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Moore SA, Rollins-Raval MA, Gillette JM, Kiss JE, Triulzi DJ, Yazer MH, Paul JS, Leeper CM, Neal MD, Raval JS. Therapeutic plasma exchange is feasible and tolerable in severely injured patients with trauma-induced coagulopathy. Trauma Surg Acute Care Open 2024; 9:e001126. [PMID: 38196934 PMCID: PMC10773431 DOI: 10.1136/tsaco-2023-001126] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Accepted: 10/11/2023] [Indexed: 01/11/2024] Open
Abstract
Objectives Trauma-induced coagulopathy (TIC) occurs in a subset of severely injured trauma patients. Despite having achieved surgical hemostasis, these individuals can have persistent bleeding, clotting, or both in conjunction with deranged coagulation parameters and typically require transfusion support with plasma, platelets, and/or cryoprecipitate. Due to the multifactorial nature of TIC, targeted interventions usually do not have significant clinical benefits. Therapeutic plasma exchange (TPE) is a non-specific modality of removing and replacing a patient's plasma in a euvolemic manner that can temporarily normalize coagulation parameters and remove deleterious substances, and may be beneficial in such patients with TIC. Methods In a prospective case series, TPE was performed in severely injured trauma patients diagnosed with TIC and transfusion requirement. These individuals all underwent a series of at least 3 TPE procedures performed once daily with plasma as the exclusive replacement fluid. Demographic, injury, laboratory, TPE, and outcome data were collected and analyzed. Results In total, 7 patients received 23 TPE procedures. All patients had marked improvements in routine coagulation parameters, platelet counts, a disintegrin and metalloproteinase with a thrombospondin type 1 motif, member 13 (ADAMTS13) activities, inflammatory markers including interleukin-6 concentrations, and organ system injuries after completion of their TPE treatments. All-cause mortality rates at 1 day, 7 days, and 30 days were 0%, 0%, and 43%, respectively, and all patients for whom TPE was initiated within 24 hours after injury survived to the 30-day timepoint. Surgical, critical care, and apheresis nursing personnel who were surveyed were universally positive about the utilization of TPE in this patient population. These procedures were tolerated well with the most common adverse event being laboratory-diagnosed hypocalcemia. Conclusion TPE is feasible and tolerable in severely injured trauma patients with TIC. However, many questions remain regarding the application of TPE for these critically ill patients including identification of the optimal injured population, ideal time of treatment initiation, appropriate treatment intensity, and concurrent use of adjunctive treatments. Level of evidence Level V.
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Affiliation(s)
- Sarah A Moore
- Surgery, University of New Mexico Health Sciences Center, Albuquerque, New Mexico, USA
| | - Marian A Rollins-Raval
- Pathology, University of New Mexico Health Sciences Center, Albuquerque, New Mexico, USA
| | - Jennifer M Gillette
- Pathology, University of New Mexico Health Sciences Center, Albuquerque, New Mexico, USA
| | - Joseph E Kiss
- Medicine, University of Pittsburgh Medical Center Health System, Pittsburgh, Pennsylvania, USA
| | - Darrell J Triulzi
- Pathology, University of Pittsburgh Medical Center Health System, Pittsburgh, Pennsylvania, USA
| | - Mark H Yazer
- Pathology, University of Pittsburgh Medical Center Health System, Pittsburgh, Pennsylvania, USA
| | - Jasmeet S Paul
- Surgery, University of New Mexico Health Sciences Center, Albuquerque, New Mexico, USA
| | | | - Matthew D Neal
- Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Jay S Raval
- Pathology, University of New Mexico Health Sciences Center, Albuquerque, New Mexico, USA
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Santos J, Grigorian A, Kuza C, Emigh B, Jeng J, Qazi A, Nguyen NT, Nahmias J. Development and Validation of a Renal Replacement after Trauma Scoring Tool. J Am Coll Surg 2023; 237:79-86. [PMID: 36847387 DOI: 10.1097/xcs.0000000000000667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/01/2023]
Abstract
BACKGROUND Stress on the healthcare system requires careful allocation of resources such as renal replacement therapy (RRT). The COVID-19 pandemic generated difficulty securing access to RRT for trauma patients. We sought to develop a renal replacement after trauma (RAT) scoring tool to help identify trauma patients who may require RRT during their hospitalization. STUDY DESIGN The 2017 to 2020 TQIP database was divided into a derivation (2017 to 2018 data) and validation (2019 to 2020 data) set. A 3-step methodology was used. Adult trauma patients admitted from the emergency department to the operating room or ICU were included. Patients with chronic kidney disease, transfers from another hospital, and emergency department death were excluded. Multiple logistic regression models were created to determine the risk for RRT in trauma patients. The weighted average and relative impact of each independent predictor was used to derive a RAT score, which was validated using area under receiver operating characteristic curve (AUROC). RESULTS From 398,873 patients in the derivation and 409,037 patients in the validation set, 11 independent predictors of RRT were included in the RAT score derived with scores ranging from 0 to 11. The AUROC for the derivation set was 0.85. The rate of RRT increased to 1.1%, 3.3%, and 20% at scores of 6, 8, and 10, respectively. The validation set AUROC was 0.83. CONCLUSIONS RAT is a novel and validated scoring tool to help predict the need for RRT in trauma patients. With future improvements including baseline renal function and other variables, the RAT tool may help prepare for the allocation of RRT machines/staff during times of limited resources.
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Affiliation(s)
- Jeffrey Santos
- From the Division of Trauma, Burns, & Surgical Critical Care, University of California, Irvine, Orange, CA (Santos, Grigorian, Jeng, Qazi)
| | - Areg Grigorian
- From the Division of Trauma, Burns, & Surgical Critical Care, University of California, Irvine, Orange, CA (Santos, Grigorian, Jeng, Qazi)
| | - Catherine Kuza
- the Department of Anesthesiology, University of Southern California, Los Angeles, CA (Kuza)
| | - Brent Emigh
- the Warren Alpert Medical School of Brown University, Providence, RI (Emigh)
| | - James Jeng
- From the Division of Trauma, Burns, & Surgical Critical Care, University of California, Irvine, Orange, CA (Santos, Grigorian, Jeng, Qazi)
| | - Alliya Qazi
- From the Division of Trauma, Burns, & Surgical Critical Care, University of California, Irvine, Orange, CA (Santos, Grigorian, Jeng, Qazi)
| | - Ninh T Nguyen
- the Division of Gastrointestinal Surgery, University of California, Irvine, Orange, CA (Nguyen)
| | - Jeffry Nahmias
- From the Division of Trauma, Burns, & Surgical Critical Care, University of California, Irvine, Orange, CA (Santos, Grigorian, Jeng, Qazi)
- the Department of Anesthesiology, University of Southern California, Los Angeles, CA (Kuza)
- the Warren Alpert Medical School of Brown University, Providence, RI (Emigh)
- the Division of Gastrointestinal Surgery, University of California, Irvine, Orange, CA (Nguyen)
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Beitland S, Os I, Sunde K. Primary injuries and secondary organ failures in trauma patients with acute kidney injury treated with continuous renal replacement therapy. SCIENTIFICA 2014; 2014:235215. [PMID: 25587490 PMCID: PMC4284970 DOI: 10.1155/2014/235215] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/17/2014] [Revised: 12/02/2014] [Accepted: 12/08/2014] [Indexed: 06/04/2023]
Abstract
Background. Acute kidney injury (AKI) treated with continuous renal replacement therapy (CRRT) is a severe complication in trauma patients. The aim of the study was to assess primary traumatic injuries and secondary organ failures in severe posttraumatic AKI. Methods. Retrospective review of adult trauma patients admitted to the trauma centre at Oslo University Hospital Ullevål. Injury severity score (ISS) was used to assess the severity of primary injuries, and sequential organ failure assessment (SOFA) score was utilized to measure secondary organ failures. Results. Forty-two (8%) of 506 trauma patients admitted to intensive care unit developed AKI treated with CRRT, whereof 40 (95%) suffered blunt trauma mechanisms. Patients had extensive primary organ injuries with median (interquartile range) ISS 36 (27-49). The majority of the patients had respiratory (93% intubated) and cardiovascular (67% with inotropic and/or vasoactive medication) failure within 24 hours after admission. AKI was often part of multiple organ failure, most frequently respiratory and cardiovascular failure, affecting 33 (75%) and 30 (71%) of the patients, respectively. Conclusion. Trauma patients with AKI undergoing CRRT often had severe primary injuries due to blunt trauma. Most of them suffered from secondary multiple organ failure concomitant to AKI.
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Affiliation(s)
- Sigrid Beitland
- Department of Anaesthesiology, Division of Emergencies and Critical Care, Oslo University Hospital, Postboks 4956, Nydalen, 0424 Oslo, Norway
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Postboks 1072, Blindern, 0316 Oslo, Norway
| | - Ingrid Os
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Postboks 1072, Blindern, 0316 Oslo, Norway
- Division of Medicine, Department of Nephrology, Oslo University Hospital, Postboks 4956, Nydalen, 0424 Oslo, Norway
| | - Kjetil Sunde
- Department of Anaesthesiology, Division of Emergencies and Critical Care, Oslo University Hospital, Postboks 4956, Nydalen, 0424 Oslo, Norway
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Postboks 1072, Blindern, 0316 Oslo, Norway
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Extracorporeal organ support following trauma: the dawn of a new era in combat casualty critical care. J Trauma Acute Care Surg 2013; 75:S120-8; discussion S128-9. [PMID: 23883896 DOI: 10.1097/ta.0b013e318299d0cb] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Practical considerations for the dosing and adjustment of continuous renal replacement therapy in the intensive care unit. J Crit Care 2013; 28:1019-26. [PMID: 23890937 DOI: 10.1016/j.jcrc.2013.05.018] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2013] [Revised: 05/23/2013] [Accepted: 05/27/2013] [Indexed: 11/22/2022]
Abstract
Familiarity with the initiation, dosing, adjustment, and termination of continuous renal replacement therapy (CRRT) is a core skill for contemporary intensivists. Guidelines for how to administer CRRT in the intensive care unit are not well documented. The purpose of this review is to discuss the modalities, terminology, and components of CRRT, with an emphasis on the practical aspects of dosing, adjustments, and termination. Management of electrolyte and acid-base derangements commonly encountered with acute renal failure is emphasized. Knowledge regarding the practical aspects of managing CRRT in the intensive care unit is a prerequisite for achieving desired physiological end points.
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Variability in Uremic Control during Continuous Venovenous Hemodiafiltration in Trauma Patients. Crit Care Res Pract 2012; 2012:869237. [PMID: 22666569 PMCID: PMC3362819 DOI: 10.1155/2012/869237] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2011] [Revised: 02/12/2012] [Accepted: 02/27/2012] [Indexed: 11/17/2022] Open
Abstract
Introduction. Acute kidney injury (AKI) necessitating continuous renal replacement therapy (CRRT) is a severe complication in trauma patients (TP). We wanted to assess daily duration of CRRT and its impact on uremic control in TP. Material and Methods. We retrospectively reviewed adult TP, with or without rhabdomyolysis, with AKI undergoing CRRT. Data on daily CRRT duration and causes for temporary stops were collected from the first five CRRT days. Uremic control was assessed by daily changes in serum urea (Δurea) and creatinine (Δcreatinine) concentrations. Results. Thirty-six TP were included with a total of 150 CRRT days, 17 (43%) with rhabdomyolysis. The median (interquartile range (IQR)) time per day with CRRT was 19 (15–21) hours. There was a significant correlation between daily CRRT duration and Δurea (r = 0.60, P≤0.001) and Δcreatinine (r = 0.43; P = 0.012). CRRT pauses were caused by filter clotting (54%), therapeutic interventions (25%), catheter related problems (10%), filter timeout (6%), and diagnostic procedures (6%). Rhabdomyolysis did not affect the CRRT data. Conclusions. TP undergoing CRRT had short daily CRRT duration causing reduced uremic control. Clinicians should modify their daily clinical practice to improve technical skills and achieve sufficient dialysis dose.
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Helmy MM, El-Gowelli HM. Montelukast abrogates rhabdomyolysis-induced acute renal failure via rectifying detrimental changes in antioxidant profile and systemic cytokines and apoptotic factors production. Eur J Pharmacol 2012; 683:294-300. [PMID: 22449377 DOI: 10.1016/j.ejphar.2012.03.018] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2011] [Revised: 03/05/2012] [Accepted: 03/07/2012] [Indexed: 12/22/2022]
Abstract
In addition to antiasthmatic effect, the cysteinyl leukotriene receptor 1 (CysLT₁) antagonist montelukast shows renoprotective effect during ischemia/reperfusion and cyclosporine-induced renal damage. Here, we proposed that montelukast protects against rhabdomyolysis-induced acute renal failure. Compared with saline-treated rats, at 48 h following the induction of rhabdomyolysis using intramuscular glycerol (10 ml 50% glycerol/kg), significant elevations in serum levels of urea, creatinine, phosphate and acute renal tubular necrosis were observed. This was associated with elevations in serum Fas, interleukin-10, tumor necrotic factor-alpha, and transforming growth factor-beta1 and renal malondialdehyde and nitrite and detrimental reductions in renal catalase and superoxide dismutase activities. The effects of rhabdomyolysis on renal functional, biochemical and structural integrity and the associated changes in cytokines and Fas levels were abolished upon concurrent administration of montelukast (10 mg/kg i.p.) for 3 days (1 day before and 2 days after induction of rhabdomyolysis). Alternatively, administration of the anti-oxidant, α-tocopherol (400 mg/kg i.m.) for 3 days, succeeded in alleviating renal oxidative stress, but had no significant effect on the circulating levels of most cytokines and partially restored kidney functional and structural damage. Serum level of interleukin-6 was not altered by rhabdomyolysis but showed significant elevations in rats treated with montelukast or α-tocopherol. Collectively, motelukast abrogated functional and structural renal damage induced by rhabdomyolysis via ameliorating renal oxidative stress and modulation of systemic cytokines and apoptotic factors production. The results of this work are expected to open new avenues for early prevention of rhabdomyolysis-induced acute renal failure using selective CysLT₁ antagonists such as montelukast.
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Affiliation(s)
- Mai M Helmy
- Department of Pharmacology and Toxicology, Faculty of Pharmacy, Alexandria University, Alexandria, Egypt
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He P, Zhou C, Li H, Yu Y, Dong Z, Wen Y, Li P, Tang W, Wang X. A portable continuous blood purification machine for emergency rescue in disasters. Blood Purif 2012; 33:227-37. [PMID: 22343795 DOI: 10.1159/000336092] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2011] [Accepted: 12/27/2011] [Indexed: 11/19/2022]
Abstract
BACKGROUND Continuous renal replacement therapy plays an important role in emergency rescue. Currently, no continuous renal replacement therapy machine can be used under unstable conditions as the fluid flow of these machines is controlled electronically. A novel machine that can provide emergency continuous renal replacement therapy in disaster rescue is therefore needed. METHODS Based on a volumetric metering method, a prototype portable continuous blood purifier based on a volumetric metering method was developed. Basic performance tests, special environmental tests, animal experiments and clinical use of the novel machine were completed to test and verify its performance under unstable conditions. RESULTS All tests completed showed that the machine met the requirements of the national industry standards with a size reduced to approximately one half of the Baxter Aquarius machine. The clearance of harmful substances by the machine described here was equal to that of the Baxter Aquarius machine and was adequate for clinical purposes. CONCLUSIONS The novel prototype performed well in all situations tested and can aid rescue work on disaster sites.
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Affiliation(s)
- Ping He
- Department of Nephrology, General Hospital of the Navy, Second Military Medical University, Beijing, China
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Beitland S, Moen H, Os I. Acute kidney injury with renal replacement therapy in trauma patients. Acta Anaesthesiol Scand 2010; 54:833-40. [PMID: 20528778 DOI: 10.1111/j.1399-6576.2010.02253.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND Acute kidney injury (AKI) with renal replacement therapy (RRT) is rare in trauma patients. The primary aim of the study was to assess incidence, mortality and chronic RRT dependency in this patient group. METHODS Adult trauma patients with AKI receiving RRT at a regional trauma referral center over a 12-year period were retrospectively reviewed. RESULTS Population-based incidence of post-traumatic AKI with RRT was 1.8 persons per million inhabitants per year (p.p.m./year) [95% confidence the interval (CI) 1.5-2.1 p.p.m./year]. In trauma patients admitted to hospital, incidence was 0.5 per thousand (95% CI 0.3-0.7 per thousand) of those treated in intensive care unit (ICU), it was 8.3% (95% CI 5.9-10.8%). The median age was 46 years. Odds ratio (OR) for post-traumatic AKI requiring RRT was higher in males than in females in general population (OR 5.6, 95% CI 2.2-14.0), and in trauma patients admitted to hospital (OR 4.4, 95% CI 1.9-10.3) and ICU (OR 4.5, 95% CI 1.9-10.7). The in-hospital mortality rate was 24% (95% CI 11-37%), 3-month mortality 36% (95% CI 21-51%) and 1-year mortality 40% (95% CI 25-55%). Age was a risk factor for death after 1 year, with 57% (95% CI 7-109%) increased risk for each 10 years added. None of the survivors was dialysis-dependent 3 months or 1 year after trauma. CONCLUSION AKI in trauma patients requiring RRT was rare in this single-center study. More males than females were affected. Mortality was modest, and renal recovery was excellent as none of the survivors became dependent on chronic RRT.
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Affiliation(s)
- S Beitland
- Department of Anaesthesiology, Oslo University Hospital Ullevaal, Oslo, Norway.
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Abstract
PURPOSE OF REVIEW An extensive search of the literature published in the past 2 years related to critical care organ support was undertaken. This review is limited to those that focus on extracorporeal life support modalities for adults. RECENT FINDINGS Traditional indications for extracorporeal life support such as oxygenation, carbon dioxide exchange and support of perfusion have expanded to include solute and toxin clearance for kidney, liver and potentially neurological failure. Enhanced understanding of cell-mediated mechanisms of injury may explain multiple-organ dysfunction following single-organ damage. Extracorporeal life support systems can be used safely in patients with traumatic brain, chest, and abdominal injury. 'Emergency perfusion and resuscitation' following traumatic exsanguination is entering clinical trials. SUMMARY Multiple-organ dysfunction followed by traumatic injury can be treated with multiple-organ support. A total extracorporeal organ support system may be used in the future as a portable, bedside organ support device.
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