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Iyanna N, Donohue JK, Lorence JM, Guyette FX, Gimbel E, Brown JB, Daley BJ, Eastridge BJ, Miller RS, Nirula R, Harbrecht BG, Claridge JA, Phelan HA, Vercruysse GA, O'Keefe T, Joseph B, Shutter LA, Sperry JL. Early Glasgow Coma Scale Score and Prediction of Traumatic Brain Injury: A Secondary Analysis of Three Harmonized Prehospital Randomized Clinical Trials. PREHOSP EMERG CARE 2024:1-15. [PMID: 39042825 DOI: 10.1080/10903127.2024.2381048] [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: 04/30/2024] [Accepted: 07/03/2024] [Indexed: 07/25/2024]
Abstract
OBJECTIVES: The prehospital prediction of the radiographic diagnosis of traumatic brain injury (TBI) in hemorrhagic shock patients has the potential to promote early therapeutic interventions. However, the identification of TBI is often challenging and prehospital tools remain limited. While the Glasgow Coma Scale (GCS) score is frequently used to assess the extent of impaired consciousness after injury, the utility of the GCS scores in the early prehospital phase of care to predict TBI in patients with severe injury and concomitant shock is poorly understood.METHODS: We performed a post-hoc, secondary analysis utilizing data derived from three randomized prehospital clinical trials: the Prehospital Air Medical Plasma trial (PAMPER), the Study of Tranexamic Acid During Air Medical and Ground Prehospital Transport trial (STAAMP), and the Pragmatic Prehospital Type O Whole Blood Early Resuscitation (PPOWER) trial. Patients were dichotomized into two cohorts based on the presence of TBI and then further stratified into three groups based on prehospital GCS score: GCS 3, GCS 4-12, and GCS 13-15. The association between prehospital GCS score and clinical documentation of TBI was assessed.RESULTS: A total of 1,490 enrolled patients were included in this analysis. The percentage of patients with documented TBI in those with a GCS 3 was 59.5%, 42.4% in those with a GCS 4-12, and 11.8% in those with a GCS 13-15. The positive predictive value (PPV) of the prehospital GCS score for the diagnosis of TBI is low, with a GCS of 3 having only a 60% PPV. Hypotension and prehospital intubation are independent predictors of a low prehospital GCS. Decreasing prehospital GCS is strongly associated with higher incidence or mortality over time, irrespective of the diagnosis of TBI.CONCLUSIONS: The ability to accurately predict the presence of TBI in the prehospital phase of care is essential. The utility of the GCS scores in the early prehospital phase of care to predict TBI in patients with severe injury and concomitant shock is limited. The use of novel scoring systems and improved technology are needed to promote the accurate early diagnosis of TBI.
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Affiliation(s)
- Nidhi Iyanna
- Division of Trauma and General Surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, PA
| | - Jack K Donohue
- Division of Trauma and General Surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, PA
| | - John M Lorence
- Division of Trauma and General Surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, PA
| | - Francis X Guyette
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Elizabeth Gimbel
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Joshua B Brown
- Division of Trauma and General Surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, PA
| | - Brian J Daley
- Department of Surgery, University of Tennessee Health Science Center, Knoxville, TN
| | - Brian J Eastridge
- Department of Surgery, University of Texas Health San Antonio, San Antonio, TX
| | | | - Raminder Nirula
- Department of Surgery, University of Utah, Salt Lake City, UT
| | | | - Jefrey A Claridge
- Department of Surgery, Metro Health Medical Center, Case Western Reserve University, Cleveland, OH
| | - Herb A Phelan
- Department of Surgery, University of Texas Southwestern, Dallas, TX
| | | | | | - Bellal Joseph
- Department of Surgery, University of Arizona, Tucson, AZ
| | - Lori A Shutter
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Jason L Sperry
- Division of Trauma and General Surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, PA
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Kravitz MS, Kattouf N, Stewart IJ, Ginde AA, Schmidt EP, Shapiro NI. Plasma for prevention and treatment of glycocalyx degradation in trauma and sepsis. Crit Care 2024; 28:254. [PMID: 39033135 PMCID: PMC11265047 DOI: 10.1186/s13054-024-05026-7] [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: 03/03/2024] [Accepted: 07/06/2024] [Indexed: 07/23/2024] Open
Abstract
The endothelial glycocalyx, a gel-like layer that lines the luminal surface of blood vessels, is composed of proteoglycans, glycoproteins, and glycosaminoglycans. The endothelial glycocalyx plays an essential role in vascular homeostasis, and its degradation in trauma and sepsis can lead to microvascular dysfunction and organ injury. While there are no proven therapies for preventing or treating endothelial glycocalyx degradation, some initial literature suggests that plasma may have a therapeutic role in trauma and sepsis patients. Overall, the literature suggesting the use of plasma as a therapy for endothelial glycocalyx degradation is non-clinical basic science or exploratory. Plasma is an established therapy in the resuscitation of patients with hemorrhage for restoration of coagulation factors. However, plasma also contains other bioactive components, including sphingosine-1 phosphate, antithrombin, and adiponectin, which may protect and restore the endothelial glycocalyx, thereby helping to maintain or restore vascular homeostasis. This narrative review begins by describing the endothelial glycocalyx in health and disease: we discuss the overlapping disease mechanisms in trauma and sepsis that lead to its damage and introduce plasma transfusion as a potential therapy for prevention and treatment of endothelial glycocalyx degradation. Second, we review the literature on plasma as an exploratory therapy for endothelial glycocalyx degradation in trauma and sepsis. Third, we discuss the safety of plasma transfusion by reviewing the adverse events associated with plasma and other blood product transfusions, and we examine modern transfusion precautions that have enhanced the safety of plasma transfusion. We conclude that the literature proposes that plasma may have the potential to prevent and treat endothelial glycocalyx degradation in trauma and sepsis, indicating the need for further research.
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Affiliation(s)
- M S Kravitz
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA.
| | - N Kattouf
- Department of Emergency Medicine, Mount Sinai School of Medicine, New York, NY, USA
| | - I J Stewart
- Department of Medicine, Uniformed Services University, Bethesda, MD, USA
| | - A A Ginde
- Department of Emergency Medicine, University of Colorado School of Medicines, Aurora, CO, USA
| | - E P Schmidt
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - N I Shapiro
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
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Cannon JW, Gruen DS, Zamora R, Brostoff N, Hurst K, Harn JH, El-Dehaibi F, Geng Z, Namas R, Sperry JL, Holcomb JB, Cotton BA, Nam JJ, Underwood S, Schreiber MA, Chung KK, Batchinsky AI, Cancio LC, Benjamin AJ, Fox EE, Chang SC, Cap AP, Vodovotz Y. Digital twin mathematical models suggest individualized hemorrhagic shock resuscitation strategies. COMMUNICATIONS MEDICINE 2024; 4:113. [PMID: 38867000 PMCID: PMC11169363 DOI: 10.1038/s43856-024-00535-6] [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: 06/02/2023] [Accepted: 05/29/2024] [Indexed: 06/14/2024] Open
Abstract
BACKGROUND Optimizing resuscitation to reduce inflammation and organ dysfunction following human trauma-associated hemorrhagic shock is a major clinical hurdle. This is limited by the short duration of pre-clinical studies and the sparsity of early data in the clinical setting. METHODS We sought to bridge this gap by linking preclinical data in a porcine model with clinical data from patients from the Prospective, Observational, Multicenter, Major Trauma Transfusion (PROMMTT) study via a three-compartment ordinary differential equation model of inflammation and coagulation. RESULTS The mathematical model accurately predicts physiologic, inflammatory, and laboratory measures in both the porcine model and patients, as well as the outcome and time of death in the PROMMTT cohort. Model simulation suggests that resuscitation with plasma and red blood cells outperformed resuscitation with crystalloid or plasma alone, and that earlier plasma resuscitation reduced injury severity and increased survival time. CONCLUSIONS This workflow may serve as a translational bridge from pre-clinical to clinical studies in trauma-associated hemorrhagic shock and other complex disease settings.
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Affiliation(s)
- Jeremy W Cannon
- Division of Traumatology, Surgical Critical Care & Emergency Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, 19104, USA.
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD, 20814, USA.
| | - Danielle S Gruen
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, 15213, USA
- Pittsburgh Trauma Research Center, Pittsburgh, PA, 15213, USA
| | - Ruben Zamora
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, 15213, USA
- Pittsburgh Trauma Research Center, Pittsburgh, PA, 15213, USA
- Center for Inflammation and Regeneration Modeling, McGowan Institute for Regenerative Medicine, Pittsburgh, PA, 15219, USA
| | - Noah Brostoff
- Immunetrics, now wholly owned by Simulations Plus, Pittsburgh, PA, 15219, USA
| | - Kelly Hurst
- Immunetrics, now wholly owned by Simulations Plus, Pittsburgh, PA, 15219, USA
| | - John H Harn
- Immunetrics, now wholly owned by Simulations Plus, Pittsburgh, PA, 15219, USA
| | - Fayten El-Dehaibi
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, 15213, USA
| | - Zhi Geng
- Division of Traumatology, Surgical Critical Care & Emergency Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Rami Namas
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, 15213, USA
- Pittsburgh Trauma Research Center, Pittsburgh, PA, 15213, USA
| | - Jason L Sperry
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, 15213, USA
- Pittsburgh Trauma Research Center, Pittsburgh, PA, 15213, USA
| | - John B Holcomb
- Department of Surgery, University of Alabama, Birmingham, AL, 35233, USA
| | - Bryan A Cotton
- Division of Acute Care Surgery, University of Texas Health Science Center at Houston, Houston, TX, 77030, USA
| | - Jason J Nam
- Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, 20814, USA
| | - Samantha Underwood
- Division of Trauma, Critical Care and Acute Care Surgery, Oregon Health & Science University, Portland, OR, 97239, USA
| | - Martin A Schreiber
- Division of Trauma, Critical Care and Acute Care Surgery, Oregon Health & Science University, Portland, OR, 97239, USA
| | | | - Andriy I Batchinsky
- Autonomous Reanimation and Evacuation (AREVA) Research and Innovation Center, San Antonio, TX, 78235, USA
| | - Leopoldo C Cancio
- US Army Institute of Surgical Research, Fort Sam Houston, TX, 78234, USA
| | - Andrew J Benjamin
- Trauma and Acute Care Surgery, Department of Surgery, The University of Chicago, Chicago, IL, 60637, USA
| | - Erin E Fox
- Division of Acute Care Surgery, University of Texas Health Science Center at Houston, Houston, TX, 77030, USA
| | - Steven C Chang
- Immunetrics, now wholly owned by Simulations Plus, Pittsburgh, PA, 15219, USA
| | - Andrew P Cap
- Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, 20814, USA
| | - Yoram Vodovotz
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, 15213, USA
- Pittsburgh Trauma Research Center, Pittsburgh, PA, 15213, USA
- Center for Inflammation and Regeneration Modeling, McGowan Institute for Regenerative Medicine, Pittsburgh, PA, 15219, USA
- Center for Systems Immunology, University of Pittsburgh, Pittsburgh, PA, 15213, USA
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Maier CL, Brohi K, Curry N, Juffermans NP, Mora Miquel L, Neal MD, Shaz BH, Vlaar APJ, Helms J. Contemporary management of major haemorrhage in critical care. Intensive Care Med 2024; 50:319-331. [PMID: 38189930 DOI: 10.1007/s00134-023-07303-5] [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: 09/08/2023] [Accepted: 12/05/2023] [Indexed: 01/09/2024]
Abstract
Haemorrhagic shock is frequent in critical care settings and responsible for a high mortality rate due to multiple organ dysfunction and coagulopathy. The management of critically ill patients with bleeding and shock is complex, and treatment of these patients must be rapid and definitive. The administration of large volumes of blood components leads to major physiological alterations which must be mitigated during and after bleeding. Early recognition of bleeding and coagulopathy, understanding the underlying pathophysiology related to specific disease states, and the development of individualised management protocols are important for optimal outcomes. This review describes the contemporary understanding of the pathophysiology of various types of coagulopathic bleeding; the diagnosis and management of critically ill bleeding patients, including major haemorrhage protocols and post-transfusion management; and finally highlights recent areas of opportunity to better understand optimal management strategies for managing bleeding in the intensive care unit (ICU).
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Affiliation(s)
- Cheryl L Maier
- Department of Pathology and Laboratory Medicine, Center for Transfusion and Cellular Therapies, Emory University School of Medicine, Atlanta, GA, USA
| | - Karim Brohi
- Centre for Trauma Sciences, Queen Mary University of London, London, UK
| | - Nicola Curry
- Oxford Haemophilia and Thrombosis Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- Nuffield Department of Clinical and Laboratory Sciences, Radcliffe Department of Medicine, Oxford University, Oxford, UK
| | - Nicole P Juffermans
- Department of Intensive Care and Laboratory of Translational Intensive Care, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Lidia Mora Miquel
- Department of Anaesthesiology, Intensive Care and Pain Clinic, Vall d'Hebron Trauma, Rehabilitation and Burns Hospital, Autonomous University of Barcelona, Passeig de La Vall d'Hebron 119-129, 08035, Barcelona, Spain
| | - Matthew D Neal
- Trauma and Transfusion Medicine Research Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Beth H Shaz
- Department of Pathology, Duke University School of Medicine, Durham, NC, USA
| | | | - Julie Helms
- Service de Médecine Intensive-Réanimation, Department of Intensive Care, Nouvel Hôpital Civil, Université de Strasbourg (UNISTRA), 1, Place de L'Hôpital, 67091, Strasbourg Cedex, France.
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5
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Donohue JK, Gruen DS, Iyanna N, Lorence JM, Brown JB, Guyette FX, Daley BJ, Eastridge BJ, Miller RS, Nirula R, Harbrecht BG, Claridge JA, Phelan HA, Vercruysse GA, O'Keeffe T, Joseph B, Neal MD, Billiar TR, Sperry JL. Mechanism matters: mortality and endothelial cell damage marker differences between blunt and penetrating traumatic injuries across three prehospital clinical trials. Sci Rep 2024; 14:2747. [PMID: 38302619 PMCID: PMC10834504 DOI: 10.1038/s41598-024-53398-1] [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: 10/05/2023] [Accepted: 01/31/2024] [Indexed: 02/03/2024] Open
Abstract
Injury mechanism is an important consideration when conducting clinical trials in trauma. Mechanisms of injury may be associated with differences in mortality risk and immune response to injury, impacting the potential success of the trial. We sought to characterize clinical and endothelial cell damage marker differences across blunt and penetrating injured patients enrolled in three large, prehospital randomized trials which focused on hemorrhagic shock. In this secondary analysis, patients with systolic blood pressure < 70 or systolic blood pressure < 90 and heart rate > 108 were included. In addition, patients with both blunt and penetrating injuries were excluded. The primary outcome was 30-day mortality. Mortality was characterized using Kaplan-Meier and Cox proportional-hazards models. Generalized linear models were used to compare biomarkers. Chi squared tests and Wilcoxon rank-sum were used to compare secondary outcomes. We characterized data of 696 enrolled patients that met all secondary analysis inclusion criteria. Blunt injured patients had significantly greater 24-h (18.6% vs. 10.7%, log rank p = 0.048) and 30-day mortality rates (29.7% vs. 14.0%, log rank p = 0.001) relative to penetrating injured patients with a different time course. After adjusting for confounders, blunt mechanism of injury was independently predictive of mortality at 30-days (HR 1.84, 95% CI 1.06-3.20, p = 0.029), but not 24-h (HR 1.65, 95% CI 0.86-3.18, p = 0.133). Elevated admission levels of endothelial cell damage markers, VEGF, syndecan-1, TM, S100A10, suPAR and HcDNA were associated with blunt mechanism of injury. Although there was no difference in multiple organ failure (MOF) rates across injury mechanism (48.4% vs. 42.98%, p = 0.275), blunt injured patients had higher Denver MOF score (p < 0.01). The significant increase in 30-day mortality and endothelial cell damage markers in blunt injury relative to penetrating injured patients highlights the importance of considering mechanism of injury within the inclusion and exclusion criteria of future clinical trials.
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Affiliation(s)
- Jack K Donohue
- Division of Trauma and General Surgery, Department of Surgery, University of Pittsburgh Medical Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Danielle S Gruen
- Division of Trauma and General Surgery, Department of Surgery, University of Pittsburgh Medical Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Nidhi Iyanna
- Division of Trauma and General Surgery, Department of Surgery, University of Pittsburgh Medical Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - John M Lorence
- Division of Trauma and General Surgery, Department of Surgery, University of Pittsburgh Medical Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Joshua B Brown
- Division of Trauma and General Surgery, Department of Surgery, University of Pittsburgh Medical Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Francis X Guyette
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Brian J Daley
- Department of Surgery, University of Tennessee Health Science Center, Knoxville, TN, USA
| | - Brian J Eastridge
- Department of Surgery, University of Texas Health San Antonio, San Antonio, TX, USA
| | | | - Raminder Nirula
- Department of Surgery, University of Utah, Salt Lake City, UT, USA
| | - Brian G Harbrecht
- Department of Surgery, University of Louisville, Louisville, KY, USA
| | - Jeffrey A Claridge
- Department of Surgery, Metro Health Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | - Herb A Phelan
- Department of Surgery, University of Texas Southwestern, Dallas, TX, USA
| | | | | | - Bellal Joseph
- Department of Surgery, University of Arizona, Tucson, AZ, USA
| | - Matthew D Neal
- Division of Trauma and General Surgery, Department of Surgery, University of Pittsburgh Medical Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Timothy R Billiar
- Division of Trauma and General Surgery, Department of Surgery, University of Pittsburgh Medical Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jason L Sperry
- Division of Trauma and General Surgery, Department of Surgery, University of Pittsburgh Medical Center, University of Pittsburgh, Pittsburgh, PA, USA.
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6
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Anand T, Crawford AE, Sjoquist M, Hashmi ZG, Richter RP, Joseph B, Richter JR. Decreased Glycocalyx Shedding on Presentation in Hemorrhaging Geriatric Trauma Patients. J Surg Res 2024; 293:709-716. [PMID: 37844411 PMCID: PMC11075129 DOI: 10.1016/j.jss.2023.09.047] [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: 03/02/2023] [Revised: 08/21/2023] [Accepted: 09/04/2023] [Indexed: 10/18/2023]
Abstract
INTRODUCTION Plasma levels of syndecan-1 (Sdc-1), a biomarker of endothelial glycocalyx (EG) damage, correlate with worse outcomes in trauma patients. However, EG injury is not well characterized in injured older adults (OA). The aims of this study were to characterize Sdc-1 shedding in OA trauma patients relative to younger adults (YA) and determine associations with putative regulators of EG sheddases. METHODS We performed a secondary analysis of data from the Pragmatic, Randomized Optimal Platelet, and Plasma Ratios (PROPPR) trial, stratifying bluntly injured subjects into OA and YA groups based on upper age quartile (57 y). Plasma Sdc-1 levels were compared in OA and YA at hospital arrival through postinjury day 3, and the independent association between age and Sdc-1 level at arrival was determined after adjusting for differences in gender, shock index (SI), and pre-existing comorbidities. In a follow-up analysis, case-control matching was used to create populations of OA and YA with equivalent SI and injury severity score. Levels of Sdc-1 were compared between these matched groups, and the relationships with candidate regulators of EG shedding were assessed. RESULTS Of 680 subjects in the Pragmatic, Randomized Optimal Platelet, and Plasma Ratios trial, 350 (51%) had blunt injuries, and 92 (26.3%) of these were OA. Plasma Sdc-1 levels at arrival, 2 h, and 6 h were significantly lower in OA compared to YA (all P < 0.05). After adjusting for sex, pre-existing morbidities and SI, age was associated with decreased Sdc-1 levels at arrival. In the matched analyses, Sdc-1, high-mobility group box 1 and tissue inhibitor of metalloproteinase-2 levels were lower in OA compared to YA. Both high-mobility group box-1 and tissue inhibitor of metalloproteinase-2 significantly correlated with arrival Sdc-1 and were inversely associated with age. CONCLUSIONS This study indicates that increased age is independently associated with decreased Sdc-1 levels among patients with blunt injuries. Suppressed plasma levels of sheddases in relation to diminished Sdc-1 shedding suggest that mechanisms regulating EG cleavage may be impaired in injured older adults. These findings provide novel insight into the age-dependent impact of injury on the vascular endothelium, which could have important implications for the clinical management of older adults following trauma.
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Affiliation(s)
- Tanya Anand
- Division of Trauma, Critical Care, Burn & Emergency Surgery, Department of Surgery, University of Arizona, Tucson, Arizona. https://twitter.com/tanyaanand8
| | - Anna E Crawford
- University of Alabama at Birmingham Heersink College of Medicine, Birmingham, Alabama
| | | | - Zain G Hashmi
- Division of Trauma & Acute Care Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama; Center for Injury Science, University of Alabama at Birmingham, Birmingham, Alabama
| | - Robert P Richter
- Center for Injury Science, University of Alabama at Birmingham, Birmingham, Alabama; Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama
| | - Bellal Joseph
- Division of Trauma, Critical Care, Burn & Emergency Surgery, Department of Surgery, University of Arizona, Tucson, Arizona
| | - Jillian R Richter
- Division of Trauma & Acute Care Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama; Center for Injury Science, University of Alabama at Birmingham, Birmingham, Alabama.
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7
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Iba T, Helms J, Neal MD, Levy JH. Mechanisms and management of the coagulopathy of trauma and sepsis: trauma-induced coagulopathy, sepsis-induced coagulopathy, and disseminated intravascular coagulation. J Thromb Haemost 2023; 21:3360-3370. [PMID: 37722532 PMCID: PMC10873124 DOI: 10.1016/j.jtha.2023.05.028] [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: 01/18/2023] [Revised: 04/18/2023] [Accepted: 05/12/2023] [Indexed: 09/20/2023]
Abstract
Disseminated intravascular coagulation can occur due to different causes but commonly following sepsis. Trauma-induced coagulopathy (TIC) occurs on hospital arrival in approximately 25% of seriously injured patients who initially presents with impaired hemostasis and a bleeding phenotype that can later progress to a prothrombotic phase. Following traumatic injury, ineffective hemostasis is driven by massive blood loss, tissue damage, and hyperfibrinolysis. This initial impaired hemostasis continues until surgical or other management strategies not only to stop the causes of hemorrhage but also progresses to a prothrombotic and hypofibrinolytic state, also termed fibrinolytic shutdown. Prothrombotic progression is also promoted by inflammatory mediator release, endothelial injury, and platelet dysregulation, which is commonly seen in sepsis with increased mortality. Unlike TIC, the early phase of sepsis is frequently complicated by multiorgan dysfunction described as sepsis-induced coagulopathy (SIC) that lacks a hemorrhagic phase. The phenotypes of SIC and TIC are different, especially in their initial presentations; however, patients who survive TIC may also develop subsequent infections and potentially sepsis and SIC. Although the pathophysiology of SIC and TIC are different, endothelial injury, dysregulated fibrinolysis, and coagulation abnormalities are common. Management includes treatment of the underlying cause, tissue injury vs infection is critical, and supportive therapies, such as hemostatic resuscitation and circulatory support are essential, and adjunct therapies are recommended in guidelines. Based on clinical studies and certain guidelines, additional therapies include tranexamic acid in the limited timing of initial traumatic injury and anticoagulants, such as antithrombin and recombinant thrombomodulin in disseminated intravascular coagulation.
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Affiliation(s)
- Toshiaki Iba
- Department of Emergency and Disaster Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan.
| | - Julie Helms
- Strasbourg University (UNISTRA); Strasbourg University Hospital, Medical Intensive Care Unit - NHC; INSERM (French National Institute of Health and Medical Research), Strasbourg, France
| | - Matthew D Neal
- Trauma and Transfusion Medicine Research Center, Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Jerrold H Levy
- Department of Anesthesiology, Critical Care, and Surgery, Duke University School of Medicine, Durham, North Carolina, USA. https://twitter.com/JerroldLevy
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8
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Obonyo NG, Sela DP, Raman S, Rachakonda R, Schneider B, Hoe LES, Fanning JP, Bassi GL, Maitland K, Suen JY, Fraser JF. Resuscitation-associated endotheliopathy (RAsE): a conceptual framework based on a systematic review and meta-analysis. Syst Rev 2023; 12:221. [PMID: 37990333 PMCID: PMC10664580 DOI: 10.1186/s13643-023-02385-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 11/06/2023] [Indexed: 11/23/2023] Open
Abstract
INTRODUCTION Shock-induced endotheliopathy (SHINE), defined as a profound sympathoadrenal hyperactivation in shock states leading to endothelial activation, glycocalyx damage, and eventual compromise of end-organ perfusion, was first described in 2017. The aggressive resuscitation therapies utilised in treating shock states could potentially lead to further worsening endothelial activation and end-organ dysfunction. OBJECTIVE This study aimed to systematically review the literature on resuscitation-associated and resuscitation-induced endotheliopathy. METHODS A predetermined structured search of literature published over an 11-year and 6-month period (1 January 2011 to 31 July 2023) was performed in two indexed databases (PubMed/MEDLINE and Embase) per PRISMA guidelines. Inclusion was restricted to original studies published in English (or with English translation) reporting on endothelial dysfunction in critically ill human subjects undergoing resuscitation interventions. Reviews or studies conducted in animals were excluded. Qualitative synthesis of studies meeting the inclusion criteria was performed. Studies reporting comparable biomarkers of endothelial dysfunction post-resuscitation were included in the quantitative meta-analysis. RESULTS Thirty-two studies met the inclusion criteria and were included in the final qualitative synthesis. Most of these studies (47%) reported on a combination of mediators released from endothelial cells and biomarkers of glycocalyx breakdown, while only 22% reported on microvascular flow changes. Only ten individual studies were included in the quantitative meta-analysis based on the comparability of the parameters assessed. Eight studies measured syndecan-1, with a heterogeneity index, I2 = 75.85% (pooled effect size, mean = 0.27; 95% CI - 0.07 to 0.60; p = 0.12). Thrombomodulin was measured in four comparable studies (I2 = 78.93%; mean = 0.41; 95% CI - 0.10 to 0.92; p = 0.12). Three studies measured E-selectin (I2 = 50.29%; mean = - 0.15; 95% CI - 0.64 to 0.33; p = 0.53), and only two were comparable for the microvascular flow index, MFI (I2 = 0%; mean = - 0.80; 95% CI - 1.35 to - 0.26; p < 0.01). CONCLUSION Resuscitation-associated endotheliopathy (RAsE) refers to worsening endothelial dysfunction resulting from acute resuscitative therapies administered in shock states. In the included studies, syndecan-1 had the highest frequency of assessment in the post-resuscitation period, and changes in concentrations showed a statistically significant effect of the resuscitation. There are inadequate data available in this area, and further research and standardisation of the ideal assessment and panel of biomarkers are urgently needed.
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Affiliation(s)
- Nchafatso G Obonyo
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, Australia.
- Faculty of Medicine, The University of Queensland, Brisbane, Australia.
- Initiative to Develop African Research Leaders (IDeAL), Kilifi, Kenya.
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya.
- Wellcome Trust Centre for Global Health Research, Imperial College London, London, UK.
- Institute of Molecular Bioscience, The University of Queensland, Brisbane, Australia.
| | - Declan P Sela
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, Australia
- Faculty of Medicine, The University of Queensland, Brisbane, Australia
- Institute of Molecular Bioscience, The University of Queensland, Brisbane, Australia
| | - Sainath Raman
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, Australia
- Faculty of Medicine, The University of Queensland, Brisbane, Australia
- Child Health Research Centre, The University of Queensland, Brisbane, QLD, Australia
- Paediatric Intensive Care Unit, Queensland Children's Hospital, South Brisbane, QLD, Australia
| | - Reema Rachakonda
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, Australia
- Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | - Bailey Schneider
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, Australia
- Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | - Louise E See Hoe
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, Australia
- Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | - Jonathon P Fanning
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, Australia
- Faculty of Medicine, The University of Queensland, Brisbane, Australia
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins School of Medicine, Baltimore, MD, USA
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
- Intensive Care Unit, St. Andrews War Memorial Hospital, Brisbane, QLD, Australia
| | - Gianluigi Li Bassi
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, Australia
- Faculty of Medicine, The University of Queensland, Brisbane, Australia
- Institute of Molecular Bioscience, The University of Queensland, Brisbane, Australia
- Intensive Care Unit, St. Andrews War Memorial Hospital, Brisbane, QLD, Australia
| | - Kathryn Maitland
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
- Imperial College London, London, UK
| | - Jacky Y Suen
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, Australia
- Faculty of Medicine, The University of Queensland, Brisbane, Australia
- Institute of Molecular Bioscience, The University of Queensland, Brisbane, Australia
| | - John F Fraser
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, Australia
- Faculty of Medicine, The University of Queensland, Brisbane, Australia
- Institute of Molecular Bioscience, The University of Queensland, Brisbane, Australia
- Intensive Care Unit, St. Andrews War Memorial Hospital, Brisbane, QLD, Australia
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9
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Gruen DS, Brown JB, Guyette FX, Johansson PI, Stensballe J, Li SR, Leeper CM, Eastridge BJ, Nirula R, Vercruysse GA, O’Keeffe T, Joseph B, Neal MD, Sperry JL. Prehospital tranexamic acid is associated with a dose-dependent decrease in syndecan-1 after trauma: A secondary analysis of a prospective randomized trial. J Trauma Acute Care Surg 2023; 95:642-648. [PMID: 37125811 PMCID: PMC10615664 DOI: 10.1097/ta.0000000000003955] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 02/25/2023] [Accepted: 03/02/2023] [Indexed: 05/02/2023]
Abstract
BACKGROUND In the Study of Tranexamic Acid During Air and Ground Prehospital Transport (STAAMP) Trial, prehospital tranexamic acid (TXA) was associated with lower mortality in specific patient subgroups. The underlying mechanisms responsible for a TXA benefit remain incompletely characterized. We hypothesized that TXA may mitigate endothelial injury and sought to assess whether TXA was associated with decreased endothelial or tissue damage markers among all patients enrolled in the STAAMP Trial. METHODS We collected blood samples from STAAMP Trial patients and measured markers of endothelial function and tissue damage including syndecan-1, soluble thrombomodulin (sTM), and platelet endothelial cell adhesion molecule-1 at hospital admission (0 hours) and 12 hours, 24 hours, and 72 hours after admission. We compared these marker values for patients in each treatment group during the first 72 hours, and modeled the relationship between TXA and marker concentration using regression analysis to control for potential confounding factors. RESULTS We analyzed samples from 766 patients: 383 placebo, 130 abbreviated dosing, 119 standard dosing, and 130 repeat dosing. Lower levels of syndecan-1, TM, and platelet endothelial cell adhesion molecule measured within the first 72 hours of hospital admission were associated with survival at 30 days ( p < 0.001). At hospital admission, syndecan-1 was lower in the TXA group (28.30 [20.05, 42.75] vs. 33.50 [23.00, 54.00] p = 0.001) even after controlling for patient, injury, and prehospital factors ( p = 0.001). For every 1 g increase in TXA administered over the first 8 hours of prehospital transport and hospital admission, there was a 4-ng/mL decrease in syndecan-1 at 12 hours controlling for patient, injury, and treatment factors ( p = 0.03). CONCLUSION Prehospital TXA was associated with decreased syndecan-1 at hospital admission. Syndecan-1 measured 12 hours after admission was inversely related to the dose of TXA received. Early prehospital and in-hospital TXA may decrease endothelial glycocalyx damage or upregulate vascular repair mechanisms in a dose-dependent fashion. LEVEL OF EVIDENCE Therapeutic/Care Management; Level III.
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10
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Maegele M, Lier H, Hossfeld B. Pre-Hospital Blood Products for the Care of Bleeding Trauma Patients. DEUTSCHES ARZTEBLATT INTERNATIONAL 2023; 120:670-676. [PMID: 37551452 PMCID: PMC10644958 DOI: 10.3238/arztebl.m2023.0176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 07/13/2023] [Accepted: 07/13/2023] [Indexed: 08/09/2023]
Abstract
BACKGROUND Controversy surrounds the administration of blood products to severely traumatized patients before they arrive in the hospital in order to compensate for early blood loss and/or to correct coagulation disturbances that arise shortly after the traumatic event. A number of terrestrial and air rescue services have begun to provide this kind of treatment. METHODS This review is based on articles using the PICO framework, published from January 2001 to January 2021, that were retrieved by a selective search, with structured searching strategies and searching bundles in Medline (OVIDSP), the Cochrane Central Register of Controlled Trials (CENTRAL), and Epistemonikos. A demand analysis was carried out on the basis of data from the trauma registry of the German Society of Trauma Surgery (TR-DGU) and practical experience from program development and implementation was provided by the Bundeswehr Hospital Ulm. RESULTS The currently available evidence on the pre-hospital administration of blood products in the early treatment of severely injured patients is based largely on retrospective, single-center case series. Two randomized controlled trials (RCTs) concerning the early use of fresh frozen plasma concentrates have yielded partly conflicting results. Three further RCTs on the use of lyophilized plasma (lyplas), lyplas plus erythrocyte concentrate, or whole blood likewise revealed non-uniform effects on short-term and intermediate-term mortality. Our demand analysis based on data from the TR-DGU showed that 300 to 1800 patients per year in Germany could benefit from the pre-hospital administration of blood products. This might be indicated in patients who have systolic hypotension (<100 mmHg) in combination with a suspected or confirmed hemorrhage, as well as pathological shock parameters in the point-of-care diagnostic testing performed on the scene (serum base excess ≤ -2.5 mmol/L and/or serum lactate concentration >4 mmol/L). CONCLUSION The studies that have been published to date yield no clear evidence either for or against the early pre-hospital administration of blood products. Any treatment of this kind should be accompanied by scientific evaluation.
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Affiliation(s)
- Marc Maegele
- *Joint first authors
- Department of Trauma and Orthopaedic Surgery, Cologne-Merheim Medical Centre (CMMC), University of Witten/Herdecke, Cologne
- Institute for Research in Operative Medicine (IFOM), University of Witten/Herdecke, Campus Cologne-Merheim, Cologne
| | - Heiko Lier
- *Joint first authors
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Cologne, Cologne
| | - Björn Hossfeld
- Department of Anaesthesiology and Intensive Care Medicine, Armed Forces Hospital Ulm, Ulm
- Rescue transport helicopter (RTH) „Christoph 22“ Ulm, ADAC-Air Rescue, Ulm
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11
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Cohen MJ, Erickson CB, Lacroix IS, Debot M, Dzieciatkowska M, Schaid TR, Hallas MW, Thielen ON, Cralley AL, Banerjee A, Moore EE, Silliman CC, D'Alessandro A, Hansen KC. Trans-Omics analysis of post injury thrombo-inflammation identifies endotypes and trajectories in trauma patients. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2023:2023.08.16.553446. [PMID: 37645811 PMCID: PMC10462097 DOI: 10.1101/2023.08.16.553446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/31/2023]
Abstract
Understanding and managing the complexity of trauma-induced thrombo-inflammation necessitates an innovative, data-driven approach. This study leveraged a trans-omics analysis of longitudinal samples from trauma patients to illuminate molecular endotypes and trajectories that underpin patient outcomes, transcending traditional demographic and physiological characterizations. We hypothesize that trans-omics profiling reveals underlying clinical differences in severely injured patients that may present with similar clinical characteristics but ultimately have very different responses to treatment and clinical outcomes. Here we used proteomics and metabolomics to profile 759 of longitudinal plasma samples from 118 patients at 11 time points and 97 control subjects. Results were used to define distinct patient states through data reduction techniques. The patient groups were stratified based on their shock severity and injury severity score, revealing a spectrum of responses to trauma and treatment that are fundamentally tied to their unique underlying biology. Ensemble models were then employed, demonstrating the predictive power of these molecular signatures with area under the receiver operating curves of 80 to 94% for key outcomes such as INR, ICU-free days, ventilator-free days, acute lung injury, massive transfusion, and death. The molecularly defined endotypes and trajectories provide an unprecedented lens to understand and potentially guide trauma patient management, opening a path towards precision medicine. This strategy presents a transformative framework that aligns with our understanding that trauma patients, despite similar clinical presentations, might harbor vastly different biological responses and outcomes.
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12
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Anand T, Reyes AA, Sjoquist MC, Magnotti L, Joseph B. Resuscitating the Endothelial Glycocalyx in Trauma and Hemorrhagic Shock. ANNALS OF SURGERY OPEN 2023; 4:e298. [PMID: 37746602 PMCID: PMC10513357 DOI: 10.1097/as9.0000000000000298] [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: 11/23/2022] [Accepted: 05/20/2023] [Indexed: 09/26/2023] Open
Abstract
The endothelium is lined by a protective mesh of proteins and carbohydrates called the endothelial glycocalyx (EG). This layer creates a negatively charged gel-like barrier between the vascular environment and the surface of the endothelial cell. When intact the EG serves multiple functions, including mechanotransduction, cell signaling, regulation of permeability and fluid exchange across the microvasculature, and management of cell-cell interactions. In trauma and/or hemorrhagic shock, the glycocalyx is broken down, resulting in the shedding of its individual components. The shedding of the EG is associated with increased systemic inflammation, microvascular permeability, and flow-induced vasodilation, leading to further physiologic derangements. Animal and human studies have shown that the greater the severity of the injury, the greater the degree of shedding, which is associated with poor patient outcomes. Additional studies have shown that prioritizing certain resuscitation fluids, such as plasma, cryoprecipitate, and whole blood over crystalloid shows improved outcomes in hemorrhaging patients, potentially through a decrease in EG shedding impacting downstream signaling. The purpose of the following paragraphs is to briefly describe the EG, review the impact of EG shedding and hemorrhagic shock, and begin entertaining the notion of directed resuscitation. Directed resuscitation emphasizes transitioning from macroscopic 1:1 resuscitation to efforts that focus on minimizing EG shedding and maximizing its reconstitution.
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Affiliation(s)
- Tanya Anand
- From the Department of Surgery, Division of Trauma, Critical Care, Burns, and Emergency Surgery, The University of Arizona, Tucson, AZ
| | | | - Michael C. Sjoquist
- Department of Surgery, University of Arizona College of Medicine, Tucson, AZ
| | - Louis Magnotti
- From the Department of Surgery, Division of Trauma, Critical Care, Burns, and Emergency Surgery, The University of Arizona, Tucson, AZ
| | - Bellal Joseph
- From the Department of Surgery, Division of Trauma, Critical Care, Burns, and Emergency Surgery, The University of Arizona, Tucson, AZ
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13
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Sperry JL, Cotton BA, Luther JF, Cannon JW, Schreiber MA, Moore EE, Namias N, Minei JP, Wisniewski SR, Guyette FX. Whole Blood Resuscitation and Association with Survival in Injured Patients with an Elevated Probability of Mortality. J Am Coll Surg 2023; 237:206-219. [PMID: 37039365 PMCID: PMC10344433 DOI: 10.1097/xcs.0000000000000708] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 03/13/2023] [Accepted: 03/13/2023] [Indexed: 04/12/2023]
Abstract
BACKGROUND Low-titer group O whole blood (LTOWB) resuscitation is becoming common in both military and civilian settings and may represent the ideal resuscitation intervention. We sought to characterize the safety and efficacy of LTOWB resuscitation relative to blood component resuscitation. STUDY DESIGN A prospective, multicenter, observational cohort study was performed using 7 trauma centers. Injured patients at risk of massive transfusion who required both blood transfusion and hemorrhage control procedures were enrolled. The primary outcome was 4-hour mortality. Secondary outcomes included 24-hour and 28-day mortality, achievement of hemostasis, death from exsanguination, and the incidence of unexpected survivors. RESULTS A total of 1,051 patients in hemorrhagic shock met all enrollment criteria. The cohort was severely injured with >70% of patients requiring massive transfusion. After propensity adjustment, no significant 4-hour mortality difference across LTOWB and component patients was found (relative risk [RR] 0.90, 95% CI 0.59 to 1.39, p = 0.64). Similarly, no adjusted mortality differences were demonstrated at 24 hours or 28 days for the enrolled cohort. When patients with an elevated prehospital probability of mortality were analyzed, LTOWB resuscitation was independently associated with a 48% lower risk of 4-hour mortality (relative risk [RR] 0.52, 95% CI 0.32 to 0.87, p = 0.01) and a 30% lower risk of 28-day mortality (RR 0.70, 95% CI 0.51 to 0.96, p = 0.03). CONCLUSIONS Early LTOWB resuscitation is safe but not independently associated with survival for the overall enrolled population. When patients were selected with an elevated probability of mortality based on prehospital injury characteristics, LTOWB was independently associated with a lower risk of mortality starting at 4 hours after arrival through 28 days after injury.
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Affiliation(s)
- Jason L Sperry
- From the Department of Surgery, University of Pittsburgh, Pittsburgh, PA (Sperry)
| | - Bryan A Cotton
- Department of Surgery, University of Texas Health Science Center, Houston, TX (Cotton)
| | - James F Luther
- University of Pittsburgh School of Public Health, Pittsburgh, PA (Luther, Wisniewski)
| | - Jeremy W Cannon
- Department of Surgery, University of Pennsylvania, Philadelphia, PA (Cannon)
| | - Martin A Schreiber
- Department of Surgery, Oregon Health & Science University, Portland, OR (Schreiber)
| | - Ernest E Moore
- Department of Surgery, Ernest E. Moore Shock Trauma Center at Denver Health, University of Colorado Health Sciences Center, Denver, CO (Moore)
| | - Nicholas Namias
- Department of Surgery, University of Miami/Jackson Memorial Hospital, Miami, FL (Namias)
| | - Joseph P Minei
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX (Minei)
| | - Stephen R Wisniewski
- University of Pittsburgh School of Public Health, Pittsburgh, PA (Luther, Wisniewski)
| | - Frank X Guyette
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA (Guyette)
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14
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Thau MR, Liu T, Sathe NA, O’Keefe GE, Robinson BRH, Bulger E, Wade CE, Fox EE, Holcomb JB, Liles WC, Stanaway IB, Mikacenic C, Wurfel MM, Bhatraju PK, Morrell ED. Association of Trauma Molecular Endotypes With Differential Response to Transfusion Resuscitation Strategies. JAMA Surg 2023; 158:728-736. [PMID: 37099286 PMCID: PMC10134038 DOI: 10.1001/jamasurg.2023.0819] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Accepted: 12/12/2022] [Indexed: 04/27/2023]
Abstract
Importance It is not clear which severely injured patients with hemorrhagic shock may benefit most from a 1:1:1 vs 1:1:2 (plasma:platelets:red blood cells) resuscitation strategy. Identification of trauma molecular endotypes may reveal subgroups of patients with differential treatment response to various resuscitation strategies. Objective To derive trauma endotypes (TEs) from molecular data and determine whether these endotypes are associated with mortality and differential treatment response to 1:1:1 vs 1:1:2 resuscitation strategies. Design, Setting, and Participants This was a secondary analysis of the Pragmatic, Randomized Optimal Platelet and Plasma Ratios (PROPPR) randomized clinical trial. The study cohort included individuals with severe injury from 12 North American trauma centers. The cohort was taken from the participants in the PROPPR trial who had complete plasma biomarker data available. Study data were analyzed on August 2, 2021, to October 25, 2022. Exposures TEs identified by K-means clustering of plasma biomarkers collected at hospital arrival. Main Outcomes and Measures An association between TEs and 30-day mortality was tested using multivariable relative risk (RR) regression adjusting for age, sex, trauma center, mechanism of injury, and injury severity score (ISS). Differential treatment response to transfusion strategy was assessed using an RR regression model for 30-day mortality by incorporating an interaction term for the product of endotype and treatment group adjusting for age, sex, trauma center, mechanism of injury, and ISS. Results A total of 478 participants (median [IQR] age, 34.5 [25-51] years; 384 male [80%]) of the 680 participants in the PROPPR trial were included in this study analysis. A 2-class model that had optimal performance in K-means clustering was found. TE-1 (n = 270) was characterized by higher plasma concentrations of inflammatory biomarkers (eg, interleukin 8 and tumor necrosis factor α) and significantly higher 30-day mortality compared with TE-2 (n = 208). There was a significant interaction between treatment arm and TE for 30-day mortality. Mortality in TE-1 was 28.6% with 1:1:2 treatment vs 32.6% with 1:1:1 treatment, whereas mortality in TE-2 was 24.5% with 1:1:2 treatment vs 7.3% with 1:1:1 treatment (P for interaction = .001). Conclusions and Relevance Results of this secondary analysis suggest that endotypes derived from plasma biomarkers in trauma patients at hospital arrival were associated with a differential response to 1:1:1 vs 1:1:2 resuscitation strategies in trauma patients with severe injury. These findings support the concept of molecular heterogeneity in critically ill trauma populations and have implications for tailoring therapy for patients at high risk for adverse outcomes.
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Affiliation(s)
- Matthew R. Thau
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle
- Sepsis Center of Research Excellence—University of Washington (SCORE-UW), Seattle
| | - Ted Liu
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle
| | - Neha A. Sathe
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle
- Sepsis Center of Research Excellence—University of Washington (SCORE-UW), Seattle
| | - Grant E. O’Keefe
- Sepsis Center of Research Excellence—University of Washington (SCORE-UW), Seattle
- Department of Surgery, University of Washington, Seattle
| | | | - Eileen Bulger
- Department of Surgery, University of Washington, Seattle
| | - Charles E. Wade
- Center for Translational Injury Research, Division of Acute Care Surgery, Department of Surgery, University of Texas Health Science Center, Houston
| | - Erin E. Fox
- Center for Translational Injury Research, Division of Acute Care Surgery, Department of Surgery, University of Texas Health Science Center, Houston
| | | | - W. Conrad Liles
- Sepsis Center of Research Excellence—University of Washington (SCORE-UW), Seattle
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle
| | - Ian B. Stanaway
- Kidney Research Institute, University of Washington, Seattle
- Division of Nephrology, Department of Medicine, University of Washington, Seattle
| | - Carmen Mikacenic
- Sepsis Center of Research Excellence—University of Washington (SCORE-UW), Seattle
- Translational Immunology, Benaroya Research Institute, Seattle, Washington
| | - Mark M. Wurfel
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle
- Sepsis Center of Research Excellence—University of Washington (SCORE-UW), Seattle
| | - Pavan K. Bhatraju
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle
- Sepsis Center of Research Excellence—University of Washington (SCORE-UW), Seattle
| | - Eric D. Morrell
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle
- Sepsis Center of Research Excellence—University of Washington (SCORE-UW), Seattle
- Hospital and Specialty Medicine, VA Puget Sound Health Care System, Seattle, Washington
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15
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Li SR, Moheimani H, Herzig B, Kail M, Krishnamoorthi N, Wu J, Abdelhamid S, Scioscia J, Sung E, Rosengart A, Bonaroti J, Johansson PI, Stensballe J, Neal MD, Das J, Kar U, Sperry J, Billiar TR. High-dimensional proteomics identifies organ injury patterns associated with outcomes in human trauma. J Trauma Acute Care Surg 2023; 94:803-813. [PMID: 36787435 PMCID: PMC10205666 DOI: 10.1097/ta.0000000000003880] [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] [Indexed: 02/16/2023]
Abstract
INTRODUCTION Severe traumatic injury with shock can lead to direct and indirect organ injury; however, tissue-specific biomarkers are limited in clinical panels. We used proteomic and metabolomic databases to identify organ injury patterns after severe injury in humans. METHODS Plasma samples (times 0, 24, and 72 hours after arrival to trauma center) from injured patients enrolled in two randomized prehospital trials were subjected to multiplexed proteomics (SomaLogic Inc., Boulder, CO). Patients were categorized by outcome: nonresolvers (died >72 hours or required ≥7 days of critical care), resolvers (survived to 30 days and required <7 days of critical care), and low Injury Severity Score (ISS) controls. Established tissue-specific biomarkers were identified through a literature review and cross-referenced with tissue specificity from the Human Protein Atlas. Untargeted plasma metabolomics (Metabolon Inc., Durham, NC), inflammatory mediators, and endothelial damage markers were correlated with injury biomarkers. Kruskal-Wallis/Mann-Whitney U tests with false discovery rate correction assessed differences in biomarker expression across outcome groups (significance; p < 0.1). RESULTS Of 142 patients, 78 were nonresolvers (median ISS, 30), 34 were resolvers (median ISS, 22), and 30 were low ISS controls (median ISS, 1). A broad release of tissue-specific damage markers was observed at admission; this was greater in nonresolvers. By 72 hours, nine cardiac, three liver, eight neurologic, and three pulmonary proteins remained significantly elevated in nonresolvers compared with resolvers. Cardiac damage biomarkers showed the greatest elevations at 72 hours in nonresolvers and had significant positive correlations with proinflammatory mediators and endothelial damage markers. Nonresolvers had lower concentrations of fatty acid metabolites compared with resolvers, particularly acyl carnitines and cholines. CONCLUSION We identified an immediate release of tissue-specific biomarkers with sustained elevation in the liver, pulmonary, neurologic, and especially cardiac injury biomarkers in patients with complex clinical courses after severe injury. The persistent myocardial injury in nonresolvers may be due to a combination of factors including metabolic stress, inflammation, and endotheliopathy.
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Affiliation(s)
- Shimena R Li
- From the Department of Surgery (S.L., H.M., B.H., M.K., N.K., J.W., S.A., J. Scioscia, E.S., A.R., J.B., M.N., U.K., J. Sperry, T.R.B.) and Pittsburgh Transfusion and Trauma Research Center (S.L., H.M., B.H., M.K., N.K., J.W., S.A., J. Scioscia, E.S., A.R., J.B., M.N., U.K., J. Sperry, T.R.B.), University of Pittsburgh, Pittsburgh; Lake Erie College of Osteopathic Medicine (B.H.), Erie, Pennsylvania; Department of Cardiology (J.W.), The Third Xiangya Hospital, Central South University, Changsha, China; Section for Transfusion Medicine (P.I.J., J. Stensballe), Capital Region Blood Bank, Rigshospitalet and Department of Anesthesia and Trauma Center (J. Stensballe), Centre of Head and Orthopaedics, Rigshospitalet, Copenhagen University Hospital, Copenhagen; Emergency Medical Services (J. Stensballe), The Capital Region of Denmark, Hillerød, Denmark; and Center for Systems Immunology, Departments of Immunology (J.D.) and Computational and Systems Biology (J.D.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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16
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David S, Russell L, Castro P, van de Louw A, Zafrani L, Pirani T, Nielsen ND, Mariotte E, Ferreyro BL, Kielstein JT, Montini L, Brignier AC, Kochanek M, Cid J, Robba C, Martin-Loeches I, Ostermann M, Juffermans NP. Research priorities for therapeutic plasma exchange in critically ill patients. Intensive Care Med Exp 2023; 11:26. [PMID: 37150798 PMCID: PMC10164453 DOI: 10.1186/s40635-023-00510-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 04/10/2023] [Indexed: 05/09/2023] Open
Abstract
Therapeutic plasma exchange (TPE) is a therapeutic intervention that separates plasma from blood cells to remove pathological factors or to replenish deficient factors. The use of TPE is increasing over the last decades. However, despite a good theoretical rationale and biological plausibility for TPE as a therapy for numerous diseases or syndromes associated with critical illness, TPE in the intensive care unit (ICU) setting has not been studied extensively. A group of eighteen experts around the globe from different clinical backgrounds used a modified Delphi method to phrase key research questions related to "TPE in the critically ill patient". These questions focused on: (1) the pathophysiological role of the removal and replacement process, (2) optimal timing of treatment, (3) dosing and treatment regimes, (4) risk-benefit assumptions and (5) novel indications in need of exploration. For all five topics, the current understanding as well as gaps in knowledge and future directions were assessed. The content should stimulate future research in the field and novel clinical applications.
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Affiliation(s)
- Sascha David
- Institute of Intensive Care Medicine, University Hospital Zurich, Zurich, Switzerland.
- Department of Nephrology and Hypertension, Hannover Medical School, Hannover, Germany.
| | - Lene Russell
- Department of Intensive Care, Copenhagen University Hospital Gentofte, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Pedro Castro
- Medical Intensive Care Unit, Hospital Clínic of Barcelona, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Andry van de Louw
- Medical Intensive Care Unit, Penn State Health Hershey Medical Center, Hershey, PA, USA
| | - Lara Zafrani
- Medical Intensive Care Unit, Saint-Louis Hospital, AP-HP, University of Paris Cité, Paris, France
| | - Tasneem Pirani
- King's College Hospital, General and Liver Intensive Care, London, UK
| | - Nathan D Nielsen
- Division of Pulmonary, Critical Care and Sleep Medicine & Section of Transfusion Medicine and Therapeutic Pathology, University of New Mexico School of Medicine, Albuquerque, USA
| | - Eric Mariotte
- Medical Intensive Care Unit, Saint-Louis Hospital, AP-HP, University of Paris Cité, Paris, France
| | - Bruno L Ferreyro
- Department of Medicine, Sinai Health System and University Health Network, Toronto, Canada
| | - Jan T Kielstein
- Medical Clinic V, Nephrology, Rheumatology, Blood Purification, Academic Teaching Hospital Braunschweig, Brunswick, Germany
| | - Luca Montini
- Department of Intensive Care Medicine and Anesthesiology, "Fondazione Policlinico Universitario Agostino Gemelli IRCCS" Università Cattolica del Sacro Cuore, Rome, Italy
| | - Anne C Brignier
- Apheresis Unit, Saint-Louis Hospital, AP-HP, University of Paris Cite, Paris, France
| | - Matthias Kochanek
- Department I of Internal Medicine, Faculty of Medicine and University Hospital Cologne, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf (CIO), University of Cologne, Cologne, Germany
| | - Joan Cid
- Apheresis and Cellular Therapy Unit, Department of Hemotherapy and Hemostasis, ICMHO, Clínic Barcelona, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Chiara Robba
- IRCCS per Oncologia e Neuroscienze, Genoa, Italy
- Dipartimento di Scienze Chirurgiche Diagnostiche ed Integrate, Universita' di Genova, Genoa, Italy
| | - Ignacio Martin-Loeches
- Department of Intensive Care Medicine, Multidisciplinary Intensive Care Research Organization (MICRO), St. James's Hospital, Dublin, D08 NHY1, Ireland
- Department of Clinical Medicine, School of Medicine, Trinity College Dublin, Dublin, D02 PN91, Ireland
- Institut D'Investigacions Biomediques August Pi i Sunyer (IDIBAPS), Hospital Clinic, Universidad de Barcelona, Ciberes, Barcelona, Spain
| | - Marlies Ostermann
- Department of Intensive Care, Guy's & St Thomas' Hospital, King's College London, London, UK
| | - Nicole P Juffermans
- Department of Intensive Care, OLVG Hospital, Amsterdam, The Netherlands
- Laboratory of Translational Intensive Care, Erasmus MC, Rotterdam, The Netherlands
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17
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Wang Z, Chen G. Immune regulation in neurovascular units after traumatic brain injury. Neurobiol Dis 2023; 179:106060. [PMID: 36871640 DOI: 10.1016/j.nbd.2023.106060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 02/19/2023] [Accepted: 02/28/2023] [Indexed: 03/07/2023] Open
Abstract
Traumatic brain injury (TBI) is a major cause of death and disability worldwide. Survivors may experience movement disorders, memory loss, and cognitive deficits. However, there is a lack of understanding of the pathophysiology of TBI-mediated neuroinflammation and neurodegeneration. The immune regulation process of TBI involves changes in the peripheral and central nervous system (CNS) immunity, and intracranial blood vessels are essential communication centers. The neurovascular unit (NVU) is responsible for coupling blood flow with brain activity, and comprises endothelial cells, pericytes, astrocyte end-feet, and vast regulatory nerve terminals. A stable NVU is the basis for normal brain function. The concept of the NVU emphasizes that cell-cell interactions between different types of cells are essential for maintaining brain homeostasis. Previous studies have explored the effects of immune system changes after TBI. The NVU can help us further understand the immune regulation process. Herein, we enumerate the paradoxes of primary immune activation and chronic immunosuppression. We describe the changes in immune cells, cytokines/chemokines, and neuroinflammation after TBI. The post-immunomodulatory changes in NVU components are discussed, and research exploring immune changes in the NVU pattern is also described. Finally, we summarize immune regulation therapies and drugs after TBI. Therapies and drugs that focus on immune regulation have shown great potential for neuroprotection. These findings will help us further understand the pathological processes after TBI.
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Affiliation(s)
- Zongqi Wang
- Department of Neurosurgery & Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, 188 Shizi Street, Suzhou, Jiangsu Province 215006, China; Institute of Stroke Research, Soochow University, Suzhou, Jiangsu Province 215006, China
| | - Gang Chen
- Department of Neurosurgery & Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, 188 Shizi Street, Suzhou, Jiangsu Province 215006, China; Institute of Stroke Research, Soochow University, Suzhou, Jiangsu Province 215006, China.
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18
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Deeb AP, Guyette FX, Daley BJ, Miller RS, Harbrecht BG, Claridge JA, Phelan HA, Eastridge BJ, Joseph B, Nirula R, Vercruysse GA, Sperry JL, Brown JB. Time to early resuscitative intervention association with mortality in trauma patients at risk for hemorrhage. J Trauma Acute Care Surg 2023; 94:504-512. [PMID: 36728324 PMCID: PMC10038862 DOI: 10.1097/ta.0000000000003820] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Hemorrhage is the leading cause of preventable death after injury. Others have shown that delays in massive transfusion cooler arrival increase mortality, while prehospital blood product resuscitation can reduce mortality. Our objective was to evaluate if time to resuscitation initiation impacts mortality. METHODS We combined data from the Prehospital Air Medical Plasma (PAMPer) trial in which patients received prehospital plasma or standard care and the Study of Tranexamic Acid during Air and ground Medical Prehospital transport (STAAMP) trial in which patients received prehospital tranexamic acid or placebo. We evaluated the time to early resuscitative intervention (TERI) as time from emergency medical services arrival to packed red blood cells, plasma, or tranexamic acid initiation in the field or within 90 minutes of trauma center arrival. For patients not receiving an early resuscitative intervention, the TERI was calculated based on trauma center arrival as earliest opportunity to receive a resuscitative intervention and were propensity matched to those that did to account for selection bias. Mixed-effects logistic regression assessed the association of 30-day and 24-hour mortality with TERI adjusting for confounders. We also evaluated a subgroup of only patients receiving an early resuscitative intervention as defined above. RESULTS Among the 1,504 propensity-matched patients, every 1-minute delay in TERI was associated with 2% increase in the odds of 30-day mortality (adjusted odds ratio [aOR], 1.020; 95% confidence interval [CI], 1.006-1.033; p < 0.01) and 1.5% increase in odds of 24-hour mortality (aOR, 1.015; 95% CI, 1.001-1.029; p = 0.03). Among the 799 patients receiving an early resuscitative intervention, every 1-minute increase in TERI was associated with a 2% increase in the odds of 30-day mortality (aOR, 1.021; 95% CI, 1.005-1.038; p = 0.01) and 24-hour mortality (aOR, 1.023; 95% CI, 1.005-1.042; p = 0.01). CONCLUSION Time to early resuscitative intervention is associated with morality in trauma patients with hemorrhagic shock. Bleeding patients need resuscitation initiated early, whether at the trauma center in systems with short prehospital times or in the field when prehospital time is prolonged. LEVEL OF EVIDENCE Therapeutic/Care Management; Level III.
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Affiliation(s)
- Andrew-Paul Deeb
- From the Division of Trauma and General Surgery, Department of Surgery (A.-P.D., J.B.B.), and Department of Emergency Medicine (F.X.G.), University of Pittsburgh, Pittsburgh, Pennsylvania; Department of Surgery (B.J.D.), University of Tennessee Health Science Center, Knoxville, Tennessee; Department of Surgery (R.S.M.), John Peter Smith Health Network, Fort Worth, Texas; Department of Surgery (B.G.H.), University of Louisville, Louisville, Kentucky;Department of Surgery (J.A.C.), MetroHealth Medical Center/Case Western Reserve University, Cleveland, Ohio; Department of Surgery (H.A.P.), Louisiana State University Health Sciences Center-New Orleans, New Orleans, Louisiana; Department of Surgery (B.J.E.), University of Texas Health San Antonio, San Antonio, Texas; Department of Surgery (B.J., G.A.V.), University of Arizona, Tucson, Arizona; Department of Surgery (R.N.), University of Utah, Salt Lake City, Utah; Division of Trauma and General Surgery, Department of Surgery (J.L.S.), University of Pittsburgh, Pittsburgh, Pennsylvania
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19
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Resuscitation with whole blood or blood components improves survival and lessens the pathophysiological burden of trauma and haemorrhagic shock in a pre-clinical porcine model. Eur J Trauma Emerg Surg 2023; 49:227-239. [PMID: 35900383 PMCID: PMC9925484 DOI: 10.1007/s00068-022-02050-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 06/30/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE In military trauma, disaster medicine, and casualties injured in remote locations, times to advanced medical and surgical treatment are often prolonged, potentially reducing survival and increasing morbidity. Since resuscitation with blood/blood components improves survival over short pre-surgical times, this study aimed to evaluate the quality of resuscitation afforded by blood/blood products or crystalloid resuscitation over extended 'pre-hospital' timelines in a porcine model of militarily relevant traumatic haemorrhagic shock. METHODS This study underwent local ethical review and was done under the authority of Animals (Scientific Procedures) Act 1986. Forty-five terminally anaesthetised pigs received a soft tissue injury to the right thigh, haemorrhage (30% blood volume and a Grade IV liver injury) and fluid resuscitation initiated 30 min later [Group 1 (no fluid); 2 (0.9% saline); 3 (1:1 packed red blood cells:plasma); 4 (fresh whole blood); or 5 (plasma)]. Fluid (3 ml/kg bolus) was administered during the resuscitation period (maximum duration 450 min) when the systolic blood pressure fell below 80 mmHg. Surviving animals were culled with an overdose of anaesthetic. RESULTS Survival time was significantly shorter for Group 1 compared to the other groups (P < 0.05). Despite the same triggers for resuscitation when compared to blood/blood components, saline was associated with a shorter survival time (P = 0.145), greater pathophysiological burden and significantly greater resuscitation fluid volume (P < 0.0001). CONCLUSION When times to advanced medical care are prolonged, resuscitation with blood/blood components is recommended over saline due to the superior quality and stability of resuscitation achieved, which are likely to lead to improved patient outcomes.
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20
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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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21
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DeBot M, Mitra S, Lutz P, Schaid TR, Stafford P, Hadley JB, Hom P, Sauaia A, Silliman CC, Moore EE, Cohen MJ. SHOCK INDUCES ENDOTHELIAL PERMEABILITY AFTER TRAUMA THROUGH INCREASED ACTIVATION OF RHOA GTPASE. Shock 2022; 58:542-548. [PMID: 36548645 PMCID: PMC9793983 DOI: 10.1097/shk.0000000000002008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
ABSTRACT Introduction: Severely injured patients develop a dysregulated inflammatory state characterized by vascular endothelial permeability, which contributes to multiple organ failure. To date, however, the mediators of and mechanisms for this permeability are not well established. Endothelial permeability in other inflammatory states such as sepsis is driven primarily by overactivation of the RhoA GTPase. We hypothesized that tissue injury and shock drive endothelial permeability after trauma by increased RhoA activation leading to break down of endothelial tight and adherens junctions. Methods: Human umbilical vein endothelial cells (HUVECs) were grown to confluence, whereas continuous resistance was measured using electrical cell-substrate impedance sensing (ECIS) Z-Theta technology, 10% ex vivo plasma from severely injured trauma patients was added, and resistance measurements continued for 2 hours. Areas under the curve (AUCs) were calculated from resistance curves. For GTPase activity analysis, HUVECs were grown to confluence and incubated with 10% trauma plasma for 5 minutes before harvesting of cell lysates. Rho and Rac activity were determined using a G-LISA assay. Significance was determined using Mann-Whitney tests or Kruskal-Wallis test, and Spearman ρ was calculated for correlations. Results: Plasma from severely injured patients induces endothelial permeability with plasma from patients with both severe injury and shock contributing most to this increased permeability. Surprisingly, Injury Severity Score (ISS) does not correlate with in vitro trauma-induced permeability (-0.05, P > 0.05), whereas base excess (BE) does correlate with permeability (-0.47, P = 0.0001). The combined impact of shock and injury resulted in a significantly smaller AUC in the injury + shock group (ISS > 15, BE < -9) compared with the injury only (ISS > 15, BE > -9; P = 0.04) or minimally injured (ISS < 15, BE > -9; P = 0.005) groups. In addition, incubation with injury + shock plasma resulted in higher RhoA activation ( P = 0.002) and a trend toward decreased Rac1 activation ( P = 0.07) compared with minimally injured control. Conclusions: Over the past decade, improved early survival in patients with severe trauma and hemorrhagic shock has led to a renewed focus on the endotheliopathy of trauma. This study presents the largest study to date measuring endothelial permeability in vitro using plasma collected from patients after traumatic injury. Here, we demonstrate that plasma from patients who develop shock after severe traumatic injury induces endothelial permeability and increased RhoA activation in vitro . Our ECIS model of trauma-induced permeability using ex vivo plasma has potential as a high throughput screening tool to phenotype endothelial dysfunction, study mediators of trauma-induced permeability, and screen potential interventions.
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Affiliation(s)
- Margot DeBot
- University of Colorado Denver, School of Medicine, Department of Surgery/Trauma Research Center, Aurora, CO
| | - Sanchayita Mitra
- University of Colorado Denver, School of Medicine, Department of Surgery/Trauma Research Center, Aurora, CO
| | - Patrick Lutz
- University of Colorado Denver, School of Medicine, Department of Surgery/Trauma Research Center, Aurora, CO
| | - Terry R. Schaid
- University of Colorado Denver, School of Medicine, Department of Surgery/Trauma Research Center, Aurora, CO
| | - Preston Stafford
- University of Colorado Denver, School of Medicine, Department of Surgery/Trauma Research Center, Aurora, CO
| | - Jamie B. Hadley
- University of Colorado Denver, School of Medicine, Department of Surgery/Trauma Research Center, Aurora, CO
| | - Patrick Hom
- University of Colorado Denver, School of Medicine, Department of Surgery/Trauma Research Center, Aurora, CO
| | - Angela Sauaia
- University of Colorado Denver, School of Medicine, Department of Surgery/Trauma Research Center, Aurora, CO
- University of Colorado Denver, School of Public Health, Management and Policy, Department of Health Systems, Aurora, CO
| | - Christopher C. Silliman
- University of Colorado Denver, School of Medicine, Department of Surgery/Trauma Research Center, Aurora, CO
| | - Ernest E. Moore
- Denver Health Medical Center, Ernest E Moore Shock Trauma Center, Denver, CO
| | - Mitchell J. Cohen
- University of Colorado Denver, School of Medicine, Department of Surgery/Trauma Research Center, Aurora, CO
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22
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Bonaroti J, Billiar I, Moheimani H, Wu J, Namas R, Li S, Kar UK, Vodovotz Y, Neal MD, Sperry JL, Billiar TR. Plasma proteomics reveals early, broad release of chemokine, cytokine, TNF, and interferon mediators following trauma with delayed increases in a subset of chemokines and cytokines in patients that remain critically ill. Front Immunol 2022; 13:1038086. [PMID: 36532045 PMCID: PMC9750757 DOI: 10.3389/fimmu.2022.1038086] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Accepted: 11/11/2022] [Indexed: 12/05/2022] Open
Abstract
Severe injury is known to cause a systemic cytokine storm that is associated with adverse outcomes. However, a comprehensive assessment of the time-dependent changes in circulating levels of a broad spectrum of protein immune mediators and soluble immune mediator receptors in severely injured trauma patients remains uncharacterized. To address this knowledge gap, we defined the temporal and outcome-based patterns of 184 known immune mediators and soluble cytokine receptors in the circulation of severely injured patients. Proteomics (aptamer-based assay, SomaLogic, Inc) was performed on plasma samples drawn at 0, 24, and 72 hours (h) from time of admission from 150 trauma patients, a representative subset from the Prehospital Plasma during Air Medical Transport in Trauma Patients at Risk for Hemorrhagic Shock (PAMPer) trial. Patients were categorized into outcome groups including Early Non-Survivors (died within 72 h; ENS; n=38), Non-Resolvers (died after 72 h or required ≥7 days of intensive care; NR; n=78), and Resolvers (survivors that required < 7 days of intensive care; R; n=34), with low Injury Severity Score (ISS) patients from the Tranexamic Acid During Prehospital Transport in Patients at Risk for Hemorrhage After Injury (STAAMP) trial as controls. The major findings include an extensive release of immune mediators and cytokine receptors at time 0h that is more pronounced in ENS and NR patients. There was a selective subset of mediators elevated at 24 and 72 h to a greater degree in NR patients, including multiple cytokines and chemokines not previously described in trauma patients. These findings were validated in a quantitative fashion using mesoscale discovery immunoassays (MSD) from an external validation cohort (VC) of samples from 58 trauma patients matched for R and NR status. This comprehensive longitudinal description of immune mediator patterns associated with trauma outcomes provides a new level of characterization of the immune response that follows severe injury.
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Affiliation(s)
- Jillian Bonaroti
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, United States,Pittsburgh Trauma and Transfusion Medicine Research Center, Division of Trauma and Acute Care Surgery, University of Pittsburgh, Pittsburgh, PA, United States
| | - Isabel Billiar
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, United States,Pittsburgh Trauma and Transfusion Medicine Research Center, Division of Trauma and Acute Care Surgery, University of Pittsburgh, Pittsburgh, PA, United States
| | - Hamed Moheimani
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, United States,Pittsburgh Trauma and Transfusion Medicine Research Center, Division of Trauma and Acute Care Surgery, University of Pittsburgh, Pittsburgh, PA, United States
| | - Junru Wu
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, United States,Pittsburgh Trauma and Transfusion Medicine Research Center, Division of Trauma and Acute Care Surgery, University of Pittsburgh, Pittsburgh, PA, United States,Xiangya School of Medicine, Central South University, Changsha, China
| | - Rami Namas
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, United States,Pittsburgh Trauma and Transfusion Medicine Research Center, Division of Trauma and Acute Care Surgery, University of Pittsburgh, Pittsburgh, PA, United States
| | - Shimena Li
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, United States,Pittsburgh Trauma and Transfusion Medicine Research Center, Division of Trauma and Acute Care Surgery, University of Pittsburgh, Pittsburgh, PA, United States
| | - Upendra K. Kar
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, United States,Pittsburgh Trauma and Transfusion Medicine Research Center, Division of Trauma and Acute Care Surgery, University of Pittsburgh, Pittsburgh, PA, United States
| | - Yoram Vodovotz
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, United States,Pittsburgh Trauma and Transfusion Medicine Research Center, Division of Trauma and Acute Care Surgery, University of Pittsburgh, Pittsburgh, PA, United States
| | - Matthew D. Neal
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, United States,Pittsburgh Trauma and Transfusion Medicine Research Center, Division of Trauma and Acute Care Surgery, University of Pittsburgh, Pittsburgh, PA, United States
| | - Jason L. Sperry
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, United States,Pittsburgh Trauma and Transfusion Medicine Research Center, Division of Trauma and Acute Care Surgery, University of Pittsburgh, Pittsburgh, PA, United States
| | - Timothy R. Billiar
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, United States,Pittsburgh Trauma and Transfusion Medicine Research Center, Division of Trauma and Acute Care Surgery, University of Pittsburgh, Pittsburgh, PA, United States,*Correspondence: Timothy R. Billiar,
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23
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Wu J, Cyr A, Gruen DS, Lovelace TC, Benos PV, Das J, Kar UK, Chen T, Guyette FX, Yazer MH, Daley BJ, Miller RS, Harbrecht BG, Claridge JA, Phelan HA, Zuckerbraun BS, Neal MD, Johansson PI, Stensballe J, Namas RA, Vodovotz Y, Sperry JL, Billiar TR. Lipidomic signatures align with inflammatory patterns and outcomes in critical illness. Nat Commun 2022; 13:6789. [PMID: 36357394 PMCID: PMC9647252 DOI: 10.1038/s41467-022-34420-4] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Accepted: 10/25/2022] [Indexed: 11/11/2022] Open
Abstract
Alterations in lipid metabolism have the potential to be markers as well as drivers of pathobiology of acute critical illness. Here, we took advantage of the temporal precision offered by trauma as a common cause of critical illness to identify the dynamic patterns in the circulating lipidome in critically ill humans. The major findings include an early loss of all classes of circulating lipids followed by a delayed and selective lipogenesis in patients destined to remain critically ill. The previously reported survival benefit of early thawed plasma administration was associated with preserved lipid levels that related to favorable changes in coagulation and inflammation biomarkers in causal modelling. Phosphatidylethanolamines (PE) were elevated in patients with persistent critical illness and PE levels were prognostic for worse outcomes not only in trauma but also severe COVID-19 patients. Here we show selective rise in systemic PE as a common prognostic feature of critical illness.
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Affiliation(s)
- Junru Wu
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
- Pittsburgh Trauma Research Center, Division of Trauma and Acute Care Surgery, Pittsburgh, PA, USA
- Department of Cardiology, The 3rd Xiangya Hospital, Central South University, Changsha, China
- Eight-year program of medicine, Xiangya School of Medicine, Central South University, Changsha, China
| | - Anthony Cyr
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
- Pittsburgh Trauma Research Center, Division of Trauma and Acute Care Surgery, Pittsburgh, PA, USA
| | - Danielle S Gruen
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
- Pittsburgh Trauma Research Center, Division of Trauma and Acute Care Surgery, Pittsburgh, PA, USA
| | - Tyler C Lovelace
- Department of Computational and Systems Biology, University of Pittsburgh, Pittsburgh, PA, USA
- Joint CMU-Pitt PhD Program in Computational Biology, Pittsburgh, PA, USA
| | - Panayiotis V Benos
- Department of Computational and Systems Biology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jishnu Das
- Center for Systems Immunology, Departments of Immunology and Computational & Systems Biology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Upendra K Kar
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
- Pittsburgh Trauma Research Center, Division of Trauma and Acute Care Surgery, Pittsburgh, PA, USA
| | - Tianmeng Chen
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
- Cellular and Molecular Pathology Program, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Francis X Guyette
- Department of Emergency Medicine, Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Mark H Yazer
- The Institute for Transfusion Medicine, Pittsburgh, PA, USA
| | - Brian J Daley
- Department of Surgery, University of Tennessee Health Science Center, Knoxville, TN, USA
| | - Richard S Miller
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Brian G Harbrecht
- Department of Surgery, University of Louisville, Louisville, KY, USA
| | - Jeffrey A Claridge
- Metro Health Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | - Herb A Phelan
- Department of Surgery, University of Texas Southwestern, Dallas, TX, USA
| | - Brian S Zuckerbraun
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
- Pittsburgh Trauma Research Center, Division of Trauma and Acute Care Surgery, Pittsburgh, PA, USA
| | - Matthew D Neal
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
- Pittsburgh Trauma Research Center, Division of Trauma and Acute Care Surgery, Pittsburgh, PA, USA
| | - Pär I Johansson
- 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 Orthopaedics, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Emergency Medical Services, The Capital Region of Denmark, Hillerød, Denmark
| | - Rami A Namas
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
- Pittsburgh Trauma Research Center, Division of Trauma and Acute Care Surgery, Pittsburgh, PA, USA
| | - Yoram Vodovotz
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
- Pittsburgh Trauma Research Center, Division of Trauma and Acute Care Surgery, Pittsburgh, PA, USA
| | - Jason L Sperry
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA.
- Pittsburgh Trauma Research Center, Division of Trauma and Acute Care Surgery, Pittsburgh, PA, USA.
| | - Timothy R Billiar
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA.
- Pittsburgh Trauma Research Center, Division of Trauma and Acute Care Surgery, Pittsburgh, PA, USA.
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24
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Wu E, Zhu J, Ma Z, Tuo B, Terai S, Mizuno K, Li T, Liu X. Gastric alarmin release: A warning signal in the development of gastric mucosal diseases. Front Immunol 2022; 13:1008047. [PMID: 36275647 PMCID: PMC9583272 DOI: 10.3389/fimmu.2022.1008047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Accepted: 09/14/2022] [Indexed: 11/13/2022] Open
Abstract
Alarmins exist outside cells and are early warning signals to the immune system; as such, alarmin receptors are widely distributed on various immune cells. Alarmins, proinflammatory molecular patterns associated with tissue damage, are usually released into the extracellular space, where they induce immune responses and participate in the damage and repair processes of mucosal diseases.In the stomach, gastric alarmin release has been shown to be involved in gastric mucosal inflammation, antibacterial defense, adaptive immunity, and wound healing; moreover, this release causes damage and results in the development of gastric mucosal diseases, including various types of gastritis, ulcers, and gastric cancer. Therefore, it is necessary to understand the role of alarmins in gastric mucosal diseases. This review focuses on the contribution of alarmins, including IL33, HMGB1, defensins and cathelicidins, to the gastric mucosal barrier and their role in gastric mucosal diseases. Here, we offer a new perspective on the prevention and treatment of gastric mucosal diseases.
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Affiliation(s)
- Enqin Wu
- Department of Gastroenterology, Digestive Disease Hospital, Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Jiaxing Zhu
- Department of Gastroenterology, Digestive Disease Hospital, Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Zhiyuan Ma
- Department of Gastroenterology, Digestive Disease Hospital, Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Biguang Tuo
- Department of Gastroenterology, Digestive Disease Hospital, Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Shuji Terai
- Division of Gastroenterology & Hepatology, Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan
| | - Kenichi Mizuno
- Division of Gastroenterology & Hepatology, Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan
| | - Taolang Li
- Department of General Surgery, Affiliated Hospital of Zunyi Medical University, Zunyi, China
- *Correspondence: Xuemei Liu, ; Taolang Li,
| | - Xuemei Liu
- Department of Gastroenterology, Digestive Disease Hospital, Affiliated Hospital of Zunyi Medical University, Zunyi, China
- *Correspondence: Xuemei Liu, ; Taolang Li,
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25
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Lewis RE, Muluk SL, Reitz KM, Guyette FX, Brown JB, Miller RS, Harbrecht BG, Claridge JA, Phelan HA, Yazer MH, Heidel RE, Rowe AS, Sperry JL, Daley BJ. Prehospital plasma is associated with survival principally in patients transferred from the scene of injury: A secondary analysis of the PAMPer trial. Surgery 2022; 172:1278-1284. [PMID: 35864051 PMCID: PMC9999176 DOI: 10.1016/j.surg.2022.04.039] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Revised: 04/06/2022] [Accepted: 04/29/2022] [Indexed: 12/01/2022]
Abstract
BACKGROUND We sought to characterize if prehospital transfer origin from the scene of injury (SCENE) or from a referral emergency department (REF) alters the survival benefit attributable to prehospital plasma resuscitation in patients at risk of hemorrhagic shock. METHODS We performed a secondary analysis of data from a recently completed prehospital plasma clinical trial. All of the enrolled patients from either the SCENE or REF groups were included. The demographics, injury characteristics, shock severity and resuscitation needs were compared. The primary outcome was a 30-day mortality. Kaplan-Meier analysis and Cox-hazard regression were used to characterize the independent survival benefits of prehospital plasma for transport origin groups. RESULTS Of the 501 enrolled patients, the REF group patients (n = 111) accounted for 22% with the remaining (n = 390) originating from the scene. The SCENE group patients had higher injury severity and were more likely intubated prehospital. The REF group patients had longer prehospital times and received greater prehospital crystalloid and blood products. Kaplan-Meier analysis revealed a significant 30-day survival benefit associated with prehospital plasma in the SCENE group (P < .01) with no difference found in the REF group patients (P = .36). The Cox-regression verified after controlling for relevant confounders that prehospital plasma was independently associated with a 30-day survival in the SCENE group patients (hazard ratio 0.59; 95% confidence interval 0.39-0.89; P = .01) with no significant relationship found in the REF group patients (hazard ratio 1.03, 95% confidence interval 0.4-3.0). CONCLUSION Important differences across the SCENE and REF cohorts exist that are essential to understand when planning prehospital studies. Prehospital plasma is associated with a survival benefit primarily in SCENE group patients. The results are exploratory but suggest transfer origin may be an important determinant of prehospital plasma benefit.
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Affiliation(s)
- Rachel E Lewis
- Department of Surgery, University of Tennessee Graduate School of Medicine, Knoxville, TN
| | - Sruthi L Muluk
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA
| | | | - Francis X Guyette
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Joshua B Brown
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA
| | - Richard S Miller
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN
| | | | - Jeffrey A Claridge
- Department of Surgery, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH
| | - Herb A Phelan
- Department of Surgery, University of Texas Southwestern, Dallas, TX
| | - Mark H Yazer
- Department of Pathology, University of Pittsburgh, Pittsburgh, PA
| | - R Eric Heidel
- Department of Surgery, University of Tennessee Graduate School of Medicine, Knoxville, TN
| | - A Shawn Rowe
- Department of Surgery, University of Tennessee Medical Center at Knoxville, Knoxville, TN
| | - Jason L Sperry
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA.
| | - Brian J Daley
- Department of Surgery, University of Tennessee Graduate School of Medicine, Knoxville, TN
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26
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Abdelhamid SS, Scioscia J, Vodovotz Y, Wu J, Rosengart A, Sung E, Rahman S, Voinchet R, Bonaroti J, Li S, Darby JL, Kar UK, Neal MD, Sperry J, Das J, Billiar TR. Multi-Omic Admission-Based Prognostic Biomarkers Identified by Machine Learning Algorithms Predict Patient Recovery and 30-Day Survival in Trauma Patients. Metabolites 2022; 12:774. [PMID: 36144179 PMCID: PMC9500723 DOI: 10.3390/metabo12090774] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Revised: 08/03/2022] [Accepted: 08/18/2022] [Indexed: 12/04/2022] Open
Abstract
Admission-based circulating biomarkers for the prediction of outcomes in trauma patients could be useful for clinical decision support. It is unknown which molecular classes of biomolecules can contribute biomarkers to predictive modeling. Here, we analyzed a large multi-omic database of over 8500 markers (proteomics, metabolomics, and lipidomics) to identify prognostic biomarkers in the circulating compartment for adverse outcomes, including mortality and slow recovery, in severely injured trauma patients. Admission plasma samples from patients (n = 129) enrolled in the Prehospital Air Medical Plasma (PAMPer) trial were analyzed using mass spectrometry (metabolomics and lipidomics) and aptamer-based (proteomics) assays. Biomarkers were selected via Least Absolute Shrinkage and Selection Operator (LASSO) regression modeling and machine learning analysis. A combination of five proteins from the proteomic layer was best at discriminating resolvers from non-resolvers from critical illness with an Area Under the Receiver Operating Characteristic curve (AUC) of 0.74, while 26 multi-omic features predicted 30-day survival with an AUC of 0.77. Patients with traumatic brain injury as part of their injury complex had a unique subset of features that predicted 30-day survival. Our findings indicate that multi-omic analyses can identify novel admission-based prognostic biomarkers for outcomes in trauma patients. Unique biomarker discovery also has the potential to provide biologic insights.
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Affiliation(s)
- Sultan S. Abdelhamid
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA 15213, USA
- Pittsburgh Trauma and Transfusion Medicine Research Center, University of Pittsburgh, Pittsburgh, PA 15213, USA
| | - Jacob Scioscia
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA 15213, USA
- Pittsburgh Trauma and Transfusion Medicine Research Center, University of Pittsburgh, Pittsburgh, PA 15213, USA
| | - Yoram Vodovotz
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA 15213, USA
- Pittsburgh Trauma and Transfusion Medicine Research Center, University of Pittsburgh, Pittsburgh, PA 15213, USA
| | - Junru Wu
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA 15213, USA
- Eight-Year Program of Medicine, Xiangya School of Medicine, Central South University, Changsha 410013, China
| | - Anna Rosengart
- Center for Systems Immunology, Departments of Immunology and Computational & Systems Biology, University of Pittsburgh, Pittsburgh, PA 15213, USA
| | - Eunseo Sung
- Center for Systems Immunology, Departments of Immunology and Computational & Systems Biology, University of Pittsburgh, Pittsburgh, PA 15213, USA
| | - Syed Rahman
- Center for Systems Immunology, Departments of Immunology and Computational & Systems Biology, University of Pittsburgh, Pittsburgh, PA 15213, USA
| | - Robert Voinchet
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA 15213, USA
- Pittsburgh Trauma and Transfusion Medicine Research Center, University of Pittsburgh, Pittsburgh, PA 15213, USA
| | - Jillian Bonaroti
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA 15213, USA
- Pittsburgh Trauma and Transfusion Medicine Research Center, University of Pittsburgh, Pittsburgh, PA 15213, USA
| | - Shimena Li
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA 15213, USA
- Pittsburgh Trauma and Transfusion Medicine Research Center, University of Pittsburgh, Pittsburgh, PA 15213, USA
| | - Jennifer L. Darby
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA 15213, USA
- Pittsburgh Trauma and Transfusion Medicine Research Center, University of Pittsburgh, Pittsburgh, PA 15213, USA
| | - Upendra K. Kar
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA 15213, USA
- Pittsburgh Trauma and Transfusion Medicine Research Center, University of Pittsburgh, Pittsburgh, PA 15213, USA
| | - Matthew D. Neal
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA 15213, USA
- Pittsburgh Trauma and Transfusion Medicine Research Center, University of Pittsburgh, Pittsburgh, PA 15213, USA
| | - Jason Sperry
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA 15213, USA
- Pittsburgh Trauma and Transfusion Medicine Research Center, University of Pittsburgh, Pittsburgh, PA 15213, USA
| | - Jishnu Das
- Center for Systems Immunology, Departments of Immunology and Computational & Systems Biology, University of Pittsburgh, Pittsburgh, PA 15213, USA
| | - Timothy R. Billiar
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA 15213, USA
- Pittsburgh Trauma and Transfusion Medicine Research Center, University of Pittsburgh, Pittsburgh, PA 15213, USA
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27
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Sloos PH, Vulliamy P, van 't Veer C, Gupta AS, Neal MD, Brohi K, Juffermans NP, Kleinveld DJB. Platelet dysfunction after trauma: From mechanisms to targeted treatment. Transfusion 2022; 62 Suppl 1:S281-S300. [PMID: 35748694 PMCID: PMC9546174 DOI: 10.1111/trf.16971] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Revised: 05/06/2022] [Accepted: 05/09/2022] [Indexed: 11/30/2022]
Affiliation(s)
- Pieter H. Sloos
- Department of Intensive Care Medicine, Amsterdam UMCUniversity of AmsterdamAmsterdamThe Netherlands
- Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam UMCUniversity of AmsterdamAmsterdamThe Netherlands
| | - Paul Vulliamy
- Centre for Trauma Sciences, Blizard Institute, Barts and the London School of Medicine and DentistryQueen Mary University of LondonLondonUK
| | - Cornelis van 't Veer
- Center for Experimental and Molecular Medicine, Amsterdam UMCUniversity of AmsterdamAmsterdamThe Netherlands
| | - Anirban Sen Gupta
- Department of Biomedical EngineeringCase Western Reserve UniversityClevelandOhioUSA
| | - Matthew D. Neal
- Pittsburgh Trauma and Transfusion Medicine Research Center and Division of Trauma and Acute Care SurgeryUniversity of PittsburghPittsburghPennsylvaniaUSA
| | - Karim Brohi
- Centre for Trauma Sciences, Blizard Institute, Barts and the London School of Medicine and DentistryQueen Mary University of LondonLondonUK
| | - Nicole P. Juffermans
- Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam UMCUniversity of AmsterdamAmsterdamThe Netherlands
- Department of Intensive Care MedicineOLVG HospitalAmsterdamThe Netherlands
| | - Derek J. B. Kleinveld
- Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam UMCUniversity of AmsterdamAmsterdamThe Netherlands
- Department of Intensive Care MedicineErasmus MCRotterdamThe Netherlands
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28
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Jost D, Lemoine S, Lemoine F, Derkenne C, Beaume S, Lanoë V, Maurin O, Louis-Delaurière E, Delacote M, Dang-Minh P, Franchin-Frattini M, Bihannic R, Savary D, Levrat A, Baudouin C, Trichereau J, Salomé M, Frattini B, Ha VHT, Jouffroy R, Seguineau E, Titreville R, Roquet F, Stibbe O, Vivien B, Verret C, Bignand M, Travers S, Martinaud C, Arock M, Raux M, Prunet B, Ausset S, Sailliol A, Tourtier JP. Prehospital Lyophilized Plasma Transfusion for Trauma-Induced Coagulopathy in Patients at Risk for Hemorrhagic Shock: A Randomized Clinical Trial. JAMA Netw Open 2022; 5:e2223619. [PMID: 35881397 PMCID: PMC9327575 DOI: 10.1001/jamanetworkopen.2022.23619] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
IMPORTANCE Blood transfusion is a mainstay of therapy for trauma-induced coagulopathy, but the optimal modalities for plasma transfusion in the prehospital setting remain to be defined. OBJECTIVE To determine whether lyophilized plasma transfusion can reduce the incidence of trauma-induced coagulopathy compared with standard care consisting of normal saline infusion. DESIGN, SETTING, AND PARTICIPANTS This randomized clinical trial was performed at multiple centers in France involving prehospital medical teams. Participants included 150 adults with trauma who were at risk for hemorrhagic shock and associated coagulopathy between April 1, 2016, and September 30, 2019, with a 28-day follow-up. Data were analyzed from November 1, 2019, to July 1, 2020. INTERVENTION Patients were randomized in a 1:1 ratio to receive either plasma or standard care with normal saline infusion (control). MAIN OUTCOMES AND MEASURES The primary outcome was the international normalized ratio (INR) on arrival at the hospital. Secondary outcomes included the need for massive transfusion and 30-day survival. As a safety outcome, prespecified adverse events included thrombosis, transfusion-related acute lung injury, and transfusion-associated circulatory overload. RESULTS Among 150 randomized patients, 134 were included in the analysis (median age, 34 [IQR, 26-49] years; 110 men [82.1%]), with 68 in the plasma group and 66 in the control group. Median INR values were 1.21 (IQR, 1.12-1.49) in the plasma group and 1.20 (IQR, 1.10-1.39) in the control group (median difference, -0.01 [IQR, -0.09 to 0.08]; P = .88). The groups did not differ significantly in the need for massive transfusion (7 [10.3%] vs 4 [6.1%]; relative risk, 1.78 [95% CI, 0.42-8.68]; P = .37) or 30-day survival (hazard ratio for death, 1.07 [95% CI, 0.44-2.61]; P = .89). In the full intention-to-treat population (n = 150), the groups did not differ in the rates of any of the prespecified adverse events. CONCLUSIONS AND RELEVANCE In this randomized clinical trial including severely injured patients at risk for hemorrhagic shock and associated coagulopathy, prehospital transfusion of lyophilized plasma was not associated with significant differences in INR values vs standard care with normal saline infusion. Nevertheless, these findings show that lyophilized plasma transfusion is a feasible and safe procedure for this patient population. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02736812.
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Affiliation(s)
- Daniel Jost
- Paris Fire Brigade Medical Emergency Department, Paris, France
| | - Sabine Lemoine
- Paris Fire Brigade Medical Emergency Department, Paris, France
| | | | | | | | - Vincent Lanoë
- Paris Fire Brigade Medical Emergency Department, Paris, France
| | - Olga Maurin
- Paris Fire Brigade Medical Emergency Department, Paris, France
| | - Emilie Louis-Delaurière
- Direction de la Formation, de la Recherche et de l’Innovation, Service de Santé des Armées, Paris, France
| | - Maëlle Delacote
- Paris Fire Brigade Medical Emergency Department, Paris, France
| | | | | | - René Bihannic
- Paris Fire Brigade Medical Emergency Department, Paris, France
| | - Dominique Savary
- Emergency Department, Angers University Hospital, Angers, France
- Research Institute for Environmental and Occupational Health–Unité Mixte de Recherche (UMR)_S 1085, France Emergency Department, Angers University Hospital, Angers, France
| | - Albrice Levrat
- Department of Intensive Care, Annecy Hospital, Annecy, France
| | - Clémence Baudouin
- Service Mobile d’Urgence et de Réanimation de Paris, Hôpital Lariboisière, Assistance Publique–Hôpitaux de Paris (AP-HP) and Université de Paris, Paris, France
| | | | - Marina Salomé
- Paris Fire Brigade Medical Emergency Department, Paris, France
| | - Benoit Frattini
- Paris Fire Brigade Medical Emergency Department, Paris, France
| | | | - Romain Jouffroy
- Paris Fire Brigade Medical Emergency Department, Paris, France
- Intensive Care Unit, Ambroise Paré Hospital, AP-HP and Paris Saclay University, Boulogne Billancourt, France
| | | | - Rudy Titreville
- Paris Fire Brigade Medical Emergency Department, Paris, France
| | - Florian Roquet
- Paris Fire Brigade Medical Emergency Department, Paris, France
- Service d’Anesthésie-Réanimation, Hôpital Européen Georges-Pompidou, AP-HP, Paris, France
- Service de Biostatistique et Informatique Médicale, Unité Institut National de la Santé et de la Recherche Médicale, UMR 1153, Université Paris Diderot, Paris, France
| | - Olivier Stibbe
- Paris Fire Brigade Medical Emergency Department, Paris, France
| | - Benoit Vivien
- Service d’Aide Médicale Urgente de Paris, Hôpital Necker-Enfants Malades, AP-HP and Université de Paris, Paris, France
| | - Catherine Verret
- Direction de la Formation, de la Recherche et de l’Innovation, Service de Santé des Armées, Paris, France
| | - Michel Bignand
- Paris Fire Brigade Medical Emergency Department, Paris, France
| | | | - Christophe Martinaud
- Department of Clinical Operations, French Military Blood Institute, Clamart, France
| | - Michel Arock
- Laboratory of Hematology, Pitié-Salpêtrière Hospital, Paris, France
| | - Mathieu Raux
- Département d’Anesthésie Réanimation, AP-HP Groupe Hospitalier Universitaire, AP-HP–Sorbonne Université, Site Pitié-Salpêtrière, Paris, France
| | - Bertrand Prunet
- Paris Fire Brigade Medical Emergency Department, Paris, France
| | - Sylvain Ausset
- Department of Anesthesiology and Intensive Care, Percy Military Teaching Hospital, Clamart, France
| | - Anne Sailliol
- Department of Clinical Operations, French Military Blood Institute, Clamart, France
| | - Jean-Pierre Tourtier
- Paris Fire Brigade Medical Emergency Department, Paris, France
- Department of Anesthesiology and Intensive Care, Bégin Military Teaching Hospital, Saint-Mandé, France
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29
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Stanworth SJ, Dowling K, Curry N, Doughty H, Hunt BJ, Fraser L, Narayan S, Smith J, Sullivan I, Green L. A guideline for the haematological management of major haemorrhage: a British Society for Haematology Guideline. Br J Haematol 2022; 198:654-667. [PMID: 35687716 DOI: 10.1111/bjh.18275] [Citation(s) in RCA: 30] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 05/07/2022] [Accepted: 05/09/2022] [Indexed: 12/17/2022]
Affiliation(s)
- Simon J Stanworth
- Transfusion Medicine, NHS Blood and Transplant, Oxford, UK.,Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.,Radcliffe Department of Medicine, University of Oxford, and NIHR Oxford Biomedical Research Centre, Oxford, UK
| | - Kerry Dowling
- Transfusion Laboratory Manager, Southampton University Hospitals NHS Foundation Trust, Southampton, UK
| | - Nikki Curry
- Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.,Radcliffe Department of Medicine, University of Oxford, and NIHR Oxford Biomedical Research Centre, Oxford, UK
| | - Heidi Doughty
- Institute of Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK.,NIHR Surgical Reconstruction and Microbiology Research Centre, Birmingham, UK
| | - Beverley J Hunt
- Department of Haematology, Guy's and St Thomas's Hospital, London, UK
| | - Laura Fraser
- Transfusion Practitioner, NHS Lanarkshire, University Hospital Wishaw, Wishaw, UK.,National Services Scotland/Scottish National Blood Transfusion, Edinburgh, UK
| | - Shruthi Narayan
- Medical director, Serious Hazards of Transfusion, Manchester, UK
| | - Juliet Smith
- Lead Transfusion Practitioner, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Ian Sullivan
- Transfusion Laboratory Manager, Royal Cornwall Hospitals NHS Trust, Truro, UK
| | - Laura Green
- Transfusion Medicine, NHS Blood and Transplant, London, UK.,Barts Health NHS Trust, London, UK.,Blizzard Institute, Queen Mary University of London, London, UK
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30
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Guyette FX, Zenati M, Triulzi DJ, Yazer MH, Skroczky H, Early BJ, Adams PW, Brown JB, Alarcon L, Neal MD, Forsythe RM, Zuckerbraun BS, Peitzman AB, Billiar TR, Sperry JL. Prehospital low titer group O whole blood is feasible and safe: Results of a prospective randomized pilot trial. J Trauma Acute Care Surg 2022; 92:839-847. [PMID: 35081595 PMCID: PMC9038638 DOI: 10.1097/ta.0000000000003551] [Citation(s) in RCA: 31] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Low titer group O whole blood (LTOWB) resuscitation is increasingly common in both military and civilian settings. Data regarding the safety and efficacy of prehospital LTOWB remain limited. METHODS We performed a single-center, prospective, cluster randomized, prehospital through in-hospital whole blood pilot trial for injured air medical patients. We compared standard prehospital air medical care including red cell transfusion and crystalloids followed by in-hospital component transfusion to prehospital and in-hospital LTOWB resuscitation. Prehospital vital signs were used as inclusion criteria (systolic blood pressure ≤90 mm Hg and heart rate ≥108 beats per minute or systolic blood pressure ≤70 mm Hg for patients at risk of hemorrhage). Primary outcome was feasibility. Secondary outcomes included 28-day and 24-hour mortality, multiple organ failure, nosocomial infection, 24-hour transfusion requirements, and arrival coagulation parameters. RESULTS Between November 2018 and October 2020, 86 injured patients were cluster randomized by helicopter base. The trial has halted early at 77% enrollment. Overall, 28-day mortality for the cohort was 26%. Injured patients randomized to prehospital LTOWB (n = 40) relative to standard care (n = 46) were similar in demographics and injury characteristics. Intent-to-treat Kaplan-Meier survival analysis demonstrated no statistical mortality benefit at 28 days (25.0% vs. 26.1%, p = 0.85). Patients randomized to prehospital LTOWB relative to standard care had lower red cell transfusion requirements at 24 hours (p < 0.01) and a lower incidence of abnormal thromboelastographic measurements. No transfusion reactions during the prehospital or in-hospital phase of care were documented. CONCLUSION Prehospital through in-hospital LTOWB resuscitation is safe and may be associated with hemostatic benefits. A large-scale clinical trial is feasible with protocol adjustment and would allow the effects of prehospital LTOWB on survival and other pertinent clinical outcomes to be appropriately characterized. LEVEL OF EVIDENCE Therapeutic/Care Management, Level II.
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Affiliation(s)
- Frank X. Guyette
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Mazen Zenati
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA
| | - Darrell J. Triulzi
- Department of Pathology and Institute for Transfusion Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Mark H. Yazer
- Department of Pathology and Institute for Transfusion Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Hunter Skroczky
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Barbara J. Early
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Peter W. Adams
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Joshua B. Brown
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA
| | - Louis Alarcon
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA
| | - Matthew D. Neal
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA
| | | | | | | | | | - Jason L. Sperry
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA
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31
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Barry M, Pati S. Targeting repair of the vascular endothelium and glycocalyx after traumatic injury with plasma and platelet resuscitation. Matrix Biol Plus 2022; 14:100107. [PMID: 35392184 PMCID: PMC8981767 DOI: 10.1016/j.mbplus.2022.100107] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Revised: 02/10/2022] [Accepted: 03/10/2022] [Indexed: 02/06/2023] Open
Abstract
Endothelial glycocalyx shedding is a key instigator of the endotheliopathy of trauma. Plasma and platelet transfusions preserve vascular integrity in pre-clinical models. However, platelets may be less effective than plasma in preserving the glycocalyx.
Severely injured patients with hemorrhagic shock can develop endothelial dysfunction, systemic inflammation, and coagulation disturbances collectively known as the endotheliopathy of trauma (EOT). Shedding of the endothelial glycocalyx occurs early after injury, contributes to breakdown of the vascular barrier, and plays a critical role in the pathogenesis of multiple organ dysfunction, leading to poor outcomes in trauma patients. In this review we discuss (i) the pathophysiology of endothelial glycocalyx and vascular barrier breakdown following hemorrhagic shock and trauma, and (ii) the role of plasma and platelet transfusion in maintaining the glycocalyx and vascular endothelial integrity.
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Affiliation(s)
- Mark Barry
- University of California, San Francisco, Department of Surgery. 513 Parnassus Ave., San Francisco, CA 94143, United States
- Corresponding author.
| | - Shibani Pati
- University of California, San Francisco, Department of Surgery. 513 Parnassus Ave., San Francisco, CA 94143, United States
- University of California, San Francisco, Department of Laboratory Medicine. 513 Parnassus Ave., San Francisco, CA 94143, United States
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32
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Harrington J, Zarzaur BL, Fox EE, Wade CE, Holcomb JB, Savage SA. Variations in clot phenotype following injury: The MA-R ratio and fragile clots. J Trauma Acute Care Surg 2022; 92:504-510. [PMID: 35196304 PMCID: PMC8887779 DOI: 10.1097/ta.0000000000003442] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Trauma-induced coagulopathy is a continuum ranging from hypercoagulable to hypercoagulable phenotypes. In single-center studies, the maximum amplitude (MA) to r-time (R) (MA-R) ratio has identified a phenotype of injured patients with high mortality risk. The purpose of this study was to determine the relationship between MA-R and mortality using multicenter data and to investigate fibrinogen consumption in the development of this specific coagulopathy phenotype. METHODS Using the Pragmatic Randomized Optimal Platelet and Plasma Ratios data set, patients were divided into blunt and penetrating injury cohorts. MA was divided by R time from admission thromboelastogram to calculate MA-R. MA-R was used to assess odds of early and late mortality using multivariable models. Multivariable models were used to assess thrombogram values in both cohorts. Refinement of the MA-R cut point was performed with Youden index. Repeat multivariable analysis was performed with a binary CRITICAL and NORMAL MA-R. RESULTS In initial analysis, MA-R quartiles were not associated with mortality in the penetrating cohort. In the blunt cohort, there was an association between low MA-R and early and late mortality. A refined cut point of 11 was identified (CRITICAL: MA-R, ≤11; NORMAL: MA-R, >11). CRITICAL MA-R was associated with mortality in both penetrating and blunt subgroups. In further injury subgroup analysis, CRITICAL patients had significantly decreased fibrinogen levels in the blunt subgroup only. In both blunt and penetrating injury, there was no difference in time to initiation of thrombin burst (lagtime). However, both endogenous thrombin potential and peak thrombin levels were significantly lower in CRITICAL patients. CONCLUSIONS MA-R identifies a trauma-induced coagulopathy phenotype characterized in blunt injury by impaired thrombin generation that is associated with early and late mortality. The endotheliopathy and tissue factor release likely plays a role in the cascade of impaired thrombin burst, possible early fibrinogen consumption and the weaker clot identified by MA-R. LEVEL OF EVIDENCE Therapeutic/care management, level II.
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Affiliation(s)
- James Harrington
- University of Wisconsin School of Medicine & Public Health, Madison, WI
| | - Ben L. Zarzaur
- University of Wisconsin School of Medicine & Public Health, Madison, WI
| | - Erin E. Fox
- University of Texas Health Science Center at Houston, Houston, TX
| | - Charles E. Wade
- University of Texas Health Science Center at Houston, Houston, TX
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Jackson BP, Sperry JL, Yazer MH. Prehospital Plasma Transfusion: What Does the Literature Show? Transfus Med Hemother 2022; 48:358-365. [PMID: 35082567 DOI: 10.1159/000519627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 09/08/2021] [Indexed: 11/19/2022] Open
Abstract
Background Early initiation of blood products transfusion after injury has been associated with improved patient outcomes following traumatic injury. The ability to transfuse patients' plasma in the prehospital setting provides a prime opportunity to begin resuscitation with blood products earlier and with a more balanced plasma: RBC ratio than what has traditionally been done. Published studies on the use of prehospital plasma show a complex relationship between its use and improved survival. Summary Examination of the literature shows that there may be a mortality benefit from the use of prehospital plasma, but that it may be limited to certain subgroups of trauma patients. The likelihood of realizing these survival benefits appears to be predicted by several factors including the type of injury, length of transport time, presence of traumatic brain injury, and total number of blood products transfused, whether the patient required only a few products or a massive transfusion. When taken as a whole the evidence appears to show that prehospital plasma may have a mortality benefit that is most clearly demonstrated in patients with blunt injuries, moderate transfusion requirements, traumatic brain injury, and/or transport time greater than 20 min, as well as those who demonstrate a certain cytokine expression profile. Key Messages The evidence suggests that a targeted use of prehospital plasma will most likely maximize the benefits from the use of this limited resource. It is also possible that prehospital plasma may best be provided through whole blood as survival benefits were greatest in patients who received both prehospital plasma and RBCs.
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Affiliation(s)
- Bryon P Jackson
- Department of Pathology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Jason L Sperry
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Mark H Yazer
- Department of Pathology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
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Wu J, Vodovotz Y, Abdelhamid S, Guyette FX, Yaffe MB, Gruen DS, Cyr A, Okonkwo DO, Kar UK, Krishnamoorthi N, Voinchet RG, Billiar IM, Yazer MH, Namas RA, Daley BJ, Miller RS, Harbrecht BG, Claridge JA, Phelan HA, Zuckerbraun BS, Johansson PI, Stensballe J, Morrissey JH, Tracy RP, Wisniewski SR, Neal MD, Sperry JL, Billiar TR. Multi-omic analysis in injured humans: Patterns align with outcomes and treatment responses. Cell Rep Med 2021; 2:100478. [PMID: 35028617 PMCID: PMC8715070 DOI: 10.1016/j.xcrm.2021.100478] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Revised: 08/18/2021] [Accepted: 11/23/2021] [Indexed: 12/16/2022]
Abstract
Trauma is a leading cause of death and morbidity worldwide. Here, we present the analysis of a longitudinal multi-omic dataset comprising clinical, cytokine, endotheliopathy biomarker, lipidome, metabolome, and proteome data from severely injured humans. A "systemic storm" pattern with release of 1,061 markers, together with a pattern suggestive of the "massive consumption" of 892 constitutive circulating markers, is identified in the acute phase post-trauma. Data integration reveals two human injury response endotypes, which align with clinical trajectory. Prehospital thawed plasma rescues only endotype 2 patients with traumatic brain injury (30-day mortality: 30.3 versus 75.0%; p = 0.0015). Ubiquitin carboxy-terminal hydrolase L1 (UCHL1) was identified as the most predictive circulating biomarker to identify endotype 2-traumatic brain injury (TBI) patients. These response patterns refine the paradigm for human injury, while the datasets provide a resource for the study of critical illness, trauma, and human stress responses.
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Affiliation(s)
- Junru Wu
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
- Pittsburgh Trauma Research Center, University of Pittsburgh, Pittsburgh, PA, USA
- Department of Cardiology & Center of Pharmacology, The 3rd Xiangya Hospital, Central South University, Changsha, China
- Eight-Year Program of Medicine, Xiangya School of Medicine, Central South University, Changsha, China
| | - Yoram Vodovotz
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
- Pittsburgh Trauma Research Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Sultan Abdelhamid
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
- Pittsburgh Trauma Research Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Francis X. Guyette
- Department of Emergency Medicine, Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Michael B. Yaffe
- Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology, Cambridge, MA, USA
- Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Danielle S. Gruen
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
- Pittsburgh Trauma Research Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Anthony Cyr
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
- Pittsburgh Trauma Research Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - David O. Okonkwo
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Upendra K. Kar
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
- Pittsburgh Trauma Research Center, University of Pittsburgh, Pittsburgh, PA, USA
| | | | | | - Isabel M. Billiar
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Mark H. Yazer
- The Institute for Transfusion Medicine, Pittsburgh, PA, USA
| | - Rami A. Namas
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
- Pittsburgh Trauma Research Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Brian J. Daley
- Department of Surgery, University of Tennessee Health Science Center, Knoxville, TN, USA
| | | | | | - Jeffrey A. Claridge
- Metro Health Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | - Herbert A. Phelan
- Department of Surgery, University of Texas Southwestern, Dallas, TX, USA
| | - Brian S. Zuckerbraun
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
- Pittsburgh Trauma Research Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Pär I. Johansson
- 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 Orthopaedics, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Emergency Medical Services, The Capital Region of Denmark, Hillerød, Denmark
| | - James H. Morrissey
- Departments of Biological Chemistry & Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Russell P. Tracy
- Department of Pathology & Laboratory Medicine and Biochemistry, University of Vermont Larner College of Medicine, Colchester, VT, USA
| | | | - Matthew D. Neal
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
- Pittsburgh Trauma Research Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jason L. Sperry
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
- Pittsburgh Trauma Research Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Timothy R. Billiar
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
- Pittsburgh Trauma Research Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - PAMPer study group
- The PAMPer study group is detailed in Supplemental acknowledgments (Document S1)
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An engineered activated factor V for the prevention and treatment of acute traumatic coagulopathy and bleeding in mice. Blood Adv 2021; 6:959-969. [PMID: 34861695 PMCID: PMC8945312 DOI: 10.1182/bloodadvances.2021005257] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Accepted: 11/15/2021] [Indexed: 11/25/2022] Open
Abstract
superFVa arrests severe bleeding and prevents the development of ATC after trauma. superFVa therapy restores functional hemostasis when initiated after onset of ATC caused by traumatic bleeding.
Acute traumatic coagulopathy (ATC) occurs in approximately 30% of patients with trauma and is associated with increased mortality. Excessive generation of activated protein C (APC) and hyperfibrinolysis are believed to be driving forces for ATC. Two mouse models were used to investigate whether an engineered activated FV variant (superFVa) that is resistant to inactivation by APC and contains a stabilizing A2-A3 domain disulfide bond can reduce traumatic bleeding and normalize hemostasis parameters in ATC. First, ATC was induced by the combination of trauma and shock. ATC was characterized by activated partial thromboplastin time (APTT) prolongation and reductions of factor V (FV), factor VIII (FVIII), and fibrinogen but not factor II and factor X. Administration of superFVa normalized the APTT, returned FV and FVIII clotting activity levels to their normal range, and reduced APC and thrombin-antithrombin (TAT) levels, indicating improved hemostasis. Next, a liver laceration model was used where ATC develops as a consequence of severe bleeding. superFVa prophylaxis before liver laceration reduced bleeding and prevented APTT prolongation, depletion of FV and FVIII, and excessive generation of APC. Thus, prophylactic administration of superFVa prevented the development of ATC. superFVa intervention started after the development of ATC stabilized bleeding, reversed prolonged APTT, returned FV and FVIII levels to their normal range, and reduced TAT levels that were increased by ATC. In summary, superFVa prevented ATC and traumatic bleeding when administered prophylactically, and superFVa stabilized bleeding and reversed abnormal hemostasis parameters when administered while ATC was in progress. Thus, superFVa may be an attractive strategy to intercept ATC and mitigate traumatic bleeding.
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Tucker H, Avery P, Brohi K, Davenport R, Griggs J, Weaver A, Green L. Outcome measures used in clinical research evaluating prehospital blood component transfusion in traumatically injured bleeding patients: A systematic review. J Trauma Acute Care Surg 2021; 91:1018-1024. [PMID: 34254958 DOI: 10.1097/ta.0000000000003360] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Trial outcomes should be relevant to all stakeholders and allow assessment of interventions' efficacy and safety at appropriate timeframes. There is no consensus regarding outcome measures in the growing field of prehospital trauma transfusion research. Harmonization of future clinical outcome reporting is key to facilitate interstudy comparisons and generate cohesive, robust evidence to guide practice. The objective of this study was to evaluate outcome measures reported in prehospital trauma transfusion trials. METHODS Data Sources, Eligibility Criteria, Participants, and InterventionsWe conducted a scoping systematic review to identify the type, number, and definitions of outcomes reported in randomized controlled trials, and prospective and retrospective observational cohort studies investigating prehospital blood component transfusion in adult and pediatric patients with traumatic hemorrhage. Electronic database searching of PubMed, Embase, Web of Science, Cochrane, OVID, clinical trials.gov, and the Transfusion Evidence Library was completed in accordance with Preferred Reporting Items for Meta-analyses guidelines.Study Appraisal and Synthesis MethodsTwo review authors independently extracted outcome data. Unique lists of salutogenic (patient-reported health and wellbeing outcomes) and nonsalutogenic focused outcomes were established. RESULTS A total of 3,471 records were identified. Thirty-four studies fulfilled the inclusion criteria: 4 military (n = 1,566 patients) and 30 civilian (n = 14,398 patients), all between 2000 and 2020. Two hundred twelve individual non-patient-reported outcomes were identified, which collapsed into 20 outcome domains with varied definitions and timings. All primary outcomes measured effectiveness, rather than safety or complications. Sixty-nine percent reported mortality, with 11 different definitions. No salutogenic outcomes were reported. CONCLUSION There is heterogeneity in outcome reporting and definitions, an absence of patient-reported outcome, and an emphasis on clinical effectiveness rather than safety or adverse events in prehospital trauma transfusion trials. We recommend stakeholder consultation and a Delphi process to develop a clearly defined minimum core outcome set for prehospital trauma transfusion trials. LEVEL OF EVIDENCE Scoping systematic review, level III.
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Affiliation(s)
- Harriet Tucker
- From the Centre for Trauma Sciences, Blizard Institute (H.T., K.B., R.D., L.G.), Queen Mary University of London, London, United Kingdom; Southmead Hospital (P.A.), North Bristol NHS Trust, Bristol, United Kingdom; Learning and Development (P.A.), South Western Ambulance Service NHS Foundation Trust, Bristol, United Kingdom; Air Ambulance Kent Surrey Sussex (J.G., H.T.), Rochester, United Kingdom; Faculty of Health Sciences (J.G.), University of Surrey, Guildford, United Kingdom; London's Air Ambulance (A.W.), London, United Kingdom; Barts Health NHS Foundation Trust (K.B., R.D., A.W., L.G.), London, United Kingdom; and NHS Blood and Transplant (L.G.), London, United Kingdom
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Bonaroti J, Abdelhamid S, Kar U, Sperry J, Zamora R, Namas RA, McKinley T, Vodovotz Y, Billiar T. The Use of Multiplexing to Identify Cytokine and Chemokine Networks in the Immune-Inflammatory Response to Trauma. Antioxid Redox Signal 2021; 35:1393-1406. [PMID: 33860683 PMCID: PMC8905234 DOI: 10.1089/ars.2021.0054] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Significance: The immunoinflammatory responses that follow trauma contribute to clinical trajectory and patient outcomes. While remarkable advances have been made in trauma services and injury management, clarity on how the immune system in humans responds to trauma is lagging. Recent Advances: Multiplexing platforms have transformed our ability to analyze comprehensive immune mediator responses in human trauma. In parallel, with the establishment of large data sets, computational methods have been adapted to yield new insights based on mediator patterns. These efforts have added an important data layer to the emerging multiomic characterization of the human response to injury. Critical Issues: Outcome after trauma is greatly affected by the host immunoinflammatory response. Excessive or sustained responses can contribute to organ damage. Hence, understanding the pathophysiology behind traumatic injury is of vital importance. Future Directions: This review summarizes our work in the study of circulating immune mediators in trauma patients. Our foundational studies into dynamic patterns of inflammatory mediators represent an important contribution to the concepts and computational challenges that these large data sets present. We hope to see further integration and understanding of multiomics strategies in the field of trauma that can aid in patient endotyping and in potentially identifiying certain therapeutic targets in the future. Antioxid. Redox Signal. 35, 1393-1406.
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Affiliation(s)
- Jillian Bonaroti
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Pittsburgh Trauma Research Center, Division of Trauma and Acute Care Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Sultan Abdelhamid
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Pittsburgh Trauma Research Center, Division of Trauma and Acute Care Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Upendra Kar
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Pittsburgh Trauma Research Center, Division of Trauma and Acute Care Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Jason Sperry
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Pittsburgh Trauma Research Center, Division of Trauma and Acute Care Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Ruben Zamora
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Center for Inflammation and Regeneration Modeling, McGowan Institute for Regenerative Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Rami Ahmd Namas
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Center for Inflammation and Regeneration Modeling, McGowan Institute for Regenerative Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Todd McKinley
- Department of Orthopedic Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Yoram Vodovotz
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Pittsburgh Trauma Research Center, Division of Trauma and Acute Care Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Timothy Billiar
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Pittsburgh Trauma Research Center, Division of Trauma and Acute Care Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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Zadorozny EV, Weigel T, Stone A, Gruen DS, Galvagno SM, Yazer MH, Brown JB, Guyette FX. Prehospital Lactate is Associated with the Need for Blood in Trauma. PREHOSP EMERG CARE 2021; 26:590-599. [PMID: 34550050 DOI: 10.1080/10903127.2021.1983096] [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: 10/20/2022]
Abstract
Background: Traumatic hemorrhage is the leading cause of preventable death, and its effects are often evident within the first 24 hours of hospital admission. We investigated the relationship between prehospital lactate measurement and administration of hospital blood products and life-saving interventions (LSIs) within 24 hours of hospital admission.Methods: We included trauma patients with recorded prehospital venous lactate transported by a single critical care transport service to a Level I trauma center between 2012 and 2019. We abstracted vital signs, mission type, anatomic location of injury, prehospital administration of crystalloid and blood products, and hospital LSIs started within 24 hours of admission. We used logistic regression to determine the association of prehospital lactate and in-hospital administration of blood products in groups with or without hypotensive patients. We investigated the effect of prehospital lactate concentration on secondary outcomes such as LSIs and mortality.Results: We included 2,170 patients transported from the scene or emergency department (ED), of whom 1,821 (84%) were normotensive. The median concentration of prehospital lactate was 2.10 mmol/L for the main population (IQR = 1.40-3.30) and 2.00 mmol/L for the normotensive subgroup (IQR = 1.30-2.90). A higher prehospital lactate concentration was associated with higher odds of needing early hospital blood products in the whole study population (OR = 1.12, (95% CI 1.06-1.20), p < 0.01) and in the normotensive subgroup (OR = 1.13, (95% CI 1.03-1.22), p = 0.01). These positive associations were also observed with the secondary outcome of hospital LSIs, and higher prehospital lactate was also associated with higher odds of mortality (OR = 1.32, (95% CI 1.20-1.45), p < 0.01).Conclusions: Higher concentrations of prehospital lactate were associated with the need for in-hospital blood transfusion within 24 hours of admission. The relationship between lactate and blood transfusion persisted among normotensive patients. Further work is needed to incorporate prehospital lactate into decision support tools for prehospital blood administration.
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Hrebinko KA, Sperry JL, Guyette FX, Brown JB, Daley BJ, Miller RS, Harbrecht BG, Claridge JA, Phelan HA, Neal MD, Zuckerbraun BS, Yazer MH, Nicholson KJ. Evaluating the Cost-effectiveness of Prehospital Plasma Transfusion in Unstable Trauma Patients: A Secondary Analysis of the PAMPer Trial. JAMA Surg 2021; 156:1131-1139. [PMID: 34550318 DOI: 10.1001/jamasurg.2021.4529] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Importance Prehospital plasma transfusion is lifesaving for trauma patients in hemorrhagic shock but is not commonly used owing to cost and feasibility concerns. Objective To evaluate the cost-effectiveness of prehospital thawed plasma transfusion in trauma patients with hemorrhagic shock during air medical transport. Design, Setting, and Participants A decision tree and Markov model were created to compare standard care and prehospital thawed plasma transfusion using published and unpublished patient-level data from the Prehospital Plasma in Air Medical Transport in Trauma Patients at Risk for Hemorrhagic Shock (PAMPer) trial conducted from May 2014 to October 2017, health care and trauma-specific databases, and the published literature. Prehospital transfusion, short-term inpatient care, and lifetime health care costs and quality of life outcomes were included. One-way, 2-way, and Monte Carlo probabilistic sensitivity analyses were performed across clinically plausible ranges. Data were analyzed in December 2019. Main Outcomes and Measures Relative costs and health-related quality of life were evaluated by an incremental cost-effectiveness ratio at a standard willingness-to-pay threshold of $100 000 per quality-adjusted life-year (QALY). Results The trial included 501 patients in the modified intention-to-treat cohort. Median (interquartile range) age for patients in the thawed plasma and standard care cohorts were 44 (31-59) and 46 (28-60) years, respectively. Overall, 364 patients (72.7%) were male. Thawed plasma transfusion was cost-effective with an incremental cost-effectiveness ratio of $50 467.44 per QALY compared with standard care. The preference for thawed plasma was robust across all 1- and 2-way sensitivity analyses. When considering only patients injured by a blunt mechanism, the incremental cost-effectiveness ratio decreased to $37 735.19 per QALY. Thawed plasma was preferred in 8140 of 10 000 iterations (81.4%) on probabilistic sensitivity analysis. A detailed analysis of incremental costs between strategies revealed most were attributable to the in-hospital and postdischarge lifetime care of critically ill patients surviving severe trauma. Conclusions and Relevance In this study, prehospital thawed plasma transfusion during air medical transport for trauma patients in hemorrhagic shock was lifesaving and cost-effective compared with standard care and should become commonplace.
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Affiliation(s)
| | - Jason L Sperry
- Division of Trauma & Acute Care Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Francis X Guyette
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Joshua B Brown
- Division of Trauma & Acute Care Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Brian J Daley
- Division of Trauma & Critical Care Surgery, Department of Surgery, University of Tennessee Graduate School of Medicine, Knoxville
| | | | - Brian G Harbrecht
- Division of Trauma Surgery, Department of Surgery, University of Louisville, Louisville, Kentucky
| | - Jeffrey A Claridge
- Division of Trauma & Critical Care, Metrohealth Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - Herb A Phelan
- Division of Burn Surgery, Department of Surgery, Louisiana State University Health Sciences Center, New Orleans
| | - Matthew D Neal
- Division of Trauma & Acute Care Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Brian S Zuckerbraun
- Division of Trauma & Acute Care Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Mark H Yazer
- Department of Pathology, University of Pittsburgh, Pittsburgh, Pennsylvania
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Kleinveld DJB, Simons DDG, Dekimpe C, Deconinck SJ, Sloos PH, Maas MAW, Kers J, Muia J, Brohi K, Voorberg J, Vanhoorelbeke K, Hollmann MW, Juffermans NP. Plasma and rhADAMTS13 reduce trauma-induced organ failure by restoring the ADAMTS13-VWF axis. Blood Adv 2021; 5:3478-3491. [PMID: 34505883 PMCID: PMC8525227 DOI: 10.1182/bloodadvances.2021004404] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 05/06/2021] [Indexed: 11/20/2022] Open
Abstract
Trauma-induced organ failure is characterized by endothelial dysfunction. The aim of this study was to investigate the role of von Willebrand factor (VWF) and its cleaving enzyme, ADAMTS13 (a disintegrin and metalloproteinase with thrombospondin type 1 motifs, member 13) in the occurrence of endothelial permeability and organ failure in trauma. In an observational study in a level-1 trauma center, 169 adult trauma patients with clinical signs of shock and/or severe injuries were included. Trauma was associated with low ADAMTS13 and high VWF antigen levels, thus generating an imbalance of ADAMTS13 to VWF. Patients who developed organ failure (23%) had greater ADAMTS13-to-VWF imbalances, persistently lower platelet counts, and elevated levels of high-molecular-weight VWF multimers compared with those without organ failure, suggesting microthrombi formation. To investigate the effect of replenishing low ADAMTS13 levels on endothelial permeability and organ failure using either recombinant human ADAMTS13 (rhADAMTS13) or plasma transfusion, a rat model of trauma-induced shock and transfusion was used. Rats in traumatic hemorrhagic shock were randomized to receive crystalloids, crystalloids supplemented with rhADAMTS13, or plasma transfusion. A 70-kDa fluorescein isothiocyanate-labeled dextran was injected to determine endothelial leakage. Additionally, organs were histologically assessed. Both plasma transfusion and rhADAMTS13 were associated with a reduction in pulmonary endothelial permeability and organ injury when compared with resuscitation with crystalloids, but only rhADAMTS13 resulted in significant improvement of a trauma-induced decline in ADAMTS13 levels. We conclude that rhADAMTS13 and plasma transfusion can reduce organ failure following trauma. These findings implicate the ADAMTS13-VWF axis in the pathogenesis of organ failure.
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Affiliation(s)
- Derek J B Kleinveld
- Department of Intensive Care Medicine
- Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Derek D G Simons
- Department of Intensive Care Medicine
- Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Charlotte Dekimpe
- Laboratory for Thrombosis Research, KU Leuven Campus Kulak Kortrijk, Kortrijk, Belgium
| | - Shannen J Deconinck
- Laboratory for Thrombosis Research, KU Leuven Campus Kulak Kortrijk, Kortrijk, Belgium
| | - Pieter H Sloos
- Department of Intensive Care Medicine
- Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - M Adrie W Maas
- Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Jesper Kers
- Department of Pathology, Amsterdam Infection & Immunity Institute, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Department of Pathology, Leiden University Medical Center, Leiden, The Netherlands
| | - Joshua Muia
- Department of Biochemistry and Microbiology, Oklahoma State University Center for Health Sciences, Tulsa, OK
| | - Karim Brohi
- Centre for Trauma Sciences, Queen Mary University of London, London, United Kingdom
| | - Jan Voorberg
- Sanquin, Department of Cellular Hemostasis, Amsterdam, The Netherlands
| | - Karen Vanhoorelbeke
- Laboratory for Thrombosis Research, KU Leuven Campus Kulak Kortrijk, Kortrijk, Belgium
| | - Markus W Hollmann
- Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Department of Anesthesiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands; and
| | - Nicole P Juffermans
- Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Department of Intensive Care Medicine, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
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Peng HT, Rhind SG, Devine D, Jenkins C, Beckett A. Ex vivo hemostatic and immuno-inflammatory profiles of freeze-dried plasma. Transfusion 2021; 61 Suppl 1:S119-S130. [PMID: 34269465 DOI: 10.1111/trf.16502] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 04/01/2021] [Accepted: 04/01/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND Hemorrhage is a leading cause of preventable death in civilian and military trauma. Freeze-dried plasma is promising for hemostatic resuscitation in remote prehospital settings, given its potential benefits in reducing blood loss and mortality, long storage at ambient temperatures, high portability, and rapid reconstitution for transfusion in austere environments. Here we assess the ex vivo characteristics of a novel Terumo's freeze-dried plasma product (TFDP). STUDY DESIGN AND METHODS Rotational thromboelastometry (ROTEM) tests (INTEM, EXTEM, and FIBTEM) were conducted on plasma samples at 37°C with a ROTEM delta-machine using standard reagents and procedures. The following samples were analyzed: pooled plasma to produce TFDP, TFDP reconstituted, and stored immediately at -80°C, reconstituted TFDP stored at 4°C for 24 h and room temperature (RT) for 4 h before freezing at -80°C. Analysis of plasma concentrations of selected cytokines, chemokines, and vascular molecules was performed using a multiplex immunoassay system. One-way ANOVA with post hoc tests assessed differences in hemostatic and inflammatory properties. RESULTS No significant differences in ROTEM variables (coagulation time [CT], clot formation time, α-angle, maximum clot firmness, and lysis index 30) between the TFDP-producing plasma and reconstituted TFDP samples were observed. Compared to control plasma, reconstituted TFDP stored at 4°C for 24 h or RT for 4 h showed a longer INTEM CT. Levels of immuno-inflammatory mediators were similar between frozen plasma and TFDP. CONCLUSIONS TFDP is equivalent to frozen plasma with respect to global hemostatic and immuno-inflammatory mediator profiles. Further investigations of TFDP in trauma-induced coagulopathy models and bleeding patients are warranted.
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Affiliation(s)
- Henry T Peng
- Defence Research and Development Canada, Toronto Research Centre, Toronto, Ontario, Canada
| | - Shawn G Rhind
- Defence Research and Development Canada, Toronto Research Centre, Toronto, Ontario, Canada
| | - Dana Devine
- Canadian Blood Services, Ottawa, Ontario, Canada
| | | | - Andrew Beckett
- St. Michael's Hospital, Toronto, Ontario, Canada.,Royal Canadian Medical Services, Ottawa, Ontario, Canada
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Hall K, Drobatz K. Volume Resuscitation in the Acutely Hemorrhaging Patient: Historic Use to Current Applications. Front Vet Sci 2021; 8:638104. [PMID: 34395568 PMCID: PMC8357988 DOI: 10.3389/fvets.2021.638104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2020] [Accepted: 05/21/2021] [Indexed: 11/13/2022] Open
Abstract
Acute hemorrhage in small animals results from traumatic and non-traumatic causes. This review seeks to describe current understanding of the resuscitation of the acutely hemorrhaging small animal (dog and cat) veterinary patient through evaluation of pre-clinical canine models of hemorrhage and resuscitation, clinical research in dogs and cats, and selected extrapolation from human medicine. The physiologic dose and response to whole blood loss in the canine patient is repeatable both in anesthetized and awake animals and is primarily characterized clinically by increased heart rate, decreased systolic blood pressure, and increased shock index and biochemically by increased lactate and lower base excess. Previously, initial resuscitation in these patients included immediate volume support with crystalloid and/or colloid, regardless of total volume, with a target to replace lost vascular volume and bring blood pressure back to normal. Newer research now supports prioritizing hemorrhage control in conjunction with judicious crystalloid administration followed by early consideration for administration of platelets, plasma and red blood during the resuscitation phase. This approach minimizes blood loss, ameliorates coagulopathy, restores oxygen delivery and correct changes in the glycocalyx. There are many hurdles in the application of this approach in clinical veterinary medicine including the speed with which the bleeding source is controlled and the rapid availability of blood component therapy. Recommendations regarding the clinical approach to volume resuscitation in the acutely hemorrhaging veterinary patient are made based on the canine pre-clinical, veterinary clinical and human literature reviewed.
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Affiliation(s)
- Kelly Hall
- Department of Clinical Sciences, Critical Care Services, Colorado State University, Fort Collins, CO, United States
| | - Kenneth Drobatz
- Section of Critical Care, Department of Clinical Studies, University of Pennsylvania, Philadelphia, PA, United States
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Canton SP, Lutfi W, Daley BJ, Miller RS, Harbrecht BG, Claridge JA, Phelan HA, Guyette FX, Sperry JL, Brown JB. Lactate as a mediator of prehospital plasma mortality reduction in hemorrhagic shock. J Trauma Acute Care Surg 2021; 91:186-191. [PMID: 33797485 DOI: 10.1097/ta.0000000000003173] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Prehospital plasma transfusion in trauma reduces mortality. However, the underlying mechanism remains unclear. Reduction in shock severity may play a role. Lactate correlates with physiologic shock severity and mortality after injury. Our objective was to determine if prehospital plasma reduces lactate and if this contributes to the mortality benefit of plasma. METHODS Patients in the Prehospital Air Medical Plasma trial in the upper quartile of injury severity (Injury Severity Score, >30) were included to capture severe shock. Trial patients were randomized to prehospital plasma or standard care resuscitation (crystalloid ± packed red blood cells). Regression determined the associations between admission lactate, 30-day mortality, and plasma while adjusting for demographics, prehospital crystalloid, time, mechanism, and injury characteristics. Causal mediation analysis determined what proportion of the effect of plasma on mortality is mediated by lactate reduction. RESULTS A total of 125 patients were included. The plasma group had a lower adjusted admission lactate than standard of care group (coefficient, -1.64; 95% confidence interval [CI], -2.96 to -0.31; p = 0.02). Plasma was associated with lower odds of 30-day mortality (odds ratio [OR], 0.27; 95% CI, 0.08-0.90; p = 0.03). When adding lactate to this model, the effect of plasma on 30-day mortality was no longer significant (OR, 0.36; 95% CI, 0.07-1.88; p = 0.23), while lactate was associated with mortality (OR, 1.74 per 1 mmol/L increase; 95% CI, 1.10-2.73; p = 0.01). Causal mediation demonstrated 35.1% of the total effect of plasma on 30-day mortality was mediated by the reduction in lactate among plasma patients. CONCLUSION Prehospital plasma is associated with reduced 30-day mortality and lactate in severely injured patients. More than one third of the effect of plasma on mortality is mediated by a reduction in lactate. Thus, reducing the severity of hemorrhagic shock appears to be one mechanism of prehospital plasma benefit. Further study should elucidate other mechanisms and if a dose response exists. LEVEL OF EVIDENCE Therapeutic, level II.
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Affiliation(s)
- Stephen P Canton
- From the Division of Trauma and General Surgery, Department of Surgery (S.P.C., J.L.S., J.B.B.), University of Pittsburgh Medical Center, Pittsburgh; Department of Surgery (W.L.), University of Pennsylvania, Philadelphia, Pennsylvania; Department of Surgery (B.J.D.), University of Tennessee Health Science Center, Knoxville, Tennessee; Department of Surgery (R.S.M.), John Peter Smith Health Network, Fort Worth, Texas; Department of Surgery (B.G.H.), University of Louisville, Louisville, Kentucky; Department of Surgery (J.A.C.), MetroHealth Medical Center/Case Western Reserve University, Cleveland, Ohio; Department of Surgery (H.A.P.), Louisiana State University Health Sciences Center-New Orleans, New Orleans, Los Angeles; and Department of Emergency Medicine (F.X.G.), University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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van den Brink DP, Kleinveld DJB, Sloos PH, Thomas KA, Stensballe J, Johansson PI, Pati S, Sperry J, Spinella PC, Juffermans NP. Plasma as a resuscitation fluid for volume-depleted shock: Potential benefits and risks. Transfusion 2021; 61 Suppl 1:S301-S312. [PMID: 34057210 PMCID: PMC8361764 DOI: 10.1111/trf.16462] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 03/04/2021] [Accepted: 03/04/2021] [Indexed: 12/13/2022]
Affiliation(s)
- Daan P. van den Brink
- Department of Intensive Care MedicineAmsterdam UMCAmsterdamThe Netherlands
- Laboratory of Experimental Intensive Care and AnesthesiologyAmsterdam UMCAmsterdamThe Netherlands
| | - Derek J. B. Kleinveld
- Department of Intensive Care MedicineAmsterdam UMCAmsterdamThe Netherlands
- Laboratory of Experimental Intensive Care and AnesthesiologyAmsterdam UMCAmsterdamThe Netherlands
- Department of Trauma SurgeryAmsterdam UMCAmsterdamThe Netherlands
| | - Pieter H. Sloos
- Laboratory of Experimental Intensive Care and AnesthesiologyAmsterdam UMCAmsterdamThe Netherlands
- Department of Trauma SurgeryAmsterdam UMCAmsterdamThe Netherlands
| | | | - Jakob Stensballe
- Department of Anesthesia and Trauma Center, Centre of Head and OrthopedicsRigshospitalet, Copenhagen University HospitalCopenhagenDenmark
- Department of Clinical immunologyRigshospitalet, Copenhagen University HospitalCopenhagenDenmark
| | - Pär I. Johansson
- Department of Clinical immunologyRigshospitalet, Copenhagen University HospitalCopenhagenDenmark
| | - Shibani Pati
- Department of Laboratory MedicineUniversity of California San FranciscoSan FranciscoCaliforniaUSA
| | - Jason Sperry
- Department of Surgery and Critical Care MedicineUniversity of Pittsburgh Medical CenterPittsburghPennsylvaniaUSA
| | | | - Nicole P. Juffermans
- Laboratory of Experimental Intensive Care and AnesthesiologyAmsterdam UMCAmsterdamThe Netherlands
- Department of Intensive CareOLVG HospitalAmsterdamThe Netherlands
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45
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Cooper ES, Silverstein DC. Fluid Therapy and the Microcirculation in Health and Critical Illness. Front Vet Sci 2021; 8:625708. [PMID: 34055944 PMCID: PMC8155248 DOI: 10.3389/fvets.2021.625708] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Accepted: 04/06/2021] [Indexed: 12/15/2022] Open
Abstract
Fluid selection and administration during shock is typically guided by consideration of macrovascular abnormalities and resuscitative targets (perfusion parameters, heart rate, blood pressure, cardiac output). However, the microcirculatory unit (comprised of arterioles, true capillaries, and venules) is vital for the effective delivery of oxygen and nutrients to cells and removal of waste products from the tissue beds. Given that the microcirculation is subject to both systemic and local control, there is potential for functional changes and impacts on tissue perfusion that are not reflected by macrocirculatory parameters. This chapter will present an overview of the structure, function and regulation of the microcirculation and endothelial surface layer in health and shock states such as trauma, hemorrhage and sepsis. This will set the stage for consideration of how these microcirculatory characteristics, and the potential disconnect between micro- and macrovascular perfusion, may affect decisions related to acute fluid therapy (fluid type, amount, and rate) and monitoring of resuscitative efforts. Available evidence for the impact of various fluids and resuscitative strategies on the microcirculation will also be reviewed.
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Affiliation(s)
- Edward S Cooper
- Department of Veterinary Clinical Sciences, Ohio State University College of Veterinary Medicine, Columbus, OH, United States
| | - Deborah C Silverstein
- Department of Clinical Studies and Advanced Medicine, University of Pennsylvania School of Veterinary Medicine, Philadelphia, PA, United States
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Moore EE, Moore HB, Kornblith LZ, Neal MD, Hoffman M, Mutch NJ, Schöchl H, Hunt BJ, Sauaia A. Trauma-induced coagulopathy. Nat Rev Dis Primers 2021; 7:30. [PMID: 33927200 PMCID: PMC9107773 DOI: 10.1038/s41572-021-00264-3] [Citation(s) in RCA: 278] [Impact Index Per Article: 92.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/19/2021] [Indexed: 12/12/2022]
Abstract
Uncontrolled haemorrhage is a major preventable cause of death in patients with traumatic injury. Trauma-induced coagulopathy (TIC) describes abnormal coagulation processes that are attributable to trauma. In the early hours of TIC development, hypocoagulability is typically present, resulting in bleeding, whereas later TIC is characterized by a hypercoagulable state associated with venous thromboembolism and multiple organ failure. Several pathophysiological mechanisms underlie TIC; tissue injury and shock synergistically provoke endothelial, immune system, platelet and clotting activation, which are accentuated by the 'lethal triad' (coagulopathy, hypothermia and acidosis). Traumatic brain injury also has a distinct role in TIC. Haemostatic abnormalities include fibrinogen depletion, inadequate thrombin generation, impaired platelet function and dysregulated fibrinolysis. Laboratory diagnosis is based on coagulation abnormalities detected by conventional or viscoelastic haemostatic assays; however, it does not always match the clinical condition. Management priorities are stopping blood loss and reversing shock by restoring circulating blood volume, to prevent or reduce the risk of worsening TIC. Various blood products can be used in resuscitation; however, there is no international agreement on the optimal composition of transfusion components. Tranexamic acid is used in pre-hospital settings selectively in the USA and more widely in Europe and other locations. Survivors of TIC experience high rates of morbidity, which affects short-term and long-term quality of life and functional outcome.
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Affiliation(s)
- Ernest E Moore
- Ernest E Moore Shock Trauma Center at Denver Health, Denver, CO, USA.
- Department of Surgery, University of Colorado Denver, Aurora, CO, USA.
| | - Hunter B Moore
- Department of Surgery, University of Colorado Denver, Aurora, CO, USA
| | - Lucy Z Kornblith
- Trauma and Surgical Critical Care, Zuckerberg San Francisco General Hospital, University of California San Francisco, San Francisco, CA, USA
| | - Matthew D Neal
- Pittsburgh Trauma Research Center, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Maureane Hoffman
- Duke University School of Medicine, Transfusion Service, Durham VA Medical Center, Durham, NC, USA
| | - Nicola J Mutch
- Aberdeen Cardiovascular & Diabetes Centre, School of Medicine, Medical Sciences and Nutrition, Institute of Medical Sciences, University of Aberdeen, Aberdeen, UK
| | - Herbert Schöchl
- Department of Anesthesiology and Intensive Care Medicine, AUVA Trauma Centre Salzburg, Academic Teaching Hospital of the Paracelsus Medical University, Salzburg and Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, AUVA Trauma Research Centre, Vienna, Austria
| | | | - Angela Sauaia
- Department of Surgery, University of Colorado Denver, Aurora, CO, USA
- Colorado School of Public Health, University of Colorado Denver, Aurora, CO, USA
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McKinley TO, Gaski GE, Zamora R, Shen L, Sun Q, Namas RA, Billiar TR, Vodovotz Y. Early dynamic orchestration of immunologic mediators identifies multiply injured patients who are tolerant or sensitive to hemorrhage. J Trauma Acute Care Surg 2021; 90:441-450. [PMID: 33093290 DOI: 10.1097/ta.0000000000002998] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Multiply injured patients (MIPs) are at risk of complications including infections, and acute and prolonged organ dysfunction. The immunologic response to injury has been shown to affect outcomes. Recent advances in computational capabilities have shown that early dynamic coordination of the immunologic response is associated with improved outcomes after trauma. We hypothesized that patients who were sensitive or tolerant of hemorrhage would demonstrate differences in dynamic immunologic orchestration within hours of injury. METHODS We identified two groups of MIPs who demonstrated distinct clinical tolerance to hemorrhage (n = 10) or distinct clinical sensitivity to hemorrhage (n = 9) from a consecutive cohort of 100 MIPs. Hemorrhage was quantified by integrating elevated shock index values for 24 hours after injury (shock volume). Clinical outcomes were quantified by average Marshall Organ Dysfunction Scores from days 2 to 5 after injury. Shock-sensitive patients had high cumulative organ dysfunction after lower magnitude hemorrhage. Shock-tolerant (ST) patients had low cumulative organ dysfunction after higher magnitude hemorrhage. Computational methods were used to analyze a panel of 20 immunologic mediators collected serially over the initial 72 hours after injury. RESULTS Dynamic network analysis demonstrated the ST patients had increased orchestration of cytokines that are reparative and protective including interleukins 9, 17E/25, 21, 22, 23, and 33 during the initial 0- to 8-hour and 8- to 24-hour intervals after injury. Shock-sensitive patients had delayed immunologic orchestration of a network of largely proinflammatory and anti-inflammatory mediators. Elastic net linear regression demonstrated that a group of five mediators could discriminate between shock-sensitive and ST patients. CONCLUSIONS Preliminary evidence from this study suggests that early immunologic orchestration discriminates between patients who are notably tolerant or sensitive to hemorrhage. Early orchestration of a group of reparative/protective mediators was amplified in shock-tolerant patients. LEVEL OF EVIDENCE Prospective clinical outcomes study, level III.
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Affiliation(s)
- Todd O McKinley
- From the Department of Orthopaedic Surgery, (T.O.M.), Indiana University School of Medicine, Indianapolis, Indiana; Department of Orthopaedic Surgery, INOVA Health System (G.E.G.), Fairfax, Virginia; Department of Surgery, (R.Z., R.A.N., T.R.B., Y.V.), University of Pittsburgh School of Medicine, Pittsburgh; Department of Biostatistics, Epidemiology and Informatics, School of Medicine (L.S.), University of Pennsylvania, Philadelphia, Pennsylvania; and Department of Preventive Medicine, Keck School of Medicine, (Q.S.), University of Southern California, Los Angeles, California
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Reitz KM, Gruen DS, Guyette F, Brown JB, Yazer MH, Vodovotz Y, Johanssen PI, Stensballe J, Daley B, Miller RS, Harbrecht BG, Claridge J, Phelan HA, Neal MD, Zuckerbraun BS, Sperry JL. Age of thawed plasma does not affect clinical outcomes or biomarker expression in patients receiving prehospital thawed plasma: a PAMPer secondary analysis. Trauma Surg Acute Care Open 2021; 6:e000648. [PMID: 33634214 PMCID: PMC7880105 DOI: 10.1136/tsaco-2020-000648] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 01/13/2021] [Accepted: 01/25/2021] [Indexed: 12/26/2022] Open
Abstract
Background Prehospital plasma administration during air medical transport reduces the endotheliopathy of trauma, circulating pro-inflammatory cytokines, and 30-day mortality among traumatically injured patients at risk of hemorrhagic shock. No clinical data currently exists evaluating the age of thawed plasma and its association with clinical outcomes and biomarker expression post-injury. Methods We performed a secondary analysis from the prehospital plasma administration randomized controlled trial, PAMPer. We dichotomized the age of thawed plasma creating three groups: standard-care, YOUNG (day 0-1) plasma, and OLD (day 2-5) plasma. We generated HRs and 95% CIs for mortality. Among all patients randomized to plasma, we compared predicted biomarker values at hospital admission (T0) and 24 hours later (T24) controlling for key difference between groups with a multivariable linear regression. Analyses were repeated in a severely injured subgroup. Results Two hundred and seventy-one patients were randomized to standard-care and 230 to plasma (40% YOUNG, 60% OLD). There were no clinically or statistically significant differences in demographics, injury, admission vital signs, or laboratory values including thromboelastography between YOUNG and OLD. Compared with standard-care, YOUNG (HR 0.66 (95% CI 0.41 to 1.07), p=0.09) and OLD (HR 0.64 (95% CI 0.42 to 0.96), p=0.03) plasma demonstrated reduced 30-day mortality. Among those randomized to plasma, plasma age did not affect mortality (HR 1.04 (95% CI 0.60 to 1.82), p=0.90) and/or adjusted serum markers by plasma age at T0 or T24 (p>0.05). However, among the severely injured subgroup, OLD plasma was significantly associated with increased adjusted inflammatory and decreased adjusted endothelial biomarkers at T0. Discussion Age of thawed plasma does not result in clinical outcome or biomarker expression differences in the overall PAMPer study cohort. There were biomarker expression differences in those patients with severe injury. Definitive investigation is needed to determine if the age of thawed plasma is associated with biomarker expression and outcome differences following traumatic injury. Level of evidence II.
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Affiliation(s)
- Katherine M Reitz
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Danielle S Gruen
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Frances Guyette
- Emergency Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Joshua B Brown
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Mark H Yazer
- Department of Pathology, University of Pittsburgh and the Institute for Transfusion Medicine, Pittsburgh, Pennsylvania, USA
| | - Yoram Vodovotz
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Pär I Johanssen
- Capital Region Blood Bank, Section for Transfusion Medicine, University of Copenhagen, Kobenhavn, Denmark
| | - Jakob Stensballe
- Capital Region Blood Bank, Section for Transfusion Medicine, University of Copenhagen, Kobenhavn, Denmark
| | - Brian Daley
- The University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Richard S Miller
- Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | | | | | - Herb A Phelan
- Surgery, The University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Matthew D Neal
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Brian S Zuckerbraun
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Jason L Sperry
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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Gruen DS, Guyette FX, Brown JB, Daley BJ, Miller RS, Harbrecht BG, Claridge JA, Phelan HA, Yazer MH, Neal MD, Zuckerbraun BS, Sperry JL. Characterization of unexpected survivors following a prehospital plasma randomized trial. J Trauma Acute Care Surg 2021; 89:908-914. [PMID: 32472902 DOI: 10.1097/ta.0000000000002816] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Prehospital plasma improves survival for severely injured trauma patients transported by air ambulance. We sought to characterize the unexpected survivors, patients who survived despite having high predicted mortality after traumatic injury. METHODS The Prehospital Air Medical Plasma trial randomized severely injured patients (n = 501) to receive either standard care (crystalloid) or two units of prehospital plasma followed by standard care fluid resuscitation. We built a generalized linear model to estimate patient mortality. Area under the receiver operating characteristic curve was used to evaluate model performance. We defined unexpected survivors as patients who had a predicted mortality greater than 50% and survived to 30 days. We characterized patient demographics, clinical features, and outcomes of the unexpected survivors. Observed to expected (O/E) ratios and Z-statistics were calculated using model-estimated mortality for each cohort. RESULTS Our model predicted mortality better than Injury Severity Score or Revised Trauma Score parameters and identified 36 unexpected survivors. Compared with expected survivors, unexpected survivors were younger (33 years [24, 52 years] vs. 47 years [32, 59 years], p = 0.013), were more severely injured (Injury Severity Score 34 [22, 50] vs. 18 [10, 27], p < 0.001), had worse organ dysfunction and hospital resource outcomes (multiple organ failure, intensive care unit, hospital length of stay, and ventilator days), and were more likely to receive prehospital plasma (67 vs. 46%, p = 0.031). Nonsurvivors with high predicted mortality were more likely to receive standard care resuscitation (p < 0.001). Unexpected survivors who received prehospital plasma had a lower observed to expected mortality than those that received standard care resuscitation (O/E 0.56 [0.33-0.84] vs. 1.0 [0.73-1.32]). The number of prehospital plasma survivors (24) exceeded the number of predicted survivors (n = 10) estimated by our model (p < 0.001). CONCLUSION Prehospital plasma is associated with an increase in the number of unexpected survivors following severe traumatic injury. Prehospital interventions may improve the probability of survival for injured patients with high predicted mortality based on early injury characteristics, vital signs, and resuscitation measures. LEVEL OF EVIDENCE Therapeutic Level III.
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Affiliation(s)
- Danielle S Gruen
- From the Department of Surgery (D.S.G., J.B.B., M.D.N., B.S.Z., J.L.S.), University of Pittsburgh; Division of Trauma and Acute Care Surgery (D.S.G., J.B.B., M.D.N., B.S.Z., J.L.S.), Pittsburgh Trauma Research Center; Department of Emergency Medicine (F.X.G.), University of Pittsburgh, Pittsburgh, Pennsylvania; Department of Surgery (B.J.D.), University of Tennessee Health Science Center, Knoxville; Department of Surgery (R.S.M.), Vanderbilt University Medical Center, Nashville, Tennessee; University of Louisville (B.G.H.), Louisville, Kentucky; MetroHealth Medical Center (J.A.C.), Case Western Reserve University, Cleveland, Ohio; Department of Surgery (H.A.P.), University of Texas Southwestern, Parkland Memorial Hospital, Dallas, Texas; and Department of Pathology (M.H.Y.), University of Pittsburgh, Pittsburgh, Pennsylvania
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Wu J, Cyr A, Gruen DS, Lovelace TC, Benos PV, Chen T, Guyette FX, Yazer MH, Daley BJ, Miller RS, Harbrecht BG, Claridge JA, Phelan HA, Zuckerbraun BS, Neal MD, Johansson PI, Stensballe J, Namas RA, Vodovotz Y, Sperry JL, Billiar TR. Lipidomic Signatures Align with Inflammatory Patterns and Outcomes in Critical Illness. RESEARCH SQUARE 2021:rs.3.rs-106579. [PMID: 33442677 PMCID: PMC7805459 DOI: 10.21203/rs.3.rs-106579/v1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Alterations in lipid metabolism have the potential to be markers as well as drivers of the pathobiology of acute critical illness. Here, we took advantage of the temporal precision offered by trauma as a common cause of critical illness to identify the dynamic patterns in the circulating lipidome in critically ill humans. The major findings include an early loss of all classes of circulating lipids followed by a delayed and selective lipogenesis in patients destined to remain critically ill. Early in the clinical course, Fresh Frozen Plasma administration led to improved survival in association with preserved lipid levels that related to favorable changes in coagulation and inflammation biomarkers. Late over-representation of phosphatidylethanolamines with critical illness led to the validation of a Lipid Reprogramming Score that was prognostic not only in trauma but also severe COVID-19 patients. Our lipidomic findings provide a new paradigm for the lipid response underlying critical illness.
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Affiliation(s)
- Junru Wu
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Pittsburgh Trauma Research Center, Division of Trauma and Acute Care Surgery, Pittsburgh, Pennsylvania, US
- Department of Cardiology, The 3rd Xiangya Hospital, Central South University, Changsha, China
- Eight-year program of medicine, Xiangya School of Medicine, Central South University, Changsha, China
| | - Anthony Cyr
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Pittsburgh Trauma Research Center, Division of Trauma and Acute Care Surgery, Pittsburgh, Pennsylvania, US
| | - Danielle S. Gruen
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Pittsburgh Trauma Research Center, Division of Trauma and Acute Care Surgery, Pittsburgh, Pennsylvania, US
| | - Tyler C. Lovelace
- Department of Computational and Systems Biology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Joint CMU-Pitt PhD Program in Computational Biology, Pittsburgh, Pennsylvania, USA
| | - Panayiotis V. Benos
- Department of Computational and Systems Biology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Joint CMU-Pitt PhD Program in Computational Biology, Pittsburgh, Pennsylvania, USA
| | - Tianmeng Chen
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Cellular and Molecular Pathology Program, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Francis X. Guyette
- Department of Emergency Medicine, Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Mark H. Yazer
- The Institute for Transfusion Medicine, Pittsburgh, Pennsylvania, USA
| | - Brian J. Daley
- Department of Surgery, University of Tennessee Health Science Center, Knoxville, Tennessee, USA
| | - Richard S. Miller
- Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Brian G. Harbrecht
- Department of Surgery, University of Louisville, Louisville, Kentucky, USA
| | - Jeffrey A. Claridge
- Metro Health Medical Center, Case Western Reserve University, Cleveland, Ohio, USA
| | - Herb A. Phelan
- Department of Surgery, University of Texas Southwestern, Dallas, Texas, USA
| | - Brian S. Zuckerbraun
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Pittsburgh Trauma Research Center, Division of Trauma and Acute Care Surgery, Pittsburgh, Pennsylvania, US
| | - Matthew D. Neal
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Pittsburgh Trauma Research Center, Division of Trauma and Acute Care Surgery, Pittsburgh, Pennsylvania, US
| | - Pär I. Johansson
- 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 Orthopaedics, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Emergency Medical Services, The Capital Region of Denmark, Denmark
| | - Rami A. Namas
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Pittsburgh Trauma Research Center, Division of Trauma and Acute Care Surgery, Pittsburgh, Pennsylvania, US
| | - Yoram Vodovotz
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Pittsburgh Trauma Research Center, Division of Trauma and Acute Care Surgery, Pittsburgh, Pennsylvania, US
| | - Jason L. Sperry
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Pittsburgh Trauma Research Center, Division of Trauma and Acute Care Surgery, Pittsburgh, Pennsylvania, US
| | - Timothy R. Billiar
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Pittsburgh Trauma Research Center, Division of Trauma and Acute Care Surgery, Pittsburgh, Pennsylvania, US
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