1
|
Racine-Brzostek SE, Cushing MM, Gareis M, Heger A, Mehta Shah T, Scully M. Thirty years of experience with solvent/detergent-treated plasma for transfusion medicine. Transfusion 2024; 64:1132-1153. [PMID: 38644541 DOI: 10.1111/trf.17836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Revised: 03/26/2024] [Accepted: 03/28/2024] [Indexed: 04/23/2024]
Affiliation(s)
| | - Melissa M Cushing
- Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York, New York, USA
- Department of Anesthesiology, Weill Cornell Medicine, New York, New York, USA
| | - Michelle Gareis
- Octapharma Pharmazeutika Produktionsges.mb.H, Vienna, Austria
| | - Andrea Heger
- Octapharma Pharmazeutika Produktionsges.mb.H, Vienna, Austria
| | | | - Marie Scully
- Department of Haematology, University College London Hospital, London, UK
| |
Collapse
|
2
|
Huang X, Zheng Y, Ming J, Ning X, Bai S. Natural polymer-based bioadhesives as hemostatic platforms for wound healing. Int J Biol Macromol 2024; 256:128275. [PMID: 38000608 DOI: 10.1016/j.ijbiomac.2023.128275] [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: 06/04/2023] [Revised: 11/16/2023] [Accepted: 11/17/2023] [Indexed: 11/26/2023]
Abstract
Medical adhesives are advanced but challenging alternatives to wound closure and repair, especially in mitigating uncontrolled hemorrhage. Ideal hemostatic adhesives need to meet good biocompatibility and biodegradability, adequate mechanical strength, and strong tissue adhesion functionality under wet and dynamic conditions. Considering these requirements, natural polymers such as polysaccharide, protein and DNA, attract great attention as candidates for making bioadhesives because of their distinctive physicochemical performances and biological properties. This review systematically summarizes the advances of bioadhesives based on natural polysaccharide, protein and DNA. Various physical and chemical cross-linking strategies have been introduced for adhesive synthesis and their hemostatic applications are introduced from the aspect of versatility. Furthermore, the possible challenges and future opportunities of bioadhesives are discussed, providing insights into the development of high-performance hemostatic materials.
Collapse
Affiliation(s)
- Xiaowei Huang
- Industrial Research Institute of Nonwovens and Technical Textiles, College of Textiles and Clothing, Qingdao University, Qingdao 266071, People's Republic of China
| | - Yankun Zheng
- College of Biological Science and Engineering, Fuzhou University, Fuzhou 350108, People's Republic of China
| | - Jinfa Ming
- Industrial Research Institute of Nonwovens and Technical Textiles, College of Textiles and Clothing, Qingdao University, Qingdao 266071, People's Republic of China.
| | - Xin Ning
- Industrial Research Institute of Nonwovens and Technical Textiles, College of Textiles and Clothing, Qingdao University, Qingdao 266071, People's Republic of China
| | - Shumeng Bai
- College of Biological Science and Engineering, Fuzhou University, Fuzhou 350108, People's Republic of China.
| |
Collapse
|
3
|
Almuwallad A, Cole E, Rossetto A, Brohi K, Perkins Z, Davenport R. Nationwide analysis of prehospital tranexamic acid for trauma demonstrates systematic bias in adherence to treatment guidelines: a retrospective cohort study. Int J Surg 2023; 109:3796-3803. [PMID: 37720941 PMCID: PMC10720772 DOI: 10.1097/js9.0000000000000712] [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: 04/28/2023] [Accepted: 08/13/2023] [Indexed: 09/19/2023]
Abstract
BACKGROUND Prehospital (PH) tranexamic acid (TXA) improves survival from trauma haemorrhage. Injury mechanism, physiology, and sex demographics vary with patient age. The authors hypothesised that these factors influence TXA guideline compliance and examined national trends in PH use to identify any systematic biases in bleeding management. MATERIALS AND METHODS The UK Trauma Audit and Research Network data for TXA eligible patients admitted to major trauma centres were divided into two cohorts: 2013-2015 ( n =32 072) and 2017-2019 ( n =14 974). Patients were stratified by PH, emergency department or no TXA use. Logistic regression models explored interaction between PH variables and TXA administration. Results are presented as odds ratios with a 95% CI. RESULTS PH TXA use increased from 8% to 27% over time ( P <0.001). Only 3% of eligible patients who fell less than 2 m received PH TXA versus 63% with penetrating injuries ( P <0.001). Older patients eligible for PH TXA were less likely to receive it compared to younger patients [≥65 years old: 590 (13%) vs. <65 years old: 3361 (33%), P <0.001]. There was a significant interaction between age and sex with fewer older women receiving PH TXA. In shocked patients, one third of females compared to a fifth of men did not receive TXA ( P <0.001). There was a decrease in PH TXA use as age increased ( P <0.001). CONCLUSIONS Despite a threefold increase in use, treatment guidance for PH TXA is not universally applied. Older people, women, and patients with low energy injury mechanisms appear to be systematically under treated. Training and education for PH providers should address these potential treatment biases.
Collapse
Affiliation(s)
- Ateeq Almuwallad
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London
- Emergency Medical Services Department, Faculty of Applied Medical Sciences, Jazan University, Kingdom of Saudi Arabia
| | - Elaine Cole
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London
| | - Andrea Rossetto
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London
- Barts Health National Health Service Trust, London, UK
| | - Karim Brohi
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London
- Barts Health National Health Service Trust, London, UK
| | - Zane Perkins
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London
- Barts Health National Health Service Trust, London, UK
| | - Ross Davenport
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London
- Barts Health National Health Service Trust, London, UK
| |
Collapse
|
4
|
Curry N, Davenport R, Lucas J, Deary A, Benger J, Edwards A, Evans A, Foley C, Green L, Morris S, Thomas H, Brohi K, Stanworth SJ. The CRYOSTAT2 trial: The rationale and study protocol for a multi-Centre, randomised, controlled trial evaluating the effects of early high-dose cryoprecipitate in adult patients with major trauma haemorrhage requiring major haemorrhage protocol activation. Transfus Med 2023; 33:123-131. [PMID: 36321753 DOI: 10.1111/tme.12932] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Revised: 09/05/2022] [Accepted: 10/03/2022] [Indexed: 11/05/2022]
Abstract
OBJECTIVES To describe the protocol for a multinational randomised, parallel, superiority trial, in which patients were randomised to receive early high-dose cryoprecipitate in addition to standard major haemorrhage protocol (MHP), or Standard MHP alone. BACKGROUND Blood transfusion support for trauma-related major bleeding includes red cells, plasma and platelets. The role of concentrated sources of fibrinogen is less clear and has not been evaluated in large clinical trials. Fibrinogen is a key pro-coagulant factor that is essential for stable clot formation. A pilot trial had demonstrated that it was feasible to deliver cryoprecipitate as a source of fibrinogen within 90 min of admission. METHODS Randomisation was via opaque sealed envelopes held securely in participating Emergency Departments or transfusion laboratories. Early cryoprecipitate, provided as 3 pools (equivalent to 15 single units of cryoprecipitate or 6 g fibrinogen supplementation), was transfused as rapidly as possible, and started within 90 min of admission. Participants in both arms received standard treatment defined in the receiving hospital MHP. The primary outcome measure was all-cause mortality at 28 days. Symptomatic thrombotic events including venous thromboembolism and arterial thrombotic events (myocardial infarction, stroke) were collected from randomisation up to day 28 or discharge from hospital. EQ5D-5Land Glasgow Outcome Score were completed at discharge and 6 months. All analyses will be performed on an intention to treat basis, with per protocol sensitivity analysis. RESULTS The trial opened for recruitment in June 2017 and the final patient completed follow-up in May 2022. DISCUSSION This trial will provide firmer evidence to evaluate the effectiveness and cost-effectiveness of early high-dose cryoprecipitate alongside the standard MHP in major traumatic haemorrhage.
Collapse
Affiliation(s)
- Nicola Curry
- Oxford UniversityHospitals NHS Foundation Trust, Nuffield Orthopaedic Hospital, Oxford, UK
| | - Ross Davenport
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, UK
| | - Joanne Lucas
- NHS Blood and Transplant Clinical Trials Unit, Cambridge, UK
| | - Alison Deary
- NHS Blood and Transplant Clinical Trials Unit, Cambridge, UK
| | - Jonathan Benger
- Faculty of Health and Applied Sciences, University of the West of England, Bristol, UK
| | - Antoinette Edwards
- Trauma Audit and Research Network, Salford Royal Hospital, Northern Care Alliance NHS Foundation Trust, Salford, UK
| | - Amy Evans
- NHS Blood and Transplant Clinical Trials Unit, Cambridge, UK
| | - Claire Foley
- NHS Blood and Transplant Clinical Trials Unit, Cambridge, UK
| | - Laura Green
- Blizard Institute, Queen Mary University of London, London, UK
- NHS Blood and Transplant and Bart's Health NHS Trust, London, UK
| | - Stephen Morris
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Helen Thomas
- NHS Blood and Transplant Clinical Trials Unit, Bristol, UK
| | - Karim Brohi
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, UK
| | - Simon J Stanworth
- NHS Blood and Transplant and Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford, UK
| |
Collapse
|
5
|
Hmidan Simsam M, Delorme L, Grimm D, Priestap F, Bohnert S, Descoteaux M, Hilsden R, Laverty C, Mickler J, Parry N, Rochwerg B, Sherman C, Smith S, Toole J, Vogt K, Wilson S, Ball I. Efficacy of high dose tranexamic acid (TXA) for hemorrhage: A systematic review and meta-analysis. Injury 2023; 54:857-870. [PMID: 36746710 DOI: 10.1016/j.injury.2022.12.029] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Revised: 12/23/2022] [Accepted: 12/29/2022] [Indexed: 01/09/2023]
Abstract
BACKGROUND Standard dose (≤ 1 g) tranexamic acid (TXA) has established mortality benefit in trauma patients. The role of high dose IV TXA (≥2 g or ≥30 mg/kg as a single bolus) has been evaluated in the surgical setting, however, it has not been studied in trauma. We reviewed the available evidence of high dose IV TXA in any setting with the goal of informing its use in the adult trauma population. METHODS We searched MEDLINE, EMBASE and unpublished sources from inception until July 27, 2022 for studies that compared standard dose with high dose IV TXA in adults (≥ 16 years of age) with hemorrhage. Screening and data abstraction was done independently and in duplicate. We pooled trial data using a random effects model and considered randomized controlled trials (RCTs) and observational cohort studies separately. We assessed the individual study risk of bias using the Cochrane Risk of Bias for RCTs and the Newcastle-Ottawa Scale for observational cohort studies. The overall certainty of evidence was assessed using the GRADE approach (Grading of Recommendations Assessment, Development and Evaluation). RESULTS We included 20 studies with a combined total of 12,523 patients. Based on pooled RCT data, and as compared to standard dose TXA, high dose IV TXA probably decreases transfusion requirements (odds ratio [OR] 0.86, 95% confidence interval [CI] 0.76 to 0.97, moderate certainty) but with possibly no effect on blood loss (mean difference [MD] 43.31 ml less, 95% CI 135.53 to 48.90 ml less, low certainty), and an uncertain effect on thromboembolic events (OR 1.33, 95% CI 0.86 to 2.04, very low certainty) and mortality (OR 0.70, 95% CI 0.37 to 1.32, very low certainty). CONCLUSION When compared to standard dose, high dose IV TXA probably reduces transfusion requirements with an uncertain effect on thromboembolic events and mortality. LEVEL OF EVIDENCE Systematic review and meta-analysis, level IV.
Collapse
Affiliation(s)
- Mohammad Hmidan Simsam
- Schulich School of Medicine and Dentistry, Western University, 1397 Medway Park Dr, London, Ontario N6G 0Z6, Canada.
| | - Laurence Delorme
- Faculty of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Dylan Grimm
- Faculty of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Fran Priestap
- London Health Sciences Centre Trauma Program, London, Ontario, Canada
| | | | | | - Rich Hilsden
- London Health Sciences Centre Trauma Program, London, Ontario, Canada; Royal Canadian Medical Service, Canada; Department of Surgery, Western University, London, Ontario, Canada; Office of Academic Military Medicine, Western University, London, Ontario, Canada
| | | | | | - Neil Parry
- London Health Sciences Centre Trauma Program, London, Ontario, Canada; Department of Surgery, Western University, London, Ontario, Canada; Office of Academic Military Medicine, Western University, London, Ontario, Canada
| | - Bram Rochwerg
- Department of Medicine, MacMaster University, Hamilton, Ontario, Canada; Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | | | - Shane Smith
- London Health Sciences Centre Trauma Program, London, Ontario, Canada; Royal Canadian Medical Service, Canada; Department of Surgery, Western University, London, Ontario, Canada; Office of Academic Military Medicine, Western University, London, Ontario, Canada
| | | | - Kelly Vogt
- London Health Sciences Centre Trauma Program, London, Ontario, Canada; Department of Surgery, Western University, London, Ontario, Canada
| | | | - Ian Ball
- London Health Sciences Centre Trauma Program, London, Ontario, Canada; Royal Canadian Medical Service, Canada; Office of Academic Military Medicine, Western University, London, Ontario, Canada; Department of Medicine, Western University, London, Ontario, Canada; Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
| |
Collapse
|
6
|
Robertson GAJ, Marsh AG, Gill SL, Martin D, Lowe DJ, Jamal B. The influence of heatwave temperatures on fracture patient presentation to hospital. Injury 2022; 53:3163-3171. [PMID: 35810044 DOI: 10.1016/j.injury.2022.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Revised: 06/07/2022] [Accepted: 07/03/2022] [Indexed: 02/02/2023]
Abstract
INTRODUCTION As global warming continues at its current rate, heatwaves are likely to become an increasing phenomenon. At present, knowledge of the influence of heatwave temperatures on fracture patient presentation to hospital remains limited. METHODS This was a retrospective descriptive epidemiology study performed through hospital database review, linked to meteorological data. Emergency Department and Fracture Patient Presentation Data was obtained for the adult (16+) South Glasgow population (population count - 525,839) and the adult (16+) population covered by the West of Scotland Major Trauma Centre (population count - 2,218,326) from May 2021 to August 2021. This was combined with maximum temperature data, along with humidity and humidex data. Humidex is a measure which quantifies the temperature experienced by the patient, through a combined score incorporating both maximum temperature and humidity RESULTS: During the study period, there was one temperature heatwave (19th to 25th July), and four humidex heatwaves (27th June to 3rd July, 15th to 17th July, 19th to 27th July, 22nd to 26th August). During the temperature heatwave, there was a significantly higher incidence of orthopaedic polytrauma patient presentation (IRR 2.37: p < 0.027), as well as ED patient presentation (IRR 1.07: p < 0.036). The humidex heatwaves were associated with a significantly higher incidence of orthopaedic polytrauma patient presentation (IRR 2.31: p < 0.002) and overall fracture patient presentation (IRR 1.18: p < 0.002). Positive correlations were found between orthopaedic polytrauma patient presentation vs temperature (R=0.217: p < 0.016), ED patient presentation vs temperature (R=0.427: p < 0.001), fracture patient presentation vs temperature (R=0.394: p < 0.001), and distal radius fracture patient presentation vs temperature (R=0.246: p < 0.006). CONCLUSION This study finds that heatwave temperatures result in a significantly increased number of orthopaedic polytrauma patients presenting to a Major Trauma Centre. Given the significant resources these patients require for care, Major Trauma Centres should be aware of such findings, and consider staff and resources profiles in response.
Collapse
Affiliation(s)
- Greg A J Robertson
- Department of Orthopaedic Major Trauma Surgery, Orthopaedic post CCT Fellow, Queen Elizabeth University Hospital, 5/6 Gladstone Terrace, Glasgow, Edinburgh EH9 1LX, United Kingdom.
| | - Andrew G Marsh
- Consultant Orthopaedic Surgeon, Queen Elizabeth University Hospital, Glasgow, United Kingdom
| | - Sarah L Gill
- Consultant Orthopaedic Surgeon, Queen Elizabeth University Hospital, Glasgow, United Kingdom
| | - David Martin
- Consultant Orthopaedic Surgeon, Queen Elizabeth University Hospital, Glasgow, United Kingdom
| | - David J Lowe
- Queen Elizabeth University Hospital, Glasgow, United Kingdom
| | - Bilal Jamal
- Consultant Orthopaedic Surgeon, Queen Elizabeth University Hospital, Glasgow, United Kingdom
| |
Collapse
|
7
|
Pollard D, Fuller G, Goodacre S, van Rein EAJ, Waalwijk JF, van Heijl M. An economic evaluation of triage tools for patients with suspected severe injuries in England. BMC Emerg Med 2022; 22:4. [PMID: 35016621 PMCID: PMC8753918 DOI: 10.1186/s12873-021-00557-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Accepted: 12/07/2021] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND Many health care systems triage injured patients to major trauma centres (MTCs) or local hospitals by using triage tools and paramedic judgement. Triage tools are typically assessed by whether patients with an Injury Severity Score (ISS) ≥ 16 go to an MTC and whether patients with an ISS < 16 are sent to their local hospital. There is a trade-off between sensitivity and specificity of triage tools, with the optimal balance being unknown. We conducted an economic evaluation of major trauma triage tools to identify which tool would be considered cost-effective by UK decision makers. METHODS A patient-level, probabilistic, mathematical model of a UK major trauma system was developed. Patients with an ISS ≥ 16 who were only treated at local hospitals had worse outcomes compared to being treated in an MTC. Nine empirically derived triage tools, from a previous study, were examined so we assessed triage tools with realistic trade-offs between triage tool sensitivity and specificity. Lifetime costs, lifetime quality adjusted life years (QALYs), and incremental cost-effectiveness ratios (ICERs) were calculated for each tool and compared to maximum acceptable ICERs (MAICERs) in England. RESULTS Four tools had ICERs within the normal range of MAICERs used by English decision makers (£20,000 to £30,000 per QALY gained). A low sensitivity (28.4%) and high specificity (88.6%) would be cost-effective at the lower end of this range while higher sensitivity (87.5%) and lower specificity (62.8%) was cost-effective towards the upper end of this range. These results were sensitive to the cost of MTC admissions and whether MTCs had a benefit for patients with an ISS between 9 and 15. CONCLUSIONS The cost-effective triage tool depends on the English decision maker's MAICER for this health problem. In the usual range of MAICERs, cost-effective prehospital trauma triage involves clinically suboptimal sensitivity, with a proportion of seriously injured patients (at least 10%) being initially transported to local hospitals. High sensitivity trauma triage requires development of more accurate decision rules; research to establish if patients with an ISS between 9 and 15 benefit from MTCs; or, inefficient use of health care resources to manage patients with less serious injuries at MTCs.
Collapse
Affiliation(s)
- Daniel Pollard
- School of Health and Related Research, University of Sheffield, Sheffield, UK.
| | - Gordon Fuller
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Steve Goodacre
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Eveline A J van Rein
- Department of Traumatology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Job F Waalwijk
- Department of Traumatology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Mark van Heijl
- Department of Traumatology, University Medical Center Utrecht, Utrecht, the Netherlands
| |
Collapse
|
8
|
Almuwallad A, Cole E, Ross J, Perkins Z, Davenport R. The impact of prehospital TXA on mortality among bleeding trauma patients: A systematic review and meta-analysis. J Trauma Acute Care Surg 2021; 90:901-907. [PMID: 33605702 DOI: 10.1097/ta.0000000000003120] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Tranexamic acid (TXA) is an antifibrinolytic drug associated with improved survival among trauma patients with hemorrhage. Tranexamic acid is considered a primary hemostatic intervention in prehospital for treatment of bleeding alongside blood product transfusion. METHODS A systematic review and meta-analysis was conducted to investigate the impact of prehospital TXA on mortality among trauma patients with bleeding. A systematic search was conducted using the National Institute for Health and Care Excellence Healthcare Databases Advanced Search library which contain the following of databases: EMBASE, Medline, PubMed, BNI, EMCARE, and HMIC. Other databases searched included SCOPUS and the Cochrane Central Register for Clinical Trials Library. Quality assessment tools were applied among included studies; Cochrane Risk of Bias for randomized control trials and Newcastle-Ottawa Scale for cohort observational studies. RESULTS A total of 797 publications were identified from the initial database search. After removing duplicates and applying inclusion/exclusion criteria, four studies were included in the review and meta-analysis which identified a significant survival benefit in patients who received prehospital TXA versus no TXA. Three observational cohort and one randomized control trial were included into the review with a total of 2,347 patients (TXA, 1,169 vs. no TXA, 1,178). There was a significant reduction in 24 hours mortality; odds ratio (OR) of 0.60 (95% confidence interval [CI], 0.37-0.99). No statistical significant differences in 28 days to 30 days mortality; OR of 0.69 (95% CI, 0.47-1.02), or venous thromboembolism OR of 1.49 (95% CI, 0.90-2.46) were found. CONCLUSION This review demonstrates that prehospital TXA is associated with significant reductions in the early (24 hour) mortality of trauma patients with suspected or confirmed hemorrhage but no increase in the incidence of venous thromboembolism. LEVEL OF EVIDENCE Systematic review and meta-analysis. Level I.
Collapse
Affiliation(s)
- Ateeq Almuwallad
- From the Centre for Trauma Science, Blizard Institute (A.A., E.C., J.R., Z.P., R.D.), Queen Mary University, London, United Kingdom; and Emergency Medical Services Department, Faculty of Applied Medical Sciences (A.A.), Jazan University, Kingdom of Saudi Arabia
| | | | | | | | | |
Collapse
|
9
|
Giuseppe G, Ilaria M, Federico D, Alessandro C, Simona G, Nazerian P, Marco B, Stefano G. Severe thoracic or abdominal injury in major trauma patients can safely be ruled out by "Valutazione Integrata Bed Side" evaluation without total body CT scan. Ir J Med Sci 2020; 190:799-805. [PMID: 32888166 DOI: 10.1007/s11845-020-02351-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 08/22/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND During the initial assessment of trauma patients, the severity of injury is very often not immediately recognizable. In trauma centers, a total body CT (TBCT) scan is routinely used to evaluate this kind of patients, even if it is burdened with health risk, economical costs, and logistical difficulties. AIM We investigated the use of a clinical guide to establish a safe alternative to this routine practice. METHODS We enrolled retrospectively 438 patients referring to the Emergency Department of Careggi University Hospital in Florence (Italy) over a 1-year period from 2014 to 2015, with the evidence of trauma and high-priority triage codes and then subjected to TBCT. We created a tool called VIBS ("Valutazione Integrata Bed Side") (from the Italian translation of "Bed Side Integrated Evaluation") which included all clinical, laboratory, and diagnostic data acquired bedside during the primary survey. Every VIBS profile was dichotomized in negative or positive if there was at least one altered item. We performed an analysis of correlation between VIBS and TBCT to determine sensibility, specificity, positive, and negative predictive value and likelihood ratio of VIBS. RESULTS Sensibility of VIBS in the prediction of positive CT scan was 100% and specificity was 31.7%. Positive and negative predictive value (95% C.I.) was 44.3 (38.8-49.5) and 100 (94.0-99.9). Positive and negative likelihood ratios were 1.464 and 0. Failure rate resulted in 0% and efficiency was 20.54%. CONCLUSIONS VIBS can safely rule out severe thoracic or abdominal injuries. This approach could limit the use of TBCT in one-fifth of suspected major trauma patients.
Collapse
Affiliation(s)
| | - Melara Ilaria
- Emergency Medicine Fellowship Program, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy
| | | | - Coppa Alessandro
- Department of Emergency Medicine, S.Giuseppe Hospital, Empoli, Italy
| | | | | | - Bartolini Marco
- Department of Radiology, Careggi University Hospital, Florence, Italy
| | | |
Collapse
|
10
|
Mackenzie CF, Elster EA, Bowyer MW, Sevdalis N. Scoping Evidence Review on Training and Skills Assessment for Open Emergency Surgery. JOURNAL OF SURGICAL EDUCATION 2020; 77:1211-1226. [PMID: 32224033 DOI: 10.1016/j.jsurg.2020.02.029] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/22/2019] [Revised: 02/18/2020] [Accepted: 02/27/2020] [Indexed: 06/10/2023]
Abstract
OBJECTIVE Scope evidence on technical performance metrics for open emergency surgery. Identify surgical performance metrics and procedures used in trauma training courses. DESIGN Structured literature searches of electronic databases were conducted from January 2010 to December 2019 to identify systematic reviews of tools to measure surgical skills employed in vascular or trauma surgery evaluation and training. SETTING AND PARTICIPANTS Faculty of Shock Trauma Anesthesiology Research Center, University of Maryland School of Medicine, Uniformed Services University of Health Sciences, Bethesda, Maryland and Implementation Science, King's College, London. RESULTS The evidence from 21 systematic reviews including over 54,000 subjects enrolled into over 840 eligible studies, identified that the Objective Structured Assessment of Technical Skill was used for elective surgery not for emergency trauma and vascular control surgery procedures. The Individual Procedure Score (IPS), used to evaluate emergency trauma procedures performed before and after training, distinguished performance of residents from experts and practicing surgeons. IPS predicted surgeons who make critical errors and need remediation interventions. No metrics showed Kirkpatrick's Level 4 evidence of technical skills training benefit to emergency surgery outcomes. CONCLUSIONS Expert benchmarks, errors, complication rates, task completion time, task-specific checklists, global rating scales, Objective Structured Assessment of Technical Skills, and IPS were found to identify surgeons, at all levels of seniority, who are in need of remediation of technical skills for open surgical hemorrhage control. Large-scale, multicenter studies are needed to evaluate any benefit of trauma technical skills training on patient outcomes.
Collapse
Affiliation(s)
| | - Eric A Elster
- The Uniformed Services University of Health Sciences and the Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Mark W Bowyer
- The Uniformed Services University of Health Sciences and the Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Nick Sevdalis
- Center for Implementation Science, King's College, London, United Kingdom
| |
Collapse
|
11
|
Callcut RA, Simpson KN, Baraniuk S, Fox EE, Tilley BC, Holcomb JB. Cost-effectiveness evaluation of the PROPPR trial transfusion protocols. Transfusion 2020; 60:922-931. [PMID: 32358836 PMCID: PMC7567498 DOI: 10.1111/trf.15784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Revised: 01/03/2020] [Accepted: 01/03/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND There have been no prior investigations of the cost effectiveness of transfusion strategies for trauma resuscitation. The Pragmatic, Randomized, Optimal Platelet and Plasma Ratios (PROPPR) study was a Phase III multisite, randomized trial in 680 subjects comparing the efficacy of 1:1:1 transfusion ratios of plasma and platelets to red blood cells with the 1:1:2 ratio. We hypothesized that 1:1:1 transfusion results in an acceptable incremental cost-effectiveness ratio, when estimated using patients' age-specific life expectancy and cost of care during the 30-day PROPPR trial period. STUDY DESIGN AND METHODS International Classification of Diseases, Ninth Revision codes were prospectively collected, and subjects were matched 1:2 to subjects in the Healthcare Utilization Program State Inpatient Data to estimate cost weights. We used a decision tree analysis, combined with standard costs and estimated years of expected survival to determine the cost effectiveness of the two treatments. RESULTS The 1:1:1 group had higher overall costs for the blood products but were more likely to achieve hemostasis and decreased hemorrhagic death by 24 hours (p = 0.006). For every 100 patients treated in the 1:1:1 group, eight more achieved hemostasis than in the 1:1:2 group. At 30 days, the total hospital cost per 100 patients was $5.6 million in the 1:1:1 group compared with $5.0 million in the 1:1:2 group. For each 100 patients, the 1:1:1 group had 218.5 more years of life expectancy. This was at a cost of $2994 per year gained. CONCLUSION The 1:1:1 transfusion ratio in severely injured hemorrhaging trauma patients is a very cost-effective strategy for increasing hemostasis and decreasing trauma deaths.
Collapse
Affiliation(s)
- Rachael A. Callcut
- Division of General Surgery, Department of Surgery, School of Medicine, University of California San Francisco, San Francisco, California
| | - Kit N. Simpson
- Department of Healthcare Leadership & Management, Medical University of South Carolina, Charleston, South Carolina
| | - Sarah Baraniuk
- Division of Biostatistics, School of Public Health, University of Texas Health Science Center at Houston, Houston, Texas
| | - Erin E. Fox
- Center for Translational Injury Research and Department of Surgery, University of Texas Health Science Center at Houston, Houston, Texas
| | - Barbara C. Tilley
- Division of Biostatistics, School of Public Health, University of Texas Health Science Center at Houston, Houston, Texas
| | - John B. Holcomb
- Division of Acute Care Surgery, Department of Surgery, Center for Injury Science, University of Alabama at Birmingham, Birmingham, Alabama
| | | |
Collapse
|
12
|
Asmamaw Y, Yitayal M, Debie A, Handebo S. The costs of traumatic head injury and associated factors at University of Gondar Specialized Referral Hospital, Northwest Ethiopia. BMC Public Health 2019; 19:1399. [PMID: 31660928 PMCID: PMC6819621 DOI: 10.1186/s12889-019-7800-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Accepted: 10/17/2019] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Head injuries account for 650,000 annual deaths worldwide. The cost for treating head injury was estimated at US $200 million annually. This contributes to economic impoverishment in low income countries like Ethiopia. Hence, this study was aimed to assess the cost of Traumatic Head Injury (THI) and associated factors in the University of Gondar Specialized Referral Hospital. METHOD An institution-based cross-sectional study was conducted from March 01 to May 30, 2017. A total of 387 THI patients were included in the study. An interviewer-administered questionnaire was used for data collection. Direct costs and indirect costs were measured by using the bottom-up approach. Data were entered into Epi-Info version 7 and imported to SPSS version 20 for analysis. Simple and multiple linear regression analysis were done to identify factors associated with cost of THI. RESULTS The mean cost of THI per patient was 4673.43 Ethiopian Birr (ETB), 95% CI (4523.6-4823.3), and length of hospital stay averaged 1.73, 95% CI (1.63-1.82). Direct non-medical cost, like transportation fee 1896.19 ETB (±762.56 SD) and medical costs 1101.66 ETB (±534.13 SD) were account for 40.57 and 23.58% of total costs respectively. The indirect cost, loss of income by patient and their attendant due to injury, was 1675.58 ETB (+ 459.26 SD). Patients with moderate and severe levels of injury have 635.167 ETB (Standardized coefficient = 0.173, p < 0.001) and 773.621 ETB (Standardized coefficient = 0. 132, p < 0.001) increased costs, respectively, compared to mild level THI patients. Costs for patients ages 31-45 years were 252.504 ETB (Standardized coefficient = - 0.066, p = 0.046) lower than costs for those 5-14 years old. The cost of THI patients increased by 1022.853 ETB for each additional day of hospital length of stay (Standardized coefficient = 0.648, p < 0.001). CONCLUSION Most expenses of the THI were from direct non-medical cost. Prior health service use, length of stay, level of injury, and age were significant predictors of cost of THI.
Collapse
Affiliation(s)
- Yilak Asmamaw
- Medical Ward, University of Gondar Specialized Referral Hospital, Gondar, Ethiopia
| | - Mezgebu Yitayal
- Department of Health Systems and Policy, Institute of Public Health, University of Gondar, Gondar, Ethiopia
| | - Ayal Debie
- Department of Health Systems and Policy, Institute of Public Health, University of Gondar, Gondar, Ethiopia
| | - Simegnew Handebo
- Department of Health Education and Behavioral Sciences, Institute of Public Health, University of Gondar, Gondar, Ethiopia.
| |
Collapse
|
13
|
Renna MS, van Zeller C, Abu-Hijleh F, Tong C, Gambini J, Ma M. A one-year cost-utility analysis of REBOA versus RTACC for non-compressible torso haemorrhage. TRAUMA-ENGLAND 2019; 21:45-54. [PMID: 30886535 PMCID: PMC6380757 DOI: 10.1177/1460408617738810] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Major trauma is a leading cause of death and disability in young adults, especially from massive non-compressible torso haemorrhage. The standard technique to control distal haemorrhage and maximise central perfusion is resuscitative thoracotomy with aortic cross-clamping (RTACC). More recently, the minimally invasive technique of resuscitative endovascular balloon occlusion of the aorta (REBOA) has been developed to similarly limit distal haemorrhage without the morbidity of thoracotomy; cost-utility studies on this intervention, however, are still lacking. The aim of this study was to perform a one-year cost-utility analysis of REBOA as an intervention for patients with major traumatic non-compressible abdominal haemorrhage, compared to RTACC within the U.K.'s National Health Service. METHODS A retrospective analysis of the outcomes following REBOA and RTACC was conducted based on the published literature of survival and complication rates after intervention. Utility was obtained from studies that used the EQ-5D index and from self-conducted surveys. Costs were calculated using 2016/2017 National Health Service tariff data and supplemented from further literature. A cost-utility analysis was then conducted. RESULTS A total of 12 studies for REBOA and 20 studies for RTACC were included. The mean injury severity scores for RTACC and REBOA were 34 and 39, and mean probability of death was 9.7 and 54%, respectively. The incremental cost-effectiveness ratio of REBOA when compared to RTACC was £44,617.44 per quality-adjusted life year. The incremental cost-effectiveness ratio, by exceeding the National Institute for Health and Clinical Effectiveness's willingness-to-pay threshold of £30,000/quality-adjusted life year, suggests that this intervention is not cost-effective in comparison to RTACC. However, REBOA yielded a 157% improvement in utility with a comparatively small cost increase of 31.5%. CONCLUSION Although REBOA has not been found to be cost-effective when compared to RTACC, ultimately, clinical experience and expertise should be the main factor in driving the decision over which intervention to prioritise in the emergency context.
Collapse
Affiliation(s)
| | | | | | | | | | - Mengyao Ma
- Imperial
College Business School, London,
UK
| |
Collapse
|
14
|
Abstract
Trauma is a leading cause of death worldwide in persons under 44 years of age, and uncontrolled haemorrhage is the most common preventable cause of death in this patient group. The transfusion management of trauma haemorrhage is unrecognisable from 20 years ago. Changes in clinical practice have been driven primarily by an increased understanding of the pathophysiology of trauma-induced coagulopathy (TIC), which is associated with poor clinical outcomes, including a 3- to 4-fold increased risk of death. Targeting this coagulopathy alongside changes to surgical and anaesthetic practices (an overarching strategy known as damage control surgery/damage control resuscitation) has led to a significant reduction in mortality rates over the last two decades. This narrative review will discuss the transfusion practices that are currently used for trauma haemorrhage and the evidence that supports these practices.
Collapse
Affiliation(s)
- Nicola S Curry
- Oxford Haemophilia & Thrombosis Centre, Department of Haematology, Oxford University Hospitals NHS Trust, Churchill Hospital, Oxford, UK.,NIHR BRC, Blood Theme, Oxford Centre for Haematology, Oxford, UK
| | - Ross Davenport
- Centre for Trauma Sciences, Blizard Institute, Barts and the London School of Medicine & Dentistry, Queen Mary University of London, London, UK
| |
Collapse
|
15
|
Frink M, Lechler P, Debus F, Ruchholtz S. Multiple Trauma and Emergency Room Management. DEUTSCHES ARZTEBLATT INTERNATIONAL 2018; 114:497-503. [PMID: 28818179 DOI: 10.3238/arztebl.2017.0497] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/16/2016] [Revised: 10/16/2016] [Accepted: 04/24/2017] [Indexed: 01/01/2023]
Abstract
BACKGROUND The care of severely injured patients remains a challenge. Their initial treatment in the emergency room is the essential link between first aid in the field and definitive in-hospital treatment. METHODS We present important elements of the initial in-hospital care of severely injured patients on the basis of pertinent publications retrieved by a selective search in PubMed and the current German S3 guideline on the care of severely and multiply traumatized patients, which was last updated in 2016. RESULTS The goal of initial emergency room care is the rapid recognition and prompt treatment of acutely life-threatening injuries in the order of their priority. The initial assessment includes physical examination and ultrasonography according to the FAST concept (Focused Assessment with Sonography in Trauma) for the recognition of intraperitoneal hemorrhage. Patients with penetrating chest injuries, massive hematothorax, and/or severe injuries of the heart and lungs undergo emergency thoracotomy; those with signs of hollow viscus perforation undergo emergency laparotomy. If the patient is hemo - dynamically stable, the most important diagnostic procedure that must be performed is computerized tomography with contrast medium. Therapeutic decision-making takes the patient's physiological parameters into account, along with the overall severity of trauma and the complexity of the individual injuries. Depending on the severity of trauma, the immediate goal can be either the prompt restoration of organ structure and function or so-called damage control surgery. The latter focuses, in the acute phase, on hemostasis and on the avoidance of secondary damage such as intra-abdominal contamination or compartment syndrome. It also involves the temporary treatment of fractures with external fixation and the planning of definitive care once the patient's organ functions have been securely stabilized. CONCLUSION The care of the severely injured patient should be performed in structured fashion according to the A-B-C-D-E scheme, which involves the securing of the airway, breathing, and circulation, the recognition of neurologic deficits, and whole-body examination by the interdisciplinary team.
Collapse
Affiliation(s)
- Michael Frink
- Center for Orthopedics and Trauma Surgery, Gießen and Marburg University Hospital, Marburg Campus, Marburg
| | | | | | | |
Collapse
|
16
|
Marsden M, Benger J, Brohi K, Curry N, Foley C, Green L, Lucas J, Rossetto A, Stanworth S, Thomas H, Davenport R. Coagulopathy, cryoprecipitate and CRYOSTAT-2: realising the potential of a nationwide trauma system for a national clinical trial. Br J Anaesth 2018; 122:164-169. [PMID: 30686301 DOI: 10.1016/j.bja.2018.10.055] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Revised: 10/06/2018] [Accepted: 10/27/2018] [Indexed: 01/10/2023] Open
Affiliation(s)
- M Marsden
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, UK; Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, UK; Barts Health NHS Trust, London, UK.
| | - J Benger
- Faculty of Health and Applied Sciences, University of the West of England, Bristol, UK
| | - K Brohi
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, UK; Barts Health NHS Trust, London, UK
| | - N Curry
- Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK; Radcliffe Department of Medicine, University of Oxford, UK
| | - C Foley
- NHS Blood and Transplant, Clinical Trials Unit, Cambridge, UK
| | - L Green
- Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary, University of London, London, UK; Barts Health NHS Trust, London, UK
| | - J Lucas
- NHS Blood and Transplant, Clinical Trials Unit, Cambridge, UK
| | - A Rossetto
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, UK; Barts Health NHS Trust, London, UK
| | - S Stanworth
- Oxford NIHR BRC Haematology Theme, Oxford Centre for Haematology, University of Oxford, UK; NHS Blood and Transplant, Transfusion Medicine, Oxford, UK; Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK; Radcliffe Department of Medicine, University of Oxford, UK
| | - H Thomas
- NHS Blood and Transplant, Clinical Trials Unit, Bristol, UK; NHS Blood and Transplant, Transfusion Medicine, Oxford, UK
| | - R Davenport
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, UK; Barts Health NHS Trust, London, UK
| | | |
Collapse
|
17
|
Walsh TS, Stanworth S, Boyd J, Hope D, Hemmatapour S, Burrows H, Campbell H, Pizzo E, Swart N, Morris S. The Age of BLood Evaluation (ABLE) randomised controlled trial: description of the UK-funded arm of the international trial, the UK cost-utility analysis and secondary analyses exploring factors associated with health-related quality of life and health-care costs during the 12-month follow-up. Health Technol Assess 2018; 21:1-118. [PMID: 29067906 DOI: 10.3310/hta21620] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND At present, red blood cells (RBCs) are stored for up to 42 days prior to transfusion. The relative effectiveness and safety of different RBC storage times prior to transfusion is uncertain. OBJECTIVE To assess the clinical effectiveness and cost-effectiveness of transfusing fresher RBCs (stored for ≤ 7 days) compared with current standard-aged RBCs in critically ill patients requiring blood transfusions. DESIGN The international Age of BLood Evaluation (ABLE) trial was a multicentre, randomised, blinded trial undertaken in Canada, the UK, the Netherlands and France. The UK trial was funded to contribute patients to the international trial and undertake a UK-specific health economic evaluation. SETTING Twenty intensive care units (ICUs) in the UK, as part of 64 international centres. PARTICIPANTS Critically ill patients aged ≥ 18 years (≥ 16 years in Scotland) expected to require mechanical ventilation for ≥ 48 hours and requiring a first RBC transfusion during the first 7 days in the ICU. INTERVENTIONS All decisions to transfuse RBCs were made by clinicians. One patient group received exclusively fresh RBCs stored for ≤ 7 days whenever transfusion was required from randomisation until hospital discharge. The other group received standard-issue RBCs throughout their hospital stay. MAIN OUTCOME MEASURES The primary outcome was 90-day mortality. Secondary outcomes included development of organ dysfunction, new thrombosis, infections and transfusion reactions. The primary economic evaluation was a cost-utility analysis. RESULTS The international trial took place between March 2009 and October 2014 (UK recruitment took place between January 2012 and October 2014). In total, 1211 patients were assigned to receive fresh blood and 1219 patients to receive standard-aged blood. RBCs were stored for a mean of 6.1 days [standard deviation (SD) ± 4.9 days] in the group allocated to receive fresh blood and 22.0 days (SD ± 8.4 days) in the group allocated to receive standard-aged blood. Patients received a mean of 4.3 RBC units (SD ± 5.2 RBC units) and 4.3 RBC units (SD ± 5.5 RBC units) in the groups receiving fresh blood and standard-aged blood, respectively. At 90 days, 37.0% of patients in the group allocated to receive fresh blood and 35.3% of patients in the group allocated to receive standard-aged blood had died {absolute risk difference 1.7% [95% confidence interval (CI) -2.1% to 5.5%]}. There were no between-group differences in any secondary outcomes. The UK cohort comprised 359 patients randomised and followed up for 12 months for the cost-utility analysis. UK patients had similar characteristics and outcomes to the international cohort. Mean total costs per patient were £32,346 (95% CI £29,306 to £35,385) in the group allocated to receive fresh blood and £33,353 (95% CI £29,729 to £36,978) in the group allocated to receive standard-aged blood. Approximately 85% of the total costs were incurred during the index hospital admission. There were no significant cost differences between the two groups [mean incremental costs for those receiving fresh vs. standard-aged blood: -£231 (95% CI -£4876 to £4415)], nor were there significant differences in outcomes (mean difference in quality-adjusted life-years -0.010, 95% CI -0.078 to 0.057). LIMITATIONS Adverse effects from the exclusive use of older RBCs compared with standard or fresh RBCs cannot be excluded. CONCLUSIONS The use of RBCs aged ≤ 7 days confers no clinical or economic benefit in critically ill patients compared with standard-aged RBCs. FUTURE WORK Future studies should address the safety of RBCs near the end of the current permitted storage age. TRIAL REGISTRATION Current Controlled Trials ISRCTN44878718. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 21, No. 62. See the NIHR Journals Library website for further project information. The international ABLE trial was also supported by peer-reviewed grants from the Canadian Institutes of Health Research (177453), Fonds de Recherche du Québec - Santé (24460), the French Ministry of Health Programme Hospitalier de Recherche Clinique (12.07, 2011) and by funding from Établissement Français du Sang and Sanquin Blood Supply.
Collapse
Affiliation(s)
- Timothy S Walsh
- Anaesthesia, Critical Care and Pain Medicine, Division of Health Sciences, University of Edinburgh, Edinburgh, UK
| | - Simon Stanworth
- Department of Haematology, Oxford University Hospitals, Oxford, UK.,NHS Blood and Transplant, John Radcliffe Hospital, Oxford, UK.,Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| | - Julia Boyd
- Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh, UK
| | - David Hope
- Edinburgh Critical Care Research Group, Royal Infirmary of Edinburgh, NHS Lothian, Edinburgh, UK
| | - Sue Hemmatapour
- Department of Haematology and Blood Transfusion, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Helen Burrows
- Department of Haematology and Blood Transfusion, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Helen Campbell
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Elena Pizzo
- Department of Applied Health Research, University College London, London, UK
| | - Nicholas Swart
- Department of Applied Health Research, University College London, London, UK
| | - Stephen Morris
- Department of Applied Health Research, University College London, London, UK
| |
Collapse
|
18
|
Docherty AB, Turgeon AF, Walsh TS. Best practice in critical care: anaemia in acute and critical illness. Transfus Med 2018; 28:181-189. [DOI: 10.1111/tme.12505] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2017] [Revised: 12/09/2017] [Accepted: 12/11/2017] [Indexed: 01/28/2023]
Affiliation(s)
- A. B. Docherty
- Department of Anaesthesia, Critical Care and Pain Medicine; University of Edinburgh; Edinburgh UK
| | | | - T. S. Walsh
- Department of Anaesthesia, Critical Care and Pain Medicine; University of Edinburgh; Edinburgh UK
| |
Collapse
|
19
|
Takada H, Hifumi T, Yoshioka H, Okada I, Kiriu N, Inoue J, Morimoto K, Matsumoto J, Koido Y, Kato H. Initial inferior vena cava diameter predicts massive transfusion requirements in blunt trauma patients: A retrospective cohort study. Am J Emerg Med 2017; 36:1155-1159. [PMID: 29174329 DOI: 10.1016/j.ajem.2017.11.049] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2017] [Revised: 11/15/2017] [Accepted: 11/20/2017] [Indexed: 10/18/2022] Open
Abstract
OBJECTIVES The inferior vena cava (IVC) diameter is associated with shock and increased mortality in trauma patients. However, there are no reports examining the association between the IVC diameter and massive transfusion (MT) requirements in trauma patients. The aim of this study was to evaluate the association between IVC diameter and MT requirements in patients with blunt trauma. METHODS We retrospectively reviewed all patients who were consecutively hospitalized with blunt trauma (Injury Severity Score [ISS] ≥16) between from November 1, 2011 to March 30, 2016. Univariate and multivariate analyzes were performed to identify the independent predictors of MT (defined as >10units of red cell concentrate transfusions within 24h of admission). Receiver operating characteristic curve and the area under the curve (AUC) were estimated. RESULTS Of the 222 patients included in this study, MT occurred in 22.5% patients. On multiple regression analysis, IVC diameter [Odds ratio (OR), 0.88; 95% confidence interval (CI), 0.80-0.96; p<0.01], fibrin degradation product (FDP; OR, 1.01; 95% CI, 1.00-1.01; p<0.01), and fibrinogen level (OR, 0.99; 95% CI, 0.98-1.00; p<0.01) were strong predictors of MT. IVC diameter demonstrated moderate accuracy (AUC, 0.74; cutoff level, 13.0mm; sensitivity, 67%; specificity, 73%). Combined cutoff levels of FDP <80.5μg/ml, fibrinogen ≥165mg/dl, and IVC diameter ≥13mm could also determine how unnecessary a MT was with 100% accuracy. CONCLUSIONS Initial IVC diameter is a predictor of MT in blunt trauma patients.
Collapse
Affiliation(s)
- Hiroaki Takada
- Department of Critical Care Medicine and Trauma, National Hospital Organization Disaster Medical Center, 3256 Midori, Tachikawa, Tokyo 190-0014, Japan
| | - Toru Hifumi
- Emergency Medical Center, Kagawa University Hospital, 1750-1 Ikenobe, Miki, Kita, Kagawa 761-0793, Japan.
| | - Hayato Yoshioka
- Department of Critical Care Medicine and Trauma, National Hospital Organization Disaster Medical Center, 3256 Midori, Tachikawa, Tokyo 190-0014, Japan
| | - Ichiro Okada
- Department of Critical Care Medicine and Trauma, National Hospital Organization Disaster Medical Center, 3256 Midori, Tachikawa, Tokyo 190-0014, Japan
| | - Nobuaki Kiriu
- Department of Critical Care Medicine and Trauma, National Hospital Organization Disaster Medical Center, 3256 Midori, Tachikawa, Tokyo 190-0014, Japan
| | - Junichi Inoue
- Division of Critical Care Medicine and Trauma, Yamanashi Prefectural Central Hospital, 1-1-1 Fujimi, Kofu, Yamanashi 400-8506, Japan
| | - Kohei Morimoto
- Department of Radiology, National Hospital Organization Disaster Medical Center, 3256 Midori, Tachikawa, Tokyo 190-0014, Japan
| | - Junichi Matsumoto
- Department of Emergency and Critical Care Medicine, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae, Kawasaki, Kanagawa, 216-8511, Japan
| | - Yuichi Koido
- Department of Critical Care Medicine and Trauma, National Hospital Organization Disaster Medical Center, 3256 Midori, Tachikawa, Tokyo 190-0014, Japan
| | - Hiroshi Kato
- Department of Critical Care Medicine and Trauma, National Hospital Organization Disaster Medical Center, 3256 Midori, Tachikawa, Tokyo 190-0014, Japan
| |
Collapse
|
20
|
Brohi K, Eaglestone S. Traumatic coagulopathy and massive transfusion: improving outcomes and saving blood. PROGRAMME GRANTS FOR APPLIED RESEARCH 2017. [DOI: 10.3310/pgfar05190] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Introduction
Dysfunction of the coagulation system, termed trauma-induced coagulopathy (TIC), is a major problem in patients who bleed after injury. Trauma haemorrhage is considered one of the leading preventable causes of death worldwide. Deaths occur early and, despite the presence of trauma teams and large transfusions of blood products, outcomes remain poor.
Methods
We conducted a multimodal programme of work to develop our understanding of coagulopathy and its optimal management. We studied the epidemiology, management and health economics of trauma haemorrhage, including the provision of care during mass casualty events. We combined systematic reviews of the literature with a national study of trauma haemorrhage, its transfusion management and associated health-care costs. We further examined several point-of-care coagulation tools for their ability to diagnose coagulopathy and assess the response to blood component therapy. We progressively implemented our findings into practice and assessed the outcomes of trauma patients presenting to our major trauma centre. To examine different approaches to the provision of blood to casualties in a mass casualty event, we constructed a discrete event model based on data from the 2005 London bombings.
Key results
Our systematic reviews found little strong evidence for the existing diagnostic tools or the practice of delivery of blood components in trauma haemorrhage. Our national study recruited 442 patients in 22 hospitals and found that the 1-year mortality rate for massive haemorrhage approached 50%. Half of these deaths occurred in the first 24 hours after injury and half of these occurred in the first 4 hours. We identified this early time window as a period when the provision of blood component therapy was often below the recommended thresholds and blood component therapy was delivered inconsistently. Studying early TIC we determined that loss of fibrinogen and excessive fibrinolysis were key derangements. We were able to determine that rotational thromboelastometry could identify early coagulopathy within 5 minutes, a large improvement on laboratory tests. We were further able to show how existing damage control resuscitation regimens with high-dose plasma do not maintain haemostatic competency during haemorrhage. In total, the estimated cost of treating a major haemorrhage patient was £20,600 and the estimated cost of treating a massive haemorrhage patient was £24,000. Nationally, the estimated cost of trauma haemorrhage is £85M annually. In mass casualty situations, early results show that the only mutable factor that affects the provision of care to a large degree, in the initial phase of the response, is the level of blood stocks held in the receiving hospital.
Conclusions
This multimodal programme of work has led to new understandings of the epidemiology of trauma haemorrhage and its underlying mechanisms and clinical course. We have defined diagnostic tools and trigger thresholds for identification and management and increased our understanding of how blood component and other therapeutics affect coagulopathy and when they are likely to be most effective. This diagnostic work has been taken forward at an international level to produce new personalised guidelines for the management of trauma haemorrhage. The findings have had important therapeutic implications, which have led to important changes in practice that have been incorporated into new national and international guidelines.
Funding
The National Institute for Health Research Programme Grants for Applied Research programme.
Collapse
Affiliation(s)
- Karim Brohi
- Centre for Trauma Sciences, Blizard Institute, Barts and the London School of Medicine, Queen Mary University of London, London, UK
| | - Simon Eaglestone
- Centre for Trauma Sciences, Blizard Institute, Barts and the London School of Medicine, Queen Mary University of London, London, UK
| |
Collapse
|
21
|
Hartley S, Foy R, Walwyn REA, Cicero R, Farrin AJ, Francis JJ, Lorencatto F, Gould NJ, Grant-Casey J, Grimshaw JM, Glidewell L, Michie S, Morris S, Stanworth SJ. The evaluation of enhanced feedback interventions to reduce unnecessary blood transfusions (AFFINITIE): protocol for two linked cluster randomised factorial controlled trials. Implement Sci 2017; 12:84. [PMID: 28673310 PMCID: PMC5496161 DOI: 10.1186/s13012-017-0614-8] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Accepted: 06/20/2017] [Indexed: 01/28/2023] Open
Abstract
Background Blood for transfusion is a frequently used clinical intervention, and is also a costly and limited resource with risks. Many transfusions are given to stable and non-bleeding patients despite no clear evidence of benefit from clinical studies. Audit and feedback (A&F) is widely used to improve the quality of healthcare, including appropriate use of blood. However, its effects are often inconsistent, indicating the need for coordinated research including more head-to-head trials comparing different ways of delivering feedback. A programmatic series of research projects, termed the ‘Audit and Feedback INterventions to Increase evidence-based Transfusion practIcE’ (AFFINITIE) programme, aims to test different ways of developing and delivering feedback within an existing national audit structure. Methods The evaluation will comprise two linked 2×2 factorial, cross-sectional cluster-randomised controlled trials. Each trial will estimate the effects of two feedback interventions, ‘enhanced content’ and ‘enhanced follow-on support’, designed in earlier stages of the AFFINITIE programme, compared to current practice. The interventions will be embedded within two rounds of the UK National Comparative Audit of Blood Transfusion (NCABT) focusing on patient blood management in surgery and use of blood transfusions in patients with haematological malignancies. The unit of randomisation will be National Health Service (NHS) trust or health board. Clusters providing care relevant to the audit topics will be randomised following each baseline audit (separately for each trial), with stratification for size (volume of blood transfusions) and region (Regional Transfusion Committee). The primary outcome for each topic will be the proportion of patients receiving a transfusion coded as unnecessary. For each audit topic a linked, mixed-method fidelity assessment and cost-effectiveness analysis will be conducted in parallel to the trial. Discussion AFFINITIE involves a series of studies to explore how A&F may be refined to change practice including two cluster randomised trials linked to national audits of transfusion practice. The methodology represents a step-wise increment in study design to more fully evaluate the effects of two enhanced feedback interventions on patient- and trust-level clinical, cost, safety and process outcomes. Trial registration http://www.isrctn.com/ISRCTN15490813 Electronic supplementary material The online version of this article (doi:10.1186/s13012-017-0614-8) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Suzanne Hartley
- Clinical Trials Research Unit, University of Leeds, Leeds, UK.
| | - Robbie Foy
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | | | - Robert Cicero
- Clinical Trials Research Unit, University of Leeds, Leeds, UK
| | - Amanda J Farrin
- Clinical Trials Research Unit, University of Leeds, Leeds, UK
| | - Jill J Francis
- Centre for Health Services Research, University of London, London, UK
| | | | - Natalie J Gould
- Centre for Health Services Research, University of London, London, UK
| | | | - Jeremy M Grimshaw
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada.,Department of Medicine, University of Ottawa, Ottawa, Canada
| | - Liz Glidewell
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Susan Michie
- Centre for Outcomes Research and Effectiveness, University College London, London, UK
| | - Stephen Morris
- Department of Applied Health Research, University College London, London, UK
| | - Simon J Stanworth
- Transfusion Medicine, NHS Blood and Transplant, Oxford, UK.,Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.,Radcliffe Department of Medicine, University of Oxford, and Oxford BRC Haematology Theme, Oxford, UK
| | | |
Collapse
|
22
|
McQuilten ZK, Bailey M, Cameron PA, Stanworth SJ, Venardos K, Wood EM, Cooper DJ. Fibrinogen concentration and use of fibrinogen supplementation with cryoprecipitate in patients with critical bleeding receiving massive transfusion: a bi-national cohort study. Br J Haematol 2017; 179:131-141. [PMID: 28653339 DOI: 10.1111/bjh.14804] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Accepted: 05/01/2017] [Indexed: 02/06/2023]
Abstract
We aimed to compare hypofibrinogenaemia prevalence in major bleeding patients across all clinical contexts, fibrinogen supplementation practice, and explore the relationship between fibrinogen concentrations and mortality. This cohort study included all adult patients from 20 hospitals across Australia and New Zealand who received massive transfusion between April 2011 and October 2015. Of 3566 patients, 2829 (79%) had fibrinogen concentration recorded, with a median first and lowest concentration of 2·0 g/l (interquartile range [IQR] 1·5-2·7) and 1·8 g/l (IQR 1·3-2·4), respectively. Liver transplant (1·7 g/l, IQR 1·2-2·1), trauma (1·8, IQR 1·3-2·5) and vascular surgery (1·9 g/l, IQR 1·4-2·5) had lower concentrations. Total median fibrinogen dose administered from all products was 7·3 g (IQR 3·3-13·0). Overall, 1732 (61%) received cryoprecipitate and 9 (<1%) fibrinogen concentrate. Time to cryoprecipitate issue in those with initial fibrinogen concentration <1 g/l was 2·5 h (IQR 1·2-4·3 h). After adjustment, initial fibrinogen concentration had a U-shaped association with in-hospital mortality [adjusted odds ratios: fibrinogen <1 g/l, 2·31 (95% confidence interval (CI) 1·48-3·60); 1-1·9 g/l, 1·29 (95% CI 0·99-1·67) and >4 g/l, 2·03 (95% CI 1·35-3·04), 2-4 g/l reference category]. The findings indicate areas for practice improvement including timely administration of cryoprecipitate, which is the most common source of concentrated fibrinogen in Australia and New Zealand.
Collapse
Affiliation(s)
- Zoe K McQuilten
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia.,Transfusion Research Unit, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia.,Monash Health, Melbourne, Australia
| | - Michael Bailey
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
| | - Peter A Cameron
- Transfusion Research Unit, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
| | - Simon J Stanworth
- NHS Blood and Transplant/Oxford University Hospitals NHS Trust, John Radcliffe Hospital, and Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| | - Kylie Venardos
- Transfusion Research Unit, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
| | - Erica M Wood
- Transfusion Research Unit, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia.,Monash Health, Melbourne, Australia
| | - D James Cooper
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
| |
Collapse
|
23
|
Rossaint R, Bouillon B, Cerny V, Coats TJ, Duranteau J, Fernández-Mondéjar E, Filipescu D, Hunt BJ, Komadina R, Nardi G, Neugebauer EAM, Ozier Y, Riddez L, Schultz A, Vincent JL, Spahn DR. The European guideline on management of major bleeding and coagulopathy following trauma: fourth edition. Crit Care 2016; 20:100. [PMID: 27072503 PMCID: PMC4828865 DOI: 10.1186/s13054-016-1265-x] [Citation(s) in RCA: 597] [Impact Index Per Article: 74.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Accepted: 03/11/2016] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Severe trauma continues to represent a global public health issue and mortality and morbidity in trauma patients remains substantial. A number of initiatives have aimed to provide guidance on the management of trauma patients. This document focuses on the management of major bleeding and coagulopathy following trauma and encourages adaptation of the guiding principles to each local situation and implementation within each institution. METHODS The pan-European, multidisciplinary Task Force for Advanced Bleeding Care in Trauma was founded in 2004 and included representatives of six relevant European professional societies. The group used a structured, evidence-based consensus approach to address scientific queries that served as the basis for each recommendation and supporting rationale. Expert opinion and current clinical practice were also considered, particularly in areas in which randomised clinical trials have not or cannot be performed. Existing recommendations were reconsidered and revised based on new scientific evidence and observed shifts in clinical practice; new recommendations were formulated to reflect current clinical concerns and areas in which new research data have been generated. This guideline represents the fourth edition of a document first published in 2007 and updated in 2010 and 2013. RESULTS The guideline now recommends that patients be transferred directly to an appropriate trauma treatment centre and encourages use of a restricted volume replacement strategy during initial resuscitation. Best-practice use of blood products during further resuscitation continues to evolve and should be guided by a goal-directed strategy. The identification and management of patients pre-treated with anticoagulant agents continues to pose a real challenge, despite accumulating experience and awareness. The present guideline should be viewed as an educational aid to improve and standardise the care of the bleeding trauma patients across Europe and beyond. This document may also serve as a basis for local implementation. Furthermore, local quality and safety management systems need to be established to specifically assess key measures of bleeding control and outcome. CONCLUSIONS A multidisciplinary approach and adherence to evidence-based guidance are key to improving patient outcomes. The implementation of locally adapted treatment algorithms should strive to achieve measureable improvements in patient outcome.
Collapse
Affiliation(s)
- Rolf Rossaint
- />Department of Anaesthesiology, University Hospital Aachen, RWTH Aachen University, Pauwelsstrasse 30, 52074 Aachen, Germany
| | - Bertil Bouillon
- />Department of Trauma and Orthopaedic Surgery, Witten/Herdecke University, Cologne-Merheim Medical Centre, Ostmerheimer Strasse 200, 51109 Cologne, Germany
| | - Vladimir Cerny
- />Department of Anaesthesiology, Perioperative Medicine and Intensive Care, J.E. Purkinje University, Masaryk Hospital, Usti nad Labem, Socialni pece 3316/12A, 40113 Usti nad Labem, Czech Republic
- />Department of Research and Development, Charles University in Prague, Faculty of Medicine in Hradec Kralove, Sokolska 581, 50005 Hradec Kralove, Czech Republic
- />Department of Anaesthesiology and Intensive Care, Charles University in Prague, Faculty of Medicine in Hradec Kralove, Sokolska 581, 50005 Hradec Kralove, Czech Republic
- />Department of Anaesthesia, Pain Management and Perioperative Medicine, Dalhousie University, Halifax, QE II Health Sciences Centre, 10 West Victoria, 1276 South Park St., Halifax, NS B3H 2Y9 Canada
| | - Timothy J. Coats
- />Emergency Medicine Academic Group, University of Leicester, University Road, Leicester, LE1 7RH UK
| | - Jacques Duranteau
- />Department of Anaesthesia and Intensive Care, Hôpitaux Universitaires Paris Sud, University of Paris XI, Faculté de Médecine Paris-Sud, 78 rue du Général Leclerc, 94275 Le Kremlin-Bicêtre, Cedex France
| | - Enrique Fernández-Mondéjar
- />Servicio de Medicina Intensiva, Complejo Hospitalario Universitario de Granada, ctra de Jaén s/n, 18013 Granada, Spain
| | - Daniela Filipescu
- />Department of Cardiac Anaesthesia and Intensive Care, C. C. Iliescu Emergency Institute of Cardiovascular Diseases, Sos Fundeni 256-258, 022328 Bucharest, Romania
| | - Beverley J. Hunt
- />King’s College, Departments of Haematology, Pathology and Lupus, Guy’s and St Thomas’ NHS Foundation Trust, Westminster Bridge Road, London, SE1 7EH UK
| | - Radko Komadina
- />Department of Traumatology, General and Teaching Hospital Celje, Oblakova 5, 3000 Celje, Slovenia
| | - Giuseppe Nardi
- />Shock and Trauma Centre, S. Camillo Hospital, Viale Gianicolense 87, 00152 Rome, Italy
| | - Edmund A. M. Neugebauer
- />Faculty of Health - School of Medicine, Witten/Herdecke University, Ostmerheimer Strasse 200, Building 38, 51109 Cologne, Germany
| | - Yves Ozier
- />Division of Anaesthesia, Intensive Care and Emergency Medicine, Brest University Hospital, Boulevard Tanguy Prigent, 29200 Brest, France
| | - Louis Riddez
- />Department of Surgery and Trauma, Karolinska University Hospital, 171 76 Solna, Sweden
| | - Arthur Schultz
- />Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, Lorenz Boehler Trauma Centre, Donaueschingenstrasse 13, 1200 Vienna, Austria
| | - Jean-Louis Vincent
- />Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Route de Lennik 808, 1070 Brussels, Belgium
| | - Donat R. Spahn
- />Institute of Anaesthesiology, University of Zurich and University Hospital Zurich, Raemistrasse 100, 8091 Zurich, Switzerland
| |
Collapse
|
24
|
Role of the RAGE Axis during the Immune Response after Severe Trauma: A Prospective Pilot Study. Mediators Inflamm 2015; 2015:691491. [PMID: 26880860 PMCID: PMC4736010 DOI: 10.1155/2015/691491] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2015] [Revised: 11/24/2015] [Accepted: 12/09/2015] [Indexed: 01/07/2023] Open
Abstract
Background. Severe traumatization induces a complex pathophysiology, driven by the patient's own immune system. The initial activation is a result of damage-associated molecular patterns, which are released from disrupted and dying cells and recognized by immune receptors, for example, RAGE. In this study we aimed to evaluate the contribution of the RAGE axis to early and late immune responses. Methods. We enrolled 16 patients with severe trauma together with 10 patients after major abdominal surgery and 10 healthy volunteers. Blood samples were taken on admission and every 48 h for a total of 8 days. Plasma concentrations of various RAGE ligands as well as RAGE isoforms and IL-6 were measured by ELISA. Monocyte surface expression of RAGE and HLA-DR was assessed by flow cytometry. Results. High and transient levels of IL-6 and methylglyoxal characterize the early immune response after trauma, whereas samples from later time points provide evidence for a secondary release of RAGE ligands. Conclusion. Our results provide evidence for a persisting activation of the RAGE axis while classical mediators like IL-6 disappear early. Considering the immunocompromised phenotype of the monocytes, the RAGE ligands might be substantial contributors to the well-known secondary stage of impaired immune responsiveness in trauma patients.
Collapse
|