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Lord JM, Midwinter MJ, Chen YF, Belli A, Brohi K, Kovacs EJ, Koenderman L, Kubes P, Lilford RJ. The systemic immune response to trauma: an overview of pathophysiology and treatment. Lancet 2014; 384:1455-65. [PMID: 25390327 PMCID: PMC4729362 DOI: 10.1016/s0140-6736(14)60687-5] [Citation(s) in RCA: 467] [Impact Index Per Article: 46.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Improvements in the control of haemorrhage after trauma have resulted in the survival of many people who would otherwise have died from the initial loss of blood. However, the danger is not over once bleeding has been arrested and blood pressure restored. Two-thirds of patients who die following major trauma now do so as a result of causes other than exsanguination. Trauma evokes a systemic reaction that includes an acute, non-specific, immune response associated, paradoxically, with reduced resistance to infection. The result is damage to multiple organs caused by the initial cascade of inflammation aggravated by subsequent sepsis to which the body has become susceptible. This Series examines the biological mechanisms and clinical implications of the cascade of events caused by large-scale trauma that leads to multiorgan failure and death, despite the stemming of blood loss. Furthermore, the stark and robust epidemiological finding--namely, that age has a profound influence on the chances of surviving trauma irrespective of the nature and severity of the injury--will be explored. Advances in our understanding of the inflammatory response to trauma, the impact of ageing on this response, and how this information has led to new and emerging treatments aimed at combating immune dysregulation and reduced immunity after injury will also be discussed.
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Affiliation(s)
- Janet M Lord
- MRC-ARUK Centre for Musculoskeletal Ageing Research, School of Immunity and Infection, University of Birmingham, Birmingham, UK; NIHR Surgical Reconstruction and Microbiology Research Centre, University of Birmingham, Birmingham, UK
| | - Mark J Midwinter
- NIHR Surgical Reconstruction and Microbiology Research Centre, University of Birmingham, Birmingham, UK; School of Health and Population Sciences, University of Birmingham, Birmingham, UK
| | - Yen-Fu Chen
- NIHR Surgical Reconstruction and Microbiology Research Centre, University of Birmingham, Birmingham, UK; School of Health and Population Sciences, University of Birmingham, Birmingham, UK; Division of Health Sciences, University of Warwick, Coventry, UK
| | - Antonio Belli
- NIHR Surgical Reconstruction and Microbiology Research Centre, University of Birmingham, Birmingham, UK; Neurotrauma and Neurodegeneration Section, University of Birmingham, Birmingham, UK
| | - Karim Brohi
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, UK
| | - Elizabeth J Kovacs
- Loyola University Chicago Health Sciences Campus, Stritch School of Medicine, Department of Surgery, Burn and Shock Trauma Institute, Maywood, IL, USA
| | - Leo Koenderman
- University Medical Centre Utrecht, Department of Respiratory Medicine, Utrecht, Netherlands
| | - Paul Kubes
- University of Calgary, Department of Physiology and Pharmacology, Calvin Phoebe and Joan Snyder Institute for Chronic Disease, Calgary, Canada
| | - Richard J Lilford
- School of Health and Population Sciences, University of Birmingham, Birmingham, UK; Division of Health Sciences, University of Warwick, Coventry, UK.
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Affiliation(s)
- Jeff Garner
- Department of Surgery, The Rotherham NHS Foundation Trust and Defence Medical Services, Rotherham, UK
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Impact of hypertonic saline on the release of selected cytokines after stimulation with LPS or peptidoglycan in ex vivo whole blood from healthy humans. Shock 2011; 34:450-4. [PMID: 20458267 DOI: 10.1097/shk.0b013e3181e68649] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The question of specific immunomodulating qualities of hypertonic saline (HTS) has not been settled. It has proven difficult to distinguish between immunomodulation directly attributable to HTS and influence because of favorable circulatory effects. The nature of immune activator may also play a role. In a whole-blood model, we have investigated these relations further, with special emphasize on osmolalities usually found after recommended dosing. Blood from 10 healthy donors was exposed to osmolalities ranging from 295 to 480 mOsm/kg and stimulated with the two clinically relevant stimulators peptidoglycan (1 µg/mL) or LPS (10 ng/mL) for 6 h at 37°C. Leukocyte response was evaluated by measuring selected cytokines in the supernatant. Moderate hyperosmolality alone boosted the release of CXCL8/IL-8. The peptidoglycan-stimulated synthesis of pivotal proinflammatory cytokines was inhibited in an osmolality-dependent way, but statistically significant only at osmolalities above those attained after routine use of HTS, i.e., 310 mOsm/kg or greater: IL-6 (P < 0.05 at 315 mOsm/kg), IL-1ß, and TNF-α (P < 0.05 at 335 mOsm/kg). Similar effects were seen for the chemokine CCL3 and the anti-inflammatory cytokine IL-10. In contrast, the effects in cells stimulated with LPS were either lower or absent. Thus, osmolalities usually found after clinical use of HTS only modestly influenced the selected immune parameters, regardless of stimulator.
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Abstract
Plasma volume expanders comprise a heterogeneous group of substances used in medicine that are intravenously administered in cases of great blood loss owing to surgery or medical emergency. These substances, however, can also be used to artificially enhance performance of healthy athletes in sport activities, and to mask the presence of others substances. These practices are considered doping, and are therefore prohibited by the International Olympic Committee and the World Antidoping Agency. Consequently, drug testing procedures are essential. The present work provides an overview of plasma volume expanders, assembling pertinent data such as chemical characteristics, physiological aspects, adverse effects, doping and analytical detection methods, which are currently dispersed in the literature.
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Easby J, Greaves I. Current concepts in the diagnosis and management of trauma-related sepsis. TRAUMA-ENGLAND 2004. [DOI: 10.1191/1460408604ta302oa] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Traumatic injury is common, and accounts for a large health care burden. Trauma and in particular haemorrhagic shock are closely related to the onset of multiple organ failure, the systemic inflammatory response and sepsis. Despite overall improvements in the care of septic critically ill patients there has been little impact on morbidity and mortality. In recent years our understanding of sepsis both as an illness and at a molecular level has led to the development of a number of therapeutic interventions. This article outlines the current evidence for such interventions and points to possible future research that is required in the diagnosis and management of trauma-related sepsis.
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Affiliation(s)
- Jason Easby
- James Cook University Hospital, University of Teeside, Middlesbrough, UK,
| | - Ian Greaves
- James Cook University Hospital, University of Teeside, Middlesbrough, UK
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