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Clausen NE, Meyhoff CS, Henriksen HH, Lindhardt A, Pott FC, Lunen TB, Gybel-Brask M, Lange T, Johansson PI, Stensballe J. Plasma as endothelial rescue in septic shock: A randomized, phase 2a pilot trial. Transfusion 2024. [PMID: 38973502 DOI: 10.1111/trf.17939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2024] [Revised: 05/17/2024] [Accepted: 06/17/2024] [Indexed: 07/09/2024]
Abstract
BACKGROUND Septic shock is associated with high morbidity and mortality, the endothelium plays an important role. Crystalloids is standard of care to maintain intravascular volume. Plasma is associated with improved endothelial integrity and restoration of the glycocalyx layer. We evaluated the efficacy and safety aspects of cell-free and pathogen inactivated pooled plasma (OctaplasLG®) as resuscitation in septic shock patients. STUDY DESIGN AND METHODS This randomized, investigator-initiated phase IIa trial ran at a Danish single center intensive care unit, from 2017 to 2019. Patients were 18 years of age or older with septic shock and randomized to fluid optimization with OctaplasLG® or Ringer-acetate in the first 24 h. The primary endpoints were changes in biomarkers indicative of endothelial activation, damage, and microvascular perfusion from baseline to 24 h. Safety events and mortality were assessed during 90 days. RESULTS Forty-four patients were randomized, 20 to OctaplasLG versus 24 to Ringer-acetate. The median age was 69, and 55% were men. Median Sequential Organ Failure Assessment score was 13. Baseline differences favoring the Ringer-acetate group were observed. The OctaplasLG® group was resuscitated with 740 mL plasma and the Ringer-acetate group with 841 mL crystalloids. There was no significant change in the microvascular perfusion or five biomarkers except VEGFR1 change, which was higher in patients receiving OctaplasLG® 0.12(SD 0.37) versus Ringer-acetate -0.24 (SD 0.39), with mean difference 0.36 (95% CI, 0.13-0.59, p = .003) in favor of Ringer-acetate. DISCUSSION This study found that fluid resuscitation with OctaplasLG® in critically ill septic shock patients is feasible. Baseline confounding prevented assessment of the potential effect of OctaplasLG®.
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Affiliation(s)
- Niels E Clausen
- Department of Anesthesia and Intensive Care, Copenhagen University Hospital -Bispebjerg and Frederiksberg, Copenhagen, Denmark
| | - Christian S Meyhoff
- Department of Anesthesia and Intensive Care, Copenhagen University Hospital -Bispebjerg and Frederiksberg, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Hanne H Henriksen
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Section for Transfusion Medicine, Capital Region Blood Bank, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Anne Lindhardt
- Department of Anesthesia and Intensive Care, Zealand University Hospital, Køge, Denmark
| | - Frank C Pott
- Department of Anesthesia and Intensive Care, Copenhagen University Hospital -Bispebjerg and Frederiksberg, Copenhagen, Denmark
| | - Thomas Bech Lunen
- Department of Anesthesia and Intensive Care, Zealand University Hospital, Køge, Denmark
| | - Mikkel Gybel-Brask
- Section for Transfusion Medicine, Capital Region Blood Bank, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Theis Lange
- Section of Biostatistics, University of Copenhagen, Copenhagen, Denmark
| | - Pär I Johansson
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Section for Transfusion Medicine, Capital Region Blood Bank, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Jakob Stensballe
- Section for Transfusion Medicine, Capital Region Blood Bank, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Anesthesia and Trauma Center, Centre of Head and Orthopedics, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
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Barry M, Trivedi A, Miyazawa B, Vivona LR, Shimmin D, Pathipati P, Keane C, Cuschieri J, Pati S. Regulation of vascular endothelial integrity by mesenchymal stem cell extracellular vesicles after hemorrhagic shock and trauma. J Transl Med 2024; 22:588. [PMID: 38907252 PMCID: PMC11191310 DOI: 10.1186/s12967-024-05406-1] [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: 04/17/2024] [Accepted: 06/14/2024] [Indexed: 06/23/2024] Open
Abstract
BACKGROUND Patients with hemorrhagic shock and trauma (HS/T) are vulnerable to the endotheliopathy of trauma (EOT), characterized by vascular barrier dysfunction, inflammation, and coagulopathy. Cellular therapies such as mesenchymal stem cells (MSCs) and MSC extracellular vesicles (EVs) have been proposed as potential therapies targeting the EOT. In this study we investigated the effects of MSCs and MSC EVs on endothelial and epithelial barrier integrity in vitro and in vivo in a mouse model of HS/T. This study addresses the systemic effects of HS/T on multiorgan EOT. METHODS In vitro, pulmonary endothelial cell (PEC) and Caco-2 intestinal epithelial cell monolayers were treated with control media, MSC conditioned media (CM), or MSC EVs in varying doses and subjected to a thrombin or hydrogen peroxide (H2O2) challenge, respectively. Monolayer permeability was evaluated with a cell impedance assay, and intercellular junction integrity was evaluated with immunofluorescent staining. In vivo, a mouse model of HS/T was used to evaluate the effects of lactated Ringer's (LR), MSCs, and MSC EVs on endothelial and epithelial intercellular junctions in the lung and small intestine as well as on plasma inflammatory biomarkers. RESULTS MSC EVs and MSC CM attenuated permeability and preserved intercellular junctions of the PEC monolayer in vitro, whereas only MSC CM was protective of the Caco-2 epithelial monolayer. In vivo, both MSC EVs and MSCs mitigated the loss of endothelial adherens junctions in the lung and small intestine, though only MSCs had a protective effect on epithelial tight junctions in the lung. Several plasma biomarkers including MMP8 and VEGF were elevated in LR- and EV-treated but not MSC-treated mice. CONCLUSIONS In conclusion, MSC EVs could be a potential cell-free therapy targeting endotheliopathy after HS/T via preservation of the vascular endothelial barrier in multiple organs early after injury. Further research is needed to better understand the immunomodulatory effects of these products following HS/T and to move toward translating these therapies into clinical studies.
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Affiliation(s)
- Mark Barry
- Department of Surgery, University of California, San Francisco, 513 Parnassus Ave, San Francisco, CA, 94143, USA
| | - Alpa Trivedi
- Department of Laboratory Medicine, University of California, San Francisco, 513 Parnassus Ave , San Francisco, CA, 94143, USA
| | - Byron Miyazawa
- Department of Laboratory Medicine, University of California, San Francisco, 513 Parnassus Ave , San Francisco, CA, 94143, USA
| | - Lindsay R Vivona
- Department of Laboratory Medicine, University of California, San Francisco, 513 Parnassus Ave , San Francisco, CA, 94143, USA
| | - David Shimmin
- NanoCraft.US., 807 Aldo Ave, Suite-101, Santa Clara, CA, 95054, USA
| | - Praneeti Pathipati
- Department of Laboratory Medicine, University of California, San Francisco, 513 Parnassus Ave , San Francisco, CA, 94143, USA
| | - Callie Keane
- Department of Laboratory Medicine, University of California, San Francisco, 513 Parnassus Ave , San Francisco, CA, 94143, USA
| | - Joseph Cuschieri
- Department of Surgery, University of California, San Francisco, 513 Parnassus Ave, San Francisco, CA, 94143, USA
| | - Shibani Pati
- Department of Surgery, University of California, San Francisco, 513 Parnassus Ave, San Francisco, CA, 94143, USA.
- Department of Laboratory Medicine, University of California, San Francisco, 513 Parnassus Ave , San Francisco, CA, 94143, USA.
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Baucom MR, Weissman N, Price AD, England L, Schuster RM, Pritts TA, Goodman MD. Syndecan-1 as the Effect or Effector of the Endothelial Inflammatory Response? J Surg Res 2024; 295:611-618. [PMID: 38096775 DOI: 10.1016/j.jss.2023.10.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 09/11/2023] [Accepted: 10/27/2023] [Indexed: 02/25/2024]
Abstract
INTRODUCTION Syndecan-1 is a heparan sulfate proteoglycan found in the glycocalyx of vascular endothelial cells. Serum levels of syndecan-1 have repeatedly been demonstrated to increase following traumatic injury and shock, but it is unclear whether syndecan-1 plays an active role in the inflammatory response or is simply a biomarker of a state of hypoperfusion. The aim of this study was to identify the role of syndecan-1 role in the inflammatory process in the absence of trauma. METHODS Male mice were randomized into five groups (n = 3). Four groups received increasing concentrations of syndecan-1 (1, 10, 100, and 1000pg/mL per blood volume) and a fifth group was given normal saline as a control via intravenous injection. These concentrations were selected based on previous syndecan-1 enzyme-linked immunosorbent assay data acquired following induced hemorrhagic shock in mice resulting in serum levels of 10-6000 pg/mL. Mice from each group were sacrificed at 1-, 4-, and 24-h time points for serum biomarker evaluation. A multiplex enzyme-linked immunosorbent assay was performed to analyze proinflammatory cytokines and chemokines including interleukin (IL)-1a, IL-1b, IL-2, IL-3, IL-4, IL-6, IL-10, IL-12, IL-17, monocyte chemoattractant protein-1, TNF-α, macrophage inflammatory protein-1α, granulocyte-macrophage colony-stimulating factor, and normal T cell expressed and presumably secreted levels. Whole blood was analyzed via rotational thromboelastometry in a separate group of mice dosed with syndecan-1 at 1000 pg/mL and compared to sham mice at 1 h. RESULTS Tumor necrosis factor-α was significantly elevated in the 1000 pg/mL group compared to sham animals. There were no significant changes in IL-1a, IL-1b, IL-2, IL-3, IL-4, IL-6, IL-10, IL-12, monocyte chemoattractant protein--1, macrophage inflammatory protein-1α, granulocyte-macrophage colony-stimulating factor, or normal T cell expressed and presumably secretedat 1, 4, and 24 h for any group when compared to mice receiving saline alone. No significant differences were noted in coagulability between the 1000 pg/mL syndecan-1 group and shams at 1 h CONCLUSIONS: Inflammatory cytokine concentrations did not change with increasing dosage of syndecan-1 within mice at any timepoint, except for an acute change in tumor necrosis factor-α which was transient. Based on our results, syndecan-1 appears to be a biomarker for inflammation rather than an active participant in eliciting an inflammatory response. Further research will focus on the role of syndecan-1 following hemorrhagic shock.
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Affiliation(s)
- Matthew R Baucom
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | | | - Adam D Price
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Lisa England
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | | | - Timothy A Pritts
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio
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Lee JH, Ward KR. Blood failure: traumatic hemorrhage and the interconnections between oxygen debt, endotheliopathy, and coagulopathy. Clin Exp Emerg Med 2024; 11:9-21. [PMID: 38018069 PMCID: PMC11009713 DOI: 10.15441/ceem.23.127] [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: 09/10/2023] [Accepted: 09/28/2023] [Indexed: 11/30/2023] Open
Abstract
This review explores the concept of "blood failure" in traumatic injury, which arises from the interplay of oxygen debt, the endotheliopathy of trauma (EoT), and acute traumatic coagulopathy (ATC). Traumatic hemorrhage leads to the accumulation of oxygen debt, which can further exacerbate hemorrhage by triggering a cascade of events when severe. Such events include EoT, characterized by endothelial glycocalyx damage, and ATC, involving platelet dysfunction, fibrinogen depletion, and dysregulated fibrinolysis. To manage blood failure effectively, a multifaceted approach is crucial. Damage control resuscitation strategies such as use of permissive hypotension, early hemorrhage control, and aggressive transfusion of blood products including whole blood aim to minimize oxygen debt and promote its repayment while addressing endothelial damage and coagulation. Transfusions of red blood cells, plasma, and platelets, as well as the use of tranexamic acid, play key roles in hemostasis and countering ATC. Whole blood, whether fresh or cold-stored, is emerging as a promising option to address multiple needs in traumatic hemorrhage. This review underscores the intricate relationships between oxygen debt, EoT, and ATC and highlights the importance of comprehensive, integrated strategies in the management of traumatic hemorrhage to prevent blood failure. A multidisciplinary approach is essential to address these interconnected factors effectively and to improve patient outcomes.
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Affiliation(s)
- Jae Hyuk Lee
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Kevin R. Ward
- Department of Emergency Medicine, Max Harry Weil Institute for Critical Care Research and Innovation, University of Michigan, Ann Arbor, MI, USA
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, USA
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Durbin S, Loss L, Buzzard L, Minoza K, Beiling M, Karsonovich C, Liu M, Garay J, Fields A, Mathews M, Kuhn B, Moskowitz K, Miyazawa B, Trivedi A, Kornblith L, Fitzpatrick M, Pati S, Schreiber M. Pilot study of frozen platelet extracellular vesicles as a therapeutic agent in hemorrhagic shock in rats. J Trauma Acute Care Surg 2024; 96:364-370. [PMID: 38011031 DOI: 10.1097/ta.0000000000004210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2023]
Abstract
BACKGROUND Hemorrhage accounts for the most preventable deaths after trauma. Resuscitation is guided by studies that demonstrate improved outcomes in patients receiving whole blood or balanced administration of blood products. Platelets present a logistical challenge due to short shelf life and need for refrigeration. Platelet-derived extracellular vesicles (PEVs) are a possible platelet alternative. Platelet-derived extracellular vesicles are secreted from platelets, have hemostatic effects and mitigate inflammation and vascular injury, similar to platelets. This pilot study aimed to elucidate the therapeutic effects of PEVs in a rat model of uncontrolled hemorrhage. METHODS Male rats were anesthetized and femoral vessels cannulated. Vital signs (MAP, HR, and RR) were monitored. Electrolytes, lactate and ABG were obtained at baseline, 1-hour and 3-hours post injury. Laparotomy was performed, 50% of the middle hepatic lobe excised and the abdomen packed with gauze. Rats received 2 mL PEVs or lactated Ringers (LR) over 6 minutes immediately after injury. Peritoneal blood loss was quantified using preweighed gauze at 5 minutes, 15 minutes, 30 minutes, 45 minutes, and 60 minutes. Laparotomy was closed 1-hour postinjury. Animals were monitored for 3 hours postinjury then euthanized. Generalized Linear Mixed Effects models were performed to assess effects of treatment and time on lactate and MAP. RESULTS Twenty-one rats were included (11 LR, 10 PEV). Overall blood loss was between 6 mL and 10 mL and not significantly different between groups. There was a 36% mortality rate in the LR group and 0% mortality in the PEV group ( p = 0.03). The LR group had significantly higher lactates at 1 hour ( p = 0.025). At 15 minutes, 45 minutes, 60 minutes, and 180 minutes, the MAP of the PEV group was significantly higher than the LR group. CONCLUSION Early studies are encouraging regarding the potential use of PEVs in uncontrolled hemorrhagic shock based on improved survival and hemodynamics.
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Affiliation(s)
- Samantha Durbin
- From the Department of Surgery (S.D., L.L., L.B., Ka.M., M.B., C.K., M.L., J.G., M.S.), Oregon Health & Science University, Portland, Oregon; Department of Laboratory Medicine (A.F., B.M., A.T., L.K., S.P.), University of California San Francisco, San Francisco, California; and Cellphire Therapeutics, Inc. (M.M., B.K., Ke.M., M.F.), Rockville, Maryland
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Abuelazm M, Rezq H, Mahmoud A, Tanashat M, Salah A, Saleh O, Morsi S, Abdelazeem B. The efficacy and safety of pre-hospital plasma in patients at risk for hemorrhagic shock: an updated systematic review and meta-analysis of randomized controlled trials. Eur J Trauma Emerg Surg 2024:10.1007/s00068-024-02461-7. [PMID: 38367091 DOI: 10.1007/s00068-024-02461-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Accepted: 01/22/2024] [Indexed: 02/19/2024]
Abstract
BACKGROUND AND OBJECTIVE Plasma is a critical element in hemostatic resuscitation post-injury, and its prompt administration within the prehospital setting may reduce the complications resulting from hemorrhage and shock. Our objective is to assess the efficacy and safety of prehospital plasma infusion in patients susceptible to hemorrhagic shock. METHODS We conducted our study by aggregating randomized controlled trials (RCTs) sourced from PubMed, EMBASE, Scopus, Web of Science, and Cochrane CENTRAL up to January 29, 2023. Quality assessment was implemented using the Cochrane RoB 2 tool. Our study protocol is registered in PROSPERO under ID: CRD42023397325. RESULTS Three RCTs with 760 individuals were included. There was no difference between plasma infusion and standard care groups in 24-h mortality (P = 0.11), 30-day mortality (P = 0.12), and multiple organ failure incidences (P = 0.20). Plasma infusion was significantly better in the total 24-h volume of PRBC units (P = 0.03) and INR on arrival (P = 0.009). For all other secondary outcomes evaluated (total 24-h volume of packed FFP units, total 24-h volume of platelets units, massive transfusion, vasopressor need during the first 24 h, any adverse event, acute lung injury, transfusion reaction, and sepsis), no significant differences were observed between the two groups. CONCLUSION Plasma infusion in trauma patients at risk of hemorrhagic shock does not significantly affect mortality or the incidence of multiple organ failure. However, it may lead to reduced packed red blood cell transfusions and increased INR at hospital arrival.
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Affiliation(s)
| | - Hazem Rezq
- Faculty of Medicine, Al-Azhar University, Cairo, Egypt.
| | | | | | | | - Othman Saleh
- Faculty of Medicine, The Hashemite University, Zarqa, Jordan
| | - Samah Morsi
- Department of Radiation Oncology, UT Texas MD Anderson, Houston, TX, USA
| | - Basel Abdelazeem
- Department of Cardiology, West Virginia University, Morgantown, WV, USA
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Dixon A, Kenny JE, Buzzard L, Holcomb J, Bulger E, Wade C, Fabian T, Schreiber M. Acute respiratory distress syndrome, acute kidney injury, and mortality after trauma are associated with increased circulation of syndecan-1, soluble thrombomodulin, and receptor for advanced glycation end products. J Trauma Acute Care Surg 2024; 96:319-325. [PMID: 37678154 DOI: 10.1097/ta.0000000000004096] [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: 09/09/2023]
Abstract
BACKGROUND Disruption of the vascular endothelium and endothelial glycocalyx (EG) has been described after severe trauma. Plasma has been suggested to restore microvascular integrity by preservation and repair of the EG. We sought to evaluate whether plasma administered in a 1:1:1 ratio was associated with less endothelial marker circulation than a 1:1:2 ratio. METHODS This is a secondary analysis of the PROPPR trial, which investigated post-traumatic resuscitation with platelets, plasma, and red blood cells in a 1:1:1 ratio compared with a 1:1:2 ratio. Syndecan-1, soluble thrombomodulin (sTM), and receptor for advanced glycation end products (RAGE) were quantified for each treatment group on admission and at 2 hours, 4 hours, 6 hours, 12 hours, 24 hours, 48 hours, and 72 hours. Patients were excluded if they did not survive longer than 3 hours or had data from fewer than two time points. RESULTS Three hundred eight patients in the 1:1:1 group and 291 in the 1:1:2 group were analyzed. There were no statistically significant differences in syndecan-1, sTM, or RAGE between treatment groups at any time point ( p > 0.05). Patients who developed acute respiratory distress syndrome, acute kidney injury, and death had significantly elevated biomarker expression at most time points when compared with patients who did not develop these sequelae ( p < 0.05). CONCLUSION Administration of FFP in a 1:1:1 ratio does not consistently affect circulation of endothelial biomarkers following significant trauma when compared with a 1:1:2 ratio. The development of post-traumatic ARDS, AKI, and death was associated with increased endothelial biomarker circulation. LEVEL OF EVIDENCE Therapeutic/Care Management; Level III.
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Affiliation(s)
- Alexandra Dixon
- From the Division of Trauma, Critical Care and Acute Care Surgery, Department of Surgery (A.D., J.E.K., L.B., M.S.), Oregon Health & Science University, Portland, Oregon; Division of Trauma and Acute Care Surgery, Department of Surgery (J.H.), University of Alabama at Birmingham, Birmingham, Alabama; Division of Trauma and Critical Care, Department of Surgery (E.B.), University of Washington, Seattle, Washington; Center for Translational Injury Research, Division of Acute Care Surgery, Department of Surgery (C.W.), University of Texas Health Science Center, Houston, Texas; and Division of Trauma and Surgical Critical Care, Department of Surgery (T.F.), University of Tennessee Health Science Center, Memphis, Tennessee
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Xie WW, Ding YJ, Bhandari S, Li H, Chen HS, Jin SW, Weng HX, Hao Y. CLINICAL VALUE OF SYNDECAN-1 LEVELS IN TRAUMA BRAIN INJURY: A META-ANALYSIS. Shock 2024; 61:49-54. [PMID: 37878479 DOI: 10.1097/shk.0000000000002255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2023]
Abstract
ABSTRACT Background: Traumatic brain injury (TBI) is a head trauma usually associated with death and endothelial glycocalyx damage. Syndecan-1 (SDC-1)-a biomarker of glycocalyx degradation-has rarely been reported in meta-analyses to determine the clinical prognostic value in TBI patients. Methods: We looked into PubMed, EMBASE, Cochrane Library, and Web of Science databases from January 1, 1990, to May 1, 2023, to identify eligible studies. A meta-analysis was conducted using RevMan 5.4 and Stata 16.0 with the search terms "SDC-1" and "traumatic brain injury." Results: The present study included five studies with a total of 640 enrolled patients included. Syndecan-1 concentrations were higher in the isotrauma TBI group than in the non-TBI group (standardized mean difference [SMD] = 0.52; 95% CI: 0.03-1.00; P = 0.04). Subgroup analysis revealed statistical significance when comparing the SDC-1 level of multitrauma TBI (TBI + other injuries) group with the isotrauma TBI group (SMD = 0.74; 95% CI: 0.42-1.05; P < 0.001), and the SDC-1 level of the TBI coagulopathy (+) group (TBI with early coagulopathy) with the TBI coagulopathy (-) group (SMD = 1.75; 95% CI: 0.41-3.10; P = 0.01). Isotrauma TBI patients with higher SDC-1 level were at a higher risk of 30-day in-hospital mortality (odds ratio = 3.32; 95% CI: 1.67-6.60; P = 0.0006). Conclusion: This meta-analysis suggests that SDC-1 could be a biomarker of endotheliopathy and coagulopathy in TBI, as it was increased in isotrauma TBI patients and was higher in multitrauma TBI patients. There is a need for additional research into the use of SDC-1 as a prognostic biomarker in TBI, especially in isotrauma TBI patients.
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Affiliation(s)
| | | | | | | | | | | | - Hai-Xu Weng
- Department of Critical Care Medicine, The Third Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang Province, PR China
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Jeong D, Jeong W, Lee JH, Park SY. Use of Automated Machine Learning for Classifying Hemoperitoneum on Ultrasonographic Images of Morrison's Pouch: A Multicenter Retrospective Study. J Clin Med 2023; 12:4043. [PMID: 37373736 DOI: 10.3390/jcm12124043] [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: 03/08/2023] [Revised: 06/09/2023] [Accepted: 06/11/2023] [Indexed: 06/29/2023] Open
Abstract
This study evaluated automated machine learning (AutoML) in classifying the presence or absence of hemoperitoneum in ultrasonography (USG) images of Morrison's pouch. In this multicenter, retrospective study, 864 trauma patients from trauma and emergency medical centers in South Korea were included. In all, 2200 USG images (1100 hemoperitoneum and 1100 normal) were collected. Of these, 1800 images were used for training and 200 were used for the internal validation of AutoML. External validation was performed using 100 hemoperitoneum images and 100 normal images collected separately from a trauma center that were not included in the training and internal validation sets. Google's open-source AutoML was used to train the algorithm in classifying hemoperitoneum in USG images, followed by internal and external validation. In the internal validation, the sensitivity, specificity, and area under the receiver operating characteristic (AUROC) curve were 95%, 99%, and 0.97, respectively. In the external validation, the sensitivity, specificity, and AUROC were 94%, 99%, and 0.97, respectively. The performances of AutoML in the internal and external validation were not statistically different (p = 0.78). A publicly available, general-purpose AutoML can accurately classify the presence or absence of hemoperitoneum in USG images of the Morrison's pouch of real-world trauma patients.
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Affiliation(s)
- Dongkil Jeong
- Department of Emergency Medicine, College of Medicine, Soonchunhyang University, Cheonan 31151, Republic of Korea
| | - Wonjoon Jeong
- Department of Emergency Medicine, School of Medicine, Chungnam National University, Daejeon 35015, Republic of Korea
| | - Ji Han Lee
- Division of Emergency Medicine, Department of Medicine, The Catholic University of Korea, Seoul 11765, Republic of Korea
| | - Sin-Youl Park
- Department of Emergency Medicine, College of Medicine, Yeungnam University, Daegu 42415, Republic of Korea
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10
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Feng Z, Fan Y, Xie J, Liu S, Duan C, Wang Q, Ye Y, Yin W. HIF-1α promotes the expression of syndecan-1 and inhibits the NLRP3 inflammasome pathway in vascular endothelial cells under hemorrhagic shock. Biochem Biophys Res Commun 2022; 637:83-92. [DOI: 10.1016/j.bbrc.2022.10.102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2022] [Revised: 10/13/2022] [Accepted: 10/29/2022] [Indexed: 11/06/2022]
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Schaid TR, Hansen KC, Sauaia A, Moore EE, DeBot M, Cralley AL, Erickson C, Silliman CC, Banerjee A, Ghasabyan A, Jones K, Lacroix I, Mitra S, D'Alessandro A, Cohen MJ. Postinjury complement C4 activation is associated with adverse outcomes and is potentially influenced by plasma resuscitation. J Trauma Acute Care Surg 2022; 93:588-596. [PMID: 35610738 PMCID: PMC9613483 DOI: 10.1097/ta.0000000000003713] [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: 11/25/2022]
Abstract
BACKGROUND Complement activation after trauma promotes hemostasis but is associated with increased morbidity and mortality. However, the specific pathways and downstream mediators remain unclear. Recently, the anaphylatoxin C4a has been shown to bind to thrombin receptors. While plasma-based resuscitation has been shown to modify the endotheliopathy of trauma, it may provide complement zymogens that fuel ongoing inflammatory cascades. We sought to characterize the activation of complement after injury and the effect of fresh frozen plasma (FFP) on this inflammatory response. We hypothesized that trauma induces C4 activation, which is associated with worse outcomes and influenced by FFP resuscitation. METHODS Blood was collected from injured patients at a single level I trauma center enrolled in the Control of Major Bleeding after Trauma (COMBAT) randomized clinical trial. Proteomic analyses were performed through targeted liquid chromatography coupled with mass spectrometry. For the present observational study, concentrations of complement proteins were analyzed at multiple time points, compared between treatment groups, and correlated with outcomes. RESULTS C4 activation occurred over the first 6 hours postinjury with peak activation 6 to 24 hours. Tissue hypoperfusion, defined as base deficit >10 mEq/L, and requirement for massive transfusion were associated with greater C4 activation. C4 activation was associated with mortality, multiple organ failure, and longer ventilator requirement. In addition, temporal trends of C1q, factor B, and C3 by outcome groups support the prevailing theory of primary classical pathway activation with alternative pathway amplification. Resuscitation with FFP over the first 6 hours was associated with increased C4 activation at 12 and 24 hours. CONCLUSION C4 activation has an important inflammatory role postinjury, and FFP has the potential to augment this complement activation during resuscitation. LEVEL OF EVIDENCE Prognostic/epidemiological, level III.
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Affiliation(s)
- Terry R Schaid
- From the Division of GI, Trauma, and Endocrine, Department of Surgery, Trauma Research Center (T.R.S., A.S., E.E.M., M.D., C.C.S., A.B., K.J., S.M., M.J.C.), Department of Biochemistry and Molecular Genetics (K.C.H., C.E., I.L., A.D.), and Department of Health Systems, Management, and Policy (A.S.), School of Medicine, University of Colorado Denver, Aurora; Department of Surgery (E.E.M., A.L.C., A.G.), Denver Health Medical Center; Vitalant Research Institute (C.C.S.), Vitalant Mountain Division, Denver; and Department of Pediatrics (C.C.S.), School of Medicine, University of Colorado Denver, Aurora, Colorado
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12
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Yang Z, Le TD, Simovic MO, Liu B, Fraker TL, Cancio TS, Cap AP, Wade CE, DalleLucca JJ, Li Y. Traumatized triad of complementopathy, endotheliopathy, and coagulopathy ˗ Impact on clinical outcomes in severe polytrauma patients. Front Immunol 2022; 13:991048. [PMID: 36341368 PMCID: PMC9632416 DOI: 10.3389/fimmu.2022.991048] [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: 07/11/2022] [Accepted: 10/07/2022] [Indexed: 11/13/2022] Open
Abstract
Complementopathy, endotheliopathy, and coagulopathy following a traumatic injury are key pathophysiological mechanisms potentially associated with multiple-organ failure (MOF) and mortality. However, the heterogeneity in the responses of complementopathy, endotheliopathy, and coagulopathy to trauma, the nature and extent of their interplay, and their relationship to clinical outcomes remain unclear. Fifty-four poly-trauma patients were enrolled and divided into three subgroups based on their ISS. Biomarkers in blood plasma reflecting complement activation, endothelial damage, and coagulopathy were measured starting from admission to the emergency department and at 3, 6, 12, 24, and 120 hours after admission. Comparative analyses showed that severely injured patients (ISS>24) were associated with longer days on mechanical ventilation, in the intensive care unit and hospital stays, and a higher incidence of hyperglycemia, bacteremia, respiratory failure and pneumonia compared to mildly (ISS<16) or moderately (ISS=16-24) injured patients. In this trauma cohort, complement was activated early, primarily through the alternative complement pathway. As measured in blood plasma, severely injured patients had significantly higher levels of complement activation products (C3a, C5a, C5b-9, and Bb), endothelial damage markers (syndecan-1, sTM, sVEGFr1, and hcDNA), and fibrinolytic markers (D-dimer and LY30) compared to less severely injured patients. Severely injured patients also had significantly lower thrombin generation (ETP and peak) and lower levels of coagulation factors (I, V, VIII, IX, protein C) than less severely injured patients. Complement activation correlated with endothelial damage and hypocoagulopathy. Logistic regression analyses revealed that Bb >1.57 μg/ml, syndecan-1 >66.6 ng/ml or D-dimer >6 mg/L at admission were associated with a higher risk of MOF/mortality. After adjusting for ISS, each increase of the triadic score defined above (Bb>1.57 µg/ml/Syndecan-1>66.6 ng/ml/D-dimer>6.0mg/L) was associated with a 6-fold higher in the odds ratio of MOF/death [OR: 6.83 (1.04-44.96, P=0.046], and a 4-fold greater in the odds of infectious complications [OR: 4.12 (1.04-16.36), P=0.044]. These findings provide preliminary evidence of two human injury response endotypes (traumatized triad and non-traumatized triad) that align with clinical trajectory, suggesting a potential endotype defined by a high triadic score. Patients with this endotype may be considered for timely intervention to create a pro-survival/organ-protective phenotype and improve clinical outcomes.
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Affiliation(s)
- Zhangsheng Yang
- United States Army Institute of Surgical Research, Joint Base San Antonio Fort Sam Houston, TX, United States
| | - Tuan D. Le
- United States Army Institute of Surgical Research, Joint Base San Antonio Fort Sam Houston, TX, United States
| | - Milomir O. Simovic
- United States Army Institute of Surgical Research, Joint Base San Antonio Fort Sam Houston, TX, United States
- Trauma Immunomodulation Program, The Geneva Foundation, Tacoma, WA, United States
| | - Bin Liu
- United States Army Institute of Surgical Research, Joint Base San Antonio Fort Sam Houston, TX, United States
| | - Tamara L. Fraker
- United States Army Institute of Surgical Research, Joint Base San Antonio Fort Sam Houston, TX, United States
- Trauma Immunomodulation Program, The Geneva Foundation, Tacoma, WA, United States
| | - Tomas S. Cancio
- United States Army Institute of Surgical Research, Joint Base San Antonio Fort Sam Houston, TX, United States
| | - Andrew P. Cap
- United States Army Institute of Surgical Research, Joint Base San Antonio Fort Sam Houston, TX, United States
| | - Charles E. Wade
- Department of Surgery, University of Texas Health McGovern Medical School, Houston, TX, United States
| | - Jurandir J. DalleLucca
- Scientific Research Department, Armed Forces Radiobiological Research Institute, Bethesda, MD, United States
| | - Yansong Li
- United States Army Institute of Surgical Research, Joint Base San Antonio Fort Sam Houston, TX, United States
- Trauma Immunomodulation Program, The Geneva Foundation, Tacoma, WA, United States
- *Correspondence: Yansong Li,
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Tyagi M, Maheshwari A, Guaragni B, Motta M. Use of Fresh-frozen Plasma in Newborn Infants. NEWBORN 2022; 1:271-277. [PMID: 36339329 PMCID: PMC9631350 DOI: 10.5005/jp-journals-11002-0039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Nearly 10% of premature and critically ill infants receive fresh-frozen plasma (FFP) transfusions to reduce their high risk of bleeding. The authors have only limited data to identify relevant clinical predictors of bleeding and to evaluate the efficacy of FFP administration. There is still no consensus on the optimal use of FFP in infants who have abnormal coagulation parameters but are not having active bleeding. The aims of this review are to present current evidence derived from clinical studies focused on the use of FFP in neonatology and then use these data to propose best practice recommendations for the safety of neonates receiving FFP.
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Affiliation(s)
- Manvi Tyagi
- Department of Pediatrics, Augusta University, Georgia, United States of America
| | - Akhil Maheshwari
- Weatherby Healthcare, Fort Lauderdale, Florida, United States of America
| | - Brunetta Guaragni
- Neonatologia e Terapia Intensiva Neonatale, ASST Spedali Civili di Brescia, Italy
| | - Mario Motta
- Neonatologia e Terapia Intensiva Neonatale, ASST Spedali Civili di Brescia, Italy
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RECOVERY OF ENDOTHELIOPATHY AT 24 HOURS IN AN ESTABLISHED MOUSE MODEL OF HEMORRHAGIC SHOCK AND TRAUMA. Shock 2022; 58:313-320. [DOI: 10.1097/shk.0000000000001984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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15
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Barry M, Wu F, Pati S, Chipman A, Geng H, Kozar R. Lyophilized plasma resuscitation downregulates inflammatory gene expression in a mouse model of sepsis. J Trauma Acute Care Surg 2022; 93:S119-S127. [PMID: 35881828 DOI: 10.1097/ta.0000000000003658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Plasma resuscitation may improve outcomes by targeting endotheliopathy induced by severe sepsis or septic shock. Given the logistical constraints of using fresh frozen plasma in military settings or areas with prolonged prehospital care, dried products such as lyophilized plasma (LP) have been developed. We hypothesized that resuscitation with LP would decrease lung injury, inflammation, and mortality in a mouse sepsis model. METHODS Adult male C57BL/6J mice received an intraperitoneal injection of cecal slurry. Twenty-two hours later, the mice were anesthetized, the femoral artery was cannulated, and the mice were randomized to receive resuscitation with LP (10 mL/kg) or lactated Ringer's (LR; 30 mL/kg) for 1 hour. At 48-hours post-cecal slurry injection, bronchoalveolar lavage fluid was collected, the lungs were harvested, and plasma was obtained. Mortality and bronchoalveolar lavage total protein concentration (as an indicator of permeability) were compared between groups. The lungs were analyzed for histopathology and inflammatory gene expression using NanoString, and the plasma was analyzed for biomarkers of inflammation and endothelial function. RESULTS There was no significant difference in short-term mortality between LR and LP mice, 38% versus 47%, respectively ( p = 0.62). Bronchoalveolar lavage protein levels were similar among mice resuscitated with LR or LP, and there was a lack of significant histopathologic lung injury in all groups. However, LP resuscitation resulted in downregulation of pulmonary inflammatory genes, including signaling pathways such as Janus kinase-signal transducer and activator of transcription and nuclear factor κB, and a circulating inflammatory biomarker profile similar to sham animals. CONCLUSION Resuscitation with LP did not improve mortality or reduce permeability or injury in this model compared with LR. However, LP downregulated pulmonary inflammatory gene signaling and may also reduce circulating biomarkers of inflammation. Future studies should evaluate LP resuscitation in combination with antibiotics and other therapeutics to determine whether the anti-inflammatory effects of LP may improve outcomes in sepsis.
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Affiliation(s)
- Mark Barry
- From the Department of Surgery (M.B., S.P.), University of California, San Francisco, San Francisco, California; Shock Trauma Center (F.W., A.C., R.K.), University of Maryland School of Medicine, Baltimore, Maryland; and Department of Laboratory Medicine (S.P., H.G.), University of California, San Francisco, San Francisco, California
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16
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Wallen TE, Singer KE, Elson NC, Baucom MR, England LG, Schuster RM, Pritts TA, Goodman MD. Defining Endotheliopathy in Murine Polytrauma Models. Shock 2022; 57:291-298. [PMID: 35759308 DOI: 10.1097/shk.0000000000001940] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
INTRODUCTION "Endotheliopathy of trauma" is recognized as endothelial dysfunction following traumatic injury leading to poor patient outcomes. Acute post-traumatic disruptions in endothelial cell function have been associated with profound physiologic, hemodynamic, and coagulation derangements. The goal of this study was to define the generation and extent of endotheliopathy in murine polytrauma models by evaluating the post-traumatic release of serum biomarkers of ongoing cellular injury. METHODS Mice were randomized to undergo moderately severe concussive TBI by weight drop, 60-min hemorrhagic shock to MAP 25 mmHg with subsequent resuscitation with Lactated Ringer's, submandibular bleed (SMB), and/or midline laparotomy with rectus muscle crush. Mice were sacrificed at 1, 4, or 24 h for serum biomarker evaluation. RESULTS Serum biomarkers revealed differential timing of elevation and injury-dependent release.At 24 h, soluble thrombomodulin was significantly elevated in combined TBI + shock + lap crush compared to untouched, and shock alone. Syndecan-1 levels were significantly elevated after shock 1 to 24 h compared to untouched cohorts with a significant elevation in TBI + shock + lap crush 24 h after injury compared to shock alone. UCHL-1 was significantly elevated in shock mice at 1 to 24 h post-injury compared to untouched mice. UCHL-1 was also significantly elevated in the TBI + shock cohort 24 h after injury compared to shock alone. Hyaluronic acid release at 4 h was significantly elevated in shock alone compared to the untouched cohort with further elevations in TBI + shock + lap crush and TBI + shock compared to shock alone at 24 h. Hyaluronic acid was also increased in lap crush and laparotomy only cohort compared to untouched mice 24 h after injury. CONCLUSIONS A murine model of polytrauma including TBI, hemorrhagic shock, and laparotomy abdominal crush is a reliable method for evaluation of endotheliopathy secondary to trauma as indicated by differential changes in serum biomarkers.
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Affiliation(s)
- Taylor E Wallen
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio
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Barry M, Trivedi A, Pathipati P, Miyazawa BY, Vivona LR, Togarrati PP, Khakoo M, Tanner H, Norris P, Pati S. Mesenchymal stem cell extracellular vesicles mitigate vascular permeability and injury in the small intestine and lung in a mouse model of hemorrhagic shock and trauma. J Trauma Acute Care Surg 2022; 92:489-498. [PMID: 34882596 PMCID: PMC8866219 DOI: 10.1097/ta.0000000000003487] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Hemorrhagic shock and trauma (HS/T)-induced gut injury may play a critical role in the development of multi-organ failure. Novel therapies that target gut injury and vascular permeability early after HS/T could have substantial impacts on trauma patients. In this study, we investigate the therapeutic potential of human mesenchymal stem cells (MSCs) and MSC-derived extracellular vesicles (MSC EVs) in vivo in HS/T in mice and in vitro in Caco-2 human intestinal epithelial cells. METHODS In vivo, using a mouse model of HS/T, vascular permeability to a 10-kDa dextran dye and histopathologic injury in the small intestine and lungs were measured among mice. Groups were (1) sham, (2) HS/T + lactated Ringer's (LR), (3) HS/T + MSCs, and (4) HS/T + MSC EVs. In vitro, Caco-2 cell monolayer integrity was evaluated by an epithelial cell impedance assay. Caco-2 cells were pretreated with control media, MSC conditioned media (CM), or MSC EVs, then challenged with hydrogen peroxide (H2O2). RESULTS In vivo, both MSCs and MSC EVs significantly reduced vascular permeability in the small intestine (fluorescence units: sham, 456 ± 88; LR, 1067 ± 295; MSC, 765 ± 258; MSC EV, 715 ± 200) and lung (sham, 297 ± 155; LR, 791 ± 331; MSC, 331 ± 172; MSC EV, 303 ± 88). Histopathologic injury in the small intestine and lung was also attenuated by MSCs and MSC EVs. In vitro, MSC CM but not MSC EVs attenuated the increased permeability among Caco-2 cell monolayers challenged with H2O2. CONCLUSION Mesenchymal stem cell EVs recapitulate the effects of MSCs in reducing vascular permeability and injury in the small intestine and lungs in vivo, suggesting MSC EVs may be a potential cell-free therapy targeting multi-organ dysfunction in HS/T. This is the first study to demonstrate that MSC EVs improve both gut and lung injury in an animal model of HS/T.
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Affiliation(s)
- Mark Barry
- University of California, San Francisco. Department of Surgery. 513 Parnassus Ave. San Francisco, CA 94143
| | - Alpa Trivedi
- University of California, San Francisco. Department of Laboratory Medicine. 513 Parnassus Ave. San Francisco, CA 94143
| | - Praneeti Pathipati
- University of California, San Francisco. Department of Laboratory Medicine. 513 Parnassus Ave. San Francisco, CA 94143
| | - Byron Y. Miyazawa
- University of California, San Francisco. Department of Laboratory Medicine. 513 Parnassus Ave. San Francisco, CA 94143
| | - Lindsay R. Vivona
- University of California, San Francisco. Department of Laboratory Medicine. 513 Parnassus Ave. San Francisco, CA 94143
| | | | - Manisha Khakoo
- University of California, San Francisco. Department of Laboratory Medicine. 513 Parnassus Ave. San Francisco, CA 94143
| | - Heather Tanner
- Vitalant Research Institute. 270 Masonic Ave. San Francisco, CA 94118
| | - Philip Norris
- Vitalant Research Institute. 270 Masonic Ave. San Francisco, CA 94118
| | - Shibani Pati
- University of California, San Francisco. Department of Laboratory Medicine. 513 Parnassus Ave. San Francisco, CA 94143
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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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Kregel HR, Hatton GE, Isbell KD, Henriksen HH, Stensballe J, Johansson PI, Kao LS, Wade CE. Shock-Induced Endothelial Dysfunction is Present in Patients With Occult Hypoperfusion After Trauma. Shock 2022; 57:106-112. [PMID: 34905531 PMCID: PMC9148678 DOI: 10.1097/shk.0000000000001866] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Shock-induced endothelial dysfunction, evidenced by elevated soluble thrombomodulin (sTM) and syndecan-1 (Syn-1), is associated with poor outcomes after trauma. The association of endothelial dysfunction and overt shock has been demonstrated; it is unknown if hypoperfusion in the setting of normal vital signs (occult hypoperfusion [OH]) is associated with endothelial dysfunction. We hypothesized that sTM and Syn-1 would be elevated in patients with OH when compared to patients with normal perfusion. METHODS A single-center study of patients requiring highest-level trauma activation (2012-2016) was performed. Trauma bay arrival plasma Syn-1 and sTM were measured by enzyme-linked immunosorbent assay. Shock was defined as systolic blood pressure (SBP) <90 mm Hg or heart rate (HR) ≥120 bpm. OH was defined as SBP ≥ 90, HR < 120, and base excess (BE) ≤-3. Normal perfusion was assigned to all others. Univariate and multivariable analyses were performed. RESULTS Of 520 patients, 35% presented with OH and 26% with shock. Demographics were similar between groups. Patients with normal perfusion had the lowest Syn-1 and sTM, while patients with OH and shock had elevated levels. OH was associated with increased sTM by 0.97 ng/mL (95% CI 0.39-1.57, p = 0.001) and Syn-1 by 14.3 ng/mL (95% CI -1.5 to 30.2, p = 0.08). Furthermore, shock was associated with increased sTM by 0.64 (95% CI 0.02-1.30, p = 0.04) and with increased Syn-1 by 23.6 ng/mL (95% CI 6.2-41.1, p = 0.008). CONCLUSIONS Arrival OH was associated with elevated sTM and Syn-1, indicating endothelial dysfunction. Treatments aiming to stabilize the endothelium may be beneficial for injured patients with evidence of hypoperfusion, regardless of vital signs.
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Affiliation(s)
- Heather R. Kregel
- Division of Acute Care Surgery, Department of Surgery, McGovern Medical School at UTHealth, Houston, TX
- Center for Surgical Trials and Evidence-based Practice, McGovern Medical School at UTHealth, Houston, TX
- Center for Translational Injury Research, Houston, TX
| | - Gabrielle E. Hatton
- Division of Acute Care Surgery, Department of Surgery, McGovern Medical School at UTHealth, Houston, TX
- Center for Surgical Trials and Evidence-based Practice, McGovern Medical School at UTHealth, Houston, TX
- Center for Translational Injury Research, Houston, TX
| | - Kayla D. Isbell
- Division of Acute Care Surgery, Department of Surgery, McGovern Medical School at UTHealth, Houston, TX
- Center for Surgical Trials and Evidence-based Practice, McGovern Medical School at UTHealth, Houston, TX
- Center for Translational Injury Research, Houston, TX
| | - Hanne H Henriksen
- Section for Transfusion Medicine, Capital Region Blood Bank, University of Copenhagen, Copenhagen, Denmark
| | - Jakob Stensballe
- Section for Transfusion Medicine, Capital Region Blood Bank, University of Copenhagen, Copenhagen, Denmark
- Department of Anaesthesia and Trauma Centre, Centre of Head and Orthopedics, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Per I Johansson
- Section for Transfusion Medicine, Capital Region Blood Bank, University of Copenhagen, Copenhagen, Denmark
| | - Lillian S. Kao
- Division of Acute Care Surgery, Department of Surgery, McGovern Medical School at UTHealth, Houston, TX
- Center for Surgical Trials and Evidence-based Practice, McGovern Medical School at UTHealth, Houston, TX
- Center for Translational Injury Research, Houston, TX
| | - Charles E. Wade
- Division of Acute Care Surgery, Department of Surgery, McGovern Medical School at UTHealth, Houston, TX
- Center for Translational Injury Research, Houston, TX
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Edwards TH, Rizzo JA, Pusateri AE. Hemorrhagic shock and hemostatic resuscitation in canine trauma. Transfusion 2021; 61 Suppl 1:S264-S274. [PMID: 34269447 DOI: 10.1111/trf.16516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 02/18/2021] [Accepted: 02/19/2021] [Indexed: 11/27/2022]
Abstract
Hemorrhage is a significant cause of death among military working dogs and in civilian canine trauma. While research specifically aimed at canine trauma is limited, many principles from human trauma resuscitation apply. Trauma with significant hemorrhage results in shock and inadequate oxygen delivery to tissues. This leads to aberrations in cellular metabolism, including anaerobic metabolism, decreased energy production, acidosis, cell swelling, and eventual cell death. Considering blood and endothelium as a single organ system, blood failure is a syndrome of endotheliopathy, coagulopathy, and platelet dysfunction. In severe cases following injury, blood failure develops and is induced by inadequate oxygen delivery in the presence of hemorrhage, tissue injury, and acute stress from trauma. Severe hemorrhagic shock is best treated with hemostatic resuscitation, wherein blood products are used to restore effective circulating volume and increase oxygen delivery to tissues without exacerbating blood failure. The principles of hemostatic resuscitation have been demonstrated in severely injured people and the authors propose an algorithm for applying this to canine patients. The use of plasma and whole blood to resuscitate severely injured canines while minimizing the use of crystalloids and colloids could prove instrumental in improving both mortality and morbidity. More work is needed to understand the canine patient that would benefit from hemostatic resuscitation, as well as to determine the optimal resuscitation strategy for these patients.
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Affiliation(s)
- Thomas H Edwards
- U.S. Army Institute of Surgical Research, Joint Base San Antonio - Fort Sam Houston, Texas, USA
| | - Julie A Rizzo
- U.S. Army Institute of Surgical Research, Joint Base San Antonio - Fort Sam Houston, Texas, USA.,Uniformed Services University of Health Sciences, Bethesda, Maryland, USA
| | - Anthony E Pusateri
- Naval Medical Research Unit San Antonio, Joint Base San Antonio - Fort Sam Houston, Texas, USA
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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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Pati S, Fennern E, Holcomb JB, Barry M, Trivedi A, Cap AP, Martin MJ, Wade C, Kozar R, Cardenas JC, Rappold JF, Spiegel R, Schreiber MA. Treating the endotheliopathy of SARS-CoV-2 infection with plasma: Lessons learned from optimized trauma resuscitation with blood products. Transfusion 2021; 61 Suppl 1:S336-S347. [PMID: 34269437 PMCID: PMC8446992 DOI: 10.1111/trf.16452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 03/30/2021] [Indexed: 11/29/2022]
Affiliation(s)
- Shibani Pati
- Department of Lab MedicineUniversity of California San Francisco School of MedicineSan FranciscoCaliforniaUSA
| | - Erin Fennern
- Department of SurgeryMount Sinai Icahn School of MedicineNew YorkNew YorkUSA
| | | | - Mark Barry
- Department of SurgeryUniversity of California San Francisco School of MedicineSan FranciscoCaliforniaUSA
| | - Alpa Trivedi
- Department of Lab MedicineUniversity of California San Francisco School of MedicineSan FranciscoCaliforniaUSA
| | - Andrew P. Cap
- U.S. Army Institute of Surgical ResearchJBSA‐FT Sam HoustonSan AntonioTexasUSA
| | | | - Charles Wade
- Department of Surgery McGovern School of MedicineUniversity of Texas Health Science CenterHoustonTexasUSA
| | - Rosemary Kozar
- Department of SurgeryUniversity of MarylandBaltimoreMarylandUSA
| | - Jessica C. Cardenas
- Department of Surgery McGovern School of MedicineUniversity of Texas Health Science CenterHoustonTexasUSA
| | - Joseph F. Rappold
- Department of Surgery Maine Medical CenterTufts University School of MedicinePortlandMaineUSA
| | - Renee Spiegel
- Department of SurgeryElmhurst Hospital CenterElmhurstNew YorkUSA
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Barry M, Trivedi A, Miyazawa BY, Vivona LR, Khakoo M, Zhang H, Pathipati P, Bagri A, Gatmaitan MG, Kozar R, Stein D, Pati S. Cryoprecipitate attenuates the endotheliopathy of trauma in mice subjected to hemorrhagic shock and trauma. J Trauma Acute Care Surg 2021; 90:1022-1031. [PMID: 33797484 PMCID: PMC8141010 DOI: 10.1097/ta.0000000000003164] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Plasma has been shown to mitigate the endotheliopathy of trauma. Protection of the endothelium may be due in part to fibrinogen and other plasma-derived proteins found in cryoprecipitate; however, the exact mechanisms remain unknown. Clinical trials are underway investigating early cryoprecipitate administration in trauma. In this study, we hypothesize that cryoprecipitate will inhibit endothelial cell (EC) permeability in vitro and will replicate the ability of plasma to attenuate pulmonary vascular permeability and inflammation induced by hemorrhagic shock and trauma (HS/T) in mice. METHODS In vitro, barrier permeability of ECs subjected to thrombin challenge was measured by transendothelial electrical resistance. In vivo, using an established mouse model of HS/T, we compared pulmonary vascular permeability among mice resuscitated with (1) lactated Ringer's solution (LR), (2) fresh frozen plasma (FFP), or (3) cryoprecipitate. Lung tissue from the mice in all groups was analyzed for markers of vascular integrity, inflammation, and inflammatory gene expression via NanoString messenger RNA quantification. RESULTS Cryoprecipitate attenuates EC permeability and EC junctional compromise induced by thrombin in vitro in a dose-dependent fashion. In vivo, resuscitation of HS/T mice with either FFP or cryoprecipitate attenuates pulmonary vascular permeability (sham, 297 ± 155; LR, 848 ± 331; FFP, 379 ± 275; cryoprecipitate, 405 ± 207; p < 0.01, sham vs. LR; p < 0.01, LR vs. FFP; and p < 0.05, LR vs. cryoprecipitate). Lungs from cryoprecipitate- and FFP-treated mice demonstrate decreased lung injury, decreased infiltration of neutrophils and activation of macrophages, and preserved pericyte-endothelial interaction compared with LR-treated mice. Gene analysis of lung tissue from cryoprecipitate- and FFP-treated mice demonstrates decreased inflammatory gene expression, in particular, IL-1β and NLRP3, compared with LR-treated mice. CONCLUSION Our data suggest that cryoprecipitate attenuates the endotheliopathy of trauma in HS/T similar to FFP. Further investigation is warranted on active components and their mechanisms of action.
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Affiliation(s)
- Mark Barry
- University of California, San Francisco. Department of Surgery. 513 Parnassus Ave. San Francisco, CA 94143
| | - Alpa Trivedi
- University of California, San Francisco. Department of Laboratory Medicine. 513 Parnassus Ave. San Francisco, CA 94143
| | - Byron Y. Miyazawa
- University of California, San Francisco. Department of Laboratory Medicine. 513 Parnassus Ave. San Francisco, CA 94143
| | - Lindsay R. Vivona
- University of California, San Francisco. Department of Laboratory Medicine. 513 Parnassus Ave. San Francisco, CA 94143
| | - Manisha Khakoo
- University of California, San Francisco. Department of Laboratory Medicine. 513 Parnassus Ave. San Francisco, CA 94143
| | - Haoqian Zhang
- University of California, San Francisco. Department of Laboratory Medicine. 513 Parnassus Ave. San Francisco, CA 94143
| | - Praneeti Pathipati
- University of California, San Francisco. Department of Laboratory Medicine. 513 Parnassus Ave. San Francisco, CA 94143
| | - Anil Bagri
- Cerus Corporation. 1220 Concord Ave. Concord, CA
| | | | - Rosemary Kozar
- Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD
| | - Deborah Stein
- University of California, San Francisco. Department of Surgery. 513 Parnassus Ave. San Francisco, CA 94143
| | - Shibani Pati
- University of California, San Francisco. Department of Laboratory Medicine. 513 Parnassus Ave. San Francisco, CA 94143
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24
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Murao S, Yamakawa K, Kabata D, Kinoshita T, Umemura Y, Shintani A, Fujimi S. Effect of Earlier Door-to-CT and Door-to-Bleeding Control in Severe Blunt Trauma: A Retrospective Cohort Study. J Clin Med 2021; 10:jcm10071522. [PMID: 33917338 PMCID: PMC8038745 DOI: 10.3390/jcm10071522] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Revised: 03/31/2021] [Accepted: 04/02/2021] [Indexed: 01/03/2023] Open
Abstract
Blunt trauma is a potentially life-threatening injury that requires prompt diagnostic examination and therapeutic intervention. Nevertheless, how impactful a rapid response time is on mortality or functional outcomes has not been well-investigated. This study aimed to evaluate effects of earlier door-to-computed tomography time (D2CT) and door-to-bleeding control time (D2BC) on clinical outcomes in severe blunt trauma. This was a single-center, retrospective cohort study of patients with severe blunt trauma (Injury Severity Score > 16). To assess the effect of earlier D2CT and D2BC on clinical outcomes, we conducted multivariable regression analyses with a consideration for nonlinear associations. Among 671 patients with severe blunt trauma who underwent CT scanning, 163 patients received an emergency bleeding control procedure. The median D2CT and D2BC were 19 min and 57 min, respectively. In a Cox proportional hazard regression model, earlier D2CT was not associated with improved 28-day mortality (p = 0.30), but it was significantly associated with decreased mortality from exsanguination (p = 0.003). Earlier D2BC was significantly associated with improved 28-day mortality (p = 0.026). In conclusion, earlier time to a hemostatic procedure was independently associated with decreased mortality. Meanwhile, time benefits of earlier CT examination were not observed for overall survival but were observed for decreased mortality from exsanguination.
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Affiliation(s)
- Shuhei Murao
- Division of Trauma and Surgical Critical Care, Osaka General Medical Center, Osaka 558-8558, Japan; (S.M.); (Y.U.); (S.F.)
| | - Kazuma Yamakawa
- Division of Trauma and Surgical Critical Care, Osaka General Medical Center, Osaka 558-8558, Japan; (S.M.); (Y.U.); (S.F.)
- Department of Emergency Medicine, Osaka Medical College, Takatsuki 569-8686, Japan
- Correspondence: ; Tel.: +81-6-6692-1201; Fax: +81-6-6692-1155
| | - Daijiro Kabata
- Department of Medical Statistics, Osaka City University Graduate School of Medicine, Osaka 545-8586, Japan; (D.K.); (A.S.)
| | - Takahiro Kinoshita
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Suita 565-0871, Japan;
| | - Yutaka Umemura
- Division of Trauma and Surgical Critical Care, Osaka General Medical Center, Osaka 558-8558, Japan; (S.M.); (Y.U.); (S.F.)
| | - Ayumi Shintani
- Department of Medical Statistics, Osaka City University Graduate School of Medicine, Osaka 545-8586, Japan; (D.K.); (A.S.)
| | - Satoshi Fujimi
- Division of Trauma and Surgical Critical Care, Osaka General Medical Center, Osaka 558-8558, Japan; (S.M.); (Y.U.); (S.F.)
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25
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Abstract
Traumatic injury remains the leading cause of death among individuals younger than age 45 years. Hemorrhage is the primary preventable cause of death in trauma patients. Management of hemorrhage focuses on rapidly controlling bleeding and addressing the lethal triad of hypothermia, acidosis, and coagulopathy. The principles of damage control surgery are rapid control of hemorrhage, temporary control of contamination, resuscitation in the intensive care unit to restore normal physiology, and a planned, delayed definitive operative procedure. Damage control resuscitation focuses on 3 key components: fluid restriction, permissive hypotension, and fixed-ratio transfusion. Rapid recognition and control of hemorrhage and implementation of resuscitation strategies to control damage have significantly improved mortality and morbidity rates. In addition to describing the basic principles of damage control surgery and damage control resuscitation, this article explains specific management considerations for and potential complications in patients undergoing damage control interventions in an intensive care unit.
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Affiliation(s)
- Shannon Gaasch
- Shannon Gaasch is Senior Nurse Practitioner II, R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, 22 S Greene St, Baltimore, MD 21201 (Shannon. )
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26
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The effects of human prothrombin complex concentrate on hemorrhagic shock-induced lung injury in rats: Implications for testing human blood products in rodents. J Trauma Acute Care Surg 2021; 89:1068-1075. [PMID: 32697449 DOI: 10.1097/ta.0000000000002890] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Hemorrhagic shock (HS) and trauma can result in an endotheliopathy of trauma, characterized by endothelial compromise, inflammation, and aberrant coagulation. Kcentra, a prothrombin concentrate, has been demonstrated to mitigate pulmonary vascular leak in a murine model of HS. We investigated the effects of Kcentra in a rat model of HS, to achieve physiologic endpoints of relevance. METHODS Rats subjected to a grade intravenous splenic injury and controlled hemorrhage for 60 minutes were resuscitated with shed volumes of (1) Lactated Ringer's (LR) solution, (2) LR + 20 IU/kg Kcentra, (3) LR + 50 IU/kg Kcentra, (4) rat fresh frozen plasma (RFFP), or (5) human fresh frozen plasma (HFFP). Blood was harvested for monitoring metabolic and coagulation function. Rat lungs were evaluated for lung injury and permeability. RESULTS Animals resuscitated with LR displayed a significant increase in pulmonary vascular permeability (sham, 407.9 ± 122.4; shock + LR, 2040 ± 1462). Resuscitation with RFFP (606.5 ± 169.3) reduced leak; however, treatment with Kcentra (HS + Kcentra [20 IU/kg]: 1792 ± 903.4, HS + Kcentra [50 IU/kg]: 1876 ± 1103), and HFFP (1450 ± 533.2) had no significant effect on permeability. Kcentra modestly altered clotting parameters. Metabolic measures, such as lactate, pH, and base deficit, were restored to baseline levels by both RFFP and HFFP, but not Kcentra or LR. CONCLUSION Kcentra did not alter pulmonary vascular permeability, but modestly increased clotting potential in injured rats. This suggests that there may be a xenogenic reaction of human products in rats and that the effects of Kcentra on vascular stability may be distinct from its ability to modulate clotting. Our data indicate that the species chosen and utilized for in vivo preclinical testing of human derived blood products is of critical importance in determining their efficacy in animal models and is the primary impetus to communicate these results.
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27
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High crystalloid volumes negate benefit of hemostatic resuscitation in pediatric wartime trauma casualties. J Trauma Acute Care Surg 2021; 89:S185-S191. [PMID: 31972756 DOI: 10.1097/ta.0000000000002590] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Recent data for adult trauma patients suggest improved survival when using hemostatic resuscitation, which includes limiting crystalloids and using closer to 1:1 ratios for both fresh frozen plasma (FFP) and platelets (PLTs) relative to packed red blood cells (PRBCs). Pediatric studies have shown similar but mixed results and often lack measuring crystalloids. We seek to evaluate in-hospital survival based on crystalloid administration and different blood product ratios in pediatric casualties during the recent conflicts. METHODS We queried the Department of Defense Trauma Registry for all pediatric encounters in Iraq and Afghanistan from January 2007 to January 2016 and included those with at least 40 mL/kg of total blood products administered provided that they received at least 1 U of PRBC. We grouped children as younger (0-7 years) and older (8-17 years). We grouped low versus high ratios for FFP/PRBC (≤1:2 vs. >1:2) and PLT/PRBC (≤1:6 vs. >1.6). We used a threshold of 40 mL/kg to for high versus low crystalloid resuscitation. RESULTS During this time, there were 3,439 encounters in the registry with 521 (15.1%) that met the inclusion criteria. The median age of casualties that met the inclusion was 10 years (interquartile range, 5-13), most were male (73.5%), with a moderate median injury severity score (17; interquartile range, 13-25). We performed regression modeling with adjustments for mechanism of injury, composite injury severity score, and total blood product volume (mL/kg based), grouping children based on high versus low fluid resuscitation. In the low-volume crystalloid group, we found that higher (>1:2) FFP/PRBC was associated with improved survival (odds ratio [OR], 3.42). However, in the high fluid crystalloid resuscitation group, we found that that higher ratios for PLT/PRBC (>1:6) overall (OR, 0.46) and the FFP/PRBC (>1:2) in younger children (OR, 0.28) was associated with worse survival. The remaining associations were not statistically significant. CONCLUSION We found an association with survival in massively transfused pediatric trauma patients who received both a high FFP/PRBC ratio and low crystalloid administration. The benefit of this high ratio is negated, in patients receiving high crystalloid volumes, particularly among smaller children. Future studies on hemostatic resuscitation evaluating blood product ratios should also account for crystalloid and colloid administration. LEVEL OF EVIDENCE Retrospective, comparative, level III.
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28
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Wu F, Wang JY, Chao W, Sims C, Kozar RA. miR-19b targets pulmonary endothelial syndecan-1 following hemorrhagic shock. Sci Rep 2020; 10:15811. [PMID: 32978505 PMCID: PMC7519668 DOI: 10.1038/s41598-020-73021-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Accepted: 08/19/2020] [Indexed: 02/07/2023] Open
Abstract
Hemorrhagic shock results in systemic injury to the endothelium contributing to post-shock morbidity and mortality. The mechanism involves syndecan-1, the backbone of the endothelial glycocalyx. We have shown in a rodent model that lung syndecan-1 mRNA is reduced following hemorrhage, whereas the molecular mechanism underlying the mRNA reduction is not clear. In this study, we present evidence that miR-19b targets syndecan-1 mRNA to downregulate its expression. Our results demonstrate that miR-19b was increased in hemorrhagic shock patients and in-vitro specifically bound to syndecan-1 mRNA and caused its degradation. Further, hypoxia/reoxygenation (H/R), our in vitro hemorrhage model, increased miR-19b expression in human lung microvascular endothelial cells, leading to a decrease in syndecan-1 mRNA and protein. H/R insult and miR-19b mimic overexpression comparably exaggerated permeability and enhanced endothelial barrier breakdown. The detrimental role of miR-19b in inducing endothelial dysfunction was confirmed in vivo. Lungs from mice undergoing hemorrhagic shock exhibited a significant increase in miR-19b and a concomitant decrease in syndecan-1 mRNA. Pretreatment with miR-19b oligo inhibitor significantly decreased lung injury, inflammation, and permeability and improved hemodynamics. These findings suggest that inhibition of miR-19b may be a putative therapeutic avenue for mitigating post shock pulmonary endothelial dysfunction in hemorrhage shock.
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Affiliation(s)
- Feng Wu
- Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Jian-Ying Wang
- Cell Biology Group, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA.,Baltimore Veterans Affairs Medical Center, Baltimore, MD, USA.,Department of Pathology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Wei Chao
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Carrie Sims
- Division of Trauma, Critical Care and Burn, Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Rosemary Ann Kozar
- Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, USA.
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29
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Endothelial glycocalyx shedding in patients with burns. Burns 2020; 46:386-393. [DOI: 10.1016/j.burns.2019.05.009] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Revised: 04/25/2019] [Accepted: 05/15/2019] [Indexed: 11/21/2022]
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30
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Beckmann N, Sutton JM, Hoehn RS, Jernigan PL, Friend LA, Johanningman TA, Schuster RM, Lentsch AB, Caldwell CC, Pritts TA. IFNγ and TNFα mediate CCL22/MDC production in alveolar macrophages after hemorrhage and resuscitation. Am J Physiol Lung Cell Mol Physiol 2020; 318:L864-L872. [PMID: 32101016 DOI: 10.1152/ajplung.00455.2019] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Acute lung injury is a major complication of hemorrhagic shock and the required resuscitation with large volumes of crystalloid fluids and blood products. We previously identified a role of macrophage-derived chemokine (CCL22/MDC) pulmonary inflammation following hemorrhage and resuscitation. However, further details regarding the induction of CCL22/MDC and its precise role in pulmonary inflammation after trauma remain unknown. In the current study we used in vitro experiments with a murine alveolar macrophage cell line, as well as an in vivo mouse model of hemorrhage and resuscitation, to identify key regulators in CCL22/MDC production. We show that trauma induces expression of IFNγ, which leads to production of CCL22/MDC through a signaling mechanism involving p38 MAPK, NF-κB, JAK, and STAT-1. IFNγ also activates TNFα production by alveolar macrophages, potentiating CCL22/MDC production via an autocrine mechanism. Neutralization of IFNγ or TNFα with specific antibodies reduced histological signs of pulmonary injury after hemorrhage and reduced inflammatory cell infiltration into the lungs.
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Affiliation(s)
- Nadine Beckmann
- Division of Research, Department of Surgery, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Jeffrey M Sutton
- Section of General Surgery, Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Richard S Hoehn
- Section of General Surgery, Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Peter L Jernigan
- Section of General Surgery, Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Lou Ann Friend
- Section of General Surgery, Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Taylor A Johanningman
- Section of General Surgery, Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Rebecca M Schuster
- Section of General Surgery, Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Alex B Lentsch
- Section of General Surgery, Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Charles C Caldwell
- Division of Research, Department of Surgery, College of Medicine, University of Cincinnati, Cincinnati, Ohio.,Division of Research, Shriners Hospital for Children, Cincinnati, Ohio
| | - Timothy A Pritts
- Section of General Surgery, Department of Surgery, University of Cincinnati, Cincinnati, Ohio
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31
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Pusateri AE, Moore EE, Moore HB, Le TD, Guyette FX, Chapman MP, Sauaia A, Ghasabyan A, Chandler J, McVaney K, Brown JB, Daley BJ, Miller RS, Harbrecht BG, Claridge JA, Phelan HA, Witham WR, Putnam AT, Sperry JL. Association of Prehospital Plasma Transfusion With Survival in Trauma Patients With Hemorrhagic Shock When Transport Times Are Longer Than 20 Minutes: A Post Hoc Analysis of the PAMPer and COMBAT Clinical Trials. JAMA Surg 2020; 155:e195085. [PMID: 31851290 DOI: 10.1001/jamasurg.2019.5085] [Citation(s) in RCA: 133] [Impact Index Per Article: 33.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Importance Both military and civilian clinical practice guidelines include early plasma transfusion to achieve a plasma to red cell ratio approaching 1:1 to 1:2. However, it was not known how early plasma should be given for optimal benefit. Two recent randomized clinical trials were published, with apparently contradictory results. The Prehospital Air Medical Plasma (PAMPer) clinical trial showed a nearly 30% reduction in mortality with plasma transfusion in the prehospital environment, while the Control of Major Bleeding After Trauma (COMBAT) clinical trial showed no survival improvement. Objective To facilitate a post hoc combined analysis of the COMBAT and PAMPer trials to examine questions that could not be answered by either clinical trial alone. We hypothesized that prehospital transport time influenced the effects of prehospital plasma on 28-day mortality. Design, Setting, and Participants A total of 626 patients in the 2 clinical trials were included. Patients with trauma and hemorrhagic shock were randomly assigned to receive either standard care or 2 U of thawed plasma followed by standard care in the prehospital environment. Data analysis was performed between September 2018 and January 2019. Interventions Prehospital transfusion of 2 U of plasma compared with crystalloid-based resuscitation. Main Outcomes and Measures The main outcome was 28-day mortality. Results In this post hoc analysis of 626 patients (467 men [74.6%] and 159 women [25.4%]; median [interquartile range] age, 42 [27-57] years) who had trauma with hemorrhagic shock, a Cox regression analysis showed a significant overall survival benefit for plasma (hazard ratio [HR], 0.65; 95% CI, 0.47-0.90; P = .01) after adjustment for injury severity, age, and clinical trial cohort (COMBAT or PAMPer). A significant association with prehospital transport time was detected (from arrival on scene to arrival at the trauma center). Increased mortality was observed in patients in the standard care group when prehospital transport was longer than 20 minutes (HR, 2.12; 95% CI, 1.05-4.30; P = .04), while increased mortality was not observed in patients in the prehospital plasma group (HR, 0.78; 95% CI, 0.40-1.51; P = .46). No serious adverse events were associated with prehospital plasma transfusion. Conclusions and Relevance These data suggest that prehospital plasma is associated with a survival benefit when transport times are longer than 20 minutes and that the benefit-risk ratio is favorable for use of prehospital plasma. Trial Registration ClinicalTrials.gov identifiers: NCT01838863 (COMBAT) and NCT01818427 (PAMPer).
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Affiliation(s)
- Anthony E Pusateri
- US Army Institute of Surgical Research, JBSA-Fort Sam Houston, San Antonio, Texas
| | - Ernest E Moore
- Department of Surgery, School of Medicine, University of Colorado Denver, Aurora
| | - Hunter B Moore
- Department of Surgery, School of Medicine, University of Colorado Denver, Aurora
| | - Tuan D Le
- US Army Institute of Surgical Research, JBSA-Fort Sam Houston, San Antonio, Texas
| | - Francis X Guyette
- Division of Emergency Medicine, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Michael P Chapman
- Department of Radiology, School of Medicine, University of Colorado Denver, Aurora
| | - Angela Sauaia
- Department of Health Systems, Management, and Policy, School of Public Health, University of Colorado Denver, Aurora
| | - Arsen Ghasabyan
- Department of Surgery, School of Medicine, University of Colorado Denver, Aurora
| | - James Chandler
- Department of Surgery, School of Medicine, University of Colorado Denver, Aurora
| | - Kevin McVaney
- Department of Emergency Medicine, School of Medicine, University of Colorado Denver, Aurora
| | - Joshua B Brown
- Division of Trauma and General Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Brian J Daley
- Department of Surgery, University of Tennessee Health Science Center, Knoxville
| | - Richard S Miller
- Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Brian G Harbrecht
- Department of Surgery, University of Louisville, Louisville, Kentucky
| | - Jeffrey A Claridge
- MetroHealth Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - Herb A Phelan
- Department of Surgery, Parkland Memorial Hospital, University of Texas Southwestern, Dallas
| | | | - A Tyler Putnam
- Altoona Hospital, University of Pittsburgh Medical Center, Altoona, Pennsylvania
| | - Jason L Sperry
- Division of Trauma and General Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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32
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Luckhurst CM, Saillant NN. Plasma: a Brief History, the Evidence, and Current Recommendations. CURRENT TRAUMA REPORTS 2020. [DOI: 10.1007/s40719-020-00181-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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33
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Stolla M, Zhang F, Meyer MR, Zhang J, Dong JF. Current state of transfusion in traumatic brain injury and associated coagulopathy. Transfusion 2019; 59:1522-1528. [PMID: 30980753 DOI: 10.1111/trf.15169] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Revised: 11/10/2018] [Accepted: 11/17/2018] [Indexed: 12/15/2022]
Abstract
Traumatic brain injury (TBI)-induced coagulopathy has long been recognized as a significant risk for poor outcomes in patients with TBI, but its pathogenesis remains poorly understood. As a result, current treatment options for the condition are limited and ineffective. The lack of information is most significant for the impact of blood transfusions on patients with isolated TBI and in the absence of confounding influences from trauma to the body and limbs and the resultant hemorrhagic shock. Here we discuss recent progress in understanding the pathogenesis of TBI-induced coagulopathy and the current state of blood transfusions for patients with TBI and associated coagulopathy.
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Affiliation(s)
- Moritz Stolla
- Bloodworks Research Institute, Seattle, Washington.,Division of Hematology, Department of Medicine, University of Washington, School of Medicine, Seattle, Washington
| | - Fangyi Zhang
- Department of Neurological Surgery, University of Washington School of Medicine, Seattle, Washington
| | - Michael R Meyer
- Department of Neurological Surgery, University of Washington School of Medicine, Seattle, Washington
| | - Jianning Zhang
- Tianjin Institute of Neurology, Tianjin, China.,Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Jing-Fei Dong
- Bloodworks Research Institute, Seattle, Washington.,Division of Hematology, Department of Medicine, University of Washington, School of Medicine, Seattle, Washington
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34
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Abstract
PURPOSE OF REVIEW Traumatic brain injury (TBI) is a leading cause of morbidity and mortality; however, little definitive evidence exists about most clinical management strategies. Here, we highlight important differences between two major guidelines, the 2016 Brain Trauma Foundation guidelines and the Lund Concept, along with recent pre-clinical and clinical data. RECENT FINDINGS While intracranial pressure (ICP) monitoring has been questioned, the majority of literature demonstrates benefit in severe TBI. The optimal cerebral perfusion pressure (CPP) and ICP are yet unknown, but likely as important is the concept of ICP burden. The evidence for anti-hypertensive therapy is strengthening. Decompressive craniectomy improves mortality, but at the cost of increased morbidity. Plasma-based resuscitation has demonstrated benefit in multiple pre-clinical TBI studies. SUMMARY The management of hemodynamics and intravascular volume are crucial in TBI. Based on recent evidence, ICP monitoring, anti-hypertensive therapy, minimal use of vasopressors/inotropes, and plasma resuscitation may improve outcomes.
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Affiliation(s)
- Henry W. Caplan
- Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, TX
| | - Charles S. Cox
- Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, TX
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35
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Miyazawa B, Trivedi A, Togarrati PP, Potter D, Baimukanova G, Vivona L, Lin M, Lopez E, Callcut R, Srivastava AK, Kornblith LZ, Fields AT, Schreiber MA, Wade CE, Holcomb JB, Pati S. Regulation of endothelial cell permeability by platelet-derived extracellular vesicles. J Trauma Acute Care Surg 2019; 86:931-942. [PMID: 31124890 PMCID: PMC7381393 DOI: 10.1097/ta.0000000000002230] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Platelet (Plt)-derived extracellular vesicles (Plt-EVs) have hemostatic properties similar to Plts. In addition to hemostasis, Plts also function to stabilize the vasculature and maintain endothelial cell (EC) barrier integrity. We hypothesized that Plt-EVs would inhibit vascular EC permeability, similar to fresh Plts. To investigate this hypothesis, we used in vitro and in vivo models of vascular endothelial compromise and bleeding. METHODS In the vitro model, Plt-EVs were isolated by ultracentrifugation and characterized for Plt markers and particle size distribution. Effects of Plts and Plt-EVs on endothelial barrier function were assessed by transendothelial electrical resistance measurements and histological analysis of endothelial junction proteins. Hemostatic potential of Plt-EVs and Plts was assessed by multiple electrode Plt aggregometry. Using an in vivo model, the effects of Plts and Plt-EVs on vascular permeability and bleeding were assessed in non-obese diabetic-severe combined immunodeficient (NOD-SCID) mice by an established Miles assay of vascular permeability and a tail snip bleeding assay. RESULTS In the in vitro model, Plt-EVs displayed exosomal size distribution and expressed Plt-specific surface markers. Platelets and Plt-EVs decreased EC permeability and restored EC junctions after thrombin challenge. Multiplate aggregometry revealed that Plt-EVs enhanced thrombin receptor-activating peptide-mediated aggregation of whole blood, whereas Plts enhanced thrombin receptor-activating peptide-, arachidonic acid-, collagen-, and adenosine diphosphate-mediated aggregation. In the in vivo model, Plt-EVs are equivalent to Plts in attenuating vascular endothelial growth factor (VEGF)-A-induced vascular permeability and uncontrolled blood loss in a tail snip hemorrhage model. CONCLUSION Our study is the first to report that Plt-EVs might provide a feasible product for transfusion in trauma patients to attenuate bleeding, inhibit vascular permeability, and mitigate the endotheliopathy of trauma.
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Affiliation(s)
- Byron Miyazawa
- From the Department of Laboratory Medicine (B.M., A.T., D.P., L.V., M.L., S.P.), University of California; Blood Systems Research Institute (P.P.T., G.B.), San Francisco, California; Department of Surgery (EL., C.E.W.), University of Texas Health Science Center at Houston; Department of Pediatric Surgery (A.K.S., J.B.H.), McGovern Medical School, University of Texas Health Science Center at Houston, Houston, Texas; Department of Surgery (R.C., L.Z.K., A.T.F.), University of California San Francisco, San Francisco, California; Department of Surgery (M.A.S.), Oregon Health Science and University, Portland, Oregon
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Abstract
Dried plasma provides an alternative for early plasma transfusion in the resuscitation of hemorrhagic shock in environments where fresh frozen plasma is not immediately available. It is produced by freeze-drying or spray-drying liquid or thawed plasma. It is shelf-stable for prolonged periods, can be stored at room temperature, and is easy to transport, reconstitute, and administer. It was widely used in WWII but fell out of favor due to the risk of infectious disease transmission. The German and French experiences with lyophilized plasma are the most extensive and show a good track record of efficacy and safety. Recent studies show many beneficial effects of dried plasma in the treatment of shock in large animal models. Currently, no FDA-licensed product is available in the USA, but several are under development.
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Affiliation(s)
- Philip C. Spinella
- School of Medicine, Washington University in St. Louis, St. Louis, MO USA
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Wade CE, Matijevic N, Wang YWW, Rodriguez EG, Lopez E, Ostrowski SR, Cardenas JC, Baer LA, Chen TA, Tomasek JS, Henriksen HH, Stensballe J, Cotton BA, Holcomb JB, Johansson PI. Absences of Endothelial Microvesicle Changes in the Presence of the Endotheliopathy of Trauma. Shock 2019; 51:180-184. [DOI: 10.1097/shk.0000000000001149] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Hemorrhagic blood failure: Oxygen debt, coagulopathy, and endothelial damage. J Trauma Acute Care Surg 2019; 82:S41-S49. [PMID: 28328671 DOI: 10.1097/ta.0000000000001436] [Citation(s) in RCA: 61] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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Gonzalez Rodriguez E, Cardenas JC, Cox CS, Kitagawa RS, Stensballe J, Holcomb JB, Johansson PI, Wade CE. Traumatic brain injury is associated with increased syndecan-1 shedding in severely injured patients. Scand J Trauma Resusc Emerg Med 2018; 26:102. [PMID: 30463625 PMCID: PMC6249764 DOI: 10.1186/s13049-018-0565-3] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Accepted: 11/02/2018] [Indexed: 01/01/2023] Open
Abstract
INTRODUCTION Head injury and exsanguination are the leading causes of death in trauma patients. Hemorrhagic shock triggers systemic endothelial glycocalyx breakdown, potentially leading to traumatic endotheliopathy (EoT). Levels of syndecan-1, a main glycocalyx component, have been used to assess the integrity of the glycocalyx. In TBI patients, it remains unclear whether syndecan-1 shedding occurs and its correlation with outcomes. We aimed to determine the frequency of EoT+, defined as a syndecan-1 level of 40 ng/ml or higher, after TBI in isolated and polytraumatic injury. We also investigated how the presence of EoT+ affected outcomes in TBI patients. METHODS Severely injured trauma patients were enrolled. From blood samples collected upon patients' arrival to the hospital, we measured syndecan-1 (main biomarker of EoT+), soluble thrombomodulin (sTM, endothelial activation) adrenaline and noradrenaline (sympathoadrenal activation), and assessed TBI patients' coagulation capacity. RESULTS Of the enrolled patients (n = 331), those with TBI and polytrauma (n = 68) had the highest rate of EoT+ compared to isolated TBI (n = 58) and Non-TBI patients (n = 205) (Polytrauma-TBI 55.9% vs. Isolated-TBI 20.0% vs. non-TBI polytrauma 40.0%; p = 0.001). TBI patients with EoT+ exhibited marked increases in sTM, adrenaline and noradrenaline levels, and physiological and coagulation derangements. In isolated TBI patients, increasing syndecan-1 levels (β for every 10 ng/ml increase: 0.14; 95% CI: 0.02, 0.26) and hypocoagulability were negatively associated with survival. CONCLUSIONS This study provides evidence of syndecan-1 shedding after TBI supporting the notion that breakdown of the glycocalyx contributes to the physiological derangements after TBI.
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Affiliation(s)
- Erika Gonzalez Rodriguez
- Center for Translational Injury Research (CeTIR), Department of Surgery, McGovern Medical School, University of Texas Health Science Center, 6431 Fannin, MSB 5.204, Houston, TX 77030 USA
| | - Jessica C. Cardenas
- Center for Translational Injury Research (CeTIR), Department of Surgery, McGovern Medical School, University of Texas Health Science Center, 6431 Fannin, MSB 5.204, Houston, TX 77030 USA
| | - Charles S. Cox
- Department of Pediatric Surgery, McGovern Medical School at The University of Texas Health Science Center, 6431 Fannin, MSB 5.258, Houston, TX 77030 USA
| | - Ryan S. Kitagawa
- Department of Neurosurgery, Mischer Neuroscience Institute, McGovern Medical School at The University of Texas Health Science Center, 6400 Fannin, Suite 2800, Houston, TX 77030 USA
| | - Jakob Stensballe
- Section for Transfusion Medicine, Capital Region Blood Bank, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 9, DK-2100 Copenhagen, Denmark
- Department of Anesthesia, Centre of Head and Orthopedics, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - John B. Holcomb
- Center for Translational Injury Research (CeTIR), Department of Surgery, McGovern Medical School, University of Texas Health Science Center, 6431 Fannin, MSB 5.204, Houston, TX 77030 USA
| | - Pär I. Johansson
- Center for Translational Injury Research (CeTIR), Department of Surgery, McGovern Medical School, University of Texas Health Science Center, 6431 Fannin, MSB 5.204, Houston, TX 77030 USA
- Section for Transfusion Medicine, Capital Region Blood Bank, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 9, DK-2100 Copenhagen, Denmark
| | - Charles E. Wade
- Center for Translational Injury Research (CeTIR), Department of Surgery, McGovern Medical School, University of Texas Health Science Center, 6431 Fannin, MSB 5.204, Houston, TX 77030 USA
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Hamidi M, Zeeshan M, Kulvatunyou N, Adun E, O'Keeffe T, Zakaria ER, Gries L, Joseph B. Outcomes After Massive Transfusion in Trauma Patients: Variability Among Trauma Centers. J Surg Res 2018; 234:110-115. [PMID: 30527461 DOI: 10.1016/j.jss.2018.09.018] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Revised: 08/13/2018] [Accepted: 09/07/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Exsanguinating trauma patients often require massive blood transfusion (defined as transfusion of 10 or more pRBC units within first 24 h). The aim of our study is to assess the outcomes of trauma patients receiving massive transfusion at different levels of trauma centers. METHODS Two-y (2013-2014) retrospective analysis of the American College of Surgeons Trauma Quality Improvement Program. We included all adult trauma patients who received massive transfusion (MT) of blood. Outcome measures were mortality, hospital length of stay, intensive care unit-free and ventilator-free days, blood products received, and complications. RESULTS We analyzed a total of 416,957 patients, of which 2776 met the inclusion criteria and included in the study. Mean age was 40.6 ± 20 y, 78.3% were males and 33.1% of the injuries were penetrating. Median injury severity score [IQR] was 29 [18-40], median [IQR] Glasgow Coma Scale 10[4-15]. Mean packed red blood cells transfusion in the first 24 h was 20 ± 13 units and mean plasma transfusion was 13 ± 11 units. Overall in-hospital mortality was 43.5%. Receiving MT in level I trauma center was independently associated with lower rates of mortality (odds ratio [OR]: 0.75 [0.46-0.96], P < 0.001). Higher injury severity score (OR: 1.020 [1.010-1.030], P < 0.001) and increased units of packed red blood cells transfused (OR: 1.067 [1.041-1.093], P < 0.001) were independently associated with increased mortality. However, there was no association between teaching status, age, gender, emergency department vitals, and units of plasma transfused. CONCLUSIONS Hemorrhage continues to remain one of the most common cause of death after trauma. Almost half of the patients who received massive transfusion died. Patients who receive massive blood transfusion in a level I trauma centers have improved survival compared with level II trauma centers.
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Affiliation(s)
- Mohammad Hamidi
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, University of Arizona, Tucson, Arizona
| | - Muhammad Zeeshan
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, University of Arizona, Tucson, Arizona
| | - Narong Kulvatunyou
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, University of Arizona, Tucson, Arizona
| | - Eseoghene Adun
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, University of Arizona, Tucson, Arizona
| | - Terence O'Keeffe
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, University of Arizona, Tucson, Arizona
| | - El Rasheid Zakaria
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, University of Arizona, Tucson, Arizona
| | - Lynn Gries
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, University of Arizona, Tucson, Arizona
| | - Bellal Joseph
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, University of Arizona, Tucson, Arizona.
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Wei S, Gonzalez Rodriguez E, Chang R, Holcomb JB, Kao LS, Wade CE. Elevated Syndecan-1 after Trauma and Risk of Sepsis: A Secondary Analysis of Patients from the Pragmatic, Randomized Optimal Platelet and Plasma Ratios (PROPPR) Trial. J Am Coll Surg 2018; 227:587-595. [PMID: 30243993 DOI: 10.1016/j.jamcollsurg.2018.09.003] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Revised: 09/10/2018] [Accepted: 09/10/2018] [Indexed: 12/25/2022]
Abstract
BACKGROUND Endotheliopathy of trauma is characterized by breakdown of the endothelial glycocalyx. Elevated biomarkers of endotheliopathy, such as serum syndecan-1 (Synd-1) ≥ 40 ng/mL, have been associated with increased need for transfusions, complications, and mortality. We hypothesized that severely injured trauma patients who exhibit elevated Synd-1 levels shortly after admission have an increased likelihood of developing sepsis. STUDY DESIGN We analyzed a subset of patients from the Pragmatic, Randomized Optimal Platelet and Plasma Ratios (PROPPR) trial who survived at least 72 hours after hospital admission, and we determined elevated Synd-1 levels (≥ 40 ng/mL) 4 hours after hospital arrival. Sepsis was defined a priori as meeting systemic inflammatory response criteria and having a known or suspected infection. Univariate analysis was performed to identify variables associated with elevated Synd-1 levels and sepsis. Significant variables at a value of p < 0.2 in the univariate analysis were chosen by purposeful selection and analyzed in a mixed effects multivariate logistic regression model to account for the 12 different study sites. RESULTS We included 512 patients. Of these, 402 (79%) had elevated Synd-1 levels, and 180 (35%) developed sepsis. Median Synd-1 levels at 4 hours after admission were 70 ng/dL (interquartile range [IQR] 36 to 157 ng/dL) in patients who did not develop sepsis, and 165 ng/dL [IQR 67 to 336 ng/dL] in those who did (p < 0.001). Adjusting for treatment arm and site, multivariable analyses revealed that elevated Synd-1 status, Injury Severity Score (ISS), and total blood transfused were significantly associated with an increased likelihood of developing sepsis. CONCLUSIONS Elevated Synd-1 levels 4 hours after admission in severely injured adult trauma patients who survived the initial 72 hours after hospital admission are associated with subsequent sepsis.
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Affiliation(s)
- Shuyan Wei
- Center for Translational Injury Research, University of Texas Health Science Center, Houston, TX; Department of Surgery, McGovern Medical School, University of Texas Health Science Center, Houston, TX.
| | - Erika Gonzalez Rodriguez
- Center for Translational Injury Research, University of Texas Health Science Center, Houston, TX; Department of Surgery, McGovern Medical School, University of Texas Health Science Center, Houston, TX
| | - Ronald Chang
- Center for Translational Injury Research, University of Texas Health Science Center, Houston, TX; Department of Surgery, McGovern Medical School, University of Texas Health Science Center, Houston, TX
| | - John B Holcomb
- Center for Translational Injury Research, University of Texas Health Science Center, Houston, TX; Department of Surgery, McGovern Medical School, University of Texas Health Science Center, Houston, TX
| | - Lillian S Kao
- Center for Translational Injury Research, University of Texas Health Science Center, Houston, TX; Department of Surgery, McGovern Medical School, University of Texas Health Science Center, Houston, TX
| | - Charles E Wade
- Center for Translational Injury Research, University of Texas Health Science Center, Houston, TX; Department of Surgery, McGovern Medical School, University of Texas Health Science Center, Houston, TX
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Abstract
PURPOSE OF REVIEW Hemorrhage remains the primary cause of preventable death on the battlefield and in civilian trauma. Hemorrhage control is multifactorial and starts with point-of-injury care. Surgical hemorrhage control and time from injury to surgery is paramount; however, interventions in the prehospital environment and perioperative period affect outcomes. The purpose of this review is to understand concepts and strategies for successful management of the bleeding military patient. Understanding the life-threatening nature of coagulopathy of trauma and implementing strategies aimed at full spectrum hemorrhage management from point of injury to postoperative care will result in improved outcomes in patients with life-threatening bleeding. RECENT FINDINGS Timely and appropriate therapies impact survival. Blood product resuscitation for life-threatening hemorrhage should either be with whole blood or a component therapy strategy that recapitulates the functionality of whole blood. The US military has transfused over 10 000 units of whole blood since the beginning of the wars in Iraq and Afghanistan. The well recognized therapeutic benefits of whole blood have pushed this therapy far forward into prehospital care in both US and international military forces. Multiple hemostatic adjuncts are available that are likely beneficial to the bleeding military patient; and other products and techniques are under active investigation. SUMMARY Lessons learned in the treatment of combat casualties will likely continue to have positive impact and influence and the management of hemorrhage in the civilian trauma setting.
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Sperry JL, Guyette FX, Brown JB, Yazer MH, Triulzi DJ, Early-Young BJ, Adams PW, Daley BJ, Miller RS, Harbrecht BG, Claridge JA, Phelan HA, Witham WR, Putnam AT, Duane TM, Alarcon LH, Callaway CW, Zuckerbraun BS, Neal MD, Rosengart MR, Forsythe RM, Billiar TR, Yealy DM, Peitzman AB, Zenati MS. Prehospital Plasma during Air Medical Transport in Trauma Patients at Risk for Hemorrhagic Shock. N Engl J Med 2018; 379:315-326. [PMID: 30044935 DOI: 10.1056/nejmoa1802345] [Citation(s) in RCA: 499] [Impact Index Per Article: 83.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND After a person has been injured, prehospital administration of plasma in addition to the initiation of standard resuscitation procedures in the prehospital environment may reduce the risk of downstream complications from hemorrhage and shock. Data from large clinical trials are lacking to show either the efficacy or the risks associated with plasma transfusion in the prehospital setting. METHODS To determine the efficacy and safety of prehospital administration of thawed plasma in injured patients who are at risk for hemorrhagic shock, we conducted a pragmatic, multicenter, cluster-randomized, phase 3 superiority trial that compared the administration of thawed plasma with standard-care resuscitation during air medical transport. The primary outcome was mortality at 30 days. RESULTS A total of 501 patients were evaluated: 230 patients received plasma (plasma group) and 271 received standard-care resuscitation (standard-care group). Mortality at 30 days was significantly lower in the plasma group than in the standard-care group (23.2% vs. 33.0%; difference, -9.8 percentage points; 95% confidence interval, -18.6 to -1.0%; P=0.03). A similar treatment effect was observed across nine prespecified subgroups (heterogeneity chi-square test, 12.21; P=0.79). Kaplan-Meier curves showed an early separation of the two treatment groups that began 3 hours after randomization and persisted until 30 days after randomization (log-rank chi-square test, 5.70; P=0.02). The median prothrombin-time ratio was lower in the plasma group than in the standard-care group (1.2 [interquartile range, 1.1 to 1.4] vs. 1.3 [interquartile range, 1.1 to 1.6], P<0.001) after the patients' arrival at the trauma center. No significant differences between the two groups were noted with respect to multiorgan failure, acute lung injury-acute respiratory distress syndrome, nosocomial infections, or allergic or transfusion-related reactions. CONCLUSIONS In injured patients at risk for hemorrhagic shock, the prehospital administration of thawed plasma was safe and resulted in lower 30-day mortality and a lower median prothrombin-time ratio than standard-care resuscitation. (Funded by the U.S. Army Medical Research and Materiel Command; PAMPer ClinicalTrials.gov number, NCT01818427 .).
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Affiliation(s)
- Jason L Sperry
- From the Division of Trauma and General Surgery, Department of Surgery (J.L.S., J.B.B., L.H.A., B.S.Z., M.D.N., M.R.R., R.M.F., T.R.B., A.B.P., M.S.Z.), and the Departments of Emergency Medicine (F.X.G., C.W.C., D.M.Y.) and Critical Care Medicine (B.J.E.-Y., P.W.A.), University of Pittsburgh Medical Center, and the Department of Pathology, University of Pittsburgh and Institute for Transfusion Medicine (M.H.Y., D.J.T.), Pittsburgh, and University of Pittsburgh Medical Center, Altoona Hospital, Altoona (A.T.P.) - all in Pennsylvania; the Department of Surgery, University of Tennessee Health Science Center, Knoxville (B.J.D.), and the Department of Surgery, Vanderbilt University Medical Center, Nashville (R.S.M.) - both in Tennessee; the Department of Surgery, University of Louisville, Louisville, KY (B.G.H.); MetroHealth Medical Center, Case Western Reserve University, Cleveland (J.A.C.); and the Department of Surgery, University of Texas Southwestern, Parkland Memorial Hospital, Dallas (H.A.P.) and Texas Health Harris Methodist Hospital (W.R.W.) and the John Peter Smith Health Network (T.M.D.), Fort Worth - all in Texas
| | - Francis X Guyette
- From the Division of Trauma and General Surgery, Department of Surgery (J.L.S., J.B.B., L.H.A., B.S.Z., M.D.N., M.R.R., R.M.F., T.R.B., A.B.P., M.S.Z.), and the Departments of Emergency Medicine (F.X.G., C.W.C., D.M.Y.) and Critical Care Medicine (B.J.E.-Y., P.W.A.), University of Pittsburgh Medical Center, and the Department of Pathology, University of Pittsburgh and Institute for Transfusion Medicine (M.H.Y., D.J.T.), Pittsburgh, and University of Pittsburgh Medical Center, Altoona Hospital, Altoona (A.T.P.) - all in Pennsylvania; the Department of Surgery, University of Tennessee Health Science Center, Knoxville (B.J.D.), and the Department of Surgery, Vanderbilt University Medical Center, Nashville (R.S.M.) - both in Tennessee; the Department of Surgery, University of Louisville, Louisville, KY (B.G.H.); MetroHealth Medical Center, Case Western Reserve University, Cleveland (J.A.C.); and the Department of Surgery, University of Texas Southwestern, Parkland Memorial Hospital, Dallas (H.A.P.) and Texas Health Harris Methodist Hospital (W.R.W.) and the John Peter Smith Health Network (T.M.D.), Fort Worth - all in Texas
| | - Joshua B Brown
- From the Division of Trauma and General Surgery, Department of Surgery (J.L.S., J.B.B., L.H.A., B.S.Z., M.D.N., M.R.R., R.M.F., T.R.B., A.B.P., M.S.Z.), and the Departments of Emergency Medicine (F.X.G., C.W.C., D.M.Y.) and Critical Care Medicine (B.J.E.-Y., P.W.A.), University of Pittsburgh Medical Center, and the Department of Pathology, University of Pittsburgh and Institute for Transfusion Medicine (M.H.Y., D.J.T.), Pittsburgh, and University of Pittsburgh Medical Center, Altoona Hospital, Altoona (A.T.P.) - all in Pennsylvania; the Department of Surgery, University of Tennessee Health Science Center, Knoxville (B.J.D.), and the Department of Surgery, Vanderbilt University Medical Center, Nashville (R.S.M.) - both in Tennessee; the Department of Surgery, University of Louisville, Louisville, KY (B.G.H.); MetroHealth Medical Center, Case Western Reserve University, Cleveland (J.A.C.); and the Department of Surgery, University of Texas Southwestern, Parkland Memorial Hospital, Dallas (H.A.P.) and Texas Health Harris Methodist Hospital (W.R.W.) and the John Peter Smith Health Network (T.M.D.), Fort Worth - all in Texas
| | - Mark H Yazer
- From the Division of Trauma and General Surgery, Department of Surgery (J.L.S., J.B.B., L.H.A., B.S.Z., M.D.N., M.R.R., R.M.F., T.R.B., A.B.P., M.S.Z.), and the Departments of Emergency Medicine (F.X.G., C.W.C., D.M.Y.) and Critical Care Medicine (B.J.E.-Y., P.W.A.), University of Pittsburgh Medical Center, and the Department of Pathology, University of Pittsburgh and Institute for Transfusion Medicine (M.H.Y., D.J.T.), Pittsburgh, and University of Pittsburgh Medical Center, Altoona Hospital, Altoona (A.T.P.) - all in Pennsylvania; the Department of Surgery, University of Tennessee Health Science Center, Knoxville (B.J.D.), and the Department of Surgery, Vanderbilt University Medical Center, Nashville (R.S.M.) - both in Tennessee; the Department of Surgery, University of Louisville, Louisville, KY (B.G.H.); MetroHealth Medical Center, Case Western Reserve University, Cleveland (J.A.C.); and the Department of Surgery, University of Texas Southwestern, Parkland Memorial Hospital, Dallas (H.A.P.) and Texas Health Harris Methodist Hospital (W.R.W.) and the John Peter Smith Health Network (T.M.D.), Fort Worth - all in Texas
| | - Darrell J Triulzi
- From the Division of Trauma and General Surgery, Department of Surgery (J.L.S., J.B.B., L.H.A., B.S.Z., M.D.N., M.R.R., R.M.F., T.R.B., A.B.P., M.S.Z.), and the Departments of Emergency Medicine (F.X.G., C.W.C., D.M.Y.) and Critical Care Medicine (B.J.E.-Y., P.W.A.), University of Pittsburgh Medical Center, and the Department of Pathology, University of Pittsburgh and Institute for Transfusion Medicine (M.H.Y., D.J.T.), Pittsburgh, and University of Pittsburgh Medical Center, Altoona Hospital, Altoona (A.T.P.) - all in Pennsylvania; the Department of Surgery, University of Tennessee Health Science Center, Knoxville (B.J.D.), and the Department of Surgery, Vanderbilt University Medical Center, Nashville (R.S.M.) - both in Tennessee; the Department of Surgery, University of Louisville, Louisville, KY (B.G.H.); MetroHealth Medical Center, Case Western Reserve University, Cleveland (J.A.C.); and the Department of Surgery, University of Texas Southwestern, Parkland Memorial Hospital, Dallas (H.A.P.) and Texas Health Harris Methodist Hospital (W.R.W.) and the John Peter Smith Health Network (T.M.D.), Fort Worth - all in Texas
| | - Barbara J Early-Young
- From the Division of Trauma and General Surgery, Department of Surgery (J.L.S., J.B.B., L.H.A., B.S.Z., M.D.N., M.R.R., R.M.F., T.R.B., A.B.P., M.S.Z.), and the Departments of Emergency Medicine (F.X.G., C.W.C., D.M.Y.) and Critical Care Medicine (B.J.E.-Y., P.W.A.), University of Pittsburgh Medical Center, and the Department of Pathology, University of Pittsburgh and Institute for Transfusion Medicine (M.H.Y., D.J.T.), Pittsburgh, and University of Pittsburgh Medical Center, Altoona Hospital, Altoona (A.T.P.) - all in Pennsylvania; the Department of Surgery, University of Tennessee Health Science Center, Knoxville (B.J.D.), and the Department of Surgery, Vanderbilt University Medical Center, Nashville (R.S.M.) - both in Tennessee; the Department of Surgery, University of Louisville, Louisville, KY (B.G.H.); MetroHealth Medical Center, Case Western Reserve University, Cleveland (J.A.C.); and the Department of Surgery, University of Texas Southwestern, Parkland Memorial Hospital, Dallas (H.A.P.) and Texas Health Harris Methodist Hospital (W.R.W.) and the John Peter Smith Health Network (T.M.D.), Fort Worth - all in Texas
| | - Peter W Adams
- From the Division of Trauma and General Surgery, Department of Surgery (J.L.S., J.B.B., L.H.A., B.S.Z., M.D.N., M.R.R., R.M.F., T.R.B., A.B.P., M.S.Z.), and the Departments of Emergency Medicine (F.X.G., C.W.C., D.M.Y.) and Critical Care Medicine (B.J.E.-Y., P.W.A.), University of Pittsburgh Medical Center, and the Department of Pathology, University of Pittsburgh and Institute for Transfusion Medicine (M.H.Y., D.J.T.), Pittsburgh, and University of Pittsburgh Medical Center, Altoona Hospital, Altoona (A.T.P.) - all in Pennsylvania; the Department of Surgery, University of Tennessee Health Science Center, Knoxville (B.J.D.), and the Department of Surgery, Vanderbilt University Medical Center, Nashville (R.S.M.) - both in Tennessee; the Department of Surgery, University of Louisville, Louisville, KY (B.G.H.); MetroHealth Medical Center, Case Western Reserve University, Cleveland (J.A.C.); and the Department of Surgery, University of Texas Southwestern, Parkland Memorial Hospital, Dallas (H.A.P.) and Texas Health Harris Methodist Hospital (W.R.W.) and the John Peter Smith Health Network (T.M.D.), Fort Worth - all in Texas
| | - Brian J Daley
- From the Division of Trauma and General Surgery, Department of Surgery (J.L.S., J.B.B., L.H.A., B.S.Z., M.D.N., M.R.R., R.M.F., T.R.B., A.B.P., M.S.Z.), and the Departments of Emergency Medicine (F.X.G., C.W.C., D.M.Y.) and Critical Care Medicine (B.J.E.-Y., P.W.A.), University of Pittsburgh Medical Center, and the Department of Pathology, University of Pittsburgh and Institute for Transfusion Medicine (M.H.Y., D.J.T.), Pittsburgh, and University of Pittsburgh Medical Center, Altoona Hospital, Altoona (A.T.P.) - all in Pennsylvania; the Department of Surgery, University of Tennessee Health Science Center, Knoxville (B.J.D.), and the Department of Surgery, Vanderbilt University Medical Center, Nashville (R.S.M.) - both in Tennessee; the Department of Surgery, University of Louisville, Louisville, KY (B.G.H.); MetroHealth Medical Center, Case Western Reserve University, Cleveland (J.A.C.); and the Department of Surgery, University of Texas Southwestern, Parkland Memorial Hospital, Dallas (H.A.P.) and Texas Health Harris Methodist Hospital (W.R.W.) and the John Peter Smith Health Network (T.M.D.), Fort Worth - all in Texas
| | - Richard S Miller
- From the Division of Trauma and General Surgery, Department of Surgery (J.L.S., J.B.B., L.H.A., B.S.Z., M.D.N., M.R.R., R.M.F., T.R.B., A.B.P., M.S.Z.), and the Departments of Emergency Medicine (F.X.G., C.W.C., D.M.Y.) and Critical Care Medicine (B.J.E.-Y., P.W.A.), University of Pittsburgh Medical Center, and the Department of Pathology, University of Pittsburgh and Institute for Transfusion Medicine (M.H.Y., D.J.T.), Pittsburgh, and University of Pittsburgh Medical Center, Altoona Hospital, Altoona (A.T.P.) - all in Pennsylvania; the Department of Surgery, University of Tennessee Health Science Center, Knoxville (B.J.D.), and the Department of Surgery, Vanderbilt University Medical Center, Nashville (R.S.M.) - both in Tennessee; the Department of Surgery, University of Louisville, Louisville, KY (B.G.H.); MetroHealth Medical Center, Case Western Reserve University, Cleveland (J.A.C.); and the Department of Surgery, University of Texas Southwestern, Parkland Memorial Hospital, Dallas (H.A.P.) and Texas Health Harris Methodist Hospital (W.R.W.) and the John Peter Smith Health Network (T.M.D.), Fort Worth - all in Texas
| | - Brian G Harbrecht
- From the Division of Trauma and General Surgery, Department of Surgery (J.L.S., J.B.B., L.H.A., B.S.Z., M.D.N., M.R.R., R.M.F., T.R.B., A.B.P., M.S.Z.), and the Departments of Emergency Medicine (F.X.G., C.W.C., D.M.Y.) and Critical Care Medicine (B.J.E.-Y., P.W.A.), University of Pittsburgh Medical Center, and the Department of Pathology, University of Pittsburgh and Institute for Transfusion Medicine (M.H.Y., D.J.T.), Pittsburgh, and University of Pittsburgh Medical Center, Altoona Hospital, Altoona (A.T.P.) - all in Pennsylvania; the Department of Surgery, University of Tennessee Health Science Center, Knoxville (B.J.D.), and the Department of Surgery, Vanderbilt University Medical Center, Nashville (R.S.M.) - both in Tennessee; the Department of Surgery, University of Louisville, Louisville, KY (B.G.H.); MetroHealth Medical Center, Case Western Reserve University, Cleveland (J.A.C.); and the Department of Surgery, University of Texas Southwestern, Parkland Memorial Hospital, Dallas (H.A.P.) and Texas Health Harris Methodist Hospital (W.R.W.) and the John Peter Smith Health Network (T.M.D.), Fort Worth - all in Texas
| | - Jeffrey A Claridge
- From the Division of Trauma and General Surgery, Department of Surgery (J.L.S., J.B.B., L.H.A., B.S.Z., M.D.N., M.R.R., R.M.F., T.R.B., A.B.P., M.S.Z.), and the Departments of Emergency Medicine (F.X.G., C.W.C., D.M.Y.) and Critical Care Medicine (B.J.E.-Y., P.W.A.), University of Pittsburgh Medical Center, and the Department of Pathology, University of Pittsburgh and Institute for Transfusion Medicine (M.H.Y., D.J.T.), Pittsburgh, and University of Pittsburgh Medical Center, Altoona Hospital, Altoona (A.T.P.) - all in Pennsylvania; the Department of Surgery, University of Tennessee Health Science Center, Knoxville (B.J.D.), and the Department of Surgery, Vanderbilt University Medical Center, Nashville (R.S.M.) - both in Tennessee; the Department of Surgery, University of Louisville, Louisville, KY (B.G.H.); MetroHealth Medical Center, Case Western Reserve University, Cleveland (J.A.C.); and the Department of Surgery, University of Texas Southwestern, Parkland Memorial Hospital, Dallas (H.A.P.) and Texas Health Harris Methodist Hospital (W.R.W.) and the John Peter Smith Health Network (T.M.D.), Fort Worth - all in Texas
| | - Herb A Phelan
- From the Division of Trauma and General Surgery, Department of Surgery (J.L.S., J.B.B., L.H.A., B.S.Z., M.D.N., M.R.R., R.M.F., T.R.B., A.B.P., M.S.Z.), and the Departments of Emergency Medicine (F.X.G., C.W.C., D.M.Y.) and Critical Care Medicine (B.J.E.-Y., P.W.A.), University of Pittsburgh Medical Center, and the Department of Pathology, University of Pittsburgh and Institute for Transfusion Medicine (M.H.Y., D.J.T.), Pittsburgh, and University of Pittsburgh Medical Center, Altoona Hospital, Altoona (A.T.P.) - all in Pennsylvania; the Department of Surgery, University of Tennessee Health Science Center, Knoxville (B.J.D.), and the Department of Surgery, Vanderbilt University Medical Center, Nashville (R.S.M.) - both in Tennessee; the Department of Surgery, University of Louisville, Louisville, KY (B.G.H.); MetroHealth Medical Center, Case Western Reserve University, Cleveland (J.A.C.); and the Department of Surgery, University of Texas Southwestern, Parkland Memorial Hospital, Dallas (H.A.P.) and Texas Health Harris Methodist Hospital (W.R.W.) and the John Peter Smith Health Network (T.M.D.), Fort Worth - all in Texas
| | - William R Witham
- From the Division of Trauma and General Surgery, Department of Surgery (J.L.S., J.B.B., L.H.A., B.S.Z., M.D.N., M.R.R., R.M.F., T.R.B., A.B.P., M.S.Z.), and the Departments of Emergency Medicine (F.X.G., C.W.C., D.M.Y.) and Critical Care Medicine (B.J.E.-Y., P.W.A.), University of Pittsburgh Medical Center, and the Department of Pathology, University of Pittsburgh and Institute for Transfusion Medicine (M.H.Y., D.J.T.), Pittsburgh, and University of Pittsburgh Medical Center, Altoona Hospital, Altoona (A.T.P.) - all in Pennsylvania; the Department of Surgery, University of Tennessee Health Science Center, Knoxville (B.J.D.), and the Department of Surgery, Vanderbilt University Medical Center, Nashville (R.S.M.) - both in Tennessee; the Department of Surgery, University of Louisville, Louisville, KY (B.G.H.); MetroHealth Medical Center, Case Western Reserve University, Cleveland (J.A.C.); and the Department of Surgery, University of Texas Southwestern, Parkland Memorial Hospital, Dallas (H.A.P.) and Texas Health Harris Methodist Hospital (W.R.W.) and the John Peter Smith Health Network (T.M.D.), Fort Worth - all in Texas
| | - A Tyler Putnam
- From the Division of Trauma and General Surgery, Department of Surgery (J.L.S., J.B.B., L.H.A., B.S.Z., M.D.N., M.R.R., R.M.F., T.R.B., A.B.P., M.S.Z.), and the Departments of Emergency Medicine (F.X.G., C.W.C., D.M.Y.) and Critical Care Medicine (B.J.E.-Y., P.W.A.), University of Pittsburgh Medical Center, and the Department of Pathology, University of Pittsburgh and Institute for Transfusion Medicine (M.H.Y., D.J.T.), Pittsburgh, and University of Pittsburgh Medical Center, Altoona Hospital, Altoona (A.T.P.) - all in Pennsylvania; the Department of Surgery, University of Tennessee Health Science Center, Knoxville (B.J.D.), and the Department of Surgery, Vanderbilt University Medical Center, Nashville (R.S.M.) - both in Tennessee; the Department of Surgery, University of Louisville, Louisville, KY (B.G.H.); MetroHealth Medical Center, Case Western Reserve University, Cleveland (J.A.C.); and the Department of Surgery, University of Texas Southwestern, Parkland Memorial Hospital, Dallas (H.A.P.) and Texas Health Harris Methodist Hospital (W.R.W.) and the John Peter Smith Health Network (T.M.D.), Fort Worth - all in Texas
| | - Therese M Duane
- From the Division of Trauma and General Surgery, Department of Surgery (J.L.S., J.B.B., L.H.A., B.S.Z., M.D.N., M.R.R., R.M.F., T.R.B., A.B.P., M.S.Z.), and the Departments of Emergency Medicine (F.X.G., C.W.C., D.M.Y.) and Critical Care Medicine (B.J.E.-Y., P.W.A.), University of Pittsburgh Medical Center, and the Department of Pathology, University of Pittsburgh and Institute for Transfusion Medicine (M.H.Y., D.J.T.), Pittsburgh, and University of Pittsburgh Medical Center, Altoona Hospital, Altoona (A.T.P.) - all in Pennsylvania; the Department of Surgery, University of Tennessee Health Science Center, Knoxville (B.J.D.), and the Department of Surgery, Vanderbilt University Medical Center, Nashville (R.S.M.) - both in Tennessee; the Department of Surgery, University of Louisville, Louisville, KY (B.G.H.); MetroHealth Medical Center, Case Western Reserve University, Cleveland (J.A.C.); and the Department of Surgery, University of Texas Southwestern, Parkland Memorial Hospital, Dallas (H.A.P.) and Texas Health Harris Methodist Hospital (W.R.W.) and the John Peter Smith Health Network (T.M.D.), Fort Worth - all in Texas
| | - Louis H Alarcon
- From the Division of Trauma and General Surgery, Department of Surgery (J.L.S., J.B.B., L.H.A., B.S.Z., M.D.N., M.R.R., R.M.F., T.R.B., A.B.P., M.S.Z.), and the Departments of Emergency Medicine (F.X.G., C.W.C., D.M.Y.) and Critical Care Medicine (B.J.E.-Y., P.W.A.), University of Pittsburgh Medical Center, and the Department of Pathology, University of Pittsburgh and Institute for Transfusion Medicine (M.H.Y., D.J.T.), Pittsburgh, and University of Pittsburgh Medical Center, Altoona Hospital, Altoona (A.T.P.) - all in Pennsylvania; the Department of Surgery, University of Tennessee Health Science Center, Knoxville (B.J.D.), and the Department of Surgery, Vanderbilt University Medical Center, Nashville (R.S.M.) - both in Tennessee; the Department of Surgery, University of Louisville, Louisville, KY (B.G.H.); MetroHealth Medical Center, Case Western Reserve University, Cleveland (J.A.C.); and the Department of Surgery, University of Texas Southwestern, Parkland Memorial Hospital, Dallas (H.A.P.) and Texas Health Harris Methodist Hospital (W.R.W.) and the John Peter Smith Health Network (T.M.D.), Fort Worth - all in Texas
| | - Clifton W Callaway
- From the Division of Trauma and General Surgery, Department of Surgery (J.L.S., J.B.B., L.H.A., B.S.Z., M.D.N., M.R.R., R.M.F., T.R.B., A.B.P., M.S.Z.), and the Departments of Emergency Medicine (F.X.G., C.W.C., D.M.Y.) and Critical Care Medicine (B.J.E.-Y., P.W.A.), University of Pittsburgh Medical Center, and the Department of Pathology, University of Pittsburgh and Institute for Transfusion Medicine (M.H.Y., D.J.T.), Pittsburgh, and University of Pittsburgh Medical Center, Altoona Hospital, Altoona (A.T.P.) - all in Pennsylvania; the Department of Surgery, University of Tennessee Health Science Center, Knoxville (B.J.D.), and the Department of Surgery, Vanderbilt University Medical Center, Nashville (R.S.M.) - both in Tennessee; the Department of Surgery, University of Louisville, Louisville, KY (B.G.H.); MetroHealth Medical Center, Case Western Reserve University, Cleveland (J.A.C.); and the Department of Surgery, University of Texas Southwestern, Parkland Memorial Hospital, Dallas (H.A.P.) and Texas Health Harris Methodist Hospital (W.R.W.) and the John Peter Smith Health Network (T.M.D.), Fort Worth - all in Texas
| | - Brian S Zuckerbraun
- From the Division of Trauma and General Surgery, Department of Surgery (J.L.S., J.B.B., L.H.A., B.S.Z., M.D.N., M.R.R., R.M.F., T.R.B., A.B.P., M.S.Z.), and the Departments of Emergency Medicine (F.X.G., C.W.C., D.M.Y.) and Critical Care Medicine (B.J.E.-Y., P.W.A.), University of Pittsburgh Medical Center, and the Department of Pathology, University of Pittsburgh and Institute for Transfusion Medicine (M.H.Y., D.J.T.), Pittsburgh, and University of Pittsburgh Medical Center, Altoona Hospital, Altoona (A.T.P.) - all in Pennsylvania; the Department of Surgery, University of Tennessee Health Science Center, Knoxville (B.J.D.), and the Department of Surgery, Vanderbilt University Medical Center, Nashville (R.S.M.) - both in Tennessee; the Department of Surgery, University of Louisville, Louisville, KY (B.G.H.); MetroHealth Medical Center, Case Western Reserve University, Cleveland (J.A.C.); and the Department of Surgery, University of Texas Southwestern, Parkland Memorial Hospital, Dallas (H.A.P.) and Texas Health Harris Methodist Hospital (W.R.W.) and the John Peter Smith Health Network (T.M.D.), Fort Worth - all in Texas
| | - Matthew D Neal
- From the Division of Trauma and General Surgery, Department of Surgery (J.L.S., J.B.B., L.H.A., B.S.Z., M.D.N., M.R.R., R.M.F., T.R.B., A.B.P., M.S.Z.), and the Departments of Emergency Medicine (F.X.G., C.W.C., D.M.Y.) and Critical Care Medicine (B.J.E.-Y., P.W.A.), University of Pittsburgh Medical Center, and the Department of Pathology, University of Pittsburgh and Institute for Transfusion Medicine (M.H.Y., D.J.T.), Pittsburgh, and University of Pittsburgh Medical Center, Altoona Hospital, Altoona (A.T.P.) - all in Pennsylvania; the Department of Surgery, University of Tennessee Health Science Center, Knoxville (B.J.D.), and the Department of Surgery, Vanderbilt University Medical Center, Nashville (R.S.M.) - both in Tennessee; the Department of Surgery, University of Louisville, Louisville, KY (B.G.H.); MetroHealth Medical Center, Case Western Reserve University, Cleveland (J.A.C.); and the Department of Surgery, University of Texas Southwestern, Parkland Memorial Hospital, Dallas (H.A.P.) and Texas Health Harris Methodist Hospital (W.R.W.) and the John Peter Smith Health Network (T.M.D.), Fort Worth - all in Texas
| | - Matthew R Rosengart
- From the Division of Trauma and General Surgery, Department of Surgery (J.L.S., J.B.B., L.H.A., B.S.Z., M.D.N., M.R.R., R.M.F., T.R.B., A.B.P., M.S.Z.), and the Departments of Emergency Medicine (F.X.G., C.W.C., D.M.Y.) and Critical Care Medicine (B.J.E.-Y., P.W.A.), University of Pittsburgh Medical Center, and the Department of Pathology, University of Pittsburgh and Institute for Transfusion Medicine (M.H.Y., D.J.T.), Pittsburgh, and University of Pittsburgh Medical Center, Altoona Hospital, Altoona (A.T.P.) - all in Pennsylvania; the Department of Surgery, University of Tennessee Health Science Center, Knoxville (B.J.D.), and the Department of Surgery, Vanderbilt University Medical Center, Nashville (R.S.M.) - both in Tennessee; the Department of Surgery, University of Louisville, Louisville, KY (B.G.H.); MetroHealth Medical Center, Case Western Reserve University, Cleveland (J.A.C.); and the Department of Surgery, University of Texas Southwestern, Parkland Memorial Hospital, Dallas (H.A.P.) and Texas Health Harris Methodist Hospital (W.R.W.) and the John Peter Smith Health Network (T.M.D.), Fort Worth - all in Texas
| | - Raquel M Forsythe
- From the Division of Trauma and General Surgery, Department of Surgery (J.L.S., J.B.B., L.H.A., B.S.Z., M.D.N., M.R.R., R.M.F., T.R.B., A.B.P., M.S.Z.), and the Departments of Emergency Medicine (F.X.G., C.W.C., D.M.Y.) and Critical Care Medicine (B.J.E.-Y., P.W.A.), University of Pittsburgh Medical Center, and the Department of Pathology, University of Pittsburgh and Institute for Transfusion Medicine (M.H.Y., D.J.T.), Pittsburgh, and University of Pittsburgh Medical Center, Altoona Hospital, Altoona (A.T.P.) - all in Pennsylvania; the Department of Surgery, University of Tennessee Health Science Center, Knoxville (B.J.D.), and the Department of Surgery, Vanderbilt University Medical Center, Nashville (R.S.M.) - both in Tennessee; the Department of Surgery, University of Louisville, Louisville, KY (B.G.H.); MetroHealth Medical Center, Case Western Reserve University, Cleveland (J.A.C.); and the Department of Surgery, University of Texas Southwestern, Parkland Memorial Hospital, Dallas (H.A.P.) and Texas Health Harris Methodist Hospital (W.R.W.) and the John Peter Smith Health Network (T.M.D.), Fort Worth - all in Texas
| | - Timothy R Billiar
- From the Division of Trauma and General Surgery, Department of Surgery (J.L.S., J.B.B., L.H.A., B.S.Z., M.D.N., M.R.R., R.M.F., T.R.B., A.B.P., M.S.Z.), and the Departments of Emergency Medicine (F.X.G., C.W.C., D.M.Y.) and Critical Care Medicine (B.J.E.-Y., P.W.A.), University of Pittsburgh Medical Center, and the Department of Pathology, University of Pittsburgh and Institute for Transfusion Medicine (M.H.Y., D.J.T.), Pittsburgh, and University of Pittsburgh Medical Center, Altoona Hospital, Altoona (A.T.P.) - all in Pennsylvania; the Department of Surgery, University of Tennessee Health Science Center, Knoxville (B.J.D.), and the Department of Surgery, Vanderbilt University Medical Center, Nashville (R.S.M.) - both in Tennessee; the Department of Surgery, University of Louisville, Louisville, KY (B.G.H.); MetroHealth Medical Center, Case Western Reserve University, Cleveland (J.A.C.); and the Department of Surgery, University of Texas Southwestern, Parkland Memorial Hospital, Dallas (H.A.P.) and Texas Health Harris Methodist Hospital (W.R.W.) and the John Peter Smith Health Network (T.M.D.), Fort Worth - all in Texas
| | - Donald M Yealy
- From the Division of Trauma and General Surgery, Department of Surgery (J.L.S., J.B.B., L.H.A., B.S.Z., M.D.N., M.R.R., R.M.F., T.R.B., A.B.P., M.S.Z.), and the Departments of Emergency Medicine (F.X.G., C.W.C., D.M.Y.) and Critical Care Medicine (B.J.E.-Y., P.W.A.), University of Pittsburgh Medical Center, and the Department of Pathology, University of Pittsburgh and Institute for Transfusion Medicine (M.H.Y., D.J.T.), Pittsburgh, and University of Pittsburgh Medical Center, Altoona Hospital, Altoona (A.T.P.) - all in Pennsylvania; the Department of Surgery, University of Tennessee Health Science Center, Knoxville (B.J.D.), and the Department of Surgery, Vanderbilt University Medical Center, Nashville (R.S.M.) - both in Tennessee; the Department of Surgery, University of Louisville, Louisville, KY (B.G.H.); MetroHealth Medical Center, Case Western Reserve University, Cleveland (J.A.C.); and the Department of Surgery, University of Texas Southwestern, Parkland Memorial Hospital, Dallas (H.A.P.) and Texas Health Harris Methodist Hospital (W.R.W.) and the John Peter Smith Health Network (T.M.D.), Fort Worth - all in Texas
| | - Andrew B Peitzman
- From the Division of Trauma and General Surgery, Department of Surgery (J.L.S., J.B.B., L.H.A., B.S.Z., M.D.N., M.R.R., R.M.F., T.R.B., A.B.P., M.S.Z.), and the Departments of Emergency Medicine (F.X.G., C.W.C., D.M.Y.) and Critical Care Medicine (B.J.E.-Y., P.W.A.), University of Pittsburgh Medical Center, and the Department of Pathology, University of Pittsburgh and Institute for Transfusion Medicine (M.H.Y., D.J.T.), Pittsburgh, and University of Pittsburgh Medical Center, Altoona Hospital, Altoona (A.T.P.) - all in Pennsylvania; the Department of Surgery, University of Tennessee Health Science Center, Knoxville (B.J.D.), and the Department of Surgery, Vanderbilt University Medical Center, Nashville (R.S.M.) - both in Tennessee; the Department of Surgery, University of Louisville, Louisville, KY (B.G.H.); MetroHealth Medical Center, Case Western Reserve University, Cleveland (J.A.C.); and the Department of Surgery, University of Texas Southwestern, Parkland Memorial Hospital, Dallas (H.A.P.) and Texas Health Harris Methodist Hospital (W.R.W.) and the John Peter Smith Health Network (T.M.D.), Fort Worth - all in Texas
| | - Mazen S Zenati
- From the Division of Trauma and General Surgery, Department of Surgery (J.L.S., J.B.B., L.H.A., B.S.Z., M.D.N., M.R.R., R.M.F., T.R.B., A.B.P., M.S.Z.), and the Departments of Emergency Medicine (F.X.G., C.W.C., D.M.Y.) and Critical Care Medicine (B.J.E.-Y., P.W.A.), University of Pittsburgh Medical Center, and the Department of Pathology, University of Pittsburgh and Institute for Transfusion Medicine (M.H.Y., D.J.T.), Pittsburgh, and University of Pittsburgh Medical Center, Altoona Hospital, Altoona (A.T.P.) - all in Pennsylvania; the Department of Surgery, University of Tennessee Health Science Center, Knoxville (B.J.D.), and the Department of Surgery, Vanderbilt University Medical Center, Nashville (R.S.M.) - both in Tennessee; the Department of Surgery, University of Louisville, Louisville, KY (B.G.H.); MetroHealth Medical Center, Case Western Reserve University, Cleveland (J.A.C.); and the Department of Surgery, University of Texas Southwestern, Parkland Memorial Hospital, Dallas (H.A.P.) and Texas Health Harris Methodist Hospital (W.R.W.) and the John Peter Smith Health Network (T.M.D.), Fort Worth - all in Texas
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Barelli S, Alberio L. The Role of Plasma Transfusion in Massive Bleeding: Protecting the Endothelial Glycocalyx? Front Med (Lausanne) 2018; 5:91. [PMID: 29721496 PMCID: PMC5915488 DOI: 10.3389/fmed.2018.00091] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2018] [Accepted: 03/22/2018] [Indexed: 12/20/2022] Open
Abstract
Massive hemorrhage is a leading cause of death worldwide. During the last decade several retrospective and some prospective clinical studies have suggested a beneficial effect of early plasma-based resuscitation on survival in trauma patients. The underlying mechanisms are unknown but appear to involve the ability of plasma to preserve the endothelial glycocalyx. In this mini-review, we summarize current knowledge on glycocalyx structure and function, and present data describing the impact of hemorrhagic shock and resuscitation fluids on glycocalyx. Animal studies show that hemorrhagic shock leads to glycocalyx shedding, endothelial inflammatory changes, and vascular hyper-permeability. In these animal models, plasma administration preserves glycocalyx integrity and functions better than resuscitation with crystalloids or colloids. In addition, we briefly present data on the possible plasma components responsible for these effects. The endothelial glycocalyx is increasingly recognized as a critical component for the physiological vasculo-endothelial function, which is destroyed in hemorrhagic shock. Interventions for preserving an intact glycocalyx shall improve survival of trauma patients.
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Affiliation(s)
- Stefano Barelli
- Division of Haematology and Central Haematology Laboratory, CHUV, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
| | - Lorenzo Alberio
- Division of Haematology and Central Haematology Laboratory, CHUV, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland.,Faculté de Biologie et Médecine, UNIL, University of Lausanne, Lausanne, Switzerland
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Shubin NJ, Pham TN, Staudenmayer KL, Parent BA, Qiu Q, O'Keefe GE. A Potential Mechanism for Immune Suppression by Beta-Adrenergic Receptor Stimulation following Traumatic Injury. J Innate Immun 2018; 10:202-214. [PMID: 29455206 DOI: 10.1159/000486972] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Accepted: 01/17/2018] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND β-Adrenergic agents suppress inflammation and may play an important role in posttraumatic infections. Mechanisms may include inhibition of MAP kinase signaling. We sought to determine whether MKP-1 contributed to catecholamine suppression of innate immunity and also wanted to know whether early catecholamine treatment after traumatic injury increases the risk of later nosocomial infection. METHODS We performed experiments using THP-1 cells and peripheral blood mononuclear cells from healthy individuals. We exposed cells to epinephrine and/or LPS and measured inflammatory gene transcription and MAP kinase activation. We inhibited MKP-1 activity to determine its role in catecholamine-induced immune suppression. Finally, we studied injured subjects to determine whether early catecholamine treatment was associated with nosocomial infection. RESULTS Epinephrine increases MKP-1 transcripts and protein and decreases LPS-induced p38 and JNK phosphorylation and TNF-α gene transcription. RNAi inhibition of MKP-1 at least partially restores LPS-induced TNF-α gene expression (p = 0.024). In the clinical cohort, subjects treated with β-adrenergic agents had an increased risk of ventilator-associated pneumonia (aOR = 1.9; 95% CI = 1.3-2.6) and bacteremia (aOR = 1.5; 95% CI = 1.1-2.3). CONCLUSIONS MKP-1 may have a role in catecholamine-induced suppression of innate immunity, and exogenous catecholamines might contribute to nosocomial infection risk.
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Affiliation(s)
- Nicholas J Shubin
- Seattle Children's Research Institute, Seattle Children's Hospital, Seattle, Washington, USA
| | - Tam N Pham
- Department of Surgery, University of Washington, Seattle, Washington, USA
| | | | - Brodie A Parent
- Department of Surgery, University of Washington, Seattle, Washington, USA
| | - Qian Qiu
- Harborview Injury Prevention and Research Center, Department of Pediatrics, University of Washington, Seattle, Washington, USA
| | - Grant E O'Keefe
- Harborview Injury Prevention and Research Center, Department of Surgery, University of Washington, Seattle, Washington, USA
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Pati S, Peng Z, Wataha K, Miyazawa B, Potter DR, Kozar RA. Lyophilized plasma attenuates vascular permeability, inflammation and lung injury in hemorrhagic shock. PLoS One 2018; 13:e0192363. [PMID: 29394283 PMCID: PMC5796727 DOI: 10.1371/journal.pone.0192363] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Accepted: 01/21/2018] [Indexed: 11/18/2022] Open
Abstract
In severe trauma and hemorrhage the early and empiric use of fresh frozen plasma (FFP) is associated with decreased morbidity and mortality. However, utilization of FFP comes with the significant burden of shipping and storage of frozen blood products. Dried or lyophilized plasma (LP) can be stored at room temperature, transported easily, reconstituted rapidly with ready availability in remote and austere environments. We have previously demonstrated that FFP mitigates the endothelial injury that ensues after hemorrhagic shock (HS). In the current study, we sought to determine whether LP has similar properties to FFP in its ability to modulate endothelial dysfunction in vitro and in vivo. Single donor LP was compared to single donor FFP using the following measures of endothelial cell (EC) function in vitro: permeability and transendothelial monolayer resistance; adherens junction preservation; and leukocyte-EC adhesion. In vivo, using a model of murine HS, LP and FFP were compared in measures of HS- induced pulmonary vascular inflammation and edema. Both in vitro and in vivo in all measures of EC function, LP demonstrated similar effects to FFP. Both FFP and LP similarly reduced EC permeability, increased transendothelial resistance, decreased leukocyte-EC binding and persevered adherens junctions. In vivo, LP and FFP both comparably reduced pulmonary injury, inflammation and vascular leak. Both FFP and LP have similar potent protective effects on the vascular endothelium in vitro and in lung function in vivo following hemorrhagic shock. These data support the further development of LP as an effective plasma product for human use after trauma and hemorrhagic shock.
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Affiliation(s)
- Shibani Pati
- Department of Laboratory Medicine, University of California San Francisco, San Francisco, California, United States of America
| | - Zhanglong Peng
- Department of Anesthesia, University of Texas Health Science Center at Houston, Houston, Texas, United States of America
| | - Katherine Wataha
- Department of Laboratory Medicine, University of California San Francisco, San Francisco, California, United States of America
| | - Byron Miyazawa
- Department of Laboratory Medicine, University of California San Francisco, San Francisco, California, United States of America
| | - Daniel R Potter
- Department of Laboratory Medicine, University of California San Francisco, San Francisco, California, United States of America
| | - Rosemary A Kozar
- Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland, United States of America
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Potter DR, Miyazawa BY, Gibb SL, Deng X, Togaratti PP, Croze RH, Srivastava AK, Trivedi A, Matthay M, Holcomb JB, Schreiber MA, Pati S. Mesenchymal stem cell-derived extracellular vesicles attenuate pulmonary vascular permeability and lung injury induced by hemorrhagic shock and trauma. J Trauma Acute Care Surg 2018; 84:245-256. [PMID: 29251710 PMCID: PMC6378956 DOI: 10.1097/ta.0000000000001744] [Citation(s) in RCA: 67] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Mesenchymal stem cells (MSCs) have been shown to mitigate vascular permeability in hemorrhagic shock (HS) and trauma-induced brain and lung injury. Mechanistically, paracrine factors secreted from MSCs have been identified that can recapitulate many of the potent biologic effects of MSCs in animal models of disease. Interestingly, MSC-derived extracellular vesicles (EVs), contain many of these key soluble factors, and have therapeutic potential independent of the parent cells. In this study we sought to determine whether MSC-derived EVs (MSC EVs) could recapitulate the beneficial therapeutic effects of MSCs on lung vascular permeability induced by HS in mice. METHODS Mesenchymal stem cell EVs were isolated from human bone marrow-derived MSCs by ultracentrifugation. A mouse model of fixed pressure HS was used to study the effects of shock, shock + MSCs and shock + MSC EVs on lung vascular endothelial permeability. Mice were administered MSCs, MSC EVs, or saline IV. Lung tissue was harvested and assayed for permeability, RhoA/Rac1 activation, and for differential phosphoprotein expression. In vitro, human lung microvascular cells junctional integrity was evaluated by immunocytochemistry and endothelial cell impedance assays. RESULTS Hemorrhagic shock-induced lung vascular permeability was significantly decreased by both MSC and MSC EV infusion. Phosphoprotein profiling of lung tissue revealed differential activation of proteins and pathways related to cytoskeletal rearrangement and regulation of vascular permeability by MSCs and MSC EVs. Lung tissue from treatment groups demonstrated decreased activation of the cytoskeletal GTPase RhoA. In vitro, human lung microvascular cells, MSC CM but not MSC-EVs prevented thrombin-induced endothelial cell permeability as measured by electrical cell-substrate impedance sensing system and immunocytochemistry of VE-cadherin and actin. CONCLUSION Mesenchymal stem cells and MSC EVs modulate cytoskeletal signaling and attenuate lung vascular permeability after HS. Mesenchymal stem cell EVs may potentially be used as a novel "stem cell free" therapeutic to treat HS-induced lung injury.
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Affiliation(s)
- Daniel R. Potter
- Department of Laboratory Medicine, University of California at San Francisco, San Francisco, California
| | - Byron Y. Miyazawa
- Department of Laboratory Medicine, University of California at San Francisco, San Francisco, California
| | - Stuart L. Gibb
- Department of Laboratory Medicine, University of California at San Francisco, San Francisco, California
| | - Xutao Deng
- Blood Systems Research Institute, San Francisco, California
| | | | - Roxanne H. Croze
- Cardiovascular Research Institute, University of California, San Francisco
| | - Amit K. Srivastava
- Department of Pediatric Surgery, McGovern Medical School, University of Texas Health Sciences Center at Houston, Houston, Texas
| | - Alpa Trivedi
- Department of Laboratory Medicine, University of California at San Francisco, San Francisco, California
| | - Michael Matthay
- Cardiovascular Research Institute, University of California, San Francisco
| | | | | | - Shibani Pati
- Department of Laboratory Medicine, University of California at San Francisco, San Francisco, California
- Blood Systems Research Institute, San Francisco, California
- Corresponding author- , (415) 502-1634. Department of Laboratory Medicine, 513 Parnassus Avenue, HSE 760, San Francisco, CA 94143
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Abstract
Traumatic hemorrhage is the leading cause of preventable death after trauma. Early transfusion of plasma and balanced transfusion have been shown to optimize survival, mitigate the acute coagulopathy of trauma, and restore the endothelial glycocalyx. There are a myriad of plasma formulations available worldwide, including fresh frozen plasma, thawed plasma, liquid plasma, plasma frozen within 24 h, and lyophilized plasma (LP). Significant equipoise exists in the literature regarding the optimal plasma formulation. LP is a freeze-dried formulation that was originally developed in the 1930s and used by the American and British military in World War II. It was subsequently discontinued due to risk of disease transmission from pooled donors. Recently, there has been a significant amount of research focusing on optimizing reconstitution of LP. Findings show that sterile water buffered with ascorbic acid results in decreased blood loss with suppression of systemic inflammation. We are now beginning to realize the creation of a plasma-derived formulation that rapidly produces the associated benefits without logistical or safety constraints. This review will highlight the history of plasma, detail the various types of plasma formulations currently available, their pathophysiological effects, impacts of storage on coagulation factors in vitro and in vivo, novel concepts, and future directions.
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Acute Traumatic Endotheliopathy in Isolated Severe Brain Injury and Its Impact on Clinical Outcome. Med Sci (Basel) 2018; 6:medsci6010005. [PMID: 29337920 PMCID: PMC5872162 DOI: 10.3390/medsci6010005] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Revised: 01/08/2018] [Accepted: 01/10/2018] [Indexed: 12/31/2022] Open
Abstract
Study design: Prospective observational cohort. Objective: To investigate the difference in plasma levels of syndecan-1 (due to glycocalyx degradation) and soluble thrombomodulin (due to endothelial damage) in isolated severe traumatic brain injury (TBI) patients with/without early coagulopathy. A secondary objective was to compare the effects of the degree of TBI endotheliopathy on hospital mortality among patients with TBI-associated coagulopathy (TBI-AC). Methods: Data was prospectively collected on isolated severe TBI (sTBI) patients with Glasgow Coma Scale (GCS) ≤8 less than 12 h after injury admitted to a level I trauma centre. Isolated sTBI patients with samples withdrawn prior to blood transfusion were stratified by conventional coagulation tests as coagulopathic (prothrombin time (PT) ≥ 16.7 s, international normalized ratio (INR) ≥ 1.27, and activated partial thromboplastin time (aPTT) ≥ 28.8 s) and non-coagulopathic. Twenty healthy controls were also included. Plasma levels of thrombomodulin and syndecan-1 were estimated by ELISA. With receiver operating characteristic curve (ROC) analysis, we defined endotheliopathy as a syndecan-1 cut-off level that maximized the sum of sensitivity and specificity for predicting TBI-AC. Results: Inclusion criteria were met in 120 cases, with subjects aged 35.5 ± 12.6 years (88.3% males). TBI-AC was identified in 50 (41.6%) patients, independent of age, gender, and GCS, but there was an association with acidosis (60%; p = 0.01). Following isolated sTBI, we found insignificant changes in soluble thrombomodulin (sTM) levels between patients with isolated TBI and controls, and sTM levels were lower in coagulopathic compared to non-coagulopathic patients. Elevations in plasma syndecan-1 (ng/mL) levels were seen compared to control (31.1(21.5–30.6) vs. 24.8(18.5–30.6); p = 0.08). Syndecan-1(ng/mL) levels were significantly elevated in coagulopathic compared to non-coagulopathic patients (33.7(21.6–109.5) vs. 29.9(19.239.5); p = 0.03). Using ROC analysis (area under the curve = 0.61; 95% Confidence Interval (CI) 0.50 to 0.72), we established a plasma syndecan-1 level cutoff of ≥30.5 ng/mL (sensitivity % = 55.3, specificity % = 52.3), with a significant association with TBI-associated coagulopathy. Conclusion: Subsequent to brain injury, elevated syndecan-1 shedding and endotheliopathy may be associated with early coagulation abnormalities. A syndecan-1 level ≥30.5 ng/mL identified patients with TBI-AC, and may be of importance in guiding management and clinical decision-making.
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