischemia-reperfusion injury, microvascular dysfunction, and intestinal epithelial injury, which contribute to the development of multiple organ dysfunction syndrome in some trauma patients. Restoration of central hemodynamics with traditional methods alone often fails to fully restore microvascular perfusion and does not protect against ischemia-reperfusion injury. We hypothesized that resuscitation (RES) with fresh frozen plasma (FFP) alone or combined with direct peritoneal resuscitation (DPR) with 2.5% Delflex solution might improve blood flow and decrease intestinal injury compared with conventional RES or RES with DPR alone. METHODS Sprague-Dawley rats underwent HS (40% mean arterial pressure) for 60 minutes and were randomly assigned to a RES group (n = 8): sham, HS-crystalloid resuscitation (CR) (shed blood + two volumes CR), HS-CR-DPR (intraperitoneal 2.5% peritoneal dialysis fluid), HS-FFP (shed blood + two volumes FFP), and HS-DPR-FFP (intraperitoneal dialysis fluid + two volumes FFP). Laser Doppler flowmeter evaluation of the ileum, serum samples for fatty acid binding protein enzyme-linked immunosorbent assay, and hematoxylin and eosin (H&E) staining were used to assess intestinal injury and blood flow. p Values of <0.05 were considered significant. RESULTS Following HS, the addition of DPR to either RES modality improved intestinal blood flow. Four hours after resuscitated HS, FABP-2 (intestinal) and FABP-6 (ileal) were elevated in the CR group but reduced in the FFP and DPR groups. The H&E staining demonstrated disrupted intestinal villi in the FFP and CR groups, most significantly in the CR group. Combination therapy with FFP and DPR demonstrated negligible cellular injury in H&E graded samples and a significant reduction in fatty acid binding protein levels. CONCLUSION Hemorrhagic shock leads to ischemic-reperfusion injury of the intestine, and both FFP and DPR alone attenuated intestinal damage; combination FFP-DPR therapy alleviated most signs of organ injury. Resuscitation with FFP-DPR to restore intestinal blood flow following shock could be an essential method of reducing morbidity and mortality after trauma.
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Dhillon NK, Huang R, Mason R, Melo N, Margulies DR, Ley EJ, Barmparas G. Vasopressors in traumatic brain injury: Quantifying their effect on mortality. Am J Surg 2020; 220:1498-1502. [DOI: 10.1016/j.amjsurg.2020.09.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Revised: 08/03/2020] [Accepted: 09/14/2020] [Indexed: 12/20/2022]
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Sims CA, Holena D, Kim P, Pascual J, Smith B, Martin N, Seamon M, Shiroff A, Raza S, Kaplan L, Grill E, Zimmerman N, Mason C, Abella B, Reilly P. Effect of Low-Dose Supplementation of Arginine Vasopressin on Need for Blood Product Transfusions in Patients With Trauma and Hemorrhagic Shock: A Randomized Clinical Trial. JAMA Surg 2020; 154:994-1003. [PMID: 31461138 DOI: 10.1001/jamasurg.2019.2884] [Citation(s) in RCA: 62] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Current therapies for traumatic blood loss focus on hemorrhage control and blood volume replacement. Severe hemorrhagic shock, however, is associated with a state of arginine vasopressin (AVP) deficiency, and supplementation of this hormone may decrease the need for blood products in resuscitation. Objective To determine whether low-dose supplementation of AVP in patients with trauma (hereinafter referred to as trauma patients) and with hemorrhagic shock decreases their need for transfused blood products during resuscitation. Design, Setting, and Participants This randomized, double-blind placebo-controlled clinical trial included adult trauma patients (aged 18-65 years) who received at least 6 U of any blood product within 12 hours of injury at a single urban level 1 trauma center from May 1, 2013, through May 31, 2017. Exclusion criteria consisted of prehospital cardiopulmonary resuscitation, emergency department thoracotomy, corticosteroid use, chronic renal insufficiency, coronary artery disease, traumatic brain injury requiring any neurosurgical intervention, pregnancy, prisoner status, or AVP administration before enrollment. Data were analyzed from May 1, 2013, through May 31, 2017, using intention to treat and per protocol. Interventions After administration of an AVP bolus (4 U) or placebo, participants received AVP (≤0.04 U/min) or placebo for 48 hours to maintain a mean arterial blood pressure of at least 65 mm Hg. Main Outcomes The primary outcome was total volume of blood product transfused. Secondary end points included total volume of crystalloid transfused, vasopressor requirements, secondary complications, and 30-day mortality. Results One hundred patients underwent randomization (49 to the AVP group and 51 to the placebo group). Patients were primarily young (median age, 27 years [interquartile range {IQR}, 22-25 years]) and male (n = 93) with penetrating trauma (n = 79). Cohort characteristics before randomization were well balanced. At 48 hours, patients who received AVP required significantly less blood products (median, 1.4 [IQR, 0.5-2.6] vs 2.9 [IQR, 1.1-4.8] L; P = .01) but did not differ in requirements for crystalloids (median, 9.9 [IQR, 7.9-13.0] vs 11.0 [8.9-15.0] L; P = .22) or vasopressors (median, 400 [IQR, 0-5900] vs 1400 [IQR, 200-7600] equivalent units; P = .22). Although the groups had similar rates of mortality (6 of 49 [12%] vs 6 of 51 [12%]; P = .94) and total complications (24 of 44 [55%] vs 30 of 47 [64%]; P = .37), the AVP group had less deep venous thrombosis (5 of 44 [11%] vs 16 of 47 [34%]; P = .02). Conclusions and Relevance Low-dose AVP during the resuscitation of trauma patients in hemorrhagic shock decreases blood product requirements. Additional research is necessary to determine whether including AVP improves morbidity or mortality. Trial Registration ClinicalTrials.gov identifier: NCT01611935.
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Affiliation(s)
- Carrie A Sims
- Division of Traumatology, Surgical Critical Care, and Emergency Surgery, Department of Surgery, University of Pennsylvania, Philadelphia.,Penn Acute Research Collaboration (PARC), Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Daniel Holena
- Division of Traumatology, Surgical Critical Care, and Emergency Surgery, Department of Surgery, University of Pennsylvania, Philadelphia.,Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Patrick Kim
- Division of Traumatology, Surgical Critical Care, and Emergency Surgery, Department of Surgery, University of Pennsylvania, Philadelphia
| | - Jose Pascual
- Division of Traumatology, Surgical Critical Care, and Emergency Surgery, Department of Surgery, University of Pennsylvania, Philadelphia
| | - Brian Smith
- Division of Traumatology, Surgical Critical Care, and Emergency Surgery, Department of Surgery, University of Pennsylvania, Philadelphia
| | - Neils Martin
- Division of Traumatology, Surgical Critical Care, and Emergency Surgery, Department of Surgery, University of Pennsylvania, Philadelphia
| | - Mark Seamon
- Division of Traumatology, Surgical Critical Care, and Emergency Surgery, Department of Surgery, University of Pennsylvania, Philadelphia
| | - Adam Shiroff
- Division of Traumatology, Surgical Critical Care, and Emergency Surgery, Department of Surgery, University of Pennsylvania, Philadelphia
| | - Shariq Raza
- Division of Traumatology, Surgical Critical Care, and Emergency Surgery, Department of Surgery, University of Pennsylvania, Philadelphia
| | - Lewis Kaplan
- Division of Traumatology, Surgical Critical Care, and Emergency Surgery, Department of Surgery, University of Pennsylvania, Philadelphia
| | - Elena Grill
- Division of Traumatology, Surgical Critical Care, and Emergency Surgery, Department of Surgery, University of Pennsylvania, Philadelphia
| | - Nicole Zimmerman
- Department of Quantitative Health Sciences and Outcomes Research, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Christopher Mason
- Department of Anesthesia, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Benjamin Abella
- Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Patrick Reilly
- Division of Traumatology, Surgical Critical Care, and Emergency Surgery, Department of Surgery, University of Pennsylvania, Philadelphia
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8
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What's New in Shock, April 2020? Shock 2020; 53:379-383. [PMID: 32168294 DOI: 10.1097/shk.0000000000001508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Hoareau GL, Williams TK, Davidson AJ, Russo RM, Ferencz SAE, Neff LP, Grayson JK, Stewart IJ, Johnson MA. Endocrine Effects of Simulated Complete and Partial Aortic Occlusion in a Swine Model of Hemorrhagic Shock. Mil Med 2020; 184:e298-e302. [PMID: 30371879 DOI: 10.1093/milmed/usy287] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Revised: 09/24/2018] [Accepted: 10/06/2018] [Indexed: 11/12/2022] Open
Abstract
INTRODUCTION Low distal aortic flow via partial aortic occlusion (AO) may mitigate ischemia induced by resuscitative endovascular balloon occlusion of the aorta (REBOA). We compared endocrine effects of a novel simulated partial AO strategy, endovascular variable aortic control (EVAC), with simulated REBOA in a swine model. MATERIALS AND METHODS Aortic flow in 20 swine was routed from the supraceliac aorta through an automated extracorporeal circuit. Following liver injury-induced hemorrhagic shock, animals were randomized to control (unregulated distal flow), simulated REBOA (no flow, complete AO), or simulated EVAC (distal flow of 100-300 mL/min after 20 minutes of complete AO). After 90 minutes, damage control surgery, resuscitation, and full flow restoration ensued. Critical care was continued for 4.5 hours or until death. RESULTS Serum angiotensin II concentration was higher in the simulated EVAC (4,769 ± 624 pg/mL) than the simulated REBOA group (2649 ± 429) (p = 0.01) at 180 minutes. There was no detectable difference in serum renin [simulated REBOA: 231.3 (227.9-261.4) pg/mL; simulated EVAC: 294.1 (231.2-390.7) pg/mL; p = 0.27], aldosterone [simulated EVAC: 629 (454-1098), simulated REBOA: 777 (575-1079) pg/mL, p = 0.53], or cortisol (simulated EVAC: 141 ± 12, simulated REBOA: 127 ± 9 ng/mL, p = 0.34) concentrations between groups. CONCLUSIONS Simulated EVAC was associated with higher serum angiotensin II, which may have contributed to previously reported cardiovascular benefits. Future studies should evaluate the renal effects of EVAC and the concomitant therapeutic use of angiotensin II.
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Affiliation(s)
- Guillaume L Hoareau
- Clinical Investigation Facility, David Grant USAF Medical Center, 101 Bodin Circle, Travis Air Force Base, CA
| | - Timothy K Williams
- Clinical Investigation Facility, David Grant USAF Medical Center, 101 Bodin Circle, Travis Air Force Base, CA.,Department of Surgery, 1 Medical Center Blvd, Winston-Salem, NC
| | - Anders J Davidson
- Clinical Investigation Facility, David Grant USAF Medical Center, 101 Bodin Circle, Travis Air Force Base, CA.,Department of General Surgery, David Grant USAF Medical Center, 101 Bodin Circle, Travis Air Force Base, CA.,Department of Surgery, University of California Davis Medical Center, 2315 Stockton Blvd, Sacramento, CA
| | - Rachel M Russo
- Clinical Investigation Facility, David Grant USAF Medical Center, 101 Bodin Circle, Travis Air Force Base, CA.,Department of General Surgery, David Grant USAF Medical Center, 101 Bodin Circle, Travis Air Force Base, CA.,Department of Surgery, University of California Davis Medical Center, 2315 Stockton Blvd, Sacramento, CA
| | | | - Lucas P Neff
- Clinical Investigation Facility, David Grant USAF Medical Center, 101 Bodin Circle, Travis Air Force Base, CA.,Department of Surgery, Emory University Hospital, 1364 Clifton Rd, Atlanta, GA
| | - J Kevin Grayson
- Clinical Investigation Facility, David Grant USAF Medical Center, 101 Bodin Circle, Travis Air Force Base, CA
| | - Ian J Stewart
- Clinical Investigation Facility, David Grant USAF Medical Center, 101 Bodin Circle, Travis Air Force Base, CA.,Uniformed Services University of the Health Sciences, 4301 Jones Bridge Rd, Bethesda, MD
| | - M Austin Johnson
- Clinical Investigation Facility, David Grant USAF Medical Center, 101 Bodin Circle, Travis Air Force Base, CA.,Department of Emergency Medicine, University of California Davis Medical Center, 2315 Stockton Blvd, Sacramento, CA
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Salvo F, Luppi F, Lucchesi DM, Canovi S, Franchini S, Polese A, Santi F, Trabucco L, Fasano T, Ferrari AM. Serum Copeptin levels in the emergency department predict major clinical outcomes in adult trauma patients. BMC Emerg Med 2020; 20:14. [PMID: 32093639 PMCID: PMC7041089 DOI: 10.1186/s12873-020-00310-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2019] [Accepted: 02/11/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Early prognostication in trauma patients is challenging, but particularly important. We wanted to explore the ability of copeptin, the C-terminal fragment of arginine vasopressin, to identify major trauma, defined as Injury Severity Score (ISS) > 15, in a heterogeneous cohort of trauma patients and to compare its performances with lactate. We also evaluated copeptin performance in predicting other clinical outcomes: mortality, hospital admission, blood transfusion, emergency surgery, and Intensive Care Unit (ICU) admission. METHODS This single center, pragmatic, prospective observational study was conducted at Arcispedale Santa Maria Nuova, a level II trauma center in Reggio Emilia, Italy. Copeptin determination was obtained on Emergency Department (ED) arrival, together with venous lactate. Different outcomes were measured including ISS, Revised Trauma Score (RTS), hospital and ICU admission, blood transfusion, emergency surgery, and mortality. RESULTS One hundred and twenty five adult trauma patients admitted to the ED between June 2017 and March 2018. Copeptin showed a good ability to identify patients with ISS > 15 (AUC 0.819). Similar good performances were recorded also in predicting other outcomes. Copeptin was significantly superior to lactate in identifying patients with ISS > 15 (P 0.0015), and in predicting hospital admission (P 0.0002) and blood transfusion (P 0.016). Comparable results were observed in a subgroup of patients with RTS 7.84. CONCLUSIONS In a heterogeneous group of trauma patients, a single copeptin determination at the time of ED admission proved to be an accurate biomarker, statistically superior to lactate for the identification of major trauma, hospital admission, and blood transfusion, while no statistical difference was observed for ICU admission and emergency surgery. These results, if confirmed, may support a role for copeptin during early management of trauma patients.
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Affiliation(s)
- Fulvio Salvo
- Department of Emergency Medicine Azienda USL-IRCCS di Reggio Emilia, via Amendola 2, 42122, Reggio Emilia, Italy. .,Present address: Respiratory and Critical Care Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, UAE.
| | - Francesco Luppi
- Department of Emergency Medicine Azienda USL-IRCCS di Reggio Emilia, via Amendola 2, 42122, Reggio Emilia, Italy
| | - Davide M Lucchesi
- Department of Emergency Medicine Azienda USL-IRCCS di Reggio Emilia, via Amendola 2, 42122, Reggio Emilia, Italy
| | - Simone Canovi
- Clinical Chemistry and Endocrinology Laboratory, Department of Diagnostic Imaging and Laboratory Medicine, Azienda USL-IRCCS di Reggio Emilia, via Amendola 2, 42122, Reggio Emilia, Italy
| | - Stefano Franchini
- Emergency Department, Ospedale San Raffaele, via Olgettina 60, 20132, Milan, Italy
| | - Alessandra Polese
- Clinical Chemistry and Endocrinology Laboratory, Department of Diagnostic Imaging and Laboratory Medicine, Azienda USL-IRCCS di Reggio Emilia, via Amendola 2, 42122, Reggio Emilia, Italy
| | - Francesca Santi
- Department of Emergency Medicine Azienda USL-IRCCS di Reggio Emilia, via Amendola 2, 42122, Reggio Emilia, Italy
| | - Laura Trabucco
- Department of Emergency Medicine Azienda USL-IRCCS di Reggio Emilia, via Amendola 2, 42122, Reggio Emilia, Italy
| | - Tommaso Fasano
- Clinical Chemistry and Endocrinology Laboratory, Department of Diagnostic Imaging and Laboratory Medicine, Azienda USL-IRCCS di Reggio Emilia, via Amendola 2, 42122, Reggio Emilia, Italy
| | - Anna Maria Ferrari
- Department of Emergency Medicine Azienda USL-IRCCS di Reggio Emilia, via Amendola 2, 42122, Reggio Emilia, Italy
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Allen CJ, Subhawong TK, Hanna MM, Chelala L, Bullock MR, Schulman CI, Proctor KG. Does Vasopressin Exacerbate Cerebral Edema in Patients with Severe Traumatic Brain Injury? Am Surg 2018. [DOI: 10.1177/000313481808400121] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Arginine vasopressin (AVP) is often used as an alternative pressor to catecholamines (CATs). However, unlike CATs, AVP is a powerful antidiuretic that could promote edema. We tested the hypothesis that AVP promoted cerebral edema and/or increased requirements for osmotherapy, relative to those who received CATs, for cerebral perfusion pressure (CPP) management after traumatic brain injury (TBI). This is a retrospective review of 286 consecutive TBI patients with intracranial pressure monitoring at a single institution from September 2008 to January 2015. Cerebral edema was quantitated using CT attenuation in prespecified areas of gray and white matter. Results: To maintain CPP >60 mm Hg, 205 patients required no vasopressors, 41 received a single CAT, 12 received AVP, and 28 required both. Those who required no pressors were generally less injured; required less hyperosmolar therapy and less total fluid; and had lower plasma Na, lower intracranial pressure, less edema, and lower mortality (all P < 0.05). Edema; daily mean, minimum, and maximum Na levels; and mortality were similar with AVP versus CATs, but the daily requirement of mannitol and 3 per cent NaCl were reduced by 45 and 35 per cent (both P < 0.05). In patients with TBI who required CPP therapy, AVP reduced the requirements for hyperosmolar therapy and did not delay resolution or increase cerebral edema compared with CATs.
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Affiliation(s)
- Casey J. Allen
- Dewitt-Daughtry Department of Surgery, Divisions of Trauma and Surgical Critical Care, Miami, Florida
| | - Ty K. Subhawong
- Department of Radiology, and, University of Miami Miller School of Medicine, Miami, Florida
| | - Mena M. Hanna
- Dewitt-Daughtry Department of Surgery, Divisions of Trauma and Surgical Critical Care, Miami, Florida
| | - Lydia Chelala
- Department of Radiology, and, University of Miami Miller School of Medicine, Miami, Florida
| | - M. Ross Bullock
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida
| | - Carl I. Schulman
- Dewitt-Daughtry Department of Surgery, Divisions of Trauma and Surgical Critical Care, Miami, Florida
| | - Kenneth G. Proctor
- Dewitt-Daughtry Department of Surgery, Divisions of Trauma and Surgical Critical Care, Miami, Florida
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12
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Sims CA, Yuxia G, Singh K, Werlin EC, Reilly PM, Baur JA. Supplemental arginine vasopressin during the resuscitation of severe hemorrhagic shock preserves renal mitochondrial function. PLoS One 2017; 12:e0186339. [PMID: 29065123 PMCID: PMC5655425 DOI: 10.1371/journal.pone.0186339] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Accepted: 10/01/2017] [Indexed: 01/30/2023] Open
Abstract
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.
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Affiliation(s)
- Carrie A. Sims
- The Trauma Center at the University of Pennsylvania, Department of Surgery, Perelman School of Medicine, Philadelphia, PA, United States of America
- Penn Acute Research Collaboration (PARC), University of Pennsylvania, Philadelphia, PA, United States of America
- * E-mail:
| | - Guan Yuxia
- The Trauma Center at the University of Pennsylvania, Department of Surgery, Perelman School of Medicine, Philadelphia, PA, United States of America
| | - Khushboo Singh
- The Trauma Center at the University of Pennsylvania, Department of Surgery, Perelman School of Medicine, Philadelphia, PA, United States of America
| | - Evan C. Werlin
- Department of Surgery, University of California, San Francisco, San Francisco, CA, United States of America
| | - Patrick M. Reilly
- The Trauma Center at the University of Pennsylvania, Department of Surgery, Perelman School of Medicine, Philadelphia, PA, United States of America
| | - Joseph A. Baur
- Penn Acute Research Collaboration (PARC), University of Pennsylvania, Philadelphia, PA, United States of America
- Department of Physiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States of America
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13
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Chiang WC, Chen SY, Ko PCI, Hsieh MJ, Wang HC, Huang EPC, Yang CW, Chong KM, Chen WT, Chen SY, Ma MHM. Prehospital intravenous epinephrine may boost survival of patients with traumatic cardiac arrest: a retrospective cohort study. Scand J Trauma Resusc Emerg Med 2015; 23:102. [PMID: 26585517 PMCID: PMC4653851 DOI: 10.1186/s13049-015-0181-4] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2015] [Accepted: 11/06/2015] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Prehospital resuscitation for patients with major trauma emphasizes a load-and-go principle. For traumatic cardiac arrest (TCA) patients, the administration of vasopressors remains under debate. This study evaluated the effectiveness of epinephrine in the prehospital setting for patients with TCA. METHODS We conducted a retrospective cohort study using a prospectively collected registry for out-of-hospital cardiac arrest in Taipei. Enrollees were ≥18 years of age with TCA. Patients with signs of obvious death like decapitation or rigor mortis were excluded. Patients were grouped according to prehospital administration, or lack thereof, of epinephrine. Outcomes were sustained (≥2 h) recovery of spontaneous circulation (ROSC) and survival to discharge. A subgroup analysis was performed by stratified total prehospital time. RESULTS From June 1 2010 to May 31 2013, 514 cases were enrolled. Epinephrine was administered in 43 (8.4%) cases. Among all patients, sustained ROSC and survival to discharge was 101 (19.6%) and 20 (3.9%), respectively. The epinephrine group versus the non-epinephrine group had higher sustained ROSC (41.9% vs. 17.6%, p < 0.01) and survival to discharge (14.0% vs. 3.0%, p < 0.01). The adjusted odds ratios (ORs) of epinephrine effect were 2.24 (95% confidence interval (CI) 1.05-4.81) on sustained ROSC, and 2.94 (95% CI 0.85-10.15) on survival to discharge. Subgroup analysis showed increased ORs of epinephrine effect on sustained ROSC with a longer prehospital time. CONCLUSION Among adult patients with TCA in an Asian metropolitan area, administration of epinephrine in the prehospital setting was associated with increased short-term survival, especially for those with a longer prehospital time.
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Affiliation(s)
- Wen-Chu Chiang
- Department of Emergency, National Taiwan University Hospital, No. 7 Zhung-Zhan S. Road, Taipei, Zhongzheng District, 100, Taiwan
| | - Shi-Yi Chen
- Department of Emergency, National Taiwan University Hospital, No. 7 Zhung-Zhan S. Road, Taipei, Zhongzheng District, 100, Taiwan
- Department of Surgery, Kaohsiung Armed Forces General Hospital, Kaohsiung, Taiwan
| | - Patrick Chow-In Ko
- Department of Emergency, National Taiwan University Hospital, No. 7 Zhung-Zhan S. Road, Taipei, Zhongzheng District, 100, Taiwan
| | - Ming-Ju Hsieh
- Department of Emergency, National Taiwan University Hospital, No. 7 Zhung-Zhan S. Road, Taipei, Zhongzheng District, 100, Taiwan
| | - Hui-Chih Wang
- Department of Emergency, National Taiwan University Hospital, No. 7 Zhung-Zhan S. Road, Taipei, Zhongzheng District, 100, Taiwan
| | - Edward Pei-Chuan Huang
- Department of Emergency, National Taiwan University Hospital, No. 7 Zhung-Zhan S. Road, Taipei, Zhongzheng District, 100, Taiwan
| | - Chih-Wei Yang
- Department of Emergency, National Taiwan University Hospital, No. 7 Zhung-Zhan S. Road, Taipei, Zhongzheng District, 100, Taiwan
- Department of Medical Education, National Taiwan University Hospital, Taipei, Taiwan
| | - Kah-Meng Chong
- Department of Emergency, National Taiwan University Hospital, No. 7 Zhung-Zhan S. Road, Taipei, Zhongzheng District, 100, Taiwan
| | - Wei-Ting Chen
- Department of Emergency, National Taiwan University Hospital, No. 7 Zhung-Zhan S. Road, Taipei, Zhongzheng District, 100, Taiwan
| | - Shey-Ying Chen
- Department of Emergency, National Taiwan University Hospital, No. 7 Zhung-Zhan S. Road, Taipei, Zhongzheng District, 100, Taiwan
| | - Matthew Huei-Ming Ma
- Department of Emergency, National Taiwan University Hospital, No. 7 Zhung-Zhan S. Road, Taipei, Zhongzheng District, 100, Taiwan.
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14
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Affiliation(s)
- D Fiorella
- Department of Neurosurgery, State University of New York at Stony Brook, Stony Brook, New York, USA
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15
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Martin DT, Schreiber MA. Modern resuscitation of hemorrhagic shock: what is on the horizon? Eur J Trauma Emerg Surg 2014; 40:641-56. [PMID: 26814779 DOI: 10.1007/s00068-014-0416-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2014] [Accepted: 05/23/2014] [Indexed: 12/24/2022]
Abstract
PURPOSE Mortality rates among the severely injured remain high. The successful treatment of hemorrhagic shock relies on expeditious control of bleeding through surgical ligation, packing, or endovascular techniques. An important secondary concern in hemorrhaging patients is how to respond to the lost blood volume. A single method that is able to adequately address all needs of the exsanguinating patient has not yet been agreed upon, despite a large growth of knowledge regarding the causative factors of traumatic shock. METHODS A review of relevent literature was performed. CONCLUSIONS Many different trials are currently underway to discriminate ways to improve outcomes in the severely injured and bleeding patient. This paper will review: (1) recent advances in our understanding of the effects hemorrhagic shock has on the coagulation cascade and vascular endothelium, (2) recent research findings that have changed resuscitation, and (3) resuscitation strategies that are not widely used but under active investigation.
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Affiliation(s)
- D T Martin
- Division of Trauma, Critical Care, and Acute Care Surgery, Department of Surgery, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, Mail Code L-611, Portland, OR, 97239, USA. .,Division of Trauma, Critical Care, and Acute Care Surgery, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, Mail Code L-611, Portland, OR, 97239, USA.
| | - M A Schreiber
- Division of Trauma, Critical Care, and Acute Care Surgery, Department of Surgery, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, Mail Code L-611, Portland, OR, 97239, USA. .,Division of Trauma, Critical Care, and Acute Care Surgery, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, Mail Code L-611, Portland, OR, 97239, USA.
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