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Clausen NE, Meyhoff CS, Henriksen HH, Lindhardt A, Pott FC, Lunen TB, Gybel-Brask M, Lange T, Johansson PI, Stensballe J. Plasma as endothelial rescue in septic shock: A randomized, phase 2a pilot trial. Transfusion 2024. [PMID: 38973502 DOI: 10.1111/trf.17939] [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: 03/31/2024] [Revised: 05/17/2024] [Accepted: 06/17/2024] [Indexed: 07/09/2024]
Abstract
BACKGROUND Septic shock is associated with high morbidity and mortality, the endothelium plays an important role. Crystalloids is standard of care to maintain intravascular volume. Plasma is associated with improved endothelial integrity and restoration of the glycocalyx layer. We evaluated the efficacy and safety aspects of cell-free and pathogen inactivated pooled plasma (OctaplasLG®) as resuscitation in septic shock patients. STUDY DESIGN AND METHODS This randomized, investigator-initiated phase IIa trial ran at a Danish single center intensive care unit, from 2017 to 2019. Patients were 18 years of age or older with septic shock and randomized to fluid optimization with OctaplasLG® or Ringer-acetate in the first 24 h. The primary endpoints were changes in biomarkers indicative of endothelial activation, damage, and microvascular perfusion from baseline to 24 h. Safety events and mortality were assessed during 90 days. RESULTS Forty-four patients were randomized, 20 to OctaplasLG versus 24 to Ringer-acetate. The median age was 69, and 55% were men. Median Sequential Organ Failure Assessment score was 13. Baseline differences favoring the Ringer-acetate group were observed. The OctaplasLG® group was resuscitated with 740 mL plasma and the Ringer-acetate group with 841 mL crystalloids. There was no significant change in the microvascular perfusion or five biomarkers except VEGFR1 change, which was higher in patients receiving OctaplasLG® 0.12(SD 0.37) versus Ringer-acetate -0.24 (SD 0.39), with mean difference 0.36 (95% CI, 0.13-0.59, p = .003) in favor of Ringer-acetate. DISCUSSION This study found that fluid resuscitation with OctaplasLG® in critically ill septic shock patients is feasible. Baseline confounding prevented assessment of the potential effect of OctaplasLG®.
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Affiliation(s)
- Niels E Clausen
- Department of Anesthesia and Intensive Care, Copenhagen University Hospital -Bispebjerg and Frederiksberg, Copenhagen, Denmark
| | - Christian S Meyhoff
- Department of Anesthesia and Intensive Care, Copenhagen University Hospital -Bispebjerg and Frederiksberg, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Hanne H Henriksen
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Section for Transfusion Medicine, Capital Region Blood Bank, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Anne Lindhardt
- Department of Anesthesia and Intensive Care, Zealand University Hospital, Køge, Denmark
| | - Frank C Pott
- Department of Anesthesia and Intensive Care, Copenhagen University Hospital -Bispebjerg and Frederiksberg, Copenhagen, Denmark
| | - Thomas Bech Lunen
- Department of Anesthesia and Intensive Care, Zealand University Hospital, Køge, Denmark
| | - Mikkel Gybel-Brask
- Section for Transfusion Medicine, Capital Region Blood Bank, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Theis Lange
- Section of Biostatistics, University of Copenhagen, Copenhagen, Denmark
| | - Pär I Johansson
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Section for Transfusion Medicine, Capital Region Blood Bank, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Jakob Stensballe
- Section for Transfusion Medicine, Capital Region Blood Bank, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Anesthesia and Trauma Center, Centre of Head and Orthopedics, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
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Park H, Lee H, Baik S, Lee JM. Analysis of hemodynamics and impedance using bioelectrical impedance analysis in hypovolemic shock-induced swine model. Sci Rep 2024; 14:15077. [PMID: 38956216 PMCID: PMC11219720 DOI: 10.1038/s41598-024-65847-y] [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: 03/15/2024] [Accepted: 06/25/2024] [Indexed: 07/04/2024] Open
Abstract
To treat hypovolemic shock, fluid infusion or blood transfusion is essential to address insufficient volume. Much controversy surrounds resuscitation in hypovolemic shock. We aimed to identify the ideal fluid combination for treating hypovolemic shock-induced swine model, analyzing bioelectrical impedance and hemodynamics. Fifteen female three-way crossbred pigs were divided into three different groups. The three resuscitation fluids were (1) balanced crystalloid, (2) balanced crystalloid + 5% dextrose water, and (3) balanced crystalloid + 20% albumin. The experiment was divided into three phases and conducted sequentially: (1) controlled hemorrhage (1 L bleeding, 60 min), (2) resuscitation phase 1 (1 L fluid infusion, 60 min), and (3) resuscitation phase 2 (1 L fluid infusion, 60 min). Bioelectrical impedance analysis was implemented with a segmental multifrequency bioelectrical impedance analyzer. A total of 61 impedance measurements were assessed for each pig at six different frequencies in five segments of the pig. Pulse rate (PR), mean arterial pressure (MAP), stroke volume (SV), and stroke volume variation (SVV) were measured using a minimally invasive hemodynamic monitoring device. The three-dimensional graph showed a curved pattern when infused with 1 L of balanced crystalloid + 1 L of 5% dextrose water and 1.6 L of balanced crystalloid + 400 ml of 20% albumin. The 1M impedance increased in all groups during the controlled hemorrhage, and continuously decreased from fluid infusion to the end of the experiment. Only balanced crystalloid + 20% albumin significantly restored MAP and SV to the same level as the start of the experiment after the end of fluid infusion. There were no significant differences in MAP and SV from the time of recovery to the initial value of 1M impedance to the end of fluid infusion in all groups. The change and the recovery of hemodynamic indices such as MAP and SV coincide with the change and the recovery of 1M impedance. Using balanced crystalloid mixed with 20% albumin in hypovolemic shock-induced swine model may be helpful in securing hemodynamic stability, compared with balanced crystalloid single administration.
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Affiliation(s)
- Hoonsung Park
- Division of Acute Care Surgery, Department of Surgery, Korea University Anam Hospital, Korea University Medical Center, Seoul, Republic of Korea
| | - Hanyoung Lee
- Division of Acute Care Surgery, Department of Surgery, Korea University Anam Hospital, Korea University Medical Center, Seoul, Republic of Korea
| | - Seungmin Baik
- Division of Critical Care Medicine, Department of Surgery, Ewha Womans University Mokdong Hospital, Ewha Womans University College of Medicine, Seoul, Republic of Korea
| | - Jae-Myeong Lee
- Division of Acute Care Surgery, Department of Surgery, Korea University Anam Hospital, Korea University Medical Center, Seoul, Republic of Korea.
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van den Brink DP, Kleinveld DJB, Bongers A, Vos J, Roelofs JJTH, Weber NC, van Buul JD, Juffermans NP. The effects of resuscitation with different plasma products on endothelial permeability and organ injury in a rat pneumosepsis model. Intensive Care Med Exp 2023; 11:62. [PMID: 37728777 PMCID: PMC10511387 DOI: 10.1186/s40635-023-00549-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Accepted: 09/11/2023] [Indexed: 09/21/2023] Open
Abstract
BACKGROUND Endothelial injury and permeability are a hallmark of sepsis. Initial resuscitation of septic patients with crystalloids is associated with aggravation of endothelial permeability, which may be related either to low protein content or to volume. We investigated whether initial resuscitation with different types of plasma or albumin decreases endothelial dysfunction and organ injury in a pneumosepsis rat model compared to the same volume of crystalloids. STUDY DESIGN AND METHODS Sprague-Dawley rats were intratracheally inoculated with Streptococcus pneumoniae. Twenty-four hours after inoculation, animals were randomized to 2 control groups and 5 intervention groups (n = 11 per group) to receive resuscitation with a fixed volume (8 mL/kg for 1 h) of either Ringer's Lactate, 5% human albumin, fresh frozen plasma derived from syngeneic donor rats (rFFP), human-derived plasma (hFFP) or human-derived solvent detergent plasma (SDP). Controls were non-resuscitated (n = 11) and healthy animals. Animals were sacrificed 5 h after start of resuscitation (T = 5). Pulmonary FITC-dextran leakage as a reflection of endothelial permeability was used as the primary outcome. RESULTS Inoculation with S. Pneumoniae resulted in sepsis, increased median lactate levels (1.6-2.8 mM, p < 0.01), pulmonary FITC-dextran leakage (52-134 µg mL-1, p < 0.05) and lung injury scores (0.7-6.9, p < 0.001) compared to healthy controls. Compared to animals receiving no resuscitation, animals resuscitated with rFFP had reduced pulmonary FITC leakage (134 vs 58 µg/mL, p = 0.011). However, there were no differences in any other markers of organ or endothelial injury. Resuscitation using different human plasma products or 5% albumin showed no differences in any outcome. CONCLUSIONS Resuscitation with plasma did not reduce endothelial and organ injury when compared to an equal resuscitation volume of crystalloids. Rat-derived FFP may decrease pulmonary leakage induced by shock.
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Affiliation(s)
- Daan P van den Brink
- Department of Intensive Care Medicine, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
- Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.
| | - Derek J B Kleinveld
- Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Department of Intensive Care Medicine, Erasmus MC, Erasmus University of Rotterdam, Rotterdam, The Netherlands
| | - Annabel Bongers
- Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Jaël Vos
- Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Joris J T H Roelofs
- Department of Pathology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Cardiovascular Sciences, Amsterdam UMC, Amsterdam, The Netherlands
| | - Nina C Weber
- Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Jaap D van Buul
- Molecular Cell Biology Lab at Department Molecular Hematology, Sanquin Research and Landsteiner Laboratory, Amsterdam, The Netherlands
- Leeuwenhoek Centre for Advanced Microscopy (LCAM), Section Molecular Cytology at Swammerdam Institute for Life Sciences (SILS) at University of Amsterdam, Amsterdam, The Netherlands
| | - Nicole P Juffermans
- Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Department of Intensive Care Medicine, OLVG Hospital, Amsterdam, The Netherlands
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Stored whole blood transfusion initiates serum amyloid A activation monitored by real-time dynamic imaging. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2023; 21:62-73. [PMID: 35302477 PMCID: PMC9918385 DOI: 10.2450/2022.0259-21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Accepted: 01/17/2022] [Indexed: 02/12/2023]
Abstract
BACKGROUND Transfusion of stored whole blood (SWB) to resuscitate severe traumatic haemorrhage patients in military operations and civilian emergency centres is being increasingly used in routine practice. It has been well established that transfusion of red blood cells (RBCs) after prolonged storage has harmful effects, mainly mediated by inflammation. Whether the side effects of inflammation are brought about by SWB transfusion remains unclear. MATERIALS AND METHODS A hepatocyte SAA (serum amyloid A) specific reporter mouse that facilitated non-invasive imaging of hepatocyte SAA expression was used to evaluate acute inflammation and acute-phase reaction after the transfusion of SWB or components separated from end-storage whole blood. The whole blood of C57BL/6 donor mouse was used to model an allogeneic transfusion to BALB/c recipient mouse. RESULTS End-storage whole blood (14 days of storage) transfusion induced the most significant SAA expression, while 10-day storage resulted in a much weaker signal compared to their fresh and 5-day storage counterparts. RBCs rather than white blood cells and plasma-containing platelets are thought to be responsible for the systemic inflammatory and SAA activation during end-storage whole blood transfusion. Circulatory and hepatic pro-inflammatory cytokines secreted by M1-polarised macrophage initiated the SAA expression in hepatocytes through nuclear transcription factor NF-κB. DISCUSSION Storage lesions will also occur during the storage of whole blood, which is related to the change in RBCs with prolonged storage. The side effect induced by systemic inflammation and acute-phase reaction should be considered before resuscitation with long-term storage whole blood transfusion.
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Neuenfeldt FS, Weigand MA, Fischer D. Coagulopathies in Intensive Care Medicine: Balancing Act between Thrombosis and Bleeding. J Clin Med 2021; 10:5369. [PMID: 34830667 PMCID: PMC8623639 DOI: 10.3390/jcm10225369] [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: 10/28/2021] [Revised: 11/10/2021] [Accepted: 11/16/2021] [Indexed: 11/23/2022] Open
Abstract
Patient Blood Management advocates an individualized treatment approach, tailored to each patient's needs, in order to reduce unnecessary exposure to allogeneic blood products. The optimization of hemostasis and minimization of blood loss is of high importance when it comes to critical care patients, as coagulopathies are a common phenomenon among them and may significantly impact morbidity and mortality. Treating coagulopathies is complex as thrombotic and hemorrhagic conditions may coexist and the medications at hand to modulate hemostasis can be powerful. The cornerstones of coagulation management are an appropriate patient evaluation, including the individual risk of bleeding weighed against the risk of thrombosis, a proper diagnostic work-up of the coagulopathy's etiology, treatment with targeted therapies, and transfusion of blood product components when clinically indicated in a goal-directed manner. In this article, we will outline various reasons for coagulopathy in critical care patients to highlight the aspects that need special consideration. The treatment options outlined in this article include anticoagulation, anticoagulant reversal, clotting factor concentrates, antifibrinolytic agents, desmopressin, fresh frozen plasma, and platelets. This article outlines concepts with the aim of the minimization of complications associated with coagulopathies in critically ill patients. Hereditary coagulopathies will be omitted in this review.
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Affiliation(s)
| | | | - Dania Fischer
- Department of Anaesthesiology, Heidelberg University Hospital, 69120 Heidelberg, Germany; (F.S.N.); (M.A.W.)
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Juffermans NP, Muller MM. Prophylactic plasma: Can we finally let go? Transfusion 2021; 61:1991-1992. [PMID: 34275151 DOI: 10.1111/trf.16546] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2021] [Accepted: 06/05/2021] [Indexed: 12/20/2022]
Affiliation(s)
- Nicole P Juffermans
- Department of Intensive Care, OLVG Hospital, Amsterdam, The Netherlands.,Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam UMC, Amsterdam, The Netherlands
| | - Marcella M Muller
- Department of Intensive Care Medicine, Amsterdam UMC, Amsterdam, The Netherlands
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