Blood transfusion associated lung injury

Phospholipid Nanoparticles: A Novel Colloid for Blood Volume Replacement, Reanimation, and Organ Protection in Hemorrhagic Shock

Background/Objectives: Exsanguination is a leading cause of preventable death in military and civilian settings due to extensive blood loss and hemorrhagic shock, which trigger systemic effects such as impaired tissue perfusion, hypoxia, inflammation, and multi-organ dysfunction. Standard resuscitation restores blood volume but fails to address critical aspects of hemorrhagic shock, including inflammation, coagulopathy, and reperfusion injury. To address these limitations, novel phospholipid nanoparticle (PNP)-based resuscitative fluids, VBI-S and VBI-1, were developed to modulate nitric oxide (NO) levels, improving hemodynamic stability, tissue oxygenation, and reducing inflammatory injury. This study assessed the potential of novel phospholipid nanoparticle fluids, VBI-S and VBI-1, as resuscitative agents for severe hemorrhagic shock by evaluating their ability to regulate nitric oxide, restore blood pressure, and mitigate ischemia-reperfusion injury. Methods: This study involved two phases with Sprague Dawley rats (n = 6 per group). Phase one, lasting 4 h, included four groups: blood, Ringer's lactate, VBI-S, and VBI-1. Phase two, lasting 12 h, comprised sham, blood, and VBI-1 groups. Under anesthesia, one femoral artery was catheterized for blood pressure monitoring, and blood withdrawal from the other induced apnea. Reanimation was performed using an intra-arterial infusion of shed blood, Ringer's lactate, VBI-S, or VBI-1. Tissue samples were analyzed histologically and for oxidative DNA damage via immunofluorescence. Chemiluminescence and rheology assessed nitric oxide interactions and viscosity. Data were analyzed using ANOVA. Results: VBI-1 and shed blood increased mean arterial pressure (MAP) from <10 mmHg to survivable levels sustained for 12 h, with VBI-1 showing significantly higher MAP at 3-4 h. Rats treated with Ringer's lactate died within 30 min. Histology revealed reduced organ damage in VBI-1-treated rats compared to shed blood. Immunohistochemistry indicated significantly less oxidative DNA damage (p < 0.001) in VBI-1-treated rats. VBI-1 exhibited superior viscosity and nitric oxide binding. Conclusions: VBI-1 demonstrates strong potential as a resuscitative fluid, offering blood pressure restoration, reduced oxidative damage, and enhanced tissue perfusion, with significant implications for use in resource-limited and pre-hospital settings.

Reversible Cerebral Vasoconstriction Syndrome Following Blood Transfusion in a Patient With Chronic Anemia: A Case Report

Reversible cerebral vasoconstriction syndrome (RCVS) is a rare neurological disorder characterized by transient constriction and dilation of cerebral arteries, leading to severe headaches and neurological deficits. This case report describes a 41-year-old woman with chronic anemia, acute chronic kidney disease, type 2 diabetes mellitus, and rheumatoid arthritis who developed RCVS following transfusion of packed red blood cells (PRBCs). She experienced sudden-onset seizures and a thunderclap headache 5 days post-transfusion. Diagnostic imaging, including computed tomography (CT) and magnetic resonance imaging (MRI), revealed the characteristic features of vasogenic edema. The patient was treated with blood pressure control and symptomatic relief for pain, resulting in gradual improvement. This case highlights the importance of recognizing RCVS as a potential complication of blood transfusions, particularly in patients with significant comorbidities. Understanding the possible mechanisms, including rapid hemoglobin correction, and the effects of residual plasma and storage lesions in transfused blood, is essential to prevent and manage this rare but serious condition.

Risk factors and early outcomes of prolonged mechanical ventilation following redo aortic arch surgery: A retrospective study

BACKGROUND

Redo aortic arch surgery is complex and associated with higher risks and mortality. Prolonged mechanical ventilation (PMV) after cardiac surgery is linked to early adverse outcomes and increased costs.

OBJECTIVES

Identify specific risk factors and early complications associated with PMV following redo aortic arch surgery.

METHODS

Retrospective study at Fuwai Hospital involving 203 patients. Data on patient characteristics, intraoperative factors, and outcomes were analyzed.

RESULTS

A total of 203 patients were included, with 42.4 % requiring PMV. PMV patients had longer ICU stays (P < 0.001), lower discharge ADL scores (P < 0.001), and higher hospitalization costs (P < 0.001). While there was no significant difference in-hospital mortality between the two groups, the long-term survival rate in the PMV group was lower than that in the non-PMV group (P = 0.029). Multivariate analysis identified longer cardiopulmonary bypass time (OR 1.008, 95% CI, 1.002 - 1.014, P = 0.006), elevated intraoperative red blood cell transfusion(OR 1.214, 95% CI, 1.057 - 1.393, P = 0.006), higher PEEP (OR 1.296, 95% CI 1.089 - 1.542, P = 0.003), and total arch replacement (OR 3.241, 95% CI 1.392 - 7.543, P = 0.006) as independent risk factors for PMV.

CONCLUSION

PMV following redo aortic arch surgery is linked to early adverse outcomes, increased healthcare costs, and reduced long-term survival, with longer cardiopulmonary bypass times, elevated intraoperative red blood cell transfusion, higher PEEP, and total arch replacement as independent risk factors.

A Prospective Observational Study on the Outcome Assessment of Conservative Management Versus Intercostal Drainage (ICD) in Blunt Chest Injury Patients With ≤3 Rib Fractures in a North Indian Tertiary Care Center

Introduction Trauma is the third most common cause of death in all age groups. One out of four trauma patients die due to thoracic injury or its complications. Seventy percent of thoracic traumas are due to blunt injury. This indicates the importance of chest trauma among all traumas. Quick and precise assessment bears paramount importance in deciding life-saving and definitive management. Often, the initial management in blunt injury patients is based on subjective assessment by the attending clinician. A scoring system that provides early identification of the patients at the greatest risk for respiratory failure and more likely to require mechanical ventilation and require prolonged care, as well as those with a higher mortality risk, may allow the early institution of intervention to improve outcomes. Thoracic Trauma Severity Score (TTSS) poses to be a precise tool in directing the management modality to be employed. Methodology This was an observational study including 112 patients of age >12 years, with blunt chest injury, sustaining ≤3 rib fractures, and with a stable chest wall. The patients with penetrating injury, those with blunt chest injury having flail segment, patients in the pediatric age group (<12 years), or polytrauma patients were excluded from our study. Of the 112 patients, 56 had been managed by intercostal drainage (ICD), and the rest (56) had been managed conservatively. Result Road traffic accidents (RTA) were the most common mode of injury in both groups. The percentage of the patients with one, two, and three rib fractures was 57.14%, 32.14%, and 10.71%, respectively, in the ICD group and 85.71%, 7.14%, and 7.14%, respectively, in the conservative management group (p = 0.124). The mean TTSS score was significantly more in the ICD group as compared to the conservative management group in the single rib fracture patients (p = 0.001*), as well as all patients of any number of rib fractures (p < 0.01*) (significance was defined as a value of p less than 0.05 {indicated by an asterisk}). The mean hospital stay was significantly lower in the conservative group as compared to the ICD group (p < 0.01*). The mean SF-36 (outcome) was significantly more in the conservative management group as compared to the ICD group (p = 0.020*). The mean cost of treatment was significantly more in the ICD group as compared to the conservative management group (p < 0.001*). Conclusion In our study, a TTSS (as measured by the primary care surgeon) of >7, across any number of rib fractures, was preferably predictive of management by ICD, while a <7 value was favorable for conservative management. TTSS can be used as an important tool to predict the management modality in blunt chest injury patients with ≤3 rib fractures.

PLATELET SUPPRESSION BY TIROFIBAN AMELIORATES PULMONARY COAGULATION AND FIBRINOLYSIS ABNORMALITIES IN THE LUNGS OF MOUSE ANTIBODY-MEDIATED TRANSFUSION-RELATED ACUTE LUNG INJURY

ABSTRACT

This study aimed to explore the ameliorating effects of the platelet surface glycoprotein IIb/IIIa receptor antagonist tirofiban on coagulation and fibrinolytic abnormalities in a mouse model of antibody-mediated transfusion-associated acute lung injury (ALI). This is important because ALI is a major cause of death attributable to the occurrence of adverse transfusion reactions. No information on a definite diagnosis or pathological mechanism exists, and targeted treatment options are not available. In this study, wild-type male Balb/c mice aged 8 to 10 weeks were randomly divided into the TRALI model, blank control, tirofiban intervention, and isotype control groups. After different treatment exposures, the mice were observed for 2 h before being killed, and lung tissue samples were collected. To explore the intervention effect of tirofiban, the degree of lung injury was quantified by estimating the lung wet/dry ratio, rectal temperature, survival rate, total protein, and myeloperoxidase and via hematoxylin-eosin staining. Furthermore, the coagulation, anticoagulation, and fibrinolysis assays were measured by automatic coagulation instrument and enzyme-linked immunosorbent assay kits, and the fluorescence densities of platelets and fibrin were quantified using immunofluorescence to analyze the effects of tirofiban on the platelet and fibrin interactions of TRALI. Compared with the TRALI model group, the lung injury indices in the tirofiban intervention group decreased significantly, and survival rates also improved. Furthermore, the level of coagulation and fibrinolytic abnormalities were obviously lower than those in the TRALI model group. In conclusion, our findings suggest that tirofiban might interfere with TRALI by inhibiting platelet activation and improving coagulation and fibrinolytic abnormalities.

Mechanism of TLR4 mediated immune effect in transfusion-induced acute lung injury based on Slit2/Robo4 signaling pathway

BACKGROUND

Transfusion-related acute lung injury (TRALI) is the infusion of blood or blood system.

OBJECTIVE

To explore the mechanism of TLR4-mediated T cell immune effect in TRALI.

METHODS

In this animal study, a mouse model of LPS-induced TRALI was established. Sixty adult C57/BL6 mice (wild-type, WT) were randomly divided into 5 groups: 1) normal WT type, 2) LPS control group of WT type lipopolysaccharide, 3) WT type TRALI group (LPS + MHC-I mAb), 4) (TLR4 antibody) lipopolysaccharide LPS control group, 5) (TLR4 antibody) TRALI group (LPS + MHC-I mAb). Mice were injected with LPS (0.1 mg/kg) and MHC-I mAb (2 mg/kg) into the tail vein. H&E staining was performed to detect pathological features. The myeloperoxidase (MPO) activity and the level of inflammatory cytokines in lung tissue homogenate supernatant were measured. Blood, spleen single-cell suspension, and bronchoalveolar lavage fluid were collected to detect the ratio of Treg and Th17 cells by flow cytometry. RT-PCR and WB were used to detect mRNA or protein expression.

RESULTS

TLR4 mAb treatment alleviated the pathogenesis of LPS-induced TRALI in vivo, the MPO activity, and the level of proinflammatory factors in lung tissues. TLR4 exerted its function by changing of Treg/Th17 ratio via the SLIT2/ROBO4 signaling pathway and downregulating CDH5 and SETSIP.

CONCLUSION

TLR4 mediates immune response in the LPS-induced TRALI model through the SLIT2/ROBO4 signaling pathway.

The Immune System in Transfusion-Related Acute Lung Injury Prevention and Therapy: Update and Perspective

As an initiator of respiratory distress, transfusion-related acute lung injury (TRALI) is regarded as one of the rare complications associated with transfusion medicine. However, to date, the pathogenesis of TRALI is still unclear, and specific therapies are unavailable. Understanding the mechanisms of TRALI may promote the design of preventive and therapeutic strategies. The immune system plays vital roles in reproduction, development and homeostasis. Sterile tissue damage, such as physical trauma, ischemia, or reperfusion injury, induces an inflammatory reaction that results in wound healing and regenerative mechanisms. In other words, in addition to protecting against pathogens, the immune response may be strongly associated with TRALI prevention and treatment through a variety of immunomodulatory strategies to inhibit excessive immune system activation. Immunotherapy based on immune cells or immunological targets may eradicate complications. For example, IL-10 therapy is a promising therapeutic strategy to explore further. This review will focus on ultramodern advances in our understanding of the potential role of the immune system in TRALI prevention and treatment.

Management and outcomes of severe pelvic fractures in level I and II ACS verified trauma centers

BACKGROUND

The aim of this study was to evaluate the management strategies and outcomes of isolated severe pelvic fractures in level I and II ACS verified trauma centers.

METHODS

ACS-TQIP database study, including patients with blunt, isolated severe pelvic facture (AIS 3-5).

RESULTS

2629 level I and 1277 level II patients were included. Early blood product transfusion was significantly higher, pharmacological VTE prophylaxis significantly lower and ICU length of stay significantly longer in level II centers (p < 0.001). On multivariate analysis, treatment at level II centers was independently associated with increased overall complications, specifically ARDS, but not mortality.

CONCLUSIONS

In isolated severe pelvic fractures there was a significantly higher use of early blood products, less VTE pharmacological prophylaxis, longer ICU length of stay and higher overall complications and ARDS in level II centers. Blood product utilization and pharmacological VTE prophylaxis are potential areas of quality improvement in level II centers.

Transfusion-Related Acute Brain Injury: A Case Report on Reversible Cerebral Vasoconstriction Syndrome

Reversible cerebral vasoconstriction syndrome (RCVS) manifests with a thunderclap headache and reversible vascular abnormalities. Red blood cell transfusions have not been well identified as a risk factor for RCVS. We report a rare case of acute brain injury resulting from RCVS after a packed red blood cell (PRBC) transfusion. A 49-year-old female with a history of menorrhagia initially presented with generalized weakness. She was found to have a hemoglobin (Hgb) of 1.7 g/dL in the setting of a fundal fibroid for which she received five units of PRBCs. Post transfusion, she complained of several days of thunderclap headache and later returned with new-onset seizures. She was admitted to the neurocritical care unit for the treatment of status epilepticus. Metabolic, infectious and toxic work-up were unremarkable except for an elevated lactate. MRI of the brain with contrast showed extensive bilateral hemispheric and cerebellar white matter T2-weighted fluid-attenuated inversion recovery (T2/FLAIR) hyperintensities with areas of enhancement. A diagnostic cerebral angiogram was performed to evaluate for a vascular etiology and revealed focal segmental stenoses in bilateral A1 segments of the anterior cerebral arteries and in branches of the bilateral middle cerebral arteries. These findings were suggestive of RCVS. Clinicians should have a high degree of suspicion for RCVS in patients presenting with neurological manifestations, such as thunderclap headache or seizures after recent transfusion. The window for injury may be longer than that seen in other organs, such as in transfusion-related acute lung injury (TRALI). 

Electrophilic nitrated fatty acids are potential therapeutic candidates for inflammatory and fibrotic lung diseases

Several types of exposures can cause acute or chronic inflammatory reactions in the lungs often leading to asthma, pulmonary fibrosis, chronic obstructive pulmonary disease (COPD), acute lung injury, lung cancer, and other deleterious health outcomes. Current therapy, with inhaled or oral glucocorticoids, successfully targets inflammation but also produces adverse effects that limit their enthusiastic use. Accordingly, the need remains for interventions that are safer and more effective. Nitrated fatty acids (NFAs) are highly electrophilic and are produced endogenously by non-enzymatic reactions of nitric oxide with conjugated unsaturated fatty acids. The literature indicates that NFAs are detected in humans at the nanomolar range and are produced more robustly under inflammatory conditions. Recent studies on novel NFAs report antiinflammatory, antioxidant, and antifibrotic effects, while also acting as partial agonists of peroxisome proliferator-activated receptor-gamma (PPAR-γ). Furthermore, these functions of NFAs occur via reversible electrophilic alkylation of cysteine residues and regulation of antiinflammatory, antioxidant signaling through modulation of transcription factors, including nuclear factor E2-related factor 2 (Nrf2), PPAR-γ, and NF-κB. Here, we review and update the role of NFA signaling mechanisms and their therapeutic potential in various lung diseases. As NFAs display strong electrophilic interaction with multimechanistic pathways, they can be considered promising drug candidates for challenging lung diseases.