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Lubkin DT, Mueck KM, Hatton GE, Brill JB, Sandoval M, Cardenas JC, Wade CE, Cotton BA. Does an early, balanced resuscitation strategy reduce the incidence of hypofibrinogenemia in hemorrhagic shock? Trauma Surg Acute Care Open 2024; 9:e001193. [PMID: 38596569 PMCID: PMC11002398 DOI: 10.1136/tsaco-2023-001193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2023] [Accepted: 03/20/2024] [Indexed: 04/11/2024] Open
Abstract
Objectives Some centers have recommended including concentrated fibrinogen replacement in massive transfusion protocols (MTPs). Given our center's policy of aggressive early balanced resuscitation (1:1:1), beginning prehospital, we hypothesized that our rates of hypofibrinogenemia may be lower than those previously reported. Methods In this retrospective cohort study, patients presenting to our trauma center November 2017 to April 2021 were reviewed. Patients were defined as hypofibrinogenemic (HYPOFIB) if admission fibrinogen <150 or rapid thrombelastography angle <60. Univariate and multivariable analyses assessed risk factors for HYPOFIB. Inverse probability of treatment weighting analyses assessed the relationship between cryoprecipitate administration and outcomes. Results Of 29 782 patients, 6618 level 1 activations, and 1948 patients receiving emergency release blood, <1%, 2%, and 7% were HYPOFIB. HYPOFIB patients were younger, had higher head Abbreviated Injury Scale value, and had worse coagulopathy and shock. HYPOFIB had lower survival (48% vs 82%, p<0.001), shorter time to death (median 28 (7, 50) vs 36 (14, 140) hours, p=0.012), and were more likely to die from head injury (72% vs 51%, p<0.001). Risk factors for HYPOFIB included increased age (OR (95% CI) 0.98 (0.96 to 0.99), p=0.03), head injury severity (OR 1.24 (1.06 to 1.46), p=0.009), lower arrival pH (OR 0.01 (0.001 to 0.20), p=0.002), and elevated prehospital red blood cell to platelet ratio (OR 1.20 (1.02 to 1.41), p=0.03). Among HYPOFIB patients, there was no difference in survival for those that received early cryoprecipitate (within 2 hours; 40 vs 47%; p=0.630). On inverse probability of treatment weighted analysis, early cryoprecipitate did not benefit the full cohort (OR 0.52 (0.43 to 0.65), p<0.001), nor the HYPOFIB subgroup (0.28 (0.20 to 0.39), p<0.001). Conclusions Low rates of hypofibrinogenemia were found in our center which treats hemorrhage with early, balanced resuscitation. Previously reported higher rates may be partially due to unbalanced resuscitation and/or delay in resuscitation initiation. Routine empiric inclusion of concentrated fibrinogen replacement in MTPs is not supported by the currently available data. Level of evidence Level III.
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Affiliation(s)
- David T Lubkin
- Surgery, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Krislynn M Mueck
- Surgery, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Gabrielle E Hatton
- Surgery, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Jason B Brill
- Surgery, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Mariela Sandoval
- Surgery, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Jessica C Cardenas
- Surgery, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Charles E Wade
- Surgery, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Bryan A Cotton
- Surgery, The University of Texas Health Science Center at Houston, Houston, Texas, USA
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Kregel HR, Hatton GE, Harvin JA, Puzio TJ, Wade CE, Kao LS. Identifying Age-Specific Risk Factors for Poor Outcomes After Trauma With Machine Learning. J Surg Res 2024; 296:465-471. [PMID: 38320366 DOI: 10.1016/j.jss.2023.12.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 12/04/2023] [Accepted: 12/27/2023] [Indexed: 02/08/2024]
Abstract
INTRODUCTION Risk stratification for poor outcomes is not currently age-specific. Risk stratification of older patients based on observational cohorts primarily composed of young patients may result in suboptimal clinical care and inaccurate quality benchmarking. We assessed two hypotheses. First, we hypothesized that risk factors for poor outcomes after trauma are age-dependent and, second, that the relative importance of various risk factors are also age-dependent. METHODS A cohort study of severely injured adult trauma patients admitted to the intensive care unit 2014-2018 was performed using trauma registry data. Random forest algorithms predicting poor outcomes (death or complication) were built and validated using three cohorts: (1) patients of all ages, (2) younger patients, and (3) older patients. Older patients were defined as aged 55 y or more to maintain consistency with prior trauma literature. Complications assessed included acute renal failure, acute respiratory distress syndrome, cardiac arrest, unplanned intubation, unplanned intensive care unit admission, and unplanned return to the operating room, as defined by the trauma quality improvement program. Mean decrease in model accuracy (MDA), if each variable was removed and scaled to a Z-score, was calculated. MDA change ≥4 standard deviations between age cohorts was considered significant. RESULTS Of 5489 patients, 25% were older. Poor outcomes occurred in 12% of younger and 33% of older patients. Head injury was the most important predictor of poor outcome in all cohorts. In the full cohort, age was the most important predictor of poor outcomes after head injury. Within age cohorts, the most important predictors of poor outcomes, after head injury, were surgery requirement in younger patients and arrival Glasgow Coma Scale in older patients. Compared to younger patients, head injury and arrival Glasgow Coma Scale had the greatest increase in importance for older patients, while systolic blood pressure had the greatest decrease in importance. CONCLUSIONS Supervised machine learning identified differences in risk factors and their relative associations with poor outcomes based on age. Age-specific models may improve hospital benchmarking and identify quality improvement targets for older trauma patients.
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Affiliation(s)
- Heather R Kregel
- Division of Acute Care Surgery, Department of Surgery, McGovern Medical School at UTHealth, Houston, Texas; Center for Surgical Trials and Evidence-Based Practice, McGovern Medical School at UTHealth, Houston, Texas; Center for Translational Injury, McGovern Medical School at UTHealth, Houston, Texas.
| | - Gabrielle E Hatton
- Division of Acute Care Surgery, Department of Surgery, McGovern Medical School at UTHealth, Houston, Texas; Center for Surgical Trials and Evidence-Based Practice, McGovern Medical School at UTHealth, Houston, Texas; Center for Translational Injury, McGovern Medical School at UTHealth, Houston, Texas
| | - John A Harvin
- Division of Acute Care Surgery, Department of Surgery, McGovern Medical School at UTHealth, Houston, Texas; Center for Translational Injury, McGovern Medical School at UTHealth, Houston, Texas
| | - Thaddeus J Puzio
- Division of Acute Care Surgery, Department of Surgery, McGovern Medical School at UTHealth, Houston, Texas
| | - Charles E Wade
- Division of Acute Care Surgery, Department of Surgery, McGovern Medical School at UTHealth, Houston, Texas; Center for Translational Injury, McGovern Medical School at UTHealth, Houston, Texas
| | - Lillian S Kao
- Division of Acute Care Surgery, Department of Surgery, McGovern Medical School at UTHealth, Houston, Texas; Center for Surgical Trials and Evidence-Based Practice, McGovern Medical School at UTHealth, Houston, Texas; Center for Translational Injury, McGovern Medical School at UTHealth, Houston, Texas
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Sanders KE, Hatton GE, Mankame AR, Allen AC, Cunningham S, Van Gent JM, Fox EE, Zhang X, Wade CE, Cotton BA, Cardenas JC. Exposure to statin therapy decreases the incidence of venous thromboembolism after trauma. J Trauma Acute Care Surg 2024:01586154-990000000-00672. [PMID: 38523132 DOI: 10.1097/ta.0000000000004319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/26/2024]
Abstract
INTRODUCTION Venous thromboembolism (VTE) is a leading cause of morbidity and mortality in trauma patients, despite chemoprophylaxis. Statins have been shown capable of acting upon the endothelium. We hypothesized that statin therapy in the pre- or in-hospital settings leads to a decreased incidence of VTE. METHODS We conducted a retrospective cohort study of injured patients who received statin therapy pre- or in-hospital. Adult, highest-level trauma activation patients admitted January 2018 - June 2022 were included. Patients on prehospital anticoagulants, history of inherited bleeding disorder, and who died within the first 24 hours were excluded. Statin users were matched to non-users by statin use indications including age, current heart and cardiovascular conditions and history, hyperlipidemia, injury severity, and body mass index. Time to in-hospital statin initiation and occurrence of VTE and other complications within 60 days were collected. Differences between groups were determined by univariate, multivariable logistic regression, and Cox proportional hazard analyses. RESULTS Of 3,062 eligible patients, 79 were statin users that were matched to 79 non-users. There were no differences in admissions demographics, vital signs, injury pattern, transfusion volumes, lengths of stay, or mortality between groups. The overall VTE incidence was 10.8% (17/158). Incidence of VTE in statin users was significantly lower (3%) than non-users (19%; P = 0.003). Differences between statin users and non-users were observed for rates of DVT (0% vs 9%), PE (3% vs 15%), and sepsis (0% vs 5%). Exposure to statins was associated with an 82% decreased risk of developing VTE (hazard ratio = 0.18, 95% CI 0.04 - 0.86; P = 0.033). CONCLUSIONS Statin exposure was associated with decline in VTE and lower individual rates of DVT, PE, and sepsis. Our findings indicate that statins should be evaluated further as a possible adjunctive therapy for VTE chemoprophylaxis after traumatic injury. LEVEL OF EVIDENCE AND STUDY TYPE Level III, Retrospective Cohort Study.
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Affiliation(s)
- Kelly E Sanders
- Center for Translational Injury Research, Department of Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, TX
| | - Gabrielle E Hatton
- Center for Translational Injury Research, Department of Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, TX
| | - Atharwa R Mankame
- Center for Translational Injury Research, Department of Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, TX
| | - Addison C Allen
- Center for Translational Injury Research, Department of Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, TX
| | - Sarah Cunningham
- Center for Translational Injury Research, Department of Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, TX
| | - Jan Michael Van Gent
- Center for Translational Injury Research, Department of Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, TX
| | - Erin E Fox
- Center for Translational Injury Research, Department of Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, TX
| | - Xu Zhang
- Center for Clinical and Translational Sciences, The University of Texas Health Science Center, Houston, TX
| | - Charles E Wade
- Center for Translational Injury Research, Department of Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, TX
| | - Bryan A Cotton
- Center for Translational Injury Research, Department of Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, TX
| | - Jessica C Cardenas
- Center for Translational Injury Research, Department of Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, TX
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Lombardo S, McCrum M, Knudson MM, Moore EE, Kornblith L, Brakenridge S, Bruns B, Cipolle MD, Costantini TW, Crookes B, Haut ER, Kerwin AJ, Kiraly LN, Knowlton LM, Martin MJ, McNutt MK, Milia DJ, Mohr A, Rogers F, Scalea T, Sixta S, Spain D, Wade CE, Velmahos GC, Nirula R, Nunez J. Weight-based enoxaparin thromboprophylaxis in young trauma patients: analysis of the CLOTT-1 registry. Trauma Surg Acute Care Open 2024; 9:e001230. [PMID: 38420604 PMCID: PMC10900334 DOI: 10.1136/tsaco-2023-001230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Accepted: 11/26/2023] [Indexed: 03/02/2024] Open
Abstract
Introduction Optimal venous thromboembolism (VTE) enoxaparin prophylaxis dosing remains elusive. Weight-based (WB) dosing safely increases anti-factor Xa levels without the need for routine monitoring but it is unclear if it leads to lower VTE risk. We hypothesized that WB dosing would decrease VTE risk compared with standard fixed dosing (SFD). Methods Patients from the prospective, observational CLOTT-1 registry receiving prophylactic enoxaparin (n=5539) were categorized as WB (0.45-0.55 mg/kg two times per day) or SFD (30 mg two times per day, 40 mg once a day). Multivariate logistic regression was used to generate a predicted probability of VTE for WB and SFD patients. Results Of 4360 patients analyzed, 1065 (24.4%) were WB and 3295 (75.6%) were SFD. WB patients were younger, female, more severely injured, and underwent major operation or major venous repair at a higher rate than individuals in the SFD group. Obesity was more common among the SFD group. Unadjusted VTE rates were comparable (WB 3.1% vs. SFD 3.9%; p=0.221). Early prophylaxis was associated with lower VTE rate (1.4% vs. 5.0%; p=0.001) and deep vein thrombosis (0.9% vs. 4.4%; p<0.001), but not pulmonary embolism (0.7% vs. 1.4%; p=0.259). After adjustment, VTE incidence did not differ by dosing strategy (adjusted OR (aOR) 0.75, 95% CI 0.38 to 1.48); however, early administration was associated with a significant reduction in VTE (aOR 0.47, 95% CI 0.30 to 0.74). Conclusion In young trauma patients, WB prophylaxis is not associated with reduced VTE rate when compared with SFD. The timing of the initiation of chemoprophylaxis may be more important than the dosing strategy. Further studies need to evaluate these findings across a wider age and comorbidity spectrum. Level of evidence Level IV, therapeutic/care management.
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Affiliation(s)
| | - Marta McCrum
- Surgery, University of Utah, Salt Lake City, Utah, USA
| | - M Margaret Knudson
- Surgery, University of California San Francisco, San Francisco, California, USA
| | | | - Lucy Kornblith
- Surgery, University of California San Francisco, San Francisco, California, USA
| | - Scott Brakenridge
- Department of Surgery, University of Washington, Seattle, Washington, USA
| | - Brandon Bruns
- Department of Surgery, UT Southwestern Medical School, Dallas, Texas, USA
| | - Mark D Cipolle
- Lehigh Valley Health Network, Allentown, Pennsylvania, USA
| | - Todd W Costantini
- Surgery, University of California San Francisco, San Francisco, California, USA
| | - Bruce Crookes
- Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Elliott R Haut
- Surgery, Johns Hopkins University, Baltimore, Maryland, USA
| | - Andrew J Kerwin
- Surgery, University of Florida College of Medicine–Jacksonville, Jacksonville, Florida, USA
| | | | | | - Matthew J Martin
- Division of Trauma and Surgical Critical Care, LAC+USC Medical Center, Los Angeles, California, USA
| | - Michelle K McNutt
- Surgery, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - David J Milia
- Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Alicia Mohr
- Surgery, University of Florida College of Medicine–Jacksonville, Jacksonville, Florida, USA
| | | | - Thomas Scalea
- University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Sherry Sixta
- St Anthony Hospital & Medical Campus, Lakewood, Colorado, USA
| | - David Spain
- Surgery, Stanford University, Stanford, California, USA
| | - Charles E Wade
- Surgery, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | | | - Ram Nirula
- University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Jade Nunez
- Surgery, University of Utah, Salt Lake City, Utah, USA
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Dodwad SJM, Mueck KM, Kregel HR, Guy-Frank CJ, Isbell KD, Klugh JM, Wade CE, Harvin JA, Kao LS, Wandling MW. Impact of Intra-Operative Shock and Resuscitation on Surgical Site Infections After Trauma Laparotomy. Surg Infect (Larchmt) 2024; 25:19-25. [PMID: 38170174 PMCID: PMC10825266 DOI: 10.1089/sur.2023.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2024] Open
Abstract
Background: Patients undergoing trauma laparotomy experience high rates of surgical site infection (SSI). Although intra-operative shock is a likely contributor to SSI risk, little is known about the relation between shock, intra-operative restoration of physiologic normalcy, and SSI development. Patients and Methods: A retrospective review of trauma patients who underwent emergent definitive laparotomy was performed. Using shock index and base excess at the beginning and end of laparotomy, patients were classified as normal, persistent shock, resuscitated, or new shock. Univariable and multivariable analyses were performed to identify predictors of organ/space SSI, superficial/deep SSI, and any SSI. Results: Of 1,191 included patients, 600 (50%) were categorized as no shock, 248 (21%) as resuscitated, 109 (9%) as new shock, and 236 (20%) as persistent shock, with incidence of any SSI as 51 (9%), 28 (11%), 26 (24%), and 32 (14%), respectively. These rates were similar in organ/space and superficial/deep SSIs. On multivariable analysis, resuscitated, new shock, and persistent shock were associated with increased odds of organ/space SSI (odds ratio [OR], 2.2; 95% confidence interval [CI], 1.3-3.5; p < 0.001) and any SSI (OR, 2.0; 95% CI, 1.4-3.2; p < 0.001), but no increased risk of superficial/deep SSI (OR, 1.4; 95% CI, 0.8-2.6; p = 0.331). Conclusions: Although the trajectory of physiologic status influenced SSI, the presence of shock at any time during trauma laparotomy, regardless of restoration of physiologic normalcy, was associated with increased odds of SSI. Further investigation is warranted to determine the relation between peri-operative shock and SSI in trauma patients.
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Affiliation(s)
- Shah-Jahan M. Dodwad
- Department of Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
- Center for Surgical Trials and Evidence-based Practice, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
| | - Krislynn M. Mueck
- Department of Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
- Center for Surgical Trials and Evidence-based Practice, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
- Red Duke Trauma Institute, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
| | - Heather R. Kregel
- Department of Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
- Center for Surgical Trials and Evidence-based Practice, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
- Center for Translational Injury Research, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
| | - Chelsea J. Guy-Frank
- Department of Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
- Center for Surgical Trials and Evidence-based Practice, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
| | - Kayla D. Isbell
- Department of Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
- Center for Surgical Trials and Evidence-based Practice, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
| | - James M. Klugh
- Department of Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
- Center for Surgical Trials and Evidence-based Practice, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
| | - Charles E. Wade
- Department of Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
- Center for Surgical Trials and Evidence-based Practice, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
- Red Duke Trauma Institute, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
| | - John A. Harvin
- Department of Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
- Center for Surgical Trials and Evidence-based Practice, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
- Red Duke Trauma Institute, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
- Center for Translational Injury Research, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
- Center for Clinical Research and Evidence-Based Medicine, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
| | - Lillian S. Kao
- Department of Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
- Center for Surgical Trials and Evidence-based Practice, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
- Red Duke Trauma Institute, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
- Center for Translational Injury Research, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
- Center for Clinical Research and Evidence-Based Medicine, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
| | - Michael W. Wandling
- Department of Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
- Red Duke Trauma Institute, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
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Dodwad SJM, Isbell KD, Mueck KM, Klugh JM, Meyer DE, Wade CE, Kao LS, Harvin JA. Patient-Reported Outcomes Following Severe Abdominal Trauma: A Secondary Analysis of the Damage Control Laparotomy Trial. J Surg Res 2024; 293:57-63. [PMID: 37716101 PMCID: PMC10841256 DOI: 10.1016/j.jss.2023.06.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 05/21/2023] [Accepted: 06/13/2023] [Indexed: 09/18/2023]
Abstract
INTRODUCTION Little is known about patient-reported outcomes (PROs) following abdominal trauma. We hypothesized that patients undergoing definitive laparotomy (DEF) would have better PROs compared to those treated with damage control laparotomy (DCL). METHODS The DCL Trial randomized DEF versus DCL in abdominal trauma. PROs were measured using the European Quality of Life-5 Dimensions-5 Levels (EQ-5D) questionnaire at discharge and six months postdischarge (1 = perfect health, 0 = death, and <0 = worse than death) and Posttraumatic Stress Disorder (PTSD) Checklist-Civilian. Unadjusted Bayesian analysis with a neutral prior was used to assess the posterior probability of achieving minimal clinically important difference. RESULTS Of 39 randomized patients (21 DEF versus 18 DCL), 8 patients died (7 DEF versus 1 DCL). Of those who survived, 28 completed the EQ-5D at discharge (12 DEF versus 16 DCL) and 25 at 6 mo (12 DEF versus 13 DCL). Most patients were male (79%) with a median age of 30 (interquartile range (IQR) 21-42), suffered blunt injury (56%), and were severely injured (median injury severity score 33, IQR 21 - 42). Median EQ-5D value at discharge was 0.20 (IQR 0.06 - 0.52) DEF versus 0.31 (IQR -0.03 - 0.43) DCL, and at six months 0.51 (IQR 0.30 - 0.74) DEF versus 0.50 (IQR 0.28 - 0.84) DCL. The posterior probability of minimal clinically important difference DEF versus DCL at discharge and six months was 16% and 23%, respectively. CONCLUSIONS Functional deficits for trauma patients persist beyond the acute setting regardless of laparotomy status. These deficits warrant longitudinal studies to better inform patients on recovery expectations.
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Affiliation(s)
- Shah-Jahan M Dodwad
- Department of Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas; Center for Surgical Trials and Evidence-based Practice, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas.
| | - Kayla D Isbell
- Department of Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas; Center for Surgical Trials and Evidence-based Practice, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas
| | - Krislynn M Mueck
- Department of Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas; Center for Surgical Trials and Evidence-based Practice, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas; Red Duke Trauma Institute, Memorial Hermann Hospital - Texas Medical Center, Houston, Texas
| | - James M Klugh
- Department of Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas; Center for Surgical Trials and Evidence-based Practice, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas
| | - David E Meyer
- Department of Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas; Center for Surgical Trials and Evidence-based Practice, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas; Red Duke Trauma Institute, Memorial Hermann Hospital - Texas Medical Center, Houston, Texas
| | - Charles E Wade
- Department of Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas; Center for Surgical Trials and Evidence-based Practice, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas; Center for Translational Injury Research, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas; Red Duke Trauma Institute, Memorial Hermann Hospital - Texas Medical Center, Houston, Texas
| | - Lillian S Kao
- Department of Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas; Center for Surgical Trials and Evidence-based Practice, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas; Center for Translational Injury Research, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas; Center for Clinical Research and Evidence-Based Medicine, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas; Red Duke Trauma Institute, Memorial Hermann Hospital - Texas Medical Center, Houston, Texas
| | - John A Harvin
- Department of Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas; Center for Surgical Trials and Evidence-based Practice, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas; Center for Translational Injury Research, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas; Center for Clinical Research and Evidence-Based Medicine, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas; Red Duke Trauma Institute, Memorial Hermann Hospital - Texas Medical Center, Houston, Texas
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7
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Koh EY, Fox EE, Wade CE, Scalea TM, Fox CJ, Moore EE, Morse BC, Inaba K, Bulger EM, Meyer DE. Resuscitative endovascular balloon occlusion of the aorta and resuscitative thoracotomy are associated with similar outcomes in traumatic cardiac arrest. J Trauma Acute Care Surg 2023; 95:912-917. [PMID: 37381147 PMCID: PMC10755074 DOI: 10.1097/ta.0000000000004094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/30/2023]
Abstract
BACKGROUND Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a minimally invasive alternative to resuscitative thoracotomy (RT) for patients with hemorrhagic shock. However, the potential benefits of this approach remain subject of debate. The aim of this study was to compare the outcomes of REBOA and RT for traumatic cardiac arrest. METHODS A planned secondary analysis of the United States Department of Defense-funded Emergent Truncal Hemorrhage Control study was performed. Between 2017 and 2018, a prospective observational study of noncompressible torso hemorrhage was conducted at six Level I trauma centers. Patients were dichotomized by REBOA or RT, and baseline characteristics and outcomes were compared between groups. RESULTS A total of 454 patients were enrolled in the primary study, of which 72 patients were included in the secondary analysis (26 underwent REBOA and 46 underwent resuscitative thoracotomy). Resuscitative endovascular balloon occlusion of the aorta patients were older, had a greater body mass index, and were less likely to be the victims of penetrating trauma. Resuscitative endovascular balloon occlusion of the aorta patients also had less severe abdominal injuries and more severe extremity injuries, although the overall injury severity scores were similar. There was no difference in mortality between groups (88% vs. 93%, p = 0.767). However, time to aortic occlusion was longer in REBOA patients (7 vs. 4 minutes, p = 0.001) and they required more transfusions of red blood cells (4.5 vs. 2.5 units, p = 0.007) and plasma (3 vs. 1 unit, p = 0.032) in the emergency department. After adjusted analysis, mortality remained similar between groups (RR, 0.89; 95% confidence interval, 0.71-1.12, p = 0.304). CONCLUSION Resuscitative endovascular balloon occlusion of the aorta and RT were associated with similar survival after traumatic cardiac arrest, although time to successful aortic occlusion was longer in the REBOA group. Further research is needed to better define the role of REBOA in trauma. LEVEL OF EVIDENCE Therapeutic/Care Management; Level III.
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Affiliation(s)
- Ezra Y. Koh
- Department of Surgery, Houston Methodist Hospital, Houston, TX
| | - Erin E. Fox
- Center for Translational Injury Research, University of Texas Health Science Center, Houston, TX
| | - Charles E. Wade
- Center for Translational Injury Research, University of Texas Health Science Center, Houston, TX
| | - Thomas M. Scalea
- R. Adams Cowley Shock Trauma Center, Program in Trauma, University of Maryland School of Medicine, Baltimore, MD
| | - Charles J. Fox
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD
| | | | | | - Kenji Inaba
- Department of Surgery, University of Southern California Keck School of Medicine, Los Angeles, CA
| | | | - David E. Meyer
- Center for Translational Injury Research, University of Texas Health Science Center, Houston, TX
- Department of Surgery, University of Texas Health Science Center McGovern Medical School, Houston, TX
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8
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Davenport R, Curry N, Fox EE, Thomas H, Lucas J, Evans A, Shanmugaranjan S, Sharma R, Deary A, Edwards A, Green L, Wade CE, Benger JR, Cotton BA, Stanworth SJ, Brohi K. Early and Empirical High-Dose Cryoprecipitate for Hemorrhage After Traumatic Injury: The CRYOSTAT-2 Randomized Clinical Trial. JAMA 2023; 330:1882-1891. [PMID: 37824155 PMCID: PMC10570921 DOI: 10.1001/jama.2023.21019] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Accepted: 09/26/2023] [Indexed: 10/13/2023]
Abstract
Importance Critical bleeding is associated with a high mortality rate in patients with trauma. Hemorrhage is exacerbated by a complex derangement of coagulation, including an acute fibrinogen deficiency. Management is fibrinogen replacement with cryoprecipitate transfusions or fibrinogen concentrate, usually administered relatively late during hemorrhage. Objective To assess whether survival could be improved by administering an early and empirical high dose of cryoprecipitate to all patients with trauma and bleeding that required activation of a major hemorrhage protocol. Design, Setting, and Participants CRYOSTAT-2 was an interventional, randomized, open-label, parallel-group controlled, international, multicenter study. Patients were enrolled at 26 UK and US major trauma centers from August 2017 to November 2021. Eligible patients were injured adults requiring activation of the hospital's major hemorrhage protocol with evidence of active hemorrhage, systolic blood pressure less than 90 mm Hg at any time, and receiving at least 1 U of a blood component transfusion. Intervention Patients were randomly assigned (in a 1:1 ratio) to receive standard care, which was the local major hemorrhage protocol (reviewed for guideline adherence), or cryoprecipitate, in which 3 pools of cryoprecipitate (6-g fibrinogen equivalent) were to be administered in addition to standard care within 90 minutes of randomization and 3 hours of injury. Main Outcomes and Measures The primary outcome was all-cause mortality at 28 days in the intention-to-treat population. Results Among 1604 eligible patients, 799 were randomized to the cryoprecipitate group and 805 to the standard care group. Missing primary outcome data occurred in 73 patients (principally due to withdrawal of consent) and 1531 (95%) were included in the primary analysis population. The median (IQR) age of participants was 39 (26-55) years, 1251 (79%) were men, median (IQR) Injury Severity Score was 29 (18-43), 36% had penetrating injury, and 33% had systolic blood pressure less than 90 mm Hg at hospital arrival. All-cause 28-day mortality in the intention-to-treat population was 26.1% in the standard care group vs 25.3% in the cryoprecipitate group (odds ratio, 0.96 [95% CI, 0.75-1.23]; P = .74). There was no difference in safety outcomes or incidence of thrombotic events in the standard care vs cryoprecipitate group (12.9% vs 12.7%). Conclusions and Relevance Among patients with trauma and bleeding who required activation of a major hemorrhage protocol, the addition of early and empirical high-dose cryoprecipitate to standard care did not improve all cause 28-day mortality. Trial Registration ClinicalTrials.gov Identifier: NCT04704869; ISRCTN Identifier: ISRCTN14998314.
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Affiliation(s)
- Ross Davenport
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, United Kingdom
| | - Nicola Curry
- Nuffield Orthopedic Hospital, Oxford University Hospitals NHS Foundation Trust, Headington, Oxford, United Kingdom
| | - Erin E. Fox
- Center for Translational Injury Research, The University of Texas Health Science Center, Houston
| | - Helen Thomas
- NHS Blood and Transplant Clinical Trials Unit, Stoke Gifford, Bristol, United Kingdom
| | - Joanne Lucas
- NHS Blood and Transplant Clinical Trials Unit, Cambridge, United Kingdom
| | - Amy Evans
- NHS Blood and Transplant Clinical Trials Unit, Cambridge, United Kingdom
| | | | - Rupa Sharma
- NHS Blood and Transplant Clinical Trials Unit, Cambridge, United Kingdom
| | - Alison Deary
- NHS Blood and Transplant Clinical Trials Unit, Cambridge, United Kingdom
| | - Antoinette Edwards
- The Trauma Audit & Research Network, University of Manchester, Salford Royal NHS Foundation Trust, Salford, United Kingdom
| | - Laura Green
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, United Kingdom
| | - Charles E. Wade
- Center for Translational Injury Research, The University of Texas Health Science Center, Houston
| | - Jonathan R. Benger
- Faculty of Health and Applied Sciences, University of the West of England, Bristol, United Kingdom
| | - Bryan A. Cotton
- Center for Translational Injury Research, The University of Texas Health Science Center, Houston
| | - Simon J. Stanworth
- Radcliffe Department of Medicine, John Radcliffe Hospital, NHS Blood and Transplant and Oxford University Hospitals NHS Foundation Trust, University of Oxford, Headington, Oxford, United Kingdom
| | - Karim Brohi
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, United Kingdom
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9
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Gerard J, Van Gent JM, Cardenas J, Gage C, Meyer DE, Cox C, Wade CE, Cotton BA. Hypofibrinogenemia following injury in 186 children and adolescents: identification of the phenotype, current outcomes, and potential for intervention. Trauma Surg Acute Care Open 2023; 8:e001108. [PMID: 38020863 PMCID: PMC10649809 DOI: 10.1136/tsaco-2023-001108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2023] [Accepted: 10/06/2023] [Indexed: 12/01/2023] Open
Abstract
Objectives Recent studies evaluating fibrinogen replacement in trauma, along with newly available fibrinogen-based products, has led to an increase in debate on where products such as cryoprecipitate belong in our resuscitation strategies. We set out to define the phenotype and outcomes of those with hypofibrinogenemia and evaluate whether fibrinogen replacement should have a role in the initial administration of massive transfusion. Methods All patients <18 years of age presenting to our trauma center 11/17-4/21 were reviewed. We then evaluated all patients who received emergency-release and massive transfusion protocol (MTP) products. Patients were defined as hypofibrinogenemic (HYPOFIB) if admission fibrinogen <150 or rapid thrombelastography (r-TEG) angle <60 degrees. Our analysis sought to define risk factors for presenting with HYPOFIB, the impact on outcomes, and whether early replacement improved mortality. Results 4169 patients were entered into the trauma registry, with 926 level 1 trauma activations, of which 186 patients received emergency-release blood products during this time; 1%, 3%, and 10% were HYPOFIB, respectively. Of the 186 patients of interest, 18 were HYPOFIB and 168 were non-HYPOFIB. The HYPOFIB patients were significantly younger, had lower field and arrival Glasgow Coma Scale, had higher head Abbreviated Injury Scale, arrived with worse global coagulopathy, and died from brain injury. Non-HYPOFIB patients were more likely to have (+)focused assessment for the sonography of trauma on arrival, sustained severe abdominal injuries, and die from hemorrhage. 12% of patients who received early cryoprecipitate (0-2 hours) had higher mortality by univariate analysis (55% vs 31%, p=0.045), but no difference on multivariate analysis (OR 0.36, 95% CI 0.07 to 1.81, p=0.221). Those receiving early cryoprecipitate who survived after pediatric intensive care unit (PICU) admission had lower PICU fibrinogen and r-TEG alpha-angle values. Conclusion In pediatric trauma, patients with hypofibrinogenemia on admission are most likely younger and to have sustained severe brain injury, with an associated mortality of over 80%. Given the absence of bleeding-related deaths in HYPOFIB patients, this study does not provide evidence for the empiric use of cryoprecipitate in the initial administration of a massive transfusion protocol. Level of Evidence Level III - Therapeutic/Care Management.
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Affiliation(s)
- Justin Gerard
- Department of Surgery, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Jan-Michael Van Gent
- Department of Surgery, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Jessica Cardenas
- Department of Surgery, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Christian Gage
- Department of Surgery, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - David E Meyer
- Department of Surgery, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Charles Cox
- Department of Surgery, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Charles E Wade
- Surgery/Center for Injury Research, The University of Texas Health Science Center McGovern School of Medicine, Houston, Texas, USA
| | - Bryan A Cotton
- Department of Surgery, The University of Texas Health Science Center at Houston, Houston, Texas, USA
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10
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Lammers D, Scerbo M, Davidson A, Pommerening M, Tomasek J, Wade CE, Cardenas J, Jansen J, Miller CC, Holcomb JB. Addition of aspirin to venous thromboembolism chemoprophylaxis safely decreases venous thromboembolism rates in trauma patients. Trauma Surg Acute Care Open 2023; 8:e001140. [PMID: 37936904 PMCID: PMC10626753 DOI: 10.1136/tsaco-2023-001140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Accepted: 10/03/2023] [Indexed: 11/09/2023] Open
Abstract
Background Trauma patients exhibit a multifactorial hypercoagulable state and have increased risk of venous thromboembolism (VTE). Despite early and aggressive chemoprophylaxis (CP) with various heparin compounds ("standard" CP; sCP), VTE rates remain high. In high-quality studies, aspirin has been shown to decrease VTE in postoperative elective surgical and orthopedic trauma patients. We hypothesized that inhibiting platelet function with aspirin as an adjunct to sCP would reduce the risk of VTE in trauma patients. Methods We performed a retrospective observational study of prospectively collected data from all adult patients admitted to an American College of Surgeons Level I Trauma center from January 2012 to June 2015 to evaluate the addition of aspirin (sCP+A) to sCP regimens for VTE mitigation. Cox proportional hazard models were used to assess the potential benefit of adjunctive aspirin for symptomatic VTE incidence. Results 10,532 patients, median age 44 (IQR 28 to 62), 68% male, 89% blunt mechanism of injury, with a median Injury Severity Score (ISS) of 12 (IQR 9 to 19), were included in the study. 8646 (82%) of patients received only sCP, whereas 1886 (18%) patients received sCP+A. The sCP+A cohort displayed a higher median ISS compared with sCP (13 vs 11; p<0.01). The overall median time of sCP initiation was hospital day 1 (IQR 0.8 to 2) and the median day for aspirin initiation was hospital day 3 (IQR 1 to 6) for the sCP+A cohort. 353 patients (3.4%) developed symptomatic VTE. Aspirin administration was independently associated with a decreased relative hazard of VTE (HR 0.57; 95% CI 0.36 to 0.88; p=0.01). There were no increased bleeding or wound complications associated with sCP+A (point estimate 1.23, 95% CI 0.68 to 2.2, p=0.50). Conclusion In this large trauma cohort, adjunctive aspirin was independently associated with a significant reduction in VTE and may represent a potential strategy to safely mitigate VTE risk in trauma patients. Further prospective studies evaluating the addition of aspirin to heparinoid-based VTE chemoprophylaxis regimens should be sought. Level of evidence Level III/therapeutic.
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Affiliation(s)
- Daniel Lammers
- Division of Trauma and Acute Care Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Michelle Scerbo
- Surgery/Center for Injury Research, The University of Texas Health Science Center McGovern School of Medicine, Houston, Texas, USA
| | - Annamaria Davidson
- Surgery/Center for Injury Research, The University of Texas Health Science Center McGovern School of Medicine, Houston, Texas, USA
| | - Matthew Pommerening
- Surgery/Center for Injury Research, The University of Texas Health Science Center McGovern School of Medicine, Houston, Texas, USA
| | - Jeffrey Tomasek
- Surgery/Center for Injury Research, The University of Texas Health Science Center McGovern School of Medicine, Houston, Texas, USA
| | - Charles E Wade
- Surgery/Center for Injury Research, The University of Texas Health Science Center McGovern School of Medicine, Houston, Texas, USA
| | - Jessica Cardenas
- Surgery/Center for Injury Research, The University of Texas Health Science Center McGovern School of Medicine, Houston, Texas, USA
| | - Jan Jansen
- Division of Trauma and Acute Care Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Charles C Miller
- Surgery/Center for Injury Research, The University of Texas Health Science Center McGovern School of Medicine, Houston, Texas, USA
| | - John B Holcomb
- Division of Trauma and Acute Care Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
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11
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Meyer DE, Harvin JA, Vincent L, Motley K, Wandling MW, Puzio TJ, Moore LJ, Cotton BA, Wade CE, Kao LS. Randomized Controlled Trial of Surgical Rib Fixation to Nonoperative Management in Severe Chest Wall Injury. Ann Surg 2023; 278:357-365. [PMID: 37317861 PMCID: PMC10527348 DOI: 10.1097/sla.0000000000005950] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
OBJECTIVE To compare the effectiveness of surgical stabilization of rib fractures (SSRFs) to nonoperative management in severe chest wall injury. BACKGROUND SSRF has been shown to improve outcomes in patients with clinical flail chest and respiratory failure. However, the effect of SSRF outcomes in severe chest wall injuries without clinical flail chest is unknown. METHODS Randomized controlled trial comparing SSRF to nonoperative management in severe chest wall injury, defined as: (1) a radiographic flail segment without clinical flail or (2) ≥5 consecutive rib fractures or (3) any rib fracture with bicortical displacement. Randomization was stratified by the unit of admission as a proxy for injury severity. Primary outcome was hospital length of stay (LOS). Secondary outcomes included intensive care unit (ICU) LOS, ventilator days, opioid exposure, mortality, and incidences of pneumonia and tracheostomy. Quality of life at 1, 3, and 6 months was measured using the EQ-5D-5L survey. RESULTS Eighty-four patients were randomized in an intention-to-treat analysis (usual care = 42, SSRF = 42). Baseline characteristics were similar between groups. The numbers of total fractures, displaced fractures, and segmental fractures per patient were also similar, as were the incidences of displaced fractures and radiographic flail segments. Hospital LOS was greater in the SSRF group. ICU LOS and ventilator days were similar. After adjusting for the stratification variable, hospital LOS remained greater in the SSRF group (RR: 1.48, 95% CI: 1.17-1.88). ICU LOS (RR: 1.65, 95% CI: 0.94-2.92) and ventilator days (RR: 1.49, 95% CI: 0.61--3.69) remained similar. Subgroup analysis showed that patients with displaced fractures were more likely to have LOS outcomes similar to their usual care counterparts. At 1 month, SSRF patients had greater impairment in mobility [3 (2-3) vs 2 (1-2), P = 0.012] and self-care [2 (1-2) vs 2 (2-3), P = 0.034] dimensions of the EQ-5D-5L. CONCLUSIONS In severe chest wall injury, even in the absence of clinical flail chest, the majority of patients still reported moderate to extreme pain and impairment of usual physical activity at one month. SSRF increased hospital LOS and did not provide any quality of life benefit for up to 6 months.
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Affiliation(s)
- David E Meyer
- Department of Surgery; McGovern Medical School at UTHealth Houston, Houston, TX
| | - John A Harvin
- Department of Surgery; McGovern Medical School at UTHealth Houston, Houston, TX
| | - Laura Vincent
- The Center for Translational Injury Research, McGovern Medical School at UTHealth Houston, Houston, TX
| | - Kandice Motley
- The Center for Translational Injury Research, McGovern Medical School at UTHealth Houston, Houston, TX
| | - Michael W Wandling
- Department of Surgery; McGovern Medical School at UTHealth Houston, Houston, TX
| | - Thaddeus J Puzio
- Department of Surgery; McGovern Medical School at UTHealth Houston, Houston, TX
| | - Laura J Moore
- Department of Surgery; McGovern Medical School at UTHealth Houston, Houston, TX
| | - Bryan A Cotton
- Department of Surgery; McGovern Medical School at UTHealth Houston, Houston, TX
| | - Charles E Wade
- The Center for Translational Injury Research, McGovern Medical School at UTHealth Houston, Houston, TX
| | - Lillian S Kao
- Department of Surgery; McGovern Medical School at UTHealth Houston, Houston, TX
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Benjamin AJ, Young AJ, Holcomb JB, Fox EE, Wade CE, Meador C, Cannon JW. Early Prediction of Massive Transfusion for Patients With Traumatic Hemorrhage: Development of a Multivariable Machine Learning Model. Ann Surg Open 2023; 4:e314. [PMID: 37746616 PMCID: PMC10513183 DOI: 10.1097/as9.0000000000000314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Accepted: 06/25/2023] [Indexed: 09/26/2023] Open
Abstract
Objective Develop a novel machine learning (ML) model to rapidly identify trauma patients with severe hemorrhage at risk of early mortality. Background The critical administration threshold (CAT, 3 or more units of red blood cells in a 60-minute period) indicates severe hemorrhage and predicts mortality, whereas early identification of such patients improves survival. Methods Patients from the PRospective, Observational, Multicenter, Major Trauma Transfusion and Pragmatic, Randomized Optimal Platelet, and Plasma Ratio studies were identified as either CAT+ or CAT-. Candidate variables were separated into 4 tiers based on the anticipated time of availability during the patient's assessment. ML models were created with the stepwise addition of variables and compared with the baseline performance of the assessment of blood consumption (ABC) score for CAT+ prediction using a cross-validated training set and a hold-out validation test set. Results Of 1245 PRospective, Observational, Multicenter, Major Trauma Transfusion and 680 Pragmatic, Randomized Optimal Platelet and Plasma Ratio study patients, 1312 were included in this analysis, including 862 CAT+ and 450 CAT-. A CatBoost gradient-boosted decision tree model performed best. Using only variables available prehospital or on initial assessment (Tier 1), the ML model performed superior to the ABC score in predicting CAT+ patients [area under the receiver-operator curve (AUC = 0.71 vs 0.62)]. Model discrimination increased with the addition of Tier 2 (AUC = 0.75), Tier 3 (AUC = 0.77), and Tier 4 (AUC = 0.81) variables. Conclusions A dynamic ML model reliably identified CAT+ trauma patients with data available within minutes of trauma center arrival, and the quality of the prediction improved as more patient-level data became available. Such an approach can optimize the accuracy and timeliness of massive transfusion protocol activation.
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Affiliation(s)
- Andrew J. Benjamin
- From the Division of Traumatology, Surgical Critical Care & Emergency Surgery, Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
- Trauma and Acute Care Surgery, Department of Surgery, The University of Chicago, Chicago, IL (Current affiliation)
| | - Andrew J. Young
- Division of Trauma, Critical Care and Burn, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH
| | - John B. Holcomb
- Division of Trauma and Acute Care Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
- Department of Surgery, F. Edward Hébert School of Medicine at the Uniformed Services University, Bethesda, MD
| | - Erin E. Fox
- Center for Translational Injury Research and Division of Acute Care Surgery, Department of Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX
| | - Charles E. Wade
- Center for Translational Injury Research and Division of Acute Care Surgery, Department of Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX
| | | | - Jeremy W. Cannon
- From the Division of Traumatology, Surgical Critical Care & Emergency Surgery, Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
- Department of Surgery, F. Edward Hébert School of Medicine at the Uniformed Services University, Bethesda, MD
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
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13
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Livingston CE, Levy DT, Saroukhani S, Fox EE, Wade CE, Holcomb JB, Gumbert SD, Galvagno SM, Kaslow OY, Pittet JF, Pivalizza EP. Volatile anesthetic and outcome in acute trauma care: planned secondary analysis of the PROPPR study. Proc AMIA Symp 2023; 36:680-685. [PMID: 37829226 PMCID: PMC10566423 DOI: 10.1080/08998280.2023.2243204] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 07/25/2023] [Indexed: 10/14/2023] Open
Abstract
Background This retrospective analysis of prospectively collected data from the PROPPR study describes volatile anesthetic use in severely injured trauma patients undergoing anesthesia. Methods After exclusions, 402 subjects were reviewed of the original 680, and 292 had complete data available for analysis. Anesthesia was not protocolized, so analysis was of contemporary practice. Results The small group who received no volatile anesthetic (n = 25) had greater injury burden (Glasgow Coma Scale P = 0.05, Injury Severity Score P = 0.001, Revised Trauma Score P = 0.03), higher 6- and 24-hour mortality (P < 0.001), and higher incidence of systemic inflammatory response syndrome (P = 0.003) and ventilator-associated pneumonia (P = 0.02) than those receiving any volatile (n = 267). There were no differences in mortality between volatile agents at 6 hours (P = 0.51) or 24 hours (P = 0.35). The desflurane group was less severely injured than the isoflurane group. Mean minimum alveolar concentration was < 0.6 and lowest in the isoflurane group compared to the sevoflurane and desflurane groups (both P < 0.01). The incidence of systemic inflammatory response syndrome was lower in the desflurane group than in the isoflurane group (P = 0.007). Conclusion In this acutely injured trauma population, choice of volatile anesthetic did not appear to influence short-term mortality and morbidity. Subjects who received no volatile were more severely injured with greater mortality, representing hemodynamic compromise where volatile agent was limited until stable. As anesthetic was not protocolized, these findings that choice of specific volatile was not associated with short-term survival require prospective, randomized evaluation.
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Affiliation(s)
- Colleen E. Livingston
- Department of Anesthesiology, McGovern Medical School at UTHealth, Houston, Texas, USA;
| | - Dominique T. Levy
- Department of Anesthesiology, McGovern Medical School at UTHealth, Houston, Texas, USA;
| | - Sepideh Saroukhani
- Department of Internal Medicine, Division of Clinical and Translational Sciences, McGovern Medical School at UTHealth, and Biostatistics/Epidemiology/Research Design Component, Center for Clinical and Translational Sciences, UTHealth, Houston, Texas, USA;
| | - Erin E. Fox
- Department of Surgery, Center for Translational Injury Research, McGovern Medical School at UTHealth, Houston, Texas, USA;
| | - Charles E. Wade
- Department of Surgery, Center for Translational Injury Research, McGovern Medical School at UTHealth, Houston, Texas, USA;
| | - John B. Holcomb
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA;
| | - Sam D. Gumbert
- Department of Anesthesiology, Cleveland Clinic, Cleveland, Ohio, USA;
| | - Samuel M. Galvagno
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, Maryland, USA;
| | - Olga Y. Kaslow
- Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA;
| | - Jean-Francois Pittet
- Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Evan P. Pivalizza
- Department of Anesthesiology, McGovern Medical School at UTHealth, Houston, Texas, USA;
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14
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Thau MR, Liu T, Sathe NA, O’Keefe GE, Robinson BRH, Bulger E, Wade CE, Fox EE, Holcomb JB, Liles WC, Stanaway IB, Mikacenic C, Wurfel MM, Bhatraju PK, Morrell ED. Association of Trauma Molecular Endotypes With Differential Response to Transfusion Resuscitation Strategies. JAMA Surg 2023; 158:728-736. [PMID: 37099286 PMCID: PMC10134038 DOI: 10.1001/jamasurg.2023.0819] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Accepted: 12/12/2022] [Indexed: 04/27/2023]
Abstract
Importance It is not clear which severely injured patients with hemorrhagic shock may benefit most from a 1:1:1 vs 1:1:2 (plasma:platelets:red blood cells) resuscitation strategy. Identification of trauma molecular endotypes may reveal subgroups of patients with differential treatment response to various resuscitation strategies. Objective To derive trauma endotypes (TEs) from molecular data and determine whether these endotypes are associated with mortality and differential treatment response to 1:1:1 vs 1:1:2 resuscitation strategies. Design, Setting, and Participants This was a secondary analysis of the Pragmatic, Randomized Optimal Platelet and Plasma Ratios (PROPPR) randomized clinical trial. The study cohort included individuals with severe injury from 12 North American trauma centers. The cohort was taken from the participants in the PROPPR trial who had complete plasma biomarker data available. Study data were analyzed on August 2, 2021, to October 25, 2022. Exposures TEs identified by K-means clustering of plasma biomarkers collected at hospital arrival. Main Outcomes and Measures An association between TEs and 30-day mortality was tested using multivariable relative risk (RR) regression adjusting for age, sex, trauma center, mechanism of injury, and injury severity score (ISS). Differential treatment response to transfusion strategy was assessed using an RR regression model for 30-day mortality by incorporating an interaction term for the product of endotype and treatment group adjusting for age, sex, trauma center, mechanism of injury, and ISS. Results A total of 478 participants (median [IQR] age, 34.5 [25-51] years; 384 male [80%]) of the 680 participants in the PROPPR trial were included in this study analysis. A 2-class model that had optimal performance in K-means clustering was found. TE-1 (n = 270) was characterized by higher plasma concentrations of inflammatory biomarkers (eg, interleukin 8 and tumor necrosis factor α) and significantly higher 30-day mortality compared with TE-2 (n = 208). There was a significant interaction between treatment arm and TE for 30-day mortality. Mortality in TE-1 was 28.6% with 1:1:2 treatment vs 32.6% with 1:1:1 treatment, whereas mortality in TE-2 was 24.5% with 1:1:2 treatment vs 7.3% with 1:1:1 treatment (P for interaction = .001). Conclusions and Relevance Results of this secondary analysis suggest that endotypes derived from plasma biomarkers in trauma patients at hospital arrival were associated with a differential response to 1:1:1 vs 1:1:2 resuscitation strategies in trauma patients with severe injury. These findings support the concept of molecular heterogeneity in critically ill trauma populations and have implications for tailoring therapy for patients at high risk for adverse outcomes.
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Affiliation(s)
- Matthew R. Thau
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle
- Sepsis Center of Research Excellence—University of Washington (SCORE-UW), Seattle
| | - Ted Liu
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle
| | - Neha A. Sathe
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle
- Sepsis Center of Research Excellence—University of Washington (SCORE-UW), Seattle
| | - Grant E. O’Keefe
- Sepsis Center of Research Excellence—University of Washington (SCORE-UW), Seattle
- Department of Surgery, University of Washington, Seattle
| | | | - Eileen Bulger
- Department of Surgery, University of Washington, Seattle
| | - Charles E. Wade
- Center for Translational Injury Research, Division of Acute Care Surgery, Department of Surgery, University of Texas Health Science Center, Houston
| | - Erin E. Fox
- Center for Translational Injury Research, Division of Acute Care Surgery, Department of Surgery, University of Texas Health Science Center, Houston
| | | | - W. Conrad Liles
- Sepsis Center of Research Excellence—University of Washington (SCORE-UW), Seattle
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle
| | - Ian B. Stanaway
- Kidney Research Institute, University of Washington, Seattle
- Division of Nephrology, Department of Medicine, University of Washington, Seattle
| | - Carmen Mikacenic
- Sepsis Center of Research Excellence—University of Washington (SCORE-UW), Seattle
- Translational Immunology, Benaroya Research Institute, Seattle, Washington
| | - Mark M. Wurfel
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle
- Sepsis Center of Research Excellence—University of Washington (SCORE-UW), Seattle
| | - Pavan K. Bhatraju
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle
- Sepsis Center of Research Excellence—University of Washington (SCORE-UW), Seattle
| | - Eric D. Morrell
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle
- Sepsis Center of Research Excellence—University of Washington (SCORE-UW), Seattle
- Hospital and Specialty Medicine, VA Puget Sound Health Care System, Seattle, Washington
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Levy DT, Livingston CE, Saroukhani S, Fox EE, Wade CE, Holcomb JB, Gumbert SD, Galvagno SM, Kaslow OY, Pittet JF, Pivalizza EG. Association of Opioid Administration During General Anesthesia and Survival for Severely Injured Trauma Patients: A Preplanned Secondary Analysis of the PROPPR Study. Anesth Analg 2023; 136:905-912. [PMID: 37058726 DOI: 10.1213/ane.0000000000006456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/16/2023]
Abstract
BACKGROUND There is a lack of reported clinical outcomes after opioid use in acute trauma patients undergoing anesthesia. Data from the Pragmatic, Randomized, Optimal Platelet and Plasma Ratios (PROPPR) study were analyzed to examine opioid dose and mortality. We hypothesized that higher dose opioids during anesthesia were associated with lower mortality in severely injured patients. METHODS PROPPR examined blood component ratios in 680 bleeding trauma patients at 12 level 1 trauma centers in North America. Subjects undergoing anesthesia for an emergency procedure were identified, and opioid dose was calculated (morphine milligram equivalents [MMEs])/h. After separation of those who received no opioid (group 1), remaining subjects were divided into 4 groups of equal size with low to high opioid dose ranges. A generalized linear mixed model was used to assess impact of opioid dose on mortality (primary outcome, at 6 hours, 24 hours, and 30 days) and secondary morbidity outcomes, controlling for injury type, severity, and shock index as fixed effect factors and site as a random effect factor. RESULTS Of 680 subjects, 579 had an emergent procedure requiring anesthesia, and 526 had complete anesthesia data. Patients who received any opioid had lower mortality at 6 hours (odds ratios [ORs], 0.02-0.04; [confidence intervals {CIs}, 0.003-0.1]), 24 hours (ORs, 0.01-0.03; [CIs, 0.003-0.09]), and 30 days (ORs, 0.04-0.08; [CIs, 0.01-0.18]) compared to those who received none (all P < .001) after adjusting for fixed effect factors. The lower mortality at 30 days in any opioid dose group persisted after analysis of those patients who survived >24 hours (P < .001). Adjusted analyses demonstrated an association with higher ventilator-associated pneumonia (VAP) incidence in the lowest opioid dose group compared to no opioid (P = .02), and lung complications were lower in the third opioid dose group compared to no opioid in those surviving 24 hours (P = .03). There were no other consistent associations of opioid dose with other morbidity outcomes. CONCLUSIONS These results suggest that opioid administration during general anesthesia for severely injured patients is associated with improved survival, although the no-opioid group was more severely injured and hemodynamically unstable. Since this was a preplanned post hoc analysis and opioid dose not randomized, prospective studies are required. These findings from a large, multi-institutional study may be relevant to clinical practice.
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Affiliation(s)
| | | | - Sepideh Saroukhani
- Department of Internal Medicine, Division of Clinical and Translational Sciences, McGovern Medical School at UTHealth, Houston, Texas
- Biostatistics/Epidemiology/Research Design (BERD) Component, Center for Clinical and Translational Sciences (CCTS) at UTHealth, Houston, Texas
| | - Erin E Fox
- Department of Surgery, Center for Translational Injury Research, McGovern Medical School at UTHealth, Houston, Texas
| | - Charles E Wade
- Department of Surgery, Center for Translational Injury Research, McGovern Medical School at UTHealth, Houston, Texas
| | - John B Holcomb
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Sam D Gumbert
- Department of Anesthesiology, Cleveland Clinic, Cleveland, Ohio
| | - Samuel M Galvagno
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Olga Y Kaslow
- Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Jean-Francois Pittet
- Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Evan G Pivalizza
- Department of Anesthesiology, McGovern Medical School at UTHealth, Houston, Texas
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Krocker JD, Cotton ME, Schriner JB, Osborn BK, Talanker MM, Wang YWW, Cox CS, Wade CE. Influence of TRPM4 rs8104571 genotype on intracranial pressure and outcomes in African Americans with traumatic brain injury. Sci Rep 2023; 13:5815. [PMID: 37037835 PMCID: PMC10086037 DOI: 10.1038/s41598-023-32819-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Accepted: 04/03/2023] [Indexed: 04/12/2023] Open
Abstract
The TRPM4 gene codes for a membrane ion channel subunit related to inflammation in the central nervous system. Recent investigation has identified an association between TRPM4 single nucleotide polymorphisms (SNPs) rs8104571 and rs150391806 and increased intracranial (ICP) pressure following traumatic brain injury (TBI). We assessed the influence of these genotypes on clinical outcomes and ICP in TBI patients. We included 292 trauma patients with TBI. DNA extraction and real-time PCR were used for TRPM4 rs8104571 and rs150391806 allele discrimination. Five participants were determined to have the rs8104571 homozygous variant genotype, and 20 participants were identified as heterozygotes; 24 of these 25 participants were African American. No participants had rs150391806 variant alleles, preventing further analysis of this SNP. Genotypes containing the rs8104571 variant allele were associated with decreased Glasgow outcome scale-extended (GOSE) score (P = 0.0231), which was also consistent within our African-American subpopulation (P = 0.0324). Regression analysis identified an association between rs8104571 variant homozygotes and mortality within our overall population (P = 0.0230) and among African Americans (P = 0.0244). Participants with rs8104571 variant genotypes exhibited an overall increase in ICP (P = 0.0077), although a greater frequency of ICP measurements > 25 mmHg was observed in wild-type participants (P = < 0.0001). We report an association between the TRPM4 rs8104571 variant allele and poor outcomes following TBI. These findings can potentially be translated into a precision medicine approach for African Americans following TBI utilizing TRPM4-specific pharmaceutical interventions. Validation through larger cohorts is warranted.
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Affiliation(s)
- Joseph D Krocker
- Center for Translational Injury Research, Department of Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston, 6431 Fannin St., MSB 5.204, Houston, TX, 77030, USA.
| | - Madeline E Cotton
- Center for Translational Injury Research, Department of Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston, 6431 Fannin St., MSB 5.204, Houston, TX, 77030, USA
| | - Jacob B Schriner
- Center for Translational Injury Research, Department of Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston, 6431 Fannin St., MSB 5.204, Houston, TX, 77030, USA
| | - Baron K Osborn
- Center for Translational Injury Research, Department of Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston, 6431 Fannin St., MSB 5.204, Houston, TX, 77030, USA
| | - Michael M Talanker
- Center for Translational Injury Research, Department of Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston, 6431 Fannin St., MSB 5.204, Houston, TX, 77030, USA
| | - Yao-Wei W Wang
- Center for Translational Injury Research, Department of Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston, 6431 Fannin St., MSB 5.204, Houston, TX, 77030, USA
| | - Charles S Cox
- Center for Translational Injury Research, Department of Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston, 6431 Fannin St., MSB 5.204, Houston, TX, 77030, USA
- Department of Pediatric Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, TX, USA
- Program in Pediatric Regenerative Medicine, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, TX, USA
- Red Duke Trauma Institute, Memorial Hermann-Texas Medical Center, Houston, TX, USA
| | - Charles E Wade
- Center for Translational Injury Research, Department of Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston, 6431 Fannin St., MSB 5.204, Houston, TX, 77030, USA
- Red Duke Trauma Institute, Memorial Hermann-Texas Medical Center, Houston, TX, USA
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17
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Van Gent JM, Clements TW, Lubkin DT, Wade CE, Cardenas JC, Kao LS, Cotton BA. Predicting Futility in Severely Injured Patients: Using Arrival Lab Values and Physiology to Support Evidence-Based Resource Stewardship. J Am Coll Surg 2023; 236:874-880. [PMID: 36728085 DOI: 10.1097/xcs.0000000000000563] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND The recent pandemic exposed a largely unrecognized threat to medical resources, including daily available blood products. Some of the most severely injured patients who arrive in extremis consume tremendous resources yet succumb shortly after arrival. We sought to identify cut points available early in the patient's resuscitation that predicted 100% mortality. STUDY DESIGN Cut points were developed from a previously collected data set of all level 1 trauma patients admitted January 2010 to December 2016. Objective values available on or shortly after arrival were evaluated. Once generated, we then validated these variables against (1) a prospective data set November 2017 to October 2021 of severely injured patients and (2) a multicenter, randomized trial of hemorrhagic shock patients. Analyses were conducted using STATA 17.0 (College Station, TX), generating positive predictive value (PPV), negative predictive value, sensitivity, and specificity. RESULTS The development data set consisted of 9,509 patients (17% mortality), with 2,137 (24%) and 680 (24%) in the two validation data sets. Several combinations of arrival vitals and labs had 100% PPV. Patients undergoing CPR in the field or on arrival (with subsequent return of spontaneous circulation) required lower fibrinolysis LY-30 (30%) than those with systolic blood pressures of ≤50 (30 to 50%), ≤70 (80 to 90%), and ≤90 mmHg (90%). Using a combination of these validated variables, the Suspension of Transfusions and Other Procedures (STOP) criteria were developed, with each element predicting 100% mortality, allowing physicians to cease further resuscitative efforts. CONCLUSIONS The use of evidence-based STOP criteria provides cut points of futility to help guide early decisions for discontinuing aggressive treatment of severely injured patients arriving in extremis.
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Affiliation(s)
- Jan-Michael Van Gent
- From the Department of Surgery, McGovern Medical School, Houston, TX (Van Gent, Clements, Lubkin, Wade, Cardenas, Kao, Cotton)
| | - Thomas W Clements
- From the Department of Surgery, McGovern Medical School, Houston, TX (Van Gent, Clements, Lubkin, Wade, Cardenas, Kao, Cotton)
| | - David T Lubkin
- From the Department of Surgery, McGovern Medical School, Houston, TX (Van Gent, Clements, Lubkin, Wade, Cardenas, Kao, Cotton)
| | - Charles E Wade
- From the Department of Surgery, McGovern Medical School, Houston, TX (Van Gent, Clements, Lubkin, Wade, Cardenas, Kao, Cotton)
- the Center for Translational Injury Research, Houston, TX (Wade, Cardenas, Kao, Cotton)
| | - Jessica C Cardenas
- From the Department of Surgery, McGovern Medical School, Houston, TX (Van Gent, Clements, Lubkin, Wade, Cardenas, Kao, Cotton)
- the Center for Translational Injury Research, Houston, TX (Wade, Cardenas, Kao, Cotton)
| | - Lillian S Kao
- From the Department of Surgery, McGovern Medical School, Houston, TX (Van Gent, Clements, Lubkin, Wade, Cardenas, Kao, Cotton)
- the Center for Translational Injury Research, Houston, TX (Wade, Cardenas, Kao, Cotton)
| | - Bryan A Cotton
- From the Department of Surgery, McGovern Medical School, Houston, TX (Van Gent, Clements, Lubkin, Wade, Cardenas, Kao, Cotton)
- the Center for Translational Injury Research, Houston, TX (Wade, Cardenas, Kao, Cotton)
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18
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Klutts GN, Kalkwarf KJ, Yang Y, Gill JP, Wade CE, Persse D, Wolf DA, Deloach JP, Smedley WA, Corbin SL, Schulz K, Tabor J, Bhavaraju A, Drake S. Geospatial Analysis of Prehospital Triage and Early Potential Preventable Traumatic Deaths. Am Surg 2023:31348231157910. [PMID: 36803085 DOI: 10.1177/00031348231157910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/20/2023]
Abstract
Severely injured patients often depend on prompt prehospital triage for survival. This study aimed to examine the under-triage of preventable or potentially preventable traumatic deaths. A retrospective review of Harris County, TX, revealed 1848 deaths within 24 hours of injury, with 186 being preventable or potentially preventable (P/PP). The analysis evaluated the geospatial relationship between each death and the receiving hospital. Out of the 186 P/PP deaths, these were more commonly male, minority, and penetrating mechanisms when compared with NP deaths. Of the 186 PP/P, 97 patients were transported to hospital care, 35 (36%) were transported to Level III, IV, or non-designated hospitals. Geospatial analysis revealed an association between the location of initial injury and proximity to receiving Level III, IV, and non-designated centers. Geospatial analysis supports proximity to the nearest hospital as one of the primary reasons for under-triage.
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Affiliation(s)
- Garrett N Klutts
- Department of Surgery, 12215University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Kyle J Kalkwarf
- Department of Surgery, 12215University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Yijiong Yang
- Department of Management, Policy and Community Health, 12340University of Texas Health Science Center, Houston, TX, USA
| | - Joseph P Gill
- Department of Emergency Medicine, 12340University of Texas Health Science Center, Houston, TX, USA
| | - Charles E Wade
- Department of Surgery, 12340University of Texas Health Science Center, Houston, TX, USA
| | - David Persse
- 11126Department of Health & Human Services City of Houston, Houston, TX, USA
| | - Dwayne A Wolf
- Arkansas Trauma Communications Center, Little Rock, AR, USA
| | - Joe P Deloach
- Department of Surgery, 12215University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Weston A Smedley
- Department of Surgery, 12215University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Seana L Corbin
- Department of Surgery, 12215University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Kevin Schulz
- Department of Emergency Medicine, 12340University of Texas Health Science Center, Houston, TX, USA
| | - Jeff Tabor
- Arkansas Trauma Communications Center, Little Rock, AR, USA
| | - Avi Bhavaraju
- Department of Surgery, 12215University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Stacy Drake
- 269115Ottawa County, Coroner's Office, Port Clinton, OH, USA
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19
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Henriksen HH, Marín de Mas I, Nielsen LK, Krocker J, Stensballe J, Karvelsson ST, Secher NH, Rolfsson Ó, Wade CE, Johansson PI. Endothelial Cell Phenotypes Demonstrate Different Metabolic Patterns and Predict Mortality in Trauma Patients. Int J Mol Sci 2023; 24:2257. [PMID: 36768579 PMCID: PMC9916682 DOI: 10.3390/ijms24032257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Revised: 01/15/2023] [Accepted: 01/19/2023] [Indexed: 01/26/2023] Open
Abstract
In trauma patients, shock-induced endotheliopathy (SHINE) is associated with a poor prognosis. We have previously identified four metabolic phenotypes in a small cohort of trauma patients (N = 20) and displayed the intracellular metabolic profile of the endothelial cell by integrating quantified plasma metabolomic profiles into a genome-scale metabolic model (iEC-GEM). A retrospective observational study of 99 trauma patients admitted to a Level 1 Trauma Center. Mass spectrometry was conducted on admission samples of plasma metabolites. Quantified metabolites were analyzed by computational network analysis of the iEC-GEM. Four plasma metabolic phenotypes (A-D) were identified, of which phenotype D was associated with an increased injury severity score (p < 0.001); 90% (91.6%) of the patients who died within 72 h possessed this phenotype. The inferred EC metabolic patterns were found to be different between phenotype A and D. Phenotype D was unable to maintain adequate redox homeostasis. We confirm that trauma patients presented four metabolic phenotypes at admission. Phenotype D was associated with increased mortality. Different EC metabolic patterns were identified between phenotypes A and D, and the inability to maintain adequate redox balance may be linked to the high mortality.
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Affiliation(s)
- Hanne H. Henriksen
- Section for Transfusion Medicine, Capital Region Blood Bank, Rigshospitalet, University of Copenhagen, 2100 Copenhagen, Denmark
- CAG Center for Endotheliomics, Copenhagen University Hospital, Rigshospitalet, 2100 Copenhagen, Denmark
| | - Igor Marín de Mas
- Novo Nordisk Foundation Center for Biosustainability, Technical University of Denmark, 2800 Kongens Lyngby, Denmark
| | - Lars K. Nielsen
- Novo Nordisk Foundation Center for Biosustainability, Technical University of Denmark, 2800 Kongens Lyngby, Denmark
- Australian Institute for Bioengineering and Nanotechnology (AIBN), The University of Queensland, 4072 Brisbane, Australia
| | - Joseph Krocker
- Center for Translational Injury Research, Department of Surgery, University of Texas Health Science Center, Houston, TX 77030, USA
| | - Jakob Stensballe
- Section for Transfusion Medicine, Capital Region Blood Bank, Rigshospitalet, University of Copenhagen, 2100 Copenhagen, Denmark
- CAG Center for Endotheliomics, Copenhagen University Hospital, Rigshospitalet, 2100 Copenhagen, Denmark
- Department of Anesthesia and Trauma Center, Center of Head and Orthopedics, Rigshospitalet, 2100 Copenhagen, Denmark
| | | | - Niels H. Secher
- Department of Anesthesiology, Centre for Cancer and Organ Diseases, Rigshospitalet, University of Copenhagen, 2100 Copenhagen, Denmark
| | - Óttar Rolfsson
- Center for Systems Biology, University of Iceland, 101 Reykjavik, Iceland
| | - Charles E. Wade
- Center for Translational Injury Research, Department of Surgery, University of Texas Health Science Center, Houston, TX 77030, USA
| | - Pär I. Johansson
- Section for Transfusion Medicine, Capital Region Blood Bank, Rigshospitalet, University of Copenhagen, 2100 Copenhagen, Denmark
- CAG Center for Endotheliomics, Copenhagen University Hospital, Rigshospitalet, 2100 Copenhagen, Denmark
- Center for Translational Injury Research, Department of Surgery, University of Texas Health Science Center, Houston, TX 77030, USA
- Center for Systems Biology, University of Iceland, 101 Reykjavik, Iceland
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20
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Weykamp MB, Stern KE, Brakenridge SC, Robinson BR, Wade CE, Fox EE, Holcomb JB, O’Keefe GE. PREHOSPITAL CRYSTALLOID RESUSCITATION: PRACTICE VARIATION AND ASSOCIATIONS WITH CLINICAL OUTCOMES. Shock 2023; 59:28-33. [PMID: 36703275 PMCID: PMC9886338 DOI: 10.1097/shk.0000000000002039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
ABSTRACT Introduction: Although resuscitation guidelines for injured patients favor blood products, crystalloid resuscitation remains a mainstay in prehospital care. Our understanding of contemporary prehospital crystalloid (PHC) practices and their relationship with clinical outcomes is limited. Methods: The Pragmatic, Randomized Optimal Platelet and Plasma Ratios trial data set was used for this investigation. We sought to identify factors associated with PHC volume variation and hypothesized that higher PHC volume is associated with worse coagulopathy and a higher risk of acute respiratory distress syndrome (ARDS) but a lower risk of acute kidney injury (AKI). Subjects were divided into groups that received <1,000 mL PHC (PHC<1,000) and ≥1,000 mL PHC (PHC≥1,000); initial laboratory values and outcomes (ARDS and AKI risk) were summarized with medians and interquartile ranges or percentages and compared using Wilcoxon rank-sum tests and chi-square tests. The primary outcome was ARDS risk. Multivariable regression was used to characterize the association of each 500 mL aliquot of PHC with initial laboratory values and clinical outcomes. Results: PHC volume among study subjects (n = 680) varied (median, 0.3 L; interquartile range, 0-0.9 L) with weak associations demonstrated among prehospital hemodynamics, intubation, Glasgow Coma Score, and Injury Severity Score (0.008 ≤ R2 ≤ 0.09); prehospital time and enrollment site explained more variation in PHC volume with R2 values of 0.2 and 0.54, respectively. Compared with PHC<1,000, PHC≥1,000 had higher INR, PT, PTT, and base deficit and lower hematocrit and platelets. The proportion of ARDS in the PHC≥1,000 group was higher than PHC<1,000 (21% vs. 12%, P < 0.01), whereas the rate of AKI was similar between groups (23% vs. 23%, P = 0.9). In regression analyses, each 500 mL of PHC was associated with increased INR and PTT, and decreased hematocrit and platelet count (P < 0.05). Each 500 mL of PHC was associated with increased ARDS risk and decreased AKI risk (P < 0.05). Conclusion: PHC administration correlates poorly with prehospital hemodynamics and injury characteristics. Increased PHC volume is associated with greater anemia, coagulopathy, and increased risk of ARDS, although it may be protective against AKI.
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Affiliation(s)
- Michael B. Weykamp
- Department of Surgery, Harborview Medical Center, The University of Washington, Washington
| | - Katherine E. Stern
- Department of Surgery, Harborview Medical Center, The University of Washington, Washington
- Department of Surgery, The University of San Francisco – East Bay, California
| | - Scott C. Brakenridge
- Department of Surgery, Harborview Medical Center, The University of Washington, Washington
| | - Bryce R.H. Robinson
- Department of Surgery, Harborview Medical Center, The University of Washington, Washington
| | - Charles E. Wade
- Department of Surgery and Center for Translational Injury Research, The University of Texas Health Science Center at Houston, Texas
| | - Erin E. Fox
- Department of Surgery and Center for Translational Injury Research, The University of Texas Health Science Center at Houston, Texas
| | - John B. Holcomb
- Department of Surgery, University of Alabama at Birmingham, Alabama
| | - Grant E. O’Keefe
- Department of Surgery, Harborview Medical Center, The University of Washington, Washington
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21
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Chen-Goodspeed A, Dronavalli G, Zhang X, Podbielski JM, Patel B, Modis K, Cotton BA, Wade CE, Cardenas JC. Antithrombin Activity is Associated with Persistent Thromboinflammation and Mortality in Patients with Severe COVID-19 Illness. Acta Haematol 2022; 146:117-124. [PMID: 36538905 PMCID: PMC9940263 DOI: 10.1159/000528584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Accepted: 12/05/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Severe COVID-19 illness can lead to thrombotic complications, organ failure, and death. Antithrombin (AT) regulates thromboinflammation and is a key component of chemical thromboprophylaxis. Our goal was to examine the link between AT activity and responsiveness to thromboprophylaxis, markers of hypercoagulability, and inflammation among severe COVID-19 patients. METHODS A single-center, prospective observational study enrolling SARS-CoV-2 positive patients admitted to the intensive care unit on prophylactic enoxaparin. Blood was collected daily for 7 days to assess AT activity and anti-FXa levels. Patient demographics, outcomes, and hospital laboratory results were collected. Continuous variables were compared using Mann-Whitney tests, and categorical variables were compared using Chi-square tests. Multivariable logistic regression was used to determine the association between AT activity and mortality. RESULTS In 36 patients, 3 thromboembolic events occurred, and 18 (50%) patients died. Patients who died had higher fibrinogen, D-dimer, and C-reactive protein (CRP) levels and lower AT activity. Reduced AT activity was independently associated with mortality and correlated with both markers of hypercoagulability (D-dimer) and inflammation (CRP). CONCLUSIONS Low AT activity is associated with mortality and persistent hypercoagulable and proinflammatory states in severe COVID-19 patients. The anti-thromboinflammatory properties of AT make it an appealing therapeutic target for future studies.
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Affiliation(s)
- Amber Chen-Goodspeed
- Department of Surgery, Center for Translational Injury Research, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Goutham Dronavalli
- Department of Internal Medicine, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Xu Zhang
- Center for Clinical and Translational Sciences, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Jeanette M. Podbielski
- Department of Surgery, Center for Translational Injury Research, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Bela Patel
- Department of Internal Medicine, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Katalin Modis
- Department of Surgery, The University of Texas Medical Branch at Galveston, Galveston, Texas, USA
| | - Bryan A. Cotton
- Department of Surgery, Center for Translational Injury Research, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, Texas, USA,Red Duke Trauma Institute, Memorial Hermann - Texas Medical Center, Houston, Texas, USA
| | - Charles E. Wade
- Department of Surgery, Center for Translational Injury Research, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, Texas, USA,Red Duke Trauma Institute, Memorial Hermann - Texas Medical Center, Houston, Texas, USA
| | - Jessica C. Cardenas
- Department of Surgery, Center for Translational Injury Research, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, Texas, USA,*Jessica C Cardenas,
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22
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Kregel HR, Attia M, Pedroza C, Meyer DE, Wandling MW, Dodwad SJM, Wade CE, Harvin JA, Kao LS, Puzio TJ. Dysphagia is associated with worse clinical outcomes in geriatric trauma patients. Trauma Surg Acute Care Open 2022; 7:e001043. [PMID: 36483590 PMCID: PMC9723949 DOI: 10.1136/tsaco-2022-001043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Accepted: 11/18/2022] [Indexed: 12/09/2022] Open
Abstract
Introduction Dysphagia is associated with increased morbidity, mortality, and resource utilization in hospitalized patients, but studies on outcomes in geriatric trauma patients with dysphagia are limited. We hypothesized that geriatric trauma patients with dysphagia would have worse clinical outcomes compared with those without dysphagia. Methods Patients with and without dysphagia were compared in a single-center retrospective cohort study of trauma patients aged ≥65 years admitted in 2019. The primary outcome was mortality. Secondary outcomes included intensive care unit (ICU) length of stay (LOS), hospital LOS, discharge destination, and unplanned ICU admission. Multivariable regression analyses and Bayesian analyses adjusted for age, Injury Severity Score, mechanism of injury, and gender were performed to determine the association between dysphagia and clinical outcomes. Results Of 1706 geriatric patients, 69 patients (4%) were diagnosed with dysphagia. Patients with dysphagia were older with a higher Injury Severity Score. Increased odds of mortality did not reach statistical significance (OR 1.6, 95% CI 0.6 to 3.4, p=0.30). Dysphagia was associated with increased odds of unplanned ICU admission (OR 4.6, 95% CI 2.0 to 9.6, p≤0.001) and non-home discharge (OR 5.2, 95% CI 2.4 to 13.9, p≤0.001), as well as increased ICU LOS (OR 4.9, 95% CI 3.1 to 8.1, p≤0.001), and hospital LOS (OR 2.1, 95% CI 1.7 to 2.6, p≤0.001). On Bayesian analysis, dysphagia was associated with an increased probability of longer hospital and ICU LOS, unplanned ICU admission, and non-home discharge. Conclusions Clinically apparent dysphagia is associated with poor outcomes, but it remains unclear if dysphagia represents a modifiable risk factor or a marker of underlying frailty, leading to poor outcomes. This study highlights the importance of screening protocols for dysphagia in geriatric trauma patients to possibly mitigate adverse outcomes. Level of evidence Level III.
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Affiliation(s)
- Heather R Kregel
- Department of Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
| | - Mina Attia
- Department of Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
| | - Claudia Pedroza
- Center for Clinical Research and Evidence-Based Medicine, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
| | - David E Meyer
- Department of Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
| | - Michael W Wandling
- Department of Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
| | - Shah-Jahan M Dodwad
- Department of Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
| | - Charles E Wade
- Center for Translational Injury Research, McGovern Medical School at The University of Texas at Houston, Houston, TX, USA
| | - John A Harvin
- Department of Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
| | - Lillian S Kao
- Department of Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
| | - Thaddeus J Puzio
- Department of Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
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Yang Z, Le TD, Simovic MO, Liu B, Fraker TL, Cancio TS, Cap AP, Wade CE, DalleLucca JJ, Li Y. Traumatized triad of complementopathy, endotheliopathy, and coagulopathy ˗ Impact on clinical outcomes in severe polytrauma patients. Front Immunol 2022; 13:991048. [PMID: 36341368 PMCID: PMC9632416 DOI: 10.3389/fimmu.2022.991048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Accepted: 10/07/2022] [Indexed: 11/13/2022] Open
Abstract
Complementopathy, endotheliopathy, and coagulopathy following a traumatic injury are key pathophysiological mechanisms potentially associated with multiple-organ failure (MOF) and mortality. However, the heterogeneity in the responses of complementopathy, endotheliopathy, and coagulopathy to trauma, the nature and extent of their interplay, and their relationship to clinical outcomes remain unclear. Fifty-four poly-trauma patients were enrolled and divided into three subgroups based on their ISS. Biomarkers in blood plasma reflecting complement activation, endothelial damage, and coagulopathy were measured starting from admission to the emergency department and at 3, 6, 12, 24, and 120 hours after admission. Comparative analyses showed that severely injured patients (ISS>24) were associated with longer days on mechanical ventilation, in the intensive care unit and hospital stays, and a higher incidence of hyperglycemia, bacteremia, respiratory failure and pneumonia compared to mildly (ISS<16) or moderately (ISS=16-24) injured patients. In this trauma cohort, complement was activated early, primarily through the alternative complement pathway. As measured in blood plasma, severely injured patients had significantly higher levels of complement activation products (C3a, C5a, C5b-9, and Bb), endothelial damage markers (syndecan-1, sTM, sVEGFr1, and hcDNA), and fibrinolytic markers (D-dimer and LY30) compared to less severely injured patients. Severely injured patients also had significantly lower thrombin generation (ETP and peak) and lower levels of coagulation factors (I, V, VIII, IX, protein C) than less severely injured patients. Complement activation correlated with endothelial damage and hypocoagulopathy. Logistic regression analyses revealed that Bb >1.57 μg/ml, syndecan-1 >66.6 ng/ml or D-dimer >6 mg/L at admission were associated with a higher risk of MOF/mortality. After adjusting for ISS, each increase of the triadic score defined above (Bb>1.57 µg/ml/Syndecan-1>66.6 ng/ml/D-dimer>6.0mg/L) was associated with a 6-fold higher in the odds ratio of MOF/death [OR: 6.83 (1.04-44.96, P=0.046], and a 4-fold greater in the odds of infectious complications [OR: 4.12 (1.04-16.36), P=0.044]. These findings provide preliminary evidence of two human injury response endotypes (traumatized triad and non-traumatized triad) that align with clinical trajectory, suggesting a potential endotype defined by a high triadic score. Patients with this endotype may be considered for timely intervention to create a pro-survival/organ-protective phenotype and improve clinical outcomes.
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Affiliation(s)
- Zhangsheng Yang
- United States Army Institute of Surgical Research, Joint Base San Antonio Fort Sam Houston, TX, United States
| | - Tuan D. Le
- United States Army Institute of Surgical Research, Joint Base San Antonio Fort Sam Houston, TX, United States
| | - Milomir O. Simovic
- United States Army Institute of Surgical Research, Joint Base San Antonio Fort Sam Houston, TX, United States
- Trauma Immunomodulation Program, The Geneva Foundation, Tacoma, WA, United States
| | - Bin Liu
- United States Army Institute of Surgical Research, Joint Base San Antonio Fort Sam Houston, TX, United States
| | - Tamara L. Fraker
- United States Army Institute of Surgical Research, Joint Base San Antonio Fort Sam Houston, TX, United States
- Trauma Immunomodulation Program, The Geneva Foundation, Tacoma, WA, United States
| | - Tomas S. Cancio
- United States Army Institute of Surgical Research, Joint Base San Antonio Fort Sam Houston, TX, United States
| | - Andrew P. Cap
- United States Army Institute of Surgical Research, Joint Base San Antonio Fort Sam Houston, TX, United States
| | - Charles E. Wade
- Department of Surgery, University of Texas Health McGovern Medical School, Houston, TX, United States
| | - Jurandir J. DalleLucca
- Scientific Research Department, Armed Forces Radiobiological Research Institute, Bethesda, MD, United States
| | - Yansong Li
- United States Army Institute of Surgical Research, Joint Base San Antonio Fort Sam Houston, TX, United States
- Trauma Immunomodulation Program, The Geneva Foundation, Tacoma, WA, United States
- *Correspondence: Yansong Li,
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Henriksen HH, Marín de Mas I, Herand H, Krocker J, Wade CE, Johansson PI. Metabolic systems analysis identifies a novel mechanism contributing to shock in patients with endotheliopathy of trauma (EoT) involving thromboxane A2 and LTC 4. Matrix Biol Plus 2022; 15:100115. [PMID: 35813244 PMCID: PMC9260291 DOI: 10.1016/j.mbplus.2022.100115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Revised: 06/10/2022] [Accepted: 06/14/2022] [Indexed: 11/17/2022] Open
Abstract
Purpose Endotheliopathy of trauma (EoT), as defined by circulating levels of syndecan-1 ≥ 40 ng/mL, has been reported to be associated with significantly increased transfusion requirements and a doubled 30-day mortality. Increased shedding of the glycocalyx points toward the endothelial cell membrane composition as important for the clinical outcome being the rationale for this study. Results The plasma metabolome of 95 severely injured trauma patients was investigated by mass spectrometry, and patients with EoT vs. non-EoT were compared by partial least square-discriminant analysis, identifying succinic acid as the top metabolite to differentiate EoT and non-EoT patients (VIP score = 3). EoT and non-EoT patients' metabolic flux profile was inferred by integrating the corresponding plasma metabolome data into a genome-scale metabolic network reconstruction analysis and performing a functional study of the metabolic capabilities of each group. Model predictions showed a decrease in cholesterol metabolism secondary to impaired mevalonate synthesis in EoT compared to non-EoT patients. Intracellular task analysis indicated decreased synthesis of thromboxanA2 and leukotrienes, as well as a lower carnitine palmitoyltransferase I activity in EoT compared to non-EoT patients. Sensitivity analysis also showed a significantly high dependence of eicosanoid-associated metabolic tasks on alpha-linolenic acid as unique to EoT patients. Conclusions Model-driven analysis of the endothelial cells' metabolism identified potential novel targets as impaired thromboxane A2 and leukotriene synthesis in EoT patients when compared to non-EoT patients. Reduced thromboxane A2 and leukotriene availability in the microvasculature impairs vasoconstriction ability and may thus contribute to shock in EoT patients. These findings are supported by extensive scientific literature; however, further investigations are required on these findings.
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Key Words
- AA, Arachidonic acid
- CPT1, Carnitine palmitoyltransferase I
- EC, Endothelial cell
- EC-GEM, Genome-scale metabolic model of the microvascular endothelial cell
- ELISA, Enzyme-linked immunosorbent assay
- Eicosanoid
- Endotheliopathy
- EoT, Endotheliopathy of trauma
- FBA, Flux balance analysis
- GEMs, Genome-scale metabolic models
- Genome-scale metabolic model
- HMG-CoA, Hydroxymethylglutaryl-CoA
- ISS, Injury Severity Score
- LTC4, Leukotriene C4
- Metabolomics
- PCA, Principal Component Analysis
- PLS-DA, Partial least square-discriminant analysis
- Systems biology
- Trauma
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Affiliation(s)
- Hanne H. Henriksen
- Department of Clinical Immunology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- CAG Center for Endotheliomics, Copenhagen University Hospital, Rigshospitalet, Denmark
| | - Igor Marín de Mas
- CAG Center for Endotheliomics, Copenhagen University Hospital, Rigshospitalet, Denmark
- Novo Nordisk Foundation Center for Biosustainability, Technical University of Denmark
| | - Helena Herand
- CAG Center for Endotheliomics, Copenhagen University Hospital, Rigshospitalet, Denmark
- Novo Nordisk Foundation Center for Biosustainability, Technical University of Denmark
| | - Joseph Krocker
- Center for Translational Injury Research, Department of Surgery, University of Texas Health Science Center, Houston, TX, USA
| | - Charles E. Wade
- Center for Translational Injury Research, Department of Surgery, University of Texas Health Science Center, Houston, TX, USA
| | - Pär I. Johansson
- Department of Clinical Immunology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- CAG Center for Endotheliomics, Copenhagen University Hospital, Rigshospitalet, Denmark
- Center for Translational Injury Research, Department of Surgery, University of Texas Health Science Center, Houston, TX, USA
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Vincent LE, Talanker MM, Butler DD, Zhang X, Podbielski JM, Wang YWW, Chen-Goodspeed A, Hernandez Gonzalez SL, Fox EE, Cotton BA, Wade CE, Cardenas JC. Association of Changes in Antithrombin Activity Over Time With Responsiveness to Enoxaparin Prophylaxis and Risk of Trauma-Related Venous Thromboembolism. JAMA Surg 2022; 157:713-721. [PMID: 35731524 PMCID: PMC9218925 DOI: 10.1001/jamasurg.2022.2214] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Importance Venous thromboembolism (VTE) affects 2% to 20% of recovering trauma patients, despite aggressive prophylaxis with enoxaparin. Antithrombin is a primary circulating anticoagulant and crucial component of enoxaparin thromboprophylaxis. Approximately 20% of trauma patients present with antithrombin deficiency (antithrombin activity <80%). Objective To examine time-dependent changes in antithrombin activity, responsiveness to enoxaparin, as measured by anti-factor Xa (anti-FXa) levels, and incidence of VTE after severe trauma and to assess the association of ex vivo antithrombin supplementation with patients' sensitivity to enoxaparin prophylaxis. Design, Setting, and Participants This single-center, prospective cohort study was performed at a level 1 trauma center between January 7, 2019, and February 28, 2020. Adult trauma patients admitted to the trauma service at high risk for VTE, based on injury pattern and severity, were screened and enrolled. Patients who were older than 70 years, were pregnant, had a known immunologic or coagulation disorder, or were receiving prehospital anticoagulants were excluded. Exposures Blood samples were collected on emergency department arrival and daily for the first 8 days of hospitalization. Main Outcomes and Measures Patients' antithrombin activity and anti-FXa levels were measured by a coagulation analyzer, and thrombin generation was measured by calibrated automated thrombography. Responsiveness to enoxaparin was assessed by measuring anti-FXa levels 4 to 6 hours after the first daily enoxaparin dose and compared between patients who developed VTE and who did not. In addition, the associations of ex vivo supplementation of antithrombin with plasma anti-FXa levels were assessed. Results Among 150 patients enrolled (median [IQR] age, 35 [27-53] years; 37 [24.7%] female and 113 [75.3%] male; 5 [3.3%] Asian, 32 [21.3%] Black, and 113 [75.3%] White; and 51 [34.0%] of Hispanic ethnicity), 28 (18.7%) developed VTE. Patients with VTE had significantly lower antithrombin activity on admission compared with patients without VTE (median [IQR], 91% [79%-104%] vs 100% [88%-112%]; P = .04), as well as lower antithrombin activity on hospital days 5 (median (IQR), 90% [83%-99%] vs 114% [99%-130%]; P = .011), 6 (median [IQR], 97% [81%-109%] vs 123% [104%-134%]; P = .003), 7 (median [IQR], 82% [74%-89%] vs 123% [110%-140%]; P < .001), and 8 (median [IQR], 99% [85%-100%] vs 123% [109%-146%]; P = .011). Anti-FXa levels were significantly lower in patients with VTE vs those without VTE at hospital day 4 (median [IQR], 0.10 [0.05-0.14] IU/mL vs 0.18 [0.13-0.23] IU/mL; P = .006), day 6 (median [IQR], 0.12 [0.08-0.14] IU/mL vs 0.22 [0.13-0.28] IU/mL; P = .02), and day 7 (median [IQR], 0.11 [0.08-0.12] IU/mL vs 0.21 [0.13, 0.28] IU/mL; P = .002). Multivariable analyses found that for every 10% decrease in antithrombin activity during the first 3 days, the risk of VTE increased 1.5-fold. Conclusions and Relevance The results of this cohort study suggest that after severe trauma, antithrombin deficiency is common and contributes to enoxaparin resistance and VTE. Interventional studies are necessary to determine the efficacy of antithrombin supplementation in the reduction of VTE incidence.
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Affiliation(s)
- Laura E. Vincent
- Center for Translational Injury Research, Department of Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston
| | - Michael M. Talanker
- Center for Translational Injury Research, Department of Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston
| | - Dakota D. Butler
- Center for Translational Injury Research, Department of Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston
| | - Xu Zhang
- Center for Clinical and Translational Sciences, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston
| | - Jeanette M. Podbielski
- Center for Translational Injury Research, Department of Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston
| | - Yao-Wei W. Wang
- Center for Translational Injury Research, Department of Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston
| | - Amber Chen-Goodspeed
- Center for Translational Injury Research, Department of Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston
| | - Selina L. Hernandez Gonzalez
- Center for Translational Injury Research, Department of Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston
| | - Erin E. Fox
- Center for Translational Injury Research, Department of Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston
| | - Bryan A. Cotton
- Center for Translational Injury Research, Department of Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston,Red Duke Trauma Institute, Memorial Hermann Hospital, Houston, Texas
| | - Charles E. Wade
- Center for Translational Injury Research, Department of Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston,Red Duke Trauma Institute, Memorial Hermann Hospital, Houston, Texas
| | - Jessica C. Cardenas
- Center for Translational Injury Research, Department of Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston
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26
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Kregel HR, Murphy PB, Attia M, Meyer DE, Morris RS, Onyema EC, Adams SD, Wade CE, Harvin JA, Kao LS, Puzio TJ. The Geriatric Nutritional Risk Index as a predictor of complications in geriatric trauma patients. J Trauma Acute Care Surg 2022; 93:195-199. [PMID: 35293374 PMCID: PMC9329178 DOI: 10.1097/ta.0000000000003588] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Malnutrition is associated with increased morbidity and mortality after trauma. The Geriatric Nutritional Risk Index (GNRI) is a validated scoring system used to predict the risk of complications related to malnutrition in nontrauma patients. We hypothesized that GNRI is predictive of worse outcomes in geriatric trauma patients. METHODS This was a single-center retrospective study of trauma patients 65 years or older admitted in 2019. Geriatric Nutritional Risk Index was calculated based on admission albumin level and ratio of actual body weight to ideal body weight. Groups were defined as major risk (GNRI <82), moderate risk (GNRI 82-91), low risk (GNRI 92-98), and no risk (GNRI >98). The primary outcome was mortality. Secondary outcomes included ventilator days, intensive care unit length of stay (LOS), hospital LOS, discharge home, sepsis, pneumonia, and acute respiratory distress syndrome. Bivariate and multivariable logistic regression analyses were performed to determine the association between GNRI risk category and outcomes. RESULTS A total of 513 patients were identified for analysis. Median age was 78 years (71-86 years); 24 patients (4.7%) were identified as major risk, 66 (12.9%) as moderate risk, 72 (14%) as low risk, and 351 (68.4%) as no risk. Injury Severity Scores and Charlson Comorbidity Indexes were similar between all groups. Patients in the no risk group had decreased rates of death, and after adjusting for Injury Severity Score, age, and Charlson Comorbidity Index, the no risk group had decreased odds of death (odds ratio, 0.13; 95% confidence interval, 0.04-0.41) compared with the major risk group. The no risk group also had fewer infectious complications including sepsis and pneumonia, and shorter hospital LOS and were more likely to be discharged home. CONCLUSIONS Major GNRI risk is associated with increased mortality and infectious complications in geriatric trauma patients. Further studies should target interventional strategies for those at highest risk based on GNRI. LEVEL OF EVIDENCE Prognostic and Epidemiologic; Level III.
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Affiliation(s)
- Heather R. Kregel
- Division of Acute Care Surgery, Department of Surgery, McGovern Medical School at UTHealth, Houston, TX
- Center for Surgical Trials and Evidence-based Practice, McGovern Medical School at UTHealth, Houston, TX
- Center for Translational Injury Research, Houston, TX
| | | | - Mina Attia
- Division of Acute Care Surgery, Department of Surgery, McGovern Medical School at UTHealth, Houston, TX
- Center for Surgical Trials and Evidence-based Practice, McGovern Medical School at UTHealth, Houston, TX
| | - David E. Meyer
- Division of Acute Care Surgery, Department of Surgery, McGovern Medical School at UTHealth, Houston, TX
- Center for Surgical Trials and Evidence-based Practice, McGovern Medical School at UTHealth, Houston, TX
- Center for Translational Injury Research, Houston, TX
| | - Rachel S. Morris
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Ezenwa C. Onyema
- Division of Acute Care Surgery, Department of Surgery, McGovern Medical School at UTHealth, Houston, TX
| | - Sasha D. Adams
- Division of Acute Care Surgery, Department of Surgery, McGovern Medical School at UTHealth, Houston, TX
- Center for Surgical Trials and Evidence-based Practice, McGovern Medical School at UTHealth, Houston, TX
- Center for Translational Injury Research, Houston, TX
| | - Charles E. Wade
- Division of Acute Care Surgery, Department of Surgery, McGovern Medical School at UTHealth, Houston, TX
- Center for Translational Injury Research, Houston, TX
| | - John A. Harvin
- Division of Acute Care Surgery, Department of Surgery, McGovern Medical School at UTHealth, Houston, TX
- Center for Surgical Trials and Evidence-based Practice, McGovern Medical School at UTHealth, Houston, TX
- Center for Translational Injury Research, Houston, TX
| | - Lillian S. Kao
- Division of Acute Care Surgery, Department of Surgery, McGovern Medical School at UTHealth, Houston, TX
- Center for Surgical Trials and Evidence-based Practice, McGovern Medical School at UTHealth, Houston, TX
- Center for Translational Injury Research, Houston, TX
| | - Thaddeus J. Puzio
- Division of Acute Care Surgery, Department of Surgery, McGovern Medical School at UTHealth, Houston, TX
- Center for Surgical Trials and Evidence-based Practice, McGovern Medical School at UTHealth, Houston, TX
- Center for Translational Injury Research, Houston, TX
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27
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Puzio TJ, Klugh J, Wandling MW, Green C, Balogh J, Prater SJ, Stephens CT, Sergot PB, Wade CE, Kao LS, Harvin JA. Ketamine for acute pain after trauma: the KAPT randomized controlled trial. Trials 2022; 23:599. [PMID: 35897081 PMCID: PMC9326146 DOI: 10.1186/s13063-022-06511-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 07/05/2022] [Indexed: 11/22/2022] Open
Abstract
Background Evidence for effective pain management and opioid minimization of intravenous ketamine in elective surgery has been extrapolated to acutely injured patients, despite limited supporting evidence in this population. This trial seeks to determine the effectiveness of the addition of sub-dissociative ketamine to a pill-based, opioid-minimizing multi-modal pain regimen (MMPR) for post traumatic pain. Methods This is a single-center, parallel-group, randomized, controlled comparative effectiveness trial comparing a MMPR to a MMPR plus a sub-dissociative ketamine infusion. All trauma patients 16 years and older admitted following a trauma which require intermediate (IMU) or intensive care unit (ICU) level of care are eligible. Prisoners, patients who are pregnant, patients not expected to survive, and those with contraindications to ketamine are excluded from this study. The primary outcome is opioid use, measured by morphine milligram equivalents (MME) per patient per day (MME/patient/day). The secondary outcomes include total MME, pain scores, morbidity, lengths of stay, opioid prescriptions at discharge, and patient centered outcomes at discharge and 6 months. Discussion This trial will determine the effectiveness of sub-dissociative ketamine infusion as part of a MMPR in reducing in-hospital opioid exposure in adult trauma patients. Furthermore, it will inform decisions regarding acute pain strategies on patient centered outcomes. Trial registration The Ketamine for Acute Pain Management After Trauma (KAPT) with registration # NCT04129086 was registered on October 16, 2019.
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Affiliation(s)
- Thaddeus J Puzio
- Department of Surgery, McGovern Medical School at UTHealth, The University of Texas, Houston, TX, USA. .,The University of Texas Medical Center at Houston, Houston, TX, USA.
| | - James Klugh
- Department of Surgery, McGovern Medical School at UTHealth, The University of Texas, Houston, TX, USA
| | - Michael W Wandling
- Department of Surgery, McGovern Medical School at UTHealth, The University of Texas, Houston, TX, USA
| | - Charles Green
- Center for Clinical Research and Evidence Based Medicine, McGovern Medical School at UTHealth, Houston, TX, USA
| | - Julius Balogh
- Department of Anesthesia, University of Arkansas for Medical Sciences, Little Rock, USA
| | - Samuel J Prater
- Department of Emergency Medicine, The University of Texas Medical Center at Houston, Houston, USA
| | | | - Paulina B Sergot
- Department of Emergency Medicine, The University of Texas Medical Center at Houston, Houston, USA
| | - Charles E Wade
- Center for Translational Injury Research, Department of Surgery, McGovern Medical School at UTHealth, Houston, TX, USA
| | - Lillian S Kao
- Department of Surgery, McGovern Medical School at UTHealth, The University of Texas, Houston, TX, USA
| | - John A Harvin
- Department of Surgery, McGovern Medical School at UTHealth, The University of Texas, Houston, TX, USA
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Schriner JB, George MJ, Cardenas JC, Olson SD, Mankiewicz KA, Cox CS, Gill BS, Wade CE. PLATELET FUNCTION IN TRAUMA: IS CURRENT TECHNOLOGY IN FUNCTION TESTING MISSING THE MARK IN INJURED PATIENTS? Shock 2022; 58:1-13. [PMID: 35984758 PMCID: PMC9395128 DOI: 10.1097/shk.0000000000001948] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT Platelets are subcellular anucleate components of blood primarily responsible for initiating and maintaining hemostasis. After injury to a blood vessel, platelets can be activated via several pathways, resulting in changed shape, adherence to the injury site, aggregation to form a plug, degranulation to initiate activation in other nearby platelets, and acceleration of thrombin formation to convert fibrinogen to fibrin before contracting to strengthen the clot. Platelet function assays use agonists to induce and measure one or more of these processes to identify alterations in platelet function that increase the likelihood of bleeding or thrombotic events. In severe trauma, these assays have revealed that platelet dysfunction is strongly associated with poor clinical outcomes. However, to date, the mechanism(s) causing clinically significant platelet dysfunction remain poorly understood. We review the pros, cons, and evidence for use of many of the popular assays in trauma, discuss limitations of their use in this patient population, and present approaches that can be taken to develop improved functional assays capable of elucidating mechanisms of trauma-induced platelet dysfunction. Platelet dysfunction in trauma has been associated with need for transfusions and mortality; however, most of the current platelet function assays were not designed for evaluating trauma patients, and there are limited data regarding their use in this population. New or improved functional assays will help define the mechanisms by which platelet dysfunction occurs, as well as help optimize future treatment.
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Affiliation(s)
- Jacob B. Schriner
- Center for Translational Injury Research, Department of Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Mitchell J. George
- Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Jessica C. Cardenas
- Center for Translational Injury Research, Department of Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Scott D. Olson
- Department of Pediatric Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Kimberly A. Mankiewicz
- Center for Translational Injury Research, Department of Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Charles S. Cox
- Center for Translational Injury Research, Department of Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, TX, USA
- Department of Pediatric Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, TX, USA
- Program in Pediatric Regenerative Medicine, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA
| | - Brijesh S. Gill
- Center for Translational Injury Research, Department of Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, TX, USA
- Department of Pediatric Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Charles E. Wade
- Center for Translational Injury Research, Department of Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, TX, USA
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29
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Krocker JD, Lee KH, Henriksen HH, Wang YWW, Schoof EM, Karvelsson ST, Rolfsson Ó, Johansson PI, Pedroza C, Wade CE. Exploratory Investigation of the Plasma Proteome Associated with the Endotheliopathy of Trauma. Int J Mol Sci 2022; 23:6213. [PMID: 35682894 PMCID: PMC9181752 DOI: 10.3390/ijms23116213] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 05/27/2022] [Accepted: 05/30/2022] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND The endotheliopathy of trauma (EoT) is associated with increased mortality following injury. Herein, we describe the plasma proteome related to EoT in order to provide insight into the role of the endothelium within the systemic response to trauma. METHODS 99 subjects requiring the highest level of trauma activation were included in the study. Enzyme-linked immunosorbent assays of endothelial and catecholamine biomarkers were performed on admission plasma samples, as well as untargeted proteome quantification utilizing high-performance liquid chromatography and tandem mass spectrometry. RESULTS Plasma endothelial and catecholamine biomarker abundance was elevated in EoT. Patients with EoT (n = 62) had an increased incidence of death within 24 h at 21% compared to 3% for non-EoT (n = 37). Proteomic analysis revealed that 52 out of 290 proteins were differentially expressed between the EoT and non-EoT groups. These proteins are involved in endothelial activation, coagulation, inflammation, and oxidative stress, and include known damage-associated molecular patterns (DAMPs) and intracellular proteins specific to several organs. CONCLUSIONS We report a proteomic profile of EoT suggestive of a surge of DAMPs and inflammation driving nonspecific activation of the endothelial, coagulation, and complement systems with subsequent end-organ damage and poor clinical outcome. These findings support the utility of EoT as an index of cellular injury and delineate protein candidates for therapeutic intervention.
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Affiliation(s)
- Joseph D. Krocker
- Center for Translational Injury Research, Department of Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, TX 77030, USA; (Y.-W.W.W.); (C.E.W.)
| | - Kyung Hyun Lee
- Center for Clinical Research and Evidence-Based Medicine, Department of Pediatrics, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, TX 77030, USA; (K.H.L.); (C.P.)
| | - Hanne H. Henriksen
- Center for Endotheliomics CAG, Department of Clinical Immunology, Copenhagen University Hospital, Rigshospitalet, 2200 Copenhagen, Denmark;
| | - Yao-Wei Willa Wang
- Center for Translational Injury Research, Department of Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, TX 77030, USA; (Y.-W.W.W.); (C.E.W.)
| | - Erwin M. Schoof
- Department of Biotechnology and Biomedicine, Technical University of Denmark, 2800 Lyngby, Denmark;
| | - Sigurdur T. Karvelsson
- Center for Systems Biology, University of Iceland, 101 Reykjavik, Iceland; (S.T.K.); (Ó.R.)
| | - Óttar Rolfsson
- Center for Systems Biology, University of Iceland, 101 Reykjavik, Iceland; (S.T.K.); (Ó.R.)
| | - Pär I. Johansson
- Center for Endotheliomics CAG, Department of Clinical Immunology, Rigshospitalet, & Department of Clinical Medicine, University of Copenhagen, 2200 Copenhagen, Denmark;
| | - Claudia Pedroza
- Center for Clinical Research and Evidence-Based Medicine, Department of Pediatrics, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, TX 77030, USA; (K.H.L.); (C.P.)
| | - Charles E. Wade
- Center for Translational Injury Research, Department of Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, TX 77030, USA; (Y.-W.W.W.); (C.E.W.)
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Kalkwarf KJ, Cardenas JC, Wade CE, Cotton BA. Green Plasma has a Superior Hemostatic Profile Compared With Standard Color Plasma. Am Surg 2022; 88:1970-1975. [PMID: 35476552 DOI: 10.1177/00031348221096571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Limitations in available donors have dramatically reduced plasma availability over the past several decades, concurrent with increasing demand for some types of plasma. Plasma from female donors who are pregnant or taking oral contraceptives often has a green appearance, which frequently results in these units being discarded. This pilot study aimed to evaluate the hemostatic potential of green compared to standard-color plasma. MATERIALS AND METHODS Plasma from twelve blood group-matched female and twelve male donors was obtained from the local blood center. Six of the female and all of the male units of plasma had a normal appearance (STANDARD), while six of the female units were grossly green (GREEN). The hemostatic potential was evaluated by thrombelastography (TEG), calibrated automated thrombogram (CAT), and coagulation factor level measurements. Univariate analysis was performed using Wilcoxon Rank-Sum. RESULTS GREEN plasma was more procoagulant for all TEG values (r-value, k-time, angle, mA) when compared to STANDARD plasma. Differences were also observed in coagulation factor levels, with GREEN plasma having higher than STANDARD (factors II; VII, IX; X, XI, Protein S, and plasminogen); conversely, GREEN plasma had a longer lag time in CAT. DISCUSSION This pilot study demonstrates that female donors with green plasma have a superior hemostatic profile than standard plasma. GREEN plasma should be further investigated for its safety profile and hemostatic potential, so if it is found to be a safe and functionally non-inferior product, it should be actively re-introduced for transfusion in bleeding patients.
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Affiliation(s)
- Kyle J Kalkwarf
- Division of Trauma and Acute Care Surgery, Department of Surgery, 12215University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Jessica C Cardenas
- Center for Translational Injury Research, 12340University of Texas Health Science Center, Houston, TX, USA
| | - Charles E Wade
- Center for Translational Injury Research, 12340University of Texas Health Science Center, Houston, TX, USA
| | - Bryan A Cotton
- Department of Surgery, 12340University of Texas Health Science Center, Houston, TX, USA
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Abstract
INTRODUCTION Trauma-induced coagulopathy is a continuum ranging from hypercoagulable to hypercoagulable phenotypes. In single-center studies, the maximum amplitude (MA) to r-time (R) (MA-R) ratio has identified a phenotype of injured patients with high mortality risk. The purpose of this study was to determine the relationship between MA-R and mortality using multicenter data and to investigate fibrinogen consumption in the development of this specific coagulopathy phenotype. METHODS Using the Pragmatic Randomized Optimal Platelet and Plasma Ratios data set, patients were divided into blunt and penetrating injury cohorts. MA was divided by R time from admission thromboelastogram to calculate MA-R. MA-R was used to assess odds of early and late mortality using multivariable models. Multivariable models were used to assess thrombogram values in both cohorts. Refinement of the MA-R cut point was performed with Youden index. Repeat multivariable analysis was performed with a binary CRITICAL and NORMAL MA-R. RESULTS In initial analysis, MA-R quartiles were not associated with mortality in the penetrating cohort. In the blunt cohort, there was an association between low MA-R and early and late mortality. A refined cut point of 11 was identified (CRITICAL: MA-R, ≤11; NORMAL: MA-R, >11). CRITICAL MA-R was associated with mortality in both penetrating and blunt subgroups. In further injury subgroup analysis, CRITICAL patients had significantly decreased fibrinogen levels in the blunt subgroup only. In both blunt and penetrating injury, there was no difference in time to initiation of thrombin burst (lagtime). However, both endogenous thrombin potential and peak thrombin levels were significantly lower in CRITICAL patients. CONCLUSIONS MA-R identifies a trauma-induced coagulopathy phenotype characterized in blunt injury by impaired thrombin generation that is associated with early and late mortality. The endotheliopathy and tissue factor release likely plays a role in the cascade of impaired thrombin burst, possible early fibrinogen consumption and the weaker clot identified by MA-R. LEVEL OF EVIDENCE Therapeutic/care management, level II.
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Affiliation(s)
- James Harrington
- University of Wisconsin School of Medicine & Public Health, Madison, WI
| | - Ben L. Zarzaur
- University of Wisconsin School of Medicine & Public Health, Madison, WI
| | - Erin E. Fox
- University of Texas Health Science Center at Houston, Houston, TX
| | - Charles E. Wade
- University of Texas Health Science Center at Houston, Houston, TX
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Kregel HR, Hatton GE, Isbell KD, Henriksen HH, Stensballe J, Johansson PI, Kao LS, Wade CE. Shock-Induced Endothelial Dysfunction is Present in Patients With Occult Hypoperfusion After Trauma. Shock 2022; 57:106-112. [PMID: 34905531 PMCID: PMC9148678 DOI: 10.1097/shk.0000000000001866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Shock-induced endothelial dysfunction, evidenced by elevated soluble thrombomodulin (sTM) and syndecan-1 (Syn-1), is associated with poor outcomes after trauma. The association of endothelial dysfunction and overt shock has been demonstrated; it is unknown if hypoperfusion in the setting of normal vital signs (occult hypoperfusion [OH]) is associated with endothelial dysfunction. We hypothesized that sTM and Syn-1 would be elevated in patients with OH when compared to patients with normal perfusion. METHODS A single-center study of patients requiring highest-level trauma activation (2012-2016) was performed. Trauma bay arrival plasma Syn-1 and sTM were measured by enzyme-linked immunosorbent assay. Shock was defined as systolic blood pressure (SBP) <90 mm Hg or heart rate (HR) ≥120 bpm. OH was defined as SBP ≥ 90, HR < 120, and base excess (BE) ≤-3. Normal perfusion was assigned to all others. Univariate and multivariable analyses were performed. RESULTS Of 520 patients, 35% presented with OH and 26% with shock. Demographics were similar between groups. Patients with normal perfusion had the lowest Syn-1 and sTM, while patients with OH and shock had elevated levels. OH was associated with increased sTM by 0.97 ng/mL (95% CI 0.39-1.57, p = 0.001) and Syn-1 by 14.3 ng/mL (95% CI -1.5 to 30.2, p = 0.08). Furthermore, shock was associated with increased sTM by 0.64 (95% CI 0.02-1.30, p = 0.04) and with increased Syn-1 by 23.6 ng/mL (95% CI 6.2-41.1, p = 0.008). CONCLUSIONS Arrival OH was associated with elevated sTM and Syn-1, indicating endothelial dysfunction. Treatments aiming to stabilize the endothelium may be beneficial for injured patients with evidence of hypoperfusion, regardless of vital signs.
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Affiliation(s)
- Heather R. Kregel
- Division of Acute Care Surgery, Department of Surgery, McGovern Medical School at UTHealth, Houston, TX
- Center for Surgical Trials and Evidence-based Practice, McGovern Medical School at UTHealth, Houston, TX
- Center for Translational Injury Research, Houston, TX
| | - Gabrielle E. Hatton
- Division of Acute Care Surgery, Department of Surgery, McGovern Medical School at UTHealth, Houston, TX
- Center for Surgical Trials and Evidence-based Practice, McGovern Medical School at UTHealth, Houston, TX
- Center for Translational Injury Research, Houston, TX
| | - Kayla D. Isbell
- Division of Acute Care Surgery, Department of Surgery, McGovern Medical School at UTHealth, Houston, TX
- Center for Surgical Trials and Evidence-based Practice, McGovern Medical School at UTHealth, Houston, TX
- Center for Translational Injury Research, Houston, TX
| | - Hanne H Henriksen
- Section for Transfusion Medicine, Capital Region Blood Bank, University of Copenhagen, Copenhagen, Denmark
| | - Jakob Stensballe
- Section for Transfusion Medicine, Capital Region Blood Bank, University of Copenhagen, Copenhagen, Denmark
- Department of Anaesthesia and Trauma Centre, Centre of Head and Orthopedics, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Per I Johansson
- Section for Transfusion Medicine, Capital Region Blood Bank, University of Copenhagen, Copenhagen, Denmark
| | - Lillian S. Kao
- Division of Acute Care Surgery, Department of Surgery, McGovern Medical School at UTHealth, Houston, TX
- Center for Surgical Trials and Evidence-based Practice, McGovern Medical School at UTHealth, Houston, TX
- Center for Translational Injury Research, Houston, TX
| | - Charles E. Wade
- Division of Acute Care Surgery, Department of Surgery, McGovern Medical School at UTHealth, Houston, TX
- Center for Translational Injury Research, Houston, TX
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Knudson MM, Moore EE, Kornblith LZ, Shui AM, Brakenridge S, Bruns BR, Cipolle MD, Costantini TW, Crookes BA, Haut ER, Kerwin AJ, Kiraly LN, Knowlton LM, Martin MJ, McNutt MK, Milia DJ, Mohr A, Nirula R, Rogers FB, Scalea TM, Sixta SL, Spain DA, Wade CE, Velmahos GC. Challenging Traditional Paradigms in Posttraumatic Pulmonary Thromboembolism. JAMA Surg 2021; 157:e216356. [PMID: 34910098 DOI: 10.1001/jamasurg.2021.6356] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Importance Pulmonary clots are seen frequently on chest computed tomography performed after trauma, but recent studies suggest that pulmonary thrombosis (PT) and pulmonary embolism (PE) after trauma are independent clinical events. Objective To assess whether posttraumatic PT represents a distinct clinical entity associated with the nature of the injury, different from the traditional venous thromboembolic paradigm of deep venous thrombosis (DVT) and PE. Design, Setting, and Participants This prospective, observational, multicenter cohort study was conducted by the Consortium of Leaders in the Study of Traumatic Thromboembolism (CLOTT) study group. The study was conducted at 17 US level I trauma centers during a 2-year period (January 1, 2018, to December 31, 2020). Consecutive patients 18 to 40 years of age admitted for a minimum of 48 hours with at least 1 previously defined trauma-associated venous thromboembolism (VTE) risk factor were followed up until discharge or 30 days. Exposures Investigational imaging, prophylactic measures used, and treatment of clots. Main Outcomes and Measures The main outcomes of interest were the presence, timing, location, and treatment of any pulmonary clots, as well as the associated injury-related risk factors. Secondary outcomes included DVT. We regarded pulmonary clots with DVT as PE and those without DVT as de novo PT. Results A total of 7880 patients (mean [SD] age, 29.1 [6.4] years; 5859 [74.4%] male) were studied, 277 with DVT (3.5%), 40 with PE (0.5%), and 117 with PT (1.5%). Shock on admission was present in only 460 patients (6.2%) who had no DVT, PT, or PE but was documented in 11 (27.5%) of those with PE and 30 (25.6%) in those with PT. Risk factors independently associated with PT but not DVT or PE included shock on admission (systolic blood pressure <90 mm Hg) (odds ratio, 2.74; 95% CI, 1.72-4.39; P < .001) and major chest injury with Abbreviated Injury Score of 3 or higher (odds ratio, 1.72; 95% CI, 1.16-2.56; P = .007). Factors associated with the presence of PT on admission included major chest injury (14 patients [50.0%] with or without major chest injury with an Abbreviated Injury Score >3; P = .04) and major venous injury (23 [82.1%] without major venous injury and 5 [17.9%] with major venous injury; P = .02). No deaths were attributed to PT or PE. Conclusions and Relevance To our knowledge, this CLOTT study is the largest prospective investigation in the world that focuses on posttraumatic PT. The study suggests that most pulmonary clots are not embolic but rather result from inflammation, endothelial injury, and the hypercoagulable state caused by the injury itself.
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Affiliation(s)
| | | | | | - Amy M Shui
- Department of Epidemiology and Biostatistics, University of California, San Francisco
| | - Scott Brakenridge
- Department of Surgery, University of Florida, Gainesville.,Now with Department of Surgery, University of Washington, Seattle
| | - Brandon R Bruns
- Department of Surgery, University of Maryland, Baltimore.,Now with the Department of Surgery, University of Texas Southwestern, Dallas
| | - Mark D Cipolle
- Department of Surgery, Christiana Health Care, Newark, Delaware.,Now with the Department of Surgery Lehigh Valley Health, Allentown, Pennsylvania
| | | | - Bruce A Crookes
- Department of Surgery, Medical University of South Carolina, Charleston
| | - Elliot R Haut
- Department of Surgery, Johns Hopkins University, Baltimore, Maryland
| | - Andrew J Kerwin
- Now with Department of Surgery, University of Washington, Seattle.,Now with the Department of Surgery, University of Tennessee, Memphis
| | - Laszlo N Kiraly
- Department of Surgery, University of Oregon Health Sciences University, Portland
| | - Lisa M Knowlton
- Department of Surgery, Stanford University, Palo Alto, California
| | - Matthew J Martin
- Department of Surgery, Scripps Mercy Hospital, San Diego, California
| | | | - David J Milia
- Department of Surgery, Medical College of Wisconsin, Milwaukee
| | - Alicia Mohr
- Now with Department of Surgery, University of Washington, Seattle
| | - Ram Nirula
- Department of Surgery, University of Utah, Salt Lake City
| | - Fredrick B Rogers
- Department of Surgery, Lancaster General Hospital, Lancaster, Pennsylvania
| | | | - Sherry L Sixta
- Department of Surgery, Christiana Health Care, Newark, Delaware
| | - David A Spain
- Department of Surgery, Stanford University, Palo Alto, California
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Williams J, Gustafson M, Bai Y, Prater S, Wade CE, Guillamondegui OD, Khan M, Brenner M, Ferrada P, Roberts D, Horer T, Kauvar D, Kirkpatrick A, Ordonez C, Perreira B, Priouzram A, Duchesne J, Cotton BA. Limitations of Available Blood Products for Massive Transfusion During Mass Casualty Events at US Level 1 Trauma Centers. Shock 2021; 56:62-69. [PMID: 33470606 PMCID: PMC8601667 DOI: 10.1097/shk.0000000000001719] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2019] [Revised: 12/26/2019] [Accepted: 01/04/2021] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Exsanguination remains a leading cause of preventable death in traumatically injured patients. To better treat hemorrhagic shock, hospitals have adopted massive transfusion protocols (MTPs) which accelerate the delivery of blood products to patients. There has been an increase in mass casualty events (MCE) worldwide over the past two decades. These events can overwhelm a responding hospital's supply of blood products. Using a computerized model, this study investigated the ability of US trauma centers (TCs) to meet the blood product requirements of MCEs. METHODS Cross-sectional survey data of on-hand blood products were collected from 16 US level-1 TCs. A discrete event simulation model of a TC was developed based on historic data of blood product consumption during MCEs. Each hospital's blood bank was evaluated across increasingly more demanding MCEs using modern MTPs to guide resuscitation efforts in massive transfusion (MT) patients. RESULTS A total of 9,000 simulations were performed on each TC's data. Under the least demanding MCE scenario, the median size MCE in which TCs failed to adequately meet blood product demand was 50 patients (IQR 20-90), considering platelets. Ten TCs exhaust their supply of platelets prior to red blood cells (RBCs) or plasma. Disregarding platelets, five TCs exhausted their supply of O- packed RBCs, six exhausted their AB plasma supply, and five had a mixed exhaustion picture. CONCLUSION Assuming a TC's ability to treat patients is limited only by their supply of blood products, US level-1 TCs lack the on-hand blood products required to adequately treat patients following a MCE. Use of non-traditional blood products, which have a longer shelf life, may allow TCs to better meet the blood product requirement needs of patients following larger MCEs.
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Affiliation(s)
- James Williams
- The Center for Translational Injury Research, The McGovern Medical School at the University of Texas Health Science Center, Houston, Texas
- Department of Surgery, The McGovern Medical School at the University of Texas Health Science Center, Houston, Texas
| | - Michael Gustafson
- Duke University Pratt School of Engineering, The McGovern Medical School at the University of Texas Health Science Center, Houston, Texas
| | - Yu Bai
- Pathology and Laboratory Medicine, The McGovern Medical School at the University of Texas Health Science Center, Houston, Texas
- Department of Emergency Medicine, The McGovern Medical School at the University of Texas Health Science Center, Houston, Texas
| | - Samuel Prater
- Department of Emergency Medicine, The McGovern Medical School at the University of Texas Health Science Center, Houston, Texas
- Department of Surgery, The Red Duke Trauma Institute at Memorial Hermann Hospital, Texas Medical Center, Houston, Texas
| | - Charles E. Wade
- The Center for Translational Injury Research, The McGovern Medical School at the University of Texas Health Science Center, Houston, Texas
- Department of Surgery, The McGovern Medical School at the University of Texas Health Science Center, Houston, Texas
| | | | - Mansoor Khan
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, UK
| | - Megan Brenner
- Department of Surgery, University of California Riverside, Riverside, California
| | - Paula Ferrada
- VCU Surgery Trauma, Critical Care and Emergency Surgery, Richmond, Virginia
| | - Derek Roberts
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Ottawa, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Tal Horer
- Department of Cardiothoracic and Vascular Surgery, Faculty of Life Science Örebro University Hospital and University, Örebro, Sweden
| | - David Kauvar
- Vascular Surgery Service, San Antonio Military Medical Center, San Antonio, Texas
| | - Andrew Kirkpatrick
- Regional Trauma Services Foothills Medical Centre, Calgary, Alberta, Canada
- Departments of Surgery, Critical Care Medicine, University of Calgary, Calgary, Alberta, Canada
- Canadian Forces Health Services, Calgary, Alberta, Canada
| | - Carlos Ordonez
- Fundación Valle del Lili, Division of Trauma and Acute Care Surgery, Department of Surgery, Universidad del Valle, Cali, Valle del Cauca, Colombia
| | - Bruno Perreira
- Department of Surgery and Surgical Critical Care, University of Campinas, Campinas, Brazil
| | - Artai Priouzram
- Department of Cardiothoracic and Vascular Surgery, Linköping University Hospital, Linköping, Sweden
| | - Juan Duchesne
- Division Chief Acute Care Surgery, Department of Surgery Tulane, New Orleans, Louisiana
| | - Bryan A. Cotton
- The Center for Translational Injury Research, The McGovern Medical School at the University of Texas Health Science Center, Houston, Texas
- Department of Surgery, The McGovern Medical School at the University of Texas Health Science Center, Houston, Texas
- Department of Surgery, The Red Duke Trauma Institute at Memorial Hermann Hospital, Texas Medical Center, Houston, Texas
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Wallen TE, Hanseman D, Caldwell CC, Wang YWW, Wade CE, Holcomb JB, Pritts TA, Goodman MD. Survival analysis by inflammatory biomarkers in severely injured patients undergoing damage control resuscitation. Surgery 2021; 171:818-824. [PMID: 34844756 DOI: 10.1016/j.surg.2021.08.060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 08/10/2021] [Accepted: 08/24/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Although early balanced blood product resuscitation has improved mortality after traumatic injury, many patients still suffer from inflammatory complications. The goal of this study was to identify inflammatory mediators associated with death and multiorgan system failure following severe injury after patients undergo blood product resuscitation. METHODS A retrospective secondary analysis of inflammatory markers from the Pragmatic Randomized Optimal Platelet and Plasma Ratios study was performed. Twenty-seven serum biomarkers were measured at 8 time points in the first 72 hours of care and were compared between survivors and nonsurvivors. Biomarkers with significant differences were further analyzed by adjudicated cause of 30-day mortality. RESULTS Biomarkers from 680 patients were analyzed. Seven key inflammatory markers (IL-1ra, IL-6, IL-8, IL-10, eotaxin, IP-10, and MCP-1) were further analyzed. These cytokines were also noted to have the highest hazard ratios of death. Stepwise selection was used for multivariate analysis of survival by time point. MCP-1 at 2 hours, eotaxin and IP-10 at 12 hours, eotaxin at 24 hours, and IP-10 at 72 hours were associated with all-cause mortality. CONCLUSION Early systemic inflammatory markers are associated with increased risk of mortality after traumatic injury. Future studies should use these biomarkers to prospectively calculate risks of morbidity and causes of mortality for all trauma patients.
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Affiliation(s)
| | | | | | - Yao-Wei W Wang
- Department of Surgery, University of Texas Health Science Center at Houston, TX
| | - Charles E Wade
- Department of Surgery, University of Texas Health Science Center at Houston, TX
| | - John B Holcomb
- Department of Surgery, University of Alabama Birmingham, AL
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Hynes AM, Geng Z, Schmulevich D, Fox EE, Meador CL, Scantling DR, Holena DN, Abella BS, Young AJ, Holland S, Cacchione PZ, Wade CE, Cannon JW. Staying on target: Maintaining a balanced resuscitation during damage-control resuscitation improves survival. J Trauma Acute Care Surg 2021; 91:841-848. [PMID: 33901052 PMCID: PMC8547746 DOI: 10.1097/ta.0000000000003245] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Revised: 03/17/2021] [Accepted: 04/10/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Damage-control resuscitation (DCR) improves survival in severely bleeding patients. However, deviating from balanced transfusion ratios during a resuscitation may limit this benefit. We hypothesized that maintaining a balanced resuscitation during DCR is independently associated with improved survival. METHODS This was a secondary analysis of the Prospective Observational Multicenter Major Trauma Transfusion (PROMMTT) study. Patients receiving >3 U of packed red blood cells (PRBCs) during any 1-hour period over the first 6 hours and surviving beyond 30 minutes were included. Linear regression assessed the effect of percent time in a high-ratio range on 24-hour survival. We identified an optimal ratio and percent of time above the target ratio threshold by Youden's index. We compared patients with a 6-hour ratio above the target and above the percent time threshold (on-target) with all others (off-target). Kaplan-Meier analysis assessed the combined effect of blood product ratio and percent time over the target ratio on 24-hour and 30-day survival. Multivariable logistic regression identified factors independently associated with 24-hour and 30-day survival. RESULTS Of 1,245 PROMMTT patients, 524 met the inclusion criteria. Optimal targets were plasma/PRBC and platelet/PRBC of 0.75 (3:4) and ≥40% time spent over this threshold. For plasma/PRBC, on-target (n = 213) versus off-target (n = 311) patients were younger (median, 31 years; interquartile range, [22-50] vs. 40 [25-54]; p = 0.002) with similar injury burdens and presenting physiology. Similar patterns were observed for platelet/PRBC on-target (n = 116) and off-target (n = 408) patients. After adjusting for differences, on-target plasma/PRBC patients had significantly improved 24-hour (odds ratio, 2.25; 95% confidence interval, 1.20-4.23) and 30-day (odds ratio, 1.97; 95% confidence interval, 1.14-3.41) survival, while on-target platelet/PRBC patients did not. CONCLUSION Maintaining a high ratio of plasma/PRBC during DCR is independently associated with improved survival. Performance improvement efforts and prospective studies should capture time spent in a high-ratio range. LEVEL OF EVIDENCE Epidemiologic/prognostic study, level II; Therapeutic, level IV.
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Affiliation(s)
- Allyson M. Hynes
- From the Division of Traumatology (A.M.H., D.S., D.R.S., D.N.H., S.H., J.W.C.), Surgical Critical Care and Emergency Surgery, Penn Acute Research Collaboration (A.M.H., D.S., D.N.H., B.S.A., P.Z.C., J.W.C.), Perelman School of Medicine, Leonard Davis Institute of Health Economics (Z.G., J.W.C.), University of Pennsylvania, Philadelphia, Pennsylvania; Center for Translational Injury Research, Division of Acute Care Surgery, Department of Surgery (E.E.F., C.E.W.), Medical School, University of Texas Health Science Center at Houston, Houston; Arcos, Inc. (C.L.M.), Missouri City, Texas; Center for Resuscitation Science, Department of Emergency Medicine (B.S.A.), Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Division of Trauma, Critical Care, and Burn, Department of Surgery (A.J.Y.), The Ohio State University, Columbus, Ohio; Department of Nursing (P.Z.C.), Penn Presbyterian Medical Center, Philadelphia, Pennsylvania; and Department of Surgery (J.W.C.), Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Zhi Geng
- From the Division of Traumatology (A.M.H., D.S., D.R.S., D.N.H., S.H., J.W.C.), Surgical Critical Care and Emergency Surgery, Penn Acute Research Collaboration (A.M.H., D.S., D.N.H., B.S.A., P.Z.C., J.W.C.), Perelman School of Medicine, Leonard Davis Institute of Health Economics (Z.G., J.W.C.), University of Pennsylvania, Philadelphia, Pennsylvania; Center for Translational Injury Research, Division of Acute Care Surgery, Department of Surgery (E.E.F., C.E.W.), Medical School, University of Texas Health Science Center at Houston, Houston; Arcos, Inc. (C.L.M.), Missouri City, Texas; Center for Resuscitation Science, Department of Emergency Medicine (B.S.A.), Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Division of Trauma, Critical Care, and Burn, Department of Surgery (A.J.Y.), The Ohio State University, Columbus, Ohio; Department of Nursing (P.Z.C.), Penn Presbyterian Medical Center, Philadelphia, Pennsylvania; and Department of Surgery (J.W.C.), Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Daniela Schmulevich
- From the Division of Traumatology (A.M.H., D.S., D.R.S., D.N.H., S.H., J.W.C.), Surgical Critical Care and Emergency Surgery, Penn Acute Research Collaboration (A.M.H., D.S., D.N.H., B.S.A., P.Z.C., J.W.C.), Perelman School of Medicine, Leonard Davis Institute of Health Economics (Z.G., J.W.C.), University of Pennsylvania, Philadelphia, Pennsylvania; Center for Translational Injury Research, Division of Acute Care Surgery, Department of Surgery (E.E.F., C.E.W.), Medical School, University of Texas Health Science Center at Houston, Houston; Arcos, Inc. (C.L.M.), Missouri City, Texas; Center for Resuscitation Science, Department of Emergency Medicine (B.S.A.), Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Division of Trauma, Critical Care, and Burn, Department of Surgery (A.J.Y.), The Ohio State University, Columbus, Ohio; Department of Nursing (P.Z.C.), Penn Presbyterian Medical Center, Philadelphia, Pennsylvania; and Department of Surgery (J.W.C.), Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Erin E. Fox
- From the Division of Traumatology (A.M.H., D.S., D.R.S., D.N.H., S.H., J.W.C.), Surgical Critical Care and Emergency Surgery, Penn Acute Research Collaboration (A.M.H., D.S., D.N.H., B.S.A., P.Z.C., J.W.C.), Perelman School of Medicine, Leonard Davis Institute of Health Economics (Z.G., J.W.C.), University of Pennsylvania, Philadelphia, Pennsylvania; Center for Translational Injury Research, Division of Acute Care Surgery, Department of Surgery (E.E.F., C.E.W.), Medical School, University of Texas Health Science Center at Houston, Houston; Arcos, Inc. (C.L.M.), Missouri City, Texas; Center for Resuscitation Science, Department of Emergency Medicine (B.S.A.), Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Division of Trauma, Critical Care, and Burn, Department of Surgery (A.J.Y.), The Ohio State University, Columbus, Ohio; Department of Nursing (P.Z.C.), Penn Presbyterian Medical Center, Philadelphia, Pennsylvania; and Department of Surgery (J.W.C.), Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Christopher L. Meador
- From the Division of Traumatology (A.M.H., D.S., D.R.S., D.N.H., S.H., J.W.C.), Surgical Critical Care and Emergency Surgery, Penn Acute Research Collaboration (A.M.H., D.S., D.N.H., B.S.A., P.Z.C., J.W.C.), Perelman School of Medicine, Leonard Davis Institute of Health Economics (Z.G., J.W.C.), University of Pennsylvania, Philadelphia, Pennsylvania; Center for Translational Injury Research, Division of Acute Care Surgery, Department of Surgery (E.E.F., C.E.W.), Medical School, University of Texas Health Science Center at Houston, Houston; Arcos, Inc. (C.L.M.), Missouri City, Texas; Center for Resuscitation Science, Department of Emergency Medicine (B.S.A.), Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Division of Trauma, Critical Care, and Burn, Department of Surgery (A.J.Y.), The Ohio State University, Columbus, Ohio; Department of Nursing (P.Z.C.), Penn Presbyterian Medical Center, Philadelphia, Pennsylvania; and Department of Surgery (J.W.C.), Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Dane R. Scantling
- From the Division of Traumatology (A.M.H., D.S., D.R.S., D.N.H., S.H., J.W.C.), Surgical Critical Care and Emergency Surgery, Penn Acute Research Collaboration (A.M.H., D.S., D.N.H., B.S.A., P.Z.C., J.W.C.), Perelman School of Medicine, Leonard Davis Institute of Health Economics (Z.G., J.W.C.), University of Pennsylvania, Philadelphia, Pennsylvania; Center for Translational Injury Research, Division of Acute Care Surgery, Department of Surgery (E.E.F., C.E.W.), Medical School, University of Texas Health Science Center at Houston, Houston; Arcos, Inc. (C.L.M.), Missouri City, Texas; Center for Resuscitation Science, Department of Emergency Medicine (B.S.A.), Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Division of Trauma, Critical Care, and Burn, Department of Surgery (A.J.Y.), The Ohio State University, Columbus, Ohio; Department of Nursing (P.Z.C.), Penn Presbyterian Medical Center, Philadelphia, Pennsylvania; and Department of Surgery (J.W.C.), Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Daniel N. Holena
- From the Division of Traumatology (A.M.H., D.S., D.R.S., D.N.H., S.H., J.W.C.), Surgical Critical Care and Emergency Surgery, Penn Acute Research Collaboration (A.M.H., D.S., D.N.H., B.S.A., P.Z.C., J.W.C.), Perelman School of Medicine, Leonard Davis Institute of Health Economics (Z.G., J.W.C.), University of Pennsylvania, Philadelphia, Pennsylvania; Center for Translational Injury Research, Division of Acute Care Surgery, Department of Surgery (E.E.F., C.E.W.), Medical School, University of Texas Health Science Center at Houston, Houston; Arcos, Inc. (C.L.M.), Missouri City, Texas; Center for Resuscitation Science, Department of Emergency Medicine (B.S.A.), Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Division of Trauma, Critical Care, and Burn, Department of Surgery (A.J.Y.), The Ohio State University, Columbus, Ohio; Department of Nursing (P.Z.C.), Penn Presbyterian Medical Center, Philadelphia, Pennsylvania; and Department of Surgery (J.W.C.), Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Benjamin S. Abella
- From the Division of Traumatology (A.M.H., D.S., D.R.S., D.N.H., S.H., J.W.C.), Surgical Critical Care and Emergency Surgery, Penn Acute Research Collaboration (A.M.H., D.S., D.N.H., B.S.A., P.Z.C., J.W.C.), Perelman School of Medicine, Leonard Davis Institute of Health Economics (Z.G., J.W.C.), University of Pennsylvania, Philadelphia, Pennsylvania; Center for Translational Injury Research, Division of Acute Care Surgery, Department of Surgery (E.E.F., C.E.W.), Medical School, University of Texas Health Science Center at Houston, Houston; Arcos, Inc. (C.L.M.), Missouri City, Texas; Center for Resuscitation Science, Department of Emergency Medicine (B.S.A.), Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Division of Trauma, Critical Care, and Burn, Department of Surgery (A.J.Y.), The Ohio State University, Columbus, Ohio; Department of Nursing (P.Z.C.), Penn Presbyterian Medical Center, Philadelphia, Pennsylvania; and Department of Surgery (J.W.C.), Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Andrew J. Young
- From the Division of Traumatology (A.M.H., D.S., D.R.S., D.N.H., S.H., J.W.C.), Surgical Critical Care and Emergency Surgery, Penn Acute Research Collaboration (A.M.H., D.S., D.N.H., B.S.A., P.Z.C., J.W.C.), Perelman School of Medicine, Leonard Davis Institute of Health Economics (Z.G., J.W.C.), University of Pennsylvania, Philadelphia, Pennsylvania; Center for Translational Injury Research, Division of Acute Care Surgery, Department of Surgery (E.E.F., C.E.W.), Medical School, University of Texas Health Science Center at Houston, Houston; Arcos, Inc. (C.L.M.), Missouri City, Texas; Center for Resuscitation Science, Department of Emergency Medicine (B.S.A.), Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Division of Trauma, Critical Care, and Burn, Department of Surgery (A.J.Y.), The Ohio State University, Columbus, Ohio; Department of Nursing (P.Z.C.), Penn Presbyterian Medical Center, Philadelphia, Pennsylvania; and Department of Surgery (J.W.C.), Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Sara Holland
- From the Division of Traumatology (A.M.H., D.S., D.R.S., D.N.H., S.H., J.W.C.), Surgical Critical Care and Emergency Surgery, Penn Acute Research Collaboration (A.M.H., D.S., D.N.H., B.S.A., P.Z.C., J.W.C.), Perelman School of Medicine, Leonard Davis Institute of Health Economics (Z.G., J.W.C.), University of Pennsylvania, Philadelphia, Pennsylvania; Center for Translational Injury Research, Division of Acute Care Surgery, Department of Surgery (E.E.F., C.E.W.), Medical School, University of Texas Health Science Center at Houston, Houston; Arcos, Inc. (C.L.M.), Missouri City, Texas; Center for Resuscitation Science, Department of Emergency Medicine (B.S.A.), Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Division of Trauma, Critical Care, and Burn, Department of Surgery (A.J.Y.), The Ohio State University, Columbus, Ohio; Department of Nursing (P.Z.C.), Penn Presbyterian Medical Center, Philadelphia, Pennsylvania; and Department of Surgery (J.W.C.), Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Pamela Z. Cacchione
- From the Division of Traumatology (A.M.H., D.S., D.R.S., D.N.H., S.H., J.W.C.), Surgical Critical Care and Emergency Surgery, Penn Acute Research Collaboration (A.M.H., D.S., D.N.H., B.S.A., P.Z.C., J.W.C.), Perelman School of Medicine, Leonard Davis Institute of Health Economics (Z.G., J.W.C.), University of Pennsylvania, Philadelphia, Pennsylvania; Center for Translational Injury Research, Division of Acute Care Surgery, Department of Surgery (E.E.F., C.E.W.), Medical School, University of Texas Health Science Center at Houston, Houston; Arcos, Inc. (C.L.M.), Missouri City, Texas; Center for Resuscitation Science, Department of Emergency Medicine (B.S.A.), Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Division of Trauma, Critical Care, and Burn, Department of Surgery (A.J.Y.), The Ohio State University, Columbus, Ohio; Department of Nursing (P.Z.C.), Penn Presbyterian Medical Center, Philadelphia, Pennsylvania; and Department of Surgery (J.W.C.), Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Charles E. Wade
- From the Division of Traumatology (A.M.H., D.S., D.R.S., D.N.H., S.H., J.W.C.), Surgical Critical Care and Emergency Surgery, Penn Acute Research Collaboration (A.M.H., D.S., D.N.H., B.S.A., P.Z.C., J.W.C.), Perelman School of Medicine, Leonard Davis Institute of Health Economics (Z.G., J.W.C.), University of Pennsylvania, Philadelphia, Pennsylvania; Center for Translational Injury Research, Division of Acute Care Surgery, Department of Surgery (E.E.F., C.E.W.), Medical School, University of Texas Health Science Center at Houston, Houston; Arcos, Inc. (C.L.M.), Missouri City, Texas; Center for Resuscitation Science, Department of Emergency Medicine (B.S.A.), Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Division of Trauma, Critical Care, and Burn, Department of Surgery (A.J.Y.), The Ohio State University, Columbus, Ohio; Department of Nursing (P.Z.C.), Penn Presbyterian Medical Center, Philadelphia, Pennsylvania; and Department of Surgery (J.W.C.), Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Jeremy W. Cannon
- From the Division of Traumatology (A.M.H., D.S., D.R.S., D.N.H., S.H., J.W.C.), Surgical Critical Care and Emergency Surgery, Penn Acute Research Collaboration (A.M.H., D.S., D.N.H., B.S.A., P.Z.C., J.W.C.), Perelman School of Medicine, Leonard Davis Institute of Health Economics (Z.G., J.W.C.), University of Pennsylvania, Philadelphia, Pennsylvania; Center for Translational Injury Research, Division of Acute Care Surgery, Department of Surgery (E.E.F., C.E.W.), Medical School, University of Texas Health Science Center at Houston, Houston; Arcos, Inc. (C.L.M.), Missouri City, Texas; Center for Resuscitation Science, Department of Emergency Medicine (B.S.A.), Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Division of Trauma, Critical Care, and Burn, Department of Surgery (A.J.Y.), The Ohio State University, Columbus, Ohio; Department of Nursing (P.Z.C.), Penn Presbyterian Medical Center, Philadelphia, Pennsylvania; and Department of Surgery (J.W.C.), Uniformed Services University of the Health Sciences, Bethesda, Maryland
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Hatton GE, Kregel HR, Pedroza C, Puzio TJ, Adams SD, Wade CE, Kao LS, Harvin JA. Age-related Opioid Exposure in Trauma: A Secondary Analysis of the Multimodal Analgesia Strategies for Trauma (MAST) Randomized Trial. Ann Surg 2021; 274:565-571. [PMID: 34506311 PMCID: PMC8783293 DOI: 10.1097/sla.0000000000005065] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Evaluate the effect of age on opioid consumption after traumatic injury. SUMMARY BACKGROUND DATA Older trauma patients receive fewer opioids due to decreased metabolism and increased complications, but adequacy of pain control is unknown. We hypothesized that older trauma patients require fewer opioids to achieve adequate pain control. METHODS A secondary analysis of the multimodal analgesia strategies for trauma Trial evaluating the effectiveness of 2 multimodal pain regimens in 1561 trauma patients aged 16 to 96 was performed. Older patients (≥55 years) were compared to younger patients. Median daily oral morphine milligram equivalents (MME) consumption, average numeric rating scale pain scores, complications, and death were assessed. Multivariable analyses were performed. RESULTS Older patients (n = 562) had a median age of 68 years (interquartile range 61-78) compared to 33 (24-43) in younger patients. Older patients had lower injury severity scores (13 [9-20] vs 14 [9-22], P = 0.004), lower average pain scores (numeric rating scale 3 [1-4] vs 4 [2-5], P < 0.001), and consumed fewer MME/day (22 [10-45] vs 52 [28-78], P < 0.001). The multimodal analgesia strategies for trauma multi-modal pain regimen was effective at reducing opioid consumption at all ages. Additionally, on multivariable analysis including pain score adjustment, each decade age increase after 55 years was associated with a 23% reduction in MME/day consumed. CONCLUSIONS Older trauma patients required fewer opioids than younger patients with similar characteristics and pain scores. Opioid dosing for post-traumatic pain should consider age. A 20 to 25% dose reduction per decade after age 55 may reduce opioid exposure without altering pain control.
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Affiliation(s)
- Gabrielle E Hatton
- Department of Surgery, Division of Acute Care Surgery, McGovern Medical School at UTHealth, Houston, Texas
- Center for Surgical Trials and Evidence-based Practice, McGovern Medical School at UTHealth, Houston, Texas
- Center for Translational Injury Research, Houston, Texas
| | - Heather R Kregel
- Department of Surgery, Division of Acute Care Surgery, McGovern Medical School at UTHealth, Houston, Texas
- Center for Surgical Trials and Evidence-based Practice, McGovern Medical School at UTHealth, Houston, Texas
- Center for Translational Injury Research, Houston, Texas
| | - Claudia Pedroza
- Department of Pediatrics, McGovern Medical School at UTHealth, Houston, Texas
| | - Thaddeus J Puzio
- Department of Surgery, Division of Acute Care Surgery, McGovern Medical School at UTHealth, Houston, Texas
- Center for Translational Injury Research, Houston, Texas
| | - Sasha D Adams
- Department of Surgery, Division of Acute Care Surgery, McGovern Medical School at UTHealth, Houston, Texas
- Center for Translational Injury Research, Houston, Texas
| | - Charles E Wade
- Department of Surgery, Division of Acute Care Surgery, McGovern Medical School at UTHealth, Houston, Texas
- Center for Translational Injury Research, Houston, Texas
| | - Lillian S Kao
- Department of Surgery, Division of Acute Care Surgery, McGovern Medical School at UTHealth, Houston, Texas
- Center for Surgical Trials and Evidence-based Practice, McGovern Medical School at UTHealth, Houston, Texas
- Center for Translational Injury Research, Houston, Texas
| | - John A Harvin
- Department of Surgery, Division of Acute Care Surgery, McGovern Medical School at UTHealth, Houston, Texas
- Center for Translational Injury Research, Houston, Texas
- Center for Clinical Research and Evidence Based Medicine, McGovern Medical School at UTHealth, Houston, Texas
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McCoy CC, Montgomery K, Cotton ME, Meyer DE, Wade CE, Cotton BA. Can RH+ whole blood be safely used as an alternative to RH- product? An analysis of efforts to improve the sustainability of a hospital's low titer group O whole blood program. J Trauma Acute Care Surg 2021; 91:627-633. [PMID: 34238860 DOI: 10.1097/ta.0000000000003342] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Low-titer group O whole blood (LTO-WB) has recently gained popularity in trauma centers for the acute resuscitation of hemorrhagic shock. However, limited supplies of Rh- product prevent implementation and strain sustainability at many trauma centers. We set out to identify whether Rh+ LTO-WB could be safely substituted for RH- product, regardless of patient's Rh status. METHODS Following Institutional Review Board approval, information on all trauma patients receiving prehospital or emergency department transfusion of uncrossed, emergency release LTO-WB (11/17-10/19) were evaluated. Patients were first divided into those who received Rh- versus Rh+ product, the assessed by Rh of the recipient. Serial hemolysis panels, transfusion reactions, and outcomes were compared. RESULTS Six hundred thirty-seven consecutive trauma patients received emergency release LTO-WB. Of these, 448 received Rh+ product, while 189 received Rh- LTO-WB. Patients receiving Rh+ product were more likely to be men (81 vs. 70%) and have lower field blood pressure (median 99 vs. 109) and GCS (median 7 vs. 12); all p < 0.05. There were no differences in blood product volume, hemolysis laboratories, transfusion reactions, complications, or survival. We then separated patients by Rh status (577 were Rh+, 70 were Rh-). Rh- patients were older (median age 54 vs. 39), more likely to be women (57 vs. 26%), and more likely to have sustained blunt trauma than their Rh+ counterparts (92 vs. 70%); all p < 0.05. There were no differences in hemolysis laboratories, transfusion reactions, complications, or survival between Rh+ and Rh- patients, regardless of Rh product received. CONCLUSION When Rh- whole blood is unavailable or in short supply, Rh+ LTO-WB appears to be a safe alternative for the resuscitation of hemorrhagic shock in both Rh+ and Rh- patients. Use of Rh+ product may help trauma centers incorporate LTO-WB into their hospital and improve sustainability of such programs. LEVEL OF EVIDENCE Therapeutic, Level III.
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Affiliation(s)
- C Cameron McCoy
- From the Department of Surgery and The Center for Translational Injury, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas
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Hatton GE, Mollett PJ, Du RE, Wei S, Korupolu R, Wade CE, Adams SD, Kao LS. High tidal volume ventilation is associated with ventilator-associated pneumonia in acute cervical spinal cord injury. J Spinal Cord Med 2021; 44:775-781. [PMID: 32043943 PMCID: PMC8477933 DOI: 10.1080/10790268.2020.1722936] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Abstract
CONTEXT/OBJECTIVE Pneumonia is the leading cause of death after acute spinal cord injury (SCI). High tidal volume ventilation (HVtV) is used in SCI rehabilitation centers to overcome hypoventilation while weaning patients from the ventilator. Our objective was to determine if HVtV in the acute post-injury period in SCI patients is associated with lower incidence of ventilator-associated pneumonia (VAP) when compared to patients receiving standard tidal volume ventilation. DESIGN Cohort study. SETTING Red Duke Trauma Institute, University of Texas Health Science Center at Houston, TX, USA. PARTICIPANTS Adult Acute Cervical SCI Patients, 2011-2018. INTERVENTIONS HVtV. OUTCOME MEASURES VAP, ventilator dependence at discharge, in-hospital mortality. RESULTS Of 181 patients, 85 (47%) developed VAP. HVtV was utilized in 22 (12%) patients. Demographics, apart from age, were similar between patients who received HVtV and standard ventilation; patients were younger in the HVtV group. VAP developed in 68% of patients receiving HVtV and in 44% receiving standard tidal volumes (P = 0.06). After adjustment, HVtV was associated with a 1.96 relative risk of VAP development (95% credible interval 1.55-2.17) on Bayesian analysis. These results correlate with a >99% posterior probability that HVtV is associated with increased VAP when compared to standard tidal volumes. HVtV was also associated with increased rates of ventilator dependence. CONCLUSIONS While limited by sample size and selection bias, our data revealed an association between HVtV and increased VAP. Further investigation into optimal early ventilation settings is needed for SCI patients, who are at a high risk of VAP.
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Affiliation(s)
- Gabrielle E. Hatton
- Center for Translational Injury Research, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA,Department of Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA,Center for Surgical Trials and Evidence-based Practice, HoustonTexas, USA,Corresponding to: Gabrielle E. Hatton, Department of Surgery, McGovern Medical School at the University of Texas Health Science Center, 6410 Fannin Street Suite 471, Houston, TX77030, USA; Ph: 713-500-4330, fax: 713-500-0714.
| | - Patrick J. Mollett
- Department of Physical Medicine and Rehabilitation, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
| | - Reginald E. Du
- Center for Translational Injury Research, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA,McGovern Medical School at the University of Texas Health Science Center, HoustonTexas, USA
| | - Shuyan Wei
- Center for Translational Injury Research, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA,Department of Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA,Center for Surgical Trials and Evidence-based Practice, HoustonTexas, USA
| | - Radha Korupolu
- Department of Physical Medicine and Rehabilitation, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
| | - Charles E. Wade
- Center for Translational Injury Research, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA,Department of Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
| | - Sasha D. Adams
- Center for Translational Injury Research, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA,Department of Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
| | - Lillian S. Kao
- Center for Translational Injury Research, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA,Department of Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA,Center for Surgical Trials and Evidence-based Practice, HoustonTexas, USA
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40
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Isbell KD, Hatton GE, Wei S, Green C, Truong VTT, Woloski J, Pedroza C, Wade CE, Harvin JA, Kao LS. Risk Stratification for Superficial Surgical Site Infection after Emergency Trauma Laparotomy. Surg Infect (Larchmt) 2021; 22:697-704. [PMID: 33404358 PMCID: PMC8377508 DOI: 10.1089/sur.2020.242] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Superficial surgical site infections (S-SSIs) are common after trauma laparotomy, leading to morbidity, increased costs, and prolonged length of stay (LOS). Opportunities to mitigate S-SSI risks are limited to the intra-operative and post-operative periods. Accurate S-SSI risk stratification is paramount at the time of operation to inform immediate management. We aimed to develop a risk calculator to aid in surgical decision-making at the time of emergency laparotomy. Methods: A retrospective cohort study of patients requiring emergency trauma laparotomy between 2011 and 2017 at a single, level 1 trauma center was performed. Operative factors, skin management strategy, and outcomes were determined by chart review. Bayesian multilevel logistic regression was utilized to create a risk calculator with variables available upon closure of the laparotomy. Models were validated on a 30% test cohort and discrimination reported as an area under the receiver operating characteristics curve (AUROC). Results: Of 1,322 patients, the majority were male (77%) with median age of 33 years, injured by blunt mechanism (54%), and median injury severity score of 19. Eighty-eight (7%) patients developed an S-SSI. Patients who developed S-SSI had higher final lactate, blood loss, transfusion requirements, and wound classification. Patients with S-SSI more frequently had mesenteric or large bowel injury than those without S-SSI. Superficial SSI was associated with increased complications and prolonged length of stay (LOS). The S-SSI predictive model demonstrated moderate discrimination with an AUROC of 0.69 (95% confidence interval [CI], 0.56-0.81). Parameters contributing the most to the model were damage control laparotomy, full-thickness large bowel injury, and large bowel resection. Conclusion: A predictive model for S-SSI was built using factors available to the surgeon upon index emergency trauma laparotomy closure. This calculator may be used to standardize intra- and post-operative care and to identify high-risk patients in whom to test novel preventative strategies and improve overall outcomes for patients requiring emergency trauma laparotomy.
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Affiliation(s)
- Kayla D. Isbell
- Department of Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
- Center for Surgical Trials and Evidence-based Practice, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
- Center for Translational Injury Research, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
| | - Gabrielle E. Hatton
- Department of Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
- Center for Surgical Trials and Evidence-based Practice, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
- Center for Translational Injury Research, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
| | - Shuyan Wei
- Department of Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
- Center for Surgical Trials and Evidence-based Practice, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
- Center for Translational Injury Research, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
| | - Charles Green
- Center for Clinical Research and Evidence-Based Medicine, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
| | - Van Thi Thanh Truong
- Center for Clinical Research and Evidence-Based Medicine, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
| | - Jacqueline Woloski
- Department of Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
| | - Claudia Pedroza
- Center for Clinical Research and Evidence-Based Medicine, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
| | - Charles E. Wade
- Department of Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
- Center for Translational Injury Research, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
| | - John A. Harvin
- Department of Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
- Center for Surgical Trials and Evidence-based Practice, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
- Center for Translational Injury Research, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
| | - Lillian S. Kao
- Department of Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
- Center for Surgical Trials and Evidence-based Practice, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
- Center for Translational Injury Research, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
- Center for Clinical Research and Evidence-Based Medicine, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
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41
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Moffatt LT, Madrzykowski D, Gibson ALF, Powell HM, Cancio LC, Wade CE, Choudhry MA, Kovacs EJ, Finnerty CC, Majetschak M, Shupp JW. Standards in Biologic Lesions: Cutaneous Thermal Injury and Inhalation Injury Working Group 2018 Meeting Proceedings. J Burn Care Res 2021; 41:604-611. [PMID: 32011688 PMCID: PMC7195554 DOI: 10.1093/jbcr/irz207] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
On August 27 and 28, 2018, the American Burn Association, in conjunction with Underwriters Laboratories, convened a group of experts on burn and inhalation injury in Washington, DC. The goal of the meeting was to identify and discuss the existing knowledge, data, and modeling gaps related to understanding cutaneous thermal injury and inhalation injury due to exposure from a fire environment, and in addition, address two more areas proposed by the American Burn Association Research Committee that are critical to burn care but may have current translational research gaps (inflammatory response and hypermetabolic response). Representatives from the Underwriters Laboratories Firefighter Safety Research Institute and the Bureau of Alcohol, Tobacco, Firearms and Explosives Fire Research Laboratory presented the state of the science in their fields, highlighting areas that required further investigation and guidance from the burn community. Four areas were discussed by the full 24 participant group and in smaller groups: Basic and Translational Understanding of Inhalation Injury, Thermal Contact and Resulting Injury, Systemic Inflammatory Response and Resuscitation, and Hypermetabolic Response and Healing. A primary finding was the need for validating historic models to develop a set of reliable data on contact time and temperature and resulting injury. The working groups identified common areas of focus across each subtopic, including gaining an understanding of individual response to injury that would allow for precision medicine approaches. Predisposed phenotype in response to insult, the effects of age and sex, and the role of microbiomes could all be studied by employing multi-omic (systems biology) approaches.
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Affiliation(s)
- Lauren T Moffatt
- Firefighters' Burn and Surgical Research Laboratory, MedStar Health Research Institute, Washington, DC.,Department of Biochemistry and Molecular and Cellular Biology, Georgetown University School of Medicine, Washington, DC
| | | | - Angela L F Gibson
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Heather M Powell
- Department of Materials Science and Engineering, The Ohio State University, Columbus, OH.,Department of Biomedical Engineering, The Ohio State University, Columbus, OH.,Research Department, Shriners Hospitals for Children, Cincinnati, OH
| | - Leopoldo C Cancio
- United States Army Institute of Surgical Research, JBSA Fort Sam Houston, TX
| | - Charles E Wade
- Center for Translational Injury Research (CeTIR), Department of Surgery, University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX
| | - Mashkoor A Choudhry
- Department of Surgery, Burn & Shock Trauma Research Institute, Health Sciences Division, Loyola University, Maywood, IL
| | - Elizabeth J Kovacs
- Department of Surgery, Division of GI, Trauma and Endocrine Surgery, University of Colorado Denver Anschutz Medical Campus, Aurora CO
| | - Celeste C Finnerty
- Departments of Surgery and Orthopaedic Surgery and Rehabilitation, University of Texas Medical Branch and Shriners Burns Hospital, Galveston TX
| | - Matthias Majetschak
- Departments of Surgery and Molecular Pharmacology and Physiology, Morsani College of Medicine, University of South Florida, Tampa, FL
| | - Jeffrey W Shupp
- Firefighters' Burn and Surgical Research Laboratory, MedStar Health Research Institute, Washington, DC.,Department of Biochemistry and Molecular and Cellular Biology, Georgetown University School of Medicine, Washington, DC.,The Burn Center, MedStar Washington Hospital Center, Washington DC.,Department of Surgery, Georgetown University School of Medicine, Washington, DC
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Harvin JA, Adams SD, Dodwad SJM, Isbell KD, Pedroza C, Green C, Tyson JE, Taub EA, Meyer DE, Moore LJ, Albarado R, McNutt MK, Kao LS, Wade CE, Holcomb JB. Damage control laparotomy in trauma: a pilot randomized controlled trial. The DCL trial. Trauma Surg Acute Care Open 2021; 6:e000777. [PMID: 34423135 PMCID: PMC8323393 DOI: 10.1136/tsaco-2021-000777] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 07/05/2021] [Indexed: 11/03/2022] Open
Abstract
Background Although widely used in treating severe abdominal trauma, damage control laparotomy (DCL) has not been assessed in any randomized controlled trial. We conducted a pilot trial among patients for whom our surgeons had equipoise and hypothesized that definitive laparotomy (DEF) would reduce major abdominal complications (MAC) or death within 30 days compared with DCL. Methods Eligible patients undergoing emergency laparotomy were randomized during surgery to DCL or DEF from July 2016 to May 2019. The primary outcome was MAC or death within 30 days. Prespecified frequentist and Bayesian analyses were performed. Results Of 489 eligible patients, 39 patients were randomized (DCL 18, DEF 21) and included. Groups were similar in demographics and mechanism of injury. The DEF group had a higher Injury Severity Score (DEF median 34 (IQR 20, 43) vs DCL 29 (IQR 22, 41)) and received more prerandomization blood products (DEF median red blood cells 8 units (IQR 6, 11) vs DCL 6 units (IQR 2, 11)). In unadjusted analyses, the DEF group had more MAC or death within 30 days (1.71, 95% CI 0.81 to 3.63, p=0.159) due to more deaths within 30 days (DEF 33% vs DCL 0%, p=0.010). Adjustment for Injury Severity Score and prerandomization blood products reduced the risk ratio for MAC or death within 30 days to 1.54 (95% CI 0.71 to 3.32, p=0.274). The Bayesian probability that DEF increased MAC or death within 30 days was 85% in unadjusted analyses and 66% in adjusted analyses. Conclusion The findings of our single center pilot trial were inconclusive. Outcomes were not worse with DCL and, in fact, may have been better. A randomized clinical trial of DCL is feasible and a larger, multicenter trial is needed to compare DCL and DEF for patients with severe abdominal trauma. Level of evidence Level II.
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Affiliation(s)
- John A Harvin
- Department of Surgery, The University of Texas Health Science Center at Houston, Houston, Texas, USA
- Center for Clinical Research and Evidence-Based Medicine, The University of Texas Health Science Center at Houston, Houston, Texas, USA
- Center for Translational Injury Research, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Sasha D Adams
- Department of Surgery, The University of Texas Health Science Center at Houston, Houston, Texas, USA
- Center for Translational Injury Research, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Shah-Jahan M Dodwad
- Department of Surgery, The University of Texas Health Science Center at Houston, Houston, Texas, USA
- Center for Translational Injury Research, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Kayla D Isbell
- Department of Surgery, The University of Texas Health Science Center at Houston, Houston, Texas, USA
- Center for Translational Injury Research, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Claudia Pedroza
- Center for Clinical Research and Evidence-Based Medicine, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Charles Green
- Center for Clinical Research and Evidence-Based Medicine, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Jon E Tyson
- Center for Clinical Research and Evidence-Based Medicine, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Ethan A Taub
- Department of Surgery, The University of Texas Health Science Center at Houston, Houston, Texas, USA
- Center for Translational Injury Research, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - David E Meyer
- Department of Surgery, The University of Texas Health Science Center at Houston, Houston, Texas, USA
- Center for Translational Injury Research, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Laura J Moore
- Department of Surgery, The University of Texas Health Science Center at Houston, Houston, Texas, USA
- Center for Translational Injury Research, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Rondel Albarado
- Department of Surgery, The University of Texas Health Science Center at Houston, Houston, Texas, USA
- Center for Translational Injury Research, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Michelle K McNutt
- Department of Surgery, The University of Texas Health Science Center at Houston, Houston, Texas, USA
- Center for Translational Injury Research, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Lillian S Kao
- Department of Surgery, The University of Texas Health Science Center at Houston, Houston, Texas, USA
- Center for Clinical Research and Evidence-Based Medicine, The University of Texas Health Science Center at Houston, Houston, Texas, USA
- Center for Translational Injury Research, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Charles E Wade
- Department of Surgery, The University of Texas Health Science Center at Houston, Houston, Texas, USA
- Center for Translational Injury Research, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - John B Holcomb
- Center for Injury Science, The University of Alabama at Birmingham School of Medicine, Birmingham, Alabama, USA
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Nichol G, Zhuang R, Russell R, Holcomb JB, Kudenchuk PJ, Aufderheide TP, Morrison L, Sugarman J, Ornato JP, Callaway CW, Vaillancourt C, Bulger E, Christenson J, Daya MR, Schreiber M, Idris A, Podbielski JM, Sopko G, Wang H, Wade CE, Hoyt D, Weisfeldt ML, May S. Variation in time to notification of enrollment and rates of withdrawal in resuscitation trials conducted under exception from informed consent. Resuscitation 2021; 168:160-166. [PMID: 34384820 DOI: 10.1016/j.resuscitation.2021.07.039] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 06/19/2021] [Accepted: 07/27/2021] [Indexed: 12/30/2022]
Abstract
IMPORTANCE Emergency research is challenging to do well as it involves time sensitive interventions in unstable patients. There is limited time to obtain informed consent from the patient or their legally authorized representative (LAR). Such research is permitted under exception from informed consent (EFIC) if specific criteria are met, including notification after enrollment. Some question whether the risks of EFIC outweighs its benefits. To date, there is limited empiric information about time to notification (TTN) and rates of withdrawal in such trials. OBJECTIVE To describe variation in TTN and rates of withdrawal among that patients enrolled in EFIC trials over a twelve-year period. DESIGN We performed post hoc descriptive analyses of data from five trials conducted under EFIC. SETTING Emergency medical services and receiving hospitals participating in the Resuscitation Outcomes Consortium in the United States and Canada. PARTICIPANTS Patients with out-of-hospital cardiac arrest or life-threatening traumatic injury. EXPOSURES Notification strategies were specified at each site before initiation of enrollment by a local institutional review board. We monitored TTN within each site centrally throughout each study's enrollment period. OUTCOMES TTN was defined as time from randomization to first-reported notification of patient or LAR of enrollment. Withdrawal was defined as patient or LAR opt out of ongoing participation at the time of notification. RESULTS Of 35,442 patients enrolled in five trials, 33,805 had cardiac arrest; and 1636 had traumatic injury. TTN varied overall and by patient outcome. Among those with cardiac arrest, TTN ranged from median (5%ile, 95%ile) of 6 (1,27) days to 28 (2, 53) days across sites. 0.3% of notified patients with cardiac arrest withdrew. Among those with traumatic injury, TTN ranged from 0 (0, 5) days to 36 (5, 68) days across sites. 7.7% of notified patients with traumatic injury withdrew. CONCLUSIONS AND RELEVANCE There is large variation in TTN in trials conducted under EFIC for emergency research. This may be due to several factors. It may or may not be modifiable. Overall rates of withdrawal are low, which suggests current practices related to EFIC are acceptable to those who have participated in emergency research.
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Affiliation(s)
- Graham Nichol
- University of Washington-Harborview Center for Prehospital Emergency Care, Departments of Medicine and Emergency Medicine, University of Washington, Seattle, WA, United States.
| | - Rui Zhuang
- Department of Biostatistics, University of Washington, Seattle, WA, United States
| | - Renee Russell
- Department of Biostatistics, University of Washington, Seattle, WA, United States
| | - John B Holcomb
- Center for Injury Science, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Peter J Kudenchuk
- King County EMS and Departments of Medicine, University of Washington, Seattle, WA, United States
| | - Tom P Aufderheide
- Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Laurie Morrison
- Rescu, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Division of Emergency Medicine, Department of Medicine, University of Toronto, Ottawa, ON and Vancouver, BC, Canada
| | - Jeremy Sugarman
- Berman Institute of Bioethics, Department of Medicine and Department of Health Policy and Management, Johns Hopkins University, Baltimore, MD, United States
| | - Joseph P Ornato
- Department of Emergency Medicine, Virginia Commonwealth University Health, Richmond, VA, United States
| | - Clifton W Callaway
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, United States
| | - Christian Vaillancourt
- Ottawa Hospital Research Institute and Department of Emergency Medicine, University of Ottawa, Ottawa, ON, United States
| | - Eileen Bulger
- Department of Surgery, University of Washington, Seattle, WA, United States
| | - Jim Christenson
- Department of Emergency Medicine, University of British Columbia, Providence Health Care Research Institute, Vancouver, BC, United States
| | - Mohamud R Daya
- Department of Emergency Medicine, Oregon Health & Science University, Portland, OR, United States
| | - Marty Schreiber
- Department of Surgery, Oregon Health & Science University, Portland, OR, United States
| | - Ahamed Idris
- Department of Emergency Medicine, University of Texas Southwestern, Dallas, TX, United States
| | - Jeanette M Podbielski
- Department of Surgery, The University of Texas Health Science Center at Houston, Houston, TX, United States
| | - George Sopko
- National Heart Lung Blood Institute, National Institutes of Health, Bethesda, MD, United States
| | - Henry Wang
- Department of Emergency Medicine, The University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Charles E Wade
- Department of Surgery, The University of Texas Health Science Center at Houston, Houston, TX, United States
| | - David Hoyt
- American College of Surgeons, Chicago, IL, United States
| | - Myron L Weisfeldt
- Department of Medicine, Johns Hopkins University, Baltimore, MD, United States
| | - Susanne May
- Department of Biostatistics, University of Washington, Seattle, WA, United States
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Donthula D, Conner CR, Truong VTT, Green C, Jiang C, Wandling MW, Komak S, Huzar TF, Adams SD, Freet DJ, Wainwright DJ, Wade CE, Kao LS, Harvin JA. Impact of Opioid-Minimizing Pain Protocols after Burn Injury. J Burn Care Res 2021; 42:1146-1151. [PMID: 34302482 DOI: 10.1093/jbcr/irab143] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
In 2019, we implemented a pill-based, opioid-minimizing pain protocol and protocolized moderate sedation for dressing changes in order to decrease opioid exposure in burn patients. We hypothesized that these interventions would reduce inpatient opioid exposure without increasing acute pain scores. Two groups of consecutive patients admitted to the burn service were compared: Pre (01/01/2018 to 07/31/2019) and Post (01/01/2020 to 06/30/2020) implementation of the protocols (08/01/2019 to 12/31/2019). We abstracted patient demographics and burn injury characteristics from the burn registry. We obtained opioid exposure and pain scale scores from the electronic medical record. The primary outcome was total morphine milligram equivalents (MME). Secondary outcomes included MME/day, pain domain-specific MME, and pain scores. Pain was estimated by creating a normalized pain score (range 0-1), which incorporated 3 different pain scales (Numeric Rating Scale, Behavioral Pain Scale, and Behavioral Pain Assessment Scale). Groups were compared using Wilcoxon Rank Sum and Chi Square. Treatment effects were estimated using Bayesian generalized linear models.There were no differences in demographics or burn characteristics between the Pre (n=495) and Post groups (n=174). The Post group had significantly lower total MME (Post 110 MME [32, 325] versus Pre 230 [60, 840], p<0.001), MME/day (Post 33 MME/day [15, 54] versus Pre 52 [27, 80], p<0.001), and domain-specific total MME. No difference in average normalized pain scores was seen.Implementation of opioid-minimizing protocols for acute burn pain was associated with a significant reduction in inpatient opioid exposure without an increase in pain scores.
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Affiliation(s)
- Deepanjli Donthula
- the Department of Surgery, the McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas
| | - Christopher R Conner
- the Department of Neurosurgery, the McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas
| | - Van Thi Thanh Truong
- the Center for Clinical Research and Evidence-Based Medicine, the McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas
| | - Charles Green
- the Center for Clinical Research and Evidence-Based Medicine, the McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas
| | - Chuantao Jiang
- the Department of Surgery, the McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas.,the John S. Dunn Burn Center at Memorial Hermann Hospital-Texas Medical Center
| | - Michael W Wandling
- the Department of Surgery, the McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas.,the John S. Dunn Burn Center at Memorial Hermann Hospital-Texas Medical Center
| | - Spogmai Komak
- the Department of Surgery, the McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas.,the John S. Dunn Burn Center at Memorial Hermann Hospital-Texas Medical Center
| | - Todd F Huzar
- the Department of Surgery, the McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas.,the John S. Dunn Burn Center at Memorial Hermann Hospital-Texas Medical Center
| | - Sasha D Adams
- Center for Translational Injury Research, the McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas.,the Department of Surgery, the McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas.,the John S. Dunn Burn Center at Memorial Hermann Hospital-Texas Medical Center
| | - Daniel J Freet
- the Department of Surgery, the McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas.,the John S. Dunn Burn Center at Memorial Hermann Hospital-Texas Medical Center
| | - David J Wainwright
- the Department of Surgery, the McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas.,the John S. Dunn Burn Center at Memorial Hermann Hospital-Texas Medical Center
| | - Charles E Wade
- Center for Translational Injury Research, the McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas.,the Department of Surgery, the McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas.,the John S. Dunn Burn Center at Memorial Hermann Hospital-Texas Medical Center
| | - Lillian S Kao
- Center for Translational Injury Research, the McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas.,the Department of Surgery, the McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas.,the Center for Clinical Research and Evidence-Based Medicine, the McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas.,the John S. Dunn Burn Center at Memorial Hermann Hospital-Texas Medical Center
| | - John A Harvin
- Center for Translational Injury Research, the McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas.,the Department of Surgery, the McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas.,the Center for Clinical Research and Evidence-Based Medicine, the McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas.,the John S. Dunn Burn Center at Memorial Hermann Hospital-Texas Medical Center
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Song J, Clark A, Wade CE, Wolf SE. Skeletal muscle wasting after a severe burn is a consequence of cachexia and sarcopenia. JPEN J Parenter Enteral Nutr 2021; 45:1627-1633. [PMID: 34296448 PMCID: PMC9293203 DOI: 10.1002/jpen.2238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Muscle wasting is common and persistent in severely burned patients, worsened by immobilization during treatment. In this review, we posit two major phenotypes of muscle wasting after severe burn, cachexia and sarcopenia, each with distinguishing characteristics to result in muscle atrophy; these characteristics are also likely present in other critically ill populations. An online search was conducted from the PubMed database and other available online resources and we manually extracted published articles in a systematic mini review. We describe the current definitions and characteristics of cachexia and sarcopenia and relate these to muscle wasting after severe burn. We then discuss these putative mechanisms of muscle atrophy in this condition. Severe burn and immobilization have distinctive patterns in mediating muscle wasting and muscle atrophy. In considering these two pathological phenotypes (cachexia and sarcopenia), we propose two independent principal causes and mechanisms of muscle mass loss after burns: (1) inflammation-induced cachexia, leading to proteolysis and protein degradation, and (2) sarcopenia/immobility that signals inhibition of expected increases in protein synthesis in response to protein loss. Because both are present following severe burn, these should be considered independently in devising treatments. Discussing cachexia and sarcopenia as independent mechanisms of severe burn-initiated muscle wasting is explored. Recognition of these associated mechanisms will likely improve outcomes.
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Affiliation(s)
- Juquan Song
- Department of Surgery, University of Texas Medical Branch, Galveston, Texas, USA
| | - Audra Clark
- Department of Surgery, University of Texas, Southwestern Medical Center, Dallas, Texas, USA
| | - Charles E Wade
- Center for Translational Injury Research and Department of Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Steven E Wolf
- Department of Surgery, University of Texas Medical Branch, Galveston, Texas, USA
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Toelle LJ, Hatton GE, Refuerzo JS, Wade CE, Cotton BA, Kao LS. Hypercoagulability in pregnant trauma patients. Trauma Surg Acute Care Open 2021; 6:e000714. [PMID: 34250259 PMCID: PMC8230999 DOI: 10.1136/tsaco-2021-000714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Circulating hormones affect coagulopathy in pregnancy and after trauma. The hemostatic profile of pregnant women after injury has not been characterized. We hypothesized that injured pregnant females would present with an initial thrombelastography (TEG) reflecting a more hypercoagulable profile and a higher incidence of venous thromboembolic events (VTE) when compared with non-pregnant females and males.
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Affiliation(s)
- Lisa J Toelle
- Surgery, McGovern Medical School at University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Gabrielle E Hatton
- Surgery, McGovern Medical School at University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Jerrie S Refuerzo
- Surgery, McGovern Medical School at University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Charles E Wade
- Surgery, McGovern Medical School at University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Bryan A Cotton
- Surgery, McGovern Medical School at University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Lillian S Kao
- Surgery, McGovern Medical School at University of Texas Health Science Center at Houston, Houston, Texas, USA
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George MJ, Litvinov J, Aroom K, Spangler LJ, Caplan H, Wade CE, Cox CS, Gill BS. Microelectromechanical System Measurement of Platelet Contraction: Direct Interrogation of Myosin Light Chain Phosphorylation. Int J Mol Sci 2021; 22:ijms22126448. [PMID: 34208643 PMCID: PMC8234414 DOI: 10.3390/ijms22126448] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Revised: 06/11/2021] [Accepted: 06/12/2021] [Indexed: 12/16/2022] Open
Abstract
Myosin Light Chain (MLC) regulates platelet contraction through its phosphorylation by Myosin Light Chain Kinase (MLCK) or dephosphorylation by Myosin Light Chain Phosphatase (MLCP). The correlation between platelet contraction force and levels of MLC phosphorylation is unknown. We investigate the relationship between platelet contraction force and MLC phosphorylation using a novel microelectromechanical (MEMS) based clot contraction sensor (CCS). The MLCK and MLCP pair were interrogated by inhibitors and activators of platelet function. The CCS was fabricated from silicon using photolithography techniques and force was validated over a range of deflection for different chip spring constants. The force of platelet contraction measured by the clot contraction sensor (CCS) was compared to the degree of MLC phosphorylation by Western Blotting (WB) and ELISA. Stimulators of MLC phosphorylation produced higher contraction force, higher phosphorylated MLC signal in ELISA and higher intensity bands in WB. Inhibitors of MLC phosphorylation produced the opposite. Contraction force is linearly related to levels of phosphorylated MLC. Direct measurements of clot contractile force are possible using a MEMS sensor platform and correlate linearly with the degree of MLC phosphorylation during coagulation. Measured force represents the mechanical output of the actin/myosin motor in platelets regulated by myosin light chain phosphorylation.
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Affiliation(s)
- Mitchell J. George
- Department of Surgery, McGovern Medical School at The University of Texas Health Science Center, Houston, TX 77030, USA; (K.A.); (C.E.W.); (C.S.C.J.); (B.S.G.)
- Correspondence:
| | - Julia Litvinov
- Department of Pediatric Surgery, McGovern Medical School at The University of Texas Health Science Center, Houston, TX 77030, USA; (J.L.); (H.C.)
| | - Kevin Aroom
- Department of Surgery, McGovern Medical School at The University of Texas Health Science Center, Houston, TX 77030, USA; (K.A.); (C.E.W.); (C.S.C.J.); (B.S.G.)
| | | | - Henry Caplan
- Department of Pediatric Surgery, McGovern Medical School at The University of Texas Health Science Center, Houston, TX 77030, USA; (J.L.); (H.C.)
| | - Charles E. Wade
- Department of Surgery, McGovern Medical School at The University of Texas Health Science Center, Houston, TX 77030, USA; (K.A.); (C.E.W.); (C.S.C.J.); (B.S.G.)
| | - Charles S. Cox
- Department of Surgery, McGovern Medical School at The University of Texas Health Science Center, Houston, TX 77030, USA; (K.A.); (C.E.W.); (C.S.C.J.); (B.S.G.)
- Department of Pediatric Surgery, McGovern Medical School at The University of Texas Health Science Center, Houston, TX 77030, USA; (J.L.); (H.C.)
| | - Brijesh S. Gill
- Department of Surgery, McGovern Medical School at The University of Texas Health Science Center, Houston, TX 77030, USA; (K.A.); (C.E.W.); (C.S.C.J.); (B.S.G.)
- Department of Pediatric Surgery, McGovern Medical School at The University of Texas Health Science Center, Houston, TX 77030, USA; (J.L.); (H.C.)
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Rahbar E, Cotton BA, Wade CE, Cardenas JC. Acquired antithrombin deficiency is a risk factor for venous thromboembolism after major trauma. Thromb Res 2021; 204:9-12. [PMID: 34091120 DOI: 10.1016/j.thromres.2021.05.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Revised: 05/11/2021] [Accepted: 05/25/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Up to 30% of severely injured patients on prophylactic anticoagulation experience venous thromboembolism (VTE). Our previous work shows that acquired antithrombin (AT) deficiency [AT<80%] occurs in approximately 20% of trauma patients upon admission and drives poor responsiveness to enoxaparin. However, changes in AT over time and its association with VTE remain unknown. The aim of this study was to determine the relationship between acquired AT deficiency and VTE in severely injured patients. METHODS A secondary analysis of the Pragmatic, Randomized Optimal Platelet and Plasma Ratios (PROPPR) clinical trial was performed. Patients who died within 24 h of hemorrhage were excluded from analysis. Demographics, mechanism and severity of injury, transfusions volumes, and outcomes were compared between patients who did and did not develop VTE. Non-parametric statistical tests were used to compare patients with and without VTE. Logistic regression analyses were performed to identify predictors of VTE risk, controlling for AT deficiency (over first 72 h), age, gender, race, body mass index, study site, randomization group and injury severity. A Cox proportional hazards model was used to assess the contribution of AT deficiency to the risk of VTE, while censoring for early deaths. RESULTS Of the 680 patients enrolled in PROPPR, 101 died of hemorrhage. Of the remaining 579 patients, 86 (14.9%) developed VTE. The median time to VTE was 6 days (IQR 3, 13). No differences in demographics, injuries, or transfusion volumes were identified between VTE cases and controls. AT deficiency at 72 h post-admission was independently associated with VTE. Patients who experienced AT deficiency at 72 h had a 3.3 fold increased risk of VTE [p < 0.01; 95% CI 1.56, 6.98]. Lastly, patients who developed VTE had worse outcomes as displayed by significantly fewer hospital-free days compared to non-VTE patients [0 (0, 8) vs. 4 (0, 18), p < 0.01, respectively]. CONCLUSIONS Acquired AT deficiency (AT<80%) is an important risk factor for VTE in severely injured patients. These data indicate that intervening, perhaps through AT supplementation, in the first three days after injury could mitigate the risk of VTE and improve patient outcomes.
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Affiliation(s)
- Elaheh Rahbar
- Wake Forest School of Medicine, Department of Biomedical Engineering, Winston-Salem, NC, United States of America
| | - Bryan A Cotton
- The University of Texas Health Science Center, McGovern School of Medicine, Department of Surgery, Division of Acute Care Surgery and Center for Translational Injury Research, Houston, TX, United States of America
| | - Charles E Wade
- The University of Texas Health Science Center, McGovern School of Medicine, Department of Surgery, Division of Acute Care Surgery and Center for Translational Injury Research, Houston, TX, United States of America
| | - Jessica C Cardenas
- The University of Texas Health Science Center, McGovern School of Medicine, Department of Surgery, Division of Acute Care Surgery and Center for Translational Injury Research, Houston, TX, United States of America.
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Hatton GE, Harvin JA, Wade CE, Kao LS. Importance of duration of acute kidney injury after severe trauma: a cohort study. Trauma Surg Acute Care Open 2021; 6:e000689. [PMID: 34124376 PMCID: PMC8162072 DOI: 10.1136/tsaco-2021-000689] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Accepted: 05/13/2021] [Indexed: 12/30/2022] Open
Abstract
Background Acute kidney injury (AKI) is common after severe trauma. AKI incidence and AKI stage have previously been shown to be associated with poor outcomes after trauma. However, AKI duration may also be important for outcomes after trauma, given that it is associated with long-term morbidity and mortality in general intensive care unit (ICU) and hospitalized patients. We hypothesized that duration of AKI is independently associated with poor outcomes after trauma. Methods A cohort study was conducted at a single, level 1 trauma center. Patients admitted to the ICU between 2009 and 2018 were included. Data were extracted from the trauma registry and electronic medical records. AKI within 7 days from presentation was defined according to the Kidney Disease Improving Global Outcomes guidelines. Multivariable analyses were performed to assess the association between AKI incidence, AKI stage, and AKI duration with outcomes including prolonged ICU and hospital length of stay, discharge to home, and mortality. Results Of 7049 patients included, 72% were male, the median age was 41 years (IQR 27–58), and 10% died. The AKI incidence was 45%, with 69% of these patients presenting with AKI on arrival. The majority (73%) of patients who suffered AKI recovered within 2 days. After adjustment in separate models, AKI incidence, AKI stage and AKI duration were each associated with prolonged hospitalization, an unfavorable discharge disposition, and mortality. AKI stage and duration were not used in the same model due to collinearity. Conclusions Post-traumatic AKI was common on arrival and frequently short lasting. Duration correlated with highest AKI stage, and both were separately associated with prolonged hospitalization, discharge destination other than home, and mortality on adjusted analyses. Given the high incidence of AKI on arrival, stage or duration may be better targets for future interventions and quality improvement initiatives to improve outcomes after post-traumatic AKI. Level of evidence III. Prognostic.
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Affiliation(s)
- Gabrielle E Hatton
- Surgery, University of Texas McGovern Medical School, Houston, Texas, USA
| | - John A Harvin
- Surgery, University of Texas McGovern Medical School, Houston, Texas, USA
| | - Charles E Wade
- Surgery, University of Texas McGovern Medical School, Houston, Texas, USA
| | - Lillian S Kao
- Surgery, University of Texas McGovern Medical School, Houston, Texas, USA
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Kalkwarf KJ, Goodman MD, Press GM, Wade CE, Cotton BA. Prehospital ABC Score Accurately Forecasts Patients Who Will Require Immediate Resource Utilization. South Med J 2021; 114:193-198. [PMID: 33787930 DOI: 10.14423/smj.0000000000001236] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVES Scoring systems, such as the Assessment of Blood Consumption (ABC) Score, are used to identify patients at risk for massive transfusion (MT, ≥10 U red blood cells in 24 hours). Our aeromedical transport helicopter uses ultrasound to perform the Focused Assessment with Sonography for Trauma (FAST) examination. Our objective was to evaluate the ability of the Prehospital ABC (PhABC) Score to predict blood transfusions and the need for emergent laparotomy. METHODS Post hoc analysis of a prospective observational study of trauma patients who underwent an in-flight FAST during aeromedical transport during a 7-month period. PhABC Score was positive if ≥2 of the following were present in flight: penetrating trauma, heart rate >120 bpm, systolic blood pressure <90 mm Hg, or a positive abdominal FAST. The PhABC Score was evaluated by area under the receiver operating characteristic (AUROC) curves and logistic regression. RESULTS A total of 291 trauma patients met inclusion criteria, 23 underwent emergent laparotomy, and 12 received an MT. A positive PhABC Score predicted emergent laparotomy, with a positive predictive value of 48% and a negative predictive value of 95% (sensitivity 46%, specificity 96%, AUROC curve 0.83). A positive PhABC Score also predicted receipt of an MT with a positive predictive value of 28% and a negative predictive value of 94% (sensitivity 33%, specificity 93%, AUROC curve 0.77). Multiple logistic regression identified FAST as the most powerful contributor of the PhABC Score to the prediction of both emergent laparotomy (odds ratio 8.5, P < 0.001) and MT (odds ratio 5.9, P < 0.001). CONCLUSIONS The PhABC Score effectively predicts in-hospital resource utilization. It provides an outstanding undertriage rate from the prehospital setting, and it is helpful to improve trauma team activation, mobilize blood products, and prepare the operating room.
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Affiliation(s)
- Kyle J Kalkwarf
- From the Department of Surgery, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, the Department of Surgery, College of Medicine, University of Cincinnati, Cincinnati, Ohio, the Department of Emergency Medicine, University of Texas at Austin Dell Medical School, Austin, and the Center for Translational Injury Research and the Department of Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston (UTHealth), Houston
| | - Michael D Goodman
- From the Department of Surgery, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, the Department of Surgery, College of Medicine, University of Cincinnati, Cincinnati, Ohio, the Department of Emergency Medicine, University of Texas at Austin Dell Medical School, Austin, and the Center for Translational Injury Research and the Department of Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston (UTHealth), Houston
| | - Gregory M Press
- From the Department of Surgery, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, the Department of Surgery, College of Medicine, University of Cincinnati, Cincinnati, Ohio, the Department of Emergency Medicine, University of Texas at Austin Dell Medical School, Austin, and the Center for Translational Injury Research and the Department of Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston (UTHealth), Houston
| | - Charles E Wade
- From the Department of Surgery, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, the Department of Surgery, College of Medicine, University of Cincinnati, Cincinnati, Ohio, the Department of Emergency Medicine, University of Texas at Austin Dell Medical School, Austin, and the Center for Translational Injury Research and the Department of Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston (UTHealth), Houston
| | - Bryan A Cotton
- From the Department of Surgery, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, the Department of Surgery, College of Medicine, University of Cincinnati, Cincinnati, Ohio, the Department of Emergency Medicine, University of Texas at Austin Dell Medical School, Austin, and the Center for Translational Injury Research and the Department of Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston (UTHealth), Houston
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