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Cudjoe EK, Hassan ZH, Kang L, Reynolds PS, Fisher BJ, McCarter J, Sweeney C, Martin EJ, Middleton P, Ellenberg M, Fowler AA, Spiess BD, Brophy DF, Hawkridge AM, Natarajan R. Temporal map of the pig polytrauma plasma proteome with fluid resuscitation and intravenous vitamin C treatment. J Thromb Haemost 2019; 17:1827-1837. [PMID: 31322812 DOI: 10.1111/jth.14580] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Accepted: 07/16/2019] [Indexed: 01/12/2023]
Abstract
BACKGROUND Fluid resuscitation plays a prominent role in stabilizing trauma patients with hemorrhagic shock yet there remains uncertainty with regard to optimal administration time, volume, and fluid composition (e.g., whole blood, component, colloids) leading to complications such as trauma-induced coagulopathies (TIC), acidosis, and poor oxygen transport. Synthetic fluids in combination with antioxidants (e.g., vitamin C) may resolve some of these problems. OBJECTIVES We applied quantitative mass spectrometry-based proteomics [liquid chromatography-mass spectrometry (LC-MS/MS)] to map the effects of fluid resuscitation and intravenous vitamin C (VitC) in a pig model of polytrauma (hemorrhagic shock, tissue injury, liver reperfusion, hypothermia, and comminuted bone fracture). The goal was to determine the effects of VitC on plasma protein expression, with respect to changes associated with coagulation and trauma-induced coagulopathy (TIC). METHODS Longitudinal blood samples were drawn from nine male Sinclair pigs at baseline, 2 h post trauma, and 0.25, 2, and 4 h post fluid resuscitation with 500 mL hydroxyethyl starch. Pigs were treated intravenously (N = 3/treatment group) with saline, 50 mg VitC/kg (Lo-VitC), or 200 mg VitC/kg (Hi-VitC) during fluid resuscitation. RESULTS A total of 436 plasma proteins were quantified of which 136 changed following trauma and resuscitation; 34 were associated with coagulation, complement cascade, and glycolysis. Unexpectedly, Lo-VitC and Hi-VitC treatments stabilized ADAMTS13 levels by ~4-fold (P = .056) relative to saline and enhanced ADAMTS13/von Willebrand factor (VWF) cleavage efficiency based on LC-MS/MS evidence for the semitryptic VWF cleavage product (VWF1275-1286 ). CONCLUSIONS This study provides the first comprehensive map of trauma-induced changes to the plasma proteome, especially with respect to proteins driving the development of TIC.
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Affiliation(s)
- Emmanuel K Cudjoe
- Department of Pharmacotherapy and Outcomes Science, Virginia Commonwealth University School of Pharmacy, Richmond, Virginia
| | - Zaneera H Hassan
- Department of Pharmaceutics, Virginia Commonwealth University School of Pharmacy, Richmond, Virginia
| | - Le Kang
- Department of Biostatistics, Virginia Commonwealth University Medical Center, Richmond, Virginia
| | - Penny S Reynolds
- Department of Anesthesiology, Virginia Commonwealth University Medical Center, Richmond, Virginia
| | - Bernard J Fisher
- Department of Internal Medicine, Virginia Commonwealth University Medical Center, Richmond, Virginia
| | - Jacquelyn McCarter
- Department of Internal Medicine, Virginia Commonwealth University Medical Center, Richmond, Virginia
| | - Christopher Sweeney
- Department of Internal Medicine, Virginia Commonwealth University Medical Center, Richmond, Virginia
| | - Erika J Martin
- Department of Pharmacotherapy and Outcomes Science, Virginia Commonwealth University School of Pharmacy, Richmond, Virginia
| | - Paul Middleton
- Department of Internal Medicine, Virginia Commonwealth University Medical Center, Richmond, Virginia
| | - Matthew Ellenberg
- Department of Internal Medicine, Virginia Commonwealth University Medical Center, Richmond, Virginia
| | - Alpha A Fowler
- Department of Internal Medicine, Virginia Commonwealth University Medical Center, Richmond, Virginia
| | - Bruce D Spiess
- Department of Anesthesiology, Virginia Commonwealth University Medical Center, Richmond, Virginia
| | - Donald F Brophy
- Department of Pharmacotherapy and Outcomes Science, Virginia Commonwealth University School of Pharmacy, Richmond, Virginia
| | - Adam M Hawkridge
- Department of Pharmacotherapy and Outcomes Science, Virginia Commonwealth University School of Pharmacy, Richmond, Virginia
- Department of Pharmaceutics, Virginia Commonwealth University School of Pharmacy, Richmond, Virginia
- Institute for Structural Biology, Drug Discovery, and Development, Virginia Commonwealth University School of Pharmacy, Richmond, Virginia
| | - Ramesh Natarajan
- Department of Internal Medicine, Virginia Commonwealth University Medical Center, Richmond, Virginia
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Johnston LR, Rodriguez CJ, Elster EA, Bradley MJ. Evaluation of Military Use of Tranexamic Acid and Associated Thromboembolic Events. JAMA Surg 2019; 153:169-175. [PMID: 29071337 DOI: 10.1001/jamasurg.2017.3821] [Citation(s) in RCA: 63] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Importance Since publication of the CRASH-2 and MATTERs studies, the US military has included tranexamic acid (TXA) in clinical practice guidelines. While TXA was shown to decrease mortality in trauma patients requiring massive transfusion, improper administration and increased risk of venous thromboembolism remain a concern. Objective To determine the appropriateness of TXA administration by US military medical personnel based on current Joint Trauma System clinical practice guidelines and to determine if TXA administration is associated with venous thromboembolism. Design, Setting, and Participants This cohort study of US military casualties in US military combat support hospitals in Afghanistan and a single US-based tertiary military treatment facility within the continental United States was conducted from 2011 to 2015, with follow-up through initial hospitalization and readmissions. Exposures Data collected for all patients included demographic information as well as Injury Severity Score; receipt of blood products, TXA, and/or a massive transfusion; and admission hemodynamics. Main Outcomes and Measures Variance from guidelines in TXA administration and venous thromboembolism. Tranexamic acid overuse was defined as a hemodynamically stable patient receiving TXA but not a massive transfusion, underuse was defined as a patient receiving a massive transfusion but not TXA, and TXA administration was considered delayed when given more than 3 hours after injury. Results Of the 455 identified patients, 443 (97.4%) were male, and the mean (SD) age was 25.3 (4.8) years. A total of 173 patients (38.0%) received a massive transfusion, and 139 (30.5%) received TXA in theater. Overuse occurred in 18 of 282 patients (6.4%) and underuse in 46 of 173 (26.6%) receiving massive transfusions, and delayed administration was found in 6 of 145 patients (4.3%) receiving TXA. Overuse increased at 3.3% per quarter (95% CI, 4.0-9.9; P < .001; R2 = 0.340) and underuse decreased at -4.4% per quarter (95% CI, -4.5 to -3.6; P < .001; R2 = 0.410). Tranexamic acid administration was an independent risk factor for venous thromboembolism (odds ratio, 2.58; 95% CI, 1.20-5.56; P = .02). Conclusions and Relevance Military medical personnel decreased missed opportunities to appropriately use TXA but also increased overuse. In addition, TXA administration was an independent risk factor for venous thromboembolism. A reevaluation of the use of TXA in combat casualties should be undertaken.
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Affiliation(s)
- Luke R Johnston
- Department of Surgery, Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Carlos J Rodriguez
- Department of Surgery, Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Eric A Elster
- Department of Surgery, Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center, Bethesda, Maryland.,Surgical Critical Care Initiative, Bethesda, Maryland
| | - Matthew J Bradley
- Department of Surgery, Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center, Bethesda, Maryland.,Surgical Critical Care Initiative, Bethesda, Maryland.,Department of Regenerative Medicine, Naval Medical Research Center, Silver Spring, Maryland
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103
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Sheppard FR, Schaub LJ, Cap AP, Macko AR, Moore HB, Moore EE, Glaser CJJ. Whole blood mitigates the acute coagulopathy of trauma and avoids the coagulopathy of crystalloid resuscitation. J Trauma Acute Care Surg 2019; 85:1055-1062. [PMID: 30124622 DOI: 10.1097/ta.0000000000002046] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
INTRODUCTION The contributions of type and timing of fluid resuscitation to coagulopathy in trauma remain controversial. As part of a multifunctional resuscitation fluid research effort, we sought to further characterize the coagulation responses to resuscitation, specifically as compared to whole blood. We hypothesized that early whole blood administration mitigates the acute coagulopathy of trauma by avoiding the coagulopathy of CR resuscitation. METHODS Anesthetized rhesus macaques underwent polytraumatic, hemorrhagic shock, then a crossover study design resuscitation (n = 6 each) with either whole blood first (WB-1st) followed by crystalloid (CR); or CR-1st followed by WB. Resuscitation strategies were the following: WB-1st received 50% shed blood in 30minutes, followed by twice the shed blood volume (SBV) of CR over 30minutes and one times the SBV CR over 60minutes, where CR-1st received twice the SBV of CR over 30minutes, followed by 50% of shed blood in 30minutes, and one times the SBV CR over 60minutes. Blood samples were collected at baseline, end-of-shock, end-of-first and end-of-second resuscitation stages, and end-of-resuscitation for assessment (thromboelastometry, platelet aggregation, and plasmatic coagulation factors). Statistical analyses were conducted using two-way analysis of variance ANOVA with Bonferroni correction and t-tests; significance was at p < 0.05. RESULTS Survival, blood loss, hemodynamics, and shock duration were equivalent between the groups. Compared to baseline, parameters measured at first and second resuscitation stage time points directly following CR infusion revealed abnormalities in thromboelastometry (clot formation time, α angle, and maximum clot firmness), platelet aggregation response (to collagen, arachidonic acid, and adenosine diphosphate), and plasmatic coagulation (prothrombin time, anti-thrombin 3, and fibrinogen), while whole blood infusion resulted in stabilization or correction of these parameters following its administration. CONCLUSIONS These data suggest that in the setting of trauma and hemorrhagic shock, the coagulation alterations begin before intervention/resuscitation; however, these are significantly aggravated by CR resuscitation and could perhaps be best termed acute coagulopathy of resuscitation. STUDY TYPE Translational animal model.
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Affiliation(s)
- Forest R Sheppard
- From the Naval Medical Research Unit San Antonio, JBSA-Ft Sam Houston, Texas (F.R.S., L.J.S., A.R.M., J.J.G.); Maine Medical Center, Portland, Maine (F.R.S.); US Army Institute of Surgical Research, JBSA-Ft Sam Houston, Texas (A.P.C.); Department of Surgery, Denver Health Medical Center, Denver, Colorado (H.B.M., E.E.M); and University of Colorado Denver, Aurora, Colorado (H.B.M., E.E.M.)
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104
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Gando S, Otomo Y. Trauma-induced coagulopathy: The past, present, and future: A comment. J Thromb Haemost 2019; 17:1567-1569. [PMID: 31479181 DOI: 10.1111/jth.14520] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Accepted: 05/21/2019] [Indexed: 12/30/2022]
Affiliation(s)
- Satoshi Gando
- Acute and Critical Care Center, Department of Acute and Critical Care Medicine, Sapporo Higashi Tokushukai Hospital, Sapporo, Japan
| | - Yasuhiro Otomo
- Trauma and Acute Critical Care Center, Medical Hospital, Tokyo Medical and Dental University, Tokyo, Japan
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105
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Plasma Angiopoietin-2/-1 Ratio is Elevated and Angiopoietin-2 Levels Correlate With Plasma Syndecan-1 Following Pediatric Trauma. Shock 2019; 52:340-346. [DOI: 10.1097/shk.0000000000001267] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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106
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Kornblith LZ, Moore HB, Cohen MJ. Response to Letter to the Editor submitted by Dr. Wada and Dr. Yamakawa re: Trauma-induced coagulopathy: The past, present, and future. J Thromb Haemost 2019; 17:1574-1576. [PMID: 31479184 PMCID: PMC6727975 DOI: 10.1111/jth.14581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2019] [Accepted: 07/17/2019] [Indexed: 11/29/2022]
Abstract
It is with equal appreciation and enthusiasm that we have the opportunity to participate in these valuable scientific discussions with our respected colleagues Dr. Wada and Dr. Yamakawa, as we did with Dr. Gando and Dr. Otomo on their analogous disseminated-intravascular coagulation (DIC)-centric views of trauma-induced coagulopathy (TIC). We welcome and appreciate Drs Wada and Yamakawa’s expounded descriptions on their areas of their expertise specific to the critical thrombin-specific biologies. We find their additions valuable to the overall framing of the state of the science and controversies that exists in TIC investigations. However, we continue to support that it would be erroneous to continue to force an inflexible view of the complex biology of TIC, thereby failing to acknowledge the various competing mechanisms and mediators described throughout the literature, including the sometimes contradictory biomarker phenotypes that are ‘impaired’ in TIC. In addition, much of our following response to Drs Wada and Yamakawa’s letter will involve referring back to what was already addressed within the manuscript that appears to have been overlooked. However, of absolute importance, we would like to stress that TIC remains open science should therefore be regarded with open minds and without siloed opinions.
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Affiliation(s)
- Lucy Z. Kornblith
- Department of Surgery, Zuckerberg San Francisco General Hospital and the University of California, San Francisco, San Francisco, California, 1001 Potrero Avenue, Building 1, Suite 210, San Francisco, CA 94110
| | - Hunter B. Moore
- Department of Surgery, Denver Health Medical Center and the University of Colorado, Denver, Colorado, 777 Bannock Street. Mail Code 0206, Denver, CO 80203
| | - Mitchell J. Cohen
- Department of Surgery, Denver Health Medical Center and the University of Colorado, Denver, Colorado, 777 Bannock Street. Mail Code 0206, Denver, CO 80203
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107
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Moore HB, Moore EE, Neal MD, Sheppard FR, Kornblith LZ, Draxler DF, Walsh M, Medcalf RL, Cohen MJ, Cotton BA, Thomas SG, Leeper CM, Gaines BA, Sauaia A. Fibrinolysis Shutdown in Trauma: Historical Review and Clinical Implications. Anesth Analg 2019; 129:762-773. [PMID: 31425218 PMCID: PMC7340109 DOI: 10.1213/ane.0000000000004234] [Citation(s) in RCA: 83] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Despite over a half-century of recognizing fibrinolytic abnormalities after trauma, we remain in our infancy in understanding the underlying mechanisms causing these changes, resulting in ineffective treatment strategies. With the increased utilization of viscoelastic hemostatic assays (VHAs) to measure fibrinolysis in trauma, more questions than answers are emerging. Although it seems certain that low fibrinolytic activity measured by VHA is common after injury and associated with increased mortality, we now recognize subphenotypes within this population and that specific cohorts arise depending on the specific time from injury when samples are collected. Future studies should focus on these subtleties and distinctions, as hypofibrinolysis, acute shutdown, and persistent shutdown appear to represent distinct, unique clinical phenotypes, with different pathophysiology, and warranting different treatment strategies.
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Affiliation(s)
- Hunter B. Moore
- Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado
| | - Ernest E. Moore
- Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado
- Department of Surgery, Denver Health Medical Center, Denver, Colorado
| | - Matthew D. Neal
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | | | - Lucy Z. Kornblith
- Department of Surgery, San Francisco General Hospital, University of California San Francisco, San Francisco, California
| | - Dominik F. Draxler
- Australian Centre for Blood Diseases, Monash University, Melbourne, Australia
| | - Mark Walsh
- Department of Surgery, Memorial Hospital Trauma Center, Springfield, Illinois
- Department of Emergency Medicine, Memorial Hospital Trauma Center, Springfield, Illinois
| | - Robert L. Medcalf
- Australian Centre for Blood Diseases, Monash University, Melbourne, Australia
| | - Mitch J. Cohen
- Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado
- Department of Surgery, Denver Health Medical Center, Denver, Colorado
| | - Bryan A. Cotton
- Department of Surgery, Center for Translational Injury Research, The McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas
| | - Scott G. Thomas
- Department of Surgery, Memorial Hospital Trauma Center, Springfield, Illinois
- Department of Emergency Medicine, Memorial Hospital Trauma Center, Springfield, Illinois
| | - Christine M. Leeper
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Barbara A. Gaines
- Department of Surgery, Children’s Hospital of Pittsburgh of the University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Angela Sauaia
- Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado
- Division of Health Systems, Management, and Policy, University of Colorado School of Public Health, Aurora, Colorado
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108
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Panzer AR, Lynch SV, Langelier C, Christie JD, McCauley K, Nelson M, Cheung CK, Benowitz NL, Cohen MJ, Calfee CS. Lung Microbiota Is Related to Smoking Status and to Development of Acute Respiratory Distress Syndrome in Critically Ill Trauma Patients. Am J Respir Crit Care Med 2019; 197:621-631. [PMID: 29035085 DOI: 10.1164/rccm.201702-0441oc] [Citation(s) in RCA: 90] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
RATIONALE Cigarette smoking is associated with increased risk of acute respiratory distress syndrome (ARDS) in patients after severe trauma; however, the mechanisms underlying this association are unknown. OBJECTIVES To determine whether cigarette smoking contributes to ARDS development after trauma by altering community composition of the lung microbiota. METHODS We studied the lung microbiota of mechanically ventilated patients admitted to the ICU after severe blunt trauma. To do so, we used 16S ribosomal RNA gene amplicon sequencing of endotracheal aspirate samples obtained on ICU admission (n = 74) and at 48 hours after admission (n = 30). Cigarette smoke exposure (quantified using plasma cotinine), ARDS development, and other clinical parameters were correlated with lung microbiota composition. MEASUREMENTS AND MAIN RESULTS Smoking status was significantly associated with lung bacterial community composition at ICU admission (P = 0.007 by permutational multivariate ANOVA [PERMANOVA]) and at 48 hours (P = 0.03 by PERMANOVA), as well as with significant enrichment of potential pathogens, including Streptococcus, Fusobacterium, Prevotella, Haemophilus, and Treponema. ARDS development was associated with lung community composition at 48 hours (P = 0.04 by PERMANOVA) and was characterized by relative enrichment of Enterobacteriaceae and of specific taxa enriched at baseline in smokers, including Prevotella and Fusobacterium. CONCLUSIONS After severe blunt trauma, a history of smoking is related to lung microbiota composition, both at the time of ICU admission and at 48 hours. ARDS development is also correlated with respiratory microbial community structure at 48 hours and with taxa that are relatively enriched in smokers at ICU admission. The data derived from this pilot study suggest that smoking-related changes in the lung microbiota could be related to ARDS development after severe trauma.
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Affiliation(s)
| | - Susan V Lynch
- 1 Division of Gastroenterology, Department of Medicine
| | - Chaz Langelier
- 2 Division of Infectious Diseases, Department of Medicine
| | - Jason D Christie
- 3 Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Mary Nelson
- 4 Department of Surgery.,5 Zuckerberg San Francisco General Hospital, San Francisco, California
| | - Christopher K Cheung
- 4 Department of Surgery.,5 Zuckerberg San Francisco General Hospital, San Francisco, California
| | - Neal L Benowitz
- 6 Division of Clinical Pharmacology, Department of Medicine.,5 Zuckerberg San Francisco General Hospital, San Francisco, California
| | - Mitchell J Cohen
- 7 Department of Surgery, Denver Health Medical Center, Denver, Colorado; and.,8 Department of Surgery, University of Colorado, Aurora, Colorado
| | - Carolyn S Calfee
- 9 Division of Pulmonary and Critical Care Medicine, Department of Medicine.,10 Department of Anesthesia.,11 Cardiovascular Research Institute, and.,12 Center for Tobacco Control Research and Education, University of California, San Francisco, San Francisco, California
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Abstract
PURPOSE OF REVIEW Uncontrolled bleeding in trauma secondary to a combination of surgical bleeding and trauma-induced complex coagulopathy is a leading cause of death. Prothrombin complex concentrates (PCCs), recombinant activated factor seven (rFVIIa) and recombinant human prothrombin act as procoagulants by increasing thrombin generation and fibrinogen concentrate aids stable clot formation. This review summarizes the current evidence for procoagulant use in the management of bleeding in trauma, and data and evidence gaps for routine clinical use. RECENT FINDINGS Retrospective and prospective studies of PCCs (±fibrinogen concentrate) have demonstrated a decreased time to correction of trauma coagulopathy and decreased red cell transfusion with no obvious effect on mortality or thromboembolic outcomes. PCCs in a porcine model of dilutional coagulopathy demonstrated a sustained increase in thrombin generation, unlike recombinant human prothrombin which showed a transient increase and has been studied only in animals. In other retrospective studies, there is a suggestion that lower doses of PCCs may be effective in the setting of acquired coagulopathy. SUMMARY There is increasing evidence that early correction of coagulopathy has survival benefits, and the use of procoagulants as first-line therapy has the potential benefit of rapid access and timely treatment. This requires confirmation in prospective studies.
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110
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Walsh M, Moore EE, Moore H, Thomas S, Lune SV, Zimmer D, Dynako J, Hake D, Crowell Z, McCauley R, Larson EE, Miller M, Pohlman T, Achneck HE, Martin P, Nielsen N, Shariff F, Ploplis VA, Castellino FJ. Use of Viscoelastography in Malignancy-Associated Coagulopathy and Thrombosis: A Review. Semin Thromb Hemost 2019; 45:354-372. [PMID: 31108555 PMCID: PMC7707018 DOI: 10.1055/s-0039-1688497] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The relationship between malignancy and coagulopathy is one that is well documented yet incompletely understood. Clinicians have attempted to quantify the hypercoagulable state produced in various malignancies using common coagulation tests such as prothrombin time, activated partial thromboplastin time, and platelet count; however, due to these tests' focus on individual aspects of coagulation during one specific time point, they have failed to provide clinicians the complete picture of malignancy-associated coagulopathy (MAC). Viscoelastic tests (VETs), such as thromboelastography (TEG) and rotational thromboelastometry (ROTEM), are whole blood analyses that have the advantage of providing information related to the cumulative effects of plasma clotting factors, platelets, leukocytes, and red cells during all stages of the coagulation and fibrinolytic processes. VETs have gained popularity in the care of trauma patients to objectively measure trauma-induced coagulopathy (TIC), but the utility of VETs remains yet unrealized in many other medical specialties. The authors discuss the similarities and differences between TIC and MAC, and propose a mechanism for the hypercoagulable state of MAC that revolves around the thrombomodulin-thrombin complex as it switches between activating the protein C anticoagulation pathway or the thrombin activatable fibrinolysis inhibitor coagulation pathway. Additionally, they review the current literature on the use of TEG and ROTEM in patients with various malignancies. Although limited research is currently available, early results demonstrate the utility of both TEG and ROTEM in the prediction of hypercoagulable states and thromboembolic complications in oncologic patients.
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Affiliation(s)
- Mark Walsh
- Saint Joseph Regional Medical Center, Mishawaka, Indiana
- Beacon Medical Group Trauma & Surgical Research Services, South Bend, Indiana
- Indiana University School of Medicine, South Bend Campus, South Bend, Indiana
| | - Ernest E. Moore
- Ernest E. Moore Trauma Center Denver General Hospital, University of Colorado School of Medicine, Denver, Colorado
| | - Hunter Moore
- Ernest E. Moore Trauma Center Denver General Hospital, University of Colorado School of Medicine, Denver, Colorado
| | - Scott Thomas
- Beacon Medical Group Trauma & Surgical Research Services, South Bend, Indiana
| | - Stefani Vande Lune
- Indiana University School of Medicine, South Bend Campus, South Bend, Indiana
| | - David Zimmer
- Indiana University School of Medicine, South Bend Campus, South Bend, Indiana
| | - Joseph Dynako
- Indiana University School of Medicine, South Bend Campus, South Bend, Indiana
| | - Daniel Hake
- Chicago College of Osteopathic Medicine at Midwestern University, Downers Grove, Illinois
| | - Zachary Crowell
- Chicago College of Osteopathic Medicine at Midwestern University, Downers Grove, Illinois
| | - Ross McCauley
- Indiana University School of Medicine, South Bend Campus, South Bend, Indiana
| | - Emilee E. Larson
- Indiana University School of Medicine, South Bend Campus, South Bend, Indiana
| | - Michael Miller
- Beacon Medical Group Trauma & Surgical Research Services, South Bend, Indiana
| | - Tim Pohlman
- Beacon Medical Group Trauma & Surgical Research Services, South Bend, Indiana
| | | | - Peter Martin
- Department of Emergency Medicine, Tulane School of Medicine, New Orleans, Louisiana
| | - Nathan Nielsen
- Division of Pulmonary Diseases, Critical Care and Environmental Medicine, Tulane School of Medicine, New Orleans, Louisiana
| | - Faisal Shariff
- Indiana University School of Medicine, South Bend Campus, South Bend, Indiana
| | - Victoria A. Ploplis
- W.M. Keck Center for Transgene Research, The University of Notre Dame, Notre Dame, Indiana
- Department of Chemistry and Biochemistry, The University of Notre Dame, Notre Dame, Indiana
| | - Francis J. Castellino
- W.M. Keck Center for Transgene Research, The University of Notre Dame, Notre Dame, Indiana
- Department of Chemistry and Biochemistry, The University of Notre Dame, Notre Dame, Indiana
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111
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Kornblith LZ, Moore HB, Cohen MJ. Trauma-induced coagulopathy: The past, present, and future. J Thromb Haemost 2019; 17:852-862. [PMID: 30985957 PMCID: PMC6545123 DOI: 10.1111/jth.14450] [Citation(s) in RCA: 137] [Impact Index Per Article: 27.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Revised: 04/02/2019] [Accepted: 04/03/2019] [Indexed: 12/12/2022]
Abstract
Trauma remains a leading cause of death worldwide, and most early preventable deaths in both the civilian and military settings are due to uncontrolled hemorrhage, despite paradigm advances in modern trauma care. Combined tissue injury and shock result in hemostatic failure, which has been identified as a multidimensional molecular, physiologic and clinical disorder termed trauma-induced coagulopathy (TIC). Understanding the biology of TIC is of utmost importance, as it is often responsible for uncontrolled bleeding, organ failure, thromboembolic complications, and death. Investigations have shown that TIC is characterized by multiple phenotypes of impaired hemostasis due to altered biology in clot formation and breakdown. These coagulopathies are attributable to tissue injury and shock, and encompass underlying endothelial, immune and inflammatory perturbations. Despite the recognition and identification of multiple mechanisms and mediators of TIC, and the development of targeted treatments, the mortality rates and associated morbidities due to hemorrhage after injury remain high. The purpose of this review is to examine the past and present understanding of the multiple distinct but highly integrated pathways implicated in TIC, in order to highlight the current knowledge gaps and future needs in this evolving field, with the aim of reducing morbidity and mortality after injury.
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Affiliation(s)
- Lucy Z. Kornblith
- Department of Surgery, Zuckerberg San Francisco General Hospital and the University of California, San Francisco, San Francisco, California, 1001 Potrero Avenue, Building 1, Suite 210, San Francisco, CA 94110
| | - Hunter B. Moore
- Department of Surgery, Denver Health Medical Center and the University of Colorado, Denver, Colorado, 777 Bannock Street. Mail Code 0206, Denver, CO 80203
| | - Mitchell J. Cohen
- Department of Surgery, Denver Health Medical Center and the University of Colorado, Denver, Colorado, 777 Bannock Street. Mail Code 0206, Denver, CO 80203
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112
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Weymouth W, Long B, Koyfman A, Winckler C. Whole Blood in Trauma: A Review for Emergency Clinicians. J Emerg Med 2019; 56:491-498. [DOI: 10.1016/j.jemermed.2019.01.024] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Revised: 01/09/2019] [Accepted: 01/21/2019] [Indexed: 11/26/2022]
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113
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Cohen J, Scorer T, Wright Z, Stewart IJ, Sosnov J, Pidcoke H, Fedyk C, Kwan H, Chung KK, Heegard K, White C, Cap A. A prospective evaluation of thromboelastometry (ROTEM) to identify acute traumatic coagulopathy and predict massive transfusion in military trauma patients in Afghanistan. Transfusion 2019; 59:1601-1607. [DOI: 10.1111/trf.15176] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Revised: 01/14/2019] [Accepted: 01/14/2019] [Indexed: 12/20/2022]
Affiliation(s)
- Jared Cohen
- Department of Internal Medicine Aviano Air Force Base Aviano Italy
| | - Thomas Scorer
- Centre of Defence Pathology RCDM Birmingham UK
- University of Bristol Bristol UK
- Coagulation and Blood Research Program US Army Institute of Surgical Research FT Sam Houston Texas
| | - Zachary Wright
- Department of Oncology and Hematology Keesler Air Force Base, Keesler Biloxi Mississippi
| | - Ian J. Stewart
- David Grant USAF Medical Center Clinical Investigation Facility Fairfield California
| | - Jonathan Sosnov
- Department of Nephrology Scott Air Force Base Scott Illinois
| | | | - Chriselda Fedyk
- Coagulation and Blood Research Program US Army Institute of Surgical Research FT Sam Houston Texas
| | - Hana Kwan
- Department of Nephrology Joint Base San Antonio Fort Sam Houston Texas
| | - Kevin K. Chung
- Department of Medicine Uniformed Services University Bethesda Maryland
| | | | | | - Andrew Cap
- Coagulation and Blood Research Program US Army Institute of Surgical Research FT Sam Houston Texas
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Systemic hyperfibrinolysis after trauma: a pilot study of targeted proteomic analysis of superposed mechanisms in patient plasma. J Trauma Acute Care Surg 2019; 84:929-938. [PMID: 29554044 DOI: 10.1097/ta.0000000000001878] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Viscoelastic measurements of hemostasis indicate that 20% of seriously injured patients exhibit systemic hyperfibrinolysis, with increased early mortality. These patients have normal clot formation with rapid clot lysis. Targeted proteomics was applied to quantify plasma proteins from hyperfibrinolytic (HF) patients to elucidate potential pathophysiology. METHODS Blood samples were collected in the field or at emergency department arrival and thrombelastography (TEG) was used to characterize in vitro clot formation under native and tissue plasminogen activator (tPA)-stimulated conditions. Ten samples were taken from injured patients exhibiting normal lysis time at 30 min (Ly30), "eufibrinolytic" (EF), 10 from HF patients, defined as tPA-stimulated TEG Ly30 >50%, and 10 from healthy controls. Trauma patient samples were analyzed by targeted proteomics and ELISA assays for specific coagulation proteins. RESULTS HF patients exhibited increased plasminogen activation. Thirty-three proteins from the HF patients were significantly decreased compared with healthy controls and EF patients; 17 were coagulation proteins with anti-protease consumption (p < 0.005). The other 16 decreased proteins indicate activation of the alternate complement pathway, depletion of carrier proteins, and four glycoproteins. CXC7 was elevated in all injured patients versus healthy controls (p < 0.005), and 35 proteins were unchanged across all groups (p > 0.1 and fold change of concentrations of 0.75-1.3). CONCLUSION HF patients had significant decreases in specific proteins and support mechanisms known in trauma-induced hyperfibrinolysis and also unexpected decreases in coagulation factors, factors II, X, and XIII, without changes in clot formation (SP, R times, or angle). Decreased clot stability in HF patients was corroborated with tPA-stimulated TEGs. LEVEL OF EVIDENCE Prognostic, level III.
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Albert V, Arulselvi S, Agrawal D, Pati HP, Pandey RM. Early posttraumatic changes in coagulation and fibrinolysis systems in isolated severe traumatic brain injury patients and its influence on immediate outcome. Hematol Oncol Stem Cell Ther 2019; 12:32-43. [DOI: 10.1016/j.hemonc.2018.09.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Revised: 08/23/2018] [Accepted: 09/06/2018] [Indexed: 12/27/2022] Open
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Platelet aggregation after blunt trauma is associated with the acute respiratory distress syndrome and altered by cigarette smoke exposure. J Trauma Acute Care Surg 2019; 84:365-371. [PMID: 29140951 DOI: 10.1097/ta.0000000000001738] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND The risk of the acute respiratory distress syndrome (ARDS) is increased in passive and active smokers after blunt trauma. However, the mechanisms responsible, including the role of platelet aggregation, for this association are unknown. METHODS We analyzed 215 patients with severe blunt trauma from a prospective observational cohort at a Level I trauma center between 2010 and 2015. Subjects underwent impedance-based platelet aggregometry in response to platelet agonists arachidonic acid, adenosine diphosphate, collagen, and thrombin receptor activating peptide-6. Acute respiratory distress syndrome within the first 8 days of admission was adjudicated using Berlin criteria. Plasma cotinine was measured to assess cigarette smoke exposure. Regression analyses were used to assess the relationship between (1) platelet aggregation and ARDS and (2) cigarette smoke exposure and platelet aggregation. RESULTS At both 0 hour and 24 hours, impaired platelet aggregation was associated with increased odds of developing ARDS. Cigarette smoke exposure was associated with increased platelet aggregation upon arrival to the emergency department. However, at 24 hours, cigarette smoke exposure was associated with increased impairment in platelet aggregation, reflecting a statistically significant decline in platelet aggregation over the initial 24 hours after trauma. The relationship between this decline in platelet aggregation and ARDS differed by cigarette smoke exposure status, suggesting that impaired platelet activation differentially affects the risk of ARDS in those with cigarette smoke exposure (arachidonic acid, p for interaction: 0.005, collagen p for interaction: 0.02, adenosine diphosphate, p for interaction: 0.05). CONCLUSION Impaired platelet aggregation at 0 hour and 24 hours is associated with an increased risk of developing ARDS after severe blunt trauma. Cigarette smoke-exposed patients are more likely to develop impaired platelet aggregation over the first 24 hours of admission, which may contribute to their increased risk of ARDS. LEVEL OF EVIDENCE Prognostic/Epidemiological, level III.
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Suehiro E, Fujiyama Y, Kiyohira M, Motoki Y, Nojima J, Suzuki M. Probability of Soluble Tissue Factor Release Lead to the Elevation of D-dimer as a Biomarker for Traumatic Brain Injury. Neurol Med Chir (Tokyo) 2019; 59:63-67. [PMID: 30674749 PMCID: PMC6375819 DOI: 10.2176/nmc.oa.2018-0254] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
D-dimer is a potential biomarker for the detection of traumatic brain injury (TBI). However, the mechanisms that trigger elevation of D-dimer in TBI remain unclear. The purpose of this study was to evaluate the reliability of D-dimer in blood as a biomarker for TBI and to determine the mechanisms involved in regulating its blood levels. Nine patients with moderate to severe isolated TBI (Glasgow Coma Scale [GCS] score 7–13) were admitted to our hospital from May 2013 to June 2014. Blood samples were collected from systemic arteries on arrival and at 1, 3, 5, and 7 days after injury. Blood levels of neuron specific enolase (NSE), D-dimer, and soluble tissue factor (sTF) were measured. NSE (33.4 ng/ml: normal <12.0 ng/ml) and D-dimer (56.1 μg/ml: normal <1.0 μg/ml) were elevated at admission and declined on day 1 after injury. At admission, there were significant correlations of D-dimer levels with NSE (R = 0.727, P = 0.026) and sTF (R = 0.803, P = 0.009) levels. The blood level of D-dimer accurately reflects the degree of brain tissue damage indicated by NSE levels. Our data suggest that release of sTF induced by brain tissue damage may activate the coagulation cascade, leading to elevation of D-dimer.
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Affiliation(s)
- Eiichi Suehiro
- Department of Neurosurgery, Yamaguchi University Graduate School of Medicine
| | - Yuichi Fujiyama
- Department of Neurosurgery, Yamaguchi University Graduate School of Medicine
| | - Miwa Kiyohira
- Department of Neurosurgery, Yamaguchi University Graduate School of Medicine
| | - Yukari Motoki
- Department of Laboratory Science, Faculty of Health Science, Yamaguchi University Graduate School of Medicine
| | - Junzo Nojima
- Department of Laboratory Science, Faculty of Health Science, Yamaguchi University Graduate School of Medicine
| | - Michiyasu Suzuki
- Department of Neurosurgery, Yamaguchi University Graduate School of Medicine
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Exposing the bidirectional effects of alcohol on coagulation in trauma: Impaired clot formation and decreased fibrinolysis in rotational thromboelastometry. J Trauma Acute Care Surg 2019; 84:97-103. [PMID: 29267182 DOI: 10.1097/ta.0000000000001716] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Alcohol has been associated with altered viscoelastic testing in trauma, indicative of impaired coagulation. Such alterations, however, show no correlation to coagulopathy-related outcomes. Other data suggest that alcohol may inhibit fibrinolysis. We sought to clarify these mechanisms after traumatic injury using thromboelastometry (ROTEM), hypothesizing that alcohol-related clot formation impairment may be counter-balanced by inhibited fibrinolysis. METHODS Laboratory, demographic, clinical, and outcome data were prospectively collected from 406 critically injured trauma patients at a Level I trauma center. ROTEM and standard coagulation measures were conducted in parallel. Univariate comparisons were performed by alcohol level (EtOH), with subsequent regression analysis. RESULTS Among 274 (58%) patients with detectable EtOH, median EtOH was 229 mg/dL. These patients were primarily bluntly injured and had lower GCS (p < 0.05) than EtOH-negative patients, but had similar admission pH and injury severity (p = NS). EtOH-positive patients had prolonged ROTEM clotting time and rate of clot formation time (CFT/α); they also had decreased fibrinolysis (max lysis %; all p < 0.05). In linear regression, for every 100 mg/dL increase in EtOH, clotting time increased by 13 seconds and fibrinolysis decreased by 1.5% (both p < 0.05). However, EtOH was not an independent predictor of transfusion requirements or mortality. In high-EtOH patients with coagulopathic ROTEM tracings, transfusion rates were significantly lower than expected, relative to EtOH-negative patients with similar ROTEM findings. CONCLUSION As assayed by ROTEM, alcohol appears to have a bidirectional effect on coagulation in trauma, both impairing initial clot formation and inhibiting fibrinolysis. This balancing of mechanisms may explain lack of correlation between altered ROTEM and coagulopathy-related outcomes. Viscoelastic testing should be used with caution in intoxicated trauma patients. LEVEL OF EVIDENCE Epidemiological study, level III.
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Guerado E, Bertrand ML, Cano JR, Cerván AM, Galán A. Damage control orthopaedics: State of the art. World J Orthop 2019; 10:1-13. [PMID: 30705836 PMCID: PMC6354106 DOI: 10.5312/wjo.v10.i1.1] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Revised: 12/11/2018] [Accepted: 12/13/2018] [Indexed: 02/06/2023] Open
Abstract
Damage control orthopaedics (DCO) originally consisted of the provisional immobilisation of long bone - mainly femur - fractures in order to achieve the advantages of early treatment and to minimise the risk of complications, such as major pain, fat embolism, clotting, pathological inflammatory response, severe haemorrhage triggering the lethal triad, and the traumatic effects of major surgery on a patient who is already traumatised (the “second hit” effect). In recent years, new locations have been added to the DCO concept, such as injuries to the pelvis, spine and upper limbs. Nonetheless, this concept has not yet been validated in well-designed prospective studies, and much controversy remains. Indeed, some researchers believe the indiscriminate application of DCO might be harmful and produce substantial and unnecessary expense. In this respect, too, normalised parameters associated with the acid-base system have been proposed, under a concept termed early appropriate care, in the view that this would enable patients to receive major surgical procedures in an approach offering the advantages of early total care together with the apparent safety of DCO. This paper discusses the diagnosis and treatment of severely traumatised patients managed in accordance with DCO and highlights the possible drawbacks of this treatment principle.
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Affiliation(s)
- Enrique Guerado
- Department of Orthopaedic Surgery and Traumatology, Hospital Costa del Sol, University of Malaga, Marbella 29603, Malaga, Spain
| | - Maria Luisa Bertrand
- Department of Orthopaedic Surgery and Traumatology, Hospital Costa del Sol, University of Malaga, Marbella 29603, Malaga, Spain
| | - Juan Ramon Cano
- Department of Orthopaedic Surgery and Traumatology, Hospital Costa del Sol, University of Malaga, Marbella 29603, Malaga, Spain
| | - Ana María Cerván
- Department of Orthopaedic Surgery and Traumatology, Hospital Costa del Sol, University of Malaga, Marbella 29603, Malaga, Spain
| | - Adolfo Galán
- Department of Orthopaedic Surgery and Traumatology, Hospital Costa del Sol, University of Malaga, Marbella 29603, Malaga, Spain
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Gando S, Mayumi T, Ukai T. The roles of activated protein C in experimental trauma models. Chin J Traumatol 2018; 21:311-315. [PMID: 30594428 PMCID: PMC6354177 DOI: 10.1016/j.cjtee.2018.07.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Revised: 06/01/2018] [Accepted: 06/19/2018] [Indexed: 02/04/2023] Open
Abstract
Trauma-induced coagulopathy is classified into primary and secondary coagulopathy, with the former elicited by trauma and traumatic shock itself and the latter being acquired coagulopathy induced by anemia, hypothermia, acidosis, and dilution. Primary coagulopathy consists of disseminated intravascular coagulation and acute coagulopathy of trauma shock (ACOTS). The pathophysiology of ACOTS is the suppression of thrombin generation and neutralization of plasminogen activator inhibitor-1 mediated by activated protein C that leads to hypocoagulation and hyperfibrinolysis in the circulation. This review tried to clarify the validity of activated protein C hypothesis that constitutes the main pathophysiology of the ACOTS in experimental trauma models.
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Affiliation(s)
- Satoshi Gando
- Acute and Critical Care Center, Department of Acute and Critical Care Medicine, Sapporo Higashi Tokushukai Hospital, Japan,Corresponding author.
| | - Toshihiko Mayumi
- Department of Emergency Medicine, School of Medicine, University of Occupational and Environmental Health, Japan
| | - Tomohiko Ukai
- Department of Social Medicine, Graduate School of Medicine, Osaka University, Japan
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Griggs JE, Jeyanathan J, Joy M, Russell MQ, Durge N, Bootland D, Dunn S, Sausmarez ED, Wareham G, Weaver A, Lyon RM. Mortality of civilian patients with suspected traumatic haemorrhage receiving pre-hospital transfusion of packed red blood cells compared to pre-hospital crystalloid. Scand J Trauma Resusc Emerg Med 2018; 26:100. [PMID: 30454067 PMCID: PMC6245557 DOI: 10.1186/s13049-018-0567-1] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Accepted: 11/06/2018] [Indexed: 12/20/2022] Open
Abstract
Background Major haemorrhage is a leading cause of mortality following major trauma. Increasingly, Helicopter Emergency Medical Services (HEMS) in the United Kingdom provide pre-hospital transfusion with blood products, although the evidence to support this is equivocal. This study compares mortality for patients with suspected traumatic haemorrhage transfused with pre-hospital packed red blood cells (PRBC) compared to crystalloid. Methods A single centre retrospective observational cohort study between 1 January 2010 and 1 February 2015. Patients triggering a pre-hospital Code Red activation were eligible. The primary outcome measure was all-cause mortality at 6 hours (h) and 28 days (d), including a sub-analysis of patients receiving a major and massive transfusion. Multivariable regression models predicted mortality. Multiple Imputation was employed, and logistic regression models were constructed for all imputed datasets. Results The crystalloid (n = 103) and PRBC (n = 92) group were comparable for demographics, Injury Severity Score (p = 0.67) and mechanism of injury (p = 0.73). Observed 6 h mortality was smaller in the PRBC group (n = 10, 10%) compared to crystalloid group (n = 19, 18%). Adjusted OR was not statistically significant (OR 0.48, CI 0.19–1.19, p = 0.11). Observed mortality at 28 days was smaller in the PRBC group (n = 21, 26%) compared to crystalloid group (n = 31, 40%), p = 0.09. Adjusted OR was not statistically significant (OR 0.66, CI 0.32–1.35, p = 0.26). A statistically significant greater proportion of the crystalloid group required a major transfusion (n = 62, 60%) compared to the PRBC group (n = 41, 40%), p = 0.02. For patients requiring a massive transfusion observed mortality was smaller in the PRBC group at 28 days (p = 0.07). Conclusion In a single centre UK HEMS study, in patients with suspected traumatic haemorrhage who received a PRBC transfusion there was an observed, but non-significant, reduction in mortality at 6 h and 28 days, also reflected in a massive transfusion subgroup. Patients receiving pre-hospital PRBC were significantly less likely to require an in-hospital major transfusion. Further adequately powered multi-centre prospective research is required to establish the optimum strategy for pre-hospital volume replacement in patients with traumatic haemorrhage.
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Affiliation(s)
- J E Griggs
- Kent, Surrey & Sussex Air Ambulance Trust, Redhill Aerodrome, Redhill, RH1 5YP, UK.
| | - J Jeyanathan
- Kent, Surrey & Sussex Air Ambulance Trust, Redhill Aerodrome, Redhill, RH1 5YP, UK.,Academic Department of Military Anaesthesia and Critical Care, London, UK
| | - M Joy
- University of Surrey, Guildford, GU2 7XH, UK
| | - M Q Russell
- Kent, Surrey & Sussex Air Ambulance Trust, Redhill Aerodrome, Redhill, RH1 5YP, UK
| | - N Durge
- Kent, Surrey & Sussex Air Ambulance Trust, Redhill Aerodrome, Redhill, RH1 5YP, UK.,Royal London Hospital, Whitechapel Road, Whitechapel, London, E1 1BB, UK
| | - D Bootland
- Kent, Surrey & Sussex Air Ambulance Trust, Redhill Aerodrome, Redhill, RH1 5YP, UK.,Royal Sussex County Hospital, Eastern Road, Brighton, BN2 5BE, UK
| | - S Dunn
- Kent, Surrey & Sussex Air Ambulance Trust, Redhill Aerodrome, Redhill, RH1 5YP, UK
| | - E D Sausmarez
- Kent, Surrey & Sussex Air Ambulance Trust, Redhill Aerodrome, Redhill, RH1 5YP, UK
| | - G Wareham
- Kent, Surrey & Sussex Air Ambulance Trust, Redhill Aerodrome, Redhill, RH1 5YP, UK
| | - A Weaver
- Royal London Hospital, Whitechapel Road, Whitechapel, London, E1 1BB, UK
| | - R M Lyon
- Kent, Surrey & Sussex Air Ambulance Trust, Redhill Aerodrome, Redhill, RH1 5YP, UK.,University of Surrey, Guildford, GU2 7XH, UK
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The evolution of activated protein C plasma levels in septic shock and its association with mortality: A prospective observational study. J Crit Care 2018; 47:41-48. [DOI: 10.1016/j.jcrc.2018.06.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2018] [Revised: 05/28/2018] [Accepted: 06/01/2018] [Indexed: 01/18/2023]
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Phillips JB, Mohorn PL, Bookstaver RE, Ezekiel TO, Watson CM. Hemostatic Management of Trauma-Induced Coagulopathy. Crit Care Nurse 2018; 37:37-47. [PMID: 28765353 DOI: 10.4037/ccn2017476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Trauma-induced coagulopathy is a primary factor in many trauma-related fatalities. Management hinges upon rapid diagnosis of coagulation abnormalities and immediate administration of appropriate hemostatic agents. Use of crystalloids and packed red blood cells has traditionally been the core of trauma resuscitation, but current massive transfusion protocols include combination therapy with fresh frozen plasma and predefined ratios of platelets to packed red blood cells, limiting crystalloid administration. Hemostatic agents such as tranexamic acid, prothrombin complex concentrate, fibrinogen concentrate, and, in cases of refractory bleeding, recombinant activated factor VIIa may also be warranted. Goal-directed resuscitation using viscoelastic tools allows specific component-centered therapy based on individual clotting abnormalities that may limit blood product use and thromboembolic risks and may lead to reduced mortality. Because of the complex management of patients with trauma-induced coagulopathy, critical care nurses must be familiar with the pathophysiology, acute diagnostics, and pharmacotherapeutic options used to treat these patients.
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Affiliation(s)
- Janise B Phillips
- Janise B. Phillips is a critical care pharmacotherapy specialist, Department of Pharmacy Services, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates.,Phillip L. Mohorn is a critical care clinical pharmacy specialist, Department of Pharmacy, Spartanburg Medical Center, Spartanburg Regional Healthcare System, Spartanburg, South Carolina.,Rebecca E. Bookstaver is a critical care clinical pharmacist, Department of Pharmacy, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina.,Tanya O. Ezekiel is a clinical informatics pharmacist, Department of Pharmaceutical Services and Clinical Nutrition, Palmetto Health Richland, Columbia, South Carolina.,Christopher M. Watson is chief of surgery, medical director of the surgical-trauma ICU and surgical step down unit, and program director of the surgical critical care fellowship, Division of Trauma, Acute Care Surgery, and Surgical Critical Care, Palmetto Health Richland and the University of South Carolina School of Medicine, Columbia, South Carolina
| | - Phillip L Mohorn
- Janise B. Phillips is a critical care pharmacotherapy specialist, Department of Pharmacy Services, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates. .,Phillip L. Mohorn is a critical care clinical pharmacy specialist, Department of Pharmacy, Spartanburg Medical Center, Spartanburg Regional Healthcare System, Spartanburg, South Carolina. .,Rebecca E. Bookstaver is a critical care clinical pharmacist, Department of Pharmacy, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina. .,Tanya O. Ezekiel is a clinical informatics pharmacist, Department of Pharmaceutical Services and Clinical Nutrition, Palmetto Health Richland, Columbia, South Carolina. .,Christopher M. Watson is chief of surgery, medical director of the surgical-trauma ICU and surgical step down unit, and program director of the surgical critical care fellowship, Division of Trauma, Acute Care Surgery, and Surgical Critical Care, Palmetto Health Richland and the University of South Carolina School of Medicine, Columbia, South Carolina.
| | - Rebecca E Bookstaver
- Janise B. Phillips is a critical care pharmacotherapy specialist, Department of Pharmacy Services, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates.,Phillip L. Mohorn is a critical care clinical pharmacy specialist, Department of Pharmacy, Spartanburg Medical Center, Spartanburg Regional Healthcare System, Spartanburg, South Carolina.,Rebecca E. Bookstaver is a critical care clinical pharmacist, Department of Pharmacy, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina.,Tanya O. Ezekiel is a clinical informatics pharmacist, Department of Pharmaceutical Services and Clinical Nutrition, Palmetto Health Richland, Columbia, South Carolina.,Christopher M. Watson is chief of surgery, medical director of the surgical-trauma ICU and surgical step down unit, and program director of the surgical critical care fellowship, Division of Trauma, Acute Care Surgery, and Surgical Critical Care, Palmetto Health Richland and the University of South Carolina School of Medicine, Columbia, South Carolina
| | - Tanya O Ezekiel
- Janise B. Phillips is a critical care pharmacotherapy specialist, Department of Pharmacy Services, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates.,Phillip L. Mohorn is a critical care clinical pharmacy specialist, Department of Pharmacy, Spartanburg Medical Center, Spartanburg Regional Healthcare System, Spartanburg, South Carolina.,Rebecca E. Bookstaver is a critical care clinical pharmacist, Department of Pharmacy, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina.,Tanya O. Ezekiel is a clinical informatics pharmacist, Department of Pharmaceutical Services and Clinical Nutrition, Palmetto Health Richland, Columbia, South Carolina.,Christopher M. Watson is chief of surgery, medical director of the surgical-trauma ICU and surgical step down unit, and program director of the surgical critical care fellowship, Division of Trauma, Acute Care Surgery, and Surgical Critical Care, Palmetto Health Richland and the University of South Carolina School of Medicine, Columbia, South Carolina
| | - Christopher M Watson
- Janise B. Phillips is a critical care pharmacotherapy specialist, Department of Pharmacy Services, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates.,Phillip L. Mohorn is a critical care clinical pharmacy specialist, Department of Pharmacy, Spartanburg Medical Center, Spartanburg Regional Healthcare System, Spartanburg, South Carolina.,Rebecca E. Bookstaver is a critical care clinical pharmacist, Department of Pharmacy, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina.,Tanya O. Ezekiel is a clinical informatics pharmacist, Department of Pharmaceutical Services and Clinical Nutrition, Palmetto Health Richland, Columbia, South Carolina.,Christopher M. Watson is chief of surgery, medical director of the surgical-trauma ICU and surgical step down unit, and program director of the surgical critical care fellowship, Division of Trauma, Acute Care Surgery, and Surgical Critical Care, Palmetto Health Richland and the University of South Carolina School of Medicine, Columbia, South Carolina
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Ozolina A, Nemme J, Ozolins A, Bjertnæs LJ, Vanags I, Gardovskis J, Viksna L, Krumina A. Fibrinolytic System Changes in Liver Surgery: A Pilot Observational Study. Front Med (Lausanne) 2018; 5:253. [PMID: 30255021 PMCID: PMC6141717 DOI: 10.3389/fmed.2018.00253] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2018] [Accepted: 08/22/2018] [Indexed: 01/19/2023] Open
Abstract
Introduction: Bleeding occurs frequently in liver surgery. Unbalance between tissue plasminogen activator (t-PA) and plasminogen activator inhibitor-1 (PAI-1) concentrations might increase bleeding. Our aim was to analyze perioperative fibrinolytic changes during liver surgery. Materials and Methods: We evaluated 15 patients for inclusion into a prospective pilot study of liver surgery. We assessed fibrinolysis by plasma PAI-1 and t-PA: before surgery (T1), before Pringle maneuver (PM;T2), at the end of surgery (T3) and 24 h postoperatively (T4), and registered demographic and laboratory data, extent and duration of surgery, hemodynamic parameters, blood loss, and transfused volumes of blood products. Data presented as mean ± SD. Significance at P < 0.05. Results: After exclusion of six patients only undergoing biopsies, we included six women and three men aged 49.1 ± 19.6 years; two patients with liver metastases of colorectal cancer and hepatocellular carcinoma, respectively, two with focal nodular hyperplasia, two with hepatic hemangioma, and one with angiomyolipoma. Six patients underwent PM. PAI-1 plasma concentration (n = 9) rose from 6.25 ± 2.25 at T1 through 17.30 ± 14.59 ng/ml at T2 and 28.74 ± 20.4 (p = 0.007) and 22.5 ± 16.0 ng/ml (p = 0.04), respectively, at T3 and T4. Correspondingly, t-PA plasma concentration (n = 9) increased from 4.76 ± 3.08 ng/ml at T1 through 8.00 ± 5.10 ng/ml (p = 0.012) at T2 and decreased to 4.25 ± 2.29 ng/ml and 3.04 ± 3.09 at T3 and T4, respectively. Plasma t-PA level at T2 was significantly different from those at T1, T3, and T4 (p < 0.004). In PM patients, t-PA levels increased from T1, peaked at T2 (p = 0.001), and subsequently decreased at T3 and T4 (p = 0.011 and p = 0.037), respectively. Mean blood loss was 1,377.7 ± 1,062.8 ml; seven patients received blood products. Patients with higher PAI-1 levels at T3 received more fresh frozen plasma (r = 0.79; p = 0.01) and red blood cells (r = 0.88; p = 0.002). Conclusions: During liver surgery, fibrinolysis increased, as evidenced by rises in plasma PAI-1and t-PA, especially after start of surgery and following PM. Transfused volumes of blood products correlated with higher plasma concentrations of PAI-1. Confirming this tendency requires a larger cohort of patients.
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Affiliation(s)
- Agnese Ozolina
- Department of Anesthesiology, Orto Clinic, Riga, Latvia.,Riga Stradins University, Riga, Latvia
| | - Janis Nemme
- Department of Anesthesiology and Intensive Care Unit, Pauls Stradins Clinical University Hospital, Riga, Latvia
| | - Arturs Ozolins
- Riga Stradins University, Riga, Latvia.,Department of Surgery, Pauls Stradins Clinical University Hospital, Riga, Latvia
| | - Lars J Bjertnæs
- Anesthesia and Critical Care Research Group, Department of Clinical Medicine, Faculty of Health Sciences, University of Tromsø, The Arctic University of Norway, Tromsø, Norway
| | - Indulis Vanags
- Riga Stradins University, Riga, Latvia.,Department of Anesthesiology and Intensive Care Unit, Pauls Stradins Clinical University Hospital, Riga, Latvia
| | - Janis Gardovskis
- Riga Stradins University, Riga, Latvia.,Department of Surgery, Pauls Stradins Clinical University Hospital, Riga, Latvia
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Matsumoto H, Takeba J, Umakoshi K, Kikuchi S, Ohshita M, Annen S, Moriyama N, Nakabayashi Y, Sato N, Aibiki M. Decreased antithrombin activity in the early phase of trauma is strongly associated with extravascular leakage, but not with antithrombin consumption: a prospective observational study. Thromb J 2018; 16:17. [PMID: 30078997 PMCID: PMC6069797 DOI: 10.1186/s12959-018-0171-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Accepted: 04/26/2018] [Indexed: 01/26/2023] Open
Abstract
Background We conducted a prospective observational study for investigating coagulofibrinolytic changes and mechanisms of antithrombin (AT) alternations in trauma. Methods Trauma patients hospitalized for more than seven days were analyzed for coagulofibrinolytic biomarkers. The patients were stratified into two groups according to AT activity level on admission (day 0), comprising normal AT and low AT patients. Results Thirty-nine patients (median Injury Severity Score 20) exhibited initial coagulatory activation and triphasic fibrinolytic changes. AT activity did not show a negative linear correlation with levels of thrombin-antithrombin complex (TAT), a marker of coagulation activity and AT consumption, but was strongly correlated with levels of albumin (Alb), an index of vascular permeability, on day 0 (r = 0.702, p < 0.001). Furthermore, Alb was one of the independent predictors for AT on day 0. IL-6 on day 0 and thrombomodulin (TM) levels during the study period, reflecting systemic inflammation and endothelial cell injury, respectively, were significantly higher in the lower AT group (n = 10) than in the normal group (n = 29) (IL-6, p = 0.004; TM, p = 0.017). On days 2 and 4, TAT levels in the lower AT group were significantly higher than in the normal group. Conclusions Trauma caused clear triphasic coagulofibrinolytic changes. Decreased AT in the later phase might lead to a prolonged hypercoagulation. AT reduction in the initial phase of trauma is strongly associated with extravascular leakage as suggested by the association of Alb depletion with IL-6 and TM elevation, but not with AT consumption.
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Affiliation(s)
- Hironori Matsumoto
- Department of Emergency and Critical Care Medicine, Ehime University, Graduate School of Medicine, Shitsukawa 454, Toon City, Ehime 791-0295 Japan
| | - Jun Takeba
- Department of Emergency and Critical Care Medicine, Ehime University, Graduate School of Medicine, Shitsukawa 454, Toon City, Ehime 791-0295 Japan
| | - Kensuke Umakoshi
- Department of Emergency and Critical Care Medicine, Ehime University, Graduate School of Medicine, Shitsukawa 454, Toon City, Ehime 791-0295 Japan
| | - Satoshi Kikuchi
- Department of Emergency and Critical Care Medicine, Ehime University, Graduate School of Medicine, Shitsukawa 454, Toon City, Ehime 791-0295 Japan
| | - Muneaki Ohshita
- Department of Emergency and Critical Care Medicine, Ehime University, Graduate School of Medicine, Shitsukawa 454, Toon City, Ehime 791-0295 Japan
| | - Suguru Annen
- Department of Emergency and Critical Care Medicine, Ehime University, Graduate School of Medicine, Shitsukawa 454, Toon City, Ehime 791-0295 Japan
| | - Naoki Moriyama
- Department of Emergency and Critical Care Medicine, Ehime University, Graduate School of Medicine, Shitsukawa 454, Toon City, Ehime 791-0295 Japan
| | - Yuki Nakabayashi
- Department of Emergency and Critical Care Medicine, Ehime University, Graduate School of Medicine, Shitsukawa 454, Toon City, Ehime 791-0295 Japan
| | - Norio Sato
- Department of Emergency and Critical Care Medicine, Ehime University, Graduate School of Medicine, Shitsukawa 454, Toon City, Ehime 791-0295 Japan
| | - Mayuki Aibiki
- Department of Emergency and Critical Care Medicine, Ehime University, Graduate School of Medicine, Shitsukawa 454, Toon City, Ehime 791-0295 Japan
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Ducloy-Bouthors AS, Duhamel A, Kipnis E, Tournoys A, Prado-Dupont A, Elkalioubie A, Jeanpierre E, Debize G, Peynaud-Debayle E, DeProst D, Huissoud C, Rauch A, Susen S. Postpartum haemorrhage related early increase in D-dimers is inhibited by tranexamic acid: haemostasis parameters of a randomized controlled open labelled trial. Br J Anaesth 2018; 116:641-8. [PMID: 27106967 DOI: 10.1093/bja/aew021] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/21/2016] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Beneficial effects of tranexamic acid (TA) have been established in surgery and trauma. In ongoing postpartum haemorrhage (PPH), a moderate reduction of blood loss was observed in a previously published randomized controlled trial. Analysis of haemostasis parameters obtained from samples collected as part of this study are presented. METHODS Women with PPH >800 ml after vaginal delivery were assigned to receive either TA (4 g over 1 h, then 1 g per h over six h) (TA) or not (H). A non-haemorrhagic group (NH), <800 ml blood loss, was included as postpartum reference. At four time-points (enrolment, +30 min, +2 h, +6 h), haemostasis was assessed. Haemostasis assays were performed blinded to group allocation. Data were expressed as median [interquartiles] and compared with non-parametric tests. RESULTS In H compared with NH group, D-dimers increase (3730 ng ml(-1) [2468-8493] vs 2649 [2667-4375]; P=0.0001) and fibrinogen and factor II decrease were observed at enrolment and became maximal 2 h later. When comparing TA to H patients, the increase in Plasmin-Antiplasmin-complexes at +30 min (486 ng ml(-1) [340-1116] vs 674 [548-1640]; P=0.03) and D-dimers at +2 h (3888 ng ml(-1) [2688-6172] vs 7495 [4400-15772]; P=0.0001) was blunted. TA had no effect on fibrinogen decrease. CONCLUSIONS This study provides biological evidence of an early increase in D-dimers and plasmin-antiplasmin complexes associated with active post-partum haemorrhage and its attenuation by the early use of a clinically effective high dose of TA, opening the perspective of dose ranging studies to determinate the optimal dose and timing in this setting. CLINICAL TRIAL REGISTRATION ISRCTN09968140.
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Affiliation(s)
| | - A Duhamel
- Pole de Santé Publique, CHU Lille, Lille, France EA2694, Université of Lille Nord de France, France
| | - E Kipnis
- Pole d'Anesthésie-Réanimation, CHU Lille, France
| | - A Tournoys
- Hématologie Transfusion, Pôle de Biologie Pathologie Génétique, CHU Lille, France Inserm U1011, Laboratoire de Recherche J&K, Institut Pasteur de Lille, Faculté de Médecine - Pôle recherche, University of Lille Nord de France, EGID, Lille, France
| | - A Prado-Dupont
- Inserm U1011, Laboratoire de Recherche J&K, Institut Pasteur de Lille, Faculté de Médecine - Pôle recherche, University of Lille Nord de France, EGID, Lille, France Pole d'hématologie, Maternité Monaco, Centre hospitalier, Valenciennes, France
| | - A Elkalioubie
- Inserm U1011, Laboratoire de Recherche J&K, Institut Pasteur de Lille, Faculté de Médecine - Pôle recherche, University of Lille Nord de France, EGID, Lille, France
| | - E Jeanpierre
- Hématologie Transfusion, Pôle de Biologie Pathologie Génétique, CHU Lille, France Inserm U1011, Laboratoire de Recherche J&K, Institut Pasteur de Lille, Faculté de Médecine - Pôle recherche, University of Lille Nord de France, EGID, Lille, France
| | - G Debize
- Pole d'hématologie, Hôpital de la Croix Rousse, Hôpitaux civils Lyon, Lyon, France
| | - E Peynaud-Debayle
- APHP, Hôpital Louis Mourier, Service d'Hématologie Biologique, F-92701 Colombes, France
| | - D DeProst
- APHP, Hôpital Louis Mourier, Service d'Hématologie Biologique, F-92701 Colombes, France University Paris Diderot, Sorbonne Paris Cité, F-75018 Paris, France
| | - C Huissoud
- Pole d'obstétrique, Hôpital de la Croix Rousse, Hôpitaux Civils Lyon, Lyon, France
| | - A Rauch
- Hématologie Transfusion, Pôle de Biologie Pathologie Génétique, CHU Lille, France Inserm U1011, Laboratoire de Recherche J&K, Institut Pasteur de Lille, Faculté de Médecine - Pôle recherche, University of Lille Nord de France, EGID, Lille, France
| | - S Susen
- Hématologie Transfusion, Pôle de Biologie Pathologie Génétique, CHU Lille, France Inserm U1011, Laboratoire de Recherche J&K, Institut Pasteur de Lille, Faculté de Médecine - Pôle recherche, University of Lille Nord de France, EGID, Lille, France
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128
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Early haemorrhage control and management of trauma-induced coagulopathy: the importance of goal-directed therapy. Curr Opin Crit Care 2018; 23:503-510. [PMID: 29059118 DOI: 10.1097/mcc.0000000000000466] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
PURPOSE OF REVIEW The aim of this study was to discuss the recent developments in trauma-induced coagulopathy and the evolvement of goal-directed therapy. RECENT FINDINGS Mortality from major trauma continues to be a worldwide problem, and massive haemorrhage remains a major cause in 40% of potentially preventable trauma deaths. Development of trauma-induced coagulopathy challenges 25-35% of the patients further increasing trauma mortality. The pathophysiology of coagulopathy in trauma reflects at least two distinct mechanisms: Acute traumatic coagulopathy, consisting of endogenous heparinization, activation of the protein C pathway, hyperfibrinolysis and platelet dysfunction, and resuscitation associated coagulopathy. Clear fluid resuscitation with crystalloids and colloids is associated with dilutional coagulopathy and poor outcome in trauma. Haemostatic resuscitation is now the backbone of trauma resuscitation using a ratio-driven strategy aiming at 1:1:1 of red blood cells, plasma and platelets while applying goal-directed therapy early and repeatedly to control trauma-induced coagulopathy. SUMMARY Trauma resuscitation should focus on early goal-directed therapy with use of viscoelastic haemostatic assays while initially applying a ratio 1:1:1 driven transfusion therapy (with red blood cells, plasma and platelets) in order to sustain normal haemostasis and control further bleeding.
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129
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The role of four-factor prothrombin complex concentrate in coagulopathy of trauma: A propensity matched analysis. J Trauma Acute Care Surg 2018; 85:18-24. [DOI: 10.1097/ta.0000000000001938] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
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130
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Hendrickson CM, Gibb SL, Miyazawa BY, Keating SM, Ross E, Conroy AS, Calfee CS, Pati S, Cohen MJ. Elevated plasma levels of TIMP-3 are associated with a higher risk of acute respiratory distress syndrome and death following severe isolated traumatic brain injury. Trauma Surg Acute Care Open 2018; 3:e000171. [PMID: 30023434 PMCID: PMC6045722 DOI: 10.1136/tsaco-2018-000171] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Accepted: 05/10/2018] [Indexed: 01/15/2023] Open
Abstract
Background: Complications after injury, such as acute respiratory distress syndrome (ARDS), are common after traumatic brain injury (TBI) and associated with poor clinical outcomes. The mechanisms driving non-neurologic organ dysfunction after TBI are not well understood. Tissue inhibitor of matrix metalloproteinase-3 (TIMP-3) is a regulator of matrix metalloproteinase activity, inflammation, and vascular permeability, and hence has plausibility as a biomarker for the systemic response to TBI. Methods: In a retrospective study of 182 patients with severe isolated TBI, we measured TIMP-3 in plasma obtained on emergency department arrival. We used non-parametric tests and logistic regression analyses to test the association of TIMP-3 with the incidence of ARDS within 8 days of admission and in-hospital mortality. Results: TIMP-3 was significantly higher among subjects who developed ARDS compared with those who did not (median 2810 pg/mL vs. 2260 pg/mL, p=0.008), and significantly higher among subjects who died than among those who survived to discharge (median 2960 pg/mL vs. 2080 pg/mL, p<0.001). In an unadjusted logistic regression model, for each SD increase in plasma TIMP-3, the odds of ARDS increased significantly, OR 1.5 (95% CI 1.1 to 2.1). This association was only attenuated in multivariate models, OR 1.4 (95% CI 1.0 to 2.0). In an unadjusted logistic regression model, for each SD increase in plasma TIMP-3, the odds of death increased significantly, OR 1.7 (95% CI 1.2 to 2.3). The magnitude of this association was greater in a multivariate model adjusted for markers of injury severity, OR 1.9 (95% CI 1.2 to 2.8). Discussion: TIMP-3 may play an important role in the biology of the systemic response to brain injury in humans. Along with clinical and demographic data, early measurements of plasma biomarkers such as TIMP-3 may help identify patients at higher risk of ARDS and death after severe isolated TBI. Level of evidence III.
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Affiliation(s)
- Carolyn M Hendrickson
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of California San Francisco, San Francisco, California, USA
| | - Stuart L Gibb
- Department of Laboratory Medicine, University of California San Francisco, San Francisco, California, USA.,Blood Systems Research Institute, San Francisco, California, USA
| | - Byron Y Miyazawa
- Department of Laboratory Medicine, University of California San Francisco, San Francisco, California, USA.,Blood Systems Research Institute, San Francisco, California, USA.,Department of Surgery, University of California San Francisco, Zuckerberg San Francisco General Hospital, San Francisco, California, USA
| | - Sheila M Keating
- Blood Systems Research Institute, San Francisco, California, USA
| | - Erin Ross
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of California San Francisco, San Francisco, California, USA
| | - Amanda S Conroy
- Department of Surgery, University of California San Francisco, Zuckerberg San Francisco General Hospital, San Francisco, California, USA
| | - Carolyn S Calfee
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of California San Francisco, San Francisco, California, USA
| | - Shibani Pati
- Department of Laboratory Medicine, University of California San Francisco, San Francisco, California, USA.,Blood Systems Research Institute, San Francisco, California, USA
| | - Mitchell J Cohen
- Department of Surgery, University of California San Francisco, Zuckerberg San Francisco General Hospital, San Francisco, California, USA.,Department of Surgery, University of Colorado, Denver, Colorado, USA
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131
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Gando S, Mayumi T, Ukai T. Activated protein C plays no major roles in the inhibition of coagulation or increased fibrinolysis in acute coagulopathy of trauma-shock: a systematic review. Thromb J 2018; 16:13. [PMID: 29946227 PMCID: PMC6006835 DOI: 10.1186/s12959-018-0167-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Accepted: 03/15/2018] [Indexed: 12/27/2022] Open
Abstract
Background The pathophysiological mechanisms of acute coagulopathy of trauma-shock (ACOTS) are reported to include activated protein C-mediated suppression of thrombin generation via the proteolytic inactivation of activated Factor V (FVa) and FVIIIa; an increased fibrinolysis via neutralization of plasminogen activator inhibitor-1 (PAI-1) by activated protein C. The aims of this study are to review the evidences for the role of activated protein C in thrombin generation and fibrinolysis and to validate the diagnosis of ACOTS based on the activated protein C dynamics. Methods We conducted systematic literature search (2007–2017) using PubMed, the Cochrane Database of Systematic Reviews (CDSR), and the Cochrane Central Register of Controlled Trials (CENTRAL). Clinical studies on trauma that measured activated protein C or the circulating levels of activated protein C-related coagulation and fibrinolysis markers were included in our study. Results Out of 7613 studies, 17 clinical studies met the inclusion criteria. The levels of activated protein C in ACOTS were inconsistently decreased, showed no change, or were increased in comparison to the control groups. Irrespective of the activated protein C levels, thrombin generation was always preserved or highly elevated. There was no report on the activated protein C-mediated neutralization of PAI-1 with increased fibrinolysis. No included studies used unified diagnostic criteria to diagnose ACOTS and those studies also used different terms to refer to the condition known as ACOTS. Conclusions None of the studies showed direct cause and effect relationships between activated protein C and the suppression of coagulation and increased fibrinolysis. No definitive diagnostic criteria or unified terminology have been established for ACOTS based on the activated protein C dynamics. Electronic supplementary material The online version of this article (10.1186/s12959-018-0167-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Satoshi Gando
- 1Division of Acute and Critical Medicine, Department of Anesthesiology and Critical Care Medicine, Hokkaido University Graduate School of Medicine, N15W7, Kita-ku, Sapporo, 060-8638 Japan
| | - Toshihiko Mayumi
- 2Department of Emergency Medicine, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Tomohiko Ukai
- 3Department of Social Medicine, Graduate School of Medicine, Osaka University, Osaka, Japan
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Rapid TEG efficiently guides hemostatic resuscitation in trauma patients. Surgery 2018; 164:489-493. [PMID: 29903508 DOI: 10.1016/j.surg.2018.04.029] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Revised: 03/31/2018] [Accepted: 04/25/2018] [Indexed: 12/20/2022]
Abstract
BACKGROUND Several thrombelastography functional assays have been developed to guide transfusion in injured patients, but how this acceleration of thrombelastography affects its ability to predict massive transfusion is unknown. The objective of this study is to compare citrated native, citrated kaolin, and citrated rapid thromboelastographies for their prediction of massive transfusion after trauma. We hypothesized that citrated native thrombelastography best predicts massive transfusion. METHODS Data were collected as part of a prospective study of trauma activation patients. All patients received citrated native, citrated kaolin, or citrated rapid thromboelastographies. Logistic regression was used to assess the predictive performance of different thrombelastography assays for massive transfusion. RESULTS Measurements for all three TEG activating systems was available for 343 patients; 57 (16.6%) required a massive transfusion. Compared to citrated rapid thromboelastographies, citrated kaolin thromboelastographies performed better for activated clotting time/rapid and citrated native thromboelastographies for maximum amplitude and angle. Yet, the 95% confidence intervals overlapped considerably, suggesting the citrated rapid thromboelastographies produced comparable results to the other assays for activated clotting time/reaction time, maximum amplitude, and angle. CONCLUSION There was substantial overlap in the performance of the different thrombelastography assays, suggesting citrated rapid thrombelastography is a quick and effective method to guide hemostatic resuscitation in trauma patients and does not perform inferiorly to the citrated native or citrated kaolin thrombelastography despite the addition of activation factors.
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Hessheimer AJ, Vendrell M, Muñoz J, Ruíz Á, Díaz A, Sigüenza LF, Lanzilotta JR, Delgado Oliver E, Fuster J, Navasa M, García-Valdecasas JC, Taurá P, Fondevila C. Heparin but not tissue plasminogen activator improves outcomes in donation after circulatory death liver transplantation in a porcine model. Liver Transpl 2018; 24:665-676. [PMID: 29351369 DOI: 10.1002/lt.25013] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Revised: 12/07/2017] [Accepted: 01/06/2018] [Indexed: 02/07/2023]
Abstract
Ischemic-type biliary lesions (ITBLs) arise most frequently after donation after circulatory death (DCD) liver transplantation and result in high morbidity and graft loss. Many DCD grafts are discarded out of fear for this complication. In theory, microvascular thrombi deposited during donor warm ischemia might be implicated in ITBL pathogenesis. Herein, we aim to evaluate the effects of the administration of either heparin or the fibrinolytic drug tissue plasminogen activator (TPA) as means to improve DCD liver graft quality and potentially avoid ITBL. Donor pigs were subjected to 1 hour of cardiac arrest (CA) and divided among 3 groups: no pre-arrest heparinization nor TPA during postmortem regional perfusion; no pre-arrest heparinization but TPA given during regional perfusion; and pre-arrest heparinization but no TPA during regional perfusion. In liver tissue sampled 1 hour after CA, fibrin deposition was not detected, even when heparin was not given prior to arrest. Although it was not useful to prevent microvascular clot formation, pre-arrest heparin did offer cytoprotective effects during CA and beyond, reflected in improved flows during regional perfusion and better biochemical, functional, and histological parameters during posttransplantation follow-up. In conclusion, this study demonstrates the lack of impact of TPA use in porcine DCD liver transplantation and adds to the controversy over whether the use of TPA in human DCD liver transplantation really offers any protective effect. On the other hand, when it is administered prior to CA, heparin does offer anti-inflammatory and other cytoprotective effects that help improve DCD liver graft quality. Liver Transplantation 24 665-676 2018 AASLD.
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Affiliation(s)
- Amelia J Hessheimer
- Department of Surgery, Institut de Malalties Digestives I Metabòliques, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Marina Vendrell
- Departments of Anesthesia, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Javier Muñoz
- Department of Surgery, Institut de Malalties Digestives I Metabòliques, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Ángel Ruíz
- Department of Hepatobiliary and Liver Transplant Surgery, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Alba Díaz
- Pathology, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Luís Flores Sigüenza
- Department of Surgery, Institut de Malalties Digestives I Metabòliques, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Jorge Rodríguez Lanzilotta
- Department of Surgery, Institut de Malalties Digestives I Metabòliques, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Eduardo Delgado Oliver
- Department of Surgery, Institut de Malalties Digestives I Metabòliques, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Jose Fuster
- Department of Surgery, Institut de Malalties Digestives I Metabòliques, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Miquel Navasa
- Liver Unit, Institut de Malalties Digestives i Metabòliques, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Juan Carlos García-Valdecasas
- Department of Surgery, Institut de Malalties Digestives I Metabòliques, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Pilar Taurá
- Departments of Anesthesia, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Constantino Fondevila
- Department of Surgery, Institut de Malalties Digestives I Metabòliques, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Hospital Clínic, University of Barcelona, Barcelona, Spain.,Department of Hepatobiliary and Liver Transplant Surgery, Hospital Clínic, University of Barcelona, Barcelona, Spain
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Computational Model for Hyperfibrinolytic Onset of Acute Traumatic Coagulopathy. Ann Biomed Eng 2018; 46:1173-1182. [PMID: 29675813 DOI: 10.1007/s10439-018-2031-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2017] [Accepted: 04/16/2018] [Indexed: 12/16/2022]
Abstract
The onset of acute traumatic coagulopathy in trauma patients exacerbates hemorrhaging and dramatically increases mortality. The disease is characterized by increased localized bleeding, and the mechanism for its onset is not yet known. We propose that the fibrinolytic response, specifically the release of tissue-plasminogen activator (t-PA), within vessels of different sizes leads to a variable susceptibility to local coagulopathy through hyperfibrinolysis which can explain many of the clinical observations in the early stages from severely injured coagulopathic patients. We use a partial differential equation model to examine the consequences of vessel geometry and extent of injury on fibrinolysis profiles. In addition, we simulate the efficacy of tranexamic acid treatment on coagulopathy initiated through endothelial t-PA release, and are able to reproduce the time-sensitive nature of the efficacy of this treatment as observed in clinical studies.
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136
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Abstract
Damage control surgery is a combination of temporizing surgical interventions to arrest hemorrhage and control infectious source, with goal directed resuscitation to restore normal physiology. The convention of damage control surgery largely arose following the discovery of the lethal triad of hypothermia, acidosis, and coagulopathy, with the goal of Damage Control Surgery (DCS) is to avoid the initiation of this "bloody vicious cycle" or to reverse its progression. While hypothermia and acidosis are generally corrected with resuscitation, coagulopathy remains a challenging aspect of DCS, and is exacerbated by excessive crystalloid administration. This chapter focuses on resuscitative principles in the four settings of trauma care: the prehospital setting, emergency department, operating room, and intensive care unit including historical perspectives, resuscitative methods, controversies, and future directions. Each setting provides unique challenges with specific goals of care.
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Limited Resuscitation With Fresh or Stored Whole Blood Corrects Cardiovascular and Metabolic Function in a Rat Model of Polytrauma and Hemorrhage. Shock 2018; 47:208-216. [PMID: 27648698 DOI: 10.1097/shk.0000000000000748] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
INTRODUCTION We have recently shown that human whole blood stored at 4°C maintains hemostatic and platelet function. In this study, we compared restoration of hemodynamic, metabolic and hemostatic function after limited resuscitation with rat fresh whole blood, rat stored whole blood, or Lactated Ringers in traumatized rats. METHODS Rat whole blood was stored for 10 days at 4°C for evaluation of hemostatic function. Polytrauma was performed on isoflurane-anesthetized Sprague-Dawley rats (350-450 g) by damage to the intestines, liver, right leg skeletal muscle, and right femur fracture, followed by 40% hemorrhage. At 1 h, rats were resuscitated (20%) with either fresh whole blood (FWB), stored whole blood, 4°C for 7 days (SWB), Lactated Ringers (LR), or nothing. Blood samples were taken before and 2 h after trauma and hemorrhage to evaluate metabolic and hemostatic function. RESULTS Whole blood stored for 10 days showed a significant prolongation in prothrombin time (PT) and activated partial thromboplastin time (aPTT), and fall in fibrinogen concentration, but no change in Maximum Clot Firmness or speed of clot formation. Platelet function was maintained until day 7 in storage, than fell significantly. Polytrauma and hemorrhage in rats led to a fall in arterial pressure, plasma bicarbonate, fibrinogen, and platelet function, and a rise in plasma lactate, PT, aPTT, and creatinine. Resuscitation with either FWB or 7 day SWB, but not LR, returned arterial pressure, plasma lactate and plasma bicarbonate to levels similar to control, but had no effect on the fall in fibrinogen or platelet function, or the rise in PT, aPTT, or creatinine. CONCLUSION Hemostatic and platelet function of rat whole blood stored at 4°C is preserved for at least 7 days in vitro. Low volume resuscitation with SWB or FWB, but not LR, restores hemodynamic and metabolic function, but not the coagulopathy after severe trauma and hemorrhage.
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β-Blockade use for Traumatic Injuries and Immunomodulation: A Review of Proposed Mechanisms and Clinical Evidence. Shock 2018; 46:341-51. [PMID: 27172161 DOI: 10.1097/shk.0000000000000636] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Sympathetic nervous system activation and catecholamine release are important events following injury and infection. The nature and timing of different pathophysiologic insults have significant effects on adrenergic pathways, inflammatory mediators, and the host response. Beta adrenergic receptor blockers (β-blockers) are commonly used for treatment of cardiovascular disease, and recent data suggests that the metabolic and immunomodulatory effects of β-blockers can expand their use. β-blocker therapy can reduce sympathetic activation and hypermetabolism as well as modify glucose homeostasis and cytokine expression. It is the purpose of this review to examine either the biologic basis for proposed mechanisms or to describe current available clinical evidence for the use of β-blockers in traumatic brain injury, spinal cord injury, hemorrhagic shock, acute traumatic coagulopathy, erythropoietic dysfunction, metabolic dysfunction, pulmonary dysfunction, burns, immunomodulation, and sepsis.
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139
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Samuels JM, Moore HB, Moore EE. Coagulopathy in Severe Sepsis: Interconnectivity of Coagulation and the Immune System. Surg Infect (Larchmt) 2018; 19:208-215. [PMID: 29346034 DOI: 10.1089/sur.2017.260] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Disseminated intravascular coagulation (DIC) remains a challenging complication of infection with inadequate treatment and significant morbidity and mortality rates. METHODS Review of the English-language literature. RESULTS Disseminated intravascular coagulation arises from the immune system's response to microbial invasion, as well as the byproducts of cell death that result from severe sepsis. This response triggers the coagulation system through an interconnected network of cellular and molecular signals, which developed originally as an evolutionary mechanism intended to isolate micro-organisms via fibrin mesh formation. However, this response has untoward consequences, including hemorrhage and thrombosis caused by dysregulation of the coagulation cascade and fibrinolysis system. Ultimately, diagnosis relies on clinical findings and laboratory studies that recognize excessive activation of the coagulation system, and treatment focuses on supportive measures and correction of coagulation abnormalities. Clinically, DIC secondary to sepsis in the surgical population presents a challenge both in diagnosis and in treatment. Biologically, however, DIC epitomizes the crosstalk between signaling pathways that is essential to normal physiology, while demonstrating the devastating consequences when failure of local control results in systemic derangements. CONCLUSIONS This paper discusses the pathophysiology of coagulopathy and fibrinolysis secondary to sepsis, the diagnostic tools available to identify the abnormalities, and the available treatments.
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Affiliation(s)
- Jason M Samuels
- 1 Department of General Surgery, University of Colorado Denver , Aurora, Colorado
| | - Hunter B Moore
- 1 Department of General Surgery, University of Colorado Denver , Aurora, Colorado
| | - Ernest E Moore
- 2 Department of Surgery, Denver Health Medical Center , Denver, Colorado
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140
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Acute Traumatic Endotheliopathy in Isolated Severe Brain Injury and Its Impact on Clinical Outcome. Med Sci (Basel) 2018; 6:medsci6010005. [PMID: 29337920 PMCID: PMC5872162 DOI: 10.3390/medsci6010005] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Revised: 01/08/2018] [Accepted: 01/10/2018] [Indexed: 12/31/2022] Open
Abstract
Study design: Prospective observational cohort. Objective: To investigate the difference in plasma levels of syndecan-1 (due to glycocalyx degradation) and soluble thrombomodulin (due to endothelial damage) in isolated severe traumatic brain injury (TBI) patients with/without early coagulopathy. A secondary objective was to compare the effects of the degree of TBI endotheliopathy on hospital mortality among patients with TBI-associated coagulopathy (TBI-AC). Methods: Data was prospectively collected on isolated severe TBI (sTBI) patients with Glasgow Coma Scale (GCS) ≤8 less than 12 h after injury admitted to a level I trauma centre. Isolated sTBI patients with samples withdrawn prior to blood transfusion were stratified by conventional coagulation tests as coagulopathic (prothrombin time (PT) ≥ 16.7 s, international normalized ratio (INR) ≥ 1.27, and activated partial thromboplastin time (aPTT) ≥ 28.8 s) and non-coagulopathic. Twenty healthy controls were also included. Plasma levels of thrombomodulin and syndecan-1 were estimated by ELISA. With receiver operating characteristic curve (ROC) analysis, we defined endotheliopathy as a syndecan-1 cut-off level that maximized the sum of sensitivity and specificity for predicting TBI-AC. Results: Inclusion criteria were met in 120 cases, with subjects aged 35.5 ± 12.6 years (88.3% males). TBI-AC was identified in 50 (41.6%) patients, independent of age, gender, and GCS, but there was an association with acidosis (60%; p = 0.01). Following isolated sTBI, we found insignificant changes in soluble thrombomodulin (sTM) levels between patients with isolated TBI and controls, and sTM levels were lower in coagulopathic compared to non-coagulopathic patients. Elevations in plasma syndecan-1 (ng/mL) levels were seen compared to control (31.1(21.5–30.6) vs. 24.8(18.5–30.6); p = 0.08). Syndecan-1(ng/mL) levels were significantly elevated in coagulopathic compared to non-coagulopathic patients (33.7(21.6–109.5) vs. 29.9(19.239.5); p = 0.03). Using ROC analysis (area under the curve = 0.61; 95% Confidence Interval (CI) 0.50 to 0.72), we established a plasma syndecan-1 level cutoff of ≥30.5 ng/mL (sensitivity % = 55.3, specificity % = 52.3), with a significant association with TBI-associated coagulopathy. Conclusion: Subsequent to brain injury, elevated syndecan-1 shedding and endotheliopathy may be associated with early coagulation abnormalities. A syndecan-1 level ≥30.5 ng/mL identified patients with TBI-AC, and may be of importance in guiding management and clinical decision-making.
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141
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Huebner BR, Dorlac WC, Cribari C. Tranexamic Acid Use in Prehospital Uncontrolled Hemorrhage. Wilderness Environ Med 2018; 28:S50-S60. [PMID: 28601210 DOI: 10.1016/j.wem.2016.12.006] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2016] [Revised: 11/08/2016] [Accepted: 12/01/2016] [Indexed: 02/06/2023]
Abstract
The use of tranexamic acid (TXA) in the treatment of trauma patients was relatively unexplored until the landmark Clinical Randomisation of an Antifibrinolytic in Significant Haemorrhage-2 (CRASH-2) trial in 2010 demonstrated a reduction in mortality with the use of TXA. Although this trial was a randomized, double-blinded, placebo-controlled study incorporating >20,000 patients, numerous limitations and weaknesses have been described. As a result, additional studies have followed, delineating the potential risks and benefits of TXA administration. A systematic review of the literature to date reveals a mortality benefit of early (ideally <1 hour and no later than 3 hours after injury) TXA administration in the treatment of severely injured trauma patients (systolic blood pressure <90 mm Hg, heart rate >110). Combined with abundant literature showing a reduction in bleeding in elective surgery, the most significant benefit may be administration of TXA before the patient goes into shock. Those trials that failed to show a mortality benefit of TXA in the treatment of hemorrhagic shock acknowledged that most patients received blood products before TXA administration, thus confounding the results. Although the use of prehospital TXA in the severely injured trauma patient will become more clear with the trauma studies currently underway, the current literature supports the use of prehospital TXA in this high-risk population. We recommend considering a 1 g TXA bolus en route to definitive care in high-risk patients and withholding subsequent doses until hyperfibrinolysis is confirmed by thromboelastography.
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Affiliation(s)
- Benjamin R Huebner
- Department of Surgery, University of Cincinnati, Cincinnati, OH (Dr Huebner)
| | - Warren C Dorlac
- University of Colorado Health, Loveland, CO and Volunteer Clinical Faculty, Department of Surgery, University of Cincinnati, Cincinnati, OH (Dr Dorlac).
| | - Chris Cribari
- University of Colorado Health, Loveland, CO (Dr Cribari)
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Histone-Complexed DNA Fragments Levels are Associated with Coagulopathy, Endothelial Cell Damage, and Increased Mortality after Severe Pediatric Trauma. Shock 2018; 49:44-52. [DOI: 10.1097/shk.0000000000000902] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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143
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Kırış T, Yazıcı S, Durmuş G, Çanga Y, Karaca M, Nazlı C, Dogan A. The relation between international normalized ratio and mortality in acute pulmonary embolism: A retrospective study. J Clin Lab Anal 2018; 32:e22164. [PMID: 28213956 PMCID: PMC6817039 DOI: 10.1002/jcla.22164] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2016] [Accepted: 01/12/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Acute pulmonary embolism (PE) is a serious clinical disease characterized by a high mortality rate. The aim of this study was to assess the prognostic value of international normalized ratio (INR) in acute PE patients not on anticoagulant therapy. METHODS The study included 244 hospitalized acute PE patients who were not receiving previous anticoagulant therapy. Based on their 30-day mortality, patients were categorized as survivors or non-survivors. INR was measured during the patients' admission, on the same day as the diagnosis of PE but before anticoagulation started. RESULTS Thirty-day mortality occurred in 39 patients (16%). INR was higher in non-survivors than in survivors (1.3±0.4 vs 1.1±0.3, P=.003). In multivariate analysis, INR (HR: 3.303, 95% CI: 1.210-9.016, P=.020) was independently associated with 30-day mortality from PE. Inclusion of INR in a model with simplified pulmonary embolism severity index (sPESI) score improved the area under the receiver operating characteristics (ROC) curve from 0.736 (95% CI: 0.659-0.814) to 0.775 (95% CI: 0.701-0.849) (P=.028). Also, the addition of INR to sPESI score enhanced the net reclassification improvement (NRI=8.8%, P<.001) and integrated discrimination improvement (IDI=0.043, P=.027). CONCLUSION Elevated INR may have prognostic value for 30-day mortality in acute PE patients not on anticoagulation. Combining INR with sPESI score improved the predictive value for all-cause mortality. However, further large-scale studies are needed to confirm it's prognostic role.
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Affiliation(s)
- Tuncay Kırış
- Department of CardiologyAtaturk Training and Research HospitalIzmir Katip Celebi UniversityIzmirTurkey
| | - Selcuk Yazıcı
- Department of CardiologyDr. Siyami Ersek Thoracic and Cardiovascular Surgery Center Training Research HospitalIstanbulTurkey
| | - Gündüz Durmuş
- Department of CardiologyHaseki Training and Research HospitalIstanbulTurkey
| | - Yiğit Çanga
- Department of CardiologyDr. Siyami Ersek Thoracic and Cardiovascular Surgery Center Training Research HospitalIstanbulTurkey
| | - Mustafa Karaca
- Department of CardiologyMedical SchoolAtaturk Training and Research HospitalIzmir Katip Celebi UniversityIzmirTurkey
| | - Cem Nazlı
- Department of CardiologyMedical SchoolAtaturk Training and Research HospitalIzmir Katip Celebi UniversityIzmirTurkey
| | - Abdullah Dogan
- Department of CardiologyMedical SchoolAtaturk Training and Research HospitalIzmir Katip Celebi UniversityIzmirTurkey
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Voelckel W, Maegele M, Solomon C, Schöchl H. Trauma-associated hyperfibrinolysis. Hamostaseologie 2017; 32:22-7. [DOI: 10.5482/ha-1178] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2011] [Accepted: 09/29/2011] [Indexed: 12/17/2022] Open
Abstract
SummaryTrauma-induced coagulopathy (TIC) has been considered for a long time as being due to depletion of coagulation factors secondary to blood loss, dilution and consumption. Dysfunction of the remaining coagulation factors due to hypothermia and acidosis is assumed to additionally contribute to TIC. Recent data suggest that hyperfibrinolysis (HF) represents an additional important confounder to the disturbed coagulation process. Severe shock and major tissue trauma are the main drivers of this HF. The incidence of HF is still speculative. According to visco-elastic testing of trauma patients upon emergency room admission, HF is present in approximately 2.5–7% of all trauma patients. However, visco-elastic tests provide information on severe forms of HF only. Occult HF seems to be much more common but diagnosis is still challenging. Results from a recent randomized, placebo-controlled trial suggest that the early treatment of trauma patients with tranexamic acid may result in a significant reduction of trauma-associated mortality.
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145
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Schlimp CJ, Schöchl H. The role of fibrinogen in trauma-induced coagulopathy. Hamostaseologie 2017; 34:29-39. [DOI: 10.5482/hamo-13-07-0038] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2013] [Accepted: 10/18/2013] [Indexed: 12/18/2022] Open
Abstract
SummaryFibrinogen plays an essential role in clot formation and stability. Importantly it seems to be the most vulnerable coagulation factor, reaching critical levels earlier than the others during the course of severe injury. A variety of causes of fibrinogen depletion in major trauma have been identified, such as blood loss, dilution, consumption, hyperfibrinolysis, hypothermia and acidosis. Low concentrations of fibrinogen are associated with an increased risk of diffuse microvascular bleeding. Therefore, repeated measurements of plasma fibrinogen concentration are strongly recommended in trauma patients with major bleeding. Recent guidelines recommend maintaining plasma fibrinogen concentration at 1.5–2 g/l in coagulopathic patients. It has been shown that early fibrinogen substitution is associated with improved outcome.
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Hifumi T, Kuroda Y, Kawakita K, Yamashita S, Oda Y, Dohi K, Maekawa T. Therapeutic hypothermia in patients with coagulopathy following severe traumatic brain injury. Scand J Trauma Resusc Emerg Med 2017; 25:120. [PMID: 29262829 PMCID: PMC5738813 DOI: 10.1186/s13049-017-0465-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2017] [Accepted: 12/11/2017] [Indexed: 01/23/2023] Open
Abstract
Background Coagulopathy in traumatic brain injury (TBI) has been associated with poor neurological outcomes and higher in-hospital mortality. In general principle of trauma management, hypothermia should be prevented as it directly worsens coagulopathy. Therefore, we examined the safety of mild therapeutic hypothermia (MTH) in patients with coagulopathy following severe TBI. Methods We re-evaluated the brain hypothermia (B-HYPO) study data based on coagulopathy and compared the Glasgow Outcome Scale scores and survival rates at 6 months using per protocol analyses. Coagulopathy was defined as an activated partial thromboplastin time (APTT) > 60 s and/or fibrin/fibrinogen degradation product levels (FDP) > 90 μg/mL on admission. Baseline characteristics, coagulation parameters, and outcomes were compared between the control and MTH groups with or without coagulopathy. Results In patients with coagulopathy, 12 patients were allocated to the control group (35.5–37.0 °C) and 20 patients to the MTH group (32–34 °C). In patients without coagulopathy, 28 were allocated to the control group and 59 patients were allocated to the MTH group. In patients with coagulopathy, favorable neurological outcomes and survival rates were comparable between the control and MTH groups (33.3% vs. 35.0%, P = 1.00; 50.0% vs. 60.0%, P = 0.72) with no difference in complication rates. On admission, no significant differences in APTT or FDP levels were observed between the two groups; however, APTT was significantly prolonged in the MTH group compared to the control group on day 3. Discussion Based on our study, MTH did not seem to negatively affect the outcomes in patients with coagulopathy following severe TBI on admission; therefore, the present study indicates that MTH may be applicable even in patients with severe TBI and coagulopathy. Conclusions Our study suggests that in comparison to control, MTH does not worsen the outcome of patients with coagulopathy following severe TBI. Trial registration UMIN-CTR, No. C000000231, Registered 13 September 2005. Electronic supplementary material The online version of this article (10.1186/s13049-017-0465-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Toru Hifumi
- Department of Emergency, Disaster and Critical Care Medicine, Kagawa University Hospital, 1750-1 Ikenobe, Miki, Kita, Kagawa, 761-0793, Japan. .,Department of Emergency, Disaster and Critical Care Medicine, 1750-1 Ikenobe, Miki, Kita, Kagawa, 761-0793, Japan.
| | - Yasuhiro Kuroda
- Department of Emergency, Disaster and Critical Care Medicine, Kagawa University Hospital, 1750-1 Ikenobe, Miki, Kita, Kagawa, 761-0793, Japan
| | - Kenya Kawakita
- Department of Emergency, Disaster and Critical Care Medicine, Kagawa University Hospital, 1750-1 Ikenobe, Miki, Kita, Kagawa, 761-0793, Japan
| | - Susumu Yamashita
- Department of Emergency Medicine, Tokuyama Central Hospital, 1-1 Kouda, Shunan, Yamaguchi, 745-8522, Japan
| | - Yasutaka Oda
- Advanced Medical Emergency and Critical Care Center, Yamaguchi University School of Medicine, 1-1-1 Minami Kogushi, Ube, Yamaguchi, 755-8505, Japan
| | - Kenji Dohi
- Department of Emergency Medicine, School of Medicine, Showa University, 1-5-8 Hatanodai, Shinagawaku, Tokyo, 142-8666, Japan
| | - Tsuyoshi Maekawa
- Yamaguchi Prefectural Grand Medical Center, 77 Osaki, Boufu, Yamaguchi, 747-8511, Japan
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Foster JC, Sappenfield JW, Smith RS, Kiley SP. Initiation and Termination of Massive Transfusion Protocols: Current Strategies and Future Prospects. Anesth Analg 2017; 125:2045-2055. [PMID: 28857793 DOI: 10.1213/ane.0000000000002436] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
The advent of massive transfusion protocols (MTP) has had a significant positive impact on hemorrhaging trauma patient morbidity and mortality. Nevertheless, societal MTP guidelines and individual MTPs at academic institutions continue to circulate opposing recommendations on topics critical to MTPs. This narrative review discusses up-to-date information on 2 such topics, the initiation and termination of an MTP. The discussion for each begins with a review of the recommendations and supporting literature presented by MTP guidelines from 3 prominent societies, the American Society of Anesthesiologists, the American College of Surgeons, and the task force for Advanced Bleeding Care in Trauma. This is followed by an in-depth analysis of the main components within those recommendations. Societal recommendations on MTP initiation in hemorrhaging trauma patients emphasize the use of retrospectively validated massive transfusion (MT) prediction score, specifically, the Assessment of Blood Consumption and Trauma-Associated Severe Hemorrhage scores. Validation studies have shown that both scoring systems perform similarly. Both scores reliably identify patients that will not require an MT, while simultaneously overpredicting MT requirements. However, each scoring system has its unique advantages and disadvantages, and this review discusses how specific aspects of each scoring system can affect widespread applicability and statistical performance. In addition, we discuss the often overlooked topic of initiating MT in nontrauma patients and the specific tools physicians have to guide the MT initiation decision in this unique setting. Despite the serious complications that can arise with transfusion of large volumes of blood products, there is considerably less research pertinent to the topic of MTP termination. Societal recommendations on MTP termination emphasize applying clinical reasoning to identify patients who have bleeding source control and are adequately resuscitated. This review, however, focuses primarily on the recommendations presented by the Advanced Bleeding Care in Trauma's MTP guidelines that call for prompt termination of the algorithm-guided model of resuscitation and rapidly transitioning into a resuscitation model guided by laboratory test results. We also discuss the evidence in support of laboratory result-guided resuscitation and how recent literature on viscoelastic hemostatic assays, although limited, highlights the potential to achieve additional benefits from this method of resuscitation.
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Affiliation(s)
- John C Foster
- From the University of Florida College of Medicine, Gainesville, Florida
| | - Joshua W Sappenfield
- Department of Anesthesiology, University of Florida College of Medicine, Gainesville, Florida
| | - Robert S Smith
- Division of Acute Care Surgery, Department of Surgery, University of Florida College of Medicine, Gainesville, Florida
| | - Sean P Kiley
- Department of Anesthesiology, University of Florida College of Medicine, Gainesville, Florida
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Gaston E, Fraser JF, Xu ZP, Ta HT. Nano- and micro-materials in the treatment of internal bleeding and uncontrolled hemorrhage. NANOMEDICINE-NANOTECHNOLOGY BIOLOGY AND MEDICINE 2017; 14:507-519. [PMID: 29162534 DOI: 10.1016/j.nano.2017.11.007] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/30/2017] [Revised: 11/01/2017] [Accepted: 11/05/2017] [Indexed: 12/14/2022]
Abstract
Internal bleeding is defined as the loss of blood that occurs inside of a body cavity. After a traumatic injury, hemorrhage accounts for over 35% of pre-hospital deaths and 40% of deaths within the first 24 hours. Coagulopathy, a disorder in which the blood is not able to properly form clots, typically develops after traumatic injury and results in a higher rate of mortality. The current methods to treat internal bleeding and coagulopathy are inadequate due to the requirement of extensive medical equipment that is typically not available at the site of injury. To discover a potential route for future research, several current and novel treatment methods have been reviewed and analyzed. The aim of investigating different potential treatment options is to expand available knowledge, while also call attention to the importance of research in the field of treatment for internal bleeding and hemorrhage due to trauma.
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Affiliation(s)
- Elizabeth Gaston
- Australian Institute for Bioengineering and Nanotechnology, the University of Queensland, Brisbane, QLD, Australia; Department of Bioengineering, Clemson University, Clemson, SC, USA
| | - John F Fraser
- Faculty of Medicine, Critical Care Research Group, Prince Charles Hospital and the University of Queensland, Brisbane, Brisbane, QLD, Australia
| | - Zhi Ping Xu
- Australian Institute for Bioengineering and Nanotechnology, the University of Queensland, Brisbane, QLD, Australia
| | - Hang T Ta
- Australian Institute for Bioengineering and Nanotechnology, the University of Queensland, Brisbane, QLD, Australia.
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Giordano S, Spiezia L, Campello E, Simioni P. The current understanding of trauma-induced coagulopathy (TIC): a focused review on pathophysiology. Intern Emerg Med 2017; 12:981-991. [PMID: 28477287 DOI: 10.1007/s11739-017-1674-0] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2017] [Accepted: 04/28/2017] [Indexed: 12/14/2022]
Abstract
The emergency management of acute severe bleeding in trauma patients has changed significantly in recent years. In particular, greater attention is now being devoted to a prompt assessment of coagulation alterations, which allows for immediate haemostatic resuscitation procedures when necessary. The importance of an early trauma-induced coagulopathy (TIC) diagnosis has led physicians to increase the efforts to better understand the pathophysiological alterations observed in the haemostatic system after traumatic injuries. As yet, the knowledge of TIC is not exhaustive, and further studies are needed. The aim of this review is to gather all the currently available data and information in an attempt to gain a better understanding of TIC. A comprehensive literature search was performed using MEDLINE database. The bibliographies of relevant articles were screened for additional publications. In major traumas, coagulopathic bleeding stems from a complex interplay among haemostatic and inflammatory systems, and is characterized by a multifactorial dysfunction. In the abundance of biochemical and pathophysiological changes occurring after trauma, it is possible to discern endogenously induced primary predisposing conditions and exogenously induced secondary predisposing conditions. TIC remains one of the most diagnostically and therapeutically challenging condition.
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Affiliation(s)
- Stefano Giordano
- Thrombotic and Haemorrhagic Diseases Unit, Department of Medicine, University of Padua, Via Giustiniani, 2, 35128, Padua, Italy.
| | - Luca Spiezia
- Thrombotic and Haemorrhagic Diseases Unit, Department of Medicine, University of Padua, Via Giustiniani, 2, 35128, Padua, Italy
| | - Elena Campello
- Thrombotic and Haemorrhagic Diseases Unit, Department of Medicine, University of Padua, Via Giustiniani, 2, 35128, Padua, Italy
| | - Paolo Simioni
- Thrombotic and Haemorrhagic Diseases Unit, Department of Medicine, University of Padua, Via Giustiniani, 2, 35128, Padua, Italy
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Abstract
Fibrinolytic dysregulation is an important mechanism in traumatic coagulopathy. It is an incompletely understood process that consists of a spectrum ranging from excessive breakdown (hyperfibrinolysis) and the shutdown of fibrinolysis. Both hyperfibrinolysis and shutdown are associated with excess mortality and post-traumatic organ failure. The pathophysiology appears to relate to endothelial injury and hypoperfusion, with several molecular markers identified in playing a role. Although there are no universally accepted diagnostic tests, viscoelastic studies appear to offer the greatest potential for timely identification of patients presenting with fibrinolytic dysregulation. Treatment is multimodal, involving prompt hemorrhage control and resuscitation, with controversy surrounding the use of antifibrinolytic drug therapy. This review presents the current evidence on the pathophysiology, diagnostic challenges, as well as the management of this hemostatic dysfunction. LEVEL OF EVIDENCE Level III.
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