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Davenport LM, Letson HL, Dobson GP. Lung Protection After Severe Thermal Burns With Adenosine, Lidocaine, and Magnesium (ALM) Resuscitation and Importance of Shams in a Rat Model. J Burn Care Res 2024; 45:216-226. [PMID: 37602979 PMCID: PMC10768784 DOI: 10.1093/jbcr/irad127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Indexed: 08/22/2023]
Abstract
The management of severe burns remains a complex challenge. Adenosine, lidocaine, and magnesium (ALM) resuscitation therapy has been shown to protect against hemorrhagic shock and traumatic injury. The aim of the present study was to investigate the early protective effects of small-volume ALM fluid resuscitation in a rat model of 30% total body surface area (TBSA) thermal injury. Male Sprague-Dawley rats (320-340 g; n = 25) were randomly assigned to: 1) Sham (surgical instrumentation and saline infusion, without burn, n = 5), 2) Saline resuscitation group (n = 10), or 3) ALM resuscitation group (n = 10). Treatments were initiated 15-min after burn trauma, including 0.7 mL/kg 3% NaCl ± ALM bolus and 0.25-0.5 mL/kg/h 0.9% NaCl ± ALM drip, with animals monitored to 8.25-hr post-burn. Hemodynamics, cardiac function, blood chemistry, hematology, endothelial injury markers and histopathology were assessed. Survival was 100% for Shams and 90% for both ALM and Saline groups. Shams underwent significant physiological, immune and hematological changes over time as a result of surgical traums. ALM significantly reduced malondialdehyde levels in the lungs compared to Saline (P = .023), and showed minimal alveolar destruction and inflammatory cell infiltration (P < .001). ALM also improved cardiac function and oxygen delivery (21%, P = .418 vs Saline), reduced gut injury (P < .001 vs Saline), and increased plasma adiponectin (P < .001 vs baseline). Circulating levels of the acute phase protein alpha 1-acid glycoprotein (AGP) increased 1.6-times (P < .001), which may have impacted ALM's therapeutic efficacy. We conclude that small-volume ALM therapy significantly reduced lung oxidative stress and preserved alveolar integrity following severe burn trauma. Further studies are required to assess higher ALM doses with longer monitoring periods.
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Affiliation(s)
- Lisa M Davenport
- Heart and Trauma Research Laboratory, College of Medicine and Dentistry, James Cook University, Queensland 4811, Australia
| | - Hayley L Letson
- Heart and Trauma Research Laboratory, College of Medicine and Dentistry, James Cook University, Queensland 4811, Australia
| | - Geoffrey P Dobson
- Heart and Trauma Research Laboratory, College of Medicine and Dentistry, James Cook University, Queensland 4811, Australia
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2
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Palmieri TL. Acute care for burn patients: fluids, surgery, and what else? Curr Opin Crit Care 2023; 29:696-701. [PMID: 37861199 DOI: 10.1097/mcc.0000000000001096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2023]
Abstract
PURPOSE OF REVIEW Recently published initiatives spanning the burn care spectrum have substantially changed the standard of care in burn care. The purpose of this article is to describe new impactful concepts in burn first aid, triage, resuscitation, and treatment as well as their impact on future research. RECENT FINDINGS First aid after burn injury traditionally consists of extinguishing the burn and applying dressings. Recent evidence suggests that applying 20 min of cool tap water to the burn wound in the first 3 h postburn mitigates burn injury extent. National burn center transfer criteria have been updated, impacting patient initial transfer and management. The adverse effects of hydroxocobalamin, a commonly used antidote for cyanide toxicity, have been delineated. Initial burn resuscitation recommendations for both volume and potentially fluid type are being reexamined. The emergence of innovative skin substitutes may improve burn survival by providing a physiologically stabilizing intermediate dressing. Finally, formal clinical practice guidelines for early mobility in the ICU after burn injury have been defined. SUMMARY These changes in burn care, triage, resuscitation, and treatment have challenged traditional burn care standards, created new standards, and are the basis for future prospective randomized trials.
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Affiliation(s)
- Tina L Palmieri
- Shriners Children's Northern California, University of California Davis, Sacramento, California, USA
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3
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Zhi L, Wang X, Pan X, Han C. Fluid balance in the resorption stage correlates with outcomes of severe burn patients. Burns 2023; 49:1916-1925. [PMID: 37821273 DOI: 10.1016/j.burns.2023.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 04/26/2023] [Accepted: 05/02/2023] [Indexed: 10/13/2023]
Abstract
OBJECTIVE The resorption stage is an important period involving early anti-shock treatment for severe burn patients. We aimed to investigate the quantitative variability in fluid balance during the resorption stage in severe burn patients, and to study its effect on patient outcomes. METHODS We conducted a single-centre retrospective study of 100 severe burn patients with involvement of > 50% total body surface area (TBSA). We extracted clinical data on demographics, clinical characteristics and outcomes; calculated the daily net fluid balance (difference between fluid intake and fluid output) and daily fluid intake/output within one week after injury; and analysed the association between fluid balance and functional outcomes and prognosis. The relative volume (ml/kg/TBSA) was used for the determination of daily fluid volume in this study. RESULTS The daily net fluid balance (ml/kg/TBSA) of the deceased patients on the 4th, 5th, 6th, and 7th days after injury was higher than that of the surviving patients, but the opposite trend was found for the daily fluid output (ml/kg/TBSA). The partial correlation test showed that in the resorption stage of severe burn patients, fluid output was negatively correlated with the index levels of renal function and liver function, CRP level, blood lactic acid (LA) level, frequency of ventilator treatment, and capillary leakage index (CLI), but net fluid balance showed a completely opposite correlation. Moreover, fluid intake was negatively correlated with the index level of renal function and LA level, but positively correlated with the frequency of ventilator treatment. Furthermore, the logistic regression analysis showed that the net fluid balance and fluid output on Day 6 post-injury were independent risk factors for prognosis. CONCLUSION This study suggested that greater fluid output in the resorption stage of severe burn patients was closely related to better outcomes, in addition, a gradually decreasing, lower positive net fluid balance may contribute to the improvement of functional outcomes, which will provide useful information for early fluid management and further prospective clinical study of severe burns.
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Affiliation(s)
- Lizhu Zhi
- Department of Burn Surgery, Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China.
| | - Xingang Wang
- Department of Burn Surgery, Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Xuanliang Pan
- Department of Burn Surgery, Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Chunmao Han
- Department of Burn Surgery, Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
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4
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Haruta A, Mandell SP. Assessment and Management of Acute Burn Injuries. Phys Med Rehabil Clin N Am 2023; 34:701-716. [PMID: 37806692 DOI: 10.1016/j.pmr.2023.06.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/10/2023]
Abstract
Burn injuries can affect patients from all walks of life and represent a significant healthcare problem globally. The skin is the largest organ of the body and consequences of injury range of minor pain to severe end-organ dysfunction and even death. The acute assessment and management of burn-injured patients is a critical part of their short-term and long-term outcomes and often benefit from specialty, multidisciplinary care. Local wound care and appropriate excision and grafting are important parts of managing the functional, cosmetic, and physiologic derangements caused by burn injuries. Large burns also require judicious fluid resuscitation. Electrical, chemical, and inhalational injuries are less common than thermal burns but require additional care and are often associated with increased morbidity.
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Affiliation(s)
- Alison Haruta
- Department of Burns, Trauma, Acute, and Critical Care Surgery, UT Southwestern, 5323 Harry Hines Boulevard, Dallas, TX 75390-9005, USA.
| | - Samuel P Mandell
- Department of Burns, Trauma, Acute, and Critical Care Surgery, UT Southwestern, 5323 Harry Hines Boulevard, Dallas, TX 75390-9005, USA
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5
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Walter AS, Volkmer E, Gauglitz G, Böcker W, Saller MM. Systematic review of molecular pathways in burn wound healing. Burns 2023; 49:1525-1533. [PMID: 37821280 DOI: 10.1016/j.burns.2023.03.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 06/29/2022] [Accepted: 03/07/2023] [Indexed: 03/13/2023]
Abstract
Depending on extent and depth, burn injuries and resulting scars may be challenging and expensive to treat and above all heavily impact the patients' lives. This systematic review represents the current state of knowledge on molecular pathways activated during burn wound healing. All currently known molecular information about gene expression and molecular interactions in mammals has been summarized. An ample interaction of regenerative cytokines, growth factors, ECM-regenerative molecules and proinflammatory immune response became apparent. We identified three molecules to be most often involved in the pathways: TGFB1, ACTA1 and COL1A1. Yet, other factors including FLII, AKT1 and miR-145 were shown to play pivotal roles in burn wound healing as well. This systematic review helps to explain the fundamental molecular proceedings participating in burn wound healing. A number of new molecular interactions and functional connections were identified yielding intriguing new research targets. An interactive version of the first network about molecular pathways and interactions during burn wound healing is provided in the online edition and on WikiPathways.
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Affiliation(s)
- Annika S Walter
- Musculoskeletal University Center Munich (MUM), Department of Orthopeadics and Trauma Surgery, Ludwig-Maximilians-University (LMU), Fraunhoferstraße 20, 82152 Martinsried, Germany
| | - Elias Volkmer
- Musculoskeletal University Center Munich (MUM), Department of Orthopeadics and Trauma Surgery, Ludwig-Maximilians-University (LMU), Fraunhoferstraße 20, 82152 Martinsried, Germany; Division of Hand Surgery, Helios Klinikum München West, Steinerweg 5, 81241 Munich, Germany
| | - Gerd Gauglitz
- Department of Dermatology and Allergy, Ludwig-Maximillians-University (LMU), Frauenlobstraße 9-11, 80337 Munich, Germany
| | - Wolfgang Böcker
- Musculoskeletal University Center Munich (MUM), Department of Orthopeadics and Trauma Surgery, Ludwig-Maximilians-University (LMU), Fraunhoferstraße 20, 82152 Martinsried, Germany
| | - Maximilian M Saller
- Musculoskeletal University Center Munich (MUM), Department of Orthopeadics and Trauma Surgery, Ludwig-Maximilians-University (LMU), Fraunhoferstraße 20, 82152 Martinsried, Germany.
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6
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Roggan CLM, Akbas S, Arvanitakis M, Mannil L, Spahn DR, Plock JA, Kaserer A. Changes in coagulation and temperature management in burn patients - A survey of burn centers in Switzerland, Austria and Germany. Burns 2023; 49:1566-1573. [PMID: 36914441 DOI: 10.1016/j.burns.2023.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 01/13/2023] [Accepted: 02/19/2023] [Indexed: 03/04/2023]
Abstract
BACKGROUND Severely burned patients suffer from both coagulopathy and hypothermia, with a lack of international consensus and appropriate treatment guidelines. This study examines recent developments and trends in coagulation and temperature management in European burn centers. METHODS A survey was sent to burn centers in Switzerland, Austria and Germany in 2016 and again in 2021. The analysis was performed using descriptive statistics, with categorical data reported in absolute numbers (n) and percentages (%) and numerical data reported as mean and standard deviation. RESULTS The rate of completed questionnaires was 84 % (16 of 19 questionnaires) in 2016 and 91 % (21 of 22 questionnaires) in 2021. The number of global coagulation tests performed has decreased over the observation period in favor of single factor determination and bed-side point-of-care coagulation tests. This has also led to increased administration of single factor concentrates in therapy. Although many centers had a defined treatment protocol for hypothermia in 2016, coverage increased such that in 2021 all centers surveyed had such a protocol. The body temperature was measured more consistently in 2021; thus, hypothermia was more actively sought, detected and treated. CONCLUSION A point-of-care guided, factor-based coagulation management and the maintenance of normothermia have gained importance in the care of burn patients in recent years.
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Affiliation(s)
- Celine L M Roggan
- Institute of Anesthesiology, University Hospital Zurich, Zurich, Switzerland
| | - Samira Akbas
- Institute of Anesthesiology, University Hospital Zurich, Zurich, Switzerland
| | - Michael Arvanitakis
- University Hospital Zurich, University of Zurich, Zurich, Switzerland; Department of Plastic Surgery and Hand Surgery, Burn Center, University of Zurich, Zurich, Switzerland
| | - Lijo Mannil
- University Hospital Zurich, University of Zurich, Zurich, Switzerland; Department of Plastic Surgery and Hand Surgery, Burn Center, University of Zurich, Zurich, Switzerland
| | - Donat R Spahn
- Institute of Anesthesiology, University Hospital Zurich, Zurich, Switzerland
| | - Jan A Plock
- University Hospital Zurich, University of Zurich, Zurich, Switzerland; Department of Plastic Surgery and Hand Surgery, Burn Center, University of Zurich, Zurich, Switzerland; Department of Plastic Surgery and Hand Surgery; Cantonal Hospital Aarau; Aarau, Switzerland
| | - Alexander Kaserer
- Institute of Anesthesiology, University Hospital Zurich, Zurich, Switzerland.
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7
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Asuku M, Shupp JW. Burn wound conversion: clinical implications for the treatment of severe burns. J Wound Care 2023; 32:S11-S20. [PMID: 37121662 DOI: 10.12968/jowc.2023.32.sup5.s11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2023]
Abstract
The identification of novel treatments for severe burn wounds relies on accurate clinical assessments of the extent of injury. However, evaluation of burn wound depth can be challenging due to the tendency for burn wounds to progress over time in a little-understood process known as 'burn wound conversion'. Local factors affecting the burn wound, such as inflammation, oxidative stress-induced tissue damage, vasostasis and bacterial infections, lead to increased cell death by apoptosis or oncosis, while systemic events may promote burn wound conversion. Acute shock, metabolic derangements, age or immunomodulation can modify cytokine secretion, lower immune responses, decrease blood flow or cause bacterial infection at the burn wound site. Therefore, therapeutic approaches targeting specific mechanisms that reduce cell death, improve wound reperfusion and promote tissue regrowth should favourably enhance burn wound healing, and long-term functional and aesthetic outcomes. Our current understanding of these mechanisms mostly comes from animal studies, underscoring the need for extensive research in humans. A streamlined approach would be to investigate the parallels in other disease states that exhibit ischaemia and potential reperfusion, such as ischaemic stroke and myocardial infarction. Moreover, in view of the limited knowledge available on the subject, the need exists for further clinical research into burn wound conversion and novel target pathways to ameliorate its effects. This review describes events that affect the viability of cells at the burn wound site resulting in burn wound conversion, and identifies potential targets for clinical interventions that may diminish burn wound conversion.
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Affiliation(s)
| | - Jeffrey W Shupp
- Department of Surgery, Biochemistry and Molecular & Cellular Biology, Georgetown University School of Medicine, MedStar Washington Hospital Center, Washington, DC, US
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8
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Ferrada P, Cannon JW, Kozar RA, Bulger EM, Sugrue M, Napolitano LM, Tisherman SA, Coopersmith CM, Efron PA, Dries DJ, Dunn TB, Kaplan LJ. Surgical Science and the Evolution of Critical Care Medicine. Crit Care Med 2023; 51:182-211. [PMID: 36661448 DOI: 10.1097/ccm.0000000000005708] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Surgical science has driven innovation and inquiry across adult and pediatric disciplines that provide critical care regardless of location. Surgically originated but broadly applicable knowledge has been globally shared within the pages Critical Care Medicine over the last 50 years.
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Affiliation(s)
- Paula Ferrada
- Division of Trauma and Acute Care Surgery, Department of Surgery, Inova Fairfax Hospital, Falls Church, VA
| | - Jeremy W Cannon
- Division of Trauma, Surgical Critical Care and Emergency Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Rosemary A Kozar
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Eileen M Bulger
- Division of Trauma, Burn and Critical Care Surgery, Department of Surgery, University of Washington at Seattle, Harborview, Seattle, WA
| | - Michael Sugrue
- Department of Surgery, Letterkenny University Hospital, County of Donegal, Ireland
| | - Lena M Napolitano
- Division of Acute Care Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Samuel A Tisherman
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Craig M Coopersmith
- Division of General Surgery, Department of Surgery, Emory University, Emory Critical Care Center, Atlanta, GA
| | - Phil A Efron
- Department of Surgery, Division of Critical Care, University of Florida, Gainesville, FL
| | - David J Dries
- Department of Surgery, University of Minnesota, Regions Healthcare, St. Paul, MN
| | - Ty B Dunn
- Division of Transplant Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Lewis J Kaplan
- Division of Trauma, Surgical Critical Care and Emergency Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Corporal Michael J. Crescenz VA Medical Center, Section of Surgical Critical Care, Surgical Services, Philadelphia, PA
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9
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Bunch CM, Chang E, Moore EE, Moore HB, Kwaan HC, Miller JB, Al-Fadhl MD, Thomas AV, Zackariya N, Patel SS, Zackariya S, Haidar S, Patel B, McCurdy MT, Thomas SG, Zimmer D, Fulkerson D, Kim PY, Walsh MR, Hake D, Kedar A, Aboukhaled M, Walsh MM. SHock-INduced Endotheliopathy (SHINE): A mechanistic justification for viscoelastography-guided resuscitation of traumatic and non-traumatic shock. Front Physiol 2023; 14:1094845. [PMID: 36923287 PMCID: PMC10009294 DOI: 10.3389/fphys.2023.1094845] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Accepted: 02/07/2023] [Indexed: 03/03/2023] Open
Abstract
Irrespective of the reason for hypoperfusion, hypocoagulable and/or hyperfibrinolytic hemostatic aberrancies afflict up to one-quarter of critically ill patients in shock. Intensivists and traumatologists have embraced the concept of SHock-INduced Endotheliopathy (SHINE) as a foundational derangement in progressive shock wherein sympatho-adrenal activation may cause systemic endothelial injury. The pro-thrombotic endothelium lends to micro-thrombosis, enacting a cycle of worsening perfusion and increasing catecholamines, endothelial injury, de-endothelialization, and multiple organ failure. The hypocoagulable/hyperfibrinolytic hemostatic phenotype is thought to be driven by endothelial release of anti-thrombogenic mediators to the bloodstream and perivascular sympathetic nerve release of tissue plasminogen activator directly into the microvasculature. In the shock state, this hemostatic phenotype may be a counterbalancing, yet maladaptive, attempt to restore blood flow against a systemically pro-thrombotic endothelium and increased blood viscosity. We therefore review endothelial physiology with emphasis on glycocalyx function, unique biomarkers, and coagulofibrinolytic mediators, setting the stage for understanding the pathophysiology and hemostatic phenotypes of SHINE in various etiologies of shock. We propose that the hyperfibrinolytic phenotype is exemplified in progressive shock whether related to trauma-induced coagulopathy, sepsis-induced coagulopathy, or post-cardiac arrest syndrome-associated coagulopathy. Regardless of the initial insult, SHINE appears to be a catecholamine-driven entity which early in the disease course may manifest as hyper- or hypocoagulopathic and hyper- or hypofibrinolytic hemostatic imbalance. Moreover, these hemostatic derangements may rapidly evolve along the thrombohemorrhagic spectrum depending on the etiology, timing, and methods of resuscitation. Given the intricate hemochemical makeup and changes during these shock states, macroscopic whole blood tests of coagulative kinetics and clot strength serve as clinically useful and simple means for hemostasis phenotyping. We suggest that viscoelastic hemostatic assays such as thromboelastography (TEG) and rotational thromboelastometry (ROTEM) are currently the most applicable clinical tools for assaying global hemostatic function-including fibrinolysis-to enable dynamic resuscitation with blood products and hemostatic adjuncts for those patients with thrombotic and/or hemorrhagic complications in shock states.
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Affiliation(s)
- Connor M Bunch
- Department of Emergency Medicine, Henry Ford Hospital, Detroit, MI, United States.,Department of Internal Medicine, Henry Ford Hospital, Detroit, MI, United States
| | - Eric Chang
- Department of Medical Education, Indiana University School of Medicine, Notre Dame Campus, South Bend, IN, United States
| | - Ernest E Moore
- Department of Surgery, Ernest E. Moore Shock Trauma Center at Denver Health, University of Colorado, Denver, CO, United States
| | - Hunter B Moore
- Department of Surgery, Ernest E. Moore Shock Trauma Center at Denver Health, University of Colorado, Denver, CO, United States.,Department of Transplant Surgery, Denver Health and University of Colorado Health Sciences Center, Denver, CO, United States
| | - Hau C Kwaan
- Division of Hematology and Oncology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Joseph B Miller
- Department of Emergency Medicine, Henry Ford Hospital, Detroit, MI, United States.,Department of Internal Medicine, Henry Ford Hospital, Detroit, MI, United States
| | - Mahmoud D Al-Fadhl
- Department of Medical Education, Indiana University School of Medicine, Notre Dame Campus, South Bend, IN, United States
| | - Anthony V Thomas
- Department of Medical Education, Indiana University School of Medicine, Notre Dame Campus, South Bend, IN, United States
| | - Nuha Zackariya
- Department of Medical Education, Indiana University School of Medicine, Notre Dame Campus, South Bend, IN, United States
| | - Shivani S Patel
- Department of Emergency Medicine, Henry Ford Hospital, Detroit, MI, United States
| | - Sufyan Zackariya
- Department of Emergency Medicine, Henry Ford Hospital, Detroit, MI, United States
| | - Saadeddine Haidar
- Department of Emergency Medicine, Henry Ford Hospital, Detroit, MI, United States
| | - Bhavesh Patel
- Division of Critical Care, Department of Medicine, Mayo Clinic Arizona, Phoenix, AZ, United States
| | - Michael T McCurdy
- Division of Pulmonary and Critical Care, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Scott G Thomas
- Department of Trauma Surgery, Memorial Leighton Trauma Center, South Bend, IN, United States
| | - Donald Zimmer
- Department of Trauma Surgery, Memorial Leighton Trauma Center, South Bend, IN, United States
| | - Daniel Fulkerson
- Department of Trauma Surgery, Memorial Leighton Trauma Center, South Bend, IN, United States
| | - Paul Y Kim
- Department of Medicine, McMaster University, Hamilton, ON, Canada.,Thrombosis and Atherosclerosis Research Institute, Hamilton, ON, Canada
| | | | - Daniel Hake
- Departments of Emergency Medicine and Internal Medicine, Saint Joseph Regional Medical Center, Mishawaka, IN, United States
| | - Archana Kedar
- Departments of Emergency Medicine and Internal Medicine, Saint Joseph Regional Medical Center, Mishawaka, IN, United States
| | - Michael Aboukhaled
- Departments of Emergency Medicine and Internal Medicine, Saint Joseph Regional Medical Center, Mishawaka, IN, United States
| | - Mark M Walsh
- Department of Medical Education, Indiana University School of Medicine, Notre Dame Campus, South Bend, IN, United States.,Departments of Emergency Medicine and Internal Medicine, Saint Joseph Regional Medical Center, Mishawaka, IN, United States
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10
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Ashouri S. An Introduction to Burns. Phys Med Rehabil Clin N Am 2022; 33:871-883. [DOI: 10.1016/j.pmr.2022.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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11
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Khandelwal A, Minuk L, Liu Y, Arnold DM, Heddle NM, Barty R, Hsia C, Solh Z, Shehata N, Thompson T, Tinmouth A, Perelman I, Skeate R, Kron AT, Callum J. Plasma transfusion practices: A multicentre electronic audit. Vox Sang 2022; 117:1211-1219. [PMID: 36102150 DOI: 10.1111/vox.13355] [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: 04/29/2022] [Revised: 08/02/2022] [Accepted: 08/16/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND OBJECTIVES Plasma is often transfused to patients with bleeding or requiring invasive procedures and with abnormal tests of coagulation. Chart audits find half of plasma transfusions unnecessary, resulting in avoidable complications and costs. This multicentre electronic audit was conducted to determine the proportion of plasma transfused without an indication and/or at a sub-therapeutic dose. METHODS Data were extracted on adult inpatients in 2017 at five academic sites from the hospital electronic chart, laboratory information systems and the Canadian Institute for Health Information Discharge Abstract Database. Electronic criteria for plasma transfusion outside recommended indications were: (1) international normalized ratio (INR) < 1.5 with no to moderate bleeding; (2) INR ≥ 1.5, with no to mild bleeding and no planned procedures; and (3) no INR before or after plasma infusion. Sub-therapeutic dose was defined as ≤2 units transfused. RESULTS In 1 year, 2590 patients received 6088 plasma transfusions encompassing 11,490 units of plasma occurred at the five sites. 77.7% of events were either outside indications or under-dosed. Of these, 34.8% of plasma orders had no indication identified, and 62% of these occurred in non-bleeding patients and no planned procedure with an isolated elevated INR. 70.7% of transfusions were under-dosed. Most plasma transfusions occurred in the intensive care unit or the operating room. Inter-hospital variability in peri-transfusion testing and dosing was observed. CONCLUSION The majority of plasma transfusions are sub-optimal. Local hospital culture may be an important driver. Electronic audits, with definitions employed in this study, may be a practical alternative to costly chart audits.
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Affiliation(s)
- Aditi Khandelwal
- Canadian Blood Services, Toronto, Ontario, Canada.,The University of Toronto Quality in Utilization, Education and Safety in Transfusion (QUEST) Research Program, Toronto, Ontario, Canada
| | - Leigh Minuk
- Department of Internal Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Yang Liu
- McMaster Centre for Transfusion Research (MCTR), McMaster University, Hamilton, Ontario, Canada
| | - Donald M Arnold
- McMaster Centre for Transfusion Research (MCTR), McMaster University, Hamilton, Ontario, Canada.,Division of Hematology and Thromboembolism, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Nancy M Heddle
- McMaster Centre for Transfusion Research (MCTR), McMaster University, Hamilton, Ontario, Canada.,Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Rebecca Barty
- McMaster Centre for Transfusion Research (MCTR), McMaster University, Hamilton, Ontario, Canada.,Ontario Regional Blood Coordinating Network (ORBCoN), Toronto, Ontario, Canada
| | - Cyrus Hsia
- Department of Medicine, Western University, London, Ontario, Canada.,Department of Pathology and Laboratory Medicine, Western University, London, Ontario, Canada.,Transfusion Medicine Laboratories, London Health Sciences Centre, London, Ontario, Canada
| | - Ziad Solh
- Department of Medicine, Western University, London, Ontario, Canada.,Department of Pathology and Laboratory Medicine, Western University, London, Ontario, Canada.,Transfusion Medicine Laboratories, London Health Sciences Centre, London, Ontario, Canada
| | - Nadine Shehata
- The University of Toronto Quality in Utilization, Education and Safety in Transfusion (QUEST) Research Program, Toronto, Ontario, Canada.,Department of Laboratory Medicine and Pathology, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Troy Thompson
- Ontario Regional Blood Coordinating Network (ORBCoN), Toronto, Ontario, Canada
| | - Alan Tinmouth
- Ottawa Hospital Centre for Transfusion Research, Ottawa Hospital and Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,Division of Hematology, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Iris Perelman
- Ottawa Hospital Research Institute (OHRI), Ottawa, Ontario, Canada
| | - Robert Skeate
- Canadian Blood Services, Toronto, Ontario, Canada.,The University of Toronto Quality in Utilization, Education and Safety in Transfusion (QUEST) Research Program, Toronto, Ontario, Canada
| | - Amie T Kron
- The University of Toronto Quality in Utilization, Education and Safety in Transfusion (QUEST) Research Program, Toronto, Ontario, Canada.,Precision Diagnostics and Therapeutics Program, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Jeannie Callum
- The University of Toronto Quality in Utilization, Education and Safety in Transfusion (QUEST) Research Program, Toronto, Ontario, Canada.,Department of Pathology and Molecular Medicine, Kingston Health Sciences Centre, Queen's University, Kingston, Ontario, Canada
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12
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Barry M, Wu F, Pati S, Chipman A, Geng H, Kozar R. Lyophilized plasma resuscitation downregulates inflammatory gene expression in a mouse model of sepsis. J Trauma Acute Care Surg 2022; 93:S119-S127. [PMID: 35881828 DOI: 10.1097/ta.0000000000003658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Plasma resuscitation may improve outcomes by targeting endotheliopathy induced by severe sepsis or septic shock. Given the logistical constraints of using fresh frozen plasma in military settings or areas with prolonged prehospital care, dried products such as lyophilized plasma (LP) have been developed. We hypothesized that resuscitation with LP would decrease lung injury, inflammation, and mortality in a mouse sepsis model. METHODS Adult male C57BL/6J mice received an intraperitoneal injection of cecal slurry. Twenty-two hours later, the mice were anesthetized, the femoral artery was cannulated, and the mice were randomized to receive resuscitation with LP (10 mL/kg) or lactated Ringer's (LR; 30 mL/kg) for 1 hour. At 48-hours post-cecal slurry injection, bronchoalveolar lavage fluid was collected, the lungs were harvested, and plasma was obtained. Mortality and bronchoalveolar lavage total protein concentration (as an indicator of permeability) were compared between groups. The lungs were analyzed for histopathology and inflammatory gene expression using NanoString, and the plasma was analyzed for biomarkers of inflammation and endothelial function. RESULTS There was no significant difference in short-term mortality between LR and LP mice, 38% versus 47%, respectively ( p = 0.62). Bronchoalveolar lavage protein levels were similar among mice resuscitated with LR or LP, and there was a lack of significant histopathologic lung injury in all groups. However, LP resuscitation resulted in downregulation of pulmonary inflammatory genes, including signaling pathways such as Janus kinase-signal transducer and activator of transcription and nuclear factor κB, and a circulating inflammatory biomarker profile similar to sham animals. CONCLUSION Resuscitation with LP did not improve mortality or reduce permeability or injury in this model compared with LR. However, LP downregulated pulmonary inflammatory gene signaling and may also reduce circulating biomarkers of inflammation. Future studies should evaluate LP resuscitation in combination with antibiotics and other therapeutics to determine whether the anti-inflammatory effects of LP may improve outcomes in sepsis.
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Affiliation(s)
- Mark Barry
- From the Department of Surgery (M.B., S.P.), University of California, San Francisco, San Francisco, California; Shock Trauma Center (F.W., A.C., R.K.), University of Maryland School of Medicine, Baltimore, Maryland; and Department of Laboratory Medicine (S.P., H.G.), University of California, San Francisco, San Francisco, California
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13
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The Effect and Evaluation of the Third Military Medical University Fluid Resuscitation Formula. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2022; 2022:8984696. [PMID: 35769159 PMCID: PMC9236776 DOI: 10.1155/2022/8984696] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Accepted: 06/02/2022] [Indexed: 11/30/2022]
Abstract
Background The clinical efficacy of the third Military Medical University formula (TMMU formula) for fluid resuscitation stage was evaluated to improve the treatment level of adult patients with extensive burns during the shock stage. Methods Retrospective analysis of the data of 55 patients undergoing fluid resuscitation according to the TMMU formula within six hours after burn injury. The following indicators were collected: (1) demographic and injury information; (2) fluid resuscitation information; (3) efficiency information, including cardiovascular function, liver function, renal function, coagulation function evaluation indicators, blood concentration, and average urine output index. Results (1) In the first and second 24 hours after injury, the median fluid rehydration coefficient was 1.68 ml/kg·(%) TBSA and 1.15 ml/kg·(%) TBSA, the median ratio of crystal to colloid was 2.24 and 1.67, and the median urine output index was 0.75 ml/kg·h and 1.05 ml/kg·h, respectively. (2) The actual fluid volume during patient resuscitation is higher than the formula calculated volume, and this difference is more obvious in patients with burn area ≥80%. (3) In the second 24 hours, the value of the actual total fluid volume minus the formula total volume in the group with crystal to colloid ratio ≤2 was significantly lower than that in the ratio >2 group. (4) At 24 and 48 hours after injury, the cardiovascular function, liver function, renal function, and coagulation function were better than those before fluid resuscitation. Conclusions Early application of the TMMU formula for fluid resuscitation in adult patients with extensive burns is safe and effective, but the actual input volume often exceeds the volume calculated by the formula, especially in the second 24 hours after burn injury and in patients with larger burn areas. Increasing the colloid input volume can help reduce the total amount of fluid used for resuscitation.
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14
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Burn Injuries from a military perspective. CURRENT TRAUMA REPORTS 2022. [DOI: 10.1007/s40719-022-00232-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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15
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Cartotto R, Burmeister DM, Kubasiak JC. Burn Shock and Resuscitation: Review and State of the Science. J Burn Care Res 2022; 43:irac025. [PMID: 35218662 DOI: 10.1093/jbcr/irac025] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Indexed: 12/31/2022]
Abstract
Burn shock and acute fluid resuscitation continue to spark intense interest and debate among burn clinicians. Following a major burn injury, fluid resuscitation of burn shock is life-saving, but paradoxically can also be a source of increased morbidity and mortality because of the unintended consequence of systemic edema formation. Considerable research over the past two decades has been devoted to understanding the mechanisms of edema formation, and to develop strategies to curb resuscitation fluids and limit edema development. Recognition of burn endotheliopathy - injury to the endothelium's glycocalyx layer- is one of the most important recent developments in our understanding of burn shock pathophysiology. Newer monitoring approaches and resuscitation endpoints, along with alternative resuscitation strategies to crystalloids alone, such as administration of albumin, or plasma, or high dose ascorbic acid, have had mixed results in limiting fluid creep. Clear demonstration of improvements in outcomes with all of these approaches remains elusive. This comprehensive review article on burn shock and acute resuscitation accompanies the American Burn Association's State of the Science meeting held in New Orleans, LA on November 2-3, 2021 and the Proceedings of that conference published in this journal.
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Affiliation(s)
- Robert Cartotto
- Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre, and University of Toronto, Canada
| | - David M Burmeister
- Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland and United States Army Institute of Surgical Research, JBSA Fort Sam Houston, Texas USA
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16
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Ning F, Jiang H, Qiu J, Wang L. Different Depths May Not Determine the Fluid Resuscitation Volume in Early-stage Management of Severe Burns: a Model-Comparison Retrospective Analysis of Fluid Volume Determining Factors. J Burn Care Res 2021; 43:412-418. [PMID: 34653244 DOI: 10.1093/jbcr/irab185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Large-volume fluid resuscitation remains irreplaceable in the early-stage management of severe burns. We aimed to explore the relationship between fluid volume and other indicators. METHOD Data of severe burn patients with successful resuscitation in the early stage was collected. Correlation and linear regression analyses were performed. Multiple linear regression models, related goodness-of-fit assessment (adjusted R-square and Akaike Information Criterion), scatter plots and paired t-test for two models, and a likelihood ratio test were performed. RESULTS 96 patients were included. The median of total burn area (TBA) was 70%TBSA, with full thickness burn area (FTBA)/TBA of 0.4, a resuscitation volume of 1.93 mL/kg/%TBSA. Among volume-correlated indicators, two linear regression models were established (Model 1: TBA × weight and tracheotomy; and Model 2: FTBA × weight, partial thickness burn area (PTBA) × weight, and tracheotomy). For these models, close values of Akaike Information Criterion, adjusted R-squares, outliers of the prediction range, and the result of paired t-test, all suggest similarity between two models estimations, while the likelihood ratio test for coefficients of FTBA × weight and PTBA × weight showed a statistical difference. CONCLUSION inhalational injury and decompression surgery only correlated with volume, while Tracheotomy, TBA × weight, FTBA × weight, and PTBA × weight correlated with and were accepted in linear models of volume. Although FTBA and PTBA differed statistically, there may be no need to distinguish them when estimating the resuscitation volume requirements in this patient set. Further study about different depths fluid should be conducted.
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Affiliation(s)
- Fanggang Ning
- Department of Burns, Beijing Jishuitan Hospital, Xicheng District, Beijing City, People's Republic of China
| | - Huihao Jiang
- Peking University Fourth School of Clinical Medicine, Xicheng District, Beijing City, People's Republic of China
| | - Jiaming Qiu
- Department of Statistics, Iowa State University, Ames, Iowa, United States
| | - Lifang Wang
- Clinical Epidemiology Research Center, Xicheng District, Beijing Jishuitan Hospital, Beijing City, People's Republic of China
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17
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Abstract
ABSTRACT Burn injuries are a common form of traumatic injury that leads to significant morbidity and mortality worldwide. Burn injuries are characterized by inflammatory processes and alterations in numerous organ systems and functions. Recently, it has become apparent that the gastrointestinal bacterial microbiome is a key component of regulating the immune response and recovery from burn and can also contribute to significant detrimental sequelae after injury, such as sepsis and multiple organ failure. Microbial dysbiosis has been linked to multiple disease states; however, its role in exacerbating acute traumatic injuries, such as burn, is poorly understood. In this article, we review studies that document changes in the intestinal microbiome after burn injury, assess the implications in post-burn pathogenesis, and the potential for further discovery and research.
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Affiliation(s)
- Marisa E. Luck
- Burn & Shock Trauma Research Institute, Stritch School of Medicine, Loyola University Chicago Health Sciences Division, Maywood, IL 60153, USA
- Alcohol Research Program, Stritch School of Medicine, Loyola University Chicago Health Sciences Division, Maywood, IL 60153, USA
- Integrative Cell Biology Program, Stritch School of Medicine, Loyola University Chicago Health Sciences Division, Maywood, IL 60153, USA
| | - Caroline J. Herrnreiter
- Burn & Shock Trauma Research Institute, Stritch School of Medicine, Loyola University Chicago Health Sciences Division, Maywood, IL 60153, USA
- Alcohol Research Program, Stritch School of Medicine, Loyola University Chicago Health Sciences Division, Maywood, IL 60153, USA
- Biochemistry and Molecular Biology Program, Stritch School of Medicine, Loyola University Chicago Health Sciences Division, Maywood, IL 60153, USA
| | - Mashkoor A. Choudhry
- Burn & Shock Trauma Research Institute, Stritch School of Medicine, Loyola University Chicago Health Sciences Division, Maywood, IL 60153, USA
- Alcohol Research Program, Stritch School of Medicine, Loyola University Chicago Health Sciences Division, Maywood, IL 60153, USA
- Department of Surgery, Stritch School of Medicine, Loyola University Chicago Health Sciences Division, Maywood, IL 60153, USA
- Department of Microbiology and Immunology, Stritch School of Medicine, Loyola University Chicago Health Sciences Division, Maywood, IL 60153, USA
- Integrative Cell Biology Program, Stritch School of Medicine, Loyola University Chicago Health Sciences Division, Maywood, IL 60153, USA
- Biochemistry and Molecular Biology Program, Stritch School of Medicine, Loyola University Chicago Health Sciences Division, Maywood, IL 60153, USA
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18
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Pati S, Fennern E, Holcomb JB, Barry M, Trivedi A, Cap AP, Martin MJ, Wade C, Kozar R, Cardenas JC, Rappold JF, Spiegel R, Schreiber MA. Treating the endotheliopathy of SARS-CoV-2 infection with plasma: Lessons learned from optimized trauma resuscitation with blood products. Transfusion 2021; 61 Suppl 1:S336-S347. [PMID: 34269437 PMCID: PMC8446992 DOI: 10.1111/trf.16452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 03/30/2021] [Indexed: 11/29/2022]
Affiliation(s)
- Shibani Pati
- Department of Lab MedicineUniversity of California San Francisco School of MedicineSan FranciscoCaliforniaUSA
| | - Erin Fennern
- Department of SurgeryMount Sinai Icahn School of MedicineNew YorkNew YorkUSA
| | | | - Mark Barry
- Department of SurgeryUniversity of California San Francisco School of MedicineSan FranciscoCaliforniaUSA
| | - Alpa Trivedi
- Department of Lab MedicineUniversity of California San Francisco School of MedicineSan FranciscoCaliforniaUSA
| | - Andrew P. Cap
- U.S. Army Institute of Surgical ResearchJBSA‐FT Sam HoustonSan AntonioTexasUSA
| | | | - Charles Wade
- Department of Surgery McGovern School of MedicineUniversity of Texas Health Science CenterHoustonTexasUSA
| | - Rosemary Kozar
- Department of SurgeryUniversity of MarylandBaltimoreMarylandUSA
| | - Jessica C. Cardenas
- Department of Surgery McGovern School of MedicineUniversity of Texas Health Science CenterHoustonTexasUSA
| | - Joseph F. Rappold
- Department of Surgery Maine Medical CenterTufts University School of MedicinePortlandMaineUSA
| | - Renee Spiegel
- Department of SurgeryElmhurst Hospital CenterElmhurstNew YorkUSA
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19
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Chi Y, Liu X, Chai J. A narrative review of changes in microvascular permeability after burn. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:719. [PMID: 33987417 PMCID: PMC8106041 DOI: 10.21037/atm-21-1267] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Objective We aimed to review and discuss some of the latest research results related to post-burn pathophysiological changes and provide some clues for future study. Background Burns are one of the most common and serious traumas and consist of a series of pathophysiological changes of thermal injury. Accompanied by thermal damage to skin and soft tissues, inflammatory mediators are released in large quantities. Changes in histamine, bradykinin, and cytokines such as vascular endothelial growth factor (VEGF), metabolic factors such as adenosine triphosphate (ATP), and activated neutrophils all affect the body’s vascular permeability. Methods We searched articles with subject words “microvascular permeability”, “burn” “endothelium”, and “endothelial barrier” in PubMed in English published from the beginning of database to Dec, 2020. Conclusions The essence of burn shock is the rapid and extensive fluid transfer in burn and non-burn tissue. After severe burns, the local and systemic vascular permeability increase, causing intravascular fluid extravasation, leading to a progressive decrease in effective circulation volume, an increase in systemic vascular resistance, a decrease in cardiac output, peripheral tissue edema, multiple organ failure, and even death. There are many cells, tissues, mediators and structures involved in the pathophysiological process of the damage to vascular permeability. Ulinastatin is a promising agent for this problem.
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Affiliation(s)
- Yunfei Chi
- Burn Institute, The Fourth Medical Center of the PLA General Hospital, Beijing, China
| | - Xiangyu Liu
- Burn Institute, The Fourth Medical Center of the PLA General Hospital, Beijing, China
| | - Jiake Chai
- Burn Institute, The Fourth Medical Center of the PLA General Hospital, Beijing, China
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20
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Walczak J, Bunn C, Saini P, Liu YM, Baldea AJ, Muthumalaiappan K. Transient Improvement in Erythropoiesis Is Achieved Via the Chaperone AHSP With Early Administration of Propranolol in Burn Patients. J Burn Care Res 2021; 42:311-322. [PMID: 32842148 DOI: 10.1093/jbcr/iraa150] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Burn patients experience erythropoietin resistant anemia in which early commitment and late maturation of erythroblasts are defective. The authors previously showed that propranolol (Prop) treatment restores erythroid committed progenitors, but terminal maturation remains impaired. Hemoglobinization and maturation occur during terminal erythropoiesis and these processes are aided by an erythroblast intrinsic functional protein called alpha-hemoglobin stabilizing protein (AHSP). The authors evaluated the role of AHSP in PBMC- (peripheral blood mono nuclear cell) derived erythroblasts and the implications of Prop in burn patients. Blood samples were collected at three time points from 17 patients receiving standard burn care (SBC) or Prop. Five healthy volunteers provided control plasma (CP). PBMCs were placed in biphasic cultures with 5% autologous plasma (BP) or CP. Erythroblasts were harvested during mid and late maturation stages; the percentage of AHSP+ erythroblasts, AHSP expression, and relative distribution of reticulocytes and polychromatophilic erythroblasts (PolyE) were determined by cytometry. During the second time point (7-10 days postburn), Prop cohort required 35% less transfusions. At mid maturation, PBMCs from Prop-treated patients cultured in BP had 33% more AHSP+ erythroblasts and 40% more AHSP expression compared with SBC. Furthermore, at late maturation, Prop had 50% more reticulocytes and 30% less PolyEs in CP vs BP compared with SBC (11% and 6%, respectively). AHSP is positively associated with late-stage maturation of PBMC-derived erythroblasts in the presence of CP. Albeit transiently, this is more pronounced in Prop than SBC. Early administration of propranolol in burn patients supports erythropoiesis via the chaperone AHSP.
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Affiliation(s)
- Julia Walczak
- Burn and Shock Trauma Research Institute, Maywood, Illinois
| | - Corinne Bunn
- Burn and Shock Trauma Research Institute, Maywood, Illinois.,Department of Surgery, Loyola University Chicago, Maywood, Illinois
| | - Pravesh Saini
- Stritch School of Medicine, Loyola University Chicago, Maywood, Illinois
| | - Yuk Ming Liu
- Department of Surgery, Loyola University Chicago, Maywood, Illinois
| | - Anthony J Baldea
- Department of Surgery, Loyola University Chicago, Maywood, Illinois
| | - Kuzhali Muthumalaiappan
- Burn and Shock Trauma Research Institute, Maywood, Illinois.,Department of Surgery, Loyola University Chicago, Maywood, Illinois
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21
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Burmeister DM, Smith SL, Muthumalaiappan K, Hill DM, Moffatt LT, Carlson DL, Kubasiak JC, Chung KK, Wade CE, Cancio LC, Shupp JW. An Assessment of Research Priorities to Dampen the Pendulum Swing of Burn Resuscitation. J Burn Care Res 2020; 42:113-125. [PMID: 33306095 DOI: 10.1093/jbcr/iraa214] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
On June 17 to 18, 2019, the American Burn Association, in conjunction with Underwriters Laboratories, convened a group of experts on burn resuscitation in Washington, DC. The goal of the meeting was to identify and discuss novel research and strategies to optimize the process of burn resuscitation. Patients who sustain a large thermal injury (involving >20% of the total body surface area [TBSA]) face a sequence of challenges, beginning with burn shock. Over the last century, research has helped elucidate much of the underlying pathophysiology of burn shock, which places multiple organ systems at risk of damage or dysfunction. These studies advanced the understanding of the need for fluids for resuscitation. The resultant practice of judicious and timely infusion of crystalloids has improved mortality after major thermal injury. However, much remains unclear about how to further improve and customize resuscitation practice to limit the morbidities associated with edema and volume overload. Herein, we review the history and pathophysiology of shock following thermal injury, and propose some of the priorities for resuscitation research. Recommendations include: studying the utility of alternative endpoints to resuscitation, reexamining plasma as a primary or adjunctive resuscitation fluid, and applying information about inflammation and endotheliopathy to target the underlying causes of burn shock. Undoubtedly, these future research efforts will require a concerted effort from the burn and research communities.
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Affiliation(s)
- David M Burmeister
- Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland.,United States Army Institute of Surgical Research, JBSA Fort Sam Houston, Texas
| | - Susan L Smith
- The Warden Burn Center, Orlando Regional Medical Center, Orlando, Florida
| | | | - David M Hill
- Firefighters' Burn Center, Regional One Health, Memphis, Tennessee
| | - Lauren T Moffatt
- Firefighters' Burn and Surgical Research Laboratory, MedStar Health Research Institute, Washington, District of Columbia.,The Burn Center, MedStar Washington Hospital Center; Department of Surgery, Georgetown University School of Medicine, Washington, District of Columbia
| | - Deborah L Carlson
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - John C Kubasiak
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Kevin K Chung
- Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Charles E Wade
- Center for Translational Injury Research, and Department of Surgery, McGovern School of Medicine and The John S. Dunn Burn Center, Memorial Herman Hospital, Houston, Texas
| | - Leopoldo C Cancio
- United States Army Institute of Surgical Research, JBSA Fort Sam Houston, Texas
| | - Jeffrey W Shupp
- Firefighters' Burn and Surgical Research Laboratory, MedStar Health Research Institute, Washington, District of Columbia.,The Burn Center, MedStar Washington Hospital Center; Department of Surgery, Georgetown University School of Medicine, Washington, District of Columbia
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22
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Gruen DS, Guyette FX, Brown JB, Okonkwo DO, Puccio AM, Campwala IK, Tessmer MT, Daley BJ, Miller RS, Harbrecht BG, Claridge JA, Phelan HA, Neal MD, Zuckerbraun BS, Yazer MH, Billiar TR, Sperry JL. Association of Prehospital Plasma With Survival in Patients With Traumatic Brain Injury: A Secondary Analysis of the PAMPer Cluster Randomized Clinical Trial. JAMA Netw Open 2020; 3:e2016869. [PMID: 33057642 PMCID: PMC7563075 DOI: 10.1001/jamanetworkopen.2020.16869] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
IMPORTANCE Prehospital plasma administration improves survival in injured patients at risk for hemorrhagic shock and transported by air ambulance. Traumatic brain injury (TBI) is a leading cause of death following trauma, but few early interventions improve outcomes. OBJECTIVE To assess the association between prehospital plasma and survival in patients with TBI. DESIGN, SETTING, AND PARTICIPANTS The Prehospital Air Medical Plasma (PAMPer) trial was a pragmatic, multicenter, phase 3, cluster randomized clinical trial involving injured patients who were at risk for hemorrhagic shock during air medical transport to a trauma center. The trial was conducted at 6 US sites with 9 level-I trauma centers (comprising 27 helicopter emergency services bases). The original trial analyzed 501 patients, including 230 patients who were randomized to receive plasma and 271 randomized to standard care resuscitation. This secondary analysis of a predefined subgroup included patients with TBI. Data analysis was performed from October 2019 to February 2020. INTERVENTIONS Patients were randomized to receive standard care fluid resuscitation or 2 units of thawed plasma. MAIN OUTCOMES AND MEASURES The primary outcome was mortality at 30 days. Patients with TBI were prespecified as a subgroup for secondary analysis and for measurement of markers of brain injury. The 30-day survival benefit of prehospital plasma in subgroups with and without TBI as diagnosed by computed tomography was characterized using Kaplan-Meier survival analysis and Cox proportional hazard regression. RESULTS In total, 166 patients had TBI (median [interquartile range] age, 43.00 [25.00-59.75] years; 125 men [75.3%]). When compared with the 92 patients who received standard care, the 74 patients with TBI who received prehospital plasma had improved 30-day survival even after adjustment for multiple confounders and assessment of the degree of brain injury with clinical variables and biomarkers (hazard ratio [HR], 0.55; 95% CI, 0.33-0.94; P = .03). Receipt of prehospital plasma was associated with improved survival among patients with TBI with a prehospital Glasgow Coma Scale score of less than 8 (HR, 0.56; 95% CI, 0.35-0.91) and those with polytrauma (HR, 0.50; 95% CI, 0.28-0.89). Patients with TBI transported from the scene of injury had improved survival following prehospital plasma administration (HR, 0.45; 95% CI, 0.26-0.80; P = .005), whereas patients who were transferred from an outside hospital showed no difference in survival for the plasma intervention (HR, 1.00; 95% CI, 0.33-3.00; P = .99). CONCLUSIONS AND RELEVANCE These findings are exploratory, but they suggest that receipt of prehospital plasma is associated with improved survival in patients with computed tomography-positive TBI. The prehospital setting may be a critical period to intervene in the care of patients with TBI. Future studies are needed to confirm the clinical benefits of early plasma resuscitation following TBI and concomitant polytrauma. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT01818427.
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Affiliation(s)
- Danielle S. Gruen
- Department of Surgery and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
- Pittsburgh Trauma Research Center, Pittsburgh, Pennsylvania
| | - Francis X. Guyette
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Joshua B. Brown
- Department of Surgery and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
- Pittsburgh Trauma Research Center, Pittsburgh, Pennsylvania
| | - David O. Okonkwo
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Ava M. Puccio
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Insiyah K. Campwala
- Department of Surgery and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
- Pittsburgh Trauma Research Center, Pittsburgh, Pennsylvania
| | - Matthew T. Tessmer
- Department of Surgery and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
- Pittsburgh Trauma Research Center, Pittsburgh, Pennsylvania
| | - Brian J. Daley
- Department of Surgery, University of Tennessee Health Science Center, Knoxville
| | - Richard S. Miller
- Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | | | - Jeffrey A. Claridge
- MetroHealth Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - Herb A. Phelan
- Department of Surgery, University of Texas Southwestern, Dallas
| | - Matthew D. Neal
- Department of Surgery and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
- Pittsburgh Trauma Research Center, Pittsburgh, Pennsylvania
| | - Brian S. Zuckerbraun
- Department of Surgery and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
- Pittsburgh Trauma Research Center, Pittsburgh, Pennsylvania
| | - Mark H. Yazer
- Department of Pathology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Timothy R. Billiar
- Department of Surgery and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
- Pittsburgh Trauma Research Center, Pittsburgh, Pennsylvania
| | - Jason L. Sperry
- Department of Surgery and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
- Pittsburgh Trauma Research Center, Pittsburgh, Pennsylvania
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23
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Dittrich MHM, Hosni ND, de Carvalho WB. Association between fluid creep and infection in burned children: A cohort study. Burns 2020; 46:1036-1042. [DOI: 10.1016/j.burns.2020.02.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Revised: 01/21/2020] [Accepted: 02/06/2020] [Indexed: 02/01/2023]
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24
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Kaserer A, Rössler J, Slankamenac K, Arvanitakis M, Spahn DR, Giovanoli P, Steiger P, Plock JA. Impact of allogeneic blood transfusions on clinical outcomes in severely burned patients. Burns 2020; 46:1083-1090. [DOI: 10.1016/j.burns.2019.11.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Revised: 10/11/2019] [Accepted: 11/13/2019] [Indexed: 12/12/2022]
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Abstract
Background: Blood product transfusion has historically been utilized after major burn injury in the resuscitative as well as the acute phase. Transfusion has been implicated in infection and immunosuppression in many disease states. Recommendations for blood product transfusion has varied, but several landmark studies have helped define optimal burn transfusion strategies with respect to infection. The purpose of this article is to review the evidence describing the relation between transfusion and infection in burn injury during different phases of burn treatment to identify optimal transfusion strategies and suggest future targets for transfusion research in burns. Methods: This article presents the history, current status, and future research directions related to blood and blood product transfusion in burn injury. Results: Patients with burns are subject to infectious complications resulting from the loss of skin and burn-related immunosuppression. The use of blood in burn treatment has varied during both the resuscitative phase and the acute treatment phase. Whole-blood use in resuscitation was replaced with crystalloid infusion. Future trials are examining the role of plasma and albumin in burn resuscitation. A randomized prospective multicenter transfusion trial was able to decrease transfusion by 50% with no change in infection. Further examination of the role of hemostatic resuscitation in burn excision may help to better define transfusion goals. Conclusions: Blood product transfusion in burn injury has varied throughout the last century. Although advances in the understanding of blood transfusion in burn injury have occurred, initiatives to define optimal care better are required.
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Affiliation(s)
- Tina L Palmieri
- Department of Surgery, University of California, Davis, Sacramento, California, USA
- Shriners Hospital for Children Northern California, Sacramento, California, USA
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26
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Contemporary resuscitation of hemorrhagic shock: What will the future hold? Am J Surg 2020; 220:580-588. [PMID: 32409009 PMCID: PMC7211588 DOI: 10.1016/j.amjsurg.2020.05.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Revised: 04/28/2020] [Accepted: 05/07/2020] [Indexed: 02/07/2023]
Abstract
Resuscitation of the critically ill patient with fluid and blood products is one of the most widespread interventions in medicine. This is especially relevant for trauma patients, as hemorrhagic shock remains the most common cause of preventable death after injury. Consequently, the study of the ideal resuscitative product for patients in shock has become an area of great scientific interest and investigation. Recently, the pendulum has swung towards increased utilization of blood products for resuscitation. However, pathogens, immune reactions and the limited availability of this resource remain a challenge for clinicians. Technologic advances in pathogen reduction and innovations in blood product processing will allow us to increase the safety profile and efficacy of blood products, ultimately to the benefit of patients. The purpose of this article is to review the current state of blood product based resuscitative strategies as well as technologic advancements that may lead to safer resuscitation.
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Abstract
Burn-injured patients provide unique challenges to those providing anaesthesia and pain management. This review aims to update both the regular burn anaesthetist and the anaesthetist only occasionally involved with burn patients in emergency settings. It addresses some aspects of care that are perhaps contentious in terms of airway management, fluid resuscitation, transfusion practices and pharmacology. Recognition of pain management failures and the lack of mechanism-specific analgesics are discussed along with the opioid crisis as it relates to burns and nonpharmacological methods in the management of distressed patients.
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Affiliation(s)
- Francois Stapelberg
- Department of Anaesthesia and Pain Medicine, New Zealand National Burn Centre, Auckland, New Zealand.,Department of Anaesthesiology, University of Auckland, Auckland, New Zealand
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Stein AL, Rössler J, Braun J, Sprengel K, Beeler PE, Spahn DR, Kaserer A, Stein P. Impact of a goal-directed factor-based coagulation management on thromboembolic events following major trauma. Scand J Trauma Resusc Emerg Med 2019; 27:117. [PMID: 31888722 PMCID: PMC6937999 DOI: 10.1186/s13049-019-0697-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Accepted: 12/23/2019] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND A factor-based coagulation management following major trauma is recommended as standard of care by the European Trauma Treatment Guidelines. However, concerns about the thromboembolic risk of this approach are still prevalent. Our study therefore aims to assess if such a haemostatic management is associated with an increased risk for thromboembolic events. METHODS In this retrospective observational study carried out at the University Hospital Zurich we compared two three-year periods before (period 1: 2005-2007) and after (period 2: 2012-2014) implementation of a factor-based coagulation algorithm. We included all adult patients following major trauma primarily admitted to the University Hospital Zurich. Thromboembolic events were defined as a new in-hospital appearance of any peripheral thrombosis, arterial embolism, pulmonary embolism, stroke or myocardial infarction. A logistic regression was performed to investigate the association of thromboembolic events with possible confounders such as age, sex, specific Abbreviated Injury Scale (AIS) subgroups, allogeneic blood products, and the coagulation management. RESULTS Out of 1138 patients, 772 met the inclusion criteria: 344 patients in period 1 and 428 patients in period 2. Thromboembolic events were present in 25 patients (7.3%) of period 1 and in 42 patients (9.8%) of period 2 (raw OR 1.39, 95% CI 0.83 to 2.33, p = 0.21). Only AIS extremities (adjusted OR 1.26, 95% CI 1.05 to 1.52, p = 0.015) and exposure to allogeneic blood products (adjusted OR 2.39, 95% CI 1.33 to 4.30, p = 0.004) were independently associated with thromboembolic events in the logistic regression, but the factor-based coagulation management was not (adjusted OR 1.60, 95% CI 0.90-2.86, p = 0.11). CONCLUSION There is no evidence that a goal-directed, factor-based coagulation management is associated with an increased risk for thromboembolic events following major trauma.
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Affiliation(s)
- Anais L Stein
- Department of Forensic Medicine and Imaging, Institute of Forensic Medicine, University of Zurich, Winterthurerstrasse 190/52, 8057, Zurich, Switzerland
| | - Julian Rössler
- Institute of Anaesthesiology, University and University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Julia Braun
- Departments of Biostatistics and Epidemiology, Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Hirschengraben 84, 8001, Zurich, Switzerland
| | - Kai Sprengel
- Department of Trauma, University and University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Patrick E Beeler
- Department of Internal Medicine, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Donat R Spahn
- Institute of Anaesthesiology, University and University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Alexander Kaserer
- Institute of Anaesthesiology, University and University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Philipp Stein
- Institute of Anaesthesiology, Cantonal Hospital Winterthur, Brauerstrasse 15, 8400, Winterthur, Switzerland.
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