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Kopra J, Litonius E, Pekkarinen PT, Laitinen M, Heinonen JA, Fontanelli L, Skrifvars MB. Oxygenation and ventilation during prolonged experimental cardiopulmonary resuscitation with either continuous or 30:2 compression-to-ventilation ratios together with 10 cmH 20 positive end-expiratory pressure. Intensive Care Med Exp 2024; 12:36. [PMID: 38607459 PMCID: PMC11014827 DOI: 10.1186/s40635-024-00620-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Accepted: 04/01/2024] [Indexed: 04/13/2024] Open
Abstract
BACKGROUND In refractory out-of-hospital cardiac arrest, the patient is commonly transported to hospital with mechanical continuous chest compressions (CCC). Limited data are available on the optimal ventilation strategy. Accordingly, we compared arterial oxygenation and haemodynamics during manual asynchronous continuous ventilation and compressions with a 30:2 compression-to-ventilation ratio together with the use of 10 cmH2O positive end-expiratory pressure (PEEP). METHODS Intubated and anaesthetized landrace pigs with electrically induced ventricular fibrillation were left untreated for 5 min (n = 31, weight ca. 55 kg), after which they were randomized to either the CCC group or the 30:2 group with the the LUCAS® 2 piston device and bag-valve ventilation with 100% oxygen targeting a tidal volume of 8 ml/kg with a PEEP of 10 cmH2O for 35 min. Arterial blood samples were analysed every 5 min, vital signs, near-infrared spectroscopy and electrical impedance tomography (EIT) were measured continuously, and post-mortem CT scans of the lungs were obtained. RESULTS The arterial blood values (median + interquartile range) at the 30-min time point were as follows: PaO2: 180 (86-302) mmHg for the 30:2 group; 70 (49-358) mmHg for the CCC group; PaCO2: 41 (29-53) mmHg for the 30:2 group; 44 (21-67) mmHg for the CCC group; and lactate: 12.8 (10.4-15.5) mmol/l for the 30:2 group; 14.7 (11.8-16.1) mmol/l for the CCC group. The differences were not statistically significant. In linear mixed models, there were no significant differences between the groups. The mean arterial pressures from the femoral artery, end-tidal CO2, distributions of ventilation from EIT and mean aeration of lung tissue in post-mortem CTs were similar between the groups. Eight pneumothoraces occurred in the CCC group and 2 in the 30:2 group, a statistically significant difference (p = 0.04). CONCLUSIONS The 30:2 and CCC protocols with a PEEP of 10 cmH2O resulted in similar gas exchange and vital sign outcomes in an experimental model of prolonged cardiac arrest with mechanical compressions, but the CCC protocol resulted in more post-mortem pneumothoraces.
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Affiliation(s)
- Jukka Kopra
- Department of Emergency Care and Services, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.
| | - Erik Litonius
- Division of Anaesthesiology, Department of Anaesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Pirkka T Pekkarinen
- Division of Intensive Care, Department of Anaesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Merja Laitinen
- VetCT Teleconsulting-Teleradiology Small Animal Team, Helsinki, Finland
| | - Juho A Heinonen
- Division of Intensive Care, Department of Anaesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Centre for Prehospital Emergency Care and Emergency Medicine, Päijät-Häme Central Hospital, Lahti, Finland
| | - Luca Fontanelli
- Department of Clinical-Surgical, Diagnostic and Paediatric Sciences, Unit of Anaesthesia and Intensive Care, University of Pavia, Pavia, Italy
| | - Markus B Skrifvars
- Department of Emergency Care and Services, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
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Arsenault V, Lieberman L, Akbari P, Murto K. Canadian tertiary care pediatric massive hemorrhage protocols: a survey and comprehensive national review. Can J Anaesth 2024; 71:453-464. [PMID: 38057534 DOI: 10.1007/s12630-023-02641-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 06/27/2023] [Accepted: 07/09/2023] [Indexed: 12/08/2023] Open
Abstract
PURPOSE Hemorrhage is the leading cause of pediatric death in trauma and cardiac arrest during surgery. Adult studies report improved patient outcomes using massive hemorrhage protocols (MHPs). Little is known about pediatric MHP adoption in Canada. METHODS After waived research ethics approval, we conducted a survey of Canadian pediatric tertiary care hospitals to study MHP activations. Transfusion medicine directors provided hospital/patient demographic and MHP activation data. The authors extracted pediatric-specific MHP data from requested policy/procedure documents according to seven predefined MHP domains based on the literature. We also surveyed educational and audit tools. The analysis only included MHPs with pediatric-specific content. RESULTS The survey included 18 sites (100% response rate). Only 13/18 hospitals had pediatric-specific MHP content: eight were dedicated pediatric hospitals, two were combined pediatric/obstetrical hospitals, and three were combined pediatric/adult hospitals. Trauma was the most common indication for MHP activation (54%), typically based on a specific blood volume anticipated/transfused over time (10/13 sites). Transport container content was variable. Plasma and platelets were usually not in the first container. There was little emphasis on balanced plasma/platelet to red-blood-cell ratios, and most sites (12/13) rapidly incorporated laboratory-guided goal-directed transfusion. Transfusion thresholds were consistent with recent guidelines. All protocols used tranexamic acid and eight sites used an audit tool. DISCUSSION/CONCLUSION Pediatric MHP content was highly variable. Activation demographics suggest underuse in nontrauma settings. Our findings highlight the need for a consensus definition for pediatric massive hemorrhage, a validated pediatric MHP activation tool, and prospective assessment of blood component ratios. A national pediatric MHP activation repository would allow for quality improvement metrics.
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Affiliation(s)
- Valérie Arsenault
- Division of Transfusion Medicine, Department of Laboratory Medicine, University of Montreal, Montreal, QC, Canada
- Centre Hospitalier Universitaire (CHU) Sainte-Justine, Mother and Child Hospital of Montreal, Montreal, QC, Canada
| | - Lani Lieberman
- Department of Laboratory Medicine and Pathology, University of Toronto, Toronto, ON, Canada
- University Health Network, Toronto General Hospital, Toronto, ON, Canada
| | - Pegah Akbari
- Department of Physical Therapy, University of Toronto, Toronto, ON, Canada
| | - Kimmo Murto
- Department of Anesthesiology and Pain Medicine, University of Ottawa, Ottawa, ON, Canada.
- Children's Hospital of Eastern Ontario Research Institute, 401 Smyth Rd., Ottawa, ON, K1H 8L1, Canada.
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Cuyutupa VR, Moser D, Diedrich V, Cheng Y, Billaud JN, Haugg E, Singer D, Bereiter-Hahn J, Herwig A, Choukér A. Blood transcriptomics mirror regulatory mechanisms during hibernation-a comparative analysis of the Djungarian hamster with other mammalian species. Pflugers Arch 2023; 475:1149-1160. [PMID: 37542567 PMCID: PMC10499953 DOI: 10.1007/s00424-023-02842-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 06/13/2023] [Accepted: 07/11/2023] [Indexed: 08/07/2023]
Abstract
Hibernation enables many species of the mammalian kingdom to overcome periods of harsh environmental conditions. During this physically inactive state metabolic rate and body temperature are drastically downregulated, thereby reducing energy requirements (torpor) also over shorter time periods. Since blood cells reflect the organism´s current condition, it was suggested that transcriptomic alterations in blood cells mirror the torpor-associated physiological state. Transcriptomics on blood cells of torpid and non-torpid Djungarian hamsters and QIAGEN Ingenuity Pathway Analysis (IPA) revealed key target molecules (TMIPA), which were subjected to a comparative literature analysis on transcriptomic alterations during torpor/hibernation in other mammals. Gene expression similarities were identified in 148 TMIPA during torpor nadir among various organs and phylogenetically different mammalian species. Based on TMIPA, IPA network analyses corresponded with described inhibitions of basic cellular mechanisms and immune system-associated processes in torpid mammals. Moreover, protection against damage to the heart, kidney, and liver was deduced from this gene expression pattern in blood cells. This study shows that blood cell transcriptomics can reflect the general physiological state during torpor nadir. Furthermore, the understanding of molecular processes for torpor initiation and organ preservation may have beneficial implications for humans in extremely challenging environments, such as in medical intensive care units and in space.
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Affiliation(s)
- Valeria Rojas Cuyutupa
- Laboratory of Translational Research 'Stress and Immunity', Department of Anesthesiology, LMU Hospital, Ludwig-Maximilians-Universität in Munich, Marchioninistr. 15, Munich, 81377, Germany
| | - Dominique Moser
- Laboratory of Translational Research 'Stress and Immunity', Department of Anesthesiology, LMU Hospital, Ludwig-Maximilians-Universität in Munich, Marchioninistr. 15, Munich, 81377, Germany
| | - Victoria Diedrich
- Institute of Neurobiology, Ulm University, Albert-Einstein-Allee 11, 89081, Ulm, Germany
| | - Yiming Cheng
- Gene Center and Department of Biochemistry, Ludwig-Maximilians-Universität in Munich, Munich, Germany
- Institute for Diabetes and Obesity, Helmholtz, Munich, Neuherberg, Germany
| | | | - Elena Haugg
- Institute of Neurobiology, Ulm University, Albert-Einstein-Allee 11, 89081, Ulm, Germany
| | - Dominique Singer
- Division of Neonatology and Pediatric Critical Care Medicine, University Medical Center Eppendorf, Hamburg, Germany
| | - Jürgen Bereiter-Hahn
- Institute for Cell Biology and Neurosciences, Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Annika Herwig
- Institute of Neurobiology, Ulm University, Albert-Einstein-Allee 11, 89081, Ulm, Germany.
| | - Alexander Choukér
- Laboratory of Translational Research 'Stress and Immunity', Department of Anesthesiology, LMU Hospital, Ludwig-Maximilians-Universität in Munich, Marchioninistr. 15, Munich, 81377, Germany.
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Jibrin A, Uzairu A, Shallangwa GA, Abechi SE, Umar AB. In-silico profiling, design, molecular docking computation, and drug kinetic model evaluation of novel curcumin derivatives as potential anticancer agents. J INDIAN CHEM SOC 2023. [DOI: 10.1016/j.jics.2023.100979] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/07/2023]
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April MD, Fisher AD, Hill R, Rizzo JA, Mdaki K, Bynum J, Schauer SG. Adherence to a Balanced Approach to Massive Transfusion in Combat Casualties. Mil Med 2023; 188:e524-e530. [PMID: 34347081 DOI: 10.1093/milmed/usab313] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Revised: 06/01/2021] [Accepted: 07/22/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Hemorrhage is the most common cause of potentially preventable death on the battlefield. Balanced resuscitation with plasma, platelets, and packed red blood cells (PRBCs) in a 1:1:1 ratio, if whole blood (WB) is not available, is associated with optimal outcomes among patients with hemorrhage. We describe the use of balanced resuscitation among combat casualties undergoing massive transfusion. MATERIALS AND METHODS We conducted a secondary analysis of data from the Department of Defense Trauma Registry (DODTR) spanning encounters from January 1, 2007, to March 17, 2020. We included all casualties who received at least 10 units of either PRBCs or WB. We categorized casualties as recipients of plasma-balanced resuscitation if the ratio of plasma to PRBC units was 0.8 or greater; similarly, we defined platelet-balanced resuscitation as a ratio of platelets to PRBC units of 0.8 or greater. We portrayed these populations using descriptive statistics and compared characteristics between non-balanced and balanced resuscitation recipients for both plasma and platelets. RESULTS We identified 28,950 encounters in the DODTR with documentation of prehospital activity. Massive transfusions occurred for 2,414 (8.3%) casualties, among whom 1,593 (66.0%) received a plasma-balanced resuscitation and 1,248 (51.7%) received a platelet-balanced resuscitation. During the study period, 962 (39.8%) of these patients received a fully balanced resuscitation with regard to both the plasma:PRBC and platelet:PRBC ratios. The remaining casualties did not undergo a balanced resuscitation. CONCLUSIONS While a majority of massive transfusion recipients received a plasma-balanced and/or platelet-balanced resuscitation, fewer patients received a platelet-balanced resuscitation. These findings suggest that more emphasis in training and supply may be necessary to optimize blood product resuscitation ratios.
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Affiliation(s)
- Michael D April
- 40th Forward Resuscitation and Surgical Detachment, 627 Hospital Center, 1st Medical Brigade, Fort Carson, CO 80913, USA
- Department of Military and Emergency Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Andrew D Fisher
- University of New Mexico Hospital, Albuquerque, NM 87131, USA
- Texas Army National Guard, Austin, TX 87131, USA
| | - Ronnie Hill
- U.S. Army Institute of Surgical Research, JBSA Fort Sam Houston, TX 78763, USA
| | - Julie A Rizzo
- Department of Military and Emergency Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
- U.S. Army Institute of Surgical Research, JBSA Fort Sam Houston, TX 78763, USA
| | - Kennedy Mdaki
- U.S. Army Institute of Surgical Research, JBSA Fort Sam Houston, TX 78763, USA
| | - James Bynum
- U.S. Army Institute of Surgical Research, JBSA Fort Sam Houston, TX 78763, USA
| | - Steven G Schauer
- Department of Military and Emergency Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
- U.S. Army Institute of Surgical Research, JBSA Fort Sam Houston, TX 78763, USA
- Department of Emergency Medicine, Brooke Army Medical Center, JBSA Fort Sam Houston, TX 78234, USA
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Sunde GA, Bjerkvig C, Bekkevold M, Kristoffersen EK, Strandenes G, Bruserud Ø, Apelseth TO, Heltne JK. Implementation of a low-titre whole blood transfusion program in a civilian helicopter emergency medical service. Scand J Trauma Resusc Emerg Med 2022; 30:65. [PMID: 36494743 PMCID: PMC9733220 DOI: 10.1186/s13049-022-01051-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 11/22/2022] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Early balanced transfusion is associated with improved outcome in haemorrhagic shock patients. This study describes the implementation and evaluates the safety of a whole blood transfusion program in a civilian helicopter emergency medical service (HEMS). METHODS This prospective observational study was performed over a 5-year period at HEMS-Bergen, Norway. Patients in haemorrhagic shock receiving out of hospital transfusion of low-titre Group O whole blood (LTOWB) or other blood components were included. Two LTOWB units were produced weekly and rotated to the HEMS for forward storage. The primary endpoints were the number of patients transfused, mechanisms of injury/illness, adverse events and survival rates. Informed consent covered patient pathway from time of emergency interventions to last endpoint and subsequent data handling/storage. RESULTS The HEMS responded to 5124 patients. Seventy-two (1.4%) patients received transfusions. Twenty patients (28%) were excluded due to lack of consent (16) or not meeting the inclusion criteria (4). Of the 52 (100%) patients, 48 (92%) received LTOWB, nine (17%) received packed red blood cells (PRBC), and nine (17%) received freeze-dried plasma. Of the forty-six (88%) patients admitted alive to hospital, 35 (76%) received additional blood transfusions during the first 24 h. Categories were blunt trauma 30 (58%), penetrating trauma 7 (13%), and nontrauma 15 (29%). The majority (79%) were male, with a median age of 49 (IQR 27-70) years. No transfusion reactions, serious complications or logistical challenges were reported. Overall, 36 (69%) patients survived 24 h, and 28 (54%) survived 30 days. CONCLUSIONS Implementing a whole blood transfusion program in civilian HEMS is feasible and safe and the logistics around out of hospital whole blood transfusions are manageable. Trial registration The study is registered in the ClinicalTrials.gov registry (NCT02784951).
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Affiliation(s)
- Geir Arne Sunde
- grid.412008.f0000 0000 9753 1393Department of Anesthesia and Intensive Care, Haukeland University Hospital, Bergen, Norway ,Helicopter Emergency Medical Services, Bergen, Norway
| | - Christopher Bjerkvig
- grid.412008.f0000 0000 9753 1393Department of Anesthesia and Intensive Care, Haukeland University Hospital, Bergen, Norway ,Helicopter Emergency Medical Services, Bergen, Norway ,grid.7914.b0000 0004 1936 7443Department of Clinical Medicine, Faculty of Medicine, University of Bergen, Bergen, Norway
| | - Marit Bekkevold
- grid.420120.50000 0004 0481 3017Department of Research, Norwegian Air Ambulance Foundation, Oslo, Norway ,grid.55325.340000 0004 0389 8485Division of Prehospital Services, Air Ambulance Department, Oslo University Hospital, Oslo, Norway
| | - Einar K. Kristoffersen
- grid.7914.b0000 0004 1936 7443Department of Clinical Science, Faculty of Medicine, University of Bergen, Bergen, Norway ,grid.412008.f0000 0000 9753 1393Department of Immunology and Transfusion Medicine, Haukeland University Hospital, Bergen, Norway
| | - Geir Strandenes
- grid.412008.f0000 0000 9753 1393Department of Immunology and Transfusion Medicine, Haukeland University Hospital, Bergen, Norway
| | - Øyvind Bruserud
- grid.412008.f0000 0000 9753 1393Department of Anesthesia and Intensive Care, Haukeland University Hospital, Bergen, Norway
| | - Torunn Oveland Apelseth
- grid.7914.b0000 0004 1936 7443Department of Clinical Science, Faculty of Medicine, University of Bergen, Bergen, Norway ,grid.412008.f0000 0000 9753 1393Department of Immunology and Transfusion Medicine, Haukeland University Hospital, Bergen, Norway ,grid.457897.00000 0004 0512 8409Norwegian Armed Forces Joint Medical Service, Sessvollmoen, Norway
| | - Jon-Kenneth Heltne
- grid.412008.f0000 0000 9753 1393Department of Anesthesia and Intensive Care, Haukeland University Hospital, Bergen, Norway ,Helicopter Emergency Medical Services, Bergen, Norway ,grid.7914.b0000 0004 1936 7443Department of Clinical Medicine, Faculty of Medicine, University of Bergen, Bergen, Norway
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Ganushchak YM, Kurniawati ER, van der Horst IC, van Kuijk SM, Weerwind PW, Lorusso R, Maessen JG. Patterns of oxygen debt repayment in cardiogenic shock patients sustained with extracorporeal life support: A retrospective study. J Crit Care 2022; 71:154044. [DOI: 10.1016/j.jcrc.2022.154044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 03/04/2022] [Accepted: 04/04/2022] [Indexed: 10/18/2022]
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Suresh MR. The Early Detection of Hypovolemic Shock and Shifting the Focus to Compensation. J Intensive Care Med 2022; 37:1673-1675. [PMID: 35850608 DOI: 10.1177/08850666221114267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Pantalone D, Chiara O, Henry S, Cimbanassi S, Gupta S, Scalea T. Facing Trauma and Surgical Emergency in Space: Hemorrhagic Shock. Front Bioeng Biotechnol 2022; 10:780553. [PMID: 35845414 PMCID: PMC9283715 DOI: 10.3389/fbioe.2022.780553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Accepted: 04/22/2022] [Indexed: 11/16/2022] Open
Abstract
Although the risk of trauma in space is low, unpredictable events can occur that may require surgical treatment. Hemorrhage can be a life-threatening condition while traveling to another planet and after landing on it. These exploration missions call for a different approach than rapid return to Earth, which is the policy currently adopted on the International Space Station (ISS) in low Earth orbit (LEO). Consequences are difficult to predict, given the still scarce knowledge of human physiology in such environments. Blood loss in space can deplete the affected astronaut’s physiological reserves and all stored crew supplies. In this review, we will describe different aspects of hemorrhage in space, and by comparison with terrestrial conditions, the possible solutions to be adopted, and the current state of the art.
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Affiliation(s)
- D. Pantalone
- Department of Experimental and Clinical Medicine, Fellow of the American College of Surgeons, Core Board and Head for Studies on Traumatic Events and Surgery in the European Space Agency-Topical Team on “Tissue Healing in Space Techniques for Promoting and Monitoring Tissue Repair and Regeneration” for Life Science Activities Agency, Assistant Professor in General Surgery, Specialist in Vascular Surgery, Emergency Surgery Unit–Trauma Team, Emergency Department–Careggi University Hospital, University of Florence, Florence, Italy
- *Correspondence: D. Pantalone,
| | - O. Chiara
- Fellow of the American College of Surgeons, Director of General Surgery–Trauma Team, ASST GOM Grande Ospedale Metropolitano Niguarda, Professor of Surgery, University of Milan, Milan, Italy
| | - S. Henry
- Fellow of the American College of Surgeons, Director Division of Wound Healing and Metabolism, R Adams Cowley Shock Trauma Center University of Maryland, Baltimore, MD, United States
| | - S. Cimbanassi
- Fellow of the American College of Surgeons, EMDM, Vice Director of General Surgery-Trauma Team, ASST GOM Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - S. Gupta
- Fellow of the American College of Surgeons, R Adams Cowl y Shock Trauma Center, University of Maryland, Baltimore, MD, United States
| | - T. Scalea
- Fellow of the American College of Surgeons, The Honorable Francis X. Kelly Distinguished Professor of Trauma Surgery.Physician-in-Chief, R Adams Cowley Shock Trauma Center, System Chief for Critical Care Services, University of Maryland Medical System, University of Maryland, Baltimore, MD, United States
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Apelseth TO, Arsenovic M, Strandenes G. The Norwegian blood preparedness project: A whole blood program including civilian walking blood banks for early treatment of patients with life-threatening bleeding in municipal health care services, ambulance services, and rural hospitals. Transfusion 2022; 62 Suppl 1:S22-S29. [PMID: 35751878 PMCID: PMC9543315 DOI: 10.1111/trf.16968] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 05/02/2022] [Accepted: 05/02/2022] [Indexed: 11/30/2022]
Abstract
Background Civilian and military guidelines recommend early balanced transfusion to patients with life‐threatening bleeding to improve survival. To provide the best care to patients with hemorrhagic shock in regions with reduced access to evacuation, blood preparedness must be ensured also on a municipal health care level. The primary aim of the Norwegian Blood Preparedness project is to enable rural hospitals, prehospital ambulance services, and municipal health care services to start early balanced blood transfusions for patients with life‐threatening bleeding regardless of etiology. Study Design and Methods The project is designed based on three principles: (1) Early balanced transfusion should be provided for patients with life‐threatening bleeding, (2) Management of an emergency requires a planned and rehearsed day‐to‐day system for blood preparedness, and (3) A decentralized system is needed to ensure local self‐sufficiency in an emergency. We developed a system for education and training in blood‐based resuscitation with a focus on the municipal health care service. Results In this publication, we describe the implementation of emergency whole blood collections from a preplanned civilian walking blood bank in the municipal health care service. This includes donor selection, whole blood collection, emergency transfusion and quality assessment of practice. Conclusion We conclude that implementation of a Whole Blood based emergency transfusion program is feasible on all health care levels and that a preplanned civilian walking blood bank should be considered in locations were prolonged transport‐times may reduce access to blood transfusion for patients with life threatening bleeding.
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Affiliation(s)
- Torunn Oveland Apelseth
- Department of Immunology and Transfusion Medicine, Haukeland University Hospital, Bergen, Norway.,Norwegian Armed Forces Joint Medical Services, Sessvollmoen, Norway.,Institute of Clinical Science, University of Bergen, Bergen, Norway
| | - Mirjana Arsenovic
- Department of Laboratory Medicine, University Hospital of North Norway, Tromso, Norway
| | - Geir Strandenes
- Department of Immunology and Transfusion Medicine, Haukeland University Hospital, Bergen, Norway
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Koons NJ, Moses CD, Thompson P, Strandenes G, Convertino VA. Identifying critical DO 2 with compensatory reserve during simulated hemorrhage in humans. Transfusion 2022; 62 Suppl 1:S122-S129. [PMID: 35733031 DOI: 10.1111/trf.16958] [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: 01/18/2022] [Revised: 03/09/2022] [Accepted: 03/18/2022] [Indexed: 12/01/2022]
Abstract
BACKGROUND Based on previous experiments in nonhuman primates, we hypothesized that DO2 crit in humans is 5-6 ml O2 ·kg-1 min-1 . STUDY DESIGN AND METHODS We measured the compensatory reserve (CRM) and calculated oxygen delivery (DO2 ) in 166 healthy, normotensive, nonsmoking subjects (97 males, 69 females) during progressive central hypovolemia induced by lower body negative pressure as a model of ongoing hemorrhage. Subjects were classified as having either high tolerance (HT; N = 111) or low tolerance (LT; N = 55) to central hypovolemia. RESULTS HT and LT groups were matched for age, weight, BMI, and vital signs, DO2 and CRM at baseline. The CRM-DO2 relationship was best fitted to a logarithmic model in HT subjects (amalgamated R2 = 0.971) and a second-order polynomial model in the LT group (amalgamated R2 = 0.991). Average DO2 crit for the entire subject cohort was estimated at 5.3 ml O2 ·kg-1 min-1 , but was ~14% lower in HT compared with LT subjects. The reduction in DO2 from 40% CRM to 20% CRM was 2-fold greater in the LT compared with the HT group. CONCLUSIONS Average DO2 crit in humans is 5.3 ml O2 ·kg-1 min-1 , but is ~14% lower in HT compared with LT subjects. The CRM-DO2 relationship is curvilinear in humans, and different when comparing HT and LT individuals. The threshold for an emergent monitoring signal should be recalibrated from 30% to 40% CRM given that the decline in DO2 from 40% CRM to 20% CRM for LT subjects is located on the steepest part of the CRM-DO2 relationship.
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Affiliation(s)
- Natalie J Koons
- Battlefield Health & Trauma Center for Human Integrative Physiology, U. S. Army Institute of Surgical Research, San Antonio, Texas, USA
| | - Catherine D Moses
- Battlefield Health & Trauma Center for Human Integrative Physiology, U. S. Army Institute of Surgical Research, San Antonio, Texas, USA
| | | | - Geir Strandenes
- Norwegian Armed Forces, Haukeland University Hospital, Bergen, Norway
| | - Victor A Convertino
- Battlefield Health & Trauma Center for Human Integrative Physiology, U. S. Army Institute of Surgical Research, San Antonio, Texas, USA
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Miller JL, Harper H, McCarty HJ, Li P, Jones AR. Time to Hemostasis After Trauma and Transfusion by Patient Blood Type. AACN Adv Crit Care 2022; 33:154-161. [PMID: 35657762 DOI: 10.4037/aacnacc2022432] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Although evidence supports an increased risk of mortality after major trauma among patients with type O blood, the relationship between patient blood type and clinical outcomes aside from mortality has not been fully elucidated. OBJECTIVE To examine the relationship between patient blood type and time to hemostasis after trauma and massive transfusion. METHODS A secondary analysis of the Pragmatic, Randomized Optimal Platelet and Plasma Ratios (PROPPR) trial was performed (N = 544). Blood type was dichotomized into type O versus non-type O. It was hypothesized that patients with non-type O blood would achieve hemostasis more quickly owing to the theoretical presence of increased clotting factors. Bivariate analysis and multiple Cox regression were conducted to test this assumption. RESULTS No significant difference was found in time to hemostasis between patients with type O blood and those with non-type O blood. However, mechanism of injury, diastolic blood pressure, and international normalized ratio affected the time to hemostasis in these trauma patients. CONCLUSION This study showed no significant difference in time to hemostasis by blood type.
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Affiliation(s)
- Justin L Miller
- Justin L. Miller is a PhD student, School of Nursing, University of Alabama at Birmingham, NB 573G, 1720 2nd Ave S, Birmingham, AL 35294-1210
| | - Hallie Harper
- Hallie Harper is a BSN student, School of Nursing, University of Alabama at Birmingham, Alabama
| | - Hannah Jane McCarty
- Hannah Jane McCarty is a BSN student, School of Nursing, University of Alabama at Birmingham, Alabama
| | - Peng Li
- Peng Li is Assistant Professor and Biostatistician, School of Nursing, University of Alabama at Birmingham, Alabama
| | - Allison R Jones
- Allison R. Jones is Assistant Professor, School of Nursing, University of Alabama at Birmingham, Alabama
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Krocker JD, Lee KH, Henriksen HH, Wang YWW, Schoof EM, Karvelsson ST, Rolfsson Ó, Johansson PI, Pedroza C, Wade CE. Exploratory Investigation of the Plasma Proteome Associated with the Endotheliopathy of Trauma. Int J Mol Sci 2022; 23:6213. [PMID: 35682894 PMCID: PMC9181752 DOI: 10.3390/ijms23116213] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 05/27/2022] [Accepted: 05/30/2022] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND The endotheliopathy of trauma (EoT) is associated with increased mortality following injury. Herein, we describe the plasma proteome related to EoT in order to provide insight into the role of the endothelium within the systemic response to trauma. METHODS 99 subjects requiring the highest level of trauma activation were included in the study. Enzyme-linked immunosorbent assays of endothelial and catecholamine biomarkers were performed on admission plasma samples, as well as untargeted proteome quantification utilizing high-performance liquid chromatography and tandem mass spectrometry. RESULTS Plasma endothelial and catecholamine biomarker abundance was elevated in EoT. Patients with EoT (n = 62) had an increased incidence of death within 24 h at 21% compared to 3% for non-EoT (n = 37). Proteomic analysis revealed that 52 out of 290 proteins were differentially expressed between the EoT and non-EoT groups. These proteins are involved in endothelial activation, coagulation, inflammation, and oxidative stress, and include known damage-associated molecular patterns (DAMPs) and intracellular proteins specific to several organs. CONCLUSIONS We report a proteomic profile of EoT suggestive of a surge of DAMPs and inflammation driving nonspecific activation of the endothelial, coagulation, and complement systems with subsequent end-organ damage and poor clinical outcome. These findings support the utility of EoT as an index of cellular injury and delineate protein candidates for therapeutic intervention.
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Affiliation(s)
- Joseph D. Krocker
- Center for Translational Injury Research, Department of Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, TX 77030, USA; (Y.-W.W.W.); (C.E.W.)
| | - Kyung Hyun Lee
- Center for Clinical Research and Evidence-Based Medicine, Department of Pediatrics, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, TX 77030, USA; (K.H.L.); (C.P.)
| | - Hanne H. Henriksen
- Center for Endotheliomics CAG, Department of Clinical Immunology, Copenhagen University Hospital, Rigshospitalet, 2200 Copenhagen, Denmark;
| | - Yao-Wei Willa Wang
- Center for Translational Injury Research, Department of Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, TX 77030, USA; (Y.-W.W.W.); (C.E.W.)
| | - Erwin M. Schoof
- Department of Biotechnology and Biomedicine, Technical University of Denmark, 2800 Lyngby, Denmark;
| | - Sigurdur T. Karvelsson
- Center for Systems Biology, University of Iceland, 101 Reykjavik, Iceland; (S.T.K.); (Ó.R.)
| | - Óttar Rolfsson
- Center for Systems Biology, University of Iceland, 101 Reykjavik, Iceland; (S.T.K.); (Ó.R.)
| | - Pär I. Johansson
- Center for Endotheliomics CAG, Department of Clinical Immunology, Rigshospitalet, & Department of Clinical Medicine, University of Copenhagen, 2200 Copenhagen, Denmark;
| | - Claudia Pedroza
- Center for Clinical Research and Evidence-Based Medicine, Department of Pediatrics, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, TX 77030, USA; (K.H.L.); (C.P.)
| | - Charles E. Wade
- Center for Translational Injury Research, Department of Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, TX 77030, USA; (Y.-W.W.W.); (C.E.W.)
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14
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Cardinale M, Mathais Q, Esnault P, Cotte J. Prehospital blood transfusion for haemorrhagic shock. THE LANCET HAEMATOLOGY 2022; 9:e395. [DOI: 10.1016/s2352-3026(22)00115-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 04/06/2022] [Indexed: 10/18/2022]
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15
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Injuries associated with hypotension after trauma: Is it always haemorrhage? TRAUMA-ENGLAND 2022. [DOI: 10.1177/14604086221099422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Introduction Restricted fluid replacement strategy is one part of damage control resuscitation for patients with trauma haemorrhage. However, not all patients presenting with physiological symptoms suggestive of haemorrhage are bleeding. This descriptive study aims to compare demographics and injuries in adult and older trauma patients presenting to the Emergency Department with hypotension versus normotension. Methods This was a retrospective, descriptive data analysis from a UK trauma registry. The records from one major trauma centre were analysed between 2014–2019, and every hypotensive (systolic blood pressure <90 mmHg) trauma patient investigated for injuries associated with hypotension. The hypotensive threshold for older patients was also adjusted to 110 mmHg for sub-cohort analysis. Results 6245 trauma patients were included, of which 255 (4.1%) arrived hypotensive at the Emergency Department. Significant blood loss was identified in 32.2% of those cases. In 27.1%, multiple potential associations obscured the underlying mechanism for the hypotension but were more commonly associated with hypotension than with normotension. Over a third (37.5%) were ≥65 years old. Neurological injuries occurred more frequently in both older hypotensive groups than younger patients. Conclusions This study sought to compare injuries of adult and older trauma patients to aid trauma teams with decision making. In severely injured hypotensive patients, significant blood loss was the principal association with hypotension. However, several factors can mimic bleeding in the hypotensive trauma patient, which should be carefully considered. A prospective study is needed to clarify the characteristics and causes of bleeding mimics.
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16
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Dyer WB, Simonova G, Chiaretti S, Bouquet M, Wellburn R, Heinsar S, Ainola C, Wildi K, Sato K, Livingstone S, Suen JY, Irving DO, Tung JP, Li Bassi G, Fraser JF. Recovery of organ-specific tissue oxygen delivery at restrictive transfusion thresholds after fluid treatment in ovine haemorrhagic shock. Intensive Care Med Exp 2022; 10:12. [PMID: 35377109 PMCID: PMC8980119 DOI: 10.1186/s40635-022-00439-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Accepted: 03/20/2022] [Indexed: 11/10/2022] Open
Abstract
Background Fluid resuscitation is the standard treatment to restore circulating blood volume and pressure after massive haemorrhage and shock. Packed red blood cells (PRBC) are transfused to restore haemoglobin levels. Restoration of microcirculatory flow and tissue oxygen delivery is critical for organ and patient survival, but these parameters are infrequently measured. Patient Blood Management is a multidisciplinary approach to manage and conserve a patient’s own blood, directing treatment options based on broad clinical assessment beyond haemoglobin alone, for which tissue perfusion and oxygenation could be useful. Our aim was to assess utility of non-invasive tissue-specific measures to compare PRBC transfusion with novel crystalloid treatments for haemorrhagic shock. Methods A model of severe haemorrhagic shock was developed in an intensive care setting, with controlled haemorrhage in sheep according to pressure (mean arterial pressure 30–40 mmHg) and oxygen debt (lactate > 4 mM) targets. We compared PRBC transfusion to fluid resuscitation with either PlasmaLyte or a novel crystalloid. Efficacy was assessed according to recovery of haemodynamic parameters and non-invasive measures of sublingual microcirculatory flow, regional tissue oxygen saturation, repayment of oxygen debt (arterial lactate), and a panel of inflammatory and organ function markers. Invasive measurements of tissue perfusion, oxygen tension and lactate levels were performed in brain, kidney, liver, and skeletal muscle. Outcomes were assessed during 4 h treatment and post-mortem, and analysed by one- and two-way ANOVA. Results Each treatment restored haemodynamic and tissue oxygen delivery parameters equivalently (p > 0.05), despite haemodilution after crystalloid infusion to haemoglobin concentrations below 70 g/L (p < 0.001). Recovery of vital organ-specific perfusion and oxygen tension commenced shortly before non-invasive measures improved. Lactate declined in all tissues and correlated with arterial lactate levels (p < 0.0001). The novel crystalloid supported rapid peripheral vasodilation (p = 0.014) and tended to achieve tissue oxygen delivery targets earlier. PRBC supported earlier renal oxygen delivery (p = 0.012) but delayed peripheral perfusion (p = 0.034). Conclusions Crystalloids supported vital organ oxygen delivery after massive haemorrhage, despite haemodilution to < 70 g/L, confirming that restrictive transfusion thresholds are appropriate to support oxygen delivery. Non-invasive tissue perfusion and oximetry technologies merit further clinical appraisal to guide treatment for massive haemorrhage in the context of Patient Blood Management. Supplementary Information The online version contains supplementary material available at 10.1186/s40635-022-00439-6.
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Affiliation(s)
- Wayne B Dyer
- Australian Red Cross Lifeblood, Sydney, Australia.
| | - Gabriela Simonova
- Australian Red Cross Lifeblood, Brisbane, Australia.,Critical Care Research Group, The Prince Charles Hospital, Brisbane, Australia.,Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | | | - Mahe Bouquet
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, Australia
| | | | - Silver Heinsar
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, Australia
| | - Carmen Ainola
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, Australia
| | - Karin Wildi
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, Australia.,Cardiovascular Research Institute, Basel, Switzerland
| | - Kei Sato
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, Australia
| | | | - Jacky Y Suen
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, Australia.,Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | - David O Irving
- Australian Red Cross Lifeblood, Sydney, Australia.,Faculty of Health, University of Technology, Sydney, Australia
| | - John-Paul Tung
- Australian Red Cross Lifeblood, Brisbane, Australia.,Critical Care Research Group, The Prince Charles Hospital, Brisbane, Australia.,Faculty of Medicine, The University of Queensland, Brisbane, Australia.,Faculty of Health, Queensland University of Technology, Brisbane, Australia
| | - Gianluigi Li Bassi
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, Australia.,Faculty of Medicine, The University of Queensland, Brisbane, Australia.,Medical Engineering Research Facility, Queensland University of Technology, Brisbane, Australia.,Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain
| | - John F Fraser
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, Australia.,Faculty of Medicine, The University of Queensland, Brisbane, Australia
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17
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Gao C, Yang L, Ju J, Gao Y, Zhang K, Wu M, Yang L, Lu X, Hou R, Guo Q. Risk and prognostic factors of replantation failure in patients with severe traumatic major limb mutilation. Eur J Trauma Emerg Surg 2022; 48:3203-3210. [PMID: 35050386 PMCID: PMC9360147 DOI: 10.1007/s00068-021-01876-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 12/04/2021] [Indexed: 11/06/2022]
Abstract
Purpose Traumatic mutilation of major limbs can result in limb loss, motor disability, or death. Patients who had replantation failure needed to undergo additional surgeries (even amputation) and had a longer length of hospital stay. Here, we determined the risk and prognostic factors of replantation failure in patients with traumatic major limb mutilation. Methods This retrospective study included adult inpatients with severed traumatic major limb mutilation who underwent replantation from Suzhou Ruixing Medical Group from October 18, 2016 to July 31, 2020. Demographic, and clinical characteristics including traumatic conditions, laboratory findings, mangled extremity severity scores (MESS), treatments, and outcomes of the patients were collected. Data were used to analyze predictors and risk factors for replantation failure. Results Among the 66 patients, 48 (72.7%) were males, the median age was 47.0 years old. Replantation failure occurred in 48 patients (72.7%). The area under the curve of the joint prediction of lactic acid on admission, 72-h cumulative fluid balance, and albumin level immediately postoperatively was 0.838 (95% confidence interval [CI], 0.722–0.954; P < 0.001) with a sensitivity of 89.7% and a specificity of 69.2%. Lower limb trauma (odds ratio [OR] 8.65, 95% CI 1.64–45.56, P = 0.011), mangled extremity severity scores (OR 2.24, 95% CI 1.25–4.01, P = 0.007), and first 72-h cumulative fluid balance > 4885.6 mL (OR 10.25, 95% CI 1.37–76.93, P = 0.024) were independent risk factors for replantation failure. Conclusions Lower limb trauma, mangled extremity severity scores, and cumulative water balance were associated with replantation failure, implying that fluid management is necessary for major limb salvage. More studies are needed to explore the predictive power of indicators related to tissue oxygenation and wound healing for replantation failure. Supplementary Information The online version contains supplementary material available at 10.1007/s00068-021-01876-w.
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Affiliation(s)
- Chang Gao
- Department of Emergency and Critical Care Medicine, Dushu Lake Hospital Affiliated to Soochow University (Suzhou Dushu Lake Hospital), Suzhou, Jiangsu, China
- Medical Center of Soochow University, Suzhou, Jiangsu, China
| | - Ling Yang
- Medical College of Soochow University, Suzhou, Jiangsu, China
| | - Jihui Ju
- Department of Orthopaedic, Ruihua Affiliated Hospital of Soochow University (Suzhou Ruixing Medical Group), Suzhou, Jiangsu, China
| | - Ye Gao
- Department of Critical Care Medicine, Taicang Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Keran Zhang
- Department of Critical Care Medicine, Ruihua Affiliated Hospital of Soochow University (Suzhou Ruixing Medical Group), Suzhou, Jiangsu, China
| | - Mingming Wu
- Department of Critical Care Rehabilitation Medicine, Suzhou Ruisheng Rehabilitation Hospital (Suzhou Ruixing Medical Group), Suzhou, Jiangsu, China
| | - Lijuan Yang
- Medical College of Soochow University, Suzhou, Jiangsu, China
| | - Xiaoting Lu
- Department of Emergency and Critical Care Medicine, Dushu Lake Hospital Affiliated to Soochow University (Suzhou Dushu Lake Hospital), Suzhou, Jiangsu, China
- Medical Center of Soochow University, Suzhou, Jiangsu, China
| | - Ruixing Hou
- Department of Orthopaedic, Ruihua Affiliated Hospital of Soochow University (Suzhou Ruixing Medical Group), Suzhou, Jiangsu, China.
| | - Qiang Guo
- Department of Emergency and Critical Care Medicine, Dushu Lake Hospital Affiliated to Soochow University (Suzhou Dushu Lake Hospital), Suzhou, Jiangsu, China.
- Medical Center of Soochow University, Suzhou, Jiangsu, China.
- The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China.
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18
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Hinojosa-Laborde C, Hudson IL, Ross E, Xiang L, Ryan KL. Pathophysiology of Hemorrhage as It Relates to the Warfighter. Physiology (Bethesda) 2022; 37:141-153. [PMID: 35001653 PMCID: PMC8977138 DOI: 10.1152/physiol.00028.2021] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Saving lives of wounded military Warfighters often depends on the ability to resolve or mitigate the pathophysiology of hemorrhage, specifically diminished oxygen delivery to vital organs that leads to multi-organ failure and death. However, caring for hemorrhaging patients on the battlefield presents unique challenges that extend beyond applying a tourniquet and giving a blood transfusion, especially when battlefield care must be provided for a prolonged period. This review will describe these challenges and potential strategies for treating hemorrhage on the battlefield in a prolonged casualty care situation.
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Affiliation(s)
| | - Ian L Hudson
- U.S. Army Institute of Surgical Research, JBSA Fort Sam Houston, TX, United States
| | - Evan Ross
- U.S. Army Institute of Surgical Research, JBSA Fort Sam Houston, TX, United States
| | - Lusha Xiang
- U.S. Army Institute of Surgical Research, JBSA Fort Sam Houston, TX, United States
| | - Kathy L Ryan
- U.S. Army Institute of Surgical Research, JBSA Fort Sam Houston, TX, United States
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19
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Dyer WB, Tung JP, Li Bassi G, Wildi K, Jung JS, Colombo SM, Rozencwajg S, Simonova G, Chiaretti S, Temple FT, Ainola C, Shuker T, Palmieri C, Shander A, Suen JY, Irving DO, Fraser JF. An Ovine Model of Hemorrhagic Shock and Resuscitation, to Assess Recovery of Tissue Oxygen Delivery and Oxygen Debt, and Inform Patient Blood Management. Shock 2021; 56:1080-1091. [PMID: 34014886 DOI: 10.1097/shk.0000000000001805] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Aggressive fluid or blood component transfusion for severe hemorrhagic shock may restore macrocirculatory parameters, but not always improve microcirculatory perfusion and tissue oxygen delivery. We established an ovine model of hemorrhagic shock to systematically assess tissue oxygen delivery and repayment of oxygen debt; appropriate outcomes to guide Patient Blood Management. METHODS Female Dorset-cross sheep were anesthetized, intubated, and subjected to comprehensive macrohemodynamic, regional tissue oxygen saturation (StO2), sublingual capillary imaging, and arterial lactate monitoring confirmed by invasive organ-specific microvascular perfusion, oxygen pressure, and lactate/pyruvate levels in brain, kidney, liver, and skeletal muscle. Shock was induced by stepwise withdrawal of venous blood until MAP was 30 mm Hg, mixed venous oxygen saturation (SvO2) < 60%, and arterial lactate >4 mM. Resuscitation with PlasmaLyte® was dosed to achieve MAP > 65 mm Hg. RESULTS Hemorrhage impacted primary outcomes between baseline and development of shock: MAP 89 ± 5 to 31 ± 5 mm Hg (P < 0.01), SvO2 70 ± 7 to 23 ± 8% (P < 0.05), cerebral regional tissue StO2 77 ± 11 to 65 ± 9% (P < 0.01), peripheral muscle StO2 66 ± 8 to 16 ± 9% (P < 0.01), arterial lactate 1.5 ± 1.0 to 5.1 ± 0.8 mM (P < 0.01), and base excess 1.1 ± 2.2 to -3.6 ± 1.7 mM (P < 0.05). Invasive organ-specific monitoring confirmed reduced tissue oxygen delivery; oxygen tension decreased and lactate increased in all tissues, but moderately in brain. Blood volume replacement with PlasmaLyte® improved primary outcome measures toward baseline, confirmed by organ-specific measures, despite hemoglobin reduced from baseline 10.8 ± 1.2 to 5.9 ± 1.1 g/dL post-resuscitation (P < 0.01). CONCLUSION Non-invasive measures of tissue oxygen delivery and oxygen debt repayment are suitable outcomes to inform Patient Blood Management of hemorrhagic shock, translatable for pre-clinical assessment of novel resuscitation strategies.
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Affiliation(s)
- Wayne B Dyer
- Australian Red Cross Lifeblood, Sydney, Australia
- Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - John-Paul Tung
- Australian Red Cross Lifeblood, Brisbane, Australia
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, Australia
- Faculty of Medicine, The University of Queensland, Brisbane, Australia
- Faculty of Health, Queensland University of Technology, Brisbane, Australia
| | - Gianluigi Li Bassi
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, Australia
- Faculty of Medicine, The University of Queensland, Brisbane, Australia
- Medical Engineering Research Facility, Queensland University of Technology, Brisbane, Australia
- Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain
| | - Karin Wildi
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, Australia
- Faculty of Medicine, The University of Queensland, Brisbane, Australia
- Cardiovascular Research Institute, Basel, Switzerland
| | - Jae-Seung Jung
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, Australia
- Department of Thoracic and Cardiovascular Surgery, College of Medicine, Korea University, Seoul, Republic of Korea
| | - Sebastiano Maria Colombo
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, Australia
- Faculty of Medicine, The University of Queensland, Brisbane, Australia
- Department of Pathophysiology and Transplantation, Universita degli Studi di Milano, Milano, Italy
| | - Sacha Rozencwajg
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, Australia
- Sorbonne Université, INSERM, UMRS-1166, ICAN Institute of Cardiometabolism and Nutrition, Medical ICU, Pitié-Salpêtrière University Hospital, Paris, France
| | - Gabriela Simonova
- Australian Red Cross Lifeblood, Brisbane, Australia
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, Australia
- Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | | | - Fergal T Temple
- Australian Red Cross Lifeblood, Brisbane, Australia
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, Australia
- Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | - Carmen Ainola
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, Australia
| | - Tristan Shuker
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, Australia
| | - Chiara Palmieri
- School of Veterinary Science, The University of Queensland, Brisbane, Australia
| | - Aryeh Shander
- Department of Anesthesiology, Critical Care and Hyperbaric Medicine, Englewood Health, Englewood
- TeamHealth, Englewood Health, Englewood
- UF College of Medicine, University of Florida, Gainesville
- Department of Anesthesiology, Medicine and Surgery, Icahn School of Medicine, Mount Sinai Hospital, New York
- Department of Anesthesiology and Critical Care, Rutgers University, Newark
| | - Jacky Y Suen
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, Australia
- Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | - David O Irving
- Australian Red Cross Lifeblood, Sydney, Australia
- Faculty of Health, University of Technology, Sydney, Australia
| | - John F Fraser
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, Australia
- Faculty of Medicine, The University of Queensland, Brisbane, Australia
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20
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Edwards TH, Rizzo JA, Pusateri AE. Hemorrhagic shock and hemostatic resuscitation in canine trauma. Transfusion 2021; 61 Suppl 1:S264-S274. [PMID: 34269447 DOI: 10.1111/trf.16516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 02/18/2021] [Accepted: 02/19/2021] [Indexed: 11/27/2022]
Abstract
Hemorrhage is a significant cause of death among military working dogs and in civilian canine trauma. While research specifically aimed at canine trauma is limited, many principles from human trauma resuscitation apply. Trauma with significant hemorrhage results in shock and inadequate oxygen delivery to tissues. This leads to aberrations in cellular metabolism, including anaerobic metabolism, decreased energy production, acidosis, cell swelling, and eventual cell death. Considering blood and endothelium as a single organ system, blood failure is a syndrome of endotheliopathy, coagulopathy, and platelet dysfunction. In severe cases following injury, blood failure develops and is induced by inadequate oxygen delivery in the presence of hemorrhage, tissue injury, and acute stress from trauma. Severe hemorrhagic shock is best treated with hemostatic resuscitation, wherein blood products are used to restore effective circulating volume and increase oxygen delivery to tissues without exacerbating blood failure. The principles of hemostatic resuscitation have been demonstrated in severely injured people and the authors propose an algorithm for applying this to canine patients. The use of plasma and whole blood to resuscitate severely injured canines while minimizing the use of crystalloids and colloids could prove instrumental in improving both mortality and morbidity. More work is needed to understand the canine patient that would benefit from hemostatic resuscitation, as well as to determine the optimal resuscitation strategy for these patients.
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Affiliation(s)
- Thomas H Edwards
- U.S. Army Institute of Surgical Research, Joint Base San Antonio - Fort Sam Houston, Texas, USA
| | - Julie A Rizzo
- U.S. Army Institute of Surgical Research, Joint Base San Antonio - Fort Sam Houston, Texas, USA.,Uniformed Services University of Health Sciences, Bethesda, Maryland, USA
| | - Anthony E Pusateri
- Naval Medical Research Unit San Antonio, Joint Base San Antonio - Fort Sam Houston, Texas, USA
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21
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Hagen KG, Strandenes G, Kristoffersen EK, Braathen H, Sivertsen J, Bjerkvig CK, Sommerfelt-Pettersen N, Aasheim IB, Lunde THF, Hervig T, Apelseth TO. A whole blood based resuscitation strategy in civilian medical services: Experience from a Norwegian hospital in the period 2017-2020. Transfusion 2021; 61 Suppl 1:S22-S31. [PMID: 34269432 DOI: 10.1111/trf.16490] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 03/11/2021] [Accepted: 03/11/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND Civilian and military guidelines recommend early balanced transfusion to patients with life-threatening bleeding. Low titer group O whole blood was introduced as the primary blood product for resuscitation of massive hemorrhage at Haukeland University Hospital, Bergen, Norway, in December 2017. In this report, we describe the whole blood program and present results from the first years of routine use. STUDY DESIGN AND METHODS Patients who received whole blood from December 2017 to April 2020 were included in our quality registry for massive transfusions. Post-transfusion blood samples were collected to analyze isohemagglutinin (anti-A/-B) and hemolysis markers. Administration of other blood products, transfusion reactions, and patient survival (days 1 and 30) were recorded. User experiences were surveyed for both clinical and laboratory staff. RESULTS Two hundred and five patients (64% male and 36% female) received 836 units in 226 transfusion episodes. Patients received a mean of 3.7 units (range 1-35) in each transfusion episode. The main indications for transfusion were trauma (26%), gastrointestinal (22%), cardiothoracic/vascular (18%), surgical (18%), obstetric (11%), and medical (5%) bleeding. There was no difference in survival between patients with blood type O when compared with non-group O. Haptoglobin level was lower in the transfusion episodes for non-O group patients, however no clinical hemolysis was reported. No patients had conclusive transfusion-associated adverse events. Both clinical and laboratory staff preferred whole blood to component therapy for massive transfusion. DISCUSSION The experience from Haukeland University Hospital indicates that whole blood is feasible, safe, and effective for in-hospital treatment of bleeding.
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Affiliation(s)
- Kristin Gjerde Hagen
- Department of Immunology and Transfusion Medicine, Haukeland University Hospital, Bergen, Norway
| | - Geir Strandenes
- Department of Immunology and Transfusion Medicine, Haukeland University Hospital, Bergen, Norway.,Department of War Surgery and Emergency Medicine, Norwegian Armed Forces Medical Services, Sessvollmoen, Norway
| | - Einar Klaeboe Kristoffersen
- Department of Immunology and Transfusion Medicine, Haukeland University Hospital, Bergen, Norway.,Institute of Clinical Science, University of Bergen, Bergen, Norway
| | - Hanne Braathen
- Department of Immunology and Transfusion Medicine, Haukeland University Hospital, Bergen, Norway.,Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Joar Sivertsen
- Department of Immunology and Transfusion Medicine, Haukeland University Hospital, Bergen, Norway.,Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Christopher Kalhagen Bjerkvig
- Institute of Clinical Science, University of Bergen, Bergen, Norway.,Department of Anesthesia and Intensive Care, Haukeland University Hospital, Bergen, Norway
| | | | - Irmelin Beathe Aasheim
- Department of Immunology and Transfusion Medicine, Haukeland University Hospital, Bergen, Norway
| | - Turid Helen Felli Lunde
- Department of Immunology and Transfusion Medicine, Haukeland University Hospital, Bergen, Norway
| | - Tor Hervig
- Department of Immunology and Transfusion Medicine, Haukeland University Hospital, Bergen, Norway.,Institute of Clinical Science, University of Bergen, Bergen, Norway.,Laboratory of Immunology and Transfusion Medicine, Haugesund Hospital, Haugesund, Norway
| | - Torunn Oveland Apelseth
- Department of Immunology and Transfusion Medicine, Haukeland University Hospital, Bergen, Norway.,Department of War Surgery and Emergency Medicine, Norwegian Armed Forces Medical Services, Sessvollmoen, Norway
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22
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Popovsky MA, White N. Spray-dried plasma: A post-traumatic blood "bridge" for life-saving resuscitation. Transfusion 2021; 61 Suppl 1:S294-S300. [PMID: 34269448 DOI: 10.1111/trf.16536] [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: 12/19/2020] [Revised: 01/25/2021] [Accepted: 01/25/2021] [Indexed: 11/27/2022]
Abstract
Massive bleeding remains a major source of morbidity and mortality worldwide. Recent studies have shed light on the pathophysiology of traumatic-induced coagulopathy and the central role of endotheliopathy. Transfusion therapy has changed dramatically in the last decade with use of red cells and plasma in a 1:1 ratio. The use of early transfusion increases the likelihood of a favorable outcome. Early intervention-preferably less than 60 min of injury-is a major factor in improved survival. Experience with dried plasma products-lyophilized or freeze-dried-in Europe and South Africa has demonstrated both safety and efficacy. Dry plasma products are not available in the United States but several products are in development. Spray-dried plasma contains clinically meaningful levels of coagulation activity and in vitro data suggest robust ability to generate thrombus. The decentralized, blood-center based manufacturing model of spray-dried plasma offers advantages for availability to meet routine and extraordinary demands.
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Affiliation(s)
- Mark A Popovsky
- Medical Affairs, Velico Medical, Beverly, Massachusetts, USA
| | - Nathan White
- Department of Emergency Medicine, University of Washington School of Medicine, Seattle, Washington, USA
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23
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Lee CF, Hung HC, Lee WC. Using Rotational Thromboelastometry to Identify Early Allograft Dysfunction after Living Donor Liver Transplantation. J Clin Med 2021; 10:jcm10153401. [PMID: 34362183 PMCID: PMC8347977 DOI: 10.3390/jcm10153401] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2021] [Revised: 07/27/2021] [Accepted: 07/29/2021] [Indexed: 12/23/2022] Open
Abstract
Background: Diagnostic tests for early allograft dysfunction (EAD) after living donor liver transplantation (LDLT) vary widely. We aimed to evaluate the predictive value of rotational thromboelastometry (ROTEM)-derived parameters in EAD. Materials and Methods: A total of 121 patients were reviewed. The definition of EAD proposed by Olthoff et al. included the presence of any of the following at postoperative day 7: bilirubin level ≥ 10 mg/dL, INR ≥ 1.6, or serum AST or ALT levels > 2000 IU/L. All patients underwent ROTEM assay, which consisted of an extrinsically activated thromboelastometric test (EXTEM) before and 24 h after LDLT. Results: The 1-year/2-year OS were 68.%8/64.5% and 94.4%/90.8% for the EAD and non-EAD groups, respectively (p = 0.001). Two independent risks were identified for EAD, the postoperative clotting time (CT, p = 0.026) and time to maximum clot firmness (maximum clot firmness (MCF)-t, p = 0.009) on the EXTEM. CT yielded a specificity of 82.0% and negative predictive value of 83.0%, and MCF-t displayed a specificity of 76.4% and negative predictive value of 81.9% in diagnosing EAD. The use of the 24 h post-LDLT ROTEM increased the effectiveness of predicting overall survival (OS) compared to using the Olthoff’s EAD criteria alone (p < 0.001). Conclusion: We conclude that CT and MCF on EXTEM were independent predictors of EAD. The 24 h post-LDLT ROTEM can be used with conventional laboratory tests to diagnose EAD. It increases the effectiveness of predicting OS.
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Affiliation(s)
- Chen-Fang Lee
- Department of Liver and Transplantation Surgery, Chang-Gung Memorial Hospital at Linkou, Taoyuan City 333, Taiwan; (C.-F.L.); (W.-C.L.)
- College of Medicine, Chang-Gung University, Taoyuan City 333, Taiwan
| | - Hao-Chien Hung
- Department of Liver and Transplantation Surgery, Chang-Gung Memorial Hospital at Linkou, Taoyuan City 333, Taiwan; (C.-F.L.); (W.-C.L.)
- Correspondence: ; Tel.: +886-3-3281200 (ext. 3366); Fax: +886-3-3285818
| | - Wei-Chen Lee
- Department of Liver and Transplantation Surgery, Chang-Gung Memorial Hospital at Linkou, Taoyuan City 333, Taiwan; (C.-F.L.); (W.-C.L.)
- College of Medicine, Chang-Gung University, Taoyuan City 333, Taiwan
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24
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Abstract
Vasopressor use in severely injured trauma patients is discouraged due to concerns that vasoconstriction will worsen organ perfusion and result in increased mortality and organ failure in hypotensive trauma patients. Hypotensive resuscitation is advocated based on limited data that lower systolic blood pressure and mean arterial pressure will result in improved mortality. It is classically taught that hypotension and hypovolemia in trauma are associated with peripheral vasoconstriction. However, the pathophysiology of traumatic shock is complex and involves multiple neurohormonal interactions that are ultimately manifested by an initial sympathoexcitatory phase that attempts to compensate for acute blood loss and is characterized by vasoconstriction, tachycardia, and preserved mean arterial blood pressure. The subsequent hypotension observed in hemorrhagic shock reflects a sympathoinhibitory vasodilation phase. The objectives of hemodynamic resuscitation in hypotensive trauma patients are restoring adequate intravascular volume with a balanced ratio of blood products, correcting pathologic coagulopathy, and maintaining organ perfusion. Persistent hypotension and hypoperfusion are associated with worse coagulopathy and organ function. The practice of hypotensive resuscitation would appear counterintuitive to the goals of traumatic shock resuscitation and is not supported by consistent clinical data. In addition, excessive volume resuscitation is associated with adverse clinical outcomes. Therefore, in the resuscitation of traumatic shock, it is necessary to target an appropriate balance with intravascular volume and vascular tone. It would appear logical that vasopressors may be useful in traumatic shock resuscitation to counteract vasodilation in hemorrhage as well as other clinical conditions such as traumatic brain injury, spinal cord injury, multiple organ dysfunction syndrome, and vasodilation of general anesthetics. The purpose of this article is to discuss the controversy of vasopressors in hypotensive trauma patients and advocate for a nuanced approach to vasopressor administration in the resuscitation of traumatic shock.
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25
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Quintero L, Meléndez-Lugo JJ, Palacios-Rodríguez HE, Caicedo Y, Padilla N, Gallego LM, Pino LF, García A, González-Hadad A, Herrera MA, Salcedo A, Serna JJ, Rodríguez-Holguín F, Parra MW, Ordoñez CA. Damage control in the emergency department, a bridge to life. Colomb Med (Cali) 2021; 52:e4004801. [PMID: 34188318 PMCID: PMC8216048 DOI: 10.25100/cm.v52i2.4801] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Patients with hemodynamic instability have a sustained systolic blood pressure less or equal to 90 mmHg, a heart rate greater or equal to 120 beats per minute and an acute compromise of the ventilation/oxygenation ratio and/or an altered state of consciousness upon admission. These patients have higher mortality rates due to massive hemorrhage, airway injury and/or impaired ventilation. Damage control resuscitation is a systematic approach that aims to limit physiologic deterioration through strategies that address the physiologic debt of trauma. This article aims to describe the experience earned by the Trauma and Emergency Surgery Group (CTE) of Cali, Colombia in the management of the severely injured trauma patient in the emergency department following the basic principles of damage control surgery. Since bleeding is the main cause of death, the management of the severely injured trauma patient in the emergency department requires a multidisciplinary team that performs damage control maneuvers aimed at rapidly controlling bleeding, hemostatic resuscitation, and/or prompt transfer to the operating room, if required.
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Affiliation(s)
- Laureano Quintero
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia.,Centro Médico Imbanaco, Cali, Colombia
| | | | - Helmer Emilio Palacios-Rodríguez
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia
| | - Yaset Caicedo
- Fundación Valle del Lili, Centro de Investigaciones Clínicas (CIC), Cali, Colombia
| | - Natalia Padilla
- Fundación Valle del Lili, Centro de Investigaciones Clínicas (CIC), Cali, Colombia
| | | | - Luis Fernando Pino
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia.,Hospital Universitario del Valle, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia
| | - Alberto García
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia.,Universidad Icesi, Cali, Colombia.,Fundación Valle del Lili, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia
| | - Adolfo González-Hadad
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia.,Centro Médico Imbanaco, Cali, Colombia.,Hospital Universitario del Valle, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia
| | - Mario Alain Herrera
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia.,Hospital Universitario del Valle, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia
| | - Alexander Salcedo
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia.,Universidad Icesi, Cali, Colombia.,Hospital Universitario del Valle, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia.,Fundación Valle del Lili, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia
| | - José Julián Serna
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia.,Universidad Icesi, Cali, Colombia.,Hospital Universitario del Valle, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia.,Fundación Valle del Lili, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia
| | - Fernando Rodríguez-Holguín
- Fundación Valle del Lili, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia
| | - Michael W Parra
- Broward General Level I Trauma Center, Department of Trauma Critical Care, Fort Lauderdale, FL - USA
| | - Carlos A Ordoñez
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia.,Universidad Icesi, Cali, Colombia.,Fundación Valle del Lili, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia
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26
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Arbaeen AF, Schubert P, Sheffield WP, Devine DV. Pathogen reduction of whole blood: Supplementing fibrinogen partly corrects clot formation in a massive transfusion model. Transfusion 2021; 61:1884-1893. [PMID: 33745131 DOI: 10.1111/trf.16382] [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: 11/29/2020] [Revised: 03/08/2021] [Accepted: 03/09/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND The use of whole blood (WB) to treat trauma patients is becoming more common. Similar to the treatment of individual components, pathogen inactivation (PI) technologies are available to treat WB. The impact of PI on WB function is not well understood. This study investigated the impact of PI of WB with riboflavin/ultraviolet (UV) light on its hemostatic function by modeling transfusion scenarios for trauma patients and assessing transfusion efficacy by rotational thromboelastometry (ROTEM). As fibrinogen is affected by PI of WB, the effect of fibrinogen supplementation commonly used in trauma patients was also analyzed in this model. STUDY DESIGN AND METHODS Trauma transfusion scenarios were simulated by mixing untreated WB or WB treated with the Mirasol PI technology (riboflavin/UV) in different ratios with hemodiluted blood, and the thromboelasticity was monitored by ROTEM. The impact of supplementation with the fibrinogen concentrate RiaSTAP was investigated in this model. RESULTS Pathogen-inactivated WB (PI-WB) showed decreased activity in the hemostatic profile compared to the untreated control. Hemodiluted blood at a hematocrit (hct) of 20%, which was reconstituted with PI-WB or untreated WB, exhibited increased alpha values, maximum clot firmness, and clot formation time. Simulating transfusion scenarios by blood replacement with PI-WB resulted in a significant difference in ROTEM parameters between reconstituted PI-treated and -untreated WB (p ≥ .05). The effect of PI treatment waned when PI-WB was enriched with fibrinogen. CONCLUSION ROTEM investigations suggest that PI treatment has a negative impact on WB clot formation unless fibrinogen supplementation is used.
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Affiliation(s)
- Ahmad F Arbaeen
- Department of Pathology & Laboratory Medicine, University of British Columbia, Vancouver, British Columbia, Canada.,Centre for Blood Research, University of British Columbia, Vancouver, British Columbia, Canada.,Faculty of Applied Medical Sciences, Department Laboratory Medicine, Umm al-Qura University, Makkah, Saudi Arabia
| | - Peter Schubert
- Department of Pathology & Laboratory Medicine, University of British Columbia, Vancouver, British Columbia, Canada.,Centre for Blood Research, University of British Columbia, Vancouver, British Columbia, Canada.,Centre for Innovation, Canadian Blood Services, Vancouver, British Columbia, Canada
| | - William P Sheffield
- Centre for Innovation, Canadian Blood Services, Hamilton, Ontario, Canada.,Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Dana V Devine
- Department of Pathology & Laboratory Medicine, University of British Columbia, Vancouver, British Columbia, Canada.,Centre for Blood Research, University of British Columbia, Vancouver, British Columbia, Canada.,Centre for Innovation, Canadian Blood Services, Vancouver, British Columbia, Canada
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27
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Xu X, Kozar R, Zhang J, Dong JF. Diverse activities of von Willebrand factor in traumatic brain injury and associated coagulopathy. J Thromb Haemost 2020; 18:3154-3162. [PMID: 32931638 PMCID: PMC7855263 DOI: 10.1111/jth.15096] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 09/02/2020] [Accepted: 09/03/2020] [Indexed: 12/20/2022]
Abstract
Traumatic brain injury (TBI) is a leading cause of death and disability. Patients with isolated TBI lose a limited amount of blood to primary injury, but they often develop secondary coagulopathy, resulting in delayed or recurrent intracranial and intracerebral hematoma. TBI-induced coagulopathy is closely associated with poor outcomes for these patients, including death. This secondary coagulopathy is consumptive in nature, involving not only brain-derived molecules, coagulation factors, and platelets, but also endothelial cells in a complex process now called blood failture. A key question is how a localized injury to the brain is rapidly disseminated to affect systemic hemostasis that is not directly affected the way it is in trauma to the body and limbs, especially with hemorrhagic shock. Increasing evidence suggests that the adhesive ligand von Willebrand factor (VWF), which is synthesized in and released from endothelial cells, plays a paradoxical role in both facilitating local hemostasis at the site of injury and also propagating TBI-induced endotheliopathy and coagulopathy systemically. This review discusses recent progress in understanding these diverse activities of VWF and the knowledge gaps in defining their roles in TBI and associated coagulopathy.
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Affiliation(s)
- Xin Xu
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Rosemary Kozar
- Shock Trauma Center, University of Maryland School of Medicine, Baltimore, US
| | - Jianning Zhang
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
- Tianjin Institute of Neurology, Tianjin, China
| | - Jing-fei Dong
- Bloodworks Research Institute, Seattle, WA, US
- Hematology Division, Department of Medicine, University of Washington School of Medicine, Seattle, WA, US
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28
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Kirkpatrick AW, Mckee JL, Netzer I, Mckee IA, McBeth P, Wachs JP, Ball CG, Glassberg E. A Randomized Trial of Mentored vs Nonmentored Military Medics Compared in the Application of a Wound Clamp Without Prior Training: When to Shut Up and Just Watch! Mil Med 2020; 185:67-72. [PMID: 32074324 DOI: 10.1093/milmed/usz251] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
INTRODUCTION Hemorrhage control is a basic task required of first responders and typically requires technical interventions during stressful circumstances. Remote telementoring (RTM) utilizes information technology to guide inexperienced providers, but when this is useful remains undefined. METHODS Military medics were randomized to mentoring or not from an experienced subject matter expert during the application of a wound clamp (WC) to a simulated bleed. Inexperienced, nonmentored medics were given a 30-second safety briefing; mentored medics were not. Objective outcomes were time to task completion and success in arresting simulated bleeding. RESULTS Thirty-three medics participated (16 mentored and 17 nonmentored). All (100%) successfully applies the WC to arrest the simulated hemorrhage. RTM significantly slowed hemorrhage control (P = 0.000) between the mentored (40.4 ± 12.0 seconds) and nonmentored (15.2 ± 10.3 seconds) groups. On posttask questionnaire, all medics subjectively rated the difficulty of the wound clamping as 1.7/10 (10 being extremely hard). Discussion: WC application appeared to be an easily acquired technique that was effective in controlling simulated extremity exsanguination, such that RTM while feasible did not improve outcomes. Limitations were the lack of true stress and using simulation for the task. Future research should focus on determining when RTM is useful and when it is not required.
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Affiliation(s)
- Andrew W Kirkpatrick
- Regional Trauma Services, University of Calgary, 1403 29 St NW, Calgary, AB T2N 2T9.,Department of Surgery, University of Calgary, 1403 29 St NW, Calgary, AB T2N 2T9.,Department of Critical Care Medicine, University of Calgary, 1403 29 St NW, Calgary, AB T2N 2T9.,Alberta Health Services, Foothills Medical Centre, 1403 29 St NW, Calgary, AB T2N 2T9.,Canadian Forces Health Services, 713 Montreal Road, Ottawa, ON K1G 0G6
| | - Jessica L Mckee
- Department of Surgery, University of Calgary, 1403 29 St NW, Calgary, AB T2N 2T9
| | - Itamar Netzer
- Israeli Defense Force Medical Corp, 9 Yitzhak Rabin Blvd., Kiryat Ben-Gurion, Jerusalem 9103001, Israel
| | - Ian A Mckee
- City of Edmonton, 10351 96 St, Edmonton, AB T5H 2H5
| | - Paul McBeth
- Regional Trauma Services, University of Calgary, 1403 29 St NW, Calgary, AB T2N 2T9.,Department of Surgery, University of Calgary, 1403 29 St NW, Calgary, AB T2N 2T9.,Department of Critical Care Medicine, University of Calgary, 1403 29 St NW, Calgary, AB T2N 2T9.,Alberta Health Services, Foothills Medical Centre, 1403 29 St NW, Calgary, AB T2N 2T9
| | - Juan P Wachs
- Regenstrief Center for Healthcare Engineering, Gerald D. and Edna E. Mann Hall, Suite 225, 203 S. Martin Jischke Drive, West Lafayette, IN 47907-1971.,School of Industrial Engineering, Purdue University, 610 Purdue Mall, West Lafayette, IN 47907
| | - Chad G Ball
- Regional Trauma Services, University of Calgary, 1403 29 St NW, Calgary, AB T2N 2T9.,Department of Surgery, University of Calgary, 1403 29 St NW, Calgary, AB T2N 2T9.,Alberta Health Services, Foothills Medical Centre, 1403 29 St NW, Calgary, AB T2N 2T9
| | - Elon Glassberg
- Faculty of Medicine, Bar-Ilan University, Ramat Gan 5290002, Israel
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Martin GE, Johnson M, Veile R, Friend LA, Elterman JB, Johannigman JA, Pritts TA, Goodman MD, Makley AT. Effects of Early Altitude Exposure on the Open Abdomen After Laparotomy in Trauma. Mil Med 2020; 184:e460-e467. [PMID: 30839078 DOI: 10.1093/milmed/usz034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Revised: 10/25/2018] [Accepted: 02/12/2019] [Indexed: 11/14/2022] Open
Abstract
INTRODUCTION While damage control surgery and resuscitation techniques have revolutionized the care of injured service members who sustain severe traumatic hemorrhage, the physiologic and inflammatory consequences of hemostatic resuscitation and staged abdominal surgery in the face of early aeromedical evacuation (AE) have not been investigated. We hypothesized that post-injury AE with an open abdomen would have significant physiologic and inflammatory consequences compared to AE with a closed abdomen. MATERIALS AND METHODS Evaluation of resuscitation and staged abdominal closure was performed using a murine model of hemorrhagic shock with laparotomy. Mice underwent controlled hemorrhage to a systolic blood pressure of 25 mmHg and received either no resuscitation, blood product resuscitation, or Hextend resuscitation to a systolic blood pressure of either 50 mmHg (partial resuscitation) or 80 mmHg (complete resuscitation). Laparotomies were either closed prior to AE (closed abdomens) or left open during AE (open abdomens) and subsequently closed. AE was simulated with a 1-hour exposure to a hypobaric hypoxic environment at 8,000 feet altitude. Mice were euthanized at 0, 4, or 24 hours following AE. Serum was collected and analyzed for physiologic variables and inflammatory cytokine levels. Samples of lung and small intestine were collected for tissue cytokine and myeloperoxidase analysis as indicators of intestinal inflammation. Survival curves were also performed. RESULTS Unresuscitated mice sustained an 85% mortality rate from hemorrhage and laparotomy, limiting the assessment of the effect of simulated AE in these subgroups. Overall survival was similar among all resuscitated groups regardless of the presence of hypobaric hypoxia, type of resuscitation, or abdominal closure status. Simulated AE had no observed effects on acid/base imbalance or the inflammatory response as compared to ground level controls. All mice experienced both metabolic acidosis and an acute inflammatory response after hemorrhage and injury, represented by an initial increase in serum interleukin (IL)-6 levels. Furthermore, mice with open abdomens had an elevated inflammatory response with increased levels of serum IL-10, serum tumor necrosis factor alpha, intestinal IL-6, intestinal IL-10, and pulmonary myeloperoxidase. CONCLUSION These results demonstrate the complex interaction of AE and temporary or definitive abdominal closure after post-injury laparotomy. Contrary to our hypothesis, we found that AE in those animals with open abdomens is relatively safe with no difference in mortality compared to those with closed abdomens. However, given the physiologic and inflammatory changes observed in animals with open abdomens, further evaluation is necessary prior to definitive recommendations regarding the safety or downstream effects of exposure to AE prior to definitive abdominal closure.
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Affiliation(s)
- Grace E Martin
- Department of Surgery, College of Medicine, University of Cincinnati, Section of General Surgery, OH.,Department of Surgery, Institute for Military Medicine, University of Cincinnati, 231 Albert Sabin Way, Cincinnati, OH
| | - Mark Johnson
- Department of Surgery, College of Medicine, University of Cincinnati, Section of General Surgery, OH.,Department of Surgery, Institute for Military Medicine, University of Cincinnati, 231 Albert Sabin Way, Cincinnati, OH
| | - Rose Veile
- Department of Surgery, College of Medicine, University of Cincinnati, Section of General Surgery, OH.,Department of Surgery, Institute for Military Medicine, University of Cincinnati, 231 Albert Sabin Way, Cincinnati, OH
| | - Lou Ann Friend
- Department of Surgery, College of Medicine, University of Cincinnati, Section of General Surgery, OH.,Department of Surgery, Institute for Military Medicine, University of Cincinnati, 231 Albert Sabin Way, Cincinnati, OH
| | - Joel B Elterman
- Department of Surgery, College of Medicine, University of Cincinnati, Section of General Surgery, OH.,Department of Surgery, Institute for Military Medicine, University of Cincinnati, 231 Albert Sabin Way, Cincinnati, OH
| | - Jay A Johannigman
- Department of Surgery, College of Medicine, University of Cincinnati, Section of General Surgery, OH.,Department of Surgery, Institute for Military Medicine, University of Cincinnati, 231 Albert Sabin Way, Cincinnati, OH
| | - Timothy A Pritts
- Department of Surgery, College of Medicine, University of Cincinnati, Section of General Surgery, OH.,Department of Surgery, Institute for Military Medicine, University of Cincinnati, 231 Albert Sabin Way, Cincinnati, OH
| | - Michael D Goodman
- Department of Surgery, College of Medicine, University of Cincinnati, Section of General Surgery, OH.,Department of Surgery, Institute for Military Medicine, University of Cincinnati, 231 Albert Sabin Way, Cincinnati, OH
| | - Amy T Makley
- Department of Surgery, College of Medicine, University of Cincinnati, Section of General Surgery, OH.,Department of Surgery, Institute for Military Medicine, University of Cincinnati, 231 Albert Sabin Way, Cincinnati, OH
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Abstract
Supplemental Digital Content is available in the text Background: Hemorrhage and its complications are the leading cause of preventable death from trauma in young adults, especially in remote locations. To address this, deliverable, shelf-stable resuscitants that provide therapeutic benefits throughout the time course of hemorrhagic shock and the progressive ischemic injury it produces are needed. SANGUINATE∗ is a novel bovine PEGylated carboxyhemoglobin-based oxygen carrier, which has desirable oxygen-carrying and oncotic properties as well as a CO moiety to maintain microvascular perfusion. Objectives: To compare the crystalloid (Lactated Ringer's Solution; LRS), and the colloid (Hextend†) standards of care with SANGUINATE in a post “golden hour” resuscitation model. Methods: Rats underwent a controlled, stepwise blood withdrawal (45% by volume), were maintained in untreated hemorrhagic shock state for >60 min, resuscitated with a 20% bolus of one of the three test solutions, and observed till demise. Parameters of tissue oxygenation (PISFO2), arteriolar diameters, and mean arterial pressure (MAP) were collected. Results: SANGUINATE-treated animals survived significantly longer than those treated with Hextend and LRS. SANGUINATE also significantly increased tissue PISFO2 2 h after resuscitation, whereas LRS and Hextend did not. SANGUINATE also produced a significantly higher MAP, which was hypotensive compared to baseline, that endured until demise. Conclusions: Resuscitation with SANGUINATE after prolonged hemorrhagic shock improves survival, MAP, and PISFO2 compared with standard of care plasma expanders. Since the pathologies of hemorrhagic shock and the associated systemic ischemia are progressive, preclinical studies of this nature are essential to determine efficacy of new resuscitants across the range of possible times to treatment.
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Lesão de superfície ocular em unidade de terapia intensiva: ensaio clinico auto-pareado. ACTA PAUL ENFERM 2020. [DOI: 10.37689/acta-ape/2020ao0279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Bjerkvig C, Sivertsen J, Braathen H, Lunde THF, Strandenes G, Assmus J, Hervig T, Cap A, Kristoffersen EK, Fosse T, Apelseth TO. Cold-stored whole blood in a Norwegian emergency helicopter service: an observational study on storage conditions and product quality. Transfusion 2020; 60:1544-1551. [PMID: 32319702 DOI: 10.1111/trf.15802] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Revised: 02/16/2020] [Accepted: 02/26/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Increasing numbers of emergency medical service agencies and hospitals are developing the capability to administer blood products to patients with hemorrhagic shock. Cold-stored whole blood (WB) is the only single product available to prehospital providers who aim to deliver a balanced resuscitation strategy. However, there are no data on the safety and in vitro characteristics of prehospital stored WB. This study aimed to describe the effects on in vitro quality of storing WB at remote helicopter bases in thermal insulating containers. STUDY DESIGN AND METHODS We conducted a two-armed single-center study. Twenty units (test) were stored in airtight thermal insulating containers, and 20 units (controls) were stored according to routine procedures in the Haukeland University Hospital Blood Bank. Storage conditions were continuously monitored during emergency medical services missions and throughout remote and blood bank storage. Hematologic and metabolic variables, viscoelastic properties, and platelet (PLT) aggregation were measured on Days 1, 8, 14, and 21. RESULTS Storage conditions complied with the EU guidelines throughout remote and in-hospital storage for 21 days. There were no significant differences in PLT aggregation, viscoelastic properties, and hematology variables between the two groups. Minor significantly lower pH, glucose, and base excess and higher lactate were observed after storage in airtight containers. CONCLUSION Forward cold storage of WB is safe and complies with EU standards. No difference is observed in hemostatic properties. Minor differences in metabolic variables may be related to the anaerobic conditions within the thermal box.
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Affiliation(s)
- Christopher Bjerkvig
- Department of Anaesthesia and Intensive Care, Haukeland University Hospital, Bergen, Norway.,Norwegian Naval Special Operations Commando, Norwegian Armed Forces, Bergen, Norway.,Institute of Clinical Sciences, University of Bergen, Bergen, Norway
| | - Joar Sivertsen
- Department of Immunology and Transfusion Medicine, Haukeland University Hospital, Bergen, Norway
| | - Hanne Braathen
- Department of Immunology and Transfusion Medicine, Haukeland University Hospital, Bergen, Norway
| | - Turid Helen Felli Lunde
- Department of Immunology and Transfusion Medicine, Haukeland University Hospital, Bergen, Norway
| | - Geir Strandenes
- Department of Immunology and Transfusion Medicine, Haukeland University Hospital, Bergen, Norway.,Department of War Surgery and Emergency Medicine, Norwegian Armed Forces Medical Services, Oslo, Norway
| | - Jörg Assmus
- Department of Research and Development, Haukeland University Hospital, Bergen, Norway
| | - Tor Hervig
- Institute of Clinical Sciences, University of Bergen, Bergen, Norway.,Department of Immunology and Transfusion Medicine, Haukeland University Hospital, Bergen, Norway
| | - Andrew Cap
- U.S. Army Institute of Surgical Research, Fort Sam Houston, Texas, USA
| | - Einar K Kristoffersen
- Institute of Clinical Sciences, University of Bergen, Bergen, Norway.,Department of Immunology and Transfusion Medicine, Haukeland University Hospital, Bergen, Norway
| | - Theodor Fosse
- Department of Anaesthesia and Intensive Care, Haukeland University Hospital, Bergen, Norway.,Norwegian Naval Special Operations Commando, Norwegian Armed Forces, Bergen, Norway.,Institute of Clinical Sciences, University of Bergen, Bergen, Norway
| | - Torunn Oveland Apelseth
- Department of Immunology and Transfusion Medicine, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Biochemistry and Pharmacology, Haukeland University Hospital, Bergen, Norway
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Nair PM, Rendo MJ, Reddoch-Cardenas KM, Burris JK, Meledeo MA, Cap AP. Recent advances in use of fresh frozen plasma, cryoprecipitate, immunoglobulins, and clotting factors for transfusion support in patients with hematologic disease. Semin Hematol 2020; 57:73-82. [PMID: 32892846 PMCID: PMC7384412 DOI: 10.1053/j.seminhematol.2020.07.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Indexed: 02/07/2023]
Abstract
Hematologic diseases include a broad range of acquired and congenital disorders, many of which affect plasma proteins that control hemostasis and immune responses. Therapeutic interventions for these disorders include transfusion of plasma, cryoprecipitate, immunoglobulins, or convalescent plasma-containing therapeutic antibodies from patients recovering from infectious diseases, as well as concentrated pro- or anticoagulant factors. This review will focus on recent advances in the uses of plasma and its derivatives for patients with acquired and congenital hematologic disorders.
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Affiliation(s)
- Prajeeda M. Nair
- United States Army Institute of Surgical Research, JBSA Fort Sam Houston, TX, USA
| | - Matthew J. Rendo
- San Antonio Military Medical Center, JBSA Fort Sam Houston, TX, USA
| | | | - Jason K. Burris
- San Antonio Military Medical Center, JBSA Fort Sam Houston, TX, USA
| | - Michael A. Meledeo
- United States Army Institute of Surgical Research, JBSA Fort Sam Houston, TX, USA
| | - Andrew P. Cap
- United States Army Institute of Surgical Research, JBSA Fort Sam Houston, TX, USA,Uniformed Services University, Bethesda, MD, USA,Corresponding author. Andrew P. Cap, MD, PhD, United States Army Institute of Surgical Research, 3650 Chambers Pass, JBSA Fort Sam Houston, TX 78234. Tel.: +1-210-539-4858 (office), +1-210-323-6908 (mobile)
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Abstract
Damage control resuscitation (DCR) is a bundle of care first described by Holcomb et al. that is aimed at reducing death from hemorrhage for patients with severe traumatic bleeding. DCR principles include compressible hemorrhage control; hypotensive resuscitation; rapid surgical control of bleeding; avoidance of the overuse of crystalloids and colloids, prevention or correction of acidosis, hypothermia, and hypocalcaemia; and hemostatic resuscitation (blood-based resuscitation). Remote damage control resuscitation (RDCR) is defined as the prehospital application of DCR concepts. The term RDCR was first published by Gerhardt and has been disseminated by the (Trauma Hemostasis and Oxygenation Research), or THOR Network. The history of DCR and RDCR starts well before the inception of the terms. The concepts behind the principles of DCR and RDCR stretch far back into the past. This chapter provides an outline of this history, but it is limited to the fluid resuscitation aspect of DCR/RDCR.
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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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Abstract
INTRODUCTION In October 2017, the American Association of Blood Bankers (AABB; Bethesda, Maryland USA) approved a petition to allow low-titer group O whole blood as a standard product without the need for a waiver. Around that time, a few Texas, USA-based Emergency Medical Services (EMS) systems incorporated whole blood into their ground ambulances. The purpose of this project was to describe the epidemiology of ground ambulance patients that received a prehospital whole blood transfusion. The secondary aim of this project was to report an accounting analysis of these ground ambulance prehospital whole blood programs. METHODS The dataset came from the Harris County Emergency Service District 48 Fire Department (HCESD 48; Harris County, Texas USA) and San Antonio Fire Department (SAFD; San Antonio, Texas USA) whole blood Quality Assurance/Quality Improvement (QA/QI) databases from September 2017 through December 2018. The primary outcome of this study was the prehospital transfusion indication. The secondary outcome was the projected cost per life saved during the first 10 years of the prehospital whole blood initiative. RESULTS Of 58 consecutive prehospital whole blood administrations, the team included all 58 cases. Hemorrhagic shock from a non-traumatic etiology accounted for 46.5% (95% CI, 34.3%-59.2%) of prehospital whole blood recipients. In the non-traumatic hemorrhagic shock cohort, gastrointestinal hemorrhage was the underlying etiology of hemorrhagic shock in 66.7% (95% CI, 47.8%-81.4%) of prehospital whole blood transfusion recipients. The projected average cost to save a life in Year 10 was US$5,136.51 for the combined cohort, US$4,512.69 for HCESD 48, and US$5,243.72 for SAFD EMS. CONCLUSION This retrospective analysis of ground ambulance patients that receive prehospital whole blood transfusion found that non-traumatic etiology accounted for 46.5% (95% CI, 34.3%-59.2%) of prehospital whole blood recipients. Additionally, the accounting analysis suggests that by Year 10 of a ground ambulance whole blood transfusion program, the average cost to save a life will be approximately US$5,136.51.
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Human Red Blood Cells as Oxygen Carriers to Improve Ex-Situ Liver Perfusion in a Rat Model. J Clin Med 2019; 8:jcm8111918. [PMID: 31717387 PMCID: PMC6912657 DOI: 10.3390/jcm8111918] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2019] [Revised: 11/03/2019] [Accepted: 11/05/2019] [Indexed: 12/11/2022] Open
Abstract
Ex-situ machine perfusion (MP) has been increasingly used to enhance liver quality in different settings. Small animal models can help to implement this procedure. As most normothermic MP (NMP) models employ sub-physiological levels of oxygen delivery (DO2), the aim of this study was to investigate the effectiveness and safety of different DO2, using human red blood cells (RBCs) as oxygen carriers on metabolic recovery in a rat model of NMP. Four experimental groups (n = 5 each) consisted of (1) native (untreated/control), (2) liver static cold storage (SCS) 30 min without NMP, (3) SCS followed by 120 min of NMP with Dulbecco-Modified-Eagle-Medium as perfusate (DMEM), and (4) similar to group 3, but perfusion fluid was added with human RBCs (hematocrit 15%) (BLOOD). Compared to DMEM, the BLOOD group showed increased liver DO2 (p = 0.008) and oxygen consumption ( V O ˙ 2) (p < 0.001); lactate clearance (p < 0.001), potassium (p < 0.001), and glucose (p = 0.029) uptake were enhanced. ATP levels were likewise higher in BLOOD relative to DMEM (p = 0.031). V O ˙ 2 and DO2 were highly correlated (p < 0.001). Consistently, the main metabolic parameters were directly correlated with DO2 and V O ˙ 2. No human RBC related damage was detected. In conclusion, an optimized DO2 significantly reduces hypoxic damage-related effects occurring during NMP. Human RBCs can be safely used as oxygen carriers.
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Cap AP, Pidcoke HF, Spinella P, Strandenes G, Borgman MA, Schreiber M, Holcomb J, Tien HCN, Beckett AN, Doughty H, Woolley T, Rappold J, Ward K, Reade M, Prat N, Ausset S, Kheirabadi B, Benov A, Griffin EP, Corley JB, Simon CD, Fahie R, Jenkins D, Eastridge BJ, Stockinger Z. Damage Control Resuscitation. Mil Med 2019; 183:36-43. [PMID: 30189070 DOI: 10.1093/milmed/usy112] [Citation(s) in RCA: 56] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2018] [Indexed: 11/14/2022] Open
Abstract
Damage control resuscitation (DCR) is a strategy for resuscitating patients from hemorrhagic shock to rapidly restore homeostasis. Efforts are focused on blood product transfusion with whole blood or component therapy closely approximating whole blood, limited use of crystalloid to avoid dilutional coagulopathy, hypotensive resuscitation until bleeding control is achieved, empiric use of tranexamic acid, prevention of acidosis and hypothermia, and rapid definitive surgical control of bleeding. Patients receiving uncrossmatched Type O blood in the emergency department and later receiving cumulative transfusions of 10 or more red blood cell units in the initial 24-hour post-injury (massive transfusion) are widely recognized as being at increased risk of morbidity and mortality due to exsanguination. Ideally, these patients should be rapidly identified, however anticipating transfusion needs is challenging. Useful indicators of massive transfusion reviewed in this guideline include: systolic blood pressure <110 mmHg, heart rate > 105 bpm, hematocrit <32%, pH < 7.25, injury pattern (above-the-knee traumatic amputation especially if pelvic injury is present, multi-amputation, clinically obvious penetrating injury to chest or abdomen), >2 regions positive on Focused Assessment with Sonography for Trauma (FAST) scan, lactate concentration on admission >2.5, admission international normalized ratio ≥1.2-1.4, near infrared spectroscopy-derived StO2 < 75% (in practice, rarely available), BD > 6 meq/L. Unique aspects of out-of-hospital DCR (point of injury, en-route, and remote DCR) and in-hospital (Medical Treatment Facilities: Role 2b/Forward surgical teams - role 3/ combat support hospitals) are reviewed in this guideline, along with pediatric considerations.
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Affiliation(s)
- Andrew P Cap
- Joint Trauma System, 3698 Chambers Pass, Joint Base San Antonio, Fort Sam Houston, TX
| | - Heather F Pidcoke
- Joint Trauma System, 3698 Chambers Pass, Joint Base San Antonio, Fort Sam Houston, TX
| | - Philip Spinella
- Joint Trauma System, 3698 Chambers Pass, Joint Base San Antonio, Fort Sam Houston, TX
| | - Geir Strandenes
- Joint Trauma System, 3698 Chambers Pass, Joint Base San Antonio, Fort Sam Houston, TX
| | - Matthew A Borgman
- Joint Trauma System, 3698 Chambers Pass, Joint Base San Antonio, Fort Sam Houston, TX
| | - Martin Schreiber
- Joint Trauma System, 3698 Chambers Pass, Joint Base San Antonio, Fort Sam Houston, TX
| | - John Holcomb
- Joint Trauma System, 3698 Chambers Pass, Joint Base San Antonio, Fort Sam Houston, TX
| | - Homer Chin-Nan Tien
- Joint Trauma System, 3698 Chambers Pass, Joint Base San Antonio, Fort Sam Houston, TX
| | - Andrew N Beckett
- Joint Trauma System, 3698 Chambers Pass, Joint Base San Antonio, Fort Sam Houston, TX
| | - Heidi Doughty
- Joint Trauma System, 3698 Chambers Pass, Joint Base San Antonio, Fort Sam Houston, TX
| | - Tom Woolley
- Joint Trauma System, 3698 Chambers Pass, Joint Base San Antonio, Fort Sam Houston, TX
| | - Joseph Rappold
- Joint Trauma System, 3698 Chambers Pass, Joint Base San Antonio, Fort Sam Houston, TX
| | - Kevin Ward
- Joint Trauma System, 3698 Chambers Pass, Joint Base San Antonio, Fort Sam Houston, TX
| | - Michael Reade
- Joint Trauma System, 3698 Chambers Pass, Joint Base San Antonio, Fort Sam Houston, TX
| | - Nicolas Prat
- Joint Trauma System, 3698 Chambers Pass, Joint Base San Antonio, Fort Sam Houston, TX
| | - Sylvain Ausset
- Joint Trauma System, 3698 Chambers Pass, Joint Base San Antonio, Fort Sam Houston, TX
| | - Bijan Kheirabadi
- Joint Trauma System, 3698 Chambers Pass, Joint Base San Antonio, Fort Sam Houston, TX
| | - Avi Benov
- Joint Trauma System, 3698 Chambers Pass, Joint Base San Antonio, Fort Sam Houston, TX
| | - Edward P Griffin
- Joint Trauma System, 3698 Chambers Pass, Joint Base San Antonio, Fort Sam Houston, TX
| | - Jason B Corley
- Joint Trauma System, 3698 Chambers Pass, Joint Base San Antonio, Fort Sam Houston, TX
| | - Clayton D Simon
- Joint Trauma System, 3698 Chambers Pass, Joint Base San Antonio, Fort Sam Houston, TX
| | - Roland Fahie
- Joint Trauma System, 3698 Chambers Pass, Joint Base San Antonio, Fort Sam Houston, TX
| | - Donald Jenkins
- Joint Trauma System, 3698 Chambers Pass, Joint Base San Antonio, Fort Sam Houston, TX
| | - Brian J Eastridge
- Joint Trauma System, 3698 Chambers Pass, Joint Base San Antonio, Fort Sam Houston, TX
| | - Zsolt Stockinger
- Joint Trauma System, 3698 Chambers Pass, Joint Base San Antonio, Fort Sam Houston, TX
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Oller L, Dyer WB, Santamaría L, Largo C, Javidroozi M, Shander A. The effect of a novel intravenous fluid (Oxsealife®) on recovery from haemorrhagic shock in pigs. Anaesthesia 2019; 74:765-777. [DOI: 10.1111/anae.14627] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/07/2019] [Indexed: 12/16/2022]
Affiliation(s)
| | - W. B. Dyer
- Australian Red Cross Blood Service and Faculty of Medicine and Health University of Sydney Sydney NSW Australia
| | - L. Santamaría
- Department of Anatomy, Histology, and Neuroscience School of Medicine Autonomous University of Madrid Madrid Spain
| | - C. Largo
- Department of Experimental Surgery IdiPAZ Hospital La Paz Madrid Spain
| | - M. Javidroozi
- TeamHealth Research Institute TeamHealth Englewood NJ USA
| | - A. Shander
- Departments of Anesthesiology Critical Care and Hyperbaric Medicine Englewood Hospital and Medical Center Englewood NJ USA
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Endotheliopathy of Trauma is an on-Scene Phenomenon, and is Associated with Multiple Organ Dysfunction Syndrome: A Prospective Observational Study. Shock 2019; 49:420-428. [PMID: 28945676 DOI: 10.1097/shk.0000000000000999] [Citation(s) in RCA: 77] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND Trauma patients are vulnerable to coagulopathy and inflammatory dysfunction associated with endotheliopathy of trauma (EoT). In vitro evidence has suggested that tranexamic acid (TXA) may ameliorate endotheliopathy. We aimed to investigate how soon after injury EoT occurs, its association with multiple organ dysfunction syndrome (MODS), and whether TXA ameliorates it. METHODS A prospective observational study included 91 trauma patients enrolled within 60 min of injury and 19 healthy controls. Blood was sampled on enrolment and again 4 to 12 h later. ELISAs measured serum concentrations of syndecan-1 and thrombomodulin as biomarkers of EoT. MODS was compared between groups according to biomarker dynamics: persistently abnormal; abnormal to normal; and persistently normal. Timing of EoT was estimated by plotting biomarker data against time, and then fitting generalized additive models. Biomarker dynamics were compared between those who did or did not receive prehospital TXA. RESULTS Median age was 38 (interquartile range [IQR] 24-55) years; 78 of 91 were male. Median injury severity score (ISS) was 22 (IQR 12-36). EoT was estimated to occur at 5 to 8 min after injury. There were no significant differences in ISS between those with or without prehospital EoT. Forty-two patients developed MODS; 31 of 42 with persistently abnormal; 8 of 42 with abnormal to normal; and 3 of 42 with persistently normal biomarkers; P < 0.05. There were no significant differences between TXA and non-TXA groups. CONCLUSIONS EoT was present at the scene of injury. MODS was more likely when biomarkers of EoT were persistently raised. There were no significant differences between TXA and non-TXA groups. Prehospital interventions aimed at endothelial restoration may represent a clinically meaningful target for prehospital resuscitation.
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Please add some clarity to transfusion thresholds-It makes my head spin! J Thorac Cardiovasc Surg 2019; 157:1043-1044. [PMID: 30598269 DOI: 10.1016/j.jtcvs.2018.11.070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Revised: 11/20/2018] [Accepted: 11/21/2018] [Indexed: 10/27/2022]
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Rieger-Fackeldey E, Aslan I, Burdach S. Hämorrhagischer Schock im frühen Kindesalter – Besonderheiten der Kreislaufregulation. Monatsschr Kinderheilkd 2018. [DOI: 10.1007/s00112-018-0602-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Knapp J, Pietsch U, Kreuzer O, Hossfeld B, Bernhard M, Lier H. Prehospital Blood Product Transfusion in Mountain Rescue Operations. Air Med J 2018; 37:392-399. [PMID: 30424860 DOI: 10.1016/j.amj.2018.08.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Revised: 07/08/2018] [Accepted: 08/24/2018] [Indexed: 12/13/2022]
Abstract
Severely injured patients with hemorrhage present major challenges for emergency medical services, especially during mountain rescue missions in which harsh environmental conditions and long out-of-hospital times are frequent. Because uncontrolled hemorrhage is the leading cause of death within the first 48 hours after severe trauma, initiating damage control resuscitation (DCR) as early as possible after severe trauma and exporting the concept of DCR to the out-of-hospital arena is pivotal for patient survival. Appropriate bleeding control, management of coagulopathy, and transfusion of blood products are core aspects of DCR. This review summarizes the available evidence on out-of-hospital blood product transfusion and the management of coagulopathy with a special focus on mountain rescue missions. An overview of upcoming trials and possible future trends in the management of coagulopathy during rescue operations is provided.
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Affiliation(s)
- Jürgen Knapp
- Department of Anaesthesiology and Pain Therapy, University Hospital of Bern, Bern, Switzerland; Air Zermatt, Emergency Medical Service, Zermatt, Switzerland.
| | - Urs Pietsch
- Air Zermatt, Emergency Medical Service, Zermatt, Switzerland; Department of Anaesthesiology and Intensive Care Medicine, Cantonal Hospital St Gallen, St Gallen, Switzerland
| | - Oliver Kreuzer
- Air Zermatt, Emergency Medical Service, Zermatt, Switzerland
| | - Björn Hossfeld
- Department of Anaesthesiology and Intensive Care Medicine, Armed Forces Hospital Ulm, Ulm, Germany; Task Force "Tactical Medicine" of the Scientific Working Group Emergency Medicine of the German Society of Anaesthesiology and Intensive Care Medicine, Nürnberg, Germany
| | - Michael Bernhard
- Emergency Department, University Hospital of Düsseldorf, Düsseldorf, Germany; Task Force "Trauma and Resuscitation Room Management" of the Scientific Working Group Emergency Medicine of the German Society of Anaesthesiology and Intensive Care Medicine, Nürnberg, Germany
| | - Heiko Lier
- Task Force "Tactical Medicine" of the Scientific Working Group Emergency Medicine of the German Society of Anaesthesiology and Intensive Care Medicine, Nürnberg, Germany; Department of Anaesthesiology and Postoperative Intensive Care Medicine, University of Cologne, Köln, Germany
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Borgman MA, Zaar M, Aden JK, Schlader ZJ, Gagnon D, Rivas E, Kern J, Koons NJ, Convertino VA, Cap AP, Crandall C. Hemostatic responses to exercise, dehydration, and simulated bleeding in heat-stressed humans. Am J Physiol Regul Integr Comp Physiol 2018; 316:R145-R156. [PMID: 30231210 DOI: 10.1152/ajpregu.00223.2018] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Heat stress followed by an accompanying hemorrhagic challenge may influence hemostasis. We tested the hypothesis that hemostatic responses would be increased by passive heat stress, as well as exercise-induced heat stress, each with accompanying central hypovolemia to simulate a hemorrhagic insult. In aim 1, subjects were exposed to passive heating or normothermic time control, each followed by progressive lower-body negative pressure (LBNP) to presyncope. In aim 2 subjects exercised in hyperthermic environmental conditions, with and without accompanying dehydration, each also followed by progressive LBNP to presyncope. At baseline, pre-LBNP, and post-LBNP (<1, 30, and 60 min), hemostatic activity of venous blood was evaluated by plasma markers of hemostasis and thrombelastography. For aim 1, both hyperthermic and normothermic LBNP (H-LBNP and N-LBNP, respectively) resulted in higher levels of factor V, factor VIII, and von Willebrand factor antigen compared with the time control trial (all P < 0.05), but these responses were temperature independent. Hyperthermia increased fibrinolysis [clot lysis 30 min after the maximal amplitude reflecting clot strength (LY30)] to 5.1% post-LBNP compared with 1.5% (time control) and 2.7% in N-LBNP ( P = 0.05 for main effect). Hyperthermia also potentiated increased platelet counts post-LBNP as follows: 274 K/µl for H-LBNP, 246 K/µl for N-LBNP, and 196 K/µl for time control ( P < 0.05 for the interaction). For aim 2, hydration status associated with exercise in the heat did not affect the hemostatic activity, but fibrinolysis (LY30) was increased to 6-10% when subjects were dehydrated compared with an increase to 2-4% when hydrated ( P = 0.05 for treatment). Central hypovolemia via LBNP is a primary driver of hemostasis compared with hyperthermia and dehydration effects. However, hyperthermia does induce significant thrombocytosis and by itself causes an increase in clot lysis. Dehydration associated with exercise-induced heat stress increases clot lysis but does not affect exercise-activated or subsequent hypovolemia-activated hemostasis in hyperthermic humans. Clinical implications of these findings are that quickly restoring a hemorrhaging hypovolemic trauma patient with cold noncoagulant fluids (crystalloids) can have serious deleterious effects on the body's innate ability to form essential clots, and several factors can increase clot lysis, which should therefore be closely monitored.
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Affiliation(s)
- Matthew A Borgman
- United States Army Institute of Surgical Research, Fort Sam Houston, Texas.,Department of Pediatrics, Brooke Army Medical Center, Fort Sam Houston, Texas
| | - Morten Zaar
- United States Army Institute of Surgical Research, Fort Sam Houston, Texas
| | - James K Aden
- Department of Pediatrics, Brooke Army Medical Center, Fort Sam Houston, Texas
| | - Zachary J Schlader
- Department of Exercise and Nutritional Sciences, Center for Research and Education in Special Environments, University of Buffalo , New York
| | - Daniel Gagnon
- Montreal Heart Institute and University of Montreal , Canada
| | - Eric Rivas
- Department of Kinesiology & Sport Management, Texas Tech University , Lubbock, Texas
| | - Jena Kern
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital of Dallas , Dallas, Texas
| | - Natalie J Koons
- United States Army Institute of Surgical Research, Fort Sam Houston, Texas
| | | | - Andrew P Cap
- United States Army Institute of Surgical Research, Fort Sam Houston, Texas
| | - Craig Crandall
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital of Dallas , Dallas, Texas.,Department of Internal Medicine, University of Texas Southwestern Medical Center at Dallas , Dallas, Texas
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Barelli S, Alberio L. The Role of Plasma Transfusion in Massive Bleeding: Protecting the Endothelial Glycocalyx? Front Med (Lausanne) 2018; 5:91. [PMID: 29721496 PMCID: PMC5915488 DOI: 10.3389/fmed.2018.00091] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2018] [Accepted: 03/22/2018] [Indexed: 12/20/2022] Open
Abstract
Massive hemorrhage is a leading cause of death worldwide. During the last decade several retrospective and some prospective clinical studies have suggested a beneficial effect of early plasma-based resuscitation on survival in trauma patients. The underlying mechanisms are unknown but appear to involve the ability of plasma to preserve the endothelial glycocalyx. In this mini-review, we summarize current knowledge on glycocalyx structure and function, and present data describing the impact of hemorrhagic shock and resuscitation fluids on glycocalyx. Animal studies show that hemorrhagic shock leads to glycocalyx shedding, endothelial inflammatory changes, and vascular hyper-permeability. In these animal models, plasma administration preserves glycocalyx integrity and functions better than resuscitation with crystalloids or colloids. In addition, we briefly present data on the possible plasma components responsible for these effects. The endothelial glycocalyx is increasingly recognized as a critical component for the physiological vasculo-endothelial function, which is destroyed in hemorrhagic shock. Interventions for preserving an intact glycocalyx shall improve survival of trauma patients.
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Affiliation(s)
- Stefano Barelli
- Division of Haematology and Central Haematology Laboratory, CHUV, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
| | - Lorenzo Alberio
- Division of Haematology and Central Haematology Laboratory, CHUV, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland.,Faculté de Biologie et Médecine, UNIL, University of Lausanne, Lausanne, Switzerland
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Abstract
The microvasculature plays a central role in the pathophysiology of hemorrhagic shock and is also involved in arguably all therapeutic attempts to reverse or minimize the adverse consequences of shock. Microvascular studies specific to hemorrhagic shock were reviewed and broadly grouped depending on whether data were obtained on animal or human subjects. Dedicated sections were assigned to microcirculatory changes in specific organs, and major categories of pathophysiological alterations and mechanisms such as oxygen distribution, ischemia, inflammation, glycocalyx changes, vasomotion, endothelial dysfunction, and coagulopathy as well as biomarkers and some therapeutic strategies. Innovative experimental methods were also reviewed for quantitative microcirculatory assessment as it pertains to changes during hemorrhagic shock. The text and figures include representative quantitative microvascular data obtained in various organs and tissues such as skin, muscle, lung, liver, brain, heart, kidney, pancreas, intestines, and mesentery from various species including mice, rats, hamsters, sheep, swine, bats, and humans. Based on reviewed findings, a new integrative conceptual model is presented that includes about 100 systemic and local factors linked to microvessels in hemorrhagic shock. The combination of systemic measures with the understanding of these processes at the microvascular level is fundamental to further develop targeted and personalized interventions that will reduce tissue injury, organ dysfunction, and ultimately mortality due to hemorrhagic shock. Published 2018. Compr Physiol 8:61-101, 2018.
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Affiliation(s)
- Ivo Torres Filho
- US Army Institute of Surgical Research, JBSA Fort Sam Houston, Texas, USA
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Kang BH, Choi D, Cho J, Kwon J, Huh Y, Moon J, Kim Y, Jung K, Lee JCJ. Efficacy of Uncross-Matched Type O Packed Red Blood Cell Transfusion to Traumatic Shock Patients: a Propensity Score Match Study. J Korean Med Sci 2017; 32:2058-2063. [PMID: 29115091 PMCID: PMC5680508 DOI: 10.3346/jkms.2017.32.12.2058] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Accepted: 09/05/2017] [Indexed: 12/20/2022] Open
Abstract
A new blood bank system was established in our trauma bay, which allowed immediate utilization of uncross-matched type O packed red blood cells (UORBCs). We investigated the efficacy of UORBC compared to that of the ABO type-specific packed red blood cells (ABO RBCs) from before the bank was installed. From March 2016 to February 2017, data from trauma patients who received UORBCs in the trauma bay were compared with those of trauma patients who received ABO RBCs from January 2013 to December 2015. Propensity matching was used to overcome retrospective bias. The primary outcome was 24-hour mortality, while the secondary outcomes were in-hospital mortality and intensive care unit (ICU) length of stay (LOS). Data from 252 patients were reviewed and UORBCs were administered to 64 patients. The time to transfusion from emergency room admission was shorter in the UORBC group (11 [7-16] minutes vs. 44 [29-72] minutes, P < 0.001). After propensity matching, 47 patients were included in each group. The 24-hour mortality (4 [8.5%] vs. 9 [13.8%], P = 0.135), in-hospital mortality (14 [29.8%] vs. 18 [38.3%], P = 0.384), and ICU LOS (9 [4-19] days vs. 5 [0-19] days, P = 0.155) did not differ significantly between groups. The utilization of UORBCs resulted in a faster transfusion but did not significantly improve the clinical outcomes in traumatic shock patients in this study. However, the tendency for lower mortality in the UORBC group suggested the need for a large study.
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Affiliation(s)
- Byung Hee Kang
- Department of Trauma Surgery, Ajou University School of Medicine, Suwon, Korea
| | - Donghwan Choi
- Department of Trauma Surgery, Ajou University School of Medicine, Suwon, Korea
| | - Jayun Cho
- Department of Trauma Surgery, Ajou University School of Medicine, Suwon, Korea
| | - Junsik Kwon
- Department of Trauma Surgery, Ajou University School of Medicine, Suwon, Korea
| | - Yo Huh
- Department of Trauma Surgery, Ajou University School of Medicine, Suwon, Korea
| | - Jonghwan Moon
- Department of Trauma Surgery, Ajou University School of Medicine, Suwon, Korea
| | - Younghwan Kim
- Department of Trauma Surgery, National Medical Center, Seoul, Korea
| | - Kyoungwon Jung
- Department of Trauma Surgery, Ajou University School of Medicine, Suwon, Korea
| | - John Cook Jong Lee
- Department of Trauma Surgery, Ajou University School of Medicine, Suwon, Korea.
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47
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Prehospital hemostatic resuscitation to achieve zero preventable deaths after traumatic injury. Curr Opin Hematol 2017; 24:529-535. [DOI: 10.1097/moh.0000000000000386] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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48
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Kang BH, Jung K, Heo Y, Lee JCJ. Safety and Efficacy of Type-O Packed Red Blood Cell Transfusion in Traumatic Hemorrhagic Shock Patients: Preliminary Study. JOURNAL OF ACUTE CARE SURGERY 2017. [DOI: 10.17479/jacs.2017.7.2.50] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Affiliation(s)
- Byung Hee Kang
- Division of Trauma Surgery, Department of Surgery, Ajou University School of Medicine, Suwon, Korea
| | - Kyoungwon Jung
- Division of Trauma Surgery, Department of Surgery, Ajou University School of Medicine, Suwon, Korea
| | - Yunjung Heo
- Department of Medical Humanities and Social Medicine, Ajou University School of Medicine, Suwon, Korea
| | - John Cook-Jong Lee
- Division of Trauma Surgery, Department of Surgery, Ajou University School of Medicine, Suwon, Korea
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49
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Leukocyte filtration lesion impairs functional coagulation in banked whole blood. J Trauma Acute Care Surg 2017; 83:420-426. [PMID: 28452876 DOI: 10.1097/ta.0000000000001535] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Whole blood (WB) transfusion is a promising alternative to component therapy in hemostatic resuscitation. Use of banked WB requires filtration of white blood cells (leukoreduction) and an established shelf life during which WB retains coagulant capacities. The goal of this study was to define the time course of coagulation stability in leukoreduced compared to unfiltered WB under standard refrigeration conditions. METHODS Twelve WB units were donated by healthy volunteers after routine screening. Five units underwent standard leukocyte filtration and five did not. Two units were aliquoted into filtered and unfiltered samples, with platelets added to each sample on day 14. Units were stored at 4°C and sampled on days 0, 1, 2, 3, 4, 5, 6, 7, 10, 14, 21, 28, and 35 for immediate thromboelastography (TEG) analysis, and centrifuged and stored at -80°C for later calibrated automated thrombogram and coagulation factor assays. RESULTS K-dependent factors and fibrinogen were low normal, decreased slightly over 35 days and were similar between unfiltered and filtered units. Labile factors were better preserved in filtered units, although unfiltered units did not show impaired coagulation over 35 days. Filtered blood had delayed clot initiation on days 0, 1, and 2 as measured by TEG R (p < 0.021); slower clot progression (TEG α-angle) on days 0, 1, 2, 3, 4, 5, and 6 (p < 0.023); weaker final clot (TEG MA) on all days (p < 0.0001). Thrombin generation was delayed on day 28 (p = 0.046) and decreased on days 10, 21, 28, and 35 (p < 0.034). Addition of platelets to filtered WB rescued TEG MA. CONCLUSION Filtered WB had decreased functional clotting capacity and thrombin generation and may not be suitable for hemostatic resuscitation as the sole blood product. LEVEL OF EVIDENCE Therapeutic, level IV.
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The Damage Control Surgery in Austere Environments Research Group (DCSAERG): A dynamic program to facilitate real-time telementoring/telediagnosis to address exsanguination in extreme and austere environments. J Trauma Acute Care Surg 2017. [PMID: 28628601 DOI: 10.1097/ta.0000000000001483] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Hemorrhage is the most preventable cause of posttraumatic death. Many cases are potentially anatomically salvageable, yet remain lethal without logistics or trained personnel to deliver diagnosis or resuscitative surgery in austere environments. Revolutions in technology for remote mentoring of ultrasound and surgery may enhance capabilities to utilize the skill sets of non-physicians. Thus, our research collaborative explored remote mentoring to empower non-physicians to address junctional and torso hemorrhage control in austere environments. Major studies involved using remote-telementored ultrasound (RTMUS) to identify torso and junctional exsanguination, remotely mentoring resuscitative surgery for torso hemorrhage control, understanding and mitigating physiological stress during such tasks, and the technical practicalities of conducting damage control surgery (DCS) in austere environments. Iterative projects involved randomized guiding of firefighters to identify torso (RCT) and junctional (pilot) hemorrhage using RTMUS, randomized remote mentoring of MedTechs conducting resuscitative surgery for torso exsanguination in an anatomically realistic surgical trainer ("Cut Suit") including physiological monitoring, and trained surgeons conducting a comparative randomized study for torso hemorrhage control in normal (1g) versus weightlessness (0g). This work demonstrated that firefighters could be remotely mentored to perform just-in-time torso RTMUS on a simulator. Both firefighters and mentors were confident in their abilities, the ultrasounds being 97% accurate. An ultrasound-naive firefighter in Memphis could also be remotely mentored from Hawaii to identify and subsequently tamponade an arterial junctional hemorrhage using RTMUS in a live tissue model. Thereafter, both mentored and unmentored MedTechs and trained surgeons completed resuscitative surgery for hemorrhage control on the Cut-Suit, demonstrating practicality for all involved. While remote mentoring did not decrease blood loss among MedTechs, it increased procedural confidence and decreased physiologic stress. Therefore, remote mentoring may increase the feasibility of non-physicians conducting a psychologically daunting task. Finally, DCS in weightlessness was feasible without fundamental differences from 1g. Overall, the collective evidence suggests that remote mentoring supports diagnosis, noninvasive therapy, and ultimately resuscitative surgery to potentially rescue those exsanguinating in austere environments and should be more rigorously studied.
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