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Wang J, Shi Y, Cao S, Liu X, Martin LJ, Simoni J, Soltys BJ, Hsia CJC, Koehler RC. Polynitroxylated PEGylated hemoglobin protects pig brain neocortical gray and white matter after traumatic brain injury and hemorrhagic shock. FRONTIERS IN MEDICAL TECHNOLOGY 2023; 5:1074643. [PMID: 36896342 PMCID: PMC9988926 DOI: 10.3389/fmedt.2023.1074643] [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: 10/19/2022] [Accepted: 01/13/2023] [Indexed: 02/23/2023] Open
Abstract
Polynitroxylated PEGylated hemoglobin (PNPH, aka SanFlow) possesses superoxide dismutase/catalase mimetic activities that may directly protect the brain from oxidative stress. Stabilization of PNPH with bound carbon monoxide prevents methemoglobin formation during storage and permits it to serve as an anti-inflammatory carbon monoxide donor. We determined whether small volume transfusion of hyperoncotic PNPH is neuroprotective in a porcine model of traumatic brain injury (TBI) with and without accompanying hemorrhagic shock (HS). TBI was produced by controlled cortical impact over the frontal lobe of anesthetized juvenile pigs. Hemorrhagic shock was induced starting 5 min after TBI by 30 ml/kg blood withdrawal. At 120 min after TBI, pigs were resuscitated with 60 ml/kg lactated Ringer's (LR) or 10 or 20 ml/kg PNPH. Mean arterial pressure recovered to approximately 100 mmHg in all groups. A significant amount of PNPH was retained in the plasma over the first day of recovery. At 4 days of recovery in the LR-resuscitated group, the volume of frontal lobe subcortical white matter ipsilateral to the injury was 26.2 ± 7.6% smaller than homotypic contralateral volume, whereas this white matter loss was only 8.6 ± 12.0% with 20-ml/kg PNPH resuscitation. Amyloid precursor protein punctate accumulation, a marker of axonopathy, increased in ipsilateral subcortical white matter by 132 ± 71% after LR resuscitation, whereas the changes after 10 ml/kg (36 ± 41%) and 20 ml/kg (26 ± 15%) PNPH resuscitation were not significantly different from controls. The number of cortical neuron long dendrites enriched in microtubules (length >50 microns) decreased in neocortex by 41 ± 24% after LR resuscitation but was not significantly changed after PNPH resuscitation. The perilesion microglia density increased by 45 ± 24% after LR resuscitation but was unchanged after 20 ml/kg PNPH resuscitation (4 ± 18%). Furthermore, the number with an activated morphology was attenuated by 30 ± 10%. In TBI pigs without HS followed 2 h later by infusion of 10 ml/kg LR or PNPH, PNPH remained neuroprotective. These results in a gyrencephalic brain show that resuscitation from TBI + HS with PNPH protects neocortical gray matter, including dendritic microstructure, and white matter axons and myelin. This neuroprotective effect persists with TBI alone, indicating brain-targeting benefits independent of blood pressure restoration.
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Affiliation(s)
- Jun Wang
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, United States
| | - Yanrong Shi
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, United States
| | - Suyi Cao
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, United States
| | - Xiuyun Liu
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, United States
| | - Lee J. Martin
- Department of Pathology, Johns Hopkins University, Baltimore, MD, United States
| | - Jan Simoni
- AntiRadical Therapeutics LLC, Sioux Falls, SD, United States
| | | | | | - Raymond C. Koehler
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, United States
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Cucher D, Harmon L, Myer B, Ngyuen A, Rankin T, Cook A, Hu C, Tesoriero R, Scalea T, Stein D. Critical traumatic brain injury is associated with worse coagulopathy. J Trauma Acute Care Surg 2021; 91:331-335. [PMID: 34397954 DOI: 10.1097/ta.0000000000003253] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES As thromboelastography (TEG) becomes the standard of care in patients with hemorrhagic shock (HS), an association between concomitant traumatic brain injury (TBI) and coagulopathy by TEG parameters is not well understood and is thus investigated. METHODS Retrospective analysis of trauma registry data at a single level 1 trauma center of 772 patients admitted with head Abbreviated Injury Scale (AIS) score of 3 and TEG studies between 2014 and 2017. Patients were stratified to moderate-severe TBI by head AIS scores of 3 and 4 (435 patients) and critical TBI by head AIS score of 5 (328 patients). Hemorrhagic shock was defined by base deficit of 4 or shock index of 0.9. Statistical analysis with unpaired t tests compared patients with critical TBI with patients with moderate-severe TBI, and patients were grouped by presence or absence of HS. A comparison of TBI data with conventional coagulation studies was also evaluated. RESULTS In the setting of HS, critical TBI versus moderate-severe TBI was associated with longer R time (p = 0.004), longer K time (p < 0.05), less acute angle (p = 0.001), and lower clot strength and stability (maximum amplitude [MA]) (p = 0.01). Worse TBI did not correlate with increased fibrinolysis by clot lysis measured by the percentage decrease in amplitude at 30 minutes after MA (p = 0.3). Prothrombin time and international normalized ratio failed to demonstrate more severe coagulopathy, while partial thromboplastin time was found to correlate with severity of TBI (p = 0.01). In patients with critical TBI, the presence of HS correlated with a statistically significant worsening of all parameters (p < 0.05) except for clot lysis measured by the percentage decrease in amplitude at 30 minutes after MA (LY-30). CONCLUSION Thromboelastography demonstrates that, with and without hemorrhagic shock, critical TBI correlates with a significant worsening of traumatic coagulopathy in comparison with moderate/severe TBI. In HS, critical TBI correlates with impaired clot initiation, impaired clot kinetics, and impaired platelet-associated clot strength and stability versus parameters found in moderate-severe TBI. Hemorrhagic shock correlates with worse traumatic coagulopathy in all evaluated patient groups with TBI. Conventional coagulation studies underestimate TBI-associated coagulopathy. Traumatic brain injury-associated coagulopathy is not associated with fibrinolysis. LEVEL OF EVIDENCE Prognostic/epidemiological, level IV; prognostic/epidemiological, level III.
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Affiliation(s)
- Daniel Cucher
- From the Division of Trauma (D.C., A.C., C.H.), Chandler Regional Medical Center, Chandler, Arizona; Section of Trauma Acute Care Surgery, Surgical Critical Care, and Burn Surgery (L.H.), Anschutz Medical Center, University of Colorado, Aurora, Colorado; Division of Critical Care & Acute Care Surgery (B.M.), University of Minnesota Health, Saint Paul, Minnesota; Division of Trauma Surgery & Surgical Critical Care (A.N.), Riverside University Health System Medical Center, Riverside, California; Department of Surgery (T.R.), Vanderbilt University Medical Center, Nashville, Tennessee; Program in Trauma ( R.T., T.S., D.S.), R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, Maryland
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Pigott A, Rudloff E. Traumatic Brain Injury-A Review of Intravenous Fluid Therapy. Front Vet Sci 2021; 8:643800. [PMID: 34307515 PMCID: PMC8299062 DOI: 10.3389/fvets.2021.643800] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 06/09/2021] [Indexed: 11/13/2022] Open
Abstract
This manuscript will review intravenous fluid therapy in traumatic brain injury. Both human and animal literature will be included. Basic treatment recommendations will also be discussed.
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Affiliation(s)
- Armi Pigott
- BluePearl Specialty + Emergency Pet Hospital, Glendale, WI, United States
| | - Elke Rudloff
- BluePearl Specialty + Emergency Pet Hospital, Glendale, WI, United States
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Chico-Fernández M, Barea-Mendoza JA, Pérez-Bárcena J, García-Sáez I, Quintana-Díaz M, Marina L, Mayor-García DM, Serviá-Goixart L, Jiménez-Moragas JM, Llompart-Pou JA. Concomitant Traumatic Brain Injury and Hemorrhagic Shock: Outcomes Using the Spanish Trauma ICU Registry (RETRAUCI). Am Surg 2020; 87:370-375. [PMID: 32993317 DOI: 10.1177/0003134820949990] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND To compare the main outcomes of trauma patients with and without traumatic brain injury (TBI), hemorrhagic shock, and the combination of both using data from the Spanish trauma intensive care unit (ICU) registry (RETRAUCI). METHODS Patients admitted to the participating ICUs from March 2015 to May 2019 were included in the study. The main outcomes were analyzed according to the presence of TBI, hemorrhagic shock, and/or both. Comparison of groups with quantitative variables was performed using the Kruskal-Wallis test, and differences between groups with categorical variables were compared using the Chi-square test or Fisher's exact test as appropriate. A P value <.05 was considered significant. RESULTS Overall, 310 patients (3.98%) were presented with TBI and hemorrhagic shock. Patients with TBI and hemorrhagic shock received more red blood cell (RBC) concentrates, fresh frozen plasma (FFP), a higher ratio FFP/RBC, and had a higher incidence of trauma-induced coagulopathy (60%) (P < .001). These patients had higher mortality (P < .001). Intracranial hypertension was the leading cause of death (50.4%). CONCLUSIONS Concomitant TBI and hemorrhagic shock occur in nearly 4% of trauma ICU patients. These patients required a higher amount of RBC concentrates and FFP and had an increased mortality.
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Affiliation(s)
- Mario Chico-Fernández
- UCI de Trauma y Emergencias, Servicio de Medicina Intensiva, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Jesús A Barea-Mendoza
- UCI de Trauma y Emergencias, Servicio de Medicina Intensiva, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Jon Pérez-Bárcena
- Servei de Medicina Intensiva, Hospital Universitari Son Espases, Institut d'Investigació Sanitària Illes Balears (IdISBa), Palma, Spain
| | - Iker García-Sáez
- Servicio de Medicina Intensiva, Hospital Universitario de Donostia, Donostia, Spain
| | | | - Luis Marina
- Servicio de Medicina Intensiva, Hospital Virgen de la Salud, Toledo, Spain
| | | | - Luis Serviá-Goixart
- Servei de Medicina Intensiva, Hospital Universitari Arnau de Vilanova, Universitat de Lleida, IRBLleida, Lleida, Spain
| | | | - Juan A Llompart-Pou
- Servei de Medicina Intensiva, Hospital Universitari Son Espases, Institut d'Investigació Sanitària Illes Balears (IdISBa), Palma, Spain
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Seno S, Wang J, Cao S, Saraswati M, Park S, Simoni J, Ma L, Soltys B, Hsia CJC, Koehler RC, Robertson CL. Resuscitation with macromolecular superoxide dismutase/catalase mimetic polynitroxylated PEGylated hemoglobin offers neuroprotection in guinea pigs after traumatic brain injury combined with hemorrhage shock. BMC Neurosci 2020; 21:22. [PMID: 32404052 PMCID: PMC7222507 DOI: 10.1186/s12868-020-00571-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Accepted: 05/09/2020] [Indexed: 12/21/2022] Open
Abstract
Background Polynitroxylated PEGylated hemoglobin (PNPH, aka SanFlow) possesses superoxide dismutase/catalase mimetic activities that may directly protect the brain from oxidative stress. Stabilization of PNPH with bound carbon monoxide prevents methemoglobin formation during storage and permits it to serve as a carbon monoxide donor. We determined whether small volume transfusion of hyperoncotic PNPH is neuroprotective in a polytrauma model of traumatic brain injury (TBI) plus hemorrhagic shock. Guinea pigs were used because, like humans, they do not synthesize their own ascorbic acid, which is important in reducing methemoglobin. Results TBI was produced by controlled cortical impact and was followed by 20 mL/kg hemorrhage to a mean arterial pressure (MAP) of 40 mmHg. At 90 min, animals were resuscitated with 20 mL/kg lactated Ringer’s solution or 10 mL/kg PNPH. Resuscitation with PNPH significantly augmented the early recovery of MAP after hemorrhagic shock by 10–18 mmHg; whole blood methemoglobin was only 1% higher and carboxyhemoglobin was 2% higher. At 9 days of recovery, unbiased stereology analysis revealed that, compared to animals resuscitated with lactated Ringer’s solution, those treated with PNPH had significantly more viable neurons in the hippocampus CA1 + 2 region (59 ± 10% versus 87 ± 18% of sham and naïve mean value) and in the dentate gyrus (70 ± 21% versus 96 ± 24%; n = 12 per group). Conclusion PNPH may serve as a small-volume resuscitation fluid for polytrauma involving TBI and hemorrhagic shock. The neuroprotection afforded by PNPH seen in other species was sustained in a species without endogenous ascorbic acid synthesis, thereby supporting potential translatability for human use.
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Affiliation(s)
- Soichiro Seno
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, 600 North Wolfe Street, Blalock 1404, Baltimore, MD, USA.,Division of Traumatology, Research Institute, National Defense Medical College, Saitama, Japan
| | - Jun Wang
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, 600 North Wolfe Street, Blalock 1404, Baltimore, MD, USA
| | - Suyi Cao
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, 600 North Wolfe Street, Blalock 1404, Baltimore, MD, USA
| | - Manda Saraswati
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, 600 North Wolfe Street, Blalock 1404, Baltimore, MD, USA
| | - Sharon Park
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, 600 North Wolfe Street, Blalock 1404, Baltimore, MD, USA
| | - Jan Simoni
- AntiRadical Therapeutics, Sioux Falls, SD, USA
| | - Li Ma
- Department of Physics, Georgia Southern University, Statesboro, GA, USA
| | | | | | - Raymond C Koehler
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, 600 North Wolfe Street, Blalock 1404, Baltimore, MD, USA.
| | - Courtney L Robertson
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, 600 North Wolfe Street, Blalock 1404, Baltimore, MD, USA
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Galvagno SM, Fox EE, Appana SN, Baraniuk S, Bosarge PL, Bulger EM, Callcut RA, Cotton BA, Goodman M, Inaba K, O’Keeffe T, Schreiber MA, Wade CE, Scalea TM, Holcomb JB, Stein DM. Outcomes after concomitant traumatic brain injury and hemorrhagic shock: A secondary analysis from the Pragmatic, Randomized Optimal Platelets and Plasma Ratios trial. J Trauma Acute Care Surg 2017; 83:668-674. [PMID: 28930959 PMCID: PMC5718977 DOI: 10.1097/ta.0000000000001584] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Often the clinician is faced with a diagnostic and therapeutic dilemma in patients with concomitant traumatic brain injury (TBI) and hemorrhagic shock (HS), as rapid deterioration from either can be fatal. Knowledge about outcomes after concomitant TBI and HS may help prioritize the emergent management of these patients. We hypothesized that patients with concomitant TBI and HS (TBI + HS) had worse outcomes and required more intensive care compared with patients with only one of these injuries. METHODS This is a post hoc analysis of the Pragmatic, Randomized Optimal Platelets and Plasma Ratios (PROPPR) trial. TBI was defined by a head Abbreviated Injury Scale score greater than 2. HS was defined as a base excess of -4 or less and/or shock index of 0.9 or greater. The primary outcome for this analysis was mortality at 30 days. Logistic regression, using generalized estimating equations, was used to model categorical outcomes. RESULTS Six hundred seventy patients were included. Patients with TBI + HS had significantly higher lactate (median, 6.3; interquartile range, 4.7-9.2) compared with the TBI group (median, 3.3; interquartile range, 2.3-4). TBI + HS patients had higher activated prothrombin times and lower platelet counts. Unadjusted mortality was higher in the TBI + HS (51.6%) and TBI (50%) groups compared with the HS (17.5%) and neither group (7.7%). Adjusted odds of death in the TBI and TBI + HS groups were 8.2 (95% confidence interval, 3.4-19.5) and 10.6 (95% confidence interval, 4.8-23.2) times higher, respectively. Ventilator, intensive care unit-free and hospital-free days were lower in the TBI and TBI + HS groups compared with the other groups. Patients with TBI + HS or TBI had significantly greater odds of developing a respiratory complication compared with the neither group. CONCLUSION The addition of TBI to HS is associated with worse coagulopathy before resuscitation and increased mortality. When controlling for multiple known confounders, the diagnosis of TBI alone or TBI+HS was associated with significantly greater odds of developing respiratory complications. LEVEL OF EVIDENCE Prognostic study, level II.
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Affiliation(s)
- Samuel M. Galvagno
- University of Maryland School of Medicine, Department of Anesthesiology, Chief, Division of Critical Care Medicine And Associate Director of Critical Care, University of Maryland Medical Center, Program in Trauma, R Adams Cowley Shock Trauma Center, 22 South Greene Street, T3N08, Shock Trauma Center, Baltimore, MD, 21201,
| | - Erin E. Fox
- Assistant Professor, Department of Surgery, Division of Acute Care Surgery, Center for Translational Injury Research (CeTIR), University of Texas Health Science Center at Houston, Houston, TX,
| | - Savitri N. Appana
- Senior Statistician, The University of Texas Health Sciences Center at Houston, School of Public Health, Department of Biostatistics, Houston, TX,
| | - Sarah Baraniuk
- Assistant Professor of Biostatistics, University of Texas-Houston Health Sciences Center School of Public Health, Houston, TX,
| | - Patrick L. Bosarge
- Associate Professor, University of Alabama School of Medicine, Department of Surgery, Division of Acute Care Surgery, Birmingham, AL,
| | - Eileen M. Bulger
- Professor, University of Washington Department of Surgery, Chief of Trauma, Harborview Medical Center, Seattle, WA,
| | - Rachel A. Callcut
- Associate Professor, Division of General Surgery, University of California San Francisco, San Francisco, CA,
| | - Bryan A. Cotton
- Professor, Department of Surgery, Division of Acute Care Surgery, University of Texas Health Science Center, Houston, TX,
| | - Michael Goodman
- Assistant Professor, Department of Surgery, University of Cincinnati School of Medicine, Cincinnati, OH,
| | - Kenji Inaba
- Associate Professor, Department of Surgery, University of Southern California Keck School of Medicine, Los Angeles, CA,
| | - Terence O’Keeffe
- Associate Professor, University of Arizona School of Medicine, Tucson, AZ,
| | - Martin A. Schreiber
- Professor, Oregon Health & Science University School of Medicine, Portland, OR
- Chief, Division of Trauma, Critical Care, and Acute Care Surgery,
| | - Charles E. Wade
- Professor, Department of Surgery, University of Texas Health Science Center, Houston, TX,
| | - Thomas M. Scalea
- Professor, Director, Program in Trauma, Francis X. Kelly Professor of Trauma Surgery, Physician-in-Chief, R Adams Cowley Shock Trauma Center, Baltimore, MD,
| | - John B. Holcomb
- Professor, Department of Surgery, University of Texas Health Science Center, Houston, TX,
| | - Deborah M. Stein
- R Adams Cowley Professor of Trauma, University of Maryland School of Medicine, Department of Surgery, Program in Trauma, Chief of Trauma and Director of Neurotrauma Critical Care, R Adams Cowley Shock Trauma Center, 22 South Greene Street, S4B04, Shock Trauma Center, Baltimore, MD, 21201,
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Prehospital plasma resuscitation associated with improved neurologic outcomes after traumatic brain injury. J Trauma Acute Care Surg 2017; 83:398-405. [PMID: 28538641 DOI: 10.1097/ta.0000000000001581] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Trauma-related hypotension and coagulopathy worsen secondary brain injury in patients with traumatic brain injuries (TBIs). Early damage control resuscitation with blood products may mitigate hypotension and coagulopathy. Preliminary data suggest resuscitation with plasma in large animals improves neurologic function after TBI; however, data in humans are lacking. METHODS We retrospectively identified all patients with multiple injuries age >15 years with head injuries undergoing prehospital resuscitation with blood products at a single Level I trauma center from January 2002 to December 2013. Inclusion criteria were prehospital resuscitation with either packed red blood cells (pRBCs) or thawed plasma as sole colloid resuscitation. Patients who died in hospital and those using anticoagulants were excluded. Primary outcomes were Glasgow Outcomes Score Extended (GOSE) and Disability Rating Score (DRS) at dismissal and during follow-up. RESULTS Of 76 patients meeting inclusion criteria, 53% (n = 40) received prehospital pRBCs and 47% (n = 36) received thawed plasma. Age, gender, injury severity or TBI severity, arrival laboratory values, and number of prehospital units were similar (all p > 0.05). Patients who received thawed plasma had an improved neurologic outcome compared to those receiving pRBCs (median GOSE 7 [7-8] vs. 5.5 [3-7], p < 0.001). Additionally, patients who received thawed plasma had improved functionality compared to pRBCs (median DRS 2 [1-3.5] vs. 9 [3-13], p < 0.001). Calculated GOSE and DRS scores during follow-up, median 6 [5-7] months, demonstrated increased function in those resuscitated with thawed plasma compared to pRBCs by both median GOSE (8 [7-8] vs. 6 [6-7], p < 0.001) and DRS (0 [0-1] vs. 4 [2-8], p < 0.001). CONCLUSION In critically injured trauma patients with TBI, early resuscitation with thawed plasma is associated with improved neurologic and functional outcomes at discharge and during follow-up compared to pRBCs alone. These preliminary data support the further investigation and use of plasma in the resuscitation of critically injured TBI patients. LEVEL OF EVIDENCE Therapeutic, level V.
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Management of Castor Bean Seed-Associated Intraventricular Hemorrhage with Fresh Frozen Plasma: A Case Report. IRANIAN RED CRESCENT MEDICAL JOURNAL 2016. [DOI: 10.5812/ircmj.27834] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
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Hwang JE, Kim K, Lee JH, Jo YH, Kim J, Lee MJ, Park CJ. Blood pressure–targeted stepwise resuscitation of hemorrhagic shock in a swine model. J Surg Res 2016; 204:192-9. [DOI: 10.1016/j.jss.2016.04.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2016] [Revised: 02/01/2016] [Accepted: 04/14/2016] [Indexed: 11/29/2022]
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Ponschab M, Schöchl H, Keibl C, Fischer H, Redl H, Schlimp CJ. Preferential effects of low volume versus high volume replacement with crystalloid fluid in a hemorrhagic shock model in pigs. BMC Anesthesiol 2015; 15:133. [PMID: 26445090 PMCID: PMC4596516 DOI: 10.1186/s12871-015-0114-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2015] [Accepted: 09/23/2015] [Indexed: 12/13/2022] Open
Abstract
Background Fluid resuscitation is a core stone of hemorrhagic shock therapy, and crystalloid fluids seem to be associated with lower mortality compared to colloids. However, as redistribution starts within minutes, it has been suggested to replace blood loss with a minimum of a three-fold amount of crystalloids. The hypothesis was that in comparison to high volume (HV), a lower crystalloid volume (LV) achieves a favorable coagulation profile and exerts sufficient haemodynamics in the acute phase of resuscitation. Methods In 24 anaesthetized pigs, controlled arterial blood loss of 50 % of the estimated blood volume was either (n = 12) replaced with a LV (one-fold) or a HV (three-fold) volume of a balanced, acetated crystalloid solution at room temperature. Hemodynamic parameters, dilution effects and coagulation profile by standard coagulation tests and thromboelastometry at baseline and after resuscitation were determined in both groups. Results LV resuscitation increased MAP significantly less compared to the HV, 61 ± 7 vs. 82 ± 14 mmHg (p < 0.001) respectively, with no difference between lactate and base excess between groups. Haematocrit after fluid replacement was 0.20 vs. 0.16 (LV vs. HV, p < 0.001), suggesting a grade of blood dilution of 32 vs. 42 % (p < 0.001) compared to baseline values. Compared to LV, HV resulted in decreased core temperature (37.5 ± 0.2 vs. 36.0 ± 0.6 °C, p < 0.001), lower platelet count (318 ± 77 vs. 231 ± 53 K/μL, p < 0.01) and lower plasma fibrinogen levels (205 ± 19 vs. 168 ± 24 mg/dL, p < 0.001). Thromboelastometric measurements showed a significant impairment on viscoelastic clot properties following HV group. While prothrombin time index decreased significantly more in the HV group, activated partial thromboplastin time did not differ between both groups. HV did not result in hyperchloraemic acidosis. Discussion Coagulation parameters represented by plasma fibrinogen and ROTEM parameters were also less impaired with LV. With regrad to hematocrit, 60 % of LV remained intracascular , while in HV only 30 % remained in circulation within the first hour of administration. In the acute setting of 50 % controlled blood loss, a one fold LV crystalloid replacement strategy is sufficient to adequately raise blood pressure up to a mean arterial pressure >50 mm Hg. The concept of damage control resuscitation (DCR) with permissive hypotension may be better met by using LV as compared to a three fold HV resuscitation strategy. Conclusion High volume administration of an acetated balanced crystalloid does not lead to hyperchloraemic acidosis, but may negatively influence clinical parameters, such as higher blood pressure, lower body temperature and impaired coagulation parameters, which could potentially increase bleeding after trauma. Replacement of acute blood loss with just an equal amount of an acetated balanced crystalloid appears to be the preferential treatment strategy in the acute phase after controlled bleeding.
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Affiliation(s)
- Martin Ponschab
- Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, AUVA Research Centre, Donaueschingenstrasse 13, A-1200, Vienna, Austria. .,Department of Anaesthesiology and Intensive Care, AUVA Trauma Hospital, Linz, Austria.
| | - Herbert Schöchl
- Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, AUVA Research Centre, Donaueschingenstrasse 13, A-1200, Vienna, Austria. .,Department of Anaesthesiology and Intensive Care, AUVA Trauma Centre, Salzburg, Austria.
| | - Claudia Keibl
- Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, AUVA Research Centre, Donaueschingenstrasse 13, A-1200, Vienna, Austria.
| | - Henrik Fischer
- Department I/10, Federal Ministry of the Interior, Vienna, Republic of Austria.
| | - Heinz Redl
- Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, AUVA Research Centre, Donaueschingenstrasse 13, A-1200, Vienna, Austria.
| | - Christoph J Schlimp
- Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, AUVA Research Centre, Donaueschingenstrasse 13, A-1200, Vienna, Austria. .,Department of Anaesthesiology and Intensive Care, AUVA Trauma Hospital, Klagenfurt, Austria.
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Søreide K. Editorial: facts, figures and the future. Scand J Trauma Resusc Emerg Med 2015; 23:1. [PMID: 25583033 PMCID: PMC4296535 DOI: 10.1186/s13049-014-0079-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2014] [Accepted: 12/15/2014] [Indexed: 12/01/2022] Open
Affiliation(s)
- Kjetil Søreide
- Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway. .,Department of Clinical Medicine, University of Bergen, Bergen, Norway.
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